Eye Hospital : Documented policies and procedures for maintaining confidentiality, integrity and security of records, data and information

 

Documented procedures exist for maintaining confidentiality, security and integrity of information as mentioned below.

SOP for maintaining Confidentiality, Security and Integrity of information.
Sr. No.	Process Flow	Responsibility
1	The patients are the owners of their medical record and in no form it should be made available to any third party without written authorization from the patient. Medical records are stored by the staff. Access to the Medical Record is limited to authorized staff.	Asst. Manager /Receptionist
2	The patient’s relatives require written authorization from the patient to obtain information from the medical record. The administrator or members of the Quality team (for audit reasons), or court-of-law or police (for legal reasons) may have access to information within medical record with an approved written request. The patients and the TPAs (for financial reasons) are given,(if needed) Xerox copies while retaining the original with the establishment.	Asst. Manager & Staff
3	Once the patient is discharged from RDEH, the medical records are stored in the Hospital.	Asst. Manager
4	The Reception Staff is responsible for proper storage, retrieval, and maintenance of confidentiality and security of the record.	Reception Staff
5	The Administrator is the overall supervisor of the medical records, from generation, storing, until destruction. All the staff members are equally responsible for maintaining integrity of the record while generating or handling it.	Asst. Manager & All Staff
6	The record means both in paper or digital form whether they are generated inside or sourced from outside. The integrity, confidentiality needs to be maintained in both the cases.	Asst. Manager
7	The Staff is informed that the record is the property of the RDEH and cannot be parted with to anyone at any cost. In case of violation, legal action can be initiated. Management views any violation with zero tolerance and staff is made aware about this policy.	Asst. Manager

 

Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization. This information is useful while executing treatment plan and various precautions to be taken during this process.

Eye Hospital : Documented disciplinary and grievance handling procedure.

 

Disciplinary & Grievance Handling

General:

 

The hospital’s policy is to ensure fair and effective arrangements exist for dealing with disciplinary matters and common practices are observed for all employees.  The procedure covers unsatisfactory conduct, unsatisfactory work performance, if this is willful or caused by carelessness.   This Disciplinary Code aims to:

1.  Promote efficient and safe performance of work.

2.  Maintain good employee relations within the hospital.

3. Help and encourage staff to achieve and maintain the appropriate standards of conduct.

 

Procedure:

Informal Action:

1. Minor faults are dealt with informally by way of advice, coaching, counseling or training as appropriate. Examples of such offences would include isolated instances of poor time keeping, unauthorized absence or non-compliance with sickness notification rules.
2. The immediate superior would normally have responsibility for bringing the matter to the attention of the Medical Director and discussing it with them. Generally, this will resolve the problem without recourse to the formal disciplinary process.
3. The member of staff should be advised clearly of the standard of behavior expected of them and informed that if he/she does not improve then they will be subject to formal disciplinary action as set out below.

 

Formal Action:

 

1.   In respect of matters that are more serious than minor breaches of conduct, a memo is issued by the Medical Director and a written explanation is sought from the employee within 5 days.

2.   In case the Medical Director is not satisfied with the explanation received, second Memo is issued and employee is expected to submit a written explanation within 2 working days. The same step is followed in case the employee doesn’t submit a written explanation within the defined time frame.

3.   In all maximum three Memos are issued to the employee.

4.   The disciplinary action against employees is taken.

5.   In case the employee doesn’t turn up with an explanation or the explanation received is not satisfactory even after three Memos then the employee is given Show Cause Notice.

6.   The employee is required to respond to the notice within seven days.

7.   In case the employee does not respond to the Show cause notice or the explanation furnished by the employee is unsatisfactory, then appropriate disciplinary action is taken.

 

Rights of Employees

 

All the employees have following rights.

1.  The right to have written notice before a decision or disciplinary action is taken.

2.   Right to be represented

3.   Right to receive written confirmation of any penalty imposed.

4.   Right to appeal to higher authorities against any action taken.

5.   Right not to be physically punished, called by race, creed etc,

6.   Right not to be discriminated on the basis of religion, caste, creed, sex, etc.

 

Grievance Handling Mechanism  

General:

 

The objective of the grievance redressal procedure is to provide easy accessible machinery for settlement of grievances and to adopt measures in organization that would ensure expeditious settlement of grievances of employees leading to increased satisfaction on the job and resulting in improved productivity and efficiency of the organization.

  

Grievance:

 

‘Grievance’ for the purpose of this scheme would only mean a grievance relating to any employee arising out of the implementation of the policies/rules or decisions of the organization. It can include matters relating to leave, internal performance appraisal, acting arrangements, non-extension of benefits under rules, etc., of an individual nature.

Procedure:

 

The following is the procedure for handling aggravated employees grievance(s)

 

1. An aggrieved employee shall take up his grievances orally with his immediate superior who will give a personal hearing and try to resolve the grievance(s) at his level.
2. If the grievance is not satisfactorily redressed, the aggrieved employee may submit his grievance in writing to the Immediate Superior concerned whose recommendation will be conveyed to the Director and the decision of the Director will be final.
3. The entire process of redressal is documented.

 

 

Issues Not Covered under Grievance: 

 

Grievance pertaining to or arising out of the following shall not come under the purview of the grievance procedure:

1. Promotions 
2. Where the grievance does not relate to an individual employee
3. In the case of any grievance arising out of discharge or dismissal of an employee.

 

Grievances pertaining to or arising out of disciplinary action or appeal against such action shall be channeled to the competent authority, which will be designated by Director. 

 

Eye Hospital : The organization has a documented safe exit plan in case of fire and non-fire emergencies

 

Fire safety management

Safety management is a very important aspect of planning in every form of infrastructure. Safety management as a whole includes aspects of not only fire safety, but also security measures in terms of safety from other unsafe encounters. Safety measures are therefore designed in such a way that safety of all service renderers, service recipients, infrastructure (property, other fixed assets) etc. is ensured.

..............Hospital, as an infrastructure, has many heat-dissipating equipment, combustible gasses / fuel, chemicals, electrical wiring, etc. that are prone to hazardous incidents, if proper precautions are not taken while planning the infrastructure. Adequate measures are considered, designed and practiced to ensure safety to all.

..............Hospital has fire safety management plan in place. Fire safety and life safety are crucial issues because of the flammable liquids and gases, lasers and other ignitable material prevalent in a clinic environment. In addition, a fire safety plan is necessary to protect patients who cannot rescue themselves in the event of danger.

How to use a fire extinguisher:

Remember the acronym: “PASS”, that stands for Pull, Aim, Squeeze and Sweep

1)   Pull: Pull the safety pin or clip: this allows the discharge of the extinguisher.

2)   Aim: Aim at the base of the fire. If you aim at the flames, the extinguishing agent will just fly through and will be of no help. Aim at the fuel causing the fire.

3)   Squeeze: Open the top handle or lever. This depresses a button that releases the pressurized extinguishing agent.

4)   Sweep: from side to side until the fire is completely put out. Start using the extinguisher from a safe distance, and then move forward. Once the fire is put out, keep an eye on the site in case the fire reignites.

Types of Fires & Extinguishers. All fires are classified as : A ,B , C or D class.

Class of fire	Materials involved	Examples	Extinguisher to be used
A	Combustible materials or organic nature	Wood, paper, rubber, plastics, etc	Water expelling type
B	Flammable liquids, flammable solids	Petrol, diesel, etc	Foam, dry chemical powder,CO2
C	Flammable gases under pressure	LPG	Dry powder and CO2
D	Combustible metals	Magnesium, aluminum, zinc sodium	Extinguisher designed to expel special dry chemical powder

Fire Drills and Training

1.   Each area of RDEH has a site-specific fire and safety plan. All employees working in that area are oriented and trained on the plan.

 

2.   Regular fire drills are held once a year to confirm that the fire safety plan is working correctly. Corrective and preventive action is taken on any deviations observed.

 

Exits

..............Hospital has one exit, on the Ground floor, through the Patient waiting area. There is an emergency exit which are marked prominently and the passage leading to all the exits are marked with radium tape. It is ensured that the exit and passages are not blocked at any point of time. This is verified during safety rounds.

Prevention plan Instructions

1.     Keep all equipment in working order.

2.     Tag all wall sockets and plugs.

3.     Ensure that the fire extinguishers are in working condition.

4.     Keep evacuation plans ready. Prepare detailed evacuation plan including who is responsible for certain areas, Keep copies in places where they can be reviewed by department heads for safety drills/ educational purposes.

5.     The plans are updated as required.

6.     In case of an emergency, safe and rapid egress is provided for all occupants.

7.     Staircases are provided with handrails and other suitable support means to prevent slipping.

Remember: You are not required to fight a fire. If you have the slightest doubt in controlling the situation DO NOT ATTEMPT FIGHTING THE FIRE.

 

Fire emergency check list

Prevention & Evacuation Plans

 

1.        Once the fire alarm sounds or if fire is alerted, prevent panic and ensure safe and orderly evacuation from all departments.

2.        Use all the exit facilities available.

3.        All occupants should gather at parking area of RDEH.

4.        Do not leave the assembled area without informing others.

5.        All fires produce carbon monoxide. It rises within a building before it starts to come down, so always stay low in a heat and smoke filled environment.

6.        If your clothing catches fire:

a)   A person is in greatest danger from fire if his clothes catch fire.

b)   Do not run blindly in panic, as it can cause the fire to spread further.

c)    STOP, DROP & ROLL on the ground to kill out the fire.

d)   If you get a blanket nearby use it to put out the flames.

e)    If you are near a water area, pour water on the fire. Do not pour ice cold water, as it may cause shock. Do not apply ice pads on burns, as it may damage the tissue.

f)     Follow the same process if somebody else is running with their clothes on fire.

g)    If the room is on fire, close all doors and windows. It will help prevent spreading of fire. While entering it, crawl along the floor and keep as close to the floor as possible. Keep close to the wall.

h)    Do not go alone into a building on fire. You can do so in the company of another.

7.        In case you are not able to fight a fire, CALL 101

8.        Give your full name, telephone number, complete address of the spot.

9.        If you are sure, inform the type of fire

10.     While using a fire extinguisher :

a)   Whenever possible, use the "Buddy System" to have someone back you up when using a fire extinguisher. If you have any doubt about your personal safety, or if you cannot extinguish a fire, leave immediately.

b)   Close off the area (close the doors, but DO NOT lock them). Leave the building but relay whatever information you have about the fire.

c)    It is dangerous to walk on an "extinguished" area as there is a possibility that  the fire may reignite or the extinguisher may run out

General care and Maintenance of the Extinguisher

At least once a month the extinguisher is inspected to ensure that:

a)   The access to extinguisher is unhindered.

b)   The pressure is at the recommended level.

c)    The pin and tamper seal are intact.

d)   Check the proper labels.

e)    Ensure the extinguisher is within its expiry period.

f)     Check all mechanical parts thoroughly.