Madurai
1, Anna Nagar, Thirunagar, Madurai, Tamil Nadu 625021
www.aravind.org
Apex Manual-2016
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Signature :
Name : Dr.LalithaPrajna
Reviewed By :
Signature :
Signature :
Name : Dr.LalithaPrajana
Responsibility of Updating :
Signature :
2
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
AMENDMENT SHEET
S.No. Section No. & Details of the Reasons Signature of the Signature of the
page no. amendment Preparatory approval authority
authority
3
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
The holder of the copy of this manual is responsible for maintaining it in good and safe condition
and in a readily identifiable and retrievable mode.
The holder of the copy of this Manual shall maintain it in current status by inserting latest
amendments as and when the amended versions are received.
Quality Manager is responsible for issuing the amended copies to the copyholders; the
copyholder should `acknowledge the same and he /she should return the obsolete copies to the
The amendment sheet, to be updated (as and when amendments received) and referred for details
of amendments issued.
The manual is reviewed once a year and is updated as relevant to the hospital policies and
procedures. Review and amendment can happen also as corrective actions to the non-
conformities raised during the self-assessment or assessment audits by NABH. The authority
over control of this manual is as follows:
The procedure manual with original signatures of the above on the title page is considered as
‘Master Copy’, and the photocopies of the master copy for the distribution are considered as
‘Controlled Copy’.
1 Director Quality-
3 Quality Manager
4
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Table of Contents
4 Organogram 10
5 Scope of services 11
6 Key Indicators 15
7 CODES 18
12 Committees 48
This Apex Manual has been formulated as per the fourth edition of the NABH Pre-Accreditation
Entry level Standards for Hospitals
5
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
1. INTRODUCTION
Blindness has been recognized as an important public health problem in India. Cataract has been
documented to be the most significant cause of bilateral blindness in India where vision < 20/200
in the better eye on presentation is defined as blindness. In India cataract has been reported to be
responsible for 50-80% of the bilaterally blind in the country.The problem of avoidable blindness
rapidly escalating remained a major cause of concern in the Indian healthcare scenario. In a
developing country the government alone cannot meet the health needs of all owing to a number
of challenges like growing population, inadequate infrastructure, low per capita income, aging
population, diseases in epidemic proportions and illiteracy.
Realizing this, Dr. Venkataswamy wished to establish an alternate health care model that could
supplement the efforts of the government and also be self-supporting. Following his retirement at
age 58 in 1976, he established the GOVEL Trust under which Aravind Eye Hospitals were
founded. The hospitals were named after SrAurobindo, one of the 20th century's most revered
spiritual leaders. In essence, Sri Aurobindo's teachings insist on transcendence into a heightened
state of consciousness and becoming better instruments for the divine force to work through.
Aravind Eye Hospital was founded in 1976, by Dr.G.Venkataswamy, a man known to most of us
simply as Dr.V.In an eleven bed hospital manned by 4 medical officers, he saw the potential for
what is today, one of the largest facilities in the world for eye care. Over the years, this
organization has evolved into a sophisticated system dedicated to compassionate service for
sight.Aravind Eye Hospital Madurai has full-fledged super-specialty clinics including, General
Ophthalmology, Retina and Vitreous, Cornea and Refractive surgery, Glaucoma, IOL, Paediatric
Ophthalmology, Neuro-ophthalmology, Uvea and Orbit and Oculoplasty with supportive and
diagnostic services. ERR (Emergency Resuscitation Room), Eye bank, laboratory and X-ray
services are available. At present the hospital having 350paying beds and 51 Day care,250 free
beds, 600 camp beds.At present Aravind Eye Hospital, Madurai has 24 vision centers and 3
community centers. AEH Madurai mainly serves the six districts of Madurai i.e. Madurai,
Dindigul, Pudukottai, Ramanathapuram, Sivagangai,Virurdhunagar covering population of
around 9.4 million population and it also serves some other districts of Madurai and other states
6
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Departments:
Key StatisticsOutpatient visits and surgery statistics from April 2015 to March 2016
Total Surgeries (paying and free) from April 2015 to March 2016 is 145,403
7
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Trust Details
Aravind Eye Hospitals are run by GOVEL Trust, a registered under Public Charitable Trust (
Registration no. 296/34 of 1977 dated 06.05.1977). Since this trust is not a private trust, this is
managed by the following Governing Body members as on 18.04.2016:
Er. G. Srinivasan
Dr. P. Namperumalsamy
Mrs. S. LalithaSrinivasan
Dr. G. Natchiar
Dr. R. Kim
Dr. S. Aravind
Dr. N. Venkatesh Prajna
Mr.Ravi Nallakrishnan
After the demise of Founder President Dr. G. Venkatasamy, the President and Secretary are
elected once in 3 years among the above Governing body members to look after the Trust affairs.
The names of the Present office bearers (i.e. President and Secretary) are as follows:
8
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
The organization aspires to perform a million surgeries and laser procedures a year by the year
2020. It set similar stretch goals for empowering and assisting other eye care organizations to
grow in parallel
Patient Care: We treat all patients with respect and compassion. We ensure that all patients
Service: We dedicate ourselves to our mission and actively seek to serve communities in need.
