Quality Manual for ISO 9001:2008




Document No. HOPE/QM

Issue No. 1

Revision No. 0

Effective From: 01.08.2007







ISO 9001:2000






Ph. 0712-2556866














Cover Sheet




Content Sheet




Issue History




Revision History of Issue




Introduction, Scope, Exclusion, Approval and Distribution




Hospital Profile




Quality Policy & Objectives




Quality Management System




General Requirements




Documentation Requirements








Quality Manual




Control of documents




Control of Records




Management Responsibility




Management Commitment




Customer Focus




Quality Policy








Quality Objectives




Quality Management System Planning




Responsibility, Authority & Communication




Responsibility and Authority




Management Representative




Internal Communication











Page No.

Rev. No.


Management Review








Review Input




Review Output




Resource Management




Provision of Resources




Human Resources








Competence Awareness & Training








Work Environment




Service Realization




Planning of Service Realization




Customer related processes




Determination of requirements related to service




Review of Requirements related to the Service




Customer Communication




Design & Development








Purchasing Process




Purchasing Information




Verification of Purchased Product/Service




Production and Service provision




Control of Production and Service provision




Validation of Process for Production and Service Provision




Identification and Tractability




Customer Property




Preservation of Service




Control of Monitoring and Measuring Device






Page No.


Rev. No.


Measurement, Analysis and Improvement








Monitoring and Measurement




Customer Satisfaction




Internal Audit




Monitoring and Measurement of Processes




Monitoring and Measurement of Service




Control of Non-Conforming Service




Analysis of Data








Continual Improvement




Corrective Action




Preventive Action




Responsibility and Authority




Hospital Organization Chart




Process Charts










Date of Issue

Issued To

Issue No.

Description of Documents Issued


























Page No.: & Rev No


Page No. & Rev No.

Date of Amendment

Nature of Change

Signature of copy holder & Date




















































































































This Quality Manual describes the Quality Management System, through chapters 4.0 to 8.0 based on the requirements of ISO 9001:2000 which are complementary to the requirements of the services provided, adopted as a strategic decision, implemented and practiced by HOPE MULTISPECIALITY HOSPITAL & RESEARCH CENTER.




The Quality Management System covers all aspects and facets of: “providing multispeciality medical care under one roof especially expertise in managing critical medical emergencies and specialized surgeries”.




The Quality Management System flows out of the Quality Policy and objectives stated in this manual, and is customer- focused & aimed at enhancing customer satisfaction and winning his loyalty. It also meets the regulatory and legal requirements of the service. It uses the process approach, systematic identification and management of activities / processes that are employed through, a sequential process of   Plan -Do -Check -Act   (PDCA) Cycle.


Plan:              It is to establish the objectives & processes necessary to deliver results.

Do:              Implement the processes identified.

Check:  Monitor & measure processes and service against plan & report results.

Act:       Take actions to continually improve process performance.




ISO 9001:2000 Requirements EXCLUSION TABLE



Design and Development (Clause 7.3)

Hospital does not perform design and development activities. It provides the Services, surgery and treatments, which are accepted worldwide in medical circles. Hence the applicability of clause 7.3 is excluded

Validation of Processes for Service Provision (Clause 7.5.2)

Hospital’s Service does not require any process to be carried out on experimental basis. Hence the applicability of clause 7.5.2 is excluded.





The Management approves this Quality Manual and is committed,

·                  To diligently practice the QMS and thus to serve customers with great & prompt responsiveness.

·                  To enhance customer satisfaction by meeting their requirements & expectations besides complying with relevant statutory and legal obligations.

·                  To establish, implement and review the quality policy and its objectives, with a view to ensuring their continuous suitability through improvements as necessary.

·                  To make available all necessary resources including providing an infrastructure of facilities for achieving this purpose.





This Manual, its copies or extract from it, must not be passed on to any person without the written permission of the Proprietor of the Hospital. Unnumbered / Uncontrolled copies may be given to customer / outside agencies purely for information purpose. UNCONTROLLED copies are not covered under “change control” but are current at the time of issue.


Management Representative (MR), appointed by the Proprietor, is responsible for establishing and maintaining the processes of the Quality Management System, for periodically reporting to the management on the performance of the system and for promoting awareness of customer requirements through out the Hospital.


The CONTROLLED copies are covered by “Change Control” and are stamped in red on all pages. It is the   responsibility of CONTROLLED copyholder of this manual to maintain and incorporate all revision on receipt and keep it up to date.

The controlled copy is given to the following:


Master Copy               (with the Proprietor)

Copy no.  1                             (with Chief Executive)

Copy no.  2                             (with Chief Manager)

All the staff members of the Hospital are allowed to have access to controlled copy lying with the Chief Manager.






HOPE MULTISPECIALITY HOSPITAL & RESEARCH CENTER is a MULTISPECIALITY HOSPITAL established in the year 2005 to render various medical services.


The overall management of the Hospital is looked after under the supervision of Dr. B. K. Murli, PROPRIETOR. Further the Hospital also employs qualified and highly experienced people to run its operations. The Hospital has the required infrastructure to render the services.


The Hospital has been following quality management systems stringently, which is clear from the fact that it has been meeting the tough quality standards prescribed by its customers. However now with a view to demonstrate it publicly, it has decided to get it certified as per ISO 9001:2000 standards so that its working team is motivated to maintain quality standards regularly thus resulting in better quality services.


1.              This Quality Manual is the apex document that describes the Quality Management System established and implemented by HOPE MULTISPECIALITY HOSPITAL & RESEARCH CENTER to meet the requirements of International Standard ISO 9001: 2000 and to consistently provide services that meet customer and, where applicable, regulatory requirements. Quality Management System, which is customer focused, aims to enhance customer satisfaction through the effective application of the system and the processes for its continual improvement and the assurance of conformity to customer and applicable regulatory requirements.


2.              This Manual applies to all activities, which contribute to the quality of services provided by the Hospital.





We ensure for our patients:

·                  The highest standards of clinical care.

·                  Safe environment.

·                  Medication safety.

·                  Respect for right and privacy.

·                  International injection control standards.

·                  Access to a dedicated well-trained staff.




The important quality objectives of the Hospital are:

·      To regularly upgrade the quality of services provided by the Hospital.

·                  To provide satisfactory customer service through continuous improvements of service Quality.

·      Achieve, sustain and improve its reputation for excellence in medical treatment by using modern and effective methods.

·      Continuously explore the developments in surgery, medicine and diagnosis and adopt the latest methods and medicines accordingly.

·      Ensure the availability of adequate resources to sustain and maintain the quality assurance programme of the Hospital and continually improve its effectiveness.



4.1         General Requirements


The Hospital has developed and implemented a documented Quality Management System to meet the requirements of ISO 9001:2000 standards. The Quality Management System is implemented by:


a)              Identifying the processes throughout the Hospital including those for management activities, provision of resources, service realization and measurement needed for the QMS.

b)              Determining the sequence and interaction of these processes.

c)              Determining the criteria and methods required to ensure the effective operation and control of these processes.

d)              Ensuring the availability of resources and information necessary to support the operation and monitoring of these processes.

e)              Measuring, monitoring and analyzing these processes.

f)                Implementing actions necessary to achieve planned results and continual improvement of these processes.


The Hospital plans & manages these processes in accordance with QMS. The system also has a framework for controlling processes, which are outsourced.


Main Service Processes:

·       Consultation & Diagnostic Process (ODP & IPD)

·       Operation Process

·       ICU (Intensive Care Unit), Recovery Room, Special ward, General ward, Neonatology Process

·       Pharmacy procurement of medicine and sale process

·       Pathology Process

·       Physiotherapy Process

·       Radiology Process


Support Service Processes:

·       Registration process

·       Insurance cover Patients

·       Stores Process

Outsourced Processes:

·       Meal process

·       House-keeping process


Reference for Service Processes:

              Annexure - C


4.2               Documentation Requirements


4.2.1 General


a.          The organization chart and job specifications of the key personnel define and document the level and responsibilities.

b.          The statement of the organization’s Quality Policy & Quality Objectives provides the basis for QMS.

c.           The Quality Manual, which is established and maintained, details the scope of the QMS and exclusions with justifications.

d.          The Quality Management System enjoins documented procedures as required by ISO 9001:2000.

e.          Documented operating process wherever required by the Hospital, such as Process flow chart and Quality Plans etc.

f.             Quality records as required by standard ISO 9001:2000 (4.2.4) for effective operation and control of activities/processes.

              The procedures describing the logical sequence of activities with necessary control and responsibility are established, documented, implemented and maintained.


NOTE:                The documentation including procedures is based on the size and type of our Hospital, complexity and inter-relation of activities and competence/skill level of personnel. It can be in any form or type of medium e.g. hard copy/electronic media.


4.2.2 Quality Manual

This Quality Manual, which is established and maintained, details the scope of the QMS, exclusions with justifications & documented procedures or reference to them. It also describes the interaction between the processes of QMS.


4.2.3 Control of Documents


All Documents of the Quality Management System are controlled. A documented procedure (QP 4.1) is established to cover the following:


a.              To approve documents for adequacy prior to issue.

b.              To review, update and re-approve documents.

c.              To identify the current revision status of documents.

d.              To ensure that relevant version of documents are available at the points of use.

e.              To ensure legibility, identifiably & irretrievability of the documents.

f.                To identify the documents of external origin & control their distribution.

g.              To prevent unintended use of obsolete documents and suitably identify them, if they are retained for any purpose.


CONTROL OF DOCUMENTS                                                                      QP 4.1


4.2.4              Control of Records


A documented procedure, QP 4.2 is established, for the identification, storage, retrieval, protection, retention-period and disposition of all quality records. Quality records are legible, readily identifiable and retrievable.


Records required, as evidence of conformance to requirements and for effective operation, of Quality Management System are controlled.


