Food, Medicine, Health care Administration and Control Authority (EFMHACA)

Comprehensive specialized hospital Assessment Checklist

The checklist is prepared using the basic components of the regulatory standard, the 4Ps- Practice, Premises, Professional and Products. The
checklist is prepared with an open ended question. Answers to these questions should be clear and precise.
General Instruction: The team leader shall introduce the team to the CEO or management body of the facility and briefly explain the purpose
of the visit. To use time efficiently, the team can do the assessment in sub groups once relevant information is collected. Finally at the end of
the visit the team will do Exit Briefing and collect recommendations.
1. General Information:[Ask CEO/director]
 Region/ Zone/ City: _____________________________________________________
 Name of facility: ________________________________________________________
 Type of Facility: _ comprehensive specialized hospital
 Facility Address:
o Telephone: _______________________________________________________
o Fax: ____________________________________________________________
o P.O.Box: _________________________________________________________
o E-mail: __________________________________________________________
 Catchment population: _________________________________________________
 Annual patient Load : __________________________________________________
2. Does the facility provide the following services? [Check]
1. Nursing Service ……………………………………………………………………..(Yes__/No__)
2. Outpatient Services………………………………………………………………….(Yes__/No__)
3. Inpatient Services……………………………………………………………………(Yes__/No__)
4. Emergency Service ………………………………………………………………….(Yes__/No__)
5. Internal Medicine Services ………………………………………………………….(Yes__/No__)
6. Pediatric Services…………………………………………………………………….(Yes__/No__)
7. Surgical Care Services……………………………………………………………….(Yes__/No__)
8. Orthopedics Services………………………………………………………………...(Yes__/No__)

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9. Gynecology and Obstetrics Care Services…………………………………………(Yes__/No__)
10. Anesthesia Services………………………………………………………………...(Yes__/No__)
11. Intensive Care unit (ICU) Services………………………………………………...(Yes__/No__)
12. Dentistry Services……………………………………………………………….….(Yes__/No__)
13. Otorhinolaryngology (ORL) Service…………………………………………….…(Yes__/No__)
14. Ophthalmology Services…………………………………………………………...(Yes__/No__)
15. Mental Healthcare Services………………………………………………………...(Yes__/No__)
16. Dermatology Services……………………………………………………………...(Yes__/No__)
17. Cardiac Services…………………………………………………………………....(Yes__/No__)
18. Neurology service………………………………………………………………..…(Yes__/No__)
19. Gastroenterology…………………………………………………………………...(Yes__/No__)
20. Renal Services……………………………………………………………………...(Yes__/No__)
21. Rehabilitation Services………………………………………………………….…(Yes__/No__)
22. Oncology Services…………………………………………………………………(Yes__/No__)
23. Nuclear Medicine Services………………………………………………………...(Yes__/No__)
24. Radiology Services…………………………………………………......................(Yes__/No__)
25. Pathology Services…………………………………………………………………(Yes__/No__)
26. Laboratory Service …………………………………………………………………(Yes__/No__)
27. Pharmacy Service ……………………………………………………………….... (Yes__/No__)
28. Infection Prevention……………………………………………………………..…(Yes__/No__)
29. Food and Dietary Services………………………………………………………...(Yes__/No__)
30. Sanitation and Waste Management………………………………………….….…(Yes__/No__)
31. Housekeeping/ Laundry/ maintenance services …………………………….…….(Yes__/No__)

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 Nursing Service Score point
S.N Compliance Status Standard to be addressed Remark
Met Partially Un Practice
met met
1. There shall be written policies and procedures of nursing services for routine Minor
taking and documenting vital signs, carrying out prescribed medication and
nursing care to be rendered. Such policies and procedures shall be reviewed at
least once every three years.
2. There shall be current clinical and administrative nursing policies and Minor
procedures available to all nursing personnel on each patient care unit at all
times.
3. Nursing care service at different service delivery areas shall be directed by a Major
licensed nurse with a minimum of BSc from recognized university and has at
least two years of relevant experience.
4. Written copies of nursing procedure manual shall be available to the nursing Minor
staff in every nursing care unit.
5. There shall be a procedure for standardized, safe and proper administration of Minor
medications and documentation of administered medicines
6. There shall be a system/ protocols in place to handle comatose or patients on Minor
life support system and also patients diagnosed to have communicable
diseases.
7. All nursing staff shall wear easily readable name tags that include their name Minor
and status, (such as licensed nurse, student, etc).
8. There shall be a policy that empowers nurses to restrict number of visitors Minor
and/ or care takers based on the condition of the patient.
9. Nurses shall explain and seek informed consent from their patients or their Minor
relatives/next of kin (for incompetent patients) before carrying out any
procedure.
10. Patient discharge instructions shall be documented in the patient's medical Minor
record at the time of discharge
11. Allergies shall be listed on the front cover of the patient's chart or, in a Critical
computerized system, highlighted on the screen
12. Patients who required/prescribed to have special diet/ care shall be identified, Major
labelled and there shall be a mechanism in place to ensure this procedure

3
13. There shall be a policy that state reporting of any signs suggestive of child Minor
abuse, substance abuse and /or abnormal psychiatric manifestations by the
nursing staff
14. There shall be a policy for reporting and documenting medication errors, Minor
quality defects and adverse drug reactions by attending nursing personnel or
the prescriber immediately to the ADE (adverse drug event) focal person.
15. There is a protocol that guides nurses copying the prescription of prescriber’s Minor
order.
16. The hospital shall have written policies and procedures regarding the use of Minor
physical restraints that are reviewed at least once every three years and
implemented
17. There shall be a policy or a protocol that state the procedure to be followed for Minor
dead body care.
Met Partially Un Premises
met met
18.  Private room /space: for isolation or special care, with toilet room Minor
and shower,
 Hand washing basin at each room,
 Toilet rooms,
 Procedure room: for nursing procedures,
 Nurse changing room:
 Nurses station: located in the middle of the wards with free access
to all wards,
Met Partially Un Professional
met met
19. The nursing staff shall have a minimum of diploma from a recognized college Critical
or university
20. Nurse staffing for inpatient patient care service within the hospital shall be in Major
accordance with not more than 6 patients under one nurse for general inpatient
care. However, for ICU and emergency there shall be one nurse for a
maximum of two patients
21. All nursing staff shall receive orientation, training and/or update at least Minor
annually including at least:
a. Hospital’s policies and procedures,
b. Routine nursing procedures,

4
 c. Emergency procedures and
d. Infection prevention and control.
Met Partially Un Product
met met
22. The following products shall be available for nursing care services. Major
(a) Specimen collection set
(b) Rubber Sheets
(c) Restraining equipment in accordance with the standards under the use
of restraints and mental health services. E.g., cushion, belt, vest, long
sleeve pullover, etc.,
(d) Patient Chart Folders
(e) Emergency resuscitation sets: airway, ambu bag of different size
(f) Vital Sign Equipments;
 Trolley for vital sign monitoring,  sphygmomanometer with
 Thermometer, BP apparatus, stethoscope,
stethoscope, measuring tape  bedside weighing scale
 wrist watch/ wall clock, Pulseoxymetry
(g) Nursing procedure equipments;
 Dressing trolley  Safety boxes,
 Dressing set,  Bed screens,
 Minor set,  Kidney basin, 475ml x 5
 Chest tubes and bottles,  Bed pan
 Enema set,
 Urinal
 IV stand,
 Mobile Examination light,
 Oxygen trolley,
 Oxygen cylinder,  Plastic apron,
 Oxygen regulator/gauge,  Drapes,
 Oxygen face mask/ nasal  Rubber sheets,
catheters,  Connectors,
 Suction machine: electrical/pedal,  Cushion bags,
 Wheel chair,  NG tube, Catheter (different
 Waste basket, type , poly , plain ,etc) ,
canuala of different gauge
(h) Soiled utility room:

5
  Soiled linen trolley  Wash tub (65L)
 Bin with lid  General purpose trolley, two
 Worktable with laminated top trays
(i) Furniture and fixtures;
 Table  Refrigerator,
 Chair, stackable, without  Bedside cabinet,
armrests  Feeding table,
 Basket, waste-paper, metal  Patient chart holder,
 Cabinet  IV stands

Outpatient Services Score point

S.N Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The hospital outpatient service shall have a central triage system Major
2. The outpatient service shall have policies and procedures regarding access, Minor
availability of service and networking
3. The outpatient service shall be available in working days for at least eight Major
hours a day
4. The hospital shall have a system to make follow up of patients by the same Minor
physician
5. The medical assessment at outpatient services shall at least includes Major
comprehensive medical and social history, physical examination, diagnostics
impression as well as laboratory and other medical workups (x-ray,
ultrasound, CT scan etc) when indicated.
6. The outpatient clinic shall have clinical protocols for management of at least Minor
common disease entities and locally significant diseases in line with the
national and international guidelines
7. The range of relevant treatment options and the clinical impression shall be Major
fully described to client and/or their families and documented accordingly
Met Partially Un Premises
met met
8. The outpatient layout shall include the following: Major

6
 a) Dedicated entrance
b) Waiting area: room /lobby preferably with public telephone, TV
area, drinking fountain and gender specific toilet
c) Reception and recording area/desk
d) Dedicated patient consultation and examination rooms /cubicles for
each specialty services
e) Room for minor procedures
f) Room for providing injections
g) Storage place for sterile supplies
h) Soiled utility
i) Staff room (for changing cloth)
j) Janitors closet
9. All rooms shall have adequate light, water and ventilation Major
10. The room arrangements of outpatient services shall consider proximity minor
between related services
11. The outpatient clinical setup shall have easy access to pharmacy, laboratory minor
and other diagnostic services
12. The outpatient clinic shall be well marked and easily accessible for disabled Major
clients, elderly patients, under five children and pregnant mother
13. The outpatient clinics shall have fire extinguishers placed in visible area Major
Met Partially Un Professionals
met met
14. At least one general medical practitioner per discipline (Internal Medicine, Critical
Pediatrics, Surgery, Gynecology and Obstetrics) for the general outpatient
service shall be assigned for eight hours in each working day
15. One specialist or sub-specialist per discipline (specialty) to run the respective Major
specialized outpatient service shall be assigned
Products
16. The outpatient service have the following equipments Critical
a) Weighing Scale f) Catheterization set
b) Refrigerator g) Trolley
c) Dressing Set h) Folding Screen
d) Minor Set i) X-Ray Film viewer
e) Examination Coach

7
18. Vital Sign and Diagnostic Set Major
 Thermometer  Otoscope
 Stethoscope  Pulseoxymeter
 Sphygmomanometer  Reflex hammer
 Fundoscop  Snellen’s chart

Inpatient Services Score point

S.N Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The inpatient service shall be available 24 hrs of a day and 365 days a year Critical
2. The inpatient service shall have consultation and functional intra and inter Major
facility referral system
3. The inpatient service shall have clinical protocols for management of at least Minor
common causes of admission in the hospital
4. The hospital shall have a system to make follow up of patients by the same Minor
physician
5. The range of relevant treatment options, plans and the clinical impression Major
shall be communicated to client and/or their families and documented
accordingly
6. The inpatient service shall conducting regular morning sessions among Minor
relevant health professionals
7. The hospital shall provide dietary service for patients who are admitted Major
8. The hospital shall provide a clean gown to admitted patients Major
9. The hospital shall secure the properties of admitted patients in a cabinet or Minor
room with shelves
10. The inpatient service shall arrange the appropriate post discharge instructions Major
and follow up for the patient
11. The hospital shall provide a post mortem care and morgue service to deceased Minor
12. The hospital shall contact the municipality or responsible body for burial Minor
service if there is no family/guardian of the deceased
Met Partially Un Premises
met met
Inpatient service shall have the following rooms Major

8
13. (a) Wards separate for male (e) Staff bathroom
and female (f) Duty room
(b) Nursing Station per ward (g) Clean utility room
(c) Doctors office (h) Soiled utility room
(d) Bathroom for patients per (i) Store
ward
15. The number of beds per room shall not exceed six (6) with the following Major
specifications
(a) Distance of bed from fixed walls shall be 0.9 m
(b) Distance between beds shall be 1.2 m
(c) Adult beds shall have 1m width and 2m length
(d) Each bed room shall have alarm
(e) The rooms shall have safe and continuous water supply, light and
ventilation
(f) There shall be washing basins for each room
Met Partially Un Professional
met met
16. Specialists and sub-specialists of the related discipline with a minimum of one Major
shall be physically available during working hours in respective wards
17. At least one general medical practitioner per discipline shall be physically Critical
available in all the shifts in respective wards
18. One nurse for a maximum of six (6) patients per shift shall be available to Major
provide nursing care services
19. Support staff such as runner, cleaner and telephone operator shall be available Major
for 24 hrs a day
Met Partially Un Products
met met
20. The following products shall be available for inpatient services Major
 Beds with wheels  Thermometer
 bed side cabinet  Stethoscope
 Bed pans  Sphygmomanometer
 Urinal (Male and Female)  Fundoscope
 Bed Pan carriage  Otoscope
 Bed pans washer and  Reflex hammer
sterilizer  Refrigerators

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  Bed pan Racks  Minor operation set
 IV Stand  Dressing Set
 Stretcher  Enema Set
 Wheel chair  Lumbar puncture(LP) set
 Safety Box  Catheterization set
 Suction machine  Folding screens
 Resuscitation set

Emergency Services Score point

S.N Level of Compliance Standard to be addressed Remark
Met partially Un Practice
met met
1. The emergency service including emergency surgical interventions shall be Critical
available 24hrs a day and 365 days a year
2. The emergency service shall have functional intra and inter facility referral Major
system which encompasses SOP for selection of referral cases, referral
directory, referral forms, referral tracing mechanism, feedback providing
mechanism, documentation of referred clients and consultation forms
3. If the patient to be referred needs to be accompanied by a physician or other Major
professional on the way to another hospital, the hospital shall arrange an
ambulance service and accompanying professionals to transfer the patient
4. Every procedure, medication and clinical condition shall be communicated to Major
the patient or family member after responding for urgent resuscitation measures
5. There shall be a mechanism of quality improvement for the service at least by Minor
collecting feedback from clients and having a formal administrative channel
through which clients place their complaints and grievances
6. The emergency service shall have a procedure for easy access to intensive care Minor
unit, pharmacy, laboratory and radiological diagnostic services 24hrs a day and
365 days a year
7. There shall be a written protocol for emergency services and the provision of Minor
this service shall be done in accordance with the clinical protocols of the service
8. The emergency service shall have clinical protocol for the initial management Minor
of at least the following emergency cases:
a) Shock i) Psychiatric emergencies

10
 b) Bleeding j) Acute diarrhea
c) Fracture and injuries k) Tetanus
d) Coma l) Meningitis
e) Seizure disorder m) Burn
f) Air way obstruction n) Poisoning
g) Cardiac emergencies o) Cerebrovascular accident
h) Hypertension emergencies p) Acute abdomen
10. Emergency referral system shall be strictly chained, controlled & managed by Minor
the emergency team of the hospital
Met partially Un Premises
met met
1. The emergency room shall be located in a place where it is easily recognizable Major
to the public and shall be labelled in bold
2. The emergency premise shall be low traffic area and there shall be reserve Major
parking place for ambulances
3. The corridor to emergency rooms shall be stretcher friendly and spacious Major
enough
4. The emergency area shall be spacious enough (> 193 m2) to provide a space for Major
the following tasks:
(a) Triaging
(b) Accepting and providing immediate care including emergency procedures
(c) Admitting for a maximum of 24 hrs to provide emergency care (8 beds)
equivalent to 67 square meters.
(d) Emergency pharmacy for emergency medicines, supplies and equipments
(e) Staff/duty room
(f) Toilet facilities separate for patients and staff
5. The size of the door for the emergency room shall not be less than 1.5 meter Major
6. The emergency premise shall allow patient dignity and privacy Major
7. The rooms shall be arranged in such a way that the first encounter to an Major
emergency patient coming from outside will be the examination room or space
8. The emergency room shall have the following facilities Major
(a) Adequate water, light and ventilation.
(b) Fire extinguishers placed in visible area
(c) Telephone
(d) Hand washing basin in each room

11
9. Waiting area for attendants and caregivers Minor
Met Partially Un Professional
met met
10. The emergency service shall be directed by emergency medicine specialist or Major
emergency medical service trained physician
11. The team composition during working and non-working hours shall have Major
similar staffing pattern
12. Each team for all the shifts shall contain a minimum of: Critical
(a) Emergency trained physician or emergency medicine specialist
(b) Nurses
(c) Cleaners
(d) Runner
(e) Regarding pharmacy, laboratory and x-ray see their respective standards
stated under this standard
13. At least one specialist or sub-specialist for each major discipline shall be Critical
available for emergency consultation on call bases
14. All health professionals working in the emergency room shall be trained on at Major
least cardio-pulmonary resuscitation
15. Rotation of staff shall not be a routine exercise for the emergency service Major
16. The staff shall have regular supportive supervision by senior staff or peer Minor
review or case conferences every three months and it shall be documented
17. The hospital shall have personnel manual which also covers staff at the Minor
emergency services
Met Partially Un Products
met met
18. The emergency service shall have readily arranged emergency medicines and Major
supplies on trolley
19. There shall be at least two coaches at emergency room Major
20. There shall be at least eight beds to be used only for emergency admission Major
The emergency service shall have at least the following products. Major

12
21. (a) Emergency Bed with wheel (l) Mobile examination light
(b) Stretcher with wheel (m) Hot air oven
(c) Wheelchair (n) Oxygen supply: Oxygen
(d) IV Stand cylinder with flow meter,
(e) EKG trolley and nasal prongs
(f) Suction machine (o) Examination Lamp
(g) Defibrillator (p) Resuscitation set on trolley
(h) Tracheotomy set (q) Intubation set
(i) NG tube (r) Ambu bags
(j) Minor surgical set (s) Examination coach
(k) Different types of splints

Internal Medicine Services Score point

S.N Compliance status Standard to be addressed Remark
Met Partially Un practice
met met
1. There shall be written protocols and procedures which shall be enforced that Minor
establish the management of the medical conditions in the unit as well as
consultation and transfer of patients admitted to this unit or other departments
2. For admitted patients the medical service shall be organized in such a way that Minor
it covers all the shifts
3. The service shall have written policies and procedures that shall include Minor
a) Admission and discharge criteria specific to the service;
b) Visitors policy t
c) Infection control or IP guideline
d) Transfer and referral of patients
e) Monitoring and follow-up of patients
4. Every medical records shall be kept for each patient Major
5. The medical unit shall have a follow-up service for patients with chronic Major
ailments
6. Notifiable diseases shall be notified through the proper channel (to chief Major
clinical officer or chief executive officer and hence to the FMOH)
7. The unit shall avail updated reference materials, treatment guidelines and Minor
manuals (e.g. National TB and leprosy, pain management, Malaria treatment,

13
 ART etc)
8. There shall be a system for clinical staff to refer patients directly to the social Minor
works unit
Met Partially Un Premises
met met
9. The maximum capacity of inpatient room shall not exceed six patients or beds Major
per room
10. Patient rooms shall be constructed to meet a minimum of 9 meter squares for Minor
single bed room
11. In case of multiple beds per room, the area per bed shall be 80 sq. ft Minor
12. Dimensions and clearances- the dimensions and arrangements of rooms shall Minor
be such that there is a minimum of 0.9m (90cm) between the sides and foot of
the bed and any wall or any other fixed wall construction. In multiple bed
rooms a clearance of 1.2 meter shall be available at the foot of each bed or
between beds to permit the passage of equipments and beds
13. The medical service unit shall have at least three isolation rooms for treatment Major
of conditions that require isolation
14. Patients in acute care shall be under direct observation in a room near the Minor
nurses’ station
15. In addition to the ward rooms, the internal medicine service shall have the Major
following rooms and facilities:
a) A private area for counselling f) Procedure room,
(examination room/office for g) Care after death room
physician); h) Rooms for follow-up clinics
b) Duty room/Station; i) Store
c) Meeting room; j) Staff Toilets, showers and changing
d) Nurse station; room and
e) Utility rooms; k) Patient Toilet and shower at least
one each per room.
Met Partially Un Professionals
met met
17. The internal medicine services shall be directed by a licensed internist Critical
18. An internist or licensed independent practitioner shall be available (physically Major
present) at all times in the adult medical service unit
19. A licensed nurse shall be available at all times to assess, evaluate, and Critical
supervise the nursing care provided

14
20. An internist or licensed independent practitioner shall be responsible for the Critical
follow-up clinics
21. The internal medicine service shall have support staff such as cleaners and Major
others available as per the service need
Met Partially Un Products
met met
22. The hospital shall prepare an emergency medicine list in accordance with the Major
hospital medicines and ensure their availability
23. The medical OPD shall have the following supplies and functional equipment Major
in addition to office furniture’s
a) Torch, Otoscope, i) Lumbar puncture, bone marrow
ophthalmoscope aspiration (and biopsy) set,
b) Weighing scales for adults pleural ( peritoneal) biopsy set,
c) Measuring board for measuring liver biopsy set, renal biopsy set,
length and height cut down set, pericadiocentesis
d) Tape meter, thermometer set, wide bore needles for
e) Stethoscopes thoracentesis
f) Sphygmomanometer j) Hand washing basin
g) X-ray viewer k) Spatula, K-Yjelly, surgical and
h) Examination couch disposable gloves, antiseptics,
cotton, gauze
25. The inpatient service shall have the following supplies and functional Major
equipments
a) Torch, Otoscope, ophthalmic m) Laryngoscope
diagnostic set with Snellen’s n) Cannulas, Nasogastric tube
chart o) Beds for patients and hand washing
b) Weighing scales basin
c) Tape meter, thermometer, p) Nebulisers for administration of
patella hammer salbutamol (electricity driven, or
d) Stethoscopes and oxygen driven or footpump driven)
Sphygmomanometer q) Equipment for pleural tapping and
e) X-ray viewer biopsy, pericardiocentesis, and
f) Examination couch, medicine paracentesis and drainage of
trolley, Cup board ascites,
g) Lumbar puncture, Bone marrow r) Equipment for skin scrapings and
aspiration set, pleural biopsy biopsy of dermatological lesions,

15
 set, tracheostomy set, chest tube bone marrow trephine needles and
h) EKG machine, defibrillator slides and others
i) Suction machine s) Gastroscope, Colonoscope and
j) Drip counters/Infusion pump, Proctoscope
Tourniquets and IV stands t) Pulse oxymeter and Defibrillator
k) Oxygen cylinder, Flow-meters u) Glucometer and glucostick
for oxygen, Nasal prongs v) Wheelchair
catheters w) Over bed table( for feeding)
l) Self inflating bags for x) Bed side cabinet and bed curtain
respiratory support, Masks, fixed with the roof and the ground
endotracheal tubes, y) Waste paper basket
24. The service shall have at least a general follow-up clinic that shall have the Major
following supplies and functional equipments:-
a) Torch, Otoscope, ophthalmic c) Stethoscopes and
diagnostic set with Snellen’s Sphygmomanometer
chart d) X-ray viewer
b) Tape meter, thermometer, e) Examination couch
patella hammer f) Weighing scales

Paediatric Services Score point

S.N Compliance Status Standard to be addressed Remark
Met Partially Un Practice
met met
1. Paediatric emergency care shall be available 24 hours a day and 365 days a Critical
year
2. Paediatric services shall have in-patient, out-patient and neonatal services Critical
3. The hospital shall have paediatric intensive care services with full-fledged Critical
neonatal unit and this service unit shall have written protocols and procedures
4. The nursing assessment and care of each paediatric patient shall consider the Major
patients developmental needs
5. Immunization services shall be available in the paediatric unit and all children Major
shall have their immunization status checked before discharge

16
6. The unit shall avail updated reference materials, treatment guidelines and Minor
manuals (eg. National TB, Malaria, ART etc.)
7. The paediatrics unit shall have a follow-up service for patients with chronic Major
ailments
8. There shall be a system for clinical staff to refer patients directly to the social Minor
works unit
Met Partially Un Premises
met met
9. Inpatient room capacity shall not exceed six patients (or beds) per room Major
10. The hospital shall have paediatric intensive care unit that accommodate a Critical
minimum of four ICU beds
11. Patient rooms shall be constructed to meet a minimum of 9 meter squares for Minor
single bed room
12. In case of multiple beds per room, the area per bed shall be 80 sq. ft Minor
13. Dimensions and clearances- the dimensions and arrangements of rooms shall Minor
be such that there is a minimum of 0.9m (90cm) between the sides and foot of
the bed and any wall or any other fixed wall construction. In multiple bed
rooms a clearance of 1.2 meter shall be available at the foot of each bed to
permit the passage of equipments and beds
14. Windows-each patient room shall have at least one window Critical
15 Each room shall have a hand washing station, toilet and bath room Major
16 The paediatric premises shall include at least emergency unit, outpatient, Critical
inpatient and neonatal units
17 The paediatric outpatient shall have a functional oral rehydration therapy Major
corner
18 Each pediatric unit shall have at least one playroom with recreation Minor
equipment and child-size tables and chairs
19 Patients in acute care shall be under direct observation in a room near the Major
nurses’ station
20 (a) Neonatal unit: shall have at least the following rooms Major

17
  Room for care of critical newborns  Toilet and bath for Staff
 isolation room for infectious cases  Toilet and bath for mothers
 Procedure room  Store room
 Nurses station  Office for physicians
 Room for mothers  The arrangement of the rooms for
 Milk preparation room the neonatal care shall avoid
 Kangaroo mother care room wind draft and shall be access
limited.
21 (b) Paediatric OPD: shall have at least the following rooms: Major
 Waiting area with safe playing  Room(s) for follow-up clinic
ground  Nurse station
 Examination Room(s)  Store
 Procedure room  Toilets for patients and staff
22 (c) Paediatric emergency shall have at least the following rooms: Major
 Resuscitation room with beds  Space for triaging/ reception
for initial management of  Examination room
patients and  ORT corner,

23 (d) Paediatric in-patient shall have at least the following rooms: Major
 Inpatient rooms  Dark room
 Procedure room  Isolation room
 Room for severely  Staff toilet and bath
malnourished patients  Toilet and bath for patients and
 Nutritional supplement care takers
preparation room  Store room
 Nurses station  Office for physicians
24 (e) Paediatric ICU shall have the following premises: Critical
 ICU room with 4 ICU beds,  Staff change room,
 Hand washing facility by  Toilet with shower,
entrance,  Store,
 Nurse station,
25 (f) In addition, paediatrics services shall have: Major

18
  Counselling room  Meeting hall and
 Duty room  Room for inpatient pharmacy
(shared)
Met Partially Un Professionals
met met
26 The paediatric service shall be directed by a licensed paediatrician Critical
27 A physician or licensed independent practitioner shall be available (physically Critical
present) at all times in the paediatric unit
28 A licensed paediatrician shall be available at all times. The paediatrician on Critical
call shall be duty bound to respond calls
29 The neonatal unit shall have at least the following professionals: Major
(a) Neonatologist, (d) Neonate caretakers/Feeders with
(b) Paediatrician training or experience and
(c) Nurses with experience in (e) Others as required.
neonatal care
30 The paediatric ICU shall have at least the following professionals: Critical
(a) Paediatrician (pulled), (c) Clinical nurse(s),
(b) Nurse with ICU training (d) Cleaners,
or experience per two (e) Runner (pulled)
beds
31 The nurse with administrative responsibility for nursing care in pediatrics Critical
shall be a licensed professional nurse with at least two years of experience in
paediatrics
Met Partially Un Products
met met
32 The paediatric emergency unit shall have the following equipment and Major
supplies:
a) Resuscitation stretcher, m) set,
examination couches, beds n) minor set,
for emergency services, o) chest tube set,
b) X-ray viewer, p) tracheostomy set
c) Sphygmomanometer q) Suction machine,
(pediatric and adult sizes), r) medicine trolley, Cup board
stethoscope, thermometer, s) Hand washing basin

19
 weight scale, tape meter, t) Nebulizers (electricity driven, or
Torch, Otoscope, oxygen driven or manual)
ophthalmoscope, patella u) Spacers with masks for sprays,
hammer, v) Consumables:
d) Oxygen cylinder with flow  Butterflies and/or cannulas of
meter, paediatric size,
e) Nasal prongs catheters,  NG-tubes and urinary
f) Self inflating bags for catheters (pediatric size),
respiratory support,  Gloves (surgical and
g) Masks (infant size, child disposable),
size, adult size),  antiseptics (alcohol, savlon,
h) endotracheal tubes iodine), cotton, gauze, K-Y
(pediatric and adult sizes), jelly,
i) laryngoscope  Spatula,
j) Equipment for intra- w) Emergency medicines as per the
osseous fluid national medicine list.
administration x) Cardiac monitor (optional),
k) Glucometer with y) lumbar puncture
glucosticks, z) EKG machine and its supplies,
l) pulse oximetery,
33 The paediatric OPD shall have the following functional equipment and Major
supplies:
a) Diagnostic equipment: e) Stethoscopes,
Torch, Otoscope, f) Sphygmomanometer (paediatric
ophthalmoscope, reflex and adult sizes),
hammer, g) X-ray viewer,
b) Weighing scales for h) Examination couch,
children and infants, i) Lumbar puncture, Bone marrow
c) Measuring board for aspiration set, pleural biopsy set,
measuring length (lying j) Hand washing basin,
for infants) and height k) Consumables: Spatula, KY Jelly,
(standing for older Surgical and disposable gloves,
children), antiseptics, cotton, gauze

20
 d) Measuring tape,
thermometer,
34 The pediatric inpatient shall have the following functional equipment and Major
supplies:
a) Diagnostic equipment: o) Radiant or Heat source,
Torch, Otoscope, p) Beds for patients, mothers and
ophthalmoscope, reflex croup tents
hammer, q) Oxygen cylinder, Flow-meters for
b) Weighing scales for oxygen
children and infants, r) Nasal prongs catheters
c) Measuring board for s) Self inflating bags for respiratory
measuring length (lying for support,
infants) and height t) Masks (infant size, child size,
(standing for older adult size)
children), u) endotracheal tubes (pediatric and
d) Measuring tape, adult sizes), laryngoscope
thermometer, v) Equipment for intra-osseous fluid
e) Stethoscopes and administration
Sphygmomanometer w) Nebulizers for administration of
(pediatric and adult sizes), salbutamol (electricity driven, or
f) X-ray viewer, oxygen driven or foot pump
g) Examination couch, driven)
medicine trolley, x) Spacers with masks for
Cupboard, administration of metered doses
h) Lumbar puncture, Bone (spray) of salbutamol
marrow aspiration set, y) Consumables: Spatula, K-Y jelly,
pleural biopsy set, Surgical and disposable gloves,
i) EKG machine and its Butterflies and/or cannulas of
supplies, pediatric size, NG-tubes-pediatric
j) Suction machine, size, antiseptics, cotton, gauze,
k) Drip counters, z) Emergency mediciness as per the
l) Infusion pump, national medicine list.
m) Tourniquets,

21
n) IV stands,
Paediatric intensive care unit (PICU) shall have the following functional Critical
equipments and supplies:
a) Cardiorespiratory o) Suction machine,
monitor, p) Tourniquets,
b) Continuous positive q) IV stands,
airway pressure r) Radiant warmers,
apparatus, Refrigerator
c) ICU bed, s) Hand washing basin,
d) Pulse oximeter, t) Medicine cupboard,
e) Ventilator, u) Oxygen cylinder, Flow-meters for
f) Glucometer, oxygen, Nasal prongs catheters,
g) Perfuser, Self inflating bags for respiratory
h) Infusion pump, support, Masks (infant size),
i) Baby weighing scale, endotracheal tubes (new born
j) Incubators, sizes), laryngoscope
k) X-ray viewer,
l) Diagnostics: Torch, v) Consumables:
Otoscope,  Butterflies and/or cannulas
ophthalmoscope, of paediatric size
Stethoscopes,  NG-tubes-paediatric size,
thermometer umbilical catheters
m) Measuring board for w) Emergency medicines as per the
measuring length, national medicine list.
Measuring tape,
n) medicine trolley, Cup
board
The neonatology unit shall have the following equipment: Major
a) Neonatal bed/ cradle, q) Lumbar puncture,
b) Incubator, r) Suction machine,
c) Oxygen source, s) Tourniquets,
d) Baby weighing scale, t) IV stands,
e) Cardiorespiratory u) Exchange transfusion sets,

22
 monitor, v) Radiant warmers,
f) Pulse oximeter, w) Oxygen cylinder with flow-meters,
g) Glucometer, x) Nasal prong catheters,
h) Infusion pump, y) Self inflating bags for respiratory
i) Phototherapy light with support,
bed, z) Masks (infant size),
j) X-ray viewer, aa) endotracheal tubes (new born
k) Diagnostics: Torch, sizes),
Otoscope, bb) laryngoscope (new born size),
ophthalmoscope, cc) Refrigerator,
Stethoscopes, dd) consumables:
thermometer  Butterflies and/or cannulas of
l) Measuring board for paediatric size,
measuring length,  NG-tubes-paediatric size,
Measuring tape,  Umbilical catheters
m) Examination couch, ee) Beds for mothers,
n) Medicine trolley,
o) Medicine Cup board,
p) Mobile X-ray machine,

Surgical Service Standard Score point

S.N Compliance Status Standard to be addressed Remark
Met Partially Un Practice
met met
1. Comprehensive emergency surgical service shall be available 24 hours a day, Critical
365 days a year
2. There shall be written protocols and procedures for admissions and discharges Minor
with follow up.
3. There shall be protocols for the management of the surgical conditions in the Minor
unit.
4. There shall be a clear policy for handling emergency surgical conditions. This Minor
service shall be available 24 hours a day throughout the year.

23
5. The hospital shall have emergency surgical services integrated with the Critical
general emergency service.
6. There shall be a mechanism of interdepartmental consultations with surgical Major
unit for which the surgeon on duty shall be responsible.
7. Surgical records shall be kept for each patient and the patient’s surgical Major
record shall be integrated with the patient's over-all hospital record.
8. The nursing care of patients undergoing surgery shall be planned and Major
documented in the medical record, directed by a trained nurse, and includes
the following:
a) Pre-operative care, 
b) Location of post-operative care,
c) Type of post-operative care and monitoring needed,
d) Pain management, and
e) Patient understands of discharge instructions.
9. There shall be policy that leads to positively identify the patient and ensure Minor
that the correct procedure and the correct side are confirmed prior to starting
the surgery.
10. The surgeon shall fill the pathology form and the specimen container shall be Major
labeled properly. The container shall be leak proof with lid & filled with 10%
formalin.
11. There shall be a policy for preparing and availing appropriate and properly Minor
functioning supplies, equipment, and instruments available for all surgeries
performed according to the country standard.
12. The hospital shall have clear protocol for surgical activities to be done at Minor
outpatients level, surgical referral clinics, follow up clinics, minor operations
and orthopedic procedures  
13. Emergency call access to each bed in the wards  and recovery room shall be Minor
in place; at switches for emergency calls (nurse alarms) shall be placed
accessible to beds
Met Partially Un Premises
met met
14. A specialized hospital shall have a minimum of seven (7) operating theatres, Critical
one of which shall be dedicated for septic procedures.
15. Surgical service shall be composed of operation room, recovery room, the Critical
surgical inpatient wards and central sterilization room (CSR).
16. Operation Theatre: Critical

24
 a) The wall of the operation theatres shall be washable
b) The ceiling shall be monolithic and scrub-able
c) Floors and walls penetrated by pipes, ducts and conduits’ shall be
tightly sealed.
d) The floor of the theatre shall be smooth, easily cleanable, non-slippery.
e) There shall be drainage on the floor,
f) There shall be at least six fixed electric outlets in each theatre with
cover,
g) The entrance and exit doors to the theatre shall be fitted with self-
closing double doors,
h) There shall be at least one ceiling operation light and one mobile
operation light for each operation table,
i) Glass cabinets and shelves shall be available,
j) The OR shall be cleansed and disinfected after each operation and
thoroughly cleansed weekly. UV lights shall be installed in the OR.
k) Appropriate temperature shall be maintained in the operation theatre
17. Scrub area: Critical
a) There shall be a scrubbing-up area outside but adjacent to the operating
theatre(s) and between the two self closing doors.
b) Scrub area shall have direct access to the operating room,
c) Scrub area shall be provided with multiple sinks with hand free
18. Nurse station: Major
a) This is a room within the restricted access area
b) There shall be a corridor or allocated area for keeping charged and
empty Oxygen cylinders
19. Entrance/Patient Transfer Area: Major
a) This area shall be large enough to allow for the transfer of patients from
a bed to OR stretcher.
b) A line shall be clearly marked in red on the floor
c) There shall be a space or corridor ( Holding bay) to keep and observe
pre-operative patients until called to theatre.
20. Staff Change Rooms Major
a) Suitable separate changing rooms for male and female,
b) Each changing room shall have two doors
c) Each changing room shall be provided with a locker
d) Each changing room shall be provided with shelves

25
 e) Separate storage bin shall be provided for used and soiled theatre
apparels.
f) Each changing room shall be provided with hand wash basins.
g) For each changing room, there shall Toilets and shower stands.
21. Operating Theatre Equipment Store room Major
22. Operating Theatre Sterile Supply Store room Major
23. Clean Utility, Surgical Suite room: There shall be a room allocated for Major
storage of IV fluids, clean linen, medicines and other sundry items
24. Soiled Utility/Sluice room shall be available with the following requirements: Minor
a) This room shall be located at the rear side of the OR.
b) Sharp containers, leak proof containers with lids shall be available
c) Container for temporary storage point for soiled linen,
d) Hand washing basin,
e) Drainage on the floor,
f) Trolley for soiled materials and waste human tissues,
25. Cleaner’s Room shall be available with the followings; Minor
a) A room provided with 2 sets of cleaning equipments and materials,
b) Hand washing basin,
c) Washing sink,
d) Detergent proof shelves and cabinets.
26. Central sterilization room shall be available with following requirements: Critical
a) Direct access to OR,
b) Needs following rooms:
 Room for reception & sorting of equipments and clothes, and
documentation process;
 Room for inbuilt autoclaves;
 Separate, properly ventilated room for storing and shelving
sterile clothes and instruments,
 Room for staff and
 Cleaners’ room
c) Shall have at least two inbuilt autoclaves, with small one as backup,
d) Continuous water supply with extra reservoir,
e) There shall be a closed drainage system for the autoclaves,
f) Shelves shall be washable ,corrosive free  and metallic racks,
g) Staff toilets,

26
27. Recovery room shall be available with the following requirements: Critical
a) It shall be close to OR, and shall be within the semi- restricted area.
b) A minimum of four beds shall be available,
c) There shall be a minimum of 1.2 meter gap between beds
d) Recovery beds shall have flexible side protections,
e) A minimum of two electric outlets shall be available for each bed,
28. Minor operation theatre shall be available with the following requirements: Major
a) Located with low or no traffic area accessible to OPD,
b) There shall be one operation room with two theatres,
c) There shall be two glass cabinets for surgical consumables in the OR,
d) There shall be two patient changing rooms,
e) There shall be mark on the floor restricting movement of unauthorized
and/or person without OR suit,
f) Utility room,
g) Store with shelves and cabinets,
h) Nurse station with table and chairs,
i) Toilet rooms for male female,
j) Cleaners room,
29. Surgical ward shall be available with the following requirements; Critical
a) It shall be part of the inpatient service,
b) The beds shall be flexible and orthopedic beds,
c) In case of multiple beds, space between beds shall be at least 1.2m.
d) There shall be a minimum of one separate room, labeled “Septic Room”
for septic patients,  
e) The beds shall be equipped with fixtures for certain surgical patients-
orthopedic cases,
f) Patient screens,
g) Patient toilets and showers with proximity to the ward, or covered
walkways to the ablution facilities.
30. Nurses’ station shall be available with the following requirements; Major
a) located amidst of the wards
b) shall have table and chairs
c) shall have lockable cabinets,
d) shall have specimen collection station/ laminated table with racks,
e) shall have hand washing basin,
31. Surgical ward clean utility room (procedure room) shall be available with Major

27
 the following;
a) Dressing trolleys,
b) Procedure beds
c) POP equipments sets,
d) Deep Sink,
e) Hand washing basin,
f) Worktable with laminated top, Cabinets and shelves
32. Surgical ward clean linen room with shelves and cabinets shall be available Minor
33. Surgical ward in patient store with shelves, cabinets and fixed electrical plugs Minor
with protection shall be available
34. Surgical ward soiled utility room with shelves and leak proof containers with Minor
leads shall be available
35. Surgical ward cleaner’s room shall be available with the following Minor
a) Hand washing basin,
b) Sinks and cleaning equipments,
c) Shelves and Cabinet,
d) One room for keeping patients belongings with lockers.
Met Partially Un Professionals
met met
36. Surgical services shall be directed by a licensed surgeon with a minimum of Critical
two (2) years experience
37. Minimum number of professionals for surgical service at OR for 24 hours Major
services:
Anesthesiologist               1 Cleanerrs 4
Anesthetist                       10 Technicians 2
Scrub nurses                    10 Porters 4
Circulating nurses            10
38. Minimum number of professionals for surgical service at recovery: Major
a) Recovery nurses                                 8
b) Porters                                          2
39. Minimum number of professionals for surgical service at CSR: Major
Nurse     ( 6 ) Technician    (1 ) Cleaner   ( 10 )
40. Minimum number of professionals for surgical service at surgical ward: Major
General surgeons       3 Nurses (1 nurse per 6 bed)
Sub specialist             1 Cleaners 10
GP                                 6 Porters 5

28
41. The nursing services in the OR shall be coordinated by a licensed BSc nurse Major
with a minimum of 2 years experience in surgical nursing.
Met partially un Products
met met
42. Surgical wardequipments and supplies: Major
a) Bed and mattress g) Waste paper paper basket
b) Pillows h) Safety box
c) Oxygen flow meter, 0-15 i) Foot stool
L/min j) Iv stand
d) Chairs, k) Wheelchairs
e) Feeding table/ Over bed l) Stretchers
table m) Oxygen on trolley
f) Bed side cabinet Bed screen, n) Hand washing basins
3 sections 
44. Equipment – Clean Utility Room  and procedure room Minor
a) Dressing trolley d) Walking rail,
b) IV stand e) Crutches,
c) Wheelchair f) Pop cutters
46. Equipment – Nurses station Major
a) Wall clock f) Waste paper basket
b) Desk g) Adult sphygmomanometer
c) Chair h) Stethoscope, dual head 
d) Trolley for vital sign i) Stethoscope, adult head
monitoring j) Thermometer
e) Refrigerator for medication k) Safety box
withtemperature control
48. Equipment –ward/ in patient store: Minor
a) General purpose trolleys, and f) Kidney basin, 475 ml
trays g) Wheelchair
b) Patient chart holder h) General surgical dressing set 
c) Bed screen, three sections  i) Tendon hammer
d) Oxygen trolley, complete j) Mobile examination light
e) Suction pump, portable  k) Adult weight scales 
Bed pans
50. Equipment – surgical ward soiled utility room: Minor
a) Soiled linen trolley e) General purpose trolley, trays
29
 b) Bin with lid f) Mobile trolley 
c) Worktable with laminated top g) Bedpans
d) Washing basins h) Kidney basin, 475 ml
52. Equipment – surgical ward cleaner’s room: Minor
a) Cleaning trolley e) Pail with handle
b) Mop rack f) Brooms
c) Worktable g) Mops
d) Cabinets and shelves h) Cabinet for detergents
54. Equipment – reception/nurse station, operating theatre suite: Major
a) Wall clock d) Chair, stackable, without armrests
b) Desk e) Basket, waste-paper,
c) Desk chair f) Cabinet
56. Equipment – entrance, patient transfer area, operating theatre suite: Major
a) Chairs 
b) Patient stretchers
57. Equipment –staff changing room, operating theatre suite: Major
a) Soiled linen trolley e) Waste basket
b) Clean linen cabinet f) Lockers
c) A big mirror g) Shoe shelves
d) Aprons
59. Equipment, operating theatre: Minimum equipment list for a single operating Major
theatre.
a) Time clock t) Mobile operating lights
b) Anesthesia trolley u) Operating table, 3 sections
c) Oxygen cylinders ,different v) Suction machines
sizes. w) Bone cutters
d) Worktable with laminated top x) IV fluid pressure bag
e) Stools y) X-ray viewer
f) IV stands z) Anesthesia machine with ventilator,
g) Kick buckets 2 vaporizers, and gas cylinders
h) Safety boxes aa) Laryngoscope, set (Mackintosh)
i) Swab rack with drip trays bb) Magill forceps (adult &pediatrics)
j) Swab count record boards cc) Laryngeal mask set
k) Bowls and stands dd) Mask holder
l) Instrument tables, Mayo type ee) Mouth gauge
m) Framed boards with pencil ff) Patient monitor

30
 trays gg) Dual head stethoscope
n) Infusion pumps hh) Tracheostomy tube,
o) Chest tubes with bottles ii) T-tube,
p) Blankets, warming jj) Colostomy bag,
q) Tourniquets kk) Urinary bag
r) Tongue depressors ll) Lights, operating, 1 large copula,
s) Coagulation unit, electro, ceiling mounted
mobile, 200 W
61. Equipment – scrub area: Major
a) Soap dispenser c) Sinks
b) Scrub-up brushes d) Mirror above each sink
63. Equipment: set up area Major
a) Worktable with laminated top d) Blood warmer
b) Cabinets and shelves e) IV fluid warmer
c) Dressing trolley f) Instrument table, Mayo type
65. Equipment – operating theatre store Major
a) Patient transfer, stretchers g) Positioner, bag, small
b) General purpose trolleys h) Positioner, bag, medium
c) IV stands i) Positioner, bag, large
d) Hygrometer, humidity and j) Apron, protective, small
temperature k) Apron, protective, medium
e) Pillows, abduction l) Apron, protective, large
f) Support, head, operating
table
67. Equipment – operating theatre sterile supply store: Major
a) General purpose trolleys, f) Gen.surg- Minor surgical set
trays g) Gen.surg- Suprapubic puncture set
b) Gen.surg- Basic surgery set h) Cholecystectomy set
c) Thyroidectomy set i) Billiary set
d) Cholecystectomy set j) Welicary set 
e) Thoracotomy set ,etc k) Gen.surg- Laparotomy set
69. Equipment – clean utility room, surgical suite: Minor
a) General purpose trolley, d) Shelves
trays e) cabinets
b) Worktable, laminated top
c) Refrigerator

31
71. Equipment – operating theatre sluice room Minor
a) Soiled linen trolley e) Worktable with laminated top
b) General purpose trolley, trays f) Wash basins
c) Bin with lid g) Kidney basin, 475 ml
d) Bedpans
73. Equipment – cleaners’ room, operating theatre: Minor
a) Cleaning trolley d) Pail with handle
b) Mop rack e) Brooms
c) Worktable f) Mops
75. Renewable/Consumables for surgical  unit Major
a) Guedel airways: size 0, 00,  Connectors - Plastic –
3, 4 & 5 Tapered
b) Alcohol Swabs pp) Container, Sample, urine, plastic,
c) Disposable aprons non-sterile, 60 ml
d) Aqua-packs Oxygen qq) Cotton
humidifier  Cotton Buds
e) Bags - Refuse - All Colors
and Sizes
 Cotton Wool Balls - Sterile/Non-
f) Bags – Urine Sterile
g) Bandage - Crepe  Cotton Wool Rolls
h) Batteries - Medical & rr) POP
General ss) Covers - PVC - Mattress/Bed
i) Bedpan Covers Wedge
j) Blood Administration Sets tt) CVP – Cannulae
k) Blood Sampling uu) Cytological Fixative Spray
 Needles, disposable, vv) Drawsheet,plastic,90x180cm
sterile, 20 G, 21 G, 23 G ww) Face Mask Water Repellent
xx) Foley Catheters – Latex/Silicone
 Tube, Vacuum 5ml Size 10, 12 and 14
(Vacutainer) yy) Gauze Absorbent Ribbon
 Tube, Vacuum EDTA zz) Gloves:
5ml (Vacutainer)  Household Large & Medium
 Tube, Vacuum  Surgical Size 6, 6 ½, 7, 7 ½, 8
Heparinised 5ml
(Vacutainer)
 Exam, latex, disp, large, medium,
small
 Vacutainer Holder aaa) Hand wash Antiseptic Liquid

32
  Vacutainer needle
l) Bottles - Suction
Glass/Plastic
m) Braun Splints (Arm)
n) Bubble tubing box
o) Cannula - Nasal-Oxygen
p) Cannula, IV short, ster,
disp, 18G, 20 G, 22 G, 24 G
q) Caps - Mop/Bonnet Type
r) Catheter - Jacques
s) Central Venous Pressure
Sets
t) Chest, Electrode, Monitor
u) Cleansing Swabs – Sterile
v) Cleansing Swabs Non-
Sterile
w) Cold/Hot Packs
x) Combur Tests
y) Connector,
 BiconicalAutoclavable
 Connector, T/Y
z) IV Infusion set Buretrol
aa) K.Y. Jelly
bb) IV stands
cc) Drums
dd) Latex Tubing
ee) Linen Savers
ff) Masks - Nebulizer/Oxygen
gg) Masks – Oxygen 40 %
hh) Nail Brushes
Autoclavable/Disposable
ii) Needles:
 Spinal disp,
(0.9x90mm),sterile,
20G, 22G, 24G
 Disp,15G, 18G, 21G,
(Hibiscrub)
- bbb) Hand wash Povidone (Betadine)
ccc) Hot Packs
ddd) I.V. Sets :
 I.V. Administration Sets – 15
Drop
 I.V. Administration Sets - 60
Drop
 I.V. Set, Infusion “Y”, Luerlock,
air inlet
eee) Incontinence Sheets
fff) Intubation stylet, adult, 15 Ch
ggg) Suture absorbable (Chromic) for
episiotomy and perinea tears
hhh) Syringes:
 Volume: 2ml, 5ml, 10ml, 20ml
 Syringes 50 ml Conical Tip
 Syringes 50 ml Luer Lock
 Syringes Insulin
iii) Tape:
 Elastic Adhesive Plaster - White
5cm and 10 cm
 Micropore tape
 Surgical Adhesive Hypo-
Allergenic
 Adhesive, zinc oxide,
perforated,10cmx5m
 Adhesive, zinc oxide, 2.5cmx5m
-
jjj) Clinical thermometer
kkk) Fridge thermometer
lll) Tourniquet, latex rubber,75cm
mmm) Tubes:
 Endo-tracheal, disp. + connector,
neonate mm, w.o balloon
33
 22G, 23G, 25G
 Butterfly 23G
jj) Oxygen T Pieces
kk) Oxygen Tubing
ll) Face Masks
mm) Razor Medical - Disposable
- Single Edge
nn) Rubber Bath Mat - Non-Slip
oo) S.G. Meter (Urine Meters)
 Endo-tracheal, disp. + connector,
balloon, 6.5mm, 7mm, 7.5mm,
8mm
 Suction, L125cm,ster,disp, CH10,
CH12, CH16
nnn) Shrouds
ooo) Soap,toilet,bar,approx.110g,wrapp
ed
ppp) Spatulas - Tongue
qqq) Spigots Large, Medium and Small
rrr) Spray Bottles - Plunger Operated
sss) Surgical Splints
ttt) Safety Pins Large & Medium
uuu) Sharps Containers (Safety
Box/used syringes and needles)

77. Operating Suite Renewable/Consumables: Major

a) Airway Guedel, pediatric& s) Survival blanketl,220x140cm
adult size t) Blood Sampling:
b) Plastic, reusable aprons  Needle, disposable, sterile,
c) Urine bags, collecting, 2000 20G, 21G
ml  Tube, Vacuum 5ml
d) 012 Band, Esmarch, 6 cm x 5
(Vacutainer)
m
u) Connector, biconical, OD 7-11-
 Tube, Vacuum EDTA 5ml 7mm
(Vacutainer) v) Cotton wool,500g,roll,non-ster
 Tube, Vacuum Heparinised w) CVP - Set
5ml (Vacutainer) x) Diathermy pencil/ball/blade
 Vacutainer holder y) Disposable, dispersive,
 Vacutainer needles, 18-24G electrode(Diathermy pad)
e) Bouffant Nurse Cap z) Drain, corrugated sheet, 3 cm x 25
f) Bubble Tubing cm
g) Cannula, IV short, ster, disp, aa) 063 Drain, wound, CH 12, ster,
18G, 20G, 22G, 24G disp, CH12, CH16, CH6
h) Catheters: bb) Drawsheet,plastic,90x180cm
cc) Elastoplasts, 10 cm x 3 m

34
  Sup-Pubic, CH 10, 1.65 cm, dd) Electrode, Chest, Monitor
ster, disp adult with trocar
 Ureteral, CH5, ster, disp
 Urethral, CH6, ster, disp
 Urethral, CH7, ster, disp
 Foley, ster, disp, CH10,
CH12, CH14
 Three way foley catheter
i) Compresses:
 Abdominal compress, 40 x 40
cm
 Compress, Swab, 20x 20 cm
 Compress,
gauze,10x10cm,n/ster/PAC-
100
 Compress,
gauze,10x10cm,ster/PAC-5
 Compress,
paraffin,10x10cm,ster/BOX-
10
j) Gum elastic bougie, CH 15,
60 cm
k) Intubation stylet, adult, 15 Ch
l) Lancet,blood,ster,disp/PAC-
200
m) Oxygen mask, adult
n) Oxygen, nasal cannula
o) Reusable, Diathermy, Cable
p) Mask, Clinical, Disposable
(non-woven)
q) Safety box for .used syrgs/ndls
r) Suturing
materials:abs,nonabs,various
types with and with out
needles
ee) Extractor,mucus,20ml,ster,disp
ff) File for ampoules
gg) Gauze:
 Ball, Large (sterile)
 Ball, Large (un-sterile)
 Ball, Peanut (sterile)
 Swabs RAYTEX® 10 X 10 cm
 Swabs, Un-sterile (Green)
 Roll,90cmx100m,non-ster
 Vaseline gauze
hh) Gloves,exam,latex,disp, large,
medium & small
ii) Gloves,surg,disp, 6.0, 6.5, 7.0, 7.5,
8, 8.5
 Abs,DEC1,need
1/2,18mm,round/BOX-36
 Abs,DEC2,need 3/8 18mm,round/
 Abs,DEC2,need 3/8,26mm,tri
 Abs,DEC3,need 1/2 30mm,round
 Abs,DEC3,need 3/8 50mm,round
 Abs,DEC3,spool
 Abs,DEC4,need 3/8 36mm,tri
 Nonabs,DEC2,need 3/8 13mm,tri
 Nonabs,DEC3,need 3/8 30mm,tri
jj) Syringe,dispos, 2ml, 5ml, 10ml,
20ml
kk) Tape,adhesive,Z.O,perforated,10cm
x5m
ll) Tape,adhesive,Z.O.,2.5cmx5m
mm) Telfa, dressing (Various Sizes)
nn) Tourniquet,latex rubber,75cm
oo) Tubes:
 Endo-tracheal, disp. + connector,
35
  Endo-tracheal, disp. + 3 mm, w/o balloon
connector, 3.5 mm, w/o  Endo-tracheal, disp. + connector,
balloon 7 mm, balloon
 Endo-tracheal, disp. +  Endo-tracheal, disp. + connector,
connector, 4 mm, w/o 7.5 mm, balloon
balloon  Endo-tracheal, disp. + connector,
 Endo-tracheal, disp. + 8 mm, balloon
connector, 4.5 mm, w/o  Trachea, balloon, int.can, ster,
balloon size 6
 Endo-tracheal, disp. +  Trachea, balloon, int.can, ster,
connector, 5 mm, balloon size 8
 Endo-tracheal, disp. +  Suction,CH08,L50cm,ster,disp,
connector, 5.5 mm, balloon CH08, CH10, CH14, CH16
 Endo-tracheal, disp. +  Double lumen endo-tracheal
connector, 6 mm, balloon tubes
 Endo-tracheal, disp. +  NG Tubes 12, 14, 16
connector, 6.5 mm, balloon pp) Scalpel blade,ster,disp,no.10, no.
11, no. 15, no. 22, no. 23
qq) Shoe cover, disposable
rr) Silicone Rubber Tubing
ss) Surgeon's Cap, Easy-Tie
tt) Set, Infusion “Y”, Luer lock, air
inlet
uu) Mask, Protection, High Filtration
vv) Needle, spinal,
0.9x90mm),ster,disp, 20G, 22G,
24G
79. Operating Room Linen: Major
a) Apron Surgical, rubber e) Sheet, draw, white
b) Trousers, Surgical, woven, f) Cellular Blanket
Small, Medium & Large g) Mayo cover
c) Drape: h) Pillow case
 Surgical, woven(1 x 1 m) i) Pillows
 Surgical, woven(1 x 1.5 m) j) Sheet, Bed
k) Towel Bath
 Surgical, woven(1.5 x 1.5 m)
36
 (fenestrated l) Towel Hand
 Surgical, woven(45 cm x 70 m) Top(shirts), Surgical, woven, Small,
cm)(fenestrated) Medium & Large
 Surgical woven (2 x 1.5 m n) Gown, Surgical, woven(Plain)
d) asks, surgical, woven o) Cap, Surgical, woven
81. Equipment  recovery area: Critical
a) Vacuum aspirator i) IV stands
b) Oxygen Flow meter, 0 - 15 j) Bed screen, 3 sections, mobile
l/min k) Pedal bin
c) Oxygen (one cylinder per bed) l) Oxygen trolley, complete
d) Oxygen concentrater m) Pulse oximeter
e) Patient transfer, (stretchers) n) Resuscitator, hand operated
f) Dressing trolley, trays o) Suction machines
g) Bed with mattress p) Mobile examination light
h) Stools q) Dual head stethoscope
83. Equipment-Central sterilization room Critical
a) Auto claves ;big e) Cabinets
b) Autoclaves ;small f) Tables
c) Drums g) Chairs
d) Metallic shelves

