Abstract of Dissertation

Agency : NABH (National Accreditation Board for Healthcare Providers), Gap Analysis, Compliance

Objective : To assess the existing service delivery standards of the Civil Hospital, Jalandhar and carry out a gap analysis between existing and desired standards of NABH.

Background : Quality Management Systems and Accreditation 65 are versatile tools to ensure equity in healthcare services and meeting the increasing aspirations of people. This ideal state of affair can be achieved by the institution of a quality management system that focuses on compliance with accreditation standards of NABH and like bodies. Gap Analysis is a tool that helps an organization to compare its actual performance with its potential performance.

Methodology : Research design was descriptive and cross sectional in nature. Initially NABH guidelines were reviewed. A self assessment toolkit provided by NABH was used to assess the existing gaps in Outpatient, Inpatient, Intensive care unit, Laboratory, Blood Bank and other functional areas of hospital. Information was gathered by means of patient and staff interviews, direct observation, hospital and clinical record review. Graphical analysis was performed to analyse the data The study was conducted for a period of three months.

Findings : The study revealed that all NABH chapters had average score below 5, which shows that they were non-compliant to NABH requirements. Hospital showed maximum compliance to standards in NABH chapter no.4 Patient Rights and Education and least compliance to standards Chapter No.8, Facility management and safety.

Recommendations : The gap analysis has revealed non compliance as per NABH Standards in legal and statutory requirements; biomedical waste management; infection control procedures; hospital maintenance; laundry services; management of medication; security and safety; information management and human resource management. The suitable recommendations for the same were given. Quality control measures such as formation of committees, introduction of adverse blood transfusion reaction form, standardisation of handover-takeover of equipments were initiated.