Gap Analysis Report

For

Facilitation of NABH Accreditation

SUBMITTED TO

VISITECH EYE CENTRE

NEW DELHI

BY

LE-DIEU
Healthcare Solutions
New Delhi
 FOREWORD

Quality Management System and the Accreditation process in compliance

with standards, is a tool for quality assurance and quality improvement for
hospitals which in turn help ensure quality healthcare services, standardized
output and aim for the best possible outcome. Spin offs of the system
include economy, effectiveness, leadership amongst peer institution,
confidence of the citizens in the establishment and a culture of team work
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
Healthcare Providers (NABH) amongst several other boards under its fold.
The NABH standards place emphasis on patient, staff, visitor and
environment safety, infection control practices and quality of patient care.

With this Le-Dieu Healthcare Solutions., wish the Visitech Eye Centre all the
very best in their voyage towards implementing the quality management
system and accreditation of the hospital with the NABH.
 ACKNOWLEDGEMENTS

The National Accreditation Board for Hospitals and Healthcare Providers

(NABH) programme in the Visitech Eye Centre has been successfully
launched because of the collective and committed work of the management
of the hospital. We are really thankful to Dr. Vinay Garodia and Dr. R.P.
Singh, the founders Visitech Eye Centre, to initiate this wonderful effort.

The team of Le-Dieu., New Delhi wants to express their gratitude to all the
distinguished leaders in the Visitech Eye Centre who all provided their
untiring support in facilitating and guiding our team in the process of gap
analysis study.

We are sincerely thankful to Dr. Anupa Gulati , Visitech Eye Centre for his
continual support in successful completion of the gap analysis study.

Also, my heartiest thanks to the Visitech Team for their active cooperation
without which it would not have been possible to accomplish this task.

Lastly, we express our gratitude to all those, whose name has not been
mentioned but who all contributed at any point towards the successful
completion of the gap analysis study.
 EXECUTIVE SUMMARY

Accreditation is a versatile tool to ensure equity in delivering of healthcare services

and in-turn meeting the increasing aspirations of people. Given the vast differences in
availability of resources to haves and have not, Private vs. Public, North vs. South,
healthcare delivery available to the less fortunate is likely to be adversely affected.

Hence, the demands of good governance dictate that the core values of health care
service delivery are equitable regardless whether services are provided to a prince or
pauper. This ideal state of affair can be achieved by the institution of a quality
management system that focuses on compliance with the Accreditation standards of
NABH. The standards for compliance are dynamic and seek to raise the bar continually;
as well as to remain contemporary and applicable to the situation obtaining in a region.

The Visitech Eye Centre, New Delhi has taken a step in the right direction to ensure
that the Hospital performs their designated and sustainable role in the community in
delivering of quality service to the people.

The Le-Dieu health care Solutions, New Delhi shall put all efforts to see to it that
Visitech Eye Centre complies with the Accreditation standards of the NABH.

To conclude, the actions to be taken for compliance with the Accreditation standards of
NABH at Visitech Eye Centre are likely to impact the delivery of healthcare services
positively, ensuring quality services, efficient outcomes with economy, risk management
with patients, staff and visitors safety and above all equity in healthcare services for all
the citizens.
 AIM AND OBJECTIVES

AIM:

To prepare Visitech Eye Centre to be accredited by the National Accreditation

Board for Hospitals & Healthcare Providers (NABH).

OBJECTIVES:

a. To assess the existing service delivery standards of the Visitech Eye

Centre, New Delhi.

b. To identify the baseline level of all quality indicators (Structure,

Process and Outcome).

c. To suggest alterations in Structural Designs of the facilities to meet

the requirement. A review of facilities including building and
associated aspects i.e. Fire fighting systems.

d. To lay down Standard Operating Procedures for various activities.

e. To Train the Key Personnel in these processes.

f. To review the Outcome.

g. To obtain NABH accreditation.

TASKS:

 To understand the existing level of health care delivery by discussion

with policy makers and senior officers and other stake holders.

 To review the secondary data available - Bed Occupancy Rate, OPD

Attendance, No. of Discharges, Average Length of Stay etc.

 To have a sensitization workshop for policy makers and officials of

the Visitech Eye Centre.

 To suggest any basic minimal civil structural alteration, if required.

 To study the equipment and instrument functionality, maintenance

and calibration of the same.

 To identify senior and potential trainers from within the facilities.

 To conduct training of trainers of various facilities.

