HOSPITAL QUALITY SCORE CARD

DEPARTMENT WISE
Operation
Emergency NBSU Theater Laboratory

100 50 50 50
OPD Hospital Score Radiology
100 50
Pharmacy &
Labour Room 60.6300268096515 Store
50 50
Blood Storage
IPD Auxiliary General/Admin
Unit
50 50 50 50

HOSPITAL QUALITY SCORE CARD

AREA OF CONCERN WISE
Service Provision Patient Rights Inputs Support Services

66% 61% 60% 56%

HOSPITAL SCORE

61%
Clinical Services Infection Control Quality Management Outcome

66% 59% 57% 61%

Area of Concern & Standards for CHC

 Area of Concern - A: Service Provision
Standard A1 The facility provides Curative Services
Standard A2 The facility provides RMNCHA Services.
Standard A3 The facility Provides diagnostic Services
Standard A4 The facility provides services as mandated in the National Health Programmes /State
Standard A5
scheme(s).
Facility provides support srvices and Administrative services.
Standard A6 Health services provided at the facility are appropriate to community needs.
Area of Concern - B: Patients' Rights
Standard B1 The facility provides information to care-seekers, attendants & community about available
services, anddelivered
Services are their modalities
in a manner that is sensitive to gender, religious and cultural needs,
Standard B2
and there are no barrier on account
The facility maintains privacy, of physical,
confidentiality economic,
& dignity cultural and
of patients, or social
has astatus.
system for
Standard B3 The facility has defined and established procedures for informing patients about the medical
guarding patient related information.
Standard B4 condition, and involving them in treatment planning, and facilitates informed decision
Standard B5 The facility ensures that there are no financial barrier to access, and that there is financial
making
protection given from the cost of hospital services.
Area of Concern - C: Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure
Standard C2 meets the prevalent
The facility norms safety including fire safety of the infrastructure.
ensures physical
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured
Standard C4 services at the
The facility current
provides caseand
drugs loadconsumables required for assured services.
Standard C5 The facility has equipment & instruments required for assured list of services.
Area of Concern - D: Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and
Standard D2 calibration
The facility of
hasEquipment.
defined procedures for storage of drugs, inventory management and
Standard D3 dispensing of drugs in pharmacy
The facility has established andfor
Program patient care areasand upkeeto of the faciity to provide
mainntenance
Standard D4 safe, secureensures
The facility and comfortable
24X7 water environment
and power to staff,as
backup patients and visitors.
per requirement of service delivery,
Standard D5 and support services norms
The facility ensures avaialblity of Diet as per nutritional requirement and clean Linen to all
Standard D6 admitted patients.
The facility has defined and established procedures for promoting public participation in
Standard D7 management of hospital
Hospital has defined and transparency and accountability.
established procedures for Financial Management
Standard D8 The facility is compliant with all statutory and regulatory requirement imposed by local,
Standard D9 state
Roles or central government
& Responsibilities of administrative and clinical staff are determined as per govt.
Standard D10 regulations
The facility has establishedoperating
and standards procedureprocedures.
for monitoring the quality of outsourced services and
adheres to contractual obligations
Area of Concern - E: Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment o
Standard E3 The facility has defined and established procedures for continuity of care of patient and
Standard E4 referral
The facility has defined and established procedures for nursing care
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
Standard E6 The facility follows standard treatment guidelines defined by state/Central government for
Standard E7 prescribing the defined
The facility has generic drugs & theirfor
procedures rational use.administration
safe drug
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’
Standard E9 clinical records
The facility has and theirand
defined storage
established procedures for discharge of patient.
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster
Standard E11 Management
The facility has defined and established procedures of diagnostic services
Standard E12 The facility has defined and established procedures for Blood Storage Management and
Standard E13 Transfusion.
The facility has established procedures for Anaesthetic Services
Standard E14 The facility has defined and established procedures of Operation theatre.
Standard E15 The facility has defined and established procedures for end of life care and death
Maternal & Child Health Services
Standard E16 The facility has established procedures for Antenatal care as per guidelines
Standard E17 The facility has established procedures for Intranatal care as per guidelines
Standard E18 The facility has established procedures for postnatal care as per guidelines
Standard E19 The facility has established procedures for care of new born, infant and child as per
Standard E20 guidelines
The facility has established procedures for abortion and family planning as per government
Standard E21 guidelines
The facilityand law Adolescent Reproductive and Sexual Health services as per guidelines
provides
National Health Programmes
Standard E22 The facility provides services as per National Health Programmes' Operational/ Clinical
Guidelines Area of Concern - F: Infection Control
Standard F1 The facility has Infection Control Programme, and there are procedures in place for
Standard F2
prevention and defined
The facility has measurement of Hospital Associated
and Implemented proceduresInfections
for ensuring hand hygiene practices
Standard F3
and antisepsis
The facility ensures availability of material for personal protection, and facility staff follow
Standard F4
standard precaution
The facility for personal
has standard protection.
procedures for processing of equipment and instruments
Standard F5 Physical layout and environmental control of the patient care areas ensure infection preventi
Standard F6 The facility has defined and established procedures for segregation, collection, treatment
and disposal of Bio-medical
Areaand
ofhazardous
Concern Waste.
- G: Quality Management
Standard G1 The facility has established organizational framework for quality improvement
Standard G2 The facility has established system for patient and employee satisfaction
Standard G3 The facility have established internal and external quality assurance Programmes wherever
Standard G4 it
Theis critical
facility to
hasquality.
established, documented implemented and maintained Standard Operating
Standard G5 Procedures for all key processes.
The facility has established system of periodic review as internal assessment , medical &
Standard G6 death audit and prescription audit
The facility has defined and established Quality Policy & Quality Objectives
standard G7 The facility seeks continual improvement by practicing Quality tool and method.
Area of Concern - H: Outcomes
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National
Standard H2 benchmarks
The facility measures Efficiency Indicators and ensure to reach State/National Benchmarks
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National
Standard H4 benchmarks
The facility measures Service Quality Indicators and endeavours to reach State/National
benchmarks
Standard wise
Score
 76%
66%
62%
mmes /State 67%
54%
eds. 64%

ty about available
61%
nd cultural needs,
cial 64%
as astatus.
system for
s about the medical 62%
med decision 65%
there is financial
56%

ble infrastructure 63%

ure. 57%
ng the assured 61%
s. 60%
vices. 60%

enance and 55%

gement and 58%
e faciity to provide 58%
service delivery, 57%
clean Linen to all 53%
participation in 50%
ent 50%
posed by local, 53%
d as per govt. 56%
ourced services and 50%

mission of patients. 74%

nt and reassessment o 60%
of patient and 64%
60%
63%
ral government for 64%
64%
ating of patients’ 59%
nt. 63%
es and Disaster 75%
56%
anagement and 50%
50%
. 57%
nd death 67%

nes 89%
es 50%
es 50%
hild as per 79%
as per government 73%
as per guidelines 100%

tional/ Clinical 97%

n place for 56%

hygiene practices 59%
acility staff follow 57%
truments 60%
re infection preventi 61%
ction, treatment 60%

ement 53%
53%
rammes wherever 59%
tandard Operating 57%
ment , medical & 54%
es 58%
method. 56%

h State/National 65%
tional Benchmarks 56%
State/National 57%
State/National 64%
 National Quality Assurance Standards for CHC 0 1 2
Checklist for Accident & Emergency 1
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
. Area of Concern - A Service Provision 32 32
Standard A1. Facility Provides Curative Services 16 16
ME A1.1. The facility provides General Facility for managing medical 2 SI/OB Dengue Haemorrhagic fever,
Medicine services emergency cases Cerebral Malaria, Poisoning, Snake
Bite, Congestive Heart Failure,
Pneumonia, Acute Respiratory
conditions, Status Epilepticus,
Status Asthamaticus, Acute
Gastroenteritis, Severe drug
reactions.

ME A1.2. The facility provides General Availability of Emergency 2 SI/OB RTA, Lacerated wound, foreign
Surgery services Management of acute Surgical body in Ear/nose, Acute Abdomen
Condition Pain, Strangulated Hernia, Pyocele,
Renal Colic & Fracture

ME A1.3. The facility provides Obstetrics & Availability of Emergency Obstetrics 2 SI/OB APH, PPH, Eclampsia , Obstructed
Gynaecology Services &Gynaecology Procedures Labour, Septic Abortion, Emergency
Contraceptives

ME A1.4. The facility provides paediatric Availability of emergency Paediatric 2 SI/OB ARI, Diarrhoeal Diseases,
services procedures Hypothermia, PEM,resuscitation,
Convulsions/Seizurs

ME A1.8 The facility provides services for Availability of Dressing room facility 2 SI/OB Drainage, dressing, suturing
OPD procedures
. Availability of injection room 2 SI/OB Injection room facility with ARV,
facilities ASV and emergency drugs
ME A1.9. Services are available for the 24X7 availability of dedicated 2 SI/RR Check for emergency register
time period as mandated emergency Services
ME A1.10. The facility provides Accident & Availability of Emergency procedures 2 SI/OB CPR, Mobilization, Intubations,
Emergency Services Tracheotomy, Cervical
immobilisation Mechanical
Ventilation

Standard A3. Facility Provides diagnostic Services 10 10

ME A3.1. The facility provides Radiology Availability / Linkage to X-ray & USG 2 SI/OB
Services services
On call Radiology Services are 2 SI/OB Check services are functional at
available 24X7 night
ME A3.2. The facility Provides Laboratory Availability of point of care 2 SI/OB Hb in gram,, Blood Sugar, RDK,
Services diagnostics in emergency 24x7 Urine Protein,
on call facility for conducting 2
Emergency diagnostic tests 24x7
ME A3.3. The facility provides other Availability of Functional ECG 2 SI/OB
diagnostic services, as mandated Services

Standard A5. Facility provides support services & Administrative Services 4 4

ME A5.3. The facility provides security 2 At least one per shift.
services Availability of Home Guard/Security
Guard SI/OB
ME A5.7. The facility has services of Availability of Medico-legal Record 2
medical record department Services
SI/OB
Standard A6. Health services provided at the facility are appropriate to community needs. 2 2
ME A6.1. The facility provides curatives & Availability of specific procedures for 2 SI/OB Ask for specific local health
preventive services for the health local prevalent emergencies emergencies e.g.. RTA, Cerebral
problems and diseases, prevalent Malaria encountered frequently.
locally. See if emergency is ready for it or
not.

. Area of Concern - B Patient Rights 60 60

Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities 16 16
ME B1.1. The facility has uniform and user- Availability departmental signage's . 2 OB Emergency department board is
friendly signage system prominently displayed with facility
of illumination in night.

. Directional signage for department 2 OB Direction is displayed from main

are displayed gate to Emergency
ME B1.2. The facility displays the services List of services that are managed at 2 OB
and entitlements available in its the facility
departments
. Names of doctor and nursing staff on 2 OB
duty are displayed and updated

. List of drugs available are displayed 2 OB

. Important numbers including 2 OB

ambulance, blood bank , police and
referral centres displayed

ME B1.6. Information is available in local Signage's and information are 2 OB

language and easy to understand available in local language

ME B1.8 The facility ensures access to Treatment note/discharge note is 2 RR/OB

clinical records of patients to given to patient
entitled personnel
Standard B2. Services are delivered in a manner that is sensitive to gender, religious, and cultural needs, and there are no barrier on account of 18 18
ME B2.1. Services are provided in manner Arrangementphysical access,
for examination of social, economic,
2 OBcultural or social status
that are sensitive to gender rape victims

. Availability of protocols /guidelines 2 OB /RR

for collection of forensic evidence in
case of rape victim

. Counselling services are available for 2 OB/RR

rape victim and domestic violence

. Availability of female staff if a male 2 OB/SI

doctor examine a female patients

Emergency contraceptive pill and 2 RR/SI

antibiotics are provided to all rape
victims

Availability of confidentiality and 2

privacy of transgender patient

ME B2.3. Availability of Wheel chair/ stretcher 2 OB

Access to facility is provided for emergency patient
without any physical barrier &
friendly to people with disability.

Availability of ramps with railing 2 OB

 Ambulance has direct access to the
receiving/triage area of the
emergency.
2 OB No vehicle parked on the way /in
front of emergency entrance.
Access road to emergency is wide
enough for streamline moment of
emergency

Standard B3. The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 10 10
ME B3.1. Adequate visual privacy is Screens and curtains are provided at 2 OB At the examination and procedure
provided at every point of care emergency area.

ME B3.2. Confidentiality of patients Confidentiality of patient's record 2 SI/OB

records and clinical information maintained
is maintained
MLC case records are kept in a 2 SI/OB
secured place with limited access to
essential personnel

ME B3.3. The facility ensures the Behaviour of staff is empathetic and 2 OB/PI
behaviours of staff is dignified courteous
and respectful, while delivering
the services

ME B3.4. The facility ensures privacy and
confidentiality to every patient,
especially of those conditions
having social stigma, and also
safeguards vulnerable groups
Privacy and confidentiality of HIV, 2 SI/OB
Rape, suicidal cases, domestic
violence and psychotic cases are
maintained

Standard B4. The facility has defined and established procedures for informing patients about the medical condition, and involving them in 10 10
ME B4.1. There is established procedures Consent is taken for invasive 2 SI/RR Lumbar Puncture, Catheterization,
for taking informed consent emergency procedures PR & PV Examination
before treatment and
procedures

ME B4.2. Patient is informed about his/her Display of charter which includes 2 OB

rights and responsibilities patient rights and responsibilities.

ME B4.3. Staff are aware of Patients rights Staff is aware of patient rights and 2 SI
responsibilities responsibilities
ME B4.4. Information about the treatment Patient/ attendant is informed about 2 PI Ask patients about what they have
is shared with patients or her clinical condition and treatment been communicated about the
attendants, regularly been provided treatment plan

ME B4.5. The facility has defined and Availability of complaint box and 2 OB Check for complaint register &
established grievance redressal display of process for grievance MOM of grievance redressal
system in place redressal and whom to contact is meeting
displayed

Standard B5. The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost of hospital 6 6
ME B5.1 The facility provides cashlessEmergency services are free for services.
2 PI/SI
services to pregnant women, pregnant woman, neonate, children
mothers and neonates as per and BPL patients as per Government
prevalent government schemes order/Scheme

ME B5.2. The facility ensures that drugs Check that parents & attendant's 2 PI/SI
prescribed are available at have not spent money on purchasing
Pharmacy and wards drugs and consumables from
outside.

ME B5.3. It is ensured that facilities for the Check that parents & attendants 2 PI/SI
prescribed investigations are have not spent money on diagnostics
available at the facility from outside.

. Area of Concern - C Inputs 150 150

Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 50 50
ME C1.1. Departments have adequate Adequate space for accommodating 2 OB
space as per patient or work load emergency load

ME C1.2. Patient amenities are provide as Availability of seating arrangement 2 OB

per patient load in the waiting area
. Availability of Drinking water 2 OB
. Availability of functional toilets 2 OB Dry with regular supply of water

ME C1.3. Departments have layout and Demarcated trolley bay 2 OB

demarcated areas as per
functions
. Demarcated receiving /triage area 2 OB

. Demarcated Nursing station 2 OB

. Demarcated duty room for doctor 2 OB
/nurse
. Demarcated resuscitation area 2 OB
. Demarcated observation area/beds 2 OB

. Demarcated dressing area /room 2 OB

. Demarcated injection room 2 OB

. Demarcated area for keeping serious 2 OB
patient for intensive monitoring

. Demarcated areas for keeping dead 2 OB Separate room or linkage with

bodies. mortuary/ Post mortem room
. Lay out is flexible 2 OB All the fixture and furniture are
movable to rearrange the different
areas in case of mass casualty

. Dedicated Minor OT 2 OB
. Shaded porch for ambulance 2 OB
. Availability of clean and dirty utility 2
room
ME C1.4. The facility has adequate Corridors at Emergency are broad 2 OB 2-3 meter
circulation area and open spaces enough for easy moment of
according to need and local law stretcher and trolley

ME C1.5. The facility has infrastructure for Availability of functional telephone 2 OB

intramural and extramural and Intercom Services
communication
. The ambulance(s) has a proper 2 OB
communication system(at least cell
phone)

ME C1.6. Service counters are available as Availability of emergency beds as per 2 OB At least 4 beds.
per patient load expected load
ME C1.7. The facility and departments are Unidirectional flow of services. 2 OB Receiving/Triage-Resuscitation-
planned to ensure structure observation beds- Procedures area.
follows the function/processes There is no criss cross
(Structure commensurate with
the function of the hospital)

. Separate entrance for emergency 2 OB

department
 Emergency is located near to the 2 OB
entrance of the hospital
Standard C2. The facility ensures the physical safety including Fire safety of the infrastructure. 16 16
ME C2.1 The facility ensures the seismic Non structural components are 2 OB Check for fixtures and furniture like
safety of the infrastructure properly secured cupboards, cabinets, and heavy
equipment , hanging objects are
properly fastened and secured

ME C2.2. The facility ensures safety of Emergency Department does not 2 OB

electrical establishment have temporary connections and
loosely hanging wires

ME C2.3 Physical condition of buildings Floors of the Emergency Department 2 OB

are safe for providing patient are non slippery and even
care
. Windows and vents if any are intact 2 OB
and sealed
ME C2.4 The facility has plan for Emergency has fire exit to permit 2 OB/SI
prevention of fire safe escape of its occupant at time
of fire

ME C2.5 The facility has adequate fire Emergency has installed fire 2 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.

