Checklist of training topics (Department wise)

Top Management Training topic Coverage Relevant to

Top management Vision, Mission and
personnel and heads of Values of the RoM
departments organization
Rights of a patient
managers of patient care
and how to protect PRE
departments
the same
admin in-charge of emergency Handling of medico-
CoP
dept. legal cases

Entire Staff Training topic Coverage Relevant to

All staff • Clinical services offered by the
Scope of hospital
hospital AAC
services
• Services not in scope
All staff for their role, Handling of disaster
Entire plan of managing epidemic
and specifically. situations, community
and disaster situation.
emergencies and CoP
Mock drills must be conducted
mass casualty
for this
situations
Rights of a patient
All staff and how to protect PRE
the same
Needlestick injury
All patient care staff HIC
protocol
In-charge and staff of each Quality indicators of
CQI
department each department
All staff involved in patient care Patient safety
CQI
activities practices
All staff involved in patient care Reporting of patient
CQI
activities safety events
All staff involved in patient care
Sentinel events CQI
activities
In-charge and staff of each
department, especially Scope of services in Services in scope and not in
RoM
of obstetric and paediatric each department scope
departments
Use of fire
All staff FMC
extinguisher
Vision, mission, values, patients’
All staff upon recruitment Induction training rights, infection control, safety, HRM
service standards
Employee rights and
All staff HRM
responsibilities
Training and
All staff HRM
development policy
Performance
All staff HRM
appraisal system
Disciplinary and
All staff grievance handling HRM
process
Prevention of sexual
All staff HRM
harassment
All staff of emergency. Handling of disaster
• Entire plan of managing
situations, community
epidemic and disaster situation.
emergencies and CoP
• Mock drills must be conducted
mass casualty
for this
situations
 Front Office
Front office and admission
Staff of reception, registration
and admission (including staff
handling emergency
admissions)
Front office staff
Customer care
executives, Admission and
discharge staff
Customer care executives,
nurses
Medical Department
Duty doctor, Consultants to be
oriented
Doctor in-charge of
emergency
Orientation to all consultants
Consultants, Duty doctors
Consultants, duty doctors
and nurses
Consultants and duty
doctors
Consultants and clinical
committee
Consultants, duty doctors,
nurses, therapists and MRD
staff
Duty doctors, consultants
Surgery resident doctors,
surgeons
Doctors
duty doctors
Duty doctors
doctors
doctors
Training topic Coverage Relevant to
• Clinical services offered by the
Scope of hospital
hospital AAC
services
• Services not in scope
• Admission policies
Registration and ad • Managing during non-
AAC
mission of patient availability of beds
• Handling un-identified patients
Rights of a patient
and how to protect PRE
the same
Normal discharge, Discharge on
Discharge process AAC
request, DAMA, Death
Patient feedback and Feedback mechanism and
PRE
complaints complaint processes
Training topic Coverage Relevant to
Contents to be included in
Discharge summary AAC
discharge summary
Handling of medico-
CoP
legal cases
Admission and
CoP
discharge criteria
Safe and rational
prescription of MoM
medicines
Taking consent from General consent and informed
PRE
patients consent
Antibiotic policy HIC
Medical audit CQI
Medical record Contents, legibility, use of
IMS
documentation abbreviation, endorsements
Rights of a patient
and how to protect PRE
the same
Pre-surgery, during surgery and
post-surgery safety measures.
These include things like site and
side marking, time out and sign
Surgical safety CoP
out process, infection control etc.
WHO surgical safety checklist
would be a good reference
material.
Bio-medical waste Segregation, storage,
HIC
safety transportation, disposal
Internal and External transfers
Safe transfer of
Transfer of stable and unstable AAC
patient
patients
Normal discharge, Discharge on
Discharge process AAC
request, DAMA, Death
CPR, use of crash cart, other life
Basic Life support CoP
support measures
Code blue system Code blue process, CPR CoP
 Mock drills must be conducted
for this
Care of vulnerable Vulnerability assessment,
duty doctors CoP
patients identification and care
Care of patients
resident doctors, consultants Physical and chemical restraints CoP
under restraint
doctors in ICU End of life care CoP
Procedure to obtain
duty doctors medicine when MoM
pharmacy is closed
High-risk medicine
duty doctors MoM
safety
Verbal orders for
duty doctors and consultants MoM
medicines
Patient identification, checks
Safe administration
duty doctors during administration, post MoM
of medicines
administration monitoring
Reporting of
duty doctors MoM
medication errors
Standard
duty doctors Hand hygiene, use of PPE HIC
precautions
Safe injection and
duty doctors HIC
infusion practices
Isolation/barrier
duty doctors HIC
nursing
Credentialing and
Consultants to be oriented.
privileging of medical HRM
Duty doctors
professionals
Data in medical records, registers
duty doctors, patient care Safety and security of
and computers. Access to medical IMS
executives patient’s data
records
Rational use of blood, blood
Safe blood
duty doctors storage, prevention of error while CoP
transfusion
transfusion, transfusion monitoring
Look-alike and sound Storage, issue and administration
duty doctors MoM
alike medication of LASA medicines

In-Patients Department Training topic Coverage Relevant to

Staff in paediatric ward/ICU
Staff in paediatric ward/ICU,
Security staff, All other staff
Care of paediatric Paediatric assessment, safety of
CoP
patients children, dealing with children
Code pink procedure, safety
Prevention of child
measures, action in case of such CoP
abduction and abuse
events

Nursing Department Training topic Coverage Relevant to

Nurses Internal and External transfers
Safe transfer of
Transfer of stable and unstable AAC
patient
patients
Nurses Normal discharge, Discharge on
Discharge process AAC
request, DAMA, Death
Triage nurse Triage in routine cases and
Triaging of patients triaging during mass casualty CoP
situation
All nurses CPR, use of crash cart, other life
Basic Life support CoP
support measures
Code blue process, CPR
All nurses Code blue system Mock drills must be conducted CoP
for this
 Care of vulnerable Vulnerability assessment,
All nurses CoP
patients identification and care
Care of patients
Nurses, nursing in-charges Physical and chemical restraints CoP
under restraint
Nurses End of life care CoP
Procedure to obtain
Nurses medicine when MoM
pharmacy is closed
High-risk medicine
Nurses MoM
safety
Verbal orders for
Nurses MoM
medicines
Patient identification, checks
Safe administration
Nurses during administration, post MoM
of medicines
administration monitoring
Reporting of
Nurses MoM
medication errors
Patient
Feedback mechanism and
nursing in-charges feedback and PRE
complaint processes
complaints
Standard
Nurses Hand hygiene, use of PPE HIC
precautions
Safe injection and
Nurses HIC
infusion practices
Laundry and linen
Nurses and laundry staff HIC
management process
Prevention of HAI in Care bundles for CA-UTI, VAP,
Nurses, especially ICU nurses HIC
patients SSI and CA-BSI
Isolation/barrier
Nurses HIC
nursing
Infection control team, Nursing Infection outbreak
Identification and action HIC
in-charges handling
Infection control
Infection control team HIC
surveillance
Sterilization process and quality
CSSD staff Sterilization activities HIC
control
Credentialing and
nursing in-charges privileging of medical HRM
professionals
Data in medical records, registers
Safety and security of
nursing in-charges and computers. Access to medical IMS
patient’s data
records
Credentialing and
All nurses and nursing in-
privileging of nursing HRM
charge to be oriented
professionals
Rights of a patient
Nurses and how to protect PRE
the same
Handling of medico-
Nurse in-charge CoP
legal cases
Pre-surgery, during surgery and
post-surgery safety measures.
These include things like site and
side marking, time out and sign
Operation theatre nurses Surgical safety CoP
out process, infection control etc.
WHO surgical safety checklist
would be a good reference
material.

Nurses.
nurses
nurse in-charge (for storing in
wards)
nurses
Laboratory Department
Lab technicians
Phlebotomist, Lab technician
Lab technicians
Technical supervisors, Lab
technicians and pathologists
All laboratory staff (technical
and non-technical)
X-Ray Department
Imaging technicians
Imaging technicians
Technical supervisors, imaging Quality control in
technicians and radiologists
All staff in imaging (technical
and non-technical)
Technical supervisors, imaging Safe disposal of
technicians and radiologists
All lab technicians and
supervisors
Dietetic Department
Dietician, Nurses
Kitchen staff and dietician
Ambulance Department
Ambulance staff and nurse-in-
charge of emergency
Bio-medical waste Segregation, storage, HIC
safety transportation, disposal
Rational use of blood, blood
Safe blood
storage, prevention of error while CoP
transfusion
transfusion, transfusion monitoring
Safe storage of MoM
medication
Look-alike and sound Storage, issue and administration MoM
alike medication of LASA medicines
Training topic Coverage Relevant to
Standard operating
procedures of various AAC
lab tests
Aseptic sample collection, patient
Collection of samples safety, labelling or samples, safe AAC
transportation and storage
Panic values, identification,
Intimation of critical confirmation and
AAC
lab results communication of critical
results
Calibration, verification, validation,
Quality control in surveillance, Internal quality
AAC
laboratory assurance, external quality
assurance
Lab waste disposal, infection
Laboratory safety control, chemical safety, Use of AAC
PPE
Training topic Coverage Relevant to
Standard operating
procedures of various AAC
imaging tests
Panic findings, Identification,
Intimation of critical
confirmation and communication AAC
imaging findings
of critical results
Calibration, verification, validation,
surveillance, clinical correlation, AAC
Imaging
clinician’s feedback
AERB regulations, Use and
Radiation safety AAC
upkeep of radiation safety devices
Types of radio-active waste,
health and environmental effect, AAC
radio-active waste
disposal
Safe transportation and shifting of
Safety of patient
patient, patient screening, safety AAC
undergoing imaging
in MRI
Training topic Coverage Relevant to
Nutritional screening
CoP
and assessment
Safe handling of food HIC
Training topic Coverage Relevant to
Maintenance of Equipment, medicines,
CoP
ambulance maintenance, communication
Ambulance staff and
emergency medical
technicians
Ambulance staff and nurse-in-
charge of emergency
Ambulance staff and
emergency medical
technicians
Handling of Road traffic accidents, trauma,
emergency patient unconscious patients, patient in CoP
on-site cardiac arrest etc.
Maintenance of Equipment, medicines,
CoP
ambulance maintenance, communication
Handling of Road traffic accidents, trauma,
emergency patient unconscious patients, patient in CoP
on-site cardiac arrest etc.

Blood Bank Department Training topic Coverage Relevant to

Blood bank technicians,
Blood bank staff
blood bank technicians
Rational use of blood, blood
Safe blood
storage, prevention of error while CoP
transfusion
transfusion, transfusion monitoring
Disposal of blood CoP
Bio-medical waste Segregation, storage,
HIC
safety transportation, disposal

Pharmacy & Stores Dept Training topic Coverage Relevant to

Store in-charge, pharmacy in- Safe storage of MoM
charge medication
Store and pharmacy in- Inventory analysis and MoM
charge control
Store and pharmacy staff, Look-alike and sound Storage, issue and administration MoM
nurses and duty doctors alike medication of LASA medicines
Safe dispensing of MoM
Pharmacy staff
medicine
Store and pharmacy in- MoM
Medication recall
charge
Safe usage of MoM
Staff involved in Preparation, administration and
chemotherapeutic
chemotherapeutic medicines disposal
medication
Staff involved in radioactive Safe usage of radio- MoM
Safe usage and disposal
drugs usage active drugs
staff from pharmacy Normal discharge, Discharge on
Discharge process AAC
request, DAMA, Death

Maintenance Dept Training topic Coverage Relevant to

Housekeeping staff and Housekeeping
HIC
supervisors procedures
Preventive and
breakdown
Maintenance staff FMC
maintenance of
equipment
Calibration of
Maintenance staff FMC
equipment
• Code red alert system
All staff specifically security Handling of fire
and maintenance emergency • Mock drills must be conducted FMC
for this
Bio-medical waste Segregation, storage,
housekeeping staff HIC
safety transportation, disposal

Medical Records Dept Training topic Coverage Relevant to

Medical record Screening, completion, storage,
MRD staff IMS
maintenance retrieval
 Hospital statistics from
MRD in-charge Various stats and reports IMS
medical record
Retention time of
MRD in-charge and staff IMS
medical record
Process of
MRD in-charge and staff condemnation of IMS
records
Data in medical records, registers
Safety and security of
MRD staff and computers. Access to medical IMS
patient’s data
records

Training topic Coverage Relevant to

OT technicians, therapists Bio-medical waste Segregation, storage,
HIC
etc. safety transportation, disposal

Training topic Coverage Relevant to

Hospital attendants (for safety Internal and External transfers
Safe transfer of
measures to be taken while Transfer of stable and unstable AAC
patient
transferring) patients
staff involved in healthcare
CPR, use of crash cart, other life
such as technicians and Basic Life support CoP
support measures
therapists
Code blue process, CPR
staff for understanding of
Code blue system Mock drills must be conducted CoP
code blue process
for this
Care of vulnerable Vulnerability assessment,
healthcare staff CoP
patients identification and care

Training topic Coverage Relevant to

billing and insurance Normal discharge, Discharge on
Discharge process AAC
request, DAMA, Death
 INDEX
S.No Training topic
01 Vision, Mission and Values of the organization
02 Scope of hospital services
03 Employee rights and responsibilities
04 Rights of a patient and how to protect the same
05
06 Patient safety practices
07 Admission and discharge criteria
08 Registration and admission of patient
09 Standard precautions
10 Care of paediatric patients
11 Reporting of patient safety events
12 Safe and rational prescription of medicines
13 Safe dispensing of medicine
14 Procedure to obtain medicine when pharmacy is closed
15 Medication recall
16 Safe usage of chemotherapeutic medication
17 Safe usage of radio-active drugs
18 High-risk medicine safety
19 Verbal orders for medicines
20 Safe administration of medicines
21 Safe injection and infusion practices
22 Needlestick injury protocol
23 Isolation/barrier nursing
24 Look-alike and sound alike medication
25 Reporting of medication errors
26 Safe blood transfusion
27 Safe transfer of patient
28 Taking consent from patients
29 Basic Life support
30 Surgical safety
31 Code blue system
32 Code pink system
33 Code red system
34 Care of vulnerable patients
35 Care of patients under restraint
36 End of life care
37 Discharge process
38 Discharge summary
39 Patient feedback and complaints

40 Quality indicators of each department

41 Scope of services in each department

42 Handling of medico-legal cases

43 Sentinel events

44 Induction training
45 Disciplinary and grievance handling process
46 Training and development policy
47 Prevention of sexual harassment
48 Performance appraisal system
49 Medical audit
50 Medical record documentation
51 Medical record maintenance
52 Hospital statistics from medical record
53 Retention time of medical record
54 Process of condemnation of records
55 Safety and security of patient’s data

56 Standard operating procedures of various imaging tests

57 Intimation of critical imaging findings
58 Quality control in Imaging
59 Radiation safety
60 Safe disposal of radio-active waste
61 Safety of patient undergoing imaging

62 Standard operating procedures of various lab tests

63 Collection of samples
64 Intimation of critical lab results
65 Quality control in laboratory
66 Laboratory safety
67 Safety of patient undergoing imaging

68 Nutritional screening and assessment

69 Safe handling of food

70 Antibiotic policy

71 Maintenance of ambulance
72 Handling of emergency patient on-site
73 Maintenance of ambulance
74 Handling of emergency patient on-site

75 Safe blood transfusion

76 Disposal of blood
77 Bio-medical waste safety

78 Safe storage of medication

79 Inventory analysis and control

80 Housekeeping procedures
81 Preventive and breakdown maintenance of equipment
82 Calibration of equipment
83 Handling of fire emergency
84 Use of fire extinguisher
85 Bio-medical waste safety
86 Prevention of child abduction and abuse
87 Handling of disaster situations, community emergencies and mass casualty situations

