RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, KARNATAKA,

BANGALORE.

APPLICATION FOR THE APPROVAL OF PROJECT PROPOSAL

1. Name of the Candidate & SOMRITA MAZUMDER.

Address.
PADMASHREE COLLEGE OF
HOSPITAL ADMINISTRATION.

2nd FLOOR, RAJANNA BUILDING,

NAGARBHAVI CIRCLE,
BANGALORE-560072

2. Name of the Institution PADMASHREE COLLEGE OF

HOSPITAL ADMINISTRATION

3. Course of Study and Subject MASTERS IN HOSPITAL

ADMINISTRATION

4. Date of admission to course 4-10-2010

5. TITLE OF THE TOPIC:

“EVALUATION OF HOSPITAL INFECTION CONTROL PROCEDURES IN A

TERTIARY CARE HOSPITAL FROM NABH PERSPECTIVE”.
6. DEFINITION AND SCOPE OF STUDY:

NABH ACCREDITATION:

National Accreditation Board For Hospitals And Healthcare Professionals (NABH) is

a constituent board of QCI (Quality Council of India), set up with co-operation of the
Ministry of Health and Family Welfare, Government Of India and the Indian Health
Industry. This Board caters to the much desired needs of the consumer and will set
standards for progress of the Health Industry.

Patients are the biggest beneficiaries from the NABH Accreditation, as it results in a
high quality of care and patient safety. The patients get services by credential medical
staff. It also helps the staffs of the hospital as it provides continuous learning and good
working environment.

NABH Accreditation to a hospital stimulates continuous improvement. It enables the

hospital in demonstrating commitment to quality care and raises the community
confidence in the services provided by the hospital. It also provides opportunity to bench
mark with the best.

NABH Standards for hospitals and health care providers has 10 chapters with 100
standards and 503 objective elements which are all related to the important functions like
patient centred, hospital centred, community centred, and environment centred of the
hospitals. This study emphasises mainly on the chapter of HOSPITAL INFECTION
CONTROL in NABH standards.

Hospital Infection Control:

Infections are a problem of serious concern in hospitals all over the world. Not only has
the added to morbidity and mortality, they also add to the financial burden on the patients.
Further they put strain on the health care resources by prolonging the patient’s hospital
stay.

Hospital Acquired Infection, also called as Nosocomial Infection, is the infection

acquired by a person in the hospital, manifestation of which may occur during
hospitalization or after discharge from the hospital.
Accreditation Standards for Infection Control

Recently, the National Accreditation Board for hospitals (NABH) has been established
under the Quality Council of India. The NABH standards guide the provision of an
effective infection control programme in a hospital aiming at reducing the risk of HCAI
(Health Care Associated Infections) in patients and staff and also ensure the safety of the
environment.

The challenges faced today in providing safe health care are:-

 Increasing antibiotic resistance.

 Emerging infections.

 Immunosuppressive therapies and modalities leading to Immuno-compromised

patients with increased vulnerability to infection.

 Increased survival and extremes of age.

 Insufficient compliance and motivation of health care staff.

GAP ANALYSIS:

Gap analysis is a component of the preparatory phase of NABH ACCREDITATION

PROGRAMME. It is a tool that helps an organization to compare its actual performance
with its potential performance. At its core are two questions “where are we?” and “where
do we want to be?”

The goal of gap analysis is to identify the gap between the optimized allocation and
integration of the inputs, and the current level of allocation. This helps provide the
company with insight into areas which could be improved. The gap analysis process
involves determining, documenting and approving the variance between business
requirements and current capabilities. Once the general expectation of performance in the
industry is understood, it is possible to compare that expectation with the organisation's
current level of performance. This comparison becomes the gap analysis. Such analysis
can be performed at the strategic or operational level of an organization. Gap analysis is a
formal study of what the organization is doing currently and where it wants to go in the
future.

This study will help to identify various gaps in infection control programme in the hospital
 and enable the infection control staff to take necessary actions towards improvement and
implementation as per the hospital infection control NABH standards.

7. OBJECTIVE OF THE STUDY :

 To study the existing infection control measures used in the hospital.

 To analyse the gaps in hospital infection control of the hospital according to
NABH standards.
 To suggest measures/procedures for improvement in hospital infection control.

8. RESEARCH METHODOLOGY

RESEARCH DESIGN: - Descriptive study.

Tools Of Data Collection:-

 Primary data: -Personal observation.

Structured interview.
Gap analysis tools.

 Secondary data: - Medical records.

9. REVIEW OF LITERATURE:

The National Accreditation Board for Hospitals & Healthcare Providers (NABH)
Standards is today the highest benchmark standard for hospital quality in India. Though
developed by the Quality Council of India on the lines of International Accreditation
Standards like the JCI, ACHS and the Canadian Hospital Accreditation Standards, the
NABH is however seen as a more practical set of Standards, topical and very relevant to
India’s unique healthcare system requirements.