. Check the expiry date for fire 2 OB/RR

extinguisher is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned

ME C2.6 The facility has a system of Check for staff competencies for 2 SI/RR
periodic training of staff and operating fire extinguisher and what
conducts mock drills regularly for to do in case of fire
fire and other disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 28 28
ME C3.1 The facility has adequate Specialist's are available on call for 2 OB/RR Gynaecologists, Paediatrician &
specialist doctors as per service emergency cases Surgeon
provision.
ME C3.2. The facility has adequate general Availability of at least one Doctor 2 OB/RR
duty doctors as per service 24x7
provision and work load

ME C3.3. The facility has adequate nursing Availability of trained Nursing staff 2 OB/RR/SI
staff as per service provision and
work load
ME C3.4. The facility has adequate Availability of dresser /paramedic 2 OB/SI
technicians/paramedics as per
requirement
ME C3.5 The facility has adequate support Availability of Drivers for Ambulance 2 SI/RR Driver may be on call for
/ general staff 24X7 emergency.
ME C3.6 The staff has been provided Triage and Mass Casualty 2 SI/RR
required training / skill sets Management
. Basic life support (BLS)/ Advance life 2 SI/RR
support (ALS)
Care of unconscious patient 2
. Bio Medical waste Management 2 SI/RR
. Infection control and hand hygiene 2 SI/RR

Patient Safety 2
ME C3.7 The Staff is skilled as per job The Staff is skilled for emergency 2 SI/RR
description procedures
The Staff is skilled for resuscitation 2 SI/RR
and use defibrillator

The Staff is skilled for maintaining 2 SI/RR

clinical records
Standard C4. Facility provides drugs and consumables required for assured list of services. 32 32
ME C4.1. The departments have Availability of 2 OB/RR Tracers as per State EDL
availability of adequate drugs at Analgesics/Antipyretics/Anti
point of use Inflammatory

. Availability of Injectable Antibiotics 2 OB/RR Tracers as per State EDL

. Availability of Infusion Fluids 2 OB/RR Tracers as per State EDL

. Availability of Drugs acting on CVS 2 OB/RR Tracers as per State EDL

. Availability of drugs action on 2 OB/RR Tracers as per State EDL

CNS/PNS
. Availability of dressing material and 2 OB/RR Tracers as per State EDL
antiseptic lotion
. Drugs for Respiratory System 2 OB/RR Tracers as per State EDL
. Availability of drugs for obstetric 2 OB/RR Tracers as per State EDL
emergencies
. Availability of emergency drugs in 2 OB/RR Megsulf, Oxytocin, Plasma
ambulance Expanders
. Availability of Medical gases 2 OB/RR Availability of Oxygen Cylinders

Availability of Immunological drugs 2 OB/RR Polyvalent Anti snake Venom, Anti

tetanus Human Immunoglobin

Antidotes and Other Substances 2 OB/RR Inj. Atropine Sulphate

used in Poisonings
ME C4.2. The departments have adequate Resuscitation Consumables / Tubes 2 OB/RR Masks, Ryle's tubes, Catheters,
consumables at point of use Chest Tube, ET tubes etc.

. Availability of disposables at 2 OB/RR

dressing room
. Availability of consumables in 2 OB/RR Dressing material / Suture material
ambulance
ME C4.3. Emergency drug trays are Emergency Drug Tray/ Crash Cart is 2 OB/RR
maintained at every point of maintained at emergency
care, where ever it may be
needed

Standard C5. The facility has equipment & instruments required for assured list of services. 24 24
ME C5.1. Availability of equipment & Availability of functional 2 OB BP apparatus, Multipara
instruments for examination & Equipment & Instruments for meter ,Torch, hammer , Spot
monitoring of patients examination & Monitoring Light ,Stethoscope, thermometer

. Availability of Monitoring 2 OB
equipment in ambulance
ME C5.2. Availability of equipment & Availability of dressing tray for 2 OB Artery forceps
instruments for treatment Emergency procedures
procedures, being undertaken in
the facility

Availability of instruments for 2 OB Speculum, D & E Set

emergency obstetrics procedure
ME C5.3. Availability of equipment & Availability of Point of care 2 OB Glucometer, ECG ,HIV rapid
instruments for diagnostic diagnostic devices diagnostic kit, RDK
procedures being undertaken in
the facility

ME C5.4. Availability of equipment and Availability of functional 2 OB Ambu bag, defibrillator,

instruments for resuscitation of Instruments for Resuscitation. Laryngoscope with spare batteries,
patients and for providing nebulizer, suction apparatus ,
intensive and critical care to Laryngeal mask
patients

ME C5.5. Availability of Equipment for Availability of equipment for 2 OB Refrigerator, Crash cart/Drug
Storage storage for drugs trolley, instrument trolley, dressing
trolley

ME C5.6 Availability of functional Availability of equipment for 2 OB Steam steriliser/ Autoclave

equipment and instruments for sterilization and disinfection
support services
ME C5.7. Departments have patient Availability of patient beds with prop 2 OB
furniture and fixtures as per load up facility and wheels
and service provision
Availability of 2 OB Hospital graded Mattress, IV stand,
attachment/accessories with patient bed rails, Bed pan for male &
bed female

Availability of fixtures 2 OB Spot light, electrical fixture for

equipment like suction, monitor
and defibrillator, X ray view box

Availability of furniture at emergency 2 OB Doctors Chair, Patient Stool,

Examination Table, Chair, Table,
Footstep, cupboard

. Area of Concern - D Support Services 82 82

Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 10 10
ME D1.1. The facility has established All equipment are covered under 2 SI/RR
system for maintenance of AMC including preventive
critical Equipment maintenance

. There is system of timely corrective 2 SI/RR

break down maintenance of the
equipment

The Staff is skilled for trouble 2 SI/RR

shooting in case equipment
malfunction

ME D1.2. The facility has established All the measuring equipment/ 2 OB/ RR Thermometer, weighting scale, BP
procedure for internal and instrument are calibrated apperatus, suction machine,
external calibration of measuring oxygen flowmeter & meter gauze
Equipment

ME D1.3. Operating and maintenance Up to date instructions for operation 2 OB/SI Suction machine, Multipara
instructions are available with and maintenance of equipment are monitor , defibrillator.
the users of equipment readily available with staff.

Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 20 20
ME D2.3. The facility ensures proper Drugs are stored in 2 OB
storage of drugs and containers/tray/crash cart and are
consumables labelled

. Empty and filled cylinders are 2 OB

labelled
ME D2.4. The facility ensures management Expiry dates' are maintained at 2 OB/RR
of expiry and near expiry drugs emergency drug tray

. No expiry drug is found 2 OB/RR

ME D2.5. The facility has established The Department maintained stock 2 RR/SI
procedure for inventory and expenditure register of drugs
management techniques and consumables in Emergency

ME D2.6. There is a procedure for periodically There is procedure for replenishing 2 SI/RR
replenishing the drugs in patient drug tray emergency crash cart
care areas

There is procedure for replenishing 2 OB/SI

drug tray emergency crash cart in
ambulance

There is no stock out of drugs 2 SI/RR

ME D2.7. There is process for storage of Temperature of refrigerators are 2 OB/RR Check for temperature charts are
vaccines and other drugs, kept as per storage requirement and maintained and updated
requiring controlled temperature records are maintained periodically

ME D2.8. There is a procedure for secure Narcotics and psychotropic drugs are 2 OB/SI
storage of narcotic and kept in lock and key
psychotropic drugs
Standard D3. The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable environment 28 28
ME D3.2. Hospital infrastructure is Check for there is no seepage , 2 OB
adequately maintained Cracks, chipping of plaster
Window panes , doors and other 2 OB
fixtures are intact
Patients beds are intact and painted 2 OB

Mattresses are intact and clean 2 OB

ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, and 2 OB All area are clean with no
hygienic circulation areas are Clean dirt,grease,littering and cobwebs

Surface of furniture and fixtures are 2 OB

clean
ME D3.4. The facility has policy of removal No condemned/Junk material in the 2 OB
of condemned junk material Emergency

ME D3.5. The facility has established No stray animal/rodent/birds/ 2 OB

procedures for pest, rodent and termites
animal control
ME D3.6. The facility provides adequate Adequate illumination at procedure 2 OB 200 Lux (Minimum)
illumination level at patient care area.
areas
ME D3.7. The facility has provision of Visitors are restricted at 2 OB/SI Resuscitation area, dressing room
restriction of visitors in patient resuscitation and procedure area and examination area
areas
ME D3.8 The facility ensures safe and Temperature control and ventilation 2 PI/OB Fans/ Air
comfortable environment for in the emergency. conditioning/Heating/Exhaust/Vent
patients and service providers ilators as per environment
condition and requirement

ME D3.9. The facility has security system in There are set procedures for 2 SI/OB See for linkage to police, Provision
place at patient care areas handling mass situation and violence for protection of staff
in emergency

. Hospital has sound security system 2 OB/SI

to manage overcrowding in
emergency

ME D3.10. The facility has established measure Ask female staff whether they feel 2 SI
for safety and security of female secure at work place
staff

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 10 10
ME D4.1. The facility has adequate Availability of 24x7 running and 2 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas

ME D4.2. The facility ensures adequate Availability of power back in 2 OB/SI

power backup in all patient care Emergency, which can take load of
areas as per load running equipment

Availability of UPS 2 OB/SI

Availability of Emergency light 2 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Oxygen cylinders and 2 OB
availability of oxygen, medical gases vacuum suction
and vacuum supply

Standard D5. The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 4 4
ME D5.4 The facility has adequate sets of Clean Linen is provided on 2 OB/RR
linen observation beds
ME D5.5 The facility has established Linen is changed every day or 2 OB/RR
procedures for changing of linen whenever it get soiled
in patient care areas
Standard D8. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 4 4
ME D8.1. The facility has requisite licences Valid licences for ambulances & PVC 2 RR/SI
and certificates for operation of certificate are available
hospital and different activities

ME D8.3. The facility ensure relevant Staff is aware of procedure & 2 SI

processes are in compliance with protocol of management of medico
statutory requirement legal cases

Standard D9. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 6 6
ME D9.1. procedures.
The facility has established job Staff is aware of their roles and 2 SI
description as per govt guidelines responsibilities

ME D9.2. The facility has a established There is procedure to ensure that 2 RR/SI Check for system for recording time
procedure for duty roster and staff is available on duty as per duty of reporting and relieving
deputation to different roster (Attendance register/ Biometrics
departments etc.)

ME D9.3. The facility ensures the Doctor, nursing staff and support 2 OB
adherence to dress code as staff adhere to their respective dress
mandated by its administration / code
the health department

. Area of Concern - E Clinical Services 206 206

Standard E1. The facility has defined procedures for registration, consultation and admission of patients. 22 22
ME E1.1. The facility has established Unique identification number is 2 RR
procedure for registration of given to each patient during
patients registration

. Patient demographic details are 2 RR Check for that patient

recorded in admission records demographics like Name, Age,
Sex,Provisional Diagnosis etc.

ME E1.3. There is established procedure There is established criteria for 2 SI/RR

for admission of patients admission through emergency
department

There is established procedure for 2 SI/RR

admission of MLC cases as per
prevalent laws

There is established procedure for 2 SI/RR

prisoners as per prevalent local laws

Admission is done by written order 2 SI/RR

of a qualified doctor
There is no delay in treatment 2 SI/RR
because of admission process
Time of admission is recorded in 2 RR
patient record
There is no delay in transfer of 2 SI/RR
patient to respective department
once admission is confirmed and
clinically patient is stable to be
transferred

The Staff is aware of procedure, if 2 SI

patient can not be admitted at the
facility due to constraint in scope of
services

ME E1.4. There is established procedure There is provision of extra beds, 2 OB/SI

for managing patients, in case trolley beds in case of high
beds are not available at the occupancy or mass casualty
facility

Standard E2. The facility has defined and established procedures for clinical assessment and reassessment of the patients. 8 8
ME E2.1. There is established procedure Assessment criteria of different kind 2 SI/RR Use of standard criteria of
for initial assessment of patients of medical emergencies is defined assessment like Glasgow Comma
and practiced scale, Poly trauma, MI, Burn
patient, Paediatric patient, Pain
assessment criteria etc.

. Initial assessment and treatment is 2 OB/RR

provided immediately

. Initial assessment is documented 2 RR

preferably within two hours

ME E2.2. There is established procedure There is fixed schedule for 2 RR/SI

for follow-up/ reassessment of reassessment of patient under
Patients observation

Standard E3. Facility has defined and established procedures for continuity of care of patient and referral 18 18
ME E3.1. Facility has established There is a procedure for hand over 2 SI/RR Check for how hand over is given
procedure for continuity of care for patient transfer from emergency from emergency to ward, ICU,
during interdepartmental to IPD /OT/LR SNCU etc.
transfer

. There is a procedure consultation 2 SI/RR

of the patient with other
specialist with in the hospital

ME E3.2. Facility provides appropriate Patient are referred with referral 2 SI/RR
referral linkages to the slips
patients/Services for transfer to
other/higher facilities to assure
their continuity of care.

. Availability of referral linkages with 2 SI/RR Check how patient are referred if
higher centres. services are not available
. Advance information is given to 2 SI/RR
higher centre
. Referral vehicle is arranged 2 SI/RR
. Referral in or referral out register is 2 RR
maintained
. Facility has functional referral 2 SI/RR
linkages to lower facilities
. Check for if there is any system of 2 RR Check for referral cards filled from
follow up lower facilities
Standard E4. The facility has defined and established procedures for nursing care 16 16
ME E4.1. Procedure for identification of There is a process for ensuring the 2 OB/SI Patient id band/ verbal
patients is established at the identification before any clinical confirmation/Bed no. etc.
facility procedure

ME E4.2. Procedure for ensuring timely and Treatment charts are maintained 2 RR Check for treatment chart are
accurate nursing care as per updated and drugs given are
treatment plan is established at the marked. Co relate it with drugs and
facility doses prescribed.

. There is a process to ensure the 2 SI/RR Verbal orders are rechecked before
accuracy of verbal/telephonic administration
orders
ME E4.3. There is established procedure of Patient hand over is given during the 2 SI/RR
patient hand over, whenever change in the shift
staff duty change happens

. Nursing Handover register is 2 RR

ME E4.4. Nursing records are maintained
ME E4.5. There is procedure for periodic
monitoring of patients
maintained
Nursing notes are maintained
adequately
Patient Vitals are monitored and
recorded periodically
2 RR/SI Check for nursing note register.
Notes are adequately written
2 RR/SI Check for TPR chart, Input output
chart, any other vital required is
monitored

. Critical patients are monitored 2 RR/OB Check for use of cardiac

continuously monitor/multi parameter
Standard E5. Facility has a procedure to identify high risk and vulnerable patients. 4 4
ME E5.1. The facility identifies vulnerable Vulnerable patients are identified 2 OB/SI Unstable, irritable, unconscious.
patients and ensure their safe care and measures are taken to protect Psychotic and serious patients are
them from any harm identified

ME E5.2. The facility identifies high risk High risk medical emergencies are 2 OB/SI MI, Head injury, Spinal injury,
patients and ensure their care, as identified and treatment given on Abdominal injuries, fracture's.
per their need priority

Standard E6. Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational 8 8
ME E6.1. Facility ensured that drugs are Check for BHT/Case sheet/Case 2 RR
prescribed in generic name only paper if drugs are prescribed under
generic name only

ME E6.2. There is procedure of rational use of Check for that relevant Standard 2 RR
drugs Treatment Guideline are available at
point of use

Check staff is aware of the drug 2 SI/RR

regime and doses as per STG
Check BHT/Case sheet/Case paper 2 RR
that drugs are prescribed as per STG

Standard E7. Facility has defined procedures for safe drug administration 22 22
ME E7.1. There is process for identifying High alert drugs available in 2 SI/OB Electrolytes like Potassium
and cautious administration of department are identified chloride,opiods, Neuro muscular
high alert drugs blocking agent, Anti Thrombolytic
agent, Insulin, Warfarin, Heparin,
Adrenergic agonist etc.

