"Analysis the Gaps in Adopting Quality System as per the National Standard of

Accreditation on Territory Care Hospital with Reference to NABH Standards ."

BY

Dr. Arbind Rout

MA, MBA, Phd, D.litt

Professor
&

Dr. ANUPAMA PANDEY

MA, MBA, Phd

NIMS SCHOOL OF BUSINESS STUDIES

NIMS UNIVERSITY RAJASTHAN

JAIPUR APRIL 2024
CONTEXT

SR.NO PARTICULAR PAGE NO.

1. INTRODUCTION 3

2. LITERATURE REVIEW 5

3. FORMULATIVE RESEARCH PROBLEM 8

4. RESEARCH OBJECTIVE 9

5. RESEARCH METHODOLOGY 10

6. SCOPE OF RESEARCH 12

7. LIMITATIONS OF RESEARCH 13

8. REFERENCES 14
 INTRODUCTION

Quality Management Systems and Accreditation are versatile tools to ensure equity in
healthcare services and the meeting the increasing aspirations of people. Optimum/ideal state
of patient care can be achieved by the healthcare institution that focuses on compliance with
accreditation standards of NABH and like bodies. 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 & Healthcare Providers (NABH). NABH accreditation system was
established in 2006 as a constituent of Quality Council of India (QCI). The first edition of
standards was released in 2006 and after that the standards has been revised every 3 years.
Currently the 4th edition of NABH standards, released in December 2015 is in use. The NABH
accreditation is currently a voluntary scheme but the QCI plans to cover all the hospitals in
India, both, in the voluntary sector and the Government Hospitals. The advantage to the
hospital would be its national recognition as a Quality Care hospital. The Health Insurance
sector, various industries, and Companies, National and International Funding Agencies, etc.
will subsequently utilize only these NABH accredited hospitals for their health needs. Gap (or
“needs”) Analysis in the studied hospital was carried in 2019 for re-accreditation against 4th
Edition of NABH. Document reviews, physical observation of the departments and informal
interviews from the staff members were taken and various gaps were found. Gaps were
intimated to the concerned persons of the departments along with their dates of closure.
Various actions were taken to close the gaps with the help of findings and suggestions given by
the study.

Literature Review

Few studies have been carried out on gap analysis for NABH accreditation. Some of them,
which were referred in the study are mentioned below: A study entitled “Analysis of Health
Record Documentation Process as Per the National Standards of Accreditation with
special emphasis on Tertiary Care Hospital” . The aim of the study was to review the health
records and evaluate them to find the incongruity in the documentation of patient’s data by
doctors, nurses and other healthcare providers involved in the documentation process. The
study was conducted in NIMS Medical College & Hospital in Jaipur, Rajasthan. A total of
400 patients files reviewed and primary data collected by checking the patient files at
nursing stations, wards, and critical areas. A documentation review audit tool was then
prepared (as per objective elements mentioned by NABH) taking into consideration the
important aspects of documentation in the health records. The files were checked as per the
parameters mentioned in the audit tool. Possible suggestions and recommendations were
also reported. A study entitled Impact of Accreditation on the Quality of Healthcare
Services. The aim of this study was to evaluate the impact of accreditation programs on the
quality of healthcare services. The study concluded that there is consistent evidence that
shows that general accreditation programs improve the process of care provided by
healthcare services. A study on Gap Analysis of Major Operation Theatre Complex of a
Tertiary Cancer Centre against NABH Accreditation Standards was done by Sudha P,
Division of Anesthesiology, Regional Cancer Centre, Trivandrum, Kerala, the
observational study aimed to review the planning and functioning of the Major Operation
Theatre (MOT) complex of a Tertiary Cancer Centre committed to obtain National
Accreditation Board for Hospitals and Health care providers (NABH) accreditation. The
study concluded that the planning and functioning of MOT complex do not satisfy the
minimum essential standards required for NABH accreditation and needs remodeling.
After review of literature, it was concluded that for NABH accreditation, a self-assessment
for identifying gaps should be done. The current study focusses on NABH gap analysis for
a super specialty hospital.
FORMULATIVE RESEARCH PROBLEM

