O R I G I N A L RESEA RCH KERALA MEDICAL JOURNAL
Gap Analysis of Major Operation Theatre Complex of
a Tertiary Cancer Centre against NABH Accreditation
Standards
Sudha P
Division of Anaesthesiology, Regional Cancer Centre, Trivandrum, Kerala 695011*
ABSTRACT Published on 28th September 2015
This observational study aims to review the planning and functioning of the Major Operation Theatre (MOT) complex of a Tertiary
Cancer Centre committed to obtain National Accreditation Board for Hospitals and Health care providers (NABH) accreditation
Context: Full advantage of new surgical development can occur only if operation theatre is properly designed. NABH is a con-
stituent board of Quality Council of India(QCI) set up to operate accreditation programme which demonstrates commitment to
quality health care .Healthcare organization should carry out a self assessment on the status of compliance with NABH standards
for accreditation
Aims:[Link] study the planning and functioning of the MOT complex against NABH standards and identify deficiencies. [Link]
review the planning and functioning MOT complex in terms of perspectives of staff
Settings and Design: This was a descriptive study. MOT complex was observed for three months.
Methods and Material: Physical facilities, safety measures, staffing pattern and equipment facilities were analysed against
NABH standards and compared with staff perspectives. Data was collected by desk research, observation and by structured inter-
view of 54 permanent staff working in MOT complex.
Statistical analysis used: Frequency and percentage
Results: Physical facilities and safety measures are inadequate .Staffing pattern and equipment facilities are satisfactory. The dif-
ference from staff opinion is mainly due to noncompliance with mandatory documentations for NABH accreditation
Conclusions: The planning and functioning of MOT complex do not satisfy the minimum essential standards required for NABH
accreditation and needs remodeling
Keywords: Healthcare Quality, Evaluation Studies, Patient safety
*See End Note for complete author details
INTRODUCTION steps to be taken in moving from a current state to
a desired future state)of planning and functioning of
Accreditation of a hospital stimulates continuous Major Operation Theatre (MOT) complex of a Tertiary
improvement and demonstrates commitment to quality Cancer Centre, committed to obtain NABH accredita-
care.1,2,3,4 National Accreditation Board for Hospitals tion, with the aid of NABH standards. It also aims to
and Health care providers (NABH) is a constituent review the planning and functioning of MOT complex
board of Quality Council of India(QCI) set up to in terms of user’s perspective.
establish and operate accreditation programme for
health care organizations.5,6 For NABH accreditation Aims of the study were as follows:
,the organisation should carry out a self assessment on
1. To study the planning and functioning of the
the status of compliance with NABH standards.5
MOT complex with the aid of NABH standards
New safer surgical skills and anaesthesia techniques and guidelines.
and development can take full advantage if operation 2. To review the planning and functioning MOT
theatre is properly planned and designed. This study complex in terms of perspectives of staff working
aims at gap analysis (a technique for determining the there.
Corresponding Author:
Dr Sudha P, Harisree, NVN 3, NV Nagar Lane 1, Peroorkada, Trivandrum 695005. Phone: 9447108605
Email: drsudhap@[Link]
84 Kerala Medical Journal | July-September 2015 | Vol VIII Issue 3
Sudha P. Gap Analysis of Major Operation Theatre Complex of a Tertiary Cancer Centre against NABH Accreditation Standards
SUBJECTS AND METHODS If any of the below 3 criteria are there
d. When none of the objective elements of
This was a descriptive study. After getting Institu-
standards are met
tional Review Board approval, the MOT complex
was observed for three months. Data was collected e. When one standard has more than one zero
by observation of the MOT Complex and from for its objective elements
the54 permanent staff working there by structured f. When there is at least one zero against elements
interview method and from records maintained in the related to legal implications
MOT complex and engineering division. A pilot study
The limitation of the study is that the results will be
conducted with four doctors and six nurses confirmed
specific to the MOT complex studied and cannot be
feasibility of the study. Judgment sampling method was
generalized.
used.
