Gap Report Astha Hospital

2015
ASSESSMENT REPORT OF
ASTHA HOSPITAL,
DIBRUGARH
RB
Integra Ventures
9/16/2015
The assumptions, interpretations, and conclusions expressed herein represent the body of work done
by Integra Ventures in the Quality Improvement and change Management domain of consulting space
and do not purport to be a comment on the inadequacies observed in the healthcare facility.
Rights & Permissions
Copying and/or transmitting portions or this entire document without permission of Hospital Authority
may be a violation of application law
Principal office
102, 1st Floor, Orion Place.
Old Post Office, G.S.Road
Guwahati-781005, Assam
1|Pag AssessmentReportofAsthaHospital,Dibrugarh
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Contents
1. BACKGROUND................................................................................................................................3
2. OBJECTIVE......................................................................................................................................4
3. APPROACH.....................................................................................................................................4
4. METHODOLOGY..............................................................................................................................5
5. ASTHA HOSPITAL FACTSHEET.........................................................................................................5
6. STRENGTH & WEAKNESS................................................................................................................7
7. CONSOLIDATED GAP REPORT.........................................................................................................8
8. STATUTORY GAP...........................................................................................................................27
9. GAP REPORT – GRAPHICAL REPRESENTATION.............................................................................28
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1. BACKGROUND
M/S Astha Hospital, a unit of M/S Nirupoma Medicure (I) Pvt. Ltd, situated at Grahambazar, Dibrugarh,
is a multispecialty hospital. The hospital since its commissioning has established itself as a quality
care health establishment amongst the people of this region.
The hospital was established in the year 2002, and is registered under Assam Health Establishment
Act, 1993 with the License No. SHA/108 and the hospital is also provided under sub-clause (b) of the
Clause
(ii) of the proviso to sub section 2 of Section 17 of the Income-Tax Act, 1961 read with Rule
3A(1) of the Income-Tax Rules, 1962.
At present the hospital has facilities for treatment of Medicine, Surgical, Obstetrical &
Gynecological, Pediatrics, ENT, Eye, Urological, and Orthopedic as well as Neurosurgical
patients. It has a modern Operation Theatre Complex bearing three (3) numbers of Operation
theatres with most recent Monitoring Gadgets. The Obstetric department is equipped with a
Labor Room with facilities for monitoring of high-risk pregnancy with Foetal Monitor & Uterine
Tocograph (Coddlegraph). The hospital is equipped with Neonatal Care Unit (Baby Care Room) to
serve new born babies with all modern resuscitative measures.
Burn Care Unit (BCU) in the hospital is taking care of those unfortunate sufferers with best
possible service. This kind of facility is available only in this hospital in this region in the private
sector.
The Intensive Care Unit (ICU) is equipped with all modern monitoring gadgets such as Ventilators,
Defibrillators, and Full featured monitors with central station, Nebulizer, Central Oxygen and
Suction System etc.
The hospital has a Post Anaesthetic Care Unit (PACU), where patients following operation are
taken care of and thus most of the post operative morbidities is minimized or avoided.
The hospital is supported by 24-hours service of Investigations including Pathological, x-ray,

Ultrasound and CT scan, Pharmacy and 24- hour Casualty attended by Specialists, Ambulance
service as well as Canteen services. The present bed capacity is 49.
Moreover, the hospital has been serving successfully as an empanelled referral hospital of ONGCL
and APL, Namrup.
To make the healthcare services more quality and safety oriented, now Astha hospital has decided to
go for NABH Pre Accreditation Entry Level.
National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent
board of Quality Council of India, set up to establish and operate accreditation programme for
healthcare organizations. The board is structured to cater to much desired needs of the
consumers and to set benchmarks for progress of health industry.
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To achieve the goal of being accredited by NABH, Astha Hospital has appointed Integra
Ventures for technical support activity to conform the hospital policies and procedures with the
standards and to meet the statutory and infrastructural requirements of NABH.
In brief, the scope of service provided by Integra Ventures for “Astha Hospital” is
1. Sensitization Programme
2. Initial Gap Analysis
3. Documentation
4. Training
5. Process streamlining
6. Internal Auditing
7. Corrective action and preventive action support
8. Support for Final assessment
2. OBJECTIVE
1. To assess the present scenario of the hospital in terms of Infrastructure, processes, facilities
etc.
2. To identify the bottlenecks of the system & processes.
3. To assess the hospital functions on the basis of NABH Pre Entry Level Standard
requirement.
3. APPROACH
Better Clinical functions
• Efficient and
patient centric
processes and
systems • Establishment of Clinical • Better patient experience
• Training and Protocols
• Better Clinical outcome
development of Human • Develop Standard
• Cost effective and
resources Operating procedures transparent
• Purchase and Inventory and STGs environment
• Establishment of • Routine Clinical Audits
Managemnent Information Operational efficiency
System + enhanced patient
BetterAdministrative satisfaction
Processes
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4. METHODOLOGY
 The secondary data of hospital performance to be collected from various departments of

the hospital regarding the productivity, human resource, infrastructure, equipment, etc.
 Non Participant Observation
 Structured and Semi Structured interview of the Staffs and with the Patients
5. ASTHA HOSPITAL FACTSHEET
5.1 Total Number of Beds: 49 functional
5.2 No. of Years of operation: 12 years
5.3 Ownership & Management
 Private Single Doctor owned
5.4 Specialties are present in the hospital
Sl. No Specialty
1 Anesthesia
2 Cardiology
3 General Surgery
4 Intensive Care Medicine
5 Neurology
6 Neuro Surgery
7 Obstetrics/ Gynecology
8 Orthopedics
9 Pediatrics
10 Urology
11 ENT
5.5 Facilities available in the hospital
Facility Mix NUMBER

Total OPD Consultation rooms 5
General Cabin 28
Semi Deluxe Cabin 2
Deluxe Cabin 6
Suite Deluxe 2
No. of General paid Beds 3
Burn Care Unit (Cabin) 4
Intensive Care Beds (all types of
ICU - Medical ICU, NICU, SICU, ICU -4, NICU (baby)-5
PICU, MICU, and Ventilator.)
5.6 Operation theatre
TYPE OF OT NUMBER of OTs(a)

Major OT 3
Minor OT 1
Labor Room 1
5.7 Diagnostic Services
Radiology & Imaging Lab Services Cardiology

Hematology & Clinical
X-Ray ECG
Pathology
Ultrasound Echocardiography
CT Scan Holter ECG
5.8 Other Support Facilities
Facilities Services Ownership Status

Cafeteria (Attendants, Staff) In-House
Bio-medical Waste Management Partly In-house/ Partly Outsourced
Laundry Partly In-house/ Partly Outsourced
General Store In-house
Pharmacy In-house
5.9 Human Capital
Particulars Number
Specialist doctors 09
B Sc. Nursing, ANM, GNM ANM-14 (38 Nursing Attendant)
Paramedical Staff (Lab, X ray technicians, Pharmacist etc.) 11
Ward Boys & Assistants 5
Sweeper + Supervisors 25
6. STRENGTH & WEAKNESS
The Analysis of Astha Hospital shows that the hospital needs a lot of improvement to develop
and sustain the quality care in the long term with the support of the staff and other stakeholders.
The analysis evaluates the Strengths, Weaknesses with the functioning of the hospital. The
analysis has scanned the internal factors both favorable and unfavorable to the hospital in
achieving the objective of providing quality healthcare to all. The following standard framework
has been used for the Analysis:
Strength
• Good Administrative Support for Quality Improvemnet
In Hospital
• Staff are cooperative
• Only private hospital in dibrugarh having a burn unit
Weakness
• Lack of Qualified Nursing Staff
• Inadequate Maintenance of the facility
• lack of supervision and moinitoring over the staffs
• unavailability of a modern robust hospital
Management software
• Unscientific distribution of Staff.
• Unavailability of Dietary Services and Medical Record
Department
7. CONSOLIDATED GAP REPORT
OPD, Registration & Admission
Sl.
Gap Statement Rationale/Explanation Gap classification
No
The services which the hospital provide
The scope of Service is
1 has to be displayed for the information Infrastructural
not displayed
of the patient and the attendant
Signage regarding floor wise
There is no
facilities, way finding signage, list of
2 comprehensive signage Infrastructural
empanelment are not available at
available in the health
strategic locations of the hospital
facility
There is no health Health education materials has to be
3 Infrastructural
education in
materials in the OPD OPD for patient & attendant
information
The patient is given multiple
There is no unique
registration numbers for OPD and
registration number
4 IPD every time patient visits the Process
generated for each patient
hospital. There is no system of
coming to the hospital
tracking a patients number of
visit made both in IPD and OPD
There is no breast
feeding area with Privacy for breast feeding mother in the
5 Infrastructural
required feeding OPD area
information outside the
O&G OPD
The Public address system is
There is no public
necessary in the OPD for crowd
6 addressable system in Infrastructural
management, or any announcement
the OPD
of emergency
situations
A documented policy should be
maintained where it is clearly
There is no policy for mentioned what to do in a situation
7 Process
non availability of beds when there is no bed available in the
hospital and same is to be oriented
among the staff
There is a manual process going on
in the hospital where the reception
staff every day morning goes to the
Front office executives
respective floor and makes a note of
are not aware of the real
8 the vacant rooms, occupied beds and Process
time availability of
to bed discharged patients. This can
rooms in the hospital
lead to error in process and if patient
are transferred without the reception
staff
notice
9 There is no uniformity in
Consultation slip is not
consultation card and everybody is Process
system generated
using their own
pad
There is no Screen available Screen is to be installed in every OPD
10 Process
in some of the OPD chamber to maintain patient privacy
chambers of the doctor
Doctor writes the investigations in a
There is no investigation
slip without provisional diagnosis. A
11 requisition slip in the OPD Process
standard uniform format is to be
& IPD
maintained in the hospital
Daily footfall of old
patient and new patient Exact footfall of daily patient is
12 Process
is not analyzed at the not known by the management
end of the
month
It helps the hospital management
There is no mechanism to assess the satisfaction level of
13 Process
for collecting OPD patients and thereby provide them
feedback with better
services
List of empanelment and
List has to displayed for the
14 corporate tie-up is not Infrastructural
information of the patient and
being
attendant
displayed in the OPD
Drinking water provision for
15 the patient & attendant is Provision for the same has to be there Infrastructural
not available in the OPD
There is no provision for
16 separate male & female Provision for the same has to be there Infrastructural
toilet
Doctors consultation timing Time has to be displayed for the
17 Infrastructural
is not displayed in the OPD convenient of the patient and
attendant
Not every doctor is noting the
Patient assessment done by
18 provisional diagnosis in the assessment Process
doctor is not uniform
slip
Hospitals contact number is For patient convenient hospital OPD
19 not displayed in the booking appointment booking number should be Process
counter in the OPD displayed
In Patient Department
Sl.
Gap Statement Rationale/Explanation Gap classification
No
There is no system available for
Expired medicine found in all periodic checking of drugs and
20 Process
nursing station what actions to be taken for near
expiry
drugs
There is no emergency drug
Emergency medicine stock is register available in the nursing
21 Process
not updated regularly stations with a system to check the
items in every
shift
posters for infection control,
There is no work instructions
medication administration, LASA
10 | P a AssessmentReportofAsthaHospital,Dibrugarh
medication, high risk medications
displayed in the nursing
22 etc will increase the awareness on Infrastructural
stations for different
related
procedures
aspects
Blood transfusion note mentioning
There is no valid record the starting time and ending time
23 Process
of blood transfusion along with the signature of staff is
not
available
There is no Blood Separate blood transfusion
24 transfusion consent and consent form and transfusion Process
transfusion reaction form
reaction form available should be maintained
Staffs are not aware of Spill
There is no policy or management and work instructions
25 Process
availability of ‘HAZMAT along with the Kit is to be placed in
KIT’ every nursing stations
There is no discharge timing Having a policy on discharge timing
26 protocols maintained in the helps in coordinating all concerned Process
hospital departments in an efficient manner
There is no counter signature of
Nursing handover system
27 who had given handover and who Process
is not appropriate
had
taken handover.
Nurses has to be BLS trained that
28 Nurses are not BLS trained in case of emergency they could Process
apply
proper CPR
In case the patient is referred to
There is no referral
29 any higher centre, referral notes are Process
slip available in the
given
hospital
in the Discharge format itself
Most of the doctors and
As per nabh guidelines the
nurses notes on the case
30 doctor, nursing notes are dated, Process
sheet and nursing records
timed and signed
are
not timed and signed
Nutritional screening is not Nutritional screening has to be done
31 Process
done for inpatient by a dietician
All the nursing are not Atleast the nurses should be
32 Process
vaccinated vaccinated for hepatitis B
vaccination
There is no policy for verbal Some nurses are saying that they do
33 orders from Doctors in not take verbal orders where as Process
the hospital others are saying opposite to that.
Less attendant means less crowds
There is no fix timing
34 which helps the hospitals the Process
for attendant visit
hospital staff in delivering quality
health care
Nurses are not aware Nurses are not aware exactly what
35 Process
regarding needle stick injury to
do after a needle stick injury
36 Bill card not is not available For better billing process Process
12 | P a A s s e s s m e n t R e p o r t o f A s t h a H o s p i t a l , D i b r u g a r h
Proper segregation of waste Plastic saline bottle is found in
37 is not followed in the yellow colour bin in the ground Process
nursing floor nursing
station station
There are multidose drugs which
Multidose vials are not
38 should not be used beyond certain Process
labelled with opening
duration of time from the date of
date
opening
Critical Care Unit
Sl. No Gap Statement Rationale/Explanation Gap classification
All the sterilized items should be
Sterilized items are not
39 labelled with date of sterilization Process
labelled
and
expiry date to prevent infection
Admitting infectious patients along
40 No isolation room in ICU with normal patient can leads to Infrastructural
nosocomial infections
The space between two
beds are not adequate in The ICU beds should be layed with
41 giving care to the ICU enough space to carry out Infrastructural
patients emergency procedure
Emergency drugs are stored in the

