Operation Theatre: 1. Hospital Planning

Operation Theatre:
1. Hospital Planning
1. Location, proximity with other department

2. Layout
3. Area
4. Roof height (just for database not for this study)
5. Type of flooring (granite, kota stone, ceramic, epoxy etc.),
6. Dadoing (round, right angle and height of dado)
7. Type of wall (plain plaster, painted, granite, stainless steel, seamless etc.)
8. Type of doors (wooden/glass, one sided opening, both side opening, springs etc.)
9. Zoning system
10. Change room for doctors/ nursing staff / ward boys-Ayas and refreshment
facilities for doctor/staff /ward boy
11. Scrub areas, kind of basin,
12. Place for cleaning /disinfecting instrument
13. Intermittent place for waste
14. Availability of patient hold area
15. Flow of activities in the department (miss-match to be identified)
16. Working environment
17. Type of furniture, sufficiency, conditions,
18. Any suggestion for the staff working environments and facilities?
19. Storage of chemical, consumable facility, safety of then place
2. Staff
1. Organogram
2. Staff strengths (sanctioned, employed, on leave, etc)
3. Shift wise staff
4. Availability of Working manual
5. Availability of Job responsibility
6. Any CME/On job Training imparted to staff (topics, frequency, level, organisers
etc.)
7. Availability of SOPS, displayed or not, staff trained or not, adhered or not, any
complaints, suggestions?
3. Electrical Fittings
1. Lights
2. No. of fans
3. Wiring (outdoor, covered, and the condition, pendants)
4. Height from the floor
5. No. of power sockets, is it sufficient,
6. Power related problem
7. Power back up facility,
8. Emergency light
9. Voltage stabilisers
10. UPS system, Stand by generators
4. Ventilation and AC
1
1. Ventilation, Exhaust fans (specially in toilets, etc.)
2. Availability of AC, (No. and type of AC)
3. AC load,
4. Is there dedicated Central AC plant? What is capacity
5. Laminar airflow is provided or not
6. Filter cleaning routine, last when cleaned etc., responsibility, records,
7. Temperature and pressure maintained
8. Temperature, pressure, humidity measuring devices installed or not
9. How much fresh air is circulated
10. Any complaint, suggestions regarding AC
5. Water Supply
1. Availability of basin, no and conditions

2. Availability of drinking water
3. municipal supply/tank water
6. Medical gas supply
1. Types of medical gas (o2, nitrous, vacuum/ suction) and mode of supply
(cylinder, piped,)
2. no. of oxygen cylinder
3. Refilling system (in case of cylinders)
4. Problem faced/Suggestions
7. Communication System
1. Mobile/Paging /Wireless/only telephone

2. Emergency contact number
3. Any problem faced etc. for ward boys, nursing staff and doctors
8. Fire Safety
1. Fire safety system (cylinder, hydrant, sprinkles etc)

2. Type, capacity and number of cylinder and locations in the department
3. Fire detection system
4. Fire alarm system
5. Any training given
6. Mock testing done or not
9. Hospital Waste Disposal:
1. Types waste and colour coded bags and for which kind of waste it is used
2. What kind of dustbin are placed (size, lid, etc.)
3. Location of the waste collection bags (where are the bags kept in the
departments)
4. Method of disinfecting the linen, sharp and other waste
2
5. Method and timing of waste transportation of waste from OT
6. Protecting instruments (gloves, face mask, head cap etc) available or not/
7. Whether staff is using those instruments or not
8. Needle burner are available or not?
9. Needle burner is used or not?
10. Infection control and Cleaning:
1. Precaution taken for self protection

2. How do you wash you hand after any procedures (liquid soap, spirit based soap,
soap cake etc.)
3. Availability of protecting materials (gloves/head cap/face mask, apron etc.)
4. Staff is inoculated or not?
5. Uses of the protecting material
6. What is the system of room cleaning
7. How often fumigation is done/What chemical is used
8. Is there UV light available in OTs
9. What is the system of equipment cleaning
10. Who is responsible and how frequently it is room and equipment cleaning is done
11. System of quality check
12. What disinfectants are used
13. Availability of Infection control policy
14. Training imparted on the infection control precautions
15. Swab testing done or not? For which areas/equipment it is taken?
16. Frequency of swab testing
17. Who is responsible
18. Results or share or not
19. What actions have been taken so for
20. Any records related to infection control is maintained?
11. Equipments:
1. List of equipment (sanctioned, present, no. in order, no. for condemnation, new
requirements) OT light(fixed, portable), OT table (automated, manual), Cautery
machines, microscopes, laryngoscope, crash cart, equipment trolley, Stat lab,
Ventilator, defibrillator, heart lung machines, cell savor, refrigerator etc.
2. Avg. no. of cases a month
3. Who do you call if the equipment get out of order
4. Who much time does service engineer takes/Is that satisfactory or not?
5. Any body within dept trained for maintenance
6. Any spare parts kept /(which equipment, who many, when last time used)
7. Any issues or suggestions
12. Instruments:
1. List of instruments (sanctioned no. of sets, no. of sets available, no. in order, no.
for condemnation, new requirements)
2. Place of storage of instrument, who is responsible
3. System of repair/replacement
4. Who do you call if the repair
3
5. Who much time does he takes
7. Any spare parts kept /(which equipment, who many , when last time used)
8. How do you send for the sterilization
9. How much times it takes
10. What records are maintained ?
11. How many days an sterile kit is kept in the department and when is this send for
re-sterilization?
12. Any reporting cases of pilferages?
13. What action are taken?
14. Linen:
1. List of Linen (sanctioned no. of sets, no. of sets available, no. in order,
no. for condemnation, new requirements)
2. Place of storage of linen
3. System of mending/replacement
4. Who decide for mending/ Where mending is done?
5. Is replacement given for mending?
8. How do you send it for the sterilisation
9. Any reporting cases of pilferages? What action are taken?
11. What records are kept in the department
15. Records
1. What records are maintained (OT register, anestheia register, narcotics
register, linen register, equipment complaint register etc.)
2. Who is maintaining which records /register
3. What MIS /reports are generated and for whom is reported and what is
the purpose?
4. Who generate these reports?
5. What is the frequency of generating different reports?
6. Where are these reports kept and how long?
7. Any problem faced
8. Any suggestion?
16. Inventory
1. Who is responsible for inventory?
2. What kind of material is kept in the OT?
3. Does hospital keeps consignment items also?
4. Where are these material kept
5. Any system of LIFO/FIFO)
6. How much quantity is kept in the department at given time?
7. What is the system of indenting (who, when, how, any specific day?
8. Who bring the material from store?
9. How much time does it takes after indenting
10. System of charging/replacement from patient
11. If material found of wrong quality/specification what is the system of
replacement and how much time it takes to replace it.
4
12. What happen in case of emergency (any cash purchase?)
13. What kind of record are maintained? How frequently it is verified?
14. Any case of pilferage? How it is shorted out?
15. What MIS /reports are generated for inventory and for whom is reported and
what is the purpose?
19. How often inventory checking for both consumables and fixed asset is done.
21. Any suggestion?
17. Quality Control

1. What are the specific quality control norms for the department
2. SOPS /Protocols are available or not?
3. Whether all the staff members are trained for SOPs
4. How do you deal with the emergency operation
5. Problems and suggestions
Intensive Care Unit:

2. Layout, (including bed and nursing station positions)
3. No. of bed, Area
4. Distance between two beds, privacy,
5. Location of nursing station ? is it properly place for better Pt. Care?
7. Type of flooring (granite, kota stone, ceramic, epoxy etc.),
10. Type of doors (wooden/glass, one sided opening, both side opening, springs etc.)
14. Availability of doctor and nurse rest room
15. Clean utility room
16. Dirty utility rooms
18. Work environment
2. Staff
1. Organogram
5
3. Shift wise staff
6. Any CME/On job Training imparted to staff (topics, frequency, level, organisers
etc.) Any document is available or not
7. Availability of SOPS, displayed or not, staff trained or not, adhered or not,
8. Any complaints, suggestions?
9. Is staff being rotated in other department, if yes how frequently?
1. Lights
2. No. of fans
8. Emergency light
9. Voltage stabilizers

2. Availability of AC, (No. and type of AC, load, filter cleaning routine, last when
cleaned etc., responsibility, records, temperature and pressure maintained,
temperature, pressure, humidity measuring devices installed or not
5. Water Supply


5. Types of medical gas (o2, vacuum/ suction) and mode of supply (cylinder, central
supply)

6
4. Signage system
8. Fire Safety

1. Types and colour coded (blue, red or black) bags and for which kind of
waste it is used
departments)
5. Method and timing of waste transportation of waste from ICU
8. Needle burner are available or not

2. How do you wash you hand after any procedures (liquid soap, spirit based
soap, soap cake etc.)
5. What is the system of ICCU cleaning
6. How often fumigation is done/What chemical is used
8. Who is responsible and how frequently it is room and equipment
cleaning is done
7
12. Equipments:
1. List of equipment (sanctioned, present, no. in order, no. for
condemnation, new requirements) Portable OT light, laryngoscope,
crash cart, equipment trolley, Stat lab, Ventilator, Defibrillator, central
monitoring system, suction machine, IABP Machine, Nurse call system,
refrigerator etc.
5. Any spare parts kept /(which equipment, who many, when last time
used)
13. Instruments:
1. List of instruments (sanctioned no. of sets, no. of sets available, no. in
order, no. for condemnation, new requirements)
7. Any spare parts kept /(which equipment, who many , when last time
used)
8. How do you send for the sterilisation
11. How many days an sterile kit is kept in the department and when is this
send for re-sterilization?
14. Linen:
1. List of Linen (sanctioned no. of sets, no. of sets available, no. in order,
Bed sheets, blanket, pillow, staff dress, draw sheet, etc.
14. Records
8
15. What records are maintained (linen register, equipment complaint
register, ICU census, etc.)
the purpose?
22. Any suggestion?
16. Inventory
2. What kind of material is kept in the ICCU?
6. What is the system of indenting (who, when, how, any specific day?)
20. Any suggestion?
17. Patient food:
1. What is the system of food requisition
2. Who makes the food requisition
3. What kind (normal food, diabetic food, clear food, etc.) of food is provided to the
patient?
4. What is timing of the food (for morning beverages, breakfast, lunch, evening
snacks, dinner)
5. What happen if patient is admitted in the evening
6. How the food is brought in the wards?
7. Who check the quality of the food
8. And who serves the food
9
9. Any system of patient feed back on quality of food
10. What measures are taken if some patient complain or suggestion is received on
food quality and taste.
11. Any other suggestion?
18 Quality Control
1 What are the specific quality control norms for the department
2 clinical Protocols are available or not?
3 Whether all the staff members are trained for SOPs
10
19. Procedures:
1. What is the admission procedures
2. Who admit the patient consultant or the ICU incharge
3. What the system for getting the lab, x-ray test to be done on patient
4. What is the system of lab test reporting
5. What is the system for transfer of the patient
6. What happen if there is no bed available in the ICCU
7. What happen if ventilator is not available
8. What is the system of discharge
9. What is there any cutoff timings for the discharge
10. Who prepares the discharge sheet of the patient
11. How much times does it takes to prepare the discharge sheet
12. Does patient complain for the discharge system
13. What kind of complain is made by the patient
14. Any suggestion to improve the system
Wards: (general, surgical, isolation, super specialty)

3. No. of bed, Type of wards(general, private, deluxe etc) , Area
4. Distance between two beds, privacy,
5. Location of nursing station
6. Is the nursing station placed for proper monitoring of patient?
8. Type of flooring (granite, kota stone, etc.),
10. Type of wall (plain plaster, painted, granite, stainless steel, seamless
etc.)
11. Type of doors (wooden/glass, one sided opening, both side opening,
springs etc.)
12. Change room for doctors/ nursing staff / ward boys-Ayas and
refreshment facilities for doctor/staff /ward boy
2. Staff
1. Organogram
11
3. Shift wise staff
6. Any CME/On job Training imparted to staff (topics, frequency, level,
organisers etc.) Any document is available or not
7. Availability of SOPS, displayed or not, staff trained or not, adhered or
not, any complaints, suggestions?
1. Lights
2. No. of fans
8. Emergency light

2. Availability of AC, (No. and type of AC, load, filter cleaning routine, last
when cleaned etc., responsibility, records, temperature and pressure
maintained, temperature, pressure, humidity measuring devices installed
or not
5. Water Supply

1. Types of medical gas (o2, vacuum/ suction) and mode of supply (cylinder, central
supply)

12
4. Signage system
8. Fire Safety

13
1. Types and colour coded (blue, red or black) bags and for which kind of waste it is
used
departments)
5. Method and timing of waste transportation of waste from wards

2. How do you wash you hand after any procedures (liquid soap, spirit based soap,
soap cake etc.)
5. What is the system of ward ‘s floor cleaning
6. What chemical is used
8. Who is responsible and how frequently it is room and equipment cleaning is done
12. Equipments:
requirements) laryngoscope, stethoscope, crash cart, equipment trolley, Stat lab,
Defibrillator, suction machine, Nurse call system, refrigerator, etc.
14
13. Instruments:
re-sterilization?
14. Linen:
1. List of Linen (sanctioned no. of sets, no. of sets available, no. in order, no. for
condemnation, new requirements)
Bed sheets, blanket, pillow, staff dress, draw sheet, etc.
15. Records
1. What records are maintained (linen register, equipment complaint register, ward
census, food register etc.)
3. What MIS /reports are generated and for whom is reported and what is the
purpose?
8. Any suggestion?
15
16. Inventory
11. If material found of wrong quality/specification what is the system of replacement
and how much time it takes to replace it.
21. Any suggestion?
17. Patient food:

patient?
snacks, dinner)
10. What measures are taken if some patient complain or suggestion is received
11. n food quality and taste.
18 . Quality Control
19. Admission and Discharge Procedures

1. What is the admission procedures?
16
2. What happen if no bed is available?
4. What is the system of lab test reporting ?
5. What happen in case of emergency ?
6. What is the system for bed transfer (from one ward to another)?
7. Who coordinates bed transfer?
8. Who accompany the patient?
9. Who prepare the patient for the operation?
10. Who accompany the patient to OT
11. How the patient handing over/taking over takes place?
12. Who get the patient consent form
13. What is the system of discharge?
14. Is there any cutoff timings for the discharge?
15. Who prepares the discharge sheet of the patient?
16. How much times does it takes to prepare the discharge sheet?
17. Does patient complain for the discharge system?
18. What kind of complain is made by the patient?
19. Any issues related to security dept.?
20. Hospital staff are given dress? How many sets? How frequently?
21. Where is the uniform cleaned?
22. In case of home washing, does the hospital provide any allowances?
23. Any other problem staff faces
17
25. Emergency:
3. No. of bed, Type of wards(general, private, deluxe etc) , Area
4. Distance between two beds, privacy, location of nursing station
9. Type of doors (wooden/glass, one sided opening, both side opening, springs
etc.)
2. Staff
1. Organogram
2. Staff strengths for medical, nursing, ward boys etc. (sanctioned, employed, on
leave, etc)
3. Shift wise staff
6. Any CME/On job Training imparted to staff (topics, frequency, level, organizers
1. Lights
2. No. of fans
18
8. Emergency light

cleaned etc., responsibility, records, temperature and pressure
maintained, temperature, pressure, humidity measuring devices
installed or not
5. Water Supply

1. Types of medical gas (o2, vacuum/ suction) and mode of supply (cylinder,
central supply)

4. Signage system
8. Fire Safety

1. Types and colour coded (yellow, blue, red or black) bags and for which kind of
waste it is used
19
departments)
5. Method and timing of waste transportation of waste from emergency department

1 Precaution taken for self protection
2 How do you wash you hand after any procedures (liquid soap, spirit based soap,
soap cake etc.)
3 Availability of protecting materials (gloves/head cap/face mask, apron etc.)
4 Uses of the protecting material
5 What is the system of floor cleaning
6 How often fumigation of OT /ICU is done/What chemical is used
7 What is the system of equipment cleaning
8 Who is responsible and how frequently it is room and equipment cleaning is done
9 System of quality check
10 What disinfectants are used
11 Availability of Infection control policy
12 Training imparted on the infection control precautions
13 Swab testing done or not? For which areas/equipment it is taken?
14 Frequency of swab testing
15 Who is responsible
16 Results or share or not
17 What actions have been taken so for
18 Any records related to infection control is maintained?
12. Equipments:
requirements) OT light, laryngoscope, stethoscope, crash cart, equipment trolley,
Stat lab, X-ray, sonography, Defibrillator, suction machine, Nurse call system,
refrigerator, etc.
20
13. Instruments:
re-sterilization?
14. Linen:
1. List of Linen (sanctioned no. of sets, no. of sets available, no. in order, no. for
condemnation, new requirements)
Bed sheets, blanket, pillow, staff dress, draw sheet, apron, etc.
8. How do you disinfect the soil linen and or how do you send it for the sterilisation
15. Records
1. What records are maintained (linen register, equipment complaint register, ICU
census, etc.)
purpose?
8. Any suggestion?
16. Inventory
21
10. If material found of wrong quality/specification what is the system of replacement
and how much time it takes to replace it.
20. Any suggestion?
17. Patient food:

patient?
snacks, dinner)
10. What measures are taken if some patient complain or suggestion is received
11. n food quality and taste.
19 . Quality Control

1. What is the admission procedures
22
3. What is the system of lab test reporting
4. What is the system for transfer of the patient
5. What happen if there is no bed available
6. What is the system of discharge
7. What is the system for bed transfer (from one ward to another)?
8. Who coordinates?
9. Who accompany the patient?
10. Who prepare the patient for the operation?
11. Who accompany the patient to OT
12. How the patient handing over/taking over takes place?
13. Is there any cutoff timings for the discharge?
14. Who prepares the discharge sheet of the patient
15. How much times does it takes to prepare the discharge sheet
16. Does patient complain for the discharge system
23
Laboratory:
1. Location, proximity with other department (OPD, Emergency, OT, ICU etc.)
2. Layout, (different section)
3. Type of sections (Biochemistry, Serology, Microbiology, etc) , Area
etc.)
8. Blood Sample collection room
9. Urine and stool collection room
10. Toilet for staff
11. Working area for different sections
2. Staff
1. Organogram
leave, etc)
3. Shift wise staff
6. Any CME/On job Training imparted to staff (topics, frequency, level, organizers
1. Lights
2. No. of fans
8. Emergency light
24

5. Water Supply


3. Any problem faced etc. for ward boys, technicians and doctors
4. Signage system
7. Fire Safety

1. Types and colour coded (yellow-for histopath, blue, red or black) bags and for
which kind of waste it is used
departments)
4. Method of disinfecting the sharp and other waste
5. Method and timing of waste transportation of waste from lab
25
5. What is the system of cleaning
7. Who is responsible and how frequently it is room and equipment cleaning is
done
12. Equipments:
1. List of equipment (sanctioned, present, no. in order, no. for condemnation,
new requirements)
Sample collection chair, Centrifuge, water bath, hot ovan, equipment trolley,
refrigerator, microscope(manual, power operated etc.), biochemistry,
microbiology, Elisa reader, ABG machines, etc.
13. Records
1. What records are maintained (linen register, equipment complaint register,
section wise work load, etc.)
purpose?
7. Any suggestion?
26
14. Inventory
1 Who is responsible for inventory?
2 What kind of material is kept in the Laboratory?
3 Where are these material kept
4 Any system of LIFO/FIFO)
5 How much quantity is kept in the department at given time?
6 What is the system of indenting (who, when, how, any specific
day?)
7 Who bring the material from store?
8 How much time does it takes after indenting
9 If material found of wrong quality/specification what is the
system of replacement and how much time it takes to replace it.
10 What happen in case of emergency (any cash purchase?)
11 What kind of record are maintained? How frequently it is
verified?
12 Any case of pilferage? How it is shorted out?
13 What MIS /reports are generated for inventory and for whom is
reported and what is the purpose?
14 Who generate these reports?
15 What is the frequency of generating different reports?
16 Where are these reports kept and how long?
17 How often inventory checking for both consumables and fixed
asset is done.
18 Any problem faced
19 Any suggestion?
15. Quality Control

2. Clinical Protocols are available or not?
3. Are they shared with the staff or not?
4. How often the equipment’s calibration is done,
5. Is calibration is done for all equipment
6. Any records is being maintained
7. When was the last calibration done
8. Any other quality control methods such as statistical quality control is used or
not?
19. Registration/ Charging and Reporting Procedures
1. What is the registration /and charging procedures
2. What the system for getting the lab test to be done on patient
3. What is the system sample collection (for IPD and OPD)
4. Does the lab staff go in to the ward for the sample collection
5. What are the timings
6. Any problem do they face in the ward
7. Who perform the test (qualification and/designation) / who checks it and when
(does the test performed in block as per need)
8. What happen in case of emergency?
9. What is the system of reporting
27
Timings, places etc., who prepares the report (technician or ward
clerk/medical transcriptionist)
10. Any problem they face while doing dual work of conducting test as well writing
reports
11. How does the staff ensure that payment is made or not
12. What if some one comes without payment and it is emergency?
14. Does patient complain for the delay in report preparation
28
Blood Bank:
springs etc.)
7. Counseling area/Screening area
8. Bleeding Space
9. Cross matching
10. Record room
11. Transfusion Medicine room
2. Staff
1. Organogram
2. Staff strengths for medical, technical, nursing, ward boys etc. (sanctioned,
employed, on leave, etc)
3. Shift wise staff
organizers etc.) Any document is available or not
any complaints, suggestions?
8. Is staff being rotated in other department(like Pathology), if yes how
frequently?
1. Lights
2. No. of fans
29
8. Emergency light

5. Water Supply

1. Mobile/Paging /Wireless/direct telephone

4. Signage system
7. Fire Safety

waste it is used
departments)
5. Method of disposing the blood bags etc.
6. Method and timing of waste transportation of waste from lab
8. Whether staff is using those instruments or not?
9. Needle burner are available or not ?
30
done
10. Equipments:
new requirements) Centrifuge, water bath, hot Ovan, equipment trolley,
refrigerator, microscope(manual, power operated etc.), Elisa reader, Walk in
coolers, Laminar airflow, plazma agitator, Aforasis machine etc.
11. Records
section wise work load, wastage of blood, chemicals etc.)
purpose?
7. Any suggestion?
12. Inventory
31
2. What kind of material is kept in the Blood bank?
19. Any suggestion?
13. Quality Control

2. Clinical Protocols are available or not?
3. Are they shared with the staff or not?
4. How often the equipment’s calibration is done,
5. Is calibration is done for all equipment
7. When was the last calibration done
8. Any other quality control methods such as statistical quality control is used
or not?
1. What is the registration /and charging procedures?
2. What the system for getting the blood bag/
3. What is the system blood donation (for IPD and OPD)
4. Does the Blood bank staff go in to the ward for the bleeding /transfusion
sample collection
5. Who perform the test (qualification and/designation) / who checks it and
when (does the test performed in block as per need)
6. What happen in case of HIV positives case?
a. Timings, places etc., who prepares the report (technician or ward
17. Any problem they face while doing dual work of conducting test as well writing
reports
32
20. What is there any cutoff timings for the Bleeding in the department
21. Does patient complain for the delay in blood donation/ issuance of blood and
its product?
33
Imaging services:
22. Location, proximity with other department (OPD, Emergency, OT, ICU
etc.)
24. Type of sections (X-ray, Sonography, CT Scan etc.), Area of different
sections
25. Machine room
26. Control room
27. Dark room
28. Stores
29. View Box/report writing room etc
etc.)
springs etc.)
34. Led sheet protection is given to ward or not?
42. Storage facility of fixtures, X-ray films, , safety of then place
2. Staff
1. Organogram
leave, etc)
3. Shift wise staff
1. Lights
2. No. of fans
34
8. Emergency light

5. Water Supply
Availability of basin in dark room, conditions

4. Signage system
7. Fire Safety

1. Types and colour coded bags (blue/red/black) used

departments)
5. Method and timing of waste transportation of waste from radiology dept.
35
done
12. Equipments:
new requirements) X-ray Machine(and its capacity in MA), Portable X-ray
Machine, CT Scan, Sonography, Processors(manual/auto), capacity of
processors, View boxes,
13. Records
section wise work load, x-ray film utilisation, wastage of films, down time of
machine register etc.)
purpose?
7. Any suggestion?
13. Inventory
2. What kind of material is kept in the radiology dept?
36
19. Any suggestion?
15. Quality Control
2. Working SOPS are available or not?
3. Staff is trained for SOPS or not?
4. How often the equipment’s preventive maintenance is done,
6. When was the last preventive maintenance/repair done
7. Protecting instruments (Led apron, goggle, TLD badges etc) available or not.

2. What the system for getting the radiology test to be done on patient ?
3. Does the radiology staff go in to the ward for the conducting test?
4. Any problem do you face in the wards
5. Who perform the test(qualification and/designation)
6. what happen in case of emergency?
Timings, places etc., who prepares the report (technician or ward clerk/medical
transcriptionist)
8. Any problem they face while doing dual work of conducting x-ray as well
writing reports.
9. Who checks the reports, when and how frequently?
37
OPD:

3. No. of OPD rooms, Type of rooms (Prof, Asst. Prof. , Lect. etc) , Area,
facilities
4. Distance between two OPDs, privacy,
5. Location of nursing/ANM station?
etc.)
springs etc.)
11. Treatment room
19. Waiting area, facilities for the patient, cleanliness etc.
2. Staff
1. Organogram
3. Shift wise staff
1. Lights
2. No. of fans
38
8. Emergency light

or not
5. Water Supply


4. Signage system
7. Fire Safety

waste it is used
departments)
39
5. What is the system of floor cleaning
done
10. Equipments:
condemnation, new requirements) laryngoscope, stethoscope, crash cart,
equipment trolley, refrigerator, etc.
3. Who much time does service engineer takes/Is that satisfactory or
not?
used)
11. Instruments:
1. List of instruments (sanctioned no. of sets, no. of sets available, no. in order,
11. How many days an sterile kit is kept in the department and when is this send
for re-sterilization?
40
12. Linen:
1. List of Linen (sanctioned no. of sets, no. of sets available, no. in order, no.
Bed sheets, pillow, staff dress, towel etc.
13. Records
OPD census etc.)
purpose?
8. Any suggestion?
14. Inventory
2. What kind of material is kept in the OPD?
14. What MIS /reports are generated for inventory and for whom is reported
and what is the purpose?
41
18. How often inventory checking for both consumables and fixed asset is
done.
20. Any suggestion?
15. . Quality Control
2. clinical Protocols are available or not?

1. What is the registration procedures?
5. Does patient complain for the registration system?
42
Registration/Reception and Admission counter:

3. No. of rooms
4. Work environment
5. The furniture and comfort of the staff and the patient relatives
6. Distance between two OPDs, IPD, Diagnostics
7. Aesthetic look of the registration area
8. Waiting area
9. Facilities for the patient and cleanliness
2. Staff
1. Organogram
3. Shift wise staff
1. Lights
2. No. of fans
8. Emergency light

43
5. Water Supply
4. Signage system
5. Public announce system
7. Fire Safety
8. Equipments:
1. List of equipment (computer etc.)
9. Records
register,)
purpose?
8. Any suggestion?
9. Inventory

2. What kind of stationary and material is kept in the dept?
7. How much time does it takes after indenting?
8. System of charging/replacement from patient?
9. If material found of poor quality/specification what is the system of
44
11. What kind of record are maintained?
12. How frequently it is verified?
13. Any case of pilferage?
14. How it is shorted out?
done?
20. Any problem faced?
21. Any suggestion?

12. Procedures
45
Medical Records:

12. Medical record officer room
13. File collection and shorting for deficiency room
14. Place for doctor to correct the files
15. Records room
16. Place for the Medico Legal files
18. The furniture and comfort of the staff
19. Distance with OPDs, IPD,
2. Staff
1. Organogram
1. Lights
2. No. of fans
8. Emergency light

maintained, temperature, pressure, humidity measuring devices
installed or not
46
1. Telephone
2. Signage system
3. Public address system for staff
6. Fire Safety
7. Equipments/Furniture:
1. List of equipment (computer/type writer etc.)
used)
8. Records
register, MLC file, file issued, incomplete file register etc.)
the purpose?
8. Any suggestion?
9. Inventory
12. What MIS /reports are generated for inventory and for whom is
47
done.
18. Any suggestion?
11. Procedures
1. What are the activities of Medical records department
2. Is shorting of incomplete files are done?
3. What kind of incompleteness is checked
4. what are the common errors
5. Which department is most commonly make these error
6. What is the process of error rectification?
7. How much time it takes usually, for error rectification
8. Does the medical staff cooperate fully for the error rectifications?
9. Till the time errors are not corrected where are files kept?
10. What action(s) are taken against medical staff?
11. Is the separate numbering done in the medical records
12. Does the hospital has ICD code booklet?
13. Is the ICD coding done for the medical records?
14. What is the system for storing the files(IPD number wise, MRD no. wise)
15. How are the files kept (vertically, in the bundles of 25 or 50 etc.)
16. Where are the MLC files kept
17. What is the system for issuing the files
18. Is the file of consultant other that treating given? if yes, whether special
permission is required ? whose? Any separate records are kept for issuing
the files etc.?
19. Does the hospital conduct Medical audit? What kind of ? what are the
outcomes and action taken so far.
48
Imaging services:
1.Hospital Planning
3. Type of sections (X-ray, Sonography, CT Scan etc.), Area of different
sections
4. Machine room
5. Control room
6. Dark room
7. Stores
8. View Box/report writing room etc
etc.)
13. Led sheet protection is given to ward or not?
21. Storage facility of fixtures, X-ray films, , safety of then place
2. Staff
1. Organogram
2. Staff strengths for medical, nursing, ward boys etc. (sanctioned,
employed, on leave, etc)
3. Shift wise staff
1. Lights
2. No. of fans
49
8. Emergency light

or not
5. Water Supply
Availability of basin in dark room, conditions

4. Signage system
7. Fire Safety

1. Types and colour coded bags (blue/red/black) used

departments)
5. Method and timing of waste transportation of waste from radiology
dept.
50
2. How do you wash you hand after any procedures (liquid soap, spirit
based soap, soap cake etc.)
4. Who is responsible and how frequently it is room and equipment
cleaning is done
12. Equipments:
condemnation, new requirements) X-ray Machine(and its capacity in
MA), Portable X-ray Machine, CT Scan, Sonography,
Processors(manual/auto), capacity of processors, View boxes,
used)
13. Records
register, section wise work load, x-ray film utilisation, wastage of films,
down time of machine register etc.)
the purpose?
7. Any suggestion?
14. Inventory
2. What kind of material is kept in the radiology dept?
51
done.
19. Any suggestion?
15. Quality Control

2. Working SOPS are available or not?
3. Staff is trained for SOPS or not?
4. How often the equipment’s preventive maintenance is done,
6. When was the last preventive maintenance/repair done
7. Protecting instruments (Led apron, goggle, TLD badges etc) available
or not.

2. What the system for getting the radiology test to be done on patient ?
3. Does the radiology staff go in to the ward for the conducting test?
4. Any problem do you face in the wards
5. Who perform the test(qualification and/designation)
6. what happen in case of emergency?
8. Timings, places etc., who prepares the report (technician or ward
9. Any problem they face while doing dual work of conducting x-ray as
well writing reports.
10. Who checks the reports, when and how frequently?
52
OPD:

3. No. of OPD rooms, Type of rooms (Prof, Asst. Prof. , Lect. etc) ,
Area, facilities
4. Distance between two OPDs, privacy,
5. Location of nursing/ANM station?
9. Type of wall (plain plaster, painted, granite, stainless steel,
seamless etc.)
10. Type of doors (wooden/glass, one sided opening, both side
opening, springs etc.)
11. Treatment room
19. Waiting area, facilities for the patient, cleanliness etc.
2. Staff
1. Organogram
3. Shift wise staff
7. Availability of SOPS, displayed or not, staff trained or not, adhered
or not, any complaints, suggestions?
1. Lights
2. No. of fans
53
8. Emergency light

2. Availability of AC, (No. and type of AC, load, filter cleaning routine,
last when cleaned etc., responsibility, records, temperature and
pressure maintained, temperature, pressure, humidity measuring
devices installed or not
5. Water Supply


2. .Emergency contact number
4. Signage system
7. Fire Safety

2. Type, capacity and number of cylinder and locations in the
department
waste it is used
departments)
54
5. What is the system of floor cleaning
8. Who is responsible and how frequently it is room and equipment cleaning
is done
10. Equipments:
new requirements) laryngoscope, stethoscope, crash cart, equipment
trolley, refrigerator, etc.
11. Instruments:
1. List of instruments (sanctioned no. of sets, no. of sets available, no. in
order, no. for condemnation, new requirements)
11. How many days an sterile kit is kept in the department and when is this
send for re-sterilization?
55
12. Linen:
1. List of Linen (sanctioned no. of sets, no. of sets available, no. in order, no.
a. Bed sheets, pillow, staff dress, towel etc.
13. Records
OPD census etc.)
purpose?
8. Any suggestion?
14.Inventory
2. What kind of material is kept in the OPD?
done.
56
20. Any suggestion?

2. clinical Protocols are available or not?

57
Registration/Reception and Admission counter:

3. No. of rooms
4. Work environment
5. The furniture and comfort of the staff and the patient relatives
6. Distance between two OPDs, IPD, Diagnostics
7. Aesthetic look of the registration area
8. Waiting area
9. Facilities for the patient and cleanliness
2. Staff
1. Organogram
3. Shift wise staff
1. Lights
2. No. of fans
8. Emergency light

2. Availability of AC, (No. and type of AC, load, filter cleaning routine,
last when cleaned etc., responsibility, records, temperature and
pressure maintained, temperature, pressure, humidity measuring
devices installed or not
58
4. Water Supply
Availability of drinking water
4. Signage system
5. Public announce system
7. Fire Safety
8. Equipments:
i. List of equipment (computer etc.)
3. Who much time does service engineer takes/Is that satisfactory or
not?
used)
9. Records
1. What records are maintained (linen register, equipment
complaint register,)
3. What MIS /reports are generated and for whom is
8. Any suggestion?
9. Inventory
5. What is the system of indenting (who, when, how, any specific
day?)
59
reported nd what is the purpose?
17. How often inventory checking for both consumables and fixed asset
is done.
19. Any suggestion?

