Quality Improvement Programme:- Gujarat (NABH / NABL)

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Quality Improvement Programme- Gujarat(NABH /
NABL)

• Steps for NABL Accreditation of Laboratory
  Service in Gujarat

Dr J L Meena State Quality Assurance
Officer Commissionerate of Health, MS
ME Government of Gujarat Phone No.
09099075162 Email- drjlmeena_at_gmail.com
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Quality Improvement Programme- Gujarat(NABH /
NABL)
Gujarat is the first state in India which
initiated for actively pursuing Quality
Improvements (NABH / NABL) in the public
healthcare facilities through the network of
Primary Health Centers (PHCs), Community Health
Centers (CHCs), District Hospitals, Blood banks,
Laboratories, Food and drug laboratories
Medical Colleges.
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Quality Improvement Programme- Gujarat(NABL)
To provide The right test result, at the Right
time, on the Right specimen, from the Right
patient, with result interpretation based on
Correct reference data, and at the Right price
(Cost of the community / country afford.)
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Quality Improvement Programme- Gujarat(PROJECT
STRATEGY FOR- NABL)
Cont.
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Quality Improvement Programme- Gujarat(PROJECT
STRATEGY FOR- NABL)
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A Case Study JOURNEY TOWARDS QUALITY
Year 2007 Events
29 May -07 Meeting on Quality improvement programme by Health Family Welfare Department, Gujarat.
20-21July 07 1st visit of the Laboratory Services as per ISO 15189, B . J. Medical College Civil Hospital, Ahmedabad, by Consultant our Team
30 Aug1 Sep 07 Sensitization workshop for faculty members to implement ISO 15189
21 Sep 07 2nd visit of the Laboratory Services as per ISO 15189, B . J. Medical College Civil Hospital, Ahmedabad, by Consultant our Team
20 Oct 07 Discussion on progress report of Laboratory Services with QA team at Commissionerate office Gandhinagar
Cont.
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A Case Study JOURNEY TOWARDS QUALITY
Year 2008 Events
7-12 Feb 08 1st Internal Audit by QA Team
27 Feb -08 1st Management Review Committee meeting, Organaogram of the Laboratory services formulated comprising of chairman, co chairman , key laboratory personnel their deputies
March Oct 08 Preparation of the Apex document of Laboratory Services Quality Manual as per ISO 151892007
10 Oct 08 Issue Date of Quality Manual
3 Dec 08 2nd Management Review Committee
Cont.
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A Case Study JOURNEY TOWARDS QUALITY
Year 2009 Events
8 Jan 09 1st Clinical Meeting
2 Feb 09 Issue Date of Quality System Procedure Primary Sample Collection Manual
31 March 09 Application for NABL Accreditation of Laboratory Services, B . J. Medical College Civil Hospital, Ahmedabad.
9 April 09 2nd Clinical Meeting Issue Date of Safety Manual
6-16 July 09 2nd Internal audit by QA Team
30 July 09 Pre assessment by NABL Assessor
6 Aug 10 Dec 09 3rd 4th Clinical Meeting
25 Aug 3 Dec 09 3rd 4th Management Review Committee for Closure of Non Conformances of Final Assessment
28-31 Dec 09 3rd Internal audit by QA Team closure report of pre assessment sent to NABL
Cont.
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A Case Study JOURNEY TOWARDS QUALITY
Year 2010 Events
1-8 Jan 10 3rd Internal Audit on going by QA team
12 Jan 10 5th Management Review Committee for preparation of laboratory to Final assessment
6-7 March 10 NABL Final Assessment by NABL Assessor
9 March 10 6th Management Review Committee for Closure of Non Conformances of Final Assessment
24 April 10 Closure of the Non conformances with documentary evidence send to NABL
July 10 Recommendation Letter from NABL Indias 2nd Govt. Medical College Lab Accredited as per NABL
Cont.
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A Case Study JOURNEY TOWARDS QUALITY
Year 2011 Events
31st January 2011 5th Internal Audit
23-24th July 2011 NABL 1st Surveillance inspection
17th August 2011 8th Management Review Committee meeting
22 Nov 2011 Continuation of Accreditation
12 December 2011 Change in the organogram
Cont.
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A Case Study JOURNEY TOWARDS QUALITY
Year 2012 Events
10-11th March 12 NABL 1st Renewal Assessment
5th April 2012 6th Internal Audit
8th July 2012 Certificate of Renewal of Accreditation Valid up to 7th July 2014
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A Case Study COMPARISON OF NON CONFORMANCE
DURING ASSESSMENT
SR No Year 2010 Year 2011 Year 2012
Quality Management System 04 09 02
Heamatology and Immunohaematology 09 03 04
Cytopathology and Histopathology 05 06 03
Microbiology and Serology 09 05 01
Clinical Biochemistry 05 10 02
Total 32 33 12
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A Case Study COMPARISON OF SCOPE OF ACCREDITATION
Name of Department Year 2010 Year 2012
Pathology 26 33
Microbiology 16 16
Biochemistry 16 16
Total 58 65
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Pre analytical Variables

