 Krati Yadav

 Agency : Gap Analysis, NABH, Structure, Process and Outcome Gaps

 Objective : 1. To assess the existing service delivery status of the hospital as per NABH
guidelines.
2. To identify the gap, if any, as per NABH guidelines.
3. To suggest viable recommendations for bridging the gaps in departments based on
customized requirements for the hospital.
4. To help the hospital management to take appropriate managerial decision to improve the
quality of their services

 Background : Gap analysis is the initial step in the review of the available service delivery
system. It is an efficient base to implement a modern management system. It can be
measured against pre set standards. It reveals the areas of improvement in the existing
service system. It focuses on the components of the management services and how effective
they are

 Methodology : The study is non- experimental, descriptive and observational which is done
in two parts i.e. present status of the department and compliance against NABH standards.
All available services were compared against the set standards and scoring was done on a
scale of 1 to 10 using NABH toolkit. Primary data was collected through unstructured
interviews in which convenient sampling was done and observation was also included.
Secondary data was collected from the records of various departments. Overall study was of
7 weeks which included the preparation of checklist, gap analysis, filling of toolkit, score
analysis and final conclusion.

 Findings : Hospital does not have infection control committee and strong HAI control
practices. They does not have SOP's for different departments and if any department is
having the SOP then they are not documented and implemented. Score analysis of NABH
toolkit shows that hospital is at NABH accreditation entry level that too not completely.

 Recommendations : /Conclusion: The analysis shows that there are some gaps in the
hospital as per NABH norms. Documentation and implementation is required. As the hospital
wishes for NABH accreditation so it must be prepared according to the evaluation criteria for
assessment. There are different stages of accreditation which needs to be fulfilled by the
organization. As of now the hospital fulfills the criteria for entry level according to which no
standard must have more than two zero and the average score of individual standard must
not less than 5 and the average score for individual chapter must be more than 5.