Detail of Corrective Actions

HAZRO THQ Hospital

ISO 9001/ISO 14001

S.No Clause/ Description of Corrective Action Cat (Maj, Route Cause Corrective Action Proposed Target Date
Standard Min, Obs and Action Taken
1 4.2, 4.3-  Interested parties and Internal Min  Initially Hospital rely on Define Interest parties and Done
9001:2015 & External issues relevant to the Primary and internal & external issues in
QMS need to be determined. secondary health context of the THQ Hazro.
department as all
policies on broader level
considered external and
 Registration with PBTA- Punjab  Hospital wrote a letter Done
internal issues to define
Blood Transfusion Authority is to PMU to provide
policies
in process, action plan required required resources to
 PBTA is basic
for nonconformities raised by acquire PBTA
requirement and
PBTA team. organization is working
on it. Due to limited
resources and
unavailability of blood
storage cabinet yet
hospital not received
 PBTA

2 6.2.1 Departmental Min Hospital believed that Smart Quality Objectives at Done
9001:2015 Quality/Environmental Objectives targets set by PMU under Departmental Level and
14001:2015 are not measureable. umbrella of MSDS will Environmental Objectives at
define quality and central level are developed in-
Environmental Objectives line with requirements of ISO
9001:2015 and ISO
14001:2015
3 9001:2015 Inpatient care units: Min Pre-anesthesia is Officer Order was issued to Done
8.1 (b2),  Pre-anaesthesia assessment is mandatory as per MSDS assure the compliance of
8.2.1, 8.2.2, the mandatory requirement in requirement as well and Anesthesia Protocol and this
8.2.3, 8.5.1, healthcare system; a surgical hospital define this issues was noted for the CQI
8.5.5, 8.6, procedure performed (under requirement in meeting. Next CQI will take
8.7 GA) on a patient without Anesthesia section CPA on this issue
anesthesia assessment. (MRN (Indicator 31-40). This
346/378). was compliance issues
 From the aforementioned, it  Issues was not

can also be established that focused in previous  New Bed Head Tickets Done
bedhead tickets. Include Safety Check List
effective controls for risk
identification and elimination
are not being monitored and
measured. It is also
 recommended that the
Surgical Safety Check list
(WHO) should be
implemented. Moreover, the
assessment of patient charts
based current and
retrospective records should
be ensured.
Hospital was providing Plan is developed to manage this Done
 There is no system or process
services with limited issues in future
to determine and adjust the resources and this issues
risk in co-morbidities or was covered upto certain
conditions. This is very level,
important measures that
determine the risk factor and
impact on outcome of the care.
Legibility is basic Training is provided to staff to Done
 The legibility / readability of
requirement of the MSDS resolve this issue
laboratory results is
and an important target for
questionable. (MRN 355/3767)
health services. This was
 A policy and procedure
employee careless attitude.
regarding the identification of
mother and neonate should be Policies are develop on Hospital Wrote a letter to PMU Done
established. In order to identification but yet not to provide required resources to
 eliminate the risk, the cross received resources like follow policies

identification mechanism is finger print scanner

applied. A training on clinical guidance is

Clinical Guidance are part of provided by senior doctor Done
 Although, the list of high risk
the basic clinical education
obstetrical patients defined but
that is reason to not include
the clinical guidelines are not
in this domain. List is
available in either form. It is
important to provide
recommended such guidelines preference
/ pathways should be
considered as a part of patient
chart / file.
 Policy and procedure regarding This was the of A training is conducted on Done
the disposal of expired blood / communication because expired blood disposal
central instruction on HIC
blood products should be
provide detail guidelines to
established. As per process
waste blood products
owner, the expired blood bag
was drained directly without
taking any precautionary
measures. In this regard,
hospital management and
clinical leader should consult
the Punjab Blood Transfusion
 Act as well as institution for
further guidelines in this
regard.
4 9.3.2 (c)  Management Committee
meeting held on 05-05-2017.
9001:2015 But point related to QMS like
results of internal audit,
process performance,
performance of external
providers were not on agenda.
9.2.2 (e)  Non-Conformities raised in
9001:2015 internal audit by PMU on 15-
08-207 team are not closed;
Need their root clause analysis,
corrective actions and
mechanism to check
effectiveness of corrective
action.
9001:2015 Emergency Department:
7.1 (b), (i) The list of emergency
8.2.2, 8.5.2 drugs available in ER cabinet is not
being maintained. The list must
Min CQI has focus on specific A training is conducting by QA Done
targets and it is possible Officer to cover all areas in
that some points may Management review related
ignore because hospital is to QMS.
developing this process
on continual approach
and system improves with
time QA Officer Develop a list of all Done
NC and close possible and
NC is miss in plan for other. Status of the
consideration because of All NC will discuss in next CQI
the evaluation process as
system not matured and
in development phase.
Min MSDS provide the Pharmacist conduct training Done
instructions to maintain on Drugs Cabinet and labeling
the ER Cabinet. Labeling cabinet protocols to assure
Protocol is are also the compliance in future
 contains the drug name (BLOCK defined
LETTER) with the approved
7.1.4, 7.1 quantity. In addition to this the
(b), 7.1.5.1, record of expensed drugs should
8.2.2, also be maintained.
8.5.1(b) (ii) At present, the ER crash Availability of resources is Hospital wrote a letter to Done
limitation
cart does not equip with PMU for equipment delivery.
defibrillator; in the absence of