Maximum dose of high alert drugs 2 SI/RR Value for maximum doses as per
are defined and communicated age, weight and diagnosis are
available with nursing station and
doctor

There is process to ensure that right 2 SI/RR A system of independent double

doses of high alert drugs are only check before administration, Error
given prone medical abbreviations are
avoided

ME E7.2. Medication orders are written Every Medical advice and 2 RR

legibly and adequately procedure are accompanied with
date , time and signature
. Check for the writing to ensure that 2 RR/SI
it is comprehendible by the clinical
staff

ME E7.3. There is a procedure to check
drug before administration/
dispensing
Drugs are checked for expiry and 2 OB/SI Turbidity, Leakage, Colour change,
other inconsistency before fungus.
administration
Check single dose vial are not used 2 OB Check for any open single dose vial
for more than one dose with left over content intended to
be used later on

Check for separate sterile needle is 2 OB

used every time for multiple dose In multi dose vial needle is not left
vial in the septum

Any adverse drug reaction is 2 RR/SI

recorded and reported
ME E7.4. There is a system to ensure right Administration of medicines done 2 SI/OB
medicine is given to right patient after ensuring right patient, right
drugs , right route, right time

ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ 2 SI/PI
administration Pharmacist /nurse about the
dosages and timings .

Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 16 16
ME E8.1. All the assessments, re- Assessment findings are written on 2 RR Day to day progress of patient is
assessment and investigations BHT/Case sheet/Case paper recorded in BHT/Case sheet/Case
are recorded and updated paper

ME E8.2. All treatment plan Treatment plan, first orders are 2 RR Treatment prescribed in nursing
prescription/orders are recorded written on BHT/Case sheet/Case records
in the patient records. paper

ME E8.3. Care provided to each patient is Maintenance of treatment 2 RR Treatment given is recorded in
recorded in the patient records chart/treatment registers treatment chat

ME E8.4. Procedures performed are Any procedure performed is written 2 RR CPR, Dressing, mobilization etc.
written on patients records on BHT/Case sheet/Case paper

ME E8.5. Adequate form and formats are Availability of form formats for 2 OB/SI MLC, Lab /X-ray requisition, death
available at point of use emergency certificate, Initial assessment
format, referral slip etc.

ME E8.6. Register/records are maintained Emergency Records are maintained 2 OB/RR Emergency register, death register,
as per guidelines MLC register, are maintained

. All register/records are identified 2 OB/RR

and numbered
ME E8.7. The facility ensures safe and Safe keeping of MLC records 2 OB/SI
adequate storage and retrieval
of medical records
Standard E9. The facility has defined and established procedures for discharge of patient. 16 16
ME E9.1. Discharge is done after assessing Assessment is done before 2 SI/RR See if there is any
patient readiness discharging patient from emergency procedure/protocol for discharging
the patient if the condition of
patient improves in emergency
itself.
What is the procedure for
discharge for short stay / day care
patients

Discharge is done by a responsible 2 SI/RR

and qualified doctor
Patient / attendants are consulted 2 PI
before discharge
ME E9.2. Case summary and follow-up Discharge summary is provided 2 RR/PI See for discharge summary, referral
instructions are provided at the slip provided.
discharge
. Discharge summary adequately 2 RR
mentions patients clinical condition,
treatment given and follow up

. Discharge summary is give to 2 SI/RR

patients going in LAMA/Referral
ME E9.3. Counselling services are provided Counselling services are provided 2 SI/PI
as during discharges wherever wherever it is required
required
ME E9.4. The facility has established Declaration is taken from the LAMA 2 RR/SI
procedure for patients leaving patient
the facility against medical
advice, absconding, etc.

Standard E10. The facility has defined and established procedures for Emergency Services and Disaster Management 50 50
ME E10.1. There is procedure for Receiving Emergency has implemented a 2 SI/OB As care provider how they triage
and triage of patients system of sorting the patients patient- immediate, delayed,
expectant, minimal, dead

. Triage area is marked 2 OB/SI

. Triage protocols are displayed 2 OB
. Responsibility of receiving and 2 SI
shifting the patient from vehicle is
defined

ME E10.2. Emergency protocols are defined Emergency protocols are available at 2 OB See for protocols of head injury,
and implemented point of use snake bite, poisoning, drawing etc.

. Staff is aware of Clinical protocols 2 SI/RR

. There is procedure for CPR 2 SI/RR

ME E10.3. The facility has disaster Line of authority is defined 2 SI/RR
management plan in place
. Procedure for internal 2 SI/RR
communication defined
. There is procedure for setting up 2 SI/RR
control room
. Disaster buffer stock of medicines 2 SI/RR
and other supplies maintained

. Role and responsibilities of staff in 2 SI/RR

disaster is defined
. Staff is aware of disaster plan 2 SI/RR
ME E10.4. The facility ensures adequate Check for how ambulances are called 2 SI/RR
and timely availability of and patients are shifted
ambulances services and
mobilisation of resources, as per
requirement

. Ambulances are equipped 2 OB

. Stable patients are transferred in 2 SI/RR
ambulance with staff
. All serious patients are transferred in 2 SI/RR
ambulance with trained staff

. Ambulance is appropriately 2 OB/RR

equipped for BLS with trained
personnel

. There is a daily checklist of all 2 RR

equipment and emergency
medications

. Ambulance has a log book for the 2 RR

maintenance of vehicle and daily
vehicle checklist

. Transfer register is maintained to 2 RR

record the detail of the referred
patient

ME E10.5. There is procedure for handling Medico legal cases are identified by 2 RR/SI
medico legal cases patient records
. Treatment of MLC cases are not 2 SI/OB/RR
delayed because of police
proceedings

. There is a establish procedure for 2 SI/RR Discharge is not done before police
informing police, as per govt consent
guidelines

. Emergency has criteria for defining 2 SI/RR Criteria is defined based on cases
medico legal cases and when to do MLC
Standard E11. The facility has defined and established procedures of diagnostic services 4 4
ME E11.1. There are established Container is labelled properly after 2 OB
procedures for Pre-testing the sample collection
Activities
ME E11.3. There are established Nursing station is provided with the 2 SI/RR
procedures for Post-testing critical value of different tests
Activities
Standard E14. The facility has defined and established procedures of Operation theatre and surgical services. 4 4
ME E14.1. Facility has established There is procedure for emergency 2 SI/RR See surgeon is available on call/on
procedures OT Scheduling surgeries duty
. Procedure for arranging logistics 2 SI Responsibilities are defined and
patient is shifted promptly
Standard E15. The facility has defined and established procedures for end of life care and death 18 18
ME E15.1. Death of admitted patient is Facility has a standard procedure 2 SI
adequately recorded and of communicating death to
communicated relatives decently.
. Death note is written on patient 2 RR
record
ME E15.2. The facility has standard Past history and sign of any medico 2 RR Check what is policy for registering
procedures for handling the legal cause is looked for brought in dead, death cases as
death in the hospital MLC

. There is criteria for declaring death 2 SI/RR Ask form how death is declared -
Physical examination or ECG is
done

. Procedure for handing over the dead 2 SI

body
. Death certificate is issued 2 SI/RR
ME E15.3 The facility has standard operating Patients Relatives are informed 2 PI/SI
procedure for end of life support clearly about the deterioration in
health condition of Patients

There is a standard procedure of 2 SI/RR Check about the policy and practice
removal of life support as per law for removing life support

There is a procedure to allow patient 2 SI/OB

relative/Next of Kin to observe
patient in last hours

. Area of Concern - F Infection Control 106 106

Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection
ME F1.4. There is Provision of Periodic
Medical Check-up's and
immunization of staff
ME F1.5. Facility has established
procedures for regular
monitoring of infection control
practices
8 8
There is a procedure for 2 SI/RR Hepatitis B, Tetanus Toxic etc.
immunization of the staff
Periodic medical check-ups of the 2 SI/RR
staff
Regular monitoring of infection 2 SI/RR Hand washing and infection control
control practices audits done at periodic intervals

ME F1.6 Facility has defined and Check if Doctors are aware of 2 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 18 18
ME F2.1. Hand washing facilities are Availability of hand washing Facility 2 OB
provided at point of use at Point of Use
. Availability of running Water 2 OB/SI Open the tap. Ask the Staff, water
is available 24*7
. Availability of antiseptic soap with 2 OB/SI Check for availability/ Ask staff if
soap dish/ liquid antiseptic with the supply is adequate and
dispenser. uninterrupted

. Availability of Alcohol based Hand 2 OB/SI Check for availability/ Ask staff for
rub regular supply. Hand rub dispenser
are provided adjacent to bed

. Display of Hand washing Instruction 2 OB Prominently displayed above the

at Point of Use hand washing facility , preferably in
Local language

ME F2.2. Staff is trained and adhere to Adherence to 6 steps of Hand 2 SI/OB Ask for demonstration
standard hand washing practices washing

. Staff is aware of occasion for hand 2 SI

washing
ME F2.3. Facility ensures standard Availability of Antiseptic Solutions 2 OB
practices and materials for
antisepsis
Procedure for proper cleaning of site 2 OB/SI e.g. before giving IM/IV injection,
with antisepsis drawing blood, putting Intravenous
and urinary catheter

Standard F3. Facility ensures standard practices and materials for Personal protection 10 10
ME F3.1. Facility ensures adequate Clean gloves are available at point of 2 OB/SI
personal protection equipment use
as per requirements

. Availability of Masks 2 OB/SI

Personal protective kit for infectious 2 OB/SI
patients
ME F3.2. Staff is adhere to standard No reuse of disposable gloves, 2 OB/SI
personal protection practices Masks, caps and aprons.
. Compliance to correct method of 2 SI
wearing and removing the gloves

Standard F4. Facility has standard Procedures for processing of equipment and instruments 20 20
ME F4.1. Facility ensures standard practices Decontamination of Procedure 2 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate work benches
and cleaning of instruments and (Wiping with 0.5% Chlorine
procedures areas solution)

Proper Decontamination of 2 SI/OB Decontamination of instruments

instruments after use and reusable of glassware are done
after procedure in 1% chlorine
solution/ any other appropriate
method

Contact time for decontamination is 2 SI/OB 10 minutes

adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with detergent
decontamination and running water after
decontamination

Proper handling of Soiled and 2 SI/OB No sorting ,Rinsing or sluicing at

infected linen Point of use/ Patient care area

The Staff knows how to make 2 SI/OB

chlorine solution
ME F4.2. Facility ensures standard practices Equipment and instruments are 2 OB/SI Autoclaving/HLD/Chemical
and materials for disinfection and sterilized after each use as per Sterilization
sterilization of instruments and requirement
equipment

High level Disinfection of 2 OB/SI Ask staff about method and time
instruments/equipment is done as required for boiling
per protocol

Chemical sterilization of 2 OB/SI Ask staff about method,

instruments/equipment is done as concentration and contact time
per protocols required for chemical sterilization

Autoclaved dressing material is used 2 OB/SI

Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention 20 20
ME F5.1. Layout of the department is Facility layout ensures separation of 2 OB
conducive for the infection control general traffic from patient traffic
practices

ME F5.2. Facility ensures availability of Availability of disinfectant as per 2 OB/SI Chlorine solution, Gluteraldehye,
standard materials for cleaning and requirement carbolic acid
disinfection of patient care areas

Availability of cleaning agent as per 2 OB/SI Hospital grade phenyl, disinfectant

requirement detergent solution
ME F5.3. Facility ensures standard practices The Staff is trained for spill 2 SI/RR
followed for cleaning and management
disinfection of patient care areas

. Cleaning of patient care area with 2 SI/RR

disinfectant detergent solution

. The Staff is trained for preparing 2 SI/RR

cleaning solution as per standard
procedure
. Standard practice of mopping and 2 OB/SI Unidirectional mopping from inside
scrubbing are followed out
. Cleaning equipment like broom are 2 OB/SI Any cleaning equipment leading to
not used in patient care areas dispersion of dust particles in air
should be avoided

ME F5.4. Facility ensures segregation Emergency department define list of 2 OB/SI

infectious patients infectious diseases require special
precaution and barrier nursing

The Staff is trained for barrier 2

nursing
Standard F6. Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous 30 30
ME F6.1. Facility Ensures segregation of Availability of colour coded bins at 2 OB
Bio Medical Waste as per point of waste generation
guidelines
. Availability of plastic colour coded 2 OB
plastic bags
. Segregation of different category of 2 OB/SI
waste as per guidelines

. Display of work instructions for 2 OB

segregation and handling of
Biomedical waste

There is no mixing of infectious and 2 OB

general waste
ME F6.2. Facility ensures management of Availability of functional needle 2 OB Verify its usage
sharps as per guidelines cutters
. Availability of puncture proof box 2 OB Should be available nears the point
of generation like nursing station
and injection room

. Disinfection of sharp before disposal 2 OB/SI Disinfection of syringes is not done

in open buckets
Staff is aware of contact time for 2 SI
disinfection of sharps
. Availability of post exposure 2 OB/SI Ask if available. Where it is stored
prophylaxis and who is in charge of that.

. Staff knows procedure in event of 2 SI/RR Staff knows what to do in case of

needle stick injury sharp injury & Whom to report. See
if any reporting has been done

ME F6.3. Facility ensures transportation Check bins are not overfilled 2 SI

and disposal of waste as per
guidelines
Disinfection of liquid waste before 2 SI/OB
disposal
Transportation of bio medical waste 2 SI/OB
is done in close container/trolley

Staff is aware of mercury spill 2 SI/RR

management
. Quality Management 48 48
Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality. 10 10
ME G3.1. Facility has established internal There is system daily round by 2 SI/RR
quality assurance program at matron/hospital manager/ hospital
relevant departments superintendent/ Hospital Manager/
Matron in charge for monitoring of
services

There is system for periodic check up 2 SI/RR

of Ambulances by designated
hospital staff

ME G3.2. Facility has established external There is periodic assessment of 2 SI/RR

assurance programs at relevant preparedness for disaster by
departments competent authority

ME G3.3. Facility has established system Departmental checklist are used 2 SI/RR
for use of check lists in different for monitoring and quality
departments and services assurance

. Staff is designated for filling and 2 SI

monitoring of these checklists

Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 32 32
ME G4.1. Departmental standard Standard operating procedure for 2 RR
operating procedures are department has been prepared and
available approved

Current version of SOP are available 2 OB

with process owner
ME G4.2. Standard Operating Procedures Emergency has documented 2 RR
adequately describes process procedure for receiving the patient
and procedures in emergency

The Department has documented 2 RR

procedure for triaging

The Department has documented 2 RR

procedure for taking consent

The Department has documented 2 RR

procedure for initial screening of
patient

The Department has documented 2 RR

procedure for nursing care

The Department has documented 2 RR

procedure for admission and
transfer of the patient to ward

The Department has documented 2 RR

procedure for maintaining records in
Emergency

The Department has documented 2 RR

procedure to handle brought in dead
patient

The Department has documented 2 RR

procedure for storage, handling and
release of dead body

The Department has documented 2 RR

procedure for storage and
replenishing the medicine in
emergency
 The Department has documented 2 RR
procedure for equipment preventive
and break down maintenance

The Department has documented 2 RR

procedure for Disaster management

ME G4.3. Staff is trained and aware of the Check if staff is aware of relevant 2 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4. Work instructions are displayed Work instruction/clinical protocols 2 OB Triage, CPR, Medical clinical
at Point of use are displayed protocols like Snake bite and
poisoning

Standard G6. The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2. The facility periodically defines Quality objective for emergency 2 RR/SI
its quality objectives and key defined
departments have their own
objectives

ME G6.3. Quality policy and objectives are Check if staff is aware of quality 2 SI
disseminated and staff is aware policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored and 2 SI/RR
objectives is monitored reviewed periodically
periodically
. Area of Concern - H Outcome 36 36
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 18 18
ME H1.1. Facility measures productivity No of Emergency cases per thousand 2 RR
Indicators on monthly basis population
. No of trips per ambulance 2 RR
. No. of trauma cases treated per 2 RR
1000 emergency cases
. No. of poisoning cases treated per 2 RR
1000 emergency cases
. No. of cardiac cases treated per 2 RR
1000 emergency cases
. No. of obstetric cases treated per 2 RR
1000 emergency cases
. No of resuscitation done per 2 RR Resuscitation should include: Chest
thousand population Compression, Airway and Breathing

. Proportion of Patients attended in 2 RR

Night
ME H1.2. The Facility measures equity Proportion of BPL Patients 2 RR
indicators periodically
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 10 10
ME H2.1. Facility measures efficiency Response time for ambulance 2 RR Between receipt of call and
Indicators on monthly basis dispatch of ambulance
. Proportion of cases referred 2 RR
. Response time at emergency for 2 RR
initial assessment
. Average Turn Around Time of patient 2 RR Average time a patient stays at
emergency observation bed
. Proportion of patient referred by 2 RR
state owned/108 ambulance per
1000 referral cases

Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 4
ME H3.1. Facility measures Clinical Care & No of adverse events per thousand 2 RR
Safety Indicators on monthly basis patients

. Death Rate 2 RR No of Deaths in Emergency/ Total

no of emergency attended

Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 4 4
ME H4.1. Facility measures Service Quality LAMA Rate 2 RR No of LAMA X 100/ No of Patients
Indicators on monthly basis seen at emergency

Absconding rate 2 RR No of Absconding X 100/ No of

Patients seen at emergency

Emergency Score Card

Emergency
Score 100
Area of Concern wise Score
A Service Provision 100
B Patient Rights 100
C Inputs 100
D Support Services 100
E Clinical Services 100
F Infection Control 100
G Quality Management 100
H Outcome 100

Obtained Maximum 1
A 32 32 100
B 60 60 100
C 150 150 100
D 82 82 100
E 206 206 100
F 106 106 100
G 48 48 100
H 36 36 100
Total 720 720 100

0
1
2
 National Quality Assurance Standards For CHC 0 1 2
Checklist for Outdoor Department 2
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method
Area of Concern - A Service Provision 92 92
Standard A1 Facility Provides Curative Services 26 26
ME A1.1 The facility provides General Medicine Availability of functional General 2 SI/OB Dedicated General Medicine
services Medicine Clinic Clinic
ME A1.2 The facility provides General Surgery Availability of functional General 2 SI/OB Dedicated General speciality
services Surgery Clinic Surgical Clinic
ME A1.3 The facility provides Obstetrics & Availability of Functional 2 SI/OB Dedicated speciality Obstetrics
Gynaecology Services Obstetrics & Gynaecology Clinic & Gynaecology Clinic. High risk
pregnancy cases are referred
from PHC & SC

Availability of IUD insertion room 2

ME A1.4 The facility provides Paediatric Availability of Paediatric Clinic 2 SI/OB Dedicated Paediatric speciality
Services Clinic
ME A1.5 The facility provides Ophthalmology Availability of functional 2 SI/OB Dedicated ophthalmology clinic
Services Ophthalmology Clinic providing consultation services

Availability of OPD eye care 2 SI/OB Vision Testing, early detection of

procedures visual impairment, Intraocular
Pressure Measurement

ME A1.6 The facility provides Dental Treatment Availability of functional Dental 2 SI/OB Dedicated Clinic providing
Services Clinic consultation services
Availability of OPD Dental 2 SI/OB Extraction, scaling, tooth
procedure extraction, denture and
Restoration.

ME A1.7 The facility provides AYUSH Services Availability of Functional Ayush 2 SI/OB AYUSH clinic accompanied by
clinic dispensary
ME A1.8 The facility provides services for OPD Availability of Dressing facilities 2 SI/OB Dressing, Suturing and drainage
procedures at OPD
Availability of Injection room 2 SI/OB
facilities at OPD
ME A1.9 Services are available for the time At least 6 Hours of OPD Services 2 SI/RR
period as mandated are available
Standard A2 Facility provides RMNCHA Services 30 30
ME A2.1 The facility provides Reproductive Availability of Spacing methods of 2 SI/OB IUCD, OCP, ECP & Condoms,
health Services family planning Progesterone only Pill (POP)
Availability of Female Limiting 2 SI/OB Tubectomy (Minilap and
Methods of family Planning Laparoscopic)

Availability of Male Limiting 2 SI/OB NSV/Conventional

Method for Family Planning
Availability of Post partum 2 SI/OB Tubal Ligation and PPIUD
sterilization services
Availability of dedicated Family 2 SI/OB Should provide Counselling and
Planning clinic. Promotive services
Abortion and Contraception 2 SI/OB
services for 1st and 2nd trimester

ME A2.2 The facility provides Maternal health Availability of functional ANC 2 SI/OB
Services clinic
Availability of post natal 2 SI/OB
counselling and follow up
services

Provision of TT and IFA 2

Nutrition and health counselling. 2

Identification and management 2 PIH, Pre-

of danger signs during pregnancy eclampsia, Bad
obstetric history,
severe anaemia,
IUGR, multiple
pregnancy.

ME A2.3 The facility provides New-born health Availability of Functional 2 SI/OB

Services immunization clinic
ME A2.4 The facility provides Child health Routine and emergency care of 2 SI/OB
Services sick children.
Services under RBSK 2 SI/OB
ME A2.5 The facility provides Adolescent Availability of Functional ARSH 2
health Services clinic
SI/OB
Standard A3 Facility Provides diagnostic Services 2 2
ME A3.3 The facility provides other diagnostic Functional ECG Services are 2 SI/OB
services, as mandated available
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 32 32
ME A4.1 The facility provides services under Availability of OPD Services 2 SI/RR OPD Management of Malaria,
National Vector Borne Disease Control Under NVBDCP Kala Azar, Dengue
Programme as per guidelines

ME A4.2 The facility provides services under
Revised National TB Control
Programme as per guidelines
ME A4.3 The facility provides services under
National Leprosy Eradication
Programme as per guidelines
Availability of Functional DOTS
clinic
Availability of OPD services under
NLEP
Assessment of Disability Status
2 SI/OB
2 SI/RR
2 SI/RR

ME A4.4 The facility provides services under Availability or linkage to a 2 SI/OB

National AIDS Control Programme as Functional ICTC
per guidelines
Availability of HIV Testing and 2 SI/RR
Counselling
PPTCT Services for HIV positive 2 SI/OB
Pregnant Women
Availability of linkage with ART 2 SI/OB
Centre
Availability of CD4 testing facility 2 SI/OB

ME A4.5 The facility provides services under Screening and early detection of 2 SI/RR Refraction, Field of Vision and
National Programme for prevention visual impairment and refraction radioscopy
and control of Blindness as per
guidelines

Availability of OPD procedures 2 SI/OB Syringing and probing, foreign

body removal , Tonometry.

ME A4.6 The facility provides services under Availability of counselling facility 2 SI/OB
Mental Health Programme as per for Suicide prevention
guidelines
ME A4.7 The facility provides services under Geriatric Clinic, twice a week. 2 SI/OB
National Programme for the health
care of the elderly as per guidelines

ME A4.8 The facility provides services under Functional NCD clinic is available 2 SI/OB
National Programme for Prevention
and control of Cancer, Diabetes,
Cardiovascular diseases & Stroke
(NPCDCS) as per guidelines
ME A4.10 The facility provide services under Management of case referred 2 SI/RR
National health Programme for from PHC/SC directly reported to
deafness Hospital

ME A4.14 The facility provides services as per State Availability of OPD services as per 2 SI/RR
specific health programmes State Health Programs/Schemes

Standard A6
ME A6.1 The facility provides curatives &
preventive services for the health
problems and diseases, prevalent
locally.
Health services provided at the facility are appropriate to community needs. 2 2
Special Clinics are available for 2 SI/OB Ask for the specific local health
local prevalent diseases problems/ diseases .i.e.. Kala
azar, arsenic poisoning etc.

Area of Concern - B Patient Rights 78 78

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 26 26
ME B1.1 The facility has uniform and user- Availability departmental 2 OB (Numbering Rooms, main
friendly signage system signage's department and inter-sectional
signage)

Display of layout/floor 2 OB
directory
ME B1.2 The facility displays the services and List of OPD Clinics are available 2 OB
entitlements available in its
departments
Names of doctor on duty is 2 OB
displayed and updated
Timing for OPD are displayed 2 OB
Entitlement under JSY , JSSK and 2 OB
other schemes
Important numbers like 2 OB
ambulance are displayed
ME B1.3 The facility has established citizen Display of citizen charter 2 OB
charter, which is followed at all levels

ME B1.4 User charges are displayed and User charges for services are 2 OB
communicated to patients effectively displayed

ME B1.5 Patients & visitors are sensitised and IEC Material is displayed 2 OB
educated through appropriate IEC /
BCC approaches
ME B1.6 Information is available in local Signage's and information are 2 OB
language and easy to understand available in local language

ME B1.7 The facility provides information to Availability of Enquiry Desk with 2 OB

patients and visitor through an dedicated staff
exclusive set-up.
ME B1.8 The facility ensures access to clinical OPD slip is given to the patient 2 RR/OB
records of patients to entitled
personnel
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of physical 16 16
access, social, economic, culturalOB
or social status.
ME B2.1 Services are provided in manner that Separate queue for females at 2
are sensitive to gender registration
Separate toilets for male and 2 OB
female
Availability of female staff if a 2 OB
male doctor examines a female
patients

Availability of Breast feeding 2 OB

corner
ME B2.3 Access to facility is provided without Availability of Wheel chair or 2 OB
any physical barrier & and friendly to stretcher for easy Access to the
people with disabilities OPD

Availability of ramps with railing 2 OB

There is no over crowding during 2 OB

OPD hours
Availability of specially abled 2 OB
friendly toilets
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 12 12
ME B3.1 Adequate visual privacy is provided at Availability of screen at 2 OB
every point of care Examination Area
One Patient is seen at a time in 2 OB
clinics
Privacy at the counselling room is 2 OB
maintained
ME B3.2 Confidentiality of patients records and Confidentiality of HIV reports. 2 SI/OB
clinical information is maintained

ME B3.3 The facility ensures that behaviours of Behaviour of staff is empathetic 2 PI/OB
staff is dignified and respectful, while and courteous
delivering the services

ME B3.4 The facility ensures privacy and Privacy and confidentiality of TB, 2 SI/OB Check in RTI/STI clinic
confidentiality to every patient, Leprosy Patients
especially of those conditions having
social stigma, and also safeguards
vulnerable groups

Standard B4 Facility has defined and established procedures for informing patients about their medical conditions and involving them in treatment 14 14
ME B4.1 There is established procedures for planning,
Informed consent for beforeand
HIV facilitates
2 informed decisioncheck
SI/RR making
for filled consent forms of
taking informed consent before testing at ICTC, minor surgeries
treatment and procedures
Informed consent for IUD 2 SI/RR
insertion
Informed consent on prescribed 2 SI/RR
form C for abortion

ME B4.2 Patient is informed about his/her Display of patient rights and 2 OB

rights and responsibilities
ME B4.4 Information about the treatment is
shared with patients or attendants,
regularly
responsibilities.
Patient is informed about her
clinical condition and treatment
being provided, possible
outcomes, and risks involved.
2 PI Ask patients about what they
have been communicated about
the treatment plan

Pre and Post test counselling is 2 SI/PI/RR

given at ICTC
ME B4.5 The facility has defined and Availability of complaint box, 2 OB
established grievance redressal display of grievance redressal
system in place process, and details of person to
contact is displayed

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services. 10 10
ME B5.1 The facility provides cashless services Free OPD Consultation / ANC 2 PI/SI For JSSK entitlement
to pregnant women, mothers and Check-up's/Investigations.
neonates as per prevalent
government schemes

ME B5.2 The facility ensures that drugs Check that patient party has not 2 PI/SI
prescribed are available at Pharmacy spent on purchasing drugs or
consumables from outside.

ME B5.3 It is ensured that facilities for the Check that patient party has not 2 PI/SI
prescribed investigations are available spent on diagnostics from
at the facility outside.

ME B5.4 The facility provides free of cost Free OPD Consultation for BPL 2 PI/SI/RR
treatment to Below poverty line patients
patients without administrative
hassles
ME B5.5 The facility ensures timely If any other expenditure occurred 2 PI/SI/RR
reimbursement of financial it is reimbursed from hospital
entitlements and reimbursement to
the patients

Area of Concern - C Inputs 128 128

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 44 44
ME C1.1 Departments have adequate space as Clinics have adequate space for 2 OB Adequate Space in Clinics (112
per patient or work load consultation and examination sq. ft.)

Availability of adequate waiting 2 OB Waiting area at the scale of 1 sq.

area ft. per average daily patient with
minimum 400 sq. ft. of area

ME C1.2 Patient amenities are provide as per Availability of seating 2 OB As per average OPD at peak time
patient load arrangement in waiting area
Availability of sub waiting areas 2 OB For clinics having high patient
at separate clinics load
2
Availability of potable Drinking See if its is easily accessible to
water OB the visitors
Availability of functional toilets 2 OB Urinals 1 per 50 person
water closet and wash basins 1
per 100 person . Dry Toilet with
running water

Availability of patient calling 2 OB

system
Availability of public telephone 2 OB
booth
ME C1.3 Departments have layout and There is designated area for 2 OB
demarcated areas as per functions registration
Dedicated clinic for each 2 OB
speciality
One clinic is not shared by 2 2 OB
doctors at one time
Demarcated dressing area /room 2 OB

Demarcated injection room 2 OB

Demarcated immunization room 2 OB
for pregnant women and children

Availability of clean and dirty 2 OB

utility room
Demarcated trolley/wheelchair 2 OB
bay
ME C1.4 The facility has adequate circulation Corridors at OPD are broad 2 OB
area and open spaces according to enough for movement of
need and local law stretcher, trolleys, patients &
visitors

ME C1.5 The facility has infrastructure for Availability of functional 2 OB

intramural and extramural telephone and Intercom Services
communication
ME C1.6 Service counters are available as per Availability of Registration 2 OB Average Time taken for
patient load counters as per Patient load registration would be 3-5 min, So
number of counter required
would be worked on scale of 12-
20 patient/hour per counter

ME C1.7 The facility and departments are Unidirectional flow of services 2 OB Layout of OPD shall follow
planned to ensure structure follows functional flow of the
the function/processes (Structure patients, e.g.:
commensurate with the function of Enquiry→Registration→Waiting
the hospital) →Sub-waiting→
Clinic→Dressing room/Injection
Room→
Diagnostics (lab/X-
ray)→Pharmacy→Exit

All OPD clinics and related 2 OB

auxiliary services are co located
in one functional area

OPD is located near to the entry 2 OB

of the CHC
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 20 20
ME C2.1 The facility ensures the seismic safety Non structural components are 2 OB Check for fixtures and furniture
of the infrastructure properly secured. Building bye- like cupboards, cabinets, and
laws and instructions of NBC heavy equipment , hanging
(National Building Code) for objects are properly fastened
seismic safety are followed. and secured

ME C2.2 The facility ensures safety of electrical OPD building does not have 2 OB
establishment temporary connections and
loosely hanging wires.

Safe installation, use of 2

appropriate wires and MCBs,
display of Danger notice,
availability of tools and PPE
(personal protective equipment),
and periodic inspections.

ME C2.3 Physical condition of buildings are Floors of the OPD are non 2 OB
safe for providing patient care slippery and even
Windows have grills and wire 2 OB
meshwork
ME C2.4 The facility has plan for prevention of OPD has sufficient fire exits to 2 OB/SI
fire permit safe escape to its
occupant in case of fire

Fire exits are clearly visible and 2 OB

routes to reach exit are clearly
marked.

ME C2.5. The facility has adequate fire fighting OPD has installed fire 2 OB
Equipment Extinguisher to fight Type A/B/C
Fire

Expiry date of fire extinguishers 2 OB/RR

are displayed on each
extinguisher as well as due date
for next refilling is clearly
mentioned

ME C2.6. The facility has a system of periodic Check for staff competencies for 2
training of staff and conducts mock operating fire extinguisher and
drills regularly for fire and other what to do in case of fire
disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 36 36
ME C3.1 The facility has adequate specialist Availability of specialist Doctor 2 OB/RR Check for specialist are available
doctors as per service provision during OPD time at scheduled time

ME C3.3. The facility has adequate nursing staff Availability of Nursing staff 2 OB/RR/SI At Injection room/ OPD Clinic as
as per service provision and work load Per Requirement

ME C3.4 The facility has adequate Availability of dresser/paramedic 2 OB/SI

technicians/paramedics as per at dressing room
requirement
Counsellor for ICTC 2 SI/RR Full Time
Lab technician for ICTC 2 SI/RR Full time
Counsellor for ARSH clinic 2 SI/RR
Availability of ECG technician 2 SI/RR
Availability of Ophthalmic 2 SI/RR
assistant
 Availability of Dental technician 2 SI/RR

ME C3.5 The facility has adequate support / Availability of security guard for 2 SI/RR
general staff OPD
Availability of housekeeping staff 2 SI/RR

ME C3.6 The staff has been provided required IMEP training 2 SI/RR
training / skill sets
ICTC Team Training 2 SI/RR
Induction and refresher training 2 SI/RR
for ICTC lab technician

ME C3.7 The Staff is skilled as per job Check the competency of staff to 2 SI/RR
description use OPD equipment like BP
apparatus etc.

At ANC clinic the staff is skilled to 2 SI/RR

identify high risk pregnancies

Counsellor is skilled for 2 SI/RR

counselling
Staff is skilled for maintaining 2 SI/RR
clinical records
Standard C4 Facility provides drugs and consumables required for assured list of services. 10 10
ME C4.1 The departments have availability of Availability of injectable in 2 OB/RR ARV, TT
adequate drugs at point of use injection room
Availability of vaccine as per 2 OB/RR
National Immunization Program

ME C4.2 The departments have adequate Availability of disposables at 2 OB/RR Examination gloves, Syringes,
consumables at point of use dressing room and clinics Dressing material , suturing
material

HIV testing Kits I, II and III at ICTC 2 OB/RR

ME C4.3 Emergency drug trays are maintained Emergency Drug Tray is 2 OB/RR Verify Presence of following
at every point of care, where ever it maintained in injection room & Drugs:-Inj Dopamine, Inj
may be needed immunization room Adrenaline, Inj Hydrocortisone
Succinate, Inj Chlorpheniramine
Maleate,Inj Ranitidine, Inj
Ondansetron

Standard C5 The facility has equipment & instruments required for assured list of services. 18 18
ME C5.1 Availability of equipment & Availability of functional 2 OB BP apparatus, thermometer,
instruments for examination & Equipment &Instruments for weighing machine, torch,
monitoring of patients examination & Monitoring stethoscope, Examination table

ME C5.2 Availability of equipment & Availability of functional 2 OB PV examination kit, measuring

instruments for treatment Instruments/Equipment for tape, fetoscope, Weighing
procedures, being undertaken in the Gynae and obstetric machine, BP apparatus etc.
facility

Availability of functional 2 OB Retinoscope, refraction kit,

Instruments / Equipment for tonometer, perimeter, distant
Ophthalmic Procedures vision chart, Colour vision chart.

