Aravind Eye Hospital Madurai: Apex Manual-2016

Aravind Eye Hospital
Madurai
1, Anna Nagar, Thirunagar, Madurai, Tamil Nadu 625021
Contact Number: 0452 435 6100
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
APEX MANUAL (AEH / APEX – 01)

Service Name :
4th May 2016

Created on :
Designation: Chairman/Director Quality
Approved By : Name : Dr. RD Ravindran
Signature :
Designation: HOD Microbiology
Name : Dr.LalithaPrajna
Reviewed By :
Signature :
Designation:ManagerPatient Care &Quality
Issued By : Name : Ms.Neha
Signature :
Designation: HOD Microbiology
Name : Dr.LalithaPrajana
Responsibility of Updating :
Signature :
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AMENDMENT SHEET
S.No. Section No. & Details of the Reasons Signature of the Signature of the
page no. amendment Preparatory approval authority
authority
CONTROL OF THE MANUAL
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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:
Approval Review Issue
Chairman HOD Microbiology Quality Manager
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’.
Distribution List of the Manual:
Sr. No. DESIGNATION
1 Director Quality-
2 HOD Microbiology(Accreditation Coordinator) – Controlled copy
3 Quality Manager
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Table of Contents
S.No. Contents Page

1 Introduction 6
2 Vision, Mission, Goals 9
3 Values of Aravind Eye Care System 9
4 Organogram 10
5 Scope of services 11
6 Key Indicators 15
7 CODES 18
8 Statutory and regulatory requirements 19
9 Hospital Policies and Procedures 21
10 Quality Policy, Quality Objectives 42
11 Quality Management System 44
12 Committees 48
This Apex Manual has been formulated as per the fourth edition of the NABH Pre-Accreditation
Entry level Standards for Hospitals
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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
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of Andhra Pradesh, and Kerala.Aravind-Madurai handled 1200606 outpatient visits and

performed 145,403 surgeries fromApril 2015- March 2016.Out of this Paying outpatient
includes 617224 and paying surgeries include 73387 from April 2015 to March 2016. Aravind
Eye Hospital, Madurai is committed to provide 50% of its services to poor patients through free
and subsidized services
Departments:
Key StatisticsOutpatient visits and surgery statistics from April 2015 to March 2016
Outpatients Numbers Surgery Numbers

Paying 617224 Paying 73,387
Free 171343 Subsidized 43380
Outreach (camps) 130075 Free 28636
Vision centers 181352
Community centers 100612
Total Outpatients examined 1200606 Total Surgery 145403
Surgery Details from April 2015 to March 2016
Type of surgery No. of surgeries Type of surgery No. of surgeries

Cataract surgeries 96,185 Ocular injuries 524
Trab and combined 2,031 Lacrimal surgeries 2,387
procedures
Retina and vitreous 4,907 Laser procedures 27,072
surgery
Squint correction 1,181 Orbit and oculoplasty 2,856
surgeries
Keratoplasty 882 Others 2,750
Pterygium 2,094 Refractive surgery 2,534
Total Surgeries (paying and free) from April 2015 to March 2016 is 145,403
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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:
 Er. G. Srinivasan BE MS., - President
 Dr. N. Venkatesh Prajna DO, DNB, FRCO., - Secretary
As per resolution dated 18.07.2015
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2. Vision, Mission and Goals
Vision: To eliminate needless blindness

Mission: To eliminate needless blindness by providing compassionate and quality eye care
affordable to all
Goals:
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
3. Values of Aravind Eye Care System
Patient Care: We treat all patients with respect and compassion. We ensure that all patients
understand their condition and treatment.
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
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4.Organogram of Aravind Eye Hospital ,Madurai
Chairman(
AECS)
CMO
Clinical MLOP OutreachIn

Administrator Academic In
HODs Supportive Incharge charge
charge
services(La
b,
Pharmacy, Nursing
Medical Senior
Managers/PRO/ Optical, Suptdt.
PGs Officers manager
Coordinators Housekeepi
ng, X ray
Supervisor
Fellows / Tutors
Camp Camp
Organizers Admin
staff
MLOPs
MLOP
Trainees
5. Scope of Services
Outpatient Department Core Services includes General Ophthalmology and Specialty

