Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital

Healthcare Management

Quality Management Systems and Accreditation are versatile tools to ensure equity in healthcare services and the meeting the increasing aspirations of people. Gap Analysis is a tool that helps an organization to compare its actual performance with expected/laid down standards. Gap analysis refers to a study where hospital compare the present policy, procedure, SOP’s, infrastructure with defined laid down standards of accreditation body, National Accreditation Board for Hospitals (NABH). It reveals the areas of improvement in the existing service system. The Gap analysis of the hospital studied (name not disclosed) was carried out for NABH re-accreditation. A medical record enables healthcare professionals to plan and evaluate a patient's treatment and ensures continuity of care among multiple providers. With this background the current study was carried out in order to maintain complete medical records at the hospital. A descriptive cross-sectional and prospective study was carried out and 206 patient files were studied for audit study. Data was collected through observation, semi-structured interviews, and with Audit tool with a structured checklist. Secondary data was collected from Files of the in-patients in various departments of the hospital and Computerized Patient Record System (CPRS) of the hospital. The observations of gap-analysis revealed that major non-compliance was due to lack of documented procedures and policies. The observations of audit study revealed that there was more than 90% compliance in pre-operative investigations, blood transfusion notes, venous thromboembolism (VTE) Assessment, while lesser compliance was observed in Referral consults, Pre-operative, Operative, Post-operative Notes, Face sheet, admission request, Doctor’s progress notes, Informed consent, Anaesthesia records etc. It was recommended that Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) training should be given to all the staff, Medication stock should be evaluated in every shift by the nursing team leader, Essential Posters like Material Safety Data Sheet (MSDS) should be placed at appropriate places, appropriate signage should be displayed, doctors need to be sensitized regarding complete filling of informed consents, Nursing needs to be trained for mandatory pain assessment, etc.

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