ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 1 NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA FACULTY OF OBSTETRICS AND GYNAECOLOGY GUIDELINES FOR ACREDITATION OF TRAINING HOSPITALS IN OBSTETRICS AND GYNAECOLOGY APPROVED BY THE FACULTY BOARD OF OBSTETRICS AND GYNAECOLOGY ON THE 6TH OF NOVEMBER, 2015
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ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 1
NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA
FACULTY OF OBSTETRICS AND GYNAECOLOGY
GUIDELINES FOR ACREDITATION OF TRAINING
HOSPITALS IN OBSTETRICS AND GYNAECOLOGY
APPROVED BY THE FACULTY BOARD OF OBSTETRICS
AND GYNAECOLOGY ON THE 6TH OF NOVEMBER, 2015
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 2
MINIMUM REQUIREMENTS FOR AN ACCREDITATION TEAM TO VISIT
The following minimum requirements should be met before a hospital seeking accreditation for training
applies for an Accreditation visit:
1. There must be at least two fellows with FMCOG in full employment of the hospital.
2. There must be an obstetric ward of capacity, 14 beds or more.
3. There must be a gynaecology ward of capacity 14-beds or more.
4. There must be a standard labour ward with modern delivery beds and equipment for maternal and
fetal monitoring
5. There must be functional gynaecologic and obstetric operation theatres.
6. There must be a Mini-theatre for minor surgical cases / MVA room
7. There must be functional clinics for antenatal care, gynaecology cases, emergency obstetric and
gynaecologic patients and family planning.
8. There must be basic equipment to support 2-7 above.
MINIMUM REQUIREMENTS FOR ACCREDITATION VISIT
(TICK AS APPROPRIATE)
REQUIREMENTS YES NO
Are there at least two fellows with FMCOG?
Is there an obstetric ward of at least 14-bed
capacity?
Is there a gynaecology ward of at least 14-bed
capacity?
Is there a standard labour ward with modern delivery
beds and equipment for maternal and fetal
monitoring?
Are there functional gynaecologic and obstetric
operation theatres?
Is there a Mini-theatre for minor surgical cases /
MVA room?
Are there clinics for antenatal, gynaecology,
emergency obstetrics and gynaecology, and family
planning patients?
Are there basic equipment to support 2-7 above?
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 3
MINIMUM REQUIREMENTS FOR AN INSTITUTION TO GET AT LEAST PARTIAL
ACCREDITATION
For an institution to get at least partial accreditation it must therefore fulfill the requirements 1-8
mentioned earlier, and must in addition have:
1. Evidence of adequate clinical exposure.
2. Evidence of robust academic program.
In line with the recommendations of the quadripartite committee, six thematic areas will be assessed for
accreditation:
1. Appropriate infrastructure
2. Qualified and experienced personnel
3. A well-structured training program that recognizes modern trends in training and assessment
4. Opportunities and evidence of acquisition of skills
5. Access to up-to-date information
6. Regular feedback and evaluation from trainers and trainees
FIELD SCORE ADEQUACY
INADEQUATE PARTIAL FULL
INFRASTRUCTURE
EQUIPMENT
PERSONNEL
PROGRAMS
SKILLS
INFORMATION
FEEDBACK
TOTAL SCORE
RECOMMENDATION
MEMBERS OF ACCREDITATION TEAM SIGNATURES
1.
2.
3.
4.
5.
6.
DETAILED ASSESSMENT
The assessment and scores for these areas should be done using a wholistic approach addressing the following:
1. Core department: Obstetrics and Gynaecology
2. Rotational departments:
a. General Surgery
b. Urology
c. Neonatology
3. Support departments:
a. Radiology
b. Laboratories: Histopathology, Chemical Pathology, Haematology and Microbiology.
c. Pharmacy
d. Health records
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 4
The overall marks should be distributed as follows:
1. Core department 70%
2. Rotation departments 20%
3. Support departments 10%
STEPWISE APPROACH TO ACCREDITATION ASSESSMENT
CORE DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY (70 MARKS)
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 7
h. Oxygen
i. Patients trolley
(iii)Evidence of training and skill acquisition
a. Number of MVAs in the last one year.
b. Number gynaecological emergencies in last one year.
c. Structured resident doctors’ rotation.
