Student Dissertation

Agency : NABH Standards; Gap Analysis; Medical Records; Medical Audit

Objective : 1. To identify the gaps against 3rd Edition NABH & Max Medical Quality Standards. 2. To suggest methods/action plan for the closure of the gaps. 3. To assess whether the documentation is being done as per the SOPs of the hospital. 4. To recommend effective solution wherever required.

Background : National Accreditation Board for Hospitals (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organizations. Gap analysis is the initial step in the review of the available service delivery system. It reveals the areas of improvement in the existing service system. Gap analysis at Max Hospital was carried out for NABH re-accreditation. A medical record enables healthcare professionals to plan and evaluate a patient's treatment and ensures continuity of care among multiple providers. With this background the current study was carried out in order to maintain complete medical records at Max Hospital, Mohali.

Methodology : Study setting: Max Super Speciality Hospital, Mohali. Study type: Descriptive, cross-sectional and prospective study. Study Duration: 8th Feb., 2016 to 30th April 2016. Sample Size: 206 patient files for audit study. Sampling technique: Convenience Sampling (Non-probability sampling). Data Collection Technique: Observation & semi-structured interviews. Instrument: Audit tool with a structured checklist. Secondary data: Files of the in-patients in various departments of the hospital and CPRS system of the hospital.

Findings : Observations of the gap-analysis study: The major non-compliance was due to lack of documented procedures and policies. A major gap regarding training and orientation of the staff was observed. Medication stock was not updated and stored as per the SOP’s in few areas. Display of essential posters like MSDS were lacking in some areas in the hospital. Appropriate signage was missing at some places such as display of tariff, OPD timings, etc. Observations of the audit study: More than 90% compliance was observed in following five Parameters: List of pre-operative investigations. (93.07%) Blood transfusion notes (99.01%) VTE Assessment (91.84%) Medication sheet (93.55%) Details of Initial assessment (94.8%) Lesser compliance was observed in the following parameters (less than 90%) Details regarding Referral consults (83.7%) Pre-operative, Operative, Post-operative Notes (80%) Details of Face sheet (86.1%) Details of Admission request (87.78%) Doctor’s progress notes (88.4%) Informed consent (87.6%) Anaesthesia record (87.6%) Markings for Vulnerable patients (85.6%)

Recommendations : 1. ACLS and BLS training should be given to all the staff. 2. Medication stock should be evaluated in every shift by the nursing team leader. 3. Essential Posters (like MSDS) should be placed at appropriate places. 4. Appropriate signage should be displayed. 5. Doctors need to be sensitized regarding complete filling of informed consents. 6. Nursing needs to be trained for mandatory pain assessment. 7. Trainings to be enhanced for nursing for management of vulnerable patients including marking on files. 8. Allowed list of abbreviations need to be displayed in the doctors OPS’s. 9. Documentation of surveillance mechanism needs to be strengthened. Special training sessions should be conducted for doctors and nurses regarding the importance of complete and effective documentation Audit study corrective actions taken: 1. The compliance rate was discussed with the concerned consultants in MRD committee meet. 2. Date and time should be mentioned by the signing consultant. 3. Results of the audit to be shared with the concerned stakeholders to sensitize them. 4. The major non-compliance was observed in entering time for Face Sheet, Admission Request Form, Medication Order Sheet, VTE analysis etc. 5. Physicians were asked to positively mention the proposed date for admission in admission request form. 6. Consultants were sensitized for counter signing for SR’s notes within the required time frame. 7. Nursing Team Leaders of various departments were instructed to check for vulnerable patient marking (V Stamp). Preventive Actions Taken 8. CME programme was conducted titled relevance importance of documentation w.r.t. Medico-legal cases. Moreover, topics related to complete filling of medical consent forms were also discussed. 9. It was suggested and decided in MRD Committee Meeting that open file audit shall be conducted regularly once in 3 months. 10. Regular sharing of audit results in the concerned committee meetings, shall be done.


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