There are no crash
42 tight containers which the staff are Infrastructural
cart available in the
not
ICU
able to open, when asked
Bar soaps is being used for
There is no liquid soap
43 washing hands which can lead to Process
in hand wash station
cross
infections.
The sterilized items should be
No validation of sterilized
44 labelled Process
items
with date of sterilization and
expiry date
Outsider entering ICU are Gown should be provided to prevent
45 Infrastructural
not provided with gown cross infection
Patient is admitted without any
documented evidence of briefing
There is no consent the patient attendants regarding the
46 Process
taken for admission in patient condition and further
ICU complications that can arise during
the
course of treatment
Vital equipments should be calibrated
The vital equipments in the periodically which in return gives
47 Process
ICU are not calibrated accurate results like Monitor, BP,
suction machine etc
Departmental master list of
There is no log for
equipments should be available
48 equipments available in Process
in each unit with all the details
the ICU
of
equipment. Eg calibration due date
etc
There is no documented If there is any problem with the
complain management of utilities , staff complain the
49 Process
departmental utilities management over the phone rather
maintained than documenting it
Consent from transfusion has to
There is no blood
50 be taken before carrying out the Process
transfusion consent form
procedure for the safety of the
hospital staff
Analysis of re-intibutation
These are the Performance
51 and re - admission of Process
Indicators of Critical care unit
patient is not done
Register to be maintained for
Narcotic drugs register not
52 administration and disposal of narcotic Process
maintained
drugs
Expired drugs found in the There is no policy of checking and
53 Process
ICU near
expiry drugs
There is no inventory / It can lead to pilferage and misuse
54 Process
stock register of
stock
ICU nurse should sanitize their hand
There is no hand
55 before and after attending a patient Process
sanitizer available in
to prevent cross contamination
ICU
Improper handover by Nurses signature not evidenced during
56 Process
nurses between shift handover process
Proof should be available against
No LAMA, DAMA form
57 patient who leave hospital against Process
available in ICU
medical advice
Humidifier has to be cleaned and
Humidifier cleaning in ICU checklist should be maintained
58 Process
could not be evidenced against humidifier cleaning to
prevent
infection
ICU nursing staff is not Staff should be trained to provide
59 Process
BLS CPR
trained during emergency
There is no freeze in the Costly drugs in the ICU should be
60 Infrastructural
ICU stored in the freeze to avoid damage
Swab analysis before and To keep a track on growth of
61 Process
after fumigation not done bacteria
which may lead to infection
There is no fumigation If at all fumigation is carried out,
62 record maintained in the records of the same is to be kept in Process
critical care unit the
department
Hospital should define the
There is no admission
admission and discharge criteria
63 and discharge criteria Process
so that evidence based treatment
maintained in the ICU
can be
followed in the department
There are no standard To ensure the uniformity and
protocols for ICU clinical standardized care staff should
64 Process
procedures displayed in the be provided training on the
department clinical
procedures protocols
Pharmacy
There is no periodic stock It can lead to theft, pilferage,
65 audit done in the wastage/misuse of items. Process
Pharmacy Maintaining stock level helps in
developing a good
reordering system and also helps
during stock auditing.
Hospital does not have Software should be available for
66 Process
pharmacy software module better
inventory control
No pest control measures
Pharmacy rack has been covered
67 has been taken for along Process
with dust and cobweb
time
No stock register is Real time stock of medicine and
68 Process
maintained consumable could not be traced
Ideally the medicine should be
Temperature chart is not
69 stored within a temperature of 2 - Process
maintained for refrigerator.
8 degree
celcius to avoid damage
Medicines are arranged in a
There is no scientific
haphazard manner in the racks. It is
method followed for
70 stored in company wise where all Process
arranging the medicines in
types of medicine like syrup,
the rack
capsules, pill,
ointment are stored in the same rack
Drugs which are prescribed by
the doctors are those which are
There is no formulary not approved by the
71 Process
followed in the management.
hospital Formulary is the approved list of
drugs that can be dispensed or
prescribed
from the hospital.
Before dispensing high risk drug
the pharmacist need to double
There is no defined check the drug name with the
72 High Risk Drugs & patient identity (UID and name)to Process
policy for dispensing it avoid any medication errors and
therefore defining drugs which are
marked as
High Risk Drug is necessary.
Defining emergency medicines
keeping in the pharmacy helps in
Emergency medicines are understanding the availability of the
73 not defined and not same and storing the same in a Process
stored in a uniform uniform location will help in easy
manner identification during emergency
situations.
There should be a list of Sound
Hospital has not defined alike and look alike drugs which
74 the LOOK ALIKE AND should be stored in separate Process
SOUND ALIKE DRUGS list racks to avoid confusion and also
the process for
dispensing it is to be defined
Keeping near expiry drugs in a
Near expiry drugs are not separate area and dispensing the
75 Process
kept separately same first will help in avoiding
storing of
expired drugs and thereby
preventing
dispensing of expired drugs.
Pests can cause property damage
There is no pest control
and also it can lead to many kinds
76 measures followed in the Process
of infections and therefore it is
pharmacy
considered as a patient safety issue.
There is no separate store
77 Sslf explanatory Infrastructural
for the pharmacy
Expired drugs is found There is no system followed for
78 Process
with periodic check of near expiry drugs
other drugs
Radio diagnostics (Ultra Sound/CT/X Ray)
No license available to
operate X - Ray/CT License and registration from AERB
79 Infrastructural
Scan/Mammography from required to operate these equipment
AERB
There is not sufficient
Protective equipment such as
protective devices available
80 gonad guard, thyroid guard is not Infrastructural
for patient while taking X
available, only lead apron is
Ray and CT
available
There is no validation of Though the machine is under AMC,
81 calibration of X-ray Calibration report of the Machine Infrastructural
machine is not available.
Radiation signage outside There is a specific Signage as per
82 the X-ray is not as AERB standards that needs to be Infrastructural
AERB displayed
guideline in front of the X-ray and CT scan
A requisition slip should be sent to
Investigation are not
the concerned department along
83 requested through Process
with a paid or credit stamp or any
requisitation slip
other
notification should be there in
There is no registered
There should be RSO approval
radiation Safety officer in
84 certificate for the radiologist available Process
the Hospital for radio
in he department
diagnostic department
To monitor radiation exposure TLD
badges should be available with
Radiographers are not
the staff working in the X-Ray and
85 being provided with TLD Infrastructural
CT scan unit. Even the orthopedic
badges.
surgeon conducting C-Arm
procedure should
have TLD badge
Lead apron should be checked
Lead aprons are not periodically under X-Ray to validate
86 Process
checked periodically for any cracks and it should be
documented
The lead aprons are Lead apron should always be
87 folded and kept in the hanged in the department to avoid Process
department any cracks
and in the OT in it
No red light installed
Red light indicates and warns
88 outside CT scan and X- Infrastructural
anyone for the procedure is in
Ray
progress
unit
Quality assurance test Conducting internal and external
and certificate is not verification and surveillance for its
89 Process
availabe for the X-ray imaging services helps in validating
machines and the
CT scan results obtained.
Human Resource
There is no documented The Organizational Hierarchy should
Organization Organogram be defined and displayed to maintain
90 Process
available although staff are a line of command and authority in
aware of it the
organization
Recruitment process is Recruitment, Screening and selection
91 Process
not process should be documented
documented
There is no documented
The staffs are not aware of the
92 leave policy followed in Process
leaves available for them in an
the
year
hospital
Awareness on the system of
There is appraisal performance appraisal followed in the
93 Process
policy defined in the hospital will motivate the staff to
hospital perform well
It is necessary to carry out a
Pre -Employment health
general medical check-up for all
94 checkup is not done in Process
staff being recruited to the
the hospital
organization to make
sure that they are fit for the job.
Not all patient handling
Virus can easily transfer through
95 staff are not hepatitis-B Process
direct contact and food
vaccinated
It can leads to confusion and poor
There is no written job
coordination among the staff in each
96 description handed to the Process
department as there is no clarity in
staff
roles to be played
Identification card/badge is
97 not being provided to the Self explanatory Process
staff
Staff are not aware
It helps the staff in understanding
about the employee
how to raise a complaint or any
98 grievance policy and Process
other grievance and also the
disciplinary policy
management policy on disciplinary
followed in the
actions
hospital
The duty roster of every
HR department is not
department is prepared by in-
99 aware of the duty roster Process
charges. But the roster should come
of all the department
to HR at the beginning of
the month
100 Induction Programme is Many staffs in the nursing Process
department
not conducted for new are not oriented with their job
staff responsibilities
Employee Satisfaction is
101 not tracked by the Self explanatory Process
hospital
management
To expect a better performance
among the staff, it is necessary to
give them on job training, which will
No training and show the commitment of the
102 development policy has organization in improving the Process
been evidenced quality of care and also it act as an
opportunity to interact with the staff
in a positive manner which can act
as a non-monitory
motivator and thereby.
All records of each employee
Employee wise files are
103 should be kept in their individual Process
not maintained in the
respective
hospital
files
Facility Management, Engineering Services and Maintenance
There is no preventive
Such records are to be maintained
maintenance & breakdown
104 to analyze the Downtime & Process
maintenance record
response time of Service
available for the DG set
engineers
‘No smoking' and 'danger' It shall be done as a safety
105 signage are not displayed precaution from any kind of Infrastructural
in front of the DG set electrical and fire
hazards
Facility inspection for patient care
There is no evidence areas and non-patient care areas
106 of facility inspection at regular interval could help in Process
being conducted improving the process and system
in
the organization.
Maintaining DG Set record
The records of the same helps the
log book and Fuel
107 management to analyze the utilization Process
consumption register has
of generator
not been evidenced
The staff are not aware The capacity of the Overhead
108 of the exact capacity of tanks should be written on the Process
overhead tanks tank along
with last cleaning and due date
Emergency phone numbers Putting up the emergency numbers
are not displayed at in the hospital helps the staff or
109 Process
strategic locations of the patient attendant to contact the
hospital concerned
persons in crisis situation
No cleaning/maintenance There is documental evidence for
110 checklists have been periodic cleaning and maintenance Process
displayed for water of
the Water purifier
purifiers.
There are no safety
Safety signage written in bilingual
signage available in front
111 language should be put up to Infrastructural
of the Electrical room,
ensure ready information to the
generator
people
set
There is no Fire Fire exit signage guide the staff
112 evacuation plan and patients to exit the building Infrastructural
displayed in the safely at
hospital the time of fire emergencies
Records of periodic testing of
Fire alarm system are
113 equipment is to be maintained in Process
not periodically tested.
the
hospital
Hazardous materials in the
hospital are not identified Guidelines to handle the
and MSDS are not hazardous materials are to be
114 Process
displayed for the same in displayed and training for the same
different department of is to be provided to the staff
the hospital
The hospital has number of entry
and exit and in order to maintain
Adequate security staff is the safety & security of the
115 Infrastructural
not available in the hospital hospital building , staff and
patients , number of security
personnel has to be
strengthened
Any breakdown of the
There is no complaint departmental utilities is to be
116 register maintained in the noted down on the register along Process
different department with the date and time. Once the
complaint is addressed the
same is to be recorded in the
register
Master list of equipment comprises
There is no master list
of a comprehensive information
117 of Equipment Process
about the equipment, contact
maintained in the
details of the
hospital
service engineer, AMC, calibration etc
Break down maintenance and
Equipment wise Log is
118 preventive maintenance is to Process
not maintained in the
documented for each equipment
hospital
Gas cylinders in the
manifold room are not
119 As per gas cylinders rule 2004 Infrastructural
labelled by date of
filling
and expiry date
Warning signage are Warning signage like "No Smoking
120 not displayed outside or "Flammable gas" has to be Infrastructural
the displayed
manifold room outside and inside the manifold
room
The storage area does
not have details of type of This instructions are necessary
121 Infrastructural
gas, hazards possible for time to time education of the
and Staff
emergency contact
numbers
Safety shoes and protective gloves
to be worn when loading and
No precaution is taken unloading medical gas, Wheeled
122 during cylinders carrier of appropriate size are to Infrastructural
transportation be used when moving cylinders
and use safety bar/strap/chain to
secure the cylinder
during transit
No gas manifold cylinder During connecting the new cylinder in
123 change register maintained the valve the pressure has to be Process
by the staff checked and documented
Alarm should start ringing when gas
There is no central nor
124 pressure level reaches the minimum Infrastructural
area gas alarm in the
limit
hospital
Staff is not aware of
Infection control measures are to be
the measures to be
125 taken to prevent infection through Process
taken to prevent
contamination of gases
contamination of
gases
Pressure gauze has not
126 Self explanatory Process
been calibrated
There is no record of This help to determine the buffer
number of cylinders issued stock and consumption of medical
127 Process
from the storage area to gas to come to a scientific
the departments distribution of the
gas cylinders
Laboratory
Lab technician is not
PPE like gloves are to be used by
128 using Process
the lab technicians
PPE during the time
of collecting sample
Ideally sample collection room
There is no separate
129 should be separate from the Process
sample collection room
investigation
room
Requisition records to be maintained
There is no lab requisition
130 in the department for exact Process
slip available in the hospital
reporting and auditing
There is no provisional
Provisional diagnosis helps the
diagnosis written by the
131 diagnostic staff in the investigation Process
doctor while prescribing a
process
diagnostic investigation
Recruiting staff with Colour blindness
Colour blindness test is
132 can affect the Lab procedures and Process
not done for the lab
test
technician
results.
The hospital have not defined the
No, sample rejection
criteria for rejecting the sample in
133 register and redo register Process
the laboratory and such events
maintained
needs to
be documented
If accidently a chemically hazardous
material spillage is there, then
No, spill management kit in
134 there are some special procedures Infrastructural
the laboratories
the staff should follow to make
sure things
don't get worse before they get
better
MSDS provide precautionary
information about a chemical
product specially useful for the
No, material safety data laboratory staff because they deal
135 Process
sheet displayed in the lab with chemicals on day to day basic.
By providing proper precaution,
employees can work with dangerous
chemicals with less chance
of negative exposure
Laboratory is not Helps the department in keeping a
136 maintaining a master list track of AMC, due date if Process
of equipments calibration of all the equipments in
the department
Record of downtime of equipment
There is no equipment
is not maintained in the hospital
137 breakdown or complaint Process
which will help in assessing the
book
efficiency of
the Maintenance department
Calibration quantifies and improves
the measurement performance of
an instruments hence the
Most of the equipment
laboratory equipment has to be
138 in the laboratories are Process
calibrated to check whether the
not calibrated
result generated by the equipment
are proper, which in turn helps the
physician in preparing
the treatment plan
All the lab equipment are to be
Lab equipment are not
pasted with stickers noting the last
tagged with AMC Due
139 date of calibration date, due date of Process
date and equipments are
calibration, maintenance date and
not calibrated
its
due date
Training certificate should be
No, user training certificate available with the staff who have
140 Process
with the staff received training from the supplier
while
installing the equipment
No standard safe practices
Laboratory safe practices
protocols have been developed by
141 protocols are not displayed Process
the hospital for the laboratory as
in the department.
per Bio safety
level 1 & 2 and staff are not aware of
it
The temperature of the refrigerator
Temperature chart is not
142 where reagents are kept are Process
maintained for refrigerator.
not regularly monitored
Water potability test for To check the level of chlorine and
143 Infrastructural
the lab is not done other chemicals present in the water
which might prevent the laboratory
staff in generating accurate report
on the contrary distilled water
should be
used in the laboratory
No OPD/IPD UID number should be pasted in
Registration number the sample to reduce the chance
144 Process
mentioned in the of mismatch and confirming the
laboratory register and in identity
the collected sample of the patient
The turnaround time is It helps in tracking the efficiency
145 not defined for tests and total performance of the Process
done in concerned
the laboratory. department.
There is no record
Duplicate copies of the lab
available in the system or
146 results should be maintained in Process
in hard copy to trace out
the lab for easy retrieval of data
the
results
Periodic quality check These are Quality control
147 of distilled water is not measures that the hospital Process
done laboratory should
in the lab maintain
If at all there is any chemical
There is no eye wash
splash in the eyes of the
148 station available in the Infrastructural
technician, eye wash facility
laboratory
enables to wash it off
immediately
Yearly once laboratory external
Hospital does not quality assurance should be done to
149 Process
participate in EQUAS validate the result of the test
performed in the
hospital
Temperature chart and Costly Reagent should be stored in
150 thermometer is not a defined temperature which in Process
maintained for return
refrigerator. gives correct results
The hospital should have a MOU
The hospital does not
with a outsourced lab that is NABL
151 have MOU with the Process
accredited for the tests that are
outsourced lab
not
been carried out by the hospital
Expiry reagent found in
the
laboratory
When asked, the lab technician
There is no fixed policy
was not able to answer properly
153 for duration of time, the Process
the time duration for which the
sample will be stored
samples are
kept
Critical vale of each and
154 every test is to be Self explanatory Process
documented and defined
There is no process
defined to inform the
critical test results to the
treating
doctor
Hospital Infection Control

