Operational Excellence bolstered by Quality Assurance is critical to sustain high performance and customer satisfaction. When it comes to choosing a medical centre, clinical excellence is probably the most vital and differentiating factor for people. Hence we have adopted a policy of ensuring the best Quality Management systems for the benefit of all our customers. They include :

>>    Accreditations (Planning stage)

>>    NIMS Infection Control Program (planning stage)

The Quality Assurance and Clinical Excellence at NIMS Hospitals will be ensured by implementing the various global accreditation programs. In addition, we will be deploying various internal quality control systems based on TQM that address quality, infection control, patient safety, and evidence based clinical processes.

NIMS will be seeking major accreditations such as those described below as part of our relentless pursuit of excellence.

The Joint Commission International (JCI) is a U.S based accreditation body dedicated to improving healthcare quality and safety around the world. The accreditation is an international gold standard for hospitals.

JCI works directly with healthcare organizations to achieve their goals of providing quality clinical care and services in safe, efficient, and well-managed facilities. JCI assesses through a rigorous on site survey process, a healthcare provider's quality in the following key areas -

>>    Access to health care

>>    Health Assessment and care processes

>>    Education and rights of individuals

>>    Management of information and human resources

>>    Safety of facility

>>    Infection control

>>    Collaborative integrated management

>>    Facility management

>>    Performance Measurement

>>    Education & Rights of Patients

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programs for healthcare organizations. The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry.

National Accreditation Board for Testing and Calibration Laboratories (NABL) is an autonomous body under the aegis of Department of Science & Technology, Government of India, and is registered under the Societies Act 1860. NABL was established with the objective to provide Government, Industry Associations and Industry in general with a scheme for third-party assessment of the quality and technical competence of testing and calibration laboratories. Government of India has authorized NABL as the accreditation body for Testing and Calibration Laboratories.

In order to achieve this objective, NABL provides laboratory accreditation services to laboratories that are performing tests / calibrations in accordance with ISO/IEC 17025:2005 and ISO 15189:2007 for medical laboratories. NABL accreditation system complies with ISO/IEC 17011:2004 and Asia Pacific Laboratory Accreditation Cooperation (APLAC) MR001. Based on evaluation of NABL operations by APLAC in 2000, NABL has been granted signatory member status by APLAC and International Laboratory Accreditation Cooperation (ILAC) under their Mutual Recognition Arrangements (MRAs). Under these MRAs, the reports issued by NABL accredited laboratories are considered to be equivalent to reports issued by laboratories accredited by (currently) 76 accreditation bodies in 64 economies. NABL has undergone re-evaluation by four member APLAC evaluation team in July 2008. APLAC/ILAC has recommended NABL's Mutual Recognition Arrangement (MRA) status for further four years with extension of scope for Medical Testing laboratory as per new international standard ISO 15189:2007.

The International Organization for Standardization (ISO) is a network of the national standards institutes of 151 countries, on the basis of one member per country. A Central Secretariat based out of Geneva, Switzerland, co-ordinates the system. NIMS Hospitals, Chennai was the first hospital in India to be awarded an ISO 9002 certification.

The ISO 9000 series is concerned with 'quality management'. It is a certification affirming the organization's ability to enhance customer satisfaction by meeting customer and applicable regulatory requirements and continually to improve its performance in this regard. The ISO standards are a guarantee of quality across boundaries and geographies. They are an assurance to the international patient of the safety and reliability of NIMS's services against global benchmarks.

NIMS Hospital has a robust infection control program designed with the understanding the control and prevention of infection in our patients and the staff who care for them, is an absolute moral commitment and responsibility. Therefore, we have designed a comprehensive infection prevention and control program.

The Infection Control program covers policies on hand hygiene, occupational health, isolation, infectious diseases notification, clinical sample collection, environmental hygiene, antibiotic usage and infection prevention in practice settings and visitor areas. It also focuses on prevention of nosocomial infections especially ventilator associated infection, surgical site infections, UTI and Intravascular device related infections and also on control of communicable diseases by policies on patient care related activities. The policies and guidelines laid down are evidence based on current scientific knowledge and recommendations from National and International societies and organizations.

The Infection Control program is supported by information management in relation to microbial surveillance and notifiable diseases. Guidelines for periodic audits are also provided so that evaluation and quality control is undertaken. The overall aim of the Program is to guide doctors and health care workers on minimizing patients' infection risk and ensuring safety.

Standard or Universal Precautions to ensure safety of healthcare worker.  Practice of Universal and Standard Precautions, will be stringently followed. Orientation and teaching/training programs will be carried out at the time of induction and on a regular basis for all employees on Standard Precautions and also on key Infection control norms such as Hand Hygiene practices. Our Staff health policy ensures that all staff are vaccinated or has immunity to Hepatitis B and Varicella. Screening and appropriate vaccination of food handlers will also be ensured.

Hand Hygiene Initiative.  Safe water supply in all patient care areas for hand washing and alcohol based hand rubs at all patient beds will be ensured and vigilant observational audits will be performed periodically to ensure high compliance to hand hygiene at patient care areas.

Use of Clinical practice guidelines and protocols.   Guidelines are followed for usage and care of intravascular devices, catheters, and in the usage of other such invasive devices. Care of equipment, linen disinfection, air conditioning for operating rooms and CCUs as well as management of blood spills and needle stick injuries is done according to International protocols. We also have an established waste management policy and lab safety program.

Management of antibiotic resistance in microorganisms – the antibiotic stewardship program.   With advent of newer antibiotics there has been a steady rise in the incidence of antibiotic resistance. While antibiotic resistance is a worldwide phenomenon, the nature of antibiotic resistance varies globally. To curb this vicious trend, this is an important aspect of our Infection control program. We will be following an Antibiotic Stewardship program wherein antibiotic prescription, dosage and appropriateness are strictly monitored and rationalized and resistant organisms identified, tracked and followed up meticulously. We also have stringent guidelines on antibiotic use and procedures on monitoring antibiotic use, as well as protocols for isolation of those affected with such organisms.

Isolation protocols.  Communicable disease identification and prevention of spread is outlined, and so are isolation protocols and procedures and barrier nursing.

Environmental sampling.   Environmental monitoring of Operating rooms, Critical care units, and other patient care areas will be conducted through air sampling. Additionally, disinfection and sterilization processes will be monitored, drinking water and dialysis water analysis will be done and food safety standards and guidelines will be laid down and followed.

Visitor Control.  We have a visitation protocol and all visitors are alerted on infection control practices through guidelines written on visitor passes.

Tracking Infection control data.  All our centers can track infection control parameters and these will be benchmarked with standards and variations and values are thoroughly analyzed. Periodically clinical studies on infection control, pathogens and other related areas will also be carried out .All infection control parameters will be tracked as part of the NIMS XL CLINICAL EXCELLENCE initiative of NIMS hospitals where key Quality parameters of each centre is entered on an Online Dashboard, scored and reviewed by the highest Leadership of the group each month.