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Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 7-12

Level of compliance to quality standards and staff attitude toward adopted practices in a specialty hospital

Department of Onco-Anaesthesia, Clinical Oncology, Delhi State Cancer Institute, Delhi, India

Date of Web Publication26-Jul-2019

Correspondence Address:
Dr. Surendra Kumar
4/2926 Sri Ram Colony, Bhola Nath Nagar, Shahdara, Delhi - 110 032
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/QAIJ.QAIJ_2_19

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Introduction and Aim: NABH accreditation is seen as an assurance towards quality services and patient safety. We conducted study at a 150 bedded, NABH non-accredited, speciality hospital to identify extent of compliance of practices and policies of the hospital with NABH standards for patient centric activities and to study staff attitude towards practices followed. Materials and Methods: In 5 patient-centered activities chapters of the NABH standards, 61 standards with 403 observable elements were identified applicable to the hospital. The prevalent practices of the staff were observed (each element observed 50 times), relevant records checked to assess compliance with the NABH standards. A sample population of staff (doctors, nurses, technicians) was randomly selected and interviewed on a set of 9 questions to assess awareness of hospital policies and rationale of the practices followed. Results: Compliance to NABH documentation requirements was 37%. Where predefined policies were present, a highly uniform practice (uniform on ≥80% observations) was observed for 96% elements, high uniformity was observed for only 15% elements in cases where no predefined policies were present. The hospital performed best on standards in 'Hospital Infection Control', where documentary compliance was 60%; and 78% elements complied at ≥80% observations with 63% complying at all observed times. The compliance rate was least for standards in 'Patient Rights and Education' where documentations compliance was 14% and only 37% elements complied at ≥80% observed times. Only 50% of the sampled population was aware of all departmental policies while 12% was completely ignorant of the policies. Practices of most of the care providers, 76%, was based on learning by seeing others doing the job, while some (18%) followed verbal instructions. Deviations from established practices were common and gave rise to near misses (66% responders). Most of the care providers, 85%, did not report such events; events not resulting in obvious harm to the patient and consideration that the event was not because of one's own fault were major factors for underreporting. Introduction of checklists and regular training was recognised as a means to prevent such events. Conclusion: The hospital needs to formulate more policies and SOPs. Training and sensitisation of staff regarding work protocols and safety measures were infrequent and inadequate.

Keywords: Accreditation, National Accreditation Board for Hospitals and Healthcare Providers, standard operating procedures, staff attitude

How to cite this article:
Kumar S, Grover RK. Level of compliance to quality standards and staff attitude toward adopted practices in a specialty hospital. QAI J Healthc Qual Patient Saf 2019;1:7-12

How to cite this URL:
Kumar S, Grover RK. Level of compliance to quality standards and staff attitude toward adopted practices in a specialty hospital. QAI J Healthc Qual Patient Saf [serial online] 2019 [cited 2021 Apr 18];1:7-12. Available from: https://www.QAIJ.org/text.asp?2019/1/1/7/263595

  Introduction Top

Globally increasing awareness and concerns for patient safety have made providing quality services a survival necessity rather than a brand value for health-care organizations. Health-care management resorts to accreditation of hospitals as a means to improve and standardize the quality of services.

In India, the National Accreditation Board for Hospitals and Healthcare Providers (NABH), a constituent board of Quality Council of India and an institutional member as well as a board member of the International Society for Quality in Health Care, has laid down standards that ensure quality improvement and protection of patient rights, patient treatment, and infection control.

NABH accreditation standards are divided into 10 chapters which include both patient-centered and management centered standards. Patient-centered chapters include access, assessment, and continuity of care (AAC); patient rights and education (PRE); care of patients (COP); management of medication (MOM); and hospital infection control (HIC). Management centered chapters include continuous quality improvement; responsibilities of management (ROM); facility management and safety; human resource management; and information management system. These 10 chapters contain 105 standards which are further divided into 683 observable elements.[1]

The present study was undertaken to evaluate the existing system on guidelines laid down by NABH, as the first step toward patient safety and quality assurance. The aim of the study was

  • To identify the extent of compliance of the current practices and policies of the hospital with standards laid down by NABH for patient-centric activities only
  • To study the attitude of staff toward practices followed by them
  • Suggest actions for improvement.