7.2 defibrillator, the cart cannot be

considered as crash cart principally.
Moreover, the contents/
components of crash cart should

4.4.1, 6.1.1, also be maintained.

8.1 (iii) The training of staff on
triage and code blue (other codes
also, where applicable) should be
6.1, 6.2 ensured. The record of training
(pre & posttest and its
effectiveness) should be
maintained as well under the CME
program.
(iv) Clinical SOPs / Protocols
Training on BLS and ALS Training on triage and code Done
was providing in last
blue are conducted
months and schedule of
the staff was tough so
these trainings face delay
SOPs of Emergency are SOPs on general operations of Done
develop but not
collective. Hospital Sops
 for emergency care should be as per case like snake Emergency are developed and
bite, Poison etc
developed, implemented and a training is conduct
established as per national /
international guidelines; such as
care / treatment of MI patients.
Triage is all ready in use
(v) In ER the timely provision Training on Triage was Done
to effectively and
of emergency services play vital efficiently use resources conducted
role in effective and efficient care
therefore the process efficiency
and capability related indicators
should be planned, measured and
improved.

5 9001:2015 Performance Evaluation and
9 &10 Improvement:
(i) The results of morbidity
and mortality should be discussed,
measured and improve as per
strategic quality improvement plan
of the hospital. Ref. MRN 182/3093
expired; suitable care for review,
but the findings of committee and
Min As Per MSDS instruction Office order is issued to Done
this data should be develop report on morbidity
monitor but hospital face and mortality and present in
issues to translate next CQI
objectives in measureable
form
improvement plan was not being
maintained.
(ii) At present, the CQI plan CQI Plan and Revise CQI Plan and Strategic Done
need to be developed; it is Organizational strategic plan are developed to cover
recommended the hospital plan are also requirement all issues
management and clinical leaders of the MSDS. Hospital
define the significant standards develop some draft but
and indicators that support the not up to the required
hospital strategic plan including: mark
a. Infection Rate (including
SSI, CAUTI, MRSA and/or as per
scope or charter)
b. Average Length of Stay
(ALOS) e.g. identification of
common diseases (as per scope)
and reducing the ALOS through
improving clinical practices and
interventions.
c. Clinical documentation
compliance rate and measuring the
effectiveness of care processes and
clinical audits.
 d. Waiting times in ER and
other areas
e. Anesthesia assessment,
surgical safety check list, fall risk
assessment, medical errors
(adverse events, near misses etc.),
competence & training
effectiveness etc.
f. Number of visits in ER with
same disease in a month and
number of admission with the
same disease etc.
g. Laboratory / Radiology
results report TAT, Planned Surgery
Cancellation Rates
Note: the certification of THQ is
subject to provision of CQI plan
coherent with the strategic plan
and corrective actions of listed
above.
6 14001:2015 Environmental Policy need to be Min Environmental policy was Hospital develop Done
5.2 properly approved by the top covered in infection Environmental policy and top
 management, issued and control program of the leadership singed the policy
understood by the all staff of the hospital in some context.
Hospital However, hospital need
to develop policy

7 14001:2015  Monitoring and test of: Min Testing is necessary to Hospital wrote a letter to Done
9.1 Environmental conditions of critical analyze and hospital is Environmental Department to
areas like OT, Labs and other wards lacking in this domain conduct these text.
shall be conducted. because of limited
 Drinking water test as potable direction in this context
water on Pakistan Standards shall from central department
be arranged and conducted
though a approved Laboratory.
 Waste water that is being drained
outside the premises of the
Hospital shall be analysis/test
from the approved Laboratory.
 Waste handling/management of
waste shall be managed as per
EPA act 1997, applicable NEQs and
SRO for the Hospitals.

Signed By- Lead Auditor: