Laboratory Section:

1. Question: Are PPE properly used while collecting blood samples?

Answer: Yes
Remarks:
NC:
NC Details:

2. Question: Are samples identified properly?

Answer: Yes
Remarks: Name and UHID written
NC:
NC Details:

3. Question: Are the samples transported in a safe manner?

Answer: Yes
Remarks:
NC:
NC Details:

4. Question: Is disposal of specimen done in safe manner?

Answer: Yes
Remarks:
NC:
NC Details:

5. Question: Is there any defined turnaround time for test?

Answer: Yes
Remarks:
NC:
NC Details:

6. Question: Are laboratory personnel using appropriate safety equipment/ devices?

Answer: Yes
Remarks:
NC:
NC Details:
 Radiology Section
1. Question: Are imaging personnel using appropriate safety equipment/ devices?
Answer: No
Remarks: No radiology services available
NC:
NC Details:

2. Question: Is there any defined turnaround time for test?

Answer: No
Remarks: No radiology services available
NC:
NC Details:

Emergency Section
1. Question: Are services being provided as per laid down Norms?
Answer: Yes
Remarks: Staff interview taken. Staffs are aware
NC:
NC Details:

High D.A. Section

1. Question: Is patient care given as per the HCO’s documented procedure?
Answer: No
Remarks: HCO does not have high dependency area
NC:
NC Details:

2. Question: Are staff in High dependency Areas adequate?

Answer: No
Remarks: HCO does not have high dependency area
NC:
NC Details:

Question: Do high dependency areas have adequate equipment (monitors, suction

equipment, oxygen cylinders/central oxygen supply)?
Answer: No
Remarks: HCO does not have high dependency area
NC:
NC Details:
 Obstetric W.N.P. Section

1. Question: Does the hospital have measures to prevent child/ neonate abduction and
abuse?
Answer: Yes
Remarks: Mock drill of code pink conducted in paediatric ward. Staffs are aware. Obstetrics
services are not in scope
NC:
NC Details:

O.T. Section
1. Question: Is pre-anaesthesia assessment done by a qualified/trained
anaesthetist?
Answer: No
Remarks:
NC:
NC Details: PAC evidenced in required cases where Regional, Spinal or Gen Anesthesia
cases.
NC Trail

2. Question: Is there a documented anaesthesia plan following pre-anaesthesia

assessment?
Answer: No
Remarks:
NC:
NC Details: Anesthesia Plan evidenced now.
NC Trail

3. Question: Is there immediate preoperative re-evaluation done?

Answer: No
Remarks: Not evident in IP no. 365/21
NC:
NC Details: Immediate Pre- Operative Reassessment is now seen.
NC Trail

4. Question: Is anaesthesia monitoring done?

Answer: No
Remarks:
NC:
NC Details: Intra-operative Anaesthesia notes are evidences
NC Trail

5. Question: Is post anaesthesia monitoring done?

Answer: Yes
Remarks:
NC:
NC Details:

6. Question: Is WHO Patient Safety Check List used to identify the right patient?
Answer: No
Remarks:
NC:
NC Details: WHO surgical safety checklist implemented

NC Trail

7. Question: Is OT Zoning done as Un-sterile, Semi-sterile, Sterile?

Answer: Yes
Remarks:
NC:
NC Details:

8. Question: Is there monitoring of infection control practices?

Answer: Yes
Remarks:
NC:
NC Details:

9. Question: Are narcotic drugs used?

Answer: No
Remarks: HCO not using narcotics
NC:
NC Details:

10. Question: Is there a record of usage, administration and disposal of narcotic

drugs?
Answer: No
Remarks:
NC:
NC Details:

11. Question: Does the OT wash up area have no-touch hand wash facility?
Answer: Yes
Remarks: Sensors available
NC:

NC Details:
 Wards and Pharmacy Section

1. Question: Are there expired drugs in any patient care area?

Answer: No
Remarks:
NC:
NC Details: Policy updated, communicated and trained to staff. Implementation evidenced

2. Question: Is there any pharmacy/Stores present?

Answer: Yes
Remarks:
NC:
NC Details:

3. Question: Are there any expired drugs in pharmacy?

Answer: Yes
Remarks: Expired drugs stored separately
NC:
NC Details:

4. Question: Is the medication expiry date checked before dispensing?

Answer: Yes
Remarks: Expiry date checked
NC:
NC Details:

