Abstract of Dissertation

Agency : Gap Analysis, NABH, Structure, Process and Outcome Gaps

Objective : 1. To assess the existing service delivery status of the hospital as per NABH guidelines. 2. To identify the gap, if any, as per NABH guidelines. 3. To suggest viable recommendations for bridging the gaps in departments based on customized requirements for the hospital. 4. To help the hospital management to take appropriate managerial decision to improve the quality of their services

Background : Gap analysis is the initial step in the review of the available service delivery system. It is an efficient base to implement a modern management system. It can be measured against pre set standards. It reveals the areas of improvement in the existing service system. It focuses on the components of the management services and how effective they are

Methodology : The study is non- experimental, cross-sectional and observational which is done in two parts i.e. present status of the department and compliance against NABH standards. All available services were compared against the set standards and scoring was done on a scale of 1 to 10 using NABH toolkit. Primary data was collected through unstructured interviews in which convenient sampling was done and observation was also included. Secondary data was collected from the records of various departments. Overall study was of 7 weeks which included the preparation of checklist, gap analysis, filling of toolkit, score analysis and final conclusion.

Findings : Hospital does not have infection control committee and strong HAI control practices. They do not have SOP’s for different departments and if any department is having the SOP then they are not documented and implemented. Score analysis of NABH toolkit shows that hospital does not even fulfil the criteria for pre-accreditation entry level. Great effort is needed on the part of the management of the hospital so as to bridge the gaps and to prepare the hospital for pre-accreditation entry level. In the present situation, the hospital is not ready to go for NABH

Recommendations : The analysis shows that there are many gaps in the hospital as per NABH norms. The policies and procedures need to be prepared, their 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 even fulfill the criteria for pre-accreditation entry level according to which no standard must 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.