AADHAR HOSPITAL

HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST

BETTER HEALTH, BETTER TOMORROW

CSSD
Sl. No. Particulars C PC NC
A. Infrastructure
1 The CSSD should be located in a delineated area where there is less or no external
traffic movement.
2 Location of CSSD should be either close to OT or should be connected to OT with
safe & quick transfer mechanism, like dumbwaiters.
3 Entry to CSSD should be restricted to only staff working in CSSD
4 The CSSD layout should have well demarcated zones, which includes
 Collection zone (or soiled zone) where the soiled and used items should be
received and sorted
 Cleaning zone where washing, cleaning and packaging of items should be done
 Sterilization zone where the actual sterilization of packages should be done
 Storage – This can be considered a part of sterilization zone, where sterilized
packs are stored till its distribution
5 The zones must lead to unidirectional movement of people and supplies.
6 Entry to sterile zone should be after taking necessary infection control precautions
such as hand washing, wearing of gowns/aprons, gloves etc.
7 The sterilization zone (specially storage) should have a higher air pressure to prevent
outside air to enter in this area
8 Emergency exit route should be identified and displayed
9 Easy access to fire fighting measures (like extinguisher, or hose pipe) should be
available
10 CSSD should have required sterilization and cleaning equipment in well-functioning
condition
11 Sterilization equipments must be under AMC/CMC and Calibrated
B Process
1 SOP should be documented for each activity done in CSSD. These activities include
 Procedure of cleaning
 Procedure of packing
 Procedure of disinfection
 Procedure of sterilization (separate SOP for each type of sterilization equipment)
 Procedure of storage and issue
 Safety precautions and guidelines
2 A policy should be there on reusable devices/items which specifies following
 List of items that can be re-used (items not in list should automatically be
considered, non-reusable)
 Number of times it can be re-used
 On whom can it be re-used (like on same patient or on different patient)
 Processing required before reuse of the items
3 Sterilization equipment must be calibrated at a regular interval. A preventive
maintenance checklist should also be available for each equipment
4 Each sterilization equipment should have an identification number, which should be
displayed on the equipment
5 Each pack, that is being sterilized must be labeled with following information
 Date of sterilization
 Date of expiry
 Equipment number in which it was sterilized
 Load number in which it was loaded for sterilization
6 Record of each load sterilized in CSSD should be maintained; w.r.t.
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

Sl. No. Particulars C PC NC

 Date
 Load number
 Description of contents that were included
 Temperature, pressure and time-record chart
7 Validation tests must be done in CSSD. The validation tests must include
 Physical/Chemical test – should be done for each load
 Biological spore test – at-least weekly basis for each equipment
8 The CSSD must maintain record of all validation test reports
9 A procedure of recalling items should be there in case of sterilization breakdown
10 List of hazardous chemicals in CSSD should be available
11 MSDS of each hazardous chemical should be available
C Staff Knowledge
1 Infection prevention practices to be followed in CSSD
2 Zones and unidirectional movement
3 Hand hygiene practices
4 Validation tests done in CSSD
5 When sterilization breakdown should be considered
6 Procedure to recall when sterilization breakdown occurs
7 Relevant staff should know their work SOP
8 Occupational health hazards of working in CSSD
9 Hazardous chemicals and its spill management
10 Other general topics like, employee rights, use of fire extinguisher, emergency codes
etc.
11 Staff in patient care areas who receive CSSD supplies must know following
 About the labels on sterile packs, specially expiry date
 Storage condition that should be maintained
 Condition under which sterile packs must not be used
 What to do in case a sterile pack has been recalled
 How to send soiled/used items
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

BIOMEDICAL & GENERAL ENGINEERING

Sl. No. Particulars C PC NC
1. Policy for equipment planning. An equipment plan should typically have specialty
wise list of equipment required, with brief specification and their quantity. The plan
should be based on clinical need and workload. Such plan should be developed in
consonance with the doctors of the clinical departments.
2. Policy for equipment procurement which specifies authority of taking decisions. For
e.g. Decision of procuring low cost equipment can be taken at the department level,
while decision of procuring high cost equipment can only be taken by a committee.
The indicative level of low cost, medium cost and high cost should be defined.
3. Availability of purchase committee, Roles & responsibilities of committee, Frequency
of meetings etc.
4. Recording of all minutes of meeting
5. Inventory record of all equipments in the hospital
6. Following points must be ensured for each equipment in the hospital
 Necessary documents related to equipment should be available. Such as purchase
bill, regulatory clearance certificate (such as type approval certificates of X-ray
machines), quality conformance certificates or marks (such as ISI certified),
factory test certificate by manufacturer
 Equipment log (history sheet) is maintained for each equipment. The log should be
used to record all important information pertaining to the equipment, such as, date
of purchase, date of calibration, preventive maintenance, date and details of
upgrades done, change of spare parts etc.
 A preventive maintenance schedule is prepared and followed.
 A preventive maintenance checklist is available, which should be used during
each servicing
 A breakdown maintenance plan is available, which specifies who will check the
equipment in case of breakdown and from where will it be repaired. Warranty and
AMC must be considered while making this policy
 The calibration certificate and calibration schedule should be available
 A label on equipment specifying its latest calibration status and due date of
calibration
7 For any new equipment purchased or equipment upgrade in the hospital training must
be organized for the users on how to use the equipment, along with its safety features.
Record of such trainings should be maintained.
8 A documented procedure is available for disposal of equipment. The document should
specify the period or conditions after which the equipment will be disposed off and the
method of disposal of equipment.
9 A documented procedure should be available that describes what to do in case a
communication of equipment recall is received from the manufacturer of the
equipment. Equipment which has been recalled by manufacturer should not be used
for patient care activity.
10 The engineering department must maintain a record of all complaint/service requests
received from user department. The record should specify date and time of receiving
complaint, date and time of attending the complaint and date and time of closure of
complaint. This data should be used to calculate average response time and average
completion time, on monthly basis.
11 A documented timeframe of responding to service request should be available. Time
frame can be different for different user areas depending upon criticality, for e.g.
Request from ICU or OT should be attended on priority.
12 Engineering department must be able to provide round the clock service, at-least for
critical equipment
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

