GAIMS Safety Manual 12.05.22

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 1 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL SAFETY MANUAL GUJRAT ADANI INSTITUTE OF MEDICAL SCIENCES G. K. GENERAL HOSPITAL Bhuj -370001. Kutch. Phone: +91-02832-246417/18, +91-02832-258071 Fax: +91-02832-258080 [email protected] Safety Manual is the property of GUJARAT ADANI INSTITUTE OF MEDICAL SCIENCES G. K. GENERAL HOSPITAL and all recipients to whom policy is issued are obliged to treat this document confidentially. No part of this policy in any form may be printed or reproduced without written permission from Medical Director/Chief Medical Superintendent of hospital. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 2 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RELEASE AUTHORIZATION THE DOCUMENT IS RELEASED UNDER THE AUTHORITY OF MEDICAL DIRECTOR/CHIEF MEDICAL SUPERINTENDENT THE DOCUMENT IS PROPERTY OF GUJRAT ADANI INSTITUTE OF MEDICAL SCIENCES G. K. GENERAL HOSPITAL Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 3 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL AMMENDMENT SHEET Sr. Document Document Page Revised Date of Reason For Initiated Approved No. Number Description No. Doc No. Revision/ Change by- HOD by – Amendment Sign Director / CMS sign Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 4 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL TABLE OF CONTENT Contents 1. HOSPITAL INTRODUCTION ........................................................................................................... 7 2. VISION, MISSION, VALUES & QUALITY POLICY ...................................................................... 8 3. POLICY ON SCOPE OF SERVICES.............................................................................................. 10 4. HOSPITAL SERVICE STANDARDS ............................................................................................. 15 5. HOSPITAL CODE OF CONDUCT ................................................................................................. 16 6. HOSPITAL EMERGENCY CODES................................................................................................ 17 7. PATIENT RIGHTS, RESPONSIBILITIES & EDUCATION ......................................................... 18 8. POLICY ON EFFECTIVE COMMUNICATION ............................................................................ 21 9. POLICY ON COMMUNICATION IN SPECIAL SITUATION WHERE ENHCANCED COMMUNICATION IS REQUIRED....................................................................................................... 24 10. POLICY ON UNACCEPTABLE COMMUNICATION.............................................................. 30 11. DEPARTMENTAL INTRODUCTION ........................................................................................ 31 12. OBJECTIVES & SCOPE OF THE DEPARTMENT ................................................................. 33 13. JOB RESPONSIBILITY (SAFETY OFFICER).......................................................................... 33 14. LIST OF POLICIES AND PROCEDURES................................................................................. 35 1. PATIENT SAFETY PROGRAM.................................................................................................. 35 2. HAZARD IDENTIFICATION AND RISK ANALYSIS .............................................................. 54 3. PLAN FOR FIRE & NON FIRE EMERGENCIES AND EMERGENCY CODES................ 59 4. CPR AND CODE BLUE ............................................................................................................... 62 Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 5 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 5. CHILD ABDUCTION & CODE PINK ......................................................................................... 67 6. DISASTER MANAGEMENT PROTOCOL & CODE YELLOW .............................................. 68 7. FIRE SAFETY PROGRAMME.................................................................................................... 82 8. (HIC 1. J) MANAGEMENT OF COMMUNITY OUTBREAK............................................... 112 9. PROVISION OF RESOURCES FOR INFECTION PREVENTION & CONTROL .............. 113 10. HOSPITAL EVACUATION PROTOCOL ............................................................................. 114 11. OTHER NON FIRE EMERGENCY: ..................................................................................... 140 12. MOCK DRILLS........................................................................................................................ 151 13. SAFETY EDUCTION PROGRAM ........................................................................................ 153 14. EMPLOYEE HEALTH SAFETY ........................................................................................... 157 15. RADIATION SAFETY ............................................................................................................ 159 16. LAB SAFETY PROGRAM ..................................................................................................... 180 17. HAZARDOUS MATERIAL SAFETY.................................................................................... 192 18. BLOOD AND BODY FLUID SPILL MANAGEMENT ....................................................... 205 19. MEDICAL GAS SAFETY....................................................................................................... 206 20. OTHER CLINICAL SAFFETY............................................................................................... 214 21. ISOLATION & NURSING BARRIER FACILITY................................................................. 219 22. STANDARD PRECAUTIONS ............................................................................................... 220 23. HAND HYGEINE (HIC 3 b) .................................................................................................. 221 24. OTHER NON CLINICAL SAFETY - IT SAFETY ............................................................. 224 25. ENGINEERING CONTROL (HIC4 a) .................................................................................. 226 26. VISITOR ACCESS CONTROL.............................................................................................. 229 Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 6 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 27. INCIDENT ANALYSIS........................................................................................................... 230 28. SENTINEL EVENT................................................................................................................. 242 29. POLICY ON PRIORITIZING ACCESS TO THE HEALTHCARE SERVICES FOR PATIENTS ACCORDING TO THE NEED ...................................................................................... 247 30. CRITICAL RESULT REPORTING ........................................................................................ 248 31. PROCEDURE OF REQUISITION, COLLECTION, IDENTIFICATION & DISPOSAL OF LAB SPECIMEN................................................................................................................................. 250 32. RECALL / AMMENDMENT OF REPORTS....................................................................... 275 33. ABSCOND PROCEDURE ..................................................................................................... 278 34. PREVENTION OF ADVERSE EVENT- WRONG PATIENT, WRONG PROCEDURE, WRONG SITE ..................................................................................................................................... 281 35. POLICY ON CLINICAL PROCEDURE ................................................................................ 282 36. POLICY ON SEDATION........................................................................................................ 284 37. PREVENTION OF PATIENT FALL ..................................................................................... 287 38. PREVENTON OF PRESSURE ULCER ............................................................................... 290 39. DVT PROPHYLAXIS.............................................................................................................. 294 40. RESTRAIN OF PATIENTS ................................................................................................... 297 41. PRESCRIPTION AND ORDER OF MEDICATION............................................................ 302 42. SAFE DISPENSING OF MEDICATION.............................................................................. 308 43. SAFE MEDICATION ADMINISTRATION.......................................................................... 311 44. MONITORING OF MEDICATION ADMINISTRATION ................................................... 314 45. NARCOTIC’S DRUGS............................................................................................................ 317 46. IDENTIFICATION REPLACEMENT AND DISPOSALOF MATERIAL NOT IN USE. . 