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)

Reference Assessment
Measurable Elements Checkpoints Means of Verification Compliance Remarks
No Method

Area of Concern A: Service Provision

Standar
The facility provides Comprehensive Primary Healthcare Services
d A1
Services for early registration, screening
ME A1.1 Availability of functional ANC services with SI/ RR 2
The facility provides care in including lab investigation ,counselling &
minimum 4 ANC check-ups
Pregnancy & child birth services identification of high risk and danger signs
APH, PIH, Pre eclampsia, Severe Anaemia, IUGR,
Multiple pregnancies, Gestational Diabetes ,
Hypothyroidism, Syphilis and bad obstetric SI/ RR 2
First aid, referral & follow up services for history
high risk pregnancies are provided
Availability of Normal Vaginal delivery Normal Delivery using partograph, identification
services and referral services for Obstetrics & management of danger sign during labour and SI/ RR 2
emergencies post delivery 24 hr stay SC type B
Availability of prompt referral services for
PPH, Eclampsia, Sepsis. SI/ RR 2
Obstetrics emergencies SC type B
New Born: Low birth weight newborn
<1800gms, Preterm, Sepsis, Birth asphyxia,
Identification, primary management &
ME A1.2 Congenital anomalies SI/ RR 2
prompt referral of sick new born & infant
Infant: ARI, Diarrhoea, Jaundice, anaemia &
The facility provides Neonatal malnutrition, developmental delays
& Infant Health services
Complete immunization schedule & reporting of
Availability of Immunization Services SI/ RR 2
AEFI both from Sub centre & Outreach
 Availability of post natal new born care Essential New born care including new born
SI/ RR 2
services resuscitation SC type B

Anaemia, malnutrition, Vaccine preventable

Identification, primary management, referral diseases, ARI, Diarrhoea, Fever, ENT problems,
ME A1.3 SI/ RR 2
& follow up services for Childhood ailments Skin infections, Worm infestations, Poisoning,
The facility provides Childhood injuries/ accidents, 4D's,Sickle cell anaemia.
& Adolescent health services
Prevention & treatment of anaemia and other
Education, Counselling and referral services deficiencies, Counselling on life style, menstrual
SI/ PI 2
for Adolescent health hygiene, harmful effects of tobacco/substance
abuse and sex education

Provision of contraceptive including ECP,OCP,

ME A1.4 The facility provides Family Availability of family planning services Injectables, condom, IUCD. SI/ RR 2
Planning services

(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
FP methods, Provide correct & appropriate SI/CI 2
for family planning services
information about chosen method. (4) Post
abortion contraceptive counselling
(5) Referral & support for sterilization,
Abortions & GBV

Identification ,management & referral (if

required)
Dysmenorrhoea, Vaginal Discharge, Mastitis, SI/ RR 2
Breast lump, Pelvic Pain and Pelvic Organ
Identification and referral for Obstetric and Prolapse, Identification and management for
Gynaecological Conditions RTI/STI

The facility provides services

for promotion, prevention and
treatment of communicable Preventive & promotive services under
ME A1.5 SI/ RR 2
diseases as mandated under NVBDCP
National Health Program/state
scheme Malaria, Dengue, Chinguniya, Filariasis,
KalaAzar, Japanese Encephalitis
(1) Diagnostic services, primary management,
Case detection, treatment, referral & follow referral & follow up of complicated cases.
SI/ RR 2
up of cases under NVBDCP (2) Mass drug administration in case of filarasis
& immunization in JE
 Preventive & promotive measures under Community engagement, facilitate referral,
promote treatment completion & reducing CI/SI 2
NTEP
stigma
Early identification, link with designed
Case detection, treatment, referral & follow
microscopy centre, referral & follow up of SI/ RR 2
up of cases under NTEP
complicated cases, & medication compliance

Preventive & promotive measures under Community engagement, facilitate referral,

promote treatment completion & reducing SI/ CI 2
NLEP
stigma
Diagnostic services, primary management,
Case detection, treatment, referral & follow
referral & follow up of complicated cases, & SI/ RR 2
up of cases under NLEP
medication compliance

Prevention & promotion among high risk

Preventive & promotive services under NACP behaviour groups, support to patient living with SI/ CI 2
HIV/AIDS
Referral & follow up of cases under NACP Compliance to ART & follow up SI/ RR 2
Referral & Support for treatment - In Type B Sub
Provision for the screening for HIV SI/ RR 2
Centre SC type B

Preventive & promotive measures under Community engagement/ peer support,

facilitate referral, promote treatment SI/ CI 2
NVHCP
completion, Convergence with other
departments
Case detection, treatment, referral & follow
Diagnostic services, referral & follow up SI/ RR 2
up of cases under NVHCP

Availability of functional services under IDSP Weekly reporting & surveillance SI/ RR 2

Fever, URIs, ARIs, Diarrhoea, Scabies, Rashes/

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

The facility provides services

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

Screening, treatment compliance and follow up

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

Oral, Breast, Cervical Cancers.

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

Screening, early identification , treatment

Availability of services for respiratory compliance and follow up of all diagnosed cases, SI/RR 2
diseases referral and follow up for complications , refill
of drugs for diseases such as COPD & Asthma.

Screening, early identification , treatment

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

Early identification, referral, & follow up care

for disease such as Pneumoconiosis, Dermatitis,
Availability of services for locally prevalent
Lead Poisoning, Fluorosis etc. & for substance RR/ CI 2
health diseases & substance abuse
abuse such as tobacco, Alcohol & others.

Community engagement to promote healthy life

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

1. Screening & referral of Blindness, Refractive

errors, Visual Acuity, Cataract
2. Identification and primary treatment of
The facility provides services
ME A1.8 Availability of Ophthalmic Services Conjunctivitis, dry Eye, Trachoma, foreign body, SI/ RR 2
for common eye aliments
eye injuries
3. Follow up medicines for chronic eye disease
such as Cataract and glaucoma

Awareness generation, vit A prophylaxis for eye

Preventive & promotive services under for (6month -5yr), eye examination for pre term SI/ PI 2
Ophthalmic (less than 32 weeks)
 Identification, primary management and
referral( if required) for Common Cold, , URI,
The facility provides services Tonsillitis, Pharyngitis, Laryngitis and Sinusitis ,
ME A1.9 Availability of ENT Services SI/ RR 2
for common ENT aliments Epistaxis, Otomycosis, Otitis Externa, ASOM ,
removal of foreign bodies, /Injuries, thyroid
swelling.

Awareness generation about causes &

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

Irregular arrangement of teeth & Jaws

(Malocclusion) , Dental Fluorosis, Cleft lip &
The facility provides service for Availability of early identification & referral
ME A1.10 palate, Abnormal growth , patch or ulcers, oral SI/ RR 2
oral health aliments services for oral Health conditions
cancers

Gum diseases (Gingivitis, Periodontitis), Dental

Availability of symptomatic management & caries and dental emergencies (Tooth ache,
Tooth injuries , uncontrolled bleeding and SI/ RR 2
referral services for oral Health conditions
abscess)

Preventive & promotive services under oral Awareness generation, oral health education &
prevention of common oral diseases through SI/ CI 2
health
dietary advice & tobacco cessation

(1) General Awareness about -Healthy life style,

social security scheme for elderly and promote
active & healthy aging , identification of age
ME A1.11 related aliments and increase supportive SI/ RR 2
environment in families
(2) Mapping of elderly Population
(3)Comprehensive Geriatric assessment by
The facility provide Elderly & Primary health Care team
Palliative care services Availability of services for elderly care (4) Domiciliary visits to bed ridden patients
 (1) Population enumeration & empanelment of
cases requiring palliative care
(2) Palliative care assessment
(3) Home visit for psycho- social support SI/ RR 2
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,
The facility provides emergency shock, chocking, fits, drowning, haemorrhage,
Availability of services for Medical
ME A1.12 medical care, including for cellulitis, Acute gastro-intestinal conditions & SI/ RR 2
Emergencies including trauma & burns
trauma and burn Genito- urinary conditions
2. Identification & referral for Cysts, Lipoma, ,
haemorrhoids, hernia, hydrocele, varicose
veins, bed ulcers, phimosis etc.

The facility provides services Identification, counselling & referral for Anxiety,
ME A1.13 for Screening & Management hysteria, Depression, Neurosis, Dementia, SI/ RR 2
of Mental Health illness Availability of services for mental health Mental Retardation, Autism

Preventive & promotive services under Awareness generation ,stigma & discrimination
reduction ,community engagement, patient SI/ CI 2
mental health
support, facilitate referral, promote treatment
completion etc
The facility provides services HWC undertakes health promotion and VHSNC/Self help group/ Patient support groups,
ME A1.14 for health promotion activities disease prevention activities through Health promotion campaign and multisectoral CI/ RR 2
& wellness Community level resources convergence

Provision of wellness services through Yoga Periodic scheduling of yoga session, Health SI/ CI 2
and other activities education for life style modification
Provision of AYUSH services As per scope of services defined by state. SI/ RR 2

Check counselling services for :

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

Standard
The facility provides drugs and diagnostic services as mandated
A2
 Point of care diagnostics including RDKs as per
Service delivery
Hb, UPT, Urine dip stick (albumin & Sugar) ,
ME A2.1 Blood sugar, Malaria -RCT, RCT for dengue, CI/ RR 2
collection of sputum sample for TB, HIV RCT, VIA
test, Test for Iodine in salt (kit), Water testing
for faecal contamination & chlorination, HBs Ag
The facility provides laboratory Availability of basic diagnostic services for hepatitis B, filariasis ( endemic areas),
services as mandated including NHP Syphilis (RTK)
Linkages with the Central diagnostic units SI/ RR 2
(Hub & spoke) As per scope of services provided
The facility provides services
ME A2.2 for drug dispensing including Availability of drugs as per EDL SI/ RR 2
medicine refills As per scope of services provided
Availability of drugs for refill for chronic cases SI/ RR 2
As per scope of service provided
Area of Concern B: Patients Right
Standard
The facility provides information to care seeker, attendants & community about available services & their modalities
B1
Name of the facility & list of services (1) Name of the HWC, Service Packages and
available are displayed prominently time mandate is displayed.
The facility displays its services (2) Check the name of HWC is visible at night
ME B1.1 OB
and entitlements also
2
Branding of HWC-HSC is done as per (1) Outer surface of the building is yellow with
guidelines specified shade.
(2) Windows & their frame in the brown with
specified shade.
(3) Six illustrations drawn on the façade. (4)
Logo of NHM and Ayushman Bharat. OB
(5). Check electronic display of boards of the
services

2
Citizen charter is displayed (1) In local language
(2) Service Provided, contact details of fire,
police ambulance. Name & contact detail of
CHW and nearest referral centre.
(3) Details of grievance re addressal mechanism
(4) Citizen rights and responsibilities OB

2
 HWC displays entitlements available as per Under all NHP including RMNCHA and PMJAY
scope of services OB
2
List of Available drugs prominently displayed Updated as per current stock
OB/RR
2
All signages are of uniform colour, user Information is available in local language and OB
friendly & in local language easy to understand 2
Directional signages are displayed in the Check prominent signage are displayed to reach
OB
catchment area HWC -SC 2
(1) Service specific relevant IEC is displayed
(2) Check availability of the updated IEC
material
Patients & visitors are (3) Check no outdated information is displayed
sensitized and educated IEC Material is displayed as per services in HWC
ME B1.2 OB
through appropriate IEC / BCC provided (4) Check audio visual aids are used to display
approaches the IEC/ information

(1) Check relevant poster are displayed

(2) Check staff engages the community in
disseminating key messages in outreach as well
as HWC related to nutrition & sanitation
HWC promotes wellness through EAT right through various activities viz: 3 D food pyramid,
OB/CI
campaign food fortification 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
2

Staff is aware of various BCC approaches for risk

factor identification, life style modification,
treatment compliance & follow up care Viz.
Health Promotion activities are undertaken SI/ CI
GATHER (Greet, Ask, tell, help, Explain & return
using various BCC approach
(FP), TALK : Tell, advise, Lead & Know (Health
promotion for NCD, 5 A's (Ask, advice, assess,
assist, arrange) ( Tobacco & alcohol cessation)
2
Information about the
Check patients is explained about - diagnosis,
treatment and entitlements are Patient is informed about clinical condition
ME B1.3 treatment plan (dosage, period etc), special CI/ RR
shared with patients or and treatment plan
instructions, referral & follow up
attendants
2
Consent is taken before procedure for Staff is aware of the conditions where consent is
SI/ RR
conditions (wherever required) taken before procedure 2
 Primary healthcare team provide JSY, JSSK, RBSK, RMNCHAN, PM JAY/ state
information to beneficiaries or families insurance scheme etc CI/SI
regarding their entitlements Also support beneficiaries to seek services 2

HWC team provide support for linkage with

Facilitate identification & registration of families SI/ CI
PM- JAY to avail the scheme benefits
for PM- JAY
2
Standard
Facility ensures services are accessible to care seekers and visitors including those required some affirmative action
B2
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
The facility is accessible from reach)
ME B2.1 CI/SI
community and referral centre (2) Preferably within 1-2 Kms of Referral Centre

2
Check for Outreach session plan - targeted
Check outreach sessions are conducted population covered & implementation as per SI/RR
plan. 2
The services are available for the time HWC is functional for at least six hours per day
CI/RR
period, as mandated 2
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
The facility provides access to expanded care, Non communicable diseases, common CI/RR
range of services ophthalmic & ENT problems, Oral health, elderly
& palliative care, Emergency medical services &
Mental health aliments

2
Access to facility is provided
Availability of Wheel chair/stretcher, ramp with
without any physical barrier & Check HWC premises is free from any
ME B2.2 railing ( At least 120 cm width, Gradient not be OB
friendly to people with physical barrier
steeper than 1:12 )
disability.
2
 (1) Passage is wide enough for wheel chair and
crutches/canes/stick users.
(2) Floors are non slippery.
Check HWC premises is obstacle free for
(3) Ramps and stairs with handrails. OB
ambulatory and semi ambulatory individuals
(4) Ramps & staircases with hip lip (20mm) on
exposed side to prevent slipping of cane/
crutches/ wheelchair
2

(1) Tactile signs with good contrast between

letters & background.
(2) One or two rows of tactile guiding blocks
Check HWC premises is obstacle free for
along the entire length of the proposed OB
sight and hearing disable individuals
accessible route
(3) Check there is no poles or uneven surfaces
along the route traversed by the guiding blocks
2
Check for special precaution is taken for HIV, Leprosy , Abortion, domestic Violence,
There is affirmative action to maintaining privacy & confidentiality of psychotic cases, GBV, abuses etc
ensure that vulnerable and cases having social stigma
ME B2.3 SI/ RR
marginalized sections can
access services
2
There are linkages of care , Counselling and Victims of Violence including domestic
Protection of vulnerable and marginalized violence/ Gender Based Violence, terminally ill
section patients, orphan, elderly etc. Linkage and
support for treatment, counselling & Legal SI/ RR
Support
2
Standard
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
B3
Services are provided in
manner that are sensitive to Availability of female staff / attendant, if a
ME B3.1 SI/CI 2
gender religious & cultural male CHO examines a female patients
need
Cultural and religious preferences of patients
Religious and cultural preferences of patients are honoured
and their attendants are taken into OB/SI 2
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
There is no discrimination based religion, (3) Check there is no discrimination due to socio
ethnicity, socio economic status, cast, gender economic status CI/OB 2
& language etc (4) Check there is no discrimination due to
ethnicity & language

Staff is aware of Patients rights Check Staff is aware of Patient rights and Display of patient rights and responsibilities
MEB3.2 OB/SI 2
and responsibilities responsibilities through citizen charter.

