HOSPITAL QUALITY SCORE CARD

DEPARTMENT WISE
Emergency NBSU Radiology General/Admin
95.7 98.9 92.2 83.3
Operation Pharmacy &
OPD
Theater Store Hospital
86.1 96.5 96.3
Score
Blood Storage
Labour Room Laboratory Unit
96.4 97.2 91.6 92.81
IPD Auxiliary PP Unit
94.1 78.9 98.5

HOSPITAL QUALITY SCORE CARD

AREA OF CONCERN WISE
Service Provision Patient Rights Inputs Support Services

91% 92% 90% 90%

HOSPITAL SCORE

92%
Clinical Services Infection Control Quality Management Outcome

94% 99% 91% 98%

 Area of Concern & Standards for CHC

Area of Concern - A: Service Provision

Standard A1 The facility provides Curative Services
Standard A2 The facility provides RMNCHA Services.
Standard A3 The facility Provides diagnostic Services
Standard A4 The facility provides services as mandated in the National Health Programmes /State
Standard A5
scheme(s).
Facility provides support srvices and Administrative services.
Standard A6 Health services provided at the facility are appropriate to community needs.
Area of Concern - B: Patients' Rights
Standard B1 The facility provides information to care-seekers, attendants & community about available
services, anddelivered
Services are their modalities
in a manner that is sensitive to gender, religious and cultural needs,
Standard B2
and there are no barrier on account
The facility maintains privacy, of physical,
confidentiality economic,
& dignity cultural and
of patients, or social
has astatus.
system for
Standard B3 The facility has defined and established procedures for informing patients about the medical
guarding patient related information.
Standard B4 condition, and involving them in treatment planning, and facilitates informed decision
Standard B5 The facility ensures that there are no financial barrier to access, and that there is financial
making
protection given from the cost of hospital services.
Area of Concern - C: Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure
Standard C2 meets the prevalent
The facility norms safety including fire safety of the infrastructure.
ensures physical
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured
Standard C4 services at the
The facility current
provides caseand
drugs loadconsumables required for assured services.
Standard C5 The facility has equipment & instruments required for assured list of services.
Area of Concern - D: Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and
Standard D2 calibration
The facility of
hasEquipment.
defined procedures for storage of drugs, inventory management and
Standard D3 dispensing of drugs in pharmacy
The facility has established andfor
Program patient care areasand upkeeto of the faciity to provide
mainntenance
Standard D4 safe, secureensures
The facility and comfortable
24X7 water environment
and power to staff,as
backup patients and visitors.
per requirement of service delivery,
Standard D5 and support services norms
The facility ensures avaialblity of Diet as per nutritional requirement and clean Linen to all
Standard D6 admitted patients.
The facility has defined and established procedures for promoting public participation in
Standard D7 management of hospital
Hospital has defined and transparency and accountability.
established procedures for Financial Management
Standard D8 The facility is compliant with all statutory and regulatory requirement imposed by local,
Standard D9 state
Roles or central government
& Responsibilities of administrative and clinical staff are determined as per govt.
Standard D10 regulations
The facility has establishedoperating
and standards procedureprocedures.
for monitoring the quality of outsourced services and
adheres to contractual obligations
Area of Concern - E: Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment o
Standard E3 The facility has defined and established procedures for continuity of care of patient and
Standard E4 referral
The facility has defined and established procedures for nursing care
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
Standard E6 The facility follows standard treatment guidelines defined by state/Central government for
prescribing the generic drugs & their rational use.
Standard E7 The facility has defined procedures for safe drug administration
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’
Standard E9 clinical records
The facility has and theirand
defined storage
established procedures for discharge of patient.
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster
Standard E11 Management
The facility has defined and established procedures of diagnostic services
Standard E12 The facility has defined and established procedures for Blood Storage Management and
Standard E13 Transfusion.
The facility has established procedures for Anaesthetic Services
Standard E14 The facility has defined and established procedures of Operation theatre.
Standard E15 The facility has defined and established procedures for end of life care and death
Maternal & Child Health Services
Standard E16 The facility has established procedures for Antenatal care as per guidelines
Standard E17 The facility has established procedures for Intranatal care as per guidelines
Standard E18 The facility has established procedures for postnatal care as per guidelines
Standard E19 The facility has established procedures for care of new born, infant and child as per
Standard E20 guidelines
The facility has established procedures for abortion and family planning as per government
Standard E21 guidelines
The facilityand law Adolescent Reproductive and Sexual Health services as per guidelines
provides
National Health Programmes
Standard E22 The facility provides services as per National Health Programmes' Operational/ Clinical
Guidelines Area of Concern - F: Infection Control
Standard F1 The facility has Infection Control Programme, and there are procedures in place for
Standard F2
prevention
The and defined
facility has measurement of Hospital Associated
and Implemented proceduresInfections
for ensuring hand hygiene practices
Standard F3
and antisepsis
The facility ensures availability of material for personal protection, and facility staff follow
Standard F4
standard precaution
The facility for personal
has standard protection.
procedures for processing of equipment and instruments
Standard F5 Physical layout and environmental control of the patient care areas ensure infection preventi
Standard F6 The facility has defined and established procedures for segregation, collection, treatment
and disposal of Bio-medical
Areaand
ofhazardous
Concern Waste.
- G: Quality Management
Standard G1 The facility has established organizational framework for quality improvement
Standard G2 The facility has established system for patient and employee satisfaction
Standard G3 The facility have established internal and external quality assurance Programmes wherever
Standard G4 it
Theis critical
facility to
hasquality.
established, documented implemented and maintained Standard Operating
Standard G5 Procedures
The for all
facility has key processes.
established system of periodic review as internal assessment , medical &
Standard G6 death audithas
The facility anddefined
prescription audit
and established Quality Policy & Quality Objectives
standard G7 The facility seeks continual improvement by practicing Quality tool and method.
Area of Concern - H: Outcomes
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National
Standard H2 benchmarks
The facility measures Efficiency Indicators and ensure to reach State/National Benchmarks
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National
Standard H4 benchmarks
The facility measures Service Quality Indicators and endeavours to reach State/National
benchmarks
 Standard wise
Score

90%
98%
85%
mmes /State 85%
96%
eds. 83%

ty about available
91%
nd cultural needs,
cial 91%
as astatus.
system for
s about the medical 93%
med decision 85%
there is financial
99%

ble infrastructure 86%

ure. 93%
ng the assured 88%
s. 99%
vices. 85%

enance and 88%

gement and 96%
e faciity to provide 92%
service delivery, 86%
clean Linen to all 92%
participation in 100%
ent 100%
mposed by local, 69%
ed as per govt. 84%
ourced services and 100%

mission of patients. 94%

nt and reassessment o 100%
of patient and 96%
94%
100%
ral government for 95%
 97%
ating of patients’ 91%
ent. 100%
es and Disaster 98%
s 90%
anagement and 93%
100%
. 94%
nd death 97%

nes 100%
es 100%
es 100%
hild as per 49%
as per government 100%
as per guidelines 100%

tional/ Clinical 87%

n place for 96%

hygiene practices 99%
acility staff follow 97%
truments 100%
re infection preventi 100%
ction, treatment 99%

ement 100%
58%
rammes wherever 97%
tandard Operating 96%
ment , medical & 83%
es 90%
method. 82%

h State/National 96%
tional Benchmarks 100%
State/National 98%
State/National 100%
 National Quality Assurance Standards for Taluka Hospital
Checklist for Accident & Emergency 1
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
. Area of Concern - A Service Provision 32 32
Standard A1. Facility Provides Curative Services 16 16
ME A1.1. The facility provides General Facility for managing medical 2 SI/OB Dengue Haemorrhagic fever,
Medicine services emergency cases Cerebral Malaria, Poisoning, Snake
Bite, Congestive Heart Failure,
Pneumonia, Acute Respiratory
conditions, Status Epilepticus,
Status Asthamaticus, Acute
Gastroenteritis, Severe drug
reactions.

ME A1.2. The facility provides General Availability of Emergency 2 SI/OB RTA, Lacerated wound, foreign
Surgery services Management of acute Surgical body in Ear/nose, Acute Abdomen
Condition Pain, Strangulated Hernia, Pyocele,
Renal Colic & Fracture

ME A1.3. The facility provides Obstetrics & Availability of Emergency Obstetrics 2 SI/OB APH, PPH, Eclampsia , Obstructed
Gynaecology S ervices &Gynaecology Procedures Labour, Septic Abortion, Emergency
Contraceptives

ME A1.4. The facility provides paediatric Availability of emergency Paediatric 2 SI/OB ARI, Diarrhoeal Diseases,
services procedures Hypothermia, PEM,resuscitation,
Convulsions/Seizurs

ME A1.8 The facility provides serv ices f or Availability of Dressing room facility 2 SI/OB Drainage, dressing, suturing
OPD procedures
. Availability of injection room 2 SI/OB Injection room facility with ARV,
facilities ASV and emergency drugs
ME A1.9. Servic es are available for the 24X7 availability of dedicated 2 SI/RR Check for emergency register
time period as mandated emergency Services
ME A1.10. The facility provides A ccident & Availability of Emergency procedures 2 SI/OB CPR, Mobilization, Cervical
Emergency Services immobilisation, Mechanical
Ventilation
Standard A3. Facility Provides diagnostic Services 10 10
ME A3.1. The facility provides Radiology Availability / Linkage to X-ray & USG 2 SI/OB
Servic es services
On call Radiology Services are 2 SI/OB Check services are functional at
available 24X7 night
ME A3.2. The facility Provides Laboratory Availability of point of care 2 SI/OB Hb in gram,, Blood Sugar, RDK,
Servic es diagnostics in emergency 24x7 Urine Protein,
on call facility for conducting 2
Emergency diagnostic tests 24x7
ME A3.3. The facility provides other Availability of Functional ECG 2 SI/OB
diagnostic serv ices, as mandated Services

Standard A5. Facility provides support services & Administrative Services 4 4

ME A5.3. The facility provides security 2 At least one per shift.
services Availability of Home Guard/Security
Guard SI/OB
ME A5.7. The facility has services of Availability of Medico-legal Record 2
medical record department Services
SI/OB
Standard A6. Health services provided at the facility are appropriate to community needs. 2 2
ME A6.1. The facility provides curatives & Availability of specific procedures for 2 SI/OB Ask for specific local health
preventive services for the health local prevalent emergencies emergencies e.g.. RTA, Cerebral
problems and diseases, prevalent Malaria encountered frequently.
locally . See if emergency is ready for it or
not.

. Area of Concern - B Patient Rights 60 60

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 unif orm and user- Availability departmental signage's . 2 OB Emergency department board is
friendly signage system prominently displayed with facility
of illumination in night.
. Directional signage for department 2 OB Direction is displayed from main
are displayed gate to Emergency
ME B1.2. The facility displays the services List of services that are managed at 2 OB
and entitlements available in its the facility
departments
. Names of doctor and nursing staff on 2 OB
duty are displayed and updated

. List of drugs available are displayed 2 OB

. Important numbers including 2 OB

ambulance, blood bank , police and
referral centres 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 Treatment note/discharge note is 2 RR/OB

clinical records of patients to given to patient
enti tled personnel
Standard B2. Services are delivered in a manne r that is s ens itive to gender, religious, and cultural ne eds , and there are no barrie r on a ccount of 18 18
ME B2.1. Servic es are provided in manner Arrangementphys ical access,
for examination of social, economic,
2 OBcultural or socia l status
that are sensitive to gender rape victims

. Availability of protocols /guidelines 2 OB /RR

for collection of forensic evidence in
case of rape victim

. Counselling services are available for 2 OB/RR

rape victim and domestic violence

. Availability of female staff if a male 2 OB/SI

doctor examine a female patients

Emergency contraceptive pill and 2 RR/SI

antibiotics are provided to all rape
victims
Availability of confidentiality and 2
privacy of transgender patient

ME B2.3. Availability of Wheel chair/ stretcher 2 OB

Access to facility is provided for emergency patient
without any phy sical barrier &
friendly to people with disability .

Availability of ramps with railing 2 OB

Ambulance has direct access to the
receiving/triage area of the
emergency.
2 OB No vehicle parked on the way /in
front of emergency entrance.
Access road to emergency is wide
enough for streamline moment of
emergency

Standard B3. The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 10 10
ME B3.1. Adequate visual priv acy is Screens and curtains are provided at 2 OB At the examination and procedure
provided at every point of care emergency area.

ME B3.2. Confidentiality of patients Confidentiality of patient's record 2 SI/OB

records and clinical information maintained
is maintained
MLC case records are kept in a 2 SI/OB
secured place with limited access to
essential personnel
ME B3.3. The facility ensures the Behaviour of staff is empathetic and 2 OB/PI
behaviours of staff is dignified courteous
and respectful, w hile delivering
the serv ices

ME B3.4. The facility ensures privacy and
confidentiality to every patient,
especially of those conditions
hav ing social stigma, and also
saf eguards v ulnerable groups
Privacy and confidentiality of HIV, 2 SI/OB
Rape, suicidal cases, domestic
violence and psychotic cases are
maintained

Standard B4. The facility has defined and established procedures for informing patients about the medical condition, a nd involving the m in 10 10
ME B4.1. There is established proceduresConsent treatment
is taken f or invasive 2 ta tesSI/RR
planning, and facili informed decisLumbar Puncture, Catheterization,
ion making
for taking informed consent emergency procedures PR & PV Examination
bef ore treatment and
procedures

ME B4.2. Patient is informed about his/her Display of charter which includes 2 OB

rights and responsibilities patient rights and responsibilities.

ME B4.3. Staff are aware of Patients rights Staff is aware of patient rights and 2 SI
responsibilities responsibilities
ME B4.4. Information about the treatment Patient/ attendant is informed about 2 PI Ask patients about what they have
is shared with patients or her clinical condition and treatment been communicated about the
attendants, regularly been provided treatment plan

ME B4.5. The facility has defined and Availability of complaint box and 2 OB Check for complaint register &
established grievance redressal display of process for grievance MOM of grievance redressal
system in place redressal and whom to contact is meeting
displayed

Standard B5. The facility ensure s tha t there are no financial barri er to acces s, and that there i s financial protection given from the cost of hos pital 6 6
ME B5.1 The facility provides cashless Emergency services are free for 2 PI/SI
services.
services to pregnant women, pregnant woman, neonate, children
mothers and neonates as per and BPL patients as per Government
prevalent government schemes order/Scheme

ME B5.2. The facility ensures that drugs Check that parents & attendant's 2 PI/SI
prescribed are av ailable at have not spent money on purchasing
Pharmacy and wards drugs and consumables from
outside.

ME B5.3. It is ensured that facilities for the Check that parents & attendants 2 PI/SI Provision of diagnostics in
prescribed inv estigations are have not spent money on diagnostics empanelled Government or Private
available at the f acility from outside. diagnostic centre under CMCHIS.

. Area of Concern - C Inputs 134 150

Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 40 50
ME C1.1. Departments hav e adequate Adequate space for accommodating 2 OB
space as per patient or work load emergency load

ME C1.2. Patient amenities are provide as Availability of seating arrangement 2 OB

per patient load in the waiting area
. Availability of Drinking water 2 OB
. Availability of functional toilets 2 OB Dry with regular supply of water

ME C1.3. Departments hav e layout and Demarcated trolley bay 2 OB

demarcated areas as per
functions
. Demarcated receiving /triage area 2 OB

. Demarcated Nursing station 2 OB

. Demarcated duty room for doctor 2 OB
/nurse
. Demarcated resuscitation area 2 OB
. Demarcated observation area/beds 2 OB

. Demarcated dressing area /room 2 OB

. Demarcated injection room 2 OB

. Demarcated area for keeping serious 2 OB
patient f or intensive monitoring

. Demarcated areas for keeping dead 2 OB Separate room or linkage with

bodies. mortuary/ Post mortem room
. Lay out is flexible 2 OB All the fixture and furniture are
movable to rearrange the different
areas in case of mass casualty

. Dedicated Minor OT 0 OB
. Shaded porch for ambulance 0 OB
. Availability of clean and dirty utility 2
room
ME C1.4. The facility has adequate Corridors at Emergency are broad 2 OB 2-3 meter
circulation area and open spaces enough f or easy moment of
according to need and local law stretcher and trolley

ME C1.5. The facility has infrastructure f or Availability of functional telephone 0 OB

intramural and extramural and Intercom Services/CUG Services
communication
. The ambulance(s) has a proper 2 OB
communication system(at least cell
phone)
ME C1.6. Servic e counters are available as Availability of emergency beds as per 2 OB At least 4 beds.
per patient load expected load
ME C1.7. The facility and departments are Unidirectional flow of services. 0 OB Receiving/Triage-Resuscitation-
planned to ensure structure observation beds- Procedures area.
follows the function/processes There is no criss cross
(S tructure commensurate with
the function of the hospital)

. Separate entrance for emergency 0 OB

department
Emergency is located near to the 2 OB
entrance of the hospital
Standard C2. The facility ensures the physical safety including Fire safety of the infrastructure. 16 16
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and furniture like
saf ety of the infrastructure properly secured cupboards, cabinets, and heavy
equipment , hanging objects are
properly fastened and secured

ME C2.2. The facility ensures saf ety of Emergency Department does not 2 OB
electrical establishment have temporary connections and
loosely hanging wires
ME C2.3 Physical condition of buildings Floors of the Emergency Department 2 OB
are safe for providing patient are non slippery and even
care
. Windows and vents if any are intact 2 OB
and sealed
ME C2.4 The facility has plan for Emergency has fire exit to permit 2 OB/SI
prevention of fire safe escape of its occupant at time of
fire
ME C2.5 The facility has adequate fire Emergency has installed fire 2 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.
. Check the expiry date for fire 2 OB/RR
extinguisher is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned

ME C2.6 The facility has a system of Check for staff competencies 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

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 22 28
ME C3.1 The facility has adequate Specialist's are available on call for 2 OB/RR Gynaecologists, Paediatrician &
specialist doctors as per service emergency cases Surgeon
provision.
ME C3.2. The facility has adequate general Availability of at least one Doctor 2 OB/RR
duty doc tors as per service 24x7
provision and w ork load

ME C3.3. The facility has adequate nursing Availability of trained Nursing staff 2 OB/RR/SI
staff as per service provision and
work load
ME C3.4. The facility has adequate Availability of dresser /paramedic 2 OB/SI
technicians/paramedics as per
requirement
ME C3.5 The facility has adequate support Availability of Drivers for Ambulance 2 SI/RR Driver may be on call for
/ general staff 24X7 emergency.
ME C3.6 The staff has been provided Triage and Mass Casualty 0 SI/RR
required training / sk ill sets Management
. Basic life support (BLS)/ Advance life 0 SI/RR
support (ALS)
Care of unconscious patient 0
. Bio Medical waste Management 2 SI/RR
. Infection control and hand hygiene 2 SI/RR

Patient Safety 2
ME C3.7 The Staff is sk illed as per job The Staff is skilled for emergency 2 SI/RR
description procedures
The Staff is skilled for resuscitation 2 SI/RR
and use defibrillator

The Staff is skilled for maintaining 2 SI/RR

clinical records
Standard C4. Facility provides drugs and consumables required for assured list of services. 32 32
ME C4.1. The departments hav e Availability of 2 OB/RR Tracers as per State EDL
availability of adequate drugs at Analgesics/Antipyretics/Anti
point of use Inflammatory

. Availability of Injectable Antibiotics 2 OB/RR Tracers as per State EDL

. Availability of Infusion Fluids 2 OB/RR Tracers as per State EDL

. Availability of Drugs acting on CVS 2 OB/RR Tracers as per State EDL

. Availability of drugs action on 2 OB/RR Tracers as per State EDL

CNS /PNS
. Availability of dressing material and 2 OB/RR Tracers as per State EDL
antiseptic lotion
. Drugs for Respiratory System 2 OB/RR Tracers as per State EDL
. Availability of drugs for obstetric 2 OB/RR Tracers as per State EDL
emergencies
. Availability of emergency drugs in 2 OB/RR Megsulf, Oxytocin, Plasma
ambulance Expanders
. Availability of Medical gases 2 OB/RR Availability of Oxygen Cylinders

Availability of Immunological drugs 2 OB/RR Polyvalent Anti snake Venom, Anti

tetanus Human Immunoglobin

Antidotes and Other Substances 2 OB/RR Inj. Atropine Sulphate

used in Poisonings
ME C4.2. The departments hav e adequate Resuscitation Consumables / Tubes 2 OB/RR Masks, Ryle's tubes, Catheters,
consumables at point of use Chest Tube, ET tubes etc.

. Availability of disposables at 2 OB/RR

dressing room
. Availability of consumables in 2 OB/RR Dressing material / Suture material
ambulance
ME C4.3. Emergency drug trays are Emergency Drug Tray/ Crash Cart is 2 OB/RR
maintained at every point of maintained at emergency
care, where ever it may be
needed

Standard C5. The facility has equipment & instruments required for assured list of services. 24 24
ME C5.1. Availability of equipment & Availability of functional 2 OB BP apparatus, Multipara
instruments for examination & Equipment & Instruments for meter ,Torch, hammer , Spot
monitoring of patients examination & Monitoring Light ,Stethoscope, thermometer

. Availability of Monitoring 2 OB
equipment in ambulance
ME C5.2. Availability of equipment & Availability of dressing tray for 2 OB Artery forceps
instruments for treatment Emergency procedures
procedures, being undertaken in
the facility

Availability of instruments for 2 OB Speculum, D & E Set

emergency obstetrics procedure

ME C5.3. Availability of equipment & Availability of Point of care 2 OB Glucometer, ECG ,HIV rapid
instruments for diagnostic diagnostic dev ices diagnostic kit, RDK
procedures being undertaken in
the facility

ME C5.4. Availability of equipment and Availability of functional 2 OB Ambu bag, defibrillator,

instruments for resuscitation of Instruments for Resuscitation. Laryngoscope with spare batteries,
patients and for prov iding nebulizer, suction apparatus ,
intensive and critical care to Laryngeal mask
patients

ME C5.5. Availability of Equipment for
Storage
ME C5.6 Availability of f unctional
equipment and instruments f or
support servic es
ME C5.7. Departments hav e patient
furniture and fix tures as per load up facility and wheels
and service provision
Availability of equipment for
storage for drugs
Availability of equipment for
sterilization and disinfection
Availability of patient beds with prop
Availability of
attachment/accessories with patient
bed
Availability of fixtures
2 OB Refrigerator, Crash cart/Drug
trolley, instrument trolley, dressing
trolley
2 OB Steam steriliser/ Autoclave
2 OB
2 OB Hospital graded Mattress, IV stand,
bed rails, Bed pan for male &
female
2 OB Spot light, electrical fixture for
equipment like suction, monitor
and defibrillator, X ray view box

Availability of furniture at 2 OB Doctors Chair, Patient Stool,

emergency Examination Table, Chair, Table,
Footstep, cupboard
. Area of Concern - D Support Services 82 82
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 All equipment are covered under 2 SI/RR
system f or maintenance of AMC including preventive
critical Equipment maintenance

. There is system of timely corrective 2 SI/RR

ME D1.2. The facility has established
procedure for internal and
external calibration of measuring
Equipment
break down maintenance of the
equipment
The Staff is skilled for trouble 2 SI/RR
shooting in case equipment
malfunction
All the measuring equipment/ 2 OB/ RR Thermometer, weighting scale, BP
instrument are calibrated apperatus, suction machine,
oxygen flowmeter & meter gauze

ME D1.3. Operating and maintenance Up to date instructions for operation 2 OB/SI Suction machine, Multipara
instructions are available with and maintenance of equipment are monitor , defibrillator.
the users of equipment readily available with staff.

Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 20 20
ME D2.3. The facility ensures proper Drugs are stored in 2 OB
storage of drugs and containers/tray/crash cart and are
consumables labelled

. Empty and filled cylinders are 2 OB

labelled
ME D2.4. The facility ensures management Expiry dates' are maintained at 2 OB/RR
of expiry and near ex piry drugs emergency drug tray

. No expiry drug is found 2 OB/RR

ME D2.5. The facility has established The Department maintained stock 2 RR/SI
procedure for inventory and expenditure register of drugs
management techniques and consumables in Emergency

ME D2.6. There is a procedure for periodically There is procedure for replenishing 2 SI/RR
replenishing the drugs in patient drug tray emergency crash cart
care areas
There is procedure for replenishing 2 OB/SI
drug tray emergency crash cart in
ambulance

There is no stock out of drugs 2 SI/RR

ME D2.7. There is process for storage of Temperature of refrigerators are 2 OB/RR Check for temperature charts are
vaccines and other drugs, kept as per storage requirement and maintained and updated
requiring controlled temperature records are maintained periodically

ME D2.8. There is a procedure for sec ure Narcotics and psychotropic drugs are 2 OB/SI
storage of narcotic and kept in lock and key
psychotropic drugs
Standard D3. The facility has established Program for maintenance and upkeep of the facil ity to provide s afe, secure a nd comfortable e nvironment 28 28
ME D3.2. Hospital infrastructure is Check for there is no seepage ,to staff, patients
2 and
OB visitors.
adequately maintained Cracks, chipping of plaster
Window panes , doors and other 2 OB
fixtures are intact
Patients beds are intact and painted 2 OB

Mattresses are intact and clean 2 OB

ME D3.3 Patient care areas are c lean and Floors, walls, roof, roof tops, and 2 OB All area are clean with no
hygienic circulation areas are Clean dirt,grease,littering and cobwebs

Surf ace of furniture and fixtures are 2 OB

clean
ME D3.4. The facility has policy of remov al No condemned/Junk material in the 2 OB
of condemned junk material Emergency

ME D3.5. The facility has established No stray animal/rodent/birds/ 2 OB

procedures for pest, rodent and termites
animal c ontrol
ME D3.6. The facility provides adequate Adequate illumination at procedure 2 OB 200 Lux (Minimum)
illumination level at patient care area.
areas
ME D3.7. The facility has prov ision of Visitors are restricted at 2 OB/SI Resuscitation area, dressing room
restriction of visitors in patient resuscitation and procedure area and examination area
areas
ME D3.8 The facility ensures saf e and Temperature control and ventilation 2 PI/OB Fans/ Air
comfortable environment for in the emergency. conditioning/Heating/Exhaust/Ven
patients and service prov iders tilators as per environment
condition and requirement

ME D3.9. The facility has security system in There are set procedures for 2 SI/OB See for linkage to police, Provision
place at patient care areas handling mass situation and violence for protection of staff
in emergency

. Hospital has sound security system 2 OB/SI

to manage overcrowding in
emergency
ME D3.10. The facility has established measure Ask female staff whether they feel 2 SI
for safety and security of female secure at work place
staff
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 10 10
ME D4.1. The facility has adequate Availability of 24x7 running and 2 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas

ME D4.2. The facility ensures adequate Availability of power back in 2 OB/SI

power backup in all patient care Emergency, which can take load of
areas as per load running equipment

Availability of UPS 2 OB/SI

Availability of Emergency light 2 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Oxygen cylinders and 2 OB
availability of oxygen, medical gases vacuum suction
and vacuum supply

Standard D5. The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 4 4
ME D5.4 The facility has adequate sets of Clean Linen is provided on 2 OB/RR
linen observation beds
ME D5.5 The facility has established Linen is changed every day or 2 OB/RR
procedures for changing of linen whenever it get soiled
in patient care areas
Standard D8. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 4 4
ME D8.1. The facility has requisite licences Valid licences for ambulances are 2 RR/SI
and certificates for operation of available
hospital and different activ ities

ME D8.3. The facility ensure relevant Staff is aware of procedure & 2 SI

processes are in compliance with protocol of management of medico
statutory requirement legal cases

Standard D9. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 6 6
ME D9.1. The facility has established job Staff is aware of their roles and 2 SI
description as per govt guidelines responsibilities

ME D9.2. 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 diff erent roster (Attendance register/ Biometrics
departments etc.)

ME D9.3. The facility ensures the Doctor, nursing staff and support 2 OB
adherence to dress code as staff adhere to their respective dress
mandated by its administration / code
the health department

. Area of Concern - E Clinical Services 196 206

Standard E1. The facility has defined procedures for registration, consultation and admission of patients. 22 22
ME E1.1. The facility has established Unique identification number is 2 RR
procedure for registration of given to each patient during
patients registration

. Patient demographic details are 2 RR Check for that patient

ME E1.3. There is established procedure
for admission of patients
recorded in admission records
There is established criteria for
admission through emergency
department
demographics like Name, Age,
Sex,Provisional Diagnosis etc.
2 SI/RR

There is established procedure for 2 SI/RR

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

Admission is done by written order 2 SI/RR

of a qualified doctor
There is no delay in treatment 2 SI/RR
because of admission process
Time of admission is recorded in 2 RR
patient record
There is no delay in transf er of 2 SI/RR
patient to respective department
once admission is confirmed and
clinically patient is stable to be
transferred

The Staff is aware of procedure, if 2 SI

patient can not be admitted at the
facility due to constraint in scope of
services

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

for managing patients, in case trolley beds in case of high
beds are not available at the occupancy or mass casualty
facility

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 Assessment criteria of different kind 2 SI/RR Use of standard criteria of
for initial assessment of patients of medical emergencies is defined assessment like Glasgow Comma
and practiced scale, Poly trauma, MI, Burn
patient, Paediatric patient, Pain
assessment criteria etc.

. Initial assessment and treatment is 2 OB/RR

provided immediately

. Initial assessment is documented 2 RR

preferably within two hours

ME E2.2. There is established procedure There is fixed schedule for 2 RR/SI

for follow -up/ reassessment of reassessment of patient under
Patients observation

Standard E3. Facility has defined and established procedures for continuity of care of patient and referral 18 18
ME E3.1. Facility has established There is a procedure for hand over 2 SI/RR Check for how hand over is given
procedure for continuity of care for patient transfer from emergency from emergency to ward, NBSU
during interdepartmental to IPD /OT/LR etc.
transfer

. There is a proc edure c onsultation 2 SI/RR

of the pati ent with other
specialist with in the hospital

ME E3.2. Facility provides appropriate Patient are referred with referral 2 SI/RR
referral linkages to the slips
patients/Services for transfer to
other/higher facilities to assure
their continuity of care.

. Availability of referral linkages with 2 SI/RR Check how patient are referred if
higher centres. services are not available
. Advance information is given to 2 SI/RR
higher centre
. Referral vehicle is arranged 2 SI/RR
. Referral in or referral out register is 2 RR
maintained
. Facility has f unctional referral 2 SI/RR
linkages to lower facilities
. Check for if there is any system of 2 RR Check for referral cards filled f rom
follow up lower facilities
Standard E4. The facility has defined and established procedures for nursing care 14 16
ME E4.1. Procedure for identification of There is a process for ensuring the 2 OB/SI Patient id band/ verbal
patients is established at the identification before any clinical confirmation/Bed no. etc.
facility procedure

ME E4.2. Procedure for ensuring timely and Treatment charts 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 proc ess to ensure the 0 SI/RR Verbal orders are rechecked bef ore
accuracy of v erbal/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 change in the shift
staff duty change happens

. Nursing Handover register is 2 RR

ME E4.4. Nursing records are maintained
ME E4.5. There is procedure for periodic
monitoring of patients
maintained
Nursing notes are maintained
adequately
Patient Vitals are monitored and
recorded periodically
2 RR/SI Check for nursing note register.
Notes are adequately written
2 RR/SI Check for TPR chart, Input output
chart, any other vital required is
monitored

. Critical patients are monitored 2 RR/OB Check for use of cardiac

continuously 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 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

ME E5.2. The facility identifies high risk High risk medical emergencies are 2 OB/SI MI, Head injury, Spinal injury,
patients and ensure their care, as identified and treatment given on Abdominal injuries, fracture's.
per their need priority
Standard E6. Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use. 8 8
ME E6.1. Facility ensured that drugs are Check for BHT/Case sheet/Case 2 RR
prescribed in generic name only paper if drugs are 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
regime and doses as per STG
Check BHT/Case sheet/Case paper 2 RR
that drugs are prescribed as per STG

Standard E7. Facility has defined procedures for safe drug administration 18 22
ME E7.1. There is process for identifying High alert drugs available in 0 SI/OB As applicable to the department
and cautious administration of department are identified
high alert drugs

Maximum dose of high alert drugs 0 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 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

ME E7.2. Medication orders are written Every M edical advice and 2 RR

legibly and adequately procedure are accompanied with
date , time and signature
. Check for the writing to ensure that 2 RR/SI
it is comprehendible by the clinical
staff
ME E7.3. There is a procedure to check Drugs are checked for expiry and 2 OB/SI Turbidity, Leakage, Colour change,
drug before administration/ other inconsistency before fungus.
dispensing 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 intended 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
Any adverse drug reaction is 2 RR/SI
recorded and reported
ME E7.4. There is a system to ensure right Administration of medicines done 2 SI/OB
medicine is given to right patient 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 SI/PI
administration Pharmacist /nurse about the 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 findings are written on 2 RR Day to day progress of patient is
assessment and investigations BHT/Case sheet/Case paper recorded in BHT/Case sheet/Case
are recorded and updated paper

ME E8.2. All treatment plan Treatment plan, first orders are 2 RR Treatment prescribed in nursing
prescription/orders are recorded written on BHT/Case sheet/Case records
in the patient records. paper

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 Any procedure performed is written 2 RR CPR, Dressing, mobilization etc.
written on patients records on BHT/Case sheet/Case paper

ME E8.5. Adequate form and formats are Availability of form formats for 2 OB/SI MLC, Lab /X-ray requisition, death
available at point of use emergency Intimation form II/MCCD f orm IV,
Initial assessment format, referral
slip etc.

ME E8.6. Register/records are maintained Emergency Records are maintained 2 OB/RR Emergency register, death register,
as per guidelines MLC register, are maintained

. All register/records are identified 2 OB/RR

ME E8.7. The facility ensures saf e and
adequate storage and retrieval
of medical rec ords
Standard E9.
ME E9.1. Discharge is done after assessing Assessment is done bef ore
patient readiness
and numbered
Safe keeping of MLC records 2 OB/SI
The facility has defined and established procedures for discharge of patient. 16 16
2 SI/RR See if there is any
discharging patient from emergency procedure/protocol for discharging
the patient if the condition of
patient improves in emergency
itself.
What is the procedure for
discharge for short stay / day care
patients

Discharge is done by a responsible 2 SI/RR

and qualified doctor
Patient / attendants are consulted 2 PI
before discharge
ME E9.2. Case summary and follow-up Discharge summary is provided 2 RR/PI See for discharge summary, referral
instructions are prov ided at the slip provided.
discharge
. Discharge summary adequately 2 RR
mentions patients clinical condition,
treatment given and follow up

. Discharge summary is give to 2 SI/RR

patients going in LAMA/Referral
ME E9.3. Counselling serv ices are provided Counselling services are provided 2 SI/PI
as during discharges wherever wherever it is required
required
ME E9.4. The facility has established Declaration is taken from the LAMA 2 RR/SI
procedure for pati ents leav ing patient
the facility against medical
adv ice, absconding, etc.

Standard E10. The facility has defined and established procedures for Emergency Services and Disaster Management 50 50
ME E10.1. There is procedure for Receiving Emergency has implemented a 2 SI/OB As care provider how they triage
and triage of patients system of sorting the patients patient- immediate, delayed,
expectant, minimal, dead

. Triage area is marked 2 OB/SI

. Triage protocols are displayed 2 OB
. Responsibility of receiving and 2 SI
shifting the patient from vehicle is
defined
ME E10.2. Emergency protoc ols are defined Emergency protocols are available at 2 OB See for protocols of head injury,
and implemented point of use snake bite, poisoning, drawing etc.

. Staff is aware of Clinical protocols 2 SI/RR

. There is procedure for CPR 2 SI/RR

ME E10.3. The facility has disaster Line of authority is defined 2 SI/RR
management plan in place
. Procedure for internal 2 SI/RR
communication defined
. There is procedure for setting up 2 SI/RR
control room
. Disaster buffer stock of medicines 2 SI/RR
and other supplies maintained

. Role and responsibilities of staff in 2 SI/RR

disaster is defined
. Staff is aware of disaster plan 2 SI/RR
ME E10.4. The facility ensures adequate Check for how ambulances are called 2 SI/RR
and timely availability of and patients are shifted
ambulances services and
mobilisation of resources, as per
requirement

. Ambulances are equipped 2 OB

. If the patient is stable than he/she is 2 SI/RR
tranferred in 108 ambulance with
trained driver and emergency
trained technician

. If the Patient is serious (As decided 2 SI/RR

by doctor) than trained driver,
Emergency medical technician, one
staff from the hospital shall
accompany the patients

. Ambulance is appropriately 2 OB/RR

equipped for BLS with trained
personnel
. There is a daily checklist of all 2 RR
equipment and emergency
medications
. Ambulance has a log book f or the 2 RR
maintenance of vehicle and daily
vehicle checklist
. Transfer register is maintained to 2 RR
record the detail of the referred
patient
ME E10.5. There is procedure for handling Medico legal cases are identified by 2 RR/SI
medico legal cases patient records
. Treatment of MLC cases are not 2 SI/OB/RR
delayed because of police
proceedings
. There is a establish procedure for 2 SI/RR Medico -legal case is discharged
informing police, as per govt and intimation given to the police.
guidelines
. Emergency has criteria for defining 2 SI/RR Criteria is defined based on cases
medico legal cases and when to do MLC
Standard E11. The facility has defined and established procedures of diagnostic services 2 4
ME E11.1. There are established Container is labelled properly after 2 OB
procedures for Pre-testing the sample collection
Activ ities
ME E11.3. There are established Nursing station is provided with the 0 SI/RR
procedures for Post-testing critical value of different tests
Activ ities
Standard E14. The facility has defined and established procedures of Operation theatre and surgical services. 2 4
ME E14.1. Facility has established There is procedure for emergency 0 SI/RR See surgeon is available on call/on
procedures OT Scheduling surgeries duty
. Procedure for arranging logistics 2 SI Responsibilities are defined and
patient is shifted promptly
Standard E15. The facility has defined and established procedures for end of life care and death 18 18
ME E15.1. Death of admitted patient is Facility has a standard procedure 2 SI
adequately recorded and of communicating death to
communicated relatives decently.
. Death note is written on patient 2 RR
record
ME E15.2. The facility has standard Past history and sign of any medico 2 RR Check what is policy for registering
procedures for handling the legal cause is looked for brought in dead, death cases as
death in the hospital MLC

. There is criteria for declaring death 2 SI/RR Ask form how death is declared -
Physical examination or ECG is
done
. Procedure for handing over the dead 2 SI
body
. Death intimation is given to the 2 SI/RR
concerned authority for the issue of
death certificate
ME E15.3 The facility has standard operating Patients Relatives are informed 2 PI/SI
procedure for end of life support clearly about the deterioration in
health condition of Patients
There is a standard procedure of 2 SI/RR Check about the policy and practice
removal of life support as per law for removing life support

There is a procedure to allow patient 2 SI/OB

relative/Next of Kin to observe
patient in last hours
. Area of Concern - F Infection Control 100 104
Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 6 8
ME F1.4. There is Provision of Periodic There is a procedure for 2 SI/RR Hepatitis B, Tetanus Toxic etc.
Medical Check -up's and immunization of the staff
immunization of staff
Periodic medical check-ups of the 2 SI/RR
staff
ME F1.5. Facility has established Regular monitoring of infection 0 SI/RR Hand washing and infection control
procedures for regular control practices audits done at periodic intervals
monitoring of inf ection control
practices

ME F1.6 Facility has defined and Check if Doctors are aware of 2 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 16 18
ME F2.1. Hand washing fac ilities are Availability of hand washing Facility 2 OB
provided at point of use at Point of Use
. Availability of running Water 2 OB/SI Open the tap. Ask the Staff, water
is available 24*7
. Availability of antiseptic soap with 2 OB/SI Check for availability/ Ask staff if
soap dish/ liquid antiseptic with the supply is adequate and
dispenser. uninterrupted
. Availability of Alcohol based Hand 0 OB/SI Check for availability/ Ask staff for
rub regular supply. Hand rub dispenser
are provided adjacent to bed

. Display of Hand washing Instruction 2 OB Prominently displayed above the

at Point of Use hand washing facility , preferably in
Local language
ME F2.2. Staff is trained and adhere to Adherence to 6 steps of Hand 2 SI/OB Ask for demonstration
standard hand washing practic es washing

. Staff is aware of occasion for hand 2 SI

washing
ME F2.3. Facility ensures standard Availability of Antiseptic Solutions 2 OB
practices and materials for
antisepsis
Procedure for proper cleaning of site 2 OB/SI e.g. before giving IM/IV injection,
with antisepsis drawing blood, putting Intravenous
and urinary catheter

Standard F3. Facility ensures standard practices and materials for Personal protection 10 10
ME F3.1. Facility ensures adequate Clean gloves are available at point of 2 OB/SI
personal protection equipment use
as per requirements

. Availability of Masks 2 OB/SI

Personal protective kit for infectious 2 OB/SI
patients
ME F3.2. Staff is adhere to standard No reuse of disposable gloves, 2 OB/SI
personal protection practices Masks, caps and aprons.
. Compliance to correct method of 2 SI
wearing and removing the gloves

Standard F4. Facility has standard Procedures for processing of equipment and instruments 20 20
ME F4.1. Facility ensures standard practices Decontamination of Procedure 2 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate work benches
and cleaning of instruments and (Wiping with 0.5% Chlorine
procedures areas solution)

Proper Decontamination of 2 SI/OB Decontamination of instruments

instruments after use and reusable of glassware are done
after procedure in 1% chlorine
solution/ any other appropriate
method

Contact time for decontamination is 2 SI/OB 10 minutes

adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with detergent
decontamination and running water after
decontamination
Proper handling of soiled / infected 2 SI/OB Soiled / infected and Dirty linen are
and dirty linen. segregated at point of generation.
No rinsing or sluicing at Point of
use/ Patient care area.

The Staff knows how to make 2 SI/OB

chlorine solution
ME F4.2. Facility ensures standard practices Equipment and instruments are 2 OB/SI Autoclaving/HLD/Chemical
and materials for disinfection and sterilized after each use as per Sterilization
sterilization of instruments and requirement
equipment

High level Disinfection of
instruments/equipment is done as
per protocol
Chemical sterilization of
instruments/equipment is done as
per protocols
2 OB/SI Ask staff about method and time
required for boiling
2 OB/SI Ask staff about method,
concentration and contact time
required for chemical sterilization

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
ME F5.1. Layout of the department is Facility layout ensures separation of 2 OB
conducive for the infection control general traffic from patient traffic
practices
ME F5.2. Facility ensures availability of Availability of disinfectant as per 2 OB/SI Chlorine solution, Gluteraldehye,
standard materials for cleaning and requirement carbolic acid
disinfection of patient care areas

Availability of cleaning agent as per 2 OB/SI Hospital grade phenyl, disinfectant

requirement detergent solution
ME F5.3. Facility ensures standard practices The Staff is trained f or spill 2 SI/RR
followed for cleaning and management
disinfection of patient care areas

. Cleaning of patient care area with 2 SI/RR

disinfectant detergent solution

. The Staff is trained f or preparing 2 SI/RR

cleaning solution as per standard
procedure
. Standard practice of mopping and 2 OB/SI Unidirectional mopping from inside
scrubbing are followed out
. Cleaning equipment like broom are 2 OB/SI Any cleaning equipment leading to
not used in patient care areas dispersion of dust particles in air
should be avoided

ME F5.4. Facility ensures segregation Emergency department define list of 2 OB/SI

infectious patients infectious diseases require special
precaution and barrier nursing

The Staff is trained f or barrier 2

nursing
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. Facility Ensures segregation of Availability of colour coded bins at 2 OB
Bio Medical W aste as per point of waste generation
guidelines
. Availability of Non chlorinated plastic 2 OB
colour coded plastic bags
. Segregation of Anatomical and solied 2 OB/SI
waste in Yellow Bin
. Segregation of infected plastic waste 2 OB
in red bin
Display of work instructions for 2 OB
segregation and handling of
Biomedical waste
There is no mixing of infectious and 2 OB
general waste
ME F6.2. Facility ensures management of Availability of functional hub cutters OB See if it has been used or just lying
sharps as per guidelines idle
. Availability of puncture proof box 2 OB
Should be available nears the point
of generation like nursing station
and injection room
. Availability of white translucent bins 2 OB Check for Puncture proof, tamper
for waste S harps proof and leak proof containers

Availability of Blue bins f or 2 OB Check for Puncture proof and leak

Galssware proof boxes with blue colored
marking
. Availability of post exposure 2
prophylaxis
Ask if available. Where it is stored
OB and who is in charge of that.
ME F6.3. Facility ensures transportation Check bins are not overfilled 2 SI
and disposal of waste as per
guidelines
Disinfection of liquid waste before 2 SI/OB
disposal
Transportation of bio medical waste 2 SI/OB
is done in close container/trolley

Staff is aware of mercury spill 2 SI/RR

management
. Quality Management 47 48
Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality. 9 10
ME G3.1. Facility has established internal There is system daily round by 1 SI/RR
quality assurance program at matron/hospital manager/ hospital
relevant departments superintendent/ Hospital Manager/
Matron in charge for monitoring of
services

There is system for periodic check up 2 SI/RR

ME G3.2. Facility has established ex ternal
assurance programs at relev ant
departments
of Ambulances by designated
hospital staff
There is periodic assessment of 2 SI/RR
preparedness for disaster by
competent authority

ME G3.3. Facility has established system Departmental checklist are used 2 SI/RR
for use of check lists in different for monitoring and quality
departments and services assurance

. Staff is designated for filling and 2 SI

monitoring of these checklists

Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 32 32
ME G4.1. Departmental standard operating Standard operating procedure for 2 RR
procedures are available department has been prepared and
approved

Current version of SOP are available 2 OB

with process owner
ME G4.2. Standard Operating Procedures Emergency has documented 2 RR
adequately describes process procedure for receiving the patient
and procedures in emergency

The Department has documented 2 RR

procedure for triaging

The Department has documented 2 RR

procedure for taking consent

The Department has documented 2 RR

procedure for initial screening of
patient
The Department has documented 2 RR
procedure for nursing care

The Department has documented 2 RR

procedure for admission and
transfer of the patient to ward

The Department has documented 2 RR

procedure for maintaining records in
Emergency

The Department has documented 2 RR

procedure to handle brought in dead
patient
The Department has documented 2 RR
procedure for storage, handling and
release of dead body

The Department has documented 2 RR

procedure for storage and
replenishing the medicine in
emergency

The Department has documented 2 RR

procedure for equipment preventive
and break down maintenance

The Department has documented 2 RR

procedure for Disaster management

ME G4.3. Staff is trained and aware of the Check if staff is aware of relevant 2 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4. W ork instructions are displayed Work instruction/clinical protocols 2 OB Triage, CPR, Medical clinical
at Point of use are displayed protocols like Snake bite and
poisoning
Standard G6. The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2. The facility periodically defines Quality objective for emergency 2 RR/SI
its quality objectives and key defined
departments have their own
objectives

ME G6.3. Quality policy and objectives are Check if staff is aware of quality 2 SI
disseminated and staff is aw are policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored and 2 SI/RR
objectives is monitored reviewed periodically
periodically
. 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 No of Emergency cases per thousand 2 RR
Indicators on monthly basis population
. No of trips per ambulance 2 RR
. No. of trauma cases treated per 2 RR
1000 emergency cases
. No. of poisoning cases treated per 2 RR
1000 emergency cases
. No. of cardiac cases treated per 1000 2 RR
emergency cases
. No. of obstetric cases treated per 2 RR
1000 emergency cases
. No of resuscitation done per 2 RR Resuscitation should include: Chest
thousand population Compression, Airway and Breathing

. Proportion of Patients attended in 2 RR

Night
ME H1.2. The Facility measures equity Proportion of BPL Patients 2 RR
indicators periodically
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 10 10
ME H2.1. Facility measures efficiency Response time for ambulance 2 RR Between receipt of call and
Indicators on monthly basis dispatch of ambulance
. Proportion of cases referred 2 RR
. Response time at emergency for 2 RR
initial assessment
. Average Turn Around Time of patient 2 RR Average time a patient stays at
emergency observation bed
. Proportion of patient referred by 2 RR
state owned/108 ambulance per
1000 referral cases
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 & No of adverse events per thousand 2 RR
Safety Indicators on monthly basis patients

. Death Rate 2 RR No of Deaths in Emergency/ Total

no of emergency 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 LAMA Rate 2 RR No of LAMA X 100/ No of Patients
Indicators on monthly basis seen at emergency

Absconding rate 2 RR No of Absconding X 100/ No of

Patients seen at emergency

Emergency Score Card

 Emergency
Score 95.682451
Area of Concern wise Score
A Service Provision 100
B Patient Rights 100
C Inputs 89.3333333333333
D Support Services 100
E Clinical Services 95.1456310679612
F Infection Control 96.1538461538462
G Quality Management 97.9166666666667
H Outcome 100

Obtained Maximum 1
A 32 32 100
B 60 60 100
C 134 150 89.3333333
D 82 82 100
E 196 206 95.1456311
F 100 104 96.1538462
G 47 48 97.9166667
H 36 36 100
Total 687 718 95.6824513

0
1
2
 National Quality Assurance Standards for Taluka Hospital
Checklist for Outdoor Department 2
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
Area of Concern - A Service Provision 74 92
Standard A1 Facility Provides Curative Services 20 26

ME A1.1 The facility prov ides General Medicine Availability of functional General 2 Dedicated General Medicine
services Medicine Clinic SI/OB Clinic
ME A1.2 The facility prov ides General Surgery Availability of functional General 1 Dedicated General speciality
services Surgery Clinic SI/OB Surgical Clinic
ME A1.3 The facility prov ides Obstetrics & Availability of F unctional 2 Dedicated speciality Obstetrics
Gy naecology Serv ices Obstetrics & Gynaecology Clinic & Gynaecology Clinic. High risk
pregnancy cases referred from
SI/OB any health facility are consulted

Availability of IUD insertion room 2

ME A1.4 The facility provides Paediatric Services Availability of Paediatric Clinic 0 Dedicated Paediatric speciality
SI/OB Clinic
ME A1.5 The facility prov ides Ophthalmology Availability of functional 2 Dedicated ophthalmology clinic
Services Ophthalmology Clinic SI/OB providing consultation services

Availability of OPD eye care 0 Vision Testing, early detection of

procedures visual impairment, Intraocular
SI/OB Pressure Measurement

ME A1.6 The facility prov ides Dental Treatment Availability of functional Dental 2 Dedicated Clinic providing
Services Clinic SI/OB consultation services
Availability of OPD Dental 1 Extraction, scaling, tooth
procedure SI/OB extraction, denture and
Restoration.
ME A1.7 The facility provides AYUSH Services Availability of Functional Ayush 2 AYUS H clinic accompanied by
clinic SI/OB dispensary
ME A1.8 The facility prov ides services for OPD Availability of Dressing facilities 2 Dressing, Suturing and drainage
procedures at OPD SI/OB
Availability of Injection room 2
facilities at OPD SI/OB
ME A1.9 Services are available for the time At least 6 Hours of OPD Services 2
period as mandated are available SI/RR
Standard A2 Facility provides RMNCHA Services 28 30
ME A2.1 The facility prov ides Reproductive Availability of Spacing methods of 2 IUCD, OCP, ECP & Condoms,
health Services family planning SI/OB
Availability of Female Limiting 1 Tubectomy (Minilap and
Methods of family Planning SI/OB Laparoscopic)

Availability of Male Limiting 2 NSV/Conventional

Method for Family Planning SI/OB
Availability of Post partum 2 Tubal Ligation and PPIUD
sterilization services SI/OB
Availability of dedicated Family 2 Should provide Counselling and
Planning clinic. SI/OB Promotive services
Abortion and Contraception 2 As per MTP Act
services for 1st and 2nd trimester SI/OB

ME A2.2 The facility prov ides Maternal health Availability of functional ANC 2
Services clinic SI/OB
Availability of post natal 2
counselling and follow up SI/OB
services
Provision of TT and IFA 2 SI/OB
Nutrition and health counselling. 2
SI/OB/PI
Identification and management 2
of danger signs during pregnancy PIH, Pre-eclampsia, Bad obstetric
SI/OB/RR history, severe anaemia, IUGR,
multiple pregnancy.

ME A2.3 The facility prov ides New- born health Availability of Functional 1
Services immunization clinic SI/OB
ME A2.4 The facility prov ides Child health Routine and emergency care of 2
Services sick children. SI/OB
Services under RBSK 2 SI/OB
ME A2.5 The facility prov ides Adolescent Availability of Functional ARSH 2
health Serv ices clinic SI/OB
Standard A3 Facility Provides diagnostic Services 2 2
ME A3.3 The facility prov ides other diagnostic Functional ECG Services are 2
services, as mandated available SI/OB
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 24 32
ME A4.1 The facility prov ides services under Availability of OPD Services 1 OPD Management of Malaria,
National Vector Borne Disease Control Under NVBDCP Kala Azar, Dengue
Programme as per guidelines SI/RR

ME A4.2 The facility prov ides services under Availability of Functional DOTS 2
Revised National TB Control clinic
SI/OB
Programme as per guidelines
ME A4.3 The facility prov ides services under Availability of OPD services under 2 Throgh DDL office
National Leprosy Eradication NLEP SI/RR
Programme as per guidelines
Assessment of Disability Status 2 Throgh DDL office
SI/RR
ME A4.4 The facility prov ides services under Availability or linkage to a 2
National AIDS Control Programme as Functional ICTC SI/OB
per guidelines
Availability of HIV Testing and 2
Counselling SI/RR
PPTCT Services for HIV positive 2
Pregnant Women SI/OB
Availability of linkage with ART 2
Centre SI/OB
Availability of CD4 testing facility 0 Linkage with DH/MCH
SI/OB
ME A4.5 The facility prov ides services under Screening and early detection of 2 Refraction, Field of Vision and
National Programme for prevention visual impairment and refraction radioscopy
and control of Blindness as per SI/RR
guidelines

Availability of OPD procedures 0 Syringing and probing, foreign

SI/OB body removal , Tonometry.

ME A4.6 The facility prov ides services under Availability of counselling facility 2 Fixed day counselling with
Mental Health Programme as per for Suicide prevention district Mental Health
SI/OB Programme or linkage
guidelines
ME A4.7 The facility prov ides services under Geriatric Clinic, twice a week. 0
National Programme for the health
care of the elderly as per guidelines SI/OB

ME A4.8 The facility prov ides services under Functional NCD clinic is available 2
National Programme for Prevention
and control of Cancer, Diabetes,
Cardiovascular diseases & Stroke SI/OB
(NPCDCS ) as per guidelines

ME A4.10 The facility prov ide services under Management of case referred 1
National health Programme f or from PHC/SC directly reported to SI/RR
deafness Hospital

ME A4.14 The facility provides services as per State Availability of OPD services as per 2
specific health programmes State Health Programs/Schemes SI/RR

Standard A6 Health services provided at the facility are appropriate to community needs. 0 2
ME A6.1 The facility prov ides curatives & Special Clinics are available for 0 Ask for the specific local health
preventiv e services for the health local prevalent diseases problems/ diseases .i.e.. Kala
problems and diseases, prevalent SI/OB azar, arsenic poisoning etc.
locally.

Area of Concern - B Patient Rights 65 76

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 21 26
ME B1.1 The facility has uniform and user- Availability departmental 2 (Numbering Rooms, main
friendly signage sy stem signage's OB department and inter-sectional
signage)

Display of lay out/floor 2

directory OB
ME B1.2 The facility display s the serv ices and List of OPD Clinics are available 1
entitlements available in its OB
departments
Names of doctor on duty is 1
displayed and updated OB
Timing for OPD are displayed 2 OB
Entitlement under JSY , JSSK and 2 Dr Muthulaxmi Redddy
other State schemes OB Maternity benefit schemes
Important numbers like 2 Information PICME and CRS
ambulance are displayed OB
ME B1.3 The facility has established citizen Display of citizen charter 1
charter, w hich is followed at all levels OB

ME B1.4 User charges are display ed and User charges for services are 2
communicated to patients effectively displayed OB

ME B1.5 Patients & visitors are sensitised and IEC Material is displayed 2
educated through appropriate IEC / OB
BCC approaches
ME B1.6 Inf ormation is available in local Signage's and information are 2
language and easy to understand available in local language OB

ME B1.7 The facility prov ides inf ormation to Availability of Enquiry Desk with 1
patients and visitor through an dedicated staff
OB
exc lusiv e set-up.
ME B1.8 The facility ensures access to clinical OPD slip is given to the patient 1
records of patients to entitled RR/OB
personnel
Standard B2 Services a re delive red in a manner that is sensitive to ge nder, religious a nd cul tural needs , and the re are no ba rrier on account of phys ical 12 16
ME B2.1 a ccess , social, e conomi
2 c, cultural or s ocial status.
Services are prov ided in manner that Separate queue for females at
are sensitive to gender registration OB
Separate toilets for male and 2
female OB
Availability of female staff if a 2
male doctor examines a female OB
patients
Availability of Breast feeding 0
corner OB
ME B2.3 Access to facility is provided without Availability of Wheel chair or 2
any phy sical barrier & and friendly to stretcher for easy Access to the OB
people with disabilities OPD

Availability of ramps with railing 2

OB
There is no over crowding during 2
OPD hours OB
Availability of specially abled 0
friendly toilets OB
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 12 12
ME B3.1 Adequate visual privacy is provided at Availability of screen at 2
ev ery point of care Examination Area OB
One Patient is seen at a time in 2
clinics OB
Privacy at the counselling room is 2
maintained OB
ME B3.2 Confidentiality of patients records and Confidentiality of HIV reports. 2
clinical information is maintained SI/OB

ME B3.3 The facility ensures that behaviours of Behaviour of staff is empathetic 2

staff is dignified and respectf ul, while and courteous
deliv ering the services PI/OB

ME B3.4 The facility ensures privacy and
confidentiality to every patient,
especially of those conditions having
social stigma, and also safeguards
vulnerable groups
Privacy and confidentiality of TB, 2 Check in RTI/STI clinic
Leprosy Patients
SI/OB

Standard B4 Facility has defined and es tabli she d procedures for informing patients about their medical conditions and involving them in tre atment 12 14
ME B4.1 planning,
Informed consent
There is established procedures f or for bef oreand
HIV facilitates
2 informed decisioncheck
making
for filled consent forms of
taking informed consent before testing at ICTC, SI/RR minor surgeries
treatment and procedures
Informed consent for IUD 2
insertion SI/RR
Informed consent on prescribed 2
form C for abortion SI/RR

ME B4.2 Patient is informed about his/her Display of patient rights and 0

rights and responsibilities
ME B4.4 Inf ormation about the treatment is
shared with patients or attendants,
regularly
responsibilities. OB
Patient is informed about her 2 Ask patients about what they
clinical condition and treatment have been communicated about
being provided, possible the treatment plan
outcomes, and risks involved. PI

Pre and Post test counselling is 2

given at ICTC SI/PI/RR
ME B4.5 The facility has defined and Availability of complaint box, 2
established grievance redressal display of grievance redressal
system in place process, and details of person to
contact is displayed OB

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services. 8 8
ME B5.1 The facility prov ides cashless services Free OPD Consultation / ANC 2 For JSSK entitlement
to pregnant women, mothers and Check-up's/Investigations.
neonates as per prevalent PI/SI
government schemes

ME B5.2 The facility ensures that drugs Check that patient party has not 2
presc ribed are available at Pharmacy spent on purchasing drugs or
consumables from outside. PI/SI

ME B5.3 It is ensured that fac ilities for the Check that patient party has not 2 Provision of free diagnostic in
presc ribed investigations are available spent on diagnostics from emanelement Govt or private
at the facility outside. PI/SI Diagnostic Centre under CMCHIS

ME B5.4 The facility prov ides free of cost Free OPD Consultation for BPL 2
treatment to Below pov erty line patients
patients without administrative PI/SI/RR
hassles

Area of Concern - C Inputs 96 126

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 25 42
ME C1.1 Departments have adequate space as Clinics have adequate space for 1 Adequate Space in Clinics (112
per patient or work load consultation and examination OB sq. ft.)

Availability of adequate waiting 1 Waiting area at the scale of 1 sq.

area ft. per average daily patient with
OB minimum 400 sq. ft. of area

ME C1.2 Patient amenities are provide as per Availability of seating 0 As per average OPD at peak time
patient load arrangement in waiting area OB
Availability of sub waiting areas 1 For clinics having high patient
at separate clinics OB load
2
Availability of potable Drinking OB See if its is easily accessible to
water the visitors
Availability of functional toilets 2 Urinals 1 per 50 person
water closet and wash basins 1
OB per 100 person . Dry Toilet with
running water

Availability of patient calling 1

system OB
ME C1.3 Departments have layout and There is designated area for 2
demarcated areas as per f unctions registration OB
Dedicated clinic for each 0
speciality OB
One clinic is not shared by 2 1
doctors at one time OB
Demarcated dressing area /room 2
OB
Demarcated injection room 0 OB
Demarcated immunization room 2
for pregnant women and children OB

Availability of clean and dirty 1

utility room OB
Demarcated trolley/wheelchair 2
bay OB
ME C1.4 The facility has adequate circulation Corridors at OPD are broad 2
area and open spac es according to enough for movement of
need and local law stretcher, trolleys, patients & OB
visitors

ME C1.5 The facility has inf rastructure for Availability of functional 1

intramural and extramural telephone and Intercom
Services/CUG services OB
communication
ME C1.6 Service counters are av ailable as per Availability of Registration 1 Average Time taken for
patient load counters as per Patient load registration would be 3-5 min, So
number of counter required
OB would be worked on scale of 12-
20 patient/hour per counter

ME C1.7 The facility and departments are Unidirectional flow of services 1 Layout of OPD shall follow
planned to ensure structure follows functional flow of the
the function/processes (Structure patients, e.g.:
commensurate with the func tion of Enquiry→Registration→Waiting
the hospital) →Sub-waiting→
OB Clinic→Dressing room/Injection
Room→
Diagnostics (lab/X-
ray)→Pharmacy→Exit

All OPD clinics and related 1

auxiliary services are co located
in one functional area OB

OPD is located near to the entry 1

of the CHC OB
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 17 20
ME C2.1 The facility ensures the seismic saf ety Non structural components are 2 Check for fixtures and furniture
of the infrastructure properly secured. Building bye- like cupboards, cabinets, and
laws and instructions of NBC heavy equipment , hanging
(National Building Code) for OB objects are properly fastened
seismic safety are followed. and secured

ME C2.2 The facility ensures safety of electrical OPD building does not have 2
establishment temporary connections and OB
loosely hanging wires.
Safe installation, use of 2
appropriate wires and MCBs,
display of Danger notice,
availability of tools and PPE
(personal protective equipment),
and periodic inspections.

ME C2.3 Physical condition of buildings are Floors of the OPD are non 2
safe f or providing patient care slippery and even OB
Windows have grills and wire 0
meshwork OB
ME C2.4 The facility has plan for prevention of OPD has sufficient fire exits to 1
fire permit safe escape to its OB/SI
occupant in case of fire
Fire exits are clearly visible and 2
routes to reach exit are clearly OB
marked.
ME C2.5. The facility has adequate fire fighting OPD has installed fire 2
Equipment Extinguisher to fight Type A/B/C OB
Fire
Expiry date of fire extinguishers 2
are displayed on each
extinguisher as well as due date
for next refilling is clearly OB/RR
mentioned

ME C2.6. The facility has a system of periodic Check for staff competencies for 2
training of staff and conducts mock operating fire extinguisher and
drills regularly for fire and other what to do in case of fire
disaster situati on

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 32 36
ME C3.1 The facility has adequate spec ialist Availability of specialist Doctor 1 Check for specialist are available
doctors as per service provision during OPD time OB/RR at scheduled time

ME C3.3. The facility has adequate nursing staff Availability of Nursing staff 2 At Injection room/ OPD Clinic as
as per service prov ision and work load OB/RR/SI Per Requirement

ME C3.4 The facility has adequate Availability of dresser/paramedic 1

technicians/paramedics as per at dressing room
OB/SI
requirement
Counsellor for ICTC 2 SI/RR Full Time
Lab technician for ICTC 2 SI/RR Full time
Counsellor for ARSH clinic 2 One Counsellor may be used for
SI/RR various types of counselling

Availability of ECG technician 0 Trained staff may be used as ECG

SI/RR Technician
Availability of Ophthalmic 2
assistant SI/RR
 Availability of Dental technician 2
SI/RR
ME C3.5 The facility has adequate support / Availability of security guard for 2
general staff OPD SI/RR
Availability of housekeeping staff 2
SI/RR
ME C3.6 The staff has been provided required IMEP training 2
training / skill sets SI/RR
ICTC Team Training 2 SI/RR
Induction and refresher training 2
for ICTC lab technician SI/RR

ME C3.7 The S taff is skilled as per job Check the competency of staff to 2
description use OPD equipment like BP SI/RR
apparatus etc.
At ANC clinic the staff is skilled to 2
identify high risk pregnancies SI/RR

Counsellor is skilled for 2

counselling SI/RR
Staff is skilled for maintaining 2
clinical records SI/RR
Standard C4 Facility provides drugs and consumables required for assured list of services. 8 10
ME C4.1 The departments have availability of Availability of injectable in 2 As per State EDL
adequate drugs at point of use injection room OB/RR
Availability of vaccine as per 0 As per UIP
National Immunization Program OB/RR

ME C4.2 The departments have adequate Availability of disposables at 2 Examination gloves, Syringes,
consumables at point of use dressing room and clinics OB/RR Dressing material , suturing
material

HIV testing Kits I, II and III at ICTC 2

OB/RR
ME C4.3 Emergency drug trays are maintained Emergency Drug Tray is 2 As per State EDL
at every point of care, where ever it maintained in injection room & OB/RR
may be needed immunization room

Standard C5 The facility has equipment & instruments required for assured list of services. 14 18
ME C5.1 Availability of equipment & Availability of f unctional 2 BP apparatus, thermometer,
instruments for ex amination & Equipment &Instruments f or weighing machine, torch,
monitoring of patients examination & Monitoring OB stethoscope, Examination table

ME C5.2 Availability of equipment & Availability of f unctional 2 PV examination kit, measuring

instruments for treatment Instruments/Equipment for tape, fetoscope, Weighing
procedures, being undertak en in the Gynae and obstetric OB machine, BP apparatus etc.
facility

Availability of f unctional 1 Retinoscope, refraction kit,

Instruments / Equipment for tonometer, perimeter, distant
Ophthalmic Procedures OB vision chart, Colour vision chart.

Availability of f unctional 1 Dental chair, Air rotor,

Instruments/ Equipment for OB Endodontic set, Extraction
Dental Procedures forceps

ME C5.5 Availability of Equipment for Storage
ME C5.6 Availability of functional equipment
and instruments f or support services
Availability of equipment for
storage for drugs
Availability of equipment for
cleaning
1 Refrigerator, Crash cart/Drug
OB trolley, instrumental trolley,
dressing trolley
1 Buckets for mopping, mops,
duster, waste trolley, Deck brush
OB

Availability of equipment for 2 Steam Sterlizer,Autoclave

sterilization and disinfection OB

ME C5.7 Departments have patient furniture Availability of Fixtures 2 Spot light, electrical fixture for
and fixtures as per load and service OB equipment, X ray view box
provision
Availability of furniture at clinics 2 Doctors Chair, Patient S tool,
Examination Table, Attendant
OB Chair, Table, Footstep, cupboard

Area of Concern - D Support Services 65 76

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 4 4
ME D1.1 The facility has established system for All equipment are covered under 2
maintenance of critical Equipment AMC including preventive SI/RR
maintenance

ME D1.2 The facility has established procedure All the measuring equipment/ 2 BP apparatus, weighing scale,
for internal and external calibration of instrument are calibrated thermometer are calibrated
measuring Equipment OB/ RR

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 16 22
ME D2.1 There is established procedure f or There is process for indenting 2 Stock level are weekly updated
forecasting and indenting drugs and consumables and drugs in Requisition are timely placed
consumables injection/ dressing room SI/RR

ME D2.3 The facility ensures proper storage of Drugs are stored in 2

drugs and consumables containers/tray/crash cart and OB
are labelled
Vaccine are kept at 0
recommended temperature at OB
immunization room
ME D2.4 The facility ensures management of Expiry dates for injectable are 2
expiry and near ex piry drugs maintained at injection and OB/RR
immunization room
No expiry drugs found 2 OB/RR
ME D2.5 The facility has established procedure There is practice of calculating 2
for inv entory management techniques and maintaining buffer stock SI/RR

Department maintained stock 2

and expenditure register of drugs
and consumables SI/RR

ME D2.6 There is a procedure f or periodically There is procedure for 2

replenishing the drugs in patient care
areas
ME D2.7 There is process f or storage of
vacc ines and other drugs, requiring
controlled temperature
replenishing drug tray /crash SI/RR
cart/Emergency Tray
There is no stock out of drugs 2 SI/RR
Temperature of ref rigerators are 0 Check for temperature charts are
kept as per storage requirement maintained and updated
and records are maintained OB/RR periodically

Cold chain is maintained at 0 Check for four conditioned Ice

immunization room packs are placed in Carrier Box,
DPT, DT, TT and Hep B Vaccines
are not kept in direct contact of
OB/RR Frozen Ice pack

The facility has es tablis hed Program for maintenance and upkee p of the facility to provide safe, s ecure and comfortable environme nt to
Standard D3 32 36
staff, patients and visitors .
ME D3.1 Exterior of the facility building is Building is painted/whitewashed 2
maintained with landscaping in open in uniform colour OB
area
Interior of patient care areas are 2
plastered & painted OB
ME D3.2 Hospital infrastructure is adequately Check for there is no seepage , 1
maintained Cracks, chipping of plaster OB
Window panes , doors and other 1
fixtures are intact OB
Patients beds are intact and 2
painted OB
Mattresses are intact and clean 2
OB
ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, 2 All area are clean with no
hygienic sinks patient care and circulation OB dirt,grease,littering and cobwebs
areas are Clean
Surface of furniture and fixtures 2
are clean OB
Toilets are clean with functional 1
flush and running water OB

ME D3.4 The facility has policy of removal of No condemned/Junk material 1

condemned junk material lying in the OPD OB
ME D3.5 The facility has established No stray animal/rodent/birds 2
procedures for pest, rodent and OB
animal control
ME D3.6 The facility prov ides adequate Adequate Illumination in clinics 2 100 Lux in each Clinic
illumination level at patient care areas OB

Adequate Illumination in 2 150 Lux in Injection Room

procedure area OB
ME D3.7 The facility has provision of restriction Only one patient is allowed one 2
of v isitors in patient areas time at clinic
OB/SI

ME D3.8 The facility ensures safe and Temperature control and 2 Fans/ Air
comf ortable environment for patients ventilation in waiting areas conditioning/Heating/Exhaust/Ve
and serv ice providers ntilators as per environment
PI/OB condition and requirement

Temperature control and 2 Fans/ Air

ventilation in clinics conditioning/Heating/Exhaust/Ve
ntilators as per environment
SI/OB condition and requirement

ME D3.9 The facility has security sy stem in Hospital has sound security 2
place at patient care areas system to manage crowd in OPD OB/SI

ME D3.10 The facility has established measure for Ask female staff whether they 2
safety and security of female staff feel secure at work place SI

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 3 4
ME D4.1 The facility has adequate arrangement Availability of 24x7 running and 2
storage and supply for potable water potable water
in all functional areas OB/SI

ME D4.2 The facility ensures adequate power Availability of power back up in 1

backup in all patient care areas as per OPD OB/SI
load
Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 2 2
ME D5.4 The facility has adequate sets of linen Availability of linen in 2
examination area OB
Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 8 8
ME D9.1 The facility has established job Staff is aware of their roles and 2
description as per govt guidelines responsibilities
SI

ME D9.2 The facility has a established There is procedure to ensure that 2 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 departments duty roster RR/SI (Attendance register/ Biometrics
etc.)

There is designated in charge for 2

department SI
ME D9.3 The facility ensures the adherence to Doctor, nursing staff and support 2
dress code as mandated by its staff adhere to their respective
administration / the health dress code OB
department

Area of Concern - E Clinical Services 217 258

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 19 24
ME E1.1 The facility has established procedure Unique identification number is 2
for registration of patients given to each patient during RR
registration

Patient demographic details are 1 Check for that patient

ME E1.2 The facility has a established
procedure for OPD c onsultation
recorded in OPD registration RR demographics like Name, age,
records Sex, Address etc.
Patients are directed to relevant 2
clinic by registration clerk based PI/SI
on complaint
Registration clerk is aware of 2
categories of the patient SI/RR
exempted from user charges
There is procedure for systematic 2 Patient is called by
calling of patients one by one Doctor/attendant as per his/her
turn on the basis of “first come
OB first examine” basis.

Patient History is taken and 2

recorded RR
Physical Examination is done and 2
recorded wherever required OB/RR

Provisional Diagnosis is recorded 2

OB/RR
No Patient is Consulted in 2
Standing Position OB
Clinical staff is not engaged in 2
administrative work OB/SI
ME E1.3 There is established procedure f or There is establish procedure for 0
admission of patients admission through OPD SI/RR
There is establish procedure for 0
day care admission SI/RR
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 8 10
ME E3.1 Fac ility has established procedure f or There is a procedure for 2
continuity of c are during consultation of the patient to
interdepartmental transf er other specialist with in the SI/RR
hospital

ME E3.2 Facility provides appropriate referral Availability of referral linkages for 2 Check how patient are referred if
linkages to the patients/Services for OPD consultation. services are not available
transf er to other/higher facilities to RR/OB
assure their continuity of care.

The Facility has functional 2

referral linkages to higher SI/RR
facilities
The Facility has functional 0
referral linkages to lower SI/RR
facilities
There is a system of follow up 2
of referred patients RR
Standard E5 Facility has a procedure to identify high risk and vulnerable patients. 2 2
ME E5.2 The facility identifies high risk patients For any critical patient needing 2
and ensure their care, as per their need urgent attention queue can be
bypassed for providing services
on priority basis OB/SI

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use. 8 10
ME E6.1 Facility ensured that drugs are prescribed Check for OPD slip if drugs are 1
in generic name only prescribed under generic name RR
only
A copy of Prescription is kept 1
with the facility RR
ME E6.2 There is procedure of rational use of Check that relevant Standard 2
drugs treatment guideline are available RR
at point of use
Check if staff is aware of the drug 2
regime and doses as per STG SI/RR

Availability of Essential Drug List 2

SI/OB
Standard E7 Facility has defined procedures for safe drug administration 12 12
ME E7.2 Medication orders are w ritten legibly Every Medical advice and 2
and adequately procedure are accompanied
with date , time and signature RR

Check for the writing, is it 2

comprehendible by the clinical RR/SI
staff
ME E7.3 There is a procedure to check drug Drugs are check ed for expiry 2
before administration/ dispensing and other inconsistency
bef ore administration OB/SI

Check single dose vial are not 2 Check for any open single dose
used for more than one dose vial with left over content
OB intended to be used later on

Check for separate sterile needle 2

is used every time for multiple OB In multi dose vial needle is not
dose vial left in the septum
ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ 2
administration Pharmacist /nurse about the SI/PI
dosages and timings .
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 10 14
ME E8.1 All the assessments, re- assessment Patient History, Chief Complaint 0
and investigations are recorded and and Examination Diagnosis/
updated Provisional Diagnosis are
recorded in OPD slip RR

ME E8.2 All treatment plan prescription/orders Written Prescription and 0

are recorded in the patient records. Treatment plan are written RR

ME E8.4 Procedures perf ormed are written on Any dressing/injection other 2

patients records procedure recorded in the OPD RR
slip
ME E8.5 Adequate form and f ormats are Check for the availability of OPD 2
available at point of use slip, Requisition slips etc. OB/SI

ME E8.6 Register/rec ords are maintained as OPD records are maintained 2 OPD register, ANC register,
per guidelines OB/RR Injection room register etc.
All register/records are identified 2
and numbered OB/RR
ME E8.7 The facility ensures safe and adequate Safe keeping of OPD records 2
storage and retrieval of medical OB/SI
records
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 4 4
ME E10.3 The facility has disaster management Staff is aware of disaster plan 2
plan in place SI/RR
Roles and responsibilities of staff 2
in disaster are defined SI/RR
Standard E11 The facility has defined and established procedures of diagnostic services 4 4
ME E11.1 There are established procedures for The Container are labelled 2
Pre-testing A ctivities properly after the sample OB
collection
ME E11.3 There are established procedures for Clinics are provided with the 2
Post- testi ng Activ ities critical value of different tests SI/RR

Maternal & Child Health Services

Standard E16 Facility has established procedures for Antenatal care as per guidelines 50 50
ME E16.1 There is an established procedure f or Facility updates “Mother and 2 Line listing
Registration and follow up of pregnant Child Protecti on Card”. RR/SI
women.
Records are maintained for ANC 2 Records of each ANC check-up's
registered pregnant women is maintained in Mother and
RR child protection card /ANC
register

ME E16.2 There is an established procedure f or History of past illness / pregnancy 2

History taking, Physical examination, complication is taken and
and counselling for each antenatal recorded RR/SI
visit.

ANC Check-up is done by the 2

qualified personnel RR/SI/PI
At ANC clinic, Pregnancy is 2
confirmed by performing urine RR/SI
test
Last menstrual period (LMP) is 2
recorded and Expected date of
Delivery (EDD) is calculated RR/SI

Weight measurement 2 RR/SI

Blood pressure 2 RR/SI
Respiratory rate 2 RR/SI
Pallor, oedema and icterus 2 RR/SI
Abdominal palpation for foetal 2
growth, f oetal lie RR/SI
Breast examination 2 RR/SI
History of past illness / pregnancy 2 <12 weeks - 1 Visit, <26 weeks -2
complication is taken and visits, < 34 -3 visits and >34
recorded RR/SI weeks to term -5 visits

ME E16.3 Fac ility ensures availability of Diagnostic test under ANC check 2 Check for Haemoglobin, urine
diagnostic and drugs during antenatal up are prescribed at ANC clinic albumin urine sugar blood group
care of pregnant women and Rh factor Syphilis
RR/SI (VDRL/RPR) HIV blood sugar
malaria Hepatitis B

ME E16.4 There is an established procedure f or High risk pregnant women are 2 Anaemia, Bad Obs history, CPD,
identification of High risk pregnancies identified, initial Management & PIH, Medical disorder
and appropriate treatment/ref erral as referred to specialist complicating pregnancy,
per scope of serv ices. RR/SI Malpresentation, PROM,
Obstructed labour, Rh negative

ME E16.5 There is an established procedure f or Line listing of pregnant women 2

identification and management of with moderate and severe RR/SI
moderate and severe anaemia anaemia

IFA Tablets given to ANC Cases 2

 Provision for Injectable Iron 2
Treatment for moderate anaemia RR/SI

ME E16.6 Counselling of pregnant women is done Nutritional counselling 2

as per standard protocol and gestational RR/PI
age
Breast feeding 2 RR/PI
Institutional delivery 2 RR/PI
Arrangement of referral transport 2
RR/PI
Birth preparedness 2 RR/PI
Pregnant women are counselled 2 Swelling, oedema, bleeding PV
for recognizing danger signs ( even spotting), blurred vision,
during pregnancy headache, pain abdomen,
PI vomiting, pyrexia, watery foul
smelling, discharge & yellow
urine

Family planning 2 RR/PI PPIUCD & vasectomy

Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 20 40
ME E19.1 The facility prov ides immunization Availability of diluents for 0 Match no. of dilatant with no. of
services as per guidelines reconstitution of Measles vaccine RR/SI measles vials

Recommended temperature of 0 Check diluents are kept under

diluents is ensured before cold chain at least 24 hours
reconstitution before reconstitution
Diluents are kept in vaccine
RR/SI carrier only at immunization
clinic but should not be in direct
contact of ice pack

Reconstituted vaccines are not 0 Check when the vials are opened
used after recommended period & constituted . Should not be
RR/SI used beyond 4 hrs. after
reconstitution

Time of opening/ Reconstitution 0 Check for records

of vial is recorded on the vial RR

Staff checks VVM level before 0 White square in side the violet
using vaccines SI circle changes the colour

Staff is aware of how to check 0 Ask staff to demonstrate how to

freeze damage for T-Series SI conduct Shake test for DPT, DT
vaccines and TT
Discarded vaccines are kept 0 Check for expired, frozen or with
separately VVM beyond the discard point
SI/OB vaccine stored separately

Check for DPT, DT, Hep Band TT 0

vials are kept in basket in upper SI/OB
section of ILR
AD syringes are available as per 2 Check for 0.1 ml AD syringe for
requirement SI/OB BCG and 0.5 ml syringe for
others are available
Vaccine recipient is asked to stay 2
for half an hour after vaccination
to observe any Adverse effect
following the immunization SI/RR

Antipyretic medicines are 2

available SI/RR
updation of Immunization card 2
SI/RR
Counselling on adverse effects 2
and follow up visits done(CEI) SI/RR

Staff is aware of how to manage 2

and report minor and serious SI
advise events (AEFI)
Staff knows what to do in case of 2
anaphylaxis SI
ME E19.2 Triage, Assessment & Management of Check for adherence to clinical 2
new-borns having protocols
emergency signs are done as per SI/RR
guidelines

ME E19.5 Management of children presenting Check for adherence to clinical 0

with f ever, cough/ breathlessness is protocols
done as per guidelines SI/RR

ME E19.6 Management of children with S ev ere Screening of children c oming 2

Acute M alnutrition is done as per to OPDs using weight for
guidelines height and/or MUAC and
further management SI/RR

ME E19.7 Management of children presenting Check for adherence to clinical 2

with protocols
SI/RR
diarrhoea is done per guidelines
Availability of ORT corner 0 SI/RR
Standard E21 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines 30 30
ME E21.1 Fac ility provides Promotive ARSH Provision of Antenatal check up 2
Services to pregnant adolescent
Nutritional Counselling,
SI/RR contraceptive counselling,
Couple counselling ANC check-
up's, ensuring institutional
delivery
Counselling and provision of 2
emergency contraceptive pills Check for the availability of
SI/RR Emergency Contraceptive pills
(Levonorgesterol)
Counselling and provision of 2
reversible Contraceptives Check for the availability of Oral
RR/SI Contraceptive Pills, Condoms and
IUD
Availability and Display of IEC 2
material OB Poster are displayed, Reading
Material hand-out's etc.
Information and advice on sexual 2
and reproductive health related
issues
Advice on topic related to
Growth and development,
SI/RR puberty, sexuality, myths &
misconception, pregnancy, safe
sex, contraception, unsafe
abortion, menstrual
disorders,anemia, sexual
abuse ,RTI/STI's etc.
ME E21.2 Fac ility provides Prev entive ARSH Services for Tetanus 2
Services immunization SI/RR
TT at 10 and 16 year
Services for Prophylaxis against 2
Nutritional Anaemia
SI/RR Haemoglobin estimation, weekly
IFA tablet, and treatment for
worm infestation
Nutrition Counselling 2 SI/RR
Services for early and safe 2
termination of pregnancy and
management of post abortion SI/RR MVA procedure for pregnancy up
complication to 8 weeks Post abortion
counselling
ME E21.3 Facility Provides Curative ARSH Services Treatment of Common RTI/STI's 2
Privacy and Confidentiality,
SI/RR treatment Compliance, Partner
Management, F ollow up visit and
referral
Treatment and counselling for 2 Symptomatic treatment ,
Menstrual disorders SI/RR
counselling
Treatment and counselling for 2
sexual concern for male and SI/RR
female adolescents
Management of sexual abuse 2 ECP, Prophylaxis against STI, PEP
amongst Girls SI/RR
for hive and Counselling
ME E21.4 Fac ility provides Referral Services for Referral Linkages to ICTC and 2
ARSH PPTCT SI/RR
Privacy and confidentiality 2
maintained at ARS H clinic
SI/RR Screens and curtains for visual
privacy, confidentility policy
displayed, one client at a time
National Health Programs
Standard E22 Facility provides National health program as per operational/Clinical Guidelines 50 58
ME E22.1 Fac ility provides servic e under Ambulatory care of 0 As per Clinical Guidelines for
National Vector Borne Disease Control uncomplicated P. Vivax malaria SI/RR
Treatment of Malaria
Program as per guidelines
Ambulatory care of 0 As per Clinical Guidelines for
uncomplicated P. Falciparum SI/RR Treatment of Malaria
Malaria
Care of drug resistant malaria 0 As per Clinical Guidelines for
SI/RR Treatment of Malaria
ME E22.2 Fac ility provides servic e under Rev ised Diagnosis and Management of 2 As per RNTCP Technical
National TB Control Program as per Pulmonary Tuberculosis SI/RR Guidelines
guidelines
Management of Paediatric 2 As per RNTCP Technical
Tuberculosis SI/RR Guidelines
Management of Patients with HIV 2 As per RNTCP Technical
infection and Tuberculosis SI/RR Guidelines

Drug administration for Intensive 2 Check for filled treatment Cards

and Continuation done as per
RNTCP treatment protocol SI/RR

Protocols for treatment for TB 2 Discontinuation of Streptomycin

during pregnancy and Post natal Chemoprophylaxis of babies in
Period is adhered case of smear positive mother
SI/RR

Monitoring and follow up of 2 Check for records/Protocols

patient done as per protocols SI/RR
ME E22.3 Fac ility provides servic e under Validation and diagnosis of 2 As per Operation/ Clinical
National Leprosy Eradication Program Referred and Directly Reported SI/RR
Guidelines of NLEP
as per guidelines Cases

Treatment of all diagnosed cases 2 As per Operation/ Clinical

including Reaction and Neuritis SI/RR Guidelines of NLEP

Assessment of Disability Status 2 Through DDL Office

Management of Complicated
Ulcers
Management of Eye
Complications
Follow-up of cases treated at
tertiary Level
Self care Counselling
Outreach Services to Leprosy
Clinics
Screening of Cases of RCS
ME E22.4 Fac ility provides servic e under Pre Test Counselling is done as
National AIDS Control program as per per protocols
guidelines
SI/RR
2 As per Operation/ Clinical
SI/RR Guidelines of NLEP
2 As per Operation/ Clinical
SI/RR Guidelines of NLEP
2 As per Operation/ Clinical
SI/RR Guidelines of NLEP
2 As per Operation/ Clinical
SI/RR Guidelines of NLEP
2 As per Operation/ Clinical
SI/RR Guidelines of NLEP
2 As per Operation/ Clinical
SI/RR Guidelines of NLEP
2 Basic information and benefits of
HIV testing
potential risks such as
discrimination. The client is also
informed about their right to
refuse, follow-up services .
Pregnant
women are given additional
information on nutrition,
SI/RR hygiene, the importance of an
institutional delivery and HIV
testing so as to avoid HIV
transmission from mother to
child.

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 E22.6 Fac ility provides servic e under Mental Treatment of Mental illnesses as 2
Health Program as per guidelines per clinical guidelines
SI/RR

ME E22.7 Fac ility provides servic e under Geriatric Care is provided as per 0
National programme for the health Clinical Guidelines
care of the elderly as per guidelines SI/RR

ME E22.8 Fac ility provides servic e under
National Programme for Prevention
and Control of cancer, diabetes,
cardiovasc ular diseases & stroke
(NPCDCS ) as per guidelines
Opportunistic screening for 2 Screening of persons above age
diabetes, of 30 - History of tobacco
hypertension, cardiovascular examination, BP Measurement
diseases and Blood sugar estimation
SI/RR Look for records at NCD clinic

screen women of the age group 2

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

Health Promotion through IEC 2 increased intake of healthy foods

and counselling increased physical activity
through sports, exercise,
etc,avoidance of tobacco and
OB alcohol, stress management
warning signs of cancer etc.

ME E22.9 Fac ility provide service for Integrated Weekly reporting of Presumptive 2
disease surveillance program cases on form "P" from OPD clinic
SI/RR

ME E22.10 Fac ility provide services under Early detection and screening for 2 As per Clinical guidelines
National program f or prevention and detection of deafness SI/RR
control of deaf ness
Area of Concern - F Infection Control 93 94
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 8 8
ME F1.4 There is Prov ision of Periodic Medical There is a procedure for 2 Hepatitis B, Tetanus Toxoid etc.
Check- up's and immunization of staff immunization of the staff SI/RR

Periodic medical check-up's of 2

the staff SI/RR
ME F1.5 Fac ility has established procedures f or Regular monitoring of infection 2 Hand washing and infection
regular monitoring of inf ection control control practices SI/RR control audits are done at
prac tices periodic intervals

ME F1.6 Fac ility has defined and established Check if Doctors are aware of 2
antibiotic policy Hospital Antibiotic Policy SI/RR
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 16 16
ME F2.1 Hand washing f acilities are provided Availability of hand washing 2 Check for availability of wash
at point of use Facility at Point of Use OB basin near the point of use
Availability of running Water 2 Open the tap ask the staff if
OB/SI water is 24*7
Availability of antiseptic soap 2 Check for availability/ Ask staff if
with soap dish/ liquid antiseptic OB/SI the supply is adequate and
with dispenser. uninterrupted
Availability of Alcohol based 2 Check for availability/ Ask staff
Hand rub OB/SI for regular supply.
Display of Hand washing 2 Prominently displayed above the
Instruction at Point of Use OB hand washing facility , preferably
in Local language
ME F2.2 Staff is trained and adhere to standard Adherence to 6 steps of Hand 2 Ask for demonstration
hand washing prac tices washing SI/OB
Staff is aware of occasion for 2
hand washing SI
ME F2.3 Fac ility ensures standard practices and Availability of Antiseptic Solutions 2
materials for antisepsis OB
Standard F3 Facility ensures standard practices and materials for Personal protection 6 6
ME F3.1 Fac ility ensures adequate personal Clean gloves are available at 2
protection equipment as per point of use OB/SI
requirements
Availability of Masks 2 OB/SI
ME F3.2 Staff is adhere to standard personal No reuse of disposable gloves, 2
protection practices Masks, caps and aprons. OB/SI

Standard F4 Facility has standard Procedures for processing of equipment and instruments 16 16
ME F4.1 Facility ensures standard practices and Decontamination of operating & 2 Ask staff about how they
materials for decontamination and Procedure surfaces decontaminate the procedure
cleaning of instruments and procedures surf ace like Examination table ,
areas dressing table, Stretcher/Trolleys
SI/OB etc.
(Wiping with .5% Chlorine
solution)

Proper Decontamination of
instruments after use
2
Ask staff how they
decontaminate the instruments
like Stethoscope, Dressing
Instruments, Examination
Instruments, Blood Pressure Cuff
etc.
SI/OB (Soaking in 0.5% Chlorine
Solution, Wiping with 0.5%
Chlorine Solution

Contact time for 2 10 minutes

decontamination is adequate SI/OB

Cleaning of instruments after 2 Cleaning is done with detergent

decontamination SI/OB and running water after
decontamination
Staff is aware of correct 2
procedure of making chlorine SI/OB
solution
ME F4.2 Facility ensures standard practices and Equipment and instruments are 2 Autoclaving/HLD/Chemical
materials for disinfection and sterilization sterilized after each use as per Sterilization
of instruments and equipment requirement OB/SI

High level Disinfection of 2 Ask staff about method and time

instruments/equipment is done OB/SI required for boiling/Chemical
as per protocol HLD
Autoclaved dressing material is 2
used OB/SI
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 20 20
ME F5.1 Layout of the department is conducive Facility layout ensures separation 2
for the infection control practices of general traffic from patient OB
traffic
Clinics for infectious diseases are 2 Preferably in remote corner with
located away from main traffic OB independent access

Sitting arrangement in TB clinic is 2

as per guideline OB
ME F5.2 Facility ensures availability of standard Availability of disinf ectant as per 2 Chlorine solution,
materials for cleaning and disinfection of requirement OB/SI Glutaraldehyde, carbolic acid
patient care areas
Availability of cleaning agent as 2 Hospital grade phenyl,
per requirement OB/SI disinfectant detergent solution

ME F5.3 Facility ensures standard practices Staff is trained for spill 2 Blood & body fluid spill
followed for cleaning and disinfection of management SI/RR management & Mercury spill
patient care areas
Cleaning of patient care area with 2
detergent solution SI/RR
Staff is trained for preparing 2
cleaning solution as per standard SI/RR
procedure
Standard practice of mopping 2 Unidirectional mopping from
and scrubbing are followed OB/SI inside out
Cleaning equipment like broom 2 Any cleaning equipment leading
are not used in patient care areas to dispersion of dust particles in
OB/SI air should be avoided

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste. 27 28
ME F6.1 Fac ility Ensures segregation of Bio Availability of colour coded bins 2
Medical Waste as per guidelines at point of waste generation OB

2
Availability of Non chlorinated OB
plastic colour coded plastic bags
2
Segregation of Anatomical and OB/SI
solied waste in Yellow Bin
Segregation of infected plastic 2
OB
waste in red bin
Display of work instructions for 2
segregation and handling of OB
Biomedical waste
There is no mixing of infectious 2
and general waste
ME F6.2 Fac ility ensures management of Availability of functional hub 2 See if it has been used or just
sharps as per guidelines cutters OB lying idle
Availability of puncture proof box 2
OB Should be available nears the
point of generation like nursing
station and injection room
Availability of white translucent 2 Check for Puncture proof,
bins for waste Sharps SI/OB tamper proof and leak proof
containers
Availability of Blue bins for 2 Check for Puncture proof and
Galssware SI leak proof boxes with blue
colored marking
 Availability of post exposure 2
prophylaxis Ask if available. Where it is
OB stored and who is in charge of
that.
ME F6.3 Fac ility ensures transportation and Check bins are not overfilled 2
disposal of waste as per guidelines SI/OB

Transportation of bio medical 1

waste is done in close SI/OB
container/trolley
Staff aware of mercury spill 2
management SI/RR
Area of Concern - G Quality Management 67 72
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 2 Preferably Medical Officer in
departmental nodal person charge
for coordinating Quality SI/RR
Assurance activities

Standard G2 Facility has established system for patient and employee satisfaction 2 2
ME G2.1 Patient S atisfac tion surveys are OPD Patient satisfaction survey 2
conducted at periodic interv als done on monthly basis RR

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 8 8
ME G3.1 Fac ility has established internal There is system daily round by 2
quality assurance program at relevant matron/hospital in-charge/ for
departments monitoring of services SI/RR

ME G3.2 Fac ility has established external External Quality assurance 2

assurance programs at relevant program is established at ICTC lab SI/RR
departments
ME G3.3 Fac ility has established sy stem for use Departmental c hecklist are 2
of check lists in diff erent departments used for monitoring and SI/RR
and serv ices quality assurance
Staff is designated for filling 2
and monitoring of these SI
chec klists
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 29 30
ME G4.1 Departmental standard operating Standard operating procedure for 2
procedures are available department has been prepared
and approved RR

Current version of SOP are 2

available with process owner OB/RR
ME G4.2 Standard Operating Procedures OPD has documented procedure 1
adequately describes process and for Registration
RR
procedures
OPD has documented procedure 2
for patient calling system in OPD RR
clinics
OPD has documented procedure 2
for receiving of patient in clinic RR

OPD has documented procedure 2

for prescription and drug RR
dispensing
OPD has documented procedure 2
for nursing process in OPD RR

OPD has documented procedure 2

for patient privacy and RR
confidentiality
OPD has documented procedure 2
for conducting, analysing patient
satisfaction survey RR

OPD has documented procedure 2

for equipment management and
maintenance in OPD RR

Department has documented 2

procedure for Administrative and RR
non clinical work at OPD
Department has documented 2
procedure for No Smoking Policy RR
in OPD
OPD has documented procedure 2
for duty roaster, punctuality,
dress code and identity for OPD RR
staff

ME G4.3 Staff is trained and aware of the Check if staff are aware of 2
standard procedures written in SOPs relevant part of S OPs SI/RR

ME G4.4 Work instructions are displayed at Work instruction/clinical 2 Relevant protocols are displayed
Point of use protocols are displayed OB like Clinical Protocols for ANC
check-up's
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 12 12
ME G5.1 The facility conducts periodic internal Internal assessment is done at 2
assessment periodic interval RR/SI
ME G5.2 The facility conducts the periodic There is procedure to conduct 2
presc ripti on/ medical/death audits Medical Audit RR/SI
There is procedure to conduct 2
Prescription audit RR/SI
ME G5.3 The facility ensures non compliances Non Compliance are enumerated 2
are enumerated and rec orded and recorded RR/SI
adequately
ME G5.4 Action plan is made on the gaps f ound Action plan prepared 2
in the assessment / audit process RR/SI

ME G5.5 Corrective and preventive actions are Corrective and preventive action 2
taken to address issues, observ ed in taken
the assessment & audit RR/SI

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2 The facility periodically defines its Quality objective for OPD defined 2
quality objectiv es and key
departments hav e their own RR/SI
objectives

ME G6.3 Quality policy and objectives are Check of staff is aware of quality 2
disseminated and staff is aware of policy and objectives
SI
that
ME G6.4 Progress towards quality objec tives is Quality objectives are monitored 2
monitored periodically and reviewed periodically SI/RR

Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 8 12

ME G7.1 Fac ility uses method for quality PDCA 2

improv ement in serv ices SI/RR
5S 2 SI/OB
Process Mapping 2 SI/OB
Any other method of QA 0 SI/RR
ME G7.2 Fac ility uses tools for quality Any 2 basic tools of Quality 2 Any two Quality Tools
improv ement in serv ices SI/RR
Pareto / Prioritization 0 SI/RR
Area of Concern - H Outcome 48 48
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 22 22
ME H1.1 Facility measures productivity Indicators Proportion of follow-up patients 2
on monthly basis RR
General OPD/1000 population 2
RR
Medicine OPD/1000 Population 2
RR
Surgical OPD/1000 Population 2 RR
Ophthalmic OPD/1000 2
population RR
Paediatric OPD/1000 population 2
RR
AYUSH OPD/1000 Population 2 RR
No of ANC done per thousand 2
RR
ICTC OPD per thousand 2 RR
Immunization OPD per thousand 2
RR
ME H1.2 The Facility measures equity indicators Proportion of BPL patients 2
periodically RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 2 2
ME H2.1 Facility measures efficiency Indicators on OPD per Doctor 2
monthly basis RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 10 10
ME H3.1 Facility measures Clinical Care & Safety Consultation time at ANC Clinic 2 Time motion study
Indicators on monthly basis RR
Consultation time at General 2
Medicine Clinic RR
Consultation time for paediatric 2
clinic RR
Proportion of High risk pregnancy 2 No of High Risk Pregnancies
detected during ANC RR X100/ Total no PW used ANC
services in the month
Proportion of severe anaemia 2
cases RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 14 14
ME H4.1 Facility measures S ervice Quality Patient Satisfaction Score 2
Indicators on monthly basis RR
Waiting time at registration 2
counter 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

OPD Score
OPD Score
86.10451
Area of Concern wise Score
A Service Provision 80.4347826086957
B Patient Rights 85.5263157894737
C Inputs 76.1904761904762
D Support Services 85.5263157894737
E Clinical Services 84.108527131783
F Infection Control 98.936170212766
G Quality Management 93.0555555555556
H Outcome 100

Obtained Maximum Percent 2

A 74 92 80.43478261
B 65 76 85.52631579
C 96 126 76.19047619
D 65 76 85.52631579
E 217 258 84.10852713
F 93 94 98.93617021
G 67 72 93.05555556
H 48 48 100
Total 725 842 86.10451306
 National Quality Assurance Standards for Taluka Hospital
Checklist for Labour Room 3
Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification
Method Remarks

Area of Concern - A Service Provision 29 30

Standard A1 The facility provides Curative Services 4 4
ME A1.3 The facility Provides Obstetrics & Availability of comprehensive 2 SI/OB LSCS, Blood storage,
Gynaecology Services obstetric services Anaesthesia.

ME A1.9 Services are available for the time Labour room services are 2 SI/RR
period as mandated functional on 24X7 basis
Standard A2 The facility provides RMNCHA Services 22 22
ME A2.1 The facility provides Reproductive Availability of Post partum 2 SI/OB PPIUD insertion
health Services sterilization services
ME A2.2 The facility provides Maternal Vaginal Delivery 2 SI/OB Term, post Date and pre term
health Services
Assisted Delivery 2 SI/OB Forceps delivery and vacuum
delivery
Caesarean-Section 2
Management of Postpartum 2 SI/OB Medical /Surgical
Haemorrhage
Management of Retained Placenta 2 SI/OB

Delivery of septic and HIV positive 2 SI/OB

PW
Management of PIH/Eclampsia/ 2 SI/OB
Pre Eclampsia
Initial Diagnosis and management 2 SI/OB
of MTP and Ectopic

ME A2.3 The facility provides New-born Availability of Essential new born 2 SI/OB
health Services care
Availability of New born 2 SI/OB
resuscitation
Standard A3 The facility Provides diagnostic Services 3 4
ME A3.1 The facility provides Radiology Availability or functional linkage 2 SI/OB
Services for USG services.
ME A3.2 The facility provides Laboratory Availability of point of care 1 SI/OB HIV, Hb in gm , Random
Services diagnostic test blood sugar /as per state
guideline
 Area of Concern - B Patient Rights 51 52
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their
21 22
ME B1.1 Availability departmental
modalities
2 OB (Numbering Rooms, main
The facility has uniform and user- signage's department and inter-
friendly signage system sectional signage)

Directional signage for 2 OB Direction is displayed from

ME B1.2 The facility displays the services
and entitlements available in its
department
department is displayed main gate to direct.
Restricted area signage 2 OB
displayed
Entitlements under JSSK are 2 OB
Displayed
Entitlements under Dr. 1 OB
Muthhulakhsmi Reddy Maternity
benefit scheme, PICME and CRS
are Displayed

Entitlement under JSY is displayed 2 OB

Name of doctor and Nurse on duty 2 OB

are displayed and updated

Contact details of referral 2 OB

transport / ambulance displayed

Services provision of labour room 2 OB

are displayed at the entrance

ME B1.5 IEC Material is displayed 2 OB Breast feeding, kangaroo

care, family planning
Patients & visitors are sensitised (Pictorial and chart ),
and educated through Immunization schedule in
appropriate IEC / BCC approaches circulation area

ME B1.6 Signage's and information are 2 OB

Information is available in local available in local language
language and easily understood
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on
10 10
ME B2.1
account of physical access,social. economic,
Only on duty staff is allowed in 2 OB
cultural or social status.
Services are provided in manner the labour room when it is
that are sensitive to gender occupied

Availability of female staff if a male 2 OB/SI

doctor examines a female
patients/Mother
ME B2.3
Access to facility is provided
without any physical barrier &
and friendly to people with
disabilities
Availability of Wheel chair or 2 OB
stretcher for easy Access to the
labour room
Availability of ramps and railing 2 OB

Labour room is located on ground 2 OB

floor; or availability of the
ramp/lift with person for shifting

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related
10 10
ME B3.1 Availability of screen/ partition at
information.
2 OB
Adequate visual privacy is
provided at every point of care delivery tables
Curtains / frosted glass have been 2 OB
provided at windows
ME B3.2 Confidentiality of patients records Patient Records are kept at secure 2 SI/OB
place beyond access to general
and clinical information is staff/visitors
maintained
ME B3.3 Behaviour of staff is empathetic 2 OB/PI
The facility ensures the and courteous
behaviours of staff is dignified
and respectful, while delivering
the services
ME B3.4 HIV status of patient is not 2 SI/OB
disclosed except to staff that is
The facility ensures privacy and directly involved in care
confidentiality to every patient,
especially of those conditions
having social stigma, and also
safeguards vulnerable groups

Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and involving
4 4
ME B4.1
them in treatment planning, and facilitates
General consent is taken before 2
informed
SI/RR
decision making
There is established procedures delivery
for taking informed consent
before treatment and procedures

ME B4.4 Labour room has system in place 2 PI

to involve patient relative in
Information about the treatment decision making about pregnant
is shared with patients or women treatment
attendants, regularly

Standard B5 The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost
6 6
of hospital services.
ME B5.1 Drugs and consumables under 2 PI/SI
The facility provides cashless JSSK are available free of cost
services to pregnant women,
mothers and neonates as per
prevalent government schemes

ME B5.2 Check that parents & attendant's 2 PI/SI

have not spent money on
The facility ensures that drugs purchasing drugs and consumables
prescribed are available at from outside.
Pharmacy and wards

ME B5.3 Check that parents & attendants 2 PI/SI Provision of diagnostics in

It is ensured that facilities for the have not spent money on empanelled Government or
prescribed investigations are diagnostics from outside. Private diagnostic centre
available at the facility under CMCHIS.

Area of Concern - C Inputs 151 156

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 44 44
ME C1.1 The Departments has adequate Adequate space as per delivery 2 OB One labour table requires
space as per patient or work load load 10X10 sqft of space, Every
labour table should have
space for vertical trolley with
space for six trays

Availability of Waiting area for 2 OB

attendants/ASHA
ME C1.2 Patient amenities are provided as Attached toilet facility available 2 OB
per patient load
Availability of Drinking water 2 OB
Availability of Changing area 2 OB
ME C1.3 The Department have layout and Delivery unit has dedicated 2 OB
demarcated areas as per Receiving area
functions
Availability of Examination Room 2 OB

Availability of Pre delivery room 2 OB

Availability of Delivery room 2 OB

Availability of Post delivery 2 OB
observation room
Dedicated nursing station within 2 OB
or proximity of labour room

Area earmarked for new-born care 2 OB

Corner
 Dedicated and separate beds for 2 OB For septic cases.
septic cases with isolation

Preparation of medicine and 2 OB

injection space.
Availability of dirty utility room 2 OB

Availability of store 2 OB
ME C1.4 The facility has adequate Corridors connecting labour room 2 OB
circulation area and open spaces are broad enough to facilitate
according to need and local law stretcher and trolley's movement

ME C1.5 The facility has infrastructure for Availability of functional telephone 2 OB

intramural and extramural and Intercom/CUG Services
communication
ME C1.6 Service counters are available as Availability of labour tables as per 2 OB At least 2 labour table for 100
per patient load delivery load deliveries per month
ME C1.7 The facility and departments are Labour room is in Proximity and 2 OB
planned to ensure structure function linkage with OT
follows the function/processes
(Structure commensurate with
the function of the hospital)

Labour room is in proximity and 2 OB

functional linkage with NBSU

Unidirectional flow of care 2 OB

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 19 20
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging objects
are properly fastened and
secured

ME C2.2 The facility ensures safety of Labour room does not have 2 OB Switch Boards other electrical
electrical establishment temporary connections and installations are intact
loosely hanging wires

Stabilizer is provided for Radiant 1 OB

warmer
ME C2.3 Physical condition of buildings are Floors of the ward are non slippery 2 OB
safe for providing patient care and even surpad
 Windows and vents if any are 2 OB
intact and sealed
ME C2.4. The facility has plan for LR has fire exit to permit safe 2 OB/SI
prevention of fire escape of its occupant at time of
fire

Check the fire exits are clearly 2 OB

visible and routes to reach exit are
clearly marked.

ME C2.5. The facility has adequate fire NBSU has installed fire 2 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.

Check the expiry date for fire 2 OB/RR

extinguisher is displayed on each
extinguisher as well as due date
for next refilling is clearly
mentioned

ME C2.6. The facility has a system of Check for staff competencies 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
fire and other disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 26 30
ME C3.1 The facility has adequate Availability of Obs 2 OB/RR Paediatrician or trained MO,
specialist doctors as per service &Gynaespecialist and Obstetrician or trained MO
provision paediatrician on call. and hirring specialist utilizing
RCH funds

ME C3.2. The facility has adequate general Availability of at least one doctor 2
duty doctors as per service 24x7 in the facility
provision and work load

ME C3.3 The facility has adequate nursing Availability of SBA trained Nursing 2 OB/RR/SI Adequate staff as per case
staff as per service provision and staff load
work load
ME C3.5 The facility has adequate Availability of labour room 2 SI/RR At least 1 sanitary worker
support / general staff attendants/ Birth Companion and 1 ayah per shift
Availability of dedicated security 2 SI/RR
staff
ME C3.6 The staff has been provided Navjat Shishu Surkasha Karyakarm 2 SI/RR Equivalent training for new
required training / skill sets (NSSK) training bron resucsitation and care
around birth

Skilled birth Attendant (SBA) 0 SI/RR

IMEP training. 2 SI/RR
 BEmOC training for MO
PPIUCD training
ME C3.7 The Staff is skilled as per job Nursing staff is skilled for
description operating radiant warmer
0 SI/RR
2 SI/RR
2 SI/RR check staff is aware of
optimal temperature, how to
set temperature, how to use
probes, and how to interpret
alarms and trouble shooting.

Nursing staff is skilled for 2 SI/RR Check the staff know how to
resuscitation set the temperature, how to
put the probe, duration and
interpretation of alarms

Nursing staff is skilled identifying 2 SI/RR Check how staff interpret

and managing complication different alarming sign like
excessive bleeding, shock ,
obstructed labour

Counsellor is skilled for postnatal 2 SI/RR

counselling
Nursing Staff is skilled for
maintaining clinical records
including partograph
2 SI/RR Check staff know what to fill
different section of
partograph and how to
interparate alert and action

Standard C4 The facility provides drugs and consumables required for assured services. 28 28
ME C4.1 The departments have availability Availability of uterotonic Drugs 2 OB/RR As per State EDL
of adequate drugs at point of use

Availability of Antibiotics 2 OB/RR As per State EDL

Availability of Antihypertensive 2 OB/RR As per State EDL

Availability of analgesics and 2 OB/RR As per State EDL

antipyretics
Availability of IV Fluids 2 OB/RR As per State EDL
Availability of local anaesthetics 2 OB/RR As per State EDL

Availability of tocolytics 2 OB/RR As per State EDL

Availability of emergency drugs 2 OB/RR As per State EDL

Availability of drugs for new-born 2 OB/RR As per State EDL

ME C4.2 The departments have adequate Availability of dressings and 2 OB/RR Gauze pieces and Cotton
consumables at point of use Sanitary pads swabs, Sanitary pads, Needle
(round body and cutting),
Chromic catgut no. 0

Availability of syringes and IV 2 OB/RR Paediatric IV-Sets,Urinary

Sets /tubes Catheter
Availability of Antiseptic Solutions 2 OB/RR Antiseptic lotion

Availability of consumables for 2 OB/RR Gastric tube and Cord clamp,

new born care Baby ID tag, Mucous sucker

ME C4.3 Emergency drug trays are Emergency Drug Tray is 2 OB/RR

maintained at every point of care, maintained
where ever it may be needed

Standard C5 The facility has equipment & instruments required for assured list of services. 34 34
ME C5.1 Availability of equipment & Availability of functional 2 OB BP apparatus, Stethoscope
instruments for examination & Equipment & Instruments for Thermometer, Foetoscope/
monitoring of patients examination & Monitoring Doppler, Baby weighting
scale, Wall clock.

ME C5.2 Availability of equipment & Availability of instrument 2 OB Scissor & Artery forceps, Cord
instruments for treatment arranged in Delivery trays clamp, Sponge holder,
procedures, being undertaken in Speculum, Kidney tray, Bowl
the facility for antiseptic lotion

Delivery kits are in adequate 2 OB As per delivery load and cycle

numbers as per load time for processing of
instruments

Availability of Instruments 2 OB Episiotomy scissors, Kidney

arranged for Episiotomy trays tray, Artery forceps, Allis
forceps, Sponge holder,
Toothed forceps, Needle
holder, Thumb forceps

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

ME C5.3 Availability of equipment &
instruments for diagnostic
procedures being undertaken in
the facility
ME C5.4 Availability of equipment and
instruments for resuscitation of
patients and for providing
intensive and critical care to
patients
ME C5.5 Availability of Equipment for
Storage
ME C5.6 Availability of functional
equipment and instruments for
support services
ME C5.7 Departments have patient
furniture and fixtures as per load
and service provision
Availability of instruments
arranged for MVA/EVA tray
Availability of instruments
arranged for PPIUCD tray
Availability of Point of care
diagnostic instruments
Availability of resuscitation
Instruments for New-born Care
Availability of resuscitation
instrument for mother
Availability of equipment for
storage for drugs
Availability of equipment for
cleaning
Availability of equipment for
sterilization and disinfection
Availability of Delivery tables
Availability of attachment/
accessories with delivery table
2 OB Speculum, Anterior vaginal
wall retractor, Posterior wall
retractor, Sponge holding
forceps, MVA Syringe,
Cannulas, MTP, Small bowl of
antiseptic lotion
2 OB Sim's speculum, PPIUCD
insertion forceps, CuIUCD
380A/Cu IUCD375 in sterile
package
2 OB Glucometer, Doppler and HIV
rapid diagnostic kit, Uristix
2 OB Bag and mask (New-born
resuscitator), Oxygen,
Suction machine/ mucus
sucker , radiant warmer,
laryngoscope, ET tube 2.5
and 3.5 sizes.
2 OB Suction machine, Oxygen
with Hood, Adult bag and
mask, mouth gag,
2 OB Refrigerator, Crash cart/Drug
trolley, instrument trolley,
dressing trolley
2 OB Buckets for mopping,
Separate mops for labour
room and circulation area
duster, waste trolley, Deck
brush
2 OB Steam steriliser and
Autoclave
2 OB Steel Top
2 OB Hospital graded Mattress, IV
stand, Kelly's pad, support
for delivery tables,
Macintosh, foot step, Bed
pan
 Availability of fixture
2 OB Wall clock with Second arm,
Wall mounted, Lamps,
Electrical fixture for
equipment like Radiant
warmer, Suction .

Availability of Furniture 2 OB Cupboard, Table, chair,

Counter.

Area of Concern - D Support Services 88 96

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 6 8
ME D1.1 The facility has established All equipment are covered under 2 SI/RR
system for maintenance of critical AMC including preventive
Equipment maintenance

There is system of timely 2 SI/RR

corrective break down
maintenance of the equipment

ME D1.2 The facility has established All the measuring equipment/ 2 OB/ RR BP apparatus, Weighing
procedure for internal and instrument are calibrated Machine etc. are calibrated
external calibration of measuring
Equipment

ME D1.3 Operating and maintenance Up to date instructions for 0 OB/SI

instructions are available with the operation and maintenance of
users of equipment equipment are readily available
with staff.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient
22 22
care areas
ME D2.1 There is established procedureThere is established system of 2 SI/RR Stock level are daily updated
for forecasting and indenting of timely indenting of consumables Requisition are timely placed
drugs and consumables and drugs at nursing station

ME D2.3 The facility ensures proper Drugs are stored in 2 OB

storage of 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 Record of expiry dates are 2 OB/RR
of expiry and near expiry drugs maintained at emergency drug
tray

No expiry drug found 2 OB/RR

Records for expiry and near expiry 2 RR
drugs are maintained for drug
stored at the department
ME D2.5 The facility has established
procedure for inventory
management technique
There is practice of calculating and 2 SI/RR
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 drug tray /crash cart
care areas

There is no stock out of drugs 2 OB/SI

ME D2.7 There is process for storage of Temperature of refrigerators are 2 OB/RR Check for temperature charts
vaccines and other drugs, kept as per storage requirement are maintained and updated
requiring controlled temperature and records are maintained periodically

Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable
32 36
environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Check for there is no seepage , 2 OB
adequately maintained Cracks, chipping of plaster
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 D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, sinks 2 OB All area are clean with no
hygienic new-born care and circulation dirt,grease,littering and
areas are Clean cobwebs

Surface of furniture and fixtures 2 OB

are clean
Toilets are clean with functional 0 OB
flush and running water

ME D3.4 The facility has policy of removal No condemned/Junk material in 2 OB

of condemned junk material the Labour room

ME D3.5 The facility has established No stray animal/rodent/birds 2 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate Illumination at delivery 2 OB 400 lux.
illumination level at patient care table
areas
Adequate Illumination at 0 OB 300 Lux.
observation area
ME D3.7 The facility has provision of
restriction of visitors in patient
areas
ME D3.8 The facility ensures safe and
comfortable environment for
patients and service providers
There is no overcrowding in labour 2 OB
room
One female family members 2 OB/SI
allowed to stay with the PW
Entry of visitors is restricted in the 2 OB/SI
labour room
Temperature control and 2 PI/OB Optimal temperature and
ventilation in Labour room warmth is ensured at labour
room. Fans/ Air
conditioning/Heating/Exhaus
t/Vents as per environment
condition and requirement

ME D3.9 The facility has security system in Lockable doors in labour room 2 OB
place at patient care areas

New born identification band are 2 OB/RR

used and foot prints of babies are
taken.

ME D3.10- The facility has established measure Ask female staff weather they feel 2 SI
for safety and security of female secure at work place
staff

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 10 12
ME D4.1 The facility has adequate Availability of 24x7 running and 2 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas

Availability of hot water 2 OB/SI

ME D4.2 The facility ensures adequate Availability of power back up in 2 OB/SI
power backup in all patient care labour room
areas as per load
Availability of UPS 0 OB/SI
Availability of Emergency light 2 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Oxygen cylinders 2 OB
availability of oxygen, medical gases and vacuum suction
and vacuum supply

Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted
10 10
ME D5.4 The facility has adequate sets of Availability of clean Drape,
patients.
2 OB/RR
linen Macintosh on the Delivery table,
 Gown are provided in labour room 2 OB/RR

Availability of Baby blanket, sterile 2 OB/RR

drape for baby
ME D 5.5. The facility has established Drape sheets are changed after 2 OB/RR
procedures for changing linen in each delivery.
patient care areas
ME D5.6 The facility has standard procedures There is system to check the 2 SI/RR
for handling , collection, cleanliness and Quantity of the
transportation and washing of linen linen received from laundry

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
8 8
operating procedures.
ME D9.1 The facility has established job Staff is aware of their roles and
2 SI
description as per govt guidelines responsibilities

ME D9.2 The facility has a established There is procedure to ensure that 2 RR/SI Check for system for
procedure for duty roster and staff is available on duty as per recording time of reporting
deputation to different duty roster and relieving (Attendance
departments register/ Biometrics etc.)

