Gap Analysis of General Hospital as per NABH Norms in a General Hospital, Gujarat
Agency : Gap Analysis, NABH Norms, NABH Accreditation, General Hospital
Objective : The gap analysis of the General
Hospital as per NABH
norms was done to assess
the existing status of the hospital and prepare
it for NABH accreditation. As Government of Gujarat is very keen on getting the NABH accreditation
for district hospitals and medical colleges,
so it becomes necessary for the hospital
to review its status on regular basis. The hospital can focus on the areas where the gaps are more
in importance or in number
and move ahead
for the achieving the accreditation status.
Background : Not Available
Methodology : The gap analysis
was done with the help of NABH Self
Toolkit which comprised of 10 chapters,
100 standards and
elements. For getting the required data the various activities in the hospital
were observed, policy manuals and records were referred and patients and
hospital staff were interviewed.
According to the toolkit the documentation and implementation of each
objective element was checked and scores were given according to NABH guidelines.
Findings : The study shows the findings of the existing status of the
hospital according to each chapter
and average scores
for all the standards and chapters.
These were checked against the evaluation
criteria for accreditation. The study focuses on the gaps according to the
evaluation criteria for accreditation and suggests ways to fulfill the gaps. The analysis shows that there are some gaps in the hospital
as per NABH norms.
Mainly the gaps were in the chapters
of management of medication, quality management and information management system. The hospital fulfills
the required criteria partially and requires
great efforts and focus
on the weak points so as to
cover the gaps and to be prepared for getting NABH accreditation.
Recommendations : Not Available
The gap analysis of the General Hospital as per NABH norms was done to assess the existing status of the hospital and prepare it for NABH accreditation