Abstract of Dissertation

Keyword : Patient Safety; International Patients Safety Goals; Quality Improvement; JCI Standards

Objective : • To assess the compliance level of International Patient Safety Goals by the staff (Doctors and Nurses) in five departments of Max Hospital • To identify the gaps and issues in all processes and procedures that correspond to JCI standards for IPSG (International Patient Safety Goals) chapter.

Background : For managing the quality of an organization and in a hospital, implementation of accreditation has been made, which involves the assessment of work and organizational practices against pre-defined standards, conducted by multidisciplinary clinical and support service teams. The level of compliance against standards is then evaluated by the external teams of surveyor and on that basis accreditation rating is arrived at for the organization. Joint Commission International (JCI) is an international body issuing healthcare standards following the principles of Total Quality Management to improve quality and patient safety.

Methodology : For the purpose of study, a descriptive study was done in Max Super Speciality Hospital, Shalimar Bagh on the population that includes Doctors and Nurses. A sample size of 100 (50 Doctors and 50 Nurses) was taken as per convenience sampling technique. The duration of the study was from Feb 2018 to May 2018. The tool that was used for the study was checklist as per IPSG guidelines and five departments were included i.e. Emergency department, Radiology department, ICU, Labour room and Wards. The observations were then noted in checklists and compared with the existing policies for the same.

Findings : The study showed the implementation of International Patient Safety Goals in the hospital and the compliance among the hospital staff i.e. doctors and nurses. The compliance of IPSG 3 and 5 is 96% among the nurses and IPSG 5 is 98% among the doctors in ICU. For emergency department, IPSG 1 is 90% among the nurses and IPSG 1 and 3 among the doctors. For the radiology department IPSG 1 is 94% among the nurses and in labour room and wards IPSG 1 is 98% among the nurses and IPSG 1 is 94% among the doctors respectively. It is recommended that training should be done periodically in the interval of 2 months and hand washing methods (8 steps) and hand washing moments (5 steps) should be strictly followed.