Discipline: We fulfill our duties through hard work and a singular focus on our shared mission.
Respect: We work as a team with open communication and consideration for each other.
Learning & Development: We engage in continuous learning through training and role-modeling
9
4.Organogram of Aravind Eye Hospital ,Madurai
Chairman(
AECS)
CMO
MLOP
Trainees
5. Scope of Services
Cataract services
The Cataract and IOL Department is a well-managed unit in providing, high-quality, high-
volume surgery with experienced doctors, adequate support staff, infrastructure and updated
technology. This is the largest cataract department in the world and is dedicated to excellence in
cataract services. It is run by a team of senior consultants who work with junior consultants,
long-term fellows and residents along with trained paramedical staff including refractionists and
counsellors.The state of art facilities available includes Femtolaser assisted cataract surgeries
(Lensx system) for all grades of normal and complicated cataracts,High end phacoemulsification
systems (Centurion, Infiniti IP) – which enable us to perform phacoemulsification (Micro
incision suture less surgery) under topical anesthesia, Microscopes (Lumera, Visulas) which help
in decreasing intra operative complications as well as incorporating specialized IOLs using
VERION precision system,Surgical instruments which help in minimal post-operative refractive
errors ,Toric planners (Version) for precise Implantation of Toric IOLs ,Zeiss Visulas YAG III
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
plus laser to treat posterior capsular opacification occurring after cataract surgery, Zeiss IOL
master to accurately calculate intra ocular lens powers in normal eyes and in eyes with pre-
existing problems (High myopes& Post retinal surgeries), iTrace -to reassess the biometry with
precision, axis determination of toric IOLs and calculating higher order aberrations, Specular
microscopy &Pachymetry which allow us to select the correct surgical options for the patients
,Digital slit lamp photography unit, Contrast sensitivity testing equipment .All types of cataract
surgeries including refractive cataract surgeries (Toric, Pseudo-accommodative lenses, LRI) and
complex cataract surgeries are performed by competent surgeons. Majority of the cataract
surgeries are performed using phacoemulsification technique.
Glaucoma services
The Glaucoma Services handle primary glaucoma’s, which are largely inherited, in addition to
secondary glaucoma’s caused by trauma, inflammation, diabetes, retinal vascular disease and
hyper mature cataracts. Deviations from normal retinal nerve fiber thickness are the earliest
structural changes in persons with glaucoma. With glaucoma services poised for significant
growth in patient services, research and training, a need-based assessment of various resources
(human, technological, etc) are planned. The clinics are equipped with the most advanced
diagnostic tools, such as the recent version of Humphrey's automated perimeter and Optical
12
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Coherence Tomography (OCT) to measure retinal nerve fiber thickness, to diagnose glaucoma at
very early stages even before there is significant loss of vision. The clinic also serves as a large
referral centre for the treatment of congenital glaucoma, a rare condition with increased eye
pressure and corneal enlargement present at birth or during the first few months of life.
Uveaclinic:Uvea Clinic handle all types of Uvea disorders both infectious and autoimmune
uveitis.The Investigations accessible are Fundus Fluorescein Angiography (FFA) with
Indocynanine Green Angiography (ICG),Optical Coherence Tomography (OCT),
Ultrasonography (3D Ultrasound),Ultra Bio Microscopy (UBM),Electro Retinogram (ERG)
including Multifocal ERG, VisualEvoked potential, Electro-oculo Gram (EOG),Blood
investigations, serological tests and TC, DC, ESR, TPHA, Mantoux, SGOT, SGPT, Polymerase
chain reaction PCR, Nested PCR, RT PCR, Bacterial and fungal smear, culture and
sensitivity,Histopathology,Fields, color vision, contrast sensitivity.Patients are referred to retina
clinic and IOL for LASER
Cornea services dedicated to the diagnosis and management of patients with corneal and
external eye diseases and provide refractive surgical services. The scope of cornea services
include Corneal Transplantation,Infectious Keratitis ( Corneal Ulcer ) management,Anterior
segment trauma assessment and management,Ocular surface disorders including Dry Eye
,Contact lens related eye problems,Stem cell and Buccal Mucosal transplantation,Amniotic
membrane transplantation, Pterygium Surgery with Fibrin Glue ( suture less), Rose K contact
lenses and collagen Cross linking with Riboflavin (C3R / laser) for Keratoconus patients.,
Keratoprosthesis, Refractive laser surgery (LASIK) and Wave front Guided Customized laser
(Zyoptix ) / PRK and FEMTO LASIK surgery, Eye Banking services.
Orbit and Oculoplasty:The orbit clinic receives a number of referrals both of common and
uncommon orbital disorders (tumors; both benign and malignant) and infections. These are
managed both conservatively (medical management / chemotherapy) and surgically with tumor
removal and the tissue sent for histopathological correlation. A large number of patients with
13
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
thyroid related orbitopathy are treated in collaboration with the general physician and
endocrinologist on a daily basis.
