Student Dissertation

Agency : Gap analysis, Accreditation, Compliance, Partial compliance and Non – compliance

Objective : • To assess the hospital’s existing set up & procedures as per NABH standards • To understand the major non-compliances for first internal assessment • To establish action plan based on the gap report

Background : The budding healthcare sector is progressing towards a full bloom in the wake of the rising demand for its services. With numerous small and large scale healthcare delivery systems coming up, a major concern for the quality of the services delivered has arisen. The consumers of these services are becoming increasingly aware and quality oriented and 100 do not hesitate to pay a little extra for better facilities offered. Owing to their increased preference for quality services the hospitals are forced to scale up the quality of the facilities provided. In order to achieve a standard delivery of care throughout the healthcare delivery institutions for the benefit of the patients, a quality council of India was established by the name of National Accreditation Board for Hospitals & Healthcare Providers in 2006. It is set up to establish and operate accreditation program for healthcare organizations. The board while being supported by all stakeholders including industry, consumers, government and has a fully functional autonomy in its operation. More and more healthcare delivery institutions are willing to have an accreditation by this quality council as a visible leap of standardization as well as to gain patient trust. It is thus a need of the hour to identify and evaluate the existing systems as per the laid down guidelines by NABH as the first step towards this goal.

Methodology : Study Area: Eternal Heart Care Centre and Research Institute, Jaipur Study Design: Analytical Cross – Sectional Study • Primary sources of data: o Personal observation. o Interviews of the staff and authorities (like nursing staff, hospital administrator, medical director etc) with the help of a Questionnaire. o Self assessment toolkit as per NABH. • Secondary sources data: o Hospital registers & records. o NABH document for hospital standards o Studies available on the internet regarding accreditation

Findings : The compliances, partial compliances and non compliances were recorded as per the given standards. The major non – compliance as observed was due to lack of documented policies and procedures and lack of apex and departmental manuals. A major gap regarding training and orientation of the staff was observed. Partial compliances for signage standards and legal compliances were also an observation.

Recommendations : Accreditation is an essential component of quality and could be easily achieved by EHCC hospital given its highly supportive management and a well qualified work force. If applied immediately it will be ready for its first assessment in about 6 months.


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