The study evaluated the following against NABH RESULTS
standards and guidelines:
The approximate MOT statistics was as follows:
a. Infrastructure facilities
Number of surgeries / year = 3300-3400
b. Patient and staff safety measures
Number of surgeries /operation theatre / day=3-4
c. Staffing pattern and human resource management
Number of working days / year =300
d. Equipment management programme
Number of surgeries per operation theatre / year=900-
e. Quality of operative services 1200
The study was completed in three months .Data was Table 1. Distribution of sample according to designation
analyzed in terms of frequency and percentage Designation Number %
The objective elements of all applicable NABH Surgeon 13 24.08
standards were marked on a scale of 0-5-10 .All the Anaesthesiologist 8 14.81
observations were recorded and a score was allocated Nurse 18 33.33
to each as follows: OT technician 8 14.81
Nursing Assistant 3 5.56
0--- NOT MET (If neither documentation nor imple- Cleaner 4 7.41
mentation is available) Total 54 100
5--- PARTIALLY MET (If only either of the two is
available or both are available but only partially) Although the number of operation theatres is adequate5
as calculated 4-5, the waiting period for surgery is 3-4
10-- FULLY MET (If both are met) weeks (ideal </= 2weeks in cancer surgeries). This is
due to inadequate number of surgical beds. Almost
The order of compliance with NABH standards were all the theatres run very late leading to overutilization
classified as follows:- which itself decreases the efficiency of services and
1. EXCELLENT causes excessive fatigue among the limited number of
all categories of staff. There are many cancellations due
When all objective elements of all standards were
fully met (score 10 for all) Table 2. Distribution of sample according to working experience
2. GOOD Total years Anaes- OT Tech- Nursing
Surgeon Nurse Cleaner
of Experi- thesiolo- nician Assistant
N=13 N=18 N=4
If all the below criteria are satisfied ence gist N=8 N=8 N=3
a. Most of the objective elements of most of the No. % No. % No. % No. % No. % No. %
standards are either partially or fully met 3-6
- - 1 12.5 - - - - - -
months
b. No standard has more than one zero for its
6 months-
objective elements 1 year
- - - - - - 3 37.5 - - - -
c. No zero is there against elements related to
1-5 years - - 2 25 11 61.11 3 37.5 2 66.67 - -
legal implications
5-10 years 5 38.46 1 12.5 4 22.22 1 12.5 1 33.33 1 25
3. POOR >10 years 8 61.54 4 50 3 16.67 1 12.5 - - 3 75
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Sudha P. Gap Analysis of Major Operation Theatre Complex of a Tertiary Cancer Centre against NABH Accreditation Standards
Table 3. Evaluation of Infrastructure facilities Table 5. Evaluation of staffing pattern and human resource
NABH Total no: of management
Sl Score Score Score Order of com-
Stan- objective A. Evaluation of staffing pattern and human resource management
No: 10 5 0 pliance
dard elements
Ci Human resource planning
A. Evaluation of infrastructure facilities
HRM
A i-iv Provision of space, light and ventilation C1 2 1 - 1 GOOD
1
A1 FMS 2 6 2 1 3 POOR C ii Qualified staff in different categories
Provision of safe water, electricity, medical gases and vacuum HRM
Av C2 3 3 - - EXCELLENT
system and provision of alternate sources in case of failure 11
A2 FMS 4 4 4 - - EXCELLENT HRM
C3 3 3 - - EXCELLENT
A vi Fulfillment of statutory/legal requirements 13
A3 FMS 1 4 4 - - EXCELENT C iii Professional training and development of staff
HRM
C4 2 - - 2 POOR
3
to inadequate theatre time. 13 surgeons, 8 anaesthesi- C iv Performance evaluation
ologists, 18 nurses, 8 operation theatre technicians, 3 HRM
nursing assistants and 4 cleaners were included in the C5 3 3 - - EXCELLENT
5
sample (Table 1) Nurses constitute the majority. They A. Evaluation of equipment management programme
are the category directly involved in the provision of Di Equipment facility for the services
D ii Maintenance of proper logs on equipment inventory
Table 4. Evaluation of patient and staff safety measures D iii Operation and maintenance of the equipments
B. Evaluation of infrastructure facilities D1 FMS 3 5 6 - - EXCELENT
Bi Provision of safe and secure environment
B1 FMS 9 4 1 2 1 GOOD basic functional facilities for the proper functioning of
B ii Facilities and resources for infection control OT.87.03% of staff have more than one year experience
B2 HIC 5 4 1 2 1 GOOD in MOT complex (Table 2). Only one anaesthesiologist
B iii Availability of infection control manual and three OT technicians have experience less than one
B3 HIC 2 4 2 1 1 GOOD year. This makes the suggestions from the staff very
B iv Sterilisation activities important as they have enough working experience.
