Quality Assurance Programme in 6 District Hospitals



Memo No. HHM/1H-78-2013/117 Dated: 02.08.2013

The Superintendent
(1-6) Balurghat DH, Sillgurl DH, MJN DH, Krishnanagar DH, Tamluk DH, Deben Mahato DH, West Bengal.

Department of Health and Family Welfare, Government of West Bengal aims to institutionalise Quality Improvement programme in 6 (six) public hospitals listed below during 2013-14 as has been approved under NRHM ROP2013-14.

For the execution of the programme, the Department of Health and Family Welfare has decided to institute the Quality management System in all the six below listed secondary level hospitals. The aim of this programme implementation is to strengthen the existing systems of these hospitals ensuring quality assurance every where as per set guidelines in order to deliver improved patient care services. In the process of implementation the NHSRC will be providing supportive supervision to the hospitals, as per the guidelines.

The QA methodology will include training of the key stakeholders of each hospital at state HQ & there after to be followed by short training to all categories of staff of the units at each of the unit level on various quality related aspects, to be followed by a gap analysis exercise based on ISO, West Bengal Hospital, IPHS and other standards. Based on the gaps identified, action plans for bridging these gaps will be prepared and implemented. To take the process ahead in the hospitals, 11 Quality Circles will be formed in each hospital along with a core Quality Committee. The Quality Circles and the Quality Core Committee will work closely with the Superintendent in identifying the gaps, preparing action plans and finally implementing the action plans to establish quality Management system. The Standard Operating Protocols and other related documents will be prepared by the Quality Circles and the Quality Committee. The timelines for all these activities will be provided to the facility in due course of time.

The programme will be directly supervised by the Hospital Administration Branch of the Directorate. The Monitoring Officer for the districts where this QA programme is being implemented shall closely monitor, guide & advise the ongoing activities at the hospital level. They will act as the main link between the hospital authorities and the state level functionaries.

The QA Programme will have to be owned by all the staff of each of the hospitals as their programme and they will have to actively participate in all the initiatives for improvement. All staffs, including all regular employees, contractual staff and staff of outsourced service providers are to attend all the trainings, meetings and other initiatives to be taken under the programme as and when called for and contribute in successfully implementing the programme in their respective hospital. The Superintendents are to provide all assistance to NHSRC and ensure that their support and technical assistance is utilised at every step.

A review meeting at the State level with representatives of the NHSRC, State Level Monitoring Officers, unit-in-charges of six hospitals and the Officers of the Hospital Administration Branch and other State Officers shall be arranged on the 3rd Friday of every month after formal commencement of the programme implementation to review the progress of the programme in each of the hospitals. The bottlenecks to the programme will be identified and necessary remedial action/(s) shall be initiated to rectify the same.

The list of hospitals is provided here below:

1.Balurghat DHDakshin Dinajpur
2.Siliguri DHDarjeeling
3.M.J.N. DHCooch Behar
4.Krishnanagar DHNadia
5.Tamluk DHPurba Medinipur
6.Deben Mahato DHPurulia

All concerned are being informed.

Sd/- Dr. B.R Satapathi
Director of Health Services &
E.O. Secretary, Govt. of West Bengal

No. HHM/117 dated 02.08.2013, Source