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Polices

Operational policy

Surgical department

Al.Adan Hospital

 

 

 

 

 

Dr. Abdullateef Al.Dawood,FRCS

Chairman of surgical department

April 2007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preface

 

 

Al.Adan Hospital

of total bed capacities 600 beds ,  was built on 1981 to provide medical health  services to   Al.Ahmadi region which consist of mainly of 3 major cities Al.Ahmadi , Al.Fahaheel , Al.Sabahaia , and other small villages like , Fintas , BuHaifa , Al.Mangaf .and others . of approximate population of 150.000 .

New cities were built at south of Kuwait like Al.Qurain , al.Dahar , Jaber Al.Ali , Ali Al.Sabah "Um Alhaiman " , plus the village has been converted into high condense – residence area  But the bed capacity remained the same.

Surgical department

 

Al.Adan Hospital has started on 1981 with time of hospital opening.

It was of 90 bed capacity divided into 2 male wards, & one female ward. Each ward of 30 beds.

The Catchments population was 0f 150.000 .increasing to the 500.000 population.

But the ward for surgical department has been reduced where has of male ward been taken for female medical patient.

But we replace that by adding extra-bed in male ward to compensate the shortage of beds.

Due to this un-ideal situation between the hospital capacity and the population the problems will go on to reach disastras situation. In form of increase the morbidities, mortalities, loss of disciplines, laws, and regulation. This situation is not accepted by Kuwaiti officials and need urgent solutions.

 

 

 

 

 

Index: -

1.     Mission

2.     vision 

3.     Department structure.

a.     Wards.

b.    Outpatients.

c.      Operating theatre.

d.    Endoscopy suite.

e.     Satellite surgical  clinic

4.     department skeleton : -

a.     Units.

5.     daily work distributions

a.     Unit A

b.    Unit B

c.      Unit urology.

6.     department administration policy : -

a.     general policy  .

b.    admission , follow-up & discharge policy .

c.      SOPD policy .

d.    Endoscopy policy .

e.     Operating theatre policy .

f.       On-call policy . 

g.    Satellite surgical clinic policy .

h.    Scientific & teaching policy .

i.       Annual leave policy .

j.        Guide lines policy .

k.    Interdepartmental policy .

l.       Research policy .

m. Department council .

7.     Hospital committees : -

a.     Hospital council committee .

b.    Accreditation committee

c.      Morbidity committee

d.    Mortality committee

e.     Medical record and statistic committee .

f.       Interdepartmental committee .

g.    Resource utilization  committee.

 

 

 

 

1.     Mission

 

 

 

a.     The main goals of surgical department are : -

                                                                         i.            to provide the surgical care to the Al.Ahmadi health area .  

                                                                      ii.            to teach the student &

                                                                   iii.            to train the junior surgeons and

                                                                   iv.            to conduct clinical research studies  .

 

 

 

 

 

 

 

2.     vision

 

 

 

a.     To solve the chronic problems

b.    Improvement and development of actual given services .

c.      to create the quality care system

d.    to introduce high technology to the department    .

e.     to introduce day-case surgery .

f.       to introduce Bariatric surgery .

g.    to activate already non-function vascular unit .

h.    to introduce neuro-surgery service .

 

 

 

 

 

 

3.     department structure

 

 

 

a.     wards : - surgical wards located in the 1st , 2nd , and 3rd floor of medical-surgical building .

                                                                         i.            surgical department has 2 male wards

1.     Ward 12 : - with 30 bed capacities located in 2nd floor .  

2.     Ward 17: - with 30 bed capacities, " but half of this ward has been taken by female medical patients " . located in 3rd floor .

                                                                      ii.            surgical department has 1 female wards

1.     Ward 10: - with 30 bed capacities. Located in the 1st floor .

                                                                   iii.            Weakness : - bed capacity are not enough to coop with the tremendous increase of patient No. what actually need double of these no. to release the congestion of the wards .

                                                                   iv.            Future : - unless the bed capacity is increased the service will be very tight and may carry  a risk of failure of service .   

b.    out patients department : -  located in ground floor , where all specialties located in that area . 

                                                                         i.            Surgical and urology and vascular clinics all are at that area .

