Ambulances CHECK LIST ● Blood bank CHECK LIST

● Adequacy of parking for Ambulances ● Blood bank license and adherence to its terms and conditions

Statutory requirements ● Adherence to part X B and Schedule F of part XII B and/or XII C
of drugs and cosmetics rules
● RC book
● License of driver (s) ● Informed consent
● Insurance
● Emission check ● Patient and family education about donation
● Ambulance: adequate equipment in working order
● Availability and transfusion of blood/ components during
● Training of personnel on BLS/ACLS
emergency
● Checklist for ambulance-lights, siren, beacon lights etc.
● Check list of Ambulance, drugs and equipment. ● Transfusion reactions analysis
● Emergency medications checking-daily /prior to dispatch using checklist.
● Proper communication system. Staff awareness on above

________________________________________________________________________ Segregation of bio-medical waste

● CATH LAB CHECK LIST ● Committee CHECK LIST

● Comply with BARC/AERB legal requirements ● Composition and functioning of Resuscitation committee

● Scope of imaging services ● Analysis of all cardiac arrests

● Performing and reporting of tests ● Corrective and preventive measures taken based on analysis

● Technician qualified as per AERB ● Pharmaco-therapeutic committee or anything similar

● Documented policies and procedures for identification and safe transportation of patients to ● Development of hospital formulary
the imaging services
● Analysis of adverse drug events
● Turnaround time - Check results are available in defined time frame
● Modification of policies where necessary based on analysis
● Critical results intimation
● Safety committee composition and functioning

1
 ● Documented procedures for outsourcing tests ● Scope of programme

● Safety programme including usage of safety equipment and TLD badges ● Development, implementation and monitoring of safety plans

● Adherence to standard precautions and safe practices ● Ethics committee

● Staff trained in safe practice; staff has safety equipment/ fire extinguisher/ dressing ● Composition as per guidelines
materials/ etc.
● Powers of this committee
● Safety devices periodically checked
● Infection control committee composition and functioning
● Imaging signage - Radiation hazard
● Quality improvement committee composition and functioning
● Procedure for procuring and using implants
Prevention of sexual harassment committee
● Entry of batch and serial number in patient’s case file and master log book
DIALYSIS CHECK LIST
● Policy on consent. Who can give consent when patient is incapable/ Informed consent
situations/ performing doctor’s name ● Overall adherence to infection control

● Re-use policy ● Re-use policy of tubes, how safely it was kept and the labelling
requirement to prevent exchange/ensure patient’s safety.
● CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of events during CPR,
Communication of corrective and preventive measures ● Quality of RO water

● Emergency drug management ● Check Adequate soap, masks, gloves and disinfectants are
available.
● All equipment are inventoried and log maintained/ calibrated
● Policy on consent. Who can give consent when patient is
Preventive maintenance/services labels on Equipment/calibration records/Refrigerator incapable.

__________________________________________________________________________ ● Water management- Endotoxin level test reports

● CSSD CHECK LIST ● All equipment are inventoried and log maintained / calibrated

● Space for sterilization activities ● Preventive maintenance/service labels on Equipment/calibration

records
● Layout - Unidirectional flow, segregation of areas
● Training in CPR – BLS/ ALS

2
 ● Shelf life of sets ● Emergency drug management

● Cleaning, packing, disinfection / sterilization, storing and issue of items ● Sterilized sets: expiry dates, storage conditions

● Reprocessing of instruments ● Check hand washing facilities for staff in all care area, instructions
for proper hand washing
● Regular validation testing for sterilization carried out and documented
● Check Adequate soap, masks, gloves and disinfectants are
● Recall procedure when breakdown in sterilization system available

● ETO Chimney ● Segregation of bio-medical waste

● Equipment cleaning and sterilization practices

● Maintenance plan of equipment

Emergency Check list ENDOSCOPY CHECK LIST

● Policies/procedure/protocols for emergency care ● Sedation policy implementation

● Procedure for handling MLC case (including capturing identification marks and police
intimation) ● Informed consent obtained
● Emergency care/ admission/ discharge documentation
● Check who gives sedation and who monitors patient Intra-
● Triage, contents of triage policy: categories, ask for demo
procedure monitoring)
● Mock drills of disaster management
● Training in CPR – BLS/ ALS
● Documentation of monitoring activities
● Patient admission/ time for admission request completion
● Managing non availability of beds ● Discharge criteria
● Admission criteria and priorities for ICU
● P & P for transfer-in of patients ● Availability of equipment and manpower
● P & P for transfer-out/referral of unstable patients to another facility
● P & P for transfer-out/referral of stable patients to another facility ● Emergency drug management
● Staff identified for transfer
● Consent
● Summary of patient’s condition
● Signposting and Directional signage’s (which language) from approach road ● Name of procedure
● Adequacy of access to Emergency (easy and unobstructed). Flow of patients, unobstructed
● Patient transfer/ In case of transfer of patients: check stability/unstable/transfer notes. ● Name of doctor
● Referral of patients
● Predefined initial assessment and re-assessment ● Explanation of risks, benefits and alternatives if any

