Abstract of Dissertation

Keyword : NABH; Hospital Facility; Quality assessment; Hospital Standards

Objective : To access and analysis the gaps in quality compliance of the facility as per NABH standards so as to prepare it for further accreditation process by NABH at Entry level certification. • To describe the policy and procedures of respective chapters of NABH in the hospital with the identification of existing process Owners, Input(s), Outputs (s) and process flow of each process occurring at each section of the hospital with the relevant records. • To identify the significant gaps observed on all the processes in each section and explanation of the gap statement with document evidences and photographs. The gaps are analyzed based on NABH entry level self assessment toolkit. • To identify the area this needs to be focused upon primarily. • To prepare actions to be taken to fulfill the gaps

Background : Hospital has undertaken an initiative for quality improvement in the health facilities with the active technical assistance of Quality Consultant of Zon Healthcare Consulting Pvt Ltd. Though, ZHC realizes the significance of increasing availability of health services, it is also aware that availability does not directly improve its utilization. It needs concerted efforts to bring about improvement in the quality and comprehensiveness of services through improvement initiatives for service delivery processes. With this understanding, ZHC had started a project to enhance the service quality level of hospital. It is time now to look at how evaluation of the hospital and subsequent improvement, go hand in hand leading to better access and quality service to all service seekers with focus on erstwhile deprived section of the society. The establishment of a quality system in a healthcare organization facilitates the standardization of the systems and processes (both clinical and administrative). This standardization further ensures improving the performance of the hospital with respect to above-stated key elements/components of quality. The quality system thus acts as a vehicle for healthcare organizations to focus on patient and provider needs and expectations. To facilitate the above goals, comprehensive study was carried out on the current processes, practices and existing infrastructure with other available resources to identify the major gaps based on NABH standards of quality management system.

Methodology : Stage I NABH self Assessment Toolkit was used for a total survey of the hospital in terms of services provided, Manpower, Physical infrastructure, Equipments, drugs and Lab services. According to toolkit standards scoring is given to each concerned area. Score ‘0’ – Non compliance Score ‘5’- Partial compliance Score ‘10’ - Complete compliance Stage II Observation and personal interview were used to map the various processes of the hospital and to know the functioning of the each department. Stage III Extensive analysis based on data collected from stage I and II. Based on this Report was prepared reflecting the processes, Infrastructure, Equipments, Manpower. The report reflects strengths of the hospital and various gaps observed in the processes and other parameters

Findings : The study includes documentation and review of manpower, equipment, infrastructure, processes including training and capacity building activities, services & facilities provided legal compliances etc against NABH Standards book. This includes all support processes including nursing, housekeeping & laundry services, security services, dietary services, information support

Recommendations : Special consideration on gaps of the department is given and time bound action plan is prepared and need to be monitor by the hospital’s internal expert consist of Hospital Administrator, Maintenance Officer, Quality Consultant, and Nursing In Charge. It will help for the quality improvement process of Hospital.