GYNAECOLOGICAL EMERGENCY (10 Marks)
Subheading Number/Presence Scores Remarks
Infrastructure
Equipment
Training/Skills
Adequacy remarks
5. Obstetrics (antenatal and postnatal) Ward (10 Marks)
(i). Infrastructure
a. Number of beds
b. Examination/treatment room
c. Ventilation
d. Lightning
e. Electricity supply: PHCN/generator back up
f. Running taps/hand washing
g. Patients privacy
h. Staff and patients toilets
(ii) Equipment
a. Wheel chairs
b. Patient trolleys
c. Angle poise lamps
d. Emergency trolley
e. Suction machines
f. Oxygen
g. Sonicaid
(iii)Evidence of training and skill acquisition
a. Number of new patients admitted in the last one year.
b. Statistics of different cases admitted in the last one year.
c. Nurses/midwives
OBSTETRICS WARD (10 Marks)
Subheading Number/Presence Scores Remarks
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 8
Infrastructure
Equipment
Training/Skills
Adequacy remarks
6. Gynaecological Ward (10 Marks)
(i.) Infrastructure
a. Number of beds
b. Examination/treatment room
c. Ventilation
d. Lightning
e. Electricity supply: PHCN/generator back up
f. Running taps/hand washing
g. Patients privacy
h. Staff and patients toilets
(ii) Equipment
a. Wheel chairs
b. Patient trolleys
c. Angle poise lamps
d. Emergency trolley
e. Suction machines
f. Oxygen
(iii)Evidence of training and skill acquisition
a. Number of new patients admitted in the last one year.
b. Statistics of different cases admitted in the last one year.
c. Nurses/midwives
GYNAECOLOGICAL WARD (10 Marks)
Subheading Number/Presence Scores Remarks
Infrastructure
Equipment
Training/Skills
Adequacy remarks
7. Labour Ward (10 Marks)
i. Infrastructure
a. Examination/admission area
b. Delivery suites/areas
c. High dependency unit
d. Ventilation
e. Lightning
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 9
f. Electricity supply: PHCN/generator back up
g. Running taps/hand washing
h. Patients privacy
i. Staff and patients toilets
(ii) Equipment
a. Number of delivering beds
b. Separate/combined first and second stage beds
c. Number of delivery packs
d. Obstetrics forceps
e. Vacuum extractors
f. Neonatal resuscitation kits
g. Radiant warmer
h. Wheel chairs
i. Patient trolleys
j. Angle poise lamps
k. Emergency trolley
l. Suction machines
m. Oxygen
n. Sonicaid
o. CTG
p. USS
(iii)Evidence of training and skill acquisition
a. Number of new deliveries in the last one year.
b. Number of Caesarean sections in last one year
c. Number of instrumental vaginal deliveries in last one year
d. Number of vaginal breech deliveries in the last one year.
e. Maternal mortality rate
f. Nurses/midwives
LABOUR WARD (10 Marks)
Subheading Number/Presence Scores Remarks
Infrastructure
Equipment
Training/Skills
Adequacy remarks
8. Operating Theatres (20 Marks)
Obstetrics Theatre
A. Consultant. Anesthetist
B. Number of suites
C. Changing rooms
D. Monitors
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 10
E. Anaesthetic machines
F. Resuscitiers
G. Transport incubator
H. Radiant warmer
Main (or Gynaecological) Theatre
(i) Qualified personnel
a. Anesthetists
b. Scrub nurses
c. Anaesthetic nurses
(ii) Infrastructure
a. Number of gynaecological suites
b. Recovery area
c. Changing rooms
d. Waiting rooms
(iii)Equipment
a. Standard operating beds
b. Anaesthetic machines
c. Monitors
d. Standard gynaecological packs: major and minor
e.
