Gap Assessment Reporting Format

H o s p i t a l & H e a l t h C a r e C o n s u l t a n t s
REPORT 1
August 2009
GAP ANALYSIS REPORT

FOR
NABH ACCREDITATION PROGRAMME
OF
CLIENT
PREPARED BY
Astron Hospital and Health Care Consultants Pvt. Ltd.

Quality and Accreditation Division
Publication, reproduction, photocopying, storage, or transmission

electronically or otherwise, of all or any part of these documents without the
prior written permission from Astron Hospital and Health Care Consultants
Pvt. Ltd. New Delhi, India is strictly prohibited. It is illegal to make copies of
all or any part of these documents (whether internally or externally) without
the prior written permission of the copyright holder. For permission regarding
the use of all or any part of the documents, contact Astron Hospital and
Health Care Consultants Pvt. Ltd. New Delhi 91-11-42148131/32
Astron Hospital and Health Care
Gap Analysis Report
Consultants Pvt. Ltd., New Delhi
Soni Hospital
FOREWORD
Quality management system and the Accreditation process in

compliance with standards, is a tool for quality assurance and quality
improvement for hospitals that in turn help ensure quality healthcare
services, standardized output, and aim for the best outcome possible.
Spin offs of the system include economy, effectiveness, leadership
amongst peer institution, confidence of the citizens in the
establishment, and a culture of teamwork with a focus on service
quality.
The Quality Council of India is an autonomous body under the

Government of India, which has the National Accreditation Board for
Hospitals and Health Care Providers (NABH) amongst several other
boards under its fold. The NABH standards place emphasis on patient,
staff, visitor and environment safety, infection control, and quality of
care. The standards are deceptively simple, however whilst
implementing them extra effort and resources will be required.
Compliance will more than compensate with the benefits that accrue,
but it shall be remembered, that ‘Quality’, like success, is a
pathway, and not a destination.
With that Astron Hospital and Health Care Consultants Pvt. Ltd. wish
the all the very best in their voyage towards implementing the quality
management system and accreditation of public hospitals with the
NABH.
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ACKNOWLEDGEMENT
Our heartfelt thanks to ………………………………….and the Governing

Board members enabling us to carry out National accreditation Board
for Hospitals & Healthcare Providers accreditation activity at their
hospital. We feel privileged to be associated with this organization of
repute and being a part of the quality movement initiative taken up by
its authorities
We are highly thankful to,…………………………………………… for

providing us a platform to initiate the accreditation activity and
complete the first step that of gap assessment study in
We are profoundly grateful to,……………………………………………………

who has been very supportive right from beginning. We are sure, that
with able leadership of, the objective of achieving quality standards of
the level of accreditation norms will not be a distant dream.
We would like to thank, …………………………………………Medical Supdt,

who has been extremely cooperative and helped us in getting the gap
assessment completed. His readiness for taking up the core
responsibility of coordinating and providing us with all necessary
arrangement required to complete the activity of Gap Assessment.
Our sincere thanks to Nursing Superintendent, and all HODs, in-

charges and staff of the hospital, who took out time from their very
busy schedule, to interact with us and provide us with the information
required for this study. Needless to say that this activity would not
have been completed without their selfless contribution.
Lastly, we would like to thank all those whose names are not
mentioned here but their contribution to this study could not be
undermined.
Astron Hospital and Health Care Consultants Pvt. Ltd.
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TABLE OF CONTENTS
Section Topic Page Number

No
Foreword 1
Acknowledgement 2
Table of Contents 3
1. Introduction 4
2. Organization of report 5
3. Hospital Profile 7-13
4. Physical structure requirement 14 - 23
5. Gap assessment as per NABH 24 -127
standards
6. Summary table of scores 128
7. Result of NABH gap assessment 129
Annexure
Annexure Signage & Displays 130-131
‘A’
Annexure Physical Safety Requirements 132-133
‘B’
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SECTION 1. INTRODUCTION
1. …………………………….is one of the finest medical institutions in
North India. The hospital is governed by
……………………………………………………
2. The philosophy with which the hospital has been incepted is
provision of medical care to the needy.
3. ……………….has taken up the initiative to standardize the patient
care and its management system and initiate an activity of
continual quality improvement
4. With this thought has chosen ……………………..NABH accreditation
norms as a reference to improve and standardize the health care
delivery in the hospital
5. Astron Hospital and Health Care Consultants Pvt. Ltd. is a
consultancy firm providing consultancy to all spheres of hospital
planning and management. Quality and accreditation division of
the consultancy is well known to provide consultancy services to
hospitals, wanting to implement quality management and
accreditation systems
6. Astron has been taken up by …………………….as consultant to
provide the consultancy services in planning and helping the
hospital’s team in achieving NABH accreditation
7. As a first step of this project, detailed gap analysis has been
carried out to identify the existing status of infrastructure and
processes vis-à-vis NABH standards requirement
8. This report is the deliverable of gap assessment study carried out
at ……………………by Astron Hospital and Health Care Consultant,
with the help of hospital’s authorities and staff
9. The report details the subjective and objective evaluation and
findings of infrastructure and NABH standards related
requirements
10. All findings and suggestions presented in this report is on
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the basis of primary visit made by Astron Consultants and data

and information provided by the hospital
11. It is to be noted that since evaluation of NABH standards
implementation in a hospital is partly subjective, difference in
score calculated for NABH compliance may vary, in case similar
study is carried out by different consultant / assessor. The analysis
has been done on the basis of standardized checkpoints and our
previous experience with other hospital’s assessment. With this
limitation, it is suggested that the score shall be used only to
make a mental picture of compliance level, while focusing on all
systems and standards required for NABH accreditation
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SECTION 2. ORGANISATION OF REPORT
• This report is intended to identify those structural requirements of quality

management and accreditation, which are cost intensive and takes long
lead-time for addressing. Other than this a detailed gap assessment with
respect to every standards and objective elements of NABH – 2nd edition
has also been carried out and presented in this report. The report has been
prepared and submitted with the objective of taking an early action on
these gaps, so that they can be addressed within time before the hospital
applies for the accreditation pre-assessment.
• Following categories of gaps and requirements have been specified in this
report
o Physical structure requirements
o Gap assessment as per NABH standards
• The report is organized in sections for specifying the aspects. Subsections
are provided within sections, wherever required. A brief profile of the
hospital is also provided in to understand the status.
• Annexure are provided at the end of the report on those aspects that
requires detailing and description. A reference has been made in the main
text wherever it has an annexure to be referred.
• The findings and requirements specified in this report have been prioritized
as per their importance and criticality, so that hospital can plan the action
as per the resource availability and practicality aspects.
• It is emphasized that these requirements are important and should be
actioned upon as early as possible, so that the same can be fulfilled
within the project time. Also many of the process related aspects required
for accreditation are dependent on fulfillment of infrastructural gaps. Thus,
delay in action on fulfilling these requirements will affect the
implementation of processes and in turn will delay the entire
project time.
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• It is suggested that hospital authorities read the report carefully and

develop a plan of action to fulfill these requirements.
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SECTION 3. HOSPITAL PROFILE
S. No. Particulars Details

1
.
Name of Hospital
2
.
Ownership Type
3
.
Address
a. for
Communi
cation
b. for
locating
Hospital
2
.
Contact person:
(for correspondence
and liaison)
3
.
Contact numbers:
(land line with area
code and mobile)
4
.
E-mail
5
.
Date of
establishment of
hospital
6
.
Vision statement
7
.
Mission statement:
8
.
Any Quality
certification or
Accreditation
received by the
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facility in past
11. Clinical services offered by the hospital Specialty(s):
Specialties Number of specialist Number of specialist

(full time) (visiting / honorary)
Anesthesia
Cardiology
Cardiothoracic
Surgery
Dentistry
Dermatology
ENT
Gastroenterology
General Medicine
GI Surgery
General surgery
Nephrology
Neurology
Neurosurgery
O&G
Ophthalmology
Orthopedic
Outreach Services
Pediatrics
Pediatric Surgery
Pathology
Physiotherapy
Plastic surgery
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Psychiatry
Radio diagnosis
Rehab
Urology
Number of Non
Specialist doctors
FACILITY DETAILS
S. Particulars Details
No.
1. Plot area
2. Total built-up area
3. Number of buildings
4. Number of floors
5. Number of Lifts
6. Number of ramps
BED DISTRIBUTION
1. Total number of complement beds (beds on which patients are
kept overnight):
2. Total number of non-compliment beds:
S. Categories of beds Number of Number of
No. beds per room rooms
1. New Deluxe
2. Super Deluxe
3. Semi Deluxe
4. Male Private + NSR + SSR
5. Female Private
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6 General Medical Ward

7 Urology Ward
8 Pediatric Ward
9 Gynae/ Maternity Ward
10 Transit Ward
11 Orthopedic Ward
12 Neuro Sciences Ward
13 Nephrology
14 Convalescent – I
15 Convalescent – II
16 Ophthalmology
17 Day Care
18 Casualty
19 Neonatal
20 Semi Pvt.
21 Pre Operative
INTENSIVE CARE BEDS
S. Designation of ICU Number of beds Number of

No. per room rooms
1. Medical Intensive Care Unit
2. Surgical Cardiac Care Unit
3. Medical Cardiac Care Unit
4. Step down Intensive Care
Unit
5. Paediatric Intensive Care Unit
6. Surgical Intensive Care Unit
7. Neuro Intensive Care Unit
8. Pre-mature Care Unit /
9. Intensive Pre-mature Unit
10
11
12
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OPERATING SUITES
S. Designation of Operation theatre Number

No. (Major and Minor) and Endoscopy
suites
1. Terrace Operation Theatre
2. New Operation Theatre
3. Old Operation Theatre
4. Endoscopy Room
5. Cath Lab
6. Dialysis
7. Labour Room
8. Transfusion Ward
9. Emergency
10. Incomplete
11.
12.
HOSPITAL HUMAN RESOURCE
Staffing pattern
Staff category On hospital pay Contractual

roll
Nursing Staff (category

wise)
Nursing Superintendent
Deputy Nursing
Superintendent
Asst. Nursing Superintendent
Sister Incharges
Acting Sister Incharges
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Staff Nurses
Nursing Aid
Technical Staff (category

wise)
Lab Technicians
OT Technicians
X-Ray Technicians
Perfusionist
Endoscopy
ECG Technicians
EEG Technicians
Technician (Nephrology)
Medical administration
(category wise)
Senior Administrative Staff
Honorary Consultants
Resident
General administration
(category wise)
Senior Administrative staff
Maintenance
Ministerial
Housekeeping and
security staff (category
wise)
Ward Boy
Ward Lady
Sweepers
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Tech. Aid
Class IV (Contract)
Security (Contract)
DETAILS OF DIAGNOSTIC SERVICES
S. Diagnostic services
No.
Laboratory Medicine (Please list scope of services)
Bio-Chemistry
Pathology
Hematology
Micro-Biology & Serology
Histopathology
Cytopathology
Imaging Sciences (Please list scope of services)

C-T
X-Ray
Ultra Sound
Special Diagnostics
EEG
Colour Doppler
ECG
Eco
TMT
Audiometery
SUPPORT SERVICES
S. Service category Available / Not available
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No.
1. Pharmacy
2. Blood Bank
3. Medical Record Department
4. CSSD
5. Piped medical gas system
6. Dietetics
Others
HIS & PACS
S. Administrative
No. departments (please list)
1. Accounts/ Finance (including IP
billing)
2. HRD
3. Maintenance
4. Stores & Purchases
5. IT
6. PRO
7. OPD, Reception & Enquiries
8. Medical Records
S. Outsourced services (please

No. list)
1. Security
2. Housekeeping
3. Kitchen
4. Laundry
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WORK LOAD DETAILS (of the current quarter)

S. Particulars Details
No.
IPD indices
1. Bed occupancy rate
2. Average length of stay
3. Average daily surgeries (major)
4. Average daily surgeries (minor)
5. Average daily deliveries
6. Average daily admissions
7. Average daily discharges
OPD indices
8. Average daily OPD attendance
9. Average daily new patients
registration
10. Average daily follow up patients
11. Average daily day care patients
Emergency indices
12 Average daily emergency attendance
.
13. Average monthly emergency surgeries
Diagnostics
14 Average number of Laboratory tests
.
per day
15. Average number of Radiological tests
per day
Please provide following documents along with this profile (if convenient)
1. Architectural plan of the facility
2. List of Major equipments
3. Specialty / Department wise bed allocation (if applicable)
4. Last audited balance sheet
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SECTION 4. PHYSICAL STRUCTURE REQUIREMENTS
This section identifies the structural deficiencies which may come

across the quality management requirements as expected by NABH
standards. The findings are presented department wise and is
prioritized as per the necessity.
Other than these structural deficiencies there are certain facility
requirements that are necessary to demonstrate a safe and secured
hospital environment. This has been listed out in Annexure ‘B’
(V- Vital; E – Essential, D – Desirable; P - Priority
This classification is given for the hospital to prioritize their work and
plan the scope of improvement as per their resource availability and
necessity)
S. Department and observations Desirab Prior
No. ility ity
1. EMERGENCY WARD
1
.
1
.
1.
2.
1.
3.
1.
4.
1.
5.
1.
6.
1.
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No. ility ity
1.
8.
2. IMAGING DEPARTMENT
2
.
1
.
2.
2.
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
3. INPATIENT DEPARTMENT
3
.
1
.
3
.
1
.
1
.
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No. ility ity
3 Support Areas-.
. Clean Utility –
1 Dirty Utility -.
. Equipment Room –
3 Treatment Rooms –
. Isolation Rooms -.
3
.
1
.
4
.
3
.
1
.
5
.
3 Resuscitation facility
.
1
.
6
.
3. Hand washing facilities
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No. ility ity
3 Electrical Backup -
.
2
.
1
.
3. PRIVATE WARDS
3.
3
.
3
.
1
.
4. INTENSIVE CARE UNIT

4 .
.
1
.
4. Zoning-
2.
4. The interbed distance

3.
4. The Nursing Station
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No. ility ity
4. The ventilation.
5.
5. DIALYSIS UNIT
5
.
1
.
5. Zoning-.
2.
5. The interbed distance

3.
5.
4.
5. The hand washing facilities

5.
6. CSSD
6.
1.
6.
2.
6.
3.
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No. ility ity
6.
4.
7. OPERATION THEATRES
7. •
1.
7.
2.
7.
3.
8. LABOR ROOMS
8. .
1.
9. LABORATORY
9.
1.
10. OPD
1
0.
1.
1
0.
2.
1
0.
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No. ility ity
1
0.
4.
1
0.
5.
11. LAUNDRY
1 •
1.
1.
12. MEDICAL RECORD DEPARTMENT

1 .
2.
1.
1 BIOMEDICAL WASTE MANAGEMENT

2.
2.
1
2.
3.
13. PIPED MEDICAL GAS SYSTEM

1
3.
1.
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No. ility ity
1
3.
2.
14. SIGNAGES AND DISPLAYS

1
4.
1.
15. FIRE FIGHTING SYSTEM

1
5.
1.
1
5.
2.
1
5.
3.
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SECTION 5: GAP ASSESSMENT AS PER NABH STANDARDS
Elements Observation Scores Recommendations

(0/ 5/
10)
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)
AAC.1: The organization defines and displays the services that it can provide.
a The services being

provided are clearly
defined and are in
consonance with the
needs of the
community.
b The defined services
are prominently
display.
c The staff is oriented to
these services.
Average Score
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AAC.2: The organization has a well-defined registration and admission process.
a. Standardized policies
and procedures are
used for registering and
admitting patients
b. The policies and
procedures address
out- patients, in-
patients and
emergency patients
c. Patients are accepted

only if the organization
can provide the
required service
d. The policies and
procedures also
address managing
patients during non
availability of beds.
e. The staff is aware of
these processes
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a. Policies guide the

transfer of unstable
patients to another
facility in an
appropriate manner.
b. Policies guide the
transfer of stable
patients to another
facility
c. Procedures identify
staff responsible
during transfer
d. The organization
gives a summary of
patient’s condition and
the treatment given
Average Score
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AAC.4 During admission the patient and/ or family members are educated to make
informed decision.
a. The patients and/ or
family members are
explained about the
proposed care.
b. The patients and/ or
family members are
explained about the
expected results.
c. The patients and/ or
family members are
explained about the
possible complications.
d. The patients and/ or
family members are
explained about the
expected costs.
Average Score
AAC.5 Patients cared for by the organization undergo an established initial assessment.
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a. The organization
defines the content of
the assessments for the
out patients, in patients
and emergency
patients.
b. The organization
determines who can
perform the
assessments.
c. The organization
defines the time frame
within which the initial
assessment is
completed.
d. The initial assessment
for in-patients is
documented within 24
hours or earlier as per
the patient's condition
or hospital policy.
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e. Initial assessment
includes screening for
nutritional needs.
f. The initial assessment
results in a documented
plan of care which is
monitored.
g. The plan of care also
includes preventive
aspects of care.
a. All patients are

reassessed at
appropriate intervals.
b. Staff involved in direct
clinical care document
reassessments.
c. Patients are reassessed
to determine their
response to treatment
and to plan further
treatment or discharge
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Average Score
AAC.7 Laboratory services are provided as per the
requirements of the patients.
a. Scope of the
laboratory services are
commensurate to the
services provided by
organization
b. Adequately qualified
and trained personnel
perform and/or
supervise the
investigations.
c. Policies and
procedures guide
collection,
identification,
handling, safe
transportation,
processing and
disposal of specimens.
d. Laboratory results are
available within a
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defined time frame.
e. Critical results are

intimated immediately
to the concerned
personnel.
f. Laboratory tests not
available in the
organization are
outsourced to
organization(s) based
on their quality
assurance system.
Average Score
AAC.8 There is an established laboratory quality assurance programme.
a. The laboratory quality

assurance programme
is documented.
b. The programme
addresses verification
and validation of test
methods
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c. The programme
addresses surveillance
of test results
d. The programme
includes periodic
calibration and
maintenance of all
equipments.
e. The programme
includes the
documentation of
corrective and
preventive actions
Average Score
AAC.9 There is an established laboratory safety programme.
a. The laboratory safety

programme is
documented.
b. This programme is
integrated with the
organization's safety
programme.
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c. Written policies and

procedures guide the
handling and disposal
of infectious and
hazardous materials.
d. Laboratory personnel
are appropriately
trained in safe
practices.
e. Laboratory personnel
are provided with
appropriate safety
equipment/ devices.
Average Score
AAC.10 Imaging services are provided as per the requirement
of the patients.
a. Imaging services
comply with the legal
and other requirement.
b. Scope of the imaging
services are
commensurate to the
services provided by
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the organization.
c. Adequately qualified
and trained personnel
perform, supervise and
interpret the
investigations.
d. Policies and procedures
guide identification and
safe transportation of
patients to imaging
services.
e. Imaging results are
available within a
defined time frame.
f. Critical results are
intimated immediately
to the concerned
personnel.
g. Imaging tests not
available in the
organization are
outsourced to
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organization(s) based
on their quality
assurance system
Average Score
AAC.11 There is an established quality assurance programme
for imaging services.
a. The quality assurance
program for imaging
services is documented.
b. The programme
addresses verification
and validation of
imaging methods.
c. The programme
addresses surveillance
of imaging results.
d. The programme
includes periodic
calibration and
maintenance of all
equipments.
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e. The programme
includes the
documentation of
corrective and
preventive actions
Average Score
AAC.12 There is an established radiation safety programme.
a. The radiation safety
programme is
documented.
b. This programme is
integrated with the
organization’s safety
programme
c. Written policies and
procedures guide the
handling and disposal
of radio-active and
hazardous materials.
d. Imaging personnel are
provided with
appropriate radiation
safety devices
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e. Radiation safety
devices are periodically
tested and documented
f. Imaging personnel are
trained in radiation
safety measures
g. Imaging signage are
prominently displayed
in all appropriate
locations
h. Policies and procedures
guide the safe use of
radioactive isotopes for
imaging services.
Average Score
AAC.13 Patient care is continuous and multidisciplinary in
nature.
a. During all phases of
care, there is a
qualified individual
identified as
responsible for
patient’s care.
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b. Care of patients is
coordinated in all care
setting within the
organization.
c. Information about the
patient's care and
response to treatment
is shared among
medical, nursing and
other care providers.
d. Information is
exchanged and
documented during
each staffing shift,
between shifts, and
during transfers
between units/
departments.
e. The patient’s record(s)
is available to
authorized care
providers to facilitated
the exchange of
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information.
f. Policies and procedures

guide the referral of
patients to other
departments/
specialties.
Average Score
AAC.14 The organization has a documented discharge
process.
a. The patient’s discharge
process is planned in
consultation with the
patient and/or family
b. Policies and procedures
exist for coordination of
various departments
and agencies involved
in the discharge
process (including
medico-legal cases)
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c. Policies and procedures

are in place for patients
leaving against medical
advice
d. A discharge summary is
given to all the patients
leaving the organization
(including patients
leaving against medical
advice)
Average Score
AAC.15 Organization define the content of the discharge
summary.
a. Discharge summary is
provided to the patients
at the time of
discharge.
b. Discharge summary
contains the reasons for
admission, significant
findings and diagnosis
and the patient’s
condition at the time of
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discharge.
c. Discharge summary
contains information
regarding investigation
results, any procedure
performed, medication
and other treatment
given.
d. Discharge summary
contains follow up
advice, medication and
other instructions in an
understandable
manner.
e. Discharge summary
incorporates
instructions about when
and how to obtain
urgent care.
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f. In case of death the

summary of the case
also includes the cause
of death.
Average Score
Total Score
Chapter 2: CARE OF PATIENTS (COP)
COP.1: Uniform care of patients is provided in all settings of
the organization and is guided by the applicable laws,
regulations and guidelines.
a Care delivery is uniform
when similar care is
provided in more than
one setting
b Uniform care is guided
by policies and
procedures which
reflect applicable laws
and regulations.
c The care and treatment
orders are signed,
named, timed and
dated by the concerned
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doctor.
d The care plan is

countersigned by the
clinician in-charge of
the patient within 24
hours.
e Evidence based
medicine and clinical
practice guidelines are
adopted to guide
patient care whenever
possible.
Average Score
COP.2: Emergency services are guided by policies, procedures
and applicable laws and regulations.
a Policies and procedure

for emergency care are
documented.
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b Policies also address

handling of medico-
legal cases
c The patient receives
care in consonance with
the policies.
d Policies and procedures

guide the triage of
patients for initiation of
appropriate care.
e Staff is familiar with the
policies and trained on
the procedures for care
of emergency patients.
f Admission or discharge
to home or transfer to
another organization is
also documented.
Average Score
COP.3: The ambulance services are commensurate with the scope of the services provided
by the organizations.
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a There is adequate
access and space for
the ambulance(s).
b Ambulance(s) is
appropriately equipped.
c Ambulance(s) is
manned by the trained
personnel
d There is a checklist of
all medical equipment
and emergency
medications.
e Equipment are checked
on a daily basis.
f Emergency medications
are checked daily and
prior to dispatch.
g The ambulance(s) has a
proper communication
system.
Average Score
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COP.4: Policies and procedures guide the care of patients

requiring cardio-pulmonary resuscitations.
a Documented policies
and procedures guide
the uniform use of
resuscitation
throughout the
organization.
b Staff providing direct
patient care is trained
and periodically update
in cardio pulmonary
resuscitations.
c The events during a
cardio pulmonary
resuscitation are
recorded.
d A post-event analysis of
all cardiac asserts is
done by a
multidisciplinary
committee.
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e Corrective and
preventive measures
are taken based on the
post-event analysis.
Average Score
COP.5: Policies and procedures define rational use of blood
and blood products.
and procedures are
used to guide rational
use of blood and blood
products
b The transfusion
services are governed
by the applicable laws
and regulations.
c Informed consent is
obtained for donation
and transfusion of
blood and blood
products
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d Informed consent also