12. Procedures
60
Ambulance:
1. Location of ambulance parking

3. Ambulance in charge room
4. No of Ambulance and type of Ambulance (general and intensive)
5. Work environment
6. The furniture and comfort of the staff
2. Staff
1. Organogram
1. Mobile/ Wireless in the ambulance /
2. Mobile/ Wireless and Telephone in the control room
3. Signage system
4. Public address system for staff
6. Fire Safety
1. Fire safety system (cylinder etc)
2. Type, capacity and number of
3. Any training given to driver etc.
7. Equipments/Consumables:
1. List of equipment (trolley, BP Apparatus, Stethoscopes, oxygen cylinder,
ventilator, Defibrillator, Suction machine, cardiac monitor, etc.) and number of
equipments
2. List of instruments and consumables (ET tubes, Ambu bags injections,
medicines, etc.) and their quantity.
7. How much quantity of consumable are kept in ambulance
8. What is the system of indenting?
9. Who authorizes for the making indent from main stores
10. What happen in case of emergency etc.?
61
8. Records
consumables uses book, indent book, cssd book, log book, diesel/petrol
book, etc)
purpose?
8. Any suggestion?
9. Inventory
18. Any suggestion?
10. Procedures
1. Who is What are the activities of Medical records department
2. Is shorting of incomplete files are done?
3. What kind of incompleteness is checked
4. what are the common errors
5. Which department is most commonly make these error
6. What is the process of error rectification?
7. How much time it takes usually, for error rectification
8. Does the medical staff cooperate fully for the error rectifications?
9. Till the time errors are not corrected where are files kept?
10. What action(s) are taken against medical staff?
11. Is the separate numbering done in the medical records
12. Does the hospital has ICD code booklet?
13. Is the ICD coding done for the medical records?
62
14. What is the system for storing the files(IPD number wise, MRD no.
wise)
15. How are the files kept (vertically, in the bundles of 25 or 50 etc.)
16. Where are the MLC files kept
17. What is the system for issuing the files
18. Is the file of consultant other that treating given? if yes, whether special
permission is required ? whose? Any separate records are kept for issuing the
files etc.?
19. Does the hospital conduct Medical audit? What kind of ? what are the
outcomes and action taken so far.
63

Operation Theatre: 1. Hospital Planning

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Operation Theatre:

1. Location, proximity with other department

1. Availability of basin, no and conditions

6. Medical gas supply

1. Mobile/Paging /Wireless/only telephone

1. Fire safety system (cylinder, hydrant, sprinkles etc)

9. Hospital Waste Disposal:

10. Infection control and Cleaning:

1. Precaution taken for self protection

17. Quality Control

Intensive Care Unit:

1. Location, proximity with other department

1. Ventilation, Exhaust fans (specially in toilets, etc.)

4. Availability of basin, no and conditions

6. Medical gas supply

1. Mobile/Paging /Wireless/only telephone

1. Fire safety system (cylinder, hydrant, sprinkles etc)

9. Hospital Waste Disposal:

10. Infection control and Cleaning:

1. Location, proximity with other department

1. Ventilation, Exhaust fans (specially in toilets, etc.)

1. Availability of basin, no and conditions

6. Medical gas supply

1. Mobile/Paging /Wireless/only telephone

1. Fire safety system (cylinder, hydrant, sprinkles etc)

10. Infection control and Cleaning:

17. Patient food:

1. What is the system of food requisition

19. Admission and Discharge Procedures

1. Ventilation, Exhaust fans (specially in toilets, etc.)

1. Availability of basin, no and conditions

6. Medical gas supply

1. Mobile/Paging /Wireless/only telephone

1. Fire safety system (cylinder, hydrant, sprinkles etc)

9. Hospital Waste Disposal:

10. Infection control and Cleaning:

17. Patient food:

1. What is the system of food requisition

19. Admission and Discharge Procedures

1. Ventilation, Exhaust fans (specially in toilets, etc.)

1. Availability of basin, no and conditions

1. Mobile/Paging /Wireless/only telephone

1. Fire safety system (cylinder, hydrant, sprinkles etc)

9. Hospital Waste Disposal:

10. Infection control and Cleaning:

15. Quality Control

1. Ventilation, Exhaust fans (specially in toilets, etc.)

1. Availability of basin, no and conditions

1. Mobile/Paging /Wireless/direct telephone

1. Fire safety system (cylinder, hydrant, sprinkles etc)

8. Hospital Waste Disposal:

13. Quality Control

1. Ventilation, Exhaust fans (specially in toilets, etc.)

Availability of basin in dark room, conditions

1. Mobile/Paging /Wireless/only telephone

1. Fire safety system (cylinder, hydrant, sprinkles etc)

9. Hospital Waste Disposal:

1. Types and colour coded bags (blue/red/black) used

19. Registration/ Charging and Reporting Procedures

1. Location, proximity with other department

1. Ventilation, Exhaust fans (specially in toilets, etc.)

1. Availability of basin, no and conditions