There is designated in charge for 2 SI

department
ME D9.3 The facility ensures adherence to Doctor, nursing staff and support 2 OB
the dress code as mandated by its staff adhere to their respective
administration / the health dress code
department

Area of Concern - E Clinical Services 180 180

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 12 12
ME E1.1 The facility has established Unique identification number is 2 RR RCH ID/ PICME number to be
procedure for registration of given to each patient during captured
patients process of registration

Patient demographic details are 2 RR Check for that patient

recorded in admission records demographics like Name,
Age, Sex,Provisional
Diagnosis etc.

ME E1.3 There is established procedure There is a procedure for admitting 2 SI/RR/OB

for admission of patients Pregnant women directly to
Labour room

Admission is done by written order 2 SI/RR/OB

of a facility's doctor

ME E1.4 There is established procedure
for managing patients, in case
beds are not available at the
facility
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients.
ME E2.1 There is established procedure
for initial assessment of patients Pregnant Women to identify
ME E2.2 There is established procedure
for follow-up/ reassessment of
Patients
Time of admission is recorded in
patient record
Check how service provider cope
with shortage of delivery tables
due to high patient load
Rapid Initial assessment of
complication and Prioritization of
care
Recording and reporting of Clinical
History
Recording of current labour details
Physical Examination
There is fixed schedule for
reassessment of Pregnant women
as per standard protocol
Partograph is used and updated
as per stages of labour
2 RR
2 OB/SI
12 12
2 RR/SI/OB Assessment and immediate
treatment following danger
sign are present - difficulty in
Breathing, Fever, Sever
abdominal pain, Convulsion
or unconsciousness, Severe
headache or Blurred vision
2 RR/SI Recording of women
Obstetric History including
LMP and EDD Parity, Gravida
status, h/o CS, Live birth, Still
Birth, Medical History (TB,
Heart diseases, STD etc., HIV
status and Surgical History)
2 RR Time of start, Frequency of
contractions, Time of Water
bag leaking, Colour and smell
of fluid and baby movement
2 RR/SI Recording of Vitals , shape &
Size of abdomen , presence
of scars, foetal lie and
presentation. & vaginal
examination
2 RR/OB There is a fixed schedule of
reassessment as per
protocols
2 RR/OB All step are recorded in
timely manner
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 16 16
ME E3.1 The facility has established There is procedure of handing 2 SI/RR
procedure for continuity of care over patient / new born from
during interdepartmental transfer labour room to OT/ Ward/NBSU

There is a procedure for 2 SI/RR

consultation of the patient with
other specialist with in the
hospital

ME E3.2 The facility provides appropriate
referral linkages to the
patients/Services for transfer to
other/higher facilities to assure the
continuity of care.
Patient is referred with referral slip 2 RR/SI A referral slip/ Discharge card
is provide to patient when
referred to another health
care facility

Advance intimation is given to 2 RR/SI

higher centre
Referral vehicle is arranged 2 RR/SI
Referral in or referral out register 2 SI/RR
is maintained
Facility has functional referral 2 SI/RR
linkage with to lower facilities

There is a system of follow up 2 SI/RR Check for referral cards filled

of referred patients from lower facilities
Standard E4 The facility has defined and established procedures for nursing care 14 14
ME E4.1 Procedure for identification of There is a process for ensuring the 2 OB/SI Identification tags for
patients is established at the identification before any clinical mother and baby / foot print
facility procedure are used for identification of
new-born's

ME E4.2 Procedure for ensuring timely and There is a process to ensue the 2 SI/RR Verbal orders are rechecked
accurate nursing care as per accuracy of verbal/telephonic before administration
treatment plan is established at the orders
facility

ME E4.3 There is established procedure of Patient hand over is given during 2 RR/SI
patient hand over, whenever staff the change of the shift
duty change happens

Nursing Handover register is 2 RR

maintained
Bed side Hand over is given 2 SI/RR
ME E4.5 There is procedure for periodic Patient's Vitals are monitored 2 RR/SI Check for TPR chart, IO chart,
monitoring of patients and recorded periodically any other vital required is
monitored

Critical patients are monitored 2 RR/SI Check for BP,

continuously Pluse,Temp,Respiratory Rate
FHR, Uterine Contraction,
Any other vital required is
monitored

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,
them from any harm swapping and baby fall

ME E5.2 The facility identifies high risk High Risk Pregnancy cases are 2 OB/SI Check for the frequency of
patients and ensure their care, as identified and kept in intensive observation: Ist stage :half an
per their need monitoring hour and 2nd stage: every 5
min

Standard E6 The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs
8 8
ME E6.1
& their rational
The facility ensured that drugs are Check for Case sheet if drugs are 2
use.
RR
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 if staff are aware of the drug 2 SI/RR

regime and doses as per Standard
treatment guidelines (STG)

Check Case sheet that drugs are 2 RR Check for rational use of
prescribed as per STG Uterotonic drugs
Standard E7 The facility has defined procedures for safe drug administration 20 20
ME E7.1 There is process for identifying High alert drugs are identified in 2 SI/OB Electrolytes like Potassium
and cautious administration of the department chloride, Insulin etc. as
high alert drugs applicable

Maximum dose of high alert drugs 2 SI/RR Value for maximum doses as
are defined and communicated per age, weight and diagnosis
are available with nursing
station and doctor
 There is process to ensure that
right doses of high alert drugs are
only given
2 SI/RR A system of independent
double check before
administration, Error prone
medical abbreviations are
avoided

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

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

Check for the writing to ensure 2 RR/SI

that it is comprehendible by the
clinical staff

ME E7.3 There is a procedure to check
drug before administration/
dispensing
Drugs are checked for expiry 2 OB/SI
and other inconsistency before
administration
Check single dose vial are not used 2 OB Check for any open single
for more than one dose dose vial with left over
content intended 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
vial not left in the septum

Any adverse drug reaction is 2 RR/SI

recorded and reported
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 dose,
right route, right time

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 14 14
ME E8.1 All the assessments, re- Progress of labour is recorded 2 RR Partograph fully
assessment and investigations are compliance ,and on bed head
recorded and updated ticket partial compliance

ME E8.2 All treatment plan Treatment prescribed in nursing 2 RR Medication order, treatment
prescription/orders are recorded records plan, lab investigation are
in the patient records. recoded adequately
ME E8.4 Procedures performed are
written on patients records
Delivery notes are adequate
2 RR Outcome of delivery, date
and time, 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 Baby cry, Essential new born

care, Resuscitation if any,
Sex, Weight, Time of
initiation of breast feed, Birth
doses, Congenital anomaly,
APGAR Score

ME E8.5 Adequate form and formats are Standard Formats available 2 RR/OB Availability of BHT,
available at point of use Partograph, etc.
ME E8.6 Register/records are maintained Registers and records are 2 RR Labour room register, OT
as per guidelines maintained as per guidelines register, MTP register,FP
register, Maternal death
register and records, Lab
register, Referral in /out
register, Internal& PPIUD
register etc.

All register/records are identified 2 RR

and numbered
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 4 4
ME E10.3 The facility has disaster Staff is aware of disaster plan 2 SI/RR
management plan in place
Roles and responsibilities of staff 2 SI/RR
in disaster is defined
Standard E11 The facility has defined and established procedures of diagnostic services 4 4
ME E11.1 There are established procedures Container is labelled properly 2 OB
for Pre-testing Activities after the sample collection

ME E11.3 There are established procedures Nursing station is provided with 2 SI/RR
for Post-testing Activities the critical value of different test

Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 12 12
ME E12.5 There is established procedure Consent is taken before 2 RR
for 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 2 SI/RR

and regulated by qualified staff

Blood transfusion note is written in 2 RR

patient record
ME E12.6. There is a established procedure Any major or minor transfusion 2 RR
for monitoring and reporting reaction is recorded and reported
Transfusion complication to Blood Bank/Designated person

Standard E16 The facility has established procedures for Antenatal care as per guidelines 4 4
ME E16.1 There is an established procedure Facility updates “Mother and 2 RR/SI
for Registration and follow up of Child Protection Card”.
pregnant women.

ME E16.3 The facility ensures availability of Tests for Urine albumin, 2 RR/SI
diagnostic and drugs during haemoglobin, blood grouping
antenatal care of pregnant
women

Standard E17 The facility has established procedures for Intranatal care as per guidelines 44 44
ME E17.1 Established procedures and Management of 1st stage of 2 SI/OB Check progress is recorded,
standard protocols for labour: Women is allowed to give
management of different stages birth in the position she
of labour including AMTSL (Active wants , Check progress is
Management of third Stage of recorded on partograph
labour) are followed at the facility

Management of 2nd stage of 2 SI/OB Allows the spontaneous

labour: delivery of head , gives
Perineal support and assist in
delivering baby. Check
progress is recorded on
partograph

Active Management of Third stage 2 SI/OB Palpation of mother's

of labour abdomen to rule out
presence of second baby

Use of Uterotonic Drugs 2 SI/RR Administration of 10 IU of

oxytocin IM with in 1 minute
of Birth

Control Cord Traction 2 SI/RR Only during Contraction


ME E17.2 There is an established procedure Staff is aware of Indications for
for assisted and C-section
deliveries per scope of services. Intervention
ME E17.3 There is established procedure
for management/Referral of
Obstetrics Emergencies as per
scope of services.
Uterine Massage
referring patient for Surgical
Management and follow up of
PIH/Eclampsia \Pre Eclampsia
2 SI/RR After placenta expulsion ,
Checks Placenta &
Membranes for
Completeness
2 SI Ask staff how they identify
slow progress of labour , How
they interpret Partogram
2 SI/RR Monitors BP in every case,
and tests for proteinuria if BP
is >140/90 mmHg
If BP is 140/90 mmHg or
more with proteinuria 2+
along with any two of the
following danger signs:
severe headache, blurring of
vision, severe pain abdomen
or reduced urine output, BP >
160/110 or more with
proteinuria 3+; OR in cases
of Eclampsia—administers
loading dose of Magnesium
Sulphate (MgSO4) and refers/
calls for specialist attention;
continues maintenance dose
of MgSO4- 5 g of MgSO4 IM
in alternate buttocks every
four hours, for 24 hours after
birth/last convulsion,
whichever is later
If BP is >160/110 mmHg or
more, give appropriate anti-
hypertensive
(Hydralazine/Methyl Dopa/
Nifedipine)
Management of Postpartum
Haemorrhage
Management of Retained Placenta
Management of Uterine Atony
2 SI/RR Assessment of bleeding (PPH
if >500 ml or > 1 pad soaked
in 5 Minutes. IV Fluid,
bladder catheterization,
measurement of urine
output, Administration of 20
IU of Oxytocin in 500 ml
Normal Saline or RL at 40-60
drops per minute . Performs
Bimanual Compression of
Uterus
2 SI/RR Administration of another
dose of 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
2 SI/RR Vigorous Uterine massage,
gives Oxytocin 20 IU in 500
ml of R/L 40 to 60
drops/minute (Continue to
administer Oxytocin uptown
maximum of 3 litres of
solution with Oxytocin) If still
bleeding perform bi manual
uterine compression with
palpation of femoral pulse
 Management of Obstructed 2 SI/RR Diagnose obstructed labour
Labour based on data registered
from the partograph, Re-
hydrate the patient to
maintain normal plasma
volume, check vitals, give
broad spectrum antibiotics,
perform bladder
catheterization and take
blood for Hb & grouping,
Decide on the mode of
delivery as per the condition
of mother and the baby

Management of Puerperal sepsis 2 SI/RR Diagnose puerperal sepsis

based on clinical criteria:
continuous fever for at least
24 hours or recurring within
the first 10 days after
delivery, increased pulse
rate, increased respiration,
offensive/foul smelling
lochia, sub involution of the
uterus, headache and general
malaise, pelvic pain, pain,
swelling and pus discharge
from laceration or episiotomy
or incision. Conduct
appropriate lab.
investigations, Prescribes IV
fluids and broad spectrum
antibiotics for seven days &
advises perennial care

Delivery of infectious cases HIV 2 SI/RR

positive PW
ME E17.4 There is an established procedure Recording date and Time of 2 SI/RR Check the records
for new born resuscitation and Birth, Weight
new-born care.
 Dried and put on mothers 2 SI/OB With a clean towel from head
abdomen to feet, discards the used
towel and covers baby
including head in a clean dry
towel

Vitamin K for low birth weight 2 SI/RR Given to all new born (1.0 mg
IM in > 1500 gms and 0.5 mg
in < 1500 gms

Warmth 2 SI/RR Check use of radiant warmer

Care of Cord and Eyes 2 SI/RR Delayed Cord Clamping,

Clamps & Cut the cords by
sterile instruments within 1-3
minutes of Birth
Clean baby's eyes with sterile
cotton/Gauge

APGAR Score 2 SI/RR Check practice of maintaining

APGAR Score, Nurse has
requisite skills

Kangaroo Mother Care 2 SI/RR Observe /Ask staff about the

practice
New born Resuscitation 2 SI/RR Ask Nursing staff to
demonstrate Resuscitation
Technique

Standard E18 The facility has established procedures for postnatal care as per guidelines 12 12
ME E18.1 Post partum Care is provided to Prevention of Hypothermia of new 2 SI/RR
the mothers born
Initiation of Breastfeeding with in 2 PI
1 Hour
Mother is monitored as per post 2 RR/SI Check for records of Uterine
natal care guideline contraction, bleeding,
temperature, B.P, pulse,
Breast examination, (Nipple
care, milk initiation)

Check for perennial washes 2 PI

performed
ME E18.3 There is an established procedure Labour room has procedure to 2 PI/SI Breast feeding and
for Post partum counselling of provide post partum Counselling prevention of hypothermia
mother
ME E18.4 The facility has established There is established criteria for 2 SI/RR
procedures for shifting new-born to NBSU
stabilization/treatment/referral
of post natal complications

Area of Concern - F Infection Control 130 132

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital
8 8
associated infection
ME F1.2 The facility has provision for Surface and environment samples 2 SI/RR Swab are taken from
Passive and active culture are taken for microbiological infection prone surfaces
surveillance of critical & high risk surveillance
areas

ME F1.4 There is Provision of Periodic There is a procedure for 2 SI/RR Hepatitis B, Tetanus Toxoid
Medical Check-up and immunization of the staff etc.
immunization of staff
Periodic medical check-ups of the 2 SI/RR
staff
ME F1.5 The facility has established Regular monitoring of infection 2 SI/RR Hand washing and infection
procedures for regular monitoring control practices control audits done at
of infection control practices periodic intervals

Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 26 26
ME F2.1 Hand washing facilities are Availability of hand washing 2 OB Check the availability of wash
provided at point of use Facility at Point of Use basin near the point of use

Availability of running Water 2 OB/SI Open the tap. Ask the Staff,
water is available 24*7

Availability of antiseptic soap with 2 OB/SI Check for availability/ Ask

soap dish/ liquid antiseptic with staff if the supply is adequate
dispenser and uninterrupted

Availability of Alcohol based Hand 2 OB/SI Check for availability/ Ask

rub staff for regular supply. Hand
rub dispenser are provided
adjacent to bed

Display of Hand washing 2 OB Prominently displayed above

Instruction at Point of Use the hand washing facility ,
preferably in Local language

Availability of elbow operated taps 2 OB

 Hand washing sink is wide and 2 OB
deep enough to prevent splashing
and retention of water

ME F2.2 The facility staff is trained in hand Adherence to 6 steps of Hand 2 SI/OB Ask of demonstration
washing practices and they washing
adhere to standard hand washing
practices

Staff is aware of occasion for hand 2 SI

ME F2.3 The facility ensures standard
practices and materials for
antisepsis
washing
Availability of Antiseptic Solutions
Proper cleaning of procedure site
with antiseptics
2 OB
2 OB/SI like before giving IM/IV
injection, drawing blood,
putting Intravenous and
urinary catheter

Proper cleaning of perennial area 2 SI

before procedure with antisepsis

Check Shaving is not done during 2 SI

part preparation/delivery cases

Standard F3 The facility ensures standard practices and materials for Personal protection 16 18
ME F3.1 The facility ensures adequate Availability of Masks 2 OB/SI
personal protection Equipment as
per requirements
Availability of Sterile s gloves 2 OB/SI
Use of elbow length gloves for 0 OB/SI
obstetrical purpose
Availability of gown/ Apron 2 OB/SI
Availability of Caps 2 OB/SI
Heavy duty gloves and gum boats 2 OB/SI
for housekeeping staff
Personal protective kit for 2 OB/SI
delivering HIV patients
ME F3.2 The facility staff adheres to No reuse of disposable gloves, 2 OB/SI
standard personal protection Masks, caps and aprons.
practices
Compliance to correct method of 2 SI
wearing and removing the gloves

Standard F4 The facility has standard procedures for processing of equipment and instruments 28 28
ME F4.1 Facility ensures standard practices Decontamination of Procedure 2 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate work benches
and cleaning of instruments and (Wiping with 0.5% Chlorine
procedures areas solution)

Proper Decontamination of 2 SI/OB Decontamination of

instruments after use instruments and reusable of
glassware are done after
procedure in 1% chlorine
solution/ any other
appropriate method

Proper handling of soiled / 2 SI/OB Soiled / infected and Dirty

infected and dirty linen. linen are segregated at point
of generation. No rinsing or
sluicing at Point of use/
Patient care area.

Contact time for decontamination 2 SI/OB 10 minutes

is adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with
decontamination detergent and running water
after decontamination

The Staff knows how to make 2 SI/OB

chlorine solution
ME F4.2 The facility ensures standard Equipment and instruments are 2 OB/SI Autoclaving/HLD/Chemical
practices and materials for sterilized after each use as per Sterilization
disinfection and sterilization of requirement
instruments and equipment

High level Disinfection of 2 OB/SI Ask staff about method and

instruments/equipment is done time required for boiling/
as per protocol Chemical HLD

Autoclaving of instruments is done 2 OB/SI Ask staff about temperature,

as per protocols pressure and time

Chemical sterilization of 2 OB/SI Ask staff about method,

instruments/equipment is done as concentration and contact
per protocols time required for chemical
sterilization

Autoclaved linen are used for 2 OB/SI

procedure
 Autoclaved dressing material is 2 OB/SI
used
There is a procedure to ensure the 2 OB/SI
traceability of sterilized packs

Sterility of autoclaved packs is 2 OB/SI Sterile packs are kept in

maintained during storage clean, dust free, moist free
environment.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 24 24
ME F5.1 Layout of the department is Labour Room is located in a 2 OB
conducive for the infection control secluded place, away from the
practices internal main traffic of the CHC

ME F5.2 The facility ensures availability of Availability of disinfectant as per 2 OB/SI Chlorine solution,
standard materials for cleaning and requirement Gluteraldehye, carbolic acid
disinfection of patient care areas

Availability of cleaning agent as 2 OB/SI Hospital grade phenyl,

per requirement disinfectant detergent
solution

ME F5.3 The facility ensures standard The Staff is trained in spill 2 SI/RR
practices are followed for the management
cleaning and disinfection of patient
care areas

Cleaning of patient care area with 2 SI/RR

detergent solution
Staff is trained for preparing 2 SI/RR
cleaning solution as per standard
procedure

Standard practice of mopping and 2 OB/SI Unidirectional mopping from

scrubbing are followed inside out
Cleaning equipment like broom 2 OB/SI Any cleaning equipment
are not used in patient care areas leading to dispersion of dust
particles in air should be
avoided

Use of three bucket system for 2 OB/SI

mopping
Fumigation/carbolization as per 2 SI/RR
schedule
External foot wares are restricted 2 OB

ME F5.4 The facility ensures segregation of Isolation and barrier nursing 2 OB/SI
infectious patients procedure are followed for septic
cases
Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and
ME F6.1 The facility Ensures segregation of
Availability of colour coded bins at
Bio Medical Waste as per
guidelines and 'on-site'
management of waste is carried
out as per guidelines
ME F6.2 Facility ensures management of
sharps as per guidelines
ME F6.3 The facility ensures
transportation and disposal of
waste as per guidelines
28 28
hazardous 2Waste.OB
point of waste generation
2 OB
Availability of Non chlorinated
plastic colour coded plastic bags
2 OB/SI
Segregation of Anatomical and
solied waste in Yellow Bin
2 OB
Segregation of infected plastic
waste in red bin
Display of work instructions for 2 OB
segregation and handling of
Biomedical waste
There is no mixing of infectious 2
and general waste
Availability of functional hub 2 OB See if it has been used or just
cutters lying idle
Availability of puncture proof box 2 OB
Should be available nears the
point of generation like
nursing station and injection
room
Availability of white translucent 2 OB Check for Puncture proof,
bins for waste Sharps tamper proof and leak proof
containers
Availability of Blue bins for 2 OB Check for Puncture proof and
Galssware leak proof boxes with blue
colored marking
Availability of post exposure 2
prophylaxis Ask if available. Where it is
stored and who is in charge
OB/SI of that.
Check bins are not overfilled 2 SI/OB
Transportation of bio medical 2 SI/OB
waste is done in close
container/trolley
Staff aware of mercury spill 2 SI/RR
management
Area of Concern - G Quality Management 64 74
Standard G1 The facility has established organizational framework for quality improvement 2 2
ME G1.1 The facility has a quality team in There is a designated 2 SI/RR Preferably Obstetrician
place departmental nodal person for
coordinating Quality Assurance
activities

Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 6 6
ME G3.1 The facility has established There is system daily round by 2 SI/RR
internal quality assurance matron/hospital manager/
programme in key departments hospital superintendent/ Hospital
Manager/ Matron in charge for
monitoring of services

ME G3.3 The facility has established Departmental checklists are 2 SI/RR

system for use of check lists in used for monitoring and quality
different departments and assurance
services

Staff is designated for filling and 2 SI

monitoring of these checklists

Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key
40 40
ME G4.1
processes and support
Departmental standard operating Standard operating procedure for 2
services.
RR
procedures are available department has been prepared
and approved

Current version of SOP's are 2 OB/RR

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

The Department has documented 2 RR

procedure for Emergency obstetric
care

The Department has documented 2 RR

procedure for management of
high risk pregnancy

The Department has documented 2 RR

procedure for rapid initial
assessment

The Department has documented 2 RR

procedure for requisition of
diagnosis and receiving of the
reports
The Department has documented 2 RR Intrapartum care includes
procedure for intra partum care Management of 1st stage of
labour, 2nd stage of labour
and 3rd stage of labour

The Department has documented 2 RR

immediate post partum care

The Department has documented 2 RR

essential new born care

The Department has documented 2 RR

procedure for neonatal
resuscitation

The Department has documented 2 RR

procedure for admission, shifting
and referral of the patient

The Department has documented 2 RR Labour room management

procedure for arrangement of include maintenance and
intervention for labour room calibration of equipment and
inventory management etc.

The Department has documented 2 RR

procedure for blood transfusion

The Department has documented 2 RR

criteria for distinguish between
new-born death and still birth

The Department has documented 2 RR

procedure for environmental
cleaning and processing of the
equipment

The Department has documented 2 RR

procedure for maintenance of
rights and dignity of pregnant
women

The Department has documented 2 RR

procedure for record Maintenance
including taking consent
ME G4.3 Staff is trained and aware of the Check if staff are aware of relevant 2 SI/RR
procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 2 OB AMSTL, PPH,Infection
Point of use are displayed control,Eclamsia, New born
resuscitation, kangaroo care

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription
4 8
audit
ME G5.1 The facility conducts periodic Internal assessment is done at 2 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 2 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps time bound Action plan is 0 RR/SI
found in the assessment / audit prepared for improvement
process
ME G5.5 Corrective and preventive actions Corrective and preventive action 0 RR/SI
are taken to address issues, taken
observed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 0 6
ME G6.2 The facility periodically defines its Quality objective for Labour Room 0 RR/SI
quality objectives and key are defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check if staff is aware of quality 0 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 0 SI/RR
objectives is monitored and reviewed periodically
periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 12 12
ME G7.1 Facility uses method for quality PDCA 2 SI/RR
improvement in services

5S 2 SI/OB
Process Mapping 2 SI/OB
Any other method of QA 2 SI/RR
ME G7.2 Facility uses tools for quality Any 2 basic tools of Quality 2 SI/RR
improvement in services
Pareto / Prioritization 2 SI/RR
Area of Concern - H Outcome 34 34
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 12 12
ME H1.1 Facility measures productivity Normal Deliveries per 1000 2 RR
Indicators on monthly basis population
Proportion of deliveries conducted 2 RR
at night
Proportion of complicated 2 RR
cases managed
Proportion of assisted delivery 2 RR
conducted
% PPIUCD inserted against 2 RR
total IUCD
ME H1.2 The Facility measures equity Proportion of BPL Deliveries 2 RR
indicators periodically
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 8 8
ME H2.1 Facility measures efficiency Proportion of cases referred to OT 2 RR
Indicators on monthly basis
Proportion of cases referred to 2 RR
Higher Facilities
% of new-born's required 2 RR
resuscitation out of total live
births

% of new-born's required 2 RR
resuscitation out of total live
births

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 12 12
ME H3.1 Facility measures Clinical Care & Proportion of Cases Partograph 2 RR
Safety Indicators on monthly basis Maintained

Episiotomy site infection rate 2

No of adverse events per thousand 2 RR
patients
Culture Surveillance sterility rate 2 RR % of environmental swab
culture reported positive

Proportion of cases of different 2 RR PPH, Eclampsia, obstructed

complications labour etc.
Rational oxytocin usage Index 2 RR No. of Oxytocin doses
used /No. of normal
deliveries conducted

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 2
ME H4.1 Facility measures Service Quality Patient satisfaction 2 RR
Indicators on monthly basis
 Labour room Score Card
Labour room
Score
96.419098
Area of Concern wise Score
A Service Provision 96.6666666666667
B Patient Rights 98.0769230769231
C Inputs 96.7948717948718
D Support Services 91.6666666666667
E Clinical Services 100
F Infection Control 98.4848484848485
G Quality Management 86.4864864864865
H Outcome 100

Obtained Maximum Percent 3

A 29 30 96.66666666667
B 51 52 98.07692307692
C 151 156 96.79487179487
D 88 96 91.66666666667
E 180 180 100
F 130 132 98.48484848485
G 64 74 86.48648648649
H 34 34 100
Total 727 754 96.41909814324
 National Quality Assurance Standards for Taluka Hospital
Checklist for IPD 4
Measurable Element Checkpoints Compliance Assessment Means of verification
Reference No Method Remarks
Area of Concern - A Service Provision 28 28
Standard A1 The facility provides Curative Services 4 4
Availability of admission 2 SI/OB Correlate with Night
ME A1.9 Services are available for the time facilities 24X7 admission rate
period as mandated
Availability of accident & 2 SI/OB
ME A1.10 The facility provides Accident & trauma beds.
Emergency Services
Standard A2 The facility provides RMNCHA Services 14 14
Availability of indoor services 2 SI/OB Separate beds for
for Antenatal cases, Normal delivery cases in female
ME A2.2 delivery and LSCS ward.
The facility provides Maternal
health Serv ices
Indoor Management of Severe 2 SI/RR
ME A2.4 Diarrhoea with dehydration
The facility provides Child health
Services
Indoor Management of Acute 2 SI/RR
Respiratory Inf ections

Seizers and convulsions 2 SI/RR

Shock 2 SI/RR
Accidental poisoning 2 SI/RR
Services Under RSBY 2 SI/RR
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme 8 8
The facility provides services Availability of Indoor services 2 SI/RR Malaria Kalazar Dengue
under National Vector Borne for Management of vector & Chikungunya
Disease Control Programme as per borne diseases AES/Japanese
ME A4.1 guidelines Encephalitis as prevalent
locally

The facility provides services Indoor treatment of TB 2 SI/RR

under Revised National TB Control patients requiring
ME A4.2 Programme as per guidelines hospitalization

The facility provides services Inpatient Management of 2 SI/RR

under National Leprosy severely ill cases
ME A4.3 Eradication Programme as per
guidelines

The facility provides services Inpatient care for cases 2 SI/RR

under National AIDS Control requiring hospitalization
ME A4.4
Programme as per guidelines
Standard A6 Health services provided at the facility are appropriate to community needs. 2 2
The facility provides curatives & Availability of indoor Services 2 SI/RR
preventive servic es for the health as per local prevalent disease
ME A6.1 problems and diseases, prev alent
locally.

Area of Concern - B Patient Rights 79 82

The facility provide s the information to care se ekers, a ttendants & community about the available services and
Standard B1 15 16
their modalities
Availability departmental 2 OB (Numbering Rooms, main
signage's department and inter-
ME B1.1 The facility has uniform and user- sectional signage)
friendly signage system

Visiting hours and visitor 2 OB

The facility displays the services
ME B1.2
and entitlements available in its
departments
policy are displayed
Entitlements under different 2 OB
National Health Programmes
are displayed
Contact details of referral 2 OB
transport / ambulance
displayed

User charges are display ed and User charges if any are 2 OB

displayed
ME B1.4 communicated to patients
effectively
Relevant IEC material 2 OB Kangaroo mother care,
Patients & visitors are sensitised displayed in wards Breast feeding,
ME B1.5 and educated through appropriate immunization & PPIUCD
IEC / BCC approaches

Signage's and information are 2 OB

Information is available in local available in local language
ME B1.6
language and easy to understand

The facility ensures access to Discharge summary is given 1 RR/OB

ME B1.8 clinic al records of patients to to the patient
entitled personnel
Standard B2 Services are delive red in a manner that is sensitive to ge nder, religious and cultural needs , and the re are no 20 20
ba rrier on account of phys ical , e conomi c, cultural or s ocial status.
Separate male & female 2 OB Where ever male and
wards female are kept in same
Services are prov ided in manner wards male and female
ME B2.1 area are demarcated
that are sensitive to gender

Male and female toilets are 2 OB/SI

demarcated
Access to toilet should not go 2 OB
through opposite sex patient
care area
Male attendants are not 2 OB/SI
allowed to stay in night in
Female ward
There is no discrimination 2 SI/PI
with transgender patients
No unnecessary /non- 2 SI/PI/RR
essential disclosure of a
person’s transgender status

Cots in Female ward are large 2

enough for stay of mother
with child
Availability of Wheel chair or 2 OB
stretcher for easy Access to
ME B2.3 Access to facility is provided the ward
without any physical barrier & and
friendly to people w ith disabilities
Availability of ramps with 2 OB
railing
Availability of disable friendly 2 OB
toilet
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and ha s a sys tem for guarding patient rela ted
14 16
Availability of Screens /
information.
2 OB Bracket screen
ME B3.1 Adequate visual privacy is
provided at ev ery point of care Curtains
Examination/ Dressing of 2 OB
patient is done in enclosed
area
No two patients are treated 2 OB
on one bed
Partitions separating men and 2 OB
women are robust enough to
prevent casual overlooking
and overhearing

Patient Records are kept in a 0 SI/OB

Confidentiality of patients records secure places beyond access
ME B3.2 and clinical inf ormation is to general staff/visitors
maintained

No information regarding 2 SI/OB

patient identity and details
are unnecessary displayed on
BHT/case sheet/case paper/
Case sheet

Behaviour of staff is 2 OB/PI

The facility ensures the behaviours empathetic and courteous
ME B3.3 of staff is dignified and respectful,
while delivering the services

HIV status of patient is not 2 SI/OB

The facility ensures privacy and disclosed except to staff that
confidentiality to every patient, is directly involved in care
ME B3.4 especially of those conditi ons
having social stigma, and also
safeguards vulnerable groups
The facility ha s defined and e stabl ishe d procedures for informing patients about the medical condition, and
Standard B4 6 6
involving the m in treatment planning, and fa cilitates informed de cision making
General Consent is taken 2 SI/RR
There is established procedures before admission
ME B4.1 for taking informed consent
before treatment and procedures

Patient is informed about 2 PI

Information about the treatment clinical condition and
ME B4.4 is shared with patients or treatment being provided
attendants, regularly

The facility has defined and Availability of complaint box 2 OB

established Grievance Redressal and display of process for
ME B4.5 System in place grievance redressal and with
contact detail.

Standard B5 The facility ensure s that there are no fina ncial barrie r to acces s, and that there is financial protection given from
The facility provides cashless
ME B5.1 servic es to pregnant women,
mothers and neonates as per
prevalent gov ernment schemes
the cos t of hospita l services. 24 24
Stay in wards is free for 2 PI/SI
entitled patients under NHP
and as per state schemes
Drugs and consumables under 2 PI/SI
NHP are freely available to
entitled personnel

Availability of free diagnostics 2

to entitled Personnel

Availability of Free drop back 2

The facility ensures that drugs
ME B5.2 prescribed are available at
Pharmacy and wards
to entitled Personnel
Availability of Free diet to 2
mother
Availability of Free patient 2
transport
Availability of Free Blood 2
Availability of Free drugs 2
Check that parents & 2 PI/SI
attendant's have not spent
money on purchasing drugs
and consumables from
outside.

Check that parents & 2 PI/SI Provision of diagnostics

attendants have not spent in empanelled
money on diagnostics from Government or Private
It is ensured that facilities f or the outside. diagnostic centre under
ME B5.3 prescribed investi gations are CMCHIS.
available at the facility

All treatment are free of cost 2 PI/SI/RR

The facility provide free of cost for BPL Patients
ME B5.4 treatment to Below poverty line
patients without administrative
hassles
The facility ensure Cashless treatment been 2 SI/RR
implementation of health provide throgh Chief Minister
ME B5.6 insurance sc hemes as per National Insurance scheme
/state sc heme

Area of Concern - C Inputs 111 124

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 39 42
The Departments has adequate Adequate space in wards with 2 OB Distance between
ME C1.1 space as per pati ent or work load no cluttering of beds centres of two beds –
2.25 meter

Patient amenities are provided as Functional toilets with 2 OB 1:12 Male & 1:8 Female
per patient load running water and flush are
available as per strength and
ME C1.2 patient load of ward

Functional bathrooms with 2 OB

running water are available as
per strength and patient load
of ward

Availability of drinking water 2 OB

Patient/ visitor Hand washing 2 OB

area
Separate toilets for visitors 2 OB

TV for entertainment and IEC 2 OB

activities
Adequate shaded waiting area 2 OB
is provided for attendants of
patient
The Departments has layout and Availability of Dedicated 2 OB
ME C1.3 demarcated areas as per f unctions nursing station

Availability of Examination 2 OB
room
Availability of Treatment room 2 OB

Availability of Doctor's Duty 2 OB

The facility has adequate
circulation area and open spaces
according to need and local law
ME C1.4
room
Availability of Nurse Duty
room
Availability of Store
Availability of Dirty utility
room
There is sufficient space
between two bed to provide
bed side nursing care and
movement
2 OB
2 OB Drug & Linen store
2 OB
2 OB Space between two beds
should be at least 4 ft.
and clearance between
head end of bed and wall
should be at least 1 ft.
and between side of bed
and wall should be 2 ft.

Corridors are wide enough for 1 OB Corridor should be at

patients, visitors and trolley/ least 3 metres wide
equipment movement

The facility has infrastructure for Availability of functional 0 OB

intramural and ex tramural telephone and Intercom
ME C1.5 Services/CUG Services
communication
Service counters are available as There is separate nursing 2 OB
ME C1.6 per patient load station for each ward
The facility and departments are Indoor beds have functional 2 OB
planned to ensure structure linkages with OT and labour
follows the function/processes room.
ME C1.7 (Structure commensurate with the
function of the hospital)

Location of nursing station 2 OB

and patients beds enables
easy and direct observation of
patients

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 18 18
The facility ensures seismic safety Non structural components 2 OB Check for fixtures and
of the infrastructure are properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging
ME C2.1 objects are properly
fastened and secured

The facility ensures safety of
ME C2.2 elec trical establishment
Physical condition of buildings is
safe f or providing patient care
ME C2.3
IPD ward does not have 2 OB Switch Boards other
temporary connections and electrical installations are
loosely hanging wires intact
Floors of the ward are non 2 OB
slippery and ev en surpad

Windows have grills and wire 2 OB

meshwork
The facility has plan for prevention Ward has fire exit to permit 2 OB/SI
ME C2.4. of fire safe escape of its occupant at
time of fire
Check the fire exits are clearly 2 OB
visible and routes to reach exit
are clearly marked.

The facility has adequate fire IPD has installed fire 2 OB

fighting Equipment Extinguisher that are capable
ME C2.5 of fighting A,B & C Type of
fire.

Check the expiry date for fire 2 OB/RR

extinguisher is displayed on
each extinguisher as well as
due date for next refilling is
clearly mentioned

The facility has a system of Check for staff competencies 2 SI/RR

periodic training of staff and for operating fire extinguisher
conducts mock drills regularly f or and what to do in case of fire
ME C2.6. fire and other disaster situation

Standard C3 The facility has adequa te qualifie d and trained s taff, required for providing the as sured s ervice s to the current
20 20
ca se load
The facility has adequate specialist Availability of specialist doctor 2 OB/RR
ME C3.1 doctors as per service provision. on call Gynae, Obs and Anesthetist

The facility has adequate general Availability of at least one 2 OB/RR

ME C3.2 duty doctors as per serv ice doctor at all time
provision
The facility has adequate nursing Availability of Nursing staff 2 OB/RR/SI As per patient load
ME C3.3 staff as per serv ice provision and
work load
The facility has adequate support / Availability of ward attendant/ 2 SI/RR
ME C3.5. general staff Ward boy/Aya
Availability of Security staff 2 SI/RR

The staff has been provided Biomedical waste 2 SI/RR

ME C3.6. required training / skill sets management
Infection control and hand 2 SI/RR
hygiene
CPR/Resuscitation 2
Patient Safety 2 SI/RR
The Staff is skilled as per job Nursing staff is skilled for 2 SI/RR
ME C3.7. description maintaining clinical records

Standard C4 The facility provides drugs and consumables required for assured services. 22 22
The departments have availability Availability of 2 OB/RR As per State EDL
ME C4.1 of adequate drugs at point of use Analgesics/Antipyretics/Anti
Inflammatory

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 2 OB/RR As per State EDL

CVS
Availability of drugs action on 2 OB/RR As per State EDL
CNS/PNS
Drugs for Respiratory System 2 OB/RR As per State EDL

Availability of Medical gases 2 OB/RR Availability of Oxygen

Cylinders
The departments have adequate Availability of dressing 2 OB/RR
ME C4.2 consumables at point of use material and antiseptic lotion

Availability of syringes and IV 2 OB/RR

Sets /Ryle's Tube/Foley's
Catheter
Availability of Antiseptic 2 OB/RR Betadine
Solutions
Emergency drug trays are Availability of emergency drug 2 OB/RR Inj Dopamine, Inj
maintained at every point of c are, tray Hydrocortisone, Inj
ME C4.3 where ev er it may be needed Adrenaline

Standard C5 The facility has equipment & instruments required for assured list of services. 12 22
Availability of equipment & Availability of functional 2 OB BP apparatus,
instruments for examinati on & Equipment &Instruments Thermometer,
monitoring of patients for examination & foetoscope, baby and
ME C5.1 Monitoring adult weighing scale,
Stethoscope ,
Glucometer

Availability of equipment & Availability of dressing tray 2 OB

instruments for treatment
ME C5.2 procedures, being undertak en in
the facility

Availability of equipment & Availability of Point of care 0 OB Lumber Puncture set in

instruments for diagnostic diagnostic instruments Paediatric ward
ME C5.3 procedures being undertaken in
the facility
 Availability of equipment and Availability of functional 0 OB Ambu bag and mask
instruments for resuscitation of Instruments for (adult and paediatric),
patients and for providing Resuscitation. Oxygen, Suction
intensiv e and critical c are to machine, Airway,
patients Nebulizer, Suction
ME C5.4 apparatus ,
Laryngoscope,
Endotracheal tube

Availability of Equipment for Availability of equipment 2 OB Refrigerator, Crash

Storage for storage for drugs cart/Drug trolley,
ME C5.5 instrument trolley,
dressing trolley

Availability of functional Availability of equipment 2 OB Buckets for mopping,

equipment and instruments for for cleaning mops, duster, waste
ME C5.6 trolley, Deck brush
support services
Availability of equipment 2 OB Autoclave/TSSU/CSSD
for sterilization and
disinfection
Departments have patient Availability of patient beds 0 OB
ME C5.7 furniture and fixtures as per load with prop up facility
and service prov ision
Availability of attachment/ 0 OB Hospital grade mattress,
accessories with patient bed Bed side/Pegion locker ,
IV stand, Bed pan

Availability of Fixtures 0 OB Spot light, electrical

fixture f or equipment like
suction, X ray view box

Availability of furniture 2 OB Cupboard, Nursing

counter, Table for
preparation of
medicines, Chair

Area of Concern - D Support Services 86 92

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 6 6
The facility has established system All equipment are covered 2 SI/RR
ME D1.1 for maintenance of critical under AMC including
Equipment preventive maintenance

There is system of timely 2 SI/RR

corrective break down
maintenance of the
equipment

The facility has established All the measuring equipment/ 2 OB/ RR BP apparatus, Weighing
procedure for internal and instrument are calibrated Machine etc. are
ME D1.2 external calibration of measuring calibrated
Equipment

Standard D2 The fa cility has de fined procedures for storage, inve ntory management and dis pensing of drugs in pharmacy and
18 18
patient care areas
There is established procedure f or There is established system of 2 SI/RR Stock level are daily
forecasting and indenting of drugs timely indenting of updated
and consumables consumables and drugs at Requisition are timely
ME D2.1 nursing station placed

The facility ensures proper storage Drugs are stored in 2 OB

ME D2.3 of drugs and consumables containers/tray/crash cart and
are labelled

Empty and filled cylinders are 2 OB

labelled
The facility ensures management Expiry dates are maintained at 2 OB/RR
of expiry and near expiry drugs emergency drug tray
ME D2.4

No expiry drug found 2 OB/RR

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

There is process f or storage of Temperature of refrigerators 2 OB/RR Check for temperature

vaccines and other drugs, are kept as per storage charts are maintained
requiring controlled temperature requirement and records are and updated periodically
ME D2.7 maintained

There is a proc edure f or secure Narcotic and psychotropic 2 OB/SI Separate prescription for
storage of narc otic and drugs are identified and narcotic and
ME D2.8 stored in lock and key psychotropic drugs
psychotropic drugs

Standard D3 The fa cility has es ta blis hed Program for ma intenance and upkee p of the facility to provide safe, s ecure and
comfortable environment to s taff, patients a nd visitors . 32 36
Exterior of the facility building is Building is 2 OB
ME D3.1 maintained with landscaping in painted/whitewashed in
the open area uniform colour

Interior of patient care areas 2 OB

are plastered & painted

Hospital infrastructure is Check for there is no seepage , 2 OB

ME D3.2 adequately maintained Cracks, chipping of plaster

Window panes , doors and 2 OB

other fixtures are intact
Patients beds are intact and 0 OB
painted
Mattresses are intact and 0 OB
clean
Patient care areas are clean and Floors, walls, roof, roof tops, 2 OB All area are clean with
hy gienic sinks in patient care and no dirt,grease,littering
ME D3.3 circulation areas are Clean and cobwebs

Surface of furniture and 2 OB

fixtures are clean
Toilets are clean with 2 OB
functional flush and running
water
The facility has policy of removal No condemned/Junk material 2 OB
ME D3.4. of condemned junk material found in the ward

The facility has established No stray animal/rodent/birds 2 OB

ME D3.5 procedures f or pest, rodent and
animal control
The facility provides adequate
ME D3.6 illumination level at patient care
areas
The facility has provision of
ME D3.7. restriction of visitors in patient
areas
The facility ensures safe and
comfortable environment for
patients and service providers
ME D3.8
Adequate Illumination at 2 OB 100 Lux of Illumination
nursing station
Adequate illumination in 2 OB 150 Lux of Illumination
patient care areas
Visiting hour are fixed and are 2 OB/PI
observed.
One family members is 2 OB/SI
allowed to stay with the
patient
Temperature control and 2 PI/OB Fans/ Air
ventilation in patient care area conditioning/Heating/Ex
haust/Ventilators as per
environment condition
and requirement

Temperature control and 2 SI/OB Fans/ Air

ventilation in nursing conditioning/Heating/Ex
station/duty room haust/Ventilators as per
environment condition
and requirement

The facility has established measure Ask female staff weather they 2 SI
ME D3.10 for safety and security of female staff feel secure at work place

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 5 6
The facility has adequate Availability of running and 2 OB/SI
arrangement storage and supply potable water on 24*7 basis
ME D4.1. for portable water in all functional
areas

The facility ensures adequate Availability of power back up 2 OB/SI

power back up in all pati ent care in patient care areas
ME D4.2
areas as per load
ME D4.3 Critical areas of the facility ensures Availability of Oxygen 1 OB
availability of oxygen, medical gases cylinders and vacuum suction
and vacuum supply

Standard D5 The facility ens ures availability of Diet as per nutritional requirement of the patients and cl ean Line n to al l
admitted patients. 17 18
The facility has provision of Appropriate diet as per 2 RR/SI
nutritional assessment of the nutritional requirement of the
ME D5.1 patients patients is prescribed by the
treating doctor

The facility provides diets Check for the adequacy and 2 OB/RR Check that all items fixed
according to nutritional frequency of diet as per in diet menu is provided
ME D5.2 requirements of the patients nutritional requirement to the patient

Check for the Quality of diet 2 PI/SI Ask patient & check the
provided record
Hospital has standard procedures for There is procedure of 2 RR/SI Normal, S emi-solid,
preparation, handling, storage and requisition of different type of Liquid diet, diet for
distribution of diets, as per diet from ward to kitchen diabetic patients, low salt
ME D5.3 requirement of patients and high protein diet etc.

The facility has adequate sets of Clean Linens are provided for 2 OB/RR
ME D 5.4. linen all occupied bed
Gown are provided to the 2 OB/RR
cases going for surgery or
delivery
Availability of Blankets, draw 1 OB/RR
sheet, pillow with pillow cover
and mackintosh

The facility has established ward has facility to provide 2 OB/RR

procedures f or changing of linen in sufficient and clean linen for
ME D5.5. patient care areas each patient

The facility has standard procedures There is system to check the 2 SI/RR
for handling , collection, cleanliness and quantity of the
ME D5.6. transportation and washing of linen linen received from laundry

Role s & Re sponsibil itie s of administra tive and clinical s taff are determined as per govt. re gulations a nd standards
Standard D9 8 8
operating procedures.
The facility has established job Staff is aware of their role and 2 SI
ME D9.1 description as per govt guidelines responsibilities

The facility has a established There is procedure to ensure 2 RR/SI Check for system for
procedure for duty roster and that staff is available on duty recording time of
deputation to different as per duty roster reporting and relieving
ME D9.2 departments (Attendance register/
Biometrics etc.)

There is designated in charge 2 SI

for department
The facility ensures the adherence Doctor, nursing staff and 2 OB
to dress code as mandated by its support staff adhere to their
ME D9.3 administration / the health respective dress code
department

Area of Concern - E Clinical Services 196 216

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 12 12
The facility has established Unique identification number 2 RR
ME E1.1 procedure for registration of is given to each patient
patients during registration

Patient demographic details 2 RR Check for that patient

are recorded in admission demographics like Name,
records Age, Sex,Provisional
Diagnosis etc.

There is established procedure f or There is no delay in admission 2 SI/RR/OB

ME E1.3 admission of patients of patient
Admission is done by written 2 SI/RR/OB
order of a facility's doctor

Time of admission is recorded 2 RR

in patient record
There is established procedure f or There is provision of extra 2 OB/SI
managing patients, in case beds Beds
ME E1.4 are not available at the facility

Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 16 16
There is established procedure f or Initial assessment's of all 2 RR/SI The assessment criteria
initial assessment of patients admitted patient done as per for different clinical
standard protocols conditions are defined
ME E2.1 and measured in
assessment sheet

Patient History is taken and 2 RR

recorded
Physical Examination is done 2 RR
and recorded wherever
required
Provisional Diagnosis is 2 RR
maintained
Initial assessment and 2 RR/SI
treatment is provided
immediately

Initial assessment is 2 RR
documented preferably within
2 hours
There is established procedure f or There is fixed schedule for 2 RR/OB
ME E2.2 follow-up/ reassessment of assessment of stable patients
Patients
For critical patients admitted 2 RR/OB
in the ward there is provision
of reassessment as per need

Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 16 16
The facility has established Facility has established 2 SI/RR
procedure for continuity of care procedure for handing over of
ME E3.1 during interdepartmental transfer patients from one department
to other department

There is a procedure for 2 RR/SI

consultation of the patient
with other spec ialist with-in
the hospital

The facility provides appropriate Patients are referred with 2 RR/SI

referral linkages to the referral slip
patients/Services for transfer to
ME E3.2 other/higher facilities to assure the
continuity of care.

Advance intimation is given to 2 RR/SI

higher centre
Referral vehicle is being 2 SI/RR
arranged
Referral in or referral out 2 RR
register is maintained
Facility has func tional 2 SI/RR Check for referral cards
referral linkages to lower filled from lower f acilities
facilities
There is a system of follow 2 RR
up of referred patients

Standard E4 The facility has defined and established procedures for nursing care 18 18
Procedure for identification of There is a process for 2 OB/SI Patient id band/ verbal
patients is established at the ensuring the identification confirmation/Bed no.
ME E4.1 facility before any clinical procedure etc.

Procedure for ensuring timely and Treatment chart are 2 RR Check for treatment
accurate nursing care as per maintained chart are updated and
treatment plan is established at the drugs given are marked.
ME E4.2 facility Co relate it with drugs
and doses prescribed.

There is a process to ensue 2 SI/RR Verbal orders are

the accuracy of rechecked before
verbal/telephonic orders administration

There is established procedure of Patient hand over is given 2 SI/RR

ME E4.3 patient hand ov er, whenever staff during the change of the shift
duty change happens
Nursing Handover register is 2 RR
maintained
Bed side Hand over is given 2 SI/RR

Nursing records are maintained Nursing notes are maintained 2 RR/SI Check for nursing note
adequately register. Notes are
ME E4.4 adequately written

There is procedure f or periodic Patient's Vitals are 2 RR/SI Check for TPR chart, IO
monitoring of patients monitored and recorded chart, any other vital
ME E4.5 periodically required is monitored

Critical patients are 2 RR/SI

monitored continuasly
Standard E5 The facility has a procedure to identify high risk and vulnerable patients. 4 4
The facility identifies vulnerable Vulnerable patients are 2 OB/SI Unstable, irritable,
patients and ensure their safe care identified and measures are unconscious. Psychotic
taken to protect them from and serious patients are
ME E5.1 any harm identified

The facility identifies high risk High risk patients are 2 OB/SI
ME E5.2 patients and ensure their care, as per identified and treatment given
their need on priority

Standard E6 T he facility follows standard treatment guide lines define d by s tate/Central government for prescribing the
gene ric drugs & their rational use. 8 8
The facility ensured that drugs are Check for BHT/case 2 RR
prescribed in generic name only sheet/case paper if drugs are
ME E6.1 prescribed under generic
name only

There is procedure of rational use of Check for that relevant 2 RR

drugs Standard Treatment Guideline
ME E6.2 are available at point of use

Check if staff are aware of the 2 SI/RR

drug regime and doses as per
Standard treatment guidelines
(STG)

Check BHT/case sheet/case 2 RR

paper that drugs are
prescribed as per STG

Standard E7 The facility has defined procedures for safe drug administration 22 22
There is process f or identif ying High alert drugs are identified 2 SI/OB AS applicable in the
ME E7.1 and cautious administration of in the department. department
high alert drugs
Maximum dose of high alert 2 SI/RR Value for maximum
drugs are defined and doses as per age, weight
communicated and diagnosis are
available with nursing
station and doctor

There is process to ensure 2 SI/RR A system of independent

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

Medication orders are written Ev ery Medical advice and 2 RR

legibly and adequately procedure are accompanied
ME E7.2 with date , time and
signature

Check for the writing to 2 RR/SI

ensure that it is
comprehendible by the clinical
staff

There is a proc edure to check drug Drugs are checked f or 2 OB/SI

before administration/ dispensing expiry and other
ME E7.3 inconsistency bef ore
administration

Check single dose vial are not 2 OB Check for any open
used for more than one dose single dose vial 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
multiple dose vial is not left in the septum

Any adverse drug reaction is 2 RR/SI

There is a system to ensure right
medicine is giv en to right patient
ME E7.4
recorded and reported
Administration of medicines 2 SI/OB
done after ensuring right
patient, right drugs , right
route, right time
 Patient is counselled f or self drug Patient is advice by doctor/ 2
administration Pharmacist /nurse about the
ME E7.5 dosages and timings .

Standard E8 The facility has defined and established procedures for ma intaining, updating of patients’ clinical records and
their s torage 16 16
All the assessments, re- Day to day progress of 2 RR
assessment and investigations are patients is recorded in
ME E8.1 recorded and updated BHT/case sheet/case paper

All treatment plan Treatment plan, first orders 2 RR Treatment prescribed Inj
prescription/orders are recorded are written on BHT/case nursing records
ME E8.2 in the patient records. sheet/case paper

Care provided to each patient is Maintenance of treatment 2 RR Treatment given is

recorded in the patient records chart/treatment registers recorded in treatment
ME E8.3 chat

Procedures perf ormed are written Any procedure performed is 2 RR Dressing, mobilization
ME E8.4 on patients records written on case sheet etc.
Adequate form and formats are Standard Format for bed head 2 RR/OB Availability of formats for
available at point of use ticket/ Patient case sheet is Treatment Charts, TPR
ME E8.5 available as per state Chart , Intake Output
guidelines Chat Etc.

Register/records are maintained Registers and records are 2 RR General order book
as per guidelines maintained as per guidelines (GOB), report book,
Admission register, lab
register, Admission
sheet/ bed head ticket,
discharge slip, referral
slip, referral in/referral
ME E8.6 out register, OT register,
Diet register, Linen
register, Drug intend
register

All register/records are 2 RR

identified and numbered
The facility ensures safe and Safe keeping of patient 2 OB
ME E8.7 adequate storage and retriev al of records
medical records

Standard E9 The facility has defined and established procedures for discharge of patient. 20 20
Discharge is done after assessing Assessment is done before 2 SI/RR
ME E9.1 patient readiness discharging patient
Discharge is done by a 2 SI/RR
authorized doctor
Patient / attendants are 2 PI/SI
consulted before discharge

Treating doctor is consulted/ 2 SI/RR

informed before discharge of
patients

Case summary and f ollow-up Discharge summary is 2 RR/PI See for discharge
instructions are provided at time provided summary, referral slip
ME E9.2 provided.
of discharge
Discharge summary mentions 2 RR
adequately patients clinical
condition, treatment given
and follow up

Discharge summary is given to 2 SI/RR

patients going on
LAMA/Referral
Counselling services are provided Patient is counselled bef ore 2 SI/PI
as during discharges w herever discharge
ME E9.3
required
Time of discharge is 2 PI/SI
communicated to patient in
prior

The facility has established Declaration is taken from the 2 RR/SI

procedure for patients leaving the LAMA patient
ME E9.4 facility against medical advice,
absconding, etc.

Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 4 4
The facility has disaster Staff is aware of disaster plan 2 SI/RR
ME E10.3 management plan in place
Roles and responsibilities of 2 SI/RR
the staff in disaster are
defined

Standard E11 The facility has defined and established procedures of diagnostic services 2 4
There are established procedures Container is labelled properly 2 OB
ME E11.1 for Pre-testing A ctivities after the sample collection

There are established procedures Nursing station is provided 0 SI/RR

for Post- testing Acti vities with the critical value of
ME E11.3 different tests

Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 12 12
There is established procedure f or Consent is taken before 2 RR
ME E12.5 transfusion of blood transfusion
Patient's identification is 2 SI/OB
verified before transfusion

blood is kept on optimum 2 RR

temperature before
transfusion
Blood transfusion is 2 SI/RR
monitored and regulated by
qualified person
Blood transfusion note is 2 RR
written in patient's record
There is a established procedure Any major or minor 2 RR
for monitoring and reporting transfusion reaction is
ME E12.6 Transfusion complication recorded and reported to
responsible staff

Standard E13
The facility has established
procedures f or Pre- anaestheti c
ME E13.1 Check up and maintenance of
records
The facility has established procedures for Anaesthetic Services 2 2
Pre anaesthesia check up is 2 SI/RR
conducted for elective /
Planned surgeries

Standard E15 The facility has defined and established procedures for end of life care and death 12 14
Death of admitted patient is Facility has a standard 2 SI
adequately recorded and procedure to decent
ME E15.1 communicated communication of death to
relatives

Death note is written in 2 RR

patient record
Death note including efforts 2
done for resuscitation is noted
in patient record

The facility has standard Death summary is given to 0 SI/RR

procedures f or handling the death patient attendant quoting the
in the hospital immediate cause and
ME E15.2 underlying cause if possible

The facility has standard All the deaths where Post- 2 RR

procedures f or referring for post- mortem is mandatory, dead
mortem, its rec ording and bodies are referred to a
ME E15.4 meeting its obligation under the facility as per state's guideline
law

2 OB/RR

Facility has system for

storage/transfer of unclaimed
body for fixed duration as per
state guideline
2 RR

Facility has system for disposal

of unclaimed bodies as per
state guideline
Maternal Health and Child health Services.
Standard E16 The facility has established procedures for Antenatal care as per guidelines 10 10
There is an established procedure Facility updates “Mother 2 RR/SI
ME E16.1 for Registration and follow up of and Child Protection Card”.
pregnant women.
There is an established procedure Management of PIH and 2 RR/SI Loading dose of
for identific ation of High risk referral of Eclampsia cases Magnesium sulphate is
pregnancy and appropriate given before referral
ME E16.4 treatment/ref erral as per scope of
servic es.

Management of sepsis 2 RR/SI

Initial Management & Referral 2 RR/SI
of diabetic pregnant mother

There is an established procedure Management of severe 2 RR/SI Blood Transfusion

for identific ation and management anaemia & referral services available for
ME E16.5 of moderate and severe anaemia anaemic patients

Standard E18 The facility has established procedures for postnatal care as per guidelines 14 14
Post partum Care is prov ided to Post Partum Care of New-born 2 SI/RR Maintaining hand
the mothers hygiene, keeps the baby
wrapped (maintains
temperature), Checks
weight, temperature,
ME E18.1 respiration, heart rate,
colour of skin and cord
stump

Initiation of Breastfeeding 2 PI Verify with mother

with in one Hour regarding a)Counselling
on Breast F eeding b)Time
Period between delivery
and first feed c)Advice in
position of baby

Post partum care of mother 2 PI/RR Ask mother about

Checking uterine
contraction, bleeding,
checking for TPR and
output chart, Breast
examination and milk
initiation and perineal
washes

The facility ensures adequate stay 48 Hour Stay of mothers and 2 SI/RR
of mother and new-born in a safe new born after delivery
ME E18.2 environment as per standard
Protocols.

