Assess

Ref No. Measurable Elements Checkpoints ment Means of Verification Remarks

Method
Area of Concern - Service Provision
Standard
The facility provides Comprehensive Primary Healthcare Services
A1
The facility provides care in Services for early registration, 1.ANC Register (ANM)
Pregnancy & child birth services Availability of functional ANC screening including lab
ME A1.1 services with minimum 4 ANC RR/SI investigation ,counselling &
check-ups identification of high risk and
danger signs
APH, PIH, Pre eclampsia, Severe 1.ANC Register (ANM) 2. High
Anaemia, IUGR, Multiple Risk ANC Register (ANM)
First aid, referral & follow up pregnancies, Gestational Diabetes , 3. Referral Register & Referral
services for high risk pregnancies RR/SI Hypothyroidism, Syphilis and bad Forms
are provided
obstetric history

New Born: Low birth weight 1.HBNC Register 2.OPD

newborn Register (CHO) 3.
<1800gms, Preterm, Sepsis, Birth Referral Register & Referral
Identification, primary asphyxia, Congenital anomalies Forms
The facility provides Neonatal &
management & prompt referral of RR/SI Infant: ARI, Diarrhoea, Jaundice,
Infant Health services
sick new born & infant anaemia & malnutrition,
developmental delays
ME A1.2
Anaemia, malnutrition, Vaccine 1. OPD Register (CHO)
preventable diseases, ARI, 2.ARSH Register
Identification, primary Diarrhoea, Fever, ENT problems,
The facility provides Childhood Skin infections, Worm infestations,
management, referral & follow up RR/SI
& Adolescent health services Poisoning, injuries/ accidents,
services for Childhood ailments
4D's,Sickle cell anaemia.
ME A1.3
Prevention & treatment of anaemia 1.ARSH Register 2.Counselling
and other deficiencies, Counselling Register
Education, Counselling and on life style, menstrual hygiene,
referral services for Adolescent PI/SI harmful effects of
health tobacco/substance abuse and sex
education

Provision of contraceptive including 1. Family Planning Register

The facility provides Family Availability of family planning ECP,OCP, (ANM) 2.Family Planning
ME A1.4 RR/SI
Planning services services Injectables, condom, IUCD. Stock Register

The facility provides services for Community engagement, facilitate 1.NLEP Register/Survey
promotion, prevention and referral, promote treatment Reports/Treatment Cards
treatment of communicable completion & reducing stigma
diseases as mandated under Preventive & promotive
SI
National Health Program/state measures under NLEP
scheme
ME A1.5
Case detection, treatment, 1.Cases Line List Register
Diagnostic services, referral &
referral & follow up RR/SI
follow up
of cases under NVHCP
Early identification, link with 1..Cases Line List
Case detection, treatment, designed microscopy centre, Register/Treatment
referral & follow up of cases RR/SI referral & follow up of complicated Cards/Sputum Collection
under NTEP cases, & medication compliance Register

Availability of functional services 1. IDSP/IHIP Form S (Last 3 to 4

under RR/SI Weekly reporting & surveillance Enteries)
IDSP/IHIP
Compliance to ART & follow up 1. Cases Line Listing 2.HIV
Referral & follow up of cases
RR/SI Testing Register (Lab)
under NACP
(1) Diagnostic services, primary 1.Lab Register (CHO)
management, referral & follow up of 2. Malaria Register (ANM/ASHA)
Case detection, treatment, complicated cases. (2) Mass drug
referral & follow up of cases RR/SI administration in case of filarasis &
under NVBDCP
immunization in JE

Diagnostic services, primary 1.NLEP Register/Survey

Case detection, treatment,
management, referral & follow up of Reports/Treatment Cards
referral & follow up of cases RR/SI
complicated cases, & medication
under NLEP
compliance
Community engagement/ peer 1. Counselling Regsiter 2. Health
support, facilitate referral, promote Camp /Rally Photos related to
Preventive & promotive
SI treatment completion, Convergence Viral Hepatitis
measures under NVHCP
with other departments
 Malaria, Dengue, Chinguniya, 1. Friday-Dryday Photos 2.
Preventive & promotive services Filariasis, Fogging Photos
RR/SI
under NVBDCP KalaAzar, Japanese Encephalitis

Prevention & promotion among 1. AIDS Day Rally Photos

Preventive & promotive services high risk behaviour groups, support
SI
under NACP to patient living with HIV/AIDS

Fever, URIs, ARIs, Diarrhoea, 1. OPD Register (CHO)

Scabies, Rashes/ Urticaria,
The facility provide services for Identification, management and Abscess, Cholera, Dysentery,
acute Simple illness & minor referral of acute illness & minor RR/SI Typhoid, Helminthiasis, Headache,
aliments aliments Body aches, Joint aches.
ME A1.6
Water born diseases (diarrhoea, 1.Water Testing Photos
dysentery, enteritis) Helminthiasis, 2. Water Tanks / Bodies Cleaning
Preventive & promotive rabies,musculosketal disorders Photos 3.VHNSC
SI (osteoporosis, arthritis, aches ) MoM & Photos
measures for acute illness

The facility provides services for Oral, Breast, Cervical Cancers. 1. NCD Register (Cancer
promotion, prevention and Screening, linking with the Screeing) 2.
treatment of Non- specialist, 2 way referral& follow up Referral Register
communicable diseases as Availability of Services for treatment compliance and 3. Cases Line list Regsiter
RR/SI
mandated under National Health Cancers complications (Cancer Cases)
Program/state scheme
ME A1.7
Community engagement to 1.VHND MoM / Photos
promote healthy life style & address 2.Camp Photos
Preventive & promotive services risk factor. Counselling and IEC 3.MMU/FDP Photos
SI activities regarding harmful effects
under NCD
of NCDs

Screening, early identification , 1. OPD Register (CHO)

treatment compliance and follow up 2.Referral Register
Availability of services for of all diagnosed cases, referral and
RR/SI follow up for complications , refill of
Epilepsy
drugs

Screening, early identification , 1. OPD Register (CHO)

treatment compliance and follow up
of all diagnosed cases, referral and
Availability of services for follow up for complications , refill of
RR/SI
respiratory diseases drugs for diseases such as COPD
& Asthma.

Screening, Diagnosis, treatment 1. Lab Register

compliance and follow up of all 2.NCD Register 3.
Availability of services for diagnosed cases, referral & follow Referral Register
RR/SI up for complications and refill of
Diabetes
drugs

Screening, treatment compliance 1. NCD Register 2.

and follow up of all positive cases, Referral Register
Availability of services for
RR/SI referral & follow up for
Hypertension
complications and refill of drugs

Screening, treatment compliance 1.NAFLD Regsiter

Availability of services for and follow up of all positive cases, 2. Referral Register
Nonalcoholic fatty liver disease RR/SI referral & follow up for
(NAFLD) complications and refill of drugs

The facility provides services for As per scope of services defined by No AYUSH Services as Per State
health promotion activities & state. Give full compliance in case Govt Norms
ME A1.14 wellness Provision of AYUSH services RR/SI separate AYUSH centre (as per
state policy)

Check counselling services for : (1) 1.VHND Register /Photos with AV

Eat Healthy: Aids
(a) Nutrition during first 1000 days
of Life (b) Balanced diet (c) Food
Provision of counselling services fortification (d) Food to avoid (2)
SI
for Eat Right Eat Safe: (a) Hygiene & Sanitation
(b) Food Safety & Safe food
practices (c) Food Adulteration

Periodic scheduling of yoga 1. Yoga Regsiter /Photos

Provision of wellness services
session, Health
through Yoga and SI
education for life style modification
other activities
Standard
The facility provides drugs and diagnostic services as mandated
A2
The facility provides services for 1. Drugs Stock Register
Availability of drugs for refill for
ME A2.2 drug dispensing RR/SI As per scope of service provided
chronic cases
including medicine refills
As per scope of services provided 1. Drugs Stock Register
Availability of drugs as per EML RR/SI
Area of Concern - Patients Right
Standard
The facility provides information to care seeker, attendants & community about available services & their modalities
B1
Information about the treatment JSY, JSSK, RBSK, RMNCHAN, PM 1. Poster / IEC
Primary healthcare team provide
and entitlements are shared with JAY/ state
information to beneficiaries or
ME B1.3 patients or attendants SI insurance scheme etc Also support
families regarding their
beneficiaries to seek services
entitlements

Standard
Facility ensures services are accessible to care seekers and visitors including those required some affirmative action
B2
The facility is accessible from Check for Outreach session plan - 1. VHND Register
community and referral centre Check outreach sessions are targeted population covered &
ME B2.1 RR/SI
conducted implementation as per plan.

(1) Ensure care is provided within

30 minutes, provision MMU for hard
to reach area (Give full compliance
Ayushman Arogya Mandir is for MMU if area is not hard to
SI
located closer to community reach) (2) Preferably within 1-2
Kms of Referral Centre

(1) Ayushman Arogya Mandir is 1. Poster / IEC of OPD Timings

The full range of services are functional for at least six hours per 2. Services Availability Poster
available for the time period, as RR day (2) Ayushman Arogya Mandir-
mandated provide services for all 12
packages
There is affirmative action to Check for special precaution is HIV, Leprosy , Abortion, domestic
1. Cases Line List if any
ensure that vulnerable and taken for maintaining privacy & Violence, psychotic cases, GBV,
ME B2.3 RR/SI
marginalized sections can confidentiality of cases having abuses etc
access services social stigma
Standard Services are delivered in a manner that are sensitive to gender, religious & cultural needs and there is no discrimination on account of
B3 economic or social reasons
Services are provided in manner
Availability of female staff /
that are sensitive to gender
ME B3.1 attendant, if a male CHO SI
religious & cultural need
examines a female patients
The facility has defined and
Check staff & community is
established procedure grievance Existing state grievance system/
ME B3.3 aware of grievance redressal SI
redressal system in place 104.
system

Standard The facility maintains privacy, confidentiality & dignity of patient

B4
(1) Check Ayushman Arogya 1.Patient Records Policy
Mandir has policy in place
regarding access of clinical
Confidentiality of patients? information & records. (2) Staff is
Check patient and their kin's have aware of it (3) Need based
records and clinical information RR/SI
access to clinical records individual's summary & prescription
is maintained
details are provided. (IT system-
have option for print)
ME B4.2
Standard
The facility ensures all services are provided free of cost to its users
B5
The facility provides free of cost 1. Tele Consultation Regsiter (2-3
services as per prevalent Availability of free teleconsultation Prescriptions Printout)
ME B5.1 SI
government schemes/ norms. and diagnostic services

(1) As per service package or 1. Free of Cost Poster/IEC

RMNCHA, CD, NCD, Eye, ENT,
Oral, Mental Health, Elderly,
Ayushman Arogya Mandir provide Pallative, Emergency medical
RR services etc (2) Screening and
free of cost services
investigation services are provided
free of cost

The facility provides free of cost Check all drugs in the Ayushman 1. Free of Cost Poster/IEC
essential Arogya Mandir-
SI
medicines and refills as per EDL are provided free of cost
treatment plan
Area of Concern - Inputs
Standard The facility has adequate and safe infrastructure for delivery of assured services as per prevalent norms and it
C1 provides optimal care and comfort to users
 (1) Availability of internet 1.Assessts Register
connnectivity (2) Check availability
of functional & updated Portals or
applications viz RCH portal,
Ayushman Arogya Mandir has Ayushman Arogya Mandir portal,
adequate ICT software for RR/SI NCD portal, ANMOL, DVDMS,
efficient delivery of services NIKSHAY, e-sanjeevani, HMIS etc.
The facility ensures availability and any state specific application.
of information & communication
ME C1.3 technologies
(1) Check availability of 1.Assessts Register
Smartphones/ Tablets and
Laptop/desktops, internet
connectivity (2mbps). (2) For tele
Ayushman Arogya Mandir has medicine services,check desktop/
adequate ICT hardware for RR/SI Laptop have headphone , HD web
efficient delivery of services camera & printer connected with it
(3) Availablity of telphone/Mb for
communication

Standard
The facility has adequate qualified and trained staff required for providing the assured services as per current case load
C2
(1) As per eligibility criteria. (2) Staff 1. Job Chart
is aware of their role and 2.Dress Code Policy
The facility ensures availability Availability of Community Health
RR/SI responsibilities (3) Staff adhere to
of Community Health officer Officer
their respective dress code and
ME C2.1 wearing their ID card
1 ASHA per 1000 population / 1. Job Chart
ASHA per 500 population for tribal 2.Dress Code Policy
The facility have adequate and hilly area. 1 ASHA
Availability of ASHA & ASHA facilitator/20,000 population Staff is
frontline health workers and RR/SI
facilitator aware of their role and
support staff as requirement
responsibilities for Ayushman
ME C2.2 Arogya Mandir & community
(1) 2ANM (1 essential & 1 1. Job Chart
Desirable)- SC type -A 2 ANM 2.Dress Code Policy
(Essential, one may be staff nurse) -
Only for SC type-B (2) Staff is
Availability of ANM RR/SI aware of their role and
responsibilities (3) Staff adhere to
their respective dress code and
wear their ID card
(1) 1 Female and 1 Male (2) Staff is 1. Job Chart
aware of their role and 2.Dress Code Policy
responsibilities for Ayushman
Availability of Multipurpose Arogya Mandir and community (3)
RR/SI
Worker Staff adhere to their respective
dress code and wearing their ID
card
Standard Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of
C3 staff
(1) Verify with records that 1. Staff Competency Assessment
performance appraisal has been (Quality Team) 2. Need Based
done at least once in a year and Trainings Analysis Audit (Quality
verify with staff for actual Team) 3. ECHO / Webex Traing
assessment done Certificates/Liks/Photos
(2) Check training needs are
identified based on performance
evaluations & adequate skills are
Check for performance evaluation
RR/SI provided (3) Check IT platforms are
is done at least once in a year used for regular continuous
learning & and capacity building (4)
Check how many capacity building
training/workshop attended by
primary
Competence assessment and
healthcare team in last quarter
performance evaluation of all
staff is done on predefined
ME C3.1 criteria
(1) Check objective checklist has 1. OSCE Checklist (Quality
been prepared for assessing Team)
competence of staff based on job
description and assessment is
Check parameters for assessing done at least once in a year (2)
skills and proficiency of staff has RR/SI Check who did the assessment
been defined - At least PHC- MO/ Competence
Matrix is
prepared for each category of staff
 (1) 6 month certificate program in 1. CHO Training Certificates
Community health, (2) 3 day IT
training including Tele medicines
(3) 5-7 days supplementary training
on new health programs, new skills
(if applicable) (4) refresher every
CHO is trained as per mandate RR/SI year (if applicable) (5) Basic
physiotherapy ( where ever elderly
& palliative care packages are
The staff is provided training as available)
per defined core competencies (6) Training on Eat right tool kit
ME C3.2 and training plan
Bio medical waste management, 1. Training Regsiter (Quality)
Infection Prevention, patient safety,
Staff is provided with Quality internal assessment, BLS, Methods
RR/SI of QA viz PSS, 5S, PDCA etc
assurance training

Area of Concern - Support Services

Standard The facility has established Programme for maintenance and upkeep of the facility
D1
The facility has established Ayushman Arogya Mandir remove
No condemned/Junk material in
system for infrastructure its junk periodically as per
Ayushman Arogya Mandir
ME D1.1 maintenance OB/RR condemnation policy.
(corridors, roof, administrative
area , backyard)

Standard
The facility has defined procedures for storage, inventory management and dispensing of drugs
D2
(1) Timely indenting the drugs for 1.Stock Register
common aliments & emergency 2. Indent Received Receipts
cases (2) Timely indenting of Drugs
There is established procedure of new or regular chronic patients
Check there is established
for estimation and indenting of under Ayushman Arogya Mandir (3)
system to timely indent the drugs RR/SI
drugs and consumables as per Check the adequacy of the
as per services package
requirement available drugs (Demand & supply)

ME D2.1
Check forecasting of drugs & 1. IT Based
consumables is done scientifically
Ayushman Arogya Mandir has a based on consumption
process to consolidate and RR/SI .Reorder & buffer levels are defined
calculate the consumption

(1) Check all near expiry drugs are 1. Expiry Corner & Near Expiry
shifted back to PHC/ referral centre/ Corner
facility where it is urgently required 2. Drugs Expiry Polcy
based on inventory turnover (that is-
There is system in place to Fast, slow or non moving drugs) (2)
maintain expiry & near expiry of OB/SI Check there is demarcated space/
drugs shelf to keep expired drugs away
from main dispensing area
The facility ensure management
ME D2.3 of expiry and near expired drugs
No expired drug is found in
In dispensing area as well as drug
Ayushman Arogya OB
storage area
Mandir
Standard The facility has defined and established procedure for clinical records and data management with progressive use of digital technology
D3
(1) Diagnosis, assessments, 1. OPD Regsiter (CHO)
treatment plan, drugs prescribed, 2.Tele Consulatation Regsiter (2-
follow up , referral in and referral 4 Prescriptions Printouts)
Information regarding out etc are recorded & updated for
ambulatory care & all cases by HSC (2) Randomly,
Information regarding illness and
management, public health and select at least 5 cases (or all cases
minor aliments are recorded & RR/SI
managerial functions are if less than 5) and check for details
updated using IT platform
recorded and updated through Give partial compliance if
IT platforms information is only available in
paper.
ME D3.1
(1) Arrange consultation with PHC- 1. OPD Regsiter (CHO)
MO or Specialist as per 2.Tele Consulatation Regsiter (2-
The facility has established Cases are identified for tele requirement. (2) Check how many 4 Prescriptions Printouts)
procedure for providing consultation for specialist & non RR/SI cases were consulted using tele
consultation using tele medicine specialist consultation
medicine in preceding 3 months
ME D3.3
Dispense drugs as per 1.Tele Consulatation Regsiter (2-
prescription received RR As per e-prescription 4 Prescriptions Printouts)
through tele consultation
 (1) As per roster - send the patient 1. Details of Hubs with Specialist
to PHC (2) Pre appointment, & Contact Details
Co ordination with specialist / location for consultation (3) Check
super specialist and patient for RR/SI reminder / SMS alerts are sent for
tele consultation appointments/ referral/ follow up
cases

Staff is aware of functional hubs & 1. Details of Hubs with Specialist

Hubs are identified for tele
OB/RR skilled to use & Contact Details
consultation
the software
Standard
The facility has defined and established procedures for hospital transparency and accountability.
D4
A. (1) Maintenance of Ayushman 1. JAS Regsiter
Arogya Mandir
- cleanliness, hygiene, safe drinking
water, clean toilet, BMW disposal &
clear signage. (2) Management of
grievances (3) Ensure conduct of
social audits & public hearing
(4)Coordinate celebration of Annual
health calendar days (5) Effective
Committee members are aware implementation of community level
RR/SI programmes viz. VISHWAS,
of its roles & responsibilities
SABLA, Eat right campaign of
FSSI, farmer groups, Self help
groups, women groups, Milk unions
etc. B. Check each member is
aware of their powers and functions

The facility has established

procedure for management of
ME D4.1 activities of Jan Arogya Samiti
(1) Check composition of 1. JAS Regsiter
committee as per JAS guidelines.
Chairperson- Sarpanch, Co -
Chairperson- MO- PHC and
Member Sect. - CHO.
Ayushman Arogya Mandir has (2) At least 50% of representation
RR/SI of women (3) Check committee has
functional Jan Arogya Samiti
representation of all
habitation or communities esp.
vulnerable

The facility has established (1) Monthly review of service 1. ASHA Day/Sector Meeting
Check PHC -MO provide
procedure for supporting and delivery & performance of MoM (PHC) MoM Register
supportive supervision &
monitoring activities of RR/SI Ayushman Arogya Mandir (2)
monitoring for Ayushman Arogya
Community health workers Supportive supervision for
Mandir activities
ME D4.3 Ayushman Arogya Mandir staff
Standard
The facility ensures health promotion and disease prevention activities through community mobilization
D5
The Ayushman Arogya Mandir 1. AWC Details with Contact No's
facilitate planning & (1) Check the list of VHND planned 2.VHND MoM
implementation of health Check number of VHND planned & conducted
promotion and disease & conducted in CHO's catering RR (2) List of AWC under Ayushman
prevention activities through area in preceding quarter Arogya Mandir & name of the AWC
community level interventions where VHNDs conducted
ME D5.1
(1) Regular meetings are being 1. VHSNC Committee / MoM
conducted , at least 2 meetings per
month (2) Community based action
Check VHSNC are constituted & plan for health is prepared (3)
RR/SI Provide support to frontline workers
functional
for health related activities

(1) Identify pool of local yoga 1. Yoga Regsiter /Photos 2.Yoga

The facility ensure multisectoral
Ayushman Arogya Mandir instructors (2) Prepare & Instructor Details & Contact No's
convergence for health
promotes wellness & health RR/SI disseminate weekly/monthly
promotion and primary
promotion through Yoga schedule of classes for community
prevention
ME D5.3 yoga trainings
(1) Education, WCD, ICDS, rural 1. VHSNC Committee / MoM
development/ municipal bodies,
Ayushman Arogya Mandir FSSAI &ICDS etc. (2) Check
engage other allied departments RR/SI VHSNC provide platform for
for intersectoral convergence
multisectoral convergence

Area of Concern - Wellness & Clinical Services

Standard
The facility has defined procedures for registration, consultation, clinical assessment and reassessment of the patients
E1
 The facility has established (1) There is established procedure 1. HWC Population Details
procedure for empanelment & Ayushman Arogya Mandir is to collect the demographic
ME E1.1 registration of individual and aware of constitution of its RR/SI composition (2) No. of individuals of
families catering population different age groups

(1) Check no. of pregnant women, 1. HWC Population Details

no. of life births, pregnant mother
with complications, eligible couple,
Ayushman Arogya Mandir sick new born are estimated (2)
periodically estimates and Population above 30yrs , break up
RR/SI of men & women above 30 yrs. (3)
updates number of beneficiaries
for RMNCHA , NCD and CD As per incidence rates/ prevalence
rates

(1) Check family folders are 1. Family Folders

maintained for entire registered
population in facility's coverage
All individuals and families are area. (2) Check data base is
RR/SI
empanelled under AAM-SC updated regularly for new entrants
and exits (annually) & their illness.

(1) Check all the patients visiting 1. OPD Register (CHO)

are registered & their demographic
The facility has established details like Name, age, Sex and
Patient demographic details are
procedure for registration & Address etc are maintained . (2)
recorded in OPD register/portal RR/SI
consultation in Ayushman Check Unique health ID is given to
with UID
Arogya Mandir all individuals and families
ME E1.2
Through tele health/ tele 1. Tele Consultation Regsiter
Facility has system to undertaken
consultation with MO PHC
opinion RR/SI
/identified hubs/ clinical decision
/consultation from higher centre
making -IT tool
Chief Complaint, Patient History, 1. OPD Slips (Filled 20 OPD Slips
Physical examination, requisite for Diferrent Diseses & Age
The facility has established diagnostics, provisional diagnosis, Groups )
RR/SI primary management & referral (if
procedure for OPD Consultation
required)

Reassessment /follow up as per 1. Follow Up Cases Marking in

schedule for all cases including OPD Regsiter (CHO)
critical /high risk patients. Follow up
includes - Treatment compliance,
Facilities provide follow up/re review of parameters, monitoring of
assessment for cases under RR side effect, adherence to life style
RMNCHA modification, timely detection of
complication and continuity and
The facility has established adequacy of treatment.
procedure for follow up/ re-
ME E1.3 assessment of patients
Standard
The facility has defined and established procedures for continuity of care through two way referral
E2
(1) specially chronic cases referred 1. Downward Referrals (Referral
for medication review (2) Form) 2.
Examination, Referral Register
The facility has established Continuity of care is ensured at development/modification of
RR/SI
procedure for continuity of care referral Centre/higher centre treatment plan, instruction for
patient, note to CHO by
ME E2.1 MO/Specialist.
Dispensation of medicines, repeat 1. OPD Regsiter (CHO)
diagnostic as required/ as per 2.Tele Consulatation Regsiter
treatment plan, identification of
Continuity of care is ensured at complication , facilitating referrals,
RR/SI
Ayushman Arogya Mandir organizing tele consultations,
maintenance of records

(1) Referral slip, referral in or out 1.Referral Register

register/portal, Advance 2. Filled Referral Slips 2-4
communication , prior appointment
The facility has established with specialist, referral vehicle (if
procedure for undertaking Facility has referral procedure in required) & follow up. (2) IT system
RR/SI
referred in & referred out of the place to ensure continuity of care to track upward & downward
cases referrals to ensure the continuity of
care
ME E2.2
Check records for treatment plan, 1.Referral Register
periodic assessment, medicine refill
Facility has defined protocols for and referred to further higher centre
RR/SI (if required)/ regular follow up at
referral in
referring centre
 (1) Early case detection, primary 1.Referral Register
management/stabilisation,
Complete details of case
records/care provided - use of
Facility has defined protocols for referral slip
RR/SI (2) Check availability of separate
referral out
colour coded
referal slip -for easy identification in
referral centre

Standard
The facility has defined and established procedures of diagnostic services.
E3
The facility has established Check OPD ticket for any irrational 1. OPD Slips (Filled 20 OPD
Check there is no irrational
procedure for prescription Slips for Diferrent Diseses &
ME E3.1 prescription of RR/SI
laboratory diagnosis as per of Lab test/USG/ X ray etc Age Groups )
Diagnostic test
guidelines
Point of care diagnostics services Check staff is aware of Quality 1.RDK Stock Register
are available RR/SI Control method 2. RDK Testing Protocols
as per mandate for various tests (RDKs) IEC/Poster at Lab
Central hub/diagnostic units are For Both laboratory/other diagnostic
identified & linkage has test. Check how much patient has
SI
established for tests not done at to travel for getting diagnostic
Ayushman Arogya Mandir services
Standard
The facility has defined procedures for safe drug administration.
E4
(1) Drugs are checked for expiry
and other inconsistency before
administration, single dose vial
/ampule are not used for more than
one dose & separate sterile needle
There is procedure to check the is used every time. (2) Check
drugs before administration and OB/SI prescription from referral centre is
dispensing verified every time before
dispensing of the drugs from
Ayushman Arogya Mandir /in home
Facility follows protocols for safe visits
ME E4.1 drug administration
(1) High alert drugs such as 1. High Alert Drugs Poster/IEC
Nonsteroidal anti- inflammatory, with Minimum 7 Maximum Doses
anti convulsant/antiepileptics,
Hypertensive, oral hypoglycaemic
Check high alerts drugs are etc. (2) Staff is aware of right dose :
identified & its maximum dose are RR/SI Value of maximum dose as per
defined age, weight and diagnosis is
There is process for identifying available with CHO.
and cautious administration of
ME E4.2 high alert drugs
Check untoward /adverse drug
event is reported
Check with staff if any untoward : Minimum information model
RR/SI (MIMPS) for medication safety is
drug events has ever occurred
followed & used for reporting &
subsequent actions planning
(1) Right patient, right drug, right 1. 7 Rights Poster/IEC
route, right time, right dose & right
Check staff follows 6 Rs of drug documentation. (2) Check system
RR/SI in place to verify the verbal orders
administration
given by MO

Standard
The facility follows standard treatment guidelines and ensures rational use of drugs
E5
Check medication review is At least once in a year with PHC 1. Prescription Audit (Quality
There is procedure of rational
ME E5.1 scheduled for RR MO/ Physician Team)
use of drugs
regular chronic cases of referral facility
Check OPD ticket if drugs are 1. OPD Slips (Filled 20 OPD Slips
prescribed under generic name for Diferrent Diseses & Age
Check that drugs are written with
RR only (specially drugs written by Groups )
generic name
CHO for minor aliments)
 (1) Check the cases in which CHO 1. OPD Slips (Filled 20 OPD Slips
has prescribed medicines/ for Diferrent Diseses & Age
antibiotics. (2) Check if the drugs Groups )
are either prescribed more than
required dose
/quantity or on more occasion than
Check staff is aware of rational necessary.
RR
use of drugs (3) Check high end or more than
one antibiotics are prescribed .
Give non compliance if any of the
above (point 2 or 3 ) is yes.

Standard
The facility has defined and established procedures for nursing care.
E6
Chronic cases/ critical patient 1. OPD Slips (Filled 20 OPD Slips
referred from higher centre/Home for Diferrent Diseses & Age
based care patient/ bed ridden/ Groups )
There is established procedure elderly cases Check Patient vital
Patient's vital are monitored and
for identification & periodic RR/SI like BP, weight, TPR, Blood sugar
recorded periodically in follow up
monitoring of the patients etc are maintained as per disease
conditions
ME E6.1
Both in Ayushman Arogya Mandir & 1.Patient Name 2.Aadhar/Abha
home based care. Investigations, No
There is process for ensuring the
refill the medicines, performing
identification of patient before any OB/SI minor procedure, administrating
procedure
vaccine etc

Patients who are not oftently 1. Dropout Cases Counselling

There is process in place to
following their treatment plan or Protocols
identify non compliant patient in RR/SI
taking the medicines as
chronic disease
recommended
Standard
The facility has defined and established procedures for Emergency care
E7
(1) Check how ambulances are 1. 108 Ambulance Regsiter
Ayushman Arogya Mandir
called & patient is shifted. (2)
Emergency protocols are ensures timely availability of
RR Transfer register is maintained to
defined and implemented ambulances services for
record the details of the refferred
emergency cases
ME E7.1 patient
Check staff is aware of steps of 1.BLS Training / Demo
BLS and also ask about how to
recognize the signs for sudden
Staff is aware of procedure for cardiac arrest (SCA), heart attack,
RR/SI
CPR stroke, and foreign-body airway
obstruction (FBAO)

Protocols for snake bite, poisoning, 1.IEC/Poster (snake bite,

drowning, trauma, burn, fits, poisoning, drowning, trauma,
cardiac or respiratory arrest , burn, fits, cardiac or respiratory
Emergency protocols for first aid haemorrhoids, rectal prolapse, arrest , haemorrhoids, rectal
RR/SI
and stabilization are available hernia, hydrocele, appendicitis etc. prolapse, hernia, hydrocele)

Staff is aware of district disaster 1. Disaster Management SOP

management team, staff is aware 9Quality Team)
The facility has disaster Emergency care is given in case
OB/SI of their roles, basic emergency 2. Training
management plan in place of disaster
management kit is available
ME E7.2
Staff is aware of process of Staff is aware of triage protocols in 1. Traige Training
sorting the patients case of
RR/SI
in case of mass causalty/ referral required
outbreak
Standard
The facility has defined & established procedures for management of communicable diseases as per operational/ clinical guidelines
E10
Persistence of fever even after 48 1. Lab Register
hrs of treatment, continuous 2.Malaria Register (Slides)
vomiting, headache, dehydration,
The facility provides services change in sensorium, convulsions,
under National vector Borne Staff is aware of Malaria referral bleeding & clotting disorders,
RR/SI
disease control programme as protocols severe anaemia, Jaundice &
per guidelines as per guidelines hypothermia

ME E10.1
Staff is aware of sign & Chikungunya, KA, JE, LF etc. Any
symptoms of prevalent SI of the cases in
vector born diseases in area their catchment area
 (1) Treatment should be started 1. Malaria Treatment Protocol
within 24 hrs of detection. (2) P. IEC/Poster
Vivax - Chloroquine/ 3days and
Primaquine/14 days.
Staff is aware of Malaria (Contraindicated in pregnant
RR/SI female or infant or G6PD
treatment protocols
deficiency/ P- falciparum- ACT (3)
Algorithm for treatment & diagnosis
is available

(1) Diagnostic- RDK (2) 1. Lab Register

Management- Bed rest, cold
Staff is aware of diagnostic & sponging,& symptomatic treatment.
management of dengue as per RR/SI (3) Check Ayushman Arogya
protocols Mandir is aware of dengue cases in
its catchment area

(1) Fortnightly Home visit & testing 1. Malaria Register (Slides)

people with current/ recent fever &
chills in past 14 days using RDT.
(2) Malaria detection in cases
presenting with fever at Ayushman
Arogya Mandir (3) Detection by
using RDT/Microscopy. (Microscopy-
result should be made available
Case detection is done for within 24 hrs) (4) Negative RDT
RR/SI
Malaria cases strongly suspected of malaria
cross checked by microscopy (5)
Check Ayushman Arogya Mandir is
aware of confirmed malaria cases
in its catchment area

Source reduction, personal 1.Fryday - Dry Day Photos

protection, environment
management, Biological control (
Larvivorus fish) & chemical control
(larvicide / Adulticide) . Staff is
involved in intersectoral
convergence with other
Primary care team is aware of departments like DODWS
vector born disease control RR/SI (Department of Drinking Water and
strategies Sanitation under Ministry of Jal
Shakti, MOHUA (Ministry of
Housing and Urban Affairs),
Municipalities etc) & carry out
weekly cleanliness drive in village
through VHSNC

RDT kits , clean slides, needles, 1. Lab Stock Register

swabs, ACT, CQ, PQ etc. Check
Facilities have adequate stock of
RR/SI how kits have been stored & near
commodities & drugs
expiry drugs are not available

The facility provides services 6,12, 18 , 24 month follow up after 1. TB Treatment Cards (If Any
Staff is aware of follow up
under National Tuberculosis treatment completion Cases)
ME E10.2 protocol after treatment RR/SI
Elimination Program (NTEP)
completion
Refer all presumptive cases to 1. Sputum Collection Register
designated Microscopy centre.
Identification of presumptive case Sputum collection and transport of
RR sputum of samples is supported in
& their referral
hard/difficult areas.

Referral slip, Patients treatment 1. TB Treatment Cards (If Any

NTEP register & records are card (if CHW is supporting Cases)
RR
maintained treatment), TB notification register

(1)Provision of DOTS at Sub- 1. TB Treatment Cards (If Any

centre, proper documentation and Cases)
follow-up, home based support, 2. Cases Line List Register
regular screening of cases for
Ayushman Arogya Mandir common adverse effects, ensure
support, supervision & manage compliance & completeness of
presumptive, confirmed & on OB/RR course (2) Check Ayushman
treatment cases including DR- TB Arogya Mandir is aware of
patients presumptive, confirmed & on
treatment cases in its catchment
area
 Ensure delivery/ availability of 2nd 1. Drugs Available at CHC Level
dose onward drugs, pulse dose to as Per the State
be given in presence of ANM/MPW, Norms/Guidelines
Check the availability / delivery of completion of treatment,
subsequent doses of MDT and identification of signs of neuritis,
RR reactions etc for treatment cases.
follow up of persons under
The facility provides services treatment Referral in case MCR footwear if
under National Leprosy required/ referral for complications
Eradication Program as per
ME E10.3 guidelines
Maintain & update case card 1. Leprosy Rx Cards
NLEP register & records are (ULF01), Update the treatment 2. Cases Line List
RR
maintained registered when visiting the PHC

(1) Pale & reddish patches on the 1. NLEP Survey Records

skin, skin thickness, shiny &
reddish, numbness & tingling,
painful tender nerves, weakness of
hands, feet or eyelid, swelling &
lumps in the face & ear lobes
Primary healthcare team identify impaired sensation. (2) Sensory
and ensure referral of suspected RR/SI testing for screening: touching the
cases of Leprosy tip of pen on patch to feel sensation
2 times (once with eyes & 2nd with
closed eyes) (3) Referral of
suspected cases to higher centre.
First dose initiated at higher centre

Health education to community 1. NLEP Survey Records / Rally

regarding signs and symptoms of Photos
Facility provide awareness about leprosy, its complications, curability
leprosy & availability of its SI & availability of free of cost
treatment treatment, self care & encourage
the patient to bring his/her contacts
to check-up
IEC for STI,HIV/AIDS Awareness 1. IEC/Posters
generation , identification of peer 2.Counselling Register
support groups for HRG- PLHIV, 3. AID Day Photos
encourage for index testing,
Staff is aware of promotional support in treatment adherence,
&supportive activities done under RR/SI arrangement for counselling/
NACP psycho therapies, community follow
up to support HIV pregnant women
The facility provides services &
under National AIDS Control
ME E10.4 Program as per guidelines
Ayushman Arogya Mandir -SC Linkage with Microscopy centre for
has linkage for HIV -TB, for
RR
management of HIV/AIDS PPTCT services
complications
Identification & referral of
suspected cases, Condom
Promotion & distribution among
high risk groups & help HIV cases
Ayushman Arogya Mandir-HSC is for receiving & adhering to ART.
RR/SI HIV/STI Counselling, Screening
aware of their roles in NACP
(consent) and referral in Type B
Sub-centres in high prevalence
districts

Fever, Cough less than 2 weeks 1. IDSP/IHIP Form S (Last 3 to 4

duration, acute flaccid paralysis Enteries)
more than 15 yrs. of age, diarrhoea
The facility provides services (3 or more loose stool /day),
Staff is aware of syndrome under
under Integrate Disease RR/SI Jaundice, Raise the signal for
surveillance in IDSP/IHIP
surveillance as per guidelines action in case of for any unusual
health event /death
ME E10.5
(1) Preliminary analysis & reporting 1. IDSP/IHIP Form S (Last 3 to 4
Check Analysis & reporting of of collected data to MO- PHC on Enteries)
information for syndromic RR/SI every Monday (2) Check any action
surveillance is done has been undertaken using IDSP
data
(1) Information is collected from 1. IDSP/IHIP Form S (Last 3 to 4
Home visit (for above described Enteries)
Check process to collect
syndrome) & from SC- OPD (2)
information in form S RR Collation of data in Register for
/IHIP
Syndromic Surveillance
 The facilities provide services for RDT for Hep B & Hep C & referral 1.Lab Regsiter
National Viral Availability of diagnostic & for
ME E10.6 RR
Hepatitis Control Programme treatment services confirmation & further management
(NVHCP)
Awareness generation & behaviour
change communication,
immunization for Hep B (Birth dose,
Staff is aware of preventive high risk group & healthcare
OB/SI
measures for NVHCP worker) , injection safety & safe
drinking water & sanitation.

Standard
The facility has defined & established procedures for management of non-communicable diseases as per operational/ clinical guidelines
E11
Interview patients for: (1) Regular & 1.NCD Register
adequate availability of medicines
as per treatment plan
(2) His/her understanding about
dosage schedule, life style
Ayushman Arogya Mandir medication, any dietary restriction
ensures frequency of follow up & RR and awareness about next follow
supply of required medicines up visit date (3) Annual consultation
with specialist
at NCD clinic
The facility provides services for
ME E11.1 hypertension as per guidelines
Awareness generation - (a)Risk 1. Yoga Register
factors: overweight & obesity, 2. Counselling Register
Physical inactivity & stress (b)
Healthy life style: diet, exercise,
Staff is aware of promotional avoidance tobacco & alcohol, (c )
&supportive activities for SI Counselling for Lifestyle
Hypertension modification (d) importance of
regular follow & compliance to
medication

(1) Population enumeration -filling 1.CBAC Forms / Family Survey

of CBAC form for all above 30Yrs of Records / Documents
age- Screening at Ayushman Offline/Online
Arogya Mandir on fixed day
approach referral of suspected
cases to higher centre for
Consultation - follow up of those
Staff is aware of process of who are diagnosed with
population identification and RR/SI hypertension & ensuring that they
referral for hypertension adhere to treatment plan- identify
warning signs of complication &
refer to higher centre.
(2) Re screening of population (new
and old) at
periodic intervals - every year

Systolic/ Diastolic BP of over 140

/Over 90 mm of Hg. Severe
Headache, fatigue, nausea,
CHO is aware of sign & sweating, feeling faint & confusion,
SI
symptoms of Hypertension vision problem, chest pain,
shortness of breath.

Interview patients for: (1) Regular & 1.NCD Register

adequate availability of medicines
as per treatment plan
(2) His/her understanding about
dosage schedule, life style
Ayushman Arogya Mandir medication, any dietary restriction
ensures frequency of follow up & RR and awareness about next follow
supply of required medicines up visit date (3) Annual consultation
with specialist
at NCD clinic
The facility provides services for
ME E11.2 Diabetes as per guidelines
 Counselled about not to miss/skip
meal, take up frequent and small
meals, increase physical activity
and side effects of anti diabetic
drugs. Hypoglycaemia: Symptoms;
tremors, nervousness, anxiety,
sweating, irritability, confusion,
Heart beat increase, headache etc
Check Patient is counselled Management: Take 5-6 toffees/
about identification & immediate SI Mishri/1 table spoon sugar/honey/ 2-
management hypoglycaemia 3 teaspoon of glucose/ 3- 4 tea
spoon of sugar/ half cup of juice or
cold drink. If symptoms persists
patient should be taken to higher
centre for further management.

(1) Population enumeration -filling 1.CBAC Forms / Family Survey

of CBAC form for all above 30Yrs of Records / Documents
age- Screening at Ayushman Offline/Online
Arogya Mandir on fixed day
approach referral of suspected
cases to higher centre for
Staff is aware of process of consultation - follow up of those
population identification and RR/SI who are diagnosed with
referral for diabetes hypertension & ensuring that they
adhere to treatment plan- identify
warning signs of complication &
refer to higher centre (2) Re
screening of population (new and
old) at periodic intervals -every year

(1) All overweight or obese cases 1.NAFLD Regsiter

with diabetes or prediabetes 2. Referral Register
symptoms or elevated blood lipids
or elevated blood pressure (2) All
such cases are screened for: ?
Abdominal Obesity (waist
Ayushman Arogya Mandir is circumference of ? 90 cm in men or
aware of risk factors of ? 80 cm in women) ? Family H/O
RR/SI
Nonalcoholic fatty liver disease diabetes, hypertension, heart
(NAFLD) diseases and cancers ? Obesity
(BMI>=25kg/m2) ? Oedema
examination (3) Referal to PHC for
management

Awareness generation - (a)Risk 1.NCD Register

factors: overweight & obesity, 2. Counselling Register
Physical inactivity & stress (b) 3. Camps / Rally Photos
Healthy life style: diet, exercise,
avoidance tobacco & alcohol, (c )
Counselling for Life style
Staff is aware of promotional & modification (d) Importance of
SI regular follow & compliance to
supportive activities for diabetes
medication (e) Counselling about
diabetes related complication viz.
Retinopathy, neuropathy & kidney
failure etc.

Random blood sugar 140mg/dl and

mg/dl. Frequent urination,
increased hunger,excessive thirst,
CHO is aware of sign & unexplained weight loss, extreme
SI tiredness, blurred vision, slow
symptoms of diabetes
wound healing numbness or
tingling hands or feet & sexual
problems
Lump in breast/under arm area,
thickening or swelling of breath,
The facility provides services for
Staff is aware about sign & puckering /dimpling of breath skin,
cancer screening and referral as SI
symptom of Breast cancer redness in nipple area, nipple
per guidelines
discharge /blood, constant pain etc
ME E11.3
 For cancers of the oral and breast, 1.Cancer HospitalDetails with
the first level of referral is the CHC / Contact No's
SDH/ DH and then to the DH for a
Check CHW is aware of referral biopsy for confirmed cases. For
RR/SI cervical cancer, if VIA positive, refer
centre for all types of cancer
to higher centre offering colposcopy

(1) At SC/ outreach/screening for 1.NCD Regsiter with Cancers

Breast, cervix & oral cancer. (2) Screening
Screening is undertaken by trained
personnel (LHV/Staff nurse/MO)
can be done in outreach
Check cancer screening services session/screening day. (3)
are provided through Ayushman RR/SI Screening of cervical cancer is
Arogya Mandir conducted on site where privacy &
facility for sterilization is available
(4) Repeat screening -every 5yrs

Vaginal bleeding between periods,

menses longer or heavier than
usual, post menopausal bleeding,
Staff is aware about sign & bleeding & pain during/after sexual
SI intercourse, smelly vaginal
symptom of cervical cancer
discharge, pain during urination etc

Awareness generation - (1)Risk

factors: smoking, multiple sexual
partner, unprotected sex, family
history, overweight, lack of physical
activity (2) Healthy life style: diet,
Staff is aware of promotional & exercise, avoidance tobacco &
SI alcohol, (3 ) Counselling for Life
supportive activities for diabetes
style modification (4) importance of
regular follow & compliance to
medication

Difficulty in chewing or swallowing ,

mouth ulcers persist for more than
3 weeks, persistent pain, lump,
Staff is aware about sign & thickening in cheek, white/red patch
SI
symptom of Oral Cancer on gums/ tongue/tonsil etc,

(1) Visual Inspection by Acetic Acid

for cervical,
(2) Oral Visual Examination for oral
Check with staff about cancer (3) clinical breast
methodology followed for cancer RR/SI examination for Breast .
screening (4)Discuss interpretation of results if
done at
SC/outreach session/screening day

The facility provides services for (1) For Withdrawal symptoms (2) 1.No Tobacco Rally Photos
de addiction, and locally Life style support changes (3) 2. Counselling Registers
prevalent health diseases as per Promotional & supportive Engagement/ linkage with patient
activities for Tobacco/alcohol/ RR/SI
guidelines support groups (4) Support
substance abuse
encouragement by family & friends
ME E11.4
Ask for local prevalent disease viz. No Local Prevalent Disesaes
Pneumoconiosis , lead poisoning,
Check Screening & referral locally
SI fluorosis etc. Give full compliance if
prevalent diseases
no such disease exists

Staff is aware 5A approach - Ask, 1. 5A Poster

advise, assess, Assist & arrange
(1) History taking and referral to
identified de addiction centre. (2)
Advise to quite in cleat, strong and
Confirmation and referral of cases personalized manner
for Tobacco/alcohol/ substance RR/SI (3) Attempt to Quit (4) Involve
abuse family & friends, remove
substances from their adjacent
area, Arrange follow up visit (5)
motivate by re
enforcing & intense follow up
 1. Check roster is available, 1. Yoga Days & Timing Display
updated & displayed
The facility promotes services Check Yoga sessions are
RR 2. Community is aware of yoga
for health & wellness conducted regularly
sessions conducted by Ayushman
ME E11.5 Arogya Mandir
(1) Generate awareness about 4
major food groups (food pyramid) -
a. Cereals & millets b. Vegetables
Check Primary health care team & fruits, c. Milk & animal products d.
generate awareness in SI Fats/ oils, sugar & nuts (2) Limit the
community about balanced diet consumption of foods high in fats,
sugar & salts

Check staff counsel mother's for

nutritious diet during first 1000 days
of life (1) Stage 1 (During
Pregnancy) : Balance & nutritious
diet including important nutrients
like iodine, folic acid, iron, vit B12
etc. (2) Stage 2 ( Period from birth
of child to 1 yr.): Early initiation of
exclusive breastfeeding for initial 6
Check counselling of mother's for months, initiation of
nutrition & hygiene maintenance SI Complementary feeding on
under Eat right completion of 6 months with
continued Breastfeeding (3)Stage 3
(Period between 12 month to 24
months of child age):
Complementary feeding & its
preparation with right consistency,
quantity, frequency, density &
variety.

(1) Awareness on benefits of

Check Primary health care team
fortified food (2) Identification of
generate awareness in SI
fortified food available in market
community about food fortification
(+F logo)
Awareness generation about
maintaining personal &
environmental hygiene while
Check Primary health care team cooking food (viz. handwashing,
generate awareness in regular bathing, wearing clean
SI clothes, keeping kitchen clean,
community about Eat safe
practices taking pest control measures,
waste disposal, using kitchen waste
for compositing etc)

(1) Awareness generation about

logos on packed food viz. fssai, ISI,
+F, green and red dots for
vegetarian and non vegetarian food
items.
Check Primary health care team (2) Safe storage of perishable &
generate awareness in SI non perishable food (3) Precautions
community about food safety to be taken while cooking & serving
the meals. (4) Awareness about
common tests for food adulteration
(Key ring
test)

(1) Guide about household

Check staff counsel and guide measurement with household
the mother's about household utensils (2) Awareness on
SI ingredients, quantity & frequency of
preparation of complementary
feeds complementary feeding for children
up to 2 yrs.
Standard
The facility has established procedures for care of new born, infant and child as per guidelines
E13
Not able drink or breast feed, 1.HBNC Register 2.OPD
vomiting, convulsions, lethargy Register (CHO) 3.
Discharge from cord, pallor, Referral Register & Referral
cyanosis, Jaundice, pustules, Forms
CHO & CHW are aware of hypothermia, unable to pass
RR/SI
danger signs of new born & infant stool/urine, fever, diarrhoea,
Post natal visit & counselling for indrawing of the chest (2-12
new born & infant care is months- 50 breaths/min & 12-5yrs-
ME E13.1 provided as per guideline 40 breaths/min)
Staff practice ETAT protocol. 1.HBNC Register
Primary management & prompt
Stabilization per 2.OPD Register (CHO) 3.
referral of sick RR/SI
disease condition. Referral Register & Referral
new born & infants
Forms
 Exclusive breast feeding, cord care, 1. Breast Feeding Posters / IEC
maintenance of temperature,
Staff is aware of post natal care
SI promoting hygiene practise, support
Counselling
for high risk babies

ARI: Chest indrawing difficulty in 1. OPD Regsiter (CHO)

breathing
,coughing, fever, fast breathing
Management of children for ARI, Assessment for identification of Malnutrition: Weakness/wasting,
diarrhoea, malnutrition and other ARI, diarrhoea, malnutrition and RR/SI check weight for age, check height
illness Other Illness for weight Diarrhoea: Sunken eyes,
lethargic, unconscious, restless,
irritable, pinch skin
ME E13.3
Young infant- Not able to feed or 1.HBNC Regsiter
convulsion or fast breathing >60/ 2.OPD Register(CHO)
min or severe chest indrawing or
axillary temp 37.5 OC or more or
Assessment for identification of movement only when stimulated
possible serious bacterial Children - General danger signs, or
infections among young infant (0- RR/SI chest indrawing - very severe or
59 days) & children (2 -59 severe pneumonia Fast breathing -
months) RR - 2-11month >or equal 50/min
12-59 months> or equal 40/min-
Pneumonia

Screening, referral and follow up Functional linkage with RBSK 1.HBNC Regsiter
of children for anomalies, team, referral & follow up 2.OPD Register(CHO)
RR/SI
disabilities and developmental
delays
(1) Give first dose of oral
Amoxicillin and injectable
Gentamycin. (2) Treat or prevent
low sugar (breastfeed/ age
Management of Possible serious appropriate feed) (3) Warm the
bacterial infection as per RR/SI young infant if temp is less than
protocols 35.5 OC. (4) Advise mother to keep
young infant warm & refer urgently
to hospital

Management of Malnutrition is
done as per SI Counselling for nutrition & referral
protocols
ORS, Zn, Lot of fluids, & treatment 1.OPD Register
Management of diarrhoea is done with Cotrimoxazole. Counselling
RR/SI
as per protocols and referral if required

Symptomatic treatment, 1.OPD Register

Paracetamol for fever, plenty of
Management of ARI is done as
RR/SI fluids, keep child & give normal diet
per protocols
. Counselling & referral if required

Standard
The facility has established procedures for family planning as per government guidelines and law.
E14
(1) BRAIDED Approach: Benefits of (1) BRAIDED Approach
method, risk, consequence of Poster/IEC
failure, alternatives, inquiries,
decision to withdraw, explanation of
Staff is aware of Method specific method chosen & document of
SI session (2) Care seeker is
counselling approaches
counselled about contraindications
Family planning counselling & adverse events of chosen FP
services are provided as per methods
ME E14.1 guidelines
Importance of FP, Options 1. FP Counselling Register 2.FP
available- ( limiting & spacing Register (ANM)
method), time for initiation &
The client is given full information advantages of various available
RR/SI
about family planning methods methods. For Limiting method -
counselled & referred to higher
centre
 (1) Hormonal (Combined oral pill) 1. FP Counselling Register 2.FP
,Non Hormonal (Chaya) & Register (ANM)
Emergency Contraceptives.
(2) Combined oral Pill taken at fixed
time daily ECP_ within 72hrs,
second dose 12hrs after first dose
Staff is aware of options, Centchroman: to be taken twice a
indications & methods for week for the first 3 months followed
RR/SI
administration for Oral by once a week thereafter. Check
Contraceptives for Chhaya/Centchroman eligibility
is checked & confirmed by MO.
Dose
may be started by trained HCW
The facility provides spacing
methods for family planning as
ME E14.2 per guidelines
No touch technique, Speculum and Done only at PHC as Per State
bimanual examination, sounding of Guidelines
uterus and placement. Follow up :
IUD insertion & follow up is done when to return / removal of IUCD.
RR/SI Check In case of 2nd trimester
as per standard protocol
abortion IUCD is provided by
Qualified Medical officer

Check the eligibility for injectables Done only at PHC as Per State
are checked & confirmed by MO. Guidelines
Dose may be started/ continue by
trained HCW. Depot MPA can be
Injectable Contraceptives are given IM or Subcutaneous, IM:
RR/SI single dose vial with disposal
given as per protocols
syringe & needle. Subcutaneous:
Pre filled AD syringe

Staff is aware of case selection 1.FP Regsister

criteria for family RR/SI 15-49 yrs., married
planning methods
For sterilization: 22-49 yrs.- 1.FP Regsister
(female) & 22-60yrs (male),
The facility provides limiting married, youngest child is at least
Staff is aware of case selection one year & spouse has not opted
methods for family planning as RR/SI
criteria for limiting mentors for sterilization. Counselled &
per guidelines
referred to Higher centre
ME E14.3
Check adherence to GoI guidelines 1.FP Regsister
Female Sterilization: Certification is
issued one month after the surgery
or after the first menstrual period,
whichever is earlier. Male
HCW is supporting & Sterilization; Certificate is issued
encouraging the clients for post RR/SI only after three months once the
sterilization follow up semen examination shows no
sperm, certificate can be delayed till
6 months if the semen shows
sperm after 3 months. (A

Standard
The facility provides Adolescent Reproductive and Sexual Health services as per guidelines.
E15
Haemoglobin estimation, weekly 1.ARSH Register 2.Counselling
IFA tablet, and treatment for worm Register 3.School Health
The facility provides promotive, Services for treatment & referral infestation, Symptomatic treatment Register
preventive & curative service for of common RTI/STI's, Nutritional RR , counselling , TT at 10 and 16
adolescent Anaemia & Menstrual disorders year. Referral linkages to ICTC and
PPTCT
ME E15.1
Nutritional Counselling, advice on 1.ARSH Register 2.Counselling
topic related to Growth and Register 3.School Health
Provision of education & development, puberty, myths & Register
counselling services for SI misconception, pregnancy, safe
adolescent sex, menstrual disorders,anemia,
sexual abuse ,RTI/STI's etc.

Standard
The facility has established procedures for Antenatal care as per guidelines
E16
Check with staff the expected 1.ANC Register
There is an established Staff has knowledge of pregnancies in her area / how to
procedure for registration and calculating expected pregnancies RR/SI calculate it.(Birth Rate X
follow up of pregnant women. in the area Population/1000 Add 10% as
ME E16.1 correction factor (Still Birth)
 1.Check with ANM how she tracks 1.ANC Register
missed out ANC. Use of MCTS by
generating work plan and follow-up
Tracking of Missed and left out with ASHA, AWW etc. 2. Check if
RR/SI there is practice of recording Mobile
ANC
no. of clients/next to kin for follow
up

1.Ask staff about schedule of 4 1.ANC Register

ANC Visits (1st -
< 12 Weeks 2nd - < 26 weeks 3rd -
< 34 weeks 4th >34 to term)
All pregnant women get ANC 2.Check ANC register whether all 4
check-up as per recommended RR/SI ANC covered for most of the
schedule women (sample cases). 3.At least
one ANC visit is attended by
Medical Officer (Preferably 3rd Visit
-28-34 Weeks)

Check Mother & Child Protection 1.ANC Register

Facility provides and updates cards have been provided for each 2.MCP Cards
?Mother and Child Protection RR pregnant women at time of 1st
Card? registration/ First ANC

Check ANC records for ensuring 1. ANC Register

Facility ensures early registration that majority of ANC registration is 2.MCP Cards
& line listing of high risk ANC RR/SI taking place within 12 week of
cases pregnancy in ANC register

Pulse, Respiratory Rate , Pallor, 1.ANC Register

Oedema. Height, weight & BP- 2.MCP Cards
Check any 3 ANC records/ MCP
There is an established card randomly to see that weight
procedure for History taking, Physical Examination & vitals of has been measured and recorded
Physical examination, and Pregnant Women is done on RR at every ANC visit Observation and
counselling of each antenatal every ANC visit Correction of Flat or Inverted
woman, visiting the facility. Nipples Palpation for any Lumps or
Tenderness
ME E16.2
Measurement of Fundal Height 1.ANC Register
(ask staff how she correspond 2.MCP Cards
fundal high with Gestational Age),
Abdominal Examination is done Auscultation for foetal heart sound ,
RR/SI Palpation for Foetal lie and
as per protocol
Presentation Check for findings
recorded in MCPcard/ANC Records

(1) History of pervious pregnancies 1.ANC Register

including complications and 2.MCP Cards
procedures done, if any, is taken.
History of current or past systemic
illness like Hypertension, Diabetes,
Comprehensive Obstetric history Tuberculosis, Rheumatic Heart
RR/SI Disease, Rh Incompatibility,
is recorded
malaria, etc. is taken. (2) Allergies
to drugs, any treatment taken for
infertility.

Check how staff confirms EDD & 1.ANC Register

LMP, (EDD = Date of LMP+9 2.MCP Cards
Months+7 Days) How she
Last menstrual period (LMP) is estimates if Pregnant women is
recorded and Expected date of unable to recall first day of last
RR/SI
Delivery (EDD) is calculated on menstrual cycle ('Quickening',
first visit Fundal Height) .Check ANC
records that it has been written
 1.Check for Haemoglobin, 1.ANC Register
confirmation of pregnancy, urine 2.MCP Cards
albumin & sugar blood, blood
sugar, Malaria. Check randomly
any 3 MCP card/ ANC record for
Haemoglobin test is done at every
Diagnostic test for every pregnant ANC visit and values are recorded.
RR/SI 2.
women
Haemoglobin & urine albumin &
sugar test is done on every ANC
visit 3. Referral is done for the
The facility ensures of drugs & remaining ANC diagnostics: blood
diagnostics are prescribed as group and
ME E16.3 per protocol Rh factor, Hepatitis B
Check randomly any 3 ANC 1.ANC Register
records for confirming that TT1 (at 2.MCP Cards
the time of registration) and TT2
Tetanus Toxoid (2 Dosages/ (one month after TT1) has been
Booster) have been during ANC RR/SI given to Primi gravida & Booster
visits dose for women getting pregnant
within three years of previous
pregnancy
Hypertension & Pre Eclampsia 1.ANC Register
There is an established (Hypertension - Two consecutive 2.MCP Cards
Staff is competent to identify reading taken four hours apart 3.High Risk Pregnancies Register
procedure for identification of
Hypertension / Pregnancy RR/SI
High risk pregnancy and shows Systolic BP >140 mmHg
Induced Hypertension
appropriate & timely referral. and/or Diastolic BP > 90 mmHg
ME E16.4
1. Prophylactic - one IFA tablet per 1.ANC Register
day for six months during ANC 2.MCP Cards
&PNC. 2.Therapeutic dose- double
Staff is aware of prophylactic & the dose in case of anaemia. 3.
Therapeutic dose of IFA & RR/SI Improvement in haemoglobin label
progress is monitored is continuously monitored and
recorded

>11 gm% -Absence of Anaemia,10 1.ANC Register

to 11 gm% mild, 7-10 gm% 2.MCP Cards
Moderate Anaemia <7 gm% 3.High Risk Pregnancies Register
Staff is competent to classify Severe Anaemia (2) Check the
anaemia and line list the cases RR/SI records whether Line-listing of
according to Haemoglobin Level severely anaemic women are
maintained

Anaemia, Bad obstetric history, 1.ANC Register

CPD, PIH, APH, Medical Disorder 2.MCP Cards
Staff can recognize the cases,
complicating pregnancy, 3.High Risk Pregnancies Register
which would need referral to RR/SI Malpresentation, foetal distress,
higher centre(FRU)
PROM, obstructed labour.

Pre - Eclampsia- High BP with 1.ANC Register

Urine Albumin (+2) Imminent 2.MCP Cards
eclampsia -BP >140/90 with 3.High Risk Pregnancies Register
Staff is competent to identify Pre- positive albumin 2++, severe
RR/SI
Eclampsia headache, Blurring of vision,
epigastria pain & oliguria in Urine

Swelling (oedema), bleeding even 1.ANC Register

spotting, blurred vision, headache, 2.MCP Cards
Counselling of pregnant women Pregnant women is counselled
pain abdomen, vomiting, pyrexia, 3.High Risk Pregnancies Register
is done as per standard protocol recognize danger signs during SI watery & foul smelling discharge &
and gestational age pregnancy
Yellow urine
ME E16.5
(1) Registration and identification of 1.ANC Register
institution as per clinical condition 2.MCP Cards
Pregnant women is counselled (2) counselled to recognize sign of 3.High Risk Pregnancies Register
for planning and preparation for SI labour & arrange for referral
birth transport
 1.Increase Dietary Intake Diet rich 1.ANC Register
in proteins, iron, vitamin A, vitamin 2.MCP Cards
C, calcium and other essential 3.High Risk Pregnancies Register
micronutrients. Initiate
breastfeeding especially colostrum
feeding within an hour of birth. 2.Do
not give any pre-lacteal feeds.
(Sugar, water, Honey) 3. Ensure
good attachment of the baby to the
Pregnant women is counselled breast.
diet, rest, breast feeding & family SI 4.Exclusively breastfeed the baby
planning for six months. 5. Breastfeed the
baby whenever he/she demands
milk. 6. Follow the practice of
rooming in. Different Options
available including IUCD, PPIUCD,
vasectomy, long acting
injectable, etc.

Standard
The facility has established procedure for post natal Care
E18
Check for records of Uterine 1.PNC Visits Register
contraction, bleeding, temperature,
Mother is monitored as per post B.P, pulse, Breast examination,
RR/SI (Nipple care, milk initiation). Check
natal care guideline
Post partum Care is provided to for perineal wash is performed
ME E18.1 the mothers
Danger signs :Excessive PV 1.PNC Visits Register
bleeding, breathing difficulty, 2. Counselling Register 3.VHND
Check Mother is educated & convulsion, severe headache, Register
There is a established
counselled about danger signs abdominal pain, foul smelling
procedures for Postnatal visits & RR/SI
during puerperium & during lochia, urine dribbling, perineal
counselling of Mother and Child
postnatal visit pain, painful & redness of breast.
ME E18.2
Area of Concern - Infection Control
Standard
The facility has established program for infection prevention and control
F1
Facility ensures that staff is All staff undergo medical Check-up 1.Staff Health Checkup (Quality
working as team and monitor Check Records of Medical Check- at least once in year and Team)
ME F1.1 RR
the infection control practices up and Immunization immunization with at least Hepatitis
B and TT
Person is identified to supervise the CHO
Staff is working as team to sanitation ald hygiene of Ayushman
improve sanitation & hygiene of RR/SI Arogya Mandir and its surrounding
the facility area.

Standard
The facility has defined and Implemented procedures for ensuring hand hygiene practices
F2
Hand Hygiene facilities are Demonstration : Six Steps of
provided at point of use & Staff is trained and adheres to Handwashing & ask about Five
ME F2.1 OB/SI
ensures adherence to standard hand washing practices Moments of handwashing
practices
Standard
The facility ensures standard practices and equipment for personal protection
F3
The facility ensures availability Staff is aware of method of donning
of personal protection and doffing the PPE
Compliance to correct method of
ME F3.1 equipment and ensures OB/SI
wearing and removing PPE
adherence to standard practices

Standard
The facility has standard procedures for disinfection and sterilization of equipment and instruments.
F4
(1) Check staff is aware of what to 1. Adverse Events Register /
do in case of sharp injury, Whom to Incident Reporting Forms
The facility ensures standard report. See if any reporting has
Check saff is aware what to do in
practices and materials for been done and treatment provided
case of exposure to injury or any RR/SI
disinfection and sterilization of (2) Linkage available to provide
blood/body fluid
instruments and equipment post- exposure prophylaxis
ME F4.2
Area of Concern - Quality Management
Standard
The facility has established system of periodic review of clinical, support and quality management processes
G4
Handholding support and 1.Visitors Register
supervision is provided to Service delivery and performance 2. MO Signatures in HWC
ME G4.1 Ayushman Arogya Mandir by of Ayushman Arogya Mandir is RR/SI Through monthly visits by MO PHC Records 3.FDP
PHC, block/ district/state teams reviewed regularly Schedule
 Quarterly -By Block nodal officer, Bi 1.Visitors Register
Ayushman Arogya Mandir Annual - by District Nodal officer 2. MO Signatures in HWC
performance is reviewed regularly RR Records 3.FDP
by block/district/state nodal officer Schedule

The facility conducts periodic 1.Internal/District/State/Latest

Periodic assessment using NQAS
ME G4.2 internal RR At least once in six months Internal Assessment Reports
checklist
assessment (Quality Team)
1.Internal/District/State/Latest
Periodic assessment using
RR Quarterly Internal Assessment Reports
Kayakalp checklist
(Quality Team)
Standard
Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve them.
G5
The facility has defined Quality Staff is aware of Quality Policy. 1. Qaulity Policy & Smart
ME G5.1 policy and Quality policy are defined RR Quality Policy is Objectives
quality objectives displayed in local language
Major Gaps (Any)
Evidence (Any)
Strength (Any)