Feasibility Study for NABH Accreditation


The first step on path to quality accreditation is to conduct a feasibility study of the hospital/ nursing home/ clinic/ dental facility etc to find out the feasibility for going ahead with the QMS planning, development and implementation. This is a 1-3 days study in which Our organization helps the top management in assessing the possibility of going ahead with quality accreditation process by considering the major factors and shortcomings of the healthcare facility in the light of quality standards to be applied. The outcome is the decision on the next step of going in for Detailed Gap Analysis as per the applicable quality standard and the allocation of resources and manpower for the quality project.

Proper estimation of feasibility requires a detailed interaction with top management of the hospital for assessing and considering their view point on quality accreditation, to take up a complete round of the hospital and check for major infrastructural and documentation part that may require proper handling during the gap analysis and to have common understanding on the future steps to accreditation. This service is a support programme for decision making for the top management before taking the major step towards QMS implementation by the hospital and is provided at a nominal cost in.

NABH Gap Analysis


Gap Analysis is a very extensive, major and important activity after the decision for going ahead with quality accreditation has been taken by the top management of a healthcare facility.
The idea for conducting a detailed gap analysis is to have clear resource and time implications and strategy formation for the complete quality accreditation project. This involves finding and calculating the detailed gaps on:

  1. Regulatory compliance
  2. Infrastructure & Engineering gaps
  3. Manpower gaps, in terms of numbers, qualifications, training, HR functions etc.
  4. Equipment gaps, in terms of number, maintenance and safety
  5. Process gaps as per the quality standards applied, ethical and regulatory requirements
  6. Other important and relevant issues specific to the hospital

Gap analysis is a very resource intensive activity and requires proper planning by the Astra Healthcare as well as the hospital. A lot of information is exchanged between the hospital and Our team. It can take anything between 15 to 30 days for planning and carrying out this activity. This project involves a lot of off-site activities and on-site engagement of quality experts and planners, depending up on the size and complexity of the organization.
The outcome of gap analysis activity is a clear understanding of the quality gaps leading to the estimation of time and resource that would go in achieving quality accreditation. This is also a requirement for any accreditation process, also called as ‘As-Is-Analysis’. The findings can be used later for comparison with the findings of internal assessment after QMs implementation to look for exact improvement that has taken place over that period.
Gap Analysis is a very powerful tool to kill the ambiguity in the decision of going ahead with quality accreditation as a lot of clarifications and objectivity in decision making is built in by this activity.

Advantages of going ahead with Gap Analysis:
  1. A great stimulus for quality and safety initiative for the staff
  2. Sensitization of management and staff on quality / safety requirements
  3. Provides immediate change in behaviour of staff and their orientation to the work practices, safety and ethics
  4. External peer review: Eye opener for many
  5. Provides objective evidence to the management for taking the project further on and also a rough cost of such initiative can be calculated by the HCO
Outcome of Detailed Gap Analysis:
  1. A detailed assessment of the facility on all elements that are otherwise also very crucial for patient care and safety
  2. Legal non-compliance awakening
  3. Safe building plans
  4. Guidance for optimizing manpower and equipment
  5. Process gap identification leading to motivation for change
  6. Road map for quality programme & accreditation

Entry Level Accreditation

Full accreditation is a dream for many healthcare facilities, but the journey towards the goal looks tough and discourages many from taking the first step on the quality pathway.
To help such healthcare provider organizations in the early phase of quality accreditation, NABH has come up with entry level accreditation standards. These standards focus more on the process and less on documentation requirements. As one becomes used to the correct processes, documentation and CAPA etc. are added to migrate them to the next level of quality accreditation, i.e. Progressive level accreditation.
We provide the right kind of guidance in this initial part of the journey of a healthcare organization on road to quality.

Progressive Level Accreditationn

For those healthcare facilities who have achieved entry level accreditation and are willing to move ahead with further improvement of quality, the next level of accreditation offered is progressive level accreditation. It is mandatory to either move to this stage and later to full accreditation or else move out as non-accredited facility.
Progressive level accreditation requires formal documentation of processes, SOPs and policies and also make improvements in processes so as to achieve further enhancement of quality.
Organizations that achieve progressive level of accreditation, find it quite easy to achieve full accreditation in little time.
Entry level-progressive level- full accreditation is a natural migration in the journey for quality and excellence in healthcare . We provide consultancy and support in all phases of accreditation due to our wide experience in all types and levels of healthcare facilities in both Government and private sector.


NABH Accreditation Projects

Taking on the complete NABH project is a big challenge that any hospital/ nursing home/ clinic/ hospital/ diagnostic /dental facility might take up. This is a very important tool for bringing quality and safety in the healthcare facility and delivery. Once this decision is taken it is important for the top management of the healthcare facility to search for various options to go ahead with technical support for complete accreditation.
Often attempts to go ahead with internal resource and expertise in this matter fail. This is due to many reasons, main ones being the bossy attitude of the top management towards change agents, with the attitude of scoring high for each quality gap and compromising on resource allocation being the major reasons. Because owners usually find no deficiency in their services.
Change management is a specialist’s job and attempts by hospital administrators require acquisition of special tools and understanding of various techniques to handle change management besides having deep understanding and expertise of handling quality issues, including documentation. Our consultant has prepared six hospitals/ for NABH Accreditation from 2011 to 2015 and All of these have undergone final Assessment & one. Is in process for final assessment

Certified Basic Life Support to Medics with Hands On trg