There is an established procedure Counselling provided for Post 2 PI/SI Nutrition ,Contraception
for Post partum counselling of partum care ,Breastfeeding ,Registrati
mother on of Birth ,IFA
ME E18.3 Supplement ,Danger
Signs.

The facility has established There is established criteria 2 SI/RR

procedures f or for shifting new-born to NBSU
ME E18.4 stabilization/treatment/ref erral of and referring to SNCU
post natal complications

There is established procedure f or Counselling is done before 2 RR/PI Danger Sign for Mother:
discharge and follow up of mother discharge, Patient is explained Bleeding, Pain abdomen,
and new-born. about follow up visits Severe Headache, Visual
disturbance, Breathing
difficulties, Fever and
Chills, Difficulty in
Urination, Foul smelling
discharge. Danger sign
for Baby: Fast & difficult
breathing, Fever,
ME E18.5 Unusual Cold, Does not
accept feed, Less active
& yellow discoloration of
skin

Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 6 22
The facility provides immunization Zero dose vaccines are given 2 RR Check for records BCG,
servic es as per guidelines Hepatitis-B and OPV-0
ME E19.1 given to New-born

Triage, Assessment & Management Assessment Protocols are 2 SI/RR Airway, Breathing,
of new-borns having available Circulation, Coma,
emergency signs are done as per Convulsion, and
ME E19.2 guidelines Dehydration

Triage Protocols are available 0 SI/RR Emergency, priority and

Staff is aware and practices
ETAT protocols
Staff is skilled in basic life
support for Infants and
children
ETAT checklist is available and
practiced
Management of Low birth w eight Care of Low Birth Weight and
new-born's is done as per Premature babies
guidelines
ME E19.3
can wait
0 SI/RR
0 SI/RR
0 SI/RR
2 SI/RR Premature and LBW
babies are 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 is
arranged, if required

Management of children Differential diagnosis 0 SI/RR

presenting algorithm are available
with fever, cough/ breathlessness
ME E19.5 is done as per guidelines

Weight chart is maintained 0 RR

Start-up and catch formula 0 SI/RR check for composition
made as per guidelines
Management of children Assessment of dehydration 0 SI/RR
presenting done as per protocols
ME E19.7 diarrhoea is done per guidelines

National Health Program

Standard E22 The facility provides National health Programme as per operational/Clinical Guidelines 2 2
The facility provide service for Weekly reporting of 2 SI/RR
ME E22.9 Integrated disease surv eillance Presumptive cases on form
Programme "P" from IPD

Area of Concern - F Infection Control 80 80

The facility has infection control Programme and procedures in pl ace for prevention and me asurement of
Standard F1 hos pital as sociate d infection 10 10
The facility measures hospital There is a procedure to report 2 SI/RR Patients are observed for
assoc iated inf ection rates cases of Hospital acquired any sign and symptoms
infection of HAI like fever,
ME F1.3 purulent discharge from
surgical site .

There is Prov ision of Periodic There is a procedure for 2 SI/RR Hepatitis B, Tetanus
ME F1.4 Medical Check-up and immunization of the staff Toxoid etc.
immunization of staff
Periodic medical check-ups of 2 SI/RR
the staff
The facility has established Regular monitoring of 2 SI/RR Hand washing and
procedures f or regular monitoring infection control practices infection control audits
ME F1.5 of infection control practices done at periodic intervals

The facility has defined and Check if Doctors are aware of 2 SI/RR
ME F1.6 established antibiotic policy Hospital Antibiotic Policy

Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 18 18
Hand washing f acilities are Availability of hand washing 2 OB FNBC guideline: Each unit
provided at point of use Facility at Point of Use should have at least 1
ME F2.1 wash basin for every 5
beds

Availability of running Water 2 OB/SI Open the tap. Ask the

Staff, water is available
24*7
Availability of antiseptic soap 2 OB/SI Check for availability/
with soap dish/ liquid Ask staff if the supply is
antiseptic with dispenser. adequate and
uninterrupted

Availability of Alcohol based 2 OB/SI Check for availability/

Hand rub Ask staff for regular
supply. Hand rub
dispenser are provided
adjacent to bed

Display of Hand washing 2 OB Prominently displayed

Instruction at Point of Use above the hand washing
facility , preferably in
Local language

The facility staff is trained in hand Adherence to 6 steps of Hand 2 SI/OB Ask for demonstration
washing practices and they adhere washing
ME F2.2 to standard hand washing
practices

Staff is aware of occasion for 2 SI

hand washing
The facility ensures standard Availability of Antiseptic
ME F2.3 practices and materials for Solutions
antisepsis
Procedure for proper cleaning
of site with antisepsis
2 OB
2 OB/SI e.g. before giving IM/IV
injection, drawing blood,
putting Intravenous and
urinary catheter

Standard F3 The facility ensures standard practices and materials for Personal protection 8 8
The facility ensures adequate Clean gloves are available at 2 OB/SI
ME F3.1 personal protection Equipment as point of use
per requirements
Availability of Masks 2 OB/SI
The facility staff adheres to No reuse of disposable gloves, 2 OB/SI
standard personal protection Masks, caps and aprons.
ME F3.2
practices
Compliance to correct method 2 SI
of wearing and removing the
gloves

Standard F4 The facility has standard procedures for processing of equipment and instruments 18 18
The facility ensures standard Decontamination of 2 SI/OB Ask staff about how they
practices and materials for Procedure surfaces decontaminate work
decontamination and cleaning of benches
ME F4.1 instruments and procedures areas (Wiping with 0.5%
Chlorine solution)

Proper Decontamination of 2 SI/OB Decontamination of

instruments after use instruments and reusable
of glassware are done
after procedure in 1%
chlorine solution/ any
other appropriate
method

Contact time for 2 SI/OB 10 minutes

decontamination is adequate

Cleaning of instruments after 2 SI/OB Cleaning is done with

decontamination detergent and running
water after
decontamination

Proper handling of soiled / 2 SI/OB Soiled / infected and

infected and dirty linen. Dirty linen are
segregated at point of
generation. No rinsing or
sluicing at Point of use/
Patient care area.

The S taff knows how to make 2 SI/OB

chlorine solution
The facility ensures standard Equipment and instruments 2 OB/SI Autoclaving/HLD/
practices and materials for are sterilized after each use Chemical S terilization
ME F4.2 disinfection and sterilization of as per requirement
instruments and equipment
 High level Disinfection of 2 OB/SI Ask staff about method
instruments/equipment is and time required for
done as per protocol boiling/ Chemical HLD

Autoclaved dressing material 2 OB/SI

is used
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 2 OB/SI Chlorine solution,
standard materials for cleaning and per requirement Gluteraldehye, carbolic
ME F5.2 disinfection of patient care areas acid

Availability of cleaning agent 2 OB/SI Hospital grade phenyl,

as per requirement disinfectant detergent
solution
The facility ensures standard Staff is trained for spill 2 SI/RR
practices are f ollowed for the management
ME F5.3 cleaning and disinfection of patient
care areas

Cleaning of patient care area 2 SI/RR

with detergent solution

Staff is trained for preparing 2 SI/RR

cleaning solution as per
standard procedure

Standard practice of mopping 2 OB/SI Unidirectional mopping

and scrubbing are followed from inside out

Cleaning equipment like 2 OB/SI Any cleaning equipment

broom are not used in patient leading to dispersion of
care areas dust particles in air
should be avoided

The facility ensures segregation Isolation and barrier nursing 2 OB/SI

ME F5.4 infectious patients procedure are followed for
septic cases

Standard F6 The facility has defined and e stabli she d procedures for s egregation, collection, treatment and dis posal of Bio
Medical and hazardous Waste. 28 28
The facility Ensures segregation of Availability of colour coded 2 OB
Bio Medical Waste as per bins at point of waste
guidelines and 'on-site' generation
ME F6.1 management of waste is carried
out as per guidelines

2 OB
Availability of Non chlorinated
plastic colour coded plastic
bags
2 OB/SI
Segregation of Anatomical
and solied waste in Yellow Bin
2 OB
Segregation of infected plastic
waste in red bin
Display of work instructions 2 OB
for segregation and handling
of Biomedical waste
0
There is no mixing of 2
infectious and general waste
1
The facility ensures management Availability of functional hub OB See if it has been used or
ME F6.2 of sharps as per guidelines cutters 2 just lying idle
2
Availability of puncture proof
box
2 Should be available nears
the point of generation
like nursing station and
OB injection room
Availability of white Check for Puncture
translucent bins for waste proof, tamper proof and
Sharps 2 leak proof containers
OB
Availability of Blue bins for Check for Puncture proof
Galssware and leak proof boxes
2 with blue colored
marking
OB
Availability of post exposure 2
prophylaxis
Ask if available. Where it
is stored and who is in
OB/SI charge of that.
The facility ensures transportation Check bins are not overfilled 2 SI/OB
ME F6.3 and disposal of waste as per
guidelines
Transportation of bio medical 2 SI/OB
waste is done in close
container/trolley
Staff aware of mercury spill 2 SI
management

Area of Concern - G Quality Management 72 72

Standard G1 Facility has established organizational framework for quality improvement 2 2
Facility has a quality team in place There is a designated 2 SI/RR
departmental nodal person
for coordinating Quality
ME G1.1 Assurance activities

Standard G2 The facility has established system for patient and employee satisfaction 2 2
Patient satisfaction surv eys are Patient satisfaction survey 2 RR
ME G2.1 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. 6 6
The facility has established There is system daily round by 2 SI/RR
internal quality assurance matron/hospital
programme in key departments superintendent/ Hospital
ME G3.1 Manager for monitoring of
services

The facility has established system Departmental checklist are 2 SI/RR

for use of check lists in different used for monitoring and
ME G3.3 departments and services quality assurance

Staff is designated f or filling 2 SI

and monitoring of these
checklists
The facil ity has es tabli she d, documented implemente d and maintained Standard Operating Procedures for all
Standard G4 30 30
key processe s.
Departmental standard operating Standard operating procedure 2 RR
procedures are available for department has been
ME G4.1 prepared and approved

Current version of SOP are 2 OB/RR

available with process owner

Standard Operating Proc edures The Department has 2 RR

adequately describes process and documented procedure for
ME G4.2 procedures receiving and initial
assessment of the patient

The Department has 2 RR

documented procedure for
admission, shifting and
referral of patient

The Department has 2 RR

documented procedure for
requisition of diagnosis and
receiving of the reports

The Department has 2 RR

documented procedure for
preparation of the patient for
surgical procedure

The Department has 2 RR

documented procedure for
transfusion of blood
The Department has 2 RR
documented procedure for
maintenance of rights and
dignity of Patient

The Department has 2 RR

documented procedure for
record maintenance including
taking consent

The Department has 2 RR

documented procedure for
counselling of the patient at
the time of discharge

The Department has 2 RR

documented procedure for
environmental cleaning and
processing of the equipment

The Department has 2 RR

documented procedure for
sorting, and distribution of
clean linen to patient

The Department has 2 RR

documented procedure for
end of life care

Staff is trained and aw are of the Check if staff is aware of 2 SI/RR

ME G4.3 procedures w ritten in S OPs relevant part of SOPs
Work instructions are displayed at Work instruction/clinical 2 OB Patient safety, CPR
ME G4.4 Point of use protocols are displayed
Standard G5 The facility ha s established s ystem of periodic re view as internal asse ssment , medical & de ath audit and
pre scription audit 14 14
The facility conducts periodic Internal assessment is done at 2 RR/SI
ME G5.1 internal assessment periodic interval
The facility conducts the periodic There is procedure to conduct 2 RR/SI
ME G5.2 prescription/ medical/death audits Medical Audit

There is procedure to conduct 2 RR/SI

Prescription audit
There is procedure to conduct 2 RR/SI
Death audit
The facility ensures non Non Compliance are 2 RR/SI
ME G5.3 compliances are enumerated and enumerated and recorded
recorded adequately
Action plan is made on the gaps Action plan is prepared 2 RR/SI
ME G5.4 found in the assessment / audit
process
Corrective and preventive acti ons Corrective and preventive 2 RR/SI
are taken to address issues, action taken
ME G5.5 observed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
The facility periodically defines its Quality objective for IPD are 2 RR/SI
quality objectives and key defined
ME G6.2 departments hav e their own
objec tives

Quality policy and objectives are Check if staff is aware of 2 SI

ME G6.3 disseminated and staff is aware of quality policy and objectives
that
Progress towards quality Quality objectives are 2 SI/RR
ME G6.4 objec tives is monitored monitored and reviewed
periodically periodically

Standard G7 The facility seeks continually improvement by practicing Quality method and tools. 12 12
The facility uses methods for PDCA 2
ME G7.1 quality improvement in services

5S 2 SI/OB
Mistake proofing 2 SI/OB
Six Sigma 2 SI/RR
The facility uses tools for quality Ant two Quality tools 2 SI/RR
ME G7.2 improvement in services

Pareto / Prioritization 2 SI/RR

Area of Concern - H Outcome 22 22
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 4
Facility measures productivity Bed Occupancy Rate of Male 2 RR
ME H1.1 Indicators on monthly basis Ward
Bed Occupancy Rate for 2 RR
Female ward
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 8 8
Facility measures efficiency Indicators Referral Rate 2 RR
ME H2.1 on monthly basis
Bed Turnover rate 2 RR
Discharge rate 2 RR
No. of drugs stock out in the 2 RR
ward
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 6 6
Facility measures Clinical Care & Average length of stay for 2 RR
ME H3.1 Safety Indicators on monthly basis Male wards

Average length of stay for 2 RR

Female ward
Time taken for initial 2 RR
assessment
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 4 4
Facility measures Service Quality LAMA Rate 2 RR
ME H4.1 Indicators on monthly basis
Patient Satisfaction Score 2 RR

IPD Card
IPD Score 94.1341
Area of Concern wise Score
A Service Provision 100
B Patient Rights 96.3414634146342
C Inputs 89.5161290322581
D Support Services 93.4782608695652
E Clinical Services 90.7407407407407
F Infection Control 100
G Quality Management 100
H Outcome 100

Obtained Maximum Percent 4

A 28 28 100
B 79 82 96.341463
C 111 124 89.516129
D 86 92 93.478261
E 196 216 90.740741
F 80 80 100
G 72 72 100
H 22 22 100
Total 674 716 94.134078
 National Quality Assurance Standards for Taluka Hospital
Checklist for NBSU 5
Reference no. Measurable Element Checkpoint Compliance A ssessment Means of verification Remarks
Method
Area of Concern - A Service Provision 23 24
Standard A1 Facility Provides Curative Services 4 4
ME A1.4 The F acility Prov ides Paediatric Availability of functional NBSU 2 SI/OB At least 4 beds.
Services
ME A1.9 Services are available for the time Availability of nursing care services 2 SI/RR
period as mandated at NBSU (24X7)
Standard A2 Facility provides RMNCHA Services 16 16
ME A2.3 The F acility prov ides New -born Management of low birth weight 2 SI/RR
health Services infants > or =1800 gm with no
other complication
Weighing the new-born. 2 SI/RR
Resuscitation 2 SI/RR
Prevention of infection including 2 SI/RR
management of new-born sepsis

Provision of Warmth 2 SI/RR

Phototherapy for new born 2 SI/RR
Breast feeding/feeding support 2 SI
and Kangaroo Mother care (KMC)

ME A2.4 The F acility prov ides child health Screening of New born for 2 SI/RR
Services congenital Birth Defects
Standard A3 Facility Provides diagnostic Services 3 4
ME A3.1 The F acility prov ides Radiology Functional linkage for USG and 1 SI/OB In house/Parent hospital/
Services X- ray services Outsourced
ME A3.2 The F acility Prov ides Laboratory NBSU has Linkage for laboratory 2 SI/OB 24x7 linkage with outside
Services investigations laboratory for critical tests like
Blood Count, Platelets, Plasma
glucose, Serum creatinine,
Blood count, Platelet, C
reactive protein, Prothrombin
time,etc.

Area of Concern - B Patient Rights 48 50

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 18 18
ME B1.1 The facility has uniform and user- Availability departmental 2 OB (Numbering Rooms, main
friendly signage sy stem signage's department and inter-
sectional signage)
Directional signage for 2 OB
department are displayed
Restricted area signage displayed 2 OB

ME B1.2 The facility display s the serv ices Entitlements under J SSK displayed 2 OB
and entitlements available in its
departments
Information about Nurse on duty 2 OB
is display ed and updated
Contact information in respect of 2 OB
NBSU ref erral services are
displayed
ME B1.5 Patients & visitors are sensitised Display of information for 2 OB Display of pictorial
and educated through education of mother /relatives information/ chart regarding
appropriate IEC / BCC approaches expression of milk/ techniques
for assisted feeding , KMC,
immunization, complimentary
feeding etc.

ME B1.6 Inf ormation is available in loc al Signage's and information are 2 OB

language and easy to understand available in local language

ME B1.8 The facility ensures access to Discharge summary is given to the 2 OB

clinical records of patients to patient
entitled personnel
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 4 6
ME B3.1 Adequate visual privacy is Privacy is maintained in breast 0 OB
provided at every point of c are feeding room/corner
ME B3.2 Confidentiality of patients records new-born Records are kept at a 2 SI/OB
and clinical inf ormation is secure place beyond access to
maintained general staff/visitors

ME B3.3 The facility ensures that Behaviour of staff is empathetic 2 OB/PI

behav iour of staff is dignified and and courteous
respectf ul, w hile delivering the
services
The facility has define d and es tablis hed proce dures for informing patients a bout the me dical condition, and involving
Standard B4 them in tre atment planning, and facilitates informed decision making 8 8
ME B4.1 There is a established procedure NBSU has a system in place to take 2 SI/RR
for taking informed consent informed consent from new- born
before treatment and procedures relative, whenever required

ME B4.4 Inf ormation about the treatment NBSU has a system in place to 2 PI
is shared w ith patients or involve new- born relatives in
attendants, regularly decision making of new-born
treatment

NBSU has system in place to 2 PI/SI

provide communication on new-
born condition to parents/
relatives at least once in day

ME B4.5 Facility has defined and Availability of complaint box and 2 OB

established grievance redressal display of process for grievance
system in place redressal and with contact detail.

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services. 18 18
ME B5.1 The facility prov ides cashless Availability of Free diagnostics 2 PI/SI Provision of diagnostics in
services to pregnant women, empanelled Government or
mothers and neonates as per Private diagnostic centre
prevalent government schemes under CMCHIS.

Availability of Free diet to 2 PI/SI

beneficiaries
Availability of Free Diet to mother 2 PI/SI

Availability of Free new-born 2 PI/SI

transport including drop back
facility
Availability of Free Blood 2 PI/SI
Availability of Free drugs 2 PI/SI
Availability of free stay to mother 2 PI/SI

ME B5.2 The facility ensures that drugs Check that new-born parents & 2 PI/SI
prescribed are available at attendant's have not spent money
Pharmacy and wards on purchasing drugs and
consumables from outside.

ME B5.3 It is ensured that fac ilities for the Check that new-born parents & 2 PI/SI Provision of diagnostics in
prescribed investigations are attendants have not spent money empanelled Government or
available at the facility on diagnostics from outside. Private diagnostic centre
under CMCHIS.

Area of Concern - C Inputs 82 86

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 14 16
ME C1.1 The Departments has adequate Adequate space as per new-born 1 OB Approximately 40-50 square
space as per new-born care work care units feet per bed where 4 radiant
load warmer can be kept.

ME C1.3 The Departments has layout and Availability of nursing station 2 OB

demarcated areas as per
functions
Hand washing and gowning area 1 OB

Mother's area for expression of 2 OB NBSU has system in place to

breast milk/ breast feeding call mother's of baby for
feeding
ME C1.4 The facility has adequate Availability of adequate circulation 2 OB
circulation area and open spaces area for easy moment of staff and
according to need and local law equipment

ME C1.5 The facility has inf rastructure for Availability of functional Intercom 2 OB
intramural and extramural Services & Telephone
communication Services/CUG Services

ME C1.7 The facility and departments are NBSU is easily accessible from 2 OB
planned to ensure structure labour room, maternity ward and
follows the function/processes OT
(Structure commensurate with
the function of the hospital)

Location of nursing station and 2 OB

patients beds enables easy and
direct observation of patients

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 20 20
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging objects
are properly fastened and
secured

ME C2.2 The facility ensures safety of NBSU does not have temporary 2 OB Switch Boards other electrical
electrical establishment connections and loosely hanging installations are intact
wires
2 OB/RR 50% 0f each should be 5amp
and 50% should be 15 amp to
handle equipment
10 electrilal outlets are available
with each warmer in NBSU
NBSU has earthling system 2 OB/RR Dedicated earthling pit
available system available
ME C2.3 Phy sical condition of building is Floors of the NBS U are non 2 OB
safe f or providing new- born care slippery and even

Windows and vents if any are 2 OB

intact and sealed
ME C2.4. The facility has a plan for NBSU has fire exit to permit safe 2 OB/SI
prevention of fire escape of its occupant at time of
fire
ME C2.5 The facility has adequate fire NBSU has installed fire 2 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.
Check the expiry date for fire 2 OB/RR
extinguisher is displayed on each
extinguisher as well as due date
for next refilling is clearly
mentioned

ME C2.6. The facility has a system of Check for staff competencies 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
fire and other disaster situation

Standard C3 Facility has the appropriate number of staff with the correct skill mix required for providing the assured services to the current case load 20 20
ME C3.1 The facility has adequate Availability of On call 2 OB/RR
specialist doctors as per serv ice Paediatrician/trained FIMNCI MO.
provision
ME C3.3 The facility has adequate nursing Availability of one Nursing staff per 2 OB/RR/SI
staff as per servic e provision and shift
work load
ME C3.6 The staff has been provided Facility based New Born Care 2 SI/RR To all Medical Officers and
required training / skill sets (FBNC) training Nursing Staff posted at NBSU

IMEP training. 2 SI/RR

Training on Bio Medical waste 2 SI/RR
Management
New-born Safety 2 SI/RR
ME C3.7 The S taff is skilled as per job Nursing staff is skilled for 2 SI/RR
description operation of equipment
The Staff is skilled for 2 SI/RR
resuscitation of New Born
Nursing staff is skilled in 2 SI/RR
identifying and managing
complications
Nursing Staff is skilled for 2 SI/RR
maintaining clinical records
Standard C4 Facility provides drugs and consumables required for assured list of services. 20 20
ME C4.1 The department has availability of Availability of Antibiotics 2 OB/RR As per State EDL
adequate drugs at point of use

Availability of Antipyretics 2 OB/RR As per State EDL

Availability of IV Fluids 2 OB/RR As per State EDL
Availability of other emergency 2 OB/RR As per State EDL
drugs
Availability of drugs for new-born 2 OB/RR As per State EDL

ME C4.2 The department has adequate Availability of dressings material 2 OB/RR Gauze piece and cotton swabs,
consumables at point of use and diapers Diapers,
Availability of syringes and IV 2 OB/RR Neoflon 24 G , micro drip set
Sets /tubes with &without burette, BT set,
Suction catheter, PT tube,
feeding tube

Availability of Antiseptic S olutions 2 OB/RR Antiseptic lotion

Others 2 OB/RR Baby ID tag, cord clamp,

mucus sucker,
ME C4.3 Emergency drug tray s are Emergency Drug Tray is 2 OB/RR
maintained at every point of care, maintained
where ever it may be needed

Standard C5 Facility has equipment & instruments required for assured list of services. 8 10
ME C5.1 Availability of equipment & Av ailability of f unctional 2 OB Thermometer, Weighing
instruments for ex amination & Equipment &Instruments for scale, pulse oxy meter2,
monitoring of patients examination & Monitoring Multipara metre. Stethoscope

ME C5.4 Availability of equipment and
instruments for resuscitation of
patients and for providing
intensive and critical care to
patients
Functional Critical care Equipment 2 OB Infusion pumps, Oxygen
cylinder/Oxygen concentrator,
oxygen hood,etc

Functional Resuscitation 2 OB Bag and mask, laryngoscope,

equipment ET tubes, Foot-suction

ME C5.7 The Department has furniture
and fixtures as per load and
service provision
Availability of Fixtures 2 OB Electrical panel with each unit,
X ray view box.
Availability of furniture 0 OB Cupboard, nursing counter,
table for preparation of
medicines, chair, furniture at
breast feeding room.

Area of Concern - D Support Services 88 88

Standard D1 Facility has established program for inspection, testing and maintenance and calibration of equipment. 8 8
ME D1.1 The facility has established All equipment are covered under 2 SI/RR Functional Radiant warmer,
system for maintenance of critical AMC including preventive suction machine, Oxygen
Equipment maintenance concentrator, pulse oximeter/
Multipara monitor and their
AMC

There is procedure to check timely 2

ME D1.2 The facility has established
procedure for internal and
ex ternal calibration of measuring
Equipment
replacement of lights in
Phototherapy unit.
All the measuring equipment/ 2 OB/ RR
instrument are calibrated

ME D1.3 Operating and maintenance Up to date instructions for 2 OB/SI

instructions are av ailable with the operation and maintenance of
users of equipment equipment are readily available
with NBS U staff.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and new-born care areas 18 18
ME D2.1 There is established procedure There is established system of 2 SI/RR Stock level are daily updated
for forecasting and indenting of timely indenting of consumables Requisition are timely placed
drugs and consumables and drugs at nursing station

ME D2.3 The facility ensures proper Drugs are stored in 2 OB

storage of 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 Expiry dates are maintained at 2 OB/RR
of expiry and near expiry drugs emergency drug tray

No expiry drug found 2 OB/RR

ME D2.5 The facility has established Department maintain stock and 2 RR/SI
procedure for inv entory expenditure register of drugs and
management techniques consumables

ME D2.6 There is a procedure for periodically There is procedure for replenishing 2 SI/RR
replenishing the drugs in new-born Emergency drug tray.
care areas
There is no stock out of drugs 2 OB/SI
ME D2.7 There is process for storage of Temperature of refrigerators are 2 OB/RR Check for temperature charts
vac cines and other drugs, kept as per storage requirement are maintained and updated
requiring controlled temperature and records are maintained periodically

The fa cility has es tablis hed Program for ma intenance and upkee p of the facility to provide safe, s ecure and
Standard D3 36 36
ME D3.2 Hospital infrastructure is
comfortable environment to staff,
Check for there is no seepage , 2
patients
OB
and visitors .
adequately maintained Cracks, chipping of plaster
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 D3.3. Patient care areas are clean and Floors, walls, roof, roof tops, sinks 2 OB All area are clean with no
hygienic new-born care and circulation dirt,grease,littering and
areas are Clean cobwebs
Surface of furniture and fixtures 2 OB
are clean
ME D3.4 The facility has policy of removal No condemned/Junk material in 2 OB
of condemned junk material the NBSU

ME D3.5 The facility has established No stray animal/rodent/birds 2 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility prov ides adequate Adequate Illumination at each 2 OB
illumination level at patient care basinet.
areas
ME D3.7 The facility has provision of Entry to NBSU is restricted 2 OB
restriction of visitors in new- born
areas
Visiting hour are fixed and are 2 OB/PI
observed.
ME D3.8 The facility ensures safe and NBSU has a system to control 2 SI/RR Temperature inside main
comf ortable environment for temperature and humidity, and NBSU should be maintained at
patients and service providers record of same is maintained (Air (22-26 OC), round O clock
conditioning). preferably by thermostatic
control. Relative humidity of
30-60% should be maintained

NBSU has procedure to check the
temperature of radiant
warmer ,phototherapy units, etc.
2 SI/RR Each equipment used should
have servo controlled devices
for heat control with cut off to
limit increase in temperature
of radiant warmers beyond a
certain temperature or
warning mechanism for
sounding alert/alarm when
temp increases beyond certain
limits

NBSU has system to control the 2 SI/RR Background sound should not
sound producing activities and be more than 45 db and peak
gadgets (like telephone sounds, intensity should not be more
staff area and equipment) than 80db.

NBSU has functional room 2 SI/RR 1 for each new-born care

thermometer and temperature is room
regularly maintained

ME D3.9 The facility has a security sy stem New born identification band are 2 OB/RR
in place at patients care area used and foot prints of babies are
taken.

There is procedure for handing 2 SI

over the baby to
mother/father/Legal Guardian
Security arrangement in NBSU are 2 OB
robust.
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 10 10
ME D4.1 The facility has arrangement for Availability of 24x7 running and 2 OB/SI
adequate storage and supply for potable water
potable water in all functional
areas

ME D4.2 The facility ensures adequate Availability of power back up in 2 OB/SI

pow er back up in all new-born new-born care areas
care areas as per load
Availability of UPS 2 OB/SI
Availability of Emergency light 2 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Oxygen and vacuum 2 OB
availability of oxygen, medical gases suction
and vacuum supply

The facility ens ures availability of Diet as per nutritional requirement of the patients and cl ean linen to all admi tted
Standard D5 10 10
ME D5.2 The facility prov ides diet Check for the adequacy and
patients.
2 OB/RR
according to nutritional frequency of feed as per
requirements of the patients nutritional requirement

ME D5.3 Hospital has standard procedures for Facility to prepare f eeds is 2 RR/SI
preparation, handling, storage and available near NBSU.
distribution of diets, as per
requirement of patients

ME D5.4 The facility has adequate sets of NBSU has facility to provide 2 OB/RR
linen av ailable. sufficient and clean linen for each
patient
ME D5.5. The facility has established Linen is changed every day and 2 OB/RR
procedures for changing of linen whenever it get soiled
in new- born care areas
ME D5.6. The facility has standard procedures There is a system to check the 2 SI/RR
for handling , collection, cleanliness and Quantity of the
transportation and washing of linen linen received from laundry

Standard D9 Role s & Responsibilities of adminis tra tive and clinical s taff are determine d as per govt. re gulations and standards
6 6
ME D9.1 The facility has established job
operating procedures
The Staff is aware of their role 2 SI .
description as per govt guidelines and responsibilities

ME D9.2 The facility has a established There is a 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 per duty roster (Attendance register/
departments Biometrics etc.)

ME D9.3 The facility ensures the Doctor, nursing staff and support 2 OB
adherence to dress code as staff adhere to their respective
mandated by its administration / dress code
the health department

Area of Concern - E Clinical Services 164 164

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 10 10
ME E1.1 The facility has established Unique identification number is 2 RR
procedure for registration of given to each New-born at time of
patients Registration

ME E1.3 There is a established procedure Admission criteria for NBSU are 2 SI/RR
for admission of patients defined & followed

There is no delay in admission of 2 SI/RR/OB

patient
Time of admission is recorded in 2 RR
new-born record
ME E1.4 There is established procedure Procedure to cope with surplus 2 OB/SI
for managing patients, if beds are new-born load
not available at the facility
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 4 4
ME E2.1 There is established procedure Initial assessment of all new- born's 2 RR/SI Defined criteria for
for initial assessment of patients is done as per standard protocols assessment like Silverman
Anderson Score and Down
score

ME E2.2 There is established procedure There is fixed schedule for periodic 2 RR/OB
for follow-up/ reassessment of assessment of new-born's
Patients
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 12 12
ME E3.1 The facility has established There is a procedure of taking 2 RR/SI Check continuity of care is
procedure for continuity of care over of new born from labour maintained while
during interdepartmental transfer Room OT/ Ward to NBSU transferring/ handover the
new-born

ME E3.2 The facility provides appropriate New- born referred with referral 2 RR/SI
referral linkages to the slip
patients/Services for transfer to
other/higher facilities to assure the
continuity of care.

Advance intimation is given to 2 RR/SI

higher centre
Referral vehicle is arranged 2 SI/RR
Referral in or ref erral out register 2 RR
is maintained
There is a system of follow up 2 RR
of referred patients
Standard E4 The facility has defined and established procedures for nursing care 14 14
ME E4.1 Procedure for identification of Identification tags are used for 2 OB/SI
patients is established at the identification of new-born's
facility
ME E4.2 Procedure for ensuring timely and Treatment chart are maintained 2 RR Check that treatment charts
accurate nursing care as per are updated and drugs given
treatment plan is established at the are marked. Co -relate it with
facility drugs and doses prescribed.

There is a process to ensue the 2 SI/RR Verbal orders are rechecked

accurac y of verbal/telephonic before administration
orders
ME E4.3 There is established procedure of new-born hand over is given 2 SI/RR
new- born hand over, whenever during the change in the shift
staff duty 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
adequately and adequacy of notes.

ME E4.5 There is procedure for periodic Vitals of new-borns are 2 RR/SI Check for TPR chart,
monitoring of patients monitored and recorded Phototherapy chart, any other
periodically vital are monitored and
recorded.

Standard E6 The facility follows sta ndard treatment guideline s de fined by state/Ce ntral government for pres cribing the generic 8 8
ME E6.1 Check for BHT if drugsdrugs
The facility ensures that drugs are are & their rational
2 use .
RR
prescribed in generic name only prescribed under the 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
regime and doses as per STG

Check BHT that drugs are 2 RR

prescribed as per STG
Standard E7 The facility has defined procedures for safe drug administration 24 24
ME E7.1 There is process for identi fying High alert drugs are identified in 2 SI/OB As applicable in the
and cautious administration of the department. department
high alert drugs
Maximum dose of high alert drugs 2 SI/RR Value for maximum doses as
are defined and communicated per age, weight and diagnosis
are available with nursing
station and doctor

ME E7.2 Medication orders are written
legibly and adequately
There is process to ensure that
right doses of high alert drugs are
only given
2 SI/RR A system of independent
double check before
administration, Error prone
medical abbreviations are
avoided

Every Medical advice and 2 RR

procedure are accompanied
with date , time and signature

Check for the writing to ensure 2 RR/SI

that it is comprehendible by the
clinical staff

ME E7.3 There is a procedure to check Drugs are check ed for ex piry
drug before administration/ and other inconsistency before
dispensing administration
Check single dose vial are not used
for more than one dose
2 OB/SI
2 OB Check for any open single dose
vial with left over content
intended 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
vial left in the septum
Any adverse drug reaction is 2 RR/SI
recorded and reported
ME E7.4 There is a sy stem to ensure right Fluid and drug dosages are 2 SI/RR Check for calculation chart
medicine is giv en to right new- calculated according to body
born weight

Drip rate and volume are 2 SI/RR Check the nursing staff how
calculated and monitored they calculate Infusion and
monitor it
Administration of medicines is 2 SI/OB
done after ensuring right patient,
right drugs , right dose, right route,
right time

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- New- born progress is recorded as 2 RR
assessment and inv estigations are per defined assessment schedule
recorded and updated
ME E8.2 All treatment plan Treatment plan are written on BHT 2 RR
prescription/orders are recorded and all drugs are written legibly in
in the new-born records. case sheet.

ME E8.3 Care provided to each new- born's Maintenance of treatment 2 RR Treatment given is recorded in
recorded in the new-born records chart/treatment registers the treatment chat

ME E8.4 Procedures perf ormed are Procedure performed are recorded 2 RR Mobilization, resuscitation etc.
written on patients rec ords in BHT
ME E8.5 Adequate forms and formats are Standard Formats are available 2 RR/OB Availability of formats for
available at point of use Treatment Charts, TPR Chart ,
Intake Output Chart,
Community follow up card,
BHT, continuation sheet,
Discharge card Etc.

ME E8.6 Register/records are maintained Registers and records are 2 RR General order book (GOB),
as per guidelines maintained as per guidelines report book, Admission
register, lab register,
Admission sheet/ bed head
ticket, discharge slip, referral
slip, referral in/referral out
register, OT register, Diet
register, Linen register, Drug
intend register

All register/records are identified 2 RR

and numbered
ME E8.7 The facility ensures safe and Safe keeping of new-born records 2 OB
adequate storage and retrieval of
medical rec ords
Standard E9 The facility has defined and established procedures for discharge of patient. 24 24
ME E9.1 Discharge is done after assessing NBSU has established criteria for 2 SI/RR New-born's shifted to
new- born readiness discharge of the new- born ward/step down after
assessment
Assessment is done before 2 SI/RR
discharging new-born
Discharge is done by a responsible 2 SI/RR Preferably Paediatrician. Or
and qualified doctor Doctor on duty in consultation
with paediatrician

New- born/ attendants are 2 PI/SI

ME E9.2 Case summary and follow-up
instructions are provided at time
of discharge
consulted before discharge
Treating doctor is consulted/ 2 SI/RR
informed before discharge of
patients
Discharge summary is provided 2 RR/PI See for discharge summary,
referral slip provided.
Discharge summary mentions 2 RR
adequately patients clinical
condition, treatment given and
follow up

Discharge summary is given to 2 SI/RR

patients going on LAMA/Referral

There is a procedure for clinical 2 RR/SI

follow up of the new born by local
PHC (Community health care
worker)/ASHA

ME E9.3 Counselling services are prov ided Counselling of mother before 2 PI/SI For care of new born and
as during discharges wherev er discharge breastfeeding, treatment and
required follow up counselling

Time of discharge is 2 PI/SI

communicated to the attendant
prior to discharge
ME E9.4 The facility has established Declaration is taken from the 2 RR/SI
procedure for patients leaving the LAMA new-born
facility against medical advice,
absconding, etc .

Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 20 20
ME E10.1 There is procedure for receiving Triaging of new born as per 2 SI/RR
and triage of patients guidelines

ME E10.3 The facility has disaster Staff is aware of disaster plan 2 SI/RR
management plan in place
ME E10.4 The facility ensures adequate and There is a System for coordination 2 SI/RR
timely availability of ambulances with 108/Neonatal Ambulance
services and mobilisation of
resources, as per requirement

NBSU has provision of Ambulance 2 SI/RR

to refer the case to higher centre

Ambulance has provision/ method 2 SI/RR

for maintenance of Warm chain
while referred to higher centre

Ambulance/transport vehicle have 2 OB/RR

adequate arrangement for Oxygen

Ambulance/transport vehicle have 2 OB/RR

dedicated rescue kit including "
essential supplies kit", emergency
drug kit

NBSU has system to periodic check 2 SI/RR

of ambulances/transport vehicle
by driver/paramedic staff and
counter checked by NBSU staff

If the newborn is stable he/she 2 SI/RR

transferred in 108/Neonatal
ambulance with trained driver and
emergency medical technician

If the newborn is Critical he/she 2 SI/RR

transferred in 108/Neonatal
ambulance with trained driver,
emergency medical technician and
one staff from the hospital shall
accomapny the patient

Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 12 12
ME E12.5 There is established procedure Consent is taken before 2 RR
for transfusion of blood transfusion
Patient's identification is verified 2 SI/OB
before transfusion
Blood is kept at optimum 2 RR
temperature before transfusion

Blood transfusion is monitored 2 SI/RR

and regulated by qualified person

Blood transfusion note is written in 2 RR

new-born record
ME E12.6. There is a established procedure Any major or minor transfusion 2 RR The event is communicated to
for monitoring and reporting reaction is recorded and reported Paediatrician Incharge as well
Transfusion c omplication at BSU as to the in charge of concern
Blood storage unit.

Standard E15 The facility has defined and established procedures for end of life care and death 16 16
ME E15.1 Death of admitted patient is F acility has a standard 2 SI
adequately recorded and procedure which respects
communicated sensitivities & sentiments to
communicate death to relatives

NBSU has system for conducting 2 RR/SI

grievance counselling of parents in
case of new-born mortality

Death note is written on new-born 2 RR

record
ME E15.2 The facility has standard Death note including efforts done 2 SI/RR
procedures for handling the for resuscitation is noted in new-
death in the hospital born record

Procedure to declare death for 2 SI/RR

brought in dead cases exists in
facility.
Death summary is given to new- 2 SI/RR
born attendant quoting the
immediate cause and underlying
cause if possible

ME E15.3 The facility has standard operating Patients Relatives are informed 2 SI/RR
procedure for end of life support clearly about the deterioration in
health condition of Patients

There is a procedure to allow new- 2 SI/OB

born relative/Next of Kin to
observe new-born in last hours

Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 4 4
ME E19.3 Management of Low birth weight Adherence to clinical protocol 2 SI/RR Competence testing
new- born's is done as per
guidelines

ME E19.4 Management of neonatal Adherence to clinical protocol 2 SI/RR Competence testing

asphyxia, jaundice and sepsis is
done as per guidelines

Area of Concern - F Infection Control 122 122

Standard F1 The facility has infection control Progra mme and procedures in place for prevention and measurement of hos pital
8 8
ME F1.4 There is Provision of Periodic There is a procedure for a ssociate d infection
2 SI/RR Hepatitis B, Tetanus Toxoid
Medical Check- up and immunization of the staff etc.
immunization of staff
Periodic medical check- ups of the 2 SI/RR
staff
ME F1.5 The facility has established Regular monitoring of inf ection 2 SI/RR Hand washing and infection
procedures for regular monitoring control practices control audits are done at
of infection control practices periodic intervals

ME F1.6 The facility has defined and Check if Doctors are aware of 2 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 24 24
ME F2.1 Hand washing facilities are Availability of hand washing 2 OB FNBC guideline: Each unit
provided at point of use Facility at Point of Use should have at least 1 wash
basin for every 5 beds
Availability of running Water 2 OB/SI Open the tap. Ask the Staff,
water is available 24*7

Availability of antiseptic soap with 2 OB/SI Check for availability/ Ask staff
soap dish/ liquid antiseptic with if the supply is adequate and
dispenser. uninterrupted

Availability of Alcohol based Hand 2 OB/SI Check for availability/ Ask

rub staff f or regular supply. Hand
rub dispenser are provided
adjacent to bed

Display of Hand washing 2 OB Prominently displayed above

Instruction at Point of Use the hand washing facility ,
preferably in Local language

Availability of elbow operated taps 2 OB

 Hand washing sink is wide and 2 OB
deep enough to prevent splashing
and retention of water

ME F2.2 The facility staff is trained in Adherence to 6 steps of Hand 2 SI/OB Ask for demonstration
correct hand washing practices washing
and they adhere to standard hand
washing practices

Staff is aware of occasion for hand 2 SI

washing
Mothers are practicing wash hand 2 PI/OB
washing with soap
ME F2.3 The facility ensures standard Availability of Antiseptic S olutions 2 OB
practices and materials for
antisepsis
Procedure for proper cleaning of 2 OB/SI e.g. before giving IM/IV
site with antisepsis injection, drawing blood,
putting Intravenous and
urinary catheter

Standard F3 The facility ensures standard practices and materials for Personal protection 14 14
ME F3.1 The facility ensures adequate Clean gloves are available at point 2 OB/SI Hand washing between each
personal protection Equipment as of use new-born & change of gloves
per requirements
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
ME F3.2 The facility staff adheres to No reuse of disposable gloves, 2 OB/SI
standard personal protection masks, caps and aprons.
practices
Compliance to correct method of 2 SI
wearing and removing the gloves

Standard F4 The facility has standard procedures for processing of equipment and instruments 26 26
ME F4.1 The facility ensures standard Cleaning & Decontamination of 2 SI/OB Cleaning of Radiant warmers
practices and materials for new-born care Units and Bassinets with detergent
decontamination and cleaning of and water
instruments and procedure areas

Proper Decontamination of 2 SI/OB Decontamination for

instruments after use Thermometer, Stethoscope,
Suction Apparatus, Ambu bag
with 70% Alcohol or detergent
& water, as applicable

Contact time for decontamination 2 SI/OB 10 minutes

is adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with
decontamination detergent and running water
after decontamination

Proper handling of Soiled/ infected 2 SI/OB Soiled / infected and Dirty

and dirty linen linen are segregated at point
of generation. No rinsing or
sluicing at Point of use/
Patient care area.

Staff is aware of correct procedure 2 SI/OB

of making chlorine solution

ME F4.2 The facility ensures standard Equipment and instruments are 2 OB/SI Autoclaving/HLD/Chemical
practices and materials for sterilized after each use as per Sterilization
disinfection and sterilization of requirement
instruments and equipment

High level Disinfection of 2 OB/SI Ask staff about method and

instruments/equipment is done time required f or boiling/
as per protocol Chemical HLD
Autoclaving of instruments is done 2 OB/SI Ask staff about temperature,
as per protocols pressure and time

Chemical sterilization of 2 OB/SI Ask staff about method,

instruments/equipment is done as concentration and contact
per protocols time required for chemical
sterilization

Autoclaved dressing material is 2 OB/SI

used
There is a procedure to ensure the 2 OB/SI
traceability of sterilized packs

Sterility of autoclaved packs is 2 OB/SI Sterile packs are kept in clean,

maintained during storage dust free, moist free
environment.
Standard F5 Physical layout and environmental control of the new-born care areas ensures infection prevention 22 22
ME F5.1 Layout of the department is Floors and wall surf aces of NBSU 2 OB
conducive for the infection control are easily cleanable
practices
ME F5.2 The facility ensures availability of Availability of disinfectant as per 2 OB/SI Chlorine solution,
standard materials for cleaning and requirement Gluteraldehye, carbolic acid
disinfection of new-born care areas

ME F5.3 The facility ensures standard Staff is trained for spill 2 SI/OB
practices are followed for the management
cleaning and disinfection of new-
born care areas

Cleaning of new-born care area 2 SI/RR

with detergent solution
Staff is trained for preparing 2 SI/RR
cleaning solution as per standard
procedure
Standard practice of mopping and 2 OB/SI Unidirectional mopping from
scrubbing are followed inside out
Cleaning equipment like broom 2 OB/SI Any cleaning equipment
are not used in new- born care leading to dispersion of dust
area. particles in air should not be
used.

Use of three bucket system for 2 OB/SI

mopping
External foot wares are restricted 2 OB

ME F5.4 The facility ensures segregation Isolation and barrier nursing 2 OB/SI
infectious patients procedure are followed for septic
cases
ME F5.5 The facility ensures air quality of high NBSU has system to maintain 2 OB Ventilation can be provided in
risk area ventilation and its environment two ways: exhaust only and
should be dust free supply-and-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

Standard F6 Facility has defined and es tablis he d proce dures for s egregation, collection, treatment a nd dispos al of Bio Me dical and
28 28
ME F6.1 ha zardous Waste.
Facility Ensures segregation of Bio Availability of colour coded bins at 2 OB
Medical Waste as per guidelines point of waste generation

ME F6.2 Facility ensures management of
sharps as per guidelines
ME F6.3 Facility ensures transportation
and disposal of w aste as per
guidelines
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
internal quality assurance
programme in the departments
2 OB
Availability of Non chlorinated
plastic colour coded plastic bags
Segregation of Anatomical and 2 OB/SI
solied waste in Yellow Bin
Segregation of infected plastic 2 OB
waste in red bin
Display of work instructions for 2 OB
segregation and handling of
Biomedical waste
There is no mixing of infectious 2
and general waste
Availability of functional Hub 2 OB See if it has been used or just
cutters lying idle
Availability of puncture proof box 2 OB
Should be available nears the
point of generation like
nursing station and injection
room
Availability of white translucent 2 OB Check for Puncture proof,
bins for waste Sharps tamper proof and leak proof
containers
Availability of Blue bins for 2 SI Check for Puncture proof and
Galssware leak proof boxes with blue
colored marking
Availability of post exposure 2
prophylaxis Ask if available. Where it is
stored and who is in charge of
OB/SI that.
Check bins are not overfilled 2 SI/OB
Transportation of bio medical 2 SI/OB
waste is done in close
container/trolley
Staff aware of mercury spill 2 SI
management
Area of Concern - G Quality Management 76 76
6 6
There is system daily round by 2 SI/RR
Paediatrician/matron/ hospital in
charge for monitoring of services

ME G3.3 The facility has established Departmental checklist is used 2 SI/RR

system for use of check lists in the for monitoring and quality
department and services assurance
S taff is designated for filling and 2 SI
monitoring of these check lists

Standard G4
T he facil ity has e stabli she d, documented implemente d and maintained Standard Operating Procedures for all key
42 42
process es.
ME G4.1 Departmental standard operating Standard operating procedure for 2 RR
procedures are available department has been prepared
and approved

Current version of SOP are 2 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures NBSU has documented procedure 2 RR
adequately describes proc ess and for receiving and assessment of
procedures the patient

NBSU has documented procedure 2 RR

for admission of the new born

NBSU has documented procedure 2 RR

for discharge of the new-born
from unit
NBSU has documented procedure 2 RR
for triage of new born

NBSU has documented procedure 2 RR

for assessment and treatment of
new born emergency signs

NBSU has documented procedure 2 RR

for neonatal transportation and
referral
NBSU has documented procedure 2 RR
for clinical assessment and
reassessment of the new-born and
doctor follows it

NBSU has documented procedure 2 RR

for key clinical protocols

NBSU has documented procedure 2 RR

for preventive- break down
maintenance and calibration of
equipment

NBSU has documented system for 2 RR

storage, retaining ,retrieval of
NBSU records
NBSU has documented procedure 2 RR
for Maintenance of infrastructure
of NBSU
NBSU has documented procedure 2 RR
for thermoregulation of new born

NBSU has documented procedure 2 RR

for drugs,intravenous,and fluid
management and nutrition
management of new born's

NBSU has documented procedure 2 RR

for resuscitation of new born if
required
NBSU has documented procedure 2 RR
for inf ection control practices

NBSU has documented procedure 2 RR

for inventory management

NBSU has documented procedure 2 RR

for entry of parents /visitor

ME G4.3 Staff is trained and aware of the Check if staff are aware of relevant 2 SI/RR
procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 2 OB STP for phototherapy, Grading
Point of use are displayed 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 J aundice,
Temperature maintenance
etc.

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 10 10
ME G5.1 The facility conducts periodic Internal assessment is done at 2 RR/SI
internal assessment periodic interval
ME G5.2 The facility conducts the periodic There is a procedure to conduct 2 RR/SI
prescription/ medical/death New born Death audit
audits
ME G5.3 The facility ensures non Non Compliance are enumerated 2 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 2 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive actions Corrective and preventive action 2 RR/SI
are taken to address issues, taken
observ ed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2 The facility periodically defines its Quality objective for NBSU are 2 RR/SI
quality objectiv es and k ey defined
departments hav e their own
objectives

ME G6.3 Quality policy and objectives are Check if staff is aware of quality 2 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 2 SI/RR
objectives is monitored and reviewed periodically
periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
12 12
ME G7.1 Facility uses method for quality PDCA 2 SI/RR
improv ement in serv ices

5S 2 SI/OB
Process Mapping 2 SI/OB
Any other method of QA 2 SI/RR
ME G7.2 Facility uses tools for quality Any 2 basic tools of Quality 2 SI/RR
improv ement in serv ices
Pareto / Prioritization 2 SI/RR
Area of Concern - H Outcome 32 32
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 2 RR
Indicators on monthly basis
ME H1.2 The Facility measures equity Proportion of female babies 2 RR
indicators periodically admitted
Male: Female LAMA ratio 2 RR
Proportion of BPL Patients 2 RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 12 12
ME H2.1 Facility measures efficiency Proportion of low birth weight 2 RR No. of low birth weight babies
Indicators on monthly basis babies (< 2500 gm but not < 1800 gm)

Down time of Critical Equipment 2 RR

Bed Turnover Rate 2 RR

Referral Rate 2 RR
Survival rate 2 RR
No. of drug stock out in NBSU 2 RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 10 10
ME H3.1 Facility measures Clinical Care & Average waiting time for initial 2 RR
Safety Indicators on monthly basis assessment of new-born

Proportion of new-born deaths 2 RR

Average length of stay 2 RR

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

No of New-born Resuscitated 2 RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 2
ME H4.1 Facility measures Service Quality LAMA Rate 2 RR
Indicators on monthly basis

NBSU Score Card

NBSU Score 98.909657
Area of Concern wise Score
A Service Provision 95.8333333333333
B Patient's Rights 96
C Inputs 95.3488372093023
D Support Services 100
E Clinical Services 100
F Infection Control 100
G Quality Management 100
H Outcome 100

Obtained Maximum Percent 5

A 23 24 95.833333
B 48 50 96
C 82 86 95.348837
D 88 88 100
E 164 164 100
F 122 122 100
G 76 76 100
H 32 32 100
Total 635 642 98.909657
 National Quality Assurance Standards for Taluka Hospital
Checklist for Operation Theatre 6
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Area of Concern - A Service Provision 16 18

Standard A1 Facility Provides Curative Services 6 8
ME A1.2 The facility provides General Availability of General Surgery 0 SI/OB Incision and drainage, Hernia,
Surgery services procedures (Fixed day services) Hydrocele, Appendicitis,
Haemorrhoids, Fistula and stitching
of injuries.

ME A1.3 The facility provides Obstetrics & Availability of Gynaecology 2 SI/OB D & E, LSCS
Gynaecology Services procedures

ME A1.9 Services are available for the time OT Services are available 24X7 2 SI/RR
period as mandated
ME A1.10 The facility provides Accident & OT services are available for 2 SI/OB
Emergency Services emergency cases.
Standard A2 Facility provides RMNCHA Services 10 10
ME A2.1 The facility provides Reproductive Availability of Post partum 2 SI/OB Tubal ligation
health Services sterilization services
Availability of Abortion services. 2 SI/OB

ME A2.2 The facility provides Maternal Availability of C-section services 2 SI/OB

health Services
ME A2.3 The facility provides New-born Availability of New born 2 SI/OB
health Services resuscitation
Availability of essential new born 2 SI/OB
care

Area of Concern - B Patient Rights 42 42

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 8 8
ME B1.1 The facility has uniform and user- Availability of departmental 2 OB (Numbering, main department and
friendly signage system signage's internal-section signage)
Signage for restricted area are 2 OB
displayed
Zones of OT are marked 2 OB
ME B1.6 Information is available in local Signage's and information are 2 OB
language and easy to understand available in local language

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
6 6
physical, economic,2cultural or social status.
ME B2.1 Services are provided in manner
Availability of female staff if a male OB/SI Availability of female staff in pre
that are sensitive to gender doctor examination/ conduct and post operative room
surgery of a female patient
ME B2.3 Access to facility is provided Availability of Wheel chair or 2 OB
without any physical barrier & stretcher for easy Access to the OT
and friendly to people with
disabilities

Availability of ramps with railing 2 OB

Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information. 10 10
ME B3.1 Adequate visual privacy is Availability of screen between OT 2 OB
provided at every point of care table
Patients are properly 2 OB
draped/covered before and after
procedure.

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 The facility ensures the Behaviour of staff is empathetic 2 PI/OB

behaviours of staff is dignified and courteous
and respectful, while delivering
the services

ME B3.4 The facility ensures privacy and Privacy and Confidentiality of HIV 2 SI/OB
confidentiality to every patient, cases
especially of those conditions
having social stigma, and also
safeguards vulnerable groups

Privacy and Confidentiality of 2

Hysterectomy cases
Standard B4 Facility has defined and established procedures for informing and involving patient about medical condtion and involving them 8 8
ME B4.1 in treatement
There is established procedures Informed/Written planning,
consent is taken and facilitates
2 informed decision making
SI/RR
for taking informed consent before any surgery
before treatment and procedures

Anaesthesia Consent for OT 2 SI/RR

ME B4.4 Information about the treatment Patients attendant is informed 2 PI/SI
is shared with patients or about clinical condition and
attendants, regularly treatment being provided

Patient/Attendant is informed 2 PI/SI

about Possible outcomes/risks
involved/alternatives available of
surgery

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital
10 10
services.
ME B5.1 The facility provides cashless All surgical procedures are free of 2 PI/SI JSSK
services to pregnant women, cost for JSSK beneficiaries
mothers and neonates as per
prevalent government schemes

All drugs and consumables are free 2

ME B5.2 The facility ensures that drugs
prescribed are available at
Pharmacy and wards
for JSSK beneficiaries
Check that patient/attendants 2 PI/SI
have not spent money on
purchasing drugs & consumable's
from outside.

ME B5.3 It is ensured that facilities for the Check that patient/attendants 2 PI/SI Provision of diagnostics in
prescribed investigations are have not spent money on empanelled Government or Private
available at the facility Diagnostic from outside. diagnostic center under CMCHIS

ME B5.4 The facility provide free of cost Surgical services are free for BPL 2 PI/SI/RR
treatment to Below poverty line patients
patients without administrative
hassles

Area of Concern - C Inputs 156 162

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 34 34
ME C1.1 Departments have adequate Adequate space for 2 OB
space as per patient or work load accommodating surgical load

Waiting area for attendants 2 OB

ME C1.2 Patient amenities are provide as Seating arrangement for patient 2 OB
per patient load attendant
ME C1.3 Department has layout and Demarcated Protective Zone 2 OB
demarcated areas as per
functions
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/Post 2 OB
operative Room

Availability of Scrub area 2 OB

Availability of earmarked area for 2 OB
new-born Corner
Availability of Autoclave room/ 2 OB
TSSU /CSSD
Availability of dirty utility area 2 OB
Availability of store 2 OB
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 C1.5 The facility has infrastructure for Availability of functional telephone 2 OB

intramural and extramural and Intercom/CUG Services
communication
ME C1.7 The facility and department are Unidirectional flow of goods and 2 OB No criss cross of infectious and
planned to ensure structure services sterile goods
follows the function/processes
(Structure commensurate with
the function of the hospital)

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 20 20
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
equipment , hanging objects are
properly fastened and secured

ME C2.2 The facility ensures safety of OT does not have temporary 2 OB

electrical establishment connections and loosely hanging
wires

ME C2.3 Physical condition of the buildings Floors of the OT are non slippery 2 OB
is safe for providing patient care and even

Walls and floor of the OT covered 2 OB

with joint less tiles
Windows and vents if any in the OT 2 OB
are intact and sealed
ME C2.4 The facility has plan for OT has fire exit to permit safe 2 OB/SI
prevention of fire escape to its occupant at time of
fire

Check the fire exits are clearly 2 OB

visible and routes to reach exit are
clearly marked.