Sl. Particulars C PC NC
No.
13. Operational & preventive maintenance plan for facility and furniture, IT &
Communication, heating, ventilation & air conditioning, electrical & water management
etc.
14. Availability of alternate sources for water & electricity
15. Initiatives taken towards and energy efficient & environmental friendly hospital
16. Records of water tank cleaning, water cooler cleaning, AHU cleaning, HEPA filter etc.
Staff Knowledge
1 Equipment procurement policy and process
2 Equipment condemnation policy and process
3 Preventive and breakdown maintenance plan
4 Calibration of equipment
5 Turn-around time for responding to complaints or service requests
6 Occupational health hazards they face and prevention strategies
7 Equipment hygiene and infection control practices
8 Safety practices to be followed with each equipment
9 Other general topics like, employee rights, use of fire extinguisher, emergency codes etc.
10 Knowledge of staffs from user departments
 Safety instructions pertaining to the equipment
 Hygiene practices to be followed to prevent cross infection from equipment
 Calibration status of the equipment
 Complaint process in case of breakdown
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

 Name of Policy: Patient identification

 Scope: Hospital Wide
 Objective: To prevent medical errors related to patient identification and to ensure patient safety.
 Responsibility: All hospital employees
 Policy Statement:
 Introduction:
One of the most common causes of medical errors in healthcare is the incorrect identification of patients. The error
can lead to potentially serious consequences such as surgery of a wrong patient or transfusion of wrong blood into a
patient. The Aadhar Health Institute, Hisar has adopted internationally recommended practices for accurately
identifying a patient.
 Patient identification details
 At the time of registration, patient’s identification details shall be taken that includes, patient’s full name, date of
birth and father’s/mother’s/spouse’s name. At-least one more identifier in addition to the name of patient shall be
obtained.
 A unique identification Number (UIN) must be generated for each registered patient. That UIN shall not be
used for any other patient, even in future.
 The name of patient and UIN shall be used as a standard identifier for identifying any patient in the hospital
 Use of Patient Identification band (ID band)
 An ID band must be placed on each admitted patient’s wrist either right or left as per convenience. In case the
wrist is not suitable for band placement (for eg. Injured or bandaged) then the band can be placed on ankle.
 Patient’s name, UIN and one more identifier (such as date of birth, father’s name etc.) shall be written on the
ID band.
 If the patient is unknown or unidentified, the ID band shall mention as ‘Unidentified -1, Unidentified – 2,
etc.), along with UIN, gender, approximate age and ward/location. As and when patient’s identity is obtained,
the ID band shall be updated
 The contents of ID band must be clear and legible.
 Patient shall not be able to self-remove the ID band, once placed. ID band shall be removed by cutting at the
time of discharge, or if a correction is required in the band.
 Procedures before which patient’s identification must be established
 Identification of patient shall be done before all care process. In particular, correct identification shall be
established before initiating any of the given procedures
 Surgical intervention and any invasive procedure
 Administration of all kind of medicines through any route
 Transfer of patient from one place to another
 Imaging investigations
 Sample collection for lab tests
 Blood sampling
 Blood transfusion
 Death confirmation
 Process of identifying
 Standard process of identifying a patient shall be as follows.
 Staff shall ask the name of the patient and his/her date of birth and match the response with the name printed
on his/her ID band.
 Staff shall then check the UIN on ID band and match it with the UIN on patient’s record.
 Blood transfusion – Bedside patient identification check is essential before initiating transfusion.
 Two separate people shall identify the patient using the standard process, one of whom shall be the RMO on
duty and second person shall be the attending nursing staff.
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