321 Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 7 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 47. RECALL PROCEDURE FOR MEDICAL EQUIPMENTS & DEVICES............................ 325 48. VULNARABLE PATIENTS ................................................................................................... 327 15. LIST OF QUALITY INDICATORS............................................................................................ 331 16. LIST OF FORMS, FORMATS & REGISTERS ....................................................................... 331 ABBREVIATIONS Particulars Full Form CMS Chief Medical Superintendent HK Housekeeping HR Human Resources MD Medical Director NS Nursing Superintendent RCA Root Cause Analysis QA Quality Assurance 1. HOSPITAL INTRODUCTION Gujarat Adani Institute of Medical Sciences (GAIMS) is first ever Public-Private- Partnership (PPP) endeavor between Government of Gujarat and Adani Education & Research Foundation. GAIMS is the only Medical College and Multi-Specialty Modern District Hospital in Bhuj, Kutch District established since 2009 under the unique PPP model. GAIMS is part of Adani Group’s Corporate Social Responsibility initiatives, and is managed by Adani Education & Research Foundation, under the umbrella of Adani Foundation. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 8 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL In affiliation with Krantiguru Shyamji Krishna Verma (KSKV) Kutch University, GAIMS has been recognized by Medical Council of India (MCI) for undergraduate course Bachelor of Medicine and Bachelor of Surgery (MBBS) with annual intake of 150 seats. Also GAIMS has been permitted by MCI for post-graduate course in various specialties with annual intake of total 51 seats. G. K. General Hospital (GKGH) is the 750 bed teaching hospital which is the only and the largest district hospital in Kutch district, currently operated and managed by Adani Foundation with the support of in house 3 Operation Theatre complexes, 5 Intensive Care Units (ICU), 1.5 Tesla MRI Machine, 16 slice CT Scan Machine, 24*7 emergency services and other allied facilities required for being a frontline modern multi-specialty district hospital. 2. VISION, MISSION, VALUES & QUALITY POLICY VISION: To establish centers of excellence that will impart quality medical education, deliver the finest clinical services and conduct data-based research with an aim to improve the population health metrics and strengthen the health infrastructure of the nation. MISSION:  To provide quality clinical care to the people with a social commitment to improve the health metrics of the society.  To produce skilled medical professionals to bridge the demand-supply gap of medical professionals within the nation. VALUES:  Courage: We shall embrace change and work to improve medical services in a responsible manner.  Trust: We shall act with integrity and honor in all situations. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 9 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Commitment: We shall stand by our promises and adhere to a high standard of patient care. QUALITY POLICY: GAIMS – GKGH, a tertiary care PPP model general hospital has all broad specialties, with firm commitment towards excellence in providing quality, ethical and affordable healthcare to affording class of the society and free healthcare services to non-affording communities, with equal stress on integral components of medical education and research. The staff and management of GAIMS aims towards achieving utmost Patients’ satisfaction and Positive Health, through Continuous Quality improvement, adhering to Safety standards and legal norms. These are achieved by:  Attracting medical professionals of eminence who develop each specialty with the updated technology and skill set resources matching the current industry standards.  Treating patients with respect, compassion and dignity.  Providing free in- and out- patient medical facilities to the economically weaker sections of the society and organizing community outreach programs and camps.  Conducting research, promoting academics and providing structured training to medical and paramedical professionals and postgraduate students.  Complying with all legal requirements  Ensuring all statutory requirements in compliance with the local civic authority needs and safety standards.  Working towards continuous quality improvement, patient safety and patient satisfaction. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 10 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 3. POLICY ON SCOPE OF SERVICES PURPOSE: GAIMS hospital has defined scope of services to commit to the scope of hospital healthcare services for patients. The scope of healthcare services of each department are defied & displayed bilingually. Departmental scope is written in the respective departmental manuals. RESPONSIBILITY All staff working in the hospital PROCEDURE  GAIMS has defined and displayed the healthcare services that it provides.  While defining scope of the service, need of the community is taken into consideration.  Hospital ensures that required privileged manpower, infrastructure is available.  All statutory and regulatory requirements are fulfilled and updated.  Defined services are displayed bilingually in a prominent place to make patient aware.  Non availability of services is also displayed.  For staff awareness is given in induction and through booklet.  Scope of the healthcare services of each department are defined.  Departmental scope is written in the respective departmental manuals. 1. CLINICAL SERVICES  Anesthesiology  Dermatology, venereology and leprosy  Dental  Emergency Medicine Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 11 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  General Medicine  General Surgery  Nephrology  Obstetrics and Gynecology  Ophthalmology  Orthopedics o Joint Replacement o Arthroscopy o Spine Surgery  Otorhinolaryngology  Pediatrics  Psychiatry  Respiratory Medicine  Thalassemia  Urology CRITICAL CARE  MICU  SICU  PICU  NICU  RICU  ER ICU 2. CLINICAL SUPPORT SERVICES  Ambulance  Blood Bank  Dietetics  Rehabilitation Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 12 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Physiotherapy o Audio & Speech 3. DIAGNOSTIC SERVICES a) Diagnostic Imaging  CT Scan  Mammography  MRI  Ultra Sound  X-Ray b) Laboratory Services  Bio-Chemistry  Microbiology & serology  Pathology  Cytopathology  Hematology  Immunology  Histopathology  Molecular Biology c) Other Diagnostic Services  ECG  2D echo  TMT  Audiometry  Bronchoscopy  Color Doppler Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 13 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  ECT  EEG  Endoscopy  Spirometry/Pulmonary Function Test 4. NON CLINICAL & ADMINISTRATIVE DEPARTMENTS  Ambulance Services  Bio medical Engineering Department  Catering & Kitchen Services  Community Service  CSSD  Finance & Accounting  Front Desk & Billing  Housekeeping  Human Resources  Information Technology  Linen/Laundry  Maintenance/Facility Management  Management of Bio-medical Waste  Medical Record Department  Pharmacy  Security  Support Chain Management/Material Management 5. SERVICES OPERATED BY GOVERNMENT OF GUJARAT  Homoeopathic OPD  Ayurveda OPD Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 14 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Immunization OPD  Revised National Tuberculosis Control Programme (RNTCP)  Integrated Counselling and Testing Centre (ICTC)  Nutritional Rehabilitation Centre (NRC)  Non Communicable Disease (NCD)  Mortuary Services  MLC  Sakhi [Destitute women] 6. Outsourced Services  Patient Food Services  Security Services  Housekeeping Services  Bio medical waste disposal  Canteen 7. SERVICES NOT OFFERED  Burns above 30%  Cardiology  Cardiothoracic surgery  Neurology  Neurosurgery  Nuclear Medicine  Oncology  Onco-surgery  Pediatric Surgery  Bone Marrow Transplant Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 15 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 4. HOSPITAL SERVICE STANDARDS GAIMS hospital believes in patient centric care & has developed standards to be maintained & followed are as follows: COURTESY:  When customers approach, be the first to greet them.  Try to welcome customers in their own language if possible. If you don’t know which region they are from, or you don’t speak their language, greet them in Kutchi, Gujarati & Hindi / English and with a smile.  Acknowledge customers with a friendly look and a smile whenever you interact with them around the hospital.  Even if you are busy or dealing with a queue, keep an eye on what is going around you. When customers are nearby, or approach you, look up from your work and acknowledge them with a smile.  When you are talking to customers, maintain an eye contact and include their name in your conversation in a natural and discreet way.  When you have just helped a customer with something, tell them your first name and ask if there’s anything else they need.  If you become aware of a customer need and you cannot deal, get in touch with someone who can help right away. Make sure you tell the customer, who is now dealing with the request, and when it will be sorted out.  