services. Specialty services includes Paediatric Ophthalmology,Cataract services,Vitreo-retinal
services,Uvea ,Cornea services, Glaucoma, Orbit and Oculoplasty,Neuro-ophthalmology,
Contact Lens Clinic,General Medicine. Supportive Services includesLow-vision rehabilitation
services,Ocular prosthetics,Eye bank,Bio-chemistry, Microbiology, X-ray,Optical,
Pharmacy,Insurance, Travel Desk, Canteen, ATM.
Inpatient Department Core Services includes surgical and treatment services.Surgical services
includeCataract services, Paediatric Ophthalmology,Vitreo-retinal services, Cornea services,
Glaucoma,Orbit and Oculoplasty.Treatment servicesChemotherapy,Uvea, Neuro-ophthalmology
General Ophthalmology core services includes common refractive errors , spectacles,contact

lens, referral for refractive surgery, cataract evaluation and surgical advice , screening for
glaucoma, Diabetic retinopathy, Hypertensive retinopathy, management of superficial foreign
bodies, allergic conjunctivitis, Mild-Moderate dry eye, Acute Catarrahal conjunctivitis, first aid
for Ocular Emergencies, referral to specialty service
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
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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.
Vitreo-retinal services:Vitreo –retinal services dedicated to providing comprehensive

management of both medical and surgical diseases that affect the retina and vitreous. The clinic
has state-of-the-art equipment for investigation and treatment various Vitreo retinal diseases.
These include Fundus FluoresceinAngiography (FFA) and Indocynanine Green Angiography
(ICG),Optical Coherence Tomography (OCT) ,Ultrasonography (3D Ultrasound) ,Ultra Bio Microscopy
(UBM) ,Electro Retino Gram (ERG) including Multifocal ERG, Visual Evoked potential, Electro Oculo
Gram. The clinic is equipped with multiple lasers with slit lamp delivery and indirect ophthalmoscope
delivery systems. Both double frequency YAG and diode laser are available for the treatment of diabetic
retinopathy, retinal holes, tumours, retinopathy of prematurity, retinal vascular disease etc. In addition,
Transpupillary Thermo Therapy for treatment of tumours and sub retinalneovascular conditions are also
available
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
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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
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thyroid related orbitopathy are treated in collaboration with the general physician and
endocrinologist on a daily basis.
Neuro-ophthalmology:Neuro ophthalmology dedicated to the diagnosis and management of

patients with visual loss due to optic neuritis,traumatic optic neuropathy, visual defects due to
neurological disorders like stroke, intracranial tumors, hemorrhage in the brain, injuries,
pupillary abnormalities, double vision due to cranial nerve palsiers, papilledema due to raised
intracranial pressure, ocular myasthenia
PaediatricOphthalmology:Paediatric service assesses and diagnoses infant and child vision,

and provides management of common childhood vision disorders. Its core services includes
refractive Errors, Paediatric Cataract, Strabismus (above 15 years also), Amblyopia, Allergic
Conjunctivitis, Congenital Abnormalities (Globe anomalies), Congenital Glaucoma, Retinal
Dystrophies, Retinopathy of Prematurity, Retinoblastoma and treatment of the above conditions
for the paediatric age group (0-15 age group)
Exclusions under NABH
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
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9. Key Indicators
S.No. Key Indicator Definition Formula Unit Remark
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
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*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
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8 % of Patients Complications No. of post OP % Standard:<3%

with post Op identified at Post complications in
complication op check the specific period
*100
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
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14 Rate of redos This include tests No. of Redos*100 %

(Lab reports) repeated before No. of tests
release of the performed
result (to confirm
the finding
15 Equipment Downtime refers Sum of downtime Checklist
h of all equipment
downtime to periods when a for all critical ours should be updated in the
system is equipment in hours unit on daily basis to
unavailable/ or in a month monitor equipment
fails to provide or utilization and downtime
perform its
primary function
16 OP satisfaction The degree to Average score %
index which the patient’s achieved*100
expectations are
fulfilled Maximum possible
score
17 IP satisfaction The degree to Average score %
index which the patient’s achieved*100
expectations are
fulfilled Maximum possible
score
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.
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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
S.No Code name Threat indicated

1. Code Blue Medical emergency including CPR
2. Code Red Fire
4 Code Pink Child Abduction
2.1.1 The response of employees to these code announcements will be predefined

and included in the safety manual.
2.1.2 The employees of Aravind Eye Hospital are trained and educated in code
situations
2.1.3 Codes is communicated to 888/999 (extn) where the message is
communicated through PAS System
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13. Statutory and regulatory requirements
License/Certificate Number Date Department Proof of Location Valid

