Rating draft standards for RGJAY

%
Sr No Category of Standard
weightage
1 HR Quality 18
2 Facilities Management 15
3 Infection Control Measures 12
4 Quality of Patient Care 20
5 Monitoring Medication 8
6 Maintenance of Patient Medical Records 7
7 Patient Satisfaction Indices 8
8 Standard Operating Protocols 5
9 Transparency In pricing 7
Total Weightages 100

All applicable standards of PSI, QPC and INF 3,4,5 reporting should be done every 3 months
For the rest of the indicators reporting should be done every 6 monthly
Mandatory indicators
Mandatory indicators mean that 50%
compliance of norm is essential and would
lead to 50% score for that parameter but in
some parameters where 50% scoring is not
possible, this is clearly indicated against
that parameter.

All doctors refers to Medical practitioner registered with MCI or State Medical Council

A MinImum mandatory fulfilled in all sheets and marks more than 50

B Marks more than 50% in 6 sheets i.e. HR,FAC,MED,EMR,ICM,TIP
C Marks more than 50% in 4 sheets i.e. HR,FAC,MED,TIP
D Marks more than 50% in 2 sheets i.e. HR,FAC
,5 reporting should be done every 3 months

ed with MCI or State Medical Council

mum mandatory fulfilled in all sheets and marks more than 50% in each sheet
s more than 50% in 6 sheets i.e. HR,FAC,MED,EMR,ICM,TIP
s more than 50% in 4 sheets i.e. HR,FAC,MED,TIP
s more than 50% in 2 sheets i.e. HR,FAC
 CHAPTER 1 HUMAN RESOURCE
Category of Std Standard definition Expected Value Scoring Remarks Minimum scoring for
Standard for 50 UID Mandatory Indicators
bed hospital (50% compliance)
1 HR Quality HR1 Number of registered doctors with MBBS Average 2 per shift for 50 bed 2 MANDATORY 1 Input
HR2 Number of qualified and registered nurses Average 4 per shift for 50 bed 2 MANDATORY 1 Input
HR3 Number of qualified and registered Post graduate Minimum 1 on call for particular 2 MANDATORY 2
degree or diploma specialists broad specialty treated by (minimum 1 on call)
hospital; Information expected
specialtywise
Input
HR4 Doctor patient ratio in ICU One Doctor per six beded ICU 2 MANDATORY (1 1 Input
HR 5 Nurse patient ratio in ICU per shift 1:1 for ventillated bed 2 MANDATORY (1:2 1 Input
HR 6 Number of doctors on call with super specialty Minimum 1 2 MANDATORY 2 Input
HR 7 Number of Qualified and Registered Anesthetist with Minimum 2 on call. 1 MANDATORY 1 Input
Number of Qualified X-Ray technicians if inhouse Minimum 1 1 MANDATORY Input
Number of Qualified Lab technician with First Minimum 1 1 MANDATORY
preference for B.Sc. With D.M.L.T. Second preference (Minimum 1) If
- DMLT after HSC if inhouse facility inhouse
Input
HR 8 Display of Qualifications of Medical personnel Should be displayed on 1 MANDATORY 1 Input
HR 9 Whether qualified and registered MD Pathologist or Minimum 1 1 MANDATORY 1 Input
HR 10 Training Policy, Calender and Schedule Availibility of Training policy, 1 Process
18 11
All HR Norms for nursing exclude Leave reserve
 Category of Std UID Standard definition Expected information Scoring Remarks Minimum
CHAPTER 2 FACILITY MANAGEMENT
2 Facilities FAC1 Sampling by trainned Phlebotomist Samples should be collected by 1
Management with centralized receiving area trainned phlebotomist and received
at a centralized area Process
FAC2 Whether ambulance Services- inhouse Either inhouse or on call 1 MANDATORY 1 input
FAC3 Availability of trained personnel with Ambulance personnel should be 1
ambulance either BLS or ALS minimum BLS trained.
input
FAC4 Avalability of foot suction machine, For BLS ambulances 1 MANDATORY MEANS 1
Emergency tray, Defibrillator/AED, IV emergency tray, oxygen,
Fluids, Oxygen, Infusion pump, infusion pump, Foot
Stethoscope and BP Apparatus. suction, stethoscope and
BP appratus, IV fluid (all
except defibrillator) input
FAC5 whether ICU equipped with life saving Minimum requirement 1 MANDATORY 1
equipment such as ventilator,
defibrillator and Pulse oxymeter input
FAC6 Bed occupancy % Sum of daily census of patients 1 More than 50%= 1; 30%- Process
FAC7 Fire Safety Measures. One fire Plan exists for exit in case of fire 1
extinguisher per ward with NOC from and non fire emergency and drill
fire department or licencing agency to carried out twice a year
be obtained within next one year
input
FAC8 Two minimum rounds by treating Round book should have record, 1 MANDATORY (Minimum 0.5 Process
FAC9 Operation theatre Whether it has functional OT zoning 1 input
FAC10 Doctors Call response time(Difference Total time interval for all calls / 1 Process
FAC11 Percentage of AMC or CMC of Total number of equipments with 1 input
FAC 12 For purposes of diet, Institution should Registration should be there 1 input
FAC 13 Uninterrupted power and water supply Availability atleast in critical areas 1 MANDATORY 1 input
FAC 14 Oxygen Supply Contineous availability of either 1 MANDATORY 1 input
FAC 15 Signages Display of various signages and in 1 input
15
 CHAPTER 3 INFECTION CONTROL
Category of Std UID Standard definition Expected information Scoring For calculated Remarks Minimum
3 Infection Control INF1 Documented Infection Air quality monitoring done atleast 1 input
INF2 Infection control committee Meeting register should be available for 1 MANDATORY 1
and regular meetings with monthly meeting with minutes of meeting
minutes documented process
INF3 Availability of Surveillance For surgical facility - Surgical site 2 No of SSI for clean Only clean process
INF4 Availability of Surveillance ICU - Ventilator Associated Pneumonia 2 Total VAP cases* Ref - CDC process
INF5 Availability of Surveillance Wards & ICU - Catheter related Urinary 2 month Ref - CDC process
INF6 Incidence of Needle stick Number of Health care providers given 1 Scoring based on process
INF7 Availability of hand hygiene Facilities for Hand wash and hand 0.5 MANDATORY 0.5 input
INF8 Monitoring of CSSD Autoclave register with evidence of 1 MANDATORY 1 process
INF9 Whether registered with Date, authorization number and date of 0.5 MANDATORY input
INF10 Hepatitis B vaccination for Protection levels should be monitored 0.5 maintanence of records MANDATORY 0.5 process
INF11 Rational use of Antibiotics Hospital to formulate and implement 0.5 process
12
 CHAPTER 4 MEDICATION MONITORING
Category of Std UID Standard definition Expected information Scoring Remarks Minimum
5 Monitoring MED1 Storage of medicines Medications are stored in clean, secure 2 input
MED2 Whether Sound Inventory control Stock register mentioning receipts and 2
practices followed expenditures. Adequate supplies
including buffer shall be maintained.
FIFO practices shall be followed
process
MED3 Whether look alike and sound alike Whether such medications are stored 1
(LASA) medicines are stored separately
separately in order to prevent drug process
mishaps input
MED4 Whether Medical store approved by Registration number with date and date 1 MANDATORY 1
MED5 Medication orders Whether medication orders on OPD and 1 process
MED6 Adequacy of refrigeration facilities Temperature monitoring record should 1 process
8
 CHAPTER 5 PATIENT MEDICAL RECORDS
Category of Std Standard definition Expected information Scoring Remark Minimum scoring
Standard UID for Mandatory
Indicators (50%
compliance)