Remember, customer rely on you to make them feel at home in the hospital. Make sure you know everything about your own department, and that you are well informed about the hospital facilities, services and features. That way, you will be well placed to provide helped information.  When customers ask you for the directions around the hospital, do more than simply showing the way. Walk the first few steps with them and offer to escort them to their destination. COMMUNICATION:  All the telephone calls will be answered within 3 rings. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 16 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  All calls are answered by wishing the caller the time of the day and identifying the call receiver or department, e.g., ‘Good Morning Pharmacy’ or ‘Good Evening, Emergency Room’ or ‘Good Afternoon, Sanket’. COMPLAINT HANDLING:  Team members should listen attentively, maintaining eye contact and without interrupting.  A sincere apology is extended, and the customer is thanked for their comments.  Complaints will be discussed discreetly, where possible in a private area away from other customers.  When follow-up is required, the team member will explain when, and by whom the follow-up will be carried out; and that deadline will be met.  If a follow-up service or correction is required, the customer will be contacted to ensure that they are satisfied with the response.  All complaints of a serious nature are brought to the immediate attention of the Medical Director. 5. HOSPITAL CODE OF CONDUCT  Values and Service standards: Inculcate hospital values and Service standards to follow mission.  Confidentiality and Privacy: Keeps the medical and non-medical information of the patient private and confidential.  Measures productivity or results: Follow processes to get expected results. Success or capability is measured in the form of achieved results.  Learning attitude with positivity: Always ready to adapt new knowledge with ‘can do ‘thought. Willing to make compatible always.  Personal Appearance/Grooming: Employees must maintain their appropriate standard of dress code and personal appearance and conduct themselves in a professional manner at all times.  Regularity & Punctuality: Employees must ensure to attend office daily; punch daily and also complete their working hours. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 17 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Safe Workplace & Environment: Employees will take all requisite precautions such as using personal protective equipment and gears and follow all rules and regulations to maintain a safe environment for the Hospitals patients, their families, employees, and visitors.  Conflicts of interest: Employees should not engage in any activity, practice or act that creates an actual or apparent conflict with the interests of the Hospital. (Eg. Dual employment)  Safeguarding hospital’s resources & assets: Employees should protect and safeguard the hospitals assets and property from any misuse/theft and ensure the appropriate use of the hospital’s resources.  Health and Safety: Employees must follow the appropriate health and safety protocols while on duty.  Honors Patients Right: Each patient has the right to be treated with respect, personal dignity &consideration.  Follow professional ethics -  Doctors need to follow professional ethics by NMC.  Nurses need to follow professional ethics by INC. 6. HOSPITAL EMERGENCY CODES GAIMS Hospital takes care of Fire & Non-fire emergency situations; List of the Emergencies is as below Sr. No Type of emergency Emergency Decided codes dial number 1 Code Red 2 Fire emergency 444 Code Black 3 Code Blue Bomb Threat/ Terrorist Attack 444 4 Code Yellow Collapse of person required CPR 444 5 Code Pink 6 Disaster Management ( Internal & 444 Code Violet External ). Infant/ Child abduction 444 Violent/ Aggressive Behavior 444 Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 18 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 7. PATIENT RIGHTS, RESPONSIBILITIES & EDUCATION PURPOSE  GAIMS hospital has a policy to protect patient and family rights. It has documented patients’ rights and responsibilities based on NABH guidelines in all manuals. All rights and responsibilities are displayed in two languages. All the staffs are trained for the same. Patient and family rights and responsibilities are actively promoted. SCOPE  All the patients & their families RESPONSIBILITY  All the patients & their families PROCEDURE  Management is keen on protecting patient’s right.  All the manuals have documented policy of patient and family rights and responsibility.  Patient and families are made aware for it by bilingual display.  All staffs are trained and made aware about it. Hospital Induction training includes the topic.  Makes staff aware about patient and family rights and responsibility.  Training emphasizes on protecting patient rights and it is the responsibility of staff. It teaches staff that their conduct should contribute in protecting patient right.  Staff booklet informs about patient and family rights and responsibility.  Hospital promotes patient and family rights and responsibility. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 19 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  List of the instances are made where patient rights can get violated, safety team is made aware about it.  The safety team see that patient rights should not get violated.  All inpatients are counseled regarding patient and family rights and responsibilities in the language they understand.  Incidence forms and Feedback forms are used to capture violation of patient and family rights.  Staff can report violation of patient and family rights by filling incidence form. Patient can write in the feedback form.  Violation of patient and family rights are monitored by, safety team incidences and feedbacks are analyzed.  Corrective and preventive action is taken by the senior management. PATIENT EDUCATION  Patients are educated regarding patient condition, treatment and risk during counseling.  At the time of discharge patient and family are explained regarding use of medication by doctors.  Considering drug-drug interaction and food -drug interaction patient is explained safe and effective utilization of the medication.  Dietician educates patients and families regarding diet by explaining Consultant educates patients and relatives regarding vaccines. Immunization chart is given to pediatric patients, all immunization is explained and documented on ANC card in carrying females.  For long term pain condition pain management techniques are explained to the patient. RIGHTS OF THE PATIENTS: 1. Right to have respect for special preferences, spiritual, and cultural need. 2. Right to considerate, personal dignity & respectful care without any form of stigma & discrimination. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 20 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 3. Right to protect from physical abuse and neglect. 4. Right to expect confidentiality regarding treatment and medical record. 5. Right to have refusal of the treatment. 6. Right to seek second opinion about his/ her clinical care. 7. Right to informed consent for treatment and procedures. 8. Right to address concerns/complaints or grievances. 9. Right to address violation of patient & family rights. 10.Right to get information on the expected cost of the treatment. 11. Right to access his /her clinical record. 12. Right to information on care plan, diagnosis, Progress and treatment. 13. Right to obtain all the relevant information about the professionals involved inpatient care. 14. Right to know what hospital rules and regulations apply to him/ her as a patient and the facilities obtainable to the patient. 15. Right to every consideration of his/ her privacy concerning his/ her medical care program. 16. Right be informed about any research activity / clinical trial and to refuse to be a part of the study. RESPONSIBILITIES OF THE PATIENTS: 1. To provide name, address & phone no. to contact in emergency. 2. To follow rules, regulations & instruction of the institute/hospital. 3. To understand the charter of rights and seek clarification, if any. 4. To provide accurate and complete information about your present and past illnesses, hospitalization and treatment. 5. To follow the treatment plan & ask relevant questions regarding treatment to treating doctor’s if you anticipate any problem in the plan. 6. To behave in polite and respectful manner with other patient and staff. 7. Give co-operation to all employees & security staff of our institute to obey their duty following. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 21 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 8. To accept the measures taken by the hospital to ensure personal privacy and confidentiality of medical records. 9. To provide Scheme related document/Insurance details at the time of admission 10.To provide your valuable feedback and suggestions. 