• Physician Test Knowledge
• Appropriateness of Test Selection
• Physician Test Ordering
• Patient Preparation
• Patient Identification
• Specimen Labelling/ Identification
• Adequacy of specimen information
• Specimen Collection/Complication of phlebotomy
  
• Sample rejection rate
• Specimen Delivery Processing and Preparation

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Analytical Variables

• Specimen Analysis
• Critical value reporting
• Housekeeping record
• ( Incidence of sample spillage)
• Report Review or Verification
• Results Review
• Incidence of needle stick other injuries
• Quality control (IQC EQAS)

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Post analytical Variables

• Turnaround Time
• Notification of Critical Values
• Report Accuracy and Completeness
• Incidence of Typographical error
• Report Delivery
• Physician Follow-up
• Interpretive Consultation
• Customer Satisfaction

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Quality Improvement Programme- Gujarat(NABL)
Outcomes..
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Comparison of Past and Present Scenario
Past Present
Lack of standards ISO 151892007 NABL- 112 for lab in place
No Gap analysis report in standard format. Gaps identified and addressed as per standards
Lack of Statutory requirements (e.g. Licenses, Acts, Rules Certificates). Statutory requirements fulfilled
Absence of written policies, procedures, forms formats. Written policies, procedures, forms formats. available.
Poor sanitation and cleanliness. Hygienic Hospital environment
Staff shortage. Recruitment of staff as per workload through RKS.
Lack of trained health care staffs Staff trained and its on ongoing
No concept of internal audit Staff trained as internal auditors, audits conducted to find out non conformances, corrective preventive measures taken to rectify it
No Management meeting9 Meeting with clinicians conducted Regular Management meeting clinical meetings conducted which facilitates the important decisions affecting the quality of care, hence achieving the total quality management.
Cont.
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Comparison of Past and Present Scenario
Past Present
Inadequate infrastructure for handling biomedical waste and infection control safety practices All required practices in place
Damaged and poor condition of building Repairing renovation done
No Calibration system of Instruments for Quality check Regular AMC Calibration system of Instruments for Quality check are available.
Shortage of equipments and proper ambulances . Sufficient equipments and ambulances.
Lack of accountability planning. Policy and processes for care of the patients in place
Absence of quality standards. Quality standards e.g. medical audit, management of medication, care of patients etc practiced
No participation in EQAS/ inter laboratory comparisons Participation in EQAS / inter laboratory comparison and achieving good scores in it.
No feedbacks from patients clinicians Feedback of patients clinician is used to monitor the continual improvement2
Cont.
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Comparison of Past and Present Scenario
Past Present
Poor signage system. Well developed signage and displays for patient information
Only some Major Equipments covered under AMC AMC for all sophisticated equipments is done with their respective companies others are maintained by biomedical workshop CHA
Absence of Patient Employees satisfaction. Established
No measurable parameter for patient safety. Measurable parameters for patient safety are available.
No realization of problems and weaknesses A clear understanding of what is lacking and what needs to be done
No monitoring or reporting of adverse events, needle stick injury, Sentinel events etc. These are being reported and are monitored.
Practically non-existent security arrangement Availability of well trained security guards
Non Implementation of Different Codes in the facilities. RED for FIRE, YELLOW for EXTERNAL CALAMITIES, BLUE for CARDIAC ARREST, BLACK for BOMB THREAT, PINK for CHILD ABDUCTION
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Sample rejection-2010-2012Microbiology Dept-
Ahmedabad
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Turn Around Time Outliers-2010-2012Microbiology
Dept- Ahmedabad
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Sir T Bhavnagar Laboratory(Total No. of Lab
