Abstract of Dissertation

Keyword : Gap Analysis; Kayakalp Program; Pre- Assessment Method

Objective : • To compare the standards given for each objective of KAYAKALP checklist and assess the existing service • To make an action plan for bridging the gap. • To see the impact of the intervention through the action plan

Background : Civil hospital Nawanshahr is a 200 bedded hospital. It is one of the hospitals which are focused on KAYAKALP program in the state of Punjab. Civil hospital Nawanshahr got the 1st prize in KAYAKALP program and won 50 lakhs rupees. A baseline assessment of the available facilities was carried out for each objective element of the KAYAKALP checklists and the gap analysis was done. Aim of the study was to first bring out the present situation and the gap areas, then on the basis of the findings, make an action plan to fulfill those gaps.

Methodology : Study type Descriptive cross-sectional study Data Collection Primary data: - KAYAKALP tool kit was used and assessment was done by direct observation. The scoring pattern was used 2 = full compliance, 1 = partial compliance, 0 = non-compliance Secondary data: - Hospital documents review, Clinical record review, Research articles.

Findings : Initially present situation and gaps were identified based on KAYAKALP checklist and the average score was calculated. On the basis of these findings, an action plan was developed for 3 months in order to fulfill those gaps. Then at the end of the 3 months again self-assessment was done to see the impact of investigation in terms of average score. Results of the above analysis suggested that initially, the percentage for the hospital came to be 73% and then after the implementation of the action plan it was observed that the score increased to 84% at the end of the 3 months.

Recommendations : Improvement in score was there but still works needs to be done to achieve full compliance. Suggestions have been given so that implementation can be done to achieve full compliance before pre-assessment.