3
 ● Time frame for doing and documenting initial assessment
● Staff awareness on above policies
● IV sedatives in emergency: conscious sedation, monitoring, consent
● Emergency drug management
● Rational prescription of medicines
● Medication administration & monitoring
● Staff interview on the methodology of administration
● Medication administration documentation
● Medications changed on monitoring
● Availability of hand washing facilities
● Segregation of bio-medical waste
__________________________________________________________________________
Engineering Support Services
● Plans for equipment as per services and strategic plan
● Equipment selection-collaborative process
● Inventory and proper logs
● Qualified and trained personnel
● Documented operational and maintenance plan
● Water Management-maintenance plan
● Electrical Systems- maintenance plan
● HVAC-maintenance plan
● Equipment replacement and disposal
____________________________________________________________________________
Biomedical Equipment Management
4
● Language (that the patient understands) used for taking consent
● Completeness of the consent form in all aspects
● Adheres to statutory norms
● Sterilization/disinfection activities being performed
● Sterilized sets: expiry dates, storage conditions
● Reprocessing of instruments if any
● Check hand washing facilities for staff in all care area, instructions
for proper hand washing
● Check Adequate soap, masks, gloves and disinfectants are
available
● All equipment are inventoried and log maintained / calibrated
● Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
● Gas and vacuum supply / Storage of oxygen cylinders/Condition
of Humidifiers
● CPR – Policy and procedure, staff trained in BLS/ALS,
Documentation of events during CPR, Communication of
corrective and preventive measures
● Medicine orders are written in a uniform location clear, legible,
dated, timed, named, signed
● Name, route ,dose, frequency / time of administration
● Verbal orders
● Written order for high risk medication
 ● Plans for equipment as per services and strategic plan ● Medication administration

● Equipment selection-collaborative process ● Staff interview on the methodology of administration

● Inventory and proper logs ● Medication administration documentation

● Qualified and trained personnel ● Patient’s self-administration of medicines

● Calibration ● Management of medications got from outside

● Documented operational and maintenance plan ● Patient monitoring after medication administration

● Equipment replacement and disposal ● Knowledge to pick adverse drug events and reporting of the same
● Validation of OT air-conditioning
● Segregation of bio-medical waste
● Change of HEPA filter (s)
● HIC CHECK LIST
_____________________________________________________________________________
● Documented Infection Control Programme
● FRONT OFFICE CHECK LIST
● Updated once a year
● Display of scope
● HIC committee and team
● Orientation of staff with respect to available services
● Infection control officer
● Procedure for registration and admission (OP, IP and Emergency)
● Qualified HIC nurse
● Generation of UHID no.
● Identified high risk areas and procedures with methods of surveillance
● Management of patients when beds are not available
● Adherence to standard precautions
● Awareness of staff
● Adherence to hand hygiene guidelines
● Display of patient rights and responsibilities
● Adherence to safe injection and infusion practices
● General consent process

● Scope of general consent ● Adherence to transmission based precautions

● Uniform pricing policy in a given setting ● Adherence to cleaning, disinfection and sterilization practices.

5
 ● Availability of tariff list ● Antibiotic policy

● Display of vision, mission & values ● Adherence to laundry and linen management

● Ownership ● Adherence to kitchen sanitation and food handling

● Services not available displayed ● Engineering controls

● Information to patients if high risk obstetric cases can be or cannot be taken ● Adherence to Housekeeping procedures

● Display of scope of paediatrics services ● Surveillance activities directed towards the identified high risk areas
and procedures
● Signage in local language

_____________________________________________________________________________ ● Collection of surveillance data

IMAGING CHECK LIST ● Verification of surveillance data

● Comply with BARC/AERB legal requirements ● Tracking and analysing of infection risks, rates and trends

● Scope of imaging services ● Compliance with hand hygiene guidelines

● Adequate Infrastructure ● Effectiveness of housekeeping services

● Performing and reporting of tests ● Appropriate feedbacks regarding HAI rates to appropriate personnel

● Technician qualified as per AERB ● Notifiable diseases are informed

● Documented policies and procedures for identification and safe transportation of ● HAI rates
patients to the imaging services
● Adequate and appropriate personal protective equipment’s
● Turnaround time - Check results are available in defined time frame
● Adequate and appropriate facilities for hand hygiene in all patient care
● Critical results intimation areas

● Standardized reporting ● Isolation/barrier nursing

● Documented procedures for outsourcing tests ● Appropriate pre and post exposure prophylaxis

● QAP documented verification and validation / surveillance / calibration/ maintenance / ● Outbreak definition

6
 corrective and preventive actions ● Procedure for handling outbreaks

● Safety programme including usage of safety equipment and TLD badges ● Implementation of laid down procedure

● Adherence to standard precautions and safe practices ● Appropriate corrective action to prevent recurrence

● Staff trained in safe practice; staff have safety equipment/ fire extinguisher/ dressing ● Authorization for generation of bio-medical waste and adherence to
materials/ etc. various conditions of the act

● Safety devices periodically checked ● Implementing & Monitoring regarding proper segregation and
collection
● Imaging signage - Radiation hazard, PC-PNDT act etc.
● Storage & transportation & Visit by the hospital authorities to the
● Emergency drug management disposal site

● Policy on consent. Who can give consent when patient is incapable/ Informed consent ● BMW facility is managed as per statutory provisions
situations/ performing doctor’s name
● Usage of appropriate personal protective equipment
● Re-use policy
● Resources
● All equipment are inventoried and log maintained / calibrated
● Budget
● Preventive maintenance/service labels on Equipment/calibration records/Refrigerator
● Induction training for all staff
_____________________________________________________________________________
● Conducts in-service training for all staff once a year
● NICU CHECK LIST
HIS CHECK LIST
● Initial assessment to include nursing assessment
● Identified information need list
● Initial assessment to include screening for nutritional needs
● License for software
● Documented plan of care including preventive aspects of the care (where applicable)
● Validation of software
● Multidisciplinary nature of care and co-ordination among various departments/ staff
/shift ● Documented policies and procedures

● Qualified individual identified as responsible for care ● IT acquisition as per the policy and procedure

7
 ● Information regarding patient’s care & response to treatment is shared ● Contributes to external databases.

