Wednesday 22 January 2020
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NABH Gap Analysis

NABH Gap Analysis

Gap Analysis is a very extensive, major and important activity after the decision for going ahead with quality accreditation has been taken by the top management of a healthcare facility.
The idea for conducting a detailed gap analysis is to have clear resource and time implications and strategy formation for the complete quality accreditation project. This involves finding and calculating the detailed gaps on:

  1. Regulatory compliance
  2. Infrastructure & Engineering gaps
  3. Manpower gaps, in terms of numbers, qualifications, training, HR functions etc.
  4. Equipment gaps, in terms of number, maintenance and safety
  5. Process gaps as per the quality standards applied, ethical and regulatory requirements
  6. Other important and relevant issues specific to the hospital

Gap analysis is a very resource intensive activity and requires proper planning by the BOC as well as the hospital. A lot of information is exchanged between the hospital and BOC team. It can take anything between 15 to 30 days for planning and carrying out this activity. This project involves a lot of off-site activities and on-site engagement of quality experts and hospital planners, depending up on the size and complexity of the organization.
The outcome of gap analysis activity is a clear understanding of the quality gaps leading to the estimation of time and resource that would go in achieving quality accreditation. This is also a requirement for any accreditation process, also called as ‘As-Is-Analysis’. The findings can be used later for comparison with the findings of internal assessment after QMs implementation to look for exact improvement that has taken place over that period.
Gap Analysis is a very powerful tool to kill the ambiguity in the decision of going ahead with quality accreditation as a lot of clarifications and objectivity in decision making is built in by this activity. BOC is the most appropriate, experienced, one station service providers in this field and are just a phone call/ Email away.

We need to impress upon you the following advantages of going ahead with Gap Analysis:

–A great stimulus for quality and safety initiative for the staff

–Sensitization of management and staff on quality / safety requirements

–Provides immediate change in behaviour of staff and their orientation to the work practices, safety and ethics

–External peer review: Eye opener for many

–Provides objective evidence to the management for taking the project further on and also a rough cost of such initiative can be calculated by the HCO


Outcome of Detailed Gap Analysis:

–A detailed assessment of the facility on all elements that are otherwise also very crucial for patient care and safety

–Legal non-compliance awakening

–Safe building plans

–Guidance for optimizing manpower and equipment

–Process gap identification leading to motivation for change

–Road map for quality programme & accreditation

View Proposal

List of Hospitals and healthcare facilities where Dr. Ashish K. Gupta/ Blue Ocean Consultants have been engaged for Gap Analysis as per NABH Standards:

NABH Projects & Gap analysis conducted for Medical College/ Tertiary Care Hospitals

Gap analysis conducted for Other Hospitals

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