involved verification of relevant Upto
files
Trust Registration Certificate 296/34 of 1977 06/05/1977 Trust Act - Trust Office Lifetime
DistricRegistar Registration
office Certificate - Trust
Members
PAN AAATG2522P 14/02/1977 Income Tax PAN Card Accounts Lifetime
Department section
Employee Provident Fund TN/12217 10/07/2012 Employees PF Code Accounts Lifetime
Provident fund section
Organisation
Employee State Insurance Code:5700071921 30/05/2012 Employees State Correspondence Accounts Lifetime
0001400 Insurance letter from Sub- section
Corporation Regional Office,
ESI Corporation
Third Party - Building Engineer
Stability Certificate
Third Party - Fire -Fighting Nil 18.10.2016 Surya Fire Service Certificate - Maintenanc 17.10.201
Inspection certificate -CBE Surya Fire e 7
Service
Proprietor
OP BLOCK (Safety SEI / CBE / 284(M) /E3/91 dt License for Maintenanc Lifetime
certificate) 26.6.91 electrical e
MDU / 1217 /A2/DRG/97 DT installation -
01.09.97 Electrical and lift
MDU 276 / E3/98 DT 27.4.98 Electrical Inspectorate
MDU / 1217 /A2/2000 DT Inspectorate
23.10.2000
IP BLOCK(Safety MDU.1208 /CEIG/D5/2008-1 DT License for Maintenanc Lifetime
certificate) 16.9.2008 electrical e
MDU.1208 /EI/MDU/A2/R- installation -
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63/SC/2009 DT 17.3.2009 Electrical and lift

MDU.1208 /SEI/CBE/E1/2011 DT Inspectorate
23.05.2011
License to Store Compressed MDU/743/20B 29.02.2000 Director of Drug RETAIL Office 01-
Gas Control Authority LICENSE - 01.2012 -
FORM 21-C 31.12.201
6
OP BLOCK 2 237 /2004 01/11/2004 31/08/201
7
OP BLOCK 3 207 / 2004 05/05/2004 04/05/201
7
OP BLOCK 4 720/2012 22/11/2012 21/11/201
7
License to allow
OP BLOCK 5 721/2012 22/11/2012 21/11/201
Lift Inspector the working of
Maintenanc 7
O/o of Electrical the lift -
IP BLOCK 1 608 / 2011 04/07/2011 e 03/07/201
Inspectorate Inspectorate of
7
Lift
IP BLOCK 2 609 / 2011 04/07/2011 03/07/201
7
IP BLOCK 3 610 / 2011 04/07/2011 03/07/201
7
IP BLOCK 4 611 / 2011 05/07/2011 03/07/201
7
X-ray TN- 38372- RF- 24/05/2016 Atomic Energy TN-38372-RF- Office 24/05/202
XR Regulatory board - XR-001 1
radiology Safety Doc No 16-
Division LOEE-108309
Equipment ID -
G-XR-49970
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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
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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
1. Policies& Procedures on Access, Assessment and Continuity of Care (AAC)
AAC.1 - Policy and Procedure on Scope of Services
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
Responsibilities: Quality Manager is responsible to implement this policy and procedure.
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
The staff of Enquiry counter, Registration, Outpatient department, Counseling, Admission
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
awareness through observation or complaints, the staff is retrained on the policy.