includes patient and
family education about
donation.
e Staff is trained to
implement the policies.
f Transfusion reactions
are analyzed for
preventive and
corrective actions.
a The organization has

documented admission
and discharge criteria
for its intensive care
and high dependency
units.
b Staff is trained to apply
these criteria
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c Adequate staff and

equipment are
available
d Defined procedures for
situation of bed
shortages are followed.
e Infection control
practices are followed
f A quality assurance
programme is
implemented
Average Score
COP.7: Policies and procedures guide the care of vulnerable patients (elderly, physically
and/ or mentally challenged and children).
a Policies and procedures

are documented and
are in accordance with
the prevailing laws and
the national and
international guidelines.
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b Care is organized and

delivered in accordance
with the policies and
procedures.
c The organization
provides for a safe and
secure environment for
this vulnerable group.
d A documented
procedure exists for
obtaining informed
consent from the
appropriate legal
representative.
e Staff is trained to care
for this vulnerable
group.
Average Score
COP.8: Policies and procedures guide the care of high-risk
obstetrical patients.
a The organization
defines and displays
whether high-risk
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obstetric care can be

cared for or not.
b Persons caring for high-

risk obstetric cases are
competent
c High-risk obstetric
patient’s assessment
also includes maternal
nutrition.
d The organization caring
for high risk obstetric
cases has the facilities
to take care of
neonates of such cases.
Average Score
COP.9: Policies and procedures guide the care of paediatric
patients.
a The organization
defines and displays
the scope of its
paediatric services
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b The policy for care of

neonatal patients is in
consonance with the
national/ international
guidelines
c Those who care for
children have age
specific competency
d Provisions are made for
special care of children.
e Patient assessment
includes detailed
nutritional, growth,
psychosocial and
immunization
assessment.
f Policies and procedures
prevent child/ neonates
abduction and abuse.
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g The children’s family

members are educated
about nutrition,
immunizations and safe
parenting and this is
documented in the
medical record.
Average Score
undergoing moderate sedation.
a Competent and trained
persons perform
sedation.
b The person
administrating and
monitoring sedation is
different from the
person performing the
procedure.
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c Intra – procedure
monitoring includes at
a minimum the heart
rate, cardiac rhythm,
respiratory rate, blood
pressure, and oxygen
saturation, and level of
sedation.
d Patients are monitored
after sedation.
e Criteria are used to

determine
appropriateness of
discharge from the
recovery area.
f Equipment and
manpower are available
to rescue patients from
a deeper level of
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sedation than that

intended.
Average Score
COP.11: Policies and procedures guide the administration of
anesthesia.
a There is a documented
policy and procedure
for the administration
of anesthesia
b Pre anaesthesia
assessment is done for
all patients who
undergo anaesthesia
administration.
c The pre-anesthesia
assessment results in
formulation of an
anesthesia plan which
is documented
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d An immediate
preoperative
reevaluation is
documented
e Informed consent for
administration of
anesthesia is obtained
by the anesthetist
f During anesthesia
monitoring includes
regular and periodic
recording of heart rate,
cardiac rhythm,
respiratory rate, blood
pressure, oxygen
saturation, airway
security and patency
and level of anesthesia
g Each patient’s post-
anesthesia status is
monitored and
documented
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h A qualified individual
applies defined criteria
to transfer the patient
from the recovery area
i All adverse anesthesia

events are recorded
and monitored
Average Score
undergoing surgical procedures.
a The policies and
procedures are
documented
b Surgical patients have
preoperative
assessment and a
provisional diagnosis
documented prior to
surgery.
c An informed consent is
obtained by the
surgeon prior to the
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procedure.
d Documented policies
and procedure exist to
prevent adverse events
like wrong site, wrong
patients and wrong
surgery.
e Persons qualified by law
are permitted to
perform the procedures
that they are entitled to
perform.
f A brief operative note is
documented prior to
transfer out of patients
from recovery area.
g The operating surgeons
documents the post
operative plan of care
h A quality assurance
programme is followed
for the surgical services
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i The quality assurance

program includes
surveillance of the
operation theatre
environment
j The plan also includes
monitoring of surgical
site infection rates
the care of patients
under restraints
b These include both
physical and chemical
restraint measures
c These include
documentation of
reasons for restraints
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d These patients are

more frequently
monitored
e Staff receive training
and periodic updating
in control and restraint
techniques
Average Score
COP.14: Policies and procedures guide appropriate pain
management.
the management of
pain.
b The organization
respects and supports
the appropriate
assessment and
management of pain for
all patients
c Patient and family are
educated on various
pain management
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techniques
Average Score
COP.15: Policies and procedures guide appropriate
rehabilitative services.
the provision of
rehabilitative services
b These services are
commensurate with the
organizational
requirements
c Rehabilitative services
are provided by a
multidisciplinary team
Average Score
COP.16: Policies and procedures guide all research activities.
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all research activities in
compliance with
national and
international guidelines
b The organization has an
ethics committee to
oversee all research
activities
c The committee has the
powers to discontinue a
research trial when
risks outweigh the
potential benefits
d Patient’s informed
consent is obtained
before entering them in
research protocols
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e Patients are informed of

their right to withdraw
from the research at
any stage and also of
the consequences (if
any) of such
withdrawal
f Patients are assured
that their refusal to
participate or
withdrawal from
participation will not
compromise their
access to the
organization’s services
Average Score
COP.17: Policies and procedures guide nutritional therapy.
nutritional assessment
and reassessment
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b Patients receive food

according to their
clinical needs
c There is a written order
for the diet
d Nutritional therapy is
planned and provided
in a collaborative
manner
e When families provide
food, they are educated
about the patients diet
limitations
f Food is prepared,
handled, stored and
distributed in a safe
manner
Average Score
COP.18: Policies and procedures guide the end of life care.
the end of life care
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b These policies and

procedures are in
consonance with the
legal requirements
c These also address the
identification of the
unique needs of such
patient and family
d These also include
sensitively addressing
issues such as autopsy
and organ donation
e Staff is educated and
trained in end of life
care
Average Score
Total Score
Chapter 3: MANAGEMENT OF MEDICATION (MOM)
MOM.1: Policies and procedures guide the organization of
pharmacy services and usage of medication.
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policy and procedure
for pharmacy services
and medication usage
b These comply with the
applicable laws and
regulations
c A multidisciplinary
committee guides the
formulation and
implementation of
these policies and
procedures
Average Score
MOM.2: There is a hospital formulary.
a A list of medication
appropriate for the
patients and
organization’s
resources is developed
b The list is developed
collaboratively by the
multidisciplinary
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committee
c There is a defined
process for acquisition
of these medications
d There is a process to
obtain medications not
listed in the formulary
Average Score
MOM.3: Policies and procedures exist for storage of
medication.
and procedures exist
for storage of
medication
b Medications are stored
in a clean, well lit and
ventilated environment
c Sound inventory control
practices guide storage
of the medications
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d Medications are
protected from loss or
theft.
e Sound alike and look
alike medications are
stored separately
f There is a method to
obtain medication when
the pharmacy is closed
g Emergency medications
are available all the
time
h Emergency medications
are replenished in a
timely manner when
used
Average Score
MOM.4: Policies and procedures exist for prescription of
medications.
for prescription of
medications
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b The organization
determines who can
write orders
c Orders are written in a
uniform location in the
medical records
d Medication orders are
clear, legible, dated,
timed, named and
signed
e Policy on verbal orders
is documented and
implemented
f The organization
defines a list of high
risk medication
g High risk medication
orders are verified prior
to dispensing
Average Score
MOM.5: Policies and procedures guide the safe dispensing of medications.
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the safe dispensing of
medications
b The policies include a
procedure for
medication recall
c Expiry dates are
checked prior to
dispensing
d Labeling requirements
are documented and
implemented by the
organization
Average Score
MOM.6: There are defined procedures for medication
administration.
a Medications are
administered by those
who are permitted by
law to do so
b Prepared medication
are labeled prior to
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preparation of a second
drug
c Patient is identified
prior to administration
d Medication is verified
from the order prior to
administration
e Dosage is verified from
the order prior to
administration
f Route is verified from
the order prior to
administration
g Timing is verified from
the order prior to
administration
h Medication
administration is
documented
i Polices and procedures
govern patient’s self
administration of
medications
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j Polices and procedures