● Information exchanged and document during each shit, between shift and transfer ● Standard format for data collection
between units / departments
● Resources for analysing data
● Safe transfer between departments / units
● Documented procedures for data dissemination and storing and
● Patient record available to authorised care providers retrieving data

● Documented procedure –referral of patients to other departments ● Participation of clinical & managerial staff in selecting, integrating and
using data

● Security, integrity and confidentiality of data

● Discharge planning in coordination with various departments, including medico-legal
cases / LAMA, discharge summary to all ● Safeguarding data/ record against loss, destruction and tampering

● Content of discharge summary ● Technology used for improving/maintaining confidentiality, security

and integrity
● Uniform care delivery
● Usage of privileged health information
● Evidence based medicine and clinical practice guidelines
● Documented policies and procedures on how to handle MR
● Care of vulnerable patients - Policy and procedure, safe and secure environment, information requirement
informed consent from the appropriate legal representative
HRD CHECK LIST
● Care of patients undergoing surgical procedures - Policy and procedure, preoperative
assessment and provisional diagnosis documented prior to surgery, informed consent ● Staff planning
obtained by a surgeon
● Job specification/Job description
● Check hand washing facilities for staff in all care area instructions for proper hand
washing ● Criminal antecedents verification

● Check Isolation /Barrier nursing facility available ● Recruitment procedure and is based on predefined criteria

● Check if adequate soap, masks, gloves and disinfectants are available Hand washing ● Induction training

● PEP o Orientation to Vision, mission and values

● Bio-medical waste o Employee rights & responsibilities

8
 ● Policy on consent. Who can give consent when patient is incapable/ Informed consent o Patient rights and responsibilities
situations/ performing doctor’s name
o Service standards
● Signage
o Organisation wide policies & procedures as well as relevant
● Fire exit ,fire extinguishers, no smoking signs etc. department / unit / service/ programmes, policies and
procedures
Medical record unique no. / Dated and timed entry / author is clear, up-to-date and chronological.
● Training policy
______________________________________________________________________________
● Training records
● MRD CHECK LIST
● Training when job responsibilities change /new equipments are
● Birth and Death report to concerned authorities introduced

● Communication pertaining to notifiable diseases ● Training effectiveness-feedback mechanism

● Voluntary participation in any database/registry Orientation of staff regarding the scope of services provided by the
organization
● Medical record unique no
● The staff is aware of admission and registration of outpatients,
● Policy on authorized person to make entry inpatients and emergency patients process, whom to contact if
they need any clarification on the services provided, managing of
● Every entry is dated and timed patients during non availability of beds
● Orientation of laboratory personnel in safe practices.
● Author is clear
● Orientation of imaging personnel in radiation safety measures
● Training of staff regarding the policies and procedures for care of
● Contents of medical record are identified
emergency patients
● Records are up to date and chronologically arranged ● Training of Staff in Ambulance staff in ACLS,BLS, First Aid &
Emergency Medicine
● 24 hour availability of the medical record to ensure continuity of care. ● Training of staff in cardio pulmonary Resuscitation( those who
provide direct patient care)
● Medical record has reason for admission / diagnosis/ plan of care/ Operative and Procedure ● Training of staff to implement the policies for rational use of
sheet blood and blood products
● Training of staff in guiding the care of patients in the Intensive
● Contains results of tests carried out
care and high dependency units
● Training regarding care of vulnerable group
● Operative and other procedures performed are incorporated.
● Training of staff on restraint techniques
● Educating and training of staff in end of life care

9
 ● Transferring patients medical records have date of transfer/reasons/name of receiving ● Staff are educated on safety precautions w.r.t usage of radio
hospital active drugs
● Training of staff regarding informed consent procedure
● Signed Discharge note/copy of death certificate with cause, date and time of death ● Regular pre-induction training and “in-service training sessions
for appropriate categories of staff
● Copy of clinical autopsy report (where applicable)
● Coordinating and communicating the staff about continuous
quality improvement programme through proper training
● Access to current and past medical record
mechanism.
● Security, integrity and confidentiality of data ● Staff is trained regarding patient-safety programme of the
organization
● Safeguarding data/ record against loss, destruction and tampering ● Training for staff regarding safety education programme
● Training for staff to operate and maintain equipment and utility
● Technology used for improving/maintaining confidentiality, security and integrity systems
● Training for staff to operate and maintain biomedical equipment
● Usage of privileged health information
● Training of staff on Fire and Non-fire emergencies
● Documented policies and procedures on how to handle MR information requirement ● Training of staff about hospital’s disaster management plan
● Educating and training of staff for handling hazardous materials
● Retention Policy ● Induction training for every staff joining the organization.
● Orientation of staff about organization’s mission, Vision,
● Maintenance of confidentiality and security at all stages Objectives, goals and Service standards. (Induction training)
● Awareness of staff about their rights and responsibilities
● Method for destruction of medical records ● Educating staff regarding patients’ rights and responsibilities
● Educating staff regarding orientation to the service standards of
● Medical record audit
the organization.
o Frequency ● Aware of staff regarding the hospital wide policies and
procedures as well as relevant department
o Sample size ● Training of staff about the risks within the hospital environment
● Training of staff on procedures to follow in the event of an
o Person (s) authorized incident
● Training of staff on occupational safety aspects
o Timeliness, legibility and completeness ● Awareness of performance appraisal system at the time of
induction
o Active and discharged patients
● Awareness of staff about the disciplinary procedure & grievance
handling of the organization
o Deficiencies identified and documentation of same
● Training on risk within the organisations environment

