Customized National Quality Assurance Standards for PHC State: Kerala

Checklist for National Health Program

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
Area of Concern - A Service Provision
Standard A4 The facility provides services as mandated in the National Health Programmes /State scheme(s).
ME A4.1 The facility provides services under Case detection & Early diagnosis of malaria 2 RR/SI Microscopy
National Vector Borne Disease Control case
Programme as per guidelines
Management of malarial cases 2 RR/SI

Referral of malaria cases 2 RR/SI Cerebral Malaria, Septecemia,

Bacterial Pneumonia etc
RR/SI Distribution of treated mosquito
net, indoor residual spray & larval
Preventive Activites for Malaria control 2 control Method
Diagnosis & treatment for local prevalent 2 RR/SI Lymphatic Filariasis
vector born Disease Dengue
Japanese Encephalitis
Chikungunya
Kala Azar (Leishmaniasis)
ME A4.2 The facility provides services under Availability of case detection & Early 2 RR/SI
Revised National TB Control Programme diagnosis of TB
as per guidelines
2 RR/SI
Availability / Linkage to microscopic centre
Availability of functional DOT Centre 2 RR/SI
Treatment of tuberculosis 2 RR/SI
2 RR/SI
Management of Common complication &
side effects of treatment
Linkage for chest X ray & culture sensitivity 2 RR/SI
of Mycobacterium bacilli for diagnosis of
TB
ME A4.3 The facility provides services under Early detection of leprosy & its 2 RR/SI Community empowerment &
National Leprosy Eradication Programme complications mobilization of self referral,
as per guidelines capacity building
Early referral of disabled cases 2 RR/SI Identification of cases having
disability their early referral &
follow up at village level
Diagnosis & treatment 2 RR/SI All reported and referred cases
examined following standard
procedure, diagnosed based on
cardinal signs and treated with
MDT & Management of Nerve
impairment
Referral Services for complicated laprosy 2 RR/SI Difficult to diagnosis cases,lepra
cases reaction difficult to
manage,Complicated ulcer,Eye
problem,cases of reconstructive
surgeries,person needs customized
footwear.

ME A4.4 The facility provides services under National Early detection of HIV 2 RR/SI Screening of Antenatal mothers,
AIDS Control Programme as per guidelines high risk behaviour cases and cases
referred by field worker

Availability/ Referral linkage with ICTC for 2 RR/SI

ME A4.5 The facility provides services under National
Programme for control of Blindness as per
guidelines
ME A4.6 The facility provides services under Mental
Health Programme as per guidelines
confirmation of HIV status
Condom Promotion & distribution among RR/SI
high risk groups 2
Counselling & guide patient with HIV/AIDS 2 RR/SI
for receiving ART
Support to patients receiving ART for their 2 RR/SI
adherence
Linkage with Microscopic centre for HIV TB 2 RR/SI
coordination
Screening and correction of refractive 2 RR/SI Availabilityof refraction services at
errors PHC /outreach (Schools)
Medical treatment for prevention &control 2 RR/SI Conjunctivitis, Night blindness, Stye
of common Eye diseases etc
Availability of diagnosis & Referral services 2 RR/SI
for cataract cases
Survey for prevalence of various eye 2 RR/SI Nutrition education (prevent vit A
diseases & Health Education for prevention deficiency), Water & sanitation
of various eye diseases education (Trachoma Control)
Maternal & child health education
(Reduce retinopathy of
prematurity), Health education
(Prevention of eye trauma,
hypertension & diabetic
retinopathy)
Early identification & treatment of 2 RR/SI Evaluation of direct/ Referred cases
common mental disorders in OPD from ANM/ community workers &
their appropriate cases. Anxiety
Neurosis, Mild depression

Referral of difficult cases to DH/ Psychiatric 2 RR/SI Meniac cases, schizophernia