 Transfusion shall be initiated only after both have confirmed the same identification.
Imaging – The operating technician shall identify the patient before starting the X-ray or investigation. The
patients’ identification details on ID band shall be matched with the identification details on request form.
 Sample collection – Patient shall be identified bedside before collection of sample for a lab test. The container in
which sample is collected shall be labeled bedside in the presence of the patient.
 Incompetent patient – For patients who are unconscious or incompetent to state their identification, help shall be
taken from the accompanying capable adult.
 Unknown and unconscious patient – For such patients’ identification shall be done by the emergency staffs who
are handling the patient.
 Patients under anesthesia – Patients in operation theatre who is under anesthesia shall be identified by a staff
from the operating team.
 Identification of Mother and Babies
 Mother’s ID band shall include the identification details as stated above
 On the baby, two separate ID band shall be placed on two separate limbs of the baby (generally both ankles). The
baby’s ID band shall contain following details
 First ID band – Mother’s name, age, UIN, and date of admission
 Second ID band – Baby’s gender followed by mother’s name, baby’s UIN, date and time of birth, mode of
delivery
 The details of ID band on baby shall be confirmed by the mother. In case, mother is not in a condition to
confirm, it shall be confirmed from the father
 Details on baby’s first ID band shall be matched with the mother’s ID band before handing over the baby on
every occasion
 Identification of deceased patient
 In all deceased patient, two ID band shall be applied. One on the wrist and one on ankle.
 Patient’s name, UIN, date of birth, date of death and religion (if known) shall be printed on both the band
 The body shall be identified using the band before handing over to the relatives.
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

MEDICAL GAS PIPELINE SYSTEM

Sl. No. Particulars C PC NC

1. Documented procedures for procurement, storage, handling, distribution, usage and
replenishments of medical gases.
2. Standardized color coding of medical gas pipeline system
3. Pressure regulators for use with medical gases
4. Flow-metering devices for connection to terminal units of medical gas pipeline
systems
5. Air purity check at the level of one terminal outlet from OT & ICU.
6. Availability of alarm units & valve boxes at different locations
7. Provision for 24 x 7 monitoring of plant alarm unit for gas pressure going beyond set
limit
8. Provision of auto switch over control panel from one source to alternate source
9. Availability of alternate source for medical gases
10. Test record of alternate source on daily basis
11. Maintenance plan for piped medical gas, compressed air & vacuum installations
12. Maintenance record of piped medical gas, compressed air & vacuum installations
13. Availability of appropriate safety measures (fire extinguishers, acoustic ear muffs etc.)
14. Appropriate record of procurement and usage of medical gases
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

DIETARY SERVICES

Sl. No. Particulars C PC NC

1. Layout of kitchen must be unidirectional to prevent criss-cross of traffic
2. Dedicated food storage/refrigeration areas exist to ensure food preservation
3. Food storage areas/refrigerators are maintained appropriately
4. Temperature record of refrigerators
5. Cleaning protocol of refrigerators
6. All food products are stored off the floor
7. Cleaning supplies stored in a separate location way from food
8. Separate dedicated food preparation areas exist;
9. Measures are in place to ensure that flies and insects do not come in contact with
prepared/stored food
10. Pest control procedure and record
11. Personal grooming of kitchen staffs
12. Health Check-up record of kitchen staffs
13. Vaccination record of kitchen staffs
14. License of kitchen
15. Stool culture for Salmonella Typhi. 6 monthly or if staff rejoins after leave of 15 days or more
16. SOP of procurement, Storage, Preparation, Packing and distribution of patient diet
17. Procedure for preparation of RT feed
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

PHARMACY
Sl. No. Particulars C PC NC
A. Legal Requirements
1. Qualification of person dispensing the medicine must be B. Pharma / D. Pharma.
2. Updated license of pharmacy (separate for OP & IP) should be displayed in Pharmacy.
3. List of schedule “H” & schedule “X” drugs which can’t be dispensed without a valid
prescription
4. Updated Excise permit to store spirit in pharmacy.
5. Updated License under NDPS Act.
6. NDPS drugs are stored in a locked container, and there is a register to record each and
every issuance of NDPS drugs. The record must have name of patient for which drug
has been issued, quantity, date and the name and signature of issuer
7. Vials of used NDPS drugs are collected back in pharmacy and discarded as per BMW
rules
B. Availability of Medicines
1. Availability of hospital Formulary at pharmacy counter and with all consultants along
with RMOs.
2. Policy and procedure for acquisition of non-formulary drugs.
3. Inventory control in pharmacy (ABC & VED)
4. Items listed as A,B,C, and/or V, E, D, must be known to all pharmacy personnel
5. There is a policy in place for each category of medicine (Category A, B, C and
Category V, E, D) and the staff of pharmacy aware of the policy
6 Stock level to be maintained, buffer level, and re-order level is defined for each
medicine
7 Policy to manage stock out of formulary drugs and awareness of staffs for the same
8 Vendor evaluation method is established and records of evaluation is available
9 Records of purchase and Goods Receipt Notes are available
10 Records of periodic stock audit, including physical verification is in place
11 Room and area used for medicine storage is clean, un-cluttered and devoid of pests
and rodents. Medicines should not be stored on floor.
12 Records of regular pest control
13 Policy for prevention of pilferage/theft
C. Medicine safety
1. Medicines are stored in a condition as described by manufacturer (conditions generally
written on packets, and they are usually related to temperature, humidity, sunlight etc.)
2. Refrigerator used for storing medicine should have a temperature monitoring system.
The device or thermometer used for recording temperature should be calibrated. A
temperature range is defined for the refrigerator and it should be maintained. The
temperature of the refrigerator should be recorded at-least 2 times a day.
3. Staff should be aware on what to do if temperature of refrigerator is not within the
defined limit. (Time limit within which medicines to be shifted to another refrigerator)
4. Look alike and sound alike (LASA) & High Risk medicines are identified and a list is
available.
5. Pairs of LASA medicines are stored separately, or are color coded to avoid any
confusion. (including inside refrigerator)
6. High risk medicines should be stored in a protected place to avoid wrongly dispensing
it to patient
7. Medicine being sold should have a label clearly mentioning its name, dose and expiry
date. This is specifically required if pharmacy sells loose medicines, cut strip
medicines, or prepared formulations of certain medicines.
8. Staff awareness on policy for safe dispensing of medicines
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

