DH NQAS Checklist Ver.2.0 - 2019

NQAS SCORE CARD-DIS
Hospital Sco
Accident & Emergency Labour Room
100% 100%
OPD Maternity OT (LaQshya)
100% 100%
Laboratory SNCU
100% 100%
Radiology PP Unit
100% 100%
HOSPITAL QUALITY SCORE CARDAREA OF C

Service Provision Patient Rights
100% 100%
HOSPITAL SCORE
Clinical Services
100%
Infection Control
100% 100%
Reference No Area of Concern &

Area of Concern A- Ser
Standard A1. Facility Provides Curative Services
Standard A2 Facility provides RMNCHA Services
Standard A3. Facility Provides diagnostic Services
Standard A4 Facility provides services as mandated in national Health Progra
Standard A5. Facility provides support services
Standard A6. Health services provided at the facility are appropriate to comm
Area of Concern B- P
Facility provides the information to care seekers, attendants &
Standard B1. modalities
Services are delivered in a manner that is sensitive to gender, re
Standard B2. account of physical economic, cultural or social reasons.
Standard B3. Facility maintains the privacy, confidentiality & Dignity of patien
Facility has defined and established procedures for informing an
Standard B4. and obtaining informed consent wherever it is required.
Facility ensures that there are no financial barrier to access and

Standard B5. care.
Facility has defined framework for ethical management includin

Standard B6 public health facilities
Area of Concern
Standard C1. The facility has infrastructure for delivery of assured services, a
Standard C2. The facility ensures the physical safety of the infrastructure.
Standard C3. The facility has established Programme for fire safety and other
The facility has adequate qualified and trained staff, required f
Standard C4. load
Standard C5. Facility provides drugs and consumables required for assured lis
Standard C6. The facility has equipment & instruments required for assured l
Facility has a defined and established procedure for effective uti
Standard C7 and performance of staff
Area of Concern D- Su
Standard D1. The facility has established Programme for inspection, testing a
The facility has defined procedures for storage, inventory mana
Standard D2. patient care areas
Standard D3. The facility provides safe, secure and comfortable environment
Standard D4. The facility has established Programme for maintenance and up
Standard D5. The facility ensures 24X7 water and power backup as per requir
StandardD6 Dietary services are available as per service provision and nutriti
Standard D7. The facility ensures clean linen to the patients
The facility has defined and established procedures for promoti
Standard D8 transparency and accountability.
Standard D9 Hospital has defined and established procedures for Financial M
Standard D10. Facility is compliant with all statutory and regulatory requireme
Roles & Responsibilities of administrative and clinical staff are
Standard D11. operating procedures.
Facility has established procedure for monitoring the quality of
Standard D12 obligations
Area of Concern E- Cl
Standard E1. The facility has defined procedures for registration, consultatio
Standard E2. The facility has defined and established procedures for clinical a
Standard E3. Facility has defined and established procedures for continuity o
Standard E4. The facility has defined and established procedures for nursing
Standard E5. Facility has a procedure to identify high risk and vulnerable pati
Facility follows standard treatment guidelines defined by state
Standard E6. & their rational use.
Standard E7. Facility has defined procedures for safe drug administration
Standard E8. Facility has defined and established procedures for maintaining
Standard E9. The facility has defined and established procedures for discharg
Standard E10. The facility has defined and established procedures for intensiv
Standard E11. The facility has defined and established procedures for Emergen
Standard E12. The facility has defined and established procedures of diagnosti
Standard E13. The facility has defined and established procedures for Blood Ba
Standard E14 Facility has established procedures for Anaesthetic Services
Standard E15. Facility has defined and established procedures of Surgical Serv
Standard E16. The facility has defined and established procedures for end of li
Standard E17 Facility has established procedures for Antenatal care as per gu
Standard E18 Facility has established procedures for Intranatal care as per gu
Standard E19 Facility has established procedures for postnatal care as per gui
Standard E20 The facility has established procedures for care of new born, inf
Standard E21 Facility has established procedures for abortion and family plan
Standard E22 Facility provides Adolescent Reproductive and Sexual Health se
Standard E23 Facility provides National health program as per operational/Cl
Area of Concern F- Inf
Facility has infection control program and procedures in place f
Standard F1. infection
Standard F2. Facility has defined and Implemented procedures for ensuring h
Standard F3. Facility ensures standard practices and materials for Personal p
Standard F4. Facility has standard Procedures for processing of equipments a
Standard F5. Physical layout and environmental control of the patient care a
Facility has defined and established procedures for segregation
Standard F6. hazardous Waste.
Area of Concern G- Q
Standard G1 The facility has established organizational framework for qualit

Standard G2 Facility has established system for patient and employee satisfa
Standard G3. Facility have established internal and external quality assurance
Facility has established, documented implemented and maintai

Standard G4. processes andits
Facility maps support services.and seeks to make them more effi
key processes
Standard G5. wastages
The facility has established system of periodic review as interna
Standard G6. audit
Standard G7. The facility has defined Mission, values, Quality policy and obje
Standard G8. Facility seeks continually improvement by practicing Quality me
Standard G9 Facility
Facility has
has de defined, approved
established and
procedures forcommunicated Risk Mana
assessing, reporting, eva
Standard G10. Plan
Area of Concern H
Standard H1 . The facility measures Productivity Indicators and ensures comp
Standard H2 . The facility measures Efficiency Indicators and ensure to reach S
Standard H3. The facility measures Clinical Care & Safety Indicators and tries
Standard H4. The facility measures Clinical Care & Safety Indicators and tries
NQAS SCORE CARD-DISTRICT HOSPITAL
Hospital Score Card (Deparatment wise)

ICU OT Pharmacy
100% 100% 100%

Maternity Ward NRC Auxillary Services
100% 100% 100%

Paediateric Ward Blood Bank General Admin
100% 100% 100%

IPD Mortuary
100% 100%
SCORE CARDAREA OF CONCERN WISE

Inputs Support Services
100% 100%
SPITAL SCORE
100% Quality Management Outcome
100% 100%
Area of Concern & Standards

Area of Concern A- Service Provivision
d in national Health Programs/ state scheme
y are appropriate to community needs.

Area of Concern B- Patient Rights
are seekers, attendants & community about the available services and their
at is sensitive to gender, religious, and cultural needs, and there are no barrier on
al or social reasons.
entiality & Dignity of patient and related information.
rocedures for informing and involving patient and their families about treatment
rever it is required.
ncial barrier to access and that there is financial protection given from cost of
hical management including dilemmas confronted during delivery of services at
Area of Concern C - Inputs
very of assured services, and available infrastructure meets the prevalent norms
y of the infrastructure.
me for fire safety and other disaster
d trained staff, required for providing the assured services to the current case
bles required for assured list of services.

ents required for assured list of services.
procedure for effective utilization, evaluation and augmentation of competence
Area of Concern D- Support Services
me for inspection, testing and maintenance and calibration of Equipment.

or storage, inventory management and dispensing of drugs in pharmacy and
comfortable environment to staff, patients and visitors.

me for maintenance and upkeep of the facility
ower backup as per requirement of service delivery, and support services norms
ervice provision and nutritional requirement of the patients.
patients
ed procedures for promoting public participation in management of hospital
procedures for Financial Management
y and regulatory requirement imposed by local, state or central government

ative and clinical staff are determined as per govt. regulations and standards
monitoring the quality of outsourced services and adheres to contractual
Area of Concern E- Clinical Services
or registration, consultation and admission of patients.

ed procedures for clinical assessment and reassessment of the patients.
rocedures for continuity of care of patient and referral
ed procedures for nursing care
gh risk and vulnerable patients.
uidelines defined by state/Central government for prescribing the generic drugs
fe drug administration
rocedures for maintaining, updating of patients’ clinical records and their storage
ed procedures for discharge of patient.
ed procedures for intensive care.
ed procedures for Emergency Services and Disaster Management
ed procedures of diagnostic services
ed procedures for Blood Bank/Storage Management and Transfusion.
r Anaesthetic Services
rocedures of Surgical Services
ed procedures for end of life care and death
r Antenatal care as per guidelines
r Intranatal care as per guidelines
r postnatal care as per guidelines
es for care of new born, infant and child as per guidelines
r abortion and family planning as per government guidelines and law
ctive and Sexual Health services as per guidelines
ram as per operational/Clinical Guidelines
Area of Concern F- Infection Control
and procedures in place for prevention and measurement of hospital associated
d procedures for ensuring hand hygiene practices and antisepsis

d materials for Personal protection
processing of equipments and instruments
ntrol of the patient care areas ensures infection prevention
rocedures for segregation, collection, treatment and disposal of Bio Medical and
Area of Concern G- Quality Control
onal framework for quality improvement

tient and employee satisfaction
external quality assurance programs wherever it is critical to quality.
implemented and maintained Standard Operating Procedures for all key

eks to make them more efficient by reducing non value adding activities and
periodic review as internal assessment , medical & death audit and prescription
es, Quality policy and objectives, and prepares a strategic plan to achieve them
nt by practicing Quality method and tools.
rcommunicated Risk Management
assessing, reporting, framework
evaluating and forrisk
managing existing
as perand
Riskpotential risks.
Management
Area of Concern H- Outcome

dicators and ensures compliance with State/National benchmarks
ators and ensure to reach State/National Benchmark
Safety Indicators and tries to reach State/National benchmark
Safety Indicators and tries to reach State/National benchmark
Version 02
Hospital
Score
100%
LaQshya
Score
100%
NQAS Score LaQshya Score
100% 100%
100% 100%
100% 100%
100% NA
100% NA
100% NA
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% NA
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% NA
100% 100%
100% NA
100% NA
100% NA
100% 100%
100% NA
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% NA
100% NA
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% NA
100% 100%
100% 100%
100% NA
100% NA
100% NA
100% NA
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% 100%
100% NA
100% 100%
100% 100%
99% 100%
100% 100%
100% 100%
Checklist 1 Accident Emergency Version - NHSRC/3.0
National Quality Assurance Standards for District Hospitals Version 2

Checklist for Accident & Emergency 1
Assessment Summary
Date of Assessment
Name of the Hospital
Names of Assessors Names of Assessees
Action plan
Type of Assessment (Internal/External) Submission Date
Accident & Emergency Score Card

Area of Concern wise Score Accident & Emergency Score
A Service Provision 100%
B Patient Rights 100%
C Inputs 100%
100%
D Support Services 100%
E Clinical Services 100%
F Infection Control 100%
Quality Manangement
G 100%
H Outcome 100%
Major Gaps Observed
1
2
3
4
5
Strengths / Good Practices
1
2
3
4
5
Recommendations/ Opportunites for Improvement
1
2
3
4
5
Signature of Assessors
Date
Checklist for Accident & Emergency

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks obt Max
Method
Area of Concern - A Service Provision 42 42
Standard A1. Facility Provides Curative Services 24 24
ME A1.1. The facility provides General Medicine services Availability of Emergency Poisoning, Snake Bite, CVA,
Medical Procedures Acute MI, ARF, Hypovolumic
2 Shock , Dyspnoea,
Unconscious Patients
SI/OB
ME A1.2. The facility provides General Surgery services Availability of Emergency
Surgical Procedures Appendicitis, Rupture spleen,
2 Intestinal Obstruction, Assault
Injuries, perforation, Burns
SI/OB
ME A1.3. The facility provides Obstetrics & Gynaecology Availability of Emergency
Services Obstetrics &Gynaecology APH, PPH, Eclampsia ,
Procedures 2 Obstructed labour, Septic
abortion, Emergency
SI/OB Contraceptives
ME A1.4. The facility provides paediateric services Availability of emergency
Paediatric procedures ARI, Diarrhoeal diseases,
2 Hypothermia,
SI/OB PEM,resustication
ME A1.5. The facility provides Ophthalmology Services Availability of Emergency
Ophthalmology procedures 2
SI/OB Foreign body and injuries
ME A1.6. The facility provides ENT Services Availability of Emergency ENT
procedures 2
SI/OB Epitasis, foreign body
Page 16
Method
ME A1.7. The facility provides Orthopaedics Services Availability of Emergency
Orthopaedic procedures 2
SI/OB Fracture, RTA, Poly trauma
ME A1.9. The facility provides Psychiatry Services Availability of Emergency
Psychiatric procedures Conversion Reactions, other
2 Psychiatric emergencies
SI/OB Hysteria, mania, psychosis
ME A1.13. The facility provides services for OPD Availability of Dressing room
procedures facility 2
SI/OB Drainage, dressing, suturing
Availability of injection room
facilities Injection room facility with
2 ARV, ASV and emergency
SI/OB drugs
ME A1.14. Services are available for the time period as 24X7 availability of dedicated SI/RR
mandated emergency Services 2
ME A1.16. The facility provides Accident & Emergency Availability of Emergency

Services procedures Defibrillation, CPR,
2 Mobilization, Chest Tube,
Intubations, Tracheotomy,
SI/OB Mechanical Ventilation
Standard A2 Facility provides RMNCHA Services 4 4
ME A2.2 The facility provides Maternal health Services Availability of Emergency SI/OB
Obstetrics & Gynaecology 2
procedure
ME A2.4 The facility provides Child health Services Triage and emergency SI/OB
management of paediatric cases 2
Standard A3 Facility Provides diagnostic Services 8 8

ME A3.1. The facility provides Radiology Services Availability / Linkage to X-ray &
USG services 2
SI/OB
Radiology Services are functional Check services are functional
24X7 2 at night
SI/OB
ME A3.2. The facility Provides Laboratory Services Availability of Emergency HB%, CPC, Blood Sugar, RDK,
diagnostic tests 24x7 2 Urine Protein, Electrolyte
(Na+K)
SI/OB
ME A3.3. The facility provides other diagnostic services, Availability of Functional ECG
as mandated Services 2
SI/OB
Standard A5. Facility provides support services 4 4
ME A5.3. The facility provides security services Availability of Police post 2 SI/OB
ME A5.7. The facility has services of medical record Availability of Medico-legal
department record services 2
SI/OB
Standard A6. Health services provided at the facility are appropriate to community needs. 2 2
ME A6.1. The facility provides curatives & preventive Availability of specific procedures
services for the health problems and diseases, for local prevalent emergencies Ask for the specific local
prevalent locally. 2 health frequent emergencies.
See if emergency is ready for
SI/OB it or not.
. Area of Concern - B Patient Rights 80 80
Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities 20 20
ME B1.1. Availability departmental Emergency department board
The facility has uniform and user-friendly signage's . is prominently displayed with
2 facility of illumination in night.
signage system
OB
Availability of Directional OB Direction is displayed from
Signage's. 2 main gate to direct.
ME B1.2. List of services including OB
The facility displays the services and emergencies that are managed 2
entitlements available in its departments at the facility
Names of doctor and nursing OB
staff on duty are displayed and 2
updated
List of drugs available are OB
displayed 2
Important numbers including OB
ambulance, blood bank , police 2
and referral centres displayed
ME B1.5 IEC Material is displayed
Patients & visitors are sensitised and educated 2
through appropriate IEC / BCC approaches
ME B1.6. Information is available in local language and Signage's and information are OB
available in local language 2
easy to understand
ME B1.7. Enquiry services are available OB Enquiry services may be
24X7. provided by registration
clerk/Nurse in a small set up.
For large and busy emergency
The facility provides information to patients departments there should be
2 dedicated enquiry counter
and visitor through an exclusive set-up.
ME B1.8 The facility ensures access to clinical records of Treatment note/discharge note RR/OB
is given to patient 2
patients to entitled personnel
Standard B2. Services are delivered in a manner that is sensitive to gender, religious, and cultural needs, and there are no barrier on account of 24 24
physical economic, cultural or social reasons.
ME B2.1. Services are provided in manner that are Separate room for examination OB
of rape victims 2
sensitive to gender
Availability of sexual assault OB
forensic evidence kit 2
Availability of protocols OB /RR
/guidelines for collection of
forensic evidence in case of rape 2
victim
Counselling services are available OB/RR

for rape victim and domestic 2
violence
Availability of female staff if a OB/SI
male doctor examine a female 2
patients
Separate toilets for male and SI/OB
females 2
Demarcated male and female OB
observation areas 2
ME B2.3. Availability of Wheel chair/ OB
Access to facility is provided without any stretcher for emergency
physical barrier & and friendly to people with 2
disabilities
Availability of ramps with railing 2 OB
Emergency is located at ground OB
floor 2
Page 17
Method
Ambulance has direct access to OB No vehicle parked on the
the receiving/triage area of the way /in front of emergency
emergency. entrance. Access road to
2 emergency is wide enough for
streamline moment of
emergency
Availability of disable friendly OB

toilet 2
Standard B3. Facility maintains the privacy, confidentiality & Dignity of patient and related information. 10 10
ME B3.1. Adequate visual privacy is provided at every Screens provided at emergency OB At the examination and
2 procedure area.
point of care
ME B3.2. Confidentiality of patients records and clinical Confidentiality of patient record SI/OB
maintained 2
information is maintained
MLC cases are kept in secure SI/OB
place beyond access of general 2
public
ME B3.3. The facility ensures the behaviours of staff is Behaviour of staff is empathetic OB/PI
dignified and respectful, while delivering the and courteous 2
services
ME B3.4. Privacy and confidentiality of SI/OB
The facility ensures privacy and confidentiality HIV, Rape, suicidal cases,
to every patient, especially of those conditions domestic violence and psychotic 2
having social stigma, and also safeguards cases
vulnerable groups
Standard B4. Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining 10 10
informed consent wherever it is required.
ME B4.1. There is established procedures for taking Consent is taken for invasive SI/RR
informed consent before treatment and emergency procedures 2
procedures
ME B4.2. Patient is informed about his/her rights and Display of patient rights and OB
responsibilities. 2
responsibilities
ME B4.3. Staff are aware of Patients rights Staff is aware about patient SI
rights and responsibilities 2
responsibilities
ME B4.4. Patient is informed about her PI Ask patients about what they
Information about the treatment is shared clinical condition and treatment 2 have been communicated
with patients or attendants, regularly been provided about the treatment plan
ME B4.5. The facility has defined and established Availability of complaint box and OB
grievance redressal system in place display of process for grievance
redresaal and whom to contact is 2
displayed
Standard B5. Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care. 8 8
ME B5.1 The facility provides cashless services to Emergency services are free for PI/SI
pregnant women, mothers and neonates as all including pregnant woman, 2
neonate and children
per prevalent government schemes
ME B5.2. Check that patient party has not PI/SI
The facility ensures that drugs prescribed are spent on purchasing drugs or 2
available at Pharmacy and wards consumables from outside.
ME B5.3. Check that patient party has not PI/SI
It is ensured that facilities for the prescribed spent on diagnostics from 2
investigations are available at the facility outside.
ME B5.4. The facility provide free of cost treatment to Free Emergency Consultation for PI/SI/RR
Below poverty line patients without BPL patients 2
administrative hassles
Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities 8 8
ME B6.6 Patients Relatives are informed PI/SI
clearly about the deterioration in 2
There is an established procedure for ‘end-of-life’ health condition of Patients
care
There is a standard procedure of SI/RR Check about the policy and
removal of life sustaining 2 practice for removing life
treatment as per law support
There is a procedure to allow SI/OB
patient relative/Next of Kin to 2
observe patient in last hours
ME B 6.7 Declaration is taken from the RR/SI
There is an established procedure for patients who LAMA patient
wish to leave hospital against medical advice or 2
refuse to receive specific c treatment
Area of Concern - C Inputs 174 174
Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 56 56
ME C1.1. Departments have adequate space as per Adequate space for OB
patient or work load accommodating emergency load 2 1000 square meters per 100
patient daily loads
Availability of adequate waiting OB
area 2
ME C1.2. Patient amenities are provide as per patient Availability of seating OB

load arrangement in the waiting area 2
Availability of cold Drinking OB

water 2
Availability of functional toilets 2 OB
ME C1.3. Departments have layout and demarcated Demarcated trolley bay OB
areas as per functions 2
Demarcated receiving /triage OB

areas 2
Demarcated Nursing station 2 OB
Demarcated duty room for OB
doctor /nurse 2
Demarcated resuscitation area 2 OB
Demarcated observation OB
area/beds 2
Demarcated dressing area /room OB
2
Demarcated injection room 2 OB
Demarcated area for keeping OB
serious patient for intensive 2
monitoring
Demarcated areas for keeping OB Separate room or linkage with
dead bodies. 2 mortuary/ Post mortem room
Lay out is flexible OB All the fixture and furniture

are movable to rearrange the
2 different areas in case of
mass casualty
Dedicated Minor OT 2 OB
Shaded porch for ambulance OB
2
Page 18
Method
availability of clean and dirty
utility room 2
ME C1.4. The facility has adequate circulation area and Corridors at Emergency are OB
open spaces according to need and local law broad enough for easy moment 2
of stretcher and trolley
2-3 meter
ME C1.5. The facility has infrastructure for intramural Availability of functional OB
and extramural communication telephone and Intercom Services 2
The ambulance(s) has a proper OB

communication system(at least 2
cell phone)
ME C1.6. Service counters are available as per patient Availability of emergency beds as OB
load per load 2
5% of the total beds
Availability of buffer beds for
handling mass causality and 2
disaster
ME C1.7. The facility and departments are planned to Unidirectional flow of services. OB
ensure structure follows the
function/processes (Structure commensurate
with the function of the hospital) 2
Receiving/Triage-Resucitation-
observtion beds- Procedures
area. There is no crises cross
Separate entrance for OB Entrance of Emergency should
emergency department 2 not be shared with OPD and
IPD
Emergency has functional linkage OB/SI
with Major OT , ICU and labour
room , Indoors and laboratories 2
Emergency is located near to the OB

entry of the hospital 2
Standard C2. The facility ensures the physical safety of the infrastructure. 8 8
ME C2.1 The facility ensures the seismic safety of the Non structural components are OB Check for fixtures and
infrastructure properly secured furniture like cupboards,
cabinets, and heavy
2 equipments , hanging objects
are properly fastened and
secured
ME C2.3. The facility ensures safety of electrical Emergency department does not OB
establishment have temporary connections and
loosely hanging wires 2
ME C2.4. Physical condition of buildings are safe for Floors of the Emergency are non OB
providing patient care slippery and even 2
Windows have grills and wire OB

meshwork 2
Standard C3. The facility has established Programme for fire safety and other disaster 10 10
ME C3.1. The facility has plan for prevention of fire Emergency has sufficient fire OB/SI
exit to permit safe escape to its
occupant at time of fire 2
Check the fire exits are clearly OB

visible and routes to reach exit
are clearly marked. 2
ME C3.2. The facility has adequate fire fighting Emergency has installed fire OB
Equipment Extinguisher that is Class A , 2
Class B, C type or ABC type
Check the expiry date for fire OB/RR
extinguishers are displayed on
each extinguisher as well as due
date for next refilling is clearly
mentioned 2
ME C3.3. The facility has a system of periodic training of Check for staff competencies for SI/RR
staff and conducts mock drills regularly for fire operating fire extinguisher and
and other disaster situation what to do in case of fire 2
Standard C4. The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 16 16
ME C4.1. The facility has adequate specialist doctors as Availability of specialist Doctor Check for specialist on call/
per service provision 2
OB/RR full time
ME C4.2. The facility has adequate general duty doctors Availability of emergency OB/RR
as per service provision and work load medical officer 2
ME C4.3. The facility has adequate nursing staff as per Availability of Nursing staff OB/RR/SI At least 2 in day and 1 in night
service provision and work load 2
ME C4.4. The facility has adequate Availability of dresser OB/SI

technicians/paramedics as per requirement /paramedic 2
ME C4.5. The facility has adequate support / general Dedicated 24X7 house keeping SI/RR
staff staff 2
availability of dedicated security SI/RR

guards 24X7 2
Availability of registration clerk 2 SI/RR
Availability of Drivers for SI/RR
Ambulance 24X7 2
Standard C5. Facility provides drugs and consumables required for assured list of services. 34 34
ME C5.1. The departments have availability of adequate Availability of OB/RR Tracers as per State EDL
drugs at point of use Analgesics/Antipyretics/Anti 2
Inflammatory
Availability of Antibiotics 2 OB/RR Tracers as per State EDL
Availability of Infusion Fluids OB/RR Tracers as per State EDL
2
Availability of Drugs acting on OB/RR Tracers as per State EDL

CVS 2
Availability of drugs action on OB/RR Tracers as per State EDL
CNS/PNS 2
Availability of dressing material OB/RR Tracers as per State EDL
and antiseptic lotion
2
Drugs for Respiratory System OB/RR Tracers as per State EDL

2
Hormonal Preparation 2 OB/RR Tracers as per State EDL
Page 19
Method
Availability of emergency drugs OB/RR Tracers as per State EDL
in ambulance 2
Availability of drugs for obstetric OB/RR Megsulf, Oxytocin, Plasma
emergencies 2 Expanders
Availability of Medical gases OB/RR Availability of Oxygen
2 Cylinders
Availability of Immunological OB/RR Polyvalent Anti snake Venom,
2 Anti tetanus Human
Immunoglobin
Antidotes and Other Substances OB/RR Inj. Atropine Sulphate
used in Poisonings 2
ME C5.2. The departments have adequate consumables Resuscitation Consumables / OB/RR
at point of use Tubes 2 Masks, Ryles tubes, Catheters,
Chest Tube, ET tubes etc
Availability of disposables at OB/RR
dressing room 2
Availability of consumables in OB/RR

ambulance 2 Dressing material / Suture
material
ME C5.3. Emergency drug trays are maintained at every Emergency Drug Tray/ Crash Cart OB/RR
point of care, where ever it may be needed is maintained at emergency 2
Standard C6. The facility has equipment & instruments required for assured list of services. 30 30
ME C6.1. Availability of equipment & instruments for Availability of functional
examination & monitoring of patients Equipment &Instruments for
examination & Monitoring 2
BP apparatus, Multiparameter
OB Torch, hammer , Spot Light
Availability of Monitoring
equipments in ambulance 2
OB
ME C6.2. Availability of equipment & instruments for Availability of dressing tray for
treatment procedures, being undertaken in Emergency procedures 2
the facility
OB
Dressing tray are in adequate
numbers as per load 2
OB
Availability of instruments for
emergency obstetrics 2
procedure
OB
ME C6.3. Availability of equipment & instruments for Availability of Point of care
diagnostic procedures being undertaken in the diagnostic devices 2
facility Glucometer, ECG and HIV
OB rapid diagnostic kit
ME C6.4. Availability of equipment and instruments for Availability of functional
resuscitation of patients and for providing Instruments for Resuscitation.
intensive and critical care to patients 2 Ambu bag, defibrillator,
layrngo scope, nebulizer,
OB suction apparatus , LMA
Availability of resuscitation
equipments in ambulance 2
OB
ME C6.5. Availability of Equipment for Storage Availability of equipment for OB Refrigerator, Crash cart/Drug
storage for drugs 2 trolley, instrument trolley,
dressing trolley
ME C6.6 Availability of functional equipment and Availability of equipments for OB Buckets for mopping, mops,
instruments for support services cleaning 2 duster, waste trolley, Deck
brush
Availability of equipment for OB Boiler
sterilization and disinfection 2
ME C6.7. Departments have patient furniture and Availability of patient beds with OB
fixtures as per load and service provision prop up facility and wheels 2
Availability of OB Hospital graded Mattress, IV

attachment/accessories with 2 stand, bed rails, Bed pan
patient bed
Availability of fixtures OB Spot light, electrical fixture for
equipments like suction,
2 monitor and defibrillator, X
ray view box
Availability of furniture at
emergency Doctors Chair, Patient Stool,
2 Examination Table, Chair,
OB Table, Footstep, cupboard
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff 20 20
ME C7.1 SI/RR
Check objective checklist has

been prepared for assessing
competence of doctors,
2 nurses and paramedical staff
based on job description
defined for each cadre of
Check parameters for assessing staff. Dakshta checklist issued
Criteria for Competence assessment are defined skills and proficiency of clinical by MoHFW can be used for
for clinical and Para clinical staff staff has been defined this purpose.
ME C7.2 SI/RR
Check for records of

2 competence assessment
including filled checklist,
Competence assessment of Clinical and Para Check for competence scoring and grading . Verify
clinical staff is done on predefined criteria at least assessment is done at least once with staff for actual
once in a year in a year competence assessment done
ME C7.9 The Staff is provided training as per defined core Triage and Mass Casualty SI/RR
Management 2
competencies and training plan
Basic life support (BLS)/ Advance SI/RR
life support (ALS) 2
Bio Medical waste Management 2 SI/RR
Infection control and hand SI/RR
hygiene 2
Patient Safety 2
ME C7.10 Staff is skilled for emergency SI/RR
procedures
Check supervisors make
periodic rounds of
department and monitor that
2 staff is working according to
the training imparted. Also
There is established procedure for utilization of staff is provided on job
skills gained thought trainings by on -job training wherever there is still
supportive supervision gaps
Page 20
Method
Staff is skilled for resuscitation SI/RR
and use defibrillator
periodic rounds of
2
staff is working according to
staff is provided on job
training wherever there is still
gaps
Staff is skilled for maintaining SI/RR
clinical records
periodic rounds of
2
training wherever there is still
gaps
Area of Concern - D Support Services 108 108
Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 10 10
ME D1.1. The facility has established system for All equipments are covered SI/RR
maintenance of critical Equipment under AMC including preventive 2
maintenance
There is system of timely SI/RR
corrective break down 2
maintenance of the equipments
Staff is skilled for trouble SI/RR
shooting in case equipment 2
malfunction
ME D1.2. The facility has established procedure for All the measuring equipments/ OB/ RR
internal and external calibration of measuring instrument are calibrated 2
Equipment
ME D1.3. Operating and maintenance instructions are Operating instructions for critical OB/SI
available with the users of equipment equipments are available 2
Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 30 30
ME D2.1 There is established procedure for forecasting There is established system of SI/RR Stock level are daily updated
and indenting drugs and consumables timely indenting of consumables Requisition are timely placed
2
and drugs
ME D2.3. The facility ensures proper storage of drugs Drugs are stored in OB
and consumables containers/tray/crash cart and 2
are labelled
Empty and filled cylinders are OB
labelled 2
ME D2.4. The facility ensures management of expiry and Expiry dates' are maintained at OB/RR
near expiry drugs emergency drug tray 2
No expiry drug found 2 OB/RR

Records for expiry and near
expiry drugs are maintained for 2
drug stored at department
RR
ME D2.5. The facility has established procedure for There is practice of calculating SI/RR
inventory management techniques and maintaining buffer stock in 2
Emergency
Department maintained stock RR/SI
and expenditure register of drugs
and consumables in Emergency 2
There is practice of calculating SI/RR

and maintaining buffer stock in
ambulance 2

and expenditure register of drugs
and consumables in ambulance
2
ME D2.6. There is a procedure for periodically replenishing There is procedure for SI/RR
the drugs in patient care areas replenishing drug tray 2
emergency crash cart
There is procedure for OB/SI
replenishing drug tray
emergency crash cart in 2
ambulance
There is no stock out of drugs SI/RR

2
ME D2.7. There is process for storage of vaccines and Temperature of refrigerators are OB/RR Check for temperature charts
other drugs, requiring controlled temperature kept as per storage requirement are maintained and updated
and records are maintained periodically
2
ME D2.8. There is a procedure for secure storage of Narcotics and psychotropic drugs OB/SI
narcotic and psychotropic drugs are kept in lock and key 2
Standard D3. The facility provides safe, secure and comfortable environment to staff, patients and visitors. 16 16
ME D3.1. The facility provides adequate illumination Adequate illumination at OB Resuscitation area, dressing
level at patient care areas procedure area 2 room and examination area
Adequate illumination at OB
receiving and triage area 2
ME D3.2. The facility has provision of restriction of Visitors are restricted at OB/SI
visitors in patient areas resuscitation and procedure 2
area
ME D3.3 The facility ensures safe and comfortable Temperature control and PI/OB Fans/ Air
environment for patients and service providers ventilation in patient care area conditioning/Heating/Exhaust
/Ventilators as per
2 environment condition and
requirement
Temperature control and SI/OB Fans/ Air

ventilation in nursing conditioning/Heating/Exhaust
station/duty room /Ventilators as per
2 environment condition and
requirement
ME D3.4. The facility has security system in place at There are set procedures for SI/OB See for linkage to police, self
patient care areas handling mass situation and protection form staff
violence in emergency 2
Hospital has sound security OB/SI

system to manage overcrowding 2
in emergency
Page 21
Method
ME D3.5 The facility has established measure for safety and Ask female staff whether they SI
security of female staff feel secure at work place 2
Standard D4. The facility has established Programme for maintenance and upkeep of the facility 22 22
ME D4.1 Exterior of the facility building is maintained Building is painted/whitewashed OB
appropriately in uniform colour 2
Interior of patient care areas are OB

plastered & painted 2
ME D4.2. Patient care areas are clean and hygienic Floors, walls, roof, roof topes,
sinks patient care and circulation
areas are Clean 2 All area are clean with no
dirt,grease,littering and
OB cobwebs
Surface of furniture and fixtures OB
are clean 2
Toilets are clean with functional OB
flush and running water 2
ME D4.3. Hospital infrastructure is adequately Check for there is no seepage , OB
maintained Cracks, chipping of plaster
2
Window panes , doors and other OB

fixtures are intact 2
Patients beds are intact and OB
painted 2
Mattresses are intact and clean 2 OB
ME D4.5. The facility has policy of removal of No condemned/Junk material in OB
condemned junk material the Emergency 2
ME D4.6 The facility has established procedures for No stray animal/rodent/birds OB

pest, rodent and animal control 2
Standard D5. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 10 10
ME D5.1. The facility has adequate arrangement storage Availability of 24x7 running and OB/SI
and supply for portable water in all functional potable water 2
areas
ME D5.2. The facility ensures adequate power backup in Availability of power back in OB/SI
all patient care areas as per load Emergency 2
Availability of UPS 2 OB/SI

Availability of Emergency light 2 OB/SI
ME D5.3. Critical areas of the facility ensures availability of Availability of Centralized /local OB
oxygen, medical gases and vacuum supply piped Oxygen and vacuum 2
supply
Standard D7. The facility ensures clean linen to the patients 6 6
ME D7.1. The facility has adequate sets of linen Clean Linens are provided at OB/RR
observation beds 2
ME D7.2. The facility has established procedures for Linen are changed after change OB/RR
changing of linen in patient care areas shift of each patient or whenever
it get soiled 2
ME D7.3 The facility has standard procedures for handling , There is system to check the SI/RR
collection, transportation and washing of linen cleanliness and Quantity of the 2
linen received from laundry
Standard D10. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 4 4
ME D10.1. The facility has requisite licences and Valid licences for ambulances are RR/SI
certificates for operation of hospital and available 2
different activities
ME D10.3. The facility ensure relevant processes are in Staff is aware of requirements of SI
compliance with statutory requirement medico legal cases 2
Standard D11. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 8 8
procedures.
ME D11.1. The facility has established job description as Staff is aware of their role and SI
per govt guidelines responsibilities
2
ME D11.2. The facility has a established procedure for There is procedure to ensure RR/SI Check for system for
duty roster and deputation to different that staff is available on duty as recording time of reporting
departments per duty roster 2 and relieving (Attendance
register/ Biometrics etc)
There is designated in charge for SI

department 2
ME D11.3. The facility ensures the adherence to dress Doctor, nursing staff and support OB
code as mandated by its administration / the staff adhere to their respective 2
health department dress code
Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations 2 2
ME D12.1 There is procedure to monitor SI/RR Verification of outsourced
the quality and adequacy of services (cleaning/
outsourced services on regular Dietary/Laundry/Security/Mai
basis 2 ntenance) provided are done
by designated in-house staff
There is established system for contract
management for out sourced services
. Area of Concern - E Clinical Services 224 224
Standard E1. The facility has defined procedures for registration, consultation and admission of patients. 24 24
ME E1.1. The facility has established procedure for Unique identification number is RR
registration of patients given to each patient during 2
process of registration
Patient demographic details are RR Check for that patient
recorded in admission records demographics like Name, age,
2 Sex, Address, Chief complaint,
etc.
ME E1.3. There is established procedure for admission There is established criteria for SI/RR
of patients admission through emergency
department 2
There is establish procedure for SI/RR

admission of MLC cases as per
prevalent laws 2
There is establish procedure for SI/RR

prisoners as per prevalent local 2
laws
Admission is done by written SI/RR
order of a qualified doctor 2
There is no delay in treatment SI/RR

because of admission process 2
Page 22
Method
Time of admission is recorded in RR
patient record 2
There is no delay in transfer of SI/RR
patient to respective department
once admission is confirmed
2
Emergency department is aware SI/RR Like ICU, SNCU, Burn cases

of admission criteria to critical 2
care units
Staff is aware of cases that can SI
not be admitted at the facility
due to constraint in scope of 2
services
ME E1.4. There is established procedure for managing The is provision of extra beds, OB/SI
patients, in case beds are not available at the trolley beds in case of high 2
facility occupancy or mass casualty
Standard E2. The facility has defined and established procedures for clinical assessment and reassessment of the patients. 8 8
ME E2.1. There is established procedure for initial Assessment criteria of different SI/RR Use of standard criteria of
assessment of patients kind of medical emergencies is assessment like Glasgow
defined and practiced comma scale, Poly trauma,
2 MI, burn patient, paediatric
patient, pain assessment
criteria etc.
Initial assessment and treatment OB/RR

is provided immediately
2
Initial assessment is documented RR

preferably within 2 hours 2
ME E2.2. There is established procedure for follow-up/ There is fixed schedule for RR/SI
reassessment of Patients reassessment of patient under 2
observation
Standard E3. Facility has defined and established procedures for continuity of care of patient and referral 20 20
ME E3.1. Facility has established procedure for There is procedure for hand over SI/RR Check for how hand over is
continuity of care during interdepartmental for patient transfer from 2 given from emergency to
transfer emergency to IPD /OT ward, ICU, SNCU etc.
There is a procedure
consultation of the patient to
other specialist with in the 2
hospital
SI/RR
ME E3.2. Facility provides appropriate referral linkages to Patient referred with referral slip
the patients/Services for transfer to other/higher 2
facilities to assure their continuity of care.
SI/RR
Availability of referral linkages to Check how patient are
higher centres. 2 referred if services are not
available
SI/RR
Advance communication is done
with higher centre 2
SI/RR
Referral vehicle is being arranged
2
SI/RR
Referral in or referral out register
is maintained 2
RR
Facility has functional referral
linkages to lower facilities 2 SI/RR
Check for if there is any system Check for referral cards filled
of follow up 2 from lower facilities
RR
ME E3.3. A person is identified for care during all steps Doctor and nurse is designated SI/RR
of care for each patient admitted to
emergency ward 2
Standard E4. The facility has defined and established procedures for nursing care 18 18
ME E4.1. Procedure for identification of patients is There is a process for ensuring OB/SI Patient id band/ verbal
established at the facility the identification before any confirmation/Bed no. etc.
clinical procedure 2
ME E4.2. Procedure for ensuring timely and accurate nursing Treatment chart are RR Check for treatment chart are
care as per treatment plan is established at the maintained updated and drugs given are
facility 2 marked. Co relate it with
drugs and doses prescribed.
There is a process to ensure SI/RR Verbal orders are rechecked

the accuracy of before administration
verbal/telephonic orders 2
ME E4.3. There is established procedure of patient hand Patient hand over is given during SI/RR
over, whenever staff duty change happens the change in the shift 2
Nursing Handover register is RR

maintained 2
Hand over is given bed side OB/SI
2
ME E4.4. Nursing records are maintained Nursing notes are maintained RR/SI Check for nursing note
adequately 2 register. Notes are adequately
written
ME E4.5. There is procedure for periodic monitoring of Patient Vitals are monitored RR/SI Check for TPR chart, IO chart,
patients and recorded periodically 2 any other vital required is
monitored
Critical patients are monitored RR/OB Check for use of cardiac
continually 2 monitor/multi parameter
Standard E5. Facility has a procedure to identify high risk and vulnerable patients. 4 4
ME E5.1. The facility identifies vulnerable patients and Vulnerable patients are OB/SI Unstable, irritable,
ensure their safe care identified and measures are unconscious. Psychotic and
taken to protect them from any 2 serious patients are identified
harm
ME E5.2. The facility identifies high risk patients and ensure High risk medical emergencies OB/SI
their care, as per their need are identified and treatment 2
given on priority
Standard E6. Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational 10 10
use.
ME E6.1. Facility ensured that drugs are prescribed in Check for BHT if drugs are RR
generic name only prescribed under generic name 2
only
Page 23
Method
ME E6.2. There is procedure of rational use of drugs Check for that relevant Standard RR
treatment guideline are available
at point of use 2
Check staff is aware of the drug SI/RR

regime and doses as per STG 2
Check BHT that drugs are RR
prescribed as per STG 2
Availability of drug formulary at SI/OB
emergency 2
Standard E7. Facility has defined procedures for safe drug administration 22 22
ME E7.1. There is process for identifying and cautious High alert drugs available in SI/OB Electrolytes like Potassium
administration of high alert drugs department are identified chloride,opiods, Neuro
muscular blocking agent, Anti
thrombolytic agent, insulin,
warfarin, Heparin, Adrenergic
2 agonist etc.
Maximum dose of high alert SI/RR Value for maximum doses as

drugs are defined and per age, weight and diagnosis
communicated 2 are available with nursing
station and doctor
There is process to ensure that SI/RR A system of independent

right doses of high alert drugs double check before
are only given administration, Error prone
2 medical abbreviations are
avoided
ME E7.2. Medication orders are written legibly and Every Medical advice and RR
adequately procedure is accompanied
with date , time and signature 2
Check for the writing, It RR/SI

comprehendible by the clinical 2
staff
ME E7.3. There is a procedure to check drug before Drugs are checked for expiry OB/SI
administration/ dispensing and other inconsistency 2
before administration
Check single dose vial are not OB Check for any open single
used for more than one dose dose vial with left over
2 content indented to be used
later on
Check for separate sterile needle OB

is used every time for multiple 2 In multi dose vial needle is not
dose vial left in the septum
Any adverse drug reaction is RR/SI

recorded and reported 2
ME E7.4. There is a system to ensure right medicine is Administration of medicines SI/OB
given to right patient done after ensuring right
patient, right drugs , right
route, right time 2
ME E7.5. Patient is counselled for self drug Patient is advice by doctor/ SI/PI
administration Pharmacist /nurse about the 2
dosages and timings .
Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 16 16
ME E8.1. All the assessments, re-assessment and Assessment findings are written RR Day to day progress of patient
investigations are recorded and updated on BHT 2 is recorded in BHT
ME E8.2. All treatment plan prescription/orders are Treatment plan, first orders are RR Treatment prescribed in
recorded in the patient records. written on BHT 2 nursing records
ME E8.3. Care provided to each patient is recorded in Maintenance of treatment RR Treatment given is recorded
the patient records chart/treatment registers 2 in treatment chat
ME E8.4. Procedures performed are written on patients Any procedure performed RR CPR, Dressing, mobilization
records written on BHT 2 etc
ME E8.5. Adequate form and formats are available at Availability of form formats for OB/SI MLC,PIB, Lab /X-ray
point of use emergency requisition, death certificate,
2 Initial assessment format,
referral slip etc.
ME E8.6. Register/records are maintained as per Emergency Records are OB/RR Emergency register, death
guidelines maintained 2 register, MLC register, are
maintained
All register/records are identified OB/RR
and numbered 2
ME E8.7. The facility ensures safe and adequate storage Safe keeping of MLC records OB/SI
and retrieval of medical records 2
Standard E9. The facility has defined and established procedures for discharge of patient. 16 16
ME E9.1. Discharge is done after assessing patient Assessment is done before SI/RR See if there is any
readiness discharging patient from procedure/protocol for
emergency discharging the patient if the
condition of patient improves
in emergency itself.
What is the procedure for
2 discharge for short stay / day
care patients
Discharge is done by a SI/RR

responsible and qualified doctor 2
Patient / attendants are PI
consulted before discharge 2
Treating doctor is consulted/ SI/RR
informed before discharge of
patients 2
ME E9.2. Case summary and follow-up instructions are Discharge summary is provided RR/PI See for discharge summary,
provided at the discharge 2 referral slip provided.
Discharge summary adequately RR
mentions patients clinical
condition, treatment given and 2
follow up
Page 24
Method
Discharge summary is give to SI/RR
patients going in LAMA/Referral 2
ME E9.3. Counselling services are provided as during Counselling services are provided SI/PI
discharges wherever required wherever it is required 2
Standard E11. 52 52
The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.1. There is procedure for Receiving and triage of Emergency has a implemented SI/OB As care provider how they
patients system of sorting the patients triage patient- immediate,
delayed, expectant, minimal,
2 dead
Triage area is marked 2 OB/SI

Triage protocols are displayed 2 OB
Responsibility of receiving and SI
shifting the patient from vehicle
is defined 2
ME E11.2. Emergency protocols are defined and Emergency protocols are OB See for protocols of head
implemented available at point of use 2 injury, snake bite, poisoning,
drawing etc.
Staff is aware of Clinical SI/RR
protocols 2
There is procedure for CPR 2 SI/RR
ME E11.3. The facility has disaster management plan in Lines of authority is defined SI/RR
place 2
Procedure for internal SI/RR

communication defined 2
There is procedure for setting up SI/RR
control room 2
Disaster buffer stock of SI/RR
medicines and other supplies 2
maintained
Role and responsibilities of staff SI/RR
in disaster is defined 2
Staff is aware of disaster plan SI/RR
2
ME E11.4. The facility ensures adequate and timely Check for how ambulances are SI/RR
availability of ambulances services and called and patient is shifted
mobilisation of resources, as per requirement 2
Ambulances are equipped 2 OB

If the patient is stable then he is SI/RR
transferred in ambulance with
the trained driver and one staff 2
from hospital.
If the patient is serious (as SI/RR

decided by the Doctor), then
trained driver and one
paramedical staff is mandatory 2
to accompany him.
The Patient’s rights are SI/RR

respected during transport. 2
Ambulance appropriately OB/RR
equipped for BLS with trained 2
personnel
There is a daily checklist of all RR
equipment and emergency 2
medications
Ambulance has a log book for RR
the maintenance of vehicle and
daily vehicle checklist 2
Transfer register is maintained to RR

record the detail of the referred
patient 2
ME E11.5. There is procedure for handling medico legal Medico legal cases are identified RR/SI
cases by on patient records 2
MLC cases are not delayed SI/OB/RR

because of police proceedings 2
There is procedure for informing SI/RR Discharge is not done before
police 2 police consent
Emergency has criteria for SI/RR Criteria is defined based on
defining medico legal cases 2 cases and when to do MLC
Standard E12. 4 4
The facility has defined and established procedures of diagnostic services
ME E12.1. There are established procedures for Pre- Container is labelled properly OB
testing Activities after the sample collection 2
ME E12.3. There are established procedures for Post- Nursing station is provided with SI/RR
testing Activities the critical value of different 2
tests
Standard E13. 14 14
The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
ME E13.8 There is established procedure for issuing There is a procedure for issuing RR/SI
blood the blood promptly for life saving 2
measures
ME E13.9 There is established procedure for transfusion Consent is taken before RR
of blood transfusion 2
Patient's identification is verified SI/OB

before transfusion 2
Blood is kept on optimum RR
temperature before transfusion 2
Blood transfusion is monitored SI/RR
and regulated by qualified 2
person
Blood transfusion note is written RR
in patient record 2
ME E13.10 There is a established procedure for Any major or minor transfusion RR
monitoring and reporting Transfusion reaction is recorded and 2
complication reported to responsible person
Standard E15. 4 4
Facility has defined and established procedures of Surgical Services
ME E15.1. Facility has established procedures OT There is procedure for SI/RR See surgeon is available on
Scheduling emergency surgeries 2 call/on duty
Page 25
Method
Procedure for arranging logistics SI Responsibilities are defined
2 and patient is shifted
promptly
Standard E16. 12 12
The facility has defined and established procedures for end of life care and death
ME E16.1. Death of admitted patient is adequately Facility has a standard SI
recorded and communicated procedure to decent
communicate death to 2
relatives
Death note is written on patient RR

record 2
ME E16.2. The facility has standard procedures for Past history and sign of any RR Check what is policy for
handling the death in the hospital medico legal cause is looked for registering brought in dead,
2 death cases as MLC
There is criteria for declaring SI/RR ask form how death is

death 2 declared - Physical
examination or ECG is done
Procedure for handing over the SI
dead body 2
Death certificate is issued 2 SI/RR
Area of Concern - F Infection Control 108 108
.
Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 10 10
Facility has provision for Passive and active Surface and environment
culture surveillance of critical & high risk areas samples are taken for 2
microbiological surveillance Swab are taken from infection
ME F1.2. SI/RR prone surfaces
There is Provision of Periodic Medical There is procedure for
Checkups and immunization of staff immunization of the staff 2
ME F1.4. SI/RR Hepatitis B, Tetanus Toxic etc
Periodic medical checkups of the
staff 2
SI/RR
Facility has established procedures for regular Regular monitoring of infection Hand washing and infection
monitoring of infection control practices control practices 2 control audits done at
periodic intervals
ME F1.5. SI/RR
Facility has defined and established antibiotic Check for Doctors are aware of
policy Hospital Antibiotic Policy
2
ME F1.6 SI/RR
Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 18 18
Hand washing facilities are provided at point of Availability of hand washing Check for availability of wash
use Facility at Point of Use 2
ME F2.1. OB basin near the point of use
Availability of running Water Ask to Open the tap. Ask Staff
2
OB/SI water supply is regular
Availability of antiseptic soap
with soap dish/ liquid antiseptic Check for availability/ Ask
2 staff if the supply is adequate
with dispenser.
OB/SI and uninterrupted
Availability of Alchol based Hand
rub
2
Check for availability/ Ask
OB/SI staff for regular supply.
Display of Hand washing
Instruction at Point of Use Prominently displayed above
2 the hand washing facility ,
OB preferably in Local language
Staff is trained and adhere to standard hand Adherence to 6 steps of Hand
washing practices washing 2
ME F2.2. SI/OB Ask of demonstration
Staff aware of when to hand
wash 2
SI
Facility ensures standard practices and Availability of Antiseptic
materials for antisepsis Solutions 2
ME F2.3. OB
Proper cleaning of procedure site OB/SI
with antisepesis
like before giving IM/IV
2 injection, drawing blood,
putting Interavenous and
urinary catheter
Standard F3. Facility ensures standard practices and materials for Personal protection 10 10
Facility ensures adequate personal protection Clean gloves are available at
equipments as per requirements point of use 2
ME F3.1. OB/SI
Availability of Masks 2 OB/SI
Personal protective kit for
infectious patients 2
OB/SI
Staff is adhere to standard personal protection No reuse of disposable gloves,
practices Masks, caps and aprons. 2
ME F3.2. OB/SI
Compliance to correct method of
wearing and removing the gloves 2
SI
Standard F4. Facility has standard Procedures for processing of equipments and instruments 20 20
Facility ensures standard practices and materials Decontamination of operating &
for decontamination and clean ing of instruments Procedure surfaces
and procedures areas Ask stff about how they
decontaminate the procedure
2 surface like Examination
table , dressing table,
Stretcher/Trolleys etc.
(Wiping with .5% Chlorine
ME F4.1. SI/OB solution
Decontamination of instruments
after use
2 Ask staff how they

decontaminate the
instruments like ambubag,
suction cannula, Airways, Face
Masks, Surgical Instruments
(Soaking in 0.5% Chlorine
Solution, Wiping with 0.5%
Chlorine Solution or 70%
SI/OB Alcohal as applicable
Contact time for 10 minutes
decontamination is adeqaute 2
SI/OB
Cleaning of instruments after
decontamination
2 Cleaning is done with
detergent and running water
SI/OB after decontamination
Page 26
Method
Proper handling of Soiled and
infected linen No sorting ,Rinsing or sluicing
2 at Point of use/ Patient care
SI/OB area
Staff know how to make chlorine
solution 2
SI/OB
Facility ensures standard practices and materials Equipment and instruments are Autoclaving/HLD/Chemical
for disinfection and sterilization of instruments and sterlized after each use as per 2 Sterlization
equipments requirement
ME F4.2. OB/SI
High level Disinfection of Ask staff about method and
instruments/equipments is done 2 time required for boiling
as per protocol
OB/SI
Chemical sterilization of Ask staff about method,
instruments/equipments is done concentration and contact
as per protocols 2 time requied for chemical
sterilization
OB/SI
Autoclaved dressing material is
used 2
OB/SI
Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention 20 20
Layout of the department is conducive for the Facility layout ensures separation
infection control practices of general traffic from patient 2
traffic
ME F5.1. OB
Facility ensures availability of standard materials Availability of disinfectant as per Chlorine solution,
for cleaning and disinfection of patient care areas requirement 2
ME F5.2. OB/SI Gluteraldehye, carbolic acid
Availability of cleaning agent as
per requirement Hospital grade phenyle,
2 disinfectant detergent
OB/SI solution
Facility ensures standard practices followed for Staff is trained for spill
cleaning and disinfection of patient care areas management 2
ME F5.3. SI/RR
Cleaning of patient care area
with disinfectant detergent 2
solution
SI/RR
Staff is trained for preparing
cleaning solution as per standard
procedure 2
SI/RR
Standard practice of mopping
and scrubbing are followed 2 Unidirectional mopping from
OB/SI inside out
Cleaning equipments like broom
are not used in patient care Any cleaning equipment
areas 2 leading to dispersion of dust
particles in air should be
OB/SI avoided
Facility ensures segregation infectious patients Emergency department define
list of infectious diseases require
special precaution and barrier 2
nursing
ME F5.4. OB/SI
Staff is trained for barrier nursing
2
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous 30 30
Standard F6. Waste.
Facility Ensures segregation of Bio Medical Availability of colour coded bins Adequate number. Covered.
Waste as per guidelines at point of waste generation 2 Foot operated.
ME F6.1. OB
Availability of colour coded non 2
chlorinated plastic bags OB
Human Anatomical waste,

Items contaminated with
blood, body fluids,dressings,
2
plaster casts, cotton swabs
and bags containing residual
or discarded blood and blood
Segregation of Anatomical and components.
solied waste in Yellow Bin OB/SI
Items such as tubing, bottles,

intravenous tubes and sets,
2 catheters, urine bags, syringes
(without needles and fixed
needle syringes) and
Segregation of infected plastic vaccutainers with their
waste in red bin OB needles cut) and gloves
Display of work instructions for Pictorial and in local language
segregation and handling of
Biomedical waste 2
OB
There is no mixing of infectious
and general waste
2
Facility ensures management of sharps as per Availability of functional needle OB See if it has been used or just
guidelines cutters lying idle
2
ME F6.2.
Seggregation of sharps waste OB Should be available nears the
including Metals in white point of generation.Needles,
(translucent) Puncture proof, syringes with fixed needles,
Leak proof, tamper proof 2 needles from needle tip cutter
containers or burner, scalpels, blades, or
any other contaminated sharp
object that may cause
Availability of post exposure SI/OB puncture
Ask and cuts.
if available. Thisit is
Where
prophylaxis includes both
stored and used,
who is indiscarded
charge of
2 and contaminated metal
that.
sharps
Staff knows what to do in SI Staff knows what to do in case
condition of needle stick injury of shape injury. Whom to
2 report. See if any reporting
has been done
Contaminated and broken Glass Vials, slides and other broken
are disposed in puncture proof infected glass
and leak proof box/ container 2
with Blue colour marking
OB
Facility ensures transportation and disposal of Check bins are not overfilled
waste as per guidelines 2
ME F6.3. SI
Disinfection of liquid waste
before disposal 2
SI/OB
Transportation of bio medical
waste is done in close 2
container/trolley
SI/OB
Staff is aware of mercury spill
management 2
SI/RR
. 78 78
Area of Concern - G Quality Management
Page 27
Method
Standard G1 The facility has established organizational framework for quality improvement 2 2
ME G1.1 The facility has a quality team in place There is a designated SI/RR
departmental nodal person
for coordinating Quality
Assurance activities 2
Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality. 8 8
ME G3.1. Facility has established internal quality There is system daily round by SI/RR
assurance program at relevant departments matron/hospital manager/
hospital superitendant/ Hospital
Manager/ Matron in charge for 2
monitoring of services
There is system for periodic SI/RR

check up of Ambulances by
designated hospital staff 2
ME G3.2. Facility has established external assurance There is periodic assessment of SI/RR
programs at relevant departments preparedness for disaster by
competent authority 2
ME G3.3. Facility has established system for use of check Departmental checklist are SI/RR Staff is designated for filling
lists in different departments and services used for monitoring and 2 and monitoring of these
quality assurance checklists
Standard G4. 34 34
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support
services.
ME G4.1. Departmental standard operating procedures Standard operating procedure RR
are available for department has been 2
prepared and approved
Current version of SOP are OB
available with process owner 2
ME G4.2. Standard Operating Procedures adequately Emergency has documented RR
describes process and procedures procedure for receiving the 2
patient in emergency
Department has documented RR
procedure for triaging
2

procedure for taking consent
2

procedure for initial screening of
patient 2

procedure for nursing care
2

procedure for admission and 2
transfer of the patient to ward
Emergency has documented RR
procedure for Handling medical 2
records
procedure for maintaining
records in Emergency 2

procedure to handle brought in
dead patient 2

procedure for storage, handling 2
and release of dead body
procedure for storage and
replenishing the medicine in
emergency 2

procedure for equipment
preventive and break down 2
maintenance

procedure for Disaster 2
management
ME G4.3. Staff is trained and aware of the standard Check Staff is a aware of relevant SI/RR
procedures written in SOPs part of SOPs 2
ME G4.4. Work instructions are displayed at Point of use Work instruction/clinical OB Triage, CPR, Medical clinical
protocols are displayed protocols like Snake bite and
2 poisoning
Standard G 5. 6 6
Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
ME G5.1. Facility maps its critical processes Process mapping of critical SI/RR
processes done 2
ME G5.2. Facility identifies non value adding activities / Non value adding activities are SI/RR
waste / redundant activities identified 2
ME G5.3 Facility takes corrective action to improve the Processes are rearranged as per SI/RR
processes requirement 2
Standard G6. The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 14 14
ME G6.1. The facility conducts periodic internal Internal assessment is done at RR/SI
assessment periodic interval 2
ME G6.2 The facility conducts the periodic prescription/ There is procedure to conduct RR/SI
medical/death audits Medical Audit 2
There is procedure to conduct RR/SI

Prescription audit 2
There is procedure to conduct RR/SI
Death audit 2
ME G6.3 The facility ensures non compliances are Non Compliance are enumerated RR/SI
enumerated and recorded adequately and recorded 2
Page 28
Method
ME G6.4. Action plan is made on the gaps found in the Action plan prepared RR/SI
assessment / audit process 2
ME G6.5. Planned actions are implemenated through Corrective and preventive action RR/SI
Quality improvement cycle (PDCA) taken
2
Standard G7. 6 6
The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
ME G7.4 SI/RR
Check short term valid quality

objectivities have been
framed addressing key quality
2
issues in each department and
cores services. Check if these
objectives are Specific,
Facility has de defined quality objectives to achieve Check if SMART Quality Measurable, Attainable,
mission and quality policy Objectives have framed Relevant and Time Bound.
ME G7.5 SI/RR
Interview with staff for their
awareness. Check if Mission
2 Statement, Core Values and
Mission, Values, Quality policy and objectives are Check of staff is aware of Mission Quality Policy is displayed
effectively communicated to staff and users of , Values, Quality Policy and prominently in local language
services objectives at Key Points
ME G7.7 SI/RR
Review the records that

action plan on quality
objectives being reviewed at
2 least onnce in month by
departmnetal incharges and
during the qulaity team
meeting. The progress on
Facility periodically reviews the progress of Check time bound action plan is quality objectives have been
strategic plan towards mission, policy and being reviewed at regular time recorded in Action Plan
objectives interval tracking sheet
Standard G8. Facility seeks continually improvement by practicing Quality method and tools. 6 6
ME G8.1. Facility uses method for quality improvement Basic quality improvement SI/OB PDCA & 5S
in services method 2
Advance quality improvement SI/OB Six sigma, lean.

method 2
ME G8.2. Facility uses tools for quality improvement in 7 basic tools of Quality SI/RR Minimum 2 applicable tools
services 2 are used in each department
Standards G10 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan 2 2
ME G10.6 SI/RR
Verify with the records. A
comprehensive risk
Check periodic assessment of 2 asesement of all clincial
medication and patient care processes should be done
Periodic assessment for Medication and Patient safety risk is done using defined using pre define critera at
care safety risks is done as per defined criteria. checklist periodically least once in three month.
Area of Concern - H Outcome 36 36
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 18 18
ME H1.1. Facility measures productivity Indicators on No of Emergency cases per
monthly basis thousand population 2
RR
No of trips per ambulance 2 RR
No. of trauma cases treated per
1000 emergency cases
2
RR
No. of poisoning cases treated
per 1000 emergency cases 2
RR
No. of cardiac cases treated per
2
RR
No. of obstetric cases treated per
2
RR
No of resuscitation done per
thousand population Resuscitation should include:
2 Chest Compression, Airway
RR and Breathing
Proportion of Patients attended
in Night 2
RR
Proportion of BPL Patients 2 RR
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 10 10
ME H2.1. Facility measures efficiency Indicators on monthly Response time for ambulance
basis 2
RR
Proportion of cases referred
2
RR
Response time at emergency for
initial assessment 2
RR
Average Turn Around Time
2 Average time a patient stays
RR at emergency observation bed
ME H2.2 Proportion of patient referred by
state owned/108 ambulance per 2
1000 referral cases
RR
Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 4
ME H3.1. Facility measures Clinical Care & Safety Indicators No of adverse events per
on monthly basis thousand patients 2
RR
Death Rate
No of Deaths in Emergency/
2 Total no of emergency
RR attended
Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 4 4
ME H4.1. Facility measures Service Quality Indicators on LAMA Rate No of LAMA X 100/ No of
monthly basis 2
RR Patients seen at emergency
Absconding rate
2 No of Absconding X 100/ No
RR of Patients seen at emergency
Page 29
Method
Obtained Maximum Percent 1

A 42 42 100%
B 80 80 100%
C 174 174 100%
D 108 108 100%
E 224 224 100%
F 108 108 100%
G 78 78 100%
H 36 36 100%
Total 850 850 100%
0
1
2
0
1
2
Page 30
Checklist No - 2 Outdoor Department Version - NHSRC/ 3.0
National Quality Assurance Standards for District Hospitals Version 2

Checklist for Outdoor Patient Department 2
Assessment Summary
Date of Assessment
Type of Assessment Action plan Submission Date

(Internal/External)
OPD Score Card

Area of Concern wise Score OPD Score
A Service 100%
Provision
Patient Rights
B 100%
C Inputs 100%
D Support 100%
E
F
Services
Clinical
Services
Infection
Control
100%
100%
100%
Quality
G Management 100%
H Outcome 98%
Major Gaps Observed
5
5
5
Date
Checklist for OPD

Reference No. Measurable Element Checkpoint Complian Assessment Means of Verification Remarks Obtain Maxi
ce Method mum
50 50
Standard A1 Facility Provides Curative Services
ME A1.1 The facility provides Availability of functional 2 Dedicated General speciality Medicine
General Medicine services General Medicine Clinic Clinic
SI/OB
Page 31
ce Method mum
ME A1.2 The facility provides Availability of functional 2 Dedicated General speciality Surgical
General Surgery services General Surgery Clinic Clinic
SI/OB
ME A1.3 The facility provides Availability of Functional 2 Dedicated speciality Obstetrics &
Obstetrics & Gynaecology Obstetrics & Gynaecology Clinic Gynaecology Clinic. High risk pregnancy
Services cases are referred from ANC clinic and
consulted.
SI/OB
ME A1.4 The facility provides Availability of Paediatric Clinic 2 Dedicated Paediatric speciality Clinic
Paediatric Services SI/OB
ME A1.5 The facility provides Availability of functional 2 Dedicated ophthalmology clinic providing
Ophthalmology Services Ophthalmology Clinic SI/OB consultation services
ME A1.6 The facility provides ENT Availability of Functional ENT 2 Dedicated ENT providing consultation
Services Clinic SI/OB services
Availability of OPD ENT 2 Foreign Body Removal (Ear and
procedures Nose),Stitching of CLW’s, Dressings,
Syringing of Ear, Chemical Cauterization
(Nose & Ear), Eustachian Tube Function
Test, Vestibular Function Test/Caloric Test
SI/OB
ME A1.7 The facility provides Availability of Functional 2 Dedicated clinical for Orthopaedic
Orthopaedics Services Orthopaedic Clinic SI/OB consultation
Availability of OPD Orthopaedic 2 plaster room procedure
procedure
SI/OB
ME A1.8 The facility provides Skin Availability of functional Skin & 2 Dedicated Clinic providing consultation
& VD Services VD Clinic SI/OB services
ME A1.9 The facility provides Availability of functional 2 Dedicated Clinic providing consultation
Psychiatry Services Psychiatry Clinic SI/OB services
ME A1.10 The facility provides Availability of functional Dental 2 Dedicated Clinic providing consultation
Dental Treatment Services Clinic services
SI/OB
Availability of OPD Dental 2 Accompanied by dental lab. Extraction,
procedure scaling, tooth extraction, denture and
Restoration.
SI/OB
ME A1.11 The facility provides Availability of Functional Ayush 2 AYUSH clinic accompanied by dispensary
AYUSH Services clinic SI/OB
ME A1.12 The facility provides Availability of Functional 2 Pain Management with cryotherapy, Pain
Physiotherapy Services Physiotherapy Unit Management with deep heat therapy
(SWD), Increase range of motion with
mobilization,
SI/OB
ME A1.13 The facility provides Availability of Dressing facilities 2 Dressing, Suturing and drainage
services for OPD at OPD
procedures
SI/OB
Availability of Injection room 2
facilities at OPD SI/OB
ME A1.14 Services are available for At least 6 Hours of OPD 2 SI/RR
the time period as Services are available
mandated
ME A1.15 The facility provides Availability of functional 2
services for Super Cardiology clinic
specialties, as mandated
SI/OB
Availability of functional gastro 2
entomology clinic SI/OB
Availability of functional 2
nephrology clinic SI/OB
Neurology clinic SI/OB
endocrinology Clinic is available
SI/OB
Oncology Clinic SI/OB
nuclear medicine clinic is
available
SI/OB
10 10
ME A2.2 The facility provides Availability of functional ANC 2
Maternal health Services clinic
SI/OB
ME A2.3 The facility provides Availability of Functional 2
Newborn health Services immunization clinic
SI/OB
ME A2.4 The facility provides Child Availability Functional IYCF 2
health Services clinic SI/OB
Services under RBSY 2 SI/OB
ME A2.5 The facility provides Availability of Functional ARSH 2
Adolescent health clinic
Services
SI/OB
6 6
Standard A3 Facility Provides diagnostic Services
ME A3.2 The facility Provides Availability of Sample collection 2 SI/OB
Laboratory Services Centre
ME A3.3 The facility provides other Functional ECG Services are 2 SI/OB
diagnostic services, as available
mandated
Availability of TMT services 2 SI/OB
34 34
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme
ME A4.1 The facility provides 2 SI/RR OPD Management of Malaeria, Kala Azar,
services under National Dengue
Vector Borne Disease
Control Programme as per
guidelines Availability of OPD Services
Under NVBDCP
Page 32
ce Method mum
ME A4.2 The facility provides Availability of Functional DOTS 2 SI/OB

services under Revised clinic
National TB Control
Programme as per
guidelines
ME A4.3 The facility provides Availability of OPD services 2 SI/RR

services under National under NLEP
Leprosy Eradication
Programme as per
guidelines
Assessment of Disability Status 2 SI/RR
Supply of Customized Foot 2 SI/RR
wear
ME A4.4 The facility provides Availability of Functional ICTC 2 SI/OB
services under National
AIDS Control Programme
as per guidelines
Availability of HIV Testing and 2 SI/RR
Counselling
PPTCT Services for HIV positive 2 SI/OB

Pregnant Women
Availability of Functional ART 2 SI/OB
Centre
Availability of CD4 testing 2 SI/OB
facility
ME A4.5 The facility provides Screening and early detection 2 SI/RR Refraction, syringing and probing, foreign
services under National of visual impairment and body removal, Tonometery and
Programme for refraction retinoscopy
prevention and control of
Blindness as per
guidelines
Availability of OPD procedures 2 SI/OB Syringing and probing, foreign body

removal , Tonometry ,Perimetry,
Retinoscopy, Retrobulbar Injection
ME A4.6 The facility provides Availability of counselling 2 SI/OB
services under Mental centre for Suicide prevention
Health Programme as per
guidelines
ME A4.7 The facility provides 2 SI/OB

services under National
Programme for the health
care of the elderly as per
guidelines Dedicated Geriatric Clinic
ME A4.8 The facility provides Functional NCD clinic is 2 SI/OB
services under National available
Programme for
Prevention and control of
Cancer, Diabetes,
Cardiovascular diseases &
Stroke (NPCDCS) as per
guidelines
ME A4.10 The facility provide Management of case referred 2 SI/RR

services under National from PHC/CHC directly
health Programme for reported to Hospital
deafness
ME A4.11 The facility provides services Availability of OPD services as 2 SI/RR

as per State specific health per State Health Programs
programmes
2 2
Standard A6 Health services provided at the facility are appropriate to community needs.
ME A6.1 The facility provides
curatives & preventive
services for the health
problems and diseases, Ask for the specific local health problems/
prevalent locally. Special Clinics are available for diseases .i.e.. Kala azar, Swine Flue,
local prevalent endemics 2 SI/OB arsenic poisoning etc.
Area of Concern - B Patient Rights 78 78
28 28
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 The facility has uniform
and user-friendly signage Availability departmental (Numbering, main department and
system signage's 2 OB internal sectional signage
Display of layout/floor
directory 2 OB
ME B1.2 2
The facility displays the
services and entitlements
available in its
departments List of OPD Clinics are available OB
Names of doctor on duty is 2
displayed and updated OB
Timing for OPD are displayed 2 OB
Entitlement under JSY , JSSK 2
and other schemes OB
Important numbers like 2
ambulance are displayed OB
ME B1.3 2
The facility has
established citizen Display of citizen charter
charter, which is followed
at all levels OB
ME B1.4 2
User charges are
displayed and
communicated to patients
effectively
User charges for services are
displayed OB
ME B1.5 2
Patients & visitors are
sensitised and educated
through appropriate IEC /
BCC approaches IEC Material is displayed OB
Page 33
ce Method mum
Education material for 2

counselling are available in
Counselling room
OB
ME B1.6 Information is available in Signage's and information are 2
local language and easy to available in local language
understand OB
ME B1.7 2
The facility provides
information to patients
and visitor through an
Availability of Enquiry Desk
exclusive set-up. with dedicated staff OB
ME B1.8 2 RR/OB
The facility ensures access
to clinical records of
patients to entitled
personnel OPD slip is given to the patient
18 18
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account
of physical economic, cultural or social reasons.
ME B2.1 Services are provided in 2 OB
manner that are sensitive Separate queue for female at
to gender registration
Separate Female general OPD 2 OB
Separate toilets for male and 2 OB
female
2 OB
Availability of female staff if a
male doctor examination a
female patients
Availability of Breast feeding 2 OB
corner
ME B2.3 2 OB
Access to facility is
provided without any
physical barrier & and Availability of Wheel chair or
friendly to people with stretcher for easy Access to the
disabilities OPD
2 OB
Availability of ramps with railing
There is no chaos and over 2 OB
crowding in the OPD
Availability of disable friendly 2 OB
toilet
12 12
Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information.
ME B3.1 Adequate visual privacy is 2 OB
provided at every point of Availability of screen at
care Examination Area
One Patient is seen at a time in 2 OB
clinics
Privacy at the counselling room 2 OB
is maintained
ME B3.2 2 SI/OB
Confidentiality of patients
records and clinical
information is maintained Confidentiality of HIV reports at
ICTC
ME B3.3 Behaviour of staff is empathetic PI/OB
The facility ensures the and courteous
behaviours of staff is
dignified and respectful,
while delivering the
services
2
ME B3.4 The facility ensures SI/OB
privacy and confidentiality
to every patient,
especially of those
conditions having social
stigma, and also
safeguards vulnerable Privacy and confidentiality of
groups HIV, Leprosy Patients 2 Check in RTI/STI clinic
10 10
Standard B4
Facility has defined and established procedures for informing and involving patient and their families about treatment and
obtaining informed consent wherever it is required.
ME B4.1 2 SI/RR
There is established
procedures for taking
informed consent before
treatment and procedures Informed consent for before
HIV testing at ICTC
ME B4.2 Patient is informed about 2 OB
his/her rights and Display of patient rights and
responsibilities responsibilities.
ME B4.4 2 PI
Information about the
treatment is shared with
patients or attendants, Patient is informed about her
clinical condition and Ask patients about what they have been
regularly treatment been provided communicated about the treatment plan
2 SI/PI/RR
Pre and Post test counselling is
given at ICTC
ME B4.5 The facility has defined 2 OB
and established grievance Availability of complaint box
redressal system in place and display of process for
grievance re redressal and
whom to contact is displayed
10 10
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.
ME B5.1 The facility provides 2 PI/SI
cashless services to
pregnant women,
mothers and neonates as
per prevalent government Free OPD Consultation / ANC
schemes Checkups For JSSK entitlement
ME B5.2 Check that patient party has 2 PI/SI
The facility ensures that not spent on purchasing drugs
drugs prescribed are or consumables from outside.
available at Pharmacy and
wards
Page 34
ce Method mum
ME B5.3 Check that patient party has 2 PI/SI

It is ensured that facilities not spent on diagnostics from
for the prescribed outside.
investigations are
available at the facility
ME B5.4 2 PI/SI/RR
The facility provide free of
cost treatment to Below
poverty line patients
without administrative
hassles Free OPD Consultation for BPL
patients
ME B5.5 2 PI/SI/RR
The facility ensures timely
reimbursement of
financial entitlements and
reimbursement to the If any other expenditure
patients occurred it is reimbursed from
hospital
48 48
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
ME C1.1 Departments have Adequate Space in Clinics (12 sq ft)
adequate space as per
patient or work load Clinics has adequate space for
consultation and examination 2 OB
Availability of adequate waiting Waiting area at the scale of 1 sq ft per
area average daily patient with minimum 400
2 OB sq ft of area
ME C1.2 Patient amenities are
provide as per patient
load Availability of seating
arrangement in waiting area 2 OB As per average OPD at peak time
Availability of sub waiting at for
separate clinics 2 OB For clinics has high patient load
Availability of cold Drinking
water 2 OB See if its is easily accessible to the visitors
Urinals 1 per 50 person
water closet and wash basins 1 per 100
Availability of functional toilets 2 OB person
Availability of patient calling 2
system OB
Availability of public telephone 2
booth OB
ME C1.3 Departments have layout
and demarcated areas as
per functions There is designated area for
registration 2 OB
Dedicated clinic for each
speciality 2 OB
One clinic is not shared by 2
doctors at one time 2 OB
Dedicated examination areas is
provided with each clinics 2 OB
Demarcated dressing area
/room 2 OB
2
Demarcated injection room OB
Demarcated immunization
room for pregnant women and
children 2 OB
OPD has separate entry and
exit from IPD and Emergency 2 OB
availability of clean and dirty
utility room 2 OB
Demarcated trolley/wheelchair
bay 2 OB
ME C1.4 The facility has adequate 2 OB
circulation area and open
spaces according to need
and local law Corridors at OPD are broad
enough to manage stretcher
and trolleys
ME C1.5 The facility has 2 OB
infrastructure for
intramural and extramural
communication Availability of functional
telephone and Intercom
Services
ME C1.6 Service counters are OB
available as per patient
load
Availability of Registration Average Time taken for registration would
counters as per Patient load be 3-5 min so number of counter required
would be worked on scale of 12-20
2 patient/hour per counter
ME C1.7 The facility and OB
departments are planned
to ensure structure
follows the
function/processes
(Structure commensurate Layout of OPD shall follow functional flow
with the function of the of the
hospital) patients, e.g.:
Enquiry→Registration→Waiting→Sub-
waiting→
Clinic→Dressing room/Injection Room→
Unidirectional flow of services 2 Diagnostics (lab/X-ray)→Pharmacy→Exit
OB
All OPD clinics and related
auxiliary services are co located
in one functional area 2
OPD is located near to the OB
entry of the hospital 2
8 8
Standard C2 The facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the Non structural components are 2 OB Check for fixtures and furniture like
seismic safety of the properly secured cupboards, cabinets, and heavy
infrastructure equipments , hanging objects are properly
fastened and secured
Page 35
ce Method mum
ME C2.3 The facility ensures safety 2 OB

of electrical establishment
OPD building does not have
temporary connections and
loosely hanging wires
ME C2.4 Physical condition of 2 OB
buildings are safe for
providing patient care Floors of the OPD are non
slippery and even
Windows have grills and wire 2 OB
meshwork
10 10
Standard C3 The facility has established Programme for fire safety and other disaster
ME C3.1 The facility has plan for 2 OB/SI
prevention of fire OPD has sufficient fire exit to
permit safe escape to its
occupant at time of fire
Check the fire exits are clearly 2 OB

are clearly marked.
fire fighting Equipment OPD has installed fire
Extinguisher that is Class A ,
Class B C type or ABC type
2 OB/RR
Check the expiry date for fire
each extinguisher as well as
due date for next refilling is
clearly mentioned
ME C3.3 The facility has a system Check for staff competencies 2
of periodic training of staff for operating fire extinguisher
and conducts mock drills and what to do in case of fire
regularly for fire and other
disaster situation
32 32
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
ME C4.1 The facility has adequate
specialist doctors as per
service provision
Availability of specialist Doctor Check for specialist are available at
at OPD time 2 OB/RR scheduled time
ME C4.2 The facility has adequate OB/RR
general duty doctors as
per service provision and
work load Availability of General duty
doctor at Screening Clinic 2
ME C4.3 The facility has adequate OB/RR/SI
nursing staff as per service
provision and work load
At Injection room/ OPD Clinic as Per
Availability of Nursing staff 2 Requirement
ME C4.4 The facility has adequate 2 OB/SI
technicians/paramedics as
per requirement Availability of
dresser/paramedic at dressing
room
2 SI/RR Full Time
Counsellor for ICTC
2 SI/RR Full time
Lab technician for ICTC
2 SI/RR
Counsellor for ARSH clinic
2 SI/RR
Availability of ECG technician
2 SI/RR
Availability of Audiometrician
2 SI/RR
Availability of Ophthalmic
assistant
2 SI/RR
Availability of Physiotherapist
2 SI/RR
Availability of Dental technician
2 SI/RR
Availability of rehabilitation
therapist
ME C4.5 The facility has adequate 2 SI/RR
support / general staff
availability of dedicated
security guard for OPD
Availability of registration 2 SI/RR
clerks as per load
Availability of housekeeping 2 SI/RR
staff
10 10
Standard C5 Facility provides drugs and consumables required for assured list of services.
ME C5.1 The departments have OB/RR
availability of adequate
drugs at point of use Availability of injectables at
injection room 2 ARV, TT
OB/RR
Availability of vaccine as per
National Immunization
Program 2
ME C5.2 The departments have Availability of disposables at OB/RR
adequate consumables at dressing room and clinics
point of use examination gloves, Syringes, Dressing
2 material , suturing material
HIV testing Kits I, II and III at OB/RR
ICTC 2
ME C5.3 Emergency drug trays are Emergency Drug Tray is 2 OB/RR
maintained at every point maintained at injection room &
of care, where ever it may immunization room
be needed
26 26
Standard C6 The facility has equipment & instruments required for assured list of services.
Page 36
ce Method mum
ME C6.1 Availability of equipment Availability of functional

& instruments for Equipment &Instruments
examination & monitoring for examination &
of patients Monitoring BP apparatus, thermometer, weighting
machine, torch, stethoscope, Examination
2 OB table
ME C6.2 Availability of equipment Availability of functional
& instruments for Instruments/Equipments for
treatment procedures, Gynae and obstetric
being undertaken in the
facility
PV examination kit, Inch tape, fetoscope,
2 OB Weighting machine, BP apparatus etc.
Availability of functional
Equipment/Instruments for
Orthopaedic Procedures
X ray view box, Equipment for plaster
2 OB room
Instruments / Equipments
for Ophthalmic Procedures Retinoscope, refraction kit,
tonometer,perimeter, distant vision chart,
2 OB Colour vision chart.
Availability of Instruments/
Equipments Procedures for
ENT procedures Audiometer, Laryngoscope, Otoscope,
Head Light, Tuning Fork, Bronchoscope,
2 OB Examination Instrument Set
Instruments/ Equipments for
Dental Procedures Dental chair, Air rotor, Endodontic set,
2 OB Extraction forceps
Equipment/Instruments of
Physiotherapy Procedures Traction, Wax bath, Short Wave
2 OB Diathermy, Exercise table Etc .
ME C6.3 Availability of equipment Availability of Equipments for 2 Micropipettes, Centrifuge, Needle
& instruments for ICTC lab destroyer, Refrigerators
diagnostic procedures
being undertaken in the
facility
OB
ME C6.5 Availability of Equipment Availability of equipment for 2 OB Refrigerator, Crash cart/Drug trolley,
for Storage storage for drugs instrumental trolley, dressing trolley
ME C6.6 Availability of functional Availability of equipments 2 OB Buckets for mopping, mops, duster, waste
equipment and for cleaning trolley, Deck brush
instruments for support
services
Availability of equipment for 2 OB Boiler

sterilization and disinfection
ME C6.7 Departments have patient Availability of Fixtures 2 OB Spot light, electrical fixture for
furniture and fixtures as equipments, X ray view box
per load and service
provision
OB
Doctors Chair, Patient Stool, Examination
Availability of furniture at Table, Attendant Chair, Table, Footstep,
clinics 2 cupboard
ME C7.1 RR/SI
Check objective checklist has been

2 prepared for assessing competence of
doctors, nurses and paramedical staff
Criteria for Competence Check parameters for assessing based on job description defined for each
assessment are defined for skills and proficiency of clinical cadre of staff. Dakshta checklist issued by
clinical and Para clinical staff staff has been defined MoHFW can be used for this purpose.
ME C7.2 RR/SI
Competence assessment of
Clinical and Para clinical staff 2 Check for records of competence
is done on predefined Check for competence assessment including filled checklist,
criteria at least once in a assessment is done at least scoring and grading . Verify with staff for
year once in a year actual competence assessment done
ME C7.9 Bio Medical waste 2 SI/RR
The Staff is provided training Management
as per defined core
competencies and training
plan
Infection control and hand 2 SI/RR
hygiene
Patient Safety 2 SI/RR
ICTC Team Training 2 SI/RR
Induction and refresher 2 SI/RR
training for ICTC counsellor
Induction and refresher 2 SI/RR
training for ICTC lab technician
ME C7.10 2 SI/RR
There is established Check supervisors make periodic rounds
procedure for utilization of of department and monitor that staff is
skills gained thought Check the competency of staff working according to the training
trainings by on -job to use OPD equipment like BP imparted. Also staff is provided on job
supportive supervision apparatus etc training wherever there is still gaps
2 SI/RR
Check supervisors make periodic rounds
of department and monitor that staff is
working according to the training
At ANC clinic staff is skilled to imparted. Also staff is provided on job
identify high risk pregnancies training wherever there is still gaps
2 SI/RR
Counsellor is skilled for imparted. Also staff is provided on job
counselling training wherever there is still gaps
2 SI/RR
Staff is skilled for maintaining imparted. Also staff is provided on job
clinical records training wherever there is still gaps
6 6
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
Page 37
ce Method mum
ME D1.1 The facility has All equipments are covered 2 SI/RR

established system for under AMC including
maintenance of critical preventive maintenance
Equipment
2 SI/RR
There is system of timely
corrective break down
maintenance of the
equipments
ME D1.2 The facility has All the measuring equipments/ 2 OB/ RR
established procedure for instrument are calibrated
internal and external
calibration of measuring
Equipment
BP apparatus, thermometer are calibrated
24 24
Standard D2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care
areas
ME D2.1 There is established 2 SI/RR
procedure for forecasting
and indenting drugs and
consumables There is process indenting Stock level are daily updated
consumables and drugs in Requisition are timely placed
injection/ dressing room
ME D2.3 The facility ensures proper 2 OB
storage of drugs and Drugs are stored in
consumables containers/tray/crash cart and
are labelled
2 OB
Vaccine are kept at

recommended temperature at
immunization room
ME D2.4 The facility ensures Expiry dates for injectables are 2
management of expiry maintained at injection and
and near expiry drugs immunization room
OB/RR
2
expiry drugs are maintained for
drug stored at department RR
ME D2.5 The facility has There is practice of calculating 2 SI/RR
established procedure for and maintaining buffer stock
inventory management
techniques
Department maintained stock 2 SI/RR

and expenditure register of
drugs and consumables
ME D2.6 There is a procedure for There is procedure for 2 SI/RR
periodically replenishing the replenishing drug tray /crash
drugs in patient care areas cart
There is no stock out of drugs 2 SI/RR
ME D2.7 There is process for 2 OB/RR Check for temperature charts are
storage of vaccines and Temperature of refrigerators maintained and updated periodically
other drugs, requiring are kept as per storage
controlled temperature requirement and records are
maintained
2 OB/RR Check for four conditioned Ice packs are
placed in Carrier Box,
DPT, DT, TT and Hep B Vaccines are not
kept in direct contact of Frozen Ice pack
Cold chain is maintained at
immunization room
18 18
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
ME D3.1 The facility provides 2 OB Examination table
adequate illumination
level at patient care areas
Adequate Illumination in clinics
Adequate Illumination in 2 OB Dressing room, injection room and
procedure area immunization room
ME D3.2 The facility has provision Only one patient is allowed one 2 OB/SI
of restriction of visitors in time at clinic
patient areas
2 OB/SI
Limited number of attendant/
relatives are allowed with
patient
2 OB/SI
Medical representative are

restricted in OPD timings
ME D3.3 The facility ensures safe Temperature control and 2 PI/OB Fans/ Air
and comfortable ventilation in waiting areas conditioning/Heating/Exhaust/Ventilators
environment for patients as per environment condition and
and service providers requirement
Temperature control and 2 SI/OB Fans/ Air

ventilation in clinics conditioning/Heating/Exhaust/Ventilators
as per environment condition and
requirement
ME D3.4 The facility has security 2 OB/SI

system in place at patient Hospital has sound security
care areas system to manage
overcrowding in OPD
ME D3.5 The facility has established Ask female staff whether they 2 SI
measure for safety and feel secure at work place
security of female staff
22 22
Standard D4 The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior of the facility 2 OB
building is maintained Building is
appropriately painted/whitewashed in
uniform colour
Interior of patient care areas 2 OB
are plastered & painted
Page 38
ce Method mum
ME D4.2 Patient care areas are Floors, walls, roof, roof topes,
clean and hygienic sinks patient care and All area are clean with no
circulation areas are Clean 2 OB dirt,grease,littering and cobwebs
Surface of furniture and 2 OB
fixtures are clean
Toilets are clean with 2 OB
functional flush and running
water
ME D4.3 Hospital infrastructure is Check for there is no seepage , 2 OB
adequately maintained Cracks, chipping of plaster
OB
Window panes , doors and
other fixtures are intact 2
Patients beds are intact and OB
painted 2
OB
Mattresses are intact and clean 2
ME D4.5 The facility has policy of 2 OB
removal of condemned
junk material No condemned/Junk material
lying in the OPD
ME D4.6 The facility has 2 OB
established procedures
for pest, rodent and
animal control
No stray animal/rodent/birds
4 4
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
ME D5.1 The facility has adequate Availability of 24x7 running and OB/SI
arrangement storage and potable water
supply for portable water
in all functional areas
2
ME D5.2 The facility ensures OB/SI
adequate power backup in
all patient care areas as
per load Availability of power back up in
OPD 2
2 2
StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.
ME D6.1 The facility has provision Nutritional assessment of 2 RR/SI
of nutritional assessment patient done as required and
of the patients directed by doctor
2 2
Standard D7 The facility ensures clean linen to the patients
ME D7.1 The facility has adequate Availability of linen in 2 OB
sets of linen examination area
8 8
Standard D11
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating
procedures.
ME D11.1 The facility has Staff is aware of their role 2 SI
established job and responsibilities
description as per govt
guidelines
ME D11.2 The facility has a There is procedure to ensure 2 RR/SI Check for system for recording time of
established procedure for that staff is available on duty as reporting and relieving (Attendance
duty roster and per duty roster register/ Biometrics etc)
deputation to different
departments
There is designated in charge 2 SI

for department
ME D11.3 The facility ensures the Doctor, nursing staff and OB
adherence to dress code support staff adhere to their
as mandated by its respective dress code
administration / the
health department
2
2 2
Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
ME D12.1 2 SI/RR Verification of outsourced services
There is procedure to monitor (cleaning/Laundry/Security/Maintenance)
There is established system the quality and adequacy of provided are done by designated in-
for contract management outsourced services on regular house staff
for out sourced services basis
Area of Concern - E Clinical Services 306 306
24 24
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
ME E1.1 The facility has Unique identification number 2 RR
established procedure for is given to each patient during
registration of patients process of registration
Patient demographic details 2 RR Check for that patient demographics like

are recorded in OPD Name, age, Sex, Address etc.
registration records
2
Patients are directed to
relevant clinic by registration
clerk based on complaint PI/SI
2
Registration clerk is aware of
categories of the patient
exempted from user charges SI/RR
ME E1.2 The facility has a There is procedure for 2
established procedure for systematic calling of patients Patient is called by Doctor/attendant as
OPD consultation one by one per his/her turn on the basis of “first
OB come first examine” basis.
Patient History is taken and 2
recorded RR
2
Physical Examination is done
and recorded wherever
required OB/RR
Provisional Diagnosis is 2
recorded OB/RR
Page 39
ce Method mum
No Patient is Consulted in 2
Standing Position OB
2
Clinical staff is not engaged in

administrative work OB/SI
ME E1.3 There is established There is establish procedure for 2 SI/RR
procedure for admission admission through OPD
of patients
There is establish procedure for 2 SI/RR
day care admission
4 4
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients.
ME E2.1 There is established 2 OB
procedure for initial There is screening clinic for
assessment of patients initial assessment of the
patients
ME E2.2 There is established 2 OB/RR
procedure for follow-up/
reassessment of Patients
Procedure for follow up of old
patients
16 16
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 Facility has established Facility has established 2 SI/RR
procedure for continuity procedure for handing over
of care during of patients during
interdepartmental departmental transfer
transfer
There is a procedure 2
consultation of the patient
to other specialist with in the
hospital
SI/RR
ME E3.2 Facility provides appropriate Check how patient are referred if services
referral linkages to the are not available
patients/Services for
transfer to other/higher
facilities to assure their
continuity of care. Availability of referral linkages
for OPD consultation. 2 RR/OB
Facility has functional 2
referral linkages to higher
facilities SI/RR
Facility has functional 2
referral linkages to lower
facilities SI/RR
2 RR
There is a system of follow
up of referred patients
ICTC has functional Linkages 2 RR/SI

with ART and state reference
Labs
ME E3.4 Facility is connected to 2 RR/SI
medical colleges through
telemedicine services
Telemedicine service are used
for consultation
2 2
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.
ME E5.2 The facility identifies high 2 OB/SI
risk patients and ensure For any critical patient needing
their care, as per their need urgent attention queue can be
bypassed for providing services
on priority basis
12 12
Standard E6
Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their
rational use.
ME E6.1 Facility ensured that drugs 2 RR
are prescribed in generic Check for OPD slip if drugs are
name only prescribed under generic name
only
A copy of Prescription is kept RR
with the facility 2
ME E6.2 There is procedure of Check for that relevant 2 RR
rational use of drugs Standard treatment guideline
are available at point of use
Check staff is aware of the drug SI/RR
regime and doses as per STG
2
Check OPD ticket that drugs are RR
prescribed as per STG
2
Availability of drug formulary 2 SI/OB
14 14
Standard E7 Facility has defined procedures for safe drug administration
ME E7.2 Medication orders are Every Medical advice and 2 RR
written legibly and procedure is accompanied
adequately with date , time and
signature
Check for the writing, It 2 RR/SI

comprehendible by the clinical
staff
ME E7.3 There is a procedure to Drugs are checked for expiry 2 OB/SI Check in Injection room
check drug before and other inconsistency
administration/ before administration
dispensing
Check single dose vial are not 2 OB Check for any open single dose vial with
used for more than one dose left over content intended to be used
later on
Check for separate sterile 2 OB
needle is used every time for In multi dose vial needle is not left in the
multiple dose vial septum
Page 40
ce Method mum
Any adverse drug reaction is 2 RR/SI

recorded and reported
ME E7.5 Patient is counselled for Patient is advice by doctor/ 2 SI/PI
self drug administration Pharmacist /nurse about the
14 14
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re- 2 RR
assessment and Patient History, Chief
investigations are Complaint and Examination
recorded and updated Diagnosis/ Provisional
Diagnosis is recorded in OPD
slip
ME E8.2 All treatment plan 2 RR
prescription/orders are
recorded in the patient Written
records. Prescription Treatment plan is
written
ME E8.4 Procedures performed are 2 RR
written on patients Any dressing/injection, other
records procedure recorded in the OPD
slip
ME E8.5 Adequate form and 2 OB/SI
formats are available at
point of use Check for the availability of
OPD slip, Requisition slips etc.
ME E8.6 Register/records are OPD records are maintained 2 OB/RR OPD register, ANC register, Injection room
maintained as per register etc
guidelines
All register/records are 2 OB/RR
identified and numbered
ME E8.7 The facility ensures safe Safe keeping of OPD records 2 OB/SI
and adequate storage and
retrieval of medical
records
4 4
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.3 The facility has disaster Staff is aware of disaster plan 2 SI/RR
management plan in place
Role and responsibilities of staff 2 SI/RR

in disaster is defined
4 4
Standard E12 The facility has defined and established procedures of diagnostic services
ME E12.1 There are established Container is labelled properly 2 OB
procedures for Pre-testing after the sample collection
Activities
ME E12.3 There are established Clinics is provided with the 2 SI/RR
procedures for Post- critical value of different tests
testing Activities
Maternal & Child Health Services
50 50
Standard E17 Facility has established procedures for Antenatal care as per guidelines
ME E17.1 There is an established Facility provides and updates RR/SI
procedure for Registration “Mother and Child
and follow up of pregnant Protection Card”.
women.
2 Line listing
RR
Records are maintained for Records of each ANC checkups is
ANC registered pregnant maintained in Mother and child
women 2 protection card
ME E17.2 There is an established 2 RR/SI
procedure for History
taking, Physical
examination, and
counselling for each
antenatal visit.
ANC checkups is done by
Qualified personnel
2 RR/SI
At ANC clinic, Pregnancy is
confirmed by performing urine
test
2 RR/SI
Last menstrual period (LMP) is
recorded and Expected date of
Delivery (EDD) is calculated
Weight measurement 2 RR/SI
blood pressure, 2 RR/SI
respiratory rate 2 RR/SI
2 RR/SI
pallor, oedema and icterus.
abdominal palpation for foetal 2 RR/SI
growth, foetal lie
auscultation for foetal heart 2 RR/SI
sound
breast examination 2 RR/SI
2 RR/SI
History of past illness /
pregnancy complication is
taken and recorded
4 ANC checkups of women is 2 RR/SI
confirmed
ME E17.3 Facility ensures availability RR/SI
of diagnostic and drugs
during antenatal care of Check for Haemoglobin, urine albumin
pregnant women Diagnostic test under ANC urine sugar blood group and Rh factor
check up are prescribed by ANC Syphilis (VDRL/RPR) HIV blood sugar
clinic 2 malaria Hepatitis B
procedure for
identification of High risk
pregnancy and
appropriate
treatment/referral as per High risk pregnant women are
scope of services. referred to specialist
Page 41
ce Method mum

procedure for
identification and
management of moderate
and severe anaemia
Line listing of pregnant women
with moderate and sever
anaemia
2 RR/SI
Provision for Injectable Iron
Treatment for moderate
anaemia
ME E17.6 Counselling of pregnant 2 RR/PI
women is done as per
standard protocol and
gestational age
nutritional counselling
recognizing danger sign of 2 RR/PI
labour
breast feeding 2 RR/PI
institutional delivery 2 RR/PI
arrangement of referral 2 RR/PI
transport
birth preparedness 2 RR/PI
family planning 2 RR/PI
44 44
Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines
ME E20.1 The facility provides Availability of diluents for 2 RR/SI
immunization services as Reconstitution of measles
per guidelines vaccine
Recommended temperature of 2 RR/SI Check diluents are kept under cold chain
diluents is insured before at least before 24 hours before
reconstitution reconstitution
Diluents are kept in vaccine carrier only at
immunization clinic but should not be in
direct contact of ice pack
Reconstituted vaccines are not 2 RR/SI Ask staff about when BCG, measles and JE
used after recommended time vaccines are constituted and till when
these are valid for use. Should not be
used beyond 4 hours after reconstitution
Time of opening/ 2 RR Check for records