Check community is aware of services provided,

grievance redressal mechanism, contact details CI/OB 2
Check community is aware of Patient's rights of higher centre, contact details of ambulances
and responsibilities by HWC-HSC.
The facility has defined and
established procedure Check staff & community is aware of
ME B3.3 Existing state grievance system/ 104. SI/CI 2
grievance redressal system in grievance redressal system
place

Complaint Box/ Complaint register/ facility

specific IT system. Defined period for resolving OB/ RR 2
Availability of complaint reporting system the complaints
SI/ RR 2
Corrective and preventive action taken Mechanism to report the patient on action taken
Standard
The facility maintains privacy, confidentiality & dignity of patient
B4
Availability of screen/ curtains in Screen/ curtain/ frosted glass on windows
Adequate visual privacy is examination area and in windows
ME B4.1 OB
provided at every point of care
2
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
Confidentiality of patients’ Family folders, CBAC form, NCD portal
ME B4.2 records and clinical information information, HIV, RTI/STI, OPD registers etc OB/ SI
is maintained Patient records are kept at safe place beyond
access of general patient flow 2
 (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 &
Check patient and their kin's have access to prescription details are provided. (IT system- SI/ RR
clinical records have option for print)

2
Behaviour of staff is empathetic and
The facility ensures behaviours courteous to patients and visitors
of its staff is dignified and
ME B4.3 CI
respectful, while delivering the
services
Ask the patient about their experience of care 2
Behaviour of staff is dignified & respectful
Care is free from any physical & verbal abuse.
Vulnerable or marginalized patients
is not left unattended/ignored. CI
Check the status separately in labour room if Check in
delivery services are provided in SC Both type
2 of SC
Standard
The facility ensures all services are provided free of cost to its users
B5
(1) As per service package or
The facility provides free of cost
HWC provide free of cost access to all the RMNCHA, CD, NCD, Eye, ENT, Oral, Mental
ME B5.1 services as per prevalent CI/ RR
services Health, Elderly, Pallative,Emergency medical
government schemes/ norms.
services etc
2
The facility provides free of cost screening All screening services and required diagnostic
and investigations services as per services are provided free of cost CI/ SI
requirement 2
The facility provides free of cost essential Check all drugs in the HWC-EDL are provided
free of cost CI/ SI
medicines and refills as per treatment plan 2
Availability of Free referral /ambulance
services CI/ SI
Through 102/108 or any other 2
Availability of free teleconsultation services CI/SI 2
Area of concern C: Inputs
Standard 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
C1
 Facility has adequate Well ventilated & illuminated clinic room (1) Check demarcated area for examination
infrastructure, space and with examination space (privacy maintained), consultation and
amenities as per patient or administrative/record keeping
work load (2) Availability of adequate Natural Light/
ME C1.1 Illumination (150 Lux in OPD area & 300 Lux in OB
drug dispensing areas)

2
Availability of adequate patient waiting area Covered waiting area which can accommodate
20-25 Chairs.
Check space is adequate to maintain Physical OB
distancing
2
Demarcated space for Laboratory / Lab. space is adequate for carrying out Lab.
diagnostics OB
activities 2
Adequate space/room for Yoga activities within HWC or its premises OB 2
Demarcated area for carrying out OB
immunization activities 2
(1) Storage space for storing
medicines ,Consumables & equipment etc.
Demarcated area of storage (2) Check the availability of racks/ Almirahs/ OB
shelf etc
2
Availability of functional telephone/Mobile CUG numbers/ Landline and internet
OB
and internet services connectivity 2

Availability of regular & uninterrupted (1) Availability of Portable emergency light ,

generators/inverters/solar panel/ for power SI/ OB
electricity supply
back up (2) Use of energy efficient bulbs for
lighting 2

(1) Potable drinking water supply is available for

patients, visitor & staff
Adequate water supply with storage facility (2) Piped water supply/ tube well with fitted OB/ SI
water pump/ other alternate source.
(3) Water Storage facility- Minimum 3 days
(4) Periodic chlorination & Quality testing of
water is done 2
(1) Check toilets are functional with running
Availability of separate toilets for male & water facility. OB
female (2) Check the toilets are disable friendly 2
Check boundary is of adequate height and it is
not broken from anywhere OB
HWC premises has intact boundary wall 2
 Availability of separate room for delivery Labour table with mattress, New born care OB
with required amenities corner 2 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
The facility ensures physical (3) PASS- Pull the pin, A- Aim at base of fire, S-
ME C1.2 safety including electrical and Squeeze the lever, S -Sweep side to side OB/ SI
fire safety of infrastructure (4) Check exists are clutter free
2
HWC does not have temporary connections
and loosely hanging wires Safe installation, use of appropriate wires &
MCB , Use of AV regulator ( for regulating the OB/ SI
fluctuations) 2
Non structural components are properly
secured
(1)Check for fixtures & furniture like Almirah/
Cabinets, hanging objects are properly fastened
& secured OB/ SI
(2) Building bye laws & instructions of NBC for
seismic safety is followed
2
HWC has adequate ICT hardware for
efficient delivery of services
(1) Check availability of Smartphones/ Tablets
The facility ensures availability and Laptop/desktops, internet connectivity
ME C1.3 of information & (2mbps). SI/ RR
communication technologies (2) For tele medicine services,check desktop/
Laptop have headphone , HD web camera &
printer connected with it 2
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, ANMOL, DVDMS, NIKSHAY, RR/ SI
e-sanjeevani, HMIS etc. and any state specific
application.
2
Standard
The facility has adequate qualified and trained staff required for providing the assured services as per current case load
C2

ME C2.1 The facility ensures availability SI/ RR

of Community Health officer As per eligibility criteria.
Availability of Community Health Officer Staff is aware of their role and responsibilities 2
2ANM (1 essential & 1 Desirable)- SC type -A
The facility have adequate 2 ANM (Essential, one may be staff nurse) - Only
ME C2.2 frontline health workers and Availability of ANM for SC type-B SI/ RR
support staff as requirement Staff is aware of their role and responsibilities
2
 1 Female and 1 Male
Staff is aware of their role and responsibilities SI/ RR
Availability of Multipurpose Worker for HWC and community 2
1 ASHA per 1000 population / ASHA per 500
population for tribal and hilly area.
1 ASHA facilitator/20,000 population
Staff is aware of their role and responsibilities SI/ RR
for HWC & community
Availability of ASHA & ASHA facilitator 2
The facility has established Check duty roster is prepared prepared,
ME C2.3 procedure for duty roster for updated & followed for all cadres SI/ RR
facility and community staff 2
Check field visit plans are prepared, updated
& followed by primary healthcare team SI/ RR
2
All staff adhere to their respective dress code (1) Staff adhere to their respective dress code
(2) Staff on duty is wearing their ID card OB
2
Standard
Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff
C3

Competence assessment and

performance evaluation of all (1) Check objective checklist has been prepared
ME C3.1 for assessing competence of staff based on job RR/ SI
staff is done on predefined
criteria description and assessment is done at least
once in a year (2) Check who did the assessment
Check parameters for assessing skills and - At least PHC- MO/ Competence Matrix is
proficiency of staff has been defined prepared for each category of staff 2

Verify with records that performance appraisal RR/ SI

Check for performance evaluation is done at has been done at least once in a year and verify
least once in a year with staff for actual assessment done 2
Check actions are taken for all the identified Check training need are identified at defined RR/ SI
gaps intervals & adequate skill are provided 2
 (1) 6 month certificate program in Community
health,
The staff is provided training as (2) 3 day IT training including Tele medicines
ME C3.2 per defined core competencies CHO is trained as per mandate (3) 5-7 days supplementary training on new RR/ SI
and training plan health programs, new skills (if applicable)
(4) refresher every year (if applicable)
(5) Basic physiotherapy ( where ever elderly &
palliative care packages are available)
(6) Training on Eat right tool kit
2

MPW- (F) : (1)4-5 days training in IUCD

insertion, NSSK, HBNC Supervision,
Management of Childhood illness, (2) 21 days of
SBA training. (Wherever applicable)
MPW is trained as per mandate MPW (All)- National Health Programmes, 3 RR/ SI
days training on NCD, 1 day joint training with
ASHA for NCD screening , 3 days training on
reporting and receiving information using digital
applications & basic nursing care training (esp.
for elderly & palliative care), training on Eat
right tool kit
2

(1) 8 days induction training, 20 days training of

module 6& 7, 5 days NCD module.
(2) Supplementary & refresher training for 15 RR/ SI
days/year. (if applicable)
(3) ASHA facilitatory is trained for Basic
physiotherapy ( where ever elderly & palliative
care packages are available),Training on Eat
AHSA is trained as per mandate right toolkit 2

Bio medical waste management, Infection RR/ SI

Staff is provided with Quality assurance Prevention, patient safety, internal assessment,
training BLS, Methods of QA viz PSS, 5S, PDCA etc 2

(1) Through access to Job aids/ MOOC (massive

open online courses)/ ECHO etc RR/ SI
(2) Check how many capacity building
Check HWC use IT platforms for regular training/workshop attended by primary
continuous learning & capacity building healthcare team in last quarter 2
Standard
The facility provides drugs and consumables required for assured services
C4
The facility have availability of
ME C4.1 OB/RR
adequate drugs Availability of Anaesthetics agents Oxygen & Lignocaine topical (5%) 2

Levocetirizine tablet (5mg) , Levocetirizine Oral

liquid , Hydrocortisone Succinate injection OB/RR
100mg, Pheniramine inj 22.75mg/ml,
Availability of Anti-allergic Adrenaline inj 1mg/ml 2

Aspirin tab 75, Diclofenac tab 50mg, Diclofenac OB/RR

injection 25mg/ml, Paracetamol tab 250mg,
Availability of Analgesics, Anti Pyretic, Paracetamol Syrup 125mg/5ml, Paracetamol
NSAIDS, Syrup250 mg/5 ml, Ibuprofen tab 200mg 2

Phenytoin Tablet 50 mg & 300 mg, Sodium

valporate Tablet 200, 500 mg & Sodium
valporate Syrup each 200mg/5ml, OB/RR
Phenobarbitone tab 30 & 60 mg,
Phenobarbitone Syrup 20 mg/5ml, Midazolam
Availability on Anticonvulsants /Anti nasal spray, Diazepam tab 5 & 10 mg,
epileptics Magnesium sulphate Inj (50% sol )- 2ml 2
Albendazole Tablet 400 mg, Albendazole Oral OB/RR
Availability of Intestinal Anti Helminthes liquid 200 mg/5 ml 2
Diethylcarbamazine Tablet 100 mg OB/RR
Availability of Antifilarial Diethylcarbamazine Oral liquid 120 mg/5 ml 2

Amoxicillin Capsule 250 & 500 mg

Amoxicillin Oral liquid 250 mg/5ml, Amoxicillin
dispersible tab 250 mg, Gentamycin inj 10& 80
mg/ ml, Ciprofloxacin Tablet 500 mg,
Ciprofloxacin Oral liquid 250 mg/5ml, OB/RR
Ciprofloxacin Inj., Tab Co-trimoxazole
[Sulphamethoxazol 80 mg +Trimethoprim 400
mg]
Tab Co-trimoxazole [Sulphamethoxazole 100 mg
+ Trimethoprim 20 mg ] Co-trimoxazole Oral
liquid ([Sulphamethoxazole 200 mg +
Trimethoprim 40 mg/5ml), Doxycycline 100mg,
Metronidazole 200 & 400 mg, Norfloxacin tab/
Availability of Anti Bacterial oral 2
 Clofazimine Capsule 50 mg
Clofazimine Capsule 100 mg, Dapsone Tablet 25 OB/RR
mg,
Dapsone Tablet 50 mg,
Availability of Anti leprosy Dapsone Tablet 100 mg 2

Chloroquine,
Artesunate (A)+ Sulphadoxine- Pyrimethamine OB/RR
(B), Combipack (A+B)
Primaquine Tablet 2.5 mg
Availability of Anti Malarial Primaquine Tablet 7.5 mg 2

Ferrous salt 100 mg + Folic acid 500 mcg Tablet

Ferrous salt 20 mg + Folic acid 100 mcg Tablet, OB/RR
Ferrous salt 60 mg + Folic acid 500 mcg, Ferrous
salt 45mg + Folic acid 100 mcg , Ferrous salt+
Folic acid Syrup, Folic acid Tablet 5 mg and 400
Availability of anti Anaemic drug mcg, Vit K inj 1mg/ml, 2
Lactulose oral liquid 10g/15ml, Povidone Iodine OB/RR
Availability of drugs for Palliative care lotion and oint. 2
Isosorbide- 5-mononitrate 5mg tab, Isosorbide
dinitrate 5mg, Atenolol 50mg, Metoprolol OB/RR
Availability of Cardiovascular medicines 25mg, Metoprolol SR 25mg 2
Amlodipine Tablet 2.5 & 5 mg, Telmisartan
Tablet 40 mg, Enalapril 5mg, OB/RR
Availability of drugs for Hypertension Hydrochlorothiazide 12.5 & 25 mg 2
Availability of drugs for Hypolipidemic Atorvastatin Tablet 10 mg OB/RR 2

Clotrimazole Cream, Miconazole oint. ,tab

fluconazole 150 mg , Silver sulphadiazine Cream OB/RR
1%, Betamethasone cream 0.05%, Calamine
Availability of Dermatological & antifungal Solution, Benzyl -benzoate oint/lot, Mupirocin,
Medicines KMnO4 -0.1%, Zinc oxide cream 10%, 2
Availability of Diuretics Furosemide Inj & tab 40 mg OB/RR 2
Availability of Drugs for dementia Alprazolam Tab 0.25 & 0.5 mg OB/RR 2
Eye drops- Methyl cellulose, Sodium
cromoglycate (2%). OB/RR
Availability of Eye drugs 2
 Ciprofloxacin drops 0.3%, Ciprofloxacin tab 250 OB/RR
& 500mg, Boro-spirit ear drops, Ear wax solvent
drops (combination of Benzocaime , Chlorbutol,
Availability of ENT drugs Paradichlorobenzene and Turpentine oil) 2

Ranitidine Tablet 150 mg, Ranitidine inj,

Omeprazole, Ondansetron tab, oral liquid and OB/RR
inj, Ispaghula granules/ Husk/ powder, Oral
rehydration salts (ORS),Zinc Sulphate Syrup &
tablet, Dicyclomine Tablet & Inj, Dioctyl sulfo
succinate Sodium, Magnesium Hydroxide liquid,
Availability of Gastroinstinal medicines Senna Powder, Domperidone Tab & Syrup 2

Ethinylestradiol (A) + Levonorgestrel Tablet 0.03

mg (A) + 0.15 mg (B),Condom, IUCD 380 A OB/RR
Copper bearing intrauterine, Ormeloxifene Tab
30mg, ECP( Levonorgestrel 1.5mg), Medroxy
Availability of Contraceptives progesterone Acetate injection, 2
Metformin SR Tablet 500 mg, Metformin Tab
500mg, Glimepiride Tab 2mg, Glibenclamide Tab OB/RR
Availability of drugs for diabetes Mellitus 2.5 & 5 mg 2
Levothyroxine Tablet 25, 50 & 100 mcg OB/RR
Availability of drugs for Thyroid 2
Misoprostol Tablet 200 mcg, Oxytocin Injection OB/RR
Availability of Oxytocin and Antioxytocics 5 IU/ml, 2 SC type B

Salbutamol Tablet 2 mg
Salbutamol Oral liquid 2 mg/5 ml
Salbutamol Respirator solution for use in OB/RR
nebulizer 5mg/ml, Budesonide Respirator
solution for use in nebulizer 0. 5mg/ml, Normal
Saline drops, Dextromethorphan oral syrup,
Availability of medicines for Tespiratory tract Hyoscinebutylbromide Tab 10 mg 2
Ringer lactate Injection, Sodium chloride OB/RR
Availability of IV Fluids injection 0.9%, Dextrose 5% & 25% 2

Calcium Carbonate Tablet 500 mg, Vit C tab

100mg, Cholecalciferol Tab 60,000 IU, OB/RR
Pyridoxine tab 25,50 & 100mg, Vit A oral liquid
Availability of Vitamins and Minerals 1,00,000 IU/ml, B complex tab 2
Availability of Antidotes Activated Charcoal, Atropine 1 mg/ml . OB/RR 2
Availability of injectables Anti rabies vaccine, Inj. Tetanus Toxoid, OB/RR 2
 Inj. Adrenaline, Inj. Hydrocortisone, Inj.
Availability of Emergency Drug Tray / Dexamethasone , Glyceryl trinitrate- Sublingual OB
injectables at injection room tab 0.5 mg 2
Hydrogen peroxide, Gentian violet, Povidone OB/RR
Availability of Anti septic Iodine, Framycetin sulphate ointment 2

Clove oil, betadine & Chlor-hexadine, Gluconate OB/RR

Availability of drugs for oral health mouth wash, Tannic acid astringent gum paint. 2

The facility have adequate Haemoglobin scale test with talquist paper,
ME C4.2 consumables as per Urine Pregnancy rapid test, Rapid Kits for OB/RR
requirement Malaria and Dengue, Urine Dip Stick for albumin
and Sugar, Glucometer with glucosticks, Sputum
Availability of Rapid Diagnostic Kits Cups, 2
Availability of disposables for Dressing /
Emergency management Splints, Syringe (10cc, 5cc, 2cc) and AD Syringe
(0.5ml and 0.1ml) for injection, Suture with OB/RR
needle holder & artery forceps, Disposable
gloves, Disposable Swabs, Disposable Lancets,
Mackintosh Sheets 2
Availability of disposables at Clinics
Mucus extractor, Wooden Spatula, Disposable
Cord clamp, Disposable Sterile Urethral
Catheter( 12fr, 14fr) , Foleys catheter , IV OB/RR
Cannula and Sets, Interdental Cleaning Aids,
cold pack, cotton and envelopes for drug
dispensing 2

Vit A prophylaxis, Glucosticks, Syringes,

Pregnancy kits, HIV Rapid Test and STI Screening OB/RR
Test kits, Kit for testing residual chlorine in
Water. Vision screening care for 6/18 vision,
Availability of Drugs and Consumables for measuring tape (6m), reading module.
VHNDs or camps 2
Availability of drugs & consumables for home OB/RR
care kit As per palliative care guidelines 2
Standard
Facility has adequate functional equipment and instruments for assured list of services
C5
 The facility ensures availability BP apparatus, Torch, stethoscope ,peak flow
of equipment and instruments meter and snelle's /near vision chart, Measuring
ME C5.1 tape, Thermometer, Foetoscope,Weighing OB
for examination and monitoring
of patients machine, Infant weighing scale, Tongue
depressor, Stadiometer.
Availability of functional Equipment & Dressing Trays, Dressing Drums, Surgical Scissors
instruments for examination & Monitoring , Examination Lamp, Cheatle's forceps, Sponge
at Clinic Holder, Artery forceps. 2

Nasal speculum, dressing/ packing forceps,

digital scope, tuning fork (512 HZ), App & OB
headphone for app based audiometery, LED
Availability of functional Equipment & head lamp, ear speculum, Jobson Horne probe,
instruments for ENT services Eustachian catheter 2
Availability of functional Equipment & Dental explorer, mouth mirror, tweezer OB
instruments for oral services Intradental brush, 2

Dressing Trays, Dressing Drums, Surgical

Scissors , Examination Lamp, Forceps, Sims
retractor / speculum , Cusco's / Graves OB
speculum, Cheatle's forceps, Sponge Holder,
Availability of functional equipment & Artery forceps, Cord clamp, cord Cutting
instruments for normal delivery services scissors, Episiotomy scissor. 2 SC type B

Ambu bag with Mask, Suction Machine, Oxygen

cylinder with Administrative equipment OB
Availability of Emergency functional (Keys),Mouth Gag , Nebulizer. AED (Automated
equipment External Defibrillator) 2

The facility have adequate

ME C5.2 furniture and fixture as per Table, Doctor chair, Patient Stool, Examination OB
service provision table, Attendant Chair, Foot Step, Screen
Separators with Stand, IV stand, Wall clock,
Availability of furniture & fixture at Clinics refrigerator (For storage of drugs & vaccines) 2
Area of Concern D: Support Services
Standard
The facility has established Programme for maintenance and upkeep of the facility
D1
The facility has established HWC Building is painted/whitewashed in Check building is white washed both from inside
ME D1.1 system for infrastructure uniform colour & its branding done as per & outside OB
maintenance the guideline
2
 Check building & its premises is well 1. No seepage, cracks and chipping of plaster
maintained from wall, roof, windows etc
2.No unwanted/outdated posters on walls of
building & boundary walls
3. Proper landscaping and maintenance of Open
Space / Gardens/ water bodies etc (if available)
4. No leaking taps, pipes, over-flowing tanks and
dysfunctional cisterns.
5. No water logging /marsh inside the premises OB

2
HWC has system for periodic maintenance of 1. Check records of building, patient amenities
Building including patient amenities maintenance and schedules.
2. Pest or rodent control measures are taken at SI/ RR
least once in 6 months
2
No condemned/Junk material in HWC HWC remove its junk periodically as per
(corridors, roof, administrative area , condemnation policy. RR/ OB
backyard)
2
There is system of timely corrective & Check staff is skilled to undertake the trouble
preventive break down maintenance of the shooting SI/ OB
equipment
2
All the measuring equipment/ instrument
are calibrated RR/ OB
E.g. Weighing machine, BP apparatus, the status
is re checked At least once in six months. 2
1. Check that floors and walls for any visible or
tangible dirt, grease, stains, etc.
Check roof, walls, corners of these area for any
cobweb, bird nest, vegetation, etc.
The facility has established 2. Surface of furniture and fixtures are clean and
ME D1.2 system for maintaining Check all the areas are clean & hygienic well maintained OB
sanitation and hygiene 3. No rusted or broken furniture
4. Schedule for cleaning is defined and
implemented

2
Check there is no foul smell in HWC Check toilets are clean and there is no
overflowing/clogged drains OB
2
 Check availability of adequate supply of (1) Availability of mops, 2- buckets system, good
cleaning material quality cleaning solution preferably a ISI mark.
(2) Composition and concentration of solution is
written on label etc.
(3) Staff is aware of correct concentration and
dilution method for preparing cleaning solution.
(4) Verify its consumption OB/ RR

2
Check staff is aware of use of 2 bucket One bucket for Cleaning solution, second for
system & disinfection of mop after cleaning wringing the mop.
Ask the cleaning staff about the process,
Disinfection , washing & keeping mops for OB/ SI
drying after every cleaning cycle
2
HWC has a system for safe disposal of No garbage piles in and around HWC.
general waste No signs of burning of waste in HWC OB
2
Clean and adequate linen is available Check Examination bed, table cloth etc are
clean. OB/ RR
There is system in place for washing of linen
2
Standard
The facility has defined procedures for storage, inventory management and dispensing of drugs
D2
HWC has a process to consolidate and Check forecasting of drugs & consumables is
There is established procedure calculate the consumption done scientifically based on
for estimation and indenting of consumption .Reorder & buffer levels are
ME D2.1 defined SI/ RR
drugs and consumables as per
requirement
2
Check Drugs and consumables forecasting Linkage with portal/ DVDMS
and indenting is IT enabled RR/SI
2
(1) Timely indenting the drugs for common
aliments & emergency cases
(2) Timely indenting of Drugs of new or regular
chronic patients under HWC
(3) Check the adequacy of the available drugs
Check there is established system to timely (Demand & supply) RR/SI
indent the drugs as per services package

2
 (1) For HWC, 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
2
(1) Check list of VED categorisation
Check drugs are categorised in Vital, (2) Check updated stock registers of the last 6 RR/SI
Essential and desirable months for vital & essential drugs
2
The facility ensures proper There is specified place to store medicines in Drugs and consumables are stored away from
ME D2.2 storage of drugs and HWC water / dampness and sources of direct heat & OB
consumables sunlight etc.
2
Check drugs are kept in racks and shelves Drugs are not stored at floor ,Heavy items are
with proper labelling stored at lower shelves/racks and fragile items OB
are not kept on the edges
2
LASA ( Look alike and Sound alike ) are stored
separately OB
2
Check heat and light sensitive drugs are (1) Medications that are considered light-
stored as per manufacturers instructions sensitive will be stored in closed drawers.
(2) Check process in place for storage of drugs,
laboratory kits & vaccines etc requiring OB/SI
controlled temperature
2
Check process followed to maintain the (1) Temperature chart is maintained
temperature of refrigerator used for drugs/ (2) De frosting is done (in case household freeze
vaccine/ lab kits is used)
(3) Staff is aware of holdover time of OB/RR
refrigerator
(4) Freeze is not used for storing eatables
2
The facility ensure
First expiry first out (FEFO) system is
ME D2.3 management of expiry and OB
followed for drugs dispensing
near expired drugs 2
There is system in place to maintain expiry & Check all near expiry drugs are shifted back to
near expiry of drugs PHC/ referral centre/ facility where it is urgently
required based on inventory turnover (that is-
Fast, slow or non moving drugs)
2
No expired drug is found in HWC In dispensing area as well as drug storage area OB 2
There is an established process for discard (1) Staff is aware about how to discard expired
the expired drugs drugs and are not stored in HWC
(2) Check there is demarcated space/ shelf to
keep expired drugs away from main dispensing SI/OB
area
2
Standard
The facility has defined and established procedure for clinical records and data management with progressive use of digital technology
D3
 Information regarding illness and minor (1) Diagnosis, assessments, treatment plan,
Information regarding aliments are recorded & updated using IT drugs prescribed, and follow up etc are
ambulatory care & platform recorded & updated for all cases by HSC
management, public health and (2) Randomly, select at least 5 cases (or all cases
ME D3.1 RR/SI
managerial functions are if less than 5) and check for details
recorded and updated through
IT platforms
2
Information regarding RMNCHA care seekers (1) Diagnosis, assessments, treatment plan,
are recorded & updated using IT platform drugs prescribed, and follow up etc are
recorded & updated for all cases by HSC/
referral centre RR/SI
(2) Randomly, select at least 5 cases (or all cases
if less than 5) and check for details
2
Information regarding cases of (1) Diagnosis, assessments, treatment plan,
communicable diseases are recorded & drugs prescribed, and follow up etc are
updated using IT platform recorded & updated for all cases by HSC/
referral centre RR/SI
(2) Randomly, select at least 5 cases (or all cases
if less than 5) and check for details
2
Information regarding cases of Non- (1) Check family folder, CBAC form are filled and
communicable diseases are recorded & complete details are updated in portal.
updated 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

2
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, RR/SI
treatment plan to be followed
Give partial compliance if information is only
available in paper.

2
Functional platform/s and updated digital Population enumeration, coverage, screening,
records to assess the coverage and measure referral & follow ups RR/SI
outcomes of healthcare facility
2
 Functional platform/s and updated digital Work plan generation- daily, weekly & missed
records for work/ task management task, reminders to team for scheduling
appointments ,follow up of home visits and RR/SI
outreach activities, Special days etc
2
Functional platform/s and updated digital Daily reporting of all the activities , IT support
records for reporting and monitoring of the to generate performance matrix of Service
performance of health care provider Providers, calculating performance based
incentive, Support for staff monitoring & RR/SI
maintenance of their credentials
2
(1) Secure place to keep records and registers
The facility ensures safe (2) Check records are easy to retrieve
storage, maintenance and HWC has established procedure for safe
ME D3.2 OB/ SI
retrieval of information & keeping & retrieval of paper based records
records of services
2
(1) System clearly define who all are authorized
to access the patient electronic information
(2) Password/finger print protected Tablets
HWC has established procedure for access & (3) Any restriction/ firewall to protect the
OB/ SI
retrieval of electronic records individual's information from mis-use etc

2
HWC has policy for retention period for As per State policy
different information & records RR/ SI
2
The facility has established
procedure for providing Staff is aware of functional hubs & skilled to use
ME D3.3 Hubs are identified for tele consultation OB/ RR
consultation using tele the software
medicine
2
(1) Arrange consultation with PHC- MO or
Cases are identified for tele consultation for Specialist as per requirement.
SI/ RR
specialist & non specialist consultation (2) Check how many cases were consulted using
tele medicine in preceding 3 months
2
Co ordination with specialist / super
As per roster - send the patient to PHC SI/ RR
specialist for tele consultation 2
(1) Pre appointment, location for consultation
Co ordination with patient & creating
(2) Check reminder / SMS alerts are sent for SI/ CI
awareness about tele consultation services
appointments/ referral/ follow up cases 2
Dispense drugs as per prescription received
through tele consultation As per e-prescription RR
2
Standard
The facility has defined and established procedures for hospital transparency and accountability.
D4
 HWC has functional Jan Arogya Samiti (1) Check composition of committee as per JAS
guidelines. Chairperson- Sarpanch, Co -
Chairperson- MO- PHC and Member Sect. - CHO.
The facility has established (2) At least 50% of representation of women
ME D4.1 procedure for management of (3) Check committee has representation of all RR/SI
activities of Jan Arogya Samiti habitation or communities esp. vulnerable

2
Committee members are aware of its roles & A. (1) Maintenance of HWC - cleanliness,
responsibilities hygiene, safe drinking water, clean toilet, BMW
disposal & clear signage.
(2) Management of grievances
(3) Ensure conduct of social audits & public
hearing
(4)Coordinate celebration of Annual health
calendar days
(5) Effective implementation of community level
programmes viz. VISHWAS, SABLA, Eat right CI/ SI/RR
campaign of FSSI, farmer groups, Self help
groups, women groups, Milk unions etc.
B. Check each member is aware of their powers
and functions

2
JAS meetings are held at defined intervals (1) Monthly.
(2) Minutes of meeting are recorded RR
2
Check JAS supports HWC to mobilize Both monetary and non monetary from PRIs/
resources/funds CSR/Govt. schemes and program /donation etc RR/ SI
2
Timely submission of Utilization certificate as
Timely planning & utilization of untied funds per state/NHM norms RR/SI
2
Check JAS provide support for Health
promotion & prevention activities SI/ RR
Organize camps, VHSNC meetings, multisectoral
convergence, formation of PSGs etc. 2
Check JAS facilitate Public hearing or Jan Check when was last public hearing was
Sunwais undertaken. HWCs undertake Jan sunwais bi SI/RR
annually
2
Check social audits are done at periodic At least once in a year. Check when last social
The facility has established intervals audit was undertaken
procedures for community
ME D4.2 RR
based monitoring of its services
through social audits
2
 Check JAS is aware of the issues issues There is mechanism in place to improve the
emerged in Social Audits & public hearing gaps identified / recommendations given by RR/SI
social audits teams 2
Gaps closure plan is prepared & status is
Check JAS committee has prepared action assessed atleast once in quarter or as per RR/SI
plan along with HWC decided timeline
2
Check social audits are conducted before Check the issues emerging out of the Social
completion of Annual planning of the gram Audit are integrated with the annual planning RR
Panchayat process of Gram Panchayat.
2

(1) At least once in a month

The facility has established (2) Assess the progress on coverage of
procedure for supporting and Check CHO conducts periodic meetings with beneficiaries & any knowledge or skill gap
ME D4.3 RR/SI
monitoring activities of MPW & ASHA (3) Identify common issues & problems faced by
Community health workers Frontline workers
(4) Actions taken thereafter
2
(1) Check CHO provide on job mentoring &
support to frontline workers (ASHA/ MPW)
Check CHO provide on job mentoring & (2) Visiting households requiring additional
support or motivation SI/RR
supervision household visits

2
(1) Check CHO provide on job mentoring &
support to frontline workers (ASHA/ MPW)
(2) Monitoring the quality of services using
checklist
Check CHO provide on job mentoring & (3) Check report is duly signed by both MPW & CI/ RR
supervision for VHSND or campaign etc. ASHA and a copy is shared with MO- PHC

2
(1) Monthly review of service delivery &
Check PHC -MO provide supportive RR/ SI
performance of HWC
supervision & monitoring for HWC activities
(2) Supportive supervision for HWC staff 2
Standard
The facility ensures health promotion and disease prevention activities through community mobilization
D5

The HWC facilitate planning &

ME D5.1 implementation of health SI/ CI 2
promotion and disease Check HWC is aware of community level
prevention activities through approaches for health promotion and disease VHSNC, VHNDs, ASHA, AWW and Monthly
community level interventions prevention campaign etc
 (1) Regular meetings are being conducted
(2) Community based action plan for health is RR/ SI 2
prepared
(3) Provide support to frontline workers for
Check VHSNC are constituted & functional health related activities

Check frontline workers part of VHSNC are

able to explain - Support to develop village
health action plan, SI/ CI 2
Awareness generation for Health Promotion &
disease prevention and support the community
Check VHSNC members are aware of their to raise their voice, need, experience &
roles & responsibilities towards Health & grievances to access health services or benefits
wellness centre

(1) Check agenda points and minutes of

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

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

(1) Check advance communication regarding

date & venue is given.
(2)Line listing of pregnant women requiring
ANC, TB patients, infant or children requiring RR/CI 2
immunisation, left or drop out children &
malnourished
(3) Check estimation about number of people
expected to attend VHND are calculated in
Micro planning to conduct VHND is done by advance
HWC staff & frontline workers (4) Check the coverage against estimation
Check functional equipment, instrument and
adequate consumables are available to SI/ OB 2
conduct VHND As per service provision
 (1) Awareness generation for various Health
program
(2) Need based counselling & interventions CI/ SI/ RR 2
Check the health promotion & disease (3) Check the list of topics covered during
presentation activities are performed during VHNDs in proceding quarter
VHNDs
Check primary healthcare team perform
advocacy with community influencers for Viz. Benefits of immunization, family planning, CI/SI 2
giving key messages for health promotion ANCs, regular check-up and Yoga for NCDs etc.