CONTROL OF RECORDS                                                                                    QP 4.2




5.1               Management Commitment


Management is committed for the development, implementation and improvement of the Quality Management System through:


a)              Its Communication to all concerned in the Hospital (through internal meetings, display on the notice board, internal circulars, internal audit etc.), the importance of meeting customer as well as regulatory and legal requirements of the service provided.

b)              Establishing of the Quality Policy.

c)              Establishing of the Quality Objectives.

d)              Conducting management review meetings (at least once in nine month).

e)              Ensuring the availability of necessary resources, physical and human, for all activities.


5.2               Customer Focus 


The Management ensures that customer requirements are determined and are fulfilled with the aim of enhancing customer satisfaction. The top management of the company believes that “Organizations depend on their customers and therefore should understand current and future customer needs, should meet customer requirements and strive to exceed customer expectations.” Customer requirements are generated through internal meetings, management review meeting, customer Suggestion / Complaint Form etc.


CUSTOMER SUGGESTION / COMPLAINT FORM                            HOPE /F/5/01


5.3               Quality Policy


The Quality Policy Statement defines the Hospital’s quality policy. Employees are fully briefed about this policy on joining the Hospital and during planned training. All employees are responsible to implement the Quality Policy of the Hospital. The Quality Policy is displayed at prominent places within the Hospital and is controlled.


Management, while defining Quality Policy, considers the following;


a.              It is appropriate to the purpose of the services provided by the Hospital.

b.              It reflects commitment to meet the requirements, and continually improve the effectiveness of Quality Management System.

c.              It has a framework for defining and reviewing of Quality Objectives.

d.              It is communicated and understood by all concerned in the Hospital.

e.              It is regularly reviewed (at least once in a year) for continuing suitability.


5.4               Planning

5.4.1 Quality Objectives


Management has established the Quality Objectives at relevant functional levels within the Hospital.

These objectives are measurable and consistent with the quality policy, commitment to continual improvement and also provide for meeting the requirements of the service.

These objectives are reviewed at least once in a year.


5.4.2 Quality Management System Planning


The Quality Management System is planned to meet the requirement of ISO 9001:2000 and also the Quality Objectives defined by the Hospital. The documented Quality Management System is the result of planning and is in line with the Quality Objectives that the Management sets. The requirement, which the system is meant to meet, are:

1.              Determination of the processes needed for the system and application thereof throughout the Hospital.

2.              Determination of the sequence and interaction of these processes.

3.              Determination of the criteria and method to ensure the effectiveness of the operation and control of the processes.

4.              Making available the requisite resources, human as well as physical, to support the operation & maintenance of the processes.

5.              Monitoring, measuring and analyzing the processes.

6.              Initiating actions to achieve planned results and also for continual improvement of the processes.

The management further ensures that the integrity of the QMS is maintained wherever and whenever any changes to the system are planned & made.



5.5               Responsibility Authority & Communication


5.5.1 Responsibility And Authority


Responsibility and authority are defined and communicated, to all concerned for effective quality management. The responsibility and authority of key persons and organization chart are given in Annexure A & Annexure B respectively.


5.5.2 Management Representative:


Management appoints Chief Executive of the Hospital as a Management Representative, who, irrespective of other responsibilities, is responsible and authorized for following:


a.              To establish, implement and maintain the processes of Quality Management System.

b.              To report to Management on the performance of the Quality Management System and also on any need for improvement.

c.              To promote awareness of customer requirements, throughout the Hospital.

d.              To liaise with external agencies on matters relating to Quality Management System as deemed necessary.

e.              Maintaining the master list of documents and records of all the forms and formats.

f.                Control and disposal of obsolete documents in the Hospital



5.5.3              Internal Communication:


Appropriate communication processes regarding Quality Management System & its effectiveness are established within the Hospital. Management verifies the effectiveness of such communication(s) and ensures that the same leads and contributes to effective Quality Management System.


Internal communication is through display of quality policy at appropriate places, briefing the requirements of QMS during internal meetings, internal memo’s, face to face verbal communication, or communication through telephone etc. Proprietor addresses the staff to build quality culture in the Hospital at regular interval. Use of these tools will depend on the type of activity.



5.6               Management Review

5.6.1 General:

Management reviews the implementation of Quality Management System, at planned intervals (once in nine months) to ensure its continuing suitability, adequacy and effectiveness.

The review covers:

1.              Assessing opportunity for improvement.

2.              Evaluation of the need for changes to the QMS.

3.              Hospital’s Quality Policy.

4.              Hospital’s Quality Objectives.

5.              Customer requirements and expectation.

6.              Resource requirement.

7.              Any other point, which come to the notice of the management.

For this purpose a Management Committee consisting of Proprietor, Chief Executive and Chief-Manager is appointed. Records of management review are maintained.




5.6.2 Review Inputs:

The inputs for the management review include the current performance and opportunities for improvements on the following:

·                 Follow up action from previous reviews.

·                 Result of audit reports.

·                 Customer feedback.

·                 Customer Suggestion / complaint.

·                 Process performance and service conformity.

·                 Resources needed.

·                 Status of Preventive and Corrective Actions.

·                 Planned changes that could affect Quality Management System such as issues related to Quality Policy and Objectives, Technological up-gradation, Training needs, Resource profiles etc.

·                 Continued suitability and effectiveness of Quality System.

·                 Recommendation for improvement.

·                 Any other issue.


5.6.3 Review outputs:             

The outputs from the management review meeting, include actions relating to:

a.              Improvement of the effectiveness of the Quality Management System and its processes.

b.              Improvement of service related to the customer requirements.

c.              Resources requirements/needs.

The proceedings of the Management Review Meetings are recorded in the form of minutes and extracts circulated to concerned functionaries for action.


MANAGEMENT REVIEW MEETING RECORDS                            HOPE/F/5/02

6.               RESOURCE MANAGEMENT


6.1               Provision Of Resources


The Management determines and provide in a timely manner the resources needed:


a.              To implement, maintain and improve the Quality Management System and continually improve its effectiveness; and

b.              To enhance customer satisfaction by meeting the customer requirements.

Resources include doctors, infrastructure, medicines, equipment, consumables, equipments, trained personnel, and process control equipments.


Review of resource requirements is carried out formally during internal meetings, management reviews meetings, resource requirement form and also when any change in courses is required.  The requirements for resources are informally monitored continuously to ensure compliance with statutory regulations, needs and expectations of patients and Industry.


RESOURCE REQUIREMENT FORM                                                                      HOPE/F/6/01


6.2               Human Resources


6.2.1 General


The management ensures that personnel who are assigned responsibilities under the Quality Management System are competent and are suitably qualified on the basis of education, training, skill and/or experience. Competency requirements for various employees have been spelt out by the Hospital.




6.2.2 Competence, Awareness and Training:


The Management takes action to:


a.              Lay down competence requisites for personnel performing activities affecting service quality.

b.              Provide suitable training to satisfy these needs.

c.               Evaluate the effectiveness of the training provided.

d.              Ensure that its employees are aware of the relevance and importance of their activities and their contribution to achieve quality objectives.

e.              Maintain appropriate personnel records of education, skills/experience & training.



AND TRAINING RECORD                                                                                                   HOPE/F/6/02

EMPLOYEE TRAINING ATTENDENCE RECORD                                                        HOPE/F/6/03


6.3               Infrastructure


The Hospital determines, provides and maintains the requisite infrastructure and facilities (in internal meetings, management review meetings and through resource requirement form) for achieving conformity of service including:


a.                    Buildings, Workspace and associated Utilities.

b.                    Process equipments, hardware and software.

c.                     Supporting services, if any.


RESOURCE REQUIREMENT FORM                                                                      HOPE/F/6/01

HOUSE KEEPING CHECK LIST                                                                                    HOPE/F/6/04


6.4               Work Environment


The Hospital further identifies and manages the human and physical factors of the work environment necessary to achieve conformity to service requirements.

7.               SERVICE REALIZATION

7.1               Planning Of Service Realization

Service realization is the sequence of processes and sub-processes required for achieving the service conformity and requirements. Management prepares Process flow chart, Quality Plans and other associated documents that describe how the processes of quality management system are applied.

In planning the processes for realization of service, the Hospital determines the following, as appropriate:

a)              Quality Objectives and requirements related to the characteristics of the service.

b)              The need to establish processes and documentation and to provide resources specific to the service.

c)              Verification, validation, monitoring and inspection, specific to the service and the criteria for its acceptance.

d)              The records evidencing the realization process and that the same meets and fulfills the requirements of the processes and conformance of the resulting service.


The Hospital determines service realization processes & acceptance criteria, through Process flow chart, Quality Plans and other documents for specific service.


To meet the requirements of service planning, following steps are followed:


a)      Adhere to diagnostic/ treatment plan as prepared by the consulting doctor.


b)      Provide skilled doctors and competent para-medical staff. Provide equipment and maintain in fit and reliable condition equipment required for - diagnosis, treatment, operation and support services.


c)      Establish procedures and stick to these procedures required for rendering quality services- from appointment to discharge of patient.


d)      Create and maintain medical records, review records, progress records, diagnosis records and surgery records.


e)      Identification and verification of patient's progress at appropriate stages during the course of treatment.


f)        Prepare and maintain quality records.



7.2               Customer Related Processes

7.2.1 Determination of requirement related to the service:


The Hospital determines the customer requirements, which includes the following:


a.                Service requirements including availability and support before, during and post treatment as specified by the customer.

b.                Requirements necessary for service, if not specified by the customer.

c.                Statutory and Regulatory requirements applicable to the service.

d.                Additional requirements as decided by the management/ specialist / consultants, related to the service.


The Hospital has determined and implemented effective arrangements for communicating with customers in relation to:


a)   Information pertaining to range of treatment, the facilities, fee structure and other pertinent details that the patient/ customer may seek.

b)   Enquiries and corporate contracts.

c)    Patient / customer feedback including suggestions & complaints from patients/ customers.


The Hospital has ensured that all patient contracts are subject to contract review. This includes release of health record information for, patient/ client payment agreements and third party administrator arrangements.



7.2.2              Review of Requirements related to service:


The Hospital reviews the customer requirements related to service, together with additional requirements as determined.