11. To take care of your valuable and belonging. 12. To prevent misuse of water and electricity. 13. Not to get overcrowded surrounding the patient. 14. Not to misuse facility, equipment and services and prevent damage to hospital property. 15. To report whether you clearly understand the instructions given by your care provider. 16. To ask question when he/she does not understand what the doctor or other members of healthcare team tells about diagnosis or treatment. RECORDS  Incident reports  Feedback forms  Staff Booklet  Display 8. POLICY ON EFFECTIVE COMMUNICATION PURPOSE  To implement effective communication between patients, families and healthcare workers and among healthcare workers so that the Intended message is successfully delivered, received & understood.  To prevent errors that happen in healthcare related to communication by way of appropriate nonverbal communication, engaging listening and assertively speaking. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 22 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RESPONSIBILITY  All Hospital Staff PROCEDURE  GAIMS hospital has documented policy and procedure of effective communication in each manual. It helps for appropriate utilization of time and minimizing mistakes due to misinformation.  GAIMS hospital has adopted the 7 C Mode of effective communication.  The 7 C’s stand for seven essential principles of communication starting with the letter C. Each one represents a requirement that the message should meet to be effective. 1. Clear Conveying the message in an easy-to-understand manner. Use of simple sentences while speaking or writing. The aim of this principle is to share the information with utmost clarity. Clear messages consist of exact and concrete words. 2. Concise Concise means to be “to the point” without using a lot of words. Staff should make sure that there are no unnecessary sentences and repetition of same points multiple times. Being concise saves the time of both the patient and the staff. 3. Concrete Concrete messages are clear and usually supported with facts. Staff should give details in the message without it being too long. The message should be solid and specific and evidence based. 4. Correct Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 23 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL A correct message with viable facts adds credibility to the communication. Staff should make sure that all the information and facts are accurate and should with seniors if necessary. 5. Considerate This principle follows the ‘You’ approach when dealing with the patient. Consideration means to keep in mind the patient’s and fellow staff’s requirements and views while communicating. Staff should consider the level of education, background, emotional quotient and mindsets of the patient. This will result in positive outcomes during your interactions. 6. Complete A complete message gives the patient & fellow staff all the information and is clear and detailed. When a message is complete, the patient/ fellow staff knows exactly what needs to be done. 7. Courteous Being courteous is the most important attribute of communication. Staff should always be friendly and honest. They should respect the patient/Fellow staff while communicating. In case of any feedback that needs to be pointed out, it can be conveyed in a constructive manner. A courteous message will leave the patient in a positive mindset rather than negative. In spite of effective communication there can be hurdles in the communication which are identified by health workers. Few of them are listed below. a) Language barrier - Interpreter is used wherever required. Hospital has adapted bilingual policy for communication. All the relevant displays and consents are bilingual. b) Speech and hearing disability – Patients relatives are involved in the communication who acts as an interpreter & can communicate by writing things Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 24 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL c) Noise - hospital sees that the noise level should be low. d) Visitor’s policy is prepared and executed. Communication is a part of hospital code of conduct. Hospital leaders assure that there is no unacceptable communication. Anything found unacceptable is considered as misconduct.  Examples of unacceptable communication are- o Abusing patient o Hurting religious and cultural sentiments. o Communicating with disrespect. o Training on various communication skills & safe communication  Communication is a part of Hospital Service Standard which is also included in General induction.  The training requirement for each group of staff varies which is done in a continuous process by Head of the Departments.  Monitoring Effective communication: o It is done with the help of patient feedbacks and complaints which are taken verbally during patient rounds and by assessing the documentation of the communication. o By conducting Audit on compliance of Opportunities for communication 9.POLICY ON COMMUNICATION IN SPECIAL SITUATION WHERE ENHCANCED COMMUNICATION IS REQUIRED PURPOSE  To implement enhanced communication between patients, families and healthcare workers and among healthcare worker during Special Situations within the organization listed out as ‘Special Situation’  To ensure purposeful, timely & reliable communication.  To train the hospital staff periodically on this policy. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 25 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  To prevent errors that happen in healthcare related to communication. RESPONSIBILITY  All Clinical HoDs & Unit In-charges  All Nursing In-charges PROCEDURE:  Special situations requiring enhanced communication are listed. 1. Breaking bad news and talking to family of a deceased patient 2. Handling adverse events. 3. Handling aggressive patient / family 4. Handling patients undergoing complicated interventions 5. Communication in case of emergency disaster 6. Communication Barriers  Enhanced communication with the patients and/or families is carried out which is purposeful, timely and reliable.  Enhanced communication recognizes limitation of the others. It is empathetic, and sensitive.  Hospital staffs are periodically trained on this policy. 1. Breaking bad news and Talking to family of a deceased patient.  Bad news is “any information which adversely and seriously affects an individual’s view of his or her future.” This includes the diagnosis of a patient which needs to be explained to the patient / family to make informed decisions such as Cancer detected, Renal Failure, Heart Failure etc.,  The Primary Consultant shall counsel such patients / families in a sensible manner. The counselling should be recorded in the medical record and signed off by the patient / family.  In case of Death the concerned treating consultant should be the one to disclose the death and not the junior doctors. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 26 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Such Communication should be done in a private, non-clinical area which can be used by the relatives and should have minimum interruptions.  Where possible, death should be anticipated and relatives should be encouraged in spending time with the patient before death occurs.  Face-to-face communication with relatives is preferable to a telephone conversation. If the relatives are not present when the patient dies, they should be contacted by telephone and encouraged to attend the hospital. However, if they ask if their relative is alive or dead, they must be told the truth.  Medical professionals should be seated when breaking bad news and maintain eye contact with the patient relative and assess the relatives’ existing knowledge before breaking the news.  Communication should always be honest and accurate, tailored to meet the family’s needs and shared in an empathetic and caring way.  Respond appropriately to relatives’ reactions and give them time to ask questions. All questions should be answered appropriately.  Inform the family about practical matters, such as collecting the death certificate.  For delivering BAD news model of SPIKES is adapted by the hospital. SPIKES Full Form Understanding Probable question or Arrange for privacy. examples Involve significant others, sit What time would suit you and your family members S Setting up down, make connection and for a chat about your diagnosis? establish rapport with the patient, manage time constraints and interruptions. Perception of Determine what the patient Explain to me what you P condition/ knows about the medical understand of your seriousness condition. recent diagnosis? Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 27 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Listen to the patient's level of comprehension, accept denial but do not confront at this stage Ask patient if she/he wishes I Invitation from to know the details of the Would you like me to the patient to medical condition, accept explain exactly what give patient's right not to know. your diagnosis means? information Offer to answer questions later if she/he wishes Use language intelligible to patient Consider educational level, When we examined your K Knowledge: socio-economical state, give chest X-ray, we saw a giving medical information in small chunks small visible mass, this is facts usually an indication of Check if patient understand cancer, is this all making what you have said, respond sense to you? to patient's reactions as they occur, give any positive aspect first Prepare to give an empathetic response E Explore Identify emotion expressed Has your diagnosis come emotions and by the patient as a shock to you? sympathize Explain to me how you Identify cause/ source of are feeling. emotion, give the patient time to express their feeling Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 28 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Close the interview Has this all made sense S Strategy and Ask whether they want to to you? Have you any Summary clarify something else more questions? When do you wish to arrange Offer agenda for the next our next meeting? meeting 2. Handling adverse events  This includes the anesthesia related adverse events, Medication related adverse events, procedure / surgery related adverse events, Sentinel events etc.  This shall be communicated by the primary consultant. The primary consultant can include other stake holders during such communications as deemed necessary.  These communications should include the explanation of cause of such events and the action(s) initiated.  The same shall be recorded in the format / document identified by organization. 3. Handling aggressive patient / family  If the aggressiveness of patient is related to clinical condition, then the primary consultant shall communicate the consequences that may arise and communicate the actions such as usage of restraints etc., the same should be documented in the restraint order form and consent should be taken from patient family in the restrain consent form.  If the aggressiveness situations are nonclinical, CODE VIOLET should be activated as per protocol.  The staff on duty along with other members as deemed necessary shall counsel / communicate to patient / family on the consequences that may arise. Necessary safety of healthcare workers shall be taken while handling the situation. The same can be documented in the incident report form.  In such situation staff must speak softly and refrain from having a judgmental attitude. Try to remain neutral, although it may be difficult with an irrational patient Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 29 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 4. Handling patients undergoing complicated interventions  These situations include the risk involved in the procedure, desired outcome, expected cost etc.  The consultant shall explain the risks, treatment options and benefits to the patient / family to make informed decisions.  The same shall be documented in respective consent forms. 5. Communicating change of surgery plan / change of anesthesia plan on table-  Sometimes the anesthetist / surgeon after assessment and as per report takes decision of change of plan of anesthesia / surgery.  In such situations surgeon and anesthetist has to explain reason of change of plan, the risk involved in the procedure, desired outcome etc.  The surgeon / anesthetist shall explain the risks, treatment options and benefits to the patient / family to make informed decisions.  The same shall be documented in another respective consent forms. 6. Communication in case of emergency disaster  Staff should Activate CODE YELLOW and follow the hospital policy on Disaster Management. 7. Communication barrier  The hospital arranges staff as per the situation who can act as interpreters in case of need for a particular language, to help in the patient interaction and counselling.  For patient with speech and hearing disability relatives also are involved in the communication who acts as an interpreter. RECORDS:  Patient Medical Record- Consents/ Counselling forms Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 30 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Incident forms  Emergency CODE reports 10.POLICY ON UNACCEPTABLE COMMUNICATION PURPOSE:  To lay down guidelines regarding communication expectations at GAIMS Hospital. RESPONSIBILITY  All healthcare workers. PROCEDURE  Unacceptable communication is the communication which is worse than the minimum expectation a patient or management would have about the staff or patient.  All staff should adhere to the CODE OF CONDUCT. Types of unacceptable communication - Employees a) Abusing Patient or fellow employees b) Hurting the religious or cultural sentiments c) Communicating with disrespect d) Discussing / disclosing the patient condition in public areas e) Any behavior violating the patient right f) Talking bad about professional colleagues of same or different specialty g) Talking bad about alternate approved system of medicine  Unacceptable communication from an employee shall be reported to the seniors. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 31 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Counselling is provided at the individual level. Depending on effect magnitude, misconduct can be raised; followed by appropriate disciplinary action and involvement of disciplinary committee if required.  A quiet area will be used to speak to a disruptive employee. Ideally departmental administrative office may be used.  The Departmental Head shall always consider his/her safety, and either leave the door open or have a second person present during the interview with the employee. RECORDS  Incident report  Misconduct form  Minutes of Grievance committee meeting  Minutes of safety committee meeting 11. DEPARTMENTAL INTRODUCTION  The purpose of this manual is to provide guideline for ensuring safety of patient their families, staff and visitors  The hospital has a system in place to provide safe and secure environment to the patients, visitors, employees and all those who are coming inside the Hospital premises.  Safety Plan is designed in to maximize human safety, preserve property, minimize risk of hazards, restore normal activities of the Hospital, and assure responsible communications with Hospital constituent.  This manual is applicable to all departments of the Hospital. The Safety Management Plan defines the mechanisms for controlling hazards, promoting and implementing safety measures for the patients, staff in particular and the hospital in general.  Aspects of safety in hospital: o Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of all errors and incidents that can Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 32 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL happen due to negligence or process errors and which may lead to adverse healthcare events. o The overall aim is to prevent these errors from happening and to provide safe and effective care to the patients. o The resulting patient safety knowledge continually aims at improving efforts such as: applying lessons learned from earlier experiences, adopting innovative technologies, educating health care providers and patients and enhancing error reporting systems.  Employee & Facility Safety: o To provide effective and efficient patient care all the employees working in the Hospital setup are to be provided with a safe, secure and healthy environment to work on. o Thus the Hospital safety aims at providing the same to the employees by maintaining the Facility a hassle free environment - Facility department will ensure flowing things considering environment safety.  Appropriate facilities are made available as per the scope of services.  The building plan has been sanctioned from the appropriate authority and up to date drawings are maintain according to the standards in the facility department.  Internal and external sign posting are made available in the organization in a language understood by the patient families and relative.  Fire singes are put according to statutory norms.  Facility department ensure the availability of potable water and electricity round the clock. Alternate sources are identified and established in the hospital in case of shortage and failure.  Daily check done for the alternate sources. Alternate source list is made available.  Qualified and trained personal is available round the clock in the hospital premises.  A protocol is set to make the services of Facility Dept.  Maintenance plan is made available for water, electricity, air conditioning, ventilation, AHU & lift. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 33 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 12. OBJECTIVES & SCOPE OF THE DEPARTMENT  To provide safe facility and environment for all the occupants.  Patient safety - Implementation of Patient Safety plan & program all over the hospital.  Education of all the employees in the hospital on all safety aspect.  Employee safety - Employees need to understand their role in safety and emergency preparedness. Employees will exactly know what are they supposed to do in case of emergency situation.  