A STUDY ON QUALITY AUDIT AT AMRI HOSPITAL FOR TWO MONTHS FOR THE YEAR 2017-2018 AMRI HOSPITAL

FOR THE PARTIAL FULFILLMENT OF THE DEGREE OF

BACHELOR IN HOSPITAL MANAGEMENT

UNDER

MAULANA ABUL KALAM AZAD UNIVERSITY OF TECHNOLOGY

FROM

DINABANDHU ANDREWS INSTITUTE OF

TECHNOLOGY AND MANAGEMENT

BY

AHARNA CHAKRABORTY

UNDER THE GUIDANCE OF

TAPENDU MONDAL

(QUALITY ASSURANCE MANAGER) REGISTRATION NO: 1541310001 SESSION: 2018-19

AMRI Hospitals in collaboration with Vision Care Hospital LOCATION- 230, Barakhola Lane, Purba Jadavpur, Behind Metro Cash and Carry, Mukundapur, Kolkata- 700099. Tel: +91-33-6606-1000 Email: [email protected]

DECLARATION FORM

I declare and inform you that this project entitled “A STUDY ON QUALITY AUDIT” has been submitted by me for the partial fulfillment for the requirement of the degree of Bachelor in Hospital Management from Dinabandhu Andrews Institute of Technology and Management under WBUT under the guidance of Mr. Surajit Das, HOD of our stream, Mrs. Paramita Banerjee, guide of the project and Dr. Tapendu Mondal (Quality Assurance Coordinator) of AMRI Hospital during the academic year of 2018-2019.

1. NAME- Aharna Chakraborty

2. ROLL NO.- 36

3. REG NO.- 1541310001

4. DURATION OF TRAINING- 1.5 Month

5. (Signature of the Student)

6. For office use only-

7. The project has been approve/not ACKNOWLEDGEMENT

I am using this opportunity to express my gratitude to everyone who supported me throughout the course of this training. I am thankful for their aspiring guidance, invaluably constructive criticism and friendly advice during my training and the project work. I am sincerely grateful to them for sharing their truthful and illuminating views on a number of issues related to the project. I express my warm thanks to Mr. Surajit Das, HOD of our stream, Mrs. Paramita Banerjee, guide of the project and Tapendu Mondal, Manager of the Quality Assurance Department of AMRI Hospital for their support and guidance and all the people who provided me with the facilities being required and conductive conditions for my project.

Thank you, AHARNA CHAKRABORTY

PREFACE

A hospital is a service organization. I have surveyed some departments and interacted with the departmental employees. I tried to analyze the perception on the present scenario of services of the Advanced Research Medical Institute (AMRI) Mukundapur. One of the main studies of my survey was to understand the outpatient department and its workflow. I have collected information about Quality Assurance and data department wise. I have done my basic project on Quality Assurance Department and an overview on other departments. I shall be satisfied if this study and findings prove beneficial to the hospital services anyway.

CONTENTS

SL CHAPTERS NO. 1. HOSPITAL PROFILE 2. INTRODUCTION 3. REVIEW OF LITERATURE 4. OBJECTIVE 5. BROAD OVERVIEW OF THE PROJECT 6. METHODOLOGY 7. DATA COLLECTIONS 8. SUMMARY OF FINDINGS 9. CONCLUSION 10. REFERENCE 11. BIBLIOGRAPHY 12. ANNEXURE 13. 14. 15. 16.

HISTORY OF THE HOSPITAL

AMRI Hospitals is a private hospital chain which is headquartered at the city of Kolkata, . It was co-founded by the Emami and Shrachi Groups in 1996, two of Kolkata’s developing groups, in a partnership with the Government of West Bengal to expand health coverage options for consumers. The company’s head office is in Kolkata with 6 branches in West Bengal, 1 at .

HOSPITAL PROFILE

AMRI Hospital Mukundapur started as the first boutique multi super specialty healthcare facility in Eastern . AMRI Mukundapur is a comprehensive healthcare treatment facility equipped with the state-of-the- art international standard equipment. The unit is currently functioning as a 175 bedded multi super specialty hospital. The best aspect about the hospital is the soothing ambience at par International Standards and highly professional staffs who manage the latest technology.

Having being geographically located at the heart of southland in Kolkata surrounded by landmarks like Satyajit Ray Film Institute, Metro Cash and Carry it is not only very easy to reach but easy transit is availed by the Eastern Metropolitan Bypass which touches the hospital premises. Internationally acclaimed consultants are attached on full time basis with the unit hence highest standards of clinical service is always maintained. The facility has advanced infrastructure and expert team of dedicated full time doctors to take care of any clinical situation for women and child-besides offering very

FACILITY LAYOUT Area Facilities Service Available

Basement Administration,MRD,HR,IT,Biomedical Engineering, Linen Storage Area,RO Plant,IBMS Room, Mortuary, Medical Air Plant, End Feed Room, Call center, Car parking area.

Ground Emergency, Laboratory Services, Radiology and Imaging, Registration, Admission and Discharge desk, TPA desk, Floor Inside Administration, Waiting Lounge.

Ground Floor Outside Pharmacy, Manifold Room, LT Panel, Children Play Area.

Annex Area LMO plant, HT plant, Generator room, Ambulance Bay, Car Parking Area, LPG Bank, Assembly Area 1 & 2.