Reconstitution of vial is
recorded
Staff checks VVM level before 2 SI Ask staff how to check VVM level and
using vaccines how to identify discard point
Staff is aware of how check 2 SI Ask staff to demonstrate how to conduct
freeze damage for T-Series Shake test for DPT, DT and TT
vaccines
Discarded vaccines are kept 2 SI/OB Check for no expired, frozen or with VVM
separately beyond the discard point vaccine stored
in clod chain
Check for DPT, DT, Hep Band TT 2 SI/OB
vials are not kept in direct
contact of ice pack
AD syringes are available as per 2 SI/OB Check for 0.1 ml AD syringe for BCG and
requirement 0.5 ml syringe for others are available
Staff knows correct use AD 2 SI Ask for demonstration , How to peel, how
syringe to remove air bubble and injection site
Check for AD syringes are not 2 OB

reused
Vaccine recipient is asked to 2 SI/RR
stay for half an hour after
vaccination to observer any
Adverse effect following
immunization
Antipyretic medicines available 2 SI/RR
Availability of Immunization 2 SI/RR

card
Counselling on side effects and 2 SI/RR
follow up visits done(CEI)
Staff is aware of how to minor 2 SI
and serious advise events
(AEFI)
Staff knows what to do in case 2 SI
of anaphylaxis
ME E20.2 Triage, Assessment & 2 SI/RR
Management of newborns
having
emergency signs are done as
per guidelines
Check for adherence to clinical
protocols
ME E20.7 Management of children 2 SI/RR
presenting
with fever, cough/
breathlessness is done as
per guidelines
Check for adherence to clinical
protocols
ME E20.8 Management of children Screening of children coming 2 SI/RR
with severe to OPDs using weight for
Acute Malnutrition is height and/or MUAC
done as per guidelines
ME E20.9 Management of children Check for adherence to clinical 2 SI/RR

presenting protocols
diarrhoea is done per
guidelines
Availability of ORT corner 2 SI/RR
Page 42
ce Method mum
30 30
Standard E22 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines
ME E22.1 Facility provides Provision of Antenatal natal
Promotive ARSH Services check up for pregnant
adolescent
Nutritional Counselling, contraceptive
counselling, Couple counselling ANC
2 SI/RR checkups, ensuring institutional delivery
Counselling and provision of Check for the availability of Emergency
emergency contraceptive pills 2 SI/RR Contraceptive pills (Levonorgesterol)
Counselling and provision of Check for the availability of Oral
reversible Contraceptives 2 RR/SI Contraceptive Pills, Condoms and IUD
Availability and Display of IEC Poster Displayed, Reading Material
material 2 OB handouts etc.
Information and advice ob
sexual and reproductive health
related issues
Advice on topic related to Growth and
development,puberty,sexuality cancers,
myths & misconception, pregnancy, safe
sex, contraception, unsafe abortion,
menstrual disorders,anemia, sexual abuse
2 SI/RR ,RTI/STI's etc.
ME E22.2 Facility provides Services for Tetanus
Preventive ARSH Services immunization
2 SI/RR TT at 10 and 16 year
Services for Prophylaxis against
Nutritional Anaemia Haemoglobin estimation, weekly IFA
tablet, and treatment for worm
2 SI/RR infestation
Nutrition Counselling 2 SI/RR
Services for early and safe
termination of pregnancy and
management of post abortion
complication MVA procedure for pregnancy up to 8
2 SI/RR week Post abortion counselling
ME E22.3 Facility Provides Curative Treatment of Common RTI/STI's
Privacy and Confidentiality, treatment
ARSH Services Compliance, Partner Management, Follow
2 SI/RR up visit and referral
Treatment and counselling for
Menstrual disorders
2 SI/RR Symptomatic treatment , counselling

Treatment and counselling for
sexual concern for male and
female adolescents
2 SI/RR
Management of sexual abuse ECP, Prophylaxis against STI, PEP for hIV
amongst Girls 2 SI/RR and Counselling
ME E22.4 Facility Provides Referral Referral Linkages to ICTC and
Services for ARSH PPTCT 2 SI/RR
Privacy and confidentiality
maintained at ARSH clinic Screens and curtains for visual
privacy,confidentaility policy displayed,
2 SI/RR one client at a time
National Health Programs
88 88
Standard E23 Facility provides National health program as per operational/Clinical Guidelines
ME E23.1 Facility provides service 2 SI/RR As per Clincal Guidelines for Treatment of
under National Vector Maleria
Borne Disease Control
Program as per guidelines
Ambulatory care of
uncomplicated P. Vivax malaria
2 SI/RR As per Clincal Guidelines for Treatment of
Ambulatory care of Maleria
uncomplicated P. Falciparum
Malaria
Ambulatory care of drug 2 SI/RR As per Clincal Guidelines for Treatment of
resistant malaria Maleria
ME E23.2 Facility provides service 2 SI/RR Cough >2 weeks, fever >2 weeks,
under Revised National TB Staff is aware of symptoms or significant weight loss, haemoptysis,
Control Program as per signs Presumptive pulmonary any abnormalities in chest radiography.
guidelines TB as per revised guidelines Addition, contact of microbiologically
confirmed
TB patients, PL HIV, diabetics,
malnourished, cancer
patients, patients on immunosuppressive
therapy
Staff is aware of Signs and 2 SI/RR Organ specific symptoms and signs like
symptoms of Extra pulmonary swelling of lymph nodes, pain & swelling
Tuberculosis in joints, neck stiffness, disorientation, etc
or constitutional symptoms like weight
loss, fever> 2 weeks night sweat
Child with persistant fever and/ or cough

for more than 2 weeks. Unexplained Loss
Staff is aware of signs and of weight/no weight gain in past 3
symptoms of presumptive months/here loss of body
2 SI/RR
paediatric TB cases as per weight loss of >5% body weight as
revised guidelines compared to highest weight recorded in
the last
3 months.
Page 43
ce Method mum
Staff is aware of presumptive 2 SI/RR (1)TB patients who have failed treatment
DRTB cases as per revised with first‑line
guidelines anti‑tubercular drugs (ATD).
(2)Paediatric TB non‑responde.
(3)TB patients who are contacts of DRTB.
(4)TB patients who are found positive on
any follow‑up sputum smear examination
during treatment with
first‑line ATD.
(5) Previously treated TB cases
(6)TB patients with HIV co‑infection
Staff is aware of classification 2 SI/RR 1. Mono resistance (MR) – Biological

done on the basis of drug specimen of TB Patient reistant to one
resistance as per revised first line anti TB drug only.
guidelines 2. Poly resistance (PDR) – Biological
speciment resitant to more than one anti
TB drug, other than INH & Rifampicin.
3. Multi‑drug resistance (MDR) –
Biological specimen resistant to both INH
and Rifampicin or with or without
resistance to other first line ATD
4. Rifampicin resistance (RR) –
Resistance to Rifampicn detected by
phenotypic or genotypic method with or
without resistant to other ATD exculding
INH. Patient with RR manged as if MDR-TB
case.
5. Extensive drug resistance-
MDR TB case whose biological speicement
resistnat to Fluroquinolone (FQ)
and a second‑line injectable ATD
Diagnosis and treatment of 2 RR/SI All the presumptive TB cases undergo

Presumptive pulmonary TB as sputum smear examination (spot early
per revised guidelines morning or spot-spot). If first sputum is
positive not at risk of DRTB, it is
microbiologically confirmed.
Treatment of New Cases:
Treatment in IP will consist of 8weeks of
INH, Rifampicin, Pyrazinamide and
Ethambutol in daily dose as per weight
band categories.
Only Pyrazinamide will be stopped in CP
rest 3 drugs will be continue for 16 weeks.
(Daily regimen with adminstration of daily
fixed dose combination of first line ATD as
per weight band)
Diagnosis and treatment of 2 RR/SI Catridge based Nucleic Acid Amplification

smear positive and test (CBNAAT) performed to rule out
presumptive multi drug Rifampicin resistance and categorized as
resistance TB (MDR-TB) as per microbiologically confirmed drug sensitive
revised guidelines TB or RIF resistant.
Treatment:
IP will be of 12 weeks, where injection
Streptomycin will be stopped after 8
weeks and remaining four drugs in daily
dose for another 4 weeks as per weight
band.
At CP, Pyrazinamide will be stopped while
rest of drugs will be continue for another
20 weeks as daily dosage
Diagnostic algorithm for 2 RR/SI Check algorithm for all the three cases are
pulmonary, extra pulmonary available.
and paediateric TB as per
revised guidelines are readily
available
Mangement of extra 2 RR/SI The CP in both new and previously

pulmonary TB cases as per treated cases may be extended 3-6
revised guidelines months in cases such as CNS, skeletal etc.
ATD given in fixed dose on daily basis as
per weight band
Mangement of 2 RR/SI 6-9 months of IP with Kanamycin,

MDR/RRTB(without additional Levofloxcin, Ethmabutol, Pyrazinamide,
resistance) as per revised Ethionamide, And Cycloserine. !8 month
guidelines of CP with Levofloxcin, Ethmabutol,
Ethionamide, And Cycloserine
Management of Paediatric
Tuberculosis 2 SI/RR As per revised RNTCP Technical Guidelines
Management of Patients vith As per revised RNTCP Technical
HIV infection and Tuberculosis 2 SI/RR Guidelines
Page 44
ce Method mum
Educate patient and family about disease,

dose schedule, duration, common side
effects,methods of prevention,
Patient and family is counselled consequence of irregular treatment or
before initating TB treatment 2 SI/PI/RR premature cessation of treatment
Treatment card and TB identity Treatment card will be issued in
card is given 2 PI/RR duplication if required
Clinical follow up:

Should be at least monthly – the patient
may visit the clinical facility or medical
officer call for review may even visit the
house of patient.
Laboratory follow up: Sputum smear
examination at the end of IP & end of
treatment (for every patient)
Long term follow up: After completion of
treatment, the patient should be followed
up at the end of 6, 12, 18 and 24 months.
Any clinical symptoms and/or cough,
Monitoring and follow up of sputum microscopy and/or culture should
patient done as per protocols 2 SI/RR be considered.
There is functional Linkage

between DMC and ICTC 2 SI/RR
ME E23.3 Facility provides service Validation and Diagnosis of 2 As per Operation/ Clincal Guidelines of
under National Leprosy Referred and Directly Reported NLEP
Eradication Program as Cases
per guidelines
SI/RR
Treatment of all diagnosed 2 As per Operation/ Clincal Guidelines of
cases including Reaction and NLEP
Neuritis
SI/RR
Assessment of Disability Status 2 As per Operation/ Clincal Guidelines of
SI/RR NLEP
Management of Lepra 2 As per Operation/ Clincal Guidelines of
Reactions SI/RR NLEP
Management of Complicated 2 As per Operation/ Clincal Guidelines of
Ulcers SI/RR NLEP
Management of Eye 2 As per Operation/ Clincal Guidelines of
Complications SI/RR NLEP
Physiotherapy including Pre 2 As per Operation/ Clincal Guidelines of
and Post Operative Care NLEP
SI/RR
Follow-up of cases treated at 2 As per Operation/ Clincal Guidelines of
tertiary Level SI/RR NLEP
Supply of Customized Foot 2 As per Operation/ Clincal Guidelines of
wear SI/RR NLEP
Self care Counselling 2 As per Operation/ Clincal Guidelines of
SI/RR NLEP
Outreach Services to Leprosy 2 As per Operation/ Clincal Guidelines of
Clinics SI/RR NLEP
Screening of Cases of RCS 2 As per Operation/ Clincal Guidelines of
SI/RR NLEP
ME E23.4 Facility provides service Pre Test Counselling is done as 2 basic information and benefits of HIV
under National AIDS per protocols testing
Control program as per potential risks such as discrimination. The
guidelines client is also informed about their right to
refuse, follow-up services . Pregnant
women are given additional information
on nutrition, hygiene, the importance of
an
institutional delivery and HIV testing so as
to avoid HIV transmission from mother to
child.
SI/RR
Post test counselling given as 2 window period, a repeat test is
per protocol recommended, clients with suspected
tuberculosis are referred to the nearest
microscopy centre. In case of a positive
test result, the counsellor assists the
client to understand the
implications of the positive test result and
helps in coping with the test result. The
counsellor also ensures access to
treatment and care, and supports
disclosure of the HIV
status to the spouse.
SI/RR
Diagnosis and treatment of 2 As per NACO guidelines
opportunistic Infections
SI/RR
Screening of PLHA for initiating 2 As per NACO guidelines
ART SI/RR
Monitoring of patients on ART 2 As per NACO guidelines
and management of side
effects
SI/RR
Counselling and Psychological 2 As per NACO guidelines
support for PLHA SI/RR
ME E23.6 Facility provides service Treatment of Mental illnesses 2
under Mental Health as per clinical guidelines
Program as per guidelines
SI/RR
Page 45
ce Method mum
ME E23.7 Facility provides service Geriatic Care is provided as per 2

under National Clinical Guidelines
programme for the health
care of the elderly as per
guidelines SI/RR
ME E23.8 Facility provides service
under National
Programme for
Prevention and Control of
cancer, diabetes,
cardiovascular diseases &
stroke (NPCDCS) as per Opportunistic screening for Screening of persons above age of 30 -
guidelines diabetes, History of tobacco examination, BP
hypertension, cardiovascular Measurement and Blood sugar estimation
diseases 2 SI/RR Look for records at NCD clinic
screen women of the age group

30-69 years approaching to the
hospital for early detection of
cervix cancer and breast
cancer. 2 SI/RR
increased intake of healthy foods

increased physical activity through
sports, exercise, etc.;
avoidance of tobacco and alcohol;
24
Health Promotion through IEC stress management

and counselling 2 OB warning signs of cancer etc
ME E23.9 Facility provide service for 2
Integrated disease Weekly reporting of
surveillance program Presumptive cases on form "P"
from OPD clinic SI/RR
ME E23.10 Facility provide services Early detection and screening 2 As per Clinical guidelines
under National program for detection of deafness
for prevention and control
of deafness
SI/RR
8 8
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection
There is Provision of There is procedure for
Periodic Medical immunization of the staff
Checkups and
immunization of staff
ME F1.4 2 SI/RR Hepatitis B, Tetanus Toxic etc
Periodic medical checkups of
the staff 2 SI/RR
Facility has established Hand washing and infection control audits
procedures for regular done at periodic intervals
monitoring of infection
control practices Regular monitoring of infection
ME F1.5 control practices 2 SI/RR
Facility has defined and
established antibiotic
policy Check for Doctors are aware of
ME F1.6 Hospital Antibiotic Policy 2 SI/RR
18 18
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are Availability of hand washing
provided at point of use Facility at Point of Use
Check for availability of wash basin near
ME F2.1 2 OB the point of use
Availability of running Water Ask to Open the tap. Ask Staff water
2 OB/SI supply is regular
with soap dish/ liquid antiseptic
with dispenser.
Check for availability/ Ask staff if the
2 OB/SI supply is adequate and uninterrupted
Availability of Alcohol based Check for availability/ Ask staff for regular
Hand rub 2 OB/SI supply.
Instruction at Point of Use Prominently displayed above the hand
washing facility , preferably in Local
2 OB language
Staff is trained and adhere Adherence to 6 steps of Hand
to standard hand washing washing
practices
ME F2.2 2 SI/OB Ask of demonstration
wash 2 SI
Facility ensures standard Availability of Antiseptic
practices and materials for Solutions
antisepsis
ME F2.3 2 OB
Proper cleaning of procedure 2 OB/SI
site with antisepsis like before giving IM/IV injection, drawing
blood, putting Intravenous and urinary
catheter
8 8
Standard F3 Facility ensures standard practices and materials for Personal protection
Facility ensures adequate
personal protection
equipments as per
requirements Clean gloves are available at
ME F3.1 point of use 2 OB/SI
Staff is adhere to standard
personal protection
practices No reuse of disposable gloves,
ME F3.2 Masks, caps and aprons. 2 OB/SI
Compliance to correct method
of wearing and removing the
gloves 2 SI
18 18
Standard F4 Facility has standard Procedures for processing of equipments and instruments
Facility ensures standard Decontamination of operating
practices and materials for & Procedure surfaces
decontamination and Ask staff about how they decontaminate
cleaning of instruments and the procedure surface like Examination
procedures areas table , dressing table, Stretcher/Trolleys
etc.
ME F4.1 2 SI/OB (Wiping with .5% Chlorine solution
Page 46
ce Method mum
Ask staff how they decontaminate the

instruments like Stethoscope, Dressing
Instruments, Examination Instruments,
Blood Pressure Cuff etc
Proper Decontamination of (Soaking in 0.5% Chlorine Solution, Wiping
instruments after use 2 SI/OB with 0.5% Chlorine Solution
Contact time for 2 10 minutes
decontamination is adequate SI/OB
Cleaning of instruments after Cleaning is done with detergent and
decontamination 2 SI/OB running water after decontamination
Proper handling of Soiled and No sorting ,Rinsing or sluicing at Point of
infected linen 2 SI/OB use/ Patient care area
Staff know how to make
chlorine solution 2 SI/OB
Facility ensures standard Equipment and instruments are Autoclaving/HLD/Chemical Sterilization
practices and materials for sterilized after each use as per
disinfection and sterilization requirement
of instruments and
equipments
ME F4.2 2 OB/SI
High level Disinfection of Ask staff about method and time required
instruments/equipments is for boiling
done as per protocol
2 OB/SI
used 2 OB/SI
20 20
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Layout of the department is
conducive for the infection Facility layout ensures
control practices separation of general traffic
ME F5.1 from patient traffic 2 OB
Clinics for infectious diseases Preferably in remote corner with
are located away from main independent access
traffic
2 OB
Sitting arrangement in TB clinic
is as per guideline 2 OB
Facility ensures availability Availability of disinfectant as
of standard materials for per requirement
cleaning and disinfection of
patient care areas Chlorine solution, Glutaraldehyde,
ME F5.2 2 OB/SI carbolic acid
Availability of cleaning agent as Hospital grade phenyl, disinfectant
per requirement 2 OB/SI detergent solution
Facility ensures standard Staff is trained for spill
practices followed for management
cleaning and disinfection of
patient care areas
ME F5.3 2 SI/RR
with detergent solution 2 SI/RR
Staff is trained for preparing 2
cleaning solution as per
standard procedure
SI/RR
and scrubbing are followed 2 OB/SI Unidirectional mopping from inside out
Cleaning equipments like
broom are not used in patient Any cleaning equipment leading to
care areas dispersion of dust particles in air should
2 OB/SI be avoided
28 28
Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and
hazardous Waste.
Facility Ensures Availability of colour coded bins
segregation of Bio Medical at point of waste generation
Waste as per guidelines
ME F6.1 2 OB
Adequate number. Covered. Foot
operated.
Availability of colour coded
non chlorinated plastic bags 2 OB Human Anatomical waste, Items
contaminated with blood, body
fluids,dressings, plaster casts, cotton
swabs and bags containing residual or
Segregation of Anatomical and discarded blood and blood components.
solied waste in Yellow Bin 2 OB/SI
Items such as tubing, bottles, intravenous

tubes and sets, catheters, urine bags,
syringes (without needles and fixed
Segregation of infected plastic needle syringes) and vaccutainers with
waste in red bin 2 OB their needles cut) and gloves
Biomedical waste
2 OB
and general waste 2
Facility ensures Availability of functional needle OB See if it has been used or just lying idle
management of sharps as cutters
per guidelines
ME F6.2 2
Seggregation of sharps waste OB Should be available nears the point of
including Metals in white generation.Needles, syringes with fixed
(translucent) Puncture proof, needles, needles from needle tip cutter or
Leak proof, tamper proof burner, scalpels, blades, or any other
containers contaminated sharp object that may
cause puncture and cuts. This includes
both used, discarded and contaminated
metal sharps
2
Availability of post exposure SI/OB Ask if available. Where it is stored and
prophylaxis 2 who is in charge of that.
Staff knows what to do in SI Staff knows what to do in case of shape
condition of needle stick injury injury. Whom to report. See if any
reporting has been done
2
Contaminated and broken Vials, slides and other broken infected
Glass are disposed in puncture glass
proof and leak proof box/
container with Blue colour
marking
2 OB
Page 47
ce Method mum
Facility ensures Check bins are not overfilled

transportation and
disposal of waste as per
ME F6.3 guidelines 2 SI/OB
waste is done in close
container/trolley
2
management 2 SI/RR
Area of Concern - G Quality Management 78 78
2 2
Standard G1 The facility has established organizational framework for quality improvement
ME G1.1 The facility has a quality There is a designated 2 SI/RR
team in place departmental nodal person
Assurance activities
2 2
Standard G2 Facility has established system for patient and employee satisfaction
ME G2.1 Patient Satisfaction OPD Patient satisfaction survey 2 RR
surveys are conducted at done on monthly basis
periodic intervals
8 8
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.
ME G3.1 Facility has established 2 SI/RR
internal quality assurance
program at relevant
departments There is system daily round by
matron/hospital manager/
hospital superintendent/
Hospital Manager/ Matron in
charge for monitoring of
services
2 SI/RR
Internal Quality Assurance is

established at ICTC lab
ME G3.2 Facility has established External Quality assurance 2 SI/RR
external assurance program is established at ICTC
programs at relevant lab
departments
ME G3.3 Facility has established Departmental checklist are 2 SI/RR Staff is designated for filling and
system for use of check used for monitoring and monitoring of these checklists
lists in different quality assurance
departments and services
34 34
Standard G4
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and
support services.
ME G4.1 Departmental standard Standard operating procedure 2 RR
operating procedures are for department has been
available prepared and approved
Current version of SOP are 2 OB/RR

available with process owner
ME G4.2 Standard Operating OPD has documented 2 RR
Procedures adequately procedure for Registration
describes process and
procedures
OPD has documented 2 RR

procedure for patient calling
system in OPD clinics
procedure for receiving of
patient in clinic
OPD has documented process 2 RR
for OPD consultation
procedure for investigation

procedure for prescription and
drug dispensing
procedure for nursing process
in OPD
procedure for patient privacy
and confidentiality
procedure for conducting,
analysing patient satisfaction
survey

procedure for equipment
management and maintenance
in OPD
Department has documented 2 RR

procedure for Administrative
and non clinical work at OPD
procedure for No Smoking
Policy in OPD
procedure for duty roaster,
punctuality, dress code and
identity for OPD staff
ME G4.3 Staff is trained and aware 2 SI/RR

of the standard
procedures written in
SOPs Check Staff is a aware of
relevant part of SOPs
Page 48
ce Method mum
ME G4.4 Work instructions are 2 OB Relevant protocols are displayed like

displayed at Point of use Clinical Protocols for ANC checkups
Work instruction/clinical
protocols are displayed
6 6
Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
ME G5.1 Facility maps its critical Process mapping of critical 2 SI/RR
processes processes done
ME G5.2 Facility identifies non 2 SI/RR
value adding activities /
waste / redundant
activities Non value adding activities are
identified
ME G5.3 Facility takes corrective Processes are rearranged as 2 SI/RR
action to improve the per requirement
processes
12 12
Standard G6 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit
ME G6.1 The facility conducts 2 RR/SI
periodic internal
assessment Internal assessment is done at
periodic interval
ME G6.2 The facility conducts the 2 RR/SI
periodic prescription/
medical/death audits There is procedure to conduct
Medical Audit
There is procedure to conduct 2 RR/SI
Prescription audit
ME G6.3 The facility ensures non Non Compliance are 2 RR/SI
compliances are enumerated and recorded
enumerated and recorded
adequately
ME G6.4 Action plan is made on the Action plan prepared 2 RR/SI
gaps found in the
assessment / audit
process
ME G6.5 Corrective and preventive 2 RR/SI

actions are taken to
address issues, observed
in the assessment & audit
Corrective and preventive
action taken
6 6
Standard G7 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
ME G7.4 2 SI/RR

objectivities have been framed addressing
key quality issues in each department and
Facility has de defined cores services. Check if these objectives
quality objectives to achieve Check if SMART Quality are Specific, Measurable, Attainable,
mission and quality policy Objectives have framed Relevant and Time Bound.
ME G7.5 2 SI/RR
Interview with staff for their awareness.
Mission, Values, Quality Check if Mission Statement, Core Values
policy and objectives are Check of staff is aware of and Quality Policy is displayed
effectively communicated to Mission , Values, Quality Policy prominently in local language at Key
staff and users of services and objectives Points
ME G7.7 2 SI/RR
Review the records that action plan on
quality objectives being reviewed at least
onnce in month by departmnetal
Facility periodically reviews incharges and during the qulaity team
the progress of strategic Check time bound action plan meeting. The progress on quality
plan towards mission, policy is being reviewed at regular objectives have been recorded in Action
and objectives time interval Plan tracking sheet
6 6
Standard G8 Facility seeks continually improvement by practicing Quality method and tools.
ME G8.1 Facility uses method for Basic quality improvement 2 SI/RR PDCA & 5S
quality improvement in method
services
Advance quality improvement 2 SI/OB Six sigma, lean.
method
ME G8.2 Facility uses tools for 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used in
quality improvement in each department
services
ME G10.6 2 SI/RR
Periodic assessment for Check periodic assessment of Verify with the records. A comprehensive
Medication and Patient care medication and patient care risk asesement of all clincial processes
safety risks is done as per safety risk is done using should be done using pre define critera at
defined criteria. defined checklist periodically least once in three month.
14 14
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures Proportion of follow-up
productivity Indicators on patients
monthly basis
2 RR
No of ANC done per thousand 2 RR
ICTC OPD per thousand 2 RR
ART patient load per thousand 2 RR
ARSH OPD per thousand 2 RR
Immunization OPD per
thousand 2 RR
Proporation of BPL patients 2
21 22
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Medicine OPD per Doctor
Indicators on monthly basis 2 RR
Surgery OPD per Doctor 2 RR
Paediatric OPD per Doctor 2 RR
OBG OPD per Doctor 1 RR
Dental OPD per Doctor 2 RR
Ophthalmology OPD per doctor
2 RR
Skin & OPD per doctor 2 RR
TB/DOT pod per doctor 2 RR
Page 49
ce Method mum
ENT OPD per doctor 2 RR

Psychiatry OPD per doctor 2 RR
AYUSH OPD per doctor 2 RR
12 12
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Consultation time at ANC Clinic
Care & Safety Indicators on
monthly basis
2 RR Time motion study
Consultation time at General
Medicine Clinic 2 RR
Consultation time for General
Surgery Clinic 2 RR
Consultation time for paediatric
clinic 2 RR
Proportion of High risk
pregnancy detected during No of High Risk Pregnancies X100/ Total
ANC 2 RR no PW used ANC services in the month
Proportion of severe anaemia
cases 2 RR
14 14
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Patient Satisfaction Score
Quality Indicators on
monthly basis
2 RR
Waiting time at registration
counter 2 RR
Waiting time at ANC Clinic 2 RR
Waiting time at general OPD
2 RR
Waiting time at paediatric
Clinic 2 RR
Waiting time at surgical clinic 2 RR
Average door to drug time 2 RR

A 102 102 100%
B 78 78 100%
C 158 158 100%
D 88 88 100%
E 306 306 100%
F 100 100 100%
G 78 78 100%
H 61 62 98%
Total 971 972 100%
0
1
2
Page 50
Checklist No. 3 Labour Room Version - NHSRC/NQAS2016
National Quality Assurance Standards Version-2

Checklist for Labour Room 3
Assessment Summary
Name of the Hospital Date of Assessment

Type of Assessment Action plan Submission
(Internal/Peer/External) Date
Labour room Score Card

Area of Concern wise Score Labour Room Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100%
100%
100%
F
G Quality Management 100%
H Outcome 100%
Major Gaps Observed
5
5
Recommendations/ Opportunities for Improvement
5
Date
Checklist for Labour Room

Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Ma %
nce Method aine xim
d um
Page 51
nce - A Service
MethodProvision aine
22 xim 100
22
Area of Concern d um
2 2 100
Standard A1 The facility provides Curative Services
ME A1.14 Services are available for the time period Labour room service is SI/RR Verify with records that deliveries
as mandated functional 24X7 have been conducted in night on
2 regular basis
18 18 100
Standard A2 The facility provides RMNCHA Services
ME A2.1 The facility provides Reproductive health Availability of Post Partum IUD 2 SI/RR Verify with records that PPIUD
Services insertion services services have been offered in labour
room
ME A2.2 The facility provides Maternal health Availability of Vaginal Delivery 2 SI/RR Normal vaginal & assisted (Vacuum /
Services services Forcep ) delivery
Availability of Pre term delivery 2 SI/RR Check if pre term delivery are being
services conducted at facility and not referred
to higher centres unnecessarily
Management of Postpartum 2 SI/RR Check if Medical /Surgical

Haemorrhage management of PPH is being done at
labour room
Management of Retained 2 SI/RR Check staff manages retained

Placenta placenta cases in labour room . Verify
with records
Septic Delivery & Delivery of 2 SI/RR Check if infected delivery cases are
HIV positive Pregnant Women managed at labour room and not
referred to higher centres
unnecessarily
Management of 2 SI/RR Check services for management of

PIH/Eclampsia/ Pre eclampsia PIH/ Eclampsia are being proved at
labour room
ME A2.3 The facility provides Newborn health Availability of New born 2 SI/OB Check if labour room has a functional
Services resuscitation New born resuscitation services
available in labour room
Availability of Essential new 2 SI/OB Check essential newborn care

born care provisions such as Keeping baby on
mother's abdomen, immediate drying
of baby, Skin to skin contact, delayed
chord clamp, initiation of breast
feeding, recording of vitals and Vit. K
are provided
2 2 100
Standard A3 The facility Provides diagnostic Services
ME A3.2 The facility Provides Laboratory Services 24 *7 Availability of point of 2 SI/OB HIV, Hb% , Random blood sugar ,
care diagnostic tests Protein Urea Test
Area of Concern - B Patient Rights 40 40 100

8 8 100
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 Availability of departmental 2 OB Numbering, main department and
signage's internal sectional signage, Restricted
area signage displayed. Directional
The facility has uniform and user-friendly signages are given from the entry of
signage system the facility
ME B1.2 Necessary Information 2 OB Name of doctor and Nurse on duty

regarding services provided is are displayed and updated. Contact
The facility displays the services and displayed details of referral transport /
entitlements available in its departments ambulance displayed
ME B1.5 IEC Material is displayed 2 OB Breast feeding, kangaroo care, family

Patients & visitors are sensitised and planning etc (Pictorial and chart ) in
educated through appropriate IEC / BCC circulation & waiting area
approaches
ME B1.6 Signage's and information are 2 OB Check all information for patients/
Information is available in local language available in local language visitors are available in local language
and easy to understand
8 8 100
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of
ME B2.1 Only on duty staff is allowed in 2 OB Pregnant woman, her birth
the labour room when it is companion, doctor, nurse/ANM on
Services are provided in manner that are occupied duty, and other support staff only, is
sensitive to gender allowed in the labour room
ME B2.3 Availability of Wheel chair or 2 OB

Access to facility is provided without any stretcher for easy Access to the
physical barrier & friendly to people with labour room
disabilities
Availability of ramps and railing 2 OB If not located on the ground floor
& Labour room is located at availability of the ramp / lift with
ground floor person for shifting
ME B2.4 Check care to pregnant women 2 OB/PI Discrimination may happen because
There is no discrimination on basis of is not denied or differed due to of religion, caste, ethnicity, cast,
social and economic status of the discrimination language, paying capacity and
patients educational level.
18 18 100
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Availability of screen/ partition 2 OB Screens / Partition has been provided
Adequate visual privacy is provided at at delivery tables from three side of the delivery table
every point of care or Cubicle for ensuring visual privacy
Curtains / frosted glass have 2 OB Check all the windows are fitted with
been provided at windows frosted glass or curtains have been
provided
Page 52
No two women are treated on nce
2 Method
OB/PI Check that observation beds and aine xim
common bed/ Delivery Table delivery tables are not shared by d um
multiple women at the same time
because of any reason
ME B3.2 Patient Records are kept at 2 SI/OB Check records are not lying in open
secure place beyond access to and there is designated space for
general staff/visitors keeping records with limited access.
Confidentiality of patients records and Records are not shared with anybody
clinical information is maintained without permission of hospital
administration
ME B3.3 Behavior of labour room staff is 2 OB/PI Check that labour staff is not
dignified and respectful providing care in undignified manner
such as yelling, scolding , shouting,
The facility ensures the behavior of staff blaming and using abusive language,
is dignified and respectful, while unnecessary touching or examination
delivering the services
Pregnant women is not left 2 OB/PI Check that care providers are
unattended or ignored during attentive and empathetic to the
care in the labour room pregnant women at no point of care
they are left alone.
Care provided at labour room is 2 OB/PI Check if the physical abuse practices
free from physical abuse or such as pinching, slapping, restraining
harm , pushing on the abdomen, extensive
episiotomy etc.
Pregnant women is explicitly 2 OB/PI Check if care providers verbally

informed before examination inform the pregnant women before
and procedures touching, examination or starting
procedure.
ME B3.4 HIV status of patient is not 2 SI Check if HIV status of pregnant

The facility ensures privacy and disclosed except to staff that is women is not explicitly written on
confidentiality to every patient, directly involved in care case sheets and avoiding any means
especially of those conditions having by which they can be identified in
social stigma, and also safeguards public such as labelling or allocating
vulnerable groups specific beds.
4 4 100
Standard B4
The facility has defined and established procedures for informing patients about the medical condition, and involving them in
treatment planning, and facilitates informed decision making
ME B4.1 There is established procedure for taking Consent is taken before 2 SI/RR Check the labour room case sheet for
informed consent before treatment and delivery and or shifting consent has been taken
procedures
ME B4.4 Labour room has system in 2 PI Check if pregnant women and her
place to involve patient's family members have been informed
Information about the treatment is relative in decision making and consulted before shifting the
shared with patients or attendants, about pregnant women patient for C-Section or referral to
regularly treatment higher center
2 2 100
Standard B5
The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost of hospital
services.
ME B5.1 Check all services including 2 PI/SI Check if there are no user charges of
drugs, consumables, any services in labour room .
The facility provides cashless services to diagnostics and blood are free Ask Pregnant women and their
pregnant women, mothers and neonates of cost in labour room attendants if they have not paid for
as per prevalent government schemes any services or any informal fees to
service providers
Area of Concern - C Inputs 108 108 100

28 28 100
ME C1.1 Departments have adequate space as per Adequate space as per delivery 2 OB Labour tables should be placed in a
patient or work load load way that there is a distance of at least
3 feet from the sidewall, at least 2
feet from head end wall, and at least
6’ from the second table
ME C1.2 Patient amenities are provided as per Availability of patients 2 OB Dedicated Toilets for Labour Room
patient load amenities such as Drinking area and Staff Rooms. LDR concept
water, Toilet & Changing area for Labour Room should have
attached toilet with each LDR unit .
Toilets are provided with western
style toilet seats. Drinking water
Facility within labour room
For Pregnant women & companion
ME C1.3 Departments have layout and Labour Room layout is 2 OB Labour Room and associated services
demarcated areas as per functions arranged in LDR concept are arranged according to Labour-
Delivery-Recovery Concepts with
each LDR unit comprising of 4 Labour
Beds and dedicated Nursing Station
and New Born Corner
Availability of Registration 2 OB Dedicated reception and registration

Area & Waiting area area the entry of Labour Room
Complex with registration desk and
seating arrangement for 30 people in
waiting area
Availability of Triage and 2 OB Dedicated Triage & Examination

Examination Area room with two examination beds for
segregation of High & Low Risk
patients
Entry to the labour room should not
be direct. Check if there is any buffer
Dedicated nursing station and 2 OB One
area common Nursing station for
Duty Rooms Conventional Labour Room
Dedicated Nursing station for Each
unit if LDR concept is followed
Availability of Storage Area 2 OB A dedicated sub store with cabinets

and storage racks for storing supplies
Separate Clean room & Dirty Utility
room for Storing Sterile and Used
Availability of Newborn Care 2 OB goods
One respectively
Dedicated Newborn care area
area for each four tables. Incase of LDR
dedicated NBCA for each unit.There
should be no obstruction between
labour table and Newborn corner for
swift shifting of newborn requiring
resuscitation Radiant Warmer Should
have free space from three sides
Availability of Staff Room & 2 OB Dedicated rooms for Nursing staff

Doctor's Duty Room and Doctors provided with beds,
storage furniture and attached toilets
Page 53
ME C1.4 The facility has adequate circulation area Corridors connecting labour nce
2 Method
OB Corridor should be wide enough that aine xim
and open spaces according to need and room are broad enough to 2 stretcher can pass simultaneously d um
local law manage stretcher and trolleys without any hassle
ME C1.5 The facility has infrastructure for Availability of functional 2 OB Check availability of functional
intramural and extramural telephone and Intercom telephone and intercom connections
communication Services
ME C1.6 Service counters are available as per Availability of labour tables as 2 OB Less than 20 Deliveries/ Month -1
patient load per delivery load 20-99 Deliveries/ Month - 2
100- 199 Deliveries/Month -4
200- 499 Deliveries/Month -6
More than 500 Deliveries-
Conventional Labour Room - Monthly
Delivery Cases X 0.014
(Labour- Delivery-Recovery) LDR
format - Monthly Delivery Cases
X.028
ME C1.7 The facility and departments are planned Labour room is in Proximity and 2 OB Check labour room is located in the
to ensure structure follows the function linkage with OT & proximity of Maternity OT and SNCU/
function/processes (Structure SNCU NICU in one block only with means of
commensurate with the function of the swift shifting of patients in case of
hospital) emergency. If located on different
floor lift/ ramp with manned trolley
should be provided
Unidirectional flow of care 2 OB Labour room lay out and

arrangement of services are designed
in a way, that there is no criss cross
movement of patient, staff, supplies
& equipment
6 6 100
ME C2.1 The facility ensures the seismic safety of Non structural components are 2 OB Check for fixtures and furniture like
the infrastructure properly secured cupboards, cabinets, and heavy
equipment , hanging objects are
properly fastened and secured
ME C2.3 The facility ensures safety of electrical Labour room does not have 2 OB Switch Boards other electrical
establishment temporary connections and installations are intact. Check
loosely hanging wires adequate power outlets have been
provided as per requirement of
electric appliances
ME C2.4 Physical condition of buildings are safe Check if safety features have 2 OB The floor of the labour room complex
for providing patient care been provided in infrastructure should be made of anti-skid material.
Each window have 2-panel sliding
doors. The outside panel be fixed The
second panel should be moving with
frosted glass and a lock.
6 6 100
ME C3.1 The facility has plan for prevention of fire Labour room has sufficient fire 2 OB/SI Check the fire exits are clearly visible
exit to permit safe escape to its and routes to reach exit are clearly
occupant at time of fire marked.
ME C3.2 The facility has adequate fire fighting Labour room has installed fire 2 OB Class A , Class B, C type or ABC type.
Equipment Extinguishers & expiry is Check the expiry date for fire
displayed on each fire extinguishers are displayed on each
extinguisher extinguisher as well as due date for
next refilling is clearly mentioned
ME C3.3 The facility has a system of periodic Check for staff competencies 2 SI/RR Check staff is aware of RACE (Rescue-
training of staff and conducts mock drills for operating fire extinguisher Alarm-Contain-Extinguish) method
regularly for fire and other disaster and what to do in case of fire for in case of fire and confident in
situation using fire extinguisher.
10 10 100
ME C4.1 The facility has adequate specialist Availability of Ob&G specialist 2 OB/RR 100-200 Deliveries -1 (OBG/EMOC)
doctors as per service provision 200 - 500 Deliveries - 1 OBG
(Mandatory + 4 (OBG/EMOC)
>500 3 OBG + 4 EMOC
Availability of Pediatrician 2 OB/RR At least 1 pediatrician
ME C4.2 The facility has adequate general duty Availability of General duty 2 OB/RR At least 4 Medical Officers
doctors as per service provision and work doctor
load
ME C4.3 The facility has adequate nursing staff as Availability of Nursing staff 2 OB/RR/SI Deliveries Per month-
per service provision and work load /ANM 100-200- 8
200-500 -12
> 500 - 16
ME C4.5 The facility has adequate support / Availability of house keeping 2 SI/RR Housekeeping Staff as per delivery
general staff staff & Security Guards load
100-200- 4
200-500 - 8
Security Guards as per Delivery Load
> 500 - 12
100-200- 4
200-500 - 6
> 500 - 8
16 16 100
Standard C5 The facility provides drugs and consumables required for assured services.
ME C5.1 The departments have availability of Availability of uterotonic Drugs 2 OB/RR Inj Oxytocin 10 IU (to be kept in
adequate drugs at point of use fridge) Tab Misoprostol 200mg
Availability of Anti-infective 2 OB/RR Cap Ampicillin 500mg, Tab

Drugs Metronidazole 400mg, Inj Gentamicin
Availability of 2 OB/RR Nifedipine, Methyldopa, Inj

Antihypertensive , analgesic Hydralazine, Tab Paracetamol, Tab
and antipyretic and Anesthetic Ibuprofen, Inj Xylocaine 2%,
Availability
drugs of IV Fluids 2 OB/RR IV fluids, Normal saline, Ringer
lactate,
Page 54
Availability of Vitamins nce
2 Method
OB/RR Vit K aine xim
d um
ME C5.2 The departments have adequate Availability of dressings 2 OB/RR Gauze piece and cotton swabs,
consumables at point of use material and Sanitary pads sanitary Napkins (2 for Each Delivery),
Sanitary Pads (4 for each delivery,
needle (round body and cutting),
chromic catgut no. 0, antiseptic
solution
Availability of syringes and IV 2 OB/RR Paediatric IV sets,urinery catheter,

Sets /tubes and consumables Gastric tube and cord clamp, Baby ID
for newborn tag
ME C5.3 Emergency drug trays are maintained at Emergency Drug Tray is 2 OB/RR Inj Magsulf 50%, Inj Calcium
every point of care, wherever it may be maintained gluconate 10%, Inj Dexamethasone,
needed inj Hydrocortisone Succinate, Inj
Ampicillin, Inj Gentamicin, inj
metronidazole, , Inj diazepam, inj
Pheniramine maleate, inj Corboprost,
Inj Pentazocine, Inj Promethazine,
Betamethasone, Inj Hydralazine,
Nifedipine, Methyldopa,ceftriaxone
28 28 100
ME C6.1 Availability of equipment & instruments Availability of functional 2 OB One set of Digital BP apparatus,
for examination & monitoring of patients Equipment &Instruments for Stethoscope, Adult Thermometer ,
examination & Monitoring Baby Thermometer, baby forehead
thermometer, Handheld Fetal
Doppler , Fetoscope, baby weighting
scale, Measuring Tape for four labour
tables or at least two sets., Wall clock
ME C6.2 Availability of equipment & instruments Availability of instrument 2 OB Cord Cutting Scissor, Artery forceps,
for treatment procedures, being arranged in Delivery trays Cord clamp, Sponge holder,
undertaken in the facility speculum, kidney tray, bowl for
antiseptic lotion are present in tray
Delivery kits are in adequate 2 OB One autoclaved delivery tray for each
numbers as per load table plus 4 extra trays
Availability of Instruments 2 OB Episiotomy scissor, kidney tray,

arranged for Episiotomy trays artery forceps, allis forceps, sponge
holder, toothed forceps, needle
holder,thumb forceps, are present in
tray
Availability of Baby tray 2 OB Two pre warmed towels/sheets for

wrapping the baby, mucus extractor,
bag and mask (0 &1 no.), sterilized
thread for cord/cord clamp,
nasogastric tube are present in tray
Availability of instruments 2 OB Speculum, anterior vaginal wall

arranged for MVA/EVA tray retractor, posterior wall retractor,
sponge holding forceps, MVA syringe,
cannulas, MTP, cannulas, small bowl
of antiseptic lotion, are present in
tray
Availability of instruments 2 OB PPIUCD insertion forceps, CuIUCD

arranged for PPIUCD tray 380A/Cu IUCD375 in sterile package
are present in tray
Availability of Radiant Warmers 2 OB 1 Functional Radiant warmer for each

four tables
ME C6.3 Availability of equipment & instruments Availability of Diagnostic 2 OB Atleast 2 Glucometers, Protien Urea
for diagnostic procedures being Instruments Test Kit , HB Testing Kits, HIV Kits.
undertaken in the facility
ME C6.4 Availability of equipment and Availability of resuscitation 2 OB Availability of Neonatal Resuscitation

instruments for resuscitation of patients Instruments for Newborn & Kit Pediatric resuscitator bag (volume
and for providing intensive and critical Mother 250 ml) with masks of
care to patients 0 and 1 size for each Radiant warmer
Adult Resuscitation Kit
ME C6.5 Availability of Equipment for Storage Availability of equipment for 2 OB Refrigerator, Movable Crash
storage for drugs cart/Drug trolley, instrument trolley,
dressing trolley
ME C6.6 Availability of functional equipment and Availability of equipment for 2 OB Buckets for mopping, Separate mops
instruments for support services cleaning & sterilization for labour room and circulation area
duster, waste trolley, Deck brush,
Autoclave
ME C6.7 Departments have patient furniture and Availability of Labour Beds with 2 OB Each labor bed should be have
fixtures as per load and service provision attachment/accessories following facilities
Adjustable side rails, Facilities for
Trendelenburg/reverse positions,
Facilities for height adjustment,
Stainless steel IV rod, wheels &
brakes ,Steel basins attachment, Calf
support, handgrip, legs support.
Availability of Mattress for each 2 OB Mattress should be in three parts and

Labour Beds seamless in each part with a thin
cushioning at the joints, detachable
at perineal end. It should be
washable and water proof with extra
set.
Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and 14 14 100
Standard C7
performance of staff
Page 55
ME C7.1 Criteria for Competence assessment are Check parameters for assessing nce
2 Method
SI/RR Check objective checklist such OSCE aine xim
defined for clinical and Para clinical staff skills and proficiency of clinical (Onsite Clinical Examination) defined d um
staff has been defined Dakshta program are available at the
labor room
ME C7.2 Check for competence 2 SI/RR Check for records of competence

assessment is done at least assessment using OSCE including
once in a year filled checklist, scoring and grading .
Verify with staff for actual
Competence assessment of Clinical and competence assessment done
Para clinical staff is done on predefined
criteria at least once in a year
ME C7.9 Navjat Shishu Surkasha 2 SI/RR Check training records
Karyakarm (NSSK) training &
The Staff is provided training as per Skilled birth Attendant (SBA)
defined core competencies and training
plan
Biomedical Waste 2 SI/RR Check training records
Management& Infection
control and hand hygiene
,Patient safety
Training on Quality 2 SI/RR Assessment, action planning, PDCA,

Management 5S & use of checklist
Training on Respectful 2 SI/RR Check training records

Maternal Care
ME C7.10 There is established procedure for Labour room staff is provided 2 Check with training records the
SI/RR
utilization of skills gained thought refresher training labour room staff have been provided
trainings by on -job supportive refresher training at lest once in
supervision every 12 month on Intrapartum care,
Area of Concern - D Support Services Identification and & management of
obstetric emergencies and Essential
62 62 100
Newborn care & Breast feeding 8 8 100

Standard D1 The facility has established Programme for inspection, testing and maintenance
support and calibration of Equipment.
ME D1.1 The facility has established system for All equipments are covered 2 SI/RR Check with AMC records/ Warranty
maintenance of critical Equipment under AMC including documents
preventive maintenance
There is system of timely 2 SI/RR Check for breakdown & Maintenance

corrective break down record in the log book
maintenance of the
equipments
ME D1.2 The facility has established procedure for All the measuring equipments/ 2 OB/ RR BP apparatus, thermometers,
internal and external calibration of instrument are calibrated weighing scale , radiant warmer etc
measuring Equipment are calibrated . Check for records
/calibration stickers
ME D1.3 Operating and maintenance instructions Up to date instructions for 2 OB/SI Check operating and trouble shooting
are available with the users of equipment operation and maintenance of instructions of equipment such as
equipments are readily radiant warmer are available at
available with labour room labour room
staff.
16 16 100
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas
ME D2.1 There is established procedure for There is established system of 2 SI/RR Stock level are daily updated
forecasting and indenting drugs and timely indenting of Requisition are timely placed well
consumables consumables and drugs before reaching the stock out level.
Check with stock and indent registers.
ME D2.3 The facility ensures proper storage of Drugs are stored in 2 OB Check drugs and consumables are
drugs and consumables containers/tray/crash cart and kept at allocated space in Crash cart/
are labelled Drug trolleys and are labelled. Look
alike and sound alike drugs are kept
seprately
Empty and filled cylinders are 2 OB Empty and filled cylinders are kept
labelled and updated separately and labelled, flow meter is
working and pressure/ flow rate is
updated in the checklist
ME D2.4 The facility ensures management of Expiry dates' are maintained at 2 OB/RR Expiry dates against drugs are
expiry and near expiry drugs emergency drug tray / Crash mentioned crash cart/ emergency
cart drug tray
ME D2.5 The facility has established procedure for There is practice of calculating 2 SI/RR At
Noleast
expiryone week
drug of minimum buffer
found
inventory management techniques and maintaining buffer stock stock is maintained all the time in the
labour room. Minimum stock and
reorder level are calculated based on
consumption in a week accordingly
Department maintained stock 2 RR/SI Check stock and expenditure register

and expenditure register of is adequately maintained
ME D2.6 There is a procedure for periodically There is procedure for 2 SI/RR/OB There is no stock out of drugs
replenishing the drugs in patient care replenishing drug tray /crash
areas cart
ME D2.7 There is process for storage of vaccines Temperature of refrigerators 2 OB/RR Check for temperature charts are
and other drugs, requiring controlled are kept as per storage maintained and updated periodically.
temperature requirement and records are Refrigerators meant for storing drugs
maintained should not be used for storing other
items such as eatables
10 10 100
ME D3.1 The facility provides adequate Adequate Illumination at 2 OB Labour Area - 500 Lux
illumination level at patient care areas delivery table & observation Support Area - 150 Lux
area
ME D3.2 The facility has provision of restriction of There is no overcrowding in 2 OB Visitors are restricted at labour room.
visitors in patient areas labour room One birth companion is allowed to
stay with the Pregnant women
ME D3.3 The facility ensures safe and comfortable Temperature control and 2 PI/OB Temperature of the labour room
environment for patients and service ventilation in patient care area should be kept around 26-28 degree
providers C ,labour complex should have split
ACs with tonnage = (square root of
area)/10 and one ceiling mounted fan
for every labour table . Area should
be drought free
Page 56
ME D3.4 The facility has security system in place Security arrangement in labour nce
2 Method
OB Dedicated security guards preferably aine xim
at patient care areas room female security staff. CCTV Camera at d um
entrance / circulation areas
ME D3.5 The facility has established measure for Ask female staff whether they 2 SI Check adequate security measures
safety and security of female staff feel secure at work place have been taken for safety and
security of staff working in labour
room
14 14 100
ME D4.1 Exterior & Interior of the facility building Interior & exterior of patient 2 OB Wall and Ceiling of Labour Room are
is maintained appropriately care areas are plastered & painted in white colour. The walls of
painted & building are white the labour room complex should be
washed in uniform colour made of white wall tiles, with
seamless joint, and extending up to
the ceiling.
ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof topes, 2 OB All area are clean with no
sinks patient care and dirt,grease,littering and cobwebs.
circulation areas are Clean Surface of furniture and fixtures are
clean
Toilets are clean with 2 OB Check toilet seats, floors, basins etc
functional flush and running are clean and water supply with
water functional cistern has been provided.
ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , 2 OB Check for delivery as well as auxiliary
maintained Cracks, chipping of plaster areas
Window panes , doors and
other fixtures are intact
Delivery table are intact and 2 OB Observe for any signs for rusting or
without rust & Mattresses are accumulation of dirt/ grease/
intact and clean encrusted body fluid
ME D4.5 The facility has policy of removal of No condemned/Junk material 2 OB Check of any obsolete article
condemned junk material in the Labour room including equipment, instrument,
records, drugs and consumables
ME D4.6 The facility has established procedures No stray animal/rodent/birds 2 OB Check for no stray animal in and
for pest, rodent and animal control around labour room
4 4 100
ME D5.1 The facility has adequate arrangement Availability of 24x7 running and 2 OB/SI Availability of 24X7 Running water &
storage and supply for portable water in portable water hot water facility.
all functional areas
ME D5.2 The facility ensures adequate power Availability of power back up 2 OB/SI Check for 24X7 availability of power
backup in all patient care areas as per in labour room backup including Dedicated UPS and
load emergency light
4 4 100
ME D7.1 The facility has adequate sets of linen Availability & use of clean linen 2 OB/RR Clean Delivery gown is provided to
Pregnant Women &
sterile drape for baby.
ME D7.3 The facility has standard procedures for There is system to check the 2 SI/RR Quantity of linen is checked before
handling , collection, transportation and cleanliness and Quantity of the sending it to laundry. Cleanliness &
washing of linen linen Quantity of linen is checked received
from laundry. Records are maintained
6 6 100
Standard D11
procedures.
ME D11.2 The facility has an established procedure There is procedure to ensure 2 RR/SI Check for system for recording time
for duty roster and deputation to that staff is available on duty as of reporting and relieving
different departments per duty roster (Attendance register/ Biometrics etc)
Staff posted in the labor room 2 RR/SI Check with the duty roster
should not be rotated outside
the labor room
ME D11.3 The facility ensures the adherence to Doctor, nursing staff and 2 OB As per hospital administration or
dress code as mandated by its support staff adhere to their state policy
administration / the health department respective dress code
Area of Concern - E Clinical Services 184 184 100

8 8 100
ME E1.1 The facility has established procedure for Unique identification number 2 RR Check for demographics like Name,
registration of patients & patient demographic records age, Sex, Chief complaint, etc.
are generated during process
of registration & admission
ME E1.3 There is established procedure for There is procedure for 2 SI/RR/OB Admission is done by written order of
admission of patients admitting Pregnant women a qualified doctor
directly coming to Labour room
There is no delay in admission 2 OB/SI/RR Co relate the time admission with &
of pregnant women in labour clinical intervention (vital chart ,
pain partograph, medication given etc.)
ME E1.4 There is established procedure for Check how service provider 2 OB/SI Provision of extra tables.
managing patients, in case beds are not cope with shortage of delivery
available at the facility tables due to high patient load
10 10 100
ME E2.1 There is established procedure for initial Rapid Initial assessment of 2 RR/SI/OB Recording of vitals and FHR.
assessment of patients Pregnant Women to identify immediate sign if following danger
complication and Prioritize care sign are present - difficulty in
breathing, fever, sever abdominal
pain, Convulsion or unconsciousness,
Severe headache or blurred vision
Page 57
Recording and reporting of nce
2 Method
RR/SI Recording of women obstetric History aine xim
Clinical History including d um
LMP and EDD Parity, Gravid status,
h/o CS, Live birth, Still Birth, Medical
History (TB, Heart diseases, STD etc)
HIV status and Surgical History
Recording of current labour 2 RR Time of start, frequency of

details contractions, time of bag of water
leaking, colour and smell of fluid and
baby movement
Physical Examination 2 RR/SI Recording of Vitals , shape & Size of

abdomen , presence of scars, foetal
lie and presentation. & vaginal
examination
ME E2.2 There is established procedure for There is fixed schedule for 2 RR/OB There is fix schedule of reassessment
follow-up/ reassessment of Patients reassessment of Pregnant as per protocols. Assessment finding
women as per standard should be recorded in partograph
protocol
20 20 100
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 The facility has established procedure for There is procedure of handing 2 SI/RR Hand over from Labour Room to the
continuity of care during over patient / new born from destination department is given while
interdepartmental transfer labour room to OT/ shifting the Mother & Baby. Shifting
Ward/SNCU to ward should be done at least two
hours after delivery in case of
conventional LR and 4 hours in case
of LDR
There is a procedure for 2 SI/RR check if there are linkages and

consultation of the patient to established process for calling other
other specialist with in the specialist in labour room if required
hospital
ME E3.2 The facility provides appropriate referral Reason for referral is clearly 2 RR Verify with referral records that
linkages to the patients/Services for stated and referral is reasons for referral were clearly
transfer to other/higher facilities to authorized competent person mentioned and rational. Referral is
assure the continuity of care. (Gynaecologist or Medical authorized by Gynaecologist or
Officer on duty) Medical officer on duty after
ascertaining that case can not be
managed at the facility
Labor room staff confirms the
suitability of referral with higher
centers to ascertain that case can be
managed at higher center and will
not require further referrals
Essential information regarding 2 RR/OB Check for availability of following -

referral facilities are available Referral Pathway
at labour room Names, Contact details and duty
schedules for responsible persons
higher referral centers
Name , Contact details, duty schedule
of Ambulance services
Advance communication 2 SI/RR The information regarding the case,

regarding the patient's expected time of arrival and special
condition is shared with the facilities such as specialist, blood,
higher center intensive care may be required is
communicated to the higher center
Patient referred with referral 2 RR/SI A referral slip/ Discharge card is

slip provided to patient when referred to
another health care facility. Referral
slip includes demographic details,
History of woman, examination
findings, management done , drugs
administered, any procedure done,
reason for referral, detail of referral
center including whom to contact
and signature of approving medical
officer
Referral vehicle is being 2 SI/RR Check labour room staff facilitates

arranged arrangement of ambulance for
transferring the patient to higher
center . Patient attendant are not
asked to arrange vehicle by their own
Check if labour room staff checks
ambulance preparedness in terms of
necessary equipments, drugs,
Referral checklist & Referral in/ 2 RR accompanying
Referral staffis in
check list terms
filled of care
before
Out register is maintained all that maytobe
referral required
ensure in transit steps
all necessary
referred cases have been taken for safe referral
including advance communication,
transport arrangement,
accompanying care provider, referral
slip , time taken for referral etc.
regarding referral cases including
demographics, date & time of
admission, date & time of referral,
diagnosis at referral and follow up of
Follow-up of referral cases is 2 SI/RR outcome
Check thatis labour
recorded
room in referral
staff follow
done register
up of referred cases for timely arrival
and appropriate care provided at
higher center. Outcome and
deficiencies if any should be recorded
in referral out register.
ME E3.3 A person is identified for care during all Nurse is assigned for each 2 RR/SI Check for nursing hand over
steps of care pregnant women
10 10 100
Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of patients is There is a process for ensuring 2 OB/SI Identification tags for mother and
established at the facility the identification before any baby
clinical procedure
ME E4.2 Procedure for ensuring timely and There is a process to ensure the 2 SI/RR Verbal orders are rechecked before
accurate nursing care as per treatment accuracy of verbal/telephonic administration. Verbal orders are
plan is established at the facility orders documented in the case sheet
Page 58
ME E4.3 There is established procedure of patient Patient hand over is given nce
2 Method
RR/SI Nursing Handover register is aine xim
hand over, whenever staff duty change during the change in the shift maintained d um
happens
Hand over is given bed side 2 SI/RR/OB Handover is given during the shift
change beside the pregnant women
explaining the condition, care
provided and any specific care if
ME E4.5 There is procedure for periodic Patient Vitals are monitored 2 RR/SI required
Check for BP, pulse,temp,Respiratory
monitoring of patients and recorded periodically rate FHR,dilation Uterine
Contractions, blood loss any other
vital required is monitored and
recoded in case sheet
4 4 100
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients Vulnerable patients are 2 OB/SI Check the measure taken to prevent
and ensure their safe care identified and measures are new born theft, sweeping and baby
taken to protect them from any fall
harm
ME E5.2 The facility identifies high risk patients High Risk Pregnancy cases are 2 OB/SI List of cases identified as High Risk is
and ensure their care, as per their need identified and kept in intensive available with labour room staff .
monitoring Check for the frequency of
observation: Ist stage :half an hour
and 2nd stage: every 5 min
6 6 100
Standard E6
The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their
rational use.
ME E6.1 The facility ensured that drugs are Check for case sheet if drugs 2 RR Check all the drugs in case sheet and
prescribed in generic name only are prescribed under generic discharge slip are written in generic
name only name only.
ME E6.2 There is procedure of rational use of Check for that relevant 2 RR Intrapartum care, Essential newborn
drugs Standard treatment protocols care, Newborn Resuscitation, Pre-
are available at point of use Eclampsia, Eclampsia, Postpartum
hemorrhage , Obstructed Labour,
Management of preterm labour
Check staff is aware of the drug 2 SI/RR Check BHT that drugs are prescribed
regime and doses as per STG as per treatment protocols &Check
for rational use of uterotonic drugs
14 14 100
Standard E7 The facility has defined procedures for safe drug administration
ME E7.1 There is process for identifying and High alert drugs available in 2 SI/OB Check high alert drugs such as
cautious administration of high alert department are identified Magsulf, Oxytocin, Carbopost,
drugs Adrenaline are identified in the
labour room
Maximum dose of high alert 2 SI/RR Value for maximum doses as per age,
drugs are defined and weight and diagnosis are available
communicated & there is with nursing station and doctor. A
process to ensure that right system of independent double check
doses of high alert drugs are before administration, Error prone
only given medical abbreviations are avoided
ME E7.2 Medication orders are written legibly and Every Medical advice and 2 RR Verify case sheets of sample basis
adequately procedure is accompanied with
date , time and signature
Check for the writing, It 2 RR/SI Verify case sheets of sample basis
staff
ME E7.3 There is a procedure to check drug Drugs are checked for expiry 2 OB/SI Check for any open single dose vial
before administration/ dispensing and other inconsistency with left over content intended to be
before administration used later on.In multi dose vial
needle is not left in the septum
Any adverse drug reaction is 2 RR/SI Check if adverse drug reaction form is
recorded and reported available in labour room and
reporting is in practice
ME E7.4 There is a system to ensure right Check Nursing staff is aware 7 2 SI/RR Administration of medicines done
medicine is given to right patient Rs of Medication and follows after ensuring right patient, right
them drugs , right route, right time, Right
dose , Right Reason and Right
Documentation
14 14 100
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re-assessment and Progress of labour is recorded 2 RR Partograph
investigations are recorded and updated
ME E8.2 All treatment plan prescription/orders Treatment prescribed in 2 RR Medication order, treatment plan, lab
are recorded in the patient records. nursing records investigation are recoded adequately
ME E8.4 Procedures performed are written on Delivery note is adequate 2 RR Outcome of delivery, date and time,
patients records gestation age, delivery conducted by,
type of delivery, complication if any
,indication of intervention, date and
time of transfer, cause of death etc
Baby note is adequate 2 RR Did baby cry, Essential new born care,
resuscitation if any, Sex, weight, time
of initiation of breast feed, birth
doses, congenital anomaly if any.
ME E8.5 Adequate form and formats are available Standard Formats are available 2 RR/OB Availability of standardized labour
at point of use room case sheets including
partograph and safe Birthing checklist
Page 59
ME E8.6 Register/records are maintained as per Registers and records are nce
2 Method
RR Labour room register, OT register, aine xim
guidelines maintained as per guidelines MTP register, Maternal death register d um
and records, lab register, referral
in /out register, internal & PPIUD
register , NBCC register, handover
register
All register/records are 2 RR Check records are numbered and

identified and numbered labelled legibily
2 2 100
ME E12.3 There are established procedures for Nursing station is provided with 2 SI/RR Check for list of critical values is
Post-testing Activities the critical value of different available at nursing station
test
2 2 100
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
ME E13.9 There is established procedure for Protocol of blood transfusion is 2 RR blood is kept on room temperature
transfusion of blood monitored & regulated (28 degree C) before transfusion.
Blood transfusion is monitored and
regulated by qualified person
4 4 100
Standard E16 The facility has defined and established procedures for end of life care and death
ME E16.2 The facility has standard procedures for Death note is written as per 2 RR Maternal and neonatal death are
handling the death in the hospital mother & neonatal death recorded as per MDR guideline.
review guidelines Death note including efforts done for
resuscitation is noted in patient
record. Death summary is given to
patient attendant quoting the
immediate cause and underlying
cause if possible
There is established criteria for 2 SI/RR Every still birth is examined, classified
distinguishing between new- by paediatrician before declaration &
born death and still birth record is maintained
74 74 100
Standard E18 The facility has established procedures for Intranatal care as per guidelines
ME E18.1 2 SI/OB
Facility staff adheres to standard Ensures 'six cleans' are Ensures 'six cleans' are followed
procedures for management of second followed during delivery during delivery
stage of labour. Clean hands, Clean Surface, clean
blade, clean cord tie, clean towel &
clean cloth to wrap mother
2 SI/OB By flexing the head and giving

Allows spontaneous delivery of perineal support
head
Delivery of shoulders and Neck 2 SI/OB Manages cord round the neck; assists
delivery of shoulders and body;
delivers baby on mother's abdomen
Check no unneccessary 2 SI/RR Check with records and interview

episiotomy performed with staff if they are still practicing
routine episiotomy.
Unnecessary augmentation and 2 SI/RR Check uterotonics such as oxytocin

induction of labour is not done and mesoperstol is not used for
using uterotonics routine induction normal labour
unless clear medical indication and
the expected
benefits outweigh the potential
harms
Outpatient induction of labour is not
done
ME E18.2 Facility staff adheres to standard Rules out presence of second 2 SI Check staff competence
procedure for active management of baby by palpating abdomen
third stage of labour
Use of Uterotonic Drugs 2 SI/RR Administration of 10 IU of oxytocin

IM immediately after Birth . Check if
there is practice of preloading the
oxytocin inj for prompt
administration after birth.
Control Cord Traction 2 SI/RR Only during Contraction
Uterine tone assessment 2 SI/RR Check staff competence
Checks for completeness of 2 SI/RR After placenta expulsion , Checks

placenta before discarding Placenta & Membranes for
Completeness
ME E18.3 Facility staff adheres to standard Wipes the baby with a clean 2 SI/OB Check staff competence through
procedures for routine care of new-born pre-warmed towel and wraps demonstration or case observation
immediately after birth baby in second pre-warmed
towel;
Performs delayed cord 2 SI/OB Check staff competence through
clamping and cutting (1-3 min); demonstration or case observation
Initiates breast-feeding soon 2 SI/OB Check staff competence through

after birth demonstration or case observation
Records birth weight and gives 2 SI/OB Check staff competence through
injection vitamin K demonstration or case observation
ME E18.4 There is an established procedure for Staff is aware of Indications for 2 SI Ask staff how they identify slow
assisted and C-section deliveries per referring patient for to Surgical progress of labour , How they
scope of services. Intervention interpret Partogram
Page 60
Management of Obstructed nce
2 Method
SI/RR Diagnosis obstructed labour based on aine xim
Labour data registered from the partograph, d um
Re-hydrates the patient to maintain
normal plasma volume, check vitals,
gives broad spectrum antibiotics,
perform bladder catheterization and
takes blood for Hb & grouping,
Decides on the mode of delivery as
per the condition of mother and the
baby
ME E18.5 Facility staff adheres to standard Records BP in every case 2 SI/RR Check staff competence through
protocols for identification and checks for proteinuria demonstration or case observation
management of Pre Eclampsia /
Eclampsia
identifies danger signs of 2 SI/RR Check staff competence through
severe PE and convulsions; demonstration or case observation
Administers injection 2 SI/RR Check staff competence through

magnesium sulphate demonstration or case observation
appropriately;
provides nursing care & 2 SI/RR Check staff competence through

ensures specialist attention. demonstration or case observation
ME E18.6 Facility staff adheres to standard Checks uterine tone and 2 SI/OB Check staff competence through
protocols for identification and bleeding PV regularly demonstration or case observation
management of PPH.
Identifies PPH 2 SI?OB/RR Assessment of bleeding (PPH if >500

ml or > 1 pad soaked in 5 Minutes or
any bleeding sufficient to cause signs
of hypovolemia in patient.
Manages PPH as per protocol 2 SI/OB/RR starts IV fluids, manages shock if

present, gives uterotonic, identifies
causes, performs cause specific
management.
Staff knows the use of oxytocin 2 SI/OB/RR Initial Dose: Infuse 20 IU in 1 L NS/RL
for Management of PPH at 60 drops per minute
Continuing dose: Infuse 20 IU in 1 L
NS/RL at 40 drops per minute
Maximum Dose: Not more than 3 L of
IV fluids containing oxytocin
Management of Retained 2 SI/RR Administration of another dose of

Placenta Oxytocin 20IU in 500 ml of RL at 40-
60 drops/min an attempt to deliver
placenta with repeat controlled cord
traction. If this fails performs manual
removal of Placenta
ME E18.7 Facility staff adheres to standard Provides ART for seropositive 2 SI/RR Check case records and Interview of
protocols for Management of HIV in mothers/ links with ART center staff
Pregnant Woman & Newborn
Provides syrup Nevirapine to 2 SI/RR Check case records and Interview of

newborns of HIV seropositive staff
mothers
ME E18.8 Facility staff adheres to standard protocol Correctly estimates gestational 2 SI/RR Assessment and evaluation to
for identification and management of age to confirm that labour is confirm gestational age,
preterm delivery. preterm administration of corticosteroid and
tocolytoics for 24-34 weeks
Magnesium sulphate given to
preterm labour < 32 weeks
identifies conditions that may 2 SI/RR (severe PE/E, APH, PPROM);

lead to preterm birth
administers antenatal 2 SI/RR Review case records

corticosteroids in pre term
labour and conditions leading
to pre term delivery (24-34
ME E18.9 Staff identifies and manages infection in weeks); mother' s temperature
Records 2 SI/RR Review case records
pregnant woman at admission and assesses need
for antibiotics
Administers appropriate 2 SI/RR Review case records

antibiotics to mother
There is Established protocol for Facility staff adheres to 2 SI/OB Performs initial steps of resuscitation
newborn resuscitation is followed at the standard protocol for within 30 seconds: immediate cord
facility. resuscitating the newborn cutting and PSSR at radiant warmer.
within 30 seconds.
ME 18.10
Facility staff adheres to 2 SI/OB Initiates bag and mask ventilation
standard protocol for using room air with 5 ventilator
preforming bag and mask breaths and continues ventilation for
ventilation for 30 seconds if next 30 seconds if baby still does not
baby is still not breathing. breathe.
Facility staff adheres to 2 SI/OB If baby still not breathing/ breathing

standard protocol for taking well, continues ventilation with
appropriate actions if baby oxygen, calls or arranges for
does not respond to bag and advanced help or referral.
mask ventilation after golden
minute.
ME E18.11 Facility ensures Physical and emotional Women are encouraged and 2 PI/SI
support to the pregnant women means counselled for allowing birth
of birth companion of her choice companion of their choice
Orientation session and 2 PI/SI

information is available for
Birth companion
16 16 100
Standard E19 The facility has established procedures for postnatal care as per guidelines
ME E19.1 Facility staff adheres to protocol for Performs detailed examination 2 SI/RR/PI Check for records of Uterine
assessment of condition of mother and of mother contraction, bleeding, temperature,
baby and providing adequate postpartum B.P, pulse, Breast examination,
care (Nipple care, milk initiation), Check
for perineal washes performed
Page 61
Looks for signs of infection in nce
2 Method
OB/SI Staff Interview aine xim
mother and baby d um
Looks for signs of hypothermia 2 RR/SI/PI Skin to skin contact with mother,
in baby and provides regular monitoring and specialist
appropriate care attention as required
ME E19.2 Facility staff adheres to protocol for Staff counsels mother on vital 2 PI/SI Counsels on danger signs to mother
counselling on danger signs, post-partum issues at time of discharge; Counsels on
family planning and exclusive breast post partum family planning to
feeding mother at discharge; Counsels on
exclusive breast feeding to mother at
discharge
ME E19.3 Facility staff adheres to protocol for Facilitates specialist care in 2 SI/RR Facilitates specialist care in newborn
ensuring care of newborns with small size newborn <1800 gm <1800 gm (seen by paediatrician)
at birth
Facilitates assisted feeding 2 SI/RR/PI

whenever required
Facilitates thermal 2 SI/RR/PI Facilitates thermal management

management including including kangaroo mother care
kangaroo mother care
The facility has established procedures There is established criteria for 2 SI/RR Check if criteria has been defined and
for stabilization/treatment/referral of shifting newborn to SNCU in practice by labour room staff
post natal complications
ME 19.4
Area of Concern - F Infection Control 74 74 100
6 6 100
Standard F1
The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated
infection
The facility has provision for Passive and Surface and environment 2 SI/RR Swab are taken from infection prone
active culture surveillance of critical & samples are taken for surfaces such as delivery tables ,
high risk areas microbiological surveillance door, handles, procedure lights etc.
ME F1.2
There is Provision of Periodic Medical There is procedure for 2 SI/RR Hepatitis B, Tetanus Toxic .
Check-up and immunization of staff immunization & medical check
up of the staff
ME F1.4
The facility has established procedures Regular monitoring of infection 2 SI/RR Hand washing and infection control
ME F1.5 for regular monitoring of infection control practices audits done at periodic intervals
control practices
14 14 100
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are provided at Availability of hand washing 2 OB Check for availability of wash basin
point of use with running Water Facility at near the point of use Ask to Open
Point of Use the tap. Ask Staff water supply is
regular
ME F2.1
Availability of antiseptic soap 2 OB/SI Check for availability/ Ask staff if the
with soap dish/ liquid antiseptic supply is adequate and
with dispenser. uninterrupted. Availability of Alcohol
based Hand rub
Display of Hand washing 2 OB Prominently displayed above the

Instruction at Point of Use hand washing facility , preferably in
Local language
Handwashing station is as per 2 OB Availability of elbow operated taps &

specification Hand washing sink is wide and deep
enough to prevent splashing and
retention of water
The facility staff is trained in hand Staff is aware of when and how 2 SI/OB Ask for demonstration of six steps &
washing practices and they adhere to to hand wash check staff awareness five moments
standard hand washing practices of handwashing
ME F2.2
The facility ensures standard practices Availability & Use of Antiseptics 2 OB like before giving IM/IV injection,
and materials for antisepsis drawing blood, putting Intravenous
and urinary catheter &Proper
cleaning of perineal area before
procedure with antisepsis
ME F2.3
Check Shaving is not done 2 SI Staff Interview
during part
preparation/delivery cases
16 16 100
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate personal Availability of Masks , caps and 2 OB/SI/ RR Check if staff is using PPEs
protection Equipment as per protective eye cover Ask staff if they have adequate supply
requirements Verify with the stock / Expenditure
register
ME F3.1
Sterile gloves are available at 2 OB/SI /RR Check if staff is using PPEs
labour room Ask staff if they have adequate supply
Verify with the stock / Expenditure
register
Use of elbow length gloves for 2 OB/SI /RR Check if staff is using PPEs
obstetrical purpose Ask staff if they have adequate supply
register
Availability of disposable gown/ 2 OB/SI /RR Check if staff is using PPEs

Apron Ask staff if they have adequate supply
register
Heavy duty gloves and gum 2 OB/SI /RR Check if staff is using PPEs
boots for housekeeping staff Ask staff if they have adequate supply
register
Personal protective kit for 2 OB/SI Cap & Mask, protective Eye cover,
delivering HIV cases Disposable apron
Page 62
The facility staff adheres to standard No reuse of disposable gloves, nce
2 Method
OB/SI aine xim
personal protection practices Masks, caps and aprons. d um
ME F3.2
Entry to the labour Room is 2 OB
only after change of shoes and
wearing Mask & Cap
12 12 100
Standard F4 The facility has standard procedures for processing of equipment and instruments
The facility ensures standard practices Disinfection of operating & 2 SI/OB Cleaning of delivery tables tops after
and materials for decontamination and Procedure surfaces each delivery with 2% carbolic acid
cleaning of instruments and procedures
areas
ME F4.1
Proper handling of Soiled and 2 SI/OB No sorting ,Rinsing or sluicing at Point
infected linen of use/ Patient care area
Cleaning of instruments 2 SI/OB Cleaning is done with detergent and

running water after use
The facility ensures standard practices Equipment and instruments are 2 OB/SI Autoclaving
and materials for disinfection and sterilized after each use as per
sterilization of instruments and requirement
ME F4.2 equipment
Autoclaving of delivery kits is 2 OB/SI Ask staff about temperature,
done as per protocols pressure and time. Ask staff about
method, concentration and contact
time required for chemical
sterilization
There is a procedure to ensure 2 OB/SI Sterile packs are kept in clean, dust
the traceability of sterilized free, moist free environment.
packs & their storage
10 10 100
Layout of the department is conducive Facility layout ensures 2 OB
for the infection control practices separation of routes for clean
and dirty items
ME F5.1
The facility ensures availability of Availability of disinfectant & 2 OB/SI Chlorine solution, Glutaraldehyde,
standard materials for cleaning and cleaning agents as per Hospital grade phenyl, disinfectant
disinfection of patient care areas requirement detergent solution
ME F5.2
The facility ensures standard practices Spill management protocols are 2 SI/RR spill management kit staff training,
are followed for the cleaning and implemented protocol displayed
disinfection of patient care areas
ME F5.3
Cleaning of patient care area 2 SI/RR Staff is trained for preparing cleaning
with detergent solution solution as per standard procedure
Standard practice of mopping 2 OB/SI Unidirectional mopping from inside
and scrubbing are followed & out. Cleaning protocols are available /
three bucket system is followed displayed
Cleaning equipment like broom are
not used in patient care areas
16 16 100
Standard F6
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous
Waste.
The facility Ensures segregation of Bio Availability of colour coded bins 2 OB Adequate number. Covered. Foot
Medical Waste as per guidelines and 'on- & Plastic bags at point of Human
operated.Anatomical waste, Items
site' management of waste is carried out waste generation contaminated with blood, body
as per guidelines fluids,dressings, plaster casts, cotton
ME F6.1 swabs and bags containing residual or
Items suchblood
discarded as tubing, bottles,
and blood
Segregation of Anatomical and 2 OB/SI intravenous
components.tubes and sets,
soiled waste in Yellow Bin catheters, urine bags, syringes
(without needles and fixed needle
Segregation of infected plastic 2 OB syringes) and vaccutainers with their
waste in red bin needles cut) and gloves
Display of work instructions for 2 OB Pictorial and in local language
Biomedical waste
The facility ensures management of Availability of functional needle 2 OB See if it has been used or just lying
sharps as per guidelines cutters & puncture proof, leak idle.
proof, temper proof white
container for seggregation of
sharps
ME F6.2
Availability of post exposure 2 OB/SI Ask if available. Where it is stored
prophylaxis & Protcols and who is in charge of that. Also
check PEP issuance register
Staff knows what to do in condition of
needle stick injury
Contaminated and broken 2 OB Includes used vials, slides and other

Glass are disposed in puncture broken infected glass
proof and leak proof box/
container with Blue colour
marking
The facility ensures transportation and Check bins are not overfilled 2 OB/SI Bins should not be filled more than
disposal of waste as per guidelines 2/3 of its capacity
ME F6.3
Area of Concern - G Quality Management 70 70 100
2 2 100
ME G1.1 The facility has a quality team in place Quality circle has been formed 2 SI/RR Check if quality circle formed and
in the Labour Room functional in the Labour Room
6 6 100
Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient satisfaction surveys are Client satisfaction survey done 2 RR
conducted at periodic intervals on monthly basis
ME G2.2 The facility analyses the patient feed Analysis of low performing 2 RR
back, and root-cause analysis attributes of client feedback is
done
ME G2.3 The facility prepares the action plans Action plan prepared is 2 RR
for the areas, contributing to low prepared to address the areas
satisfaction of patients of low satisfaction
4 4 100
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.
Page 63
ME G3.1 The facility has established internal There is system of daily round nce
2 Method
SI/RR Facility Incharge should visit at least aine xim
quality assurance programme in key by matron/hospital manager/ twice in a week. OBG Incharge d um
departments hospital superintendent/ should visit Labour room atleast
Hospital Manager/ Matron in twice a day, Matron/Nursing
charge for monitoring of supervisor should visit at once in each
services shift
Findings/instructions during the visits
are recorded
ME G3.3 The facility has established system for Departmental checklist are 2 SI/RR Daily Checklist to check labour room
use of check lists in different used for monitoring and quality preparedness and cleanliness is used
departments and services assurance for quality assurance
Staff is designated for filling and
monitoring of these checklists
28 28 100
Standard G4
The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and
support services.
ME G4.1 Departmental standard operating Standard operating procedure 2 RR Check if SOPs available at labour
procedures are available for department has been room are formally approved
Current version of SOP are 2 OB/RR Check current version of SOP is

available with process owner available with all staff members of
labour room
ME G4.2 Standard Operating Procedures Department has documented 2 RR Review the Labour Room SOPs for
adequately describes process and procedure for ensuring patients description of processes pertaining to
procedures rights including consent, ensuring privacy, confidentiality,
privacy, confidentiality & respectful maternity care and
entitlement consent
Department has documented 2 RR Review the Labour Room SOPs for

procedure for safety & risk inclusion for processes to Physical as
management well as patient safety, assessment of
risks and their timely mitigation
Department has documented 2 RR Review the Labour Room SOPs for

procedure for support services process description of support
& facility management. services such as equipment
maintenance , calibration,
housekeeping, security, storage and
inventory management
Department has documented 2 RR Review Labour room SOPS for

procedure for general patient processes of triage, assessment,
care processes admission, identification of high risk
patients, Referral , Medication
management and maintenance of
clinical records
Department has documented 2 RR Review Labour room SOPs for process

procedure for specific of intrapartum care, management of
processes to the department complications, immediate
postpartum care , Natural Birthing
Process and Birth Companion
Department has documented 2 RR Review Labour room SOPs for process

procedure for infection control description of Hand Hygiene,
& bio medical waste personal protection, environmental
management cleaning, instrument sterilization,
asepsis, Bio Medical Waste
management , surveillance and
monitoring of infection control
Department has documented 2 RR Review
practices,Labour room
Periodic SOPsreview
quality for process
procedure for quality description of function
such as Maternal DeathofAudit,
quality
management & improvement circles,
Newborn internal
Deathquality assessment,
Audit, Referral audit
Quality
and Near improvement
miss audit. using PDCA
cycle client satisfaction surveys,
processes improvement , Maternal
Death Audit, Newborn Death Audit,
Referral Death Audit and Near Miss
audits.
Department has documented 2 RR Review Labour room SOPs for

procedure for data collection, description of process related to
analysis & use for improvement collection of data & quality
indicators , their analysis and use for
quality improvement
ME G4.3 Staff is trained and aware of the Check Staff is aware of relevant 2 SI/RR Interview labour room staff for their
procedures written in SOPs part of SOPs awareness about content of SOPs
ME G4.4 Work instructions are displayed at Point clinical protocols for 2 OB Clinical Protocols on AMSTL,
of use Intrapartum care and Preparing Partograph, , PPH,
Management of obstetric Eclampsia, Infection control,
emergency are Displayed Referral, Infection Control
Clinical protocols on Newborn 2 OB Clinical Protocols on Essential

Care are displayed Newborn Care, New born
resuscitation
Don'ts/ Harmful Activities are 2 OB 1. No routine enema

Displayed at labour Room 2. No routine shaving
3. No routine
induction/augmentation of labour
4. No place for routine suctioning of
the baby
5. No pulling of the baby.
6. No routine episiotomy
7. No fundal pressure
8. No immediate cord cutting
9. No immediate bathing of the
newborn
10. No routine resuscitation on
warmer
6 6 100
Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
Page 64
ME G5.1 The facility maps its critical processes Process mapping of critical nce
2 Method
SI/RR Critical process are the ones where is aine xim
processes done some problem-delays, errors, cost, d um
time, etc. and improvement will make
our process effective and efficient.
ME G5.2 Facility identifies non value adding Non value adding activities are 2 SI/RR Non value adding activities are
activities / waste / redundant identified wastes. In these steps resources are
activities expended, delays occur, and no value
is added to the service.
ME G5.3 Facility takes corrective action to Processes are improved & 2 SI/RR Look for the improvements made in
improve the processes implemented the critical process.
14 14 100
ME G6.1 The facility conducts periodic internal Internal assessment is done at 2 RR/SI Check for assessment records such as
assessment periodic interval circular, assessment plan and filled
checklists. Internal assessment should
be done at least quarterly
ME G6.1 Referral Audits are conducted 2 RR/SI Check for records referral audit is
on Monthly Basis being done on regular basis
Maternal Death Audits are 2 RR/SI Check for records maternal audit is
conducted on Monthly Basis being done on regular basis
Neonatal Death Audits are 2 RR/SI Check for records Neonatal audits is
conducted on Monthly Basis being done on regular basis
ME G6.3 The facility ensures non compliances are Non Compliance are 2 RR/SI Check points having scores partial
enumerated and recorded adequately enumerated and recorded and Non Compliances are listed
ME G6.4 Action plan is made on the gaps found in Action plan prepared 2 RR/SI With details of action, responsibility,
the assessment / audit process time line and Feedback mechanism.
ME G6.5 Planned actions are implemented Check correction & corrective 2 RR/SI Check actions have been taken to
through Quality improvement cycle actions are taken close the gap. Can be in form of
(PDCA) Action taken report or Quality
Improvement (PDCA) project report
4 4 100
Check if SMART Quality 2 SI/RR Check short term valid quality
Objectives have framed objectives have been framed
addressing key quality issues in each
department and cores services. Check
if these objectives are Specific,
ME G7.4 Measurable, Attainable, Relevant and
Time Bound.
Facility has defined quality objectives to

achieve mission and quality policy
Check of staff is aware of 2 SI/RR Interview with staff for their
Mission , Values, Quality Policy awareness. Check if Mission
and objectives Statement, Core Values and Quality
ME G7.5 Policy is displayed prominently in
local language at Key Points
Mission, Values, Quality policy and
objectives are effectively communicated
to staff and users of services
4 4 100
Standard G8 The facility seeks continually improvement by practicing Quality method and tools.
ME G8.1 The facility uses method for quality Basic quality improvement 2 SI/OB PDCA & 5S
improvement in services method
ME G8.2 The facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used
improvement in services in each department
Standards G10 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan 2 2 100
ME G10.6 Check periodic assessment of 2 SI/RR Verify with the records. A
medication and patient care comprehensive risk assessment of all
safety risk is done using clinical processes should be done
Periodic assessment for Medication and defined checklist periodically using pre define criteria at least once
Patient care safety risks is done as per in three month.
defined criteria.
Area of Concern - H Outcome 40 40 100
6 6 100
ME H1.1 Facility measures productivity Indicators Percentage of deliveries 2 RR
on monthly basis conducted at night
Percentage of complicated 2 RR
cases managed
% PPIUCD inserted against 2 RR
total number of normal
delivery
6 6 100
ME H2.1 Facility measures efficiency Indicators on Percentage of cases referred to 2 RR
monthly basis OT
% of newborns required 2 RR
resuscitation out of total live
births
No of drugs stock out in the 2 RR
month
24 24 100
ME H3.1 Facility measures Clinical Care & Safety Percentage of deliveries 2 RR
Indicators on monthly basis conducted using real time
partograph
Percentage of deliveries 2 RR
conducted using safe birth
checklist
No of adverse events per 2 RR
thousand patients
The percentage of Women, 2 RR
administered Oxytocin,
immediately after birth.
Intrapartum stillbirth rate 2 RR
Page 65
Percentage newborn breastfed nce
2 Method
RR aine xim
within 1 hour of birth d um
No. of cases of Neonatal 2 RR
asphyxia
No. of cases of Neonatal Sepsis 2 RR
Percentage of antenatal 2 RR
corticosteroid administration in
case of preterm labour
No. of cases of Maternal death 2 RR
related to APH/ PPH
No of cases pf maternal death 2 RR
related to Eclampsia/ PIH
OSCE Score 2 RR
4 4 100
Standard H4 The facility measures Service Quality Indicators and endeavors to reach State/National benchmark
ME H4.1 Facility measures Service Quality Percentage of Deliveries 2 RR

Indicators on monthly basis attended by Birth Companion
Client Satisfaction Score 2 RR

A 22 22 100%
B 40 40 100%
C 108 108 100%
D 62 62 100%
E 184 184 100%
F 74 74 100%
G 70 70 100%
H 40 40 100%
Total 600 600 100%
0
1
2
Page 66
Checklist No. 4 Maternity Ward Version - NHSRC 3.0
National Quality Assurance Standards for District Hospitals Version -2

Checklist for Maternity Ward 4
Assessment Summary
Type of Assessment (Internal/External) Action plan Submission

Date
Maternity Ward Score Card

Area of Concern wise Score Maternity Ward Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for Maternity Ward

Reference no Measurable Element Checkpoints Complian Assessment Means of verification Remarks Obtai Maximu
ce method ned m Marks
Mark
s
Standard A1 The facility provides Curative Services 6 6
Page 67
Mark
s
ME A1.3 The facility provides Obstetrics & Availability of Gynaecology indoor 2 SI/OB For obstetric indoor services kindly
Gynaecology Services services refer to ME A2.2
ME A1.14 Services are available for the time Availability of nursing services 2 SI/RR
period as mandated 24X7
ME A1.18 The facility provides Blood bank & Availability/ linkage with blood 2 SI/OB
transfusion services bank
Standard A2 The facility provides RMNCHA Services 14 14
ME A2.2 The facility provides Maternal health Availability of indoor services for 2 SI/OB
Services Antenatal cases Antenatal ward- Clean Ward
Availability of indoor services for 2 SI/OB
normal delivery Postnatal ward -Normal delivery
Availability of indoor services for C 2 SI/OB
section Postnatal ward -C-section delivery
Septic cases Septic ward
Eclampsia cases Eclampsia room
ME A2.3 The facility provides Newborn health Prevention of hypothermia and 2 SI/OB
Services initiation of breast feeding
ME A2.4 The facility provides Child health Screening of New born for Birth 2 SI/OB
Services Defects
Standard A3 The facility Provides diagnostic Services 4 4
ME A3.1 The facility provides Radiology Services 2 SI/OB
Availability / linkage with Radiology
ME A3.2 The facility Provides Laboratory Availability / linkage with 2 SI/OB
Services laboratory
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme 4 4
ME A4.1 The facility provides services under Treatment of Malaria in pregnancy 2 SI/OB check the records for management
National Vector Borne Disease Control of cases in last one year
Programme as per guidelines
ME A4.10 The facility provide services under 2 SI/OB

National health Programme for
prevention and control of deafness
Referral of of child born of High
Risk pregnancy showing features
suggestive of hearing empairment
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities 22 22
ME B1.1 The facility has uniform and user- Availability departmental (Numbering, main department and
friendly signage system signage's 2 OB internal sectional signage
Visiting hours and visitor policy are
displayed 2 OB
ME B1.2 The facility displays the services and
entitlements available in its
departments Entitlements under JSSK Displayed 2 OB
Entitlement under JSY displayed 2 OB
List of drugs available are
displayed and updated 2 OB
Contact details of referral
transport / ambulance displayed 2 OB
ME B1.5
Patients & visitors are sensitised and Breast feeding and care of breast,
educated through appropriate IEC / kangaroo care, family planning,
Danger signs, PN advice,
BCC approaches Information material about
IEC Material is displayed 2 OB PCPNDT etc
Counselling aids like flip chart etc
are available for post partum
counselling 2 OB
ME B1.6 Information is available in local Signage's and information are
language and easy to understand available in local language 2 OB
ME B1.7 The facility provides information to OB Enquiry desk serving both
patients and visitor through an maternity ward and labour
Availability of Enquiry Desk with
exclusive set-up. dedicated staff 2
ME B1.8 The facility ensures access to clinical Discharge summery is given to the RR/OB
records of patients to entitled patient
personnel 2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of physical economic, 12 12
Standard B2
cultural or social reasons.
ME B2.1 Services are provided in manner that No Male attendant allowed to stay 2 OB/SI
are sensitive to gender in female wards at night
Availability of female staff if a male 2 OB/SI
doctor examine a female patients
Availability of Breast feeding 2 OB

corner
ME B2.3 2 OB
Access to facility is provided without Availability of Wheel chair or
any physical barrier & and friendly to stretcher for easy Access to the
people with disabilities ward
Availability of ramps and railing 2 OB
Availability of disable friendly toilet 2 OB
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 16 16
ME B3.1 Adequate visual privacy is provided at Availability of screen at
every point of care Examination Area 2 OB Bracket screen
Curtains have been provided at
windows 2 OB
Patients are dressed/covered while
shifting the patients from one
department to other 2 OB
No two patients are treated on
one bed 2 OB
Page 68
Mark
s
ME B3.2 SI/OB
Confidentiality of patients records and Patient Records are kept at secure
clinical information is maintained place beyond access to general
staff/visitors 2
SI/OB
No information regarding patient
identity and details are
unnecessary displayed 2
ME B3.3 The facility ensures the behaviours of Behaviour of staff is empathetic OB/PI
staff is dignified and respectful, while and courteous
delivering the services 2
ME B3.4 SI/OB
The facility ensures privacy and
confidentiality to every patient,
especially of those conditions having
social stigma, and also safeguards HIV status of patient is not
vulnerable groups disclosed except to staff that is
directly involved in care 2
The facility has defined and established procedures for informing patients about the medical condition, and involving them in treatment planning, 6 6
Standard B4 and facilitates informed decision making
ME B4.1 There is established procedures for 2 SI/RR
taking informed consent before General Consent is taken before
treatment and procedures admission
ME B4.4 2 PI
Information about the treatment is Patient and their attendent is
shared with patients or attendants, informed about her clinical
regularly condition and treatment being
provided
ME B4.5 The facility has defined and established 2 OB
grievance redressal system in place Availability of complaint box and
display of process for grievance
redresaal and whom to contact is
displayed
Standard B5 The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost of hospital services. 22 22
ME B5.1 2 PI/SI
The facility provides cashless services
to pregnant women, mothers and
neonates as per prevalent government
schemes Stay in ward is free of cost
Availability of Free Diet 2 PI/SI
Availability of Free drop back 2 PI/SI
Availability of Free referral 2 PI/SI
vehicle/Ambulance services
Availability of Free Blood 2 PI/SI
Availability of Free drugs 2 PI/SI
Availability of free diagnostic 2 PI/SI
ME B5.2 The facility ensures that drugs Check that patient party has not 2 PI/SI
prescribed are available at Pharmacy spent on purchasing drugs or
consumables from outside.
and wards
ME B5.3 It is ensured that facilities for the Check that patient party has not 2 PI/SI
prescribed investigations are available spent on diagnostics from outside.
at the facility
ME B5.5 2 PI/SI/RR
reimbursement of financial
entitlements and reimbursement to the
If any other expenditure occurred
patients it is reimbursed from hospital
JSY Payment is done before 2 PI/SI/RR
discharge
ME B 6.7 2 RR/SI
There is an established procedure for
patients who wish to leave hospital against
medical advice or refuse to receive specific Declaration is taken from the
c treatment LAMA patient
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 48 48
ME C1.1 Departments have adequate space as Adequate space in wards with no 2 OB Distance between centres of two
per patient or work load cluttering of beds beds – 2.25 meter
ME C1.2 Patient amenities are provide as per 2 OB one toilet for 12 patients
patient load Functional toilets with running
water and flush are available as
per strength and patient load of
ward
2 OB one toilet for 12 patients
Functional bathroom with running
water are available as per strength
and patient load of ward
Availability of drinking water 2 OB
Patient/ visitor Hand washing area 2 OB
Separate toilets for visitors 2 OB
TV for entertainment and health 2 OB
promotion
Adequate shaded waiting area is 2 OB
provide for attendants of patient
ME C1.3 Departments have layout and Availability of Dedicated nursing 2 OB
demarcated areas as per functions station
Availability of Examination room 2 OB
Availability of Treatment room 2 OB
Availability of Doctor's Duty room 2 OB
Availability of Nurse Duty room 2 OB
Availability of Store 2 OB Drug &Linen store
Availability of Dirty room 2 OB
ME C1.4 The facility has adequate circulation 2 OB
area and open spaces according to Space between two beds should
need and local law be at least 4 ft and clearance
between head end of bed and wall
There is sufficient space between should be at least 1 ft and
two bed to provide bed side between side of bed and wall
nursing care and movement should be 2 ft
2 OB
Corridors are wide enough for
patient, visitor and trolley/
equipment movement Corridor should be 3 meters wide
Page 69
Mark
s
ME C1.5 The facility has infrastructure for 2 OB

communication Availability of functional telephone
and Intercom Services
ME C1.6 Service counters are available as per There is separate nursing station 2 OB
patient load for each ward
Availability of adequate beds as 2 OB 10 beds for 100 delivery per month
per delivery load
ME C1.7 The facility and departments are 2 OB
planned to ensure structure follows the
function/processes (Structure Prepartaum and post partum
commensurate with the function of the wards are in proximity and
hospital) functional linkage with labour
room
Postpartum ward and SNCU are in 2 OB
proximity and functional linkage
C section ward is in Proximity and 2 OB/SI
has functional linkage with OT
2 OB
Location of nursing station and
patients beds enables easy and
direct observation of patients
Standard C2 The facility ensures the physical safety of the infrastructure. 8 8
ME C2.1 The facility ensures the seismic safety Non structural components are 2 OB Check for fixtures and furniture
of the infrastructure properly secured like cupboards, cabinets, and
heavy equipments , hanging
objects are properly fastened and
secured
ME C2.3 The facility ensures safety of electrical 2 OB

