ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-1 Date: 1/12/2022

Department: OPD &ER

The organization has not defined the content of the initial assessments for the
What:
outpatients and emergency patients.
The Non-
conformity/ Where: OPD &ER
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: AAC.3a
Immediate Correction Plan:
Standardized format introduced for the content of the initial assessments for the
Corrective Action with Date:
outpatients and emergency patients.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. N Ranjana Devi Nursing Head

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-2 Date: 1/12/2022

Department: IP
During assessment, it was observed that there is a Non-allopathy Doctors handling the
emergency care and the MD Pharmacology is admitting and taking care as MD
What:
medicine. There is no fulltime Obstetrician though the SHCO handles antenatal cases
The Non- for deliveries.
conformity/
Problem Where: IP
description (Is)
When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: AAC.4a HRM.1a
Immediate Correction Plan:
MBBS Doctor hired for handling emergency cases.
Corrective Action with Date: MD Medicine hired.
Part time obstetrician promoted as full time obstetrician.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation:
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV IP In-charge

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-3 Date: 1/12/2022

Department: Dentistry & Radiology

Dental Imaging services do not comply with legal and other requirements. The
PCPNDT license does not contain the
What: Doctors name and also a USG machine shifted from the SHCO premises has not been
The Non- communicated as there required regulations.
conformity/ There is no RSO level 1 certificate.
Problem
Where: Dentistry & Radiology
description (Is)
When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: AAC.6a
Immediate Correction Plan :
Dental intra-oral machine license is received
Corrective Action with Date: Doctors name has been updated in the PCPNDT portal
RSO level 1 registration done, certification is awaited
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Dr. Shreyas KP HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-4 Date: 1/12/2022

Department: Radiology
Imaging personnel are not adequately provided with appropriate safety equipment/
What:
devices like TLD badges.
The Non-
conformity/ Where: Radiology
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: AAC.6f
Immediate Correction Plan:
TLD batches for Dental assistant nurse, USG assistant nurse 7 new X-ray techncian
Corrective Action with Date:
are provided
Preventive Action with Date: TLD badges if new staffs are hired.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Dr Shreyas KP HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-5 Date: 1/12/2022

Department: IP
What: Discharge summary does not contain details of implants.
The Non- Where: IP
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: AAC.7c
Immediate Correction Plan :
Details of implants added in all discharge summaries of Ortho surgery cases
Corrective Action with Date:
(implants)
Preventive Action with Date: Cross check by treating doctor and nurses before releasing discharge summary
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV IP In-charge

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-6 Date: 1/12/2022

Department: IP
What: Discharge summary does not uniformly contain follow up advice.
The Non- Where: IP
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: AAC.7d
Immediate Correction Plan :
Corrective Action with Date: Discharge summaries format updated to contain follow up advice.
Preventive Action with Date: Cross check by treating doctor and nurses before releasing discharge summary
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV IP In-charge

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-7 Date: 1/12/2022

Department: IP
The care and treatment orders are not uniformly signed, named, timed and dated by
What:
the concerned doctor.
The Non-
conformity/ Where: IP
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: COP.1c
Immediate Correction Plan .
Standardized format introduced for care and treatment orders which are duly signed,
Corrective Action with Date:
named, timed & dated by the concerned doctor.
Preventive Action with Date: Daily rounds by quality manager to review all the in-patient files
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV IP In-charge

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-8 Date: 1/12/2022

Department: Pediatrics
Staff providing direct paediatric patient care are not trained and periodically updated
What:
in paediatric cardio- pulmonary resuscitation.
The Non-
conformity/ Where: Pediatrics
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: COP.3b
Immediate Correction Plan
BLS CPR training for Adult, Child, infant & choking given by third party to two
Corrective Action with Date:
nurses handling paediatric patients.
Preventive Action with Date: Training incase of newly recruited staff for paediatric department.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Signature
Department
Mrs. Vijaya Sonawane Managing
Director

Ms. Jatoveda Haldar Quality

Manager &
NABH
Coordinator
RCCA Team Members Mr. Sathish CM Patient Safety
Identified Officer
Dr. Annie Rose Clinical Safety
Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Dr Anuradha HOD/IN-

Plan CHARGE
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-9 Date: 1/12/2022

Department: Pediatrics
Patient assessment does not uniformly include detailed nutritional, growth, and
What:
immunization assessment and family members are not educated on the same.
The Non-
conformity/ Where: Pediatrics
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: COP.7c COP.7e PRE.4c PRE.4d
Immediate Correction Plan
Corrective Action with Date: Standardized format & pamphlets for eduating family members are introduced
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH
Coordinator

RCCA Team Members Mr. Sathish CM Patient Safety

Identified Officer
Dr. Annie Rose Clinical Safety
Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Dr Anuradha HOD/IN-

Plan CHARGE
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-10 Date: 1/12/2022

Department: Facilities & Safety

Procedure does not uniformly address prevention of child/ neonate abduction and
What:
abuse as observed during mock drill.
The Non-
conformity/ Where: Facilities & Safety
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: COP.7d
Immediate Correction Plan
Corrective Action with Date: NA
Preventive Action with Date: Training program conducted and mock drills conducted to ascertain learning
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Sathish CM HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-11 Date: 1/12/2022

Department: IP
What: An immediate preoperative re- evaluation is not uniformly documented.
The Non- Where: IP
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: COP.9d
Immediate Correction Plan
Corrective Action with Date: Standardized formats introduced and are unifromly documented
Preventive Action with Date: Daily rounds by quality manager to review all the in-patient files
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-12 Date: 1/12/2022

Department: OT
What: All adverse anesthesia events are not uniformly recorded and monitored.
The Non- Where: OT
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: COP.9i
Immediate Correction Plan
Corrective Action with Date: Standardized format introduced and are uniformly recorded & monitored
Preventive Action with Date: Daily rounds by quality manager to review all the in-patient files
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Puneeth SL HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-13 Date: 1/12/2022

Department: OT
The documented procedure does not uniformly address the prevention of adverse
What:
events like wrong site, wrong patient and wrong surgery.
The Non-
conformity/ Where: OT
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: COP.10c
Immediate Correction Plan
Corrective Action with Date: Standardized format introduced and are uniformly recorded & monitored
Preventive Action with Date: Daily rounds by quality manager to review all the in-patient files
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Puneeth SL HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-14 Date: 1/12/2022

Department: Pharmacy
In Pharmacy Polio vaccine was not stored as per the manufactures recommendation of
What:
below -20 degrees centigrade but at 2-8 degrees centigrade.
The Non-
conformity/ Where: Pharmacy
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: MOM.1a
Immediate Correction Plan
Corrective Action with Date: Vaccines shifted immediately to -20 degrees.
Preventive Action with Date: Daily check by the phamacist to ensure proper storage
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Bhaskar N HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-15 Date: 1/12/2022

Department: Pharmacy
Documented procedures do not uniformly address procurement and usage of
What:
implantable prosthesis
The Non-
conformity/ Where: Pharmacy
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: MOM.1f
Immediate Correction Plan
Corrective Action with Date: Implants requisition form introduced and Implant record register maintained.
Preventive Action with Date: Impant record regsiter maintenance
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Bhaskar N HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-16 Date: 1/12/2022

Department: IP
What: Orders are not written in a uniform location in the medical records.
The Non- Where: IP
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: MOM.2b
Immediate Correction Plan
Orders are written in caps by the treating doctor only in Drug Chart attached in the
Corrective Action with Date:
patient file.
Preventive Action with Date: Daily rounds by quality manager to review all the in-patient files
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-17 Date: 1/12/2022