ME C2.5 The facility has adequate fire OT room has installed fire 2 OB
fighting Equipment Extinguisher that are capable of
fighting A,B,C Type of Fire

Check the expiry date for fire 2 OB/RR

extinguisher is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned
ME C2.6 The facility has a system of Check for staff competencies 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
fire and other disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 36 38
ME C3.1 The facility has adequate Availability of Obs & Gynae 2 OB/RR As per case load,
specialist doctors as per service Surgeon In-house/Outsourced or diverted
provision
Availability of trained surgeon for 0 OB/RR As per case load,
Minilap/ Laparoscopic/NSV In-house/Outsourced or diverted
Availability of anaesthetist 2 OB/RR As per case load,
In-house/Outsourced or diverted
ME C3.3 The facility has adequate nursing Availability of Nursing staff 2 OB/RR/SI As per patient load , at least two
staff as per service provision and
work load
ME C3.4 The facility has adequate Availability of OT 2 OB/SI Trained Staff
technicians/paramedics as per attendant/assistant
requirement
ME C3.6 The staff has been provided Advance Life support 2 SI/RR
required training / skill sets
OT Management 2 SI/RR
IMEP training. 2 SI/RR
Infection control and hand hygiene 2 SI/RR

Training on processing/sterilization 2 SI/RR

of equipment

Patient Safety 2 SI/RR

PPIUCD insertion 2 SI/RR
Family planning counselling 2 SI/RR
Laparoscopic surgery/Minilap 2 SI/RR
NSV 2 SI/RR
ME C3.7 The Staff is skilled as per job Staff is skilled for resuscitation and 2 SI/RR
description intubation
Nursing Staff is skilled for 2 SI/RR
maintaining clinical records
Staff is Skilled to operate OT 2 SI/RR
equipment
Staff is skilled for processing and 2 SI/RR
packing instrument
Standard C4 Facility provides drugs and consumables required for assured list of services. 30 30
ME C4.1 The departments have availability Availability of medical gases 2 OB/RR Availability of Oxygen Cylinders
of adequate drugs at point of use /Nitrous oxide Gas supply

Availability of Uterotonic Drugs 2 OB/RR As per State EDL

 Availability of Antibiotics 2 OB/RR As per State EDL
Availability of Antihypertensive 2 OB/RR As per State EDL

Availability of analgesics and 2 OB/RR As per State EDL

antipyretics
Availability of IV Fluids 2 OB/RR As per State EDL
Availability of anaesthetics 2 OB/RR As per State EDL
Availability of emergency drugs 2 OB/RR As per State EDL

Availability of drugs for new-born 2 OB/RR As per State EDL

ME C4.2 The departments have adequate Availability of dressings and 2 OB/RR

consumables at point of use Sanitary pads

Availability of syringes and IV Sets 2 OB/RR

Availability of Antiseptic Solutions 2 OB/RR

Availability of consumables for new 2 OB/RR

born care
Availability of personal protective 2 OB/RR
equipment
ME C4.3 Emergency drug trays are Emergency drug tray is maintained 2 OB/RR
maintained at every point of care, in OT/pre and post operative room
where ever it may be needed

Standard C5 The facility has equipment & instruments required for assured list of services. 36 40
ME C5.1 Availability of equipment & Availability of functional 2 OB BP apparatus, Thermometer, Pulse
instruments for examination & Equipment &Instruments for Oxy meter, Multipara meter , PV
monitoring of patients examination & Monitoring Set

ME C5.2 Availability of equipment & Availability of functional 2 OB LSCS Set, Cervical Biopsy Set, MVA
instruments for treatment instruments for Gynae and set, D&C Set, Defibrillator,
procedures, being undertaken in obstetrics Nebulizers
the facility

Availability of functional 2 OB Radiant warmer, Baby tray with

equipment/ Instruments for New Two pre warmed towels/sheets for
Born Care wrapping the baby, mucus
extractor, bag and mask (0 &1 no.),
sterilized thread for cord/cord
clamp, nasogastric tube

Availability of functional General 2 OB General Surgical Instruments for

surgery equipment Piles, Fistula, & Fissures. Surgical
set for Hernia & Hydrocele, Cautery

Operation Table with 2 OB

Trendelenburg facility

ME C5.3 Availability of equipment &
instruments for diagnostic
procedures being undertaken in
the facility
ME C5.4 Availability of equipment and
instruments for resuscitation of
patients and for providing
intensive and critical care to
patients
ME C5.5 Availability of Equipment for
Storage
ME C5.6 Availability of functional
equipment and instruments for
support services
ME C5.7 Departments have patient
furniture and fixtures as per load
and service provision
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
ME D1.1 The facility has established
system for maintenance of critical the AMC including preventive
Equipment
Minilap instruments 2 OB
Laparoscopic set 2 OB
NSV sets 0 OB
Instruments for Laparoscopy 0 OB
Availability of Point of care 2 OB Glucometer, HIV rapid diagnostic
diagnostic instruments kit. Uristix.
Availability of functional 2 OB Ambu bag, Oxygen, Suction
Instruments for Resuscitation machine , laryngoscope, ET Tube,
defibrillator
Availability of functional 2 OB Boyles apparatus, Bains Circuit or
anaesthesia equipment Soda lime absorbent in close circuit
Availability of equipment for 2 OB Crash cart/Drug trolley, instrument
storage for drugs trolley, dressing trolley
Availability of equipment for 2 OB Instrument cabinet and racks for
storage of sterilized items storage of sterile items (not inside
OT)
Availability of equipment for 2 OB Buckets for mopping, Separate
cleaning mops for patient care area and
circulation area duster, waste
trolley, Deck brush
Availability of equipment for 2 OB Autoclave
TSSU/CSSD
Availability of functional OT light 2 OB Shadow less , Ceiling and Stand
Model, Focus Lamp
Availability of attachment/ 2 OB Hospital grad mattress , IV stand
accessories with OT table
Availability of Fixtures 2 OB Electrical panel for anaesthesia
machine, cautery, monitors etc., X-
ray view box
Availability of furniture 2 OB Cupboard, table for preparation of
medicines, chair, racks,
Area of Concern - D Support Services 92 104
12 16
All equipment are covered under 2 SI/RR
maintenance
 There is system of timely corrective 2 SI/RR
break down maintenance of the
equipment

There has system to label 2 OB/RR

Defective/Out of order equipment
and stored appropriately until it
has been repaired

Staff is skilled for trouble shooting 0 SI/RR

in case equipment malfunction

Periodic cleaning, inspection and 0 SI/RR

maintenance of the equipment is
done by the operator

ME D1.2 The facility has established All the measuring equipment/ 2 OB/ RR Boyles apparatus, cautery, BP
procedure for internal and instrument are calibrated apparatus, autoclave etc.
external calibration of measuring
Equipment

There is system to label/ code the 2 OB/ RR

equipment to indicate status of
calibration/ verification when
recalibration is due

ME D1.3 Operating and maintenance Up to date instructions for 2 OB/SI

instructions are available with the operation and maintenance of
users of equipment equipment are readily available
with staff.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care 20 24
ME D2.1 There is established procedure There is established system of 2areas SI/RR Stock level are daily updated
for forecasting and indenting of timely indenting of consumables Requisition are timely placed
drugs and consumables and drugs

ME D2.3 The facility ensures proper Drugs are stored in 2 OB

storage of 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 Expiry dates are maintained at 2 OB/RR
of expiry and near expiry drugs emergency drug tray, crash cart,
anaesthesia drug trolley.

No expired drug is found 2 OB/RR

ME D2.5 The facility has established
procedure for inventory
management techniques
There is practice of calculating and 0 SI/RR
maintaining buffer stock
Department maintained stock and 0 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 drug tray /crash cart
care areas

There is no stock out of drugs 2 OB/SI

ME D2.7 There is process for storage of Temperature of refrigerators are 2 OB/RR Check for temperature charts are
vaccines and other drugs, kept as per storage requirement maintained and updated
requiring controlled temperature and records are maintained periodically

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
secured place
Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable
36 36
ME D3.2 Hospital infrastructure is
environment to staff,
Interior of patient care areas are 2
patients
OB
and visitors.
adequately maintained plastered & painted
Check to ensure that there is no 2 OB
seepage , cracks, chipping of
plaster

Window panes , doors and other 2 OB

fixtures are intact
OT Table are intact and without 2 OB
rust
Mattresses are intact and clean 2 OB
ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, sinks 2 OB All area are clean with no
hygienic patient care and circulation areas dirt,grease,littering and cobwebs
are Clean

Surface of furniture and fixtures 2 OB

are clean
Toilets are clean with functional 2 OB
flush and running water

ME D3.4. The facility has policy of removal No condemned/Junk material in 2 OB

of condemned junk material the OT

ME D3.5. The facility has established No pests are noticed 2 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate Illumination at OT table 2 OB 100000 lux
illumination level at patient care
areas
Adequate Illumination at pre 2 OB General area 300 Lux
operative and post operative area

ME D3.7 The facility has provision of Entry to OT is restricted 2 OB

restriction of visitors in patient
areas
 Warning light is provided outside 2 OB/SI
OT and its been used when OT is
functional

ME D3.8 The facility ensures safe and Temperature is maintained and 2 SI/RR 20-250C, ICU has functional room
comfortable environment for record of same is kept thermometer and temperature is
patients and service providers regularly maintained

Humidity is maintained at desirable 2 SI/RR 50-60%

level
Positive pressure is maintained in 2 SI/RR
OT
ME D3.9 The facility has security system in Security arrangement at OT 2 OB
place at patient care areas

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 8 12
ME D4.1 The facility has adequate Availability of 24x7 running and 2 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas

Availability of Hot water supply 2 OB/SI

ME D4.2 The facility ensures adequate Availability of power back up in OT 0 OB/SI 2 tier backup with UPS
power backup in all patient care
areas as per load
Availability of UPS 0 OB/SI
Availability of Emergency light 2 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Centralized /local 2 OB
availability of oxygen, medical gases piped Oxygen, nitrous Oxide and
and vacuum supply vacuum supply

Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 8 8
ME D5.4 The facility has adequate sets of OT has facility to provide sufficient 2 OB/RR Drape, draw sheet, cut sheet and
linen and clean linen for surgical patient gown

OT has facility to provide linen for 2 OB/RR

staff
ME D5.5 The facility has established Linen is changed after each 2 OB/RR
procedures for changing of linen procedure
in patient care areas
ME D5.6 The facility has standard procedures There is system to check the 2 SI/RR
for handling , collection, cleanliness and Quantity of the
transportation and washing of linen linen received from laundry

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 8 8
ME D9.1 The facility has established job procedures.
Staff is aware of their roles and
2 SI
description as per govt guidelines responsibilities
ME D9.2 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.)

There is designated in charge for 2 SI

department
ME D9.3 The facility ensures the Doctor, nursing staff and support 2 OB
adherence to dress code as staff adhere to their respective
mandated by its administration / dress code
the health department

Area of Concern - E Clinical Services 150 150

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 4 4
ME E3.1 Facility has established procedure There is procedure of handing over 2 SI/RR
for continuity of care during while receiving patient from OT to
interdepartmental transfer indoor and ICU

There is a procedure for 2 RR/SI

consultation of the patient with
other specialists with in the
hospital

Standard E4 The facility has defined and established procedures for nursing care 10 10
ME E4.1 Procedure for identification of There is a process for ensuring the 2 OB/SI Patient id band/ Patient ID
patients is established at the identification before any clinical No./verbal confirmation 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

ME E4.3 There is established procedure of Patient hand over is given during 2 SI/RR
patient hand over, whenever staff the change in the shift
duty change happens

Handover register is maintained 2 RR

ME E4.5 There is procedure for periodic
monitoring of patients
Standard E5
ME E5.1 The facility identifies vulnerable
patients and ensure their safe care
Patient Vitals are monitored and 2 RR/SI Check for use of multi parameter
recorded periodically
Facility has a procedure to identify high risk and vulnerable patients. 4 4
Vulnerable patients are identified 2 OB/SI Check the measure taken to
and measures are taken to protect prevent new born theft, baby
them from any harm sweeping and baby fall

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

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their
rational use. 6 6
ME E6.1 Facility ensured that drugs are Check for BHT if drugs are 2 RR
prescribed in generic name only prescribed under generic name
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

Check BHT that drugs are 2 RR

prescribed as per STG
Standard E7 Facility has defined procedures for safe drug administration 20 20
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 muscular
high alert drugs blocking agent, Anti thrombolytic
agent, insulin, warfarin, Heparin,
Adrenergic agonist etc. as
applicable

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

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

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

Check for the writing, is it 2 RR/SI

comprehendible by the clinical
staff

ME E7.3 There is a procedure to check Drugs are checked for expiry 2 OB/SI Check for availability of magnifying
drug before administration/ and other inconsistency before glass.
dispensing 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 intended 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

Any adverse drug reaction is 2 RR/SI

recorded and reported
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 dose,
right route, right time

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- Records of Monitoring/ 2 RR PAC, Intraoperative monitoring
assessment and investigations are Assessments are maintained
recorded and updated
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 on patients records
Operative Notes are Recorded
2 RR Name of person in attendance
during procedure, Pre and post
operative diagnosis, Procedures
carried out, length of procedures,
estimated blood loss, Fluid
administered, specimen removed,
complications etc.

Anaesthesia Notes are Recorded 2 RR

ME E8.5 Adequate form and formats are Standard Formats available 2 RR/OB Consents, surgical safety check list
available at point of use
ME E8.6 Register/records are maintained Registers and records are 2 RR OT Register, Schedule, Infection
as per guidelines maintained as per guidelines control records, autoclaving
records etc.

All register/records are identified 2 RR

and numbered
ME E8.7 The facility ensures safe and Safe keeping of patient records 2 RR
adequate storage and retrieval of
medical records
Standard E12 The facility has defined and established procedures for Blood Storage Management and Transfusion. 14 14
ME E12.4 There is established procedure Availability of blood units in case of 2 RR/SI The blood is ordered for the patient
for issuing blood emergency with out replacement according to the MSBOS (Maximum
Surgical Blood Order Schedule)

ME E12.5 There is established procedure Patient's identification is verified 2 SI/OB

for transfusion of blood before transfusion
Blood is kept on optimum 2 RR
temperature before transfusion

Blood transfusion is monitored and 2 SI/RR

regulated by qualified staff

Blood transfusion note is written in 2 RR

patient's record
ME E12.6 There is a established procedure Any major or minor transfusion 2 RR
for monitoring and reporting reaction is recorded and reported
Transfusion complication to responsible staff
 Staff is competent to identify 2 RR/SI
transfusion reaction and its
management

Standard E13 Facility has established procedures for Anaesthetic Services 20 20

ME E13.1 Facility has established There is procedure to ensure that 2 RR/SI
procedures for Pre Anaesthetic PAC has been done before surgery
Check up and maintenance of
records

There is procedure to review 2 RR/SI

findings of PAC
ME E13.2 Facility has established Anaesthesia plan is documented 2 RR
procedures for monitoring during before entering into OT
anaesthesia
Food intake status of Patient is 2 RR/SI
checked
Patients vitals are recorded during 2 RR Heart rate , cardiac rate , BP, O2
anaesthesia Saturation,
Airway security is ensured 2 RR/SI Breathing system is securely and
correctly assembled
Potency and level of anaesthesia is 2 RR/SI
monitored
Anaesthesia notes are recorded 2 RR Check for the adequacy

Any adverse Anaesthesia Event is 2 RR

recorded and reported
ME E13.3 Facility has established Post anaesthesia status is 2 RR/SI
procedures for Post Anaesthesia monitored and documented
care
Standard E14 Facility has defined and established procedures for Operation Theatre and Surgical Services 24 24
ME E14.1 Facility has established There is procedure OT Scheduling 2 RR/SI Schedule is prepared in
procedures OT Scheduling consonance with available OT
house and patients requirement

ME E14.2 Facility has established Patient evaluation before surgery 2 RR/SI Vitals , Patients fasting status etc.
procedures for Preoperative care is done and recorded

Antibiotic Prophylaxis given as 2 RR/SI

indicated
Tetanus Prophylaxis is given if 2 RR/SI
Indicated
There is a process to prevent 2 RR/SI Surgical Site is marked before
wrong site and wrong surgery entering into OT
Surgical site preparation is done as 2 RR/SI Cleaning , Asepsis and Draping
per protocol
ME E14.3 Facility has established Surgical Safety Check List is used 2 RR/SI Check for Surgical safety check list
procedures for Surgical Safety for each surgery has been used for surgical
procedures

ME E14.4 Facility has established
procedures for Post operative
care
Standard E17
ME E17.2 There is an established procedure pre operative care
for assisted and C-section
deliveries per scope of services.
Sponge and Instrument Count
Practice is implemented
Adequate Haemostasis is ensured
during surgery
Appropriate suture material is used
for surgery as per requirement
Post operative monitoring is done
before discharging to ward
Post operative notes and orders
are recorded
Facility has established procedures for Intranatal care as per guidelines
Proper selection of Anaesthesia
Intraoperative care
Post operative care
2 RR/SI Instrument, needles and sponges
are counted before beginning of
case, before final closure and on
completing of procedure
2 RR/SI Check for Cautery and suture
legation practices
2 RR/SI Check for what kind of sutures
used for different surgeries .
Braided Biological sutures are not
used for dirty wounds, Catgut is
not used for closing facial layers of
abdominal wounds or where
prolonged support is required
2 RR/SI Check for post operative operation
ward is used and patients are not
immediately shifted to wards after
surgery
2 RR/SI Post operative notes contains Vital
signs, Pain control, Rate and type
of IV fluids, Urine and
Gastrointestinal fluid output, other
medications and Laboratory
investigations
26 26
2 SI/RR Check for Haemoglobin level is
estimated , and arrangement of
Blood, IV line established,
Catheterization, Demonstration of
Antacids
2 SI/RR Check Both General and Spinal
Anaesthesia Options are available.
Ask for what are the criteria for
using spinal and GA
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
2 SI/RR Monitoring of vitals I/O charting,
uterine contraction, bleeding
ME E17.3 There is established procedure
for management of Obstetrics
Emergencies as per scope of
services.
Management of PIH/Eclampsia
2 SI/RR Ask for how to secure airway and
breathing, Loading and
Maintenance dose of Magnesium
sulphate , Administration of
Hypertensive Drugs

Postpartum Haemorrhage 2 SI/RR

Management of shock. 2 SI/RR
Ruptured Uterus 2 SI/RR
ME E17.4 There is an established procedure Recording Time of Birth 2 RR
for new born resuscitation and
new-born care.

Vitamin K 2 SI/RR
Care of Cord and Eyes 2 SI/RR
APGAR Score 2 SI/RR
New born Resuscitation 2 SI/RR
Standard E18 Facility has established procedures for postnatal care as per guidelines 6 6
ME E18.1 Post partum Care is Provided to Prevention of Hypothermia 2 SI/RR
Mother
Initiation of Breastfeeding with-in 1 2 PI/SI
Hour
ME E18.4 The facility has procedures for There is established criteria for 2 SI/RR
Stabilization/treatment/referral shifting new-born to NBSU/SNCU
of post natal complication

Area of Concern - F Infection Control 162 162

Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 12 12
ME F1.2 Facility has provision for Passive Surface and environment samples 2 SI/RR Swab are taken from infection
and active culture surveillance of are taken for microbiological prone surfaces
critical & high risk areas surveillance

ME F1.3 Facility measures hospital There is procedure to report cases 2 SI/RR Patients are observed for any sign
associated infection rates of Hospital acquired infection and symptoms of HAI like fever,
purulent discharge from surgical
site .

ME F1.4 There is Provision of Periodic There is procedure for 2 SI/RR Hepatitis B, Tetanus Toxoid etc.
Medical Check-up's and immunization of the staff
immunization of staff
Periodic medical check-up of the 2 SI/RR
staff
ME F1.5 Facility has established Regular monitoring of infection 2 SI/RR Hand washing and infection control
procedures for regular monitoring control practices audits done at periodic intervals
of infection control practices

ME F1.6 Facility has defined and Check for Doctors are aware of 2 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
ME F2.1 Hand washing facilities are
provided at point of use
ME F2.2 The Facility Staff is trained in Adherence to 6 steps of Hand
correct Hand washing practices washing
and they adhere to standard hand
washing practices
ME F2.3 Facility ensures standard
practices and materials for
antisepsis
30 30
Availability of hand washing Facility 2 OB Check for availability of wash basin
at Point of Use near the point of use
Availability of running Water 2 OB/SI Open the tap. Ask the staff, water
is 24*7
Availability of antiseptic soap with 2 OB/SI Check for availability/ Ask staff if
soap dish/ liquid antiseptic with the supply is adequate and
dispenser. uninterrupted
Availability of Alcohol based Hand 2 OB/SI Check for availability/ Ask staff for
rub regular supply.
Display of Hand washing 2 OB Prominently displayed above the
Instruction at Point of Use hand washing facility , preferably in
Local language
Availability of elbow operated taps 2 OB
Hand washing sink is wide and 2 OB
deep enough to prevent splashing
and retention of water
2 SI/OB Ask for demonstration
Adherence to Surgical scrub 2 SI/OB 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.
Staff is aware of occasions for hand 2 SI
washing
Availability of Antiseptic Solutions 2 OB
Procedure for proper cleaning of 2 OB/SI E.g.. before giving IM/IV injection,
site with Antisepsis drawing blood, putting Intravenous
and urinary catheter
Proper cleaning of perineal area 2 SI
before procedure with antisepsis
Check Shaving is not done during 2 SI
part preparation/delivery cases
 Check sterile field is maintained 2 OB/SI Surgical site covered with sterile
during surgery drapes, sterile instruments are kept
within the sterile field.

Standard F3 Facility ensures standard practices and materials for Personal protection 18 18
ME F3.1 Facility ensures adequate Clean gloves are available at point 2 OB/SI
personal protection equipment as of use
per requirements
Availability of Masks 2 OB/SI
Sterile gloves are available in OT 2 OB/SI
and Critical areas
Use of elbow length gloves for 2 OB/SI
obstetrical purpose
Availability of gown/ Apron 2 OB/SI
Availability of Caps 2 OB/SI
Personal protective kit for 2 OB/SI HIV kit
infectious patients
ME F3.2 Staff is adhere to standard No reuse of disposable gloves, 2 OB/SI
personal protection practices Masks, caps and aprons.
Compliance to correct method of 2 SI
wearing and removing the gloves

Standard F4 Facility has standard Procedures for processing of equipment and instruments 36 36
ME F4.1 Facility ensures standard practices Decontamination of operating 2 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate the procedure
and cleaning of instruments and surface like OT Table,
procedures areas Stretcher/Trolleys etc.
(Wiping with 0.5% Chlorine
solution

Proper Decontamination of 2 SI/OB

instruments after use Ask staff how they decontaminate
the instruments like ambubag,
suction cannula, Surgical
Instruments
(Soaking in 0.5% Chlorine Solution,
Wiping with 0.5% Chlorine Solution
or 70% Alcohol as applicable

Contact time for decontamination 2 SI/OB 10 minutes

is adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with detergent
decontamination and running water after
decontamination
 Proper handling of Soiled/infected 2 SI/OB Soiled/infected and dirty linen are
and dirty linen segregated at point of generation.
No rinsing or sluising at point of
use/Patient care area

Staff know how to make chlorine 2 SI/OB

solution
ME F4.2 Facility ensures standard practices Equipment and instruments are 2 OB/SI Autoclaving/HLD/Chemical
and materials for disinfection and sterilized after each use as per Sterilization
sterilization of instruments and requirement
equipment

High level Disinfection of 2 OB/SI Ask staff about method and time
instruments/equipment is done required for boiling/Chemical HLD
as per protocol

Chemical sterilization of 2 OB/SI Ask staff about method,

instruments/equipment is done as concentration and contact time
per protocols required for chemical sterilization

Formaldehyde or glutaraldehyde 2 OB/SI

solution replaced as per
manufacturer instructions

Autoclaved linen are used for 2 OB/SI

procedure
Autoclaved dressing material is 2 OB/SI
used
Instruments are packed according 2 OB/SI
for autoclaving as per standard
protocol

Autoclaving of instruments is done 2 OB/SI Ask staff about temperature,

as per protocols pressure and time
Regular validation of sterilization 2 OB/SI/RR
through biological and chemical
indicators

Maintenance of records of 2 OB/SI/RR

sterilization
There is a procedure to ensure the 2 OB/SI/RR
traceability of sterilized packs

Sterility of autoclaved packs is 2 OB/SI Sterile packs are kept in clean, dust
maintained during storage free, moist free environment.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 36 36
ME F5.1 Layout of the department is Facility layout ensures separation 2 OB Faculty layout ensures separation
conducive for the infection control of general traffic from patient of general traffic from patient
practices traffic traffic

Zoning of High risk areas 2 OB

 Facility layout ensures separation 2 OB
of routes for clean and dirty items

Floors and wall surfaces of OT are 2 OB

easily cleanable
CSSD/TSSU has demarcated 2 OB
separate area for receiving dirty
items, processes, keeping clean
and sterile items

ME F5.2 Facility ensures availability of Availability of disinfectant as per 2 OB/SI Chlorine solution, Gluteraldehye,
standard materials for cleaning and requirement carbolic acid
disinfection of patient care areas

Availability of cleaning agent as per 2 OB/SI Hospital grade phenyl, disinfectant

requirement detergent solution
ME F5.3 Facility ensures standard practices Staff is trained for spill 2 SI/RR
followed for cleaning and management
disinfection of patient care areas

Cleaning of patient care area with 2 SI/RR

detergent solution
Staff is trained for preparing 2 SI/RR
cleaning solution as per standard
procedure

Standard practice of mopping and 2 OB/SI

scrubbing are followed
Cleaning equipment like broom are 2 OB/SI
not used in patient care areas

Use of three bucket system for 2 OB/SI

mopping
Fumigation/carbolization as per 2 SI/RR
schedule
External foot wares are restricted 2 OB

ME F5.4 Facility ensures segregation Isolation and barrier nursing 2 OB/SI

infectious patients procedure are followed for septic
cases

ME F5.5 Facility ensures air quality of high Positive Pressure in OT 2 OB/SI

risk area
Adequate air exchanges are 2 SI/RR
maintained
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous
Waste. 30 30
ME F6.1 Facility Ensures segregation of Bio
Medical Waste as per guidelines
Availability of colour coded bins at
point of waste generation 2 OB
 Availability of Non chlorniated
plastic colour coded plastic bags 2 OB
Segrattion of Anatomocal and
solied waste in Yellow Bin 2 OB/SI
Segregation of infected plastic
waste in red bin 2 OB

Display of work instructions for

segregation and handling of
Biomedical waste 2 OB
There is no mixing of infectious and
general waste
2 OB
ME F6.2 Facility ensures management of Availability of functional Hub See if it has been used or just lying
sharps as per guidelines cutters idle
2 OB
Availability of puncture proof box

Should be available nears the point

of generation like nursing station
2 OB and injection room
Availability of white translucent Check for Puncture proof, tamper
bins for waste Sharps proof and leak proof containers
2 OB
Availability of Blue bins for Check for Puncture proof and leak
Galssware proof boxes with blue colored
marking
2 OB
Availability of post exposure
prophylaxis
Ask if available. Where it is stored
2 OB/SI and who is in charge of that.
ME F6.3 Facility ensures transportation Check bins are not overfilled
and disposal of waste as per
guidelines
2 SI
Disinfection of liquid waste before
disposal
2 SI/OB Through Local Disinfection
Transportation of bio medical
waste is done in close
container/trolley
2 SI/OB
Staff aware of mercury spill
management
2 SI/RR aspire for mercury free
Area of Concern - G Quality Management 56 62
Standard G1 The facility has established organizational framework for quality improvement 2 2
ME G1.1 The facility has a quality team in There is a designated 2 SI/RR Preferably Anaesthetist or surgeon
place departmental nodal person for
coordinating Quality Assurance
activities

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 6 6
ME G3.1 Facility has established internal
quality assurance program at
relevant departments
There is system daily round by 2 SI/RR
Surgeon/Matron/Hospital
manager/ Hospital
Superintendent/for monitoring of
services

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
departments and services assurance

Staff is designated for filling and 2 SI

monitoring of these checklists

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 28 28
ME G4.1 Departmental standard operating Standard operating procedure for 2 RR
procedures are available department has been prepared
and approved

Current version of SOP are 2 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures The Department has documented 2 RR
adequately describes process and procedure for scheduling the
procedures Surgery and its booking

The Department has documented 2 RR

procedure for pre operative
procedure

The Department has documented 2 RR

procedure for pre operative
anaesthetic check up

The Department has documented 2 RR

procedure for in process check
during surgery

The Department has documented 2 RR

procedure for post operative care
of the patient

The Department has documented 2 RR

procedure for operation theatre
asepsis and environment
management

The Department has documented 2 RR

procedure for OT documentation.

The Department has documented 2 RR

procedure for reception of dirt
packs and issue of sterile packs
from TSSU/CSSD
 The Department has documented 2 RR
procedure for maintenance and
calibration of equipment

The Department has documented 2 RR

procedure for general cleaning of
OT and annexes

ME G4.3 Staff is trained and aware of the Check staff if aware of relevant 2 SI/RR
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 equipment,
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 8 8
ME G5.1 The facility conducts periodic Internal assessment is done at 2 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 2 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 2 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive actions Corrective and preventive actions 2 RR/SI
are taken to address issues, are taken
observed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2 The facility periodically defines its Quality objective for OT are 2 RR/SI
quality objectives and key defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check of staff is aware of quality 2 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 2 SI/RR
objectives is monitored and reviewed periodically
periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
6 12
ME G7.1 Facility uses method for quality PDCA 0 SI/RR
improvement in services

5S 2 SI/OB
Process Mapping 2 SI/OB
Any other method of QA 0 SI/RR
ME G7.2 Facility uses tools for quality Any 2 basic tools of Quality 2 SI/RR
improvement in services
Pareto / Prioritization 0 SI/RR
Area of Concern - H Outcome 36 36
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 8 8
ME H1.1 Facility measures productivity C-Section Rate 2 RR
Indicators on monthly basis
Proportion of C-Sections done in 2 RR
night
Proportion of other emergency 2 RR
surgeries done in the night
No. of Major surgeries done per 1 2 RR
lakh population
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 10 10
ME H2.1 Facility measures efficiency Downtime of critical equipment 2 RR
Indicators on monthly basis
No of major surgeries per surgeon 2 RR

Proportion of elective C-Sections 2 RR

Proportion emergency surgeries 2 RR

Cycle time for instrument 2 RR

processing
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 16 16
ME H3.1 Facility measures Clinical Care & Surgical Site infection Rate 2 RR No. of observed surgical site
Safety Indicators on monthly basis infections*100/total no. of Major
surgeries

No of adverse events per thousand 2 RR

patients
Incidence of re-exploration of 2 RR
surgery
% of environmental swab culture 2 RR
reported positive
Perioperative Death Rate 2 RR Deaths occurred from pre
operative procedure to discharge
of the patient

Proportion of General Anaesthesia 2 RR

to spinal anaesthesia

Proportion of PAC done out of total 2 RR

surgeries
No. of autoclave cycle failed in 2 RR
Bowie dick test out of total
autoclave cycle

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 2
ME H4.1 Facility measures Service Quality Operation Cancellation rates 2 RR No. of cancelled operation*1000
Indicators on monthly basis /total operation done

Planned operations
cancelled due to any
reason like clinical,
non clinical (theatre),
or by patient

Operation Theatre Score

Card 96.467391
Operation
Theatre
Area of Concern wise Score
A Service Provision 88.8888888888889
B Patient Rights 100
C Inputs 96.2962962962963
D Support Services 88.4615384615385
E Clinical Services 100
F Infection Control 100
G Quality Management 90.3225806451613
H Outcome 100

Obtained Maximum Percent 6

A 16 18 88.88888889
B 42 42 100
C 156 162 96.2962963
D 92 104 88.46153846
E 150 150 100
F 162 162 100
G 56 62 90.32258065
H 36 36 100
Total 710 736 96.4673913

0
 National Quality Assurance Standards for Taluka Hospital
Checklist for Laboratory 7
Re fere nce Measurable Element Checkpoint Complian As sess ment Means of Verification
No. ce Method Remarks

Area of Concern - A Service Provision 22 28

Standard A3 Facility Provides diagnostic Services 10 16

ME A3.2 The facility Provides All lab services are available in 2 SI/RR
Laboratory Services routine working hours

Emergency lab services are 2 SI/RR Facility for on call laboratory

available technician
Availability of Haematology 2 SI/OB Hb, TLC, DLC, AEC, Reti count,
services ESR, PBS, Malaria/Filaria,
Platelets count, PCV, Blood
grouping, Rh typing.

Availability of Bio chemistry 2 SI/OB B. sugar, B urea, LF T, KFT, lipid

services profile
Availability of Microbiology 0 SI/OB Smear for AFB, KLB, Gram stain
services for throat Swab, Sputum etc.

Availability of urine analysis 2 SI/OB Urine for Albumin, Sugar,

services Deposits, Bile salts, Bile
pigments, Ketone Bodies, spc.
Gravity, pH.

Availability of stool analysis 0 SI/OB Stool for ova/cyst (EH), Occult

blood.
Availability of sputum 0 SI/OB
cytology
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 10 10

ME A4.1 The facility provides Tests for Diagnosis of malaria 2 SI/OB

services under National (Smear and RDTK)
Vector Borne Disease
Control Programme as per
guidelines

Tests for Kala Azar, Dengue, 2 SI/OB As per prevalent endemic

JE, Chikunganya
ME A4.2 The facility provides Availability of Designated 2 SI/OB
services under Revised Microscopy Centre (AFB)
National TB Control
Programme as per
guidelines

ME A4.3 The facility provides Availability of Skin S mear 2 SI/OB Linkage with DDL
services under National Examination
Leprosy Eradication
Programme as per
guidelines

ME A4.8 The facility provides Haemogram, BT CT, 2 SI/RR

services under National Fasting/PP Sugar, Lipid Profile,
Programme f or Prev ention Blood Urea , LF T Kidney
and control of Cancer, Function Test
Diabetes, Cardiov ascular
diseases & Stroke ( NPCDCS)
as per guidelines

Standard A6 Health services provided at the facility are appropriate to community needs. 2 2

ME A 6.1 The facility provides Laboratory provides specific 2 SI/RR

curatives & preventiv e test for local health
services for the health problems/ diseases e.g..
problems and diseases, Dengue, Kalazar etc.
prevalent locally.

Area of Concern - B Patient Rights 36 36

Standard B1 Facility provide s the i nformation to care s eekers, attenda nts & community about the available services and 12 12
their modalities
ME B1.1 The facility has uniform and Availability departmental 2 OB (Numbering of rooms, main
user-friendly signage system signage's department and inter- sectional
signage)

ME B1.2 The facility displays the List of services available are 2 OB

services and entitlements displayed at the entrance
available in its departments

Timing for collection of 2 OB

sample and delivery of reports
are displayed
ME B1.4 User c harges are displayed User charges in r/o laboratory 2 OB
and communic ated to services are displayed
patients eff ectively

ME B1.6 Information is av ailable in Signage's and information are 2 OB

local language and easy to
understand
ME B1.8 The facility ensures access
to clinical records of
patients to entitled
personnel
available in local language
Lab Reports are provided to 2 OB
Patient in proper printed
format

Standard B2 Services are delivere d in a ma nner that is s ensitive to gende r, religious and cultural ne eds , and there are no
4 4
ba rrier on account of phys ical , e conomic, cultural or social status.
ME B2.1 S ervices are provided in Separate queue for female 2 OB
manner that are sensitive to patients at lab
gender
ME B2.3 Acc ess to facility is prov ided Check the availability of ramp 2 OB
without any phy sical barrier in lab building area /sample
& and f riendly to people collection area
with disabilities

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and ha s a sys tem for guarding patient rela te d
6 6
information.
ME B3.2 Confidentiality of patients Laboratory has a system to 2 SI/OB Laboratory staff do not discuss
records and clinic al ensure the confidentiality of the lab result and reports are
information is maintained the reports generated kept in secure place

ME B3.3 The facility ensures the Behaviour of staff is 2 PI/OB

behaviours of staff is empathetic and courteous
dignified and respectf ul,
while delivering the services

ME B3.4 The facility ensures priv acy HIV positive 2 SI/OB

and confidenti ality to every reports/pregnancy reports are
patient, espec ially of those communicated as per NACO
conditions having social guidelines
stigma, and also safeguards
v ulnerable groups

Standard B4 The facility has defined and es tablis he d procedures for informing patients about the medical condition, and 4 4
involving them in treatment planning, and facilitates informed decision making
ME B4.1 There is established Informed Consent is taken 2 SI/RR Before testing for HIV patient is
procedures for taking before HIV testing, Biopsy informed the that test is
informed consent before and any other invasive voluntary and result will be
treatment and proc edures procedure disclosed to him/her only

ME B4.4 Information about the Pre test counselling is done 2 PI/SI/RR

treatment is shared w ith before HIV testing
patients or attendants,
regularly

Standard B5 Facility ensure s tha t there are no financial barri er to acces s and that there is financial protection given from cos t 10 10
of ca re.
ME B5.1 The facility provides Free Diagnostic tests for 2 PI/SI
cashless services to Pregnant women & Infant
pregnant women, mothers
and neonates as per
prevalent government
schemes

ME B5.2 The facility ensures that Check that patient has not 2 PI/SI
drugs prescribed are incurred expenditure on
available at Pharmacy and purchasing consumables from
wards outside.

ME B5.3 It is ensured that f acilities Check that patient party not 2 PI/SI Provision of diagnotics in
f or the prescribed incurred expenditure on empanalled Government or
investigations are available diagnostics from outside. Private diagnostics centres
at the facility under CMCHIS.

ME B5.4 The facility provide free of Tests are free of cost for BPL 2 PI/SI/RR
cost treatment to Below patients
Poverty Line( BPL) patients
without administrative
hassles

ME B5.5 The facility ensures timely All the inhouse lab tests and 2 PI/SI/RR
reimbursement of financial tests under CMCHIS are free
entitlements and
reimbursement to the
patients

Area of Concern - C Inputs 78 80

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 20 20

ME C1.1 Departments have Laboratory space is adequate 2 OB Adequate area for sample
adequate space as per for carrying out activities collection, waiting, performing
patient or work load test, keeping equipment and
storage of drugs and records

ME C1.2 Patient amenities are Availability of adequate 2 OB

prov ide as per patient load waiting area

Availability of functional 2 OB
toilets
Availability of drinking water 2 OB
near laboratory.
ME C 1.3 Departments have layout Demarcated sample collection 2 OB
and demarcated areas as area
per functions
Demarcated testing area 2 OB
Designated report writing area 2 OB

Demarcated washing and 2 OB

waste disposal area
ME C 1.5 The facility has Availability of functional 2 OB
infrastructure f or intramural telephone and Intercom /CUG
and ex tramural Services
communication

ME C 1.7 The facility and Unidirectional flow of services 2 OB Sample collection- Sample
departments are planned to processing- Analytical area-
ensure structure f ollows the reporting.
f unction/processes
(S tructure commensurate
with the f unction of the
hospital)

Standard C 2 The facility ensures the physical safety including Fire safety of the infrastructure. 20 20

ME C2.1 The facility ensures the
seismic safety of the
infrastructure
Non structural components
are properly secured
2 OB Check for fixtures and furniture
like cupboards, cabinets, and
heavy equipment , hanging
objects are properly fastened
and secured

ME C2.2 The facility ensures safety of Laboratory does not have 2 OB

electrical establishment temporary connections and
loose hanging wires

Adequate electrical sockets 2 OB/RR

are provided for safe and
smooth operation of lab
equipment

ME C2..3 Physical condition of Work benches are chemical 2 OB

buildings are safe for
prov iding patient care
ME C2.4. The facility has plan for
prevention of fire
resistant
Floors of the Laboratory are 2 OB
non slippery and ev en its
surface is acid resistant
Windows have grills and wire 2 OB
meshwork
Laboratory has plan for safe 2 OB/SI
storage and handling of
potentially flammable
materials.

ME C2.5. The facility has adequate
fire fighting Equipment
Lab has installed fire 2 OB/RR
Extinguishers to handle fire
ABC type
Check if expiry date for fire 2 OB/RR
extinguishers are displayed on
each extinguisher as well as
due date for next refilling is
clearly mentioned

ME C2.6. The facility has a sy stem of Check for staff competencies 2 SI/RR
periodic training of staff and for operating fire extinguisher
conduc ts mock drills and what to do in case of fire
regularly for fire and other
disaster situation

Standard C3 The facility has a dequate qualifie d and trained s taff, required for providing the as sured s ervice s to the current 16 16
ca se load
ME C3.4 The facility has adequate Availability of Lab. technicians 2 OB/RR Atleast 1 Lab technician
technicians/paramedics as
per requirement
ME C3.6. The staff has been prov ided Training on automated 2 SI/RR
required training / skill sets Diagnostic Equipment like
semi auto analyser

Bio Medical waste 2 SI/RR

Management
Infection control and hand 2 SI/RR
hygiene
Training on Internal and 2 SI/RR
External Quality Assurance
Laboratory Safety 2 SI/RR
ME C3.7 The Staff is skilled as per job Staff is skilled to run 2 SI/RR
desc ription automated equipment like
semi auto analyser.
Staff is skilled for maintaining 2 SI/RR
Laboratory records

Standard C 4 Facility provides drugs and consumables required for assured list of services. 6 6

ME C4.2 The departments hav e Regular availability of supplies 2 OB/RR Clean slides, slide markers,
adequate consumables at for Laboratory gloves, transport medium, test
point of use tubes, vials, swabs, culture
bottles, sealing material etc.

Availability of RD kits. 2 OB/RR RDK for malaria, Ttyphoid ,

Dengue and NISHCHAY Kit
ME C4.3 Emergency drug trays are Emergency Drug Tray is 2 OB/RR
maintained at every point of maintained
care, where ever it may be
needed

Standard C5 The facility has equipment & instruments required for assured list of services. 16 18

ME C 5.1 Av ailability of equipment & Availability of f unctional 2 OB BP apparatus, Stethoscope at

instruments for examination Equipment &Instruments sample collection area
& monitoring of patients for examination &
Monitoring

ME C 5.3 Av ailability of equipment & Availability of f unctional 2 OB Micropipettes , Spirit lamp,

instruments for diagnostic equipment for sample Centrifuge, Water Bath, Hot air
procedures being collection and processing oven.
undertaken in the f acility

Availability of equipment for 2 OB Ice box, stool transport carrier,

storage and transfer of test tube rack, ref rigerator,
samples smear transporting box, sterile
leak proof containers.

Availability of f unctional 2 OB Binocular Micro scope,, staining

Microscopy equipment rack
Availability of equipment 2 Photocalorie meter, semi
for testing & analysis autoanalyzer, glucometer.
ME C5.6 Av ailability of functional Availability of equipment 2 OB Buckets for mopping, mops,
equipment and instruments for cleaning duster, waste trolley, Deck
f or support services brush

Availability of equipment 0 OB Autoclave/TSSU/CSSD

ME BC 5.7 The Department hav e
patient furniture and
fixtures as per load and
service prov ision
for sterilization and
disinfection
Availability of fixtures at lab
2 OB Illumination at work stations,
Electrical fixture for lab
equipment and storage
equipment

Availability of furniture 2 OB Lab stools, Work bench's, rack

and cupboard for storage of
reagent ,Patient stool, Chair
table

Area of Concern - D Support Services 66 68

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 20 20

ME D 1.1 The facility has established All equipment are covered 2 SI/RR Agency/ is identified for
system for maintenance of under the AMC including maintenance of the equipment
critical Equipment preventive maintenance

There is a system of timely 2 SI/RR

corrective break down
maintenance of the
equipment

There is a system to label 2 OB/RR

Defective/Out of order
equipment and they are
stored appropriately until its
repair

The Staff is skilled for trouble 2 SI/RR

shooting in case equipment
malfunction
Periodic cleaning, inspection 2 SI/RR
and maintenance of the
equipment is done by the
operator

ME D1.2 The facility has established All the measuring equipment/ 2 OB/ RR
procedure f or internal and instrument are calibrated
external calibration of
measuring Equipment

There is system to label/ code 2 OB/ RR

the equipment to indicate
status of calibration/
verification when recalibration
is due

Laboratory has a system to 2 SI/RR

update correction factor after
calibration of equipment (if
required)

Each lot of reagents matched 2 SI/RR

against earlier tested in-use
reagent lot or with suitable
reference material before
being put in service and
result's are recorded.

ME D1.3 Operating and maintenance Up to date instructions for 2 OB/SI

instructions are available operation and maintenance of
with the users of equipment equipment are readily
available with staff.

Standard D2 The fa cility has de fined procedures for stora ge, inve ntory management and dis pensing of drugs in pharmacy and 16 16
patient care areas
ME D2.1 There is a established There is established system of 2 SI/RR Stock level are daily updated
procedure f or f orecasting timely indenting of Requisition are timely placed
and indenti ng of drugs and consumables and reagents
consumables

ME D2.3 The facility ensures proper Reagents and consumables 2 OB/RR

storage of drugs and are kept away from water and
consumables sources of heat,
direct sunlight

Reagents are labelled 2 OB/RR Reagents label contain name,

appropriately concentration, date of
preparation/opening, date of
expiry, storage conditions and
warning

ME D2.4 The facility ensures No expired reagent found 2 OB/RR

management of expiry and
near expiry drugs
ME D2.5 The facility has established Department maintains stock 2 RR/SI
procedure f or inventory and expenditure register of
management techniques reagents

There is no stock out of 2 OB/SI

reagents
ME D2.7 There is process for storage Temperature of refrigerators 2 OB/RR Check, if temperature charts are
of vaccines and other drugs, are kept as per storage maintained and updated
requiring controlled requirement and records are periodically
temperature maintained

Regular Defrosting is done 2 SI/RR

Standard D3 The facility ha s esta blished Program for mai ntenance and upkeep of the facility to provide safe, se cure and 18 20
comfortable environme nt to s taff, pa tie nts a nd vis itors .
ME D3.2 Hospital inf rastructure is Floors, walls, roof, roof tops, 2 OB All area are clean with no
adequately maintained. sinks in patient care and dirt,grease,littering and
circulation areas are Clean cobwebs

Surface of furniture and 2 OB

fixtures are clean
ME D3.3 Patient care areas are clean Check for there is no seepage , 2 OB
and hygienic Cracks, chipping of plaster

Window panes , doors and 2 OB

other fixtures are intact
ME D3.4. The facility has a policy of No condemned/Junk material 2 OB
removal of condemned junk found in the lab
material
ME D3.5 The facility has established No stray animal/rodent/birds 2 OB
procedures for pest, rodent
and animal control

ME D3.6 The facility provides Adequate illumination in the 2 OB

adequate illumination level laboratory.
at patient care areas

ME D3.8 The facility ensures safe and Temperature control and 2 SI/RR Fans/ Air
comfortable env ironment ventilation in the laboratory. conditioning/Heating/Exhaust/V
f or patients and serv ice entilators as per environment
prov iders condition and requirement

Availability of Eye washing 0 OB

facility
ME D3.10. The facility has established Ask female staff weather they 2 SI
measure for safety and feel secure at work place
security of female staff
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 4 4

ME D4.1 The facility has adequate Availability of running and 2 OB/SI

arrangement storage and potable water on 24*7 basis
supply for potable water in
all func tional areas

ME D4.2 The facility ensures Availability of power back up 2 OB/SI

adequate power back up in in laboratory
all patient care areas as per
load

Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 2 2

ME D8.3 The facility ensure relevant Any positive report of 2 RR/SI

processes are in compliance notifiable disease is intimated
with the statutory to designated authorities
requirements within the stipulated time-
limit

Standard D9 Role s & Responsibilities of adminis tra tive and clinical s taff are determine d as per govt. re gulations and 6 6
s tandards operating procedures .
ME D9.1 The facility has established Staff is aw are of their role 2 SI
job description as per govt and responsibilities
guidelines

ME D9.2 The facility has a There is procedure to ensure 2 RR/SI Check for system of recording
established procedure f or that staff is available on duty time of reporting and relieving
duty roster and deputation as per duty roster (Attendance register/ Biometrics
to different departments etc.)

ME D9.3 The facility ensures Technician and support staff 2 OB

adherence to dress code as adhere to their respective
mandated by its dress code
administration / the health
department

Area of Concern - E Clinical Services 50 54

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 4 4

ME E1.1 The facility has established Unique laboratory 2 RR

procedure f or registration identification number is given
of patients to each patient sample

Patient demographic details 2 RR Check for that patient

are recorded in laboratory demographics like Name, Age,
records Sex,Provisional Diagnosis etc.

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 4 4

ME E3.2 Facility provides appropriate Laboratory has referral linkage 2 RR/SI

referral linkages to the for test, which are not
patients/Services for transfer available at the facility
to other/higher facilities to
assure their continuity of care.

Facility gets referred patients 2 RR/SI linkage for disease surveillance

from lower level of facility and water testing with Public
Health Lab

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 9 10

ME E8.5 Adequate f orm and formats Standard Formats are 1 RR/OB Printed formats for requisition
are available at point of use available and reporting are available

ME E8.6 Register/records are Lab records are labelled and 2 RR

maintained as per indexed
guidelines
Records are maintained for 2 RR Test registers, IQAS/EQAS
the laboratory Registers, Expenditure registers,
Accession list etc.
ME E8.7 The facility ensures safe and Laboratory has adequate 2 OB
adequate storage and facility for storage of records
retrieval of medical records

Laboratory has a system of 2 OB Ask for retrieval of a sample

easy retrieval of record record
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 6 6

ME E10.3 The facility has Disaster The staff is aware of Disaster 2 SI/RR
Management Plan in place Plan

Roles and responsibilities of 2 SI/RR

the staff in disaster are
defined
ME E10.5 There is a procedure for Samples of medico legal cases
handling medico legal cases are identified, Secured,
preserved and processed
2 SI/RR Requisition and reports are
marked with MLC, and the
reports are handed over to
authorized personnel only

Standard E11 The facility has defined and established procedures of diagnostic services 25 28

ME E11.1 There are established Requisitions of all laboratory 2 RR/OB Request form contains relevant
procedures for Pre-testing test are received on information: Name and
Activ ities designated and apparent identification number of patient,
forms. 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 samples
are communicated to those
responsible for collection

Laboratory has system in 2 RR/SI

place to label the primary
samples
Laboratory has system to 2 RR/SI
trace the primary sample from
requisition form
Laboratory has system in 2 RR/SI Transportation of sample
place to monitor includes: Time frame,
transportation of the sample temperature and carrier
specified for transportation

ME E11.2 There are established Testing procedure are readily 2 OB/RR

procedures for testing available at work station and
Activ ities staff is aware of the same

Laboratory has Biological 2 OB/RR

reference interval for its
examination of various results

Laboratory has identified 2 RR/SI

critical intervals for which
immediate notification is done
to concerned physician

ME E11.3 There are established Laboratory has a system to 2 RR/SI

procedures for Post-testing review the results of
activities examination by authorized
person before release of the
report

Laboratory has format for 1 RR/OB

reporting of results
Laboratory has system to 2 RR/SI
provide the reports within
defined cycle time for 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 0 RR/SI

retention period and disposal
of used sample
Laboratory has a system to 2 RR/SI
retain the copies of reported
results, which are promptly
retrieved when required

Standard E22 Facility provides National health program as per operational/Clinical Guidelines 2 2

ME E22.9 The Fac ility provide service Weekly reporting of 2 SI/RR

f or Integrated Disease Confirmed cases on form "L"
S urveillance Programme from laboratory

Area of Concern - F Infection Control 94 94

Standard F1 Facil ity has infection control program and proce dures in place for prevention and meas ure me nt of hospital 6 6
as sociated infection
ME F1.4 There is Provision of There is procedure for 2 SI/RR Hepatitis B, Tetanus Toxoid etc.
Periodic Medical Check- up's immunization of the staff
and immunization of staff

Periodic medical check-up's of 2 SI/RR

the staff is undertaken

ME F1.5 F acility has established Regular monitoring of 2 SI/RR Hand washing and infection
procedures for regular infection control practices control audits are done at
monitoring of inf ection periodic intervals
control practices

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 20 20

ME F2.1 Hand w ashing facilities are Availability of hand washing 2 OB Check for availability of wash
prov ided at point of use Facility at Point of Use basin near the point of use

Availability of running Water
Availability of antiseptic soap
with soap dish/ liquid
antiseptic with dispenser.
Display of Hand washing
Instruction at Point of Use
2 OB/SI Open the tap. Ask the Staff,
water is available 24*7
2 OB/SI Check for availability/ Ask staff if
the supply is adequate and
uninterrupted
2 OB Prominently displayed above
the hand washing facility ,
preferably in Local language

Availability of elbow operated 2 OB

taps
Hand washing sink is wide and 2 OB
deep enough to prevent
splashing and retention of
water

ME F2.2 S taff is trained and adhere Adherence to 6 steps of Hand 2 SI/OB Ask of demonstration
to standard hand washing washing
practices
Staff aware of when to hand 2 SI
wash
ME F2.3 F acility ensures standard Availability of Antiseptic 2 OB
practices and materials for Solutions
antisepsis
Proper cleaning of procedure 2 OB/SI before drawing blood,
site with antisepsis

Standard F3 Facility ensures standard practices and materials for Personal protection 8 8

ME F3.1 F acility ensures adequate Clean gloves are available at 2 OB/SI

personal protection point of use
equipment as per
requirements

Availability of lab 2 OB/SI

aprons/coats
Availability of Masks 2 OB/SI
ME F3.2 S taff adheres to standard No reuse of disposable gloves 2 OB/SI
personal protection and Masks.
practices

Standard F4 Facility has standard Procedures for processing of equipment and instruments 12 12

ME F4.1 Facility ensures standard
practices and materials for
decontamination and clean ing
of instruments and
procedures areas
Decontamination of 2 SI/OB Ask staff about how they
Procedure surfaces decontaminate work benches
(Wiping with 0.5% Chlorine
solution)

Proper Decontamination of 2 SI/OB Decontamination of instruments

instruments after use and reusable of glassware are
done after procedure in 1%
chlorine solution/ any other
appropriate method

Contact time for 2 SI/OB 10 minutes

decontamination is adequate

Cleaning of instruments after 2 SI/OB Cleaning is done with detergent

decontamination and running water after
decontamination

The Staff knows how to make 2 SI/OB

ME F4.2 Facility ensures standard
practices and material f or
disinfection and sterilization of
instruments and equipment
chlorine solution
Disinfection of reusable 2 SI/OB Disinfection by hot air oven at
glassware 160 oC for 1 hour

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 16 16

ME F5.2 Facility ensures availability of Availability of disinf ectant as 2 OB/SI Chlorine solution,
standard material for cleaning per requirement Gluteraldehye, Carbolic acid(If
and disinfection of patient Gluteraldehyde-Check for its
care areas activation period.)

Availability of cleaning agent 2 OB/SI Hospital grade phenyl,

as per requirement disinfectant detergent solution

ME F5.3 Facility ensures standard Staff is trained for spill 2 SI/RR

practices followed for cleaning management
and disinfection of patient
care areas

Cleaning of patient care area 2 SI/RR

with detergent solution

Staff is trained for preparing 2 SI/RR

cleaning solution as per
standard procedure

Standard practice of mopping 2 OB/SI Unidirectional mopping from

and scrubbing are followed inside out

Cleaning equipment like 2 OB/SI Any cleaning equipment leading

broom are not used in to dispersion of dust particles in
Laboratory air should be avoided

ME F5.4 Facility ensures segregation Precaution with infectious 2 OB/SI

infectious patients patients like TB

Standard F6 Facility has defined and established procedures for segregation, coll ection, trea tme nt and dis posal of Bio Medical 32 32
and hazardous Waste .
ME F6.1 F acility Ensures segregation Availability of colour coded 2 OB
of Bio Medical Waste as per bins at point of waste
guidelines generation

2 OB
Availability of Non chlorinated
plastic colour coded plastic
bags
2 OB/SI
Segregation of Anatomical
and solied waste in Yellow Bin
Segregation of inf ected plastic 2 OB
waste in red bin
Display of work instructions 2 OB
for segregation and handling
of Biomedical waste

There is no mixing of 2
infectious and general waste

ME F6.2 F acility ensures Availability of functional Hub 2 OB See if it has been used or just
management of sharps as cutters lying idle
per guidelines
Availability of puncture proof 2 OB
box
Should be available nears the
point of generation like nursing
station and injection room
 Availability of white 2 OB Check for Puncture proof,
translucent bins for waste tamper proof and leak proof
Sharps containers
Availability of Blue bins for 2 OB Check for Puncture proof and
Galssware leak proof boxes with blue
colored marking
Availability of post exposure 2
prophylaxis Ask if available. Where it is
stored and who is in charge of
OB/SI that.
ME F6.3 F acility ensures Disinfection of liquid waste 2 SI/OB
transportation and disposal before disposal
of waste as per guidelines

Disposal of sputum cups as 2 SI/OB

per guidelines
Check bins are not overfilled 2 SI

Transportation of bio medical 2 SI/OB

waste is done in close
container/trolley
Staff aware of mercury spill 2 SI/RR
management
Area of Concern - G Quality Management 106 106
Standard G1 The facility has established organizational framework for quality improvement 2 2
ME G1.1 The facility has a quality There is a designated 2 SI/RR
team in place departmental nodal person
for coordinating Quality
Assurance activities

Standard G2 Facility has established system for patient and employee satisfaction 2 2

ME G2.1 Patient Satisf action surv eys There is system to take feed 2 RR
are conducted at periodic back from clinician about
intervals quality of services

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 24 24

ME G3.1 F acility has established Internal Quality assurance 2 SI/RR

internal quality assurance programme is in place
program at relevant
departments

Standards are run at defined 2 SI/RR

interval
Control charts are prepared 2 SI/RR
and outliers are identified.

Corrective action is taken on 2 SI/RR

the identified gaps
Internal Quality Control for 2 SI/RR Routine checking of equipment,
RNTCP Lab. is in place new lots of regent, smear
preparation, grading etc.

ME G3.2 F acility has established Cross Validation of Lab tests 2 SI/RR

external assurance are done and records are
programs at relevant maintained
departments

Corrective actions are taken 2 SI/RR

on abnormal values
External quality assurance 2 SI/RR Onsite evaluation done Monthly
program is implemented as Random Blinded rechecking
per RNTCP program (RBRC) done Monthly

External quality assurance 2 SI/RR

program is implemented for
NVBDCP
External quality assurance 2 SI/RR
under NACP
ME G3.3 F acility has established Departmental checklist is 2 SI/RR
system for use of check lists used for monitoring and
in different departments quality assurance
and services

Staff is designated for filling 2 SI

and monitoring of these
chec klists
Standard G4 Facility has e stablishe d, documented implemente d and maintained Standard Operating Procedures for all key 50 50
processe s and support s ervices .
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

ME G4.2 S tandard Operating
Procedures adequately
desc ribes process and
procedures
available with the respective
process owners
Laboratory has documented 2 RR
process for Collection and
handling of primary sample

Laboratory has documented 2 RR

procedure for transportation
of primary sample with
specification about time
frame, temperature and
carrier

Laboratory has documented 2 RR

process on acceptance and
rejection of primary samples

Laboratory has documented 2 RR

procedure on receipt,
labelling, processing and
reporting of primary sample

Laboratory has documented 2 RR

system f or storage of
examined samples

Laboratory has documented 2 RR

system f or repeat tests due to
analytical failure

Laboratory has documented 2 RR

validated procedure for
examination of samples

Laboratory has documented 2 RR

biological reference intervals

Laboratory has documented 2 RR

critical reference values and
procedure for immediate
reporting of results

Laboratory has documented 2 RR

procedure for release of
reports including details of
personal, authorised to
release the results and details
of recipient's of the reports

Laboratory has documented 2 RR

internal quality control system
to verify the quality of results

Laboratory has documented 2 RR

External Quality assurance
program
Laboratory has documented 2 RR
procedure for calibration of
equipment

Laboratory has documented 2 RR

procedure for validation of
results of reagents ,stains ,
media and kits etc. wherever
required

Laboratory has documented 2 RR

system of resolution of
complaints and other
feedback received from
patients, clinicians and RKS
members.