IPD building does not have Switch Boards other electrical
establishment temporary connections and loosely installations are intact. There is
hanging wires proper earthing
ME C2.4 Physical condition of buildings are safe Floors of the maternity ward are 2 OB
for providing patient care non slippery and even
2 OB
Windows have grills and wire
meshwork
Standard C3 The facility has established Programme for fire safety and other disaster 10 10
ME C3.1 The facility has plan for prevention of 2 OB/SI
fire Maternity ward has sufficient fire
exit to permit safe escape to its

visible and routes to reach exit are
clearly marked.
ME C3.2 The facility has adequate fire fighting 2 OB
Equipment Maternity ward has installed fire
Extinguisher that is ethier Class
A , Class B, C type or ABC type
Check the expiry date for fire 2 OB/RR

mentioned
ME C3.3 The facility has a system of periodic Check for staff competencies for 2 SI/RR
training of staff and conducts mock operating fire extinguisher and
drills regularly for fire and other what to do in case of fire
disaster situation
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 14 14
ME C4.1 The facility has adequate specialist Availability of Ob&G specialist on
doctors as per service provision duty and on call paediatrician 2 OB/RR
ME C4.2 The facility has adequate general duty OB/RR
doctors as per service provision and
work load Availability of General duty doctor
at all time 2
ME C4.3 The facility has adequate nursing staff OB/RR/SI
as per service provision and work load 6 for 100-200 Deliveries/Month
8 for More than 200 deliveries per
Availability of Nursing staff 2 month
ME C4.4 The facility has adequate OB/SI
technicians/paramedics as per
requirement Counsellor available for
Availability of RMNCH counsellor 2 postpartum counselling of mothers
Availability of dresser for C section SI/RR
ward 2
ME C4.5 The facility has adequate support / SI/RR Availability of mamta/ ayahs and
general staff Availability of ward attendant 2 Sanitary worker
Availability Security staff 2 SI/RR
Standard C5 The facility provides drugs and consumables required for assured services. 24 24
ME C5.1 The departments have availability of OB/RR
adequate drugs at point of use Availability of Uterotonic Drugs 2 Tocolytics ,Isoxsuprine
OB/RR Tab metronidazole 400mg,
Availability of Antibiotics 2 Gentamicin,
Availability of Antihypertensive 2 OB/RR Tab Misprostol 200mg, Labetalol
availability of analgesics and OB/RR Tab Paracetamol, Tab Ibuprofen,
antipyretics 2 Piroxicam
OB/RR IV fluids, Normal saline, Ringer
Availability of IV Fluids 2 lactate,
OB/RR
Tab Retrodrine, Misoprostol,
Prostodin, steroid as
Hydrocortisone, dexamethasone,
Availability of other emergency iron, calcium, and folic acids
drugs 2 tablets
OB/RR
Inj Vit K 10mg, Vaccine OPV, Hep
B, BCG, paracetamol syrup/drops,
Syp Calcium with Vit D,
Multivitamin drops, colicaid drops,
Nevirapine drops (for HIV + ve
mother born children), gentian
Availability of drugs for newborn 2 Violet (0.50%)
ME C5.2 The departments have adequate OB/RR
gauze piece and cotton swabs,
consumables at point of use Availability of dressings and sanitary pads, needle (round body
Sanitary pads 2 and cutting), chromic catgut no. 0,
Page 70
Mark
s
OB/RR
Paediatric iv sets, urinary catheter
Availability of syringes and IV with bag, Foyle's catheter
Sets /tubes 2 Nasogastric tube, Syringe A/D
Availability of Antiseptic Solutions 2 OB/RR Betadine
Availability of consumables for OB/RR gastric tube and cord clamp,
new born care 2 dressing pad
ME C5.3 Emergency drug trays are maintained Availability of emergency drug tray OB/RR
at every point of care, where ever it in Maternity ward
may be needed
2
Standard C6 The facility has equipment & instruments required for assured list of services. 22 22
ME C6.1 Availability of equipment & Availability of functional
instruments for examination & Equipment &Instruments for BP apparatus, Thermometer,
monitoring of patients examination & Monitoring foetoscope, baby and adult
weighing scale, Stethoscope,
2 OB Doppler
instruments for treatment procedures, Equipment/Instruments Gynae
being undertaken in the facility & Obstetric Procedures Dressing and suture removal kit,
speculum, Anterior vaginal wall
2 OB retractor.
ME C6.3 Availability of equipment & Availability of Point of care
instruments for diagnostic procedures diagnostic instruments
being undertaken in the facility
Glucometer and HIV rapid
2 OB diagnostic kit
ME C6.4 Availability of equipment and Availability of resuscitation
instruments for resuscitation of equipments
patients and for providing intensive and Adult and baby bag and mask,
critical care to patients Oxygen, Suction machine, Airway,
2 OB Laryngoscope, ET tube
ME C6.5 Availability of Equipment for Storage Availability of equipment for Refrigerator, Crash cart/Drug
storage for drugs trolley, instrument trolley, dressing
trolley
2 OB
ME C6.6 Availability of functional equipment Availability of equipments for Buckets for mopping, mops,
and instruments for support services cleaning duster, waste trolley, Deck brush
2 OB
Availability of equipment for Boiler
sterilization and disinfection 2 OB
ME C6.7 Departments have patient furniture Availability of patient beds with
and fixtures as per load and service prop up facility
provision
2 OB
Availability of attachment/ Hospital graded mattress, Bed side
accessories with patient bed 2 OB locker , IVstand, Bed pan
Availability of Fixtures Spot light, electrical fixture for
equipments like suction, X ray view
box
2 OB
cupboard, nursing counter, table
for preparation of medicines,
Availability of furniture 2 OB chair.
ME C7.1 RR/SI

prepared for assessing
2 competence of doctors, nurses and
paramedical staff based on job
description defined for each cadre
Check parameters for assessing of staff. Dakshta checklist issued
Criteria for Competence assessment are skills and proficiency of clinical by MoHFW can be used for this
defined for clinical and Para clinical staff staff has been defined purpose.
ME C7.2 RR/SI
Check for records of competence
2 assessment including filled
Competence assessment of Clinical and checklist, scoring and grading .
Para clinical staff is done on predefined Check for competence assessment Verify with staff for actual
criteria at least once in a year is done at least once in a year competence assessment done
ME C7.9 SI/RR
The Staff is provided training as per
defined core competencies and training Infant and young Child Feeding
plan ( IYCF) practices 2
Biomedical waste management 2 SI/RR
SI/RR
Infection control and hand hygiene 2
ME C7.10 SI/RR
Check supervisors make periodic

rounds of department and monitor
that staff is working according to
There is established procedure for the training imparted. Also staff is
utilization of skills gained thought trainings Nursing staff is skilled identificaton provided on job training wherever
by on -job supportive supervision and managing complication 2 there is still gaps
SI/RR

the training imparted. Also staff is
Staff is skilled for maintaining provided on job training wherever
clinical records 2 there is still gaps
SI/RR

Counsellor is skilled for postnatal provided on job training wherever
counselling 2 there is still gaps
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 6 6
ME D1.1 The facility has established system for All equipments are covered under 2 SI/RR
maintenance of critical Equipment AMC including preventive
maintenance
2 SI/RR
Page 71
Mark
s
ME D1.2 The facility has established procedure All the measuring equipments/ 2 OB/ RR
for internal and external calibration of instrument are calibrated
measuring Equipment BP apparatus, thermometers etc
are calibrated
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 24 24
ME D2.1 There is established procedure for 2 SI/RR Stock level are daily updated
forecasting and indenting drugs and There is established system of Requisition are timely placed
consumables timely indenting of consumables
and drugs at nursing station
ME D2.3 The facility ensures proper storage of 2 OB
Drugs are stored in
drugs and consumables containers/tray/crash cart and are
labelled
Empty and filled cylinders are 2 OB
labelled
ME D2.4 The facility ensures management of Expiry dates' are maintained at 2 OB/RR
expiry and near expiry drugs emergency drug tray
2
Records for expiry and near expiry
drugs are maintained for drug
stored at department RR
ME D2.5 The facility has established procedure There is practice of calculating and 2 SI/RR
for inventory management techniques maintaining buffer stock
Department maintained stock and 2 RR/SI

expenditure register of drugs and
consumables
ME D2.6 There is a procedure for periodically There is procedure for replenishing 2 SI/RR
replenishing the drugs in patient care drug tray /crash cart
areas
There is no stock out of drugs 2 OB/SI
ME D2.7 There is process for storage of vaccines 2 OB/RR Check for temperature charts are
and other drugs, requiring controlled Temperature of refrigerators are maintained and updated
temperature kept as per storage requirement periodically
and records are maintained
ME D2.8 There is a procedure for secure storage Narcotics and psychotropic drugs 2 OB/SI
of narcotic and psychotropic drugs are kept in lock and key
Separate prescription for narcotic
and psychotropic drugs
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors. 18 18
ME D3.1 The facility provides adequate 2 OB
illumination level at patient care areas
Adequate Illumination at nursing
station
Adequate illumination in patient 2 OB
care areas
ME D3.2 The facility has provision of restriction 2 OB/PI
of visitors in patient areas
Visiting hour are fixed and
practiced
There is no overcrowding in the 2 OB
wards during to visitors hours
ME D3.3 The facility ensures safe and Temperature control and 2 PI/OB Optimal temperature and warmth
comfortable environment for patients ventilation in patient care area is ensured Fans/ Air
and service providers conditioning/Heating/Exhaust/Ven
tilators as per environment
condition and requirement

ventilation in nursing station/duty conditioning/Heating/Exhaust/Ven
room tilators as per environment
ME D3.4 The facility has security system in place New born identification band and 2 OB/RR
at patient care areas foot prints are in practice
Security arrangement in maternity 2 OB/SI
ward
ME D3.5 The facility has established measure for Ask female staff weather they feel 2 SI
safety and security of female staff secure at work place
Standard D4 The facility has established Programme for maintenance and upkeep of the facility 22 22
ME D4.1 Exterior of the facility building is Building is painted/whitewashed in 2 OB
maintained appropriately uniform colour
Interior of patient care areas are 2 OB
plastered & painted
ME D4.2 Patient care areas are clean and 2 OB
Floors, walls, roof, roof topes, sinks
hygienic patient care and circulation areas All area are clean with no
are Clean dirt,grease,littering and cobwebs
Surface of furniture and fixtures 2 OB
are clean
Toilets are clean with functional 2 OB
flush and running water
ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , 2 OB
Window panes , doors and other 2 OB

fixtures are intact
Patients beds are intact and 2 OB
painted
Mattresses are Intact and clean 2 OB
ME D4.5 The facility has policy of removal of No condemned/Junk material in 2 OB
condemned junk material the ward
ME D4.6 The facility has established procedures 2 OB
for pest, rodent and animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 6 6
ME D5.1 The facility has adequate arrangement Availability of 24x7 running and 2 OB/SI
storage and supply for portable water potable water
Availability of hot water 2 OB/SI
Page 72
Mark
s
ME D5.2 The facility ensures adequate power 2 OB/SI

backup in all patient care areas as per
load
Availability of power back in ward
StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients. 8 8
ME D6.1 The facility has provision of nutritional
assessment of the patients Nutritional assessment of patient
done specially for high risk For hypertensive patient, diabetic
pregnancy and other specified cases. Check nutrition advice from
cases 2 RR/SI records
ME D6.2 The facility provides diets according to
nutritional requirements of the Check for the adequacy and
patients frequency of diet as per nutritional Check that all items fixed in diet
requirement 2 OB/RR menu is provided to the patient
Check for the Quality of diet Ask patient/staff weather they are
provided 2 PI/SI satisfied with the Quality of food
ME D6.3 Hospital has standard procedures for
preparation, handling, storage and
distribution of diets, as per There is procedure of requisition
requirement of patients of different type of diet from ward diet for diabetic patients, low salt
to kitchen 2 RR/SI and high protein diet etc
Standard D7 The facility ensures clean linen to the patients 10 10
ME D7.1 The facility has adequate sets of linen Clean Linens are provided for all 2 OB/RR
occupied bed
Gown are provided at least to the 2 OB/RR
cases going for surgery
2 OB/RR
Availability of Blankets, draw
sheet, pillow with pillow cover and
mackintosh
ME D7.2 The facility has established procedures 2 OB/RR
for changing of linen in patient care
areas Linen is changed every day and
whenever it get soiled
ME D7.3 The facility has standard procedures for 2 SI/RR
handling , collection, transportation There is system to check the
and washing of linen cleanliness and Quantity of the
Standard 8 8
D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
ME D11.1 The facility has established job Staff is aware of their role and 2 SI
description as per govt guidelines responsibilities
ME D11.2 The facility has a established procedure There is procedure to ensure that 2 RR/SI Check for system for recording
for duty roster and deputation to staff is available on duty as per time of reporting and relieving
different departments duty roster (Attendance register/ Biometrics
etc)
There is designated in charge for 2 SI

department
ME D11.3 The facility ensures the adherence to Doctor, nursing staff and support 2 OB
dress code as mandated by its staff adhere to their respective
administration / the health department dress code
Standard 2 2
D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
(cleaning/
There is procedure to monitor the Dietary/Laundry/Security/Mainten
quality and adequacy of ance) provided are done by
There is established system for contract outsourced services on regular designated in-house staff
management for out sourced services basis
Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 14 14
ME E1.1 The facility has established procedure Unique identification number is 2 RR
for registration of patients given to each patient during
process of registration
Patient demographic details are 2 RR Check for that patient

recorded in admission records demographics like Name, age, Sex,
Chief complaint, etc.
ME E1.3 There is established procedure for There is no delay in treatment 2 SI/RR/OB
admission of patients because of admission process
Admission is done by written order 2 SI/RR/OB
of a qualified doctor
There is separate counter for 2 OB/RR
admission of patients
Time of admission is recorded in 2 RR
patient record
ME E1.4 There is established procedure for 2 OB/SI
managing patients, in case beds are not
There is provision of extra Beds
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 16 16
ME E2.1 There is established procedure for 2 The assessment criteria for
initial assessment of patients Initial assessment of all admitted different clinical conditions are
patient done as per standard defined and measured in
protocols assessment sheet
RR/SI/OB
ANC history of pregnant women 2
is reviewed and recorded RR/SI
2 Assesses general condition,
including: vital signs, conjunctiva
for pallor and jaundice, and
bladder and bowel function,
Physical Examination is done and conducts breast examinations
recorded wherever required RR
2 Examines the perineum for
inflammation, status of
episiotomy/tears, lochia for colour,
amount, consistency and odour,
Checks calf tenderness, redness or
Dangers signs are identified and swelling
recorded RR/SI
Page 73
Mark
s
2
Initial assessment and treatment is
provided immediately
RR/SI
Initial assessment is documented 2
preferably within 2 hours RR
ME E2.2 There is established procedure for There is fixed schedule for 2
follow-up/ reassessment of Patients assessment of stable patients RR/OB
2
For critical patients admitted in the
ward there is provision of
reassessment as per need RR/OB
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 20 20
ME E3.1 The facility has established procedure Facility has established 2 SI/RR
for continuity of care during procedure for handing over of
interdepartmental transfer patients from maternity ward to
OT/labour room
There is a procedure for 2

other specialist with in the
hospital
SI/RR
ME E3.2 The facility provides appropriate 2
referral linkages to the
patients/Services for transfer to
other/higher facilities to assure the
continuity of care.
Patient referred with referral slip RR/SI
Advance communication is done 2
with higher centre RR/SI
Referral vehicle is being arranged 2 RR/SI
Referral in or referral out register 2
is maintained SI/RR
Facility has functional referral 2 Check for referral cards filled from
linkages to lower facilities RR lower facilities
Facility has functional referral 2

linkages to higher facilities
There is a system of follow up of 2
SI/RR
referred patients
ME E3.3 A person is identified for care during all Duty Doctor and nurse is assigned 2 RR/SI
steps of care for each patients
Standard E4 The facility has defined and established procedures for nursing care 18 18
ME E4.1 Procedure for identification of patients There is a process for ensuring the OB/SI
Identification tags for mother and
is established at the facility identification before any clinical
procedure baby / foot print are used for
2 identification of newborns
ME E4.2 Procedure for ensuring timely and Treatment chart are maintained RR Check for treatment chart are
accurate nursing care as per treatment updated and drugs given are
plan is established at the facility marked. Co relate it with drugs and
doses prescribed.
2
There is a process to ensue the SI/RR Verbal orders are rechecked
accuracy of verbal/telephonic before administration
orders
2
ME E4.3 There is established procedure of Patient hand over is given during SI/RR
patient hand over, whenever staff duty the change in the shift
change happens
2
maintained 2
Hand over is given bed side 2 SI/RR
ME E4.4 Nursing records are maintained Nursing notes are maintained RR/SI Check for nursing note register.
adequately 2 Notes are adequately written
ME E4.5 There is procedure for periodic Patient Vitals are monitored RR/SI Check for TPR chart, IO chart, any
monitoring of patients and recorded periodically 2 other vital required is monitored
Critical patients are monitored RR/SI
continually 2
Standard E5 The facility has a procedure to identify high risk and vulnerable patients. 4 4
ME E5.1 The facility identifies vulnerable Vulnerable patients are identified 2 OB/SI Check the measure taken to
patients and ensure their safe care and measures are taken to protect prevent new born theft, sweeping
them from any harm and baby fall
ME E5.2 The facility identifies high risk patients 2 OB/SI
and ensure their care, as per their need
High Risk Pregnancy cases are High risk cases : Eclampsia, Sepsiss,
identified and kept in intensive diabetic, cardiac diseases and
monitoring Intrauterine growth retardation
Standard E6 The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use. 10 10
ME E6.1 The facility ensured that drugs are 2 RR
Check for BHT if drugs are
prescribed in generic name only prescribed under generic name
only
ME E6.2 There is procedure of rational use of Check for that relevant Standard 2 RR
drugs treatment guideline are available
at point of use
Check staff is aware of the drug 2 SI/RR
Check BHT that drugs are 2 RR
Standard E7 The facility has defined procedures for safe drug administration 22 22
ME E7.1 There is process for identifying and High alert drugs available in 2 SI/OB
cautious administration of high alert department are identified
drugs Magsulf (to be kept in fridge) ,
Methergine
Maximum dose of high alert drugs 2 SI/RR Value for maximum doses as per
are defined and communicated age, weight and diagnosis are
available with nursing station and
doctor
There is process to ensure that 2 SI/RR A system of independent double

right doses of high alert drugs are check before administration, Error
only given prone medical abbreviations are
avoided
Page 74
Mark
s
ME E7.2 Medication orders are written legibly Every Medical advice and 2 RR
and adequately procedure is accompanied with

staff
ME E7.3 There is a procedure to check drug Drugs are checked for expiry 2 OB/SI
before administration/ dispensing and other inconsistency before
administration
Check single dose vial are not used 2 OB Check for any open single dose vial
for more than one dose with left over content kept to be
used later on
Check for separate sterile needle is 2 OB
used every time for multiple dose In multi dose vial needle is not left
vial in the septum
ME E7.4 There is a system to ensure right Administration of medicines 2 SI/OB
medicine is given to right patient done after ensuring right
patient, right drugs , right route,
right time
ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ 2 RR/SI
administration Pharmacist /nurse about the
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 16 16
ME E8.1 All the assessments, re-assessment and 2 RR
investigations are recorded and
updated Day to day progress of patient is
recorded in BHT
ME E8.2 All treatment plan prescription/orders Treatment plan, first orders are 2 RR Treatment prescribed in nursing
are recorded in the patient records. written on BHT records
ME E8.3 Care provided to each patient is Maintenance of treatment 2 RR Treatment given is recorded in
recorded in the patient records chart/treatment registers treatment chat
ME E8.4 Procedures performed are written on Any procedure performed written 2 RR Dressing, mobilization etc
patients records on BHT
ME E8.5 Adequate form and formats are 2 RR/OB
Standard Format for bed head Availability of formats for
available at point of use ticket/ Patient case sheet Treatment Charts, TPR Chart ,
available as per state guidelines Intake Output Chat Etc.
ME E8.6 Register/records are maintained as per 2 RR
guidelines
General order book (GOB), report
book, Admission register, lab
register, Admission sheet/ bed
head ticket, discharge slip, referral
slip, referral in/referral out
register, OT register, FP register,
Registers and records are Diet register, Linen register, Drug
maintained as per guidelines indent register
All register/records are identified 2 RR
and numbered
ME E8.7 The facility ensures safe and adequate Safe keeping of patient records 2 OB
storage and retrieval of medical
records
Standard E9 The facility has defined and established procedures for discharge of patient. 20 20
ME E9.1 Discharge is done after assessing Assessment is done before 2 SI/RR
patient readiness discharging patient
Discharge is done by a responsible 2 SI/RR

and qualified doctor
Patient / attendants are consulted 2 PI/SI
before discharge
2 SI/RR
Treating doctor is consulted/
patients
ME E9.2 Case summary and follow-up Discharge summary is provided 2 RR/PI See for discharge summary,
instructions are provided at the referral slip provided.
discharge
2 RR
Discharge summary adequately
condition, treatment given and
follow up
Discharge summary is give to 2 SI/RR
patients going in LAMA/Referral
ME E9.3 Counselling services are provided as Patient is counselled before 2 SI/PI
during discharges wherever required discharge
2 RR/SI
Advice includes the information
about the nearest health centre
for further follow up
Time of discharge is 2 PI/SI
communicated to patient in prior
4 4
ME E11.3 The facility has disaster management Staff is aware of disaster plan 2 SI/RR
plan in place
Role and responsibilities of staff in 2 SI/RR
disaster is defined
4 4
ME E12.1 There are established procedures for Container is labelled properly 2 OB
Pre-testing Activities after the sample collection
ME E12.3 There are established procedures for Nursing station is provided with 2 SI/RR
Post-testing Activities the critical value of different tests
12 12
Page 75
Mark
s
ME E13.9 There is established procedure for Consent is taken before 2 RR

transfusion of blood transfusion
Patient's identification is verified 2 SI/OB
before transfusion
blood is kept on optimum 2 RR
temperature before transfusion
Blood transfusion is monitored and 2 SI/RR
Blood transfusion note is written in 2 RR
patient recorded
ME E13.10 There is a established procedure for 2 RR
monitoring and reporting Transfusion Any major or minor transfusion
complication reaction is recorded and reported
to responsible person
Standard E14 2 2
The facility has established procedures for Anaesthetic Services
ME E14.1 The facility has established procedures 2 SI/RR
for Pre-anaesthetic Check up and
maintenance of records Pre anaesthesia check up is
conducted for elective / Planned
surgeries
8 8
ME E16.1 Death of admitted patient is adequately Facility has a standard 2 SI
communicate death to relatives
Death note is written on patient 2 RR

record
ME E16.2 The facility has standard procedures for 2 SI/RR
handling the death in the hospital Death summary is given to patient
attendant quoting the immediate
cause and underlying cause if Maintenance of records as per
possible guideline
2 RR
Death note including efforts done
for resuscitation is noted in patient
record Maternal and neonatal death
Maternal Health
14 14
Standard E17 The facility has established procedures for Antenatal care as per guidelines
ME E17.1 There is an established procedure for Facility provides and updates 2 RR/SI
Registration and follow up of pregnant “Mother and Child Protection
women. Card”.
ME E17.4 There is an established procedure for Management of PIH/Eclampsia 2 RR/SI
identification of High risk pregnancy
and appropriate treatment/referral as
per scope of services.
Management of sepsis 2 RR/SI

Management of diabetic pregnant 2 RR/SI
mother
Management of cardiac cases 2 RR/SI
Management of IUGR 2 RR/SI
ME E17.5 There is an established procedure for Management of of severe anaemia 2 RR/SI
identification and management of
moderate and severe anaemia Blood Transfusion services
available for anaemic patients
20 20
Standard E19 The facility has established procedures for postnatal care as per guidelines
ME E19.1 Facility staff adheres to protocol for
assessment of condition of mother and
baby and providing adequate postpartum Maintains hand hygiene, keeps the
care baby wrapped (maintains
temperature), Checks weight,
temperature, respiration, heart
Post Partum Care of Newborn 2 SI/RR rate, colour of skin and cord stump
Checks and discusses with the

mother on breastfeeding pattern,
emphasising exclusive and on
demand feeding. Demonstrates
Initiation of Breastfeeding with in 1 the proper positioning and
Hour 2 PI attachment of the baby
Check uterine contraction,

bleeding as per treatment plan,
check for TPR and output chart,
Breast examination and milk
Post partum care of mother 2 PI initiation and perineal washes
ME E19.2 Facility staff adheres to protocol for Staff counsels mother on vital 2 PI/SI Counsels on danger signs to
counselling on danger signs, post-partum issues mother at time of discharge;
family planning and exclusive breast Counsels on post partum family
feeding planning to mother at discharge;
Counsels on exclusive breast
feeding to mother at discharge
ME E19.3 Facility staff adheres to protocol for Facilitates specialist care in 2 SI/RR Facilitates specialist care in
ensuring care of newborns with small size newborn <1800 gm newborn <1800 gm (seen by
at birth paediatrician)
Facilitates assisted feeding 2 SI/RR/PI
whenever required
Facilitates thermal management 2 SI/RR/PI
including kangaroo mother care
ME E19.4 The facility has established procedures for
stabilization/treatment/referral of post
natal complications There is established criteria for
shifting newborn to SNCU 2 SI/RR
ME E19.5 The facility ensure adequate stay of 2
mother and new born in a safe
environoment as per standard protocols 48 Hour Stay of mothers and new
born after delivery
Page 76
Mark
s
ME E19.6 There is established procedure for

discharge and follow up of mother and Check patient is explained about
newborn. follow up visits, advice and
counselling is done before
discharge 2 RR/PI
4 4
ME E20.1 The facility provides immunization Zero dose vaccines are given 2 RR Check for records BCG, Hepatitis
services as per guidelines Band OPV 0 given to New born
ME E20.3 Management of Low birth weight Care of Low Birth Weight and 2 SI/RR Premature and LBW babies are
newborns is done as per guidelines Premature babies identified: Weight less than 2500 g
for low birth weight babies,
gestation of less than 37 weeks
for prematurely, Kangaroo Mother
Care (KMC) is implemented for
Low Birth Weight/Prematurely and
assisted feeding arranged, if
Area of Concern - F Infection Control required 98 98
Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection 10 10
The facility measures hospital
associated infection rates Patients are observed for any sign
and symptoms of HAI like fever,
There is procedure to report cases purulent discharge from surgical
ME F1.3 of Hospital acquired infection 2 SI/RR site .
Check-up and immunization of staff immunization of the staff
ME F1.4 2 SI/RR Hepatitis B, Tetanus Toxid etc
staff 2 SI/RR
The facility has established procedures Hand washing and infection
for regular monitoring of infection control audits done at periodic
control practices Regular monitoring of infection intervals
The facility has defined and established Check for Doctors are aware of
ME F1.6 antibiotic policy Hospital Antibiotic Policy 2 SI/RR
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 18 18
Hand washing facilities are provided at Availability of hand washing Check for availability of wash basin
ME F2.1 point of use Facility at Point of Use 2 OB near the point of use
2 OB/SI water supply is regular
Availability of antiseptic soap with
soap dish/ liquid antiseptic with Check for availability/ Ask staff if
dispenser. the supply is adequate and
2 OB/SI uninterrupted
Availability of Alcohol based Hand Check for availability/ Ask staff for
rub 2 OB/SI regular supply.
Instruction at Point of Use Prominently displayed above the
hand washing facility , preferably
2 OB in Local language
The facility staff is trained in hand Adherence to 6 steps of Hand
washing practices and they adhere to washing
standard hand washing practices
Staff aware of when to hand wash
2 SI
The facility ensures standard practices Availability of Antiseptic Solutions
and materials for antisepsis
ME F2.3 2 OB
with antisepsis like before giving IM/IV injection,
drawing blood, putting Intravenous
2 and urinary catheter
Standard F3 The facility ensures standard practices and materials for Personal protection 8 8
The facility ensures adequate personal
protection Equipment as per
requirements Clean gloves are available at point
ME F3.1 of use 2 OB/SI
The facility staff adheres to standard
personal protection practices
No reuse of disposable gloves,
wearing and removing the gloves 2 SI
Standard F4 The facility has standard procedures for processing of equipment and instruments 18 18
The facility ensures standard practices Decontamination of operating &
and materials for decontamination and Procedure surfaces Ask stff about how they
cleaning of instruments and decontaminate the procedure
procedures areas surface like Examination table ,
Patients Beds Stretcher/Trolleys
etc.
Ask staff how they decontaminate

the instruments like Stethoscope,
Dressing Instruments, Examination
Instruments, Blood Pressure Cuff
etc
(Soaking in 0.5% Chlorine Solution,
Proper Decontamination of Wiping with 0.5% Chlorine Solution
instruments after use 2 SI/OB or 70% Alcohol as applicable
Contact time for decontamination 10 minutes
is adequate 2 SI/OB
decontamination Cleaning is done with detergent
and running water after
2 SI/OB decontamination
Proper handling of Soiled and No sorting ,Rinsing or sluicing at
infected linen 2 SI/OB Point of use/ Patient care area
solution 2 SI/OB
Page 77
Mark
s
The facility ensures standard practices Equipment and instruments are Autoclaving/HLD/Chemical
and materials for disinfection and sterilized after each use as per Sterilization
equipment
ME F4.2 2 OB/SI
High level Disinfection of Ask staff about method and time
instruments/equipments is done required for boiling
as per protocol
2 OB/SI
used 2 OB/SI
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 16 16
The facility ensures availability of Availability of disinfectant as per
standard materials for cleaning and requirement
disinfection of patient care areas Chlorine solution, Gluteraldehye,
The facility ensures standard practices Staff is trained for spill
are followed for the cleaning and management
ME F5.3 2 SI/RR
Cleaning of patient care area with
detergent solution 2 SI/RR
procedure
2 SI/RR
Standard practice of mopping and Unidirectional mopping from
scrubbing are followed 2 OB/SI inside out
are not used in patient care areas Any cleaning equipment leading to
dispersion of dust particles in air
2 OB/SI should be avoided
The facility ensures segregation Isolation and barrier nursing
infectious patients procedure are followed for septic
ME F5.4 cases 2 OB/SI
28 28
Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
The facility Ensures segregation of Bio Availability of colour coded bins at Adequate number. Covered. Foot
Medical Waste as per guidelines and point of waste generation operated.
'on-site' management of waste is
carried out as per guidelines
ME F6.1 2 OB
Availability of colour coded non
chlorinated plastic bags 2 OB
Human Anatomical waste, Items

fluids,dressings, plaster casts,
cotton swabs and bags containing
residual or discarded blood and
Segregation of Anatomical and blood components.

catheters, urine bags, syringes
Segregation of infected plastic syringes) and vaccutainers with
Biomedical waste
2 OB
and general waste 2
The facility ensures management of Availability of functional needle OB See if it has been used or just lying
ME F6.2 sharps as per guidelines cutters 2 idle.
Seggregation of sharps waste 2 OB Should be available nears the point
including Metals in white of generation.Needles, syringes
(translucent) Puncture proof, with fixed needles, needles from
Leak proof, tamper proof needle tip cutter or burner,
containers scalpels, blades, or any other
contaminated sharp object that
may cause puncture and cuts. This
includes both used, discarded and
contaminated metal sharps
Availability of post exposure 2 SI/OB Ask if available. Where it is stored

prophylaxis and who is in charge of that.
Staff knows what to do in 2 SI Staff knows what to do in case of
condition of needle stick injury shape injury. Whom to report. See
if any reporting has been done
Contaminated and broken Glass 2 Vials, slides and other broken
are disposed in puncture proof and infected glass
leak proof box/ container with
Blue colour marking
OB
The facility ensures transportation and Check bins are not overfilled
disposal of waste as per guidelines
ME F6.3 2 SI/OB
container/trolley
2
management 2 SI/RR
Standard G1 Facility has established organizational framework for quality improvement 2 2

ME G1.1 Facility has a quality team in place There is a designated 2
departmental nodal person for
coordinating Quality Assurance
activities
SI/RR
Standard G2 The facility has established system for patient and employee satisfaction 2 2
Page 78
Mark
s
ME G2.1 Patient satisfaction surveys are Client/Patient satisfaction survey 2 RR

conducted at periodic intervals done on monthly basis
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 4 4
ME G3.1 The facility has established internal 2 SI/RR
quality assurance programme in key There is system daily round by
departments matron/hospital manager/ hospital
superintendent/ Hospital
Manager/ Matron in charge for
ME G3.3 The facility has established system for Departmental checklist are used 2 SI/RR Staff is designated for filling and
use of check lists in different for monitoring and quality monitoring of these checklists
departments and services assurance
Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services. 44 44
ME G4.1 Departmental standard operating Standard operating procedure for 2 RR
procedures are available department has been prepared
and approved
ME G4.2 Standard Operating Procedures Department has documented 2 RR Department has
adequately describes process and procedure for receiving and initial documented
procedures assessment of the patient in procedure for
Maternity ward ensuring patients
rights including
consent, prviacy,
confidentaility &
entitlement
Department has documented 2 RR Department has

procedure for admission, shifting documented
and referral of pregnant mother proedure for safety &
risk management

procedure for shifting the mother documented
to labour room procedure for support
services & facility
mangement.

procedure for requisition of documented
diagnosis and receiving of the procedure for general
reports patient care processes
2 RR Department has
documented
procedure for specific
Department has documented processes to the
procedure for preparation of the department
patient for surgical procedure
2 RR Department has
documented
procedure for
infection control & bio
Department has documented medical waste
procedure for transfusion of blood mangement
in maternity ward
2 RR Department has
documented
Department has documented procedure for quality
procedure for maintenance of management &
rights and dignity of pregnant improvement
women
2 RR Depatment has
documented
procedure for data
Department has documented collection, analysis &
procedure for record Maintenance use for improvement
including taking consent
2 RR
Department has documented
procedure for discharge of the
patient from maternity ward
2 RR
procedure for post natal inpatient
care of mother
2 RR
procedure for post natal inpatient
care of new born
2 RR
procedure for payment/ incentives
of beneficiary
2 RR
procedure for counselling of the
patient at the time of discharge
2 RR
Maternity ward has documented
procedure for environmental
cleaning and processing of the
equipment
2 RR
procedure for arrangement of
intervention for maternity ward
2 RR
procedure for sorting, cleaning and
distribution of clean linen to
patient
2 RR
procedure for providing free diet
to the patient as per their
requirement
procedure for end of life care
ME G4.3 Staff is trained and aware of the Check staff is a aware of relevant 2 SI/RR
procedures written in SOPs part of SOPs
Page 79
Mark
s
ME G4.4 Work instructions are displayed at 2 OB

Patient safety, Identification of
Point of use Work instruction/clinical protocols danger sign, postnatal care and
are displayed counselling, new born care etc
6 6
ME G5.1 The facility maps its critical processes Process mapping of critical 2 SI/RR
processes done
ME G5.2 The facility identifies non value adding 2 SI/RR
activities / waste / redundant activities
Non value adding activities are
identified
ME G5.3 The facility takes corrective action to Processes are rearranged as per 2 SI/RR
improve the processes requirement
Standard G6 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 16 16
ME G6.1 The facility conducts periodic internal Internal assessment is done at 2 RR/SI
assessment periodic interval
ME G6.2 The facility conducts the periodic There is procedure to conduct 2 RR/SI
prescription/ medical/death audits Medical Audit
Prescription audit
maternal Death audit
New born Death audit
ME G6.3 The facility ensures non compliances Non Compliance are enumerated 2 RR/SI
are enumerated and recorded and recorded
adequately
ME G6.4 Action plan is made on the gaps found 2 RR/SI
in the assessment / audit process
Action plan prepared
ME G6.5 Planned actions are implemenated 2 RR/SI PDCA
through Quality improvement cycle
(PDCA) Check correction & corrective
actions are taken
6 6
ME G7.4 2 SI/RR

objectivities have been framed
addressing key quality issues in
each department and cores
services. Check if these objectives
are Specific, Measurable,
Facility has de defined quality objectives to Check if SMART Quality Objectives Attainable, Relevant and Time
achieve mission and quality policy have framed Bound.
ME G7.5 2 SI/RR
Statement, Core Values and
Mission, Values, Quality policy and Check of staff is aware of Mission , Quality Policy is displayed
objectives are effectively communicated to Values, Quality Policy and prominently in local language at
staff and users of services objectives Key Points
2 SI/RR
Review the records that action

plan on quality objectives being
reviewed at least onnce in month
ME G7.7 by departmnetal incharges and
during the qulaity team meeting.
Facility periodically reviews the progress of Check time bound action plan is The progress on quality objectives
strategic plan towards mission, policy and being reviewed at regular time have been recorded in Action Plan
Standard G8 The facility seeks continually improvement by practicing Quality method and tools. 6 6
ME G8.1 The facility uses method for quality Basic quality improvement method 2 SI/OB PDCA & 5S
improvement in services
method
ME G8.2 The facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are
improvement in services used in each department
ME G10.6 2 SI/RR
Check periodic assessment of comprehensive risk asesement of
Periodic assessment for Medication and medication and patient care safety all clincial processes should be
Patient care safety risks is done as per risk is done using defined checklist done using pre define critera at
defined criteria. periodically least once in three month.
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 8 8
ME H1.1 Facility measures productivity Bed Occupancy Rate for normal
Indicators on monthly basis delivery ward 2 RR
Bed Occupancy Rate for C section
ward 2
Proproation of Severe anaemia
cases treated with blood
transfusion
2 RR
Standard operating procedure for
department has been prepared
and approved 2 RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 8 8
ME H2.1 Facility measures efficiency Indicators Referral Rate
on monthly basis 2 RR
Bed Turnover rate 2 RR
Discharge rate 2 RR
No. of drugs stock out in the ward 2 RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 14 14
ME H3.1 Facility measures Clinical Care & Safety Average length of stay for normal
Indicators on monthly basis delivery 2 RR
Average length of stay for C
section 2
Page 80
Mark
s
Newborns Breastfed within 1 hr of

Birth 2 RR
Maternal Death per 1000
deliveries 2 RR
No of adverse events per thousand
patients 2 RR
Proportion of mother given
postnatal counselling 2 RR
Time taken for initial assessment 2 RR

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 6 6
ME H4.1 Facility measures Service Quality LAMA Rate
Patient Satisfaction Score 2 RR
Proportion of mothers given drop
back facility 2 RR
Obtained Maximum Percent

A 28 28 100%
B 80 80 100%
C 144 144 100%
D 104 104 100%
E 208 208 100%
F 98 98 100%
G 88 88 100%
H 36 36 100%
Total 786 786 100%
0
1
2
Page 81
Checklist No. 5 Paediatrics Ward Version- NHSRC/3.0

Checklist for Paediatrics Ward 5
Assessment Summary

Action plan Submission
Type of Assessment (Internal/External)
Date
Paediatrics Ward Score Card

Area of Concern wise Score Paediatrics Ward Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for Paediatrics Ward

Reference No. Measurable Element Checkpoint Complian Assessmen Means of verification Remarks
ce t Method
Full/Parti
Area of Concern - Aal/No
Service Provision 32 32
6 6
Standard A1 The facility provides Curative Services
ME A1.4 The facility provides Paediatric Services Availability of dedicated paediatric 2 SI/OB
ward
Availability of isolation room 2 SI/OB Particularly for chicken pox, measles
etc.)
Page 82
ce t Method
Full/Parti
ME A1.14 Services are available for the time Availability of nursing care services 2
al/No SI/RR
14 14
Standard A2 The facility provides RMNCHA Services
ME A2.4 The facility provides Child health Indoor Management of Severe Acute 2 SI/RR
Services Malnutrition
Indoor Management of Severe 2 SI/RR
Diarrhoea with severe dehydration
Indoor Management of Meningitis 2 SI/RR
Indoor Management of Acute 2 SI/RR

respiratory infections
Seizers and convulsions 2 SI/RR
Shock 2 SI/RR
Accidental poisoning 2 SI/RR
12 12
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme
ME A4.1 The facility provides services under Indoor management of malaria 2 SI/RR check the records for management of
National Vector Borne Disease Control cases in last one year
Indoor management of Chikungunia 2 SI/RR check the records for management of

cases in last one year
Indoor management of JE 2 SI/RR check the records for management of
cases in last one year
ME A4.2 The facility provides services under Management of paediateric 2 SI/RR
Revised National TB Control Tuberculosis
ME A4.10 The facility provide services under 2 SI/RR
National health Programme for Referral of child born of High Risk
deafness pregnancy showing features
suggestive of hearing impairment
ME A 4.12 The facility provided services as per Availability of services under RBSK 2 SI/RR
Rashtriya bal swasthya Karykram
14 14
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 The facility has uniform and user- 2 OB (Numbering, main department and
friendly signage system Availability departmental signage's internal sectional signage
Visiting hours and visitor policy are 2 OB
displayed
ME B1.2 The facility displays the services and 2 OB
entitlements available in its Contact details of referral transport /
departments ambulance displayed
Entitlement under RBSK are displayed 2 OB
ME B1.5 Patients & visitors are sensitised and 2 OB Breast feeding, immunization
educated through appropriate IEC / schedule and Zn, ORS, nutrition and
hand washing etc.
BCC approaches IEC Material is displayed
ME B1.6 Information is available in local Signage's and information are 2 OB
language and easy to understand available in local language
ME B1.8 The facility ensures access to clinical Discharge summery is given to the 2 RR/OB
records of patients to entitled patient
personnel
6 6
Standard B2
Services are delivered in a manner that is sensitive to gender, religious, and cultural needs, and there are no barrier on account of
ME B2.1 Services are provided in manner that Cots in paediatric ward are large 2 OB
are sensitive to gender enough for stay of mother with child
ME B2.3 2 OB
Access to facility is provided without
any physical barrier & and friendly to Availability of Wheel chair or stretcher
people with disabilities for easy Access to the ward
2 OB
Availability of ramps with railing
6 6
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Adequate visual privacy is provided at 2 OB
every point of care Availability of screen
ME B3.2 2 SI/OB
Confidentiality of patients records and

clinical information is maintained Patient Records are kept at secure
place beyond access to general
staff/visitors
ME B3.3 The facility ensures the behaviours of Behaviour of staff is empathetic and 2 OB/PI
staff is dignified and respectful, while courteous
6 6
Standard B4
The facility has defined and established procedures for informing patients about the medical condition, and involving them in
taking informed consent before General Consent is taken before
treatment and procedures admission
ME B4.4 Information about the treatment is 2 PI
Patient is informed about her clinical
shared with patients or attendants, condition and treatment been
regularly provided
display of process for grievance re
addressal and whom to contact is
displayed
24 24
Standard B5
The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost of hospital
services.
ME B5.1 2 PI/SI
The facility provides cashless services
to pregnant women, mothers and
neonates as per prevalent government
schemes Availability of free diagnostics
Availablity of Free drop back 2 PI/SI
Availablity of Free diet to patient 2 PI/SI
Availablity of Free Diet to mother 2 PI/SI
Availablity of Free patient transport 2 PI/SI
Page 83
ce t Method
Full/Parti
Availabliity of Free Blood 2
al/No PI/SI
Availablity of Free drugs 2 PI/SI
Availablity of free stay in paediatric 2 PI/SI
ward
ME B5.2 The facility ensures that drugs Check that patient party has not spent 2 PI/SI
prescribed are available at Pharmacy on purchasing drugs or consumbles
from outside.
and wards
ME B5.3 It is ensured that facilities for the Check that patient party has not spent 2 PI/SI/RR
prescribed investigations are available on diagnostics from outside.
at the facility
ME B5.4 Treatment to BPL patient is free 2 PI/RR
The facility provide free of cost
treatment to Below poverty line
patients without administrative hassles
ME B5.5 2 PI/SI/RR
entitlements and reimbursement to the
If any other expenditure occurred it is
patients reimbursed from hospital
ME B 6.7 2 RR/SI
medical advice or refuse to receive specific Declaration is taken from the LAMA
c treatment patient
42 42
ME C1.1 Departments have adequate space as Adequate space in wards with no 2 OB Distance between centres of two
per patient or work load cluttering of beds beds – 2.25 meter
ME C1.2 Patient amenities are provide as per Functional toilets with running water
2 OB
patient load and flush are available as per strength
2 OB
promotion
ME C1.3 Departments have layout and Availability of Dedicated nursing 2 OB
demarcated areas as per functions station
Availability of play room 2 OB
ME C1.4 The facility has adequate circulation 2 OB
area and open spaces according to
need and local law
Space between two beds should be at
least 4 ft and clearance between head
There is sufficient space between two end of bed and wall should be at least
bed to provide bed side nursing care 1 ft and between side of bed and wall
and movement should be 2 ft
2 OB
Corridors are wide enough for patient,
visitor and trolley/ equipment
movement Corridor should be 3 meters wide
ME C1.6 Service counters are available as per 2 OB
patient load Availability of IPD beds as per load
function/processes (Structure
commensurate with the function of the Location of nursing station and
hospital) patients beds enables easy and direct
observation of patients
8 8
ME C2.1 The facility ensures the seismic safety Non structural components are 2 OB Check for fixtures and furniture like
of the infrastructure properly secured cupboards, cabinets, and heavy
equipments , hanging objects are
ME C2.3 The facility ensures safety of electrical Paediatric building does not have
2 OB
establishment temporary connections and loosely
hanging wires
ME C2.4 Physical condition of buildings are safe Floors of the paediatric wards are non 2 OB
for providing patient care slippery and even
meshwork
10 10
ME C3.1 The facility has plan for prevention of Paediatric Ward has sufficient fire exit 2 OB/SI
fire to permit safe escape to its occupant
at time of fire
Check the fire exits are clearly visible 2 OB
and routes to reach exit are clearly
marked.
ME C3.2 The facility has adequate fire fighting Paediatric ward has installed fire 2 OB
Equipment Extinguisher that is Class A , Class B, C
type or ABC type

extinguishers are displayed on each
extinguisher as well as due date for
Page 84
ce t Method
Full/Parti
ME C3.3 The facility has a system of periodic Check for staff competencies for 2
al/No SI/RR
training of staff and conducts mock operating fire extinguisher and what
drills regularly for fire and other to do in case of fire
disaster situation
10 10
ME C4.1 The facility has adequate specialist Availability of Paediatrician on call 2
doctors as per service provision OB/RR
ME C4.2 The facility has adequate general duty Availability of general duty doctor 2
work load
OB/RR
ME C4.3 The facility has adequate nursing staff Availability of nursing staff 2
as per service provision and work load
OB/RR As per patient load
ME C4.5 The facility has adequate support / Availability of ward attendant/ Ward 2
general staff boy OB/RR availability of ayahs/ Sanitary worker
Availability Security staff 2 OB/RR
18 18
Standard C5 The facility provides drugs and consumables required for assured services.
ME C5.1 The departments have availability of Availability of emergency drugs 2 OB/RR Adrenaline
adequate drugs at point of use Diazepam,
Phenobarbitone
Pheniramine (Cetirizine)
Hydrocortisone
Calcium gluconate
Sodium bicarbonate
Dopamine, methasone
Availability of IV fluid 2 OB/RR Ringer’s lactate
· Normal saline
· N/5 in 5% Dextrose
Availability of antibiotics 2 OB/RR Dextrose (10%)
(Ampicillin, Gentamicin,
,Cefotaxime,Ceftriaxone
Other Injectables 2 OB/RR Quinine, Mannitol, Potassium
chloride(KCL), Vitamin K, Nebuliser
solution of salbutamol, Artesunate
Oral Drugs 1 2 OB/RR ORS

Cotrimoxazole paediatric tablets &
Syrup
Amoxicillin tablets Doxycycline &
Syrup
Zinc tablets
Chloroquine tablets
Paracetamol, Metrindazol, Albendazol
Oral Drugs 2 2 OB/RR Vitamin A, IFA tablets, Salbutamol,

Prednisolone tablets, Frusemide
tablets
ME C5.2 The departments have adequate Consumables for Paediatric ward 2 OB/RR Plastic / disposable syringes
consumables at point of use · IV cannulas (22G and 24G)
· Scalp vein set No. 22 and 24
· IV infusion sets (adult and
paediatric), simple rubber catheter
Resuscitation consumables 2 OB/RR Nasogastric tube (8,10,12FG)

Suction catheter (6,8,10 FG)
Uncuffed tracheal tube (all sizes)
Oropharyngeal airway
ME C5.3 Emergency drug trays are maintained Emergency Drug Tray is maintained 2 OB/RR
at every point of care, where ever it
may be needed
22 22
ME C6.1 Availability of equipment & Availability of functional Equipment 2 Weighing machine( infant & adult)
instruments for examination & &Instruments for examination & · Stadiometer for height
monitoring of patients Monitoring · Infantometer for length
BP apparatus with paediatric cuff,
Thermometer.
OB
ME C6.2 Availability of equipment & Availability of dressing tray 2
instruments for treatment procedures,
OB
ME C6.3 Availability of equipment & Availability of Point of care 2 Glucometer
instruments for diagnostic procedures diagnostic instruments
OB
ME C6.4 Availability of equipment and Availability of functional 2 Face masks (3 type; Neonate, Infant
instruments for resuscitation of Instruments for Resuscitation. and paediatric type)
patients and for providing intensive and Self-inflating ventilation bag (all sizes)
critical care to patients
Laryngoscope
Nebulizer
Suction machines Oxygen supply, ET
tube (different sizes)
OB
ME C6.5 Availability of Equipment for Storage Availability of equipment for 2 Refrigerator, Crash cart/Drug trolley,
storage for drugs OB instrument trolley, dressing trolley
ME C6.6 Availability of functional equipment Availability of equipments for 2 Buckets for mopping, mops, duster,
and instruments for support services cleaning waste trolley, Deck brush
OB
Availability of equipment for 2 Boiler
sterilization and disinfection OB
ME C6.7 Departments have patient furniture Availability of patient beds 2
and fixtures as per load and service
provision
OB
Availability of attachment/ accessories 2 Hospital graded mattress, Bed side
with patient bed OB locker , IVstand, Bed pan, bed rail
Page 85
ce t Method
Full/Parti
Availability of Fixtures 2
al/No Electrical fixture for equipments like
OB suction, X ray view box
2 cupboard, nursing counter, table for
Availability of furniture OB preparation of medicines, chair.
ME C7.1 RR/SI
prepared for assessing competence of
2 doctors, nurses and paramedical staff
based on job description defined for
Check parameters for assessing skills each cadre of staff. Dakshta checklist
Criteria for Competence assessment are and proficiency of clinical staff has issued by MoHFW can be used for this
defined for clinical and Para clinical staff been defined purpose.
ME C7.2 RR/SI
2 assessment including filled checklist,
Competence assessment of Clinical and scoring and grading . Verify with staff
Para clinical staff is done on predefined Check for competence assessment is for actual competence assessment
criteria at least once in a year done at least once in a year done
ME C7.9 Facility based immunization 2 SI/RR
plan
Infant and young Child Feeding ( IYCF) 2 SI/RR
practices
IMNCI Training 2 SI/RR
Biomedical waste management 2 SI/RR
Infection control and hand hygiene 2 SI/RR
Patient safety 2 SI/RR
ME C7.10 2 SI/RR
that staff is working according to the
There is established procedure for training imparted. Also staff is
utilization of skills gained thought trainings Nursing staff is skilled for maintaining provided on job training wherever
by on -job supportive supervision clinical records there is still gaps
2 OBI/RR
training imparted. Also staff is
provided on job training wherever
Counsellor is skilled IYCF counselling there is still gaps
6 6
maintenance
2 SI/RR
There is system of timely corrective
break down maintenance of the
equipments
measuring Equipment BP apparatus, thermometers etc are
calibrated
24 24
forecasting and indenting drugs and There is established system of timely Requisition are timely placed
consumables indenting of consumables and drugs
at nursing station
Drugs are intended in Paediatric 2 OB/RR/SI
dosages only
ME D2.3 The facility ensures proper storage of Drugs are stored in
2 OB
labeled
Empty and filled cylinders are labeled 2 OB
2
drugs are maintained for drug stored
at department RR
for inventory management techniques maintaining buffer stock in paediatric
ward

consumables
replenishing the drugs in patient care areas drug tray /crash cart

and other drugs, requiring controlled Temperature of refrigerators are kept maintained and updated periodically
temperature as per storage requirement and
records are maintained
24 24
station
Adequate illumination in patient care 2 OB
areas
ME D3.2 The facility has provision of restriction 2 OB/PI
of visitors in patient areas
Visiting hour are fixed and practiced
There is no overcrowding in the wards 2 OB
during visitors hours
One female/ family members allowed 2 OB/SI
to stay with the child
ME D3.3 The facility ensures safe and Temperature control and ventilation in 2 PI/OB Room kept between 25° - 30° C (to the
comfortable environment for patients patient care area extent possible) Fans/ Air
and service providers conditioning/Heating/Exhaust/Ventilat
ors as per environment condition and
requirement
Safe measures used for re-warming 2 SI/OB Check availability of Blankets to cover
children the children
Page 86
ce t Method
Full/Parti
Temperature control and ventilation in al/No
2 SI/OB Fans/ Air
nursing station/duty room conditioning/Heating/Exhaust/Ventilat
ors as per environment condition and
requirement
Side railings has been provided to 2 OB

prevent fall of patient
ME D3.4 The facility has security system in place Identification band for children below 2 OB
at patient care areas 5 years
Security arrangement in Paediatric . 2 OB/SI
Ward
22 22
plastered & painted
hygienic patient care and circulation areas are All area are clean with no
Clean dirt,grease,littering and cobwebs
Surface of furniture and fixtures are 2 OB
clean
Toilets are clean with functional flush 2 OB
and running water
ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , Cracks, 2 OB
maintained chipping of plaster

fixtures are intact
Patients beds are intact and painted 2 OB
ME D4.5 The facility has policy of removal of No condemned/Junk material in the 2 OB
condemned junk material ward
4 4
storage and supply for portable water potable water

load Availability of power back up in
patient care areas
8 8
ME D6.1 The facility has provision of nutritional Nutritional assessment of patient done 2
assessment of the patients as required and directed by doctor
RR/SI
ME D6.2 The facility provides diets according to 2
nutritional requirements of the
patients Check for the adequacy and frequency Check that all items fixed in diet menu
of diet as per nutritional requirement OB/RR is provided to the patient
2 Ask patient/staff weather they are
Check for the Quality of diet provided PI/SI satisfied with the Quality of food
ME D6.3 Hospital has standard procedures for 2
distribution of diets, as per requirement of There is procedure of requisition of
patients different type of diet from ward to
kitchen RR/SI
8 8
occupied bed
2 OB/RR
Availability of Blankets, draw sheet,
pillow with pillow cover and
machintosh
handling , collection, transportation and There is system to check the
washing of linen cleanliness and Quantity of the linen
received from laundry
8 8
Standard D11
procedures.
ME D11.2 The facility has a established procedure There is procedure to ensure that staff 2 RR/SI Check for system for recording time of
for duty roster and deputation to is available on duty as per duty roster reporting and relieving (Attendance
different departments register/ Biometrics etc)

department
ME D11.3 The facility ensures the adherence to Doctor, nursing staff and support staff 2 OB
dress code as mandated by its adhere to their respective dress code
administration / the health department
2 2
Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
(cleaning/
Dietary/Laundry/Security/Maintenanc
There is procedure to monitor the e) provided are done by designated
There is established system for contract quality and adequacy of outsourced in-house staff
management for out sourced services services on regular basis
14 14
Page 87
ce t Method
Full/Parti
ME E1.1 The facility has established procedure Unique identification number is 2
al/No RR
for registration of patients given to each patient during process of
registration
Patient demographic details are 2 RR Check for that patient demographics

recorded in admission records like Name, age, Sex, Chief complaint,
etc.
ME E1.3 There is established procedure for There is established criteria for 2 SI/RR Age Criteria & clinical diagnosis, all
admission of patients admission emergency and serious cases
There is no delay in admission of 2 SI/RR/OB

patient
Admission is done by written order of 2 SI/RR/OB
a qualified doctor
patient record
managing patients, in case beds are not
16 16
Standard E2 Facility has defined and established procedures for clinical assessment and reassessment of the patients.
ME E2.1 There is established procedure for 2
initial assessment of patients Initial assessment of all admitted
patient done as per standard
protocols
RR/SI
Patient History is taken and recorded 2 RR
Physical Examination is done and 2 RR
recorded wherever required
Provisional Diagnosis is recorded 2 RR
2
RR/SI
ME E2.2 There is established procedure for There is fixed schedule for assessment 2
follow-up/ reassessment of Patients of stable patients RR/OB
2
18 18
ME E3.1 The facility has established procedure Facility has established procedure 2
for continuity of care during for handing over of patients during
interdepartmental transfer departmental transfer
SI/RR
other specialist with in the hospital
RR/SI
ME E3.2 The facility provides appropriate referral 2 Check for referral cards filled from
linkages to the patients/Services for lower facilities
transfer to other/higher facilities to assure
the continuity of care.
Advance communication is done with 2
higher centre RR/SI
Referral vehicle is being arranged 2 SI/RR
Referral in or referral out register is 2
maintained RR
SI/RR
linkages to lower facilities
There is a system of follow up of 2 RR
referred patients
ME E3.3 A person is identified for care during all Duty Doctor and nurse is assigned for 2 RR/SI
steps of care each patients
18 18
ME E4.1 Procedure for identification of patients There is a process for ensuring the 2 OB/SI
procedure Identification tags are used for
children less than 5 yrs
ME E4.2 Procedure for ensuring timely and accurate Treatment chart are maintained 2 RR Check for treatment chart are
nursing care as per treatment plan is updated and drugs given are marked.
established at the facility Co relate it with drugs and doses
prescribed.
There is a process to ensue the 2 SI/RR Verbal orders are rechecked before
accuracy of verbal/telephonic administration
orders
ME E4.3 There is established procedure of Patient hand over is given during the 2 SI/RR
patient hand over, whenever staff duty change in the shift
change happens
Nursing Handover register is 2 RR
maintained
ME E4.4 Nursing records are maintained Nursing notes are maintained 2 RR/SI Check for nursing note register. Notes
adequately are adequately written
ME E4.5 There is procedure for periodic Patient Vitals are monitored and 2 RR/SI Check for TPR chart, IO chart, weight
monitoring of patients recorded periodically records any other vital required is
monitored
Critical patients are monitored 2 RR/SI
continually
4 4
ME E5.1 The facility identifies vulnerable patients Vulnerable patients are identified and 2 OB/SI Check the measure taken to prevent
and ensure their safe care measures are taken to protect them new born theft, sweeping and baby
from any harm fall
ME E5.2 The facility identifies high risk patients and High risk patients are identified and 2 OB/SI
ensure their care, as per their need treatment given on priority
10 10
Standard E6
rational use.
ME E6.1 The facility ensured that drugs are Check for BHT if drugs are prescribed 2 RR
prescribed in generic name only under generic name only
Page 88
ce t Method
Full/Parti
ME E6.2 There is procedure of rational use of drugs Check for that relevant Standard 2
al/No RR
treatment guideline are available at
point of use
Check BHT that drugs are prescribed 2 RR
as per STG
26 26
ME E7.1 There is process for identifying and High alert drugs available in 2 SI/OB Electrolytes like Potassium chloride,
cautious administration of high alert department are identified Opioids, Neuro muscular blocking
drugs agent, Anti thrombolytic agent,
insulin, warfarin, Heparin, Adrenergic
agonist etc.
Maximum dose of high alert drugs are 2 SI/RR Value for maximum doses as per age,
defined and communicated weight and diagnosis are available
with nursing station and doctor
There is process to ensure that right 2 SI/RR A system of independent double
doses of high alert drugs are only check before administration, Error
given prone medical abbreviations are
avoided
comprehendible by the clinical staff
ME E7.3 There is a procedure to check drug Drugs are checked for expiry and 2 OB/SI
before administration/ dispensing other inconsistency before
administration
Check single dose vial are not used for 2 OB Check for any open single dose vial
more than one dose with left over content intended to be
used later on
used every time for multiple dose vial In multi dose vial needle is not left in
the septum
Any adverse drug reaction is recorded 2 RR/SI
and reported
ME E7.4 There is a system to ensure right Fluid and drug dosages are calculated 2 SI/RR Check for calculation chart
medicine is given to right patient according to body weight
Drip rate and volume is calculated and 2 SI/RR Check the nursing staff how they
monitored calculate Infusion and monitor it
2 SI/OB
Administration of medicines done
after ensuring right patient, right drugs
, right route, right time
ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ Pharmacist 2 PI/SI
administration /nurse about the dosages and timings .
16 16
investigations are recorded and
updated Day to day progress of patient is
recorded in BHT
ME E8.2 All treatment plan prescription/orders Treatment plan, first orders are 2 RR Treatment prescribed in nursing
ME E8.4 Procedures performed are written on Procedures performed are written 2 RR Nebulization, Resuscitation etc
patients records on patients records
ME E8.5 Adequate form and formats are Standard Format for bed head ticket/
2 RR/OB TPR chart, IO chart, Growth chart (Pre
available at point of use term)
Patient case sheet available as per
state guidelines
guidelines
book, Admission register, lab register,
Admission sheet/ bed head ticket,
discharge slip, referral slip, referral
in/referral out register, OT register,
Registers and records are maintained Diet register, Linen register, Drug
as per guidelines intend register
All register/records are identified and 2 RR
numbered
storage and retrieval of medical
records
18 18
Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing Assessment is done before discharging 2 SI/RR
patient readiness patient
Discharge is done by a responsible and 2 SI/RR

qualified doctor
before discharge
2 SI/RR
Treating doctor is consulted/ informed
before discharge of patients
ME E9.2 Case summary and follow-up Discharge summary is provided 2 RR/PI See for discharge summary, referral
instructions are provided at the slip provided.
discharge
2 RR
mentions patients clinical condition,
treatment given and follow up
Discharge summary is give to patients 2 SI/RR
going in LAMA/Referral
ME E9.3 Counselling services are provided as Counselling the mother on correct 2
during discharges wherever required treatment and feeding of the child at
home, when to return for follow-up
care and immunization
PI/SI
Time of discharge is communicated to 2 PI/SI
patient in prior
Page 89
ce t Method
Full/Parti
al/No 4 4
plan in place
disaster is defined
4 4
ME E12.1 There are established procedures for Container is labeled properly after the 2 OB
Pre-testing Activities sample collection
ME E12.3 There are established procedures for Nursing station is provided with the 2 SI/RR
Post-testing Activities critical value of different tests
14 14
ME E13.8 There is established procedure for Paediatric bags for blood available 2 RR/SI
issuing blood
ME E13.9 There is established procedure for 2 RR
transfusion of blood Consent is taken before transfusion
before transfusion
patient recorded
complication reaction is recorded and reported to
responsible person
2 2
Standard E14 The facility has established procedures for Anaesthetic Services
ME E14.1 The facility has established procedures 2 SI/RR
for Pre-anaesthetic Check up and
maintenance of records
Pre anaesthesia check up is conducted
for elective / Planned surgeries
8 8
Standard E16 Facility has defined and established procedures for end of life care and death
ME E16.1 Death of admitted patient is adequately Facility has a standard procedure to 2 SI
recorded and communicated decent communicate death to
relatives
Death note is written on patient record 2 RR
ME E16.2 The facility has standard procedures for 2 SI/RR

handling the death in the hospital
Death note including efforts done for
resuscitation is noted in patient record
2 RR
Death summary is given to patient
cause and underlying cause if possible
The facility has established procedures for Antenatal care as per guidelines 2 2
Standard E17
women. Card”.
The facility has established procedures for care of new born, infant and child as per guidelines 20 20
Standard E20
ME E20.2 Triage, Assessment & Management of Assessment Protocols are available 2 SI/RR Airway, Breathing, Circulation, Coma,
newborns having Convulsion, and Dehydration
emergency signs are done as per
guidelines
Triage Protocols are available 2 SI/RR Emergency, priority and can wait
Staff aware and practice ETAT 2 SI/RR
protocols
Staff is skilled for basic life support for 2 SI/RR
young infants and children's
ETAT checklist is available and 2 SI/RR
practiced
ME E20.7 Management of children presenting Differential diagnosis algorithm are 2 SI/RR
with fever, cough/ breathlessness is available
done as per guidelines
ME E20.8 Management of children with severe Food/ fluid intake is chart is 2 RR
Acute Malnutrition is done as per maintained
guidelines
Weight chart is maintained 2 RR
Start-up and catch formula made as 2 SI/RR check for composition
per guidelines
ME E20.9 Management of children presenting Assessment of dehydration done as 2 SI/RR
diarrhoea is done per guidelines per protocols

The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated 10 10
Standard F1 infection
The facility measures hospital Patients are observed for any sign and
associated infection rates There is procedure to report cases of symptoms of HAI like fever, purulent
ME F1.3 Hospital acquired infection 2 SI/RR discharge from surgical site .
There is Provision of Periodic Medical There is procedure for immunization
Check-up and immunization of staff of the staff
Periodic medical checkups of the staff
2 SI/RR
The facility has established procedures Hand washing and infection control
for regular monitoring of infection audits done at periodic intervals
control practices Regular monitoring of infection control
ME F1.5 practices 2 SI/RR
Page 90
Reference No. Measurable Element CheckpointComplian Assessmen Means of verification Remarks

ce t Method
Full/Parti
The facility has defined and Implemented proceduresal/No
for ensuring hand hygiene practices and antisepsis 20 20
Standard F2
Hand washing facilities are provided at Availability of hand washing Facility at Check for availability of wash basin
ME F2.1 point of use Point of Use 2 OB near the point of use
soap dish/ liquid antiseptic with
dispenser. Check for availability/ Ask staff if the
Availability of Alcohol based Hand rub Check for availability/ Ask staff for
2 OB/SI regular supply.
Display of Hand washing Instruction at
Point of Use Prominently displayed above the hand
2 OB language
The facility staff is trained in hand Adherence to 6 steps of Hand washing
washing practices and they adhere to
Staff aware of when to hand wash 2 SI
Mothers are practicing wash hand After using the toilet or changing
washing with soap 2 PI/OB diapers and before feeding children
ME F2.3 2 OB
Proper cleaning of procedure site with OB/SI
antisepsis like before giving IM/IV injection,
The facility ensures standard practices and materials for Personal protection 8 8
Standard F3

requirements Clean gloves are available at point of
ME F3.1 use 2 OB/SI
The facility staff adheres to standard
personal protection practices
No reuse of disposable gloves, Masks,
ME F3.2 caps and aprons. 2 OB/SI
The facility has standard procedures for processing of equipment and instruments 18 18
Standard F4
The facility ensures standard practices and Decontamination of operating &

materials for decontamination and Procedure surfaces Ask stff about how they
cleaning of instruments and procedures decontaminate the procedure surface
areas like Examination table , Patients Beds

instruments like Stethoscope,
Instruments, Blood Pressure Cuff etc
Proper Decontamination of Wiping with 0.5% Chlorine Solution or
instruments after use 2 SI/OB 70% Alcohol as applicable
Contact time for decontamination is 10 minutes
adequate 2 SI/OB
Proper handling of Soiled and infected No sorting ,Rinsing or sluicing at Point
linen 2 SI/OB of use/ Patient care area
solution 2 SI/OB
The facility ensures standard practices and Equipment and instruments are Autoclaving/HLD/Chemical
materials for disinfection and sterilization sterilized after each use as per Sterilization
of instruments and equipment requirement
ME F4.2 2 OB/SI
instruments/equipments is done as required for boiling
per protocol
2 OB/SI
Autoclaved dressing material is used 2 OB/SI
Physical layout and environmental control of the patient care areas ensures infection prevention 16 16
Standard F5
The facility ensures availability of standard Availability of disinfectant as per

materials for cleaning and disinfection of requirement
patient care areas Chlorine solution, Gluteraldehye,
Availability of cleaning agent as per Hospital grade phenyl, disinfectant
requirement 2 OB/SI detergent solution
The facility ensures standard practices are Staff is trained for spill management
followed for the cleaning and disinfection
of patient care areas
ME F5.3 2 SI/RR
Staff is trained for preparing cleaning
solution as per standard procedure 2 SI/RR
Standard practice of mopping and Unidirectional mopping from inside
scrubbing are followed 2 OB/SI out
Cleaning equipments like broom are
not used in patient care areas Any cleaning equipment leading to
The facility ensures segregation infectious
patients Isolation and barrier nursing
procedure are followed for septic
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous 28 28
Standard F6 Waste.
The facility Ensures segregation of Bio Availability of colour coded bins at Adequate number. Covered. Foot
Medical Waste as per guidelines and point of waste generation operated.
'on-site' management of waste is
carried out as per guidelines
ME F6.1 2 OB
Page 91
ce t Method
Full/Parti
al/No
discarded blood and blood
Segregation of Anatomical and solied components.
waste in Yellow Bin 2 OB/SI

intravenous tubes and sets, catheters,
urine bags, syringes (without needles
and fixed needle syringes) and
Segregation of infected plastic waste vaccutainers with their needles cut)
in red bin 2 OB and gloves
Biomedical waste
2 OB
There is no mixing of infectious and
general waste 2
The facility ensures management of Availability of functional needle OB See if it has been used or just lying
Seggregation of sharps waste 2 OB Should be available nears the point of
including Metals in white (translucent) generation.Needles, syringes with
Puncture proof, Leak proof, tamper fixed needles, needles from needle tip
proof containers cutter or burner, scalpels, blades, or
any other contaminated sharp object
that may cause puncture and cuts.
This includes both used, discarded and
Availability of post exposure 2 SI/OB Ask if available. Where it is stored and

prophylaxis who is in charge of that.
Staff knows what to do in condition of 2 SI Staff knows what to do in case of
needle stick injury shape injury. Whom to report. See if
any reporting has been done
Contaminated and broken Glass are 2 Vials, slides and other broken infected
disposed in puncture proof and leak glass
proof box/ container with Blue colour
marking
OB
ME F6.3 2 SI/OB
Transportation of bio medical waste is
done in close container/trolley 2
management 2 SI/RR
The facility has established organizational framework for quality improvement 2 2
Standard G1
ME G1.1 The facility has a quality team in place There is a designated departmental 2 SI/RR
nodal person for coordinating
Quality Assurance activities
The facility has established system for patient and employee satisfaction 2 2
Standard G2
ME G2.1 Patient satisfaction surveys are 2 RR

conducted at periodic intervals Patient satisfaction survey done on
monthly basis
The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 4 4
Standard G3

quality assurance programme in key
departments
There is system daily round by

matron/hospital manager/ hospital
superintendent/ Matron in charge for
ME G3.3 The facility has established system for Departmental checklist are used for 2 SI/RR Staff is designated for filling and
use of check lists in different monitoring and quality assurance monitoring of these checklists
departments and services
The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and 28 28
Standard G4 support services.
procedures are available department has been prepared and
approved
Current version of SOP are available 2 OB/RR
with process owner
ME G4.2 Standard Operating Procedures 2 RR
adequately describes process and Department has documented
procedures Procedure for receiving and initial
assessment of the patient
2 RR
procedure for reassessment of the
patient as per clinical condition
Department has documented 2 RR Check availability of documented
procedure for ensuring patients rights procedure for taking consent,
including consent, prviacy, maintenance of privacy,
confidentaility & entitlement confidentaility & entitlements
Department has documented 2 RR Check availability of risk management

proedure for safety & risk record/register to identify risk &
management action taken to mitigate them
Department has documented 2 RR Department has documented

procedure for support services & procedure for sorting, cleaning and
facility mangement. distribution of clean linen &
documented procedure for providing
free diet to patient, preventive- break
down maintenance and calibration of
equipments, inventory management
& storage, retaining ,retrieval of
records
Page 92
ce t Method
Full/Parti
Department has documented 2
al/No RR Department has documented
procedure for general patient care procedure for admission, shifting,
processes referral & discharge of paediateric
cases
Department has documented 2 RR Department has documented

procedure for specific processes to the procedure for emergency triage,
department assessment and treatment.
Documented procedure for
Management of fever, cough,
breathlessness, diarrhoea and
malnutrition,documented procedure
for blood transfusion, documented
procedure for requisition and
reporting of diagnostics,documented

procedure for infection control & bio procedure for infection control
medical waste mangement practices& BMW
Department has documented 2 RR Check availbility of documented
procedure for quality management & procedure for departmental quality
improvement actvities viz: nomination of
department Nodal officer, internal
assessments, audits, patient
satsifection survey, internal &
external quality assurance processes,
Depatment has documented 2 RR Check availbility of documented

procedure for data collection, analysis departmanental Data set need to be
& use for improvement measured monthly & procedure for
their collection, analysis &
improvement
ME G4.3 Staff is trained and aware of the Check staff is a aware of relevant part 2 SI/RR
procedures written in SOPs of SOPs
ME G4.4 Work instructions are displayed at 2 OB Patient safety, formula for calculation
Point of use of paediatric doses , CPR etc
Work instruction/clinical protocols are
displayed
The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages 6 6
Standard G 5
ME G5.1 The facility maps its critical processes Process mapping of critical processes 2 SI/RR
done
identified
The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 10 10
Standard G6
ME G6.1 Facility ensures standard practices and 2 RR/SI

materials for decontamination and
cleaning of instruments and procedures
areas Internal assessment is done at periodic
interval
ME G6.2 The facility conducts the periodic There is procedure to conduct child 2 RR/SI Medical & prescription
prescription/ medical/death audits Death audit audit = GA cl
ME G6.3 The facility ensures non compliances Non Compliance are enumerated and 2 RR/SI
are enumerated and recorded recorded
adequately
ME G6.4 Action plan is made on the gaps found 2 RR/SI
in the assessment / audit process
ME G6.5 Planned actions are implemenated 2 RR/SI PDCA
through Quality improvement cycle
(PDCA) Check correction & corrective actions
are taken
6 6
ME G7.4 2 SI/RR
if these objectives are Specific,
Facility has de defined quality objectives to Check if SMART Quality Objectives Measurable, Attainable, Relevant and
achieve mission and quality policy have framed Time Bound.
ME G7.5 2 SI/RR
Mission, Values, Quality policy and Statement, Core Values and Quality
objectives are effectively communicated to Check of staff is aware of Mission , Policy is displayed prominently in local
staff and users of services Values, Quality Policy and objectives language at Key Points
ME G7.7 2 SI/RR

quality objectives being reviewed at
least onnce in month by departmnetal
incharges and during the qulaity team
Facility periodically reviews the progress of meeting. The progress on quality
strategic plan towards mission, policy and Check time bound action plan is being objectives have been recorded in
objectives reviewed at regular time interval Action Plan tracking sheet
ME G8.1 The facility uses method for quality Basic quality improvement method SI/OB PDCA & 5S
improvement in services 2
Advance quality improvement method SI/OB Six sigma, lean.
2
ME G8.2 The facility uses tools for quality 7 basic tools of Quality SI/RR Minimum 2 applicable tools are used
improvement in services 2 in each department
ME G10.6 SI/RR
Check periodic assessment of comprehensive risk assessment of all
Periodic assessment for Medication and medication and patient care safety risk clinical processes should be done
Patient care safety risks is done as per is done using defined checklist using pre define criteria at least once
defined criteria. periodically 2 in three month.
The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 12 12
Standard H1
Page 93
ce t Method
Full/Parti
ME H1.1 Facility measures productivity Indicators Bed Occupancy Rate al/No
Proporation of mothers given
nutritional counselling 2 RR
No. of paediatric admission per 1000
indoor admission 2 RR
Proportion of female patient 2 RR
LAMA rate for female patient 2 RR
Proportion of BPL patient 2 RR
The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 8 8
Standard H2
ME H2.1 Facility measures efficiency Indicators on Referral Rate

monthly basis 2 RR
No. of drug stock out in the paediatric
ward 2 RR
Discharge Rate 2 RR
The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 14 14
Standard H3
ME H3.1 Facility measures Clinical Care & Safety No of Newborn / Child Resuscitated
Average length of Stay 2 RR
Death rate 2 RR
patients 2 RR
% of infants exclusively breastfed from
admission to discharge 2 RR
Case fatality rate 2 RR
The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 4 4
Standard H4
ME H4.1 Facility measures Service Quality Indicators LAMA Rate

Attendent Satisfaction Score
2 RR question may be asked with attendant
Obtatained Maximum Percent

A 32 32 100%
B 58 58 100%
C 130 130 100%
D 106 106 100%
E 194 194 100%
F 100 100 100%
G 66 66 100%
H 38 38 100%
Total 724 724 100%
0
1
2
Page 94
Checklist No. 6 SNCU Version - NHSRC /3.0

Checklist for Sick Newborn Care Unit (SNCU) 6
Assessment Summary

Date
SNCU Score Card

Area of Concern wise Score SNCU Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
G Quality 100%
Management
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Reference ME Statement Checkpoint Complia Assessmen Means of verification Remarks

nce/Full t Method
/
Partial/
No

Facility Provides Curative Services 4 4
Standard A1
ME A1.4 The Facility Provides Paediatric Availability of functional SNCU 2 SI/OB For detailed service provision kindly
Services refer A2.3
ME A1.14 Services are available for the time Availability of nursing care services 2 SI/RR
Facility provides RMNCHA Services 16 16
Standard A2
ME A2.3 The Facility provides Newborn Management of low birth weight 2 SI/RR
health Services infants <1800 gm and preterm
2 SI/RR
Management of all sick new borns
except those requiring mechanical
ventilation and major surgical
intervention
Page 95

nce/Full t Method
/
Partial/
No
Resuscitation 2 SI/RR
Prevention of infection including 2 SI/RR
management of newborn sepsis
Provision of Warmth 2 SI/RR
Phototherapy for new born 2 SI/RR
Breast feeding/feeding support and 2 SI/RR
Kangaroo Mother care (KMC)
ME A2.4 The Facility provides child health Screening of New born for Birth 2 SI/RR
Services Defects
Facility Provides diagnostic Services 4 4
Standard A3
ME A3.1 The Facility provides Radiology Availability for USG and portable X ray In house, Parent hospital and
Services services 2 SI/OB Outsourced
ME A3.2 The Facility Provides Laboratory
Services
Availability of side laboratory:
Serum billirubin, Plasma glucose,
Serum creatnine, Blood count,
Platelet, C reactive protein,
Prothrobin time, Blood gas analysis
with PH measurement analysis. If
SNCU has facility /Linkage for linkage with outside lab than give
laboratory investigation. 2 SI/OB partial compliance
22 22
ME B1.1 The facility has uniform and user- 2 OB (Numbering, main department and
friendly signage system Availability departmental signage's internal sectional signage
Directional signage for department is 2 OB
displayed
2 OB
Restricted area signage displayed
ME B1.2 The facility displays the services Services available in SNCU are 2 OB
and entitlements available in its displayed
departments
Entitlements under JSSK Displayed 2 OB
Information about doctor/ Nurse on 2 OB
duty is displayed and updated
Contact information in respect of 2 OB
SNCU referral services are displayed
ME B1.5 Patients & visitors are sensitised 2
Display of pictorial information/
and educated through chart regarding expression of milk/
appropriate IEC / BCC approaches techniques for assistive feeding ,
Display of information for education KMC, complimentary feeding etc.
of mother /relatives OB
Counselling aids are available for 2
education of mother OB
ME B1.6 Information is available in local Signage's and information are 2
language and easy to understand available in local language
OB
ME B1.8 The facility ensures access to Discharge summery is given to the 2 OB
clinical records of patients to patient
entitled personnel
6 6
ME B3.1 Adequate visual privacy is Privacy is maintained in breast 2 OB

provided at every point of care feeding room
ME B3.2 Confidentiality of patients records Patient Records are kept at secure 2 SI/OB
and clinical information is place beyond access to general
maintained staff/visitors
ME B3.3 Behaviour of staff is empathetic and 2 OB/PI
The facility ensures the courteous
behaviours of staff is dignified and
respectful, while delivering the
services
8 8
Standard B4
Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent
wherever it is required.
ME B4.1 2 SI/RR
There is established procedures
for taking informed consent SNCU has system in place to take
before treatment and procedures informed consent from patient
relative whenever required
ME B4.4 2 PI
Information about the treatment
is shared with patients or SNCU has system in place to involve
attendants, regularly patient relatives in decision making of
patient treatment
2 PI/SI
SNCU has system in place to provide
communication of newborn condition
to parents/ relatives at least once in
day
ME B4.5 Facility has defined and 2 OB
established grievance redressal Availability of complaint box and
system in place display of process for grievance re
displayed
22 22
ME B5.1 2 PI/SI
The facility provides cashless
services to pregnant women,
mothers and neonates as per
prevalent government schemes Availability of Free diagnostics
Availability of free drop back 2 PI/SI
Availability of Free diet to patient 2 PI/SI
Availability of Free Diet to mother 2 PI/SI
Availability of Free patient transport 2 PI/SI
Availabliity of Free Blood 2 PI/SI
Availability of Free drugs 2 PI/SI
Availability of free stay to mother 2 PI/SI
prescribed are available at spent on purchasing drugs or
Pharmacy and wards
prescribed investigations are spent on diagnostics from outside.
Page 96

nce/Full t Method
/
Partial/
No
ME B5.5 2 PI/SI/RR
entitlements and reimbursement
If any other expenditure occurred it is
to the patients reimbursed from hospital
ME B6.6 Patients Relatives are informed clearly 2 SI/RR
about the deterioration in health
There is an established procedure for condition of Patients
‘end-of-life’ care
There is a procedure to allow patient 2 SI/OB
relative/Next of Kin to observe patient
in last hours
ME B 6.7 2 RR/SI

patients who wish to leave hospital
against medical advice or refuse to Declaration is taken from the LAMA
receive specific c treatment patient
The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 52 52
Standard C1
ME C1.1 Departments have adequate Adequate space as per patient care 2 OB

space as per patient or work load units Space between 2 adjacent beds in
SNCU should be 4 ft. Space
between wall and beds is 2 ft
Availability of adequate waiting area 2 OB
ME C1.2 Patient amenities are provide as 2 OB
per patient load Availability of drinking water
Toilets for visitors 2 OB
promotion
Adequate sitting area for patient 2 OB
relative
ME C1.3 Departments have layout and 2
demarcated areas as per
functions
SNCU has separate Inborn unit OB
SNCU has separate Out born unit 2 OB
SNCU has separate designed washing 2
area OB
The rooms has been separated by 2
transparent observation windows
from the nurses' working place in
between Patient care area has 2
OB interconnected rooms
Availability of nursing station 2 OB
Hand washing and gowning area 2 OB
Receiving room with examination 2
area OB
2
Clean area for mixing intravenous
fluids and Medications/ fluid
preparation area OB
Doctors duty room, 2 OB
Dirty utility area 2 OB
Mother's area for expression of breast 2 SNCU has system in place to call
milk/ Breast feeding OB mother's of baby for feeding
Unit stores 2 OB
Side lab. Nurses change room, 2
autoclaving room, Counselling room OB
Step down area in close proximity 2 OB
ME C1.4 The facility has adequate 2
circulation area and open spaces
according to need and local law Availability of adequate circulation
area for easy moment of staff and
equipments OB
ME C1.5 The facility has infrastructure for 2
and Intercom Services OB
ME C1.6 Service counters are available as Availability of adequate patient care 2 According to the delivery load
per patient load units as per case load OB (Calculation as per GOI guidelines)
ME C1.7 The facility and departments are 2
planned to ensure structure
follows the function/processes
(Structure commensurate with
the function of the hospital)
SNCU is easily accessible from labour
room, maternity ward and obstetric
OT OB
Arrangement of different section 2 Unidirectional flow of goods and
ensures unidirectional flow OB services.
2
patients beds enables easy and direct
observation of patients OB
Facility ensures the physical safety of the infrastructure. 26 26
Standard C2
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and furniture like
safety of the infrastructure properly secured cupboards, cabinets, and heavy
ME C2.3 The facility ensures safety of 2 OB

electrical establishment SNCU does not have temporary Switch Boards other electrical
connections and loosely hanging wires installations are intact
2 OB/RR
SNCU has mechanism for periodical
check / test of all electrical installation
by competent electrical Engineer
2 OB/RR
10 central Voltage stabilize outlets are
available with each warmer in main 50% 0f each should be 5amp and
SNCU, Step down area and triage 50% should be 15 amp to handle
room equipments
2 OB/RR
SNCU has system for power audit of
unit at defined intervals and records
of same is maintained
2 OB/RR Dedicated earthling pit system
SNCU has earthling system available available
2 OB/RR
SNCU has dedicated earthling pit Earth resistance should be
system available and records of its measured twice in a year and
measurement is maintained logged
2
Wall mounted digital display is
available in SNCU to show earth to Normal range 3-5 V (if exceed to
neutral voltage OB report immediately)
Page 97

nce/Full t Method
/
Partial/
No
2
Quality output of voltage stabilizer is
displayed in each stabilizer as per
manufacturer guideline OB
Power boards are marked as per 2
phase to which it belongs OB
2 Earth resistance should be
measured twice in a year and
SNCU has system to measure earth logged
resistance at defined interval OB/RR
ME C2.4 Physical condition of buildings are 2
safe for providing patient care
Floors of the SNCU are non slippery
and even OB
Windows/ ventilators if any in the OT 2
are intact and sealed OB
Facility has established program for fire safety and other disaster 14 14
Standard C3
ME C3.1 The facility has plan for SNCU has sufficient fire exit to permit 2 OB/SI
prevention of fire safe escape to its occupant at time of
fire
Check the fire exits are clearly visible 2 OB
and routes to reach exit are clearly
marked.
ME C3.2 The facility has adequate fire SNCU has installed fire Extinguisher 2 OB
fighting Equipment that is Class A , ClassB, C type or ABC
type
SNCU has provision of Smoke and 2 OB
heat detector
SNCU has electrical and automatic 2 OB/RR
fire alarm system or alarm system
sounded by actuation of any
automatic fire extinguisher

ME C3.3 The facility has a system of Check for staff compatencies for 2 SI/RR
periodic training of staff and operating fire extinguisher and what
conducts mock drills regularly for to do in case of fire
fire and other disaster situation
Facility has the appropriate number of staff with the correct skill mix required for providing the assured services to the current case load 14 14
Standard C4
ME C4.1 The facility has adequate 2 At least one paediatrician

specialist doctors as per service
provision
Availability of fulltime Paediatrician OB/RR
ME C4.2 The facility has adequate general 2 OB/RR
duty doctors as per service
provision and work load Availability of 1 Medical officer per
shift
ME C4.3 The facility has adequate nursing 2 OB/RR/SI
staff as per service provision and
work load
Availability of 3 Nursing staff per shift
ME C4.4 The facility has adequate Availability 1 technician for side lab 2 OB/SI
requirement
ME C4.5 The facility has adequate 2 SI/RR Availability of one sanitary staff and
support / general staff Availability of SNCU attendant ayahs
Availability of one data entry operator 2 SI/RR
Facility provides drugs and consumables required for assured list of services. 22 22
Standard C5
ME C5.1 The departments have availability OB/RR

of adequate drugs at point of use Inj. Ampicillin with Cloxacillin, Inj.
Ampicillin
Inj. Cefotaxime
Inj. Gentamycin Amoxycillin-
Availability of Antibiotics 2 Clavulanic Suspension
Availability of analgesics and OB/RR
antipyretics 2 Paracetamol
OB/RR 5%, 10%, 25% Dextrose
Availability of IV Fluids 2 Normal saline
OB/RR
Inj.Adrenaline (1:10000)
Inj. Naloxone
Sodium Bicarbonate Injection
Aminophylline
Phenobarbitone (Injection +oral)
Injection
Hydrocortisone,Inj.Dexamethasone
Availability of other emergency drugs 2 , Inj. Phenytoin
OB/RR
Inj. Potassium Chloride 15%
Inj. Calcium Gluconate 10%
Drugs for electrolyte imbalance 2 Inj. Magnesium Sulphate 50%
Availability of drugs for newborn 2 OB/RR Vit K ,
consumables at point of use
Availability of dressings material and Gauze piece and cotton swabs,
diapers 2 Diapers,
OB/RR
Neoflon 24 G , microdrip set with
Availability of syringes and IV Sets &without burette, BT set, Suction
/tubes 2 catheter, PT tube, feeding tube
Availability of Antiseptic Solutions 2 OB/RR Antiseptic lotion
OB/RR Baby ID tag, cord clamp, mucus
Others 2 sucker,
ME C5.3 Emergency drug trays are Emergency Drug Tray is maintained OB/RR
maintained at every point of care,
where ever it may be needed
2
Facility has equipments & instruments required for assured list of services. 22 22
Standard C6

instruments for examination & Equipment &Instruments for Multiparamonitor , Thermometer,
monitoring of patients examination & Monitoring Weighing scale, pulse oxy meter,
2 OB Stethoscope
ME C6.3 Availability of equipment & Availability of diagnostic
instruments for diagnostic instruments for side laboratory Availability of services in side lab;
procedures being undertaken in Micro
the facility hematocrit,Multistix,Bilirubinomete
r,Microscope,Dextrometer,
2 OB Glucometer
Page 98

nce/Full t Method
/
Partial/
No
ME C6.4 Availability of equipment and

instruments for resuscitation of
patients and for providing
intensive and critical care to
patients Radiant warmers and
Functional Patient care units 2 OB phototherapy machine
Infusion pumps,Oxygen
cylinder/central line/Oxygen
Functional Critical care Equipments 2 OB concentrator, oxygen hood,
Bag and mask, laryngoscope, ET
Functional Resuscitation equipments 2 OB tubes, suction machine
ME C6.5 Availability of Equipment for Availability of equipment for Refrigerator, Crash cart/Drug
Storage storage for drugs trolley, instrument trolley, dressing
trolley
2 OB
ME C6.6 Availability of functional Availability of equipments for Buckets for mopping, Separate
equipment and instruments for cleaning mops for inborn and outborn and
support services circulation area, duster, waste
trolley, Deck brush
2 OB
Availability of dedicated washing
machine for SNCU 2 OB
Availability of equipment for Autoclave
ME C6.7 Departments have patient Availability of Fixtures Electrical panel with each unit, X
furniture and fixtures as per load ray view box.
and service provision
2 OB
Cupboard, nursing counter, table

for preparation of medicines, chair,
Availability of furniture 2 OB furniture at breast feeding room.
ME C7.1 RR/SI

2 prepared for assessing competence
of doctors, nurses and paramedical
staff based on job description
Criteria for Competence assessment Check parameters for assessing skills defined for each cadre of staff.
are defined for clinical and Para and proficiency of clinical staff has Dakshta checklist issued by MoHFW
clinical staff been defined can be used for this purpose.
ME C7.2 RR/SI
Competence assessment of Clinical 2 assessment including filled
and Para clinical staff is done on checklist, scoring and grading .
predefined criteria at least once in a Check for competence assessment is Verify with staff for actual
year done at least once in a year competence assessment done
ME C7.9 Facility based New Born Care (FBNC) 2 SI/RR
The Staff is provided training as per training
defined core competencies and To all Medical Officers and Nursing
training plan Staff posted at SNCU
Training on infection control and hand 2 SI/RR
hygiene
Training on Bio Medical waste 2 SI/RR
Management
ME C7.10 Nursing staff is skilled for operation of 2 SI/RR
equipments Check supervisors make periodic
There is established procedure for that staff is working according to
utilization of skills gained thought the training imparted. Also staff is
trainings by on -job supportive provided on job training wherever
supervision there is still gaps
2 SI/RR
Staff is skilled for resuscitation of provided on job training wherever
New Born there is still gaps
2 SI/RR
Nursing staff is skilled identifying and provided on job training wherever
managing complication there is still gaps
2 SI/RR
Nursing Staff is skilled for maintaining provided on job training wherever
clinical records there is still gaps
Facility has established program for inspection, testing and maintenance and calibration of equipments. 16 16
Standard D1
ME D1.1 The facility has established system All equipments are covered under SI/RR
for maintenance of critical AMC including preventive Radiant warmer, suction machine,
Equipment maintenance Oxygen concentrator, pulse
2 oximeter/ Multipara monitor
SI/RR
equipments 2
There has system to label
Defective/Out of order equipments
and stored appropriately until it has
been repaired
2 OB/RR
Staff is skilled for trouble shooting in SI/RR
case equipment malfunction 2
Periodic cleaning, inspection and SI/RR
maintenance of the equipments is
done by the operator
2
ME D1.2 The facility has established All the measuring equipments/ OB/ RR
procedure for internal and instrument are calibrated
external calibration of measuring
Equipment
2
OB/ RR
There is system to label/ code the
equipment to indicate status of
calibration/ verification when
recalibration is due 2
ME D1.3 Operating and maintenance OB/SI
instructions are available with the Up to date instructions for operation
users of equipment and maintenance of equipments are
readily available with SNCU staff. 2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 26 26
Standard D2
Page 99

nce/Full t Method
/
Partial/
No
forecasting and indenting drugs There is established system of timely Requisition are timely placed
and consumables indenting of consumables and drugs
at nursing station
dosages only
storage of drugs and consumables Drugs are stored in
containers/tray/crash cart and are
labelled
labelled
Expressed milk is stored at 2 OB/RR
recommended temperature
ME D2.4 The facility ensures management Expiry dates' are maintained at 2 OB/RR
of expiry and near expiry drugs emergency drug tray