(iv) Evidence of skill acquisition
a. Number of gynaecological surgeries: major/minor in last one yea
b. Number of abdominal hysterectomies in last one year
c. Number of vaginal hysterectomies in last one year
d. Number of pelvic floor repairs in last one year
e. Number of myomectomies in last one year
f. Number of laparoscopies in last one year
OPERATING THEATRES (20 Marks)
Subheading Number/Presence Scores Remarks
Personnel
Infrastructure
Equipment
Training/Skills
Adequacy remarks
9. Specialized Units (10 Marks) Colposcopy Unit
1. Qualified colpocopist
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 11
2. Designated room 3. Functional colposcope 4. Evidence of skill acquisition: number of cases in last one year ART Unit. 1. Qualified ART team 2. Designated room 3. Functional equipment 4 Evidence of skill acquisition: number of cases in last one year
Minimally Invasive Surgery Unit
Qualified minimally invasive surgeon
(i) Designated room
(ii) Functional equipment
(iii)Evidence of skill acquisition: number of cases in last one year
SPECIALISED UNITS (10 Marks)
Subheading Number/Presence Scores Remarks
Colposcopy
ART
Minimally invasive
surgery
Adequacy remarks
10. Resident Doctors Sleep-In Rooms (10 Marks)
(i) Infrastructure
a. Ventilation/air conditioning
b. Lightning
c. Electricity supply: PHCN/generator back up
d. Toilet facilities
e. Separate male from female rooms
f.
(ii) Equipment
a. TV/Cable TV
b. Beds
c. Reading table and chair
d. Cleaning/Cleanliness
RESIDENT DOCTORS’ ROOMS (10 Marks)
Subheading Number/Presence Scores Remarks
Infrastructure
Equipment
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 12
Adequacy remarks
11. Seminar Rooms and Library (10 Marks)
Departmental seminar room (5 Marks)
Seating capacity
Ventilation and air conditioning
Audio-visual aids
Departmental Library (5 Marks)
Standard textbooks
Standard journals
National postgraduate medical journal
Internet access
Reading tables and chairs
Ventilation and air conditioning
DEPARMENTAL SEMINAR ROOM AND LIBRARY (10 Marks)
Subheading Number/Presence Scores Remarks
Seminar Room
ART
Library
Adequacy remarks
12. ROTATION DEPARTMENTS (20 MARKS)
General Surgery and Urology
(i) Qualified personnel
a. Accredited for training
b. Endoscopic surgery
c. Residents on rotation
(ii) Neonatology Ward (NICU/SCBU)
a. Qualified personnel
b. Accredited for training
c. Equipment
i. Number of beds: Inborn: Out born:
ii. Phototherapy machines
iii. Incubators
iv. Apnoeic monitors
v. Transport incubator
vi. Exchange blood transfusion
vii. Kangaroo nursing
viii. Radiant warmer
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 13
ix. Residents on rotation
ROTATION DEPARTMENTS (20 MARKS)
Subheading Number/Presence Scores Remarks
Personnel
Infrastructure
Equipment
Training/Skills
Adequacy remarks
13. SUPPORT DEPARTMENTS (10 MARKS
Radiology (3)
(i) Qualified personnel
(ii) Accredited for training
(iii)Equipment
a. HSG
b. Fluoroscopy
c. Ultrasound scan: 3D, Doppler
d. Computer axial tomography
e. Magnetic resonance imaging
f. Positron emission tomography
g. Residents participation in HSG
Haematology (3)
(i) Qualified personnel
(ii) Accredited for training
(iii)Equipment
(iv) Services
a. Packed cells
b. Platelet concentrates
c. Blood products
d.
Histopathology (3)
(i) Qualified personnel
(ii) Accredited for training
(iii)Equipment
(iv) Services
a. Cytology
b. Frozen section
c. Turn over time
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 14
Chemical Pathology (3)
(i) Qualified personnel
(ii) Accredited for training
(iii)Equipment
(iv) Services
a. Hormone assays
b. Gynecological cancer biomarkers: bhcg, CA125, CEA
Microbiology (3)
(i) Qualified personnel
(ii) Accredited for training
(iii)Equipment
(iv) Services
a. Specialized cultures
b. Transport media
c. Anaerobic culture
d. Blood culture
Health Information (2)
(i) Qualified personnel
(ii) Equipment:
a. Computerized records
b. Separate ANC records
Pharmacy (3)
(i) Qualified personnel
(ii) Equipment
(iii)Specialized drugs e.g
a. Oxytocics: oxytocin, ergometrine, misoprostol
b. Ovulation induction drugs
c. Cytotoxics
d. Antibiotics
SUPPORT DEPARTMNTS (10 Marks)
Subheading Number/Presence Scores Remarks
Personnel
Infrastructure
Equipment
Training/Skills
Adequacy remarks
ACCREDITATION GUIDELINES FOR RESIDENCY TRAINING IN OBSTETRICS AND GYNAECOLOGYPage 15