Sl. No. Particulars C PC NC

9. Staff awareness to policy for dispensing of high risk drugs
10 Staff awareness on policy for near expiry medicines
11 Staff awareness on policy of medication recall whenever it be initiated.
D. Safety of pharmacy
1. Fire safety measurement
2. Staff awareness on hospital emergency codes
3. List of hazardous materials, MSDS of listed hazardous materials & staff awareness on the same
E. Quality Indicators applicable to Pharmacy
1. Incidence of dispensing errors
2. Percentage of stock out of drugs
3. Percentage of drugs & consumables procured by local purchase
4. Percentage of drugs & consumables rejected before GRN
5. Percentage of variations from procurement process
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

HUMAN RESOURCE DEPARTMENT

Sl. No. Particulars C PC NC
1. Policy for manpower planning with supporting evidence of manpower planning done
2. Updated and approved organogram of each department
3. Job Specification and job description of each category of staff
4. Policy for antecedent verification of employees and supporting evidence
5. Documented procedure for recruitment
6. Policy of induction training, List of topics to be covered and record of trainings
provided which must be ratified by trainee.
7. Service standards of the hospital and awareness of staffs regarding the same
8. Policy for training and development
9. Procedure for identification of training needs and availability of records for the same
10. Training calendar and training records (must be the part of employee personal file)
11. Training record if job responsibility of any staff being changed or any new equipment
introduced
12. Evaluation of training effectiveness
13. Training feedback forms(Internal & External both) in personal file for each training
session
14. Training topics must cover all safety related topics such as risks within hospital, what
to do in case of disaster, procedure to follow in case of an incident, occupational safety
etc.
15. Documented policy and process of conducting performance appraisal of employee.
Performance appraisal system should be based on identified and defined criteria,
Record of the same
16. Documented policy and process of receiving employee grievance and redressing them
17. Records of all grievances redressed
18. Grievance redressal committee as a final authority to take decisions on grievance
related matters, Frequency of meetings and MOM of all meetings.
19. Committee to ensure anti-sexual harassment activities within the hospital and
awareness of staff that how to lodge complains.
20. Pre-employment health examination policy and record for the same
21. Annual health check-up and pre-exposure prophylaxis record of the employees
22. Policy to take care of healthcare needs of the employee
23. There should be personnel file of each employee which must be updated and is kept
confidential. It should contain information on
 Staff’s qualification and experience
 Background verifications
 Health status
 Record of all in-service training and education availed by the staff
 Results of all evaluations of the trainings
24. Policy for credentialing and privileging of doctors & nurses and supporting evidences
in personal files
25. Mechanism for intimation of granted privileges to other employees
26. Policy for health & safety
27. Quality Indicators of HR department
 Absenteeism rate (Category wise)
 Attrition Rate (Category wise)
 Awareness among employees on employee rights & responsibilities
 Employee satisfaction index
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

NABH Audit Checklist for Imaging Services

Sl. No. Attributes C PC NC
1 Radiology/Imaging Manual is available
2 Standard Operating Procedures for tests being done is available
3 Scope of Radiology services defined
4 Organogram of radiology services
5 Job description and Job specification of each employee is defined and well maintained
6 Turn Around time of each test is defined
7 Turn Around Time is being monitored
8 Patients are informed if there is any deviation from defined TAT
9 Critical Limit of each and every test is defined
10 Critical Results are being monitored
11 Critical Results are intimated to concerned clinician immediately
12 Policy for recall of imaging reports is there in place
13 Investigation reports are reported in standardized formats
14 All reports are being authorized by suitably qualified signatories
15 Imaging quality Assurance program is there in place
16 Internal and External peer review of reports are there in place
17 Appropriate MOU is there in place; if required
18 Calibration of equipments is done
19 Calibration certificates are properly documented
20 Calibration certificates have traceability with National/ International guidelines
21 AMC/CMC of radiology equipments
22 Equipment downtime record id maintained
23 All imaging equipments properly labeled w.r.t. calibration and maintenance schedules
24 Radiation safety program is documented
25 Radiation safety devices and signages are adequately available
26 Patients are screened for radiation safety
27 Hazardous materials are defined
28 MSDS w.r.t. all defined hazardous materials are there in place
29 Staff are trained to handle hazardous materials and their spill management
30 Staffs are trained on radiation safety practices
31 Adequate radiation safety devices are there in place
32 Observe Compliance to safety precautions taken by lab staffs
33 Appropriate fire safety equipments are installed
34 Availability & credentials of RSO
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