88 Credentialing and privileging of medical professionals

Checklist of training topics (Topic wise)
Training topics related to Access, Assessment and Continuity of Care
Training topic Coverage Relevant to
Clinical services offered by the hospital
Scope of hospital services All staff, especially staff of front office and admission
Services not in scope
Admission policies Staff of reception, registration and
Registration and admission of
Managing during non-availability of beds admission (including staff handling emergency
patient
Handling un-identified patients admissions)
Nurses and duty doctors
Internal and External transfers
Safe transfer of patient Hospital attendants (for safety measures to be taken
Transfer of stable and unstable patients
while transferring)
Standard operating procedures of
Lab technicians
various lab tests
Aseptic sample collection, patient safety, labelling or
Collection of samples Phlebotomist, Lab technician
samples, safe transportation and storage
Panic values, identification, confirmation and
Intimation of critical lab results Lab technicians
communication of critical results
Calibration, verification, validation, surveillance, Internal Technical supervisors, Lab technicians
Quality control in laboratory
quality assurance, external quality assurance and pathologists
Lab waste disposal, infection control, chemical safety, Use of
Laboratory safety All laboratory staff (technical and non-technical)
PPE
Standard operating procedures of
Imaging technicians
various imaging tests
Safety of patient undergoing Safe transportation and shifting of patient, patient screening,
All lab technicians and supervisors
imaging safety in MRI
Intimation of critical imaging Panic findings, Identification, confirmation and
Imaging technicians
findings communication of critical results
Calibration, verification, validation, surveillance, clinical Technical supervisors, imaging technicians
Quality control in Imaging
correlation, clinician’s feedback and radiologists
AERB regulations, Use and upkeep of radiation safety
Radiation safety All staff in imaging (technical and non-technical)
devices
Safe disposal of radio-active Types of radio-active waste, health and environmental effect, Technical supervisors, imaging technicians
waste disposal and radiologists
Nurses, Duty doctors, Customer care
Discharge process Normal discharge, Discharge on request, DAMA, Death executives, Admission and discharge staff, staff from
pharmacy, billing and insurance
Discharge summary Contents to be included in discharge summary Duty doctor, Consultants to be oriented
. Training topics related to Care of Patient
Training topic
Triage in routine cases and triaging during mass casualty
Triaging of patients
situation
Handling of medico-legal cases
Maintenance of ambulance
Handling of emergency patient
on-site
Handling of disaster situations,
community emergencies and
mass casualty situations
Basic Life support
Code blue system
Safe blood transfusion
Disposal of blood
Admission and discharge criteria
Care of vulnerable patients
Care of paediatric patients
Prevention of child abduction and
abuse
Surgical safety
Care of patients under restraint
Nutritional screening and
assessment
End of life care
Coverage
Equipment, medicines, maintenance, communication
Road traffic accidents, trauma, unconscious patients, patient
in cardiac arrest etc.
Entire plan of managing epidemic and disaster situation.
Mock drills must be conducted for this
CPR, use of crash cart, other life support measures
Code blue process, CPR
Mock drills must be conducted for this
Rational use of blood, blood storage, prevention of error
while transfusion, transfusion monitoring
Vulnerability assessment, identification and care
Paediatric assessment, safety of children, dealing with
children
Code pink procedure, safety measures, action in case of
such events
Pre-surgery, during surgery and post-surgery safety
measures. These include things like site and side marking,
time out and sign out process, infection control etc. WHO
surgical safety checklist would be a good reference material.
Physical and chemical restraints
Relevant to
Triage nurse
Doctor in-charge of emergency, Nurse in-charge or
admin in-charge of emergency dept.
Ambulance staff and nurse-in-charge of emergency
Ambulance staff and emergency medical technicians
All staff for their role, and specifically to all staff of
emergency.
All nurses and doctors, other staff involved in
healthcare such as technicians and therapists
All nurses and doctors, All other staff for
understanding of code blue process
Blood bank technicians, duty doctors and
nurses. Consultants to be oriented on rational use of
blood
Blood bank staff
Orientation to all consultants
All nurses and duty doctors. Other healthcare staff
Staff in paediatric ward/ICU
Staff in paediatric ward/ICU, Security staff, All other
staff
Operation theatre nurses, surgery resident doctors,
surgeons
Nurses, nursing in-charges, resident doctors,
consultants
Dietician, Nurses
Nurses and doctors in ICU
C. Training topics related to Management of Medication
Training topic
Procedure to obtain medicine
when pharmacy is closed
Safe storage of medication
Safe and rational prescription of
medicines
Inventory analysis and control
Look-alike and sound alike
medication
High-risk medicine safety
Verbal orders for medicines
Safe dispensing of medicine
Medication recall
Safe administration of medicines
Reporting of medication errors
Safe usage of chemotherapeutic
medication
Safe usage of radio-active drugs
D. Training topics related to Patients’ Rights and Education
Training topic
Rights of a patient and how to
protect the same
Taking consent from patients
Patient feedback and complaints Feedback mechanism and complaint processes
Coverage Relevant to
Nurses and duty doctors
Store in-charge, pharmacy in-charge, nurse in-
charge (for storing in wards)
Consultants, Duty doctors
Store and pharmacy in-charge
Storage, issue and administration of LASA medicines Store and pharmacy staff, nurses and duty doctors
Nurses and duty doctors
Nurses, duty doctors and consultants
Pharmacy staff
Store and pharmacy in-charge and nurse in-charges
Patient identification, checks during administration, post
Nurses and duty doctors
administration monitoring
Nurses and duty doctors
Preparation, administration and disposal Staff involved in chemotherapeutic medicines
Safe usage and disposal Staff involved in radioactive drugs usage
Coverage Relevant to
All staff specially front office, nurses, duty doctors,
consultants and managers of patient care
departments
General consent and informed consent Consultants, duty doctors and nurses
Customer care executives, nurses, nursing in-
charges
E. Training topics related to Hospital Infection Control
Training topic
Standard precautions
Safe injection and infusion
practices
Antibiotic policy
Laundry and linen management
process
Safe handling of food
Housekeeping procedures
Bio-medical waste safety
Needlestick injury protocol
Infection control surveillance
Prevention of HAI in patients
Isolation/barrier nursing
Infection outbreak handling
Sterilization activities
Coverage Relevant to
Hand hygiene, use of PPE Nurses and duty doctors
Nurses and duty doctors
Consultants and duty doctors
Nurses and laundry staff
Kitchen staff and dietician
Housekeeping staff and supervisors
Nurses, doctors, housekeeping staff. Other staff such
Segregation, storage, transportation, disposal as lab and blood bank technicians, OT technicians,
therapists etc.
All patient care staff
Infection control team
Care bundles for CA-UTI, VAP, SSI and CA-BSI Nurses, especially ICU nurses
Nurses and duty doctors
Identification and action Infection control team, Nursing in-charges
Sterilization process and quality control CSSD staff

F. Training topics related to Continual Quality Improvement

Training topic Coverage Relevant to
Quality indicators of each
In-charge and staff of each department
department
Patient safety practices All staff involved in patient care activities
Reporting of patient safety events All staff involved in patient care activities
Medical audit Consultants and clinical committee
Sentinel events All staff involved in patient care activities

G. Training topics related to Responsibilities of Management

Training topic Coverage Relevant to
Vision, Mission and Values of the Top management personnel and heads of
organization departments
Scope of services in each In-charge and staff of each department, especially
Services in scope and not in scope
department of obstetric and paediatric departments
 . Training topics related to Facility Management and Safety
Training topic Coverage Relevant to
Preventive and breakdown
Maintenance staff
maintenance of equipment
Calibration of equipment Maintenance staff
Code red alert system
Handling of fire emergency All staff specifically security and maintenance
Mock drills must be conducted for this
Use of fire extinguisher All staff

. Training topics related to Human Resources Management

Training topic Coverage Relevant to
Vision, mission, values, patients’ rights, infection control,
Induction training All staff upon recruitment
safety, service standards
Employee rights and
All staff
responsibilities
Training and development policy All staff
Performance appraisal system All staff
Disciplinary and grievance
All staff
handling process
Prevention of sexual harassment All staff
Credentialing and privileging of Consultants to be oriented. Duty doctors and
medical professionals nursing in-charges to be informed
Credentialing and privileging of
All nurses and nursing in-charge to be oriented
nursing professionals

. Training topics related to Information Management System

Training topic
Safety and security of patient’s Data in medical records, registers and computers. Access to
data
Medical record documentation
Medical record maintenance
Hospital statistics from medical
record
Retention time of medical record
Process of condemnation of
records
Coverage Relevant to
All nurses, nursing in-charges, duty doctors, patient
medical records care executives and MRD staff
Consultants, duty doctors, nurses, therapists and
Contents, legibility, use of abbreviation, endorsements
MRD staff
Screening, completion, storage, retrieval MRD staff
Various stats and reports MRD in-charge
MRD in-charge and staff
MRD in-charge and staff