The Clinical serviceas per the fourth edition of the NABH Pre-Accreditation Entry level
Standards for Hospitals mentioned below are not applicable to the Scope of Services provided by
Aravind Eye Hospital and thus excluded from the Scope of NABH accreditation
COP Chapter
COP.3: Documented procedures define rational use of blood and blood products
COP.4: Documented procedures guide the care of patients as per the scope of services
provided by hospital in Intensive care and high dependency unit
COP.5: Documented procedures guide the care of obstetrical patients as per the scope of
services provided by hospital
MOM chapter
MOM.7: Documented policies & procedures govern usage of radioactive drugs
14
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
9. Key Indicators
1 Time taken for The time shall Sum of time taken minu The average time is 30
initial begin from the for the assessment tes minutes for the initial
assessment of OP patient's arrival at Total number of assessment of outpatient in
the OPD till the patients (OPD) general OPD.Those taking
time initial more than 20% of the
assessment (Initial average time will be
assessment audited. The hospital will
includes vision & make efforts to keep this
ophthalmic measure at low levels, and
assessment is track trends in times of
completed increased patient flow
2 No.of patients The time taken for No. of patient seen % Standard: >90% of the
seen within 90 a patient to be within 90 patient are seen within 90
minutes in a attended to by min in a specified minutes. In order to provide
month doctor starting period *100 priority to prompt attention
from the patient's Total no. of patient to patient needs by
registration time in attending OPD in reducing waiting time for
the clinic the specified consultation at all levels in
month the process of care
3 Waiting time for Time measured No. of patients % >75% of patient have
cataract surgery from the day a with waiting time advised for cataract surgery
decision is for cataract within 12 weeks
made(as advised surgery of < 12
by the care weeks * 100
provider and Total no. of
agrees by the patients advised
patient) on the for cataract
need for the surgery
cataract surgery to
the date of
appointment for
cataract surgery
4 Rate of Intraocular Total no. of % <0.2% (2 cases per 1000
infectious inflammation patient developing operations)
endophthalmitis judged on clinical post
grounds to be operativeendophth
caused by an almitis following
infectious process intraocular surgery
15
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
*100
Total no. of
intraocular
surgeries
5 Rate of PCR A breach in the No. of cases of % <5% (50 cases per 1000
during cataract posterior capsule PCR during operations)
surgery of the lens with or cataract surgery *
without vitreous 100
loss at any point in Total no. of
the performance of cataract surgeries
cataract surgery performed in the
period
6 Post op visual Post op visual Total no. of % standard:>85% (850 cases
acuityof 6/12 or acuity of 6/12 or patients without per 1000 operations)Post
better within 3 better within 3 ocular co operative visual acuity
months following months following morbidity, who within 12 weeks for each
cataract surgery cataract surgery in underwent patient operated, for both
in patient with patient with ocular cataract surgery in best corrected visual
ocular co- co morbidity a specified month acuity(BCVA) and unaided
morbidity (ECCE, SICS, and attained visual vision with pin hole is to be
(ECCE,SICS,Ph Phaco) acuity of 6/12 or recorded
aco) better within 3
months following
surgery *
100
Total no. of
patients without
ocular co
morbidity, who
underwent
cataract surgery in
the corresponding
month
7 % of Patients Complication No. of Intra OP % Standard:<2%
with Intra Op occurred during complications in
complication the surgery the specific
period* 100
Total no. of
surgeries done in
that period
16
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Total no. of
surgeries done in
that specific
period
9 % Resurgeries Any procedure No. of re surgeries % Standard:<1%
performed to in the specific
manage period *100
complications Total no. of
found during surgeries done in
surgery or that period
postoperatively(im
mediately or late,
but within 6
months) and
enhances the
outcome of
surgery
10 Bed occupancy The bed No. of inpatient %
rate occupancy rate is days in a given
the percentage of month *100
official beds Number of
occupied by available bed days
hospital inpatients in that month
for a given period
of time
11 Average length To measure the No. of inpatient %
of stay( duration of a days (speciality
speciality) single episode of wise)in a given
hospitalization month * 100No. of
discharges and
deaths in that
month
12 % of Re scheduling of No. of cases re %
rescheduling of patients includes scheduled *100
cataract cancellation and No. of surgeries
surgeries postponement planned
13 No. of reporting Number of No. of reporting %
errors reporting errors *1000
(Lab reports) errors/1000 Number of tests
investigation performed
17
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
12.CODES
1.1 Purpose: To design a system of notification to all employees working in the hospital
when a state of emergency has occurred.