This research problem focuses on the specific link between identifiable shortcomings within
the QMS and the prevalence of incomplete medical records. By investigating this connection,
the dissertation can offer valuable insights for healthcare institutions:

1. Identifying Critical QMS Deficiencies: The study will delve deeper into the specific QMS
deficiencies identified during the gap analysis. This might include areas like:
Lack of clear and standardized documentation policies and procedures
Inadequate staff training on proper documentation practices
Inefficient workflows or cumbersome documentation processes
Limited access to necessary resources or technology for documentation
Poor communication and collaboration between departments
2. Understanding Impact on Documentation: The research will explore how these deficiencies
hinder the complete and accurate documentation of medical records. For instance, unclear
documentation policies might lead to confusion among staff regarding what information
needs to be recorded. Inadequate staff training could result in a lack of knowledge or skills
required for proper documentation. Inefficient workflows might create time constraints
that pressure staff to rush through documentation tasks, increasing the risk of errors or
omissions.
3. Developing Targeted Interventions: Based on the findings, the study will propose targeted
interventions to address the identified issues and improve medical record completion.
These interventions might include:
Revising documentation processes to streamline workflows and improve efficiency
Developing clear and standardized documentation policies and procedures
Implementing staff training programs on proper documentation practices
Providing staff with easy access to necessary resources and technology for
documentation
Fostering improved communication and collaboration between departments to ensure
consistent documentation practices.
4. Evaluating Intervention Effectiveness: The potential impact of these interventions on
improving medical record completion will be assessed. This might involve implementing the
interventions in a pilot program and measuring changes in documentation completeness
before and after the intervention.
RESEARCH OBJECTIVE

The study was carried keeping in mind following objectives:

1. To evaluate Hospital’s compliance to 3rd Edition NABH & Hospital Medical Quality Standards.

2. To assess the gaps in the compliance.

3. To suggest methods for the closure of the gaps.

RESEARCH METHODOLOGY
Type of Study: Non-experimental, cross-sectional, and observational (which is done in two
parts i.e. present status of the department and compliance against NABH standards). The
departments of hospital which were studied included:

Oncology Day-care Centre

Front Office & Out Patient Department (OPD)

Radiology Department

In-patient (IP) and Out-patient (OP) pharmacy

Emergency and ambulatory day care

Laboratory and sample collection

Nuclear medicine

Food & Beverage (F&B), Dietetics

Labor room, neonatal intensive care unit (NICU) and Nursery

Cardiac Catheterization Laboratory (Cath Lab) & Critical Care Unit (CCU)

Operation Theatre (OT)-1st Floor & OT 2nd Floor

Medical Intensive Care Unit (MICU)

Surgical Intensive Care Unit (SICU)

Biomedical Engineering Department including Civil & Electrical Services

Physiotherapy Department

Medical Records Department (MRD) & IT Department

Security

Mortuary

Blood Bank

House keeping

2nd Floor Ward

Study respondents: Duty Doctors, Nurses, customer care staff and staff of the
departments.

Sampling Technique: Random Sampling

Type of data – Both Quantitative & Qualitative data was collected.

Methods of data collection: Document Review, Physical Observation, Informal Interviews

– semi-structured interviews (Duty Doctors Nurses, customer care in-charge, and Staff of
the departments).

Instruments and Tools used: Checklists of NABH standards.

SCOPE OF RESEARCH

Assessing Current Compliance:

This involves a comprehensive evaluation of the hospital's existing policies, procedures,

infrastructure, and practices against the established standards. Methods like gap analysis,
medical record audits, and staff surveys will be used to identify areas where the hospital
meets or falls short of these standards.

Identifying Compliance Gaps:

By analyzing the findings from the evaluation, the research will pinpoint specific
deficiencies in the hospital's adherence to quality standards. This includes categorizing the
severity of these gaps and understanding their potential impact on patient care.

