National Quality Assurance Standards

Health & Wellness Centre -Sub Centre

Name of HWC Vansjaliya Date of Assessment 06/11/2024
Name of Assesssors Ram Modhvadiya Name of Assessee

Type of Assessment (Internal/

State/External) Internal Action Plan submission date

Reference No Measurable Elements Checkpoints Means of Verification Assessment Compliance Remarks

Method
Area of Concern A: Service Provision 60 108

Standard A1 The facility provides Comprehensive Primary Healthcare Services

56 100

Services for early registration, screening including lab

Availability of functional ANC services with
ME A1.1 minimum 4 ANC check-ups
investigation ,counselling & identification of high risk and SI/ RR 2
danger signs
The facility provides care in Pregnancy & child birth
services 5 8
APH, PIH, Pre eclampsia, Severe Anaemia, IUGR, Multiple
pregnancies, Gestational Diabetes , Hypothyroidism,
Syphilis and bad obstetric history SI/ RR 1
First aid, referral & follow up services for high
risk pregnancies are provided

Normal Delivery using partograph, identification &

Availability of Normal Vaginal delivery services
and referral services for Obstetrics emergencies
management of danger sign during labour and post SI/ RR 1
delivery 24 hr stay
SC type B
Availability of prompt referral services for
Obstetrics emergencies
PPH, Eclampsia, Sepsis. SI/ RR 1
SC type B

New Born: Low birth weight newborn <1800gms, Preterm,

Identification, primary management & prompt Sepsis, Birth asphyxia, Congenital anomalies
ME A1.2 referral of sick new born & infant Infant: ARI, Diarrhoea, Jaundice, anaemia & malnutrition,
SI/ RR 1
developmental delays

The facility provides Neonatal & Infant Health services 3 6

Complete immunization schedule & reporting of AEFI both

Availability of Immunization Services
from Sub centre & Outreach
SI/ RR 1

Availability of post natal new born care services Essential New born care including new born resuscitation SI/ RR 1
SC type B

Anaemia, malnutrition, Vaccine preventable diseases, ARI,

Identification, primary management, referral & Diarrhoea, Fever, ENT problems, Skin infections, Worm
ME A1.3 follow up services for Childhood ailments infestations, Poisoning, injuries/ accidents, 4D's,Sickle cell
SI/ RR 1
The facility provides Childhood & Adolescent health anaemia.
services 2 4

Prevention & treatment of anaemia and other deficiencies,

Education, Counselling and referral services for
Adolescent health
Counselling on life style, menstrual hygiene, harmful SI/ PI 1
effects of tobacco/substance abuse and sex education
 Provision of contraceptive including ECP,OCP, Injectables,
ME A1.4 Availability of family planning services condom, IUCD. SI/ RR 1

The facility provides Family Planning services 4 6

(1)Provide Information about Family planning options to

eligible clients (2) Motivate families for spacing b/w
2 children (3) Counselling to support couple in choosing the
Education, Counselling and referral services for
family planning services
FP methods, Provide correct & appropriate information SI/CI 2
about chosen method. (4) Post abortion contraceptive
counselling
(5) Referral & support for sterilization, Abortions & GBV

SI/ RR 1
Identification ,management & referral (if required)
Dysmenorrhoea, Vaginal Discharge, Mastitis, Breast lump,
Identification and referral for Obstetric and Pelvic Pain and Pelvic Organ Prolapse, Identification and
Gynaecological Conditions management for RTI/STI

The facility provides services for promotion,

ME A1.5 prevention and treatment of communicable Preventive & promotive services under NVBDCP SI/ RR 1
diseases as mandated under National Health
Program/state scheme Malaria, Dengue, Chinguniya, Filariasis, KalaAzar,
Japanese Encephalitis 12 24

(1) Diagnostic services, primary management, referral &

Case detection, treatment, referral & follow follow up of complicated cases. SI/ RR 1
up of cases under NVBDCP (2) Mass drug administration in case of filarasis &
immunization in JE

Preventive & promotive measures under NTEP CI/SI 1

Community engagement, facilitate referral, promote
treatment completion & reducing stigma

Case detection, treatment, referral & follow Early identification, link with designed microscopy centre,
referral & follow up of complicated cases, & medication SI/ RR 1
up of cases under NTEP compliance

Preventive & promotive measures under NLEP SI/ CI 1

Community engagement, facilitate referral, promote
treatment completion & reducing stigma

Case detection, treatment, referral & follow Diagnostic services, primary management, referral & follow SI/ RR 1
up of cases under NLEP up of complicated cases, & medication compliance

Preventive & promotive services under NACP SI/ CI 1

Prevention & promotion among high risk behaviour groups,
support to patient living with HIV/AIDS

Referral & follow up of cases under NACP Compliance to ART & follow up SI/ RR 1

Provision for the screening for HIV Referral & Support for treatment - In Type B Sub Centre SI/ RR 1
SC type B

Preventive & promotive measures under NVHCP Community engagement/ peer support, facilitate referral, SI/ CI 1
promote treatment completion, Convergence with other
departments
Case detection, treatment, referral & follow Diagnostic services, referral & follow up SI/ RR 1
up of cases under NVHCP
 Availability of functional services under IDSP Weekly reporting & surveillance SI/ RR 1

Identification, management and referral of Fever, URIs, ARIs, Diarrhoea, Scabies, Rashes/
ME A1.6 Urticaria, Abscess, Cholera, Dysentery, Typhoid, SI/ RR 1
acute illness & minor aliments Helminthiasis, Headache, Body aches, Joint aches.
The facility provide services for acute Simple illness &
minor aliments 2 4

Preventive & promotive measures for acute Water born diseases (diarrhoea, dysentery, enteritis)
Helminthiasis, rabies,musculosketal disorders SI/ CI 1
illness (osteoporosis, arthritis, aches )

The facility provides services for promotion,

prevention and treatment of Non-communicable Screening, treatment compliance and follow up of all
ME A1.7 Availability of services for Hypertension positive cases, referral & follow up for complications and SI/RR 2
diseases as mandated under National Health refill of drugs
Program/state scheme

11 16

Screening, Diagnosis, treatment compliance and follow up

Availability of services for Diabetes of all diagnosed cases, referral & follow up for SI/RR 2
complications and refill of drugs

Availability of services for Nonalcoholic fatty Screening, treatment compliance and follow up of all
positive cases, referral & follow up for complications and SI/RR 1
liver disease (NAFLD) refill of drugs

Oral, Breast, Cervical Cancers.

Availability of Services for Cancers Screening, linking with the specialist, 2 way referral& SI/ RR 1
follow up treatment compliance and complications

Screening, early identification , treatment compliance and

follow up of all diagnosed cases, referral and follow up for
Availability of services for respiratory diseases
complications , refill of drugs for diseases such as COPD &
SI/RR 1
Asthma.

Screening, early identification , treatment compliance and

Availability of services for Epilepsy follow up of all diagnosed cases, referral and follow up for SI/ RR 1
complications , refill of drugs

Early identification, referral, & follow up care for disease

such as Pneumoconiosis, Dermatitis, Lead Poisoning,
Availability of services for locally prevalent
health diseases & substance abuse
Fluorosis etc. & for substance abuse such as tobacco, RR/ CI 1
Alcohol & others.

Community engagement to promote healthy life style &

address risk factor. Counselling and IEC activities
Preventive & promotive services under NCD regarding harmful effects of NCDs SI/ CI 2

1. Screening & referral of Blindness, Refractive errors,

Visual Acuity, Cataract
The facility provides services for common eye 2. Identification and primary treatment of
ME A1.8 Availability of Ophthalmic Services Conjunctivitis, dry Eye, Trachoma, foreign body, eye SI/ RR 1
aliments injuries
3. Follow up medicines for chronic eye disease such
as Cataract and glaucoma
2 4
Awareness generation, vit A prophylaxis for eye (6month -
5yr), eye examination for pre term (less than 32 weeks)
Preventive & promotive services under for
Ophthalmic
SI/ PI 1
 Identification, primary management and referral( if
The facility provides services for common ENT required) for Common Cold, , URI, Tonsillitis,
ME A1.9 Availability of ENT Services Pharyngitis, Laryngitis and Sinusitis , Epistaxis, SI/ RR 1
aliments Otomycosis, Otitis Externa, ASOM , removal of foreign
bodies, /Injuries, thyroid swelling.

2 4
Awareness generation about causes & prevention of ENT
problem viz. Protection from excessive noise, Safe listening
(< 85db), improving acoustic environment, avoid self
medication and not to attempt foreign body removal at
Preventive & promotive services under for ENT home SI/ CI 1

Irregular arrangement of teeth & Jaws (Malocclusion) ,

ME A1.10 The facility provides service for oral health aliments Availability of early identification & referral
services for oral Health conditions
Dental Fluorosis, Cleft lip & palate, Abnormal growth ,
patch or ulcers, oral cancers
SI/ RR 1

3 6

Gum diseases (Gingivitis, Periodontitis), Dental caries and

Availability of symptomatic management & dental emergencies (Tooth ache, Tooth injuries ,
referral services for oral Health conditions uncontrolled bleeding and abscess) SI/ RR 1

Preventive & promotive services under oral

health Awareness generation, oral health education & prevention SI/ CI 1
of common oral diseases through dietary advice & tobacco
cessation

(1) General Awareness about -Healthy life style, social

ME A1.11 security scheme for elderly and promote active & healthy SI/ RR 2
aging , identification of age related aliments and increase
supportive environment in families
(2) Mapping of elderly Population
(3)Comprehensive Geriatric assessment by Primary health
Care team
The facility provide Elderly & Palliative care services Availability of services for elderly care (4) Domiciliary visits to bed ridden patients 3 4

(1) Population enumeration & empanelment of cases

requiring palliative care
(2) Palliative care assessment
(3) Home visit for psycho- social support SI/ RR 1
and basic nursing care
(4) Dispense drugs & consumables as per
requirement
Availability of services for palliative care

1. Stabilization and referral services for minor injuries,

animal bites, poisoning, burn, Respiratory arrest, cardiac
arrest, fractures, shock, chocking, fits, drowning,
ME A1.12 The facility provides emergency medical care, Availability of services for Medical Emergencies haemorrhage, cellulitis, Acute gastro-intestinal conditions
SI/ RR 1
including for trauma and burn including trauma & burns & Genito- urinary conditions
2. Identification & referral for Cysts, Lipoma, ,
haemorrhoids, hernia, hydrocele, varicose veins, bed
ulcers, phimosis etc.

1 2

ME A1.13 SI/ RR 1
Identification, counselling & referral for Anxiety, hysteria,
The facility provides services for Screening & Depression, Neurosis, Dementia, Mental Retardation,
Management of Mental Health illness Availability of services for mental health Autism 2 4
 Preventive & promotive services under mental
health
SI/ CI 1
Awareness generation ,stigma & discrimination
reduction ,community engagement, patient support,
facilitate referral, promote treatment completion etc

ME A1.14 The facility provides services for health promotion HWC undertakes health promotion and
disease prevention activities through
VHSNC/Self help group/ Patient support groups,
Health promotion campaign and multisectoral CI/ RR 1
activities & wellness Community level resources convergence

4 8

SI/ CI 1
Provision of wellness services through Yoga and Periodic scheduling of yoga session, Health education for
other activities life style modification

SI/ RR 1
Provision of AYUSH services As per scope of services defined by state.

Check counselling services for :

(1) Eat Healthy: (a) Nutrition during first 1000 days of
Provision of counselling services for Eat Right Life (b) Balanced diet (c) Food fortification (d) Food to SI/CI 1
avoid
(2) Eat Safe: (a) Hygiene & Sanitation (b) Food Safety
& Safe food practices (c) Food Adulteration

Standard A2 The facility provides drugs and diagnostic services as mandated

4 8

ME A2.1 CI/ RR 1
Point of care diagnostics including RDKs as per Service
delivery
Hb, UPT, Urine dip stick (albumin & Sugar) , Blood sugar,
Malaria -RCT, RCT for dengue, collection of sputum sample
for TB, HIV RCT, VIA test, Test for Iodine in salt (kit), Water
Availability of basic diagnostic services including testing for faecal contamination & chlorination, HBs Ag for
The facility provides laboratory services as mandated NHP hepatitis B, filariasis ( endemic areas), Syphilis (RTK) 2 4

Linkages with the Central diagnostic units (Hub & SI/ RR 1

spoke) As per scope of services provided

ME A2.2 The facility provides services for drug dispensing Availability of drugs as per EDL SI/ RR 1
including medicine refills
As per scope of services provided 2 4

Availability of drugs for refill for chronic cases SI/ RR 1

As per scope of service provided
Area of Concern B: Patients Right 44 84 52%

Standard B1 The facility provides information to care seeker, attendants & community about available services & their modalities
15 28
Name of the facility & list of services (1) Name of the HWC, Service Packages and time
available are displayed prominently mandate is displayed.
(2) Check the name of HWC is visible at night also
ME B1.1 The facility displays its services and entitlements OB

1 7 14
Branding of HWC-HSC is done as per (1) Outer surface of the building is yellow with specified OB 1
guidelines
Citizen charter is displayed shade.
(1) In local language OB 1
HWC displays entitlements available as per scope (2) Service
Under Provided,
all NHP contact
including details
RMNCHA andofPMJAY
fire, police
OB 1
of services ambulance. Name & contact detail of CHW and nearest
List of Available drugs prominently displayed Updatedcentre.
referral as per current stock OB/RR 1
All signages are of uniform colour, user friendly & Information is available in local language and easy to
in local language understand OB 1

Directional signages are displayed in the Check prominent signage are displayed to reach HWC OB
catchment area -SC
1
 (1) Service specific relevant IEC is displayed
(2) Check availability of the updated IEC material
(3) Check no outdated information is displayed in HWC
(4) Check audio visual aids are used to display the IEC/
ME B1.2 Patients & visitors are sensitized and educated IEC Material is displayed as per services provided
information
OB
through appropriate IEC / BCC approaches

1 3 6

(1) Check relevant poster are displayed

(2) Check staff engages the community in
disseminating key messages in outreach as well as
HWC promotes wellness through EAT right HWC related to nutrition & sanitation through various
activities viz: 3 D food pyramid, food fortification OB/CI
campaign pocket flyer, +F logo puzzle, waste management, hand
washing, food adulteration etc.
(3) Check AV aids are played in waiting area as well as
during EAT right campaign

Staff is aware of various BCC approaches for risk factor

identification, life style modification, treatment compliance
Health Promotion activities are undertaken using & follow up care Viz. GATHER (Greet, Ask, tell, help, Explain
SI/ CI
various BCC approach & return (FP), TALK : Tell, advise, Lead & Know (Health
promotion for NCD, 5 A's (Ask, advice, assess, assist,
arrange) ( Tobacco & alcohol cessation)

Information about the treatment and entitlements Patient is informed about clinical condition and Check patients is explained about - diagnosis, treatment
ME B1.3 plan (dosage, period etc), special instructions, referral & CI/ RR
are shared with patients or attendants treatment plan
follow up
1 5 8

Consent is taken before procedure for conditions Staff is aware of the conditions where consent is taken
SI/ RR
(wherever required) before procedure
1

Primary healthcare team provide information to JSY, JSSK, RBSK, RMNCHAN, PM JAY/ state insurance
beneficiaries or families regarding their scheme etc CI/SI
entitlements Also support beneficiaries to seek services
1

HWC team provide support for linkage with SI/ CI

PM- JAY to avail the scheme benefits Facilitate identification & registration of families for PM-
JAY
2
Standard B2 Facility ensures services are accessible to care seekers and visitors including those required some affirmative action
9 18
HWC is located closer to community (1) Ensure care is provided within 30 minutes, provision
MMU for hard to reach area (Give full compliance for
MMU if area is not hard to reach)
ME B2.1 The facility is accessible from community and (2) Preferably within 1-2 Kms of Referral Centre
CI/SI
referral centre

Check for Outreach session plan - targeted population 1 4 8

Check outreach sessions are conducted covered & implementation as per plan. SI/RR 1
The services are available for the time period, HWC is functional for at least six hours per day CI/RR
as mandated 1
Care in pregnancy & child birth, Neonatal & infant
healthcare services, childhood & adolescent healthcare
services, family planning & reproductive healthcare
services, communicable diseases including NHPs, Common
communicable disease & out patient care, Non
communicable diseases, common ophthalmic & ENT
The facility provides access to expanded problems, Oral health, elderly & palliative care, Emergency CI/RR
range of services medical services & Mental health aliments

1
ME B2.2 Access to facility is provided without any physical Check HWC premises is free from any Availability of Wheel chair/stretcher, ramp with railing ( At
OB
barrier & friendly to people with disability. physical barrier least 120 cm width, Gradient not be steeper than 1:12 )

1 3 6

(1) Passage is wide enough for wheel chair and

crutches/canes/stick users.
Check HWC premises is obstacle free for (2) Floors are non slippery.
OB
ambulatory and semi ambulatory individuals (3) Ramps and stairs with handrails.
(4) Ramps & staircases with hip lip (20mm) on exposed side
to prevent slipping of cane/ crutches/ wheelchair

(1) Tactile signs with good contrast between letters &

background.
Check HWC premises is obstacle free for (2) One or two rows of tactile guiding blocks along the
OB
sight and hearing disable individuals entire length of the proposed accessible route
(3) Check there is no poles or uneven surfaces along the
route traversed by the guiding blocks

1
Check for special precaution is taken for HIV, Leprosy , Abortion, domestic Violence, psychotic
maintaining privacy & confidentiality of cases cases, GBV, abuses etc
ME B2.3 There is affirmative action to ensure that vulnerable having social stigma SI/ RR
and marginalized sections can access services
1 2 4
There are linkages of care , Counselling and Victims of Violence including domestic violence/ Gender
Protection of vulnerable and marginalized Based Violence, terminally ill patients, orphan, elderly etc.
section Linkage and support for treatment, counselling & Legal
Support SI/ RR

Standard B3 Services are delivered in a manner that are sensitive to gender, religious & cultural needs and there is no discrimination on account of economic or social reasons
8 16

ME B3.1 Services are provided in manner that are sensitive to Availability of female staff / attendant, if a male SI/CI 1
gender religious & cultural need CHO examines a female patients

3 6
Cultural and religious preferences of patients are honoured
Religious and cultural preferences of patients
and their attendants are taken into OB/SI 1
consideration, while delivering services

(1) Check there is no discrimination due to religion, cast

and tribe
(2) Check there is no discrimination due to gender
(3) Check there is no discrimination due to socio economic
There is no discrimination based religion, status
ethnicity, socio economic status, cast, gender (4) Check there is no discrimination due to ethnicity & CI/OB 1
& language etc language

MEB3.2 Staff is aware of Patients rights and responsibilities OB/SI 1

Check Staff is aware of Patient rights and Display of patient rights and responsibilities through citizen
responsibilities charter. 2 4

CI/OB 1
Check community is aware of services provided, grievance
Check community is aware of Patient's rights and redressal mechanism, contact details of higher centre,
responsibilities contact details of ambulances by HWC-HSC.
ME B3.3 The facility has defined and established procedure Check staff & community is aware of Existing state grievance system/ 104. SI/CI 1
grievance redressal system in place grievance redressal system

Complaint Box/ Complaint register/ facility specific IT 3 6

Availability of complaint reporting system system. Defined period for resolving the complaints OB/ RR 1
Corrective and preventive action taken Mechanism to report the patient on action taken SI/ RR 1
Standard B4 The facility maintains privacy, confidentiality & dignity of patient
7 12
Availability of screen/ curtains in examination Screen/ curtain/ frosted glass on windows
ME B4.1 Adequate visual privacy is provided at every point of area and in windows OB
care
1 3 4
One Patient is seen at a time by CHO Clinic is not shared by two patients at a time
OB
2
Patient records are kept in safe custody

ME B4.2 Confidentiality of patients’ records and clinical Family folders, CBAC form, NCD portal information, HIV, OB/ SI
information is maintained RTI/STI, OPD registers etc
Patient records are kept at safe place beyond access of
general patient flow 1 2 4
(1) Check HWC has policy in place regarding access of
clinical information & records. (2) Staff
is aware of it
(3) Need based individual's summary & prescription details
Check patient and their kin's have access to are provided. (IT system- have option for print) SI/ RR
clinical records
Care is free from any physical & verbal abuse. Vulnerable
or marginalized patients
is not left unattended/ignored. 1
ME B4.3 The facility ensures behaviours of its staff is dignified Behaviour of staff is empathetic and courteous to Check the status separately in labour room if delivery CI
and respectful, while delivering the services Ask the patient
services about in
are provided their
SC experience of care 1 2 4
patients and visitors
Behaviour of staff is dignified & respectful CI 1 Check in Both type of SC

Standard B5 The facility ensures all services are provided free of cost to its users
(1) As per service package or 5 10
ME B5.1 The facility provides free of cost services as per HWC provide free of cost access to all the RMNCHA, CD, NCD, Eye, ENT, Oral, Mental Health, CI/ RR
prevalent government schemes/ norms. The facility provides free of cost screening
services 1 5 10
and investigations services as per Elderly,
All Pallative,Emergency
screening medical
services and required services
diagnostic etc are
services CI/ SI 1
The facility provides free of cost essential
requirement provided free ofincost
Check all drugs the HWC-EDL are provided free of cost CI/ SI
medicines and refills as per treatment plan 1
Availability of Free referral /ambulance services Through 102/108 or any other CI/ SI 1
Availability of free teleconsultation services CI/SI 1
Area of concern C: Inputs 36 70 51%
The facility has adequate and safe infrastructure for delivery of assured services as per prevalent norms and it provides optimal care and comfort to users
Standard C1
17 34
Facility has adequate infrastructure, space and Well ventilated & illuminated clinic room with (1) Check demarcated area for examination (privacy
amenities as per patient or work load examination space maintained), consultation and administrative/record
keeping
(2) Availability of adequate Natural Light/ Illumination (150
Lux in OPD area & 300 Lux in drug dispensing areas)
ME C1.1 OB

1 12 24
Availability of adequate patient waiting area Covered waiting area which can accommodate 20-25 OB 1
Demarcated space for Laboratory / diagnostics Chairs.
Lab. space is adequate for carrying out Lab. activities OB 1
Adequate space/room for Yogaout
activities OB
Demarcated area for carrying immunization within HWC or its premises 1
activities OB 1
Demarcated area of storage (1) Storage space for storing medicines ,Consumables & OB 1
Availability of functional telephone/Mobile (1) equipment
CUG
etc.of Portable emergency light ,
Availability
numbers/ Landline and internet connectivity OB
and internetofservices generators/inverters/solar panel/ for power back up (2) 1
Availability regular & uninterrupted SI/ OB
electricity supply Use of energy efficient bulbs for lighting 1

(1) Potable drinking water supply is available for patients,

Adequate water supply with storage facility visitor & staff OB/ SI
(2) Piped water supply/ tube well with fitted water pump/
other alternate source.
(3) Water Storage facility- Minimum 3 days
(4) Periodic chlorination & Quality testing of water is done 1

OB
(1) Check toilets are functional with running water facility.
Availability of separate toilets for male & female (2) Check the toilets are disable friendly 1
 Check boundary is of adequate height and it is not broken OB
from anywhere
HWC premises has intact boundary wall 1
Availability of separate room for delivery with OB
required amenities Labour table with mattress, New born care corner 1 SC Type B
HWC has installed fire extinguisher and staff (1) Fire extinguisher ABC type
know how to operate it (2) Check expiry date & refill date is displayed
(3) PASS- Pull the pin, A- Aim at base of fire, S- Squeeze the
lever, S -Sweep side to side
ME C1.2 The facility ensures physical safety including (4) Check exists are clutter free OB/ SI
electrical and fire safety of infrastructure

(1)Check for fixtures & furniture like Almirah/ Cabinets,

hanging objects are properly fastened & secured 1 3 6
SafeBuilding
(2) installation, use &
bye laws of appropriateof wires &for
MCB , Use of
HWC does not have temporary connections and (1) Check
AV availability
regulator of instructions
Smartphones/
( for regulating
NBC
Tablets
the fluctuations)
seismic
and OB/ SI 1
loosely hangingcomponents
wires safety is followed
Laptop/desktops, internet connectivity (2mbps).
Non structural are properly secured OB/ SI 1
The facility ensures availability of information & (2) For tele medicine services,check desktop/ Laptop have
ME C1.3 HWC has adequate ICT hardware for efficient headphone , HD web camera & printer connected with it SI/ RR 1 2 4
communication technologies delivery of services
HWC has adequate ICT software for efficient
delivery of services
Check availability of functional & updated Portals or
applications viz RCH portal, HWC portal, NCD portal, RR/ SI
ANMOL, DVDMS, NIKSHAY, e-sanjeevani, HMIS etc. and
any state specific application.
1
Standard C2 The facility has adequate qualified and trained staff required for providing the assured services as per current case load
7 14

ME C2.1 The facility ensures availability of Community Health SI/ RR

officer
As per eligibility criteria.
Availability of Community Health Officer Staff is aware of their role and responsibilities 1 1 2

2ANM (1 essential & 1 Desirable)- SC type -A

The facility have adequate frontline health workers Availability of ANM 2 ANM (Essential, one may be staff nurse) - Only for
ME C2.2 SC type-B SI/ RR
and support staff as requirement Staff is aware of their role and responsibilities

1 Female and 1 Male

Staff is aware of their role and responsibilities for HWC and 1 3 6
Availability of Multipurpose Worker community SI/ RR 1
Availability of ASHA & ASHA facilitator 1 ASHA per 1000 population / ASHA per 500 population for SI/ RR 1
ME C2.3 The facility has established procedure for duty Check duty roster is prepared prepared, updated tribal and hilly area.
SI/ RR
roster for facility and community staff 1 3 6
& followed
Check for all
field visit cadres
plans are prepared, updated & SI/ RR 1
followed by primary
All staff adhere healthcare
to their team
respective dress code (1) Staff adhere to their respective dress code
(2) Staff on duty is wearing their ID card
OB

(1) Check objective checklist has been prepared for 1

assessing competence of staff based on job description
Standard C3 Facility has a defined and established procedure for effective utilization,
and assessment evaluation
is done at leastandonceaugmentation
in a year (2) Checkof competence and performance of staff
Check parameters for assessing skills and who 9 16
ME C3.1 Competence assessment and performance (1) 6 did
Verify with
month therecords
assessment
certificatethat -performance
At least
program in PHC- MO/ Competence
appraisal
Community has been
health, RR/ SI
proficiency
evaluation of all staff is done on predefined criteria Check of staff has evaluation
for performance been defined Matrix
is done at least done
(2) atis(F)
3 day prepared
least for
once days
IT: (1)4-5
training in aeach
year
including category
and verify
Tele ofwith
staffstaff for actual
medicines 1 3 6
MPW- training in IUCD insertion, NSSK, RR/ SI
once in a year assessment
(3)
HBNC daysdone
5-7Supervision,
supplementary
Management training on new health
of Childhood illness, (2) 1
programs, new skills (if applicable)
21 days of SBA training. (Wherever applicable)
(4) refresher
MPW (All)- every year
National (if applicable)
Health Programmes, 3 days training
(1) Basic
(5) 8 daysphysiotherapy
induction training, ( where 20 days elderly
training&ofpalliative
module 6& RR/ SI
Check actions are taken for all the identified on 5NCD,
Check
7, 1NCD
training
days day module.
joint
need training withever
are identified ASHA for NCD
at defined screening
intervals & ,
care
3 dayspackages
training are available)
on reporting andtraining
receiving information
gaps adequate
(2) skill
(6) Supplementary
Training on are
Eatprovided
& refresher
right tool kit nursingfor 15 days/year. (if 1
ME C3.2 The staff is provided training as per defined core CHO is trained as per mandate using digital
applicable) applications & basic care training (esp. RR/ SI
competencies and training plan for elderly & palliativeiscare), training on physiotherapy
Eat right tool kit 1 6 10
MPW is trained as per mandate (3) ASHA facilitatory trained for Basic RR/ SI
( where everwaste
elderly & palliative care packages are 2
Bio
(1) medical
Through access on management,
to Job aids/ Infection Prevention,
AHSA is trained as per mandate available),Training
patient safety, internal Eat right MOOC
assessment, toolkit (massive open
BLS, Methods of QA viz
RR/ SI 1
online courses)/ ECHO etc RR/ SI
Staff isHWC
Check provided
use with Quality assurance
IT platforms for regulartraining (2)
PSS,Check
5S, PDCAhow etc many capacity building training/workshop 1
continuous learning & capacity building attended by primary healthcare team in last quarter RR/ SI 1
Standard C4 The facility provides drugs and consumables required for assured services
0 0
ME C4.1 The facility have availability of adequate drugs Availability of Anaesthetics agents Oxygen & Lignocaine topical (5%) OB/RR 0 0

Levocetirizine tablet (5mg) , Levocetirizine Oral liquid , OB/RR

Hydrocortisone Succinate injection 100mg, Pheniramine inj
Availability of Anti-allergic 22.75mg/ml, Adrenaline inj 1mg/ml
 Aspirin tab 75, Diclofenac tab 50mg, Diclofenac injection OB/RR
25mg/ml, Paracetamol tab 250mg, Paracetamol Syrup
125mg/5ml, Paracetamol Syrup250 mg/5 ml, Ibuprofen
Availability of Analgesics, Anti Pyretic, NSAIDS, tab 200mg

Amoxicillin Capsule 250 & 500 mg

Phenytoin
AmoxicillinTablet 50 mg
Oral liquid 250& 300 mg, Sodium
mg/5ml, valporate
Amoxicillin dispersible
Tablet OB/RR
tab 250200,
mg,500 mg & Sodium
Gentamycin inj 10&valporate
80 mg/ Syrup each
ml, Ciprofloxacin
200mg/5ml,
Tablet 500 mg,Phenobarbitone
Ciprofloxacin Oraltab 30 & 60250
liquid mg,mg/5ml,
Phenobarbitone Syrup 20 mg/5ml, Midazolam
Ciprofloxacin Inj., Tab Co-trimoxazole [Sulphamethoxazol nasal spray,
Diazepam
80 tab 5 & 10 mg,
mg +Trimethoprim 400Magnesium
mg] sulphate Inj (50%
Availability on Anticonvulsants /Anti epileptics sol
Tab )- 2ml
Co-trimoxazole [Sulphamethoxazole 100
Albendazole Tablet 400 mg, Albendazole Oral liquid 200 mg +
Availability of Intestinal Anti Helminthes Trimethoprim
mg/5 ml 20 mg ] Co-trimoxazole Oral liquid OB/RR
Diethylcarbamazine
([Sulphamethoxazole Tablet
200 100
mg mg
+ Trimethoprim 40 mg/5ml),
Availability of Antifilarial Clofazimine Capsule 50
Diethylcarbamazine Oralmgliquid 120 mg/5 OB/RR
Chloroquine,
Doxycycline
Clofazimine 100mg, 100
Capsule Metronidazole
mg, Dapsone 200 &ml40025mg,
Tablet mg,
Availability of Anti Bacterial Artesunate
Norfloxacin
Ferrous salt(A)+
tab/
100 50Sulphadoxine-
oral
mg + Folic acidPyrimethamine
500 mcg Tablet(B), OB/RR
Dapsone
Combipack Tablet
(A+B) mg,
Availability of Anti leprosy Ferrous
Dapsonesalt 20 mg
Tablet +mg
1002.5 Folic acid 100 mcg Tablet, Ferrous salt OB/RR
Primaquine Tablet mg
60 mg + Folic acid 500 mcg, Ferrous salt 45mg + Folic acid
Availability of Anti Malarial Primaquine Tabletsalt+
7.5 mg OB/RR
100 mcg , Ferrous Folic acid Syrup, Folic acid Tablet 5
Availability of anti Anaemic drug mg and 400 mcg, Vit 10g/15ml,
K inj 1mg/ml, OB/RR
Lactulose
Isosorbide-oral liquid
5-mononitrate 5mgPovidone Iodine dinitrate
tab, Isosorbide lotion and
Availability of drugs for Palliative care oint. OB/RR
5mg, Atenolol 50mg, Metoprolol 25mg, Metoprolol SR
Availability of Cardiovascular medicines 25mg OB/RR
Amlodipine Tablet 2.5 & 5 mg, Telmisartan Tablet 40 mg,
Availability of drugs for Hypertension Enalapril 5mg, Hydrochlorothiazide 12.5 & 25 mg OB/RR

OB/RR
Availability of drugs for Hypolipidemic Atorvastatin Tablet 10 mg
Clotrimazole Cream, Miconazole oint. ,tab fluconazole 150
mg , Silver sulphadiazine Cream 1%, Betamethasone
Availability of Dermatological & antifungal cream 0.05%, Calamine Solution, Benzyl -benzoate oint/lot, OB/RR
Medicines Mupirocin, KMnO4 -0.1%, Zinc oxide cream 10%,

OB/RR
Availability of Diuretics Furosemide Inj & tab 40 mg

OB/RR
Availability of Drugs for dementia Alprazolam Tab 0.25 & 0.5 mg

OB/RR

Eye drops- Methyl cellulose, Sodium cromoglycate (2%).

Availability of Eye drugs

Ciprofloxacin drops 0.3%, Ciprofloxacin tab 250 & 500mg,

Boro-spirit ear drops, Ear wax solvent drops (combination OB/RR
Ranitidine Tablet
of Benzocaime 150 mg, Ranitidine
, Chlorbutol, inj, Omeprazole,
Paradichlorobenzene and
Availability of ENT drugs Ondansetron
Turpentine oil)tab, oral liquid and inj, Ispaghula granules/
Husk/ powder, Oral rehydration salts (ORS),Zinc Sulphate
Syrup & tablet, Dicyclomine Tablet & Inj, Dioctyl sulfo
succinate Sodium, Magnesium Hydroxide liquid, Senna OB/RR
Availability of Gastroinstinal medicines Powder, Domperidone Tab & Syrup

Ethinylestradiol (A) + Levonorgestrel Tablet 0.03 mg (A) + OB/RR

0.15 mg (B),Condom, IUCD 380 A Copper bearing
intrauterine, Ormeloxifene Tab 30mg, ECP( Levonorgestrel
Availability of Contraceptives Salbutamol Tabletprogesterone
1.5mg), Medroxy 2 mg Acetate injection,
Metformin
Salbutamol SR Tablet
Oral liquid500 mg, Metformin
2 mg/5 ml Tab 500mg,
Availability of drugs for diabetes Mellitus Glimepiride
Salbutamol TabTablet
2mg, 25,
Respirator Glibenclamide
solution Tab
for use in 2.5 & 5 mg
nebulizer OB/RR
Levothyroxine 50 & 100 mcg
Availability of drugs for Thyroid 5mg/ml, Budesonide Respirator solution for use in OB/RR
nebulizer 0. 5mg/ml, Normal Saline drops, OB/RR
Availability of Oxytocin and Antioxytocics Misoprostol Tablet 200
Dextromethorphan oralmcg, Oxytocin
syrup, Injection 5 IU/ml,
Hyoscinebutylbromide Tab SC type B
Availability of medicines for Tespiratory tract 10 mg lactate Injection, Sodium chloride injection 0.9%, OB/RR
Ringer
Calcium Carbonate Tablet 500 mg, Vit C tab 100mg,
Availability of IV Fluids Dextrose 5% & 25% OB/RR
Cholecalciferol Tab 60,000 IU, Pyridoxine tab 25,50 &
Availability of Vitamins and Minerals 100mg, Vit A oral liquid 1,00,000 IU/ml, B complex tab OB/RR

OB/RR

Availability of Antidotes Activated Charcoal, Atropine 1 mg/ml .

Availability of injectables Anti rabies vaccine, Inj. Tetanus Toxoid, OB/RR
 OB
Availability of Emergency Drug Tray / injectables Inj. Adrenaline, Inj. Hydrocortisone, Inj. Dexamethasone ,
at injection room Glyceryl trinitrate-
Hydrogen peroxide,Sublingual tab 0.5Povidone
Gentian violet, mg Iodine,
Availability of Anti septic Framycetin sulphate ointment OB/RR

OB/RR
Haemoglobin scale test with talquist paper, Urine
Clove oil, betadine
Pregnancy & Chlor-hexadine,
rapid(10cc,
test, Rapid Kitsand
forADGluconate
Malaria mouth
and(0.5ml
Dengue,
Availability of drugs for oral health Splints,Tannic
wash, Syringe acid 5cc, 2cc) Syringe and
The facility have adequate consumables as per Urine
0.1ml)Dip
for Stick forastringent
injection,albumin gum paint.
and
withSugar,
SutureSpatula, needleGlucometer
holder Cordwith
& artery
ME C4.2 Availability of Rapid Diagnostic Kits Mucus extractor,
glucosticks, Wooden
Sputum gloves, Disposable
Cups, Disposable Swabs, Disposable clamp, OB/RR 0 0
requirement forceps, Disposable
Disposable Sterile Urethral Catheter( 12fr, 14fr) , Foleys
Availability of disposables for Dressing / Lancets, Mackintosh OB/RR
Emergency management catheter , IV Cannula Sheets
and Sets, Interdental Cleaning Aids,
Availability of disposables at Clinics cold pack, cotton and envelopes for drug dispensing OB/RR

Vit A prophylaxis, Glucosticks, Syringes, Pregnancy kits, HIV OB/RR

Rapid Test and STI Screening Test kits, Kit for testing
residual chlorine in Water. Vision screening care for 6/18
Availability of Drugs and Consumables for VHNDs vision, measuring tape (6m), reading module.
or camps

OB/RR

Availability of drugs & consumables for home

care kit As per palliative care guidelines
Standard C5 Facility has adequate functional equipment and instruments for assured list of services
3 6

The facility ensures availability of equipment and

ME C5.1 instruments for examination and monitoring of BP apparatus, Torch, stethoscope ,peak flow meter and OB
patients snelle's /near vision chart, Measuring tape, Thermometer,
Foetoscope,Weighing machine, Infant weighing scale,
Tongue depressor, Stadiometer.
Availability of functional Equipment & Dressing Trays, Dressing Drums, Surgical Scissors ,
instruments for examination & Monitoring at Examination Lamp, Cheatle's forceps, Sponge Holder,
Clinic Artery forceps. 2 4

OB
Nasal speculum, dressing/ packing forceps, digital scope,
tuning fork (512 HZ), App & headphone for app based
Availability of functional Equipment & audiometery, LED head lamp, ear speculum, Jobson Horne
instruments for ENT services probe, Eustachian catheter

Dressing Trays, Dressing Drums, Surgical Scissors , OB

Examination Lamp, Forceps, Sims retractor / speculum ,
Availability of functional Equipment & Cusco's / Graves speculum, Cheatle's forceps, Sponge
instruments
Availability offor oral services
functional equipment & Dental explorer,
Holder,bag
Artery mouth Cord
mirror, tweezer
cordIntradental brush,
Ambu withforceps, clamp,
Mask, Suction Machine, Cutting scissors,
Oxygen cylinder OB
instruments for normal delivery services Episiotomy scissor. equipment (Keys),Mouth Gag ,
with Administrative 1 SC type B
Availability of Emergency functional equipment Nebulizer. AED (Automated External Defibrillator) OB 1

ME C5.2 The facility have adequate furniture and fixture as Table, Doctor chair, Patient Stool, Examination table, OB
per service provision Attendant Chair, Foot Step, Screen Separators with Stand,
IV stand, Wall clock, refrigerator (For storage of drugs &
Availability of furniture & fixture at Clinics vaccines) 1 1 2
Area of Concern D: Support Services 12 24 50%

Standard D1 The facility has established Programme for maintenance and upkeep of the facility
12 24
 HWC Building is painted/whitewashed in uniform Check building is white washed both from inside & outside
colour & its branding done as per the guideline

ME D1.1 The facility has established system for infrastructure OB

maintenance

1 6 12
1. No seepage, cracks and chipping of plaster from wall,
Check building & its premises is well maintained OB 1
HWC has system for periodic maintenance of roof, windows
1. Check etcof building, patient amenities
records
Building including patient amenities maintenance and schedules.
2. Pest or rodent control measures are taken at least once SI/ RR
in 6 months 1
No condemned/Junk material in HWC (corridors, HWC remove its junk periodically as per condemnation
roof, administrative area , backyard) policy.
RR/ OB
1
There is system of timely corrective & preventive Check staff is skilled to undertake the trouble shooting SI/ OB 1
break E.g. Weighing machine, BP apparatus, the status is re
All the down maintenance
measuring of the
equipment/ equipment
instrument are checked At least once in six months. RR/ OB 1
ME D1.2 The facility has established system for maintaining calibrated
Check all the areas are clean & hygienic 1. Check that floors and walls for any visible or tangible OB
sanitation and hygiene 1 6 12
Check there is no foul smell in HWC dirt, grease,
Check toiletsstains, etc.and there is no overflowing/clogged
are clean OB 1
drains
Check availability of adequate supply of cleaning (1) Availability of mops, 2- buckets system, good quality OB/ RR 1
material
Check cleaning
staff is aware of use of 2 bucket system & One solution
bucket preferably
for Cleaning a ISI mark.
solution, second for OB/ SI 1
disinfection
HWC of mopfor
has a system after cleaning
safe disposal of general wringing
No garbagethepiles
mop.in and around HWC.
OB 1
waste
Clean and adequate linen is available No signs
Check of burning bed,
Examination of waste
tableincloth
HWCetc are clean.
There is system in place for washing of linen OB/ RR
1

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs
There is established procedure for estimation and 0 0
ME D2.1 indenting of drugs and consumables as per HWC has a process to consolidate and calculate Check forecasting of drugs & consumables is done SI/ RR 0 0
requirement the consumption
Check Drugs and consumables forecasting and scientifically based on
Linkage with portal/ consumption .Reorder & buffer
DVDMS
indenting is IT enabled levels are defined
RR/SI

Check there is established system to timely (1) Timely indenting the drugs for common aliments & RR/SI
indent the drugs as per services package emergency
(1) For HWC,cases
campaigns and home based care.
Check there is no stock out of essential & (2) Check staff is aware of any stock out
RR/ Ci
vital drugs

(1) Check list of VED categorisation

Check drugs are categorised in Vital, Essential (2) Check updated stock registers of the last 6 months for RR/SI
vital & essential drugs
and desirable

ME D2.2 The facility ensures proper storage of drugs and There is specified place to store medicines in Drugs and consumables are stored away from water / OB
consumables 0 0
HWC drugs are kept in racks and shelves with Drugs
Check dampness andstored
are not sourcesat of direct
floor heatitems
,Heavy & sunlight etc. at
are stored OB
proper labelling
LASA ( Look alike and Sound alike ) are stored lower shelves/racks and fragile items are not kept on the
edges OB
separately
Check heat and light sensitive drugs are stored as (1) Medications that are considered light-sensitive will be OB/SI
per manufacturers
Check process followedinstructions
to maintain the stored in closed drawers.
(1) Temperature chart is maintained OB/RR
ME D2.3 The facility ensure management of expiry and near First expiry first
temperature out (FEFO)used
of refrigerator system is followed (2) De frosting is done (in case household freeze is used)
for drugs/
OB
expired drugs vaccine/
for drugslab kits
dispensing 0 0
There is system in place to maintain expiry & Check all near expiry drugs are shifted back to PHC/
near expiry drug
No expired of drugs
is found in HWC referral centre/ facility where it is urgently required based
In dispensing
on area as(that
inventory turnover well is-
as drug storage
Fast, slow area
or non moving OB
There is an established process for discard the (1) Staff is aware about how to discard expired drugs and
drugs) SI/OB
expired drugs are not stored in HWC
Standard D3 The facility has defined and established procedure for clinical records and data management with progressive use of digital technology
0 0
Information regarding illness and minor aliments (1) Diagnosis, assessments, treatment plan, drugs
are recorded & updated using IT platform prescribed, and follow up etc are recorded & updated for
all cases by HSC
Information regarding ambulatory care & (2) Randomly, select at least 5 cases (or all cases if less
ME D3.1 management, public health and managerial than 5) and check for details RR/SI
functions are recorded and updated through IT
platforms

0 0
 Information regarding RMNCHA care seekers are (1) Diagnosis, assessments, treatment plan, drugs
recorded & updated using IT platform prescribed, and follow up etc are recorded & updated for
all cases by HSC/ referral centre
(2) Randomly, select at least 5 cases (or all cases if less
than 5) and check for details RR/SI

Information regarding cases of communicable (1) Diagnosis, assessments, treatment plan, drugs
diseases are recorded & updated using IT prescribed, and follow up etc are recorded & updated for
platform all cases by HSC/ referral centre
(2) Randomly, select at least 5 cases (or all cases if less
than 5) and check for details RR/SI

Information regarding cases of Non- (1) Check family folder, CBAC form are filled and complete
communicable diseases are recorded & updated details are updated in portal.
for each case using IT platform (2) Diagnosis, assessments, treatment plan, drugs
prescribed, and follow up etc are recorded & updated for
all cases by HSC/ referral centre RR/SI
(3) Randomly, select at least 5 cases (or all cases if less
than 5) and check for details

Check referral in & referral out records are (1) Referral out, Assessments, re-assessments,
maintained using IT platform investigation, treatment plan and medicines dispensed.
(2) Referral in- status at time of discharge, treatment given,
vitals medicine dispensed, follow up, any adverse drug
reaction reported, treatment plan to be followed
Give partial compliance if information is only available in
paper. RR/SI

Functional platform/s and updated digital records Population enumeration, coverage, screening, referral & RR/SI
to assess the
Functional coverageand
platform/s andupdated
measuredigital
outcomes follow ups generation- daily, weekly & missed task,
Work plan
of healthcare facility RR/SI
records forplatform/s
Functional work/ taskand
management
updated digital records reminders to team
Daily reporting of allfor
thescheduling
activities ,appointments
IT support to ,follow
generateup
for reporting and monitoring of the of home visitsmatrix
performance and outreach
of Serviceactivities, Special
Providers, days etc
calculating
performance of health care provider performance based incentive, Support for staff monitoring
& maintenance of their credentials
RR/SI

ME D3.2 The facility ensures safe storage, maintenance and HWC has established procedure for safe (1) Secure place to keep records and registers OB/ SI
retrieval of information & records of services keeping 0 0
HWC has&established
retrieval ofprocedure
paper based
for records
access & (2)
(1) Check
Systemrecords
clearly are easywho
define to retrieve
all are authorized to access OB/ SI
retrieval of electronic records
HWC has policy for retention period for different the patient
As per Stateelectronic
policy information
RR/ SI
ME D3.3 The facility has established procedure for providing information & records
Hubs are identified for tele consultation Staff is aware of functional hubs
(1) Arrange consultation with PHC- & skilled
MO orto use the as
Specialist OB/ RR
consultation using tele medicine 0 0
Cases are identified for tele consultation for software
per requirement. SI/ RR
specialist & non specialist consultation (2) Check how many cases were consulted using tele
medicine in preceding 3 months
Co ordination with specialist / super As per roster - send the patient to PHC SI/ RR
specialist for tele consultation

Co ordination with patient & creating (1) Pre appointment, location for consultation
awareness about tele consultation services (2) Check reminder / SMS alerts are sent for SI/ CI
appointments/ referral/ follow up cases

Dispense drugs as per prescription received As per e-prescription RR

through tele consultation
Standard D4 The facility has defined and established procedures for hospital transparency and accountability.
0 0
ME D4.1 The facility has established procedure for HWC has functional Jan Arogya Samiti (1) Check composition of committee as per JAS guidelines. RR/SI
management of activities of Jan Arogya Samiti 0 0
Committee members are aware of its roles & Chairperson- Sarpanch,
A. (1) Maintenance Co -Chairperson-
of HWC MO- PHCsafe
- cleanliness, hygiene, and
Member Sect. - clean
CHO. toilet, BMW disposal & clear signage. CI/ SI/RR
responsibilities
JAS meetings are held at defined intervals drinking water,
(1) Monthly. RR
Check JAS supports HWC to mobilize (2) Minutes
Both of meeting
monetary and nonare recorded
monetary from PRIs/ CSR/Govt. RR/ SI
resources/funds schemes and program /donation etc
Timely planning & utilization of untied funds Timely submission of Utilization certificate as per RR/SI
Check JAS provide support for Health promotion state/NHM norms
& prevention activities
SI/ RR
Organize camps, VHSNC meetings, multisectoral
convergence, formation of PSGs etc.
 Check JAS facilitate Public hearing or Jan Sunwais Check when was last public hearing was undertaken. HWCs
undertake Jan sunwais bi annually
SI/RR

Check social audits are done at periodic intervals At least once in a year. Check when last social audit was
undertaken
The facility has established procedures for
ME D4.2 community based monitoring of its services through RR
social audits
0 0
Check JAS is aware of the issues issues emerged
in Social Audits & public hearing
There is mechanism in place to improve the gaps
identified / recommendations given by social audits RR/SI
teams

Gaps closure plan is prepared & status is assessed atleast

once in quarter or as per decided timeline
Check JAS committee has prepared action RR/SI
plan along with HWC

Check social audits are conducted before Check the issues emerging out of the Social Audit are
completion of Annual planning of the gram integrated with the annual planning process of Gram
Panchayat Panchayat.
RR
(1) At least once in a month
The facility has established procedure for supporting Check CHO conducts periodic meetings with (2) Assess the progress on coverage of beneficiaries &
any knowledge or skill gap
ME D4.3 and monitoring activities of Community health RR/SI 0 0
workers MPW & ASHA
Check CHO provide on job mentoring & (3) Identify common issues & problems faced by
(1) Check CHO
Frontline provide on job mentoring & support to
workers SI/RR
supervision household
Check CHO provide on visits
job mentoring & frontline workers (ASHA/
(4) Check
(1) Actions
CHOtaken
provide onMPW)
thereafter
job mentoring & support to CI/ RR
supervision for VHSND or campaign etc. frontline workers (ASHA/ MPW)

Check PHC -MO provide supportive (1) Monthly review of service delivery & performance
supervision & monitoring for HWC activities of HWC RR/ SI
(2) Supportive supervision for HWC staff

Standard D5 The facility ensures health promotion and disease prevention activities through community mobilization
0 0

ME D5.1 SI/ CI

The HWC facilitate planning & implementation of health Check HWC is aware of community level
promotion and disease prevention activities through approaches for health promotion and disease
community level interventions prevention VHSNC, VHNDs, ASHA, AWW and Monthly campaign etc 0 0

RR/ SI
(1) Regular meetings are being conducted
(2) Community based action plan for health is prepared
(3) Provide support to frontline workers for health related
Check VHSNC are constituted & functional activities

Check frontline workers part of VHSNC are able to

explain - Support to develop village health action plan,
Awareness generation for Health Promotion & disease SI/ CI
prevention and support the community to raise their
Check VHSNC members are aware of their roles voice, need, experience & grievances to access health
& responsibilities towards Health & wellness services or benefits
centre

(1) Check agenda points and minutes of meeting of

preceding quarter
(2) Check health & wellness activities are prioritized RR
VHSNC actively involved in review of public (3) Check the status of planned actions & activities
services & programmes viz. ICDS, drinking water, proposed for or in co ordination with health & wellness
sanitation , mid day meal including HWCs etc centre
 RR
Check number of VHSNC meeting attended by
CHO in preceding quarter At least 2 VHSNC per month

RR/CI
(1) Check the list of VHND planned & conducted
Check number of VHND planned & conducted in (2) List of AWC under HWC & name of the AWC where
CHO's catering area in preceding quarter VHNDs conducted

(1) Check advance communication regarding date & venue RR/CI

is given.
(2)Line listing of pregnant women requiring ANC, TB
patients, infant or children requiring immunisation, left or
drop out children & malnourished
(3) Check estimation about number of people expected to
Micro planning to conduct VHND is done by attend VHND are calculated in advance
HWC staff & frontline workers (4) Check the coverage against estimation
(1) Identify the individual with health risk
(2) Community mobilization for screening
(3) Holding or Support village meetings or campaigns for
awareness
(1) Awarenessgeneration
generation& life
forstyle modification
various Health program SI/ OB
Check functional equipment, instrument and (4)
(2) Support
Need basedtreatment compliance
counselling for pregnant women,
& interventions
adequate
Check the consumables
health promotionare available
& diseaseto conduct new born,the
(3) Check NCDlist&ofacute of chronic
topics coveredconditions
during VHNDsas per
in
VHND
presentation As per service
service provisionprovision
Check primaryactivities
healthcareare team
performed during
perform proceding
(5)
quarter
CI/ SI/ RR
VHNDs
advocacy with community influencers for giving (1) Check
Viz.Based number
on of
Benefits
of newenumeration,
Population
immunization,
individuals identified
family
with health
village health
planning, ANCs,
risk & mobilized
register, CBAC, ASHA for screening in proceding quarter CI/SI
key messages
Check for health promotion regular check-up and diary,
Yoga forVHSNC
NCDsrecords,
etc. RCH registers
Check the
the health
processpromotion
followed to& identify
disease key (6)
etc Check number of individual supported treatment SI/ RR
prevention activities
challenges and list ofare performed
priorities by ASHA
for monthly compliance
(2) Based oninsocial
proceding quarter
resource map - it identify location &
campaigns vulnerable section SI/ RR

(1) Check advance plan is available with HWC

(2) At least 30 diseases/national health program specific
awareness or health promotion campaign are organized RR/ SI
per year. Viz. WASH, Eat right/eat safe, Nutrition
(1) Prepared
screening, draft campaign
deaddiction plan & define
& substance abuse,responsibilities
Indoor and
of primary
outdoor care team
pollution, Case detection for NCD & CD, childhood
Check Annual calendar is prepared for monthly (2) Conduct
illness meeting
diarrhoea of HWC team
& pneumonia, & other stakeholders
prevention of childhood
campaign based on situational analysis i.e. panchayat,
marriage, ICDS etc
GBV etc
Check health promotion campaign are Check
(3) number of healthorpromotion
Gather/PreparedIEC campaign
IPC material requiredconducted
conducted as per planning
Check the involvement of HWC in planning & out of planned in proceding quarter
(4) Engage community volunteer, support & supervise
RR
falcitation of monthly campaign activities them RR/SI
There is a system of taking feedback from ASHAs
/ VHNSCs/ VHND to improve the services
SI/ RR

ME D5.2 For ensuring treatment compliance, reduce stigma, CI/ RR

The facility has Patient Support Groups(PSG) as per the HWC have created Patient support groups for increase acceptance toward disease, reduce stress &
issues/ diseases in its catering population various issues/ disease conditions anxiety & increase self understanding 0 0

SI/RR
(1) Identify
(1) Based onthe
issues/diseases with high
potential member prevalence
& encourage in area
them to
Check the process followed to create PSGs using
join bydata &information
explaining them thecollected
advantages of joining
(2) Friends, relatives, frontline workers and patients
suffering from same disease conditions.
(3) PSGs meetings should be open to all community SI/ CI
Check staff is aware of guiding principles to be members
followed to constitute PSGs

(1) Sharing the knowledge & experience with other

(2) Work together to solve the problems SI/CI
(3 Helping health functionaries in health promotion (as
Check members of PSGs aware of their roles convenient)
No. of planned PSGs & how many actually conducted
(1) Flexible location, - in house of group member, arranged
after VHNSC/ VHNDs, SHC, AWW - preferable near to RR/CI
Check the frequency , location & timing of PSG marginalized or distant hamlets
meetings facilitated by HWC (2) Time- mutually convenient
 (1) Encourage participants to sit together
(2) Summarize the learnings from meeting
(3) Listening & respecting the opinion of members SI
Primary health care team/worker is aware of (4) Inform group about content, date , time & place for
their role in conducting PSGs next meeting
(1) Education, WCD, ICDS, rural development/
ME D5.3 The facility ensure multisectoral convergence for HWC engage other allied departments for municipal bodies, FSSAI &ICDS etc. RR/SI
health promotion and primary prevention intersectoral convergence (2) Check VHSNC provide platform for multisectoral
convergence 0 0

HWC support & felicitate promotion Community level education, malnutrition, sanitation
activities with their convergence drives, promotion of healthy behaviour, sanitation SI/ RR
departments drives etc
(1) In schools in HWC-SHC coverage area
(2) Ayushman Ambassador - 1Male & 1 female
Check Ayushman ambassador are identified teacher -provide age appropriate learning for SI/ RR
promotion of healthy behaviour

HWC organize training sessions & With support of Ayushman ambassadors SI/ RR
competitions for school children

HWC promotes wellness & health promotion SI/ RR

through Yoga (1) Identify pool of local yoga instructors
(2) Prepare & disseminate weekly/monthly schedule of
classes for community yoga trainings

Standards D6 The facility is compliant with statutory and regulatory requirement

0 0
ME D6.1 The facility ensures its processes are in compliance Authorization for Bio Medical waste Management Prior approval from Pollution control board (if HWC is using RR
with statutory and legal requirement 0 0
No Smoking sign is displayed at the prominentdeep burial pit)
Both inside & outside the building OB
places
Any positive report of notifiable disease is RR/SI
intimated copies
Updated of relevant
to designated laws, regulations BMW rules, fire safety, electrical installations and any
authorities
RR
and Govt orders are available other as per state mandate
Area of Concern E: Wellness & Clinical Services 208 322 65%

Standard E1 The facility has defined procedures for registration, consultation, clinical assessment and reassessment of the patients
0 0

The facility has established procedure for

ME E1.1 empanelment & registration of individual and RR/SI
families (1) There is established procedure to collect the
HWC is aware of constitution of its catering demographic
Check composition
no. of pregnant women, no. of life births, pregnant
population
HWC periodically estimates & updates number (2) No. of
mother individuals
with of different
complications, agecouple,
eligible groupssick new born 0 0
of beneficiaries for RMNCHA services are estimated RR/SI

RR/SI
HWC periodically estimates & updates number Population above 30yrs , break up of men & women above
of beneficiaries for NCDs 30 yrs.

RR/SI
HWC periodically estimates & updates number
(1) per
Check family folders are maintained
ratesfor entire
of beneficiaries
All forfamilies
individuals and CDs are empanelled under As incidence rates/ prevalence
registered population in facility's coverage area.
H WC RR/SI
(2) Check data base is updated regularly for new entrants
and exits (annually) & their illness.
ME E1.2 The facility has established procedure for Check Unique health ID is given to all individuals and
RR/CI
registration & consultation in HWC Unique identification number is given to each families .
patient 0 0

RR/SI
Check all the patients visiting HWC are registered & their
Patient demographic details are recorded in OPD demographic details like Name, age, Sex and Address etc
register/portal are maintained
Chief Complaint, Patient History, Physical
The facility has established procedure for examination, requisite diagnostics, provisional RR/SI
OPD Consultation diagnosis, primary management & referral (if
required)
Through tele health/ tele consultation with MO PHC
Facility has system to undertaken opinion /identified hubs/ clinical decision making -IT tool RR/SI
/consultation from higher centre
 All the empanelled individuals are screened Through fix day/routine OPD consultation RR/CI

ME E1.3 The facility has established procedure for follow up/ Facilities provide follow up/re assessment for CI/ RR
re-assessment of patients cases under RMNCHA Reassessment /follow up as per schedule for all cases
including
Reassessment critical /highup
/follow riskaspatients.
per schedule
schedule forfor all
all cases
cases
Reassessment
Follow
(1) Eye,up ENT, /follow
includes
oral, up as
- Treatment
elderly per compliance,
&patients.
palliative, mentalreview
health ofetc.
including
including critical
critical /high
/high risk
risk patients.
parameters,
Give
Follow monitoring
fullupcompliance
includes if any of services
- Treatment side effect, adherence
is not
compliance, given as to
review oflife
per
style modification,
service mandate
parameters, timely
monitoring detection of
of side compliance,complication
effect, adherence and
toof
life
Follow
(2) up includes
continuity
Follow up - Treatment
andincludes
adequacy of treatment.
-timely
Treatment compliance,reviewmonitoring 0 0
style
Facilities provide follow up/re assessment for of modification
parameters, and detection of complication
andside effect,monitoring
continuity adherence
and adequacy
of
to side
life
of
effect,
style adherence and
modification
treatment.
to life CI/ RR
cases under
Facilities Communicable
provide diseases
follow up/re assement for style modification and timely detection
timely detection of complication and continuity and of complication
CI/ RR
cases under
Facilities non communicable
provide diseasesfor and
follow up/re assement
continuity
adequacy and adequacy of treatment.
of treatment.
CI/ RR
other clinical conditions
Standard E2 The facility has defined and established procedures
CHW ensures homefor continuity
visit, of care
counselling/ through two way referral
supportive 0 0
ME E2.1 The facility has established procedure for continuity Facility ensures continuity of care at activities for risk
Dispensation factor modification,
of medicines, provide as
repeat diagnostic CI/ RR
of care reminder for follow up at HWC 0 0
community/household level at Health & wellness required/
Continuity of care is ensured as per treatment plan,&identification
collection of drugs.
of SI/ RR
Linkage with MMU/RBSK
complication , facilitating mobile unit
referrals, organizing tele
centre Examination,
Continuity of care is ensured at referral consultations,development/modification
maintenance of records of treatment RR/SI/CI
The facility has established procedure for undertaking Centre/higher centre plan,
Early instruction
case for
detection, patient,
primary note to CHO by
management/stabilisation,
ME E2.2 referred in & referred out of the cases Facilityavailability
Check has defined ofprotocols
separate for referral
colour coded out RR/ SI 0 0
MO/Specialist.
Complete details of case records/care provided - use of
referal slip for easy identification in referral centre OB/SI
referral slip
Facility has defined protocols for referral in Check records for treatment plan, periodic assessment, RR/SI
medicine
(1) refill
Referral slip,and referred
referral in ortoout
further higher centre
register/portal, (if
Advance
required)/
communicationregular follow
, prior up at referring
appointment withcentre
specialist, referral
vehicle (if required) & follow up.
(2) IT system to track upward & downward referrals to RR/SI
ensure the continuity of care
Facility has referral procedure in place to ensure
continuity of care

Standard E3 The facility has defined and established procedures of diagnostic services.
0 0

ME E3.1 The facility has established procedure for laboratory SI/RR

diagnosis as per guidelines
Point of care diagnostics services are available as Check staff is aware of Quality Control method for various
per mandate tests (RDKs) 0 0

CI/ SI
Central hub/diagnostic units are identified &
linkage has established for tests not done at For Both laboratory/other diagnostic test. Check how much
HWC patient has to travel for getting diagnostic services

(1) Check IT system is used for reporting of diagnostic RR

results from PHC/referral centre or identified hub results.
HWC has system for timely reporting, retaining & (2) Biological reference intervals for laboratory tests are
prompt retrieval of diagnostic result available in HWC

RR/SI

Check there is no irrational prescription of Check OPD ticket for any irrational prescription of Lab
Diagnostic test test/USG/ X ray etc

Standard E4 The facility has defined procedures for safe drug administration.
0 0
ME E4.1 Facility follows protocols for safe drug Medication orders are written legibly and
RR/SI
administration updated (1) Every medical advice is accompanied with date, time
and signature. Check orders/ instructions are
comprehendible
(2) Ask the staff what protocols are followed in case
orders/instructions are not legible due use of
abbreviations, handwriting etc 0 0

(1) Drugs are checked for expiry and other inconsistency

There is procedure to check the drugs before before administration, single dose vial /ampule are not OB/SI
administration and dispensing used for more than one dose & separate sterile needle is
used every time.
(2) Check prescription from referral centre is verified every
time before dispensing of the drugs from HWC /in home
visits
Patients are counselled for self drug (1) Medication calendars /schedules, specify the time to
administration take medications, medicine related information sheets,
specific packaging’s such as pill boxes/ envelope,
indicating the time/ frequency of dose. CI/ SI
(2) Check patient is aware of 5 moments of medication
safety

ME E4.2 There is process for identifying and cautious Check high alerts drugs are identified & its SI/ RR
administration of high alert drugs maximum dose are defined High alert drugs such as Nonsteroidal anti-inflammatory,
anti convulsant/antiepileptics, Hypertensive, oral
(1) Right patient,
hypoglycaemic right drug, right route, right time, right
etc. 0 0
Check staff is aware of right dose of high alert Value dose &ofright
maximum dose as per age, weight and diagnosis is
documentation. SI/RR
drugs staff follows 6 Rs of drug available
(2) Check with
systemCHO.in place to verify the verbal orders given
Check SI/RR
administration
Check by MO
with staff if any untoward drug events has Minimum information model (MIMPS) for medication
ever SI/RR
Checkoccurred
any untoward/adverse drug events are safety is followed & used for reporting & subsequent
recorded and reported actions planning RR/ SI
Check the cases in which CHO has prescribed medicines/
Standard E5 The facility follows standard treatment
antibiotics. Check guidelines andare
if the drugs ensures rational use
either prescribed of drugs
more
than required dose 0 0
ME E5.1 There is procedure of rational use of drugs Check availability of/quantity or on
STG/clinical more occasion
algorithm/ Clinicalthan RR
Check staff is aware of rational use of drugs necessary.
decision making tool (IT based), Staff is aware of drug 0 0
Check RR/ SI
Check STG/ clinicalreview
medication algorithm is followed
is scheduled for regular regime
At leastand
oncedoses
in a year
chronic cases with RR/CI
CheckPHCOPDMO/ Physician
ticket if drugsofare
referral facility
prescribed under generic
Check drugs are prescribed with generic name Well
namedefined
only and standardized format is used to assess the RR
quality and accuracy of treatment provided. Valid sample RR/SI
Check HWCprovided
Treatment has antibiotic
by CHO policy
is monitored Check
is takenstaff is aware ofofantibiotic
& frequency monitoringpolicy
process is defined and
ME E5.2 Facility has system in place to periodically monitor RR/ SI
the treatment provided by CHO regularly followed 0 0
Check medication
monitoring is done by qualifiedispersonnel Preferably MO advise
of Mother PHC/referralwith
sitedate, time & SI/ RR
Check orders/ procedure written Check medical is accompanied
legibly & comprehendible signature RR

(1) Non compliances ( viz over prescription, irrational use RR/SI

of antibiotics, drugs, vitamins, vaccines, diagnostics etc)
are enumerated , (2) Action plan is prepared & Primary
health care team is hand holded & guided for
Action taken on non compliances improvement
Standard E6 The facility has defined
Both inand
HWC established
& home based procedures
care. for nursing care.
There is process for ensuring the identification of Investigations, refill the medicines, performing minor 0 0
ME E6.1 There is established procedure for identification & SI/OB
periodic monitoring of the patients patient before any procedure procedure, administrating vaccine etc 0 0

Chronic cases/ critical patient referred from higher SI/ RR

There is process in place to identify non Patients who are
centre/Home notcare
based oftently following
patient/ their treatment
bed ridden/ elderly cases
compliantvital
Patient's patient in chronic disease
are monitored and recorded plan orPatient
Check taking vital
the medicines as recommended
like BP, weight, TPR, Blood sugar etc are
Prescribed Treatment plan , procedure RR/SI
periodically are
performed in follow
written upin case sheet/OPD maintainedplan
Treatment as per disease, medication
followed conditions administered are
ME E6.2 Prescribed treatment plan and procedure RR
performed are recorded in patient's record ticket/Portal
Day to day progress of patient is recorded where documented
Progress is monitored & documented as per schedule 0 0
ever required/ critical/ chronic cases prescribed RR
HWC, home based care/ home visits, patient self
Adequate forms, formats and records are available managements
ME E6.3 OPD slip, family folders, referral slips , Disease specific RR/ OB
as per services mandate forms & formats (any hard /soft copy)
Standard forms & formats are available Registers & records are maintained as per guidelines/range 0 0
Updated Registers & records are available of services provided RR
All the register/records are identified and Check the master listby
&H WC (SC)
unique identification number is
numbered followed to identify records OB/ RR
Standard E7 The facility has defined and established
Protocols for snake bite,procedures for Emergency
poisoning, drowning, care
trauma,
burn,
Checkfits,
staffcardiac or of
is aware respiratory arrest
steps of BLS and, haemorrhoids,
also ask about how
Emergency protocols for first aid and stabilization to
rectal 0 4
ME E 7.1 Emergency protocols are defined and implemented are available recognize the signs for sudden cardiac arrest (SCA), SI/RR
prolapse, hernia,
heart attack, hydrocele,
stroke, appendicitis
and foreign-body etc. obstruction
airway 0 0
Staff is aware of procedure for CPR (FBAO) SI/RR

As per state guidelines or

(1) Primary management & referral
(2) Staff is aware of procedure for preservation & sealing
of samples of suspected MLC cases viz. aspiration, vomitus SI/RR
etc.
(3) Samples are sealed and dispatched along with patient
(Samples are taken by resposible HCW & handed it over to
responsible
(1) Check how personnel
ambulancesat referral centre).
are called & patient is shifted.
Staff is aware of protocols to manage suspected (2)
(4) Transfer
Separateregister
records isare generatedtofor
maintained suspected
record MLC of
the details
Medico legal cases cases
HWC ensures timely availability of ambulances the refferred patient
services for emergency cases RR/CI

ME E 7.2 The facility has disaster management plan in place Staff is aware of district disaster management team, staff SI/ OB
is aware of their roles, basic emergency management kit is
Emergency care
Staff is aware of isprocess
given inofcase of disaster
sorting the patients available
Staff is aware of triage protocols in case of referral 0 0 4
in case of mass causalty/ outbreak required SI/RR 0

Standard E8 The facility has defined & established procedures for management of ophthalmic, ENT and Oral aliments as per operational/ clinical guidelines
4 10

Ask staff about common ophthalmic aliments & their

cardinal signs & symptoms
Cataract: Clouded/ blurred or difficulty with vision at
Ask staff
night, about common
sensitivity to lightophthalmic
and glare,aliments
Need for & their
brighter
cardinal
light forsigns & symptoms
reading & its primary
, seeing "halos" aroundmanagement
lights,
Conjunctivitis:
frequent changes Redness, itching, , watery
in eyeglass Fadingdischarge fromof
or yellowing
The facility provides services for Ophthalmic Staff screen & refer cases of common eyes andmostly
colours crustingagearound eyes.
related.
Trachoma: usually affect both eyes and may include: Mild
ME E8.1 aliments including blindness and refractive errors as ophthalmic aliments lead to blindness & Presbyopia: having eyestrain or headaches/
itching and irritation of the eyes and eyelids, discharge fatigue SI/ RR
per guidelines refractive errors after the
from reading/ doingswelling,
eyes, eyelid close work,light sensitivity
Glaucoma: Severe eye pain, reddening of the eye,
(photophobia).
Sudden onset conjunctiva
Xeropthalmia: of visual disturbance- in low light,
dries out, thickens, and begins
Corneal
to wrinkle, Disease:
inabilityVisual
to see impairment, blurredlesions
in dim light, progress or
cloudy vision,
form cornea and severe
depositspain
of in the are
tissue eye,called
tearing, and.
Bitot’s spots.
sensitivity
Redness to light
in eyes, removal of foreign body & allergic
reactions,,
Awareness eyeabout injury and acid/
contagious eyealkaline
disease,/chemical
personalexposure
etc
hygiene, cleanliness of environment to prevent the spread
Management:
of trachoma, do's Symptomatic
& do not's treatment,
for eye careCounselling
during eye for eye
care and referral 0 1 4
infection, life styleif modification,
required. avoid myths & mis
Staff is aware of identification & primary conceptions, mobilize children for vit A prophylaxis, RR/ OB/SI 1
management Visual acuity by using Snell's chart, near vision card.
of vitASHA/
Staff is aware common
of methods ophthalmic conditions
for measuring the Blindness & of
distribution
MPW is skilled
visual impairment
spectacles,
assess follow
to use
register,
vision
records
upscreening
of referral, post
chart.
A SI/RR
including
refractiveemergencies
errors prophylaxis, listing of eye disorders,
operative and cases required long term Surveillance records of
medications.
Staff maintain records under ophthalmic care TT/TI cases for
as per RR/SI
Promotion & supportive activities for ophthalmic Motivation eyeNPCB & VI
donation
CI/ RR
care

(1) Community based new born screening till 6 weeks

of age- through home visit/ immunization ,Children- 6
ME E8.2 The facility provides services for ENT aliments as per Screening of population for ENT aliments week -18 yrs. -Screening through RBSK , Adults & SI/RR
guidelines elderly - through whisper test.
(2)Check opportunistic & planned screening form is
used for early identification

0 0
 Ask staff about common ear aliments & their cardinal signs
& symptoms & its primary management
Acute suppurative Otitis media: irritability, ear pain, neck
pain, fullness in ear, lack of balance.
Otitis Externa: Ear pain, itching & irritation in & around
ear, ear discharge
Otomycosis: Fullness, redness of outer ear, itching, pain.
Ear Discharge: Otoscopy. Identification of discharge: any
Identification & primary management of fluid leaking out is ear wax. A ruptured eardrum can cause
SI/ RR
common ear problems a white, slightly bloody, or yellow discharge from the ear.
Dry crusted material on a child's pillow is often a sign of a
ruptured eardrum
Ear Wax removal : By syringing / instrumentation, foreign
body removal.
Treatment: Symptomatic treatment - analgesics & ear
drops & warm compression where ever required

Ask staff test:

Patency aboutCheckcommon nose aliments
the patency of each&naristheirby cardinal
standing
signsstaff
Ask & symptoms
directly inabout
front of & itspatient
common
the primary
oralandmanagement.
aliments
occluding & the
their cardinal
patient's
Staff is trained & using diagnostic tools for Common
Check
signs
left &CHO
naris cold,
symptoms
with blocked
is trained
the &and
index nose,
its usinginjury,
primary
finger sinusitis,
ofotoscopy forhand.
management.
your right earrhinitis,
discharge,
Ask the
epistaxis and foreign body in anterior part of nasal cavity RR/ OB
identification of ear problems Hearing
Tooth
patientdecay:test:
to breathe whisper/
Discoloration/App based
normally through audiometry.
hole, the
sensitivity,
right naris. pain,
Repeat
Identification & management of nose problem Treatment:
swelling
by occluding Symptomatic
/ pus.
thecommon treatment,
patient'sthroatright naris nasalthe
with packing
index in case
finger RR/OB
Staff is trained & using diagnostic tools for Asknasal
of staffbleed,
about Analgesic, Nasal aliments & their
drops/spray, cardinal
Antibiotic
identification Gum
of your
signs Diseases:
& left hand Foul
symptoms and& smell,
ask
its the bleeding,
primary patient loose
to breathe
management. teeth,
through SI/ OB
Identification of Nose aliments
& primary management of throat may
the be
(1) left
swollen
deferred
Educating
naris.
gums
in children-two
community
Normally years
about will
the patient or
healthy older
be able ENT with mild
tohabits,
exhale
Injury,
symptoms.pharyngitis, laryngitis, URI, tonsillitis. SI/ RR
aliments
Check staff is trained & able to perform Heimlich awareness
First
through
Dental
Treatment: theRefer
aidFluorosis:
for the patient
protection
dislodging
unoccluded
SymptomaticWhite/anagainst
naris. if Nasal
persist
obstruction
Yellow/
treatment:
for more
excessive
from anoise,
obstruction
brown
Analgesic,
than
person's 5
is safe
present
discoloured
antibiotic,
days.
windpipe.
listening
if the patient&Sudden
improving strong
is unable to pressure
acoustic
exhale than applied onnares.
environment.(2)
through the their Teach SI/RR
manoeuvre/ dislodge obstruction from windpipe
Staff is trained to identify ENT aliments require patched
Refer
Thyroid
abdomen
on
theswelling,teeth
patient
between if persist
discharge
naval &more
from
ribcage ear, 5 days.
hearing impairment
for early
Cotton
Treatment: care
wisp: seeking
Fluff of behaviour
cotton
After symptomatic is held for allergies
against
relief& at each &
nostrils
H WC refer to & SI/ RR
referral to higher centre &
itsdeafness,
movements
common blocked nose,teach
are noticed hoarseness
whenhow patientto dysphagia
inhale & exhale
Promotion & supportive activities for ENT dentist atENT
Ask staff about
problems
CHC/DH. instil CI/ SI/ RR
nasal/ear /eye:common
drops, dentalhow
teach emergencies
to pinch nose & its inprimary
case
ME E8.3 The facility provides service for oral health aliments Staff is aware about Oral health conditions, Malocclusion
management.
of epistaxis,
Reverse bites, protruding/forwardly SI/ RR 3 6
primary
Staff management
is aware & referral
of symptomatic treatment for placed teethperform
spacing between
Pain, swelling/abscess,
Heimlich teeth.
tooth
manoeuvre
injury, non(4) Treatment:
healing
etc (3)
ulcer,
Follow
Cessation up of forhabits
treatment such compliance
asgums,
thumb sucking, Identified
mouth SI/ RR 1
dental emergencies uncontrolled
cases requiring bleeding
surgery, fromhearing extraction
aid fittingsite.or
breathing.
Treatment: Refer to dentist
Symptomatic reliefatatDH.HWC & refer to dentist
rehabilitative
Cleft lip/palate:
at CHC/DH therapy
Split lip/gap in palate, inability to feed
the baby. Refer to dentist at DH
Oral Cancer:
(1) Filling White/red
of CBAC form (more patch,
thannon healing
30yrs ulcer,
- Check records
Screening of oral health conditions is done as per reduced mouth opening, change in voice, lump in
screening is not limited up to oral cancers it should include
screening
neck. of other
burning dental conditions
sensation, inability as eat
to wellspicy
) food. RR/SI
protocol
(2)
UseCheck linkage
of CBAC formwith RBSK (0-18
is filled Yrs.)is referred at
and case
(3) Rest 18-29level
appropriate yrs. - under opportunistic screening

(1) Oral health education & dietary advise for (a) Oral
Promotion & supportive activities for oral health hygiene (b) Tobacco cessation CI/ SI

Common Mental Disorders( CMDs) : Depression,

Anxiety/panic disorders, psychosomatic disorders 1
Severe
(1) Check Mental
CommunityDisorder (SMDs) :decision
informant Schizophrenia,
tool (CIDT) Bipolar
is as per Operational/ clinical guidelines
Standard E9 The facility has defined & established procedure for screening &
disorder,
Awareness
used
basic & management
severeusedepression
for identification of techniques of Mental
by ASHA/MPW/CHW
Health
for psychosocial ailments
Child & Adolescent Mental 5 10
The facility provides services under mental health Check staff is aware of MNS (Mental, intervention:(1)
(2) Standard screening toolsHealth
Psychoeducation, are used disorder
by CHO(C&
psychological AMHD):
vizfirst aid,
:Screening
ME E9.1 Conduct
relation
tool disorder, Attention
techniques
for dementia, (breathing
Screening deficit disorder
exercise),
tools for basic
Epilepsy, (ADHD),
suicide
patient SI/RR 1 5 10
Program as per guidelines neurological & substance
Check Staff uses specific use)
tools conditions
for early oppositional defiant disorder
management,
health
Source reduction, basic
Questionnaire counselling
(PHQ-9)
personal for(problem
depression
protection, solving
,
environment & risk
suicide SI/ RR 1
identification & screening of MNS
Staff is competent for basic management, Epilepsy
(1)
behaviour &
Fortnightly dementia
Home
activation), (Alzheimer's
visit &
community testing disease)
people
based with current/
rehabilitation, first
assessment
(1) Awareness
management, & Alcohol
about
Biological use
improvingdisorder
control ( identification
mental health
Larvivorus test
literacy,
fish) & SI/ RR
referral & follow up offor
MNS Substance
recent
aid for fever
(AUDIT) use
overdose/
for disorder
& chills
alcohol in past(SUD):
intoxication
disorders. Tobacco,
14Check
days
etc. using
(2) alcohol
RDT.
Dispensing
staff is trained &ofdrug
to use use 1
Check staff is trained emergency understanding
chemical
Administer
disorder
(2) Malaria control
eitherof(larvicide
detection common
intranasal
in cases/symptoms,
Adulticide)
orpresenting reduction
. with
intramuscular Staff is in
Midazolam.
fever social
involved
at
medicines
these
stigma,
in tools. as
technique
intersectoral per prescription
of self care,with (3) Review
community & counsel
based SI/ RR 1
management of Epilepsyactivities for mental
Promotion & supportive Stabilize
HWC & refer convergence other departments like
periodically
rehabilitation,
DODWS Home/
(3) Check(Department
number Life community/
cases
style of screened
modification
Drinking HWC
Water and
& identified
etc and(4)Sanitation
Provide CI/ SI 1
health (3) Detection
adherence by using
support RDT/Microscopy. (Microscopy-
(2) Awareness
under
result Ministry
should be Jalfor
&ofmade
advocacy treatment
Shakti, about
availableMOHUA (5) Side
society
within
effects
problems
(Ministry
24 hrs) of and that act
Housing
Standard E10 The facility has defined & established proceduresand toxicities
for
as risk for
Urban for
management prescribed
mental
Affairs), of
health medications
communicable
conditions viz. diseases
gender as
based per operational/ clinical guidelines
The facility provides services under National vector Primary care team is aware of vector born (4) Treatment
(1) Negative RDT casesbestrongly
should started suspected
within 24 hrsof malaria cross
of detection. 26 48
violence,
Municipalities
checked abuse,
by suicide
etc) & carry ideation & substance
out weekly cleanliness dependence
drive in
ME E10.1 Borne disease control programme as per guidelines disease control strategies (2) P. Vivax
village through -microscopy
Chloroquine/
VHSNC 3days and Primaquine/14 days. SI/ RR 1 8 16
(5) Check HWC is
(Contraindicated aware
in pregnantof confirmed
female ormalaria
infant cases
or G6PD in its
as per guidelines Case detection is done for Malaria Persistence
catchment of
area fever even after 48 hrs of treatment, RR/ SI 1
(1) Diagnostic-
deficiency/ P- RDK
falciparum- ACT dehydration, change in
continuous
(2) Management- vomiting, Bed headache,
rest, RR/ SI
Staff is aware of Malaria treatment protocols (3) Algorithm
sensorium, for treatment
convulsions, & diagnosis
bleeding is available
& clotting disorders, 1
cold sponging,& symptomatic treatment. SI/RR
Staff is
Staff is aware of Malaria
aware of referral
diagnostic protocols of
& management severe
(3) Check anaemia, Jaundice
aware of&dengue
HWCisismaintained hypothermia
cases reporting
in its catchment 1
Check register & updated, in form SI/ RR
dengue as per protocols area
M 1 (ASHA/SC), M2 (if needles,
using slides), M4- fortnight 1
RDT kits , clean slides, swabs, ACT, CQ, PQcomplied
etc. RR/SI
NVBDCP register & records are maintained report
Facilities have adequate stock of commodities & (1)Provision of
Check how kits malaria surveillance
have been submitted
stored & near by SC
expiry drugs are 1
of DOTS at Sub-centre, proper
drugs not available KA,
documentation and RR/SI 1
Staff is aware of sign & symptoms of prevalent Chikungunya,
Refer all presumptive JE,follow-up,
LF home based support,
etc. to designated
cases Microscopy
vector born diseases in area case & their regular
Any screening
of the inoftheir
cases
cases collection for common
catchment areaadverse effects, SI 1
The facility provides services under National Identification
HWC support,of presumptive
supervision & manage centre.
ensure Sputum
compliance and transport
& completeness of sputum of
of course
ME E10.2 referral samples
(2) CheckisHWC supported in ofhard/difficult areas. RR 1 4 8
Tuberculosis Elimination Program (NTEP) presumptive, confirmed & on treatment cases is aware presumptive, confirmed & on
including DR- TB patients treatment cases in its catchment area OB/ RR 1
Staff is aware of follow up protocol after
treatment completion 6,12, 18 , 24 month follow up after treatment completion SI/ RR 1
 (1) Pale & reddish patches on the skin, skin thickness, shiny
& reddish, numbness & tingling, painful tender nerves,
weakness of hands, feet or eyelid, swelling & lumps in the
face & ear lobes impaired sensation.
(2) Sensory testing for screening: touching the tip of pen on RR
patch todelivery/
Ensure feel sensation 2 times
availability (once
of 2nd dosewith eyes &drugs,
onward 2nd with
Referral
closeddose slip, Patients
eyes) treatment card (if CHW is supporting
NTEP register & records are maintained pulse
treatment), toTBbenotification
given in presence
register of ANM/MPW, 1
ME E10.3 The facility provides services under National Leprosy Primary
Check the healthcare team
availability identify
/ delivery of and ensure
subsequent (3) Referral of
completion of suspected
treatment,cases to higherofcentre.
identification signs ofFirst dose
neuritis, RR/ SI
Eradication Program as per guidelines referralofofMDT
doses suspected cases
and follow upofofLeprosy
persons under initiated atetc
reactions higher centre cases. Referral in case MCR
for treatment 1 4 8
treatment Health education
footwear & if required/
Identification to community
& referralreferral regarding signs
for complications
of suspected cases, and
Condom RR 1
Maintain
symptoms of update
leprosy,case
itscard (ULF01),
complications, Update the
curability
NLEP register & awareness
records areabout
maintained Promotion
treatment & distribution
registered when among high
visiting therisk
PHC groups && help RR 1
Facility provide leprosy & availability
HIV cases for of receiving
free of cost treatment,
& adhering to self
ART.care & encourage
availability of its treatment the
IEC patient to
for STI,HIV/AIDS bring his/her contacts to check-up CI/ SI 1
The facility provides services under National AIDS HIV/STI Counselling, Awareness generation
Screening (consent) and, identification
referral
ME E10.4 HWC-HSC is aware offor
their roles in NACP of
in peer support
Type Bwith
Sub-centresgroupsinfor HRG-
high PLHIV, encourage
prevalence districts for RR/ SI 1 4 6
Control Program as per guidelines HWC -SC has linkage management of Linkage
index
Fever, testing, Microscopy
Coughsupport less than
centre
in treatment for adherence,
HIV -TB,
2 weeks duration,
for PPTCT
acute flaccid
HIV/AIDS complications services RR 2
Staff is aware of promotional &supportive arrangement
paralysis more forthan
counselling/
15 yrs. psycho
of age, therapies,
diarrhoea community
NACP under surveillance (1)(1)Information
Preliminary is collected fromwomen
Home visit (foror
(3 above
The facility provides services under Integrate Disease activities done under
Staff is aware of syndrome follow
more loose
described stoolanalysis
up to support
syndrome) /day), & reporting
HIV pregnant
& Jaundice,
from SC- OPD
of collected
Raise the signaldata
& for RR/ SI 1
ME E10.5 in to MO-inPHC onofevery Monday SI/ RR
surveillance as per guidelines Check process to collect information in form (2) Collation of data in Register for Syndromic /death
IDSP action case for any unusual health event
(2) Check any action has been undertaken using IDSP
2 5 6
S
Check Analysis & reporting of information Surveillance
data RR 1
for syndromic surveillance is done RR/ SI 2