B4 HIC 7 1 1 EXCELLENT Analysis and scoring are summarized in Tables 3-6.
Bv Biomedical Waste Management
B5 HIC 8 4 4 - - EXCELLENT Table 6 Evaluation of the quality of operative services
B vi Management of hazardous materials B. Evaluation of the quality of operative services
B6 FMS 8 5 4 1 - GOOD Ei Policies and procedures for anaesthesia
B vii Storage of medication E1 COP 11 10 7 - 3 POOR
B7 MOM 3 3 2 1 - GOOD E ii Policies and procedures for surgery
B viii Use of narcotic drugs and psychotropic substances E2 COP 12 9 4 3 2 POOR
B8 MOM 9 3 3 - - EXCELLENT E iii Informed consent
B ix Prescription of medication E3 PRE 3 1 - - 1 GOOD
B9 MOM 4 4 1 3 - GOOD E iv Continuous Quality improvement
Bx Medication administration E4 CQI 2 4 - 3 1 GOOD
B 10 MOM 6 5 4 1 - GOOD
B xi Monitoring after medication administration • The order of compliance of the infrastructure
B 11 MOM 8 2 2 - - EXCELLENT facilities is POOR as the NABH standard A 1 (FMS
B xii Use of medical gases 2) has more than one 0 for its objective elements
B 12 MOM 13 2 1 1 - GOOD • The order of compliance of patient and staff safety
B xiii Use of implantable prosthesis measures is POOR as the NABH standard B 14
B 13 MOM 12 3 3 - - EXCELLENT (FMS 5) has score 0 for all its objective elements
B xiv Addressing fire and non fire emergencies • The order of compliance of staffing pattern and
B 14 FMS 5 4 - - 0 POOR human resource management is POOR as the
B xv Training of staff on safety measures NABH standard C 4 (HRM 3) has score 0 for all
B 15 HIC 9 3 1 2 - GOOD its objective elements
B 16 HRM 4 4 3 1 - GOOD
• The order of compliance of equipment
86 Kerala Medical Journal | July-September 2015 | Vol VIII Issue 3
Sudha P. Gap Analysis of Major Operation Theatre Complex of a Tertiary Cancer Centre against NABH Accreditation Standards
management programme is EXCELLENT as the Poor compliance of the quality of operative services is
NABH standard D1 (FMS 3) has score 10 for all mainly due to lack of some mandatory documentations
its objective elements needed for NABH accreditation like documentation
• The order of compliance of the quality of operative of anaesthesia plan at preanaesthetic check up and of
services is POOR as the NABH standard E 1 an immediate preanaesthetic evaluation on the day of
(COP 11) has score 0 for three objective elements surgery, separate informed consents for anaesthesia
and NABH standard E 2 (COP 12) has score 0 for and surgery ,documentation of time out and sign
two of its objective elements out procedures, regular documentation of surveil-
lance of OT environment and monitoring of the use
of blood and blood products using Key Peformance
DISCUSSION Indicators.7,8,9
Poor compliance of infrastructure facilities is due to The staff opinion is that it is satisfactory. The difference
space constraints, poor documentations and inadequate between staff opinion and assessment against NABH
policies& protocols regarding maintenance of facilities. standards is due to noncompliance with the mandatory
According to the staff except for the space constraints, documentations for NABH accreditation.