Developing Improvement Strategies:

Based on the identified gaps, the research will propose practical solutions to bridge the
divide and improve compliance. This will involve targeted interventions like staff training,
updated documentation procedures, and workflow improvements. Additionally, the
research will prioritize these recommendations and develop a concrete implementation
plan for enacting the proposed changes.
LIMITATIONS OF RESEARCH

Generalizability:

Single Hospital Focus: The research is limited to a single hospital. The findings may not be
generalizable to other hospitals due to variations in size, resources, patient population, and
existing quality management systems.

Specificity of Standards: The research focuses on the 3rd Edition NABH standards and
other relevant hospital medical quality standards. However, the specific details of these
"other standards" haven't been defined. This lack of specificity could limit the
generalizability of the findings to hospitals adhering to different quality standards
frameworks.

Data Collection Methods:

Gap Analysis: The effectiveness of a gap analysis depends on the comprehensiveness of the
chosen methodology and the expertise of the individuals conducting the analysis. Potential
biases in interpretation could exist.

Medical Record Audit: The sample size of medical records reviewed may not be large
enough to capture the full spectrum of documentation practices within the hospital.
Additionally, the accuracy of the audit depends on the chosen criteria and the reviewers'
interpretation of the standards.

Staff Surveys: Response rates and potential biases in staff perceptions could affect the
reliability of data collected from staff surveys.

Intervention Implementation:
Feasibility and Cost: The proposed interventions for improving compliance may not be
feasible for the hospital to implement due to resource constraints, time limitations, or staff
resistance to change.

Evaluation of Effectiveness: The research does not propose methods to evaluate the
effectiveness of the implemented interventions on improving medical record completion or
overall quality of care.

Time Frame: The research may be limited by the timeframe in which the gap analysis and
medical record audit were conducted. Standards and practices may have evolved since that
time.
 REFERENCES

[1]. Gyani Girdhar J., Thomas Alexander, Handbook of Healthcare Quality & Patient Safety, 2017, Jaypee
Publishers, New Delhi.

[2]. NABH Standards for hospitals, 4th Edition, December 2015 Guide Book to Accreditation Standards
to Hospitals, Quality Council of India, New Delhi.

[3]. Sakharkar, B.M., Principles Of Hospital Administration And Planning, 2017, Jaypee Publishers, New
Delhi.

[4]. C.M.Francis, Mario C de Souza Hospital Administration, Jaypee Brothers Medical Publishers (P)
Ltd., New Delhi. 2000 Edition.

[5]. Raza Arif, Accreditation of Healthcare Organizations, 2017, Jaypee Publishers, New Delhi.

[6]. Kothari, C.R., Garg Gaurav, Research Methodology: Methods and Techniques, New Age
International Publishers, 2017 Edition, New Delhi, India.

[7]. Ballabh Chandra, Health Care Service in Hopital, Alfa Publications, 2017 Reprint, New Delhi, India.

[8]. Yadav Krati Gap Analysis Of Multispecialty Hospital In Bahadurgarh As Per NABH Norms, IIHMR
University Dissertation Research Study. Journal Articles:

[9]. Singh P, John S. Analysis of health record documentation process as per the national standards of
accreditation with special emphasis on tertiary care hospital. Int J Health Sci Res. 2017; 7(6):286-292.,
http://www.ijhsr.org/IJHSR_Vol.7_Issue.6_June2017/43.pdf

[10]. Sudha P. Gap Analysis of Major Operation Theatre Complex of a Tertiary Cancer Centre against
NABH Accreditation Standards. Kerala Medical Journal. 2015 Aug 31;8(3):9–14.,
http://journals.publishmed.com/index.php/KMJ/article/view/123/419

[11]. Alkhenizan A, Shaw C. Impact of accreditation on the quality of healthcare services: a systematic
review of the literature. Ann Saudi Med. 2011 Aug;31(4):407–16.