Department: IP
What: Medication orders are not uniformly clear, legible, dated, named and signed.
The Non- Where: IP
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: MOM.2c IMS.2c
Immediate Correction Plan
Corrective Action with Date: Drug chart are uniformly clear, legible, dated , named & signed.
Preventive Action with Date: Daily rounds by quality manager to review all the in-patient files
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-18 Date: 1/12/2022

Department: IP
What: Medications are administered by Non allopathy Doctors.
The Non- Where: IP
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: MOM.4a
Immediate Correction Plan
Corrective Action with Date: MBBS Doctor is hired for administering medications.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Shashirekha DV HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-19 Date: 1/12/2022

Department: OPD and IP

The procedure does not address patient’s self administration of medications and
What:
medications brought from outside the organization.
The Non-
conformity/ Where: OPD and IP
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: MOM.4h
Immediate Correction Plan
Standardized format introduced to understand the level of capability of patient of self
Corrective Action with Date:
administration & further steps are taken.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. N Ranjana Devi HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-20 Date: 1/12/2022

Department: Management
Patient rights do not
What: include protection from physical abuse or neglect, obtaining
The Non- informed consent before carrying out procedures and how to voice a complaint.
conformity/
Where: Management
Problem
description (Is) When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: PRE.2b PRE.2e PRE.2g
Immediate Correction Plan
Rights like protection from physical abuse or neglect, obtaining
Corrective Action with Date: informed consent before carrying out procedures and how to voice a complaint are
added for patients.
Preventive Action with Date: Updation according to NABH requirements.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Vijaya Sonawane HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-21 Date: 1/12/2022

Department: OP
General consent for treatment is obtained on the surgical consent when the patient
enters the organization and patient and/ or his family members are not informed of the
What:
scope of such general consent. The organization has not uniformly listed those
The Non- situations where informed consent is required as per national guidelines.
conformity/
Problem Where: OP
description (Is)
When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: PRE.3a PRE.3b PRE.3c
Immediate Correction Plan
General consent bilingual format introduced.
Register maintained at Front office for the record of patient and/ or his family
Corrective Action with Date:
members who are informed of the scope of such general consent. Situations for which
informed consent is required are clearly ment
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. N Ranjana Devi HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-22 Date: 1/12/2022

Department: HIC
Scope of surveillance activities incorporates tracking but not analyzing appropriate
What: infection rates and feedbacks regarding these rates are not uniformly provided on a
The Non- regular basis to medical and nursing staff.
conformity/ Where: HIC
Problem
description (Is) When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: HIC.2i HIC.2j
Immediate Correction Plan
Data is being analyzed and cross verified.
Corrective Action with Date: Staff's are being updated on the on the infection rates and corrective actions if any by
the respective department heads as well in All Hands Meet
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Hemalatha VM HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-23 Date: 1/12/2022

Department: CSSD
What: There is no zoning available for sterilization activities.
The Non- Where: CSSD
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: HIC.4a
Immediate Correction Plan
Corrective Action with Date: Autoclave room divided into sterile, clean and unsterlie area
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Puneeth SL HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-24 Date: 1/12/2022

Department: CSSD
Regular validation tests for sterilisation are not uniformly carried out and
What:
documented.
The Non-
conformity/ Where: CSSD
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: HIC.4b
Immediate Correction Plan
Corrective Action with Date: Biological indicator tests done weekly
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Puneeth SL HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-25 Date: 1/12/2022

Department: Facilities & Safety

Appropriate personal protective measures are not uniformly used by all categories of
What:
staff handling Bio-Medical Waste.
The Non-
conformity/ Where: Facilities & Safety
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: HIC.5f
Immediate Correction Plan
Corrective Action with Date: All cateogories of staff are given personal protective items
Staff has been trained on the risks and importance of using Personal protective items
Preventive Action with Date:
while handling biomedical waste
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Sathish CM HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-26 Date: 1/12/2022

Department: Quality
The designated programme is not uniformly communicated and coordinated amongst
all the employees of the organization through proper training mechanism. The quality
What:
improvement programme is not uniformly reviewed at predefined intervals and
The Non- opportunities for improvement are identified.
conformity/
Problem Where: Quality
description (Is)
When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: CQI.1d CQI.1e
Immediate Correction Plan
Training done according to training calendar and the same is informed to the staffs by
Corrective Action with Date: circulars. Training attendance, Pre test post test, score card, effectivesness & feedback
records are maintained for all training sessions.
Preventive Action with Date: Quarterly training on required topics based on NABH Standards.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Ms. Jatoveda Haldar HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-27 Date: 1/12/2022

Department: Quality
What: Data collected are not used as tools for further improvements
The Non- Where: Quality
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: CQI.2h
Immediate Correction Plan
Bar diagram & pie charts are used to present monthly HIC data, Lab TAT, Patient
Corrective Action with Date: feedback analysis etc. and interpretation are made for further implementation &
training.
Preventive Action with Date: Monthly data analysis and presentation.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Ms. Jatoveda Haldar HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-28 Date: 1/12/2022

Department: Quality
Appropriate statistical and management tools are not uniformly applied whenever
What:
required.
The Non-
conformity/ Where: Quality
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: CQI.3b
Immediate Correction Plan
Fish bone diagram/Ishikawa diagram/Cause effect analysis is used as management
Corrective Action with Date: tool for root cause analysis & histrogram, line , scattered diagram, bar diagram etc are
used as statistical tool.
Monthly data analysis and presentation using statistical & management tools &
Preventive Action with Date:
further interpretation & report making.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Ms. Jatoveda Haldar HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-29 Date: 1/12/2022

Department: Quality
Clinical audit remedial measures are not
What:
implemented.
The Non-
conformity/ Where: Quality
Problem
description (Is) When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: CQI.4e
Immediate Correction Plan
Formats introduced on the basis of the data analysis from data collected for clinical
Corrective Action with Date:
Audit.
Preventive Action with Date: Quarterly Clinical audit and remedial measures on the basis of the result of the audit.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Ms. Jatoveda Haldar HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-30 Date: 1/12/2022

Department: Facilities & Safety

The hospital has not
What: identified the potential safety and security risks including hazardous materials
The Non- uniformly.
conformity/ Facilities & Safety
Where:
Problem
description (Is) When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: FMS.1e
Immediate Correction Plan
Corrective Action with Date: Potential safety and security risks identified using HIRA
Staff has been trained on the risks and precautions to be taken while handling
Preventive Action with Date:
hazardous material
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Sathish CM HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-31 Date: 1/12/2022

Department: Facilities & Safety

What: The organization has not displayed the fire exit signage as per the requirements.
The Non- Where: Facilities & Safety
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: FMS$B
Immediate Correction Plan
Normal fire signage was displayed beside the Terrace staircase, for which Radium
Corrective Action with Date:
fire exit signage board displayed at the same place.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Sathish CM HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-32 Date: 1/12/2022

Department: Facilities & Safety

Staff not adequately trained for their role in case of such emergencies as observed in
What:
the mock drill.
The Non-
conformity/ Where: Facilities & Safety
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: FMS.4c
Immediate Correction Plan
Training given to Emergency Response Team memebers by Third party for Code
Corrective Action with Date:
Red.
Preventive Action with Date: Annually twice in-house Code Red Mock drill.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mr. Sathish CM HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-33 Date: 1/12/2022

Department: HR
What: Occupational health hazards are not adequately addressed.
The Non- Where: HR
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: HRM.6b
Immediate Correction Plan
Corrective Action with Date: Training given to all staffs on occupational health hazards.
Preventive Action with Date: Quarterly training on occupational health hazards to new employees.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Rekha M HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-34 Date: 1/12/2022