Follow up of the cases having treatment at 2 RR/SI

ME A4.7 The facility provides services under National
Programme for the health care of the elderly
as per guidelines
higher central
Geriatric clinic on fixed day for Conducting 2 RR/SI Every week, Display fixed day &
a routine health assessment & treatment time
Sensitization on promotional, preventive 2 RR/SI
and rehabilitative aspects of geriatrics
ME A4.8 The facility provides services under National Health Promotion Services to modify
Programme for Prevention and control of individual, group and community
Cancer, Diabetes, Cardiovascular diseases & behaviour
Stroke (NPCDCS) as per guidelines
Early detection, management and referral
of Diabetes Mellitus, Hypertension and
other Cardiovascular diseases and Stroke
ME A4.9 The facility Provides services under Integrated Weekly reporting of epidemic prone
Disease Surveillance Programme as per diseases
Guidelines
Availability of Water Quality Tests
ME A4.10 The facility provide services under National Early identification of cases of hearing
health Programme for prevention and control impairment
of deafness
Ear Screening Camps
Primary ear care for common problems
Rehabilitation services
ME A4.11 The facility provides services under School Screening of general health of school going
Health Programme children
Early detection, diagnosis, treatment and
referal for health problems
Micronutrient (vit A & IFA) Management
Deworming as per National guidelines
Health Promotion & health education
ME A4.12 The facility provides services under Universal Functional Immunization Clinic
Immunization Programme
Immunization of Pregnant Women
Immunization of Infants
Immunization of Children
Vit A
Management & logistic support for
immunization program
ME A4.13 The facility provides services under National Promotion & monitoring for consumption
Iodine deficiency Programme of iodized salt
ME A4.14 The facility provides services under National Promotion of quitting of tobacco in the
tobacco Control Programme community.
Counselling service on tobacco cessation to
all
smokers/tobacco users.
ME A4.15 The facility provides services as per local Avaialbility of Pallative care services for bed
needs/ State specific health programmes ridden patients
Availability of services during home visit
Availability of procedures during home
visit
Area of Concern B - Patients' Right
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.2 The facility displays the services and Availability of Information for services
entitlements available in its departments under all National Health Program
2 RR/SI Promotion of Healthy Dietary
Habits.
Increase physical activity.
Avoidance of tobacco and alcohol.
Stress Management.
2 RR/SI history, measuring blood pressure,
checking for blood, urine sugar
2 RR/SI S, P & L forms and SOS reporting of
any cluster of cases
2 RR/SI Water samples are collected & sent
to public Health lab. for Quality
testing
2 RR/SI At PHC and outreach
2 RR/SI Organized as per state schedule (1
screening camp is orgnaized at
PHC/CHC/DH on rotation basis per
month)
2 RR/SI Early treatment of Upper
respiratory infection, Impacted
Wax, Otitis Media,foreign body
removal
2 RR/SI Reffered to Higher Centre
2 RR/SI
2 RR/SI Assessment of Anaemia/Nutritional
status, visual acuity, hearing
problems, dental check up,
common skin conditions, Heart
defects, physical disabilities,
learning disorders, behaviour
problems
2 RR/SI On fixed day, Weekly supervised
distribution of Iron-Folate tablets
coupled with
education about the issue and vit A
in needy cases
2 RR/SI
2 RR/SI Regular Practice of Yoga, Physical
education, Health education &
counselling services, personal
hygiene, HIV/AIDS, supply of IEC
package to schools,Health clubs,
Health cabinets &First Aid
room/corners or clinics
2 RR/SI Fix day immunization
2 RR/SI TT1 & 2
TT Booster
2 RR/SI OPV 123, DPT 123, /Pentavalent
Hepatitis 123, Measles 1& 2
2 RR/SI DPT Booster, OPV Booster, JE , DT
booster, TT
2 RR/SI 1st dose at 9 month with measles,
2nd to 9th dose 16 month with
DPT/OPV booseter, then 1 dose
every 6th month up to age of 5 yrs
2 RR/SI Microplanning, supervision &
storage of vaccines &
transportation
2 RR/SI
2 RR/SI Health education and IEC activities
regarding harmful effects of
tobacco use and passive smoke.
2 RR/SI
2 RR/SI Home visits & Special Out patient
department
2 RR/SI Evaluate & treatment of Physcial
symptoms, Adjust medication,
psychosocial support, Empower &
teach patient for selfcare,
Empower & educate family to care
2 RR/SI Adminstration of parenteral drugs,
Nasogastric tube, cathetrisation,
wound care, Mouth care, Bowel
2 OB Pictorial & Local language
ME B1.4 Patients & visitors are sensitised and Availability &display of IEC material for
educated through appropriate IEC / BCC RNTCP
approaches
Availability &display of IEC material for
NVBDCP
Availability & display of IEC material under
National blindness control program is
available
Availability of IEC kit for mental health
program
Availability of IEC material for National
Deafness Control Program
Provision of basic information on modes of
transmission and prevention of HIV/AIDS
for promoting behavioural change and
reducing vulnerability.
Area of Concern - C Inputs
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
ME C3.3 The facility has adequate Health workers Availability of Multiple Health worker/
as per requirement MPW as per guideline
ME C3.5 The Staff has been imparted necessary Training of Medical officer for RNTCP
trainings/skill set to enable them to meet
their roles & responsibilities
Training on Lab technician for RNTCP
Training for Pharmacist RNTCP
Training for MPW module under
RNTCP
Training of Aganwadi workers/
ANM/Community volunteer under
RNTCP
Re-training is conducted as per
retraining schedules of RNTCP
Induction training for newly appointed LT
working for NVBDCP
Reorientation training for LT working for
NVBDCP
Training of Medical officer under National
Blindness Control Program
Training of MO for mental health program
Training of Health Worker for Mental
health Program
Training of Medical Officer for National
Deafness Control Program
Training of nurse/ ANM/ AWW supervisors
at PHC on National Deafness Control
Program
Training of MO on National Program for
Health care of elderly
Training of Paramedics staff for National
Program for Health care of elderly
Training of MO on immunization
Training of Health workers on
immunization
Training of Cold chain handlers on
immunization
Training on NACP
Training on leprosy
Training on IDSP
Training on School health Program
Training on Tabacco control
Standard C4 The facility provides drugs and consumables required for assured services.
ME C4.1 The departments have availability of
adequate drugs at point of use Availability of Anti tuberculor drugs under
RNTCP
2 OB Availability of information about
facts of TB, do's & donot's, sure
cure of TB, adverse effects of
having incomplete treatment.
2 OB Posters for Treated Mosquito nets,
Signs of maleria fever, preventing
Stagnant Water, Preventing Maleria
in pregnancy
2 OB Diabetic retinopathy, cataract,
glucoma, refractive error,
trochoma, prevention from corneal
blindness. Also IEC material for eye
donation
2 OB Poster with 10 feature of mental
disorder & flip chart for use of
health educator
2 OB For prevention & early detection of
hearing impairment & deafness
2 OB IEC activities to enhance awareness
& preventive measures about STI
,HIV/AIDS & PPCT
2 SI/RR
2 RR/SI Module 1-4, TB-HIV module
2 RR/SI LT module & EQA module
2 RR/SI DOTS
2 RR/SI Senior treatment supervisor
module, TB Health visitor module &
MPW /Health assistant module
training as applicable
2 RR/SI DOT provider module on TB, DOT
provider module on TB-HIV
2 RR/SI
2 RR/SI
2 RR/SI
2 RR/SI Orientation & refresher training of
Medical Officers of PHCs in
community ophthalmology &
Prevention of Blindness
2 RR/SI 6 days training each year for
doctors at district level under
DMHP for early identification,
diagnosis and management of
common mental disorders
2 RR/SI 2 days training each year for health
workers of PHC (All paramedical
staff, ANM/ Nursing staff, Health
educator )
2 RR/SI Sensitization about program,
Creating of awareness regarding
preventable diseases of ear,
reorientation in early diagnosis &
treatment of common ear diseases,
2 RR/SI Sensitization about program&
awareness regarding ear & hearing
care,enable them to identify
deafness at early stage & motivate
them for awareness generation at
community level
2 RR/SI At least 1 MO is trained
2 RR/SI At least 2 nurses are trained
2 RR/SI 3 day training at district level
2 RR/SI 2 day training for ANM, LHV
2 RR/SI 2 day training at district level to
designated cold chain handler
(ANM, Clerk or Pharmacist
2 RR/SI
2 RR/SI
2 RR/SI
2 RR/SI
2 RR/SI
As per internationally accepted first
2 OB/RR/SI line treatment regimen