5. Question: Is there a list of emergency medications?

Answer: Yes
Remarks:
NC:
NC Details:

6. Question: Is there a list of high risk medications?

Answer: Yes
Remarks:
NC:
NC Details:

7. Question: Are high risk medications verified before dispensing?

Answer: No
Remarks:
NC:
NC Details: High Risk medication is now verified. Training imparted to staff.
NC Trail

8. Question: Does the labelling of drug have name, UHID, dose, date strength when
more than one drug is loaded before administration?
Answer: Yes
Remarks:
NC:
NC Details:

9. Question: Is medication order checked for name, dosages, route and timings
before administration?
Answer: Yes
Remarks: All the details are verified by staff.
NC:
NC Details:

10. Question: Is medication administration documented?

Answer: No
Remarks:
NC:
NC Details: Med Administration is now signed by staff.

11. Question: Is fridge temperature record present?

Answer: Yes
Remarks:
NC:
NC Details:

Patient / Staff Section

Question: Is privacy maintained during procedures?
Answer: Yes
Remarks: Male and female wards are separate. All the pt has eye related disease. Whenever
required HCO using curtains for privacy
NC:
NC Details:

Question: Are patients protected from physical abuse & neglect?

Answer: No
Remarks:
NC:
NC Details: Vulnerable patients are now identified. Training done for staff.
NC Trail
Question: Is patient’s information confidential?
Answer: Yes
Remarks: Patient right include confidentiality
NC:
NC Details:
Question Is patients consent taken before carrying out any procedure?
Answer: Yes
Remarks: Infirmed consent and anesthesia consent taken
NC:
NC Details:

Question: Is patient aware of how to voice a complaint?

Answer: Yes
Remarks: patients are aware
NC:
NC Details:

Question: Does hospital inform patients about expected cost of treatment?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Does patient have access to their clinical records?

Answer: Yes
Remarks:
NC:
NC Details: Right to Access to medical records is now trained to staff
NC Trail
Question: Is patient aware of plan of care, preventive aspects, possible complications,
medications, the expected results and cost as applicable?
Answer: Yes
Remarks: Patients are aware
NC:
NC Details:

Wards Emergency Section

Question: Does hospital maintain cleanliness and general hygiene of areas/surfaces,
furniture, fixtures and items used in patient care?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Does hospital adhere to standard precautions in all areas?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Does hospital provide adequate gloves, masks, soaps, and disinfectants and
are they used correctly?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are admissions or discharge to home or transfer to another organization is

documented in emergency unit?
Answer: No
Remarks:
NC:
NC Details: Transfer register is evidenced.

Question: Are there adequate staff present in ICU?

Answer: No
Remarks: HCO does not have ICU
NC:
NC Details:
 HRM Section
Question: Are staff health related issues/problems taken care by the hospital?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are staffs' personal files maintained?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Are occupational health hazards taken care of?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Does training occur when job responsibility changes?

Answer: No
Remarks:
NC:
NC Details: Staff trained on SOP

Question: Are past medical records of doctors retrievable?

Answer: Yes
Remarks:
NC:
NC Details:

Question: In case of grievances, is any action taken to redress the same?

Answer: Yes
Remarks: Record checked
NC:
NC Details:

Question: Is staff aware of disciplinary procedure?

Answer: Yes
Remarks: Staffs are aware
NC:
NC Details:

Question: Is staff able to demonstrate and take actions to report and eliminate/minimize
risks?
Answer: No
Remarks:
NC:
NC Details: Appropriate training imparted.

MRD Section
Question: Does medical record have copy of death certificate?
Answer: No
Remarks:
NC:
NC Details:

Question: Is the documented procedure for maintaining confidentiality, security and

integrity of information adhered ?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Is any information disclosed without patient authorization?

Answer: No
Remarks:
NC:
NC Details:

Question: Is destruction of medical records as per HCO procedure?

Answer: No
Remarks: In process, evidences to be uploaded
NC:
NC Details: Process initiated for Destruction.

Question: Is fire extinguisher present?

Answer: Yes
Remarks:
NC:
NC Details:
 Housekeeping Section
Question: Does staff know the procedure of cleaning non-infected patient's room?
Answer: Yes
Remarks:
NC:
NC Details:
Question: Does staff know the procedure of cleaning infected patient's room?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Does staff know the procedure of cleaning blood spill?

