Quality Assessment of Endocrine Surgery Department in the In-patient Services using National Quality Assurance Standards in a Tertiary Care Hospital: An Observational Study

Abstract

Background: The National Quality Assurance Standards (NQAS) aim to enhance quality of the health facilities by aligning with global best practices along with addressing the specific needs of the healthcare system. Currently, NQAS applies to District Hospitals, CHCs, PHCs, Urban PHCs, and HWC-SCs. These above-mentioned standards help providers assess and improve their quality of care, with the possibility of certification.

Objectives: In the Endocrine Surgery Department of the Tertiary Care Hospital, an observational study was done to assess the compliance of In-Patient Department (IPD) with a customized NQAS checklist, including any recommendations for improvement.

Methodology: This observational study was conducted in the IPD of the Endocrine Surgery Department of a Tertiary Care Hospital in North India. All other departments were excluded from the study. The Compliance for the study was evaluated by using a customized NQAS checklist, with a scoring toolkit (0, 1, 2), based on Observations (OB), Patient Interviews (PI), Staff Interviews (SI), and Record Reviews (RR). The scoring toolkit was as per NQAS guidelines.

Results: The NQAS compliance assessment within the IPD of the Endocrine Surgery Department focused on eight "Areas of Concern": Service Provision, Patient Rights, Inputs, Support Services, Clinical Care, Infection Control, Quality Management, and Outcomes. The overall compliance in results was found to be 84%. The highest compliance was in Service Provision (100%), while Outcome showed 0% compliance.

Conclusion: The IPD demonstrated varying levels of compliance across the eight NQAS areas. While several standards were fully compliant, others were partially or non-compliant, emphasizing the need for targeted quality improvement efforts.