GAP ANALYSIS SHEET

Scoring
Partialy
2.1Responsibiilties of Management (ROM) Documentation Meet Meet Not Meet
Standard 1. ROM 1: The hospial is identifiable as an entity, ansd easily
accessible and the saff on duty is identifiable
Ind 1. The hospital is identifiabl wih name, and PHC
Registration/License OSV
number on sign board/s.
Ind 2. The hospital is easily accessible to the people. OSV
Ind 3. Door plate/s at clinics/offices clearly display name qualificaion/s
and designation of the staff on duty . SOP available for all steps, HR files - OSV
Ind 4. The staff on duty uses identify badge SOP available

Standard 2. ROM. 2: Responsibilities of the management are defined

Ind 5. The individual who heads the hospital has requisite qualifications
and experience HR files - OSV
Ind 6. The management apoints staff having qualifications according to
the job description
Ind 7. The hospital mangement, monitors the performance of the
hospital.
Ind 8. The management addresses the hospital's community and
social responsibilities.
Standard 3. ROM. 3: Hospital premises support the scope of services
and its adequately maintained
Ind 9. The hospital space is in accordance with the minimum
requirement. Minimum 10 patients can be catered at a time in waiting area.
Ind 10. Hospital has adequate fascilities and civic amenities for the
comfort of the patients and attendants and these are
adequately maintained.
Ind 11. Hospital has adequate arrangements for the privacy of patients
during consultation/ examination/ procedures etc.
2.2 Facility Mangement and Safety (FMS)
Standard 4. FMS. 1: The hospital is aware of and complies with the
relevant laws, rules, regulations, bylaws and relevant building /
associated codes applicable to hospital
Ind 12. The management is conversant with the relevant laws and
regulations.
Ind 13. The licenses/ registrations/ certifications are current and there is
a mechanism to regularly update the system.

Standard 5. FMS. 2: The hospital management / HCE has a

programm for management of equipment for clinical and support
services.
Ind 14.
Ind 15.
Ind 16.
Standard 6. FMS. 3: The hospital / HCE has a plan gor fire and non-fire
emergencies within the facilities

Ind 17.

Ind 18.
Ind 19.
Ind 20.
2.3 Human Resource Management (HRM)

Standard 7. HRM. 1: All the employees of the hospital are oriented

to the environment , respective sections, their individual jobs and
the performance appraisal system.
Ind 21.
Ind 22.
Standard 8. HRM. 2: An annual system for evaluating the performance
of the employees exist
Ind 23.

Standard 9. HRM. 3: Personnel record of each emlployee is

maintained and there is process of collecting , verifying and
evaluating the credentials ( education, registration, training, and
experience) of medical professionals including doctors and nurses.
Ind 24.
Ind 25.
2.4 Information Management System (IMS)
Standard 10. IMS.1 : The hospital has a complete and accurate medical
record for every patient.
Ind 26.
Ind 27.
Ind 28.
Ind 29.
Standard 11. IMS.1 : The hospital regularly carries out review of
medical records.
Ind 30.
Ind 31.
2.5 Continuous Quality Improvement (CQI)
Standard 12. CQI. 1: There is a structured quality improvement and
continuous monitoring programme in the hospital.
Ind 32.
Ind 33.
Standard 13. CQI. 2: There is a structured quality improvement and
continuous monitoring programme in the hospital.
Ind 34.
Ind 35.
Ind 36.
Ind 37.
Ind 38.
Ind 39.
Standard 14. CQI. 3: Sentinel events are intensively analyzed.
Ind 40.
2.6 Access, Assessment and Continuity of Care (AAC)
Standard 15. ACC. 1: Services are provided as portrayed and the HCE
has a well established patient management system.
Ind 41.
Ind 42.
Ind 43.
Standard 16. ACC. 2: Laboratory services are provided as per the
requirements of patients.
Ind 44.
Ind 45.
Ind 46.
Ind 47.
Ind 48.
Ind 49.
Standard 17. ACC. 3: Imaging services are provided as per the clinical
requirements of the patients.
Ind 50.
Ind 51.
Ind 52.
Ind 53.
Ind 54.
Ind 55.
Ind 56.
Ind 57.
2.7 Care Of Patients ( COP)
Standard 18. COP. 1: Energency Services are guided bypolicies,
procedures and applicabalbe laws and regulations.
Ind 58.
Ind 58.
Ind 60.
Ind 61.
Standard 19. C0P. 2: Policies and procedures define rational use of
blood and blood products
Ind 62.
Ind 63.
Ind 64.
Ind 65.
Standard 20. COP. 3: Policies and procedures define the care of high
risk obstetrical patients.
Ind 66.
Ind 67.
Ind 68.
Ind 69.
Standard 21. COP. 4: The hospital policies guide the administration of
anasthesia
Ind 70.
Ind 71.
Ind 72.
Ind 73.
Ind 74.
Ind 75.
Ind 76.
Ind 77.
Standard 22. COP. 5: Policies and procedures guide the care of patients
undergoing surgical procedures.
Ind 78.
Ind 79.
Ind 80.
Ind 81.
Ind 82.
Ind 83.
Ind 84.
Ind 85.
Ind 86.
2.8 Management of Medications (MOM)
Standard 23. MOM. 1: Policies and the procedures are defined for the
prescription of medication are defined
Ind 87.
Ind 88.
Ind 89.
Ind 90.
Ind 91.
Standard 24. MOM. 2: The Sops of the safe storage and dispensing of
medications
Ind 92.
Ind 93.
Ind 94.
Ind 95.
Ind 96.
Ind 97.
Standard 25. MOM. 3: There are defined procedures of medication
administration
Ind 98.
Ind 99.
Ind 100.
Ind 101.
Ind 102.
Ind 103.
Ind 104.
2.9 Patients right and education(PRE)
Standard 26. PRE. 1: Policies and the procedures are defined for the
prescription of medication are defined
Ind 105.
Ind 106.
Ind 107.
Ind 108.
Standard 27. PRE. 2: The Sops of the safe storage and dispensing of
medications
Ind 109.
Ind 110.
Ind 111.
Standard 28. PRE. 3: There are defined procedures of medication
administration
Ind 112.
Ind 113.
Ind 114.
2.10 Hospital Infection Control(HIC)
Standard 29. IHC. 1: The hospital has a comprehensive infection
control
programm aimmed at reducing/ eliminating risks to patients ,
visitors, and care providers.
Ind 115.
Ind 116.
Ind 117.
Ind 118.
Ind 119.
Standard 30. IHC. 2: The hospital has a comprehensive infection
control
programm aimmed at reducing/ eliminating risks to patients ,
visitors, and care providers.
Ind 120.
Ind 121.
Ind 122.