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Clinical Excellence

Patient Safety and Quality at FMRI

At FMRI we ensure to deliver high-quality, compassionate care to all patients across our health system. By providing privilege and confidentiality, the quality & patient safety department create a secure environment where clinicians and health care organizations can use common formats to collect, aggregate, and analyze data that can improve quality by identifying and reducing the risks and hazards associated with patient care.

Our Commitment to Transparency

Patients and their loved ones deserve to be informed about the quality of their health care. At FMRI, we are dedicated to sharing our performance and how we work to provide the best care with past, present and future patients. We coordinate safety and quality improvement efforts and training across our health system.

Quality Policy

FMRI is committed to treat all patients and caregivers with compassion, integrity, teamwork and honesty. We endeavour to achieve high standards of medical care through a quality improvement system. We continuously strive to improve and sustain patient satisfaction, patient safety and clinical outcomes.

Quality Objectives:

  • To practice patient centric approach
  • To ensure safety of patients, employees and other service providers.
  • To monitor, measure, assess and improve our performance to achieve service and clinical excellence and patient satisfaction.
  • To provide a platform for continuous learning at all levels of the organization.
  • To empower and involve all employees in continuous quality improvement

Patient Safety and Quality Measures

Fortis Memorial Research Institute (FMRI) has been accredited in June 2015 by NABH. We measure, monitor and analyze 64 indicators (Clinical and Non Clinical Indicators). Besides we have defined Process Audits for Service and Clinical Parameters under Fortis operating System and Medical Operating System respectively. Regular monthly audits are also done and data presented in the Validation meetings. We check our compliance to high risk medicines and maintain a Medication safety Scorecard, Compliance Scorecard for consents. Safe surgery checklist and mortality are also maintained.

We have a committee framework of 18 committees (Infection Control, Pharmacy and Therapeutic, Safety Committee, HR Committee, Quality and Patient safety Committee etc.) to ensure protocols are adhered and action taken whenever there is deviation.

Infection Control Programme

Our comprehensive infection prevention and control program covers policies on hand hygiene, occupational health, isolation, infectious diseases notification, clinical sample collection, environmental hygiene, antibiotic usage and infection prevention in practice settings and visitor areas. It also focuses on prevention of nosocomial infections especially ventilator associated infection, surgical site infections, UTI and Intravascular device related infections and also on control of communicable diseases by policies on patient care related activities.

Practice of Universal and Standard Precautions, are stringently followed. Orientation and teaching/training programs are carried out at the time of induction and on a regular basis for all employees on Standard Precautions and also on key Infection control norms such as Hand Hygiene practices. Our Staff health policy ensures that all staff is vaccinated or has immunity to Hepatitis B. Screening and appropriate vaccination of food handlers is also done.

Guidelines are followed for usage and care of intravascular devices, catheters and in the usage of other such invasive devices. Care of equipment, linen disinfection, air conditioning for operating rooms and Intensive care units as well as management of blood spills and needle stick injuries is done according to International protocols. We also have an established waste management policy and lab safety program; it not only helps us in meeting international norms in Infection control but also assures excellent world class clinical outcomes and exceptional patient safety and satisfaction.

Clinical Excellence Programme

Clinical Outcomes

We monitor and analyze outcomes of clinical procedures like Knee Replacement Surgery, PTCA, radiation Oncology etc.

Clinical Pathways

Standard care pathways for uniform patient care across different health settings

Clinical Audits

Being virtue of a Quaternary care multispecialty hospital, FMRI has engaged various departments in clinical audits.

Awards and accolades

Our quality initiatives are recognised at the highest level through accreditation from the prestigious NABL and NABH.

AccreditationForEffective from
NABHHospital – FMRIJune 2015
NABHBlood Bank - FMRIJune 2013
NABLLab - SRL - FMRIJune 2015
  • Received “Certificate of Merit” at DL SHAH awards(QCI) for Quality Improvement Project done on Improving Compliance to Surgical Safety Checklist.
  • Received Frost and Sullivan Awards 2015 for two projects under project evaluation & recognition programme-
     • Safety - "Improving Compliance to the Surgical Safety Check list (SSCL) at a quaternary care Private Healthcare.
     • Process Innovation - Indigenously Developed Technique For Total Body Irradiation.
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