Student Dissertation

Agency : Gap Analysis; NABH Guidelines; Hospital Accreditation; Quality of Health Services

Objective : The objectives of the study were: • To identify gaps in the structure, process, and outcome. • To identify the non-compliances and gaps of current services with respect to four patient-centric standards of NABH 4th edition • To compare the gaps with the non-compliances of Final assessment of the hospital • To suggests the required alterations in structure, processes, and outcomes to reduce the non-compliances in surveillance

Background : Hospital and healthcare services are vital components of any well-ordered and humane society and will indisputably be the recipients of societal resources. The hospitals should serve as places of safety, not only for patients but also for the staff and for the general public. Thus, the quality of services provided in various departments is of prime concern for any hospital. NABH has a role in ensuring quality services in a hospital. Hospital is accredited by NABH after a process of accreditation which includes: Self-Assessment as per tool kit, submitting an application for accreditation, a Pre - Assessment visit by NABH accessors, Final Assessment of the hospital within a period of three years, and finally issuance of Accreditation Certificate. This is followed by Surveillance (after 18 months of final accreditation) and Re-assessment (after a period of 6 months of surveillance). This study was conducted to understand the role of NABH standards in assuring the quality of healthcare in a hospital.

Methodology : Four Patient-centric chapters (Access Assessment and Continuity of care, Care of Patient, Patients’ rights and Education & Hospital Infection Control) were considered for comparing the data at the time of final assessment and pre-surveillance check. The study was observational, descriptive, which was done in two parts i.e. a present status of the department with non-compliance against NABH standards and comparing the non-compliances of the final assessment of hospital by NABH. All available services were compared against the set standards and scoring was done on a scale of 1 to 10 using NABH toolkit. Primary data was collected through unstructured interviews and observation. Secondary data was collected from the records, standard operating procedures, and manuals of various departments. The overall study was of 12 weeks which included the preparation of checklist, gap analysis, filling of the toolkit, score analysis, and final conclusion.

Findings : This study revealed that non-compliances had increased from Final assessment of NABH to assessment before NABH surveillance. It was found that non-compliance in ‘Access assessment and continuity of care’ increased from 8.3% to 12.5%, non-compliance in ‘Care of patient’ increased from 10% to 17.2%, non-compliance in ‘Patient Rights and Education’ increased from 9.3% to 13% & non-compliance in ‘Hospital Infection Control’ increased from 13% to 31.5%. Ideally, after the final assessment, the non-compliance should have decreased, and compliances should have increased.

Recommendations : Accreditation of Hospital is mandatory for Empanelment with various TPAs, ECHS, CGHS, etc. To get empaneled, hospitals try for accreditation and hire consultants to maintain all standards as per the requirement of standards of NABH. However, when they get NABH certificate, the standards are not adhered to on a routine basis. By the time, NABH surveillance or reassessment which occurs after a gap of at least 18 months takes place, hospitals do not maintain the desired status. The derive to maintain the standards occur only when there is surveillance. This shows that NABH periodic visits to HCO are not effective in maintaining Quality on a continuous basis. It should be a continuous process so that HCO adhere completely to the desired quality services.


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