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The relevant staff is oriented on the services provided by the hospital either by in training
program or by reading this document, as appropriate. The same to be recorded in training
record of the individual staff.
AAC.2 – Policy and Procedure on Registration of Patients
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
ophthalmology services at Aravind Eye Hospital, Madurai.
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
consultation fee previously paid.
Responsibilities: Enquiry counter staff, Registration counters staff
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.
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Registration of patients to Aravind Eye Hospital, Madurai is limited to the scope of
services provided by the hospital.
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
form will be duly signed by the patient / patient attendant.
A unique M.R. No. and Unique Identification Number (UIN) are allotted for the new
registrations and an ID card is handed over to the patient.
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
counter, the same to be carried out in parallel to treatment.
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
the registration staff and directed thereafter.
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
referred to the concerned Specialty clinic directly.
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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
be maintained at the Enquiry Counter.
Emergency and Patient on wheelchair/stretcher will be given preference and fast track
throughout the process
For details of the procedure, refer to Medical Records Department Manual.
AAC.2 – Policy and Procedure on Admission of Patients
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:
Routine Admission: A planned admission as advised by a doctor for medical or surgical
treatment and stay in the inpatient building throughout the treatment period. This involves the
patient stay one day prior to the treatment.
Day-Care Admission: A planned admission as advised by a doctor for medical or surgical
treatment and does not require stay in the inpatient building for treatment. The patient leaves
home after few hours of intervention.
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.
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Emergency Admissions: Patients presenting with emergency conditions are admitted on
holidays or after working hours, waiting for the consultation / intervention.
Admission of Observation Patients: When an observation patient is determined to require
inpatient care, the doctors’ order in the medical record to admit the patient shall be sent to the
Admission counter.
Responsibilities: Admission counter staff, Counseling staff, Ward staff
Policy
Patients are admitted only when the admission is authorized by a doctor.
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
services provided by the hospital.
No patient is to be denied admission due to race, color, religion, ancestry or national
origin.
The patient’s treating doctor shall establish the patient’s condition and provisional
diagnosis with differential diagnosis on admission.
All Insurance patients’ admissions require an authorization letter (in case of planned
admission).
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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
examination / intervention, as determined by the patient’s condition.
For specific details, refer to the policy and procedures for Medical Records Department
Manual, Insurance department Manual, Ward Manual
AAC.2 – Policy and Procedure on Transfer of Patients
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
serious impairment / dysfunction of organs / body function
Stable patients:The term “Stable Medical condition” means a medical condition not requiring
immediate medical attention / emergency intervention according to their hemodynamic status.
The patients should not have any of the following entities:
Responsibilities: Emergency Resuscitation staff, Nursing Superintendent, OP staff, Ward staff,
OT staff
Policy:
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Transfer of Unstable patients:
Unstable patients are shifted to other organizations after stabilizing the patient in
Emergency Resuscitation Room.
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
of tertiary level medical care to handle the severity
All appropriate medical reports such as discharge summary including treatment details
and investigations should be handed over during the time of transfer / discharge.
Prior intimation to be given for the receiving organization
The transfer is made in a fully equipped ambulance with identified personnel, which
includes Emergency Resuscitation Staff and a doctor, if required to accompany the
patient.
Transfer of stable patients
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
to handle the condition.
All appropriate medical reports including investigations should be handed over during
the time of transfer / discharge.
The transfer should be made with adequate transportation equipment.
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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.
Referral of Patient to Other Centre
The patients are referred to external centres, when the required services are not
available in Aravind Eye Hospital, Madurai
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
Records: Registration Information Form, Inpatient Admission Record, Emergency Resuscitation
Register
For specific details, refer to the policy and procedures for Emergency Resuscitation
Department Manual
AAC.3 Policy and procedure on patient initial assessment
Purpose
To define Policy and Procedure for initial assessment of outpatients, inpatients and
emergency patients at Aravind Eye Hospital, Madurai
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.
To provide patient with the right care at the time, it is needed.
To assure care provided to patient is based on an assessment of Patient’s relevant
physical, psychological and social needs.
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Scope: This Policy and procedure is applicable to all patients who require consultation /
treatment in the outpatient or inpatient services
Responsibilities: Outpatient department staffs, ward staff
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:
For outpatients: Visual acuity,Presenting complaints,History collection – Ocular and
systemic,Torch light examination,
For inpatients:Vital signs,Slit lamp examination,Nursing assessment,For emergency
patients:Visual acuity,History collection,Slit lamp examination
The identified personnel perform the initial assessments, as required.
Initial assessment of Patient in Outpatient department is done by the MLOP and doctor.
Initial assessments of emergency Patient are to be carried out by the doctor
immediately, as soon as patient arrives at emergency unit (Unit-1).
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
in the case record by the MLOP or the doctors.
Torch light examination is done by the doctor or the OPD MLOP and documented in
the case record.
Vital signs are collected by the MLOP
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The time frame for the initial assessment is defined accordingly.
For Outpatients: To be completed within 1 hour, from the time of registration.
For Inpatients: To be completed within 12 hours, from the time of admission. If a
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
For emergency patients: To be completed within 20 minutes, from the time of
registration.
For pediatric patients, the height, weight and the immunization status are documented
in the case sheet, as a part of initial assessment.
Records: Outpatient record, Inpatient record
For specific details, refer to the policy and procedures for Outpatient department
AAC.4 Policy and procedure on patient reassessment
Purpose:
To define Policy and Procedure for reassessment of inpatients at Aravind Eye Hospital,
Madurai
To provide patient with the right care at the time, it is needed.
To assure care provided to patient is continuous
Scope: This Policy and procedure is applicable to all patients who require consultation /
treatment in the outpatient or inpatient services
Responsibilities: Ward staff, doctors
Policies:
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Reassessment is to be performed by doctor and MLOP and must be documented in the
medical record
All patient are reassessed at appropriate interval as per each specialties protocols
Reassessment of Patient needs to be done at the following conditions:
Whenever there is a significant change in patient condition and / or Diagnosis.
When the patient feels discomfort
At the time of discharge.
Reassessments to be documented throughout the care process.
Multidisciplinary approach to be adopted, when the patient has a condition requiring
more than one specialty examination
When required, the plan of care should be revised as appropriate to the patient
condition and ongoing assessment process to be carried and this same to be
documented.
Records: Inpatient record
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
Services and laboratory safety requirements
Purpose: To define Policy and Procedure for Laboratory services provided at Aravind Eye
Hospital, Madurai
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Scope: This Policy and procedure is applicable to all patients who require laboratory services
consultation / treatment in the outpatient or inpatient services
Responsibilities: OPD staff, doctors, Laboratory Staff
Policies:Refer to Laboratory manual
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
consultation / treatment in the outpatient or inpatient services
Responsibilities: OPDstaff, doctors, Radiologists
Policies:
In AEH Madurai, radiology department only include X ray Services, for other required
radiology services patient are referred other centers KGS/ GH
The radiology department is approved from AERB (Atomic Energy Radiation board)
Radiation monitor badge (TLD badges) is worn by radiology department personnel
during the work Day and are sent regularly in every three months to the Avanttec
laboratories (P) ltd for testing the exposure of radiation of radiographers
Safety warning is displayed in front of x ray department
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Protective lead aprons are used in all exams, whenever required otherwise personnel
operate x ray machine standing behind the Lead shield
All equipment controlled by the Radiology Department is to be operated by licensed
Radiographers with specific training in Radiologic Technology
Patient will be identified by with the Radiology Request Form.
Each female patient will be asked if there is any possibility that she could be pregnant;
this response is documented on the form
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
Emergency patients / Vulnerable patient should be given priority in the radiology
department
Outsourced Imaging services

