04 — Consulting service
Gap Audit & Detailed Reporting
Comprehensive Accreditation Readiness Assessment
Systematic review of processes, documents, infrastructure, and practices to identify compliance status, strengths, weaknesses, and improvement opportunities against NABH, NABL, JCI, NQAS, or other standards.
Ideal for
Healthcare organizations at any stage of their accreditation journey seeking a clear, objective baseline assessment before committing to a full implementation program.
Standards covered
NABH · NABL · JCI · NQAS · Other quality standards
Scope of services
What this engagement covers
- 01Document review — Policies, SOPs, Registers, Records
- 02Departmental assessment — Clinical areas, Support services, Administrative functions
- 03Staff interviews — Leadership, Clinical teams, Nursing teams, Support staff
- 04Physical verification — Facility inspection, Safety compliance, Infection control practices
Engagement process
Clear stages, clear ownership.
Each stage is structured to reduce confusion, build team ownership, and move measurably toward accreditation readiness.
- 1Pre-audit planning and document request
- 2On-site departmental and document review
- 3Staff interviews across leadership, clinical, and support teams
- 4Physical facility and safety verification
- 5Compliance scoring and non-conformity identification
- 6Detailed gap report and roadmap delivery
Benefits
What you can expect when you engage with us.
Detailed Gap Analysis Report
Compliance Scoring and Non-Conformity Identification
Risk Assessment Findings
Priority-Based Action Plan
Accreditation Readiness Score
Implementation Roadmap
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