Standard D8 Hospital has defined and established procedure for monitoring & reporting of National Health Program as per state specifications
ME D8.1 The facility provides monitoring &
reporting services under National Vector
Borne Disease Control Programme
ME D8.2 The facility provides services monitoring
& reporting services under Revised
National TB Control Programme
ME D8.3 The facility provides monitoring &
reporting services under National
Leprosy Eradication Programme as per
guidelines
ME D8.4 The facility provides services under
National AIDS Control Programme
ME D8.9 The facility provide monitoring & reporting
service for Integrated disease surveillance
Programme
Availability of first dose drugs under
NVBDCP
Subsequent doses are arranged from block
CHC and proovided to patient
Availability of first dose of Drugs for
National Leprosy Eradication Program
Availability of Drugs for Mental Health
Program
Area of Concern - D Support Services
Reporting is done on Form 01 (MF 2)
Reporting is done on Form 02 (MF 4)
Reporting is done on Form 03 (MF 5)
Reporting is done on Form 08 (MF 16)
Availability of Quarterly reports on New
and retreatment cases of TB
Availability of Quarterly report on sputum
conversion of New and retreatment cases
registered 4-6 month earlier
Availability of Quarterly report on result of
treatment of TB patient registered 13-15
month earlier.
Availability of Monthly report on Program
Management, Logistics and Microscopy by
Peripheral Health Institutions
Monthly report on programme
management, logistics and microscopy
filled at all healthcare facilities & sent to
CMO/DTO/ concerned TU within defined
period
Reporting is done on MLF -04 under NLEP
Details of referral to & from various
facilities
Check form S is filled for information
required
Reporting format (Form S) are sent to PHC
as per guidelines
Chloroquine phosphate,Primaquine
2 OB/RR/SI
Artesunate,Pyrimethamine,Quinine
sulphate,Sulfadoxine +
Pyrimethamine
2 OB/RR/SI
2 Availability of MDT
OB/RR/SI Availability of Prednisolone
2 Tab. Diazapam 5mg
Inj. Promethazine 50mg
OB/RR/SI
2 RR For reporting of blood smear by
surveillance worker/MPW/Passive
agency etc.e.g., patient’s name,
age, sex and village, etc. A code
number is given to each patient in
terms of blood smear number. This
will help in identification of each
fever case screened, for tracing out
to provide radical treatment and
also for follow up
2 RR Monthly reporting of malaria
program of PHC , it provides details
of the worker wise blood smears
received and their results.
2 RR Monthly epidemiological report of
malaria program of PHC, it provides
species wise details of the positive
cases and radical treatment
provided
2 RR for reporting drug distribution
centre, fever treatment depots &
malaria clinics
2 RR
2 RR
2 RR
2 RR
2 RR Before 5th of next month
2 RR Monthly progress report from PHC
to District regarding different
DPMR activities
2 RR
2 RR Form for syndromic surveillance
reporting
Check -Form S contain information
about State, district, block, year,
Name of reporting unit, name of
reporting person, name of
supervisor ,reporting week, Cases:
Male or female <5 yrs or >5yrs,
Deaths : Male or female <5 yrs or
>5yrs, total of each along with date
& signature
2 RR Form S is filled in triplicate, Health
worker place carbon papers
between each page of form S. First
& second page (Yellow & green)
sent to MO PHC while third (Blue)
copy is kept by Health worker
 Check form P is filled for information
required
Reporting format (Form P) are sent to DSU
as per guidelines
Check form L is filled for information
required
Reporting format (Form L) are sent to
District Surveillance Unit (DSU) as per
guidelines
PHC ensures the submission of data from
Sub centre & other rural reporting points
PHC ensure submission of data to DSU
MO is aware of what to do with form S
submitted by sub centre
ME D8.10 The facility provide services under Reporting format on PHC
National Programme for prevention and
control of deafness
ME D8.12 The facility provides monitoring & Staff Know AEFI cases to be reported
reporting services under Universal immediately to MO/ District Immunization
Immunization Programme Officer
Formats for First Information Report &
Preliminery Investigation Report are
available at the faclity
Staff is awrae of Cycle time for reporting
FIR/PIR
Routine Monthly reporting is done to
District Immunization Officer
Area of Concern - E Clinical Services
Standard E5 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E5.4 Adequate form and formats are available Availability of Form / Format for testing
at point of use and Diagnosis of TB under RNTCP
Availability of formats for National Leprosy
Eradication Program
ME E5.5 Register/records are maintained as per Availability of Records for RNTCP
guidelines
Blind register is maintained at facility
Availability of records for National Leprosy
Eradication Program
2 RR Form for presumptive surveillance
reporting
Form P contain information Name
of reporting unit, state, district,
Block,Name of officer incharge
along with signature, IDSP
reporting week, No.of cases under
each disease and syndrome
2 RR Form P will be filled in duplicate
(two copies), Surveillance officer
may place carbon paper in
between 2 sheets, One copy (blue )
is retained by MO and other
(Yellow) will be sent to DSU
2 RR Form for Laboratory surveillance
reporting
Form L contain information for
Name of Lab, state, district, block,
Name & signature of officer
incharge along with information
about no, of samples tested and
no. of sample found positive.
Format also include line listing of
positive cases except malaria cases
along with age &sex breakage
2 RR Form L will be filled in duplicate
(Blue & Yellow), PHC retain blue
copy while Yellow will be sent to
DSU
2 RR By Monday of every week
2 RR By Tuesday of every week
2 RR/SI Form S (Yellow coloured) copy is
submitted to DSU by PHC,
Simultaneously MO I/C for disease
surveillance of PHC will analyse the
information available in form S
w.r.t occurance of any target
disease above expected frequency
2 RR Contain detail of PHC, village, no.
of doctors at PHC are trained ,
number of cases identified
between 0-5, 6-15, 16-50, >50 yrs
(separately male & female), no. of
cases treated, no. of cases
referred, to whom and reason of
referral.
2 SI Death , Anaphylaxis, Toxic Shock
Syndrome, Hospitalization ,
Disablity etc.
2 RR
2 SI 24 hrs for FIR
7 Days for PIR
2 RR Check for the records
2 RR/OB Mycobacteriology
culture/sensitivity test form
Laboratory form for sputum
examination
tuberculosis treatment Card
referral treatment form
transfer form
2 RR/OB Assessment of disability &Nerve
function/Disability assessment
form (P1/S1/T1), Sensory
assessment, Predisolone Card
(P4/S4/T4), Referral Slip for
ASHA/HW/PHC/CHC (P5/S5)
2 RR TB laboratory monthly abstract
Referral/Treatment Register
TB Register
2 RR Blind register have information on
name of district, block /PHC, village,
name of patient along with address
and age, visual acuity (Left & right),
Main cause of blindness, &
outcome)
2 RR Disability register (P1/S1), Record
of lepra reactions/Neuritis cases
(form P3/S3/T3)

