Gap Analysis of Major Operation Theatre Complex of a Tertiary Cancer Centre against NABH Accreditation Standards

Abstract

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 constituent 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: 1. To study the planning and functioning of the MOT complex against NABH standards and identify deficiencies. 2.To 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 interview 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 difference 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