NABH case study of Rajasthan hospital, Ahmedabad

Name of the project

NABH Gap Analysis – Large healthcare organization

Name of the Hospital

Rajasthan Hospitals, Ahmedabad

Owner of the hospital

Shri Gautam Jain – Chairman


Hospital Profile in Brief:

The Gujarat Research & Medical Institute (Rajasthan Hospitals) is a charitable trust, founded and registered in the year 1982, now a 250 bed multidisciplinary, super specialty tertiary healthcare centre with recognized Post-graduate diploma for Critical Care Medicine, recognized nursing school and nursing college and a recognized Research organization. The trust aims to provide high quality healthcare and medical facilities and contribute to the advancement of knowledge in medical science by conducting research and providing training and educational facilities in the field of medicine.


Project Summary:

The Gap analysis for Rajasthan Hospital, Ahmedabad was conducted in December 2012. A visit to the hospital premises and personal interviews of all categories of hospital staff was organized during this period. The purpose was to assess the functional areas of hospital services with a view of preparing the hospital for NABH Accreditation.

The following points indicated the need for further intervention and enhancement, in order to meet the standards set by the NABH.

Hospital Care system has been broadly divided into two categories specifically for this
hospital. This includes baseline assessment of the hospital as per normal workflow and
basic system and processes followed and other criteria included quality parameters
followed in the department which includes documentation and assessment by the way of

In terms of the Infrastructure, the hospital is really strong and has huge resources as far as
space is concerned. However we identified certain areas which were in unkempt condition and could encourage Hospital Cross Infection. The Bio-Medical Waste Segregation area was one of the major concerns, though the same could be addressed with minimal hassles and appropriate guidance was provided to them.

Hospital Signage, another important NABH Criteria, did invite re-designing to follow
uniformity for the standardization of design, color coding, symbols, directional signs, etc as
per the standard signage system.

Formal Training needs were identified regarding Standard Hand washing procedures, general housekeeping procedures in the hospital, equipment cleaning, infection control
surveillance audits, and clinical performance indicators.

Biomedical engineering was also identified for re-modulation in the form of more documentation and in-house calibration and preventive maintenance of the equipments.


Executive summary

The hospital, being a teaching institution, has staff who are very well aware of the
guidelines to be practiced and are motivated enough to implement the changes and
elevate the standard for delivery of healthcare. Accreditation for the institution is
merely a step away since it is a research based organization and all the staff members
are oriented to recent advancements.

The need of the hour was just to re-modulate the system and processes as per the laid down
guidelines, with the involvement of all staff members which includes the grass root
employees too. In totality institution has high potential for accreditation.

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