18
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
1.2 Scope: It is applicable to all employees working in the hospital at that time.
1.3 Policy:Policy related to all the codes has been mentioned in Safety manual (Refer: Safety
Manual)
1.4 Guidelines:
2.0 Aravind Eye Hospital has established the following codes
19
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
20
13. Statutory and regulatory requirements
22
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Transplantation registration 07975/E7/2/11 04/05/2011 Eye Bank Correspondence Eye Bank 03/05/202
letter from 1
Medical and
Rural Health
Services
Department
Drugs-Bulk license MDU/508/20B 25/06/2012 Asst Director of License for Drug Pharmacy 01/04/201
MDU/477/21B Drug Control - wholesale 7
MDU/104/20F
MDU/156/20G
Drugs-Retail license MDU/74/20 25/06/2012 Asst Director of License for Drug Pharmacy 01/04/201
MDU/74/21 Drug Control - retail 7
Narcotic license NDRC 8 / 2016- 30/08/2016 NDRC- Dictrict License for Pharmacy 31/03/201
2017 Collector Narcotic drug 7
Canteen/ F & B license -OP 12416012000153 Tamilnadu Food License under OP 02/03/201
03/03/2016
Safety and drug Food Safety and Canteen 7
Canteen/ F & B license -IP 12417012000011 11/01/2017 Administration standards Act, IP Canteen 10/01/202
Dept 2006 2
License for Possession and 3/84-85 20/07/1993 License for Stores 31/03/201
use of Methylated spirit, Denatured spirit 7
denatured spirit and methyl Distric Revenue
alcohol officer
License for Possession of 1/1998-1999 20/03/1998 License for Stores 31/03/201
Rectified Spirit and ENA rectified spirit 7
NOC from Pollution Control OP - WATER- 10/03/2016 License for PCB Office 30/06/201
Board F0803 Tamilnadu 7
IP - AIR- F0803 10/03/2016 Pollution Control License for PCB Office 30/06/201
Board 7
IP - WATER- 10/03/2016 License for PCB Office 30/06/201
23
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
F0806 7
IP - AIR- F0806 10/03/2016 License for PCB Office 30/06/201
7
Bio-medical Waste 9905 01/08/2011 Ramky Energy Agreement Office 31/12/201
Management and Handling Environment Ltd between AEH 6
Authorization and RAEL
Building permit - OP Plan
276/78 08/06/1978 Office Lifetime
approval - Block A
Building Plan
Building permit - OP Plan
66/91 28/01/1991 MDU Corporation Approval Office Lifetime
approval - Block B
Drawing
161/2008 28/03/2008
Building permit - IP Plan Office Lifetime
102/2009 25/02/2009
24
14. Hospital Policies and Procedures
Purpose: To define the services provided by hospital and ensure that the staff are oriented to
these
Scope: To define the services provided by hospital and ensure that the staff are oriented to these
Policy:
Display of Services
The services provided by the hospital are displayed prominently in the language of English and
Tamil.The details of services provided are displayed prominently at the entrances of the
Outpatient and Inpatient buildings. Quality Manager is responsible to identify the requirement
of signage boards, to provide the same and rectify in case of any damage.
Staff Orientation
Counter, inpatient department and all the supportive services is trained on the scope of services
provided and not provided by the organization. The staff of Enquiry counter, registration
counter, counseling, insurance desk and admission counter are trained on the tariff policy and
any changes / updation of tariff / services / policy.If any staff is found to have lack of
The relevant staff is oriented on the services provided by the hospital either by in training
Purpose: To define Policy and Procedure for Registration of the patients at Aravind Eye
Hospital, Madurai
Scope: This Policy and procedure is applicable to all patients who undergo Registration for
Definition
New Registration: Any patient who walks in to Aravind Eye Hospital for the first time is
considered as a new patient and is charged a sum of Rs.50 as consultation fee. This
consultation fee is valid for a period of 90 days or first 3 visits within 90 days whichever is
earlier.
Review Registration: Patient who visits the hospital for the second time onwards is
considered as a revisit patient and is charged the consultation fee based on the validity of the
Policy
Aravind Eye Hospital, Madurai provides care to all patients who walk into the facility.
No patient will be denied registration due to race, color, religion, ancestry or national
origin.
26
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
It is the policy of AEH - Madurai to register all the patients presenting themselves for
care and shall be registered at the registration counter and then only assessed by the
consultants.
All Patients register at the hospital with a general consent for treatment. The consent
A unique M.R. No. and Unique Identification Number (UIN) are allotted for the new
The patient shall use this ID number for further follow-up at the hospital.
When the patient presents with an ocular emergency condition at the registration
Other patients requiring consultation are referred to the General Outpatient department.
Patients who already have the reference letter are directed to the concerned OPD for
further evaluation. For patients who do not have reference, the needs are identified by
Patients who need specialty care (both surgical & non-surgical) are to be evaluated by
the General Ophthalmology Department to identify the required Specialty and are
27
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
When there is no provision to treat the patient in the hospital, assist to transfer the
patient to other hospitals where provision exists. For this a list of nearby Hospitals shall
Emergency and Patient on wheelchair/stretcher will be given preference and fast track
Purpose: To define Policy and Procedure for Admission of the patients at Aravind Eye Hospital,
Madurai
Scope: This Policy and procedure is applicable to all patients who undergo Admission for
surgical or medical treatment, as advised by the doctor in Aravind Eye Hospital, Madurai.