Aravind Eye Hospital shall refer patients for medical imaging for Computed Tomography (CT)
and medical resonance Imaging (MRI)
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
AAC.7 The organisation has a defined discharge process
Purpose: To define Policy and Procedure for discharge process provided at Aravind Eye
Hospital, Madurai
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Scope: This Policy and procedure is applicable to all in patients who are admitted for any
medical or surgical treatment
Responsibilities: Ward MLOP, Doctor
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
2. Policies& Procedures on Care of Patients (COP)
COP.1: Care of patients is guided by accepted norms & practice
PURPOSE: To provide guidelines for the organization for patient care
SCOPE: All patient care areas
RESPONSIBILTY: All clinical staff
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.
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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
as to provide excellent service
Uniform care is guided by laws and regulations.
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
OPD services and emergency services.
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
are identifiable by all and the chronology of care process is maintained.
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
COP.2: Emergency services including ambulance are guided by documented

Procedures
PURPOSE: To provide guidelines for the organization for emergency patient
SCOPE: All patient care areas
RESPONSIBILTY: All clinical staff
2015
POLICIES:
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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
COP.3: Documented procedures define rational use of blood and blood

Products
PURPOSE: To provide guidelines for the rational use of blood and blood products
SCOPE: Orbit OT
RESPONSIBILTY: OT staff
2015
POLICIES: Refer to Orbit Manual
COP.7: Documented procedures guide the administration of anaesthesia
PURPOSE: To provide guidelines for the administration of anesthesia
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SCOPE: GA room
2015
POLICIES: Refer to Anesthesia manual
COP.8: Documented procedure guides the care of patients undergoing

Surgical procedures
PURPOSE: To provide guidelines for the care of patients undergoing Surgical procedures
SCOPE: Operation Theater
2015
POLICIES: Refer to Operation Theater manual
3. Policies& Procedures on Management of Medication (MOM)
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)
RESPONSIBILTY: Chairman,Chief Medical Officer,Departmental Heads,Stores In-

charge,Pharmacists
2015
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POLICIES:Refer to MOM manual
4. Policies& Procedures on Patient Rights and Education (PRE)
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
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At AEH, patient is responsible for:

 Providing accurate and complete information
 Health lifestyle
 Treat others with respect and dignity
 Safe handling of the hospital property
 Following the hospital rules and regulations
 Safeguarding your belongings
 Following the treatment plan agreed upon
 Following the medical advice
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
5. Policies& Procedures on Hospital Infection Control (HIC)
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.
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RESPONSIBILTY: Hospital Infection Control committee
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.
POLICIES: Refer to HIC Manual
6. Policies& Procedures on Continuous Quality Improvement (CQI)
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
April 2015
CQI.1: There is a structured quality improvement, patient safety and continuous

monitoring programme in the organization
CQI.2: The organization identifies key indicators to monitor the structures,
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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.
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
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Aravind Eye Hospital has identified key performance indicators to monitor the clinical and
managerial areas
Quality Policy and Quality Objectives
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:
Parameters for Benchmarking

It is a process in which organizations evaluate various aspects of their processes in
relation to best practice, usually within their own sector.
The key parameters for evaluation are:
 Quality of case records (periodical evaluation)