Availability of functional 2 OB Dental chair, Air rotor,

Instruments/ Equipment for Endodontic set, Extraction
Dental Procedures forceps

ME C5.5 Availability of Equipment for Storage Availability of equipment for 2 OB Refrigerator, Crash cart/Drug
storage for drugs trolley, instrumental trolley,
dressing trolley

ME C5.6 Availability of functional equipment Availability of equipment for 2 OB Buckets for mopping, mops,
and instruments for support services cleaning duster, waste trolley, Deck brush

Availability of equipment for 2 OB Steam Sterlizer,Autoclave

sterilization and disinfection

ME C5.7 Departments have patient furniture
and fixtures as per load and service
provision
Availability of Fixtures
Availability of furniture at clinics
2 OB Spot light, electrical fixture for
equipment, X ray view box
2 OB Doctors Chair, Patient Stool,
Examination Table, Attendant
Chair, Table, Footstep, cupboard

Area of Concern - D Support Services 76 76

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 4 4
ME D1.1 The facility has established system for All equipment are covered under 2 SI/RR
maintenance of critical Equipment AMC including preventive
maintenance

ME D1.2 The facility has established procedure All the measuring equipment/ 2 OB/ RR BP apparatus, weighing scale,
for internal and external calibration of instrument are calibrated thermometer are calibrated
measuring Equipment

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas 22 22
ME D2.1 There is established procedure for There is process for indenting 2 SI/RR Stock level are weekly updated
forecasting and indenting drugs and consumables and drugs in Requisition are timely placed
consumables injection/ dressing room

ME D2.3 The facility ensures proper storage of Drugs are stored in 2 OB

drugs and consumables containers/tray/crash cart and
are labelled

Vaccine are kept at 2 OB

recommended temperature at
immunization room

ME D2.4 The facility ensures management of Expiry dates for injectable are 2 OB/RR
expiry and near expiry drugs maintained at injection and
immunization room

No expiry drugs found 2 OB/RR

ME D2.5 The facility has established procedure There is practice of calculating 2 SI/RR
for inventory management techniques and maintaining buffer stock

Department maintained stock 2 SI/RR

and expenditure register of drugs
and consumables

ME D2.6 There is a procedure for periodically There is procedure for 2 SI/RR

replenishing the drugs in patient care replenishing drug tray /crash
areas cart/Emergency Tray

There is no stock out of drugs 2 SI/RR

ME D2.7 There is process for storage of Temperature of refrigerators are 2 OB/RR Check for temperature charts are
vaccines and other drugs, requiring kept as per storage requirement maintained and updated
controlled temperature and records are maintained periodically

Cold chain is maintained at 2 OB/RR Check for four conditioned Ice

immunization room packs are placed in Carrier Box,
DPT, DT, TT and Hep B Vaccines
are not kept in direct contact of
Frozen Ice pack

Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable environment to 36 36
staff, patients and visitors.
ME D3.1 Exterior of the facility building is Building is painted/whitewashed
2 OB
maintained with landscaping in open in uniform colour
area
Interior of patient care areas are 2 OB
plastered & painted
ME D3.2 Hospital infrastructure is adequately Check for there is no seepage , 2 OB
maintained Cracks, chipping of plaster
Window panes , doors and other 2 OB
fixtures are intact
Patients beds are intact and 2 OB
painted
Mattresses are intact and clean 2 OB

ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, 2 OB All area are clean with no
hygienic sinks patient care and circulation dirt,grease,littering and cobwebs
areas are Clean

Surface of furniture and fixtures 2 OB

are clean
Toilets are clean with functional 2 OB
flush and running water

ME D3.4 The facility has policy of removal of No condemned/Junk material 2 OB

condemned junk material lying in the OPD
ME D3.5 The facility has established No stray animal/rodent/birds 2 OB
procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate Illumination in clinics 2 OB 100 Lux in each Clinic
illumination level at patient care areas

Adequate Illumination in 2 OB 150 Lux in Injection Room

procedure area
ME D3.7 The facility has provision of restriction Only one patient is allowed one 2 OB/SI
of visitors in patient areas time at clinic

ME D3.8 The facility ensures safe and Temperature control and 2 PI/OB Fans/ Air
comfortable environment for patients ventilation in waiting areas conditioning/Heating/Exhaust/Ve
and service providers ntilators as per environment
condition and requirement

Temperature control and 2 SI/OB Fans/ Air

ventilation in clinics conditioning/Heating/Exhaust/Ve
ntilators as per environment
condition and requirement

ME D3.9 The facility has security system in Hospital has sound security 2 OB/SI
place at patient care areas system to manage crowd in OPD

ME D3.10 The facility has established measure for Ask female staff whether they 2 SI
safety and security of female staff feel secure at work place

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 4 4
ME D4.1 The facility has adequate arrangement Availability of 24x7 running and 2 OB/SI
storage and supply for potable water potable water
in all functional areas

ME D4.2 The facility ensures adequate power Availability of power back up in 2 OB/SI
backup in all patient care areas as per OPD
load
Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 2 2
ME D5.4 The facility has adequate sets of linen Availability of linen in 2 OB
examination area
Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures. 8 8
ME D9.1 The facility has established job Staff is aware of their roles and 2 SI
description as per govt guidelines responsibilities

ME D9.2 The facility has a established There is procedure to ensure that 2 RR/SI Check for system for recording
procedure for duty roster and staff is available on duty as per time of reporting and relieving
deputation to different departments duty roster (Attendance register/ Biometrics
etc.)

There is designated in charge for 2 SI

department
ME D9.3 The facility ensures the adherence to Doctor, nursing staff and support 2 OB
dress code as mandated by its staff adhere to their respective
administration / the health dress code
department

Area of Concern - E Clinical Services 280 280

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 24 24
ME E1.1 The facility has established procedure Unique identification number is 2 RR
for registration of patients given to each patient during
registration

Patient demographic details are 2 RR Check for that patient

recorded in OPD registration demographics like Name, age,
records Sex, Address etc.

Patients are directed to relevant 2 PI/SI

clinic by registration clerk based
on complaint

Registration clerk is aware of 2 SI/RR

categories of the patient
exempted from user charges

ME E1.2 The facility has a established There is procedure for systematic 2 OB Patient is called by
procedure for OPD consultation calling of patients one by one Doctor/attendant as per his/her
turn on the basis of “first come
first examine” basis.

Patient History is taken and 2 RR

recorded
Physical Examination is done and 2 OB/RR
recorded wherever required

Provisional Diagnosis is recorded 2 OB/RR

No Patient is Consulted in 2 OB
Standing Position
Clinical staff is not engaged in 2 OB/SI
administrative work
ME E1.3 There is established procedure for There is establish procedure for 2 SI/RR
admission of patients admission through OPD
There is establish procedure for 2 SI/RR
day care admission
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 10 10
ME E3.1 Facility has established procedure for There is a procedure for 2 SI/RR
continuity of care during consultation of the patient to
interdepartmental transfer other specialist with in the
hospital

ME E3.2 Facility provides appropriate referral Availability of referral linkages for 2 RR/OB Check how patient are referred if
linkages to the patients/Services for OPD consultation. services are not available
transfer to other/higher facilities to
assure their continuity of care.

The Facility has functional 2 SI/RR

referral linkages to higher
facilities
The Facility has functional 2 SI/RR
referral linkages to lower
facilities
There is a system of follow up 2 RR
of referred patients
Standard E5 Facility has a procedure to identify high risk and vulnerable patients. 2 2
ME E5.2 The facility identifies high risk patients For any critical patient needing 2 OB/SI
and ensure their care, as per their need urgent attention queue can be
bypassed for providing services
on priority basis

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use. 10 10
ME E6.1 Facility ensured that drugs are prescribed Check for OPD slip if drugs are 2 RR
in generic name only prescribed under generic name
only

A copy of Prescription is kept 2 RR

with the facility
ME E6.2 There is procedure of rational use of Check that relevant Standard 2 RR
drugs treatment guideline are available
at point of use

Check if staff is aware of the drug 2 SI/RR

regime and doses as per STG

Availability of Essential Drug List 2 SI/OB

Standard E7 Facility has defined procedures for safe drug administration 12 12

ME E7.2 Medication orders are written legibly Every Medical advice and 2 RR
and adequately procedure are accompanied
with date , time and signature

Check for the writing, is it 2 RR/SI

comprehendible by the clinical
staff

ME E7.3 There is a procedure to check drug Drugs are checked for expiry 2 OB/SI
before administration/ dispensing and other inconsistency
before administration

Check single dose vial are not 2 OB Check for any open single dose
used for more than one dose vial with left over content
intended to be used later on

Check for separate sterile needle 2 OB

is used every time for multiple In multi dose vial needle is not
dose vial left in the septum

ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ 2 SI/PI
administration Pharmacist /nurse about the
dosages and timings .

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 14 14
ME E8.1 All the assessments, re-assessment Patient History, Chief Complaint 2 RR
and investigations are recorded and and Examination Diagnosis/
updated Provisional Diagnosis are
recorded in OPD slip

ME E8.2 All treatment plan prescription/orders Written Prescription and 2 RR

are recorded in the patient records. Treatment plan are written

ME E8.4 Procedures performed are written on Any dressing/injection other 2 RR

patients records procedure recorded in the OPD
slip

ME E8.5 Adequate form and formats are Check for the availability of OPD 2 OB/SI
available at point of use slip, Requisition slips etc.

ME E8.6 Register/records are maintained as OPD records are maintained 2 OB/RR OPD register, ANC register,
per guidelines Injection room register etc.
All register/records are identified 2 OB/RR
and numbered
ME E8.7 The facility ensures safe and adequate Safe keeping of OPD records 2 OB/SI
storage and retrieval of medical
records
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 4 4
ME E10.3 The facility has disaster management Staff is aware of disaster plan 2 SI/RR
plan in place
Roles and responsibilities of staff 2 SI/RR
in disaster are defined
Standard E11 The facility has defined and established procedures of diagnostic services 4 4
ME E11.1 There are established procedures for The Container are labelled 2 OB
Pre-testing Activities properly after the sample
collection

ME E11.3 There are established procedures for Clinics are provided with the 2 SI/RR
Post-testing Activities critical value of different tests

Maternal & Child Health Services

Standard E16 Facility has established procedures for Antenatal care as per guidelines 50 50
ME E16.1 There is an established procedure for Facility provides and updates 2 RR/SI Line listing
Registration and follow up of pregnant “Mother and Child Protection
women. Card”.
Records are maintained for ANC 2 RR Records of each ANC check-up's
registered pregnant women is maintained in Mother and
child protection card /ANC
register

ME E16.2 There is an established procedure for History of past illness / pregnancy 2 RR/SI
History taking, Physical examination, complication is taken and
and counselling for each antenatal recorded
visit.

ANC Check-up is done by the 2 RR/SI/PI

qualified personnel
At ANC clinic, Pregnancy is 2 RR/SI
confirmed by performing urine
test

Last menstrual period (LMP) is 2 RR/SI

recorded and Expected date of
Delivery (EDD) is calculated

Weight measurement 2 RR/SI

Blood pressure 2 RR/SI
Respiratory rate 2 RR/SI
Pallor, oedema and icterus 2 RR/SI
Abdominal palpation for foetal 2 RR/SI
growth, foetal lie
Breast examination 2 RR/SI
History of past illness / pregnancy 2 RR/SI <12 weeks - 1 Visit, <26 weeks -2
complication is taken and visits, < 34 -3 visits and >34
recorded weeks to term -5 visits

ME E16.3 Facility ensures availability of Diagnostic test under ANC check 2 RR/SI Check for Haemoglobin, urine
diagnostic and drugs during antenatal up are prescribed at ANC clinic albumin urine sugar blood group
care of pregnant women and Rh factor Syphilis
(VDRL/RPR) HIV blood sugar
malaria Hepatitis B

ME E16.4 There is an established procedure for High risk pregnant women are 2 RR/SI Anaemia, Bad Obs history, CPD,
identification of High risk pregnancies identified, initial Management & PIH, Medical disorder
and appropriate treatment/referral as referred to specialist complicating pregnancy,
per scope of services. Malpresentation, PROM,
Obstructed labour, Rh negative

ME E16.5 There is an established procedure for Line listing of pregnant women 2 RR/SI
identification and management of with moderate and severe
moderate and severe anaemia anaemia

IFA Tablets given to ANC Cases 2

 Provision for Injectable Iron 2 RR/SI
Treatment for moderate anaemia

ME E16.6 Counselling of pregnant women is done Nutritional counselling 2 RR/PI

as per standard protocol and gestational
age

Breast feeding 2 RR/PI

Institutional delivery
Arrangement of referral
transport
Birth preparedness
Pregnant women are counselled
for recognizing danger signs
during pregnancy
2 RR/PI
2 RR/PI
2 RR/PI
2 PI Swelling, oedema, bleeding PV
( even spotting), blurred vision,
headache, pain abdomen,
vomiting, pyrexia, watery foul
smelling, discharge & yellow
urine

Family planning 2 RR/PI PPIUCD & vasectomy

Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 40 40
ME E19.1 The facility provides immunization Availability of diluents for 2 RR/SI Match no. of dilatant with no. of
services as per guidelines reconstitution of Measles vaccine measles vials

Recommended temperature of 2 RR/SI Check diluents are kept under

diluents is ensured before cold chain at least 24 hours
reconstitution before reconstitution
Diluents are kept in vaccine
carrier only at immunization
clinic but should not be in direct
contact of ice pack

Reconstituted vaccines are not 2 RR/SI Check when the vials are opened
used after recommended period & constituted . Should not be
used beyond 4 hrs. after
reconstitution

Time of opening/ Reconstitution 2 RR Check for records

of vial is recorded on the vial

Staff checks VVM level before 2 SI White square in side the violet
using vaccines circle changes the colour

Staff is aware of how to check 2 SI Ask staff to demonstrate how to

freeze damage for T-Series conduct Shake test for DPT, DT
vaccines and TT

Discarded vaccines are kept 2 SI/OB Check for expired, frozen or with
separately VVM beyond the discard point
vaccine stored separately

Check for DPT, DT, Hep Band TT 2 SI/OB

vials are kept in basket in upper
section of ILR

AD syringes are available as per 2 SI/OB Check for 0.1 ml AD syringe for
requirement BCG and 0.5 ml syringe for
others are available

Vaccine recipient is asked to stay 2 SI/RR

for half an hour after vaccination
to observe any Adverse effect
following the immunization

Antipyretic medicines are 2 SI/RR

available
Availability & updation of 2 SI/RR
Immunization card
Counselling on adverse effects 2 SI/RR
and follow up visits done(CEI)

Staff is aware of how to manage 2 SI

and report minor and serious
advise events (AEFI)

Staff knows what to do in case of 2 SI

anaphylaxis
ME E19.2 Triage, Assessment & Management of Check for adherence to clinical 2 SI/RR
new-borns having protocols
emergency signs are done as per
guidelines

ME E19.5 Management of children presenting Check for adherence to clinical 2 SI/RR

with fever, cough/ breathlessness is protocols
done as per guidelines

ME E19.6 Management of children with Severe Screening of children coming 2 SI/RR

Acute Malnutrition is done as per to OPDs using weight for
guidelines height and/or MUAC and
further management

ME E19.7 Management of children presenting Check for adherence to clinical 2 SI/RR

with protocols
diarrhoea is done per guidelines
Availability of ORT corner 2 SI/RR
Standard E20 Facility has established procedures for abortion and family planning as per government guidelines and law 22 22
ME E20.1 Family planning counselling services The client is given full 2 PI/SI The importance of timely
provided as per guidelines information about optimal initiation of an FP method after
spacing of pregnancy and childbirth, miscarriage,
the benefits of it as a part of FP or abortion will be emphasized.
health education and counselling.

Client is counselled about the 2 PI/SI

available options for family
planning

The client is informed that use of 2 PI/SI

condoms prevent sexually
transmitted infections (STIs) &
HIV

ME E20.2 Facility provides spacing method of Oral Pills is given only to those 2 SI/RR Oral Pills are not given to mother
family planning as per guideline who meet the Medical Eligibility within 6 weeks of the delivery
Criteria

The client is given full 2 PI/SI

information about the risks,
advantages, and possible side
effects before OCPs are
prescribed for her.

