GAP ANALYSIS (NABH) & CLINICAL AUDIT ROAD MAP
Accreditation is an incentive to improve capacity of Heath Care Organizations to provide quality of care. Clinical Audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes and implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery”. The aim of the clinical audit is to measure the gap between ideal practice(determined from evidence and guidelines) and actual practice. Audit does not seek to apportion blame on individual practitioners, but aims to improve the systems in which individuals work. Done correctly, audit can bring about change and improve practice and clinical effectiveness.
  
Outline structure of Nephrology Audit Processes
Step 1: Preliminary meeting with Steering committee/interested parties involved in this project(Includes                             Nephrologist, Department Representative and Management Representative)(3-4 hours)
Step 2: Pre-evaluation Audit(Center overview, patient view, Physical Plant and Water)(4 hours)
Step 3: Gap Analysis(Related to Nephrology – As per NABH clinics Standard)(16 hours)
Step 4: Meeting with steering committee/interested Parties(Includes Nephrologist, Department Representative                  and Management Representative) – Discussion regarding clinical audit topics as per main priority of the                Nephrology Department.(3-4 hours)
Step 5: Clinical Audit topic will be finalized as per high priority – Standard setting will be done as per Clinical                     audit process includes selecting criteria, measuring level of performance, making improvements,                            Sustaining improvement. (2 months)
Step 6: Final report submission.