2
drugs are maintained for drug stored
at department RR
ME D2.5 The facility has established There is practice of calculating and 2 SI/RR
procedure for inventory maintaining buffer stock in SNCU
management techniques
consumables
areas
ME D2.7 There is process for storage of 2 OB/RR Check for temperature charts are
vaccines and other drugs, maintained and updated
requiring controlled temperature Temperature of refrigerators are kept periodically
as per storage requirement and
The facility provides safe, secure and comfortable environment to staff, patients and visitors. 26 26
Standard D3
ME D3.1 The facility provides adequate OB

illumination level at patient care
Separate procedure lightening
areas capable of providing not less than
200Lux at the plane of infant bed,
Ambient lightening
levels in infants spaces shall be
Adequate Illumination at nursing adjustable through range of at least
station 2 50 to more than 600 Lux.
Adequate illumination in patient care OB
unit 2
ME D3.2 The facility has provision of OB/SI
restriction of visitors in patient One female family members allowed
areas to stay with the new born in step
down 2
Entry to SNCU is restricted 2 OB
Visiting hour are fixed and practiced 2 OB/PI
ME D3.3 The facility ensures safe and SNCU has system to control
comfortable environment for temperature and humidity and record Temperature inside main SNCU
patients and service providers of same is maintained should be maintained at (22-26OC),
round O clock preferably by
thermostatic control. Relative
humidity of 30-60% should be
2 SI/RR maintained
Each equipment used should have

servo controlled devices for heat
control with cut off to limit increase
in temperature of radiant warmers
SNCU has procedure to check the beyond a certain temperature or
temperature of radiant warmer warning mechanism for sounding
,phototherapy units, baby incubators alert/alarm when temp increases
etc. 2 SI/RR beyond certain limits
SNCU has system to control the sound
producing activities and gadgets (like Background sound should not be
telephone sounds, staff area and more than 45 db and peak density
equipments) 2 SI/RR should not be more than 80db.
SNCU has functional room
thermometer and temperature is
regularly maintained 2 SI/RR 1 for each patient care room
ME D3.4 The facility has security system in New born identification band and foot OB/RR
place at patient care areas prints are in practice 2
There is procedure for handing over SI
the baby to mother/father 2
Security arrangement in SNCU 2 OB
ME D3.5 The facility has established measure Ask female staff whether they feel SI
for safety and security of female staff secure at work place
2
The facility has established Programme for maintenance and upkeep of the facility 22 22
Standard D4

plastered & painted
hygienic patient care and circulation areas are All area are clean with no
Clean dirt,grease,littering and cobwebs
clean
Toilets are clean with functional flush 2 OB
and running water
ME D4.3 Hospital infrastructure is Check for there is no seepage , Cracks, 2 OB
adequately maintained chipping of plaster

fixtures are intact
Patients beds are intact and painted 2 OB
ME D4.5 The facility has policy of removal 2 OB
of condemned junk material
No condemned/Junk material in the
SNCU
ME D4.6 The facility has established 2 OB
procedures for pest, rodent and
animal control
Page 100

nce/Full t Method
/
Partial/
No
The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 10 10
Standard D5
ME D5.1 The facility has adequate Availability of 24x7 running and 2 OB/SI
arrangement storage and supply potable water
for portable water in all functional
areas
ME D5.2 The facility ensures adequate 2 OB/SI

power backup in all patient care
areas as per load Availability of power back up in
patient care areas
ME D5.3 Critical areas of the facility ensures Availability of Centralized /local piped 2 OB
availability of oxygen, medical gases Oxygen and vacuum supply
and vacuum supply
6 6
ME D6.1 The facility has provision of 2
nutritional assessment of the Nutritional assessment of patient
patients done specially for mother of admitted
baby RR/SI
ME D6.2 The facility provides diets 2
according to nutritional Check for the adequacy and
requirements of the patients frequency of diet as per nutritional Check that all items fixed in diet
requirement OB/RR menu is provided to the patient
2 Ask patient/staff weather they are
Check for the Quality of diet provided PI/SI satisfied with the Quality of food
8 8
ME D7.1 The facility has adequate sets of 2 OB/RR
linen SNCU has facility to provide sufficient
and clean linen for each patient
Gown are provided to visitors/staff at 2 OB/RR
the entrance of SNCU
ME D7.2 The facility has established 2 OB/RR
procedures for changing of linen
in patient care areas Linen is changed every day and
ME D7.3 The facility has standard procedures 2 SI/RR
for handling , collection, There is system to check the
transportation and washing of linen cleanliness and Quantity of the linen
8 8
Standard D11
procedures.
ME D11.2 The facility has a established There is procedure to ensure that 2 RR/SI Check for system for recording time
procedure for duty roster and staff is available on duty as per duty of reporting and relieving
deputation to different roster (Attendance register/ Biometrics
departments etc)

department
ME D11.3 The facility ensures the adherence 2 OB
to dress code as mandated by its
administration / the health
department Doctor, nursing staff and support staff
adhere to their respective dress code
2 2
Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
ME D12.1 There is established system for 2 SI/RR Verification of outsourced services
contract management for out (cleaning/
sourced services Dietary/Laundry/Security/Maintena
There is procedure to monitor the nce) provided are done by
quality and adequacy of outsourced designated in-house staff
services on regular basis
14 14
ME E1.1 The facility has established Unique identification number is 2 RR
procedure for registration of given to each patient during process
patients of registration

ME E1.3 There is established procedure for Admission criteria for SNCU is defined 2 SI/RR
admission of patients & followed
patient
Admission is done by written order of 2 SI/RR/OB
a qualified doctor
patient record
managing patients, in case beds
are not available at the facility
Procedure cope with surplus patient
load
16 16
ME E2.1 There is established procedure for Defined criteria for assessment like
initial assessment of patients Initial assessment of all admitted Silverman Anderson Score and
patient done as per standard down score
protocols
2 RR/SI
Patient History is taken and recorded 2 RR
Physical Examination is done and RR
recorded wherever required 2
2 RR/SI
Initial assessment is documented
preferably within 2 hours 2 RR
follow-up/ reassessment of
Patients There is fixed schedule for assessment
of stable patients 2 RR/OB
Page 101

nce/Full t Method
/
Partial/
No

reassessment as per need 2 RR/OB
16 16
ME E3.1 The facility has established 2 Check continuity of care is
procedure for continuity of care maintained while transferring/
during interdepartmental transfer There is procedure of taking over of handover the patient
new born from labour OT/ Ward to
SNCU RR/SI
continuity of care.
Advance communication is done with 2
higher centre RR/SI
maintained RR
SI/RR lower facilities
referred patients
ME E3.3 A person is identified for care Duty Doctor and nurse is assigned for 2 RR/SI
during all steps of care each patients
18 18
ME E4.1 Procedure for identification of 2 OB/SI
patients is established at the
facility Identification tags are used for
identification of newborns
ME E4.2 Procedure for ensuring timely and Treatment chart are maintained 2 RR Check for treatment chart are
accurate nursing care as per updated and drugs given are
treatment plan is established at the marked. Co relate it with drugs and
facility doses prescribed.
There is a process to ensue the 2 SI/RR Verbal orders are rechecked before
orders
ME E4.3 There is established procedure of Patient hand over is given during the 2 SI/RR
patient hand over, whenever staff change in the shift
duty change happens
maintained
ME E4.4 Nursing records are maintained Nursing notes are maintained 2 RR/SI Check for nursing note register.
adequately Notes are adequately written
ME E4.5 There is procedure for periodic Patient Vitals are monitored and 2 RR/SI Check for TPR chart, Phototherapy
monitoring of patients recorded periodically chart, any other vital required is
monitored
Critical patients are monitored 2 RR/SI Check for use of cardiac
continually monitor/multi parameter
4 4
ME E5.1 The facility identifies vulnerable Vulnerable patients are identified and 2 OB/SI Check the measure taken to
patients and ensure their safe care measures are taken to protect them prevent new born theft, sweeping
from any harm and baby fall
ME E5.2 The facility identifies high risk High risk patients are identified and 2 OB/SI
patients and ensure their care, as per treatment given on priority
their need
10 10
Standard E6
rational use.
ME E6.1 The facility ensured that drugs are Check for BHT if drugs are prescribed 2 RR
prescribed in generic name only under generic name only
drugs treatment guideline are available at
point of use
as per STG
24 24
ME E7.1 There is process for identifying High alert drugs available in 2 SI/OB Electrolytes like Potassium chloride,
and cautious administration of department are identified Opioids, Neuro muscular blocking
high alert drugs (to check) agent, Anti thrombolytic agent,
insulin, warfarin, Heparin,
Adrenergic agonist etc. as
applicable
Maximum dose of high alert drugs are 2 SI/RR Value for maximum doses as per
defined and communicated age, weight and diagnosis are
doctor

avoided
ME E7.2 Medication orders are written Every Medical advice and 2 RR

legibly and adequately procedure is accompanied with
ME E7.3 There is a procedure to check Drugs are checked for expiry and 2 OB/SI
drug before administration/ other inconsistency before
dispensing administration
Check single dose vial are not used for 2 OB Check for any open single dose vial
more than one dose with left over content intended to
be used later on
used every time for multiple dose vial In multi dose vial needle is not left
in the septum
Any adverse drug reaction is recorded 2 RR/SI
and reported
Page 102

nce/Full t Method
/
Partial/
No
ME E7.4 There is a system to ensure right Fluid and drug dosages are calculated 2 SI/RR Check for calculation chart
medicine is given to right patient according to body weight
Drip rate and volume is calculated and 2 SI/RR Check the nursing staff how they
monitored calculate Infusion and monitor it
2 SI/OB
after ensuring right patient, right
drugs , right route, right time
16 16
assessment and investigations are
recorded and updated Patient progress is recorded as per
defined assessment schedule
ME E8.2 All treatment plan Treatment plan, first orders are 2 RR Treatment prescribed in nursing
prescription/orders are recorded written on BHT records
in the patient records.
ME E8.4 Procedures performed are written Procedure performed are recorded in 2 RR

on patients records BHT Mobilization, resuscitation etc
available at point of use Availability of formats for
Treatment Charts, TPR Chart ,
Intake Output Chart, Community
follow up card, BHT, continuation
Standard Formats are available sheet, Discharge card Etc.
ME E8.6 Register/records are maintained 2 RR
as per guidelines
slip, referral in/referral out register,
Registers and records are maintained OT register, Diet register, Linen
as per guidelines register, Drug intend register
All register/records are identified and 2 RR
numbered
ME E8.7 The facility ensures safe and Safe keeping of patient records 2 OB
adequate storage and retrieval of
medical records
22 22
ME E9.1 Discharge is done after assessing SNCU has established criteria for 2 SI/RR Patient is shifted to ward/step
patient readiness discharge of the patient down after assessment
Assessment is done before 2 SI/RR
discharging patient
before discharge
2 SI/RR
patients
discharge
2 RR
Discharge summary is give to patients 2 SI/RR
going in LAMA/Referral
2 RR/SI
there is procedure for clinical follow
up of the new born by local CHW
(Community health care
worker)/ASHA
ME E9.3 Counselling services are provided 2
as during discharges wherever for care of new born and
required Counselling of mother before breastfeeding, treatment and
discharge PI/SI follow up counselling
Time of discharge is communicated to 2 PI/SI
patient in prior
2 2
Standard E10 The facility has defined and established procedures for intensive care.
ME E10.3 The facility has explicit clinical 2 RR/SI
criteria for providing intubation &
extubation, and care of patients
on ventilation and subsequently
on its removal
Criteria are defined for intubation

20 20
ME E11.1 There is procedure for Receiving 2 SI/RR
and triage of patients Triaging of new born as per guidelines
disaster is defined
ME E11.4 The facility ensures adequate and 2 SI/RR
timely availability of ambulances
services and mobilisation of
resources, as per requirement
System for coordinating with
ambulances
SNCU has provision of Ambulance to 2 SI/RR
refer the case to higher centre
2 SI/RR
Ambulance has provision/ method for
maintenance of Warm chain while
referred to higher centre
Ambulance/transport vehicle have 2 OB/RR
adequate arrangement for Oxygen
2 OB/RR
Ambulance/transport vehicle have
dedicated rescue kit including "
essential supplies kit", emergency
drug kit
Page 103

nce/Full t Method
/
Partial/
No
2 SI/RR
SNCU has system to periodic check of
ambulances/transport vehicle by
driver/paramedic staff and counter
checked by SNCU staff
2 SI/RR
Transfer of patient in Ambulance
/patient transport vehicle is
accompanied by trained medical
Practitioner
4 4
ME E12.1 There are established procedures Container is labelled properly after OB
for Pre-testing Activities the sample collection
2
ME E12.3 There are established procedures SI/RR
for Post-testing Activities
SNCU has critical values of various lab
test 2
14 14
ME E13.8 There is established procedure for RR/SI if not available than how facility
issuing blood Paediatric blood bags are available 2 cope with it
ME E13.9 There is established procedure for RR
transfusion of blood Consent is taken before transfusion 2
Blood is kept on optimum RR
Blood transfusion is monitored and SI/RR
regulated by qualified person 2
Blood transfusion note is written in RR
patient recorded 2
ME E13.10 There is a established procedure RR
for monitoring and reporting
Transfusion complication Any major or minor transfusion
reaction is recorded and reported to
responsible person 2
12 12
ME E16.1 Death of admitted patient is Facility has a standard procedure 2 SI
adequately recorded and to decent communicate death to
communicated relatives
2 RR/SI
SNCU has system for conducting
grievance counselling of parents in
case of newborns' mortality
record
ME E16.2 The facility has standard 2 SI/RR
procedures for handling the death Death note including efforts done for
in the hospital resuscitation is noted in patient
record
Procedure to declare death for 2 SI/RR
brought in dead cases
2 SI/RR
Death summary is given to patient
cause and underlying cause if possible
12 12
ME E20.1 The facility provides immunization Immunization services as per national
services as per guidelines guidelines
zero dose, system of ensuing
2 SI/RR immunization
ME E20.2 Triage, Assessment & Management
of newborns having
emergency signs are done as per
guidelines
Adherence to clinical protocol 2 SI/RR As per FBHC guidelines
ME E20.3 Management of Low birth weight
newborns is done as per
guidelines
Adherence to clinical protocol 2 SI/RR As per FBNC guidelines
ME E20.4 Management of children with
Jaundice is done as per guidelines
ME E20.5 Management of neonatal sepsis is
done as per guidelines Adherence to clinical protocol 2 SI/RR As per FBNC guidelines
ME E20.6 Management of neonatal
jaundice is done as per guidelines
12 12
Standard F1
The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated
infection
The facility has provision for
Passive and active culture
surveillance of critical & high risk
areas Surface and environment samples are Swab are taken from infection
ME F1.2 taken for microbiological surveillance 2 SI/RR prone surfaces
The facility measures hospital
There is procedure to report cases of purulent discharge from surgical
ME F1.3 Hospital acquired infection 2 SI/RR site .
There is Provision of Periodic There is procedure for immunization
Medical Check-up and of the staff
Periodic medical checkups of the staff
2 SI/RR
The facility has established Hand washing and infection control
procedures for regular monitoring audits done at periodic intervals
of infection control practices
Regular monitoring of infection
The facility has defined and Check for Doctors are aware of
ME F1.6 established antibiotic policy Hospital Antibiotic Policy 2 SI/RR
24 24
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Page 104

nce/Full t Method
/
Partial/
No
Hand washing facilities are Availability of hand washing Facility at

FNBC guideline: Each unit should
provided at point of use Point of Use
have at least 1 wash basin for every
ME F2.1 2 OB 5 beds
Availability of Alcohol based Hand rub
Check for availability/ Ask staff for
regular supply. Hand rub dispenser
2 OB/SI are provided adjacent to bed
Display of Hand washing Instruction at
Point of Use Prominently displayed above the
hand washing facility , preferably in
2 OB Local language
Availability of elbow operated taps 2 OB
Hand washing sink is wide and deep
enough to prevent splashing and
retention of water
2 OB
washing practices and they washing
adhere to standard hand washing
practices
Mothers are practicing wash hand
washing with soap 2 PI/OB
The facility ensures standard Availability of Antiseptic Solutions
practices and materials for
antisepsis
ME F2.3 2 OB
16 16
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate
personal protection Equipment as
per requirements Clean gloves are available at point of Handwashing b/w each patient &
ME F3.1 use 2 OB/SI change of gloves
Availability of Mask 2 OB/SI
Availability of gown/ Apron 2 OB/SI Staff and visitors
Availability of shoe cover 2 OB/SI Staff and visitors
Availability of Caps 2 OB/SI Staff and visitors
Personal protective kit for infectious
patients 2 OB/SI HIV kit
The facility staff adheres to
standard personal protection
practices No reuse of disposable gloves, Masks,
ME F3.2 caps and aprons. 2 OB/SI
28 28
Standard F4 The facility has standard procedures for processing of equipment and instruments
The facility ensures standard Cleaning & Decontamination of
practices and materials for patient care Units
decontamination and cleaning of
instruments and procedures areas
Cleaning of Radiant warmer,
Incubators and Bassinets with
ME F4.1 2 SI/OB detergent water
Decontamination for thermometer,

Stethoscope, Suction apparatus,
Proper Decontamination of ambu bag 70% Alcohol or
instruments after use 2 SI/OB detergent water as applicable
Contact time for decontamination is 10 minutes
adequate 2 SI/OB
Proper handling of Soiled and infected No sorting ,Rinsing or sluicing at
linen 2 SI/OB Point of use/ Patient care area
solution 2 SI/OB
The facility ensures standard Equipment and instruments are Autoclaving/HLD/Chemical
practices and materials for sterilized after each use as per Sterilization
disinfection and sterilization of requirement
instruments and equipment
ME F4.2 2 OB/SI
per protocol
2 OB/SI
Autoclaving of instruments is done as Ask staff about temperature,
per protocols 2 OB/SI pressure and time
instruments/equipments is done as concentration and contact time
per protocols required for chemical sterilization
2 OB/SI
Autoclaved linen are used for
procedure 2 OB/SI
Autoclaved dressing material is used 2 OB/SI
There is a procedure to ensure the
traceability of sterilized packs 2 OB/SI
Sterility of autoclaved packs is Sterile packs are kept in clean, dust
maintained during storage 2 OB/SI free, moist free environment.
34 34
conducive for the infection control
practices Facility layout ensures separation of
ME F5.1 general traffic from patient traffic 2 OB
Facility layout ensures separation of
routes for clean and dirty items 2 OB
SNCU has double door system 2 OB
There is separation between in born
and out born unit 2 OB by glass pane
Floors and wall surfaces of SNCU are
easily cleanable 2 OB
Page 105

nce/Full t Method
/
Partial/
No
The facility ensures standard Staff is trained for spill management

practices are followed for the
cleaning and disinfection of patient
care areas
ME F5.3 2 SI/RR
Staff is trained for preparing cleaning
solution as per standard procedure 2 SI/RR
not used in patient care areas Any cleaning equipment leading to
Use of three bucket system for
mopping 2 OB/SI
Fumigation/carbolization as per
schedule 2 SI/RR
External foot wares are restricted 2 OB
The facility ensures segregation
infectious patients Isolation and barrier nursing
The facility ensures air quality of high SNCU has system to maintain Ventilation can be provided in two
risk area ventilation and its environment ways: exhaust only and supply-and-
should be dust free exhaust. Exhaust fans pull stale air
out of the unit while drawing fresh
air in through cracks, windows or
fresh air intakes. Exhaust-only
ventilation is a good choice for
units that do not have existing
ductwork to distribute heated or
cooled air
ME F5.5 2 OB
30 30
Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous
Waste.
Facility Ensures segregation of Bio Availability of colour coded bins at Adequate number. Covered. Foot
Medical Waste as per guidelines point of waste generation operated.
ME F6.1 2 OB

Segregation of Anatomical and solied blood components.
waste in Yellow Bin 2 OB/SI

Segregation of infected plastic waste syringes) and vaccutainers with
in red bin 2 OB their needles cut) and gloves
Biomedical waste
2 OB
general waste 2
Facility ensures management of Availability of functional needle OB See if it has been used or just lying
(translucent) Puncture proof, Leak with fixed needles, needles from
proof, tamper proof containers needle tip cutter or burner,
scalpels, blades, or any other

Staff knows what to do in condition of 2 SI Staff knows what to do in case of
needle stick injury shape injury. Whom to report. See
Contaminated and broken Glass are 2 Vials, slides and other broken
disposed in puncture proof and leak infected glass
proof box/ container with Blue colour
marking
OB
Facility ensures transportation Check bins are not overfilled
and disposal of waste as per
guidelines
ME F6.3 2 SI/OB
Disinfection of liquid waste before
disposal 2 SI/OB
Transportation of bio medical waste is
done in close container/trolley 2
management 2 SI/RR
2 2
ME G1.1 The facility has a quality team in There is a designated 2 SI/RR
place departmental nodal person for
activities
2 2
Standard G2 The facility has established system for patient and employee satisfaction
conducted at periodic intervals
Patient relative satisfaction survey
done on monthly basis
4 4
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.
ME G3.1 The facility has established There is system daily round by 2 SI/RR
internal quality assurance matron/hospital manager/ hospital
programme in key departments superintendent/ Matron in charge
for monitoring of services
Page 106

nce/Full t Method
/
Partial/
No
ME G3.3 The facility has established system Departmental checklist are used 2 SI/RR Staff is designated for filling and
for use of check lists in different for monitoring and quality monitoring of these checklists
24 24
Standard G4
support services.
approved

with process owner
ME G4.2 Standard Operating Procedures Department has documented 2 RR Check availability of documented
adequately describes process and procedure for ensuring patients rights procedure for taking consent,
procedures including consent, privacy, maintenance of privacy,
confidentaility & entitlement confidentaility & entitlements
Department has documented 2 RR Check availability of risk

proedure for safety & risk management record/register to
management identify risk & action taken to
address them
Department has documented 2 RR Documented procedure for

procedure for support services & preventive- break down
facility mangement. maintenance and calibration of
equipments, Maintenance of
infrastructure, inventory
management & storage, retaining
,retrieval of SNCU records
Department has documented 2 RR Availability of documented criteria

procedure for general patient care & procedure for triage, admission,
processes assessment & re assesment,
referral & discharge of the patient
Department has documented 2 RR SNCU has documented procedure

procedure for specific processes to for key clinical processes including
the department resuscitatio,thermoregulation of
new borns, ,drugs,intravenous,and
fluid management and nutrition
management of new borns

procedure for infection control & bio procedure for infection control
medical waste mangement practices& BMW
Department has documented 2 RR Check availbility of documented
procedure for quality management & procedure for departmental
improvement quality actvities viz: nomination of
department Nodal officer, internal
assessments, audits, patient
satsifection survey, internal &
external quality assurance
processes,
Depatment has documented 2 RR Check availbility of documented

procedure for data collection, analysis departmanental Data set need to
& use for improvement be measured monthly & procedure
for their collection, analysis &
improvement
ME G4.3 Staff is trained and aware of the Check staff is a aware of relevant part 2 SI/RR
procedures written in SOPs of SOPs
ME G4.4 Work instructions are displayed at 2 OB

Point of use
STP for phototherapy, Grading and

management of hypothermia,
Expression of milk\, Monitoring of
babies receiving I/V, Precaution for
phototherapy, Management of
hypoglycaemia, housekeeping
protocols, Administration of
commonly used drugs, assessment
of neonatal sepsis, Assessment of
Work instruction/clinical protocols Jaundice, Temperature
are displayed maintenance etc
6 6
ME G5.1 The facility maps its critical Process mapping of critical processes 2 SI/RR
processes done
ME G5.2 The facility identifies non value 2 SI/RR
adding activities / waste /
redundant activities Non value adding activities are
identified
ME G5.3 The facility takes corrective action Processes are rearranged as per 2 SI/RR
to improve the processes requirement
10 10
ME G6.1 The facility conducts periodic Internal assessment is done at 2 RR/SI
internal assessment periodic interval
ME G6.2 The facility conducts the periodic 2 RR/SI
prescription/ medical/death
audits There is procedure to conduct New
born Death audit
ME G6.3 The facility ensures non Non Compliance are enumerated and 2 RR/SI
compliances are enumerated and recorded
recorded adequately
ME G6.4 Action plan is made on the gaps 2 RR/SI
found in the assessment / audit
process
ME G6.5 Corrective and preventive actions 2 RR/SI
are taken to address issues,
observed in the assessment &
audit Corrective and preventive action
taken
Check short term valid quality 6 6
Standard G7 The facility has defined mission, values, Quality policy & objectives & preparedobjectivities
a strategic plan
have beento achieve them
framed
ME G7.4 2 SI/RR each department and cores
Facility has de defined quality are Specific, Measurable,
objectives to achieve mission and Check if SMART Quality Objectives Attainable, Relevant and Time
quality policy have framed Bound.
Page 107

nce/Full t Method
/
Partial/
No
ME G7.5 2 SI/RR

Mission, Values, Quality policy and awareness. Check if Mission
objectives are effectively Statement, Core Values and Quality
communicated to staff and users of Check of staff is aware of Mission , Policy is displayed prominently in
services Values, Quality Policy and objectives local language at Key Points
Page 108

nce/Full t Method
/
Partial/
No
ME G7.7 2 SI/RR
Review the records that action plan

on quality objectives being
by departmnetal incharges and
Facility periodically reviews the The progress on quality objectives
progress of strategic plan towards Check time bound action plan is being have been recorded in Action Plan
mission, policy and objectives reviewed at regular time interval tracking sheet
6 6
ME G8.1 The facility uses method for Basic quality improvement method 2 SI/RR PDCA & 5S
quality improvement in services

method
ME G10.6 2 SI/RR
Periodic assessment for Medication medication and patient care safety all clincial processes should be
and Patient care safety risks is done risk is done using defined checklist done using pre define critera at
as per defined criteria. periodically least once in three month.
12 12
ME H1.1 Facility measures productivity 2
Indicators on monthly basis no. of babies weighting less than
1.8 kg admitted / Total admission in
Inborn Admission rate RR SNCU in Month
Propration of admission which is 2
outborn RR
Bed Occupancy rate 2 RR
Propration oof female baboes 2
admitted
LAMA rate for female babies 2
Proporation of BPL patients 2
ME H2.1 Facility measures efficiency 2
Indicators on monthly basis No. of very low birth weight babies
Proporation of very low birth weight (< 1200 gm)/No. of Low birth+ Very
babies survived RR low birth babies
2
Down time Critical Equipments RR
2
Bed turn out rate
Referral Rate 2 RR
Survival rate 2
RR Discharge rate
No. of drug stock out in SNCU 2
ME H3.1 Facility measures Clinical Care & Average waiting time for initial 2
Safety Indicators on monthly basis assessment of new born RR
Proportion of new born death among 2
inborn RR
Case fatality rate 2
2
Proportion of asphyxiated new born
babies admitted out of deliveries
conducted at facility
Antibiotic use rate 2 RR
2
Average length of stay RR

2 Baby theft, wrong drug
administration, needle stick injury,
Adverse events are reported RR absconding patients etc
2
No. of newborn resuscitated

2
% of environmment swab cultutre
reported positive
4 4
ME H4.1 Facility measures Service Quality LAMA Rate 2
Indicators on monthly basis RR
Attendent satisfaction score 2

A 26 26 100%
B 64 64 100%
C 170 170 100%
D 124 124 100%
E 204 204 100%
F 144 144 100%
G 62 62 100%
H 46 46 100%
Total 840 840 100%
0
1
2
Page 109
Checklist -7 NRC Version- NHSRC/3.0
National Quality Assurance Standards for District Hospitals Version-2

Checklist for Nutrition Rehabilitation Center (NRC) 7
Assessment Summary

Date
NRC Score Card

Area of Concern wise Score NRC Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for NRC

Reference no. Measurable Elements Checkpoint Compliance/Full/ Assessment Means of verification Remarks
Partial/No Method
Standard A1 Facility Provides Curative Services 4 4

ME A1.4 The Facility Provides Paediatric Services Availability of functional NRC 2 SI/OB For detail service provision kindly
refer A2.4
ME A1.14 Services are available for the time period Availability of nursing care services 2 SI/RR
as mandated 24X7
ME A2.4 The Facility provides child health Management of hypoglycaemia as 2
Services per the guideline SI/RR
Management of hypothermia as per 2
the guideline SI/RR
Management of dehydration in the 2
children with SAM, without shock as
per the guideline
SI/RR
Management of SAM child with 2
shock as per the guideline SI/RR
Management of infection is done as 2

per the guideline. SI/RR
Management of SAM children less 2
than 6 month SI/RR
Management of SAM in HIV 2
exposed/HIV infected and TB
infected children as per the
guideline
SI/RR
Provision of Therapeutic feeding as 2
per guideline SI/RR/OB
Counselling on appropriate feeding, 2
care and hygiene as per guideline SI/RR/OB
Demonstration and practice- by 2
-doing on preparation of energy
dense child food using locally
available item
SI/RR/OB
ME A3.2 The Facility Provides Laboratory Services 2 Availability of Side lab. Blood
glucose, Haemoglobin, Serum
electrolyte, TLC, DLC, urine
routine, urine culture,Mantoux
test, HIV (after counselling) and
NRC has facility /Linkage for any specific test based on local
laboratory investigation and geographic needs like coeliac
disease and malaria. If linkage to
outside lab than give partial
compliance
SI/OB
Standard A5 Facility provides support services 2 2
ME A5.1 The facility provides dietary services Availability of functional nutritional 2 SI/OB
services
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 20 20
ME B1.1 The facility has uniform and user- 2 OB (Numbering, main department
friendly signage system Availability departmental signage's and internal sectional signage
2 OB
displayed
ME B1.2 The facility displays the services and 2 OB
entitlements available in its
departments Service available at NRC are
displayed
Entitlement under JSSK and RBSY 2 OB
are displayed
Information about doctor/ Nurse on 2 OB
duty is displayed and updated
Contact information in respect of 2 OB
NRC referral services are displayed
ME B1.5 Patients & visitors are sensitised and 2 Display of pictorial information/
educated through appropriate IEC / BCC Display of information for chart regarding expression of milk,
approaches education of mother /care taker management of sick children with
OB SAM etc.,
2
Counselling aids are available for
education of the mother/care taker
OB
ME B1.6 Information is available in local language Signage's and information are 2
and easy to understand available in local language OB
ME B1.8 The facility ensures access to clinical Discharge summery is given to the 2 RR/OB
records of patients to entitled personnel patient
Standard B2
Services are delivered in manners that are sensitive to gender, religious, social and cultural needs and there are no barrier on account of 2 2
physical access, language, cultural or social status.
ME B2.1 Services are provided in manner that are Cots in NRC are large enough for 2 OB
sensitive to gender stay of mother with child
Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information. 6 6
ME B3.1 Adequate visual privacy is provided at Privacy is maintained at breast 2 OB
every point of care feeding area
ME B3.2 2 SI/OB
Confidentiality of patients records and Patient Records are kept at secure
clinical information is maintained place beyond access to general
staff/visitors
ME B3.3 The facility ensures the behaviours of Behaviour of staff is empathetic and 2 PI/OB
staff is dignified and respectful, while courteous
Standard B4
Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed 8 8
consent wherever it is required.
NRC has system in place to take
taking informed consent before informed consent from patient
treatment and procedures relative whenever required
ME B4.4 Information about the treatment is 2 PI
NRC has system in place to involve
shared with patients or attendants, patient relatives in decision making
regularly of patient treatment
2 PI/SI
NRC has system in place to provide
communication of child condition to
parents/ relatives at least once in
day
ME B4.5 Facility has defined and established 2 OB
displayed
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care. 24 24
ME B5.1 2 PI/SI
The facility provides cashless services to
pregnant women, mothers and neonates
as per prevalent government schemes
Availability of Free diagnostics
Availablity of Free drop back 2 PI/SI
Availablity of Free diet to patient 2 PI/SI
Availablity of Free Diet to mother 2 PI/SI
2 PI/SI
Availablity of Free patient transport
Availabliity of Free Blood 2 PI/SI
Availablity of Free drugs 2 PI/SI
Availablity of free stay in NRC 2 PI/SI
prescribed are available at Pharmacy spent on purchasing drugs or
and wards
prescribed investigations are available at spent on diagnostics from outside.
the facility
ME B5.5 2 PI/SI/RR
reimbursement of financial entitlements
and reimbursement to the patients If any other expenditure occurred it
is reimbursed from hospital
2 PI/SI/RR
NRC has system to provide Wage

compensation to mother/caregiver
for the duration of the stay at NRC
as per basic daily wages of the state
ME B 6.7 2 RR/SI
medical advice or refuse to receive specific c Declaration is taken from the LAMA
treatment patient
ME C1.1 Covered area for NRC should be
Departments have adequate space as NRC has adequate space as per
about 150 sq ft per bed with 30%
per patient or work load guideline
of ancillary area.
2 OB
ME C1.2 Patient amenities are provide as per
patient load Availability of drinking water 2 OB
Toilets for attendant/visitor 2 OB
Availability of sitting arrangement
for patient attendant 2 OB
Availability of separate Bathing
area and laundry area for mothers 2 OB
ME C1.3 Departments have layout and
demarcated areas as per functions Availability of nursing station 2 OB
Receiving room with examination
area 2 OB
Clean area for mixing intravenous
fluids and Medications/ fluid
preparation area 2 OB
Availability of Doctors duty room 2 OB
Availability of dirty utility area 2 OB
Availability of breast feeding
corner/ Area for expression of
breast milk
2 OB
Availability of unit stores 2 OB
NRC has designated play area and
counselling room in proximity to
NRC ward 2 OB
NRC has designated kitchen area in
proximity to NRC ward 2 OB
NRC has separate washing area 2 OB

ME C1.4 The facility has adequate circulation area
and open spaces according to need and Space between two beds should
local law be at least 4 ft and clearance
between head end of bed and wall
There is sufficient space between should be at least 1 ft and
two bed to provide bed side nursing between side of bed and wall
care and movement 2 OB should be 2 ft
equipment movement 2 OB Corridor should be 3 meters wide
ME C1.5 The facility has infrastructure for
and Intercom Services 2 OB
ME C1.6 Service counters are available as per Availability of adequate beds as per
patient load case load 2 OB
ME C1.7 The facility and departments are
function/processes (Structure NRC should be in proximity with
commensurate with the function of the Paediatric/in patient facility
hospital)
2 OB

direct observation of patients 2 OB
Standard C2 Facility ensures the physical safety of the infrastructure. 8 8
ME C2.1 The facility ensures the seismic safety of Non structural components are 2 OB Check for fixtures and furniture
the infrastructure properly secured like cupboards, cabinets, and
secured
ME C2.3 The facility ensures safety of electrical NRC does not have temporary 2 OB
establishment connections and loosely hanging Switch Boards other electrical
wires installations are intact
ME C2.4 Physical condition of buildings are safe Floors of the NRC are non slippery 2 OB
for providing patient care and even
Windows covered with mosquito 2 OB
and fly covers
Standard C3 Facility has established program for fire safety and other disaster 10 10
ME C3.1 The facility has plan for prevention of fire NRC has sufficient fire exit to 2 OB/SI
permit safe escape to its occupant
at time of fire
clearly marked.
ME C3.2 The facility has adequate fire fighting NRC has installed fire Extinguisher 2 OB
Equipment that is Class A , Class B C type or
ABC type

training of staff and conducts mock drills operating fire extinguisher and what
regularly for fire and other disaster to do in case of fire
situation
Standard C4 Facility has the appropriate number of staff with the correct skill mix required for providing the assured services to the current case load 14 14
ME C4.2 The facility has adequate general duty Availability of Medical officer 2 OB/RR
work load Availability of 1 Medical officer
per 10 bed
ME C4.3 The facility has adequate nursing staff as Availability of Nursing staff 2 OB/RR/SI
per service provision and work load
Availability of 4 Nursing staff for
10 bedded NRC
ME C4.5 The facility has adequate support / Availability of nutrition counsellor 2 SI/RR Availability of 1 Nutrition
general staff Counsellor for 10 bedded NRC
Availability of cook 2 SI/RR Availability of one cook cum care
taker
Availability of cleaner/ Attendant 2 SI/RR Availability of 2 attendant/cleaner
Availability of Medical social worker 2 SI/RR Availability of 1 Medical Social

Worker
Availability of security staff 2 SI/RR 1 Security staff per shift

Standard C5 Facility provides drugs and consumables required for assured list of services. 20 20
ME C5.1 The departments have availability of OB/RR
adequate drugs at point of use Inj. Ampicillin with Cloxacillin, Inj.
Availability of Antibiotics Ampicillin
Inj. Cefotaxime
2 Inj. Gentamicin,
Availability of analgesics and OB/RR
antipyretics 2 Paracetamol
OB/RR
Ringer's lactate solution with 5%
Availability of IV Fluids glucose,0.45%(half normal) saline
with 5% glucose,0.9%saline(for
2 soaking eye pads)
OB/RR
Metronidazole, Tetracycline or
Availability of other drugs Chloramphenicol eye drops,
2 Atropine eye drops
OB/RR
ORS, Potassium chloride,
Magnesium chloride/sulphate,
Electrolyte and minerals Iron syrup, multivitamin, folic acid,
Vitamin A syrup, Zinc sulphate or
dispersible Zinc tablets,
2 Glucose(or sucrose)
Availability of drugs for OB/RR
management of SAM in HIV Antiretroviral drugs,
exposed 2 cotrimoxazole prophylaxis
consumables at point of use Availability of dressings material
2 Gauze piece and cotton swabs.
Availability of syringes and IV Sets OB/RR Cannulas, IV sets, paediatric
/tubes 2 nasogastric tubes
Availability of Antiseptic Solutions 2 OB/RR Antiseptic lotion
ME C5.3 Emergency drug trays are maintained at Emergency Drug Tray is maintained OB/RR
every point of care, where ever it may
be needed
2
Standard C6 Facility has equipments & instruments required for assured list of services. 24 24
ME C6.1 Availability of equipment & instruments Availability of functional
for examination & monitoring of Equipment &Instruments for Thermometers, Weighing
patients examination & Monitoring scales(digital),Infantometer,Stadio
2 OB meter,
ME C6.3 Availability of equipment & instruments Availability of Point of care
for diagnostic procedures being diagnostic instruments
2 OB Glucometer
ME C6.4 Availability of equipment and Availability of functional
instruments for resuscitation of patients Instruments for Resuscitation.
and for providing intensive and critical
care to patients
2 OB
ME C6.5 Availability of Equipment for Storage Availability of equipment for OB Refrigerator, Crash cart/Drug
storage for drugs trolley, instrument trolley,
dressing trolley
2
ME C6.6 Availability of functional equipment and Availability of kitchen equipments OB Cooking Gas, Dietary scales (to
instruments for support services weigh to 5 gms.), Measuring jars,
Electric Blender (or manual
whisks),Water Filter,Refrigrator,
Utensils (large containers, cooking
utensils, feeding cups, saucers,
spoons, jugs etc.)
2
Availability of equipments for OB Buckets for mopping, mops,
cleaning 2 duster, waste trolley, Deck brush
Availability of equipment for OB Boiler
sterilization and disinfection 2
ME C6.7 Departments have patient furniture and Availability of patient beds OB
fixtures as per load and service provision
2
OB
accessories with patient bed 2 locker , IVstand, Bed pan, bed rail
Availability of Fixtures OB Electrical fixture for equipments
2 like suction, X ray view box
OB
cupboard, nursing counter, table
Availability of furniture 2 chair.
Availability of toys 2 OB Washable toys
ME C7.1 RR/SI

competence of doctors, nurses
2
and paramedical staff based on
job description defined for each
Check parameters for assessing cadre of staff. Dakshta checklist
Criteria for Competence assessment are skills and proficiency of clinical staff issued by MoHFW can be used for
defined for clinical and Para clinical staff has been defined this purpose.
ME C7.2 RR/SI
Competence assessment of Clinical and Para checklist, scoring and grading .
clinical staff is done on predefined criteria Check for competence assessment Verify with staff for actual
at least once in a year is done at least once in a year competence assessment done
ME C7.9 The Staff is provided training as per defined Facility based care of Severe acute 2 SI/RR
core competencies and training plan malnutrition
ME C7.10 2 SI/RR
rounds of department and
monitor that staff is working
according to the training
There is established procedure for utilization imparted. Also staff is provided on
of skills gained thought trainings by on -job Nursing staff is skilled for job training wherever there is still
supportive supervision maintaining clinical records gaps
2 SI/RR
imparted. Also staff is provided on
Staff is skilled for nutritional job training wherever there is still
assessment of baby gaps
Standard D1 Facility has established program for inspection, testing and maintenance and calibration of equipments. 6 6
ME D1.1 The facility has established system for All equipments are covered under SI/RR
maintenance of critical Equipment AMC including preventive Glucometer,Infantometer,
maintenance Resuscitation equipments,
2
SI/RR
equipments 2
ME D1.2 The facility has established procedure All the measuring equipments/ OB/ RR
measuring Equipment
2
forecasting and indenting drugs and There is established system of Requisition are timely placed
consumables timely indenting of consumables
,drugs and food material
dosages only
ME D2.3 The facility ensures proper storage of 2 OB
Drugs are stored in
labelled
labelled
Food items are stored at 2 OB/RR
2
for inventory management techniques maintaining buffer stock

consumables
replenishing the drugs in patient care areas drug tray /crash cart
and other drugs, requiring controlled Temperature of refrigerators are maintained and updated
temperature kept as per storage requirement periodically
station 2
Adequate illumination in patient OB
care areas 2
ME D3.2 The facility has provision of restriction of OB/PI
visitors in patient areas Visiting hour are fixed and practiced 2
There is no overcrowding in the OB
wards during to visitors hours 2
One female/ family members OB/SI
allowed to stay with the child 2
ME D3.3 The facility ensures safe and Temperature control and ventilation PI/OB Room kept between 25° - 30° C (to
comfortable environment for patients in patient care area the extent possible) Fans/ Air
and service providers conditioning/Heating/Exhaust/Ve
ntilators as per environment
2
Safe measures used for re-warming SI/OB Check availability of Blankets to
children 2 cover the children
Temperature control and ventilation SI/OB Fans/ Air
in nursing station/duty room conditioning/Heating/Exhaust/Ve
2
Side railings has been provided to OB
prevent fall of patient 2
ME D3.4 The facility has security system in place NRC has system for identification OB
at patient care areas tagging for babies if baby is less
than 6 months
2
Security arrangement in NRC 2 OB/SI
ME D3.5 The facility has established measure for Ask female staff weather they feel SI
safety and security of female staff secure at work place 2
plastered & painted
Walls of patient care area are 2 OB
brightly painted and decorated
ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof topes, sinks 2 OB
patient care and circulation areas All area are clean with no
clean

fixtures are intact
2 OB
Patients beds are intact and painted
Mattresses are Intact and clean 2 OB
ME D4.5 The facility has policy of removal of No condemned/Junk material in the 2 OB
condemned junk material NRC
storage and supply for portable water in potable water
patient care areas
ME D6.1 The facility has provision of nutritional NRC has system in place to assess 2 RR/SI/PI Check appetite test for SAM baby
assessment of the patients appetite of baby based on their is done as per standard guideline
nutritional needs
NRC has system to assess feeding 2 RR/SI/PI Counselling is done by nutrition

problems of child and provide counsellor
individual counselling to mother
NRC has system to access 2 RR/SI As per standards guideline
requirement and dose of
micronutrient of SAM children as
per their age
ME D6.2 The facility provides diets according to NRC has system to provides diet to 2 RR/SI/OB Management of SAM are based
nutritional requirements of the patients children based on their clinical on 3 phases: Stabilization Phase,
condition/ Medical complication Transition Phase and
rehabilitation phase
Starter diet (F-75) is given to child 2 RR/SI/OB Feeding should begin as soon as
just after admission. possible after admission with
‘Starter diet’ until the child is
stabilized
Catch up diet (F-100) is given to the 2 RR/SI/OB Catch up diet is started when child
child. is clinically stable and can tolerate
increased energy and protein
intake .Quantity of catch up diet
given is equal to Quantity of
starter diet given in stabilization
phase
ME D6.3 Hospital has standard procedures for F-75 and F-100 made as per the 2 SI F-75 and F-100 refers to the
preparation, handling, storage and guideline. specific combination of calories
distribution of diets, as per requirement of proteins, electrolytes and minerals
patients that should be delivered to
children with SAM as per WHO
guidelines made available for this
purpose.
The cook prepare special diet for 2 SI

children under the supervision of
the Nutrition counsellor.
Check raw material is kept in closed 2 OB
air tight containers
Check all perishable items are kept 2 OB
refrigerator
NRC has system to monitor the 2 RR
amount of food served to baby as
per guideline
NRC has system to monitor the 2 RR Check any system to left over
amount of feed left over as per recorded
guideline

occupied bed
2 OB/RR
mackintosh
washing of linen cleanliness and Quantity of the linen
Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 8 8
ME D11.2 The facility has a established procedure There is procedure to ensure that 2 RR/SI Check for system for recording
for duty roster and deputation to staff is available on duty as per duty time of reporting and relieving
different departments roster (Attendance register/ Biometrics
etc)

department
ME D11.3 The facility ensures the adherence to 2 OB
dress code as mandated by its
administration / the health department Doctor, nursing staff and support
staff adhere to their respective
dress code
Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations 2 2
ME D12.1 There is established system for contract 2 SI/RR Verification of outsourced services
management for out sourced services (cleaning/
Dietary/Laundry/Security/Mainten
There is procedure to monitor the ance) provided are done by
quality and adequacy of outsourced designated in-house staff
services on regular basis
ME E1.1 The facility has established procedure Unique identification number is 2 RR
for registration of patients given to each patient during process
of registration
ME E1.2 The facility has a established procedure Screening of children coming to 2
for OPD consultation OPDs using weight for height
and/or MUAC
ME E1.3 There is established procedure for There is no delay in admission of 2
admission of patients patient
2 SI/RR NRC has criteria for admission of
children from 6-59 months and
less than 6 month as per standard
Admission criteria for NRC is defined guideline.
& followed
2 SI/RR Child previously discharged from
in-patient care but meets
NRC has established criteria for re admission criteria again.
admission
2 SI/RR Child who returns after default
(away from in-patient care for 2
consecutive days) and meets the
NRC has established criteria for admission criteria.
return after default
patient record
managing patients, in case beds are not Procedure cope with surplus patient
available at the facility load
ME E2.1 There is established procedure for initial
assessment of patients Initial assessment of all admitted
patient done as per standard
protocols
2 RR/SI
Patient History is taken and RR
recorded 2
Physical Examination is done and RR
2 RR/SI
Initial assessment is documented

preferably within 2 hours 2 RR
ME E2.2 There is established procedure for There is fixed schedule for
follow-up/ reassessment of Patients reassessment by Medical
Officer/Nutrition Counsellor 2 RR/OB
ME E3.1 The facility has established procedure There is a procedure for 2
for continuity of care during consultation of the patient to
interdepartmental transfer other specialist with in the
hospital
RR/SI
ME E3.2 The facility provides appropriate referral 2
linkages to the patients/Services for
transfer to other/higher facilities to assure
the continuity of care.
2 To and back transport for the
mother and the child with SAM
children
Referral vehicle is being arranged SI/RR
maintained RR
linkages to higher facilities SI/RR lower facilities

referred patients
ME E3.3 A person is identified for care during all Duty Doctor and nurse is assigned 2 RR/SI
steps of care for each patients
ME E4.1 Procedure for identification of patients There is a process for ensuring the 2 OB/SI
procedure Identification tags are used for
children less than 5 yrs
ME E4.2 Procedure for ensuring timely and accurate Treatment chart are maintained 2 RR Check for treatment chart are
nursing care as per treatment plan is updated and drugs given are
established at the facility marked. Co relate it with drugs
and doses prescribed. dispensing
feed, time of oral drugs,
supervision of intravenous fluids .
There is a process to ensue the 2 SI/RR Verbal orders are rechecked

accuracy of verbal/telephonic before administration
orders
ME E4.3 There is established procedure of Patient hand over is given during 2 SI/RR
patient hand over, whenever staff duty the change in the shift
change happens
maintained
ME E4.5 There is procedure for periodic Patient Vitals are monitored and 2 RR/SI Check for TPR chart, weight
monitoring of patients recorded periodically records any other vital required is
monitored
Critical patients are monitored 2 RR/SI
continually
ME E5.1 The facility identifies vulnerable patients Vulnerable patients are identified 2 OB/SI Check the measure taken to
and ensure their safe care and measures are taken to protect prevent new born theft, sweeping
them from any harm and baby fall
ME E5.2 The facility identifies high risk patients and High risk patients are identified and 2 OB/SI
ensure their care, as per their need treatment given on priority
Standard E6 The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use. 10 10
prescribed in generic name only
prescribed under generic name only
ME E6.2 There is procedure of rational use of drugs Check for that relevant Standard 2 RR
treatment guideline are available at
point of use
as per STG
ME E7.1 There is process for identifying and High alert drugs available in 2 SI/OB Electrolytes like Potassium
cautious administration of high alert department are identified chloride, Opioids, Neuro muscular
drugs blocking agent, Anti thrombolytic
agent, insulin, warfarin, Heparin,
applicable
doctor

avoided
ME E7.3 There is a procedure to check drug Drugs are checked for expiry and 2 OB/SI
before administration/ dispensing other inconsistency before
administration
Check single dose vial are not used 2 OB Check for any open single dose
for more than one dose vial with left over content
indented to be used later on
used every time for multiple dose In multi dose vial needle is not left
vial in the septum
ME E7.4 There is a system to ensure right Fluid and drug dosages are 2 SI/RR Check for calculation chart
medicine is given to right patient calculated according to body weight
Drip rate and volume is calculated 2 SI/RR Check the nursing staff how they
and monitored calculate Infusion and monitor it
2 SI/OB
ME E7.5 Patient is counselled for self drug Mother is advice by doctor/ 2 PI/SI
administration. Pharmacist /nurse about the
investigations are recorded and updated
Day to day progress of patient is
recorded in BHT
ME E8.2 All treatment plan prescription/orders Treatment plan, first orders are 2 RR Treatment prescribed inj nursing
ME E8.4 Procedures performed are written on Procedure performed are recorded 2 RR
patients records in BHT
available at point of use Availability of formats for
Standard Formats are available Treatment Charts, Community
follow up card, BHT, continuation
sheet, Discharge card Etc.
guidelines
register, OT register, Diet register,
Registers and records are Linen register, Drug intend
maintained as per guidelines register
and numbered
storage and retrieval of medical records
ME E9.1 Discharge is done after assessing patient 2 SI/RR Discharge criterion for all infants
readiness and children is 15% weight gain
NRC has established criteria for and no signs of illness
discharge of the patient
discharging patient
before discharge
2 SI/RR
patients
discharge
2 RR
2 RR/SI By local CHW (Community health
There is procedure for clinical follow care worker)/ASHA/AWW. Follow
up of the child for assessment and up also includes enrolment of
monitoring of growth and baby to Anganwadi centre and
development till the child recovers provide Supplementary food
completely
ME E9.3 Counselling services are provided as 2
during discharges wherever required
Preparation and feeding the child,
how to give prescribed
Counselling of mothers/caregiver medication, folic acid, vitamins
before discharge and iron at home, how to give
home treatment for diarrhoea,
fever and acute respiratory
PI/SI infections
2 RR/SI
about the nearest health centre for
further follow up
Time of discharge is communicated 2 PI/SI
to patient in prior
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management 6 6
ME E11.1 There is procedure for Receiving and Triaging of sick children as per 2 SI/RR
triage of patients guideline
plan in place
disaster is defined
Standard E12 The facility has defined and established procedures of diagnostic services 4 4
ME E12.1 There are established procedures for Container is labelled properly after OB
Pre-testing Activities the sample collection 2
ME E12.3 There are established procedures for NRC has critical values of various lab SI/RR
Post-testing Activities test 2
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 18 18
ME E13.8 There is established procedure for RR/SI if not available than how facility
issuing blood Paediatric blood bags are available 2 cope with it
RR Blood transfusion is required (1)
Hb is less than 4 g/dl (2) or if there
is respiratory distress and Hb is
Blood transfusion of SAM child is between 4 and 6 g/dl.
done as per standard Guideline 2
Blood is kept on optimum SI/RR
RR Give (1) whole blood 10 ml/kg
body weight slowly over 3 hours
(2) furosemide 1 mg/kg IV at the
Blood transfusion is monitored and start of the transfusion
patient recorded 2
SI/RR (1) Blood transfusion should not

be started until the child has
begun to gain weight.(2) Following
the transfusion, if the Hb remains
less than 4 g/dl or between 4 and
6 g/dl with continuing respiratory
distress, DO NOT repeat the
transfusion within 4 days
Staff is aware of conditions in which
blood transfusion is not
done/repeated 2
ME E13.10 There is a established procedure for RR
complication reaction is recorded and reported to
responsible person 2
Standard E17 The facility has established procedures for Antenatal care as per guidelines 2 2
women. Card”.
Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines 20 20
ME E20.1 The facility provides immunization Immunization services as per
services as per guidelines national guidelines 2 SI/RR
ME E20.2 Triage, Assessment & Management of
newborns having
emergency signs are done as per guidelines
Adherence to clinical protocol 2 SI/RR
ME E20.3 Management of Low birth weight
newborns is done as per guidelines Adherence to clinical protocol 2 SI/RR
ME E20.4 Management of neonatal asphyxia is
done as per guidelines Adherence to clinical protocol 2 SI/RR
ME E20.5 Management of neonatal sepsis is done
as per guidelines Adherence to clinical protocol 2 SI/RR
ME E20.6 Management of children with Jaundice
is done as per guidelines Adherence to clinical protocol 2 SI/RR
ME E20.8 Management of children with severe Staff is aware and practice of 10 SI (1) Treat /Prevent Hypoglycaemia
Acute Malnutrition is done as per General principles of routine care as (2) treat and prevent Hypothermia
guidelines per guideline (3) treat and prevent dehydration
(4) Correct electrolyte imbalance
(5) treat/ prevent infection (6)
Correct micro nutrient deficiency
(7) Start cautious diet (8) Achieve
catch up growth (9) Provide
sensory stimulation and emotional
support (10) Prepare follow up
after recovery
2
Staff is aware of Emergency SI/RR
treatment of shock and anaemia as
per guideline
2 Competence testing
Staff is aware of treatment of SI/RR
associated conditions like Vitamin A
deficiency, Dermatosis, Parasitic
worms, Continual diarrhoea and TB
as per guideline
Staff is aware of criteria for failure SI/RR
to respond to treatment as per
guideline
The facility measures hospital associated
infection rates Patients are observed for any sign
There is procedure to report cases purulent discharge from surgical
ME F1.3 of Hospital acquired infection 2 SI/RR site .
ME F1.4 Check-up and immunization of staff immunization of the staff 2 SI/RR Hepatitis B, Tetanus Toxid etc
staff 2 SI/RR
The facility has established procedures Hand washing and infection
Hand washing facilities are provided at Availability of hand washing Facility Check for availability of wash
ME F2.1 point of use at Point of Use 2 OB basin near the point of use
Display of Hand washing Instruction
at Point of Use Prominently displayed above the
washing practices and they adhere to washing
Mothers are aware of importance of
washing hands 2 PI
Mothers are practicing wash hand
washing with soap After using the toilet or changing
diapers and before feeding
2 PI/OB children
ME F2.3 and materials for antisepsis 2 OB
drawing blood, putting
2 Intravenous and urinary catheter
requirements Clean gloves are available at point Hand washing b/w each patient &
ME F3.1 of use 2 OB/SI change of gloves
The facility staff adheres to standard No reuse of disposable gloves,
ME F3.2 personal protection practices Masks, caps and aprons. 2 OB/SI
The facility ensures standard practices and Decontamination of operating & 2

materials for decontamination and cleaning Procedure surfaces
of instruments and procedures areas Ask stff about how they
decontaminate the procedure
surface like Examination table ,
Patients Beds
ME F4.1 SI/OB (Wiping with .5% Chlorine solution
2
Check for availability for 0.5

chlorine solution
Proper Decontamination of the instruments after use (Should
instruments after use SI/OB be at least for 10 minutes
Contact time for decontamination 2 10 minutes
is adequate SI/OB
Cleaning of instruments after 2
SI/OB decontamination
Proper handling of Soiled and 2 No sorting ,Rinsing or sluicing at
infected linen SI/OB Point of use/ Patient care area
Staff know how to make chlorine 2
solution SI/OB
Toys washed regularly, and after 2 Check for decontamination and
each child uses SI/OB washing of toys
The facility ensures standard practices and Equipment and instruments are 2 Autoclaving/HLD/Chemical
materials for disinfection and sterilization of sterilized after each use as per Sterilization
instruments and equipment requirement
ME F4.2 OB/SI
High level Disinfection of 2 Ask staff about method and time
per protocol
OB/SI
2
Autoclaved dressing material is used OB/SI
materials for cleaning and disinfection of requirement
patient care areas Chlorine solution, Gluteraldehye,
Availability of cleaning agent as per Hospital grade phenyle,
requirement 2 OB/SI disinfectant detergent solution
The facility ensures standard practices are Staff is trained for spill management
followed for the cleaning and disinfection of
patient care areas
ME F5.3 2 SI/RR
procedure
2 SI/RR
not used in patient care areas Any cleaning equipment leading
to dispersion of dust particles in
2 OB/SI air should be avoided
The facility ensures segregation infectious
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste. 28 28
ME F6.1 Medical Waste as per guidelines point of waste generation 2 OB operated.



Biomedical waste
2 OB
general waste 2
Facility ensures management of sharps Availability of functional needle OB See if it has been used or just lying
ME F6.2 as per guidelines cutters 2 idle.
Seggregation of sharps waste 2 OB Should be available nears the
(translucent) Puncture proof, Leak syringes with fixed needles,
proof, tamper proof containers needles from needle tip cutter or
burner, scalpels, blades, or any
other contaminated sharp object
This includes both used, discarded
and contaminated metal sharps

Staff knows what to do in condition 2 SI Staff knows what to do in case of
of needle stick injury shape injury. Whom to report. See
Contaminated and broken Glass are 2 Vials, slides and other broken
disposed in puncture proof and leak infected glass
proof box/ container with Blue
colour marking
OB
Facility ensures transportation and Check bins are not overfilled
ME F6.3 disposal of waste as per guidelines 2 SI/OB
Transportation of bio medical waste
is done in close container/trolley
2
management 2 SI/RR
Standard G1
ME G1.1 The facility has a quality team in place There is a designated 2 SI/RR
activities
The facility has established system for patient and employee satisfaction 2 2
Standard G2
ME G2.1 Patient satisfaction surveys are Patient relative satisfaction survey 2 RR

conducted at periodic intervals done on monthly basis
The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 4 4
Standard G3

quality assurance programme in key There is system daily round by
departments matron/hospital manager/ hospital
superintendent/ Matron in charge
for monitoring of services
ME G3.3 The facility has established system for Departmental checklist are used 2 SI/RR Staff is designated for filling
use of check lists in different for monitoring and quality and monitoring of these
departments and services assurance checklists
The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support 34 34
Standard G4 services.

approved
with process owner
ME G4.2 Standard Operating Procedures Department has documented 2 RR
adequately describes process and procedure for receiving and initial
procedures assessment of the patient

procedure for admission, shifting
and referral 0f patient
procedure for requisition of
diagnosis and receiving of the
reports
2 RR
procedure for counselling of Mother
for feeding, care and Hygiene
2 RR
Department have standard
procedures for management of
medical complications associated
with Severe Acute Malnutrition
2 RR
procedures for feeding of Child with
SAM
2 RR
procedure for management of SAM
children less than 6 month of age
2 RR
procedure for Management of SAM
in HIV exposed /HIV infected and TB
infected children
2 RR
procedure for Structures play
therapy and loving care
2 RR
equipment
2 RR
procedure for sorting, and
distribution of clean linen to patient
2 RR
procedures for demonstration and
practice of energy dense child food
2 RR
procedure for follow up of children
discharge from the NRC
ME G4.4 Work instructions are displayed at Point 2 OB
of use Appropriate feeding practices,
wall charts for assessment and
management of sick children with
SAM, Management of medical
complications, Triage, 10 steps for
Work instruction/clinical protocols management of SAM, Grading and
are displayed management of hypothermia,
Management of hypoglycaemia,
Management of Dehydration,
housekeeping protocols,
Administration of commonly used
drugs, etc
The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages 6 6
Standard G 5
ME G5.1 The facility maps its critical processes Process mapping of critical 2 SI/RR
processes done
identified
Standard G6
ME G6.2 The facility conducts the periodic There is procedure to conduct 2 RR/SI
prescription/ medical/death audits Death audit
ME G6.3 The facility ensures non compliances are Non Compliance are enumerated 2 RR/SI
enumerated and recorded adequately and recorded
ME G6.4 Action plan is made on the gaps found in 2 RR/SI

the assessment / audit process
ME G6.5 Corrective and preventive actions are 2 RR/SI PDCA
taken to address issues, observed in the
assessment & audit Corrective and preventive action
taken
6 6
ME G7.4 2 SI/RR

Facility has de defined quality objectives to Check if SMART Quality Objectives Attainable, Relevant and Time
achieve mission and quality policy have framed Bound.
ME G7.5 2 SI/RR
Mission, Values, Quality policy and Quality Policy is displayed
objectives are effectively communicated to Check of staff is aware of Mission , prominently in local language at
staff and users of services Values, Quality Policy and objectives Key Points
ME G7.7 2 SI/RR

Facility periodically reviews the progress of Check time bound action plan is The progress on quality objectives
strategic plan towards mission, policy and being reviewed at regular time have been recorded in Action Plan
The facility seeks continually improvement by practicing Quality method and tools. 6 6
Standard G8
ME G8.1 The facility uses method for quality Basic quality improvement method 2 SI/OB PDCA & 5S
method
ME G10.6 2 SI/RR
Periodic assessment for Medication and medication and patient care safety all clincial processes should be
Patient care safety risks is done as per risk is done using defined checklist done using pre define critera at
ME H1.1 Facility measures productivity Indicators on
monthly basis Total admissions 2 RR
Bed Occupancy Rate 2 RR
Proportion of admissions by gender 2 RR
Proportion of BPL Patients 2 RR
ME H2.1 Facility measures efficiency Indicators on Achieved target weight(15% weight
monthly basis gain) 2 RR
Down time Critical Equipments 2 RR
Bed Turnover Rate 2 RR
Referral Rate 2 RR
Discharge Rate 2 RR
Acceptable-<15%
Defaulter rate 2 RR Not Acceptable->25%
Relapse rate 2 RR
Average waiting time for admission
(mins) 2 RR
ME H3.1 Facility measures Clinical Care & Safety Acceptable- 1-4 week
Indicators on monthly basis Average length of stay in (weeks) 2 RR Not Acceptable-<1 and >6
Death rate following discharge from Acceptable- <5% Not Acceptable-
NRC 2 RR >15%
Recovery rate Acceptable- >75% Not
2 RR Acceptable- <50%
wrong drug administration,

needle stick injury, absconding
Adverse events are reported 2 RR patients etc
ME H4.1 Facility measures Service Quality Indicators LAMA Rate
Attendant Satisfaction Score 2 RR

A 28 28 100%
B 62 62 100%
C 134 134 100%
D 128 128 100%
E 200 200 100%
F 104 104 100%
G 72 72 100%
H 36 36 100%
Total 764 764 100%
0
1
2
Checklist No 8 Operation Theatre Version - NHSRC /3.0

Checklist for Operation Theatre 8
Assessment Summary

Type of Assessment (Internal/External) Date
Operation Theatre Score Card

Area of Concern wise Score Operation Theatre Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
G Quality 100%
Management
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for Operation Theatre

Reference No. ME Statement Checkpoint Complia Assessm Means of Verification Remarks
nce ent
Method
Page 122

nce ent
Method
18 18
ME A1.2 The facility provides General 2 SI/OB Appendectomy, Intestinal
Surgery services Obstruction, Perforation, Tongue Tie,
Availability of General Surgery Inguinal Hernia
procedures
ME A1.3 The facility provides Obstetrics & Availability of Gynaecology 2 SI/OB D & E, Hysterectomy . For Obstetric
Gynaecology Services procedures procedure kindly see A2.2
ME A1.4 The facility provides Paediatric 2 SI/OB I&D, Pepuceal Dilation, Meatomy,
Services Gland Biopsy, Reduction
Paraphimosis, Brachial/Thyoglossal
Cyst and Fistula, Inguinal
Herniotomy, Neonatal Intestinal
Availability of Paediatric Surgery Obstruction
procedure
ME A1.5 The facility provides 2 SI/OB Cataract Extraction with IOL,
Ophthalmology Services Canthotomy, Paracentesis,
Enucleation, Glaucoma, Cunjuctival
Availability of Ophthalmic Surgery Cyst,
procedures
ME A1.6 The facility provides ENT Services 2 SI/OB Nose, Ear and Throat surgical
procedures
Packing , Antral Puncture , Fracture
Reduction, Mastoid Abscess I &
D, Mastoidectomy Stapedotomy,
Adenoidectomy, Tonsillectomy
Availability of ENT surgical

procedure
ME A1.7 The facility provides Orthopaedics 2 SI/OB Open and Closed Reduction, Nailing
Services and Plating, Amputation,
Availability of Orthopaedic surgical Disarticulation of Hip and Shoulder
procedures
ME A1.10 The facility provides Dental Availability of Oral surgery 2 SI/OB Trauma Including Vehicular
Treatment Services procedures Accidents , Fracture Wiring
ME A1.14 Services are available for the time 2 SI/RR
period as mandated OT Services are available 24X7
ME A1.16 The facility provides Accident & Availability of Emergency OT
2 SI/OB
Emergency Services services as and even when
required
12 12
ME A2.1 The facility provides Reproductive Availability of Post partum 2 SI/OB tubal ligation
health Services sterilization services
ME A2.2 The facility provides Maternal 2 SI/OB
health Services Availability of C-section services
Availability of OT for Management 2 SI/OB
of complications
ME A2.3 The facility provides Newborn Availability of New born 2 SI/OB
health Services resuscitation
Availability of essential new born 2 SI/OB
care
ME A2.4 The facility provides Child health Availability of Paediatric surgical 2 SI/OB Developmental Dysplasia of
Services Procedure under RBSY the Hip,Congenital Cataract, cleft lip
and palate
4 4
ME A3.1 The facility provides Radiology Availability of C arm services 2 SI/OB
Services
ME A3.2 The facility Provides Laboratory Availability of point of care 2 SI/OB Blood gas analyser& USG
Services diagnostic test
4 4
ME A4.3 The facility provides services under 2 SI/OB
National Leprosy Eradication
Availability of Reconstructive
Surgery
Availability of Amputation Surgery 2 SI/OB
12 12
ME B1.1 The facility has uniform and user- Availability of departmental 2 OB (Numbering, main department and
friendly signage system signage's internal sectional signage
Signage for restricted area are 2 OB
displayed
Zones of OT are marked 2 OB
ME B1.2 The facility displays the services 2 OB
and entitlements available in its Display doctor/ Nurse on duty and
departments updated
OT schedule displayed 2 OB
ME B1.6 Signage's and information are 2 OB
Information is available in local available in local language
language and easy to understand
6 6
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on
account of physical, economic, cultural or social reasons.
ME B2.1 2 OB/SI Availability of female staff in pre and
Services are provided in manner post operative room
Availability of female staff if a male
that are sensitive to gender doctor examination/ conduct
surgery of a female patients
ME B2.3 2 OB
Access to facility is provided

without any physical barrier & and Availability of Wheel chair or
friendly to people with disabilities stretcher for easy Access to the OT
Page 123

nce ent
Method
12 12
ME B3.1 Adequate visual privacy is provided Availability of screen between OT 2 OB
at every point of care table
2 OB
Patients are properly
draped/covered before and after
produce
ME B3.2 Confidentiality of patients records Patient Records are kept at secure 2 SI/OB
maintained staff/visitors
2 SI/OB
unnecessary displayed
ME B3.3 Behaviour of staff is empathetic 2 PI/OB
The facility ensures the behaviours and courteous
of staff is dignified and respectful,
while delivering the services
ME B3.4 Privacy and Confidentiality of HIV 2 SI/OB

The facility ensures privacy and cases
especially of those conditions
having social stigma, and also
safeguards vulnerable groups
8 8
Standard B4
ME B4.1 2 SI/RR
There is established procedures for
taking informed consent before
treatment and procedures High risk consent is taken before
major surgeries
2 SI/RR
Anaesthesia Consent for OT
ME B4.4 2 PI/SI
Information about the treatment is
shared with patients or attendants, Patient attendant is informed
regularly about clinical condition and
treatment been provided
ME B4.5 The facility has defined and 2 OB
established grievance redressal Availabilty of complaint box and
displayed
10 10
ME B5.1 2 PI/SI JSSK
Free medicines and consumables
prevalent government schemes are available
2 PI/SI
All surgical procedure are free of

cost for JSSK beneficeries
consumbles from outside.
Pharmacy and wards
ME B5.4 2 PI/SI/RR
patients without administrative
Surgical services are free for BPL
hassles patients
48 48
ME C1.1 Departments have adequate space 2 OB
as per patient or work load
Adequate space for
accommodating surgical load
2 OB 100-200 -1OT, 200-300-2,
300-400 -3
Availability of OT for elective
major surgeries
Availability of OT for Emergency 2 OB Emergency OT 1
surgeries
Availability of OT ophthalmic/ENT 2 OB Ophthalmic/ENT- 1
Waiting area for attendants 2 OB
ME C1.2 Patient amenities are provide as 2 OB
per patient load Hot water facility
2 OB
Toilet facility for patient attendant
Seating arrangement for patient 2 OB
attendant
ME C1.3 Departments have layout and 2 OB

demarcated areas as per functions
Demarcated of Protective Zone
Demarcated Clean Zone 2 OB
Demarcated sterile Zone 2 OB
Demarcated disposal Zone 2 OB
2 OB
Availability of Changing Rooms
2 OB
Availability of Pre Operative Room
Page 124

nce ent
Method
Availability of earmarked area for 2 OB

newborn Corner
2 OB
Availability of Post Operative Room
2 OB
Availaility of Scrub Area
2 OB
Availability of Autoclave room/
TSSU
2 OB
Availability of dirty utility area
2 OB
Availability of store
ME C1.4 The facility has adequate Corridors are wide enough for 2 OB 2-3 meters
circulation area and open spaces movement of trolleys
according to need and local law

ME C1.6 Service counters are available as 2 OB Hydrolic OT Tables
per patient load As per case load at least two for 100
- 200 beded DH and 4 for More than
OT tables are available as per load 200 beds
(Structure commensurate with the
function of the hospital) Unidirectional flow of goods and No cris cross of infectious and sterile
services goods
10 10

electrical establishment OT does not have temporary
connections and loosely hanging
wires
ME C2.4 Physical condition of buildings are 2 OB
Floors of the ward are non slippery
and even
2 OB
Walls and floor of the OT covered
with joint less tiles
2 OB
Windows/ ventilators if any in the
OT are intact and sealed
10 10
ME C3.1 The facility has plan for prevention OT has sufficient fire exit to permit 2 OB/SI
of fire safe escape to its occupant at time
of fire
clearly marked.
ME C3.2 The facility has adequate fire OT room has installed fire 2 OB
fighting Equipment Extinguisher that is Class A , Class
B, C type or ABC type
2 OB/RR
mentioned
ME C3.3 The facility has a system of Check for staff compatencies for 2 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
22 22
ME C4.1 The facility has adequate specialist 2 As per case load
doctors as per service provision
Availability of Obg & Gynae
Surgeon OB/RR
2 As per case load
Availability of general surgeon OB/RR
2 As per case load
Availability of Orthopaedic Surgeon OB/RR
Availability of ophthalmic surgeon 2 OB/RR As per case load
Availability of ENT surgeon 2 OB/RR As per case load
Availability of anaesthetist 2 OB/RR As per case load
ME C4.3 The facility has adequate nursing 2 OB/RR/SI As per patient load , at least two
work load
Availability of Nursing staff
ME C4.4 The facility has adequate 2 OB/SI
requirement
Availability of OT technician
ME C4.5 The facility has adequate support / Availability of OT 2 SI/RR
general staff attendant/assistant
Availability CSSD/ TSSU Asstt. 2 SI/RR
Availability of Security staff 2 SI/RR
30 30
Page 125

nce ent
Method
ME C5.1 The departments have availability OB/RR Availability of Oxygen Cylinders /
of adequate drugs at point of use Piped Gas supply, Nitrogen
Availability of medical gases 2
OB/RR Inj Oxytocin 10 IU (to be kept in
Availability of Uterotonic Drugs 2 fridge)
OB/RR Inj Ampillicin, Inj. metronizazole Inj
Availability of Antibiotics 2 Gentamycin,
Availability of Antihypertensive 2 OB/RR Injectable preaprtions
OB/RR
Availability of analgesics and Tab Paracetamol Ibuprofen, inj
antipyretics 2 Diclofenac, Sodium plasma expender
OB/RR IV fluids, Normal saline, Ringer
Availability of IV Fluids 2 lactate,
OB/RR
Tab B complex, Inj Betamethason, Inj
Hydrazaline, methyldopa, (Nevirapin
Availability of anesthetics 2 and other HIV drugs)
OB/RR
Inj Magsulf 50%, Inj Calcium

gluconate 10%, Inj Dexamethasone,
inj Hydrocortisone, Succinate, Inj
diazepam, inj Pheneramine maleate,
inj Corboprost, Inj Fortwin, Inj
Phenergen, Betameathazon, Inj
Hydrazaline, Nefidepin,
Availability of emergency drugs 2 Methyldopa,ceftriaxone
Availability of drugs for newborn 2 OB/RR Availability of Oxygen Cylinders
Availability of dressings and
Sanitary pads 2
Availability of syringes and IV Sets 2 OB/RR
Availability of Antiseptic Solutions 2 OB/RR
Availability of consumables for new OB/RR
born care 2
Availability of personal protective OB/RR
equipments 2
ME C5.3 Emergency drug trays are Emergency drug tray is maintained OB/RR
maintained at every point of care, in OT in pre and post operative
where ever it may be needed room
2
38 38
instruments for examination & Equipment &Instruments for
monitoring of patients examination & Monitoring BP apparatus, Thermometer, Pulse
2 OB Oxy meter, Multiparameter , PV Set
ME C6.2 Availability of equipment &
instruments for treatment
procedures, being undertaken in Availability of functional LSCS Set, Cervical Biopsy Set,
the facility instruments for Gynae and Proctoscopy Set, Hysterectomy set,
obstetrics 2 OB D&C Set
Radiant warmer, Baby tray with Two

pre warmed towels/sheets for
wrapping the baby, mucus extractor,
Availability of functional bag and mask (0 &1 no.), sterilized
equipments/ Instruments for New thread for cord/cord clamp,
Born Care 2 OB nasogastric tube
Diathermy (Unit and Bi Polar),

Proctoscopy set, general Surgical
Instruments for Piles, Fistula, &
Availability of functional General Fissures. Surgical set for Hernia &
surgery equipments 2 OB Hydrocele, Cautery
C arm, check OT table is C arm

compatible, Thomas Splint, IM
Nailing Set, SP Nailing, Compression
Availability of functional Plating Kit, Sislocation Hip Screw
orthopaedic surgery equipments 2 OB Fixation
Operating Microscope, IOL
Availability of Ophthalmic surgery Operation Set, Ophthalmoscope
equipments 2 OB Keratometer, A Scan Biometer
Operating Microscope, ENT

Operation set, Mastoid Set,
Availability of functional ENT Tracheotomy set, Microdrill System
surgery equipments 2 OB set
Operation Table with
Trendelenburg facility 2 OB
ME C6.3 Availability of equipment & Availability of Point of care Portable X-Ray Machine,
instruments for diagnostic diagnostic instruments Glucometer, HIV rapid diagnostic kit,
procedures being undertaken in USG and Blood gas analyser
the facility
2 OB
patients and for providing Ambu bag, Oxygen, Suction
intensive and critical care to machine , laryngoscope scope,
patients Availability of functional Defibrillator (Paediatric and adult) ,
Instruments Resuscitation 2 OB LMA, ET Tube
Availability of functional Boyles apparatus, Bains Circuit or
anaesthesia equipment 2 OB Sodalime absorbent in close circuit
ME C6.5 Availability of Equipment for Availability of equipment for Refrigerator, Crash cart/Drug trolley,
Storage storage for drugs instrument trolley, dressing trolley
2 OB
Availability of equipment for Instrument cabinet and racks for
storage of sterilized items 2 OB storage of sterile items
ME C6.6 Availability of functional Availability of equipments for Buckets for mopping, Separate mops
equipment and instruments for cleaning for patient care area and circulation
support services area duster, waste trolley, Deck
brush
2 OB
Page 126

nce ent
Method
Availability of equipment for Autoclave Horizontal & Vertical,
CSSD/TSSU 2 OB Sterlizer Big & Small
ME C6.7 Departments have patient Availability of functional OT light Shadow less Major & Minor, Ceiling
furniture and fixtures as per load and Stand Model, Focus Lamp
2 OB
Availability of attachment/ Hospital graded mattress , IVstand,
accessories with OT table 2 OB Bed pan
Trey for monitors, Electrical panel

for anaesthesia machine, cardiac
monitor etc, panel with outlet for
Availability of Fixtures 2 OB Oxygen and vacuum, X ray view box.
Cupboard, table for preparation of
Availability of furniture 2 OB medicines, chair, racks,
24 24
Standard C7
Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and
performance of staff
ME C7.1 Criteria for Competence assessment SI/RR
are defined for clinical and Para Check objective checklist has been
clinical staff prepared for assessing competence
Check parameters for assessing of doctors, nurses and paramedical
skills and proficiency of clinical staff staff based on job description
has been defined 2 defined for each cadre of staff.
ME C7.2 Check for competence assessment 2 SI/RR Check for records of competence
is done at least once in a year assessment including filled checklist,
Competence assessment of Clinical scoring and grading . Verify with staff
and Para clinical staff is done on for actual competence assessment
predefined criteria at least once in a done
year
ME C7.9 Advance Life support 2 SI/RR ALS and CPR by recognized agency to
The Staff is provided training as per all category of staff.
defined core competencies and
training plan
OT Management 2 SI/RR OT scheduling, maintenance,
Fumigation, Surveillance,
equipment-operation and
maintenance, infection control,
surgical procedures and emergency
protocols.
Bio Medical waste Management 2 SI/RR To all category of staff. At the time
of induction and once in a year.
Training on processing/sterilization 2 SI/RR

of equipments
Patient Safety 2 SI/RR Assessment, action planning, PDCA,

5S & use of checklist
ME C7.10 There is established procedure for 2 SI/RR
utilization of skills gained thought
trainings by on -job supportive
supervision Staff is skilled for resuscitation and
intubation
Nursing Staff is skilled for 2 SI/RR
maintaining clinical records
Staff is Skilled to operate OT 2 SI/RR
equipments
Staff is skilled for processing and 2 SI/RR
packing instrument
16 16
ME D1.1 The facility has established system All equipments are covered under 2 SI/RR
for maintenance of critical AMC including preventive
Equipment maintenance
2 SI/RR
equipments
There has system to label 2
and stored appropriately until it
has been repaired
OB/RR
Staff is skilled for trouble shooting 2 SI/RR
in case equipment malfunction
Periodic cleaning, inspection and 2 SI/RR
ME D1.2 The facility has established All the measuring equipments/ 2 OB/ RR
Equipment Boyels apparatus, cautery, BP
apparatus, autoclave etc.
2 OB/ RR
recalibration is due
ME D1.3 Operating and maintenance 2 OB/SI
instructions are available with the Up to date instructions for
users of equipment operation and maintenance of
equipments are readily available
with staff.
26 26
Standard D2
areas
forecasting and indenting drugs There is established system of Requisition are timely placed
and consumables timely indenting of consumables
and drugs
Page 127

nce ent
Method
ME D2.3 The facility ensures proper storage 2 OB
of drugs and consumables Drugs are stored in
labelled
labelled
2
No expiry drug found OB/RR
drugs are maintained for drug 2
procedure for inventory maintaining buffer stock
consumables
areas
vaccines and other drugs, requiring Temperature of refrigerators are maintained and updated periodically
controlled temperature kept as per storage requirement
ME D2.8 There is a procedure for secure Narcotic and psychotropic drugs 2 OB/SI
storage of narcotic and are kept in lock and key
psychotropic drugs
Anaesthetic agents are kept at 2 OB/SI
secure place
18 18
areas
Adequate Illumination at OT table 2 100000 lux
OB
Adequate Illumination at pre
operative and post operative area 2
ME D3.2 The facility has provision of OB
restriction of visitors in patient Entry to OT is restricted 2
areas
OB/SI
Warning light is provided outside

OT and its been used when OT is
functional 2
ME D3.3 The facility ensures safe and
comfortable environment for 20-25OC, ICU has functional room
patients and service providers Temperature is maintained and thermometer and temperature is
record of same is kept 2 SI/RR regularly maintained
Humidity is maintained at desirable

level 2 SI/RR 50-60%
Positive pressure is maintained in
OT 2 SI/RR
ME D3.4 The facility has security system in OB
place at patient care areas Security arrangement at OT 2
ME D3.5 The facility has established measure Ask female staff weather they feel SI
for safety and security of female staff secure at work place 2
22 22
plastered & painted
hygienic Floors, walls, roof, roof topes, sinks
patient care and circulation areas All area are clean with no
are clean



fixtures are intact
OT Table are intact and without 2 OB
rust
2 OB
Mattresses are intact and clean
condemned junk material the OT
animal control
No pests are noticed
12 12
Page 128

nce ent
Method
areas
2 OB/SI
Availability of Hot water supply

ME D5.2 The facility ensures adequate 2 OB/SI 2 tier backup with UPS
areas as per load
Availability of power back up in OT
ME D5.3 Critical areas of the facility ensures Availability of Centralized /local 2 OB

availability of oxygen, medical gases piped Oxygen, nitrogen and
and vacuum supply vacuum supply
8 8
ME D7.1 The facility has adequate sets of OB/RR Drape, draw sheet, cut sheet and
linen gown
OT has facility to provide sufficient
and clean linen for surgical patient 2
OT has facility to provide linen for OB/RR
staff 2
ME D7.2 The facility has established Linen is changed after each OB/RR
procedures for changing of linen in procedure
patient care areas
2
ME D7.3 The facility has standard procedures SI/RR
transportation and washing of linen cleanliness and Quantity of the
linen received from laundry 2
8 8
Standard D11
procedures.
ME D11.2 The facility has a established There is procedure to ensure that 2 RR/SI Check for system for recording time
procedure for duty roster and staff is available on duty as per of reporting and relieving
deputation to different duty roster (Attendance register/ Biometrics etc)
departments
ME D11.3 The facility ensures the adherence department 2 OB
administration / the health Doctor, nursing staff and support
department staff adhere to their respective
dress code
2 2
ME D12.1 There is procedure to monitor the 2 SI/RR Verification of outsourced services
There is established system for quality and adequacy of (cleaning/
contract management for out sourced outsourced services on regular Dietary/Laundry/Security/Maintenan
services basis ce) provided are done by designated
Area of Concern - E Clinical in-house staff
Services 146 146
2 2
initial assessment of patients Physical examination, results of lab
There is procedure for Pre investigation, diagnosis and
Operative assessment 2 RR/SI proposed surgery
6 6
ME E3.1 Facility has established procedure 2
for continuity of care during There is procedure of handing over
interdepartmental transfer while receiving patient form OT to
indoor and ICU SI/RR
hospital
RR/SI
ME E3.3 A person is identified for care Duty Doctor and nurse is assigned 2 RR/SI
during all steps of care for each patients
10 10
ME E4.1 Procedure for identification of There is a process for ensuring the 2 OB/SI Patient id band/ verbal confirmation
patients is established at the identification before any clinical etc.
facility procedure
ME E4.2 Procedure for ensuring timely and There is a process to ensue the 2 SI/RR Verbal orders are rechecked before
accurate nursing care as per accuracy of verbal/telephonic administration
treatment plan is established at the orders
facility
patient hand over, whenever staff the change in the shift
duty change happens
maintained
ME E4.5 There is procedure for periodic Patient Vitals are monitored and 2 RR/SI Check for use of cardiac
monitoring of patients recorded periodically monitor/multi parameter
4 4
Page 129

nce ent
Method
ME E5.1 The facility identifies vulnerable Vulnerable patients are identified 2 OB/SI Check the measure taken to prevent
patients and ensure their safe care and measures are taken to protect new born theft, sweeping and baby
them from any harm fall
patients and ensure their care, as per treatment given on priority HIV, Infectious cases
their need
8 8
Standard E6
rational use.
ME E6.1 Facility ensured that drugs are prescribed under generic name 2 RR
prescribed in generic name only only
ME E6.2 There is procedure of rational use of Check staff is aware of the drug 2 SI/RR
drugs regime and doses as per STG
20 20
ME E7.1 There is process for identifying and High alert drugs available in 2 SI/OB Electrolytes like Potassium chloride,
cautious administration of high department are identified Opioids, Neuro muscular blocking
alert drugs (to check) agent, Anti thrombolytic agent,
Adrenergic agonist etc. as applicable
doctor
ME E7.2 Medication orders are written Every Medical advice and 2 RR avoided

staff
administration
for more than one dose with left over content intended to
be used later on

used every time for multiple dose In multi dose vial needle is not left in
vial the septum


patient, right drugs , right route,
right time
16 16
ME E8.1 All the assessments, re-assessment Records of Monitoring/ 2 RR
and investigations are recorded Assessments are maintained
and updated
PAC, Intraoperative monitoring
ME E8.4 Procedures performed are written 2 RR Name of person in attendance
on patients records Operative Notes are Recorded during procedure, Pre and post
operative diagnosis, Procedures
2 RR carried out, length of procedures,
Anaesthesia Notes are Recorded estimated blood loss, Fluid
administered, specimen removed,
ME E8.5 Adequate form and formats are 2 RR/OB complications etc.
available at point of use Standard Formats available Consents, surgical safety check list
ME E8.6 Register/records are maintained as 2 RR OT Register, Schedule, Infection
per guidelines control records, autoclaving records
Registers and records are etc
maintained as per guidelines
and numbered
ME E8.7 The facility ensures safe and Safe keeping of patient records 2 RR
medical records
4 4
disaster is defined
4 4
ME E12.1 There are established procedures Container is labelled properly after 2 OB
ME E12.3 There are established procedures 2 SI/RR
OT is provided with the critical
value of different test
Page 130

nce ent
Method
14 14
ME E13.8 There is established procedure for RR/SI
issuing blood The blood is ordered for the patient
according to the MSBOS (Maximum
Availability of blood units in case of Surgical Blood Order Schedule)
emergency with out replacement 2
RR
blood is kept on optimum
SI/RR
Blood transfusion is monitored and
patient recorded 2
ME E13.10 There is a established procedure RR
reaction is recorded and reported
to responsible person 2
26 26
ME E14.1 Facility has established procedures 2 RR/SI
for Pre Anaesthetic Check up There is procedure to ensure that
PAC has been done before surgery
There is procedure to review 2 RR/SI
findings of PAC
Minimum PAC for emergency cases 2 RR/SI in emergency & life saving
conditions, surgery may be started
with General physical examination of
ME E14.2 Facility has established procedures 2 RR the patient & sending the sample for
for monitoring during anaesthesia Anaesthesia plan is documented lab. Examination
before entering into OT
Anesthesia Safety Checklist is used 2 RR Check use of WHO Anesthesia Safety
for safe administration of Checklist
anaesthesia
Anesthesia equipment are checked 2 RR Sufficient reserve of gases.

before induction Vaporizers are connected,
Laryngoscope, ET tube and suction
App are ready and clean
2 RR/SI
Food intake status of Patient is
checked
2 RR Heart rate , cardiac rate , BP, O2
Saturation,
Patients vitals are recorded during
anaesthesia
2 RR/SI Breathing system is securely and
correctly assembled
Airway security is ensured
2 RR/SI
Potency and level of anaesthesia is
monitored
2 RR Check for the adequacy
Anaesthesia note is recorded

2 RR
Any adverse Anaesthesia Event is
ME E14.3 Facility has established procedures Post anaesthesia status is 2 RR/SI
for Post Anaesthesia care monitored and documented
26 26
Standard E15 Facility has defined and established procedures of Surgical Services
ME E15.1 Facility has established procedures RR/SI
OT Scheduling
Schedule is prepared in consonance
with available OT house and patients
There is procedure OT Scheduling 2 requirement
ME E15.2 Facility has established procedures Patient evaluation before surgery is RR/SI Vitals , Patients fasting status etc.
for Preoperative care done and recorded 2
Antibiotic Prophylaxis given as RR/SI
indicated 2
Tetanus Prophylaxis is given if RR/SI
Indicated 2
There is a process to prevent RR/SI Surgical Site is marked before
wrong site and wrong surgery 2 entering into OT
Surgical site preparation is done as RR/SI Cleaning , Asepsis and Draping

per protocol 2
ME E15.3 Facility has established procedures RR/SI
Check for Surgical safety check list
for Surgical Safety Surgical Safety Check List is used has been used for surgical
for each surgery 2 procedures
RR/SI
Instrument, needles and sponges are
counted before beginning of case,
Sponge and Instrument Count before final closure and on
Practice is implemented 2 completing of procedure
Adequate Haemostasis is secured RR/SI Check for Cautery and suture
during surgery legation practices
2
Page 131

nce ent
Method
Appropriate suture material is used RR/SI Check for what kind of sutures used
for surgery as per requirement for different surgeries . Braided
Biological sutures are not used for
dirty wounds, Catgut is not used for
closing fascial layers of abdominal
wounds or where prolonged support
is required
2
Check for suturing techniques are RR/SI
applied as per protocol 2
ME E15.4 Facility has established procedures Post operative monitoring is done RR/SI Check for post operative operation
for Post operative care before discharging to ward 2 ward is used and patients are not
immediately shifted to wards after
Post operative notes and orders RR/SI Post operative notes contains Vital
surgery
are recorded 2 signs, Pain control, Rate and type of
IV fluids, Urine and Gastrointestinal
fluid output, other medications and 6 6
Standard E16 The facility has defined and established procedures for end ofinvestigations
Laboratory life care and death
ME E16.1 Death of admitted patient is Death note is written on patient 2 RR
adequately recorded and record
communicated
ME E16.2 The facility has standard 2
procedures for handling the death Death note including efforts done
for resuscitation is noted in patient Includes both maternal and neonatal
in the hospital Death
recordsummary is given to patient RR death
cause and underlying cause if 2
possible RR/SI
12 12
Standard F1
Facility has infection control program and procedures in place for prevention and measurement of hospital associated
infection
Facility has provision for Passive
and active culture surveillance of Surface and environment samples
critical & high risk areas are taken for microbiological Swab are taken from infection prone
ME F1.2 surveillance 2 SI/RR Patients
surfaces are observed for any sign
Facility measures hospital There is procedure to report cases purulent discharge from surgical
ME F1.3 associated infection rates of Hospital acquired infection 2 SI/RR site .
There is Provision of Periodic There is procedure for
ME F1.4 Medical Checkups and immunization of the staff 2 SI/RR Hepatitis B, Tetanus Toxid etc
Periodic medical checkup of the
staff 2 SI/RR
Facility has established procedures Hand washing and infection control
for regular monitoring of infection audits done at periodic intervals
control practices Regular monitoring of infection
Facility has defined and Check for Doctors are aware of
30 30
Hand washing facilities are Availability of hand washing Facility Check for availability of wash basin
ME F2.1 provided at point of use at Point of Use 2 OB near the point of use
Availability of running Water
Ask to Open the tap. Ask Staff water
soap dish/ liquid antiseptic with Check for availability/ Ask staff if the
dispenser. supply is adequate and
Availability of Alcohol based Hand
rub Check for availability/ Ask staff for
2 OB/SI regular supply.
Prominently displayed above the
Display of Hand washing hand washing facility , preferably in
Instruction at Point of Use 2 OB Local language
Availability of elbow operated taps
2 OB
Hand washing sink is wide and
deep enough to prevent splashing 2 OB
and retention of water
Staff is trained and adhere to Adherence to 6 steps of Hand
ME F2.2 standard hand washing practices washing 2 SI/OB Ask of demonstration
Adherence to Surgical scrub procedure should be repeated
method 2 SI/OB several times so that the scrub lasts
for 3 to 5
Staff aware of when to hand wash minutes. The hands and forearms
2 SI should be dried with a sterile towel
only.
Facility ensures standard practices Availability of Antiseptic Solutions
ME F2.3 and materials for antisepsis 2 OB
like before giving IM/IV injection,
Proper cleaning of procedure site drawing blood, putting Intravenous
with antisepsis 2 OB/SI and urinary catheter
Proper cleaning of perineal area SI
before procedure with antisepsis 2
Check Shaving is not done during SI
part preparation/delivery cases 2
Surgical site covered with sterile
Check sterile field is maintained drapes, sterile instruments are kept
during surgery 2 OB/SI within the sterile field.
18 18
Facility ensures adequate personal
protection equipments as per
requirements Clean gloves are available at point
Sterile s gloves are available at OT
and Critical areas 2 OB/SI
Use of elbow length gloves for
obstetrical purpose
2 OB/SI
Availability of gown/ Apron 2 OB/SI

Availability of Caps 2 OB/SI
Page 132

nce ent
Method

infectious patients 2 OB/SI HIV kit
Staff is adhere to standard
personal protection practices No reuse of disposable gloves,
36 36
Facility ensures standard practices Decontamination of operating & Ask stff about how they
and materials for decontamination Procedure surfaces decontaminate the procedure
and clean ing of instruments and surface like OT Table,
procedures areas Stretcher/Trolleys etc.

the instruments like ambubag,
suction canulae, Surgical
Instruments
Proper Decontamination of Wiping with 0.5% Clorine Solution or
instruments after use 2 SI/OB 70% Alcohal as applicable
is adeqaute
2 SI/OB
decontamination
Cleaning is done with detergent and
2 SI/OB running water after decontamination

solution 2 SI/OB
Facility ensures standard practices Equipment and instruments are Autoclaving/HLD/Chemical
and materials for disinfection and sterlized after each use as per Sterlization
equipments
ME F4.2 2 OB/SI
instruments/equipments is done 2 OB/SI required for bioling
as per protocol
instruments/equipments is done as concentration and contact time
per protocols requied for chemical sterilization
2 OB/SI
Formaldehyde or glutaraldehyde
solution replaced as per
manufacturer instructions 2 OB/SI

procedure 2 OB/SI

used 2 OB/SI
Instruments are packed according

for autoclaving as per standard
protocol 2 OB/SI
Autoclaving of instruments is done Ask staff about temperature,
as per protocols pressure and time
2 OB/SI
Regular validation of sterilization

through biological and chemical
indicators 2 OB/SI/RR
Maintenance of records of
sterilization 2 OB/SI/RR
There is a procedure to enusure

the tracibility of sterilized packs 2 OB/SI/RR

36 36
conducive for the infection control Facility layout ensures separation
practices of general traffic from patient Faculty layout ensures separation of
ME F5.1 traffic 2 OB general traffic from patient traffic
Zoning of High risk areas 2 OB
Facility layout ensures separation
of routes for clean and dirty items 2 OB
Floors and wall surfaces of ICU are
easily cleanable 2 OB
CSSD/TSSU has demarcated
separate area for receiving dirty
items, processes, keeping clean
and sterile items 2 OB
Facility ensures availability of Availability of disinfectant as per
Availability of cleaning agent as per
requirement
Hospital grade phenyl, disinfectant
2 OB/SI detergent solution
Facility ensures standard practices Staff is trained for spill
followed for cleaning and disinfection management
ME F5.3 2 SI/RR
Cleaning of patient care area with 2 SI/RR
detergent solution
Page 133

nce ent
Method
procedure
2 SI/RR
Standard practice of mopping and
scrubbing are followed
2 OB/SI
are not used in patient care areas 2 OB/SI
mopping 2 OB/SI
schedule 2 SI/RR
External footwares are restricted
2 OB
Isolation and barrier nursing
Facility ensures segregation infectious procedure are followed for septic
ME F5.4 patients cases 2 OB/SI
Facility ensures air quality of high risk
ME F5.5 area Positive Pressure in OT 2 OB/SI
Adequate air exchanges are
maintained 2 SI/RR
24 24
Standard F6
hazardous Waste.
Facility Ensures segregation of Bio Availability of colour coded bins & 2 OB Adequate number.
contaminated with Covered. Foot
blood, body
Medical Waste as per guidelines Plastic bags at point of waste operated.
generation swabs and bags containing residual
ME F6.1
Segregation of Anatomical and 2 OB/SI components.
soiled waste in Yellow Bin intravenous tubes and sets,
Segregation of infected plastic 2 OB catheters, urine bags, syringes
waste in red bin (without needles and fixed needle
syringes) and vaccutainers with their
needles cut) and gloves
Biomedical waste

general waste
2 OB
Facility ensures management of Availability of functional needle 2 OB See if it has been used or just lying
ME F6.2 sharps as per guidelines cutters & puncture proof, leak idle.
proof, temper proof white
Availability
container forofseggregation
post exposureof 2 OB/SI Ask if available. Where it is stored
prophylaxis
sharps & Protcols and who is in charge of that. Also
check PEP issuance register
Contaminated and broken Glass 2 Vials,knows
Staff slides what
and other
to dobroken
in condition
are disposed in puncture proof and OB infected
of needleglass
stick injury
Facility ensures transportation and Check bins are
Blue colour not overfilled
marking Not more than two-third.
ME F6.3 disposal of waste as per guidelines 2 SI
Disinfection of liquid waste before Through Local Disinfection
disposal 2 SI/OB
container/trolley
2 SI/OB
Staff aware of mercury spill
management
2 SI/RR
2 2
activities 6 6
ME G3.1 Facility has established internal There is system daily round by 2 SI/RR
quality assurance program at matron/hospital manager/ hospital
relevant departments superintendent/ Hospital
ME G3.3 Facility has established system for Departmental checklist are used 2 SI/RR
use of check lists in different for monitoring and quality
Staff is designated for filling and 2 SI
28 28
Standard G4
support services.
and approved


procedures procedure for scheduling the
Surgery and its booking
2 RR
procedure for pre operative
procedure
2 RR
procedure for pre operative
anaesthetic check up
Page 134

nce ent
Method
2 RR
procedure for in process check
during surgery
2 RR
procedure for post operative care
of the patient
procedure for operation theatre
asepsis and environment
management
2 RR
procedure for OT documentation.
procedure for reception of dirt
packs and issue of sterile packs
from TSSU
2 RR
procedure for maintenance and
calibration of equipments
2 RR
procedure for general cleaning of
OT and annexes
standard procedures written in part of SOPs
SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 2 OB processing and sterilization of
Point of use are displayed equipments,
6 6
ME G5.1 Facility maps its critical processes Process mapping of critical 2 SI/RR
processes done
ME G5.2 Facility identifies non value adding 2 SI/RR
activities / waste / redundant
identified
ME G5.3 Facility takes corrective action to Processes are rearranged as per 2 SI/RR
8 8
ME G6.1 The facility conducts periodic 2 RR/SI
internal assessment Internal assessment is done at
periodic interval
ME G6.3 The facility ensures non Non Compliance are enumerated 2 RR/SI
compliances are enumerated and and recorded
recorded adequately
process
observed in the assessment & Corrective and preventive action
audit taken
6 6
Facility has de defined quality
ME G7.4 objectives to achieve mission and Check if SMART Quality Objectives 2 SI/RR Check short
Review term valid
the records thatquality
action plan
Mission, Values, Quality policy and
quality policy have framed objectivities
on have been
quality objectives framed
being reviewed
objectives are effectively addressing
at least once keyin quality
month issues
by in each
ME G7.5 communicated to staff and users of Check of staff is aware of Mission , 2 SI/RR Interview
department
departmental with instaff
and coresforservices.
charges their
and during
services Values, Quality Policy and awareness.
Check
the quality Check
if these
team if Mission
objectives
meeting. are
The
Facility periodically reviews the objectives
Check time bound action plan is Statement,
progress onCore
Specific, Measurable,
qualityValues and Quality
Attainable,
objectives have
ME G7.7 progress of strategic plan towards being reviewed at regular time 2 SI/RR Policy
Relevantis displayed
and Time
been recorded prominently
Bound.
in Action Plan in
mission, policy and objectives interval local language
tracking sheet at Key Points
4 4
ME G8.1 Facility uses method for quality Basic quality improvement method 2 SI/OB PDCA & 5S
ME G8.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used
Periodic assessment
improvement for Medication
in services in each department
Standards G10 Facility has established procedures for assessing, reporting, evaluating and
and Patient care safety risks is done as managing risk as per Risk Management Plan 2 2
ME G10.6 per defined criteria. Check periodic assessment of 2 SI/RR Verify with the records. A
medication and patient care safety comprehensive risk assessment of all
Areachecklist
risk is done using defined of Concern - H Outcome
clinical processes should be done
40 40
periodically using pre define criteria at least once 10 10
Standard H1 The facility measures Productivity Indicators and ensures compliance in three month.
with State/National benchmarks
ME H1.1 Facility measures productivity C-Section Rate
Proportion of C-Sections done in 2 RR
night
Proportion of other emergency
surgeries done in the night 2 RR
No. of Major surgeries done per 1
lakh population
2 RR
CSSD/TSSU productivity index No. of packs sterilized against the
2 RR no. of surgeries
12 12
ME H2.1 Facility measures efficiency Indicators Downtime critical euipments
Skin to skin time 2 RR
No of major surgeries per surgeon 2 RR
Proportion of elective C-Sections 2 RR
Page 135

nce ent
Method
Proportion emergency surgeries 2 RR

Cycle time for instrument
processing 2 RR
16 16
ME H3.1 Facility measures Clinical Care & Surgical Site infection Rate
Safety Indicators on monthly basis No. of observed surgical site
infections*100/total no. of Major
2 RR surgeries
patients 2 RR
Incidence of re-exploration of
surgery 2 RR
% of environmental swab culture
reported positive 2 RR
Deaths occurred from pre operative

Perioperative Death Rate procedure to discharge of the
2 RR patient
Proportion of General Anaesthesia

to spinal anaesthesia
2 RR
Proportion of PAC done out of total
elective surgeries 2 RR
No. of autoclave cycle failed in
Bowie dick test out of total
autoclave cycle 2 RR
2 2
ME H4.1 Facility measures Service Quality
Indicators on monthly basis
Planned operations
cancelled due to any reason
No. of cancelled operation*1000 like clinical, non clinical
Operation Cancellation rates 2 RR /total operation done (theatre), or by patient

A 38 38 100% 8
B 48 48 100%
C 182 182 100%
D 112 112 100%
E 146 146 100%
F 156 156 100%
G 62 62 100%
H 40 40 100%
Total 784 784 100%
0
1
2
Page 136
Checklist No 8 Operation Theatre Version - NHSRC /NQAS2016
National Quality Assurance Standards Version-2

Checklist for Maternity Operation Theatre 9
Assessment Summary
Names of Assessors Names of Assesses

Action plan
Operation Theatre Score Card

Area of Concern wise Score Operation Theatre Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100%
100%
100%
F
G Quality 100%
Management
H Outcome 100%
Major Gaps Observed
5
5
Recommendations/ Opportunities for Improvement
5
Date
Checklist for Operation Theatre

Reference No. ME Statement Checkpoint Complia Assessm Means of Verification Remarks %
nce ent
Method
Area of Concern - A Service Provision 18 18 100
6 6 100
Page 137

nce ent
Method
ME A1.14 Services are available for the OT Services are available 24X7 2 SI/RR Check with OT records that OT
time period as mandated services were functional in 24X7
and surgeries are being
conducted in night hours
ME A1.16 The facility provides Accident Availability of Emergency OT 2 SI/OB

& Emergency Services services as and when required
ME A1.17 The facility provides Intensive Availability of Maternity 2 SI/OB

care Services HDU/ICU services in the facility
10 10 100
ME A2.1 The facility provides Availability of Post partum 2 SI/OB tubal ligation
Reproductive health Services sterilization services
ME A2.2 The facility provides Maternal Availability of Elective C- 2 SI/RR Check services are available and
health Services section services are being utilized
Availability of Emergency C- 2 SI/RR Check services are available and
section services are being utilized
Management of MTP 2 SI/OB Surgical management
ME A2.3 The facility provides New-born Availability of New born 2 SI/OB Dedicated Functional New born
health Services resuscitation& essential new Care services in Operation
born care theatre
2 2 100
ME A3.2 The facility Provides Availability of point of care 2 SI/OB Glucometer, RDK , Blood
Laboratory Services diagnostic test grouping
Area of Concern - B Patient Rights 22 22 100

4 4 100
Standard B1
Facility provides the information to care seekers, attendants & community about the available services and their
modalities
ME B1.1 Availability of departmental 2 OB Numbering, main department
signage's and internal sectional signage,
Restricted area signage
The facility has uniform and displayed. Directional signages
user-friendly signage system are given from the entry of the
facility
ME B1.2 The facility displays the Information regarding services 2 OB Display doctor/ Nurse on duty
services and entitlements are displayed and updated OT schedule
displayed
available in its departments
2 2 100
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier
on account of physical, economic, cultural or social reasons.
ME B2.3 OT is easily accessible 2 OB Availability of Wheel chair or
Access to facility is provided stretcher for easy Access. Door
without any physical barrier & is wide enough for passage of
and friendly to people with trolley and staff.
disabilities
10 10 100
ME B3.1 Adequate visual privacy is Patients are properly 2 OB Look patients are covered while
provided at every point of draped/covered before and transferred from ward to OT
after procedure and vice-versa.
care
Visual Privacy is maintained 2 OB Preferably only one OT table
between two OT Tables should be placed in theatre, if it
is not possible because of high
case load adequate visual
privacy should be provided
through screens of multiple
patients are present in same OT
ME B3.2 Confidentiality of patients Patient Records are kept at 2 SI/OB In drawers/Amirah; preferably
records and clinical secure place beyond access to with lock facility.
general staff/visitors
information is maintained
ME B3.3 Behaviour of OT staff is 2 OB/PI Check that OT staff is not
The facility ensures the dignified and respectful providing care in undignified
behavior of staff is dignified manner such as yelling, scolding
and respectful, while , shouting, blaming and using
delivering the services abusive language
ME B3.4 Pregnant women is not left 2 OB/PI Check that care providers are
The facility ensures privacy unattended or ignored during attentive and empathetic to the
and confidentiality to every care in the OT pregnant women at no point of
patient, especially of those care they are left alone.
conditions having social
stigma, and also safeguards
vulnerable groups
4 4 100
Standard B4
Facility has defined and established procedures for informing and involving patient and their families about
treatment and obtaining informed consent wherever it is required.
ME B4.1 Consent is taken for surgical 2 SI/RR written consent with details of
There is established procedures the procedure with potentials
procedures for taking risks and complication. Should
informed consent before be signed by patient/next of kin
treatment and procedures and one witness
Separate consent is taken for 2 SI/RR written consent with details of

Anesthesia procedure the anaesthesia with potentials
risks and complication. Should
be signed by patient/next of kin
and one witness
2 2 100
Standard B5
Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of
care.
Page 138

nce ent
Method
ME B5.1 All surgical procedure are free 2 PI/SI free drugs, consumables ,
The facility provides cashless of cost for JSSK beneficiaries blood, referral etc.
prevalent government
schemes
Area of Concern - C Inputs 116 116 100

30 30 100
ME C1.1 Departments have adequate Adequate space for 2 OB OT around 40 Square meter.
space as per patient or work accommodating surgical load Two OT tables are not kept in
load one OT
ME C1.3 Departments have layout and Demarcated Protective Zone 2 OB Reception, waiting area,
demarcated areas as per stretcher/Trolley bay, Pre and
functions post operative rooms,
Demarcated Clean Zone 2 OB Doctor's and Nurse's room,

Anesthesia room, equipment
room, emergency exit.
Demarcated sterile Zone 2 OB Operating room, Scrub station,
Anesthesia station,
Demarcated disposal Zone 2 OB Disposal corridor, janitor closet
Availability of Changing Rooms 2 OB Separate for male and females
Availability of demarcated Pre 2 OB Can be in a single room with a

& post Operative Room /area partition.
Availability of earmarked area 2 OB Functional warmer,
for new born Corner resuscitation apparatus,
suction/mucous extractor, O2
cylinder, weighing scale and
sterile gloves.
Availability of Scrub Area 2 OB Height around 96 cm with

elbow taps/sensors, both hot
and cold water available. Sink is
deep and wide enough to avoid
spoiling. Scrub area should not
be inside the OT room.
Availability of TSSU /CSSD 2 OB Dedicated areas with provision

of Washing, Packing ,
Autoclaving the instruments
and linen
Availability of store 2 OB
ME C1.4 The facility has adequate Corridors are wide enough for 2 OB 7 to 10 feet.
circulation area and open movement of trolleys
spaces according to need and
local law
ME C1.5 The facility has infrastructure Availability of functional 2 OB Intercom should connects
for intramural and extramural telephone and Intercom Operation theatre to key areas
communication Services like ICU, Blood Bank, SNCU, Lab,
Accident and emergency,
wards, Administration
ME C1.6 Service counters are available OT tables are available as per 2 OB Hydraulic OT Tables
as per patient load load As per case load at least two
ME C1.7 The facility and departments Unidirectional flow of goods 2 OB Services are designed in a way,
are planned to ensure and services that there is no criss cross in
structure follows the moment of sterile & no sterile
function/processes (Structure supplies & equipment etc.
commensurate with the
function of the hospital)
10 10 100
ME C2.1 The facility ensures the Non structural components are 2 OB Check for fixtures and furniture
seismic safety of the properly secured like cupboards, cabinets, and
infrastructure heavy equipment , hanging
objects are properly fastened
and secured
ME C2.3 The facility ensures safety of OT does not have temporary 2 OB No extension cord or multi-
electrical establishment connections and loosely plugs
hanging wires
Availability of three phase 2 SI/OB Check electricity bill or Power

electricity supply Distribution Board. Meter have
three wires coming out (with
one neutral).
ME C2.4 Physical condition of buildings Walls and floor of the OT 2 OB made of anti-skid & Epoxy
are safe for providing patient covered with joint less tiles flooring
care
Windows/ ventilators if any in 2 OB No broken glass, gap or cracks
the OT are intact and sealed in window/ventilator.
6 6 100
ME C3.1 The facility has plan for OT has sufficient fire exit to 2 OB/SI Check the fire exits are clearly
prevention of fire permit safe escape to its visible and routes to reach exit
occupant at time of fire are clearly marked
ME C3.2 The facility has adequate fire Labour room has installed fire 2 OB Class A , Class B, C type or ABC
fighting Equipment Extinguishers & expiry is type. Check the expiry date for
displayed on each fire fire extinguishers are displayed
extinguisher on each extinguisher as well as
due date for next refilling is
clearly mentioned
Page 139

nce ent
Method
ME C3.3 The facility has a system of Check for staff competencies 2 SI/RR staff should be able to
periodic training of staff and for operating fire extinguisher demonstrate how to open the
conducts mock drills regularly and what to do in case of fire extinguisher and operate it.
for fire and other disaster PASS (Pull the pin, Aim at the
situation base of fire, Sway from side to
side)
10 10 100
Standard C4
The facility has adequate qualified and trained staff, required for providing the assured services to the current case
load
ME C4.1 The facility has adequate Availability of Obs. & Gynae 2 100 beds 2, 200 beds-3, 3oo
specialist doctors as per Surgeon beds-4, 400 beds-5 and 500
service provision beds-6
OB/RR
Availability of anaesthetist 2 OB/RR At least One
ME C4.3 The facility has adequate Availability of Nursing staff 2 OB/RR/SI As per patient load , at least
nursing staff as per service two
provision and work load
ME C4.4 The facility has adequate Availability of OT technician 2 OB/SI One per shift.
requirement
ME C4.5 The facility has adequate Availability of OT 2 SI/RR 1 each
support / general staff attendant/assistant & TSSU
assistant
22 22 100
ME C5.1 The departments have Availability of medical gases OB/RR Availability of Oxygen, nitrogen
availability of adequate drugs Cylinders / Piped Gas supply.
at point of use
2
Availability of drugs for local OB/RR Procaine, lignocaine,
anaesthesia 2 bupivacaine, Xylocaine jelly
Availability of drugs for general OB/RR Inhaled agents-Halothane,
anaesthesia nitrous oxide. Injectable:
Barbiturates (Theopental,
Thiamylal, methohexital,
Benzodiazepines (diazepam,
Lorazepam, Midazolam),
Ketamine, Etomidate, Propofol .
Neostigmine, Naloxone,
Flumazenil, Sugammadex-as per
EDL/State guidelines.
2
Availability of opioid OB/RR Fentanyl, Sufentanil, Morphine,
analgesics. Buprenorphine, Levorphanol,
Methadone-As per EDL/State
guidelines.
2
Availability of muscle relaxants OB/RR Succinylcholine, Vecuronium,
drugs Mivacurlum, Tubocarine as per
EDL/state guidelines
2
Availability of emergency OB/RR Inj Magsulf 50%, Inj Calcium
drugs gluconate 10%, Inj
Dexamethasone, inj
Hydrocortisone, Succinate, Inj
diazepam, inj Pheneramine
maleate, inj Corboprost, Inj
Fortwin, Inj Phenergen,
Betameathazon, Inj
Hydrazaline, Nefidepin,
Methyldopa,ceftriaxone
2
Availability of other drugs OB/RR Antibiotics, Analgesics,
Uterotonic drugs, IV fluids and
anithypertensive drugs as per
EDL/ state guidelines
2
ME C5.2 The departments have Availability of dressings OB/RR Adequate quantity of sterile
adequate consumables at Material pads, gauze, bandages ,
point of use Antiseptic Solution.
2
Availability of syringes and IV OB/RR In adequate quantity as per
Sets 2 load.
Availability of consumables for OB/RR Cord Clamp, mucous sucker,
new born care airway, NG Tube, Suction
catheter, IV cannula, paed IV
set and Bag and Mask (0 & 1
no.)
2
ME C5.3 Emergency drug trays are Emergency drug tray is OB/RR Every tray is labelled with name
maintained at every point of maintained in OT in pre and and number of drugs and
care, where ever it may be post operative room consumables along with their
needed date of expiry.
2
26 26 100
ME C6.1 Availability of equipment & Availability of functional BP apparatus, Thermometer,
instruments for examination & Equipment &Instruments Pulse Oxy meter,
monitoring of patients for examination & Multiparameter , PV Set, torch
Monitoring & wall clock.
2 OB
ME C6.2 Availability of equipment & Availability of functional LSCS Set, Cervical Biopsy Set,
instruments for treatment instruments for Gynae and Proctoscopy Set, Hysterectomy
procedures, being undertaken obstetrics set, D&C Set
in the facility
2 OB
Availability of functional Radiant warmer, Baby tray with
equipment/ Instruments for Two pre warmed towels/sheets
New Born Care for wrapping the baby, mucus
extractor, bag and mask (0 &1
no.), sterilized thread for
cord/cord clamp, nasogastric
tube
2 OB
Availability of functional Diathermy (Unit and Bi Polar),
General surgery equipments 2 OB Cautery
Operation Table with OT Table hydraulic major and
Trendelenburg type 2 OB OT table hydraulic minor
Page 140

nce ent
Method
ME C6.3 Availability of equipment & Availability of Point of care Glucometer, HIV rapid
instruments for diagnostic diagnostic instruments diagnostic kit, USG, ABG
procedures being undertaken machine
in the facility
2 OB
ME C6.4 Availability of equipment and Availability of functional Resuscitation bag (Adult &
instruments for resuscitation Instruments Resuscitation for paediaterics) Ambu bag,
of patients and for providing new born & Mother Oxygen, Suction machine ,
intensive and critical care to laryngoscope scope,
patients Defibrillator (Paediatric and
adult) , LMA, ET Tube
2 OB
Availability of functional Boyles apparatus, Bains Circuit
anaesthesia equipment or Sodalime absorbent in close
circuit ,AGSS (Anesthesia gas
scavenging system)
2 OB
ME C6.5 Availability of Equipment for Availability of equipment for Refrigerator, Crash cart/Drug
Storage storage of drugs & trolley, instrument trolley,
Instruments dressing trolley, Instrument
cabinet and racks for storage of
sterile items
2 OB
ME C6.6 Availability of functional Availability of equipments Three Bucket system for
equipment and instruments for cleaning mopping, Separate mops for
for support services patient care area and
circulation area duster, waste
trolley, Deck brush
2 OB
Availability of equipment for Autoclave Horizontal & Vertical,
TSSU 2 OB Steriliser Big & Small
ME C6.7 Departments have patient Availability of functional OT Shadow less Major & Minor,
furniture and fixtures as per light Ceiling and Stand Model, Focus
load and service provision Lamp
2 OB
Availability of Fixtures Tray for monitors, Electrical
panel for anaesthesia machine
with minimum 6 electrical
sockets ( 2= 15 amp power
point), panel with outlet for
Oxygen and vacuum, X ray view
box.
2 OB
12 12 100
Standard C7
Facility has a defined and established procedure for effective utilization, evaluation and augmentation of
competence and performance of staff
ME C7.1 Criteria for Competence SI/RR
assessment are defined for Check objective checklist has
clinical and Para clinical staff been prepared for assessing
competence of doctors, nurses
Check parameters for assessing and paramedical staff based on
skills and proficiency of clinical job description defined for each
staff has been defined 2 cadre of staff.
ME C7.2 Check for competence 2 SI/RR Check for records of
assessment is done at least competence assessment
once in a year including filled checklist, scoring
Competence assessment of and grading . Verify with staff
Clinical and Para clinical staff is for actual competence
done on predefined criteria at assessment done
least once in a year
ME C7.9 Advance Life support 2 SI/RR ALS and CPR by recognized
The Staff is provided training as agency to all category of staff.
per defined core competencies
and training plan
Training on OT Management 2 SI/RR OT scheduling, maintenance,
Fumigation, Surveillance,
equipment-operation and
maintenance, infection control,
surgical procedures and
emergency protocols.
Biomedical Waste SI/RR To all category of staff. At the

Management& Infection time of induction and once in a
control and hand hygiene year.
,Patient safety
2
Training on Quality SI/RR Assessment, action planning,
Management 2 PDCA, 5S & use of checklist
Area of Concern - D Support Services 70 70 100
10 10 100
ME D1.1 The facility has established All equipment are covered 2 SI/RR look for MOU and visit records
system for maintenance of under AMC including of the empaneled agency.
critical Equipment preventive maintenance
There is system of timely 2 SI/RR Back up for critical equipment.

corrective break down Label Defective/Out of order
maintenance of the equipment equipment and stored
appropriately until it has been
repaired
Staff is skilled for cleaning, 2 SI/RR E.g. when to change water of

inspection & trouble shooting batteries, when to oil, change
in case equipment malfunction fuse, replace filters etc.
ME D1.2 The facility has established All the measuring equipment/ 2 OB/ RR Boyels apparatus, cautery, BP
procedure for internal and instrument are calibrated apparatus, autoclave etc. There
external calibration of is system to label/ code the
measuring Equipment equipment to indicate status of
ME D1.3 Operating and maintenance Up to date instructions for 2 OB/SI If operator doesn't understand
instructions are available with operation and maintenance of English, then instructions
the users of equipment equipment are readily available should be in local language.
with staff.
18 18 100
Standard D2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and
patient care areas
ME D2.1 There is established There is established system of 2 SI/RR Stock level are daily updated
procedure for forecasting and timely indenting of Requisition are timely placed
indenting drugs and consumables and drugs
consumables
Page 141

nce ent
Method
ME D2.3 The facility ensures proper Drugs are stored in 2 OB Away from direct sunlight and
storage of drugs and containers/tray/crash cart are temperature is maintained as
consumables labelled per instructions of
manufacturer.
Empty and filled cylinders are 2 OB Each cylinder is provided with
labelled & kept separately a checklist & flow meter and
key for opening the cylinder
ME D2.4 The facility ensures Expiry dates' are maintained at 2 OB/RR Records for expiry and near
management of expiry and emergency drug tray expiry drugs are maintained for
near expiry drugs drug stored at department. No
ME D2.5 The facility has established There is practice of calculating 2 SI/RR At least one
expirred week
drugs of minimum
found
procedure for inventory and maintaining buffer stock buffer stock is maintained all
management techniques the time in the labour room.
Minimum stock and reorder
level are calculated based on
consumption in a week
accordingly
Department maintained stock 2 RR/SI Check that records are regularly

and expenditure register of updated
ME D2.6 There is a procedure for There is procedure for 2 SI/RR There is no stock out of drugs
periodically replenishing the replenishing drug tray /crash
drugs in patient care areas cart
ME D2.7 There is process for storage of Temperature of refrigerators 2 OB/RR Check for temperature charts
vaccines and other drugs, are kept as per storage are maintained and updated
requiring controlled requirement and records are periodically
temperature maintained
ME D2.8 There is a procedure for Narcotic ,psychotropic & 2 OB/SI Under direct supervision of
secure storage of narcotic and Anaesthetic agents are kept in anaesthetist
psychotropic drugs lock and key
8 8 100
ME D3.1 The facility provides adequate Adequate Illumination at OT OB 100000 lux
illumination level at patient table
care areas
2
ME D3.2 The facility has provision of Warning light outside the OT is OB/SI Only persons required in OT are
restriction of visitors in switched on when OT is allowed to enter the OT
patient areas functional
2
ME D3.3 The facility ensures safe and Temperature & humidity is 20-25OC, ICU has functional
comfortable environment for maintained and record of room thermometer and
patients and service providers same is kept temperature is regularly
maintained. 50-60% humidity
2 SI/RR
ME D3.4 The facility has security Security arrangement at OT OB Restricted Signage, security
system in place at patient care guard, CCTV camera
2
areas
16 16 100
ME D4.1 Exterior of the facility building Department is 2 OB Painted in soothing colours Not
is maintained appropriately painted/whitewashed in bright colours.
uniform colour &plastered &
ME D4.2 Patient care areas are clean Floors,
paintedwalls, roof, roof tops, 2 OB All area are clean with no
and hygienic sinks patient care and dirt,grease,littering and
circulation areas are Clean cobwebs
Surface of furniture and 2 OB Look for dirt above OT light,

fixtures are clean behind stationary equipment
etc.
ME D4.3 Hospital infrastructure is Check for there is no seepage , 2 OB check corners, false ceiling.
OT Table are intact and 2 OB Mattresses are intact and clean
without rust
No unnecessary items in sterile 2 No slabs, almirah, storing
zone unnecessary items like drums,
equipment, Instruments etc
Items not required for
immediate procedures are kept
out of sterile zone
ME D4.5 The facility has policy of No condemned/Junk material 2 OB No partial compliance.

removal of condemned junk in the OT
material
ME D4.6 The facility has established No stray animal/rodent/birds 2 OB Check for no stray animal in and
procedures for pest, rodent around OT. Also no lizard,
and animal control cockroach, mosquito, flies,rats
etc.
8 8 100
ME D5.1 The facility has adequate Availability of 24x7 running and 2 OB/SI Availability of Hot water supply
arrangement storage and potable water
supply for portable water in all
functional areas
ME D5.2 The facility ensures adequate Availability of power back up in 2 OB/SI 2 tier backup with UPS
power backup in all patient OT
care areas as per load
Availability of UPS & 2 OB/SI Check their functionality.
Emergency light
ME D5.3 Critical areas of the facility Availability of Centralized 2 OB Cylinders are provided with
ensures availability of oxygen, /local piped Oxygen, nitrogen trolleys to prevent fall and
medical gases and vacuum and vacuum supply injuries.
supply
8 8 100
ME D7.1 The facility has adequate sets OT has facility to provide OB/RR Drape, draw sheet, cut sheet
of linen sufficient and clean linen for and gown
surgical patient
2
OT has facility to provide linen OB/RR OT dress, gown. Separate OT
for staff 2 dress for OT staff.
Page 142

nce ent
Method
ME D7.2 The facility has established Linen is changed after each OB/RR Bed sheets, draw sheets and
procedures for changing of procedure Macintosh.
linen in patient care areas
2
ME D7.3 The facility has standard There is system to check the SI/RR OT tech/Nurse checks Number
procedures for handling , cleanliness and Quantity of the of linen, cleanliness, whether it
collection, transportation and linen received from laundry is torned or stained
washing of linen
2
2 2 100
Standard D11
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
operating procedures.
ME D11.3 The facility ensures the Doctor, nursing staff and 2 OB Check staff is wearing dress as
adherence to dress code as support staff adhere to their per their dress code.
mandated by its respective dress code
administration / the health
department
Area of Concern - E Clinical Services 168 168 100
2 2 100
ME E2.1 There is established There is procedure for Pre Physical examination, results of
procedure for initial Operative assessment lab investigation, X-Rays,
assessment of patients diagnosis and proposed surgery
2 RR/SI
2 2 100
ME E3.1 Facility has established There is procedure of handing 2 Transfer Register is maintained.
procedure for continuity of over from OT to Maternity
care during interdepartmental Ward, HDU and SNCU
transfer
SI/RR
6 6 100
ME E4.1 Procedure for identification of There is a process for ensuring 2 OB/SI Patient id band/ verbal
patients is established at the the identification before any confirmation etc. At least two
facility clinical procedure identifiers are used.
ME E4.3 There is established Patient hand over is given 2 SI/RR Handover register is maintained
procedure of patient hand during the change in the shift
over, whenever staff duty
change happens
ME E4.5 There is procedure for Patient Vitals are monitored 2 RR/SI Check for use of cardiac
periodic monitoring of and recorded periodically monitor/multi parameter
patients
4 4 100
ME E5.1 The facility identifies vulnerable Vulnerable patients are 2 OB/SI Check the measure taken to
patients and ensure their safe identified and measures are prevent new born theft,
care taken to protect them from sweeping of baby or fall
any harm
ME E5.2 The facility identifies high risk High risk patients are identified 2 OB/SI HIV, Infectious cases
patients and ensure their care, as and treatment given on priority
per their need
6 6 100
Standard E6
Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic
drugs & their rational use.
ME E6.1 Facility ensured that drugs are Check for Case Sheet if drugs 2 RR Check at least 5 case sheets
prescribed in generic name only are prescribed under generic selected randomly
name only
ME E6.2 There is procedure of rational Check staff is aware of the drug 2 SI/RR Check if drugs are prescribed as
use of drugs regime and doses as per STG per STG in at least 5 case sheets
selected randomly
Check Case Sheet that drugs 2 RR Check if drugs are prescribed as
are prescribed as per STG per STG in at least 5 case sheets
selected randomly
14 14 100
ME E7.1 There is process for identifying High alert drugs available in 2 SI/OB Electrolytes like Potassium
and cautious administration of department are identified chloride, Opioids, Neuro
high alert drugs (to check) muscular blocking agent, Anti
thrombolytic agent, insulin,
warfarin, Heparin, Adrenergic
Maximum dose of high alert 2 SI/RR agonist etc.
Value for as applicable
maximum doses as
drugs are defined and per age, weight and diagnosis
communicated & there is are available with nursing
process to ensure that right station and doctor. A system of
doses of high alert drugs are independent double check
only given before administration, Error
prone medical abbreviations
are avoided
ME E7.2 Medication orders are written Every Medical advice and 2 RR Look for pre-op, Procedure and
legibly and adequately procedure is accompanied Post op notes and instructions.
with date , time and
signature
Check for the writing, It 2 RR/SI Ask OT/Ward staff to read the
comprehendible by the clinical orders written by doctor.
staff
ME E7.3 There is a procedure to check Drugs are checked for expiry 2 OB/SI Check for any open single dose
drug before administration/ and other inconsistency vial with left over content
dispensing before administration intended to be used later on. In
multi dose vial needle is not left
in the septum
Any adverse drug reaction is 2 RR/SI Check for ADR forms and
recorded and reported records.
ME E7.4 There is a system to ensure Check Nursing staff is aware 7 2 SI/RR Administration of medicines
right medicine is given to right Rs of Medication and follows done after ensuring right
patient them patient, right drugs , right route,
right time, Right dose , Right
Reason and Right
Documentation
16 16 100
Standard E8
Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their
storage
Page 143

nce ent
Method
ME E8.1 All the assessments, re- Records of Monitoring/ 2 RR PAC, Intraoperative monitoring
assessment and investigations Assessments are maintained
are recorded and updated
prescription/orders are written on Case Sheet records
recorded in the patient
records.
ME E8.4 Procedures performed are Operative Notes are Recorded 2 RR Name of person in attendance
written on patients records during procedure, Pre and post
operative diagnosis, Procedures
carried out, length of
procedures, estimated blood
loss, Fluid administered,
specimen removed,
complications etc.
Anesthesia Notes are Recorded 2 RR notes includes Anesthesia type,

induction, airway, intubation,
inhalation agents, epidural,
spinal, allergies, IV lines, IV
fluids, regional block.
ME E8.5 Adequate form and formats Standard Formats are available 2 RR/OB Consent forms, Anesthesia
are available at point of use form, surgical safety check list
ME E8.6 Register/records are Registers and records are 2 RR OT Register, Schedule, Infection
maintained as per guidelines maintained as per guidelines control records, autoclaving
records etc
All register/records are 2 RR Register are labelled and

identified and numbered numbered.
ME E8.7 The facility ensures safe and Safe keeping of patient 2 RR Records are kept in place
adequate storage and records without seepage, moisture,
retrieval of medical records termite, pests.
2 2 100
ME E11.3 The facility has disaster Staff is aware of disaster plan & 2 SI/RR Ask role of staff in case of
management plan in place their role and responsibilities disaster.
of staff is defined
4 4 100
ME E12.1 There are established Container is labelled properly 2 OB Including Specimen for HPE &
procedures for Pre-testing after the sample collection biopsy. Name, Age, Sex, date,
Activities UHID
ME E12.3 There are established OT is provided with the critical 2 SI/RR Critical values are displayed.
procedures for Post-testing value of different test
Activities
10 10 100
ME E13.8 There is established Availability of blood units in RR/SI The blood is ordered for the patient
procedure for issuing blood case of emergency with out according to the MSBOS (Maximum
replacement Surgical Blood Order Schedule)
2
ME E13.9 There is established Consent is taken before 2 RR Duly signed by patient/next of
procedure for transfusion of transfusion kin
blood
Patient's identification is 2 SI/OB At least two identifiers are
verified before transfusion used.
Protocol of blood transfusion is 2 RR blood is kept on optimum
monitored & regulated temperature before
transfusion. Blood transfusion is
monitored and regulated by
qualified person
ME E13.10 There is a established Any major or minor transfusion RR After transfusion, Reaction form
procedure for monitoring and reaction is recorded and is returned back to blood bank,
reporting Transfusion reported to responsible person even when there is no reaction.
complication
2
24 24 100
ME E14.1 Facility has established There is procedure to ensure 2 RR/SI There is procedure to review
procedures for Pre that PAC has been done before findings of PAC
Anaesthetic Check up surgery
Minimum PAC for emergency 2 RR/SI in emergency & life saving
cases conditions, surgery may be
started with General physical
examination of the patient &
sending the sample for lab.
Examination
ME E14.2 Facility has established Anesthesia plan is documented 2 RR Type of anaesthesia planned-
procedures for monitoring before starting surgery local/general/spinal/epidural.
during anaesthesia Time is mentioned on all entries
of anaesthesia monitoring sheet
Anesthesia Safety Checklist is 2 RR Check use of WHO Anesthesia
used for safe administration of Safety Checklist
anaesthesia
Anesthesia equipment are 2 RR Sufficient reserve of gases.

checked before induction Vaporizers are connected,
Laryngoscope, ET tube and
suction App are ready and clean
Food intake status of Patient is 2 RR/SI Time of last food intake is

checked mentioned
Page 144

nce ent
Method
Patients vitals are recorded 2 RR Heart rate , cardiac rate , BP, O2
during anaesthesia Saturation, temperature,
Respiration rate.
Airway security is ensured 2 RR/SI Breathing system of

anaesthesia equipment that
delivers gas to the patient is
securely and correctly
assembled and breathing
circuits are clean
Potency and level of 2 RR/SI Recorded in the Anesthesia
anaesthesia is monitored Record Form.
Anesthesia note is recorded 2 RR Check for the adequacy, signed,

complete, and post anaesthesia
instructions.
Any adverse Anesthesia Event 2 RR Reduced level of consciousness,

is recorded and reported reparatory depression,
malignant hyperpyrexia, bone
marrow depression, life
threatening pressure effect,
anaphylaxis
ME E14.3 Facility has established Post anaesthesia status is 2 RR/SI Check for anaesthetic notes &
procedures for Post monitored and documented post operating instructions in
Anesthesia care post operative room & area
42 42 100
Standard E15 Facility has defined and established procedures of Surgical Services
ME E15.1 Facility has established List of Elective Surgeries for the RR/SI Surgery list is prepared in
procedures OT Scheduling day is prepared and displayed consonance with availability of
outside OT. the OT hours and patients
requirement.
2
Surgery list is complete in all OB/SI Day, date and time of surgeries.
respect Name, Age, Gender of patients.
Clear description of the
procedure ( name of procedure
which side, )
Name of the surgeon &
anaesthetist.
Major or minor case.
2
Operation list is sent to OT well RR/SI By 12:00 hours, a day before
in advance the surgery.
2
Surgery list is informed to 2 RR/SI Verify the surgery
surgeon and ward sister. register/email
The operation list does not 2 RR/SI This does not refer to the time
exceed the time allocated to it. during an operation of an
individual patient
ME E15.2 Facility has established Patient evaluation before RR/SI Vitals , Patients fasting status
procedures for Preoperative surgery is done and recorded 2 etc.
care
Antibiotic Prophylaxis and RR/SI As per instructions of
Tetanus given as indicated 2 surgeon/anaesthetist.
Surgeries planned under local RR/SI lidocaine sensitivity test
anaesthesia/Regional Block
sensitivity test is done
2
There is a process to prevent RR/SI Surgical Site is marked before
wrong site and wrong surgery 2 entering into OT
No shaving of the surgical site SI/RR Only clipping on the day of
2 surgery in OT is done
Skin preparation before SI/RR Bathing with soap and water
surgery is done. 2 prior to surgery in ward.
Skin preparation is done as per RR/SI Prepare the skin with antiseptic
protocol solution (Chlorhexidine
gluconate and iodine), starting
in the centre and moving out to
the periphery. This area should
be large enough to include the
entire incision and an adjacent
working area.
2
Draping is done as per protocol SI/OB Scrub, gown and glove before
covering the patient with sterile
drapes. Leave uncovered only
the operative field and those
areas necessary for the
maintenance of anaesthesia.
2
ME E15.3 Facility has established Surgical Safety Check List is RR/SI Check for Surgical safety check
procedures for Surgical Safety used for each surgery list has been used for surgical
procedures
2
Sponge and Instrument Count RR/SI Instrument, needles and
Practice is implemented sponges are counted before
beginning of case, before final
closure and on completing of
procedure & documented
2
Adequate Haemostasis is RR/SI Check for functional Cautery,
secured during surgery use of artery forceps and suture
ligation techniques
2
Page 145

nce ent
Method
Appropriate suture material is RR/SI For closing abdominal wall or
used for surgery as per ligating blood vessel use non-
requirement absorbable sutures (braided
suture, nylon, polyester etc).
absorbable sutures in urinary
tract. Braided Biological
sutures are not used for dirty
wounds, Catgut is not used for
closing fascial layers of
abdominal wounds or where
prolonged support is required
2
Check for suturing techniques RR/SI Braided sutures for interrupted
are applied as per protocol stiches. Absorbable and non-
absorbable monofilament
sutures for continuous stiches.
2
ME E15.4 Facility has established Post operative monitoring is RR/SI Check for post operative
procedures for Post operative done before discharging to operation room /area is used
care ward and patients are not
immediately shifted to wards
2 after surgery
Post operative notes and RR/SI Post operative notes contains
orders are recorded Vital signs, Pain control, Rate
and type of IV fluids, Urine and
Gastrointestinal fluid output,
other medications and
Laboratory investigations
2
Information & instructions are RR/SI Instructions given by surgeon
given to nursing staff before and anaesthetist.
shifting the patient to the ward
from the OT
2
2 2 100
ME E16.2 The facility has standard Death note including efforts 2 Includes both maternal and
procedures for handling the done for resuscitation is noted neonatal death. Death
death in the hospital in patient record summary is given to patient
attendant quoting the
immediate cause and
RR underlying cause if possible
28 28 100
Standard E18 Facility has established procedures for Intranatal care as per guidelines
ME 18.3 Facility staff adheres to standard Wipes the baby with a clean 2 SI/OB Check staff competence
procedures for routine care of pre-warmed towel and wraps through demonstration or case
newborn immediately after birth baby in second pre-warmed observation
towel;
Performs delayed cord 2 SI/OB Check staff competence

clamping and cutting (1-3 min); through demonstration or case
observation
Initiates breast-feeding soon 2 SI/OB Check staff competence

after birth through demonstration or case
observation
Records birth weight and gives 2 SI/OB Check staff competence

injection vitamin K through demonstration or case
observation
ME E18.4 There is an established Pre operative care and part 2 SI/RR Check for Haemoglobin level is
procedure for assisted and C- preparation estimated , and arrangement of
section deliveries per scope of Blood, Catheterization,
services. Administration of Antacids
Proper cleaning of perineal area
before procedure with
antisepsis
Proper selection Anesthesia 2 SI/RR Check Both General and Spinal

technique Anesthesia Options are
available. Ask for what are the
criteria for using spinal and GA.
Regional block and epidural
anaesthesia used wherever
required/indicated
Intraoperative care 2 SI/RR Check for measures taken to
prevent Supine Hypotension
(Use of pillow/Sandbag to tilt
the uterus), Technique for
Incision, Opening of Uterus,
Delivery of Foetus and placenta,
and closing of Uterine Incision
Post operative care 2 SI/RR Frequent monitoring of vitals,
Strict IO charting, Flat bed
without pillow for SA, NPO
depending on type of
ME 18.5 Facility staff adheres to Management of PIH/Eclampsia 2 SI/RR anaesthesia
Ask for how and surgery.
to secure airway
standard protocols for and breathing, Loading and
identification and Maintenance dose of
management of Pre Eclampsia Magnesium sulphate ,
/ Ecalmpsia Administration of anti
Hypertensive Drugs
ME 18.6 Facility staff adheres to Postpartum Haemorrhage 2 SI/RR IV fluids, parental oxytocin and
standard protocols for antibiotics, manual removal of
identification and placenta, blood transfusion, B-
management of PPH. lynch suturing, surgery
Ruptured Uterus 2 SI/RR Put patient in left lateral

position, maintain Airway,
breathing and circulation, IV
Fluid, antibiotics, urgent
laparotomy and hysterectomy.
Page 146

nce ent
Method
ME 18.7 Facility staff adheres to Provides ART for seropositive 2 SI/RR Check case records and
standard protocols for mothers/ links with ART center Interview of staff
Management of HIV in
Pregnant Woman & Newborn
Provides syrup Nevirapine to 2 SI/RR Check case records and

newborns of HIV seropositive Interview of staff
mothers
ME 18.10 There is Established protocol SI/RR Ask Nursing staff to
for newborn resuscitation is demonstrate Resuscitation
followed at the facility. Technique
New born Resuscitation 2
6 6 100
Standard E19 Facility has established procedures for postnatal care as per guidelines
ME E19.1 Facility staff adheres to protocol Prevention of Hypothermia 2 SI/RR Skin contact, Kangaroo mother
for assessment of condition of care, radiant warmer, warm
mother and baby and providing clothes.
adequate postpartum care
ME E19.2 Facility staff adheres to protocol Initiation of Breastfeeding with 2 PI/SI Shall be initiated as early as
for counselling on danger signs, in 1 Hour possible and exclusive breast
post-partum family planning and feeding
ME E19.5 The facility
exclusive ensure
breast adequate stay
feeding There is established criteria for 2 SI/RR only the new born requiring
of mother and new born in a shifting new born to SNCU intensive care should be
safe environoment as per transferred to SNCU
standard protocols Area of Concern - F Infection Control 126 126 100
10 10 100
Standard F1
Facility has infection control program and procedures in place for prevention and measurement of hospital
associated infection
Facility has provision for Surface and environment Swab are taken from infection
Passive and active culture samples are taken for prone surfaces
surveillance of critical & high microbiological surveillance
ME F1.2 risk areas 2 SI/RR
Facility measures hospital There is procedure to report Patients are observed for any
associated infection rates cases of Hospital acquired sign and symptoms of HAI like
infection fever, purulent discharge from
surgical site .
ME F1.3 2 SI/RR
There is Provision of Periodic There is procedure for Hepatitis B, Tetanus Toxoid etc
ME F1.4 Medical Check-ups and immunization medical check- 2 SI/RR
immunization of staff up of the staff
Facility has established Regular monitoring of infection Hand washing and infection
procedures for regular control practices control audits done at periodic
monitoring of infection intervals
Facility has defined and Check for Doctors are aware of Antibiotics prescribed are in line
ME F1.6 established antibiotic policy Hospital Antibiotic Policy 2 SI/RR with Antibiotic Policy.
24 24 100
Hand washing facilities are Availability of hand washing Check for availability of wash
provided at point of use with running Water Facility at basin near the point of use Ask
ME F2.1 2 OB
Point of Use to Open the tap. Ask Staff
Availability of antiseptic soap Check for availability/
water supply is regularAsk staff
with soap dish/ liquid if the supply is adequate and
antiseptic with dispenser. uninterrupted.
2 OB/SI
Display of Hand washing Prominently displayed above
Instruction at Point of Use 2 OB the hand washing facility ,
preferably in Local language
Availability of elbow operated elbow /foot operated or sensor
taps 2 OB
Hand washing sink is wide and Tap should be approx. 96 cm
deep enough to prevent from the ground.
splashing and retention of
water
2 OB
Staff is trained and adhere to Adequate preparation for Check Finger nails of staff. They
standard hand washing surgical scrub. should not reach beyond finger
practices tip. No nail polish or artificial
nails. All jewelry on the fingers,
wrists and arms should be
removed. Adjust water to a
comfortable temperature.
ME F2.2 2 OB/SI/RR
Adherence to Surgical scrub Procedure should be repeated
method several times so that the scrub
lasts for 3 to 5
minutes. Hands must always be
kept above elbow level. The
hands and forearms should be
dried with a sterile towel only.
2 SI/OB
Use of antibiotic soap/liquid Check adequate quantity of
antibiotic soap/Chlorhexidine
solution is available and used.
2 SI/OB
Staff aware of when to hand Ask for 5 moments of hand
wash 2 SI washing
Facility ensures standard Availability of Antiseptic Povidine iodine solution
ME F2.3 practices and materials for Solutions 2 OB
antisepsis
Proper cleaning of procedure like before giving IM/IV
site with antisepsis injection, drawing blood,
putting Intravenous and urinary
catheter
2 OB/SI
Check sterile field is Surgical site covered with
maintained during surgery sterile drapes, sterile
instruments are kept within the
sterile field.
2 OB/SI
16 16 100
Page 147

nce ent
Method
Facility ensures adequate Sterile gloves are available at In adequate quantity, as per
personal protection OT and Critical areas load
equipment's as per
ME F3.1 requirements 2 OB/SI
Availability of Masks 2 OB/SI In adequate quantity, as per
Availability of Caps & gown/ load
In adequate quantity, as per
Apron 2 OB/SI load
Personal protective kit for Disposable surgery kit for HIV
infectious patients patients
2 OB/SI
Availability of gum boots In adequate quantity, as per
load
2 OB/SI
Staff is adhere to standard No reuse of disposable gloves, Check Autoclaving/sterilization
personal protection practices Masks, caps and aprons. records.
ME F3.2 2 OB/SI/RR
Compliance to correct method Adherence to standard
of wearing and removing the technique so that sterile area is
gloves not in contact with unsterile at
any given point of time.
2 SI
Compliance to standard 2 SI Adherence to standard
technique of wearing and technique so that sterile area is
removing of gown not in contact with unsterile at
any given point of time.
30 30 100
Standard F4 Facility has standard Procedures for processing of equipment's and instruments
Facility ensures standard Decontamination of operating Ask staff about how they
practices and materials for & Procedure surfaces decontaminate the procedure
decontamination and clean in of surface like OT Table,
instruments and procedures Stretcher/Trolleys etc.
areas (Wiping with .5% Chlorine
solution)
ME F4.1 2 SI/OB
use Ask staff how they clean the
instruments like ambubag,
Instruments
(Soaking in 0.5% Chlorine
Solution, Wiping with 0.5%
Chlorine Solution or 70%
2 SI/OB Alcohol as applicable )
infected linen Point of use/ sterile area
2 SI/OB
Staff know how to make Carbolic acid, chlorine solution,
disinfectant solution 2 SI/OB glutaraldehyde or any other
disinfectant used
Facility ensures standard Equipment and instruments Autoclaving/Chemical
practices and materials for are sterilized after each use as Sterilization
disinfection and sterilization of per requirement
instruments and equipment's
ME F4.2 2 OB/SI
instruments/equipment's is concentration and contact time
done as per protocols required for chemical
sterilization.
2 OB/SI
Glutaraldehyde solution is Date of preparation & due date
changed as per manufacturer of change of solution is
instructions mentioned on container and
2 OB/SI staff is aware of When to
Autoclaved linen and Dressing change the
Gowns, chemical.
draw sheets , Cotton,
are used for procedure Gauze, bandages.etc.
2 OB/SI
Instruments are packed as per Check for Window of autoclave
standard protocol drum is closed, drum is not
filled more than 3/4th,
2 OB/SI instruments are not hinged,
Autoclaving of instruments is Ask staff about temperature,
done as per protocols pressure and time
2 OB/SI
Regular validation of Indicators (temperature
sterilization through chemical sensitive tape) that change
indicators colour after being exposed to
2 OB/SI/RR certain temperature.
Regular validation of Bacillus Thermophilus spores
sterilization through biological are used, for measuring
indictor biological performance of
autoclaving process. Performed
monthly. Label the spore
ampule, place in horizontal
position, kept at the bottom or
farthest part of autoclave
2 OB/SI/RR
Maintenance of records of Autoclave Register have
sterilization column: Date, Time started,
Time finished, Temp, pressure,
Autoclave tape, spore test,
2 OB/SI/RR
There is a procedure to ensure Each Sterilized pack is marked
the traceability of sterilized with Date/Time of sterilization,
packs contents, name/signature of
2 OB/SI/RR the Technician,
Sterility of autoclaved packs is Sterile packs are kept in clean,
maintained during storage dust free, moist free
environment.
2 OB/SI
28 28 100
Functional area of the Facility layout ensures Facility layout ensures
department are arranged to separation of routes for clean separation of general traffic
ensure infection control and dirty items from patient traffic. Separate
practices disposal zone
ME F5.1 2 OB
Page 148

nce ent
Method
CSSD/TSSU has demarcated Sterile & unsterile store are
separate area for receiving separately.
dirty items, processes, keeping
clean and sterile items
2 OB
Facility ensures availability of Availability of disinfectant as Chlorine solution,
standard materials for cleaning per requirement Glutaraldehyde, carbolic acid ,
and disinfection of patient care fumigation material
ME F5.2 areas 2 OB/SI
Availability of cleaning agent as Hospital grade phenyl,
per requirement disinfectant detergent solution
2 OB/SI
Facility ensures standard Spill management protocols spill management kit. staff
practices followed for cleaning are implemented training, protocol displayed
and disinfection of patient care
ME F5.3 areas 2 SI/RR
Mercury Spill management Kit Hospital should aspire to be
is available mercury free. If used than Hg
spill management kit should be
2 SI/OB available with gloves, cap,
Cleaning of patient care area mask, goggles,
Washing polybag,
of floor Plastic
with luke
with detergent solution container
warm & torch.
water and detergent.
2 SI/RR
Standard practice of mopping Use of three bucket system for
and scrubbing are followed mopping
2 OB/SI
Cleaning equipment's like Look in janitors closet
broom are not used in patient 2 OB/SI
care areas
Fumigation as per schedule check that Formalin is not used.
2 SI/RR safer commercially available
disinfectants such as Bacillicidal
External footwears are adequate numbers
are used for are available
fumigation
restricted 2 OB at the entrance
Entry to sterile zone is only persons really required are
permitted only after hand allowed to enter the sterile
washing, change of clothes, zone
gowning & PPE
2 OB/SI
Facility ensures air quality of high Positive Pressure in OT OT to have an independent air
risk area handling unit with controlled
ventilation such that the lay-up
room and the OT table is under
positive pressure
ME F5.5 2 OB/SI
Adequate air exchanges are Independent AHU also allows to
maintained 2 SI/RR maintain required number of
Air exchange side. 20-25.
18 18 100
Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical
and hazardous Waste.
Facility Ensures segregation of Availability of colour coded 2 OB Adequate number. Covered.
Bio Medical Waste as per bins & Plastic bags at point of Human Anatomical waste,
Foot operated.
guidelines waste generation Items contaminated with blood,
ME F6.1 body fluids,dressings, plaster
Segregation of Anatomical and 2 OB/SI casts, cotton swabs and bags
soiled waste in Yellow Bin containing
Items such residual or bottles,
as tubing, discarded
blood and blood
intravenous tubescomponents.
and sets,
Segregation of infected plastic 2 OB (without needles and fixed
waste in red bin needle syringes) and
vaccutainers with their needles
cut) and gloves
Biomedical waste
Facility ensures management Availability of functional 2 OB See if it has been used or just
ME F6.2 of sharps as per guidelines needle cutters & puncture lying idle.
proof, leak proof, temper proof
Availability of post
white container forexposure 2 OB/SI Ask if available. Where it is
prophylaxis
seggregation&ofProtcols
sharps stored and who is in charge of
that. Also check PEP issuance
Contaminated and broken 2 OB Includes
register used vials, slides and
Glass are disposed in puncture other brokenwhat
Staff knows infected
to doglass
in
proof and leak proof box/ condition
Check binswith
Facility ensures transportation container are not
Blueoverfilled
colour Not more of needle
than stick injury
two-third.
ME F6.3 and disposal of waste as per marking 2 SI
guidelines
Disinfection of liquid waste Through Local Disinfection
before disposal 2 SI/OB
Area of Concern - G Quality Management 58 58 100
2 2 100
ME G1.1 The facility has a quality team Quality circle has been formed 2 SI/RR Check if quality circle formed
in place in the operation theatre and functional in the OT
4 4 100
ME G3.1 Facility has established There is system of daily round 2 SI/RR Check for entries in Round
internal quality assurance by matron/hospital manager/ Register.
program at relevant hospital superintendent/ OT in
departments charge for monitoring of
services
ME G3.3 Facility has established system Departmental checklist are 2 SI/RR Staff is designated for filling
for use of check lists in used for monitoring and and monitoring of these
different departments and quality assurance checklists
services
24 24 100
Standard G4
Facility has established, documented implemented and maintained Standard Operating Procedures for all key
processes and support services.
ME G4.1 Departmental standard Standard operating procedure 2 RR Can be prepared by junior
operating procedures are for department has been surgeon and approved by
available prepared and approved HOD/OT in charge
Current version of SOP are 2 OB/RR Look for version.

ME G4.2 Standard Operating Department has documented 2 RR Check SOP for adequacy
Procedures adequately procedure for ensuring
describes process and patients rights including
procedures consent, privacy,
confidentiality & entitlement
Page 149

nce ent
Method
Department has documented 2 RR Check SOP for adequacy
procedure for safety & risk
management

procedure for support services
& facility management.

procedure for general patient
care processes

procedure for specific
processes to the department

procedure for infection control
& bio medical waste
management
procedure for quality
management & improvement

procedure for data collection,
analysis & use for
improvement
ME G4.3 Staff is trained and aware of Check staff is a aware of 2 SI/RR Ask staff how they carry out a
the standard procedures relevant part of SOPs specific activity.
written in SOPs
ME G4.4 Work instructions are Work instruction/clinical 2 OB processing and sterilization of
displayed at Point of use protocols are displayed equipment's,
6 6 100
Standard G 5
Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and
wastages
ME G5.1 Facility maps its critical Process mapping of critical 2 SI/RR Critical process are the ones
processes processes done where is some problem-delays,
errors, cost, time, etc. and
improvement will make our
process effective and efficient.
ME G5.2 Facility identifies non value Non value adding activities are 2 SI/RR Non value adding activities are
adding activities / waste / identified wastes. In these steps resources
redundant activities are expended, delays occur,
and no value is added to the
ME G5.3 Facility takes corrective action Processes are improved & 2 SI/RR service.
Look for the improvements
to improve the processes implemented made in the critical process.
10 10 100
Standard G6
The facility has established system of periodic review as internal assessment , medical & death audit and
prescription audit
ME G6.1 The facility conducts periodic Internal assessment is done at 2 RR/SI Check for assessment records
internal assessment periodic interval such as circular, assessment
plan and filled checklists.
Internal assessment should be
2 RR done
Checkatwith
least quarterly
audit records
C-Section Audits are done on
Monthly Bases
ME G6.3 The facility ensures non Non Compliance are 2 RR/SI Check points having scores
compliances are enumerated enumerated and recorded partial and Non Compliances
and recorded adequately are listed
ME G6.4 Action plan is made on the Action plan prepared 2 RR/SI with details of action to be
gaps found in the taken, responsibility, time line
assessment / audit process and Feedback mechanism.
ME G6.5 Planned actions are Check correction & corrective 2 RR/SI Check actions have been taken
implemented through Quality actions are taken to close the gap. Can be in form
improvement cycle (PDCA) of Action taken report or
Quality Improvement (PDCA)
project report
6 6 100
ME G7.4 Check if SMART Quality 2 SI/RR Check short term valid quality
Facility has de defined quality Objectives have framed objectivities have been framed
objectives to achieve mission and Review the key
addressing records
qualitythatissues
action
in
quality policy plan
each on quality objectives
department and cores being
ME G7.5 Mission, Values, Quality policy Check of staff is aware of 2 SI/RR reviewed
Interview at least
services. Check
with if once
staff for in
these month
their
and objectives are effectively Mission , Values, Quality Policy by departmental
objectives
awareness. are inifcharges
Specific,
Check Missionand
communicated to staff and users and objectives during the quality
Measurable,
Statement, Core team and
Attainable,
Values
Facility periodically reviews the
of services meeting.
Relevant The
and progress
Time on
Bound.
Quality Policy is displayed
progress of strategic plan Check time bound action plan quality objectives
prominently have
in local been at
language
ME G7.7 towards mission, policy and is being reviewed at regular 2 SI/RR recorded
Key Pointsin Action Plan tracking
objectives time interval sheet
4 4 100
ME G8.1 Facility uses method for Basic quality improvement 2 SI/OB PDCA & 5S
quality improvement in method
services
ME G8.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are
Standards G10 2 2 100
Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
ME G10.6 Check periodic assessment of 2 SI/RR Verify with the records. A
medication and patient care comprehensive risk assessment
safety risk is done using of all clinical processes should
Periodic assessment for defined checklist periodically be done using pre define
Medication and Patient care criteria at least once in three
safety risks is done as per month.
defined criteria.
Area of Concern - H Outcome 24 24 100
4 4 100
ME H1.1 Facility measures productivity C-Section Rate Total LSCS done x 100/Total
Indicators on monthly basis 2 RR deliveries conducted (Normal
+LSCS)
Page 150

nce ent
Method
Percentage of C-Sections done Total C-Section done in night x
in the night 100/Total surgeries conducted
(Day Night)
2 RR
8 8 100
ME H2.1 Facility measures efficiency Downtime critical equipment Sum total of time Elapsed
Indicators on monthly basis between when equipment had
problem and when the problem
is sorted out for critical
2 RR equipment.
No of C-Section per OBG Total number of C-Section
surgeon done/No. of OBG Surgeon
available
2 RR
Percentage of elective C- No. of elective LSCS x 100/Total
Sections 2 RR LSCS (Elective + Emergency)
No of drug stock out in the

month 2 RR
10 10 100
ME H3.1 Facility measures Clinical Care & Surgical Site infection Rate No. of observed surgical site
Safety Indicators on monthly infections*100/total no. of
basis Major surgeries
2 RR
No of adverse events per No of Adverse events reported
thousand patients 2 RR x 1000/total no of patient
treated in OT
% of environmental swab No. of swab culture reported
culture reported positive 2 RR positive x 100/Total no. of swab
sent for culture
Perioperative Death Rate Deaths occurred from pre
operative procedure to
discharge of the patient
2 RR
No. of C- Section Conducted
Percentage of C-Sections using safe surgery checklist
conducted using Safe Surgery *100/Total no. C-Section
Checklist 2 RR Conducted
2 2 100
Standard H4 The facility measures Service Quality Indicators and endeavors to reach State/National benchmark
ME H4.1 Facility measures Service Quality Operation Cancellation rates No. of cancelled
Indicators on monthly basis operation*1000 /total
operation done
2 RR

A 18 18 100%
B 22 22 100%
C 116 116 100%
D 70 70 100%
E 168 168 100%
F 126 126 100%
G 58 58 100%
H 24 24 100%
Total 602 602 100%
0
1
2
Page 151
Checklist - 9 Post Partum Unit Version- NHSRC 3.0

Checklist for Post Partum Unit 10
Assessment Summary

Post Partum Unit Score Card

Area of Concern wise Score Post Partum Unit Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
G Quality 100%
Management
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for Post Partum Unit

Reference No ME Statement Checkpoint Complia Assessmen Means of Verification Remarks
nce t Method

4 4
ME A1.14 Services are available for the OPD services are available for 2 SI/RR At least 6 hours
time period as mandated family planning
Page 152

nce t Method
Days for FP Surgeries are fixed 2 SI/RR As per Operational Guidelines for
Fixed Day Surgery ( At least one day
per week)

ME A2.1 The facility provides 2 SI/OB
Reproductive health Services Availability of Spacing methods IUCD, OCP, ECP & Condoms, Antra
of family planning (injectables) & Chhaya (weekly OCP)
Availability of Female Limiting 2 SI/OB Tubectomy (Minilap and
Methods of family Planning Laparoscopic)
Availability of Male Limiting 2 SI/OB
Method for Family Planning NSV/Conventional
Availability of Post partum FP 2 SI/OB Tubal Ligation and PPIUD
services
2 SI/OB
Availability of Family Planning
Counselling and Promotive
services Counselling and IEC
2 SI/OB
Abortion and Contraception
services for Ist and 2nd
trimester
2 SI/OB Dedicated postpartum ward for FP
Postpartum ward surgeries and abortion clients
ME A2.2 The facility provides Maternal Availability of post natal 2 SI/OB
health Services counselling and follow up
services
ME A2.3 The facility provides Newborn Availability/Linkage to 2 SI/OB
health Services immunization services
ME A2.5 The facility provides Adolescent Availability of Abortion services 2 SI/OB
health Services for adolescent
Availability of Contraception 2 SI/OB
services
ME A3.2 The facility Provides Laboratory 2 SI/OB For sterilization surgeries,
Services availability of haemoglobin, Urine
pregnacy test, urine analysis for
sugar
Availability of point of care and albumin
diagnostic test
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 16 16
ME B1.1 The facility has uniform and user- Availability departmental 2 OB (Numbering, main department and
friendly signage system signage's internal sectional signage
Restricted area signage are 2 OB
displayed
ME B1.2 The facility displays the services 2 OB
and entitlements available in its List of Family Planning Services
departments available
Compensation for family 2 OB
planning indemnity scheme
Compensation for family 2 OB
planning services are displayed
ME B1.5 2 OB
Patients & visitors are sensitised
and educated through IEC materials such as posters,
appropriate IEC / BCC banners, and handbills
IEC Material regarding family available at the site and displayed
approaches planning displayed
Education material for 2 OB
counselling are available in Flip charts, models, specimens, and
Counselling room samples of
contraceptives available
10 10
Standard B2
of physical economic, cultural or social reasons.
ME B2.1 2 OB/SI
Services are provided in manner Availability of female staff if a
that are sensitive to gender male doctor examine a female
patients
2 SI/PI Ask Staff/client whether they were
convinced for one method or given
There is no over emphasis on informed choice
one method
ME B2.3 2 OB
without any physical barrier & Availability of Wheel chair or
and friendly to people with stretcher for easy Access to the
disabilities OT
Availability of disable friendly 2 OB
toilet
Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information. 16 16
ME B3.1 2 OB
Adequate visual privacy is
provided at every point of care Availability of screens at IUD
insertion room
Availability of screens at family 2 OB
planning OT
2 OB
Patients are properly
draped/covered before and
after procedure
Privacy at the counselling room 2 OB
is maintained
ME B3.2 Confidentiality of patients 2 SI/OB
Patient Records are kept at
records and clinical information secure place beyond access to
is maintained general staff/visitors
2 SI/OB
No information regarding
patient identity and details are
behaviours of staff is dignified
and respectful, while delivering
the services
Page 153

nce t Method
ME B3.4 2 SI/OB No entry shall be made in any case

sheet , PT register , follow-up card or
The facility ensures privacy and any other document, register
confidentiality to every patient, indicating there in the name of the
especially of those conditions pregnant women . Only reference
having social stigma, and also serial no. is mentioned on all the
safeguards vulnerable groups document
Confidentiality of Abortion cases
Standard B4
Facility has defined and established procedures for informing and involving patient and their families about treatment and 14 14
ME B4.1 2 SI/PI/RR
for taking informed consent
before treatment and
Informed consent for IUD
procedures insertion
Informed consent for family 2 SI/RR
planning surgeries
Informed consent on prescribed 2 SI/RR
form C for abortion
ME B4.2 2 OB
Patient is informed about his/her
rights and responsibilities Display of reproductive rights of
clients
ME B4.3 Staff are aware of Patients rights Staff about awareness 2 SI
responsibilities reproductive rights of clients
ME B4.4 Client is informed about various 2 PI/SI
Information about the treatment options of family planning and
is shared with patients or assisted in decision making
attendants, regularly

system in place display of process for grievance
re addressal and whom to
contact is displayed
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care. 12 12
ME B5.1 2 PI/SI
mothers and neonates as per Drugs, consumables and
prevalent government schemes contraceptives are available
free
2 PI/SI
All surgical procedure for family
planning are free of cost
Pharmacy and wards
prescribed investigations are spent on diagnostics from
outside.
ME B5.5 2 PI/SI/RR
entitlements and reimbursement If any other expenditure
to the patients occurred it is reimbursed from
hospital
Timely payment of family 2 PI/SI/RR
planning compensation
ME B 6.7 2 RR/SI
There is an established procedure
for patients who wish to leave
hospital against medical advice or
refuse to receive specific c Declaration is taken from the
treatment LAMA patient
ME C1.1 Departments have adequate 2 OB
space as per patient or work load
Adequate Space is for
counselling and examination
2 OB
Availability of dedicated OT for
Family planning surgeries in PP
unit
ME C1.2 Patient amenities are provide as 2 OB Availability of drinking water
per patient load Functional toilets with running
water and flush are available as
per bed strength and patient
load of ward
Availability of seating 2 OB
arrangement
demarcated areas as per
functions
Demarcated of Protective Zone
Demarcated Clean Zone 2 OB
Demarcated sterile Zone 2 OB
Demarcated disposal Zone 2 OB
Availability of Changing Rooms 2 OB
Availability of Pre Operative 2 OB
Room
Availability of Post Operative 2 OB
Room
Availability of Scrub Area 2 OB
Availability of Autoclave room/ 2 OB
TSSU
Availability of dirty utility area 2 OB
Availability of dedicated 2 OB
counselling area
2 OB
Availability of examination cum
minor procedure area for IUD
insertion
Page 154

nce t Method
ME C1.4 The facility has adequate Corridors are wide enough for 2 OB
circulation area and open spaces movement of trolleys and
according to need and local law stretchers

intramural and extramural Availability of functional
communication telephone and Intercom
Services
ME C1.6 Service counters are available as OT tables are available as per 2 OB Atleast 2 laproscopic OT tables
per patient load load (Hydrulic table)
(Structure commensurate with
the function of the hospital)
Unidirectional flow of goods and
services

OT does not have temporary
electrical establishment connections and loosely hanging
wires
ME C2.4 Physical condition of buildings 2 OB
are safe for providing patient
care Floors of the ward are non
slippery and even
Walls and floor of the OT 2 OB
covered with joint less tiles
Windows if any in the OT are 2 OB
intact and sealed
ME C3.1 The facility has plan for OT has sufficient fire exit to 2 OB/SI
prevention of fire permit safe escape to its
are clearly marked.
ME C3.2 The facility has adequate fire PP unit has installed fire 2 OB
fighting Equipment Extinguisher that is Class A ,
Class BC type or ABC type
2 OB/RR
mentioned
ME C3.3 The facility has a system of Check for staff competencies for 2 SI/RR
specialist doctors as per service
provision Minilap - MBBS trained in procedure
Availability of trained surgeon Laparoscopic- DGO,MS, MD
for Minilap/ Laparoscopic/NSV 2 OB/RR trained in laparoscopic surgery
ME C4.3 The facility has adequate nursing OB/RR/SI Trained in PPIUCD and IUCD
staff as per service provision and insertion
work load
Availability of Nursing staff 2
ME C4.4 The facility has adequate Viability of Counsellor for family OB/SI RMNCHA counseller (Applicable only
technicians/paramedics as per planning in High priority districts)
requirement
2
Availability of OT technician 2 SI/RR
ME C4.5 The facility has adequate support Availability of OT SI/RR
/ general staff attendant/assistant 2
Availability of Security staff 2 SI/RR
Standard C5 Facility provides drugs and consumables required for assured list of services. 22 22
ME C5.1 The departments have Availability of Oral 2 OB/RR
availability of adequate drugs at Contraceptive Pills
point of use
Stock for Month
Availability of emergency 2 OB/RR
Contraceptive Pills Stock for Month
Availability of IUD devices 2 OB/RR Stock for Month
Availability of Condoms 2 OB/RR Stock for Month
2 OB/RR
Availability of Antra (Injectables) Stock for Month
Availability of Chaaya (Weekly 2 OB/RR
contraceptive) Stock for Month
Availability of anaesthetics 2 OB/RR
Availability of medical gases 2 OB/RR Centralized /Cylinders
2 OB/RR
Availability of drugs for MMA Mifepristone & Misoprostol

ME C5.2 The departments have adequate 2 OB/RR At OT
Sterilized consumables in
dressing drum
ME C5.3 Emergency drug trays are 2 OB/RR
maintained at every point of
care, where ever it may be
needed Availability of emergency drugs
tray
monitoring of patients examination & Monitoring
BP apparatus, Thermometer, Pulse
2 OB Oxymeter, Multiparameter
Page 155

nce t Method
ME C6.2 Availability of equipment & Availability of

instruments for treatment Instruments/Equipments for
procedures, being undertaken in Gynae and obstetric
the facility
2 OB PV examination kit
Availability of Sterile IUD
insertion and removal Kits 2 OB
Operation Table with
Trendelenburg facility 2 OB
Minilap instrument 2 OB
Laparoscopic set 2 OB
NSV sets 2 OB
PP IUCD tray 2 OB
Instrument for MVA Check MVA kit (Aspirator &
2 OB cannuala)
Instruments for Laparoscopy
2 OB
instruments for diagnostic diagnostic instruments
procedures being undertaken in Glucometer, Doppler and HIV rapid
the facility diagnostic kit, digitial Haemoglobin
2 OB meter
intensive and critical care to Bag and mask, Oxygen, Suction
patients Availability of functional machine , laryngoscope scope. LMA,
Instruments Resuscitation 2 OB ET Tube , Airway ,Defibrillator
Storage storage for drugs instrument trolley, dressing trolley
2 OB
ME C6.6 Availability of functional Availability of equipments for Buckets for mopping, Separate mops
equipment and instruments for cleaning for patient care area and circulation
support services area duster, waste trolley, Deck
brush
2 OB
Availability of equipment for Autoclave/ boiler, glutaraldehye
2 OB
ME C6.7 Departments have patient Availability of functional OT light
furniture and fixtures as per load
2 OB
Availability of attachment/ Hospital graded mattress , IV stand,
accessories with OT table 2 OB Bed pan
Tray for monitors, Electrical panel

for anaesthesia machine, cardiac
monitor etc, panel with outlet for
Oxygen and vacuum, X ray view
Availability of Fixtures 2 OB box.
Cupboard, table for preparation of
Availability of furniture 2 OB medicines, chair, racks,
ME C7.1 RR/SI
prepared for assessing competence
2 of doctors, nurses and paramedical
staff based on job description
Criteria for Competence assessment Check parameters for assessing defined for each cadre of staff.
are defined for clinical and Para skills and proficiency of clinical Dakshta checklist issued by MoHFW
clinical staff staff has been defined can be used for this purpose.
ME C7.2 RR/SI
Competence assessment of Clinical 2 assessment including filled checklist,
and Para clinical staff is done on Check for competence scoring and grading . Verify with
predefined criteria at least once in assessment is done at least once staff for actual competence
a year in a year assessment done
ME C7.9 SI/RR
training plan PPIUCDand IUD insertion 2
Family planning counselling 2 SI/RR
Laparoscopic surgery/Minilap 2 SI/RR
NSV 2 SI/RR
Training on Antra (Injectable SI/RR
Conctrapcetives) 2
Chhaya training (Weekly SI/RR
contraceptive) 2
Comprehensive Aboration care SI/RR Post abortion IUCD
(CAC) 2
SI/RR
Bio medical waste Management 2
Training on infection control and SI/RR
hand hygiene 2
BLS training for all staff 2
ME C7.10 SI/RR
There is established procedure for that staff is working according to the
utilization of skills gained thought training imparted. Also staff is
trainings by on -job supportive Staff is skill for counselling provided on job training wherever
supervision services 2 there is still gaps
SI/RR
provided on job training wherever
Staff is skilled for resuscitation 2 there is still gaps
SI/RR
Nursing Staff is skilled for provided on job training wherever
maintaining clinical records 2 there is still gaps
Page 156

nce t Method
SI/RR
Staff is Skilled to operate OT provided on job training wherever
equipments 2 there is still gaps
SI/RR
Staff is skilled for processing and provided on job training wherever
packing instrument 2 there is still gaps
ME D1.1 The facility has established All equipments are covered 2 SI/RR
system for maintenance of under AMC including preventive
critical Equipment maintenance
2 SI/RR
Defective/Out of order
equipments and stored
repaired
OB/RR
Equipment
2 OB/ RR
There is system to label/ code

the equipment to indicate status
of calibration/ verification when
ME D1.3 Operating and maintenance 2 OB/SI Laparoscope, MVA etc
instructions are available with Up to date instructions for
the users of equipment operation and maintenance of
with staff.
Standard D2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care 22 22
areas
ME D2.1 There is established procedure SI/RR
for forecasting and indenting Check FP LIMS for stock update
drugs and consumables There is process indenting
consumable and drugs 2
ME D2.3 The facility ensures proper
storage of drugs and
consumables Contraceptives are stored away
from water and sources of heat,
direct sunlight etc. 2 OB/RR
ME D2.4 The facility ensures management Expiry dates' are maintained at OB/RR
of expiry and near expiry drugs emergency drug tray Are expired contraceptives
destroyed to prevent resale
2 or other inappropriate use
drug stored at department 2 RR
ME D2.5 The facility has established There is practice of calculating SI/RR
procedure for inventory and maintaining buffer stock of
management techniques contraceptives
2
and expenditure register of
contraceptives
2
ME D2.6 There is a procedure for periodically There is procedure for SI/RR
replenishing the drugs in patient replenishing drug tray /crash
care areas cart
2
There is no stock out of OB/SI
contraceptives 2
ME D2.7 There is process for storage of OB/RR Check for temperature charts are
vaccines and other drugs, maintained and updated periodically
requiring controlled temperature Temperature of refrigerators are
kept as per storage requirement
and records are maintained 2
ME D2.8 There is a procedure for secure Anaesthetic agents are kept at OB/SI
storage of narcotic and secure place
psychotropic drugs
2
areas Adequate Illumination at OT
table
Adequate Illumination at 2 OB At IUD insertion area
procedure area in OPD
ME D3.2 The facility has provision of 2 OB
restriction of visitors in patient
areas
Entry to OT is restricted
Only one client is allowed one 2 OB/SI
time at clinic
2
Warning light is provided
outside OT and its been used
when OT is functional SI/RR
ME D3.3 The facility ensures safe and 2
comfortable environment for 20-25OC, OT has functional room
patients and service providers Temperature is maintained and thermometer and temperature is
record of same is maintainted SI/RR regularly maintained
Appropriate humidity level is 2
maintained SI/RR
ME D3.4 The facility has security system in Security arrangement at PP 2 OB
place at patient care areas unit
ME D3.5 The facility has established measure Ask female staff whether they 2 SI
for safety and security of female feel secure at work place
staff
Page 157

nce t Method
ME D4.1 Exterior of the facility building is 2 OB

maintained appropriately
Building is painted/whitewashed
in uniform colour
plastered & painted
Floors, walls, roof, roof topes,
hygienic sinks patient care and All area are clean with no
circulation areas are Clean dirt,grease,littering and cobwebs
are clean


fixtures are intact
OT Table are intact and without 2 OB
rust
No condemned/Junk material in
the PP unit
animal control
No pests are noticed
for portable water in all
functional areas
Availability of Hot water supply 2 OB/SI

OT
Availability of UPS & generator 2 OB/SI
availability of oxygen, medical gases piped Oxygen, nitrogen and
and vacuum supply vacuum supply

ME D7.1 The facility has adequate sets of OT has facility to provide OB/RR Drape, draw sheet, cut sheet and
linen gown
sufficient and clean linen for
surgical patient 2
OT has facility to provide linen OB/RR
for staff 2
ME D7.2 The facility has established Linen is changed after each OB/RR
procedures for changing of linen procedure
in patient care areas
2
ME D7.3 The facility has standard procedures SI/RR
for handling , collection,
transportation and washing of linen There is system to check the
cleanliness and Quantity of the
linen received from laundry 2
Standard D10 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 2 2
ME D10.3 The facility ensure relevant
processes are in compliance with
statutory requirement Staff is aware of legal age for
family planning beneficiaries 2 SI/RR 22-49 yrs married only
Standard D11
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 8 8
procedures.
ME D11.1 The facility has established job Staff is aware of their role 2 SI
description as per govt guidelines and responsibilities
ME D11.2 The facility has a established There is procedure to ensure 2 RR/SI Check for system for recording time
procedure for duty roster and that staff is available on duty as of reporting and relieving
deputation to different per duty roster (Attendance register/ Biometrics
departments etc)

for department
ME D11.3 The facility ensures the 2 OB
adherence to dress code as
mandated by its administration /
the health department Doctor, nursing staff and
support staff adhere to their
respective dress code
2 2
(cleaning/
There is procedure to monitor Dietary/Laundry/Security/Maintena
There is established system for the quality and adequacy of nce) provided are done by
contract management for out outsourced services on regular designated in-house staff
sourced services basis
ME E1.1 The facility has established Unique identification number 2 RR
procedure for registration of is given to each client during
patients process of registration
Client demographic details are 2 RR Check for that patient demographics

etc.
ME E1.3 There is established procedure Age criteria for family planning 2 RR/SI
for admission of patients surgeries is adhered
There is established criteria for 2 RR/SI

admission of abortion cases
patient
Admission is done by written 2 SI/RR/OB
order of a qualified doctor
patient record
Page 158

nce t Method
ME E1.4 There is established procedure There is provision of extra beds 2 OB/SI

for managing patients, in case during fixed day family planning
beds are not available at the surgery
facility
ME E2.1 There is established procedure History of illness to screen for 2 RR/SI
for initial assessment of patients the diseases mentioned under
the medical
eligibility criteria
Immunization status of women 2 RR/SI

for tetanus
Current medications 2 RR/SI
Last contraceptive used and 2 RR/SI
when
Menstrual history: Date of last 2 RR/SI
menstrual period
Current pregnancy status 2 RR/SI
Obstetrics history
Physical Examination 2 RR/SI
Pulse, blood pressure, respiratory

rate, temperature, body
weight, general condition and pallor,
auscultation of heart and lungs,
examination
of abdomen, pelvic examination,
and other examinations as indicated
by the
client’s medical history or general
physical examination.
ME E2.2 There is established procedure 2
for follow-up/ reassessment of
Patients There is fixed schedule for
assessment of patients RR/OB
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 6 6
ME E3.1 Facility has established Facility has established 2
procedure for continuity of care procedure for handing over
during interdepartmental form OT to ward
transfer
SI/RR
ME E3.2 Facility provides appropriate 2
referral linkages to the Facility has functional referral
patients/Services for transfer to linkages to higher facilities for
other/higher facilities to assure cases which can not be
their continuity of care. managed at the facility
RR/SI
ME E3.3 A person is identified for care A nurse /doctor is identified 2 RR/SI
during all steps of care responsible for each case
ME E4.1 Procedure for identification of There is a process for ensuring 2 OB/SI Patient id band/ verbal confirmation
patients is established at the the identification before any etc.
facility clinical procedure
ME E4.2 Procedure for ensuring timely and There is a process to ensue 2 RR Verbal orders are rechecked before
accurate nursing care as per the accuracy of administration
treatment plan is established at the verbal/telephonic orders
facility
ME E4.3 There is established procedure of Patient hand over is given 2 SI/RR

patient hand over, whenever during the change in the shift
staff duty change happens

maintained
ME E4.5 There is procedure for periodic Patient Vitals are monitored 2 RR/SI
monitoring of patients and recorded periodically
4 4
ME E5.1 The facility identifies vulnerable Vulnerable patients are 2 OB/SI
patients and ensure their safe care identified and measures are
taken to protect them from any
harm
ME E5.2 The facility identifies high risk High risk medical emergencies 2 OB/SI
patients and ensure their care, as are identified and treatment
per their need given on priority
10 10
Standard E6
rational use.
ME E6.1 Facility ensured that drugs are 2 RR
prescribed in generic name only Check for BHT if drugs are
prescribed under generic name
only
drugs treatment guideline are
available at point of use
Standard E7 Facility has defined procedures for safe drug administration 22 22
high alert drugs (to check) agent, Anti thrombolytic agent,
Adrenergic agonist etc. as applicable
Maximum dose of high alert 2 SI/RR Value for maximum doses as per
drugs are defined and age, weight and diagnosis are
communicated available with nursing station and
doctor
Page 159

nce t Method

right doses of high alert drugs check before administration, Error
are only given prone medical abbreviations are
avoided

legibly and adequately procedure is accompanied
with date , time and signature

staff
ME E7.3 There is a procedure to check Drugs are checked for expiry 2 OB/SI
drug before administration/ and other inconsistency
dispensing before administration
Check single dose vial are not 2 OB Check for any open single dose vial
used for more than one dose with left over content intended to
be used later on
Check for separate sterile 2 OB
needle is used every time for In multi dose vial needle is not left in
multiple dose vial the septum
route, right time
ME E7.5 Patient is counselled for self drug Client is advice by doctor/ 2 SI/PI
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 18 18
ME E8.1 All the assessments, re- Records of Monitoring/ 2 RR
assessment and investigations Assessments are maintained
are recorded and updated History and Physical examination are
recorded as per FP casesheet
ME E8.2 All treatment plan Treatment plan, first orders are 2 RR
prescription/orders are recorded written on BHT
Drugs administered are recorded
ME E8.4 Procedures performed are Anaesthesia and surgery note 2 RR
written on patients records recorded
ME E8.5 Adequate form and formats are 2 RR/OB Check availability and recording in
available at point of use Standard Formats available FP case sheet
as per guidelines
Check for availability of sterilization
register, IUCD & PPIUCD & service
Check for availability of eligible delivery register, Antra- register
couple and sterilization register (injectable contraceptives)
2 RR follow up register, injectble &
Records on family planning (FP) contraceptive register (Antra
(including the number register)
of clients counselled and the
number of acceptors)
2 RR Check filled and updated DMPA
(Antra card) client card and register
for beneficiaries utilizing Antra
Follow-up records for FP clients services
All register/records are 2 RR

adequate storage and retrieval
of medical records
20 20
2 SI/RR
Discharge is done by a
responsible and qualified doctor
Patient / attendants are 2 PI/SI
consulted before discharge
2 SI/RR
patients
ME E9.2 Case summary and follow-up Discharge summary is provided 2 RR/PI Check FP case Sheet
instructions are provided at the
discharge
2 RR Check FP case Sheet
follow up
ME E9.3 Counselling services are provided 2 SI/PI
as during discharges wherever Counselling of client before
required discharge
2 RR/SI
about the nearest health centre
for further follow up
2 PI/SI
Time of discharge is
communicated to patient in
prior
4 4
4 4
Page 160

nce t Method
ME E12.1 There are established Container is labelled properly 2 OB

procedures for Pre-testing after sample collection
Activities
ME E12.3 There are established 2 SI/RR
procedures for Post-testing
Activities Nursing station is provided with
the critical value of different test
Standard E14 Facility has established procedures for Anaesthetic Services 2 2
ME E14.2 Facility has established 2 SI/RR
procedures for monitoring during
anaesthesia Local anaesthesia is given as per
guidelines
Standard E15 Facility has defined and established procedures of Surgical Services 16 16
ME E15.1 Facility has established FP surgeries are scheduled as 2 RR/SI
procedures OT Scheduling per guidelines
Preoperative instructions given 2 RR/PI
to the client
ME E15.2 Facility has established 2 RR/SI
procedures for Preoperative care
Part preparation is done as per
guidelines
ME E15.3 Facility has established RR/SI
Check for Surgical safety check list
procedures for Surgical Safety Surgical Safety Check List is used has been used for surgical
for each surgery 2 procedures
RR/SI
Instrument, needles and sponges
are counted before beginning of
Sponge and Instrument Count case, before final closure and on
Practice is implemented 2 completing of procedure
Adequate Haemostasis is RR/SI Check for Cautery and suture
secured during surgery 2 legation practices
Check for suturing techniques RR/SI
are applied as per protocol 2
ME E15.4 Facility has established 2 RR/SI
procedures for Post operative
care Post operative care as per
guidelines
Standard E16 The facility has defined and established procedures for end of life care and death 8 8
ME E16.1 Death of admitted patient is Facility has a standard 2 SI
adequately recorded and procedure to decent
communicated communicate death to
relatives

record
ME E16.2 The facility has standard 2 RR
procedures for handling the Death note including efforts
death in the hospital done for resuscitation is noted
in patient record
2 SI/RR
Death summary is given to
cause if possible
Standard E17 Facility has established procedures for Antenatal care as per guidelines 2 2
ME E17.1 There is an established Facility provides and updates 2 SI/RR
procedure for Registration and “Mother and Child Protection
follow up of pregnant women. Card”.
Standard E21 Facility has established procedures for abortion and family planning as per government guidelines and law 50 50
ME E21.1 Family planning counselling The client is given full
services provided as per information about optimal
pregnancy spacing and The importance of timely initiation
guidelines of an FP method after childbirth,
the benefits of it as a part of FP
health education and miscarriage,
counselling. or abortion will be emphasized.
2 PI/SI
Client is counselled about the
options for family planning
available
2 PI/SI
The client is informed that
condoms prevent sexually
transmitted infections (STIs) &
HIV
2 PI/SI
ME E21.2 Facility provides spacing method Pills should be given only to Contraindication of COC in
of family planning as per those who meet the Medical Breastfeeding mothers within 6week
guideline Eligibility Criteria and hypertension
2 SI/RR
The client should be given full
information about the risks,
advantages, and possible side
effects before OCPs are
prescribed for her.
2 PI/SI
Staff is aware of what to do if
dose of contraceptive is missed 2 SI/RR
Staff is aware of indication and Single Tablet within 72 hours
method of administration of ECP unprotected intercourse.
2 SI/RR
IUD insertion is done as per No touch technique, Speculum and
standard protocol bimanual examination, sounding of
2 SI/RR uterus and placement
Client is informed about the Cramping, vaginal discharge, heavier
adverse effect that can happen menstruation, checking of IUD
and their remedy
2 SI/PI
Follow up services are provided Removal of IUD, Instructions for
as per protocols SI/RR when to return
2
IUD insertion is done as per
standard protocol SI/RR
2
Page 161

nce t Method
PPIUD insertion is done as per

standard protocol
Grasp IUCD with PPIUCD forcep

using no touch technique, apply
traction on anterior lip of cervix with
ring (sponge holding) forcep and
insert IUCD in to lower utrine wall,
SI/RR remove the ring forcep and move
other hand upward to women's
abdomen, move PPIUCD insertion
forcep upward toward fundus, feel
the resitance & thrust of instrument
by hand kept on abdomen, open
PPIUCD forcep and realease IUCD,
instument is slowly withdrawn by
keeping side way to avoid dislodging
of IUCD. Ensure IUCD is not visible
2 if yes remove & reinsert
Staff is aware of case selection
criteria for family planning
SI/RR 22-49 year age
Married
at least having one year old
2 Spouse has not gone for sterilization
ME E21.3 Facility provides limiting method Assessment of client done Physical examination and Medical
of family planning as per before surgery for any Delay, SI/RR History taken,
guideline refer of caution signs
2
Consent is confirmed before the surgeon check for informed consent
procedure RR signed and ask client for the same
2
Client is informed about post use of another family planning
operative care, complication SI/RR/PI method for 3 months only,
and follow up
2
Follow up visits done as per GoI Visit after 48 hours, first follow up
guidelines visit at 7th day and semen analysis
SI/RR/PI after 3 months, emergency follow
up
2
ME E21.4 Facility provide counselling Pre procedure Counselling
services for abortion as per provided As per national Guidelines
guideline SI/RR/PI Transition phase after family
planning surgery specially
2 vasectomy defined
Post procedure Counselling
provided SI/RR/PI
2 As per national guidelines
Counselling on the follow-up
visit SI/RR/PI
2
ME E21.5 Facility provide abortion services MVA procedures are done as SI/RR Allowed upto 12 weeks of gestation.
for 1st trimester as per guideline per guidelines
2
Staff is aware of gestational SI/RR Allowed upto7 weeks of
period for Medical Method of gestation(49 days from the first day
Abortion (MMA) of the LMP).
2
MMA drug protocols are SI/RR First Visit (Day 1) - 200 mg
followed as per guidelines Mifepristone (oral)
2nd Visit (Day 3) -400 mcg
Misprostole (sublingual/ buccal/
vaginal/oral)
3rd Visit (Day 15)- Confirm & ensure
complete abortion
2
ME E21.6 Facility provide abortion services Surgical Procedures procedures SI/RR Allowed upto 12 weeks of gestation.
for 2nd trimester as per are done as per guidelines
guideline
2
Surgical Procedures procedures SI/RR
are done as per guidelines
1. Check aspirator retains vaccum &

choose appropriate size cannula.
2. Prepare Women for procedure
(form c & pain management)
3 Clean cervix twice with Antiseptic
sol.
4. Adminster paracervical block
(lignocaine)
5. Dilate Cervix using cannula
6. Suction of utrine content
7. Inspect tissue
2
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 12 12
and active culture surveillance of
critical & high risk areas Surface and environment
samples are taken for Swab are taken from infection prone
ME F1.2 microbiological surveillance 2 SI/RR surfaces
Facility measures hospital
There is procedure to report and symptoms of HAI like fever,
cases of Hospital acquired purulent discharge from surgical site
ME F1.3 infection 2 SI/RR .
Medical Checkups and immunization of the staff
Periodic medical checkups of
the staff 2 SI/RR
Facility has established Hand washing and infection control
procedures for regular audits done at periodic intervals
monitoring of infection control
practices Regular monitoring of infection
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 30 30
Hand washing facilities are Availability of hand washing Check for availability of wash basin
ME F2.1 provided at point of use Facility at Point of Use 2 OB near the point of use
with soap dish/ liquid antiseptic Check for availability/ Ask staff if the
with dispenser. supply is adequate and
Page 162

nce t Method
Availability of Alcohol based Check for availability/ Ask staff for

Hand rub 2 OB/SI regular supply.
hand washing facility , preferably in
2 OB Local language
Availability of elbow operated
taps 2 OB
deep enough to prevent
splashing and retention of water
2 OB
standard hand washing practices washing
Adherence to Surgical scrub procedure should be repeated
method several times so that the scrub lasts
for 3 to 5
minutes. The hands and forearms
should be dried with a sterile towel
only.
2 SI/OB
wash 2 SI Ask of demonstration
Facility ensures standard Availability of Antiseptic
practices and materials for Solutions
antisepsis
ME F2.3 2 OB
Proper cleaning of procedure
site with antisepsis like before giving IM/IV injection,
2 OB/SI and urinary catheter
Cleaning of cervix before IUD SI
insertion with antiseptic solution
2 Iodine, betadine etc.
Check Shaving is not done SI
during part preparation/delivery
cases
2
Check sterile filled is maintained
during surgery Surgical site covered with sterile
drapes, sterile instruments are kept
2 OB/SI within the sterile field.
Standard F3 Facility ensures standard practices and materials for Personal protection 18 18
Facility ensures adequate
personal protection equipments
as per requirements
Clean gloves are available at
Sterile s gloves are available at
OT and Critical areas 2 OB/SI
Use of elbow length gloves for
obstetrical purpose 2 OB/SI
Availability of gown/ Apron 2 OB/SI
Availability of Caps 2 OB/SI
infectious patients 2 OB/SI HIV kit
Staff is adhere to standard No reuse of disposable gloves,
gloves 2 SI
Standard F4 Facility has standard Procedures for processing of equipments and instruments 36 36
Facility ensures standard practices Decontamination of operating &
and materials for decontamination Procedure surfaces Ask stff about how they
and clean ing of instruments and decontaminate the procedure
procedures areas surface like OT Table,

the instruments like ambubag,
Instruments
Proper Decontamination of Wiping with 0.5% Clorine Solution or
instruments after use 2 SI/OB 70% Alcohal as applicable
decontamination is adeqaute 2 SI/OB
decontamination Cleaning is done with detergent and
running water after
Staff know how to make
chlorine solution 2 SI/OB
Facility ensures standard practices Equipment and instruments are Autoclaving/HLD/Chemical
and materials for disinfection and sterlized after each use as per Sterlization
equipments
ME F4.2 2 OB/SI
instruments/equipments is required for bioling
2 OB/SI
instruments/equipments is done concentration and contact time
as per protocols requied for chemical sterilization
2 OB/SI
Formaldehyde or glutaraldehyde
solution replaced as per
manufacturer instructions 2 OB/SI
procedure 2 OB/SI
used 2 OB/SI
Page 163

nce t Method
Instruments are packed

according for autoclaving as per
standard protocol 2 OB/SI
done as per protocols 2 OB/SI pressure and time
Regular validation of
sterilization through biological
and chemical indicators 2 OB/SI/RR
Maintenance of records of
sterilization 2 OB/SI/RR
There is a procedure to enusure
the tracibility of sterilized packs 2 OB/SI/RR
conducive for the infection control Facility layout ensures
practices separation of general traffic Faculty layout ensures separation of
ME F5.1 from patient traffic 2 OB general traffic from patient traffic
Zoning of High risk areas 2 OB
Facility layout ensures
separation of routes for clean
and dirty items 2 OB
Floors and wall surfaces of ICU
are easily cleanable 2 OB
CSSD/TSSU has demarcated

separate area for receiving dirty
items, processes, keeping clean
and sterile items 2 OB
followed for cleaning and management
ME F5.3 2 SI/RR
cleaning solution as per
standard procedure
2 SI/RR
and scrubbing are followed 2 OB/SI
are not used in patient care
areas
2 OB/SI
Use of double bucket system for
mopping 2 OB/SI
schedule 2 SI/RR
External footwares are
restricted 2 OB
Facility ensures air quality of high Adequate air exchanges are
ME F5.5 risk area maintained 2 SI/RR
Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and 30 30
hazardous Waste.
Facility Ensures segregation of Availability of colour coded bins Adequate number. Covered. Foot
Bio Medical Waste as per at point of waste generation operated.
guidelines
ME F6.1 2 OB
non chlorinated plastic bags 2 OB

swabs and bags containing residual

Biomedical waste
2 OB
and general waste 2
including Metals in white of generation.Needles, syringes with
(translucent) Puncture proof, fixed needles, needles from needle
Leak proof, tamper proof tip cutter or burner, scalpels,
containers blades, or any other contaminated
sharp object that may cause
puncture and cuts. This includes
both used, discarded and

condition of needle stick injury shape injury. Whom to report. See if
and leak proof box/ container
OB
Facility ensures transportation Check bins are not overfilled
guidelines
ME F6.3 2 SI/OB
Page 164

nce t Method

container/trolley
2
management 2 SI/RR
2 2
place departmental nodal person
2 2
ME G2.1 Patient Satisfaction surveys are 2 RR
Client satisfaction survey done
on monthly basis
4 4
ME G3.1 Facility has established internal 2 SI/RR
quality assurance program at There is system daily round by
relevant departments Hospital superintendent/
services
ME G3.3 Facility has established system Departmental checklist are 2 SI/RR Staff is designated for filling and
for use of check lists in different used for monitoring and monitoring of these checklists
departments and services quality assurance
40 40
Standard G4
support services.
ME G4.1 Departmental standard Standard operating procedure 2 RR
operating procedures are for department has been
available prepared and approved

adequately describes process
and procedures Department has documented
procedure for registration,
admission and discharge
2 RR
procedure for initial assessment
of the patient
2 RR
procedure for providing
appointment/day and date for
the surgery
2 RR
procedure for preparation of
patient for surgery
procedure for IUD insertion
Department has documented 2
procedure for PPIUCD insertion
2 RR
procedure for taking consent of
the patient for procedure
2 RR
procedure for record
maintenance
2 RR
patient
Department has manual for 2 RR
male and female sterilization
2 RR
Department has manual for
Quality assurance for
sterilization
2 RR
Department has guideline for
administration of Emergency
contraceptive
2 RR
Department has standard for
various technique of
contraception
2 RR
Department has standard IEC
material for patient education
and counselling
Department has manual for FP 2 RR
indemnity scheme
Department has manual for FP 2
Anatra and Chhaya
ME G4.3 Staff is trained and aware of the 2 SI/RR
standard procedures written in
SOPs Check staff is a aware of
relevant part of SOPs
ME G4.4 Work instructions are displayed Work instruction/clinical 2 OB IUD insertion, Processing of
at Point of use protocols are displayed instruments
6 6
processes done
ME G5.2 Facility identifies non value 2 SI/RR
identified
Page 165

nce t Method
10 10

audits There is procedure to conduct
Death audit
ME G6.3 The facility ensures non Non Compliance are 2 RR/SI
compliances are enumerated and enumerated and recorded
recorded adequately
process
ME G6.5 Planned actions are 2 RR/SI PDCA
implemenated through Quality
improvement cycle (PDCA)
Check correction & corrective
actions are taken
6 6
ME G7.4 2 SI/RR

department and cores services.
Facility has de defined quality Check if these objectives are
objectives to achieve mission and Check if SMART Quality Specific, Measurable, Attainable,
quality policy Objectives have framed Relevant and Time Bound.
ME G7.5 2 SI/RR
objectives are effectively Check of staff is aware of Statement, Core Values and Quality
communicated to staff and users of Mission , Values, Quality Policy Policy is displayed prominently in
services and objectives local language at Key Points
ME G7.7 2 SI/RR
Review the records that action plan

on quality objectives being reviewed
at least onnce in month by
departmnetal incharges and during
the qulaity team meeting. The
Facility periodically reviews the Check time bound action plan is progress on quality objectives have
progress of strategic plan towards being reviewed at regular time been recorded in Action Plan
mission, policy and objectives interval tracking sheet
6 6
ME G8.1 Facility uses method for quality Basic quality improvement 2 SI/OB PDCA & 5S

method
ME G8.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used
Standards G10 2 2
ME G10.6 2 SI/RR
Check periodic assessment of comprehensive risk asesement of all
Periodic assessment for Medication medication and patient care clincial processes should be done
and Patient care safety risks is done safety risk is done using defined using pre define critera at least once
as per defined criteria. checklist periodically in three month.
26 26
ME H1.1 Facility measures productivity IUD insertion per 1000 eligible
Indicators on monthly basis female 2 RR Denominator to be discussed
Vasectomy performed 2 RR
Tubectomy performed 2 RR
No of First Trimester MTP 2 RR
No. of Second Trimester MTP 2 RR
OCP Users 2 RR
No. Antara (injectable
contraceptive) user 2 RR
No. Chhaya user 2
No. of PP- FP Method 2 RR at least 10% of deliveries per facility

