Quality Assurance Programme for Emergency department - COP.2-i - NABH (Healthcare)

Objective Element COP.2-i of NABH 5th Edition - states that the organization should implement a quality assurance programme, but actually the initiative for this should come from the Emergency department

Given here are the salient NABH requirements that you should consider while planning the Quality Assurance programme of the Emergency department

These are only guidelines, you may or may not agree with me. But this video will help you to prepare your own QA programme

You should consider at least the following for preparing the QA programme

1. Requirements of the Key Performance Indicators (KPI)
2. Requirements of COP.2
3. Requirements of COP.3

By including these in your QA programme, you will be able to maintain the quality requirements of NABH

I have identified 9 key factors that should be included in your department’s QA programme. Apart from these, you can also include other parameters which you feel are very important

Key Factor 1

This is a Key Performance Indicator (KPI) - PSQ.3-a

Return to the emergency department within 72 hours with similar presenting complaints

There may be quite a few reasons for this. May be the treatment during the first visit was not appropriate, or may be the patient has developed some other complications after going back home

Such return visits should be investigated to find out the root cause and, wherever applicable, suitable actions should be taken. The findings of the root cause should be documented properly

Key Factor 2

This is a Key Performance Indicator (KPI) - PSQ.3-b

Hand hygiene compliance rate

Since hands are the main source of infection, so it is important to monitor this. It is usually the responsibility of the Infection Control department to ensure that hand hygiene protocol is adhered to

Key Factor 3

This is a Key Performance Indicator (KPI) - PSQ.4-d

Percentage of near misses

It is important to monitor near miss incidents because a near miss is a good indication. It means that your quality checks and balances are strong, that is why the error was detected before it actually took place

Such near miss incidents should be investigated, to ensure that they are not repeated. If required, you may have to make changes to your existing processes to strengthen them further

Key Factor 4

This is a Key Performance Indicator (KPI) - PSQ.3-d

Compliance rate to medication prescription in capitals

NABH demands that the Doctors should write all prescriptions in capital letters, to prevent misinterpretation by the person reading the prescription

It is mandatory to monitor this requirement, otherwise it may lead to medication administration error by the Nurse, or dispensing error by the Pharmacist

I have given these 3 Key Performance Indicators, because if you will include these in your QA programme, you will be able to ensure that the mandatory KPIs requirements are complied with. Rest of the key factors given here are from the Objective Elements COP.2 and COP.3

Key Factor 5

This is an Objective Element - COP.2-e

Initiation of appropriate care is guided by a system of triage

This is a mandatory requirement, whereby you should have a well-planned protocol for attending to patients as per their severity of medical conditions

You should have a written guideline on which medical conditions demand immediate attention, what types of medical conditions should be attended to within 5 minutes, what types of medical conditions can be kept waiting for 10 minutes, and so on

Key Factor 6

This is an Objective Element - COP.3-c

The ambulance(s) is fit for purpose and is appropriately equipped

This is self-explanatory. The ambulances should not only be appropriately and adequately equipped; but should also be kept in proper running condition all the time

The legal documents of the ambulances should always be kept updated

Key Factor 7

This is an Objective Element - COP.3-d

The ambulance(s) is operated by trained personnel

The ambulance driver and other ambulance attendants should be well trained in Basic Life Support (BLS)

Key Factor 8

This is an Objective Element - COP.3-e

The ambulance(s) is checked daily

Read this with reference to COP.3-c, whereby the ambulance is required to be appropriately equipped

Your department should have a Daily Check List of all the ambulance equipment and other medical devices

It is the responsibility of the Nurse to tally the contents of the ambulance with the contents of the Daily Check List, and ensure that the ambulance is kept fully stocked always

Key Factor 9

This is an Objective Element - COP.3-g

A mechanism is in place to ensure that emergency medications are available in the ambulance

Your department should have a Daily Check List of ambulance emergency medications

It is the responsibility of the Nurse to tally the contents of the ambulance with the contents of the Daily Check List, and ensure that all the required emergency medications are always available in the ambulance

Along with these 9 key factors, I have given two more additional factors of your department:

1. The Emergency Crash Cart, the Medicine Crash Cart, and the Dressing Trolley are always fully stocked
2. The emergency staff are well trained in discharge of their duties

Your department should have separate Daily Check Lists for Emergency Crash Cart, Medicine Crash Cart, and Dressing Trolley

The Nurse should tally the contents of the Crash Carts and the Trolley with the contents of the Check Lists on a daily basis, and ensure that they are well stocked all the time

All the emergency department staff should be well trained in discharge of their duties

The Doctors attending to emergency patients and the Senior Nurses should be fully aware of ACLS and CPR

All the other emergency staff, ambulance drivers and ambulance attendants should be trained in BLS

If you so desire, you can also watch the video given right at the beginning of this blog article

Thank you for reading till the end