Call for Papers:Vol.12 Issue.1

Submission
Last date		 28-Feb-2026
Acceptance Status In One Day
Paper Publish In Two Days
Submit ManuScript

News & Updates

Submit Article

Dear Authors, Article publish in our journal for Volume-12,Issue-1. For article submission on below link: Submit Manuscript


Join As Board

Dear Reviewer, You can join our Reviewer team without given any charges in our journal. Submit Details on below link: Join As Board


Paper Publication Charges

IJARIIE APP
Download Android App

For Authors

Archives

IJARIIE Board

Downloads

Android App

Download IJARIIE APP

Authors

Title: :  Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital
PaperId: :  6515
Published in:   International Journal Of Advance Research And Innovative Ideas In Education
Publisher:   IJARIIE
e-ISSN:   2395-4396
Volume/Issue:    Volume 3 Issue 5 2017
DUI:    16.0415/IJARIIE-6515
Licence: :   IJARIIE is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Author NameAuthor Institute
Dr. Jasmeen BawaInstitute of Health Management Research, IIHMR University, Jaipur.
Dr. Susmit JainInstitute of Health Management Research, IIHMR University, Jaipur.

Abstract

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

Citations

Copy and paste a formatted citation or use one of the links to import into a bibliography manager and reference.

IJARIIE Dr. Jasmeen Bawa, and Dr. Susmit Jain. "Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital" International Journal Of Advance Research And Innovative Ideas In Education Volume 3 Issue 5 2017 Page 18-31
MLA Dr. Jasmeen Bawa, and Dr. Susmit Jain. "Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital." International Journal Of Advance Research And Innovative Ideas In Education 3.5(2017) : 18-31.
APA Dr. Jasmeen Bawa, & Dr. Susmit Jain. (2017). Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital. International Journal Of Advance Research And Innovative Ideas In Education, 3(5), 18-31.
Chicago Dr. Jasmeen Bawa, and Dr. Susmit Jain. "Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital." International Journal Of Advance Research And Innovative Ideas In Education 3, no. 5 (2017) : 18-31.
Oxford Dr. Jasmeen Bawa, and Dr. Susmit Jain. 'Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital', International Journal Of Advance Research And Innovative Ideas In Education, vol. 3, no. 5, 2017, p. 18-31. Available from IJARIIE, https://ijariie.com/AdminUploadPdf/Gap_Analysis_in_Internal_Assessment_against_National_Accreditation_Board_for_Hospitals___Healthcare_Providers__NABH__Standards_in_200+_Bedded_Super_Specialty_Hospital_ijariie6515.pdf (Accessed : 24 June 2025).
Harvard Dr. Jasmeen Bawa, and Dr. Susmit Jain. (2017) 'Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital', International Journal Of Advance Research And Innovative Ideas In Education, 3(5), pp. 18-31IJARIIE [Online]. Available at: https://ijariie.com/AdminUploadPdf/Gap_Analysis_in_Internal_Assessment_against_National_Accreditation_Board_for_Hospitals___Healthcare_Providers__NABH__Standards_in_200+_Bedded_Super_Specialty_Hospital_ijariie6515.pdf (Accessed : 24 June 2025)
IEEE Dr. Jasmeen Bawa, and Dr. Susmit Jain, "Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital," International Journal Of Advance Research And Innovative Ideas In Education, vol. 3, no. 5, pp. 18-31, Sep-Oct 2017. [Online]. Available: https://ijariie.com/AdminUploadPdf/Gap_Analysis_in_Internal_Assessment_against_National_Accreditation_Board_for_Hospitals___Healthcare_Providers__NABH__Standards_in_200+_Bedded_Super_Specialty_Hospital_ijariie6515.pdf [Accessed : 24 June 2025].
Turabian Dr. Jasmeen Bawa, and Dr. Susmit Jain. "Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital." International Journal Of Advance Research And Innovative Ideas In Education [Online]. volume 3 number 5 (24 June 2025).
Vancouver Dr. Jasmeen Bawa, and Dr. Susmit Jain. Gap Analysis in Internal Assessment against National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards in 200+ Bedded Super Specialty Hospital. International Journal Of Advance Research And Innovative Ideas In Education [Internet]. 2017 [Cited : 24 June 2025]; 3(5) : 18-31. Available from: https://ijariie.com/AdminUploadPdf/Gap_Analysis_in_Internal_Assessment_against_National_Accreditation_Board_for_Hospitals___Healthcare_Providers__NABH__Standards_in_200+_Bedded_Super_Specialty_Hospital_ijariie6515.pdf
BibTex EndNote RefMan RefWorks

Number Of Downloads


Last download on 6/24/2025 10:01:53 AM

Save in Google Drive

Similar-Paper

TitleArea of ResearchAuther NameAction
Solar Project Site Operations and Work Execution MonitoringElectrical EngineeringSuresh B K Download
Operation and Supply Chain Management: Insights from Ground-Level Exposure in Solar O&MOperation & Supply Chain ManagementKalyan Parasram Pawar Download
Beyond Compliance: A Holistic Evaluation of the Implementation of the Department of Education's Healthy School Canteen PolicyHome EconomicsCyrele T. Dueñas Download
EFFECTS OF STAKEHOLDERS' PARTICIPATION ON THE PERFORMANCE OF MENTAL HEALTH PROGRAMMES IN KILIFI COUNTY, KENYA.Business AdminstrationKhira Geoffrey Download
"Exploring Healthcare Quality: Patient-Centered Care, Patient Satisfaction, and Strategies for Enhanced Patient Care"-A Reviewhospital managementDr.abdul azeez Download
THE IMPACT OF E-SERVICE QUALITY ON CUSTOMER ENGAGEMENT AND CUSTOMER LOYALTY IN B2C E-COMMERCE WEBSITEmanagementDR. G. BALA MURUGAN Download
IMPACT OF MOTIVATION, TRAINING, AND REDUNDANCY ON WORKFORCE AND PERFORMANCE OF PAKISTAN AIRLINESAviationJAVIED ANWAR Download
Study on warehouse management in pump industryWarehouse ManagementK.T.BHARANITHARAN Download
Procurement Development Strategy for a Diary IndustryOperations ManagmentSANJAY BABU Download
IMPLEMENTATION OF LEAN MANUFACTURING USING VALUE STREAM MAPPINGMBAV.Rinissha Download
MANAGING THE SHORTAGE OF BEDS IN HEALTH CARE SCETOR IN THIS PANDEMICMaster of Business Administartion (Operations)Shriram Manikandan Download
A STUDY ON CUSTOMERS INTENTION AND PURCHASE DECISION BEHAVIOUR ON OMNI-CHANNEL E-TAILINGManagementYoseph Jacin Download
Inventory Management Of Fast Moving Spares Parts Of Veh/Eqpt/ Plants : A Practical Approach For Field Workshops & Base Workshops Of Border Roads OrganisationENGINEERING MANAGEMENT R K SINGH Download
A study on employees’ perspective on the impact of COVID-19 on IT industryOperations managementS.Monish Raj Download
A STUDY ON REDUCTION OF TRUCK TURN AROUND TIME AT AAVIN MILK DAIRY, ERODEManagementV.Rajesh Download
12