Proportion of users using
limiting method 2 RR
Proportion of target met for
male sterilization surgery 2 RR
Proportion of target met for
female sterilization surgery 2 RR
No. of family planning
counselling done per 1000 client
2 RR
ME H2.1 Facility measures efficiency
Indicators on monthly basis Skin to Skin time 2 RR
Proportion of clients agreed for
family planning methods out of
total counselled 2 RR
Surgeries done/ surgeon : 30 /day. 2
FP surgeries done per surgeon 2 RR Surgeon :50 /day.
ME H3.1 Facility measures Clinical Care & Surgical Site Infection rate
Safety Indicators on monthly basis 2 RR
Page 166

nce t Method
Medical Audit Score 2 RR

No of adverse events per
thousand patients 2 RR
No. of complication per 1000
male sterilization surgeries 2 RR
No. of complication per 1000
female sterilization surgeries 2 RR
Surgical site infection rate 2 RR
No. of post operative deaths
per 1000 surgeries 2 RR
No. of sterilization failure per
1000 surgeries 2 RR
Indicators on monthly basis Client Satisfaction score 2 RR
Average counselling time 2 RR

A 28 28 100%
B 70 70 100%
C 172 172 100%
D 106 106 100%
E 212 212 100%
F 158 158 100%
G 76 76 100%
H 52 52 100%
Total 874 874 100%
0
1
2
Page 167
Checklist No. - 10 Intensive Care Unit Version - NHSRC/3.0

Checklist for Intensive Care Unit 11
Assessment Summary

Intensive Care Unit Score Card

Area of Concern wise Score Intensive Care Unit Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for Intensive Care Unit

Reference No ME Statement Checkpoint Compliance Assessment Means of Verification Remarks
Full/Partial/No Method

Facility Provides Curative Services 10 10
Standard A1
Page 168

ME A1.1 The facility provides General

Medicine services Major medical cases like
CVA,Haematomas, CAD,
Availability of Intensive care Haemoptysis, Snake bite, Br.
services for medical cases 2 SI/OB Asthma Poisoning etc
ME A1.2 The facility provides General Surgery Availability of Intensive care Major surgical cases including
services services for Surgical cases 2 SI/OB trauma
ME A1.3 The facility provides Obstetrics & Availability of Intensive care If ICU services are not available
Gynaecology Services services for Gynae and obstetrics then facility ensure linkages
cases 2 SI/OB (Partial Compliance)
ME A1.14 Services are available for the time Availability of ICU services 24X7 SI/RR
period as mandated 2
ME A1.17 The facility provides Intensive care
Services Intubation, Tracheotomy,
Mechanical Ventilation, short term
cardio respiratory support,
Availability of Intensive care Defibrillation, CPR, Mobilization,
services. 2 SI/OB Chest Tube, ventilator
Standard A3
ME A3.1 The facility provides Radiology Availability of Portable X ray 2 SI/OB

Services services
Availability of USG services 2 SI/OB
ME A3.2 The facility Provides Laboratory Functional side laboratory 2 SI/OB ABG & Electrolyte
Services services are available
ME A3.3 The facility provides other diagnostic Functional ECG Services are 2 SI/OB 12 lead ECG
services, as mandated available
Facility provides services as mandated in national Health Programs/ state scheme 2 2
Standard A4
ME A4.8 The facility provides services under 2 SI/OB 5 bedded ICU

National Programme for Prevention
and control of Cancer, Diabetes,
Cardiovascular diseases & Stroke
(NPCDCS) as per guidelines
Availability of cardiac care unit

22 22
ME B1.1 The facility has uniform and user- Availability departmental (Numbering, main department and
friendly signage system signage's 2 OB internal sectional signage
Availability of Directional
Signage's 2 OB
Signage for restricted area 2 OB
ME B1.2 The facility displays the services and
entitlements available in its Services provision in ICU are
departments displayed 2 OB
Services not available in ICU are
displayed 2 OB
Names of doctor and nursing
staff on duty are displayed and
updated 2 OB
Important numbers including
ambulance, blood bank and
referral centres displayed 2 OB
ME B1.4 User charges are displayed and OB
communicated to patients User charges in r/o lCU services
effectively are displayed 2
ME B1.5 Patients & visitors are sensitised and IEC material displayed in waiting OB
educated through appropriate IEC / area
BCC approaches 2
ME B1.6 Information is available in local Signage's and information are OB
language and easy to understand available in local language 2
ME B1.8 The facility ensures access to clinical Discharge summery is given to OB
records of patients to entitled the patient
personnel 2
6 6
Standard B2
physical, economic, cultural or social reasons.
ME B2.1 2 OB/SI 2423
Services are provided in manner that Availability of female staff if a
are sensitive to gender male doctor examination a
female patients
ME B2.3 2 OB
Access to facility is provided without Availability of Wheel chair or

any physical barrier & and friendly to stretcher for easy Access to the
people with disabilities ICU
2 OB for easy , safe and fast transport of
bed/trolley of critically sick patient
ICU is connected to lift/ramp
10 10
ME B3.1 Adequate visual privacy is provided 2 OB
at every point of care Availability of screen
ME B3.2 Confidentiality of patients records 2 SI/OB
Patient Records are kept at
and clinical information is secure place beyond access to
maintained general staff/visitors
2 SI/OB
No information regarding
patient identity and details are
ME B3.4 2 SI/OB
especially of those conditions having
social stigma, and also safeguards
vulnerable groups Privacy and confidentiality of
HIV cases
Page 169

10 10
Standard B4
Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining
taking informed consent before Admission, intubation, blood
treatment and procedures Informed consent for ICU transfusion
Consent for Invasive procedure 2 SI/RR
ME B4.3 Staff are aware of Patients rights Staff is aware of patients rights 2 SI
responsibilities and responsibilities
ME B4.4 2 PI/SI
Information about the treatment is ICU has system in place to
shared with patients or attendants, communicate with patient/ their Ask patients relative about
family member the nature and whether they have been
regularly seriousness of the illness at least communicated about the
once in day treatment plan and progress
system in place display of process for grievance
8 8
ME B5.1 ICU services are free for JSSK 2 PI/SI
The facility provides cashless beneficiaries
prevalent government schemes
ME B5.2 Check that patient party has not 2 PI/SI
The facility ensures that drugs incurred expenditure on
prescribed are available at Pharmacy purchasing drugs or
and wards consumables from outside.
prescribed investigations are incurred expenditure on
diagnostics from outside.
ME B5.4 2 PI/SI/RR
ICU services are free for BPL
hassles patients
ME B6.6 Patients Relatives are informed 2 SI/RR
clearly about the deterioration
There is an established procedure for in health condition of Patients
‘end-of-life’ care
The is a standard procedure of 2 SI/RR Check about the policy and
removal of life sustaining practice for removing life support
treatment as per law
There is a procedure to allow 2 SI/OB
patient relative/Next of Kin to
observe patient in last hours
ME B 6.7 2 RR/SI
patients who wish to leave hospital Declaration is taken from the
against medical advice or refuse to LAMA patient and the
receive specific c treatment consequences are explained
Standard C1
ME C1.1 Departments have adequate space

as per patient or work load Space requirement in ICU is 100-
125 sq feet area per bed in patient
ICU has adequate space as per care area including space for
requirement 2 OB storage and duty room etc
Availability of adequate waiting
area
2 OB
ME C1.2 Patient amenities are provide as per Availability of seating
patient load arrangement 2 OB
Availability of cold Drinking
water 2 OB
ME C1.3 Departments have layout and
There is no thoroughfare through
ICU has single entry and exit 2 OB ICU
All monitors/ patients must be

observable from nursing station
Central nursing station is either directly or through central
available in ICU 2 OB monitoring station
ICU has designated Isolation
room 2 OB
Ancillary area includes: Nursing

station, clean and dirty utility
area, Unit stores, Hand washing
Availability of Ancillary area 2 OB and gowning area,
ICU has dedicated change room Separate doctor and nurse change
for staff 2 OB room are available
ICU has dedicated counselling
room 2 OB
ME C1.4 The facility has adequate circulation Corridors are wide enough for 2-3 Meters
area and open spaces according to easy movement of Trolleys
need and local law
2 OB
There is sufficient space

between two bed to provide bed
side nursing care and movement 2 OB
telephone and Intercom Services 2 OB
ME C1.6 Service counters are available as per Availability of ICU beds as per
patient load load 2 OB
Page 170


planned to ensure structure follows
the function/processes (Structure
commensurate with the function of
the hospital)
Unidirectional flow of services 2 OB
direct observation of patients 2 OB
ICU is in Proximity of OT and has
functional linkage with OT 2 OB
The facility ensures the physical safety of the infrastructure. 18 18
Standard C2
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and furniture
safety of the infrastructure properly secured like cupboards, cabinets, and
secured

ICU building does not have
electrical establishment temporary connections and
loose hanging wires
ICU has mechanism for 2 OB/RR
periodical check / test of all
electrical installation by
competent electrical Engineer
ICU has dedicated earthling pit 2 OB/RR

system available
2 OB
Wall mounted digital display is
available in ICU to show earth to
neutral voltage
2 OB
Quality output of voltage
stabilizer is displayed in each
stabilizer as per manufacturer
guideline
Power boards are marked as per 2 OB
phase to which it belongs
ME C2.4 Physical condition of buildings are Floors of the ICU are non 2 OB
safe for providing patient care slippery and even
Windows/ ventilators if any in 2 OB
the OT are intact and sealed
The facility has established Programme for fire safety and other disaster 14 14
Standard C3
ME C3.1 The facility has plan for prevention ICU has sufficient fire exit to 2 OB/SI
of fire permit safe escape to its
are clearly marked.
ME C3.2 The facility has adequate fire fighting OPD has installed fire 2 OB
Equipment Extinguisher that is Class A ,
Class B C type or ABC type
2 OB
mentioned
ICU has provision of Smoke and 2 OB/RR

heat detector
2 OB/RR
ICU has electrical and automatic
fire alarm system or alarm
system sounded by actuation of
any automatic fire extinguisher
training of staff and conducts mock operating fire extinguisher and
drills regularly for fire and other what to do in case of fire
disaster situation
The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 14 14
Standard C4
ME C4.1 The facility has adequate specialist

Availability of full time
intensivist 2 OB/RR
ME C4.2 The facility has adequate general OB/RR
duty doctors as per service provision
and work load Availability of General duty
doctor 2 Duty doctor in 1: 5 ratio
ME C4.3 The facility has adequate nursing OB/RR/SI
work load Availability of Nursing staff as
per requirement 2 As per guideline
ME C4.4 The facility has adequate OB/SI
requirement
Availability of paramedic staff 2 1: 5 ratio
ME C4.5 The facility has adequate support / SI/RR
general staff Availability of ICU attendant 2
Availability Security staff 2 SI/RR 1 in each shift
SI/RR
Availability of housekeeping staff 2
Standard C5
ME C5.1 The departments have availability of Availability of

adequate drugs at point of use Analgesics/Antipyretics/Anti
Inflammatory 2 OB/RR As per State EDL
Availability of Antibiotics 2 OB/RR As per State EDL
Availability of Infusion Fluids 2 OB/RR As per State EDL
Availability of Drugs acting on
CVS 2 OB/RR As per State EDL
Availability of drugs action on
nervous system 2 OB/RR As per State EDL
Page 171

Availability of dressing material

and antiseptic lotion 2 OB/RR As per State EDL
Drugs for Respiratory System 2 OB/RR As per State EDL
Hormonal Preparation 2 OB/RR As per State EDL
Availability of Medical gases 2 OB/RR Availability of Oxygen Cylinders
ME C5.2 The departments have adequate Availability of disposables
consumables at point of use 2 OB/RR examination gloves, Syringes,
Resuscitation Consumables / Masks, Ryles tubes, Catheters,
Tubes 2 OB/RR Chest Tube, ET tubes etc
ME C5.3 Emergency drug trays are Emergency and resuscitation
maintained at every point of care, tray are maintained
2 OB/RR
The facility has equipment & instruments required for assured list of services. 24 24
Standard C6

Bed side monitor, pluse oximeter,
2 OB thermometer, BP apparatus, ECG
ME C6.2 Availability of equipment & Availability of dressing tray
instruments for treatment for Surgical Ward
procedures, being undertaken in the
facility
2 OB
procedures being undertaken in the
facility
2 OB ABG Machine, Glucometer,
ME C6.4 Availability of equipment and Availability of Functional
instruments for resuscitation of Intensive care equipment and
patients and for providing intensive instruments
and critical care to patients
2 OB Ventilator, Infusion pump, C-PAP,
Bag and mask, laryngoscope, ET

tubes, fibro optic bronchoscope
Oxygen cylinder/central line,
oxygen hood, Trey for procedures
Availability of Functional like central line, Defibrillator
Resuscitation equipments 2 OB (Ambu bag)
ME C6.5 Availability of Equipment for Storage Availability of equipment for OB Refrigerator, Crash cart/Drug
storage for drugs trolley, instrument trolley, dressing
trolley
2
ME C6.6 Availability of functional equipment Availability of equipments for OB Buckets for mopping, Separate
and instruments for support services cleaning mops for patient care area and
circulation area duster, waste
trolley, Deck brush
2
Availability of equipment for OB Autoclave
2
ME C6.7 Departments have patient furniture Availability of specialized ICU OB
and fixtures as per load and service bed
provision
2 ICU bed (shock proof -fibre).
Availability of attachment/ OB Over bed tables, Head end panel,
accessories with patient bed 2 IV stand, Bed pan, bed rail,
OB
Trey for monitors, Electrical panel
with bed, bedhead panel with
outlet for Oxygen and vacuum, X
Availability of Fixtures 2 ray view box.
OB
Cupboard, nursing counter, table
Availability of furniture 2 chair.
ME C7.1 RR/SI

2 competence of doctors, nurses and
paramedical staff based on job
description defined for each cadre
Criteria for Competence assessment are Check parameters for assessing of staff. Dakshta checklist issued
defined for clinical and Para clinical skills and proficiency of clinical by MoHFW can be used for this
staff staff has been defined purpose.
ME C7.2 RR/SI
Competence assessment of Clinical and Check for competence checklist, scoring and grading .
Para clinical staff is done on predefined assessment is done at least once Verify with staff for actual
criteria at least once in a year in a year competence assessment done
ME C7.9 Bio Medical waste Management SI/RR
plan 2
Infection control and hand SI/RR
hygiene 2
Advance life support Training 2 SI/RR
Code Blue 2 SI/RR
Patient safety 2 SI/RR
ME C7.10 SI/RR

There is established procedure for that staff is working according to
utilization of skills gained thought the training imparted. Also staff is
trainings by on -job supportive Staff is skilled to operate ICU provided on job training wherever
supervision equipments 2 there is still gaps
SI/RR

Staff is skilled for resuscitation provided on job training wherever
and intubation 2 there is still gaps
Page 172

SI/RR

Nursing staff is skilled identifying provided on job training wherever
and managing complication 2 there is still gaps
SI/RR

Nursing Staff is skilled for provided on job training wherever
maintaining clinical records 2 there is still gaps
The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 16 16
Standard D1
ME D1.1 The facility has established system All equipments are covered 2 SI/RR
for maintenance of critical under AMC including preventive
2 SI/RR
repaired
OB/RR
Staff is skilled for trouble 2 SI/RR
shooting in case equipment
malfunction
is done by the operator
procedure for internal and external instrument are calibrated
calibration of measuring Equipment
2 OB/ RR

ME D1.3 Operating and maintenance 2 OB/SI
equipments are readily available Check the down time of
with staff. equipments
Standard D2
ME D2.1 There is established procedure for 2 SI/RR

forecasting and indenting drugs and Stock level are daily updated
consumables There is established system of Requisition are timely placed
timely indenting of consumables
ME D2.3 The facility ensures proper storage 2 OB
Drugs are stored in
of drugs and consumables containers/tray/crash cart and
are labelled
labelled
2
drug stored in ICU RR
ME D2.5 The facility has established There is practice of calculating 2 SI/RR
procedure for inventory and maintaining buffer stock
Department maintains stock and 2 RR/SI
expenditure register of drugs
and consumables
ME D2.6 There is a procedure for periodically There is procedure for 2 SI/RR
replenishing the drugs in patient care replenishing drug tray /crash
areas cart
vaccines and other drugs, requiring maintained and updated
controlled temperature Temperature of refrigerators are periodically
ME D2.8 There is a procedure for secure Narcotic and Psychotropic drugs 2 OB/SI
storage of narcotic and psychotropic are kept in lock and key
drugs
Standard D3
ME D3.1 The facility provides adequate 2 OB General Patient Care - 200-50 Lux
illumination level at patient care Procedure Spot Light - 1500 Lux
areas Adequate Illumination at nursing
station
care unit
restriction of visitors in patient areas
Entry to ICU is restricted
Visiting hour are fixed and 2 OB/PI
practiced
ME D3.3 The facility ensures safe and 2
comfortable environment for 20-25OC, ICU has functional room
patients and service providers Temperature is maintained in thermometer and temperature is
ICU and record of same is kept SI/RR regularly maintained
Page 173

2
Humidity is maintained in ICU
and record of same is
maintained SI/RR 50-60%
2
ICU has system to maintain its
ventilation and its environment
is dust free SI/RR
ICU has system to control the 2
sound producing activities and
gadgets' (like telephone sounds,
staff area and equipments) SI/RR
ME D3.4 The facility has security system in Security arrangement at ICU 2 OB
place at patient care areas
ME D3.5 The facility has established measure for Ask female staff weather they 2 SI
safety and security of female staff feel secure at work place
Standard D4

maintained appropriately Building is painted/whitewashed
in uniform color
plastered & painted
hygienic sinks patient care and circulation All area are clean with no
areas are Clean dirt,grease,littering and cowebs
are clean

fixtures are intact
painted
condemned junk material the ICU
animal control
No rodent/pests are noticed
Standard D5
ME D5.1 The facility has adequate Availability of 24x7 running and OB/SI
arrangement storage and supply for potable water
portable water in all functional areas
2
ME D5.2 The facility ensures adequate power OB/SI
backup in all patient care areas as
per load Availability of power back up in Power back for all critical
ICU 2 equipments
availability of oxygen, medical gases and piped Oxygen and vacuum
vacuum supply supply
Dietary services are available as per service provision and nutritional requirement of the patients. 8 8
StandardD6
ME D6.1 The facility has provision of Nutritional assessment of 2

nutritional assessment of the patient done as required and
patients directed by doctor
RR/SI
ME D6.2 The facility provides diets according 2
to nutritional requirements of the Check for the adequacy and
patients frequency of diet as per Check that all items are as per
nutritional requirement OB/RR clinical advice
2
provided in ICU PI/SI satisfied with the Quality of food
ME D6.3 Hospital has standard procedures for 2
distribution of diets, as per requirement There is procedure of requisition
of patients of different type of diet from
ward to kitchen RR/SI
The facility ensures clean linen to the patients 8 8
Standard D7
ME D7.1 The facility has adequate sets of Clean Linens are provided for all 2 OB/RR
linen occupied bed
Gown is provided to all patients 2 OB/RR
procedures for changing of linen in
patient care areas Linen is changed every day and
washing of linen cleanliness and Quantity of the
Standard D11 procedures.
ME D11.2 The facility has a established There is procedure to ensure 2 RR/SI Check for system for recording
procedure for duty roster and that staff is available on duty as time of reporting and relieving
deputation to different departments per duty roster (Attendance register/ Biometrics
etc)

for department
dress code
Page 174

2 2
Standard D12
Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
(cleaning/
There is procedure to monitor Dietary/Laundry/Security/Mainten
the quality and adequacy of ance) provided are done by
There is established system for contract outsourced services on regular designated in-house staff
The facility has defined procedures for registration, consultation and admission of patients. 14 14
Standard E1
ME E1.1 The facility has established Unique identification number 2 RR

procedure for registration of is given to each patient during

ME E1.3 There is established procedure for 2 SI/RR
admission of patients
Criteria based on Vital sign,
There is established criteria for Laboratory value/ Diagnostic
admission at ICU values and Physical finding
2 SI/RR/OB
There is no delay in admission of

patient
Admission is done on written 2 SI/RR/OB
order by authorized doctor

patient record
ME E1.4 There is established procedure for 2 OB/SI Check for admission criteria. Check
managing patients, in case beds are for linkage with higher facilities
not available at the facility Procedure cope with surplus
patient load
The facility has defined and established procedures for clinical assessment and reassessment of the patients. 16 16
Standard E2

initial assessment of patients Initial assessment of all admitted
patient done as per standard Assessment criteria of different
protocols kind of medical /surgical
conditions is defined and
2 RR/SI practiced
Patient History is taken and RR
recorded 2
RR
Physical Examination is done and
RR
Provisional Diagnosis is recorded 2
Initial assessment and treatment

is provided immediately
2 RR/SI
Initial assessment is
documented preferably within 1
hours 2 RR
follow-up/ reassessment of Patients
There is fixed schedule for
reassessment of stable patients 2 RR/OB
For critical patients admitted in
the ward there is provision of
reassessments as per need 2 RR/OB
Facility has defined and established procedures for continuity of care of patient and referral 24 24
Standard E3
ME E3.1 Facility has established procedure

for continuity of care during There is procedure for hand over
interdepartmental transfer for patient transferred from ICU Check for how hand over is given
to IPD /OT/ Emergency and vice from ICU to ward and vice versa
versa 2 SI/RR etc.
Check for the procedure for calling

Check for the procedure if specialist on call to ICU for
patient is to be consulted with opinion /advice. Is there any list of
other specialist 2 RR/SI specialist with phone no. available
ME E3.2 Facility provides appropriate referral
linkages to the patients/Services for
transfer to other/higher facilities to
assure their continuity of care.
Patient referred with referral slip 2 RR/SI
Check for whom it is referred. List
Advance communication is done of higher centres is available with
with higher centre 2 RR/SI phone no.
Referral vehicle is being
arranged 2 SI/RR
Referral in or referral out
register is maintained 2 RR

linkages to lower facilities SI/RR
2

linkages to higher facilities
2
There is a system of follow up RR
of referred patients 2
ME E3.3 A person is identified for care during Doctor and nurse is designated RR/SI
all steps of care for each patient admitted to ICU
ward 2 Treating doctor is designated
Page 175

There is established RR/SI

procedure for co ordination of
care between duty doctor and
treating doctor/specialist
Duty doctor takes round with
2 treating doctor
RR/SI
Patient condition is reviewed
during hand over between duty
doctors 2
The facility has defined and established procedures for nursing care 18 18
Standard E4
ME E4.1 Procedure for identification of There is a process for ensuring 2 OB/SI Patient id band/ verbal
patients is established at the facility the identification before any confirmation/Bed no. etc.
clinical procedure
ME E4.2 Procedure for ensuring timely and Treatment chart are 2 RR Check for treatment chart are
accurate nursing care as per treatment maintained updated and drugs given are
plan is established at the facility marked. Co relate it with drugs and
doses prescribed.
There is a process to ensue 2 SI/RR Verbal orders are rechecked

the accuracy of before administration
verbal/telephonic orders
duty change happens
maintained
ME E4.5 There is procedure for periodic Patient Vitals are monitored 2 RR/SI Check for TPR chart, IO chart, any
monitoring of patients and recorded periodically other vital required is monitored
Critical patients are 2 RR/SI Check for use of cardiac

monitored continually monitor/multi parameter
Facility has a procedure to identify high risk and vulnerable patients. 4 4

Standard E5
ME E5.1 The facility identifies vulnerable Vulnerable patients are OB/SI

patients and ensure their safe care identified and measures are
taken to protect them from any Unconscious and comatose
harm patient, stuprose patient, patient
2 with suppressed immune system
ME E5.2 The facility identifies high risk patients High risk patients are identified OB/SI
and ensure their care, as per their need and treatment given on priority 2
Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational 10 10
Standard E6 use.
ME E6.1 Facility ensured that drugs are 2 RR
only
drugs treatment guideline are
available at point of use
Facility has defined procedures for safe drug administration 20 20
Standard E7
ME E7.1 There is process for identifying and High alert drugs available in 2 SI/OB Electrolytes like Potassium
cautious administration of high alert department are identified chloride, Uploads, Neuro muscular
drugs (to check) blocking agent, Anti thrombolytic
agent, insulin, warfarin, Heparin,
applicable
Maximum dose of high alert 2 SI/RR Value for maximum doses as per
drugs are defined and age, weight and diagnosis are
communicated available with nursing station and
doctor

right doses of high alert drugs check before administration, Error
are only given prone medical abbreviations are
not used
and adequately procedure is accompanied
with date , time and signature

staff
before administration/ dispensing and other inconsistency
before administration
Check single dose vial are not 2 OB Check for any open single dose vial
used for more than one dose with left over content indented to
be used later on
Check for separate sterile needle 2 OB
is used every time for multiple In multi dose vial needle is not left
dose vial in the septum
route, right time
Page 176

Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 16 16
Standard E8
ME E8.1 All the assessments, re-assessment 2 RR

and investigations are recorded and Patient progress is recorded as
updated per defined assessment
schedule
prescription/orders are recorded in written on BHT records
the patient records.
recorded in the patient records chart/treatment registers treatment chart
ME E8.4 Procedures performed are written Procedure performed are 2 RR
on patients records recorded in BHT Mobilization, resuscitation etc
ME E8.5 Adequate form and formats are 2 RR/OB Check for the availability of ICU
available at point of use Standard Formats are available slip, Requisition slips etc.
ME E8.6 Register/records are maintained as 2 RR
per guidelines
Registers and records are register, OT register, Diet register,
maintained as per guidelines Linen register, Drug intend register
All register/records are 2 RR
medical records
The facility has defined and established procedures for discharge of patient. 20 20
Standard E9
ME E9.1 Discharge is done after assessing ICU has established criteria for 2 SI/RR Patient is shifted to ward/step
patient readiness discharge of the patient down after assessment
discharging patient
Discharge is done by an 2 SI/RR
authorised doctor
Patient / attendants are 2 PI/SI
consulted before discharge
2 SI/RR
patients
discharge
2 RR
follow up
patients going in LAMA/Refered
out
ME E9.3 Counselling services are provided as 2
during discharges wherever required
Patient is counselled before
discharge PI/SI
2 PI/SI
Time of discharge is
communicated to patient before
hand
The facility has defined and established procedures for intensive care. 24 24
Standard E10
ME E10.1 The facility has established procedure

for shifting the patient to step-
down/ward based on explicit Step down of the patient is
assessment criteria ICU has procedure for step down planned by on duty doctor in
of the patient. 2 RR/SI consultation with treating doctor
ME E10.2 The facility has defined and established ICU has protocols for pain
procedure for intensive care management 2 RR/SI
ICU has protocol for sedation 2 RR/SI
ICU has procedure for starting
Central lines 2 RR/SI
ICU has protocol for early
eternal nutrition 2 RR/SI
Protocol for Care of unconscious Prevention of decubits in ICU

paraplegic patients is available 2 RR/SI patient
ICU has protocol for
management of anaphylactic
shock 2 RR/SI
ME E10.3 The facility has explicit clinical
criteria for providing intubation &
extubation, and care of patients on
ventilation and subsequently on its ICU has criteria defined for non
removal invasive ventilation in case of
respiratory failure 2 RR/SI C -PEP and V -PEP
Criteria for intubation 2 RR/SI
Criteria for extubation 2 RR/SI

Criteria of tracheotomy 2 RR/SI
Monitoring include subjective

ICU has protocols for care and responses, physiological
Monitoring of patient on responses, blood gas
ventilator 2 RR/SI measurement
The facility has defined and established procedures for Emergency Services and Disaster Management 4 4
Standard E11
plan in place
The facility has defined and established procedures of diagnostic services 4 4
Standard E12
Page 177

ME E12.1 There are established procedures Container is labelled properly 2 OB

for Pre-testing Activities after the sample collection
ME E12.3 There are established procedures ICU has critical values of various 2 SI/RR
for Post-testing Activities lab test
The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 14 14
Standard E13
ME E13.8 There is established procedure for 2 RR/SI

There is a procedure for issuing
issuing blood the blood promptly for life
saving measures
ME E13.9 There is established procedure for Consent is taken before 2 RR
transfusion of blood transfusion
before transfusion
Blood is kept on optimum 2 RR
2 SI/RR
Blood transfusion is monitored
and regulated by qualified
person
Blood transfusion note is written 2 RR
in patient recorded
monitoring and reporting Any major or minor transfusion
Transfusion complication reaction is recorded and
reported to responsible person
Facility has established procedures for Anaesthetic Services 2 2
Standard E14
ME E14.1 Facility has established procedures 2 SI/RR

for Pre Anaesthetic Check up Pre anaesthesia check up is
conducted for elective / Planned
surgeries
The facility has defined and established procedures for end of life care and death 10 10
Standard E16
ME E16.1 Death of admitted patient is 2 SI

adequately recorded and ICU has procedure to inform
communicated patient relatives about poor
prognostic status of inpatient
2 RR/SI
ICU has system for conducting
grievance counselling of
patient's relative in case of
mortality and at initiation of End
of life care
record
ME E16.2 The facility has standard procedures 2 SI/RR
for handling the death in the hospital Death note including efforts
done for resuscitation is noted in
patient record
2 SI/RR
Death summary is given to
cause if possible
Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 12 12
Standard F1

and active culture surveillance of Surface and environment
critical & high risk areas samples are taken for Swab are taken from infection
ME F1.2 microbiological surveillance 2 SI/RR prone surfaces
Facility measures hospital associated
infection rates Patients are observed for any sign
There is procedure to report and symptoms of HAI like fever,
cases of Hospital acquired purulent discharge from surgical
ME F1.3 infection 2 SI/RR site .
Medical Checkups and immunization immunization of the staff
of staff
staff 2 SI/RR
Facility has established procedures Hand washing and infection
Facility has defined and established Check for Doctors are aware of
Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 22 22
Standard F2
Hand washing facilities are provided Availability of hand washing FNBC guideline: Each unit should
at point of use Facility at Point of Use
have at least 1 wash basin for
ME F2.1 2 OB every 5 beds
with soap dish/ liquid antiseptic Check for availability/ Ask staff if
with dispenser. the supply is adequate and
Availability of Alcohol based
Hand rub
Check for availability/ Ask staff for
regular supply. Hand rub dispenser
2 OB/SI are provided adjacent to bed
Availability of elbow operated
taps 2 OB
deep enough to prevent
splashing and retention of water
2 OB
ME F2.2 standard hand washing practices washing 2 SI/OB Ask of demonstration
Page 178


wash 2 SI
Facility ensures standard practices Availability of Antiseptic
ME F2.3 and materials for antisepsis Solutions 2 OB
Proper cleaning of procedure OB/SI
site with antisepsis like before giving IM/IV injection,
Facility ensures standard practices and materials for Personal protection 16 16
Standard F3

requirements Clean gloves are available at
Availability of Mask 2 OB/SI
Availability of gown/ Apron 2 OB/SI Staff and visitors
Availability of shoe cover 2 OB/SI Staff and visitors
Availability of Caps 2 OB/SI Staff and visitors
infectious patients 2 OB/SI
Staff is adhere to standard personal No reuse of disposable gloves,
ME F3.2 protection practices Masks, caps and aprons. 2 OB/SI
gloves 2 SI
Facility has standard Procedures for processing of equipments and instruments 28 28
Standard F4
Facility ensures standard practices and Cleaning & Decontamination of

materials for decontamination and patient care Units Ask stff about how they
clean ing of instruments and decontaminate the procedure
procedures areas surface like Examination table ,
Patients Beds Stretcher/Trolleys
etc.

the instruments like abusage,
suction cannula, Airways, Face
Masks, Surgical Instruments
Proper Decontamination of Wiping with 0.5% Chlorine Solution
instruments after use 2 SI/OB or 70% Alcohol as applicable
decontamination is adequate 2 SI/OB
solution 2 SI/OB
Facility ensures standard practices and Equipment and instruments are Autoclaving/HLD/Chemical
materials for disinfection and sterilized after each use as per Sterilization
equipments
ME F4.2 2 OB/SI
instruments/equipments is required for boiling
2 OB/SI
done as per protocols 2 OB/SI pressure and time
instruments/equipments is done concentration and contact time
as per protocols required for chemical sterilization
2 OB/SI
procedure 2 OB/SI
used 2 OB/SI
There is a procedure to ensure
the traceability of sterilized
packs 2 OB/SI
Standard F5
Layout of the department is conducive

for the infection control practices Facility layout ensures
separation of general traffic
ME F5.1 from patient traffic 2 OB
and dirty items 2 OB
Floors and wall surfaces of ICU
are easily cleanable 2 OB
Facility ensures availability of standard Availability of disinfectant as per
materials for cleaning and disinfection requirement
of patient care areas Chlorine solution, Gluteraldehye,
Availability of cleaning agent as Hospital grade phenyle,
per requirement 2 OB/SI disinfectant detergent solution
followed for cleaning and disinfection of management
patient care areas
ME F5.3 2 SI/RR
procedure
2 SI/RR
Standard practice of mopping Unidirectional mopping from
and scrubbing are followed 2 OB/SI inside out
are not used in patient care Any cleaning equipment leading to
areas dispersion of dust particles in air
Page 179


mopping 2 OB/SI
schedule 2 SI/RR
External footwares are
resitricated 2 OB
Facility ensures segregation infectious
procedure are followed for
ME F5.4 septic cases 2 OB/SI
Facility ensures air quality of high risk Negative pressure is maintained
ME F5.5 area in Isolation 2 OB/SI
Standard F6 Waste.
Facility Ensures segregation of Bio Availability of colour coded bins Adequate number. Covered. Foot
ME F6.1 Medical Waste as per guidelines at point of waste generation 2 OB operated.



Biomedical waste
2 OB
and general waste 2
(translucent) Puncture proof, with fixed needles, needles from
Leak proof, tamper proof needle tip cutter or burner,
containers scalpels, blades, or any other

condition of needle stick injury shape injury. Whom to report. See
OB
Facility ensures transportation and Check bins are not overfilled
ME F6.3 2 SI/OB
container/trolley
2
management 2 SI/RR
Standard G1

place departmental nodal person
Facility have established internal and external quality assurance programs wherever it is critical to quality. 4 4
Standard G3

quality assurance program at
relevant departments There is system daily round by
charge for monitoring of services
ME G3.3 Facility has established system for Departmental checklist are 2 SI/RR Staff is designated for filling and
use of check lists in different used for monitoring and monitoring of these checklists
departments and services quality assurance
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support 44 44
Standard G4 services.
ME G4.1 Departmental standard operating Standard operating procedure 2 RR
procedures are available for department has been
ME G4.2 Standard Operating Procedures 2 RR registration, consultation,
adequately describes process and Department has documented Procedures, assessment of
procedures procedure for receiving and patient , counselling, Monitoring
initial assessment etc.
procedure for admission
Page 180

2 RR
procedure for clinical
assessment and reassessment of
patient in ICU
2 RR
procedure for discharge of the
patient
ICU has documented procedure 2 RR
nursing care for critical patient
2 RR
ICU has documented procedure
for collection, transfer and
reporting the sample to
laboratory
for nutrition in critical illness
for key clinical protocols
2 RR
for preventive- break down
maintenance and calibration of
equipments
2 RR
ICU has documented system for
storage, retaining ,retrieval of
records
2 RR
for purchase of External services
and supplies
2 RR
for Maintenance of
infrastructure of SNCU
for thermoregulation
2 RR
for drugs,intravenous,and fluid
management of patient
2 RR
for counselling of the patient
attendant
for infection control practices
for inventory management
for entry of visitor in ICU
standard procedures written in SOPs
Check staff is a aware of relevant
part of SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical 2 OB Admission and discharge criteria,
Point of use protocols are displayed Intubation protocol, CPR
Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages 6 6
Standard G 5
processes done
identified
Standard G6

prescription/ medical/death audits
There is procedure to conduct
Medical Audit
Prescription audit
Death audit
ME G6.3 The facility ensures non compliances Non Compliance are 2 RR/SI
are enumerated and recorded enumerated and recorded
adequately
process
observed in the assessment & audit
Corrective and preventive
action taken
6 6
ME G7.4 2 SI/RR

Facility has de defined quality objectives Check if SMART Quality Attainable, Relevant and Time
to achieve mission and quality policy Objectives have framed Bound.
ME G7.5 2 SI/RR
Mission, Values, Quality policy and Check of staff is aware of Quality Policy is displayed
objectives are effectively communicated Mission , Values, Quality Policy prominently in local language at
to staff and users of services and objectives Key Points
Page 181

ME G7.7 2 SI/RR

Facility periodically reviews the progress Check time bound action plan is The progress on quality objectives
of strategic plan towards mission, policy being reviewed at regular time have been recorded in Action Plan
and objectives interval tracking sheet
Facility seeks continually improvement by practicing Quality method and tools. 6 6
Standard G8
method
ME G10.6 2 SI/RR
Periodic assessment for Medication and medication and patient care all clincial processes should be
Patient care safety risks is done as per safety risk is done using defined done using pre define critera at
defined criteria. checklist periodically least once in three month.
Standard H1
ME H1.1 Facility measures productivity Indicators Bed Occupancy Rate

Proportion of BPL patients
admitted 2 RR
Standard H2
ME H2.1 Facility measures efficiency Indicators Downtime critical equipments

on monthly basis
2 RR
Transfer Rate
2 RR
Re admission rate 2 RR
Standard H3
ME H3.1 Facility measures Clinical Care & Safety Average length of stay
Risk Adjusted Mortality
Rate/Standard Mortality Rate 2 RR
No of Pressure Ulcer developed
per thousand cases 2 RR
UTI rate 2 RR
VAP rate 2 RR
Injection room : Post exposure
prophylaxis, medication error,
Adverse events are identified 2 RR patient fall.
Reintubation Rate 2 RR
% of environmental swab culture
Culture Surveillance sterility rate
2 RR reported positive
Standard H4
ME H4.1 Facility measures Service Quality LAMA Rate


A 20 20 100%
B 64 64 100%
C 152 152 100%
D 118 118 100%
E 200 200 100%
F 138 138 100%
G 84 84 100%
H 32 32 100%
Total 808 808 100%
0
1
2
Page 182
Checklist No. 11 IPD Version - NHSRC 3.0

Checklist for Indoor Patient Department 12
Assessment Summary

Indoor Patient Department Score Card

Area of Concern wise Score IPD Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
G Quality 100%
Management
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for IPD

Reference No/ ME Statement Checkpoints Complia Assessme Means of verification Remarks
nce nt
Method

ME A1.1 The facility provides General Availability of general medicine 2 SI/OB
Medicine services indoor services
Page 183

nce nt
Method
Availability of isolation ward 2 SI/OB

services
ME A1.2 The facility provides General Availability of general surgery 2 SI/OB
Surgery services indoor services
Availability of burn ward indoor 2 SI/OB
services
ME A1.5 The facility provides Availability of ophthalmology 2 SI/OB
Ophthalmology Services indoor services
ME A1.7 The facility provides Orthopaedics Availability of Orthopaedics indoor 2 SI/OB
Services services
ME A1.9 The facility provides Psychiatry Availability of Psychiatry Indoor 2 SI/OB
Services services
ME A1.12 The facility provides Availability of Indoor 2 SI/OB
Physiotherapy Services Physiotherapy Procedures
ME A1.14 Services are available for the time 2 SI/OB
period as mandated Availability of nursing services 24X7
ME A1.15 The facility provides services for 2 SI/OB
Super specialties, as mandated Availability of dialysis services
ME A1.16 The facility provides Accident & Availability of accident & trauma 2 SI/OB
Emergency Services ward
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme 12 12
ME A4.1 The facility provides services 2 SI/RR Maleria Kalaazar Dengue &
under National Vector Borne Chikunguna AES/Japanese
Disease Control Programme as per Encephalitis as prevelant locally
guidelines Availability of Indoor services for
Management
ME A4.2 The facility provides services 2 SI/RR
under Revised National TB Control
Indoor treatment of TB patients
requires hospitalization
under National Leprosy
Eradication Programme as per
guidelines Inpatient Management of severly
ill cases
under National AIDS Control
Programme as per guidelines Inpatient care for cases require
hospitilization
ME A4.5 The facility provides services 2 SI/OB
under National Programme for
prevention and control of
Blindness as per guidelines
Availabily of Opthalmic ward
ME A4.7 The facility provides services 2 SI/OB
under National Programme for the
health care of the elderly as per
guidelines
Availbilty of Geriatic ward
Standard A6 Health services provided at the facility are appropriate to community needs. 2 2
ME A6.1 The facility provides curatives &
preventive services for the health
problems and diseases, prevalent
locally. Availability of indoor Services as
per local prevalent disease 2 SI/RR
ME B1.1 The facility has uniform and user- (Numbering, main department and
friendly signage system Availability departmental signage's 2 OB internal sectional signage
Display of layout/floor directory 2 OB
displayed 2 OB
ME B1.2 The facility displays the services
and entitlements available in its List of services available are
departments displayed 2 OB
Entitlement under different
national health program 2 OB
List of drugs available are
displayed and updated 2 OB
Contact details of referral transport
/ ambulance displayed 2 OB
ME B1.4 User charges are displayed and OB
communicated to patients
effectively User charges if any displayed 2
ME B1.5 OB
and educated through appropriate
IEC / BCC approaches Relevant IEC material displayed at
wards 2
ME B1.6 Signage's and information are OB
2
ME B1.8 The facility ensures access to Discharge summery is given to the RR/OB
clinical records of patients to patient
entitled personnel 2
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of 18 18
physical , economic, cultural or social reasons.
ME B2.1 2 OB
Services are provided in manner Where ever male and female are kept
that are sensitive to gender in same wards male and female area
Separate male & female wards are demarcated
Male and female toilets are 2 OB/SI
demarcated
2 OB
Access to toilet should not go
through opposite sex patient care
area
Male attendants are not allowed to 2 OB/SI
stay at night in female ward
There is no discrimination with 2 SI/PI
transgender patients
2 SI/PI/RR
No unnecessary /non-essential
disclosure of a person’s trans
status
Page 184

nce nt
Method
ME B2.3 2 OB
Access to facility is provided Availability of Wheel chair or

without any physical barrier & and stretcher for easy Access to the
friendly to people with disabilities ward
Availability of disable friendly toilet 2 OB
ME B3.1 Adequate visual privacy is
provided at every point of care Availability of screens / Curtains 2 OB Bracket screen
Examination/ Dressing of patient is
done in enclosed area 2 OB
Availability of complaint box and

redressal and whom to contact is
displayed 2 OB
No two patients are treated on one
bed 2 OB
Partitions separating men and

women are robust enough to
prevent casual overlooking and
overhearing 2 OB
ME B3.2 Confidentiality of patients records Patient Records are kept at secure SI/OB
maintained staff/visitors 2
SI/OB
unnecessary displayed 2
ME B3.3 Behaviour of staff is empathetic OB/PI
services 2
ME B3.4 SI/OB
having social stigma, and also HIV status of patient is not
safeguards vulnerable groups disclosed except to staff that is
directly involved in care 2
Standard B4
The facility has defined and established procedures for informing patients about the medical condition, and involving them in 6 6
ME B4.1 2 SI/RR
for taking informed consent
before treatment and procedures General Consent is taken before
admission
ME B4.4 2 PI
Information about the treatment
is shared with patients or Patient is informed about clinical
attendants, regularly condition and treatment been
provided
redressal and whom to contact is
displayed
Standard B5
The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost of hospital 12 12
services.
ME B5.1 2 PI/SI
mothers and neonates as per Stay in wards is free for entitled
patients under NHP and state
prevalent government schemes scheme
Drugs and consumables under NHP 2 PI/SI
are free of cost
Pharmacy and wards
ME B5.4 2 PI/SI/RR
All treatments are free of cost for
hassles BPL Patients
ME B5.6 The facility ensure 2 SI/RR
implementation of health
insurance schemes as per National
/state scheme Cashless treatment been provide
to smart card holders
ME B 6.7 2 RR/SI

patients who wish to leave hospital Declaration is taken from the
against medical advice or refuse to LAMA patient and the
receive specific c treatment consequences are explained
ME C1.1 Departments have adequate 2 OB Distance between centres of two
space as per patient or work load beds – 2.25 meter
Adequate space in wards with no
cluttering of beds
ME C1.2 Patient amenities are provide as 2 OB one toilet for 12 patients
per patient load
Functional toilets with running
water and flush are available as per
strength and patient load of ward
2 OB
promotion
Page 185

nce nt
Method

Availability of Dedicated nursing
station
circulation area and open spaces Space between two beds should be at
according to need and local law least 4 ft and clearance between head
There is sufficient space between end of bed and wall should be at least
two bed to provide bed side 1 ft and between side of bed and wall
nursing care and movement should be 2 ft
2 OB
equipment movement Corridor should be 3 meters wide
ME C1.6 Service counters are available as There is separate nursing station 2 OB
per patient load for each ward
Availability of IPD beds as per load 2 OB
function of the hospital) Surgical wards has functional
linkages with OT
2 OB
direct observation of patients

IPD building does not have
electrical establishment temporary connections and loosely Switch Boards other electrical
hanging wires installations are intact
ME C2.4 Physical condition of buildings are 2 OB
Floors of the ward are non slippery
and even
meshwork
ME C3.1 The facility has plan for 2 OB/SI
Ward has sufficient fire exit to
prevention of fire permit safe escape to its occupant
at time of fire
2 OB
Check the fire exits are clearly
clearly marked.
ME C3.2 The facility has adequate fire 2 OB
IPD has installed fire Extinguisher
fighting Equipment that is Class A , Class B, C type or
ABC type
2 OB/RR
mentioned
ME C4.1 The facility has adequate specialist
Availability of specialist doctor on
call 2 OB/RR
ME C4.2 The facility has adequate general OB/RR
duty doctors as per service
provision and work load Availability of General duty doctor
at all time 2
ME C4.3 The facility has adequate nursing OB/RR/SI
work load
Availability of Nursing staff 2 As per patient load
ME C4.4 The facility has adequate OB/SI/RR
requirement Availability of dresser in surgical
ward 2
ME C4.5 The facility has adequate Availability of ward attendant/ SI/RR
support / general staff Ward boy 2
ME C5.1 The departments have availability
of adequate drugs at point of use Availability of
Analgesics/Antipyretics/Anti
Inflammatory 2 OB/RR
Availability of Antibiotics 2 OB/RR
Availability of Infusion Fluids 2 OB/RR
Availability of Drugs acting on CVS 2 OB/RR
Availability of drugs action on
CNS/PNS 2 OB/RR
Availability of dressing material
and antiseptic lotion 2 OB/RR
Drugs for Respiratory System 2 OB/RR
Hormonal Preparation 2 OB/RR
Page 186

nce nt
Method
Availability of Medical gases 2 OB/RR Availability of Oxygen Cylinders
ME C5.2 The departments have adequate
Availability of dressing material in
surgical wards 2 OB/RR
Availability of syringes and IV
Sets /tubes 2 OB/RR
Availability of Antiseptic Solutions 2 OB/RR Betadine
ME C5.3 Emergency drug trays are
maintained at every point of care,
Availability of emergency drug tray 2 OB/RR
instruments for examination & Equipment &Instruments for BP apparatus, Thermometer,
monitoring of patients examination & Monitoring foetoscope, baby and adult weighing
2 OB scale, Stethoscope , Doppler
ME C6.2 Availability of equipment & Availability of dressing tray for
instruments for treatment Surgical Ward
procedures, being undertaken in
the facility
2 OB
procedures being undertaken in
the facility
2 OB Glucometer
ME C6.4 Availability of equipment and Availability of functional
instruments for resuscitation of Instruments for Resuscitation.
patients and for providing Adult bag and mask, Oxygen, Suction
intensive and critical care to machine, Airway,nebulizer, suction
patients apparatus , LMA, Laryngoscope, ET
2 OB tube
Storage storage for drugs 2 OB instrument trolley, dressing trolley
ME C6.6 Availability of functional Availability of equipments for Buckets for mopping, mops, duster,
equipment and instruments for cleaning waste trolley, Deck brush
support services
2 OB
Availability of equipment for Boiler
ME C6.7 Departments have patient Availability of patient beds with
furniture and fixtures as per load prop up facility
2 OB
accessories with patient bed 2 OB locker , IVstand, Bed pan
Availability of Fixtures Spot light, electrical fixture for
equipments like suction, X ray view
box
2 OB
cupboard, nursing counter, table for
Availability of furniture 2 OB preparation of medicines, chair.
ME C7.1 RR/SI
Criteria for Competence assessment Check parameters for assessing each cadre of staff. Dakshta checklist
are defined for clinical and Para skills and proficiency of clinical staff issued by MoHFW can be used for this
clinical staff has been defined purpose.
ME C7.2 RR/SI
and Para clinical staff is done on scoring and grading . Verify with staff
predefined criteria at least once in a Check for competence assessment for actual competence assessment
year is done at least once in a year done
ME C7.9 SI/RR
training plan Biomedical waste management 2
SI/RR
Infection control and hand hygiene 2
ME C7.10 SI/RR
trainings by on -job supportive Nursing staff is skilled for provided on job training wherever
supervision maintaining clinical records 2 there is still gaps
ME D1.1 The facility has established system All equipments are covered under 2 SI/RR
2 SI/RR
equipments
Equipment BP apparatus, thermometers etc are
calibrated
storage of drugs and consumables Drugs are stored in
labelled
labelled
Page 187

nce nt
Method
2
procedure for inventory maintaining buffer stock
consumables
areas
vaccines and other drugs, maintained and updated periodically
requiring controlled temperature Temperature of refrigerators are
ME D2.8 There is a procedure for secure 2 OB/SI
storage of narcotic and Narcotic and psychotropic drugs
psychotropic drugs are identified and stored in lock Separate prescription for narcotic and
and key psychotropic drugs
areas Adequate Illumination at nursing
station
care areas
ME D3.2 The facility has provision of 2 OB/PI
areas Visiting hour are fixed and
practiced
There is no overcrowding in the 2 OB
wards during to visitors hours
One family members is allowed to 2 OB/SI
stay with the patient
ME D3.3 The facility ensures safe and Temperature control and 2 PI/OB Fans/ Air
comfortable environment for ventilation in patient care area conditioning/Heating/Exhaust/Ventilat
patients and service providers ors as per environment condition and
requirement

ventilation in nursing station/duty conditioning/Heating/Exhaust/Ventilat
room ors as per environment condition and
requirement
ME D3.4 The facility has security system in 2 OB/SI

place at patient care areas Security arrangement in IPD
ME D3.5 The facility has established measure Ask female staff weather they feel 2 SI
plastered & painted
are clean

fixtures are intact
painted
the ward
animal control
areas

patient care areas
ME D6.1 The facility has provision of Nutritional assessment of patient
nutritional assessment of the done as required and directed by
patients doctor
2 RR/SI
ME D6.2 The facility provides diets
according to nutritional Check for the adequacy and
requirements of the patients frequency of diet as per nutritional Check that all items fixed in diet menu
requirement 2 OB/RR is provided to the patient
provided 2 PI/SI satisfied with the Quality of food
ME D6.3 Hospital has standard procedures for
distribution of diets, as per There is procedure of requisition of
requirement of patients different type of diet from ward to diet for diabetic patients, low salt and
kitchen 2 RR/SI high protein diet etc
ME D7.1 The facility has adequate sets of Clean Linens are provided for all 2 OB/RR
linen occupied bed
Page 188

nce nt
Method
Gown are provided at least to the 2 OB/RR

cases going for surgery
2 OB/RR
mackintosh
procedures for changing of linen
in patient care areas Linen is changed every day and
ME D7.3 The facility has standard procedures 2 SI/RR
transportation and washing of linen cleanliness and Quantity of the
Standard D11
procedures.
ME D11.1 The facility has established job 2 SI
description as per govt guidelines
Staff is aware of their role and
responsibilities
ME D11.2 The facility has a established There is procedure to ensure that 2 RR/SI Check for system for recording time of
procedure for duty roster and staff is available on duty as per reporting and relieving (Attendance
deputation to different duty roster register/ Biometrics etc)
departments

department
dress code
(cleaning/
There is procedure to monitor the Dietary/Laundry/Security/Maintenanc
There is established system for quality and adequacy of e) provided are done by designated
contract management for out outsourced services on regular in-house staff
ME E1.1 The facility has established Unique identification number is 2 RR
procedure for registration of given to each patient during
Patient demographic details are 2 RR Check for that patient demographics

etc.
ME E1.3 There is established procedure for There is no delay in admission of 2 SI/RR/OB
admission of patients patient
patient record
managing patients, in case beds
are not available at the facility
ME E2.1 There is established procedure for 2 The assessment criteria for different
initial assessment of patients Initial assessment of all admitted clinical conditions are defined and
patient done as per standard measured in assessment sheet
protocols
RR/SI
Patient History is taken and 2 RR
recorded
Physical Examination is done and 2 RR
recorded wherever required
2
RR/SI
ME E2.2 There is established procedure for 2
follow-up/ reassessment of
Patients There is fixed schedule for
assessment of stable patients RR/OB
2
ME E3.1 The facility has established 2
procedure for continuity of care Facility has established procedure
during interdepartmental transfer for handing over of patients from
one department to other
department SI/RR
hospital
RR/SI
continuity of care.
maintained RR
SI/RR lower facilities
referred patients
Page 189

nce nt
Method
ME E3.3 A person is identified for care Duty Doctor and nurse is assigned 2 RR/SI
during all steps of care for each patients
ME E4.1 Procedure for identification of There is a process for ensuring the OB/SI Patient id band/ verbal
patients is established at the identification before any clinical confirmation/Bed no. etc.
facility procedure
2
ME E4.2 Procedure for ensuring timely and Treatment chart are maintained RR Check for treatment chart are
accurate nursing care as per updated and drugs given are marked.
treatment plan is established at the Co relate it with drugs and doses
facility prescribed.
2
There is a process to ensue the SI/RR Verbal orders are rechecked before
orders
2
ME E4.3 There is established procedure of Patient hand over is given during SI/RR
duty change happens
2
maintained 2
ME E4.4 Nursing records are maintained Nursing notes are maintained RR/SI Check for nursing note register. Notes
adequately 2 are adequately written
ME E4.5 There is procedure for periodic Patient Vitals are monitored and RR/SI Check for TPR chart, IO chart, any
monitoring of patients recorded periodically 2 other vital required is monitored
Critical patients are monitored RR/SI
continually 2
ME E5.1 The facility identifies vulnerable Vulnerable patients are identified 2 OB/SI Unstable, irritable, unconscious.
patients and ensure their safe care and measures are taken to protect Psychotic and serious patients are
them from any harm identified
patients and ensure their care, as per treatment given on priority
their need
Standard E6
The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their 10 10
rational use.
only
drugs treatment guideline are available
at point of use
high alert drugs agent, Anti thrombolytic agent,
insulin, warfarin, Heparin, Adrenergic
agonist etc.
Maximum dose of high alert drugs 2 SI/RR Value for maximum doses as per age,
are defined and communicated weight and diagnosis are available
with nursing station and doctor
avoided


staff
administration
for more than one dose with left over content intended to be
used later on
used every time for multiple dose In multi dose vial needle is not left in
vial the septum
ME E7.4 There is a system to ensure right 2 SI/OB
medicine is given to right patient Administration of medicines done
ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ 2
assessment and investigations are
recorded and updated Day to day progress of patient is
recorded in BHT
ME E8.2 All treatment plan Treatment plan, first orders are 2 RR Treatment prescribed inj nursing
ME E8.4 Procedures performed are written Any procedure performed written 2 RR Dressing, mobilization etc
on patients records on BHT
Standard Format for bed head Availability of formats for Treatment
available at point of use ticket/ Patient case sheet available Charts, TPR Chart , Intake Output Chat
as per state guidelines Etc.
Page 190

nce nt
Method
as per guidelines
book, Admission register, lab register,
Admission sheet/ bed head ticket,
discharge slip, referral slip, referral
in/referral out register, OT register,
Registers and records are Diet register, Linen register, Drug
maintained as per guidelines intend register
and numbered
medical records

before discharge
2 SI/RR
patients
discharge
2 RR
follow up
ME E9.3 Counselling services are provided 2 SI/PI
as during discharges wherever
required Patient is counselled before
discharge
Time of discharge is communicated 2 PI/SI
to patient in prior
disaster is defined
Standard E12 The facility has defined and established procedures of diagnostic services 4 4
ME E12.3 There are established procedures 2 SI/RR

Nursing station is provided with
the critical value of different tests
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 12 12
ME E13.9 There is established procedure for 2 RR
transfusion of blood Consent is taken before transfusion
before transfusion
patient recorded
ME E13.10 There is a established procedure 2 RR
reaction is recorded and reported
to responsible person
Standard E14 The facility has established procedures for Anaesthetic Services 2 2
ME E14.1 The facility has established 2 SI/RR
procedures for Pre-anaesthetic
Check up and maintenance of Pre anaesthesia check up is
records conducted for elective / Planned
surgeries
Standard E16 The facility has defined and established procedures for end of life care and death 8 8
ME E16.1 Death of admitted patient is Facility has a standard SI
adequately recorded and procedure to decent
communicated communication of death to
relatives
2
Death note is written on patient RR
record 2
ME E16.2 The facility has standard SI/RR
procedures for handling the death Death summary is given to patient
in the hospital attendant quoting the immediate
cause and underlying cause if
possible 2
RR
Death note including efforts done
for resuscitation is noted in patient
record 2
National Health Program
Standard E23 The facility provides National health Programme as per operational/Clinical Guidelines 2 2
ME E23.9 The facility provide service for 2 SI/RR
Integrated disease surveillance
Programme Weekly reporting of Presumptive
cases on form "P" from IPD
Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated 10 10
infection
The facility measures hospital Patients are observed for any sign and
associated infection rates There is procedure to report cases symptoms of HAI like fever, purulent
ME F1.3 of Hospital acquired infection 2 SI/RR discharge from surgical site .
Page 191

nce nt
Method
Medical Check-up and immunization of the staff
staff 2 SI/RR
The facility has established Hand washing and infection control
The facility has defined and Check for Doctors are aware of
ME F2.1 provided at point of use at Point of Use 2 OB near the point of use
2 OB language
washing practices and they adhere washing
to standard hand washing
practices
The facility ensures standard Availability of Antiseptic Solutions
practices and materials for
antisepsis
ME F2.3 2 OB
The facility ensures adequate
personal protection Equipment as
per requirements Clean gloves are available at point
The facility staff adheres to
standard personal protection
practices No reuse of disposable gloves,
The facility ensures standard Decontamination of operating &
practices and materials for Procedure surfaces Ask stff about how they
decontamination and cleaning of decontaminate the procedure surface
instruments and procedures areas like Examination table , Patients Beds

instruments like Stethoscope,
Instruments, Blood Pressure Cuff etc
Proper Decontamination of Wiping with 0.5% Chlorine Solution or
instruments after use 2 SI/OB 70% Alcohol as applicable
is adequate SI/OB
Proper handling of Soiled and No sorting ,Rinsing or sluicing at Point
infected linen 2 SI/OB of use/ Patient care area
solution 2 SI/OB
The facility ensures standard Equipment and instruments are Autoclaving/HLD/Chemical
practices and materials for sterilized after each use as per Sterilization
disinfection and sterilization of requirement
instruments and equipment
ME F4.2 2 OB/SI
instruments/equipments is done required for boiling
as per protocol
2 OB/SI
used 2 OB/SI
The facility ensures standard Staff is trained for spill
practices are followed for the management
cleaning and disinfection of patient
care areas
ME F5.3 2 SI/RR
procedure
2 SI/RR
Page 192

nce nt
Method
The facility ensures segregation
infectious patients Isolation and barrier nursing
Standard F6
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous 28 28
Waste.
The facility Ensures segregation of Availability of colour coded bins at Adequate number. Covered. Foot
Bio Medical Waste as per point of waste generation operated.
guidelines and 'on-site'
management of waste is carried
out as per guidelines
ME F6.1 2 OB


intravenous tubes and sets, catheters,
urine bags, syringes (without needles
and fixed needle syringes) and
Segregation of infected plastic vaccutainers with their needles cut)
waste in red bin 2 OB and gloves
Biomedical waste
2 OB
general waste 2
The facility ensures management Availability of functional needle OB See if it has been used or just lying
of sharps as per guidelines cutters idle.
ME F6.2 2
including Metals in white generation.Needles, syringes with
(translucent) Puncture proof, Leak fixed needles, needles from needle tip
proof, tamper proof containers cutter or burner, scalpels, blades, or

prophylaxis who is in charge of that.
of needle stick injury shape injury. Whom to report. See if
Contaminated and broken Glass 2 Vials, slides and other broken infected
are disposed in puncture proof and glass
Blue colour marking
OB
The facility ensures transportation Check bins are not overfilled
guidelines
ME F6.3 2 SI/OB
container/trolley
2
management 2 SI/RR
Standard G1 Facility has established organizational framework for quality improvement 2 2

ME G1.1 Facility has a quality team in place There is a designated 2 SI/RR
activities
Standard G2 The facility has established system for patient and employee satisfaction 2 2
Patient satisfaction survey done
on monthly basis
ME G3.1 The facility has established 2 SI/RR
internal quality assurance There is system daily round by
programme in key departments Hospital superintendent/ Hospital
ME G3.3 The facility has established system 2 SI/RR
for use of check lists in different
departments and services Departmental checklist are used
for monitoring and quality Staff is designated for filling and
assurance monitoring of these checklists
30 30
Standard G4
support services.

and approved

adequately describes process and procedure for receiving and initial
procedures assessment of the patient

procedure for admission, shifting
and referral 0f patient
procedure for requisition of
diagnosis and receiving of the
reports
Page 193

nce nt
Method
2 RR
procedure for preparation of the
patient for surgical procedure
2 RR
procedure for transfusion of blood
2 RR
procedure for maintenance of
rights and dignity of Patient
2 RR
procedure for record eminence
including taking consent
2 RR
patient at the time of discharge
2 RR
equipment
2 RR
procedure for sorting, and
distribution of clean linen to
patient
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 2 OB
Point of use are displayed Patient safety, CPR
6 6
ME G5.1 The facility maps its critical Process mapping of critical 2 SI/RR
processes processes done
ME G5.2 The facility identifies non value 2 SI/RR
identified
ME G5.3 The facility takes corrective action Processes are rearranged as per 2 SI/RR
to improve the processes requirement
14 14

audits There is procedure to conduct
Medical Audit
Prescription audit
Death audit
recorded adequately
process
ME G6.5 Planned actions are 2 RR/SI PDCA
implemenated through Quality
improvement cycle (PDCA) Check correction & corrective
actions are taken
6 6
ME G7.4 2 SI/RR
Facility has de defined quality if these objectives are Specific,
objectives to achieve mission and Check if SMART Quality Objectives Measurable, Attainable, Relevant and
quality policy have framed Time Bound.
ME G7.5 2 SI/RR
objectives are effectively Check of staff is aware of Mission , Statement, Core Values and Quality
communicated to staff and users of Values, Quality Policy and Policy is displayed prominently in local
services objectives language at Key Points
ME G7.7 2 SI/RR

Facility periodically reviews the Check time bound action plan is meeting. The progress on quality
progress of strategic plan towards being reviewed at regular time objectives have been recorded in
mission, policy and objectives interval Action Plan tracking sheet
6 6
ME G8.1 The facility uses method for Basic quality improvement method 2 SI/OB PDCA & 5S
quality improvement in services
method
ME G8.2 The facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used
Standards G10 2 2
Page 194

nce nt
Method
ME G10.6 2 SI/RR

Periodic assessment for Medication medication and patient care safety clincial processes should be done
and Patient care safety risks is done risk is done using defined checklist using pre define critera at least once
as per defined criteria. periodically in three month.
ME H1.1 Facility measures productivity Bed Occupancy Rate of Medical
Indicators on monthly basis Wards 2 RR
Bed Occupancy Rate for surgical
wards 2 RR
ME H2.1 Facility measures efficiency
Indicators on monthly basis Referral Rate 2 RR
Discharge rate 2 RR
No. of drugs stock out in the ward 2 RR
ME H3.1 Facility measures Clinical Care & Average length of stay for Medical
Safety Indicators on monthly basis wards 2 RR
Average length for surgical wards 2 RR
4 4
Indicators on monthly basis LAMA Rate 2 RR

A 36 36 100%
B 78 78 100%
C 134 134 100%
D 102 102 100%
E 166 166 100%
F 98 98 100%
G 72 72 100%
H 22 22 100%
Total 708 708 100%
0
1
2
Page 195
Checklist No. 12 Blood Bank Version- NHSRC/3.0

Checklist for Blood Bank 13
Assessment Summary

Type of Assessment Action plan Submission
(Internal/External) Date
Blood Bank Score Card

Area of Concern wise Score Blood Bank Score
C Inputs 100%
E Clinical Services
Infection Control
100% 100%
F 100%
Quality
G Management 100%
H Outcome 100%
Major Gaps Observed
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Date
Checklist for Blood Bank

Reference ME Statement Checkpoint Compli Assessme Means of Verification Remarks
No. ance nt
Method
. Area of Concern - A Service Provision 18 18
10 10
Standard A1. Facility Provides Curative Services
Page 196

No. ance nt
Method
ME A1.14. Services are available for the time Blood bank services available 24X7 2 SI/RR
period as mandated
ME A1.18. The facility provides Blood bank & Blood bank has facility of whole 2 SI/OB
transfusion services blood collection and Storage
. Blood Bank Has facility for Blood 2 SI/OB PRC, Platelets Concentrate, FMP,
Components Plasma& Single donor Cryo
Precipitate
. Blood bank has emergency stock of 2 SI/OB For A+, B+, O+ and O-
blood
Provision of blood donation camps 2 SI/OB
Facility provides RMNCHA Services 2 2

Standard A2
ME A2.2 The facility provides Maternal Availability of transfusion services 2 SI/OB

health Services
Standard A3
ME A3.2 The facility Provides Laboratory Availability of screening and cross 2 SI/OB
Services matching services
2 2
ME A4.1 The facility provides services Availability of platelets for 2 SI/RR
under National Vector Borne management of Dengue cases
Disease Control Programme as per
guidelines
2 2
Standard A6. Health services provided at the facility are appropriate to community needs.
ME A6.1. The facility provides curatives & Blood Bank provides blood 2 SI/RR
preventive services for the health components for thalassemia,
problems and diseases, prevalent dengue, haemophilia etc. as per
locally. local need
. Area of Concern - B Patient Rights 42 42

16 16
Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1. The facility has uniform and user- Availability of Departmental 2 OB (Numbering, main department and
friendly signage system signages internal sectional signage
Directional signage for department 2 OB
is displayed
ME B1.2. The facility displays the services List of services available are 2 OB
and entitlements available in its displayed
departments
. 2 OB
Blood bank has displayed of
Information regarding donors
eligibility
2 OB
Blood bank has displayed
information regarding number of
blood units available
ME B1.4. User charges are displayed and 2 OB
communicated to patients User services charges in r/o blood
effectively are displayed at entrance
ME B1.5. 2 OB
and educated through appropriate IEC material is available in blood
IEC / BCC approaches bank to provide information and to
promote blood donation
ME B1.6. Signage's and information are 2 OB
2 2
Standard B2.
physical economic, cultural or social reasons
ME B2.3. 2 OB

without any physical barrier & and Availability of ramp or alternate
friendly to people with disabilities for easy access to the blood bank
8 8
Standard B3. Facility maintains the privacy, confidentiality & Dignity of patient and related information.
ME B3.1. Adequate visual privacy is Privacy at blood donation and 2 OB
provided at every point of care counselling room
ME B3.2. Confidentiality of patients records Blood Bank has system to ensure 2 SI/OB
Blood bank staff do not discuss the lab
and clinical information is the confidentiality of results of result outside. reports are kept in
maintained screening test done secure place
services
ME B3.4. 2 SI/OB
safeguards vulnerable groups Confidentiality and privacy of HIV
patients
10 10
Standard B4.
ME B4.1. SI/RR
There is established procedures In consent form, procedure of
for taking informed consent donation is explained along with
informing the donor regarding testing
before treatment and procedures Blood bank is taking informed of blood is mandatory for safety of
consent of donor 2 recipient
ME B4.3. Staff are aware of Patients rights Awareness of staff on donor rights SI About the confidentiality and privacy
responsibilities and donor responsibilities 2 of donor information
Page 197

No. ance nt
Method
ME B4.4. PI/SI/RR
Information about the treatment Post donation counselling also include
is shared with patients or counselling on HIV for which blood
attendants, regularly Post donation counselling for sero bank may refer the donor to ICTC
reactive donors 2 /SACS
. Pre donation counselling is done PI/SI Procedure include preparation of
before donation venepuncture site, use of blood bags
and anticoagulant solution, collecting
sample for laboratory test
2
ME B4.5. The facility has defined and OB
established grievance redressal Availabilty of complaint box and
displayed 2
6 6
Standard B5. Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.
ME B5.1. 2 PI/SI
Free blood for Pregnant woman,
prevalent government schemes Mothers and New Borns
prescribed are available at spent on purchasing blood from
outside.
Pharmacy and wards
ME B5.4. 2 PI/SI/RR
hassles Free blood for BPL patients
. Area of Concern C: Inputs 102 102
Standard C1.
ME C1.1. Departments have adequate Blood bank has adequate space as 2 OB Space required is more than 100 sq
space as per patient or work load per requirement meters
Availability of waiting area in blood 2 OB

bank
ME C1.2. Patient amenities are provide as Separate toilet facilities for male & 2 OB
per patient load female are available
Seating arrangement in waiting 2 OB
area
ME C1.3. Departments have layout and Dedicated examination room 2 OB
. Dedicated Blood collection room 2 OB

. Dedicated transfusion 2 OB
transmissible infection (TTI) lab
. Availability of refreshment cum 2 OB
rest room
. Dedicated sterilization area 2 OB
. Dedicated store cum record room 2 OB
. Availability of Duty room for staff 2 OB

equipments
ME C1.5. The facility has infrastructure for 2 OB
ME C1.6. Service counters are available as Adequate Donor couches/ donor 2 OB
per patient load units as per load
ME C1.7. The facility and departments are Blood bank layout ensures smooth 2 OB
planned to ensure structure flow of donor and services
function of the hospital)
The facility ensures the physical safety of the infrastructure. 12 12

Standard C2.
ME C2.3 The facility ensures safety of Blood bank does not have 2 OB
electrical establishment temporary connections and loosely
hanging wires
. Adequate electrical socket 2 OB/RR
provided for safe and smooth
operation of lab equipments
ME C2.4 Physical condition of buildings are Work benches are chemical 2 OB
safe for providing patient care resistant
Floors of the Laboratory are non 2 OB

slippery and even
meshwork
Standard C3.
ME C3.1. The facility has plan for Blood bank has sufficient fire exit 2 OB/SI
prevention of fire to permit safe escape to its
Page 198

No. ance nt
Method
. Check the fire exits are clearly 2 OB
clearly marked.
2 OB
Blood bank has plan for safe
storage and handling of potentially
flammable materials.
ME C3.2. The facility has adequate fire Blood Bank has installed fire 2 OB/RR
fighting Equipment Extinguisher that is Class A , Class
BC type or ABC type
. Check the expiry date for fire 2 OB/RR
mentioned
ME C3.3. The facility has a system of Check for staff competencies for 2 SI/RR
Standard C4.
ME C4.1. The facility has adequate specialist Availability of dedicated blood 2 MBBS doctor with one year experience
doctors as per service provision bank medical officer
OB/RR
ME C4.3. The facility has adequate nursing Availability of dedicated Nursing 2 OB/RR/SI
staff as per service provision and Staff
work load
ME C4.4. The facility has adequate Availability of dedicated Blood 2 SI/RR
technicians/paramedics as per Bank Technician round the clock
requirement
ME C4.5. The facility has adequate Availability of housekeeping staff 2 SI/RR
support / general staff
Availability of security staff 2 SI/RR
Standard C5.
ME C5.1. The departments have availability Departments have availability of 2 OB/RR Inj Adrenaline,Inj Deriphylline,Inj
of adequate drugs at point of use adequate emergency drugs at Dexamethasone ,Inj
point of use Chlorpheniramine,Inj
Metochlorpromide
2 OB/RR
Evacuated Blood collection tubes,
Swabs, Syringes, Glass slides, Glass
Availability Laboratory materials marker/paper stickers
ME C5.2. The departments have adequate Availability of Reagents /Kits for lab 2 OB/RR Standard Grouping Sera Anti A, Anti B
consumables at point of use & Anti D ,VDRL/RPR Kit for
Syphillis,RDK/ ELISA for Malarial
Antigen, ELISA kit for Hep B &C, ELISA
kit for HIV1 & 2, malarial parasite
stains
Standard C6.
ME C6.1. Availability of equipment & Availability of functional 2 Adult Weighing machine, BP

instruments for examination & Equipment &Instruments for apparatus , clinical thermometer
OB
ME C6.3. Availability of equipment & Availability of laboratory 2 OB Microscope with water bath, ELISA
instruments for diagnostic equipment & instruments for reader with washer, RH viewer, Sahli's
procedures being undertaken in laboratory Haemoglobino meter/Others
the facility
ME C6.4. Availability of equipment and Availability of functional 2 OB

instruments for resuscitation of Instruments for Resuscitation.
intensive and critical care to
patients
Adult bag and mask and Oxygen
ME C6.5. Availability of Equipment for Check for availability of storage 2 OB Blood bags refrigerator with thermo
Storage equipments for blood products graph and alarm device, Insulated
carrier boxes with ice packs, Blood bag
weighting machine, deep freezer,
Platelets agitators
ME C6.6. Availability of functional Availability of equipments for 2 OB Buckets for mopping, mops, duster,
equipment and instruments for cleaning waste trolley, Deck brush
support services
Availability of equipment for 2 OB Autoclave
ME C6.7. Departments have patient Availability of beds in blood bank 2 OB Blood collection bed, recovery beds
furniture and fixtures as per load
Availability of attachment/ 2 OB Hospital graded Mattress, bed sheet,

accessories blanket, and bed side table
2 OB Electrical fixture for equipments lab
Availability of Fixtures and storage equipments
2 OB cupboard, counter for issuing blood,
Availability of furniture work benches for lab, chair.
ME C7.1 RR/SI
Criteria for Competence assessment Check parameters for assessing each cadre of staff. Dakshta checklist
are defined for clinical and Para skills and proficiency of clinical staff issued by MoHFW can be used for this
clinical staff has been defined purpose.
ME C7.2 RR/SI
and Para clinical staff is done on scoring and grading . Verify with staff
predefined criteria at least once in a Check for competence assessment for actual competence assessment
year is done at least once in a year done
Page 199

No. ance nt
Method
ME C7.9 Bio Medical waste Management 2 SI/RR
training plan
2 SI/RR
Infection control and hand hygiene
ME C7.10 Staff is skilled for operating the 2 SI/RR
equipments Check supervisors make periodic
trainings by on -job supportive provided on job training wherever
supervision there is still gaps
. Area of Concern - D Support Services 96 96
Standard D1.
ME D1.1. The facility has established system All equipments are covered under 2 SI/RR Agency/ ies identified for
for maintenance of critical AMC including preventive maintenance for equipments
. 2 SI/RR
equipments
. There has system to label 2
and stored appropriately until it
has been repaired
OB/RR
Staff is skilled for trouble shooting 2 SI/RR
ME D1.2. The facility has established All the measuring equipments/ 2 OB/ RR
Equipment
. 2 OB/ RR
. Blood bank has system to update 2 SI/RR Check for records
correction factor after calibration
wherever required
. Each lot of reagents has to be 2 SI/RR
checked against earlier tested in
use reagent lot or with suitable
reference material before being
placed in service and result should
be recorded.
ME D1.3. Operating and maintenance 2 OB/SI

with staff.
Standard D2.
ME D2.1. There is established procedure for 2 SI/RR Stock level are daily updated
and reagents
ME D2.3 The facility ensures proper Reagents and consumables are 2
storage of drugs and consumables kept away from water and sources
of heat,
direct sunlight
OB/RR
Reagents are labelled appropriately 2 Reagents label contain name,
concentration, date of
preparation/opening, date of expiry,
storage conditions and warning
OB/RR
ME D2.4. The facility ensures management Expiry dates' of the blood bags are 2 OB/RR
of expiry and near expiry drugs maintained
No expired blood is found in 2

storage OB/RR
Records for expiry and near expiry 2
blood are maintained RR
procedure for inventory maintaining buffer stock of
management techniques reagents

expenditure register of reagents
areas
There is no stock out of reagents 2 OB/SI
ME D2.7. There is process for storage of 2 OB/RR Check for temperature charts are
vaccines and other drugs, Temperature of refrigerators used maintained and updated periodically
requiring controlled temperature for storing lab reagents are kept as for refrigerators used storing lab
per storage requirement and reagents
. Regular Defrosting is done 2 SI/RR
Standard D3.
ME D3.1. The facility provides adequate Adequate illumination at work 2 OB Illumination level of blood bank is as
illumination level at patient care station in laboratory per recommendation/ sufficient to
areas carry out blood bank activities
Page 200

No. ance nt
Method
Adequate illumination at donation 2 OB
area
ME D3.2. The facility has provision of Entry is restricted in storage and 2 OB
restriction of visitors in patient lab area of the blood bank
areas
ME D3.3. The facility ensures safe and 2 Air conditioned blood collection room,
comfortable environment for blood group serology lab, testing lab
patients and service providers for Transfusion Transmissible
Diseases, refreshment cum rest room
Temperature is maintained and
record of same is kept SI/RR
Standard D4.

plastered & painted
ME D4.2. Patient care areas are clean and 2 OB
are clean
ME D4.3. Hospital infrastructure is Check for there is no seepage , 2 OB

fixtures are intact
painted
ME D4.5. The facility has policy of removal No condemned/Junk material in 2 OB
of condemned junk material the lab

animal control
Standard D5.
areas
ME D5.2. The facility ensures adequate 2 OB/SI

areas as per load
Availability of power back up in OT
The facility ensures clean linen to the patients 2 2
Standard D7
ME D7.1 The facility has adequate sets of Blood bank provides Linen for 2 OB/RR Blankets
linen donors
Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 2 2
Standard D10.
ME D10.1. The facility has requisite licences Blood bank has valid license under 2 RR
and certificates for operation of Rule 122(G) Drug and cosmetic act
hospital and different activities
Standard D11. procedures.
ME D11.1. The facility has established job Staff is aware of their role and 2 SI
ME D11.2. The facility has a established There is procedure to ensure that 2 RR/SI Check for system for recording time of
procedure for duty roster and staff is available on duty as per reporting and relieving (Attendance
deputation to different duty roster register/ Biometrics etc)
departments

department
ME D11.3. The facility ensures the adherence 2 OB
administration / the health Doctor, technician and support
dress code
2 2
Standard D12.
(cleaning/
There is procedure to monitor the Dietary/Laundry/Security/Maintenanc
There is established system for quality and adequacy of e) provided are done by designated
contract management for out outsourced services on regular in-house staff
. Area of Concern - E Clinical Services 124 124
Standard E1.
ME E1.1. The facility has established Unique identification number is 2 RR

procedure for registration of given to each donor during process
patients of registration
Donors demographic details are 2 RR Check for that patient demographics

recorded like Name, age, Sex, Address etc.
Page 201

No. ance nt
Method
The facility has defined and established procedures for clinical assessment and reassessment of the patients. 2 2
Standard E2

initial assessment of patients
There is procedure for assessment
of patient before donation 2 RR/SI Initial assessment is recorded
Standard E3.
ME E3.1. Facility has established procedure Facility has established 2 SI/RR

for continuity of care during procedure for handing over of
interdepartmental transfer patients during departmental
transfer
. There is a procedure 2
hospital
SI/RR
ME E3.2. Facility provides appropriate referral There is procedure for referral 2
linkages to the patients/Services for of cases for which requested
transfer to other/higher facilities to blood group is not available
SI/RR
. Facility has functional referral 2
linkages to blood storage unit SI/RR
Standard E4.
ME E4.3 There is established procedure of Procedure to handover test/ 2 RR/SI

patient hand over, whenever staff results during shift change
duty change happens
Handover register is maintained 2 RR
Standard E8.
ME E8.1 All the assessments, re- Records of donor assessment is 2 RR

assessment and investigations are maintained
recorded and updated
ME E8.5 Adequate form and formats are 2 RR/OB Format for consent, requisition form,
available at point of use blood transfusion reaction form,
referral slip
Standard Formats available
ME E8.6. Register/records are maintained Blood bank records are labelled 2 RR
as per guidelines and indexed
. Records are maintained for blood 2 RR Records includes daily group wise
bank stock register, daily temperature
recording of temperature dependent
equipment, stock register of
consumables and non consumables,
documents of proficiency testing,
records of equipment maintenance,
records of recipient, compatibility
records, transfusion reaction records,
donors records etc.
ME E8.7. The facility ensures safe and Safe keeping of patient records 2 OB Blood bank has facility to store
adequate storage and retrieval of records for 5 year
medical records
Standard E11.
ME E11.3. The facility has disaster Blood bank has system of coping 2 SI/RR
management plan in place with extra demand of blood in case
of disaster
Staff is aware of disaster plan 2 SI/RR
disaster is defined
Standard E12

The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 88 88
Standard E13.
ME E13.1. Blood bank has defined and Blood bank has defined criteria for 2 RR/SI Based on Physical examination,
implemented donor selection donor selection Medical history, condition that affects
criteria safety of recipients, donation
intervals,
. Blood bank ensures that blood is 2 RR/PI/SI

taken from voluntary donors only
Pre donation counselling is done 2 RR/PI
before donation
Check for questionnaire is available 2 OB/RR
in local language for taking pre
donation information
ME E13.2. There is established procedure for Blood bank has standardized 2 RR/SI Procedure include preparation of
the collection of blood procedure for collection of blood venepuncture site, use of blood bags
from donor and anticoagulant solution, collecting
sample for laboratory test
. Instructions for collection and 2 RR/SI Mostly numeric or alpha numeric label
handling the collected blood are should be used for tracing
communicated to those
responsible for collection
. Blood bank has identified 2 RR/OB

procedure for labelling of blood
bag/blood component /pilot tubes
. Blood bank has system to trace of 2 RR/SI Blood should be kept at 4oC to 6oC
unit of blood /component from except if it is used for component
source to final destination preparation it will be stored at 22oC
until platelet are separated
Page 202

No. ance nt
Method
. Blood bank has system to maintain 2 RR/SI
temperature of collected blood
immediately after donation
. Blood bank has system in place to 2 RR/SI
monitor the transportation of the
blood from camp site
ME E13.3. There is established procedure for Determination of ABO group is 2 RR/SI Tube or Microplate or gel technology
the testing of blood done by recommended methods
Determination of Rh (D) Type done 2 RR/SI Check for the protocol/ Algorithm
as per recommended method followed for determining RH + or RH-
Blood type
Laboratory tests for Infectious 2 RR/SI or infectious diseases
diseases done as per (VDRL/RPR/TPHAfor syphilis,
recommended method ELISA/Rapid test for Hep A, Hep B, HIV
and Malaria for malarial parasite
There is provision of Quarantine 2 RR/OB/SI Check for untested blood is stored in

Storage untested blood different refrigerator
Blood units with reactive test result 2 RR/OB/SI In dedicate secure area with
area kept separately biohazard sign until disposal
Sterility of Blood units checked 2 RR/OB/SI Check Sterility is checked at least for
with adequate sample size 1% of blood unit collected or 4 per
month which ever higher by
appropriate culture method
ME E13.4 There is established procedure for Sterility of Blood component is 2 SI/RR Check for use of aseptic method and
preparation of blood component insured during processing availability of Sterile pyrogen free
disposable bags and solutions
Transfusion time limits are adhered 2 SI/RR Within 6 hours

one frozen component have been
thawed
Blood components are prepared as 2 SI/RR Check availability and adherence to
per technical standards NACO standards
Approximate volume of the 2 RR
component is indicated on bag
ME E13.5. There is establish procedure for Blood bank has system to ensure 2 RR/SI
labelling and identification of that final blood bags are labelled
blood and its product only after all mandatory testing is
completed.
. Blood bank has system of 2 RR/SI Blood bags are Identified with a
identification traceability of its numeric or alpha numeric system /
products Barcode
. Blood bank has system to the affix 2 RR/SI Name of product, numeric
the product information on bag, information, date of collection and
after processing expiry, amount of anticoagulant and
approximate blood collected, Name,
address and manufacturing license
number of collecting facility, storage
temperature and expiry date
Instruction for transfusion are 2 RR/SI

printed on label
. Blood bank has colour coded 2 RR/SI Blood group O -blue, Blood group A-
scheme for differentiate ABO yellow, Blood group B- Pink, Blood
groups group AB- White
ME E13.6 There is established procedure for Check for refrigerators or freezers 2 OB Lab reagents etc.
storage of blood for blood storage are not used for
storing other items
Check for refrigerators used for 2 OB/RR Check records that temperature is
blood storage are kept at maintained at 4c + 2 C
Storage temperature is monitored 2 OB/RR Check the records
at every 4 hours
Alarm system has been provided 2 RR/SI
with refrigerator
Adequate alternate storage facility 2 RR/SI
available
Shelf life of blood and components 2 RR/SI
is adhered as per NACO protocols
ME E13.7. There is established the Blood bank has system to testing 2 RR/SI Testing of recipient blood includes
compatibility testing and cross matching the recipient Determination ABO type, Rh (D) type,
blood detection of unexpected antibodies
etc.
There is established procedure for 2 RR/SI Check for practice in case of ABO type
selection of blood and components specific groups are not available. Issue
for transfusion of blood to RH+ and Negative
recipient
There is established procedure for 2 RR/SI

re cross matching in case of
massive transfusion
Paediatric blood collection bags are 2 RR/SI
available
ME E13.8. There is established procedure for Blood bank has system to testing 2 RR/SI Testing of recipient blood includes
issuing blood and cross matching the recipient Determination ABO type, Rh (D) type,
blood detection of unexpected antibodies
etc.
. Instructions for collection and 2 RR/SI Blood sample collection vial is label
handling blood sample of recipient with Patient Name, identification no,
are communicated to those name of hospital, ward/bed number,
responsible for collection date time , Phlebotomist signature
. Blood bank has system to confirm 2 RR/SI

that information on transfusion
requisition form and recipients
blood sample label is same
. Blood bank has system to retain 2 RR/SI

recipient and donor blood sample
for 7 days at specified temperature
(2-8 c) after each transfusion
Page 203

No. ance nt
Method
. Blood bank has system to issue the 2 RR/SI
blood along with cross matching
report
. Blood bank has system to identify 2 RR/SI Record of same should be available
the person who is performing the
cross matching test and issue the
blood
. Blood bank has procedure to issue 2 RR/SI

the blood in case of its urgent
requirement
ME E13.10. There is a established procedure Transfusion reaction form is 2 RR/SI
for monitoring and reporting provided when blood is issued
Transfusion complication
. Blood bank has system of 2 RR/SI

detection, reporting and
evaluations of transfusion errors

.
Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 8 8
Standard F1.

critical & high risk areas Surface and environment samples
are taken for microbiological Swab are taken from infection prone
ME F1.2 surveillance 2 SI/RR surfaces
ME F1.4. 2 SI/RR Hepatitis B, Tetanus Toxid etc
staff 2 SI/RR
Facility has established Hand washing and infection control
.ME F1.5. control practices 2 SI/RR
Standard F2.
ME F2.1. provided at point of use at Point of Use 2 OB near the point of use
. 2 OB/SI supply is regular
. 2 OB/SI supply is adequate and uninterrupted
. rub 2 OB/SI regular supply.
2 OB language
2 OB
deep enough to prevent splashing
2 OB
ME F2.2. 2 SI/OB Ask of demonstration
. Staff aware of when to hand wash 2 SI
ME F2.3 2 OB
Proper cleaning of procedure site
2 OB/SI and urinary catheter
Standard F3.
Facility ensures adequate personal Clean gloves are available at point 2 All personal use gloves while drawing
protection equipments as per of use sample, examining and disposable of
requirements the samples
ME F3.1. OB/SI
. Availability of lab aprons/coats 2 OB/SI
. Availability of Masks 2 OB/SI
Staff is adhere to standard No reuse of disposable gloves, 2
ME F3.2. personal protection practices Masks, caps and aprons. OB/SI
Compliance to correct method of 2
wearing and removing the gloves SI
Standard F4.
Facility ensures standard practices Decontamination of operating & 2

and materials for decontamination Procedure surfaces
and clean ing of instruments and Ask staff about how they
procedures areas decontaminate work benches
ME F4.1. SI/OB (Wiping with .5% Chlorine solution
Proper Decontamination of 2 Decontamination of instruments and
instruments after use reusable of glassware are done after
procedure in 1% chlorine solution/
any other appropriate method
. SI/OB
is adequate SI/OB
Cleaning of instruments after 2 Cleaning is done with detergent and
decontamination SI/OB running water after decontamination
solution SI/OB
Page 204

No. ance nt
Method
Facility ensures standard practices Disinfection of reusable glassware 2 Disinfection by hot air oven at 160 oC
and materials for disinfection and for 1 hour
sterilization of instruments and
equipments
ME F4.2. SI/OB
Standard F5.

