Abstract of Dissertation

Keyword : Gap Analysis; Emergency Department; NABH Standards; Healthcare Delivery

Objective : • To assess the existing service delivery standards of Emergency Department at EHCC HOSPITAL JAIPUR. • To identify the gaps in terms of structure, process and outcome. • To recommend alterations in structural designs, process of the facilities to meet the requirement. • To give recommendations on measures to be taken to fulfil the gaps.

Background : Healthcare scenario across the world is changing with the arrival of newer healthcare delivery models. Faculty of Emergency Medicine is one such development in India. Today Indian hospitals have recognized the need to focus on Emergency Medicine Departments (ED) because the quality of care provided there shows the level of care hospital provides and this goes a long way in the reputation of the hospital. Getting quality and safe acute care is the right of every patient who comes in through the door of the ED. However, there are very few trained experts in Emergency Medicine and there are no standards or processes to guide and govern the functionality of the Emergency Department. The ED becomes the place for overcrowding not only for patient disease conditions and their emotions but also for a cluster of opportunities to make medical errors. This is an opportunity for us to defeat the challenges and create standards and processes to make sure the patients in EDs get the quality acute care he or she deserves. Keeping this in mind NABH has formed its first draft of standards for Certification of Emergency Department which would result in improved quality care and patient safety.

Methodology : A. Data Collection Tool ? Checklist NABH emergency self-assessment toolkit which includes 8 chapters, 47 standards and 245 objective elements. The chapters are: • Chapter 1 - Access, Assessment and Information (AAI) • Chapter 2 - Patient Care and Rights (PCR) • Chapter 3 - Management of Medication (MOM) • Chapter 4 - Hospital Infection Control (HIC) • Chapter 5 - Continuous Quality Improvement (CQI) • Chapter 6 - Responsibilities of Management (ROM) • Chapter 7 - Facility Management and Safety (FMS) • Chapter 8- Human Resource Management (HRM) B. Data Collection Method ? Reviewing of Hospital Manuals, Policies, Records (e.g. - Register of these departments) , HMIS and interaction with hospital staff and patients. The NABH emergency toolkit consists of: 1. Implementation (Yes/No): Whether the objective is implemented in the department or not. 2. Documentation (Yes/No): If the objective is implemented, whether there is proper documentation regarding the same or not. 3. Evidence: If there is proper documentation of the said objective, then evidence will be collected regarding the same. 4. Score (0/5/10): Once all the above criteria is fulfilled score would be given as follows: • Compliance to the requirement :10 • Partial compliance to the requirement: 5 • Non-compliance to the requirement: 0 • Not applicable: NA Evaluation criteria during final assessment: • No individual standard should have more than one zero to qualify. • However, no zero is accepted in the regulatory/legal requirements. • The average score for individual standard must not be less than 5. • The overall average score for all standards must exceed 7.

Recommendations : The study revealed that the average score of Emergency Department is 9.628 which make the hospital eligible for appearing for final assessment, as minimum score required was 7. The area of concern lies with implementation of policies and procedures as documentation is almost covered. The Emergency Department has: • 92.6 % Compliance • 5% partial compliance • 1.22% non-compliance. • The average score for individual standard is not less than 5. • Average score for individual chapter is not less than 7. • No individual standard should have more than one zero.