FACULTY OF OBSTETRICS AND GYNAECOLOGY GUIDELINES FOR

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


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?


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


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)

1. Qualified personnel (20 marks)

a. FMCOG (10)

b. FWACS and others (4)

c. Subspecialities (4):

1. Feto-maternal

2. Infertility and endocrinology

3. Gynaecological oncology

4. Uro-gynaecology

d. Nurses/Midwives' (2)

QUALIFIED PERSONEL AND SUBSPECIALITY (20 Marks)

Personnel/Subspecialty Number/Presence Scores Remarks

FMCOG

FWACS

Subspecialties

Feto-maternal

nfertility/endocrinology

Gynae. Oncology

Uro-gynaecology

Nurses/Midwives

Adequacy remarks

2. Antenatal and Gynaecology Clinics (20 marks)

(i) Infrastructure (5)

a. Waiting area/space

b. Number of seats

c. Comfort of seats

d. Consulting rooms

e. Ventilation/air conditioning

f. Lightning

g. Electricity supply: PHCN/generator back up

h. Running taps/hand washing

i. Patients privacy

j. Staff and patients toilets

k. Separate health information unit


(ii) Equipment (10)

a. Audio-visuals for health education

b. Wheel chairs

c. Patient trolleys

d. Examination couches

e. Angle poise lamps

f. Examinations trays

g. Emergency trolley

h. Suction machines

i. Oxygen

j. Sonicaid

k. USS

l. CTG

m. Colposcope

(iii)Evidence of training and skill acquisition (5)

a. Number of new cases in the last one year.

b. Number of follow ups in the last one year.

c. Number of units

d. Number of clinic days per unit

e. Number of residents/consultants per unit

f. Access to consultants in the clinic.

g. Nurses/midwives

h. Chaperones

ANTENATAL AND GYNECOLOGICAL CLINICS (20 MARKS)

Subheading Number/Presence Scores Remarks

Infrastructure

Equipment

Training/Skills

Adequacy remarks

3. Family Planning Clinic (10 Marks)

(i) Qualified personnel (4)

a. Consultant in charge

b. Trained family planning providers

(ii) Infrastructure (2)

a. Waiting area/space

b. Ventilation/air conditioning

c. Lightning

d. Patients privacy

e. One on one counseling room


f. Procedure room

g. Staff and patients toilets

(iii)Equipment (2)

a. Examination couch

b. Angle poise lamp

c. Examination trays

d. Commodities

e. Resuscitation tray

(iv) Evidence of training and skill acquisition (2)

a. Number of new clients in the last one year.

b. Number of follow ups in the last one year.

c. Number of procedures done by residents in last one year

d. Structured resident doctors’ rotation.

FAMILY PLANNING CLINIC (10 Marks)


Personnel

Infrastructure

Equipment

Training/Skills

Adequacy remarks

4. Gynaecological Emergency/MVA Facility (10 Marks)

(i) Infrastructure

a. Gynaecological Emergency room

b. MVA Procedure room

c. Ventilation/air conditioning

d. Lightning

e. Patients privacy

f. Accessible patients toilets

(ii) Equipment

a. Examination couch

b. MVA procedure couch

c. Angle poise lamp

d. Examination trays

e. MVA kits

f. Resuscitation tray

g. Suction machine


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)


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


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)



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


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)


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


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


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)


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


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)


Personnel

Infrastructure

Equipment

Training/Skills

Adequacy remarks

9. Specialized Units (10 Marks) Colposcopy Unit

1. Qualified colpocopist


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)


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)


Infrastructure

Equipment


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)


Seminar Room

ART

Library

Adequacy remarks

12. ROTATION DEPARTMENTS (20 MARKS)

General Surgery and Urology


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


ix. Residents on rotation

ROTATION DEPARTMENTS (20 MARKS)


Personnel

Infrastructure

Equipment

Training/Skills

Adequacy remarks

13. SUPPORT DEPARTMENTS (10 MARKS

Radiology (3)


(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)



(iii)Equipment

(iv) Services

a. Packed cells

b. Platelet concentrates

c. Blood products

d.

Histopathology (3)



(iii)Equipment

(iv) Services

a. Cytology

b. Frozen section

c. Turn over time


Chemical Pathology (3)



(iii)Equipment

(iv) Services

a. Hormone assays

b. Gynecological cancer biomarkers: bhcg, CA125, CEA

Microbiology (3)



(iii)Equipment

(iv) Services

a. Specialized cultures

b. Transport media

c. Anaerobic culture

d. Blood culture

Health Information (2)


(ii) Equipment:

a. Computerized records

b. Separate ANC records

Pharmacy (3)


(ii) Equipment

(iii)Specialized drugs e.g

a. Oxytocics: oxytocin, ergometrine, misoprostol

b. Ovulation induction drugs

c. Cytotoxics

d. Antibiotics

SUPPORT DEPARTMNTS (10 Marks)


Personnel

Infrastructure

Equipment

Training/Skills

Adequacy remarks


SUMMARY OF ACCREDITATION

Subheading Scores (100) Remarks

CORE DEPARTMENT

ROTATION

DEPARTMENTS

SUPPORT

DEPARTMENTS

TOTAL

RECOMMENDATION:

GUIDELINE FOR RECOMMENDATION

Full accreditation 80

Partial 60 - <80

Denial/Withdrawal of Accreditation < 60

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FACULTY OF OBSTETRICS AND GYNAECOLOGY GUIDELINES FOR