10
 o Corrective and preventive actions ● Reporting format

● Discharge summary ● Staff awareness in the event of an incident

o reason for admission, findings, diagnosis, condition at the time of discharge ● Training on occupational safety aspects

o investigation results, procedure performed, medication and other treatment given ● Documented performance appraisal system

o follow up advice and medication instructions ● Employee awareness

o when and how to obtain urgent care ● Predetermined criteria

o Summary includes cause of death in case of deceased patients ● Used as tool for further development

● Check for completeness of consent documents ● Carried out at predefined intervals and documented

● Consent for anaesthesia, blood transfusion, research and surgical procedures ● Documented disciplinary procedure based on principles of natural
justice and in
● Authorized legal representative
● consonance with laws
● General consent
● Staff awareness
● Language of consent
● Provision of appeal
● Care plan is countersigned by the clinician in-charge of the patient within 24 hours
● Redress procedure addresses the grievance
● Medico legal case documentation
● Action takenPre-employment medical examination
LAMA case file has discharge summary and risks explained
● Medical benefits for employees
● Authorized legal representative
● Regular health check (at least once a year) of staff involved in patient
● Patient assessment includes detailed nutritional, growth, psychosocial and immunization care
assessment
● Occupational health hazards
The children’s family members are educated about nutrition, immunization and safe parenting
and this is documented in the medical record ● Personal file for every employee containing information on

______________________________________________________________________________ o Educational qualification

11
 CANTEEN CHECK LIST o Disciplinary background

o Food is prepared, handled, stored and distributed safely o Health status

● Storage of raw materials especially pest control, dry storage, cold storage o In service training

● Washing facility o Performance appraisal

● Unidirectional / non cross-over of flow of activities (clean/dirty) ● Credentialing of doctors

● Hygiene and cleanliness ● Updating of credentials

● Food handlers use personal protective gear ● Verification where appropriate

● License for canteen ● Granted privileges

● Any usage of domestic gas cylinders ● Requisite services are known to them as well as the various
departments / units
● Maintenance plan of machinery
● Admit patients and care as per their privileging
● Layout/ space
● Credentialing of nurses
● Fire safety awareness , safe exit plan and fire-fighting equipment
● Updating of credentials
● Electrical safety practices
● Verification where appropriate
● Staff awareness on safety practices
● Granted privileges
● Health status of employees – Immunization for Typhoid and Hepatitis A/Stool culture and
sensitivity ● Requisite services are known to them as well as the various
departments / units
HK CHECK LIST
● Admit patients and care as per their privileging
● Effectiveness of housekeeping services
● Prevention of sexual harassment committee
● Disinfection process
● Registration and admission process training
● Identified hazardous materials
● Training of lab personnel in safety
● Hazardous materials identified have documented procedure for sorting, storing, handling etc.

12
 ● Availability of MSDS for all such material ● Training of imaging personnel in safety

● Spill management plan ● CPR training

● Staff awareness ● ICU CHECK LIST

______________________________________________________________________________ ● Initial assessment to include nursing assessment

● LAUNDRY CHECK LIST ● Initial assessment to include screening for nutritional needs

● Process flow ● Documented plan of care including preventive aspects of the care
(where applicable)
● Segregation of linen
● Multidisciplinary nature of care and co-ordination among various
● Disinfection departments/ staff /shift

● Bags and labels ● Qualified individual identified as responsible for care

● Quality control system ● Information regarding patient’s care & response to treatment is
shared
● Quality control of outsourced activity (if outsourced)
● Information exchanged and document during each shit, between
● Maintenance plan of machinery
shift and transfer between units / departments
● Layout/ space
● Safe transfer between departments / units
● Electrical safety practices
● Patient record available to authorised care providers
● Staff awareness on safety practices
● Documented procedure –referral of patients to other
______________________________________________________________________________ departments

OPD CHECK LIST

● Predefined initial assessment ● Discharge planning in coordination with various departments,

including medico-legal cases / LAMA, discharge summary to all
● Who performs the initial assessment
● Content of discharge summary
● Time frame for doing and documenting initial assessment

13
 ● Initial assessment includes nursing assessment at the time of admission and documented. ● Uniform care delivery

● Initial assessment to include screening for nutritional needs. ● Evidence based medicine and clinical practice guidelines

● Documented plan of care including preventive aspects of the care ● Care of vulnerable patients - Policy and procedure, safe and
secure environment, informed consent from the appropriate
● Plan of care countersigned by the clinician-in-charge within 24 hours legal representative

● Plan of care includes goals or desired results, care or services
● Regular reassessments at appropriate intervals.
● Informed of their next follow-up.
● Staff involved in direct clinical care documents reassessments.
● Care of high risk obstetrical patients – display
● Provision of antenatal services.
● Care of patients undergoing surgical procedures - Policy and
procedure, preoperative assessment and provisional diagnosis
documented prior to surgery, informed consent obtained by a
surgeon
● Check hand washing facilities for staff in all care area instructions
for proper hand washing
● Check Isolation /Barrier nursing facility available