CRITICAL CARE UNITS

Sl. No. Attributes C PC NC
1. Manual of ICU is there in place
2. Restricted entry to ICU. There should be a demarcation from where entry should be
restricted to ICU staff only.
3. Hand washing (or hand rub) at the entry of ICU. Staff must wash their hands or use
hand rub before entering ICU and after coming out of it
4. Adequate Nurse: Patient Ratio for ventilated & non-ventilated patients in each shift
5. Nurses in ICU should be trained in intensive nursing care and monitoring
6. ICU should be under the charge of an intensivist or a doctor qualified for providing
intensive care
7. All staff in ICU should have Basic Cardiac Life Support (BCLS) skills. At-least one
doctor of ICU in each shift should have Advanced Cardiac Life Support (ACLS)
skills.
8. Admission and discharge criteria should be followed for admitting or discharging a
patient from ICU. ICU in-charge and consultants of hospital must be aware of the
criteria.
9. Nurses should know their part of admission and discharge criteria
10. Necessary life-saving and monitoring equipment must be available in working
condition in ICU. A list of such equipment must be decided by the hospital.
11. All equipment in ICU should be calibrated bearing the label of their calibration status.
12. ICU Staff should know hospital’s policy on what to do in case of bed shortage in
ICU.
13. Staff should have very good awareness of infection control practices. In addition to
standard precautions, ICU staff must also know the care bundles to be followed for
patients on ventilator, urinary catheter, central line catheter and post-surgical patients.
14. Staff should know the indicators used for measuring quality of ICU care
15. Staff should know hospital’s policy and processes on end of life care
16. Staff should know hospital’s process on care of dead body
17. Updated record of crash cart, daily check record of defibrillator, and Cross matching
of record Vs physical stock.
18. Daily counseling of patient/family is documented by treating consultant
19. Standardized distance between two beds is maintained
20. Facility should be safe from any physical injury chances (non-slippery floor, safe
electrical fittings, no accidental spots etc.)
21. Adequate fire safety devices and signages are present
22. Linen on patient’s beds to be changed daily (or as defined by hospital’s policy)
23. Periodic cleaning of mattresses, pillow and other bed items
24. Temperature of refrigerator in which medicines are stored should be monitored and
recorded, at-least once in each shift
25. High risk & LASA medicines to be identified and stored separately
26. Proper identification of patient before carrying out any patient care activity
27. Reporting of adverse patient events
28. List of hazardous materials in the ward to be identified and MSDS sheet for them
should be available
29. All areas of units, including washrooms should be maintained neat and tidy
30. Separate cleaning checklist for patient care unit and washroom are maintained
31. Record of environmental sampling and appropriate CAPA
32. Multi-use open vials to have labels of date of opening and date of expiry
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

Sl. No. Attributes C PC NC

Quality indicators related to ICUs
1. Return to ICU within 48 hours
2. Re-Intubation Rate
3. VAP
4. CAUTI
5. CLBSI
6. Medication Error
7. Bed Sore
8. Incidence of fall
9. Nurse Patient Ratio
10. NSI/BBF exposure
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