This review is conducted prior to the commitment to supply the service to the customer to ensure:


a.              Service requirements are defined.

b.              Contract requirements differing from those previously expressed are resolved, if any.

c.               The Hospital has the ability to meet the defined service requirements.


The results of the review and subsequent follow-up actions are recorded in the customer file.

Where the customer does not provide any documented statement of requirements, the customer requirements are consociated before acceptance, wherever required.


It is ensured that, wherever service requirements are changed, the relevant documents are amended and the concerned persons are made aware of the changed requirements.


Note:               Such awareness is relevant in the case of service information catalogues, brochures, advertisements etc.


7.2.3              Customer Communication


The Hospital identifies and implements effective arrangements for communicating with the customer relating to following:


a.              Service information. (Through information catalogues, brochures, advertisements etc.)

b.              Enquiries, contracts including amendments.

c.               Customer feedback including Customer complaints.


7.3               Design & Development

Hospital does not perform design and development activities. It provides the Services, surgery and treatments, which are accepted worldwide in medical circles. Hence the applicability of clause 7.3 is excluded.

7.4         Purchasing

7.4.1 Purchasing Process


The Hospital controls its purchasing processes to ensure that purchased Product/Services conform to specified purchase requirements. The type and extent of control applied to the suppliers and purchased Product/Service depends upon the effect on subsequent Product/Service realization processes or the final results of the Service.


The Hospital evaluates and selects suppliers/consultant Doctors/service providers based on their ability to supply Product/Service in accordance with Hospital’s requirement. Criteria for selection, evaluation and periodical re-evaluation of suppliers are established. The results of evaluations and necessary follow up actions are recorded and maintained.




SUPPLIER / SERVICE PROVIDER/CONSULTANTS                                          QPL/7.4.1

QUALITY PLAN FOR PURCHASE                                                                                    QPL/7.4



7.4.2 Purchasing Information


Purchasing documents contains information describing the Product/Service to be purchased including, where appropriate, the following:


a.    Requirement for approval of Product/Service, procedures, processes and equipment.

b.    Requirement for qualification of Product/Service.

c.    Quality management system requirements.


The Hospital ensures the adequacy of specified purchase requirements contained in the purchasing documents, prior to their communication to the supplier. The purchasing order can be verbally, telephonic or through purchase order.



QUALITY PLAN FOR PURCHASE                                                                                    QPL/7.5


7.4.3 Verification of Purchased Product/Service


The Hospital establishes and implements, inspection and other activities necessary for verification of the purchased Product/Service vis a vis the specified purchase requirements. Where it is proposed either by the Hospital or its customer, to perform verification activities at the suppliers premises, the intended verification arrangements and method of Product/Service release, are clearly specified in the purchasing information.


7.5               Service Provision


7.5.1 Control of Service Provision


The Hospital plans and controls all operations/ service provision under controlled conditions including as applicable:


a.              Making available, information that describes the characteristics of the service.

b.              Availability of work instructions, as necessary.

c.               Using and maintaining suitable support services.

d.              Availability and use of the monitoring and measuring devices, where applicable.

e.              Implementing of monitoring and measurement activities, where applicable.

f.                 The implementation of release and post-service activities.


7.5.2 Validation of Processes for Service Provision


Hospital’s Service does not require any process to be carried out on experimental basis. Hence the applicability of clause 7.5.2 is excluded.


7.5.3              Identification and Traceability


The Hospital identifies, the service provided by suitable means throughout the process of service realization.


The Hospital does identify the status of the service with respect to monitoring and measurement requirements.


The Hospital does control and record the unique identification of the all the patients to whom the service has been provided.


7.5.4 Customer Property


The Hospital takes care of the customer property like medical documents etc. while it is under its control or is being used by the people working in the Hospital. The Hospital identifies, verifies, protects and safeguards the property of customer. These medical documents are kept with the incharge/head of the related department. The Hospital duly informs the customer if any of the customer property is lost damaged or is otherwise found to be unsuitable for use.


7.5.5 Preservation of Product / Service


The Hospital does preserve the conformity of the service / product, including constituent parts, with the customer requirements during internal processing and till release of patient / delivery. This covers identification, handling, storage and protection.


The Hospital ensures that medicines, equipment, documents, patient items used in the Hospital are maintained and delivered in a manner that prevents damage, deterioration and loss. Instructions have been given to staff for handling, storage, preservation and timely delivery of services to patients so as to achieve the highest level of customer satisfaction.


Adequate care is taken during treatment of patients, staff takes appropriate care at applicable stages of treatment / diagnosis.


The diagnostic records etc. are preserved against damage and deterioration.


The Hospital ensures that the services provided match the treatment plan evolved during the initial visit of the patient and in the time frame as decided during the initial consultation. On completion of the treatment, the patient is given detail record.



7.6               Control Of Monitoring And Measuring Devices


Hospital has determined the Monitoring and Measurement to be undertaken and Monitoring & Measuring devices to provide evidence of conformity of service provided.


To ensure valid results, measuring equipment’s are: -


(a)                     Periodically calibrated or verified against measurement standards traceable to National or International Standards and Calibration Records are reviewed/maintained.

(b)                     Adjusted or Re-adjusted as necessary.

(c) Identified for the Calibration Status.

(d)                     Safeguarded from Adjustments.

(e)                     Protected from Damage and Deterioration during Handling, Maintenance and Storage.


When the results of calibration are found to be unsatisfactory or the instrument goes out of order, the equipment is immediately discontinued from use and the service agency is informed. The equipment is put back in use only after the defect is satisfactorily rectified.


In addition the Hospital assess and record the validity of the previous measuring results when the equipment is found not to conform to requirements.


When used in the monitoring and measurement of specified requirements, the ability of computer software to satisfy the intended application is confirmed. This is undertaken prior to initial use and reconfirmed as necessary.




REGISTER                                                                                                                 HOPE/F/7/11

CALIBERATION REPORT                                                                                    HOPE/F/7/12


MEASURING RESULT                                                                                    HOPE/F/7/13


8.1               General

The Hospital does define, plan and implement the monitoring, measurement, analysis and improvement processes needed:

1.              To demonstrate conformity of the service.

2.              To ensure conformity of Quality Management System.

3.              To continually improve the effectiveness.


8.2               Monitoring And Measurement

8.2.1 Customer Satisfaction:

The Hospital does monitor information relating to customer satisfaction as one of the measurements of performance of the quality management system. The Hospital also monitors information relating to customer perception for fulfillment of customer requirement. The methodologies for obtaining and using this information are determined.


CUSTOMER FEED BACK FORM                                                        HOPE/F/8/01


8.2.2 Internal Audit:

The Hospital conducts periodic planned internal audits (at least once in nine month) to determine whether the quality management system:


a.              Conforms to planned arrangement of the requirements of the International Standard and to the Quality Management System established by the Hospital.

b.              That the internal audit system is effectively implemented and maintained.

The Hospital plans the audit program taking into consideration, the status and importance of the processes and areas to be audited, as well as the results of the previous audits. The audit criteria, scope, frequency and methods are defined. Selection of auditors is done in a manner, which brings about objectivity and impartiality of the audit process. In case the audit is conducted departmentally then it is ensured that no person conducts audit in respect of his own area of activity.


A documented procedure (QP 8.2.2) specifying the responsibilities and requirements for planning and conducting audits and for reporting results and maintaining records are defined in documented procedures.


Management takes timely corrective actions on deficiencies found and eliminates non-conformities and the causes detected during the audit without undue delay. Follow up activities includes the verification of the implementation of corrective actions, and reporting of verification results.



QUALITY PLAN FOR INTERNAL AUDIT                                                        QP 8.2.2


8.2.3 Monitoring and Measurement of Processes


The Hospital applies suitable methods for monitoring & where applicable measurement of QMS processes. These methods do demonstrate their   ability to achieve planned results. When planned results are not achieved, appropriate preventive & corrective action is taken to ensure conformity of the service.


·       QMS process will be monitored and measured by No. of N.C. from Internal Audit.

·       Resource requirement process will be monitored by no. of resource requirement raised and there compliance status.

·       Purchase Process will be monitored and measured by supplier / service provider performance rating and consultant performance rating.

·       HRD process will be monitored and measured by No. of Training Programs arranged and effectiveness of training.

·       Service Process will be monitored by the progress of service and result of the service.

·       Quality Control process will by monitored and measured by no. of complaints on Quality.

·       Monitoring of quality objectives also is one of the ways to monitor process performance and its effectiveness and other way is to have a formal review of the process during management review and index the effectiveness based on a questionnaire (Monitoring and Measurement of QMS Processes).




8.2.4 Monitoring and Measurement of Service


The Hospital monitors and measures the characteristic of the service, to verify that requirements for the service are fulfilled. This is carried out at appropriate stage of the service realization process according to planned arrangement.

Evidence of conformity with the acceptance criteria is documented in the patient file. Records do indicate the person authorizing for release of service.

Discharge of patient does not proceed until all the planned arrangements have been satisfactorily completed, unless otherwise approved by the relevant authority and where applicable by the customer.


8.3               Control Of Non Conforming Service


The Hospital ensures that the service, which does not confirm to the requirements, is identified and controlled to prevent unintended use, delivery and treatment. The control and related responsibilities and authorities for dealing with non-conformance service are defined in a documented procedure (QP 8.3).



CONTROL OF NON-CONFORMING SERVICES                                                        QP 8.3


8.4               Analysis of Data


The Hospital collects and analyzes appropriate data to determine the suitability and effectiveness of the Quality Management System and to evaluate where continual improvements of the Quality Management System can be made. This includes data generated as a result of monitoring & measurement and from other relevant sources. The Hospital analyses this data, to provide information on:


a.    Customer satisfaction.

b.    Conformance to service requirements.

c.     Characteristics and trends of processes and service including opportunities for preventive action.

d.    Suppliers / Consultants contribution.


8.5               Improvements


8.5.1 Continual Improvement


The Hospital plans and manages the processes necessary for the continual improvement of the effectiveness of Quality Management System and facilitates the continual improvement of Quality Management System through the use of Quality Policy, Quality Objectives, Audit results, Analysis of data, Corrective and Preventive actions and Management Review.


