CHAPTER 1 HUMAN RESOURCE

Category of Std UID Standard definition Expected Value Scoring Remarks Minimum scoring for
Standard for 50 Mandatory Indicators
bed hospital (50% compliance)
HR Quality HR1 Number of registered doctors with MBBS qualification Average 2 per shift for 50 bed 2 MANDATORY 1
hospital (minimum 1 per
shift)
HR2 Number of qualified and registered nurses (GNM,B.Sc. Average 4 per shift for 50 bed 2 MANDATORY 1
And M.Sc.(Nursing) hospital with one Incharge Sister (Minimum 3 per
with minimum GNM shift for 50 bed
Qualification excluding 20% hospital excluding
leave reserve 20% leave reserve)
HR3 Number of qualified and registered Post graduate degree Minimum 1 on call for particular 2 MANDATORY 2
or diploma specialists broad specialty treated by (minimum 1 on call)
hospital; Information expected
specialtywise
HR4 Doctor patient ratio in ICU One Doctor per six beded ICU in 2 MANDATORY (1 1
each shift doctor for 12 beds
per shift)
HR 5 Nurse patient ratio in ICU per shift 1:1 for ventillated bed 2 MANDATORY (1:2 1
1:3 for non-ventillated bed for ventilated bed
(excluding 20% leave reserve) and 1:5 for non
ventilated bed
excluding 20% leave
reserve)
HR 6 Number of doctors on call with super specialty Minimum 1 2 MANDATORY 2
qualifications according to specialties treated by hospital (Minimum 1)

HR 7 Number of Qualified and Registered Anesthetist with Minimum 2 on call. 1 MANDATORY 1

degree or Diploma. (Minimum 2 on call)

Number of Qualified X-Ray technicians if inhouse Minimum 1 1 MANDATORY

facility-B.Sc. and trained (Minimum 1) If
inhouse
Number of Qualified Lab technician with First Minimum 1 1 MANDATORY
preference for B.Sc. With D.M.L.T. Second preference - (Minimum 1) If
DMLT after HSC if inhouse facility inhouse

HR 8 Display of Qualifications of Medical personnel Should be displayed on signboard 1 MANDATORY 1

HR 9 Whether qualified and registered MD Pathologist or Minimum 1 1 MANDATORY 1

Diploma in Clinical Pathology available if inhouse lab (Minimum 1)
or outsourced
HR 10 Training Policy, Calender and Schedule Availibility of Training policy, 1
calender and schedule for all
human resources
18 11
All HR Norms for nursing exclude Leave reserve component of 20%
 CHAPTER 2 FACILITY MANAGEMENT
Category of Std UID Standard definition Expected information Scoring Remarks Minimum scoring
Standard for Mandatory
Indicators (50%
compliance)
2 Facilities FAC1 Sampling by trainned Phlebotomist with Samples should be collected by 1
Management centralized receiving area trainned phlebotomist and received
at a centralized area
FAC2 Whether ambulance Services- inhouse Either inhouse or on call 1 MANDATORY 1
or available on call
FAC3 Availability of trained personnel with Ambulance personnel should be 1
ambulance either BLS or ALS minimum BLS trained.

FAC4 Avalability of foot suction machine, For BLS ambulances
Emergency tray, Defibrillator/AED, IV
Fluids, Oxygen, Infusion pump,
Stethoscope and BP Apparatus.
FAC5 whether ICU equipped with life saving
equipment such as ventilator,
defibrillator and Pulse oxymeter
FAC6 Bed occupancy %
FAC7 Fire Safety Measures. One fire
extinguisher per ward with NOC from
fire department or licencing agency to
be obtained within next one year
FAC8 Two minimum rounds by treating
doctors in a day i.e. Morning and
evening
FAC9 Operation theatre
1 MANDATORY MEANS 1
emergency tray, oxygen,
infusion pump, Foot
suction, stethoscope and
BP appratus, IV fluid (all
Minimum requirement 1 except defibrillator)
MANDATORY 1
Sum of daily census of patients 1 More than 50%= 1; 30%-
admitted ( measured at 12 50%= 0.5 and less than
midnight) x 100 / Number of 30%= 0
operational beds x days in month
Plan exists for exit in case of fire and 1
non fire emergency and drill carried
out twice a year
Round book should have record, 1 MANDATORY 0.5
which should be maintained by (Minimum 1 round)
nursing incharge
Whether it has functional OT zoning 1
as per requirements of sterile areas.
Temperature and Humidity
monitoring inside operation theater
and charting done on a daily
basisWhether it has functional OT
zoning as per requirements of sterile
areas.
Temperature and Humidity
monitoring inside operation theater
and charting done on a daily basis

FAC10 Doctors Call response time(Difference Total time interval for all calls / 1
between the time of receiving the call Total number of calls sent
and the time of physically attending the
call by the doctor

FAC11 Percentage of AMC or CMC of Total number of equipments with 1

Equipments AMC or CMC x 100 / Total number
of equipments
FAC 12 For purposes of diet, Institution should Registration should be there 1
be registered under Food Safety Act

FAC 13 Uninterrupted power and water supply Availability atleast in critical areas 1 MANDATORY 1
like ICU, OT & Labour ward
FAC 14 Oxygen Supply Contineous availability of either 1 MANDATORY 1
piped oxygen or oxygen cylinder
with backup
FAC 15 Signages Display of various signages and in 1
bilingual languages
15 5.5
 CHAPTER 3 INFECTION CONTROL
Category of Std UID Standard definition Expected information Scoring For calculated Remarks Minimum scoring
Standard parameters, formula is for Mandatory
indicated Indicators (50%
compliance)
3 Infection INF1 Documented Infection Air quality monitoring done atleast 1
Control control procedures monthly with the help of simple air settle
Measures plate or air sampling for OT, Fogging of
O.T., Labor room, Burn ward and NICU.
Surface cleaning and disinfection as per
norms
INF2 Infection control committee Meeting register should be available for 1 MANDATORY 1
and regular meetings with monthly meeting with minutes of meeting
minutes documented
INF3 Availability of Surveillance For surgical facility - Surgical site 2 No of SSI for clean Only clean
of Hospital acquired infections operations*100/Total operations being
infections with record-SSI conducted major taken. Wound
surgeries in month apperance be
documented by
photo on day 5

INF4 Availability of Surveillance ICU - Ventilator Associated Pneumonia 2 Total VAP cases* Ref - CDC
of Hospital acquired 1000/Total ventilator Guidelines
infections with record-VAP days for the month

INF5 Availability of Surveillance Wards & ICU - Catheter related Urinary 2 Total cases of UTI Ref - CDC
of Hospital acquired Tract Infections secondary to Guidelines
infections with record- catheterisation
Catheter related UTI *1000/Total Foleys
catheter days for the
month
INF6 Incidence of Needle stick Number of Health care providers given 1 Scoring based on
injuries with PEP as per PEP maintanence of
standard protocol records
INF7 Availability of hand hygiene Facilities for Hand wash and hand 0.5 MANDATORY 0.5
guidelines and facilities scrubbing in all patient care areas as
applicable plus elbow cock in OT and
NICU
INF8 Monitoring of CSSD Autoclave register with evidence of 1 MANDATORY 1
services inhouse signolac strip monitoring and Chemical
disinfectant
INF9 Whether registered with Date, authorization number and date of 0.5 MANDATORY
MPCB under BMW Rules expiry.
1998
INF10 Hepatitis B vaccination for Protection levels should be monitored 0.5 MANDATORY 0.5
health care providers should Scoring based on
be ensured maintanence of records
INF11 Rational use of Antibiotics Hospital to formulate and implement 0.5
policy
12 3
 CHAPTER 4 MEDICATION MONITORING
Category of Std UID Standard definition Expected information Scoring Remarks Minimum
Standard scoring for
Mandatory
Indicators (50%
compliance)
Monitoring MED1 Storage of medicines Medications are stored in clean, secure 2
Medication environment as per FDA
recommendations
MED2 Whether Sound Inventory control Stock register mentioning receipts and 2
practices followed expenditures. Adequate supplies
including buffer shall be maintained.
FIFO practices shall be followed
MED3 Whether look alike and sound alike Whether such medications are stored 1
(LASA) medicines are stored separately
separately in order to prevent drug
MED4 Whether Medical store approved by Registration number with date and date 1 MANDATORY 1
FDA of expiry
MED5 Medication orders Whether medication orders on OPD 1
and IPD papers contain name of
medicine, dosage, route of
administration and frequency in legible
handwriting
MED6 Adequacy of refrigeration facilities Temperature monitoring record should 1
with temperature monitoring. be available.

