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|Page Assessment Report of Astha Hospital, Dibrugarh

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

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.

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
• Efficient and patient functions
centric processes and
systems
•Establishment of Clinical •Better patient experience
•Training and development
Protocols •Better Clinical outcome
of Human resources
•Develop Standard •Cost effective and
•Purchase and Inventory
Operating procedures and transparent environment
•Establishment of STGs
Managemnent Information •Routine Clinical Audits
System Operational efficiency
+ enhanced patient
BetterAdministrative satisfaction
Processes

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 not
1 has to be displayed for the information Infrastructural
displayed
of the patient and the attendant
Signage regarding floor wise facilities,
There is no comprehensive
way finding signage, list of
2 signage available in the Infrastructural
empanelment are not available at
health facility
strategic locations of the hospital
There is no health education Health education materials has to be in
3 Infrastructural
materials in the OPD OPD for patient & attendant information
The patient is given multiple registration
There is no unique
numbers for OPD and IPD every time
registration number
4 patient visits the hospital. There is no Process
generated for each patient
system of tracking a patients number of
coming to the hospital
visit made both in IPD and OPD
There is no breast feeding
area with required feeding Privacy for breast feeding mother in the
5 Infrastructural
information outside the OPD area
O&G OPD
The Public address system is necessary
There is no public
in the OPD for crowd management, or
6 addressable system in the Infrastructural
any announcement of emergency
OPD
situations
A documented policy should be
maintained where it is clearly
There is no policy for non mentioned what to do in a situation
7 Process
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 are
respective floor and makes a note of the
not aware of the real time
8 vacant rooms, occupied beds and to bed Process
availability of rooms in the
discharged patients. This can lead to
hospital
error in process and if patient are
transferred without the reception staff
notice
9 There is no uniformity in consultation
Consultation slip is not
card and everybody is using their own Process
system generated
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 slip
There is no investigation
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 is not Exact footfall of daily patient is not
12 Process
analyzed at the end of the known by the management
month
It helps the hospital management to
There is no mechanism for assess the satisfaction level of patients
13 Process
collecting OPD feedback and thereby provide them with better
services
List of empanelment and
List has to displayed for the information
14 corporate tie-up is not being Infrastructural
of the patient and 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 what
20 Process
nursing station actions to be taken for near expiry
drugs
There is no emergency drug register
Emergency medicine stock is available in the nursing stations with a
21 Process
not updated regularly system to check the items in every
shift
posters for infection control,
There is no work instructions
medication administration, LASA
displayed in the nursing
22 medication, high risk medications etc Infrastructural
stations for different
will increase the awareness on related
procedures
aspects

Blood transfusion note mentioning the
There is no valid record of starting time and ending time along
23 Process
blood transfusion with the signature of staff is not
available
There is no Blood transfusion Separate blood transfusion consent
24 consent and transfusion form and transfusion reaction form Process
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 KIT’ along with the Kit is to be placed in
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 who
Nursing handover system is
27 had given handover and who had Process
not appropriate
taken handover.
Nurses has to be BLS trained that in
28 Nurses are not BLS trained case of emergency they could apply Process
proper CPR
In case the patient is referred to any
There is no referral slip
29 higher centre, referral notes are given Process
available in the hospital
in the Discharge format itself
Most of the doctors and
As per nabh guidelines the doctor,
nurses notes on the case
30 nursing notes are dated, timed and Process
sheet and nursing records are
signed
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 the not take verbal orders where as others Process
hospital are saying opposite to that.
Less attendant means less crowds
There is no fix timing for
34 which helps the hospitals the hospital Process
attendant visit
staff in delivering quality health care
Nurses are not aware Nurses are not aware exactly what to
35 Process
regarding needle stick injury do after a needle stick injury
36 Bill card not is not available For better billing process Process
Proper segregation of waste is Plastic saline bottle is found in yellow
37 not followed in the nursing colour bin in the ground floor nursing Process
station station
There are multidose drugs which
Multidose vials are not
38 should not be used beyond certain Process
labelled with opening date
duration of time from the date of
10 | P a g e Assessment Report of Astha Hospital, Dibrugarh

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 and Process
labelled
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 emergency Infrastructural
patients procedure
Emergency drugs are stored in the

There are no crash cart
42 tight containers which the staff are not Infrastructural
available in the ICU
able to open, when asked
Bar soaps is being used for washing
There is no liquid soap in
43 hands which can lead to cross Process
hand wash station
infections.
The sterilized items should be labelled
No validation of sterilized
44 with date of sterilization and expiry Process
items
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 the
There is no consent taken patient attendants regarding the
46 Process
for admission in ICU patient condition and further
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 in
48 equipments available in Process
each unit with all the details of
the ICU
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 be
There is no blood
50 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 Indicators
51 and re - admission of Process
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 near
53 Process
ICU expiry drugs
There is no inventory / It can lead to pilferage and misuse of
54 Process
stock register stock
ICU nurse should sanitize their hand
There is no hand sanitizer
55 before and after attending a patient to Process
available in ICU
prevent cross contamination
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 against
58 Process
could not be evidenced humidifier cleaning to prevent
infection
ICU nursing staff is not BLS Staff should be trained to provide CPR
59 Process
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 bacteria
61 Process
after fumigation not done 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 the Process
critical care unit department
Hospital should define the admission
There is no admission and
and discharge criteria so that
63 discharge criteria Process
evidence based treatment can be
maintained in the ICU
followed in the department
There are no standard To ensure the uniformity and
protocols for ICU clinical standardized care staff should be
64 Process
procedures displayed in the provided training on the clinical
department procedures protocols
Pharmacy

There is no periodic stock It can lead to theft, pilferage,
65 audit done in the wastage/misuse of items. Maintaining Process
Pharmacy stock level helps in developing a good

reordering system and also helps
during stock auditing.
Hospital does not have Software should be available for better
66 Process
pharmacy software module inventory control
No pest control measures
Pharmacy rack has been covered with
67 has been taken for along Process
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 stored
Temperature chart is not
69 within a temperature of 2 - 8 degree Process
maintained for refrigerator.
celcius to avoid damage
Medicines are arranged in a haphazard
There is no scientific
manner in the racks. It is stored in
method followed for
70 company wise where all types of Process
arranging the medicines in
medicine like syrup, capsules, pill,
the rack
ointment are stored in the same rack
Drugs which are prescribed by the
doctors are those which are not
There is no formulary approved by the management.
71 Process
followed in the 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 check the
There is no defined High drug name with the patient identity
72 Risk Drugs & policy for (UID and name)to avoid any Process
dispensing it 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 stored same and storing the same in a Process
in a uniform manner uniform location will help in easy
identification during emergency
situations.
There should be a list of Sound alike
Hospital has not defined and look alike drugs which should be
74 the LOOK ALIKE AND stored in separate racks to avoid Process
SOUND ALIKE DRUGS list 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 same
75 Process
kept separately first will help in avoiding storing of
expired drugs and thereby preventing

dispensing of expired drugs.
Pests can cause property damage and
There is no pest control
also it can lead to many kinds of
76 measures followed in the Process
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 with There is no system followed for
78 Process
other drugs periodic check of near expiry 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 gonad
protective devices available
80 guard, thyroid guard is not available, Infrastructural
for patient while taking X
only lead apron is available
Ray and CT
There is no validation of Though the machine is under AMC,
81 calibration of X-ray Calibration report of the Machine is Infrastructural
machine not available.
Radiation signage outside There is a specific Signage as per AERB
82 the X-ray is not as AERB standards that needs to be displayed Infrastructural
guideline in front of the X-ray and CT scan
A requisition slip should be sent to the
Investigation are not
concerned department along with a
83 requested through Process
paid or credit stamp or any other
requisitation slip
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 the
Radiographers are not
staff working in the X-Ray and CT scan
85 being provided with TLD Infrastructural
unit. Even the orthopedic surgeon
badges.
conducting C-Arm procedure should
have TLD badge
Lead apron should be checked
Lead aprons are not periodically under X-Ray to validate for
86 Process
checked periodically any cracks and it should be
documented
The lead aprons are folded Lead apron should always be hanged
87 and kept in the department in the department to avoid any cracks Process
and in the OT in it