8.5.2 Corrective Action


The Hospital takes actions to eliminate the cause of non-conformity in order to prevent recurrence. Corrective actions are appropriate to the effect of non-conformities encountered.


The documented procedure (QP 8.5.2) for corrective action defines requirements for:


a.              Reviewing Non-conformities (including customer complaints).

b.              Determining the causes of non-conformities.

c.              Evaluating the need for actions to ensure that non-conformities do not recur.

d.              Determining and implementing the action needed.

e.              Recording results of action taken.

f.                Reviewing of corrective action taken.


CORRECTIVE / PREVENTIVE ACTIONS                                                        QP 8.5



8.5.3 Preventive Action


The Hospital determines action to eliminate the causes of potential non-conformities in order to prevent their occurrence. Preventive action(s) taken are appropriate to the effect of the potential problems.


The documented procedure (QP 8.5.3) for preventive action defines requirements for:


a.              Determining potential non-conformities and their causes.

b.              Evaluating the need for action, to prevent occurrence of non-conformities.

c.               Determining and implementing preventive action needed.

d.              Recording results of action taken.

e.              Reviewing of preventive action taken.


CORRECTIVE / PREVENTIVE ACTIONS                                                        QP 8.5





-               All statutory and regulatory requirements related to service

-               Service planning and Service control

-               Effective utilization of resources

-               Over all responsibility for service quality

-               Evaluation, Selection and Re-evaluation of Consultants

-               To mobilize and monitor finances

-               Analysis of QMS data

-               Overall incharge for continual improvement of QMS

-               Controlling Non confirmity Services

-               Taking action for customer Suggestion and complaints



              CHIEF EXECUTIVE     

-               Overall responsibility to see whether all the documents are controlled and records are maintained

-               To communicate properly the decision of the Management to the all employees

-               Planning and Conducting management review meetings

-               Planning and conducting internal audits

-               Corporate Empanelment

-               Overall Pharmacy & store control and authorizing purchase

-               Pathology & Physiotherapy

-               Business Development

-               Patient Outstanding

-               Evaluation, Selection and Re-evaluation of Suppliers

-               Mobilize and monitor human-resource requirement

-               To create and provide environment and facility for development of human resources

-               Ensure availability of all type of resources and infrastructure

-               Total responsibility for recruitment and training

-               Taking corrective & preventive action



              CHIEF MANAGER                  

-               Developing market and establishing Brand

-               Customer Communication, Customer Complaints and Customer Support & Customer Relation

-               Overall control on outsourced process

-               To maintain the equipments in working condition

-               Taking care of calibration process

-               Ensure timely correction of breakdowns

-               Ensure effective planning & implementation of preventive maintenance

-               Maintain safety of employees

-               Preparing all QMS related data




-               Billing of Patients

-               Consultant Co-Ordination




-               Total responsibility to plan and control the Service

-               Discharge Summary

-               Appointments

-               Consultant Co-Ordination

-               Leave approval

-               Marinating consultants log sheet



              ACCOUNT OFFICER   

-               Hospital & Pharmacy overall Accounting, Auditing and related legal compliance

-               Prepare and distribute Salary

-               Manage Bank operations

-               Maintain Management information system (MIS)



              FRONT OFFICE EXECUTIVE    

-               Complaints

-               Telephone Handing

-               STD/Coin Box

-               Asst. Patient Relation

-               Repair & Maintenance



              NURSE IN-CHARGE 

-               Sister In charge

-               Medical Equipment Maintenance



              WARD ASSISTANT

-               Assistant House Keeping

-               Maintaining Of H/R Stock

-               Repairs & Maintenance Report Sister In charge




-               Party Purchase

-               Pharmacy Purchase

-               Maintain minimum stocks, where applicable

-               Maintain stock record in computer and Maintain physical and ledger balance





  This department assists all the patients for treatment.





2.1 Goal

To give the patients immediate  and right treatment



2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize the Services Provided


2.3 Type of customers and age groups of patients served


·         All types of patients (Pvt,TPA,Corporate)

·         All types of patients (Below Poverty Line to Higher class)

·         All age groups (infants to adults)


2.4 Timeliness of services provided

Counseling of the relatives while admission(by CMO Billing)

20 min

Meeting the patient after admission / transfer(RMO)

15 min


Information to the consultant(RMO)

10 min

Doctor’s referral(RMO)

30 min

Reporting of the investigation (to consultant)(RMO)

Acc to lab TAT

Complaint or query of patient (RMO)

30 min

Filling pre Auth Form(RMO)

1 hour

Filling Discharge card after intimation(RMO)

30 min





2.5 Extent to which level of care / service meets patient needs.

Administering the deliverance of inpatient care on time with accuracy and zero error.






3.1 Organization chart





4.2 Job description

Medical Suprintendent


1.      He shall be the head of the medical department, responsible for supervision of the doctors  and making policies for them. He shall hold meetings with the RMO incharge weekly.

2.      He sees the establishment and administers the proper treatment and medicines to the patient by RMO.

3.      He shall be answerable for all the medico legal cases.

4.      He shall be the head medical records and responsible for making policies for medical records.

5.      He is the authority to  the release any information from the medical records (patient’s file).

6.      Address the medical  issues / complaints of the patients and take action.

7.      Communicating with the consultant in case if there is any problem.

8.      He shall examine every patient on admission and make proper entries thereof and take care that such medicines as he may think proper for their certain and speedy cure be duly administered.

9.      6. He shall see every patient once a day and oftener, if requested. He shall order and be responsible for the drugs, surgical instruments and books belonging to the asylum and he shall report the case of every patient fit for discharge to one or more of the Committee of Visitors.

10.   At each monthly meeting  he shall state the number of patients received and discharged, the number of deaths, the manner of employment, the weekly cost of maintenance with such matters as may appear as desirable.

11.  He shall be responsible for the management and condition of the establishment of the medical, surgical and moral treatment of the patients and of all general arrangements within the institute, and in case of emergency shall have the power of calling on the assistance of any physician or surgeon. He shall also in all cases of fatal or dangerous accident or other emergency immediately communicate to the Director.

12.  He shall regulate the duties of the Doctors and and prepare from time to time a manual there of for their guidance.

13.  He shall review all the discharge summaries before giving it to the patients.





5.1 Qualification:

MS, MD or diploma in any specialized field after


5 years experience in hospital.


 5.2 Key skills-

  • Managerial  skills, Leadership.
  • Knowledge of medico legal systems.



5.3  Staffing model

 1 FTE



5.4  Infrastructure


  • Working area Medical superintendent office.
  • 1 PC, Printer,Telephone line-1




RMO Incharge-

1.      He shall be the incharge of all RMOs and  responsible for supervision of the RMOs.

2.      He will make sure that all the medical policies are adhered by the RMOs.

3.      Helping Director or Medical superintendent in drafting policies and implementing them.

4.      Address RMO inter-personal issues.

5.      He shall lead the team of RMOs and motivate the time to time.

6.      He shall hold meetings with the RMOs weekly Address the medical issues / complaints of the patients and take action.

7.      He sees the establishment and administers the proper treatment and medicines to the patient by RMO.

8.      He shall handle all the medico legal issues.

9.      He shall check the entire patient’s files everyday.

10.  Helping RMOs in Providing answer to queries / justification to the TPA regards to any patient.

11.  Communicating with the consultant in case if there is any problem.

12.  He should take round everyday ,speak to the patient relative and ask for feedback.

13.   He shall see every patient once a day and oftener, if requested.

14.   At each monthly meeting he shall state the number of patients received and discharged the number of deaths, DAMA, any mismanagement at our end.

15.  He shall be responsible for the management and condition of the establishment of the medical, surgical treatment of the patients and of all general arrangements within the institute, and in case of emergency shall have the protocol of calling on the assistance of any physician or surgeon. He shall also in all cases of fatal or dangerous accident or other emergency immediately communicate to the medical superintendent.

16.  He shall regulate the duties of the Doctors and and prepare from time to time a manual there of for their guidance.


A.   Resident Medical Officer (R.M.O.)

(1) RESIDENT MEDICAL OFFICER is the most responsible member of the staff of the Hospital and is present all times of the day and night on his shift duty. As such no moment the Hospital can be left uncovered by R.M.O. Even at the end of his shift, he will not leave the post till the other RMO takes over.

(2) He should also be responsible for the conduct of other junior staff posted in his department.

(3) Though they are administratively responsible to hospital managers but for their work they are directly responsible to consultants.

(4) He is responsible for all the patients admitted in his department (Pvt./Semi- Pvt./ICU/ICCU or Economy wards) towards proper medical care. Though a patient as always admitted being on the spot under a consultant, but he on the spot, will be responsible for either first-aid if consultant has not seen the case or for carrying out the orders of that consultant.

(5) He will also he responsible for nursing care being provided by the nursing staff. He will ensure that all advised tests and procedures are carried out without any delay.

(6) On admission or in emergency he will always carry out necessary examination and history taking so that case sheet of the patient is completed in all respect. He will ensure that the patient’s documents are complete more so in cases of medico legal. He should also make sure that uncommon abbreviations are not used in the case sheet. He will sign the case sheet with his comments during all his rounds.

(7) He will also be providing medical aid to admitted cases under a consultant, in time of emergency, but latter informing the consultant about the action taken. He will also consult the specialists at time of requirements.

(8) He himself should take round of all the patient under his care at least thrice a day and as often as necessary. He will also accompany the consultants, when they come on round and will ensure that all his orders are carried out.

(9) He will ensure that proper diet is being to the patient as per his medical condition or as advised by the consultant.

(10)              Discharge summary of the patient who is going to be discharged is to be prepared by RMO and should be signed by the consultant and RMO both.

(11)              He will also explain the patient about the precaution and medications to be taken after discharge.

(12)              He will perform his duties as assign to him by the RMO incharge.









