NABH Gap Analysis (Entry Level) Case Study – Eva Woman’s Hospital

Name of the project

NABH Gap Analysis (Entry Level)

Name of the Hospital

Eva Woman’s Hospital, Ahmedabad

Owner of the hospital

Dr. Dipak Limbachiya


Hospital Profile in Brief:

Eva Women’s Hospital is established on singular thought of “Providing Excellence to Women wellness Programs” for both domestic as well as international patients. Eva has well established services in the fields of complicated Laparoscopic Surgeries, Gynaecological and Obstetrics programs with excellent track record to reckon with.
Dr. Dipak Limbachiya is the guiding force in managing Eva as Centre of Excellence in women wellness programs which span from departments of Endoscopic Surgeries, Gynaecology & Obstetrics, Academics, and economical and custom made programs for International patients.


Project Summary:

Eva Women’s Hospital approached us to assess their hospital with respect to the NABH Standards for Small Healthcare Organization. The purpose was to assess the functional areas with a view of preparing the hospital for the accreditation. The staff and top management being inclined towards ensuring quality for the patient supported the team well and was highly motivated.

During assessment the team observed that the hospital was lacking a structured Quality department. There were a few regulatory & Statutory deficiencies due to which the hospital was advised to develop a tracker sheet that could monitor and track the expiry of the licenses / certificates as well as update them.

In terms of the Infrastructure, the hospital is really strong and has appropriate resources. However, there are a few concerns related to safety of patients as well as employees. Fire & Emergency Codes needed to be defined and displayed across the hospital.

The Bio-Medical Waste Management including storage, segregation and disposal area was one of the major concerns. Training needs were identified to be strengthened and conducted more frequently for the awareness of BMW Management.

Appropriate signage were lacking and needed to be designed properly including Safety and directional signage. Also, the biomedical equipment although were regularly calibrated, the tracking needed to be done and preventive maintenance needed to be ensured.


Executive summary

Our team of consultants helped them develop a tracker in consultation with their administrative head. We also could guide them about preparing a Quality team identifying from within their existing employees without having a need to recruit more personnel.

Our consultants also provided the staff with some comprehensive guidance regarding appropriate signage designing, tracker sheet for the biomedical equipments, preparing policies & procedures and manuals, biomedical waste guidelines, and some important information about Fire & disaster management protocols.

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