Safer care through measurement, learning, and improvement

Quality & Patient Safety Cell
NIMHANS

We enable system-wide quality improvement, patient safety surveillance, clinical audits, and accreditation readiness through standards-driven governance and data-informed action.

Incident Learning
Reporting • RCA • CAPA
Clinical Audits
Sampling • Scoring • Action
KPI Monitoring
Trends • Dashboards • Alerts
Accreditation
NABH • Training • Evidence
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Shortcuts for clinicians, nurses, and staff.


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About the Cell

The Quality & Patient Safety Cell supports hospital-wide quality governance, patient safety incident learning, performance measurement, audit cycles, and compliance documentation. Our approach is practical: define standards, measure reliably, learn quickly, and improve sustainably.

Mission

Reduce preventable harm and variability by enabling a learning health system, strengthening safety culture, and ensuring evidence-backed quality improvement across clinical and support services.

Measure Learn Improve Engage

Core Services

Key capabilities offered to clinical and support teams.

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Incident Reporting & Learning

Capture near-misses and adverse events, enable triage, RCA, CAPA, and transparent learning loops.

Clinical & Process Audits

NABH-ready audit tools, sampling logic, compliance scoring (Yes/No/NA), and corrective action tracking.

KPI Measurement & Dashboards

Definitions, data validation, run charts, and governance reporting for quality indicators.

Training & Safety Culture

ISBAR documentation, hand hygiene, medication safety, and unit-based quality training support.

Policy & SOP Support

Standardization, document control, evidence readiness, and policy harmonization across services.

Accreditation Readiness

Gap assessments, internal audits, documentation support, and structured preparedness for assessments.

How We Work

A standard improvement loop to ensure changes are measurable and sustainable.

Define

Clear definitions (denominator/numerator), ownership, and measurement frequency.

Measure

Reliable data capture with validation checks, exclusions, and audit trails.

Learn

Trend review, incident learning, and root-cause analysis when needed.

Improve

CAPA and PDSA cycles with accountability, timelines, and verification.

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Featured Focus Areas

Rotate focus themes to accelerate shared learning and reduce harm.

Medication Safety
High-alert meds • LASA • Storage
Infection Prevention
Hand hygiene • Bundles • Surveillance
Patient Identification
Two identifiers • Specimen labeling
Documentation Quality
ISBAR • Legibility • Timeliness

Quality Governance

Structured reviews to close the loop from data to action.

Minutes & Actions
Monthly KPI Review
Trend • Outliers • Actions
Incident Review
Learning • RCA • CAPA
Audit Closure
Corrective actions verified

Resources

Downloadable tools, templates, and reference materials (placeholders).

Incident Reporting Guide
How to report • What to include
Audit Checklists
Yes/No/NA • Notes • Scoring
KPI Definitions
Numerator • Denominator • Exclusions
ISBAR Pocket Cards
Unit-adapted documentation aids
Policies & SOPs
Patient rights • Safety • Documentation
Training Slides
Orientation • Refreshers • Posters

FAQs

Common questions (placeholders you can edit).

Use the Incident Reporting Portal. Provide what happened, when/where, who was involved, immediate actions taken, and any contributing factors. Reporting is for learning and improvement.
No. “NA” items are excluded from compliance calculations. Only valid Yes/No responses are considered.
KPI data validation typically includes definition checks, logic checks, missingness/outlier checks, source-trace audits, and reconciliation against primary records before publishing.
Yes. Submit a request through the dashboard or contact the QPS Cell. We can support audit planning, tool setup, training, and closure tracking.

Contact

Replace with official email/phone/room details as needed.


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