First Floor Registration, Billing, Report dispatch, OPD Clinics, Mammography, USG, Urodynamics, Uroflowmetry, Sample Collection, Eye, Cardiology, Play area, Feeding Room, Electrophysiology, Dental procedure, Toilet.

Second Floor Labour room, NICU, Operation Theatre Complex, Cath lab.

Third Floor Stroke Unit, Bone Marrow Transplant, ICU, Neuro ICU, PICU, CTVS ICU.

Fourth Floor Dialysis Unit, Male Ward, Pediatric Ward, Twin Sharing Rooms.

Fifth Floor Gastroenterology Unit, Single Room, General Ward, Physiotherapy Unit.

Sixth Floor Executive Room, Nursery

Area Facility Services Available

Seventh Floor Kitchen, Cafeteria, Dietician Work Station, AC panel room.

Terrace Water tank, Lift machine room.

Service Floor Training room.

FACILITIES OF AMRI MUKUNDAPUR

▪ Full Range Paediatric & Gynaecology specialty clinic. ▪ 24*7 Qualified Specialist Doctor ▪ Premium Quality House Staff ▪ Advanced Paediatric Unit, Adult Dialysis Unit ▪ Round the clock support of qualified doctors for high risk pregnancies ▪ Advanced Laparoscopic Services ▪ Easy Transit- Geographical Location ▪ Boutique Ambiance ▪ Super deluxe category rooms with lawn terrace ▪ Basement parking ▪ Landscaped green area with fountains ▪ Attractive kids play area

SERVICES PROVIDED

MEDICAL SERVICES

• 24X7 Ambulance services(Dedicated Critical Care Ambulance for Adults/ Neonates & Paediatric Patients) with retrieval facility

• CO2 Laser Therapy

• 24 hrs. Frank Ross Pharmacy inside the Hospital

• 24x7 Path Laboratory & Imaging Services

• Comprehensive Health Check Up Services

• Advanced Neonatal & Paediatric Surgery provision

• Highly developed Nursery

• NICU & PICU of International Standard

• Epidural Painless Delivery

• Modernized LDRP suits (Labor, Delivery, Recovery & Postpartum)

• Anesthesiology

• Cardiac services noninvasive cardiology, Interventional cardiology (cath lab)

• Clinical hematology, Hemato and Bone marrow transplant

• Critical care

• Dermatology

• Dentistry and Maxillofacial surgery

• Diabetology and

• ENT and Head Neck surgery

• General medicine or Internal medicine

• Gastroenterology and Gastrointestinal surgery

• Gynecology and Obstetrics

• High risk pregnancy unit

• • (dialysis)

• Neuro sciences: Neuro medicine, Neuro surgery, Neuro intervention, Neuro rehabilitation, Neuro psychiatry

• Nutrition and diabetes

• Oncology: medical and surgical

•

• Orthopedics and Replacement surgery

• Level 3 NICU, PICU

• Paediatric cardiology, Gastroenterology, Endocrinology, Eneuresis clinic, Growth and obesity, Neonatal dialysis psychiatry.

• Uro-dynamics, Neurology, Nephrology, Urology, , Surgery, ENT and Audiology, Immunization

• Plastic reconstructive and Cosmetic surgery

• Psychiatry

SERVICES

• Ambulance(ALS) 24 Hours

• Emergency medicine and trauma care

• Laboratory services

• X-ray

• 128 slice CT scan

• Pharmacy

OTHER SERVICES

• MRI (1.5 Telsa, D-strean) • Mammography • Ultrasonography • 2D Echocardiography • TMT • 2H Hours Holter • Ambulatory blood pressure monitor • PFT • Video EEG, EMG & NCV, BERA, VEP • Trans Cranial Doppler • Audiometry, Stroboscopy (voice clinic), Speech therapy

SCOPE OF SERVICES: OBSTETRICS AND GYNAECOLOGY • High risk pregnancy care • Endocrine (Diabetes, Thyroid disorders) • Recurrent abortion clinic • 24 hours facility for Antenatal CTG, USG, Doppler • Level 3 NICU support • Labour room • Nutritional advice for pregnant and lactating mothers • Painless labour with Epidural Analgesia • Urogynaecology with Urodynamics • Gynae oncology with Colposcopy clinic • Laporoscopy gynaecology • Menstrual disorder clinic • Infertility clinic

services like CO2 Laser Therapy and Bariatric Surgery for child obesity.

INTRODUCTION

Healthcare services, especially, the standard of medical care has always been of prime concern in every society and in every country. As a result, the healthcare providers who have been hitherto insensitive have started paying attention to the quality aspect of healthcare. The quality can be defined in the simplest words as the “Degree of Excellence”. The quality is a dynamic phenomenon, it keeps on changing. It changes with time, with place and varies from person to person. The level of knowledge, awareness and perception, which determines quality.

.

FUNCTIONS OF QUALITY DEPARTMENT:

The functions of quality are as follows-

1. Rapid advancement in health sector. 2. Rapid development in diagnostic and operation technology. 3. Increase awareness of people about health. 4. The type of function is multi centric and multifaceted. 5. Provide good patient care up to their level of satisfaction.

