Quality Assurance

Quality Assurance

Quality Assurance is assured by the Quality Department. The department aims to improve the quality of care and patient safety in Lisie hospital. It formulates policies and procedures to ensure the safety of patients and the quality of care.

    • The hospital has a structured patient safety programme and quality improvement programme in place and ensures the involvement of all areas of the hospital. The departments leaders play an active role in patient safety and quality improvement with support from the top management.
    • A proactive risk management plan is in place to identify the risks to the patients and corrective and preventive actions are taken to eliminate the risk.
    • Internal audits are conducted to check whether the procedures are in place. The drawbacks are identified and actions taken based on the reports.
    • An extensive medication audit is conducted by the Clinical Pharmacy team to identify the errors. The errors are classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index for categorizing medication errors.Errors are analyzed, corrective and preventive actions are taken for errors identified.
    • Safe patient care is practiced by following 70 hospital quality indicators on structures, processes and outcomes, especially in areas of high-risk situations and is used for further improvements to ensure quality of care and patient safety. Some of the indicators are listed below
    • Clinical outcomes through comparison to national benchmarks of care, while identifying and utilizing best practices.
    • Having world-class infrastructure and cutting edge technology utilized by highly skilled employees
    • Lisie hospital has an incident management system. All the incidents are reported in the standardized incident reporting format. Near misses, adverse events and sentinel events are identified and intensively analyzed.
    • Complying with the statutory requirements
    • Collecting and analyzing the patient feedback to ensure patient satisfaction
    • Lisie hospital has an efficient patient complaint management system in place.
    • Various committee meetings are conducted at regular intervals to monitor the process, protocols and patient care activities whileimplementing new quality improvement projects on various areas of hospital


Laboratory and Radiology:

      • Number of reporting errors per 1000 investigations
      • Percentage of adherence to safety precautions by staff working in diagnostics
      • No. of Re-Dos

Medication Safety

      • Medication errors rate
      • Percentage of medication charts with error-prone abbreviations
      • Percentage of in-patients developing adverse drug reaction(s).
      • Compliance rate to medication prescription in capitals

Clinical and Managerial

    • Appropriate handovers during shift change (To be done separately for doctors and nurses) - (per patient per shift).
    • Incidence of needle stick injuries
    • Percentage of near misses
    • Patient fall rate (Falls per 1000 patient days
    • Stock out rate of emergency medications
    • Time taken for discharge
    • Waiting time for diagnostics
    • Waiting time for out- patient consultation
    • Nurse-patient ratio for ICUs and wards
    • Percentage of cases who received appropriate prophylactic antibiotics within the specified timeframe
    • Hand hygiene compliance rate
    • Incidence of hospital associated pressure ulcers after admission (Bed sore per 1000 patient days)
    • Return to the emergency department within 72 hours with similar presenting complaints
    • Percentage of transfusion reactions
    • Percentage of surgeries where the organization’s procedure to prevent adverse events like wrong site, wrong patient and wrong surgery have beenadhered to.

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