Laboratory has documented 2 RR

procedure for examination by
referral laboratories

Laboratory has documented 2 RR

system f or storage, retaining
and retrieval of laboratory
records, primary sample,
Examination sample and
reports of results.

Laboratory has documented 2 RR

system f or control of its
documents
Laboratory has documented 2 RR
procedure for preventive and
break down maintenance

Laboratory has documented 2 RR

procedure for internal audits

Laboratory has documented 2 RR

procedure for purchase of
External services and supplies

ME G4.3 S taff is trained and aware of Check, if staff is a aware of 2 SI/RR

the standard procedures relevant part of S OPs
written in S OPs

ME G4.4 W ork instructions are Work instruction/clinical 2 OB Work instruction for Internal
display ed at Point of use protocols are displayed Quality control,
Standard G5 The facility has established s ystem of periodic revie w as interna l a sse ssment , medical & de ath audit and 8 8
pre scription audit
ME G5.1 The facility conducts Internal assessment is done at 2 RR/SI
periodic internal periodic interval
assessment
ME G5.3 The facility ensures non Non Compliance are 2 RR/SI
compliances are enumerated and recorded
enumerated and recorded
adequately

ME G5.4 Action plan is made on the Action plan prepared 2 RR/SI

gaps found in the
assessment / audit process

ME G5.5 Corrective and Preventive Corrective and preventive 2 RR/SI

actions are taken to address action taken
issues, observed in the
assessment & audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6

ME G6.2 The facility periodically Quality Objectives are 2 RR/SI

defines its quality objectiv es defined
and key departments hav e
their own objectives

ME G6.3 Quality policy and Check for staff is aware of 2 SI

objectives are disseminated quality policy and objectives
and staff is aware of that

ME G6.4 Progress towards quality Quality objectives are 2 SI/RR

objectives is monitored monitored and reviewed
periodically periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 14 14

ME G7.1 F acility uses method for PDCA 2 SI/RR

quality improv ement in
services
5S 2 SI/OB
Process Mapping 2 SI/OB
Any other method of QA 2 SI/RR
ME G7.2 F acility uses tools for quality Any 2 basic tools of Quality 2 SI/RR
improvement in services

Pareto / Prioritization 2 SI/RR

Control charts 2 SI/RR
Area of Concern - H Outcome 40 40
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 16 16

ME H1.1 Facility measures productivity No. of HIV test done per 1000 2 RR
Indicators on monthly basis population

No. of VDRL test done per 2 RR

1000 population
No. of Blood Smear Examined 2 RR
per 1000 population

No. of AFB Examined per 1000 2 RR

population
No. of HB test done per 1000 2 RR
population
Lab test done per patients in 2 RR
OPD
Lab test done per patients IPD 2 RR

ME H1.2 The Facility measures equity Percentage of Lab 2 RR

indicators periodically Investigations for BPL IPD
Patients out of total
investigations for IPD Patients

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 12 12

ME H2.1 Facility measures efficiency No of test not matched in 2 RR

Indicators on monthly basis validation

Z score for biochemistry or 2 RR

equivalent
Z score for haematology or 2 RR
equivalent
Down time of critical 2 RR
equipment
Turn around time for routine 2 RR
lab investigations
Turn around time for 2 RR
emergency lab investigations

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 8 8

ME H3.1 Facility measures Clinical Care % of critical values reported 2 RR

& Safety Indicators on monthly within one hour
basis
No of adverse events per 2 RR
thousand patients
Report correlation rate 2 RR Proportion of lab report co
related with clinical examination

Proportion of false positive 2 RR For Rapid diagnostic Kit test

/false negative
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 4 4

ME H4.1 Facility measures Service Waiting time at sample 2 RR

Quality Indicators on monthly collection area
basis
Number of stock out 2 RR
incidences of reagents

Laboratory Score Card

Laboratory
Score
97.2332
Area of Concern wise Score
A Service Provision 78.5714285714286
B Patient Rights 100
C Inputs 97.5
D Support Services 97.0588235294118
E Clinical Services 92.5925925925926
F Infection Control 100
G Quality Management 100

H Outcome 100

Obtained Maximum Percent 7

A 22 28 78.571429
B 36 36 100
C 78 80 97.5
D 66 68 97.058824
E 50 54 92.592593
F 94 94 100
G 106 106 100
H 40 40 100
Total 492 506 97.233202
 National Quality Assurance Standards for Taluka Hospital
Checklist for Radiology 8
Reference no. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Area of Concern - A Service Provision 4 4

Standard A3 Facility Provides diagnostic Services 4 4
ME A3.1 The facility provides Radiology Availability of X-ray services 2 SI/OB f or chest, bones, skull,
S ervices spine and abdomen.
Availability/Functional linkage of 2 SI/OB Pre natal diagnostic
ultrasound services procedure:
Ultrasonography,

Area of Concern - B Patient Rights 36 36

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 14 14
ME B1.1 The facility has uniform and Availability departmental signage 2 OB (Numbering and rooms,
user-friendly signage system main department and
inter- sectional signage )

Display of PNDT Notice at USG 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 cautionary signage 2 OB Radiation hazard sign and

outside the X-ray department caution for pregnant
women and children

ME B1.2 The facility displays the services Timing for taking X-ray and 2 OB
and entitlements av ailable in its collection of reports are displayed
departments outside the X-ray department

ME B1.4 User charges are displayed and User charges in r/o X-ray services 2 OB
communicated to patients are displayed at entrance
effectively
ME B1.6 Information is av ailable in local Signage's and information are 2 OB
language and easy to available in local language
understand
ME B1.8 The facility ensures access to Reports are provided to Patient in 2 OB
clinical records of patients to proper printed format
entitled personnel
Standard B2
Services a re delive red in a manner that is sensitive to ge nder, religious a nd cultural needs, and the re are no ba rrier on 4 4
account of phys ical, economic, cultural or s ocial status.
ME B2.1 S ervices are provided in manner Female attendant should 2 OB/SI
that are sensitive to gender accompany female patients during
radiological procedures

ME B2.3 Acc ess to facility is prov ided Check the availability of ramp in 2 OB
without any phy sical barrier & OPD/ X-ray room
and friendly to people with
disabilities

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 8 8
ME B3.1 Adequate v isual privacy is X-ray department has provision of 2 OB
prov ided at every point of care privacy while taking X-ray.

USG department has provision of 2 OB provision of screen

privacy while taking sonography

ME B3.2 Confidentiality of patients Radiology has system to ensure 2 RR/SI Radiology staff do not
records and clinic al information the confidentiality of the reports discuss the X-Ray/USG
is maintained result outside. And reports
are kept in secure place

ME B3.3 The facility ensures the Behaviour of staff is empathetic 2 PI

behaviours of staff is dignified and courteous
and respectf ul, while delivering
the services

Standard B4 Facility ha s defined and e stabl ishe d procedures for informing patient a bout the ir me dical condition and involving them 2 2
ME B4.1 There is established procedures iForm
n treatement planning,
F for USG under PNDT and facili2ta tes informed
RR decis ion making.
for tak ing inf ormed consent maintained f or scan of pregnant
before treatment and woman
procedures
Facility ensure s tha t there are no financial barri er to acces s and that there is financial protection given from cos t of
Standard B5 8 8
hospita l services.
ME B5.1 The facility provides cashless Free radiology services for 2 PI/SI USG and X-ray
services to pregnant women, Pregnant women and infant
mothers and neonates as per
prevalent government schemes

ME B5.3 It is ensured that f acilities for Check that patient/attendant has 2 PI/SI
the prescribed investigations are not incurred expenditure on having
available at the facility Radiological Investigation(s) from
outside.

ME B5.4 The facility provide free of cost Tests are free of cost to BPL 2 PI/SI
treatment to Below poverty line patients
patients without administrative
hassles

ME B5.5 The facility ensures timely JS SK beneficiaries get free 2 PI/SI/RR All in-house tests and tests
reimbursement of financial investigations even f or the tests under Chief maisters
entitlements and not available at the facility comprehensive health
reimbursement to the patients insurance scheme are free

Area of Concern - C Inputs 62 74

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 14 22
ME C1.1 Departments have adequate Room Size of X-ray unit is as per 0 OB Room housing shall not be
space as per patient or w ork AERB safety code less than 18 sq m, any
load dimension not less than
4m

ME C1.3 Departments have layout and Unshielded opening for 2 OB Unshielded opening in X-
demarcated areas as per Ventilation and natural light has ray room shall be located
functions been provided in X-ray room as per above height of 2 m from
AERB safety code finished floor level outside
the X-ray room

Installation of control panel of X- 0 OB Control panel of X-ray

ray equipment is as Per AERB equipment operation at
safety Code 125 kVp or above shall be
installed in a separate
room located outside
contiguous to X-ray room,
with appropriate shielding,
direct viewing and oral
communication facility

Distance between control panel 0 OB The distance between

and X-ray unit is as per AERB safety control panel and X-ray
code unit shall not be less than
3m

Location of dark room is as per 2 OB Dark room is located such

AERB safety code that no significant primary
or secondary X-ray reaches
inside dark room

Dark room has X-ray developing 2 OB S S processing tank to

tanks with water supply accommodate 14"X 17"
approx. capacity of 13 litre

Dark room has provision of safe 2 OB

light in dark room
There is separate storage area for 2 OB
undeveloped X-ray films and
personal monitoring devices in
protected area away from
radiation sources

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 and
according to need and local law stretchers

ME C1.5 The facility has infrastructure f or Availability of functional telephone 0 OB

intramural and extramural and Intercom/CUG Services
communication
ME C1.7 The facility and departments are Internal Layout of X-ray 2 OB No criss cross in the
planned to ensure structure department is unidirectional movement patient traffic
follow s the f unction/processes and services flow
(S tructure commensurate with
the functi on of the hospital)

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 18 20
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and
safety of the infrastructure properly secured f urniture like cupboards,
cabinets, and heavy
equipment , hanging
objects are properly
f astened and secured

ME C2.2 The facility ensures safety of X-ray - does not have temporary 2 OB S witch Boards other
electrical establishment connections and loosely hanging electrical installation are
wires intact
Stabilizer is provided for X-ray 2 OB
machine
ME C2.3 Physic al condition of the Floors of the Radiology 2 OB
buildings is safe for providing department are non slippery and
patient care even

Window and door in X-ray room is 0 OB

provided with lead lining

Thickness of walls at X room are as 2 OB

AERB safety code
X-ray department should not be 2 OB
located adjacent to patient care
area
ME C2.5. The facility has adequate fire Radiology department has 2 OB
fighting Equipment installed fire Extinguisher for
fighting Type A,B and C Fire
Check the expiry date for fire 2 OB/RR
extinguishers are displayed on
each extinguisher as well as due
date for next refilling is clearly
mentioned

ME C2.6. The facility has a system of
periodic training of staff and
conduc ts mock drills regularly
for fire and other disaster
situation
Check for staff competencies for 2 SI/RR
operating fire extinguisher and
what to do in case of fire

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 10 10
ME C3.4 The facility has adequate Availability of Radiographer 2 SI/RR One radiographer
technicians/paramedics as per
requirement
ME C3.6 The staff has been prov ided Training on radiation safety 2 SI/RR
required training / skill sets
Training on infection control and 2 SI/RR
hand hygiene
Training on Bio Medical waste 2 SI/RR
Management
ME C3.7 The Staff is skilled as per job Radiographers are skilled to 2 SI/RR
desc ription operating equipment
Standard C4 Facility provides drugs and consumables required for assured list of services. 6 6
ME C4.2 The departments hav e adequate Availability Consumables 2 OB/RR X-ray films, Developer,
consumables at point of use F ixer, USG gel, printing
paper

Availability of personal protective 2 OB/RR Lead apron with hanger,

equipment lead shield
ME C4.3 Emergency drug trays are Emergency Drug Tray is maintained 2 OB/RR Verify Presence of
maintained at every point of f ollowing Drugs:-Inj
care, where ever it may be Dopamine, Inj Adrenaline,
needed Inj Hydrocortisone
S uccinate, Inj
Chlorpheniramine
Maleate,Inj Ranitidine, Inj
Onendestron

Standard C5 The facility has equipment & instruments required for assured list of services. 14 16
ME C5.1 Av ailability of equipment & A vailability of func tional 2 OB TLD badges
instruments for examination & Equipment &Instruments for
monitoring of patients examination & Monitoring
ME C5.3 Av ailability of equipment & A vailability of f unctional X-ray 2 OB
instruments for diagnostic machines
procedures being undertak en in
the facility

A vailability of func tional Dental 2 OB At least one

X-Ray Machine
A vailability of func tional 0 OB Desirable in the facility.
Ultrasonography Otherwise functional
linkage with nearby
f acility.

A vailability of Accessories for X- 2 OB Cassettes X-ray,

ray Intensifying screen X-ray,
Lead letter (A-Z),Letter
figures (0-9) and R & L

ME C5.7 Departments have patient
furniture and fixtures as per
load and service prov ision
Availability of attachment/ 2 OB X-ray hangers, Bucky Stand
accessories
Availability of fixtures at lab 2 OB X-ray View box, Electrical
fixture for equipment

Availability of furniture 2 OB Rack and cupboard , Chair

table
Area of Concern - D Support Services 70 84
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 8 14
ME D1.1 The facility has established All equipment are covered under 0 SI/RR
system for maintenance of AMC including preventive
critical Equipment maintenance

There is system of timely corrective 2 SI/RR

break down maintenance of the
equipment

Staff is skilled for trouble shooting 2 SI/RR

in case equipment malfunction

Periodic cleaning, inspection and 2 SI/RR

maintenance of the equipment is
done by the operator

ME D1.2 The facility has established All the measuring equipment/ 0 OB/ RR
procedure f or internal and instrument are calibrated
external calibration of
measuring Equipment

There is system to label/ code the 0 OB/ RR

equipment to indicate status of
calibration/ verification when
recalibration is due

ME D1.3 Operating and maintenance Operating instructions and factor 2 OB/SI

instructions are available with charts are available with the
the users of equipment equipment

Standard D2 T he facility has define d proce dures for s torage, inventory mana ge ment and dispens ing of drugs in pharmacy and 12 12
ME D2.1 There is established procedure There is established system ofpatient care
2 area
SI/RR
s S tock level are daily
for f orecasting and indenting timely indenting of X-ray films, updated
drugs and consumables fixer and developers etc. Requisition are timely
placed

ME D2.3 The facility ensures proper Fixers, developer and X-ray films/ 2 OB/RR
storage of drugs and consumables are kept away from
consumables water and sources of heat,
direct sunlight

Fixers and developer are labelled 2 OB/RR Reagents label contain

properly name, concentration, date
of preparation/opening,
date of expiry, storage
conditions and warning

ME D2.5 The facility has established Department maintains stock and 2 RR/SI
procedure f or inventory expenditure register of chemicals
management techniques and X-ray films

ME D2.6 There is a procedure for There is procedure f or replenishing 2 SI/RR

periodically replenishing the drugs drug tray
in patient care areas
There is no stock out of x-ray films 2 RR/SI
The fa cility has es tablis hed Program for ma intenance and upkee p of the facility to provide safe, s ecure and comfortable
Standard D3 34 34
ME D3.2 Hospital inf rastructure is
environment
Check to ensure that there is noto staff, patients
2 OB
and visitors .
adequately maintained seepage , cracks, chipping of
plaster
Window panes , doors and other 2 OB
fixtures are intact
ME D3,3 Patient care areas are clean and Floors, walls, roof, roof tops, sinks 2 OB All area are clean with no
hygienic patient care and circulation areas dirt,grease,littering and
are Clean cobwebs
Surface of furniture and fixtures 2 OB
are clean
ME D3.4. The facility has policy of remov al No condemned/Junk material in 2 OB
of condemned junk material the X-ray and USG

ME D3.5 The facility has established No rodent/birds 2 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate illumination at work 2 OB
illumination level at patient care station at X-ray room
areas
Adequate illumination at 2 OB
workstation at USG
ME D3.7 The facility has prov ision of Only one patient is allowed one 2 OB
restriction of visitors in patient time in X room
areas
Warning light is provided outside 2 OB/SI
X-ray room and its been used when
unit is functional

ME D3.8 The facility ensures safe and
comfortable environment f or
patients and service providers
Protective apron and gloves are 2 OB/SI
being provided to relative of the
child patient who escort the child
for X-ray examination/
immobilisation support is provided
to children

X-ray room has been kept closed at 2 OB

the time of radiation exposure

Lead apron and other protective 2 OB

equipment are available with
radiation workers and they are
using it

TLD badges are available with all 2 OB

staff of X-ray department and
records of its regular assessment is
done by X-ray department

Temperature control and 2 SI/RR F ans/ Air

ventilation in X-ray room conditioning/Heating/Exha
ust/Ventilators as per
environment condition and
requirement

Temperature control and 2 SI/RR Exhaust in dark room

ventilation in dark room
Temperature control and 2 SI/RR F ans/ Air
ventilation USG conditioning/Heating/Exha
ust/Ventilators as per
environment condition and
requirement

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.1 The facility has adequate Availability of 24x7 running and 2 OB/SI
arrangement storage and supply potable water
for potable w ater in all
functional areas

ME D4.2 The facility ensures adequate Availability of power back up in 0 OB/SI

power backup in all patient care Radiology and USG room
areas as per load
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 8 14
ME D8.1 The facility has requisite licences X-ray has valid registration from 0 RR
and certificates for operation of AERB.
hospital and different acti vities

X-ray department has layout 0 RR

approval f rom AERB
X-ray department has type 2 RR
approval of equipment with QA
test report for X- ray machine

USG department has registration 2 RR

under PCPNDT
Duplicate copy of Certificate of 2 OB
registration under Form B is
displayed inside the department

ME D8.3 The facility ensure relevant USG is taken by staff qualified as 2 RR

processes are in compliance per PCPNDT
with statutory requirement
Records of submission of Form F to 0 RR
appropriate district authorities

Standard D9 Roles & Responsibilities of a dminis trative and clinical staff are determined as per govt. regul ations and standa rds 6 6
ME D9.1 The facility has established job The Staff is aw are of theiroperating
role procedure
2 SI s.
desc ription as per govt and responsibilities
guidelines
ME D9.2 The facility has a established There is procedure to ensure that 2 RR/SI Check for system for
procedure f or duty roster and the staff is available on duty as per recording time of reporting
deputation to diff erent duty roster and relieving (Attendance
departments register/ Biometrics etc.)

ME D9.3 The facility ensures the Technician and support staff 2 OB

adherence to dress code as adhere to their respective dress
mandated by its code
administration / the health
department

Area of Concern - E Clinical Services 44 44

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 4 4
ME E1.1 The facility has established Unique identification number is 2 RR
procedure f or registration of given to each patient
patients
Patient demographic details are 2 RR Check for that patient
recorded in radiology/USG records demographics like Name,
age, Sex, Chief complaint,
etc.

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 2 2
ME E3.2 Facility provides appropriate There is procedure for ref erral 2 RR/SI
referral linkages to the of patient for which services can
patients/Services for transfer to not be provided at the facility
other/higher facilities to assure
their continuity of care.

Standard E5 Facility has a procedure to identify high risk and vulnerable patients. 2 2
ME E5.1 The facility identifies vulnerable Women in reproductive age are 2 OB/SI/RR Notice in local language is
patients and ensure their safe care asked for pregnancy (LMP)before displayed at entrance of X-
X-ray ray department asking
every female to inform
radiographer/radiologist
whether she is likely to be
pregnant

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 6 6
ME E8.5 Adequate f orm and formats are Standard Formats available 2 RR/OB Printed formats for
available at point of use requisition and reporting
are available
ME E8.6 Register/records are maintained Radiology records are labelled and 2 RR
as per guidelines indexed and maintained.
ME E8.7 The facility ensures safe and Radiology has adequate facility for 2 OB
adequate storage and retrieval storage of records
of medical records
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 6 6
ME E10.3 The facility has disaster Staff is aware of disaster plan 2 SI/RR
management plan in place
Role and responsibilities of staff in 2 SI/RR
disaster is defined
ME E10.5 There is procedure for handling Procedure for handling of MLC 2 SI/RR Requisition and reports are
medico legal cases marked with MLC and
reports are handed over to
authorize person

Standard E11 The facility has defined and established procedures of diagnostic services 24 24
ME E11.1 There are established Requisition of all X-ray examination 2 RR/OB Request form contain
procedures for Pre-testing is done in request form information: Name and
Activ ities identification number of
patient, Provisional
diagnosis, Indication for
the investigation, 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 department has system in 2 RR/SI

place to label the X-rays
X-ray has system to trace the X-ray 2 RR/SI
from requisition form
Requisition of all USG examination 2 RR/OB
is done in request form

The USG department has system in 2 RR/SI

place to label the USGs

Preparation of the patient is done 2 RR/SI

as per requirement
Instructions to be followed by 2 RR/SI
patient for USG are displayed in
local language at reception
ME E11.2 There are established The X-ray taking and processing 2 OB/RR
procedures for testing Activities procedure are readily available at
work station and staff is aware of it

The Radiographer is aware of 2 RR/SI

operation of X-ray machine
USG of the patient is taken as per 2 OB/RR
consultant requirement
ME E11.3 There are established The X-ray department has format 2 RR/OB
procedures for Post-testing for reporting of results
Activ ities
The USG department has format 2 RR/OB
for reporting of results
Area of Concern - F Infection Control 38 38
Standard F1 Facility has infection control program and procedures in place for prevention a nd me asurement of hos pital as sociated 4 4
ME F1.4 There is Provision of Periodic There is procedure f or infection
2 SI/RR Hepatitis B, Tetanus Toxoid
Medic al Check-up's and immunization of the staff etc.
immunization of staff
Periodic medical check-up's of the 2 SI/RR F or Alopecia, Gonadal
staff atrophy, Peripheral Blood
S mear
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 14 14
ME F2.1 Hand w ashing facilities are Availability of hand washing Facility 2 OB Check for availability of
prov ided at point of use at Point of Use wash basin near the point
of use
Availability of running Water 2 OB/SI Open the tap. Ask the
S taff, water is available
24X7
Availability of antiseptic soap with 2 OB/SI Check for availability/ Ask
soap dish/ liquid antiseptic with staff if the supply is
dispenser. adequate and
uninterrupted

Availability of Alcohol based Hand 2 OB/SI Check for availability/ Ask

rub staff for regular supply.

Display of Hand washing 2 OB Prominently displayed

Instruction at Point of Use above the hand washing
f acility , preferably in Local
language

ME F2.2 S taff is trained and adhere to Adherence to 6 steps of Hand 2 SI/OB Ask of demonstration
standard hand washing practices washing

Staff is aware of when to hand 2 SI

wash
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 8 8
ME F5.2 Facility ensures availability of Availability of cleaning agent as per 2 OB/SI Hospital grade phenyl,
standard materials for cleaning and requirement disinfectant detergent
disinfection of patient care areas solution

ME F5.3 Facility ensures standard practices Staff is trained for spill 2 SI/RR
followed for cleaning and management
disinfection of patient care areas

Cleaning of patient care area with 2 SI/RR

detergent solution
Standard practice of mopping and 2 OB/SI Unidirectional mopping
scrubbing are followed f rom inside out
Standard F6 Fa cility has defined and established procedures for segregation, coll ection, trea tme nt and dis posal of Bio M edical and 12 12
ME F6.1 hazardous
F acility Ensures segregati on of Availability of colour coded bins at Waste .
Bio Medic al W aste as per point of waste generation
guidelines
2 OB
Availability of plastic colour coded
plastic bags 2 OB
Segregation of different category
of waste as per guidelines
2 OB/SI
Display of work instructions for
segregation and handling of
Biomedical waste
2 OB
There is no mixing of infectious and
general waste 2 OB
ME F6.3 F acility ensures transportation Disposal of Fixer and Developer 2 SI/OB/RR
and disposal of waste as per
guidelines

Area of Concern - G Quality Management 50 50

Standard G2 Facility has established system for patient and employee satisfaction 2 2
ME G2.1 Patient Satisf action surv eys are There is system to take feed back 2 RR
conduc ted at periodic intervals from clinician about quality of
services

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 4 4
ME G3.2 The facility has established TLD Badges are analysed at 2
external assurance programmes stipulated intervals
at relevant departments

SI/RR
ME G3.3 F acility has established system Departmental check list is used 2 SI/RR
for use of check lists in different f or monitoring and quality
departments and serv ices assurance

S taff is designated f or filling and 2 SI

monitoring of these check lists

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 30 30
ME G4.1 Departmental standard Standard operating procedure for 2 RR
operating procedures are department has been prepared
available and approved

Current version of SOP are 2 OB/RR

available with process owner
ME G4.2 S tandard Operating Procedures The Department has documented 2 RR
adequately describes process procedure for process of taking
and procedures and handling X-ray

The Department has documented 2 RR

procedure for acceptance and
rejection of X-ray taken

The Department has documented 2 RR

procedure for receipt, labelling ,
Processing and reporting of X-ray

The Department has documented 2 RR

procedure for taking X-ray in
emergency conditions

The Department has documented 2 RR

procedure for quality control
system to verify the quality of
results

The Department has documented 2 RR

system for repeat X-ray.

The Department has documented 2 RR

procedure for storage, retaining
and retrieval of department
records, and reports of results.

The Department has documented 2 RR

procedure preventive and break
down maintenance

The Department has documented 2 RR

procedure for purchase of External
services and supplies

The Department has documented 2 RR

procedure for inventory
management
The Department has documented 2 RR
procedure for radiation safety of
staff , patients and visitors

ME G4.3 S taff is trained and aware of the Check if staff is aware of relevant 2 SI/RR
standard procedures written in part of SOPs
S OPs
ME G4.4 W ork instructions are display ed Work Instructions are displayed for 2 OB F actor chart, radiation
at Point of use radiation safety safety, development for x-
ray films
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 8 8
ME G5.1 The facility conducts periodic Internal assessment is done at 2 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 2 RR/SI
compliances are enumerated and recorded
and recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 2 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive Corrective and preventive action 2 RR/SI
actions are taken to address are taken
issues, observed in the
assessment & audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2 The facility periodically defines Quality objectives for Radiology are 2 RR/SI
its quality objectiv es and k ey defined
departments have their own
objectives

ME G6.3 Quality policy and objectiv es are Check of staff is aware of quality 2 SI
disseminated and staff is aware policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored 2 SI/RR
objectives is monitored and reviewed periodically
periodically

Area of Concern - H Outcome 26 28

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 8 10
ME H1.1 Facility measures productivity X-ray done per 1000 OPD patient 2 RR
Indicators on monthly basis
X-ray done per 1000 IPD patient 2 RR

Ultrasound done per 1000 OPD 2 RR

patient
No. of dental X-ray per 1000 dental 0 RR
OPD
ME H1.2 The Facility measures equity Proportion of BPL Patients 2 RR
indicators periodically underwent x-ray & USG
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 8 8
ME H2.1 Facility measures efficiency Downtime for critical equipment 2 RR
Indicators on monthly basis
Turn around time for X-Ray film 2 RR
development
Proportion of wastage of films 2 RR
Proportion of X-ray 2 RR
rejected/repeated
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 & Proportion of scans for which F 2 RR
Safety Indicators on monthly basis form is filled out of pregnant
women scanned
No of events of over limit of 2 RR
radiation exposure
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 6 6
ME H4.1 Facility measures Service Quality Average waiting time at radiology 2 RR
Indicators on monthly basis

Average waiting time at USG 2 RR

Incidences of X- ray films stock-out 2 RR

Radiology Score Card

Radiology Score 92.178771

Area of Concern wise Score

A Service Provision 100
B Patient Rights 100
C Inputs 83.7837837837838
D Support Services 83.3333333333333
E Clinical Services 100
F Infection Control 100
G Quality Management 100
H Outcome 92.8571428571429

Obtained Maximum Percent 8

A 4 4 100
B 36 36 100
C 62 74 83.783784
D 70 84 83.333333
E 44 44 100
F 38 38 100
G 50 50 100
H 26 28 92.857143
Total 330 358 92.178771
 National Quality Assurance Standards for Taluka Hospital
Checklist for Pharmacy & Stores 9
Ref erence Measurable Element Checkpoint Assessment
No Compliance Method Means of Verification Remarks

Area of Concern - A Service Provision 28 28

Standard A1 Facility Provides Curative Services 4 4
ME A1.9 Serv ices are available for the time Dispensary services are available 2 SI/RR
period as mandated during OPD hours
Facility ensure access to drug store 2 SI/RR
after OPD hours

Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 10 10
ME A4.1 The facility provides serv ices under Availability of Drugs under NVBDCP 2 SI/OB Chloroquine, Primaquine, ACT
National Vector Borne Disease (Artemisinin Combination
Control Programme as per Therapy)- Linkage with DDHS
guidelines office for ACT

ME A4.2 The facility provides serv ices under Availability of Drugs under RNTCP 2 SI/OB
Revised National TB Control
Programme as per guidelines

As per RNTCP Guidelines

ME A4.3 The facility provides serv ices under Availability of Drugs under NLEP 2 SI/OB
National Leprosy Eradication
Programme as per guidelines
As per NLEP Guidelines
ME A4.4 The facility provides serv ices under Availability of ARV Drugs under NACP 2 SI/OB As per NACO Guidelines
National A IDS Control Programme
as per guidelines

Availability of Drugs for Paediatric HIV 2 SI/OB As per NACO Guidelines

management

Standard A5 Facility provides support services and Administrative services 14 14

ME A5.6 The facility provides pharmacy and Dispensing of Medicines and 2
store services consumables for OPD Patients
SI/OB Functional dispensary
Storage of drugs 2 SI/OB
Storage of consumables 2 SI/OB
Storage of equipments 2 SI/OB
Storage of Stationaries. 2 SI/OB
Cold chain management services 2 SI/OB
Storage of Linen 2 SI/OB
Area of Concern - B Patient Rights 26 28
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 8 10
ME B1.1 Availability departmental signages 2 OB (Numbering, main department
and internal sectional signage
The facility has unif orm and user-
friendly signage system

ME B1.2 The facility displays the services and List of available drugs displayed at 2 OB
Pharmacy
entitlements available in its
departments
Status of availability of drugs is 0 OB
updated weekly
Timings for dispensing counter of 2 OB
pharmacy are displayed
ME B1.6 Signage's and information are 2 OB
Information is available in local available in local language
language and easy to understand
Standard B2 Service s are delivered in a manner that is se nsi tive to gender, re ligious and cultura l needs, a nd there are no barrier on account of
4 4
physical, economic, cultural or social s tatus .
ME B2.1 Availability of separate Queue for 2 OB
Serv ices are provided in manner Male and female patients at
that are sensitive to gender 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 physical barrier and is friendly
to people with disabilities
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 2 2
ME B3.3 Behaviour of staff is empathetic and 2 PI
The facility ensures the behaviours courteous
of staff is dignified and respectf ul,
while deliv ering the serv ices
The fa cility has de fined a nd established procedures for informing patients about the medical condition, and involving them in treatment
Standard B4 planning, and facilitates informed decision making 2 2
ME B4.4 Method of Administration /taking of 2 OB/SI
the medicines is informed to patient/
Information about the treatment is their relatives by pharmacist as per
shared with patients or attendants, doctors prescription in OPD Pharmacy
regularly

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services.
ME B5.1
The facility provides cashless
services to pregnant women,
mothers and neonates as per
prevalent government schemes
ME B5.2 The facility ensures that drugs
prescribed are av ailable at
Pharmacy and wards
10 10
Free drugs and consumables for JSSK 2 PI/SI
beneficiaries
Pharmacy supplies generic drugs list 2 SI/OB
to all hospital departments as per
their internal demand
Check that patient has not incurred 2 PI/SI
expenditure on purchasing drugs or
consumables from outside.

ME B5.4 Free drugs for BPL & other entitled 2 PI/SI/RR As per state guideline e. g:
The facility provide free of cost patients geriateric patient
treatment to Below poverty line
patients w ithout administrativ e
hassles
ME B5.5 Local purchase of stock out drug are 2 PI/SI/RR
The facility ensures timely done
reimbursement of financial
entitlements and reimbursement to
the patients

Area of Concern - C Inputs 130 136

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 22 24
ME C1.1 Departments hav e adequate space The hospital has allocated space for 2
as per patient or work load Pharmacy in OPD
Minimum space required is
250sq F or 5% of
average OPD X 0.8 sq m.
OB
Dispensary has adequate waiting 2
space as per load OB
ME C1.2 Patient amenities are provide as per Pharmacy has patients sitting 2
patient load arrangement as per requirement
OB
ME C1.3 Departments hav e layout and Dedicated area for keeping medical 2
demarcated areas as per functions gases
OB
Dedicated area for keeping 2
inflammables
OB Storage of sprit etc.
Demarcated are of keeping near 2
expiry drugs
OB
Demarcated area for keeping 2
instruments and consumables
OB
Dedicated area for cold chain 2
management
OB
ME C1.4 The facility has adequate circulation Availability of adequate circulation 2
area and open spaces according to area for easy moment of staff , drugs
need and loc al law and carts
OB
ME C1.5 The facility has infrastructure f or Availability of functional telephone 0
intramural and extramural and Intercom/CUG Services
communication
OB
ME C1.6 Serv ice 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 Unidirectional flow of goods in the 2 Receipt and Inspection area at
planned to ensure structure follows Pharmacy . one side and issue area on the
the f unction/processes (S tructure other side
commensurate with the function of
the hospital)
OB
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 14 18
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and furniture
saf ety of the infrastructure properly secured like cupboards, cabinets, and
heavy equipments , hanging
objects are properly fastened
and secured

ME C2.2 The facility ensures saf ety of Pharmacy does not have temporary 2 OB
electrical establishment connections and loosely hanging wires

Stabilizer is provided for cold chain 2 OB

room
ME C2.3 Physical condition of buildings are Windows of drug store have grills and 2 OB
saf e for providing patient care wire meshwork

Floors of the Pharmacy department 2 OB

are non slippery, acid resistant & even
surf ace
ME C2.4 The facility has plan f or prev ention Pharmacy has plan for safe storage 2 OB/SI
of fire and handling of potentially flammable
materials.
ME C2.5 The facility has adequate fire Pharmacy has installed fire 0 OB/RR
fighting Equipment Extinguisher for A,B, C class of fire

Check the expiry date on fire 0 OB/RR

extinguishers is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned

ME C2.6 The facility has a system of periodic Check staff competencies for 2 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

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 14 14
ME C3.4 The facility has adequate Availability of Pharmacist 2 SI/RR
technicians/paramedics as per
requirement
ME C3.6 The staff has been provided Inventory management 2 SI/RR
required training / sk ill sets
Cold chain management of ILR and 2 SI/RR
deep freezer
Rational use of drugs 2 SI/RR
Prescription Audit 2 SI/RR
ME C3.7 The Staff is sk illed as per job Staff is skilled for estimation of the 2 SI/RR
description requirement and proper storage of
the drugs
Staff is skilled for maintaining 2 SI/RR
pharmacy records and bin cards
Standard C4 Facility provides drugs and consumables required for assured list of services. 74 74
ME C4.1 The departments have availability of Analgesics,Antipyretics, Nonsteroidal 2 OB/RR As per State EDL
adequate drugs at point of use Anti-Inflammatory Medicines,
Medicines For Gout, Rheumatoid
Disorders

Antiallergic And Medicines Used In 2 As per State EDL

Anaphylaxis

Antidotes And Other Substances Used 2 As per State EDL

In Poisoning
Anti-Epileptic & Anti Convulsant 2 As per State EDL
Medicines
Intestinal Anthelmintics 2 As per State EDL

Anti-Filarial Medicines 2 As per State EDL

Anti Bacterial Medicines 2 As per State EDL

Anti Microbial 2 As per State EDL

Anti -Anaemic Medicines 2 As per State EDL

Anti Fungal Medicines 2 As per State EDL

Anti Protozoal Medicines 2 As per State EDL
Anti-Viral Medicines 2 As per State EDL

Anti- Malerial 2 As per State EDL

Medicines Affecting Coagulation 2 As per State EDL

Antineoplastic, Immunosuppressives 2 As per State EDL
And Medicines Used In Palliative Care

Anti-Parkinsonism Medicines 2 As per State EDL

Cardiovascular Medicines 2 As per State EDL

Dental Preparations 2 As per State EDL

Dermatological Medicines 2 As per State EDL

Diuretics 2 OB/RR As per State EDL
Ear, Nose And Throat Medicines 2 OB/RR As per State EDL
Liver, Kidney, Gall Stones, Antacids 2 OB/RR As per State EDL
And Other Anti Ulcer Medicines

Antiemetic Medicines 2 OB/RR As per State EDL

Anti Hemorrhoidal Medicines 2 OB/RR As per State EDL
Anti Spasmodic Medicines 2 OB/RR As per State EDL
Laxative Medicines 2 OB/RR As per State EDL
Medicines Used In Diarrhoea 2 OB/RR As per State EDL

Hormones, Other Endocrine 2 OB/RR As per State EDL

Medicines And Contraceptives

Immunological Agents 2 OB/RR As per State EDL

Muscle / Relaxant & Cholinesterase 2 OB/RR As per State EDL

Inhibitors
Ophthalmological /Preparations 2 OB/RR As per State EDL

Oxytocics And Antioxytocics 2 OB/RR As per State EDL

Psycotherapeutic Medicines 2 OB/RR As per State EDL
Medicines Acting On Respiratory 2 OB/RR As per State EDL
System

Solutions Correcting Water, 2 OB/RR As per State EDL

Electrolyte And Acid Base

Vitamines And Minerals 2 OB/RR As per State EDL

ME C4.2 The departments have adequate Availability of Consumables 2 OB/RR As per Sate EDL
consumables at point of use
Standard C5 The facility has equipment & instruments required for assured list of services. 6 6
ME C5.5 Availability of Equipment for Storage Av ailability of Equipment for 2 OB ILR, Deep Freezers, Insulated
maintenance of Cold chain carrier boxes with ice packs,

ME C5.6 Availability of f unctional equipment Av ailability of equipment for 2 OB Buckets for mopping, mops,
and instruments for support cleaning duster, waste trolley, Deck brush
services

ME C5.7 Department have patient furniture Storage furniture for drug store 2 OB Racks ,Cupboards, Sectional
and fix tures as per load and servic e Drawer cabinet/ Shelves, Work
provision table

Area of Concern - D Support Services 108 116

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 4 4
ME D1.2 The facility has established All the measuring equipment/ 2 OB/ RR Calibration of thermometers at
procedure for internal and external instruments are calibrated cold chain room
calibration of measuring Equipment

ME D1.3 Operating and maintenance Operating instructions for ILR/ Deep 2 OB/SI
instructions are available with the Freezers are available at cold chain
users of equipment room

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 78 78
ME D2.1 There is established procedure for Drug store has process to consolidate 2 RR/SI
forecasting and indenting drugs and and calculate the consumption of all
consumables drugs and consumables

Forecasting of drugs and 2 RR/SI

consumables is done scientifically
which is realistic & is based on
consumption pattern and disease load

Staff is trained f or forecasting the 2 RR/SI

requirement using scientific system

ME D2.2 The facility has establish procedure The facility has a established 2 RR/SI
for procurement of drugs procedure for local purchase of drugs
in emergency conditions

The facility has a system for placing 2 RR/SI

requisition to district drug store

ME D2.3 The facility ensures proper storage There is specified place to store 2
of drugs and consumables medicines in Pharmacy and drug store
OB
All the shelves/racks containing 2
medicines are labelled in pharmacy
and drug store Stock is arranged neatly in
alphabetic order with name
OB facing the front.
Product of similar name and different 2
strength are stored separately
OB
Heavy items are stored at lower 2
shelves/racks
OB
Fragile items are not stored at the 2
edges of the shelves.
OB
Sound alike and look alike medicines 2
are stored separately in patient care
area and pharmacy
OB
There is separate shelf /rack for 2
storage near expiry drugs
OB
Drug store and pharmacy has system 2
of inventory Management
OB/SI
Drugs and consumables are stored 2
away from water and sources of heat,
direct sunlight etc.

Medications that are considered

light-sensitive will be stored in
OB/RR closed drawers.
Drugs are not stored on floor and 2
adjacent to wall

Pallets are provided if required

OB to store at floor
ME D2.4 The facility ensures management of The Dispensing counter has system to 2 RR/SI
expiry and near expiry drugs check the expiry of drugs

Drug store has system to check the 2 RR/SI

expiry of drugs
Drug store has system to inform the 2 RR/SI
patient care areas about near expiry
and system of call back of Expired
drugs

There is a system of periodic random 2 RR/SI

quality testing of drugs
ME D2.5 The facility has established Physical verification of inventory is 2 RR/SI
procedure for inventory done periodically
management techniques
Facility uses bin card system 2 RR/OB
First expiry first out system is 2 OB
established for drugs
Stores has defined minimum stock for 2 RR/OB
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 (VED)
ME D2.6 There is a procedure for periodically Hospital has system of collection of 2 RR/SI
replenishing the drugs in patient care medicines from store in case of
areas emergency
ME D2.7 There is process for storage of Check that vaccines are kept in 2
vaccines and other drugs, requiring sequence
controlled temperature
OB
Work instruction for storage of 2
vaccines are displayed at point of use
OB
 ILR and deep freezer have functional 2
temperature monitoring devices
OB
There is a system in place to maintain 2
temperature chart of ILR

Temp. of ILR: Min +2O C to 8O c in

case of power failure min temp.
+10 OC . Daily temperature log are
OB maintained
There is a system in place to maintain 2
temperature chart of deep freezers

Temp. of Deep freezer cabinet is

maintained between -15 OC to -
25O C.Daily temperature log are
OB maintained
Check that thermometer in ILR is in 2
hanging position OB
ILR and deep freezer have functional 2
alarm system SI/RR
the staff is aware of hold over time of 2
cold storage equipments SI/RR
ME D2.8 There is a procedure for secure Narcotic medicines are kept in double 2
storage of narcotic and psychotropic lock
drugs

As per Narcotic act, Narcotic

medicines are kept in 2 Keys with
2 locks kept by 2 different
OB persons
Empty ampoules/strips are returned 2
along with narcotic administration
detail sheet
OB/RR
Hospital has a system to discard the 2
expired narcotic drugs
Discarded narcotic drugs are
RR/SI documented with witness.
The facility maintains the list of 2
narcotic and psychotropic drugs
available at facility
RR
Standard D3 The facility has established Program for maintena nce and upkeep of the faciity to provide s afe, secure and comfortable e nvironment to 14 20
staff , patients and vis itors.
ME D3.2. Hospital infrastructure is adequately Check for there is no seepage , Cracks, 0 OB
maintained chipping of plaster
Window panes , doors and other 0 OB
fixtures are intact
ME D3.3 Patient care areas are clean and Interior of patient care areas are 2 OB
hygienic plastered & painted
Floors, walls, roof , roof tops, sinks 2 OB
patient care and circulation areas are
Clean

All area are clean with no

dirt,grease,littering and cobwebs
Surface of furniture and fixtures are 2 OB
clean
ME D3.4. The facility has policy of remov al of Actions f or removing junk condemned 2 OB At least 6 month interval
condemned junk material articles are periodically taken

ME D3.5 The facility has established No stray animal/rodent/birds 2 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate
illumination level at patient care
areas
ME D3.8 The facility ensures saf e and
comfortable environment for
patients and service prov iders
Adequate Illumination inside drug
store
Temperature control and ventilation
in pharmacy is maintained
2
OB
2 Fans/ Air
conditioning/Heating/Exhaust/V
entilators as per environment
condition and requirement

SI/RR
ME D3.9 The facility has security system in Security arrangement at pharmacy is 0 OB
place at patient care areas robust
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 4 4
ME D4.2 The facility ensures adequate power Availability of power back up in the 2 OB/SI
back up in all patient care areas as Pharmacy
per load
Availability of power back up for the 2 OB/SI
cold chain maintenance
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 0 2
ME D8.1 The facility has requisite licenc es License for storing spirit 0 RR
and certificates for operation of
hospital and different activ ities

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 8 8
ME D9.1 The facility has established job Staff is aware of their roles and 2 SI
description as per govt guidelines responsibilities

ME D9.2 The facility has a established There is a procedure to ensure that 2 RR/SI Check for system for recording
procedure for duty roster and staff is available on duty as per duty time of reporting and relieving
deputation to different departments roster (Attendance register/ Biometrics
etc)

There is designated in charge for 2 SI

department
ME D9.3 The facility ensures the adherence Pharmacist adhere to their respective 2 OB
to dress code as mandated by its dress code
administration / the health
department

Area of Concern - E Clinical Services 26 26

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use. 10 10
ME E6.1 Facility ensured that drugs are The facility has essential drug list as 2 RR/SI
prescribed in generic name only per State guideline
Drugs are purchased by generic name 2 OB
only
The facility has enabling order 2 RR/SI
from state f or w riting drugs in
generic name only
The facility provide list of drugs 2 RR/SI
available to different departments
as per essential drug list

There is system of conducting 2 RR/SI

periodic prescription audit to
ensure that only generic and
rational drugs are prescribed

Standard E7 Facility has defined procedures for safe drug administration 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
drugs
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 8 8
ME E8.5 Adequate form and formats are Standard Formats available 2 RR/OB Bin cards, indent forms etc
av ailable at point of use
ME E8.6 Register/records are maintained as Pharmacy records are labeled and 2 RR
per guidelines indexed
Records are maintained for Pharmacy 2 RR

ME E8.7 The facility ensures saf e and Pharmacy has adequate facility for 2 OB
adequate storage and retrieval of storage of records
medical records
Standard E10
The facility has defined and established procedures for Emergency Services and Disaster Management
6 6
ME E10.3 The facility has disaster Staff is aware of disaster plan 2 SI/RR
management plan in place
Roles and responsibilities of staff in 2 SI/RR
disaster are defined
Contingency/Buffer stock for Disaster 2 SI/RR
and mass casualties.
Area of Concern - F Infection Control 14 14
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 6 6
There is Provision of Periodic There is a procedure for immunization 2
Medical Check ups and of the staff
immunization of staff
ME F1.4 SI/RR Hepatitis B, Tetanus Toxid etc
Periodic medical checkups of the staff 2
are conducted SI/RR
Facility has defined and established Check for Pharmacist are aware of 2
antibiotic policy Hospital Antibiotic Policy
ME F1.6 SI/RR
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 2 2
Facility ensures availability of standard Availability of cleaning agent as per 2
materials for cleaning and disinfection requirement
of patient care areas

Hospital grade phenyl,

ME F5.2 OB/SI disinfectant detergent solution
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste. 6 6
Facility Ensures segregation of Bio Availability of colour coded bins and 2
Medical Waste as per guidelines liner for disposal of expired drugs
ME F6.1 OB
There is no mixing of infectious and 2
general waste OB
Facility ensures transportation and Disposal of expired drugs as per 2
disposal of waste as per guidelines state guidelines
ME F6.3 SI/OB
Area of Concern - G Quality Management 70 70
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 6 6
ME G3.1 Facility has established internal Physical verification of the inventory 2 SI/RR
quality assurance program at by Pharmacist at periodic intervals
relev ant departments
ME G3.3 Facility has established system for Departmental checklist are used 2 SI/RR
use of c heck lists in diff erent for monitoring and quality
departments and services assurance
Staff is designated for filling and 2 SI
monitoring of these check lists

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services. 34 34
ME G4.1 Departmental standard operating Standard operating procedure for 2 RR
procedures are av ailable department has been prepared and
approved

Current version of SOP are available 2 OB/RR

with process owner
ME G4.2 Standard Operating Procedures Department has documented 2 RR
adequately describes process and procedure for indent the drugs and
procedures items from district drug warehouse

Department has documented 2 RR

procedure for local purchase of drugs/
generic drug stores
Department has documented 2 RR
procedure for reception of drugs and
items
Department has documented 2 RR
procedure for storage of drugs
Department has documented 2 RR
procedure for disposal of expired
drugs
Department has documented 2 RR
procedure for dispensing of medicines
at Pharmacy
Department has documented 2 RR
procedure of supply the drugs to
patient care area
Department has documented 2 RR
procedure for issue of the drugs in
emergency condition
Department has documented 2 RR
procedure for maintenance of
temperature of ILR/Deep freezer
/refrigerators

Department has documented 2 RR

procedure for maintaining near expiry
drugs at store and pharmacy

Department has documented 2 RR

procedure for rational use of drugs
and prescription audit
Department has documented 2 RR
procedure for storage of narcotic and
psychotropic drugs
Department has documented system 2 RR
for periodic random check and
quality testing of drugs

ME G4.3 Staff is trained and aware of the Check staff is a aware of relevant part 2 SI/RR
standard procedures w ritten in of SOPs
SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 2 OB Work instruction for storing
Point of use are displayed drugs, Cold chain management

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 12 12
ME G5.1 The facility conducts periodic Internal assessment is done at 2 RR/SI
internal assessment periodic interval
ME G5.2 The facility conducts the periodic Pharmacy department co ordinates 2 RR/SI
prescription/ medical/death audits the prescription audit

Storage and compilation of records of 2 RR/SI

prescription audit
ME G5.3 The facility ensures non Non Compliance are enumerated and 2 RR/SI
compliances are enumerated and recorded
recorded adequately
ME 5.4 Action plan is made on the gaps Action plan is prepared 2 RR/SI
found in the assessment / audit
process
ME G5.5 Correctiv e and prev entive actions Corrective and preventive actions 2 RR/SI
are taken to address issues, taken
observed in the assessment & audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2 The facility periodically defines its Quality objectives for Pharmacy are 2 RR/SI
quality objectives and key defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check if staff is aware of quality policy 2 SI
disseminated and staff is aw are of and objectives
that
ME G6.4 Progress towards quality objectives Quality objectives are monitored and 2 SI/RR
is monitored periodically reviewed periodically

Sta ndard Facility seeks continually improvement by practicing Quality method and tools.
G7 12 12
ME G7.1 Facility uses method f or quality PDCA 2 SI/RR
improvement in services
5S 2 SI/OB
Process Mapping 2 SI/OB
Any other method of QA 2 SI/RR
ME G7.2 Facility uses tools for quality Any 2 Basic tools for Quality 2 SI/RR
improvement in services
Pareto / Prioritization 2 SI/RR
Area of Concern - H Outcome 20 20
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 4
ME H1.1 Facility measures productivity Percentage of drugs available against 2
Indicators on monthly basis essential drug list RR
ME H1.2 The Facility measures equity indicators Expenditure on drugs procured 2
periodically through local purchase for BPL patient
RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 6 6
ME H2.1 Facility measures efficiency Indicators Number of stock out situations for 2
on monthly basis Vital category of drugs/consumables.
RR
Turn Around time for dispensing 2
medicine at Dispensary RR
Percentage of drugs expired during 2
the months RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 8 8
ME H3.1 Facility measures Clinical Care & Safety Proportion of prescription found 2
Indicators on monthly basis prescribing non generic drugs RR
No of advere drug reaction per 2
thosuand patients RR
Antibiotic rate 2

No. of antibiotic prescribed /No.

RR of patient admitted or consulted
Percentage of irrational use of 2
drugs/overprescription RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 2
ME H4.1 Facility measures Service Quality Waiting time for Pharmacy Counter 2
Indicators on monthly basis RR

Pharmacy Card
Pharmacy Score96.347032
Area of Concern wise Score
A Service Provision 100
B Patient Rights 92.8571428571429
C Inputs 95.5882352941176
D Support Services 93.1034482758621
E Clinical Services 100
F Infection Control 100
G Quality Management 100
H Outcome 100

Obtained Maximum Percent 9

A 28 28 100
B 26 28 92.8571429
C 130 136 95.5882353
D 108 116 93.1034483
E 26 26 100
F 14 14 100
G 70 70 100
H 20 20 100
Total 422 438 96.347032
 National Quality Assurance Standards for Taluka Hospital
Checklist for Blood Storage Centres 10
Reference Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
No. Method
. Area of Concern - A Service Provision 8 10
Standard A1. Facility Provides Curative Services 6 6
ME A1.9. The Services are available for Blood storage services are available 2 SI/RR Lab Technician is available
the time period as mandated 24X7 on call after working hour

ME A1.11. The facility provides Blood Blood storage has facility for 2 SI/OB
storage & transfusion services storage of whole blood

. Blood storage has emergency stock 2 SI/OB May be modified as per

of blood as per MoHFW Guideline usage and requirements

Standard A3 Facility Provides diagnostic Services 2 2

ME A3.2 The facility Provides Laboratory Availability of Blood Grouping, 2 SI/OB
Services compatability testing and cross
matching services

Standard A4 Facility provides services as mandated in National Health Programs/ state scheme 0 2
ME A4.1 The facility provides services Facility to arrange for platelets 0 SI/RR
under National Vector Borne from parent blood bank for
Disease Control Programme as management of Dengue cases.
per guidelines

. Area of Concern - B Patient Rights 16 16

Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their 8 8
ME B1.1. The facility has uniform and Availability of Departmental modalities
2 OB (Numbering Rooms, main
user-friendly signage system signages department and inter-
sectional signage)

ME B1.2. The facility displays the services Blood storage has displayed 2 OB
and entitlements available in its information regarding number of
departments blood units available

ME B1.5. Patients & visitors are sensitised IEC material is available in Blood 2 OB
and educated through Storage to provide information and
appropriate IEC / BCC to promote blood donation
approaches

ME B1.6. Information is available in local Signage's and information are 2 OB

language and easy to available in local language
understand
Standard B3. The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 2 2
ME B3.3 The facility ensures the Behaviour of staff is empathetic 2 PI/OB
behaviours of staff is dignified and courteous
and respectful, while delivering
the services

Standard B5. Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of 6 6
ME B5.1. The facility provides cashless Free blood for Pregnant women, 2 PI/SI
services to pregnant women, Mothers and New-Borns and
mothers and neonates as per infants.
prevalent government schemes

ME B5.2 The facility ensures that drugs Check that parents & attendant's 2 PI/SI
prescribed are available at have not spent money on
Pharmacy and wards purchasing bloods from outside.

ME B5.4. The facility provide free of cost Free blood is provided to BPL 2 PI/SI/RR
treatment to Below poverty line patients
patients without administrative
hassles

.
Area of Concern C: Inputs
41 42
Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent
norms 8 8
ME C1.1. Departments have adequate Blood storage has adequate space 2 OB Space required is more
space as per patient or work as per requirement than 10sq meters
load
ME C1.3. Departments have layout and Dedicated area for Whole blood 2 OB
demarcated areas as per
functions
. Dedicated space for keeping 2 OB
records
ME C1.5. The facility has infrastructure Availability of functional Intercom 2 OB
for intramural and extramural and telephone/CUG services
communication
Standard C2. The facility ensures the physical safety including Fire safety of the infrastructure. 16 16
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment ,hanging
objects are properly
fastened and secured
ME C2.2 The facility ensures safety of Blood storage does not have 2 OB
electrical establishment temporary connection and loosely
hanging wires

. Adequate electrical socket 2 OB/RR

provided for safe and smooth
operations of testing equipment

ME C2.3 Physical condition of buildings Work benches are chemical 2 OB

are safe for providing patient
care
resistant
Blood storage has plan for safe 2 OB
storage and handling of potentially
flammable materials.

ME C2.5. The facility has adequate fire At least one Fire Extinguisher ABC 2 OB/RR
fighting Equipment Type is available in vicinity of blood
storage.

. Check the expiry date for fire 2 OB/RR

extinguisher is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned

ME C2.6 The facility has a system of
periodic training of staff and
conducts mock drills regularly
for fire and other disaster
situation
Check for staff competencies for 2 SI/RR
operating fire extinguisher and
what to do in case of fire

Standard C3. The facility has adequate qualified and trained staff, required for providing the assured services to the current case 10 10
ME C3.1. The facility has adequate Availability of designated Blood load 2 OB/RR MBBS doctor with 3 days
specialists doctors as per storage officer. recognized training on
service provision blood storage

ME C3.4. The facility has adequate Availability of Trained Technician 2 SI/RR DMLT with one day
technicians/paramedics as per for Blood storage recognized training on
requirement blood storage.

ME C3.6. The staff has been provided IMEP training. 2 SI/RR

required training / skill sets
Blood storage management 2
ME C3.7 The Staff is skilled as per job Staff is skilled in operating the 2 SI/RR
description equipment
Standard C4. Facility provides drugs and consumables required for assured list of services. 4 4
ME C4.1. The departments have Availability of Laboratory materials 2 OB/RR Pauster pipette, glass
availability of adequate drugs at tubes, gloves, tooth picks
point of use Glass slides, Glass
marker/paper stickers

ME C4.2. The departments have Availability of Reagents /Kits and 2 OB/RR Standard Grouping Sera
adequate consumables at point other consumables for testing. Anti A, Anti B & Anti D,
of use Antihuman Globulin.

Standard C5. The facility has equipment & instruments required for assured list of services. 3 4
ME C5.3. Availability of equipment & Availability of laboratory 1 OB Microscope, RH viewer.
instruments for diagnostic equipment & instruments for
procedures being undertaken in laboratory
the facility

ME C5.5. Availability of Equipment for Check for availability of storage 2 OB Blood bags refrigerator
Storage equipment for blood products with thermo graph and
alarm device, Insulated
carrier boxes with ice
packs, Blood bag weighting
machine, deep freezer,

. Area of Concern - D Support Services 61 72

Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 16 20
ME D1.1. The facility has established All equipment are covered under 2 SI/RR Agency/ ies identified for
system for maintenance of AMC including preventive maintenance for
critical Equipment maintenance equipments

. There is system of timely corrective 2 SI/RR

break down maintenance of the
equipments

. There has system to label 2 OB/RR

Defective/Out of order equipments
and stored appropriately until it
has been repaired

Staff is skilled for trouble shooting 0 SI/RR

in case equipment malfunction

Periodic cleaning, inspection and 2 SI/RR

maintenance of the equipments is
done by the operator
ME D1.2. The facility has established All the measuring equipments/ 2 OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment

. There is system to label/ code the 2 OB/ RR

equipment to indicate status of
calibration/ verification when
recalibration is due

. Blood storage has system to update 2 SI/RR Check for records

correction factor after calibration
wherever required

. Each lot of reagents has to be 0 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 Up to date instructions for 2 OB/SI

instructions are available with operation and maintenance of
the users of equipment equipments are readily available
with staff.

Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and 20 20
ME D2.1. There is established procedure There is established system patient
of care areas
2 SI/RR Stock level are daily
for forecasting and indenting timely indenting of consumables updated
drugs and consumables and reagents Requisition are timely
placed

ME D2.3 The facility ensures proper Reagents and consumables are 2 OB/RR
storage of drugs and kept away from water and sources
consumables of heat,
direct sunlight

Reagents are labelled appropriately 2 OB/RR Reagents label contain

name, concentration, date
of preparation/opening,
date of expiry, storage
conditions and warning

ME D2.4. The facility ensures Expiry dates' of the blood bags are 2 OB/RR
management of expiry and near maintained
expiry drugs
No expired blood is found in 2 OB/RR
storage

ME D2.5 The facility has established
procedure for inventory
management techniques
ME D2.6 There is a procedure for
periodically replenishing the drugs
in patient care areas
Records for expiry and near expiry 2 RR
blood are maintained
Department maintained stock and 2 SI/RR
expenditure register of reagents
There is no stock out of reagents 2 OB/SI

ME D2.7. There is process for storage of
vaccines and other drugs,
requiring controlled
temperature
Temperature of refrigerators used
for storing lab reagents are kept as
per storage requirement and
records are maintained
2 SI/RR Check for temperature
charts are maintained and
updated periodically for
refrigerators used storing
lab reagents

. Regular Defrosting is done 2 SI/RR

Standard D3. The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and 10 12
ME D3.2. Hospital infrastructure is comfortable
there is no seepage environment
, Cracks, to staff,
2 patients
OB and visitors.
adequately maintained chipping of plaster
Window panes , doors and other 2 OB
fixtures are intact
ME D3.3. Patient care areas are clean and Floors, walls, roof, sinks,are Clean 2 OB All area are clean with no
hygienic dirt,grease,littering and
cobwebs

Surface of furniture and fixtures are 2 OB

clean
ME D3.4. The facility has policy of No condemned/Junk material in 0 OB
removal of condemned junk blood storage
material
ME D3.6. The facility provides adequate Adequate illumination at blood 2 OB Illumination level of Blood
illumination level at patient care storage storage is as per
areas recommendation/
sufficient to carry out
Blood storage activities

Standard D4. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services 4 6
ME D4.1 The facility has adequate Availability of 24x7 running and norms 2 OB/SI
arrangement storage and supply potable water
for portable water in all
functional areas

ME D4.2. The facility ensures adequate Availability of power back up for 2 OB/SI
power backup in all patient care blood storage
areas as per load

Availability of UPS 0 OB/SI

Standard D8. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 3 6
ME D8.1. The facility has requisite Blood storage has obtained 1 RR
licences and certificates for approval from the State/UT
operation of hospital and licensing Authority.
different activities

Facility has obtained consent from 2 RR/SI

Parent blood bank.
Parent Blood Bank has valid 0 RR
license under Rule 122(G) Drug
and cosmetic act
Standard D9. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 8 8
ME D9.1. operating
The facility has established job Staff is aware of their role and procedures.
2 SI
description as per govt responsibilities
guidelines
ME D9.2. The facility has a established There is procedure to ensure that 2 RR/SI Check for system for
procedure for duty roster and staff is available on duty as per duty recording time of reporting
deputation to different roster and relieving (Attendance
departments register/ Biometrics etc)

There is designated in charge for 2 SI

department
ME D9.3. The facility ensures the Doctor, technician and support 2 OB
adherence to dress code as staff adhere to their respective
mandated by its dress code
administration / the health
department

. Area of Concern - E Clinical Services 42 52

Standard E3. Facility has defined and established procedures for continuity of care of patient and referral 2 4
ME E3.2. Facility provides appropriate There is procedure for referral 0 SI/RR
referral linkages to the of cases for which requested
patients/Services for transfer to blood group is not available
other/higher facilities to assure
their continuity of care.

. Facility has functional referral 2 SI/RR

linkages to parent blood bank

Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their 8 8
ME E8.5 storage2
Adequate form and formats are Standard Formats available RR/OB Format for requisition
available at point of use form, blood transfusion
reaction form, referral slip
ME E8.6. Register/records are maintained Blood storage records are labelled 2 RR
as per guidelines and indexed
. Records are maintained for Blood 2 RR Records includes daily
storage group wise 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 storage has facility
adequate storage and retrieval to store records for 5 year
of medical records
Standard E10. The facility has defined and established procedures for Emergency Services and Disaster Management
0 2
ME E10.3. The facility has disaster Blood storage has system of coping 0 SI/RR
management plan in place with extra demand of blood in case
of disaster

Standard E12 The facility has defined and established procedures for Blood storage Management and Transfusion. 32 38
ME 12.1 There is established procedure Blood storage has standardized 2 RR/SI
for Transport of blood from procedure for transporting blood
parent blood bank. from parent blood bank.

Cold chain is maintained at all 2 OB/SI During transportation

levels i.e. from parent blood bank
to blood storage to the issue of
blood.
blood is properly packed in
cold boxes surrounded by
ice packs. Ice should not
come in contact with blood
bags.
ME 12.2 There is established procedure Blood storage has standardized 0 RR/SI all the blood/component
for storage of blood procedure for receipt of blood from units are checked for
parent blood bank. haemolysis, turbidity, or
change in colour on receipt
from parent blood bank

Check for refrigerators or freezers 0 OB Lab reagents etc.

for blood storage are not used for
storing other items

Check for refrigerators used for 2 OB/RR Check records that

blood storage are kept at temperature is maintained
recommended temperature at 4OC + 2OC

Storage temperature is monitored 2 OB/RR Check the records

atleast twice a day.
Alarm system has been provided 0 RR/SI
with refrigerator
Shelf life of blood and components 2 RR/SI
is adhered as per NACO protocols

. Blood storage has system to trace 2 RR/SI Blood should be kept at

of unit of blood /component from 4oC to 6oC except if it is
source to final destination used for component
preparation it will be
stored at 22oC until
platelet are separated

ME E12.3. There is established procedure Determination of ABO group is 2 RR/SI Tube or Microplate or gel
for the Cross matching of blood done by recommended methods technology

Determination of Rh (D) Type done 2 RR/SI Check for the protocol/

as per recommended method Algorithm followed for
determining RH + or RH-
Blood type

Blood storage has system to testing 2 RR/SI Testing of recipient blood

and cross matching the recipient includes Determination
blood ABO type, Rh (D) type,
detection of unexpected
antibodies etc.
ME E12.4 There is established procedure Blood storage has system to testing 2 RR/SI Testing of blood includes
for issuing blood and cross matching the unit before Determination ABO type,
issuing Rh (D) type, detection of
unexpected antibodies etc.

. Blood storage has system to 2 RR/SI

confirm that information on
transfusion requisition form and
recipients blood sample label is
same

. Blood storage has system to retain 2 RR/SI

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

. Blood storage has system to issue 2 RR/SI

the blood along with cross
matching report

. Blood storage has procedure to 2 RR/SI

issue the blood in case of its
emergency requirement

ME E12.6 There is a established Transfusion reaction form is 2 RR/SI

procedure for monitoring and provided when blood is issued
reporting Transfusion
complication

. Blood storage has system of 2 RR/SI

detection, reporting and
evaluations of transfusion errors

. Area of Concern - F Infection Control 64 66

Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital 4 4
ME F1.4. There is Provision of Periodic There is procedure for associated infection
2 SI/RR Hepatitis B, Tetanus Toxid
Medical Checkups and immunization of the staff etc
immunization of staff
.ME F1.5. Facility has established Regular monitoring of infection 2 SI/RR Hand washing and
procedures for regular control practices infection control audits
monitoring of infection control done at periodic intervals
practices

Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 14 14
ME F2.1. Hand washing facilities are Availability of hand washing Facility 2 OB Check for availability of
provided at point of use at Point of Use wash basin near the point
of use
. Availability of running Water 2 OB/SI Ask to Open the tap. Ask
Staff water supply is
regular

. Availability of antiseptic soap with 2 OB/SI Check for availability/ Ask

soap dish/ liquid antiseptic with staff if the supply is
dispenser. adequate and
uninterrupted

Display of Hand washing Instruction 2 OB Prominently displayed

at Point of Use above the hand washing
facility , preferably in Local
language

Hand washing sink is wide and 2 OB

deep enough to prevent splashing
and retention of water

ME F2.2. Staff is trained and adhere to Adherence to 6 steps of Hand 2 SI/OB Ask of demonstration
standard hand washing washing
practices
. Staff aware of when to hand wash 2 SI

Standard F3. Facility ensures standard practices and materials for Personal protection 4 4
ME F3.1. Facility ensures adequate Clean gloves are available at point 2 OB/SI All personal use gloves
personal protection equipments of use while drawing sample,
as per requirements examining and disposable
of the samples

. Availability of lab aprons/coats 2 OB/SI

Standard F4. Facility has standard Procedures for processing of equipments and instruments 10 10
ME F4.1. Facility ensures standard practices Proper Decontamination of 2 SI/OB Decontamination of
and materials for decontamination instruments after use instruments and reusable
and cleaning of instruments and of glassware are done after
procedures areas procedure in 1% chlorine
solution/ any other
appropriate method

. Contact time for decontamination 2 SI/OB 10 minutes

is adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with
decontamination detergent and running
water after
decontamination
 Staff know how to make chlorine 2 SI/OB
solution
ME F4.2. Facility ensures standard practices Disinfection of reusable glassware 2 SI/OB Disinfection by hot air
and materials for disinfection and oven at 160 oC for 1 hour
sterilization of instruments and
equipments

Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention 6 6
ME F5.3. Facility ensures standard practices Staff is trained for spill 2 SI/RR
followed for cleaning and management
disinfection of patient care areas

Staff is trained for preparing 2 SI/RR

cleaning solution as per standard
procedure

Standard practice of mopping and 2 OB/SI Unidirectional mopping

scrubbing are followed from inside out
Standard F6. Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical 26 28
ME F6.1. Facility Ensures segregation of and
Availability of colour coded hazardous
bins at 2Waste. OB
Bio Medical Waste as per point of waste generation
guidelines
. 2 OB
Availability of Non chlorinated
plastic colour coded plastic bags
. 2 OB/SI
Segregation of Anatomical and
solied waste in Yellow Bin
. 2 OB
Segregation of infected plastic
waste in red bin
Display of work instructions for 2 OB
segregation and handling of
Biomedical waste

There is no mixing of infectious and 2

general waste
ME F6.2. Facility ensures management of Availability of functional Hub 0 OB See if it has been used or
sharps as per guidelines cutters just lying idle
. Availability of puncture proof box 2 OB

Should be available nears

the point of generation like
nursing station and
injection room
. Availability of white translucent 2 OB Check for Puncture proof,
bins for waste Sharps tamper proof and leak
proof containers

. Availability of Blue bins for 2 OB Check for Puncture proof

Galssware and leak proof boxes with
blue colored marking

Availability of post exposure 2 OB/SI

prophylaxis Ask if available. Where it is
stored and who is in
charge of that.
ME F6.3. Facility ensures transportation Check bins are not overfilled 2 SI/OB
and disposal of waste as per
guidelines
. Transportation of bio medical 2 SI/OB
waste is done in close
container/trolley

. Staff aware of mercury spill 2 SI

management
. Area of Concern - G Quality Management 48 50
Standard G2 Facility has established system for patient and employee satisfaction 0 2
ME G2.1 Patient Satisfaction surveys are There is system to take feed back 0 RR
conducted at periodic intervals from clinician about quality of
services

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 Internal Quality assurance program 2 SI/RR
quality assurance program at is in place
relevant departments

. Standards are run at defined 2 SI/RR

interval
ME G3.3. Facility has established system Departmental checklist are used 2 SI/RR
for use of check lists in different for monitoring and quality
departments and services assurance

. Staff is designated for filling and 2 SI

monitoring of these checklists

Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key 24 24
ME G4.1. Departmental standard processes.2
Standard operating procedure for RR
operating procedures are department has been prepared and
available approved
. Current version of SOP are 2 OB/RR
available with process owner
ME G4.2. Standard Operating Procedures Blood storage has documented 2 RR
adequately describes process procedure for Transport of
and procedures Blood/components from parent
blood bank.

. Blood storage has documented 2 RR

procedure for receipt and storage
of blood/components

. Blood storage has documented 2 RR

procedure for issue of blood for
transfusion

. Blood storage has documented 2 RR

procedure for issue of blood in case
of urgent requirement

. Blood storage has documented 2 RR

procedure to address the
transfusion reactions

. Blood storage has documents 2 RR

procedure for calibration and
maintenance of equipment

. Blood storage has documented 2 RR

procedure for HAI and disposal of
BMW

. Blood storage has documented 2 RR

system for storage, retaining and
retrieval of records, and reports of
results.

ME G4.3. Staff is trained and aware of the Check staff is a aware of relevant 2 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4. Work instructions are displayed Work instruction/clinical protocols 2 OB work instruction for
at Point of use are displayed screening of blood, storage
of blood, maintaining
blood and component in
event of power failure

Standard G5. The facility has established system of periodic review as internal assessment , medical & death audit and 8 8
ME G5.1. The facility conducts periodic Internal assessment is done prescription
at audit
2 RR/SI
internal assessment periodic interval
ME G5.3. The facility ensures non Non Compliance are enumerated 2 RR/SI
compliances are enumerated and recorded
and recorded adequately
ME G5.4. Action plan is made on the gaps Action plan prepared 2 RR/SI
found in the assessment / audit
process
ME G5.5. Corrective and preventive Corrective and preventive action 2 RR/SI
actions are taken to address taken
issues, observed in the
assessment & audit

Standard G6. The facility has defined and established Quality Policy & Quality Objectives 8 8
ME G6.2. The facility periodically defines Quality objectives for Blood storage 2 RR/SI
its quality objectives and key are defined
departments have their own
objectives

ME G6.3. Quality policy and objectives are Check if staff is aware of quality 2 SI
disseminated and staff is aware policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored 2 SI/RR
objectives is monitored and reviewed periodically
periodically
Control charts 2 SI/RR
. Area of Concern - H Outcome 24 24
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
6 6
ME H1.1. Facility measures productivity No. of Blood unit issued per 2 RR No. of Unit issued X1000/
Indicators on monthly basis thousand population Population of serving area

Proportions of requests refused by 2 number of units

parent blood bank. received/Total number of
requistion made to parent
blood bank.

ME H1.2. The Facility measures equity No of blood units issued free of 2 RR JSSK, Thalassemia , BPL
indicators periodically cost
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
4 4
ME H2.1. Facility measures efficiency Downtime of critical equipments 2 RR Time period for which
Indicators on monthly basis equipment was out of
order/Total no of working
hours for equipments

. % of Blood Units discarded 2 RR No of unit discarded *100/

Total no of unit received.

Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 8 8
ME H3.1. Facility measures Clinical Care & Blood transfusion reaction rate 2 RR No of Blood Transfusion
Safety Indicators on monthly basis reactions 1000/ No of
patient blood issued

. Propotion of Adverse events 2 RR Chemical splash, Needle

identified and reported stick injuries. Major blood
transfusion reaction,
wrong cross matching,
wrong blood issue

. Cross matched/ Transfused Ratio 2 RR No of unit are cross

matched on request/ No of
unit actually transfused

. % of single unit transfusion 2 RR % of single use

transfusionX 100/ Total no
of units transfused

Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 6 6
ME H4.1. Facility measures Service Quality Time gap between issuing and 2 RR
Indicators on monthly basis requisition of blood in routine
conditions

. Time gap between issuing and 2 RR

requisition of blood in emergency
conditions

. No of refusal cases 2 RR No of requisition refused/

referred due to non
availability of blood group
or any other reason

Blood storage Unit Score

Card
Blood storage
Score 91.566265
Area of Concern wise Score
A Service Provision 80
B Patient Rights 100
C Inputs 97.6190476190476
D Support Services 84.7222222222222
E Clinical Services 80.7692307692308
F Infection Control 96.969696969697
G Quality Management 96
H Outcome 100

Obtained Maximum Percent 10

A 8 10 80
B 16 16 100
C 41 42 97.61904761905
D 61 72 84.72222222222
E 42 52 80.76923076923
F 64 66 96.9696969697
G 48 50 96
H 24 24 100
Total 304 332 91.56626506024
 National Quality Assurance Standards for Taluka Hospital
Checklist for Auxillary Services 11
Reference no Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
Area of Concern - A Service Provision 12 14
Standard A5 Facility provides support services
12 14
ME A5.1 The facility provides dietary Availability of functional Kitchen 2 SI/OB Arrangement of Kitchen
services services services inhouse or outsourced

ME A5.2 The facility provides laundry Availability of functional laundry 2 SI/OB Arrangement of laundry
services services services inhouse or outsourced

ME A5.3 The facility provides security Availability of functional security 2 SI/OB In-house or outsourced, At
services services 24 X7 least one guard per shift
ME A5.4. The facility provides Availability of Housekeeping 2 SI/OB In-house or outsourced, At
housekeeping servic es services 24X7 least 3 in morning shift & 2
each in morning & evening shift

Availability of waste disposal 2 SI/OB Arrangement f or disposal of

services Bio medical and general waste
Inhouse or outsouced

A
ME A5.5 The facility ensures maintenance Availability of maintenance 2 SI/OB Includes Physical infrastructure
services services maintenance and equipment
maintenance

ME A5.7 The facility has services for Availability of dedicated space for 0 SI/OB
medical records storing Medical records

Area of Concern - B Patient Rights 6 8

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 0 2
ME B1.8 The facility ensures access to Medical records are provided to 0 RR/OB
clinical records of patients to patient/ Next to kin on request as
enti tled personnel per state guideline

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 2 2
ME B3.2 Confidentiality of patients The facility has a system to 2 SI/RR Patient records are not shared
records and clinical information maintain Confidentiality of patient except the patient until it is
is maintained records authorized by law

Standard B5 Facility ensure s that there are no fina ncial barrie r to acces s and tha t there is financial protection given from cost of 4 4
ME B5.1 The facility provides cashless Availability of free diet hos pital s2ervices.PI/SI
services to pregnant women,
mothers and neonates as per
prevalent government schemes

ME B5.4 The facility provide free of cost Free diet is provided to BPL 2 PI/SI
treatment to Below poverty line patients and JSSK beneficiaries
patients without administrativ e
hassles

Area of Concern - C Inputs 40 64

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 4 12
ME C1.1 Departments hav e adequate The kitchen has adequate space 2 OB
space as per patient or work as per requirement
load
The Laundry Department has 0 OB
adequate space as per
requirement
The Medical record Department 0 OB
has adequate space as per
requirement
ME C1.3 Departments hav e layout and Check if Kitchen has demarcated 2 OB Layout as per functional flow
demarcated areas as per area for various activities that is receipt, storage,
functions preparation & Cooking
area ,Service area, dish
washing area, Garbage
collection area and
administrative area.Minimum
space requirement 10sq ft/bed

Check laundry department has 0 OB Layout as per functional flow

demarcated and dedicated area that is from dirty end (receipt)
for its various activities to clean end (Issue). That is
receipt, sorting, sluicing,
washing, drying, ironing and
issue

ME C1.5 The facility has infrastructure f or All support services department 0 OB

intramural and extramural are connected with intercom/
communication CUG services

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 16 18
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and f urniture
saf ety of the infrastructure properly secured like cupboards, cabinets, and
heavy equipments , hanging
objects are properly fastened
and secured

ME C2.2 The facility ensures saf ety of Support services departments do 2 OB

electrical establishment not have temporary connections
and loose hanging wires

Equipment in wet areas like 2 OB

Laundry and Kitchen are equipped
with ground fault protection and
designed for wet conditions

ME C2.3 Physical condition of buildings Floors of the Support services are 0 OB

are safe for providing patient
care
ME C2.4 The facility has plan for
prevention of fire
non slippery and even
Surface of Kitchen flor is not 2
chipped
Dietary Department has plan for 2 OB Dietary Department
saf e storage and handling of
potentially flammable materials.

ME C2.5. The facility has adequate fire Support services has installed fire 2 OB/RR dietary department and
fighting Equipment Extinguisher for A, B, C type of fire Medical record department

Check the expiry date on fire 2 OB/RR dietary department and

extinguishers are displayed on Medical record department
each extinguisher as well as due
date for next refilling is clearly
mentioned

ME C2.6. The facility has a system of
periodic training of staff and
conducts mock drills regularly
for fire and other disaster
situation
Check for staff competencies for 2 SI/RR
operating fire extinguisher and
what to do in case of fire

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 10 16
ME C3.5 The facility has adequate Availability of washer man 2 SI/RR
support / general staff
Availability of Cook 2 SI/RR
Availability of Data Entry operator 0 SI/RR Trained Hospital staff
trained in medical records (RC/SN/Pharmacist/DEO)
management.
ME C3.6 The staff has been provided Infection Control Management 2 SI/RR
required training / sk ill sets
Cleaning Practices 2 SI/RR
Training on Medical record 0 SI/RR
Management
ME C3.7 The Staff is sk illed as per job MRD Staff is skilled for indexing 0 SI/RR
description and storage of Medical records

Laundry staff is skilled for 2 SI/RR

segregating and processing of
soiled and infectious linen
Standard C4 Facility provides drugs and consumables required for assured list of services. 4 4
ME C4.2 The departments hav e adequate Availability of consumables in 2 OB/RR Cap, gowns, gloves, Detergent
consumables at point of use dietary department for cleaning of utensil and Soap
for hand washing

Availability of consumables in 2 OB/RR Detergent and disinfectant,

laundry department starch, Blue, bleach, Heavy
utility gloves, apron.
Standard C5 The facility has equipment & instruments required for assured list of services. 6 14
ME C5.6 Availability of f unctional Availability of Equipment & 2 OB Refrigerator, LPG, food trolley
equipment and instruments f or utensils for Dietary department and cooking utensils
support servic es
Availability of Equipment for 0 OB Laundary equipments,
Laundry Separate trolley f or clean and
dirty linen and soiled/infected
linen

Availability of Equipment for 0 OB Computer with scanner

Medical record department
Availability of equipment for 2 OB Buckets for mopping, mops,
cleaning duster, waste trolley, Deck
brush
ME C5.7 Departments hav e patient Availability of furniture and 2 OB Exhaust fan, Storage
furniture and fix tures as per load fixtures for Dietary department containers, Work bench/slab,
and service provision Utensil stand

Availability of furniture and 0 OB Stand/ Hanger for drying of

fixtures for Laundry department linen, Iron table, Cupboard

Availability of furniture and 0 OB Racks and cupboard, table,

fixtures for Medical record Sectional Drawer cabinet/
department Shelves,
Area of Concern - D Support Services 70 84
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 All equipment are covered under 2 SI/RR
system f or maintenance of AMC including preventive
critical Equipment maintenance

There is system of timely 2 SI/RR

corrective break down
maintenance of the equipment

ME D1.3 Operating and maintenance Up to date instructions for 2 OB/SI

instructions are available with operation and maintenance of
the users of equipment equipment are readily available
with staff.

Standard D3 The fa cility has esta blis hed Program for ma intenance and upkeep of the faciity to provide safe, s ecure and comfortable 18 22
ME D3.2 Hospital infrastructure is environme
Check that there nt ,to s taff, pa
is no seepage 0 tientsOB
a nd vis itors . Dietary department, laundry
adequately maintained Cracks, chipping of plaster and medical record
department
Window panes , doors and other 0 OB Dietary department, laundry
fixtures are intact and medical record
department
ME D3.3 Patient care areas are c lean and Floors, walls, roof, rooftops, sinks 2 OB All area are clean with no
hygienic patient care and circulation areas dirt,grease,littering and
are Clean cobwebs
Surface of furniture and fixtures 2 OB
are clean
ME D3.4 The facility has policy of remov al No condemned/Junk material is 2 OB Dietary department, laundry
of condemned junk material found in any of the department and medical record
department

ME D3.5 The facility has established No stray 2 OB Dietary department, laundry

procedures for pest, rodent and animal/rodent/birds/pests and medical record
animal c ontrol department

Kitchen is rodent & pet proof 2 OB/SI

ME D3.8 The facility ensures saf e and Temperature control and 2 SI/RR Fans/Coolers/Exhaust/Vents/
comfortable environment for ventilation in dietary department heaters as per environment
patients and service prov iders condition and requirement

Temperature control and 2 SI/RR Fans/Coolers/Exhaust/Vents/

ventilation in Laundry heaters as per environment
condition and requirement

Temperature control and 2 SI/RR Fans/Coolers/Exhaust/Vents/

ventilation in Medical record heaters as per environment
Department condition and requirement

ME D3.10 The facility has established Check female staff feels secure at 2 SI
measure for safety and security of work place
female staff
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.1 The facility has adequate Availability of 24x7 running and 2 OB/SI Dietary and laundry
arrangement storage and supply potable water department
for portable water in all
functional areas

ME D4.2 The facility ensures adequate Availability of power back up 0 OB/SI For Laundry, Diet and MRD
power backup in all patient care department
areas as per load
StandardD5 The facility ensures avaialblity of Diet as per neutritional requirement of the patients and clean Linen to all admitted patients. 36 44
ME D5.2 The facility provides diets The facility has defined diet 1 RR/SI
according to nutritional schedule & menu for the
requirements of the patients patients.
The facility has Special diet 1 RR/SI Normal diet, Liquid diet, Semi-
schedule f or patients suffering solid diet, diabetic diet, Low
from Heart Disease, salt, Low fat diet
Hypertension, Diabetes,
Pregnant Women, diarrhoea
and renal patients

ME D5.3 Hospital has standard procedures Dietary department has system to 2 RR/SI
for preparation, handling, storage calculate the number of diets to
and distribution of diets, as per be prepared
requirement of patients

Dietary department has 2 OB/SI/RR Time interval for procurement

procedure for procurement of of Perishable and non
perishable and non perishable perishable items is fixed
items

Perishable items are stored at 2 OB Like milk, cheese, butter, egg,

cold temeperature vegetables, and fruits
Non perishable items are kept in 0 OB All the food items are stored
racks/ storage container, in above floor level.
ventilated and rodent proof room

Food is prepared by trained staff, 2 OB/SI

ensuring standard practices

Distribution of the f ood is done in 2 OB

covered trolleys
Dietary department has system to 2 RR/SI There is designated person
check the quality of food provided preferably nurse in Ward to
to patient check the Quality of food
Dietary department has 2 OB/SI
procedure to collect and dispose
of kitchen garbage at defined
interv al and place

Department maintain stock and 2 RR/SI

expenditure register in Kitchen

ME D5.4 The facility has adequate sets of The facility has sufficient set of 2 RR/SI at least 5 sets for each
linen linen available per bed functional bed
ME D5.6 The facility has standard There is a system for Periodic 2 RR/SI To check the theft and
procedures for handling , physical verification of linen pilferage
collection, transportation and inventory
washing of linen

Separate trolley/Heavy duty bags 0 OB

are used for collection and
distribution of clean and dirty
linen

Infectious linen are transported 0 OB/RR

into separate containers / bags

There is a system of sorting of 2 OB/RR Soiled, infected fouled type of

different category of linen before linen
putting in to washing machine

The linen department has 2 OB/RR

procedure for sluicing of soiled
&infected linen
Linen department has procedure 2 RR
to keep record of daily load
received from each department

Hospital has a designated person 2 RR/SI

to check quality of washed linen

There is a system for verifying the 2 RR/SI

quantity of linen received
There is procedure for 2 RR/SI
condemnation of linen
There is system to check pilf erage 2 RR/SI Security guards keep vigil
of linen from ward
Standard D9 Roles & Responsibilities of adminis trative and cli nical staff are determined as per govt. regula tions and standards 6 6
ME D9.1 The facility has established job The staff is aware of theiroperating
roles procedures
2 SI .
description as per govt and responsibilities
guidelines
ME D9.2 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 diff erent duty roster (Attendance register/
departments Biometrics etc)

ME D9.3 The facility ensures the Staff is adhere to their respective 2 OB

adherence to dress code as dress code
mandated by its administration /
the health department

Standard D10 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
2 2
ME D10.1 There is established system for There is procedure to monitor 2 SI/RR Verification of outsourced
contract management for out the quality and adequacy of services (cleaning/
sourced services outsourced services on regular Dietary/Laundry/S ecurity/Main
basis tenance) provided are done by
designated in-house staff

Area of Concern - E Clinical Services 17 28

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 13 24
ME E8.6 Register/records are maintained Diet Registers are maintained at 2 RR
as per guidelines Kitchen
Laundry registers are maintained 2 RR
at laundry
ME E8.7 The facility ensures saf e and Hospital has procedure for 0 RR
adequate storage and retrieval collection, Compilation and
of medical rec ords maintenance of patient's records
after discharge

Thre is a system to check 0 RR Checking the records as per

completion of records checklist for completion
There is a system for indexing/ICD 0 RR As per ICD coding / indexing
coding the records name, disease, diagnosis,
physician and surgical
procedure carried out

Medical record department has 0 RR Submitting the reports to

system to generate statistics for required health authorities
clinical and administrative use (Birth death notification,
notification of communicable
diseases etc),

There is a system for safe storage 1 RR

of records
Medical record department has 1 RR Retention is as per state
procedure for guideline
retention/Preservation of records

Medical record department has 1 RR

procedure for destruction of old
records
Medical record department has 2 RR/SI
system for retrieval of records

Medical record department has 2 RR/SI In case of MLC

procedure for production of
records in Courts of law when
summoned

Medical records are issued to 2 RR/SI To patient/next kin to patient

authorized personnel only
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management
4 4
ME E10.3 The facility has disaster The Staff is aware of disaster plan 2 SI/RR Kitchen and Laundry
management plan in place
Roles and responsibilities of staff 2 SI/RR Kitchen and Laundry
in disaster is defined
Area of Concern - F Infection Control 36 36
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 4 4
ME F1.4 There is Provision of Periodic There is procedure for 2 SI/RR Hepatitis B, Tetanus Toxid etc
Medical Check ups and immunization of the staff
immunization of staff
Periodic medical checkups of the 2 SI/RR
staff with f ood handlers
undergoing investigations, as
required

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 8 8
ME F2.1 Hand washing fac ilities are Availability of the hand washing 2 OB Preferably in preparation and
provided at point of use Facility in kitchen cooking area
Availability of Running Water (Hot 2 OB/SI Ask to Open the tap. Ask Staff
and cold) water supply is regular

Availability of soap with soap 2 OB/SI Check for availability/ Ask staff
dish/ liquid antiseptic with if the supply is adequate and
dispenser uninterrupted

Display of Hand washing the 2 OB Prominently displayed above

Instructions at Point of Use the hand washing facility ,
preferably in Local language

Standard F3 Facility ensures standard practices and materials for Personal protection 12 12
ME F3.1 Facility ensures adequate Clean gloves are available for 2 OB/SI
personal protection equipments distribution of food
as per requirements

Availability of apron 2 OB/SI

Availability of caps 2 OB/SI
Availability of Heavy duty gloves 2 OB/SI
for laundry
Availability of gum boots for 2 OB/SI
laundry
ME F3.2 Staff adheres to standard No reuse of disposable gloves, 2 OB/SI
personal protection practices caps and aprons.
Standard F4 Facility has standard Procedures for processing of equipments and instruments 12 12
ME F4.1 Facility ensures standard practices Cleaning and decontamination of 2 SI/OB Ask the cleanliness and ask
and materials for decontamination food preparation surfaces like staff how frequent they clean it
and cleaning of instruments and cutting board
procedure areas

Cleaning of utensils and food 2 SI/OB Check the cleanliness and how
trolleys frequent they clean it
Decontamination of heavily soiled 2 SI/OB
linen
Cleaning of washing equipment 2 SI/OB

Floors are clean 2 OB

No stray animals in the facility/ 2 OB
Patient Care areas
Area of Concern - G Quality Management 80 96
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 There is system daily round by 2 SI/RR
quality assurance program in matron/hospital manager/
relevant departments hospital superintendent/ Hospital
Manager/ Matron in charge for
monitoring of services

ME G3.2 Facility has established ex ternal Kitchen is has system of regular 2 SI/RR
assurance programs at relev ant external inspection by Municipal/
departments FDA authorities

ME G3.3 Facility has established system Departmental checklist is used 2 SI/RR

for use of check lists in different for monitoring and quality
departments and services assurance

The staff is designated for 2 SI

filling and monitoring of these
check lists
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 58 66
ME G4.1 Departmental standard Standard operating procedure f or 2 RR
operating procedures are Dietary department has been
available prepared and approved

Current version of SOP are 2 OB/RR

available with process owner
Standard operating procedure f or 2 RR
Laundry Department has been
prepared and approved
Current version of SOP are 2 OB/RR
available with process owner
Standard operating procedure f or 2 RR
Medical record Department has
been prepared and approved

Current version of SOP are 2 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures Record Department has 0 RR
adequately describes process documented procedure for
and procedures receiving, compiling, and
maintaining records

Record Department has 0 RR

documented procedure for
issuing of the records
Record Department has 0 RR
documented procedure for
retention of records
Record department has 2 RR
documented procedure for pest
and rodent control
Diet department has documented 2 RR
procedure for diet schedule

Diet department has documented 2 RR

procedure for calculation of diet
required in wards

Diet department has documented 2 RR

procedure for procurement of
food items
Diet department has documented 2 RR
procedure for preparation and
distribution of food

Diet department has documented 2 RR

procedure to check the quality of
food provided to the patient

Diet department has documented 2 RR

procedure for cleaning of kitchen
and utensils

Department has documented 2 RR

procedure for checkups of kitchen
workers, MRD Staff, Laoudary
Staff, housekeeoing staff and
security staff at defined intervals

Linen department has 2 RR

documented procedure for
collection, sorting and cleaning of
linen

Linen department has 2 RR

documented procedure for
sluicing of the blood/ body fluid
stained linen

Linen department has 2 RR

documented procedure for
distribution of linen in all patient
care area

Linen department has 2 RR

documented procedure for
condemnation of linen
Linen department has 2 RR
documented procedure corrective
and preventive maintenance of
laundry equipments

Security department has 2 RR

documented procedure for duty
hours
Security department has 2 RR
documented procedure for
control of incoming and outgoing
items

Security department has 2 RR

documented procedure for
visiting hours in patient care area

Security department has 2 RR

documented procedure for fire
saf ety in hospital
Security department has 2 RR
documented procedure for
electrical safety
Security department has 2 RR
documented procedure for
training and drills of security staff

ME G4.3 Staff is trained and aware of the Check if staff is a aware of 2 SI/RR
standard procedures written in relevant part of SOPs
SOPs
ME G4.4 W ork instructions are displayed Work instructios are displayed in 2 OB
at Point of use Dietary Department

Work instructions are displayed in 2 OB

Laundry Department

Work instructions are displayed 0 OB

in Medical Record Department

Work instructions are displayed 2 OB

for hospital cleaniness

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 4 12
ME G5.1 The facility conducts periodic Internal assessment is done at 2 RR/SI Dietary department, laundry
internal assessment periodic interval and medical record
department
ME G5.2 The facility conducts the Storage and compilation of 0 RR/SI
periodic prescription/ records medical audit
medical/death audits
Storage and compilation of 0 RR/SI
records of death audit
ME G5.3 The facility ensures non Non Compliances are 2 RR/SI
compliances are enumerated enumerated and recorded
and recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 0 RR/SI
found in the assessment / audit
process
ME G5.5 Correctiv e and prev entive Corrective and preventive action 0 RR/SI
actions are taken to address taken
issues, observed in the
assessment & audit

Standards G6 The facility has defined and established Quality Policy & Quality Objectives
4 4
ME G6.3 Quality policy and objectives are Check if staff is aware of quality 2 SI
disseminated and staff is aw are policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored 2 SI/RR
objectives is monitored and reviewed periodically
periodically
Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 6 6
ME G7.1 Facility uses method for quality PDCA 2 SI/RR
improvement in services

5S 2 SI/OB
ME G7.2 Facility uses tools for quality Any 2 basic tools of Quality 2 SI/RR
improvement in services
Area of Concern - H Outcome 20 26
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 8
ME H1.1 Facility measures productivity No of cases for which medical 0 RR
Indicators on monthly basis audit done
No of cases for which death audit 0 RR
has done
Linen Index 2 RR No. of bed sheet washed in a
month/Patient bed days in
month
Diet Index 2 RR No. of meals provided in the
month/no. of times meal
served in a day * bed days

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Proportion of maternal deaths
Indicators on monthly basis audited
Proportion of newborn deaths
audited
Cycle time for laundry services
Proportion of special diets
8 8
2 RR
2 RR
2 RR Time elapsed between
collection of used linen and
receiving clean linen
2 RR No. of special diets (Liquid,
Semi-solid, Diabetic, Low salt,
low fat diet or other diet) in the
month*100/tital no. of diets
provided in the month

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 2 4
ME H3.1 Facility measures Clinical Care & Medical Audit Score 0 RR
Safety Indicators on monthly basis

Death Audit Score 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 Waiting time for getting handicap 2 RR
Indicators on monthly basis certificate

Patient f eedback on cleanliness of 2 RR

linen
Patient f eedback on quality of 2 RR
food

Auxiliary Services Card

Auxiliary
Services Score
78.93258

Area of Concern wise Score

A Service Provision 85.7142857142857
B Patient Rights 75
C Inputs 62.5
D Support Services 83.3333333333333
E Clinical Services 60.7142857142857
F Infection Control 100
G Quality Management 83.3333333333333
H Outcome 76.9230769230769

Obtained Maximum Percent 11

A 12 14 85.71428571
B 6 8 75
C 40 64 62.5
D 70 84 83.33333333
E 17 28 60.71428571
F 36 36 100
G 80 96 83.33333333
H 20 26 76.92307692
Total 281 356 78.93258427
Checklist - 9 Post Partum Unit Version- NHSRC 3.0

National Quality Assurance Standards for Taluka Hospital

Checklist for Post Partum Unit 12
Checklist for Post Partum Unit
Reference No ME Statement Checkpoint Complian Assessment Means of Verification Remarks
ce Method

Area of Concern - A Service Provision 28 28

4 4
Standard A1 Facility Provides Curative Services
ME A1.9 Services are available for the time At least 6 hours of OPD services 2 SI/RR
period as mandated are available at Family Planning
Clinic

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

Standard A2 Facility provides RMNCHA Services 22 22

ME A2.1 The facility provides Reproductive 2 SI/OB
health Services Availability of Spacing methods
of family planning IUCD, OCP, ECP & Condoms
2 SI/OB
Availability of Female Limiting Tubectomy (Minilap and
Methods of family Planning Laparoscopic)
2 SI/OB
Availability of Male Limiting
Method for Family Planning NSV/Conventional
2 SI/OB Tubal Ligation and PPIUD
Availability of Post partum
sterilization services
2 SI/OB
Availability of Family Planning
Counselling and Promotive
services Counselling and IEC
2 SI/OB As per MTP Act
Abortion and Contraception
services for Ist and 2nd trimester
2 SI/OB Dedicated postpartum beds for FP
surgeries and abortion clients
Dedeicated Postpartum beds
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

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ME A2.5 The facility provides Adolescent 2 SI/OB

Availability of Abortion services
health Services for adolescent
2 SI/OB
Availability of Contraception
services
Standard A3 Facility Provides diagnostic Services 2 2
ME A3.2 The facility Provides Laboratory Availability of point of care 2 SI/OB For sterilization surgeries, availability
Services diagnostic test of haemoglobin, urine analysis for
sugar
and albumin

Area of Concern - B Patient Rights 64 68

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
friendly signage system
ME B1.2 The facility displays the services
and entitlements available in its
departments
ME B1.5
Patients & visitors are sensitised
and educated through
appropriate IEC / BCC approaches
ME B1.6
Information is available in local available in local language
language and easy to understand
16 18
0 OB
(Numbering, main department and
signage's internal sectional signage
Restricted area signage are 2 OB
displayed
2 OB
List of Family Planning Services
available
2 OB
Compensation for family
planning indemnity scheme
2 OB
Compensation for family
planning services are displayed
2 OB
Family planning insurance
scheme displayed
2 OB
IEC materials such as posters,
banners, and handbills
IEC Material regarding family available at the site and displayed
planning displayed
Education material for 2 OB
counselling are available in Flip charts, models, specimens, and
Counselling room samples of
contraceptives available
Signage's and information are 2 OB

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10 10
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
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
Access to facility is provided
without any physical barrier & Availability of Wheel chair or
and friendly to people with stretcher for easy Access to the
disabilities OT
2 OB
Availability of ramps with railing
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 Adequate visual privacy is 2 OB
Availability of screens at IUD
provided at every point of care insertion room
2 OB
Availability of screens at family
planning OT
2 OB
Patients are properly
draped/covered before and after
produce
2 OB
Privacy at the counselling room
is maintained
ME B3.2 Confidentiality of patients records 2 SI/OB
and clinical information is Patient Records are kept at
secure place beyond access to
maintained general staff/visitors
2 SI/OB
No information regarding patient
identity and details are
unnecessary displayed
ME B3.3 Behaviour of staff is empathetic 2 PI/OB
The facility ensures the and courteous
behaviours of staff is dignified
and respectful, while delivering
the services

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ME B3.4
The facility ensures privacy and
confidentiality to every patient,
especially of those conditions
having social stigma, and also
safeguards vulnerable groups
Confidentiality of Abortion cases 2
SI/OB No entry shall be made in any case
sheet , PT register , follow-up card or
any other document, register
indicating there in the name of the
pregnant women . Only reference
serial no. is mentioned on all the
document

Standard B4
Facility has defined and established procedures for informing Patient about medical condition, and involving them in treatment 12 14
planning, and facilitates informed decision making
ME B4.1 2 SI/RR
There is established procedures
for taking informed consent
before treatment and procedures Informed consent for IUD
insertion
2 SI/RR
Informed consent for family
planning surgeries
2 SI/RR
Informed consent on prescribed
form C for abortion
ME B4.2 0 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

ME B4.5 The facility has defined and 2 OB

established grievance redressal
system in place
Standard B5
Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital
ME B5.1
The facility provides cashless
services to pregnant women,
mothers and neonates as per
prevalent government schemes
Availability of complaint box and
display of process for grievance
re addressal and whom to
contact is displayed
10 10
services
2 PI/SI
Drugs, consumables and
contraceptives are available free
2 PI/SI

All surgical procedure for family

planning are free of cost
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ME B5.2 Check that patient party has not 2 PI/SI

The facility ensures that drugs spent on purchasing drugs or
prescribed are available at consumables from outside.
Pharmacy and wards

ME B5.3 Check that patient party has not 2 PI/SI Provision of diagnostic in
It is ensured that facilities for the spent on diagnostics from
outside.
empanneled Government or private
diagnostic center under CMCHIS.
prescribed investigations are
available at the facility

ME B5.5 Timely payment of family 2 PI/SI/RR

The facility ensures timely planning compensation
reimbursement of financial
entitlements and reimbursement
to the patients
Area of Concern - C Inputs 146 152

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 44 46
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 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 drinking water 2 OB
Availability of seating 2 OB
arrangement
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
2 OB
Availability of earmarked area
for newborn Corner

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2 OB
Availability of Post Operative
Room
Availability of Scrub Area 2 OB
2 OB
Availability of Autoclave room/
TSSU/CSSD
2 OB
Availability of dirty utility area
Availability of store 2 OB
2 OB
Availability of dedicated
counselling area
2 OB
Availability of examination cum
minor procedure area for IUD
insertion
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

ME C1.5 The facility has infrastructure for 0 OB

intramural and extramural
communication
ME C1.6 Service counters are available as
per patient load
ME C1.7 The facility and departments are
planned to ensure structure
follows the function/processes
(Structure commensurate with
the function of the hospital)
Standard C2 The facility ensures the physical safety including fire safety of the infrastructure.
ME C2.1 The facility ensures the seismic
safety of the infrastructure
Availability of functional
telephone and Intercom
Services/CUG Services
2 OB
OT tables are available as per
load
2 OB
Unidirectional flow of goods and
services
20 20
Non structural components are 2 OB Check for fixtures and furniture like
properly secured cupboards, cabinets, and heavy
equipments , hanging objects are
properly fastened and secured

ME C2.2 The facility ensures safety of 2 OB

electrical establishment OT does not have temporary
connections and loosely hanging
wires

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ME C2.3 Physical condition of buildings are 2 OB

safe for providing patient care
ME C2.4 The facility has plan for
prevention of fire
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 if any in the OT are
intact and sealed
OT has sufficient fire exit to 2 OB/SI
permit safe escape to its
occupant at time of fire
2 OB
Check the fire exits are clearly
visible and routes to reach exit
are clearly marked.

ME C2.5 The facility has adequate fire
fighting Equipment
ME C2.6 The facility has a system of
periodic training of staff and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation
PP unit has installed fire 2 OB
Extinguisher that is Class A ,
Class BC type or ABC type
2 OB/RR
Check the expiry date for fire
extinguishers are displayed on
each extinguisher as well as due
date for next refilling is clearly
mentioned
Check for staff competencies for 2 SI/RR
operating fire extinguisher and

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 36 36
ME C 3.1 The facility has adequate
specialist doctors as per service
provision
Minilap - MBBS trained in procedure
Laparoscopic- DGO,MS, MD
trained in laparoscopic surgery- in
Availability of trained surgeon house/out sourced or diverted for
for Minilap/ Laparoscopic/NSV 2 OB/RR fixed day services
ME C3.3 The facility has adequate nursing OB/RR/SI Trained in IUCD insertion
staff as per service provision and
work load
Availability of Nursing staff 2
ME C3.4 The facility has adequate Viability of Counsellor for family OB/SI One Counselor may be used for
technicians/paramedics as per planning various types of counselling
requirement
2
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Availability of OT technician 2 SI/RR Trained Staff (MPW/Nurse)

ME C3.5 The facility has adequate SI/RR Trained Staff (MPW/Nurse)
Availability of OT
support / general staff attendant/assistant 2
Availability of Security staff 2 SI/RR
ME C3.6 The staff has been provided SI/RR
required training / skill sets IUD insertion 2
Family planning counselling 2 SI/RR
SI/RR
Laparoscopic surgery/Minilap 2
NSV 2 SI/RR
SI/RR
Bio medical waste Management 2
SI/RR
Training on infection control and
hand hygiene 2
Patient Safety 2 SI/RR
ME C3.7 The Staff is skilled as per job SI/RR
Staff is skill for counselling
description services 2
SI/RR
Staff is skilled for resuscitation 2
SI/RR
Nursing Staff is skilled for
maintaining clinical records 2
SI/RR
Staff is Skilled to operate OT
equipments 2
SI/RR
Staff is skilled for processing and
packing instrument 2
Standard C4 Facility provides drugs and consumables required for assured list of services. 16 16
ME C4.1 The departments have availability Availability of Oral Contraceptive 2 OB/RR
of adequate drugs at point of use Pills
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
Availability of anaesthetics 2 OB/RR Stock for Month
2 OB/RR
Availability of Oxygen cylinder/ Piped
Gas supply, nitrous oxide, carbon
Availability of medical gases dioxide.

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Reference No ME Statement
ME C4.2 The departments have adequate
consumables at point of use
ME C4.3 Emergency drug trays are
maintained at every point of care,
where ever it may be needed
Standard C5
ME C5.1 Availability of equipment &
instruments for examination &
monitoring of patients
ME C5.2 Availability of equipment &
instruments for treatment
procedures, being undertaken in Gynae and obstetric
the facility
ME C5.3 Availability of equipment &
instruments for diagnostic
procedures being undertaken in
the facility
ME C5.4 Availability of equipment and
instruments for resuscitation of
patients and for providing
intensive and critical care to
patients
ME C5.5 Availability of Equipment for
Storage
Post Partum Unit Version- NHSRC 3.0
Checkpoint Complian Assessment Means of Verification Remarks
ce Method
2 OB/RR At OT
Sterilized consumables in
dressing drum
2 OB/RR
Availability of emergency drugs
tray
The facility has equipment & instruments required for assured list of services. 30 34
Availability of functional
Equipment &Instruments for
examination & Monitoring
BP apparatus, Thermometer, Pulse
2 OB Oxymeter, Multiparameter
Availability of
Instruments/Equipments for
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 0 OB On the day of seurgery
NSV sets 2 OB
Instruments for Laparoscopy
0 OB
Availability of Point of care
diagnostic instruments
Glucometer, Doppler and HIV rapid
2 OB diagnostic kit
Bag and mask, Oxygen, Suction
Availability of functional machine , laryngoscope scope. LMA,
Instruments Resuscitation 2 OB ET Tube , Airway ,Defibrillator
Availability of equipment for Refrigerator, Crash cart/Drug trolley,
storage for drugs instrument trolley, dressing trolley
2 OB
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ME C5.6 Availability of functional
equipment and instruments for
support services
ME C5.7 Departments have patient
furniture and fixtures as per load
and service provision
Availability of equipments for Buckets for mopping, Separate mops
cleaning for patient care area and circulation
area duster, waste trolley, Deck
brush
2 OB
Availability of equipment for Autoclave/ TSSU/CSSD
sterilization and disinfection
2 OB
Availability of functional OT light
2 OB
Availability of attachment/
accessories with OT table 2 OB Hospital graded mattress , IV stand

Tray for monitors, Electrical panel

Availability of Fixtures 2 OB
Availability of furniture 2 OB
Area of Concern - D Support Services
for anaesthesia machine, cardiac
monitor etc, panel with outlet for
Oxygen and vacuum, X ray view box.
Cupboard, table for preparation of
medicines, chair, racks,
104 106

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 12 12
ME D1.1 The facility has established All equipments are covered 2 SI/RR
system for maintenance of critical under AMC including preventive
Equipment maintenance

2 SI/RR

There is system of timely

ME D1.2 The facility has established
procedure for internal and
external calibration of measuring
Equipment
corrective break down
maintenance of the equipments
There has system to label 2
Defective/Out of order
equipments and stored
appropriately until it has been
repaired
OB/RR
All the measuring equipments/ 2 OB/ RR
instrument are calibrated

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2 OB/ RR

There is system to label/ code

the equipment to indicate status
of calibration/ verification when
recalibration is due
ME D1.3 Operating and maintenance 2 OB/SI Laparoscope, MVA etc
instructions are available with the Up to date instructions for
users of equipment operation and maintenance of
equipments are readily available
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 Stock level are daily updated
for forecasting and indenting Requisition are timely placed
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
No expiry drug found 2 OB/RR

Records for expiry and near

ME D2.5 The facility has established
procedure for inventory
management techniques
expiry drugs are maintained for
drug stored at department 2 RR
There is practice of calculating SI/RR
and maintaining buffer stock of
contraceptives

2
Department maintained stock RR/SI
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 cart
care areas
2
There is no stock out of OB/SI
contraceptives
2

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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
40 40
Standard D3
The facility has established program for maintenance and upkeep of the facility to provides safe, secure and comfortable
environment to staff, patients and visitors.
ME D3.1 Exterior of the facility building is 2 OB
maintained appropriately
Building is painted/whitewashed
in uniform colour
2 OB
Interior of patient care areas are
plastered & painted
ME D3.2 Hospital infrastructure is Check for there is no seepage , 2 OB
adequately maintained Cracks, chipping of plaster

2 OB
Window panes , doors and other
fixtures are intact
2 OB
OT Table are intact and without
rust
2 OB
Mattresses are intact and clean
ME D3.3 Patient care areas are clean and 2 OB
hygienic Floors, walls, roof, roof topes,
sinks patient care and circulation All area are clean with no
areas 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 D3.4 The facility has policy of removal 2 OB

of condemned junk material
No condemned/Junk material in
the PP unit
ME D3.5 The facility has established 2 OB
procedures for pest, rodent and
animal control
No pests are noticed

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ME D3.6 The facility provides adequate 2 OB

illumination level at patient care
areas Adequate Illumination at OT
table
2 OB At IUD insertion area
Adequate Illumination at
procedure area at family
planning clinic
ME D3.7 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 D3.8 The facility ensures safe and 2
comfortable environment for
patients and service providers 20-25OC, ICU has functional room
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 D3.9 The facility has security system in Security arrangement at PP 2 OB
place at patient care areas unit

ME D3.10 The facility has established measure Ask female staff weather they 2 SI
for safety and security of female feel secure at work place
staff

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 10 12
ME D4.1 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 D4.2 The facility ensures adequate
power backup in all patient care
areas as per load
2 OB/SI
Availability of Hot water supply
2 OB/SI
Availability of power back up in
OT
Availability of UPS 2 OB/SI
Availability of Emergency light 0 OB/SI

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ME D4.3 Critical areas of the facility ensures Availability of Centralized /local 2 OB

availability of oxygen, medical gases piped Oxygen, Nitrous Oxide and
and vacuum supply vacuum supply

Standard D5 The facility ensures availablity of diet as per nutritional requirement of patientr & clean linen to all admitted patients 8 8
ME D5.4 The facility has adequate sets of OB/RR Drape, draw sheet, cut sheet and
linen OT has facility to provide gown
sufficient and clean linen for
surgical patient 2
OT has facility to provide linen OB/RR
for staff
2
ME D5.5 The facility has established Linen is changed after each OB/RR
procedures for changing of linen procedure
in patient care areas
2
ME D5.6 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 D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 2 2
ME D8.3 The facility ensure relevant
processes are in compliance with
statutory requirement Staff is aware of legal age for
family planning 2 SI/RR 22-49 married only
Standard D9
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 8 8
procedures.
ME D9.1 The facility has established job Staff is aware of their role and 2 SI
description as per govt guidelines responsibilities

ME D9.2 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 etc)
departments

There is designated in charge for 2 SI

department
ME D9.3 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
Standard D10 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

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ME 10.1 2 SI/RR Verification of outsourced services

There is established system for
contract management for out
sourced services
(cleaning/
Dietary/Laundry/Security/Maintenan
There is procedure to monitor ce) provided are done by designated
the quality and adequacy of in-house staff
outsourced services on regular
basis
Area of Concern - E Clinical Services 198 198

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 16 16
ME E1.1 The facility has established Unique identification number is 2 RR
procedure for registration of given to each client during
patients process of registration

Client 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 Age criteria for family planning 2 RR/SI
for admission of patients surgeries is adhered

ME E1.4 There is established procedure
for managing patients, in case
beds are not available at the
facility
2 RR/SI
There is established criteria for
admission of abortion cases
2 SI/RR/OB
There is no delay in admission of
patient
Admission is done by written 2 SI/RR/OB
order of a qualified doctor
Time of admission is recorded in 2 RR
patient record
There is provision of extra beds 2 OB/SI
during fixed day family planning
surgery

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 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

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last contraceptive used and when 2 RR/SI

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 procedure Facility has established 2
for continuity of care during procedure for handing over
interdepartmental transfer form OT to ward

SI/RR
ME E3.2 Facility provides appropriate referral 2
linkages to the patients/Services for Facility has functional referral
transfer to other/higher facilities to linkages to higher facilities for
assure their continuity of care.
cases which can not be
managed at the facility
RR/SI
ME E3.3 A person is identified for care A nurse /doctor is identified 2 RR/SI One Doctor/Nurse can be
during all steps of care responsible for each case responsible for group of patients

Standard E4 The facility has defined and established procedures for nursing care 14 14
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

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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 during 2 SI/RR
patient hand over, whenever staff the change in the shift
duty change happens

Nursing Handover register is 2 RR

ME E4.4 Nursing records are maintained
ME E4.5 There is procedure for periodic
monitoring of patients
maintained
Hand over is given bed side 2 SI/RR
Nursing notes are maintained 2 RR/SI Check for nursing note register.
adequately Notes are adequately written
Patient Vitals are monitored 2 RR/SI
and recorded periodically

4 4
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.
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
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 2 RR
prescribed in generic name only Check for BHT if drugs are
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

regime and doses as per STG

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Check BHT that drugs are 2 RR

prescribed as per STG
Availability of drug formulary 2 SI/OB

Standard E7 Facility has defined procedures for safe drug administration 22 22

ME E7.1 There is process for identifying High alert drugs available in 2 SI/OB As applicable in the department
and cautious administration of department are identified
high alert drugs

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

There is process to ensure that 2 SI/RR A system of independent double

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

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

legibly and adequately procedure is accompanied
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 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 needle 2 OB

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

Any adverse drug reaction is 2 RR/SI

recorded and reported
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
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ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ 2 SI/PI
administration Pharmacist /nurse about the
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- Records of Monitoring/ 2 RR
assessment and investigations are Assessments are maintained
recorded and updated History and Physical examination
are recorded
ME E8.2 All treatment plan Treatment plan, first orders are 2 RR
prescription/orders are recorded written on BHT
in the patient records.

Drugs administered are recorded

ME E8.4 Procedures performed are
written on patients records
ME E8.5 Adequate form and formats are
available at point of use
ME E8.6 Register/records are maintained
as per guidelines
2 RR
Anaesthesia and surgery note
recorded
2 RR/OB
Standard Formats available Formats for Consent etc available
2 RR
Records on family planning (FP)
(including the number
of clients counselled and the
number of acceptors)
2 RR
Follow-up records for FP clients

All register/records are identified 2 RR

and numbered
ME E8.7 The facility ensures safe and Safe keeping of patient records 2 OB
adequate storage and retrieval of
medical records
20 20
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 2 SI/RR
patient readiness discharging patient
2 SI/RR
Discharge is done by a
responsible and qualified doctor
2 PI/SI
Patient / attendants are
consulted before discharge
2 SI/RR
Treating doctor is consulted/
informed before discharge of
patients
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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

Discharge summary adequately

mentions patients clinical
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 2 SI/PI

as during discharges wherever Counselling of client before
required discharge

2 RR/SI

Advice includes the information

about the nearest health centre
for further follow up
2 PI/SI
Time of discharge is
communicated to patient in prior
4 4
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E10.3 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 E11 The facility has defined and established procedures of diagnostic services
ME E11.1 There are established procedures Container is labelled properly 2 OB
for Pre-testing Activities after the sample collection

ME E11.3 There are established procedures 2 SI/RR

for Post-testing Activities
Nursing station is provided with
the critical value of different test
Standard E13 Facility has established procedures for Anaesthetic Services 2 2

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ME E13.2 Facility has established 2 SI/RR

procedures for monitoring during
anaesthesia Local anaesthesia is given as per
guidelines
Standard E14 Facility has defined and established procedures of operation theater & Surgical Services 8 8
ME E14.1 Facility has established 2 RR/SI
procedures OT Scheduling FP surgeries are scheduled as oer
guidelines
2 RR/PI
Preoperative instructions given
to the client
ME E14.2 Facility has established 2 RR/SI
procedures for Preoperative care
Part preparation is done as per
guidelines
ME E14.4 Facility has established 2 RR/SI
procedures for Post operative
care Post operative care as per
guidelines
Standard E15 The facility has defined and established procedures for end of life care and death 8 8
ME E15.1 Death of admitted patient is Facility has a standard 2 SI
adequately recorded and procedure to decent
communicated communicate death to
relatives

Death note is written on patient 2 RR

record
ME E15.2 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
patient attendant quoting the
immediate cause and underlying
cause if possible
Standard E16 Facility has established procedures for Antenatal care as per guidelines 2 2
ME E16.1 There is an established procedure Facility updates “Mother and 2 SI/RR
for Registration and follow up of Child Protection Card”.
pregnant women.