NABH standards

 Patient centred standards

1. Access, Assessment and Continuity of Care (AAC)
2. Care of Patients (COP)
3. Management of Medication (MOM)
4. Patient Rights and Education (PRE)
5. Hospital Infection Control (HIC)

 Organization cantered standards

1. Continuous Quality Improvement (CQI)
2. Responsibilities of Management (ROM)
3. Facility Management and Safety (FMS)
4. Human Resource Management (HRM)
5. Information Management System (IMS)

Within just 2 years of its launch, the Indian Accreditation Standards, the NABH was
accepted by ISQUa, the International Society for Quality Assurance in Healthcare, as an
International Accreditation on par with the world’s best.1

More important than the infrastructure, it is essential to know if the hospital has a
documented process for its healthcare activities. Patient care not only involves the core
clinical care, but also other support activities like requisition of tests, medicines, nurse
doctor coordination, infection control practices, training, and so on. These need to run
seamlessly in the background to provide the best experience to the patient and the relative2

The changing health care environment with revised hospital accreditation guidelines have
sharpened the clinical and administrative hospital staff’s concern for evaluating the quality
of care they provide. Clinicians now see accreditation standards as a framework by which
organizational processes will be improved and their patients will receive better care.
Physicians and administrators now must face the challenge of establishing comprehensive
and vigorous systems of quality assurance and learn to avoid the traps that impede
implementation of such systems. Quality assurance is a very simple process that deals
with finding problems and fixing them.

A comprehensive definition of quality health care would be, “The optimal achievable
result for each patient, the avoidance of physician-induced (iatrogenic) complications, and
attention to patient and family needs in a manner that is both cost effective and reasonably
documented.”3

Hospital Infection Control:

Hospital infection is perhaps the single most important factor that adversely affects the
performance and the image of hospitals. Besides morbidity, mortality it prolongs the
hospital stay of the patients, increases bed occupancy rate and thereby puts undue pressure
on the already strained resources of the hospitals, community and the country. Hospital
acquired infection due to negligence of hospital authorities, treating doctors or other staff
can be a potential source of litigation under the Consumer Protection Act.

It is therefore necessary that an effective on-going programme of surveillance and control

of hospital acquired infections is implemented in every hospital. There should be a
hospital infection control committee with a detailed charter of duties to plan and supervise
the implementation of Infection Control Programme in each and every department of the
hospital.4

High risk areas in hospitals :

 Nurseries.
 Intensive care unit.
 Dialysis unit.
 Organ transplant unit.
 Burn unit.
  Isolation unit.
 Cancer ward.
 Operation theatres.
 Delivery rooms
 Post-operative ward.5

Hospital Infection Society India is an association of medical professionals with a special

interest in the prevention and control of hospital infection. It is registered with Registrar of
Societies at Delhi.

Infection control has been incorporated in medical and paramedical curriculum. Inmedical
journals, increasing number of articles is being published on infection control in the
country.

In the field of Health Care waste management, rules have been notified, national
guidelines developed,and pilot projects have been implemented with help from the WHO
across the country.

Infection control programmes are being established in increasing number of hospitals .It is
being accepted now that the quality of a hospital's infection control programme is a
reflection of the standard of care provided by the institution so hospitals are applying for
accreditation with JCI and NABH.6

Laboratory acquired infection is an area of concern for hospital authorities.The important

task is to determine which laboratory procedures, accidents or other exposures to
infectious agents are the source of laboratory acquired infection.Importance should be
given to monitor the various procedures in the laboratory.Hospital authorities should
implement infection control program and ensure the safety of the staff & the patients.7
10. LIST OF REFERENCES:

1. NABH & NABL ACCREDITATION ASSISTANCE, ACME Consulting.

www.acmeconsulting.in. (Accessed on 2-6-11).

2. NABH ACCREDITATION: CHOOSING THE RIGHT HOSPITAL. By Akash

Rajpal in Simple Rules Discuss / 11 may 2008.
www.completewellbeing.com/article/nabh-accreditation-choosing-the-right-
hospital.(accessed on 2-6-11).

3. Guidelines For Quality Accreditation: By Rashi Agarwal. www.quality

digest.com/inside/health-care-article/guideline-quality-accreditation-hospitals.
(accessed on 2-6-11).

4. Joshi SK, “Quality Management in Hospitals”.JAYPEE BROTHERS MEDICAL

PUBLISHERS (P) LTD. First edition: 2009.pp. 46 -51.

5. Sakharkar BM, “Principles of Hospital Administration & Planning”. JAYPEE

BROTHERS MEDICAL PUBLISHERS(P) LTD. Second edition: 2009. Pp. 244.

6. www/hisindia.org/president%20appeal (accessed on 2-6-11)

7. A study of infection control measures used in clinical laboratory of a tertiary care

teaching by S Castelino and S.D. Sinha. Taken from the journal of the academy of

hospital administration. , vol. 19/ July – Dec 2007. pp: 25 –29.

11 SIGNATURE OF THE CANDIDATE:

12 REMARKS OF PROJECT SUPERVISOR:

13 NAME AND DESIGNATION OF

13.1 SUPERVISOR: Ms. Sharon Saxena.

13.2 SIGNATURE:

13.3 CO-SUPERVISOR:

13.4 SIGNATURE:

14 14.1 NAME OF THE PRINCIPAL:

Ms RESHMA LOBO

Padmashree College of Hospital Administration

Bangalore – 72

14.2 REMARKS:

14.3 SIGNATURE: