Professional Documents
Culture Documents
NEW Taluka Level Customized Checklist 3.01.18
NEW Taluka Level Customized Checklist 3.01.18
DEPARTMENT WISE
Emergency NBSU Radiology General/Admin
50.0 50.0 50.0 50.0
Operation Pharmacy &
OPD Theater Store Hospital
50.0 50.0 50.0
Score
Blood Storage
Labour Room Laboratory Unit
50.0 50.0 50.0 50.00
IPD Auxiliary PP Unit
50.0 50.0 50.0
50%
Clinical Services Infection Control Quality Management Outcome
50%
50%
50%
mmes /State 50%
50%
eds. 50%
ty about available
50%
nd cultural needs,
50%
ialastatus.
as system for
s about the medical 50%
med decision 50%
there is financial
50%
es 50%
es 50%
es 50%
hild as per 50%
as per government 50%
as per guidelines 50%
h State/National 50%
onal Benchmarks 50%
State/National 50%
State/National 50%
National Quality Assurance Standards for Taluka Hospital 0 1 2
Checklist for Accident & Emergency 1
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
. Area of Concern - A Service Provision 16 32
Standard A1. Facility Provides Curative Services 8 16
ME A1.1. The facility provides General Facility for managing medical 1 SI/OB Dengue Haemorrhagic fever,
Medicine services emergency cases Cerebral Malaria, Poisoning, Snake
Bite, Congestive Heart Failure,
Pneumonia, Acute Respiratory
conditions, Status Epilepticus,
Status Asthamaticus, Acute
Gastroenteritis, Severe drug
reactions.
ME A1.2. The facility provides General Availability of Emergency 1 SI/OB RTA, Lacerated wound, foreign
Surgery services Management of acute Surgical body in Ear/nose, Acute Abdomen
Condition Pain, Strangulated Hernia, Pyocele,
Renal Colic & Fracture
ME A1.3. The facility provides Obstetrics & Availability of Emergency Obstetrics 1 SI/OB APH, PPH, Eclampsia , Obstructed
Gynaecology Services &Gynaecology Procedures Labour, Septic Abortion,
Emergency Contraceptives
ME A1.4. The facility provides paediatric Availability of emergency Paediatric 1 SI/OB ARI, Diarrhoeal Diseases,
services procedures Hypothermia, PEM,resuscitation,
Convulsions/Seizurs
ME A1.8 The facility provides services for Availability of Dressing room facility 1 SI/OB Drainage, dressing, suturing
OPD procedures
. Availability of injection room 1 SI/OB Injection room facility with ARV,
facilities ASV and emergency drugs
ME A1.9. Services are available for the 24X7 availability of dedicated 1 SI/RR Check for emergency register
time period as mandated emergency Services
ME A1.10. The facility provides Accident & Availability of Emergency 1 SI/OB CPR, Mobilization, Intubations,
Emergency Services procedures Tracheotomy, Cervical
immobilisation Mechanical
Ventilation
Standard B3. The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 5 10
ME B3.1. Adequate visual privacy is Screens and curtains are provided at 1 OB At the examination and procedure
provided at every point of care emergency area.
ME B3.3. The facility ensures the Behaviour of staff is empathetic and 1 OB/PI
behaviours of staff is dignified courteous
and respectful, while delivering
the services
ME B3.4. The facility ensures privacy and Privacy and confidentiality of HIV, 1 SI/OB
confidentiality to every patient, Rape, suicidal cases, domestic
especially of those conditions violence and psychotic cases are
having social stigma, and also maintained
safeguards vulnerable groups
Standard B4. The facility has defined and established procedures for informing patients about the medical condition, and involving them in 5 10
ME B4.1. There is established proceduresConsent treatment planning, and facilitates
is taken for invasive 1 informed decision
SI/RR making
Lumbar Puncture, Catheterization,
for taking informed consent emergency procedures PR & PV Examination
before treatment and
procedures
ME B4.3. Staff are aware of Patients rights Staff is aware of patient rights and 1 SI
responsibilities responsibilities
ME B4.4. Information about the treatment Patient/ attendant is informed about 1 PI Ask patients about what they have
is shared with patients or her clinical condition and treatment been communicated about the
attendants, regularly been provided treatment plan
ME B4.5. The facility has defined and Availability of complaint box and 1 OB Check for complaint register &
established grievance redressal display of process for grievance MOM of grievance redressal
system in place redressal and whom to contact is meeting
displayed
Standard B5. The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost of hospital 3 6
ME B5.1 The facility provides cashlessEmergency services are free for services.
1 PI/SI
services to pregnant women, pregnant woman, neonate, children
mothers and neonates as per and BPL patients as per Government
prevalent government schemes order/Scheme
ME B5.2. The facility ensures that drugs Check that parents & attendant's 1 PI/SI
prescribed are available at have not spent money on
Pharmacy and wards purchasing drugs and consumables
from outside.
ME B5.3. It is ensured that facilities for the Check that parents & attendants 1 PI/SI
prescribed investigations are have not spent money on
available at the facility diagnostics from outside.
. Dedicated Minor OT 1 OB
. Shaded porch for ambulance 1 OB
. Availability of clean and dirty utility 1
room
ME C1.4. The facility has adequate Corridors at Emergency are broad 1 OB 2-3 meter
circulation area and open spaces enough for easy moment of
according to need and local law stretcher and trolley
ME C1.6. Service counters are available as Availability of emergency beds as 1 OB At least 4 beds.
per patient load per expected load
ME C1.7. The facility and departments are Unidirectional flow of services. 1 OB Receiving/Triage-Resuscitation-
planned to ensure structure observation beds- Procedures area.
follows the function/processes There is no criss cross
(Structure commensurate with
the function of the hospital)
. Separate entrance for emergency 1 OB
department
Emergency is located near to the 1 OB
entrance of the hospital
Standard C2. The facility ensures the physical safety including Fire safety of the infrastructure. 8 16
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and furniture like
safety of the infrastructure properly secured cupboards, cabinets, and heavy
equipment , hanging objects are
properly fastened and secured
ME C2.5 The facility has adequate fire Emergency has installed fire 1 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.
ME C2.6 The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and what
conducts mock drills regularly for to do in case of fire
fire and other disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 14 28
ME C3.2. The facility has adequate general Availability of at least one Doctor 1 OB/RR
duty doctors as per service 24x7
provision and work load
ME C3.3. The facility has adequate nursing Availability of trained Nursing staff 1 OB/RR/SI
staff as per service provision and
work load
ME C3.4. The facility has adequate Availability of dresser /paramedic 1 OB/SI
technicians/paramedics as per
requirement
ME C3.5 The facility has adequate support Availability of Drivers for Ambulance 1 SI/RR Driver may be on call for
/ general staff 24X7 emergency.
ME C3.6 The staff has been provided Triage and Mass Casualty 1 SI/RR
required training / skill sets Management
. Basic life support (BLS)/ Advance life 1 SI/RR
support (ALS)
Care of unconscious patient 1
. Bio Medical waste Management 1 SI/RR
. Infection control and hand hygiene 1 SI/RR
Patient Safety 1
ME C3.7 The Staff is skilled as per job The Staff is skilled for emergency 1 SI/RR
description procedures
The Staff is skilled for resuscitation 1 SI/RR
and use defibrillator
Standard C5. The facility has equipment & instruments required for assured list of services. 12 24
ME C5.1. Availability of equipment & Availability of functional 1 OB BP apparatus, Multipara meter
instruments for examination & Equipment & Instruments for ,Torch, hammer , Spot Light
monitoring of patients examination & Monitoring ,Stethoscope, thermometer
. Availability of Monitoring 1 OB
equipment in ambulance
ME C5.2. Availability of equipment & Availability of dressing tray for 1 OB Artery forceps
instruments for treatment Emergency procedures
procedures, being undertaken in
the facility
ME C5.5. Availability of Equipment for Availability of equipment for 1 OB Refrigerator, Crash cart/Drug
Storage storage for drugs trolley, instrument trolley, dressing
trolley
ME D1.2. The facility has established All the measuring equipment/ 1 OB/ RR Thermometer, weighting scale, BP
procedure for internal and instrument are calibrated apperatus, suction machine,
external calibration of measuring oxygen flowmeter & meter gauze
Equipment
ME D1.3. Operating and maintenance Up to date instructions for operation 1 OB/SI Suction machine, Multipara
instructions are available with and maintenance of equipment are monitor , defibrillator.
the users of equipment readily available with staff.
Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 10 20
ME D2.3. The facility ensures proper Drugs are stored in 1 OB
storage of drugs and containers/tray/crash cart and are
consumables labelled
ME D2.6. There is a procedure for periodically There is procedure for replenishing 1 SI/RR
replenishing the drugs in patient drug tray emergency crash cart
care areas
ME D2.8. There is a procedure for secure Narcotics and psychotropic drugs are 1 OB/SI
storage of narcotic and kept in lock and key
psychotropic drugs
Standard D3. The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable environment 14 28
ME D3.2. Hospital infrastructure is Check for there is no seepage , 1 OB
adequately maintained Cracks, chipping of plaster
Window panes , doors and other 1 OB
fixtures are intact
Patients beds are intact and painted 1 OB
ME D3.9. The facility has security system in There are set procedures for 1 SI/OB See for linkage to police, Provision
place at patient care areas handling mass situation and violence for protection of staff
in emergency
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 5 10
ME D4.1. The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for potable water in all
functional areas
Standard D5. The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 2 4
ME D5.4 The facility has adequate sets of Clean Linen is provided on 1 OB/RR
linen observation beds
ME D5.5 The facility has established Linen is changed every day or 1 OB/RR
procedures for changing of linen whenever it get soiled
in patient care areas
Standard D8. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 2 4
ME D8.1. The facility has requisite licences Valid licences for ambulances & PVC 1 RR/SI
and certificates for operation of certificate are available
hospital and different activities
Standard D9. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 3 6
ME D9.1. The facility has established job Staff is aware of their roles and 1 SI
description as per govt responsibilities
guidelines
ME D9.2. The facility has a established There is procedure to ensure that 1 RR/SI Check for system for recording time
procedure for duty roster and staff is available on duty as per duty of reporting and relieving
deputation to different roster (Attendance register/ Biometrics
departments etc.)
ME D9.3. The facility ensures the Doctor, nursing staff and support 1 OB
adherence to dress code as staff adhere to their respective dress
mandated by its administration / code
the health department
Standard E2. The facility has defined and established procedures for clinical assessment and reassessment of the patients. 4 8
ME E2.1. There is established procedure Assessment criteria of different kind 1 SI/RR Use of standard criteria of
for initial assessment of patients of medical emergencies is defined assessment like Glasgow Comma
and practiced scale, Poly trauma, MI, Burn
patient, Paediatric patient, Pain
assessment criteria etc.
Standard E3. Facility has defined and established procedures for continuity of care of patient and referral 9 18
ME E3.1. Facility has established There is a procedure for hand over 1 SI/RR Check for how hand over is given
procedure for continuity of care for patient transfer from emergency from emergency to ward, ICU,
during interdepartmental to IPD /OT/LR SNCU etc.
transfer
ME E3.2. Facility provides appropriate Patient are referred with referral slips 1 SI/RR
referral linkages to the
patients/Services for transfer to
other/higher facilities to assure
their continuity of care.
. Availability of referral linkages with 1 SI/RR Check how patient are referred if
higher centres. services are not available
. Advance information is given to 1 SI/RR
higher centre
. Referral vehicle is arranged 1 SI/RR
. Referral in or referral out register is 1 RR
maintained
. Facility has functional referral 1 SI/RR
linkages to lower facilities
. Check for if there is any system of 1 RR Check for referral cards filled from
follow up lower facilities
Standard E4. The facility has defined and established procedures for nursing care 8 16
ME E4.1. Procedure for identification of There is a process for ensuring the 1 OB/SI Patient id band/ verbal
patients is established at the identification before any clinical confirmation/Bed no. etc.
facility procedure
ME E4.2. Procedure for ensuring timely and Treatment charts are maintained 1 RR Check for treatment chart are
accurate nursing care as per updated and drugs given are
treatment plan is established at the marked. Co relate it with drugs and
facility doses prescribed.
. There is a process to ensure the 1 SI/RR Verbal orders are rechecked before
accuracy of verbal/telephonic administration
orders
ME E4.3. There is established procedure Patient hand over is given during the 1 SI/RR
of patient hand over, whenever change in the shift
staff duty change happens
ME E5.2. The facility identifies high risk High risk medical emergencies are 1 OB/SI MI, Head injury, Spinal injury,
patients and ensure their care, as identified and treatment given on Abdominal injuries, fracture's.
per their need priority
Standard E6. Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational 4 8
ME E6.1. Facility ensured that drugs are Check for BHT/Case sheet/Case 1 RR
prescribed in generic name only paper if drugs are prescribed under
generic name only
ME E6.2. There is procedure of rational use Check for that relevant Standard 1 RR
of drugs Treatment Guideline are available at
point of use
Standard E7. Facility has defined procedures for safe drug administration 11 22
ME E7.1. There is process for identifying High alert drugs available in 1 SI/OB Electrolytes like Potassium
and cautious administration of department are identified chloride,opiods, Neuro muscular
high alert drugs blocking agent, Anti Thrombolytic
agent, Insulin, Warfarin, Heparin,
Adrenergic agonist etc.
Maximum dose of high alert drugs 1 SI/RR Value for maximum doses as per
are defined and communicated age, weight and diagnosis are
available with nursing station and
doctor
ME E7.3. There is a procedure to check Drugs are checked for expiry and 1 OB/SI Turbidity, Leakage, Colour change,
drug before administration/ other inconsistency before fungus.
dispensing administration
Check single dose vial are not used 1 OB Check for any open single dose vial
for more than one dose with left over content intended to
be used later on
ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ 1 SI/PI
administration Pharmacist /nurse about the
dosages and timings .
Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 8 16
ME E8.1. All the assessments, re- Assessment findings are written on 1 RR Day to day progress of patient is
assessment and investigations BHT/Case sheet/Case paper recorded in BHT/Case sheet/Case
are recorded and updated paper
ME E8.2. All treatment plan Treatment plan, first orders are 1 RR Treatment prescribed in nursing
prescription/orders are recorded written on BHT/Case sheet/Case records
in the patient records. paper
ME E8.3. Care provided to each patient is Maintenance of treatment 1 RR Treatment given is recorded in
recorded in the patient records chart/treatment registers treatment chat
ME E8.4. Procedures performed are Any procedure performed is written 1 RR CPR, Dressing, mobilization etc.
written on patients records on BHT/Case sheet/Case paper
ME E8.5. Adequate form and formats are Availability of form formats for 1 OB/SI MLC, Lab /X-ray requisition, death
available at point of use emergency certificate, Initial assessment
format, referral slip etc.
ME E8.6. Register/records are maintained Emergency Records are maintained 1 OB/RR Emergency register, death register,
as per guidelines MLC register, are maintained
Standard E10. The facility has defined and established procedures for Emergency Services and Disaster Management 25 50
ME E10.1. There is procedure for Receiving Emergency has implemented a 1 SI/OB As care provider how they triage
and triage of patients system of sorting the patients patient- immediate, delayed,
expectant, minimal, dead
ME E10.2. Emergency protocols are defined Emergency protocols are available at 1 OB See for protocols of head injury,
and implemented point of use snake bite, poisoning, drawing etc.
ME E10.5. There is procedure for handling Medico legal cases are identified by 1 RR/SI
medico legal cases patient records
. Treatment of MLC cases are not 1 SI/OB/RR
delayed because of police
proceedings
. There is a establish procedure for 1 SI/RR Discharge is not done before police
informing police, as per govt consent
guidelines
. Emergency has criteria for defining 1 SI/RR Criteria is defined based on cases
medico legal cases and when to do MLC
Standard E11. The facility has defined and established procedures of diagnostic services 2 4
ME E11.1. There are established Container is labelled properly after 1 OB
procedures for Pre-testing the sample collection
Activities
ME E11.3. There are established Nursing station is provided with the 1 SI/RR
procedures for Post-testing critical value of different tests
Activities
Standard E14. The facility has defined and established procedures of Operation theatre and surgical services. 2 4
ME E14.1. Facility has established There is procedure for emergency 1 SI/RR See surgeon is available on call/on
procedures OT Scheduling surgeries duty
. Procedure for arranging logistics 1 SI Responsibilities are defined and
patient is shifted promptly
Standard E15. The facility has defined and established procedures for end of life care and death 9 18
ME E15.1. Death of admitted patient is Facility has a standard procedure 1 SI
adequately recorded and of communicating death to
communicated relatives decently.
. Death note is written on patient 1 RR
record
ME E15.2. The facility has standard Past history and sign of any medico 1 RR Check what is policy for registering
procedures for handling the legal cause is looked for brought in dead, death cases as
death in the hospital MLC
. There is criteria for declaring death 1 SI/RR Ask form how death is declared -
Physical examination or ECG is
done
ME F1.6 Facility has defined and Check if Doctors are aware of 1 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 9 18
ME F2.1. Hand washing facilities are Availability of hand washing Facility 1 OB
provided at point of use at Point of Use
. Availability of running Water 1 OB/SI Open the tap. Ask the Staff, water
is available 24*7
. Availability of antiseptic soap with 1 OB/SI Check for availability/ Ask staff if
soap dish/ liquid antiseptic with the supply is adequate and
dispenser. uninterrupted
. Availability of Alcohol based Hand 1 OB/SI Check for availability/ Ask staff for
rub regular supply. Hand rub dispenser
are provided adjacent to bed
ME F2.2. Staff is trained and adhere to Adherence to 6 steps of Hand 1 SI/OB Ask for demonstration
standard hand washing practices washing
Standard F3. Facility ensures standard practices and materials for Personal protection 5 10
ME F3.1. Facility ensures adequate Clean gloves are available at point of 1 OB/SI
personal protection equipment use
as per requirements
Standard F4. Facility has standard Procedures for processing of equipment and instruments 10 20
ME F4.1. Facility ensures standard practices Decontamination of Procedure 1 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate work benches
and cleaning of instruments and (Wiping with 0.5% Chlorine
procedures areas solution)
High level Disinfection of 1 OB/SI Ask staff about method and time
instruments/equipment is done as required for boiling
per protocol
Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention 10 20
ME F5.1. Layout of the department is Facility layout ensures separation of 1 OB
conducive for the infection control general traffic from patient traffic
practices
ME F5.2. Facility ensures availability of Availability of disinfectant as per 1 OB/SI Chlorine solution, Gluteraldehye,
standard materials for cleaning and requirement carbolic acid
disinfection of patient care areas
ME G3.3. Facility has established system Departmental checklist are used 1 SI/RR
for use of check lists in different for monitoring and quality
departments and services assurance
Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 16 32
ME G4.1. Departmental standard Standard operating procedure for 1 RR
operating procedures are department has been prepared and
available approved
ME G4.3. Staff is trained and aware of the Check if staff is aware of relevant 1 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4. Work instructions are displayed Work instruction/clinical protocols 1 OB Triage, CPR, Medical clinical
at Point of use are displayed protocols like Snake bite and
poisoning
Standard G6. The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2. The facility periodically defines Quality objective for emergency 1 RR/SI
its quality objectives and key defined
departments have their own
objectives
ME G6.3. Quality policy and objectives are Check if staff is aware of quality 1 SI
disseminated and staff is aware policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically
. Area of Concern - H Outcome 18 36
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 9 18
ME H1.1. Facility measures productivity No of Emergency cases per 1 RR
Indicators on monthly basis thousand population
. No of trips per ambulance 1 RR
. No. of trauma cases treated per 1 RR
1000 emergency cases
. No. of poisoning cases treated per 1 RR
1000 emergency cases
. No. of cardiac cases treated per 1 RR
1000 emergency cases
. No. of obstetric cases treated per 1 RR
1000 emergency cases
. No of resuscitation done per 1 RR Resuscitation should include: Chest
thousand population Compression, Airway and
Breathing
Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 2 4
ME H3.1. Facility measures Clinical Care & No of adverse events per thousand 1 RR
Safety Indicators on monthly basis patients
Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 4
ME H4.1. Facility measures Service Quality LAMA Rate 1 RR No of LAMA X 100/ No of Patients
Indicators on monthly basis seen at emergency
0
1
2
National Quality Assurance Standards for Taluka Hospital 0 1 2
Checklist for Outdoor Department 2
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
Area of Concern - A Service Provision 46 92
Standard A1 Facility Provides Curative Services 13 26
ME A1.1 The facility provides General Availability of functional General 1 Dedicated General Medicine
Medicine services Medicine Clinic SI/OB Clinic
ME A1.2 The facility provides General Surgery Availability of functional General 1 Dedicated General speciality
services Surgery Clinic SI/OB Surgical Clinic
ME A1.3 The facility provides Obstetrics & Availability of Functional 1 Dedicated speciality Obstetrics
Gynaecology Services Obstetrics & Gynaecology Clinic & Gynaecology Clinic. High risk
pregnancy cases are referred
SI/OB from PHC & SC
ME A1.4 The facility provides Paediatric Availability of Paediatric Clinic 1 Dedicated Paediatric speciality
Services SI/OB Clinic
ME A1.5 The facility provides Ophthalmology Availability of functional 1 Dedicated ophthalmology clinic
Services Ophthalmology Clinic SI/OB providing consultation services
ME A1.6 The facility provides Dental Treatment Availability of functional Dental 1 Dedicated Clinic providing
Services Clinic SI/OB consultation services
Availability of OPD Dental 1 Extraction, scaling, tooth
procedure SI/OB extraction, denture and
Restoration.
ME A1.7 The facility provides AYUSH Services Availability of Functional Ayush 1 AYUSH clinic accompanied by
clinic SI/OB dispensary
ME A1.8 The facility provides services for OPD Availability of Dressing facilities 1 Dressing, Suturing and drainage
procedures at OPD SI/OB
ME A1.9 Services are available for the time At least 6 Hours of OPD Services 1
period as mandated are available SI/RR
ME A2.4 The facility provides Child health Routine and emergency care of 1
Services sick children. SI/OB
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 16 32
ME A4.1 The facility provides services under Availability of OPD Services 1 OPD Management of Malaria,
National Vector Borne Disease Control Under NVBDCP Kala Azar, Dengue
Programme as per guidelines SI/RR
ME A4.5 The facility provides services under Screening and early detection of 1 Refraction, Field of Vision and
National Programme for prevention visual impairment and refraction radioscopy
and control of Blindness as per SI/RR
guidelines
ME A4.14 The facility provides services as per State Availability of OPD services as 1
specific health programmes per State Health SI/RR
Programs/Schemes
Standard A6 Health services provided at the facility are appropriate to community needs. 1 2
ME A6.1 The facility provides curatives & Special Clinics are available for 1 Ask for the specific local health
preventive services for the health local prevalent diseases problems/ diseases .i.e.. Kala
problems and diseases, prevalent SI/OB azar, arsenic poisoning etc.
locally.
Display of layout/floor 1
directory OB
ME B1.2 The facility displays the services and List of OPD Clinics are available 1
entitlements available in its OB
departments
Names of doctor on duty is 1
displayed and updated OB
ME B1.4 User charges are displayed and User charges for services are 1
communicated to patients effectively displayed OB
ME B1.5 Patients & visitors are sensitised and IEC Material is displayed 1
educated through appropriate IEC / OB
BCC approaches
ME B1.6 Information is available in local Signage's and information are 1
language and easy to understand available in local language OB
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 6 12
ME B3.1 Adequate visual privacy is provided at Availability of screen at 1
every point of care Examination Area OB
ME B3.4 The facility ensures privacy and Privacy and confidentiality of TB, 1 Check in RTI/STI clinic
confidentiality to every patient, Leprosy Patients
especially of those conditions having
social stigma, and also safeguards SI/OB
vulnerable groups
Standard B4 Facility has defined and established procedures for informing patients about their medical conditions and involving them in treatment 7 14
ME B4.1 There is established procedures for planning,
Informed consent for beforeand
HIV facilitates
1 informed decisioncheck
making
for filled consent forms of
taking informed consent before testing at ICTC, SI/RR minor surgeries
treatment and procedures
Informed consent for IUD 1
insertion SI/RR
ME B4.4 Information about the treatment is Patient is informed about her 1 Ask patients about what they
shared with patients or attendants, clinical condition and treatment have been communicated about
regularly being provided, possible the treatment plan
outcomes, and risks involved. PI
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services. 5 10
ME B5.1 The facility provides cashless services Free OPD Consultation / ANC 1 For JSSK entitlement
to pregnant women, mothers and Check-up's/Investigations.
neonates as per prevalent PI/SI
government schemes
ME B5.2 The facility ensures that drugs Check that patient party has not 1
prescribed are available at Pharmacy spent on purchasing drugs or
consumables from outside. PI/SI
ME B5.3 It is ensured that facilities for the Check that patient party has not 1
prescribed investigations are available spent on diagnostics from PI/SI
at the facility outside.
ME B5.4 The facility provides free of cost Free OPD Consultation for BPL 1
treatment to Below poverty line patients
patients without administrative PI/SI/RR
hassles
ME C1.2 Patient amenities are provide as per Availability of seating 1 As per average OPD at peak time
patient load arrangement in waiting area OB
Demarcated trolley/wheelchair 1
bay OB
ME C1.4 The facility has adequate circulation Corridors at OPD are broad 1
area and open spaces according to enough for movement of
need and local law stretcher, trolleys, patients & OB
visitors
ME C1.7 The facility and departments are Unidirectional flow of services 1 Layout of OPD shall follow
planned to ensure structure follows functional flow of the
the function/processes (Structure patients, e.g.:
commensurate with the function of Enquiry→Registration→Waiting
the hospital) →Sub-waiting→
OB Clinic→Dressing room/Injection
Room→
Diagnostics (lab/X-
ray)→Pharmacy→Exit
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic safety Non structural components are 1 Check for fixtures and furniture
of the infrastructure properly secured. Building bye- like cupboards, cabinets, and
laws and instructions of NBC heavy equipment , hanging
(National Building Code) for OB objects are properly fastened
seismic safety are followed. and secured
ME C2.2 The facility ensures safety of electrical OPD building does not have 1
establishment temporary connections and OB
loosely hanging wires.
ME C2.3 Physical condition of buildings are Floors of the OPD are non 1
safe for providing patient care slippery and even OB
ME C2.4 The facility has plan for prevention of OPD has sufficient fire exits to 1
fire permit safe escape to its OB/SI
occupant in case of fire
ME C2.5. The facility has adequate fire fighting OPD has installed fire 1
Equipment Extinguisher to fight Type A/B/C OB
Fire
ME C2.6. The facility has a system of periodic Check for staff competencies for 1
training of staff and conducts mock operating fire extinguisher and
drills regularly for fire and other what to do in case of fire
disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 18 36
ME C3.1 The facility has adequate specialist Availability of specialist Doctor 1 Check for specialist are available
doctors as per service provision during OPD time OB/RR at scheduled time
ME C3.3. The facility has adequate nursing staff Availability of Nursing staff 1 At Injection room/ OPD Clinic as
as per service provision and work load OB/RR/SI Per Requirement
ME C3.5 The facility has adequate support / Availability of security guard for 1
general staff OPD SI/RR
ME C3.7 The Staff is skilled as per job Check the competency of staff to 1
description use OPD equipment like BP SI/RR
apparatus etc.
Standard C4 Facility provides drugs and consumables required for assured list of services. 5 10
ME C4.1 The departments have availability of Availability of injectable in 1 ARV, TT
adequate drugs at point of use injection room OB/RR
ME C4.2 The departments have adequate Availability of disposables at 1 Examination gloves, Syringes,
consumables at point of use dressing room and clinics OB/RR Dressing material , suturing
material
ME C4.3 Emergency drug trays are maintained Emergency Drug Tray is 1 Verify Presence of following
at every point of care, where ever it maintained in injection room & Drugs:-Inj Dopamine, Inj
may be needed immunization room Adrenaline, Inj Hydrocortisone
Succinate, Inj Chlorpheniramine
OB/RR Maleate,Inj Ranitidine, Inj
Ondansetron
Standard C5 The facility has equipment & instruments required for assured list of services. 9 18
ME C5.1 Availability of equipment & Availability of functional 1 BP apparatus, thermometer,
instruments for examination & Equipment &Instruments for weighing machine, torch,
monitoring of patients examination & Monitoring OB stethoscope, Examination table
ME C5.5 Availability of Equipment for Storage Availability of equipment for 1 Refrigerator, Crash cart/Drug
storage for drugs OB trolley, instrumental trolley,
dressing trolley
ME C5.6 Availability of functional equipment Availability of equipment for 1 Buckets for mopping, mops,
and instruments for support services cleaning OB duster, waste trolley, Deck brush
ME C5.7 Departments have patient furniture Availability of Fixtures 1 Spot light, electrical fixture for
and fixtures as per load and service OB equipment, X ray view box
provision
Availability of furniture at clinics 1 Doctors Chair, Patient Stool,
Examination Table, Attendant
OB Chair, Table, Footstep, cupboard
ME D1.2 The facility has established procedure All the measuring equipment/ 1 BP apparatus, weighing scale,
for internal and external calibration of instrument are calibrated thermometer are calibrated
measuring Equipment OB/ RR
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 11 22
ME D2.1 There is established procedure for There is process for indenting 1 Stock level are weekly updated
forecasting and indenting drugs and consumables and drugs in Requisition are timely placed
consumables injection/ dressing room SI/RR
ME D2.4 The facility ensures management of Expiry dates for injectable are 1
expiry and near expiry drugs maintained at injection and OB/RR
immunization room
Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable environment to 18 36
staff, patients and visitors.
ME D3.1 Exterior of the facility building is Building is painted/whitewashed 1
maintained with landscaping in open in uniform colour OB
area
Interior of patient care areas are 1
plastered & painted OB
ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, 1 All area are clean with no
hygienic sinks patient care and circulation OB dirt,grease,littering and cobwebs
areas are Clean
ME D3.7 The facility has provision of restriction Only one patient is allowed one 1
of visitors in patient areas time at clinic OB/SI
ME D3.8 The facility ensures safe and Temperature control and 1 Fans/ Air
comfortable environment for patients ventilation in waiting areas conditioning/Heating/Exhaust/V
and service providers entilators as per environment
PI/OB condition and requirement
ME D3.9 The facility has security system in Hospital has sound security 1
place at patient care areas system to manage crowd in OPD OB/SI
ME D3.10 The facility has established measure for Ask female staff whether they 1
safety and security of female staff feel secure at work place SI
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.1 The facility has adequate Availability of 24x7 running and 1
arrangement storage and supply for potable water
potable water in all functional areas OB/SI
Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 4 8
ME D9.1 The facility has established job Staff is aware of their roles 1
description as per govt guidelines and responsibilities
SI
ME D9.2 The facility has a established There is procedure to ensure that 1 Check for system for recording
procedure for duty roster and staff is available on duty as per time of reporting and relieving
deputation to different departments duty roster RR/SI (Attendance register/ Biometrics
etc.)
ME D9.3 The facility ensures the adherence to Doctor, nursing staff and support 1
dress code as mandated by its staff adhere to their respective
administration / the health dress code OB
department
ME E1.2 The facility has a established There is procedure for systematic 1 Patient is called by
procedure for OPD consultation calling of patients one by one Doctor/attendant as per his/her
turn on the basis of “first come
OB first examine” basis.
No Patient is Consulted in 1
Standing Position OB
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 5 10
ME E3.1 Facility has established procedure for There is a procedure for 1
continuity of care during consultation of the patient to
interdepartmental transfer other specialist with in the SI/RR
hospital
ME E3.2 Facility provides appropriate referral Availability of referral linkages for 1 Check how patient are referred if
linkages to the patients/Services for OPD consultation. services are not available
transfer to other/higher facilities to RR/OB
assure their continuity of care.
Standard E5 Facility has a procedure to identify high risk and vulnerable patients. 1 2
ME E5.2 The facility identifies high risk patients For any critical patient needing 1
and ensure their care, as per their need urgent attention queue can be
bypassed for providing services
on priority basis OB/SI
Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use. 5 10
ME E6.1 Facility ensured that drugs are prescribed Check for OPD slip if drugs are 1
in generic name only prescribed under generic name RR
only
ME E7.3 There is a procedure to check drug Drugs are checked for expiry 1
before administration/ dispensing and other inconsistency
before administration OB/SI
Check single dose vial are not 1 Check for any open single dose
used for more than one dose vial with left over content
OB intended to be used later on
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 7 14
ME E8.1 All the assessments, re-assessment Patient History, Chief Complaint 1
and investigations are recorded and and Examination Diagnosis/
updated Provisional Diagnosis are
recorded in OPD slip RR
ME E8.5 Adequate form and formats are Check for the availability of OPD 1
available at point of use slip, Requisition slips etc. OB/SI
ME E8.6 Register/records are maintained as OPD records are maintained 1 OPD register, ANC register,
per guidelines OB/RR Injection room register etc.
All register/records are identified 1
and numbered OB/RR
ME E8.7 The facility ensures safe and adequate Safe keeping of OPD records 1
storage and retrieval of medical OB/SI
records
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 2 4
ME E10.3 The facility has disaster management Staff is aware of disaster plan 1
plan in place SI/RR
Standard E11 The facility has defined and established procedures of diagnostic services 2 4
ME E11.1 There are established procedures for The Container are labelled 1
Pre-testing Activities properly after the sample OB
collection
ME E11.3 There are established procedures for Clinics are provided with the 1
Post-testing Activities critical value of different tests SI/RR
ME E16.3 Facility ensures availability of Diagnostic test under ANC check 1 Check for Haemoglobin, urine
diagnostic and drugs during antenatal up are prescribed at ANC clinic albumin urine sugar blood group
care of pregnant women and Rh factor Syphilis
RR/SI (VDRL/RPR) HIV blood sugar
malaria Hepatitis B
ME E16.4 There is an established procedure for High risk pregnant women are 1 Anaemia, Bad Obs history, CPD,
identification of High risk pregnancies identified, initial Management & PIH, Medical disorder
and appropriate treatment/referral as referred to specialist complicating pregnancy,
per scope of services. RR/SI Malpresentation, PROM,
Obstructed labour, Rh negative
Reconstituted vaccines are not 1 Check when the vials are opened
used after recommended period & constituted . Should not be
RR/SI used beyond 4 hrs. after
reconstitution
Staff checks VVM level before 1 White square in side the violet
using vaccines SI circle changes the colour
ME E22.3 Facility provides service under Validation and diagnosis of 1 As per Operation/ Clinical
National Leprosy Eradication Program Referred and Directly Reported SI/RR Guidelines of NLEP
as per guidelines Cases
ME E22.10 Facility provide services under Early detection and screening for 1 As per Clinical guidelines
National program for prevention and detection of deafness SI/RR
control of deafness
ME F1.5 Facility has established procedures for Regular monitoring of infection 1 Hand washing and infection
regular monitoring of infection control practices SI/RR control audits are done at
control practices periodic intervals
ME F1.6 Facility has defined and established Check if Doctors are aware of 1
antibiotic policy Hospital Antibiotic Policy SI/RR
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 8 16
ME F2.1 Hand washing facilities are provided Availability of hand washing 1 Check for availability of wash
at point of use Facility at Point of Use OB basin near the point of use
Availability of running Water 1 Open the tap ask the staff if
OB/SI water is 24*7
Availability of antiseptic soap 1 Check for availability/ Ask staff if
with soap dish/ liquid antiseptic OB/SI the supply is adequate and
with dispenser. uninterrupted
ME F2.2 Staff is trained and adhere to standard Adherence to 6 steps of Hand 1 Ask for demonstration
hand washing practices washing SI/OB
Standard F3 Facility ensures standard practices and materials for Personal protection 3 6
ME F3.1 Facility ensures adequate personal Clean gloves are available at 1
protection equipment as per point of use OB/SI
requirements
Availability of Masks 1 OB/SI
ME F3.2 Staff is adhere to standard personal No reuse of disposable gloves, 1
protection practices Masks, caps and aprons. OB/SI
Standard F4 Facility has standard Procedures for processing of equipment and instruments 8 16
ME F4.1 Facility ensures standard practices and Decontamination of operating & 1 Ask staff about how they
materials for decontamination and Procedure surfaces decontaminate the procedure
cleaning of instruments and procedures surface like Examination table ,
areas dressing table, Stretcher/Trolleys
SI/OB etc.
(Wiping with .5% Chlorine
solution)
Proper Decontamination of 1
instruments after use Ask staff how they
decontaminate the instruments
like Stethoscope, Dressing
Instruments, Examination
Instruments, Blood Pressure Cuff
etc.
SI/OB (Soaking in 0.5% Chlorine
Solution, Wiping with 0.5%
Chlorine Solution
ME F4.2 Facility ensures standard practices and Equipment and instruments are 1 Autoclaving/HLD/Chemical
materials for disinfection and sterilization sterilized after each use as per Sterilization
of instruments and equipment requirement OB/SI
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 10 20
ME F5.1 Layout of the department is conducive Facility layout ensures separation 1
for the infection control practices of general traffic from patient OB
traffic
ME F5.2 Facility ensures availability of standard Availability of disinfectant as per 1 Chlorine solution,
materials for cleaning and disinfection of requirement OB/SI Glutaraldehyde, carbolic acid
patient care areas
ME F5.3 Facility ensures standard practices Staff is trained for spill 1 Blood & body fluid spill
followed for cleaning and disinfection of management SI/RR management & Mercury spill
patient care areas
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste. 13 26
ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins 1
Medical Waste as per guidelines at point of waste generation OB
1
Availability of Non chlorinated OB
plastic colour coded plastic bags
1
Segregation of Anatomical and OB/SI
solied waste in Yellow Bin
Segregation of infected plastic 1
OB
waste in red bin
Display of work instructions for 1
segregation and handling of OB
Biomedical waste
ME F6.3 Facility ensures transportation and Check bins are not overfilled 1
disposal of waste as per guidelines SI/OB
Standard G2 Facility has established system for patient and employee satisfaction 1 2
ME G2.1 Patient Satisfaction surveys are OPD Patient satisfaction survey 1
conducted at periodic intervals done on monthly basis RR
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 4 8
ME G3.1 Facility has established internal There is system daily round by 1
quality assurance program at relevant matron/hospital in-charge/ for
departments monitoring of services SI/RR
ME G3.3 Facility has established system for use Departmental checklist are 1
of check lists in different departments used for monitoring and SI/RR
and services quality assurance
Staff is designated for filling 1
and monitoring of these SI
checklists
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 15 30
ME G4.1 Departmental standard operating Standard operating procedure for 1
procedures are available department has been prepared
and approved RR
ME G4.3 Staff is trained and aware of the Check if staff are aware of 1
standard procedures written in SOPs relevant part of SOPs SI/RR
ME G4.4 Work instructions are displayed at Work instruction/clinical 1 Relevant protocols are displayed
Point of use protocols are displayed OB like Clinical Protocols for ANC
check-up's
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 6 12
ME G5.1 The facility conducts periodic internal Internal assessment is done at 1
assessment periodic interval RR/SI
ME G5.3 The facility ensures non compliances Non Compliance are enumerated 1
are enumerated and recorded and recorded RR/SI
adequately
ME G5.4 Action plan is made on the gaps found Action plan prepared 1
in the assessment / audit process RR/SI
ME G5.5 Corrective and preventive actions are Corrective and preventive action 1
taken to address issues, observed in taken
the assessment & audit RR/SI
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objective for OPD defined 1
quality objectives and key
departments have their own RR/SI
objectives
ME G6.3 Quality policy and objectives are Check of staff is aware of quality 1
disseminated and staff is aware of policy and objectives SI
that
ME G6.4 Progress towards quality objectives is Quality objectives are monitored 1
monitored periodically and reviewed periodically SI/RR
Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 6 12
5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1
improvement in services SI/RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 1 2
ME H2.1 Facility measures efficiency Indicators on OPD per Doctor 1
monthly basis RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 5 10
ME H3.1 Facility measures Clinical Care & Safety Consultation time at ANC Clinic 1 Time motion study
Indicators on monthly basis RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 7 14
ME H4.1 Facility measures Service Quality Patient Satisfaction Score 1
Indicators on monthly basis RR
OPD Score
OPD Score 50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50
ME A2.3 The facility provides New-born Availability of Essential new born 1 SI/OB
health Services care
Availability of New born 1 SI/OB
resuscitation
Standard A3 The facility Provides diagnostic Services 2 4
ME A3.1 The facility provides Radiology Availability or functional linkage 1 SI/OB
Services for USG services.
ME A3.2 The facility provides Laboratory Availability of point of care 1 SI/OB HIV, Hb in gm , Random
Services diagnostic test blood sugar /as per state
guideline
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on 5 10
account of physical access,social. economic, cultural or social status.
ME B2.1 Only on duty staff is allowed in 1 OB
Services are provided in manner the labour room when it is
that are sensitive to gender occupied
Standard B3
The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 5 10
information.
ME B3.1 Adequate visual privacy is 1
Availability of screen/ partition at OB
provided at every point of care delivery tables
Curtains / frosted glass have been 1 OB
provided at windows
ME B3.2 Confidentiality of patients records Patient Records are kept at secure 1 SI/OB
and clinical information is place beyond access to general
staff/visitors
maintained
ME B3.3 Behaviour of staff is empathetic 1 OB/PI
The facility ensures the and courteous
behaviours of staff is dignified
and respectful, while delivering
the services
ME B3.4 HIV status of patient is not 1 SI/OB
The facility ensures privacy and disclosed except to staff that is
directly involved in care
confidentiality to every patient,
especially of those conditions
having social stigma, and also
safeguards vulnerable groups
Standard B4
The facility has defined and established procedures for informing patients about the medical condition, and involving them 2 4
in treatment planning, and facilitates informed decision making
ME B4.1 General consent is taken before 1 SI/RR
There is established procedures delivery
for taking informed consent
before treatment and procedures
Standard B5
The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost 4 8
of hospital services.
ME B5.1 Drugs and consumables under 1 PI/SI
The facility provides cashless JSSK are available free of cost
services to pregnant women,
mothers and neonates as per
prevalent government schemes
Availability of store 1 OB
ME C1.4 The facility has adequate Corridors connecting labour room 1 OB
circulation area and open spaces are broad enough to facilitate
according to need and local law stretcher and trolley's movement
ME C2.2 The facility ensures safety of Labour room does not have 1 OB Switch Boards other
electrical establishment temporary connections and electrical installations are
loosely hanging wires intact
ME C2.5. The facility has adequate fire NBSU has installed fire 1 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.
Check the expiry date for fire 1 OB/RR
extinguisher is displayed on each
extinguisher as well as due date
for next refilling is clearly
mentioned
ME C2.6. The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 15 30
ME C3.1 The facility has adequate Availability of Obs 1 OB/RR Paediatrician or trained MO,
specialist doctors as per service &Gynaespecialist and Obstetrician or trained MO
provision paediatrician on call.
ME C3.2. The facility has adequate general Availability of at least one doctor 1
duty doctors as per service 24x7 in the facility
provision and work load
ME C3.3 The facility has adequate nursing Availability of SBA trained Nursing 1 OB/RR/SI At least Three per shift
staff as per service provision and staff
work load
ME C3.5 The facility has adequate Availability of labour room 1 SI/RR At least 1 sanitary worker
support / general staff attendants/ Birth Companion and 1 ayah per shift
Availability of dedicated security 1 SI/RR
staff
ME C3.6 The staff has been provided Navjat Shishu Surkasha Karyakarm 1 SI/RR
required training / skill sets (NSSK) training
Skilled birth Attendant (SBA) 1 SI/RR
IMEP training. 1 SI/RR
BEmOC training for MO 1 SI/RR
PPIUCD training 1 SI/RR
ME C3.7 The Staff is skilled as per job Nursing staff is skilled for 1 SI/RR check staff is aware of
description operating radiant warmer optimal temperature, how to
set temperature, how to use
probes, and how to interpret
alarms and trouble shooting.
Nursing staff is skilled for 1 SI/RR Check the staff know how to
resuscitation set the temperature, how to
put the probe, duration and
interpretation of alarms
Standard C4 The facility provides drugs and consumables required for assured services. 14 28
ME C4.1 The departments have availability Availability of uterotonic Drugs 1 OB/RR Inj Oxytocin 10 IU (to be kept
of adequate drugs at point of use in fridge)
ME C4.2 The departments have adequate Availability of dressings and 1 OB/RR Gauze pieces and Cotton
consumables at point of use Sanitary pads swabs, Sanitary pads, Needle
(round body and cutting),
Chromic catgut no. 0
ME C4.3 Emergency drug trays are Emergency Drug Tray is maintained 1 OB/RR
maintained at every point of care,
where ever it may be needed
Standard C5 The facility has equipment & instruments required for assured list of services. 17 34
ME C5.1 Availability of equipment & Availability of functional 1 OB BP apparatus, Stethoscope
instruments for examination & Equipment & Instruments for Thermometer, Foetoscope/
monitoring of patients examination & Monitoring Doppler, Baby weighting
scale, Wall clock.
ME C5.2 Availability of equipment & Availability of instrument 1 OB Scissor & Artery forceps,
instruments for treatment arranged in Delivery trays Cord clamp, Sponge holder,
procedures, being undertaken in Speculum, Kidney tray, Bowl
the facility for antiseptic lotion
ME C5.3 Availability of equipment & Availability of Point of care 1 OB Glucometer, Doppler and HIV
instruments for diagnostic diagnostic instruments rapid diagnostic kit, Uristix
procedures being undertaken in
the facility
ME C5.4 Availability of equipment and Availability of resuscitation 1 OB Bag and mask (New-born
instruments for resuscitation of Instruments for New-born Care resuscitator), Oxygen,
patients and for providing Suction machine/ mucus
intensive and critical care to sucker , radiant warmer,
patients laryngoscope, ET tube 2.5
and 3.5 sizes.
ME C5.5 Availability of Equipment for Availability of equipment for 1 OB Refrigerator, Crash cart/Drug
Storage storage for drugs trolley, instrument trolley,
dressing trolley
ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR BP apparatus, Weighing
procedure for internal and instrument are calibrated Machine etc. are calibrated
external calibration of measuring
Equipment
Standard D2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient 11 22
care areas
ME D2.1 There is established procedure 1
There is established system of SI/RR Stock level are daily updated
for forecasting and indenting of timely indenting of consumables Requisition are timely placed
drugs and consumables and drugs at nursing station
Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable 18 36
environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Check for there is no seepage , 1 OB
adequately maintained Cracks, chipping of plaster
Window panes , doors and other 1 OB
fixtures are intact
Patients beds are intact and 1 OB
painted
Mattresses are intact and clean 1 OB
ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, sinks 1 OB All area are clean with no
hygienic new-born care and circulation dirt,grease,littering and
areas are Clean cobwebs
ME D3.9 The facility has security system in Lockable doors in labour room 1 OB
place at patient care areas
ME D3.10- The facility has established measure Ask female staff weather they feel 1 SI
for safety and security of female secure at work place
staff
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 6 12
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas
Standard D5
The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted 5 10
patients.
ME D5.4 The facility has adequate sets of Availability of clean Drape, 1 OB/RR
linen Macintosh on the Delivery table,
Standard D9
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 4 8
operating procedures.
ME D9.1 The facility has established job Staff is aware of their roles and
1 SI
description as per govt guidelines responsibilities
ME D9.2 The facility has a established There is procedure to ensure that 1 RR/SI Check for system for
procedure for duty roster and staff is available on duty as per recording time of reporting
deputation to different duty roster and relieving (Attendance
departments register/ Biometrics etc.)
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 6 12
ME E2.1 There is established procedure Rapid Initial assessment of 1 RR/SI/OB Assessment and immediate
for initial assessment of patients Pregnant Women to identify treatment following danger
complication and Prioritization of sign are present - difficulty in
care Breathing, Fever, Sever
abdominal pain, Convulsion
or unconsciousness, Severe
headache or Blurred vision
ME E2.2 There is established procedure There is fixed schedule for 1 RR/OB There is a fixed schedule of
for follow-up/ reassessment of reassessment of Pregnant women reassessment as per
Patients as per standard protocol protocols
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 8 16
ME E3.1 The facility has established There is procedure of handing 1 SI/RR
procedure for continuity of care over patient / new born from
during interdepartmental transfer labour room to OT/ Ward/NBSU
ME E3.2 The facility provides appropriate Patient is referred with referral slip 1 RR/SI A referral slip/ Discharge card
referral linkages to the is provide to patient when
patients/Services for transfer to referred to another health
other/higher facilities to assure the care facility
continuity of care.
ME E4.2 Procedure for ensuring timely and There is a process to ensue the 1 SI/RR Verbal orders are rechecked
accurate nursing care as per accuracy of verbal/telephonic before administration
treatment plan is established at the orders
facility
ME E4.3 There is established procedure of Patient hand over is given during 1 RR/SI
patient hand over, whenever staff the change of the shift
duty change happens
Nursing Handover register is 1 RR
maintained
Bed side Hand over is given 1 SI/RR
ME E4.5 There is procedure for periodic Patient's Vitals are monitored 1 RR/SI Check for TPR chart, IO chart,
monitoring of patients and recorded periodically any other vital required is
monitored
Critical patients are monitored 1 RR/SI Check for BP,
continuously Pluse,Temp,Respiratory Rate
FHR, Uterine Contraction,
Any other vital required is
monitored
Standard E5 The facility has a procedure to identify high risk and vulnerable patients. 2 4
ME E5.1 The facility identifies vulnerable Vulnerable patients are identified 1 OB/SI Check the measure taken to
patients and ensure their safe care and measures are taken to protect prevent new born theft,
them from any harm swapping and baby fall
ME E5.2 The facility identifies high risk High Risk Pregnancy cases are 1 OB/SI Check for the frequency of
patients and ensure their care, as identified and kept in intensive observation: Ist stage :half an
per their need monitoring hour and 2nd stage: every 5
min
Standard E6
The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & 4 8
their rational use.
ME E6.1 The facility ensured that drugs are Check for Case sheet if drugs are 1 RR
prescribed in generic name only prescribed under generic name
only
ME E6.2 There is procedure of rational use of Check for that relevant Standard 1 RR
drugs Treatment Guideline are available
at point of use
Check Case sheet that drugs are 1 RR Check for rational use of
prescribed as per STG Uterotonic drugs
Standard E7 The facility has defined procedures for safe drug administration 10 20
ME E7.1 There is process for identifying High alert drugs are identified in 1 SI/OB Electrolytes like Potassium
and cautious administration of the department chloride, Insulin etc. as
high alert drugs applicable
Maximum dose of high alert drugs 1 SI/RR Value for maximum doses as
are defined and communicated per age, weight and
diagnosis are available with
nursing station and doctor
ME E7.3 There is a procedure to check Drugs are checked for expiry 1 OB/SI
drug before administration/ and other inconsistency
dispensing before administration
Check single dose vial are not 1 OB Check for any open single
used for more than one dose dose vial with left over
content intended to be used
later on
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 7 14
ME E8.1 All the assessments, re- Progress of labour is recorded 1 RR Partograph fully
assessment and investigations are compliance ,and on bed
recorded and updated head ticket partial
compliance
ME E8.2 All treatment plan Treatment prescribed in nursing 1 RR Medication order, treatment
prescription/orders are recorded records plan, lab investigation are
in the patient records. recoded adequately
ME E8.4 Procedures performed are Delivery notes are adequate 1 RR Outcome of delivery, date
written on patients records and time, gestation age,
delivery conducted by, type
of delivery, complication if
any ,indication of
intervention, date and time
of transfer, cause of death
etc.
ME E8.5 Adequate form and formats are Standard Formats available 1 RR/OB Availability of BHT,
available at point of use Partograph, etc.
ME E8.6 Register/records are maintained Registers and records are 1 RR Labour room register, OT
as per guidelines maintained as per guidelines register, MTP register,FP
register, Maternal death
register and records, Lab
register, Referral in /out
register, Internal& PPIUD
register etc.
ME E11.3 There are established procedures Nursing station is provided with 1 SI/RR
for Post-testing Activities the critical value of different test
Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 6 12
ME E12.5 There is established procedure Consent is taken before 1 RR
for transfusion of blood transfusion
Patient's identification is verified 1 SI/OB
before transfusion
Blood is kept on optimum 1 RR
temperature before transfusion
Standard E16 The facility has established procedures for Antenatal care as per guidelines 2 4
ME E16.1 There is an established procedure Facility provides and updates 1 RR/SI
for Registration and follow up of “Mother and Child Protection
pregnant women. Card”.
ME E16.3 The facility ensures availability of Tests for Urine albumin, 1 RR/SI
diagnostic and drugs during haemoglobin, blood grouping
antenatal care of pregnant
women
Standard E17 The facility has established procedures for Intranatal care as per guidelines 22 44
ME E17.1 Established procedures and Management of 1st stage of 1 SI/OB Check progress is recorded,
standard protocols for labour: Women is allowed to give
management of different stages birth in the position she
of labour including AMTSL (Active wants , Check progress is
Management of third Stage of recorded on partograph
labour) are followed at the facility
ME E17.2 There is an established procedure Staff is aware of Indications for 1 SI Ask staff how they identify
for assisted and C-section referring patient for Surgical slow progress of labour ,
deliveries per scope of services. Intervention How they interpret
Partogram
ME E17.3 There is established procedure Management and follow up of 1 SI/RR Monitors BP in every case,
for management/Referral of PIH/Eclampsia \Pre Eclampsia and tests for proteinuria if BP
Obstetrics Emergencies as per is >140/90 mmHg
scope of services. If BP is 140/90 mmHg or
more with proteinuria 2+
along with any two of the
following danger signs:
severe headache, blurring of
vision, severe pain abdomen
or reduced urine output, BP
> 160/110 or more with
proteinuria 3+; OR in cases
of Eclampsia—administers
loading dose of Magnesium
Sulphate (MgSO4) and
refers/ calls for specialist
attention; continues
maintenance dose of
MgSO4- 5 g of MgSO4 IM in
alternate buttocks every four
hours, for 24 hours after
birth/last convulsion,
whichever is later
If BP is >160/110 mmHg or
more, give appropriate anti-
hypertensive
(Hydralazine/Methyl Dopa/
Nifedipine)
Vitamin K for low birth weight 1 SI/RR Given to all new born (1.0
mg IM in > 1500 gms and 0.5
mg in < 1500 gms
Standard E18 The facility has established procedures for postnatal care as per guidelines 6 12
ME E18.1 Post partum Care is provided to Prevention of Hypothermia of new 1 SI/RR
the mothers born
Initiation of Breastfeeding with in 1 PI
1 Hour
Mother is monitored as per post 1 RR/SI Check for records of Uterine
natal care guideline contraction, bleeding,
temperature, B.P, pulse,
Breast examination, (Nipple
care, milk initiation)
ME F1.4 There is Provision of Periodic There is a procedure for 1 SI/RR Hepatitis B, Tetanus Toxoid
Medical Check-up and immunization of the staff etc.
immunization of staff
Periodic medical check-ups of the 1 SI/RR
staff
ME F1.5 The facility has established Regular monitoring of infection 1 SI/RR Hand washing and infection
procedures for regular monitoring control practices control audits done at
of infection control practices periodic intervals
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 13 26
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB Check the availability of
provided at point of use Facility at Point of Use wash basin near the point of
use
Availability of running Water 1 OB/SI Open the tap. Ask the Staff,
water is available 24*7
ME F2.2 The facility staff is trained in hand Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
washing practices and they washing
adhere to standard hand washing
practices
Standard F3 The facility ensures standard practices and materials for Personal protection 9 18
ME F3.1 The facility ensures adequate Availability of Masks 1 OB/SI
personal protection Equipment as
per requirements
Availability of Sterile s gloves 1 OB/SI
Use of elbow length gloves for 1 OB/SI
obstetrical purpose
Availability of gown/ Apron 1 OB/SI
Availability of Caps 1 OB/SI
Heavy duty gloves and gum boats 1 OB/SI
for housekeeping staff
Personal protective kit for 1 OB/SI
delivering HIV patients
ME F3.2 The facility staff adheres to No reuse of disposable gloves, 1 OB/SI
standard personal protection Masks, caps and aprons.
practices
Compliance to correct method of 1 SI
wearing and removing the gloves
Standard F4 The facility has standard procedures for processing of equipment and instruments 14 28
ME F4.1 Facility ensures standard practices Decontamination of Procedure 1 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate work
and cleaning of instruments and benches
procedures areas (Wiping with 0.5% Chlorine
solution)
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 12 24
ME F5.1 Layout of the department is Labour Room is located in a 1 OB
conducive for the infection control secluded place, away from the
practices internal main traffic of the CHC
ME F5.2 The facility ensures availability of Availability of disinfectant as per 1 OB/SI Chlorine solution,
standard materials for cleaning and requirement Gluteraldehye, carbolic acid
disinfection of patient care areas
ME F5.3 The facility ensures standard The Staff is trained in spill 1 SI/RR
practices are followed for the management
cleaning and disinfection of patient
care areas
ME F5.4 The facility ensures segregation of Isolation and barrier nursing 1 OB/SI
infectious patients procedure are followed for septic
cases
Standard F6
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and 13 26
hazardous Waste.
ME F6.1 The facility Ensures segregation of Availability of colour coded bins at 1 OB
Bio Medical Waste as per point of waste generation
guidelines and 'on-site'
management of waste is carried
out as per guidelines
1 OB
Availability of Non chlorinated
plastic colour coded plastic bags
Segregation of Anatomical and 1 OB/SI
solied waste in Yellow Bin
Segregation of infected plastic 1 OB
waste in red bin
Display of work instructions for 1 OB
segregation and handling of
Biomedical waste
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 3 6
ME G3.1 The facility has established There is system daily round by 1 SI/RR
internal quality assurance matron/hospital manager/
programme in key departments hospital superintendent/ Hospital
Manager/ Matron in charge for
monitoring of services
Standard G4
The facility has established, documented implemented and maintained Standard Operating Procedures for all key 20 40
processes and support services.
ME G4.1 Departmental standard operating Standard operating procedure for 1 RR
procedures are available department has been prepared
and approved
ME G4.3 Staff is trained and aware of the Check if staff are aware of relevant 1 SI/RR
procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical 1 OB AMSTL, PPH,Infection
Point of use protocols are displayed control,Eclamsia, New born
resuscitation, kangaroo care
Standard G5
The facility has established system of periodic review as internal assessment , medical & death audit and prescription 4 8
audit
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps time bound Action plan is 1 RR/SI
found in the assessment / audit prepared for improvement
process
ME G5.5 Corrective and preventive actions Corrective and preventive action 1 RR/SI
are taken to address issues, taken
observed in the assessment &
audit
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objective for Labour Room 1 RR/SI
quality objectives and key are defined
departments have their own
objectives
ME G6.3 Quality policy and objectives are Check if staff is aware of quality 1 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically
Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services
5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 17 34
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 6 12
ME H1.1 Facility measures productivity Normal Deliveries per 1000 1 RR
Indicators on monthly basis population
Proportion of deliveries conducted 1 RR
at night
Proportion of complicated 1 RR
cases managed
Proportion of assisted delivery 1 RR
conducted
% PPIUCD inserted against 1 RR
total IUCD
ME H1.2 The Facility measures equity Proportion of BPL Deliveries 1 RR
indicators periodically
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 4 8
ME H2.1 Facility measures efficiency Proportion of cases referred to OT 1 RR
Indicators on monthly basis
Proportion of cases referred to 1 RR
Higher Facilities
% of new-born's required 1 RR
resuscitation out of total live
births
% of new-born's required 1 RR
resuscitation out of total live
births
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 6 12
ME H3.1 Facility measures Clinical Care & Proportion of Cases Partograph 1 RR
Safety Indicators on monthly basis Maintained
ME A1.9 Services are available for the time Availability of admission 1 SI/OB Correlate with Night
period as mandated facilities 24X7 admission rate
Standard B5
The facility ensures that there are no financial barrier to access, and that there is financial protection given from
12 24
the cost of hospital services.
Stay in wards is free for 1 PI/SI
The facility provides cashless entitled patients under NHP
ME B5.1 services to pregnant women, and as per state schemes
mothers and neonates as per
prevalent government schemes
Drugs and consumables under 1 PI/SI
NHP are freely available to
entitled personnel
Patient amenities are provided as Functional toilets with 1 OB 1:12 Male & 1:8 Female
per patient load running water and flush are
available as per strength and
ME C1.2 patient load of ward
Functional bathrooms with 1 OB
running water are available as
per strength and patient load
of ward
Availability of Examination 1 OB
room
Availability of Treatment room 1 OB
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 9 18
The facility ensures seismic safety Non structural components 1 OB Check for fixtures and
of the infrastructure are properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging
ME C2.1 objects are properly
fastened and secured
The facility ensures safety of IPD ward does not have 1 OB Switch Boards other
ME C2.2 electrical establishment temporary connections and electrical installations
loosely hanging wires are intact
Standard C3
The facility has adequate qualified and trained staff, required for providing the assured services to the current
10 20
case load
The facility has adequate Availability of specialist doctor 1 OB/RR
ME C3.1 specialist doctors as per service on call
provision.
The facility has adequate general Availability of at least one 1 OB/RR
ME C3.2 duty doctors as per service doctor at all time
provision
The facility has adequate nursing Availability of Nursing staff 1 OB/RR/SI As per patient load
ME C3.3 staff as per service provision and
work load
The facility has adequate Availability of ward attendant/ 1 SI/RR
ME C3.5. support / general staff Ward boy/Aya
Availability of Security staff 1 SI/RR
Standard C4 The facility provides drugs and consumables required for assured services. 11 22
The departments have availability Availability of 1 OB/RR
ME C4.1 of adequate drugs at point of use Analgesics/Antipyretics/Anti
Inflammatory
Standard C5 The facility has equipment & instruments required for assured list of services. 11 22
Availability of equipment & Availability of functional 1 OB BP apparatus,
instruments for examination & Equipment &Instruments Thermometer,
monitoring of patients for examination & foetoscope, baby and
ME C5.1 Monitoring adult weighing scale,
Stethoscope ,
Glucometer
Standard D2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and
9 18
patient care areas
There is established procedure for There is established system of 1 SI/RR Stock level are daily
forecasting and indenting of drugs timely indenting of updated
and consumables consumables and drugs at Requisition are timely
ME D2.1 nursing station placed
There is process for storage of Temperature of refrigerators 1 OB/RR Check for temperature
vaccines and other drugs, are kept as per storage charts are maintained
ME D2.7 requiring controlled temperature requirement and records are and updated periodically
maintained
There is a procedure for secure Narcotic and psychotropic 1 OB/SI Separate prescription for
ME D2.8 storage of narcotic and drugs are identified and narcotic and
psychotropic drugs stored in lock and key psychotropic drugs
Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and
18 36
comfortable environment to staff, patients and visitors.
Exterior of the facility building is Building is 1 OB
ME D3.1 maintained with landscaping in painted/whitewashed in
the open area uniform colour
The facility ensures safe and Temperature control and 1 PI/OB Fans/ Air
comfortable environment for ventilation in patient care conditioning/Heating/Ex
patients and service providers area haust/Ventilators as per
ME D3.8 environment condition
and requirement
The facility has established measure Ask female staff weather they 1 SI
ME D3.10 for safety and security of female staff feel secure at work place
Standard D4
The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services
3 6
norms
The facility has adequate Availability of running and 1 OB/SI
arrangement storage and supply potable water on 24*7 basis
ME D4.1. for portable water in all functional
areas
The facility provides diets Check for the adequacy and 1 OB/RR Check that all items fixed
according to nutritional frequency of diet as per in diet menu is provided
ME D5.2 requirements of the patients nutritional requirement to the patient
Check for the Quality of diet 1 PI/SI Ask patient & check the
provided record
Hospital has standard procedures for There is procedure of 1 RR/SI Normal, Semi-solid,
preparation, handling, storage and requisition of different type of Liquid diet, diet for
distribution of diets, as per diet from ward to kitchen diabetic patients, low
ME D5.3 requirement of patients salt and high protein diet
etc.
The facility has adequate sets of Clean Linens are provided for 1 OB/RR
ME D 5.4. linen all occupied bed
Gown are provided to the 1 OB/RR
cases going for surgery or
delivery
The facility has standard procedures There is system to check the 1 SI/RR
for handling , collection, cleanliness and quantity of
ME D5.6. transportation and washing of linen the linen received from
laundry
Standard D9
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
4 8
operating procedures.
The facility has established job Staff is aware of their role and 1 SI
ME D9.1 description as per govt guidelines responsibilities
The facility has a established There is procedure to ensure 1 RR/SI Check for system for
procedure for duty roster and that staff is available on duty recording time of
deputation to different as per duty roster reporting and relieving
ME D9.2 departments (Attendance register/
Biometrics etc.)
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 8 16
There is established procedure for Initial assessment's of all 1 RR/SI The assessment criteria
initial assessment of patients admitted patient done as per for different clinical
standard protocols conditions are defined
ME E2.1 and measured in
assessment sheet
Provisional Diagnosis is 1 RR
maintained
Initial assessment and 1 RR/SI
treatment is provided
immediately
Initial assessment is 1 RR
documented preferably within
2 hours
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 8 16
The facility has established Facility has established 1 SI/RR
procedure for continuity of care procedure for handing over of
ME E3.1 during interdepartmental transfer patients from one
department to other
department
Standard E4 The facility has defined and established procedures for nursing care 9 18
Procedure for identification of There is a process for 1 OB/SI Patient id band/ verbal
patients is established at the ensuring the identification confirmation/Bed no.
ME E4.1 facility before any clinical procedure etc.
Procedure for ensuring timely and Treatment chart are 1 RR Check for treatment
accurate nursing care as per maintained chart are updated and
treatment plan is established at the drugs given are marked.
ME E4.2 facility Co relate it with drugs
and doses prescribed.
Nursing records are maintained Nursing notes are maintained 1 RR/SI Check for nursing note
adequately register. Notes are
ME E4.4 adequately written
There is procedure for periodic Patient's Vitals are 1 RR/SI Check for TPR chart, IO
monitoring of patients monitored and recorded chart, any other vital
ME E4.5 periodically required is monitored
The facility identifies high risk High risk patients are 1 OB/SI
ME E5.2 patients and ensure their care, as per identified and treatment
their need given on priority
Standard E6
The facility follows standard treatment guidelines defined by state/Central government for prescribing the
4 8
generic drugs & their rational use.
The facility ensured that drugs are Check for BHT/case 1 RR
prescribed in generic name only sheet/case paper if drugs are
ME E6.1 prescribed under generic
name only
Standard E7 The facility has defined procedures for safe drug administration 11 22
There is process for identifying High alert drugs are identified 1 SI/OB Electrolytes like
and cautious administration of in the department. Potassium chloride,
high alert drugs Opioids, Neuro muscular
blocking agent, Anti
thrombolytic agent,
ME E7.1 Insulin, Warfarin,
Heparin, Adrenergic
agonist etc.
Check single dose vial are not 1 OB Check for any open
used for more than one dose single dose vial with left
over content intended to
be used later on
Standard E8
The facility has defined and established procedures for maintaining, updating of patients’ clinical records and
8 16
their storage
All the assessments, re- Day to day progress of 1 RR
assessment and investigations are patients is recorded in
ME E8.1 recorded and updated BHT/case sheet/case paper
All treatment plan Treatment plan, first orders 1 RR Treatment prescribed Inj
prescription/orders are recorded are written on BHT/case nursing records
ME E8.2 in the patient records. sheet/case paper
Register/records are maintained Registers and records are 1 RR General order book
as per guidelines maintained as per guidelines (GOB), report book,
Admission register, lab
register, Admission
sheet/ bed head ticket,
discharge slip, referral
slip, referral in/referral
ME E8.6 out register, OT register,
Diet register, Linen
register, Drug intend
register
Standard E9 The facility has defined and established procedures for discharge of patient. 10 20
Discharge is done after assessing Assessment is done before 1 SI/RR
ME E9.1 patient readiness discharging patient
Discharge is done by a 1 SI/RR
authorized doctor
Patient / attendants are 1 PI/SI
consulted before discharge
Case summary and follow-up Discharge summary is 1 RR/PI See for discharge
ME E9.2 instructions are provided at time provided summary, referral slip
of discharge provided.
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 2 4
The facility has disaster Staff is aware of disaster plan 1 SI/RR
ME E10.3 management plan in place
Roles and responsibilities of 1 SI/RR
the staff in disaster are
defined
Standard E11 The facility has defined and established procedures of diagnostic services 2 4
There are established procedures Container is labelled properly 1 OB
ME E11.1 for Pre-testing Activities after the sample collection
Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 7 14
There is established procedure for Consent is taken before 1 RR
ME E12.5 transfusion of blood transfusion
Patient's identification is 1 SI/OB
verified before transfusion
Standard E13 The facility has established procedures for Anaesthetic Services 1 2
The facility has established Pre anaesthesia check up is 1 SI/RR
procedures for Pre-anaesthetic conducted for elective /
ME E13.1 Check up and maintenance of Planned surgeries
records
Standard E15 The facility has defined and established procedures for end of life care and death 7 14
Death of admitted patient is Facility has a standard 1 SI
adequately recorded and procedure to decent
ME E15.1 communicated communication of death to
relatives
1 OB/RR
Standard E18 The facility has established procedures for postnatal care as per guidelines 7 14
Post partum Care is provided to Post Partum Care of New- 1 SI/RR Maintaining hand
the mothers born hygiene, keeps the baby
wrapped (maintains
temperature), Checks
weight, temperature,
ME E18.1 respiration, heart rate,
colour of skin and cord
stump
The facility ensures adequate stay 48 Hour Stay of mothers and 1 SI/RR
of mother and new-born in a safe new born after delivery
ME E18.2 environment as per standard
Protocols.
There is established procedure for Counselling is done before 1 RR/PI Danger Sign for Mother:
discharge and follow up of mother discharge, Patient is explained Bleeding, Pain abdomen,
and new-born. about follow up visits Severe Headache, Visual
disturbance, Breathing
difficulties, Fever and
Chills, Difficulty in
Urination, Foul smelling
discharge. Danger sign
for Baby: Fast & difficult
breathing, Fever,
ME E18.5 Unusual Cold, Does not
accept feed, Less active
& yellow discoloration of
skin
Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 11 22
The facility provides immunization Zero dose vaccines are given 1 RR Check for records BCG,
services as per guidelines Hepatitis-B and OPV-0
ME E19.1 given to New-born
Triage, Assessment & Management Assessment Protocols are 1 SI/RR Airway, Breathing,
of new-borns having available Circulation, Coma,
emergency signs are done as per Convulsion, and
ME E19.2 guidelines Dehydration
The facility has defined and Check if Doctors are aware of 1 SI/RR
ME F1.6 established antibiotic policy Hospital Antibiotic Policy
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 9 18
Hand washing facilities are Availability of hand washing 1 OB FNBC guideline: Each
provided at point of use Facility at Point of Use unit should have at least
ME F2.1 1 wash basin for every 5
beds
The facility staff is trained in hand Adherence to 6 steps of Hand 1 SI/OB Ask for demonstration
washing practices and they washing
ME F2.2 adhere to standard hand washing
practices
Standard F3 The facility ensures standard practices and materials for Personal protection 4 8
The facility ensures adequate Clean gloves are available at 1 OB/SI
ME F3.1 personal protection Equipment as point of use
per requirements
Availability of Masks 1 OB/SI
The facility staff adheres to No reuse of disposable gloves, 1 OB/SI
ME F3.2 standard personal protection Masks, caps and aprons.
practices
Compliance to correct 1 SI
method of wearing and
removing the gloves
Standard F4 The facility has standard procedures for processing of equipment and instruments 9 18
The facility ensures standard Decontamination of 1 SI/OB Ask staff about how they
practices and materials for Procedure surfaces decontaminate work
decontamination and cleaning of benches
ME F4.1 instruments and procedures areas (Wiping with 0.5%
Chlorine solution)
Standard F6
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio
13 26
Medical and hazardous Waste.
The facility Ensures segregation of Availability of colour coded 1 OB
Bio Medical Waste as per bins at point of waste
guidelines and 'on-site' generation
ME F6.1 management of waste is carried
out as per guidelines
1 OB
Availability of Non chlorinated
plastic colour coded plastic
bags
1 OB/SI
Segregation of Anatomical
and solied waste in Yellow Bin
Segregation of infected plastic 1 OB
waste in red bin
Display of work instructions 1 OB
for segregation and handling
of Biomedical waste
There is no mixing of
infectious and general waste
The facility ensures management Availability of functional 1 OB See if it has been used or
ME F6.2 of sharps as per guidelines needle cutters just lying idle
Standard G2 The facility has established system for patient and employee satisfaction 1 2
Patient satisfaction surveys are Patient satisfaction survey 1 RR
ME G2.1 conducted at periodic intervals done on monthly basis
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 3 6
The facility has established There is system daily round by 1 SI/RR
internal quality assurance matron/hospital
programme in key departments superintendent/ Hospital
ME G3.1 Manager for monitoring of
services
Standard G4
The facility has established, documented implemented and maintained Standard Operating Procedures for all key
15 30
processes.
Departmental standard operating Standard operating procedure 1 RR
procedures are available for department has been
ME G4.1 prepared and approved
Standard G5
The facility has established system of periodic review as internal assessment , medical & death audit and
7 14
prescription audit
The facility conducts periodic Internal assessment is done at 1 RR/SI
ME G5.1 internal assessment periodic interval
The facility conducts the periodic There is procedure to conduct 1 RR/SI
ME G5.2 prescription/ medical/death Medical Audit
audits
There is procedure to conduct 1 RR/SI
Prescription audit
There is procedure to conduct 1 RR/SI
Death audit
The facility ensures non Non Compliance are 1 RR/SI
ME G5.3 compliances are enumerated and enumerated and recorded
recorded adequately
Action plan is made on the gaps Action plan is prepared 1 RR/SI
ME G5.4 found in the assessment / audit
process
Corrective and preventive actions Corrective and preventive 1 RR/SI
are taken to address issues, action taken
ME G5.5 observed in the assessment &
audit
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
The facility periodically defines its Quality objective for IPD are 1 RR/SI
quality objectives and key defined
ME G6.2 departments have their own
objectives
Standard G7 The facility seeks continually improvement by practicing Quality method and tools. 6 12
The facility uses methods for PDCA 1
ME G7.1 quality improvement in services
5S 1 SI/OB
Mistake proofing 1 SI/OB
Six Sigma 1 SI/RR
The facility uses tools for quality 6 basic tools of Quality 1 SI/RR
ME G7.2 improvement in services
IPD Card
IPD Score 50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50
ME A2.4 The Facility provides child health Screening of New born for 1 SI/RR
Services congenital Birth Defects
Standard A3 Facility Provides diagnostic Services 2 4
ME A3.1 The Facility provides Radiology Functional linkage for USG and 1 SI/OB In house/Parent hospital/
Services X- ray services Outsourced
ME A3.2 The Facility Provides Laboratory NBSU has Linkage for laboratory 1 SI/OB 24x7 linkage with outside
Services investigations laboratory for critical tests like
Blood Count, Platelets, Plasma
glucose, Serum creatinine,
Blood count, Platelet, C
reactive protein, Prothrombin
time,etc.
ME B1.5 Patients & visitors are sensitised Display of information for 1 OB Display of pictorial
and educated through education of mother /relatives information/ chart regarding
appropriate IEC / BCC approaches expression of milk/ techniques
for assisted feeding , KMC,
immunization, complimentary
feeding etc.
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services. 10 20
ME B5.1 The facility provides cashless Availability of Free diagnostics 1 PI/SI
services to pregnant women,
mothers and neonates as per
prevalent government schemes
ME B5.2 The facility ensures that drugs Check that new-born parents & 1 PI/SI
prescribed are available at attendant's have not spent money
Pharmacy and wards on purchasing drugs and
consumables from outside.
ME B5.3 It is ensured that facilities for the Check that new-born parents & 1 PI/SI
prescribed investigations are attendants have not spent money
available at the facility on diagnostics from outside.
ME B5.5 The facility ensures timely If any other expenditure has been 1 PI/RR
reimbursement of financial incurred, then it is reimbursed
entitlements and reimbursement from hospital
to the patients
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging objects
are properly fastened and
secured
ME C2.2 The facility ensures safety of NBSU does not have temporary 1 OB Switch Boards other electrical
electrical establishment connections and loosely hanging installations are intact
wires
ME C2.5 The facility has adequate fire NBSU has installed fire 1 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.
ME C2.6. The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation
Standard C3 Facility has the appropriate number of staff with the correct skill mix required for providing the assured services to the current case load 10 20
ME C3.1 The facility has adequate Availability of On call 1 OB/RR
specialist doctors as per service Paediatrician/trained FIMNCI MO.
provision
ME C3.3 The facility has adequate nursing Availability of one Nursing staff 1 OB/RR/SI
staff as per service provision and per shift
work load
ME C3.6 The staff has been provided Facility based New Born Care 1 SI/RR To all Medical Officers and
required training / skill sets (FBNC) training Nursing Staff posted at NBSU
ME C4.2 The department has adequate Availability of dressings material 1 OB/RR Gauze piece and cotton swabs,
consumables at point of use and diapers Diapers,
Availability of syringes and IV 1 OB/RR Neoflon 24 G , micro drip set
Sets /tubes with &without burette, BT set,
Suction catheter, PT tube,
feeding tube
Standard C5 Facility has equipment & instruments required for assured list of services. 5 10
ME C5.1 Availability of equipment & Availability of functional 1 OB Thermometer, Weighing
instruments for examination & Equipment &Instruments for scale, pulse oxy meter2,
monitoring of patients examination & Monitoring Multipara metre. Stethoscope
ME C5.4 Availability of equipment and Functional Critical care Equipment 1 OB Infusion pumps, Oxygen
instruments for resuscitation of cylinder/Oxygen concentrator,
patients and for providing oxygen hood,etc
intensive and critical care to
patients
ME C5.7 The Department has furniture Availability of Fixtures 1 OB Electrical panel with each unit,
and fixtures as per load and X ray view box.
service provision
Availability of furniture 1 OB Cupboard, nursing counter,
table for preparation of
medicines, chair, furniture at
breast feeding room.
ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of measuring
Equipment
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and new-born care areas 9 18
ME D2.1 There is established procedure There is established system of 1 SI/RR Stock level are daily updated
for forecasting and indenting of timely indenting of consumables Requisition are timely placed
drugs and consumables and drugs at nursing station
Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and 18 36
comfortable environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Check for there is no seepage , 1 OB
adequately maintained Cracks, chipping of plaster
Window panes , doors and other 1 OB
fixtures are intact
Patients beds are intact and 1 OB
painted
Mattresses are intact and clean 1 OB
ME D3.3. Patient care areas are clean and Floors, walls, roof, roof tops, sinks 1 OB All area are clean with no
hygienic new-born care and circulation dirt,grease,littering and
areas are Clean cobwebs
NBSU has procedure to check the 1 SI/RR Each equipment used should
temperature of radiant warmer have servo controlled devices
,phototherapy units, etc. for heat control with cut off to
limit increase in temperature
of radiant warmers beyond a
certain temperature or
warning mechanism for
sounding alert/alarm when
temp increases beyond certain
limits
NBSU has system to control the 1 SI/RR Background sound should not
sound producing activities and be more than 45 db and peak
gadgets (like telephone sounds, intensity should not be more
staff area and equipment) than 80db.
ME D3.9 The facility has a security system New born identification band are 1 OB/RR
in place at patients care area used and foot prints of babies are
taken.
Standard D5
The facility ensures availability of Diet as per nutritional requirement of the patients and clean linen to all admitted 5 10
patients.
ME D5.2 The facility provides diet Check for the adequacy and 1 OB/RR
according to nutritional frequency of feed as per
requirements of the patients nutritional requirement
ME D5.3 Hospital has standard procedures for Facility to prepare feeds is 1 RR/SI
preparation, handling, storage and available near NBSU.
distribution of diets, as per
requirement of patients
ME D5.4 The facility has adequate sets of NBSU has facility to provide 1 OB/RR
linen available. sufficient and clean linen for each
patient
ME D5.5. The facility has established Linen is changed every day and 1 OB/RR
procedures for changing of linen whenever it get soiled
in new-born care areas
ME D5.6. The facility has standard procedures There is a system to check the 1 SI/RR
for handling , collection, cleanliness and Quantity of the
transportation and washing of linen linen received from laundry
Standard D9
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 3 6
operating procedures.
ME D9.1 The facility has established job The Staff is aware of their role
1 SI
description as per govt guidelines and responsibilities
ME D9.2 The facility has a established There is a procedure to ensure 1 RR/SI Check for system for recording
procedure for duty roster and that staff is available on duty as time of reporting and relieving
deputation to different per duty roster (Attendance register/
departments Biometrics etc.)
ME D9.3 The facility ensures the Doctor, nursing staff and support 1 OB
adherence to dress code as staff adhere to their respective
mandated by its administration / dress code
the health department
ME E1.3 There is a established procedure Admission criteria for NBSU are 1 SI/RR
for admission of patients defined & followed
ME E3.2 The facility provides appropriate New-born referred with referral 1 RR/SI
referral linkages to the slip
patients/Services for transfer to
other/higher facilities to assure the
continuity of care.
ME E4.5 There is procedure for periodic Vitals of new-borns are 1 RR/SI Check for TPR chart,
monitoring of patients monitored and recorded Phototherapy chart, any other
periodically vital are monitored and
recorded.
Standard E6
The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic 4 8
drugs & their rational use.
ME E6.1 The facility ensures that drugs are 1
Check for BHT if drugs are RR
prescribed in generic name only prescribed under the generic
name only
ME E6.2 There is procedure of rational use of Check for that relevant Standard 1 RR
drugs treatment guideline are available
at point of use
Maximum dose of high alert drugs 1 SI/RR Value for maximum doses as
are defined and communicated per age, weight and diagnosis
are available with nursing
station and doctor
ME E7.2 Medication orders are written There is process to ensure that 1 SI/RR A system of independent
legibly and adequately right doses of high alert drugs are double check before
only given administration, Error prone
medical abbreviations are
avoided
ME E7.3 There is a procedure to check Drugs are checked for expiry 1 OB/SI
drug before administration/ and other inconsistency
dispensing before administration
Check single dose vial are not 1 OB Check for any open single
used for more than one dose dose vial with left over
content intended to be used
later on
Drip rate and volume are 1 SI/RR Check the nursing staff how
calculated and monitored they calculate Infusion and
monitor it
Standard E8
The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their 8 16
storage
ME E8.1 All the assessments, re- New-born progress is recorded as 1 RR
assessment and investigations are per defined assessment schedule
recorded and updated
ME E8.2 All treatment plan Treatment plan are written on BHT 1 RR
prescription/orders are recorded and all drugs are written legibly in
in the new-born records. case sheet.
ME E8.3 Care provided to each new-born's Maintenance of treatment 1 RR Treatment given is recorded in
recorded in the new-born records chart/treatment registers the treatment chat
ME E8.4 Procedures performed are Procedure performed are 1 RR Mobilization, resuscitation etc.
written on patients records recorded in BHT
ME E8.5 Adequate forms and formats are Standard Formats are available 1 RR/OB Availability of formats for
available at point of use Treatment Charts, TPR Chart ,
Intake Output Chart,
Community follow up card,
BHT, continuation sheet,
Discharge card Etc.
ME E8.6 Register/records are maintained Registers and records are 1 RR General order book (GOB),
as per guidelines maintained as per guidelines report book, Admission
register, lab register,
Admission sheet/ bed head
ticket, discharge slip, referral
slip, referral in/referral out
register, OT register, Diet
register, Linen register, Drug
intend register
ME E9.2 Case summary and follow-up Discharge summary is provided 1 RR/PI See for discharge summary,
instructions are provided at time referral slip provided.
of discharge
Discharge summary mentions 1 RR
adequately patients clinical
condition, treatment given and
follow up
ME E9.3 Counselling services are provided Counselling of mother before 1 PI/SI For care of new born and
as during discharges wherever discharge breastfeeding, treatment and
required follow up counselling
ME E9.4 The facility has established Declaration is taken from the 1 RR/SI
procedure for patients leaving LAMA new-born
the facility against medical
advice, absconding, etc.
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 9 18
ME E10.1 There is procedure for receiving Triaging of new born as per 1 SI/RR
and triage of patients guidelines
ME E10.3 The facility has disaster Staff is aware of disaster plan 1 SI/RR
management plan in place
ME E10.4 The facility ensures adequate and There is a System for coordination 1 SI/RR
timely availability of ambulances of ambulances
services and mobilisation of
resources, as per requirement
Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 6 12
ME E12.5 There is established procedure Consent is taken before 1 RR
for transfusion of blood transfusion
Patient's identification is verified 1 SI/OB
before transfusion
Blood is kept at optimum 1 RR
temperature before transfusion
Standard E15 The facility has defined and established procedures for end of life care and death 8 16
ME E15.1 Death of admitted patient is Facility has a standard 1 SI
adequately recorded and procedure which respects
communicated sensitivities & sentiments to
communicate death to relatives
ME E15.3 The facility has standard operating Patients Relatives are informed 1 SI/RR
procedure for end of life support clearly about the deterioration in
health condition of Patients
Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 2 4
ME E19.3 Management of Low birth weight Adherence to clinical protocol 1 SI/RR Competence testing
new-born's is done as per
guidelines
ME F1.6 The facility has defined and Check if Doctors are aware of 1 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 12 24
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB FNBC guideline: Each unit
provided at point of use Facility at Point of Use should have at least 1 wash
basin for every 5 beds
Availability of running Water 1 OB/SI Open the tap. Ask the Staff,
water is available 24*7
Availability of antiseptic soap with 1 OB/SI Check for availability/ Ask staff
soap dish/ liquid antiseptic with if the supply is adequate and
dispenser. uninterrupted
Standard F3 The facility ensures standard practices and materials for Personal protection 7 14
ME F3.1 The facility ensures adequate Clean gloves are available at point 1 OB/SI Hand washing between each
personal protection Equipment as of use new-born & change of gloves
per requirements
Availability of Mask 1 OB/SI
Availability of gown/ Apron 1 OB/SI Staff and visitors
Availability of shoe cover 1 OB/SI Staff and visitors
Availability of Caps 1 OB/SI Staff and visitors
ME F3.2 The facility staff adheres to No reuse of disposable gloves, 1 OB/SI
standard personal protection masks, caps and aprons.
practices
Compliance to correct method of 1 SI
wearing and removing the gloves
Standard F4 The facility has standard procedures for processing of equipment and instruments 13 26
ME F4.1 The facility ensures standard Cleaning & Decontamination of 1 SI/OB Cleaning of Radiant warmers
practices and materials for new-born care Units and Bassinets with detergent
decontamination and cleaning of and water
instruments and procedure areas
ME F4.2 The facility ensures standard Equipment and instruments are 1 OB/SI Autoclaving/HLD/Chemical
practices and materials for sterilized after each use as per Sterilization
disinfection and sterilization of requirement
instruments and equipment
Standard F5 Physical layout and environmental control of the new-born care areas ensures infection prevention 11 22
ME F5.1 Layout of the department is Floors and wall surfaces of NBSU 1 OB
conducive for the infection control are easily cleanable
practices
ME F5.2 The facility ensures availability of Availability of disinfectant as per 1 OB/SI Chlorine solution,
standard materials for cleaning and requirement Gluteraldehye, carbolic acid
disinfection of new-born care areas
ME F5.3 The facility ensures standard Staff is trained for spill 1 SI/RR
practices are followed for the management
cleaning and disinfection of new-
born care areas
ME F5.4 The facility ensures segregation Isolation and barrier nursing 1 OB/SI
infectious patients procedure are followed for septic
cases
ME F5.5 The facility ensures air quality of NBSU has system to maintain 1 OB Ventilation can be provided in
high risk area ventilation and its environment two ways: exhaust only and
should be dust free supply-and-exhaust. Exhaust
fans pull stale air out of the
unit while drawing fresh air in
through cracks, windows or
fresh air intakes. Exhaust-only
ventilation is a good choice for
units that do not have existing
ductwork to distribute heated
or cooled air
Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and 13 26
hazardous Waste.
ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins at 1 OB
Medical Waste as per guidelines point of waste generation
1 OB
Availability of Non chlorinated
plastic colour coded plastic bags
Segregation of Anatomical and 1 OB/SI
solied waste in Yellow Bin
Segregation of infected plastic 1 OB
waste in red bin
Display of work instructions for 1 OB
segregation and handling of
Biomedical waste
Standard G4
The facility has established, documented implemented and maintained Standard Operating Procedures for all key 21 42
processes.
ME G4.1 Departmental standard operating Standard operating procedure for 1 RR
procedures are available department has been prepared
and approved
ME G4.3 Staff is trained and aware of the Check if staff are aware of relevant 1 SI/RR
procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed Work instruction/clinical 1 OB STP for phototherapy, Grading
at Point of use protocols are displayed and management of
hypothermia, Expression of
milk\, Monitoring of babies
receiving I/V, Precaution for
phototherapy, Management of
Hypoglycaemia, housekeeping
protocols, Administration of
commonly used drugs,
assessment of neonatal sepsis,
Assessment of Jaundice,
Temperature maintenance etc.
Standard G5
The facility has established system of periodic review as internal assessment , medical & death audit and prescription 5 10
audit
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.2 The facility conducts the periodic There is a procedure to conduct 1 RR/SI
prescription/ medical/death New born Death audit
audits
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive actions Corrective and preventive action 1 RR/SI
are taken to address issues, taken
observed in the assessment &
audit
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objective for NBSU are 1 RR/SI
quality objectives and key defined
departments have their own
objectives
ME G6.3 Quality policy and objectives are Check if staff is aware of quality 1 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically
Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services
5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 16 32
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 8
ME H1.1 Facility measures productivity Bed Occupancy Rate 1 RR
Indicators on monthly basis
ME H1.2 The Facility measures equity Proportion of female babies 1 RR
indicators periodically admitted
Male: Female LAMA ratio 1 RR
Proportion of BPL Patients 1 RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 6 12
ME H2.1 Facility measures efficiency Proportion of low birth weight 1 RR No. of low birth weight babies
Indicators on monthly basis babies (< 2500 gm but not < 1800
gm)
No of New-born Resuscitated 1 RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 1 2
ME H4.1 Facility measures Service Quality LAMA Rate 1 RR
Indicators on monthly basis
ME A1.3 The facility provides Obstetrics & Availability of Gynaecology 1 SI/OB D & E, LSCS, Hysterectomy.
Gynaecology Services procedures
ME A1.9 Services are available for the time OT Services are available 24X7 1 SI/RR
period as mandated
ME A1.10 The facility provides Accident & OT services are available for 1 SI/OB
Emergency Services emergency cases.
Standard A2 Facility provides RMNCHA Services 5 10
ME A2.1 The facility provides Reproductive Availability of Post partum 1 SI/OB Tubal ligation
health Services sterilization services
Availability of Abortion services. 1 SI/OB
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of 3 6
physical, economic, cultural or social status.
ME B2.1 Services are provided in manner Availability of female staff if a male 1 OB/SI Availability of female staff in pre
that are sensitive to gender doctor examination/ conduct and post operative room
surgery of a female patient
Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information. 5 10
ME B3.1 Adequate visual privacy is Availability of screen between OT 1 OB
provided at every point of care table
Patients are properly 1 OB
draped/covered before and after
procedure.
ME B3.2 Confidentiality of patients records Patient Records are kept at secure 1 SI/OB
and clinical information is place beyond access to general
maintained staff/visitors
ME B3.4 The facility ensures privacy and Privacy and Confidentiality of HIV 1 SI/OB
confidentiality to every patient, cases
especially of those conditions
having social stigma, and also
safeguards vulnerable groups
Standard B5
Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital 5 10
services.
ME B5.1 The facility provides cashless All surgical procedures are free of 1 PI/SI JSSK
services to pregnant women, cost for JSSK beneficiaries
mothers and neonates as per
prevalent government schemes
ME B5.3 It is ensured that facilities for the Check that patient/attendants 1 PI/SI
prescribed investigations are have not spent money on
available at the facility Diagnostic from outside.
ME B5.4 The facility provide free of cost Surgical services are free for BPL 1 PI/SI/RR
treatment to Below poverty line patients
patients without administrative
hassles
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and furniture like
safety of the infrastructure properly secured cupboards, cabinets, and heavy
equipment , hanging objects are
properly fastened and secured
ME C2.3 Physical condition of the buildings Floors of the OT are non slippery 1 OB
is safe for providing patient care and even
ME C2.5 The facility has adequate fire OT room has installed fire 1 OB
fighting Equipment Extinguisher that are capable of
fighting A,B,C Type of Fire
ME C2.6 The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 19 38
ME C3.1 The facility has adequate Availability of Obs & Gynae 1 OB/RR As per case load
specialist doctors as per service Surgeon
provision
Availability of trained surgeon for 1 OB/RR Minilap - MBBS trained in
Minilap/ Laparoscopic/NSV procedure
Laparoscopic
Availability of emergency drugs 1 OB/RR Inj Adrenaline, Inj Magsulf 50%, Inj
Calcium gluconate 10%, Inj
Hydrocortisone, Succinate, Inj
Diazepam, Inj Pheniramine
maleate, inj Cerboprost, Inj Fort
win, Inj Phenergan,
Betamethasone, Inj Hydralazine,
Nifidepin, Methyldopa
Standard C5 The facility has equipment & instruments required for assured list of services. 20 40
ME C5.1 Availability of equipment & Availability of functional 1 OB BP apparatus, Thermometer, Pulse
instruments for examination & Equipment &Instruments for Oxy meter, Multipara meter , PV
monitoring of patients examination & Monitoring Set
ME C5.2 Availability of equipment & Availability of functional 1 OB LSCS Set, Cervical Biopsy Set, MVA
instruments for treatment instruments for Gynae and set, D&C Set, Defibrillator,
procedures, being undertaken in obstetrics Nebulizers
the facility
ME C5.4 Availability of equipment and Availability of functional 1 OB Ambu bag, Oxygen, Suction
instruments for resuscitation of Instruments for Resuscitation machine , laryngoscope, ET Tube,
patients and for providing defibrillator
intensive and critical care to
patients
ME C5.5 Availability of Equipment for Availability of equipment for 1 OB Crash cart/Drug trolley, instrument
Storage storage for drugs trolley, dressing trolley
ME C5.6 Availability of functional Availability of equipment for 1 OB Buckets for mopping, Separate
equipment and instruments for cleaning mops for patient care area and
support services circulation area duster, waste
trolley, Deck brush
ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR Boyles apparatus, cautery, BP
procedure for internal and instrument are calibrated apparatus, autoclave etc.
external calibration of measuring
Equipment
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care 12 24
ME D2.1 There is established procedure There is established system of 1areas SI/RR Stock level are daily updated
for forecasting and indenting of timely indenting of consumables Requisition are timely placed
drugs and consumables and drugs
ME D2.6 There is a procedure for periodically There is procedure for replenishing 1 SI/RR
replenishing the drugs in patient drug tray /crash cart
care areas
ME D2.8 There is a procedure for secure Narcotic and psychotropic drugs 1 OB/SI
storage of narcotic and are kept in lock and key
psychotropic drugs
Anaesthetic agents are kept at 1 OB/SI
secured place
Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable 18 36
environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Interior of patient care areas are 1 OB
adequately maintained plastered & painted
Check to ensure that there is no 1 OB
seepage , cracks, chipping of
plaster
ME D3.8 The facility ensures safe and Temperature is maintained and 1 SI/RR 20-250C, ICU has functional room
comfortable environment for record of same is kept thermometer and temperature is
patients and service providers regularly maintained
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 6 12
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas
ME D4.2 The facility ensures adequate Availability of power back up in OT 1 OB/SI 2 tier backup with UPS
power backup in all patient care
areas as per load
Availability of UPS 1 OB/SI
Availability of Emergency light 1 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Centralized /local 1 OB
availability of oxygen, medical gases piped Oxygen, nitrogen and
and vacuum supply vacuum supply
Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 4 8
ME D5.4 The facility has adequate sets of OT has facility to provide sufficient 1 OB/RR Drape, draw sheet, cut sheet and
linen and clean linen for surgical patient gown
Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 4 8
ME D9.1 The facility has established job procedures.
Staff is aware of their roles and
1 SI
description as per govt guidelines responsibilities
ME D9.2 The facility has a established There is procedure to ensure that 1 RR/SI Check for system for recording
procedure for duty roster and staff is available on duty as per time of reporting and relieving
deputation to different duty roster (Attendance register/ Biometrics
departments etc.)
Standard E4 The facility has defined and established procedures for nursing care 5 10
ME E4.1 Procedure for identification of There is a process for ensuring the 1 OB/SI Patient id band/ Patient ID
patients is established at the identification before any clinical No./verbal confirmation etc.
facility procedure
ME E4.2 Procedure for ensuring timely and There is a process to ensue the 1 SI/RR Verbal orders are rechecked before
accurate nursing care as per accuracy of verbal/telephonic administration
treatment plan is established at the orders
facility
ME E4.3 There is established procedure of Patient hand over is given during 1 SI/RR
patient hand over, whenever staff the change in the shift
duty change happens
Handover register is maintained 1 RR
ME E4.5 There is procedure for periodic Patient Vitals are monitored 1 RR/SI Check for use of multi parameter
monitoring of patients and recorded periodically
Standard E5 Facility has a procedure to identify high risk and vulnerable patients. 2 4
ME E5.1 The facility identifies vulnerable Vulnerable patients are identified 1 OB/SI Check the measure taken to
patients and ensure their safe care and measures are taken to protect prevent new born theft, baby
them from any harm sweeping and baby fall
ME E5.2 The facility identifies high risk High risk patients are identified 1 OB/SI HIV, Infectious cases
patients and ensure their care, as and treatment given on priority
per their need
Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their
3 6
rational use.
ME E6.1 Facility ensured that drugs are Check for BHT if drugs are 1 RR
prescribed in generic name only prescribed under generic name
only
ME E6.2 There is procedure of rational use of Check staff is aware of the drug 1 SI/RR
drugs regime and doses as per STG
Maximum dose of high alert drugs 1 SI/RR Value for maximum doses as per
are defined and communicated age, weight and diagnosis are
available with nursing station and
doctor
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 8 16
ME E8.1 All the assessments, re- Records of Monitoring/ 1 RR PAC, Intraoperative monitoring
assessment and investigations are Assessments are maintained
recorded and updated
ME E8.2 All treatment plan Treatment plan, first orders are 1 RR Treatment prescribed in nursing
prescription/orders are recorded written on BHT records
in the patient records.
ME E8.4 Procedures performed are Operative Notes are Recorded 1 RR Name of person in attendance
written on patients records during procedure, Pre and post
operative diagnosis, Procedures
carried out, length of procedures,
estimated blood loss, Fluid
administered, specimen removed,
complications etc.
ME E8.5 Adequate form and formats are Standard Formats available 1 RR/OB Consents, surgical safety check list
available at point of use
ME E8.6 Register/records are maintained Registers and records are 1 RR OT Register, Schedule, Infection
as per guidelines maintained as per guidelines control records, autoclaving
records etc.
ME E14.2 Facility has established Patient evaluation before surgery 1 RR/SI Vitals , Patients fasting status etc.
procedures for Preoperative care is done and recorded
ME E14.4 Facility has established Post operative monitoring is done 1 RR/SI Check for post operative operation
procedures for Post operative before discharging to ward ward is used and patients are not
care immediately shifted to wards after
surgery
Post operative notes and orders 1 RR/SI Post operative notes contains Vital
are recorded signs, Pain control, Rate and type
of IV fluids, Urine and
Gastrointestinal fluid output, other
medications and Laboratory
investigations
Standard E17 Facility has established procedures for Intranatal care as per guidelines 13 26
ME E17.2 There is an established procedure pre operative care 1 SI/RR Check for Haemoglobin level is
for assisted and C-section estimated , and arrangement of
deliveries per scope of services. Blood, IV line established,
Catheterization, Demonstration of
Antacids
ME E17.3 There is established procedure Management of PIH/Eclampsia 1 SI/RR Ask for how to secure airway and
for management of Obstetrics breathing, Loading and
Emergencies as per scope of Maintenance dose of Magnesium
services. sulphate , Administration of
Hypertensive Drugs
Vitamin K 1 SI/RR
Care of Cord and Eyes 1 SI/RR
APGAR Score 1 SI/RR
New born Resuscitation 1 SI/RR
Standard E18 Facility has established procedures for postnatal care as per guidelines 3 6
ME E18.1 Post partum Care is Provided to Prevention of Hypothermia 1 SI/RR
Mother
Initiation of Breastfeeding with-in 1 PI/SI
1 Hour
ME E18.4 The facility has procedures for There is established criteria for 1 SI/RR
Stabilization/treatment/referral shifting new-born to NBSU/SNCU
of post natal complication
ME F1.3 Facility measures hospital There is procedure to report cases 1 SI/RR Patients are observed for any sign
associated infection rates of Hospital acquired infection and symptoms of HAI like fever,
purulent discharge from surgical
site .
ME F1.4 There is Provision of Periodic There is procedure for 1 SI/RR Hepatitis B, Tetanus Toxoid etc.
Medical Check-up's and immunization of the staff
immunization of staff
Periodic medical check-up of the 1 SI/RR
staff
ME F1.5 Facility has established Regular monitoring of infection 1 SI/RR Hand washing and infection
procedures for regular monitoring control practices control audits done at periodic
of infection control practices intervals
ME F1.6 Facility has defined and Check for Doctors are aware of 1 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 15 30
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB Check for availability of wash basin
provided at point of use Facility at Point of Use near the point of use
Availability of running Water 1 OB/SI Open the tap. Ask the staff, water
is 24*7
Availability of antiseptic soap with 1 OB/SI Check for availability/ Ask staff if
soap dish/ liquid antiseptic with the supply is adequate and
dispenser. uninterrupted
Availability of Alcohol based Hand 1 OB/SI Check for availability/ Ask staff for
rub regular supply.
Display of Hand washing 1 OB Prominently displayed above the
Instruction at Point of Use hand washing facility , preferably in
Local language
ME F2.2 The Facility Staff is trained in Adherence to 6 steps of Hand 1 SI/OB Ask for demonstration
correct Hand washing practices washing
and they adhere to standard hand
washing practices
Check sterile field is maintained 1 OB/SI Surgical site covered with sterile
during surgery drapes, sterile instruments are
kept within the sterile field.
Standard F3 Facility ensures standard practices and materials for Personal protection 9 18
ME F3.1 Facility ensures adequate Clean gloves are available at point 1 OB/SI
personal protection equipment as of use
per requirements
Availability of Masks 1 OB/SI
Sterile gloves are available in OT 1 OB/SI
and Critical areas
Use of elbow length gloves for 1 OB/SI
obstetrical purpose
Availability of gown/ Apron 1 OB/SI
Availability of Caps 1 OB/SI
Personal protective kit for 1 OB/SI HIV kit
infectious patients
ME F3.2 Staff is adhere to standard No reuse of disposable gloves, 1 OB/SI
personal protection practices Masks, caps and aprons.
Compliance to correct method of 1 SI
wearing and removing the gloves
Standard F4 Facility has standard Procedures for processing of equipment and instruments 18 36
ME F4.1 Facility ensures standard practices Decontamination of operating 1 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate the procedure
and cleaning of instruments and surface like OT Table,
procedures areas Stretcher/Trolleys etc.
(Wiping with 0.5% Chlorine
solution
High level Disinfection of 1 OB/SI Ask staff about method and time
instruments/equipment is done required for boiling
as per protocol
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 18 36
ME F5.1 Layout of the department is Facility layout ensures separation 1 OB Faculty layout ensures separation
conducive for the infection control of general traffic from patient of general traffic from patient
practices traffic traffic
ME F5.2 Facility ensures availability of Availability of disinfectant as per 1 OB/SI Chlorine solution, Gluteraldehye,
standard materials for cleaning and requirement carbolic acid
disinfection of patient care areas
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 3 6
ME G3.1 Facility has established internal There is system daily round by 1 SI/RR
quality assurance program at Surgeon/Matron/Hospital
relevant departments manager/ Hospital
Superintendent/for monitoring of
services
ME G3.3 Facility has established system for Departmental checklist are used 1 SI/RR
use of check lists in different for monitoring and quality
departments and services assurance
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 14 28
ME G4.1 Departmental standard operating Standard operating procedure for 1 RR
procedures are available department has been prepared
and approved
ME G4.3 Staff is trained and aware of the Check staff if aware of relevant 1 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 1 OB Processing and sterilization of
Point of use are displayed equipment,
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 4 8
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive actions Corrective and preventive actions 1 RR/SI
are taken to address issues, are taken
observed in the assessment &
audit
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objective for OT are 1 RR/SI
quality objectives and key defined
departments have their own
objectives
ME G6.3 Quality policy and objectives are Check of staff is aware of quality 1 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically
Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services
5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 18 36
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 8
ME H1.1 Facility measures productivity C-Section Rate 1 RR
Indicators on monthly basis
Proportion of C-Sections done in 1 RR
night
Proportion of other emergency 1 RR
surgeries done in the night
No. of Major surgeries done per 1 1 RR
lakh population
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 5 10
ME H2.1 Facility measures efficiency Downtime of critical equipment 1 RR
Indicators on monthly basis
No of major surgeries per surgeon 1 RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 1 2
ME H4.1 Facility measures Service Quality Operation Cancellation rates 1 RR No. of cancelled operation*1000
Indicators on monthly basis /total operation done
Planned operations
cancelled due to any
reason like clinical,
non clinical (theatre),
or by patient
0
National Quality Assurance Standards for Taluka Hospital 0 1 2
ME A3.2 The facility Provides All lab services are available in 1 SI/RR
Laboratory Services routine working hours
Standard A6 Health services provided at the facility are appropriate to community needs. 1 2
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their 6 12
modalities
ME B1.1 The facility has uniform and Availability departmental 1 OB (Numbering of rooms, main
user-friendly signage system signage's department and inter- sectional
signage)
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no 2 4
barrier on account of physical , economic, cultural or social status.
ME B2.1 Services are provided in Separate queue for female 1 OB
manner that are sensitive to patients at lab
gender
ME B2.3 Access to facility is provided Check the availability of ramp 1 OB
without any physical barrier in lab building area /sample
& and friendly to people collection area
with disabilities
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 3 6
information.
ME B3.2 Confidentiality of patients Laboratory has a system to 1 SI/OB Laboratory staff do not discuss
records and clinical ensure the confidentiality of the lab result and reports are
information is maintained the reports generated kept in secure place
Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and 2 4
involving them in treatment planning, and facilitates informed decision making
ME B4.1 There is established Informed Consent is taken 1 SI/RR Before testing for HIV patient is
procedures for taking before HIV testing, Biopsy informed the that test is
informed consent before and any other invasive voluntary and result will be
treatment and procedures procedure disclosed to him/her only
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost 5 10
of care.
ME B5.1 The facility provides Free Diagnostic tests for 1 PI/SI
cashless services to Pregnant women & Infant
pregnant women, mothers
and neonates as per
prevalent government
schemes
ME B5.2 The facility ensures that Check that patient has not 1 PI/SI
drugs prescribed are incurred expenditure on
available at Pharmacy and purchasing consumables from
wards outside.
ME B5.3 It is ensured that facilities Check that patient party not 1 PI/SI
for the prescribed incurred expenditure on
investigations are available diagnostics from outside.
at the facility
ME B5.4 The facility provide free of Tests are free of cost for BPL 1 PI/SI/RR
cost treatment to Below patients
Poverty Line(BPL) patients
without administrative
hassles
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent 10 20
norms
ME C1.1 Departments have Laboratory space is adequate 1 OB Adequate area for sample
adequate space as per for carrying out activities collection, waiting, performing
patient or work load test, keeping equipment and
storage of drugs and records
Availability of functional 1 OB
toilets
Availability of drinking water 1 OB
near laboratory.
ME C 1.3 Departments have layout Demarcated sample collection 1 OB
and demarcated areas as area
per functions
Demarcated testing area 1 OB
Designated report writing 1 OB
area
Demarcated washing and 1 OB
waste disposal area
ME C 1.5 The facility has Availability of functional 1 OB
infrastructure for intramural telephone and Intercom
and extramural Services
communication
ME C 1.7 The facility and Unidirectional flow of services 1 OB Sample collection- Sample
departments are planned to processing- Analytical area-
ensure structure follows the reporting.
function/processes
(Structure commensurate
with the function of the
hospital)
Standard C The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
2
ME C2.1 The facility ensures the Non structural components 1 OB Check for fixtures and furniture
seismic safety of the are properly secured like cupboards, cabinets, and
infrastructure heavy equipment , hanging
objects are properly fastened
and secured
ME C2.5. The facility has adequate Lab has installed fire 1 OB/RR
fire fighting Equipment Extinguishers to handle fire
ABC type
ME C2.6. The facility has a system of Check for staff competencies 1 SI/RR
periodic training of staff and for operating fire extinguisher
conducts mock drills and what to do in case of fire
regularly for fire and other
disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current 8 16
case load
ME C3.4 The facility has adequate Availability of Lab. technicians 1 OB/RR Two Lab technicians
technicians/paramedics as
per requirement
ME C3.6. The staff has been provided Training on automated 1 SI/RR
required training / skill sets Diagnostic Equipment like
semi auto analyser
Standard C Facility provides drugs and consumables required for assured list of services. 3 6
4
ME C4.2 The departments have Regular availability of supplies 1 OB/RR Clean slides, slide markers,
adequate consumables at for Laboratory gloves, transport medium, test
point of use tubes, vials, swabs, culture
bottles, Zeil Neelsen Acid Fast
stain, sealing material etc.
Standard C5 The facility has equipment & instruments required for assured list of services. 9 18
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 10 20
ME D 1.1 The facility has established All equipment are covered 1 SI/RR Agency/ is identified for
system for maintenance of under the AMC including maintenance of the equipment
critical Equipment preventive maintenance
ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and 8 16
patient care areas
ME D2.1 There is a established There is established system of 1 SI/RR Stock level are daily updated
procedure for forecasting timely indenting of Requisition are timely placed
and indenting of drugs and consumables and reagents
consumables
ME D3.8 The facility ensures safe and Temperature control and 1 SI/RR Fans/ Air
comfortable environment ventilation in the laboratory. conditioning/Heating/Exhaust/V
for patients and service entilators as per environment
providers condition and requirement
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services 2 4
norms
ME D4.1 The facility has adequate Availability of running and 1 OB/SI
arrangement storage and potable water on 24*7 basis
supply for potable water in
all functional areas
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 1 2
Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 3 6
operating procedures.
ME D9.1 The facility has established Staff is aware of their role 1 SI
job description as per govt and responsibilities
guidelines
ME D9.2 The facility has a There is procedure to ensure 1 RR/SI Check for system of recording
established procedure for that staff is available on duty time of reporting and relieving
duty roster and deputation as per duty roster (Attendance register/
to different departments Biometrics etc.)
Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 2 4
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 2 4
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their 5 10
storage
ME E8.5 Adequate form and formats Standard Formats are 1 RR/OB Printed formats for requisition
are available at point of use available and reporting are available
ME E10.5 There is a procedure for Samples of medico legal cases 1 SI/RR Requisition and reports are
handling medico legal cases are identified, Secured, marked with MLC, and the
preserved and processed reports are handed over to
authorized personnel only
Standard The facility has defined and established procedures of diagnostic services 14 28
E11
ME E11.1 There are established Requisitions of all laboratory 1 RR/OB Request form contains relevant
procedures for Pre-testing test are received on information: Name and
Activities designated and apparent identification number of
forms. patient, name of authorized
requester, type of primary
sample, examination requested,
date and time of primary
sample collection and date and
time of receipt of sample by
laboratory,
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital 3 6
associated infection
ME F1.4 There is Provision of There is procedure for 1 SI/RR Hepatitis B, Tetanus Toxoid etc.
Periodic Medical Check-up's immunization of the staff
and immunization of staff
Periodic medical check-up's of 1 SI/RR
the staff is undertaken
ME F1.5 Facility has established Regular monitoring of 1 SI/RR Hand washing and infection
procedures for regular infection control practices control audits are done at
monitoring of infection periodic intervals
control practices
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 10 20
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB Check for availability of wash
provided at point of use Facility at Point of Use basin near the point of use
Availability of running Water 1 OB/SI Open the tap. Ask the Staff,
water is available 24*7
Availability of antiseptic soap 1 OB/SI Check for availability/ Ask staff
with soap dish/ liquid if the supply is adequate and
antiseptic with dispenser. uninterrupted
ME F2.2 Staff is trained and adhere Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
to standard hand washing washing
practices
Staff aware of when to hand 1 SI
wash
ME F2.3 Facility ensures standard Availability of Antiseptic 1 OB
practices and materials for Solutions
antisepsis
Proper cleaning of procedure 1 OB/SI before drawing blood,
site with antisepsis
Standard F3 Facility ensures standard practices and materials for Personal protection 4 8
Standard F4 Facility has standard Procedures for processing of equipment and instruments 6 12
ME F4.1 Facility ensures standard Decontamination of 1 SI/OB Ask staff about how they
practices and materials for Procedure surfaces decontaminate work benches
decontamination and clean ing (Wiping with 0.5% Chlorine
of instruments and solution)
procedures areas
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 8 16
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical 15 30
and hazardous Waste.
ME F6.1 Facility Ensures segregation Availability of colour coded 1 OB
of Bio Medical Waste as per bins at point of waste
guidelines generation
1 OB
Availability of Non chlorinated
plastic colour coded plastic
bags
1 OB/SI
Segregation of Anatomical
and solied waste in Yellow Bin
Segregation of infected plastic 1 OB
waste in red bin
Display of work instructions 1 OB
for segregation and handling
of Biomedical waste
There is no mixing of
infectious and general waste
ME F6.2 Facility ensures Availability of functional 1 OB See if it has been used or just
management of sharps as needle cutters lying idle
per guidelines
Availability of puncture proof 1 OB Should be available nears the
box point of generation like nursing
station and injection room
Standard G2 Facility has established system for patient and employee satisfaction 1 2
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 12 24
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key 25 50
processes and support services.
ME G4.1 Departmental standard Standard operating procedure 1 RR
operating procedures are for department has been
available prepared and approved
ME G4.4 Work instructions are Work instruction/clinical 1 OB Work instruction for Internal
displayed at Point of use protocols are displayed Quality control,
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and 4 8
prescription audit
ME G5.1 The facility conducts Internal assessment is done at 1 RR/SI
periodic internal periodic interval
assessment
ME G5.3 The facility ensures non Non Compliance are 1 RR/SI
compliances are enumerated and recorded
enumerated and recorded
adequately
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 7 14
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 8 16
ME H1.1 Facility measures productivity No. of HIV test done per 1000 1 RR
Indicators on monthly basis population
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 6 12
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 8
H Outcome 50
ME B1.2 The facility displays the services Timing for taking X-ray and 1 OB
and entitlements available in its collection of reports are displayed
departments outside the X-ray department
ME B1.4 User charges are displayed and User charges in r/o X-ray services 1 OB
communicated to patients are displayed at entrance
effectively
ME B1.6 Information is available in local Signage's and information are 1 OB
language and easy to available in local language
understand
ME B1.8 The facility ensures access to Reports are provided to Patient in 1 OB
clinical records of patients to proper printed format
entitled personnel
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on 2 4
account of physical, economic, cultural or social status.
ME B2.1 Services are provided in manner Female attendant should 1 OB/SI
that are sensitive to gender accompany female patients during
radiological procedures
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 4 8
ME B3.1 Adequate visual privacy is X-ray department has provision of 1 OB
provided at every point of care privacy while taking X-ray.
ME B3.2 Confidentiality of patients Radiology has system to ensure 1 RR/SI Radiology staff do not
records and clinical information the confidentiality of the reports discuss the X-Ray/USG
is maintained result outside. And reports
are kept in secure place
Standard B4 Facility has defined and established procedures for informing patient about their medical condition and involving them 1 2
ME B4.1 There is established procedures Form F for USG under PNDT 1 RR
for taking informed consent maintained for scan of pregnant
before treatment and woman
procedures
Standard B5
Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of 4 8
hospital services.
ME B5.1 The facility provides cashless Free radiology services for 1 PI/SI USG and X-ray
services to pregnant women, Pregnant women and infant
mothers and neonates as per
prevalent government schemes
ME B5.3 It is ensured that facilities for Check that patient/attendant has 1 PI/SI
the prescribed investigations not incurred expenditure on
are available at the facility having Radiological Investigation(s)
from outside.
ME B5.4 The facility provide free of cost Tests are free of cost to BPL 1 PI/SI
treatment to Below poverty line patients
patients without administrative
hassles
ME B5.5 The facility ensures timely JSSK beneficiaries get free 1 PI/SI/RR Check that empanelled
reimbursement of financial investigations even for the tests labs are providing cashless
entitlements and not available at the facility facilities.
reimbursement to the patients
ME C1.4 The facility has adequate Corridors are wide enough for 1 OB 2-3 meters
circulation area and open movement of trolleys and
spaces according to need and stretchers
local law
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging
objects are properly
fastened and secured
ME C2.2 The facility ensures safety of X-ray - does not have temporary 1 OB Switch Boards other
electrical establishment connections and loosely hanging electrical installation are
wires intact
ME C2.6. The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly what to do in case of fire
for fire and other disaster
situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case 5 10
ME C3.4 The facility has adequate Availability of Radiographer load
1 SI/RR One radiographer
technicians/paramedics as per
requirement
ME C3.6 The staff has been provided Training on radiation safety 1 SI/RR
required training / skill sets
Training on infection control and 1 SI/RR
hand hygiene
Training on Bio Medical waste 1 SI/RR
Management
ME C3.7 The Staff is skilled as per job Radiographers are skilled to 1 SI/RR
description operating equipment
Standard C4 Facility provides drugs and consumables required for assured list of services. 3 6
ME C4.2 The departments have Availability Consumables 1 OB/RR X-ray films, Developer,
adequate consumables at point Fixer, USG gel, printing
of use paper
Standard C5 The facility has equipment & instruments required for assured list of services. 8 16
ME C5.1 Availability of equipment & Availability of functional 1 OB TLD badges
instruments for examination & Equipment &Instruments for
monitoring of patients examination & Monitoring
ME C5.3 Availability of equipment & Availability of functional X-ray 1 OB 300 MA X-ray machine
instruments for diagnostic machines
procedures being undertaken in
the facility
ME C5.7 Departments have patient Availability of attachment/ 1 OB X-ray hangers, Bucky Stand
furniture and fixtures as per accessories
load and service provision
Availability of fixtures at lab 1 OB X-ray View box, Electrical
fixture for equipment
ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and 6 12
ME D2.1 There is established system of patient care
There is established procedure 1 areas
SI/RR Stock level are daily
for forecasting and indenting timely indenting of X-ray films, updated
drugs and consumables fixer and developers etc. Requisition are timely
placed
ME D2.3 The facility ensures proper Fixers, developer and X-ray films/ 1 OB/RR
storage of drugs and consumables are kept away from
consumables water and sources of heat,
direct sunlight
ME D2.5 The facility has established Department maintains stock and 1 RR/SI
procedure for inventory expenditure register of chemicals
management techniques and X-ray films
Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable 17 34
environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Check to ensure that there is no 1 OB
adequately maintained seepage , cracks, chipping of
plaster
ME D3.8 The facility ensures safe and Protective apron and gloves are 1 OB/SI
comfortable environment for being provided to relative of the
patients and service providers child patient who escort the child
for X-ray examination/
immobilisation support is provided
to children
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for potable water in all
functional areas
Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 3 6
ME D9.1 The facility has established job The Staff is aware of their role 1 SI
description as per govt and responsibilities
guidelines
ME D9.2 The facility has a established There is procedure to ensure that 1 RR/SI Check for system for
procedure for duty roster and the staff is available on duty as per recording time of reporting
deputation to different duty roster and relieving (Attendance
departments register/ Biometrics etc.)
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 1 2
ME E3.2 Facility provides appropriate There is procedure for referral 1 RR/SI
referral linkages to the of patient for which services
patients/Services for transfer to can not be provided at the
other/higher facilities to assure facility
their continuity of care.
Standard E5 Facility has a procedure to identify high risk and vulnerable patients. 1 2
ME E5.1 The facility identifies vulnerable Women in reproductive age are 1 OB/SI/RR Notice in local language is
patients and ensure their safe care asked for pregnancy (LMP)before displayed at entrance of X-
X-ray ray department asking
every female to inform
radiographer/radiologist
whether she is likely to be
pregnant
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 3 6
ME E8.5 Adequate form and formats are Standard Formats available 1 RR/OB Printed formats for
available at point of use requisition and reporting
are available
Standard E11 The facility has defined and established procedures of diagnostic services 12 24
ME E11.1 There are established Requisition of all X-ray examination 1 RR/OB Request form contain
procedures for Pre-testing is done in request form information: Name and
Activities identification number of
patient, Provisional
diagnosis, Indication for
the investigation, name of
authorized requester,
examination requested,
type of X-ray, date and
time of X-ray taken and
date and time of receipt of
X-ray from X-ray
department
ME E11.2 There are established The X-ray taking and processing 1 OB/RR
procedures for testing Activities procedure are readily available at
work station and staff is aware of it
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 7 14
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB Check for availability of
provided at point of use Facility at Point of Use wash basin near the point
of use
ME F2.2 Staff is trained and adhere to Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
standard hand washing washing
practices
Staff is aware of when to hand 1 SI
wash
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 4 8
ME F5.2 Facility ensures availability of Availability of cleaning agent as 1 OB/SI Hospital grade phenyl,
standard materials for cleaning and per requirement disinfectant detergent
disinfection of patient care areas solution
ME F5.3 Facility ensures standard practices Staff is trained for spill 1 SI/RR
followed for cleaning and management
disinfection of patient care areas
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 2 4
ME G3.2 The facility has established TLD Badges are analysed at 1
external assurance programmes stipulated intervals
at relevant departments
SI/RR
ME G3.3 Facility has established system Departmental checklist is used 1 SI/RR
for use of check lists in different for monitoring and quality
departments and services assurance
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key 15 30
ME G4.1 Departmental standard Standard operating procedure for 1 RR
operating procedures are department has been prepared
available and approved
ME G4.3 Staff is trained and aware of the Check if staff is aware of relevant 1 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4 Work instructions are displayed Work Instructions are displayed for 1 OB Factor chart, radiation
at Point of use radiation safety safety, development for x-
ray films
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription 4 8
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and recorded
and recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive Corrective and preventive action 1 RR/SI
actions are taken to address are taken
issues, observed in the
assessment & audit
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines Quality objectives for Radiology 1 RR/SI
its quality objectives and key are defined
departments have their own
objectives
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 5 10
ME A4.1 The facility provides services under Availability of Drugs under NVBDCP 1 SI/OB Chloroquine, Primaquine, ACT
National Vector Borne Disease (Artemisinin Combination
Control Programme as per Therapy)
guidelines
ME A4.2 The facility provides services under Availability of Drugs under RNTCP 1 SI/OB
Revised National TB Control
Programme as per guidelines
CAT 1, CAT II CAT IV &
Paediateric
ME A4.3 The facility provides services under Availability of Drugs under NLEP 1 SI/OB
National Leprosy Eradication
Programme as per guidelines
Rifampicin, Clofazimine,
Dapsone
ME A4.4 The facility provides services under Availability of ARV Drugs under NACP 1 SI/OB Zidovudine, Stavudine,
National AIDS Control Programme Lamivudine, Nevirapine in
as per guidelines combination as per NACO
Availability of Drugs for Paediatric HIV 1 SI/OB Paediatric Dosages FDC 6, FDC
management 10, Efavirenz, Cotrimoxazole
ME B1.2 The facility displays the services and List of available drugs displayed at 1 OB
Pharmacy
entitlements available in its
departments
Status of availability of drugs is 1 OB
updated weekly
Timings for dispensing counter of 1 OB
pharmacy are displayed
ME B1.6 Information is available in local Signage's and information are 1 OB
language and easy to understand available in local language
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of 2 4
physical, economic, cultural or social status.
ME B2.1 Availability of separate Queue for 1 OB
Services are provided in manner Male and female patients at
that are sensitive to gender dispensing counter
ME B2.3 Pharmacy has easy access for 1 OB Check for availability of ramp
moment of goods and goods trolley/ cart
Access to facility is provided
without any physical barrier and is
friendly to people with disabilities
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 1 2
ME B3.3 Behaviour of staff is empathetic and 1 PI
The facility ensures the behaviours courteous
of staff is dignified and respectful,
while delivering the services
The facility has defined and established procedures for informing patients about the medical condition, and involving them in treatment
Standard B4 planning, and facilitates informed decision making 1 2
ME B4.4 Method of Administration /taking of 1 OB/SI
the medicines is informed to patient/
Information about the treatment is their relatives by pharmacist as per
shared with patients or attendants, doctors prescription in OPD Pharmacy
regularly
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services. 5 10
ME B5.1 Free drugs and consumables for JSSK 1 PI/SI
The facility provides cashless beneficiaries
services to pregnant women,
mothers and neonates as per
prevalent government schemes
ME B5.2 The facility ensures that drugs Pharmacy supplies generic drugs list 1 SI/OB
to all hospital departments as per
prescribed are available at their internal demand
Pharmacy and wards
Check that patient has not incurred 1 PI/SI
expenditure on purchasing drugs or
consumables from outside.
ME B5.4 Free drugs for BPL & other entitled 1 PI/SI/RR As per state guideline e. g:
The facility provide free of cost patients geriateric patient
treatment to Below poverty line
patients without administrative
hassles
ME B5.5 Local purchase of stock out drugs/ 1 PI/SI/RR
The facility ensures timely Reimbursement of expenditure to the
reimbursement of financial beneficiaries
entitlements and reimbursement to
the patients
ME C2.2 The facility ensures safety of Pharmacy does not have temporary 1 OB
electrical establishment connections and loosely hanging
wires
ME C2.4 The facility has plan for prevention Pharmacy has plan for safe storage 1 OB/SI
of fire and handling of potentially flammable
materials.
ME C2.5 The facility has adequate fire Pharmacy has installed fire 1 OB/RR
fighting Equipment Extinguisher for A,B, C class of fire
ME C2.6 The facility has a system of periodic Check staff competencies for 1 SI/RR
training of staff and conducts mock operating fire extinguisher and what
drills regularly for fire and other to do in case of fire
disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 7 14
ME C3.4 The facility has adequate Availability of Pharmacist 1 SI/RR
technicians/paramedics as per
requirement
ME C3.6 The staff has been provided Inventory management 1 SI/RR
required training / skill sets
Cold chain management of ILR and 1 SI/RR
deep freezer
Rational use of drugs 1 SI/RR
Prescription Audit 1 SI/RR
ME C3.7 The Staff is skilled as per job Staff is skilled for estimation of the 1 SI/RR
description requirement and proper storage of
the drugs
Anti-Parkinsonism Medicines 1
Cardiovascular Medicines 1 Metoprolol, Glyceryl
Trinitrate,Isosorbide Dinitrate ,
Isosorbide Mononitrate,
Amlodipine, Enalapril,
Telmisartan,Prazosin,Methyl
Dopa ,Digoxin, Atorvastatin,
Carvedilol,Chlorthalidone
,Clopidogrel, Diltiazem ,Diltiazem
,Enalapril Maleate, Nifedipine,
Propranolol,Ramipril, Warfarin
Sodium,
ME C4.2 The departments have adequate Availability of Consumables 1 OB/RR As per Sate EDL
consumables at point of use
Standard C5 The facility has equipment & instruments required for assured list of services. 3 6
ME C5.5 Availability of Equipment for Storage Availability of Equipment for 1 OB ILR, Deep Freezers, Insulated
maintenance of Cold chain carrier boxes with ice packs,
ME C5.6 Availability of functional equipment Availability of equipment for 1 OB Buckets for mopping, mops,
and instruments for support cleaning duster, waste trolley, Deck brush
services
ME C5.7 Department have patient furniture Storage furniture for drug store 1 OB Racks ,Cupboards, Sectional
and fixtures as per load and service Drawer cabinet/ Shelves, Work
provision table
ME D1.3 Operating and maintenance Operating instructions for ILR/ Deep 1 OB/SI
instructions are available with the Freezers are available at cold chain
users of equipment room
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 39 78
ME D2.1 There is established procedure for Drug store has process to consolidate 1 RR/SI
forecasting and indenting drugs and and calculate the consumption of all
consumables drugs and consumables
ME D2.2 The facility has establish procedure The facility has a established 1 RR/SI
for procurement of drugs procedure for local purchase of drugs
in emergency conditions
ME D2.3 The facility ensures proper storage There is specified place to store 1
of drugs and consumables medicines in Pharmacy and drug
store
OB
All the shelves/racks containing 1
medicines are labelled in pharmacy
and drug store
ME D2.7 There is process for storage of Check that vaccines are kept in 1
vaccines and other drugs, requiring sequence
controlled temperature
(Top to bottom) : Hep B, DPT, DT,
OB TT, BCG, Measles, OPV
Work instruction for storage of 1
vaccines are displayed at point of use
OB
ILR and deep freezer have functional 1
temperature monitoring devices
OB
There is a system in place to maintain 1
temperature chart of ILR
SI/RR
ME D3.9 The facility has security system in Security arrangement at pharmacy is 1 OB
place at patient care areas robust
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.2 The facility ensures adequate power Availability of power back up in the 1 OB/SI
backup in all patient care areas as Pharmacy
per load
Availability of power back up for the 1 OB/SI
cold chain maintenance
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 1 2
ME D8.1 The facility has requisite licences License for storing spirit 1 RR
and certificates for operation of
hospital and different activities
Standard D9
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 4 8
ME D9.1 The facility has established job Staff is aware of their roles and 1 SI
description as per govt guidelines responsibilities
ME D9.2 The facility has a established There is a procedure to ensure that 1 RR/SI Check for system for recording
procedure for duty roster and staff is available on duty as per duty time of reporting and relieving
deputation to different departments roster (Attendance register/ Biometrics
etc)
ME E8.7 The facility ensures safe and Pharmacy has adequate facility for 1 OB
adequate storage and retrieval of storage of records
medical records
Standard E10
The facility has defined and established procedures for Emergency Services and Disaster Management 3 6
ME E10.3 The facility has disaster Staff is aware of disaster plan 1 SI/RR
management plan in place
Roles and responsibilities of staff in 1 SI/RR
disaster are defined
Contingency/Buffer stock for Disaster 1 SI/RR
and mass casualties.
ME G4.3 Staff is trained and aware of the Check staff is a aware of relevant part 1 SI/RR
standard procedures written in of SOPs
SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 1 OB Work instruction for storing
Point of use are displayed drugs, Cold chain management
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 6 12
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.2 The facility conducts the periodic Pharmacy department co ordinates 1 RR/SI
prescription/ medical/death audits the prescription audit
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objectives for Pharmacy are 1 RR/SI
quality objectives and key defined
departments have their own
objectives
ME G6.3 Quality policy and objectives are Check if staff is aware of quality policy 1 SI
disseminated and staff is aware of and objectives
that
ME G6.4 Progress towards quality objectives Quality objectives are monitored and 1 SI/RR
is monitored periodically reviewed periodically
Standard Facility seeks continually improvement by practicing Quality method and tools.
G7 6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services
5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 10 20
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 2 4
ME H1.1 Facility measures productivity Percentage of drugs available against 1
Indicators on monthly basis essential drug list RR
ME H1.2 The Facility measures equity indicators Expenditure on drugs procured 1
periodically through local purchase for BPL
patient
RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 3 6
ME H2.1 Facility measures efficiency Indicators Number of stock out situations for 1
on monthly basis Vital category of drugs/consumables.
RR
Turn Around time for dispensing 1
medicine at Dispensary RR
Percentage of drugs expired during 1
the months RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 8
ME H3.1 Facility measures Clinical Care & Safety Proportion of prescription found 1
Indicators on monthly basis prescribing non generic drugs RR
No of advere drug reaction per 1
thosuand patients RR
Antibiotic rate 1
Pharmacy Card
Pharmacy Score 50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50
ME A1.11. The facility provides Blood Blood storage has facility for 1 SI/OB
storage & transfusion services storage of whole blood
Standard A4 Facility provides services as mandated in National Health Programs/ state scheme 1 2
ME A4.1 The facility provides services Facility to arrange for platelets 1 SI/RR
under National Vector Borne from parent blood bank for
Disease Control Programme as management of Dengue cases.
per guidelines
ME B1.2. The facility displays the services Blood storage has displayed 1 OB
and entitlements available in its information regarding number of
departments blood units available
ME B1.4. User charges are displayed and Applicable user charges of blood 1 OB
communicated to patients are displayed at the entrance
effectively
ME B1.5. Patients & visitors are IEC material is available in Blood 1 OB
sensitised and educated Storage to provide information and
through appropriate IEC / BCC to promote blood donation
approaches
Standard B5. Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of 3 6
ME B5.1. The facility provides cashless Free blood for Pregnant women, 1 PI/SI
services to pregnant women, Mothers and New-Borns and
mothers and neonates as per infants.
prevalent government schemes
ME B5.2 The facility ensures that drugs Check that parents & attendant's 1 PI/SI
prescribed are available at have not spent money on
Pharmacy and wards purchasing bloods from outside.
ME B5.4. The facility provide free of cost Free blood is provided to BPL 1 PI/SI/RR
treatment to Below poverty line patients
patients without administrative
hassles
.
Area of Concern C: Inputs 21 42
Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent 4 8
ME C1.1. Departments have adequate Blood storage has adequate space 1 OB Space required is more
space as per patient or work as per requirement than 10sq meters
load
ME C1.3. Departments have layout and Dedicated area for Whole blood 1 OB
demarcated areas as per and components
functions
. Dedicated space for keeping records 1 OB
ME C2.2 The facility ensures safety of Blood storage does not have 1 OB
electrical establishment temporary connection and loosely
hanging wires
ME C2.6 The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly what to do in case of fire
for fire and other disaster
situation
Standard C3. The facility has adequate qualified and trained staff, required for providing the assured services to the current case 5 10
ME C3.1. The facility has adequate Availability of designated Blood 1 OB/RR MBBS doctor with 3 days
specialists doctors as per storage officer. recognized training on
service provision blood storage
ME C3.4. The facility has adequate Availability of Trained Technician 1 SI/RR DMLT with one day
technicians/paramedics as per for Blood storage recognized training on
requirement blood storage.
ME C4.2. The departments have Availability of Reagents /Kits and 1 OB/RR Standard Grouping Sera
adequate consumables at point other consumables for testing. Anti A, Anti B & Anti D,
of use Antihuman Globulin.
Standard C5. The facility has equipment & instruments required for assured list of services. 2 4
ME C5.3. Availability of equipment & Availability of laboratory 1 OB Microscope, RH viewer.
instruments for diagnostic equipment & instruments for
procedures being undertaken in laboratory
the facility
ME C5.5. Availability of Equipment for Check for availability of storage 1 OB Blood bags refrigerator
Storage equipment for blood products with thermo graph and
alarm device, Insulated
carrier boxes with ice
packs, Blood bag
weighting machine, deep
freezer,
ME D1.2. The facility has established All the measuring equipments/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment
Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and 10 20
ME D2.1. There is established procedure There is established system of 1 SI/RR Stock level are daily
for forecasting and indenting timely indenting of consumables updated
drugs and consumables and reagents Requisition are timely
placed
ME D2.3 The facility ensures proper Reagents and consumables are 1 OB/RR
storage of drugs and kept away from water and sources
consumables of heat,
direct sunlight
ME D2.7. There is process for storage of Temperature of refrigerators used 1 SI/RR Check for temperature
vaccines and other drugs, for storing lab reagents are kept as charts are maintained and
requiring controlled per storage requirement and updated periodically for
temperature records are maintained refrigerators used storing
lab reagents
Standard D4. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services 3 6
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and potable water
supply for portable water in all
functional areas
ME D4.2. The facility ensures adequate Availability of power back up for 1 OB/SI
power backup in all patient care blood storage
areas as per load
Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their 4 8
ME E8.5 storage 1
Adequate form and formats are Standard Formats available RR/OB Format for requisition
available at point of use form, blood transfusion
reaction form, referral slip
ME E8.7. The facility ensures safe and Safe keeping of patient records 1 OB Blood storage has facility
adequate storage and retrieval to store records for 5 year
of medical records
Standard E10. The facility has defined and established procedures for Emergency Services and Disaster Management
1 2
ME E10.3. The facility has disaster Blood storage has system of coping 1 SI/RR
management plan in place with extra demand of blood in case
of disaster
Standard E12 The facility has defined and established procedures for Blood storage Management and Transfusion. 19 38
ME 12.1 There is established procedure Blood storage has standardized 1 RR/SI
for Transport of blood from procedure for transporting blood
parent blood bank. from parent blood bank.
ME 12.2 There is established procedure Blood storage has standardized 1 RR/SI all the blood/component
for storage of blood procedure for receipt of blood units are checked for
from parent blood bank. haemolysis, turbidity, or
change in colour on
receipt from parent blood
bank
ME E12.3. There is established procedure Determination of ABO group is 1 RR/SI Tube or Microplate or gel
for the Cross matching of blood done by recommended methods technology
ME E12.4 There is established procedure Blood storage has system to testing 1 RR/SI Testing of blood includes
for issuing blood and cross matching the unit before Determination ABO type,
issuing Rh (D) type, detection of
unexpected antibodies
etc.
Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 7 14
ME F2.1. Hand washing facilities are Availability of hand washing Facility 1 OB Check for availability of
provided at point of use at Point of Use wash basin near the point
of use
ME F2.2. Staff is trained and adhere to Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
standard hand washing washing
practices
. Staff aware of when to hand wash 1 SI
Standard F3. Facility ensures standard practices and materials for Personal protection 2 4
ME F3.1. Facility ensures adequate Clean gloves are available at point 1 OB/SI All personal use gloves
personal protection of use while drawing sample,
equipments as per examining and disposable
requirements of the samples
Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention 3 6
ME F5.3. Facility ensures standard practices Staff is trained for spill 1 SI/RR
followed for cleaning and management
disinfection of patient care areas
Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality. 4 8
ME G3.1. Facility has established internal Internal Quality assurance program 1 SI/RR
quality assurance program at is in place
relevant departments
Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key 13 26
ME G4.1. Departmental standard Standard operating procedure for 1 RR
operating procedures are department has been prepared
available and approved
ME G4.3. Staff is trained and aware of the Check staff is a aware of relevant 1 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4. Work instructions are displayed Work instruction/clinical protocols 1 OB work instruction for
at Point of use are displayed screening of blood,
storage of blood,
maintaining blood and
component in event of
power failure
Standard G5. The facility has established system of periodic review as internal assessment , medical & death audit and 4 8
ME G5.1. The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.3. The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and recorded
and recorded adequately
ME G5.4. Action plan is made on the gaps Action plan prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5. Corrective and preventive Corrective and preventive action 1 RR/SI
actions are taken to address taken
issues, observed in the
assessment & audit
Standard G6. The facility has defined and established Quality Policy & Quality Objectives 4 8
ME G6.2. The facility periodically defines Quality objectives for Blood 1 RR/SI
its quality objectives and key storage are defined
departments have their own
objectives
ME H1.2. The Facility measures equity No of blood units issued free of 1 RR JSSK, Thalassemia , BPL
indicators periodically cost
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
2 4
ME H2.1. Facility measures efficiency Downtime of critical equipments 1 RR Time period for which
Indicators on monthly basis equipment was out of
order/Total no of working
hours for equipments
Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 8
ME H3.1. Facility measures Clinical Care & Blood transfusion reaction rate 1 RR No of Blood Transfusion
Safety Indicators on monthly basis reactions 1000/ No of
patient blood issued
Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 3 6
ME H4.1. Facility measures Service Quality Time gap between issuing and 1 RR
Indicators on monthly basis requisition of blood in routine
conditions
ME A5.2 The facility provides laundry Availability of functional laundry 1 SI/OB Arrangement of laundry
services services services inhouse or outsourced
ME A5.3 The facility provides security Availability of functional security 1 SI/OB In-house or outsourced, At
services services 24 X7 least one guard per shift
ME A5.4. The facility provides Availability of Housekeeping 1 SI/OB In-house or outsourced, At
housekeeping services services 24X7 least 3 in morning shift & 2
each in morning & evening
shift
A
ME A5.5 The facility ensures Availability of maintenance 1 SI/OB Includes Physical infrastructure
maintenance services services maintenance and equipment
maintenance
ME A5.7 The facility has services for Availability of dedicated space for 1 SI/OB
medical records storing Medical records
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 1 2
ME B3.2 Confidentiality of patients The facility has a system to 1 SI/RR Patient records are not shared
records and clinical information maintain Confidentiality of except the patient until it is
is maintained patient records authorized by law
Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of 2 4
ME B5.1 The facility provides cashless Availability of free diet 1 PI/SI
services to pregnant women,
mothers and neonates as per
prevalent government schemes
ME B5.4 The facility provide free of cost Free diet is provided to BPL 1 PI/SI
treatment to Below poverty line patients and JSSK beneficiaries
patients without administrative
hassles
ME C1.3 Departments have layout and Check if Kitchen has demarcated 1 OB Layout as per functional flow
demarcated areas as per area for various activities that is receipt, storage,
functions preparation & Cooking area
,Service area, dish washing
area, Garbage collection area
and administrative
area.Minimum space
requirement 10sq ft/bed
ME C1.5 The facility has infrastructure for All support services department 1 OB
intramural and extramural are connected with intercom &
communication have telephone as well
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 9 18
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and furniture
safety of the infrastructure properly secured like cupboards, cabinets, and
heavy equipments , hanging
objects are properly fastened
and secured
ME C2.5. The facility has adequate fire Support services has installed fire 1 OB/RR dietary department and
fighting Equipment Extinguisher for A, B, C type of Medical record department
fire
Check the expiry date on fire 1 OB/RR dietary department and
extinguishers are displayed on Medical record department
each extinguisher as well as due
date for next refilling is clearly
mentioned
ME C2.6. The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly what to do in case of fire
for fire and other disaster
situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 8 16
ME C3.5 The facility has adequate Availability of washer man 1 SI/RR
support / general staff
Availability of Cook 1 SI/RR
Availability of Data Entry operator 1 SI/RR
trained in medical records
management.
ME C3.6 The staff has been provided Infection Control Management 1 SI/RR
required training / skill sets
Cleaning Practices 1 SI/RR
Training on Medical record 1 SI/RR
Management
ME C3.7 The Staff is skilled as per job MRD Staff is skilled for indexing 1 SI/RR
description and storage of Medical records
Standard C4 Facility provides drugs and consumables required for assured list of services. 2 4
ME C4.2 The departments have adequate Availability of consumables in 1 OB/RR Cap, gowns, gloves, Detergent
consumables at point of use dietary department for cleaning of utensil and
Soap for hand washing
Standard C5 The facility has equipment & instruments required for assured list of services. 7 14
ME C5.6 Availability of functional Availability of Equipment & 1 OB Refrigerator, LPG, food trolley
equipment and instruments for utensils for Dietary department and cooking utensils
support services
Availability of Equipment for 1 OB Washing machine, drier, Iron,
Laundry Separate trolley for clean and
dirty linen
ME C5.7 Departments have patient Availability of furniture and 1 OB Exhaust fan, Storage
furniture and fixtures as per fixtures for Dietary department containers, Work bench/slab,
load and service provision Utensil stand
Standard D3 The facility has established Program for maintenance and upkeep of the faciity to provide safe, secure and comfortable 11 22
ME D3.2 Hospital infrastructure is Check that there is no seepage , 1 OB Dietary department, laundry
adequately maintained Cracks, chipping of plaster and medical record
department
ME D3.3 Patient care areas are clean and Floors, walls, roof, rooftops, sinks 1 OB All area are clean with no
hygienic patient care and circulation areas dirt,grease,littering and
are Clean cobwebs
ME D3.10 The facility has established Check female staff feels secure at 1 SI
measure for safety and security of work place
female staff
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI Dietary and laundry
arrangement storage and supply potable water department
for portable water in all
functional areas
ME D4.2 The facility ensures adequate Availability of power back up 1 OB/SI For Laundry, Diet and MRD
power backup in all patient care department
areas as per load
StandardD5 The facility ensures avaialblity of Diet as per neutritional requirement of the patients and clean Linen to all admitted 22 44
ME D5.2 The facility provides diets The facility has defined diet patients.
1 RR/SI
according to nutritional schedule & menu for the
requirements of the patients patients.
The facility has Special diet 1 RR/SI Normal diet, Liquid diet, Semi-
schedule for patients suffering solid diet, diabetic diet, Low
from Heart Disease, salt, Low fat diet
Hypertension, Diabetes,
Pregnant Women, diarrhoea
and renal patients
ME D5.3 Hospital has standard procedures Dietary department has system to 1 RR/SI
for preparation, handling, storage calculate the number of diets to
and distribution of diets, as per be prepared
requirement of patients
ME D5.4 The facility has adequate sets of The facility has sufficient set of 1 RR/SI at least 5 sets for each
linen linen available per bed functional bed
ME D5.6 The facility has standard There is a system for Periodic 1 RR/SI To check the theft and pilferage
procedures for handling , physical verification of linen
collection, transportation and inventory
washing of linen
Standard D10 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual
obligations 1 2
ME D10.1 There is established system for There is procedure to monitor 1 SI/RR Verification of outsourced
contract management for out the quality and adequacy of services (cleaning/
sourced services outsourced services on regular Dietary/Laundry/Security/Main
basis tenance) provided are done by
designated in-house staff
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 4 8
ME F2.1 Hand washing facilities are Availability of the hand washing 1 OB Preferably in preparation and
provided at point of use Facility in kitchen cooking area
Availability of Running Water (Hot 1 OB/SI Ask to Open the tap. Ask Staff
and cold) water supply is regular
Availability of soap with soap 1 OB/SI Check for availability/ Ask staff
dish/ liquid antiseptic with if the supply is adequate and
dispenser uninterrupted
Standard F3 Facility ensures standard practices and materials for Personal protection 6 12
ME F3.1 Facility ensures adequate Clean gloves are available for 1 OB/SI
personal protection equipments distribution of food
as per requirements
Cleaning of utensils and food 1 SI/OB Check the cleanliness and how
trolleys frequent they clean it
Decontamination of heavily soiled 1 SI/OB
linen
Cleaning of washing equipment 1 SI/OB
ME G3.2 Facility has established external Kitchen is has system of regular 1 SI/RR Food sample of each meal are
assurance programs at relevant external inspection by Municipal/ preserved in refrigrators for 24
departments FDA authorities hours
ME G4.3 Staff is trained and aware of the Check if staff is a aware of 1 SI/RR
standard procedures written in relevant part of SOPs
SOPs
ME G4.4 Work instructions are displayed Work instructios are displayed in 1 OB
at Point of use Dietary Department
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription 6 12
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI Dietary department, laundry
internal assessment periodic interval and medical record
department
Standards G6 The facility has defined and established Quality Policy & Quality Objectives
2 4
ME G6.3 Quality policy and objectives are Check if staff is aware of quality 1 SI
disseminated and staff is aware policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically
Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 3 6
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services
5S 1 SI/OB
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Area of Concern - H Outcome 14 28
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 8
ME H1.1 Facility measures productivity No of cases for which medical 1 RR
Indicators on monthly basis audit done
No of cases for which death audit 1 RR
has done
Linen Index 1 RR No. of bed sheet washed in a
month/Patient bed days in
month
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 4 8
ME H2.1 Facility measures efficiency Proportion of maternal deaths 1 RR
Indicators on monthly basis audited
Proportion of newborn deaths 1 RR
audited
Cycle time for laundry services 1 RR Time elapsed between
collection of used linen and
receiving clean linen
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 2 4
ME H3.1 Facility measures Clinical Care & Medical Audit Score 1 RR
Safety Indicators on monthly basis
Days for FP Surgeries are fixed 1 SI/RR As per Operational Guidelines for
Fixed Day Surgery ( At least one day
per week)
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 9 18
ME B1.1 The facility has uniform and user- Availability departmental 1 OB (Numbering, main department and
friendly signage system signage's internal sectional signage
Restricted area signage are 1 OB
displayed
ME B1.2 The facility displays the services 1 OB
and entitlements available in its List of Family Planning Services
departments available
Compensation for family 1 OB
planning indemnity scheme
1 OB
Compensation for family
planning services are displayed
Family planning insurance 1 OB
scheme displayed
ME B1.5 1 OB
Patients & visitors are sensitised
and educated through IEC materials such as posters,
appropriate IEC / BCC approaches banners, and handbills
IEC Material regarding family available at the site and displayed
planning displayed
Education material for 1 OB
counselling are available in Flip charts, models, specimens, and
Counselling room samples of
contraceptives available
ME B1.6 Signage's and information are 1 OB
Information is available in local available in local language
language and easy to understand
5 10
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account
of physical economic, cultural or social reasons.
ME B2.1 1 OB/SI
Services are provided in manner Availability of female staff if a
that are sensitive to gender male doctor examine a female
patients
1 SI/PI Ask Staff/client whether they were
convinced for one method or given
There is no over emphasis on informed choice
one method
ME B2.3 1 OB
Access to facility is provided
without any physical barrier & Availability of Wheel chair or
and friendly to people with stretcher for easy Access to the
disabilities OT
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1 OB
Availability of ramps with railing
Availability of disable friendly 1 OB
toilet
Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information. 8 16
ME B3.1 Adequate visual privacy is 1 OB
Availability of screens at IUD
provided at every point of care insertion room
Availability of screens at family 1 OB
planning OT
1 OB
Patients are properly
draped/covered before and after
produce
Privacy at the counselling room 1 OB
is maintained
ME B3.2 Confidentiality of patients 1 SI/OB
Patient Records are kept at
records and clinical information is secure place beyond access to
maintained general staff/visitors
1 SI/OB
No information regarding patient
identity and details are
unnecessary displayed
ME B3.3 Behaviour of staff is empathetic 1 PI/OB
The facility ensures the and courteous
behaviours of staff is dignified
and respectful, while delivering
the services
ME B3.4 1 SI/OB No entry shall be made in any case
sheet , PT register , follow-up card or
The facility ensures privacy and any other document, register
confidentiality to every patient, indicating there in the name of the
especially of those conditions pregnant women . Only reference
having social stigma, and also serial no. is mentioned on all the
safeguards vulnerable groups document
ME B5.3 It is ensured that facilities for the Check that patient party has not 1 PI/SI
prescribed investigations are spent on diagnostics from
outside.
available at the facility
ME B5.5 1 PI/SI/RR
The facility ensures timely
reimbursement of financial
entitlements and reimbursement If any other expenditure
to the patients occurred it is reimbursed from
hospital
Timely payment of family 1 PI/SI/RR
planning compensation
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 23 46
ME C1.1 Departments have adequate 1 OB
space as per patient or work load
Adequate Space is for
counselling and examination
1 OB
Availability of dedicated OT for
Family planning surgeries in PP
unit
ME C1.2 Patient amenities are provide as 1 OB Availability of drinking water
per patient load Functional toilets with running
water and flush are available as
per bed strength and patient
load of ward
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ME C2.5 The facility has adequate fire PP unit has installed fire 1 OB
fighting Equipment Extinguisher that is Class A ,
Class BC type or ABC type
1 OB/RR
Check the expiry date for fire
extinguishers are displayed on
each extinguisher as well as due
date for next refilling is clearly
mentioned
ME C2.6 The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 18 36
ME C 3.1 The facility has adequate
specialist doctors as per service
provision Minilap - MBBS trained in procedure
Availability of trained surgeon Laparoscopic- DGO,MS, MD
for Minilap/ Laparoscopic/NSV 1 OB/RR trained in laparoscopic surgery
ME C3.3 The facility has adequate nursing OB/RR/SI Trained in IUCD insertion
staff as per service provision and
work load
Availability of Nursing staff 1
ME C3.4 The facility has adequate Viability of Counsellor for family OB/SI
technicians/paramedics as per planning
requirement
1
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Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 6 12
ME D1.1 The facility has established All equipments are covered 1 SI/RR
system for maintenance of critical under AMC including preventive
Equipment maintenance
1 SI/RR
1 OB/ RR
1
Department maintained stock RR/SI
and expenditure register of
contraceptives
1
ME D2.6 There is a procedure for periodically There is procedure for SI/RR
replenishing the drugs in patient replenishing drug tray /crash
care areas cart
1
There is no stock out of OB/SI
contraceptives 1
ME D2.7 There is process for storage of OB/RR Check for temperature charts are
vaccines and other drugs, maintained and updated periodically
requiring controlled temperature Temperature of refrigerators are
kept as per storage requirement
and records are maintained 1
ME D2.8 There is a procedure for secure Anaesthetic agents are kept at OB/SI
storage of narcotic and secure place
psychotropic drugs
1
The facility has established program for maintenance and upkeep of the facility to provides safe, secure and comfortable 20 40
Standard D3
environment to staff, patients and visitors.
ME D3.1 Exterior of the facility building is 1 OB
maintained appropriately
Building is painted/whitewashed
in uniform colour
Interior of patient care areas are 1 OB
plastered & painted
ME D3.2 Hospital infrastructure is Check for there is no seepage , 1 OB
adequately maintained Cracks, chipping of plaster
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ME D3.10 The facility has established measure Ask female staff weather they 1 SI
for safety and security of female feel secure at work place
staff
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 6 12
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for portable water in all
functional areas
1 OB/SI
Availability of Hot water supply
ME D4.2 The facility ensures adequate 1 OB/SI
power backup in all patient care
areas as per load Availability of power back up in
OT
Availability of UPS 1 OB/SI
Availability of Emergency light 1 OB/SI
Standard D5 The facility ensures availablity of diet as per nutritional requirement of patientr & clean linen to all admitted patients 4 8
ME D5.4 The facility has adequate sets of OB/RR Drape, draw sheet, cut sheet and
linen OT has facility to provide gown
sufficient and clean linen for
surgical patient 1
OT has facility to provide linen OB/RR
for staff 1
ME D5.5 The facility has established Linen is changed after each OB/RR
procedures for changing of linen procedure
in patient care areas
1
ME D5.6 The facility has standard procedures SI/RR
for handling , collection,
transportation and washing of linen There is system to check the
cleanliness and Quantity of the
linen received from laundry 1
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 1 2
ME D8.3 The facility ensure relevant
processes are in compliance with
statutory requirement Staff is aware of legal age for
family planning 1 SI/RR 22-49 married only
Standard D9
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 4 8
procedures.
ME D9.1 The facility has established job Staff is aware of their role and 1 SI
description as per govt guidelines responsibilities
ME D9.2 The facility has a established There is procedure to ensure 1 RR/SI Check for system for recording time
procedure for duty roster and that staff is available on duty as of reporting and relieving
deputation to different per duty roster (Attendance register/ Biometrics etc)
departments
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Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 8 16
ME E1.1 The facility has established Unique identification number 1 RR
procedure for registration of is given to each client during
patients process of registration
ME E1.3 There is established procedure Age criteria for family planning 1 RR/SI
for admission of patients surgeries is adhered
1 RR/SI
There is established criteria for
admission of abortion cases
There is no delay in admission of 1 SI/RR/OB
patient
Admission is done by written 1 SI/RR/OB
order of a qualified doctor
Time of admission is recorded in 1 RR
patient record
ME E1.4 There is established procedure There is provision of extra beds 1 OB/SI
for managing patients, in case during fixed day family planning
beds are not available at the surgery
facility
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 8 16
ME E2.1 There is established procedure History of illness to screen for 1 RR/SI
for initial assessment of patients the diseases mentioned under
the medical
eligibility criteria
Standard E4 The facility has defined and established procedures for nursing care 7 14
ME E4.1 Procedure for identification of There is a process for ensuring 1 OB/SI Patient id band/ verbal confirmation
patients is established at the the identification before any etc.
facility clinical procedure
ME E4.2 Procedure for ensuring timely and There is a process to ensue 1 RR Verbal orders are rechecked before
accurate nursing care as per the accuracy of administration
treatment plan is established at the verbal/telephonic orders
facility
ME E4.3 There is established procedure of Patient hand over is given during 1 SI/RR
patient hand over, whenever staff the change in the shift
duty change happens
2 4
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.
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ME E5.2 The facility identifies high risk High risk medical emergencies 1 OB/SI
patients and ensure their care, as are identified and treatment
per their need given on priority
5 10
Standard E6
Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their
rational use.
ME E6.1 Facility ensured that drugs are 1 RR
prescribed in generic name only Check for BHT if drugs are
prescribed under generic name
only
ME E6.2 There is procedure of rational use of Check for that relevant Standard 1 RR
drugs treatment guideline are
available at point of use
Maximum dose of high alert 1 SI/RR Value for maximum doses as per
drugs are defined and age, weight and diagnosis are
communicated available with nursing station and
doctor
ME E7.3 There is a procedure to check Drugs are checked for expiry 1 OB/SI
drug before administration/ and other inconsistency
dispensing before administration
Check single dose vial are not 1 OB Check for any open single dose vial
used for more than one dose with left over content intended to
be used later on
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 9 18
ME E8.1 All the assessments, re- Records of Monitoring/ 1 RR
assessment and investigations Assessments are maintained
are recorded and updated History and Physical examination
are recorded
ME E8.2 All treatment plan Treatment plan, first orders are 1 RR
prescription/orders are recorded written on BHT
in the patient records.
Drugs administered are recorded
ME E8.4 Procedures performed are Anaesthesia and surgery note 1 RR
written on patients records recorded
ME E8.5 Adequate form and formats are 1 RR/OB
available at point of use Standard Formats available Formats for Consent etc available
ME E8.6 Register/records are maintained 1 RR
as per guidelines
Check for availability of eligible
couple and sterilization register
1 RR
Records on family planning (FP)
(including the number
of clients counselled and the
number of acceptors)
1 RR
Follow-up records for FP clients
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ME E8.7 The facility ensures safe and Safe keeping of patient records 1 OB
adequate storage and retrieval of
medical records
10 20
Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing Assessment is done before 1 SI/RR
patient readiness discharging patient
1 SI/RR
Discharge is done by a
responsible and qualified doctor
Patient / attendants are 1 PI/SI
consulted before discharge
1 SI/RR
Treating doctor is consulted/
informed before discharge of
patients
ME E9.2 Case summary and follow-up Discharge summary is provided 1 RR/PI See for discharge summary, referral
instructions are provided at the slip provided.
discharge
1 RR
1 RR/SI
Standard E20 Facility has established procedures for abortion and family planning as per government guidelines and law 23 46
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1
ME E20.4 Facility provide counselling Pre procedure Counselling
services for abortion as per provided As per national Guidelines
guideline SI/RR/PI Transition phase after family
planning surgery specially vasectomy
1 defined
Post procedure Counselling
provided SI/RR/PI
1 As per national guidelines
Counselling on the follow-up visit
SI/RR/PI
1
ME E20.5 Facility provide abortion services MVA procedures are done as per SI/RR
for 1st trimester as per guideline guidelines
1
Medical termination of SI/RR
pregnancy done as per
guidelines
1
ME E20.6 Facility provide abortion services Surgical Procedures procedures SI/RR
for 2nd trimester as per guideline are done as per guidelines
1 Dilation and evacuation
Medical termination of SI/RR
pregnancy done as per
guidelines ethacridine lactate extra amniotic
1 instillation
Area of Concern - F Infection Control 79 158
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 6 12
Facility has provision for Passive
and active culture surveillance of
critical & high risk areas Surface and environment
samples are taken for Swab are taken from infection prone
ME F1.2 microbiological surveillance 1 SI/RR surfaces
Facility measures hospital
associated infection rates Patients are observed for any sign
There is procedure to report and symptoms of HAI like fever,
cases of Hospital acquired purulent discharge from surgical
ME F1.3 infection 1 SI/RR site .
There is Provision of Periodic There is procedure for
Medical Checkups and immunization of the staff
immunization of staff
ME F1.4 1 SI/RR Hepatitis B, Tetanus Toxid etc
Periodic medical checkups of the
staff 1 SI/RR
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1 OB
The facility staff is trained in Adherence to 6 steps of Hand
hand washing practices and washing
adhere to standard hand washing
practices
ME F2.2 1 SI/OB Ask of demonstration
Adherence to Surgical scrub procedure should be repeated
method several times so that the scrub lasts
for 3 to 5
minutes. The hands and forearms
should be dried with a sterile towel
only.
1 SI/OB
Staff aware of when to hand
wash 1 SI Ask of demonstration
Facility ensures standard Availability of Antiseptic
practices and materials for Solutions
antisepsis
ME F2.3 1 OB
Proper cleaning of procedure
site with antisepsis
like before giving IM/IV injection,
drawing blood, putting Intravenous
1 OB/SI and urinary catheter
Cleaning of cervix before IUD SI
insertion with antiseptic solution
1
Check Shaving is not done SI
during part preparation/delivery
cases
1
Check sterile filled is maintained
during surgery Surgical site covered with sterile
drapes, sterile instruments are kept
1 OB/SI within the sterile field.
Standard F3 Facility ensures standard practices and materials for Personal protection 9 18
Facility ensures adequate
personal protection equipments
as per requirements
Clean gloves are available at
ME F3.1 point of use 1 OB/SI
Availability of Masks 1 OB/SI
Sterile s gloves are available at
OT and Critical areas 1 OB/SI
Use of elbow length gloves for
obstetrical purpose 1 OB/SI
Availability of gown/ Apron 1 OB/SI
Availability of Caps 1 OB/SI
Personal protective kit for
infectious patients 1 OB/SI HIV kit
Staff is adhere to standard
personal protection practices
No reuse of disposable gloves,
ME F3.2 Masks, caps and aprons. 1 OB/SI
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1 OB/SI
Formaldehyde or glutaraldehyde
solution replaced as per
manufacturer instructions 1 OB/SI
Autoclaved linen are used for
procedure 1 OB/SI
Autoclaved dressing material is
used 1 OB/SI
ME F5.3 1 SI/RR
Cleaning of patient care area
with detergent solution 1 SI/RR
Staff is trained for preparing
cleaning solution as per standard
procedure
1 SI/RR
Standard practice of mopping
and scrubbing are followed
1 OB/SI
Cleaning equipments like broom
are not used in patient care
areas
1 OB/SI
Use of double bucket system for
mopping 1 OB/SI
Fumigation/carbolization as per
schedule 1 SI/RR
External footwares are restricted
1 OB
Facility ensures air quality of high Adequate air exchanges are
ME F5.5 risk area maintained 1 SI/RR
Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous 15 30
Waste.
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Standard G1 The facility has established organizational framework for quality improvement 1 2
ME G1.1 The facility has a quality team in There is a designated 1 SI/RR
place departmental nodal person
for coordinating Quality
Assurance activities
Standard G2 Facility has established system for patient and employee satisfaction 1 2
ME G2.1 Patient Satisfaction surveys are 1 RR
conducted at periodic intervals
Client satisfaction survey done
on monthly basis
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 3 6
ME G3.1 Facility has established internal 1 SI/RR
quality assurance program at
relevant departments
There is system daily round by
matron/hospital manager/
hospital superintendent/
Hospital Manager/ Matron in
charge for monitoring of services
ME G3.3 Facility has established system for Departmental checklist are 1 SI/RR
use of check lists in different used for monitoring and
departments and services quality assurance
Standard G4
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and 18 36
support services.
ME G4.1 Departmental standard operating Standard operating procedure 1 RR
procedures are available for department has been
prepared and approved
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1 RR
Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 5 10
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services
5S 1 SI/OB
Mistake proofing 1 SI/OB
Six Sigma 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Area of Concern - H Outcome 22 44
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 10 20
ME H1.1 Facility measures productivity IUD insertion per 1000 eligible
Indicators on monthly basis female 1 RR Denominator to be discussed
Vasectomy performed 1 RR
Tubectomy performed 1 RR
No of First Trimester MTP 1 RR
No. of Second Trimester MTP 1 RR
OCP Users 1 RR
Proportion of users using
limiting method 1 RR
Proportion of target met for
male sterilization surgery 1 RR
Proportion of target met for
female sterilization surgery 1 RR
No. of family planning
counselling done per 1000 client
1 RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 2 4
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0
1
2
Page 133
National Quality Assurance Standards for Tal
Checklist for General Administration
Reference No. Measurable Element Checkpoint Compliance
ME A4.8. The facility provides services under Facility for early detection and 1
National Programme for Prevention referral of suspected cases, ,
and control of Cancer, Diabetes,
Cardiovascular diseases & Stroke
(NPCDCS) as per guidelines
ME B1.1. The facility has uniform and user- Name of the facility prominently 1
friendly signage system displayed at front of CHC building
Availability of administrative 1
services like handicap certificate,
death certificate services are
displayed.
ME B2.1 Services are provided in manner CHC has defined policy for non 1
that are sensitive to gender discrimination according to
gender
ME B3.1 Adequate visual privacy is provided CHC has defined policy for 1
at every point of care maintenance of privacy of
patients
ME B3.3 The facility ensures the behaviours CHC defines and communicate 1
of staff is dignified and respectful, policy regarding decent
while delivering the services communication and courteous
behaviour towards the patient
and visitors
ME B3.4 The facility ensures privacy and CHC defines the policy for privacy 1
confidentiality to every patient, and confidentiality of the patient
especially of those conditions having and condition related with social
social stigma, and also safeguards stigma and vulnerable groups
vulnerable groups
ME B4.1 There is established procedures for CHC define policy for taking 1
taking informed consent before consent.
treatment and procedures
ME B4.2 Patient is informed about his/her Display of patient rights and 1
rights and responsibilities responsibilities.
ME B4.3 Staff are aware of Patients rights The staff is aware of patients 1
responsibilities rights responsibilities
The staff is regularly sensitised 1
about rights and responsibilities
of the patient
ME B4.5. The facility has defined and Availability of complaint box at 1
established grievance redressal administrative office and display
system in place of process for grievance Redressal
and whom to contact are
displayed
ME B5.2 The facility ensures that drugs CHC has established policy for 1
prescribed are available at providing all drugs in the EDL free
Pharmacy and wards of cost as per state directives
ME B5.3 It is ensured that facilities for the CHC has established policy for 1
prescribed investigations are providing all diagnostics free of
available at the facility cost as per state directives
ME B5.5 The facility ensures timely CHC has establish policy for timely 1
reimbursement of financial reimbursement and payment to
entitlements and reimbursement to beneficiaries
the patients
ME C1.5. The facility has infrastructure for CHC has 24X7 functional 1
intramural and extramural telephone connection and
communication intercom facility for internal
communication
ME C1.6 Service counters are available as per Availability of OPD counter as per 1
patient load load
ME C1.7. The facility and departments are There is no cris-cross between 1
planned to ensure structure follows General and Patient Traffic
the function/processes (Structure
commensurate with the function of
the CHC)
ME C2.1. The facility ensures the seismic The facility has been surveyed 1
safety of the infrastructure by Structural engineer for
seismic vulnerability in high
risk zone
Structural Components been 1
made earthquake proof
ME C2.3. Physical condition of buildings are Windows have grills and wire 1
safe for providing patient care meshwork
ME C2.5. The facility has adequate fire Facility has installed fire 1
fighting Equipment extinguisher that are capilbility of
fighting A, B & C type of fire
ME C2.6. The facility has a system of periodic Periodic Training is provided for 1
training of staff and conducts mock using fire extinguishers
drills regularly for fire and other
disaster situation
ME C4.1 The departments have availability of CHC has policy to ensure drugs at 1
adequate drugs at point of use all point of use as per state EDL
ME D1.2. The facility has established Facility has contracted agency for 1
procedure for internal and external calibration of equipments.
calibration of measuring Equipment
ME D2.8 There is a procedure for secure CHC has a policy for ensuring 1
storage of narcotic and psychotropic proper management and
drugs restriction of unintended use of
narcotic substance and
psychotropic drugs as per
prevalent law
ME D3.3. Patient care areas are clean and General waste from CHC is 1
hygienic removed daily by
municipal/outsourced agency
ME D3.4. The facility has policy of removal of CHC has condemnation policy in 1
condemned junk material place
. Periodic removal of junk material 1
done
. CHC has designated covered place 1
to keep junk/condemned material
. No junk/condemned articles in 1
open spaces
ME D3.5. The facility has established Pest control measures are evident 1
procedures for pest, rodent and at facility
animal control
. Anti Termite treatment of the 1
wooden furniture
ME D3.6. The facility provides adequate Adequate illumination in open 1
illumination level at patient care areas in night
areas
Adequate illumination in 1
circulation area
Adequate illumination in toilets 1
Adequate illumination at 1
approach roads to CHC
ME D3.7. The facility has provision of There is restriction on entry of 1
restriction of visitors in patient areas vendors and hawkers inside the
premise of the CHC
ME D4.1. The facility has adequate CHC has adequate water storage 1
arrangement storage and supply for facility as per requirements
portable water in all functional
areas
ME D5.5 The facility has established Clean linen is provided to all the 1
procedures for changing of linen in occupied beds
patient care areas
ME D6.1. The facility has established RKS or eqvivalent body is 1
procedures for management of registered under societies
activities of Rogi Kalyan Samitis registration act
Registration of Ultrasound 1
machine under PCPNDT act.
Drug and cosmetic Act 2005 1
Safety code for Medical diagnostic 1
X ray equipment and installation
ME D9.3. The facility ensures the adherence Facility has policy for dress code 1
to dress code as mandated by its for different cadre of CHC.
administration / the health
department
ME E4.2. Procedure for ensuring timely and There is a policy for ensuring 1
accurate nursing care as per treatment accuracy of verbal/telephonic
plan is established at the facility orders
ME E4.3 There is established procedure of CHC has policy for patient hand 1
patient hand over, whenever staff over during shift change
duty change happens
ME E4.4 Nursing records are maintained CHC has policy for maintaining 1
nursing records
ME E4.5 There is procedure for periodic There is policy for periodic 1
monitoring of patients monitoring of patient
ME E5.1 The facility identifies vulnerable CHC identify and communicate 1
patients and ensure their safe care the category of patient
considered as vulnerable
ME E5.2 The facility identifies high risk patients CHC identify and communicate 1
and ensure their care, as per their need the category of patient
considered as high risk
ME E6.1. Facility ensured that drugs are Facility has policy and enabling 1
prescribed in generic name only order for prescribing drugs by
generic name only
ME E15.3 The facility has standard operating Facility has established has 1
procedure for end of life support established policy for end of life
care
ME F1.6. Facility has defined and established Facility has antibiotic policy in 1
antibiotic policy place
There is system for reporting Anti 1
Microbial Resistance with in the
facility
ME F2.2 Staff is trained and adhere to Check for the records that training 1
standard hand washing practices have been provided
ME F2.3 Facility ensures standard practices Facility ensures uninterrupted and 1
and materials for antisepsis adequate supply of antiseptics
ME F3.2 Staff is adhere to standard personal There is policy for judicious use of 1
protection practices personal protective equipments
specially sterile gloves
ME F4.1 Facility ensures standard practices and The facility ensure adequate 1
materials for decontamination and supply of disinfectant at the point
cleaning of instruments and of use
procedures areas
ME F5.4 Facility ensures segregation infectious CHC has policy for identification 1
patients and segregation of infectious
patient
ME G1.1 The facility has a quality team in Quality Assurance Team for CHCs 1
place is Constituted
ME G2.3. Facility prepares the action plans for There is procedure for preparing 1
the areas, contributing to low Action plan for improving patient
satisfaction of patients. satisfaction
ME G6.1. The facility defines its quality policy Quality policy are defined and 1
displayed in local language
Quality policy is in local language 1
ME G6.2. The facility periodically defines its Quality objective are reviewed at 1
quality objectives and key periodic intervals
departments have their own
objectives
ME G7.2 The facility uses tools for quality 5s, Prioritization, 7 Quality tools, 1
improvement. Mistake proofing etc.
ME H1.1. Facility measures productivity Bed Occupancy Rate 1
Indicators on monthly basis
. IPD per thousand population 1
. OPD consultation per Thousand 1
Population
. Maternal mortality per 1000 1
deliveries
. Neonatal mortality per 1000 live 1
births
. Nurse to bed ratio 1
. No. of meeting held under RKS 1
ME H1.2. The Facility measures equity indicators Proportion of BPL patient in OPD 1
periodically & Indoor admission
ME H2.1 Facility measures efficiency Indicators Overall Referral Rate 1
on monthly basis
Overall discharge rate 1
. Proportion of obstetric cases out 1
of total IPD
. Proportion of fund/ grant utilized 1
ME H3.1 Facility measures Clinical Care & Safety Average Length of Stay 1
Indicators on monthly basis
. Crude mortality rate 1
. Maternal mortality per 1000 1
deliveries
. Neonatal mortality per 1000 live 1
births
. CHC acquired infection rate 1
0
dards for Taluka Hospital
tration 13
Assessment Means of Verification Remarks
Method
SI/OB
SI/OB
SI/OB
SI/OB
SI/OB
SI/OB
SI/RR
SI/OB
SI/OB
SI/OB
SI/OB
SI/OB
For storing consumables,
Stationaries, and
equipments
SI/OB
SI/OB
SI/OB
SI/OB
SI/OB
SI/RR
SI/RR
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
OB
SI/PI
PI/RR
PI/SI
RR/SI
OB
OB
OB
OB
OB
OB
OB at least 120 cm
OB
OB
OB
PI/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
OB
SI
SI/RR
OB
RR/SI
RR/SI
RR
RR/SI
RR
RR
RR/SI
RR/SI
RR/SI
PI/SI
RR/SI
RR/SI
OB
OB/SI/RR
RR/SI/PI
OB
RR/SI
OB/RR
OB
OB/SI
OB/SI
OB/SI
OB/SI
OB
OB
OB
OB
OB
OB/SI/RR
OB
OB/RR
OB/RR
OB/RR
OB/RR
OB
OB/RR
OB/RR
OB
OB
OB/SI
OB
OB
OB
OB
OB
OB
OB
OB
OB/RR
OB/RR
OB/RR
OB
OB/RR
OB/RR
OB/RR
OB/RR/SI 1
OB/RR/SI 1
OB/RR/SI 1
OB/RR/SI 1
OB/RR/SI 1
OB/RR/SI 2
OB/RR/SI 1
OB/RR/SI 1
OB/RR/SI As per patient load
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
OB Equipments for
horticulture, electrical
repair, plumbing material
etc
OB
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
RR
SI/RR
SI/RR
RR/SI
OB
OB
OB
OB/RR
OB
OB
OB
OB
OB
OB
OB
OB
OB/RR
OB
OB/SI/RR
OB
OB
RR/SI
OB/RR
RR/SI
OB/RR
OB
OB
RR/SI
RR/SI
OB
OB
OB
OB
OB/RR
OB/RR
OB/RR
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI/OB
RR/SI
RR/SI
SI
SI/RR
SI/RR
RR/SI
RR/SI
OB/SI
OB
RR
OB
RR/SI
OB/SI
RR/SI
RR/SI
SI
RR
RR
RR
RR
RR
RR
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR
RR/PI
RR/SI
RR
RR/SI
RR/SI
RR
RR
RR
RR
RR
RR
RR AERB safety code no.
AERB/SC/MED-2(Rev 1)
RR
RR
RR
RR
RR
RR
RR
RR
RR Regular + contractual
RR Regular + contractual
RR Regular + contractual
RR Regular + contractual
RR Regular + contractual
RR Regular + contractual
RR Regular + contractual
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
OB
OB
RR
RR
RR Check for that Contract
document has provision
for dedication of payment
if quality of services is not
good
RR
RR
RR/SI
RR
RR/SI
RR/SI/PI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/OB
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
OB/SI
OB/SI
RR
SI/RR
RR
SI/RR
RR/SI
RR
RR
RR
RR
RR
RR Availability of security
services
RR Availability of
Housekeeping services
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
OB/SI
OB/SI
OB/SI
OB/SI
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
RR
SI/RR
SI/RR
SI/RR
SI/RR
SI/RR
RR
RR
RR
RR
RR Overall department
wise/attribute wise score
are calculated
RR
RR/SI
RR
RR
RR/SI
RR/SI
RR/SI
SI/RR
SI/RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/SI
RR/OB
RR/OB
RR/SI
RR Specific, Measurable,
Achievable, Repeatable,
and time bound
RR/SI
RR/SI
RR/SI All clinical and support
services process that are
critical to quality ,e.g.
OPD, IPD, OT, LR, NBSU,
Diagnostics, Pharmacy,
Blood storage, Admin,
Kitchen, Laundry,
Housekeeping etc.
RR/SI
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
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