No red light installed
Red light indicates and warns anyone
88 outside CT scan and X-Ray Infrastructural
for the procedure is in progress
unit
Quality assurance test and Conducting internal and external
certificate is not availabe verification and surveillance for its
89 Process
for the X-ray machines and imaging services helps in validating the
CT scan results obtained.
Human Resource
There is no documented The Organizational Hierarchy should
Organization Organogram be defined and displayed to maintain a
90 Process
available although staff are line of command and authority in the
aware of it organization
Recruitment process is not Recruitment, Screening and selection
91 Process
documented process should be documented
There is no documented
The staffs are not aware of the leaves
92 leave policy followed in the Process
available for them in an year
hospital
Awareness on the system of
There is appraisal policy performance appraisal followed in the
93 Process
defined in the hospital hospital will motivate the staff to
perform well
It is necessary to carry out a general
Pre -Employment health
medical check-up for all staff being
94 checkup is not done in the Process
recruited to the organization to make
hospital
sure that they are fit for the job.
Not all patient handling
Virus can easily transfer through direct
95 staff are not hepatitis-B Process
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 about
It helps the staff in understanding how
the employee grievance
to raise a complaint or any other
98 policy and disciplinary Process
grievance and also the management
policy followed in the
policy on disciplinary actions
hospital
The duty roster of every department is
HR department is not
prepared by in-charges. But the roster
99 aware of the duty roster of Process
should come to HR at the beginning of
all the department
the month
100 Induction Programme is Many staffs in the nursing department Process

not conducted for new are not oriented with their job
staff responsibilities
Employee Satisfaction is
101 not tracked by the hospital Self explanatory Process
management
To expect a better performance
among the staff, it is necessary to give
them on job training, which will show
No training and the commitment of the organization in
102 development policy has improving the quality of care and also Process
been evidenced 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 should
Employee wise files are not
103 be kept in their individual respective Process
files
Facility Management, Engineering Services and Maintenance
There is no preventive
Such records are to be maintained to
maintenance & breakdown
104 analyze the Downtime & response Process
maintenance record
time of Service engineers
available for the DG set
‘No smoking' and 'danger' It shall be done as a safety precaution
105 signage are not displayed from any kind of electrical and fire Infrastructural
in front of the DG set hazards
Facility inspection for patient care
There is no evidence of areas and non-patient care areas at
106 facility inspection being regular interval could help in Process
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 of The capacity of the Overhead tanks
108 the exact capacity of should be written on the tank along Process
overhead tanks with last cleaning and due date
Emergency phone numbers Putting up the emergency numbers in
are not displayed at the hospital helps the staff or patient
109 Process
strategic locations of the attendant to contact the concerned
hospital persons in crisis situation
No cleaning/maintenance There is documental evidence for
110 checklists have been periodic cleaning and maintenance of Process
displayed for water the Water purifier

purifiers.
There are no safety signage
Safety signage written in bilingual
available in front of the
111 language should be put up to ensure Infrastructural
Electrical room, generator
ready information to the people
set
There is no Fire evacuation Fire exit signage guide the staff and
112 plan displayed in the patients to exit the building safely at Infrastructural
hospital the time of fire emergencies
Records of periodic testing of
Fire alarm system are not
113 equipment is to be maintained in the Process
periodically tested.
hospital
Hazardous materials in the
hospital are not identified Guidelines to handle the hazardous
and MSDS are not materials are to be displayed and
114 Process
displayed for the same in training for the same is to be provided
different department of to the staff
the hospital
The hospital has number of entry and
exit and in order to maintain the
Adequate security staff is safety & security of the hospital
115 Infrastructural
not available in the hospital building , staff and patients , number
of security personnel has to be
strengthened
Any breakdown of the departmental
There is no complaint utilities is to be noted down on the
116 register maintained in the register along with the date and time. Process
different department Once the complaint is addressed the
same is to be recorded in the register
Master list of equipment comprises of
There is no master list of
a comprehensive information about
117 Equipment maintained in Process
the equipment, contact details of the
the hospital
service engineer, AMC, calibration etc
Break down maintenance and
Equipment wise Log is not
118 preventive maintenance is to Process
documented for each equipment
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 not Warning signage like "No Smoking or
120 displayed outside the "Flammable gas" has to be displayed Infrastructural
manifold room outside and inside the manifold room
The storage area does not
have details of type of gas, This instructions are necessary for
121 Infrastructural
hazards possible and time to time education of the Staff
emergency contact

numbers
Safety shoes and protective gloves to
be worn when loading and unloading
No precaution is taken medical gas, Wheeled carrier of
122 during cylinders appropriate size are to be used when Infrastructural
transportation 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 area
124 pressure level reaches the minimum Infrastructural
gas alarm in the hospital
limit
Staff is not aware of the
Infection control measures are to be
measures to be taken to
125 taken to prevent infection through Process
prevent contamination of
contamination of gases
gases
Pressure gauze has not
126 Self explanatory Process
been calibrated
There is no record of This help to determine the buffer stock
number of cylinders issued and consumption of medical gas to
127 Process
from the storage area to come to a scientific distribution of the
the departments gas cylinders
Laboratory
Lab technician is not using
PPE like gloves are to be used by the
128 PPE during the time of Process
lab technicians
collecting sample
Ideally sample collection room should
There is no separate
129 be separate from the investigation Process
sample collection room
room
Requisition records to be maintained
There is no lab requisition
130 in the department for exact reporting Process
slip available in the hospital
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 not
132 can affect the Lab procedures and test Process
done for the lab technician
results.
The hospital have not defined the
No, sample rejection
criteria for rejecting the sample in the
133 register and redo register Process
laboratory and such events needs to
maintained
be documented

If accidently a chemically hazardous
material spillage is there, then there
No, spill management kit in
134 are some special procedures the staff Infrastructural
the laboratories
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 laboratory staff
No, material safety data because they deal with chemicals on
135 Process
sheet displayed in the lab 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 of track of AMC, due date if calibration of Process
equipments all the equipments in the department
Record of downtime of equipment is
There is no equipment
not maintained in the hospital which
137 breakdown or complaint Process
will help in assessing the efficiency of
book
the Maintenance department
Calibration quantifies and improves
the measurement performance of an
instruments hence the laboratory
Most of the equipment in
equipment has to be calibrated to
138 the laboratories are not Process
check whether the result generated by
calibrated
the equipment are proper, which in
turn helps the physician in preparing
the treatment plan
All the lab equipment are to be pasted
Lab equipment are not
with stickers noting the last date of
tagged with AMC Due date
139 calibration date, due date of Process
and equipments are not
calibration, maintenance date and its
calibrated
due date
Training certificate should be available
No, user training certificate with the staff who have received
140 Process
with the staff training from the supplier while
installing the equipment
No standard safe practices protocols
Laboratory safe practices
have been developed by the hospital
141 protocols are not displayed Process
for the laboratory as per Bio safety
in the department.
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 not Process
maintained for refrigerator.
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 Registration UID number should be pasted in the
number mentioned in the sample to reduce the chance of
144 Process
laboratory register and in mismatch and confirming the identity
the collected sample of the patient
The turnaround time is not It helps in tracking the efficiency and
145 defined for tests done in total performance of the concerned Process
the laboratory. department.
There is no record available
Duplicate copies of the lab results
in the system or in hard
146 should be maintained in the lab for Process
copy to trace out the
easy retrieval of data
results
Periodic quality check of These are Quality control measures
147 distilled water is not done that the hospital laboratory should Process
in the lab maintain
If at all there is any chemical splash in
There is no eye wash
the eyes of the technician, eye wash
148 station available in the Infrastructural
facility enables to wash it off
laboratory
immediately
Yearly once laboratory external quality
Hospital does not assurance should be done to validate
149 Process
participate in EQUAS the result of the test performed in the
hospital
Temperature chart and Costly Reagent should be stored in a
150 thermometer is not defined temperature which in return Process
maintained for refrigerator. gives correct results
The hospital should have a MOU with
The hospital does not have
a outsourced lab that is NABL
151 MOU with the outsourced Process
accredited for the tests that are not
lab
been carried out by the hospital
Expiry reagent found in the
laboratory
When asked, the lab technician was
There is no fixed policy for
not able to answer properly the time
153 duration of time, the Process
duration for which the samples are
sample will be stored
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 it
hypochlorite solution
156 has to be decontaminated with the Process
available near the needle
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 by
BMW storage area is not
158 fences and it should be under lock and Infrastructural
under lock and key
key
The waste from different section of
There is no uniform way of
the hospital are carried either by hand,
159 carrying the waste to the Process
some in dustbin, where there are
BMW treatment facility
chances of spillage
Though there is register available with
BMW is not weighed the Hospital administrator for amount
160 before they are disposed of waste generated day wise, the Process
off authenticity of the same is
questionable
Staff handling BMW should use PPE to
PPE is not used by BMW
161 safeguard themselves from cross Process
handlers
contamination
No surveillance activity for Urinary tract infection, Hospital
162 Infection control is acquired infection, Surgical Site Process
followed in the HCO Infection is not tracked
All types of linen are mixed and
There is no segregation of
163 ultimately every linen become Process
soiled and dirty linen
infectious
Appointing an Infection Control Nurse
No Infection Control Nurse
164 can help in assigning her all infection Process
has been appointed
control related activities
Operation Theatre