Staff is aware of what to advice if 2 SI/RR

dose of contraceptive is missed
by a lady

Staff is aware of indication and 2 SI/RR within 72 hours, second dose 12

method of administration of ECP hours after first dose

IUD insertion is done as per 2 SI/RR No touch technique, Speculum

standard protocol and bimanual examination,
sounding of Uterus and
placement

Client is informed about the 2 SI/PI Cramping, vaginal discharge,

adverse effect that can happen heavy menstruation, checking of
and their remedy IUD

Follow up services are provided 2 SI/RR Removal of IUD, Instructions for

as per protocols when to return
 Staff is aware of case selection
criteria for family planning
Standard E21 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines
ME E21.1 Facility provides Promotive ARSH Provision of Antenatal check up
Services to pregnant adolescent
Counselling and provision of
emergency contraceptive pills
Counselling and provision of
reversible Contraceptives
Availability and Display of IEC
material
Information and advice on sexual
and reproductive health related
issues
ME E21.2 Facility provides Preventive ARSH Services for Tetanus
Services immunization
Services for Prophylaxis against
Nutritional Anaemia
Nutrition Counselling
Services for early and safe
termination of pregnancy and
management of post abortion
complication
ME E21.3 Facility Provides Curative ARSH Treatment of Common RTI/STI's
Services
Treatment and counselling for
Menstrual disorders
Treatment and counselling for
sexual concern for male and
female adolescents
Management of sexual abuse
amongst Girls
ME E21.4 Facility provides Referral Services for Referral Linkages to ICTC and
ARSH PPTCT
Privacy and confidentiality
maintained at ARSH clinic
National Health Programs
Standard E22 Facility provides National health program as per operational/Clinical Guidelines
ME E22.1 Facility provides service under Ambulatory care of
National Vector Borne Disease Control uncomplicated P. Vivax malaria
Program as per guidelines
Ambulatory care of
uncomplicated P. Falciparum
Malaria
Care of drug resistant malaria
ME E22.2 Facility provides service under Revised Diagnosis and Management of
National TB Control Program as per Pulmonary Tuberculosis
guidelines
Management of Paediatric
Tuberculosis
Management of Patients with HIV
infection and Tuberculosis
Drug administration for Intensive
and Continuation done as per
RNTCP treatment protocol
Protocols for treatment for TB
during pregnancy and Post natal
Period is adhered
Monitoring and follow up of
patient done as per protocols
ME E22.3 Facility provides service under Validation and diagnosis of
National Leprosy Eradication Program Referred and Directly Reported
as per guidelines Cases
Treatment of all diagnosed cases
including Reaction and Neuritis
Assessment of Disability Status
Management of Complicated
Ulcers
Management of Eye
Complications
Follow-up of cases treated at
tertiary Level
Self care Counselling
Outreach Services to Leprosy
Clinics
Screening of Cases of RCS
ME E22.4 Facility provides service under Pre Test Counselling is done as
National AIDS Control program as per per protocols
guidelines
Screening of PLHA for initiating
ART
Monitoring of patients on ART
and management of side effects
2 SI/RR 22-49 years age
Married
at least having one year old and
Spouse has not undergone for
sterilization
30 30
2
Nutritional Counselling,
contraceptive counselling,
Couple counselling ANC check-
up's, ensuring institutional
SI/RR delivery
2
Check for the availability of
Emergency Contraceptive pills
SI/RR (Levonorgesterol)
2
Check for the availability of Oral
Contraceptive Pills, Condoms and
RR/SI IUD
2
Poster are displayed, Reading
OB Material hand-out's etc.
2
Advice on topic related to
Growth and development,
puberty, sexuality, myths &
misconception, pregnancy, safe
sex, contraception, unsafe
abortion, menstrual
disorders,anemia, sexual
SI/RR abuse ,RTI/STI's etc.
2
SI/RR TT at 10 and 16 year
2
Haemoglobin estimation, weekly
IFA tablet, and treatment for
SI/RR worm infestation
2 SI/RR
2
MVA procedure for pregnancy up
to 8 weeks Post abortion
SI/RR counselling
2
Privacy and Confidentiality,
treatment Compliance, Partner
Management, Follow up visit and
SI/RR referral
2
Symptomatic treatment ,
SI/RR counselling
2
SI/RR
2
ECP, Prophylaxis against STI, PEP
SI/RR for hive and Counselling
2
SI/RR
2
Screens and curtains for visual
privacy, confidentility policy
SI/RR displayed, one client at a time
58 58
2 SI/RR As per Clinical Guidelines for
Treatment of Malaria
2 SI/RR As per Clinical Guidelines for
Treatment of Malaria
2 SI/RR As per Clinical Guidelines for
Treatment of Malaria
2 SI/RR As per RNTCP Technical
Guidelines
2 SI/RR As per RNTCP Technical
Guidelines
2 SI/RR As per RNTCP Technical
Guidelines
2 SI/RR Check for filled treatment Cards
2 SI/RR Discontinuation of Streptomycin
Chemoprophylaxis of babies in
case of smear positive mother
2 SI/RR Check for records/Protocols
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR As per Operation/ Clinical
Guidelines of NLEP
2 SI/RR Basic information and benefits of
HIV testing
potential risks such as
discrimination. The client is also
informed about their right to
refuse, follow-up services .
Pregnant
women are given additional
information on nutrition,
hygiene, the importance of an
institutional delivery and HIV
testing so as to avoid HIV
transmission from mother to
child.
2 SI/RR As per NACO guidelines
2 SI/RR As per NACO guidelines
 Counselling and Psychological 2 SI/RR As per NACO guidelines
support for PLHA

ME E22.6 Facility provides service under Mental Treatment of Mental illnesses as 2 SI/RR
Health Program as per guidelines per clinical guidelines

ME E22.7 Facility provides service under Geriatric Care is provided as per 2 SI/RR
National programme for the health Clinical Guidelines
care of the elderly as per guidelines

ME E22.8 Facility provides service under
National Programme for Prevention
and Control of cancer, diabetes,
cardiovascular diseases & stroke
(NPCDCS) as per guidelines
Opportunistic screening for 2 SI/RR Screening of persons above age
diabetes, of 30 - History of tobacco
hypertension, cardiovascular examination, BP Measurement
diseases and Blood sugar estimation
Look for records at NCD clinic

screen women of the age group 2 SI/RR

30-69 years approaching to the
hospital for early detection of
cervix cancer and breast cancer.

Health Promotion through IEC 2 OB increased intake of healthy foods

and counselling increased physical activity
through sports, exercise,
etc,avoidance of tobacco and
alcohol, stress management
warning signs of cancer etc.

ME E22.9 Facility provide service for Integrated Weekly reporting of Presumptive 2 SI/RR
disease surveillance program cases on form "P" from OPD clinic

ME E22.10 Facility provide services under Early detection and screening for 2 SI/RR As per Clinical guidelines
National program for prevention and detection of deafness
control of deafness

Area of Concern - F Infection Control 92 92

Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 8 8
ME F1.4 There is Provision of Periodic Medical There is a procedure for 2 SI/RR Hepatitis B, Tetanus Toxoid etc.
Check-up's and immunization of staff immunization of the staff

Periodic medical check-up's of 2 SI/RR

the staff
ME F1.5 Facility has established procedures for Regular monitoring of infection 2 SI/RR Hand washing and infection
regular monitoring of infection control control practices control audits are done at
practices periodic intervals

ME F1.6 Facility has defined and established Check if Doctors are aware of 2 SI/RR
antibiotic policy Hospital Antibiotic Policy
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 16 16
ME F2.1 Hand washing facilities are provided Availability of hand washing 2 OB Check for availability of wash
at point of use Facility at Point of Use basin near the point of use
Availability of running Water 2 OB/SI Open the tap ask the staff if
water is 24*7
Availability of antiseptic soap 2 OB/SI Check for availability/ Ask staff if
with soap dish/ liquid antiseptic the supply is adequate and
with dispenser. uninterrupted

Availability of Alcohol based 2 OB/SI Check for availability/ Ask staff

Hand rub for regular supply.
Display of Hand washing 2 OB Prominently displayed above the
Instruction at Point of Use hand washing facility , preferably
in Local language

ME F2.2 Staff is trained and adhere to standard Adherence to 6 steps of Hand 2 SI/OB Ask for demonstration
hand washing practices washing
Staff is aware of occasion for 2 SI
hand washing
ME F2.3 Facility ensures standard practices Availability of Antiseptic Solutions 2 OB
and materials for antisepsis
Standard F3 Facility ensures standard practices and materials for Personal protection 6 6
ME F3.1 Facility ensures adequate personal Clean gloves are available at 2 OB/SI
protection equipment as per point of use
requirements
Availability of Masks 2 OB/SI
ME F3.2 Staff is adhere to standard personal No reuse of disposable gloves, 2 OB/SI
protection practices Masks, caps and aprons.

Standard F4 Facility has standard Procedures for processing of equipment and instruments 16 16
ME F4.1 Facility ensures standard practices and Decontamination of operating & 2 SI/OB Ask staff about how they
materials for decontamination and Procedure surfaces decontaminate the procedure
cleaning of instruments and procedures surface like Examination table ,
areas dressing table, Stretcher/Trolleys
etc.
(Wiping with .5% Chlorine
solution)

Proper Decontamination of 2 SI/OB

instruments after use Ask staff how they
decontaminate the instruments
like Stethoscope, Dressing
Instruments, Examination
Instruments, Blood Pressure Cuff
etc.
(Soaking in 0.5% Chlorine
Solution, Wiping with 0.5%
Chlorine Solution

Contact time for 2 SI/OB 10 minutes

decontamination is adequate

Cleaning of instruments after 2 SI/OB Cleaning is done with detergent

decontamination and running water after
decontamination

Staff is aware of correct 2 SI/OB

procedure of making chlorine
solution

ME F4.2 Facility ensures standard practices and Equipment and instruments are 2 OB/SI Autoclaving/HLD/Chemical
materials for disinfection and sterilization sterilized after each use as per Sterilization
of instruments and equipment requirement

High level Disinfection of 2 OB/SI Ask staff about method and time
instruments/equipment is done required for boiling
as per protocol

Autoclaved dressing material is 2 OB/SI

used
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 20 20
ME F5.1 Layout of the department is conducive Facility layout ensures separation 2 OB
for the infection control practices of general traffic from patient
traffic

Clinics for infectious diseases are 2 OB Preferably in remote corner with

located away from main traffic independent access

Sitting arrangement in TB clinic is 2 OB

as per guideline
ME F5.2 Facility ensures availability of standard Availability of disinfectant as per 2 OB/SI Chlorine solution,
materials for cleaning and disinfection of requirement Glutaraldehyde, carbolic acid
patient care areas

Availability of cleaning agent as 2 OB/SI Hospital grade phenyl,

per requirement disinfectant detergent solution
ME F5.3 Facility ensures standard practices Staff is trained for spill 2 SI/RR Blood & body fluid spill
followed for cleaning and disinfection of management management & Mercury spill
patient care areas

Cleaning of patient care area with 2 SI/RR

detergent solution
Staff is trained for preparing 2 SI/RR
cleaning solution as per standard
procedure

Standard practice of mopping 2 OB/SI Unidirectional mopping from

and scrubbing are followed inside out
Cleaning equipment like broom 2 OB/SI Any cleaning equipment leading
are not used in patient care areas to dispersion of dust particles in
air should be avoided

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste. 26 26
ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins 2 OB
Medical Waste as per guidelines at point of waste generation

Availability of plastic colour 2 OB

coded plastic bags
Segregation of different category 2 OB/SI
of waste as per guidelines

Display of work instructions for 2 OB

segregation and handling of
Biomedical waste

There is no mixing of infectious 2 OB

ME F6.2 Facility ensures management of
sharps as per guidelines
and general waste
Availability of functional needle
cutters
Availability of puncture proof box
2 OB See if it has been used or just
lying idle
2 OB Should be available nears the
point of generation like nursing
station and injection room

Disinfection of sharp before 2 OB/SI Disinfection of syringes is not

disposal done in open buckets
Availability of post exposure 2 OB/SI Ask if available. Where it is
prophylaxis stored and who is in charge of
that.

Staff knows what to do in 2 SI Staff knows what to do in case of

condition of needle stick injury sharpe injury. Whom to report.
See if any reporting has been
done

ME F6.3 Facility ensures transportation and Check bins are not overfilled 2 SI/OB
disposal of waste as per guidelines

Transportation of bio medical 2 SI/OB

waste is done in close
container/trolley

Staff aware of mercury spill 2 SI/RR

management
Area of Concern - G Quality Management 72 72
Standard G1 The facility has established organizational framework for quality improvement 2 2
ME G1.1 The facility has a quality team in place There is a designated 2 SI/RR Preferably Medical Officer in
departmental nodal person charge
for coordinating Quality
Assurance activities

Standard G2 Facility has established system for patient and employee satisfaction 2 2
ME G2.1 Patient Satisfaction surveys are OPD Patient satisfaction survey 2 RR
conducted at periodic intervals done on monthly basis

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 8 8
ME G3.1 Facility has established internal There is system daily round by 2 SI/RR
quality assurance program at relevant matron/hospital in-charge/ for
departments monitoring of services

ME G3.2 Facility has established external External Quality assurance 2 SI/RR

assurance programs at relevant program is established at ICTC lab
departments
ME G3.3 Facility has established system for use Departmental checklist are 2 SI/RR
of check lists in different departments used for monitoring and
and services quality assurance
Staff is designated for filling 2 SI
and monitoring of these
checklists
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 30 30
ME G4.1 Departmental standard operating Standard operating procedure for 2 RR
procedures are available department has been prepared
and approved

Current version of SOP are 2 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures OPD has documented procedure 2 RR
adequately describes process and for Registration
procedures
OPD has documented procedure 2 RR
for patient calling system in OPD
clinics

OPD has documented procedure 2 RR

for receiving of patient in clinic

OPD has documented procedure 2 RR

for prescription and drug
dispensing

OPD has documented procedure 2 RR

for nursing process in OPD

OPD has documented procedure 2 RR

for patient privacy and
confidentiality

OPD has documented procedure 2 RR

for conducting, analysing patient
satisfaction survey

OPD has documented procedure 2 RR

for equipment management and
maintenance in OPD

Department has documented 2 RR

procedure for Administrative
and non clinical work at OPD

Department has documented 2 RR

procedure for No Smoking Policy
in OPD

OPD has documented procedure 2 RR

for duty roaster, punctuality,
dress code and identity for OPD
staff

ME G4.3 Staff is trained and aware of the Check if staff are aware of 2 SI/RR
standard procedures written in SOPs relevant part of SOPs

ME G4.4 Work instructions are displayed at Work instruction/clinical 2 OB Relevant protocols are displayed
Point of use protocols are displayed like Clinical Protocols for ANC
check-up's

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 12 12
ME G5.1 The facility conducts periodic internal Internal assessment is done at 2 RR/SI
assessment periodic interval
ME G5.2 The facility conducts the periodic There is procedure to conduct 2 RR/SI
prescription/ medical/death audits Medical Audit
There is procedure to conduct 2 RR/SI
Prescription audit
ME G5.3 The facility ensures non compliances Non Compliance are enumerated 2 RR/SI
are enumerated and recorded and recorded
adequately
ME G5.4 Action plan is made on the gaps found Action plan prepared 2 RR/SI
in the assessment / audit process

ME G5.5 Corrective and preventive actions are Corrective and preventive action 2 RR/SI
taken to address issues, observed in taken
the assessment & audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 6 6
ME G6.2 The facility periodically defines its Quality objective for OPD defined 2 RR/SI
quality objectives and key
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check of staff is aware of quality 2 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality objectives is Quality objectives are monitored 2 SI/RR
monitored periodically and reviewed periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 12 12

ME G7.1 Facility uses method for quality PDCA 2 SI/RR

improvement in services
5S 2 SI/OB
Process Mapping 2 SI/OB
Any other method of QA 2 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 2 SI/RR
improvement in services
Pareto / Prioritization 2 SI/RR
Area of Concern - H Outcome 48 48
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 22 22
ME H1.1 Facility measures productivity Indicators Proportion of follow-up patients 2 RR
on monthly basis
General OPD/1000 population 2 RR

Medicine OPD/1000 Population 2 RR

Surgical OPD/1000 Population 2 RR

Ophthalmic OPD/1000 2 RR
population
Paediatric OPD/1000 population 2 RR

AYUSH OPD/1000 Population 2 RR

No of ANC done per thousand 2 RR

ICTC OPD per thousand 2 RR

Immunization OPD per thousand 2 RR

ME H1.2 The Facility measures equity indicators Proportion of BPL patients 2 RR

periodically
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 2 2
ME H2.1 Facility measures efficiency Indicators on OPD per Doctor 2 RR
monthly basis
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 10 10
ME H3.1 Facility measures Clinical Care & Safety Consultation time at ANC Clinic 2 RR Time motion study
Indicators on monthly basis
Consultation time at General 2 RR
Medicine Clinic
Consultation time for paediatric 2 RR
clinic
Proportion of High risk pregnancy 2 RR No of High Risk Pregnancies
detected during ANC X100/ Total no PW used ANC
services in the month