 Service : Efficiency of the Quality and quantity of services
 Human Resources Manpower ratio according to the standard
(Ophthalmologists, MLOP and Admin), Retention and turnover of employees
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 Academic & training activities in each clinic, publications, Extracurricular

activities etc.,
 Meetings
Process
These parameters are collected by the concerned HR department from each department
4 times a year
For the month of
o January to March } 1st week of April

o April to June } 1st week of July
o July to September } 1st week of October
o October to December } 1st week of January
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
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8. Quality Management System
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 1: Quality Manual (Apex Manual)

Level 2: Standard Operating Procedures (SOP)
Level 3: Forms, Report, Records, Registers
Level – 1 Apex Manual

Contains documented Quality Policy and Quality Objectives, Policies and Procedures, Quality
Improvement, Organizational Structure and containing the documented procedures as required by the
standard
Level – 2 Standard Operating Procedures (SOP)/Departmental Manual

Containing overall Department functions describes the activities necessary to achieve process
outputs Assigns responsibility for the activity describes the method and controls to be applied
Describes when, where & why and how an activity is done. Identifies the records produced
Level – 3 Records
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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
Standard Operating Procedures is codified as AEH/Dept. Abbreviation- Issue

Number/Revision Number
Standard related records are codified as AEH/Dept. abbrev/doc abbrev –serial

number/Revision Number
Documentation: Each Department quality in charge at Aravind Eye Hospital has the overall
authority, responsibility and commitment to communicate, implement, control and supervise the
compliance of their departments with the accreditation standards. The roles and responsibility of
the Quality manager include:
Establishing and maintaining the Quality Improvement and Patient Safety Program.
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
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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.
Procedures for Internal Parameter Evaluation:

Parameter evaluation shall be conducted by the internal audit team members once in 3, 6
and 12 months.
Evaluation will be done on the set parameters.
The parameter Audit team studies the statistics, trend and recommend measures for
improvement.
The team also tracks the progress over a period of time.
All minor corrections aresuggested and discussed then and there by the auditors to the
departmental staff.
Parameter feedback report of each department is sent to the HOD of respective
department
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.
7. Policies& Procedures on Responsibilities of Management (ROM)
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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
SCOPE: Hospital Wide
RESPONSIBILTY: Top Management, Managerial staff
April 2015
ROM.1: The responsibilities of the management are defined
ROM.2: The organization is managed by the leaders in an ethical manner
ROM.3: The organization has set up multi-disciplinary committees to oversee Specific areas of
quality and patient safety
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.
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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
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3. Pharmacy Therapeutic committee

4. Quality Committee
1. Safety Committee
Frequency of Meeting Monthly once// when ever required

Members Dr.Kim/Dr.Aravind Chairpersons
Mr.Vishnu Electrical manager
Mr.JothiKurpaswamy Safety Officer
Mr. Ramanathan Radiologist
Dr.Lalitha Laboratory ( HIC committee
Chairperson)
Mr.Jeyachandran Instrument
Mr.RMS Senior Manager community
outreach
Sr.Banu OT supervisor
Sr.Jyothi CSSD
Sr.Vasanthi Pharmacy
Mrs.Varlakshmi Housekeeping
Sr.Sakthimayil Ward supervisor
Mr.Ramanath Public relation officer
Mr.Malaichamy Civil Manager
Ms.Alamelu Patient care Coordinator
Ms.Jeeva Nursing Superintendent
Ms.Deepa HR Manager
Mr. Gnana Manager Operations
Ms.Sunytha Manager in patient services
Mr.Damien Manager Patient care
Ms.Neha Manager Patient care & Quality
Ms.Shobha Managers Stores
Ms.Mala Manager Systems and IT
Ms.ChandraVadhna Fellow In EHM
Ms.Bharathi Fellow In EHM
Mr.Santhosh Fellow In EHM
Responsibilities:
 To conduct regular periodic inspection of the entire facility
(FIR) Facility Inspection Round), once in a quarter
 To identify the various safety hazards in various areas of the
hospital. To make an estimate of the damage potential,
probability of occurrence and hazard potential in r/o each and
every hazard
 To prioritize the hazards on the basis of the risk/hazard
potential worked out, for corrective action
 To find out the root cause of the hazard/problem and
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recommend corrective measures