Definitions:
treatment and stay in the inpatient building throughout the treatment period. This involves the
treatment and does not require stay in the inpatient building for treatment. The patient leaves
Day admit Admission: A planned admission as advised by a doctor for medical or surgical
treatment and requires stay in the inpatient building only after intervention.
28
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
inpatient care, the doctors’ order in the medical record to admit the patient shall be sent to the
Admission counter.
Policy
The patient pays a partial amount in advance or pays the full amount and gets admitted
in the Inpatient building. The remaining amount will be collected or returned during the
time of discharge.
AEH Madurai receives all patients who are getting admitted, limited to the scope of
origin.
The patient’s treating doctor shall establish the patient’s condition and provisional
All Insurance patients’ admissions require an authorization letter (in case of planned
admission).
29
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
For patients presenting with emergency conditions after working hours or on holidays,
the patient shall be examined by the duty doctor and shall be admitted for further
For specific details, refer to the policy and procedures for Medical Records Department
Purpose: To define Policy and Procedure for transfer and referral of the patients at Aravind Eye
Hospital, Madurai
Scope: This Policy and procedure is applicable to all stable / unstable patients who need transfer
/ referral, where the required services are not available in Aravind Eye Hospital, Madurai.
Definition
Unstable patient: The term “UnStable Medical condition” means a medical condition
manifested by acute symptoms within such severity that in the absence of immediate medical
attention probably may result in placing the health of the individual in serious jeopardy and / or
Stable patients:The term “Stable Medical condition” means a medical condition not requiring
OT staff
Policy:
30
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Unstable patients are shifted to other organizations after stabilizing the patient in
The same is done when the service required is not available in Aravind Eye Hospital,
Madurai.
It should be confirmed that the receiving organization has adequate resources / services
All appropriate medical reports such as discharge summary including treatment details
and investigations should be handed over during the time of transfer / discharge.
The transfer is made in a fully equipped ambulance with identified personnel, which
patient.
Stable patients are shifted to other organizations after being treated in emergency(ERR)
The same is done when the service required is not available in Aravind Eye Hospital,
Madurai
It should be confirmed that the receiving organization has adequate resources / services
All appropriate medical reports including investigations should be handed over during
31
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Treatment details and time shifted out is noted in the ERR register
The transfer can be arranged, in consultation with the patient and the attendant.
The patients are referred to external centres, when the required services are not
While referring, the patient has to be given a referral letter with the details of reason for
referral and same detail is documented in the transfer note at each area
Register
For specific details, refer to the policy and procedures for Emergency Resuscitation
Department Manual
Purpose
To define Policy and Procedure for initial assessment of outpatients, inpatients and
To outline a systematic process for gathering pertinent clinical data about a patient.
To establish a comprehensive information base for decision making about patient care.
32
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Scope: This Policy and procedure is applicable to all patients who require consultation /
POLICY
The initial assessments are standardized according to the need of the department.
The list of the minimum initial assessment to be followed in all the departments is as
follows:
Initial assessment of Patient in Outpatient department is done by the MLOP and doctor.
Visual acuity of the patient is documented in the case record by the Refraction MLOP.
Presenting complaints and the systemic and ocular history of the patient is documented
Torch light examination is done by the doctor or the OPD MLOP and documented in
33
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
detailed assessment has been done in OPD on the same day, it need not be written in
detail again. But , there shall be a comment linking the assessment to the earlier
assessment and the finding of all such assessment is being reviewed and or verified
registration.
For pediatric patients, the height, weight and the immunization status are documented
For specific details, refer to the policy and procedures for Outpatient department
Purpose:
To define Policy and Procedure for reassessment of inpatients at Aravind Eye Hospital,
Madurai
Scope: This Policy and procedure is applicable to all patients who require consultation /
Policies:
34
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
medical record
All patient are reassessed at appropriate interval as per each specialties protocols
When required, the plan of care should be revised as appropriate to the patient
documented.
For specific details, refer to the policy and procedures for Ward Department Manual
AAC.5 Laboratory services are provided as per the scope of the hospital’s
Purpose: To define Policy and Procedure for Laboratory services provided at Aravind Eye
Hospital, Madurai
35
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Scope: This Policy and procedure is applicable to all patients who require laboratory services
AAC.6 Imaging services are provided as per the scope of the hospital’sservices and
established radiation safety programme
Purpose: To define Policy and Procedure for imaging services provided at Aravind Eye
Hospital, Madurai
Scope: This Policy and procedure is applicable to all patients who require imaging services
Policies:
In AEH Madurai, radiology department only include X ray Services, for other required
The radiology department is approved from AERB (Atomic Energy Radiation board)
during the work Day and are sent regularly in every three months to the Avanttec
36
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Protective lead aprons are used in all exams, whenever required otherwise personnel
Each female patient will be asked if there is any possibility that she could be pregnant;
The patient is appropriately prepared by removing clothing, jewelry, and/or other articles
from the body that may obstruct the radiographic image, and is shielded for the procedure
whenever possible
department
All Aravind Eye Hospital patients shall be identified with their Name, Age, Sex and Aravind Eye
Hospital’s medical record number/ Unique Identification number
An imaging test requisition slip will be given to the referred diagnostic center
Purpose: To define Policy and Procedure for discharge process provided at Aravind Eye
Hospital, Madurai
37
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Scope: This Policy and procedure is applicable to all in patients who are admitted for any
Policy:
Discharge summary is given to all the patients who are admitted at AEH, Madurai for
any surgical or medical intervention including medico legal cases and patient leaving
against Medical advice
For patient leaving against medical advice the risks related to leaving without taking
complete treatment , LAMA form will be filled and get signature form the patient
/Attendant by the ward MLOP /duty doctor
At the time of discharge patient along with his or her attendant medication instructions
should be explained by the MLOP
In case of the patient’s death, the summary should include the cause of the death
Discharge summary also includes when and how to obtain the urgent care
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April
2015
POLICIES:
The planning and provision of care shall be based on individual patient assessment.
38
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
All patients are treated alike irrespective of their religion, cast, social status, financial
ability etc. The safety of all patients seeking health care at this hospital is the prime
responsibility of this hospital. A uniform patient care system is laid down in all areas so
Aravind Eye Hospital has the policy for delivering uniform care to all patients
irrespective of the care setting right from the admission to discharge for IPD cases, in
It is further ensured that the care and treatment orders are legibly signed, named, timed
and dated by the concerned doctors, the main idea being that the authors of these orders
Clinical practice guidelines are adopted to guide patient care whenever possible.
For more detail on the clinical practice Refer to each specialty, general OPD and ward manual
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April
2015
POLICIES:
39
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Ocular emergency patients: (Any injury, sudden loss of vision, acute endophthalmitis, CRAO,
Macula “on” retinal detachment, Angle closure glaucoma, congenital glaucoma and patient on
stretcher)
Ocular emergency patient will be prioritized at every station
Systemic Emergency:In case if any patient get systemic emergency then patient will be shifted
to the ERR (Emergency Resuscitation room) , where patient will be attended by physician and if
patient required speciality opinion then will be referred to other hospital .
Policies:
All eye emergencies will be attended on a priority basis
Patient’s with injury which is in the judgment of the consultant having legal implications
will be considered as medico-legal cases and after rendering treatment will be intimated
to the police station.
All emergencies for which this hospital is not equipped to handle will be appropriately
referred.
A summary of the treatment will be given.
For specific details, refer to the policy and procedures for ERR Manual
PURPOSE: To provide guidelines for the rational use of blood and blood products
SCOPE: Orbit OT
RESPONSIBILTY: OT staff
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April
2015
40
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
SCOPE: GA room
RESPONSIBILTY: OT staff
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April
2015
PURPOSE: To provide guidelines for the care of patients undergoing Surgical procedures
RESPONSIBILTY: OT staff
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April
2015
PURPOSE: To provide guidelines for the organization for pharmacy services, management and
usage of medication.
To provide guidelines for the organization for procurement and usage of implantable prostheses
SCOPE: Pharmacy and other Patient Care Areas – Outpatient department (OPD), Inpatient
department (IPD) and Free Hospital (FH)
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April
2015
41
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
PURPOSE: To provide guidelines for the organization on patient rights and education
SCOPE: All patients who avail services at Aravind Eye Hospital, Madurai
RESPONSIBILTY: Hospital wide – all staff’s (Enquiry Counter, Clinical and Non-clinical
department staff and paramedical staff involved in direct patient care.
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition,
April 2015
PRE.1: Patient rights are documented displayed and support individualbeliefs, values and
involve the patient and family in decision making processes
PRE.2: Patient and families have a right to information and education about their healthcare
needs
POLICY:
Aravind Eye Hospital identifies and ensures that the Patient and Patient’s family
member’s rights are protected.
The following are the Patient and Patient’s family rights followed by Aravind Eye
Hospital, Madurai
To Provide information and education about their healthcare needs
To respect for personal dignity and privacy during examination, Procedures
and treatment
To protect patients from physical abuse or neglect
To treat patient information as confidential
To obtain informed consent before carrying out procedures
To provide information on how to voice a complaint
To provide information on the expected cost of the treatment
To have access to his / her clinical records
Patient’s Responsibilities
42
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Patient and family rights are displayed bilingual in OPD as well as in IP block. These rights shall
be respected and protected by entire staff of the AEH Madurai.
Staff shall be made aware of their responsibility towards protecting of patients and family rights.
Violation of patient rights is recorded, reviewed and corrective / preventive measures taken by
the designated official in accordance with Indian medical council code of conduct.
Patient and patient’s family members are informed about their rights in two
languages (English and Tamil) as appropriate.
This is done by playing Patient rights and responsibilities on the display board in the hospital and
also available in form of brochures
Brochures and poster are available related to the patient’s right and responsibilities
PURPOSE: To provide safety for patient and employee within the hospital environment through
an infection control program
SCOPE:
The hospital infection control programmes are to prevent or minimize the Potential for infections
to patients as well as to staff.
43
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition,
April 2015
HIC.1: The hospital has an infection control manual, which is periodically updated and conducts
surveillance activities.
HIC.2: The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections
(HAI) in patients and employees.
HIC.3: Bio-medical Waste (BMW) management practices are followed.
PURPOSE:
To guide and ensure the continuous improvement of quality services provided byAravind Eye
Hospital.
To fix key indicators for the processes, to organize measurement process to assess the
performance index on such key indicators.
Scheduling of periodical measurement of performance index of key indicators
To identify appropriate tools for continual improvement
SCOPE:
Hospital Wide – All patient care areas
Applicable to all employees of the hospital
RESPONSIBILTY:
All hospital staff and Core/Quality Assurance Committee
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition,
April 2015
44
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
processes and outcomes which are used as tools for continual improvement
DEFINITION:
Quality Indicators: Quality indicators are the means to judge the real performance of certain
clinical as well as managerial parameters selected for monitoring and evaluation.
Non Conformance: Defined as any event or circumstance not consistent with the standard
routine operations or not having compliance to defined processes of the hospital in staff
functions on support activities to internal/external customers or on care processes to patients.
Sentinel Events: An unexpected occurrence involving death or serious physical or psychological
injury, or the risk thereof to a patient, visitor, or an employee. Serious injury specifically
includes loss of vision. The phrase, “or the risk thereof”, includes any process variation for
which a recurrence would carry a significant chance of a serious adverse outcome.
Near Miss: Any process variation which did not affect the outcome but for which a recurrence
carries a significant chance of a serious adverse outcome.
Hazardous conditions: Refer to any set of circumstances (exclusive of disease or condition for
which the patient is being treated), which significantly increases the likelihood of a serious
adverse outcome. Lapse in compliance to statutory safety norms resulting in near miss harms the
patients/ staff /visitors or to infrastructure.
Quality improvements: It is an ongoing response to quality assessment data about a service in
ways that improve the process by which services are provided to the patients.
Risk management: Clinical and administrative activities to identify evaluate and reduce the risk
of injury.
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition,
April 2015
POLICY:
Quality improvement and patient safety programme shall be implemented by Quality & Safety
Team
The Hospital management makes available adequate resources required for quality improvement
and patient safety program
45
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Aravind Eye Hospital has identified key performance indicators to monitor the clinical and
managerial areas
Quality Policy
To ensure quality in every aspect of eye care, delivered in a timely manner with utmost safety to
the patient and thus achieve high level of patient satisfaction
Quality Objectives
To ensure respect for patients' values, preferences and expressed needs (equity / patient
centred care)
To provide a safe environment for patients and staff (safety)
To ensure that clinical outcomes are comparable to the best in the world (effectiveness)
To ensure appropriate communication to allow patients to make an informed decision
while alleviating any fear and anxiety (communication)
To ensure services offered are cost effective to the patients (efficiency)
To ensure that there is a focus on timely delivery of care (timeliness) both in the delivery
and by empowering the patients to seek timely care
To ensure employee satisfaction by providing an enabling work environment
Measurement:
46
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Process
These parameters are collected by the concerned HR department from each department
4 times a year
For the month of
Evaluation
Each department will present this parameters report in their weekly and monthly
meeting and decide the actionable items
Quarterly Review meeting with CMO and Clinical Heads and send the report to
AMECS Central office
Internal Communications: The top management has defined and implemented an effective and
efficient process for communicating the Quality Policy, Objectives, Quality management
requirements and accomplishments.
This helps the hospital to improve the performance and directly involves its people in the
achievement of the Quality Objectives.
The Management actively encourages feedback and communication from people in the hospital
as a means of involving them through the following modes:
Parameter meeting
Weekly Operations meeting
Department meeting
Clinical meeting
47
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
QMS Structure
The Hospital quality management system is documented in Apex Manual, which lay down the
architecture of QMS followed at Aravind Eye Hospital, policies of hospital and references to the
procedure related to the policies, describes how and in what term quality of AEH service
delivery get measured, monitored and improved
QMS Documentation
The QMS Documentation of Aravind Eye Hospital is addressed in 3 levels. Some are maintained
as soft and some as hard copies. The documentation consists of the
Level – 3 Records
48
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Provide objective evidence of and demonstrate conformance to specified requirements and the
Management System; are retained for specified period
Document Preparation
All the documents within the scope of QMS are prepared by the respective process owners and
checked for accuracy prior to authorization & distribution
Identification and Codification. They are codified as Apex Manual is codified as AEH/Apex
manual-xy, where x indicates the issue and y indicates the revision
Document Control:
Documents such as regulations, standards, and policies, SOPs, manuals and other
normative documents as well as drawings, software form part of the Hospital Quality
Management System.
A copy of each of these controlled documents shall be archived for future reference and
the
documents shall be retained in their respective department.
The documents are maintained in paper or electronic media as appropriately required.