                                                                      ii.            The clinics ware distributed  according to seniority . " Appendix 2 "      

                                                                   iii.            Saturday clinics : -

1.     Number of clinics : - 8 clinics .

2.     Unit B : -

3.     Doctors : -

a.     Dr. Adullateef Al.Dawood, chairman, Room 14.

b.    Dr. Moh'd Saeed Khan, consultant, Room 17.

c.      Dr. Hamid Labib, consultant, Room 15.

d.    Dr. Hussain Moh'd Hussain, Senior registrar. Room 21.

e.     Dr. Jaber Al.Shammari, senior registrar, Room 18.

f.       Dr. A/Rahman Attia, registrar. Room 12.

g.    Dr. Tarek Salem , registrar, Room 16.

h.    Dr. Ahmad sulaiman , appointment and admission clinic , room 23.

i.       Dr. Dawood Al.Halabi & Diabetic clinic .

j.        Dr. Hani Shaeban , Urolodynamic clinic .

                                                                   iv.            Sunday clinics : -

1.     No. of clinics : - 4 clinics

2.     U.  unit

3.     Doctors : -

a.     Dr.Ahmad Al.Khandari head of urology Unit , Room 17.

b.    Dr. Hamdi Ibrahim , room 16 .

c.      Dr. Mohammad Omar , Room 15 .

d.    Dr. Abdullah Taqi , Room 18 .

                                                                      v.            Monday clinics : -

1.     No. of clinic : - 8 clinics .

2.     Unit A

3.     Doctors : -

a.     Dr. Nema Al.Awadi , head of unit A , Room 18

b.    Dr. Medhat Fargaly, consultant, Room 23.

c.      Dr. Pyiary Dhar , consultant , Room 15

d.    Dr. Dawood Al.Halabi, consultant, Room 12.

e.     Dr. Fahad Al.Asfar, consultant, Room 21.

f.       Dr. Atef Al.Jamal , senior registrar , Room 16 .

g.    Dr. Mohamad Saber , registrar , Room 17 .

h.    Dr. Muneera Bin Niki , registrar , Room 14 .

i.       Dr. A/Rahman Attia , Diabetic clinic .

                                                                   vi.            Tuesday clinic : -

1.     No. of clinic : - 2 clinics .

2.     units  rectal clinic ,

3.     doctors : -

a.     Dr. Jaber Al.Shammari , Dr. Muneera Bin Niki , Rectal clinic ,  Room 15 .

b.    Dr. Nazim Al.Refae , Admission clinic , Unit A , Room 16 .

c.       Dr. Ashraf Maher , urodynamic clinic ,

                                                                vii.            Wednesday clinic : -

1.     No. of clinic : - 8 clinics .

2.     Units : - B & U

3.     Doctors : -

a.     Dr. Hamdi Ibrahim , senior registrar urology , Room 14 .

b.    Dr. Yahia Al.Shibini , senior registrar urology , Room 18 .

c.      Dr. Khalid Refaat , registrar urology , Room 12 .

d.    Dr. Ashraf Maher , registrar urology , Room

e.     Dr. Ahmad sulaiman , registrar , obesity clinic , Room 21 .

f.       Dr. Faraj Al.Dehani , registrar , Room 17 .  

g.    Dr. Ayman Al.Khalaji , registrar , Room 15 .

h.    Dr. Basim Al.Saka , registrar , Room 16  

c.      Operating theatre : -

                                                                         i.            Total number of sessions are 10 sessions / week

                                                                      ii.            There are 6 sessions general surgery / week, 3 on Sunday and 3 on Wednesday.

                                                                   iii.            There are 4 sessions of urology / week, 2 on Saturday and 2 on Monday.

                                                                   iv.            There is one emergency room available for surgical cases 24 hrs.

                                                                      v.            There is extracorporeal shock wave lithotripsy " ESWL " room located in old x-ray department .

                                                                   vi.              Saturday 

1.     2 rooms used by U unit.

2.     ESWL run by Dr. Abdullah Taqi & Dr. Hani Shaaban .

                                                                vii.            Sunday  :

1.     3 rooms used by unit B.

2.     ESWL run by Dr. Khalid refaat .

                                                             viii.            Monday : -

1.     2 rooms used by U unit.

2.     ESWL run by Dr. Ashraf Maher .

                                                                    ix.            Tuesday : -

1.     No rooms for surgery

                                                                       x.            Wednesday : -

1.     3 rooms used by Unit A.

2.     ESWL run by Dr. Mohammad Omar .

d.    Endoscopic suite

                                                                         i.            Endoscopy suite was started on 1982 , it gives mainly diagnostic procedures for upper and lower GI with some therapeutic procedures , the suite has been recently revolutionized by Tareq Company with 2 working rooms , sterilization room,  reception , 2 observation rooms , doctor office , nurse room and 2 toilet and store .