ME E10.6 Awareness generation & behaviour change RR

The facilities provide services for National Viral Hepatitis Availability of diagnostic & treatment RDT for Hep B & immunization
communication, Hep C & referral forfor
Hepconfirmation
B (Birth dose, &
Control Programme (NVHCP) services further
high riskmanagement
group & healthcare worker) , injection safety 1 1 4
Staff is aware of preventive measures for NVH Interview
(1) Population
& safe drinking
patients enumeration
water -filling of CBAC form for
for: & sanitation. SI/ OB 0
all above
(1) Regular30Yrs of age-availability
& adequate Screening ofat HWC onasfixed
medicines per day
Standard E11 The facility has defined & established procedures for management plan of of
approach-referral
treatment non-communicable
suspected cases to diseases
higher centreas per operational/ clinical guidelines
for His/her
(2) Consultation - followabout
understanding up ofdosage
those who are life style
schedule, 36 58
ME E11.1 The facility provides services for hypertension as per Staff is aware of process of population Systolic/
diagnosed
medication, Diastolic
with BP ofrestriction
hypertension
any dietary over 140 /Over
& ensuring
and 90that
awareness mmthey of Hg.
about RR/ SI
guidelines identification Awareness generation - (a)Risk factors: overweight & 2 8 8
CHO is awareand referral
of sign for hypertension
& symptoms of Severe
next
adhere
(1) Headache,
follow
to
Population
obesity, up visit
treatment
Physical fatigue,
dateplan-
enumeration
inactivity & nausea,
identify
-filling
stress sweating,
warning
of
(b) CBAC
Healthy feeling
signs
form
life of
for
style: SI
HWC ensures frequency of follow up & supply of faint
Hypertension Interview
(3) &
Annual patients
confusion,
consultation for:
vision
withproblem,
specialist chest
at NCD pain,
clinic 2
complication
all above
diet,
(1) 30Yrs
exercise,
Regular & & ofrefer
avoidance
adequate to
age- higher centre.
Screening
tobacco
availability at HWC
&ofalcohol,
medicines(con) asfixed
per day
required medicines shortness offorbreath.
(2) Re screening ofofpopulation (new and old) at centre RR/CI 2
Staff is aware of promotional &supportive Counselling
approach-referral
treatment plan Lifestyle modification
suspected (d)
cases importance
to higher of
activities for Hypertension Counselled
periodic
regular about
intervals
follow -not to
every
& compliance miss/skip
year meal, take up CI/ SI 2
The facility provides services for Diabetes as per Staff is aware of process of population for
(2) consultation
His/her
Random
frequent blood
and - follow
understanding
sugar
small upto
about
140mg/dl
meals, ofmedication
those
dosage
increase who
and physical
mg/dl. areactivity
schedule, life style
ME E11.2 diagnosed
medication,
Frequent
and side with
any
urination,
effects hypertension
dietary
ofdateincreased
anti &
restriction ensuring
and that
awareness
diabetichunger,excessive
drugs. they
about
thirst, RR/ SI 2 9 12
guidelines identification
CHO is awareand referral
of sign for diabetes
& symptoms of next
adherefollow upweight
visit
to treatment plan-extreme
identify warning signs of
unexplained
Hypoglycaemia: loss,
Symptoms; tremors, tiredness,
nervousness,blurred SI 2
diabetes
HWC ensures frequency of follow up & supply of (3) Annual consultation
complication
vision, slow & refer with
to
woundirritability,
specialist
higher centre
healing numbness
at NCD clinic
orHeart
tingling
required medicines anxiety, sweating, confusion, beat RR/ CI 2
Check Patient (2) Re screening
is counselled about identification & increase,
hands or feet of population
& sexual
headache etcproblems (new and old) at
immediate management hypoglycaemia periodic intervals -every year Mishri/1 table spoon SI/ CI 2
Management: Take 5-6 toffees/
sugar/honey/ 2-3 teaspoon of glucose/ 3-4 tea spoon
of sugar/ half cup of juice or cold drink. If symptoms
persists
(1) patient should
All overweight be taken
or obese casestowithhigher centreorfor
diabetes
further management.
prediabetes symptoms or elevated blood lipids or
elevated blood pressure
(2) All such cases are screened for:
● Abdominal Obesity (waist circumference of ≥ 90
cm in men or ≥ 80 cm in women) SI/RR
● Family H/O diabetes, hypertension, heart diseases
and cancers
● Obesity
Awareness (BMI>=25kg/m2)
generation - (a)Risk factors: overweight &
● Oedema
obesity, Physical examination
inactivity & stress (b) Healthy life style:
(3) Referal
diet, exercise, to avoidance
PHC for management
tobacco & alcohol, (c )
Counselling for Life style modification (d) Importance of
HWC is aware of risk factors of Nonalcoholic regular follow & compliance tofor medication (e) Counselling
fatty is
liver disease (NAFLD) & supportive (1) At SC/ outreach/screening Breast, cervix & oral 0
Staff aware of promotional about
cancer.diabetes related complication viz. Retinopathy,
activities for diabetes neuropathy
(2) Screening &iskidney
undertakenfailurebyetc. trained personnel (LHV/Staff CI/ SI 1
ME E11.3 The facility provides services for cancer screening Check cancer screening services are provided Vaginal
nurse/MO) bleedingcan bebetweendone in periods,
outreachmenses longer or day.
session/screening RR/ SI
and referral as per guidelines through HWC about sign & symptom of cervical heavier than usual, post menopausal bleeding, bleeding & 1 7 14
Staff is aware (3) Screening of cervical cancer is conducted on site
Lump inprivacy
breast/under arm area, thickening or swelling of SI 1
cancer
Staff is aware about sign & symptom of Breast pain
where during/after sexual
& facility intercourse,
for sterilization smelly vaginal
is available
Difficulty
breath,
discharge,
(4)
(1) Repeat
Visual
in
puckering
pain chewing
screening
Inspectionduring orAcetic
/dimpling swallowing
byurination
-every of Acid
5yrs breath , mouth
etc forskin, cervical,
ulcers
redness (2) in
Oral SI 1
cancer Awareness
persist for generation
more -3(1)Risk factors: smoking, multiple
Staff is aware about sign & symptom of Oral nipple Examination
Visual area, nipplethan discharge
for oral weeks,/blood,
cancer persistent
(3) constant
clinical pain,
pain
breast lump,
etc SI
Cancerwith staff about methodology followed for sexual thickening partner, in unprotected
cheek, sex, family history, 1
Check For cancers
examination offorthe oralwhite/red
Breast and breast,
. patch
the firston level
gums/ of referral
overweight,
tongue/tonsil
Staff is aware
is(4)Discuss lack
5A
the CHC /interpretation of
etc, physical
approach
SDH/ DH and then - activity
Ask, (2)
advise,
to theif DH Healthy
assess, life style:
Assist
forata SC/outreach
biopsy for & RR/ SI 1
cancerCHW
Check screening
is aware of referral centre for all diet, exercise, avoidance tobacco of results done
& alcohol, (3 )
arrange
confirmed
session/screening cases. day SI /RR 1
typesisofaware
Staff cancer of promotional & supportive Counselling for Life style modification
(1)
For History
cervicaltaking cancer, and referral
if VIA refer(4)
to identified
positive, toimportance
de addiction
higher centre of
CI/ SI
activities for diabetes regular
offeringfollow
centre. colposcopy & compliance to medication 1
ME E11.4 The facility provides services for de addiction, and Confirmation and referral of cases for (2) For
Advise to quite in cleat, strong andstyle
personalized SI/ RR
locally prevalent health diseases as per guidelines Promotional
Tobacco/alcohol/ substanceactivities
abuse for (1) Withdrawal symptoms (2) Life support 1 3 6
& supportive manner
changes
Ask (3) Engagement/
for local prevalent linkage with patient support CI/ SI/RR 1
Tobacco/alcohol/
Check Screening &substance abuseprevalent
referral locally (3) Attempt
groups (4) to
Support (4) disease
Involve viz.
Quit encouragement familyPneumoconiosis
by &family
friends, , lead
remove
poisoning,
Check
substancesstafffluorosis
counsel
from their etc.
mother's Give full
adjacent compliance
forarea,
nutritious
Arrange if&
diet
friends
no such
during
follow upfirst SI/CI 1
diseases Through trainer Yoga instructor (ASHA/ Asha facilitator/
ME E11.5 The facility promotes services for health & wellness Check HWC is providing Yoga services disease
1000
visit days
(5) existsof
motivate life by re enforcing & intense follow up SI/ RR
Yoga teacher/ physical instructor from school) 1 9 18
(1) Stage
1. Check 1 (During
roster Pregnancy)
is available, : Balance
updated & nutritious diet
& displayed
Check Yoga sessions are conducted regularly including important nutrients RR/CI 1
One
2. day fixed
Community Ayurveda
is aware yogalike
ofclinic for iodine,
diet
sessions folic acid, by
counselling,
conducted iron, vit
HWC
Check Ayurveda services are available B12 etc.
management of chronic aches & pains & elderly care. OB/ RR 1
Check counselling of mother's for nutrition & (1) (2)
CheckStage
Guide 2about
( Period
availability offrom
Ayurveda
household birth of child to&1with
physician
measurement yr.): household
Early
medicines SI/CI
Check
hygiene staff counsel and
maintenance guideEat
under theright
mother's (1) Generateexclusive
initiation awareness about 4 major for food
initialgroups (food 1
utensils of
pyramid) - a.Complementary
breastfeeding
Cereals & millets
6 months,
about household preparation of initiation
(2) Awareness of feeding on & completion ofof6 SI/CI 1
Check Primary health
complementary care team generate
feeds b. Vegetables
months
(1) &on
with continued
Awareness
Awareness on
ingredients,
fruits,
generation
benefits &quantity
c.Breastfeeding
Milk about
ofchildrenanimal
fortified logos
food
frequency
products
on packedd. Fats/food
complementary feeding for up to 2 yrs. SI/CI 1
awareness
Check in community
Primary health careabout
teambalanced
generate diet oils, sugar3 &
(3)Stage
Awareness
(2) Identification nutsofbetween
(Period
generation about
fortified 12 month
maintaining
food to
available 24 months
personal
in market & of(+F
child
viz.Limit
fssai,the ISI,consumption
+F, green and red dots for vegetarian & and SI/CI
Check Primary
awareness health careabout
in community teamfood fortification (2)
generate age):vegetarian
Complementary
environmental
logo)
non hygiene
food feeding
while
items.
of foods
& its high
cooking foodin fats,
preparation (viz. sugar
with right 1
awareness in community about Eat safe salts
consistency, quantity,
handwashing, regular frequency,
bathing, density
wearing & variety.
clean clothes, SI/CI 1
(2) Safe storage of perishable & non perishable food
Check Primary health care team generate
practices keeping kitchen clean,
awareness in community about food safety (3) Precautions to be taking
taken pest while control
cooking measures,
& serving waste CI/SI 1
disposal, using kitchen waste for compositing etc)
the meals.
(4) Awareness about common tests for food
adulteration (Key ring test)
 (1) Activity of daily living
Standard E12 Elderly & palliative(2)
(1)
health
Mapping
caredepression
Geriatric of
services
elderlyare
population
providedin
scale, ascategory
per guidelines
of Bed
bound
(3) Mini,restricted
mental state& examination.
mobile elderly, destitute, poor & 8 22
ME E12.1 The facility provides services for elderly Care as per Elderly population is mapped & screened single
(4) Check how many cases are identified & referred (if RR/ SI
guidelines CHO is aware & competent to use various (2) Screening using comprehensive Geriatric
required) 1 1 8
geriatric tools assessment tools OB/ RR 0
(3) Primary management & timely referral

Check
(1) howeducation
Health many elderly supported
regarding by HWCs
healthy aging, for RR
supportive aidsmodifications,
environmental viz Walking sticks, callipers,
nutritional infrared lamp,
requirements, life
shoulder wheel, pully
style & behaviour & walker
changes (as per requirement)
(2) Educate family members for
HWC ­undertake preliminary assessment for the looking
throughafter
PHCsdisabled elderly person (3) Linkage with
need of assistive devices
Promotional & supportive activities for Geriatric support group & day care centre. (4) Motivate to join 0
care annual health check-up at village level CI/ SI 0

(1) Assessment using Palliative care screening tool by

CHO./MPW
The facility provides services for Palliative care as (2) Scheduled visits to patients/ families for basic nursing
Screening, basic management & referral of
ME E12.2 care/drugs or consumables dispensing /psycho social RR/ CI
per guidelines Palliative Care patient is done
support.
(3) Referral of palliative patients based on pain score

1 7 14

(1) Check palliative care team is constituted, comprising of

CHO, MPW, ASHA & volunteer.
Home based palliative care services are being
92) Check updated roster for undertaking scheduled visits. RR/ SI
provided
(3) Check the compliance to roster

Check sufficient number of kits are available, it contains 1

Check Home care kit is available & case sheet are supplies, equipment & drugs as per requirement & kits are
Check 'outrefilled.
of hours care',care
basic nursing care SI/ RR 1
updated
Check end of life care is given by Palliative care regularly Home case sheets areisfilled
provided,
reporting
completely
Patient of&death
support in HWC
legible
group - PHC/UPHC,
comprise bereavement
of care givers, volunteer, SI/ RR 1
team (whenever required)
Check patient support groups are available support
patients is given
& CHO.areCheck their to
gathering SI/ RR
(1) Volunteers trained performissimple
convened at least
nursing task, 1
HWC identify & train volunteer for supporting once in month
training on communication skills SI/ OB 1
palliative care activities
(2) List of trained volunteers is displayed in HWC area

(1) Health education regarding needs of palliative patients CI/SI

(2) Educate family members for routine home based care
Promotional & supportive activities for palliative (3) Linkage with support group & day care centre. (4)Help
care in assessing various services as needed 1

Standard E13 The facility has established procedures for care of new born, infant and child as per guidelines
Not able drink or breast feed, vomiting, convulsions,
lethargy Discharge from cord, pallor, cyanosis, Jaundice, 56 68
ME E13.1 Post natal visit & counselling for new born & infant CHO & CHW are aware of danger signs of new pustules, hypothermia, unableStabilization
to pass stool/urine, fever, SI/RR
care is provided as per guideline born & infant Staff practice ETAT protocol. per disease 2 6 6
Primary management & prompt referral of sick diarrhoea, indrawing of the chest (2-12 months-50
condition.
Exclusive breast feeding, cord care, maintenance of SI/ RR 2
new born & infants breaths/min & 12-5yrs-40 breaths/min)
Staff is aware of post natal care Counselling DPT, DT, Hep promoting
temperature, B ,TT vials & diluents
hygiene are notsupport
practise, kept in direct
for high CI/ SI 2
ME E13.2 The facility provides immunization services as per Check for vaccines & diluents are kept as per the contact of ice pack , Discarded medicines are kept
risk babies OB/ SI
guideline recommendation of guidelines separately 2 38 48

(1) Ask staff about when BCG, measles and JE vaccines are
constituted and till when these are valid for use. Should
not be used beyond 4 hours after reconstitution.
Reconstituted vaccines are not used after
(2) Vials should be kept in plastic box with label ' NOT TO OB/SI
recommended time
BE USED' & discarded after 48 hrs/ before the next
session, whichever is earlier.

2
Staff checks VVM level before using vaccines and Staff is aware of how check freeze damage for T-Series SI 2
identify discard
Parents are point for informing any
counselled vaccines
Observe interaction at session site and interview parents OB/CI 2
untoward
Antipyreticevent
drugsofare
concern following
provided vaccination
wherever required /care
Observegiver
session site and interview parents /care giver OB/CI 1
Beneficiary is asked to stay for half an hour after To observe any AEFI, Staff is aware of minor & serious AEFI CI/ OB 1
vaccinationis aware about how to manage any
Vaccinator withthe
Ask its management,
vaccinator what reporting
steps toof AEFI
take Counselling
in case on
of serious
side effects and follow up visits (CEI) SI 1
immediate
Check serious reaction/anaphylaxis
the availability of anaphylaxis kit with reaction/anaphylaxis
Kit constitute of job-aid, dose chart for adrenaline as per OB 2
ANM
Checkatadrenaline
session site
is not expired in kit age (1non
Give ml compliance
ampoule -3 ifno.),
kit isTuberculin syringe (1ml-3 no.),
not available
24H/25G needle- 3 no, swabs-3 no. updated contact
information of DIO, MO PHC/CHC & local ambulance OB
1
Check for injection site is not cleaned with spirit Cleaning of injection site with spirit swab is not OB/SI 1
before administering
Check that Staff knowsvaccine
how todose
use AD Syringe recommended
Ask for demonstration , How to peel, how to remove air SI/OB 2
Staff is aware of the shelf life of Vit A once it is bubble
Shelf lifeand
6-8injection site mention of opening date is
weeks. Check SI/ OB 1
opened and ensures it is not given after shelf life marked on bottle
 ANM/CHW is aware segregation policy after 1. Segregate use & unused vials, Kept in sealed/zipper bag SI/OB 2
completion
Staff is awareofof
immunization session
Open vial policy in
OVPtheisvaccine carrier cold
not applicable chain (reverse
to opened cold chain)
reconstituted &
vials of
picked byBCGAVD& JE SI/ OB 2
Check for HWC -SHC micro plan for immunization measles,
RR 2
& its is
Staff adequacy
aware of how to calculate the number of Estimating the beneficiaries & logistic. Preparing due list of RR/ SI 2
beneficiaries,
HWC -SC maintainquantity of vaccines
tracking & syringes
bag/ tickler box expected beneficiaries
Counter foil are updatedincluding
& utilizednumber of beneficiaries
for follow up &
wastage/dosage per multidose vials SI/RR 2
Check Vaccinator is aware of different categories 1. Ask the staff to enumerate categories or whether he/she SI/RR 2
of AEFI
Check person responsible for notifying & can differentiate
Ask the between
staff regarding the minor & severefor
responsibility AEFI.
notifying and
reporting of the AEFI is identified reporting the AEFI
SI/RR
2
Process of reporting and route is communicated Ask staff to whom the cases are reported & how SI/RR 1
to all concerned
Reporting of AEFI cases is ensured by ANM 1.Verify weekly report of AEFI cases. RR 1
Frontline workers & Health supervisor is aware of 2.NilVerifyreporting in case
with current ofguidelines
AEFI no AEFI case.
SI/RR 1
his/her roles
Vaccinator is & responsibility
aware about how fortoAEFI surveillance Ask vaccinator how to prevent immunization related
prevent
Programme SI 1
Primary healthcare
immunization team communicate
error related reactions the Observe
reactions the
fromsession interaction/ interview the
occurring
OB/CI
benefits of RI at VHND sessions beneficiaries 2
ME E13.3 Management of children for ARI, diarrhoea, (1)
ARI:Give
Assessment for identification of ARI, diarrhoea, first
Chest dose of oral
indrawing Amoxicillin
difficulty and injectable
in breathing ,coughing, SI/RR
malnutrition and other illness 2 12 14
malnutritionfor
andidentification Gentamycin.
Other Illnessof possible serious
fever, fast breathing
Assessment Young infant-
(2) Treat Not able
or prevent lowtosugar
feed(breastfeed/
or convulsionage or appropriate
fast SI/RR 1
bacterial infections
Management among young
of diarrhoea is doneinfant (0-59
as per breathing
Symptomatic
ORS, Zn, Lot>60/ min or severe
treatment, chest indrawing
Paracetamol orplenty
for fever, axillaryof
feed) O of fluids, & treatment with Cotrimoxazole. SI/RR 2
days) & children (2 -59 months)
protocols temp
fluids,37.5
Counselling C or
child
and more
& or
give
referral movement
normal
if diet
required only
. when
Counsellingstimulated
(3) Warm the young infant if temp is less than 35.5& Oreferral
keep C.
Management of ARI is done as per protocols if SI/RR 2
(4)required
Advise mother to keep young infant warm & refer
Management of Possible serious bacterial urgently to hospital SI/RR 2
infection
Managementas per
ofprotocols
Malnutrition is up
done
Screening, referral
protocols
and follow of as per
Counselling for nutrition & referral
children CI/ SI 2
for anomalies, disabilities and developmental Functional linkage with RBSK team, referral & follow up RR/SI 1
delays
Standard E14 The facility has established procedures for family planning as per government guidelines and law.
11 20
ME E14.1 Family planning counselling services are provided as The client is given full information about family Importance of FP, Options available- ( limiting & spacing SI/RR
per guidelines 1 5 8
planning methods
Staff is aware of Method specific counselling method), time for initiation & advantages of various
approaches available methods. For Limiting method -counselled &
referred to higher centre
BRAIDED Approach: Benefits of method, risk, consequence
of failure, alternatives, inquiries, decision to withdraw, SI/CI
explanation of method chosen & document of session