STAFFING OF QUALITY DEPARTMENT:

• Quality specialists—one FTE per one hundred beds • Process Improvement Specialists – one FTE per one hundred beds • Data Analysts—one FTE for every two quality specialists • Specialists—one FTE per two hundred beds • Infection Prevention Specialists—one FTE per one hundred beds • Accreditation Specialist (The Joint Commission and CMS)—one per hospital • Medication Safety Specialist (PharmD)—one per hospital • Environmental Safety – one per hospital ADVANTAGES OF QUALITY DEPARTMENT:

1. Improved care 2. Shorter lead times 3. Better relationships with the customers 4. Reduced cost, increased profit 5. Improved systems and standardized procedures 6. Better workmanship 7. Guaranteed quality

QUALITY REQUIREMENTS:

1. Customer participation in QM. 2. Leadership for the steering of quality 3. Personnel as prerequisite of high quality. 4. QM for preventive as well as for other activities. 5. Information as a basis for continuous enhancement of quality. 6. Feedback and detailed recommendation.

REVIEW OF LITERATURE

Sneddon et al (2006) provide an effective summary of the clinical audit purpose and process. Clinical audit is for them “… One of the main tools to establish whether the best evidence is being used in practice, as it compares actual practice to a standard of practice. Clinical audit identifies any gaps between what is done and what should be done, and rectifies any deficiencies in the actual processes of care.”

One of the earliest reviews, Balogh et al (1995), argued that clients should be involved in every stage of the audit process from defining the topics to the actual audit process.

A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of “audit”, “audit of audits”, and “evaluation of audits” and a hand search of the indexes of relevant journals for key papers. To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process.

According to Institute of Medicine (2001), healthcare quality can be accessed from two viewpoints: patients and technical or professional. The former includes assessment of service provider’s ability to meet customer demand, customers’ perception and satisfaction. Customer perception with respect to evaluation of healthcare quality has been supported by a number of researchers (Mashhadiabdol et al., 2014; Kitapci et al., 2014).

Extensive investigations and studies have been mounted in general practice over the last two decades which have examined such areas as the doctor's attributes (Peterson et a!., 1956), his equipment (Irvine, 1972), his administrative arrangements in the surgery (Stott and Davies, 1975), his activities during the consultation (Buchan, 1978; Floyd and Livesey, 1975), and the availability of supporting services (Marsh, 1969).

OBJECTIVE

The basic objective of doing this project is to study and observe the Quality Audit of AMRI Hospital for better knowledge and to understand the workflow of the Quality Assurance Department. The study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting.

Secondly, the objective of doing the project is to know how the services are to be controlled, the quality is maintained thus gaining maximum attention in the provision of the quality services and getting feedback from the patients and relatives of the patients. The primary purpose of such an audit is to elevate the quality & efficiency of medical care, & for so doing, to seek the cause for poor results.

QUALITY AUDIT

Quality audit is defined as the evaluation of medical care in retrospect. It is the review of the professional work in the hospital or in other words the quality of medical care i.e. we try to see how far the clinicians and nurses have conformed to the norms and standards of the defined medical practice while treating and serving the patients. This is not punitive or coercive. The very purpose of the medical audit is improvement of services. Whatever mistakes we have committed during the process of rendering services, we try not to repeat those in the future and improve the services.

The program of quality audit is an ongoing activity involving study of medical records of the patients aimed at assessing quality of care given to the patients as well as the quality of records generated. Since it is based on the study of records, the outcome of study depend a lot of the quality of records generated.

OBJECTIVE OF QUALITY AUDIT:

1. To improve the quality of records generated. 2. To improve the quality of patient care. 3. To stimulate the practice of scientific medicine. 4. To eliminate substandard practices.

PURPOSE OF QUALITY AUDIT:

1. To plan future course of action- It is necessary to obtain baseline information through evaluation of achievements for comparison purpose with a view to improve the service. 2. Regulatory in nature- Ensures full and effective utilization of staff and facilities available. 3. Assess the effectiveness of efficiency of health program and services put into practice.

PREREQUISITES OF QUALITY AUDIT:

1. Hospital operational statistics: • Hospital resources: Bed compliment, diagnostic and treatment facilities, staff available. • Hospital utilization rates- Days of care, operations, deliveries, deaths, OPD investigations, laboratory investigations, etc. • Admission data- Information on patients i.e. hospital morbidity statistics, average length of stay (ALS), operation morbidity, outcome operation. 2. The procedure of collection and tabulation of hospital statistics should be standardized. 3. Primary source of this data is medical records, hence accurate and complete medical records should be ensured. 4. A well trained medical record librarian should be present for carrying out quantitative analysis. 5. Hospital planning and research cell should be established at state level to tabulate and analyze data, with recommendations for improvement.

QUALITY AUDIT COMMITTEE:

• Quality audit committee should consist of hospital consultants, who are committed to Quality Audit. • The committee should meet once in a month and submit the report to medical superintendant (MS) as confidential. • It should be constituted of – ➢ Senior Clinical Consultant - Chairman ➢ Consultants from concerned clinical departments (Heads of Surgery, Medicines, Pediatric, Gynae, Pathology, Radiology, Casualty, Anais, Nursing Superintendent) - Members ➢ Representatives of MS - Member ➢ Medical Record Officer - Member Secretary

OUTLINE CRITERIA INVOLVED IN QUALITY AUDIT:

1. Selection of Quality Criteria. 2. Review of medical records of patients to evaluate all aspects of patient management including the case history, the investigations ordered and their justification, the diagnosis, the management plan, the results of treatment, period of hospitalization, the complications, if any, their causes and outcome of treatment. 3. Evaluation of content and quality of medical records generated. 4. Identification of deviations, if any, from SOPs. 5. Analysis of deviations with a view to establish causes. 6. Commenting on the effectiveness of patient management system on the basis of general pattern of outcome.

