Abstract of Dissertation

Agency : Gap Analysis, District Hospital, NABH Norms, NABH Accreditation

Methodology : A Non experimental evidence based study has done in the district hospital. Over all hospital and departments are reviewed on the basis of checklist.

Findings : There are 3 standards in chapter 1, 10 standards in chapter 2, 7 standards in chapter 3, 3 standards in chapter 4, 5 standards in chapter 5,all standards in chapter 6, 1 standard in chapter 7, 5 standards in chapter 8, 4 standards in chapter 9 and 4 standards in chapter 10 having zero . There are 36 standards out of 102 standards having average score less than 5. All individual chapters having average score less than 5.The overall average of all the standards does not meet the criteria as it is greater than 5.With the above analysis it is clear that the hospital is not fulfilling the pre-accreditation entry level criteria.

Recommendations : The analysis shows that there are lots of gaps in the hospital as per NABH norms. Documentation and implementation is required. As the hospital wishes for NABH accreditation so it must be prepared according to the evaluation criteria for assessment. There are different stages of accreditation which needs to be fulfilled by the organization. As of now the hospital does not fulfil the criteria for entry level according to which no standard must not have more than two zero and the average score of individual standard must not less than 5 and the average score for individual chapter must be more than 5. The gap analysis to analyze the present status of the hospital concluded that the hospital is not at the entry level as there are many standards having less than 5 score. Therefore these all are the areas which require greatest attention.

Government of Uttar Pradesh has adopted several strategies for sensitization towards importance of quality health services. One of the strategies is to get NABH accreditation of public hospitals. Assistant Consultants have been appointed in all the district hospitals to coordinate the NABH related gap analysis. So, a gap analysis report as per NABH norms was required to be prepared for analysis of gaps and progress in accreditation preparedness activities.