There is no 1% sodium
Before disposing the sharp waste
hypochlorite solution
156 it has to be decontaminated Process
available near the needle
with the prepared solution
destroyer machine
Staff are not aware of spill There is a process to clean mercury
157 Process
management and blood spillage
The storage area should be guarded
BMW storage area is not
158 by Infrastructural
under lock and key
fences and it should be under lock
and key
The waste from different section of
There is no uniform way
the hospital are carried either by
159 of carrying the waste to Process
hand, some in dustbin, where there
the BMW treatment
are
facility
chances of spillage
Though there is register available
BMW is not weighed with the Hospital administrator for
160 before they are disposed amount of waste generated day Process
off wise, the authenticity of the same
is
questionable
Staff handling BMW should use PPE
PPE is not used by to
161 Process
BMW handlers
safeguard themselves from cross
contamination
No surveillance activity for Urinary tract infection, Hospital
162 Infection control is acquired infection, Surgical Process
followed in the HCO Site Infection is not tracked
All types of linen are mixed and
There is no segregation
163 ultimately every linen become Process
of soiled and dirty linen
infectious
Appointing an Infection Control
No Infection Control Nurse
164 Nurse can help in assigning her all Process
has been appointed
infection
control related activities
Operation Theatre

High risk consent in OT is High risk consent to be explained
165 and Process
not taken
signed by the patient attendant
Soiled instruments are cleaned in
There is no separate the scrub sink, where the surgeon
166 area for cleaning soiled used to do the scrubbing before Infrastructural
instruments performing operation. Hence there
is potential
threat for surgical infection
Proper handover checklist It is required to take proper
is not available with the handover of the patient from the
167 Process
OT staff ward. i.e to check wether all the
paper in the
patient MR is available or not during
the handover
Intra operative and post Both Anesthetist and surgeon
168 operative notes are not post operative notes are not Process
maintained comprehensive
Early intimation of surgeries to be
Don’t have a defined done next day improves the
169 Process
surgery booking procedure efficiency of the OTprocesses and
avoid
confusions among doctors and OT
staff
There is no record of It can be used as a quality
170 surgery cancelled and indicator to assess the efficiency of Process
postponed the OT and OT
booking process
There is no disinfectant
171 Phenyl is used for cleaning Process
used for cleaning in the
OT
Surgical safety checklist is a simple
tool designed to improve the safety
of surgical procedures by bringing
Surgical safety checklist is together the whole operating team
172 Process
not used by the OT staff (surgeons, anesthesia providers and
the whole nurses) to perform key
safety checks during vital phases of
perioperative care
The circulating nurse should
No, record is kept for document and keep records of the
173 the sponges & gauges sponges and gauges, needles & Process
during the perioperative other sharp instruments both before
session and after
surgery
Following parameters should be
followed 1)Consciousness level 2)
There is no fixed criteria
Respiration 3) Circulation 4) Pain
for transferring a patient
174 Control 5) Nausea & Vomiting 6) Process
from the recovery room
Fluid Balance 7) Heat
to the ward
Conservation 8) Wound Site,
drains & Dressing 9)
Documentation
Daily checking of OT attendant to check all the
instruments before the equipments/instruments and utilities
175 Process
first surgery is not done daily before the start of the first
and not surgery
documented
There has to be a monthly
Analysis of OT Utilization
analysis done for the OT
176 at the end of the month Process
utilization rate, Surgical Site
is not done
Infection rate and
department wise surgery
People are allowed to
It can make the OT
177 come to the sterile Process
environment unsterile
area
without the OT Dress
There is no fixed schedule There has to be a fixed schedule for
178 Process
of cleaning the operation cleaning the OT e.g. Beginning of
the
theatre day i.e. before the first surgery,
during the procedure, End of the
day, weekly or monthly and a
checklist should be
used for that
Scrub does not have To prevent contamination of the
179 Infrastructural
elbow surgeons hand
operated tape
Scrubbing sink is
not cleaned daily
180 It helps in preventing HAI Process
with 1% sodium
hypochlorite
solution
No fixed schedule for
performing OT fumigation Fumigation has to be done in OT
181 Process
and fumigation register is every fortnight and as and when
not maintained required
Staff are not aware of
182 the preperation of the self-explanatory Process
disinfectant solution
Lead aprons in the OT Lead aprons are folded and kept in
183 are not kept in hanging the store room which might lead to Infrastructural
condition crack
in the apron
Expired medicine are found There is no system in place for daily
184 Process
in the OT checking of drugs and other items
Segregation of BMW is There is no BMW bins in the
185 Infrastructural
not operation
followed Theatre
There is stain mark under the OT
OT floor is good but
186 table, when asked sister explains that Infrastructural
not maintained
the HK
staffs cleans the floor with "Phenyl"
Flat surface and grooves should
Dust accumulates at the
be avoided in the walls and floor
187 corner walls of the Infrastructural
of the OT to ensure minimum
operation room
accumulation
of dust particles
Swab culture to identify any growth
in the OT will help in assessing the
OT swab test is not
188 sterility of the OT and also it helps Process
performed frequently
in reducing the chance of getting
any
kind of surgical infection
There is no chemical It helps to make sure that the steam
189 indicator used for reached all parts and the equipment Process
sterilization of instruments are properly sterilized
Fumigation & sterilization There is no evidence of fumigation &
190 Process
register is not available sterilization conducted.
There is no validation of Record of counting of OT swabs
191 Process
OT before
swab count & after surgery should be
maintained
There is no HVAC (Heating, There is no temperature monitoring of
192 Ventilation & Air- the OT suites as well as control of Infrastructural
conditioning) setup in positive & negative air pressure
Critical areas in
Operation theatres
instead window A/C are
fitted which could be a
main source for
contamination
Patients tagging helps in site
There is no tagging of
