GAP ANALYSIS REPORT FOR HEALTH CARE ORGANNIZATION (HCO)

HOSPITAL PROFILE
S.NO PARTICULAR DETAILS
1 Name of the hospital
2 Ownership: Proprietorship/ partnership/ company/ trust/ others
3 Address for communication for locating hospital
4 Contact Person
5 Contact Number
6 Contact Email
7 Numbers of sanctioned beds as per hospital registration
8 Year of Establishment
9 Vision
10 Mission statement
11 Any Quality certificate or accreditation received by the facility in the past

FACILITY DETAILS
S.NO PARTICULAR DETAILS
1 Number of building
2 Number of floor
3 Number of lift
4 Number of ramps
5 Number of staircase

MAJOR CLINICAL AREAS

S.NO PARTICULAR Number
1 Opreation Theatre
2 Recovery room
3 Labor room
4 ICU

DETAILS OF CLINICAL SCOPE OF SERVICES

S.NO SPECIALITY AVAILABLE/NOT AVAILABLE
1 General Medicine
2 General surgery
3 Orthopedics
4 Emergency Services
5 Anesthesia services
6 Dental
7 Obs& Gynec.
 DETAILS OF SUPPORT SERVICES
S.NO PARTICULAR AVAILABLE/NOT AVAILABLE
1 Pharmacy
2 Blood bank
3 TSSU/CSSD
4 Piped medical gas system/ Gas Manifold
5 Security
6 House keeping
7 Kitchen
8 Ambulance
9 Laboratory
10 Radiology services

S.NO Department & Observation Remarks

A Pharmacy
Air conditioning system available in pharmacy to maintain required
temperature& humidity as per prescribed pharma manufacturer
1 Guidelines
Temperature monitored device available for refrigerator, where
2 medicine being stored
The pharmacy license displayed in pharmacy store. All the dispensing
3 staff are licensed pharmacist
4 LASA & High risk medication defined &stored as per NABH guidelines
5 Hospital Drug formulary available & in practice
There is dedicated storage space to store expired medicines prior
6 sending back to vendors
B RECEPTION/FRONTOFFICE
The mission, Vision Scope of services & other key signage’s are
7 displayed in the front office
8 OPD consultation fees for consultant displayed near the OPD Counter.
9 OPD timing of consultants displayed near to the registration desk
10 General consent form for OPD patient in practice
11 OPD prescription as per MCI & NABH guidelines
C LABORATORY
12 Agreement for outsource lab services available
13 The critical value/ panic value identified & displayed in the lab
14 The BMW management practice in the lab appropriate
The turnaround time (TAT) of the lab test defined & displayed near to
Front office/information desk
15
D Emergency & Ambulance
16 The Emergency deptt. Need to be organized as per NABH standards
The staircase near to front desk have ramp for safe transportation of
17 the patient
18 The infection control practice in the ambulance appropriate
The existing MLC practice in the ambulance need to improvised as per
19 NABH Guidelines
20 The CPR guidelines being displayed in the emergency
21 BLS training being Done of the Emergency staff
22 The treatment summary for Emergency patient evidenced
23 In ambulance, medicine are available & inspected by the staff nurse
E RADIOLOGY
24 Lead doors & red light available in X-ray rooms
25 crack test of lead apron is evidenced
F Patient rooms
26 patient ID Bands used for admitted patients.
The solution used for sterility of cheatle forceps on medicine trolley in
28 the patient room maintained properly
BMW segregation & the dustbins being used as per pollution control
29 guidelines 2016 proper across the hospital
30 code blue concept evidenced in the hospital
patient waiting areas having the poster of how to complaint & patient
31 rights/responsibility
32 Complaint box available for the patient coming to the hospital
G Operation theater & TSSU/CSSD
33 The autoclave machine must be in enclosed area/room
34 The hot water system available for scrub section
Chemical indicators used for autoclave items. Micro biological
35 indicators are used for autoclave machines.
36 The autoclave registers being monitored properly
37 Laryngoscopes properly cleaned & sterility not in proper
38 Almira in OT bust be changed into stainless material
39 The overall OT area must be zoned as dirty, semi & sterile zone.
40 Humidity & temperature of OT are being monitored & Documented
The Doors of OT wooden it has to be material of non-corrosive
41 material
42 The wall & sheiling of OT must be crack free & dust free
43 white board available in OT for recording of surgery details
44 Double lock key boards available for narcotics in the OT area
45 Currently zip lock bags being used for Ambu bags
H ICU (INTENSIVE CARE UNIT)
The ICU area must be enclosed & zoning must be done as per Infection
46 control practice.
 The narcotics drug storage in the ICU as per prescribed guidelines,
47 stored in double locker & key
Defibrillator near to crash cart it was placed in the position which is
48 being accessible
49 Infection control practice in the ICU as per infection control practice.
50 Hand washing practice in the ICU.
I INFECTION CONTROL PRACTICE
51 HIC committee available
52 ICN appointed in the hospital
Hand washing posters available near to the hand washing facilities &
53 patient care of the hospital
54 IC manual & policies documented & implemented
55 Dedicated infection control staff available
Bio medical waste collection proper across the hospital as per the
56 latest pollution control guidelines 2016
57 Appropriate Needle destroyer container available in the hospital
Personal protection equipment’s (PPE) like hand gloves mask apron
58 practice very minimal evidenced in the hospital
Awareness of IC practice among the employees evidenced in the
59 hospital
The existing process flow & storage of clean & dirty linen in the
60 hospital satisfactory as per best infection control practice
J QUALITY INDICATORS
Hospital has identified KPIs for various areas of the hospital , hence
61 analysis of the same evidenced
Designated person for the Quality assurance activities & data collection
62 of Quality indicators available in the hospital.
K COMMITTEES
There are committee formed in the hospital. At least QA,IC,CPR &
hospital safety committee must be constituted as per NABH
63 requirement
L HAZARDIOUS MATERIAL MANAGEMENT
All the chemical used in the hospital listed & identified as per their
64 location & hazardous severity
hazardous chemical are uniformly leveled & staff are not aware of the
65 same
Spill management kits (HAZMAT kits) available to deal with chemical
66 spillage situation
M BIO MEDICAL EQUIMENT MANAGEMENT
Master Equipment register for both biomedical and non-bio medical
67 equipment are available
68 Asset coding for the hospital equipment’s available
69 Calibration of the key equipment’s evidenced in the hospital
70 Equipment Down time for critical equipment’s of the hospital
71 Safe usage instruction for the biomedical equipment’s displayed
N MEDICAL GAS SERVICE
The Flow direction signage’s displayed on the medical gas pipeline
system evidenced across the hospital & proper color coding as per ISO
72 guidelines
73 Cylinder on OT complex being labelled as fully or empty
The gas panel room being maintained, unsafely, loose wiring being
74 found in the room
75 The empty & full cylinders being stored separately
O HOSPITAL SAFTEY ISSUE
76 Fire exit plan & signage’s on every floor corridor
77 Public address system available in the hospital
Electric panel box closed properly in the various location of the
hospital. Hard rubber duty mats available near to electric panel &
78 other electric hazardous material
79 Daily maintenance checklist for the DG sets available
80 send buckets are available near to DG sets
81 preventive maintenance available for DG sets
82 Lots of construction material found on the top floor of the hospital
83 Fire tank has to be ear marked in the rooftop
P HUMAN RESOURCE MANAGEMENT
Personal file for each staff of hospital documented & maintained
84 properly
BLS training certificate for nurse & technicians available in the staff
85 personal files
Master training records with training evaluation documents are
86 available for hospital staff
Employees grievance handling procedure documented & staff are
87 aware on the same
Q MEDICAL RECORD MANAGEMENT
88 Anesthesia consent are available
89 History of allergy should be in Bold in initial part of discharge summary
90 Surgery anesthesia consent available
91 BT consent available
92 General consent form available
93 Doctors & Nursing initial assessment form in practice
94 LAMA is available
95 Surgical safety checklist available
96 Existing consent form used in the hospital, in bilingual
97 In the discharge summary which type of emergency describe
98 Operative notes are proper
99 Plan of care available
 SIGNAGES & DISPLAY
S.NO DISPLAY LOCATION
1 Fire emergency exits Across the hospital
2 Emergency exit plan For each floor
3 Lift licenses Inside the lift
4 Drug licenses Pharmacy store
5 License to sell drugs Pharmacy store
6 Hand wash display Right next to all hand wash facility

7 BMW Bins, lab & other critical areas

Bio hazard symbol entrance
8 Radiation areas symbol All radiation areas entrance
9 BMW (color coding) Near all BMW bins
10 No smoking In the entrance & all patient care areas
11 Mission statement Public location like lift, OPD
12 Floor plan Ground floor and Hospital entrance
13 Floor plan (Floor wise) each floor with fire exit
14 Directional signage’s For different departments & facility
15 Parking Mentioned for Ambulance, cars & bike.
16 Scope of services Hospital entrance
17 Timing for OPD consultation OPD waiting area

18 Near OPD desk, admission desk,

Patient rights & responsibility waiting areas, diagnostic services,
19 CPR Process OT,ICU, emergency
20 How to use fire extinguisher (PASS) & (RACE) Next to fire extinguisher point
21 Caution signage’s All high voltage points

22 Near the storage of respective

Material saftey data sheet hazardous material
23 general instruction Keep silent, use bins, No smoke Zone
24 Emergency Phone Numbers Like Ambulance, fire, police
25 Notice board OT Complex
26 Notice board Near Biometric machine
For patient, visitor for public education
27 of common diseases like TB, AIDS,
IEC material cancer
 ALL SIGNAGES & DISPLAY IN MULTI OR BILINGUAL
PHYSICAL SAFTEY REQUIEMENTS REMARKS
1 Anti-skid mats near public utilities like hand wash & toilets
2 Medical gases (Empty & filled cylinder stored separately with tags)
3 Cylinder of different gases Stored sepreatly

4 Gum boots to the staff working in wet areas like kitchen Wash area, laundry,
CSSD
5 Safety alarm (Admitted patient/visitors toilets)

6 Fire exit & fire equipment’s properly signposted, far from public and well
maintained and in good condition
7 protective equipment’s are used in radiology& lab
8 All equipment’s are in good condition with equipment log book
9 sharp, exposed objects or low overheard structure
10 Chemical safety - MSDS sheets are available in respective location
11 Electrical safety- Insulating matting floor near high voltage area
12 Anti static mats for BME deptt. At their work stations.
13 All bio medical equipment’s shall be open for service if required

Any Other Suggestions: -

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