HOSPITAL INFECTION CONTROL

Sl. No. Attributes C PC NC
A. Facility and infrastructure for infection control
1. Appropriate distance (1-2metre) is maintained between adjacent beds.
2. Adequate hand wash basins must be available in wards and ICUs.
3. The isolation room has appropriate, pressure, airlock, and exhaust depending upon its type.
4. Demarcated CU & DU is available to store clean and dirty items respectively
5. The floor and walls, especially in ICU must be easily cleanable and non-porous.
6. ICU should have defined protective and clean zone
7. Appropriate air changes in ICUs & OT as per national guidelines
8. Operation theatre is having appropriate zoning and ventilation requirements
B. Organization for Infection control
1. Availability of Infection control team, Hospital Infection Control Committee, Frequency of
meetings & Records of MOM
2. Infection control programme: Infection control programme describes everything that is
planned and done to prevent infections in the hospitals. This programme must be updated
once a year
3. Infection control manual – The manual documents infection control practices for various
functions in the hospital
4. Availability of designated Infection Control Officer & ICN and their privileging
C. Policies, processes, practices and implementation
1. Identification of high risk areas and documented procedures to prevent infection in these
areas. These are areas which has higher potential of spreading infection. Such areas include,
OT, ICU, post-operative ward, blood bank, CSSD,
2. High risk procedures that are performed within hospital is identified and listed. These are
procedures that have higher chance of causing infection to patients. Such procedures
include, endoscopies, long surgeries, cardiac catheterization etc.
3. Standard precaution is being followed across the hospital while providing patient care.
Standard precautions are a set of guidelines to protect healthcare professionals from
pathogens. Under standard precaution, it is assumed that all body fluid of a patient is
infectious and must be treated accordingly.
4. Staff must use appropriate hand hygiene guidelines. This guideline includes, when wash
hands, what kind of hand washing is required in different situations, proper method of hand
washing (7 steps & 5 moments) and other measures to keep hand hygienic.
5. Hand washing technique must be displayed near every hand wash basin
6. Personal protective equipment must be available in all patient care area as per requirements.
These include thing like gloves, masks, aprons etc. The healthcare staff knows when and
how to use the personal protective equipment.
7. Policy of safe injection & infusion and staff is trained on the same
8. Barrier nursing practices must be followed for isolation patients
9. Appropriate care bundles are being used for patients on high risk of acquiring HAI, such as
patients on ventilator, urinary catheters, central line catheter and surgical patients
10. An antibiotic policy is available and followed for prescribing antibiotics – Antibiotic policy
is a policy document that guides what kind of antibiotics should be prescribed for different
kind of clinical conditions. The antibiotic policy is revised from time to time (atleast once in
a year).
11. A policy should be there for change of linen – The linen must be changed daily, and
whenever it gets soiled. It should also be changed for every new patient getting admitted.
12. Identification of disinfectants to be used in patient care units for various purposes, their
dilution factor, availability/ display of relevant MSDS and staff training/awareness
regarding the same
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

Sl. No. Attributes C PC NC

13. Kitchen is in hygienic and sanitized condition. Health check-ups of food handlers is done to
identify those who are suffering with communicable diseases.
14. Housekeeping procedures must be defined and standardized to achieve optimal infection
control
15. Procedure for identifying and handling infection outbreaks is available
16. Procedures for CSSD activities for preventing spread of infections are followed
17. Procedure of segregation and handling of biomedical waste should be followed, as per
regulatory guidelines
18. Notifiable diseases are being notified to appropriate authority
19. Appropriate pre & post exposure prophylaxis is given to all staffs
20. On site visit report & evidence of biomedical waste treatment facility
21. Audit for biomedical waste segregation and handling is being done
22. Policy for engineering control to prevent infections which includes design of patient care
areas (operating rooms, air quality and water supply. Issues such as air-conditioning plant
and equipment maintenance, cleaning of AC ducts/filters, AHUs, cleaning / replacement of
filters, seepage leading to fungal colonization, replacement/repair of plumbing, sewer lines
(in shafts) should be included. Water-supply sources and system of supply, testing for water
quality must be included. Any renovation work in hospital patient-care areas should be
planned with infection control team with regard to architectural segregation, traffic flow, use
of materials, etc
23. Action plan to prevent possible infections whenever any construction/renovation/civil work
has to be done and supporting evidence of all such incidents
D. Quality Indicators
1 CAUTI
2. VAP
3. CLABSI
4. SSI
5. Compliance to Hand Hygiene Practices
6. Percentage of NSI/BBF exposure
7. Percentage of employees provided pre-exposure prophylaxis
8. Percentage of Transfusion Reactions
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

INPATIENT WARDS
Sl. No. Attributes C PC NC
A. Physical facilities
1. Sufficient space for carrying out patient care activities with adequate circulation space
2. Facility safe from any physical injury chances (non-slippery floor, safe electrical fittings, no
accidental spots etc.)
3. Hand washing area easily accessible to healthcare staff
4. Availability & Accessibility of fire-fighting equipment
5. Crash cart placed at a location from where it could be immediately accessed when required
6. Patient’s washroom should have safety arrangements (anti-skid mats/emergency call button/
grab bars)
7. Adequate privacy arrangement for patient
8. Availability of all necessary patient care equipments
9. Placement of bio-medical waste bins as per BMW rules-2016/18
10. Separate or segregated storage area for clean and dirty supplies
11. Emergency exit route and display
B. Staffing
1. Categories of nurses required to be identified (depending upon the type of ward, for eg.
Pediatric ward must have nurses trained in pediatric care)
2. Nurse: patient ratio to be defined for the ward in each shift
3. Duty roster to serve as an evidence of nurse patient ratio
4. Record of bed allocation between staffs
5. Duty doctor should be available round the clock (physical or on call)
C. Ward management
1. Linen on patients’ beds to be changed daily (or as defined by hospital’s policy)
2. Periodic cleaning of mattresses, pillow and other bed items
3. Temperature of refrigerator in which medicines are stored monitored and recorded, once in
each shift
4. Crash cart should have all life-saving drugs and equipment. It should be replenished
whenever used.
5. All emergency medicines available as per defined quantity
6. Mechanism of replenishing emergency medicines and supporting evidence
7. Separate storage of LASA & HRM drugs
8. Multi-use open vials to have labels of date of opening and date of expiry
9. Proper identification of patient before carrying out any patient care activity
10. Reporting of adverse patient events
11. List of hazardous materials and MSDS sheet for them is available
12. Bio-medical waste is being segregated as per BMW Rules 2016/18
13. Separate storage of clean & dirty supplies
14. Maintenance of medical records as per hospital’s policy
15. Security and confidentiality of medical records to be maintained as per hospital’s policy
16. Maintenance of necessary registers (admission-discharge, stock, laundry, adverse incident register etc.)
D. Staff awareness
1. Components and time-frame for initial assessment of admitted patients
2. Uniform care policy and patient care processes that falls under it
3. Patients’ rights
4. Dealing with HIV +ve patients and maintaining confidentiality
5. Provision of basic cardiac life support
6. Code blue policy and procedure
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BETTER HEALTH, BETTER TOMORROW