High risk consent in OT is High risk consent to be explained and
165 Process
not taken signed by the patient attendant
Soiled instruments are cleaned in the
There is no separate area scrub sink, where the surgeon used to
166 for cleaning soiled do the scrubbing before performing Infrastructural
instruments operation. Hence there is potential
threat for surgical infection
Proper handover checklist It is required to take proper handover
is not available with the OT of the patient from the ward. i.e to
167 Process
staff check wether all the paper in the
patient MR is available or not during

the handover
Intra operative and post Both Anesthetist and surgeon post
168 operative notes are not operative notes are not Process
maintained comprehensive
Early intimation of surgeries to be
Don’t have a defined done next day improves the efficiency
169 Process
surgery booking procedure of the OTprocesses and avoid
confusions among doctors and OT staff
There is no record of It can be used as a quality indicator to
170 surgery cancelled and assess the efficiency of the OT and OT Process
postponed 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 document
No, record is kept for the and keep records of the sponges and
173 sponges & gauges during gauges, needles & other sharp Process
the perioperative session instruments both before and after
surgery
Following parameters should be
followed 1)Consciousness level 2)
There is no fixed criteria for
Respiration 3) Circulation 4) Pain
transferring a patient from
174 Control 5) Nausea & Vomiting 6) Fluid Process
the recovery room to the
Balance 7) Heat Conservation 8)
ward
Wound Site, drains & Dressing 9)
Documentation
Daily checking of OT attendant to check all the
instruments before the first equipments/instruments and utilities
175 Process
surgery is not done and not daily before the start of the first
documented surgery
There has to be a monthly analysis
Analysis of OT Utilization at
done for the OT utilization rate,
176 the end of the month is not Process
Surgical Site Infection rate and
done
department wise surgery
People are allowed to
It can make the OT environment
177 come to the sterile area Process
unsterile
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 elbow To prevent contamination of the
179 Infrastructural
operated tape surgeons hand
Scrubbing sink is not
cleaned daily with 1%
180 It helps in preventing HAI Process
sodium hypochlorite
solution
No fixed schedule for
performing OT fumigation Fumigation has to be done in OT every
181 Process
and fumigation register is fortnight and as and when required
not maintained
Staff are not aware of the
182 preperation of the self-explanatory Process
disinfectant solution
Lead aprons in the OT are Lead aprons are folded and kept in the
183 not kept in hanging store room which might lead to crack Infrastructural
condition 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 not There is no BMW bins in the operation
185 Infrastructural
followed Theatre
There is stain mark under the OT table,
OT floor is good but not
186 when asked sister explains that the HK Infrastructural
maintained
staffs cleans the floor with "Phenyl"
Flat surface and grooves should be
Dust accumulates at the
avoided in the walls and floor of the
187 corner walls of the Infrastructural
OT to ensure minimum accumulation
operation room
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 in Process
performed frequently
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 OT Record of counting of OT swabs before
191 Process
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 of
194 Process
at the point of generation generation avoids spreading of
infection
Emergency drugs register
and consumables & For proper stock update and prevent
195 Process
disposable register is not pilferage
maintained
196 TSSU is not in a sterile area Self explanatory Process
Proper sterilization of TSSU technician is not aware of proper
operation theatre autoclaving process, sterilized items
197 Process
instruments could not be 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 of Process
and expiry date sterilized items is 7 days
EMERGENCY

