Abstract of Dissertation

Keyword : Gap Analysis of Medical Imaging Services as Per NABH Standards

Objective : To assess the existing service delivery of the diagnostic center. To identify gaps in the existing service delivery of the diagnostic center.

Background : Krsnaa diagnostics works on PPP model with MY hospital, Indore which is a 1200-bedded hospital. It is one of the diagnostic centers which provide Medical Imaging Services with two modalities CT and MRI at affordable rates. The diagnostic center applied for the NABH accreditation. A baseline assessment of the available facilities was carried out for each objective element of the NABH checklist and it shows that average score for the Diagnostic center is more than the desired (i.e.8.75); work in this regard is still required. Through NABH accreditation we aim at disseminating information, surveillance activities, investigation, prevention and control of infection.

Methodology : Study Design: - Descriptive Observational study was done to find out the gaps between the current status of the diagnostic center and NABH standard. Study Area: - Radiology department of MY hospital Indore. Duration of study: - 3 months (1st February- 30th April 2018) Method of data collection: Data collection tool: Data was collected through a structured NABH pre-assessment Tool kit. • Primary & secondary data collection • Primary data: Data was collected through checklist, staff interviews and by directly observing the set of activities performed by doctors, technicians, paramedic staff and clerical staff. • Scoring pattern: - 10 marks- full compliance 5 marks- partial compliance 0- Non-compliance • Secondary data: Diagnostic centre documents reviews & clinical Record Review

Findings : Overall average score is 8.75 which makes diagnostic center eligible for final assessment. The minimum score required was 7. The average score for an individual standard is not less than 7 and the average score for the individual chapter was not less than 8.

Recommendations : The hospital had a score of 8.75 and in accreditation stage as per NABH standards was fit for accreditation. Few gaps were identified, if fulfilled, will help in improving the efficiency of Hospital and attracts more patients. The analysis showed that there are some gaps like feedback form were not submitted by the patient’s regular basis, Technicians are not aware of CPR and BMW awareness was low among hospital staff as per NABH norms. There is a need for Staff Training, adequate documentation and implementation of BMW waste management is required.