 To submit recommendations for preventive and corrective
actions, giving the approximate cost involved and indicating
the urgency involved (immediate/urgent/deferred) on the
basis of the hazard potential
 Investigating all the sentinel/adverse events, including
recommendations to the management
 Monitoring the implementation of preventive / corrective
measures
 Maintaining a record of all the safety violations, the
investigation reports, the remedial actions taken
 Investigating the complaints (related to safety violation, the
investigation reports, the remedial action taken
 Periodic review of the safety manual and introducing
amendments where required with the approval of the
management
 Periodic review of the technical protocols related to patient
care and suggest improvements where indicated especially in
the areas/activities known to be hazardous such as
medication errors, sampling errors, surgical negligence ,
surgical site infection, needle stick injuries
 To act as a watch dog over all areas and activities of the
hospital to detect any safety violation or potential safety
hazard in the making for immediate preemptive action.
 Education and training of staff and patients about various
safety aspects
2. Hospital Infection Control Committee

Frequency of Meeting Quarterly once
Members Dr.LalithaPrajna Chairperson
Mr. G Ramesh Convener
Dr. Neeraj IOL Medical Officer
Dr.RenuRajan Retina Medical Officer
Sr.Chitra HIC Nurse
Sr.Sakthimayil Ward Supervisor
Sr.Banu OT Supervisor
Sr.Sankari House Keeping supervisor
Sr.Jyothi CSSD supervisor
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Responsibilities:  Develop policies and practices of the infection control

programme and review periodically
 Develop a system for identifying, reporting, analyzing,
investigating and controlling hospital-acquired infections
 Review reported incidence of infections, identify root causes
and establish guidelines to initiate corrective and preventive
actions Review and approve revisions of the Hospital
Infection Control Manual
 Maintain surveillance of hospital-acquired infections
 Review occurrence of clusters of infections
 Review records of all infected patients
 Develop an antibiotic policy in consultation with Clinical
Review Committee and review the use of antibiotics
 Prepare recommendations in relation to selection of
equipment used for sterilization
 Prepare and update procedure manuals in relation to aseptic
techniques used in the hospital
 Determine the policy relating to screening and immunization
of hospital staff
 Develop the content and methodology of training programs
for hospital staff in prevention and control of HAIs
 Document proceedings of the Committee
3. Pharmacy Therapeutic committee
Frequency of Meeting Once in four months or whenever required

Scope and purpose
To serve in an advisory capacity to the doctors and the
hospital administration in all matters pertaining to drug
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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
Members Dr.Rathinam Chairperson

Dr.Vedhanayaki Convener
Dr. Aravind Administrator
Dr. Banushree Physician
Mrs.Kannama HOD Pharmacy & Opticals
Dr. Liz Mary Medical Officer
Sr. Jeyanthi Medical shop in charge
MsVasanthi Pharmacist
Sr.Anbajyothi Staff Nurse
Sr.Jyothi Medical Store staff
Ms.Neha Manager Patientcare & Quality
Responsibilities:  To formulate and implement policies for selection and use of
drugs
 To develop and manage a Hospital essential drug list/ A
Hospital formulary
 To develop and implement Standard Treatment guidelines
(STG) otherwise to approve protocols for the use of cytotoxic
in specific cancers, to include shared care protocols when
appropriate
 To carry out educational and other activities aimed at
improving prescriptive and dispensing practices in the
hospital
 To monitor and report Adverse Drug reactions (ADR) and
medications errors
 To carry out Drug utilization review
 To advise the pharmacy regarding drug distribution and
control procedures
 To provide prescribes with objective drug information
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 To ensure that the audit and research activities are undertaken

in relation to prescribing of cytotoxic and associated
therapies, including adherence to chemotherapy protocols to
ensure that the evidence based prescribing is implemented in
the institution
 To be updated as applicable in consultation with Committee
members
4. Quality Committee:
Frequency of Parameter 6 month once

Meeting
Members Dr.Ravindran Chairperson
Dr.Krishnadas Director HR
Dr.Kim Chief Medical Officer
Mr.Gnana Manager Operation & HR
Ms.Neha Manager Patient Care & Quality
Ms.Deepa Manager HR
Sr.Jeeva Nursing Superintendent
Responsibilities:  To advise, guide and mentor team inclusive of key senior
clinicians to ensure delivery of highest level of patient care,
while attaining operational efficiency, credible &
compassionate image and profitability
 Review annual performance and at periodic intervals as
parameter meeting
 Any other specific program related to education and research
activities including formal and non-formal training courses /
programs.
 To regularly monitor and review the performance of the
hospital against the agreed performance measurement criteria
/ budgeted targets with regard to Volumes including
differential utilization of services, Implementation of key
strategies / specific projects and/ or activities, Provision of
strategic guidelines to individual departments / functions for
meeting targets / expansion and / or enhancement of services
 To review and advise corrections / modifications in the
management plan for effective and efficient operation of the
organization (based on the review of achievements and
periodic income expenditure statement of the unit as against
the set targets / resources), where necessary
 To formulate and implement new policies and recommend
best practices
 To discuss and decide if any change required in the objective
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and the quality policy of the hospital