Answer: Yes
Remarks: Staff to use tongs / brush & dust collector for collecting soiled tissues
NC:
NC Details:

Question: Is the waste collected, segregated, transported and disposed as per the
Biomedical Waste regulations?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Does staff know the procedure of cleaning or washing the blood stained linen?

Answer: Yes
Remarks:
NC:
NC Details:

Sterilization Section
Question: Are equipment cleaning, disinfection and sterilisation practices adhered?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are indicators used to monitor effectiveness of sterilization process?

Answer: Yes
Remarks:
NC:
NC Details:
Question: Do the sterilized drums and trays have date of expiry?
Answer: No
Remarks: cycle date is written but not expiry date although claimed to be used with in 24 hrs..
NC:
NC Details: Expiry dates are now mentioned

Management Section

Question: Are requisite fee for BMW, related documents & reports submitted to
competent authorities on stipulated date?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Do leaders/management guide the organization to function in an ethical

manner ?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Is any documented hospital mission present?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Are document for registration and admission of patient being maintained in
OPD?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are document for registration and admission of patient being maintained in
IPD?
Answer: Yes
Remarks:
NC:
NC Details:
Question: Are document for registration and admission of patient being maintained in
Emergency?
Answer: Yes
Remarks:
NC:
NC Details:
Question: Is copy of basic Tariff List including bed charges, OT charges, ICU bed
charges, packages, etc. present?
Answer: Yes
Remarks: Emergency registration same as IP series
NC:
NC Details:

Question: What is the parameter for patient identification?

Answer: By Name, By Unique Identifier
Remarks:
NC:
NC Details:

Question: Does the continuous process of quality improvement programme and patient
safety programme gets updated at least once in a year?
Answer: Yes
Remarks: KPI are reviewed, committee meets regularly,
NC:
NC Details:

Maintenance/Bio-Medical Engg. Section

Question: Is Maintenance staff contactable round the clock for emergency repairs?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Does the hospital plan for equipment in accordance with its services?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Is the documented operational and maintenance (preventive and breakdown)

plan adhered?
Answer: No
Remarks: equipment are calibrated but no tracker of Preventive maintenance is maintained
NC:
NC Details: Tracker implemented.
 Maintenance/Facility Checks
Question: Are all the medical gas cylinders stored in racks or in chains?
Answer: No
Remarks: Filled cylinders are not secured.
NC:
NC Details: Cylinders secured

Question: Are fire/smoke detectors installed in patient care areas with fire-panel?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are there fire extinguisher present in patient care areas?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Is fire fighting equipment kept up-to-date?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Does HCO have safe exit plan?

Answer: Yes
Remarks:
NC:
NC Details:

Safety Management
Question: Are adequate safety devices available in the lab ?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are aprons and shields used for shielding of body parts of staff and patients?
Answer: Yes
Remarks:
NC:
NC Details:
Question: Are TLD badges/dosimeters (as applicable) provided to each staff member in the
radiation area?
Answer: No
Remarks: not applicable.
NC:
NC Details:

Question: Are there standardised colour coding of cylinders & medical gas pipelines?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are there safe storage of medical gas cylinders?

Answer: No
Remarks:
NC:
NC Details: Medical Gases cylinders are secured

Ambulance Accessibility Section

Question: Select the level of access available for the ambulance for patient drop off
Answer: Patient can be shifted on trolley directly from ambulance to emergency/ward bed
Remarks:
NC:
NC Details:

Question: Select the type of ownership of the ambulance

Answer: Outsourced 
Remarks:
NC:
NC Details:

Question: What is the total number of ambulance available?

Answer: 01
Remarks:
NC:
NC Details:

Question: Is ambulance appropriately equipped?

Answer: Yes
Remarks:
NC:
NC Details:
Question: How many drivers for the ambulances are available?
Answer: 03
Remarks:
NC:
NC Details:

Question: How many doctors are available for the ambulances?

Answer: 12
Remarks:
NC:
NC Details:

Question: How many nurses are available for the ambulances?

Answer: 9
Remarks:
NC:
NC Details:

Uniform Signage Section

Question: Are scope of services present?
Answer: Yes
Remarks:
NC:
NC Details:

Question: Are Patients’ rights & responsibility displayed?

Answer: Yes
Remarks: The display is very high (1st floor) in lobby. Not at eye level. Change the display
height
NC:
NC Details:

Question: Are there fire exit signage present?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Are directional signages present?