193 identification which reduces the Process
patients before surgery
chances of wrong site incision
Treating soiled linen with sodium
Soiled linen are not treated Hypochlorite solution at the point
194 Process
at the point of generation of generation avoids spreading of
infection
Emergency drugs register
and consumables & For proper stock update and
195 Process
disposable register is not prevent pilferage
maintained
196 TSSU is not in a sterile Self explanatory Process
area
Proper sterilization of TSSU technician is not aware of
operation theatre proper autoclaving process, sterilized
197 Process
instruments could not be items are not labelled with chemical
validated indicator
Sterilized items are not These helps to track the unutilized
198 labeled by sterilization date items for re-sterilization as validity Process
and expiry date of
sterilized items is 7 days
EMERGENCY
There is no separate Assessment of the patient is done in
199 emergency case sheet a Process
available in the ED white paper without
adequate assessment
criteria defined
The nursing staff maintain separate
There is no central registers for different department
200 casualty record available to note which patient has been Process
in the department transferred to which respective
department
List of Emergency drugs
along with Minimum
quantity is not checked
on
a daily basis
Emergency beds do When Accident patient arrives and
202 not have any hand kept for observation, there are Infrastructural
rails or chances of patient fall
safety belts
There is no liquid soap in Bar soap is used which may lead to
203 Process
hand wash station cross infection
There are no work
Instructions displayed like
list of cases which are
considered MLC and
the necessary actions
to be
taken
There is no record of time at
Call book is not maintained
205 which doctor comes to the Process
in the emergency
hospital after
they get a call from the hospital.
When patients are referred from
There is no referral card the casualty to other hospital, there
206 maintained in the is no record of treatment given to Process
emergency department. the patient in the hospital and also
why he
or she has been referred out.
Defining triaging system will help
Triaging system in the in facing any kind of internal or
207 Process
HCO is not defined. external disaster. It will help in
handling mass
casualty
AMBULANCE
Minimum requirements
Ambulance is not equipped enough
including first aid box in
to handle a patient during an Infrastructural
an ambulance are not
emergency situation
208 available
No emergency medicines Ambulance is not equipped enough
are available in the to handle a patient during an Infrastructural
209 ambulance emergency
situation.
Ambulance driver is not
Driver should be trained in BLS Process
210 BLS trained
BIO MEDICAL DEPARTMENT
In-house bio-medical engineer can
No in-house bio medical address any complaints at the
211 Infrastructural
engineer earliest and there by reduces the
equipment
breakdown time
Equipment log book helps in
tracking easily the details
Equipment log book is not
212 including last calibration date, due Process
maintaining
date, vendors name and whether
the equipment is
under AMC or not
Preventive maintenance shall be
carried out at predetermined intervals
No preventive
or according to prescribed criteria and
213 maintenance of bio Process
intended to reduce the probability of
medical equipment
failure or the degradation of the
functioning of an item
Equipment shall be coded and a
214 Equipments are not coded Infrastructural
master data of the coded equipment
shall be available with the
management
It helps in calculating the average
Equipment down town
time taking to address the
215 tracking is not in a Process
complaint and it is considered as a
standardized manner
quality indicator of
the bio-medical department.
Department wise master Master list helps in easy identification
216 list of equipment is not of details of equipment used in the Infrastructural
available in the hospital. concerned department
PATIENT RIGHT & EDUCATION
Patient and family rights Patient rights and responsibilities
217 and responsibilities are not can be communicated easily Infrastructural
displayed through
signage boards
Need to implement patient counseling
Patient counseling system
218 system and the same shall be Process
is not followed in the
documented
HCO
Cost tariff is not available It helps the patient/patient attendant
219 Process
in in taking informed decisions
the front office department
Patient visitors timing shall be shall
Visiting time in the be communicated at the time of
220 Process
hospital is not clearly counseling. It helps in controlling
defined the
visitors flow to the hospital
GENERAL STORE
Daily indenting is difficult for the
221 No fixed indent policy Process
store
in charge to maintain the store.
There is no pest control
222 measures followed in the Pests can cause property damage Process
general store
The actual stock and the stock in
Stock audit is not done the record shall be same and it
223 Process
in a fixed interval can be achieved through regular
stock audit
at fixed interval
Minimum stock level/re-
It avoids stock out and improves
224 order level for each item Process
the inventory management
needs to be defined
No stock register is
225 To track real time stock of any item Process
maintained
HK & BMW
PPE is not used by HK
PPE like gloves are to be used by the
226 staff during cleaning Process
HK staff
process
Cleaning checklist for It can be used as a documented
227 patient rooms and evidence of the cleaning schedule Process
other of
departments is not the house keeping staff. The same
maintaining. shall be signed by the
housekeeping staff in each
department and patient room once
the cleaning procedure is
over
Staff carry the waste to No personal protective equipment are
228 the storage area with used while carrying the wastes bags Process
bare
hands
HK staff doesn't follow
This process is used for proper
229 three bucket method Process
cleaning procedure cleaning procedure
LAUNDRY
Treating soiled linen at the point of
Soiled linen are not treated
230 generation avoids spreading of Process
at the point of generation
infection
Laundry register format is There is no records of the linen that
231 Process
not standardized is
not given by the dhobi
8. STATUTORY GAP
Sl. Legal & Statutory Issuing Authority Status
No requirements
AERB registration of X-Ray,
1 AERB Not available
C-Arm, Portable X-Ray
2 License to operate CT Scan AERB Not available
9. GAP REPORT – GRAPHICAL REPRESENTATION
183
200
150
100
50 48
0 2
Process
Infrastructure
Statutory
Process Infrastructure Statutory

