Abstract of Dissertation

Keyword : Multi Speciality Hospital; Gap Analysis; NABH Self-Assessment Toolkit; Accreditation

Objective : To identify the gaps in terms of structure, process and outcome To suggest alterations in the structural designs, process of the facilities to meet the requirement. To give remedial and pre-emptive action for the gaps identified.

Background : Accreditation is "A public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organization's level of performance in relation to the standards". It shows that the hospital has undertaken a challenging, comprehensive evaluation. It has made a noteworthy extra effort to review and improve the key issues that can affect the quality and safety of patients. The hospital has gone through NABH evaluation shows an extraordinary obligation to provide safe, high quality care and preparedness to be measured against the highest standards of performance. A study was conducted to find out the gaps between the current services and the standards of NABH in various departments of the hospital. Data collection tool applied for the study is NABH self-assessment toolkit.

Methodology : Study design: Descriptive study was done to find out the gap between the status of the hospital and NABH standards as per 4th edition. Study Area: All departments of the hospital - Front office, OPD, Emergency department, ICU, Operation theatre, IPD, Laboratory (Pathology, microbiology, biochemistry), Radiology and imaging, CSSD, BMW department, Pharmacy, Kitchen, Maintenance, MRD, Human resource department, Dialysis, Security, Engineering and facility management department Data collection tool: checklist, NABH self-assessment toolkit Data collection technique: 1. Primary data: Direct observation 2. Discussion with the hospital staff 3. Discussion with the patients of the hospital Secondary data: 1. Hospital Manuals, Policies 2. Records (e.g. - Register of these departments), HMIS

Findings : The study revealed that the average score as per NABH was 8.66 which makes the hospital eligible for appearing for final assessment, as minimum score required was 7. The area of concern lies with implementation of policies and procedures as documentation part was up to the mark. The hospital had maximum of process i.e. 48 % followed by structural gaps i.e. 27 % and then outcome gaps i.e. only 24 %. The hospital has fulfilled all the four criteria of accredited level. No individual standard has a zero score. No individual standard has an average score below 5. No individual chapter has an average score below 7. The overall average score is more than 7.

Recommendations : The hospital had a score of 8.7 in accreditation stage as per NABH standards and was fit for accreditation. Few gaps were identified, if fulfilled, will help in improving the efficiency of Hospital and attract more patients.