  Materials and Methods Top

In this prospective, observational, descriptive study data were collected in the following ways:

Primary data

a. Observation of practices followed by health-care workers against a checklist as per NABH standards; or the uniformity of practices if written guidelines were not available; number of times a procedure under observation complied with standards/uniformity was noted, the observed personnel was blinded to the observation.

b. Direct interview of health-care workers to assess their awareness regarding institutional policies; and attitude toward procedures followed by them, on a preformulated questionnaire, containing nine questions, based on the general awareness of institutional policies and rationale of their practice; the gender, functional role like doctor/nurse/technician of the interviewee and professional experience both total and at the present hospital were also noted.

Secondary data

Secondary data were collected by studying institutional documents regarding policies and procedures including standard operating procedures (SOPs), where available.

Sample size

For direct observation, 10 observations on each of five different and noncontinuous days for each observable element, i.e., each element was observed 50 times (or the number of observations was limited to the number of occurrences of that activity during the study). The observation results were grouped into two groups, those with 80% or more compliance and second group with compliance <80%. Standards/elements, for which no documented guidelines were available, were observed for uniformity of practice on different occasions and divided into similar two groups. The two groups implied the requirement of less rigorous and more rigorous remedial actions.

For the direct interview, 25% each of major health-care workers, i.e., doctors, nurses, and technicians were randomly chosen by draw of lots. The consent of the sample population to participate in the project was obtained. The sample size for interview consisted of the following: Doctors: 12; Nurses: 26; Technicians: 12.

The study population consisted only of that staff which had been working for 1 month or more in the hospital, those working for <1 month in the hospital were not included in the study project.

  Results Top

Among 66 standards and 431 objective elements included in five chapters (AAC, PRE, COP, MOM, and HIC) containing patient-centered activities, five standards with their constituent 28 elements were not observed, leaving 61 standards and 403 elements to be observed.

Among the 403 elements, NABH requires 139 elements spread over different chapters and standards to have documented policies and procedures laid down or the activities be recorded in relevant documents. The hospital had only 51 such documented policies and recorded procedures while 88 did not have any predefined policies or that the activities were not recorded, this is graphically represented in [Figure 1].
Figure 1: The documentation compliance to standards was 37%

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Of the 51 documentations, 28 required laying down of institutional policies; they were found to comply with standards, one of the elements related to “appropriate pre- and post-exposure prophylaxis is provided to all staff members concerned could not be observed for PEP because of the nonoccurrence of any such event during the study period. Among the remaining 22 elements, 12 elements complied on all the observations, nine complied on 80% or more of observed occasions while one complied on <80% observations. Overall, 49 (96%) of 51 elements showed high compliance, 2% low compliance whereas 2% could not be observed. This is shown in [Figure 2].
Figure 2: Compliance status of available documented policies

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Of the 88 elements for which documentation compliance was not met, practices for only 13 (15%) elements showed high uniformity (80%–100%), 73 (83%) elements showed low uniformity (<80%) in practice while practice for 2 (2%) elements could not be observed because of nonoccurrence of the event [Figure 3].
Figure 3: Compliance status of 88 elements for which documented policies were not available

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Among 264 elements for which documentation was not mandatory, 5 (2%) elements, three related to research and two related to patient complaints review, could not be observed because of nonoccurrence of the event. High uniformity in practice was observed for 134 (51%) elements, while practices for 125 (47%) elements were uniform on < 80% occasions [Figure 4].
Figure 4: Compliance status of 264 elements for which documentation was not mandatory

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In the chapter-wise assessment of elements, the documentation requirements was fulfilled ranging from 14% in chapter 4%–60% in chapter 5 [Figure 5].
Figure 5: Chapter-wise compliance to documentation requirement

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Overall compliance of practice pattern for all the chapters is shown in [Figure 6].
Figure 6: Chapter wise overall practice pattern

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Fifty responders were interviewed directly with the help of preformulated set of nine questions. The demographic profile of the interviewee is shown in [Table 1].
Table 1: Demographic data of studied sample

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The first question elicited their awareness about the existing institutional policies/departmental SOPs. The responses are summarized in [Table 2].
Table 2: Responses to question-1 (are you aware of the documented policies and procedures of your department on various services?)