There is no separate Assessment of the patient is done in a
199 emergency case sheet white paper without adequate Process
available in the ED assessment criteria defined
The nursing staff maintain separate
There is no central casualty registers for different department to
200 record available in the note which patient has been Process
department transferred to which respective
department
List of Emergency drugs
along with Minimum
quantity is not checked on
a daily basis
Emergency beds do not When Accident patient arrives and
202 have any hand rails or kept for observation, there are Infrastructural
safety belts chances of patient fall
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 which
Call book is not maintained
205 doctor comes to the hospital after Process
in the emergency
they get a call from the hospital.
When patients are referred from the
There is no referral card casualty to other hospital, there is no
206 maintained in the record of treatment given to the Process
emergency department. patient in the hospital and also why he
or she has been referred out.
Defining triaging system will help in
Triaging system in the HCO facing any kind of internal or external
207 Process
is not defined. disaster. It will help in handling mass
casualty
AMBULANCE
Minimum requirements
Ambulance is not equipped enough to
including first aid box in an
handle a patient during an emergency Infrastructural
ambulance are not
situation
208 available
No emergency medicines Ambulance is not equipped enough to
are available in the handle a patient during an emergency Infrastructural
209 ambulance 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 earliest
211 Infrastructural
engineer and there by reduces the equipment
breakdown time
Equipment log book helps in tracking
easily the details including last
Equipment log book is not
212 calibration date, due date, vendors Process
maintaining
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 time
Equipment down town
taking to address the complaint and it
215 tracking is not in a Process
is considered as a quality indicator of
standardized manner
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 can
217 and responsibilities are not be communicated easily through Infrastructural
displayed signage boards
Need to implement patient counseling
Patient counseling system
218 system and the same shall be Process
is not followed in the HCO
documented
Cost tariff is not available in It helps the patient/patient attendant
219 Process
the front office department in taking informed decisions
Patient visitors timing shall be shall be
Visiting time in the hospital communicated at the time of
220 Process
is not clearly defined counseling. It helps in controlling the
visitors flow to the hospital
GENERAL STORE
Daily indenting is difficult for the store
221 No fixed indent policy Process
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 the
Stock audit is not done in a record shall be same and it can be
223 Process
fixed interval achieved through regular stock audit
at fixed interval
Minimum stock level/re-
It avoids stock out and improves the
224 order level for each item Process
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 other evidence of the cleaning schedule of Process
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 the No personal protective equipment are
228 storage area with bare used while carrying the wastes bags Process
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 is
231 Process
not standardized 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 48
50 2
0
Process
Infrastructure
Statutory
Process Infrastructure Statutory

Series1 183 48 2
Process Infrastructure Statutory
Figure 1: Total Number of Gaps
Department wise gaps

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

Gap Report Astha Hospital

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2015

ASSESSMENT REPORT OF ASTHA

Rights & Permissions

102, 1st Floor, Orion Place.

Old Post Office, G.S.Road

1|Page Assessment Report of Astha Hospital, Dibrugarh

2|Page Assessment Report of Astha Hospital, Dibrugarh

3|Page Assessment Report of Astha Hospital, Dibrugarh

4|Page Assessment Report of Astha Hospital, Dibrugarh

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

5|Page Assessment Report of Astha Hospital, Dibrugarh

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|Page Assessment Report of Astha Hospital, Dibrugarh

6. STRENGTH & WEAKNESS

7|Page Assessment Report of Astha Hospital, Dibrugarh

8|Page Assessment Report of Astha Hospital, Dibrugarh

9|Page Assessment Report of Astha Hospital, Dibrugarh

10 | P a g e Assessment Report of Astha Hospital, Dibrugarh

Emergency drugs are stored in the

11 | P a g e Assessment Report of Astha Hospital, Dibrugarh

Sl. No Gap Statement Rationale/Explanation Gap classification

12 | P a g e Assessment Report of Astha Hospital, Dibrugarh

13 | P a g e Assessment Report of Astha Hospital, Dibrugarh

14 | P a g e Assessment Report of Astha Hospital, Dibrugarh

15 | P a g e Assessment Report of Astha Hospital, Dibrugarh

16 | P a g e Assessment Report of Astha Hospital, Dibrugarh

17 | P a g e Assessment Report of Astha Hospital, Dibrugarh

18 | P a g e Assessment Report of Astha Hospital, Dibrugarh

19 | P a g e Assessment Report of Astha Hospital, Dibrugarh

20 | P a g e Assessment Report of Astha Hospital, Dibrugarh

Sl. No Gap Statement Rationale/Explanation Gap classification

Sl. No Gap Statement Rationale/Explanation Gap classification

21 | P a g e Assessment Report of Astha Hospital, Dibrugarh

22 | P a g e Assessment Report of Astha Hospital, Dibrugarh

23 | P a g e Assessment Report of Astha Hospital, Dibrugarh

Sl. No Gap Statement Rationale/Explanation Gap classification

24 | P a g e Assessment Report of Astha Hospital, Dibrugarh

Sl. No Gap Statement Rationale/Explanation Gap classification

25 | P a g e Assessment Report of Astha Hospital, Dibrugarh

Sl. No Gap Statement Rationale/Explanation Gap classification

26 | P a g e Assessment Report of Astha Hospital, Dibrugarh

27 | P a g e Assessment Report of Astha Hospital, Dibrugarh

Process Infrastructure Statutory

Process Infrastructure Statutory

Figure 1: Total Number of Gaps

Department wise gaps

Department wise gaps

Figure 2: department wise gaps

28 | P a g e Assessment Report of Astha Hospital, Dibrugarh

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