Proportion of severe anaemia 2 RR

cases
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 14 14
ME H4.1 Facility measures Service Quality Patient Satisfaction Score 2 RR
Indicators on monthly basis
Waiting time at registration 2 RR
counter
Waiting time at ANC Clinic 2 RR
Waiting time at general OPD 2 RR
Waiting time at paediatric Clinic 2 RR

Waiting time at surgical clinic 2 RR

Average door to drug time 2 RR

OPD Score
OPD Score
100
Area of Concern wise Score
A Service Provision 100
B Patient Rights 100
C Inputs 100
D Support Services 100
E Clinical Services 100
F Infection Control 100
G Quality Management 100
H Outcome 100

Obtained Maximum Percent 2

A 92 92 100
B 78 78 100
C 128 128 100
D 76 76 100
E 280 280 100
F 92 92 100
G 72 72 100
H 48 48 100
Total 866 866 100
 National Quality Assurance Standards for CHC 0 1 2
Checklist for Labour Room 3
Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification
Method Remarks

Area of Concern - A Service Provision 15 30

Standard A1 The facility provides Curative Services 2 4
ME A1.3 The facility Provides Obstetrics & Availability of comprehensive 1 SI/OB LSCS, Blood storage,
Gynaecology Services obstetric services Anaesthesia.
ME A1.9 Services are available for the time Labour room services are 1 SI/RR
period as mandated functional on 24X7 basis
Standard A2 The facility provides RMNCHA Services 11 22
ME A2.1 The facility provides Reproductive Availability of Post partum 1 SI/OB PPIUD insertion
health Services sterilization services
ME A2.2 The facility provides Maternal Vaginal Delivery 1 SI/OB Term, post Date and pre term
health Services
Assisted Delivery 1 SI/OB Forceps delivery and vacuum
delivery
Caesarean-Section 1
Management of Postpartum 1 SI/OB Medical /Surgical
Haemorrhage
Management of Retained Placenta 1 SI/OB

Delivery of septic and HIV positive 1 SI/OB

PW
Management of PIH/Eclampsia/ 1 SI/OB
Pre Eclampsia
Initial Diagnosis and management 1 SI/OB
of MTP and Ectopic

ME A2.3 The facility provides New-born Availability of Essential new born 1 SI/OB
health Services care
Availability of New born 1 SI/OB
resuscitation
Standard A3 The facility Provides diagnostic Services 2 4
ME A3.1 The facility provides Radiology Availability or functional linkage 1 SI/OB
Services for USG services.
ME A3.2 The facility provides Laboratory Availability of point of care 1 SI/OB HIV, Hb in gm , Random
Services diagnostic test blood sugar /as per state
guideline

Area of Concern - B Patient Rights 26 52

Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their
10 20
ME B1.1 Availability departmental
modalities
1 OB (Numbering Rooms, main
The facility has uniform and user- signage's department and inter-
friendly signage system sectional signage)

Directional signage for 1 OB Direction is displayed from

department is displayed main gate to direct.
Restricted area signage 1 OB
displayed
ME B1.2 Entitlements under JSSK are 1 OB
The facility displays the services Displayed
and entitlements available in its
department
Entitlement under JSY is displayed 1 OB

Name of doctor and Nurse on duty 1 OB

are displayed and updated

Contact details of referral 1 OB

transport / ambulance displayed

Services provision of labour room 1 OB

are displayed at the entrance

ME B1.5 IEC Material is displayed 1 OB Breast feeding, kangaroo

care, family planning
Patients & visitors are sensitised (Pictorial and chart ),
and educated through Immunization schedule in
appropriate IEC / BCC approaches circulation area

ME B1.6 Signage's and information are 1 OB

Information is available in local available in local language
language and easily understood
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on
5 10
ME B2.1
account of physical access,social. economic,
Only on duty staff is allowed in 1 OB
cultural or social status.
Services are provided in manner the labour room when it is
that are sensitive to gender occupied

Availability of female staff if a male 1 OB/SI

doctor examines a female
patients/Mother

ME B2.3 Availability of Wheel chair or 1 OB

Access to facility is provided
without any physical barrier &
and friendly to people with
disabilities
stretcher for easy Access to the
labour room
Availability of ramps and railing 1 OB

Labour room is located on ground 1 OB

floor; or availability of the
ramp/lift with person for shifting

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related
5 10
ME B3.1 Availability of screen/ partition at
information.
1 OB
Adequate visual privacy is
provided at every point of care delivery tables
Curtains / frosted glass have been 1 OB
provided at windows
ME B3.2 1 SI/OB
Confidentiality of patients records Patient Records are kept at secure
place beyond access to general
and clinical information is staff/visitors
maintained
ME B3.3 Behaviour of staff is empathetic 1 OB/PI
The facility ensures the and courteous
behaviours of staff is dignified and
respectful, while delivering the
services
ME B3.4 HIV status of patient is not 1 SI/OB
disclosed except to staff that is
The facility ensures privacy and directly involved in care
confidentiality to every patient,
especially of those conditions
having social stigma, and also
safeguards vulnerable groups

Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and involving
2 4
them in treatment planning, and facilitates informed decision making
ME B4.1 General consent is taken before 1 SI/RR
There is established procedures delivery
for taking informed consent
before treatment and procedures

ME B4.4 Labour room has system in place 1 PI

to involve patient relative in
Information about the treatment decision making about pregnant
is shared with patients or women treatment
attendants, regularly

Standard B5 The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost
4 8
ME B5.1
of hospital 1services.
Drugs and consumables under PI/SI
The facility provides cashless JSSK are available free of cost
services to pregnant women,
mothers and neonates as per
prevalent government schemes

ME B5.2 Check that parents & attendant's 1 PI/SI

have not spent money on
The facility ensures that drugs purchasing drugs and consumables
prescribed are available at from outside.
Pharmacy and wards

ME B5.3 Check that parents & attendants 1 PI/SI

It is ensured that facilities for the have not spent money on
prescribed investigations are diagnostics from outside.
available at the facility
ME B5.5 If any other expenditure has been 1 PI/SI/RR
The facility ensures timely incurred, then it is reimbursed
reimbursement of financial from hospital
entitlements and reimbursement
to the patients
Area of Concern - C Inputs 78 156
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 22 44
ME C1.1 The Departments has adequate Adequate space as per delivery 1 OB One labour table requires
space as per patient or work load load 10X10 sqft of space, Every
labour table should have
space for vertical trolley with
space for six trays

Availability of Waiting area for 1 OB

attendants/ASHA
ME C1.2 Patient amenities are provided as Attached toilet facility available 1 OB
per patient load
Availability of Drinking water 1 OB
Availability of Changing area 1 OB
ME C1.3 The Department have layout and Delivery unit has dedicated 1 OB
demarcated areas as per Receiving area
functions
Availability of Examination Room 1 OB

Availability of Pre delivery room 1 OB

Availability of Delivery room 1 OB

Availability of Post delivery 1 OB
observation room
Dedicated nursing station within 1 OB
or proximity of labour room

Area earmarked for new-born care 1 OB

Corner
Dedicated Isolation room 1 OB For septic cases.
Preparation of medicine and 1 OB
injection space.
Availability of dirty utility room 1 OB

Availability of store 1 OB
ME C1.4 The facility has adequate Corridors connecting labour room 1 OB
circulation area and open spaces are broad enough to facilitate
according to need and local law stretcher and trolley's movement

ME C1.5 The facility has infrastructure for Availability of functional telephone 1 OB

intramural and extramural and Intercom Services
communication
ME C1.6 Service counters are available as Availability of labour tables as per 1 OB At least 2 labour table for
per patient load delivery load 100 deliveries per month
ME C1.7 The facility and departments are Labour room is in Proximity and 1 OB
planned to ensure structure function linkage with OT
follows the function/processes
(Structure commensurate with
the function of the hospital)

Labour room is in proximity and 1 OB

functional linkage with NBSU

Unidirectional flow of care 1 OB

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging objects
are properly fastened and
secured

ME C2.2 The facility ensures safety of Labour room does not have 1 OB Switch Boards other
electrical establishment temporary connections and electrical installations are
loosely hanging wires intact

Stabilizer is provided for Radiant 1 OB

warmer
ME C2.3 Physical condition of buildings are Floors of the ward are non slippery 1 OB
safe for providing patient care and even surpad

Windows and vents if any are 1 OB

intact and sealed
ME C2.4. The facility has plan for LR has fire exit to permit safe 1 OB/SI
prevention of fire escape of its occupant at time of
fire

Check the fire exits are clearly 1 OB

visible and routes to reach exit are
clearly marked.

ME C2.5. The facility has adequate fire NBSU has installed fire 1 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.
 Check the expiry date for fire 1 OB/RR
extinguisher is displayed on each
extinguisher as well as due date
for next refilling is clearly
mentioned

ME C2.6. The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 15 30
ME C3.1 The facility has adequate Availability of Obs 1 OB/RR Paediatrician or trained MO,
specialist doctors as per service &Gynaespecialist and Obstetrician or trained MO
provision paediatrician on call.

ME C3.2. The facility has adequate general Availability of at least one doctor 1
duty doctors as per service 24x7 in the facility
provision and work load

ME C3.3 The facility has adequate nursing Availability of SBA trained Nursing 1 OB/RR/SI At least Three per shift
staff as per service provision and staff
work load
ME C3.5 The facility has adequate Availability of labour room 1 SI/RR At least 1 sanitary worker
support / general staff attendants/ Birth Companion and 1 ayah per shift
Availability of dedicated security 1 SI/RR
staff
ME C3.6 The staff has been provided Navjat Shishu Surkasha Karyakarm 1 SI/RR
required training / skill sets (NSSK) training
Skilled birth Attendant (SBA) 1 SI/RR
IMEP training. 1 SI/RR
BEmOC training for MO 1 SI/RR
PPIUCD training 1 SI/RR
ME C3.7 The Staff is skilled as per job Nursing staff is skilled for 1 SI/RR check staff is aware of
description operating radiant warmer optimal temperature, how to
set temperature, how to use
probes, and how to interpret
alarms and trouble shooting.

Nursing staff is skilled for 1 SI/RR Check the staff know how to
resuscitation set the temperature, how to
put the probe, duration and
interpretation of alarms

Nursing staff is skilled identifying 1 SI/RR Check how staff interpret

and managing complication different alarming sign like
excessive bleeding, shock ,
obstructed labour

Counsellor is skilled for postnatal 1 SI/RR

counselling
Nursing Staff is skilled for
maintaining clinical records
including partograph
1 SI/RR Check staff know what to fill
different section of
partograph and how to
interparate alert and action

Standard C4 The facility provides drugs and consumables required for assured services. 14 28
ME C4.1 The departments have availability Availability of uterotonic Drugs 1 OB/RR Inj Oxytocin 10 IU (to be kept
of adequate drugs at point of use in fridge)

Availability of Antibiotics 1 OB/RR Cap Ampicillin 500mg, Tab

Metronidazole 400mg, Inj.
Gentamicin,

Availability of Antihypertensive 1 OB/RR Nifedipine.

Availability of analgesics and 1 OB/RR Tab Paracetamol, Tab

antipyretics Ibuprofen
Availability of IV Fluids 1 OB/RR IV fluids, Normal saline,
Ringer lactate, Dextrose
Availability of local anaesthetics 1 OB/RR Inj Xylocaine 2%,

Availability of tocolytics 1 OB/RR Inj. Labetolol, Inj.

Hydralazine, Inj. Isoprene.

Availability of emergency drugs 1 OB/RR Inj Magsulf 50%, Inj Calcium

gluconate 10 mg, Inj
Dexamethasone, Inj
Hydrocortisone, Succinate,
Inj Diazepam, Inj
Pheniramine maleate, Inj
Carboprost, Inj Pentazocine,
Inj Promethazine,
Betamethasone, Inj
Hydralazine, Nifedipine,
Methyldopa, Ceftriaxone, Inj
Adrenaline.

Availability of drugs for new-born 1 OB/RR Vit K1 1 mg.

ME C4.2 The departments have adequate Availability of dressings and 1 OB/RR Gauze pieces and Cotton
consumables at point of use Sanitary pads swabs, Sanitary pads, Needle
(round body and cutting),
Chromic catgut no. 0

Availability of syringes and IV 1 OB/RR Paediatric IV-Sets,Urinary

Sets /tubes Catheter
Availability of Antiseptic Solutions 1 OB/RR Antiseptic lotion

Availability of consumables for 1 OB/RR Gastric tube and Cord clamp,

new born care Baby ID tag, Mucous sucker

ME C4.3 Emergency drug trays are Emergency Drug Tray is 1 OB/RR

maintained at every point of care, maintained
where ever it may be needed

Standard C5 The facility has equipment & instruments required for assured list of services. 17 34
ME C5.1 Availability of equipment & Availability of functional 1 OB BP apparatus, Stethoscope
instruments for examination & Equipment & Instruments for Thermometer, Foetoscope/
monitoring of patients examination & Monitoring Doppler, Baby weighting
scale, Wall clock.
ME C5.2 Availability of equipment & Availability of instrument 1 OB Scissor & Artery forceps,
instruments for treatment arranged in Delivery trays Cord clamp, Sponge holder,
procedures, being undertaken in Speculum, Kidney tray, Bowl
the facility for antiseptic lotion

Delivery kits are in adequate 1 OB As per delivery load and cycle

numbers as per load time for processing of
instruments

Availability of Instruments 1 OB Episiotomy scissors, Kidney

arranged for Episiotomy trays tray, Artery forceps, Allis
forceps, Sponge holder,
Toothed forceps, Needle
holder, Thumb forceps

Availability of Baby tray 1 OB Two pre warmed

towels/Sheets for wrapping
the baby, Mucus extractor,
Bag and Mask (0 &1 no.),
Sterilized thread for
Cord/Cord clamp,
Nasogastric tube

Availability of instruments 1 OB Speculum, Anterior vaginal

arranged for MVA/EVA tray wall retractor, Posterior wall
retractor, Sponge holding
forceps, MVA Syringe,
Cannulas, MTP, Small bowl of
antiseptic lotion

Availability of instruments 1 OB Sim's speculum, PPIUCD

arranged for PPIUCD tray insertion forceps, CuIUCD
380A/Cu IUCD375 in sterile
package

ME C5.3 Availability of equipment & Availability of Point of care 1 OB Glucometer, Doppler and HIV
instruments for diagnostic diagnostic instruments rapid diagnostic kit, Uristix
procedures being undertaken in
the facility

ME C5.4 Availability of equipment and
instruments for resuscitation of
patients and for providing
intensive and critical care to
patients
Availability of resuscitation
Instruments for New-born Care
1 OB Bag and mask (New-born
resuscitator), Oxygen,
Suction machine/ mucus
sucker , radiant warmer,
laryngoscope, ET tube 2.5
and 3.5 sizes.

Availability of resuscitation 1 OB Suction machine, Oxygen

instrument for mother with Hood, Adult bag and
mask, mouth gag,

ME C5.5 Availability of Equipment for Availability of equipment for 1 OB Refrigerator, Crash cart/Drug
Storage storage for drugs trolley, instrument trolley,
dressing trolley

ME C5.6 Availability of functional Availability of equipment for 1 OB Buckets for mopping,

equipment and instruments for cleaning Separate mops for labour
support services room and circulation area
duster, waste trolley, Deck
brush

Availability of equipment for 1 OB Steam steriliser and

ME C5.7 Departments have patient
furniture and fixtures as per load
and service provision
sterilization and disinfection Autoclave
Availability of Delivery tables 1 OB Steel Top
Availability of attachment/ 1 OB Hospital graded Mattress, IV
accessories with delivery table stand, Kelly's pad, support
for delivery tables,
Macintosh, foot step, Bed
pan

Availability of fixture 1 OB Wall clock with Second arm,

Wall mounted, Lamps,
Electrical fixture for
equipment like Radiant
warmer, Suction .

Availability of Furniture 1 OB Cupboard, Table, chair,

Counter.

