Abstract of Dissertation

Agency : Quality Assessment, IPHS Standards, NABH, ISO

Objective : • To describe the process flow of respective departments in the hospital with the identification of Owners, Input(s), Outputs (s) and process flow of each process occurring at each section of the hospital with the relevant records. • To identify the significant gaps observed in all the processes in each section and explanation of the gap statement with document evidences and photographs. The gaps are analyzed based on IPHS and National Quality assurance standard checklist. • To identify the area which needs to be focused upon.To prepares actions to be taken to fulfill the gaps.

Methodology : Stage I IPHS Checklist was used for a total survey of the hospital in terms of services provided, Manpower, Physical infrastructure, Equipments, drugs and Lab services. Stage II National Quality assurance standards checklist was used to audit OPD AND IPD areas of the hospital and accordingly scoring is given to each concerned area. Stage III Observation and personal interview were used to map the various processes of the hospital and to know the functioning of the each department. Stage IV Extensive analysis based on data collected from stage I, II and Stage III. Based on this Report was prepared reflecting the processes, Infrastructure, Equipments, Manpower. The report reflects strengths of the hospital and various gaps observed in the processes and other parameters.

Findings : From the IPH Survey, it was found that the gaps of all the departments are mainly Process gaps, some of those gaps are Infrastructure, Equipment and Manpower gaps. According to National Quality assurance checklist it was found that the main area of concern was Quality Management which is 23.10% for OPD and 28.20% for IPD department according to score cards. The gaps as identified will be taken up strategically and short term, long term goals will be identified in liaison with the hospital, which involves developing documentations including quality manual, SOP’s for all the departments, developing benchmarks, capacity building which includes training & orientation of staff according to IPHS guidelines and towards Quality Improvement.

Recommendations : Special consideration on gaps of the department is given and time bound action plan is prepared. This needs to o be monitored by the hospital’s internal expert consisting of Civil Surgeon, Senior Medical Officer, Hospital Manager and Nursing In Charge. It will help for the quality improvement process of Sub district Hospital, Kharar, Punjab. Government of Punjab in its bid to bring about a paradigm shift in healthcare delivery system across the state has undertaken an initiative for quality improvement in the public health facilities with the active technical assistance of National Health Systems Resource Centre (NHSRC), a technical support wing of Ministry of Health & Family Welfare, Govt. of India. Quality improvement in these public health facilities is to be initiated through implementation of Quality Management Systems (QMS) as per the Indian Public Health Standards (IPHS). Aim of the Study: To access and analyse the gaps in quality compliance of the facility as per IPHS standards so as to prepare it for further accreditation process by ISO and NABH .