 To assist in organizing Training Program for all personnel.

 To observe and analyse the effectiveness of such training by carrying

out patient satisfaction survey, employee satisfaction surveys and
hospital utilization rates coupled with analysing the healthcare
service indicators.

 To assist to create signage, work instructions, manuals etc.

necessary for the facilities.

 To facilitate carrying out internal audit as per NABH standards for the
Hospital.

 To assist in carrying out the self assessment as per NABH standards.

 To assist in submitting application for the Accreditation.

 SCOPE AND APPROACH

Scope:

 To evaluate the following aspects at the Visitech Eye Center for

their compliance with NABH standards:
o Civil works
o Manpower
o Equipment
o Licenses
 To carry out a gap analysis between desired and existing level.
 To suggest recommendations for streamlining the processes.
 To assist the Visitech Eye Centre in charting the further course of
action which will lead to compliance with accreditation standards of
the NABH and institutionalization of a quality management system,
leading further to a continuous quality improvement plan.
 To plan the activities for action subsequent to the Gap analysis.

Approach

 Collection of primary data and secondary data from the hospital for
assessing of Structure (civil work, manpower and equipment), Process
(Policies and procedures) and Outcome so that gaps can be identified.
 Structure and civil works have been evaluated using the National
Building Code applicable to the hospitals as per their bed strength.
 Manpower for the hospitals has been compared with the work load.
 Equipment gaps have been assessed using the work load of specialty
and advancement of technology.
 The processes involved in the quality management system is assessed
and action taken in due course as a follow up of the gap analysis
 study.
 The system and processes will be further assessed by Chief
Consultant, by inspection, interviews, discussions and observations on
ground using the NABH standards as a yardstick.
 The report shall be handed over to the policy makers so as to have an
early decision for smooth implementation of the program on a mission
mode.

Limitations:

 The Core Committee and the Quality Team of Visitech Eye Centres has to
be in full swing-and gear up the work to meet up the standards.

OBSERVATIONS AND ANALYSIS

 The observations are classified as follows:

- Structural
 Physical Facilities
 Manpower
 Equipment
 Licenses
- Processes
 Policy and Procedures
- Outcome
 Secondary Data
 HOSPITAL INTRODUCTION

Visitech Eye Center aim at providing comprehensive eye care services using
the best in technology and skills. Besides delivering the regular eye-care
services, the Center take pride in providing advanced level of diagnostic and
therapeutic services in the field of vitreous and retinal diseases,
Phacoemulsification surgery for Cataract and Customised Wave front LASIK
Laser for removing glasses.

The center is equipped with state of the art equipments from USA and
Germany, in a fully air-conditioned premise with computerised record
keeping. These are managed by a team of surgeons with special expertise in
their own specialities. They provide world class surgical and medical
treatment, even for the most complicated forms of diseases in vitreous and
retina. Both the center have day care surgeries as well as admission
facilities, and also facilities for surgeries under general anaesthesia.

Visitech Eye Center aim to provide an early treatment to the patients at

affordable expenses. Besides, providing a complete and comprehensive
routine eye checkup and surgeries, our centres provide specialized services
ranging from Indirect Ophthalmoscopy, Fluorescein Angiography, OCT,
Lasers, Ultrasonography, to Consultation and opinion on telephone and on
email, to fellow ophthalmologists for their difficult cases.
 SCOPE OF SERVICES

Besides providing a complete and comprehensive eye checkup and

surgeries, the center provide the following specialised services:

Surgical Services:

 Phacoemulsification
 Customised Wave-front LASIK laser for removing glasses
 Retina Surgeries (Buckling)
 Vitrectomy Surgeries
 Vitreo-Retina Surgeries
 Silicone Oil Removal Surgery
 Glaucoma Surgeries
 Squint Surgeries
 Corneal Transplant Surgeries
 Oculoplasty Surgeries
 Surgeries to manage complications of other surgeries, like dropped
lens/IOL, Endophthalmitis etc.