Standard E8
ME E 8.4 There are established procedures for
Laboratory Diagnosis of Tuberculosis as
per prevelant Guidelines
ME E 8.5 There are established procedures for
Laboratory Diagnosis of Malaria as per
prevelant Guidelines
National Health Programmes
Standard E15 The facility provides National health Programme as per operational/Clinical Guidelines of the Government
ME E15.1 The facility provides services under
National Vector Borne Disease Control
Programme as per guidelines
ME E15.2 The facility provides services under
Revised National TB Control Programme
as per guidelines
Availability of Records for School Health
Program
The facility has defined and established procedures for diagnostic services
Medical Practioner fills standardized
laboratory form for sputum
examination
Laboratory staff follow guideline for
collecting sputum for smear microscopy
Laboratory staff/ health worker
provide guidance to patient for sputum
collection
Laboratory staff is aware of
methodology for smear preparation &
staining slides
Staff is aware of how to examine and
interpetate sputum smear
Instruction to Ziel Neelsen Staining
procedure &interpretation chart are
displayed at working station
Availability of Standard operating
procedure for equipments required for
malarial diagnosis
Availability of Standard operating
procedure for processes required for
malarial diagnosis
Health worker/Health professionals are
skilled to identify cases of suspected
malaria
Microscopic result is available within
defined period
Treatment for confirmed P. Vivax Malaria is
done as per protocols
Staff is aware of cases contraindicated for
administration of Primaquine
Patient on malaria treatment (specially on
Primaquine) are provided with information
about when to report back
Algorithm for treatment & diagnosis of
malaria is available with treating physician
Identification of drug resistance /failure
cases especially falciparum is done as per
protocols
Decision on treatment is taken based on
Drug sensitivity pattern & history of anti TB
treatment
Staff is aware of pre treatment evaulation
of MDR_TB
Pre treatment counselling is provided to all
TB patients
Education & counselling is provided to
patients' family
Patient identity card is prepared
2 RR Health appraisal register (Appraisal
register contain information on
date of visit1, visit2 &visit 3,
class,name & type of school, name
of student,age, height, weight,
clincal diagnosis, treatment,
referred to, follow up and
immunization status), Referral
register
Drug stock register
2 OB/RR
2 RR/SI Two sample will be collected: Early
morning-Spot
2 SI/PI Provide guidence about steps how
to collect the sputum
2 SI/RR Ziel Neelsen /(1% Carbol fuchsion,
25% Sulphuric Acid, 0.1%
Methylene blue). If Laboratory is
not designated DMC, give full
compliance
2 SI/RR If Laboratory is not designated
DMC, give full compliance
2 OB If Laboratory is not designated
DMC, give full compliance
2 SI/RR
2 SI/RR
2 SI/RR Fever is cardinal symptom. It may
be intermittent with or without
priodicity or continuous, Fever in
many cases accompanied with
rigours & chills. Headache, myalgia,
arthralgia, anorexia, nausea &
vomiting.
2 RR Within 24 hrs. If in Pf predominant
area result is not available with in
24 hrs. check the provision of RDT
2 SI/RR P.vivax cases should be treated
with chloroquine for three days
and Primaquine for
14 days.
2 SI/RR Primaquine is used to prevent
relapse but is contraindicated in
pregnant
women, infants and individuals
with G6PD deficiency.
2 SI/RR/PI Patients should be instructed to
report back in case of haematuria
or high colored urine / cyanosis or
blue coloration of lips and
Primaquine should be stopped
2 SI/RR Check for availability of Alogrithm
2 SI/RR
2
2
2
2 About Disease, treatment, schedule
& adherence to treatment,
transmission of disease
&consequences of irregualr
treatment
2