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The second question was based on their respective compliance to the institutional policies/SOPs; this question was asked only to those who were aware of at least some policies. Only 30 out of 44 (68%) admitted to follow the procedure always. The responses are summarized in [Table 3].
Table 3: Responses to question-2 (do you practice in accordance with laid down policies and procedures?)

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The third question, asked to those responders only who were aware of the documented policies but did not follow the policies always, was directed to elicit the reasons of not following the procedure despite being aware of the SOPs, the responses are summarized in [Table 4].
Table 4: Responses to question-3 (why do you not follow prescribed procedures always?)

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The fourth question elicited the rationale of the followed practice when they were not aware of the policy or when the SOPs were not available, the responses are summarized in [Table 5].
Table 5: Responses to question-4 (what makes you follow a particular practice, in the absence of knowledge of laid down procedures or when SOPs was not available?)

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Next, question number 5 was directed to explore if the deviations from the laid down standards of practice resulted in recognized mishap/near miss, the responses are depicted in [Table 6].
Table 6: Responses to question-5 (have you ever witnessed a mishap or a near miss because of nonfollowing of laid down procedures or absence of guidelines?)

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Question 6, explored whether they reported a near miss when they witnessed one and what prompted them to report, the responses are summarized in [Table 7].
Table 7: Responses to question-6 (do you report near misses, what makes you reporting them?)

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Next question explored the barriers to reporting near misses; it was put to those who did not report near misses; the responses are summarised in [Table 8].
Table 8: Responses to question-7 (why do you not report near misses?)

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With the next question, their opinion on methods to prevent mishaps and near misses were sought, the responses are summarized in [Table 9].
Table 9: Responses to question-8 (how do you think the mishaps/near misses can be prevented and safety increased?)

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The ninth question was asked to ascertain the institutional effort on making the staff aware of the policies and SOPs; the responses are summarized in [Table 10].
Table 10: Responses to question 9 (how often are you updated/trained on the institutional policies/SOPs?)

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  Discussion Top

High uniformity up to 96% was observed for the elements where documented policies were available while uniformity was as low as 15% where documented policies were not present [Figure 2] and [Figure 3]. Where documentation was not required, again a low uniformity in practice was observed, 51% [Figure 4]. The high contribution of well-defined and documented policies in bringing about uniform practices is further strengthened by analyzing [Figure 5] and [Figure 6], the documentation requirements were fulfilled to maximum level of 60% for chapter 5 and the uniformity in practices for elements in this chapter was also maximum (78%), whereas the documentation requirements were met least for chapter 4 (14%) and also the uniformity in practice for the elements on this chapter was minimum (37%). Thus, we can say that well-defined policies and SOPs provide a measurable standard of performance and result in uniformity of practice followed by most health-care providers.

Surbhi Deo Gupta [2] did a gap analysis at EHCC hospital and found that major noncompliance was due to lack of documented policies and procedures and lack of hospital and departmental manuals; Neha Arora [3] studied the practices at a multispecialty hospital in Delhi and found that though the documentation of policies was up to the mark the implementation of policies and procedures was an area of concern. They all collected primary data by direct observation and staff interview and secondary data from hospital registers and records, the same way as we did.

In our study, even in the presence of documented policies, they were not followed always, the reasons included lack of awareness of the policies/SOPs, heavy workload, “assumingly” safe situation to bypass the laid down guidelines and assuming that the alternative approach adopted was also safe [Table 2], [Table 3], [Table 4]. The problem of nonawareness of policies among staff is not new, Bedi et al.[4] reported that only 50% of doctors and 46% of nurses were aware of the SOPs in a secondary care hospital; however, the awareness level was higher, around 87% in tertiary care hospital, this was much higher than the awareness level in our hospital, Bedi et al. also discovered that more than 91% doctors and nurses in secondary care hospitals; and 50% of nurses and 100% of doctors in tertiary care hospitals denied having been given a copy of the instruction manual to read at the time of their joining, we did not explore this specific practice in our study.