govern patient’s
medications brought
from outside the
organization.
Average Score
MOM.7: Patients and family members are educated about safe medication and food-drug
interactions.
a Patient and family are
educated about safe
and effective use of
medication
b Patient and family are
educated about food-
drug interactions
Average Score
MOM.8: Patients are monitored after medication
administration.
a Patients are monitored
after medication
administration and this
is documented
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b Adverse drug events

are defined
c Adverse drug events

are reported within a
specified time frame
d Adverse drug events
are collected and
analyzed
e Policies are modified to
reduce adverse drug
events when
unacceptable trends
occur
Average Score
MOM.9: Policies and procedures guide the use of narcotic
drugs and psychotropic substances.
the use of narcotic
drugs and psychotropic
substances
b These policies are in
consonance with local
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and national
regulations
c A proper record is kept
of the usage,
administration and
disposal of these drugs
d These drugs are
handled by appropriate
personnel in
accordance with
policies
Average Score
MOM.10: Policies and procedures guide the usage of
chemotherapeutic agents.
the usage of
chemotherapeutic
agents
b Chemotherapy is
prescribed by those
who have the
knowledge to monitor
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and treat the adverse

effect of chemotherapy
c Chemotherapy is
prepared and
administered by
qualified personnel
d Chemotherapy drugs
are disposed off in
accordance with legal
requirements
Average Score
MOM.11: Policies and procedures govern usage of radioactive
drugs.
and procedures govern
usage of radioactive
drugs.
b These policies and
procedures are in
consonance with laws
and regulations
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c The policies and

procedures include the
safe storage,
preparation, handling,
distribution and
disposal of radioactive
drugs
d Staff, patients and
visitors are educated on
safety precautions
procurement and
usage of implantable
prosthesis
b Selection of
implantable prosthesis
is based on scientific
criteria and
national/internationally
recognized approvals
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c The batch and serial

number of the
implantable prosthesis
are recorded in the
patient’s medical
record and the master
logbook.
Average Score
MOM.13: Policies and procedures guide the use of medical
gases.
procurement, handling,
storage, distribution,
usage and
replenishment of
medical gases.
b The policies and
procedures address the
safety issues at all
levels
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c Appropriate records are

maintained in
accordance with the
policies, procedures
and legal requirements
Average Score
Total Score
Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)
PRE.1: The organization protects patient and family right

during care and informs them about their responsibilities.
a Patient and family

rights and
responsibilities are
documented.
b Patients and families
are informed of their
rights and
responsibilities in a
format and language
that they can
understand.
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c The organization’s
leaders protect
patient's and family
rights.
d Staff is aware of their
responsibility in
protecting patients and
family rights
e Violation of patient and
family rights is
recorded, reviewed and
corrective/ preventive
measures taken
Average Score
PRE.2: Patient and family rights support individual beliefs,
values and involve the patient and family in decision-making
processes.
a Patient and family
rights address any
special preferences,
spiritual and cultural
needs.
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b Patient and family

rights include respect
for personal dignity and
privacy during
examination,
procedures and
treatment.
c Patient and family
rights include
protection from
physical abuse and
neglect.
d Patient and family
rights include treating
patient information as
confidential.
e Patient and family
rights include refusal of
treatment.
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f Patient and family

rights include informed
consent before
anaesthesia, blood and
blood product
transfusions and any
invasive/ high-risk
procedures/ treatment.
g Patient and family right
include information and
consent before any
research protocol is
initiated.
h Patient and family
rights include
information on how to
voice a complaint.
i Patient and family
rights include
information on the
expected cost of the
treatment.
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j Patient and family has

a right to have an
access to his/ her
clinical records.
Average Score
PRE.3: A Documented process for obtaining patient and / or
families consent exists for informed decision making about
their care.
a General consent for
treatment is obtained
when the patient
enters the
organization.
b Patient and / or his
family members are
informed of the scope
of such general
consent.
c The organization has
listed those situations
where informed
consent is required.
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d Informed consent
includes information on
risks , benefits,
alternatives and as to
who will perform the
requisite procedure in
a language that they
can understand.
e The policy describes
who can give consent
when patient is
incapable of
independent decision-
making.
Average Score
PRE.4: Patient and families have a right to information and
education about their health care needs.
a When appropriate,
patient and families
and are educated
about the safe and
effective use of
medication and the
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potential side effects of

the medication.
b Patient and families are

educated about diet
and nutrition.
c Patient and families are

educated about
immunizations.
d Patient and families are
educated about their
specific disease
process, complications
and prevention
strategies.
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e Patient and families are

educated about
preventing infections.
f Patients and family are
taught in a language
and format that they
can understand.
Average Score
PRE.5: Patient and families have a right to information on
expected costs.
a There is uniform pricing
policy in a given setting
(out-patient and ward
category)
b The tariff list is
available to patients.
c Patients and family are

educated about the
estimated cost of
treatment.
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d Patients and family are

educated about the
financial implications
when there is a change
in the patient condition
or treatment setting.
Average Score
Total Score
Chapter 5: HOSPITAL INFECTION CONTROL (HIC)
HIC.1: The organization has a well-designed, comprehensive
and coordinated infection control programme aimed at
reducing/ eliminating risks to patients, visitors and providers
of care.
a The hospital infection
control programme is
documented which
aims at preventing and
reducing risk of
nosocomial infections.
b The hospital has a
multi-disciplinary
infection control
committee.
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c The hospital has an

infection control team.
d The hospital has
designated and
qualified infection
control nurse(s) for this
activity.
Average Score
HIC.2: The organization has an infection control manual, which
is periodically updated.
a The manual identifies
the various high-risk
areas & procedures.
b It outlines methods of
surveillance in the
identified high-risk
areas.
c It focuses on
adherence to standard
precautions at all times
d Equipment cleaning
and sterilisation
practices are included.
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e An appropriate
antibiotic policy is
established and
implemented
f Laundry and linen
management
processes are also
included.
g Kitchen sanitation and
food handling issues
are included in the
manual
h Engineering controls to
prevent infections are
included
i Mortuary practices and
procedures are
included as appropriate
to the organization.
j The organization
defines the periodicity
of updating the
infection control
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manual
Average Score
HIC.3: The infection control team is responsible for
surveillance activities in identified areas of the hospital.
a Surveillance activities
are appropriately
directed towards the
identified high-risk
areas
b Collection of
surveillance data is an
ongoing process
c Verification of data is
done on regular basis
by the infection control
team
d In cases of notifiable
diseases, information
(in relevant format) is
sent to appropriate
authorities.
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e Scope of surveillance
activities incorporates
tracking and analyzing
of infection risks, rates
and trends.
f Surveillance activities
include monitoring the
effectiveness of
housekeeping services.
a The organization
monitors urinary tract
infections.
b The organization
monitors respiratory
tract infections.
c The organization
monitors intra-vascular
device infections
d The organization
monitors surgical site
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infections.
e Appropriate feedback
regarding HAI rates are
provided on a regular
basis to medical and
nursing staff.
Average Score
HIC.5: Proper facilities and adequate resources are provided
to support the infection control programme.
a Hand washing facilities

in all patient care areas
are accessible to health
care providers.
b Compliance with proper
hand washing is
monitored regularly.
c Isolation/ barrier
nursing facilities are
available.
d Adequate gloves,
masks, soaps, and
disinfectants are
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available and used