ME E15.3 The facility provides services under
National Leprosy Eradication Programme
as per guidelines
Treatment card is open for each patient
Treatment of new TB patient is done as per
internationally accepted first line treatment
regimen
Staff is aware of drugs & duration of
treatment of New TB patients in initial
phase
Staff is aware of drugs & duration of
treatment of New TB patients in
continuation phase
Staff is aware of drugs & duration of
treatment of previously treated cases of
TB in initial phase
Staff is aware of drugs & duration of
treatment of previously treated cases of
TB in continuation phase
PHC provide drugs for intial &
continuation phase as per revised regimen
Staff is aware of conditions in which
duration of continuation phase is
increased
Staff is aware of drug formulation for fixed
dose combination of four, three & two
drugs
Staff is aware re treatment regimen
Staff is aware of classification based on
drug resistance
Staff is aware of drug regimen for MDR TB
cases
Algorithm for treatment is available with
treating physician for MDR /RR TB cases
with additional resitance
HIV testing of all TB cases is ensured
Staff is aware of Patient flow in case of DR-
TB patients
History taking as per guidelines
Examination of skin as per guidelines
Physical Examination as per guidelines
2 In duplicate when required
2 SI/RR
2 The initial phase consist of two
months of Isoniazid (H), Rifampicin
(R), Pyrazinamide (Z), and
Ethambutol (E )as per weight band
category
2 SI/RR The continuation phase should
consist of three drugs (Isoniazid,
Rifampicin and Ethambutol) given
for at least four months as per
weight band categories
2 SI/RR (2) HRZES +(1) HRZE IP will be of
12 weeks where injection
Streptomycin will be stopped after
8 weeks as per weight bands
2 SI/RR 5 HRE
2 SI/RR
2 OB/RR Extended by three to six months in
special situations like bone & joint
TB, spinal TB with neurological
involvement and neuro-
tuberculosis
2 SI/RR Fixed dose combinations (FDCs) of
four drugs (Isoniazid, Rifampicin,
Pyrazinamide, and Ethambutol),
and three drugs (Isoniazid,
Rifampicin and Ethambutol) and
two drugs (Isoniazid and
Rifampicin) are recommended
2 SI/RR Retreatment regimen containing
first-line drugs:
2HREZS/1HREZ/5HRE. Retreatment
for Patient returning after lost to
follow up, relapse , new TB patients
failing with first treatment course
2 SI/RR Mono resistance (MR), poly drug
resitance (PDR), multidrug resitance
(MDR), Rifampicin resitance (RR)
Extensive drug resistance (X DR)
2 SI/RR 6-9 month Kanamycin,
Levofloxacin, Ethmabutol,
Pyrazinamide, Ethionamide,
cycloserine - IP. 18 month
Levofloxacin, Ethmabutol,
Ethionamide & cycloserine- CP
2 SI/RR
2 SI/RR
2 SI/RR registration of cases in DR-TB
register, pre treatment evaluation,
treatment cards, initation of
treatment, issue of IP box , follow
up etc
2 SI/RR Includes duration of lesion,
duration of disability if any, family
history/ contact history &previous
treatment
2 SI/RR Include information No. of patches,
colour of patch, morphology of
patch, nodule, infiltration, test for
loss of sensation in patch
2 SI/RR Dryness of hands & feet, swelling &
redness of patches and joints,
Wasting of muscle, visible
deformity in hand, feet,
eye,Redness on palm or sole,
callous, Blister, ulcer,High stepping
gait or any change in
gait,Appearance of new lesions or
expansion of existing
lesion,Absence of blink in the
eyes,Redness and watering in the
eyes

ME E15.4 The facility provides services under
National AIDS Control Programme as per Positive
guidelines
ME E15.5 The facility provides services under
National Programme for control of
Blindness as per guidelines
ME E15.6 The facility provides services under
Mental Health Programme as per
guidelines
ME E15.7 The facility provides services under
National Programme for the health care
of the elderly as per guidelines
ME E15.9 The facility provide service for Integrated PHC has defined schedule for testing of
disease surveillance Programme
Examination of eye as per guidelines
Management of disability grade I as per
guidelines
Standard adult treatment regimen for MB
leprosy is followed
Standard adult treatment regimen for PB
leprosy is followed
Standard children (10-14yrs) treatment
regimen for MB leprosy is followed
Staff is aware of adverse reactions to MDT
and their management
Staff is aware of leprosy reaction and their
treatment
Referral out of Patient as per guideline
Referral in of the patient as per guidelines
Check the method to declare client HIV
Criteria to diagnosis the cases of HIV in
window period
Availability of protocols for visual acuity
measurement for children
Availability of protocols for visual acuity
measurement for aged/ adult aged 45yrs
Elementary diagnosis of Mental disorders
as per guidelines
Treatment of functional psychosis as per
guidelines
Treatment of uncomplicated cases of
psychiatric cases associated with physical
diseases as per guidelines
Management of uncomplicated
psychosocial problems as per guidelines
Epidemiological surveillance of mental
disorders as per guideline
Health assessment for elderly person
based on simple clinical examination
relating to vision, joints, hearing, chest, BP
and simple
investigations including blood sugar, etc. is
done
A simple questionnaire will be filled up
during the first visit of each Elderly as per
guideline and record updated and
maintained
drinking water sources
2 SI/RR Look for any redness of the
eye,Note “watering from the eye”
from history and
observation,Observe for blink –
Present or Absent, Look for lid gap
or inability to close one or both
eyes (Lagophthalmos)
and check for normal strength of
eye closure,Check the visual acuity
of each eye separately, using a
Snellen’s chart or
by counting fingers at 6 meters
2 SI/RR If the duration of disability grade 1
i.e. anaesthesia along the course of
trunk nerve is recent (< 6 months),
a course of Prednisolone is to be
started to treat neuritis.
2 SI/RR Rifampicin: 600mg once in month,
Clofazimine: 300mg once in month
& 50mg every day, Dapsone: 100
mg (for 12 month)
2 SI/RR Rifampicin: 600 mg once in month,
Dapsone; 100 mg daily (for 6
month)
2 SI/RR MB: Rifampicin:450mg once in
month,Clofazimine: 150mg once in
month,50 mg daily, Dapsone: 50
mg daily (12month). PB:
Rifampicin: 450 mg once in month,
Dapsone; 50 mg daily (for 6 month)
2 SI/RR Like Red urine, anaemia, brown
discoloration of skin, gastro
intestinal upset. Management
reassurance, given iron and folic
acid, counselling & give drug with
food
2 SI/RR 2 types of reaction: Type 1-
Reversal reaction, Type 2- Erthyma
Nodosum leprosum(ENL)
2 SI/RR Referral of cases where lepra
reaction is difficult to
manage,complicated ulcer, eye
problem,reconstruction surgery
cases, persons needing gradeII foot
wear,follow up of RCS
2 SI/RR Referral of the cases having
reaction, disability, neuritis and
ulcer.
2 SI/RR A client is declared to be HIV-
positive when the same blood
sample is tested three times using
kits with different
antigens/principles and the result
of all three tests is positive.
2 SI/RR Such cases require testing after 12
weeks
2 SI/OB Check flow chart/ Instruction
available with POA
2 SI/OB Check flow chart/ Instruction
available with POA
2 SI/RR
2 SI/RR
2 SI/RR
2 SI/RR
2 SI/RR
2 SI/RR
2 SI/RR
2 SI/RR Frequency of testing is decided by
MO on basis of incidence of water
borne diseases. During out break
test must be done at least once in a
day
 Health worker is competant to conduct test
for drinking water sources at village level
Presumptive surveillance register is
available at PHC
MO/ treating Physician is using
Presumptive surveillance register for
recording of cases during routine OPD
activities.
Presumptive surveillance register contain
information as per requirement
Hospital has system in place to count and
fill weekly total of cases before starting the
new week
There is some designated person to
supervise the job and confirm information
before submitting
Laboratory technician of PHC is aware of
IDSP target diseases required to be
reported on weekly basis
Staff is aware of what to do in case they
recognize early signals of outbreak
ME E15.10 The facility provide services under Diagnosis & treatment of chronic
National Programme for prevention and supportive otitis media (CSOM) (Safe type)
control of deafness as per standard treatment guideline
Diagnosis & treatment of chronic
supportive otitis media (CSOM) (unsafe
type) as per standard treatment guideline
ME E15.11 The facility provides services under School Action plan for school health is available at
Health Programme PHC level
School medical team is formed at PHC level
Medical Examination of the student is done
as per guidelines
Eye care services are provided as per
guideline
Dental care services are provided as per
guidelines
De worming as per guidleines
Anaemia Management
School environment survey is done by PHC
staff as per guideline
ME E15.12 The facility provides services under Staff is aware of when not to give
Universal Immunization Programme pentavalent vaccines
Staff is aware of how to cover if some of
the dosages missed
Staff is aware of what to do if a child
completely missed the vaccination up to 9
months of age
Check for Sub centre Micro plan for
Immunization is available at PHC
Check for Micro plan are adequately
prepared
Staff is aware of how to calculate the no. of
Beneficiaries (pregnant women & Infants
for every vaccination)
Staff is aware of how to calculate the
quantity of vaccines and syringes based on
estimated beneficiaries
2 SI/RR Test Ortho Toludine test (using
chloroscope). Accepted value on
consumer side is 0.2 -0.8 ppm
2 RR/OB
2 RR/OB
2 RR/OB Recording of date &personal details
(Name, age& Sex) of case as well as
write probable diagnosis of disease
based on clinical examination or
record of presenting symptoms
2 RR/OB Check total is available on Top left
hand corner of the every page of
register
2 RR/SI MO confirm the information before
submission
2 RR/SI Laboratory assistant/technician at
PHC are required to report for
Malaria, Tuberculosis & Typhoid
2 SI During analysis of data if staff
encounter unusual increase in
no.of cases in a particular category,
they have to notify on telephone
same to DSU, A written report /mail
can follow subsequently.
2 SI/RR
2 SI/RR
2 RR/SI There is fixed as school health day,
Each school should be visited 3
times/ year
2 RR/SI
2 SI/RR Medical examination include
general health checkup,Physical
measurement & personal hygiene,
Eye examination, Ear discharge&
hearing problem,Common dental
defects,congenital heart
defects,disability screening,
learning disoders, behaviour
disoders,stress and anxiety etc
2 SI/RR Screening by teacher, PMOA
assesssment & conformation, order
of spectacles & supply of spectacles
2 SI/RR screening by teacher, sent to
dental camp at block level, filling,
extraction and referral during camp
2 SI/RR Biannually administration of
Albendazole
2 SI/RR Weekly IFA tablet given to
adolescent girls, distribution
through class teachers
2 SI/RR Survey includes safe water & clean
sanitation, hygienic class room &
environment, Quality of food
provided
2 SI If child had severe allergic reactions
in previous dose of immunization
and if Child has severe acute illness
2 SI DPT can be given till 2 year, OPV till
5 year. Do not start the schedule if
some dosages are missed , instead
administer the dosage needed to
complete the series
2 SI
2 RR
2 RR
2 SI/RR
2 SI/RR No. of Beneficiaries X
Wastage/Dosages per multidoages
vial

