Abstract of Dissertation

Keyword : NABH Standards; Gynecology; Obstetrics; NABH Accreditation

Objective : • To identify gaps in the existing system of Obstetrics and Gynaecology Department in th context of NABH Standards.

Background : The concerns on quality are increasing every day. Most of us try and take initiatives to bring quality in the work we do because it is not only the need of the hour, but our consumers have got ample options to judge quality depending upon the services they utilize, and they are offered. National Accreditation Board for Hospitals and Health care Providers is a body which has set some standards to measure quality. NABH is an institutional member of International Society for Quality in Health Care (ISQua).

Methodology : A checklist was prepared consisting of all required parameters to be assessed with respect to NABH standards in the Department of Obstetrics and Gynecology at JIMS hospital. Gaps identified The Noncompliance thus identified were chiefly in the areas from • Lack of documented policy and procedure for obstetrics services • Lack of a proper definition as to what constitutes high-risk obstetrics • Lack of proper display of high-risk obstetric at a prominent location • In Ante natal services o Lack of Diet counselling by dietician o Lack of Ante natal card for every patient • Lack Labour Augmentation Bundles • Lack of Staff Safety measures o Hand Hygiene o Spill management o Needle stick injury o Bio- Medical waste management • Lack of a proper policy for HIRA & MSDS • Sodium Hypo chloride • Lack of Fire Exit Plan • No Crash Cart • Early Warning Signs monitoring/ • Clinical Alarm (no documentation and reporting protocol) • Lack of Code Blue Mock Drills • Lack of Code pink Mock Drills • Noncompliance wrt ID Proof Notice for PNDT (form f) • Lack of MTP- Form C & I (Informed Consent and their documentation and Storage) • Noncompliance wrt Triaging of Patients • Noncompliance wrt Care of vulnerable patients • Noncompliance wrt Management of Medicine o LASA drugs o Labelling Policy o Verbal Order Policy o Medication errors documenting o Documenting Adverse reaction o Vaccine storage policy o Emergency drugs stock Maintenance. • Lack of Policy regarding infection control • Lack of Policy regarding maintenance of equipment’s • Lack of Temperature and humidity control at Labour room • Lack of Calibration record of equipment’s

Recommendations : This study stressed on how core indicators of NABH contribute towards safety in delivering Obstetrics and Gynecology services and making it more effective for all economic strata’s. Every possible measure was taken to take concerns from all the staff and patients in the form of inputs in order to incorporate it in the study. Efforts were successful in a way that organization is going to file its application for NABH accreditation on 25th May.