                                                                      ii.            We have 2 endoscopies and 2 colonoscopies .

                                                                   iii.            The Endoscopy unit is totally under the surgical department care , there are 5 days / week . there are monthly list distributed to perform the procedures. Also there is emergency list for emergency cases.

                                                                   iv.            There are general thought to improve the department in view of diagnostic and of therapeutic .

                                                                      v.            4 new registrars have been appointed to be trained on endoscopy and colonoscopy procedures .   

e.     satellite  surgical clinic : -

                                                                         i.            Being the population at Al.Ahmadi area tremendously increase , the department has run surgical clinics in Al.Fahaheel, Al.Qurain polyclinics aiming to reduce the number of patients coming  to the hospital and to extend the service closer to the people.

                                                                      ii.            Surgical service

1.     Saturday: - one clinic in Fahaheel clinic & one clinic in Qurain clinic 

2.     Monday: - one clinic in Fahaheel clinic & one clinic in  Qurain clinic.

                                                                   iii.            Urology service

1.     Saturday: - one clinic in Fahaheel clinic.

2.     Wednesday: - one clinic in Qurain clinic.

                                                                   iv.            There are monthly Rota distributed to the clinic .

                                                                      v.            There official communication with Head of primary care section for improvement of such service .     

 

4.     department skeleton " manpower "   " Appedix 1 "

 

 

 

a.     department has organized into : -

                                                                         i.            Chairman of department.

                                                                      ii.            2 general surgical units.

                                                                   iii.            1 urology unit

                                                                   iv.            I Diabetic foot clinic

                                                                      v.            Vascular unit

                                                                   vi.            Endoscopy unit.

b.    Chairman of department: - Dr. Abdullateef Al.Dawood.

c.      Unit B team : -

                                                                         i.            Dr. Abdullateef Al.Dawood, chairman and head of the unit B.

                                                                      ii.            Dr. Moh'd Saeed Khan, consultant.

                                                                   iii.            Dr. Hamid Labib, consultant.

                                                                   iv.            Dr. Hussain Mohamad Hussain, senior registrar.

                                                                      v.            Dr. Jaber Al.Shammari, senior registrar.

                                                                   vi.            Dr. Abdulrahman Attia. registrar

                                                                vii.            Dr. Ahmad sulaiman , registrar.

                                                             viii.            Dr. Tarek Salem. registrar

                                                                    ix.            Dr. Ayman Al.Khalaji , registrar.

                                                                       x.            Dr. Basim Al.Saka , registrar.

                                                                    xi.            Dr. Ahmad Fuad, vascular registrar.

                                                                 xii.            Dr. Amash Al.Harbi , assistant registrar.

                                                              xiii.            Dr. Mohamad Asad Al.Khandari , assistant registrar .

d.    Unit A team : -

                                                                         i.            Dr. Nema Al.Awadi , head of unit A

                                                                      ii.            Dr. Medhat Farghaly, consultant.

                                                                   iii.            Dr. Piary Dhar , consultant

                                                                   iv.            Dr. Dawood Al.Halabi , consultant

                                                                      v.            Dr. Fahad Al.Asfar, consultant .

                                                                   vi.            Dr. Atef Al.Jamal, senior registrar.

                                                                vii.            Dr. Mohad Saber , registrar.

                                                             viii.            Dr. Muneera Bin Niki , registrar.

                                                                    ix.            Dr. Ahmad Al.Mosa , registrar.

                                                                       x.            Dr. Hussain Al. Doki , registrar.

                                                                    xi.            Dr. Nazim Al.Refae , registrar

                                                                 xii.            Dr. Amal yousef , registrar

                                                              xiii.            Dr. Samer Bidas , registrar .

                                                              xiv.            Dr. Ahmad Sarkouh , assistant registrar .

                                                                 xv.            Dr.  Amar Al.Naqi , assistant registrar .

                                                              xvi.            Dr. khalid Al.shamari , assistant registrar .

e.     Urology unit team : -

                                                                         i.            Dr. Ahmad Al.Khandari, head of the Unit.

                                                                      ii.            Dr. Yahia Al.Shibini, senior registrar.

                                                                   iii.            Dr. Hamdi Ibrahim, senior registrar.

