GREATER HYDERABAD MUNICIPAL CORPORATION

SELF ASSESSMENT FORM FOR SWACHH HOSPITAL RANKING FOR THE MONTH OF
…………………..
Name of Hospital :
Circle Name and Number :
Address:

Phone No:
Manager Name & No:
Tick ( ) the correct option
INFRASTRUCTURE (MAX SCORE - 60)
Hospital infrastructure
is well maintained (No
major cracks, seepage, In broken
In good condition In a fair condition
1 chipping, plaster, condition
chipped floors in
hospital)
4 2 0
In good condition In broken condition No Gate
2 Entrance / Exit Gate
4 2 0
In good condition In broken condition
3
Corridors in the Hospital 4 2

Dustbins (Refer Available as per requirement Available as per requirement but

No available
4 'Cleaning Equipment' in good condition in poor condition
section)
4 2 0
Waste collection
Available Not Available
5 equipment (wheeled
trolleys/handcart) 2 0
Composting equipment
Available Not Available
6 / compost pit
4 0
Cleaning equipment
/brooms Available in good condition Available in Not Available
7
poor condition
4 2 0
Toilets and baths with Available in
Available in good condition No toilets available
8 wash basins available poor condition
for clinical and non 4 2 0
clinicaland
Toilet staff
bath facilities Available in
Available in good condition No toilets available
9 available for IPD poor condition
patients 4 2 0
Toilet facilities Available in
Available in good condition No toilets available
10 available for visitors poor condition
and OPD patients 4 2 0
Stair Case / Lift as Available in
Available in good condition Not Available
11 applicable poor condition
4 2 0

Hospital Management Deputy Commisioner

 Covered sources of Available in
Available in good condition Not Available
12 drinking water poor condition
4 2 0
Facility for parking of Available in
Available in good condition Not Available
13 vehicles poor condition
4 2 0
Sterilization facility Available in
Available in good condition Not Available
14 poor condition
4 2 0
Garden/Park/Lawn/ Available in
Available in good condition Not Available
15 Recreation Rooms for poor condition
IPD patients 4 2 0
Ambulance Well maintained and equipped Poorly maintained
16
2 0
SUB-TOTAL (INFRASTRUCTURE SCORE) - A

SERVICE/MAINTENANCE (MAX.SCORE - 40)

Cleaning within Swept
Swept daily Never swept
1 Hospital premises periodically
4 2 0
Toilet and bath cleaning Cleaned some
Cleaned regularly Never cleaned
2 times
4 2 0
Toilet and bath water Available Not available
3
availability 3 0
Cleaning of water tanks Cleaned some
Cleaned regularly Never cleaned
4 wherever applicable times
4 2 0
Cleaning of drinkng Cleaned once
Cleaned regularly Never cleaned
5 water coolers in a week
4 2 0
Infrastructure like
special care rooms,
Maintained regularly No regular maintenance
operation theaters,
6
labour rooms, ICUs,
laboratories etc.
4 0

Cleaning of speical care

rooms, operation
theatres, labour rooms, Cleaned regularly or as and when required Not cleaned on a regular basis
7
ICUs, laboratories etc

4 0
Collecting waste from Daily Fortnightly Not collected
8 dustbins
4 2 0
Segregating waste At the point of waste
Not segregated
9 collected generation Daily
4 2 0

Hospital Management Deputy Commisioner

 Bio-degradable waste
Processed at compost Sent for
processing
pit/copost equipment within composting Not composted
10 outside the
the hospital premises
hospital
5 3 0
SUB-TOTAL (MAINTENANCE SCORE) - B

FEEDBACK FROM PATIENTS/STAFF (MAX.SCORE 30)

Whether Hospital has
Yes No
1 Feedback Mechanism
6 0
Availability of toilet Inadequate number available for
Adequate number available for use
2 facilities for patients use
4 0
Availability of toilet Inadequate number available for
Adequate number available for use
3 facilities for visitors use
staff 4 0
Availability of
sufficient number of Inadequate number available for
Adequate number available for use
4 dustbins for disposing use
waste
4 0
Waste collection done Yes No
5 daily
4 0
Cleaning of drinking
water coolers and Sources of drinking water and surroundings Sources of drinking water and
6 surroundings are kept clean surroundings are not kept clean

4 0
Cleanliness and
maintenance of special Well maintained and clean Poorly maintained and not clean
7 care rooms including

4 0
SUB TOTAL (FEEDBACK SCORE) - C
Between 50 to
Swachhata App More than 100 staff
100 staff Less than 50 downloads
1 downloads by Hospital downloads
downloads
Staff
10 5 0
<50% staff
Swachh Dhooth app
100% staff have downloaded 99% - 50% staff have downloaded have
2 Downloads by Hospital
downloaded
Staff
10 5 0
<50% staff
GHMC Mosquito App
100% staff have downloaded 99% - 50% staff have downloaded have
3 downloaded by
downloaded
Hospital Staff
10 5 0
SUB TOTAL (SWACHHATA APP) - D
TOTAL SCORE (Max.Marks. 160) (A+B+C+D):

Hospital Management Deputy Commisioner