● Check if adequate soap, masks, gloves and disinfectants are

● Maternal Nutrition assessment.
available Hand washing
● Care of paediatric patients
● PEP
o display the scope
● Bio-medical waste
o Age Specific competency
● Policy on consent. Who can give consent when patient is
o provisions for special care of children incapable/ Informed consent situations/ performing doctor’s
name
o detailed nutritional, growth, psychosocial and immunization assessment
● Signage
o Child / Neonate abduction & abuse.
● Fire exit ,fire extinguishers, no smoking signs etc.
● Parent education on nutrition, immunization and safe parenting and documentation of the
● Medical record unique no. / Dated and timed entry / author is
same
clear, up-to-date and chronological.
● Staff awareness on above policies
● Patient interview
● PICU CHECK LIST
● Patient admission from OPD.
● Generation of UHID Number. ● Initial assessment to include nursing assessment
● Managing non availability of beds.

14
 ● Patient transfer-in. ● Initial assessment to include screening for nutritional needs
● Patient transfer-out/ referral of unstable patients.
● Patient transfer-out/ referral of stable patients. ● Documented plan of care including preventive aspects of the care
● Staff responsible during transfer / referral. (where applicable)
● Summary of patient’s condition & treatment given.
● Multidisciplinary nature of care and co-ordination among various
● Referral of patients
departments/ staff /shift
● Hand washing facilities, adequate gloves, masks, soaps, and disinfectants
● Bio-medical waste segregation
● Qualified individual identified as responsible for care
● Personal Protective Measures.
● Information regarding patient’s care & response to treatment is
shared

Nutrition CHECK LIST ● Information exchanged and document during each shit, between
shift and transfer between units / departments
● Procedure (s) for nutritional assessment and reassessment
● Safe transfer between departments / units
● Food according to the patient’s clinical needs
● Patient record available to authorised care providers
● Written order for the diet
● Documented procedure –referral of patients to other
● Planning of nutritional therapy in a collaborative manner
departments
● Families are educated about the patients diet limitations

● Food is stored and distributed safely

● Discharge planning in coordination with various departments,
including medico-legal cases / LAMA, discharge summary to all
● Maternal nutrition assessment
● Content of discharge summary
● Paediatric nutrition assessment

Patient & family education on diet and nutrition

● Uniform care delivery
______________________________________________________________________________
● Evidence based medicine and clinical practice guidelines
● Paediatric CHECK LIST
● Care of paediatric patients - display the scope, age specific competency, provisions for
● Care of vulnerable patients - Policy and procedure, safe and
special care of children, detailed nutritional, growth, psychosocial and immunization
secure environment, informed consent from the appropriate
assessment, provision for preventing child/neonate abduction and abuse
legal representative
● Parent education on nutrition, immunization and safe parenting and documentation of the

15
 same ● Care of patients undergoing surgical procedures - Policy and
procedure, preoperative assessment and provisional diagnosis
documented prior to surgery, informed consent obtained by a
surgeon
Purchase CHECK LIST
● Check hand washing facilities for staff in all care area instructions
● Procedures for procuring implants for proper hand washing

● Equipment planning
● Check Isolation /Barrier nursing facility available
● Equipment selection
● Check if adequate soap, masks, gloves and disinfectants are
● Equipment replacement and disposal available Hand washing

● Equipment planning ● PEP

● Equipment selection ● Bio-medical waste

● Equipment replacement and disposal ● Policy on consent. Who can give consent when patient is
incapable/ Informed consent situations/ performing doctor’s
Medical gases, vacuum and compressed air name

_______________________________________________________________________________ ● Signage
_
● Fire exit ,fire extinguishers, no smoking signs etc.
● Mortuary CHECK LIST
Medical record unique no. / Dated and timed entry / author is clear, up-to-
● Mortuary facilities date and chronological.

● Cold storage and back-up power LAB CHECK LIST

● Staff safety and personal protective equipment ● Standard operating procedures

● Disinfection ● Appropriate use of logos (e.g. NABL) and scope of lab accreditation (if
accredited)
● Maintenance plan of machinery
● Technician qualified
● Electrical safety practices
● Turn-around time - Results are available in defined time frame
● Staff awareness on safety practices
● Policies and Procedures for collection, identification, handling, safe

16
 ________________________________________________________________________ transportation, processing and disposal of specimens

RADIATION THERAPY CHECK LIST ● Alert and Panic levels - Critical results intimated immediately,
documented procedures of out sourcing test Measurement
● Comply with BARC/AERB legal requirements uncertainties

● Scope of imaging services ● Signatures

● Performing and reporting of tests ● Standardized reporting manner

● Technician qualified as per AERB ● Outsourcing and controls

● Documented policies and procedures for identification and safe transportation of patients to ● ILQA - ELQA - QAP documented
the imaging services
● Traceability of calibration records to national / international standards
● Turnaround time - Check results are available in defined time frame
● Verification/ validation and LJgraphs / software validation/
● Critical results intimation surveillance / calibration/ maintenance / Corrective and Preventive
actions
● Documented procedures for outsourcing tests
● Documented lab safety programme
● QAP documented verification and validation / surveillance / calibration/ maintenance /
corrective and preventive actions ● Documented policies and procedures for disposal of infectious and
hazardous materials
● Safety programme including usage of safety equipment and TLD badges
● Awareness of safety among employees - Staff trained in safe practice
● Adherence to standard precautions and safe practices
Staff have safety equipment / fire extinguisher / dressing materials /
etc.
● Staff trained in safe practice; staff has safety equipment/ fire extinguisher/ dressing
materials/ etc.
● Usage of gloves
● Safety devices periodically checked
● Reagent storage
● Imaging signage - Radiation hazard
● Handling spills
● Documented procedures
● Segregation of bio-medical waste
● Storage, preparation, handling, distribution and disposal
MANAGEMENT CHECK LIST

17
 ● Staff and patient education ● Vision, mission and values

● Emergency drug management ● Operation and strategic plans in consultation with various stakeholders

● Policy on consent. Who can give consent when patient is incapable/ Informed consent ● Budget
situations/ performing doctor’s name
● Monitor and measure the performance of the organisation against the
● All equipment are inventoried and log maintained / calibrated stated mission

Preventive maintenance/service labels on Equipment/calibration records/Refrigerator ● Organogram

________________________________________________________________________________ ● Appointment of senior leaders

SAFETY CHECK LIST ● Support safety initiatives and quality improvement plans

● Documented plan for handling fire and non-fire emergencies which includes exit plan ● Support research activities

● Signage pertaining to fire exits ● Addresses the organisations social responsibility

● Open and easily accessible fire exits without any obstruction ● Inform public regarding quality and performance of services

● Mock drill schedule and record - Twice a year mock drill ● Adherence to statutory requirements, mechanism to update
amendments and adherence to same; renewal of licenses
● Smoke detectors, fire alarms, fire alarm control panel etc. (where applicable)
● Social responsibility
● Maintenance [plan for fire related equipment
● All statutory and legal requirements
● Safety Manual
● Ensures implementation of these requirements
● Potential emergencies (Community emergencies, epidemics and disasters) identified
● Regular Updation of amendments in the prevailing laws
● Documented disaster management plan
● Mechanism for regular Updation of licences, registrations,
● Provision of supplies certifications

● Staff training in disaster management plan ● Scope of services of various departments including designated heads

● Tested at least twice a year ● Administrative policies & procedures

18
 ● Identified hazardous materials ● Effective leadership

● Hazardous materials identified have documented procedure for sorting, storing, handling etc. ● Involvement of department heads in quality initiatives

● Availability of MSDS for all such material ● Leaders make public the mission, vision and values

● Spill management plan ● Ethical management

● Staff awareness ● Revealing ownership

● Safety committee meeting minutes ● Portrays services that it can and cannot provide

RESEARCH CHECK LIST ● Affiliations and accreditations

● Policies and procedures ● Billing based on standard tariff

● Ethics committee ● Qualification and experience of person heading the organization

● Check for any discontinued trials and its reason ● Prepares the strategic and operational plans including long term and
short term goals
● Informed consent
● Coordinates the functioning with departments and external agencies
● Patient interview and monitors the progress

Assurance regarding patient refusal to participate/withdraw ● Annual budget

___________________________________________________________________-_________ ● Review of the performance of senior leaders

● PHARMACY CHECK LIST ● Review of committee functioning for its effectiveness

● Documented policies and procedures on medication procurement, storage, formulary, ● Documents employee rights and responsibilities
prescription, dispensing, administration, monitoring etc.
● Documents service standards
● Separate license for each of the pharmacies.
● MOU for all outsourced services
● Adherence to terms and conditions mentioned in the license.
● Monitoring the quality of the outsourced services
● Duty roster to ensure that there is a qualified pharmacist at all times (his/her name being
mentioned in the license). ● Proactive risk management

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 ● Procedure to obtain medication when pharmacy is closed. ● Resources for risk assessment and risk reduction activities

● Hospital formulary-list of medications. ● Implementation of systems for internal and external reporting of
system and process failures
● Collaboratively developed list.
● Appropriate CAPA with respect to safety related incidents
● Formulary available to the clinicians.
● Protection of patient rights by addressing grievance
● Defined process of acquisition of medicine and to obtain non listed medicines.
● Availability of resources
● Documented policies and procedures for storage
● Quality improvement budget
● Storage of medicines in clean, well lit and ventilated environment and/or as per
manufacture’s requirement ● Identifies organisational performance improvement targets

● Inventory control practices like FIFO ● Usage of statistical and management tools

● Stock of medicines ● HIC programme

● Precautions against theft ● Budget - research / quality improvement/ HIC

● Identification and storage of sound alike and look alike drugs ● Training and Development program

● Procedure to obtain medications when pharmacy is closed ● Grievance handling

● Availability of emergency medicines –list and storage in a uniform manner. ● Staff health programme

● Emergency medications replenished in timely manner. ● Obs&GnaecCHECK LIST

● P & P for safe & rational prescription of medication ● Care of high risk obstetrical patients –

● Audit of outpatient prescription ● Display of whether high risk obstetric cases can be cared for or
not
● Procedures for dispensing
● Assessment of maternal nutrition
● Medication recall policy
● Competence of staff handling high risk obstetrical patients
● Expiry date check before dispensing
● Maternal nutrition
● Procedure for near expiry medications.

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 ● Proper labelling on medicines (especially ones prepared in-house) ● Pre-natal, peri-natal and post-natal monitoring & documentation.

● Verification of high risk medications ● Facilities to take care of neonates of high risk pregnancies,
NICU/PICU with proper equipment and staff to take care of
● Procedure for narcotic drugs neonates of high risk obstetric cases

● Storage OT CHECK LIST

● Proper record ● Pre-Anaesthesia assessment and immediate pre-operative

assessment.
● Handling
● Consent for anaesthesia and surgery.
● Implantable prosthesis usage as per national/international guidelines
● Monitoring during and post anaesthesia.
● Documented P & P- procurement, storage/stocking, issuance and usage of implantable
prosthesis & medical devices as per manufacturer’s specifications. ● Criteria for discharge to recovery area.

● Documented P & P-Medical Supplies and consumables ● Documentation of Mode of anaesthesia and anaesthetic
medications.
● Defined process for acquisition
● Procedures comply with infection control guidelines.
● Medical supplies and consumables used in a safe manner
● Care of patients undergoing surgical procedures - Policy and
● Storage
procedure
● Inventory control practices-FIFO/ABC/VED etc.
● Preoperative assessment and provisional diagnosis
● Multidisciplinary committee
● documented prior to surgery
● Identified high risk medicines
● Informed consent obtained by a surgeon
● Procedure for dispensing these medicines
● Documented policies and procedures to prevent adverse events.
(Surgical safety check list0
Nuclear Medicine CHECK LIST
● Operating notes and post-operative plan of care
● Comply with BARC/AERB legal requirements
● Comply with infection control practices
● Scope of imaging services
● Appropriate facilities / equipments/ instruments are available.
● Performing and reporting of tests

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 ● Technician qualified as per AERB ● Quality assurance programme

● Documented policies and procedures for identification and safe transportation of ● Surveillance of OT environment
patients to the imaging services
● Monitoring of SSI
● Turnaround time - Check results are available in defined time frame
● Emergency drug management
● Critical results intimation
● Narcotic drug procedure
● Documented procedures for outsourcing tests
● Handling
● QAP documented verification and validation / surveillance / calibration/ maintenance /
corrective and preventive actions ● Documentation

● Safety programme including usage of safety equipment and TLD badges ● Procedure for procuring and using implants

● Adherence to standard precautions and safe practices ● Entry of batch and serial number in patient’s case file and master
log book
● Staff trained in safe practice; staff has safety equipment/ fire extinguisher/ dressing
materials/ etc. ● Consent

● Safety devices periodically checked ● Name of procedure

● Imaging signage - Radiation hazard ● Name of doctor

● Documented procedures ● Explanation of risks, benefits and alternatives if any

● Storage, preparation, handling, distribution and disposal ● Language (that the patient understands) used for taking consent

● Staff and patient education ● Completeness of the consent form in all aspects

● Emergency drug management ● Adheres to statutory norms

● Policy on consent. Who can give consent when patient is incapable/ Informed consent ● Sterilized sets: expiry dates, storage conditions
situations/ performing doctor’s name
● Reprocessing of instruments if any
● All equipment are inventoried and log maintained / calibrated
● Antibiotic policy
Preventive maintenance/service labels on Equipment/calibration records/Refrigerator
● Engineering controls (AC requirements as mentioned in

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 ● wARDS CHECK LIST guidebook), change of HEPA filters
● Predefined initial assessment and re-assessment
● Who performs the initial assessment ● Linen disinfection (if any) in OT
● Time frame for doing and documenting initial assessment - finished within 24 hours.
● Check hand washing facilities for staff in all care area, instructions
● Includes nursing assessment
for proper hand washing
● Includes nutritional needs screening
● Documented care plan
● Check Adequate soap, masks, gloves and disinfectants are
● Preventive aspects of care
available
● Care plan countersigned by the clinician within 24 hours
● Care plan includes goals or desired treatment results ● Sterilization/disinfection activities being performed
● Reassessment – frequency of reassessment, documentation of response to treatment, plan
for further treatment or discharge ● Layout of OT (no mix of sterile and un sterile)
● Multidisciplinary nature of care and co-ordination among various departments/ staff / shift
● Information about patient care shared among medical, nursing & other care providers ● All equipment are inventoried and log maintained / calibrated
● Information exchanged & documented during each shift, between shifts and during
● Preventive maintenance/service labels on Equipment/calibration
transfers.
records/Refrigerator
● Safe transportation
● Referral of patients to other departments/specialties ● Gas and vacuum supply / Storage of oxygen cylinders/Condition
● Discharge planning in coordination with various departments, including medico-legal cases / of Humidifiers
LAMA, discharge summary to all
● Content of discharge summary ● Credentialing of doctors
● Evidence based medicine and clinical practice guidelines
● CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of events during CPR, ● Credentialing of nurses
Communication of corrective and preventive measures
● Documented P & P ● CPR – Policy and procedure, staff trained in BLS/ALS,
● Reflects current standards, relevant regulations and purposes Documentation of events during CPR, Communication of
● Assignment of patient care as per current good practices. corrective and preventive measures
● Nursing care is aligned & integrated with overall patient care
● Rational use of blood and blood products - Policy and procedure,
● Documentation of nursing care
informed consent, patient and family education about donation,
● Adequate equipments for safe & efficient nursing services
monitoring transfusion reactions
● Nursing related decisions
● Rational use of blood and blood products - Policy and procedure, informed consent, patient Segregation of bio-medical waste
and family education about donation, monitoring transfusion reactions, staff training.
● Care of vulnerable patients - Policy and procedure, safe and secure environment, informed Palliative care CHECK LIST
consent from the appropriate legal representative, staff training
● Care of patients undergoing surgical procedures - Policy and procedure, preoperative ● Define the group of patients for whom palliative care is applicable

