Student Dissertation

Agency : NABH Standards; GAP Analysis, Hospital Standards; Hospital Quality

Objective : • To assess the compliance and non-compliance of district hospital as per NABH standards for two chapters namely Care of Patient and Responsibility of Management

Background : A Gap analysis in the initial steps is 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 area of improvement in the existing service system. It focuses on the component of the management services and how effective they are. The scope of improvement will mark the level up in which services are to be upgraded. Scope of improvement will give the percentage of progress needed to achieve the pre-set standards

Methodology : In the Study, the important identified gaps of the hospital have mentioned and discussed available facilities if hospital compared against the act standards and scoring was done on it. The scale of 1 to 10 to know compliance, partial compliance, and non- compliance. For compliance, I have given score 10 which means the parameter\ present in the checklist fully comply with the services present in the hospital. Similarly, if the parameter mentioned in the checklist are not completely met by the services present inside the hospital the score is 5 as partial compliance. If the hospital present services are completely non-comply then the score given is 0. Scoring done for the scope of improvement in the present services on the hospital”.

Findings : It was found that the hospital was partial compliance in these two specific chapters. As of now hospital even fails to full fill the criteria for pre-entry level as the standards were not meeting the evaluation criteria given as per NABH norms. Gap Analysis shows that there are many standards more than two zeros which shows the present status of the hospital is not satisfactory. As the criteria average score “for individual chapter must not be less than 7, as a study shows Chapter 2 Average score is 5.5 and similarly Chapter 7 have 6.2”.

Recommendations : At present, the hospital is not prepared for pre-assessment and require proper vigilance on the loopholes and ensure to cover all the huge GAPs to match & to prepare the hospital for pre-accreditation level.


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