8.1 Quality objectives

  • Higher patient satisfaction through prompt treatment and accurate documentation.
  • Develop an empathetic approach towards patient care.
  • Positively impact discharge-planning process/TPAprocess by reducing the time taken for discharge



8.2 Quality Monitors



8.3 Performance Metrics

  • No. of pending discharge cards
  • No of DAMA
  • No of death due to mismanagement





















  The Nursing department assists all the patients for bedside nursing care,mediaction and administrative functions in the ward.






2.1 Goal

To give the patients comprehensive nursing care which will help the patients in the recovery.



2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize the Services Provided


·         Feedback verbal and written

·         Patients/ relatives / RMO/consultant





2.3 Type of customers and age groups of patients served


·         All types of patients (Pvt,TPA,Corporate)

·         All types of patients (Below Poverty Line to Higher class)

·         All age groups (infants to adults)











2.4 Timeliness of services provided

Meeting the patient after admission / transfer

(Checking vitals)

10 min


Doctor’s referral

30 min

Investigation appointment

30 min

Reporting of the investigation

Acc to lab TAT

Complaint or query of patient

30 min

Forms to get filled (insurance)

1 hour

Discharge process

2 hour

Returns of medicine

15 min

Discharge card (doctor to be called)

30 min





2.5 Extent to which level of care / service meets patient needs.

Administering the deliverance of inpatient care on time with accuracy and zero error.






3.1 Organization chart





























4.2 Job describtion


1. Nursing Superintendent / Matron

            The Matron will be responsible to the MS for the administrative and technological aspects of nursing in the hospital. Her charter of duties will include the following:

1)      Administration of nurses, their accommodation and messing, viz. equitable distribution and economic utilization of nursing staff, maintenance of duty roster, turnout and discipline, supervision over living conditions, amenities and messing facilities in the Nurse mess and hostel; leave, temporary duty, training etc.; reports and returns; service record of nurses.

2)      Nursing care of patient in the hospital:

(a)                Supervision of nursing by Sister/Nurses to ensure that the high 

            Standard is maintained all the time.

(b)               Welfare of patients including recreational facilities.

(c)                Cleanliness of Wards/Departments.

(d)               Accompany the MS on his round.

3)      Such other duties, as may be delegated to her by MS.  


2. Nursing Supervisor

            Duties of Nursing/Superintendent/Matron/Nursing Supervisor can be clubbed or divided as per available manpower.

A. General Management:

To ensure

1.      Adequate nursing staff.

2.      Duty roster well planned.

3.      Punctuality of staff working under her.

4.      Nurses in proper uniform.

5.      Visit to all the patients.

6.      Availability of material consumable and non-consumable items.

7.      Availability of life-saving drugs.

8.      Availability and functioning of the saving equipment.

9.      To check and ensure the judicious use of telephone.

10.   Eatables are not allowed/used at OT or ICU Nursing Stations.


B. Patient Welfare and Safety:

  1. Call be well within easy reach.
  2. Patient clean and presentable.
  3. Patient appears comfortable, free from pain and tension.
  4. Bed neatly made.
  5. Patient position is correct.
  6. Used bed pans and urinals removed promptly.
  7. After meals, the food trays removed promptly.



E. Ward General Appearance:

  1. Ward/room cleaned and ventilation satisfactory.
  2. Patients bathroom are clean and in order.
  3. All wash basins clean.
  4. All the beds in line.
  5. All bed pans, kidney trays and dustbins clean and dry.
  6. All drugs to be checked for expiry date.
  7. Injection, medicines trolleys fully equipped, clean and tidy.
  8. Nursing station clean and organized.
  9. Notice board tidy and outdated notice removed.
  10. Medicine containers labeled, legible and clean, cupboard tidy and locked.
  11. Oxygen cylinders and suction apparatus are adequate and in working order.
  12. Adequate supply of linen, thermometer, syringes, dressing sets and other materials are kept out for use in the ward in her absence.


3. Ward In-Charge/Sister

      She will be responsible to the Matron/Nursing Superintendent for the efficiency of the Nursing services in her ward/department.

Her duties will be administrative and professional.


A. Administrative duties of her will include the following:

  1.  Public relations.
  2. General sanitation in the Ward/department.
  3. Attention to prevention of hospital cross-infection.
  4. Nursing documentation and reports are required.
  5. Allotment of duties to subordinates their disciplines, welfare and supervision.
  6. Attention to economy in manpower and materials.
  7. Maintenance of stock register/inventories and periodicals checks.
  8. Check of custody, expenditure and accounting of dangerous and controlled stores.

B. Professional duties of her will be as follows:

  1. Supervision of Patient care as laid-down under duties of staff nurses and other ward staff.
  2. Attention to details of arrangements for medical and surgical procedures carries out in ward/department such as sterilization and observation of asepsis, administration of oxygen, medicines etc.
  3. Supervisions over demands for and utilization of diets.
  4. Training of nurses and paramedical personnel.
  5. Actual nursing care of patients, if required.
  6. Participation in training programs.


4. Staff Nurse

    General: A nurse by the very nature of her duties is in closer touch with the patients and therefore is in a better position to win his confidence. It is the duty of every nurse to uphold the noble traditions of her profession and dedicate herself to the care of patient in her charge. She should pay particular attention to her turnout and conduct. While maintaining the dignity and decorum of her profession, she must at all times be cheerful, kind and courteous and sympathetic towards her patients and their anxious relatives. These qualities along with professional skill will win her respect and cooperation of her patients. She must remember as good nursing is as important part of efficient patient care as good doctoring.


Specific :

  1. All staff nurses should be –wearing white aprons as well overall supplied from the hospital.
  2. All nurses should enter the hospital from the back gate as specified for staff entry.
  3. Staff nurses posted in any department (ward, ICU, ICCU, OT etc.) are responsible to the Sister in-charge of that department for all administrative and clinical work. As far as clinical work is concerned, they are also responsible to the Resident Doctors on duty and to specialists.
  4. The nurses are assisted by the other staff of the ward such as ward boy, ward girl, Housekeeping staff.
  5. She has to perform some administrative duties as well along with her professional duties.
  6. Any other duty, administrative or clinical, assigned by her seniors related to nursing.
  7. The administrative duties are concerned with efficient and economical ward management and include activities, which are subsidiary to but cannot be divorced from patient care.   

These duties are as follows:

i)              Handing over and taking over charges on change of duty staff.

ii)            Cleanliness of ward, annexes, furniture, linen, equipment and stores.

iii)          Preparation of demands for diet.

iv)          Preparation of dressings, bandages and splints and items required for dealing with emergencies.

v)            Keeping an inventory of all items under their charge.

vi)          Ensuring the serviceability of all equipment and store on charge and accounting for them.

vii)        Safe custody and accounting of dangerous and controlled drugs.

viii)      Replacement of expandable stores and obtaining replacement of unserviceable non-expandable items, in accordance with standing orders.

ix)          Exchange of clean linen and patient’s clothing for solid ones.

x)            Disinfecting the ward, when required.

xi)          Safe custody and maintenance of medical records of patients.

xii)        Control of visitors and public relation.

  1. Her Professional Duties are:

i)              General Nursing Care.

ii)            Technical Nursing Care.

iii)          Training Responsibilities.

General nursing care consist of the care of attention to the patient in the interest of his/her comforts and general well being of his/her physical health. The activities grouped under this functional heading are generally speaking common to all patients irrespective of the nature of his/her illness. These duties will be as follows:

i)              Admission and Discharge of patients.

ii)            Assistance and instruction to the patient and their relatives.

iii)          Personal hygiene of the patient, viz. sponging, care of mouth, eyes, hair and nails.

iv)          4-hourly or more frequent attention to pressure points, as ordered, in the case of bed ridden patients.

v)            Serving and removing hot water bottles, bedpans and urinals.

vi)          Bed-making.

vii)        Feeding of patient incapable of feeding themselves, distribution of diet and preparation of special items of food.

viii)      Ward rounds with Sister/Doctor.

ix)          Supervision of work of staff placed under her.


Technical nursing care comprises those tasks and activities concerned with the treatment and management of the particular illness of which the patient is suffering. These duties will be as follows:

i)              Administration medicines and/or injections as ordered and recording the same.

ii)            Assisting or actually caring out technical procedures sterilization preparation of injections, preparing and serving of enemas, catheterization, fomentation, irrigation, dressing, oxygen therapy etc. and cleaning up thereafter.

iii)          Preparation for and assistance in carrying out clinical tests, investigations, including collecting, labeling and dispatching specimens.

iv)          Taking and recording Pulse, Temperature and Respiration.

v)            Rounds with doctors.

vi)          Pre and Pos-operative care.

vii)        Escorting patients to and from departments.

viii)      Technical reports.

     Training Responsibilities

cover not only the training of those placed under her control but also attention to self-improvement. These will be as follows:

i)              Demonstration and guidance to student nurses and domestic staff.

ii)            Assistance in orientation of new staff .

iii)          Participation in training program and other professional activities for the advancement of knowledge and skill.

iv)          Any other duties related to nursing services.

Main points in nursing duties and responsibilities (Clinical) : 

1.            Admission and Discharge of patients.

2.            Preparation of patient’s file. 

3.            Sending the patient’s file at the reception at the time of discharge.

4.            Getting discharge summery prepared by RMO.

5.            Informing the reception about the room no. of the new admission.

6.            Informing all transfers to the reception.

7.            Assistance and instructions to the patients and their relatives.   

8.            Personal hygiene of the patient, viz. sponging, care of mouth, back etc.

9.            Serving and removing hot water bottles, bedpans and urinals.

10.        Feeding of patients who can not eat themselves.

11.        Ward rounds with Nursing Superintendent, M.S. and Consultant if required.

12.        Administration of medicines and /or injections as ordered and recording the same in case sheet.

13.        Assisting doctors in carrying out certain procedures whenever required.

14.        Assisting or actually carrying out technical procedures, sterilization    preparation of injections, indenting of medicines, giving enemas, oxygen therapy etc.

15.         Collecting samples for investigation whenever required. Getting all tests done, which the treating doctor ordered.