(1) Identify the individual with health risk

(2) Community mobilization for screening
(3) Holding or Support village meetings or
campaigns for awareness generation & life style
modification SI/ RR 2
(4) Support treatment compliance for pregnant
women, new born, NCD & acute of chronic
conditions as per service provision
(5) Check number of new individuals identified
with health risk & mobilized for screening in
proceding quarter
Check the health promotion & disease (6) Check number of individual supported
prevention activities are performed by ASHA treatment compliance in proceding quarter

(1) Based on Population enumeration, village

health register, CBAC, ASHA diary, VHSNC SI/ RR 2
Check the process followed to identify key records, RCH registers etc
challenges and list of priorities for monthly (2) Based on social resource map - it identify
campaigns location & vulnerable section

(1) Check advance plan is available with HWC

(2) At least 30 diseases/national health program
specific awareness or health promotion RR/ SI 2
campaign are organized per year. Viz. WASH,
Eat right/eat safe, Nutrition screening,
deaddiction & substance abuse, Indoor and
Check Annual calendar is prepared for outdoor pollution, Case detection for NCD & CD,
monthly campaign based on situational childhood illness diarrhoea & pneumonia,
analysis prevention of childhood marriage, GBV etc

Check health promotion campaign are Check number of health promotion campaign RR 2
conducted as per planning conducted out of planned in proceding quarter
 (1) Prepared draft campaign plan & define
responsibilities of primary care team RR/SI 2
(2) Conduct meeting of HWC team & other
stakeholders i.e. panchayat, ICDS etc
(3) Gather/PreparedIEC or IPC material required
Check the involvement of HWC in planning & (4) Engage community volunteer, support &
falcitation of monthly campaign activities supervise them
There is a system of taking feedback from
ASHAs / VHNSCs/ VHND to improve the SI/ RR 2
services

The facility has Patient Support For ensuring treatment compliance, reduce
ME D5.2 Groups(PSG) as per the issues/ stigma, increase acceptance toward disease, CI/ RR 2
diseases in its catering HWC have created Patient support groups for reduce stress & anxiety & increase self
population various issues/ disease conditions understanding
(1) Based on issues/diseases with high
prevalence in area using data &information SI/RR 2
Check the process followed to create PSGs collected

(1) Identify the potential member & encourage

them to join by explaining them the advantages
of joining SI/ CI 2
(2) Friends, relatives, frontline workers and
patients suffering from same disease conditions.
(3) PSGs meetings should be open to all
Check staff is aware of guiding principles to community members
be followed to constitute PSGs

(1) Sharing the knowledge & experience with

other SI/CI 2
(2) Work together to solve the problems
(3 Helping health functionaries in health
Check members of PSGs aware of their roles promotion (as convenient)

No. of planned PSGs & how many actually

conducted
(1) Flexible location, - in house of group RR/CI 2
member, arranged after VHNSC/ VHNDs, SHC,
AWW - preferable near to marginalized or
Check the frequency , location & timing of distant hamlets
PSG 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 SI 2
members
Primary health care team/worker is aware of (4) Inform group about content, date , time &
their role in conducting PSGs place for next meeting
The facility ensure (1) Education, WCD, ICDS, rural development/
multisectoral convergence for HWC engage other allied departments for municipal bodies, FSSAI &ICDS etc.
ME D5.3 RR/SI 2
health promotion and primary intersectoral convergence (2) Check VHSNC provide platform for
prevention multisectoral convergence

HWC support & felicitate promotion Community level education, malnutrition,

activities with their convergence sanitation drives, promotion of healthy SI/ RR 2
departments behaviour, sanitation 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 2
promotion of healthy behaviour

HWC organize training sessions &

With support of Ayushman ambassadors SI/ RR 2
competitions for school children

HWC promotes wellness & health promotion (1) Identify pool of local yoga instructors
(2) Prepare & disseminate weekly/monthly SI/ RR 2
through Yoga
schedule of classes for community yoga
trainings
Standards
The facility is compliant with statutory and regulatory requirement
D6
Authorization for Bio Medical waste Prior approval from Pollution control board (if
The facility ensures its Management HWC is using deep burial pit)
processes are in compliance
ME D6.1 RR
with statutory and legal
requirement
2
No Smoking sign is displayed at the Both inside & outside the building
prominent places OB
2
Any positive report of notifiable disease is
intimated to designated authorities RR/SI
2
Updated copies of relevant laws, regulations BMW rules, fire safety, electrical installations
and any other as per state mandate RR
and Govt orders are available 2
Area of Concern E: Wellness & Clinical Services
Standard
The facility has defined procedures for registration, consultation, clinical assessment and reassessment of the patients
E1
 The facility has established
procedure for empanelment &
ME E1.1 (1) There is established procedure to collect the RR/SI
registration of individual and
families HWC is aware of constitution of its catering demographic composition
population (2) No. of individuals of different age groups 2
HWC periodically estimates & updates Check no. of pregnant women, no. of life births,
number of beneficiaries for RMNCHA pregnant mother with complications, eligible RR/SI
services couple, sick new born are estimated 2
HWC periodically estimates & updates Population above 30yrs , break up of men & RR/SI
number of beneficiaries for NCDs women above 30 yrs. 2
HWC periodically estimates & updates RR/SI
number of beneficiaries for CDs As per incidence rates/ prevalence rates 2

(1) Check family folders are maintained for

entire registered population in facility's
coverage area. RR/SI
(2) Check data base is updated regularly for new
All individuals and families are empanelled entrants and exits (annually) & their illness.
under H WC 2
The facility has established Check Unique health ID is given to all individuals
ME E1.2 procedure for registration & Unique identification number is given to each and families . RR/CI
consultation in HWC patient 2

Check all the patients visiting HWC are RR/SI

Patient demographic details are recorded in registered & their demographic details like
OPD register/portal Name, age, Sex and Address etc are maintained 2
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)
2

Through tele health/ tele consultation with MO

PHC /identified hubs/ clinical decision making - RR/SI
Facility has system to undertaken opinion IT tool
/consultation from higher centre 2
All the empanelled individuals are screened Through fix day/routine OPD consultation RR/CI 2

Reassessment /follow up as per schedule for all

The facility has established
Facilities provide follow up/re assessment for cases including critical /high risk patients.
ME E1.3 procedure for follow up/ re- Follow up includes - Treatment compliance, CI/ RR
cases under RMNCHA
assessment of patients review of parameters, monitoring of side effect,
adherence to life style modification, timely
detection of complication and continuity and
adequacy of treatment. 2
 Reassessment /follow up as per schedule for all
Facilities provide follow up/re assessment for cases including critical /high risk patients.
Follow up includes - Treatment compliance, CI/ RR
cases under Communicable diseases
review of parameters, monitoring of side effect,
adherence to life style modification and timely
detection of complication and continuity and
adequacy of treatment. 2

Reassessment /follow up as per schedule for all

cases including critical /high risk patients.
Facilities provide follow up/re assement for
CI/ RR
cases under non communicable diseases Follow up includes - Treatment compliance,
review of parameters, monitoring of side effect,
adherence to life style modification and timely
detection of complication and continuity and
adequacy of treatment. 2

(1) Eye, ENT, oral, elderly & palliative, mental

health etc.
Facilities provide follow up/re assement for Give full compliance if any services is not given
as per service mandate CI/ RR
other clinical conditions
(2) Follow up includes - Treatment compliance,
monitoring of side effect, adherence to life style
modification and timely detection of
complication and continuity and adequacy of
treatment.
2
Standard
The facility has defined and established procedures for continuity of care through two way referral
E2
Facility ensures continuity of care at
community/household level CHW ensures home visit, counselling/
The facility has established supportive activities for risk factor modification,
ME E2.1 procedure for continuity of care provide reminder for follow up at HWC & CI/ RR
collection of drugs. Linkage with MMU/RBSK
mobile unit
2
Continuity of care is ensured at Health &
wellness centre Dispensation of medicines, repeat diagnostic as
required/ as per treatment plan, identification SI/ RR
of complication , facilitating referrals, organizing
tele consultations, maintenance of records
2
 Continuity of care is ensured at referral Examination, development/modification of
Centre/higher centre treatment plan, instruction for patient, note to
CHO by MO/Specialist.
RR/SI/CI

2
Early case detection, primary
The facility has established management/stabilisation, Complete details of
procedure for undertaking case records/care provided - use of referral slip
ME E2.2 RR/ SI
referred in & referred out of
the cases
Facility has defined protocols for referral out 2
Check availability of separate colour coded for easy identification in referral centre
OB/SI
referal slip 2
Check records for treatment plan, periodic
assessment, medicine refill and referred to
further higher centre (if required)/ regular RR/SI
follow up at referring centre
Facility has defined protocols for referral in 2
(1) Referral slip, referral in or out
register/portal, Advance communication , prior
appointment with specialist, referral vehicle (if
required) & follow up. RR/SI
(2) IT system to track upward & downward
referrals to ensure the continuity of care
Facility has referral procedure in place to
ensure continuity of care 2
Standard
The facility has defined and established procedures of diagnostic services.
E3
The facility has established
ME E3.1 procedure for laboratory Point of care diagnostics services are Check staff is aware of Quality Control method SI/RR
diagnosis as per guidelines available as per mandate for various tests (RDKs) 2
Central hub/diagnostic units are identified & For Both laboratory/other diagnostic test. Check
linkage has established for tests not done at how much patient has to travel for getting CI/ SI
HWC diagnostic services 2

(1) Check IT system is used for reporting of

diagnostic results from PHC/referral centre or RR
HWC has system for timely reporting, identified hub results.
retaining & prompt retrieval of diagnostic (2) Biological reference intervals for laboratory
result tests are available in HWC 2
Check there is no irrational prescription of Check OPD ticket for any irrational prescription RR/SI
Diagnostic test of Lab test/USG/ X ray etc 2
Standard
The facility has defined procedures for safe drug administration.
E4
 (1) Every medical advice is accompanied with
Facility follows protocols for Medication orders are written legibly and date, time and signature. Check orders/
ME E4.1 instructions are comprehendible RR/SI
safe drug administration updated
(2) Ask the staff what protocols are followed in
case orders/instructions are not legible due use
of abbreviations, handwriting etc 2

(1) Drugs are checked for expiry and other

inconsistency before administration, single dose
There is procedure to check the drugs before vial /ampule are not used for more than one
OB/SI
administration and dispensing 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 2
Patients are counselled for self drug (1) Medication calendars /schedules, specify the
administration time to 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

There is process for identifying

Check high alerts drugs are identified & its
ME E4.2 and cautious administration of High alert drugs such as Nonsteroidal anti- SI/ RR
maximum dose are defined
high alert drugs inflammatory, anti convulsant/antiepileptics,
Hypertensive, oral hypoglycaemic etc. 2
Check staff is aware of right dose of high Value of maximum dose as per age, weight and SI/RR
alert drugs diagnosis is available with CHO. 2

Check staff follows 6 Rs of drug (1) Right patient, right drug, right route, right
time, right dose & right documentation. SI/RR
administration
(2) Check system in place to verify the verbal
orders given by MO 2
Check with staff if any untoward drug events SI/RR
has ever occurred 2
Minimum information model (MIMPS) for
Check any untoward/adverse drug events are medication safety is followed & used for RR/ SI
recorded and reported reporting & subsequent actions planning 2
Standard
The facility follows standard treatment guidelines and ensures rational use of drugs
E5
 There is procedure of rational Check the cases in which CHO has prescribed
ME E5.1 RR
use of drugs medicines/ antibiotics. Check if the drugs are
either prescribed more than required dose
Check staff is aware of rational use of drugs /quantity or on more occasion than necessary. 2
Check availability of STG/clinical algorithm/
Clinical decision making tool (IT based), Staff is RR/ SI
Check STG/ clinical algorithm is followed aware of drug regime and doses 2
Check medication review is scheduled for At least once in a year RR/CI
regular chronic cases with PHC MO/ Physician of referral facility 2
Check drugs are prescribed with generic Check OPD ticket if drugs are prescribed under RR
name generic name only 2
Check HWC has antibiotic policy Check staff is aware of antibiotic policy RR/SI 2

Facility has system in place to

ME E5.2 periodically monitor the Well defined and standardized format is used to RR/ SI
treatment provided by CHO assess the quality and accuracy of treatment
Treatment provided by CHO is monitored provided. Valid sample is taken & frequency of
regularly monitoring process is defined and followed 2
Check monitoring is done by qualified SI/ RR
personnel Preferably MO of Mother PHC/referral site 2
Check medication orders/ procedure is Check medical advise is accompanied with date, RR
written legibly & comprehendible time & signature 2

(1) Non compliances ( viz over prescription,

irrational use of antibiotics, drugs, vitamins, RR/SI
vaccines, diagnostics etc) are enumerated , (2)
Action plan is prepared & Primary health care
Action taken on non compliances team is hand holded & guided for improvement 2
Standard
The facility has defined and established procedures for nursing care.
E6

There is established procedure

ME E6.1 for identification & periodic There is process for ensuring the Both in HWC & home based care. SI/OB
monitoring of the patients identification of patient before any Investigations, refill the medicines, performing
procedure minor procedure, administrating vaccine etc 2
Patients who are not oftently following their
There is process in place to identify non treatment plan or taking the medicines as SI/ RR
compliant patient in chronic disease recommended 2
 Chronic cases/ critical patient referred from
higher centre/Home based care patient/ bed
ridden/ elderly cases RR/SI
Check Patient vital like BP, weight, TPR, Blood
Patient's vital are monitored and recorded sugar etc are maintained as per disease
periodically in follow up conditions 2
Prescribed treatment plan and Prescribed Treatment plan , procedure
ME E6.2 procedure performed are performed are written in case sheet/OPD Treatment plan followed , medication RR
recorded in patient's record ticket/Portal administered are documented 2
Day to day progress of patient is recorded Progress is monitored & documented as per RR
where ever required/ critical/ chronic cases schedule prescribed 2

