1. MSDS Volume 9 Implementation by Medical Superintendents 18-3-17
District headquarter hospital, mandi Bahauddin

2. 1) Lab: provision of lab safety manual and primary specimen collection manual in lab

3. 2) Radiology: quality assurance plan in radiology
Panaflex display in radiology department

4. 3) Training of Emergency Staff on Emergency Manual

5. 4. Gynae: indicator :high risk cases red strip and also tagged in labour and pre op room.

6. 5.Surgery : indicator 41: notification of OT Incharge with responsibility

7. 6.Surgery : indicator 41: OT management committee/OT MC

8. 7.Surgery : indicator 41: Surgeon's Register:

9. 8.Surgery : indicator 41: Anaesthesia Register:

10. 9.Surgery : indicator 41: Stock Register for Electro-medical Equipment:
Suggested
Existing

11. 10.Surgery : indicator 41: Prosthesis Register:

12. 11.Surgery : indicator 41: Criteria selection selected by OTMC for OT performance analysis

13. 12.Surgery : indicator 41: Operating theatre efficiency measurement tools by OTMC

14. 13.Surgery : indicator 41 : Daily Operation Theater Efficiency Measurement / performance Reports

15. 14.Surgery : indicator 41 : Daily Operation Theater Efficiency monitoring

16. 15.Monthly OT Performance for Elective Cases

17. 16.Monthly OT Performance for Emergency Cases

18. 17.Surgery : indicator 41: OTMC meeting record

19. 18.Surgery : indicator 41: display of restricted and high risk areas and urdu ( ghair mutaliqa afrad ka dakhla mamnoo ha)
General OT
LAB
Dialysis Unit
Dental Department
Emergency
Labour Room

20. 19.Surgery : indicator 41: display of changing area and formation of changing area or portable changing room

21. 20. Surgery : indicator 41: floor mapping in OT (Red line demarcations etc)
Children Hospital Nursery
Labour Room
General OT
General OT

22. 21.Surgery : indicator 42: request form for pre op assessment of surgery

23. 22. Surgery : indicator 44: Check list for time out protocol

24. 23.Surgery : indicator 44: Displays of SOP for patient identification and SOP for preventing wrong surgery, wrong patient etc
Ortho OT
General OT
LAB
General OT

25. 24Surgery : indicator 44: Display of correct operations site is the responsibility of surgical team members
General OT
Gynae OT

26. 25.Surgery: indicator 44: stamp for patient identification

27. 26.Surgery : indicator: Credential verification form in HR related to surgery

28. 27.Surgery : indicator 46: post op notes/ operating notes

29. 28.Surgery : indicator 47: post oP plan oF care form

30. 29. Surgery : indicator 47: call bell to call nurse/ doctor in recovery room
Due to very limited space available, there is no designated recovery room in operation theatre. Patients are shifted directly from OT to ward after full recovery from anesthesia and mean while the OT staff remains present and vigilant.

31. 30. Surgery : indicator 47: sequence compression devices in recovery room
So far could not made available from the market even in Lahore. However efforts are on the way.

32. 31. Surgery : indicator 48: documented surgical quality assurance program

33. 32. Surgery: indicator 48: surgery safety check list

34. 33.Surgery : indicator 48: MIS
1.Number of surgeries performed by individual surgeon

35. 33.Surgery : indicator 48: MIS
2.Quantity of medicine and consumable used

36. 34.Surgery : indicator 48: internal audit of OT by OTA pg 215

37. 35. Surgery : indicator 49: surveillance of OT.

38. 36. Surgery : indicator 50: SSIS register WITH CPA AND CPA log sheet and cause analysis on monthly basis

39. 37. Coordinator for every department to ensure msds distribute it and display in every department
Display in all departments

40. 38. HR: Indicator : Enlist the legal affairs i. e
38.HR: Indicator : Enlist the legal affairs i.e. proceedings against Healthcare Establishment

41. 39.HR: Indicator : required laws (from above stated heads) has been implemented

42. 40. HR: Indicator: Enlist the legal affairs (including out-sourcing or contracts with external agencies

43. 41. HR: Indicator: list of unions or associations or societies active in a Healthcare Establishment

44. 42.HR: Indicator 132 and 133: provision of written JD and employee rights and responsibilities to every employee with distribution list

45. 43.Employee record keeping by verifying their degrees, updating their professional registrations and / or adding extra or updated qualification in registration or record