ME E15.14 The facility provides services under
National tobacco Control Programme
ME E 15.15 The facility provide services under
Pallative care Program
Check for PHC has prepared map with
route of alternate vaccine Delivery and
sessions site
Check for supervision plan has been
prepared for immunization activities
Daily plan for Alternative Vaccine Delivery
is prepared
Linkages with tobacco cessation facility
Doctor/ Staff are skilled for tobacco
cessation counselling
Facility has been declared tobacco free
zone
Check for any specific community level
activity is done for generating awareness
Facility has adequate staff for Palliative
care
MO is trained for palliative care activities
Staff involved in Home care is trained for
palliative care activities
Community Palliative care nurse is trained
for Palliative care
Patient require Palliative care are identified
& registration of patient is arranged by
Medical Officer
Check data is available on number of
patient's requiring palliative care in
catering population
Check the availability of Home care visits
plan
Drugs & supplies are available regularly
Facility has provision to purchase drugs
from LSGI (Local self Govt. Institutions)
Regular meetings are conducted by
Medical officer with Home care team
Separate OPD services are available for
Palliative care patients
Adequate medicine is given to patients
registered under Palliative care
Vehicle is available for Home care visits
Home Visit kit is available with staff
involved in home care visits
Home visit kit contain monitoring devices
Home visit kit contain grooming tools
Home visit kit contain consumables
Home visit kit contain drugs
Material in kit is available in adequate
quantity
Drugs are available in facility for palliative
care
Palliative care nurse is trained in
assessment of pain
2 SI/RR Check for whether map dipcating
route for supplying vaccines to
different sites /immunization
session has been prepared
2 RR
2 RR Check for Session site, distance
from ILR point and Travel time,
time of delivering and collecting
vaccines is filled correctly
2 SI/RR Check for doctor aware of nearest
tobacco cessation facility Check
how many patients are referred to
cessation centre
2 SI Ask about 5 As and 5 Rs Full form
for R s & A s
2 OB Restriction on use of tobacco
product by staff or visitors
2 SI/PI
2 RR/SI
Check availability of community
Palliative care Nurse, volunteer
from Community based
organizations
2 RR
MO has completed foundation
course in pain management/ Basic
certificate course in Palliative care
2 RR
JHI, JPHN & supervisors etc.
2 RR Received 3 week Certificate course
in community Palliative Nursing
care
2 RR
Check register in maintained
2 RR
Check data is updated on defined
intervals
2 RR Check patient's are getting visits as
per their needs
2 RR/SI Check there is no stock out of
drugs.
2 RR/SI
For the drugs not available
regularly through KMSCL
2 RR/SI
2 SI/PI/RR
At least once in week
2 RR/SI
1 Month /extended up to 6 weeks
on Medical officers' direction
2 SI/OB
Either of facility /provided by CBO
2 SI/OB
2 SI/OB BP apparatus, Glucometer,
Stethoscope, Torch
2 SI/OB
Nail cutter, Shaving kit & Scissors
2 SI/OB
Catheter (different sizes), Urobag,
Sterile gloves, Sterile water,
Syringe, Ryle's tube, suction tub,
SV set, IV set, cotton ,gauze, Sterile
bin with dressing material,
Adhesive plaster, paper plaster
2 SI/OB Betadine lotion, Cremaffin,
Bisacodyl suppository, IVF NS 500
ml, Inj. Metrogyl, Xylocaine jelly,
Paracetamol, Norflox, Ranitidine,
Sucralphate
2 SI/OB Check how staff calculate the
requirement for each day
2 SI/OB
Meloxicam, Dextropropoxyphene,
Paracetamol, Dexamathazone,
cetrizine, Sodium valproate,
Fluconazole, Liq. Paraffin+ mil of
magnesia, Metoclopramide,
Bisacodyl, Sodium Phosphate
enema, Omeprazole, Aldactone,
Ethamsylate, Lignocaine gel,
Imipramine, Fluoxetine,
Haloperidol
2 SI/RR
Check staff is aware of classification
of pain ( Nociceptive & Neuropathic
Pain) & strategies used for its
assessment
 2 SI/RR
Ask the staff about Hand washing,
PPE, disposal of waste, including
Standard Precaution are followed by Staff dressings contaminated with blood
during home visit & body fluids etc.
2 SI/RR
Communication with family,
anticipatory planning including
psychosocial & spiritual needs,
symptom control like pain,
Staff is aware of end of life care & care agitation, respiratory tract
after death prcoesses secretion & care of death
Area of Concern - F Infection Control
Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
ME F6.1 The facility Ensures segregation of Bio Availability of colour coded bins at point of 2 OB
Medical Waste as per guidelines and 'on- waste generation
site' management of waste is carried out
as per guidelines
2 OB