Proper implementation, maintenance and development of Patient safety program and emergency preparedness plan.  Internal and external bilingual sign posting in the organization  Implementation of patient safety protocols.  Improving safety culture in the organization.  Radiation safety  Safe laboratory practices.  Safety of hazardous material management.  Safe infection control practices.  Incident analysis of safety related issues.  Capturing various safety related indicator (Patient Safety, Employee Safety, Facility Safety) etc.  Analysis of risk registers  To conduct facility round in patient care area, non-patient care area.  HIRA once in a year.  Facility rounds. SCOPE  All departments & employees 13. JOB RESPONSIBILITY (SAFETY OFFICER) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 34 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Lay down safety policies  Nominate members for the Safety Committee and emergency response team  Ensure availability of personnel for training and mock-drills.  Ensure availability of necessary equipment/resources.  Ensure periodic checking of all medical equipment and other infrastructure to detect any leak or damage which may result in fire or explosion by maintenance, biomedical and safety team.  Ensure regular maintenance of firefighting equipment.  Ensure availability of trained manpower to operate alternate equipment in case of power failure and nonfunctioning of oxygen supply and ventilators etc.  Maintain close liaison with Civil Administration, Police, Fire Fighting Department, and the media.  Ensure regular training to selected personnel in firefighting and also see to it that trained personnel are available in all departments and floors. Services of local firefighting department to be availed of for training.  Telephone numbers including Mobile numbers of concerned civil officials, police and fire fighting officials.  Telephone numbers of ambulance services, water supply agencies, home nursing services, security agencies, local Red-Cross, Civil Defense Agencies and NSS, Rotary club. RESPONSIBILITY OF CLINICAL SAFETY OFFICER  To prepare of safety plan & program and review of adherence of same.  Patient Safety program monitoring and adherence  Radiation safety policies and procedures compliance.  Laboratory safety policies and procedures compliance.  Oversee pro-active risk assessment in both clinical and non-clinical processes and areas using tools. For example: Hazard Identification and Risk Analysis (HIRA) and Failure Mode and Effects Analysis (FMEA).  Monitoring, management and prevention of incidences, near miss, adverse events Sentinel event related to safety. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 35 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Device a systematic course of action for analysis of all safety related incidents within a specified time frame and formulate recommendations for implementation.  Ensure education and training to support safety.  Conduct safety audits, assessments and present reports for taking corrective action.  Emergency codes and conduction Mock-drills. 14. LIST OF POLICIES AND PROCEDURES 1. PATIENT SAFETY PROGRAM POLICY:  GAIMS has a patient-safety programme which is developed, implemented and maintained by a multi-disciplinary safety Committee  Patient safety programme is documented in the safety manual.  Patient safety programme is comprehensive and covers all major elements related to patient, visitors and safety.  Hospital Patient safety programme adheres to national patient safety goals. PURPOSE:  To prevent all the major elements related to patient safety, focusing safe health care delivery.  To minimize incidents ranging from \"no harm\" to \"sentinel events\"  To identify opportunities for improvement based on the review at pre-defined intervals. SCOPE:  Entire Hospital- Clinical and non-clinical areas Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 36 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RESPONSIBILITY:  Medical Director  Chief Medical superintendent  Safety Officers  Quality Department PROCEDURE  The patient-safety programme is developed, implemented and maintained by a multi-disciplinary Safety committee. The patient-safety programme is comprehensive and focuses on patients’ safety and safety of support services.  Patient safety programme is updated once a year by the safety committee.  Patient Safety programme covers clinical and support services. Separate safety programme is established for certain clinical areas like Laboratory, radiology, blood bank, emergency department , ICU, OT which is incorporated in the respective manuals.  Hospital Patient safety programme adheres to current national patient safety goals ( national safety goals by joint commission 2022)  Programme includes pro-active risk assessment for clinical and nonclinical areas and processes in-house and out sourced. Here tools like hazard identification (HIRA), Failure mode analysis (FMEA) are used. Management ensures patient-safety aspects and proactive risk management across the organization through Risk management plan once in a year.  Management provides resources for proactive risk assessment and risk reduction activities. Keep sufficient resources as contingency which are used to take preventive actions whenever feasible.  Management ensures integration between quality improvement, risk management and strategic planning within the organization. The management ensures that strategic planning & Quality Improvement incorporates risk management aspect in its strategic plan.  Programme covers incidents ranging from no Harm to sentinel events. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 37 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The defined programme is coordinated by privileged patient safety officer. Programme is implemented by clinical safety officer in the clinical domain and safety officer in the non- clinical domain. A safety team is formed for safety drive in the organization.  The patient-safety programme identifies opportunities for improvement through- 1. Report of facility inspection rounds/ clinical rounds 2. Patient safety incidents. 3. Analysis of key-safety indicators. 4. Safety Audits In Safety committee meeting is conducted every month to review implementation and effectiveness of the safety program and documented accordingly. Safety committee meets once in a three month to co-ordinate development, implementation, and monitoring of the safety plans. Plans are implemented and reviewed monthly.  Monthly review of implementation of Safety programme identifies opportunities for improvement. Analysis is done by using tools like HIRA, FMEA. For continued effectiveness and results are communicated to the relevant stakeholders.  The patient safety programme is reviewed and updated once a year. Yearly safety plan is finalized. 1. Composition of Safety Committee Chairperson: Medical Director Members Secretary: Clinical safety Officer and Safety Officer Members- 1. Medical Administrator 2. Nursing Superintendent 3. Human Resources Manager 4. Quality Head 5. Infection Control Consultant 6. Anesthetist Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 38 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Champions meet every month to review implementation and effectiveness of the safety program.  Safety Champion: safety champions support drive of safety in the organization. Clinical and non-clinical staffs are identified and developed in the organization. 1. In charge – Engineering and Maintenance 2. In charge – Security Services 3. Bio medical In charge 4. Housekeeping In charge 5. Service line managers 6. Canteen In charge 7. Radiation Safety Officer (RSO) 8. In charge – Radiology 9. Laboratory In charge 10.Asst. Nursing Superintendent 11. Pharmacy In charge 12. Blood Bank In charge 13. ICN Responsibility of Clinical Safety Officer –  To prepare of safety plan & program and review of adherence of same.  Patient Safety program monitoring and adherence  Radiation safety policies and procedures compliance.  Laboratory safety policies and procedures compliance.  Oversee pro-active risk assessment in both clinical and non-clinical processes and areas using tools. For example: Hazard Identification and Risk Analysis (HIRA) and Failure Mode and Effects Analysis (FMEA).  Monitoring, management and prevention of Incidences, Near miss, adverse events Sentinel event related to safety.  Device a systematic course of action for analysis of all safety related incidents within a specified time frame and formulate recommendations for implementation.  Ensure education and training to support safety. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 39 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Conduct safety audits, assessments and present reports for taking corrective action.  Emergency codes and conduction Mock-drills. 