|
ACCESS, ASSESSMENT AND CONTINUITY OF
CARE (AAC)
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||
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Sl no
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AAC no
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Reason
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1
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AAC1a
|
Some of the services are not defined
|
|
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2
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AAC1b
|
All defined services are not displayed
|
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3
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AAC1c
|
Proper orientation is not there for majority staffs
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4
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AAC2f
|
All staffs are not fully aware about the documented policies and
procedures of registration and admission
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5
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AAC3a
|
Procedures for transferring the patients need more clarity.
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6
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AAC3c
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No proper staffs are assigned for transferring patients to other units
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7
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AAC4e
|
Initial assessment of nutritional needs are not done in all patients
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|
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8
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AAC4i
|
The care plan doesn’t include desired results of the treatment, care
or service
|
|
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9
|
AAC6e
|
Critical results are not intimated due to lack of advanced
communication methods.
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10
|
AAC6g
|
Lab tests are not out sourced to other organization
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|
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11
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AAC8a
|
The lab safety program is not properly documented.
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|
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12
|
AAC8c
|
Written procedures do not guide the handling and disposal of
infectious and hazardous materials.
|
|
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13
|
AAC14f
|
Discharge summary doesn’t incorporates instructions about when and how
to obtain urgent care.
|
|
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Sl no
|
AAC no
|
Reason
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|
|
1
|
AAC2b
|
Emergency patients are not properly addressed.
|
|
|
2
|
AAC8d
|
Not appropriate training for personnel.
|
|
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3
|
AAC9i
|
Imaging tests not available in the organization are not out sourced to
other organization due to absence of MOU
|
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Sl no
|
AAC no
|
Reason
|
|
|
1
|
AAC2b
|
Emergency patients are not properly addressed.
|
|
|
2
|
AAC8d
|
Not appropriate training for personnel.
|
|
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3
|
AAC9i
|
Imaging tests not available in the organization are not out sourced to
other organization due to absence of MOU
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|
Table1shows Individual and average score for each standards
|
||||||
|
Sl no
|
Standards
|
score
|
average
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|||
|
1
|
AAC1a
|
5
|
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|||
|
2
|
AAC1b
|
5
|
5
|
|||
|
3
|
AAC1c
|
5
|
|
|||
|
4
|
AAC2a
|
10
|
|
|||
|
5
|
AAC2b
|
5
|
|
|||
|
6
|
AAC2c
|
10
|
|
|||
|
7
|
AAC2d
|
5
|
7.14
|
|||
|
8
|
AAC2e
|
5
|
|
|||
|
9
|
AAC2f
|
5
|
|
|||
|
10
|
AAC2g
|
10
|
|
|||
|
11
|
AAC3a
|
5
|
|
|||
|
12
|
AAC3b
|
5
|
5
|
|||
|
13
|
AAC3c
|
0
|
|
|||
|
14
|
AAC3d
|
10
|
|
|||
|
15
|
AAC4a
|
10
|
|
|||
|
16
|
AAC4b
|
10
|
|
|||
|
17
|
AAC4c
|
0
|
|
|||
|
18
|
AAC4d
|
10
|
7.77
|
|||
|
19
|
AAC4e
|
5
|
|
|||
|
20
|
AAC4f
|
10
|
|
|||
|
21
|
AAC4g
|
10
|
|
|||
|
22
|
AAC4h
|
10
|
|
|||
|
23
|
AAC4i
|
5
|
|
|||
|
24
|
AAC5a
|
10
|
|
|||
|
25
|
AAC5b
|
10
|
|
|||
|
26
|
AAC5c
|
10
|
10
|
|||
|
27
|
AAC5d
|
10
|
|
|||
|
28
|
AAC5e
|
10
|
|
|||
|
29
|
AAC6a
|
5
|
|
|||
|
30
|
AAC6b
|
10
|
|
|||
|
31
|
AAC6c
|
10
|
|
|||
|
32
|
AAC6d
|
10
|
7.14
|
|||
|
33
|
AAC6e
|
5
|
|
|||
|
34
|
AAC6f
|
10
|
|
|||
|
35
|
AAC6g
|
0
|
|
|||
|
36
|
AAC7a
|
10
|
|
|||
|
37
|
AAC7b
|
10
|
|
|||
|
38
|
AAC7c
|
10
|
10
|
|||
|
39
|
AAC7d
|
10
|
|
|||
|
40
|
AAC7e
|
10
|
|
|||
|
41
|
AAC8a
|
5
|
|
|||
|
42
|
AAC8b
|
0
|
|
|||
|
43
|
AAC8c
|
0
|
3
|
|||
|
44
|
AAC8d
|
0
|
|
|||
|
45
|
AAC8e
|
10
|
|
|||
|
46
|
AAC9a
|
10
|
|
|||
|
47
|
AAC9b
|
5
|
|
|||
|
48
|
AAC9c
|
5
|
|
|||
|
49
|
AAC9d
|
10
|
7.22
|
|||
|
50
|
AAC9e
|
5
|
|
|||
|
51
|
AAC9f
|
10
|
|
|||
|
52
|
AAC9g
|
10
|
|
|||
|
53
|
AAC9 h
|
10
|
|
|
||
|
54
|
AAC9i
|
0
|
|
|||
|
55
|
AAC10a
|
10
|
|
|
||
|
56
|
AAC10b
|
10
|
|
|
||
|
57
|
AAC10c
|
10
|
10
|
|
||
|
58
|
AAC10d
|
10
|
|
|
||
|
59
|
AAC10e
|
10
|
|
|
||
|
60
|
AAC11a
|
10
|
|
|
||
|
61
|
AAC11b
|
10
|
|
|
||
|
62
|
AAC11c
|
10
|
|
|
||
|
63
|
AAC11d
|
10
|
10
|
|
||
|
64
|
AAC11e
|
10
|
|
|
||
|
65
|
AAC11f
|
10
|
|
|
||
|
66
|
AAC11g
|
10
|
|
|
||
|
67
|
AAC12a
|
10
|
|
|
||
|
68
|
AAC12b
|
10
|
|
|
||
|
69
|
AAC12c
|
10
|
10
|
|
||
|
70
|
AAC12d
|
10
|
|
|
||
|
71
|
AAC12e
|
10
|
|
|
||
|
72
|
AAC12f
|
10
|
|
|
||
|
73
|
AAC13a
|
10
|
|
|
||
|
74
|
AAC13b
|
10
|
|
|
||
|
75
|
AAC13c
|
10
|
10
|
|
||
|
76
|
AAC13d
|
10
|
|
|
||
|
77
|
AAC14a
|
10
|
|
|
||
|
78
|
AAC14b
|
10
|
|
|
||
|
79
|
AAC14c
|
10
|
|
|
||
|
80
|
AAC14d
|
10
|
8.57
|
|
||
|
81
|
AAC14e
|
10
|
|
|
||
|
82
|
AAC14f
|
0
|
|
|
||
|
83
|
AAC14g
|
10
|
|
|
||
PRIMARY REPORT OF THE GAP ANALYSIS
There are in total of 83 questions under 14 categories in
the self-assessment tool kit. Each questions will be given the scores of zero,
five and ten based on its compliance with the standards of NABH.
Final observations are reported under three categories viz
List 1= non compliance that can be easily closed
List 2= non compliance that require more time.
List 3= facility corrections.