infrastructure facilities are satisfactory. The difference
between staff opinion and assessment against NABH
standards is due to noncompliance with certain SUMMARY
mandatory documentations. Mandatory documenta-
The study revealed that planning and functioning
tions for NABH accreditation like documentation of
of the MOT complex has mostly POOR order of
policies and procedures and detailed drawings on site
compliance with NABH standards. The difference
lay out might seem unimportant for the staff.7, 8, 9
between staff opinion and assessment against NABH
Poor compliance of patient and staff safety measures standards is due to the absence of certain documen-
is due to inadequate documented policies & protocols tations which are mandatory for NABH accreditation
on elements like fire and non fire safety plan, facility but not considered so important by the staff probably
inspection by safety committee, antibiotic policy, due to unawareness. This study highlights the fact that
and usage of implantable prosthesis and absence understanding of the concepts of quality management
of isolation/barrier nursing facility.10 According to and requirements of accreditation standards helps to
majority of staff the infrastructure compliance with guide the efforts in the right direction.7, 8,9,10
safety measures is average except for the absence of
fire safety measures. Level of safety is also considered END NOTE
average by majority of the staff except for the absence
of isolation/barrier nursing facility. The difference Author Information
between staff opinion and assessment against NABH Dr Sudha P
standards is due to noncompliance with the essential MD, Associate Professor,
documentations for NABH accreditation Division of Anaesthesiology,
Regional Cancer Centre, Trivandrum,
Poor compliance of staffing pattern and human Kerala 695011
resource management is due to inadequate number of
staff, absence of documented training and development Conflict of Interest: None declared
policy & feedback mechanism for the assessment of Cite this article as:
the same. Majority of the doctors opined that a regular
Sudha P. Gap Analysis of Major Operation Theatre Complex
professional training and development programme is
of a Tertiary Cancer Centre against NABH Accreditation
not available. Majority of other staff opined that it
Standards. Kerala Medical Journal. 2015 Aug 31;8(3):9–14.
is available. The difference in opinion is because the
nurses and nursing assistants are getting some sort
of regular internal professional training. Regarding REFERENCES
staffing pattern the opinion of the staff and assessment 1. Alkhenizan A, Shaw C. Impact of accreditation on the quality of
against NABH standards were the same i.e. inadequate. healthcare services: a systematic review of the literature. Ann Saudi
The equipment management programme has excellent Med. 2011 Aug;31(4):407–16.
compliance with NABH standards. The staff opinion 2. Dastur FD. Hospital accreditation: a certificate of proficiency for
healthcare institutions. J Assoc Physicians India. 2012 Apr;60:12–3.
is also the same
Kerala Medical Journal | July-September 2015 | Vol VIII Issue 3 87
Sudha P. Gap Analysis of Major Operation Theatre Complex of a Tertiary Cancer Centre against NABH Accreditation Standards
3. Wendy Nicklin : The value and impact of health care accredita- 7. Greenfield D, Braithwaite J. Health sector accreditation research: a
tion: a literature review: Driving quality health services Updated: systematic review. Int J Qual Health Care. 2008 Jun;20(3):172–83.
October 2013 8. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy SM, Foy
4. Leigh G. Turner Quality in health care and globalization of health R, et al. Advancing the science of patient safety. Ann Intern Med.
services: accreditation and regulatory oversight of medical tourism 2011 May 17;154(10):693–6.
companies: International Journal for Quality in Health Care 2011; 9. La1 N. Quality in hospitals. Quality India (a QCI publication)
1 –7 2011:5:32-33
5. [Link] and [Link] 10. Varkey P, Kollengode A. A framework for healthcare quality im-
6. Atkinson S, Ingham J, Cheshire M, Went S. Defining quality and provement in India: the time is here and now! J Postgrad Med. 2011
quality improvement. Clin Med. 2010 Dec;10(6):537–9. Sep;57(3):237–41.
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