ME F5.2. 2 OB/SI carbolic acid
. requirement 2 OB/SI detergent solution
ME F5.3. 2 SI/RR
procedure
2 SI/RR
Standard F6. Waste.
ME F6.1. 2 OB
. chlorinated plastic bags 2 OB
Segregation of different category
. of waste as per guidelines 2 OB/SI
Biomedical waste
. 2 OB
general waste 2 OB
ME F6.2. sharps as per guidelines cutters 2 idle.
including Metals in white generation.Needles, syringes with
(translucent) Puncture proof, Leak fixed needles, needles from needle tip
proof, tamper proof containers cutter or burner, scalpels, blades, or
.
. prophylaxis who is in charge of that.
of needle stick injury shape injury. Whom to report. See if
.
Facility ensures transportation Disinfection of liquid waste before
and disposal of waste as per disposal
guidelines
ME F6.3. 2 SI/OB
Disposal of discarded blood bags as
. per guideline 2 SI/OB
. Check bins are not overfilled 2 SI
container/trolley
2 SI/OB
management 2 SI/RR
. Area of Concern - G Quality Management 80 80

Standard G1.
ME G1.1. The facility has a quality team in There is a designated 2 SI/RR

activities
Facility has established system for patient and employee satisfaction 4 4

Standard G2

There is system to take feed back
conducted at periodic intervals from clinician about quality of
services
Feedback from donor are taken on 2 RR
periodic basis
Standard G3.
ME G3.1. Facility has established internal 2 SI/RR

relevant departments Internal Quality assurance program
is in place
. Standards are run at defined 2 SI/RR
interval
Control charts are prepared and 2 SI/RR
outliers are identified.
Corrective action is taken on the 2 SI/RR
identified outliers
ME G3.2. Facility has established external 2 SI/RR
assurance programs at relevant
departments Cross validation of lab test are It includes participation of laboratory
done and reports are maintained in inter laboratory comparison
Page 205

No. ance nt
Method
. 2 SI/RR
Blood bank takes corrective action
when control criteria are not fulfilled
Corrective actions are taken on in Interlaboratory comparisons and
abnormal values records of same is maintained
ME G3.3. Facility has established system for Departmental checklist are used 2 SI/RR
use of check lists in different for monitoring and quality
. Staff is designated for filling and 2 SI

Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support 28 28
Standard G4. services.
ME G4.1. Departmental standard operating Standard operating procedure for 2 RR
and approved
. Current version of SOP are 2 OB/RR

ME G4.2. Standard Operating Procedures 2 RR
adequately describes process and Blood bank has documented
procedures procedure for Donor selection and
collection of blood from donor
. 2 RR
Blood bank has documented
procedure for testing of donated
blood
. 2 RR
procedure for preparation of blood
components
. 2 RR
procedure for storage,
transportations of blood and issue
of blood for transfusion
. 2 RR
procedure for issue of blood in
case of urgent requirement
. 2 RR
procedure to address the
transfusion reactions
. 2 RR
Blood bank has documents
procedure for calibration and
maintenance of equipment
. 2 RR
procedure for HAI and disposal of
BMW
. 2 RR
system for storage, retaining and
retrieval of laboratory records,
primary sample, Examination
sample and reports of results.
. 2 RR
system for internal and external
Quality control of Equipments,
reagent and tests
ME G4.3. Staff is trained and aware of the 2 SI/RR
SOPs Check staff is a aware of relevant
part of SOPs
ME G4.4. Work instructions are displayed at 2 OB work instruction for screening of
Point of use blood, storage of blood, maintaining
blood and component in event of
Work instruction/clinical protocols power failure
are displayed
Standard G 5.
ME G5.1. Facility maps its critical processes Process mapping of critical 2 SI/RR
processes done
ME G5.2. Facility identifies non value adding 2 SI/RR
identified
ME G5.3. Facility takes corrective action to Processes are rearranged as per 2 SI/RR
Standard G6.
ME G6.1. The facility conducts periodic Internal assessment is done at 2 RR/SI

ME G6.2. The facility conducts the periodic There is procedure to conduct 2 RR/SI
prescription/ medical/death Traceability audit for Blood issue
audits
ME G6.3. The facility ensures non Non Compliance are enumerated 2 RR/SI
recorded adequately
ME G6.4. Action plan is made on the gaps 2 RR/SI
process
ME G6.5. Corrective and preventive actions 2 RR/SI
observed in the assessment &
audit Corrective and preventive action
taken
6 6
Standard G7. The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
Page 206

No. ance nt
Method
ME G7.4 2 SI/RR
Facility has de defined quality if these objectives are Specific,
objectives to achieve mission and Check if SMART Quality Objectives Measurable, Attainable, Relevant and
quality policy have framed Time Bound.
ME G7.5 2 SI/RR
objectives are effectively Check of staff is aware of Mission , Statement, Core Values and Quality
communicated to staff and users of Values, Quality Policy and Policy is displayed prominently in local
services objectives language at Key Points
ME G7.7 2 SI/RR

Facility periodically reviews the Check time bound action plan is meeting. The progress on quality
Standard G8.
ME G8.1. Facility uses method for quality Basic quality improvement method 2 SI/RR PDCA & 5S
. Advance quality improvement 2 SI/OB Six sigma, lean.

method
ME G8.2. Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used
ME G10.6 2 SI/RR
Periodic assessment for Medication medication and patient care safety clincial processes should be done
and Patient care safety risks is done risk is done using defined checklist using pre define critera at least once
as per defined criteria. periodically in three month.
. Area of Concern - H Outcome 40 40
Standard H1 .
ME H1.1. Facility measures productivity No. of Blood unit issued per No. of Unit issued X1000/ Population
Indicators on monthly basis thousand population 2 RR of serving area
. % of units issued for the
transfusion at facility No. of Unit issued for
facility*100/Total no of units issued in
2 RR the period
. No of voluntary donation done per No of Voluntary Donation
thousand population 2 RR X1000/Population of the serving area
. No. of units supplied to storage
units 2 RR Self Explanatory
. Blood donation camps held 2 RR Self Explanatory
.
Proportion of blood units issued in
emergency cases out of total unit
issued in month 2 RR
No of blood units issued for free of

cost 2 RR JSSK, Thalassemia , BPL
Standard H2 .
ME H2.1. Facility measures efficiency Downtime critical equipments

Indicators on monthly basis Time period for which equipment was
out of order/Total no of working hours
2 RR for equipments
. % of Blood Units discarded No of unit discarded *100/ Total no of
2 RR unit collected
. % of unit issued against No of unit issued on replacement
replacement 2 RR *100/ Total no of unit issued
. No of unit found sero reactiveX100/
% of unit tested seroreactive 2 RR No of unit tested
Standard H3.
ME H3.1. Facility measures Clinical Care & No of Blood Transfusion reactions

Safety Indicators on monthly basis Blood transfusion reaction rate
2 RR 1000/ No of patient blood issued
.
Chemical splash, Needle stick injuries.
Major blood transfusion reaction,
Adverse events are identifies and wrong cross matching, wrong blood
reported 2 RR issue
. No of component unit issued/No of
Component to whole blood ratio 2 RR whole blood issued
.
No of unit are cross matched on
Cross matched/ Transfused Ratio 2 RR request/ No of unit actually transfused
. % of single use transfusionX 100/ Total
% of single unit transfusion 2 RR no of units transfused
Standard H4.
ME H4.1. Facility measures Service Quality

Indicators on monthly basis Time gap between issuing and
requisition of blood in routine
conditions 2 RR
.
Time gap between issuing and
requisition of blood in emergency
conditions 2 RR
. Donor Satisfaction Score at Blood
Bank 2 RR
.
No of requisition refused/ referred
due to non availability of blood group
No of refusal cases 2 RR or any other reason
Page 207

No. ance nt
Method

A 18 18 100%
B 42 42 100%
C 102 102 100%
D 96 96 100%
E 124 124 100%
F 94 94 100%
G 80 80 100%
H 40 40 100%
Total 596 596 100%
0
1
2
Page 208
Checklist No. 13 Laboratory Version- NHSRC /3.0

Checklist for Laboratory 14
Assessment Summary

Date
Laboratory Score Card

Area of Concern wise Score Laboratory Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
G Quality 100%
Management
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for Laboratory

Standard ME Statement Checkpoint CompliaAudit Method Means of Verification Remarks
nce
Full/Par
tial/No
Page 209

nce
Full/Par
Area of Concerntial/No
- A Service Provision 30 30

Standard A3
ME A3.2 The facility Provides Laboratory 2 SI/RR
Services
All lab services are available in
routine working hours
2 SI/RR
Emergency lab services are
available for selected tests of
Haematology, Biochemistry and
Serology 24X7
Availability of Haematology 2
services SI/OB
Availability of Bio chemistry 2
services SI/OB
Availability of Microbiology 2
services SI/OB
Availability of Cytology services 2 SI/OB
Availability of Histopathology 2
services SI/OB
Availability of Clinical Pathology 2
services SI/OB
Availability of Serology services 2 SI/OB
Facility provides services as mandated in national Health Programs/ state scheme 10 10
Standard A4
ME A4.1 The facility provides services under
National Vector Borne Disease
Control Programme as per
guidelines Tests for Diagnosis of maleria
(Smear and RDTK) 2 SI/OB
Tests for Kala Azar, Dengue, JE,
Chikengunia 2 SI/OB As per prevalant endemic
Revised National TB Control
Availability of Designated
Microscoy Center (AFB) 2 SI/OB
National Leprosy Eradication
Availability of Skin Smear
Examination 2 SI/OB
ME A4.8 The facility provides services under SI/RR
National Programme for
Prevention and control of Cancer,
Diabetes, Cardiovascular diseases
& Stroke (NPCDCS) as per
guidelines
Haemogram, BT CT, Fasting/PP
Sugar, Lipid Profile, Blood Urea ,
LFT Kidney Function Test 2
Health services provided at the facility are appropriate to community needs. 2 2
Standard A6
ME A 6.1 The facility provides curatives & 2 SI/RR
preventive services for the health
problems and diseases, prevalent Laboratory provides specific test
locally. for local health problems/ diseases
e.g.. Dengue, swine flu etc.
14 14
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their
modalities
ME B1.1 The facility has uniform and user- Availability departmental 2 OB (Numbering, main department
friendly signage system signage's and internal sectional signage
Restricted area signage are 2 OB

displayed
ME B1.2 The facility displays the services List of services available are 2 OB
and entitlements available in its displayed at the entrance
departments
Timing for collection of sample 2 OB
and delivery of reports are
displayed
ME B1.4 User charges are displayed and User charges in r/o laboratory 2 OB
communicated to patients services are displayed
effectively
ME B1.8 The facility ensures access to Lab Reports are provided to 2 OB

clinical records of patients to Patient in proper printed format
entitled personnel
4 4
Standard B2 Services are delivered in a manner that is sensitive to gender, religiousand cultural needs, and there are no barrier on
account of physical , economic, cultural or social reasons.
ME B2.1 Services are provided in manner Separate queue for females at lab 2 OB
that are sensitive to gender
ME B2.3 Check the availability of ramp in 2 OB
lab building area /sample
Access to facility is provided collection area
without any physical barrier & and
friendly to people with disabilities
6 6
Page 210

nce
Full/Par
ME B3.2 Confidentiality of patients records Laboratory has system to ensure 2
tial/No SI/OB Laboratory staff do not discuss
and clinical information is the confidentiality of the reports the lab result outside. And
generated reports are kept in secure place
maintained
ME B3.4 HIV positive reports/pregnancy 2 SI/OB

The facility ensures privacy and reports are communicated as per
confidentiality to every patient, NACO guidelines
safeguards vulnerable groups
6 6
Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and
ME B4.1 Informed Consent is taken before 2 SI/RR Before testing HIV patient is
There is established procedures for HIV testing, Biopsy and any other informed that test is voluntary
taking informed consent before invasive procedure and result will be disclosed to
treatment and procedures him/her only
ME B4.4 Information about the treatment is Pre test counselling is given before 2 PI/SI/RR
shared with patients or attendants, HIV testing
regularly
displayed
12 12
ME B5.1 Free Diagnostic tests for Pregnant 2 PI/SI
The facility provides cashless women & Infant
prevalent government schemes
ME B5.2 Check that patient party has not 2 PI/SI
The facility ensures that drugs incurred expenditure on
prescribed are available at purchasing consumables from
Pharmacy and wards outside.
prescribed investigations are incurred expenditure on
diagnostics from outside.
Laboratory provides complete list 2 PI/SI
of diagnostic test available to all
department of the hospital
ME B5.4 Tests are free of cost for BPL 2 PI/SI/RR
The facility provide free of cost patients
hassles
ME B5.5 Cashless investigation by 2 PI/SI/RR
The facility ensures timely empanelled lab for JSSK
reimbursement of financial beneficiaries for test not available
entitlements and reimbursement within the facility
to the patients
Standard C1
ME C1.1 Departments have adequate space Adequate area for sample
as per patient or work load collection, waiting, performing
test, keeping equipment and
Laboratory space is adequate for storage of drugs and records
carrying out activities 2 OB
area 2 OB
ME C1.2 Patient amenities are provide as Availability of sitting arrangement
per patient load of sub waiting area
2 OB
Availability of patient calling
system at lab 2 OB
ME C 1.3 Departments have layout and
Demarcated sample collection
area 2 OB
Demarcated testing area 2 OB
Designated report writing area 2 OB
Demarcated washing and waste
disposal area 2 OB
ME C 1.4 The facility has adequate
equipments 2 OB
ME C 1.5 The facility has infrastructure for
and Intercom Services 2 OB
ME C 1.6 Service counters are available as Availability of collection counters
per patient load as per load 2 OB
ME C 1.7 The facility and departments are
(Structure commensurate with the Unidirectional flow of services Sample collection- Sample
function of the hospital) processing- Analytical area-
2 OB reporting.
Page 211

nce
Full/Par
The facility ensures the physical safety of the infrastructure.
tial/No 12 12
Standard C 2
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and furniture
safety of the infrastructure properly secured like cupboards, cabinets, and
secured

Laboratory does not have
electrical establishment temporary connections and loose
hanging wires
2 OB/RR
Adequate electrical socket

provided for safe and smooth
operation of lab equipments
ME C2..4 Physical condition of buildings are Work benches are chemical 2 OB
safe for providing patient care resistant
2 OB
Floors of the Laboratory are non
slippery and even surfaces and
acid resistent
meshwork
Standard C3
ME C3.1 The facility has plan for prevention Laboratory has plan for safe 2 OB/SI
of fire storage and handling of potentially
2 OB
Department has sufficient fire exit
with signage to permit safe escape
to its occupant at time of fire

clearly marked.
ME C3.2 The facility has adequate fire 2 OB/RR
Lab has installed fire Extinguisher
fighting Equipment that is Class A , Class B C type or
ABC type
2 OB/RR
mentioned
Standard C4
ME C4.1 The facility has adequate specialist 2
Availability of dedicated For 100 bed - 1 , 200-1, 300-3,
pathologist OB/RR 400-3, 500-4.
Availability of dedicated 2 OB/RR
Microbiologist For 300-500 bed -1
ME C4.4 The facility has adequate 2 SI/RR
requirement For 100 beds- 6, 200-9, 300- 12,
Availability of Lab Technician 24X7 400-15, 500-18
ME C4.5 The facility has adequate support / Availability of Lab assistant 2 SI/RR
general staff
Availability of housekeeping staff 2 SI/RR
Standard C 5
consumables at point of use Iodine Solution, Gram
Romanowsky ,StainZiehl- neelsen,
Acridine orange, Acridine orange
Availability of stains 2 (?)
OB/RR Reagents for auto analyzers,
Availability of reagents 2 ELISA Readers
OB/RR Acetone, Alcohol, distilled water,
Availability of other Chemicals 2 Microscope gel etc.
OB/RR
Evacuated Blood collection tubes,
Swabs, Syringes, Glass slides,
Availability Laboratory materials 2 Glass marker/paper stickers
ME C5.3 Emergency drug trays are Emergency Drug Tray is OB/RR
maintained at every point of care, maintained
2
Standard C 6
ME C 6.1 Availability of equipment & Availability of functional 2 OB BP apparatus, Stethoscope at
instruments for examination & Equipment &Instruments for sample collection area
ME C 6.3 Availability of equipment & Availability of functional auto 2
instruments for diagnostic analyzers
procedures being undertaken in
the facility Auto/ Semi Auto analyzers
OB according to need
Page 212

nce
Full/Par
tial/No Cell Counters/ Counting
haematology equipments Chambers , Heamoglobinometer ,
OB ESR stands with tubes
Availability of functional 2 Calorie meter, Blood Gas
Biochemistry Equipment OB Analyzer, Electrolyte analyzer
equipments for sample
processing Micropipettes , Centrifuge, Water
OB Bath, Hot air oven.
Availability of functional 2 Binocular Micro scope , FNAC,
Microscopy equipments OB staining rack
Availability functional 2
Histopathology equipments OB Microtome
Serology Equipments OB Elisa Reader, Elisa washer
Availability of functional 2 Incubator , Inoculators, safety
Microbiology equipments OB hood and bio safety cabinet
ME C 6.5 Availability of Equipment for Availability of equipment for 2 OB Refrigerators
Storage storage of sample and reagents
ME C6.6 Availability of functional Availability of equipments for 2 OB Buckets for mopping, mops,
equipment and instruments for cleaning duster, waste trolley, Deck brush
support services
Availability of equipment for 2 OB Autoclave
ME BC 6.7 Departments have patient 2 OB Illumination at work stations,
furniture and fixtures as per load Electrical fixture for lab
and service provision equipments and storage
equipments
Availability of fixtures at lab
2 OB
Lab stools, Work bench's, rack
and cupboard for storage of
Availability of furniture reagent ,Patient stool, Chair table
ME C7.1 SI/RR

2 competence of doctors, nurses
and paramedical staff based on
job description defined for each
Criteria for Competence assessment Check parameters for assessing cadre of staff. Dakshta checklist
are defined for clinical and Para skills and proficiency of clinical issued by MoHFW can be used for
clinical staff staff has been defined this purpose.
ME C7.2 SI/RR

Competence assessment of Clinical 2 assessment including filled
and Para clinical staff is done on checklist, scoring and grading .
predefined criteria at least once in a Check for competence assessment Verify with staff for actual
year is done at least once in a year competence assessment done
ME C7.9 2 SI/RR
defined core competencies and Training on automated Diagnostic
training plan Equipments like auto analyzer
Infection control and hand 2 SI/RR
hygiene
Training on Internal and External 2 SI/RR
Quality Assurance
Laboratory Safety 2 SI/RR
ME C7.10 2 SI/RR
There is established procedure for according to the training
utilization of skills gained thought imparted. Also staff is provided
trainings by on -job supportive Staff is skilled to run automated on job training wherever there is
supervision equipments still gaps
2 SI/RR
imparted. Also staff is provided
Staff is skilled for maintaining on job training wherever there is
Laboratory records still gaps
Standard D1
ME D 1.1 The facility has established system All equipments are covered under SI/RR
Equipment maintenance Agency/ is identified for
2 maintenance for equipments
SI/RR
maintenance of the equipments 2
There has system to label
repaired
2 OB/RR
Staff is skilled for trouble shooting SI/RR
2
Periodic cleaning, inspection and SI/RR
2
Page 213

nce
Full/Par
ME D1.2 The facility has established All the measuring equipments/ tial/No OB/ RR
Equipment
2
OB/ RR
recalibration is due 2
SI/RR
Calibrators are available for
Automated haematology analyzers 2
SI/RR
Laboratory has system to update
correction factor after calibration
wherever required 2
SI/RR
Each lot of reagents has to be
checked against earlier tested in
use reagent lot or with suitable
reference material before being
placed in service and result should
be recorded. 2
ME D1.3 Operating and maintenance OB/SI
with staff. 2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient 22 22
Standard D2 care areas
and reagents
ME D2.3 The facility ensures proper storage Reagents and consumables are 2
of drugs and consumables kept away from water and sources
of heat,
direct sunlight
OB/RR
Reagents are labelled 2 Reagents label contain name,
appropriately concentration, date of
preparation/opening, date of
expiry, storage conditions and
warning
OB/RR
ME D2.4 The facility ensures management 2 OB/RR
of expiry and near expiry drugs
No expired reagent found
Records for expiry and near expiry 2
reagent are maintained RR
procedure for inventory maintaining buffer stock of
management techniques reagents

expenditure register of reagents
replenishing the drugs in patient care replenishing drug tray
areas
There is no stock out of reagents 2 OB/SI
vaccines and other drugs, requiring maintained and updated
controlled temperature Temperature of refrigerators are periodically
Regular Defrosting is done 2 SI/RR
Standard D3
areas Adequate illumination at work
station
Adequate illumination at 2 OB
Collection area
areas
Entry is restricted in testing area
ME D3.3 The facility ensures safe and Temperature control and 2 Fans/ Air
comfortable environment for ventilation in collection area conditioning/Heating/Exhaust/Ve
patients and service providers ntilators as per environment
SI/RR
Temperature control and 2 Fans/ Air
ventilation testing area conditioning/Heating/Exhaust/Ve
SI/RR
2 OB
In histopathology, for tissue
processing separate room with
fume hood is available
Availability of Eye washing facility 2 OB
Standard D4
ME D4.1 Exterior of the facility building is Building is painted/whitewashed 2 OB
maintained appropriately in uniform colour
plastered & painted
Page 214

nce
Full/Par
ME D4.2 Patient care areas are clean and 2
tial/No OB
hygienic sinks patient care and circulation All area are clean with no
areas are Clean dirt,grease,littering and cobwebs
are clean

fixtures are intact
ME D4.5 The facility has policy of removal of 2 OB
condemned junk material
the lab
animal control
Standard D5
ME D5.1 The facility has adequate Availability of 24x7 running and 2 OB/SI Water use for analytical purpose
arrangement storage and supply potable water should be of reagent grade
areas

laboratory
Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 2 2
Standard D10
ME D10.3 The facility ensure relevant Any positive report of notifiable 2 RR/SI
processes are in compliance with disease is intimated to designated
statutory requirement authorities
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 8 8
Standard D11 operating procedures.
ME D11.2 The facility has a established There is procedure to ensure that 2 RR/SI Check for system for recording
procedure for duty roster and staff is available on duty as per time of reporting and relieving
deputation to different duty roster (Attendance register/ Biometrics
departments etc)

department
administration / the health Doctor, technician and support
dress code
2 2
Standard D12
ME D12.1 2 SI/RR Verification of outsourced
services (cleaning/
There is procedure to monitor the Dietary/Laundry/Security/Mainte
There is established system for quality and adequacy of nance) provided are done by
contract management for out sourced outsourced services on regular designated in-house staff
services basis
Standard E1
ME E1.1 The facility has established Unique laboratory identification 2 RR
procedure for registration of number is given to each patient
patients sample

recorded in laboratory records demographics like Name, age,
Sex, Chief complaint, etc.
Standard E3
ME E3.2 Facility provides appropriate referral Laboratory has referral linkage for 2 RR/SI
linkages to the patients/Services for tests not available at the facility
transfer to other/higher facilities to
Facility gets referred patients from 2 RR/SI e.g.: linkage for disease
lower level of facility surveillance and water testing
Standard E4
ME E4.3 There is established procedure of Procedure to handover test/ 2 RR/SI
patient hand over, whenever staff results during shift change
duty change happens
Handover register is maintained 2 RR
Standard E8
ME E8.5 Adequate form and formats are 2 RR/OB Printed formats for requisition
available at point of use Standard Formats available and reporting are available
ME E8.6 Register/records are maintained as Lab records are labelled and 2 RR
per guidelines indexed
Records are maintained for 2 RR Test registers, IQAS/EQAS
laboratory Registers, Expenditure registers,
Accession list etc.
Page 215

nce
Full/Par
ME E8.7 The facility ensures safe and Laboratory has adequate facility 2
tial/No OB
adequate storage and retrieval of for storage of records
medical records
Standard E11
disaster is defined
ME E11.5 There is procedure for handling Samples of medico legal cases are 2 SI/RR Requisition and reports are
medico legal cases identified marked with MLC and reports are
handed over to authorized
personnel only

Standard E12
ME E12.1 There are established procedures Requisition of all laboratory test is 2 RR/OB Request form contain
for Pre-testing Activities done in request form information: Name and
identification number of patient,
name of authorized requester,
type of primary sample,
examination requested, date and
time of primary sample collection
and date and time of receipt of
sample by laboratory,
Instructions for collection and 2 RR/SI

handling of primary sample are
communicated to those
responsible for collection
Laboratory has system in place to 2 RR/SI

label the primary sample
Laboratory has system to trace the 2 RR/SI
primary sample from requisition
form
Laboratory has system to record 2 RR/SI
the identity of person collecting
the primary sample
Laboratory has system in place to 2 RR/SI Transportation of sample
monitor the transportation of the includes: Time frame,
sample temperature and carrier specified
for transportation
ME E12.2 There are established procedures testing procedure are readily 2 OB/RR
for testing Activities available at work station and staff
is aware of them
Laboratory has Biological 2 OB/RR
reference interval for its
examination of various results
Laboratory has identified critical 2 RR/SI
intervals for which immediate
notification is done to concerned
physician
ME E12.3 There are established procedures Laboratory has system to review 2 RR/SI
for Post-testing Activities the results of examination by
authorized person before release
of report
Laboratory has format for 2 RR/OB

reporting of results
Laboratory has system to provide 2 RR/SI
the reports within defined cycle
time/ or each category of patient
-routine and emergency
Laboratory results written in 2 RR/SI

reports are legible without error in
transcription
Laboratory has defined the 2 RR/SI
retention period and disposal of
used sample
Laboratory has system to retain 2 RR/SI
the copies of reported result and
promptly retrieved when required
National Health Programs
Facility provides National health program as per operational/Clinical Guidelines 2 2

Standard E23
ME E23.9 Facility provide service for 2 SI/RR
Integrated disease surveillance
program Weekly reporting of Confirmed
cases on form "L" from laboratory
Facility has infection control program and procedures in place for prevention and measurement of hospital associated 12 12
Standard F1 infection
critical & high risk areas Surface and environment samples
are taken for microbiological Swab are taken from infection
ME F1.2 surveillance 2 SI/RR prone surfaces
Technician is trained for taking
and processing surface and air
sample 2 SI/RR
Page 216

nce
Full/Par
Periodic medical checkups of the tial/No
staff 2 SI/RR
Facility has established procedures Hand washing and infection
control practices intervals
Standard F2
Hand washing facilities are Availability of hand washing Check for availability of wash
ME F2.1 provided at point of use Facility at Point of Use 2 OB basin near the point of use
Availability of Alcohol based Hand Check for availability/ Ask staff
rub 2 OB/SI for regular supply.
2 OB
deep enough to prevent splashing
2 OB
Staff aware of when to hand wash
2 SI
ME F2.3 2 OB
Proper cleaning of procedure site
drawing blood, putting
2 OB/SI Intravenous and urinary catheter
Standard F3
Facility ensures adequate personal Clean gloves are available at point
protection equipments as per of use
requirements
ME F3.1 2 OB/SI
Availability of lab aprons/coats 2 OB/SI
Staff is adhere to standard No reuse of disposable gloves and
ME F3.2 personal protection practices Masks. 2 OB/SI
Standard F4
Facility ensures standard practices Decontamination of operating & 2
and materials for decontamination Procedure surfaces Ask staff about how they
and clean ing of instruments and decontaminate work benches
procedures areas (Wiping with .5% Chlorine
ME F4.1 SI/OB solution
Proper Decontamination of 2 Decontamination of instruments
instruments after use and reusable of glassware are
done after procedure in 1%
chlorine solution/ any other
appropriate method
SI/OB
is adequate SI/OB
Cleaning of instruments after 2
SI/OB decontamination
solution SI/OB
Facility ensures standard practices Disinfection of reusable glassware 2 Disinfection by hot air oven at
and materials for disinfection and 160 oC for 1 hour
sterilization of instruments and
equipments
ME F4.2 SI/OB
Autoclaving for used culture media 2
and other infected material
SI/OB
Standard F5
ME F5.3 2 SI/RR
procedure
2 SI/RR
Page 217

nce
Full/Par
Standard practice of mopping and tial/No Unidirectional mopping from
are not used in patient care areas Any cleaning equipment leading
to dispersion of dust particles in
2 OB/SI air should be avoided
Facility ensures segregation infectious Precaution with infectious patients
ME F5.4 patients like TB 2 OB/SI
Facility ensures air quality of high risk Air quality in Lab Negative Pressure for
ME F5.5 area 2 OB/SI microbiology
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and 32 32
Standard F6 hazardous Waste.
ME F6.1 2 OB


Segregation of infected plastic vaccutainers with their needles
waste in red bin 2 OB cut) and gloves
Biomedical waste
2 OB
and general waste 2
Facility ensures management of Availability of functional needle OB See if it has been used or just
ME F6.2 sharps as per guidelines cutters 2 lying idle.
Leak proof, tamper proof needles from needle tip cutter or
containers burner, scalpels, blades, or any
other contaminated sharp object
that may cause puncture and
cuts. This includes both used,
discarded and contaminated
metal sharps


condition of needle stick injury shape injury. Whom to report.
See if any reporting has been
done

and leak proof box/ container with
Blue colour marking
OB
Facility ensures transportation and Disinfection of liquid waste before
disposal of waste as per guidelines disposal
ME F6.3 2 SI/OB
Disposal of sputum cups as per
guidelines 2 SI/OB
Check bins are not overfilled 2 SI
container/trolley
2 SI/OB
management 2 SI/RR

Standard G1
activities
Facility has established system for patient and employee satisfaction 4 4

Standard G2
There is system to take feed back
conducted at periodic intervals from clinician about quality of
services
Client/Patient satisfaction survey 2 RR
done on monthly basis
Standard G3
relevant departments Internal Quality assurance
programme is in place
Standards are run at defined 2 SI/RR
interval
Page 218

nce
Full/Par
Control charts are prepared and 2
tial/No SI/RR
outliers are identified.
Corrective action is taken on the 2 SI/RR
identified outliers
2 SI/RR
Routine checking of equipments,
Internal Quality Control for Public new lots of regent, smear
Health lab is in place preparation, grading etc
ME G3.2 Facility has established external Proficiency Test / EQUAS is 2 SI/RR For tests where Nationnal
assurance programs at relevant done Proficiency Test program is
departments available
External / Internal split testing 2 SI/RR For test where PT program is not
is done available
EQAs reporst are analysed and 2 Staff is aware of EQAS reporting
evaluated system, how to evaluate, and
compare
Corrective actions are taken on 2 SI/RR
abnormal values/ Outliers
External quality assurance 2 SI/RR
program implemented as per Onsite evaluation done Monthly
RNTCP program Random Blinded rechecking
(RBRC) done Monthly
program implemented for
NVBDCP
under NACP
ME G3.3 Facility has established system for Departmental checklist are 2 SI/RR Staff is designated for filling
use of check lists in different used for monitoring and quality and monitoring of these
departments and services assurance checklists
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes 52 52
Standard G4 and support services.
ME G4.1 Departmental standard operating Standard operting procedure for 2 RR
and approved

adequately describes process and Laboratory has documented
procedures process for Collection and
handling of primary sample
2 RR
Laboratory has documented
procedure for transportation of
primary sample with specification
about time frame, temperature
and carrier
2 RR
process on acceptance and
rejection of primary samples
2 RR
procedure on receipt, labeling,
processing and reporting of
primary sample
2 RR
procedure on receipt, labeling,
processing and reporting of
primary sample for emergency
cases
2 RR
system for storage of examined
samples
2 RR
system for repeat tests due to
analytical failure
2 RR
validated procedure for
examination of samples
Laboratory has documented 2 RR
biological reference intervals
2 RR
critical reference values and
procedure for immediate
2 RR
procedure for release of reports
including details of who may
release result and to whom
2 RR
internal quality control system to
verify the quality of results
2 RR
External Quality assurance
program
2 RR
procedure for calibration of
equipments
2 RR
procedure for validation of results
of reagents ,stains , media and kits
etc. wherever required
2 RR
system of resolution of complaints
and other feedback received from
stakeholders
Page 219

nce
Full/Par
2
tial/No RR
procedure for examination by
referral laboratories
2 RR
system for storage, retaining and
retrieval of laboratory records,
primary sample, Examination
sample and reports of results.
2 RR
system to control of its documents
2 RR
procedure for preventive and
break down maintenance
Laboratory has documented 2 RR
procedure for internal audits
2 RR
procedure for purchase of External
services and supplies
SOPs Check staff is a aware of relevant
part of SOPs
ME G4.4 Work instructions are displayed at Work instruction/clincal protocols 2 OB Work instruction for Internal
Point of use are displayed Quality control,
Standard G 5
processes done
identified
Standard G6
recorded adequately
process
ME G6.5 Planned actions are implemenated 2 RR/SI
through Quality improvement
cycle (PDCA) Check correction & corrective
actions are taken
6 6
ME G7.4 2 SI/RR

services. Check if these
Facility has de defined quality objectives are Specific,
objectives to achieve mission and Check if SMART Quality Objectives Measurable, Attainable, Relevant
quality policy have framed and Time Bound.
ME G7.5 2 SI/RR
Mission, Values, Quality policy and Statement, Core Values and
objectives are effectively Check of staff is aware of Mission , Quality Policy is displayed
communicated to staff and users of Values, Quality Policy and prominently in local language at
services objectives Key Points
2 SI/RR

ME G7.7 reviewed at least onnce in month
Facility periodically reviews the Check time bound action plan is The progress on quality
Standard G8
method
ME G10.6 2 SI/RR
Periodic assessment for Medication medication and patient care safety all clincial processes should be
and Patient care safety risks is done as risk is done using defined checklist done using pre define critera at
per defined criteria. periodically least once in three month.
Standard H1
Page 220

nce
Full/Par
ME H1.1 Facility measures productivity No. of HIV test done per 1000 tial/No
Indicators on monthly basis population 2 RR
No. of VDRL test done per 1000
population 2 RR
No. of Blood Smear Examined per
1000 population 2 RR
No. of AFB Examined per 1000
population 2 RR
No. of HB test done per 1000
population 2 RR
Lab test done per patients in 100
OPD 2 RR
Lab test done per patients100 IPD

2 RR
Percentage of lab test done at
night 2 RR
Proportion of test done for BPL
patients 2 RR
Standard H2
ME H2.1 Facility measures efficiency Indicators No of test not matched in
on monthly basis validation 2 RR
Z score for biochemistry or
equivalent 2 RR
Percentage of test not matched in
Split test 2
VIS / Z scores 2
Down time of critical equipments 2
Turn around time for emergency
lab investigations 2
Z score for haematology or
equivalent 2 RR
Turn around time for routine lab
investigations 2 RR
Standard H3
ME H3.1 Facility measures Clinical Care & % of critical values reported within
Safety Indicators on monthly basis one hour 2 RR
Proportion of Haematology,
Test demography biochemistry, serology,
Microbiology, cytology, clinical
2 RR pathology
Report correlation rate Proportion of lab report co
2 RR related with clinical examination
Proportion of false positive /false
negative 2 RR For Rapid diagnostic Kit test
Standard H4
ME H4.1 Facility measures Service Quality Waiting time at sample collection
Indicators on monthly basis area 2 RR
Number of stock out incidences of
reagents 2 RR

A 30 30 100%
B 42 42 100%
C 122 122 100%
D 94 94 100%
E 58 58 100%
F 108 108 100%
G 112 112 100%
H 48 48 100%
Total 614 614 100%
0
1
2
Page 221
Checklist No. 14 Radiology Version - NHSRC/3.0

Checklist for Radiology Department 15
Assessment Summary
Date of
Name of the Hospital Assessment
Names of
Names of Assessors
Assessees
Type of Assessment (Internal/External) Action plan

Submission Date
Radiology Score Card

Area of Concern wise Score Radiology Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Reference no. ME Statement Checkpoint Complianc Assessment Means of Verification Remarks

e Method
Full/Partial
/No

4 4
ME A1.14 Services are available for the time period All radiology services are 2 SI/RR
as mandated available in routine working
hours
Page 222

e Method
Full/Partial
/No
2 SI/RR
Emergency radiology services
are available for selected
procedure 24X7
2 2
ME A2.2 The facility provides Maternal health Availability of USG services for 2 SI/OB
Services Pregnant women
10 10
ME A3.1 The facility provides Radiology Services for chest, bones, skull,
Availability of X ray services 2 SI/OB spine and abdomen.
Barium Swallow, Barium

enema, Barium
Availability of special radio meal,MMR (Miniature
graphy services 2 SI/OB mass radiography) Chest
Availability of Dental X ray Dental X-ray. OPG
Services 2 SI/OB services
342342
Pre natal diagnostic
procedure:
Availability of ultrasound Ultrasonography,
services 2 SI/OB Fetoscopy
Availability of CT scan facility 2 SI/OB

16 16
Standard B1
Facility provides the information to care seekers, attendants & community about the available services and their
modalities
ME B1.1 Availability departmental 2 OB (Numbering, main
The facility has uniform and user- signage's department and internal
friendly signage system sectional signage
2 OB Notice in local language

is displayed at entrance
of USG department that
All persons including
the employer,
employee or any other
person associated with
department shall not
conduct or associate
with or help in carrying
out detection or
disclosure of sex of
foetus in any manner
Display of PNDT Notice at USG

Display of cautionary signage 2 OB Radiation hazard sign
outside the X ray department and caution for
pregnant women and
children
ME B1.2 The facility displays the services and List of services available are 2 OB
entitlements available in its displayed at the entrance
departments
Timing for taking X ray and 2 OB
collection of reports are
displayed outside the X ray
department
ME B1.4 User charges in r/o X ray services 2 OB

User charges are displayed and are displayed at entrance
communicated to patients effectively
ME B1.6 Information is available in local language Signage's and information are 2 OB
and easy to understand available in local language
ME B1.8 Reports are provided to Patient 2 OB
The facility ensures access to clinical in proper printed format
records of patients to entitled personnel
4 4
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on
account of physical economic, cultural or social reasons
ME B2.1 Female attendant should 2 OB/SI
Services are provided in manner that are accompany female patients
sensitive to gender during radiological procedures
ME B2.3 Check the availability of ramp in 2 OB
Access to facility is provided without any OPD/ X ray room
physical barrier & and friendly to people
with disabilities
8 8
ME B3.1 Adequate visual privacy is provided at X ray department has provision 2 OB
every point of care of privacy while taking X ray.
USG department has provision 2 OB provision of screen
of privacy while taking
sonography
ME B3.2 Radiology has system to ensure 2 RR/SI Radiology staff do not
Confidentiality of patients records and the confidentiality of the reports discuss the lab result
clinical information is maintained generated outside. And reports are
kept in secure place
ME B3.3 The facility ensures the behaviours of Behaviour of staff is empathetic 2 PI

4 4
Standard B4
Facility has defined and established procedures for informing and involving patient and their families about treatment
and obtaining informed consent wherever it is required.
ME B4.1 There is established procedures for Form F for USG under PNDT 2 RR
taking informed consent before maintained for scan of pregnant
woman
treatment and procedures
Page 223

e Method
Full/Partial
/No
8 8
ME B5.1 Free radiology services for 2 PI/SI
The facility provides cashless services to Pregnant women and infant
prescribed investigations are available at spent on diagnostics from
outside.
the facility
ME B5.4 Tests are free of cost for BPL 2 PI/SI
The facility provide free of cost patients
treatment to Below poverty line patients
without administrative hassles
ME B5.5 Cashless investigation by 2 PI/SI/RR

The facility ensures timely empanelled lab for JSSK
reimbursement of financial entitlements beneficiaries for test not
and reimbursement to the patients available within the facility

24 24
ME C1.1 Departments have adequate space as
per patient or work load
The room housing X -ray
equipment have
appropriate area to
faciltiate easy
movement of staff &
Room Size of X ray unit is as per proper patient
AERB safety code 2 OB poisitioning.
area 2 OB
ME C1.2 Patient amenities are provide as per
patient load Attached toilet facility available 2 OB For USG
Waiting area with sitting facility 2 OB
ME C1.3 Departments have layout and Entrance of X ray room is as per 2 OB Preferably one entrance
demarcated areas as per functions AERB layout guidelines with door having
hydraulic mechanism to
ensure that it is closed
during procedure
Opening for Ventilation and 2 OB Windows should be

natural light has been provided above 2m from finished
in X ray room as per AERB layout floor level outside the x
guidelines ray. If no then shielding
is provided is provided
on the window up to 2
m
Poistioning of chest stand as per 2 OB The chest stand should

AERB layout guidelines be located opposite to
entrance door and
control console
Positioning of control console as 2 Control console should

per AERB layout guidelines be poistioned as far
away as possible from
the X ray tube.
ME C1.4 The facility has adequate circulation area Corridors are wide enough for
and open spaces according to need and movement of trolleys and
local law stretchers
2 OB 2-3 meters
telephone and Intercom Services 2 OB
ME C1.6 Service counters are available as per Check for the adequacy
patient load X-ray machines as per
No of X ray machines as per load 2 OB load
planned to ensure structure follows the No cris cross in the
function/processes (Structure movement patient
commensurate with the function of the traffic and services flow
hospital) Unidirectional flow of goods and Should be near
services 2 OB emergency department
14 14
ME C2.1 The facility ensures the seismic safety of Non structural components are 2 OB Check for fixtures and
the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipments , hanging
objects are properly
fastened and secured
ME C2.3 The facility ensures safety of electrical X-ray - does not have temporary
2
Switch Boards other
establishment connections and loosely hanging electrical installation are
wires OB intact
Stabilizer is provided for X-ray 2
machine OB
ME C2.4 Physical condition of buildings are safe Floors of the Radiology
2
for providing patient care department are non slippery and
even OB
2
Mobile protective
barrier should to
positioned in such as
manner that the
operator is completely
sheilded during
Poistioning of mobile protective exposure
barrier as AERB layout guidelines OB
Page 224

e Method
Full/Partial
/No
Thickness of walls at X room are 2

as AERB layout guidelines The thickness is
appropriate taking into
consideration of (1)
Distance from centre of
patient table (2) type of
sheilding material (brick,
concrete, steel, lead or
any other material)
OB/RR
X ray department should not be 2
located adjacent to patient care
area
OB
10 10
ME C3.1 The facility has plan for prevention of Radiology has sufficient fire exit 2 OB/SI
fire to permit safe escape to its
are clearly marked.
ME C3.2 The facility has adequate fire fighting Radiology department has 2 OB
Equipment installed fire Extinguisher that is
Class A , Class B C type or ABC
type
2 OB/RR
mentioned
training of staff and conducts mock drills operating fire extinguisher and
regularly for fire and other disaster what to do in case of fire
situation
10 10
ME C4.1 The facility has adequate specialist 100-200 -1
doctors as per service provision 200-400- 2
Availability of Radiologist 2 OB/RR >400 - 3
requirement 100-2, 200-3, 300-5,
Availability of Radiographer 2 SI/RR 400-7, 500-9
ME C4.5 The facility has adequate support /
general staff Availability of Darkroom Asset. 2 SI/RR
Availability of housekeeping staff
2 SI/RR
6 6
ME C5.2 The departments have adequate X ray films, Developer,
consumables at point of use Fixer, USG gel, printing
Availability Consumables 2 OB/RR paper
Mobile protective
barrier, Lead apron,
Rubber hanging flaps,
Availability of personal hand glove, lead
protective equipments 2 OB/RR shields.
ME C5.3 Emergency drug trays are maintained at Emergency Drug Tray is
every point of care, where ever it may maintained
be needed
2 OB/RR
22 22
ME C6.1 Availability of equipment & instruments Availability of functional
for examination & monitoring of Equipment &Instruments for
patients examination & Monitoring
2 OB TLD badges
ME C6.3 Availability of equipment & instruments Availability of functional X-
for diagnostic procedures being ray machines
300 MA X ray machine &
2 OB 100 MA X ray machine
Dental X-Ray Machine 2 OB At least 1
Ultrasonography 2 one general purpose &
one for Obstetric
purpose
2 OB
Availability of functional 60 MA X ray machine
Portable X-ray Machine 2 OB (Mobile)
Availability of functional CT-
scan machine 2 OB
Availability of Accessories for
X ray
Cassettes X ray,
Intensifying screen X
ray, Lead letter (A-
Z),Letter figures (0-9)
and R & L (Manual).
Computer, printer, x -ray
holder/poistioner,
2 OB (Digital)
ME C6.6 Availability of functional equipment and Availability of equipments for OB Buckets for mopping,
instruments for support services cleaning mops, duster, waste
trolley, Deck brush
2
ME C6.7 Departments have patient furniture and OB
Availability of attachment/
accessories 2 Bucky Stand
OB
X-ray View box,
Availability of fixtures at Electrical fixture for
radiology 2 equipments
OB rack and cupboard ,
Availability of furniture 2 Chair table
Page 225

e Method
Full/Partial
/No
Standard C7 12 12
Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of
staff
ME C7.1
Check objective
checklist has been
2 nurses and paramedical
staff based on job
description defined for
each cadre of staff.
Check parameters for assessing Dakshta checklist issued
Criteria for Competence assessment are skills and proficiency of clinical by MoHFW can be used
defined for clinical and Para clinical staff staff has been defined for this purpose.
ME C7.2

competence assessment
2
including filled checklist,
scoring and grading .
Competence assessment of Clinical and Para Check for competence Verify with staff for
clinical staff is done on predefined criteria assessment is done at least once actual competence
at least once in a year in a year assessment done
ME C7.9 The Staff is provided training as per defined
core competencies and training plan Training on radiation safety 2 SI/RR
Training on infection control and
hand hygiene 2 SI/RR
Training on Bio Medical waste
Management 2 SI/RR
ME C7.10 Radiographers are skilled to
operating equipment
periodic rounds of
department and
monitor that staff is
working according to
the training imparted.
There is established procedure for utilization Also staff is provided on
of skills gained thought trainings by on -job job training wherever
supportive supervision 2 SI/RR there is still gaps
16 16
ME D1.1 The facility has established system for All equipments are covered 2 SI/RR
maintenance of critical Equipment under AMC including preventive
maintenance
2 SI/RR
repaired
OB/RR
Staff is skilled for trouble 2 SI/RR
shooting in case equipment
malfunction
is done by the operator
measuring Equipment
2 OB/ RR

ME D1.3 Operating and maintenance instructions Operating instructions and 2 OB/SI
are available with the users of factor charts are available with
equipment the equipments
18 18
Standard D2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient
care areas
ME D2.1 There is established procedure for 2 SI/RR
forecasting and indenting drugs and Stock level are daily
consumables updated
There is established system of Requisition are timely
timely indenting of X ray films, placed
fixer and developers etc.
ME D2.3 The facility ensures proper storage of There is separate storage area 2
drugs and consumables for undeveloped X ray films and
personal monitoring devcies
OB/RR
X ray films/ Fixers, developer 2
and consumables are kept away
from water and sources of heat,
direct sunlight
ME D2.4 The facility ensures management of 2 OB/RR X ray films, USG jelly,
expiry and near expiry drugs contrast media, plate
cleaner ( fixer &
developer - manual)
No expired consumbles is found

Records for expiry and near 2
expiry are maintained RR
ME D2.5 The facility has established procedure There is practice of calculation 2 SI/RR X ray films, USG jelly,
for inventory management techniques and maintaining buffer stock contrast media, plate
cleaner, print paper roll
( fixer & developer -
manual)
Page 226

e Method
Full/Partial
/No
Department maintained stock 2 RR/SI

and expenditure register in X ray
& USG
replenishing the drugs in patient care areas replenishing drug tray /crash
cart
There is no stock out of x-ray 2 OB/SI

films
22 22
Adequate illumination at work
station at X ray room
workstation at USG
ME D3.2 The facility has provision of restriction of Only one patient is allowed one 2 OB
visitors in patient areas time at X room
2 OB/SI
Warning light is provided outside
X ray room and its been used
when unit is functional
ME D3.3 The facility ensures safe and Protective apron and gloves are 2 OB/SI
comfortable environment for patients being provided to relative of the
and service providers child patient who escort the
child for X ray examination/
immobilisation support is
provided to children
X ray room has been kept closed 2 OB

at the time of radiation exposure
2 OB Check TLD batch is worn

Lead apron and other protective below the lead apron
equipments are available with
radiation workers and they are
using it
2 OB Records of its regular
assessment is done by X
ray department
TLD badges are available with all
staff of X ray department
ventilation in X ray room conditioning/Heating/Ex
haust/Ventilators as per
environment condition
and requirement
SI/RR
ventilation USG conditioning/Heating/Ex
haust/Ventilators as per
environment condition
and requirement
SI/RR
18 18
maintained appropriately Building is painted/whitewashed
in uniform colour
plastered & painted
ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof topes, 2 OB
All area are clean with
sinks patient care and circulation no dirt,grease,littering
areas are Clean and cobwebs
are clean

fixtures are intact
ME D4.5 The facility has policy of removal of 2 OB
condemned junk material
the X-ray and USG
4 4
Radiology and USG room
16 16
Standard D10 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
ME D10.1 The facility has requisite licences and 2 RR
certificates for operation of hospital and
different activities X ray department has
registration from AERB.
X ray department has layout 2 RR
approval
2 RR
X ray department has type
approval of equipment with QA
test report for X ray machine
USG department has registration 2 RR
under PCPNDT
2 OB
Duplicate copy of Certificate of
registration under Form B is
displayed inside the department
Page 227

e Method
Full/Partial
/No
ME D10.3 The facility ensure relevant processes 2 RR

are in compliance with statutory
requirement USG is taken by person Qualified
as per PCPNDT
2
X ray department has
X ray department has certification from AERB
Radiological safety officer (RSO) for any person
approved by competent discharging duties and
authority RR functions of RSO.
2
Records of submission of Form F
to appropriate district
authorities RR
8 8
Standard D11
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
operating procedures.
ME D11.1 The facility has established job Staff is aware of their role and SI
2
ME D11.2 The facility has a established procedure There is procedure to ensure RR/SI Check for system for
for duty roster and deputation to that staff is available on duty as recording time of
different departments per duty roster reporting and relieving
(Attendance register/
Biometrics etc)
2
There is designated in charge SI
for department 2
ME D11.3 The facility ensures the adherence to OB
administration / the health department Doctor, technician and support
staff adhere to their respective
dress code 2
2 2
Standard D12
Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual
obligations
ME D12.1 2 SI/RR Verification of
outsourced services
(cleaning/Laundry/Secur
ity/Maintenance)
provided are done by
There is procedure to monitor designated in-house
the quality and adequacy of staff
There is established system for contract outsourced services on regular
4 4
ME E1.1 The facility has established procedure Unique identification number 2 RR
for registration of patients is given to each patient
recorded in radiology/USG demographics like
records Name, age, Sex, Chief
complaint, etc.
4 4
ME E3.1 Facility has established procedure for Facility has established 2
continuity of care during procedure for handing over of
interdepartmental transfer patients during transfer to X-
Ray department
SI/RR
ME E3.2 Facility provides appropriate referral There is procedure for 2
linkages to the patients/Services for referral of patient for which
transfer to other/higher facilities to assure services can not be provided
their continuity of care. at the facility
RR/SI
4 4
ME E5.1 The facility identifies vulnerable patients Radiology/ USG department 2 SI/RR Check there is any
and ensure their safe care identify vulnerable patients as system to give them
per requirement preference for
radiographic procedure
ME E5.2 The facility identifies high risk patients and Women in reproductive age are 2 OB/SI/RR Notice in local language
ensure their care, as per their need asked for pregnancy is displayed at entrance
(LMP)before X-ray of X ray department
asking every female to
inform
radiographer/radiologist
whether she is likely to
be pregnant
8 8
ME E8.5 Adequate form and formats are 2 RR/OB Printed formats for
available at point of use requisition and
reporting are available
Standard Formats available
ME E8.6 Register/records are maintained as per Radiology records are labelled 2 RR
guidelines and indexed
Records are maintained for 2 RR
radiology
ME E8.7 The facility ensures safe and adequate Radiology has adequate facility 2 OB
storage and retrieval of medical records for storage of records
6 6
plan in place
ME E11.5 There is procedure for handling medico Procedure for handling of MLC 2 SI/RR Requisition and reports
legal cases are marked with MLC
and reports are handed
over to authorize person
42 42
Page 228

e Method
Full/Partial
/No
ME E12.1 There are established procedures for Requisition of all X ray 2 RR/OB Request form contain
Pre-testing Activities examination is done in request information: Name and
form identification number of
patient, name of
authorized requester,
examination requested,
type of X ray, date and
time of X ray taken and
date and time of receipt
of X ray from X ray
department
X ray has system to identify 2 RR/SI

radiographer from who has
taken X ray
X ray department has system in 2 RR/SI
place to label X ray films
X ray deparment has system to 2 RR/SI
trace back the recorded X ray
film from requisition form
Records of type of X ray 2 RR/SI
prescribed is made at the time
of reception
Requisition of all USG 2 RR/OB
examination is done in request
form
USG department has system in 2 RR/SI
place to label the USGs
Preparation of the patient is 2 RR/SI
done as per requirement
Instructions to be followed by 2 RR/SI
patient for USG are displayed in
local language at reception
ME E12.2 There are established procedures for X ray taking and processing 2 OB/RR
testing Activities procedure are readily available
at work station and staff is
aware of it
Necessary Instruction for taking 2 OB/RR

X ray and its processing are
displayed at work station in
language understood by staff
X ray department has system in 2 RR/SI

place to take X ray of patients in
case of Emergency.
Radiographer is aware of 2 RR/SI
operation of X ray machine
Necessary Instruction for USG 2 OB/RR
Examination are displayed at
work station in language
understood by staff
USG of the patient is taken as 2 OB/RR

per consultant requirement
USG department has system in 2 RR/SI
place to take sonograph of
patients in case of Emergency.
ME E12.3 There are established procedures for X ray department has format for 2 RR/OB
Post-testing Activities reporting of results
X ray department has system to 2 RR/SI
provide the reports within
defined time intervals
USG department has format for 2 RR/OB
USG report is signed by 2 RR/OB
Radiologist/Sonologist
USG department has system to 2 RR/SI
provide the reports within
defined time intervals

6 6
Standard F1
infection
There is Provision of Periodic Medical There is procedure for Hepatitis B, Tetanus
ME F1.4 Checkups and immunization of staff immunization of the staff 2 SI/RR Toxid etc
staff 2 SI/RR
Facility has established procedures for Hand washing and
regular monitoring of infection control infection control audits
practicices done at periodic
Regular monitoring of infection intervals
14 14
Hand washing facilities are provided at Availability of hand washing
Check for availability of
point of use Facility at Point of Use
wash basin near the
ME F2.1 2 OB point of use
Ask to Open the tap. Ask
Staff water supply is
2 OB/SI regular
with soap dish/ liquid antiseptic Check for availability/
with dispenser. Ask staff if the supply is
adequate and
Availability of Alcohol based
Hand rub Check for availability/
Ask staff for regular
2 OB/SI supply.
Instruction at Point of Use Prominently displayed
above the hand washing
facility , preferably in
2 OB Local language
Staff is trained and adhere to standard Adherence to 6 steps of Hand
ME F2.2 hand washing practices washing 2 SI/OB Ask of demonstration
wash 2 SI
Page 229

e Method
Full/Partial
/No
6 6
Facility ensures adequate personal Clean gloves are available at
protection equipments as per point of use
requirements
ME F3.1 2 OB/SI
Staff is adhere to standard personal No reuse of disposable gloves
ME F3.2 protection practices and Masks. 2 OB/SI
4 4
Facility ensures standard practices and Decontamination of operating &
materials for decontamination and clean ing Procedure surfaces Ask stff about how they
of instruments and procedures areas decontaminate the
procedure surface
stretcher/Trolleys etc.
(Wiping with .5%
ME F4.1 2 SI/OB Chlorine solution
solution 2 SI/OB
14 14
Facility ensures availability of standard Availability of disinfectant as per
materials for cleaning and disinfection of requirement Chlorine solution,
patient care areas Gluteraldehye, carbolic
ME F5.2 2 OB/SI acid
Availability of cleaning agent as
per requirement Hospital grade phenyl,
disinfectant detergent
2 OB/SI solution
Facility ensures standard practices followed Staff is trained for spill
for cleaning and disinfection of patient care management
areas
ME F5.3 2 SI/RR
procedure
2 SI/RR
Standard practice of mopping Unidirectional mopping
and scrubbing are followed 2 OB/SI from inside out
are not used in patient care Any cleaning equipment
areas leading to dispersion of
dust particles in air
12 12
Standard F6
hazardous Waste.
Facility Ensures segregation of Bio Availability of colour coded bins Adequate number.
Medical Waste as per guidelines at point of waste generation Covered. Foot operated.
ME F6.1 2 OB
of waste as per guidelines
2 OB/SI
Display of work instructions for Pictorial and in local
segregation and handling of language
Biomedical waste
2 OB
and general waste 2
Facility ensures transportation and Disposal of Fixer and Developer
ME F6.3 disposal of waste as per guidelines 2 SI/OB/RR
2 2
4 4
ME G2.1 Patient Satisfaction surveys are There is system to take feed
2 RR
conducted at periodic intervals back from clinician about quality
of services
Patient satisfaction survey done 2 RR
on monthly basis
6 6
ME G3.1 Facility has established internal quality Internal quality Assurance 2 SI/RR
assurance program at relevant program is established in
departments Radiology
Periodic QA of equipment by 2 SI/RR QA to be carried out at

AERB authorized agencies least once in 2 yrs and
also after any repairs
having radition safety
implications
ME G3.3 Facility has established system for use of Departmental checklist are 2 SI/RR Staff is designated for
check lists in different departments and used for monitoring and filling and monitoring
services quality assurance of these checklists
32 32
Standard G4
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes
and support services.
procedures are available for department has been
Page 230

e Method
Full/Partial
/No

adequately describes process and procedure for process of taking
procedures and handling X ray

procedure for acceptance and
rejection of X ray taken

procedure for receipt, labelling ,
Processing and reporting of X ray

procedure for taking X ray in
emergency conditions
procedure for quality control
system to verify the quality of
results
Radiology has documented 2 RR

system for repeat X ray.
procedure for storage, retaining
and retrieval of department
records, and reports of results.

procedure preventive and break
down maintenance
procedure for purchase of
External services and supplies
procedure for inventory
management
procedure for upkeep
management of department
procedure for radiation safety of
staff , patients and visitors
standard procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed at Point Work Instructions are displayed 2 OB Factor chart, radiation
of use for radiation safety safety, development for
x-ray films
6 6
Standard G 5
Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and
wastages
processes done
identified
8 8
Standard G6
The facility has established system of periodic review as internal assessment , medical & death audit and prescription
audit
ME G6.3 The facility ensures non compliances are Non Compliance are 2 RR/SI
enumerated and recorded adequately enumerated and recorded
ME G6.4 Action plan is made on the gaps found in Action plan prepared 2 RR/SI
ME G6.5 Corrective and preventive actions are 2 RR/SI

assessment & audit Corrective and preventive
action taken
4 4
ME G7.4 2 SI/RR
Check short term valid

quality objectivities have
been framed addressing
key quality issues in
each department and
cores services. Check if
these objectives are
Specific, Measurable,
Facility has de defined quality objectives to Check if SMART Quality Attainable, Relevant and
achieve mission and quality policy Objectives have framed Time Bound.
ME G7.5 2 SI/RR
Interview with staff for
their awareness. Check
if Mission Statement,
Core Values and Quality
Mission, Values, Quality policy and Check of staff is aware of Policy is displayed
objectives are effectively communicated to Mission , Values, Quality Policy prominently in local
staff and users of services and objectives language at Key Points
Standard G8
method
ME G8.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable
improvement in services tools are used in each
department
Page 231

e Method
Full/Partial
/No
ME G10.4 SI/RR
Verify with the
assessment records.
Comprehensive of
Check if periodic assessment of physical and electrical
Physical and electrical safety risk safety should be done at
Periodic assessment for Physical and is done using the risk assessment least once in three
Electrical risks is done as per defined criteria checklist 2 month
ME G10.6 2 SI/RR
Verify with the records.
A comprehensive risk
asesement of all clincial
Check periodic assessment of processes should be
Periodic assessment for Medication and medication and patient care done using pre define
Patient care safety risks is done as per safety risk is done using defined critera at least once in
defined criteria. checklist periodically three month.
12 12
ME H1.1 Facility measures productivity Indicators on X ray done per 1000 OPD patient
monthly basis 2 RR
X ray done per 1000 IPD patient 2 RR
Ultrasound done per 1000 OPD
patient 2 RR
Proporation of X ray done at
night 2 RR
No. of dental X ray per 1000
dental OPD 2 RR
Proportion of BPL Patients
screened 2 RR
10 10
ME H2.1 Facility measures efficiency Indicators on Downtime for critical
monthly basis equipments 2 RR
Turn around time for X-Ray film
development 2 RR
Proportion of waste of films 2 RR
Proportion of X ray
rejected/repeated 2 RR
X ray done per radiographer
2 RR
12 12
ME H3.1 Facility measures Clinical Care & Safety Proportion of X rays for which
Indicators on monthly basis report is signed by radiologist 2 RR
Proportion of scans for which F
form is filled out of pregnant
women scanned
2 RR
Examination Demography
Proportion of General,
Chest examination and
2 RR specialised examination
Report correlation rate
Proportion of radiology
report co related with
clinical
examination/laboratory
reports out of Total X
2 RR ray reported
No of events of over limit of
radiation exposure 2 RR
6 6
ME H4.1 Facility measures Service Quality Indicators Average waiting time at
on monthly basis radiology 2 RR
Average waiting time at USG 2 RR
Number of stock out incidences
of x ray films 2 RR

A 16 16 100%
B 40 40 100%
C 98 98 100%
D 104 104 100%
E 68 68 100%
F 56 56 100%
G 72 72 100%
H 40 40 100%
Total 494 494 100%
0
1
2
Page 232
Checklist No. 15 Pharmacy Version - NHSRC/3.0

Checklist for Pharmacy Department 16
Assessment Summary
Date of Assessment
Action plan
Pharmacy Score Card

Area of Concern wise Score Pharmacy Score
C Inputs 100%
D
E
Support Services
Clinical Services
100%
100% 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date

Full/Partial/ Method
No

6 6
ME A1.14 Services are available for the time period Dispensary services are available 2 SI/RR
as mandated in OPD hours
Facility ensure access to drug store 2 SI/RR
after OPD hours
Page 233

No
Generic Drug store is operational 2 SI/RR
24X7
10 10
ME A4.1 The facility provides services under Availability of Drugs under 2 SI/OB Chloroquine, Primaquine,
National Vector Borne Disease Control NVBDCP ACT (Artemisinin
Programme as per guidelines Combination Therapy)
ME A4.2 The facility provides services under Availability of Drugs under RNTBCP 2 SI/OB
Revised National TB Control Programme
as per guidelines
ME A4.3 The facility provides services under SI/OB
National Leprosy Eradication Programme
as per guidelines Rifampicin, Clofazimine,
Availability of Drugs under NLEP 2 Dapsone
ME A4.4 The facility provides services under Availability of ARV Drugs under 2 SI/OB Zidovudine, Stavudine,
National AIDS Control Programme as per NACP Lamivudine, Nevirapine in
guidelines combination as per NACO
Availability of Drugs for Paediatric 2 SI/OB Paediatric Dosages FDC 6,

HIV management FDC 10, Efavirenz,
Cotrimoxazole
Standard A5 Facility provides support services 8 8

ME A5.6 The facility provides pharmacy services
Dispensing of Medicines and

consumables for OPD Patients 2 SI/OB Functional dispensary
Functional jan ayushdhalya in

Generic Drug Store 2 SI/OB premises or equivalent
Storage of drugs 2 SI/OB
Cold chain management services 2 SI/OB
14 14
ME B1.1 Availability departmental 2 OB (Numbering, main
The facility has uniform and user- signage's department and internal
friendly signage system sectional signage
2 OB
Directional signage's are displayed
in hospital for easy access to
Pharmacy/Generic drug store
ME B1.2 The facility displays the services and List of Drugs available displayed at 2 OB
entitlements available in its Pharmacy
departments
Status of availability of drugs is 2 OB
updated daily
Timing for dispensing counter of 2 OB
pharmacy are displayed
ME B1.4 2 OB
User charges are displayed and User charges in r/o services are
communicated to patients effectively displayed at entrance of generic
drug store
4 4
Standard B2
physical, economic, cultural or social reasons.
ME B2.1 2 OB
Services are provided in manner that are Availability of separate Queue for
sensitive to gender Male and female at dispensing
counter
ME B2.3 Pharmacy has easy access for 2 OB Check for availability of ramp
moment of goods and goods trolley/ cart
Access to facility is provided without any
with disabilities
2 2
4 4
Standard B4
ME B4.4 2 OB/SI
Information about the treatment is Method of Administration /taking
shared with patients or attendants, of the medicines is informed to
patient/ their relative by
regularly pharmacist as per doctors
prescription in OPD Pharmacy
displayed
10 10
ME B5.1 2 PI/SI
as per prevalent government schemes Free drugs and consumables for
JSSK beneficiaries
ME B5.2 The facility ensures that drugs 2 SI/OB
prescribed are available at Pharmacy Pharmacy provides generic drug
and wards list to all hospital department
Check that patient party has not 2 PI/SI
incurred expenditure on
purchasing drugs or consumables
from outside.
ME B5.4 2 PI/SI/RR
Free drugs for BPL patients
Page 234

No
ME B5.5 2 PI/SI/RR
reimbursement of financial entitlements Local purchase of stock out drugs/
and reimbursement to the patients Reimbursement of expenditure to
the beneficiaries
28 28
ME C1.1 Minimum space required is
Departments have adequate space as 250sq F or 5%
per patient or work load Hospital has allocated space for of average OPD X 0.8 sq m.
Pharmacy in OPD 2 OB
Dispensary has adequate waiting
space as per load 2 OB
ME C1.2 Patient amenities are provide as per Pharmacy has patients sitting 2
patient load arrangement as per requirement OB
Dispensary counter has provision 2
of shade OB
ME C1.3 Departments have layout and Dedicated area for keeping
demarcated areas as per functions medical gases 2 OB
Dedicated area for keeping
inflammables 2 OB Storage of sprit etc.
Demarcated are of keeping near
expiry drugs 2 OB
Demarcated are of keeping near
expiry drugs 2 OB
Demarcated area for keeping
instruments and consumables 2 OB
Dedicated area for cold chain
management 2 OB
ME C1.4 The facility has adequate circulation area 2
and open spaces according to need and Availability of adequate circulation
local law area for easy moment of staff ,
drugs and carts OB
ME C1.5 The facility has infrastructure for 2
and Intercom Services OB
ME C1.6 Service counters are available as per Adeqauate No of drug dispensing 2
patient load counter as per load OB
ME C1.7 The facility and departments are 2 Receipt and Inspection area
planned to ensure structure follows the at one side and issue area on
function/processes (Structure the other side
commensurate with the function of the
hospital) Unidirectional flow of goods in the
Pharmacy . OB
10 10
ME C2.1 The facility ensures the seismic safety of Non structural components are 2 OB Check for fixtures and
the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipments , hanging objects
are properly fastened and
secured

Pharmacy does not have
establishment temporary connections and
Stabilizer is provided for cold chain 2 OB
room
ME C2.4 Physical condition of buildings are safe Windows of drug store have grills 2 OB
for providing patient care and wire meshwork
2 OB
Floors of the Pharmacy
department are non slippery and
even
12 12
ME C3.1 The facility has plan for prevention of Pharmacy has plan for safe 2 OB/SI
fire storage and handling of potentially
Department has sufficient fire exit 2 OB
to permit safe escape to its
clearly marked.
ME C3.2 The facility has adequate fire fighting Pharmacy has installed fire 2 OB/RR
Equipment Extinguisher that is Class A , Class
B C type or ABC type
2 OB/RR
mentioned
situation
4 4
ME C4.4 The facility has adequate Availability of Pharmacist 2 SI/RR
requirement
ME C4.5 The facility has adequate support / Availability of security staff 2 SI/RR
general staff
40 40
ME C5.1 The departments have availability of Analgesics/ Antipyretics/Anti
adequate drugs at point of use inflammatory 2 OB/RR As per State EDL
Antibiotics 2 OB/RR As per State EDL
Anti Diarrhoeal 2 OB/RR As per State EDL
Page 235

No
Antiseptic lotion 2 OB/RR As per State EDL
Dressing material 2 OB/RR As per State EDL
IV fluids and plasma expenders 2 OB/RR As per State EDL
Eye and ENT drops 2 OB/RR As per State EDL
Anti allergic 2 OB/RR As per State EDL
Drugs acting on Digestive system 2 OB/RR As per State EDL
Drugs acting on cardio vascular
system 2 OB/RR As per State EDL
Drugs acting on central/Peripheral
Nervous system 2 OB/RR As per State EDL
Drugs acting on respiratory system 2 OB/RR As per State EDL
Drugs acting on uro genital system 2 OB/RR As per State EDL

Drugs used on Obstetrics and
Gynaecology 2 OB/RR As per State EDL
Hormonal Preparation 2 OB/RR As per State EDL
Other drugs and materials 2 OB/RR As per State EDL
Vaccine drug and logistics 2 OB/RR As per State EDL
Surgical accessories for Eye 2 OB/RR As per State EDL
Vitamins and nutritional
supplement 2 OB/RR As per State EDL
ME C5.2 The departments have adequate
consumables at point of use Availability of Consumables
2 OB/RR As per Sate EDL
6 6
ME C6.5 Availability of Equipment for Storage Availability of Equipment for ILR, Deep Freezers, Insulated
maintenance of Cold chain 2 OB carrier boxes with ice packs,
ME C6.6 Availability of functional equipment and Availability of equipments for 2 Buckets for mopping, mops,
instruments for support services cleaning duster, waste trolley, Deck
brush
OB
ME C6.7 Departments have patient furniture and
fixtures as per load and service provision Racks ,Cupboards, Sectional
Drawer cabinet/ Shelves,
Storage furniture for drug store 2 OB Work table
ME C7.1

2 nurses and paramedical staff
based on job description
defined for each cadre of
Check parameters for assessing staff. Dakshta checklist issued
Criteria for Competence assessment are skills and proficiency of clinical by MoHFW can be used for
defined for clinical and Para clinical staff staff has been defined this purpose.
ME C7.2
2 including filled checklist,
scoring and grading . Verify
Competence assessment of Clinical and Para with staff for actual
clinical staff is done on predefined criteria Check for competence assessment competence assessment
at least once in a year is done at least once in a year done
ME C7.9 The Staff is provided training as per defined SI/RR
core competencies and training plan Inventory management 2
Cold chain management of ILR SI/RR
and deep freezer 2
Rational use of drugs 2 SI/RR
Prescription Audit 2 SI/RR
ME C7.10 Staff is skilled for estimation of the 2 SI/RR
requirement and proper storage of
the drugs Check supervisors make
periodic rounds of
There is established procedure for utilization staff is provided on job
of skills gained thought trainings by on -job training wherever there is
supportive supervision still gaps
Staff is skilled for maintaining 2 SI/RR
pharmacy records and bin cards
periodic rounds of
training wherever there is
still gaps
8 8
maintenance
2 SI/RR ILR, Deep freezer and

There is system of timely Refrigerator
ME D1.2 The facility has established procedure All the measuring equipments/ 2 OB/ RR Calibration of thermometers
for internal and external calibration of instrument are calibrated at cold chain room
measuring Equipment
ME D1.3 Operating and maintenance instructions Operating instructions for ILR/ 2 OB/SI
are available with the users of Deep Freezers are available at cold
equipment chain room
78 78
ME D2.1 There is established procedure for Drug store has process to 2 RR/SI
forecasting and indenting drugs and consolidate and calculate the
consumables consumption of all drugs and
consumables
2 RR/SI
Forecasting of drugs and
consumables is done scientifically
based on consumption and
disease load
Page 236

No
2 RR/SI
Staff is trained for forecast the
requirement using scientific
system
ME D2.2 The facility has establish procedure for Facility has a established 2 RR/SI
procurement of drugs procedures for local purchase of
drugs in emergency conditions
Hospital has system for placing 2 RR/SI

requisition to district drug store
ME D2.3 The facility ensures proper storage of There is specified place to store
drugs and consumables medicines in Pharmacy and drug
store 2 OB
All the shelves/racks containing Stock is arranged neatly in
medicines are labelled in alphabetic order with name
pharmacy and drug store 2 OB facing the front.
Product of similar name and
different strength are stored
separately 2 OB
Heavy items are stored at lower
shelves/racks 2 OB
Fragile items are not stored at the
edges of the shelves. 2 OB
Sound alike and look alike

medicines are stored separately in
patient care area and pharmacy 2 OB
There is separate shelf /rack for
storage near expiry drugs 2 OB
Drug store and pharmacy has
system of inventory Management 2 OB/SI
Drugs and consumables are stored

away from water and sources of Medications that are
heat, considered light-sensitive will
direct sunlight etc. 2 OB/RR be stored in closed drawers.
Drugs are not stored at floor and Pallets are provided if
adjacent to wall 2 OB required to store at floor
ME D2.4 The facility ensures management of Dispensing counter has system to 2 RR/SI
expiry and near expiry drugs check the expiry of drugs
Drug store has system to check 2 RR/SI
the expiry of drugs
2 RR/SI
Drug store has system to inform
the patient care areas about near
expiry/expired drugs
There is a system of periodic 2 RR/SI
random quality testing of drugs
ME D2.5 The facility has established procedure Physical verification of inventory is 2 RR/SI
for inventory management techniques done periodically
Facility uses bin card system 2 RR/OB

First expiry first out system is 2 OB
established for drugs
Stores has defined minimum stock 2 RR/OB
for each category of drug as per
there consumption pattern
Reorder level is defined for each 2 RR
category of drugs
Drug store has inventory 2 OB/RR
management software
Drugs are categorized in Vital, 2 OB/RR
Essential and Desirable
ME D2.6 There is a procedure for periodically 2 RR/SI
replenishing the drugs in patient care areas Hospital has system to take
medicines from store in case of
emergency or if required urgently
ME D2.7 There is process for storage of vaccines
and other drugs, requiring controlled
temperature Check vaccines are kept in (Top to bottom) : Hep B, DPT,
sequence 2 OB DT, TT, BCG, Measles, OPV
Work instruction for storage of
vaccines are displayed at point of
use 2 OB
ILR and deep freezer have
functional temperature
monitoring devices 2 OB
Temp. of ILR: Min +2OC to

8Oc in case of power failure
min temp. +10OC . Daily
There is system in place to temperature log are
maintain temperature chart of ILR 2 OB maintained
Temp. of Deep freezer

cabinet is maintained
There is system in place to between -15OC to
maintain temperature chart of -25OC.Daily temperature log
deep freezers 2 OB are maintained
Check thermometer in ILR is in
hanging position 2 OB
ILR and deep freezer has
functional alarm system 2 SI/RR
Staff is aware of Hold over time of
cold storage equipments 2 SI/RR
ME D2.8 There is a procedure for secure storage
of narcotic and psychotropic drugs As per Narcotic act, Narcotic
medicines are kept in 2 Keys
Narcotic medicines are kept in with 2 locks kept by 2
double lock 2 OB different persons
Empty ampoules/strips are
returned along with narcotic
administration detail sheet 2 OB/RR
Hospital has system to discard the Discarded narcotic drugs are
expired narcotic drugs 2 RR/SI documented with witness.
Facility maintains the list of
narcotic and psychotropic drugs
available at facility 2 RR
10 10
Page 237

No
ME D3.1 The facility provides adequate
Adequate Illumination at drug
store 2 OB
Adequate Illumination at
dispensing counter 2 OB
comfortable environment for patients ventilation in pharmacy conditioning/Heating/Exhaus
and service providers t/Ventilators as per
environment condition and
requirement
SI/RR
ME D3.4 The facility has security system in place 2 OB
at patient care areas Security arrangement at pharmacy
18 18
ME D4.1 Exterior of the facility building is Building is painted/whitewashed 2 OB
maintained appropriately in uniform colour
plastered & painted
ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof topes, OB
All area are clean with no
sinks patient care and circulation dirt,grease,littering and
areas are Clean 2 cobwebs
are clean

fixtures are intact
condemned junk material the Pharmacy and drug store
4 4
load Availability of power back in
Pharmacy
Availability of power back for cold 2 OB/SI
chain
2 2
ME D10.1 The facility has requisite licences and 2 RR
certificates for operation of hospital and
different activities
License for storing spirit
8 8
Standard D11
procedures.
ME D11.2 The facility has a established procedure There is procedure to ensure that 2 RR/SI Check for system for
for duty roster and deputation to staff is available on duty as per recording time of reporting
different departments duty roster and relieving (Attendance
register/ Biometrics etc)

department
Pharmacist adhere to their
2 2
ME D12.1 2 SI/RR Verification of outsourced
services (cleaning/
Dietary/Laundry/Security/Ma
There is procedure to monitor the intenance) provided are
quality and adequacy of done by designated in-house
There is established system for contract outsourced services on regular staff
18 18
Standard E6
rational use.
ME E6.1 Facility ensured that drugs are prescribed in Drugs are purchased in generic 2 RR/SI
generic name only name only
Facility has essential drug list as 2 OB
per State guideline
Facility provide list of drugs 2 RR/SI
available to different
departments as per essential
drug list
Facility has enabling order 2 RR/SI

from state for writing drugs in
generic name only
There is system of conducting 2 RR/SI
periodic prescription audit to
ensure that only generic drugs
are prescribed
ME E6.2 There is procedure of rational use of drugs Hospital has its own drug 2 RR/SI
formulary based on EDL
Drug formulary is available with 2
doctors and nurses/ clinical table RR/SI
Page 238

No
2
Hospital has system to review the
drug formulary as per EDL at
defined intervals RR/SI
2
Hospital has system to review the
prescription as per drug formulary
and STG RR/SI
2 2
ME E7.1 There is process for identifying and Pharmacy has list of high risk drugs 2 RR/SI
cautious administration of high alert are available
drugs
8 8
ME E8.5 Adequate form and formats are 2 RR/OB Bin cards, indent forms etc
available at point of use Standard Formats available
ME E8.6 Register/records are maintained as per Pharmacy records are labeled and 2 RR
guidelines indexed
Records are maintained for 2 RR
Pharmacy
ME E8.7 The facility ensures safe and adequate Pharmacy has adequate facility for 2 OB
storage and retrieval of medical records storage of records
4 4
plan in place
disaster is defined
6 6
ME F1.4 Checkups and immunization of staff immunization of the staff 2 SI/RR Hepatitis B, Tetanus Toxid etc
staff 2 SI/RR
Facility has defined and established Check for Pharmacist are aware of
2 2
Facility ensures availability of standard Availability of cleaning agent as
materials for cleaning and disinfection of per requirement Hospital grade phenyl,
patient care areas disinfectant detergent
ME F5.2 2 OB/SI solution
10 10
Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous
Waste.
Facility Ensures segregation of Bio Availability of colour coded bins at Adequate number. Covered.
ME F6.1 Medical Waste as per guidelines point of waste generation 2 OB Foot operated.

Pharmaceutical waste like

antibiotics, cytotoxic drugs
including all items
contaminated with cytotoxic
Segregation of expired or drugs along with glass or
discarded drugs in Yellow Bin 2 plastic ampoules, vials etc.
and general waste 2 OB
Facility ensures transportation and
Either sent back to

Disposal of expired drugs as per manufacturer or disposed by
ME F6.3 state guidelines 2 SI/OB incineration
2 2
activities
2 2
ME G2.1 Patient Satisfaction surveys are Patient satisfaction survey done 2 RR
conducted at periodic intervals on monthly basis
6 6
ME G3.1 Facility has established internal quality Physical verification of the 2 SI/RR
assurance program at relevant inventory by Pharmacist/hospital
departments manager at periodic intervals
ME G3.2 Facility has established external Periodic and random sampling of 2 SI/RR By drug controller/State Drug
assurance programs at relevant the drugs for Quality Assurance quality Assurance
departments
ME G3.3 Facility has established system for use of Departmental checklist are 2 SI/RR Staff is designated for
check lists in different departments and used for monitoring and quality filling and monitoring of
services assurance these checklists
34 34
Standard G4
support services.
and approved
Page 239

No
procedures procedure for indent the drugs
and items from district drug
warehouse
2 RR
procedure for local purchase of
drugs/ generic drug stores
2 RR
procedure for reception of drugs
and items
procedure for storage of drugs
2 RR
procedure for disposal of expired
drugs
2 RR
procedure for dispensing of
medicines at Pharmacy
2 RR
procedure of indenting the drugs
to patient care area
2 RR
procedure for issue of the drugs in
emergency condition
2 RR
temperature of ILR/Deep
freezer /refrigerators
2 RR
procedure for maintaining near
expiry drugs at store and
pharmacy
2 RR
procedure for rational use of drugs
and prescription audit
2 RR
procedure for storage of narcotic
and psychotropic drugs
2 RR
system for periodic random check
and quality testing of drugs
standard procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed at Point 2 OB Work instruction for storing
of use drugs, Cold chain
Work instruction/clinical management
protocols are displayed
6 6
processes done
identified
12 12
ME G6.2 The facility conducts the periodic Pharmacy department co ordinate 2 RR/SI
prescription/ medical/death audits the prescription audit
Storage and compilation of 2 RR/SI
records of prescription audit
ME G6.3 The facility ensures non compliances are Non Compliance are enumerated 2 RR/SI
enumerated and recorded adequately and recorded
ME G6.4 Action plan is made on the gaps found in Action plan prepared 2 RR/SI
ME G6.5 Corrective and preventive actions are 2 RR/SI

taken
6 6
ME G7.4 2 SI/RR

been framed addressing key
quality issues in each
department and cores
Facility has de defined quality objectives to Check if SMART Quality Objectives Measurable, Attainable,
achieve mission and quality policy have framed Relevant and Time Bound.
ME G7.5 2 SI/RR
Mission, Values, Quality policy and Check of staff is aware of Mission , Quality Policy is displayed
objectives are effectively communicated to Values, Quality Policy and prominently in local language
staff and users of services objectives at Key Points
ME G7.7 2 SI/RR

objectives being reviewed at
least onnce in month by
departmnetal incharges and
during the qulaity team
meeting. The progress on
Facility periodically reviews the progress of Check time bound action plan is quality objectives have been
Page 240

No

Standard G8
method
ME G8.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools
improvement in services are used in each department
ME G10.6 2 SI/RR
comprehensive risk
Check periodic assessment of asesement of all clincial
Periodic assessment for Medication and medication and patient care safety processes should be done
Patient care safety risks is done as per risk is done using defined checklist using pre define critera at
6 6
ME H1.1 Facility measures productivity Indicators on Percentage of drugs available
monthly basis against essential drug list for OPD 2 RR
Percentage of drugs available
against essential drug list for IPD 2 RR
Expenditure on drugs procured
throughlocal purchase for BPL
patient 2 RR
6 6
ME H2.1 Facility measures efficiency Indicators on Number of stock out situations in
monthly basis Vital category medicines 2 RR
Turn Around time for dispensing
medicine at Pharmacy 2 RR
% of drugs expired during the
months 2 RR
8 8
ME H3.1 Facility measures Clinical Care & Safety Proportion of prescription found
Indicators on monthly basis prescribing non generic drugs 2 RR
No of advere drug reaction per
thosuand patients 2 RR
Antibiotic rate
No. of antibiotic
prescribed /No. of patient
2 RR admiited or consulted
Percentage of irrational use of
drugs/overprescription 2 RR
2 2
ME H4.1 Facility measures Service Quality Indicators Waiting time for Pharmacy
on monthly basis Counter
2 RR

A 24 24 100%
B 34 34 100%
C 116 116 100%
D 130 130 100%
E 32 32 100%
F 18 18 100%
G 76 76 100%
H 22 22 100%
Total 452 452 100%
0
1
2
Page 241
Checklist No. 16 Support Services Version- NHSRC/3.0

Checklist for Auxillary Services 17
Assessment Summary

Type of Assessment (Internal/External) Action plan Submission Date
Auxillary Services Score Card

Area of Concern wise Score Auxillary Services Score
C Inputs 100%
E
F
Clinical Services
Infection Control
100%
100%
100%
Quality Management
G 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Reference no ME Statement Checkpoint Complia Assessmen Means of Verification Remarks

nce t Method

14 14
Standard A5 Facility provides support services
ME A5.1 The facility provides dietary services Availability of operational Functional Kitchen within the premise of the
Kitchen 2 SI/OB hospital
ME A5.2 The facility provides laundry services Arrangement of laundry services inhouse or
Availability of functional laundry 2 SI/OB outsourced
ME A5.3 The facility provides security services Availability of functional security
services 24 X7 2 SI/OB
ME A5.4 The facility provides housekeeping Availability of Housekeeping
services services 24X7 2 SI/OB
ME A5.5 Availability of waste disposal Arrangement for disposal of Bio medical and
services 2 SI/OB general waste Inhouse or outsouced
ME A5.6 The facility ensures maintenance Availability of maintenance Includes Physical infrastructure maintenance
services services 24X7 2 SI/OB and equipment maintenance
Page 242

nce t Method
ME A5.8 The facility has services of medical Availability of Medical record 2

record department department SI/OB
6 6
ME B1.1 Availability of departmental 2 OB
The facility has uniform and user- signage for support service
friendly signage system department
ME B1.8 2 RR/OB
The facility ensures access to clinical
records of patients to entitled personnel Medical records are provided to
patient/ Next to kin on request
4 4
ME B3.2
Confidentiality of patients records and
clinical information is maintained MRD has system to maintain Patient records are not shared except the
Confidentiality of patient records 2 SI/RR patient until it is authorized by law
2 2
Standard B4
4 4
ME B5.1 Availability of free diet 2 PI/SI
ME B5.4 Free diet for BPL patients and 2 PI/SI

The facility provide free of cost JSSK beneficiaries

24 24
ME C1.1 Departments have adequate space as 2 OB
Dietary Department has
per patient or work load adequate space as per 15-20 sq ft/bed space requirement for 100
requirement and more than 100 bed hospital.
2 OB
Laundry Department has
adequate space as per
requirement Minimum space requirement 10sq ft/bed
2 OB
Medical record Department has
adequate space as per Minimum space requirement is 2.5 to 3,5 sq ft
requirement per bed
demarcated areas as per functions Layout as per functional flow that is receipt,
storage, daily storage, preparation, Cooking
Check Dietary department has area ,Service area, dish washing area,
demarcated and dedicated area Garbage collection area and administrative
for various activities area.
2 OB
Layout as per functional flow that is from
Check laundry department has dirty end (receipt) to clean end (Issue). That is
demarcated and dedicated area receipt, sorting, sluicing, washing, drying,
for its various activities ironing and issue
2 OB
Availability of complaint box and
display of process for grievance Layout as per functional flow that is receipt,
redressal and whom to contact checking of completion of records, indexing
is displayed and filling of records, storage.
ME C1.4 The facility has adequate circulation area 2 OB
and open spaces according to need and Availability of adequate
local law circulation area for easy
moment of staff , goods and
food trolley in dietary
department
2 OB
Availability of adequate
circulation area for easy
moment of staff, equipments
and carts in laundry
Availability of adequate 2 OB
circulation area in MRD
ME C1.5 The facility has infrastructure for All support services department 2 OB
intramural and extramural are connected with intercom
communication
ME C1.6 Service counters are available as per Unidirectional flow of goods and 2 OB
patient load services in dietary services
Unidirectional flow of goods and 2 OB
services in laundry services
8 8
ME C2.1 The facility ensures the seismic safety of Non structural components are 2 OB Check for fixtures and furniture like
the infrastructure properly secured cupboards, cabinets, and heavy equipments ,
hanging objects are properly fastened and
secured

establishment Support services departments
does not have temporary
connections and loosely hanging
wires
2 OB
Equipments in wet areas like
Laundry and Kitchen are
equipped with ground fault
protection and designed for wet
conditions
ME C2.4 Physical condition of buildings are safe Floors of the Support services 2 OB
for providing patient care are non slippery and even
12 12
Page 243

nce t Method
ME C3.1 The facility has plan for prevention of Building has sufficient fire exit OB/SI
fire dietary department laundry and Medical
to permit safe escape to its record department
occupant at time of fire 2
Check the fire exits are clearly OB
visible and routes to reach exit dietary department laundry and Medical
record department
are clearly marked. 2
OB
Dietary Department has plan for
safe storage and handling of Dietary Department
potentially flammable materials.
2
ME C3.2 The facility has adequate fire fighting OB/RR
Support services has installed
Equipment fire Extinguisher that is Class A , dietary department and Medical record
Class B C type or ABC type are
installed in adeqaute number at department
every strategic points
2
OB/RR
dietary department and Medical record
date for next refilling is clearly department
mentioned
2
situation
10 10
ME C4.4 The facility has adequate Availability of Dietician 2 SI/RR
requirement
Availability of MRD technician 2 SI/RR
ME C4.5 The facility has adequate support / Availability of washer man 2 SI/RR
general staff
Availability of Cook 2 SI/RR
Availability of Data Entry 2 SI/RR
operator for MRD
4 4
ME C5.2 The departments have adequate Availability of consumables at Cap, gowns, gloves, Detergent for cleaning of
consumables at point of use dietary department 2 OB/RR utensil and Soap for hand washing
Availability of consumables at Detergent and disinfectant, Heavy utility
laundry department 2 OB/RR gloves, apron.
16 16
ME C6.5 Availability of Equipment for Storage Availability of equipment for 2 OB Refrigerator
storage for drugs
ME C6.6 Availability of functional equipment and Availability of Equipments & OB Refrigerator, LPG, food trolley and cooking
instruments for support services utensils for Dietary department 2 utensils
Availability of Equipments for OB Washing machine, drier, Iron, Separate trolley
Laundry 2 for clean and dirty linen
Availability of Equipments for OB
Medical record department
2 Computer with scanner
Availability of equipments for OB Buckets for mopping, mops, duster, waste
cleaning 2 trolley, Deck brush
ME C6.7 Departments have patient furniture and OB
Availability of furniture and Exhaust fan, Storage containers, Work
fixtures for Dietary department 2 bench/slab, Utensil stand
Availability of furniture and OB Stand/ Hanger for drying of linen, Iron table,
fixtures for laundry department 2 Cupboard
OB
Availability of furniture and
fixtures for Medical record Racks and cupboard, table, Sectional Drawer
department 2 cabinet/ Shelves,
ME C7.9 The Staff is provided training as per defined Bio Medical waste Management 2 SI/RR
core competencies and training plan
Infection Control Management 2 SI/RR
Training on Medical record 2 SI/RR
Management
ME C7.10 MRD Staff is skilled for indexing 2 SI/RR
and storage of Medical records Check supervisors make periodic rounds of
department and monitor that staff is working
There is established procedure for utilization according to the training imparted. Also staff
of skills gained thought trainings by on -job is provided on job training wherever there is
supportive supervision still gaps
Laundry staff is skilled for 2 SI/RR
segregating and processing of Check supervisors make periodic rounds of
soiled and infectious linen department and monitor that staff is working
according to the training imparted. Also staff
is provided on job training wherever there is
still gaps
6 6
ME D1.1 The facility has established system for All equipments are covered 2 SI/RR
maintenance of critical Equipment under AMC including preventive
maintenance
2 SI/RR
ME D1.3 Operating and maintenance instructions 2 OB/SI
are available with the users of Up to date instructions for
equipment operation and maintenance of
with staff.
20 20
ME D3.1 The facility provides adequate
Adequate Illumination at Kitchen 2 OB
Laundry 2 OB
Medical record department 2 OB
Page 244

nce t Method
ME D3.2 The facility has provision of restriction of Hospital ensures unauthorised

visitors in patient areas entry into dietary department is
not permitted 2 OB/SI
Hospital ensures unauthorised
entry into Laundry department
is not permitted 2 OB/SI
Hospital ensures unauthorised
entry into Medical record
department is not permitted 2 OB/SI
comfortable environment for patients ventilation in dietary conditioning/Heating/Exhaust/Ventilators as
and service providers department per environment condition and requirement
SI/RR
ventilation in Laundry conditioning/Heating/Exhaust/Ventilators as
per environment condition and requirement
SI/RR
ventilation in Medical record conditioning/Heating/Exhaust/Ventilators as
Department per environment condition and requirement
SI/RR
22 22
ME D4.1 Exterior of the facility building is
maintained appropriately Building is painted/whitewashed Dietary department, laundry and medical
in uniform colour 2 OB record department
Interior of patient care areas are
plastered & painted 2 OB
ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof topes,
sinks patient care and circulation All area are clean with no dirt,grease,littering
areas are Clean 2 OB and cobwebs
Surface of furniture and fixtures
are clean 2 OB
Toilets are clean with functional
flush and running water 2 OB
ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , Dietary department, laundry and medical
maintained Cracks, chipping of plaster 2 OB record department
Window panes , doors and other Dietary department, laundry and medical
fixtures are intact 2 OB record department
ME D4.5 The facility has policy of removal of No condemned/Junk material in Dietary department, laundry and medical
condemned junk material the Diet department 2 OB record department
the Laundry 2 OB
the MRD 2 OB
ME D4.6 The facility has established procedures
No stray Dietary department, laundry and medical
animal/rodent/birds/pests 2 OB record department
4 4
ME D5.1 The facility has adequate arrangement Availability of 24x7 running and OB/SI
2 Dietary and laundry department
ME D5.2 The facility ensures adequate power OB/SI For Laundry, Diet and MRD department
load
Availability of power back up 2
28 28
ME D6.2 The facility provides diets according to Hospital has defined diet 2 RR/SI
nutritional requirements of the patients schedule for the patients.
Hospital has Special diet 2 RR/SI

schedule for the critical ill
patients suffering from Heart
Disease, Hypertension,
Diabetes, Pregnant Women,
diarrhoea and renal patients
ME D6.3 Hospital has standard procedures for 2 RR/SI

distribution of diets, as per requirement of Dietary department has system
patients to calculate the number of diets
to be prepared
2 OB/SI/RR
Dietary department has
procedure for procurement of
perishable and non perishable Time interval for procurement of Perishable
items and non perishable items is fixed
Perishable items are stored in 2 OB Like milk, cheese, butter, egg, vegetables, and
the cold room or refrigerators. fruits
2 OB
Non perishable items are kept in
racks/ storage container, in
ventilated and rodent proof All the food items are stored above floor
room level.
2 OB/SI
Food is prepared by trained
staff, ensuring standards
practices
There is a procedure for the 2 SI/RR
distribution of the diet Ensure diet is supplied at defined duration.
Distribution of the food is done 2 OB
in covered food trolleys
2 RR/SI
Dietary department has system
to check the quality of food There is designated person preferably nurse
provided to patient in Ward to check the Quality of food
2 OB/SI
Dietary department has
procedure to collect and dispose
of kitchen garbage at defined
interval and place
There is practice of calculating 2 SI/RR
and maintaining buffer stock in
Kitchen
Department maintained stock 2 RR/SI
and expenditure register in
Kitchen
There is system to replenish raw 2 RR/SI
food material
Page 245

nce t Method
28 28
ME D7.1 The facility has adequate sets of linen 2 RR/SI at least 5 sets for each functional bed
Hospital has sufficient set of
linen available per bed
Hospital/ department has
inventory of total linen available 2 RR/SI
with category wise distribution
in every area Patient, staff and bed linen
ME D7.3 The facility has standard procedures for 2 RR/SI
handling , collection, transportation and Linen department has system for
washing of linen Periodic physical verification of
linen inventory To check the theft and pilferage
2 OB
Linen department has separate
trolley for distribution of clean
linen and collection of dirty linen
2 OB
Linen are transported into
closed leak proof containers
/bags
2 OB/RR
Infectious and non infectious
linen are transported into
separate containers / bags
2 OB/RR
Linen department has system of
sorting of different category of
linen before putting in to
washing machine Soiled, infected fouled type of linen
2 OB/RR
Linen department has procedure
for sluicing of soiled, infected
and fouled linen
2 RR
Linen department has procedure
to keep record of daily load
received from each department
2 RR/SI
Hospital has system/ designated
person to check quality of
washed linen
There is a fix time for collection 2 RR/SI
for dirty linen and supply of
clean linen
There is a system for verifying 2 RR/SI
the quantity of linen received
There is procedure for 2 RR/SI
condemnation of linen
There is system to check 2 RR/SI Security guards keep vigil
pilferage of linen from ward
12 12
Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
ME D11.2 The facility has a established procedure There is procedure to ensure 2 RR/SI Check for system for recording time of
for duty roster and deputation to that staff is available on duty as reporting and relieving (Attendance register/
different departments per duty roster Biometrics etc)
There is designated in charge 2 RR/SI

for Laundry department
for Dietary department
for MRD department
Staff is adhere to their
2 2
ME D12.1 2 SI/RR Verification of outsourced services (cleaning/
Dietary/Laundry/Security/Maintenance)
There is procedure to monitor provided are done by designated in-house
the quality and adequacy of staff
28 28
ME E8.6 Register/records are maintained as per All register/records are 2 RR
guidelines identified and numbered
Diet Registers are maintained at 2 RR
Kitchen
Laundry registers are maintained 2 RR
at laundry
ME E8.7 The facility ensures safe and adequate 2 RR
storage and retrieval of medical records Hospital has procedure for
collection, Compilation and
maintenance of patient's records
after discharge
2 RR
Medical record department has
system to check for completion Checking the records as per checklist for
of records completion
2 RR
Medical record department has As per ICD coding / indexing name, disease,
system for ICD coding /indexing diagnosis, physician and surgical procedure
the records carried out
2 RR
Medical record department has Submitting the reports to required health
system to generate statistics for authorities (Birth death notification,
clinical use notification of communicable diseases etc)
2 RR
system to generate statistics for
administrative use Hospital information system
2 RR
system for filling and safe
storage of records
2 RR
procedure for
retention/Preservation of
records Retention is as per state guideline
2 RR
procedure for destruction of old
records
Page 246

nce t Method
2 RR/SI
Medical records department has
system for retrieval of records
2 RR/SI
procedure for production of
records in Courts of law when
summoned In case of MLC
Medical records are issued to 2 RR/SI
authorized personnel only To patient/next kin to patient
4 4
plan in place
6 6
ME F1.4 Checkups and immunization of staff immunization of the staff 2 SI/RR Hepatitis B, Tetanus Toxid etc
staff 2 SI/RR
Facility has established procedures for Hand washing and infection control audits
regular monitoring of infection control done at periodic intervals
practices Regular monitoring of infection
12 12
Hand washing facilities are provided at Availability of hand washing
ME F2.1 point of use Facility in kitchen 2 OB Preferably in preparation and cooking area
Availability of Running Water Ask to Open the tap. Ask Staff water supply is
(Hot and cold) 2 OB/SI regular
Availability of soap with soap
dish/ liquid antiseptic with
dispenser Check for availability/ Ask staff if the supply is
2 OB/SI adequate and uninterrupted
Instruction at Point of Use
Prominently displayed above the hand
2 OB washing facility , preferably in Local language
Staff is trained and adhere to standard Adherence to 6 steps of Hand
ME F2.2 hand washing practices washing 2 OB Ask of demonstration
wash 2 SI
12 12
requirements Clean gloves are available for
ME F3.1 distribution of food 2 OB/SI
Availability of apron 2 OB/SI
Availability of caps 2 OB/SI
Availability of Heavy duty gloves
for laundry 2 OB/SI
Availability of gum boats for
laundry 2 OB/SI
Staff is adhere to standard personal No reuse of disposable gloves,
ME F3.2 protection practices caps and aprons. 2 OB/SI
10 10
Facility ensures standard practices and Cleaning and decontamination
materials for decontamination and clean ing of food preparation surfaces like
of instruments and procedures areas cutting board Ask the cleanliness and ask staff how
ME F4.1 2 SI/OB frequent they clean it
Cleaning of utensils and food Check the cleanliness and how frequent they
trolleys 2 SI/OB clean it
Decontamination of heavily
soiled linen 2 SI/OB
Cleaning of washing equipments 2 SI/OB
Facility ensures standard practices and
materials for disinfection and sterilization of Proper cleaning of items used
instruments and equipments for preparation and cooking of
ME F4.2 food 2 SI/OB
22 22
Layout of the department is conducive for
the infection control practices Facility layout ensures
ME F5.1 and dirty items in kitchen 2 OB
and dirty items in laundry 2 OB
Facility ensures availability of standard Staff is trained for spill
materials for cleaning and disinfection of management
patient care areas
ME F5.2 2 SI/RR
Staff is trained for preparing 2
procedure
SI/RR
and scrubbing are followed 2 OB/SI Unidirectional mopping from inside out
are not used in patient care
areas Any cleaning equipment leading to dispersion
2 OB/SI of dust particles in air should be avoided
Facility ensures standard practices followed
for cleaning and disinfection of patient care
areas Surface & fixtures are visibly
ME F5.3 clean with no dust or debris 2 OB
Staff is trained for spill
management 2 SI/RR
Floors are clean 2 OB
No stray animals in the facility/
Patient Care areas 2 OB
18 18
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
Facility Ensures segregation of Bio Availability of colour coded bins Adequate number. Covered. Foot operated.
ME F6.1 Medical Waste as per guidelines at point of waste generation 2 OB
Page 247

nce t Method

of waste as per guidelines
2 OB/SI
Biomedical waste
2 OB
and general waste 2 OB
Facility ensures management of sharps Availability of post exposure Ask if available. Where it is stored and who is
ME F6.2 as per guidelines prophylaxis 2 OB/SI in charge of that.
Staff knows what to do in
condition of needle stick injury Staff knows what to do in case of shape
injury. Whom to report. See if any reporting
2 SI has been done
Facility ensures transportation and Disinfection of liquid waste
ME F6.3 disposal of waste as per guidelines before disposal 2 SI/OB
Daily disposal of food waste with
general waste 2 SI/OB
2 2
4 4
ME G2.1 Patient Satisfaction surveys are Hospital has system to take feed 2 RR
conducted at periodic intervals back regarding quality of diet
Hospital has system to take feed 2 RR

back regarding cleanliness of
linen provided
6 6
ME G3.1 Facility has established internal quality 2 SI/RR
assurance program at relevant
departments There is system daily round by
matron/hospital manager/
charge for monitoring of services
ME G3.2 Facility has established external Kitchen is has system of regular 2 SI/RR
assurance programs at relevant external inspection by
departments Municipal/ FDA authorities
ME G3.3 Facility has established system for use of Departmental checklist are 2 SI/RR Staff is designated for filling and
check lists in different departments and used for monitoring and monitoring of these checklists
services quality assurance
72 72
Standard G4
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support
services.
procedures are available for Dietary department has been
Standard operating procedure 2 RR
for Laundry Department has
been prepared and approved
Standard operating procedure 2 RR
for Medical record Department
has been prepared and
approved

ME G4.2 Standard Operating Procedures RR
adequately describes process and Record Department has
procedures documented procedure for
indexing of the records 2
RR
Record Department has
documented procedure for
receiving, compiling, and
maintaining records 2
RR
issuing of the records 2
RR
retention of records 2
RR
Record department has
documented procedure for pest
and rodent control 2
RR
Diet department has
documented procedure for diet
schedule 2
RR
Diet department has
calculation of diet required in
wards 2
RR
Diet department has
procurement of food items 2
RR
Diet department has
preparation and distribution of
food 2
RR
Diet department has
documented procedure to check
the quality of food provided to
the patient 2
RR
Diet department has
disposal of remaining food 2
RR
Diet department has
cleaning of kitchen and utensils 2
Page 248

nce t Method
RR
Diet department has
checkups of kitchen workers at
defined intervals 2
RR
Linen department has
collection, sorting and cleaning
of linen 2
RR
sluicing of the blood/ body fluid
stained linen 2
RR
distribution of linen in all patient
care area 2
RR
physical verification of the linen
for cleanliness or torn out 2
RR
condemnation of linen 2
RR
documented procedure
corrective and preventive
maintenance of laundry
equipments 2
RR
Security department has
documented procedure for duty
hours 2
RR
control of incoming and
outgoing items 2
RR
visiting hours in patient care
area 2
RR
documented procedure for fire
safety in hospital 2
RR
electrical safety 2
RR
training and drills of security
staff 2
ME G4.3 Staff is trained and aware of the Check staff is a aware of relevant SI/RR
standard procedures written in SOPs part of SOPs 2
ME G4.4 Work instructions are displayed at Point Work instruction/clinical OB
of use protocols are displayed in
Dietary Department 2
OB
protocols are displayed in
Laundry Department 2
OB
protocols are displayed in
Medical Record Department 2
Work instructions are displayed OB
for hospital cleaniness 2
6 6
processes done
identified
12 12
ME G6.1 The facility conducts periodic internal Internal assessment is done at RR/SI Dietary department, laundry and medical
assessment periodic interval 2 record department
ME G6.2 The facility conducts the periodic Storage and compilation of RR/SI
prescription/ medical/death audits records medical audit 2
Storage and compilation of RR/SI
records death audit 2
ME G6.3 The facility ensures non compliances are Non Compliance are 2 RR/SI
enumerated and recorded adequately enumerated and recorded
ME G6.4 Action plan is made on the gaps found in RR/SI

Action plan prepared 2
ME G6.5 Corrective and preventive actions are RR/SI
assessment & audit Corrective and preventive
action taken 2
6 6
ME G7.4 2 SI/RR
Check short term valid quality objectivities

have been framed addressing key quality
issues in each department and cores services.
Check if these objectives are Specific,
Facility has de defined quality objectives to Check if SMART Quality Measurable, Attainable, Relevant and Time
achieve mission and quality policy Objectives have framed Bound.
Page 249

nce t Method
ME G7.5 2 SI/RR
Interview with staff for their awareness.