Sl. No. Attributes C PC NC

7. Other emergency codes (such as code pink, code yellow etc.)
8. Identification and care of vulnerable patients
9. Care of surgical patient/pediatric patients/obstetric patients (as per ward specialty)
10. International patient safety goals
11. Safe medication practices (things to check before administration, monitoring, verbal orders,
administering high risk medicines etc.)
12. Safe blood transfusion practices
13. Policy and procedure of patient’s restraint
14. Consent Policy
15. Crash Cart Management
16. Knowledge on applicable quality indicators
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW
OPERATION THEATRE

Sl. No. Attributes C PC NC

A. Physical facilities
1. Regulated entry to clean zone and beyond
2. Facility should be safe, for eg. Non-slippery, safe electrical fittings, no accidental spots etc.
3. Separate storage area for clean and dirty items
4. Accessibility of fire-fighting equipment, in all areas of OT
5. Arrangement for quick availability of sterilized items (For e.g. a flash sterilizer within OT
complex or direct connection with CSSD through dumbwaiters)
6. Space for changing, shower and personal storage of staff and doctors
7. All equipment in OT should be calibrated having label of calibration date and status
8. OT complex has an emergency evacuation route to be used in case of any emergency
B. Pre-operative and post-operative ward/area:
1. Easy accessibility of crash cart
2. Use of defined criteria for shifting out of surgical patients
3. Immediate pre-operative check-up before wheeling in patient in operation room from pre-op
4. Availability of anesthesiologist whenever required
5. All staff to be trained atleast in BLS
C. Related to medicines/consumable/supplies
1. Narcotics to be stored as per regulation (under lock and key, record maintenance etc.)
2. Multi-use open vials to have a label of date of opening and expiry
3. High risk medicines (as per defined list) must be stored separately
4. Spirit (if in large quantity) should be stored under lock
5. All high risk materials should be identified, listed and MSDS for each of them should be
kept easily available for the staff
D. Processes for patient safety
1. Use of OT attire by all staff
2. Having pre-operative assessment and provisional diagnosis before surgery
3. Use of WHO surgical safety checklist for each patient.
4. Compliance to blood and blood products transfusion practices
5. Monitoring of patient during surgical procedure (at minimum heart rate, cardiac rhythm,
respiratory rate, blood pressure, oxygen saturation and level sedation)
6. Documentation of type of anesthesia and aesthetic medication in patient’s medical record
7. All staff must be aware of standard precautions and OT specific infection control practices
(scrubbing, sterility maintenance, use of PPE etc.)
E. Environmental process
1. Daily monitoring record of humidity and temperature of each operating room
2. Daily monitoring record pressure differential of each operating room
3. Monitoring record for filter integrity for all operating rooms separately (at-least once in six
month)
4. All areas of OT to be kept clean from dust all the time
5. Regular environmental surveillance for microbes to be done in each OT and other areas to
identify forming of any colonies of bacteria
6. Regular cleaning with anti-septic solution of all surfaces in OT.
7. Segregation of route of biomedical waste movement. If this is not possible, time of BMW
movement should be different from time of staff and clean supplied movement
8. Environmental culture samples must be taken at regular intervals and documentation of
CAPA on any adverse report
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BETTER HEALTH, BETTER TOMORROW

Sl. No. Attributes C PC NC

1. Percentage of cases in which plan of surgery changed intra-operatively
2 Percentage of cases in which organisation’s procedure to prevent wrong site, wrong patient,
wrong procedure adhered to
3 Percentage of unplanned return to OT
4 Percentage of re-scheduling of surgeries
5 Percentage of re-exploration of surgical site
6 Percentage of modification of anaesthesia plan
7 Percentage of unplanned ventilation following anaesthesia
8 Percentage of adverse anaesthesia events
9 Anaesthesia related mortality rate
10 Percentage of patients received prophylactic antibiotic within specified timeframe
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW
MEDICAL RECORDS DEPARTMENT