In the absence of predefined policies/SOPs, the service providers devise their own ways of practice by watching the way others do it (76%), been instructed (verbally) to do it that way (18%) or doing it the easy way (4%) [Table 5]. Bedi et al. found that verbal instructions and self-learning on-the-job were the most important sources behind adopting a particular practice. Deviation from following laid down procedures poses potential risk to patients and near misses were witnessed by two-third of the responders [Table 6], however only 15% of them chose to report them, they realized the significance of reporting in preventing recurrences in future while rest wanted to get their conscience clearer by reporting the event [Table 7]. Whatever the force behind it, reporting does provide an opportunity of systems check and eliminating the causative factor. The major barriers to reporting the near misses were either considering them as minor issues because no harm was done (50%) or they did not report because the event did not happen due to their own fault (36%) or because the process to report was not known (7%), 7% feared punitive action restraining themselves from reporting the event [Table 8]. Kang et al.[5] reported three most common reasons for underreporting of medication errors were unclear reporting protocols, no time for reporting (heavy workload) and no obligation to report; fear of action was also a minor reason to not report the event. Haw et al.[6] also explored the barriers to reporting near misses knowledge, fear, burden of work, and excusing the error were identified the most common reasons for underreporting. These barriers stress the need to sensitize the staff to the significance of near-miss events and their reporting; clearly define the procedures to report such an event and making provisions that the reporting would help in devising methods to prevent such events in future and would safeguard the interest and wellbeing of the reporter. The use of checklist was suggested by most to help in preventing mishaps and near misses, that itself speaks for the significance of following SOPs, reducing workload, and regular training were other suggested measures [Table 9]. It is interesting to note that while use of the checklist was suggested by most to help preventing such events, not all followed the available guidelines, analysing this observation combined with observations in [Table 4], there is strong need to look into the workload on the staff also combining it with observations in [Table 10], administrators must incorporate training and sensitisation sessions in the work schedule.

  Conclusion and Recommendations Top

The present study revealed that the hospital has a large gap to fill to meet the documentation requirements of NABH; at present, only 37% of such requirements are met. There is visibly large gap in compliance to standards for which defined policies are available and for which such policies are not available (96% high compliance vs. 15% high compliance). Staff perceived the workload on them to be high, which causes them to compromise with the work quality. Training and sensitization of staff regarding work protocols and safety measures was infrequent and inadequate.

Limitations of the study

  • This study was focussed only on patient-centered activity chapters of NABH standards and did not study the management centered chapters; hence, a complete picture of hospital practices and infrastructure cannot be ascertained from this study
  • The sample size was small; a larger study may be planned in future.

In order to improve compliance to NABH standards we recommend that the hospital should:

  • Formulate more policies and procedural guidelines/SOPs and update the care providers of the same
  • Train and sensitize the staff to patient rights and encourage the staff to educate the patients
  • Remove barriers, and motivate care providers, to report mishaps/near misses more frequently.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

National Accreditation Board for Hospitals and Healthcare Providers, General Information Brochure. Available from: http://www.nabh.co/h-doc.aspx. [Last accessed on 2018 Jan12].  Back to cited text no. 1
Indian Institute of Health Management Research University, Student Dissertation. Available from: https://www.iihmr.edu.in/student-dissertation/2012-2014/gap-analysis-of-ehcc-hospital-as-per-the-nabh-standards. [Last accessed on 2018 Feb 02].  Back to cited text no. 2
Indian Institute of Health Management Research University, Student Dissertation, Available from: https://www.iihmr.edu.in/student-dissertation/2011-2013/Gap-Analysis-of-a-Multispecialty-Hospital-in-Delhi-as-per-NABH-Standards. [Last accessed on 2018 Feb 02].  Back to cited text no. 3
Bedi S, Behera SD, Arya SK, Singh S. Standard operating procedures in hospitals – A reality Check. JAHA 2006;18:5-9.  Back to cited text no. 4
Kang HJ, Park H, Oh JM, Lee EK. Perception of reporting medication errors including near-misses among Korean hospital pharmacists. Medicine (Baltimore) 2017;96:e7795.  Back to cited text no. 5
Haw C, Stubbs J, Dickens GL. Barriers to the reporting of medication administration errors and near misses: An interview study of nurses at a psychiatric hospital. J Psychiatr Ment Health Nurs 2014;21:797-805.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]


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