Orthopedics Services Score point

S.N Level of Compliance Standard to be addressed Remark
Met Partially Un Practice
met met
1. Comprehensive emergency orthopaedic surgical service shall be available 24 Critical
hours a day 365 days a year
2. There shall be written protocols and procedures for admissions and discharges Minor
with follow up
3. There shall be protocols for consultation and transfer of patients admitted to Minor
this unit and to other departments
4. The hospital shall have emergency orthopedic surgical services integrated Major
with the general emergency service
5. Adequate orthopedic surgical records shall be kept for each patient and the Major
patient’s orthopedic surgical record shall be integrated with the patient's over-

37
 all hospital record
6. The nursing care of patients undergoing orthopedic surgery shall be planned Major
and documented in the medical record, directed by a trained nurse, and
includes the following:
a) Pre-operative care, 
b) Location of post-operative care,
c) Type of post-operative care and monitoring needed,
d) Pain management, and
e) Patient’s understanding of discharge instructions.
7. The hospital shall have clear protocol for orthopedic surgical activities to be Minor
done at outpatients level, orthopedic surgical referral clinics, follow up
clinics, minor operations and orthopedic procedures 
8. There shall be a policy or procedure that clearly shows at least one orthopedic Minor
surgeon shall be on call/ on duty to respond for orthopedic surgical requests
from emergency and/ or orthopedic ward physician
9. There shall be a mechanism by which the orthopedic unit provides board Minor
certificate in response to hospital medical board request
Met Partially Un Premises
met met
10. Orthopedics Operation Room / Suite : Critical
The operation room shall have
 three operation theatres of  four changing rooms with lockers,
which one is for septic  one rest room,
procedures,  anesthesia store,
 one nurse station,    nurse store,
 four staff toilets,  one general store
 six shower stands,
13. Operation Theatre: Critical
a) At least three standard size operation theatres and one septic operation
theatre shall be available
b) The wall of the operation theatres shall be washable;
c) The ceiling shall be monolithic, scrub-able
d) Floors and walls penetrated by pipes, ducts and conduits’ shall be tightly
sealed.
e) The floor of the theatre shall be smooth, easily cleanable, non-slippery

38
 f) There shall be drainage on the floor,
g) There shall be at least six fixed electric outlets in each theatre with cover,
h) The entrance and exit doors to the theatre shall be fitted with self-closing
double doors,
i) There shall be at least one operation table in each theatre,
j) At least one ceiling operation light and one mobile operation light per
theatre shall be available
k) Glass cabinet and shelves shall be available
l) The OR shall be thoroughly cleansed weekly.
m) Heater fixed on the wall shall be available in each theatre,
14. Scrub area: Critical
a) There shall be a scrubbing-up area outside but adjacent to the operating
theatre(s).  
b) This area shall have direct access to the operating room,
c) It shall be provided with multiple sinks or with wide sink and taps
for running (warm) water.
15. Nurse station: Major
(a) This is a room within the restricted access areas,
16. Entrance/Patient Transfer Area: Critical
a) A line shall be clearly marked in red on the floor,
b) Holding bay:.
17. Staff Change Rooms Major
a) Suitable changing shall be available and labeled for male and female,
b) Each changing room shall be provided with a locker
c) Each changing room shall be provided with shelves
d) Separate storage bin shall be provided for used and soiled theatre
apparels.
e) Wash hand basins: Toilets, showers,
18. Operating Theatre Equipment Store: Major
a) There shall be equipment store area in the operating room  
b) Shelves and cabinets
19. Operating Theatre Sterile Supply Store Major
20. Clean Utility, Orthopedic surgical Suite: Major
a) Shall be situated where OR staff have easy access to the clean utility
store.
b) Metallic washable rack for storage shall be available,

39
 c) Refrigerator with thermometer shall be available
d) Sink, cabinets and shelves
21. Soiled Utility/Sluice room shall be available with the followings: Minor
a) This room shall be located at the back of the OR.
b) This room shall be for keeping contaminated materials until they are
disposed.
c) Sharp containers, leak proof containers with lids shall be available,
d) Container for temporary storage point for soiled linen,
e) Hand Washing basin,
f) Drainage on the floor,
g) Trolley for soiled materials and waste human tissues,
22. Cleaner’s Room shall be available with the followings: Minor
a) A room provided with two sets of cleaning equipments and materials,
b) Hand washing Basin,
c) Washing sink,
d) Detergent proof shelves and cabinets.
21 Central sterilization room shall be available with followings: Not
Direct access to OR, scored
a) Needs a minimum of needs rooms:
 One for reception, sorting of equipments; or clothes and
documentation process;
 One for inbuilt autoclaves;
 One separate properly ventilated room,
 One staff room and
 One cleaners’ room
b) Shall have at least two inbuilt autoclaves, with small one as backup,
c) Continuous water supply with extra reservoir,
d) Shelves shall be washable ,corrosive free  and metallic racks
e) The date of sterilization & the name of the instruments shall be written
f) Staff toilets,
23. Recovery facilities shall be available with the followings: Critical
a) It shall be close to OR, and shall be within the semi- restricted area.
b) A minimum of four beds shall be available,
c) There shall be a minimum of 1.2 meter gap between beds
d) Recovery beds shall have flexible side protections,

40
 e) A minimum of two electric outlets shall be available for each bed,
f) A trolley carrying functional emergency equipments shall be available
g) A minimum of four bed pans
h) A minimum of four patient screens shall be available,
i) There shall be sufficient light for each bed, one head light per bed,
j) There shall be a heater,
24. Minor operation theatre shall be available with the followings: Major
a) It shall hall be located accessible to OPD,
b) There shall be one minor operation room with two OR tables,
c) There shall be two glass cabinets for orthopedic surgical consumables
d) There shall be two patient changing rooms,
e) There shall be mark on the floor restricting movement
f) Staff room
g) Utility room,
h) Store with shelves and cabinets,
i) Nurse station with table and chairs,
j) Toilet rooms for male female,
k) Cleaners room,
25. Orthopedic ward shall be available with the followings; Critical
a) It shall be part of the inpatient service,
b) The beds shall be flexible and orthopedic beds,
c) In case of multiple bed room, space between beds shall be at least 1.2m.
d) There shall be a minimum of one separate room, labeled “Septic Room”  
e) The beds shall be equipped with fixtures for certain orthopedic surgical
patients- orthopedic cases
f) Patient screens,
g) Patient toilets and showers with proximity to the ward, or covered
walkways to the ablution facilities.
26. Orthopedics ward Nurses’ station shall be available with the following; Major
a) located amidst of the wards
b) shall have table and chairs
c) shall have lockable cabinets,
d) shall have specimen collection station/ laminated table with racks
e) shall have hand washing basin
27. Orthopedic ward clean utility room (procedure room) shall have; Major
a) Dressing trolleys ,beds

41
 b) POP equipments sets,
c) Deep Sink,
d) Hand washing basin,
e) Worktable with laminated top,
f) Cabinets and shelves,
28. Orthopedic ward clean linen room with shelves and cabinets shall be Minor
available
29. Orthopedic ward in patient store with shelves, cabinets and fixed electrical Minor
plugs with protection shall be available
30. Orthopedic ward soiled utility room with shelves and leak proof containers Minor
with leads shall be available
31. Orthopedic ward cleaner’s room shall be available with the following Minor
a) Hand washing basin,
b) Sinks and cleaning equipments,
c) Shelves and Cabinet,
d) One room for keeping patients belongings with lockers

Met Partially Un Professionals

met met
32. Orthopedic services shall be directed by a licensed orthopedic surgeon with a Critical
minimum of two years of work experience
33. If the hospital has separate orthopedics surgical unit, it shall have the Major
following minimum number of professionals
a) Orthopedics OR: c) Orthopedic ward:
 Anesthesiologist            2  General orthopedic surgeons 3
 Anesthetist  Pediatric orthopedic surgeon 2
10 (optional)
 Scrub urses                       20  Hand surgeon 2 (optional)
 Circulating nurses            20  GP        6
 Cleaners                             4  Nurses 30
 Technicians                        1  Cleaners 20
 Porters                                4  Porters 20
b) Orthopedic surgical CSR (shared d) Orthopedic surgical recovery:
with surgical unit):  Recovery nurses                8
 CSR nurse                          6

42
  Technician                          1  Porters                                   2
 Cleaner                               10
Met Partially Un Product
met met
35. The hospital shall have the following orthopedics equipment for operating
theatre
a) Basic Orthopedic set ee) Forearm set with plate and Major
b) Amputation set screw
c) Drill- electrical, pneumatic, ff) Spine fixation- plate with
manual joint sets
d) Wire cutter gg) External fixatures, different
e) Kritchner wire types
f) Rush pin hh) Hand surgery sets with
g) Kuncher nail microsurgery instruments
h) Sign nail ii) Skin graft sets, manual,
i) Dynamic hip screw electrical
j) Cindylar screw jj) Hip replacement set with
k) Patellar wire implants
l) Patellar clamp kk) Shoulder replacement set
m) Bone cutters ll) Elbow replacement set
n) Different osteotomes: manual, mm) Plates
electrical, compressed air (angle: 95° and 135°)
o) Knee replacement set with nn) Fluoroscope, C-arm
implants oo) Swab rack with drip trays
p) Arthroscopic machine with pp) Swab count record boards
sets qq) Bowls and stands
q) POP tray with POP rr) Instrument tables, Mayo type
r) POP cutter, electrical , manual ss) Framed boards with pencil
s) POP spreader trays
t) Tourniquet, upper limb, lower tt) Blankets, warming
limb, (pneumatic, manual) uu) Coagulation unit, electro-
u) Central compressed air system cauthery, mobile, 200 W
v) Anesthesia machine vv) Lights, operating, 1 large
w) Anesthesia trolley copula, ceiling mounted

43
 x) Stools ww) Mobile
y) Walking rail, operating lights
z) Crutches, xx) Operating table, 3 sections
aa) Thomas splints, yy) Suction machines
bb) Brown’s frame, zz) Hip spica tables
cc) Oxygen cylinders, different aaa)Anesthesia machine with
size ventilator, 2 vaporizers, and
dd) Tendon hammer gas cylinders
bbb) Apron, protective

ccc)Kick buckets
ddd) Safety boxes
eee) IV stands
37. Surgery Equipment – OR sterile supply store: Major
a) General purpose trolleys,  trays
b) General surgical Suture set
c) Minor surgical set
38. Renewable/Consumables for orthopedic surgical  service
a) Tongue depressors pp) Blood Administration Sets Major
b) Guedel airways: size 0, 00, 3, 4 & 5 qq) Blood Sampling
c) Disposable aprons  Needles, disposable,
d) Bags - Refuse - All Colors and Sizes sterile, 20 G, 21 G, 23
e) Bags – Urine G
f) Bandage -
 Tube, Vacuum 5ml
g) Batteries - Medical & General
h) Bedpan Covers (Vacutainer)
 Vacutainer Holder  Tube, Vacuum EDTA
5ml (Vacutainer)
 Vacutainer needle
i) Bottles - Suction - Glass/Plastic  Tube, Vacuum
j) Braun Splints (Arm) Heparinised 5ml
k) Bubble tubing box (Vacutainer
l) Cannula - Nasal-Oxygen rr) Foley Catheters –
m) Cannula, IV short, ster, disp, 18G, Latex/Silicone Size 10, 12
20 G, 22 G, 24 G and 14
n) Caps - Mop/Bonnet Type ss) Gauze Absorbent Ribbon

44
o) Catheter - Jacques tt) Gloves:
p) Chest, Electrode, Monitor  Household Large &
q) Cleansing Swabs – Sterile Medium
r) Cleansing Swabs Non-Sterile  Orthopedic surgical
s) Cold/Hot Packs
Size 6, 6 ½, 7, 7 ½, 8
t) Connector,
 Exam, latex, disp,
 Biconical Autoclavable
large, medium, small
 Connector, T/Y uu) Hand wash Antiseptic Liquid
 Connectors - Plastic – (Hibiscrub)
Tapered vv) Hand wash Povidone
u) Container, Sample, urine, plastic, (Betadine)
non-sterile, 60 ml ww) Hot Packs
v) Cotton xx) I.V. Sets :
 Cotton Buds  I.V. Administration
 Cotton Wool Balls - Sets – 15 Drop
Sterile/Non-Sterile  I.V. Administration
 Cotton Wool Rolls Sets - 60 Drop
w) POP  I.V. Set, Infusion “Y”,
x) Covers - PVC - Mattress/Bed Wedge Luer lock, air inlet
y) CVP – Cannulae yy) Intubation stylet, adult, 15 Ch
z) Drawsheet,plastic,90x180cm zz) IV Infusion set Buretrol
 Spinal disp, aaa) K.Y. Jelly
(0.9x90mm),sterile, 20G, bbb) IV stands
22G, 24G ccc) Drums
 Disp,15G, 18G, 21G, 22G, ddd) Latex Tubing
23G, 25G eee) Linen Savers
 Butterfly 23G fff) Nail Brushes -
aa) Oxygen T Pieces Autoclavable/Disposable
bb) Oxygen Tubing ggg) Tape:
cc) Face Masks  Elastic Adhesive
dd) Razor Medical - Disposable - Single Plaster - White 5cm
Edge and 10 cm
ee) Safety Pins Large & Medium  Micropore tape
ff) Sharps Containers (Safety Box/used  Orthopedic surgical
syringes and needles)

45
 gg) Shrouds Adhesive Hypo-
hh) Soap,toilet,bar,approx.110g,wrapped Allergenic
ii) Spigots Large, Medium and Small  Adhesive, zinc oxide,
jj) Spray Bottles - Plunger Operated perforated,10cmx5m
kk) Orthopedic surgical Splints
ll) Syringes:  Adhesive, zinc oxide,
2.5cmx5m
 Volume: 2ml, 5ml, 10ml,
hhh) Tubes:
20ml
 Endo-tracheal, disp. +
 Syringes 50 ml Conical Tip
connector, neonate
mm) Needles:
mm, w.o balloon
 Syringes 50 ml Luer Lock
 Endo-tracheal, disp. +
 Syringes Insulin
nn) Tourniquet, latex rubber,75cm
connector, balloon,
oo) Tourniquet, pneumatic 6.5mm, 7mm, 7.5mm,
8mm
 Suction,
L125cm,ster,disp,
CH10, CH12, CH16
40. Operating Suite Renewable/Consumables
a) Airway Guedel, pediatric & adult Urine jj) Plastic, reusable aprons Major
bags, collecting, 2000 ml  Compress,
b) 012 Band, Esmarch, 6 cm x 5 m gauze,10x10cm,n/
c) Survival blanket, 220x140cm ster/PAC-100
d) Blood Sampling:
 Compress,
 Needle, disposable, sterile, 20G, 21G gauze,10x10cm,st
 Tube, Vacuum 5ml (Vacutainer) er/PAC-5
 Tube, Vacuum EDTA 5ml  Compress,
(Vacutainer) paraffin,10x10cm,
 Tube, Vacuum Heparinised 5ml ster/BOX-10
(Vacutainer) kk) Connector, biconical,
 Vacutainer holder OD 7-11-7mm
 Vacutainer needles, 18-24G ll) Cotton
e) Bouffant Nurse Cap wool,500g,roll,non-ster
f) Cannula, IV short, ster, disp, 18G, 20G, mm) Gauze:

46
 22G, 24G  Ball, Large
g) Catheters: (sterile)
 Sup-Pubic, CH 10, 1.65 cm, ster,  Ball, Large (un-
disp adult with trocar sterile)
 Urethral, CH6, ster, disp  Ball, Peanut
 Urethral, CH7, ster, disp (sterile)
 Foley, ster, disp, CH10, CH12,  Swabs
CH14 RAYTEX® 10 X
h) Compresses: 10 cm
 Abdominal compress, 40 x 40 cm  Swabs, Un-sterile
i) Compress, Swab, 20x 20 cmsize (Green)
 Vaseline gauze  Roll,90cmx100m,
j) Gloves,exam,latex,disp, large, medium & non-ster
small
k) Gloves,surg,disp, 6.0, 6.5, 7.0, 7.5, 8, 8.5  Abs,DEC1,need
l) Gum elastic bougie, CH 15, 60 cm 1/2,18mm,round/B
m) Intubation stylet, adult, 15 Ch OX-36
n) Mask, Clinical, Disposable (non-woven)  Abs,DEC2,need
o) Mask, Protection, High Filtration 3/8 18mm,round/
p) Needle, spinal, 0.9x90mm),ster,disp, 20G,  Abs,DEC2,need
22G, 24G 3/8,26mm,tri
q) Oxygen mask, adult
 Abs,DEC3,need
r) Oxygen, nasal cannula
s) Reusable, Diathermy, Cable
1/2 30mm,round
t) Safety box for .used syrgs/ndls  Abs,DEC3,need
u) Set, Infusion “Y”, Luer lock, air inlet 3/8 50mm,round
v) Scalpel blade,ster,disp,no.10, no. 11, no.  Abs,DEC3,spool
15, no. 22, no. 23  Abs,DEC4,need
w) Shoe cover, disposable 3/8 36mm,tri
x) Silicone Rubber Tubing  Nonabs,
y) Orthopedic surgeon's Cap, Easy-Tie
DEC2,need 3/8
z) Suturing materials:
13mm,tri
 Endo-tracheal, disp. + connector, 3.5
 Nonabs,
mm, w/o balloon
DEC3,need 3/8
 Endo-tracheal, disp. + connector, 4

47
 mm, w/o balloon 30mm,tri
 Endo-tracheal, disp. + connector, 4.5  Wires, different
mm, w/o balloon size/thickness
 Endo-tracheal, disp. + connector, 5  Plates and screws,
mm, balloon different size and
 Endo-tracheal, disp. + connector, 5.5 shape
mm, balloon  Implants, different
 Endo-tracheal, disp. + connector, 6 types and size
mm, balloon nn) Tubes:
aa) Drain, wound, CH 12, ster, disp, CH12,  Endo-tracheal,
CH16, CH6 disp. + connector,
bb) Drawsheet,plastic,90x180cm 3 mm, w/o balloon
cc) Elastoplasts, 10 cm x 3 m  Endo-tracheal,
dd) Tape,adhesive,Z.O,perforated,10cmx5m disp. + connector,
ee) Tape,adhesive,Z.O.,2.5cmx5m
6.5 mm, balloon
ff) Electrode, Chest, Monitor
gg) Diathermy pencil/ball/blade  Endo-tracheal,
hh) Disposable, dispersive, disp. + connector,
electrode(Diathermy pad) 7 mm, balloon
ii) Drain, corrugated sheet, 3 cm x 25 cm  Endo-tracheal,
disp. + connector,
7.5 mm, balloon
 Endo-tracheal,
disp. + connector,
8 mm, balloon
 suction,CH08,L50
cm,ster,disp,
CH08, CH10,
CH14, CH16
 N.G Tubes 12, 14,
16
42. Operating Room Linen
a) Apron Orthopedic surgical, rubber i) Masks, orthopedic Major
b) Trousers, Orthopedic surgical, woven, surgical, woven

48
 Small, Medium & Large j) Drape:
c) Top(shirts), Orthopedic surgical, woven,  Orthopedic
Small, Medium & Large surgical, woven(1
d) Gown, Orthopedic surgical, woven(Plain) x 1 m)
e) Cap, Orthopedic surgical, woven
 Orthopedic
 Orthopedic surgical, woven(45 cm surgical, woven(1
x 70 cm)(fenestrated) x 1.5 m)
 Orthopedic surgical woven (2 x 1.5  Orthopedic
m) surgical,
f) Pillow case
woven(1.5 x 1.5
g) Pillows
h) Sheet, Bed m)(fenestrated
k) Sheet, draw, white
l) Cellular Blanket
m) Mayo cover
n) Towel Bath
o) Towel Hand
44. Equipment  recovery area Critical
a) Vacuum aspirator j) IV stands
b) Oxygen Flow meter, 0 - 15 l/min k) Bed screen, 3 sections,
c) Oxygen (one cylinder per bed) mobile
d) Oxygen concentrater l) Pedal bin
e) Patient transfer, (stretchers) m) Oxygen trolley,
f) Dressing trolley, trays complete
g) Bed with mattress n) Pulse oximeter
h) Stools o) Resuscitator, hand
i) Dual head stethoscope operated
p) Suction machines
q) Mobile examination
light
46. Equipment-Central sterilization room
a) Auto claves ;big
b) Autoclaves ;small
c) Drums, metallic shelves, cabinets, tables and chairs

Gynecology and Obstetrics Care Service Score point

49
S.N Level of Compliance Standard to be addressed Remark
Met Partially Un Practice
met met
1. The gynecological and obstetrics services shall have written protocols and Minor
procedures including
a) Antenatal care g) Manual removal of the placenta
b) Follow up of labour h) Assisted delivery
c) New born care i) Infertility
d) Postnatal care j) Admission and discharge
e) Immunization k) Transfer and referal
f) Administration of antibiotics, l) Infection prevention
oxytocics and anticonvulsant m) Pre and post operative care
3. Normal delivery and comprehensive emergency obstetric care shall be Critical
available 24 hours a day, 365 days a year
4. Essential newborn care and newborn resuscitation care shall be available 24 Critical
hours a day and 365 days a year
5. Routine examination for detection of congenital hip dysplasia and other Critical
congenital anomalies shall be done
6. Emergency gynaecological services shall be available 24 hours a day, 365 Critical
days a year
7. Non emergency maternal health services shall be available during regular Critical
working hours
8. Gynaecology and obstetrics records shall be kept for each patient and the Major
patient’s record shall be integrated with the patient's over-all hospital record
9. The nursing care of patients undergoing gynaecologic/obstetrics surgery shall Major
be planned and documented in the medical record, directed by a trained nurse,
and includes the following:
a) Pre-operative care, 
b) Location of post-operative care,
c) Type of post-operative care and monitoring needed,
d) Pain management, and
e) Patient’s understanding of discharge instructions
Met Partially Un Premises
met met
10. The gynaecology and obstetrics services shall have inpatient, outpatient, Critical
maternity and surgical facilities

50
11. The maternity unit shall have the following facilities: Major
a) Maternity Ward:
 Facilities shall be provided for antenatal and postnatal care
 Curtain tracks shall be installed around each bed, or in their absence bed
screens shall be provided.
 Sinks shall be provided in each patient bay or room. Patient toilets and
showers
 A nurses’ station shall be available
b) Maternity Ward clean utility room
c) Maternity Ward clean linen room with cabinets and shelves
d) Maternity Ward inpatient store
e) Maternity Ward soiled utility room: This is used for:
f) Maternity Ward cleaner’s room
g) Maternity Ward kitchen: It requires stainless steel sink, drainer and
cabinets
h) Staff toilet, shower and changing facilities with lockers
i) Nursery: It requires:
 The nursery unit shall have a room for milk preparation
 The nursery shall have a single entrance to control access.
 Work surface for washing, drying and changing babies
 Sink, cabinets and shelves
j) Baby isolation room: It requires:
 This room shall be located close to the nurses’ station.
 A clinical basin and separate bathing facility are required.
 There shall be a work surface for basic hygiene and nappy changing.
 An extraction ventilation system with air conditioning control to
maintain and regulate room temperature shall be available, or the room
shall be designed to avoid air-borne cross infections
k) Delivery Suite shall have the following
 Labour Bay (6 beds)
 Sink, cabinets and toilet facilities;
 Delivery Room (s) (two beds): Obstetrics operation theatre;
 Delivery room store:
12. The hospital shall preferably have a separate operating theatre for Major

51
 gynaecological cases. it shall comply with the following requirements
a) Reception/Nurse station:
b) Entrance/Patient transfer area
c) Changing room
 Suitable separate changing room facilities shall be provided for male
and female staff.
 The changing room shall have one door that opens into the restricted
access area, and must have a separate entrance from outside the
restricted access area.
 Storage facilities for the personnel’s personal clothing and effects.
 Storage of clean theatre attire and inside shoes and operation theatre
gum boots.
 Provision must also be made for soiled theatre apparel.
 Wash hand basins: Toilets, showers, shelves, lockers
d) Operating theatre shall have the following:
 Patient entrance into theatre and exit out of theatre shall be through
double self-closing doors situated in the centre of the operating room
entrance.
 General anaesthesia administration could be given in an anaesthetic
room and patient then transferred to the operating room. Alternatively,
the patient can be induced and anaesthesia will be maintained in the
operating room.
 Cabinets and shelves
 Scrub area
 Operating theatre equipment and sterile supply store with shelves and
cabinets
 Operating theatre sterile supply store with shelives
 Clean Utility, Surgical Suite:with sinks,cabinets and shelves shall be
available
 3-Bed Recovery room
 Soiled Utility/Sluice room
 Cleaner’s Room.
Met Partially Un Professionals
met met

52
13. The gynaecology and obstetrics services shall be directed by a licensed Critical
obstetrician and gynaecologist with a minimum of two years work experience
14. A physician or licensed independent practitioner shall be available (physically Critical
present) at all times in the gynecology and obstetrics unit
15. The nursing care in obstetric shall be administered by a licensed professional Critical
nurse with at least two years of work experience in gynecology and obstetrics
services
Met Partially Un Products
met met
16. Equipment – Clean Utility Room Major
a) Trolley for vital sign monitoring with thermometer and
sphygmomanometer
b) Dressing trolley (s)
c) Refrigerator for medication with temperature control
d) IV stand
e) Wheelchair
17. Equipment - Clean linen room Minor
a) Trolley to be used for bed linen changes during patient hygiene
b) Cabinet (s)
18. Equipment – maternity ward: Major
a) Bed and mattress e) Baby cot
b) Vacuum aspirator, 0 – f) Bed side cabinet
250mm/Hg with bottle and g) Over bed table
tubing h) Bed screen, 3 sections
c) Oxygen flow meter, 0-15 i) Footstool
L/min j) IV stands
d) Oxygen source k) Wheelchairs
20. Equipment – Nurses station Minor
a) Crash cart, with sufficient equipment and medicines for the resuscitation
of mother and neonate, including defibrillator, intubation sets and oxygen
b) Diagnostic set with ophthalmoscope and Otoscope
c) Adult sphygmomanometer
d) Paediatric sphygmomanometer
e) Stethoscope, foetal
f) Stethoscope, dual head
g) Stethoscope, paediatric head

53
 h) Thermometer
21. Equipment – maternity ward store: Major
a) Patient transfer, roller h) Suction pump, portable
system i) Bed pan
b) General purpose trolley, j) Kidney basin, 475 ml
two trays, stainless steel k) Wheelchair
c) Patient chart holder l) General surgical dressing set
d) Bed screen, three sections m) Tendon hammer
e) IV stand n) Mobile examination light
f) Mobile bedpan trolley o) Adult weight scales
g) Oxygen trolley, complete
23. Equipment – maternity ward soiled utility room: Major
a) Soiled linen trolley e) General purpose trolley, two trays
b) Bin with lid f) Mobile trolley and bedpans
c) Worktable with laminated g) Bedpan
top h) Kidney basin, 475 ml
d) Wash tub (65L)
25. Equipment – maternity ward cleaner’s room: Minor
a) Cleaning trolley e) Pail with handle
b) Mop rack f) Broom
c) Worktable g) Mop
d) Cabinets and shelves
27. Equipment – maternity ward kitchen: Minor
a) Pedal bin
b) Worktable with laminated top
c) Stove or kettle to prepare beverages for patients
28. Equipment – milk formula room: Major
a) Worktable with laminated e) Stove or kettle to heat water for
top warming feeds
b) Refrigerator f) Baby bottles, teats and bottle brushes
c) Kitchen scale g) Pedal bin
d) Sterilizing equipment or h) Stool
solutions
30. Equipment – nursery Major
a) Vacuum aspirator, 0 - 250 h) Infusion pump, drop controlled
mm/Hg, w bottle and tubing i) Pedal bin

54
 b) Flow meter, 0 - 15 l/min j) Baby warmer or overhead heater
c) Oxygen source k) Incubator, automatic
d) Baby cot l) Breast pump
e) Chair m) Neonatal resuscitation kit
f) Stool n) Infant scale
g) IV stand
32. Equipment – baby isolation room Major
a) Vacuum aspirator, 0- g) Patient monitor
250mmHg, with bottle and h) Baby bassinet with mattress
tubing i) Waste container, with lid
b) Oxygen j) Bedside cabinet
c) Flow meter, 0 - 15 l/min k) Baby dressing table, with padded
d) Oxygen hood top
e) Oxygen saturation monitor l) Pedal bin
f) Baby warmer or overhead m) Chairs
heater
34. Equipment – labour bay: Major
a) CTG monitor on trolley f) Worktable with laminated top
b) Foetal Doppler g) Bed
c) Vacuum aspirator, 0- h) Bedside cabinet
250mm/Hg with bottle and i) IV stand
tubing j) Bed screen, three sections
d) Flow meter, 0-15l/min k) Waste paper basket
e) Oxygen source l) Stethoscope, dual head
Wall clock
36. Equipment – delivery room store: Major
a) Patient transfer, roller system e) Vacuum extractor, Bird, manual,
b) Patient stretcher complete set
c) IV stand f) Newborn circumcision set
d) Portable suction pump g) Delivery set
h) Obstetric forceps
38. Equipment –delivery room (s) Major
a) Vacuum aspirator, 0 - 250 j) Kick bucket, stainless steel
mm/Hg, w bottle and tubing k) Bowl and stand
b) Trolley, oxygen, complete l) Instrument table, Mayo type, mobile
c) Flow meter, 0 - 15 l/min m) Infusion pump, volumetric

55
 d) Wall clock n) Newborn care table
e) Dressing trolley, two trays o) Operating light, ceiling mounted or
f) Soiled line trolley, 2 rings mobile
g) Baby cot p) Neonatal resuscitation kit
h) Delivery bed q) CTC monitor on trolley
i) IV stand r) Foetal Doppler
40. Equipment – soiled utility room, delivery suite: Minor
a) Soiled linen trolley e) General purpose trolley, two trays
b) Bin with lid f) Mobile trolley and bedpans
c) Worktable with laminated g) Bedpan
top h) Kidney basin, 475 ml
d) Wash tub (65L)
42. Equipment – reception/nurse station, operating theatre suite Major
a) Wall clock d) Chair, stackable, without armrests
b) Desk e) Basket, waste-paper, metal
c) Desk chair f) Cabinet
44. Equipment – entrance, patient transfer area, operating theatre suite: Major
a) Patient transfer, roller system
b) Patient stretcher
45. Equipment –staff changing room, operating theatre suite: Major
a) Soiled linen trolley
b) Waste basket
46. Equipment, one operating theatre Critical
a) Elapsed time clock l) Swab count record board
b) Anaesthesia trolley and m) Bowl and stand
Oxygen cylinders n) Instrument table, Mayo type
c) Worktable with laminated o) Framed board with pencil tray
top p) Infusion pump and Suction pump
d) Stool q) Blanket, warming
e) IV stand r) Anaesthesia machine with ventilator,
f) Kick bucket vaporizers, and gas cylinders
g) Swab rack with drip tray s) Laryngoscope set
h) Tourniquet and Tongue t) Magill forceps (adult)
depressor u) Laryngeal mask set and Mask holder
i) Coagulation unit, electro, v) Mouth gauge
mobile, 200 W w) Patient monitor

56
 j) Light, operating, large x) Dual head stethoscope
copula, ceiling mounted y) IV fluid pressure bag
k) Three operating tables,
48. Equipment – scrub area Major
a) Soap dispenser
b) Scrub-up brushes
49. Equipment: set up area Major
a) Worktable with laminated d) Instrument table, Mayo type
top e) Blood warmer
b) Cabinets and shelves f) IV fluid warmer
c) Dressing trolley
51. Equipment – operating theatre store Major
a) Patient transfer, roller system g) Positioner, bag, patient, small
b) General purpose trolley h) Positioner, bag, patient, medium
c) IV stand i) Positioner, bag, patient, large
d) Hygrometer, humidity and j) Apron, protective, small
temperature k) Apron, protective, medium
e) Newborn general care table l) Apron, protective, large
f) Pillow, abduction m) Support, head, operating table
53. Equipment – operating theatre sterile supply store: Major
a) General purpose trolley, 2 l) Gyn/Obs- Cranioplasty/craniotomy
trays set
b) Gen.surg-Suture set m) Gyn/Obs- Dilation & curettage
c) Gen.surg- Abdominal set (D&C) set
d) Gen.surg- Basic surgery set n) Gyn/Obs- Manual vacuum aspiration
e) Gen.surg- Laparotomy set set
f) Gen.surg- Small dissection set o) Gyn/Obs- Obstetric forceps
g) Gen.surg- Minor surgical set p) Gyn/Obs- Caesarean section set
h) Gen.surg- Suprapubic q) Gyn/Obs- Abdominal hysterectomy
puncture set set
i) Gen.surg- Circumcision set, r) Gyn/Obs- Vaginal hysterectomy set,
newborns extras
j) Gyn/Obs-IUD set s) Gyn/Obs- Gynaecology examination
k) Gyn/Obs- Cervical biopsy set set (EUA)
55. Equipment – clean utility room, surgical suite: Major
a) General purpose trolley, two trays

57
 b) Worktable, laminated top
c) Refrigerator, 140 l + 20 l
d) Steam sterilizer
56. Equipment recovery area: Major
a) Vacuum aspirator g) Bed screen, 3 sections, mobile
b) Oxygen Flow meter, 0 - 15 h) Pedal bin
l/min i) Oxygen trolle, complete
c) Oxygen (one cylinder per j) Ventilator
bed) k) Resuscitator, hand operated
d) Patient transfer, roller system l) Mobile examination light
e) Dressing trolley, two trays m) Dual head stethoscope
f) Bed with mattress
58. Equipment – operating theatre sluice room Major
a) Soiled linen trolley e) Wash tub, 65 L
b) General purpose trolley, two f) Mobile bedpan trolley
trays g) Bedpan
c) Bin with lid h) Kidney basin, 475 ml
d) Worktable with laminated top
60. Equipment – cleaners’ room, operating theatre Major
a) Cleaning trolley d) Pail with handle
b) Mop rack e) Broom
c) Worktable f) Mop
62. Renewable/Consumables for maternity unit Major
 Guedel airways: size 0, 00,  Bottles - Suction - Glass/Plastic
3, 4 & 5  Braun Splints (Arm)
 Alcohol Swabs  Bubble tubing box
 Disposable aprons  Cannula - Nasal-Oxygen
 Aqua-packs Oxygen  Cannula, IV short, ster, disp,
humidifier 18G, 20 G, 22 G, 24 G
 Bag urine baby  Caps - Mop/Bonnet Type
 Bags - Refuse - All Colours  Catheter - Jacques
and Sizes  Central Venous Pressure Sets
 Bags – Urine  Chest, Electrode, Monitor
 Bandage - Crepe  Cleansing Swabs – Sterile

58
 Batteries - Medical &  Cleansing Swabs Non-Sterile
General  Cold/Hot Packs
 Bedpan Covers  Combur Tests
 Blood Administration Sets  Connectors:
 Blood Sampling Needles,  BiconicalAutoclavable
disposable, sterile, 20 G, 21  Connector, T/Y
G, 23 G  Connectors - Plastic – Tapered
 Blood Sampling Tubes:  Container, Sample, urine, plastic,
 Vacuum 5ml (Vacutainer) non-sterile, 60 ml
 Vacuum EDTA 5ml  Cotton:
(Vacutainer)  Buds
 Vacuum Heparinised 5ml  Wool Balls - Sterile/Non-Sterile
(Vacutainer)  Wool Rolls
 Blood Sampling Vacutainer  Covers - PVC - Mattress/Bed
Holder Wedge
 Hand wash Antiseptic  CVP – Cannulae
Liquid (Hibiscrub)  Cytological Fixative Spray
 Hand wash Povidone  Drawsheet,plastic,90x180cm
(Betadine)  Face Mask Water Repellent
 Hot Packs  Foley Catheters – Latex/Silicone
 I.V set: Size 10, 12 and 14
o Administration Sets – 15  Gauze Absorbent Ribbon
Drop  Gloves:
o Administration Sets - 60 o Household Large & Medium
Drop o Surgical Size 6, 6 ½, 7, 7 ½, 8
o Set, Infusion “Y”, Luer
o Exam, latex, disp, large,
lock, air inlet
medium, small
o Infusion set Buretrol
 Nail Brushes -
 Incontinence Sheets Autoclavable/Disposable
 Intubation stylet, adult, 15  Needles:
Ch o Spinal disp,
 K.Y. Jelly (0.9x90mm),sterile, 20G, 22G,

59
 Latex Tubing 24G
 Linen Savers o Disp,15G, 18G, 21G, 22G,
 Masks - Nebulizer/Oxygen 23G, 25G
 Masks – Oxygen 40 % o Butterfly 23G
 N.G Tubes 12, 14, 16  Oxygen T Pieces and Oxygen
 Spatulas - Tongue Tubing
 Spigots Large, Medium and  Pads - Sanitary - Maternity
Small  Paper CTG
 Spray Bottles - Plunger  Face Masks
Operated  Razor Medical - Disposable -
 Surgical Spirits Single Edge
 Suture absorbable  Rubber Bath Mat - Non-Slip
(Chromic) for episiotomy  S.G. Meter (Urine Meters)
and perinea tears  Safety Pins Large & Medium
 Syringes:  Sharps Containers (Safety
o 2ml, 5ml, 10ml, 20ml Box/used syringes and needles)
o Syringes 50 ml Conical  Shrouds
Tip  Soap,toilet,bar,approx.110g,wrap
o Syringes 50 ml Luer ped
Lock  Tapes
o Syringes Insulin o Elastic Adhesive Plaster -
 Umbilical clamp White 5cm and 10 cm
 Umbilical cord tape o Micropore tape
 Fridge thermometer o Tape Surgical Adhesive Hypo-
 Clinical thermometer Allergenic
 Tourniquet, latex o Tape,adhesive,Z.O,perforated,
rubber,75cm 10cmx5m
 Tube: o Tape,adhesive,Z.O.,2.5cmx5m
o Endo-tracheal, disp. +
connector, neonate mm,
w.o balloon
o Endo-tracheal, disp. +

60
 connector, balloon,
6.5mm, 7mm, 7.5mm,
8mm
o Suction,
L125cm,ster,disp, CH10,
CH12, CH16
64. Operating Suite Renewable/Consumables Major
 Airway Guedel, 00 (neonatal),  Catheters:
3, 4 & 5 o 036 Catheter Sup-Pubic, CH
 Plastic, reusable aprons 10, 1.65 cm, ster,disp., adult
 Urine bags, collecting, 2000 o 037 Catheter, ureteral, CH5,
ml ster, disp
 012 Band, Esmarch, 6 cm x 5 o 038 Catheter, urethral, CH6,
m
ster, disp
 Survival blanketl,220x140cm
o 039 Catheter, urethral, CH7,
 First Referral Hospitals
 Blood Sampling: ster, disp
 Needle, disposable, sterile, o Catheter, Foley, ster, disp,
20G, 21G CH10, CH12, CH14
 Tube, Vacuum 5ml  Compresses:
(Vacutainer) o Abdominal compress, 40 x 40
 Tube, Vacuum EDTA 5ml cm
(Vacutainer) o Compress, Swab, 20x 20 cm
 Tube, Vacuum Heparinised o Compress,gauze,10x10cm,n/
5ml (Vacutainer) ster/PAC-100
 Vacutainer Holder o Compress,gauze,10x10cm,ste
 Bouffant Nurse Cap
r/PAC-5
 Bubble Tubing
o Compress,paraffin,10x10cm,s
 Cannula,IVshort,ster,disp,
18G, 20G, 22G, 24G ter/BOX-10
 File for ampoules  Connector, biconical, OD 7-11-7mm
 Gauze:  Cotton wool,500g,roll,non-ster
o Gauze Ball, Large  CVP - Set
 Diathermy pencil/ball/blade
(sterile)
 Disposable, dispersive,

61
 o Gauze Ball, Large (un- electrode(Diathermy pad)
sterile)  Drain, corrugated sheet, 3 cm x 25
o Gauze Ball, Peanut cm
(sterile)  Drain, wound, CH 12, ster, disp, 450
ml (Redon + Needle), CH12, CH16,
o Gauze Swabs
CH6
RAYTEX® 10 X 10  Drawsheet,plastic,90x180cm
cm  Elastoplasts, 10 cm x 3 m
o Gauze Swabs, Un-  Electrode, Chest, Monitor
sterile (Green)  Extractor,mucus,20ml,ster,disp
o Gauze,roll,90cmx100m,  Gum elastic bougie, CH 15, 60 cm
non-ster  I.U.D., copper, T
 Gloves:  Intubation stylet, adult, 15 Ch
o Gloves, exam, latex,  Lancet,blood,ster,disp/PAC-200
disp, large, medium &  Mask, Clinical, Disposable (non-
small woven)
o Gloves, gynaeco, ster,  Mask, Protection, High Filtration
disp, 6.5, 7,5 & 8.5  Needle,spinal, 0.9x90mm),ster,disp,
o Gloves, surg, disp, 6.0, 20G, 22G, 24G
6.5, 7.0, 7.5, 8, 8.5  Obstetrical Pads
 Syringe, dispos, 2ml, 5ml,  Opsite Flexi-grid (Various Sizes)
10ml, 20ml  Oxygen mask, adult
 Tape,adhesive,Z.O,perforated,  Oxygen, nasal cannula
10cmx5m  Reusable, Diathermy, Cable
 Tape,adhesive,Z.O.,2.5cmx5  Safety box for .used syrgs/ndls
m 5lt/BOX-25
 Telfa, dressing (Various  Set, Infusion “Y”, Luer lock, air
Sizes) inlet
 Tourniquet,latex rubber,75cm  Scalpel blades:
 Tubes different type and size o Scalpel blade,ster,disp,no.10,
 Umbilical Cord Clamp no. 11, no. 15, no. 22, no. 23
 Operating Room Linen: o Scalpel blade,ster,disp,no.11
 Apron Surgical, rubber  Shoe cover, disposable
 Trousers, Surgical, woven,  Silicone Rubber Tubing

62
 Small, Medium & Large  Surgeon's Cap, Easy-Tie
 Top, Surgical, woven, Small,  Sut, abs, non-absorbable, various
Medium & Large  Bed
 Gown, Surgical, woven(Plain)  Sheet, draw, white
 Cap, Surgical, woven  Cellular Blanket (Recovery and
 Drapes: outside blankets)
o Drape, Surgical,  Mayo cover
woven(1 X 1 m)  Towel Bath
o Drape, Surgical,  Towel Hand
woven(1 X 1,5 m)
o Drape, Surgical,
woven(1.5 x 1,5 m)
(fenestrated
o Drape, Surgical,
woven(45 cm X 70 cm)
(fenestrated)

Anesthesia Services Score point

S.N Levelof Compliance Standard to be addressed Remark
Met Partially Un Practice
met met
1. The general anesthesia service shall be provided only in the operation theatre Critical
(OR) facility
2. There shall be a written policy about administration and monitoring of Minor
regional and general anesthesia in the hospital
3. The hospital shall have written policy to administer and monitor minor Minor
regional blocks
4. Anesthesia services shall be administered in accordance with written policies Minor
and procedures
5. The conduct of the anesthesia and operation is monitored and recorded in line Major

63
 with the monitoring standards and formats, to a minimum these shall contain:
a) A continuous display of the ECG,
b) Continuous pulse oximeter,
c) The inspired oxygen concentration; and
d) A written record of the anesthetic shall be kept as a permanent record in
the case notes
6. The policies and procedures used for anesthesia service shall be available and Minor
well understood by the surgical team
7. There shall be a written protocol to assure that surgery does not proceed when Minor
there are disabled alarms, depleted batteries and inactive sensors in oxygen
monitors or carbon dioxide monitors, improperly positioned breathing-circuit
sensors, or other insufficiencies
Met Partially Un Premises
met met
8. Operation theatre: in addition to the standards prescribed under the Surgical Critical
service:
(a) There shall be a mechanism for taking exhaust air from anesthesia
machine to outside of OR; important when performing open system for
pediatricanesthesia,
(b) There shall be central oxygen system or a system where there is
continuous supply of Oxygen cylinders
9. Anesthesia store: in addition to the standards prescribed under the Surgical Major
service
a) Shall be well ventilated and illuminated room with shelves and cabinets,
b) The anesthetic shall be kept on shelves and/ or cabinets, separate from
medicines,
c) There shall be at least 4 electric plugs in the room,
d) Anestheticequipments shall be stored clean and being ready for use,
e) Ambu bags and resuscitation kits shall be kept labeled in easily reachable
place,
f) There shall be separate place for keeping new and rechargeable Batteries
and dry cells. Used batteries and cells shall be stored and discarded
properly
10. Staff office room with chairs, table, cabinet; in addition to the standards Minor
prescribed under the Surgical service
11. Recovery Room: in addition to the standards prescribed under the Surgical

64
 service and shall be sited within the operating suit and has a minimum of:
 Two beds with side protection,
 Monitoring equipment, including ECG;
 Resuscitation equipment including a defibrillator on trolley,
 Oxygen source,
 Ensures ease of communication and access for anesthesia department
staff for close follow up
Met Partially Un Professional
met met
12. Anesthesia service shall be directed by a licensed anesthesiologist Critical
13. a) General or major regional anesthesia shall be administered and monitored Critical
only by the following:
b) An anesthesiologist;
c) BSc in anesthesiology;
d) nurse anesthetist; or
e) A physician resident (anesthesiology), a student nurse anesthetist, a
student anesthetist under the supervision of a licensed anesthesiologist,
BSc in anesthesiology and/or nurse anesthetist
14. The supervision of general or major regional anesthesia shall be provided by Critical
anesthesiologist who is immediately available
Minor regional blocks shall be administered by the following licensed Critical
professionals:
a) An Anesthesiologist, or
b) An anesthetist,
c) A physician, podiatrist (foot doctor) or dentist;
d) A medical intern, physician resident, dental resident, or a student nurse
anesthetist, or student anesthetist, licensed health officer, a licensed nurse
midwife or clinical nurse under the supervision of a physician
Met Partially Un Product
met met
15. Anaesthesia supplies and equipment and safety systems shall include the Major
following:
a) Diameter index safety systems or equivalent
b) Pin index safety systems with a single washer
c) All medical gas hoses and adapters shall be colour-coded and labeled
d) An oxygen failure-protection device ("fail-safe" system)

65
 e) Vaporizer exclusion ("interlock") system
f) To prevent delivery of excess anaesthesia during an oxygen flush, no
vaporizer shall be placed in the circuit downstream of the oxygen flush
valve.
g) All anaesthesia vaporizers shall be pressure-compensated in order to
administer a constant non-pulsatile output.
h) Accurate flow meters and controllers
i) Alarm systems shall be in place for high (disconnect), low (sub
atmospheric), and minimum ventilatory pressures in the breathing circuit
for each patient under general anaesthesia
16. Anaesthesia supplies and equipment and patient monitoring shall include: Critical
a) An in-circuit oxygen analyzer
b) A respirometer (volumeter) measuring exhaled tidal volume
c) The capacity for invasive monitoring of arterial pressure
d) A difficult airway container or trolley . The following items are required
for inclusion in the difficult airway container or trolley:
 Resuscitation equipment
 Emergency medicines,
 Laryngeal mask airway, and/or other items of similar technical
capability.
e) A precordial stethoscope or oesophageal stethoscope
f) A peripheral nerve stimulator
g) Supplemental oxygen
17. Equipments: Major
a) Anesthesia machine with v) Patient monitor
ventilator, 2 vaporizers, and  ECG monitor
gas cylinders  12 leads Electrode, Monitor
b) Adult and
 Pulse oximeter
pediatricanesthesia circuits
with filters  Temperature monitor
c) Mechanical ventilators  Nerve stimulator
d) Oxygen cylinders, oxygen  Dual head stethoscope
trolley and oxygen regulator  BP apparatus with different size
e) Worktable with laminated cuffs
top w) Intubation gadgets:
f) Resuscitation equipments;

66
 Ambu bag, adult pediatric  Airway Guedel, pediatric& adult
neonates, with inflatable size: 0, 00, 3, 4 & 5
bag,  Laryngeal mask set
g) Refrigerator, 
 Mask holder
h) Time clock
i) Stools  Cannula - Nasal-Oxygen,
j) Clips  Face mask- Oxygen,
k) Bathroom Weight scale;  Masks – Oxygen 40 %
adult &pediatric  Laryngoscope sets with different
l) Resuscitation trolley size blades (Mackintosh)
m) Syringe pump  Magill forceps (adult &pediatrics)
n) Defibrillator
 Intubation stylet, adult, 15 Ch,/
o) Blood gas analyzer
Endo-tracheal tube guide
(optional)
p) Dust bin  Mouth gauge
q) Blankets, warming  Tube, Endo-tracheal, different size
r) Framed boards with pencil with connectors:
trays  Tube, Trachea, balloon, different
s) IV stands, infusion pumps, size
IV fluid pressure bags, blood  Tube,
warmer and IV fluid warmer Suction,CH08,L50cm,ster,disp,
t) Tourniquets, tongue CH08, CH10, CH14, CH16
depressors, disposable  Extractor, mucus,20ml,ster,disp
u) Operation table and  Safety Pins Large & Medium
accessories:
 Connector, Biconical, Autoclavable
 Pillows, abduction
 Connector, T/Y
 Support, head, operating
table  Connectors - Plastic – Tapered
 Positioner bag, small,  Masks - Nebulizer/Oxygen
medium, large   Other accessories/ supplies:
 Adjustable Head screen  Braun Splints (Arm)
 Patient transferring  Draw sheet, plastic,90x180cm
Stretchers  Clinical thermometer
 Suction machines
 Fridge thermometer

67
  Tourniquet, latex
rubber,75cm
19. All anesthetic medicines and supplies shall be available as per the national Critical
medicine list of Ethiopia
20. Operating Room Linen Major
a) Apron Surgical, rubber g) Pillows
b) Trousers, Surgical, woven; h) Sheet, Bed
Small, Medium & Large i) Sheet, draw, white
c) Top(shirts), Surgical, woven; j) Cellular Blanket
Small, Medium & Large k) Organ protections,
d) Gown, Surgical, l) Shelves
woven(Plain) m) Cabinets
e) Caps, Surgical, woven n) Pillow case
f) Masks, surgical, woven

ICU Service Score point

S.N Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The hospital shall have at least one intensive care unit comprising of medical- Critical
surgical intensive care services
2. The ICU is open 24 hours and 7 days a week, with available medical Critical
personnel with CPR training available round the clock with shift
3. The ICU shall have written policies and procedures that are reviewed at least Minor
once every 5 years and implemented
4. A ratio of two patients to one nurse shall be available at a general ICU Critical
5. There shall be portable life-support equipment for use in patient transport, Critical
both within the hospital and for transfer
6. There shall be a policy or protocol available that state availability of 24 hours Minor
access for the services of advanced diagnostic facilities
7. There shall be a system in the hospital of assuring the functionality of the ICU Major
gadgets/ equipments and evidence with labelling of the service
Met Partially Un Premises
met met
8. The ICU shall be located in access restricted area of the hospital and well Critical

68
 identified
9. The ICU shall be at least 8m x 10m in size that accommodate a maximum of 4 Critical
electrically or manually operated ICU patient beds fitted with full range of
monitors and a screen.
a) The header of beds shall be 1 m away from the wall.
b) There shall be a 2m wide free traffic area by side of beds and between any
of two beds.
c) There shall be a nurse station within the ICU having a computer and a
computer point, telephone and telephone point, cabinets and shelves, and
lockers for controlled drugs.
d) There should be a separate physical area devoted to nursing management
for the care of the intermediate patient (32 sq m area including nurse
station).
10. Nurse station in the ICU: Critical
a) Isolated with glass, full visual access to monitor admitted patients on
monitors,
b) Equipped with chairs, working laminated top tables, drawers and
computers, Linen boards, shelves, lockers
c) Telemetry monitoring for critical or post operative patients with
transmitters
11. The ICU shall have easily accessible hand wash basin around the entrance- Critical
exit door
12. In addition to the main ICU for critical care, the unit shall have the following Major
spaces (rooms):
nurse room cleaner’s room
utility room staff tea room
store room toilets with shower
duty room spacious corridor for stretchers and wheelchairs
13. The ICU shall have at least 2 electric outlets per bed Critical
Met Partially Un Professional
met met
14. The hospital ICU shall be directed by a licensed anesthesiologist or intensivist Critical
or ICU trained internist who has clinical responsibility for the standard of care
rendered in each critical care unit or combination of critical care units
15. Each specialized ICU shall be lead by the sub-specialists Critical
16. The nursing staff of each unit within the ICU service shall have special Major

69
 training in critical care nursing and certified by the Authority
17. All practicing nurses in the ICU shall be trained and certified in basic cardiac Major
life support
18. At least the following professionals are required: Critical
a) One anesthesiologist or intensivist
b) At least one ICU trained nurse for two beds
c) Clinical nurse
d) Cleaners
e) Porters
Met Partially Un Products
met met
19. Medicines selected for ICU services by the hospital shall be available at all Critical
times
The hospital ICU shall have the following equipment, instruments and system:
a) The ICU beds shall have removable side protections; functional wheels;
shall be easily adjustable to multipurpose positions
b) Mechanical ventilator to assist breathing through an endotracheal tube
or a tracheotomy opening; at least 4; All ventilators shall be equipped
with an integral minimum ventilation pressure (disconnect) alarm.
c) Different size endotracheal tubes and tracheotomy sets, at least 4 sets,
d) monitoring equipment, equipment for the constant monitoring of bodily
functions;
e) cardiac monitors including telemetry,
f) Standard 12 lead EKG machines,
g) external pacemakers,
h) defibrillators; at least 2,
i) Reliable Oxygen delivery systems: Oxygen cylinder or oxygen
concentrator,
j) Oxygen regulator,
k) pulse oximeter,
l) end-tidal carbon dioxide monitoring,
m) Titrated therapeutic interventions with infusion pumps,
n) a web of intravenous lines for medicine infusions fluids or total
parenteral nutrition,
o) Suction pumps,
p) Infusion pumps,

70
 q) Laryngoscopes with different size blades,
r) Ophthalmoscope,
s) Mouth gags, different size
t) Air ways, different size
u) Resuscitation trolleys,
v) Exam coaches,
w) Syringe pump,
x) Endotracheal tubes ,(different sets)
y) Wheel chair,
z) Patient transport stretcher,
aa) Sphygmomanometer, with adult and pediatric cuffs,
bb) Stethoscopes: pediatric and adult,
cc) Electrical suction machine (at least 1 as a backup),
dd) Pedal suction machine,
ee) Acid base analyzer, minimum two ventilators and a mobile x-ray
ff) Nasal CPAP,
gg) Bed pan, plenty in number, different size,
hh) Pacing boxes (at least 2)
ii) X-ray viewer per bed, at least 4
jj) Wall clock (at least 2)
kk) Soiled cloth hampers,
ll) Telemetry monitoring with transmitters,
mm) Telephone end,
nn) Medication boards,
oo) Calculators,
pp) Weight scale,
qq) Ready to use CPR equipments and defibrillator on trolley,
rr) Patient labeling for diet, allergy, etc.,
ss) Patient screen per bed and
tt) IV stands, at least two per bed,

Dentistry Services Score point

S.N Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The dental service shall be available during working hours Critical

71
2. There shall be written protocols and procedures for the management of dental Minor
conditions as well as consultation, referral and transfer of inpatients
/outpatients to other services inside/outside the hospital
3. The dental unit shall be functional for dental emergency cases on on-call basis Major
after working hours
4. Emergency oral and maxillofacial surgery services shall be available 24 hours Critical
a day and 365 days a year
5. Non emergency oral and maxillofacial surgery services should be available Critical
during the regular working hours
6. Non emergency dental services shall be available during the regular working Critical
hours. This includes:
a) Restorative
b) Prosthetic
c) Endodontic therapy
d) Periodontal therapy
e) Exodontias
f) Oral Community (Oral Health Education)
7. Adequate dental records shall be kept for each patient and the patient’s dental Major
service record shall be integrated with the patient's over-all hospital record
8. Informed Consent (written/verbal) shall be complete for every dental Major
procedure in addition to minor & major surgeries
Met Partially Un Premises
met met
9. The dental service shall be located in the outpatient service of the hospital Minor
10. There shall be inpatient rooms for admission of surgical cases Major
11. There shall be a minimum of one room with two dental units or set ups Major
12. There shall be a reception area which will serve as oral health education Minor
13. There shall be X-Ray mounted dental unit with leaded door and lead apron Critical
14. The dental service shall have a dental laboratory room for orthodontics and Critical
prosthodontics
15. The premises for dental service shall have the following rooms: Major
a) Examination Room with dental units,
b) Room for dental laboratory,
c) Dental Sterilization area/ Store room /shelves
d) Staff Office

72
 e) Store
f) Room for mini pharmacy
g) Staff toilets, showers and changing room
h) Patient toilet and shower
i) Places for air compressor and equipment for evacuation,
j) Places for electric generator, back up
Met Partially Un Professional
met met
16. The dental service shall be directed by licensed Dental Specialist or dental Critical
surgeon
17. Dental surgeon/doctor or licensed independent practitioner shall be available Critical
(Physically present) at all times in the dental unit
18. A senior Dental Specialist shall be on duty or on call at all times Critical
19. Licensed dental professionals (BDSc, Dental Therapist, Dental Technician, Major
and Dental & Hygienist) shall be available at all times to assess, evaluate, and
follow the dental care provided
20. The Dental nurse with administrative responsibility for dental care shall be a Major
licensed dental professional with at least two years of experience in dentistry
Met Partially Un Products
met met
21. The dental services shall have the following equipment and instruments Major
a) The dental units
 Air-water syringes  Operating light
 Saliva ejector (oral evacuator  Abrasive stones and dics
system) (green, white)
 Cuspidor  Brushes (prophylaxix type)
 Rubber disc with abrasives
 Adjustable work surface
 Polishing pastes
 Individual hand-piece holder
 Sand paper disc
 Halogen cure light  Mortar and pestle
 Dental Chair  Kit for friction lock retention
 Operator’s stool pin
 Assistant stool  Spatula (various sizes and
 Matrix band (metallic & shapes metallic, plastic)
celluloid, different size for  Rubber bowl

73
 molar & bicuspid)  Sets of preformed temporary
 Aticulating paper stainless steel crown
 Wooden wedge  Sets or preformed anatomical
 Paper pad plastic crown of polycarbonate
resin
 Glass slab
 Finishing disc (various sizes
 Dental floss
and grits
 Dappen dishes
24. b) Instruments for examining Major
 Dental mirror  Spoon excavator (different size)
 Explorers (different types, no.  Periodontal pocket probe
521,22,17 & 23)
 Cotton pliers
26. c)Instruments for filling treatment Major
 Condenser (serrated & plain, Medium, and big size)
 Beaver tail
 Burnisher (ball type, football type, interproximal type)
 Carve (Hollenback, tanner, ward, discoid-cleoid)
 Trimmers
 Knife (interproximal, finishing gold foil)
 Amalgam carriers (doubled ended, guntype)
 Proximal trimmer
 Matrix retainer (different types tofflemire, ziqueland
27. d)Plastic Instruments for filling treatment Major
 Carriers for restorative materials
 Carvers
 Condenser Beaver tail
28. e)Materials & instruments to keep the area free from moistures & to Major
improve visibility
 Rubber dam equipment  Universal rubber-Dam clamps
 Clamps (different type, forceps
posterior & anterior,  Rubber- dam punch
mandibular &maxillar)  Holder young frame

74

30. f) Dental hand pieces
 Low speed hand pieces
 Straight hand pieces
 Contra angle hand pieces
 Automation
Major
 High speed hand pieces
 Polishing hand pieces unit
 Ultrasonic Scaler

32. g) Scissors: Major

 Hemostats (curved , straight ,mosquito, Kelly needle holder)
 Crow scissors
 Ligature scissors
 Surgical scissors
33. h) Instruments for root canal treatment Major
 Endodontic probe  Spreaders
 Straight and curved  Lebtykisourak
guttaperchapluggers  Millimeter ruler
 Broach (smooth and barber  Vitalometer (electrical pulp tester)
type)  Glass bead sterilizer
 Files ( Hedstrom files, K  Endodontic measureing Gauge
types files, Rat-Tail files
 Gates Glidden drills
 Disposable syringe
35. i) Materials for root canal treatment Major
 Paper points  Guttapercha points (From 1 to 6
 Endodontic kits and from 7 to 12

37. j) Rotating instruments & hand cutting instruments Major

 Burs (carbide, diamonds,  Flames burs (242-246)
plain steel, carborundum for  Straight fissure (55 ½-62
slow hand piece& high hand plain,556-563 dentate)
piece types)  Composites burs
 Round burs (Number ½-11)  Bud Burs (44 ½-51)
 Pear- shape burs (230-232)  Oval burs (218-221)
 Inverted cone burs (31 ½-44)  Cone burs (22 ½ -33)

75
  Taper fissure burs (169-171  Mandrel (straight and latch type)
plain, 699-703)  Carborundum, Silica, Crocus, discs
 Round- end and stones
 Fissure burs  Enamel Hatches
 Flat-end fissure burs (957-  Enamel chisel
959)  Discoid-cleoid
 Cylinder burs  Dental Hoe
 Wheel burs (11 ½ -16)  Gingival margin Trimmer
 End-cutting burs  Angle former
 Drills for pin retention
39. k) Instrument for Oral Surgery Major
 Periosteoteme (Periosteal elevator)
 Surgical Kit (MFS)
 elevators
 Root
40. l) Forceps for Dental Extractions (Deciduous teeth) Major
 Maxillary forceps for anterior teeth:
o Forceps 99 A (Canine forceps)
o Forceps 99 C (incisor forceps)
o Forceps 150 (Universal forceps)
o Forceps 213 (incisor forceps)
 Maxillary forceps for back teeth
o Forceps 18 right and left
o Forceps 210 (wisdom forceps)
o Forceps 24 (universal forceps for molar)
41. m) Mandibular forceps for anterior & posterior teeth extraction Major
 Mandibular forceps for anterior teeth
o Forceps 103-(incisors forceps)
o Forceps 203 (incisor forceps)
o Forceps 1519 universal forceps)
 Mandibular forceps for posterior teeth:
o Forceps 16 (1st molar forceps)

76
 o Forceps 23 (1st molar forceps)
o Forceps 297 (2nd molar forceps)
o Forceps 222 (Wisdom forceps
42. n) Right-angled forceps for mandibular Extraction Major
 Mead 3 forceps
 Mead 4 forceps
43. o) Maxillar Forceps for anterior & posterior teeth extraction Major
44. p) Forceps for maxillary Root Extractions Major
 Upper frontal milk forceps (forceps 1)
 Upper molar milk forceps (forceps 8)
 Lower frontal milk forceps (forceps 4)
 Lower molar molk forceps (Forceps 5)
 Root forceps (Bayonet)-(forceps 2)
45. q) Forceps for Maxillary and mandibular root extraction Major
 Forceps for Maxillary Root Extraction:
 Forceps 286 (Bayonet forceps)
 Forceps for mandibular root Extractions:
 Forceps 44
46. r) Orthodontics instrument Major
 Band removing pliers  Lingual arch forming pliers
 Band pusher  Loop pliers
 Band adapter  Clasp bending pliers
 How pliers (straight and  TP pliers (110,130)
curved)  Assorted orthodontics band
 Bird-beak pliers Preformed edgewise arch wires
 Ligature cutter  Band removing pliers
 Distal end cutler Wire bending pliers
48. s) Periodontal instruments Major
 Scalers- different types, sickle,  Periodontal pocket marker
Jaquete, Chisel, Hoe, file  Electro surgery apparatus with
scaler different netting tips
 Curettes (Universal, Gracey)  Arkansas flat stones,

77
  Periodontal knives:  Electrical sharpener
o Kirkland  Mounted
o Interdentally  Stones
o Surgical Hoe
50. t) Prosthodontics Instruments: Major
 Crown remover  Wax spatula
 Trays-(perforated, rim lock,  Acrylic stones
acrylic, metallic, different  Stones for gold alloy
sizes, for the upper & lower  Bunsen burner
jaws)
 Porcelain carvers
 Wax carvers
52. u) Basic Dental Laboratory Equipments: Major
 Model trimmer Vibrator  Sep up & units for heating &
 Bench lathe processing dentures materials
 Vacuum Spatulator  Laboratory spatula
 Bench motor with Hand piece  Coping saw
 Casting unit  Laboratory Knife
 Arch articulator  Simulation laboratory
 Typodont
54. v) Equipment for Radiology Department: Major
 Dental X-ray unit
 Panoramic radiography
 Cephalometricradiolgrapy (Optional)
 Intraoral X-rays system
 Extraoral X-rays ststem
 View box for radiography (Negatoscope)
 Automatic film processing
 Lead aprone
55. w) Equipments for sterilization Major
 Super heated steam under pressure (Autoclave)
 Dry heat sterilization (Oven)
 Chemical autoclave-

78
  Ultrasonic cleaner system
 Different pans use for disinfections & sterilization of instruments
 Cotton roll sterilizer
56. x) Equipment used for amalgam restoration: Major
 Amalgam mixing machine (Amalgamatory)
 Electric spot welder
57. y) Different operatory cabinets: Major
 Mobile cabinets
 Fixed cabinet
58. z) Central Air compressor Major
59. aa) Other surgical instruments Major
 Curettes (Angled, Straight,  Bone chisels
different Sizes)  Mallets
 Rongeurs (Bone-cutting  Suture needles
forceps)  Irrigation syringe
 Bone-file  Aspirating tip
 Scalped and Handle for scalped  Local anesthetic equipment
 Cheek and Tongue retractors (metal anesthesia syringe
 a) Farabeut  Pliers flat nose and serrated
 b) 3rd molar retractors  Contouring pliers (Number
 Mouth props 112,114,118,800,417
61. The dental service shall have the following materials Major
a) Dental materials: Temporary & permanent fillings
b) Dental films (Periapical, occlusal & panoramic view)
c) Light curing unit with composite materials
d) Local anesthesia (Spray, Cartridge with & without adrenalin)
e) Other consumables (analgesics, disposable syringe & gloves etc)

Otorhinolaryngology (ORL) Service Score point

S.N Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met

79
1. The ORL service shall have written policies and procedures Minor
2. There shall be written protocols and procedures for the management of the Minor
medical conditions in the unit as well as consultation and transfer of patients
admitted to this unit or other departments
3. Outpatient and elective interventions for ORL service shall be available Critical
during working hours
4. The ORL service shall include the following. Critical
a) Daily outpatient services.
b) Minor and major surgical services.
c) Inpatient services
d) ORL diagnostic tests and procedures.
e) Pre operative investigations and Postoperative follow ups.
f) Outpatient and inpatient consultations from other departments.
g) ORL emergency services management.
h) Post graduate training and research, optional
Met Partially Un Premises
met met
5. a) The outpatient service unit which shall be located adjacent to the general Major
OPD, or in a separate area. It shall include the following rooms
 Three examination rooms
 Staff office
 Waiting room
 Nurses station
 Staff room and teaching hall, optional
 Toilets for staff (female and male)
 Toilet for patients (Female and male)
6. b) There shall be in patient service unit for ORL services including; Major
 ORL ward
 Nurses station
 Reception area and mini store
 room for duty doctors
 Private and common toilet rooms
7. c) Minor operation room Critical

80
8. d) Diagnostic unit shall have the following rooms Major
 Room for neurotology tests and procedures
 Room for endoscopy
Met Partially Un Professional
met met
9. The ORL service shall be directed by an licensedENT specialist Critical
10. The ORL service shall have and maintain job descriptions, including Minor
qualifications to perform specific jobs
11. The Otorhinolaryngology services shall have the following professionals and Major
staffs.
a) two licensed ORL specialists e) Three in-patient nurses.
b) One neurottologist or f) Two OR nurses.
audiometrist (Optional). g) Three cleaners
c) Two GPs h) Porter
d) Five OPD nurses i) Runner.
Met Partially Un Products
met met
13. The ORL OPD shall have Major
a) Three ORL diagnostic unites f) head lights
each integrated with : g) Tongue depressors
 Suction machine h) Rhinoscopes(nasal specula)
 Compressed air system i) Otoscopes( ear specula)
j) Laryngeal mirrors
 Warm water irrigation
k) Tuning
 Cold light source, for forks(250,500,1000,2000,4000,80
endoscopes 00hzs)
 Instrument cabin l) Metallic suction tips
 Container for used m) Aural forceps
instruments. n) Packing forceps
 One wall mounted OPD o) Minor surgical sets
microscope p) Ear hooks
b) Flexible patient chairs. q) Nasal packing forceps
c) mobile doctors chairs r) Biopsy forceps(Laryngeal,
d) Sterilizer. Nasopharyngeal)
e) X-ray viewers

81
15. The in-patient unit shall have, Major
a) Adult and pediatric beds.
b) One cupboard to store medicines and materials
16. The OR shall have the following: Major
a) Major OR  ENT OR Chairs (mobile)
 OR table for general anesthesia  Anesthesia machines as desired
 Ceiling lights as for General by the anesthesia service.
Surgery. One Co2 laser machine.
 Operating microscope ceiling b) Minor OR
mounted or mobile  OR Table for local anesthesia
 OR Table flexible in all sides,  ENT OR Table with head rest.
up - Down with Head Rest.  Light Source & head lights
 Medicines and instrument cup  Cupboards for instruments
Boards and medicines
 Central oxygen and suction  Suction machine
system if possible  Cautery machine
 Separate suction  One Mobile chair
 Cautery machine  Easy access to general
 Cold light source and head anesthesia when needed.
lights
18. a) Other ORL Surgical Instrument Sets that includes: Major
 Myryngoplasty sets  Rhinoplasty sets
 Typanoplasty sets  Septoplasty sets
 Mastoidectomy sets  Cald –wel- luc sets
 Surgical drill and tips  Nasal polyp sets
 Otoplasty sets  Total laryngectomy sets
 FESS sets  Tracheostomy tubes
 Neck dissection sets plastic( with inner canmula)
 Laryngoscopy sets(adult)  Parotidecomy set
 Laryngoscopy set(pediatric)  Adeno-tonsillectomy sets
 Laser laryngoscopy adult set  Suture materials
 Laser laryngoscopy pediatric set  Esophagoscopy set
 Tracheostomy tubes metallic  Bronchoscopy set
(weith inner canula)  Tracheostomy sets

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20. The diagnostic unit shall have the followings: Major
a) Endoscopic room with video, video camera, 21 inch TV set, Stroboscope
etc.
b) Neurotology room with audiometry, tympanometry, brain evoked
response audiometry, (BERA), Sound proof box, computer and printer

Ophthalmology Services Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The Ophthalmology service shall have written policies and procedures Minor
including:
a) Admission and discharge criteria specific to the service;
b) Visitors policy
c) Transfer and referral of patients
d) Monitoring and follow-up of patients
e) Infection prevention and control as per the IP section of this standard
2. The Ophthalmology service shall provide at least the following services critical
a) Visual acuity testing
b) Slit lamp examination
c) Keratometry and ultrasound examinations
d) Laser therapy
e) Visual field examination
f) Minor and major ophthalmologic surgical procedures (Tarsoraphy,
cataract, enoculationetc)
g) Medical management of glaucoma
h) Optometry service
3. The ophthalmology service shall have protocols and procedure at least for the Minor
following:
a) Penetrating eye injury
b) Glaucoma management
c) Red eye
d) Corneal laceration
e) Surgical interventions
4. The Ophthalmology service shall be available during the regular working critical
hours

83
 Met Partially Un Premises
met met
5. The ophthalmology service shall have the following premises for outpatient Major
service.
a) Waiting room with TV news paper and magazines and brochures about
eye disease
b) Nurse station
c) Examination rooms
 Visual acuity: 2 rooms each having 6 m length or 3 m with mirror and
washing basin facilities
 Visual field room
 Keratometery and Ultrasound room
 Two rooms having Slit lamp biomicroscopy with washing basin
d) Physicians room
e) Minor OR room with washing basin
f) Administration staff rooms
g) Sterilization room
h) Toilet room for staffs separate for male and female
i) Toilet rooms for patients separate for male and female
6. The ward shall have the following service areas: Major
a) The number of admission rooms and beds shall be determined depending
on the nature of the work to be performed.
b) Staff room
c) Nurse station
d) Examination room for visual acuity testing with Slit lamp and Tonometry
shall have washing basin
e) Shower and toilet.
f) Laser room
g) Staff toilet and shower separate for female and male
7. The hospital ophthalmology service shall have changing room, the staff room, Major
recovery room, major operating theatre and ICU shared with other services of
the hospital
8. The ophthalmology service shall have a minor operation theater including. Critical
a) Patient’s preparation room
b) Changing room with lockers separate for male and female
c) Scrubbing room with washing basins

84
 d) Minor operation theater with swinging doors
e) Toilet for male and female
9. In addition, the ophthalmology service shall have following rooms: Minor
a) Meeting room; as appropriate
b) Utility rooms;
c) Store;
d) Pharmacy as appropriate
Met Partially Un Professional
met met
10. The ophthalmology service shall be directed by a licensed ophthalmologist Critical
11. There shall be qualified medical and nursing personnel for ophthalmology Critical
services at all times
12. An ophthalmologist shall be available at all working hours and he/she shall be Critical
also available on call at duty hours
13. Optometrist/refractionist shall be available on working hours Critical
14. Ophthalmic nurse or OR trained nurse shall be available during working Critical
hours and on call at duty hours
Met Partially Un Products
met met
15. a) Diagnostic Equipment Major
 Slit lamp  Torch (light)
 Trial set with trial frame (children  Ophthalmoscope (direct and
and adult), Cross cylinder indirect
 Slit lamp biomicroscopy with
applanationtonometery  Aspheric funds lenses volk: 78
 Snellen test chart (Distance chart) /90 dpt.
 Near point Acuity test card  Gonioscopy lens
 Color test (Ishara)  Three mirror Lens
 Fundus camera, optional  Lacrimal dilator and probe
 Lang stereo test  Probung set
 PD meter  BP apparat
 Retinoscopy  Glucometer
 Autorefractometer  Ex Ophthalmometer (Hertel)
 Lensometer  Aplanation tonometer /Schiotz

85
  Prisma set /Prisma Bar (horizontal +  A-scan ultrasound
vertical)  B-scan ultrasound
 Consumable materials  Autoclave
17. b) Diagnostic Medicines Major
 Phenynephrine  Fluorescein strips /drops
 Tropicamide eye drops  Cyclopentlate drops
 Atropin drops  Tetracaine drops
19. c) Therapeutic Equipment/Instrument Major
 Laser (Diode /Argon, Nd YAG  Neodymium: Yttruium-
Laser- Aluminium-garnet)
 OR microscope  chamber lenses of different
 Cataract set diopters)
 Glaucoma OP set  Suture different size (3.0, 4.0, 9.0,
 Tarsotomy set 10.0)
 Chalazion set  Viscoelastic
 Enuclation set  Eye pad
 Strabismus set  Ringer, saline
 Keratome set,  Ambu bag and oxygen cylinder
 Crescent set  Patient cardio-respiratory monitor
 IOL (both Posterior chamber and  DCR set
anterior  Bucking set

21. The inpatient service shall have the following supplies and facilities Major
a) Beds with toilet
b) Ambu bag and oxygen cylinder
22. The service shall have at least a general follow-up clinic that shall have the Major
following supplies and functional equipments:
a) One examination bed
b) Slit lamp biomicroscopy
c) Tonometer
23. Medicines and supplies shall be available in line with national medicines list Critical
Mental Healthcare Services Score point
Compliance status Standard to be addressed Remark

86
 Met Partially Un Practice
met met
1. Psychiatry service shall have written policies and procedures Minor
2. There shall be written protocols and procedures for the management of the Minor
psychiatric conditions in the hospital
3. There shall be written SOPs regarding the admission, consultation, discharge, Minor
transfer and follow-up of psychiatric patients
4. There shall be an integrated psychiatry emergency service for 24 hours a day Critical
and 365 days a year in the hospital
5. There shall be psychiatry follow-up service during working hour Critical
6. There shall be pharmacotherapy and Electro Convulsive Therapy (ECT) Critical
services in the hospital
7. There shall be a dedicated outpatient and inpatient service for mental Critical
healthcare services
8. The following services shall be available as part of the program of the Critical
psychiatry care unit;
a) Individual, group and family therapy;
b) Rehabilitative services;
c) Psychological services and
d) Recreational therapy
e) Electro Convulsive Therapy (ECT
9. A social worker shall complete a psychosocial assessment for each patient Major
which includes at least the following :
a) Identified problems;
b) Social and family history;
c) Educational and employment history;
d) Financial status; and
e) Present living arrangements.
10. Psychiatric evaluation shall be documented in the medical record Major
11. An individual, comprehensive, multidisciplinary care plan shall be developed Major
for each patient based on an assessment of the patients’ strength and
limitations which includes the followings:
a) A psychiatric diagnosis specifying undercurrent diseases.
b) Observable treatment goals

87
 c) The specific treatment methods to be used and;
d) The responsibilities of each member of the interdisciplinary care
team
12. There shall be Safety and security precautions for the prevention of suicide, Critical
assault, elopement and patient injury
13. An accurate schedule of activities shall be posted conspicuously in the unit Major
14. The hospital shall have addictive substances’ detoxification, treatment, Major
rehabilitation services specific to the problem and shall have access to
psychiatric, clinical or general psychological, and clinical or general social
works service every day
15. There shall be substance abuse care and follow up service Critical
16. There shall be a pediatric and adolescent psychiatry care and service Critical
Met Partially Un Premises
met met
17. A private setting shall be available for interviewing patients Critical
18. There shall be a separate psychiatry emergency room (s) Critical
19. The unit shall have access to at least one acute care/seclusion room Critical
20. There shall be psychiatric ward dedicated for psychiatry services Critical
21. There shall be an Electro Convulsive Therapy procedure room Critical
22. The psychiatry unit shall have a day room/dining room that allows for social Major
interaction, dining, and therapy
23. Space for structured physical exercise programs shall be available to patients Major
24. There shall be space in each patient room for storage of patient’s personal Major
belongings
25. The outpatient layout shall include the following: Major
a) Waiting area of the psychiatric wing: room /lobby with public telephone,
TV area, drinking tap water, and gender specific toilets
b) Reception and Recording area/desk
c) Dedicated patient examination rooms
d) Room for providing injections
e) Storage place for sterile supplies
f) Utility room for cleaning and holding used equipments and disposing
patients specimen
g) Staff room (for changing cloth)
h) Janitors closet

88
 The psychiatric service unit shall have a isolation room for treatment of Critical
conditions that require isolation for inpatients
Met Partially Un Professional
met met
27. The Psychiatric service shall be directed by a licensed psychiatrist Critical
28. Nursing care on the psychiatrist care unit shall be directed by a licensed Critical
psychiatry professional nurse with at least two years of experience in clinical
psychiatric service
29. In addition; Major
a) Clinical psychologist or General psychologist with exposure to clinical
medicine in hospital for one year should be available
b) Professional nurse with clinical psychiatry experience.
c) Nurses with clinical psychiatric experience
d) A social worker with experience in social work or mental health
Met Partially Un Products
met met
30. The restraint equipment needed by the unit shall be immediately available on Major
the unit and accessible to unit staff
31. Recreational and therapy equipment and supplies needed for psychiatry care Major
shall be available on the unit and stored in locked storage
32. All medicines to this level of hospital shall be available at all times Critical
33. The psychiatric OPD shall have the following supplies and functional Major
equipment in addition to office furniture’s
a) Torch,
b) Weighing scales for adults and/or children
c) thermometer
d) Stethoscopes
e) Sphygmomanometer
f) Examination couch
g) Vaccutainer needles with stand for blood drawing for laboratory
investigation
h) Hand washing basin
i) Emergency ECT access when inpatient treatment is not possible
j) Spatula, disposable gloves, cotton, gauze
k) Prescription, certificate, and appropriate referral forms, request forms
for laboratory, X-ray and other imaging investigations

89
34. The inpatient service shall have the following supplies and functional Major
equipments
a) ECT machine, gags, electrode application rubbers, electrodes, gel for
electrode placement
b) Torch,
c) Weighing scales
d) Tape meter, thermometer, patella hammer
e) Stethoscopes and Sphygmomanometer
f) Examination couch, medicine trolley, Cup board
g) EKG machine,
h) Computerized EEG mach with at least 18 channels
i) Suction machine
j) Drip counters/Infusion pump, Tourniquets and IV stands
k) Oxygen cylinder, Flow-meters for oxygen, Nasal prongs catheters
l) Self inflating bags for respiratory support, Masks, endotracheal tubes,
m) Cannulas, Nasogastric tube
n) Beds for patients and hand washing basin
o) Glucometer
35. The service shall have at least a general follow-up clinic that shall have the Major
following supplies and functional equipments:-
a) Weighing scales
b) Tape meter (optional), thermometer, patella hammer
c) Stethoscopes and Sphygmomanometer
d) Examination couch
e) Gauzes, Vaccutainer needles with appropriate stands for blood drawing
f) Disposable rubber gloves
g) partitioned spaces for Injection
h) hand Washing basin

Dermatology Services Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. Dermatological services shall be available for 24 hours a day and 365 days a Critical
year
2. There shall be written policies, procedures and protocols for admission, ward Minor

90
 rounds, management, appointment, discharge, and referral of patients
3. There shall be regular training of the non-dermatology nursing staff on a good Minor
nursing care of patients with severe skin diseases
4. There shall be a protocol or a policy that states the report of critical conditions Minor
which need urgent response/intervention like suspected melanoma or
squamous cell carcinoma in the hospital
5. The dermatology outpatient services shall provide the following services: Critical
a) Occupational skin disease clinic
b) Photo dermatology clinic
c) Specialized skin cancer/pigmented lesion (dermato- oncology clinic)
d) Allergy clinic with side laboratory
e) Venerology/STI clinic
f) Paediatric dermatology clinic(eg. atopic eczema)
g) Electrocautery
h) Cryotherapy
6. The dermatology inpatient services shall have: Critical
a) A 24 hours admission services
b) Admission and treatment of patients requiring such facilities which at
least include:
 generalized skin failure (e.g., erythroderma of different causes),
 severe drug eruptions (e.g.,Stevens-Johnson syndrome and TEN)
 severe blistering disorders (e.g., immunobullous diseases),
 Leprosy reactions and diffuse cutaneous leishmaniasis,
 Acute neutrophilicdermatoses (e.g., pyodermagangrenosum, sweet
syndrome amongst others
7. There shall be cooperation with the pharmacy services to have access for the Major
preparation of topical medicaments and allergens for contact allergy testing
Met Partially Un Premises
met met
8. The dermatological services shall have the following units: Critical
a) Outpatient units (as per the outpatient section of this standard)
b) Surgical units
c) Inpatient units (as per the inpatient section of this standard)
d) Dermato-histopathology and immuno-pathology unit, optional
e) Phototherapy units, optional
f) LASER unit, optional

91
 g) Laboratory unit (eg. to perform dermatologic and STI diagnostic tests,
culture and serologic test)
Outpatient units shall have a dedicated outpatient service area with Major
consultation and examination rooms with the following requirements:
a) Examination room :
 Two adjacent communicating rooms per doctor,
 Patient undressing room,
 Hand wash basin,
 Adequate natural lighting and additional lighting
 External wall fitted with laminated glass above 1.8 m high,
 Space for Cautery machine,
 Space for cryotherapy machine,
 Phototherapy unit including UVB and UVA panel (phototest,
photopatch test, etc), (optional)
 Wound dressing area
 Treatment rooms with facilities for adults and children
b) Waiting area (room or shaded area)
c) Side Laboratory with facilities for contact allergy testing (Patch testing,
prick tests) including appropriate storage for allergens, optional
d) Separate roomfor Medical photography services, (optional)
e) Special room for Wood lamp.
9. The surgical units shall have the following requirements: Major
a) Well-lit and ventilated operating room with couches,
b) Access to latex free facilities,
c) Facilities for freezing biopsies and storing frozen samples (optional),
d) Laser-safe areas where required
e) Facilities for Moh’s surgery, e.g., specialist micrographic surgery,
cryostat and histopathology equipment in some specialist units
(optional).
The inpatient service unit shall have: Major
a) Dedicated inpatient room or integrated with other inpatient services with
dedicated dermatology beds for adults in internal medicine ward and
children in pediatric ward.
b) Adjacent bathing and showering facilities.
c) Proximity to the outpatient unit.
d) At least one bed in isolation room, with provision of photo-protection.

92
 e) Treatment area.
10. Dermatology offices shall include: Minor
a) Staff rooms,
b) Nurse station,
Met Partially Un Professional
met met
11. The dermatologic services shall be directed by licensed dermatovenerologist Critical
or dermatologist
12. The following professionals shall be available: Major
a) Dermato-venereologist,
b) GPIS,
c) Nurse Experienced or trained in dermatology,
d) Physiotherapist,
e) Supportive staffs,
Met Partially Un Products
met met
13. The dermatology service shall have the following products: Major
a) Dermatology examination kit, l) Examination couches,
b) Examination lamp, m) Surgical packs of appropriate
c) Cautery machine, instruments,
d) Cryotherapy machine, n) Equipment for electrocautery
e) Wood lamp, ( diathermy and hyfrecation),
f) Dermojet, o) Equipment for cryosurgery and
g) Dermatoscope, storage for liquid nitrogen,
h) Magnifying glass, p) PUVA (1,3,5
i) Laser machine, TrimethoxyPsoralen, UV-A),
j) Specula, q) Radiation monitoring
k) Punch biopsy set and minor set, equipment,
r) Phlebotomy set and others,

Cardiac Services Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. Cardiac emergency services shall be available 24 hours a day and 365 days a Critical
year

93
2. The cardiac unit outpatient service shall be available during working hours Critical
which at least includes the following:
a) Acceptance and evaluation of patients with heart diseases,
b)Follow-up care for patients on whom cardiac surgery or
interventional catheterization has been performed,
c) Follow-up of patients on whom medical or conservative
management has been decided.
d)The cardiac unit shall provide Stress testing.
e) The cardiac unit shall provide Echocardiography
3. The cardiac unit of the hospital shall have policies, protocols and procedures Minor
for cardiac conditions, interventions including, not limited with:
a) Patient admission, discharge and referral,
b)Advanced life support,
c) Common Cardiovascular accidents,
d)Catheterization,
e) Emergency resuscitation,
4. The Cardiac unit inpatient services shall be available 24 hours a day and 365 Critical
days a year including the following:
a) Admission of patients on emergency basis for care and
management of cardiac related conditions.
b) Admission of patients for cardiac surgery or interventional
catheterization purposes.
c) Transfer of patients from ICU after cardiac surgery or
interventional procedure.
5. The cardiac unit shall have intensive care unit (ICU) available for 24 hours a Major
day and 365 days a year
Met Partially Un Premises
met met
6. The outpatient service shall have the following space and specified Critical
requirements:
a) Examination rooms:
 The room shall have adequate space (at least 20 square meters
wide with good lighting and ventilation windows).
 Hand maneuvered patient examination coach.

94
  Hand washing sink in each examination room.
 Patient waiting area equipped with chairs to accommodate at least
10 patients at a time.
b) The emergency resuscitation room:
 The emergency resuscitation room shall at least be 50 sq. m. wide
with a good lighting and ventilation windows.
 There shall at least be two resuscitation couches, cupboards and
shelves, a wheelchair and patient transporter.
c) Stress testing room:
 With good lighting and ventilation.
 There shall be a Treadmill or a bicycle ergo meter, the stress test
recording panel and at least a chair.
 There shall be a resuscitation trolley and a defibrillator available
for immediate use.
 Provided with at least three (3) electric outlets
The cardiac inpatient ward shall fulfill the followings: Major
a) The cardiac unit shall have at least 10 beds.
b) Nursing stations with telephone and telephone terminals,
computer and computer points, chairs and working laminated top
tables.
c) Patient toilet and shower facilities.
d) There shall be separate staff toilet, shower and changing facilities.
e) Clean utility room
7. Cardiac Intensive Care Unit (CICU): Major
a) The cardiac ICU shall accommodate at least 4 electrically
operated patient beds fitted with full range of monitors, better with
a central monitor.
b) There shall be a distance of at least one and half meters between
any of two beds.
c) There shall be a nurse station within the ICU having a computer
and a computer point, telephone and telephone point, cabinets and
shelves, and lockers for controlled drugs.
d) There shall be a hand washing basin by the entrance/ exit of the

95
 ICU room.
e) There shall be patient toilet and shower facilities.
f) There shall be an ICU staff locker room in proximity with the ICU.
g) The ICU area is generally regarded as a sterile zone and there shall
be shoe and cloth change point for families and staff.
h) There shall be soiled utility/sluice room
i) There shall be an ICU supply room with cabinets and shelves.
j) There shall be an ICU cleaner’s room
Cardiac Operating Theatre Critical
a) The cardiac operation theatre:
 The operating theatre size shall at least be 9m x 7m wide and
shall accommodate all the equipments mentioned under the
section ‘Cardiac OR equipments’ below.
 There shall be enough space for safe and adequate movement of
the surgical team (cardiac surgeon, assistant surgeon, anesthetist,
Transesophagealechocardiographer, perfusionist, scrub nurse and
circulating nurses).
b) The scrub room:
 The scrub room shall be in close proximity with the operation
theatre and no more than one door shall be crossed after
scrubbing.
 The scrub room shall accommodate at least two professionals
scrubbing simultaneously.
c) The OR supply room:
 The OR supply room storage of consumable and small sized
equipments shall be in continuity with the operation theatre.
d) Staff locker rooms:
 There shall be separate staff locker rooms for ladies and
gentlemen used for staff changing facilities, placement of scrub
suits and scrub shoes in proximity with the procedure room.
 There shall be separate staff toilets and shower facilities for
ladies and gentlemen in proximity with the locker rooms.
e) Soiled utility / sluice rooms:

96
  The room shall have the facility for storage of contaminated OR
materials until wastes are disposed off and cleaning of
contaminated equipments.
 There shall be supply of hot and cold running water.
 There shall be adequate supply of clean gloves and heavy duty
gloves for those working in the soiled utility area.
CAT Lab (Cardiac Catheterization Laboratory): Critical
a) Catheterization room / procedure room:
 The procedure room shall be at least 36 sq. m and accommodate
all the equipments mentioned in ‘catheterization laboratory
equipments’.
 The catheterization room shall have enough space for free
movement of the operator, assistant operator, scrub nurse,
circulating nurse, anesthetist, sonographer and the X – ray
technologist.
 There shall be catheter hangers on the wall with in the procedure
room.
 The doors and wall of the procedure room shall be leaded or the
wall thickness shall be appropriately thick to reduce radiation
hazards to the surrounding area and the radiation safety shall be
approved by the Ethiopian Radiation Protection Authority and
this standard.
b) The control room:
 The size shall at least be 12 m2 in size and accommodate the
CATHCOR system, the HICOR system and the CD writer
system and all other data management systems.
 The control room shall be separated from the procedure room
with a leaded door and there must be a leaded glass window of at
least 2m x 1m size to enable visual communication between the
staff in the procedure room and the control room.
c) The Catheterization lab scrub room:
 The scrub room shall be in proximity with the procedure room
and there shall be no more than one door separation between the

97
 two.
 The scrub room shall have adequate scrub facilities and allow at
least two professionals scrubbing simultaneously.
d) Catheterization lab supply room:
 The supply room shall in close proximity to the Catheterization
lab and is used for storage of a range of consumables used for the
procedure.
 The room shall be furnished with shelves, cupboards and
lockers.
e) Staff locker rooms:
 There shall be separate locker rooms for ladies and gentlemen
located in proximity with the procedure room.
 There shall be toilet, shower facilities and hand wash sinks either
in or in proximity with the locker rooms
Met Partially Un Professional
met met
8. The cardiac unit shall be directed by a licensed cardiologist Critical
9. There shall be at least one licensed cardiologist with a minimum of nine Critical
months training on diagnostic and interventional cardiac catheterization
during working time
10. There shall be at least one licensed anesthesiologist with a minimum of six Critical
months training in cardiovascular anesthesia
11. There shall be at least one perfusionist with a minimum of two years of Major
training
12. There shall be at least three qualified nurses with enough experience in the Major
operating room
13. There shall be at least three qualified nurses with enough experience in the Major
diagnostic and interventional catheterization laboratory
There shall be at least two qualified nurses in the outpatient and emergency Major
department available 24 hrs a day and 365 days a year
14. There shall be an x-ray technologist with at least three months of training in Critical
the diagnostic and interventional catheterization laboratory
Met Partially Un Products
met met

98
15. The cardiac unit of the hospital shall have the following equipment for Critical
outpatient service unit:
a) sphygmomanometer a) Reliable oxygen source
b)stethoscopes (preferably central oxygen
c) Thermometers supply)
d)A pulse oximeter b) Exam coaches
e) Weight and height scales c) Syringe pumps
f) Holter monitors (24 hour d) Endotracheal tubes
ambulatory EKG) or event e) Laryngoscopes
recorder f) Defibrillators
g)Ultrasound machine with 2D, g) Wheel chair
color Doppler, spectral h) Patient transport stretcher
Doppler and tissue Doppler h)Standard 12 lead EKG machines
i) Resuscitation trolleys

17. The cardiac unit of the hospital shall have the following equipment for Major
inpatient service unit:
a) Patient beds fitted with non- l) Bed pans
invasive monitors and m) Kidney dishes
mounting rails behind all n) Scissors
beds o) Surgical blade holders
b) Chairs (one per bed) p) Lockers and cupboards
c) Drip stands q) shelves
d) Medical gas ports r) Telemetry monitoring for post
e) Telephone terminals operative patients with
f) Working laminated top table transmitters for step down care
g) Nurse trolleys and selected patients in the
h) Resuscitation trolleys ward.
i) Reliable oxygen source s) Nurse stations with chairs and
j) Syringe pump computers plus computer
k) Endotracheal tubes of points
different sizes t) Defibrillators
u) Dressing sets
v) Laryngoscopes

99
19. Consumables Major
a) Disposable gloves e) Venous cannulae of different
b) Sterile surgical gloves sizes
c) Foley catheters of different f) Transfusion sets
sizes g) Surgical blades
d) Needles and syringes of h) Patient cards/charts
different sizes i) Sterile gauze
21. The cardiac unit of the hospital shall have the following equipment for Major
Operating theatre:
a) Surgical instrument cabinet dd) Closed heart surgical set
b) Endoscope cabinets ee) Electric / pneumatic saw
c) Sterile instruments cabinet ff) Patient transport stretcher
d) Electrically maneuvered gg) Refrigerators
operating tables hh) Heart lung machine with all its
e) Anesthesia machine designed accessories
and dedicated for ii) Standard OR lights
cardiovascular anesthesia jj) Surgeons head light
f) Laryngoscope kk) Headlight source
g) Backup cylinder ports for ll) Cardiac monitors with screens
oxygen/air (fitted with all invasive
h) Tubing clump and Tubing monitors)
scissors mm) Surgeon’s goggles
i) Drip stands nn) Surgeon’s sitting and standing
j) Drums stools
k) kidney dishes oo) Scrub shoes
l) Vacuum/electrical suctions pp) Defibrillator with internal
m) Medical gas supply (ports for paddles
oxygen, atmospheric air and qq) Echo machine with pediatric
nitrous oxide) and adult Transesophageal
n) Diathermy facilities
o) Theatre trolleys rr) Heater/cooler
p) Anesthetic trolley ss) Patient warmer with electric
q) Perfusionist’s trolley blanket

100
 r) Bowl trolley tt) Heating cabinet to warm
s) Sterilized device and cloth patient fluid
trolley uu) Balloon pump
t) Medication trolley vv) Pressure transducers
u) Medical waste trolley ww) Syringe pumps
v) Laundry collection trolley xx) Pressure bags
w) Mayo stand yy) Stainless steel bowel
x) Sharp container’s zz) Racks
y) Digitally operated air aaa) Blood gas analyzer
conditioner bbb) Transport monitor
z) Autoclaves (Tabletop) ccc) Transport oxygen cylinder
aa) Wall sockets ddd) Activated Clotting time
bb) Open heart surgical set Testing machine (ACT
cc) machine)
eee) Temporary pacing boxes
fff) Sharp/blunt sterile scissors
ggg) Oxygen saturation probes
(newborn, infant pediatric)
23. The cardiac unit of the hospital shall have the following Consumables for OR Major
service unit
a) Scrub brushes with soap and ii) Heart exchanger
iodine jj) Disposable connectors
b) Antiseptics kk) Arterial for perfusion (range of
c) Angled perfusion cannullae of sizes)
different sizes ll) Left heart vent catheters
d) IV cannullae of different sizes mm) Blood transfusion filters
e) Pressure domes for perfusion
f) Oxygenator and venous nn) Arterial Cannullae of different
reservoir sizes
g) Cardioplegia set oo) Connecting 3-way stopcocks
h) Cardiovascular set pp) Bladder syringes
i) Coated, braided polyester qq) Luer-lock syringes
sutures (1/0, 2/0, 3/0, 4/0, 5/0, rr) Luer-Slip syringes

101
 6/0) ss) Sterile suction tubing
j) ECG electrodes tt) Non-sterile examination
k) Diathermy pencils gloves
l) Gore-Tex stretch graft suture uu) Sterile surgical gloves of
m) Gore-Tex large diameter different sizes
stretch graft vv) Tender tip suction catheter of
n) Gore-Tex stretch graft different sizes
o) Quadrilumen CVC sets ww) Wound care packs
p) Triplelumen CVC sets xx) Sterile oral hygiene packs
q) ACT cartridges yy) Non-woven swabs
r) Pediatric multi-lumen Central zz) X-ray detectable gauze swabs
Venous Catheterization sets of aaa) Pre-injection swabs
different sizes bbb) Nasogastric tubes of
s) Swan-Ganz pulmonary artery different sizes
wedge catheters of different ccc) Silk stitches
sizes ddd) Sterile drapes
t) Uncuffed Endotracheal tubes eee) Scrub suits
of different sizes fff) Ambubag
u) Cuffed Endotracheal tubes of ggg) Snapper plate
different sizes hhh) Haemofilters
v) I-STAT cartridges iii) Foley catheter of different
w) Temporary pacing wires sizes
x) Blood burettes jjj) Steel wires
y) Clear fluid burettes kkk) Surgical gowns of different
z) Chest tube set sizes
aa) Urine bags with urinary lll) Chest drainage bottles
catheters and urine meter mmm) Powder free latex sterile
bb) Intraosseous infusion needle gloves of different sizes
cc) Nasal cannula nnn) Surgical blades of different
dd) Oxygen face mask (infant, sizes
pediatric, adult) ooo) Thoracic catheter of
ee) Nebulisers Hypodermic needles (orange,
ff) Micropore tape b Blood transfusion set

102
 gg) IV site dressing
hh) Balloon tipped silicon
coronary artery ostial cannula
of different sizes
25. The cardiac unit of the hospital shall have the following equipment for
Intensive Care Unit
a) Electrically
maneuveredpediatric and adult
beds fitted with monitors and
screens
b) Invasive pressure transducers
(1 per bed)
c) Ventilators with
accompanying accessories
d) Feeding tables (per bed)
e) Ports for oxygen, atmospheric
air and vacuum (1 of each per
bed)
f) Electrical suction machine (at
least 1 as a backup)
g) Drip stands (2 per bed)
h) Infusion pumps (1per bed)
i) Syringe pump (3 per bed)
j) Incubators and radiant
warmers
k) Refrigerator (at least 1)
l) Nasal CPAP
m) Bed pan (1 per bed)
n) Pacing boxes (at least 2)
o) Device trolleys (1 per bed)
p) Pharmacy trolley (at least 1)
q) Resuscitation trolley (at least
1) Refrigerator
ppp) lue, white, green different
sizes
Major
w) Portable x-ray machine with
protective lead apron and lead
curtain
x) X-ray viewer
y) Echocardiography machine
with 2D, color, spectral
Doppler and tissue Doppler.
z) Nurse stations equipped with
chairs, tables, drawers and
computers, shelves, lockers
aa) Linen boards
bb) Screen and curtain (for
privacy)
cc) Water supply and sink facility
with soap
dd) Paper towel dispenser
ee) Telephone and telephone point
ff) Arterial pressure bags
gg) Blood gas analyzer
hh) A 12 – lead standard ECG
machine
ii) Medication boards
jj) Controlled drug locker
kk) Calculators
ll) Weight scale
mm) Wall clock (at least 2)
nn) Soiled cloth hampers
103
 r) Electrical sockets on the nurse oo) Manual sphygmomanometers
station desk (at least 12-16) with infant, pediatric and adult
s) Intubation set cuffs.
t) 2 meter long mounting rails pp) Thermometers
behind all beds qq) Stethoscope
u) 10 main sockets behind each
bed
v) Defibrillator (at least 1)
27. The cardiac unit of the hospital shall have the following Consumables for Major
intensive care unit:
a) Non-sterile examination gloves
b) Sterile surgical gloves
c) Chest drainage bottles
d) Foley catheters with urine bags
e) Adhesive plasters
f) Cannullae of different sizes
g) Needles
h) A range of crystalloid and colloid IV fluids
i) Patient charts/cards (case summary, order sheet, nurses
monitoring sheet etc.) and other stationeries.
28. The cardiac unit of the hospital shall have the following equipment for Major
Diagnostic and interventional cardiac catheterization laboratory
a) At least a single C-arm t) Lead aprons and thyroid shield
angiography machine with a for every member of staff
movable angiography table working in the cath lab
b) Angiography and RGB u) A telephone and telephone
monitoring screens point
c) A well functioning v) Catheter and wire rinsing
CATHCOR system basins
d) CD recorder w) Drums
e) Digitally operated air x) Galipot
conditioner y) Kidney dishes
f) Standalone pressure injector z) Scissors
system aa) Artery forceps
104
 g) A pressure amplifier box bb) Surgical blade holders
h) Pressure transducer cables cc) Sponge forceps
i) ECG monitor system dd) Blood gas analyzer
j) Syringe pump ee) Nurse trolleys
k) Infusion pump ff) Device trolley
l) An anesthesia machine gg) Resuscitation trolley
m) Laryngoscope hh) Defibrillators
n) Gas ports for oxygen, medical ii) Computer and computer
air and nitrous oxide network terminal
o) Echocardiogram with jj) Patient transport coaches
pediatric and adult kk) Pulse oximeter
Transesophageal facilities ll) Vital sign tray
p) An Ambubag mm) Waste baskets for soiled
q) A control room with chairs and dry linen
r) Scrub room with scrub nn) Sharp disposal containers
facilities oo) Catheter hangers
s) Drip stands Apron hangers
pp) Light source
30. The cardiac unit of the hospital shall have the following Consumables for Critical
Diagnostic and interventional cardiac catheterization laboratory:
a) Local anesthetics (Lidocaine, t) Vascular stents with associated
Bupivacaine, Xylocaine, etc) delivery systems (a range of
b) Contrast injector syringes sizes)
c) 3, 5 and 10ml syringes u) Duct occluders with associated
d) Puncture needles delivery systems (a range of
e) Surgical blades sizes)
f) Disinfectants v) Septaloccluders with
g) Sterile gauze associated delivery systems (a
h) Small guide wires (J-guide range of sizes)
wires) w) Face mask
i) Valved introducers with x) IV cannullae (a range of sizes)
dilators (with a range of sizes) y) Butterfly needles
j) Multipurpose catheters (a z) Patient drapes

105
 range of sizes) aa) Scrub suits (single use or
k) NIH catheters (with a range of fabric)
sizes) bb) Pressure domes and connectors
l) Pigtail catheters (a range of cc) Injector connecting tubes
sizes) dd) Endotracheal tubes of different
m) Balloon tipped flow guided sizes
catheters (a range of sizes) ee) Cidex solution for probe
n) Left and right coronary cleaning
catheters (a range of sizes) ff) Probe covers
o) Soft tipped guide wires (a gg) Lubricant and transmission gel
range of sizes) hh) Adult and pediatric ECG
p) Exchange range guide wires (a electrodes
range of sizes) ii) Non sterile examination gloves
q) Super stiff guide wires (a jj) Sterile surgical gloves of
range of sizes) different sizes
r) Contrast agents (Omnipac, kk) Suction tubes
Iopamiron) ll) Medicines as per the national
s) Balloon angiocatheters of list of such hospitals
different types ( with a range mm) Coronary stents with
of sizes) associated delivery systems (a
range of sizes
32. In addition the cardiac unit should have the following devices: Major
a) Stent graft thrombectomy device,
b) Distal protection device,
c) Intra aortic balloon counterpulation,
d) Medicines as per the national medicine list

Neurology service Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The Neurology service unit shall have a minimum of the following services: Critical
a) outpatient and follow-up clinic service
b) neurologic consultations

106
 c) referral services to respective facilities
d) Emergency and/ or stroke care
e) Inpatient neurologic care
f) Advanced Neurologic tests and procedures
g) Headache and pain management (optional)
2. There shall be written protocols and procedures which shall be enforced that Minor
establish the management of the neurological conditions in the unit as well as
consultation and transfer of patients admitted to this unit or other services
3. For emergency neurological condition the service shall be available 24 hours a Critical
day throughout the year
4. For non-emergency condition the neurological service shall be available Critical
during the regular working hours
5. The neurological unit shall have a follow-up service for patients with chronic Critical
ailments
6. There shall be a system for clinical staff to refer patients directly to the social Minor
works unit
Met Partially Un Premises
met met
7. The neurological service unit shall have an isolation room Critical
The neurology service of the hospital shall have the following rooms: Major
a) Examination room(s),
b) Rooms for follow-up clinics,
c) Electroencephalography (EEG) room,
d) Nerve conduction test room,
e) Inpatient rooms,
f) Nurse station
g) Utility rooms
h) office for physician
i) Duty room/Station,
j) Staff/ changing room
k) Meeting room
l) Store
m) Staff Toilets, showers (male and female) and
n) Toilet and shower, Separate male, female or at least one per each room
Met Partially Un Professional
met met

107
8. The neurological service shall be directed by a licensed neurologist Critical
9. There shall be qualified neurological and nursing personnel in the Critical
neurological service unit available at all times
10. The neurology unit shall have at least the following professionals: Critical
a) Licensed neurologist
b) Licensed physician
c) Licensed nurses
d) EEG trained nurse or EEG technician
e) Cleaners
Met Partially Un Products
met met
11. The neurology service unit shall have at least the following equipments: Critical
a) Stethoscope, h) EEG machine,
b) reflex hammers, i) Nerve
c) ophthalmoscope, conduction/electromyography,
d) thermometer, j) Examination coach,
e) sphygmomanometer, k) Doppler ultrasound (optional)
f) Snellen’s chart, l) Lumbar puncture set with
g) Tuning fork, manometer,

Gastroenterology Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The Gastroenterology unit shall have the following services: Critical
a) outpatient service,
b) follow-up clinic,
c) Emergency gastroenterology and/ or care for GI bleedings,
d) Inpatient care for different gastroenterology diseases,
e) Investigation & interventions with endoscopies
2. There shall be written policies, protocols and procedures for the consultation Minor
and management of cases that shall include:
a) Identifying critical cases,
b) Handling of Emergency & critically ill patients,
c) Infection control specified as per the IP section of this standard and
National IP guideline,

108
 d) Procedures, interventions and special investigations like Endoscopy,
sigmoidoscopy, proctoscopy, etc. ,
e) Admission, discharge and referral of patients,
f) Monitoring and follow-up of patients.
g) Inpatient Gastroenterology Service
3. The Gastroenterology unit shall have a follow-up service for patients with Critical
chronic ailments
4. The gastroenterology unit shall have a system for involving patients, family Minor
members &/ or caretakers in the process of care & treatment
5. There shall be written protocol for disinfection and processing of endoscopic Minor
instruments with high level disinfection
Met Partially Un Premises
met met
6. The gastroenterology unit shall have inpatient service. Admission rooms shall Not
be with a maximum capacity of six beds per room scoring
The Gastroenterology unit shall have an isolation room for treatment of Not
conditions that require such services scoring
7. In addition to the ward rooms the Gastroenterology unit shall have the Major
following rooms & facilities:
a) Examination rooms, (Minor) d) Instrument processing room,
b) Nurse station, (Minor) (Minor)
c) Endoscopy room, (Critical) e) Utility rooms (Minor)
f) Duty room/Station (Minor)
Met Partially Un Professional
met met
9. The Gastroenterology unit shall be directed by a gastroenterologist with a Critical
minimum of two years related experience
10. At least one gastroenterologist shall be available to run the outpatient and Critical
inpatient service during working time
11. The unit shall have an internist and general practitioner Critical
12. The nursing service in the unit shall be directed by licensed nurse trained on Major
gastroenterology patient care
Met Partially Un Products
met met

109
13. The gastroenterology unit shall have the following supplies and functional Major
equipments at OPD:
a) Diagnostic Equipments e) Resuscitation kits: Ambu bag,
 Stethoscope, air ways,
 Sphygmomanometer, f) Oxygen cylinder, Flow-meters
 Weighing scales for for oxygen, Nasal prongs/
adults, catheters,
 Height Measurement g) Plastic bowels for chemical
 Tape meter, disinfection
 Thermometer, h) Cut down set,
i) Endoscope,
 Reflex/patellar hammer
j) Proctoscope,
b) X-ray viewer,
k) Laryngoscope (optional)
c) Examination couch,
l) Biopsy set,
d) Examination light,
15. The inpatient service of Gastroenterology unit shall have the following Major
supplies and functional equipments:
a) Examination couch, k) Nasal prongs catheters,
b) Patient beds, l) Self inflating bags for
c) Bed side cabinet, respiratory support, Masks,
d) Diagnostic sets (like Torch, endotracheal tubes,
Otoscope, fundoscope, patella m) Laryngoscope,
hammer) n) Cannulas,
e) Weighing scales, o) Nasogastric tubes,
f) Vital sign set like p) Glucometer and glucostick,
thermometer, BP apparatus, q) Pulse oximeter,
stethoscope, r) Wheelchair,
g) Medicine trolley, s) Kick buckets,
h) Suction machine, t) Cup board,
i) IV stands, u) Over bed table (for feeding),
j) Oxygen source/ Oxygen v) Curtain fixed with the ceiling
cylinder, Flow-meters for w) Oxygen face mask
oxygen,

110
 Renal Services
Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. There shall be written protocols and procedures for medical & surgical Minor
management of common genito- urinary & kidney conditions
2. The unit shall avail both nephrology & urology services for emergency renal Critical
conditions for 24 hours a day throughout the year
3. For non-emergency condition the nephrology & urology services shall be Critical
available during the regular working hours
4. The service shall have written policies and procedures that shall include: Minor
a) Admission and discharge criteria specific to the service;
b) A visitors policy,
c) Infection control as per the National IP guideline and this standard,
d) Transfer and Referral of patients,
e) Monitoring and follow-up of patients,
f) Criteria for interventions like haemodialysis and surgical interventions
5. The renal unit shall have the following urology services: Critical
a) Urethroscopy,
b) Extracorporal Shock Wave Lithotripsy,
c) Percutaneous lithotripsy,
d) Insertion of stents,
e) Transurethral diagnostic procedures &/ or lithotripsy
f) And other related services
6. The renal unit shall have the following nephrology services: Critical
a) Medical treatment,
b) Dialysis
7. The unit shall develop & implement operational policies addressing at least Minor
the following concerns:
(a) Policies & protocols related with Lithotripsy
(b) Policies & protocols related with Hemodialysis
8. There shall be a red alarm light and an audible beep on the dialysis machine Critical
9. There shall be a written protocol or procedure for application of Minor
haemodialysis machine
10. There shall be chronic care follow up service for certain prevalent renal Major

111
 conditions in the unit
Met Partially Un Premises
met met
11. The renal unit shall have the following premises:
 examination rooms at outpatient, (Critical)
 inpatient ward with isolation room (Minor)
 nurse station, rooms for surgical procedures (Minor)
 haemodialysis rooms (critical)
Admission rooms shall be with a maximum capacity of six beds per room Minor
12. The haemodialysis unit shall have the following premises and requirements: Major
a) nurse station:
b) staff locker room with shoe and cloth change point,
c) soiled utility room with sink with hot and cold water,
d) store room,
e) hand washing basin,
f) toilets,
13. The renal unit shall have the following premises for surgical procedure:
a) Urethroscopy room, (Critical)
b) Lithotripsy (ESWL) rooms, (Critical)
c) Operation theatre, shared with the general OR, (Critical)
d) Staff rooms with lockers, (Minor)
e) Store room, (Minor)
f) Toilets with shower for patients and staff (Minor)
Met Partially Un Professional
met met
14. The renal unit shall be directed by a licensed nephrologist or urologist/ Critical
urosurgeon
15. At least one nephrologist and urologist shall be available to run the outpatient Major
and inpatient service during working time
16. In summary the renal unit shall have the following staff Critical
a) Nephrologist e) Technician/Engineer (pulled)
b) Urologist/Urosurgeon f) Nurses
c) Internist g) Cleaners
d) General Practitioner h) Porters
18. The nursing service in the unit shall be directed by licensed nurse trained on Critical

112
 renal patient care
Met Partially Un Products
met met
19. The outpatient service of the renal unit shall have the following equipment & Major
supplies:
a) Examination couches,  sphygmomanometer
b) Examination light,  Tuning fork
c) X-Ray viewer, e) Weighing scale,
d) Diagnostic sets: f) Height measurement,
 reflex hammers g) Doppler ultrasound (shared),
 ophthalmoscope h) Cystoscope
 thermometer
21. The inpatient service for renal unit shall have the following equipments& Major
supplies:
a) Patient beds, n) Self inflating bags for respiratory
b) Diagnostic sets like torch, support, Masks, endotracheal
Otoscope, funduscope, patella tubes,
hammer o) Laryngoscope,
c) Weighing scales, p) Cannulas,
d) Vital sign set like thermometer, q) Nasogastric tubes,
BP apparatus, stethoscope r) Glucometer and glucostick,
e) Examination couch, s) Pulseoximeter,
f) Medicine trolley, t) Wheelchair,
g) Cystoscope, u) Over bed table(for feeding),
h) Suction machine, v) Bed side cabinet,
i) Drip counters/Infusion pump, w) Curtain fixed with the ceiling,
j) IV stands, x) Kick buckets,
k) Oxygen source with flow-meters, y) Cup board,
l) Oxygen face mask/ nasal prongs z) Wall clock,
catheters Trolley for vital sign monitoring,
m) Medication Cupboard with lock Refrigerator with temperature
control for medication,
aa) Patient chart holder
23. Dialysis Unit: Critical

113
 a) Dialysis machine with red alarm light and an audible beep
b) Water treatment facility
 Sand filter,
 Carbon filter and
 Reverse osmosis machine.
c) Separate leak proof containers on trolley for used dialysis sets and waste
products
24. The renal unit shall have the following equipments, not limited to: Critical
a) Extracorporal shock wave e) Cyctoscope,
Lithotripsy machine f) Suprapubic puncture with trocar,
b) Percutaneous lithotripsy g) Railroading/ Urethral dilators,
machine h) General surgery set,
c) Dura bascket, Retroperitoneal set/ Kidney set
d) Ureteroscope,

Rehabilitation Services Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. At least two of the following services shall be available in the hospital: Critical
a) Physical therapy/ physiotherapy
b) Occupational therapy
c) Vocational Rehabilitation
d) Drug dependency rehabilitation
e) Speech therapy
f) Pain management
2. There shall be written policies and protocols that ensure rehabilitation Minor
services are properly provided
3. There shall be specific treatment and/or procedure protocols for each service Minor
available and rendered in the unit
4. Visual and Auditory privacy shall be offered and provided to all patients Major
during evaluation and treatment, when clinically indicated
5. There shall be a policy that states written orders shall be given to patients Minor
when patients are discharged with exercise or treatment to continue at home
6. There shall be a protocol or policy for safety and ethical practice of physical Minor