OUTCOME OF QUALITY AUDIT:

1. High quality medical records, complete, correct and as per the prescribed format. 2. Increased accountability of the staff. 3. Reduction in the incidence of avoidable complications, morbidity and mortality. 4. Improved quality of patient care.

TYPES OF QUALITY AUDIT:

1. Morbidity Audit – Findings are matched with predetermined norms and standards of care laid down by medical staff for this disease category. It is done ward/unit wise. 2. Audit of Operated Cases – • A group of patients who have been operated for a similar surgical condition are analyzed under this method. • Again a group of surgeons is asked to lay down the desirable norms and standards. • Particular emphasis is laid on the pathological reports of the tissues during operation. • The percentage of preoperative diagnosis which tally with the pathological diagnosis is an important parameter • Type of antibiotic used, number of postoperative infections, the anesthesia and operation notes are the points which are investigated in this type of audit. 3. Audit of Obstetrics Cases – Done in more or less on the same line as in operated cases. Here percentage of C/S, forceps, application, MMR, NMR, etc. are the important parameters. 4. Audit of Death Cases – • All the deaths which takes place after 48 hrs. Of admission to the hospital are normally subjected to a review by a committee. • Also useful to review the deaths within 48 hrs. (Especially death in emergency department). • Case sheets are examined for quantitative as well as qualitative adequacies. 5. On spot quality audit – In this method quality audit team goes to a particular ward and carries out audit when patient is still in ward and treating medical team is available. 6. Nursing Audit – Nursing audit is a review of patient record, designed to identify, examine or verify the performances of certain specified aspects of nursing care by using established criteria.

PRINCIPLES OF QUALITY AUDIT:

1. Health authorities and medical staff should define explicitly their respective responsibilities for the quality of patient care. 2. Medical staff should organize themselves in order to fulfill responsibilities for audit and for taking actions to improve clinical performances. 3. Each hospital and specialty should agree a regular programme of audit in which doctors in all grade participate. 4. The process of audit should be relevant, objective, quantified, repeatable and able to affect appropriate change in organization of service and clinical practice. 5. Clinicians should be provided with the resource for quality audit. 6. The process and outcome of quality audit should be documented. 7. Quality audit should be subject to evaluation.

MECHANICS OF QUALITY AUDIT:

1. Preparatory Phase: • See the completeness, accuracy, & adequacy of components of the record. • Agreement or lack of agreement between provisional & final diagnosis and that cause of death identified by the Post Mortem Examination, i.e. the history & physical findings & the end results; • Whether the final & pathological diagnosis and the cause of death agree; • Whether a consultation was requested or not, and if so, recorded or not. • Whether P.M. Examination was done or not and what was the result. 2. Analysis of Recorded Data: • The other phase of the death audit is the actual analysis of the recorded data in the clinical records, the field reports pertaining to the professional work of the hospital & other related information. These are of two kinds:- (i) External (ii) Internal

3. Duties of the Committee:

i) To detect possible errors in diagnosis, treatment, judgment or technique. ii) To check the statement of prognosis & results (discharge or death). If he agrees with the statement of the physician he will approve the record for indexing; if disagrees, the committee will:

a) Confer with the attending physician & arrive at a decision.

b) Return the records to the physician for elaboration & correction, or

c) If the results are entirely out of line (confirmed by P.M. Examination), make necessary suggestions & recommendations so that the error is not repeated. iii) To indicate if a case is of educational value for inclusion in the staff meetings. iv) After the auditor or the audit committee has finished with the record, it is sent to the medical record librarian for filing .

STAGES OF QUALITY AUDIT:

The stages of medical audit are as follows-

1. PREPARING FOR AUDIT:- a) Involving the Users - • The focus of any audit project must be those receiving care. • Users can be genuine collaborators, rather than merely sources of data. • The concerns of users can be identified from various sources, including: ➢ Letters containing comments or complaints ➢ Critical incident report ➢ Individual patients’ stories from focus groups ➢ Direct observation of care ➢ Direct conversations b) Selecting a Topic – • Topic should be of concern to service users and has potential to improve service users ‘outcomes’. • It should be of clinical concern (e.. an acknowledged variation in clinical practices, high-risk procedures, complex management). • It should be financially important (either very common and/or very expensive). • It should be of local and/or national importance (e.g. a Department of Health initiative) • It should be practically variable (e.g. can be measured and you will be able to implement change or effect the implementation of change). • There should be new research evidence available on the topic. E.g. the incidence of wound infection following hernia repair. c) Defining the Purpose – The following series of “action verbs” may be useful in defining the aims of the quality audit: • To improve • To enhance • To increase • To change • To ensure