6 Maintenance EMR1 Whether Patient UID generated Every OPD and IPD paper should 1 MANDATORY 1 process
EMR2 Every inpatient should have unique This record should contain the 1 MANDATORY 1 process
EMR3 Arrangements made for transmitting Documentation should be 1 process
EMR4 Whether reporting of Medical 100% reporting of Medical 2 MANDATORY 2 process
EMR5 Morbidity and Mortality statistics with Morbidity statistics and Mortality 2 process
7
 CHAPTER 6 PATIENT SATISFACTION INDICES
Category of Std UID Standard definition Expected information Scoring Remark Minimum scoring for
Standard Mandatory Indicators
(50% compliance)
7 Patient PSI1 Appointment Whether appointment scheduling 1
Satisfaction possible on phone/internet
Indices
PSI2 Whether patient stabilised before Number of patients died during referral 1 upto 2%=1; more than
PSI3 Percentage of DAMA / LAMA Total number of patients who left 1 upto 5%=1; more than
PSI4 % of cancellation of surgeries Total number of cancelled surgeries x 1 upto 10% =1; more than
PSI5 Informed consent before Informed consent of patient taken by 1 MANDATORY 1
PSI6 Feedback form made available Total number of feedback forms made 1
PSI7 Citizen's Charter and Suggestion Availability of Citizen's charter at 1 MANDATORY 1
PSI8 Patient’s Rights and Education. Patient's record should be accesible to 1 MANDATORY 1
8
process
output
output
process
process
process
input
process
 CHAPTER 7 STANDARD OPERATING PROTOCOLS
Category of Std UID Standard definition Scoring Scoring Remark Minimum scoring
Standard for Mandatory
Indicators (50%
compliance)

8 Standard SOP1 SOP for Diagnosis and management 0.5

Operating of top 10 common diseases
Protocols input
SOP2 SOP for Admission and Discharge 0.5 MANDATORY 0.5 input
SOP3 SOP for medicine storage and 0.5 input
SOP4 SOP for Operation Theatre work 0.5 MANDATORY 0.5 input
SOP5 SOP for ICU(Admission and 1 input
SOP6 SOP for Emergency services(10 0.5
most common emergencies and how
they are managed) input
SOP7 SOP for Laboratory services. (SOP 0.5 MANDATORY 0.5 input
SOP8 SOP for Radiodiagnostic 0.5 input
SOP8 Use of ICD Code for diseases and 0.5 input
5
 CHAPTER 8 TRANSPARENCY IN PRICING
Category of Std UID Standard definition Scoring Remarks
9 Transparency In TIP1 Whether pricing information on bed 1 MANDATORY input
TIP2 Whether bill of discharge gives break 2 MANDATORY process
TIP3 Whether patient provided list of 2 process
TIP4 For medical devices, whether patient 2 process
7
 CHAPTER 9 QUALITY OF PATIENT CARE
For these indicators, scoring would be based only on maintenance of records and not on actual figures
Category of Std UID Standard Whether record kept Scoring Remarks
Standard definition and information
recorded
4 Quality of QPC 1 Reporting of 1. Total medication errors 1 Scoring will be
Patient Care Adverse Events x 100 / Total no of in based on
patient days maintainence of
records and
2. No of Blood 1 corrective actions
Transfusion reactions x taken
100 / No of Blood Units
issued
3. Total Drug reactions x 1
100/ Total No of in
patient days
4. Total Wrong patient 1
surgery or wrong side
surgery(Absolute
number)

QPC 2 Regular Discussion Record of Monthly 1

of Adverse Events Meetings in meeting
with corrective register.
measures

QPC 3 Use of Surgical Whether displayed and 1

Safety Check lists followed in all Operation
Theatres, ICU, SNCU,
Casualty and wards

QPC 4 Postoperative Record of documentation 1 1= Surgical Complicati For each positive

QPC 5 Average Length of Total In patient 0
stay Days/Total IPD patients
discharged
QPC 6 ICU care APACHE (Acute 1 If it
QPC 7 Gen Surgery Number of patients 1
requiring repeat surgery
within 30 days *100/ No
of major planned and
emergency surgeries for a
month

QPC 8 Gen Surgery Number of Post-operative 1 Only clean

Deaths *100/ Total no of surgeries
major planned and
emergency surgeries in
30 days

QPC 9 Transferred Out Total no of transferred 1

out patients*100/Total
IPD
QPC 10 Avg Door to Needle Average time taken in 1
or door-to-balloon minutes for patients with
times in acute acute ST elevation
STEMI myocardial infarction to
receive fibrinolytic
therapy after arrival in
hospital, or primary PCI
after arrival in hospital.
Timings to be given in
minutes.

QPC 11 Use of dual Total No of patients 1

Category of Std UID Standard Whether record kept Scoring Remarks
Standard definition and information
recorded
QPC 12 In-hospital mortalit Percentage of patients 1
undergoing CABG
surgery who died before
discharge
QPC 13 Use of Left Internal Percentage of patients 1
Mammary artery undergoing CABG
grafts surgery who received a
left internal mammary
artery graft

QPC 14 In-hospital Percentage of patients 1

mortality for valve undergoing valve surgery
surgery who died before
discharge
QPC 15 Post Operative Percentage of patients 1
Sternotomy undergoing sternotomy
infection (for CABG or valve
surgery) who developed
sternal wound infection

QPC 16 Post PCNL No of post PCNL patients 1

percentage calculi with residual Calculi
*100/ No of operated
PCNL patients

QPC 17 Orthopaedics Number of patients with 1

fracture nonunion or
delayed union requiring
repeat surgery *100/ No
of surgeries for open
reduction of fracture(>9
months for Non-union
and >3 months for
delayed union)

QPC 18 Gynae Number of Post-operative 1 Within the

Deaths in Gynae Surgery same
*100/ Total no of major hospitalizati
planned and emergency on period
Gynac
surgeries(Obstetrics cases
not included)
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Sr No Category of Std UID Standard definition Expected Expected Minimum
1 HR Quality HR1 Number of registered Average 2 per shift 2 Minimum 1 per
for 50 beded doctors with MBBS shift)
Hospital qualification

HR2 Number of qualified and Average 4 per shift 2 MANDATOR

registered nurses incluing Incharge Y (Minimum 2
(GNM,B.Sc. And M.Sc. Sister with minimum per shift
(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve

Total doctors 7 2
Total nurses including leave reserve 18 10
20%
2 HR Quality HR1 Number of registered Average 3 per shift 2 MANDATOR
for 100 HR2 doctors
Numberwith MBBS and
of qualified Average 8 per shift 2 Y (minimum 1
MANDATOR
beded qualification
registered nurses with one Incharge per shift)
Y (Minimum 5
hospital (GNM,B.Sc. And M.Sc. Sister with minimum per shift
(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve

Total
Total doctors
nurses including leave reserve 11 4
20% 45 20
3 HR Quality HR1 Number of registered Average 4 per shift 2 MANDATOR
for 200 doctors with MBBS Y (minimum 2
beded qualification per shift)
hospital
HR2 Number of qualified and Average 20 per shift 2 MANDATOR
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And M.Sc. Sister with minimum 12 per shift
(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve

Total
Total doctors
nurses including leave reserve 13 6
20% 90 45
4 HR Quality HR1 Number of registered Average 5 per shift 2 MANDATOR
for 300 doctors with MBBS Y (minimum 2
beded qualification per shift)
hospital
HR2 Number of qualified and Average 30 per shift 2 MANDATOR
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And M.Sc. Sister with minimum 20 per shift
(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve

Total
Total doctors
nurses including leave reserve 15 7
20% 135 62
5 HR Quality HR1 Number of registered Average 7 per shift 2 MANDATOR
for 400 doctors with MBBS for 400 bed hospital Y (minimum 3
beded qualification per shift)
hospital
5 HR Quality
for 400
beded
hospital
HR2 Number of qualified and Average 35 per shift 2 MANDATOR
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And M.Sc. Sister with minimum 25 per shift
(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve

Total
Total doctors
nurses including leave reserve 19 9
20% 138 93
6 HR Quality HR1 Number of registered Average 08 per shift 2 MANDATOR
for 500 doctors with MBBS Y (minimum 3
beded qualification per shift)
hospital
HR2 Number of qualified and Average 60 per shift 2 MANDATOR
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And M.Sc. Sister with minimum 30 per shift
(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve

Total
Total doctors
nurses including leave reserve 23 9
20% 225 108
7 HR Quality HR1 Number of registered Average 10 per shift 2 MANDATOR
for 1000 doctors with MBBS Y (minimum 8
beded qualification per shift)
hospital
HR2 Number of qualified and Average 70 per shift 2 MANDATOR
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And M.Sc. Sister with minimum 50 per shift
(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve

Total
Total doctors
nurses including leave reserve 30 16
20% 260 180
Minimum
1

1
1

1
1