Abstract of Dissertation

Keyword : Gap Analysis; NABH-SHCO Standards; Hospital Setup; NABH Guidelines; Facility Management

Objective : • To assess the hospitals existing set up and procedures as per NABH standards • To understand major non-Compliance

Methodology : Study Design: Descriptive and Observational Study Source of Data: This study was based on a checklist prepared based on the applicable guidelines of NABH for the small health organization. The primary data was collected by conducting interviews with the staff and the patient. It also included direct observation. Secondary data was reviewed from records and certificates of the hospital Sample Selection: Inclusion criteria was20 papers/articles/research thesis/research documents to review. Inclusion criteria included last 15years studies addressing the effect of hospital accreditation and certification. An outcome includes both clinical outcomes and process measures. An exclusion criterion includes literature which is older than 15 years and not relevant due to vintage, technological changes or relevance. Data Collection Procedure: Primary data through a checklist for various elements involved in input, process and output procedures for all departments such as human resource planning, bio-medical waste management checklist for record review, datasheet for data review, etc. and secondary data through hospital records.

Findings : • Facility management has many objective elements which non-complaint are but the average is quite better due to a few of the standards like providing a safe and secure environment which are partially complaint. • Care of patients has some objective elements which non-complaint are but the average is quite better due to few of the standards like as the organization provides patient safety but there are few infection control practices which are to be put in place. • Patient’s right and education is emphasized a great deal due to a special category of staff i.e. the counselors who are specially meant to make the patient aware of their rights and educate them to take an informed decision. • Hospital infection control is also one area where the greater emphasis has to be laid as there is no documented infection control program and team which exclusively works upon infection control. • The information management system provides an authenticated, secure, accurate inputs to the right personnel at right time and place, but needs to work on the manual records which are handwritten • The chapter management of medication which basically deals with the pharmacy and medical gas has some non-complaint objective elements as there is no standard operating protocol and centralized medical gas supply with safety precautions. • Continuous quality improvement chapter needs to be worked upon to the greatest extent as the quality program is yet to be documented, and data collection and analysis with regard to the structure process and outcome is still on the cards. • Human resource management though acquires, provides, retains and maintains competent staff needs to emphasize more on training and development of staff and needs to perform credentialing and privileging before authorizing personnel with a job responsibility • The hospital fares best with regard to the responsibilities of management chapter as the leaders encourage the governance and management of the organization in a professional and ethical manner.

Recommendations : The hospital being a part of the Dr. Virendra Laser Eye Hospital, Jaipur, has staffs that are well aware that a systematic protocol has to be practiced and are motivated enough to implement the changes and elevate the standard for delivery of healthcare. Accreditation is merely a step away as all the staff members are oriented to the recent advancement The need of the hour is to re-modulate the system and processes as per the guidelines, with the involvement of all staff members. In totality, the institution has a high potential for accreditation.