16.        Taking and recording of vital signs like Pulse, Temperature and Respiration.

17.        Pre and Pos-operative care.

18.        Escorting patients to and from departments. OT, either herself or with the help of ward boy.

19.        Supervision and housekeeping staff getting patient’s room cleaned thrice a day.

20.        At each change of over, the outgoing nurse will go with the incoming to each patient from bed to bed, room to room and thus hand over to the patient.

21.        Any worsening of the condition of the patient must be reported to the RMO/Consultant in-Charge.

22.        Imparting health education to the patients and relatives.

23.        Staff nurse on duty should be changing of IV fluid bottles and in no circumstances attendant help should be sought for the same.

24.        While putting cannula to the patient, there should be deep plastic sheet under the site of arm so as not to strain the bed sheet. This should be strictly followed part should be properly fixed after confirming its patency.

25.        In obstetric cases special attention should be given in care of breasts and perineum care, catheterization of female patient, baby care, assisting in breastfeeding.

26.        Please ensure that no torn up linen, i.e bed sheets, pillow covers, draw sheets, blankets etc. are given to the patient at any cost.

27.        Extra caution to be taken for deluxe/VIP suit room patients.

·    Tissue Box.

·    Small Soap.


28.         A fresh towel should be given to the patient at the time of admission.

29.        In case of surgical patient to prepare patient for operation, i.e. shaving, cleaning and dressing etc.

30.        To confirm that pre-op papers are complete and fully documented (consent, investigation etc.). Proper consent must be taken signature of patient (if major and mentally sound) and nearest relative must in presence of proper witness.

31.        To confirm that advance for surgery has been paid, before sending the patient for surgery.


ICU Patients

32.        Taking care of bedsore and bedridden patients (after physician’s permission).

33.        Any terminal ill patient should not be left alone.

34.        Strict vitals charting of ICU patients.

35.        Assisting in physiotherapy.

36.        Take care while administering NTG drip, Dopamine drip etc. and should start in presence of doctor on duty.

37.        ICU should not be misused for sitting purposes by any other staff while on duty.

38.        Assistance in orientation of new nurses.

39.        Any other duty related to nursing services.

40.        Last but not least, to see chargeable procedures and consumable are written in the patient’s file in charge sheet.

    Some of the chargeable items are:

(a) Blood transfusion.                               (b) Enema.

(c) Bowl wash.                                          (d) Gastric lavage.

(e) All lab tests.                                         (f) All imaging tests.

(g) Oxygen inhalation                               (h) Cut down.

(i) Aspiration                                             (j) Dressing.

(k) Baby care for new born.                      (l) All consultants’ visits.

(m) Medicines are from ward                   (n) ECG, Echo, U.S., TMT, Endoscopy.

 but not replaced.


Main Points in Nursing Duties and Responsibilities (Administrative)

1.            Night nurses, if found sleeping either with patient or attendant or security staff will be terminated immediately.

2.            No junior nurse will give an I.V. injection either in vein or in drip set, special drugs like Insulin, Potassium chloride and Lariago.

3.            Do not appear for duty without your nametag/Identity Card.  

4.            Telephone should not be used for personal chat and staff nurse on duty must check its misuses, by all means.

5.            Eatable should not be allowed or used at Nursing Stations of ICU/OT complex.


5. Additional responsibilities

  • Attend the phone calls and enquiries about the ward
  • Make entries in admissions and discharge book
  • Coordinate with various departments (Admission counter, Casualty, Wards, OT, Medical Records, Diagnostics, Linen, Security, Food & Beverages etc.) for facilitating services.
  • Providing reference information to consultants
  • Ordering stationary twice a month and weekly orders  of materials.
  • Co oordinating discharge summary to the patients.
  • Completing the documents in the file before dispatching.
  • Ensure accurate documentation of treatment related documents
  • Scheduling tests and invasive procedures/ investigations
  • Liaison with other support services (Housekeeping, F&B, Maintenance, Waste Management and others) to ensure delivery of care
  • Requisition for medicines and other medical supplies
  • Ensure accurate billing entries and facilitate discharge planning
  • To meet the patients daily and assist them in their queries.
  • Check the insurance status of the patients.
  • To coordinate with different departments and to see the best comfort of the patients during their stay.
  • Escalate the feedback to the GRO for proper action to be taken.
  •  Complaints received by the nurses to be recorded, follow up is taken if not resolved, and   are escalated to guest relations executives.
  • Updating the documents in the file in the proper sequence.







5.1 Qualification:

  • GNM. Multi-lingual preferred.



 5.2 Key skills-

  • Good communication skills, mannerism, telephone etiquettes, helping attitude.
  • Multi-task and to enjoy costumers interaction
  • Knowledge of customer management techniques to deliver higher satisfaction.



5.3  Staffing model

 Total staff- 37


Ward                            M          E         N

Special ward-1              3           2         2

Special ward-2              3           2         2        

Special ward-3              3           2         2

ICU                                3           2         2

OT ( including nurses  3           2         2

and tech)                 



5.4  Infrastructure


  • Working area is at the nursing station of the respective ward.
  • 1 PC, Telephone line-1


      Documents to be maintained

  1. Patient file-charting
  2. Nurse record written (TPP – I/O).
  3. All medications are charted correctly.
  4. All other treatments charted correctly
  5. Stock Register
  6. Investigation reports file
  7. IP register- entry of the details to be made in the register on admission, discharge, transfer in or transfer outg
  8. Medication register
  9. Intubation register
  10. Linen Register- Daily stock taking of linen is to be maintained.
  11. Maintenance Log book- the maintenance complaint/issues.
  12. Inventory register
  13. CT MRI register
  14. Blood issue register
  15. Communication book
  16. Duty book
  17. Stationary order book

























Flowchart: Decision: Blood test                                              YES

















































































Text Box: H.R.D                                                                                                       






























8.1 Quality objectives

  • Higher patient satisfaction through efficient  nursing and accurate documentation.
  • Develop an empathetic approach towards patient care.
  • Positively impact discharge-planning process by reducing the time taken for discharge



8.2 Quality Monitors

  • Complaint resolution rate of 95%( at ward level)
  • Turnaround time (getting the room ready after discharge)
  • Average time taken for discharge per patients



8.3 Performance Metrics

  • No. of Feedback forms collected from the patients
  • No. of pending discharge cards
  • No. of Medication error
  • No. of bedsore
  • No of patient fall








Guest Relations Department                                                    Page No

·         Introduction                                                                                 2

·         Scope of the Department                                                             2

·         Structure                                                                                      3

·          Job Descriptions                                                                         4

·         General Instructions                                                                    8

·         Stationary / records to be maintained                           9

·         Process Maps                                                                               10                                                                                     

·         Interdepartmental Links                                                              13

·         Infrastructure                                                                               14

·         Quality Outcomes                                                                        15















  The Front office department assists for the all OPD processes and avoiding errors.






2.1 Goal

To give the patients best service with no grievance. Being the first contact point of patients with the hospital, the experience should be delightful.



2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize the Services Provided


·         Feedback verbal and written

·         Patients/ relatives / consultant





2.3 Type of customers and age groups of patients served


·         All types of patients (Pvt,TPA,Corporate)

·         All types of patients (Below Poverty Line to Higher class)

·         All age groups (infants to adults)




2.4 Timeliness of services provided

·         Enquiry                                         3-5 minutes

·         Registration                                   5-7 minutes

·         Admission                                     5-10minutes(depending upon bed availability)

·         OPD billing                                   5-10 minutes

·         Doctor’s appointment                   5 minutes

Retrieving file                               10 –15 minutes (subject to godown files)






2.5 Extent to which level of care / service meets patient needs.

Administering the deliverance of inpatient care on time with accuracy and zero error.





3.1 Organization chart


























3.2 Day- to -day activities


·         Enquiry

·         Registration

·         Admission

·         OPD billing

·         Doctor’s appointment






2.1  Job Descriptions


2.3.1.      ENQUIRY


·         This is generally the first interface of customer interaction, when a prospective customer, patient, relative, or visitor comes to the hospital for any reason.


·         This desk may be required to furnish information on –

·         Availability of consultants in various specialties.

·         Timings of consultants.   

(Lists are made available at terminal for information for staff.)

·         Various diagnostic services available in the hospital and their location.

·         Information on admitted patients and their ward and bed numbers, etc. – Refer computer system provided for the same.

·         Information on various programmes, seminars, workshops being conducted in the hospital. F.O. Executive/ assistants will communicate these through IOCs and circulars.

·         Information on procedures involved in admission, O.P.D. consultation, taking appointments for diagnostic services, etc.

·         Company tie-ups – Marketing department will inform from time to time about credit facilities offered to various companies.


Duties of front office assistant -


a)      A pleasant countenance and eagerness to serve the customers are basic requirements for this counter.

b)      Patience and careful understanding of the customer’s / visitor’s requirements.

c)      Clear and comprehensive guidance, in reply to different enquiries.


2.3.2        REGISTRATION



This terminal deals with the registration of the patient. In this process a Registration No. is given to the patient. The file is created for the patient and it is continued for any a OPD process consultation / procedure .The registration no. is mandatory for any treatment or investigation in the hospital.


Procedure For Registration –



This involves filling up the patient’s details by the patient / relative. Registration is mandatory for all patients


·         Patient’s particulars like name, age, address, phone no, family physician  and consulting doctors name.

·         The above data is fed in the system and permanent registration no. is generated. The file is made and given to the patient.

·         For company  patients the a note is written in file for differentiation.

·         For Company patients credit facility is provided on presenting company referral letter  and the same information is fed in the system.


Other duties-


1.      Ensure registration numbers and other details are accurately written on registration documents (registration file, registration card etc..).

2.      Help the patient’s relative in filling up the details of the patient if the relative is illiterate.

3.      Handle registration related queries.





This terminal deals with the formalities related to admission. Any patient who comes for admission should be registered with the hospital. If the patient comes back for admission in few days then his discharge summary is retrieved from the system, (and file if needed)


Procedure For Admission –

This involves the admission of the patient by the admission staff based on the information given by patient/ relative.



·         The different categories of bed and the tariffs are explained to the relative.

