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Gap Analysis of General Hospital as per NABH Norms in a General Hospital, Gujarat


  • Namrata
  • 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 Assessment Toolkit which comprised of 10 chapters, 100 standards and 514 objective 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