Mission, Values, Quality policy and Check of staff is aware of Check if Mission Statement, Core Values and
objectives are effectively communicated to Mission , Values, Quality Policy Quality Policy is displayed prominently in local
staff and users of services and objectives language at Key Points
ME G7.7 2 SI/RR
Review the records that action plan on quality

objectives being reviewed at least onnce in
month by departmnetal incharges and during
Facility periodically reviews the progress of Check time bound action plan is the qulaity team meeting. The progress on
strategic plan towards mission, policy and being reviewed at regular time quality objectives have been recorded in
objectives interval Action Plan tracking sheet
6 6
method
ME G8.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used in each
improvement in services department
ME G10.6 2 SI/RR
Check periodic assessment of Verify with the records. A comprehensive risk
Periodic assessment for Medication and medication and patient care asesement of all clincial processes should be
Patient care safety risks is done as per safety risk is done using defined done using pre define critera at least once in
defined criteria. checklist periodically three month.
8 8
ME H1.1 Facility measures productivity Indicators on No of cases for which medical
monthly basis audit done 2 RR
No of cases for which death
audit is done 2 RR
No. of bed sheet washed in a month/Patient
Linen Index 2 RR bed days in month
No. of meals provided in the month/no. of
Diet Index 2 RR times meal served in a day * bed days
8 8
ME H2.1 Facility measures efficiency Indicators on Proportion of maternal deaths
monthly basis audited 2 RR
Proportion of newborn deaths
audited 2 RR
Time elapsed between collection of used
Cycle for laundry services 2 RR linen and receiving clean linen
No. of special diets (diabetic, hypertensive,

semi solid or other diet) in the
month*100/tital no. of diets provided in the
Proportion of special diets 2 RR month
4 4
ME H3.1 Facility measures Clinical Care & Safety
Indicators on monthly basis Medical Audit Score 2 RR
Death Audit Score 2 RR
8 8
ME H4.1 Facility measures Service Quality Indicators Waiting time for getting
on monthly basis handicap certificate 2 RR
Waiting time for getting death
certificate 2 RR
Patient feedback on cleanliness
of linen 2 RR
Patient feedback on quality of
food 2 RR

A 14 14 100%
B 16 16 100%
C 84 84 100%
D 122 122 100%
E 32 32 100%
F 80 80 100%
G 114 114 100%
H 28 28 100%
Total 490 490 100%
0
1
2
Page 250
Checklist - 17 Mortuary Version-NHSRC/3.0

Checklist for Mortuary 18
Assessment Summary
Type of Assessment (Internal/External) Action plan

Submission Date
Mortuary Score Card

Area of Concern wise Score Mortuary Score
C Inputs 100%
D
E
Support Services
Clinical Services
Infection Control
100%
100% 100%
F 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for Mortuary

Reference No. ME Statement Checkpoints Compliance Assessmen Audit Support Remark
t method

ME A1.14 Services are available for the time period as
mandated
Availability of services 24X7 2 SI/RR
Standard A5 The facility provides support services 8 8
ME A5.8 The facility provides mortuary services
Dead bodies are kept till the

relatives take over the bodies 2 SI/RR
Dead bodies are brought to
hospital for medico legal post
mortem work 2 SI/RR
Unclaimed bodies are kept until
disposal is arranged 2 SI/RR
Facility for pathological post
mortem 2 SI/RR
ME B1.1 The facility has uniform and user-friendly Availability of departmental
signage system signage 2 OB
Restricted area signage are
displayed 2 OB
ME B1.6 Information is available in local language and Signage's are available in local
easy to understand language and pictorial 2 OB
ME B1.8
The facility ensures access to clinical records Post mortem records of deceased
of patients to entitled personnel are issued to police/next kin of
deceased as per state guideline 2 OB
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of physical
4 4
economic, cultural or social reasons
ME B2.2
Religious and cultural preferences of patients Religious and cultural preferences
and attendants are taken into consideration of deceased and relatives are
while delivering services taken in to consideration while
handling over the body 2 OB/SI
ME B2.3 Access to facility is provided without any Availability of ramp/level ground
physical barrier & and friendly to people with for easy access of stretcher to
mortuary/ post mortem room
disabilities 2 OB
ME B3.1
Adequate visual privacy is provided at every There are arrangements that

point of care Post mortem room is not in direct Provision of curtain, screen or
line of sight of general public/ buffer area or any other in post
visitors 2 OB mortem room
ME B3.2 Confidentiality of patients records and Confidentiality of PM records are
clinical information is maintained maintained for all MLC cases 2 RR/SI
ME B3.3 The facility ensures the behaviours of staff is Behaviour of staff is empathetic
dignified and respectful, while delivering the and courteous to deceased
services 2 PI/OB
relative
ME B3.4 The facility ensures privacy and Privacy and confidentiality of HIV
confidentiality to every patient, especially of and suicidal cases
those conditions having social stigma, and
also safeguards vulnerable groups 2 RR/SI
Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and involving them in treatment
planning, and facilitates informed decision making 2 2
ME B4.5 The facility has defined and established
grievance redressed system in place Availability of complaint box and
redressed and whom to contact is
displayed 2 OB
ME C1.1 Departments have adequate space as per
patient or work load
Adequate space to accommodate
Post mortem and dead bodies
load 2 OB
2 OB
ME C1.2 Patient amenities are provide as per patient
load
area
Availability of seating 2 OB
arrangement 2 OB
Availability of Drinking water 2 OB
Availability of functional toilets 2
ME C1.3 Departments have layout and demarcated
areas as per functions
Waiting area has space of 17.5
Mortuary has reception and sq m along with toilet and
waiting area as per requirement 2 OB drinking water facility
Cold room has area of 14 sq m

Mortuary has cold room for body and 6 cabinets for 101-300
preservation of bodies as per beds and 8 cabinets for 301-
requirement 2 OB 500 beds
Post mortem room has area of

Mortuary has post mortem room 17.5 sq m for 101-300 beds
as per requirement 2 OB and 21 sq m for 301-500 beds
Ancillary area consist of

Mortuary and post mortem has Consultant room, mortuary
Ancillary area as per requirement 2 OB supervisor room and stores
Cold room should lead to

Cold room and autopsy room are entrance area into autopsy
interconnected 2 OB room
As protection in wet weather

Access way connected from and as screen from adjoining
hospital to mortuary is covered 2 OB area
ME C1.4 The facility has adequate circulation area and Corridors of Mortuary area are
open spaces according to need and local law wide enough to allow passage of
trolleys 2 OB Not less than 8 ft
ME C1.5 The facility has infrastructure for intramural Availability of telephone and
and extramural communication Intercom Services 2 OB
ME C1.6 Service counters are available as per patient Availability of deep freezer for
load storage as per load 2 OB
ME C1.7 The facility and departments are planned to
ensure structure follows the Mortuary has functional linkage
function/processes (Structure commensurate with hospital Emergency, OT and
with the function of the hospital) IPD etc. 2 OB
ME C2.1 The facility ensures the seismic safety of the Non structural components are OB Check for fixtures and furniture
infrastructure properly secured like cupboards, cabinets, and
objects are properly fastened
and secured
2
ME C2.3 The facility ensures safety of electrical Mortuary building does not have
establishment temporary connections and
2 OB
ME C2.4 Physical condition of buildings are safe for Floors of the Mortuary are thick,
providing patient care durable and can be easily cleaned 2 OB
Window have wire meshwork and
intact window panes 2 OB
Floors of the Mortuary are non
slippery and even 2 OB
ME C3.2 The facility has adequate fire fighting Fire Extinguisher that is Class A , OB
Equipment Class C type or ABC type are
installed in mortuary
2
Check the expiry date for fire OB/RR
mentioned
2
ME C3.3 The facility has a system of periodic training Check for staff competencies for SI/RR
of staff and conducts mock drills regularly for operating fire extinguisher and
fire and other disaster situation what to do in case of fire
2
ME C4.1 The facility has adequate specialist doctors as Availability of specialist/MO to
per service provision conduct autopsy as per state
norms 2 OB/RR
ME C4.4 The facility has adequate Availability of post mortem
SI/RR
technicians/paramedics as per requirement technician/assistant as per state
guideline 2
ME C4.5 The facility has adequate support / general Availability of sweeper in SI/RR
staff Mortuary 2
Availability of security staff in SI/RR
mortuary 2
Thread, needle, cotton wool,

wool waste, clothes, malleable
wire, polythene bag, gloves,
Repairing Material 2 mask and apron
OB/RR
Plastic bins 2 for fixing specimens
ME C6.1 Availability of equipment & instruments for Availability of functional

examination & monitoring of patients Equipment &Instruments for
examination & Monitoring
Weighting Mechanise.
Platform scale Weighting
Whole body, Balance to weight
100gm to 10 Kg, Balance to
2 OB weight 0.2 gm to 10gm
ME C6.2 Availability of equipment & instruments for Availability of Cutting
treatment procedures, being undertaken in Instruments trays
the facility
Skull Cutter, Organ Knife blade,

cartilage Knife, Caltin solid, Rib
cutter, Brain knife, resection
knife, Scissor (of varying sizes),
2 OB forceps (of varying sizes)
ME C6.5 Availability of Equipment for Storage
Availability of Cabinets for storage Refrigerated body storage
of dead bodies 2 OB room, Instrument trolley
ME C6.6 Availability of functional equipment and Availability of equipments for Buckets for mopping, mops,
instruments for support services cleaning duster, waste trolley, Deck
brush
2 OB
Availability of equipment for Autoclave/ Boiler
ME C6.7 Departments have patient furniture and
fixtures as per load and service provision Availability of Post mortem table 2 OB
Availability of Fixtures Electrical fixture for storage
2 OB cabinet
cupboard, counter for delivery

of reports, table for
Availability of furniture 2 OB preparation of reports chair.
Standard C7
Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff 8 8
ME C7.9 SI/RR
The Staff is provided training as per defined core Infection control and hand
competencies and training plan hygiene 2
Bio Medical waste Management SI/RR
2 Check supervisors make

ME C7.10 Staff is skilled for preservation of SI/RR periodic rounds of department
dead bodies in the mortuary and monitor that staff is
working according to the
There is established procedure for utilization of training imparted. Also staff is
skills gained thought trainings by on -job provided on job training
supportive supervision 2 wherever
Check there is still
supervisors make gaps
Staff is skilled for maintaining post SI/RR periodic rounds of department
mortem records and monitor that staff is
working according to the
provided on job training
2 wherever there is still gaps
ME D1.1 The facility has established system for All equipments are covered under SI/RR
maintenance
2
SI/RR
maintenance of the equipments 2
ME D1.2 The facility has established procedure for All the monitoring equipments OB/ RR
internal and external calibration of are calibrated 2
measuring Equipment
ME D1.3 Operating and maintenance instructions are Operating instructions for critical OB/SI
available with the users of equipment equipments are available 2
ME D2.5 The facility has established procedure for Department maintained stock and RR/SI
inventory management techniques expenditure register 2
ME D2.7 There is process for storage of vaccines and Temperature of refrigerators are OB/RR
other drugs, requiring controlled kept as per storage requirement
temperature and records are maintained 2
Staff is aware of Hold over time of SI/RR
cold storage equipments 2
ME D3.1 The facility provides adequate illumination Adequate illumination at post
level at patient care areas mortem table 2 OB
Adequate illumination at morgue 2 OB
ME D3.2 The facility has provision of restriction of Hospital ensures unauthorised
visitors in patient areas entry into mortuary is not
permitted 2 OB/SI
ME D3.3 The facility ensures safe and comfortable Temperature control and OB/RR Fans/ Air
environment for patients and service ventilation in Mortuary conditioning/Heating/Exhaust/
providers Ventilators as per environment
2
ME D3.4 The facility has security system in place at Hospital has sound security
patient care areas system to manage overcrowding
in Mortuary
2 OB
ME D3.5 The facility has established measure for safety Ask female staff weather they feel
and security of female staff secure at work place 2 SI
ME D4.1 Exterior of the facility building is maintained Building is painted/whitewashed
appropriately in uniform colour 2 OB
Interior of patient care areas are
plastered & painted 2 OB
ME D4.2 Patient care areas are clean and hygienic
Floors, walls, roof, roof topes, All area are clean with no
sinks patient care and circulation dirt,grease,littering and
areas are Clean 2 OB cobwebs
Surface of furniture and fixtures
are clean 2 OB
Toilets are clean with functional
flush and running water 2 OB
ME D4.3 Hospital infrastructure is adequately Check for there is no seepage ,
maintained Cracks, chipping of plaster 2 OB
Window panes , doors and other
fixtures are intact 2 OB
Post-mortem table is intact and
with out rust 2 OB
ME D4.5 The facility has policy of removal of No condemned/Junk material
condemned junk material stored in the mortuary 2 OB
ME D4.6 The facility has established procedures for
pest, rodent and animal control No stray animal/rodent/birds 2 OB
ME D5.1 The facility has adequate arrangement Availability of 24x7 running and OB/SI
storage and supply for portable water in all potable water
functional areas
Availability of water in sinks,
washbasin and post mortem
table should be fitted with
2 water hose
ME D5.2 The facility ensures adequate power backup Availability of power back in OB/SI
in all patient care areas as per load mortuary 2
Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 8 8
ME D11.1 The facility has established job description as Staff is aware of their role and SI
per govt guidelines responsibilities
2
ME D11.2 The facility has a established procedure for There is procedure to ensure that RR/SI Check for system for recording
duty roster and deputation to different staff is available on duty as per time of reporting and relieving
departments duty roster (Attendance register/
Biometrics etc)
2
There is designated in charge for SI
department 2
ME D11.3 The facility ensures the adherence to dress Doctor and support staff adhere OB
code as mandated by its administration / the to their respective dress code 2
health department
ME D12.1 SI/RR Verification of outsourced
services (cleaning/
Dietary/Laundry/Security/Main
tenance) provided are done by
designated in-house staff
There is procedure to monitor

the quality and adequacy of
management for out sourced services basis 2
ME E8.7 The facility ensures safe and adequate Department has process for
storage and retrieval of medical records storage and retrieval of Medico-
legal record 2 RR/SI MLC case reports etc.
ME E11.3 The facility has disaster management plan in Staff is aware of disaster plan 2 SI/RR
place Role and responsibilities of staff in 2 SI/RR
Standard E16 The facilitydisaster is defined
has defined and established procedures for end of life care and death 28 28
ME E16.1 Death of admitted patient is adequately Facility has a standard
communicate death to
relatives
2 SI/RR
ME E16.3 The facility has standard procedures for Mortuary has system for SI/RR Main categorization in Non
conducting post-mortem, its recording and categorize the dead bodies before medico legal and medico legal
meeting its obligation under the law preservation. which is further divided into
Identified and Unknown
Check Mortuary register which

contain details: Identification
number, Name, Sex, age of
deceased, date and time of
death, identification mark of
deceased and finger
impression, details of near
relative, weather autopsy is
done or not, if done then date
and time of autopsy, name of
autopsy surgeon, date and time
when body is placed in cold
storage, length of body and
breadth across should, list of
valuables which have been
removed from body, signature
of technician, date and time of
Mortuary technician to maintain when body is removed & Name
full records of body brought to of relative/police collecting
mortuary 2 body.
Identification tag should be of

plastic water proof type and
carry information on full
name,address,age,sex,
Mortuary has system to provide registration number, date and
identification tag/wrist band for time of death and when body
each stored dead body 2 RR/OB kept for storage
Mortuary has system for
preparation of body before cold
storage 2 RR/SI
Check identification ticket is

Each cold storage door has holder available on storage cabin
for identification ticket 2 RR/OB containing dead body
Name of deceased is written on

board on wall of the room which
list each cold storage
compartment 2 RR/OB
Temperature should not be

allowed to fall below 0oC for
short duration preservation
while to preserve the body for
long time it must be deep
Cold storage room has system to frozen so -20oC temp must be
maintain temperature of cabinets 2 RR/OB/SI kept for one compartment
Hospital has system to intimate
mortuary staff before sending
body to mortuary 2 SI/RR
All bodies sent to mortuary is
accompanied with copy of death
certificate issued by hospital 2 SI/RR
Death Certificate and label is
marked MLC in bold if medico Check death certificate /dead
legal cases 2 RR/OB body.
The upper part of the body is

Mortuary/Hospital has standard taken out of mortuary cold
label fixed to winding cloth over storage room i.e. head for
upper part of body 2 RR/OB identification
Mortuary has system for storage
of unclaimed body for fixed
duration as per state guideline 2 SI/RR
Mortuary has system for disposal
of unclaimed bodies as per state
guideline 2 SI/RR
There is Provision of Periodic Medical Check- There is procedure for
ME F1.4 up and immunization of staff immunization of the staff 2 SI/RR Hepatitis B, Tetanus Toxic etc
staff 2 SI/RR
The facility has established procedures for Hand washing and infection
regular monitoring of infection control control audits done at periodic
practices intervals
Hand washing facilities are provided at point Availability of hand washing
of use Facility at Point of Use
Check for availability of wash
ME F2.1 2 OB basin near the point of use
Ask to Open the tap. Ask Staff

dispenser.
Check for availability/ Ask staff
if the supply is adequate and
Availability of Alcohol based Hand
rub
Check for availability/ Ask staff
2 OB/SI for regular supply.
Instruction at Point of Use
Prominently displayed above

the hand washing facility ,
2 OB preferably in Local language
The facility staff is trained in hand washing Adherence to 6 steps of Hand
ME F2.2 practices and they adhere to standard hand washing 2 SI/OB Ask of demonstration
washing practices
The facility ensures adequate personal Clean gloves are available at point
protection Equipment as per requirements of use
ME F3.1 2 OB/SI
The facility staff adheres to standard No reuse of disposable gloves,
Staff knows when to wear clean &
Sterile gloves 2 OB/SI
The facility ensures standard practices and Decontamination of mortuary
materials for decontamination and cleaning of table
instruments and procedures areas
ME F4.1 2 SI/OB
Decontamination of instrument
after use 2 SI/OB
is adequate 2 SI/OB
solution 2 SI/OB
Sterilization of mortuary
equipment 2 SI/OB
The facility ensures standard practices and High level disinfection by boiling
materials for disinfection and sterilization of or chemical done as per protocol
instruments and equipment at mortuary
ME F4.2 2 SI/OB
Layout of the department is conducive for the Facility layout ensures separation
infection control practices of general traffic from patient
traffic
ME F5.1 2 OB
materials for cleaning and disinfection of patient requirement
care areas Chlorine solution,
ME F5.2 2 OB/SI Gluteraldehye, carbolic acid
The facility ensures standard practices are Staff is trained for spill
followed for the cleaning and disinfection of management
patient care areas
ME F5.3 2 SI/RR
procedure
2 SI/RR
are not used in patient care areas Any cleaning equipment
leading to dispersion of dust
particles in air should be
2 OB/SI avoided
Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste. 30 30
The facility Ensures segregation of Bio Availability of colour coded bins Adequate number. Covered.
Medical Waste as per guidelines and 'on-site' at point of waste generation Foot operated.
management of waste is carried out as per
guidelines
ME F6.1 2 OB
Human Anatomical waste,

Items contaminated with
blood, body fluids,dressings,
plaster casts, cotton swabs and
bags containing residual or

Segregation of infected plastic vaccutainers with their needles
waste in red bin 2 OB cut) and gloves
Biomedical waste
2 OB
and general waste 2
The facility ensures management of sharps as Availability of functional needle OB See if it has been used or just
ME F6.2 per guidelines cutters 2 lying idle.
Leak proof, tamper proof needles from needle tip cutter
containers or burner, scalpels, blades, or
any other contaminated sharp
object that may cause puncture
and cuts. This includes both
used, discarded and
Availability of post exposure 2 SI/OB Ask if available. Where it is

prophylaxis stored and who is in charge of
that.
Staff knows what to do in 2 SI Staff knows what to do in case
condition of needle stick injury of shape injury. Whom to
report. See if any reporting has
been done

OB
ME F6.3 disposal of waste as per guidelines 2 SI/OB
container/trolley
2
management 2 SI/RR
Standard G1 The facility has established organizational framework for quality improvement 2 2
ME G1.1 The facility has a quality team in place There is a designated SI/RR
activities
2
ME G3.1 The facility has established internal quality There is system daily round by SI/RR
assurance programme in key departments Hospital superintendent/
services
2
ME G3.3 The facility has established system for use of Departmental checklist are SI/RR
check lists in different departments and used for monitoring and
services quality assurance
2
Staff is designated for filling SI
and monitoring of these
checklists
2
Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support
services.
32 32
ME G4.1 Departmental standard operating procedures Standard operating procedure for RR
are available department has been prepared
and approved
2
Current version of SOP are OB/RR
2
ME G4.2 Standard Operating Procedures adequately RR

describes process and procedures
procedure for death in ward and
emergency 2
RR
procedure for receiving the body
in mortuary 2
RR
procedure for storage of the
body in mortuary 2
RR
procedure for temperature
maintenance in cold store 2
RR

procedure for corrective and
preventive maintenance of cold
stores 2
RR
procedure for tagging of the
dead bodies 2
RR
records 2
RR
procedure sending the bodies for
autopsy 2
RR
procedure for hand over the body
to deceased relatives 2
RR

procedure for issuing the records
to police and patient relatives 2
RR

procedure for storage and send
the viscera/tissue for further
investigation 2
RR

procedure for cleaning and
upkeep of mortuary and post
mortem room 2
ME G4.3 Staff is trained and aware of the procedures Check staff is a aware of relevant SI/RR
written in SOPs part of SOPs 2
ME G4.4 Work instructions are displayed at Point of OB
Work Instruction for Dead body
use storage, receiving and issue of
Work instructions are displayed 2 dead body
Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages 6 6
ME G5.1 The facility maps its critical processes Process mapping of critical SI/RR
processes done 2
ME G5.2 The facility identifies non value adding Non value adding activities are SI/RR
activities / waste / redundant activities identified 2
ME G5.3 The facility takes corrective action to Processes are rearranged as per SI/RR
improve the processes requirement 2
Standard G6 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 8 8
ME G6.1 The facility conducts periodic internal Internal assessment is done at RR/SI
assessment periodic interval 2
ME G6.3 The facility ensures non compliances are Non Compliance are enumerated RR/SI
enumerated and recorded adequately and recorded 2
ME G6.4 Action plan is made on the gaps found in the RR/SI
assessment / audit process Action Plan is prepared 2
ME G6.5 Corrective and preventive actions are taken RR/SI
to address issues, observed in the Check short term valid quality
taken 2 objectivities have been framed
Standard G7 The facility has defined mission, values, Quality policy & objectives & prepared
eachadepartment
strategic and plancores
to achieve them 4 4
ME G7.4 2 SI/RR services. Check if these
Facility has de defined quality objectives to Check if SMART Quality Interview with
Measurable, staff for their
Attainable,
achieve mission and quality policy Objectives have framed awareness.
Relevant and Check
TimeifBound.
Mission
ME G7.5 2 SI/RR Statement, Core Values and
Mission, Values, Quality policy and objectives are Check of staff is aware of Quality Policy is displayed
effectively communicated to staff and users of Mission , Values, Quality Policy prominently in local language
services and objectives at Key Points
ME G8.1 The facility uses method for quality Basic quality improvement 2 SI/OB PDCA & 5S
Standards G10
Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan 2 2
ME G10.6 2 SI/RR

Check periodic assessment of comprehensive risk asesement
medication and patient care of all clincial processes should
Periodic assessment for Medication and Patient safety risk is done using defined be done using pre define critera
care safety risks is done as per defined criteria. checklist periodically at least once in three month.
Area of Concern - H Outcomes 12 12
ME H1.1 Facility measures productivity Indicators on
monthly basis Proportion of non MLC cases 2 RR
Occupancy rate of cold storage
for dead bodies 2 RR
ME H2.1 Facility measures efficiency Indicators on Mean storage time for dead body
monthly basis in cold storage 2 RR
Down time Cold storage
equipments 2 RR
ME H4.1 Facility measures Service Quality Indicators on Waiting time for carrying out post
monthly basis mortem 2 RR
Waiting time for getting post
mortem report in MLC cases 2 RR

A 10 10 100%
B 22 22 100%
C 84 84 100%
D 60 60 100%
E 34 34 100%
F 88 88 100%
G 62 62 100%
H 12 12 100%
Total 372 372 100%
0
1
2
Checklist No. 18 General Administration Version- NHSRC/3.0

Checklist for Administration 19
Assessment Summary
Date of
Name of the Hospital Assessment
Names of Assessors Names of

Assessees
Action plan
Administration Score Card

Area of Concern wise Score Administration Score
C Inputs 100%
100%
E Clinical Services 100%
H Outcome 100%
Major Gaps Observed
5
5
5
Date
Checklist for General Administration

Reference No. ME Statement Checkpoint Compliance Assessment Means of Verification Remarks
Method
Page 261
8 8
ME A1.16. The facility provides Accident & Availability of functional A& E 2 SI/OB
Emergency Services department
Availability of functional disaster 2 SI/OB
management unit
ME A1.17. The facility provides Intensive care Availability of functional 2 SI/OB
Services Intensive care unit
ME A1.18. The facility provides Blood bank & Availability of functional Blood 2 SI/OB
transfusion services Bank
10 10
ME A 2.1. The facility provides Reproductive health Availability of Post Partum unit 2 SI/OB
Services at the facility
ME A2.3. The facility provides Newborn health Availability of functional SNCU 2 SI/OB
Services
ME A2.4. The facility provides Child health Availability of Functional NRC 2 SI/OB
Services
Availability of dedicated 2 SI/OB

paediatric ward
Availability District Early 2 SI/OB
Intervention Centre (DEIC)
10 10
ME A3.1. The facility provides Radiology Services Availability of X-Ray Unit 2 SI/OB Availability of in-house
services. Partial
Compliance if it is
outsourced
. Availability of Ultrasound 2 SI/OB Availability of in-house

services services. Partial
Compliance if it is
outsourced
. Availability of CT scan 2 SI/OB

ME A3.2 The facility Provides Laboratory Services Availability of In-house lab 2 SI/OB If lab is outsourced than
give partial compliance
ME A 3.3 The facility provides other diagnostic Availability of ECG Services 2 SI/OB
services, as mandated
16 16
ME A4.3 The facility provides services under Formation of District Apex 2 SI/RR Headed by Dermatologist/
National Leprosy Eradication Programme Group Physician along with
as per guidelines specialists of
Orthopaedics/ General
Surgery, Ophthalmology,
assisted by
Physiotherapist and
laboratory Technician
ME A4.4 The facility provides services under Availability Functional ICTC is 2 SI/OB
National AIDS Control Programme as per available
guidelines
Availability Functional ART 2 SI/OB
centre is available
ME A4.7. The facility provides services under Availability of geriatric 2 SI/OB
National Programme for the health care ward/Clinic
of the elderly as per guidelines
ME A4.8. The facility provides services under Availability of CCU 2 SI/OB
National Programme for Prevention and
control of Cancer, Diabetes,
Cardiovascular diseases & Stroke
(NPCDCS) as per guidelines
ME A4.9 The facility Provides services under 2 SI/RR

Integrated Disease Surveillance Hospital has System for
Programme as per Guidelines immediate reporting of any
disease out break authorities
2 SI/RR
A Nodal person is designated for
collecting and reporting data to
IDSP cell
2 SI/RR
Hospital disseminate the list of
conditions to be reported to all
clinical department
16 16
Standard A5 Facility provides support services
ME A5.1. The facility provides dietary services 2 SI/OB
Availability of dietary service
ME A5.2. The facility provides laundry services Availability of laundry services 2 SI/OB
ME A5.3. The facility provides security services Availability of security services 2 SI/OB
ME A5.4. The facility provides housekeeping Availability of Housekeeping 2 SI/OB
services services
ME A5.5. The facility ensures maintenance Availability of maintenance 2 SI/OB
services services
ME A5.6. The facility provides pharmacy services Availability of drug storage and 2 SI/OB
dispensing services
ME A5.7. The facility has services of medical Availability of Medical record 2 SI/OB
record department services
ME A5.8 The facility provides mortuary services 2 SI/OB
Availability of mortuary services
6 6
Standard A6 Health services provided at the facility are appropriate to community needs.
Page 262
ME A 6.1. The facility provides curatives & Availability of 300 indoor 2 SI/RR
preventive services for the health functional beds per ten lakh
problems and diseases, prevalent locally. population
ME A 6.2. There is process for consulting Community representative are 2 SI/RR

community/ or their representatives Consulted while revising or
when planning or revising scope of expanding the scope of service
services of the facility
User charges if any are decided 2 SI/RR

in consultation with user
groups /RKS

54 54
ME B1.1. 2 OB
The facility has uniform and user- Name of the facility prominently
friendly signage system displayed at front of hospital
building
. Hospital lay out with location 2 OB
and name of the
departments are displayed at
the entrance.
. Hospital has established 2 OB

directional signage
. List of departments are 2 OB
displayed
All signage are in uniform colour 2 OB
scheme
Signage's are user friendly and 2 OB
pictorial
ME B1.2 The facility displays the services and Services not available are 2 OB
entitlements available in its displayed
departments
Availability of administrative 2 OB
services like handicap certificate,
death certificate services are
displayed.
Processing time for issuing 2 OB

documents and Medical records
are displayed
Mandatory information under 2 OB
RTI is displayed
ME B1.3. The facility has established citizen Citizen charter is established in 2 OB
charter, which is followed at all levels the facility
. Citizen charter includes the 2 OB
service Available at the facility
Citizen Charter Includes the 2 OB
Timings of different services
available
Citizen Charter Includes Rights of 2 OB
Patients
Citizen Charter Includes 2 OB
Responsibilities of Patients and
Visitors
Citizen Charters Includes Beds 2 OB
available
Standards and Quality of
services Provided
Citizen Charters Includes 2 OB
Complaints and Grievances
Mechanism
Citizen Charter Includes Mention 2 OB
of Services available on payment
if any
Citizen Charter Includes about 2 OB
person and place avail
Information and assistance
Cycle time for Critical Processes
ME B1.4 Facility prepares a 2 OB
User charges are displayed and comprehensive list of user
communicated to patients effectively charges and display at strategic
point in the hospital
ME B1.6. Information is available in local language Signage's and information are 2 OB

ME B1.7. The facility provides information to A dedicated facilitation 2 OB
patients and visitor through an exclusive counter/rogi sahayata kendra
available
set-up.
. Information regarding services 2 OB
available at the counter
. Important contact no. are 2 OB
available at the counter
. Availability of ASHA help desk 2 OB
46 46
Standard B2
of physical economic, cultural or social reasons
ME B2.1 Hospital has defined policy for 2 SI/PI
Services are provided in manner that are non discrimination according to
sensitive to gender gender
ME B2.2 2 PI/RR
Religious and cultural preferences of Availability of complaint box and
patients and attendants are taken into display of process for grievance
consideration while delivering services redresaal and whom to contact
is displayed
Page 263
2 OB
Environment of the health
facility should be inclusive of all
religious faiths
Staff is respectful to patients 2 PI/SI
religious and cultural beliefs
2 RR/SI
Hospital has defined policy to
ensure the religious and cultural
preferences of the patient
ME B2.3. Approach road to hospital is 2 OB
accessible without congestion
or encroachment
Access to facility is provided without any
with disabilities
Internal Pathways and corridors 2 OB
of the facility are without any
obstruction / Protruding Object
There are no open 2 OB

manholes/Potholes at access
road and internal pathways
Hospital has defined policy to 2 OB

provide barrier free services to
patient
Ramps shall have a slope of 2 OB

conducive for use Gradient not be steeper
than 1:12
Ramps are provide with slip 2 OB
resistance surface
Ramps shall have adequate 2 OB at least 120 cm

width
Warning blocks have been 2 OB To aid people with visual

provide at beginning and end of impairment
the ramp and Stairs
Hand rails are provided with 2 OB
stairs
Facility conducts periodic Access 2 OB

Audits
Hospital has defined policy for 2 OB

providing disable friendly
services
Parking area is earmarked for 2 OB
People with disabilities
Symbol of Access is displayed at 2 OB Ramps, Wheel Chair Bay,

the facilities available for people Lifts, Toilets
with disabilities
ME B2.4 There is no discrimination on basis of There is no discrimination on 2 PI/SI
social and economic status of the basis of social and economic
status of the patients
patients
Hospital has defined policy for 2 RR/SI
ensuring non discrimination on
basis of social and economic
status of the patient
ME B2.5 There is affirmative actions to ensure There are arrangement and 2 RR/SI Linkage for Palliative
that vulnerable sections can access Linkages for care of terminally ill Care , Hospice
patients
services
There are Linkages for care , 2 RR/SI Linkages with NGOS,
Counselling and Protection of Police Mediation Cell
Victims of Violence including
domestic violence
There are arrangements of for 2 RR/SI Linkages with NGOS ,

adequate care and post Orphan , old age home,
discharge support of Orphan Children home
patients including homeless
children
8 8
ME B3.1 Hospital has defined policy for 2 RR/SI
Adequate visual privacy is provided at maintenance of privacy of
every point of care patients
ME B3.2 Hospital has defined policy for 2 RR/SI
Confidentiality of patients records and maintenance of patient records
clinical information is maintained and clinical information
ME B3.3 Hospital defines and 2 RR/SI

communicate policy regarding
The facility ensures the behaviours of decent communication and
staff is dignified and respectful, while courteous behaviour towards
delivering the services the patient and visitors
ME B3.4 Hospital defines the policy for 2 RR/SI

The facility ensures privacy and privacy and confidentiality of the
confidentiality to every patient, patient and condition related
especially of those conditions having with social stigma and
social stigma, and also safeguards vulnerable groups
vulnerable groups
22 22
Standard B4
ME B4.1 There is established procedures for Hospital define policy for taking 2 RR/SI
taking informed consent before consent.
treatment and procedures
ME B4.2 Patient is informed about his/her rights Display of patient rights and 2 OB
and responsibilities responsibilities.
Page 264
ME B4.3 Staff are aware of Patients rights Staff is aware of patients rights 2 SI
responsibilities responsibilities
Staff is regularly sensitize about 2 SI/RR
rights and responsibilities of the
patient
ME B4.5. The facility has defined and established Availability of complaint box at 2 OB
grievance redressal system in place administrative office and display
of process for grievance re
Redressal and whom to contact
is displayed
Hospital defines policy for 2 RR/SI

grievance redressal mechanism
There is defined frequency of 2 RR/SI

collecting complaints from
complaint box
Records of patient complaints 2 RR

suggestion are maintained
. There is system of periodic 2 RR/SI
review of patient complaints
. There is evidence of action taken 2 RR

on complaints
. Action taken are informed to the 2 RR

complainant
22 22
ME B5.1 Hospital establish policy for 2 RR/SI
The facility provides cashless services to providing free services for GoI
pregnant women, mothers and neonates and state scheme
ME B5.2 The facility ensures that drugs Hospital has established policy 2 RR/SI
prescribed are available at Pharmacy for providing all drugs in the EDL
free of cost
and wards
ME B5.3 It is ensured that facilities for the Hospital has established policy 2 RR/SI
prescribed investigations are available at for providing all diagnostics
free of cost
the facility
ME B5.4 Methods for verification of 2 PI/SI
The facility provide free of cost documents of patient is user
treatment to Below poverty line patients friendly
Hospital has established policy 2 RR/SI

to provide free of cost treatment
to BPL patients
ME B5.5 Hospital has establish policy for 2 RR/SI
The facility ensures timely timely Reimbursement and
reimbursement of financial entitlements payment to beneficiaries
and reimbursement to the patients
ME B5.6 The facility ensure implementation of 2 OB

health insurance schemes as per
National /state scheme Availability of dedicated RSBY
help desk
Finger print verification is done 2 OB/SI/RR
through a finger print scanner
2 RR/SI/PI
All tests and drugs are covered
under RSBY
2 OB
Services and entitlements
available under RSBY are
prominently displayed
Manual process is in place in 2 RR/SI
case smart card is not working
ME B6.1
Check for any circular,
policy, notice,
Check that hospital 2 government order issued
Ethical norms and code of conduct for administration has defined code that explains the code of
medical and paramedical staff have been of conduct for various cadre of conduct for staff such as
established. staff doctor and nurses.
ME B6.2
Interview doctors and
The Facility staff is aware of code of conduct Check if staff is aware of code of 2 nursing / paramedical
established conduct staff on sample basis.
ME B6.3
Ask medical
superintendent / manager
regarding any such
circular / instructions
2 issued to the doctors.
Check on sample basis if
Check hospital has implemented doctors are aware of this
a policy of not entertaining policy and do not
The Facility has an established procedure for representative of pharma entertain medical
entertaining representatives of drug companies within hospital representatives in hospital
companies and suppliers premises premises
ME B6.4
The Facility has an established procedure for
medical examination and treatment of Check hospital administration 2
individual under judicial or police detention has aware of protocols for
as per prevalent law and examination and treatment t of As per state law and
government directions individuals brought police supreme court direction
Page 265
ME B6.5
Check list of agencies with

which data shared has
routinely shred has been
2 prepared . For any other
agency a formal
permission is sought from
There is an established procedure for competent authorities
sharing of hospital/patient data with Check hospital administration before sharing the data
individuals and external agencies including has defined protocols for data including international
non governmental organization sharing agencies, press and NGOs.
ME B6.6 Facility has established has 2 SI/RR
established policy of end of life
There is an established procedure for ‘end- care
of-life’ care
ME B6.8
There is an established procedure for Check hospital ensures that 2

obtaining informed consent from the informed consent is taken from
patients in case facility is participating in any patient participating in any Check for policy or
clinical or public health research clinical or public Health research practice
ME B6.9
Check for policy defines

List of certificates can be
issued by hospital
2 Who can issue certificates
Formats shall used for
different certificates
Record keeping of issued
certificate
Check hospital has documented procedures for issuing
There is an established procedure to issue of policy for issuing medical duplicate certificates
medical certificates and other certificates certificates
ME B6.10
Check hospital
administration has made
Buffer stock and alternate
2 source pf supplies for
consumables
There is an established procedure to ensure Hospital has laid strategy to Strategy and coordination
medical services during strikes or any other resume the basic emergency and with local disruption to
mass protest leading to dysfunctional patient care services during maintain hospital
medical services strikes functions
ME B6.11
Check for availability of
An updated copy of code of ethics under 2 printed copies of code of
Indian Medical council act is available with Check code of conduct copies conduct distributed to
the facility are available at the hospital staff
56 56
ME C1.1. Departments have adequate space as Residential quarters are for 2 OB/RR
per patient or work load clinical and support staff
Hospital has adequate space as 2 OB/RR 80 to 85 sqm per bed .

per bed strength
ME C1.2. Patient amenities are provide as per Availability of public toilet for 2 OB
patient load visitors
. Availability of dharmshala/stay 2 OB
facility for attendants
Adequate number of Staff toilets 2 OB/SI
available in proximity to duty
area
Adequate number of Staff 2 OB/SI
change room available in
proximity to duty area
2 OB
Separate cafeteria for patient
and their relatives
2 OB/SI
Cafeteria/ Recreation room for
staff
Availability of Staff amenities at 2 OB/SI
nursing station and duty room
ME C1.3. Departments have layout and Hospital has independent entry 2 OB

demarcated areas as per functions for emergency, OPD and support
services/staff
. Corridors shall be at Wide to 2 OB
accommodate the daily traffic.
. The general traffic should not 2 OB

pass through the indoor/ critical
patient care area
. Ambulatory services are located 2 OB OPD, Emergency and
in outermost zone Administrative offices are
situated in near the entry/
exit of the hospital with
direct access from
approach road
. Clinical support Services are 2 OB Lab , Radiology and

located in proximity to outer Pharmacy
zone
Procedure and Intensive Care 2 OB Operation Theatre, ICU,
areas are located in Middle zone SNCU, Labour Room
of the Hospital
Page 266
Indoor area are located in Inner 2 OB Wards and Nursing Units

zone of the Hospital are located in inner most
area
ME C1.4. The facility has adequate circulation area Corridors shall be at Wide to 2 OB
and open spaces according to need and accommodate the daily traffic.
local law
Facility maintains open area as 2 OB
per floor area ratio mandated by
authorities
ME C1.5. The facility has infrastructure for Hospital has 24X7 functional 2 OB
intramural and extramural telephone connection
communication
. There is designated person to 2 OB/SI/RR
answer the telephone enquiries
. Hospital has broadband internet 2 OB
connectivity
There is establish system for 2 OB/RR Records are maintained
managing postal communication for received and
dispatched
communication
There is established system for 2 OB/RR System for

internal movement of communicating circulars,
documents and communication notices and orders etc.
There is assigned person for 2 OB/RR

managing internal and external
movement of documents and
communications
General notices and information 2 OB/RR

are displayed at notice boards at
relevant points
There is system of removal of 2 OB/RR

old notices and updating the
notice board
ME C1.6 Service counters are available as per Availability of admission counter 2 OB/RR
patient load as per load
ME C1.7. The facility and departments are There is no crises cross between 2 OB
planned to ensure structure follows the General and Patient Traffic
function/processes (Structure
commensurate with the function of the
hospital)
44 44
ME C2.1. The facility ensures the seismic safety of Facility has been surveyed by 2 OB/RR Ask for records of survey
the infrastructure Structural engineer for
seismic vulnerability
Structural Components been 2 OB/RR Check for records of in
made earthquake proof correction has been done
to strengthen structural
components like columns,
Foundation of buildings are 2 OB/RR beams,for
Check slabs,
any walls etc.
information
adequate available about the depth
of foundation. Its should
not be less the 1.5 meters
There is no irregularity in 2 OB/RR In multi story building
height of different stories height of the story should
be of same height
(Difference should not be
ME C2.2. The facility ensures safety of lifts and 2 OB/RR more than 5%.
lifts have required certificate from the
designated bodies/ board Lifts are installed with Automatic
Rescue device.
. Every lift has Emergency Alarm 2 OB/RR
System
. Periodic Maintenance of lift 2 OB/RR
. Licence for lift operation 2 OB/RR
ME C2.3. The facility ensures safety of electrical Facility has mechanism for 2 OB/RR
establishment periodical check / test of all
electrical installation by
competent electrical Engineer
. Facility has system for power 2 OB/RR
audit of unit at defined intervals
Danger sign is displayed at High 2 OB
voltage electrical installation
All electrical panels are covered 2 OB
and has restricted access
Personal protective equipments 2 OB/SI
are available with electrician
ME C2.4. Physical condition of buildings are safe Windows have grills and wire 2 OB
for providing patient care meshwork
. 2 OB
Building including walls, roofs,
floor, windows , balconies and
terraces are maintained
. 2 OB
Terrace, roof, balconies and stair
case have protective railing
. Hospital premises has intact 2 OB
boundary wall
. Hospital has functional gate with 2 OB
provision of cow catcher
. 2 OB
There is system of periodic
inspection of patient care areas
of safety related issues
Page 267
2 OB
Hospital building including walls,
roofs, floor, windows , balconies
and terraces are maintained
Access to roof and terraces are 2 OB
restricted
2 OB
Terrace, roof, balconies and stair
case have protective railing
19 20
ME C3.1. The facility has plan for prevention of 1 OB
fire
Check the fire exits provide
egress to exterior of the building
or to exterior open space
. Check the fire exits are free from 2 OB
obstruction
. Facility has conducted fire safety 2 OB/RR
audit by competent authority
. Evacuation plan is displayed at 2 OB

critical areas
Facility has defined and 2 OB/RR
implemented evacuation plan in
case of fire
No smoking sign displayed inside 2 OB/RR
and outside the working area
ME C3.2. The facility has adequate fire fighting Facility has fire safety alarm 2 OB
Equipment
There is system to track the 2 OB/RR
expiry dates and periodic
refilling of the extinguishers
ME C3.3. The facility has a system of periodic Periodic Training is provided for 2 OB/RR
training of staff and conducts mock drills using fire extinguishers
regularly for fire and other disaster
situation
Periodic mock drills are 2 OB/RR

conducted
66 66
ME C4.1. The facility has adequate specialist 2 OB/RR/SI As per patient load
doctors as per service provision Availability of General Surgeon
. Availability of Obstetric & Gynae 2 OB/RR/SI As per patient load
Specialist
Availability of General Medicine 2 OB/RR/SI
specialist
. Availability of Paediatrician 2 OB/RR/SI As per patient load
. Availability of Anaesthetics 2 OB/RR/SI As per patient load
. Availability of Ophthalmologist 2 OB/RR/SI As per patient load
. Availability of Orthopaedic 2 OB/RR/SI As per patient load
Surgeon
. Availability of Radiologist 2 OB/RR/SI As per patient load
. Availability of Pathologist 2 OB/RR/SI As per patient load
. Availability of ENT specialist 2 OB/RR/SI As per patient load
. Availability of Dentist 2 OB/RR/SI As per patient load
. 2 OB/RR/SI As per patient load
Availability of Dermatologist
. Availability of Psychiatrist 2 OB/RR/SI As per patient load
Availability of Microbiologist
Availability of AYUSH Doctors
ME C4.2. The facility has adequate general duty 2 OB/RR/SI As per patient load
work load Availability of general duty
doctors
ME C4.3. The facility has adequate nursing staff as 2 OB/RR/SI As per patient load
per service provision and work load
Availability of nursing staff
ME C4.4. The facility has adequate 2 OB/RR/SI As per patient load
requirement
Availability Lab Tech
. Availability Pharmacist 2 SI/RR As per patient load
. Availability Radiographer 2 SI/RR As per patient load
. Availability ECG Tech/Eco 2 SI/RR As per patient load
. Availability Audiometrician 2 SI/RR As per patient load
. Availability Optha. 2 SI/RR As per patient load
Technician/Referactionist
. Availability Dietician 2 SI/RR As per patient load
. Availability Physiotherapist 2 SI/RR As per patient load
. Availability O.T. technician 2 SI/RR As per patient load
. Counsellor 2 SI/RR As per patient load
. Dental Technician 2 SI/RR As per patient load
. Rehabilitation Therapist 2 SI/RR As per patient load
. Biomedical Engineer 2 SI/RR As per patient load
ME C4.5. The facility has adequate support / 2 SI/RR
general staff Availability of storekeeper
. 2 SI/RR
Availability of Housekeeping
supervisor/In charge
. Availability of security In charge 2 SI/RR
Page 268
2 2
ME C5.1 The departments have availability of Hospital has policy to ensure 2 SI/RR
adequate drugs at point of use drugs at all point of use as per
state EDL
8 8
ME C6.6 Availability of functional equipment and Availability of equipments for 2 Equipments for
instruments for support services Facility management horticulture, electrical
repair, plumbing material
etc
OB
Availability of equipments for 2 Autoclave and mutilator
processing of Bio medical waste OB
ME C6.7 Departments have patient furniture and Availability of fixture for 2
fixtures as per load and service provision administrative office
OB
Availability of furniture for 2
administrative office OB
ME C7.1
Check objective checklist

has been prepared for
assessing competence of
2 doctors, nurses and
paramedical staff based
on job description defined
for each cadre of staff.
Check parameters for assessing Dakshta checklist issued
Criteria for Competence assessment are skills and proficiency of clinical by MoHFW can be used
defined for clinical and Para clinical staff staff has been defined for this purpose.
ME C7.2
2 including filled checklist,
scoring and grading .
Competence assessment of Clinical and Para Check for competence Verify with staff for actual
clinical staff is done on predefined criteria assessment is done at least once competence assessment
at least once in a year in a year done
ME C7.3
Check if performance
appraisal critical clinical
2 staff has been defines as
per state service rules/
Criteria for performance evaluation clinical Check performance criteria for NHM Guidelines and job
and Para clinical staff are defined clinical staff has been defined description of staff
ME C7.4
Verify with records that

performance appraisal has
been done at least once in
2 a year for all Doctor,
Nurses and paramedic
staff .l. Check that
Performance evaluation of clinical and para Check if annual performance predefined criteria has
clinical staff is done on predefined criteria at appraisal for clinical staff is been used for the
least once in a year practiced appraisal only.
ME C7.5
Check if performance
appraisal critical for both
2 support/ administrative
staff has been defines as
Criteria for performance evaluation of Check performance criteria per state service rules/
support and administrative staff are for support staff has been NHM Guidelines and job
defined defined description of staff
ME C7.6

performance appraisal has
been done at least once in
2 a year for all
administrative and
support staff either
appointed at hospital .
Performance evaluation of support and Check if annual performance Check that predefined
administration staff is done on predefined appraisal for support & criteria has been used for
criteria at least once in a year administration staff is practiced the appraisal only.
ME C7.7

staff on contract under
NHM or any other
program, staff working
through outsource
2 agencies such as
housekeeping and
security are also go
through the competence
assessment along with
regular staff. Also their
Check staff if competence performance appraisal is
Competence assessment and performance assessment and performance done at least once in year
assessment includes contractual, appraisal program includes staff by their respective
empanelled, and outsourced staff is inclusive contractual staff. employer.
ME C7.8
Check that hospital

administration has listed
the gaps found during
2 competence assessment
and performance
appraisal exercise . These
gaps in performance and
competence are factored
Training needs are identified based on Check if hospital administration in while developing
competence assessment and performance has a system for identifying the training plan for staff. This
evaluation and facility prepares the training training needs and plan to includes both clinical as
plan address them well as non clinical staff.
Page 269
ME C7.9 Facility conduct training need 2 SI/RR

assessment periodically for all
The Staff is provided training as per defined cadre of staff
core competencies and training plan
Facility has program for 2 SI/RR
continuous medical education
for doctors and nursing staff
2 SI/RR
Facility prepares training
calendar as per training need
assessment
Training feed back is taking and 2 SI/RR
records are maintained for
training
Details and Records of training 2 SI/RR

provided are available with unit
Training on Disaster 2 SI/RR
Management
Training on Cardio Pulmonary 2 SI/RR
resuscitation
Training on staff Safety 2 SI/RR
Training on Measuring Hospital 2 SI/RR
Performance Indicators
Training on facility level Quality 2 SI/RR
Assurance
ME C7.10 Hospital has policy for regular 2 SI/RR
competence testing as per job
description. Check supervisors make
periodic rounds of
department and monitor
that staff is working
imparted. Also staff is
There is established procedure for utilization provided on job training
of skills gained thought trainings by on -job wherever there is still
supportive supervision gaps
ME C7.11
Verify with records of

performance appraisal for
2 feedback has been written
on appraisal form and
Check if feedback is given after shared with staff.
Feedback is provided to the staff on their each round of competence Interview staff for
competence assessment and performance assessment and performance verification for feedback
evaluation appraisal has been shared
18 18
ME D1.1. The facility has established system for Facility has contract agency for 2 SI/RR
maintenance of critical Equipment maintenance for equipments
2 SI/RR
Contact details of the agencies
responsible for maintenance are
communicated to the staff
Asset list of all equipments are 2 SI/RR
maintained
2 SI/RR
There is system to maintain
records of down time of
equipments
Indexing of all equipments is 2 SI/RR
done
All equipments are covered 2 SI/RR
under AMC including preventive
maintenance for computers and
other IT equipments
2 SI/RR
maintenance of the for
computers and other IT
equipments
ME D1.2. The facility has established procedure Facility has contracted agency 2 SI/RR
for internal and external calibration of for calibration of equipments.
measuring Equipment
Records of the calibrated 2 RR
equipments are maintained
10 10
Standard D2
areas
ME D2.4 The facility ensures management of Hospital has system to ensure 2 SI/RR
expiry and near expiry drugs that short expiry drugs are not
procured
Hospital has process for proper 2 SI/RR
disposal and prevention of
unintended use of expired drugs
ME D2.5 The facility has established procedure Hospital implements scientific 2 OB/RR/SI ABC, VED, FSN,FIFO
for inventory management techniques inventory management system
according to their needs
ME D2.6 There is a procedure for periodically Hospital has policy that there is 2 RR/SI
replenishing the drugs in patient care areas no stock out of the drugs and
consumables at patient care
area
ME D2.8 There is a procedure for secure storage Hospital has a policy for ensuring 2 RR/SI
of narcotic and psychotropic drugs proper management and
restriction of unintended use of
narcotic substance and
psychotropic drugs as per
prevalent law
48 48
ME D3.1. The facility provides adequate Adequate illumination in open 2 OB
illumination level at patient care areas area at night
Page 270
Adequate illumination in 2 OB Stairs, corridor and

circulation area waiting area
Adequate illumination in toilets 2 OB
Hospital periodically measure 2 OB
illumination at different area of
the hospitals
approach roads to hospital
ME D3.2. The facility has provision of restriction of There is restriction on entry of 2 OB
visitors in patient areas vendors and hawkers inside the
premise of the hospital
. Hospital has visitor policy in 2 OB/RR
place
. Hospital has policy for restriction 2 OB/RR
of media person in side the
hospital
Hospital implement visitor pass 2 OB/RR
area for indoor areas
ME D3.4. The facility has security system in place Hospital has in- 2 RR/SI
at patient care areas house/outsourced security
system in place
. Duty roaster is available for 2 RR/SI
security staff
. Training and Drills of security 2 RR/SI
staff is done
. Security staff is aware of patient 2 RR/SI
right, visitor policy and disaster
Management
. There is system for supervision 2 RR/SI
of security staff
. Facility has a security plan for 2 RR/SI
deputation of guard at different
location
. Responsibility and timing of 2 RR/SI
opening and closing different
department is fixed and
documented
. There is established procedure 2 RR/SI/OB

for safe custody of keys
. There is procedure for handing 2 RR/SI
over the keys at the time of shift
change
. Hospital has system to manage 2 RR/SI
violence /mass situation
ME D3.5. The facility has established measure for No female stff is posted alone at 2 SI
safety and security of female staff night
. Where ever there are male 2 SI/RR
employees/patients female staff
are posted in pairs
. Timing of the shift is arranged 2 SI/RR
keeping in mind the safety of
female staff
. Committee against sexual 2 RR/SI
harassment is constituted at the
facility
Staff has been provided 2 RR/SI
awareness training on Gender
issues
52 52
ME D4.1. Exterior of the facility building is Boundary Walls of building is 2 OB
maintained appropriately plastered and whitewashed.
. No unwanted/outdated posters 2 OB
on hospital boundary and
building walls
. Hospital Buildings are in uniform 2 OB
colour scheme
. Hospital has system to 2 OB/RR
whitewash the building
periodically
ME D4.2. Patient care areas are clean and hygienic General waste from hospital is 2 OB/RR
removed daily by
municipal/outsourced agency
SI/RR
Every department has
Every department has Schedule schedule for inspection of
of cleaning 2 cleaning work
ME D4.3. Hospital infrastructure is adequately 2 OB/RR
maintained
Hospital has system for periodic
maintenance of infrastructure at
defined interval
. There is no clogged/over flowing 2 OB
drain in facility
. Hospital sewage is linked with 2 OB/SI/RR
municipal drainage system
. Facility has a closed drainage 2 OB
system
. Intramural roads are in good 2 OB
condition without
potholes/ditches
. Facility has a annual 2 RR/SI
maintenance plan for its
infrastructure
ME D4.4. Hospital maintains the open area and Availability of parking space as 2 OB
landscaping of them per requirement
. Dedicated parking space for 2 OB
ambulances
. No water logging in side the 2 OB
premises of the hospital
Page 271
. There is no abandoned 2 OB
/dilapidated building in the
premises
. Proper landscaping and 2 OB
maintenance of trees, garden
. There shall be no encroachment 2 OB
in and around
the hospital
. Hospital has rain water 2 OB
harvesting facility
. Hospital has Herbal garden 2 OB
ME D4.5. The facility has policy of removal of Hospital has condemnation 2 RR/SI
condemned junk material policy in place
. Periodic removal of junk 2 OB/RR
material done
. Hospital has designated covered 2 OB
place to keep junk/condemned
material
. No junk/condemned articles in 2 OB
open spaces
ME D4.6. The facility has established procedures Pest control measures are 2 RR/SI
for pest, rodent and animal control evident at facility
. Anti Termite treatment of the 2 RR/SI

wooden furniture
46 46
ME D5.1. The facility has adequate arrangement Hospital has adequate water 2 OB/RR/SI 450-500 Litres per bed per
storage and supply for portable water in storage facility as per day
all functional areas requirements
. Hospital has adequate water 2 OB/SI

supply from municipal /under
ground source
. All water tanks are kept tightly 2 OB
closed
. Periodic cleaning of water tanks 2 OB/RR Records of cleaning is
carried out maintained
Hospitals periodically tests the 2 RR
quality of water from the source
(municipal supply, bore well etc)
for bacterial and chemical
content
Chlorination of water is done as 2 RR

per requirement
RO/ Filters are available for 2 OB
potable drinking water
2 RR/SI
Hospital ensures that the
distribution pipelines are not
running in close vicinity of the
sewage system.
ME D5.2. The facility ensures adequate power Availability of noiseless 2 OB/SI
backup in all patient care areas as per generators for power back up
load
Estimation of power 2 RR/SI
consumption of different
department of hospitals is done
Generator has adequate 2 RR/SI
capacity to provide 24x7 power
back at least critical areas
. Hospital has dedicated sub 2 OB/RR/SI
station for electrical supply
Hospital has adequate power 2 RR/SI 3Kw to 5Kw per bed
supply connection
Use of energy efficient bulbs for 2 SI
light
ME D5.3. Critical areas of the facility ensures Manifold room is located on 2 OB
availability of oxygen, medical gases and ground floor
vacuum supply
Manifold room has adequate 2 OB/SI At least for three days
stock of Oxygen and Nitrogen
Cylinders
Cylinders banks are in duplicate 2 OB/RR/SI Check for there two
dedicated banks - Running
and reserve fitted with
automatic changeover
Colour of gas pipeline and Gas 2 OB/RR device
Cylinder are as per standards
Alarm system has been provided 2 RR/SI
to indicate any abnormal
pressure change
There is procedure for prompt 2 SI/RR/OB
replacement of empty cylinders
with filled cylinders
There is a procedure for periodic 2 SI/RR
checking of all terminal units for
malfunctioning
Entry to Manifold room is 2 OB/SI
prohibited
Instruction for operating 2 OB
different equipment clearly
displayed
2 2
ME D7.2 The facility has established procedures Hospital has policy to change 2 RR/SI
for changing of linen in patient care linen
areas
Page 272
20 20
Standard D8
The facility has defined and established procedures for promoting public participation in management of hospital transparency
and accountability.
ME D8.1. The facility has established procedures Hospital Management 2 RR
for management of activities of Rogi Society/RKS is registered under
Kalyan Samitis societies registration act
. Availability of Income tax 2 RR

exemption certificate for
donations
. RKS meeting are held at 2 RR
prescribed interval
. Minutes of meeting are recorded 2 RR
. Participation of community 2 RR
representatives/NGO is ensured
. RKS reviews the patient 2 RR
complaint/ feedback and action
taken
. RKS generates its own resources 2 RR/SI
from donation/leasing of space
ME D8.2. The facility has established procedures Community based 2 RR/SI

for community based monitoring of its monitoring/social audits are
services done at periodic intervals
Facility communicate updated 2 RR/SI

information on Quality of
services
Facility conducts public hearing 2 RR/SI
at regular intervals
16 16
Standard D9 Hospital has defined and established procedures for Financial Management
ME D9.1. The facility ensures the proper utilization There is system to track and 2 RR/SI
of fund provided to it ensure that funds are received
on time
Funds/Grants provided are 2 RR
utilized in specific time limit
. There is no backlog in payment 2 RR/PI E.g.; Payment for JSY and
to beneficiaries as per their Family planning
entitlement under different
schemes
. Payment to ASHA done on time 2 RR/PI

. Salaries and compensation are 2 RR/SI
provided to contractual staff on
time
. Facility provides utilization 2 RR
certificate for funds on time
ME D9.2. The facility ensures proper planning and Facility prioritize the resource 2 RR/SI
requisition of resources based on its available
need
. Requirement for funds are sent 2 RR/SI
to state on time
30 30
ME D10.1. The facility has requisite licences and Availability of valid No objection 2 RR
certificates for operation of hospital and Certificate from fire safety
different activities authority
. Availability of authorization for 2 RR

handling Bio Medical waste from
pollution control board
. Availability of certificate of 2 RR
inspection of electrical
installation
Availability of licence for 2 RR
operating lift
ME D10.2. Updated copies of relevant laws, Availability of copy of Bio 2 RR
regulations and government orders are medical waste management and
available at the facility handling rule 1998
Drug and cosmetic Act 2005 2 RR

Safety code for Medical 2 RR AERB safety code no.
diagnostic X ray equipment and AERB/SC/MED-2(Rev 1)
installation
Narcotics and Psychotropic 2 RR
substances act 1985
Code of Medical ethics 2002 2 RR
Nursing Council Act 2 RR
Medical Termination of 2 RR
Pregnancy 1971
Person with disability Act 1995 2 RR
Pre conception pre natal 2 RR
diagnostic test 1996
Right to information act 2005 2 RR
Indian Tobacco control Act 2003 2 RR
38 38
Standard D11
procedures.
ME D11.1. The facility has established job Job description of Specialist 2 RR Regular + contractual
description as per govt guidelines Doctor is defined and
communicated
Job description of General duty 2 RR Regular + contractual
Doctor is defined and
communicated
. Job description of nursing staff 2 RR Regular + contractual
is defined and communicated
Page 273
. Job description of paramedic 2 RR Regular + contractual. Lab

staff is defined and technician, X ray
communicated technician, OT technician,
MRD technician etc.
Job description of counsellor is 2 RR Regular + contractual

defined and communicated
Job description of ward boy is 2 RR Regular + contractual
defined and communicated
Job description of security staff 2 RR Regular + contractual
Job description of cleaning staff 2 RR Regular + contractual
Job description of Administrative 2 RR Regular + Contractual MS,

staff is defined and Hospital Manager,
communicated supervisor, Matron, Ward
Master. Pharmacist etc.
ME D11.2. The facility has a established procedure Duty roster of doctors is 2 RR/SI
for duty roster and deputation to prepared, updated and
different departments communicated
Duty roster of Nurses is 2 RR/SI

prepared, updated and
communicated
Duty roster of Paramedics is 2 RR/SI
communicated
Duty roster of Cleaning staff is 2 RR/SI
communicated
Duty roster of security staff is 2 RR/SI
communicated
There is provision of Rotatory 2 RR/SI
posting of staff
Facility has established line of 2 RR/SI
reporting for clinical and
administrative staff
ME D11.3. The facility ensures the adherence to Facility has policy for dress code 2 RR/SI
dress code as mandated by its for different cadre of hospital.
. I Cards have been provided to 2 OB

staff
. Name plate have been provided 2 OB
to staff
18 18
ME D12.1. Valid contract for disposal for 2 RR
Bio Medical waste with common
There is established system for contract treatment facility
management for out sourced services
. Selection of outsourced agencies 2 RR
done through competitive
tendering system
Eligibility criteria is explicitly 2 RR
defined as per term of reference
. There is system to make 2 RR Check for that Contract

payment as per adequacy and document has provision
quality of services provided by for dedication of
the vendor payment if quality of
services is not good
. Payment to the outsourced 2 RR

services are made on time
ME D12.2. Facility as defined criteria for 2 RR
assessment of quality of
There is a system of periodic review of outsourced services
quality of out sourced services
2 RR
Regular monitoring and
evaluation of staff is done
according against defined
criteria
2 RR/SI
Actions are taken against non
compliance / deviation from
contractual obligations
Records of blacklisted vendors 2 RR
are available with facility
8 8
ME E1.3 There is established procedure for Facility ensures that there is 2 RR/SI
admission of patients process for admission of patients
after routine working hours
ME E1.4 There is established procedure for Facility updates daily availability 2 RR/SI/PI
managing patients, in case beds are not of vacant patient beds in
available at the facility different in door units
Facility has established plan for 2 RR/SI

accommodating high patient
load due to situation like
disaster/ mass casualty or
disease outbreak
Facility has policy for internal 2 RR/SI

adjustment of the patient within
cold wards for accommodating
patient as extra temporary
measure
Page 274
18 18
ME E3.1. Facility has established procedure for Facility has established policy 2 RR/SI
continuity of care during for co ordination and
interdepartmental transfer handover during
interdepartmental transfer
. There is a policy for 2 RR/SI

hospital
ME E3.2. Facility provides appropriate referral There is policy for referral of 2 RR/SI
linkages to the patients/Services for patient for which services can
transfer to other/higher facilities to assure not be provided at the facility
their continuity of care.
. Facility maintain list of higher 2 RR/SI

centres where patient can be
managed.
. Facility ensures the referral 2 RR/SI
patient to public healthcare
facilities
. Facility defines and 2 RR/SI
communicate referral criteria for
different departments
2 RR/OB
There is system to check that
patient are not unduly
referred for the services those
can be available at the facility
ME E3.4 Facility is connected to medical colleges There is functional telemedicine 2 OB

through telemedicine services centre
Telemedicine services are 2 RR/SI

utilized for continual medical
education
10 10
ME E4.1 Procedure for identification of patients There is policy for identification 2 RR/SI
is established at the facility of patient before any clinical
procedure
ME E4.2. Procedure for ensuring timely and accurate There is a policy for ensuring 2 RR/SI
nursing care as per treatment plan is accuracy of verbal/telephonic
established at the facility orders
ME E4.3 There is established procedure of Hospital has policy for patient 2 RR/SI
patient hand over, whenever staff duty hand over during shift change
change happens
ME E4.4 Nursing records are maintained Hospital has policy for 2 RR/SI
maintaining nursing records
ME E4.5 There is procedure for periodic There is policy for periodic 2 RR/SI
monitoring of patients monitoring of patient
4 4
ME E5.1 The facility identifies vulnerable patients Hospital identify and 2 OB/SI
and ensure their safe care communicate the category of
patient considered as vulnerable
ME E5.2 The facility identifies high risk patients and Hospital identify and 2 OB/SI
ensure their care, as per their need communicate the category of
patient considered as high risk
8 8
Standard E6
rational use.
ME E6.1. Facility ensured that drugs are prescribed in Facility has policy and enabling 2 RR
generic name only order for prescribing drugs in
generic drug only
ME E6.2 There is procedure of rational use of drugs Facility provides adequate 2 SI/RR
copies of STG to respective
department
Facility maintains a list of 2 RR
updated version of STG
Facility provides training on use 2 SI/RR
of STG
2 2
ME E7.3 There is a procedure to check drug Facility has policy for reporting 2 RR/SI
before administration/ dispensing of adverse drug reaction
4 4
ME E8.7 The facility ensures safe and adequate Hospital has policy for retention 2 RR
storage and retrieval of medical records period for different kinds of
records
Hospital has policy for safe 2 RR

disposal of records
4 4
ME E11.3. The facility has disaster management Hospital has prepared disaster 2 RR Availability of security
plan in place plan services
. Disaster management 2 RR
committee has been constituted
Availability of
Housekeeping services
2 2
Page 275
ME E16.1. Death of admitted patient is adequately Facility has a standard 2 SI/RR

communicate death to
relatives
4 4
ME E20.1 The facility provides immunization Facility has established produce 2 SI/RR
services as per guidelines for reporting and follow up of
AEFI
Staff is trained for detecting , 2 SI/RR
managing and reporting of AEFIs

48 48
Standard F1
infection
Facility has functional infection control Infection control committee
ME F1.1. committee constitute at the facility 2 SI/RR
ICC is approved by appropriate
authority 2 SI/RR
Roles and responsibilities are
defined and communicated to
its members
. 2 SI/RR
ICC meet at periodic time
interval 2 SI/RR
Records of Infection control
activities are maintained 2 SI/RR
Facility has provision for Passive and Facility has in-house/ linkage
active culture surveillance of critical & with microbiology lab for culture
high risk areas surveillance
ME F1.2. 2 SI/RR
There is defined format for
requisition and reporting of
culture surveillance
2 SI/RR
Reports of culture surveillance
are collated and analyzed 2 SI/RR
Feedback is given to the
respective departments 2 SI/RR
Facility measures hospital associated Sample are taken for culture to
ME F1.3 infection rates detect HAI in suspected cases. 2 SI/RR
There is defined criteria and
format for reporting HAI based
on clinical observation
2 SI/RR
Reports from different
department are collated and
analyzed
2 SI/RR
Feedback is given to the
respective departments 2 SI/RR
There is Provision of Periodic Medical Records of immunization
ME F1.4. Checkups and immunization of staff available 2 SI/RR
Records of Medical Checkups are
. available 2 SI/RR
Facility has established procedures for There is designated person for
regular monitoring of infection control Co coordinating infection
practices control activities
ME F1.5. 2 SI/RR Infection control nurse
There is defined format/checklist
for monitoring of hand washing
and infection control practices
. 2 SI/RR
Facility has defined and established Facility has antibiotic policy in
ME F1.6. antibiotic policy place 2 SI/RR
There is system for reporting
Anti Microbial Resistance with in
the facility
2 SI/RR
Antibiotic policy includes plan
for identifying, transferring ,
discharging and readmitting
patients with specific
antimicrobial resistant pathogen
2 SI/RR
Policy Includes Rational Use of
Antibiotics 2 SI/RR
Standard treatment guidelines
are followed while developing
Antibiotic Policy
2 SI/RR
There is procedure for periodic
Laboratory Surveillance for
Antibiotic Resistance
2 SI/RR
Facility Measures the Antibiotic
Consumption Rates 2 SI/RR
6 6
Hand washing facilities are provided at
point of use Facility ensures uninterrupted
and adequate supply of
antiseptic soap and alcohol hand
ME F2.1 rub in all departments 2 SI/RR
Staff is trained and adhere to standard Check for the records that
ME F2.2 hand washing practices training have been provided 2 SI/RR
Facility ensures standard practices and Facility ensures uninterrupted
materials for antisepsis and adequate supply of
ME F2.3 antiseptics 2 SI/RR
12 12
requirements Availability of Heavy duty gloves
ME F3.1 for cleaning staff 2 OB/SI
Page 276
Availability of gum boats for

cleaning staff 2 OB/SI
Availability of mask for cleaning
staff 2 OB/SI
Availability of apron for cleaning
staff 2 OB/SI
Facility ensure adequate and
regular supply of personal
protective equipments 2 SI/RR
Staff is adhere to standard personal
protection practices There is policy for judicious use
of personal protective
equipments specially sterile
ME F3.2 gloves 2 SI/RR
4 4
Facility ensures standard practices and
materials for decontamination and cleaning
of instruments and procedures areas Facility ensure adequate supply Disinfectant like
of disinfectant at the point of hypochlorite, bleaching
ME F4.1 use 2 SI/RR powder etc.
Staff is trained for preparation of
disinfectant solution 2 SI/RR
4 4
Facility ensures availability of standard
materials for cleaning and disinfection of Facility ensure the availability of
patient care areas good quality disinfectant and
ME F5.2 cleaning material 2 SI/RR
Facility ensures segregation infectious
patients Hospital has policy for
identification and segregation of
ME F5.4 infectious patient 2 SI/RR
42 42
Standard F6
hazardous Waste.
Facility Ensures segregation of Bio Facility ensures adequate and 2 SI/RR
Medical Waste as per guidelines regular supply of non
chlorinated colour coded liners
ME F6.1
Separate bins for Recyclable and 2 Check adequacy in patient
biodegradable waste is available care and administarive
areas. Also check there is
no mixing of waste
There is established procedure 2 SI/RR

for daily monitoring of proper
segregation of Bio medical waste
by a designated person
Bar code system for the bags or 2

containers containing BMW
Facility ensures management of sharps Facility ensures supply of 2 SI/RR
Containers are puncture
as per guidelines puncture proof containers and
needle cutters proof, leak proof and
ME F6.2 temper proof
Facility ensures availability of 2 SI/RR
post exposure prophylaxis drugs
There is system for reporting of 2 SI/RR
needle stick injuries
Facility ensures transportation and Facility has secured designated 2 SI/OB
disposal of waste as per guidelines place for storage of Bio Medical
waste before disposal
ME F6.3.
BMW is stored in lock and key 2 SI/OB Check there is no scope
for unauthorized entry
Log book /Record of waste 2 RR Check records are being
generated is maintained on day displayed monthly on its
to day basis web site
No signs of burning within the 2 OB
premises.
Check infectious liquid waste is 2 OB
not directly drained in to
municipal sewerage system
Display of Bio Hazard sign at the 2 OB
point of use
Infectious Waste is not stored 2 RR
for more than 48 hours
Disposal of anatomical waste as 2 OB/SI/RR Preferably by CTWF/in-
per BMW rule house deep burial pits/ In
house incinerator with
prior approval
Disposal of solid waste as per 2 OB/SI/RR Preferably by CTWF/ Deep

BMW rule burial/ in absence of
above autoclaving or
micro waving/
hydroclaving followed by
shredding or mutilation or
combination of
sterlization and shredding.
Disposal of sharp waste as per 2 OB/SI/RR Preferably by

BMW rule CTWF/autoclaving or dry
heat sterlization followed
by shredding or mutilation
or encapsulation in metal
contained or cement
concrete
Disposal of contaminated waste 2 OB/SI/RR Preferably by

(recyclable) as per BMW rule CTWF/Autoclaving or
microwaving/
hydroclaving followed by
shredding or mutiliation
or combination of
sterlization and shredding
Page 277
Preferably By CTWF/
disinfection (by soaking
the washed glass waste
after cleaning with
detergent and Sodium
Hypochlorite treatment)
or through autoclaving or
Disposal of Glass ware and microwaving or
metallic body implants (Blue) 2 hydroclaving
Annual report to the pollution 2 RR
control board is submitted
Biomedical waste transported in 2 OB/SI/RR
authorized vehicle
32 32
ME G1.1 The facility has a quality team in place District Quality Team for district 2 SI/RR Check for Office order by
hospitals are Constituted designated authority
. 2 SI/RR Hospital Manager
There is designated person for
co coordinating overall quality
assurance program at the facility
There is designated head of the 2 SI/RR MS
quality team
2 SI/RR
Team members are aware for of
there respective responsibilities
ME G1.2. The facility reviews quality of its services at Quality team meets monthly and 2 SI/RR
periodic intervals review the quality activities
Minutes of meeting are 2 RR
recorded
Results for internal /External 2 SI/RR Check the meeting
assessment are discussed in the records
meeting
Hospital performance and 2 SI/RR Check the meeting
indicators are reviewed in records
meeting
Progress on time bound action 2 SI/RR Check the meeting
plan is reviewed records
Follow up actions from previous 2 SI/RR Check the meeting
meetings are reviewed records
Resource requirement and 2 SI/RR Check the meeting
support from higher level are records
discussed
Quality team review that all the 2 SI/RR
services mentioned in RMNCHA
are delivered as per guideline
Quality team review that all the 2 SI/RR
services mentioned in National
Health Program are delivered as
per guideline
Resolution of the meeting are 2 SI/RR Check how resolution are

effectively communicated to communicated to staff
hospital staff
Quality team report regularly to 2 SI/RR
DQAC about Key Performance
Indicators
Quality Team DQAC about 2 SI/RR
internal assessment results and
action taken
26 26
ME G2.1. Patient Satisfaction surveys are There is person designated to co 2 SI/RR
conducted at periodic intervals ordinate satisfaction survey
. Patient feedback form are 2 RR
available in local language
Adequate sample size is taken to 2 RR
conduct patient satisfaction
There is procedure to conduct 2 RR
employee satisfaction survey at
periodic intervals
ME G2.2. Facility analyses the patient feed back There is procedure for 2 RR
and do root cause analysis compilation of patient feedback
forms
Patient feedback is analyzed on 2 RR Overall department
monthly basis wise/attribute wise score
are calculated
Root cause analysis is done for 2 RR
low performing attributes
Results of Patient satisfaction 2 RR/SI
survey are recorded and
disseminated to concerned staff
There is procedure for analysis 2 RR

of Employee satisfaction survey
There is procedure for root 2 RR
cause analysis of Employee
satisfaction survey
ME G2.3. Facility prepares the action plans for the There is procedure for 2 RR/SI
areas of low satisfaction preparing Action plan for
improving patient satisfaction
There is procedure to take 2 RR/SI
corrective and preventive action
Page 278
There is procedure for preparing 2 RR/SI

action plan for improving
employee satisfaction
8 8
ME G3.1. Facility has established internal quality Daily round schedule is defined 2 SI/RR
assurance program at relevant and practiced
departments
ME G3.2. Facility has established external External Quality assurance is 2 SI/RR
assurance programs at relevant done on defined interval by
departments DQAC
External Quality assurance is 2 SI/RR

done on defined interval by
SQAC
ME G3.3. Facility has established system for use of 2 SI/RR At departmental /Hospital
check lists in different departments and There is system for reviewing Level
services departmental checklist and
taking appropriate action
20 20
Standard G4
support services.
ME G4.1. Departmental standard operating Hospital has documented 2 RR
procedures are available Quality system manual
. Hospital has Records of 2 RR
distribution of Standard
operating procedure
. 2 RR
Hospital has system for
periodic review of the
standard procedures as and
when required
ME G4.2. Standard Operating Procedures Hospital has documented 2 RR
adequately describes process and system for Internal audits at
procedures defined intervals
Hospital has documented 2 RR
procedure for control of
documents and records
procedure for defining Quality
objectives
procedure for action planning

procedure for training and
CMEs of hospital staff at
defined intervals

procedure for monthly
review meeting
ME G4.3. Staff is trained and aware of the Check Staff is trained for 2 SI/RR Check for the training
standard procedures written in SOPs relevant part of SOPs records
6 6
ME G5.1. Facility maps its critical processes Process mapping of critical 2 SI/RR
processes done
ME G5.2. Facility identifies non value adding 2 SI/RR
identified
ME G5.3. Facility takes corrective action to Processes are rearranged as per 2 SI/RR
40 40
ME G6.1. The facility conducts periodic internal Internal audit plan is prepared . 2 RR/SI
assessment
Internal audit schedule is 2 RR/SI
prepared .
Internal Assessors are identified 2 RR/SI
Training of internal assessors is 2 RR/SI
done
There is process of 2 RR/SI
communicating about the
assessment to concerned
departments
Records of internal assessment 2 RR/SI

are maintained
Person is designed for co 2 RR/SI
coordinating internal
assessment
ME G6.2. The facility conducts the periodic There is established committee 2 RR/SI
prescription/ medical/death audits for reviewing maternal death
There is established committee 2 RR/SI
for reviewing new born death
There is established committee 2 RR/SI
for medical and death audit
Drug and therapeutic committee 2 RR/SI
for Prescription audits
Medical audits are conducted at 2 RR/SI

periodic interval
2 RR/SI Maternal and death audits
are conducted as per
Death audits are conducted at guideline
periodic interval
Prescription audits are 2 RR/SI
conducted at periodic interval
Page 279
. There is predefined criteria and 2 RR/SI

format for medical audit
There is predefined criteria and 2 RR/SI
format for prescription audit
There is predefined criteria and 2 RR/SI
format for death audit
Training has been provided for 2 RR/SI
conducting medical and death
audits
ME G6.4. Action plan is made on the gaps found in 2 RR/SI
Departmental Action plan is
reviewed periodically
ME G6.5. Corrective and preventive actions are 2 RR/SI
taken to address issues, observed in the There is system to ensure that
assessment & audit corrective and preventive action
are taken timely
12 12
2 SI/RR
Mission state meant

should define the purpose
, target users and long
term goal of facility.
ME G7.1 Mission should be defined
in consultation with
stakeholders and duly
approved by head of
facility. Mission should be
in coherence with the
stated mission of state
Check if mission statement has health department and
Facility has defined mission statement been defined adequately National Health Mission
2 SI/RR
Check if core values of
organization such as non
ME G7.2 discrimination,
transparency, ethical
clinical practices,
Facility has defined core values of the Check if core values of the competence etc have
organization facilities have been defined been defined
2 SI/RR
Check quality policy of the

facility has been defined
in consultation with
ME G7.3 hospital staff and duly
approved by the head of
the facility . Also check
Quality Policy enables
achievement of mission of
Facility has defined Quality policy, which is Check if Quality Policy has been the facility and health
in congruency with the mission of facility defined and approved department
ME G7.4 2 SI/RR

been framed addressing
key quality issues in each
department and cores
Facility has de defined quality objectives to Check if SMART Quality Measurable, Attainable,
achieve mission and quality policy Objectives have framed Relevant and Time Bound.
ME G7.5 2 SI/RR
Interview with staff for
their awareness. Check if
Mission Statement, Core
Values and Quality Policy
Mission, Values, Quality policy and Check of staff is aware of is displayed prominently
objectives are effectively communicated to Mission , Values, Quality Policy in local language at Key
staff and users of services and objectives Points
ME G7.6 2 SI/RR
Verify with records that a

time bound action plan
has been prepared to
achieve quality policy and
objectives in consultation
with hospital staff . Check
Check if plan for implementing if the plan has been
Facility prepares strategic plan to achieve quality policy and objectives approved by the hospital
mission, quality policy and objectives have prepared management
ME G7.7 2 SI/RR

objectives being reviewed
at least onnce in month
by departmnetal
incharges and during the
qulaity team meeting. The
progress on quality
Facility periodically reviews the progress of Check time bound action plan is objectives have been
14 14
ME G8.1. Facility uses method for quality PDCA 2 SI/RR
. 5S 2 SI/OB
. Mistake proofing 2 SI/OB
. Six Sigma 2 SI/RR
ME G8.2. Facility uses tools for quality Basic tools of Quality 2 SI/RR
. Prateo/Priorization 2 SI/RR
. Gantt Chart/Project 2 SI/RR
Management
Standard G9 Facility has defined, approved and communicated Risk Management framework for existing and potential risks. 12 12
Page 280
ME G9.1 2 SI/RR
Review the risk

management framework
document. Check scope
and objectives of the
framework is contextual
Risk Management framework has been to the facility and criterion
defined including context, scope, objectives Check for adequacy of Risk for identifying risk has
and criteria Management Framework been explicitly laid out.
ME G9.2 2 SI/RR
Review risk management

framework delineation of
responsibilities amongst
staff for identifying the
risk in their work area and
Check if responsibilities for their management. Verify
Risk Management framework defines the identifying and managing risk with the staff members if
responsibilities for identifying and managing has been defined and they are aware of their
risk at each level of functions communicated responsibilities
ME G9.3 2 SI/RR
framework for process of
Risk Management Framework includes Check if process of reporting reporting incidents
process of reporting incidents and potential risks and hazards have been including near miss and
risk to all stakeholders defined potential risks
ME G9.4 2 SI/RR

framework includes list of
identified current and
potential risks. These may
A compressive list of current and potential included safety, strategic,
risk including potential strategic, regulatory, Check if list of existing and financial, statutory,
operational, financial, environmental risks potential risk have been operational and
has been prepared prepared environmental risks.
ME G9.5 2 SI/RR
Verify with the training
records . Training on risk
management at least
should be provided to
Check training on risk person responsible for
Modality for staff training on risk management has been provided indemnifying and
management is defined to key staff members managing risks
ME G9.6 2 SI/RR
Check with the records
that quality team/ risk
Check risk management management committee
Risk Management Framework is reviewed framework is reviewed at least reviews the framework at
periodically once in a year least once in a year
G10.1 2 SI/RR
Review the risk
management plan
document. Check it has
Risk management plan has been prepared been updated at lest once
and approved by the designated authority in a month and duly
and there is a system of its updating at least Check if a valid risk management approved by the head of
once in a year plan is available at the facility facility.
G10.2 2 SI/RR
ask staff if they are aware

of key actionable points of
risk management plan of
their concerned areas.
Check what measures
hospital administration
has taken for effective
dissemination of risk
management plan
amongst staff members,
outsource agencies and as
Risk Management Plan has been effectively Check if risk management plan well as concerned officials
communicated to all the staff, and as well as has been communicated to all in district and state health
relevant external stakeholders stake holders administration
G10.3 2 SI/RR
Check if facility has

prepared assessment
checklist for identifying
risk on routine basis. This
checklist has been
disseminate to the staff
Risk assessment criteria and checklist for Check if risk assessment members responsible for
assessment have been defined and checklist is available with identifying and reporting
communicated to relevant stakeholders stakeholders risks
G10.4 2 SI/RR
Verify with the
assessment records.
Check if periodic assessment of Comprehensive of
Physical and electrical safety risk physical and electrical
Periodic assessment for Physical and is done using the risk assessment safety should be done at
Electrical risks is done as per defined criteria checklist least once in three month
G10.5 2 SI/RR
Check comprehensive
assessment of both
Periodic assessment for potential disasters Check periodic assessment pf manmade and natural
including re is done as per de defined potential disaster is done potential disaster is done
criteria periodically at least once in year
G10.7 2 SI/RR
Periodic assessment for potential risk Verify with records. At
regarding safety and security of staff least once in year and
including violence against service providers Check if Peridic assessment of whenever a major
is done as per defined criteria voillence risks is done incident has occurred.
Page 281
G10.8 2 SI/RR
Risk identified should be

listed and evaluated for
their secerity and
frequency for occurance.
A risk severity score /
grade should be give to
each rsik identified and
Check if various risks identified according gaps should be
Risks identified are analyzed evaluated and during the risk assessment rated. Verify with the
rated for severity procees are formaly evaluated records
G10.9 2 SI/RR
Check risks are prioritized
base on their severity
Identifed risks are treated based on severity Check if risk have high severy are rating. Verify with the
and resources available priorazied. records
G10.10 2 SI/RR
Check hospital
administration/
responsible committee
maintains a risk register
which risk identified, their
severity, action to be
taken to mitigate risk and
A risk register is maintained and updated follow up action. Check if
regularly to risk records identify ed risks, Check if a risk register is risk register share been
there severity and action to be taken maintained updated timely.
20 20
ME H1.1. Facility measures productivity Indicators on Bed Occupancy Rate
monthly basis 2 RR
. No. of total admissions per
thousand population 2 RR
. IPD per thousand population 2 RR
. OPD consultation per Thousand
Population 2 RR
. Number of beds per 10 thousand
2 RR
. Maternal mortality per 1000
deliveries 2 RR
. Neonatal mortality per 1000 live
births 2 RR
. Nurse to bed ratio 2 RR
. No. of meeting held under RKS 2 RR
Proportion of BPL patient in
hospital 2 RR
8 8
ME H2.1 Facility measures efficiency Indicators on Overall Referral Rate
monthly basis 2 RR
Overall discharge rate 2 RR
. Proportion of obstetric cases out
of total IPD 2 RR
. Proportion of fund/ grant utilized
2 RR
10 10
ME H3.1 Facility measures Clinical Care & Safety Average Length of Stay
. Crude mortality rate 2 RR
. Maternal mortality per 1000
deliveries 2 RR
. Neonatal mortality per 1000 live
births 2 RR
. Hospital acquired infection rate
Surgical Site, Device
related hospital acquired
2 RR infection rate
8 8
ME H4.1 Facility measures Service Quality Indicators Overall LAMA Rate
. Patient satisfaction Score IPD
2 RR
. Staff Satisfaction Score
2 RR
. Turn over rate of contractual
staff 2 RR
Obtained Maximum
A 66 66 100%
B 172 172 100%
C 235 236 100%
D 298 298 100%
E 64 64 100%
F 116 116 100%
G 188 188 100%
H 46 46 100%
Total 1185 1186 100%
0
1
2
Page 282

DH NQAS Checklist Ver.2.0 - 2019

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

DH NQAS Checklist Ver.2.0 - 2019

Uploaded by

Copyright:

Available Formats

NQAS SCORE CARD-DIS

HOSPITAL QUALITY SCORE CARDAREA OF C

Reference No Area of Concern &

Facility ensures that there are no financial barrier to access and

Facility has defined framework for ethical management includin

Standard G1 The facility has established organizational framework for qualit

Facility has established, documented implemented and maintai

Hospital Score Card (Deparatment wise)

100% 100% 100%

100% 100% 100%

100% 100% 100%

SCORE CARDAREA OF CONCERN WISE

Area of Concern & Standards

d in national Health Programs/ state scheme

y are appropriate to community needs.

hical management including dilemmas confronted during delivery of services at

Area of Concern C - Inputs

bles required for assured list of services.

Area of Concern D- Support Services

me for inspection, testing and maintenance and calibration of Equipment.

comfortable environment to staff, patients and visitors.

procedures for Financial Management

y and regulatory requirement imposed by local, state or central government

monitoring the quality of outsourced services and adheres to contractual

Area of Concern E- Clinical Services

or registration, consultation and admission of patients.

d procedures for ensuring hand hygiene practices and antisepsis

Area of Concern G- Quality Control

onal framework for quality improvement

implemented and maintained Standard Operating Procedures for all key

Area of Concern H- Outcome

National Quality Assurance Standards for District Hospitals Version 2

Names of Assessors Names of Assessees

Accident & Emergency Score Card

Major Gaps Observed

Checklist for Accident & Emergency

ME A1.16. The facility provides Accident & Emergency Availability of Emergency

Standard A3 Facility Provides diagnostic Services 8 8

Counselling services are available OB/RR

Availability of disable friendly OB

ME C1.2. Patient amenities are provide as per patient Availability of seating OB

Availability of cold Drinking OB

Demarcated receiving /triage OB

Lay out is flexible OB All the fixture and furniture

The ambulance(s) has a proper OB

Emergency is located near to the OB

Windows have grills and wire OB

Check the fire exits are clearly OB

ME C4.4. The facility has adequate Availability of dresser OB/SI

availability of dedicated security SI/RR

Availability of Drugs acting on OB/RR Tracers as per State EDL

Drugs for Respiratory System OB/RR Tracers as per State EDL

Hormonal Preparation 2 OB/RR Tracers as per State EDL

Availability of consumables in OB/RR

Availability of OB Hospital graded Mattress, IV

Check objective checklist has

Check for records of

No expiry drug found 2 OB/RR

There is practice of calculating SI/RR

Department maintained stock RR/SI

There is no stock out of drugs SI/RR

Temperature control and SI/OB Fans/ Air

Hospital has sound security OB/SI