Abstract of Dissertation

Keyword : Super Specialty Hospital; Quality of Services; Tracer Methodology; Quality Improvement Tool

Objective : To understand norms and standards laid by hospital for various departments/institutions. To assess the non compliances of various departments/institutions for these norms/ standards. To make suggestions to overcome these non compliances.

Background : Tracer methodology is a flexible, straightforward management tool that allows an organization to assess and closely examine its systems and process of care delivery. This is accomplished by following the path of those systems in question, by observing the process as it is demonstrated by staff, or by observing the care experiences of those individuals who receive care, treatment, or services from the organization. It was employed by The Joint Commission as an assessment methodology when the accrediting body launched its revamped accreditation process in 2004. Since its inception by The Joint Commission, the use of tracer methodology has evolved further within the health care field. Before 2004, organizations were eager for knowledge about the new accreditation process and, in particular, how tracer methodology would be used by surveyors during their next on-site survey. After the new process was launched in 2004, the use of tracer methodology evolved, and some staff members conducted practice tracers within their organization to orient others and become more familiar with its use during an on-site survey.

Methodology : Research Design- Qualitative descriptive study Study area- Medanta, The Medicity Gurgaon Study population- all institutes of hospital. Study period- 3 months Sampling technique- purposive (non sampling technique) Sample size- No. of tracer audits done by investigators in each institute of hospital. Data collection- Technique- A team of 36 investigators is formed for conducting tracer audits in 9 institutes of hospital, i.e 4 in each institute. This four member team consists of four cadres of staff, Doctor, nurse, administrator and Medical Admininstrator. They are provided with a guiding tool for their audits and they are supposed to conduct face to face interview with the associated stakeholders and would submit their report in word format with their finding in it.

Findings : In this study only 6% of standards come out to be “Not Met” and 43% of standards come out to be “Partially Met”. Among “Not Met” Standards hand hygiene and Illegible hand writing were highest non compliance with 57% and followed by food and nutrition and fall risk as 54% and 51% respectively. Among “Partially Met” standards patient education and plan of care are highest non compliant standards with 49% and 34% non compliance respectively. Similar way all department overall compliance were taken out and gastroenterology had highest compliance and neurosciences had least compliance with 88% and 75% overall compliance.

Recommendations : Standards with highest non compliance are tested statistically with other hospitals of the world and found out that only illegible handwriting and fall risk prevention were standards which were fall out of normal range and thus need to focus on them for their improvement