8 1
 CHAPTER 5 PATIENT MEDICAL RECORDS
Category of Std Standard definition Expected information Scoring Remark Minimum scoring
Standard UID for Mandatory
Indicators (50%
compliance)
Maintenance EMR1 Whether Patient UID generated Every OPD and IPD paper should 1 MANDATORY 1
of Patient have number.
Medical
Records
EMR2 Every inpatient should have unique This record should contain the 1 MANDATORY 1
medical record chronological order of care
including date and time of
admission, assessments, consent,
test reports, monitoring
medication, procedure,
prescription, discharge summary

EMR3 Arrangements made for transmitting Documentation should be 1

information during shifts, transfer in available
shifts and between treating departments

EMR4 Whether reporting of Medical 100% reporting of Medical 2 MANDATORY 2

Certification of Cause of Death carried Certification of Cause of Death
out. (MCCD) (41 for Govt & 41A for
Private Hospitals) is expected.
EMR5 Morbidity and Mortality statistics with Morbidity statistics and Mortality 2
ICD Classification statistics with ICD Classification
should be available

7 4
 CHAPTER 6 PATIENT SATISFACTION INDICES
Category of Std UID Standard definition Expected information Scoring Remark Minimum scoring for
Standard Mandatory Indicators
(50% compliance)
Patient PSI1 Appointment Whether appointment scheduling 1
Satisfaction possible on phone/internet
Indices
PSI2 Whether patient stabilised Number of patients died during referral 1 upto 2%=1; more than
before referral x 100/ Total referrals 2%= 0
PSI3 Percentage of DAMA / LAMA Total number of patients who left 1 upto 5%=1; more than
patients. All patients discharged against medical advice x 100 / Total 5% =0
against medical advice should number of admissions
be given daywise details of
treatment given.

PSI4 % of cancellation of surgeries Total number of cancelled surgeries x 1 upto 10% =1; more than
100 / Total number of scheduled 10%= 0
elective surgeries
PSI5 Informed consent before Informed consent of patient taken by 1 MANDATORY 1
surgery/Procedure treating professionals before surgery in
patient's own language.
PSI6 Feedback form made available Total number of feedback forms made 1
at the time of discharge in available at the time of discharge x 100
patients own language / Total IPD
PSI7 Citizen's Charter and Suggestion Availability of Citizen's charter at 1 MANDATORY 1
Box available prominant place and Suggestion box
with lock and key with authorized
person.
PSI8 Patient’s Rights and Education. Patient's record should be accesible to 1 MANDATORY 1
patient and authorized patient's relative
on request
8 3
 CHAPTER 7 STANDARD OPERATING PROTOCOLS
Category of Std UID Standard definition Scoring Remark Minimum scoring
Standard for Mandatory
Indicators (50%
compliance)

Standard SOP1 SOP for Diagnosis and management 0.5

Operating of top 10 common diseases
Protocols
SOP2 SOP for Admission and Discharge 0.5 MANDATORY 0.5

SOP3 SOP for medicine storage and 0.5

dispensing
SOP4 SOP for Operation Theatre work 0.5 MANDATORY 0.5
flow
SOP5 SOP for ICU(Admission and 1
discharge criterion, Criteria for
putting patient on ventillator and
weaning from ventillator)
SOP6 SOP for Emergency services(10 0.5
most common emergencies and how
they are managed)
SOP7 SOP for Laboratory services. (SOP 0.5 MANDATORY 0.5
for sample collection, receiving,
processing, transport and internal &
external validation of results

SOP8 SOP for Radiodiagnostic 0.5

services(For patient and staff safety)

SOP8 Use of ICD Code for diseases and 0.5

procedures
5 1.5
 CHAPTER 8 TRANSPARENCY IN PRICING
Category of Std UID Standard definition Scoring Remarks Minimum scoring for
Standard Mandatory Indicators
(50% compliance)

Transparency In TIP1 Whether pricing information on bed 1 MANDATORY 1

pricing prices, room prices, nursing care,
standard procedures available at the
help desk
TIP2 Whether bill of discharge gives break 2 MANDATORY 2
up of all the above
TIP3 Whether patient provided list of 2
items used in his case at time of
discharge (list of medical devices,
medicines and investigations done)

TIP4 For medical devices, whether patient 2

informed of choices available before
surgery as per hospital purchase
policy
7 3
 CHAPTER 9 QUALITY OF PATIENT CARE
For these indicators, scoring would be based only on maintenance of records and not on actual figures
Category of Std UID Standard Whether record kept Scoring Remarks
Standard definition and information
recorded
Quality of QPC 1 Reporting of 1. Total medication errors 1 Scoring will be
Patient Care Adverse Events x 100 / Total no of in based on
patient days maintainence of
2. No of Blood 1 records and
Transfusion reactions x corrective actions
100 / No of Blood Units taken
issued
3. Total Drug reactions x 1
100/ Total No of in
patient days
4. Total Wrong patient 1
surgery or wrong side
surgery(Absolute
number)
QPC 2 Regular Discussion Record of Monthly 1
of Adverse Events Meetings in meeting
with corrective register.
measures

QPC 3 Use of Surgical Whether displayed and 1

Safety Check lists followed in all Operation
Theatres, ICU, SNCU,
Casualty and wards
QPC 4 Postoperative Record of documentation 1 1= Surgical Complicati For each positive
complications and corrrective actions Complicatio on Grade- response, pl fill
should be available. No n; 2= 1: No out the Patient
of cases in each Anaesthetic treatement; Complications
complication grade for Complicatio 2: Medicine Form
each category of n; 3= treatment; 3-
complication needed. Complicatio Surgical
Number of post operative n due to Intervention
complications / Total Patients Pre ; 4- ICU; 5:
number of emergency and Existing Death
planned major surgeries x Illness
100

QPC 5 Average Length of Total In patient 0

stay Days/Total IPD patients
discharged
QPC 6 ICU care APACHE (Acute 1 If it
Physiology and Chronic exceeds
Health Evaluation) 40%, the
admission score of hospital
patients in ICU: number should get a
of patients with '0' score and
APACHE II scores if it is less
between 20 and 24 than 40%,
(inclusive) as a the hospital
proportion of the total should get a
ICU admissions and their '1'.
mortality rate.
QPC 7 Gen Surgery Number of patients 1
requiring repeat surgery
within 30 days *100/ No
of major planned and
emergency surgeries for a
month
QPC 8 Gen Surgery Number of Post-operative 1 Only clean
Deaths *100/ Total no of surgeries
major planned and
emergency surgeries in
30 days
Category of Std UID Standard Whether record kept Scoring Remarks
Standard definition and information
recorded
QPC 9 Transferred Out Total no of transferred 1
out patients*100/Total
IPD
QPC 10 Avg Door to Needle Average time taken in 1
or door-to-balloon minutes for patients with
times in acute acute ST elevation
STEMI myocardial infarction to
receive fibrinolytic
therapy after arrival in
hospital, or primary PCI
after arrival in hospital.
Timings to be given in
minutes.
QPC 11 Use of dual Total No of patients 1
antiplatelet therapy discharged with a
and statins in acute diagnosis of acute
coronary coronary syndrome
syndromes (including ST elevation
MI) receiving both dual
antiplatelet therapy (i.e.,
aspirin and
clopidogrel/prasugrel/tica
grelol) AND statin at
discharge * 100/ Total MI
patients discharged
QPC 12 In-hospital mortality Percentage of patients
for CABG surgery 1
undergoing CABG
surgery who died before
discharge
QPC 13 Use of Left Internal Percentage of patients 1
Mammary artery undergoing CABG
grafts surgery who received a
left internal mammary
artery graft
QPC 14 In-hospital Percentage of patients 1
mortality for valve undergoing valve surgery
surgery who died before
discharge
QPC 15 Post Operative Percentage of patients 1
Sternotomy undergoing sternotomy
infection (for CABG or valve
surgery) who developed
sternal wound infection
QPC 16 Post PCNL No of post PCNL patients 1
percentage calculi with residual Calculi
*100/ No of operated
PCNL patients
QPC 17 Orthopaedics Number of patients with 1
fracture nonunion or
delayed union requiring
repeat surgery *100/ No
of surgeries for open
reduction of fracture(>9
months for Non-union
and >3 months for
delayed union)
QPC 18 Gynae Number of Post-operative 1 Within the
Deaths in Gynae Surgery same
*100/ Total no of major hospitalizati
planned and emergency on period
Gynac
surgeries(Obstetrics cases
not included)
Sr No Category of Std UID Standard definition Expected Expected Minimum Minimum
Standard Scoring scoring for
with Mandatory
number of 50%
beds compliance
1 HR Quality HR1 Number of registered Average 2 per shift 2 Minimum 1 per 1
for 50 beded doctors with MBBS shift)
Hospital qualification

HR2 Number of qualified and Average 4 per shift 2 MANDATOR 1

registered nurses incluing Incharge Y (Minimum 2
(GNM,B.Sc. And Sister with minimum per shift
M.Sc.(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve
Total doctors 7 2
Total nurses including leave reserve 18 10
20%
2 HR Quality HR1 Number of registered Average 3 per shift 2 MANDATOR 1
for 100 HR2 Number of qualified and Average 8 per shift 2 MANDATOR 1
beded registered nurses with one Incharge Y (Minimum 5
hospital (GNM,B.Sc. And Sister with minimum per shift
M.Sc.(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve
Total doctors
nurses including leave reserve 11 4
20% 45 20
3 HR Quality HR1 Number of registered Average 4 per shift 2 MANDATOR 1
for 200 doctors with MBBS Y (minimum 2
beded qualification per shift)
hospital HR2 Number of qualified and Average 20 per shift 2 MANDATOR 1
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And Sister with minimum 12 per shift
M.Sc.(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve
doctorsincluding leave reserve
Total nurses 13 6
20% 90 45
4 HR Quality HR1 Number of registered Average 5 per shift 2 MANDATOR 1
for 300 doctors with MBBS Y (minimum 2
beded qualification per shift)
hospital HR2 Number of qualified and Average 30 per shift 2 MANDATOR 1
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And Sister with minimum 20 per shift
M.Sc.(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve
doctorsincluding leave reserve
Total nurses 15 7
20% 135 62
5 HR Quality HR1 Number of registered Average 7 per shift 2 MANDATOR 1
for 400 doctors with MBBS for 400 bed hospital Y (minimum 3
beded qualification per shift)
hospital HR2 Number of qualified and Average 35 per shift 2 MANDATOR 1
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And Sister with minimum 25 per shift
M.Sc.(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve
 doctorsincluding leave reserve
Total nurses 19 9
20% 138 93
6 HR Quality HR1 Number of registered Average 08 per shift 2 MANDATOR 1
for 500 doctors with MBBS Y (minimum 3
beded qualification per shift)
hospital HR2 Number of qualified and Average 60 per shift 2 MANDATOR 1
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And Sister with minimum 30 per shift
M.Sc.(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve
doctors including leave reserve
Total nurses 23 9
20% 225 108
7 HR Quality HR1 Number of registered Average 10 per shift 2 MANDATOR 1
for 1000 doctors with MBBS Y (minimum 8
beded qualification per shift)
hospital HR2 Number of qualified and Average 70 per shift 2 MANDATOR 1
registered nurses with one Incharge Y (Minimum
(GNM,B.Sc. And Sister with minimum 50 per shift
M.Sc.(Nursing) GNM Qualification excluding 20%
excluding 20% leave leave reserve)
reserve
Total doctors
nurses including leave reserve 30 16
20% 260 180