Series1 183 48 2
ProcessInfrastructureStatutory
Figure 1: Total Number of Gaps
Department wise gaps

40 34
35
30 26 26 25
19 21
25
15 14
20 11 9 9
15 5 5
3 4 4 2
10
5
0
Department wise gaps
Figure 2: department wise gaps

Gap Report Astha Hospital

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Gap Report Astha Hospital

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2015

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102, 1st Floor, Orion Place.

Old Post Office, G.S.Road

The hospital is supported by 24-hours service of Investigations including Pathological, x-ray,

Better Clinical functions

 The secondary data of hospital performance to be collected from various departments of

5. ASTHA HOSPITAL FACTSHEET

5.1 Total Number of Beds: 49 functional

5.2 No. of Years of operation: 12 years

5.3 Ownership & Management

 Private Single Doctor owned

5.4 Specialties are present in the hospital

Facility Mix NUMBER

5.6 Operation theatre

TYPE OF OT NUMBER of OTs(a)

5.7 Diagnostic Services

Radiology & Imaging Lab Services Cardiology

5.8 Other Support Facilities

Facilities Services Ownership Status

6. STRENGTH & WEAKNESS

Emergency drugs are stored in the

Sl. No Gap Statement Rationale/Explanation Gap classification

Sl. No Gap Statement Rationale/Explanation Gap classification

Process Infrastructure Statutory

Figure 1: Total Number of Gaps

Department wise gaps

Department wise gaps

Figure 2: department wise gaps

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