 To evaluate the efficacy and the effectiveness of the Quality
Management system on the basis of, Review of previous
action points, Results of internal & external audits, Patient
feedback questionnaire (Patient satisfaction analysis),Service
Delivery monitoring, Status of corrective and preventive
actions, Supplier performance, Resource allocation, New
Technologies, Changes and improvements required on the
Quality Management System
5.Disciplinary Committee
Refer HR manual
6. Mahila Committee
Refer HR manual
8. Policies& Procedures on Facility Management and Safety (FMS)
PURPOSE:To provide guidelines for ensuring safety of Patients, their Families, Staff and
Visitors
SCOPE: Hospital Wide
RESPONSIBILTY: Top Management, Safety committee members
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
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POLICIES: Refer to the safety manual
Policies& Procedures on Human Resource Management (HRM)
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
HRM.4: The organization addresses the health needs of the employees
HRM.5: There is documented personal record for each staff member
Policy: Refer to HRM manual
10. Policies& Procedures on Information Management System (IMS)
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
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
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IMS.3: Documented policies and procedures are in place for maintaining

Confidentiality, integrity and security of records, data and information
IMS.4: Documented procedures exist for retention time of records, data and
Information
POLICY: Refer to the Medical record and Electronic medical record manual
60

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Aravind Eye Hospital

Contact Number: 0452 435 6100

APEX MANUAL (AEH / APEX – 01)

4th May 2016

Designation: Chairman/Director Quality

Approved By : Name : Dr. RD Ravindran

Designation: HOD Microbiology

Designation:ManagerPatient Care &Quality

Issued By : Name : Ms.Neha

Designation: HOD Microbiology

CONTROL OF THE MANUAL

Approval Review Issue

Chairman HOD Microbiology Quality Manager

Distribution List of the Manual:

Sr. No. DESIGNATION

2 HOD Microbiology(Accreditation Coordinator) – Controlled copy

S.No. Contents Page

2 Vision, Mission, Goals 9

3 Values of Aravind Eye Care System 9

8 Statutory and regulatory requirements 19

9 Hospital Policies and Procedures 21

10 Quality Policy, Quality Objectives 42

11 Quality Management System 44

of Andhra Pradesh, and Kerala.Aravind-Madurai handled 1200606 outpatient visits and

Outpatients Numbers Surgery Numbers

Surgery Details from April 2015 to March 2016

Type of surgery No. of surgeries Type of surgery No. of surgeries

 Er. G. Srinivasan BE MS., - President

 Dr. N. Venkatesh Prajna DO, DNB, FRCO., - Secretary

As per resolution dated 18.07.2015

2. Vision, Mission and Goals

Vision: To eliminate needless blindness

3. Values of Aravind Eye Care System

understand their condition and treatment.

Clinical MLOP OutreachIn

Outpatient Department Core Services includes General Ophthalmology and Specialty

General Ophthalmology core services includes common refractive errors , spectacles,contact

Vitreo-retinal services:Vitreo –retinal services dedicated to providing comprehensive

Neuro-ophthalmology:Neuro ophthalmology dedicated to the diagnosis and management of

PaediatricOphthalmology:Paediatric service assesses and diagnoses infant and child vision,

Exclusions under NABH

S.No. Key Indicator Definition Formula Unit Remark

8 % of Patients Complications No. of post OP % Standard:<3%

14 Rate of redos This include tests No. of Redos*100 %

S.No Code name Threat indicated

2.1.1 The response of employees to these code announcements will be predefined

License/Certificate Number Date Department Proof of Location Valid

63/SC/2009 DT 17.3.2009 Electrical and lift

1. Policies& Procedures on Access, Assessment and Continuity of Care (AAC)

AAC.1 - Policy and Procedure on Scope of Services

Responsibilities: Quality Manager is responsible to implement this policy and procedure.

The staff of Enquiry counter, Registration, Outpatient department, Counseling, Admission

awareness through observation or complaints, the staff is retrained on the policy.

program or by reading this document, as appropriate. The same to be recorded in training

record of the individual staff.

AAC.2 – Policy and Procedure on Registration of Patients

ophthalmology services at Aravind Eye Hospital, Madurai.

consultation fee previously paid.

Responsibilities: Enquiry counter staff, Registration counters staff

Registration of patients to Aravind Eye Hospital, Madurai is limited to the scope of

services provided by the hospital.

form will be duly signed by the patient / patient attendant.

registrations and an ID card is handed over to the patient.