HEALTH AUDIT OF VICTORIA JUBILEE (WOMEN SHI**ING UP LABOR ROOM)

The Victoria Jubilee Hospital is the largest referral maternity hospital in the English
Speaking Caribbean. It provides obstetric and gynaecological care for women island-wide.
Victoria Jubilee Hospital sees more than 70,000 women and approximately 8,000 babies
are delivered each year. The institution has a bed capacity of 248. Forty percent of the
hospital’s out-patients are from the inner city communities which surround the hospital.
The areas audited were the Operating Theatre Suite, Fertility Control Unit (FCU), Neonatal
Nursery and Maternity/Obstetric Unit.
NON-CONFORMANCES
Operating Theatre Suite
a) There is a shortage of theatre clothes in the FCU theatre.
b) The bathrooms in the FCU need urgent attention. Nursing staff and patients are using
the same facilities in the FCU.
c) Storage of sterile supplies is in uncovered areas. In addition a trolley is used
for additional storage.
d) There is no specific assignment of personnel to assessing the adherence to infection
control practices.
e) The access areas are not clearly identified. Hence traffic flow is not monitored or
restricted as it should be.
f) Anaesthetists are resisting the wearing of facial masks in the operating room
g) The janitorial staff all need to be given training on the proper mixing and use of
the cleaning materials
h) The timely removal of waste from the outer corridors needs to be organised to
be in tandem with the heavy patient load.
i) Contractors have not provided utility gloves for the janitors.
j) Instruments are being soaked in antiseptic solutions out of keeping with the standard.
k) The health and immunisation status of the staff are to be monitored according to
the recommended schedule.
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Maternity/Obstetrics Unit
a) The cleaning materials and methods do not conform to the MOH standards
b) The labour and delivery suite need to have dedicated janitors- there are
confidentiality and privacy issues.
c) More oxygen cylinders are required for the wards and the cylinders that exist need to
be anchored to prevent injury to staff and patients in the event of a mishap.
d) There is one Resuscitaire in the delivery room. On occasions more than one child
has to be on the tray.
e) There is one Foetal monitor which has to be shared by mothers in the first stage
room.
f) There is one pulse-oximeter for the entire Labour and Delivery suite.
g) Adequate wheelchairs are in the labour and delivery suite but there are no
dedicated stretchers.
h) New delivery beds have been acquired however the upper 2/3rds of these beds
have mattresses which are fixed and therefore are unable to be adequately
cleaned. Macintoshes are required to cover and protect these new beds.
i) There are no permanent screens in the first stage room and in a case where a
delivery is imminent there is no possibility of privacy. Addition mobile screens are
necessary.
j) There are no emergency buzzers or any form of communication for the patients to
alert the clinical staff. “Shouting” is the mode of alert.
k) The sluice room is in a terrible condition. The sink is inappropriate, the ceiling is
non- existent, and the whole room is grimy. Urgent refurbishment is necessary.
l) Buckets are being used as Sharps containers.
m) Fire drills are not being done. A number of areas have fire extinguishers.
n) There are a number of small items of equipment and supplies which are in short
supply:
i) Kidney dishes, forceps
ii) Foetal stethoscopes, kockers forceps
iii) Cord scissors, cord clamps
iv) Thermometers, episiotomy scissors
v) Supplies of enema
vi) Linen
Neonatal Nursery
a) There is no cleaning schedule available.
b) The cleaning materials and methods do not conform to the MOH standards
c) There was no copy of the Health Facility Infection prevention and Control Manual.
d) The inventory for the equipment is kept solely by the maintenance unit.
e) There is no system to monitor the usage pattern of essential drugs and supplies.
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This is important in order to facilitate supplies management.
f) There is no auditing process in place.
g) Staff are unaware of the Client Complaint Mechanism.
h) No death review meetings are held.
i) There is a shortage of sharps containers
j) The Resuscitaire is defective. One side is absent which may result in a child falling to
the floor.
k) The sluice room is in a terrible condition. The sink is inappropriate, the ceiling is
non- existent, and the whole room is grimy. Urgent refurbishment is necessary.
l) Buckets are being used as Sharps containers.
m) Fire drills are not being done. A number of areas have fire extinguishers.
n) There are a number of small items of equipment and supplies which are in short
supply:
i) Kidney dishes, forceps
ii) Foetal stethoscopes, kockers forceps
iii) Cord scissors, cord clamps
iv) Thermometers, episiotomy scissors
v) Supplies of enema
vi) Linen
Neonatal Nursery
a) There is no cleaning schedule available.
b) The cleaning materials and methods do not conform to the MOH standards
c) There was no copy of the Health Facility Infection prevention and Control Manual.
d) The inventory for the equipment is kept solely by the maintenance unit.
e) There is no system to monitor the usage pattern of essential drugs and supplies

This is important in order to facilitate supplies management.
f) There is no auditing process in place.
g) Staff are unaware of the Client Complaint Mechanism.
h) No death review meetings are held.
i) There is a shortage of sharps containers
j) The Resuscitaire is defective. One side is absent which may result in a child falling to
the floor.
k) There is one physiological monitor for the entire unit.
l) There are three suction machines – none are functional. One portable unit is being
shared among babies.
m) The fire exit needs a ramp to facilitate the easy removal of cots and equipment in
an emergency. Currently there is only the stairway.