The Heads of the Departments of the respective departments shall review all
documentsand shall approve it for the use
49
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
Document Changes:
Revision of policies and procedures is carried out when necessary by the original author
and updated at least once in a year.
When alternate persons are designated for review, they shall first familiarize themselves
with pertinent background information upon which to base their review and approval.
Document control system does not follow for the amendments by hand unless there is an
extreme circumstance.
These amendments shall be marked, initialled and dated only by the authorized person.
The amendment shall be brought to the notice of the Quality manager and the same shall
be reissued.
Accreditation coordinatorat Aravind Eye Hospital, Madurai has the overall authority,
responsibility and commitment to communicate, implement, control and supervise the
compliance of various departments with the accreditation standards.
50
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
PURPOSE:
To define the responsibilities of those responsible for governance.
To ensure that the organization is registered with appropriate legal authorities
To ensure that the organization is managed in an ethical manner
To define responsibilities of multi-disciplinary committees for overseeing specific
aspects of quality and patient safety
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition,
April 2015
ROM.1: The responsibilities of the management are defined
ROM.3: The organization has set up multi-disciplinary committees to oversee Specific areas of
POLICIES:
The hospital shall have a documented Organogram, defining clearly the responsibilities of key
personnel
The persons responsible for management shall support the quality improvement and patient safety
plans of the organization
The organization is registered with (appropriate authorities) Indian Medical Association as single,
super specialty hospital, with 351 beds
The hospital’s top management shall define, document and establish the following in the
organization: Mission, Vision Values, Quality policy and initiatives
The organization shall display the following: Ownership, Services provided, standard billing
tariff and billing
The leaders / Management guide the Hospital to function in an ethical manner.
51
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
The organization shall document agreements for all the outsourced services such as those given
below and monitor them periodically Security, Referral of patients for treatment, Diagnostic tests,
Investigations, Maintenance – Air-conditioning, electrical, lifts, etc.
The Hospital has multi-disciplinary committees covering core /Quality assurance, Safety,
Infection Control, Pharmacy & Therapeutics, disciplinary, Grievance, welfare committees and the
membership, responsibilities and periodicity of meetings of each shall be defined
Committees:
Committee procedure:
Committee shall discuss, implement and monitors the scope of activities identified for
respective committees.
Chairman and convener of the committee shall bear the responsibility of committee
functioning.
Each committee shall maintain a file to record their proceedings, decisions taken and
instructions framed.
Committees shall record their proceedings, document minutes and monitor the
implementation of decision taken.
Committees shall distribute the work amongst members as required and develop their
own guidelines for functioning.
Necessary instructions shall be passed on to the relevant staff through circulars and a
copy of all these shall be retained in committee’s file.
Hospital and staff are obliged to follow the instructions.
Committee shall review their functioning at appropriate intervals, as decided by chairman
/ convener, to assess their functioning.
Following committees have been constituted:
1. Safety Committee
2. Hospital Infection Control Committee
52
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
1. Safety Committee
53
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
54
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
55
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
usage
To develop a formulary of drugs, for use in the hospital
and provide for its regular revision
The committee should lay down procedures that help
ensures cost containment in drug therapy
To review ADR(Adverse Drug reactions), if any,
occurring in the hospital
To assure quality standards in drug procurement and
distribution systems
56
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
4. Quality Committee:
57
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
5.Disciplinary Committee
Refer HR manual
6. Mahila Committee
Refer HR manual
PURPOSE:To provide guidelines for ensuring safety of Patients, their Families, Staff and
Visitors
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April 2015
FMS.1: The organization’s environment and facilities operate to ensure safety of patients, their
families, staff and visitors
FMS.2: The organization has a program for clinical and support service Equipment management
FMS.3: The organization has provisions for safe water, electricity, medical gasand vacuum
systems
FMS.4: The organization has plans for fire and non-fire emergencies within the facilities
58
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
PURPOSE:
SCOPE:
Applicable to all employees of the hospital
RESPONSIBILTY:HR department
Reference: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition, April 2015
HRM.1: The organization has staffing commensurate with patient care needs
HRM.2: There is an on-going programme for professional training and Development of the staff
HRM.3: The organization has a well-documented disciplinary and grievance handling procedure
PURPOSE: To meet the information needs of the care providers, management as well as other
agencies that require data and information from the organization as per the prevailing laws and
regulations.
SCOPE: Hospital Management, Health Care Providers, TPA – Insurance companies, Patients,
Government agencies
RESPONSIBILTY: IT staff, Medical records department staff, EMR team
REFERENCE: NABH Pre Accreditation Entry Level Standards for Hospitals, fourth Edition,
April 2015
IMS.1: The organization has a complete and accurate medical record for every
Patient
IMS.2: The medical record reflects continuity of care
59
Doc no. AEH/Apex
Aravind Eye Hospital manual-01
Issue No. 01
Madurai Rev No. 00
Apex Manual Date of issue
Pages
04/05/2016
1-58
POLICY: Refer to the Medical record and Electronic medical record manual
60