Adequate forms, formats and HWC, home based care/ home visits, patient
ME E6.3 records are available as per self managements RR/ OB
services mandate OPD slip, family folders, referral slips , Disease
specific forms & formats (any hard /soft copy)
Standard forms & formats are available 2
Registers & records are maintained as per
guidelines/range of services provided by H WC RR
Updated Registers & records are available (SC) 2
All the register/records are identified and Check the master list & unique identification OB/ RR
numbered number is followed to identify records 2
Standard
The facility has defined and established procedures for Emergency care
E7

Emergency protocols are Protocols for snake bite, poisoning, drowning,

ME E 7.1 trauma, burn, fits, cardiac or respiratory arrest , SI/RR
defined and implemented
Emergency protocols for first aid and haemorrhoids, rectal
stabilization are available prolapse, hernia, hydrocele, appendicitis etc. 2

Check staff is aware of steps of BLS and also ask SI/RR

about how to recognize the signs for sudden
cardiac arrest (SCA), heart attack, stroke, and
Staff is aware of procedure for CPR foreign-body airway obstruction (FBAO) 2
 As per state guidelines or
(1) Primary management & referral
(2) Staff is aware of procedure for preservation
& sealing of samples of suspected MLC cases SI/RR
viz. aspiration, vomitus etc.
(3) Samples are sealed and dispatched along
with patient (Samples are taken by resposible
HCW & handed it over to responsible personnel
at referral centre).
Staff is aware of protocols to manage (4) Separate records are generated for
suspected Medico legal cases suspected MLC cases 2

(1) Check how ambulances are called & patient

is shifted. RR/CI
(2) Transfer register is maintained to record the
HWC ensures timely availability of details of the refferred patient
ambulances services for emergency cases 2

The facility has disaster Staff is aware of district disaster management

ME E 7.2 team, staff is aware of their roles, basic SI/ OB
management plan in place
Emergency care is given in case of disaster emergency management kit is available 2
Staff is aware of process of sorting the Staff is aware of triage protocols in case of SI/RR
patients in case of mass causalty/ outbreak referral required 2
Standard
The facility has defined & established procedures for management of ophthalmic, ENT and Oral aliments as per operational/ clinical guidelines
E8
 Ask staff about common ophthalmic aliments &
their cardinal signs & symptoms
Cataract: Clouded/ blurred or difficulty with
vision at night, sensitivity to light and glare,
Need for brighter light for reading , seeing
"halos" around lights, frequent changes in
eyeglass , Fading or yellowing of colours mostly
The facility provides services
age related.
for Ophthalmic aliments Staff screen & refer cases of common
Presbyopia: having eyestrain or headaches/
ME E8.1 including blindness and ophthalmic aliments lead to blindness & SI/ RR
fatigue after reading/ doing close work,
refractive errors as per refractive errors
Glaucoma: Severe eye pain, reddening of the
guidelines
eye,
Sudden onset of visual disturbance- in low light,
Corneal Disease: Visual impairment, blurred or
cloudy vision, severe pain in the eye, tearing,
and.
sensitivity to light

2
Staff is aware of identification & primary
management common ophthalmic conditions
including emergencies

Ask staff about common ophthalmic aliments &

their cardinal signs & symptoms & its primary
management
Conjunctivitis: Redness, itching, watery
discharge from eyes and crusting around eyes.
Trachoma: usually affect both eyes and may
include: Mild itching and irritation of the eyes RR/ OB/SI
and eyelids, discharge from the eyes, eyelid
swelling, light sensitivity (photophobia).
Xeropthalmia: conjunctiva dries out, thickens,
and begins to wrinkle, inability to see in dim
light, progress lesions form cornea and deposits
of tissue are called Bitot’s spots.
Redness in eyes, removal of foreign body &
allergic reactions,, eye injury and acid/
alkaline /chemical exposure etc
Management: Symptomatic treatment,
Counselling for eye care and referral if required.
2
 Staff is aware of methods for measuring the
refractive errors Visual acuity by using Snell's chart, near vision
card. ASHA/ MPW is skilled assess to use vision SI/RR
screening chart. 2

Blindness & visual impairment register, records

of vit A prophylaxis, listing of eye disorders, RR/SI
Surveillance records of TT/TI cases as per NPCB
Staff maintain records under ophthalmic care & VI 2

Awareness about contagious eye disease,

personal hygiene, cleanliness of environment to
Promotion & supportive activities for prevent the spread of trachoma, do's & do not's CI/ RR
ophthalmic care for eye care during eye infection, life style
modification, avoid myths & mis conceptions,
mobilize children for vit A prophylaxis,
distribution of spectacles, follow up of referral,
post operative and cases required long term
medications. Motivation for eye donation
2

(1) Community based new born screening till 6

weeks of age- through home visit/ immunization
The facility provides services
,Children- 6 week -18 yrs. -Screening through
ME E8.2 for ENT aliments as per Screening of population for ENT aliments SI/RR
RBSK , Adults & elderly - through whisper test.
guidelines
(2)Check opportunistic & planned screening
form is used for early identification
2
 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
Identification & primary management of discharge: any fluid leaking out is ear wax. A SI/ RR
common ear problems ruptured eardrum can cause 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

2
Check CHO is trained and using otoscopy for ear
Staff is trained & using diagnostic tools for
discharge, Hearing test: whisper/ App based RR/ OB
identification of ear problems
audiometry. 2

Ask staff about common nose aliments & their

cardinal signs & symptoms & its primary
management.
Common cold, blocked nose, injury, sinusitis,
rhinitis, epistaxis and foreign body in anterior
Identification & management of nose part of nasal cavity
RR/OB
problem Treatment: Symptomatic treatment, nasal
packing in case of nasal bleed, Analgesic, Nasal
drops/spray, Antibiotic may be deferred in
children-two years or older with mild
symptoms. Refer the patient if persist for more
than 5 days.
2
 Patency test: Check the patency of each naris by
standing directly in front of the patient and
occluding the patient's left naris with the index
finger of your right hand. Ask the patient to
breathe normally through the right naris.
Repeat by occluding the patient's right naris
with the index finger of your left hand and ask
Staff is trained & using diagnostic tools for
the patient to breathe through the left naris. SI/ OB
identification of Nose aliments
Normally the patient will be able to exhale
through the unoccluded naris. Nasal obstruction
is present if the patient is unable to exhale
through the nares.
Cotton wisp: Fluff of cotton is held against each
nostrils & its movements are noticed when
patient inhale & exhale

Ask staff about common throat aliments & their

cardinal signs & symptoms & its primary
management.
Identification & primary management of
Injury, pharyngitis, laryngitis, URI, tonsillitis. SI/ RR
throat aliments
Treatment: Symptomatic treatment: Analgesic,
antibiotic, Refer the patient if persist more than
5 days.
2
First aid for dislodging an obstruction from a
Check staff is trained & able to perform
person's windpipe. Sudden strong pressure
Heimlich manoeuvre/ dislodge obstruction SI/RR
applied on their abdomen between naval &
from windpipe
ribcage
2
Thyroid swelling, discharge from ear, hearing
Staff is trained to identify ENT aliments
impairment & deafness, blocked nose, SI/ RR
require referral to higher centre
hoarseness & dysphagia 2

(1) Educating community about healthy ENT

habits, awareness protection against excessive
noise, safe listening & improving acoustic
environment.(2) Teach for early care seeking
behaviour for allergies & common ENT
Promotion & supportive activities for ENT problems teach how to instil nasal/ear /eye CI/ SI/ RR
drops, teach how to pinch nose in case of
epistaxis, perform Heimlich manoeuvre etc (3)
Follow up for treatment compliance (4)
Identified cases requiring surgery, hearing aid
fitting or rehabilitative therapy
2
 Ask staff about common oral aliments & their
cardinal signs & symptoms & its primary
management.
Tooth decay: Discoloration/ hole, sensitivity,
pain, swelling / pus.
Gum Diseases: Foul smell, bleeding, loose teeth,
swollen gums
Dental Fluorosis: White/ Yellow/ brown
discoloured patched on teeth
Treatment: After symptomatic relief at H WC
refer to dentist at CHC/DH.
ME E8.3 The facility provides service for Staff is aware about Oral health conditions, Malocclusion : Reverse bites, SI/ RR
oral health aliments primary management & referral protruding/forwardly placed teeth spacing
between teeth. Treatment: Cessation of habits
such as thumb sucking, mouth breathing. Refer
to dentist at DH.
Cleft lip/palate: Split lip/gap in palate, inability
to feed the baby. Refer to dentist at DH
Oral Cancer: White/red patch, non healing
ulcer, reduced mouth opening, change in voice,
lump in neck. burning sensation, inability to eat
spicy food. Use of CBAC form is filled and case is
referred at appropriate level
2

Ask staff about common dental emergencies &

its primary management.
Pain, swelling/abscess, tooth injury, non healing
Staff is aware of symptomatic treatment for
ulcer, uncontrolled bleeding from gums, SI/ RR
dental emergencies
extraction site.
Treatment: Symptomatic relief at HWC & refer
to dentist at CHC/DH
2

(1) Filling of CBAC form (more than 30yrs -

Check records screening is not limited up to oral
cancers it should include screening of other
Screening of oral health conditions is done as
dental conditions as well ) RR/SI
per protocol
(2) Check linkage with RBSK (0-18 Yrs.)
(3) Rest 18-29 yrs. - under opportunistic
screening
2
(1) Oral health education & dietary advise for (a)
Promotion & supportive activities for oral
Oral hygiene (b) Tobacco cessation CI/ SI
health
2
Standard
The facility has defined & established procedure for screening & basic management of Mental Health ailments as per Operational/ clinical guidelines
E9
 Common Mental Disorders( CMDs) :
Depression, Anxiety/panic disorders,
psychosomatic disorders
Severe Mental Disorder (SMDs) : Schizophrenia,
Bipolar disorder, severe depression
The facility provides services
Check staff is aware of MNS (Mental, Child & Adolescent Mental Health disorder (C&
ME E9.1 under mental health Program SI/RR
neurological & substance use) conditions AMHD): Conduct disorder, Attention deficit
as per guidelines
disorder (ADHD), oppositional defiant disorder
Epilepsy & dementia (Alzheimer's disease)
Substance use disorder (SUD): Tobacco, alcohol
& drug use disorder

(1) Check Community informant decision tool

(CIDT) is used for identification by
ASHA/MPW/CHW
(2) Standard screening tools are used by CHO viz
:Screening tool for dementia, Screening tools for
Check Staff uses specific tools for early
Epilepsy, patient health Questionnaire (PHQ-9) SI/ RR
identification & screening of MNS
for depression , suicide risk assessment &
Alcohol use disorder identification test (AUDIT)
for alcohol disorders. Check staff is trained to
use these tools.
(3) Check number cases screened & identified

Awareness & use of techniques for

psychosocial intervention:(1) Psychoeducation,
psychological first aid, relation techniques
(breathing exercise), basic suicide management,
basic counselling (problem solving & behaviour
Staff is competent for basic management, activation), community based rehabilitation,
SI/ RR
referral & follow up of MNS first aid for overdose/ intoxication etc. (2)
Dispensing of medicines as per prescription (3)
Review & counsel periodically Home/
community/ HWC and (4) Provide adherence
support for treatment (5) Side effects and
toxicities for prescribed medications

2
 Check staff is trained for emergency Administer either intranasal or intramuscular
SI/ RR
management of Epilepsy Midazolam. Stabilize & refer 2

(1) Awareness about improving mental health

literacy, understanding of common symptoms,
reduction in social stigma, technique of self
care, community based rehabilitation, Life style
Promotion & supportive activities for mental
modification etc CI/ SI
health
(2) Awareness & advocacy about society
problems that act as risk for mental health
conditions viz. gender based violence, abuse,
suicide ideation & substance dependence
2
Standard
The facility has defined & established procedures for management of communicable diseases as per operational/ clinical guidelines
E10

Source reduction, personal protection,

The facility provides services environment management, Biological control
under National vector Borne ( Larvivorus fish) & chemical control (larvicide /
ME E10.1 SI/ RR
disease control programme as Adulticide) . Staff is involved in intersectoral
per guidelines as per guidelines convergence with other departments like
DODWS (Department of Drinking Water and
Sanitation under Ministry of Jal Shakti, MOHUA
(Ministry of Housing and Urban Affairs),
Primary care team is aware of vector born Municipalities etc) & carry out weekly
disease control strategies cleanliness drive in village through VHSNC 2

(1) Fortnightly Home visit & testing people with

current/ recent fever & chills in past 14 days
using RDT.
(2) Malaria detection in cases presenting with
fever at HWC RR/ SI
(3) Detection by using RDT/Microscopy.
(Microscopy- result should be made available
within 24 hrs)
(4) Negative RDT cases strongly suspected of
malaria cross checked by microscopy
(5) Check HWC is aware of confirmed malaria
Case detection is done for Malaria cases in its catchment area 2
 (1) Treatment should be started within 24 hrs of
detection.
(2) P. Vivax - Chloroquine/ 3days and RR/ SI
Primaquine/14 days. (Contraindicated in
pregnant female or infant or G6PD deficiency/
P- falciparum- ACT
(3) Algorithm for treatment & diagnosis is
Staff is aware of Malaria treatment protocols available 2

Persistence of fever even after 48 hrs of

treatment, continuous vomiting, headache, SI/RR
dehydration, change in sensorium, convulsions,
bleeding & clotting disorders, severe anaemia,
Staff is aware of Malaria referral protocols Jaundice & hypothermia 2

(1) Diagnostic- RDK

(2) Management- Bed rest, SI/ RR
cold sponging,& symptomatic treatment.
Staff is aware of diagnostic & management of (3) Check HWC is aware of dengue cases in its
dengue as per protocols catchment area 2

Check register is maintained & updated,

reporting in form M 1 (ASHA/SC), M2 (if using RR/SI
slides), M4- fortnight complied report of malaria
NVBDCP register & records are maintained surveillance submitted by SC 2
RDT kits , clean slides, needles, swabs, ACT, CQ,
Facilities have adequate stock of PQ etc. Check how kits have been stored & near RR/SI
commodities & drugs expiry drugs are not available 2
Staff is aware of sign & symptoms of Chikungunya, KA, JE, LF etc. SI
prevalent vector born diseases in area Any of the cases in their catchment area 2

The facility provides services Refer all presumptive cases to designated

ME E10.2 under National Tuberculosis Microscopy centre. Sputum collection and RR
Elimination Program (NTEP) Identification of presumptive case & their transport of sputum of samples is supported in
referral hard/difficult areas. 2

(1)Provision of DOTS at Sub-centre, proper

documentation and follow-up, home based
support, regular screening of cases for common OB/ RR
adverse effects, ensure compliance &
completeness of course
HWC support, supervision & manage (2) Check HWC is aware of presumptive,
presumptive, confirmed & on treatment confirmed & on treatment cases in its
cases including DR- TB patients catchment area 2
 Staff is aware of follow up protocol after 6,12, 18 , 24 month follow up after treatment SI/ RR
treatment completion completion 2

Referral slip, Patients treatment card (if CHW is RR

NTEP register & records are maintained supporting treatment), TB notification register 2

(1) Pale & reddish patches on the skin, skin

The facility provides services thickness, shiny & reddish, numbness & tingling,
under National Leprosy painful tender nerves, weakness of hands, feet
ME E10.3 or eyelid, swelling & lumps in the face & ear RR/ SI
Eradication Program as per
guidelines lobes impaired sensation.
(2) Sensory testing for screening: touching the
tip of pen on patch to feel sensation 2 times
(once with eyes & 2nd with closed eyes)
Primary healthcare team identify and ensure (3) Referral of suspected cases to higher centre.
referral of suspected cases of Leprosy First dose initiated at higher centre 2

Ensure delivery/ availability of 2nd dose onward

drugs, pulse dose to be given in presence of RR
ANM/MPW, completion of treatment,
Check the availability / delivery of identification of signs of neuritis, reactions etc
subsequent doses of MDT and follow up of for treatment cases. Referral in case MCR
persons under treatment footwear if required/ referral for complications 2

Maintain & update case card (ULF01), Update RR

NLEP register & records are maintained the treatment registered when visiting the PHC 2

Health education to community regarding signs

and symptoms of leprosy, its complications, CI/ SI
curability & availability of free of cost
Facility provide awareness about leprosy & treatment, self care & encourage the patient to
availability of its treatment bring his/her contacts to check-up 2

Identification & referral of suspected cases,

The facility provides services Condom Promotion & distribution among high
ME E10.4 under National AIDS Control risk groups & help HIV cases for receiving & RR/ SI
Program as per guidelines adhering to ART.
HIV/STI Counselling, Screening (consent) and
referral
in Type B Sub-centres in high prevalence
HWC-HSC is aware of their roles in NACP districts 2
HWC -SC has linkage for management of Linkage with Microscopy centre for HIV -TB, for RR
HIV/AIDS complications PPTCT services 2
 IEC for STI,HIV/AIDS Awareness generation ,
identification of peer support groups for HRG-
PLHIV, encourage for index testing, support in RR/ SI
treatment adherence, arrangement for
Staff is aware of promotional &supportive counselling/ psycho therapies, community
activities done under NACP follow up to support HIV pregnant women & 2

Fever, Cough less than 2 weeks duration, acute

ME E10.5 flaccid paralysis more than 15 yrs. of age, SI/ RR
The facility provides services diarrhoea (3 or more loose stool /day), Jaundice,
under Integrate Disease Staff is aware of syndrome under surveillance Raise the signal for action in case of for any
surveillance as per guidelines in IDSP unusual health event /death 2

(1) Information is collected from Home visit (for RR

above described syndrome) & from SC- OPD
Check process to collect information in form (2) Collation of data in Register for Syndromic
S Surveillance 2

(1) Preliminary analysis & reporting of collected

data to MO- PHC on every Monday RR/ SI
(2) Check any action has been undertaken using
Check Analysis & reporting of information IDSP data
for syndromic surveillance is done 2
The facilities provide services
ME E10.6 for National Viral Hepatitis Availability of diagnostic & treatment RDT for Hep B & Hep C & referral for RR
Control Programme (NVHCP) services confirmation & further management 2

Awareness generation & behaviour change

Staff is aware of preventive measures for NVH communication, immunization for Hep B (Birth SI/ OB
dose, high risk group & healthcare worker) ,
injection safety & safe drinking water &
sanitation. 2
Standard
The facility has defined & established procedures for management of non-communicable diseases as per operational/ clinical guidelines
E11
 (1) Population enumeration -filling of CBAC form
for all above 30Yrs of age- Screening at HWC on
fixed day approach-referral of suspected cases
to higher centre for Consultation - follow up of
The facility provides services
Staff is aware of process of population those who are diagnosed with hypertension &
ME E11.1 for hypertension as per RR/ SI
identification and referral for hypertension ensuring that they adhere to treatment plan-
guidelines
identify warning signs of complication & refer to
higher centre.
(2) Re screening of population (new and old) at
periodic intervals - every year

2
Systolic/ Diastolic BP of over 140 /Over 90 mm
of Hg.
CHO is aware of sign & symptoms of
Severe Headache, fatigue, nausea, sweating, SI
Hypertension
feeling faint & confusion, vision problem, chest
pain, shortness of breath.
2

Interview patients for:

(1) Regular & adequate availability of medicines
as per treatment plan
(2) His/her understanding about dosage RR/CI
schedule, life style medication, any dietary
restriction and awareness about next follow up
visit date
(3) Annual consultation with specialist at NCD
HWC ensures frequency of follow up & clinic
supply of required medicines 2

Awareness generation - (a)Risk factors:

overweight & obesity, Physical inactivity &
stress (b) Healthy life style: diet, exercise, CI/ SI
avoidance tobacco & alcohol, (c ) Counselling for
Staff is aware of promotional &supportive Lifestyle modification (d) importance of regular
activities for Hypertension follow & compliance to medication 2
 (1) Population enumeration -filling of CBAC form
for all above 30Yrs of age- Screening at HWC on
fixed day approach-referral of suspected cases
to higher centre for consultation - follow up of
The facility provides services Staff is aware of process of population those who are diagnosed with hypertension &
ME E11.2 RR/ SI
for Diabetes as per guidelines identification and referral for diabetes ensuring that they adhere to treatment plan-
identify warning signs of complication & refer to
higher centre
(2) Re screening of population (new and old) at
periodic intervals -every year

Random blood sugar 140mg/dl and mg/dl.

Frequent urination, increased hunger,excessive
CHO is aware of sign & symptoms of thirst, unexplained weight loss, extreme
SI
diabetes tiredness, blurred vision, slow wound healing
numbness or tingling hands or feet & sexual
problems
2

Interview patients for:

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

Check Patient is counselled about

identification & immediate management
hypoglycaemia 2

(1) All overweight or obese cases with diabetes

or 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 (BMI>=25kg/m2)
● Oedema examination
(3) Referal to PHC for management
HWC is aware of risk factors of Nonalcoholic
fatty liver disease (NAFLD) 2

Awareness generation - (a)Risk factors:

overweight & obesity, Physical inactivity &
stress (b) Healthy life style: diet, exercise,
avoidance tobacco & alcohol, (c ) Counselling for CI/ SI
Life style modification (d) Importance of regular
follow & compliance to medication (e)
Counselling about diabetes related complication
Staff is aware of promotional & supportive viz. Retinopathy, neuropathy & kidney failure
activities for diabetes etc. 2
 (1) At SC/ outreach/screening for Breast, cervix
& oral cancer.
(2) Screening is undertaken by trained
The facility provides services personnel (LHV/Staff nurse/MO) can be done in
Check cancer screening services are provided
ME E11.3 for cancer screening and outreach session/screening day. RR/ SI
through HWC
referral as per guidelines (3) Screening of cervical cancer is conducted on
site where privacy & facility for sterilization is
available
(4) Repeat screening -every 5yrs
2
Vaginal bleeding between periods, menses
longer or heavier than usual, post menopausal
Staff is aware about sign & symptom of SI
bleeding, bleeding & pain during/after sexual
cervical cancer
intercourse, smelly vaginal discharge, pain
during urination etc
2
Lump in breast/under arm area, thickening or
Staff is aware about sign & symptom of swelling of breath, puckering /dimpling of
SI
Breast cancer breath skin, redness in nipple area, nipple
discharge /blood, constant pain etc
2
Difficulty in chewing or swallowing , mouth
Staff is aware about sign & symptom of Oral ulcers persist for more than 3 weeks, persistent
SI
Cancer pain, lump, thickening in cheek, white/red patch
on gums/ tongue/tonsil etc,
2

(1) Visual Inspection by Acetic Acid for cervical,

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

2
For cancers of the oral and breast, the first level
of referral is the CHC / SDH/ DH and then to the
Check CHW is aware of referral centre for all SI /RR
DH for a biopsy for confirmed cases.
types of cancer
For cervical cancer, if VIA positive, refer to
higher centre offering colposcopy
2
 Awareness generation - (1)Risk factors:
smoking, multiple sexual partner, unprotected CI/ SI
sex, family history, overweight, lack of physical
activity (2) Healthy life style: diet, exercise,
avoidance tobacco & alcohol, (3 ) Counselling
Staff is aware of promotional & supportive for Life style modification (4) importance of
activities for diabetes regular follow & compliance to medication 2

Staff is aware 5A approach - Ask, advise, assess,

Assist & arrange
(1) History taking and referral to identified de
The facility provides services addiction centre.
ME E11.4 for de addiction, and locally Confirmation and referral of cases for (2) Advise to quite in cleat, strong and SI/ RR
prevalent health diseases as Tobacco/alcohol/ substance abuse personalized manner
per guidelines (3) Attempt to Quit (4) Involve family & friends,
remove substances from their adjacent area,
Arrange follow up visit (5) motivate by re
enforcing & intense follow up
2
(1) For Withdrawal symptoms (2) Life style
Promotional & supportive activities for support changes (3) Engagement/ linkage with
CI/ SI/RR
Tobacco/alcohol/ substance abuse patient support groups (4) Support
encouragement by family & friends
2

Ask for local prevalent disease viz.

Check Screening & referral locally prevalent
Pneumoconiosis , lead poisoning, fluorosis etc. SI/CI
diseases
Give full compliance if no such disease exists
2
Through trainer Yoga instructor (ASHA/ Asha
The facility promotes services
ME E11.5 Check HWC is providing Yoga services facilitator/ Yoga teacher/ physical instructor SI/ RR
for health & wellness
from school) 2

1. Check roster is available, updated & displayed

Check Yoga sessions are conducted regularly 2. Community is aware of yoga sessions RR/CI
conducted by HWC
2
One day fixed Ayurveda clinic for diet
counselling, management of chronic aches &
Check Ayurveda services are available OB/ RR
pains & elderly care. Check availability of
Ayurveda physician & medicines
2
 Check staff counsel mother's for nutritious diet
during first 1000 days of life
(1) Stage 1 (During Pregnancy) : Balance &
nutritious diet including important nutrients like
iodine, folic acid, iron, vit B12 etc.
(2) Stage 2 ( Period from birth of child to 1 yr.):
Check counselling of mother's for nutrition & Early initiation of exclusive breastfeeding for
SI/CI
hygiene maintenance under Eat right initial 6 months, initiation of Complementary
feeding on completion of 6 months with
continued Breastfeeding
(3)Stage 3 (Period between 12 month to 24
months of child age): Complementary feeding &
its preparation with right consistency, quantity,
frequency, density & variety.

2
(1) Guide about household measurement with
Check staff counsel and guide the mother's household utensils
about household preparation of (2) Awareness on ingredients, quantity & SI/CI
complementary feeds frequency of complementary feeding for
children up to 2 yrs.
2

(1) Generate awareness about 4 major food

groups (food pyramid) - a. Cereals & millets
Check Primary health care team generate
b. Vegetables & fruits, c. Milk & animal products
awareness in community about balanced SI/CI
d. Fats/ oils, sugar & nuts
diet
(2) Limit the consumption of foods high in fats,
sugar & salts
2
(1) Awareness on benefits of fortified food
Check Primary health care team generate
(2) Identification of fortified food available in
awareness in community about food SI/CI
market (+F logo)
fortification
2

Awareness generation about maintaining

personal & environmental hygiene while
Check Primary health care team generate
cooking food (viz. handwashing, regular bathing,
awareness in community about Eat safe SI/CI
wearing clean clothes, keeping kitchen clean,
practices
taking pest control measures, waste disposal,
using kitchen waste for compositing etc)
2
 (1) Awareness generation about logos on
packed food viz. fssai, ISI, +F, green and red dots
for vegetarian and non vegetarian food items.
(2) Safe storage of perishable & non perishable
Check Primary health care team generate food
CI/SI
awareness in community about food safety (3) Precautions to be taken while cooking &
serving the meals.
(4) Awareness about common tests for food
adulteration (Key ring test)

2
Standard
Elderly & palliative health care services are provided as per guidelines
E12

(1) Mapping of elderly population in category of

Bed bound ,restricted & mobile elderly,
The facility provides services
destitute, poor & single
ME E12.1 for elderly Care as per Elderly population is mapped & screened RR/ SI
(2) Screening using comprehensive Geriatric
guidelines
assessment tools
(3) Primary management & timely referral
2

(1) Activity of daily living

(2) Geriatric depression scale,
(3) Mini mental state examination. OB/ RR
(4) Check how many cases are identified &
CHO is aware & competent to use various referred (if required)
geriatric tools 2

Check how many elderly supported by HWCs for

supportive aids viz Walking sticks, callipers, RR
infrared lamp, shoulder wheel, pully & walker
HWC ­undertake preliminary assessment for (as per requirement) through PHCs
the need of assistive devices 2

(1) Health education regarding healthy aging,

environmental modifications, nutritional
requirements, life style & behaviour changes (2) CI/ SI
Educate family members for looking after
disabled elderly person (3) Linkage with support
Promotional & supportive activities for group & day care centre. (4) Motivate to join
Geriatric care annual health check-up at village level 2
 (1) Assessment using Palliative care screening
tool by CHO./MPW
(2) Scheduled visits to patients/ families for
The facility provides services
Screening, basic management & referral of basic nursing care/drugs or consumables
ME E12.2 for Palliative care as per RR/ CI
Palliative Care patient is done dispensing /psycho social support.
guidelines
(3) Referral of palliative patients based on pain
score

(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
RR/ SI
provided scheduled visits.
(3) Check the compliance to roster
2

Check sufficient number of kits are available, it

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

(1) Health education regarding needs of

palliative patients (2) Educate family members CI/SI
for routine home based care (3) Linkage with
Promotional & supportive activities for support group & day care centre. (4)Help in
palliative care assessing various services as needed 2
Standard
The facility has established procedures for care of new born, infant and child as per guidelines
E13
 Not able drink or breast feed, vomiting,
convulsions, lethargy Discharge from cord,
Post natal visit & counselling
CHO & CHW are aware of danger signs of pallor, cyanosis, Jaundice, pustules,
ME E13.1 for new born & infant care is SI/RR
new born & infant hypothermia, unable to pass stool/urine, fever,
provided as per guideline
diarrhoea, indrawing of the chest (2-12 months-
50 breaths/min & 12-5yrs-40 breaths/min)
2
Staff practice ETAT protocol. Stabilization per
Primary management & prompt referral of
disease condition. SI/ RR
sick new born & infants
2
Exclusive breast feeding, cord care,
Staff is aware of post natal care Counselling maintenance of temperature, promoting CI/ SI
hygiene practise, support for high risk babies 2
DPT, DT, Hep B ,TT vials & diluents are not kept
The facility provides
Check for vaccines & diluents are kept as per in direct contact of ice pack , Discarded
ME E13.2 immunization services as per OB/ SI
the recommendation of guidelines medicines are kept separately
guideline
2

(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
Reconstituted vaccines are not used after hours after reconstitution.
OB/SI
recommended time (2) Vials should be kept in plastic box with label
' NOT TO BE USED' & discarded after 48 hrs/
before the next session, whichever is earlier.

2
Staff checks VVM level before using vaccines Staff is aware of how check freeze damage for T-
and identify discard point Series vaccines SI
2
Parents are counselled for informing any Observe interaction at session site and
untoward event of concern following interview parents /care giver OB/CI
vaccination
2
Antipyretic drugs are provided wherever Observe session site and interview parents
required /care giver OB/CI
2
Beneficiary is asked to stay for half an hour To observe any AEFI, Staff is aware of minor &
after vaccination serious AEFI with its management, reporting of
AEFI Counselling on side effects and follow up CI/ OB
visits (CEI)
2
Vaccinator is aware about how to manage Ask the vaccinator what steps to take in case of
any immediate serious reaction/anaphylaxis serious reaction/anaphylaxis SI
2
Check the availability of anaphylaxis kit with Kit constitute of job-aid, dose chart for
ANM at session site adrenaline as per age (1 ml ampoule -3 no.),
Tuberculin syringe (1ml-3 no.), 24H/25G needle-
3 no, swabs-3 no. updated contact information
of DIO, MO PHC/CHC & local ambulance services OB
and adrenaline administration record slip.

2
Check adrenaline is not expired in kit Give non compliance if kit is not available OB 2
Check for injection site is not cleaned with Cleaning of injection site with spirit swab is not
spirit before administering vaccine dose recommended OB/SI
2
Check that Staff knows how to use AD Syringe Ask for demonstration , How to peel, how to
remove air bubble and injection site SI/OB
2
Staff is aware of the shelf life of Vit A once it Shelf life 6-8 weeks. Check mention of opening
is opened and ensures it is not given after date is marked on bottle SI/ OB
shelf life
2
ANM/CHW is aware segregation policy after 1. Segregate use & unused vials, Kept in
completion of immunization session sealed/zipper bag in the vaccine carrier cold
chain (reverse cold chain) & picked by AVD
2 Vaccine carrier/ vaccines are not kept in field , SI/OB
in exceptional cases the vial should be discarded

2
Staff is aware of Open vial policy OVP is not applicable to opened reconstituted
vials of measles, BCG & JE SI/ OB
2
Check for HWC -SHC micro plan for
immunization & its adequacy RR
2
Staff is aware of how to calculate the number Estimating the beneficiaries & logistic. Preparing
of beneficiaries, quantity of vaccines & due list of expected beneficiaries including
syringes number of beneficiaries & wastage/dosage per
multidose vials RR/ SI
All the vaccines covered under OVP can be used
up to 4 weeks if meeting OVP norms
2
HWC -SC maintain tracking bag/ tickler box Counter foil are updated & utilized for follow up
SI/RR
2
Check Vaccinator is aware of different 1. Ask the staff to enumerate categories or
categories of AEFI whether he/she can differentiate between
minor & severe AEFI.
2. The case definition list of severe/serious AEFI SI/RR
is available with provider
2
Check person responsible for notifying & Ask the staff regarding the responsibility for
reporting of the AEFI is identified notifying and reporting the AEFI SI/RR
2
 Process of reporting and route is Ask staff to whom the cases are reported & how
communicated to all concerned SI/RR
2
Reporting of AEFI cases is ensured by ANM 1.Verify weekly report of AEFI cases.
2.Nil reporting in case of no AEFI case. RR
3. Verify HMIS report of previous months
2
Frontline workers & Health supervisor is Verify with current AEFI guidelines
aware of his/her roles & responsibility for SI/RR
AEFI surveillance Programme
2
Vaccinator is aware about how to prevent Ask vaccinator how to prevent immunization
immunization error related reactions related reactions from occurring SI
2
Primary healthcare team communicate the Observe the session interaction/ interview the
OB/CI
benefits of RI at VHND sessions beneficiaries 2
Assessment for identification of ARI, ARI: Chest indrawing difficulty in
diarrhoea, malnutrition and Other Illness breathing ,coughing, fever, fast breathing
Management of children for Malnutrition: Weakness/wasting, check weight
ME E13.3 ARI, diarrhoea, malnutrition for age, check height for weight SI/RR
and other illness Diarrhoea: Sunken eyes, lethargic, unconscious,
restless, irritable, pinch skin
2
Assessment for identification of possible Young infant- Not able to feed or convulsion or
serious bacterial infections among young fast breathing >60/ min or severe chest
infant (0-59 days) & children (2 -59 months) indrawing or axillary temp 37.5 OC or more or
movement only when stimulated
Children - General danger signs, or chest
indrawing - very severe or severe pneumonia SI/RR
Fast breathing - RR -2-11month >or equal
50/min
12-59 months> or equal 40/min- Pneumonia

2
Management of diarrhoea is done as per ORS, Zn, Lot of fluids, & treatment with
protocols Cotrimoxazole. Counselling and referral if SI/RR
required
2
Management of ARI is done as per protocols
Symptomatic treatment, Paracetamol for fever,
plenty of fluids, keep child & give normal diet . SI/RR
Counselling & referral if required 2
 Management of Possible serious bacterial
infection as per protocols
(1) Give first dose of oral Amoxicillin and
injectable Gentamycin.
(2) Treat or prevent low sugar (breastfeed/ age SI/RR
appropriate feed)
(3) Warm the young infant if temp is less than
35.5 OC.
(4) Advise mother to keep young infant warm &
refer urgently to hospital 2
Management of Malnutrition is done as per
protocols CI/ SI
Counselling for nutrition & referral 2
Screening, referral and follow up of children
for anomalies, disabilities and developmental Functional linkage with RBSK team, referral & RR/SI
delays follow up 2
Standard
The facility has established procedures for family planning as per government guidelines and law.
E14
The client is given full information about Importance of FP, Options available- ( limiting &
family planning methods spacing method), time for initiation &
Family planning counselling advantages of various available methods. For
ME E14.1 services are provided as per Limiting method -counselled & referred to SI/RR
guidelines higher centre
2
Staff is aware of Method specific counselling
approaches BRAIDED Approach: Benefits of method, risk,
consequence of failure, alternatives, inquiries,
SI/CI
decision to withdraw, explanation of method
chosen & document of session
2
Care seeker is counselled about Such as risks, advantages, and possible side
contraindications & adverse events of chosen effects of OCPs/ECP/ Injectable/IUCD/ cent
FP methods chroman , what to do if dose of contraceptive is CI/SI
missed, method of administration of ECP.
2
1.Nayi Pahel Kit, Saas Bahu Samelan, Saarthi.
2. Give full compliance if facility is not covered
under MPV but undertake promotional
CI/ RR
Promotional activities for Family Planning are activities.
provided at facility under Mission Parivar
Vikas 2
The facility provides spacing Staff is aware of case selection criteria for 15-49 yrs., married
ME E14.2 methods for family planning as family planning methods SI/RR
per guidelines 2
 Staff is aware of options, indications & (1) Hormonal (Combined oral pill) ,Non
methods for administration for Oral Hormonal (Chaya) & Emergency Contraceptives.
Contraceptives (2) Combined oral Pill taken at fixed time daily
ECP_ within 72hrs, second dose 12hrs after first
dose
Centchroman: to be taken twice a week for the
first 3 months followed by once a week
thereafter.
Check for Chhaya/Centchroman eligibility is
checked & confirmed by MO. Dose may be SI/ RR
started by trained HCW

2
IUD insertion & follow up is done as per
standard protocol No touch technique, Speculum and bimanual
examination, sounding of uterus and placement.
Follow up : when to return / removal of IUCD. SI/ RR
Check In case of 2nd trimester abortion IUCD is
provided by Qualified Medical officer
2
Injectable Contraceptives are given as per Check the eligibility for injectables are checked
protocols & confirmed by MO. Dose may be started/
continue by trained HCW. Depot MPA can be
given IM or Subcutaneous, SI/ RR
IM: single dose vial with disposal syringe &
needle. Subcutaneous: Pre filled AD syringe
2
The facility provides limiting Staff is aware of case selection criteria for For sterilization: 22-49 yrs.- (female) & 22-60yrs
methods for family planning as limiting mentors (male), married, youngest child is at least one
per guidelines year & spouse has not opted for sterilization.
ME E14.3 Counselled & referred to Higher centre SI/ RR

2
HCW is supporting & encouraging the clients
for post sterilization follow up
Check adherence to GoI guidelines
Female Sterilization: Certification is issued one
month after the surgery or after the first
menstrual period, whichever is earlier. SI/ RR
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 sperm after 3
months. (A 2
Standard
The facility provides Adolescent Reproductive and Sexual Health services as per guidelines.
E15
Provision of education & counselling services
for adolescent
The facility provides promotive,
ME E15.1 preventive & curative service Nutritional Counselling, advice on topic related CI/ SI
for adolescent to Growth and development, puberty, myths &
misconception, pregnancy, safe sex, menstrual
disorders,anemia, sexual abuse ,RTI/STI's etc. 2
Services for treatment & referral of common
RTI/STI's, Nutritional Anaemia & Menstrual
disorders Haemoglobin estimation, weekly IFA tablet, and RR/ CI
treatment for worm infestation, Symptomatic
treatment , counselling , TT at 10 and 16 year.
Referral linkages to ICTC and PPTCT 2
Standard
The facility has established procedures for Antenatal care as per guidelines
E16
There is an established Facility provides and updates “Mother and Check Mother & Child Protection cards have
ME E16.1 procedure for registration and Child Protection Card” been provided for each pregnant women at RR/ CI 2
follow up of pregnant women. time of 1st registration/ First ANC
Facility ensures early registration & line Check ANC records for ensuring that majority of
listing of high risk ANC cases ANC registration is taking place within 12 week RR/SI 2
of pregnancy in ANC register
Clinical information & records of ANC is kept Check, if there is a system of keeping copy of
with HWC ANC information like LMP, EDD, Lab
Investigation Findings , Examination findings etc.
with them. Records of each ANC check-up is RR/SI 2
maintained in ANC register

Staff has knowledge of calculating expected Check with staff the expected pregnancies in her
pregnancies in the area area / how to calculate it.(Birth Rate X
Population/1000 Add 10% as correction factor SI/RR 2
(Still Birth)

Tracking of Missed and left out ANC 1.Check with ANM how she tracks missed out
ANC. Use of MCTS by generating work plan and
follow-up with ASHA, AWW etc.
2. Check if there is practice of recording Mobile SI/RR 2
no. of clients/next to kin for follow up
 All pregnant women get ANC check-up as per 1.Ask staff about schedule of 4 ANC Visits
recommended schedule (1st - < 12 Weeks
2nd - < 26 weeks
3rd - < 34 weeks
4th >34 to term)
2.Check ANC register whether all 4 ANC covered
for most of the women (sample cases).
3.At least one ANC visit is attended by Medical SI/RR 2
Officer (Preferably 3rd Visit -28-34 Weeks)

At ANC clinic, Pregnancy is confirmed by Check for ANC record that pregnancy has been
There is an established performing urine test confirmed by using pregnancy test Kit (Nischay
procedure for History taking, Kit)
ME E16.2 Physical examination, and SI/RR 2
counselling of each antenatal
woman, visiting the facility.
Last menstrual period (LMP) is recorded and Check how staff confirms EDD & LMP, (EDD =
Expected date of Delivery (EDD) is calculated Date of LMP+9 Months+7 Days) How she
on first visit estimates if Pregnant women is unable to recall
first day of last menstrual cycle ('Quickening', SI/RR 2
Fundal Height) .Check ANC records that it has
been written

Comprehensive Obstetric history is recorded

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

Physical Examination & vitals of Pregnant Pulse, Respiratory Rate , Pallor, Oedema.
Women is done on every ANC visit Height, weight & BP- Check any 3 ANC records/
MCP card randomly to see that weight has been
measured and recorded at every ANC visit
Observation and Correction of Flat or Inverted
Nipples RR 2
Palpation for any Lumps or Tenderness
 Abdominal Examination is done as per Measurement of Fundal Height (ask staff how
protocol she correspond fundal high with Gestational
Age), Auscultation for foetal heart sound ,
Palpation for Foetal lie and Presentation Check SI/RR 2
for findings recorded in MCPcard/ANC Records

The facility ensures of drugs & 1.Check for Haemoglobin, confirmation of

ME E16.3 diagnostics are prescribed as pregnancy, urine albumin & sugar blood, blood SI/ RR 2
per protocol sugar, Malaria. Check randomly any 3 MCP card/
ANC record for Haemoglobin test is done at
every ANC visit and values are recorded.
2. Haemoglobin & urine albumin & sugar test is
Diagnostic test for every pregnant women done on every ANC visit
Referral is done for the remaining ANC SI/ RR 2
diagnostics Such as blood group and Rh factor, Hepatitis B
Tetanus Toxoid (2 Dosages/ Booster) have Check randomly any 3 ANC records for
been during ANC visits confirming that TT1 (at the time of registration)
and TT2 (one month after TT1) has been given
to Primi gravida & Booster dose for women SI/ RR 2
getting pregnant within three years of previous
pregnancy

Staff can recognize the cases, which would Anaemia, Bad obstetric history, CPD, PIH, APH,
There is an established need referral to higher centre(FRU) Medical Disorder complicating pregnancy,
procedure for identification of Malpresentation, foetal distress, PROM,
ME E16.4 SI/ RR 2
High risk pregnancy and obstructed labour.
appropriate & timely referral.
Staff is competent to identify Hypertension / Hypertension & Pre Eclampsia
Pregnancy Induced Hypertension (Hypertension - Two consecutive reading taken
four hours apart shows Systolic BP >140 mmHg
and/or Diastolic BP > 90 mmHg SI/ RR 2

Staff is competent to identify Pre-Eclampsia Pre - Eclampsia- High BP with Urine Albumin
(+2)
Imminent eclampsia -BP >140/90 with positive
albumin 2++, severe headache, Blurring of SI/ RR 2
vision, epigastria pain & oliguria in Urine
 Staff is competent to identify high risk cases Identification and referral of cases with
based on Abdominal examination Cephalo-pelvic presentation, Malpresentation,
medical disorder complicating pregnancy, IUFD,
amniotic fluid abnormalities. SI/ RR 2

Staff is competent to classify anaemia >11 gm% -Absence of Anaemia,10 to 11 gm%

according to Haemoglobin Level mild,
7-10 gm% Moderate Anaemia SI/ RR 2
<7 gm% Severe Anaemia

Line listing of pregnant women with Check the records whether Line-listing of
moderate and severe anaemia severely anaemic women are maintained at the SI/ RR 2
HWC
Staff is aware of prophylactic & Therapeutic 1. Prophylactic - one IFA tablet per day for six
dose of IFA & progress is monitored months during ANC &PNC. 2.Therapeutic dose-
double the dose in case of anaemia. 3.
Improvement in haemoglobin label is SI/ RR 2
continuously monitored and recorded

Pregnant women is counselled for planning Registration, Identification of institution as per

Counselling of pregnant women and preparation for birth clinical condition
ME E16.5 is done as per standard CI/SI 2
protocol and gestational age

Pregnant women is counselled recognize Swelling (oedema), bleeding even spotting,

danger signs during pregnancy blurred vision, headache, pain abdomen,
vomiting, pyrexia, watery & foul smelling CI/ SI 2
discharge & Yellow urine

Pregnant women is counselled to recognize A bloody, sticky discharge (Show) and regular
sign of labour & arrange for referral painful uterine contractions. Contact number of SI/ CI 2
transport the ambulance is communicated
 Pregnant women is counselled diet, rest, 1.Increase Dietary Intake
breast feeding & family planning Diet rich in proteins, iron, vitamin A, vitamin C,
calcium and other essential micronutrients.
Initiate breastfeeding especially colostrum
feeding within an hour of birth.
2.Do not give any pre-lacteal feeds. (Sugar,
water, Honey)
3. Ensure good attachment of the baby to the
breast.
4.Exclusively breastfeed the baby for six
months.
5. Breastfeed the baby whenever he/she SI/ CI 2
demands milk.
6. Follow the practice of rooming in. Different
Options available including
IUCD, PPIUCD, vasectomy, long acting
injectable, etc.