                                                                   iv.            Dr. Abdullah Taqi, registrar.

                                                                      v.            Dr. Khalid Refaat, registrar.

                                                                   vi.            Dr. Mohamad Omar, registrar.

                                                                vii.            Dr. Hani Shaban, registrar.

                                                             viii.            Dr. Ashraf Maher   , registrar.

                                                                    ix.            Dr. Rash Al.Ramah, assistant registrar.

                                                                       x.            Dr. Hussain Al Enezi, assistant registrar.

f.       Diabetic foot unit : -

                                                                         i.            Dr. Dawood Al.Halabi, consultant.

                                                                      ii.            Dr. Abdulrahman, registrar.

                                                                   iii.            Dr. Faraj Al.Dehani .

                                                                   iv.            Dr. Hussain Al.Doki

g.    Vascular unit

                                                                         i.            Dr. Medhat Fargaly, consultant.

                                                                      ii.            Dr. Ahmad Fuad , registrar vascular .  

h.    Endoscopy unit

                                                                         i.            Dr. Moh'd Saeed Khan, consultant.

 

5.     daily – work schedules

 

 

a.     Each unit has and daily activities

                                                                         i.            Unit B : -

1.     Saturday: - surgical outpatient. + Al.Qurain clinic

2.     Sunday: - operating theatre.

3.     Monday : - endoscopy

4.     Tueasday: - grand round.

5.     Wednesday: - SOPD + Round.

                                                                      ii.            Unit A : -

                                                                   iii.            Saturday : - Round + Endoscopy + Al.Fahaheel clinic

                                                                   iv.            Sunday : - Round

                                                                      v.            Monday : - SOPD

                                                                   vi.            Tuesday: - Grand Round.

                                                                vii.            Wednesday: - Operating theatre.

b.    U. Unit : -

                                                                         i.            Saturday : - Operating theatre + Fahaheel clinic + lithotripsy + Urodynamic

                                                                      ii.            Sunday : - SOPD + lithotripsy +

                                                                   iii.            Monday : - Operating theatre + lithotripsy +

                                                                   iv.            Tuesday : - Grand Round + urodynamics

                                                                      v.            Wednesday: - SOPD + lithotripsy.

6.     department administration & policies  

 

a.     general policies : -

                                                                         i.            General rules of Ministry Of Health MOH are applied on the department .

                                                                      ii.            General rules of the hospital also applied on the department. 

b.    Admission , daily follow up & discharge policies : -

                                                                         i.            Admission policies : -

1.     General Rules : -

a.     All admissions should be either from SOPD or from causality.

b.    All admissions should be through the consultants concern or senior registrars.

c.      All admission slip should be clearly written , with name of unit & name of head of unit and name of consultant concern .

d.    Patient under age 12 should admitted to female ward " ward 10 " .

e.     Transferred patient from other department e.g medical to the surgical department should be clearly under care of unit and consultant .  

f.       Admission notes should immediately written by the trainee , assistant registrars or registrars .

g.    Final treatment plan should be documented by senior registrars , or consultants .

h.    Progress follow up notes should be written daily . and according to seriousness of the case may need more frequent documents in patients note  .

2.     elective admission :-

a.     all patients should be completely investigated , Diagnosed , prepared and evaluated by other specialties prior the admission .

b.    all relevant patients documents should be checked by treating surgeon and sure available in patients file .

c.      all patients should be schedule in appointment book with contact phone numbers for early appointment or for any cancellation .

d.     patient coming to elective admission should be instructed to attend admission clinic at 8 – 9 am for possible admission , and in case no bed available another near appointment should be given with priority .

3.     Emergency admission : -

a.     Those patient whom really need urgent or early surgery or early work up should be admitted through emergency department to have priority in investigation .

b.    No cold cases should be admitted through emergency department even if labeled as emergency cases .

c.      Emergency admission should be by senior registrar on call , no admission allowed by emergency department doctors without informing the on call team .

d.    Treatment decision is surgical senior registrar on call for urgent surgery , ICU admission , investigation priorities after discussing the case with his or her consultant and other specialties e.g Intensive therapist .

4.     Day case admission : - 

a.     There are many of surgical patients do not need overnight sleep and the project of DCS was applied all over the ward , and has advantage on both patients & hospital .

b.    Patient whom are scheduled for day case surgery should fulfilled the criteria of DCS .

c.      Patient documents should be available and checked by the surgeon .

d.    Patient should be evaluated by the anaesthetist .

e.     Patient should be instructed by written paper about the time appriving to the ward and duration of fasting and to be accompanying by relatives . 