Diagnostic Services:

 Indirect Ophthalmoscopy
 Digital Fluorescein Angiography (FA)
 Optical Coherence Tomography (OCT)
 Ultrasonography: A scan and B scan
 Humphrey Visual Field Analysis
 Squint workup
 Glaucoma workup, Eye Pressure checkup (Tonometry)
  Uvea Clinic with workup for Choroiditis, etc.
 Trauma Clinic for patients with Eye Trauma
 Diabetes Clinic
 ROP (Retinopathy of Prematurity) Clinic for Retinal Screening of
Preterm babies

Therapeutic Services:

 Green Laser (532 nm) for retinal diseases like Diabetic Retinopathy,
Eales’ Disease, Vascular Block, Retinal Breaks etc.
 Photo Dynamic Therapy (PDT) Laser for ARMD, SRNVM etc.
 Transpupillary Thermo Therapy (TTT) Laser for ARMD, SRNVM etc.
 YAG laser for aftercataract, glaucoma
 Cryopexy for retinal breaks
 Cyclocryopexy for Glaucoma
 DLCT Laser treatment for Glaucoma
 Anti VEGF Agents - Lucentis/Avastin/Macugen
 IVTA (Intravitreal Steroid Injection) for Diabetic patients and other
retinal diseases
 ROP (Retinopathy of Prematurity) treatment with Laser, Surgery

SUPPORT SERVICES:-

 LINEN & LAUNDRY

 MAINTENANCE
 PHARMACY
 SECURITY
 BIOMEDICAL WASTE
ADMINISTRATIVE SERVICES:-

 ADMINISTRATION
 HR / FINANCE
 INSURANCE & PANEL

HOSPITAL DIRECTORY (BUILDING):-

BASEMENT

MRD

STORE (MISLLANIOUS)

CONFERENCE ROOM

GROUND FLOOR

TSSU ROOM (PROPOSED)

STAFF ROOM

LOUNGE

GENERATOR

ETO

1ST FLOOR

FRONT DESK/ADMISSION/ENQUIRY

OPD CHAMBERS

PHARMACY & OPTICAL COUNTER

INSURANCE / PANEL ROOM

BILLING

OPTHALMIST ROOM

HR / FINANCE

DIRECTORS ROOM
2ND FLOOR

OT COMPLEX

POST OPERATIVE ROOM

ROOM B 1(OT 1)

ROOM B 2 (OT 2)

PANTRY ROOM/AQUA GUARD

HOSPITAL DETAILS

AREA:-

TOTAAL LAND AREA:- 320 SQ YARDS

COVERED AREA:- 4616.8 SQ FT.

TOTAL WAITING AREA:- 1064 SQ. FT.

LIST OF STATUTARY REQUIREMENTS:-

Sl.N Name of the particulars Status of Availability

o
1. Building permit Yes
2. NOC fire No (applied)
3. BIO Medical waste Management Yes
4. Delhi Pollution Control Board (DPCC) Yes
5. License for sprit No
6. Income tax assumption Yes
7. Working of LIFT Yes
8. Sale tax Registration No
9. Retail drug License No
10. NOC of noise from Generator Yes
SIGNAGE SYSTEM

There are number of signages showing the various departments and utilities
like drinking water, toilets, different OPDs etc at appropriate places but they
are only in English. It is recommended that the signages should be at least
in bilingual i.e. English & Hindi for e.g. drinking water, toilets, fire exit,
handicapped toilet, scope of service, departmental signage’s, floor
directories etc.

Signage's Displayed Bilingual Pictorial

(Yes / (Yes / (Yes /

No / NA) No / NA) No / NA)

Citizen Charter NO NO NA

Mission NO NO NA

Vision NO NO NA

Core values NO NO NA

Patients Rights and NO NO NA

Responsibilities

Service Available NO NO NO

Complaint Redressal box NO NO NA

Tariff List NO NO NA

Doctors list along with their YES NO NA

Specialities and Qualifications

OPD Schedule of Doctors YES NO NA

(Speciality, Timings and Day of
Availability)

Biohazard Symbols NO NO NO

Fire Exit Plan NO NO NO

Floor Directory NO NO NO

Departmental Signages YES NO NO

Wash Rooms (Handicap) NO NO NO

Toilets NO NO NO

Ambulance Parking Area NO NO NO

Drinking Water YES NO NO

Health Education Related NO NO NO

Signages
OUT PATIENT DEPARTMENT

The outpatient department block is well visible from the entrance. Drinking water
facilities are available in the OPD area. There is a waiting area for the patients in OPD .

IDENTIFIED GAPS

 Citizen Charter, Patient rights & responsibilities and signages for

drinking water, registration counter were not displayed in bilingual.
 Scopes of services are not displayed in bilingual.

 Doctors’ name, qualifications, specialty, OPD days & timings are not
STRUCTURAL

displayed in bilingual.
 Fire exit plans were not displayed in the OPD area.

 Elbow taps were not evidenced in all wash basins.

 Bio-Medical Waste were not available uniformly in the OPD

chambers.
 Soap bars to be replaced with Liquid hand sanitizer.

 OPD records are not being stored uniformly for future referral.

 No SOP available for the department.

 Content of assessment for the outpatients are not defined.

PROCESS

 No training schedule & records of training for the staff was evidenced.

 No standardized format used for initial assessment of OPD patients.

 Housekeeping services for the toilets needs strengthening.

 Waiting time of OPD patients is not being monitored.

OUTCOME

 OPD utilization is not done.

 Out patient satisfaction is not being carried out.

 REGISTRATION, ADMISSION & BILLING

IDENTIFIED GAPS

 Citizen Charter, Patient rights & responsibilities and signages for

STRUCTURA

registration counter were not displayed in bilingual.

L

 Fire exit & fire escape routes are not displayed.

 Tariff list is not displayed at the Admission counter.

 No SOP is available for the department.

 Tariff book with date of effect is not available.

PROCESS

 Service available policy is not available.

 Policy on Non availability of beds is not available.

 Staffs are not trained on these policies.

 No monitoring of waiting time for registration.

OUTCOM
E

AMBULANCE SERVICES

 The Hospital need to have an Ambulance (At least BLS) or MoU with other.
 The Hospital needs to designate a parking space for the ambulance.

CASUALTY DEPARTMENT

 The Hospital need to have a functional Casualty Department.

 Disaster cupboard with all emergency drugs, items need to be available (Disaster
Plan).
 OPERATION THEATRE COMPLEX

IDENTIFIED GAPS

 AHU is not installed in the Operation theatre complex.

STRUCTURAL

 defibrillator is not available.

 Spillage kit is not available.

 Fire exit and fire escape routes are not displayed.

 No documented SOP for the Operation theatre, informed consent,

anaesthesia, sedation, restraints, pain management, wrong patient &
wrong site surgery and surgical services.
PROCESS

 Surgical safety checklist is not available.

 Temperature is not monitored for fridges.

 Sound alike and look alike medication are not stored separately.

 Biomedical waste is transported through the same patient entry.

 Re-exploration rates & rescheduling of procedures are not monitored.

OUTCOME

 No monitoring of anaesthesia related events like percentage of

modification of anaesthesia plan, percentage of unplanned ventilation
following anaesthesia, anaesthesia related adverse events and
anaesthesia related mortality rate.

WARDS

IDENTIFIED GAPS
  Crash cart is not available. .
STRUCTURAL
 No spillage kit is available.

 Toilets do not have grab bars.

 Fire exit and fire escape routes are not displayed in the ward areas.

 Bed side rails are not available in all beds.

 No documented policy and procedure for CPR, Rational use of blood

& blood components, informed consent, blood transfusion, referral,
transfer, discharge, care of vulnerable patients, pain management,
verbal orders, high risk medication, safe dispensing of medication,
patient monitoring after medication, self administration of medicines,
PROCESS

medicines brought from outside, adverse drug events, storage of

medicines, sound alike & look alike medicines, ward management,
nursing services in wards, and linen management.
 Look alike and sound alike drugs are not stored separately.

 High risk medication is not stored under single lock & key.

 Material safety data sheet is not available.

 Staff is not trained uniformly for the same.

 No monitoring of time taken for discharge.

OUTCOM

 No monitoring of medication errors, ADR, accidental removal of tubes

E

& catheters, strip & falls, sentinel events etc.

*** All Diagnostic Services, Therapeutic Services and Surgical Services

needs documented SOPs, performance monitoring indicators according to
the scope.
* The Hospital has well maintained Diagnostic department but system for
monitoring of quality are not available.

Medical record department

 Medical Record Department needs to be Stable with qualified medical
record technician.

INFECTION CONTROL

IDENTIFIED GAPS

 Infection control committee and Team not available.

 There is no documented and structured infection control surveillance

STRUCTURAL

program.
 Elbow taps are not available in wash basins.

 Provision for infected Patients not available in the hospital.

 Hand wash signage is not displayed uniformly in all washing areas.

 No documented infection control manual available.

 Soap bars are found in all hand washing areas.

 Evidence of Efficacy test for disinfectants is not available.

 Feedback on Infection rates are not provided to staff (Infection control

Bulletin).
PROCESS

 Induction & In-service training are not provided uniformly to all staffs.

 Hand wash monitoring is not carried out regularly.

 Staff adherence to standard precautions is not being monitored

uniformly.
 Equipment cleaning & sterilization practices need to be strengthened.

 Hand towels are being used in all hand washing areas.

 Monitoring of BMW not available.

OUTCOM

 Infection rates like SSI, CIR are not being monitored.

E
 PHARMACY

IDENTIFIED GAPS

 No hospital drug formulary.

STRUCTURA

 Fire exit & fire escape routes were not displayed in the department.
L

 Labelling of drugs in pharmacy was not evident (preferably Bar

coding).
 No documented SOP for the department like prescription of drugs,
high risk medication, safe dispensing of medication, proper storage of
drugs, storage of narcotic drugs, local purchase., procurement of
drugs, formulary, procurement of medicines not listed, look alike &
sound alike, medication recall, safe & effective use of medication, etc.
PROCESS

 Adverse drug reactions are not monitored and analyzed.

 Look alike & sound alike medications are not stored separately.

 High risk medication list is not available.

 Prescription bounce register is not available.

 Prescription audit is not being done.

 Temperature is not monitored for drugs kept in fridges.

 No monitoring of indicators like percentage of stock out including

OUTCOME

emergency drugs, percentage of local purchase, incidence of variation

from the procurement process and percentage of goods rejected
before preparation of GRN.
 SECURITY

Security post is available in main entrance of Hospital. Round the clock security guards
are present in the hospital.

IDENTIFIED GAPS

 Fire exit signages are not displayed in the hospital.

STRUCTURAL

 Fire escape plan are not displayed in the hospital.

 No measures on physical check in entrance to the hospital.

 Metal detector for security is not available.

 No documented policies and procedures on safety and security in the

hospital, civil disturbances, fire & non fire emergencies and disaster.
 Inadequate measures on access and traffic control in the hospital.

 Staffs training on fire & non fire emergencies were not evident.

 No mock drills for fire & disaster are conducted.

PROCESS

 No strict control on smoking, chewing gutkha and pan in the hospital

premises.
 Hazardous materials are not identified and the staffs are not trained
on the management of these materials.
 No root cause analysis was done on breach/thefts on security
grounds.
 Material Safety Data Sheet is not available for hazardous materials.
  No monitoring of security related incidents and thefts in the hospital
OUTCOM
premises.
E

BIOMEDICAL WASTE MANAGEMENT

The biomedical waste management facility is outsourced. The hospital has a temporary
storage room. The biomedical waste management practices in the hospital needs to be
strengthened.

IDENTIFIED GAPS

 Appropriate colour bins with colour plastic bags were not evident
uniformly.
 Housekeeping staffs handling BMW are not provided with PPE like
heavy duty rubber gloves, shoes, mask, plastic apron & caps.
STRUCTURAL

 No labelling of biohazard symbol in the BMW buckets as per the

schedule III of biomedical waste management handling rules, 1998
were evidenced.
 No stainless covered trolleys used for transportation of biomedical
waste from the patient care areas to the temporary storage area.
 No signage for temporary storage area for biomedical waste.
  No documented SOP for BMW management.

 Staffs are not trained uniformly to handle BMW properly (no proper
segregation at the source of generation & no proper transport to the
PROCESS

temporary storage area).

 No evidence of on site visit by the team of the hospital to the
treatment facility periodically.
 Bio-medical waste management audit needs to be carried out.

 No monitoring of biomedical waste generated per bed per day in the

OUTCOM

hospital.
E

HOUSEKEEPING DEPARTMENT

The Hospital does not have a specified place for Housekeeping Department.

IDENTIFIED GAPS

 Housekeeping staffs are not provided with PPE like heavy duty rubber
STRUCTURAL

gloves, shoes, mask & caps.

 Hazardous materials are not identified.

 Master cleaning schedule is not available.

 Spillage kit is not available in the department.

 No documented SOP for housekeeping service.

 Material Safety Data Sheet is not available.

PROCESS

 Staffs are not trained on handling of hazardous materials & spill

management.
 Efficacy test for disinfectant is done periodically.
  Effectiveness of housekeeping services is not being monitored.
OUTCOM
E

LAUNDRY DEPARTMENT

The center has outsourced for the linen and laundry services.

** Periodic audit for the monitoring of outsourced organization not evidence.

TSSU

IDENTIFIED GAPS

 Sufficient space for sterilisation activities is not available (Proper

zoning, unidirectional flow & separation of clean & dirty areas).
STRUCTURAL

 Covered trolleys are not available for transporting of sterile & unsterile
items.
 Bowie Dick tape test, Biological indicator & test leak rate test are not
being evidenced.
 Elbow taps are not available in the washing area.

 No documented SOP for TSSU department.

PROCESS

 No recall procedure available for sterile & unsterile items.

 No re-use policy available in the department.

 Infection control practices needs to be strengthened.

  No record available for monitoring of pressure during the load run.
OUTCOME
 No proper issue & receipt register available.

HUMAN RESOURCE DEPARTMENT

There is no proper human resource department and qualified leader for the
same.

IDENTIFIED GAPS

 Approved manpower plan was not evidenced.

 Organogram with the version & issue number was not evidenced.
STRUCTURAL

 Proper job description and job specifications of all categories of

employees were not evidenced.
 No evidence of documentation of Employee & Patient rights.

 Personal files of employees were not maintained properly.

  No documented SOP for HR department which includes manpower
planning, recruitment & selection, job description & job specifications,
induction of all new employees, training and development, grievance
redressal mechanism, documented appraisal system, well
documented disciplinary procedure etc.
 Antecedent’s verification with regard to criminal/negligence
background was not uniformly evidenced.
 No structured induction programme for all categories of staff was
uniformly evident. (Organization mission & goals, Policies &
procedures (Hospital & Department), Service standards, Patient
Rights & Responsibilities & Employee Rights etc).
 No documented Training & Development policy available.
 No evidence of Training needs analysis being done.
 No evidence of Training calendar & Department Training schedule.
PROCESS

 No evidence of Trainer’s & post training of trainee’s evaluation.

 No evidence of training when job responsibilities change and when
new equipment is introduced.
 No evidence of staff training on risks within the hospital environment
(Fire & Non fire emergencies, needle stick injury etc).
 No evidence of documented performance appraisal system for all
employees on the basis of the KRA’s defined.
 Performance appraisal system is not being used as a tool for further
development.
 Pre-employment and annual health check up for all employees was
not evidenced.
 Staffs working in direct patient care areas were not given hepatitis B
vaccine dose.
 Occupational health hazards of employees are not adequately
addressed.
 Doctors & nurses competency mapping & privileging was not evident.
 No monitoring of employee satisfaction.

 No monitoring of employee attrition rate.

OUTCOME

 No monitoring of employee absenteeism rate.

 Percentage of employees who are aware of employee rights,

responsibilities and welfare schemes.
 Percentage of employees provided pre-exposure prophylaxis.
 ENGINEERING AND FACILITY MANAGEMENT

There is no department available in the facility to look after the facility

management.

IDENTIFIED GAPS

 No documented operational and maintenance (preventive and

breakdown plan).
 Up-to-date drawings, layout and escape route are not available.
 Signages for internal and external posting are not uniformly displayed.
 Personal Protective Equipments (gloves, shoes, safety goggles) are
not available.
STRUCTURAL

 Beds in ward do not have provision of Side rails.

 Stretchers & wheel chairs do not have brakes, straps for restraint,
side rails & file holder.
 Toilets in the hospital do not have grab bars.
 Elbow taps are not available in wash basins.
 Rubber mats are not placed in front of electrical panel boards for
safety during operation.
 Sewage treatment plant is not available for the hospital
 Danger signs are not available on electrical panel boards.
 Air changes, temperature & humidity are not measured in Operation
Theatres.
 Noise & air pollution test for DG sets needs to be carried out regularly.

 Facility inspection rounds by safety & risk management team are not
PROCESS

documented.
 No documented SOP for the engineering & facility management
department.
 Water quality test is not done.

 No response time monitored for the complaints received and analyzed

OUTCOM

for corrective actions.

E

 No monitoring of breakdown time of equipments was evident.

 BIOMEDICAL ENGINEERING DEPARTMENT

There is no any specified place for biomedical Engineering department.

Biomedical Engineer is also not available in the Hospital.

CENTRAL STORE & PURCHASE

IDENTIFIED GAPS

 Labelling of items stored was not evidenced.

 No documented SOP for purchase department.

 No documented condemnation policy available.

 No documented procedures for procuring implants.

SELF ASSRSSMENT TOOLKIT

**** Attached.