·         With the help of occupancy chart, if The room of choice/ward is available ,is allotted to the patient.

·         Facilities are explained to the patient/relative.

·         IPD registration is done

·         A print out of the registration form is taken and signature of the relative is taken.

·         A consent for treatment is taken,form is filled up by the relatives, in that at least 2 relatives mobile no. is taken. The declaration is to be signed by the patient or his relative / next of kin with the full name written clearly on the consent.

·         Once the Performa is completed, it should be filed in the patient’s record. The person on duty at admission counter must sign on the admission form for identification of originator, if the requirement arises.

·         The patient’s relative is then sent to the I.P billing department, with details of admission and the bed/ room allotted, for payment of deposit.

·         A call is made to the ward regarding the new admission.


Other Duties-


·         Patients are often admitted in emergency situation. Ensure that the admission procedures are quickly completed and the patient’s record is delivered to the 
emergency department as speedily as possible.


·         Contact various wards from time to time, (2 hourly, from 8 a.m. to 2 p.m.)And keep yourself updated with the bed situation and expected discharges.


·         The occupancy chart has to be updated  and kept handy.


·         Responding to enquiries regarding admission is duty of front office staff at this counter. Correct information expeditiously given, is of paramount importance.


·         In case of out station enquiries for admission, it is advisable to counter check with wards before confirming bed availability. This is even more significant when a patient is being transferred under emergency circumstances.









This counter handles

1.      Centralized collection of cash (consultation, follow-up, investigation, pharmacy diagnostics and various procedures i.e. dressing, minor O.T and major O.T.)

2.      Collecting payments by Credit card and Debit card.

3.      Refund if any.


Duties Of Staff


·         A pleasant countenance and eagerness to serve the customers are basic requirements for this counter.

·         Patience and careful understanding of the customer’s / visitor’s requirements.

·         Clear and comprehensive guidance, in reply to different enquiries.




General Instructions -


1.      In case of any difficulty, inform the administrator.

2.      Every patient should get the receipt against the payment.


3.      On change of shift the information should be meticulously handed over with all-important messages recorded in writing in log book.   


4.      Person handing over charge will be held responsible if any lapse occurs on that account.






This counter handles

1.      The doctors appointment

2.      Calling consultant

3.      Making file

4.      Retrieving files from medical record

5.      Sending file to Doctor’s chamber

6.      Attending patients and consultants queries

7.      Attending phone calls

8.      Keeping record of the files.

9.      Keeping track of doctors availability.


Duties Of Staff


·         A pleasant countenance and eagerness to serve the customers are basic requirements for this counter.

·         Patience and careful understanding of the customer’s / visitor’s requirements.

·         Clear and comprehensive guidance, in reply to different enquiries.


3.General Instructions for all the


1)                        No staff except the designated ones are allowed to sit in the reception


2)                        All staff will enter from the back gate of the hospital in proper dress code.

3)                        Reception staff not eat or drink at the counter.

4)                        All receptionists should greet a visitor, even if the visitor seems to be

Agitated should not agitate them.

5)                        Every receptionist at the start of his shift will make sure that hospital’s

charge schedule is available. computers are working normally and telephones are in working order. If any equipment is not working, it should always be informed immediately to the concerned (maintenance) department and the seniors and he will be responsible for getting repaired.

6)                        Outside telephone calls should not be transferred to certain telephone

Extensions, viz ….…….which are mainly to be used as intercoms.

7)                        All the telephonic messages for the Director/MS or the consultant who

was not available at that time should be neatly written and sent through

to their chambers.

8)                        Reception staff will make sure that the housekeeping staff has done their

job properly in the area overlooking the reception.

9)                        A logbook  shall be maintained at the reception and receptionist should read it before starting his shift. He has to take action on certain points.

10)                    As soon as a patient is admitted by him (if there is no separate admitting

office, or at nights), he shall immediately inform the concerned ward in-

charge and the consultant –n-charge after completing all formalities of


11)                    If the patient is referred by an outside consultant, the reference slip

details should be entered in a register especially maintained for such record purpose.

12)                    The details of a patient’s bill are only for his consumption and should not

be disclosed to any outsider.




Stationary / records to be maintained                         

Depending on the job description, following record will be maintained at the reception. One of the hospital administrators or In-charge reception will ensure that all records are properly maintained.


1)      IPD register

2)      OPD register

3)      Cash Book

4)      Pharmacy book

5)      Voucher file

6)      Corporate register

7)      Doctors Tariff

8)      Maintenance Book

9)      Communication / Log Book

10)  Telephone Directory

11)  Occupancy Chart

12)  Medical Certificate Book

13)  Death Certificate Book

14)   OPD feedback forms

























3.Processes maps






3.1.      Enquiry process flow






Medical Records





































3.2.  Process Flow in OPD


Flowchart: Alternate Process:        Patient walk in /Appointment



















































Flowchart: Alternate Process: Patient sent to ward3.3. Admission Process flow















Flowchart: Process: Admission counter


























Text Box: Diagnostics









































·        Enquiry,registration,OPD billing, Admission    -1 counter two Telephone                   lines, 1PC, printer           





7.1 Qualification:

  • Bachelor’s degree.
  • Proficiency with Microsoft Office. Multi-lingual preferred.

7.2 Experience:

0-2 years in customer care


7.3 Knowledge, skills and abilities:

  • Work requires ability to take initiative, multi-task, communicate well, problem-solve and enjoy customer interactions.
  • Knowledge of customer management techniques to deliver higher satisfaction.






8. Staffing model


           Department                             M                      E         

·         Registration                             1                    1                      

·         OPD billing


·         Admission                               1                    1                       

·         Enquiry                                                          


At night single person handles the following duties:


·         Registration

·         Admission

·         OPD billing

·         Enquiry







4.1. Quality Objectives


·         Enquiry-The queries are answered promptly and accurately

·         Registration – All the registration are done with accuracy.

·         Admission – To accommodate the patients and manage the beds effectively thereby catering critical and emergency patients.

·         OPD billing – Provides smooth and fast service to the out patients .

·         Doctor’s appointment – Has systematic appointment system, the waiting time of the patients is minimized.



4.2. Quality Monitors


·         Enquiry           - completion within stipulated time

·         Registration     - completion within stipulated time and errors

·         Admission       - completion within stipulated time and errors

·         OPD billing     - completion within stipulated time

·         Doctor’s appointment – waiting time and file retrieval time from medical records.



4.3 Performance Metrics        


·         Enquiry-Avg time taken- Complains-CRR more than 85%

·         Registration Avg time taken

·         Admission Avg time taken

·         OPD billing Avg time taken

·         Doctor’s appointment Avg time taken










Guest Relations Department                                                    Page No

·         Introduction                                                                                 5

·         Scope of the Department                                                             5

·         Structure                                                                                      6

·         Process Flow                                                                               8

·         Interdepartmental Links                                                              9

·         Feedback   Mechanism   Process  Flow                                      10

·         Job Descriptions                                                                          11

·         Outcomes                                                                                     12


















List of Abbreviations


1.      Admin-Administration


2.      Engg- Engineering


3.      F&B- Food And Beverages


4.      FTE.-Full Time Employee


5.      G.R-Guest Relations


6.      GRD-Guest Relations Department


7.      GRO-Guest Relations Officer


8.      HK-House Keeping


9.      HOD-Head Of Department


10.  HRD-Human Resource Department


11.  OPD-Out Patient Department


12.  OT-Operation Theatre


13.  PGD-Post Graduation Diploma


13.  TAT-Turn Around Time












  The guest relations department assists the patients and visitors in making their stay comfortable in the hospital. Guest Relations Executives handle patient’s queries, concerns, complaints in terms services and administrative functions and collect the feedback from the patients.







2.1 Goal


Quick access to care, good outcomes, meeting the patients needs and avoiding errors.




2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize the Services Provided


  • Meeting the in patients on daily basis to facilitate the comfortable stay of the patients.
  • Easy access for patients to get in touch with guest relations.
  • Feedback given to the concerned HOD and facilitate the corrective action taken.
  • The feedback form (inpatient and outpatient) is to capture the patients feedback, suggestions / comments.
  • Analysis and presentation of the patient satisfaction results and access the gap in patient’s services.





2.3 Type of customers and age groups of patients served


All age groups and types of patients.








2.4 Timeliness of services provided


  • Meeting the patients within 12 hours of admission.
  • Acknowledging complaints within 24 hrs of receipt of the initial complaint.
  • Informing the complainant of the approximate time that it will take to resolve the complaint.



2.5 Extent to which level of care / service meets patient needs.

Administering the deliverance of inpatient care on time with accuracy and zero error.





3.1 Organization chart




























3.2 Day- to -day activities


  • To take daily rounds in all wards, check the patients list.


  • To coordinate with different departments and to see the best comfort of the patients during their stay.


  • Colleting the feedback forms from the patients and their relatives, and escalate the things to concerned HODs for proper action to be taken.


  • Maintaining the database for feedback forms.


  • Complaint management Cell: - G.R. Executives and the maintenance co ordinator are the members of the cell.  Complaints are recorded by them , follow up is taken if not resolved, and are escalated to the CEO


  • Written complaints received through patient’s or their relatives are investigated, counseling (assurance or commitment) is done the same is escalated to higher authorities for further action.


  • Out patients department visits should be done , queries regarding billing, and other queries are attended.