Investigations)
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B J Medical College Laboratory Ahmedabad(Total
No. of Lab Investigations)
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Govt. Medical Laboratory Surat(Total No. of Lab
Investigations)
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SSG Medical College Laboratory Vadodara(Total
No. of Lab Investigations)
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Quality Improvement Programme- Gujarat(NABL)
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Quality Improvement Programme- Gujarat(NABL)
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Quality Improvement Programme- Gujarat(NABL)
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Quality Improvement Programme- Gujarat(NABL)
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Quality Improvement Programme- Gujarat(NABL)
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Quality Improvement Programme- Gujarat(NABL)
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A Success Story Quality Improvement Programme-
Gujarat
S. N. Name of the Facility Total Facility Under NABH /NABL Total Accredited facilities Final Assessment done Pre Assessment done Facilities under Process for NABH/ NABL
1 District Hospitals 23 2 3 4 14
2 Medical college Hospitals 6 0 0 0 6
3 Medical college, Blood banks 6 5 0 0 1
4 Medical college, Laboratories 6 4 0 1 1
5 Mental Hospitals 2 2 0 0 0
6 Dental Hospitals 2 0 0 0 2
7 Paraplegia Hospital, Ahmedabad 1 0 0 1 0
8 Primary Health Centers (PHCs) 29 12 0 0 17
9 Community Health Centers (CHCs) 26 1 0 0 25
10 NABL Food Drug Laboratories 2 2 0 0 0
Total 103 28 3 6 66
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Award received by Government of Gujarat for
Quality Improvement
Appreciation awarded by QCI to Ministry of Health
and Family Welfare Government of Gujarat for
establishing Quality Assurance framework in
providing quality healthcare to the people of
Gujarat in 5th National Quality Conclave, New
Delhi.
Appreciation awarded to Department of Health and
Family Welfare Government of Gujarat for their
pioneering effort to spearhead the Quality and
Accreditation Programme in health care
organization. In 3rd International Health Care
Quality Conclave
FICCI Health care Excellence Award to Dist
Hospital Gandhinagar PHC Gadboriad, Govt of
Gujarat in FICCI Heal 2010, New Delhi Date 6th
Sept 2010
FICCI Health care Excellence Award to Dist
Hospital Gandhinagar, Govt of Gujarat in FICCI
Heal 2011, New Delhi Date 8th Sept 2011
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Strategies Adopted for sustainability Capacity
building

• Appointment of Quality Assurance officers at
  State level, District level, Assistant Hospital
  Administrator (AHA) at facility level. We are
  designated NABH Coordinators NABL Directors at
  Facility level.
• NABH lead assessor training (Total 290) NABL
  Internal audit training (Total 238).
• Quality Improvement Programme (NABH, BMW, Kaizen,
  HOPE, fire Non fire emergency, Radiation
  Safety, Cleanliness) Training (Total 114).
• Post Graduation Certificate Course in Quality
  Management and Accreditation of Health care
  Organization (PGQM AHO) to (Total trained
  persons194) .
• Training regarding Various Codes like code blue,
  red, orange, pink disaster management training
  (Fire Non Fire emergencies), sentinel events,
  Bio Medical Waste Management, Infection control
  practices, new born care training end of life
  care.
• New posts of clinicians, paramedical and other
  are sanction by Government of Gujarat as per
  requirement.
• Extra budgets from 13th finance commission,
  Government of Gujarat and NRHM.
• Formation of the state level review committee
  under the Chairmanship of Commissioner of Health,
  Medical Service Medical Education and Member
  secretary is State Quality Assurance Officer.

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Road Ahead

• To create a Quality culture based on various
  standards which is sustainable, affordable,
  equitable reliable having state of art
  technology and which can be easy to follow and
  replicate.

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Quality Improvement Programme- Gujarat
The woods are lovely dark and deep And we have
promises to keep And miles to go before we
sleep.. And miles to go before we sleep..