2
Care seeker is counselled about contraindications Such as risks, advantages, and possible side effects of
& adverse events of chosen FP methods OCPs/ECP/ Injectable/IUCD/ cent chroman , what to do if
dose of contraceptive is missed, method of administration CI/SI
of ECP. 1
Promotional activities for Family Planning are
provided at facility under Mission Parivar Vikas 1.Nayi Pahel Kit, Saas Bahu Samelan, Saarthi. CI/ RR 1
ME E14.2 The facility provides spacing methods for family Staff is aware of case selection criteria for family 2. Giveyrs.,
15-49 full married
compliance if facility is not covered under MPV
SI/RR
planning as per guidelines but undertake promotional activities. 1 4 8
planning methods
Staff is aware of options, indications & methods No (1) Hormonal (Combined
touch technique, oral pill)
Speculum and,Non Hormonal
bimanual (Chaya)
examination, SI/ RR 1
for administration
IUD for Oral
insertion & follow up isContraceptives & Emergency
done as per standard sounding Contraceptives.
of uterus and placement. Follow up : when to
return / removal of IUCD. Check In case of 2nd trimester SI/ RR 1
protocol
Injectable Contraceptives are given as per Check the eligibility for injectables are checked &
abortion IUCD is provided by Qualified Medical officer SI/ RR 1
The facility provides limiting methods for family protocols
Staff confirmed
is aware of case selection criteria for limiting For by MO.22-49
sterilization: Dose mayyrs.-be started/&continue
(female) 22-60yrsby
trained HCW. Depot
Check adherence MPAguidelines
can be given IM or
planning as per guidelines mentors (male), married, toyoungest
Subcutaneous,
GoI child is at least one year &
Female Sterilization:
spouse has not opted Certification is issuedCounselled
for sterilization. one month &after
ME E14.3 the surgery
referred toor after the
Higher first menstrual period, whichever is
centre SI/ RR
earlier.
Male Sterilization; Certificate is issued only after three
months once the semen examination shows no sperm,
certificate can be delayed till 6 months if the semen shows 1 2 4
HCW is supporting & encouraging the clients for sperm after 3 months. (A SI/ RR 1
post sterilization follow up
Standard E15 The facility provides Adolescent Reproductive
Nutritional and Sexual
Counselling, advice Health
on topicservices asGrowth
related to per guidelines.
and development,
Haemoglobin puberty,
estimation, mythsIFA
weekly & misconception,
tablet, and treatment
pregnancy, safe sex, menstrual disorders,anemia, 2 4
ME E15.1 The facility provides promotive, preventive & Provision of education & counselling services for for worm infestation, Symptomatic treatment , sexual CI/ SI
curative service for adolescent abuse ,RTI/STI's
counselling , TT etc.
at 10 and 16 year. Referral linkages to ICTC 1 2 4
adolescent
Services for treatment & referral of common and PPTCT RR/ CI 1
RTI/STI's, Nutritional Anaemia & Menstrual
Standard E16 disorders The facility has established procedures for Antenatal care as per guidelines
46 50
There is an established procedure for registration and Facility provides and updates “Mother and Check Mother & Child Protection cards have been provided
ME E16.1 follow up of pregnant women.
RR/ CI 1 11 12
Child Protection
Facility Card”registration & line
ensures early for each
Check ANC pregnant
recordswomen at time
for ensuring of 1st
that registration/
majority of ANC First
ANC RR/SI 2
listing of
Clinical high risk ANC
information registration
casesof ANC is kept with
& records Check, if there is taking place of
is a system within
keeping12 week
copy ofof pregnancy
ANC in
ANC register RR/SI 2
HWC has knowledge of calculating expected
Staff information
Check with staff like LMP, EDD, Labpregnancies
the expected Investigation in Findings
her area ,/
Examination findings etc. with them. Records of each ANC SI/RR 2
pregnancies in the area
Tracking of Missed and left out ANC how to calculate
1.Check with ANM it.(Birth
how she Rate X Population/1000
tracks missed out ANC.Add Use of
check-up
10% is maintained in ANC register SI/RR 2
All pregnant women get ANC check-up as per MCTSasstaff
1.Ask bycorrection
generating factor
about schedule work(Still
plan Birth)
of 4 and
ANCfollow-up
Visits with ASHA,
There is an established procedure for History taking, AWW etc. SI/RR 2
recommended schedule (1st - <for
12ANC Weeks
ME E16.2 Physical examination, and counselling of each antenatal At ANC clinic, Pregnancy is confirmed by Check record that pregnancy has been confirmed SI/RR 2 9 10
woman, visiting the facility. performing
Last menstrual urine test (LMP) is recorded and
period by usinghow
Check pregnancy test KitEDD
staff confirms (Nischay
& LMP, Kit)(EDD = Date of
SI/RR 2
Expected date of Delivery (EDD) is calculated on 1.Check
LMP+9 for Haemoglobin,
Months+7 Days) How confirmation
she estimates of pregnancy,
if Pregnanturine
Comprehensive Obstetric history is recorded albumin SI/ RR 2
first visit women
(1) History is&unable
sugar blood,
of pervious to recallblood
firstsugar,
pregnancies day of Malaria. Check cycle
last menstrual
including complications
Physical Examination & vitals of Pregnant Pulse,
randomly Respiratory
('Quickening', any 3 MCP
Fundal Rate , Pallor,
card/
Height) ANC Oedema.
record
.Check ANCforHeight, weight
Haemoglobin
records &
that it or RR 2
Women is done on everyisANC and Check
procedures 3done, if any,
visitisand
taken. History of current
Abdominal Examination donevisit BP-
as per protocol test
past
is doneany
Measurement
systemic
at every
of ANC
Fundal
illness
records/
ANC
like Height MCP
Hypertension,
card
(askvalues
staff randomly
how
Diabetes,she to see
are recorded. SI/RR 1
The facility ensures of drugs & diagnostics are prescribed thatHaemoglobin
2. weight fundal
correspond has been & high measured
urine albumin
with and recorded
& sugar
Gestational test at
Age), is everyon
done ANC
Auscultation
ME E16.3 Diagnostic test for every pregnant women Tuberculosis,
visit
every ANCheart Rheumatic
visit sound , Heart Disease, Rh Incompatibility, SI/ RR 2 6 6
as per protocol for foetal
 Referral is done for the remaining ANC
diagnostics Such as blood group and Rh factor, Hepatitis B SI/ RR 2
Tetanus Toxoid (2 Dosages/ Booster) have been
Check randomly any 3 ANC records for confirming that TT1 SI/ RR 2
There is an established procedure for identification of during
Staff canANC visits the cases, which would need
recognize (at the time
Anaemia, Badofobstetric
registration) and CPD,
history, TT2 (one
PIH, month after TT1)
APH, Medical
ME E16.4 High risk pregnancy and appropriate & timely referral. has been complicating
given to Primipregnancy,
gravida & Malpresentation,
Booster dose for women SI/ RR 1 13 14
referral to higher centre(FRU)
Staff is competent Disorder
to identify Hypertension /
Hypertension & Pre Eclampsia foetal
getting pregnant within
distress, PROM,- Two three years
obstructed labour. of previous pregnancy SI/ RR 2
Pregnancy InducedtoHypertension
Staff is competent (Hypertension
Pre - Eclampsia- Highconsecutive
identify Pre-Eclampsia BP with Urinereading
Albumintaken
(+2)four hours
apart shows Systolic BP SI/ RR 2
Imminent
Staff is competent to identify high risk cases eclampsia
Identification -BP>140
and referral
mmHg and/or
>140/90
of caseswith
Diastolic BP >
withpositive albumin 2+
90 mmHgheadache,
+, severe Blurring of vision, epigastriamedical
pain & SI/ RR 2
based on Abdominal examination Cephalo-pelvic
Staff is competent to classify anaemia according
>11 gm%in-Absencepresentation, Malpresentation,
oliguria
disorder Urine of Anaemia,10
complicating pregnancy,
to 11 gm% mild,
IUFD, amniotic fluid SI/ RR 2
to Haemoglobin
Line Level women with moderate
listing of pregnant 7-10
Checkgm% Moderate
the records Anaemia
whether Line-listing of severely anaemic
abnormalities. SI/ RR 2
and
Staffsevere
is awareanaemia women are
of prophylactic & Therapeutic dose maintained at the HWC
1. Prophylactic - one IFA tablet per day for six months SI/ RR 2
of IFA & progress
Counselling of pregnant women is done as per standard Pregnant women isiscounselled
monitored for planning and
during ANC &PNC.
Registration, 2.Therapeutic
Identification dose- double
of institution as per the dose in
clinical
ME E16.5 protocol and gestational age case of anaemia. 3. Improvement in haemoglobin label is CI/SI 2 7 8
preparation
Pregnant for birth
women condition
is counselled recognize danger
Swelling (oedema), bleeding
continuously monitored and even spotting, blurred vision,
recorded CI/ SI 2
signs during
Pregnant pregnancy
women headache,
is counselled to recognize sign
A pain abdomen,
bloody, sticky vomiting,
discharge (Show) andpyrexia,
regularwatery
painful& foul
smelling discharge & Yellow urine SI/ CI 2
of labour &
Pregnant arrange
women for referraldiet,
is counselled transport
uterine contractions.
rest, breast
1.Increase Contact
Dietary Intake number of the ambulance is
communicated SI/ CI 1
feeding & family planning Diet rich in proteins, iron, vitamin A, vitamin C, calcium and 12
Standard E17 other essential
The facility has established proceduremicronutrients.
for intranatalInitiate
carebreastfeeding
as per guidelines
especially colostrum feeding within an hour of birth. 24
Established procedures and standard protocols for Management of 1st stage of labour: 1. Check progress is recorded, Women is allowed to give
management of different stages of labour including birth in the position she wants , Check progress is recorded
AMTSL (Active Management of third Stage of labour) on partograph.
ME E17.1 are followed at the facility 2. Women are encouraged and counselled for allowing SI/ RR
birth companion of their choice

1 SC type B 5 10
Management of 2nd stage of labour: 1. Ensures 'six cleans' are followed during delivery SI/ RR 1 SC type B
Check no unnecessary episiotomy and 2. Clean
Check hands,
with Cleaninterview
records/ Surface, clean blade,
with staff cleanare
if they cordstilltie,
clean towelroutine
& clean cloth to wrap mother . SI/ RR 1 SC type B
unnecessary augmentation
Active Management of Thirdand induction
stage labour
practicing
Palpation
of labour episiotomy
of mother's abdomen & check
to ruleuterotonics
out presence suchofas
is done using uterotonic drugs oxytocin and misoprostol is not used for routine induction SI/RR 1 SC type B
Staff is aware of route, doses and time ofsecond baby, use
Administration of of
10uterotonic
IU drugs,
of oxytocin IMControlled
with in and cord of
1 minute
normal
tractionlabour
duringunless clear
contraction, medical
uterineindication
massage & the
Checks RR/ SI 1 SC type B
Uterotonic Drugs Birth
Facility staff adheres to standard procedures for routine Wipes the baby with a clean pre-warmed towel
Check staff competencefor through demonstration or case
ME E17.2 placenta & membranes completeness SI/ RR 1 SC type B 4 8
care of new-born immediately after birth and new born and wrapsdelayed
Performs baby incord
second pre-warmed
clamping towel;(1-3
observation.
and cutting Also Check recording
Check staff competence for date, Timeor
through demonstration ofcase
Birth &
resuscitation Weight of new born OB/ SI 1 SC type B
min) & Initiates
Records breast-feeding
birth weight soon aftervitamin
and gives injection birth K
observation
Check staff competence through demonstration or case SI/ RR 1 SC type B
New born Resuscitation observation
Check staff competence through demonstration SI/ OB 1 SC type B
ME E17.3 There is established procedure for Staff is aware of Indications for reffering patient Resuscitation
Ask staff how Technique
they identify slow progress of labour , How SI/ RR 1 SC type B 3 6
management/Referral of Obstetrics Emergencies as for to higher centre they
Initial Management of Eclampsia \Pre Eclampsia Ask staff interpret
aboutPartogram
how they manage eclampsia cases
per scope of services. Monitors BP in every case, and tests for proteinuria if BP is
>140/90 mmHg with convulsion and proteinuria, Give Inj.
Magnesium Sulphate
5g (10ml, 50% ) in each buttock deep I.M.)
If delivery is not imminent refer the patient to FRU SI/ RR

1 SC type B
Post Partum Haemorrhage Ask staff how they manage pots partum haemorrhage SI/ RR 1 SC type B
Assessment of bleeding (PPH if >500 ml or > 1 pad soaked
Standard E18 The facility has
in 5 established procedure
Minutes. IV Fluid, bladderfor post natal Care
catheterization, 2 4
ME E18.1 Post partum Care is provided to the mothers Check Mother is educated & counselled about
Mother is monitored as per post natal care Check for records of Uterine contraction, bleeding, RR/ SI
danger signs during puerperium & during measurement of urine output, Administration of 20 IU of 1 1 2
There is a established procedures for Postnatal visits & guideline temperature,
Oxytocinsigns
Danger B.P, pulse,
in 1L:Excessive
NS/RL 60 PVBreast
drops examination,
per minute
bleeding, (Nipple
. Refer
breathing the care,
difficulty,
ME E18.2 counselling of Mother and Child postnatal visit milk initiation). Check for perineal wash ispain,
performed SI/ RR 1 1 2
convulsion, severe headache, abdominal foul smelling
Area of Concern F: Infection Control
lochia, urine dribbling, perineal pain, painful & redness of 43 62 69%
breast.
Standard F1 The facility has established program for infection prevention and control
4 6
ME F1.1 Facility ensures that staff is working as team and Staff is working as team to improve sanitation & Person is identified to supervise the sanitation ald hygiene SI/ RR
monitor the infection control practices 1 4 6
hygiene of the facility
Check Records of Medical Check-up and of
AllHWC and its surrounding
staff undergo area. at least once in year
medical Check-up RR 1
Immunization
Facility has a system to monitor cleanliness & and immunization
Regular monitoringwith at least Hepatitis
of cleanliness B and TT
& hygiene OB/ RR 2
hygiene practices
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices
8 8
ME F2.1 Hand Hygiene facilities are provided at point of use Availability of Hand washing facilities Washbasin with functional drainage pipe, tap, running OB
& ensures adherence to standard practices 2 8 8
Check Washbasin, tap & running water as per water, Soap
Check (Soapisbar/liquid),
washbasin wide and AHR,
deep Display
enoughoftohand
prevent
washing OB/ SI 2
standard
Check protocolsof Soap and Alcohol Hand rub
availability splashingposter (Pictorial-
and retention ofLocal language)
water.
OB 2
Staff is trained and adheres to hand washing
for outreach Demonstration and random observation (Five Moments of SI/ OB
practices 2
handwashing , Six Steps of Hand washing )
Standard F3 The facility ensures standard practices and equipment for personal protection
3 6
Check availability & use of PPE (1) Check adequate required gloves, mask & apron etc is
available & used
The facility ensures availability of personal (2) Check Disposable Gloves, Cap, Mask are not reused,
ME F3.1 protection equipment and ensures adherence to (3) Check records for continuity of supply. OB/ RR
standard practices
1 3 6
 Compliance to correct method of wearing and Staff is aware of method of donning and doffing the PPE
removing PPE SI/ OB
1
Availability & adherence to Personal protective
kit for infectious patients/ HIV pts.
SI/ RR
1

Standard F4 The facility has standard procedures for disinfection and sterilization of equipment and instruments.
11 12
Adequate supply of decontamination and Check records of indent & Utilization
The facility ensures availability of material and cleaning agents at the point of use
ME F4.1 adherence to Standard Practices for RR/ OB
decontamination and cleaning of instruments and
followed by procedure/ patient care areas.
2 6 6
Staff is trained for the decontamination and Ask whether staff know how to make chlorine solution
cleaning procedure
OB/SI
2
Decontamination and cleaning of instruments Observe staff about the decontamination of instruments is
and surfaces done with 0.5% of chlorine solution for 10 min. Check SI/ OB
instrument are cleaned thoroughly with soap or detergent 2
Availability of disinfectants Ethyl alcohol
and water. Ask70% , Bleaching
staff when & howPowder/ hypo chloride
they clean the surfaces
solution containing not less than 30% w/w of available
The facility ensures standard practices and materials chlorine.
ME F4.2 for disinfection and sterilization of instruments and Check availability of boiler / sterilisers RR/ OB
equipment
2 5 6
Staff adhere to the process of disinfection (1) Check staff is aware of process of HLD and sterilization
(2) Check the reusable items are free from visible
contamination & disinfected
SI/ RR

2
Sterilization/HLD records are maintained To ensure the status of sterilized/HLD instruments,
equipment & materials etc
RR/SI

Standard F5 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
17 30
Availability of colour coded bins and non (1)Availability of bins and non chlorinated plastic bag,
ME F5.1 The facility ensures segregation and storage of Bio chlorinated plastic bags and needle cutters at Covered and Foot operated bins with Display of Bio Hazard
Segregation of BMW rules: OB/ SI
Medical Waste as per guidelines point of waste generation sign.
Yellow - HumanofAnatomical
(2) Availability needle/hubwaste,
cutterItems contaminated
& puncture proof
with 1 5 10
Segregation of BMW is done as per latest boxesblood, body fluids, dressings, cotton swabs and bags
containing residual or discarded components. etc.
prevalent rules Red - Items such as tubing, bottles, intravenous tubes and
sets, catheters, urine bags, syringes (without needles and
fixed needle syringes) and vacutainers with their needles
cut) and gloves
White - Sharps waste including Metals in (translucent)
Puncture proof, Leak proof, temper proof
containers :Needles, syringes with fixed needles, needles OB/ SI
from needle tip cutter or burner, scalpels, blades, or any
other contaminated sharp object that may cause puncture
and cuts. This includes both used, discarded and
contaminated metal sharps.
Blue : Contaminated and broken Glass are disposed in
puncture proof and leak proof box/ container such as
Vials, slides and other broken infected glass
1
Check there is no mixing of the Biomedical &
general waste OB
1
Display of work instructions for segregation Pictorial and in local language;