Flowchart: Alternate Process: Co- Ordinate with Different HOD


Flowchart: Alternate Process: Generate Gross repot on feedback

Flowchart: Alternate Process: Informed Higher Authorities





Flowchart: Alternate Process: Daily Round 

Flowchart: Alternate Process: Inform Higher Authorities Flowchart: Alternate Process: Maintaining Database for feedback                                                                                                                                   

Flowchart: Alternate Process: Counseling                                                                                                                

Flowchart: Alternate Process: Follow up done on Discrepancies ahead                            


Flowchart: Alternate Process: Written complaints ReceivedFlowchart: Alternate Process: Consultants Requirements                                                          Guests Relations                                              



Flowchart: Alternate Process: HOD’s / Dept’s For further Action

Flowchart: Alternate Process: Complaint management Cell




Flowchart: Alternate Process: OPD                                                                       

Rounded Rectangle: Feedback / Patient Satisfaction Survey

Flowchart: Alternate Process: Complaints unresolved






                            Patient Queries                                                                                         

Flowchart: Alternate Process: Complaints Resolved

Flowchart: Alternate Process: Refer to higher AuthoritiesFlowchart: Alternate Process: Patient Discharge                                                           






















Text Box: Diagnostics










































Text Box:      Remarks























  • Overall responsibility of patient care areas facilitates patients care and resolves their concerns/ issues.
  • Assess each patient’s concerns/ feedback, take suitable action and ensure satisfaction of patients and their relatives.
  • Administer patient feedback forms to outpatients and inpatients, ensure higher response rate, submit data to central complaint management cell and participate in analyses.
  • Coordinate effectively with various departments and their respective HODs to ensure care delivery to patients.
  • Additional responsibilities/assignments as per senior management’s discretion.
  • Making the complaints process accessible to guests;
  • Privacy and open disclosure for patients.
  • Liaison with other support services (Housekeeping, F&B, Maintenance, Waste Management) to ensure delivery of care
  • Facilitate Discharge process.
  • Facilitate admission process / bed allotment.
  • Call back or sending E mail/letter to the patients after discharge.
  • Distribution of get well soon cards.
  • Continuous service improvement by new quality initiatives/projects.




7.1 Qualification:

  • Bachelor’s degree, PGD in Hospital Administration.
  • Proficiency with Microsoft Office. Multi-lingual preferred.

7.2 Experience:

  • 1-2 years experience in hospital industry



7.3 Knowledge, skills and abilities:

  • Work requires ability to take initiative, multi-task, communicate well, problem-solve and enjoy customer interactions.
  • Ability to go out of one’s way to help patients and deliver on commitments.
  • Knowledge of customer management techniques to deliver higher satisfaction.






7.4 Staffing model

  • 2 FTE. Morning -Night
  • Shift timings




7.5    Infrastructure

  • Working area GR ofice
  • PC, Printer, telephone lines (internal / external).
  • Documents to be maintained:

Ø  Daily reports on patient’s feedback

Ø  All complaints and related information

Ø  Patient Satisfaction Survey forms (inpatients and outpatients)

Ø  Register complaints

Ø  Register the calls made to the patients

Ø  Monthly performance indicators

Ø  Monthly Analysis






8.1 Quality objectives

  • Quick access to care
  • Responding to the patient’s feedback



8.2 Quality Monitors

  • Patient satisfaction scores
  • Timeliness of response



8.3 Performance Indicators

  • No. Of Feedback collected per month.
  • No. of complaints received per month.
  • Complaint Resolution rate (CRR)

      CRR = (No. of complaints resolved in a month / no. Of complaints received

                    In that month) * 100                                                            

  • Complaint Redress Index (CRI)
  •              CRI = (No. of complaints resolved within 5 days / no. of complaints to be    resolved in that Month)
  • No of calls made
  • No  of E mails sent









Accounts Department                                                          Page No

·         Introduction                                                                                 

·         Scope of the Department                                                             

·         Structure                                                                                      

·         Day to day activities                                                                                 

·         Interdepartmental Links                                                              

·         Job Descriptions                                                                          

·         Outcomes                                                                                     























  This department deals with all accounting ,Budgeting, Cash management and Billing including safekeeping of hospital cash and books of accounts.






2.1 Goal


Recording  of all financial transactions and statements and preparation of reports in a systematic manner.




2.2 Methods Used to Assess the hospital needs in order to customize the Services Provided.






2.3 Type of ventors/customers and age groups of patients served


All age groups and types of patients.






2.4 Timeliness of services provided



2.5 Extent to which level of care / service meets patient needs.

Administering the deliverance of inpatient care on time with accuracy and zero error.







3.1 Organization chart




























3.2 Day- to -day activities


Accounts Section Hope Hospital

Type of work


Ø  Accounting entries

Ø  Salary Entries

Ø  Insurance related work

Ø  Bank Related Work

Ø  Loan Related Work

Ø  Provident fund related work

Ø  Reconciliation of all bank and loan accounts

Ø  Reconciliation of Blood bank, Ct MRI Oxygen ledgers.

Ø  Reconciliation of pharmacy parties

Ø  Tax related work (PF, PT, TDS, Vat, income tax, etc)

Ø  Reporting

Ø  Manual Work

Ø  Maintenance of Records

Ø  Receivable statement

Ø  Payables statement 


Accounting entries


·         Entries of IPD bills, and fileing of bills.

·         Entries of Pharmacy bills fileing of Bills, Payment of Various pharmacy Parties

·         Entries of CT Scan, MRI Scan, Blood Bank Oxygen etc fileing of statement and payment to parties.

·         Entries of implant bills fileing of bills and payment to implant parties.

·         Cross checking of cash book daily.

·         Bank reconciliation daily.

·         Handling of creditors parties (CT, Blood, MRI, Oxygen, etc)

·         Handling consultants for payment and visit fess related work.

·         Handling of staff for PF, PT, salary, salary certificate, PF withdrawal etc related work.

·         Handling of Corporate payment issues.

·         Outstanding statements of corporates.

·         Daily Admission and discharge register

·         Correspondence work




Salary Related work


·         Checking of Attendance of each staff

·         Calculation of PF PT TDS of each staff

·         Preparation of salary sheet

·         Payment of salary Cash as well as cheque

·         Entries of Salary payment in bank book

·         Salary calculation of ML Enterprises and Hope trust

·         Calculation of Contract payment

·         Salary related staff queries, and rechecking of sheet.

·         Correspondence work (bank transfer letter)

·         Deduction of salary advance, staff loan, pharmacy adv, hospital IPD, Staff welfare.

·         Entries in tally

·         Overtime calculation


Tax related work


·         TDS deduction and entries in tally

·         Payment of tds challan

·         Return filling of tds

·         Vat calculation

·         Vat payment

·         Handling of income tax survey case


Insurance related work


·         Coordination with TPA

·         Preparation of cheques of insurance

·         Reminders of polices, general insurance, life insurance, equipments, vehicles and other assets.



Bank related work


·         Bank reconciliation


Loan related work


·         Arrangement of funds before installment date.

·         Arrangement of various loan related documents for loan

·         Follow up for various works to the bank agent (like amortization schedule, account statement, insurance, etc)

·         Reconciliation of loan statement in ledger and excel sheet.


Provident fund related work


·         Nomination form

·         PF withdrawal form

·         Checking of PF deduction from salary

·         Attending PF case

·         Entries in tally

·         Payment of PF


Manual Work


·         Maintain consultant register manual

·         Daily Admission and discharge register

·         Bank ledger

·         Other manual work


















Text Box: Diagnostics














































CMO Billing


  1. He has to prepare bills of all discharged patients for that day as per the charge schedule in the minimum time. The rough bill, prepared by him, may be required to be checked by seniors ,Director. He will also collect payment of the discharged patients as per the final bill.

A discharged patient should take minimum time in settling his dues. It helps in making good public relations.

  1. He has to counsel the patient’s relative for depositing at the time of admission.
  2. Time to time updating of IP bill and recovery from patients.
  3. The copy of the advance statement should be made everyday.
  4. Files of all discharged patients after payment are sent to Medical Records Department
  5. All pending payments are informed to Director, through advance statement.
  6. Issueing the discharge summary to the patients.
  7. Collect the advances from the admitted patients, if required.








B. Senior accountant


1.      He will be responsible for the maintenance of all statutory and otherwise required books in prescribed  format.

2.      Accounts Officer will be responsible for :

(a)    Safe custody of all cash cheque-books.

(b)   Check number of cheque in the blank cheque-book recently issued by the bank.

(c)    Preserve counter foils of cheque for stipulated time period.(Till assessment is done)


3.      The cash more than Rs……required for day-to-day functioning of the hospital, should be deposited in the bank.

4.      Cash safe should be in the personal custody of the Accounts Officer. He will be responsible for any shortage etc.

5.      Money/valuables deposited by patients for staff custody will be accounted for separately.

Again accounts officer will be responsible for this.

6.      His duty will include arranging of periodical internal/external audits of amounts and deal with objections/observations raised by such audit.

7.      He will also be responsible for payment of salary to all staff whether by cheque or cash by 7th of every month.

For it he will ensure that enough cash is available on the 7th of each month for the payment of the staff.

8.      Ledgers and cashbooks will be closed at the end of each month and trail balance matched. The Trail Balance will be signed by the Accounts Officer and countersigned by the Director/Administrator.

9.      He will prepare all reports required for budgeting and future expansion of the hospital.

10.   His duties and responsibilities will also include any other work assigned by his seniors pertaining to his department.











7.1 Qualification-CMO Billing

·         BAMS or MBBS

·         Multi-lingual preferred.



  • 5 years of experience


Qualification-Senior accountant

  • Bachelor’s /Masters degree in commerce.
  • Proficiency with Microsoft Office and Tally


  • 5 years experience in hospital industry


7.3 Knowledge, skills and abilities:

  • Work requires ability to take initiative, multi-task, communicate well, problem-solve and enjoy customer interactions.
  • Ability to go out of one’s way to help patients and deliver on commitments.
  • Knowledge of customer management techniques to deliver higher satisfaction.






7.4 Staffing model-CMO Billing

  • 2 FTE. Morning –Night



Staffing model-Accountant

  • 2 FTE. Morning
  • Shift-10 -6


7.5    Infrastructure

  • Working area Accounts
  • 2 PC, Printer, telephone lines (internal / external).



Documents to be maintained:

Attendance register

Admission and discharge register

CT and MRI register

Sundry Debtors

Sundry Creditors

IPD bill file.

General file of bills

Bank voucher files

TDS File

PF related files

Insurance file

Loan files









8.1 Quality objectives

8.2 Quality Monitors

8.3 Performance Indicators








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ChaptersEvidenceIn ChargeActions
ChaptersEvidenceIn ChargeActions
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