114
 therapy
7. There shall be patient education on prevention of: Critical
a) pressure sores in clients with sensory loss,
b) contractures in clients with limb and/or trunk paralysis
Met Partially Un Premises
met met
8. There shall be physically separated room or area for rehabilitation and Major
therapy
9. There shall be direct access to inpatients and outpatients with clearly written Minor
labels
10. The premises shall be friendly for persons with disability and shall have Critical
smooth pavement rail for wheelchairs
11. There shall be waiting area with shade Major
12. Staff room for developing documentation and storing reference books and Minor
personal items shall be available
13. Private room for patients and staff Minor
14. Separate toilet with hand washing facility in an accessible location, Major
15. Call bells/beeper bells shall be provided to patients in the physical therapy Major
service who are not under visual supervision
16. Workshop for production of prostheses, walking sticks: auxiliary and/or Major
elbow crutches shall be available or there shall be a documented mechanism
of accessing such services
17. There shall be a separate room for exercise therapy Critical
Met Partially Un Professional
met met
18. The service shall be directed by a licensed physiotherapist or practitioner Critical
therapist graduated from recognized university or institute
19. The hospital shall have at least a Major
 chiropractor,
 physiotherapist,
 occupational therapist,
 clinical psychologist/health psychologist,
 speech therapist
20. Trained and certified therapist shall be available or shall supervise daily Critical

115
 sessions of physiotherapy
21. The service shall have dedicated cleaners Major
Met Partially Un Products
met met
22. Standard equipments and consumables which shall be available for Major
rehabilitation services include:
a) Physiotherapy mats, n) Ultrasound therapy equipment,
b) Splinting materials, o) Diathermy,
c) Bobath balls, p) Electro-massage apparatus for
d) Balance boards, hands, legs, spine,
e) Mirror, q) Massaging coach,
f) Waking rail/ parallel bars, r) Organ protection pad,
g) Pressure garment materials, s) Educational toys,
h) Goniometers, t) Material for making assistive
i) Spring, devices for daily living
j) Rollers, functions,
k) Infrared, u) Specific assessment tools for
l) Ultraviolet/ blue lamp, occupational-, speech-, and
m) Paraffin bath, physiotherapy,
v) Muscle stimulator,

Oncology Services
Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The oncology outpatient services shall include: Major
a) New patient services,
b) Follow-up services,
c) Radiotherapy planning services,
d) Radiotherapy treatment sessions,
e) Weekly Radiotherapy treatment checks,
f) Chemotherapy sessions,
g) Oncologic emergency services including emergency procedures,
h) Health education on cancer related topics

116
 i) Pain clinics if possible
2. The oncology inpatient services shall include: Major
a) Delivering chemotherapy sessions,
b) Nursing care according to individual patients’ needs
c) Brach therapy (Low dose rate or high dose rate, preferably high dose rate
sources)
3. There shall be a multidisciplinary cancer committee, chaired by a physician Major
4. The service shall have written policies and procedures that are reviewed at Major
least once every five years. They shall include at least:
a) Criteria for admission
b) Guidelines for mixing chemotherapy, when performed on the unit,
c) Guidelines for administering chemotherapy
d) Training of nursing and housekeeping staff in the disposal of
chemotherapeutic agents;
e) Use, handling, storage, and disposal of specific chemicals, agents, and
body wastes;
f) Assuring informed consents to chemotherapy; and
g) Psychological/social and spiritual aspects of patient care
5. Patient and family teaching shall be provided in any case where the patient Minor
and family are in need of and able to receive instruction
6. Criteria shall be developed in consultation with the social work department Minor
for identifying patients in need of social work services and/or discharge
planning and making referrals as needed
7. There shall be a system to refer patients and family and direct staff to in- Minor
house and community support groups and services
8. Medications shall be administered per written policies and procedures Minor
9. The patient shall be oriented to the room, service unit and to their assigned Minor
nurse upon arrival
10. Patient teaching shall begin during the admission process and shall be Major
ongoing. Documentation shall include the teaching plan and patient response
11. Consent for procedure and patient understanding shall be verified prior to Critical
implementation
12. Chemotherapy Major
a) All chemotherapy regimens shall be given according to the treatment
guidelines
b) Inpatient chemotherapy shall only be given in wards where it is agreed

117
 as the whole of, the wards allowed activities.
c) Out-patient chemotherapy shall only be given in outpatient areas where
it is agreed as part of, or the whole of, that areas allowed activity.
d) While out-patient chemotherapy is being given the area shall only be
used for this purpose and other aseptic treatments and procedures on
cancer patients.
e) Oncology nurse administers parentheral chemotherapy as prescribed by
the oncologist in the presence of oncologist or other trained physician
13. Radiotherapy Critical
a) The safety standards of radiotherapy shall be according to the Ethiopian
National Radiation Protection Authority (ENRPA) /IAEA standards
b) The radiotherapy technician can deliver Radiation in the presence of a
radiation oncologist
c) Both acceptance and commissioning test should be done by experienced
medical physicist for Barchytherapy and teletherapy machine before
being used for patients’ treatment
Met Partially Un Premises
met met
14. Buildings and rooming styles shall generally be in accordance with the Critical
Ethiopian Radiation Protection Authority’s standards
15. Minimal requirements for outpatient section Major
 Three examination rooms with indirect laryngoscope head lights, spirit
lamps & screen, a gynecology examination coach in at least one of the
rooms
 Nurses office in between the examination rooms
 Staff offices
 Radiotherapy planning room with planning coach & measuring utensils
 Dedicated Chemotherapy room with reclining chairs
 Store for immobilizers and consumables and
 Conference room.
 Separate toilet for patients with hand washing basin (male/female)
 Separate toilet for staff with hand washing basin (male/female)
16. Minimal requirements for radiotherapy treatment rooms Major
 Therathrone

118
  Linear accelerator room
 Simulation room
 Brach therapy room
 Office of Occupational Medicine (to prepare chemotherapy.)
 Chemotherapy rooms with at least 3 coaches/ reclining chairs each
 Library with shelves for quick reference
 Patient toilets separate for male and female
 staff toilets separate for male and female
17. Minimum requirements for inpatient section Major
a) Nurses office
b) Single bed rooms with ensuite bath room with toilets. The single
bedrooms shall be available as needed to accommodate patients with
Neutrogena, or critically ill patient and the other single bed room will be
a septic room for those with offensive smelling wounds, that needs
wound care
c) Rooms with 3 beds (the distance between the beds shall be at least 1.2m)
d) Rooms with 4 beds (the distance between the beds shall be at least 1.2m)
e) Duty rooms
f) Shared toilets for the patients (separate for male and female)
g) Separate toilets for staff (separate for male and female)
h) Inpatient store
i) Molding Room
j) Physics Laboratory with planning computers
k) The inpatient environment shall be conducive for rest and recovery
Met Partially Un Professional
met met
18. The oncology service shall be directed by a licensed oncologist Critical
19. The oncology service shall have at least the following category of Major
professionals
a) Clinical oncologists
b) General practitioners with adequate on job training in the care of
malignancies
c) Medical physicists
d) Radiotherapy technicians

119
 e) Radiographers with adequate on job training and assist the RTT
f) Full time Maintenance Technician
g) Biomedical Engineer (Shared)
h) Oncology trained nurses
i) Nurses with adequate on job training
20. Other core allied licensed health professionals required are: Major
a) Dietitian
b) Physiotherapist
c) Speech therapist
d) Occupational therapist
e) Oncology pharmacist
21. Designated social worker/s who is a member of social work services of the Minor
hospital shall be assigned to the unit to provide psychosocial services, assist
with discharge planning, and provide information regarding financial aspects
of care
22. One data manager for the service is required Major
Met Partially Un Products
met met
23. Antineoplastic medicines and pain medications shall be available in line with Major
the national medicines list of Ethiopia
24. The oncology service shall have the following supplies Major
a) Lead Bars ( supply)
b) Goggles for chemotherapy
c) Orfit Packs 5 per year
d) Molding foams
e) Leaded Aprons at least 3, for RT planning, and simulation and C-Arm
imaging
25. The oncology shall have the following equipments Major
a) Teletherapy machines bb) E, F Total Two Sets,
b) CO-60 machine thermoplastic head casts, head
c) Linear Accelerator and neck uniframe immobilizer
d) Orthovoltage X-Ray 100KvP set
e) CT simulator cc) Digitizer
f) C-Arm machines dd) Molding Machine( cutter)

120
 g) Brach therapy machines ee) Planning computers with color
h) High dose rate source of CO-60 printers with backup system
or low dose rate Cesium source ff) Boiler for orfit preparation
i) Immobilization devices gg) Lead Melting machine for
j) Breast Board Minimum 2, Plastic molding lead
head rests A, B, C, D, hh) Fume hood for chemotherapy
k) Brachytherapy machine mixing
l) Simulation equipment : one CT ii) Perfuser
simulator and C-Arm x-ray unit jj) Computers with printers ( one of
m) Mould room equipment the printers should be colour
n) Alloy melting pot printer)
o) Steriofoam cutter kk) Treatment planning software
p) Boiler for orfit preparation ll) Digitizer
q) Coach mm) Immobilizers
r) Dosimeter equipment nn) Breast board
s) Farmer dosimeter oo) Plastic head rests ( with size A,
t) Electrometer B, C, D, E, F)
u) Personal dosimeter pp) Head and Neck uniframe
v) Survey meter immobilizers two sets
w) Appropriate Ion chambers to qq) Pelvi-meter
radiotherapy machines used rr) Flexi curve ruler
x) Water phantom ss) Orfit packs as required
y) Barometer tt) Chemotherapy equipment: One
z) Digital thermometer fume hood and two perfuser for
chemotherapy
aa) Treatment planning system

Nuclear Medicine Services Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The hospital shall have written procedure for in vitro techniques such as
radio-immunoassay (RIA) and immuno-radiometric assay (IRMA)
2. The hospital shall have written procedure for the diagnosis of different health
problems using radiopharmaceuticals or radionuclides for both in vivo

121
 imaging and non-imaging diagnostic techniques
3. Acceptance testing and commissioning shall be performed based on written
policies and procedures
4. The nuclear medicine technologist shall be responsible for verifying day-to-
day operation of instruments and performing a few additional tests on a
quarterly basis
5. Documentation of compliance with all quality control tests and corrective
action shall be required as part of the application process
6. Policies and procedures related to quality, patient education, infection control,
and safety shall be developed and implemented in accordance with the IAEA
Policy on Quality Control and Improvement, Safety, Infection Control and
Patient Education Concerns
7. All films (or hard copies) or/and burned CDs are an important part of the
medical record
8. The hospital shall have written procedure(s) for the preparation of various
radiopharmaceuticals
9. The compounding and dispensing area for radioactive medicines shall be
separate from that of non-radioactive medicines, and shall be secured from
unauthorized personnel
10. The amount of radioactivity shall be determined by radiometric methods for
each product immediately prior to dispensing
11. A nuclear pharmacy practice site shall conduct and keep proper records of
appropriate internal test assessments on all radiopharmaceuticals, with
interpretation of the resulting data to determine suitability for use in humans
12. The hospital shall have written procedure for the management and disposal
of radiopharmaceutical and other nuclear medicine wastes
Met Partially Un Premises
met met
13. The nuclear medicine premise shall have the following:
a) Interpretation areas
b) Patient records, reports, and digital data storage areas
c) Administration records and support areas
d) Equipment/supply storage areas
e) Therapeutic procedures areas, if applicable
f) Waiting, reception, and patient/staff bathrooms

122
 g) Radioactive materials use and storage areas
h) Diagnostic imaging and processing areas which shall include
adequate space and proper orientation to eliminate “cross talk”
(counts being acquired from other than the patient being imaged)
into images from other patients, radioactive materials, or
radioactive waste.
i) Patient education, consultation and examination areas including
accessible hand washing for staff
j) Performance of stress procedures within appropriate proximity of
the imaging area including adequate space for performing
resuscitation in case of emergency
Adequate space, facility configuration, and doorways for the emergency
transport of patients from patient care areas and for emergency exit of staff
14. All surfaces of Radiopharmacy: walls, floors, benches, tables and seats shall
be smooth, impervious and non-absorbent, to allow for easy cleaning and
decontamination
15. In-vitro section of the nuclear medicine shall have a minimum of 24 meter
square space to conduct all RIA/IMRA procedures
16. A nuclear pharmacy practice site shall contain adequate space,
commensurate with the scope of services required and provided
17. Radiopharmacy shall have a minimum of 40 m2 space with two or more
rooms
18. Imaging section of the nuclear medicine service shall have a minimum of 30
meter square space to install and use one SPECT machine
Met Partially Un Professional
met met
19. The clinical nuclear medicine service of the hospital shall be directed by a
licensed specialized medical doctor who has been trained in nuclear medicine
20. The Radiopharmacy service of the hospital shall be directed by a licensed
pharmacist who has been trained in nuclear pharmacy
21. In addition, the nuclear medicine service of the hospital shall have at least the
following licensed professionals
a) Nuclear medicine technologist: A radiographer with B.Sc degree in
Radiography and who has been trained in nuclear medicine technology
b) Nuclear medicine technician: A radiographer with Diploma in

123
 Radiography and who has been trained in nuclear medicine technology
c) RIA/IRMA Technologist: A biologist/ chemist /laboratory technologist/
pharmacist who has been trained in RIA/IMRA techniques.
d) Nuclear medicine physicist: A physicist who has been trained in nuclear
medicine physics
e) Radiopharmacy technician: A pharmacy technician who has been trained
in nuclear pharmacy services
f) Nuclear medicine nurse: A nurse who has been trained in nuclear
medicine services.
g) Nuclear medicine engineer/Biomedical engineer (may not be necessary as
full time job
h) Radiation protection committee presided by Radiation Protection Officer
or Radiation Safety Officer
Met Partially Un Products
met met
22. The following shall be minimum equipment requirements for RIA/IMRA
work:
a) Refrigerator j) Semi-analytical balance
b) Deep freezer k) Magnetic stirrer with Teflon
c) Centrifuge to hold 60-100 tubes coated stirring bars,
d) Thermostatically controlled l) Vortex mixer,
water bath m) Automatic pipette washer,
e) Ice bath n) Scientific calculator
f) RIA Counter o) Ultrasonic cleaner
g) Distilling or de-ionizing water p) Foot-operated dustbin
h) Voltage stabilizer, q) Air conditioner
i) Precision balance r) Centrifuge
s) Survey meter data ‘monitor’
24. The following equipment shall be needed for the QC of Scintillation Gamma
Camera:
a) Sufficient Supply of Tc-99m Generators
b) Co-57 Flood Source
c) Four Quadrant Bar Phantom
d) SPECT Phantom
e) Disposable; Petri dish, Capillary tubes
f) The following Equipments are also recommended in order to follow

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 good work practices:
 Refillable flood source
 Copper plates for evaluation of count rate response
 Computer generated test image
25. The following shall be the list of Equipment and Instrumentation used in the
imaging and clinical nuclear medicine section:
a) Dose calibrator or decay correction calculation system
b) Imaging/counting equipment
c) Radiation monitoring devices including
 portable survey meter (required)
 removable contamination counting equipment (as applicable)
 fixed area survey meter for dose preparation/storage areas (as
applicable)
d) Resuscitation equipment and supplies (appropriate to the types of
procedures being performed)
 oxygen
 defibrillator/AED (checks scored in B3.3.1)
 emergency medicines (including a master list; all unexpired)
e) Exercise equipment (as applicable)
f) ECG equipment (as applicable)
g) Ancillary monitoring equipment (as applicable)
h) Infusion pumps/automated injectors (as applicable)
i) Glucometers (as applicable)
j) Hood for volatile radionuclides or cell handling (as applicable)
k) Xenon (or other gas) trap (as applicable)
l) Lead apron, decontamination solution, goggle and thyroid shield
26. Each nuclear pharmacy practice site shall contain at least the following list of
products (equipment):
a) Radiopharmaceuticals and non-radioactive supplies as per the national
medicines list
b) Vertical laminar flow hood;
c) Dose calibrator;
d) Gamma spectrometer;
e) Analytical balances and PH Meters
f) Lead pot, lead syringe carrier and lead bencher with glasses

125
 g) Refrigerator, dry and wet autoclaves
h) Radiation exposure monitor;
i) Portable survey meter;
j) Single or multiple channel scintillation counter;
k) Microscope, test tubes, different supplies;
l) Radio chemical exhaust hood and filter system
m) Lead apron, decontamination solution, goggle and thyroid shield

Radiology Services
Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The radiology service shall have written policies and procedures that are Minor
reviewed at least once every five years and implemented. These policies and
procedures shall include at least:
a) Radiation protection and safety practices;
b) Emergencies;
c) Adverse reactions;
d) Management of the critically ill patient;
e) Infection control, including patients in isolation;
f) Diagnostic imaging and result delivery
g) Quality control program covering the inspection, maintenance, and
calibration of all equipment
2. Policies and procedures for radiology services shall be available to all staff in Minor
the radiology unit
3. All digital X-Rays shall be taken by licensed radiological technologists Critical
4. All x-rays imaging requests shall be done by licensed physician Critical
5. All radiologic tests shall be interpreted on a preliminary basis within 24 hours Critical
at all times
6. The radiology service of the hospital shall have the following services at all Critical
times
a) Digital X-Ray,
b) Computer tomography (CT) service and/ or MRI ( magnetic resonance
imaging) services,
c) Ultrasound service,
d) Mammography,

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 e) Special procedures such as angiography and interventional procedures,
7. Proper safety precautions shall be maintained against fire and explosion Critical
hazards, electrical hazards, and radiation hazards
8. The hospital shall get approval from the Ethiopian Radiation Protection Critical
Authority through periodic inspection and hazards shall be promptly
corrected if identified
9. Radiation workers shall be checked periodically for amount of radiation Critical
exposure by the use of exposure meters or badge tests and this shall be
documented
10. Signed reports shall be filed with the patient's medical record and duplicate Major
copies kept in the service unit
11. The reporting form shall have minimum information such as name of Major
institution, date, patient name, age, gender, findings and name and signature
of radiologist
12. X-ray films shall be labeled with a minimum of the following information: Critical
a) date,
b) name, age, gender,
c) right/left mark
d) name of the institution and
e) Name of professional who took the film.
13. A radiation protection and safety program including timely reporting of Major
radiation safety findings shall be in place, followed, and documented
14. Radiological equipment quality assurance/control test shall be available Major
Met Partially Un Premises
met met
15. The radiology service shall have the following minimum rooms: Critical
S.N Room Requirements # required
1. Digital x-ray rooms (Critical) 2
2. Fluoroscopy room (Minor) 1
3. CT room (Critical) or 1
4. MRI room (Critical) 1
5. Mammography room (Critical) 1
6. Ultrasound room (Critical) 3
7. Angiography room (Minor) 1
8. Dark room as appropriate (Critical) 1

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 9. Quality control room (Minor) 1
10. Staff and Patients toilets (Critical) 4
11. Patient dressing rooms (Critical) 4
12. Waiting area (Major) 1
13. Recording and reporting room 1
(Critical)
14. Doctors rooms (Minor) 1
15. Duty room (Major) 2
16. Store room (Major) 1
17. Conference and data room (Minor) 1
18. Staff room (Minor) 1
19. Film library/Archive (Major) 1
Design requirements for radiology rooms shall be according to Ethiopian Critical
Radiation Protection Authority guidelines and this standard
Met Partially Un Professional
met met
16. The radiology service of the hospital shall be directed by licensed radiologists Critical
17. A licensed radiology technologist or radiographer shall be present in the Critical
hospital at all times
18. Equipment maintenance engineer as part time shall be available to ensure the Critical
proper functioning of all diagnostic radiology equipment
19. The hospital shall have the following professionals: Critical
a) Radiologist, e) Biomedical Engineer
b) Interventional radiologist, (Minor) f) Cleaner,
c) Radiologic technologist, g) Receptionist,
d) Nurse h) Port
Met Partially Un Products
met met
21. The hospital shall have the following radiological equipments: Critical
a) Color duplex ultrasound j) Video recorder
machines. k) Viewing boxes
b) Echocardiography ultrasound l) Refrigerator with thermometer
machine with cardiac probe. m) Resuscitation equipments
c) Digital X-ray machines. n) Emergency medicines

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 d) Combined x-ray machine (x- /supplies
ray with fluoroscopy) o) Procedure sets
e) Mobile X-Ray machine p) Telephone service
f) CT machine q) Computers and typewriter
g) MRI machine ( High Tesla) r) Dark room accessories as
h) Mammography machine appropriate
i) Manual & digital processor s) Actinic marker
t) Quality controls kit
23. At least the following radiation protection equipments shall be available in Critical
radiology services:
a) lead gloves d) Dosimeter/ TLD for each
b) lead apron radiology professional
c) Gonad shield e) lead eye-glass/goggle

Pathology Services Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. There shall be written procedures and protocols for pathology service Minor
2. The pathology service shall be available during working hours Critical
3. All Pathological examination results shall be signed by the pathologist Critcal
4. A tissue file paraffin blocks and slides shall be maintained in the hospital Critical
5. All tissues removed from patients during surgery shall be macroscopically, Critical
and if necessary, microscopically examined by the pathologist
6. There shall be a Quality Assurance and Quality control (QA & QC) Major
mechanism for Pathology services
Met Partially Un Premises
met met
7. The hospital shall have an organized separate pathology service area Major
including
a) Surgical Pathology unit:
 Reception & Recording room
 Gross room
 Tissue processing room

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  Special stain room
b) Histochemistry Unit:
 Immunostaining room
 Microscope reading room
 Store with two shelves (Chemical & Reagent)
c) Cytology Examination Unit:
 Reception room
 Waiting room
 Procedure room
 Superficial organ aspiration room
 Aspiration of internal organs room
d) Autopsy Unit shall be together with morgue with the following
requirements:
 Procedure room
 Dressing room with locker, toilet and shower
 Reception & Record room,
 post mortem technician/assistant room
e) Frozen section room near the Operation Theatre (Optional)
f) Forensic Autopsy: (Optional)
In addition, the pathology service shall have the following rooms for: Major
a) Pathologists office,
b) Photography room,
c) Staff room(s) with lockers,
d) Store room for Chemical Reagents and Paraffin blocks,
e) Toilet rooms for staff and patients (Male and Female)
Met Partially Un Professional
met met
8. The pathology services shall be directed by a licensed pathologist Critical
9. The pathology service shall have the following staffing: Major
a) Pathologists,
b) Laboratory technologist or technician with training in tissue
processing,
c) Autopsy assistants,
d) Post mortem technicians/assistants,

130
 e) Receptionist,
f) Cleaner,
Met Partially Un Products
met met
10. The pathology service shall have the following equipments for Autopsy Major
service:
a) Procedure Room: c) Dressing Room with
 body table with cold and documentation facility:
warm water sinks  Lockers
 Display table with glass  Reading table with two chairs
curtail  Book shelves
 Cupboard for instruments  Computer
 Refrigerator d) Reception and Record Room:
 Scale  Shelf with locker
 Pedaled tape recorder  File cabinet
 Video camera with  A table with two chairs
screen/Camera with stand  Computer
b) Postmortem
Technician/Assistant Room:
 Personal locker
 A table with two chairs
12. The pathology service shall have the following equipments for Surgical Major
Pathology Unit:
a) Reception and Record Room  one dissect table cutting board
(can be shared with gross room): placed in metal box and ready
 Lab. table or counter access to a sink withcold and
 Computer warm water
 Shelf  One wheeled chair
b) Tissue Processing Room:  Pedaled recording tape
 Two embedding system lab  Camera with stand
tables  Lidded garbage container
 Tissue processor –vacuum  Tissue shelf store
processor and Rotary processor  X-ray
 Dry air oven

131
  Refrigerator large & small  Electric skull saw
 Freezer  Box for instruments
 Balancer weighing scale o Heavy & small scissors
 Microtome o Different size smooth &
 Box with cassettes and labels toothed forceps
o Malleable probe
 A large formalin container
o Scalpel handle
 Water bath
o Disposable bladders
 HE staining table o King knife
 Fume extractor o Pins for attaching specimen to
 Knife sharpener a cork surface.
 Large sink for dissection of f) Special stain rooms with fume
wage specimens extractor
 Central table for multiple use g) Histochemistry Room:
 Ruler  Lab table
c) Microscopy Reading Room:  Rotary chair
 Multiple headed microscopes >6  Refrigerator
heads at a time  Microtones
 Laboratory stools  Water bath
d) Chemical Reagent Store:  PH meter
 Shelves  Staining bench
 Lab. Table two rotary chairs h) Immunostaining Room:
 Fume extractor  Refrigerator
e) Gross Room:  Microtones
 One dissection table with cold  Water bath
and warm water
 PH meter
 Staining bench
14. The pathology service shall have the following equipments for Cytology Major
Examination unit:
a) Procedure Room:  Mobile illumination
 Coach table  Rotary chair
 Office table  Locker
 Reading table

132
16. The pathology service shall have the following equipments for Office Major
Facilities
(a) Service head/ Pathologist office  Computer
 Office tables arranged in T-  File cabinet
pattern  Meeting room
 Book shelf (c) Secretary office
 File cabinet (d) Photography room
 Bi-headed microscope  Bi-headed microscope fitted to
 Swivel chair video camera
 Normal chair  Camera (normal and video)
 Computer  Chair
(b) Laboratory Technicians room:  Computer
 Microscope  Video
 Office table  TV
 Chair

Medical Laboratory service Score point

Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
1. The laboratory shall have written policies and procedures and include at least Major
the followings:
a) Procedure manuals (Standard Operating Procedure, SOP) or guidelines
for all tests and equipment
b) Report times for results (Established turnaround time)
c) Quality assurance and control processes
d) Inspection, maintenance, calibration, and testing of all equipment
e) Management of reagents, including availability, storage, and testing for
accuracy
f) Procedures for collecting, identifying, processing, and disposing of
specimens
g) All normal ranges for all tests shall be stated
h) Laboratory safety program, including infection control
i) There shall be documentation of quality control data (internal and

133
 external quality control), calibration report, refrigerator readings and so
on.
2. The hospital shall have policies and procedures for the availability of paper Minor
based or electronic laboratory information management system (LIMS)
3. The hospital shall have standardized data collection instruments and including Major
at least the followings:
a) Laboratory request forms
b) Laboratory report forms
c) Laboratory specimen and results registers
d) Quarterly/monthly reporting forms including
e) Equipment and supplies inventory registers
f) Quality assurance record forms
g) Referral forms
4. The hospital shall develop monitoring and evaluation tools to assess activities Major
including:
a) adherence to SOPs
b) adherence to safety guidelines
c) QA activities
d) Laboratory performance and workload
e) Laboratory service
5. The laboratory shall have procedures or (SOP) for proper specimen collection Major
6. Policies and procedures shall be documented and communicated to concerned Minor
personnel
7. The laboratory shall follow standard operating procedures (SOP) and conduct Minor
routine quality assessments to ensure reliable and cost-effective testing of
patient specimens
8. Laboratory staff shall test quality control materials every eight hour and Major
document in combinations suitable to detect analytical error
9. Requests for testing shall provide: Major
a) The name of the ordering physician or other person authorized to order
testing
b) The clinician’s working address
c) Type of primary sample collected
d) The anatomic site where appropriate
e) The test requested
f) Patient gender

134
 g) Age
h) Pertinent clinical information as appropriate for purposes of test
interpretation (Clinical Diagnosis)
i) Date and time of sample collection and receipt in the laboratory
10. There shall be SOP or criteria developed for acceptance or rejection of Major
clinical samples
11. The laboratory shall maintain a record of all samples received Major
12. Laboratory shall have a procedure for storage of clinical samples if it is not Major
immediately examined
13. There shall be documentation of inspection and quality control of the tests Major
done under the hospital
14. When reports altered, the record shall show the time, date and name of the Major
person responsible for the change
15. No eating, drinking, smoking or other application of cosmetics in laboratory Major
work areas or in any area where workplace materials are handled
16. Wearing of protective clothing of an approved design(splash proof), always Major
fastened, within the laboratory work area and removed before leaving the
laboratory work area
Met Partially Un Premises
met met
17. The laboratory of the hospital shall have the following premises setup Critical
a) One main working room for recording and reporting
b) Specimen collection room
c) Medical Microbiology room
d) Serology room
e) Parasitology and urine analysis room
f) Viral load rooms
g) Hematology room
h) Clinical chemistry room
i) Sterilization, disinfection and media preparation room
j) Store-room (Major)
k) Staff room and office (Minor)
l) Separate Toilets for patients (2 for Male and 2 for female)
m) Separate Toilet for staff (Male and female) (Major)
n) There shall be access to shower upon emergency (Major)
The laboratory facilities shall meet at least the following: Critical

135
 a) The laboratory shall have a reliable supply of running water. At least
two sinks shall be provided in each room, one for general laboratory use
and the other reserved for hand washing and shall have access to
hospitals reserve tank whenever there is water interruption.
b) Continuous power supply
c) Working surface covered with appropriate materials
d) Suitable stools for the benches. Bench tops shall be impervious to water
and resistant to moderate heat and the organic solvents, acids, alkalis,
and chemicals used to decontaminate the work surface and equipment.
e) Internal surfaces, i.e. of floors, walls, and ceilings shall be :
 Smooth, impervious, free from cracks, cavities, recesses,
projecting ledges and other features that could harbor dust or
spillage
 Easy to clean and decontaminate effectively
 Constructed of materials that are non-combustible or have high
fire-resistance and low flame-spread characteristics
f) Laboratory furniture is capable of supporting anticipated loading and
uses. Spaces between benches, cabinets, and equipment are accessible
for cleaning.
g) Lockable doors and cupboards
h) Closed drainage from laboratory sinks to a septic tank
i) Facilities for disposal of contaminated materials and solid waste
j) Separate toilets/latrines for staff and patients
k) Emergency of safety services such as deluge showers and eye-wash
stations, fire alarm systems and emergency power supplies shall be
included in the laboratory services design specifications
l) Telephone or radio communication.
Met Partially Un Professional
met met
18. All laboratory services shall be directed by a licensed medical laboratory Critical
technologist
19. The Laboratory service shall have and maintain job descriptions, including Major
qualifications to perform specific functions
20. The Laboratory management shall provide adequate training, continuing Minor
education or access to training for technical staff, and assess staff competency
at regular intervals

136
21. The laboratory of this hospital shall have the following minimum staffing Major
requirements.
a) One professional with masters of degree in any of the clinical
laboratory science specialties (Hematology , clinical chemistry,
laboratory management and Medical microbiology)
b) Two Medical Laboratory Technologists (BSc) for hematology
c) One Medical Laboratory Technologists (BSc) for clinical chemistry
d) Four Medical Laboratory Technologists (BSc) for parasitology,
serology and urinalysis
e) One Medical Laboratory Technologists (BSc) for virology
f) Two Medical Laboratory Technologists (BSc) for microbiology and
mycology
g) One Medical Laboratory Technologist (BSc) for QC/QA
h) Supportive staff (clerks, cleaners, trained sample collectors)
Met Partially Un Products
met met
22. Laboratory shall establish a programme that regularly monitors and Critical
demonstrates proper calibration and function of instruments, reagents and
analytical system. It shall also have a document
23. Laboratory shall have a documented and recorded programme of preventive Major
maintenance which at a minimum follows the manufacturer’s
recommendation
24. There shall be a written chemical hygiene plan that defines the safety Major
procedures to be followed for all hazardous chemicals used in the laboratory.
The plan defines at least the following:
a) The storage requirements
b) Handling procedures
c) Requirements for personal protective equipment
d) Procedures following accidental contact or overexposure
e) The plan is reviewed annually, and updated if needed, and is part of
new employee orientation and the continuing education program
25. The following minimum equipments and consumables shall be required Major
Tests Major Equipments
Clinical chemistry:  Autoclave
 Blood glucose  Timer
 Lipid profile  Clinical chemistry analyzer

137
 o Cholesterol (Automated)
o Triglyceride  Chemistry analyzer (semi
o LDL automated)
o HDL  Glucometer
 Serum electrolytes  PC and a printer
o Na+,K+,Cl-  Bunsen burner
 Liver function tests  Power surge protectors
o ALKP, AST, ALT,   Weighing balance
GT  Spectrophotometer/
o Total bilirubine Colorimeter
o Direct bilirubine  Micropipettes of different :
o Total protein  Hemacytometers
o Albumin  Hemacytometer cover slips
 Renal function tests (standardized thickness)
o Urea  Microcapillary tubes (if
o Creatinine dilutions are not needed)
o Uric acid  WBC pipette
 Cardiac function tests  RBC pipette
o LDH
 Pipette bulb Petri dish and
o CK-MB
cover
o Troponine
 Timer with alarm
o CPK
 Hormonal assay analyzer
 Hormonal tests
o T3, T4, TSH, FSH,
LH
o Testosterone
o Prolactine
28. Parasitology:  Blood film for malaria and Major
 Stool microscopy other hemoparasite/Malaria
 Occult blood Rapid Test
Urine and body fluid analysis:  CSF analysis Major
 Urinalysis
30. Mycology:  Fungal culture Major
 KOH test

138
Microbiology Smear and Culture Major
Hematology:  Haemoglobinometer
 Haemoglobin  Automated Hematology analyzer
 Total WBC count  Blood roller/mixer
 Differential white cell count  Water bath
 Peripheral blood film  Coagulometer
 ESR  Refrigerator
 Hematocrit  Electrophoresis machine
 Binocular microscope x10, x40,
 Platelet count
x100
 Bleeding time
 Haemocytometer
 Reticulocyte count  Microhematocrit centrifuge
 prothrombin time  Microhematocrit reader
 Hb electrophoresis  Differential counter
 Lupus Erythematosus  Tally counter
Serology:  Deep freezer
 H.Pylori  Centrifuge
 Troponin  Timer
 HBs Ag  Vortex mixer
 HCV  Distillation unit
 Toxoplasma latex  CD4 machine
 ASO  Viral load machine
 RF  Autoclave
 CD4 count  Dry oven
 RPR  Safety cabinet
 TPHA  Refrigerator
 CRP  Deepfrezer
 Salmonella Typhi-O  Waterbath
 Salmonella Typhi-H  Incubator
 Proteus-OX19  PH meter
 HIV-test  Digital balance
 Viral load  Microscope
 Blood Group (Anti-A, Anti-  And other major culture and
B, Anti-D, Compatibility sensitivity equipments
testing and Cross match)
Bacteriology

139
 Pharmaceuticals Service Score point
S.N Compliance status Standard to be addressed Remark
Met Partially Un Practice
met met
Dispensing and Medication Use Counseling:
1. Standard operating procedure for dispensing and medication use counseling Minor
shall be established to ensure patients’ safety and correct use of medications
2. Dispensers shall make sure that prescriptions are legible, written by Critical
authorized prescriber and complete. Prescription papers shall be standardized
3. All medicines shall be dispensed with adequate and appropriate information Critical
and counseling to patients for correct use of their medications
4. The containers used for dispensing shall be appropriate for the product Critical
dispensed and all containers intended for medicines shall be protected and
kept free from contamination, moisture and light
5. All medicines to be dispensed shall be labelled and the labels shall be Critical
unambiguous, clear, legible and indelible
6. Filled prescriptions shall be signed and accountability must be accepted by Critical
the dispensing pharmacist
7. The pharmacy shall keep individualized information for patients with chronic Major
illnesses medication program using standardized information tracking formats
and update patient medication profile during each refill visit
8. Cautionary instructions and ancillary information about medications shall be Critical
communicated in writing to the personnel responsible for administering
medications
Control of Drug Abuse, Toxic or Dangerous Drugs:
9. The specialized hospital shall establish Policies and procedures to control the Major
administration of narcotic drugs and psychotropic substances with specific
reference to the duration of the order and the dosage in accordance with
relevant laws
10. All controlled substances (narcotic and psychotropic drugs) shall be Critical
dispensed to the authorized health professional designated to handle
controlled substances by a licensed pharmacist in the hospital
11. When the controlled substances are not in use, they shall be maintained in a Critical
securely locked, substantially constructed cabinet or area

140
12. The administration of all controlled substances to patients shall be carefully Critical
recorded into the standard record for controlled substances and returned back
to the pharmacist upon refill of controlled substances
13. All partially used quantities of controlled substances shall be recorded in to Minor
the control substance record and returned back to the responsible pharmacist
for control substances for disposal
14. Any return of controlled substances to the pharmacy in the hospital shall be Minor
documented by a licensed pharmacist responsible for controlled substance
handing in the hospital
15. The hospital shall submit regular report to the appropriate organ regarding the Critical
consumption and stock of controlled drugs
Hospital Based Medicine Preparations:
16. Written procedures/SOPs for hospital based medicine preparations shall be Major
established for preventing errors, medicine-medicine interactions and
medicine contamination
17. Licensed pharmacists shall be responsible for the preparations of various Critical
medicine formulations
18. The hospital shall have a pharmacy-based intravenous infusion admixture Minor
program
19. Ingredients used in preparations shall have their expected identity, quality, Critical
and purity, and shall be from legally licensed sources
20. Medicine preparations shall be of acceptable strength, quality, and purity, Critical
with appropriate packaging and labeling, and prepared in accordance with
good compounding practices, official standards, and relevant scientific data
and information
21. Appropriate stability evaluation shall be performed or determined using Major
international standards for establishing reliable beyond-use date to ensure that
the finished preparations have their expected potency, purity, quality, and
characteristics, at least until the labeled beyond-use date
22. Written procedures and records shall exist for investigating and correcting Major
failures or problems in compounding, testing, or in the preparation itself.
23. Clinical Pharmacy Services:
24. The hospital through drug and therapeutic committee shall establish policies Minor
and procedures for the provision of clinical pharmacy services
25. The pharmacist shall review, monitor and propose for modification of the Major
therapeutic plan in case of adverse effects, patient noncompliance, evidence-

141
 based efficacy problem and as appropriate, in consultation with the patient,
prescriber and nurse
26. Medication education shall be delivered to patients or their caregivers upon Major
discharge by the clinical pharmacist
27. The drug and therapeutic committee of the hospital shall develop/adopt and Minor
implement antimicrobial prescribing, dispensing and usage policy
28. Emergency Pharmacy Services:
29. Emergency pharmacy service shall be opened for 24 hours and directed by a Critical
licensed pharmacist who is accountable to the emergency unit of the hospital
30. The responsible pharmacist shall take the duty to coordinate and prepare Major
emergency medicines lists and ambulance kits for the hospital
31. The emergency pharmacy, in addition to supply of medicines, shall record Major
patient medication information and ensure correct use of medications
Adverse Drug Event, ADE/ Pharmacovigilance:
32. The specialized hospital pharmacy shall appoint an ADE (adverse drug event) Major
focal person responsible for the collection, compilation, analysis and
communication of adverse drug reaction, medication error and product
quality defects related information to the DTC then finally to FMHACA
33. Adverse medication effects shall be noted in the patient’s medication record Critical
34. All the ADE reports, patient identity, reporters and medicine trade names Major
shall be kept confidential until verified by concerned authority
35. The reporting of ADE shall be done by the national ADE prepaid yellow form Major
prepared by FMHACA
Medicine Supply and Management:
36. A drug and therapeutics committee (DTC) representing different service units Major
of the hospital shall be in place for selection of medicines and other medical
items
37. The specialized hospital shall have written policies for the procurement of Minor
medicines from government and private suppliers shall be available in the
pharmacy
38. The pharmacist shall ensure that both the supplier and the manufacturer of Critical
any medicine purchased are reputable and licensed by FMHACA
39. The hospital shall be responsible to make sure that donation of medicines has Critical
been made in accordance with the relevant medicine related laws
40. The responsible pharmacist shall ensure that all medicine storage areas are Minor
inspected regularly

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41. Special storage conditions shall be maintained for medicines requiring cold Critical
chain system, controlled substances, radiopharmaceuticals and medical gases
42. Firefighting equipment or system shall be installed to medicine storage places Major
43. There shall be written SOPs on how supplies of stock are to be obtained from Minor
the medical store
44. Written procedures shall be available for the return of expired, damaged, Minor
leftover and empty packs from outlets to medical store to prevent potential
misuse
45. The hospital shall maintain stock control system (manual and/or Major
computerized system) in the central medical store and dispensaries
46. The DTC should be responsible for developing policies and guidelines on Minor
how to organize and conduct medicines use studies
Medicines/Drug Information Services
47. The hospital shall establish a medicine information center which provides Major
medicine information services and shall be directed by a licensed pharmacist
trained in the provision of medicine information services
48. The medicine information pharmacist shall be member of the hospital DTC Major
49. The service shall be available at least during normal working hours Major
Medicine Waste Management and Disposal:
50. The disposal of medicine wastes shall be in compliance with the medicines Critical
waste management and disposal directives issued by FMHACA
51. All personnel involved in medicines waste handling shall wear protective Critical
devices like apron, plastic shoes, gloves, head gears and eye glasses when
appropriate
52. Solid wastes from the pharmacy shall be categorized as “hazardous” and Major
‘non-hazardous” and shall be collected separately for proper treatment
53. The hospital shall form a medicines disposal committee to ensure safety, Major
accountability and transparency
Recording:
54. Each hospital shall maintain records to assure that patients receive the Major
medications prescribed by a prescriber and maintain records to protect
medications against theft and loss
55. There shall be a standardized Prescription Registration Book for recording Major
prescriptions and dispensed medicine
56. Each patient with a chronic disease shall have a separate Patients Medication Major

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 Profile Card (PMP) that should be filled appropriately with all the relevant
information for each patient
57. Every transaction related with medicines should be recorded on stock control Major
cards and/or computerized stock control system in the medical store and
dispensaries
Billing:
58. Medicines shall be received and issued using standard receiving and issuing Major
vouchers with serial number licensed by the appropriate finance bureau of the
government
59. Dispensing pharmacies shall use a standard stamp and seal for approving Major
legal transactions
60. A multidisciplinary drug and therapeutic committee chaired by the CCO and Major
supported by a licensed pharmacist representing the hospital pharmacy
services as a secretary must be functional for the overall improvement of
pharmaceutical services in the hospital
61. The pharmaceutical services shall be represented by a licensed senior Major
pharmacist in every management meetings of the hospital
Met Partially Un Premises
met met
62. Dispensing counter shall be designed to secure patient privacy and Minor
confidentiality
Entrances, dispensing counters and doorways shall be accessible to persons Minor
with disability
The pharmacy premises shall have the following minimum space at different Major
service delivery points.
a) Waiting area g) Cashier room
b) Inpatient dispensing room h) Medical store intended for
c) Outpatient dispensing with medicines, vaccines, lab reagents
counseling room and
d) Emergency dispensing room i) Medical equipment storage
e) Compounding room j) Office and duty room
f) Medicine information center k) Staff toilet (female and male
room(s) l) Cold room, optional
Met Partially Un Professional
met met
63. The overall hospital pharmaceutical service shall be directed by a licensed Critical

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 pharmacist
64. In addition, the hospital shall have the following licensed pharmacist for each Major
of the following service delivery points.
 Two for outpatient pharmacy,
 Two for inpatient pharmacy (clinical pharmacist),
 One for emergency pharmacy,
 One for compounding service,
 One for medicines information center, and
 Two for central medical store and overall medicine supply
management.
65. The pharmacist who is working at the inpatient pharmacy shall serve as ADE Critical
focal person for the hospital
66. The hospital pharmacy shall have an accountant from finance division, clerks, Minor
cashiers, cleaners and porters
67. All staff shall receive appropriate training, information and orientation at the Minor
time of appointment to any position in the pharmacy
68. The responsible pharmacist shall ensure that written job descriptions are Minor
prepared for all staff and that all staff are acquainted with their job
descriptions and responsibilities
Met Partially Un Products
met met
 Working bench  Micropipettes: Major
 Mortar and pestle  Glass type
 Water distiller  Cylindrical graduate
 Water bath  Conical graduate
 Electrical hotplate  Weighing dishes
 Evaporating dish  Weighing paper
 Spatula  Refrigerators
 Gloves  Wall thermometers
 Glass rod  Ventilator or AC as required
 Wash bottle  Hygrometer
 Funnel:  Tablet counter
 Beakers  Scientific calculator

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  Volumetric flask  Table and chair
 Volumetric flask  Scissors
 Balances  Adult and pediatric
 Ointment tile weighing balance
 Internet facility access (optional  Telephone line

Infection prevention Score point

S.N Compliance Status Tasks to be addressed Remark
Met Partially Un Practice
met met
1. All activities performed for infection prevention shall comply with the Major
national infection prevention guidelines.
2. Infection risk-reduction activities shall include: Critical
a) equipment cleaning and sterilization, in particular, invasive equipment;
b) laundry and linen management;
c) disposal of infectious waste and body fluids;
d) the handling and disposal of blood and blood components;
e) kitchen sanitation and food preparation and handling;
f) Operation of the mortuary and postmortem area;
g) Disposal of sharps and needles;
h) Separation of patients with communicable diseases from patients and staff
who are at greater risk due to immunosuppression or other reasons;
i) management of hemorrhagic (bleeding) patients; and
j) Engineering controls, such as positive ventilation systems, biological
hoods in laboratories, and thermostats on water heaters.
3. The following policies and procedures shall be maintained Major
a) Hand hygiene
b) Transmission-based precautions
c) Post-Exposure Prophylaxis programs (PEP) for some
communicable diseases like rabies, HIV, meningitis, hepatitis
d) Environmental infection prevention
e) Waste management
Met Partially Un Professional
met met

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4. The hospital shall have an IP committee coordinated by a full-time infection Major
prevention and control officer.
5. The officer shall be a licensed infectious diseases specialist or IP trained Critical
health professional (physician or health officer or BSc nurse), or a public
health specialist knowledgeable of infection prevention principles and
hospital epidemiology.
6. The IP committee shall be composed of professionals at least from the Major
following service units
a) Nursing care g) Laboratory
b) Medical services h) Laundry
c) Environmental health i) Kitchen
d) Housekeeping j) Instrument sterilization and supply
e) Administration k) Occupational health and safety
f) Pharmacy l) Quality management
8. The infection prevention committee or designate shall have written protocols, Minor
procedures
Met Partially Un Products
met met
9. The hospital shall have the following adequate supplies and equipment Critical
needed for infection prevention and control practice.
a) Waste management equipment and supplies:
 Incinerator  Garbage bins
 Placenta pit  Large garbage bin
 Wheelbarrows  Plastic garbage bags (optional)
 Ash pit  Safety boxes
 Burial pit
b) Cleaning
 Mop  Cleaning cloth
 Bucket  Detergent
 Broom  Bleach
 Dust mop
c) Laundry
 Washing machine  Dryers
 Sink  Irons

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  Washing basin (for  Wheelbarrows (to transport linens
decontamination of linens) to/from wards)
 Drying rack/line  Detergent
 Bleach
d) Instrument processing
 Autoclaves and steam  0.5% chlorine solution (diluted
sterilizers, bleach)
 Test strips  Storage shelves for the medical
 Chemicals equipment
 Commercial steamer  Disinfectant chemicals
 Boiler  Brushes (tooth brush for small
 Oven items)
e) Hand hygiene
 Sinks (ward and other  Soap
areas)  Alcohol based hand rub
 Water container with faucet  Personal Towels
 Paper Towel
f) Personal Protective Equipment
 Heavy duty glove  Surgical/Disposable
 Surgical glove  Respiratory mask
 Examination glove  Other type of face mask
 (latex or nitrile)  Plastic apron
 Other types (ex. those worn  Other types
by cleaning and laundry  Boots
staff)  Nurse shoes
 Eye shield  Other protective shoes
 Goggle  Caps
 Visors  Face shield
 Dust mask

Food & dietary service Score point

S.N Compliance Status Tasks to be addressed Remark

148
 Met Partially Un Practice
met met
1. The hospital shall provide nutritionally adequate meals, food supplemental Critical
supplies for inpatients and staffs on duty
2. The dietary service shall be available for 24 hours a day and 365 days a year Critical
3. The dietary service shall have written policies and procedures for all dietary Minor
services including
a) Preparation and handling
b) Meal distribution and/or request and receive special event service for
inpatients.
c) Special diet order
d) Holidays
e) A diet manual detailing nutritional and therapeutic standards for meals
and snacks, and a nutrient analysis of menus.
f) Nutritional assessment guide for patients' nutritional needs for food and
food supplements.
4. Each patient's diet shall be recorded in the medical record. records of diet Major
instructions shall include:
a) The diet instruction provided to the patient and/or responsible person.
b) Patient response, participation and understanding.
c) Written instructional material provided to the patient and/or responsible
person.
5. At least three meals (breakfast, lunch and dinner) shall be served daily, and Critical
no more than 15 hours shall elapse between dinner and breakfast.
6. The dietary service shall follow the policies and procedures developed by the Minor
drug and therapeutics committee regarding possible food/medicine
interactions.
7. Patients with special dietary needs, based on criteria established by the Major
hospital, shall receive dietary instruction from a physician during
hospitalization.
8. The dietician shall provide nutrition information as requested by the patient, Minor
family, or treatment team including
a) diet instructions,
b) written instructional material,
c) community dietary referrals regarding special diets
d) current diet order,

149
 e) nutritional problems,
f) appetite,
g) nutritional counselling,
h) comprehension of diet instruction,
9. Inpatient’s or discharged patient’s diet instructions shall include education Major
involving:
a) therapeutic or modified diets
b) food- medicines interactions
c) nutritional care for certain diagnoses/conditions
d) recommendations for changes in diet order,
e) treatment plan,
f) significant food allergy (lactose, wheat gluten, soya ,egg, dairy)
10. Therapeutic goals related to nutritional needs shall be based on the following Major
standards
 Standard Height/Weight
 Dietary Reference Intakes
 Nutrition-related laboratory values
 Body Mass Index for Adults
11. Physician diet orders shall be legible, concise, and written in an Major
understandable manner. The following information shall be included in diet
orders:
 Patient Name
 Unit
 Date
 Specific diet order; including food allergies/intolerances
 Physician’s signature
12. Dry or staple food items shall be stored at least 12 inches off the floor in a Major
ventilated room which is not subject to sewage or waste water back-flow, or
contamination by condensation, leakage, rodents or vermin
13. All perishable foods shall be refrigerated at the appropriate temperature and Major
in an orderly food safety manner (cold and hot holding principle).
14. Three compartments dish washing procedures and techniques shall be Critical
developed and carried out in compliance with the national hotel and
restaurants sanitary control guideline.
15. All garbage and kitchen refuse which is not disposed of shall be kept in leak Major
proof non-absorbent containers with close fitting covers and all garbage

150
 containers shall be thoroughly cleaned inside and outside each time emptied.
Met Partially Un Premises
met met
16. The following minimum facilities shall be available for dietary services Major
a) Food preparation room d) Dietitian's office.
 All cooking appliances shall e) Janitor’s closet
have ventilating hood f) Personnel toilets with hand
 Dish washing sink with three washing facilities
compartment g) Approved automatic fire
extinguisher system in range hood.
 Pot washing sink
h) Continuous electricity (power)
 Cart cleaning sink supply
 Can wash sink i) safe and adequate water supply
b) Storage room
c) Cart storage.
Met Partially Un Professional
met met
18. The hospital shall have an organized dietary service unit directed by licensed Critical
dietitian or catering chef or food science personnel.
19. In addition, the hospital shall have the following food personnels: Critical
a) Meal distributor d) Store keeper
b) Chef cooker e) Bakers
c) Kitchen workers f) Dishwashers
21. Food handlers shall meet routine health examinations according to the Critical
Ethiopian Food Handlers’ Hygiene Guideline for food service personnel.
22. All kitchen workers shall wear protective kitchen clothes according to the Critical
Ethiopian Food Handlers’ Hygiene Guideline.
Met Partially Un Products
met met
23. The following products are available for dietary services: Critical
a) Refrigerator j) Pressure cooker
b) Kitchen utensils k) Stoves
c) Pots l) Working closes (like apron, boots,
d) Jars hair cover, gown, hand gloves)
e) Carts m) Barrel (garbage containers) for
f) Dishes kitchen rest handling

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 g) Oven n) Lockers convenient to, but not in
h) Knives the kitchen proper
i) Detergent materials

Sanitation & waste management Score point

S.N Compliance Status Task to be assessed Remark
Met Partially Un Practice
met met
1. There shall be a written policy and procedures for ground water treatment. Minor
2. Infectious medical wastes shall be handled and managed according to the Major
recent Health Care Waste Management National Guideline.
3. Infectious and non infectious medical waste containers shall be leak proof, Critical
have tight-fitting covers and be kept clean and in good repair until disposal.
4. Placenta disposal pit shall be available in the hospital and shall be secured Critical
5. Wastes shall be segregated and segregation of healthcare waste shall include Critical
the following procedures,
a) Separate different types of waste
b) The hospital shall provide colored waste receptacles specifically suited
for each category of waste
c) Segregation shall take place at the source, like ward bedside, OR,
laboratory etc
d) There shall be 3 bin systems used to segregate different types of waste
in the hospital
6. All generators of infectious medical waste and general medical waste shall Minor
have a medical waste management plan that shall include the following:
a) Storage of medical waste
b) Segregation of medical waste
c) Transport of medical waste
d) Disposal of medical waste
Met Partially Un Premises
met met
7. Placenta disposal pit shall have dimension of height 2.5m, width 2.5m and Critical
lateral to the disposal pit the two sides shall be filled with concrete.
8. In addition, the hospital sanitary system shall have Critical
a) Functional sewerage system f) Sanitary office

152
 b) Flushing toilets g) Incinerator
c) Plumbing setup stores h) Dumpster (Genda for solid waste
d) Kitchen accumulation)
e) Laundry
Met Partially Un Professional
met met
9. Hospital sanitation shall be administered by a licensed environmental health Critical
professional or any related professional trained on sanitary sciences
10. The hospital shall have the following personnels. Major
a) Environmental health professional
b) Housekeeping staff such as cleaners and waste handlers
c) Laundry staff
d) Gardeners
e) Incinerator operator
f) Instrument processors (disinfector and sterilizer)
Met Partially Un Product
met met
11. The hospital shall have the following equipment and supplies required for Critical
sanitation activities:
a) Incinerator i) PPE (personal protective
b) Ash pit equipment)
c) Burial pit j) Autoclave
d) Placenta pit k) Pressure cooker (Minor)
e) Garbage bins l) Cleaning supplies
f) Safety boxes (detergents,
g) Trolley to transport waste Disinfectants and other
h) Dumpster (Genda) shall be cleaning solutions etc
placed in a clean isolated and m) Laundry washers,
fenced area. n) Laundry dryers,
o) Mops and dust bins

Housekeeping, laundry & maintenance service

S.N Level of Compliance Task to be assessed Remark
Met Partially Un Practice

153
 met met
1. The housekeeping service shall have the following sanitary activities. Critical
a) Basic cleaning such as dusting, sweeping, polishing and washing
b) Special cleaning of
 Different types of floors
 Wall & Ceiling
 Doors & Windows
 Furniture & Fixtures
 Venetian Blinds
c) Cleaning and maintenance of toilet.
d) Water treatment, filtering & purification.
2. Collection, transportation and disposal of hospital wastes shall be supervised Major
and controlled
3. The following LINEN services shall be provided in the hospital Major
a) Maintain an adequate supply e) Issues linen in service units like
of clean linens at all times wards.
b) Obtain linen from stores and f) Keep proper accounting of linen.
laundry. g) Ensure proper sorting of linen.
c) Ensure proper storage of h) Understand different color scheme.
linen. i) Maintain linen properly
d) Supervise washing,
sterilization in the laundry
5. Potable water and electrical services shall be available 24 hours a day and Critical
365 days a year through regular or alternate sources.
6. There shall be written protocols and procedures for medical equipment Minor
maintenance
7. If the hospital does not have its own housekeeping, laundry and maintenance Critical
services; it may have a contract agreement with external organizations and
shall have documentation for a contractual agreement
8. No flammable cleaning agents or other flammable liquids or gases shall be Major
stored in any janitor's closet or other area of the hospital except in a properly
fire rated and properly ventilated storage area
Met Partially Un Premises
met met
9. If the hospital maintains its own laundry, it shall have separate areas for: Critical

154
 a) Collection of soiled linens.
b) Washing, drying and ironing.
c) Clean linen storage and mending area.
10. Clean linen storage shall be readily accessible to nurses' stations Major
11. Soiled linen storage shall be well ventilated and shall be located convenient Major
to the laundry or service entrance of the hospital.
12. There shall be separate space provided for the storage of housekeeping Major
equipment and supplies
13. Exits, stairways, doors, and corridors shall be kept free of obstructions. Major
14. The hospital shall have an alternate emergency power supply. If such Critical
emergency power supply is a diesel emergency power generator, there shall
be enough stored fuel to maintain power for at least 24 hours.
Met Partially Un Professional
met met
15. The housekeeping, maintenance and laundry functions of the hospital shall Critical
be under the direction of a licensed environmental health professional or
engineer.
16. The following professionals shall be available depending on the work load Critical
analysis
a) Engineer (electrical, civil) or architect as appropriate
b) Plumber or Painter.
c) Maintenance technician or Biomedical engineer for equipment
maintenance
d) Cleaners
Met Partially Un products
met met
17. The hospital shall have the following tools, equipment & raw materials for Major
housekeeping services
a) Equipment b) Cleaning material
 Reserve electrical c) Deodorants & disinfectant
generator d) Laundry cleaning material
 Floor cleaning brush air e) Insecticides & rodenticides
f) Stain removal
 Floor wiping brush
 Scraping pump
 Hockey type brush
 Spraying pump
 Counter brush.
155
  Ceiling brush  Flit pump.
 Glass cleaning / wiping  Rate trapping cage
brush.  Gum boots
 Scrappers  Gown, Masks & Gloves
 Dustbins paddles.  Torch
 Waste paper basket.  Manual sweeping machine.
 Plastic Mug  Floor scrubbing/polishing
 Plastic Bucket machine
 Plastic drum  Wet vacuum cleaner.
 Wheel barrow  Dry vacuum cleaner portable
 Water trolley  Fumigation machine (Oticare)
 Ladder  Bed pan washer.

1. I confirm that the above filled information/data is true about the facility.
Name of CEO/CCO _____________________________________________________________
Signature ____________________________ Date ____________________________________
2. Assessors inspection comment _________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
3. Name of Assessors:
S.N Name Title Sign
1.
2.
3.
4.

Finally, at the end of the visit, thank the management body and all staff who participated in the interview for their valuable time and comment.
Present warm greetings.

NB: This checklist is prepared based on the new comprehensive specialized hospital, but it doesn’t represent the minimum requirement of
the comprehensive specialized hospital so that you don’t only stick on this checklist you better also use the print out comprehensive
specialized hospital standard as a reference during training and assessment.

156