Abstract of Dissertation

Keyword : Gap Analysis; NABH Standards; Super Speciality Hospital; Patient Centric; Accreditation

Background : The budding healthcare sector is progressing towards a full bloom in the wake of the rising demand for its services. The consumers are becoming increasingly aware and quality oriented & do not hesitate to pay a little extra for better facilities offered. Owing to the increased preference for quality services the hospitals have to scale up the quality of services provided by them. In order to achieve a standard delivery of care in the hospitals, National Accreditation Board for Hospitals & Healthcare Providers was established in 2006. More and more hospitals are willing to have an accreditation by this quality council as a visible leap of standardization as well as to gain patient trust. In order to maintain the standards of service delivery, monitoring the performance, to bring about patient centric practices and to focus on safety to have a collective effort across the region in order to continually improve, there is a need to do gap analysis. To identify the gaps as per the patient centric chapters of NABH 4th Edition standards using the NABH Self-Assessment Toolkit. Methodology: Descriptive Cross-sectional study. Results and Conclusion: The assessment score for the hospital is above average using the NABH 4th Self-Assessment toolkit and it fulfils all the criteria laid down by NABH to be eligible for the pre-assessment audit. Staff has to be trained on a frequent basis to stress upon following the SOPs, improve the documentation in order to provide quality healthcare services to the patients. Policies, SOP and manuals have been prepared but the implementation of these policies has to be done meticulously throughout the hospital. The hospital is in the process of bringing in standardisation in its operations thus improving the quality of patient care. Quality being a continuous process, by streamlining the processes, reducing the waste and improving efficiency the hospital is on the right path to fulfil its quality goal of achieving accreditation