Availability of Non chlorniated plastic

colour coded plastic bags
2 OB

Segregation of Anatomical and solied waste

in Yellow Bin
2

Segregation of infected plastic waste in red

bin
Display of work instructions for segregation 2 OB
and handling of Biomedical waste

There is no mixing of infectious and general 2 OB

waste

ME F6.2 The facility ensures management of Availability of functional needle cutters 2 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
Availability of post exposure prophylaxis 2 SI/OB and
Ask ifinjection room
available. Where it is stored
and who is in charge of that.
Staff knows what to do in condition of 2 SI Staff knows what to do in case of
needle stick injury shape injury. Whom to report. See
Glass sharps are disposed in Blue coded 2 if any reporting has been done
Cardbox OB
Area of Concern - G Quality Management
Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient satisfaction surveys are conducted Client feed back is done for services 2 RR School health Program , VHND
at periodic intervals provide
Standard G3 The facility have established system for assuring and improving quality of Clinical & support services by internal & external program.
ME G3.1 The facility has established internal Internal Assessment of National Health 2 RR/SI
quality assurance programme Program is done at periodic Interval

ME G3.2 The facility has established external assurance Quality Assurance of designated 2 RR/SI Onsite evaluation at least once in a
programmes microscopy centre is done at regular month/ decided as per
intervals performance of DMC
Inspection of microscope, supplies and 2 RR/SI
laboratory is done as per checklists

5 Positive and 5 Negative slides are re 2 RR/SI

examined by systematic random
method by STLS
Feedback on smear, stains,reading and 2 RR/SI
reporting is given
Sample slides are systematically selected 2 RR/SI Onsite evaluation at least once in a
for rechecking (RBRC) along with result month/ decided as per
during QA visit by STLS performance of DMC
Feedback on RBRC slides is given to 2 RR/SI
MC under information to CMO/CS
DMC is supervised by DTO/MO-TB as 2 RR/SI
per their tour programme
Feedback is given for Observations & 2 RR/SI
recommendations for corrective action
by DTO/MO-TB
Laboratory has system in place to cross 2 RR/SI
check all positive slides & 10% or 5% of the
negative blood smear slides (to check 3% of
CML & 1.5 % Regional Medical Laboratory)

There is system in place for coding of all 2 RR/SI

the examined slides by zonal malaria officer

Laboratory has system to collect all coded 2 RR/SI

negative slides examined during last month
&dispatch it to concerned cross checking
laboratory
Laboratory has system to send all positive 2 RR/SI
slides to Regional office of health & family
welfare/ state laboratories for cross
checking
Laboratory has system to keep the report 2 RR/SI
sent after cross checking of slides
 Laboratory has system to participate in 2 RR/SI
EQAS program organized by NRL/
designated laboratoroy
There is system in place for Performance 2 RR/SI
Evaluation of laboratory technician

Supervision for efficiency of laboratory is 2 RR/SI

done
Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
ME G4.1 Departmental standard operating Current version of SOP are available with 2 SI/RR/OB
procedures are available process owner

ME G4.2 Standard Operating Procedures SOP covers all key processes of National 2 SI/RR
adequately describes process and Health Programs adequately
procedures
PHC has process & procedure for National 2 SI/RR
Vector Borne Disease Control Programme

PHC has Process & procedure for Revised 2 SI/RR

National TB Control Programme

PHC has Process & procedure for National 2 SI/RR

Leprosy Eradication Programme

PHC has process & procedure for National 2 SI/RR

AIDS Control Programme
PHC has process &procedure for National 2 SI/RR
Programme for control of Blindness

PHC has process &procedure for Mental 2 SI/RR

Health Programme
PHC has process & procedure for 2 SI/RR
Integrated disease surveillance Programme

PHC has process & procedure for School 2 SI/RR

Health Programme
PHC has process & procedure for Universal 2 SI/RR
Immunization Programme Programme

ME G4.3 Staff is trained and aware of the Check Staff is a aware of relevant part of 2 SI
procedures written in SOPs SOPs
ME G4.4 Work instructions are displayed at Point Work instruction/clincal protocols are 2 OB
of use displayed
Area of Concern - H Outcomes
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Indicators on No. of sputum culture reported postive 2 RR
monthly basis
No. of pherpherial smear reported postive 2 RR
for malaria
No. of water sample collected & sent per 2 RR
month
No. of school visited under School health 2 RR
program
No. of HIV positive cases reported 2 RR
Percentage of women HIV positive out of 2 RR
total registered
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators on Percentage of DOTS cases completed 2 RR
monthly basis successfully
Failure rate including Death & defaults 2 RR
under RNTCP
No. of children referred to higher centre 2 RR
under School Health Program
No. of refrection error detected 2 RR
No. of Diabetic & hypetensive cases are 2 RR
detected
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Percentage of suspected TB cases are 2 RR
Indicators on monthly basis referred to HIV
Monthly blood examination rate (MBER) 2 RR

Multidrug treatment completion rate 2 RR

under NLCP