Sl. No. Attributes C PC NC

1 Medical record of each patient should have a unique identification number.
2 Unique identification number of the medical record should be printed/written on every sheet
inside the medical record to prevent misplacement of sheets
3 MLC identification and number and details should be mentioned on medical record
4 Medical record should contain general consent of the patient in all admissions
5 Initial assessment record should have name, signature, date and time
6 Plan of care should be signed / counter-signed by consultant in-charge of the patient
7 Medical records should contain results of tests carried out, the care provided and re-
assessment findings
8 If patient is transferred to other hospital medical records should contain date of transfer,
reason of transfer and name of receiving hospital
9 Each entry in medical records should be signed, named, dated and timed
10 Entries in medical records should be legible
11 Medication orders and charts should not have any non-standard abbreviations. Or should
have only those abbreviations that are defined by the hospital
12 Entries in medical records should be up-to-date
13 Informed consent in medical records should contain following
Information on the surgical procedure, risks, benefits, alternatives, name of the doctor who
will perform surgery
Informed consent should be in language that patient understand (having a bi-lingual consent
form can be of help)
Consent form signed by patient (or guardian if applicable)
Consent form signed by the doctor taking consent
Consent form signed by an independent witness
14 Medical records of discharge patients should contain following documents
Discharge summary
Death summary in case of deaths (should mention cause of death)
Final diagnosis of the patient
ICD coding on the file within a defined timeframe
In case of autopsy, a copy of autopsy report
Pre-operative assessment
Type of anesthesia and anesthetic medications used
Completed immediate pre-operative Re-evaluation & pre-op anesthetic record
Peri & Post Anesthesia monitoring record
Applied discharge criteria to shift from recovery (Modified Alderate Scoring)
Filled surgical safety checklist
Informed consent for all procedures
Post-Operative note by the surgeon or his/her team member
Post-operative plan of care
15. Discharge summary of patient should contain following documentation
Patient’s name, demographic details and unique identification number
Date of admission and date of discharge
Reason of admission, significant findings, diagnosis and patient’s condition as the time of
discharge
Information regarding investigation results, any procedure performed, medication
administered and other treatment given
Follow up advice, medication and other instructions
Instruction on when & how to obtain urgent care
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BETTER HEALTH, BETTER TOMORROW

Sl. No. Attributes C PC NC

16 Safety, security and confidentiality of medical records
Sufficient and safe storage for medical records
Regular pest control in medical record storage area
Availability of fire extinguisher near-by and knowledge on how to use the same
Policy of who can access medical records
How to respond to different request for accessing medical records
Mechanism to quickly retrieve the medical records
ICD codification
Screening of medical records
17 Quality Indicators related to MRD
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW

EMERGENCY DEPARTMENT
Sl. No. Attributes C PC NC
1 Entrance should be easily accessible by ambulance
2 The main entrance of the emergency should be wide enough for easily moving 2 or more
stretchers at the same time
3 The doors of the emergency should not be locked from inside. It should open wide enough
to accommodate stretchers and wheelchairs
4 The stretchers and wheelchairs should be kept available in a dedicated bay immediately
outside the main entrance. A signboard can be put for the same
5 Inside the emergency, there should be dedicated areas for triage, emergency processes (like
wound care, gastric lavage, fracture handling etc.) and for emergency observation. Others
support areas that should be there in emergency includes, nursing station, store (separately
for clean and dirty items) and duty doctor’s chamber
6 The emergency department has sufficient space for carrying out patient care activities and
circulation in routine as well as in situation of mass casualty also.
7 Facility should be safe, for eg. Non-slippery, safe electrical fittings, no accidental spots etc.
8 Inter-bed distance in emergency ward to be maintained at around 6 feet in emergency
observation ward
9 Hand washing area easily accessible to healthcare staf
10 Accessibility of fire-fighting equipment
11 Crash cart kept at a location from where it could be immediately accessed when required
12 Patient’s washroom should have safety arrangements (anti-skid mats, emergency call button,
grab bars, disabled friendliness, door opening outside, latch type locking which can be
opened from outside)
13 Adequate privacy arrangement for patient
14 Availability of all necessary emergency care equipment
15 Bio-medical waste bins as per BMW rules
16 Separate or segregated storage area for clean and dirty supplies
17 Emergency medical officer, who should at-least be MBBS and preferably have training in
emergency care.
18 Nurses trained in emergency nursing care
19 Number of staff depends upon the workload of the emergency and should be determined by
the hospital
20 Linen on patients’ beds to be changed daily and as and when required (or as defined by
hospital’s policy)
21 All emergency medicines should be available round the clock as per defined quantity
22 Mechanism of replenishing emergency medicines to be followed
23 Identification and separate storage of LASA & HRM drugs
24 Multi-use open vials to have labels of date of opening and date of expiry
25 Maintenance of necessary registers (admission-discharge-transfer, stock, laundry, adverse
incident register etc.)
26 Emergency handling protocol for commonly visiting emergencies
27 Emergency handling protocol for paediatric cases
28 Protocol for Handling of MLC cases, brought dead and death on arrival cases
29 Handling of mass casualty situation
30 Admission, discharge and transfer from emergency.
31 Transfer of stable and unstable patient
 AADHAR HOSPITAL
HEALTH INSTITUTE INTERNAL AUDIT CHECKLIST
BETTER HEALTH, BETTER TOMORROW