Standard E20 Facility has established procedures for abortion and family planning as per government guidelines and law 46 46

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ME E20.1 Family planning counselling The client is given full

services provided as per information about optimal
guidelines pregnancy spacing and The importance of timely initiation
the benefits of it as a part of FP of an FP method after childbirth,
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 E20.2 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 within 72 hours, second dose 12
method of administration of ECP hours after first dose
2 SI/RR
IUD insertion is done as per No touch technique, Speculum and
standard protocol bimanual examination, sounding of
uterus and placement

2 SI/RR
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

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Staff is aware of case selection

criteria for family planning
SI/RR 49-22 year age
Married
at least having one year old
2 Spouse has not gone for sterilization
ME E20.3 Facility provides limiting method Assessment of client done before Physical examination and Medical
of family planning as per surgery for any Delay, refer of History taken,
caution signs SI/RR
guideline
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 and SI/RR/PI method for 3 months only,
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 E20.4 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 vasectomy
2 defined
Post procedure Counselling
provided SI/RR/PI
2 As per national guidelines
Counselling on the follow-up visit
SI/RR/PI
2
ME E20.5 Facility provide abortion services MVA procedures are done as per SI/RR
for 1st trimester as per guideline guidelines
2
Medical termination of SI/RR
pregnancy done as per
guidelines
2
ME E20.6 Facility provide abortion services Surgical Procedures procedures SI/RR
for 2nd trimester as per guideline are done as per guidelines
2 Dilation and evacuation
Medical termination of SI/RR
pregnancy done as per
guidelines
2 As per State Guidelines
Area of Concern - F Infection Control 158 158

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Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 12
Facility has provision for Passive
and active culture surveillance of
critical & high risk areas
ME F1.2
Facility measures hospital
associated infection rates
ME F1.3
There is Provision of Periodic
Medical Checkups and
immunization of staff
ME F1.4
Facility has established
procedures for regular
monitoring of infection control
practices
ME F1.5
Facility has defined and
established antibiotic policy
ME F1.6
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are
ME F2.1
provided at point of use
Post Partum Unit Version- NHSRC 3.0
Checkpoint Complian Assessment Means of Verification Remarks
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12
Surface and environment
samples are taken for Swab are taken from infection prone
microbiological surveillance 2 SI/RR surfaces
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
infection 2 SI/RR site .
There is procedure for
immunization of the staff
2 SI/RR Hepatitis B, Tetanus Toxid etc
Periodic medical checkups of the
staff
2 SI/RR
Hand washing and infection control
audits done at periodic intervals
Regular monitoring of infection
control practices 2 SI/RR
Check for Doctors are aware of
Hospital Antibiotic Policy 2 SI/RR
30 30
Availability of hand washing
Facility at Point of Use Check for availability of wash basin
2 OB near the point of use
Availability of running Water
Ask to Open the tap. Ask Staff water
2 OB/SI supply is regular
Availability of antiseptic soap
with soap dish/ liquid antiseptic Check for availability/ Ask staff if the
with dispenser. supply is adequate and
2 OB/SI uninterrupted
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 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
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The facility staff is trained in Adherence to 6 steps of Hand

hand washing practices and
adhere to standard hand washing
practices
ME F2.2
Facility ensures standard
practices and materials for
antisepsis
washing
2 SI/OB Ask of demonstration
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
Staff aware of when to hand
wash
2 SI Ask of demonstration
Availability of Antiseptic
Solutions

ME F2.3 2 OB
Proper cleaning of procedure site
with antisepsis
like before giving IM/IV injection,
drawing blood, putting Intravenous
2 OB/SI and urinary catheter
Cleaning of cervix before IUD SI
insertion with antiseptic solution
2
Check Shaving is not done during SI
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
ME F3.1 point of use 2 OB/SI
Availability of Masks 2 OB/SI
Sterile s gloves are available at
OT and Critical areas 2 OB/SI
Use of elbow length gloves for
obstetrical purpose
2 OB/SI
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Availability of gown/ Apron
Availability of Caps
Personal protective kit for
infectious patients
Staff is adhere to standard
personal protection practices
No reuse of disposable gloves,
ME F3.2 Masks, caps and aprons.
Compliance to correct method of
wearing and removing the gloves 2
Standard F4 Facility has standard Procedures for processing of equipments and instruments
Facility ensures standard practices Decontamination of operating &
and materials for decontamination Procedure surfaces
and cleaning of instruments and
procedures areas
ME F4.1
Proper Decontamination of
instruments after use
Contact time for
decontamination is adeqaute
Cleaning of instruments after
decontamination
Proper handling of Soiled/
infected and dirty linen
Staff know how to make chlorine
solution
Post Partum Unit Version- NHSRC 3.0
Complian Assessment Means of Verification Remarks
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2 OB/SI
2 OB/SI
2 OB/SI HIV kit
2 OB/SI
SI
36 36
Ask stff about how they
decontaminate the procedure
surface like OT Table,
Stretcher/Trolleys etc.
2 SI/OB (Wiping with .5% Chlorine solution
Ask staff how they decontaminate
the instruments like ambubag,
suction canulae, Surgical Instruments
(Soaking in 0.5% Chlorine Solution,
Wiping with 0.5% Clorine Solution or
2 SI/OB 70% Alcohal as applicable
10 minutes
2 SI/OB
Cleaning is done with detergent and
2 SI/OB running water after decontamination
Soiled/Infected and dirty linen are
segregated at point of generation.
No rinsing or sluicing at point of use/
patient care area.
2 SI/OB
2 SI/OB
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Facility ensures standard practices Equipment and instruments are Autoclaving/HLD/Chemical

and materials for disinfection and
sterilization of instruments and
equipments
ME F4.2
sterlized after each use as per Sterlization
requirement
2 OB/SI
High level Disinfection of Ask staff about method and time
instruments/equipments is done required for bioling/ Chemical HLD of
as per protocol instruments/ equipments

2 OB/SI
Chemical sterilization of Ask staff about method,
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
Autoclaved linen are used for
procedure 2 OB/SI
Autoclaved dressing material is
used 2 OB/SI

Instruments are packed

according for autoclaving as per
standard protocol
Autoclaving of instruments is
done as per protocols
2 OB/SI
Ask staff about temperature,
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

Sterility of autoclaved packs is Sterile packs are kept in clean, dust

maintained during storage 2 OB/SI free, moist free environment.
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 32 32

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Reference No ME Statement
Layout of the department is
conducive for the infection control
practices
ME F5.1
Facility ensures availability of
standard materials for cleaning and requirement
disinfection of patient care areas
ME F5.2
Facility ensures standard practices
followed for cleaning and
disinfection of patient care areas
ME F5.3
Post Partum Unit Version- NHSRC 3.0
Checkpoint Complian Assessment Means of Verification Remarks
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Facility layout ensures
separation of general traffic from Faculty layout ensures separation of
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 OT
are easily cleanable 2 OB
CSSD/TSSU has demarcated
separate area for receiving dirty
items, processes, keeping clean
and sterile items 2 OB
Availability of disinfectant as per
Chlorine solution, Gluteraldehye,
2 OB/SI carbolic acid
Availability of cleaning agent as
per requirement Hospital grade phenyl, disinfectant
2 OB/SI detergent solution
Staff is trained for spill
management
2 SI/RR
Cleaning of patient care area
with detergent solution
2 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 OB/SI
Cleaning equipments like broom
are not used in patient care
areas
2 OB/SI
Use of three bucket system for
mopping
2 OB/SI
Fumigation/carbolization as per
schedule
2 SI/RR
External footwares are restricted
2 OB
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Facility ensures air quality of high

risk area Adequate air exchanges are
ME F5.5 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 Bio
Medical Waste as per guidelines
Availability of colour coded bins
ME F6.1 at point of waste generation 2 OB
Availability of plastic colour
coded plastic bags 2 OB

Segregation of different category

of waste as per guidelines 2 OB/SI

Display of work instructions for

Facility ensures management of
ME F6.2
sharps as per guidelines
Facility ensures transportation
and disposal of waste as per
guidelines
ME F6.3
segregation and handling of
Biomedical waste 2 OB
There is no mixing of infectious
and general waste
2 OB
Availability of functional Hub
cutters See if it has been used or just lying
2 OB idle
Availability of puncture proof
box Should be available nears the point
of generation like nursing station
2 OB and injection room
Availability of white translucent Check for Puncture proof, tamper 0
bins for waste Sharps proof and leak proof containers
2 OB
Availability of Blue bins for Check for Puncture proof and leak 1
Galssware proof boxes with blue colored
marking
2 OB
Availability of post exposure 2
prophylaxis
Ask if available. Where it is stored
2 OB/SI and who is 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
2 SI any reporting has been done
Check bins are not overfilled
2 SI
Disinfection of liquid waste
before disposal
2 SI/OB

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Transportation of bio medical

waste is done in close
container/trolley
2 SI/OB
Staff aware of mercury spill
management
2 SI/RR
Area of Concern - G Quality Management 74 74

Standard G1 The facility has established organizational framework for quality improvement 2 2
ME G1.1 The facility has a quality team in There is a designated 2 SI/RR
place departmental nodal person
for coordinating Quality
Assurance activities

Standard G2 Facility has established system for patient and employee satisfaction 2 2
ME G2.1 Patient Satisfaction surveys are 2 RR
conducted at periodic intervals
Client satisfaction survey done
on monthly basis
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 6 6
ME G3.1 Facility has established internal 2 SI/RR
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
ME G3.3 Facility has established system for Departmental checklist are 2 SI/RR
use of check lists in different used for monitoring and
departments and services quality assurance

Staff is designated for filling 2 SI

and monitoring of these
checklists

Standard G4
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and 36 36
support services.
ME G4.1 Departmental standard operating Standard operating procedure 2 RR
procedures are available for department has been
prepared and approved

Current version of SOP are 2 OB/RR

available with process owner

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ME G4.2 Standard Operating Procedures 2 RR

adequately describes process and
procedures Department has documented
procedure for registration,
admission and discharge
2 RR

Department has documented

procedure for initial assessment
of the patient
2 RR
Department has documented
procedure for providing
appointment/day and date for
the surgery
2 RR

Department has documented

procedure for preparation of
patient for surgery
2 RR
Department has documented
procedure for IUD insertion
2 RR

Department has documented

procedure for taking consent of
the patient for procedure
2 RR
Department has documented
procedure for record
maintenance
2 RR
Department has documented
procedure for counselling of the
patient
2 RR
Department has manual for male
and female sterilization
2 RR
Department has manual for
Quality assurance for
sterilization
2 RR
Department has guideline for
administration of Emergency
contraceptive

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2 RR
Department has standard for
various technique of
contraception
2 RR
Department has standard IEC
material for patient education
and counselling
2 RR
Department has manual for FP
indemnity scheme
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 2 OB IUD insertion, Processing of
at Point of use Work instruction/clinical instruments
protocols are displayed
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 12 12
ME G5.1 The facility conducts periodic 2 RR/SI
internal assessment Internal assessment is done at
periodic interval
ME G5.2 The facility conducts the periodic 2 RR/SI
prescription/ medical/death
audits There is procedure to conduct
Medical Audit
2 RR/SI
There is procedure to conduct
Death audit
ME G5.3 The facility ensures non Non Compliance are enumerated 2 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps 2 RR/SI
found in the assessment / audit
process
Action plan prepared
ME G5.5 Corrective and preventive actions 2 RR/SI
are taken to address issues,
observed in the assessment &
audit Corrective and preventive action
taken
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2 The facility periodically defines its 2 RR/SI
quality objectives and key
departments have their own
objectives
Quality objective are defined
ME G6.3 Quality policy and objectives are 2 SI
disseminated and staff is aware of
that Check of staff is aware of quality
policy and objectives
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Reference No ME Statement Checkpoint Complian Assessment Means of Verification Remarks
ce Method

ME G6.4 Progress towards quality Quality objectives are monitored 2 SI/RR

objectives is monitored and reviewed periodically
periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 10 10
ME G7.1 Facility uses method for quality PDCA 2 SI/RR
improvement in services

5S 2 SI/OB
Mistake proofing 2 SI/OB
Six Sigma 2 SI/RR
ME G7.2 Facility uses tools for quality Any two basic tools of Quality 2 SI/RR
improvement in services
Area of Concern - H Outcome 42 42

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 20 20
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
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
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 4 4
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
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 16 16

Page 137
Checklist - 9 Post Partum Unit Version- NHSRC 3.0
Reference No ME Statement Checkpoint Complian Assessment Means of Verification Remarks
ce Method

ME H3.1 Facility measures Clinical Care & Surgical Site Infection rate
Safety Indicators on monthly basis
2 RR
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
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 2
ME H4.1 Facility measures Service Quality
Indicators on monthly basis
Client Satisfaction score 2 RR

Page 138
Checklist - 9 Post Partum Unit Version- NHSRC 3.0
Reference No ME Statement Checkpoint Complian Assessment Means of Verification Remarks
ce Method

PP Unit Score Card

PP unit 98.54722
Score
Area of Concern wise Score
A Service Provision 100
B Patient Rights 94.117647058824
C Inputs 96.052631578947
D Support Services 98.11320754717
E Clinical Services 100
F Infection Control 100
G Quality
Management 100
H Outcome 100

Obtained Maximum Percent 12

Page 139
Checklist - 9 Post Partum Unit Version- NHSRC 3.0
Reference No ME Statement Checkpoint Complian Assessment Means of Verification Remarks
ce Method

A 28 28 100
B 64 68 94.11765
C 146 152 96.05263
D 104 106 98.11321
E 198 198 100
F 158 158 100
G 74 74 100
H 42 42 100
Total 814 826 98.54722

0
1
2

Page 140
 National Quality Assurance Standards for Taluka Hospital
Checklist for General Administration 13
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Area of Concern - A Service Provision

Standard A1 Facility Provides Curative Services
ME A1.10. The facility provides Accident & Availability of functional A& E 2 SI/OB
Emergency Services department
Availability of functional disaster 2 SI/OB
management team
ME A1.11. The facility provides Blood bank & Availability of functional Blood 2 SI/OB
transfusion services storage
Standard A2 Facility provides RMNCHA Services
ME A 2.1. The facility provides Reproductive Avaiability of dedicated Female 2 SI/OB
health Services ward
ME A2.3. The facility provides Newborn health Availability of functional NBSU 2 SI/OB
Services
Standard A3 Facility Provides diagnostic Services
ME A3.1. The facility provides Radiology Availability of X-Ray Unit 2 SI/OB Availability of in-house
Services services. Partial
Compliance if it is
outsourced

. Availability of Ultrasound services 2 SI/OB Availability of in-house

services. Partial
Compliance if it is
outsourced

ME A3.2 The facility Provides Laboratory Availability of In-house lab 2 SI/OB If lab is outsourced than
Services give partial compliance

ME A 3.3 The facility provides other diagnostic Availability of ECG Services 2 SI/OB
services, as mandated
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme
ME A4.2 The facility provides services under The laboratory has facility to carry 2
Revised National TB Control out sputum microscopy
Programme as per guidelines

SDH/Taluk functions as DOTS 2

centre.

ME A4.3 The facility provides services under Facility for Diagnosis and 2 SI/RR
National Leprosy Eradication treatment of Leprosy.
Programme as per guidelines

Facility for management of 2

reactions
Councelling and advise on 2
prevention of disabilities
Availablity of separate MDT 2
regimens in separate blister packs
for MB-Adult, MB-child, PB-adult
and PB child.

ME A4.4 The facility provides services under Availability of Functional ICTC 2 SI/OB
National AIDS Control Programme as
per guidelines
Availability of link ART centre 2 SI/OB
ME A4.5 The facility provides services under Availability of Refraction room 0
National Programme for control of
Blindness as per guidelines

Availability or Eye OT, if Eye 0

surgeon posted; else linkage with
higher facilities.
ME A4.7. The facility provides services under Availability of geriatric Clinic 2 SI/OB
National Programme for the health
care of the elderly as per guidelines

ME A4.8. The facility provides services under Facility for early detection and 2 SI/OB
National Programme for Prevention referral of suspected cases, ,
and control of Cancer, Diabetes,
Cardiovascular diseases & Stroke
(NPCDCS) as per guidelines

Sreeening for cervical, breast and 2

oral cancer
Education about self examination 2
of breast and oral self
examination.

ME A4.9 The facility Provides services under SDH/Taluk functions as peripheral 2

Integrated Disease Surveillance surveillance unit
Programme as per Guidelines

SDH/Taluk collate, analyse and 2 SI/RR check for IDSP reporting

report informationn to District format and
Surveillance unit on epidemic Annexure 7A, 7B and 7C.
prone disease.

Standard A5 Facility provides support services

ME A5.1. The facility provides dietary services Availability of dietary service (in- 2 SI/OB
house/oursourced)
ME A5.2. The facility provides laundry services Availability of laundry services (in- 2 SI/OB
house/outsourced)

ME A5.3. The facility provides security Availability of security services 2 SI/OB

services (in-house/outsourced)

ME A5.4. The facility provides housekeeping Availability of Housekeeping 2 SI/OB

services services (in-house/outsourced)

ME A5.5. The facility ensures maintenance Availability of maintenance 2 SI/OB

services services
ME A5.6. The facility provides pharmacy Availability of drug storage and 2 SI/OB
services dispensing services
ME A5.7. The facility has services of medical Availability of Medical record 1 SI/OB
record department services
Standard A5 Facility provides Support and Administrative services
ME A5.1. The facility provides dietary services 2 SI/OB In house or outsourced
Availability of dietary service
ME A5.2. The facility provides laundry services 2 SI/OB In house or outsourced
Availability of laundry services
ME A5.3. The facility provides security 2 SI/OB In house or outsourced
services Availability of security services
ME A5.4. The facility provides housekeeping 2 SI/OB In house or outsourced
services Availability of Housekeeping
services
ME A5.5. The facility ensures maintenance 2 SI/OB In house or outsourced
services Availability of maintenance
services
ME A5.6. Facility provides pharmacy and store Availability of drug storage and 2 SI/OB
services. dispensing services
Avaialbility of General stores 2 For storing consumables,
Stationaries, and
equipments

ME A5.7. The facility has services of medical 2 SI/OB

records Availability of Medical record
services
Standard A6 Health services provided at the facility are appropriate to community needs.
ME A 6.1. The facility provides curatives & Treatment/referral facilities 2 SI/RR Arsenic poisioning, Snake
preventive services for the health available for health problems of bite, KFD, Leptospirosis &
problems and diseases, prevalent local community. Flurosis
locally.
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

Area of Concern - B Patient Rights

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their
ME B1.1. The facility has uniform and user- modalities2
Name of the facility prominently OB
friendly signage system displayed at front of SDH/Taluk
building

. SDH/Taluk lay out with location 2 OB

and name of the departments are
displayed at the entrance.

. SDH/Taluk has established 1 OB

directional signage
. List of departments are displayed 1 OB

All signage are in uniform colour 1 OB

scheme
Signages are user friendly and 0 OB
pictorial
ME B1.2 The facility displays the services and Services which are not available 2 OB
entitlements available in its are also mentioned with name of
departments facilities, where such failicites are
available

Availability of administrative 0 OB Clical examination and

services like handicap certificate intimation to appropriate
services are displayed. authority

Processing time for issuing 2 OB

certificates & availability of
medical records are displayed

Mandatory information under RTI 2 OB

is displayed
ME B1.3. The facility has established citizen Citizen charter is established in 2 OB
charter, which is followed at all the facility
levels
. Citizen charter includes the 2 OB
Services 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
Citizen Charter includes the 2 OB
Standards and Quality of services
Provided

Citizen Charters Includes 2 OB

Complaints and Grievances
redressal Mechanism

Citizen Charter includes Services 2 OB

that are available on payment, if
any.

Citizen Charter includes the Cycle 2 OB

time for Critical Processes

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 B1.7. The facility provides information to A dedicated facilitation 2 OB
patients and visitor through an counter/rogi sahayata kendra
exclusive set-up. available

Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier
ME B2.1 on account
Services are provided in manner of physical
that SDH/Taluk access,
has defined social,
policy for economic,
2 cultural or social status.
SI/PI
are sensitive to gender non discrimination according to
gender

ME B2.2 Religious and cultural preferences of Availability of complaint box and 0 PI/RR
patients and attendants are taken display of process for grievance
into consideration while delivering redresaal and personnel to be
services contacted.

Staff is respectful to patients 2 PI/SI

religious and cultural beliefs
The facility has defined policy to 2 RR/SI
ensure the religious and cultural
preferences of the patient

ME B2.3 Access to facility is provided without Approach road to facility is 2 OB

accessible without congestion or
any physical barrier & friendly to encroachment
people with disability.
There are no open 0 OB
manholes/Potholes at access road
and internal pathways

Internal Pathways and corridors of 1 OB

the facility are without any
obstruction / Protruding Objects

SDH/Taluk has defined policy to 2 OB

provide barrier free services to
patient

Ramps shall have a slope of 2 OB

conducive for use
Ramps are provide with slip 2 OB
resistance surface
Ramps shall have adequate width 2 OB at least 120 cm

Warning blocks have been provide 1 OB To aid people with visual

at beginning and end of the ramp impairment
and Stairs

Hand rails are provided with stairs 1 OB

The facility has defined policy for 2 OB

providing disable friendly services

Parking area is earmarked for 2 OB

People with disabilities
ME B2.4 There is no discrimination on basis There is no discrimination on basis 2 PI/SI
of social and economic status of the of social and economic status of
patients the patients

SDH/Taluk 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 There are arrangement and 2 RR/SI Linkage for Palliative Care ,
Linkages for care of terminally ill Hospice
ensure that vulnerable sections can patients
access 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 1 RR/SI Linkages with NGOS ,

adequate care and post discharge Orphan , old age home,
support of Orphan patients Children home
including homeless children
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related
ME B3.1 information.
Adequate visual privacy is provided SDH/Taluk has defined policy for 1 RR/SI
at every point of care maintenance of privacy of
patients

ME B3.2 Confidentiality of patients records SDH/Taluk has defined policy for 1 RR/SI
and clinical information is maintenance of patient records
maintained and clinical information

ME B3.3 The facility ensures the behaviours
of staff is dignified and respectful,
while delivering the services
SDH/Taluk defines and 1 RR/SI
communicate policy regarding
decent communication and
courteous behaviour towards the
patient and visitors

ME B3.4 The facility ensures privacy and
confidentiality to every patient,
especially of those conditions having
social stigma, and also safeguards
vulnerable groups
SDH/Taluk defines the policy for 1 RR/SI
privacy and confidentiality of the
patient and condition related with
social stigma and vulnerable
groups

Standard B4 Facility has defined and established procedures for informing patient about the medical conditions and involving
ME B4.1 them
There is established procedures forin SDH/Taluk
treatment planning,
define policy forand facilitates
taking 2 informed
RR/SI decision making.
taking informed consent before consent.
treatment and procedures
ME B4.2 Patient is informed about his/her Display of patient rights and 2 OB
rights and responsibilities responsibilities.
ME B4.3 Staff are aware of Patients rights The staff is aware of patients 2 SI
responsibilities rights responsibilities
The staff is regularly sensitised 2 SI/RR
about rights and responsibilities of
the patient

ME B4.5. The facility has defined and Availability of complaint box at 0 OB

established grievance redressal administrative office and display
system in place of process for grievance Redressal
and whom to contact are
displayed

SDH/Taluk defines policy for 0 RR/SI

grievance redressal mechanism

There is defined frequency of 0 RR/SI

collecting complaints from
complaint box

Records of patient complaints & 0 RR

suggestion are maintained
. There is system of periodic review 0 RR/SI
of patient complaints
. There is evidence of action taken 2 RR
on complaints
. Action taken is informed to the 2 RR
complainant
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of
ME B5.1 The facility provides cashless Hospital
SDH/Taluk establish policy for services.
2 RR/SI
services to pregnant women, providing free services to
mothers and neonates as per benficieries of Central and state
prevalent government schemes schemes

ME B5.2 The facility ensures that drugs SDH/Taluk has established policy 2 RR/SI
prescribed are available at Pharmacy for providing all drugs in the EDL
and wards free of cost as per state directives

ME B5.3 It is ensured that facilities for the SDH/Taluk has established policy 2 RR/SI
prescribed investigations are for providing all diagnostics free
available at the facility of cost as per state directives

ME B5.4 The facility provide free of cost Methods for verification of 2 PI/SI
treatment to Below poverty line documents of patient is user
patients without administrative friendly
hassles
 SDH/Taluk has established policy 2 RR/SI
to provide free treatment to BPL
patients

ME B5.6 The facility ensure implementation Availability of dedicated RSBY/ 2 OB

of health insurance schemes as per CMCHS scheme help desk
National /state scheme

Finger print verification is done 0 OB/SI/RR

through a finger print/Smart card

All tests and drugs are covered 2 RR/SI/PI

under RSBY/CMCHS
Services and entitlements 2 OB
available under RSBY/CMCHS are
prominently displayed

Manual process is in place in case 2 RR/SI

smart card is not working

Area of Concern - C Inputs

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent
ME C1.1. norms 2
Departments have adequate space Availability of residential quarters OB/RR
as per patient or work load for clinical and support staff

SDH/Taluk 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
Adequate number of Staff toilets 2 OB/SI
available in proximity to duty area

Adequate number of Staff change 2 OB/SI

room are available in proximity to
duty area

Dinning area for staff 0 OB/SI

Availability of Staff amenities at 2 OB/SI
nursing station and duty room

ME C1.3. Departments have layout and SDH/Taluk has independent entry 2 OB

demarcated areas as per functions to emergency and OPD.

. Corridors are wide enough to 2 OB

accommodate daily traffic.

. The general traffic should not pass 2 OB

through the indoor/ critical
patient care area

. Ambulatory services are located in 2 OB OPD, Emergency and

outermost zone Administrative offices are
situated in near the entry/
exit of the SDH/Taluk with
direct access from
approach road

. Clinical support Services are 2 OB Lab , Radiology and

located in proximity to outer zone Pharmacy

Indoor area are located in inner 2 OB Wards and Nursing Units

zone of the SDH/Taluk are located in inner most
area

ME C1.4. The facility has adequate circulation Corridors are wide enough to 2 OB
area and open spaces according to accommodate daily traffic.
need and local law
Facility maintains open area as 2 OB
per floor area ratio mandated by
authorities
ME C1.5. The facility has infrastructure for SDH/Taluk has 24X7 functional 0 OB
intramural and extramural telephone connection/CUG/
communication intercom facility for internal
communication

. There is designated person to 0 OB/SI/RR

answer the telephone enquiries

. SDH/Taluk has broadband 2 OB

internet connectivity
There is established 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 communicating

internal movement of documents circulars, notices and
and communication 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 old 2 OB/RR

notices and updating the notice
board

ME C1.6 Service counters are available as per Availability of OPD counter as per 2 OB/RR
patient load load
ME C1.7. The facility and departments are There is no cris-cross between 2 OB
planned to ensure structure follows General and Patient Traffic
the function/processes (Structure
commensurate with the function of
the SDH/Taluk)

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure.
ME C2.1. The facility ensures the seismic The facility has been surveyed 2 OB/RR Ask for records of survey
safety of the infrastructure by Structural engineer for
seismic vulnerability in high risk
zone

Structural Components been 2 OB/RR Check for records of in

made earthquake proof correction has been done
to strengthen structural
components like columns,
beams, slabs, walls etc.

ME C2.2. The facility ensures safety of Facility has mechanism for 2 OB/RR
electrical establishment periodical check / test of all
electrical installation by
competent electrical Engineer

. Facility has system for power 0 OB/RR

audit of unit at defined intervals

Danger sign is displayed at High 0 OB

voltage electrical installation

All electrical panels are covered 0 OB

and has restricted access

Personal protective equipments 2 OB/SI

are available with electrician

ME C2.3. Physical condition of buildings are Windows have grills and wire 2 OB
safe for providing patient care meshwork
. Building including walls, roofs, 2 OB
floor, windows , balconies and
terraces are maintained

. Terrace, roof, balconies and stair 2 OB

case have protective railing

. SDH/Taluk premises has intact 2 OB

boundary wall
. SDH/Taluk has functional gate 2 OB
with provision of animal catcher

Access to roof and terraces is 2 OB

restricted
ME C2.4. The facility has plan for prevention Fire exits provide egress to 2 OB
of fire exterior of the building in open
space

. Check the fire exits are free from 2 OB

obstruction
. Facility has conducted fire safety 2 OB/RR
audit by competent authority

Facility has defined, displayed 2 OB/RR

and implemented evacuation plan
in case of fire

No smoking sign displayed inside 2 OB/RR

and outside the working area

ME C2.5. The facility has adequate fire fighting Facility has installed fire 2 OB
Equipment extinguisher that are capilbility of
fighting A, B & C type of fire

There is system to track the expiry 2 OB/RR

dates and periodic refilling of the
extinguishers

ME C2.6. The facility has a system of periodic Periodic Training is provided for 2 OB/RR
training of staff and conducts mock using fire extinguishers
drills regularly for fire and other
disaster situation

Periodic mock drills for diaster 2 OB/RR

management are conducted

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case
ME C3.1. The facility has adequate specialists Availability of General Surgeon load 0 OB/RR/SI As per patient load, in
doctors as per service provision house/ diverted/
outsourced

. Availability of Obstetric & Gynae 2 OB/RR/SI As per patient load, in

Specialist house/ diverted/
outsourced

Availability of General Medicine 2 OB/RR/SI As per patient load, in

specialist house/ diverted/
outsourced

. Availability of Paediatrician 2 OB/RR/SI As per patient load, in

house/ diverted/
outsourced

. Availability of Anaesthetics 2 OB/RR/SI As per patient load, in

house/ diverted/
outsourced

ME C3.2 The facility has adequate general Availability of General Duty 2 OB/RR/SI As per patient load, in
duty doctors as per service provision Doctors as per load house/ diverted/
and work load outsourced

. Availability of AYUSH Doctor 2 OB/RR/SI As per patient load, in

house/ diverted/
outsourced

Availability of Dentist 2 OB/RR/SI As per patient load, in

house/ diverted/
outsourced
ME C3.3. The facility has adequate nursing Availability of nursing staff 2 OB/RR/SI As per patient load
staff as per service provision and
work load
ME C3.4. The facility has adequate Availability Lab Tech 2 OB/RR/SI As per patient load
technicians/paramedics as per
requirement
. Availability Pharmacist 2 SI/RR As per patient load
. Availability Radiographer 2 SI/RR As per patient load
. Availability ECG Tech 2 SI/RR Trained Staff
. Availability Optha. 0 SI/RR As per patient load
Technician/Referactionist
. Availability O.T. technician 0 SI/RR Trained Staff
. Counsellor 2 SI/RR As per patient load
. Dental Technician 0 SI/RR As per patient load
. Rehabilitation worker 2 SI/RR Trained PHYSIO
THERAPAST.
ME C3.5. The facility has adequate support / Registration Clerk 2 SI/RR
general staff
. Statistical Assistant/Data entry 2 SI/RR
operator
. Account Assistant 2 SI/RR
Administrative assistant. 2
ME C3.6. The staff has been provided required The facility conduct training need 0 SI/RR
training / skill sets assessment periodically for all
cadre of staff

The facility has program for 2 SI/RR

continuous medical education for
doctors and nursing staff

The facility prepares training 0 SI/RR

calendar as per training need
assessment

Training feed back is taken and 0 SI/RR

records are maintained for
training

Details and Records of training 2 SI/RR

provided are available with unit

Training on Disaster Management 2 SI/RR

Training on Cardio Pulmonary 2 SI/RR

resuscitation
Training on staff Safety 0 SI/RR
Training on Measuring SDH/Taluk 2 SI/RR
Performance Indicators

Training on facility level Quality 2 SI/RR

Assurance
ME C3.7. The Staff is skilled as per job SDH/Taluk has policy for regular 0 SI/RR
description competence testing as per job
description.

Standard C4 Facility provides drugs and consumables required for assured list of services.
ME C4.1 The departments have availability of SDH/Taluk has policy to ensure 2 SI/RR
adequate drugs at point of use drugs at all point of use as per
state EDL

Standard C5 The facility has equipment & instruments required for assured list of services.
ME C5.6 Availability of functional equipment Availability of equipment for 2 OB Equipments for
and instruments for support services Facility management horticulture, electrical
repair, plumbing material
etc

Availability of equipment for 2 OB Autoclave and mutilator

processing of Bio medical waste

Availability of computer for HMIS 2

and MCTS reporting
ME C5.7 Departments have patient furniture Availability of fixture for 2 OB
and fixtures as per load and service administrative office
provision
Availability of furniture for 2 OB
administrative office
Area of Concern - D Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
ME D1.1. The facility has established system Facility has contract agency for 2 SI/RR
for maintenance of critical maintenance for equipments
Equipment
Contact details of the agencies 2 SI/RR
responsible for maintenance are
communicated to the staff

Asset list of all equipments are 2 SI/RR

maintained
There is system to maintain 2 SI/RR
records of down time of
equipments

Indexing of all equipments is done 0 SI/RR

All equipments are covered under 2 SI/RR

AMC including preventive
maintenance for computers and
other IT equipments

There is system of timely 2 SI/RR

corrective break down
maintenance of the for
computers and other IT
equipments

ME D1.2. The facility has established Facility has contracted agency for 2 SI/RR
procedure for internal and external calibration of equipments.
calibration of measuring Equipment

Records of the calibrated 2 RR

equipments are maintained
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and
ME D2.4 The facility ensures management of SDH/Taluk has system to patient
ensure care areas
2 SI/RR
expiry and near expiry drugs that short expiry drugs are not
procured

SDH/Taluk has process for proper 2 SI/RR

disposal and prevention of
unintended use of expired drugs

ME D2.5 The facility has established SDH/Taluk implements scientific 2 OB/RR/SI ABC, VED, FSN,FIFO
procedure for inventory inventory management system
management techniques according to their needs

ME D2.6 There is a procedure for periodically SDH/Taluk has policy that there is 2 RR/SI
replenishing the drugs in patient care no stock out of the drugs and
areas consumables at patient care area

ME D2.8 There is a procedure for secure SDH/Taluk has a policy for 1 RR/SI
storage of narcotic and psychotropic ensuring proper management and
drugs restriction of unintended use of
narcotic substance and
psychotropic drugs as per
prevalent law

Standard D3 The facility has established Program for maintenance and upkeep of the faciity to provide safe, secure and
ME D3.1. Exterior of the facility building is comfortable
Boundary Wallsenvironment
of building is to staff,2 patients
OB and visitors.
maintained with landscaping in open plastered and whitewashed.
areas.
. No unwanted/outdated posters 2 OB
on SDH/Taluk boundary and
building walls
. SDH/Taluk Buildings are in 1 OB
uniform colour scheme
. SDH/Taluk has system to 2 OB/RR
whitewash the building
periodically

Availability of parking space as per 2 OB

requirement
Dedicated parking space for 1 OB
ambulances
No water logging in side the 2 OB
premises of the SDH/Taluk
There is no abandoned 2 OB
/dilapidated building in the
premises

Proper landscaping and 2 OB

maintenance of trees, garden
no encroachment in and around 2 OB
the SDH/Taluk
SDH/Taluk has rain water 0 OB
harvesting facility
SDH/Taluk has Herbal garden 2 OB
ME D3.2. Hospital infrastructure is adequately SDH/Taluk has system for 2 OB/RR
maintained periodic maintenance of
infrastructure at defined interval

. There is no clogged/over flowing 2 OB

drain in facility
. SDH/Taluk sewage is linked with 0 OB/SI/RR
municipal drainage system or it
has functional septic tanks

. Facility has a closed drainage 2 OB

system
. Intramural roads are in good 2 OB
condition without
potholes/ditches

. Facility has a annual maintenance 2 RR/SI

plan for its infrastructure

ME D3.3. Patient care areas are clean and General waste from SDH/Taluk is 2 OB/RR
hygienic removed daily by
municipal/outsourced agency

Every department has a Schedule 2 SI/RR Every department has

of cleaning schedule for inspection of
cleaning work

ME D3.4. The facility has policy of removal of SDH/Taluk has condemnation 2 RR/SI
condemned junk material policy in place
. Periodic removal of junk material 2 OB/RR
done
. SDH/Taluk has designated 2 OB
covered place to keep
junk/condemned material

. No junk/condemned articles in 2 OB
open spaces
ME D3.5. The facility has established Pest control measures are evident 2 RR/SI
procedures for pest, rodent and at facility
animal control
. Anti Termite treatment of the 2 RR/SI
wooden furniture
ME D3.6. The facility provides adequate Adequate illumination in open 2 OB
illumination level at patient care areas in night
areas
Adequate illumination in 2 OB Stairs, corridor and waiting
circulation area area
Adequate illumination in toilets 2 OB
 SDH/Taluk periodically measure 2 OB
illumination at different area of
the SDH/Taluks

Adequate illumination at 2 OB
approach roads to SDH/Taluk
ME D3.7. The facility has provision of There is restriction on entry of 2 OB
restriction of visitors in patient areas vendors and hawkers inside the
premise of the SDH/Taluk

. SDH/Taluk has visitor policy in 2 OB/RR

place
. SDH/Taluk has policy for 2 OB/RR
restriction of media person in side
the SDH/Taluk

SDH/Taluk implement visitor pass 2 OB/RR

for indoor areas
ME D3.9. The facility has security system in SDH/Taluk has 2 RR/SI
place at patient care areas in-house/outsourced security
system in place

. Duty roaster is available for 2 RR/SI

security staff
. Training and Drills of security staff 2 RR/SI
is done
. Security staff is aware of patient 2 RR/SI
right, visitor policy and disaster
Management

. There is system for supervision of 2 RR/SI

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 a 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

. SDH/Taluk has system to manage 1 RR/SI

violence /mass casualty

ME D3.10. The facility has established measure for No female staff 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 0 RR/SI

awareness training on Gender
issues

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services
ME D4.1. The facility has adequate SDH/Taluk has adequate waternorms 2 OB/RR/SI 450-500 Litres per bed per
arrangement storage and supply for storage facility as per day
portable water in all functional areas requirements

. SDH/Taluk 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
The facility 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
The facility ensures that the 2 RR/SI
distribution pipelines are not
running in close vicinity of the
sewage system.

ME D4.2. The facility ensures adequate power Availability of noiseless generators 2 OB/SI
backup in all patient care areas as for power back up
per load
Estimation of power consumption 2 RR/SI
by SDH/Taluks is done

Generator has adequate capacity 2 RR/SI

to provide 24x7 power backup at
least to critical areas

SDH/Taluk has adequate power 2 RR/SI 3Kw to 5Kw per bed

supply connection
Use of energy efficient bulbs for 2 SI
light
Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted
ME D5.2 The facility provides diets according There is provision of differentpatients. 2 Normal diet, Diabetic diet,
to nutritional requirements of the types of diets as per nutritional liquid diet, Low salt/low
patients requirements of patients fat diet

ME D5.5 The facility has established Clean linen is provided to all the 2
procedures for changing of linen in occupied beds
patient care areas
Standard D6 The facility has defined and established procedures for promoting public participation in management of SDH/Taluk
ME D6.1. The facility has established transparency
RKS or eqvivalent body is and accountability.
2 RR
procedures for management of registered under societies
activities of Rogi Kalyan Samitis 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

ME D6.2. The facility has established Community based 2 RR/SI

procedures for community based monitoring/social audits are done
monitoring of its services at periodic intervals

Facility communicate updated 2 RR/SI

information on Quality of services

Facility conducts public hearing at 2 RR/SI

regular intervals
Standard D7 SDH/Taluk has defined and established procedures for Financial Management
ME D7.1. The facility ensures the proper There is system to track and 2 RR/SI
utilization 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 to 2 RR/PI E.g.; Payment for JSY and
beneficiaries as per their Family planning
entitlement under different
schemes

. Salaries and compensation are 2 RR/SI

provided to contractual staff on
time

. Facility provides utilization 2 RR

certificate for funds on time
ME D7.2. The facility ensures proper planning Facility prioritize the resource 2 RR/SI
and requisition of resources based required
on its need
. Requirement for funds are 2 RR/SI
communicated to state on time

Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
ME D8.1. The facility has requisite licences Availability of valid No objection 0 RR
and certificates for operation of Certificate from fire safety
SDH/Taluk and 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 D8.2. Updated copies of relevant laws, Availability of copy of Bio medical 2 RR
regulations and government orders waste management Rule 2016
are available at the facility and 2018 (Amend.)

Registration of Ultrasound 2
machine under PCPNDT act.
Drug and cosmetic Act 2005 0 RR
Safety code for Medical diagnostic 0 RR AERB safety code no.
X ray equipment and installation AERB/SC/MED-2(Rev 1)

Narcotics and Psychotropic 0 RR

substances act 1985
Code of Medical ethics 2002 2 RR
Nursing Council Act 2 RR
Medical Termination of Pregnancy 2 RR
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

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
ME D9.1. The facility has established job operating procedures.
Job description of Specialist 0 RR Regular + contractual
description as per govt guidelines Doctor is defined and
communicated

Job description of General duty 0 RR Regular + contractual

Doctor is defined and
communicated

. Job description of nursing staff is 0 RR Regular + contractual

defined and communicated
. Job description of paramedic staff 0 RR Regular + contractual. Lab
is defined and communicated technician, X ray
technician, OT technician,
etc.

Job description of counsellor is 0 RR Regular + contractual

defined and communicated
Job description of ward boy is 0 RR Regular + contractual
defined and communicated
Job description of security staff is 0 RR Regular + contractual
defined and communicated

Job description of cleaning staff is 0 RR Regular + contractual

defined and communicated

Job description of Administrative 0 RR Regular + Contractual MS,

staff is defined and communicated SDH/Taluk Manager,
supervisor, Matron, Ward
Master. Pharmacist etc.

ME D9.2. The facility has a established Duty roster of doctors is prepared, 2 RR/SI
procedure for duty roster and updated and communicated
deputation to different departments

Duty roster of Nurses is prepared, 2 RR/SI

updated and communicated

Duty roster of Paramedics is 2 RR/SI

prepared, updated and
communicated

Duty roster of Cleaning staff is 2 RR/SI

prepared, updated and
communicated

Duty roster of security staff is 2 RR/SI

prepared, updated and
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 D9.3. The facility ensures the adherence Facility has policy for dress code 2 RR/SI
to dress code as mandated by its for different cadre of SDH/Taluk.
administration / the health
department

. I Cards have been provided to 2 OB

staff
. Name plate have been provided 0 OB
to staff
Standard D10 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual
ME D10.1. obligations2
There is established system for contract Selection of outsourced agencies RR
management for out sourced services done through competitive
tendering system

. Eligibility criteria is explicitly 2 RR

defined as per term of reference

There is system to make payment 2 RR Check for that Contract

as per adequacy and quality of document has provision
services provided by the vendor for dedication of payment
if quality of services is not
good

. Payment to the outsourced 2 RR

services are made on time
ME D10.2. There is a system of periodic review of Facility has defined criteria for 2 RR
quality of out sourced services assessment of quality of
outsourced services
 Actions are taken against non 2 RR/SI
compliance / deviation from
contractual obligations

Records of blacklisted vendors are 2 RR

available with facility

Area of Concern - E Clinical Services

Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
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 of vacant patient beds
not available at the facility

Facility has established procedure 0 RR/SI

for accommodating high patient
load due to situation like disaster/
mass casualty or disease outbreak

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral
ME E3.1. Facility has established procedure Facility has established policy 2 RR/SI
for continuity of care during for co ordination and handover
interdepartmental transfer during interdepartmental
transfer

. There is a policy for 2 RR/SI

consultation of the patient to
other specialists with in the
SDH/Taluk

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 not be provided at the facility
assure their continuity of care.

. Facility maintains 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 communicate 2 RR/SI
referral criteria
There is system to check that 2 RR/OB
patient are not unduly referred
for the services those can be
available at the facility

Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of There is policy for identification of 0 RR/SI
patients is established at the facility patient before any clinical
procedure

ME E4.2. Procedure for ensuring timely and There is a policy for ensuring 0 RR/SI
accurate nursing care as per treatment accuracy of verbal/telephonic
plan is established at the facility orders

ME E4.3 There is established procedure of SDH/Taluk has policy for patient 2 RR/SI
patient hand over, whenever staff hand over during shift change
duty change happens
ME E4.4 Nursing records are maintained SDH/Taluk 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
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable SDH/Taluk identify and 2 OB/SI
patients and ensure their safe care communicate the category of
patient considered as vulnerable

ME E5.2 The facility identifies high risk patients SDH/Taluk identify and 2 OB/SI
and ensure their care, as per their need communicate the category of
patient considered as high risk

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic
ME E6.1. Facility ensured that drugs are Facility has policy drugs & their rational
and enabling 2 use.
RR
prescribed in generic name only order for prescribing drugs by
generic name only

ME E6.2 There is procedure of rational use of Facility provides adequate copies 2 SI/RR
drugs of STG to respective department

Facility maintains a list of updated 2 RR

version of STG
Facility provides training on use of 0 SI/RR
STG
Standard E7 Facility has defined procedures for safe drug administration
ME E7.3 There is a procedure to check drug Facility has policy for reporting of 2 RR/SI
before administration/ dispensing adverse drug reaction

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their
ME E8.7 The facility ensures safe and Dedicatd space for storage of storage 2 RR
adequate storage and retrieval of records.
medical records
SDH/Taluk has a policy for storing 2 RR
records in safe and secure
manner.

Records are stored in a manner 2 RR

that they could be retrieved
easily.

SDH/Taluk has policy for retention 2 RR

period for different kinds of
records

SDH/Taluk has policy for safe 2 RR

disposal of records
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E10.3. The facility has disaster SDH/Taluk has prepared disaster 2 RR
management plan in place plan
. Disaster management Committee 2 RR
has been constituted

Standard E15 The facility has defined and established procedures for end of life care and death
ME E15.1. Death of admitted patient is Facility has a standard 2 SI/RR
adequately recorded and procedure for decent
communicated communicate of death to
relatives

ME E15.3 The facility has standard operating Facility has established has 2 SI/RR
procedure for end of life support established policy for end of life
care

Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines
ME E19.1 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

Area of Concern - F Infection Control

Standard F1 Facility has infection control program and procedures in place for prevention and measurement of SDH/Taluk
ME F1.1. Facility has functional infection associated
Infection control committee is infection
2 SI/RR
control committee constituted at the facility
ICC is approved by appropriate 2 SI/RR
authority
. Roles and responsibilities of ICC 0 SI/RR
are defined and communicated to
its members

ICC meet at periodic time interval 2 SI/RR

Records of Infection control 2 SI/RR

activities are maintained
ME F1.2. Facility has provision for Passive Facility has linkage with 2 SI/RR
and active culture surveillance of microbiology lab for culture
critical & high risk areas surveillance

There is defined format for 2 SI/RR

requisition and reporting of
culture surveillance

Reports of culture surveillance are 2 SI/RR

collated and analyzed

Feedback is given to the 2 SI/RR

respective departments
ME F1.3 Facility measures hospital associated Samples are taken for culture to 2 SI/RR
infection rates detect HAI in suspected cases.

There is a defined criteria and 2 SI/RR

format for reporting HAI based on
clinical observation

Reports are collated and analyzed 2 SI/RR

Feedback is given to the 2 SI/RR

respective departments
ME F1.4. There is Provision of Periodic Records of immunization available 2 SI/RR
Medical Checkups and immunization
of staff
. Records of Medical Checkups are 2 SI/RR
available
ME F1.5. Facility has established procedures There is designated person for Co 2 SI/RR Infection control nurse
for regular monitoring of infection coordinating infection control
control practices activities

. There is defined format/checklist 2 SI/RR

for monitoring of hand washing
and infection control practices

ME F1.6. Facility has defined and established Facility has antibiotic policy in 2 SI/RR
antibiotic policy place
There is system for reporting Anti 2 SI/RR
Microbial Resistance with in the
facility

Antibiotic policy includes plan for 2 SI/RR

identifying, transferring ,
discharging and readmitting
patients with specific
antimicrobial resistant pathogen

The Policy Includes Rational Use 2 SI/RR

of Antibiotics
Standard treatment guidelines are 2 SI/RR
followed while developing
Antibiotic Policy

Facility Measures the Antibiotic 0 SI/RR

Consumption Rates
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
ME F2.1 Hand washing facilities are provided Facility ensures uninterrupted and 2 SI/RR
at point of use adequate supply of antiseptic
soap and alcohol hand rub in all
departments

ME F2.2 Staff is trained and adhere to Check for the records that training 2 SI/RR
standard hand washing practices have been provided
ME F2.3 Facility ensures standard practices Facility ensures uninterrupted and 2 SI/RR
and materials for antisepsis adequate supply of antiseptics

Standard F3 Facility ensures standard practices and materials for Personal protection
ME F3.1 Facility ensures adequate personal Availability of Heavy duty gloves 0 OB/SI
protection equipments as per for cleaning staff
requirements
Availability of gum boots for 2 OB/SI
cleaning staff
Availability of masks for cleaning 2 OB/SI
staff
Availability of apron for cleaning 2 OB/SI
staff
The facility ensures adequate and 2 SI/RR
regular supply of personal
protective equipments

ME F3.2 Staff is adhere to standard personal There is policy for judicious use of 2 SI/RR
protection practices personal protective equipments
specially sterile gloves

Standard F4 Facility has standard Procedures for processing of equipments and instruments
ME F4.1 Facility ensures standard practices and The facility ensure adequate 2 SI/RR Disinfectant like
materials for decontamination and supply of disinfectant at the point hypochlorite, bleaching
cleaning of instruments and of use powder etc.
procedures areas

Staff is trained for preparation of 2 SI/RR

disinfectant solution
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
ME F5.2 Facility ensures availability of standard Facility ensure the availability of 2 SI/RR
materials for cleaning and disinfection good quality disinfectant and
of patient care areas cleaning material

ME F5.4 Facility ensures segregation infectious SDH/Taluk has policy for 2 SI/RR
patients identification and segregation of
infectious patient

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical
ME F6.1 Facility Ensures segregation of Bio and hazardous
Facility ensures adequate and Waste.
2 SI/RR
Medical Waste as per guidelines regular supply of colour coded
liners

There is established procedure for 2 SI/RR

daily monitoring of proper
segregation of Bio medical waste
by a designated person

ME F6.2 Facility ensures management of Facility ensures supply of 2 SI/RR

sharps as per guidelines puncture proof containers and
hub cutters

Facility ensures availability of post 2 SI/RR

exposure prophylaxis drugs

There is system for reporting of 2 SI/RR

needle stick injuries
ME F6.3. 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

BMW is stored in lock and key and 2 SI/OB

unauthorized entry is prohibited

Log book /Record of waste 2 RR

generated is maintained
No signs of burning within the 2 OB
premises.
Check that infectious liquid waste 2 OB
is not directly drained in to
municipal sewerage system
 Disinfection & mutilation of solid 2 OB
plastic waste before disposal

Display of Bio Hazard sign at the 2 OB

point of use
Infectious Waste is not stored for 2 RR
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

Disposal of solid infectious waste 2 OB/SI/RR Preferably by CTWF/in-

as per BMW rule house incinerator
Disposal of sharp waste as per 2 OB/SI/RR Preferably by
BMW rule CTWF/disinfection
followed by
mutilation/shredding

Disposal of infectious plastic 2 OB/SI/RR Preferably by

waste as per BMW rule CTWF/Disposal as general
plastic waste after
decontamination and
mutilation

Annual report to the pollution 2 RR

control board is submitted
Biomedical waste transported in 2 OB/SI/RR
authorized vehicle
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for quality improvement
ME G1.1 The facility has a quality team in Quality Assurance Team for 2 SI/RR Check for Office order by
place SDH/Taluks is Constituted designated authority

. There is designated person for co 2 SI/RR SDH/Taluk Manager

coordinating overall quality
assurance program at the facility

Team members are aware for of 2 SI/RR

their respective responsibilities

ME G1.2. The facility reviews quality of its Quality team meets monthly and 2 SI/RR
services at periodic intervals review the quality activities

Minutes of meeting are recorded 2 RR

Results for internal /External 2 SI/RR Check the meeting records

assessment are discussed in the
meeting

SDH/Taluk performance and 2 SI/RR Check the meeting records

indicators are reviewed in
meeting

Progress on time bound action 2 SI/RR Check the meeting records

plan is reviewed
Follow up actions from previous 2 SI/RR Check the meeting records
meetings are reviewed

Resource requirement and 2 SI/RR Check the meeting records

support from higher level are
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
SDH/Taluk staff
 Quality team report regularly to 2 SI/RR
DQAC about Key Performance
Indicators

Quality Team report regularly to 2 SI/RR

DQAC about internal assessment
results and action taken

Standard G2 Facility has established system for patient and employee satisfaction
ME G2.1. Patient Satisfaction surveys are There is person designated to co 1 SI/RR
conducted at periodic intervals ordinate satisfaction survey

. Patient feedback form are 1 RR

available in local language
Adequate sample size is taken to 0 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 There is a procedure for 2 RR

back 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 0 RR

low performing attributes
Results of Patient satisfaction 2 RR/SI
survey are recorded and
disseminated to concerned staff

There is procedure for analysis of 2 RR

Employee satisfaction survey

There is procedure for root cause 0 RR

analysis of Employee satisfaction
survey

ME G2.3. Facility prepares the action plans for There is procedure for preparing 0 RR/SI
the areas, contributing to low Action plan for improving patient
satisfaction of patients. satisfaction

There is procedure to take 0 RR/SI

corrective and preventive action

There is procedure for preparing 0 RR/SI

action plan for improving
employee satisfaction

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.
ME G3.1. Facility has established internal Daily round schedule is defined 1 SI/RR
quality assurance program at and practiced
relevant departments
ME G3.2. Facility has established external External Quality assurance is done 1 SI/RR
assurance programs at relevant on defined interval
departments
ME G3.3. Facility has established system for There is system for reviewing 2 SI/RR At departmental
use of check lists in different departmental checklist and taking /SDH/Taluk Level
departments and services appropriate action

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key
ME G4.1. Departmental standard operating SDH/Taluk has documentedprocesses.0 RR
procedures are available Quality system manual
. SDH/Taluk has Records of 0 RR
distribution of Standard operating
procedure

. SDH/Taluk has system for 2 RR

periodic review of the standard
procedures as and when
required
ME G4.2. Standard Operating Procedures
adequately describes process and
procedures
ME G4.3. Staff is trained and aware of the
standard procedures written in SOPs part of SOPs
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and
ME G5.1. The facility conducts periodic
Periodic internal assessment plan
internal assessment
ME G5.2. The facility conducts the periodic
prescription/ medical/death audits
. There is predefined criteria and
SDH/Taluk has documented 2 RR
system for Internal audits at
defined intervals
SDH/Taluk has documented 2 RR
procedure for control of
documents and records
SDH/Taluk has documented 2 RR
procedure for defining Quality
objectives
SDH/Taluk has documented 2 RR
procedure for action planning
SDH/Taluk has documented 2 RR
procedure for training and
CMEs of SDH/Taluk staff at
defined intervals
SDH/Taluk has documented 0 RR
procedure for monthly review
meeting
Check Staff is trained for relevant 0 SI/RR Check for the training
records
prescription
audit
2 RR/SI
is prepared & followed
Internal Assessors are identified 2 RR/SI
Training of internal assessors is 0 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
There is established committee 0 RR/SI
for reviewing maternal death
There is established committee 0 RR/SI
for reviewing new born death
There is established committee 2 RR/SI
for medical and death audit
Drug and therapeutic committee 1 RR/SI
for Prescription audits
Medical audits are conducted at 1 RR/SI
periodic interval
Death audits are conducted at 2 RR/SI Maternal and death audits
periodic interval are conducted as per
guideline
Prescription audits are conducted 2 RR/SI
at periodic interval
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 0 RR/SI
conducting medical and death
audits
ME G5.4. Action plan is made on the gaps Departmental Action plan is 0 RR/SI
found in the assessment / audit reviewed periodically
process
ME G5.5. Corrective and preventive actions There is system to ensure that 0 RR/SI
are taken to address issues, corrective and preventive action
observed in the assessment & audit are taken timely

Standard G6 The facility has defined and established Quality Policy & Quality Objectives
ME G6.1. The facility defines its quality policy Quality policy are defined and 1 RR/OB
displayed in local language
Quality policy is in local language 1 RR/OB

ME G6.2. The facility periodically defines its Quality objective are reviewed at 2 RR/SI
quality objectives and key periodic intervals
departments have their own
objectives

. Quality Objectives are SMART 2 RR Specific, Measurable,

Achievable, Repeatable,
and time bound

ME G6.3. Quality policy and objectives are Check if top management is 2 RR/SI
disseminated and staff is aware of aware of quality policy and
that objectives

ME G6.4. Progress towards quality objectives Top management review progress 2 RR/SI
is monitored periodically on Quality objectives periodically

standard G7 The facility seeks continual improvement by practicing Quality tool and method.
ME G7.1 The faclity uses methods for quality SDH/Taluk maps critical processes 0 RR/SI All clinical and support
improvement in services and identify non value adding services process that are
activities critical to quality ,e.g.
OPD, IPD, OT, LR, NBSU,
Diagnostics, Pharmacy,
Blood storage, Admin,
Kitchen, Laundry,
Housekeeping etc.

The facility identifies non value 0 RR/SI Analysis of the Process

adding activities/waste/redundant map is done. All non-value
activities. adding activities, waste
and redundant activities
are identified.

The facility takes corrective action 0 RR The processes are

to improve the processes. reorganized and
implemented after taking
corrective actions.

Facility implements Plan do check 0 RR/SI

act (PDCA) approach to identify
the critical processes

ME G7.2 The facility uses tools for quality 5s, Prioritization, 7 Quality tools, 0 RR Any two Quality Tools
improvement. Mistake proofing etc.

Area of Concern -H Outcome

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1. Facility measures productivity Bed Occupancy Rate 2 RR
Indicators on monthly basis
. IPD per thousand population 2 RR
. OPD consultation per Thousand 2 RR
Population
. Maternal mortality per 1000 2 RR
deliveries
. Neonatal mortality per 1000 live 2 RR
births
. Nurse to bed ratio 2 RR
. No. of meeting held under RKS 2 RR
ME H1.2. The Facility measures equity indicators Proportion of BPL patient in OPD 2 RR
periodically & Indoor admission
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators Overall Referral Rate 2 RR
on monthly basis
Overall discharge rate 2 RR
. Proportion of obstetric cases out 2 RR
of total IPD
. Proportion of fund/ grant utilized 2 RR

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Average Length of Stay 2 RR
Indicators on monthly basis
. Crude mortality rate 2 RR
. Maternal mortality per 1000 2 RR
deliveries
. Neonatal mortality per 1000 live 2 RR
births
. SDH/Taluk acquired infection rate 2 RR Surgical Site, Device
related SDH/Taluk
acquired infection rate

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality overall LAMA Rate 2 RR
Indicators on monthly basis
. Patient satisfaction Score IPD 2 RR
Patient satisfaction Score OPD 2
. Staff Satisfaction Score 2 RR
. Turn over rate of contractual staff 2 RR

Administration Score Card

Administration
Score 83.3004
Area of Concern wise Score
A Service Provision 94.2857142857143
B Patient Rights 76.865671641791
C Inputs 82.5581395348837
D Support Services 85.4014598540146
E Clinical Services 87.8787878787879
F Infection Control 94.5454545454546
G Quality Management 64.7887323943662
H Outcome 100

Obtained Maximum Percent 13

A 66 70 94.28571429
B 103 134 76.86567164
C 142 172 82.55813953
D 234 274 85.40145985
E 58 66 87.87878788
F 104 110 94.54545455
G 92 142 64.78873239
H 44 44 100
Total 843 1012 83.30039526