Sample In-Service
Training Module
Quality and Safety Policy
Introduction to ISO 9001-2008
ISO stands for the International Organization for
Standardization. It is an international standard for
Quality Management System (QMS) and is
recognized worldwide.
AKUH has been certified on ISO-based Quality
Management System since 1998. Our current
certification is on ISO 9001:2008 which was
achieved in 2009. Our next recertification is due in
May/June 2012.
Under ISO 9001:2008, following are the main
requirements:
Quality Management System
Management Responsibility
Resource Management
Introduction to JCIA
Joint Commission International Accreditation
Its mission is to improve the quality of health care
in the international community by providing
accreditation services
AKUH got JCI Accreditation in 2006 and was
reaccredited in 2009
Our next reaccreditation survey is due in Aug./Sep.
2012
In 2012, we will be surveyed against the 4th edition
of JCIA Standards for Hospitals.
JCIA Standards are grouped under 14 chapters with
315+ standards and 1020+ measureable elements
Division/Department Process
Approach Model
Environment of Care
Safety
Management
Utilities
Management
Fire Safety
Management
Security
Management
Patient-Care
Medical Equipment
Management
Emergency
Management
Hazardous
Materials & Waste
Management
FIRE SAFETY
MANAGEMENT
Fire Safety and Evacuation
In case of Fire incident, follow R.A.C.E.
Rescue
Alarm
Contain
Extinguish
Patients and others
Pull Fire Alarm and Dial 1600
Close doors and windows
If safe to do so, otherwise
Evacuate
To use a Fire Extinguisher, remember P.A.S.S.
Pull/Push
Pin/Clip
Aim
fire
Squeeze
Sweep
the Safety
the nozzle at the base of
the handle
from side to side
EMERGENCY
MANAGEMENT
Emergency Color Codes
Type Of Emergency
1. Disaster (Patient Influx)
2. Fire
3. Evacuation
4. Bomb Threat/Search
Color Code
Orange
Red
Green
Black
5. Nuclear/Chemical Contamination
Yellow
Blue
6. Cardiac Arrest/Medical Emergency
Pink
7. Infant/Child Abduction
Types of Emergencies
EXTERNAL
EMERGENCIES
INTERNAL
EMERGENCIES
Extremes of
Weather/Natural
Disaster
Fire
Terrorism/Bio-Terrorism
Fire
Loss of Environmental
Support
Loss of Medical Gases
Transport Accidents
Bomb
Threat/Explosion
Civil Disturbance
Acts of Terrorism/BioTerrorism
Hazardous Material
Release
Evacuation of
Natural Disaster
Strikes and Pickets
HAZARDOUS
MATERIALS
& WASTES
MANAGEMENT
Hazardous Materials & Waste
Never work with a chemical without first
understanding its hazards;
Always read chemical label and MSDS for
necessary information and follow safety
measures;
MSDS (Material Safety Data Sheet) provides
detailed chemical information;
Label gives pictorial and written brief
information;
Explosive Flammable
Toxic
Irritant
Corrosiv
Hazardous Materials & Waste
Always label secondary containers with
chemical name and its hazard.
Ensure spill kit are properly located
in the area, fully filled and staff
knows
how and when to use
these kits.
Ensure proper waste segregation at
source normal waste in
green liner and infectious waste in red liner.
Classification of Hospital
Non-medical
waste
(Domestic)
Medical
Waste
(Infectious)
SECURITY
MANAGEMENT
SMOKING IS PROHIBITED AT
AKU
AKU IS A WEAPON FREE
HOSPITAL
AKU HAS A ZERO TOLERANCE
POLICY ON WORKPLACE VIOLENCE
Code 10
(If patient becomes
violent)
Code 10
Alpha
(If visitor becomes violent)
Panic Alarm System
Panic Alarms are installed at around 42
inpatient and Cash Handling areas.
Panic Alarm Response Time is 3 minutes
Emergency Response Team
ERT Responding to Panic Alarm
Emergency Response Time is 3 minutes
How Can We Enhance Our
Security?
We must;
Keep our work areas secure.
Monitor access control in our work areas.
Safeguard our equipment.
Report all security emergencies, incidents,
suspicious activity or persons at EXT 1900
Wear our ID while at work.
Follow traffic and parking regulations.
Some Other Potential Topics
(where applicable)
Required Infection Control practices
Radiation safety
Medication safety and storage
Temperature monitoring of refrigerators
Any special hazards/risks in the area and related
protection.
Utilities and Medical Equipment management.