                                                                      ii.            Daily follow-up progress notes policy : -

1.     general Rules : -  

a.     the junior doctors should be available in the ward for immediate need of patient and to answer any inquiries of patient .

b.    always patient file should be updated with new data according to patient's seriousness .

c.      initial notes should be written by most junior doctor in the unit and been confirmed by the SR. 

2.     2 rounds system : -   

a.     2 round should be done by each unit one at morning & one at afternoon .

b.    this round should be done head of unit or his deputy but not less than senior registrar .

c.      morning round is the round to make decision for discharges or investigations .    

                                                                   iii.            discharge policy : -

1.     All discharges should be decided by senior registrar / registrar after informing concern consultant.

2.     Discharge summary should be written by registrar or his assistants "assistant registrar  and trainee".

3.     Appointment for SOPD follow up and suture removal should be arranged and clearly written & understanding by the patient or relatives before patient leaving the hospital. 

4.     Medicine and sick-leave should be ready before discharge.  

c.      SOPD policy : -

                                                                         i.            The department should be function not late than 8 am .  

                                                                      ii.            All doctors concern should be in their clinics before 7.45 am.

                                                                   iii.            The doctor should not leave their room before last patient has finished.

                                                                   iv.            The No. of appointment should be around 12 patients " new & FU ".

                                                                      v.            The doctor for any reason can't be in their room should arrange other doctor to replace him.

                                                                   vi.            Any doctors has planned leave should inform the appointment department. To cut his appointment.

                                                                vii.            We still have difficulties in arrange an smooth well organized OPD with fixed time with so many factors .

                                                             viii.            The aim of OPD to see new patients , follow up patients , and post operative patients .

                                                                    ix.            Problems : - can be identified as following : -

1.     traditional way of appointment system , where patients coming to the appointment department by him self or by one of his relatives and appointment is given according book which many factors concern .

2.     no contact system with patients when the appointment changed .

d.    Endoscopy  policy : - look to "  " .

                                                                         i.            All room started at 8 am  .

                                                                      ii.            Appointment should be scheduled by time starting on 9 am .

                                                                   iii.            All emergency should be done first and patient called earlier than 8 am .

                                                                   iv.            Priority for upper GI bleeding .

                                                                      v.            Unscheduled patient should be done after 12 noon. And not more than 2 cases.

                                                                   vi.            No doctors are allowed to do any procedures not in his date.

e.     Operating theatre policy : -

                                                                         i.            Operation List : -

1.     should be prepared by doctor concern for each unit .

2.     it should be designed by varieties of cases , major , intermediate and minor .

3.     all admitted patient should be final checked by preoperative round by head of unit .

4.      list after checked by the head of unit should be shown to the chairman for final agreement .

5.     list should be distributed before 12 noon .

6.     copy of list should be sent to hospital director .

                                                                      ii.            time of surgery : -

1.     all surgeon concern for first case should be at theatre 7 am .

2.     all surgeries should start at 7.15 am .

3.     no wasting times between the cases .

4.     respect the time for each cases , unnecessary time waste are not need .   

                                                                   iii.            responsibility in the theatre : -

1.     Head of unit is doctor in charge to run the theatre , if any rearrangement to be done .

2.     no room changes without consultant information .

3.     Emergency surgery should be taken according to booking and in top emergency the priority should be for bleeding.

f.       On – call policy : -

                                                                         i.            The department is  covering the hospital for surgical or urological emergency cases over 24 hrs / days , 7 days / week .

                                                                      ii.            There are a team of consultant , senior registrar , registrar , and assistant registrar and trainee covering the hospital every 4 days . as well as a team of urology .

                                                                   iii.            The team on call they look after inpatient where evening round for all patient and also deal with fresh emergency patient or consultation from other department .

                                                                   iv.            There are monthly Rota for this purpose .

g.    Satellite surgical clinics : - 

                                                                         i.            Being the population at Al.Ahmadi area tremendously increase , the department has run surgical clinics in Al.Fahaheel, Al.Qurain polyclinics aiming to reduce the number of patients coming  to the hospital and to extend the service closer to the people.

