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Gap Analysis of District Hospital in Conformance to NABH Standards


  • Priyanka Vashishta
  • Agency : Gap Analysis, District Hospital, NABH Standards
  • Objective : The objectives of the present study were to study the different procedures at District Hospital for assurance and conformance with the standards as laid by NABH and to identify the gap between the NABH laid down practices and prevalent practices at hospital.
  • Background : A gap analysis report is necessarily a document, which evolves as per circumstantial requirements of the client organization and to know scope of activities required to meet standards to achieve project goal i.e. National Accreditation Board of Hospital and health care (NABH) accreditation status. The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health.
  • Methodology : Sources of data were both primary data (personal interviews, observations.) and secondary data.(literatures, reports, registers and records.)
  • Findings : The findings of the study shows that out of the total 514 objective elements,307 ( 60%) are in non compliance,149 (29%) are in partial compliance and 58 (11%) are on compliance to N.A.B.H standards. Gap analysis is the initial and one of the most critical exercises of the entire process. It helps us to revisit existing system with an eye to finding facts not faults.
  • Recommendations : The analysis that has been conducted has divulged various quality related issues in clinical and non clinical departments. It will take a long time to close the existing non compliances. To close these non compliances the hospital has to bear a huge financial implication in terms of infrastructure, manpower equipments & other resources.
to study the different procedures at District Hospital for assurance and conformance with the standards as laid by NABH