Example –

i. To improve the blood transfusion processes within the trust ii. To increase the proportion of patients with hypertension whose blood pressure is controlled iii. To ensure that every infant has access to immunization against diphtheria, tetanus, pertussis, polio before 6 months of age. d) Planning – • Involve ALL the people concerned • Time and resources • Access the evidence • Data collection instrument all these should be • Methodology documented • Pilot • Report and action • Re-audit 2. SELECTION OF CRITERIA:- a) Defining criteria – • The audit criteria will provide a statement on what should be happening. • The standards will set the minimum acceptable performance for those criteria. • The criteria and standards must be ➢ Specific – clear, understandable ➢ Measurable ➢ Achievable ➢ Relevant – to the aims of the audit ➢ Theoretically sound – based on current research For example – Audit title – the incidence of wound infection following hernia Criteria – there should be non wound infection in such cases Standard – 95%, i.e. practice is satisfactory if less than 5% of cases have wound infection • The basic types and sources of criteria ➢ Statistical (empirical) criteria ➢ Normative (consensus) criteria - optimal care (general consensus) , essential (critical) ➢ Scientific (validated) criteria b) Sources of Evidence – standards may be based on one, or any combination, of the following: • National guidance or standards (e.g. Patients’ Charter). • College or professional organization guidelines. • Laws (e.g. Mental Health Act, 1983). • Current practice (observes and assesses current practice). • Standards used locally by colleagues or competitors (e.g. neighboring trust, ward, etc). • Research evidence (from which standards can be developed). • Literature review of other quality audits which have published their standards or results. • Current knowledge from clinical experience. c) Appraising the evidence – Evidence needs to be evaluated to find out if it is valid, reliable and important. • Aim/ objectives • Methodology • Results/conclusions • Applicable the patient group 3. MEASURING LEVEL OF PERFORMANCE :- a) Data Collection – • Data can be collected from computer stored data, case notes/medical records, surveys, questionnaires, interviews, Focus Groups, Prospective recording of specific data. • The careful selection of an appropriate data collection tool is also important. • Always conduct a small pilot study. • The reliability of data can be improved but providing appropriate training in data collection for the person undertaking this task. • Ensure that the data is Stored in such a way that it is both secure and conforms to legal requirements. b) Data Analysis – • The following approaches may be used in analysing data ➢ Descriptive statistics ➢ Statistical tests ➢ Qualitative analysis • When analysing data, it is tried to reach conclusions about the general pattern of actual practice. c) Comparing with Standards Set – Results may prove most meaningful if the following percentage are calculated: • Percentages of cases meeting each standards. • Percentages of cases not meeting each standards. • Percentages of cases considered non-applicable. • Percentages of applicable cases meeting each standards. • Percentages of applicable cases not meeting each standards. d) Dissemination of feedback findings – • It is important that all of the key stakeholders are made aware of the findings of the project and are provided with an oppurtunity to comment on them. • A combination of passive feedback (written information) and active feedback (discussion of findings) is preferable when communicating the findings of project. 4. MAKING IMPOROVEMENTS :- a) Identifying barriers to Change – • Fear • Lack of understanding • Low morale • Poor communication • Culture • Pushing too hard • Consensus not gained

Some methods are-

• Interviews of key staff and/or users • Discussion at a meeting • Observations of pattern of work • Identification of the care pathway • Facilitated team meetings with the use of brain storming or fishbone diagrams b) Implementing Changes – Develop a quality audit plan which specifies- • What needs to change • How change could be achieved – what actions need to take place • Who needs to take these actions • When the proposed actions will begin • How these actions will be monitored and by whom • How and when to assess whether the actions taken have achieved the desired outcome 5. SUSTAINING IMPROVEMENTS :- a) Monitoring and Evaluation – • Although improvng performance is the primary goal of audit, sustaining that improvement is also essential. • Only minimum number of essential indicators should be included in monitoring. • If performance targets have not been reached during implementation, modifications to the plan or additional interventions will be needed. b) Re-audit – It is important to go around the quality audit cycle for a second time in order to discover whether- • Agreed actions ave occurred • Changes have achieved the desired improvements – i.e. closer to set target and, therefore, improvements in service delivery. • Standards continue to be met (where no changes were made). c) Maintaining and Reinforcing improvement – Factors that have been identified for maintaining improvements: • Reinforcing or motivating factors built in by the management to support the continual cycle of quality improvement. • Strong leadership. • Integration of audit into organization’s wider quality improvement system.

WORKFLOW OF QUALITY ASSURANCE DEPARTMENT IN AMRI:

I Aharna Chakraborty was a trainee in AMRI Hospital in the Quality assurance department. Being on training, I observed the workflow of the Quality assurance department. Quality management at AMRI HOSPITAL meets the requirements of National Accreditation Board for Hospitals and Healthcare Providers (NABH). The Expansive Scope of Services available at AMRI HOSPITAL, the Expertise of Physicians, the Advanced Technology, and the Dedication of Quality in Patient Care, the Infection Control Programs, and positive patient’s outcome has clearly made AMRI HOSPITAL a provider of high quality healthcare. Being on training, I observed that quality department does the following works-

• Sincere commitment to quality and quality system. • A written policy statement specific to the organization’s goals, expectations and needs of the customers. • Understood and implemented policy at every level. • Quality system was periodically reviewed. • Quality Head and an Executive management headed by the Director General deals with all quality matters. • Quality system fully documented and implemented. • Quality manual well maintained. • Procedures documented and implemented.