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 assessment and provisional diagnosis documented prior to surgery, informed consent ● All patients are screened for pain
obtained by a surgeon, documented policies and procedures to prevent adverse events.
● Documented P & P ● Detailed assessment and periodic reassessment of pain
● Pain assessment
● Patient and family education on various pain management
● Pain assessment & reassessment
techniques
● Education of family
● Nutritional assessment & reassessment
● End of life care – Documented policies and procedures, unique
● Food as per clinical needs & Order for diet
needs identification, autopsy/ organ donation process
● Planning of nutritional therapy in a collaborative manner
● High risk obstetrics patient assessment include maternal nutrition ● Staff awareness on end of life care
● Food is stored and distributed safely
● Medication administration ● Check labelling prior to making a secondary medicine
● Labelling requirements
● Patient identification ● Check patient is identified before administering medication,
● Medication verification from the order prior to administration. verified from the order/ dosage route/ timing.
● Dosage, route, timing verification
● Medication administration is documented.
● Staff interview on the methodology of administration
● Medication administration documentation ● Patient’s self administration of medication.
● Patient’s self-administration of medicines
● Management of medications got from outside ● Medications brought from outside.
● Patient monitoring after medication administration
● Situations where close monitoring is required ● Procedure for handling narcotics/ license/ documentation of
● Collaborative monitoring usage/ disposal/ handled by competent staff
● Medication changes where appropriate based on monitoring
● Near misses, medication errors and adverse drug events Quality CHECK LIST
● Narcotic drug procedure
● Documented Quality Improvement programme (QIP) model
● Handling
● Documentation ● Committee-composition and functioning
● Medication storage units- stocks, expiry dates, storage conditions, emergency crash carts ,
sound alike and look alike, high risk medications ● Designed individual
● Adherence to standard precautions
● Adherence to hand hygiene guidelines ● Comprehensive and covers all the major elements related to quality
● Adherence to safe injection & infusion practices assurance
● Adherence to transmission based precautions
● Adherence to cleaning, disinfection and sterilization practices ● QIP is communicated and coordinated among all the staff

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 ● Check hand washing facilities for staff in all care area, instructions for proper hand washing ● Review of QIP and identification of improvement activities
● Check Isolation /Barrier nursing facility available
● Check Adequate soap, masks, gloves and disinfectants are available ● Annual update of QIP
● Pre & Post PEP
● Internal audits and documentation
● Segregation of bio-medical waste
● Policy on consent. Who can give consent when patient is incapable/ Informed consent
● Established process to monitor and improve the quality of nursing and
situations/ performing doctor’s name
complete patient care
● Layout of beds, spacing, visual privacy
● Signage ● Patient Safety Programme is developed, implemented and maintained
● Fire exit ,fire extinguishers, no smoking signs etc. by a multi-disciplinary committee
● Potable water & electricity round the clock
● All equipment are inventoried and log maintained /calibrated ● Documented Patient Safety Programme
● All equipment are inventoried and log maintained / calibrated
● Preventive maintenance/service labels on Equipment/calibration records/Refrigerator ● Comprehensive and covers all the major elements related to patient
● Gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers safety and risk management
● Management of hazardous materials-identification, sorting, labelling, handling, storage,
● Scope includes adverse events ranging from no-harm to sentinel
transporting and disposal
events
● Management of spills
● Staff training ● Designated individual for coordinating and implementing the
● Medical record unique no. / Dated and timed entry / author are clear, up-to-date and programme
chronological.
● Programme communicated and coordinated amongst all the staff
Rehabilitation CHECK LIST
● Programme identifies opportunities for improvement based on review
● Policies and procedures on rehabilitative services at predefined intervals

● Scope of the departments ● Continuous process and updated atleast once a year

● Functional assessment & periodic reassessment is done and documented. ● Adapts and implements national / international patient safety goals /
solutions
● Adherence to infection control and safe practices.
● Atleast two identifiers for identifying patients across the hopsital
● Multidisciplinary team approach
● Data for all indicators mentioned in the guidebook
● Adequate space and equipment
● Check raw data
● Care of vulnerable patients

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 Safety of patients ● Verify collection methodology of data

Recovery Dept CHECK LIST ● Data analysis

● Discharge criteria ● Improvement activities carried out based on analysis and results of the
improvement activity
● Patient monitoring post anaesthesia
● Adequate resources for quality improvement programme
● Operating notes and post-operative plan of care
● Adequate funds-budget
● Medicine orders are written in a uniform location clear, legible, dated, timed, named,
signed ● Identifies organisational performance improvement targets

● Name, route ,dose, frequency / time of administration ● Use of appropriate quality improvement, statistical and management
tools
● Verbal orders
● Clinical Audit-Medical & Nursing staff participates
● Written order for high risk medication
● Audit parameters are defined
● Medication administration
● Patient and staff anonymity maintained
● Staff interview on the methodology of administration
● Audits documented
● Medication administration documentation
● Implementation of remedial measures
● Patient’s self-administration of medicines
● Incident reporting system
● Management of medications got from outside
● Process for collecting feedbacks and receive complaints
● Patient monitoring after medication administration
● Process for analysis of incidents, feedbacks and complaints
● Knowledge to pick adverse drug events and reporting of the same
● CAPA based on the findings
● Narcotic drug procedure
● Feedbacks about care communicated to staff
● Handling & Storage Documentation
● Identification of sentinel events

● Procedure for reporting and analysis

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 Corrective and preventive action

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