                                                                      ii.            Surgical service

1.     Saturday: - one clinic in Fahaheel clinic & one clinic in Qurain clinic 

2.     Monday: - one clinic in Fahaheel clinic & one clinic in  Qurain clinic.

                                                                   iii.            Urology service

1.     Saturday: - one clinic in Fahaheel clinic.

2.     Wednesday: - one clinic in Qurain clinic.

                                                                   iv.            There are monthly Rota distributed to the clinic .

                                                                      v.            There official communication with Head of primary care section for improvement of such service .

h.    Medical Board policy  : -

                                                                         i.            Many patient asking for medical – board for treatment abroad or for medical compensation .

                                                                      ii.            There are surgical committee of 3 members meet every Monday .

                                                                   iii.            There are urology committee of 3 members meet every Wednesday .

                                                                   iv.             The report is countersigned by chairman and the director .

i.       scientific & teaching policy : -  

                                                                         i.                scientific department meeting : -

1.     there are 2 days fixed for department meetings , Saturday at 12.30 pm & Tuesday 8 am .

2.     there is monthly program distributed .

3.     on Saturday , there are alternatively oncology meeting where all cancer patients discussed with oncologist expertise to achieve the best treatment plan . and radiology meeting where the all types of x-rays are discussed with radiologist colleagues . In case there are no cancer cases the medical companies are allowed to present there products of new antibiotics generation , new drugs in the market .

4.     On Tuesday , there are morbidity & mortality meeting where all cases discuss with relevant events and to learn from such cases how to avoid the complications . alternatively there are case presentations & literature review presented by one surgeon  lectures , interesting cases may be presented .

5.     this meeting is credited by KIMS .

                                                                      ii.            Medical student teaching program : -

1.     The surgical department is a teaching department recognized by Kuwait medical faculty and royal college of the surgeon  .

2.     there are regularly patch of medical student attend the department .

3.     we have qualified and experience surgeons as tutors .

4.     there are well – designed program issued to the student to cover all aspect of surgery , such as outpatient , inpatient , and operation. There are short & long cases discussion .

5.     there are assement at the end of the period .

                                                                   iii.            Trainee – training program : - 

1.     those post-graduated doctors joining the department for 4 months .

2.     there are consider one of the team where they start their clinical practice .

3.     there are programs issued from the department as well as from the KIMS .

4.     evaluation is done at the end of the period .

                                                                   iv.            post – graduate Kuwaiti Board : - 

1.     Those whom they join the Kuwaiti surgical board .

2.     This board is 5 years in duration , structure program where the candidate rotate between different general surgical department in Kuwait and sub-specialties .

3.     Usually we have surgeon whom the mother hospital is al.adan , whom they leave the department for 2-3 years . also department receive surgeon from other hospital

4.     The board candidate have priorities for training and teaching .

j.        Annual leave policy : -

k.    Guide lines policy : -

                                                                         i.            guide line of antibiotics policy .

                                                                      ii.            guide line of management of head injury

                                                                   iii.            guide line of management of upper GI bleeding .

                                                                   iv.            guide line of management of lower GI bleeding .

                                                                      v.            Guide line of managment of acute abdomen.

                                                                   vi.            Guide line of management of Diabetic foot.

                                                                vii.            Guide line of investigation for elective case.

l.       Interdepartmental policy : -

                                                                         i.            Anesthesia department.

                                                                      ii.            Radiology department

                                                                   iii.            Gynecological department

                                                                   iv.            Orthopedica department .

                                                                      v.            Ophalmology department

                                                                   vi.            ENT department .

                                                                vii.            Emergency department .

                                                             viii.            Nursing .

m. Research policy

n.    department council : -

                                                                         i.            This council consists of chairman as head of council and all consultants and senior registrars , registrars and urology  representatives .

                                                                      ii.            The council meets on Monthly bases.

                                                                   iii.            The aim of the council is to discuss the issue of concern and to take the decision.

                                                                   iv.            There should be minute for each meeting.

 

     

 

7.     Hospital Committees

 

 

a.     Hospital council committee : -

                                                                         i.            This is committee which discuss the main hospital issue .

b.    Accreditation committee  : -

                                                                         i.            This committee is concern to prepare all necessary requirement and data available .

c.      Morbidity committee

                                                                         i.            To discuss the incidental report which happened .

d.    Mortality committee : -

                                                                         i.            To discuss all mortality occurred in the hospital .

e.     Medical record and statastics committee : -

                                                                         i.            this committee provide hospital statistics .

f.       interdepartmental committee : -

g.    Resource utilization  committee.

 

 

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