OPEN FILE AUDIT: open file audit is a process that has been defined as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change”. Audit in healthcare is a process used by health professionals to assess, evaluate and improve care of patients in a systematic way. Audit measures current practice against a defined (desired) standard. It forms part of clinical governance, which aims to safeguard a high quality of clinical care for patients. Audit should be transparent and non-judgmental. The aim is to find out how the present provision compares with the desired standard. This information can then be used to plan improvements in the service. It is not intended to cause confrontation or blame. It is done on a regular basis by the quality department of the hospital to note down the total number of compliance and non-compliance of various particulars. The particulars are as follows:

• Daily two treatments given to every patient by doctors: it means there should be minimum two assessments each day from the date of admission of patient to the date of discharge. If there is not minimum two assessments every day then it is wrong as per quality measures and should be written in open audit checklist as NC otherwise C. • Initial nursing assessment done by the nurses in wards at the time when patient is shifted to the concerned wad from emergency within 30 minutes: within 30 minutes of reaching time of the patient to his or her concerned ward the allocating nurse of that patient should make a complete assessment of the patient in a checklist where starting time and ending time of assessment, date and sign of the allocated nurse is written by herself which results in C in open audit checklist and if the time is not written then it will be NC. • Initial assessment done by doctors within 2 hours of the reaching time of the patients: it is the assessment done by the doctor within 2 hours of patient’s admitting time in the hospital, and if it crosses more than 2 hours then it will be written in open audit checklist as NC otherwise C. • The goal and plan of care written in each file of the wards: the goal and care plan is mainly written in patient’s file in the history sheet by Resident Medical Officer (RMO) or by the doctor. If it is written properly then it will be C in open audit checklist otherwise NC. • Counter sign of the concerned practitioner:thefile of every patient in every ward should be signed by the concerned doctors or by their team members. If it is not done then the quality staffs have to go to the OPD clinics of those doctors for collecting their counter signature in the history sheet of the patient’s file or if any doctor does not have his OPD chamber then the quality staffs have to instruct the ward’s nursing officer to take the counter sign of the doctors when they will come to treat their patients in the ward. In generally if the place of counter sign is blank then it will be expressed in the open audit checklist as NC otherwise C. • The nutritional assessment and reassessment checklist should be given within 24 hours of patient admission: the nutritional assessment checklist should be present in every patient’s file within 24 hours of patient admission and reassessment should be done every day till the date of discharge. Reassessment means a dietician would visit to every bed and makes diet chart on day to day basis depending on which the F&B department provides the patient’s food. If the nutritional assessment sheet is not present in patient’s file even after 24 hours of his or her admission then it will be written NC in open audit checklist otherwise C. • Consent: consent is a legal approval of doctor, patient and witness for each and every procedure done to a patient in a hospital which means they have conscious approval for those procedures. There are various types of consent present in a patient’s file viz. admission consent, radiology consent, blood transfusion consent, OT consent, anesthesiology consent etc. The parts which are examined by the quality department at the time of audit are whether the consent form is properly filled or not and whether the witness, doctor, and patient signed in the consent or not. If these are filled properly then there will be written in open audit checklist C otherwise NC. Also if there is any Bengali sign in English consent or vice versa then it will also a non-compliance and written NC in open audit checklist. • Medicine-card:medicine card is a card where the name of the drugs and their doses are written by the doctors for every patients. The medicine names should be written in capital letter and the doses are also should be written. Also there should be given by and checked by sign by the doctors and nurses beside the name of medicines. If all of these conditions are properly field in medicine card then there will be C in open audit checklist otherwise NC. Minimum one error in medicine card is considerable. • Pain assessment: pain assessment is a part of open file audit. It can be seen in the page of initial nursing assessment. Pain assessment is done by the allocated nurse for every patient. Pain assessment means to show how much pain the patient is having at the time of admission. There is a chart format which denotes from no pain to heavy pain. Also it includes skin care plan, risk for fall etc. If all this aspects are properly fill-up by the nurse then it will be written C in open audit checklist otherwise NC. • Transfer of patient from one ward to another or one bed to another: the patients many times have to transfer from one bed to another or from one ward to another. In that case there should be a transfer checklist present in the patient’s file and to be properly filled. If the checklist is present and properly filled then there will be compliance in open audit checklist otherwise non-compliance. And at the end of the month a report have to be prepared by quality to show the percentage of compliance and non-compliance of the particulars present in the open audit checklist.

PURPOSES OF OPEN FILE AUDIT • To plan future course of action, it is necessary to obtain baseline information through evolution of achievements. • For comparison purpose with a view to improve the services. • It is regulatory in nature ensuring full and effective utilization of staff and facilities available. • Describe and measure present performance. • Help developing explicit standards. • Suggests what need to be change.

Open audit file looks after the several types of consent whether it is properly signed by the doctors, nurses and patient relatives, the treatment sheet whether proper date, time, name and counter signature of the doctors are provided, initial nutritional assessment is properly done or not. It also looks that the initial nursing assessment is properly done providing proper time, date and signature of the attending nurses. The transfer checklist is also looked after. The medication card is thoroughly looked after whether proper dose is given, medicine is written in capital letter, no overwriting is there and doctor’s signature is there.

Problems in open file audit: • Not every time doctors usually give two minimum treatments on a daily basis. Also sometime signature and date is missed by him. • Initial nursing assessment is done casually. Date and time are missed sometime, also proper information are not there. The time limit of initial nursing assessment is 2 hrs. after patient get admitted. But most of the times the time exceeds from 2 hrs. • Initial emergency assessment should done by the doctors within 2 hrs. after the patient got admitted in the hospital. But the time duration is not maintained and the time is also not mentioned sometime in the emergency shit. • The goal and plan of care are not always filled properly by the RMO’S. They did not give detail information in there. • The most problematic section is the counter sign of the doctor. Not a single doctor signed in the history sheet of the patient file. Sometime RMO’s signed on behalf of the doctor which is not done. Also the nurses and nursing supervisor are not much responsible about this matter. • Nutritional assessment are not properly given to every patient every day. Some dates are missed sometime for some patients. Assessment should done within 2 hrs. of patient admission. This is not also maintained all the time. The manpower of dietitian is poor in the hospital. • Consent are the major problematic area in open file audit. There are various types of consent in a patient file like admission consent, radiology consent, OT consent, blood transfusion consent etc. the main problem in the consent form are the missing of signature of either patient or doctor or nurses or the patient’s family member. Also there is problem of giving Bengali sign in English consent and vice versa. • Medicine card error is the problem of open file audit. Nurses are so much irresponsible while giving the medicine to the patient that don’t even identify the patient properly at the time of medication. They not always signed in the medicine card after giving medicine to the patient on particular time. • Pain assessment is not observed on daily basis. Score is not always there in the pain assessment form and wrong information is also there.

CONTINUOUS QUALITY IMPROVEMENT

Quality improvement is about ensuring that our focus is on improving, not just maintaining our services at hospital. Quality improvement involves a focus on safety, effectiveness, efficiency, acceptability, accessibility and appropriateness of services for customers (who might patients, relatives/parents, or the other health care personalities).

PURPOSE OF CONTINUOUS QUALITY IMPROVEMENT IS TO:

1) Monitor patient and staff satisfaction. 2) Monitor quality indicators. 3) Monitor adverse drug reaction and medication error. 4) Monitor patient safety indicators. 5) Monitor medical audit results. 6) Monitor utilization of facilities. GOALS OF CONTINUOUS QUALITY IMPROVEMENT:

➢ To employ the staff-members of wards, departments etc. of the hospital continuously to document the work done properly so that at any point of time in future, the lapse can be pointed out and properly addressed. ➢ To maintain a quality improvement team to be responsible for each key function and evaluate the need for quality improvement activities for the function on an ongoing basis by reviewing policies and procedures relating to that function and to make necessary revisions to initiate quality improvement measures in a prioritized manner. ➢ To improve patient care guidelines relating to operative and other procedure, in a collaboration effort. ➢ To utilize a standard format for documenting and reporting all quality measures hospital- wide. ➢ To collect data on staff views regarding quality improvement activities. ➢ To develop a formal tool for prioritizing quality improvement activities. ➢ To strive to raise the bench mark in all aspects of service delivery and meet the quality standard expected for the same.

The CQI audit is as important as open file audit. The CQI checklist has four particulars in it. Some of these are:

• Patient identification: patient identification is done in every ward by the nurses. Identification is done by verifying the identification band which is present in the wrist or foot of every patients which carries the name, age, sex, time of admission, UHID number (AM3000568), practitioner name, and ward name at the time of medication. Also identification is done when thepatient have to go to X-ray, CT scan, USG etc. The nurses should have to verify the name, bed number, UHID number before the patient enters in the concerned investigation department. Also at the time of medication the nurses should have to provide medicine to the patients in accordance with the name of the drugs written in the medicine card. The quality staffs have to examine whether the concerned staff nurses are properly doing the patient identification or not. Whether they are identifying the patients before giving medication or not. If they are properly doing it then there will be compliance written in CQI checklist otherwise non- compliance. • Nursing handover: nursing handover means to hand over the overall responsibility of a patient by one nurse to another nurse at the end of their duty on a daily basis. Nursing handover is mainly done thrice a day. The nursing handover sheet is divided in to three shifts viz. morning, evening and night. The allocating morning nurse has to fill up the morning column and has to sign below. The same process is also followed by the evening and night shift nurses. There should be the name, age, date of handover and UHID number of the patient should be written at top of the page. If the date, and signature of the nurses are done properly there will be compliance in CQI checklist otherwise non- compliance. • Surgical safety checklist- surgical safety checklist is a page which is present in the OT consent and which is filled up in the OT at the time of patient’s surgery. This Patient Safety Alert alerts healthcare organizations to the release of a World Health Organization (WHO) Surgical Safety Checklist for use in any operating theatre environment. It is a tool for the relevant clinical teams to improve the safety of surgery by reducing deaths and complication. The checklist should carry the name and sign of the doctor, nurse and the anesthesiologist. If all these are properly done then there will be compliance in the CQI checklist otherwise non-compliance. And at the end of the month a report have to be prepared by quality to show the percentage of compliance and non-compliance of the particulars present in the CQI checklist.

METHODOLOGY

TRAINING DURATION: 8/01/2018 to 23/02/2018 TIMING: Monday to Saturday from 10:30 A.M to 7:00 P.M.

DATA COLLECTION METHOD:

SECONDARY DATA- The secondary data had been collected directly from the hospital, with the help of hospital yearly records and other reports. The data are collected through surveys, medical charts and insurance claims for hospitalizations, medical office visits and procedures.

The data were mainly collected through observation during the training period and regular interactions with the doctors, employees, and nurses of the hospital.

DATA COLLECTION

NO. OF SURGICAL SITE INFECTION IN PAEDIATRIC WARDS:

2

1.8

1.6

1.4 JANUARY'18 1.2 FEBRUSRY'18 1 Column1 0.8

0.6

0.4

0.2

0 No. of surgcal site infections

PERCENTAGE OF SURGICAL SITE INFECTION IN PAEDIATRIC WARDS:

0.27

0.265

0.26 Jan'18 Feb'18 0.255 Column1

0.25

0.245

0.24 % of SSI

TOTAL DISCHARGE IN GENERAL WARDS:

TOTAL DISCHARGE

JAN'18 FEB'18

ALOS IN PAEDIATRIC WARDS:

ALOS

JAN'18 FEB'18

TOTAL DEATH IN PAEDATRIC WARDS:

TOTAL DEATHS

22

21.8

21.6

21.4

TOTAL DEATHS 21.2

21

20.8

20.6

20.4 JAN'18 FEB'18

MORTALITY PERCENTAGE IN PAEDIATRIC WARDS:

MORTALITY % 3.00%

2.50%

2.00%

1.50% MORTALITY %

1.00%

0.50%

0.00% JAN'18 FEB'18

SUMMARY OF FINDINGS PROBLEM AREAS IN THE QUALITY ASSURANCE:

• Counter signature by consultant in history and Physical Record Sheet is not found. • Most of the time it is found that the doctor’s name and attending time is not found in the treatment sheet. • The nursing attendants forget to fill up the Initial Nursing Assessment sheet. If they fill up also then they forget to mention the time of arrival and time of assessment. • The nursing handover is sometimes not well by the nursing attendants. They forget sign or provide the date of the handover. • In the Surgical Safety Checklist, sometimes the consultant does not sign or provide their full name. • There is a lack of standing guidelines and procedures. • Low number of auditors is also a concern. SOLUTIONS FOR EFFECTIVE FUNCTIONING:

• Circular distribution has been started to the consultants and it is informed verbally to provide signature in the counter sign column by mentioning the name, date and time in History and Physical record sheet and treatment sheet. • Nurse must be actively involved and trained throughout the process. • Decisions must be supported by quality research. • Staff should feel empowered to make decisions and be held accountable. • Quality outcomes should be transparent.

CONCLUSION

It should be remembered that patient care includes elements that may be examined objectively or subjectively or both. The objective elements can be measured by statistical documentation & analysis to serve as a point of departure from which qualitative judgment can be made, whereas the subjective elements require qualitative judgment through clinical evaluation. Continuous evaluation provides stimulation for improvement of clinical services, professional education, hospital administration & better patient care. Medical audit, when practiced can go long way in improving the quality of patient care in our hospitals, which at present is far below the expectation of the community.

In healthcare delivery, quality audit focuses on guaranteeing and maintaining high standard of the service provided in different healthcare systems. When the services delivered by the care provider is in accordance with what the recipients of healthcare expect, then quality in healthcare is considered to be present. Quality audit is needed for rapid advancement in healthcare sector, rapid development in diagnostic and operation technology. The value of quality audit, as an instrument for improvement of quality of care is being gradually realized now as it has been included in the NABH/JCI accreditation standards also.

REFERENCE

1. Satish Munjal-Quality management-Raj Publishing House Jaipur, 1999. 2. Srivastava M, et al. Principles and Practice of Medical Audit, JAHA, Vol.4, No.1, Jan 1992. 3. Chatterjee B Chandrima -Accreditation of Hospitals: An overview- Express Healthcare Management 1-15 Sep 2005. 4. Healthcare: eleventh Five-Year Plan (2007-2012)- An ADI Media Publication/ August 07/ Medical Buyer. 5. Sharma Y, Maajan P. Role of Medical Audit in Healthcare Evaluation. Jk Science. 1991;1 (4). 193-6. 6. Sanzarop J. Medical Audit, Continuing Medical Education and Quality Assurance. West. J. 1976; 125.241- 52.

BIBLIOGRAPHY HOSPITAL ADMINISTRATION by DC JOSHI and MAMTA JOSHI. 1. QUALITY MANAGEMENT by SD JOSHI. 2. http:// en.wikipedia.org/wiki/Joint Commission. 3. http:// www.ishqua.org.au 4. http:// en.wikipedia.org/wiki/HL7.

ANNEXURE

DINABANDHU ANDREWS INSTITUTE OF TECHNOLOGY AND MANAGEMENT

1. NAME : AHARNA CHAKRABORTY

2. ROLL NO.: 15403315001

3. EMAIL-ID : [email protected]

4. NAME OF THE HOSPITAL : AMRI HOSPITAL, MUKUNDAPUR

5. TOPIC OF TRAINING : MAJOR PROJECT TRAINING

6. ADDRESS OF THE HOSPITAL: 230, BARAKHOLA LANE, PURBA JADAVPUR, BEIND METRO CASH AND CARRY, MUKUNDAPUR, KOLKATA-700099.

7. DATE OF FILE COMPLETING : 20 APRIL, 2018

8. NAME OF THE HOSPITAL SUPERVISOR : TAPENDU MONDAL