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

2 SC type B
Management of 2nd stage of labour: 1. Ensures 'six cleans' are followed during
delivery
2. Clean hands, Clean Surface, clean blade, clean
cord tie, clean towel & clean cloth to wrap
mother .
3. Allows the spontaneous delivery of head , SI/ RR
gives Perineal support and assist in delivering
baby. Check progress is recorded on partograph

2 SC type B
 Check no unnecessary episiotomy and Check with records/ interview with staff if they
unnecessary augmentation and induction are still practicing routine episiotomy & check
labour is done using uterotonic drugs uterotonics such as oxytocin and misoprostol is
not used for routine induction normal labour
unless clear medical indication and the expected SI/ RR
benefits outweigh the potential harms

2 SC type B
Active Management of Third stage of labour Palpation of mother's abdomen to rule out
presence of second baby, use of uterotonic
drugs, Controlled cord traction during
contraction, uterine massage & Checks SI/RR
placenta & membranes for completeness
2 SC type B
Staff is aware of route, doses and time of Administration of 10 IU of oxytocin IM with in 1
Uterotonic Drugs minute of Birth RR/ SI
2 SC type B
Facility staff adheres to Wipes the baby with a clean pre-warmed Check staff competence through demonstration
standard procedures for towel and wraps baby in second pre-warmed or case observation. Also Check recording for
routine care of new-born towel; date, Time of Birth & Weight of new born
ME E17.2 immediately after birth and SI/ RR
new born resuscitation
2 SC type B
Performs delayed cord clamping and cutting Check staff competence through demonstration
(1-3 min) & Initiates breast-feeding soon or case observation OB/ SI
after birth
2 SC type B
Records birth weight and gives injection Check staff competence through demonstration
vitamin K or case observation SI/ RR
2 SC type B
New born Resuscitation Check staff competence through demonstration
Resuscitation Technique SI/ OB
2 SC type B
There is established procedure Staff is aware of Indications for reffering Ask staff how they identify slow progress of
for management/Referral of patient for to higher centre labour , How they interpret Partogram
Obstetrics Emergencies as per
ME E17.3 scope of services. SI/ RR

2 SC type B
 Initial Management of Eclampsia \Pre Ask staff about how they manage eclampsia
Eclampsia cases 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

2 SC type B
Post Partum Haemorrhage Ask staff how they manage pots partum
haemorrhage
Assessment of bleeding (PPH if >500 ml or > 1
pad soaked in 5 Minutes. IV Fluid, bladder
catheterization, measurement of urine output,
Administration of 20 IU of Oxytocin in 1L NS/RL SI/ RR
60 drops per minute . Refer the patient

2 SC type B
Standard
The facility has established procedure for post natal Care
E18
Post partum Care is provided to Mother is monitored as per post natal care Check for records of Uterine contraction,
the mothers guideline bleeding, temperature, B.P, pulse, Breast
ME E18.1 examination, (Nipple care, milk initiation). Check RR/ SI
for perineal wash is performed
2
Danger signs :Excessive PV bleeding, breathing
There is a established difficulty, convulsion, severe headache,
procedures for Postnatal visits abdominal pain, foul smelling lochia, urine
ME E18.2 dribbling, perineal pain, painful & redness of SI/ RR
& counselling of Mother and Check Mother is educated & counselled
Child about danger signs during puerperium & breast.
during postnatal visit 2
Area of Concern F: Infection Control
Standard
The facility has established program for infection prevention and control
F1
Staff is working as team to improve Person is identified to supervise the sanitation
sanitation & hygiene of the facility ald hygiene of HWC and its surrounding area.
Facility ensures that staff is Check staff is aware of their roles and
ME F1.1 working as team and monitor responsibilities in terms of sanitation & hygiene. SI/ RR
the infection control practices
2
 Check Records of Medical Check-up and All staff undergo medical Check-up at least
Immunization once in year and immunization with at least RR
Hepatitis B and TT
2
Facility has a system to monitor cleanliness Regular monitoring of cleanliness & hygiene
& hygiene practices OB/ RR
2
Standard
The facility has defined and Implemented procedures for ensuring hand hygiene practices
F2
Washbasin with functional drainage pipe, tap,
Hand Hygiene facilities are running water, Soap (Soap bar/liquid), AHR,
provided at point of use & Display of hand washing poster (Pictorial- Local
ME F2.1 Availability of Hand washing facilities OB
ensures adherence to standard language)
practices
2
Check Washbasin, tap & running water as Check washbasin is wide and deep enough to
per standard protocols prevent splashing and retention of water.
Check for availability of elbow operated tap
adequate running water through piped water OB/ SI
distribution system.
2
Check availability of Soap and Alcohol Hand
rub for outreach OB
2
Demonstration and random observation (Five
Staff is trained and adheres to hand washing Moments of handwashing , Six Steps of Hand
SI/ OB
practices washing )
2
Standard
The facility ensures standard practices and equipment for personal protection
F3
Check availability & use of PPE (1) Check adequate required gloves, mask &
The facility ensures availability apron etc is available & used
of personal protection (2) Check Disposable Gloves, Cap, Mask are not
ME F3.1 equipment and ensures reused, OB/ RR
adherence to standard (3) Check records for continuity of supply.
practices
2
Compliance to correct method of wearing Staff is aware of method of donning and doffing
and removing PPE the PPE SI/ OB
2
Availability & adherence to Personal
protective kit for infectious patients/ HIV pts. SI/ RR
2
Standard
The facility has standard procedures for disinfection and sterilization of equipment and instruments.
F4
 Adequate supply of decontamination and Check records of indent & Utilization
cleaning agents at the point of use
The facility ensures availability
of material and adherence to
Standard Practices for
ME F4.1 RR/ OB
decontamination and cleaning
of instruments and followed by
procedure/ patient care areas.
2
Staff is trained for the decontamination and Ask whether staff know how to make chlorine
cleaning procedure solution OB/SI
2
Decontamination and cleaning of Observe staff about the decontamination of
instruments and surfaces instruments is done with 0.5% of chlorine
solution for 10 min. Check instrument are
cleaned thoroughly with soap or detergent and SI/ OB
water. Ask staff when & how they clean the
surfaces
2
Availability of disinfectants Ethyl alcohol 70% , Bleaching Powder/ hypo
The facility ensures standard chloride solution containing not less than 30%
practices and materials for w/w of available chlorine.
ME F4.2 Check availability of boiler / sterilisers RR/ OB
disinfection and sterilization of
instruments and equipment
2
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 SI/ RR
visible contamination & disinfected
2
Sterilization/HLD records are maintained To ensure the status of sterilized/HLD
instruments, equipment & materials etc RR/SI
2
Standard
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
F5
Availability of colour coded bins and non (1)Availability of bins and non chlorinated
chlorinated plastic bags and needle cutters plastic bag, Covered and Foot operated bins
The facility ensures segregation at point of waste generation with Display of Bio Hazard sign.
ME F5.1 and storage of Bio Medical (2) Availability of needle/hub cutter & puncture OB/ SI
Waste as per guidelines proof boxes
(3)Check the adequacy of supply
2
 Segregation of BMW is done as per latest
prevalent rules

Segregation of BMW rules:

Yellow - Human Anatomical waste, Items
contaminated with blood, body fluids, dressings,
cotton swabs and bags containing residual or
discarded components. etc.
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 OB/ SI
(translucent) Puncture proof, Leak proof,
temper proof containers :Needles, syringes with
fixed needles, needles 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
2
Check there is no mixing of the Biomedical &
general waste OB
2
Display of work instructions for segregation Pictorial and in local language;
OB
2
HWC has designated area for storage for (1) BMW is not stored for more than 48 hours
BMW (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 OB/ SI
sign at the point of use.

2
The facility ensures Disinfection of broken / discarded Glassware Check if such waste is pre treated with 1-2% of
ME F5.2 management of sharps as per is done as per recommended procedure Sodium Hypo chloride (having 30% of residual OB/ SI
guidelines chlorine) for 20 min
2
Sharp waste is stored in puncture proof Check availability of puncture, leak and temper
OB/ SI
container proof container at point of use 2
Availability of post exposure prophylaxis and Check staff is aware of what to do in case of
staff is aware what to do in such condition sharp injury, Whom to report. See if any
reporting has been done and treatment SI/ RR
provided
2
 The facility ensures Facility has provision for liquid waste Liquid waste is made safe before mixing with
ME F5.3 management of hazardous & management other waste. On site provision liquid waste OB/ SI
general waste disinfection set up
2
Check facility is mercury free Give partial compliance if staff know how to
manage mercury spill & mercury spill kit is SI/ OB
available
2
Disposal of general waste Mechanism for removal of general waste from
facility & its disposal OB/ RR
2
The facility ensures HWC waste is collected & transported in Check the functional linkage/records with
ME F5.4 transportation & disposal of close container/bag CBWTF operator or has pre approved functional RR
waste as per guidelines deep burial
2
HWC has facility for disposal of Biomedical HWC have valid contract with CTF for disposal of
waste BMW waste/ else facility should have deep
burial pit and sharp pit within premises of
Health facility. Such deep burial pit should have RR/ OB
prior approval from prescribed authority &
meet the specified norms
2
Facility manages recyclable waste as per Facility hand over the plastic waste to registered
approved procedure vendor through BPHC /CHC SI/ RR
2
No burning of any category of waste
within/outside HWC OB
2
Area of Concern G: Quality Management
Standard
The facility has established organizational framework for quality improvement.
G1
The HWC has Quality team in place (1) CHO, ANM/Staff nurse, MPW & ASHA.
(2) Team members are aware of their respective
responsibilities and roles viz. ensure cleaniness,
The facility has a quality hygiene and infection control practices are
improvement team and it followed, internal audits are conducted,
ME G1.1 feedback from stakeholders are taken etc RR/ SI
review its quality activities at
periodic intervals

2
Quality team meets monthly and review its Check the records/ Minutes of meetings
activities RR
2
HWC reviews performance of its indicators RR 2
Review & update work plan as per
requirement RR
2
Identify the issues needed to be addressed at
PHC review meeting RR/SI
2
 Results of Kayakalp and NQAS Internal Gaps are identified
/External assessments are reviewed RR
2
Progress on time bound action plan is Resolutions of meeting is effectively
reviewed communicated RR/ SI
2
Standard
The facility has established system for patient and employee satisfaction
G2
Client satisfaction survey is done (1) On defined intervals for patient or their 2
attendant visiting HWC & Client visiting Health
campaigns, VHNDs, PSGs etc.
(2) Check Valid Sample size is taken (3) Check
The facility ensures mechanism format is in local language or easy to
ME G2.1 for conducting patient understand (4) Sample having representation RR/SI
satisfaction survey from all sections (age, gender, cast, religion etc)

Analysis of low performing attributes is done Client satisfaction survey results are analysed 2
and lowest performing attributes are identified RR
and action plan is prepared.
Actions are taken on lowest performing 2
factors RR

Standard
The facility has established, documented, implemented and updated Standard Operating Procedures for all key processes and support services.
G3
Updated work instructions for Check it covers details of process of testing, 2
MEG3.1 all key clinical processes are Instructions for using RDK are available control & interpretation. (As per Service RR/ SI
available mandate)
Work instruction for RMNCHA services RR 2
Protocols and instructions for preventing, Verify protocols are displayed at session sites 2
identifying and managing AEFI are displayed OB/RR
at immunization site
WI for screening, management and HT, Diabetes Oral, cervical and breast cancer. 2
appropriate referral of NCDs Screening using acetyl salicylic acid. RR
WI for screening, management and Malaria , dengue, TB, Leprosy, HIV-AIDS and 2
appropriate referral of Communicable Hepatitis RR
disease
WI for screening and referral of patients with 2
mental disorders RR
WI for screening of common ophthalmic 2
problems RR
WI for screening of ENT problems RR 2
WI for screening of common oral problems 2
RR
 WI for screening of common elderly & 2
palliative care RR
WI for management of emergency medical 2
services RR
WI for infection prevention & Bio medical 2
waste management RR
Work instruction for conducting the Normal Simplified Partograph; First aid management in 2 SC Type B
vaginal delivery case of PPH, sepsis, eclampsia and RMC RR
Work instruction for management of new Essential new born care, New born Asphyxia 2 SC Type B
born management , assessment for identification of RR
danger sign.

Check with staff if they are well versed with the 2

WI are updated as per current practices RR
Work Instructions
Standard
The facility has established system of periodic review of clinical, support and quality management processes
G4
Service delivery and performance of HWC is Through monthly visits by MO PHC
Handholding support and reviewed regularly
supervision is provided to HWC
ME G4.1 SI/ RR
by PHC, block/ district/state
teams
2
HWC performance is reviewed regularly by Quarterly -By Block nodal officer, Bi Annual - by
block/district/state nodal officer District Nodal officer RR
2
Check gaps have been identified and actions Check number gaps closed as per last quarter
are taken report RR
2
The facility conducts periodic Periodic assessment using NQAS checklist At least once in six months
ME G4.2 RR
internal assessment 2
Periodic assessment using Kayakalp checklist Quarterly
RR
2
Non Compliance found in the internal Check gaps are identified and time bound action
The facility ensures non Assessment using NQAS, Kayakalp and other plan is prepared
compliances are recorded monitoring checklists are recorded
adequately and action plan is
ME G4.3 made on the gaps found in the RR
assessment/review process
using quality improvement
methods
2
Root cause analysis is done Using brainstorming, Fishbone analysis or why-
why analysis RR/ SI
2
HWC team improve on the identified non Using PDCA approach
compliances & action are taken RR/ SI
2
Standard
Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve them.
G5
 Quality policy are defined Staff is aware of Quality Policy.
The facility has defined Quality Quality Policy is displayed in local language
ME G5.1 RR
policy and quality objectives
2
Quality objectives are defined for the HWC Check whether the objectives are SMART and in
sync with the Quality Policy RR
2
There is system for monitoring of
performance toward quality objectives RR/ SI
2
Area of Concern H: Outcome
Standard
The facility measures productivity indicators
H1
The facility measures No. of OPD Cases per month Case specific OPD of pregnant mothers,
ME H1.1 productivity indicators services neonate, infant, children, adolescent, FP and RR
on monthly basis CD
2
No. of follow up cases (repeat visit) per Case specific OPD of pregnant mothers,
month neonate, infant, children, adolescent, FP and RR
CD
2
No. of cases referred to higher centre per Case specific referral of pregnant mothers,
month neonate, infant, children, adolescent, FP and RR
CD
2
No. of Normal deliveries conducted RR 2 Type B SC
As per Service package i.e. NCD (Hypertension,
No. of Case specific OPD per month( as per Diabetes & cancer), Eye, ENT, Oral Health,
RR
defined service package) elderly, palliative, Medical Emergency & Mental
Health etc
2
No. of cases referred to higher centre per
month As per Service package i.e. NCD (Hypertension,
Diabetes & cancer), Eye, ENT, Oral Health,
RR
elderly, palliative, Medical Emergency & Mental
Health etc
2
As per Service package i.e. NCD (Hypertension,
Diabetes & cancer), Eye, ENT, Oral Health,
No. of case specific follow up per month RR
elderly, palliative, Medical Emergency & Mental
Health etc
2
As per Service package i.e. NCD (Hypertension,
No. of drop out rate cases following Diabetes & cancer), Eye, ENT, Oral Health,
RR
identification (as per service Package) elderly, palliative, Medical Emergency & Mental
Health etc
2
Standard
The facility measures efficiency indicators.
H2
 The facility measures efficiency
ME H2.1 Percentage of women receiving all four ANCs RR
indicators on monthly basis
2
Drop out rate for Pentavalent immunization RR
2
Drop out rate for NCDs RR 2
No. of stock out days of essential medicines As per Service package RR
2
No. of stock out days of essential diagnostic
As per Service package RR
test 2
No. of Yoga session conducted in month RR 2
No of VHNDs conducted (for vulnerable
RR
population) 2
Standard
The facility measures clinical care indicators.
H3
The facility measures clinical
No. of high risk pregnancy identified during
ME H3.1 care indicators on monthly RR
ANC
basis 2
No. of AEFI cases reported RR 2
No. of Children with diarrhoea treated with
RR
ORS & Zn 2
Contraceptives acceptance rate RR 2
No. of Anaemia cases treated successfully RR 2
Treatment completion rate for Tuberculosis RR
2
Percentage of cases on treatment achieved
RR
blood pressure control 2
Percentage of cases on treatment achieved
RR
blood sugar control 2
Percentage of cases screened positive for
RR
cancer underwent biopsy 2
Percentage of cancer cases underwent
RR
treatment for each cancer 2
Standard
The facility measures service quiality indicators
H4
Client Satisfaction Score (Patients) Sum of average satisfaction score of each
respondent
The facility measures service (Average satisfaction score = sum total of scores
ME H4.1 quality indicators on monthly of attributes/number of total attributes) RR
basis
2
Client Satisfaction Score (Community) Sum of average satisfaction score of each
respondent
(Average satisfaction score = sum total of scores
of attributes/number of total attributes) RR

2
Percentage of chronic cases who started
treatment at PHC/above are still under As per service package RR
treatment for last 3 months 2