Answer: Yes
Remarks:
NC:
NC Details:

Question: Are departmental signages present?

Answer: Yes
Remarks:
NC:
NC Details:
 Documentation Section
Question: Is document related to procedure(s) of collection, identification, handling,
safe transportation, processing and disposal of specimens available and properly
documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing process addresses discharge of all patients including
Medico-legal cases and patients leaving against medical advice available and properly
documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing care of patients arriving in the emergency including
handling of medico-legal cases available and properly documented?
Answer: No
Remarks: Emergency case sheet is uploaded. Share Emergency Dept. protocols. Triage,
Initial assessment, admission, clinical protocols, protocols on Handling MLC cases, Transfer
out protocols, diagnostic referrals, discharge from ER etc.
NC:
NC Details: Appropriate SOPs added. Advised to detail further in next revision.
                                                    
Question: Is document showing policies and procedures used to guide the rational use of
blood and blood products available and properly documented?
Answer: No
Remarks: not applicable
NC:
NC Details:
                                                    
Question: Is document showing procedures to govern transfusion of blood and blood
products available and properly documented?
Answer: No
Remarks: Not applicable
NC:
NC Details:
                                                    
Question: Is document showing procedure for the administration of anaesthesia
available and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing defined criteria to transfer the patient from the
recovery area available and properly documented?
Answer: No
Remarks: Although the policy is present in Anaesthesia manual ( modified Aldrete scoring).
Please refer that instead of TRANFER policy which is uploaded instead.
NC:
NC Details:
                                                    
Question: Is document showing procedure of prevention of adverse events like wrong
site, wrong patient and wrong surgery available and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing procedure for incorporating purchase, storage,
prescription and dispensation of medications available and properly documented?
Answer: No
Remarks: Only prescription SOP is available. Storage (including LASA, High Risk Med,
Emergency Medicine, Scheduled drugs etc.) attached in later document also to be uploaded
here. Dispensing SOP are missing. Purchase (local purchase if applicable) is to be
mentioned..
NC:
NC Details: Appropriate SOPs added & Policy modified appropriately.
                                                    
Question: Is document showing procedure to address procurement and usage of
implantable prostheses available and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing policies and procedure exit for storage of medications
available and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing policies and procedures to govern usage of radioactive
drugs available and properly documented?
Answer: No
Remarks: not applicable
NC:
NC Details:
                                                    
Question: Is document showing Policies and procedures of safe storage, preparation,
handling, distribution and disposal of radioactive drugs available and properly
documented?
Answer: No
Remarks: not applicable
NC:
NC Details:
                                                    
Question: Is Infection control manual showing periodic update and surveillance
activities available and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing operational and maintenance (preventive and
breakdown) plan for clinical and support service equipment available and properly
documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing safe exit plan in case of fire and non-fire emergencies
available and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing well defined staff recruitment process available and
properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing disciplinary and grievance handling procedure
available and properly documented?
Answer: No
Remarks: No Disciplinary policy (what constitutes indiscipline, dos n don't, list of penalty
which can be given- in order of severity); similarly grievance policy and its escalation
protocol. Add training evidence of the same to staff
NC:
NC Details: Appropriate Policy & SOP added to existing one.

Question: Is document showing policies and procedures for maintaining confidentiality,

integrity and security of records, data and information available and properly
documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing procedures of exist for retention time of medical
records, data and information available and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Is document showing define process to whom the patient record can be
released available and properly documented?
Answer: No
Remarks: No SOP documented on whom the records can be handed over. Process of the
same. Although told well during staff interview.
NC:
NC Details: Appropriate SOPs added & Policy modified appropriately.
                                                    
Question: Is document showing procedure on destruction of medical records available
and properly documented?
Answer: Yes
Remarks:
NC:
NC Details:
                                                    
Question: Photograph of signed document of Scope of Services
Answer:
Remarks:
NC:
NC Details:

Question: Photograph of signed list of General Duty Medical Officers

Answer:
Remarks:
NC:
NC Details:

Question: Photograph of signed list of Nurses

Answer:
Remarks:
NC:
NC Details:

Question: Photograph of signed list of Paramedical Staff: (OT, ECG, Radiology, PFT,
Lab, Optometrist, EMG, Dialysis)
Answer:
Remarks:
NC:
NC Details:
Question: Photograph of signed list of Administrative & Support Staff
Answer:
Remarks:
NC:
NC Details: