Quality assurance program in OT
A quality assurance
program shall be followed for the surgical services which includes:
1.
Written Guidance
a.
SOP
b.
OT
Manual
c.
QAP
for OT
2.
List of all surgical
procedure
3.
Competency level for
performing these procedure
a.
Privileging
and credentialing of surgeon & Anesthetist
b.
Privileging
and credentialing of Nurse
c.
Privileging
and credentialing of OT Technician
d.
Competency
level check of Nursing staff and OT technician
4.
Preoperative assessment,
diagnosis instruction to be documented
5.
Steps to be taken to prevent
adverse event like Wrong site, wrong surgery and wrong patient
a.
By
patient tag
b.
Cross
checking
c.
Time
out
d.
Site
marking
e.
Implementation
of surgical safety checklist
6.
Operative notes shall
include:
a.
Identification
of patient
b.
IPD
NO/UHID
c.
Name
of surgeon
d.
Name
of Anesthesiologist
e.
Time
in
f.
Time
out
g.
Silent
step of Procedure
h.
Intra
op notes
i.
Post
-op- Plan shall include
i.
Medication
ii.Advice
on IV fluid
iii.Care
of wound
iv.Nursing
care
v.Observing
any complication
7.
Appropriate Infrastructure
a.
Facility
( 3 door assess to OT)
b.
Modular
OT
c.
Appropriate
equipment
d.
Appropriate
instrument
e.
Rusting
proof environment
8.
Informed Consent form
a.
Should
be bilingual
b.
Taken
before surgery
c.
Should
be taken by consultant surgeon and anesthetist
d.
Risk,
benefit and alternative should be explained
e.
Signed
by patient and doctor
9.
Prophylactic
Antibiotic shall be given administered ideally within 30-60 minutes but
certainly within two hours of the time of incision.
10. Surveillance
of OT environment: Surveillance
activities of each and every OT shall include:
a.
Daily
monitoring of humidity
b.
Daily
monitoring of temperature
c.
Daily
monitoring of differential pressure
d.
Daily
cleaning of OT
e.
Daily
Fumigation of OT
f.
Weekly
monitoring the efficacy of the OT fumigations
g.
Monthly
monitoring of the AHU filters and AC ducts
h.
6
monthly monitoring of integrity of HEPA filters (OT Validation)
11. Infection
control practices in OT: Infection control activities in OT shall include:
a.
Schedule
for cleaning
b.
Schedule
for fumigation
c.
Monitoring
of culture reports
d.
All
the staff who enter restricted /semi restricted must follow the sterilization
technique like not to wear slipper outside OT and its area change the OT dress
before leaving OT complex. Follow DON Theatre ATTIRE for OT e.g:
i.
Remove
outer clothing and jewelry.
ii.
Wash
Hand
iii.
Wear
CAP and MASK
iv.
Don
the freshly laundries scrub cloth/OT dress
v.
Putt
on clean theatre footwear
vi.
Nail
cut
e.
Ensure
Patient flow will be such that mix of sterile and unsterile patient does not
happens
f.
Material
flow will also flow unidirectional flow and sterile material should not enter
in unsterile zone.
9. KPI (Quality indicator) for OT as per 5th edition NABH
Standards
a.
Unplanned
return to OT
b.
Percentage
of surgeries where organization procedure to prevent adverse event like wrong,
surgery, wrong patient and wrong site should be followed.
c.
Percentage
of cases who receive appropriate prophylactic antibiotic
d.
Percentage
of rescheduling of surgeries
e.
Percentage
of Surgical site infection
f.
Percentage
of Deep venous thrombosis
g.
Percentage
of cautery burns
h.
Incidence
of fall
i.
Percentage
of “Position related to nerve injuries”.
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