correctly.
Average Score
HIC.6: The organization takes appropriate actions to control
outbreaks of infections.
a Hospital has a
documented procedure
for handling such
outbreaks.
b This procedure is
implemented during
outbreaks.
c After the outbreak is
over appropriate
corrective actions are
taken to prevent
recurrence.
Average Score
HIC.7: There are documented procedures for sterilization
activities in the organization.
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a There is adequate
space available for
sterilization activities
b Regular validation tests
for sterilization are
carried out and
documented
c There is an established
recall procedure when
breakdown in the
sterilization system is
identified.
Average Score
HIC.8: Statutory provisions with regard to Bio-medical Waste
(BMW) management are complied with
a The hospital is
authorized by
prescribed authority for
the management and
handling of Bio-medical
Waste.
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b Proper segregation and

collection of Bio-
medical Waste from all
patient care areas of
the hospital is
implemented and
monitored
c The organization
ensures that Bio-
medical Waste is
stored and transported
to the site of treatment
and disposal in proper
covered vehicles within
stipulated time limits in
a secure manner.
d Bio-medical Waste
treatment facility is
managed as per
statutory provisions (if
in-house) or outsourced
to authorized
contractor(s).
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e Requisite fees,
documents and reports
are submitted to
competent authorities
on stipulated dates.
f Appropriate personal
protective measures
are used by all
categories of staff
handling Bio-medical
Waste.
Average Score
HIC.9: The infection control programme is supported by the organization's management
and includes training of staff and employee health.
a Hospital management
makes available
resources required for
the infection control
programme.
b The hospital regularly
earmarks adequate
funds from its annual
budget in this regard.
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c It conducts regular pre-

induction training for
appropriate categories
of staff before joining
concerned
department(s).
d It also conducts regular
“in-service” training
sessions for all
concerned categories
of staff at least once in
a year.
e Appropriate pre and
post exposure
prophylaxis is provided
to all concerned staff
members
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a The quality
improvement
programme is
developed,
implemented and
maintained by a multi-
disciplinary committee.
b The quality
improvement
programme is
documented.
c There is a designated
individual for
coordinating and
implementing the
quality improvement
programme
d The quality
improvement
programme is
comprehensive and
covers all the major
elements related to
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quality assurance and

risk management.
e The designated
programme is
communicated and
coordinated amongst
all the employees of
the organization
through proper training
mechanism.
f The quality
improvement
programme is reviewed
at predefined intervals
and opportunities for
improvement are
identified.
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g The quality
improvement
programme is a
continuous process and
updated at least once
in a year.
Average Score
CQI.2: The organization identifies key indicators to monitor the clinical structures,
processes and outcomes which are used as tools for continual improvement.
a Monitoring includes
appropriate patient
assessment.
b Monitoring includes
safety and quality
control programmes of
diagnostics services.
c Monitoring includes all
invasive procedures
d Monitoring includes
adverse drug events.
e Monitoring includes use
of anesthesia.
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f Monitoring includes use

of blood and blood
products.
g Monitoring includes
availability and content
of medical records.
h Monitoring includes
infection control
activities.
i Monitoring includes
clinical research.
j Monitoring includes
data collection to
support further
improvements
k Monitoring includes
data collection to
support evaluation of
these improvements
Average Score
CQI.3: The organization identifies key indicators to monitor
the managerial structures, processes and outcomes which are
used as tools for continual improvement..
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a Monitoring includes
procurement of
medication essential to
meet patient needs.
b Monitoring includes
reporting of activities
as required by laws
and regulations.
c Monitoring includes risk
management.
d Monitoring includes
utilisation of space,
manpower and
equipment.
e Monitoring includes
patient satisfaction
which also incorporates
waiting time for
services.
f Monitoring includes
employee satisfaction
g Monitoring includes
adverse events and
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near misses.
h Monitoring includes
data collection to
support further study
for improvements.
i Monitoring includes
data collection to
support evaluation of
the improvements
Average Score
CQI.4: The quality improvement programme is supported by
the management.
a Hospital Management
makes available
adequate resources
required for quality
improvement
programme.
b Hospital earmarks
adequate funds from
its annual budget in
this regard.
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c Appropriate statistical
and management tools
are applied whenever
required.
Average Score
CQI.5: There is an established system for audit of patient care
services.
a Medical and nursing
staff participates in this
system.
b The parameters to be
audited are defined by
the organization
c Patient and staff
anonymity is
maintained.
d All audits are
documented.
e Remedial measures are
implemented.
Average Score
CQI.6: Sentinel events are intensively analyzed.
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defined sentinel
events.
b The organization has
established processes
for intense analysis of
such events.
c Sentinel events are
intensively analyzed
when they occur
d Corrective and
preventive Actions are
taken based on the
findings of such
analysis.
Average Score
Total Score
Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)
ROM.1: The responsibilities of the management are defined.
a Those responsible for

governance lay down
the organization’s
mission statement
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b Those responsible for

governance lay down
the strategic and
operational plans
commensurate to the
organization’s mission
in consultation with the
various stake holders.
c Those responsible for
governance approve
budget and allocate the
resources required to
meet the organization’s
mission.
d Those responsible for
governance monitor
and measure the
performance of the
organization against
the stated mission
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e Those responsible for

governance establish
organogram.
f Those responsible for
governance appoint
the senior leaders in
the organization.
g Those responsible for
governance support
research activities and
quality improvement
plans.
h The organization
complies with the laid
down and applicable
legislations and
regulations
i Those responsible for
governance address
social responsibility
Average Score
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ROM.2: The services provided by each department are

documented.
a Each organizational
program, service, site
or department has
effective leadership
b Scope of services of
each department is
defined.
c Administrative policies
and procedures for
each department is
maintained.
d Departmental leaders
are involved in quality
improvement.
Average Score
ROM.3: The organization is managed by the leaders in an
ethical manner.
a The leaders make
public the mission
statement of the
organization
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b The leaders establish

ethical management
c The organization
discloses its ownership
d The organization
honestly portrays the
services which it can
and cannot provide
e The organization
honestly portrays its
affiliations and
accreditation
f The organization
accurately bills for it’s
services based upon a
standard billing tariff.
Average Score
ROM.4: A suitably qualified and experienced individual heads
the organization.
a The designated
individual has requisite
and appropriate
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administrative
qualifications
b The designated
individual has requisite
and appropriate
administrative
experience
Average Score
ROM.5: Leaders ensure that patient safety aspects and risk
management issues are an integral part of patient care and
hospital management.
an interdisciplinary
group assigned to
oversee the hospital
wide safety programme
b The scope of the
programme is defined
to include adverse
events ranging from
“no harm” to “sentinel
events”.
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c Management ensures
implementation of
systems for internal
and external reporting
of system and process
failures
d Management provides
resources for proactive
risk assessment and
risk reduction
activities.
Average Score
Total Score
Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)
FMS.1: The organization is aware of and complies with the relevant rules and regulations,
laws and byelaws and requisite facility inspection requirements.
a The management is
conversant with the
laws and regulations
and knows their
applicability to the
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organization
b Management regularly
updates any
amendments in the
prevailing laws of the
land.
c The management
ensures
implementation of
these requirements.
d There is a mechanism
to regularly update
licenses/
registrations/certificatio
ns.
Average Score
FMS.2: The organization’s environment and facilities operate to ensure safety of patients,
their families, staff and visitors.
operational and
maintenance
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(preventive and
breakdown) plan.
b Up-to-date drawings
are maintained which
detail the site layout,
floor plans and fire
escape routes.
c There is internal and
external sign posting in
the organization in a
language understood
by patient, families and
community.
d The provision of space
shall be in accordance
with the available
literature on good
practices (Indian or
International
Standards) and
directives from
government agencies
e There are designated
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individuals responsible
for the maintenance of
all the facilities
f Maintenance staff is
contactable round the
clock for emergency
repairs.
g Response times are
monitored from
reporting to inspection
and implementation of
corrective actions.
Average Score
FMS.3: The organization has a program for clinical and
support service equipment management.
a The organization plans
for equipment in
accordance with its
services and strategic
plan
b Equipment is selected
by a collaborative
process.
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Soni Hospital
c All equipment is
inventoried and proper
logs are maintained as
required.
d Qualified and trained
personnel operate and
maintain the
equipment.
e Equipment are
periodically inspected
and calibrated for their
proper functioning
f There is a documented
operational and
maintenance
(preventive and
breakdown) plan
Average Score
FMS.4: The organization has provisions for safe water,
electricity, medical gases and vacuum systems.
a Potable water and

electricity are available
round the clock.
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b Alternate sources are

provided for in case of
failure.
c The organization
regularly tests the
alternate sources.
d There is a maintenance
plan for piped medical
gas, compressed air
and vacuum
installation
Average Score
FMS.5: The organization has plans for fire and non-fire
emergencies within the facilities.
plans and provisions
for early detection,
abatement and
containment of fire and
non-fire emergencies.
b The organization has a
documented safe exit
plan in case of fire and
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non-fire emergencies
c Staff is trained for their

role in case of such
emergencies.
d Mock drills are held at
least twice in a year
Average Score
FMS.6: The organization has a smoking limitation policy
a The organization
defines and
implements its polices
to reduce or eliminate
smoking
b The policy has
provisions for granting
exceptions for patients
and families to smoke
Average Score
FMS.7: The organization plans for handling community
emergencies, epidemics and other disasters.
a The hospital identifies
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potential emergencies.
b The organization has a
documented disaster
management plan.
c Provision is made for
availability of medical
supplies, equipment
and materials during
such emergencies.
d Hospital staff is trained
in the hospital’s
disaster management
plan
e The plan is tested at
least twice in a year.
Average Score
FMS.8: The organization has a plan for management of
hazardous materials
a Hazardous materials
are identified within
the organization
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Soni Hospital
b The hospital
implements processes
for sorting, handling,
labelling, storage,
transporting and
disposal of hazardous
material.
c Requisite regulatory
requirements are met
in respect of
radioactive materials
d There is a plan for
managing spills of
hazardous materials
e Staff is educated and
trained for handling
such materials.
Average Score
FMS.9: The organization has system in place to provide a safe
and secure environment
a The hospital has a
safety committee to
identify the potential
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safety and security

risks
b This committee
coordinates
development,
implementation, and
monitoring of the
safety plan and
policies.
c Patient safety devices
are installed across the
organization and
inspected periodically.
d Facility inspection
rounds to ensure safety
are conducted at least
twice in a year in
patient care areas and
at least once in a year
in non-patient care
areas.
e Inspection reports are
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Gap Analysis Report
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documented and
corrective and
preventive measures
are undertaken.
f There is a safety
education programme
for all staff.
Average Score
Total Score
Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)
HRM.1: The organization has a documented system of human

resource planning.
a The organization
maintains an adequate
number and mix of
staff to meet the care,
treatment and service
needs of the patient.
b The required job
specifications and job
description are well
defined for each
category of staff.
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c The organization
verifies the
antecedents of the
potential employee
with regards to
criminal/negligence
background.
Average Score
HRM.2: The staff joining the organization is socialized and
oriented to the hospital environment.
a Each staff member,

employee, student and
voluntary worker is
appropriately oriented
to the organization’s
mission and goals.
b Each staff member is
made aware of hospital
wide policies and
procedures as well as
relevant department /
unit / service /
programme’s policies
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and procedures.
c Each staff member is
made aware of his/her
rights and
responsibilities.
d All employees are
educated with regard
to patients’ rights and
responsibilities.
e All employees are
oriented to the service
standards of the
organization.
Average Score
HRM.3: There is an ongoing programme for professional
training and development of the staff.
a A documented training
and development
policy exists for the
staff.
b Training also occurs
when job
responsibilities change/
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new equipment is
introduced
c Feedback mechanisms
for assessment of
training and
development
programme exist.
Average Score
HRM.4: Staff members, students and volunteers are adequately trained on specific job
duties or responsibilities related to safety.
a All staff is trained on

the risks within the
hospital environment.
b Staff members can
demonstrate and take
actions to report,
eliminate / minimize
risks.
c Staff members are
made aware of
procedures to follow in
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the event of an
incident.
d Reporting processes for
common problems,
failures and user errors
exist
Average Score
HRM.5: An appraisal system for evaluating the performance of
an employee exists as an integral part of the human resource
management process.
a A well-documented
performance appraisal
system exists in the
organization.
b The employees are

made aware of the
system of appraisal at
the time of induction.
c Performance is
evaluated based on
the performance
expectations
described in job
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description
d The appraisal system

is used as a tool for
further development.
e Performance appraisal
is carried out at pre
defined intervals and
is documented.
Average Score
HRM.6: The organization has a well-documented disciplinary
procedure.
a A written statement of
the policy of the
organization with
regard to discipline is
in place.
b The disciplinary policy
and procedure is
based on the
principles of natural
justice.
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c The policy and

procedure is known to
all categories of
employees of the
organization.
d The disciplinary
procedure is in
consonance with the
prevailing laws.
e There is a provision
for appeals in all-
disciplinary cases.
Average Score
HRM.7: A grievance handling mechanism exists in the
organization.
a The employees are
aware of the
procedure to be
followed in case they
feel aggrieved.
b The redress procedure
addresses the
grievance.
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c Actions are taken to

redress the grievance.
Average Score
HRM.8: The organization addresses the health needs of the
employees.
a A pre-employment
medical examination
is conducted on all
the employees.
b Health problems of
the employees are
taken care of in
accordance with the
organization’s policy.
c Regular health checks
of staff dealing with
direct patient care are
done at-least once a
year and the findings/
results are
documented.
d Occupational health
hazards are
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Gap Analysis Report
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adequately
addressed.
Average Score
HRM.9: There is a documented personal record for each staff
member.
a Personal files are
maintained in respect
of all employees.
b The personal files
contain personal
information regarding
the employees
qualification,
disciplinary
background and
health status
c All records of in-
service training and
education are
contained in the
personal files
d Personal files contain
result of all
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Soni Hospital
evalutions.
Average Score
HRM.10: There is a process for collecting, verifying and
evaluating the credentials (education, registration, training
and experience) of medical professionals permitted to provide
patient care without supervision.
a Medical professionals
permitted by law,
regulation and the
hospital to provide
patient care without
supervision is
identified.
b The education,
registration, training
and experience of the
identified medical
professionals is
documented and
updated periodically.
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c All such information

pertaining to the
medical professionals
is appropriately
verified when
possible.
Average Score
HRM.11: There is a process for authorising all medical professionals to admit and treat
patients and provide other clinical services commensurate with their qualifications.
a Medical professionals
admit and care for
patients as per the
laid down policies and
authorisation
procedures of the
organization.
b The services provided
by the medical
professionals are in
consonance with their
qualification, training
and registration.
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c The requisite services

to be provided by the
medical professionals
are known to them as
well as the various
departments/ units of
the hospital.
Average Score
HRM.12: There is a process for collecting, verifying and evaluating the credentials
(education, registration, training and experience) of nursing staff.
a The education,
registration, training
and experience of
nursing staff is
documented and
updated periodically.
b All such information
pertaining to the
nursing staff is
appropriately verified
when possible.
Average Score
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HRM.13: There is a process to identify job responsibilities and make clinical work
assignments to all nursing staff members commensurate with their qualifications and any
other regulatory requirements.
a The clinical work
assigned to nursing
staff is in consonance
with their qualification,
training and
registration.
b The services provided
by nursing staff are in
accordance with the
prevailing laws and
regulations.
c The requisite services
to be provided by the
nursing staff are known
to them as well as the
various departments /
units of the hospital.
Average Score
Total Score
Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)
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IMS.1: Policies and procedures exist to meet the information needs of the care providers,
management of the organization as well as other agencies that require data and
information from the Organization.
a The information needs
of the organization
are identified and are
appropriate to the
scope of the services
being provided by the
organization and the
complexity of the
organization
b Policies and
procedures to meet
the information needs
are documented.
c These policies and
procedures are in
compliance with the
prevailing laws and
regulations.
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d All information
management and
technology
acquisitions are in
accordance with the
policies and
procedures.
e The organization
contributes to
external databases in
accordance with the
law and regulations
Average Score
IMS.2: The organization has processes in place for effective
management of data
a Formats for data
collection are
standardized
b Necessary resources
are available for
analyzing data.
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c Documented
procedures are laid
down for timely and
accurate
dissemination of data
d Documented
procedures exist for
storing and retrieving
data
e Appropriate clinical
and managerial staff
participates in
selecting, integrating
and using data.
Average Score
IMS.3: The organization has a complete and accurate medical
record for every patient.
a Every medical record
has a unique
identifier.
b Organization policy
identifies those
authorized to make
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entries in medical
record.
c Every medical record

entry is dated and
timed
d The author of the
entry can be identified
e The contents of
medical record are
identified and
documented
f The record provides
an up-to-date and
chronological account
of patient care
a The medical record

contains information
regarding reasons for
admission, diagnosis
and plan of care.
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b Operative and other

procedures performed
are incorporated in
the medical record
c When patient is
transferred to another
hospital, the medical
record contains the
date of transfer, the
reason for the transfer
and the name of the
receiving hospital
d The medical record
contains a copy of the
discharge note duly
signed by appropriate
and qualified
personnel
e In case of death, the
medical record
death certificate
indicating the cause,
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date and time of

death.
f Whenever a clinical
autopsy is carried out,
the medical record
report of the same.
g Care providers have
access to current and
past medical record.
Average Score
IMS.5: Policies and procedures are in place for maintaining
confidentiality, integrity and security of information.
for maintaining
confidentiality,
security and integrity
of information
b Policies and
procedures are in
consonance with the
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Gap Analysis Report
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applicable laws
c The policies and

procedures
incorporate
safeguarding of data/
record against loss,
destruction and
tampering
d The hospital has an
effective process of
monitoring
compliance of the laid
down policy
e The hospital uses
developments in
appropriate
technology for
improving,
confidentiality,
integrity and security
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f Privileged health
information is used for
the purposes
identified or as
required by law and
not disclosed without
the patient’s
authorization
g A documented
procedure exists on
how to respond to
patients/ physicians
and other public
agencies requests for
access to information
in the medical record
in accordance with
the local and national
law.
Average Score
IMS.6: Policies and procedures exist for retention time of
records, data and information.
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and procedures are in
place on retaining the
patient’s clinical
records, data and
information
b The policies and
procedures are in
consonance with the
local and national
laws and regulations
c The retention process
provides expected
confidentiality and
security
d The destruction of
medical records, data
and information is in
accordance with the
laid down policy
Average Score
IMS.7: The organization regularly carries out review of
medical records.
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a The medical records

are reviewed
periodically.
b The review uses a
representative sample
based on statistical
principles.
c The review is
conducted by
identified care
providers.
d The review focuses on
the timeliness,
legibility and
completeness of the
medical records
e The review process
includes records of
both active and
discharged patients
f The review points out
and documents any
deficiencies in records
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g Appropriate corrective
and preventive
measures undertaken
are documented.
Average Score
Total Score
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Gap Analysis Report
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SECTION 6: SUMMARY OF SCORES OF VARIOUS CHAPTERS
S. NO. CHAPTER SCORE

1 Access, Assessment And Continuity
Of Care (AAC)
2 Care Of Patients (COP)
3 Management Of Medication (MOM)
4 Patient Rights And Education (PRE)
5 Hospital Infection Control (HIC)
6 Continuous Quality Improvement
(CQI)
7 Responsibilities Of Management
(ROM)
8 Facility Management And Safety
(FMS)
9 Human Resource Management
(HRM)
10 Information Management System
(IMS)
AVERAGE SCORE OF ALL CAHPTERS
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SECTION 7: RESULT:
On the basis of detailed gap assessment on every standard and
objective elements of NABH, following conclusions can be derived.
1. Average score of the NABH standards (all chapters) is coming out
to be 4.5 or 45%. This score is much below the desirable value of
>70% as per accreditation norms. Hence rigorous efforts are
required to be made to bring the score up from 45% to >70%
2. No chapters have scored 70% or more score individually. Thus
there is a scope to improve and strengthen the documentation
and implementation in every chapter of NABH. Having a score of
70% in every chapter, individually, is a must for accreditation
3. Compliance score of individual standards gives following
quantum of deficiencies.
S. Chapter No. of standards No. of standards with

No. with average more than one zero in
score less than 5 its objective elements
1. Overall
2. AAC
3. COP
4. MOM
5. PRE
6. HIC
7. CQI
8. ROM
9. FMS
10. HRM
11. IMS
Note: It is mandatory for accreditation that no standard should have a

score of less than 5 and no standard can have more than one zero in
its objective elements
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Soni Hospital
ANNEX ‘A’.SIGNAGE & DISPLAYS
Specific signage requirements that shall be addressed in signage plan

of the hospital are as given below.
………………………………………………………………………………………..
……………………………………………………………………………………………
………………………..
……………………………………………………………………………………………
……………………
……………………………………………………………………………………………
…………………….
All signage and displays in the hospital shall be made in minimum two
languages and a symbolic representation. The two languages shall be
‘English’ and ‘Hindi’. The dimensions of all signage and displays shall
be kept such that it should be clearly visible from distance
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Gap Analysis Report
Soni Hospital
ANNEX ‘B’ – Physical Safety Requirements
Following physical safety aspects shall be taken care in the hospital
……………………………………………………………………………………………
………………
……………………………………………………………………………………………
………………..
……………………………………………………………………………………………
……………………
150

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H o s p i t a l & H e a l t h C a r e C o n s u l t a n t s

GAP ANALYSIS REPORT

Astron Hospital and Health Care Consultants Pvt. Ltd.

Publication, reproduction, photocopying, storage, or transmission

Consultants Pvt. Ltd., New Delhi

Quality management system and the Accreditation process in

The Quality Council of India is an autonomous body under the

Consultants Pvt. Ltd., New Delhi

Our heartfelt thanks to ………………………………….and the Governing

We are highly thankful to,…………………………………………… for

We are profoundly grateful to,……………………………………………………

We would like to thank, …………………………………………Medical Supdt,

Our sincere thanks to Nursing Superintendent, and all HODs, in-

Astron Hospital and Health Care Consultants Pvt. Ltd.

Consultants Pvt. Ltd., New Delhi

Section Topic Page Number

Consultants Pvt. Ltd., New Delhi

Consultants Pvt. Ltd., New Delhi

the basis of primary visit made by Astron Consultants and data

Consultants Pvt. Ltd., New Delhi

SECTION 2. ORGANISATION OF REPORT

• This report is intended to identify those structural requirements of quality

Consultants Pvt. Ltd., New Delhi

• It is suggested that hospital authorities read the report carefully and

Consultants Pvt. Ltd., New Delhi

SECTION 3. HOSPITAL PROFILE

S. No. Particulars Details

Consultants Pvt. Ltd., New Delhi

11. Clinical services offered by the hospital Specialty(s):

Specialties Number of specialist Number of specialist

Consultants Pvt. Ltd., New Delhi

4. Male Private + NSR + SSR

Consultants Pvt. Ltd., New Delhi

6 General Medical Ward

S. Designation of ICU Number of beds Number of

Consultants Pvt. Ltd., New Delhi

S. Designation of Operation theatre Number

HOSPITAL HUMAN RESOURCE

Staff category On hospital pay Contractual

Nursing Staff (category

Consultants Pvt. Ltd., New Delhi

Technical Staff (category

Consultants Pvt. Ltd., New Delhi

DETAILS OF DIAGNOSTIC SERVICES

Imaging Sciences (Please list scope of services)

S. Service category Available / Not available

Consultants Pvt. Ltd., New Delhi

S. Outsourced services (please

Consultants Pvt. Ltd., New Delhi

WORK LOAD DETAILS (of the current quarter)

Consultants Pvt. Ltd., New Delhi

SECTION 4. PHYSICAL STRUCTURE REQUIREMENTS

This section identifies the structural deficiencies which may come

Consultants Pvt. Ltd., New Delhi

S. Department and observations Desirab Prior

Consultants Pvt. Ltd., New Delhi

S. Department and observations Desirab Prior

3. Hand washing facilities

Consultants Pvt. Ltd., New Delhi

S. Department and observations Desirab Prior

4. INTENSIVE CARE UNIT

4. The interbed distance

4. The Nursing Station