Department: HR
Medical professionals do not admit and care for patients as per the laid down policies
and authorisation procedures of the organization. The services provided by the
What:
medical professionals are not in consonance with their qualification, training and
The Non- registration.
conformity/
Problem Where: HR
description (Is)
When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: HRM.8b HRM.8c
Immediate Correction Plan
Doctors with proper qualification and experience are admitting and taking care of
Corrective Action with Date:
patients.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Rekha M HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-35 Date: 1/12/2022

Department: HR
The clinical work assigned to nursing staff are not in consonance with their
What:
qualification, training and registration.
The Non-
conformity/ Where: HR
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: HRM.9a
Immediate Correction Plan
Corrective Action with Date: Nurses with proper qualification & experience are assigned for specific clinical work.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Rekha M HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-36 Date: 1/12/2022

Department: IMS
What: Necessary resources are not uniformly available for analysing data.
The Non- Where: IMS
conformity/
Problem When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: IMS.1c
Immediate Correction Plan
Two softwares namely IP Data analysis software & MIS software available for data
Corrective Action with Date: analysis. After segregation of data from the softwares these are presented through
excel as bar diagram, histogram, pie chart etc.
Preventive Action with Date: Updating according to new software rquirements.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Kavya RN HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-37 Date: 1/12/2022

Department: IMS
The organization does not contribute to external databases in accordance with the law
What:
and regulations.
The Non-
conformity/ Where: IMS
Problem
When: NABH Assessment on 19, 20 Nov 2022
description (Is)
Who: NABH Assessor
Standard: IMS.1e
Immediate Correction Plan
Since January 2016 external databases are contributed as per law & regulations like
Corrective Action with Date:
no of Nosocomial infections, MLC cases, Births, deaths etc.
Preventive Action with Date: NA
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Kavya RN HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-38 Date: 1/12/2022

Department: MRD
Though the documented procedures are in place on retaining the patient’s clinical
What: records, data and information but the same has not been implemented there are
The Non- Medical records from the year 2009.
conformity/ Where: MRD
Problem
description (Is) When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: IMS.5a IMS.5d
Immediate Correction Plan
Corrective Action with Date: All the old files from 2009-2016 are discrded as per the hospital policy.
Preventive Action with Date: All OP & IP files will be henceforth discarded as per the hospital rentention policy.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Kavya RN HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-39 Date: 1/12/2022

Department: MRD
The review process
What:
includes records of only discharged patients.
The Non-
conformity/ Where: MRD
Problem
description (Is) When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: IMS.6e
Immediate Correction Plan
Corrective Action with Date: Active patients IP file audit format introduced & implemented.
Preventive Action with Date: Daily rounds by quality manager to review all the in-patient files
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Mrs. Kavya RN HOD/IN-CHARGE

Plan
 ROOT CAUSE CORRECTIVE ACTION (RCCA)

Report Ref. No.: S.H.P.L/NABH/RCCA/NC-40 Date: 1/12/2022

Department: Quality
The review does not uniformly point out and documents any deficiencies in records
What: hence appropriate corrective and preventive measures are not undertaken are
The Non- documented.
conformity/ Where: Quality
Problem
description (Is) When: NABH Assessment on 19, 20 Nov 2022
Who: NABH Assessor
Standard: IMS.6f IMS.6g
Immediate Correction Plan
CAPA records created for active medical records & medical records of discharged
Corrective Action with Date:
patients. Format introduced as a remedial measure of the CAPA done.
Preventive Action with Date: Quarterly MRD audit and CAPA records for the same.
Evidence Attached.
RCCA Methodology Brain storming 5 WHY
RCCA Team Formation
Name Function/ Department Signature

Mrs. Vijaya Sonawane Managing Director

Ms. Jatoveda Haldar Quality Manager &

NABH Coordinator
Mr. Sathish CM Patient Safety Officer
RCCA Team Members
Identified
Dr. Annie Rose Clinical Safety Officer

Mrs. N Ranjana Devi Nursing Head

Mrs. Shashirekha DV IP In-charge

Acceptance of the Action Ms. Jatoveda Haldar HOD/IN-CHARGE

Plan