OB

1
 HWC has designated area for storage for BMW (1) BMW is not stored for more than 48 hours
(2) Functional linkage with CTF/ If Functional deep burial &
sharp pit is available- dispose waste on regular basis,
Check there is no scope for unauthorized entry; Display of
Bio Hazard sign at the point of use.
OB/ SI

1
Disinfection of broken / discarded Glassware is Check if such waste is pre treated with 1-2% of Sodium
The facility ensures management of sharps as per done as per recommended procedure Hypo chloride (having 30% of residual chlorine) for 20 min
ME F5.2 OB/ SI
guidelines
1 3 6
Sharp waste is stored in puncture proof Check availability of puncture, leak and temper proof OB/ SI
container container at point of use
1
Availability of post exposure prophylaxis and Check staff is aware of what to do in case of sharp injury,
staff is aware what to do in such condition Whom to report. See if any reporting has been done and
treatment provided
SI/ RR

1
Facility has provision for liquid waste Liquid waste is made safe before mixing with other waste.
management On site provision liquid waste disinfection set up
ME F5.3 The facility ensures management of hazardous & OB/ SI
general waste
2 5 6
Check facility is mercury free Give partial compliance if staff know how to manage
mercury spill & mercury spill kit is available SI/ OB
2
Disposal of general waste Mechanism for removal of general waste from facility & its OB/ RR 1
The facility ensures transportation & disposal of disposal
ME F5.4 HWC waste is collected & transported in close Check the functional linkage/records with CBWTF operator RR 1 4 8
waste as per guidelines container/bag
HWC has facility for disposal of Biomedical waste or
HWChashave
pre approved functional
valid contract deep
with CTF forburial
disposal of BMW
waste/ else facility should have deep burial pit and sharp
pit within premises of Health facility. Such deep burial pit
should have prior approval from prescribed authority &
meet the specified norms RR/ OB

1
Facility manages recyclable waste as per Facility hand over the plastic waste to registered vendor SI/ RR 1
approved
No burningprocedure
of any category of waste through BPHC /CHC
OB 1
within/outside HWC
Area of Concern G: Quality Management 34 74 46%

Standard G1 The facility has established organizational framework for quality improvement.
8 14
ME G1.1 The facility has a quality improvement team and it The HWC has Quality team in place (1) CHO, ANM/Staff nurse, MPW & ASHA. RR/ SI
review its quality activities at periodic intervals 2 8 14
Quality team meets monthly and review its (2) Team
Check themembers are aware
records/ Minutes ofof their respective
meetings
responsibilities and roles viz. ensure cleaniness, hygiene RR 1
activities
HWC reviews performance of its indicators and infection control practices are followed, internal audits RR 1
Review & update work plan as per requirement are conducted, feedback from stakeholders are taken etc RR 1
Identify the issues needed to be addressed at RR/SI 1
PHC review
Results meetingand NQAS Internal /External
of Kayakalp Gaps are identified RR 1
assessments are reviewed
Progress on time bound action plan is reviewed Resolutions of meeting is effectively communicated
RR/ SI
1

Standard G2 The facility has established system for patient and employee satisfaction
1 6
Client satisfaction survey is done (1) On defined intervals for patient or their attendant 1
visiting HWC & Client visiting Health campaigns, VHNDs,
PSGs etc.
(2) Check Valid Sample size is taken (3) Check format is in
local language or easy to understand (4) Sample having
ME G2.1 The facility ensures mechanism for conducting representation from all sections (age, gender, cast, religion RR/SI
patient satisfaction survey etc)

1 6
Analysis of low performing attributes is done Client satisfaction survey results are analysed and lowest RR 0
Actions are taken on lowest performing factors performing attributes are identified and action plan is 0
prepared. RR
Standard G3 The facility has established, documented, implemented and updated Standard Operating Procedures for all key processes and support services.
13 30
MEG3.1 Updated work instructions for all key clinical Instructions for using RDK are available Check it covers details of process of testing, control & RR/ SI 1
processes are available interpretation. (As per Service mandate) 13 30
Work instruction for RMNCHA services RR 1
Protocols and instructions for preventing, Verify protocols are displayed at session sites OB/RR 1
identifying and managing
WI for screening, AEFI are
management anddisplayed at
appropriate HT, Diabetes Oral, cervical and breast cancer. 1
immunization site RR
referral of NCDs
WI for screening, management and appropriate Screening using acetyl
Malaria , dengue, salicylic HIV-AIDS
TB, Leprosy, acid. and Hepatitis 1
RR
referral of Communicable
WI for screening disease
and referral of patients with 1
RR
mental disorders of common ophthalmic
WI for screening 1
RR
problems
WI for screening of ENT problems 1
RR
WI for screening of common oral problems RR 1
WI for screening of common elderly & palliative 1
care RR

WI for management of emergency medical 1

services RR

WI for infection prevention & Bio medical waste 1

management RR
Work instruction for conducting the Normal Simplified Partograph; First aid management in case of RR 0 SC Type B
vaginal delivery for management of new born
Work instruction PPH, sepsis,
Essential neweclampsia
born care,andNew
RMCborn Asphyxia management 0 SC Type B
RR
WI are updated as per current practices Check with staff
, assessment if they are well
for identification versedsign.
of danger with the Work RR 1
Instructions

Standard G4 The facility has established system of periodic review of clinical, support and quality management processes
8 16
ME G4.1 Handholding support and supervision is provided to Service delivery and performance of HWC is Through monthly visits by MO PHC SI/ RR
HWC by PHC, block/ district/state teams 1 3 6
reviewed regularly
HWC performance is reviewed regularly by Quarterly -By Block nodal officer, Bi Annual - by District RR 1
block/district/state
Check gaps have been identified and actions are Check officer
nodal officer Nodal number gaps closed as per last quarter report RR 1
taken
Periodic assessment using NQAS checklist At least once in six months
ME G4.2 The facility conducts periodic internal assessment RR 1 2 4
The facility ensures non compliances are recorded Periodic assessment using Kayakalp checklist Quarterly RR 1
ME G4.3 adequately and action plan is made on the gaps Non Compliance found in the internal Check gaps are identified and time bound action plan is RR
found in the assessment/review process using 1 3 6
Assessment using NQAS,
Root cause analysis Kayakalp and other
is done prepared
Using brainstorming, Fishbone analysis or why-why analysis
quality improvement methods monitoring checklists are recorded RR/ SI 1
HWC team improve on the identified non Using PDCA approach
compliances & action are taken RR/ SI
1

Standard G5 Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve them.
0 6
ME G5.1 The facility has defined Quality policy and quality Quality policy are defined Staff is aware of Quality Policy. RR
objectives 0 0 6
Quality objectives are defined for the HWC Qualitywhether
Check Policy isthe
displayed in local
objectives language
are SMART and in sync with RR 0
There is system for monitoring of performance the Quality Policy
toward quality objectives
RR/ SI
0
Area of Concern H: Outcome 0 56 0%
Standard H1 The facility measures productivity indicators 0 16
ME H1.1 The facility measures productivity indicators No. of OPD Cases per month Case specific OPD of pregnant mothers, neonate, infant, RR
services on monthly basis 0 0 6
No. of follow up cases (repeat visit) per month children, adolescent,
Case specific FP and CDmothers, neonate, infant,
OPD of pregnant RR 0
No. of cases referred to higher centre per month children, adolescent,
Case specific FP pregnant
referral of and CD mothers, neonate,
RR 0
No. of Normal deliveries conducted infant, children, adolescent, FP and CD
As per Service package i.e. NCD (Hypertension, RR 0 Type B SC 0 2
No. of Case specific OPD per month( as per Diabetes & cancer), Eye,i.e.
ENT, Oral Health, elderly, RR
defined service package) As per Service package NCD (Hypertension, 0 0 8
No. of cases referred to higher centre per month palliative,
Diabetes
As &Medical
per Service
Emergency
cancer), Eye,i.e.
package ENT, & Mental
Oral
NCD
Health
Health, etc
elderly,
(Hypertension, RR 0
No. of case specific follow up per month palliative,
Diabetes &Medical
cancer),Emergency
Eye,i.e.
ENT, & Mental
Oral Health
Health, etc
elderly, RR 0
No. of drop out rate cases following As per Service package NCD (Hypertension,
palliative,
Diabetes &Medical
cancer),Emergency & Mental
Eye, ENT, Oral Health
Health, etc
elderly, RR 0
identification (as per service Package) palliative, Medicalefficiency
Emergency & Mental Health etc
Standard H2 The facility measures indicators. 0 14
ME H2.1 The facility measures efficiency indicators on Percentage of women receiving all four ANCs RR
monthly basis 0 0 2
Drop out rate for Pentavalent immunization RR 0 0 2
Drop out rate for NCDs RR 0 0 2
No. of stock out days of essential medicines As per Service package RR 0 0 2
No. of stock out days of essential diagnostic As per Service package RR
test 0 0 2
No. of Yoga session conducted in month RR 0
No of VHNDs conducted (for vulnerable RR
population) 0
Standard H3 The facility measures clinical care indicators. 0 20
ME H3.1 The facility measures clinical care indicators on No. of high risk pregnancy identified during RR
monthly basis ANC 0 0 4
No. of AEFI cases reported RR 0 0 4
 No. of Children with diarrhoea treated with RR
ORS & Zn 0
Contraceptives acceptance rate RR 0
No. of Anaemia cases treated successfully RR 0
Treatment completion rate for Tuberculosis RR 0 0 2
Percentage of cases on treatment achieved RR
blood pressure control 0 0 8
Percentage of cases on treatment achieved RR
blood sugar of
control 0
Percentage cases screened positive for RR
cancer underwent biopsy 0
Percentage of cancer cases underwent RR
treatment for each cancer 0
Standard H4 The facility measures service quiality indicators 0 6
ME H4.1 The facility measures service quality indicators on Client Satisfaction Score (Patients) Sum of average satisfaction score of each respondent RR
monthly basis 0
Client Satisfaction Score (Community) (Average
Sum satisfaction
of average score =score
satisfaction sum total of scores
of each of
respondent
Percentage of chronic cases who started attributes/number of score
total attributes) RR 0
(Average satisfaction = sum total of scores of
treatment at PHC/above are still under As per service package
attributes/number of total attributes) RR 0 0 2
treatment for last 3 months

Obtained Max Percentage

60 108 56%
44 84 52%
36 70 51%
12 24 50%
208 322 65%
43 62 69%
34 74 46%
0 56 0%
437 800 55%

1 65%
2 65%
3 57% Management of Non-Communicable diseases. 7

4 58% Care for Common Ophthalmic and ENT 8

5 48% Oral health care. 9

6 50% Elderly and Palliative health care 10

7 42% Emergency Medical Services. 11

8 50% Management of Mental health ailments. 12

9 42%
10 17%
11 50%
12 33%
2 1 0 NA
 National Quality Assurance Standards
Health & Wellness Centre -Sub Centre
Name of HWC Date of Assessment

Name of Assesssors Name of Assessee

Type of Assessment
(Internal/ Action Plan submission date
State/External)
Details of Services Provided At HWC_HSC
1 Care in pregnancy & Childbirth Mandatory 7
2 Neonatal & Infant Health Services Mandatory 8
Childhood & adolescent Health
3 Mandatory 9
Services
4 Family Planning Mandatory 10
Management of Communicable
5 Mandatory 11
diseases
Management of Simple illness
6 Mandatory 12
including Minor Elements

HWC -HSC Overall Score & Area of Concern wise Sc

Score Card
 HWC_HSC Overall Score Card
Service Provision Patient Rights
Overall Score of
56% 52%
HWC -HSC

Inputs Support Services

55%
51% 50%
Theme Wise Score

Theme Wise Score

Care in pregnancy & Childbirth 65%
Neonatal & Infant Health Services 65%
Childhood & adolescent Health 57%
Services
Family Planning 58%
Management of Communicable 48%
diseases
Management of Non 50%
Communicable Diseases

Reference No. Area of Concern/ Standards

Area of Concern -A - Service Provision
Standard A1 The facility provides Comprehensive Primary Healthcare Services

Standard A2 The facility provides drugs and diagnostic services as mandated

Area of Concern -B- Patient Rights
 The facility provides information to care seeker, attendants & community about available
Standard B1 services & their modalities

Facility ensures services are accessible to care seekers and visitors including those
Standard B2 required some affirmative action

Services are delivered in a manner that are sensitive to gender, religious & cultural needs
Standard B3 and there is no discrimination on account of economic or social reasons

Standard B4 The facility maintains privacy, confidentiality & dignity of patient

Standard B5 The facility ensures all services are provided free of cost to its users
Area of Concern -C- Inputs

The facility has adequate and safe infrastructure for delivery of assured services as per
Standard C1 prevalent norms and it provides optimal care and comfort to users

The facility has adequate qualified and trained staff required for providing the assured
Standard C2 services as per current case load

Facility has a defined and established procedure for effective utilization, evaluation and
Standard C3 augmentation of competence and performance of staff

Standard C4 The facility provides drugs and consumables required for assured services

Standard C5 Facility has adequate functional equipment and instruments for assured list of services
Area of Concern -D- Support Services

Standard D1 The facility has established Programme for maintenance and upkeep of the facility

The facility has defined procedures for storage, inventory management and dispensing of
Standard D2 drugs
 The facility has defined and established procedure for clinical records and data
Standard D3 management with progressive use of digital technology
The facility has defined and established procedures for hospital transparency and
Standard D4 accountability.

The facility ensures health promotion and disease prevention activities through
Standard D5 community mobilization

Standards D6 The facility is compliant with statutory and regulatory requirement

Area of Concern -E- Clincal Care
The facility has defined procedures for registration, consultation, clinical assessment and
Standard E1 reassessment of the patients
The facility has defined and established procedures for continuity of care through two
Standard E2 way referral

Standard E3 The facility has defined and established procedures of diagnostic services.

Standard E4 The facility has defined procedures for safe drug administration.

Standard E5 The facility follows standard treatment guidelines and ensures rational use of drugs

Standard E6 The facility has defined and established procedures for nursing care.
Standard E7 The facility has defined and established procedures for Emergency care
The facility has defined & established procedures for management of ophthalmic, ENT
Standard E8 and Oral aliments as per operational/ clinical guidelines
The facility has defined & established procedure for screening & basic management of
Standard E9 Mental Health ailments as per Operational/ clinical guidelines

The facility has defined & established procedures for management of communicable
Standard E10 diseases as per operational/ clinical guidelines

The facility has defined & established procedures for management of non-communicable
Standard E11 diseases as per operational/ clinical guidelines
Standard E12 Elderly & palliative health care services are provided as per guidelines
 The facility has established procedures for care of new born, infant and child as per
guidelines
Standard E13
The facility has established procedures for family planning as per government guidelines
and law.
Standard E14 The facility provides Adolescent Reproductive and Sexual Health services as per
Standard E15 guidelines.

Standard E16 The facility has established procedures for Antenatal care as per guidelines
Standard E17 The facility has established procedure for intranatal care as per guidelines
Standard E18 The facility has established procedure for post natal Care
Area of Concern -F-Infection Control
Standard F1 The facility has established program for infection prevention and control
The facility has defined and Implemented procedures for ensuring hand hygiene
Standard F2 practices

Standard F3 The facility ensures standard practices and equipment for Personal protection
The facility has standard procedures for disinfection and sterilization of equipment and
Standard F4 instruments.
The facility has defined and established procedures for segregation, collection, treatment
Standard F5 and disposal of Bio Medical and hazardous Waste.
Area of Concern -G- Quality Management Systems
The facility has established organizational framework for quality improvement.
Standard G1

Standard G2 The facility has established system for patient and employee satisfaction
The facility has established, documented, implemented and updated Standard Operating
Standard G3 Procedures for all key processes and support services.
The facility has established system of periodic review of clinical, support and quality
Standard G4 management processes
Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to
Standard G5 achieve them.
Area of Concern -H- Outcome
Standard H1 The facility measures Productivity Indicators
Standard H2 The facility measures efficiency Indicators.
Standard H3 The facility measures Clinical Care Indicators.
Standard H4 The facility measures Service Quality Indicators
nce Standards
re -Sub Centre
te of Assessment

me of Assessee

tion Plan submission date

rovided At HWC_HSC
Management of Non
Mandatory
Communicable Diseases
Care for Common Ophthalmic
and ENT
Oral health care.
Elderly and Palliative health care
Emergency Medical Services
Management of Mental health
ailments.

Score & Area of Concern wise Scores

 Clinical Services Infection Control
Overall Score of
HWC -HSC 65% 69%

Quality
Management Output
55% System

46% 0%

Theme Wise Score

Care for Common Ophthalmic 42%
and ENT
Oral health care. 50%
Elderly and Palliative health care 42%
Emergency Medical Services 17%
Management of Mental health 50%
ailments.
Drugs & Diagnostics 33%

Score Obtained Maximum Scores Percentage

a of Concern -A - Service Provision
56 100 56%

4 8 50%
rea of Concern -B- Patient Rights
 54%
15 28

50%
9 18

50%
8 16
58%
7 12
50%
5 10
Area of Concern -C- Inputs

50%
17 34

50%
7 14

56%
9 16

#DIV/0!
0 0

50%
3 6
ea of Concern -D- Support Services

50%
12 24

#DIV/0!
0 0
 #DIV/0!
0 0
#DIV/0!
0 0

#DIV/0!
0 0
#DIV/0!
0 0
Area of Concern -E- Clincal Care

#DIV/0!
0 0
#DIV/0!
0 0

0 0 #DIV/0!

#DIV/0!
0 0

#DIV/0!
0 0
#DIV/0!
0 0
0 4 0%
40%
4 10
50%
5 10

54%
26 48

62%
36 58
8 22 36%
 82%
56 68

55%
11 20
2 4 50%
92%
46 50
12 24 50%
2 4 50%
ea of Concern -F-Infection Control
4 6 67%

100%
8 8
50%
3 6
92%
11 12
57%
17 30
oncern -G- Quality Management Systems
57%
8 14

1 6 17%

43%
13 30
50%
8 16
0%
0 6
Area of Concern -H- Outcome
0 16 0%
0 14 0%
0 20 0%
0 6 0%