2. Incidence - The program covers incident management system ranging from \"no harm\" to \"sentinel events\"(Quality manual) which includes:  Identification  Reporting  Review, and  Action on incidents. All incidents are captured and are reported in the incident reporting form and submitted to the Quality Department. 3. Indicators- The hospital has identified a list of key indicators and monitors these key indicators to oversee -  the clinical structures, processes and outcomes;  infection control activities  the managerial structures, processes and outcomes  patient safety activities  A system exists for data capturing, analysis and monitoring of Quality Indicators in the hospital. NATIONAL SAFETY GOALS The organisation observes national patient-safety goals 2022. Total 7 are as follows – 1. Improve the accuracy of patient identification. 2. Improve staff communication. 3. Use medicines safely. 4. Use alarm safely 5. Reduce the risk of healthcare-associated infections. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 40 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 6. Identify patient safety risks in the hospital. 7. Prevent mistakes in surgery. 1. Improve the accuracy of patient identification.  Accurate patient identification is essential. It is the responsibility of all staffs who involved in patient care to ensure they are providing correct care to the correct patient every time.  Patient identification process is uniform in all care settings.  Unique identification number [CR] is generated at time of registration for each patient.  Two identifiers are used for care related aspect. - o Patient name o CR Number  Patient identification few of the opportunities are : o Whenever administering the medication. o Before administering blood and blood products. o Before providing any treatment or procedure to the patient. o While Transferring patient to and from for procedure or diagnostics o While collecting blood sample, etc.  There will be ID wristband on every patient admitted in the hospital, it mentions: - Patients full name. (Including father and mother’s name) - Age /Gender - CR NO (UHID). - Date of admission.  If an ID wristband is removed, it is the responsibility of the person who removed it, to replace it immediately  It is responsibility of every staff of the hospital to ensure ID band is present with the patient throughout his/ her stay.  If a patient is unable to communicate for themselves, as they are too young, confused, or don’t understand the local language, it is especially important these patients have an ID wristband to facilitate identification. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 41 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Don’t rely on patients to correctly identify them if you are giving them the name to confirm. Some patients will agree to absolutely anything you say to them, due to anxiety, deafness, confusion etc. 2. Improve staff communication.  Organization has developed a policy for effective communication. it is documented in each manual. All staffs are trained for the same. Also special situations are identified and how to do effective enhanced communication is documented. Effective communication is mapped from incidences, and feedbacks.  Standardized communication tools are used amongst the staff are –  ISBAR- Handing and Taking over tool used for communication need to start.  Critical results of tests and diagnostic procedures that fall significantly outside the normal range and may indicate a life-threatening situation are communicated established time frame for further management of the patient.  The hospital has established Verbal order policy which is followed in emergency situation while treating the patient. Verbal/telephonic orders must be repeated and ensure that the listener is properly heard and understood the communication. This is called as read back policy.  Informed consents are duly explained to the patient before taking their signature.  Patients are counseled at regular intervals during the course of treatment and same is documented in counselling forms.  At time of discharge staff provide the patient with information on discharge diagnoses, treatment plans, medications, and test results & follow up advice. 3. Use medicines safely. Safe medication Practices are adopted in the hospital as follows  Medication prescriptions are written legible  Medication orders explain the all parameters of prescription.  Prescription is generic, capital and abides formulary.  Test dose policy followed. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 42 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Medication orders are written details of dilution solution with specification of how much time to be infused in case of high risk medication.  Patient’s history taken for drug allergy.  Drug orders are transcribed properly.  Medication reconciliation is considered during each transit.  Storage of medication done as per policy.  Medications are administered by privileged staff.  07 Rights of medication administration are known & followed.  High risk medication are identified & policy for its safe use is implemented  Near Expiry medication policy is implemented  Multi dose vial policy followed  Medications are stored as per the manufacturer’s guidelines  Medications are labelled before administration to the patient  Medication administration is documented & signed  IV fluids are labelled appropriately with additives when on flow for the patient  When patient is on anticoagulant therapy/High risk medications necessary monitoring is done  Emergency medication list is identified & implemented in form of crash cart to all patient care areas and available easily when asked.  Self-administration is not allowed.  Policy for Medications brought from outside pharmacy is implemented  Medication recall policy is implemented.  Food-drug and Drug-Drug interaction is considered in patient treatment  Blood transfusion is followed as per the procedure.  Narcotic medication policy is followed in case the patient on narcotic medication.  Patients and family are educated on side effects of the drugs.  Implants are procured as per the procedure, from an authenticated vendor with scientifically selected. (FDA approved)  Measures are taken to avoid catheter and tubing miss-connections during medication administration. 4. Use alarm safely Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 43 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Make improvements to ensure that alarms on medical equipment are heard and responded to on time.  To make sure equipment’s alarm is in working condition.  Medical gases alarm, fire alarm is in working condition.  All staffs are aware of the alarms system and respond on time.  To check all the above daily checklists are maintained. 5. Reduce the risk of healthcare-associated infections.  Use the hand cleaning guidelines from the World Health Organization. Set goals for improving hand cleaning.  Adherence to hand hygiene guidelines. Staffs are known to steps of hand hygiene and 5 movements of hand hygiene. Staffs are following hand hygiene guidelines throughout during the patient care.  Adherence to safe injection and infusion Care bundles are followed during catheter associated urinary tract infection.  Care bundles are followed during CVP line associated infections  Care bundles are followed for Ventilator associated infections  Prerequisites for infection controls are adhered to during surgery (Preoperative area preparation, prophylactic antibiotics, Sterilization stickers, proper scrubbing, aseptic techniques during surgery, etc.)  Surgical dressings are performed under strict aseptic technique.  GAIMS has a documented safe injection and infusion practices. 6. Identify patient safety risks in the hospital. Proactive Clinical Risk assessment: It is captured during assessment of the patient.  Appropriate score is assessed for Morse scale in assessment on admission and reassessment daily to identify the risk of patient fall.  Prone to clinical risk patients are priorities in the screening at OPD and accident emergency area. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 44 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  To identify risk of bedsore Braden scale is followed.  Sedation, anesthesia risk is monitored as per ASA scale  During labor partogram is used to monitor risk.  EWS is captured.  Risk of DVT is captured. Proactive risk management non-clinical. Risk is mitigated by providing safe facility aids  Patient’s side rails are up.  All wheel chairs are having safety belts.  All patients’ beds are having railings.  All patient shifting trolleys are having railings and stopper.  Staffs are aware of the safe transportation of patients.  Toilet floors are anti-skid, clean and dry.  To reduce the risk for suicide, window grills are in place, patients are always accompanied with relatives in the wards.  Restraint policy is adhered to prevent harm to self and to the healthcare workers. 7. Prevent mistakes in surgery.  Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.  Site marking to be done on the where the surgery is to be done.  Ensure proper preoperative checklist.  Procedure explained to the patients by operation surgeon  Call out is done in front of surgical team before induction of anesthesia.  Surgical safety /Procedure safety checklist is followed at each step of surgery. LABORATORY SAFETY Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 45 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  There is an established laboratory safety program in GAIMS hospital. (Laboratory Safety manual)  It ensures safety of workforce and equipment.  It is in consonance with identified risks and hazards.  It incorporates material safety and data sheet (MSDS).  Staff are trained for laboratory safety and safety in the laboratory department  Laboratory safety program is monitored through Audits & safety Indicators. RADIATION SAFETY  The radiation-safety programme is implemented and documented in radiation safety manual & Radiology manual.  It is available in the radiology department & radiation areas in the hospital.  It ensures safety of workforce and equipment.  It is in consonance with identified risks and hazards.  It incorporates material safety and data sheet (MSDS).  Staff is trained for radiation safety & safety in radiology department.  Radiation safety program is monitored through Audits & safety Indicators. CLINICAL SAFETY  Clinical policies and procedures are defined for different clinical topics and are incorporated in the manuals. Continues training in given to staff.  Clinical audits, Clinical pathways are developed, implemented and audited periodically to check the compliance as per the standard clinical guidelines.  Privileging and credentials of stake holders are documented in the HR. it is taken care that patient care staff is privileged.  Care givers undergo hospital and dept. induction, job description is made clear to each designation.  Skills are mapped and training needs are identified. Continues training is arranged.  Forms and formats, checklists are prepared to avoid mishaps trainings are given, champions are sensitized for monitoring compliance. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 46 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL MONITORING SAFE AND SECURE ENVIRONMENT THROUGHOUT THE YEAR 1. Patient safety devices and infrastructure Installed across the organization and checked periodically –  List of patient safety devise in the organization ( grab bars, bed rails, sign posting , safety belts on stretcher and wheelchairs , alarms both visual and auditory, warning signs like radiation and biohazards, fire safety devices)  Regular inspection for checking – monthly  Preventive maintenance as per schedule 2. Facility available for differently abled and maintained - facility round checklist. 3. Identify the potentially risk in the organization Risk register, risk identification and risk control for all dept. 4. Operational security plan which identifies areas for extra security and describes  Access to different areas in the hospital by staff, patients, and visitors.  Potential security risk areas and restricted area are Identified & monitored as checkpoints.  List of access to different areas.  Signages are checked on monthly basis for restricted area. 5. Facility plan and budget to upgrade/replace for Key systems, Buildings-yearly budget. 6. Provisions are made for physically challenged, visually impaired and mentally impaired person for special toilets and wheelchair accessible entrance. 7. Facility inspection round in patient care and non-patient care area monthly for identification of potential safety risk.  Potential security risk areas and restricted Ares are identified and monitored.  Hazard identification and risk analysis during the facility round with checklist.  Budgets preparation – budgets are prepared for upgrading or replacing key system, building or components.  Facility inspection reports are reviewed monthly by the safety committee and appropriate corrective actions are taken.  Compliance report and review in monthly safety committee. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 47 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 8. Risk assessment - Construction / renovation – Risk assessment is carried out before the commencement of renovation and expansion of the facility through infection control risk assessment tools (ICRA ) form for noise, vibration and infection Control for new commencement or renovation or expansion of the facility through work permit. 9. Hospital Facility and environment are operated in a planner manner and promotes environment friendly measures environment safety plan  Facility and space provision are appropriate as per the regulatory requirement  Compliance of statutory norms for building and facility – monthly statutory tracker sheet.  A designated person maintains updated site layouts, floor wise drawings, fire evacuation plans, and separate civil, electrical, plumbing and Medical oxygen pipe drawings as per statutory norms.  Internal and external sign postings are displayed bilingually as per statutory requirements in a manner understood by patient, families and community.  List of display  Monthly check for all signages – repair and maintenance. 10.Structural safety: The hospital ensure patient safety aspects in terms of structural safety of hospitals especially of critical areas are considered while planning, design and construction of new hospitals and re-planning, assessment and retrofitting of existing hospitals. Facilities are updated accordingly. 11. Safe and potable water available round the clock. 12. Alternate sources availability backup for any failure/shortage.- Daily check 13. Safe & Adequate electricity available through the year. 14. The hospital takes initiatives towards an energy-efficient and environmentally friendly hospital. Hospital focus on efficient and sustainable use of energy, water and other utilities for promoting the basic concepts of green hospital. 15. Operational security plan is defined to security and access in different areas in the hospitals for staff, patients and visitors. 16. Hazardous materials are identified and used safety in the organization. MSDS sheets are maintained in all departments. Spillage management plan of hazardous material is implementing through defined policy and procedure. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 48 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 17. The hospital has a program for facility, engineering support services and utility 18.The hospital has aligned program for medical gases, vacuum and compressed air with patient safety program. 19. The hospital plans for medical equipment, utility equipment & bio medical equipment in accordance with its services and strategic plan. Considering future requirements. Equipments are selected, rented updated and upgrade by a collaborative process. 20. The hospital has aligned program for medical gases, vacuum and compressed air with patient safety program. 21. Monitoring of all safety related incident and preventive action plan. 22.Service continuity plan - To maintain service continuity of critical operations. RECORD: SAFETY PLAN CLINICAL SAFETY PLAN 2022 Sr. No. CONSENT FREQUENCY 1. Yearly The patient-safety programme is reviewed and Monthly 2. updated Monthly Clinical Patient safety round for proactive 3. analysis of patient safety risks and makes Once in 4 months improvements accordingly in Clinical areas Once in 4 months Safety committee Meeting QUALITY ASSURANCE 4. Quality assurance program of Radiology, Lab & Blood Bank 5. QA program for Critical Areas (ICU, NICU, PICU, OT) DEPARTMENTAL CLINICAL AUDIT Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 49 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 6. Clinical audit-medicine Once in 6 monthly 7. Clinical audit-surgery Once in 6 monthly 8. Clinical audit- ortho Once in 6 monthly 9. Clinical audit- gynec Once in 6 monthly 10. Clinical audit- pediatric Once in 6 monthly 11. Clinical audit-medicine Once in 6 monthly CLINICAL SAFETY AUDIT 4 Monthly 12. Doctors & Nurses Handover Communication 4 Monthly 13. Informed Consent Audit 4 Monthly 14. Braden & Morse scale in assessment 4 Monthly 15. Audit on Care of Vulnerable Patients 4 Monthly 16. Administration of Medication 4 Monthly 17. Audit on patient identification Bi Monthly 18. Medication storage Monthly 19. Critical result reporting - lab Monthly 20. Prescription Audit Monthly 21. Uses of alarm safely audit Monthly 22. Narcotic drug and usage audit Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 50 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 23. Moderate Sedation Monitoring Monthly 24. Adherence to Verbal order policy Quarterly SURVAILANCE AUDITS Monthly 25. Hand hygiene surveillance Monthly INDICATOR Monthly 26. Radiology safety indicators Monthly 27. Laboratory safety indicators Monthly 28. Patient Identification Monthly 29. Medication Error Monthly 30. Adverse Drug Reaction Monthly 31. Blood transfusion Reaction Monthly 32. CAUTI Monthly 33. CLABSI Monthly 34. VAP Monthly 35. SSI Monthly 36. Incidences of phlebitis Monthly 37. Monitoring Pressure Ulcers 38. NSI Signatory Prepared by Reviewed by Approved by Name Designation Signature