Area of Concern - D Support Services 48 96

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 4 8
ME D1.1 The facility has established All equipment are covered under 1 SI/RR
system for maintenance of critical AMC including preventive
Equipment maintenance

There is system of timely 1 SI/RR

corrective break down
maintenance of the equipment

ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR BP apparatus, Weighing
procedure for internal and instrument are calibrated Machine etc. are calibrated
external calibration of measuring
Equipment

ME D1.3 Operating and maintenance Up to date instructions for 1 OB/SI

instructions are available with the operation and maintenance of
users of equipment equipment are readily available
with staff.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient
11 22
ME D2.1 There is established procedure for There is established system of
care areas
1 SI/RR Stock level are daily updated
forecasting and indenting of drugs timely indenting of consumables Requisition are timely placed
and consumables and drugs at nursing station

ME D2.3 The facility ensures proper Drugs are stored in 1 OB

storage of drugs and consumables containers/tray/crash cart and are
labelled

Empty and filled cylinders are 1 OB

labelled
ME D2.4 The facility ensures management Record of expiry dates are 1 OB/RR
of expiry and near expiry drugs maintained at emergency drug
tray

No expiry drug found 1 OB/RR

Records for expiry and near expiry 1 RR
drugs are maintained for drug
stored at the department

ME D2.5 The facility has established There is practice of calculating and 1 SI/RR
procedure for inventory maintaining buffer stock
management technique
 Department maintained stock and 1 RR/SI
expenditure register of drugs and
consumables

ME D2.6 There is a procedure for periodically There is procedure for replenishing 1 SI/RR
replenishing the drugs in patient care drug tray /crash cart
areas

There is no stock out of drugs 1 OB/SI

ME D2.7 There is process for storage of Temperature of refrigerators are 1 OB/RR Check for temperature charts
vaccines and other drugs, kept as per storage requirement are maintained and updated
requiring controlled temperature and records are maintained periodically

Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable
18 36
environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Check for there is no seepage , 1 OB
adequately maintained Cracks, chipping of plaster
Window panes , doors and other 1 OB
fixtures are intact
Patients beds are intact and 1 OB
painted
Mattresses are intact and clean 1 OB

ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, sinks 1 OB All area are clean with no
hygienic new-born care and circulation dirt,grease,littering and
areas are Clean cobwebs

Surface of furniture and fixtures 1 OB

are clean
Toilets are clean with functional 1 OB
flush and running water

ME D3.4 The facility has policy of removal No condemned/Junk material in 1 OB

of condemned junk material the Labour room

ME D3.5 The facility has established No stray animal/rodent/birds 1 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate
illumination level at patient care table
areas
ME D3.7 The facility has provision of
restriction of visitors in patient
areas
ME D3.8 The facility ensures safe and
comfortable environment for
patients and service providers
Adequate Illumination at delivery 1 OB 400 lux.
Adequate Illumination at 1 OB 300 Lux.
observation area
There is no overcrowding in labour 1 OB
room
One female family members 1 OB/SI
allowed to stay with the PW
Entry of visitors is restricted in the 1 OB/SI
labour room
Temperature control and 1 PI/OB Optimal temperature and
ventilation in Labour room warmth is ensured at labour
room. Fans/ Air
conditioning/Heating/Exhaus
t/Vents as per environment
condition and requirement

ME D3.9 The facility has security system in Lockable doors in labour room 1 OB
place at patient care areas

New born identification band are 1 OB/RR

used and foot prints of babies are
taken.

ME D3.10- The facility has established measure Ask female staff weather they feel 1 SI
for safety and security of female staff secure at work place

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 6 12
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas

Availability of hot water 1 OB/SI

ME D4.2 The facility ensures adequate Availability of power back up in 1 OB/SI
power backup in all patient care labour room
areas as per load
Availability of UPS 1 OB/SI
Availability of Emergency light 1 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Oxygen cylinders 1 OB
availability of oxygen, medical gases and vacuum suction
and vacuum supply

Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted
5 10
patients.
ME D5.4 The facility has adequate sets of
Availability of clean Drape, 1 OB/RR
linen Macintosh on the Delivery table,

Gown are provided in labour room 1 OB/RR

Availability of Baby blanket, sterile 1 OB/RR

drape for baby
ME D 5.5. The facility has established Drape sheets are changed after 1 OB/RR
procedures for changing linen in each delivery.
patient care areas
ME D5.6 The facility has standard procedures There is system to check the 1 SI/RR
for handling , collection, cleanliness and Quantity of the
transportation and washing of linen linen received from laundry

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
4 8
ME D9.1 The facility has established job
operating procedures.
Staff is aware of their roles and
1 SI
description as per govt guidelines responsibilities

ME D9.2 The facility has a established There is procedure to ensure that 1 RR/SI Check for system for
procedure for duty roster and staff is available on duty as per recording time of reporting
deputation to different duty roster and relieving (Attendance
departments register/ Biometrics etc.)

There is designated in charge for 1 SI

department
ME D9.3 The facility ensures adherence to Doctor, nursing staff and support 1 OB
the dress code as mandated by its staff adhere to their respective
administration / the health dress code
department

Area of Concern - E Clinical Services 103 206

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 6 12
ME E1.1 The facility has established Unique identification number is 1 RR
procedure for registration of given to each patient during
patients process of registration

Patient demographic details are 1 RR Check for that patient

recorded in admission records demographics like Name,
Age, Sex,Provisional
Diagnosis etc.

ME E1.3 There is established procedure for There is a procedure for admitting 1 SI/RR/OB
admission of patients Pregnant women directly to
Labour room

Admission is done by written order 1 SI/RR/OB

of a facility's doctor
Time of admission is recorded in 1 RR
patient record
ME E1.4 There is established procedure for Check how service provider cope 1 OB/SI
managing patients, in case beds with shortage of delivery tables
are not available at the facility due to high patient load

Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 6 12
ME E2.1 There is established procedure for Rapid Initial assessment of 1 RR/SI/OB Assessment and immediate
initial assessment of patients Pregnant Women to identify treatment following danger
complication and Prioritization of sign are present - difficulty in
care Breathing, Fever, Sever
abdominal pain, Convulsion
or unconsciousness, Severe
headache or Blurred vision

Recording and reporting of Clinical 1 RR/SI Recording of women

History Obstetric History including
LMP and EDD Parity, Gravida
status, h/o CS, Live birth, Still
Birth, Medical History (TB,
Heart diseases, STD etc., HIV
status and Surgical History)

Recording of current labour details 1 RR Time of start, Frequency of

contractions, Time of Water
bag leaking, Colour and smell
of fluid and baby movement

Physical Examination 1 RR/SI Recording of Vitals , shape &

Size of abdomen , presence
of scars, foetal lie and
presentation. & vaginal
examination

ME E2.2 There is established procedure for There is fixed schedule for 1 RR/OB There is a fixed schedule of
follow-up/ reassessment of reassessment of Pregnant women reassessment as per
Patients as per standard protocol protocols

Partograph is used and updated 1 RR/OB All step are recorded in

as per stages of labour timely manner

Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 8 16
ME E3.1 The facility has established There is procedure of handing 1 SI/RR
procedure for continuity of care over patient / new born from
during interdepartmental transfer labour room to OT/ Ward/NBSU

There is a procedure for 1 SI/RR

consultation of the patient with
other specialist with in the
hospital

ME E3.2 The facility provides appropriate
referral linkages to the
patients/Services for transfer to
other/higher facilities to assure the
continuity of care.
Patient is referred with referral slip 1 RR/SI A referral slip/ Discharge card
is provide to patient when
referred to another health
care facility

Advance intimation is given to 1 RR/SI

higher centre
Referral vehicle is arranged 1 RR/SI
Referral in or referral out register 1 SI/RR
is maintained
Facility has functional referral 1 SI/RR
linkage with to lower facilities

There is a system of follow up 1 SI/RR Check for referral cards filled

of referred patients from lower facilities
Standard E4 The facility has defined and established procedures for nursing care 7 14
ME E4.1 Procedure for identification of There is a process for ensuring the 1 OB/SI Identification tags for
patients is established at the identification before any clinical mother and baby / foot print
facility procedure are used for identification of
new-born's

ME E4.2 Procedure for ensuring timely and There is a process to ensue the 1 SI/RR Verbal orders are rechecked
accurate nursing care as per accuracy of verbal/telephonic before administration
treatment plan is established at the orders
facility

ME E4.3 There is established procedure of Patient hand over is given during 1 RR/SI
patient hand over, whenever staff the change of the shift
duty change happens
Nursing Handover register is 1 RR
maintained
Bed side Hand over is given 1 SI/RR
ME E4.5 There is procedure for periodic Patient's Vitals are monitored 1 RR/SI Check for TPR chart, IO chart,
monitoring of patients and recorded periodically any other vital required is
monitored

Critical patients are monitored 1 RR/SI Check for BP,

continuously Pluse,Temp,Respiratory Rate
FHR, Uterine Contraction,
Any other vital required is
monitored

Standard E5 The facility has a procedure to identify high risk and vulnerable patients. 2 4
ME E5.1 The facility identifies vulnerable Vulnerable patients are identified 1 OB/SI Check the measure taken to
patients and ensure their safe care and measures are taken to protect prevent new born theft,
them from any harm swapping and baby fall
ME E5.2 The facility identifies high risk High Risk Pregnancy cases are 1 OB/SI Check for the frequency of
patients and ensure their care, as per identified and kept in intensive observation: Ist stage :half an
their need monitoring hour and 2nd stage: every 5
min

Standard E6 The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs
4 8
ME E6.1 The facility ensured that drugs are
& their rational
Check for Case sheet if drugs are 1
use.
RR
prescribed in generic name only prescribed under generic name
only

ME E6.2 There is procedure of rational use of Check for that relevant Standard 1 RR
drugs Treatment Guideline are available
at point of use

Check if staff are aware of the drug 1 SI/RR

regime and doses as per Standard
treatment guidelines (STG)

Check Case sheet that drugs are 1 RR Check for rational use of
prescribed as per STG Uterotonic drugs
Standard E7 The facility has defined procedures for safe drug administration 10 20
ME E7.1 There is process for identifying High alert drugs are identified in 1 SI/OB Electrolytes like Potassium
and cautious administration of the department chloride, Insulin etc. as
high alert drugs applicable

Maximum dose of high alert drugs 1 SI/RR Value for maximum doses as
are defined and communicated per age, weight and diagnosis
are available with nursing
station and doctor

There is process to ensure that 1 SI/RR A system of independent

right doses of high alert drugs are double check before
only given administration, Error prone
medical abbreviations are
avoided

ME E7.2 Medication orders are written Every Medical advice and 1 RR

legibly and adequately procedure are accompanied
with date , time and signature

Check for the writing to ensure 1 RR/SI

that it is comprehendible by the
clinical staff

ME E7.3 There is a procedure to check Drugs are checked for expiry 1 OB/SI
drug before administration/ and other inconsistency before
dispensing administration
Check single dose vial are not used 1 OB Check for any open single
for more than one dose dose vial with left over
content intended to be used
later on

Check for separate sterile needle is 1 OB

used every time for multiple dose In multi dose vial needle is
vial not left in the septum

Any adverse drug reaction is 1 RR/SI

recorded and reported
ME E7.4 There is a system to ensure right Administration of medicines 1 SI/OB
medicine is given to right patient done after ensuring right
patient, right drugs , right dose,
right route, right time

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 7 14
ME E8.1 All the assessments, re- Progress of labour is recorded 1 RR Partograph fully
assessment and investigations are compliance ,and on bed head
recorded and updated ticket partial compliance

ME E8.2 All treatment plan Treatment prescribed in nursing 1 RR Medication order, treatment
prescription/orders are recorded records plan, lab investigation are
in the patient records. recoded adequately

ME E8.4 Procedures performed are written Delivery notes are adequate 1 RR Outcome of delivery, date
on patients records and time, gestation age,
delivery conducted by, type
of delivery, complication if
any ,indication of
intervention, date and time
of transfer, cause of death
etc.

Baby note is adequate 1 RR Baby cry, Essential new born

care, Resuscitation if any,
Sex, Weight, Time of
initiation of breast feed, Birth
doses, Congenital anomaly,
APGAR Score

ME E8.5 Adequate form and formats are Standard Formats available 1 RR/OB Availability of BHT,
available at point of use Partograph, etc.
ME E8.6 Register/records are maintained Registers and records are 1 RR Labour room register, OT
as per guidelines maintained as per guidelines register, MTP register,FP
register, Maternal death
register and records, Lab
register, Referral in /out
register, Internal& PPIUD
register etc.

All register/records are identified 1 RR

and numbered
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 2 4
ME E10.3 The facility has disaster Staff is aware of disaster plan 1 SI/RR
management plan in place
Roles and responsibilities of staff 1 SI/RR
in disaster is defined
Standard E11 The facility has defined and established procedures of diagnostic services 2 4
ME E11.1 There are established procedures Container is labelled properly 1 OB
for Pre-testing Activities after the sample collection

ME E11.3 There are established procedures Nursing station is provided with 1 SI/RR
for Post-testing Activities the critical value of different test

Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 6 12
ME E12.5 There is established procedure for Consent is taken before 1 RR
transfusion of blood transfusion
Patient's identification is verified 1 SI/OB
before transfusion
Blood is kept on optimum 1 RR
temperature before transfusion
 Blood transfusion is monitored 1 SI/RR
and regulated by qualified staff

Blood transfusion note is written in 1 RR

patient record
ME E12.6. There is a established procedure Any major or minor transfusion 1 RR
for monitoring and reporting reaction is recorded and reported
Transfusion complication to Blood Bank/Designated person

Standard E16 The facility has established procedures for Antenatal care as per guidelines 2 4
ME E16.1 There is an established procedure Facility provides and updates 1 RR/SI
for Registration and follow up of “Mother and Child Protection
pregnant women. Card”.
ME E16.3 The facility ensures availability of Tests for Urine albumin, 1 RR/SI
diagnostic and drugs during haemoglobin, blood grouping
antenatal care of pregnant
women

Standard E17 The facility has established procedures for Intranatal care as per guidelines 22 44
ME E17.1 Established procedures and Management of 1st stage of 1 SI/OB Check progress is recorded,
standard protocols for labour: Women is allowed to give
management of different stages birth in the position she
of labour including AMTSL (Active wants , Check progress is
Management of third Stage of recorded on partograph
labour) are followed at the facility

Management of 2nd stage of 1 SI/OB Allows the spontaneous

labour: delivery of head , gives
Perineal support and assist in
delivering baby. Check
progress is recorded on
partograph

Active Management of Third stage 1 SI/OB Palpation of mother's

of labour abdomen to rule out
presence of second baby

Use of Uterotonic Drugs 1 SI/RR Administration of 10 IU of

oxytocin IM with in 1 minute
of Birth

Control Cord Traction 1 SI/RR Only during Contraction

Uterine Massage 1 SI/RR After placenta expulsion ,
Checks Placenta &
Membranes for
Completeness

ME E17.2 There is an established procedure Staff is aware of Indications for 1 SI Ask staff how they identify
for assisted and C-section referring patient for Surgical slow progress of labour , How
deliveries per scope of services. Intervention they interpret Partogram

ME E17.3 There is established procedure for Management and follow up of
management/Referral of
Obstetrics Emergencies as per
scope of services.
1 SI/RR Monitors BP in every case,
PIH/Eclampsia \Pre Eclampsia and tests for proteinuria if BP
is >140/90 mmHg
If BP is 140/90 mmHg or
more with proteinuria 2+
along with any two of the
following danger signs:
severe headache, blurring of
vision, severe pain abdomen
or reduced urine output, BP >
160/110 or more with
proteinuria 3+; OR in cases
of Eclampsia—administers
loading dose of Magnesium
Sulphate (MgSO4) and
refers/ calls for specialist
attention; continues
maintenance dose of MgSO4-
5 g of MgSO4 IM in alternate
buttocks every four hours, for
24 hours after birth/last
convulsion, whichever is later
If BP is >160/110 mmHg or
more, give appropriate anti-
hypertensive
(Hydralazine/Methyl Dopa/
Nifedipine)

Management of Postpartum 1 SI/RR Assessment of bleeding (PPH

Haemorrhage if >500 ml or > 1 pad soaked
in 5 Minutes. IV Fluid,
bladder catheterization,
measurement of urine
output, Administration of 20
IU of Oxytocin in 500 ml
Normal Saline or RL at 40-60
drops per minute . Performs
Bimanual Compression of
Uterus

Management of Retained Placenta 1 SI/RR Administration of another

dose of Oxytocin 20IU in 500
ml of RL at 40-60 drops/min
an attempt to deliver
placenta with repeat
controlled cord traction. If
this fails performs manual
removal of Placenta

Management of Uterine Atony 1 SI/RR Vigorous Uterine massage,

gives Oxytocin 20 IU in 500
ml of R/L 40 to 60
drops/minute (Continue to
administer Oxytocin uptown
maximum of 3 litres of
solution with Oxytocin) If still
bleeding perform bi manual
uterine compression with
palpation of femoral pulse
 Management of Obstructed 1 SI/RR Diagnose obstructed labour
Labour based on data registered
from the partograph, Re-
hydrate the patient to
maintain normal plasma
volume, check vitals, give
broad spectrum antibiotics,
perform bladder
catheterization and take
blood for Hb & grouping,
Decide on the mode of
delivery as per the condition
of mother and the baby

Management of Puerperal sepsis 1 SI/RR Diagnose puerperal sepsis

based on clinical criteria:
continuous fever for at least
24 hours or recurring within
the first 10 days after
delivery, increased pulse
rate, increased respiration,
offensive/foul smelling
lochia, sub involution of the
uterus, headache and general
malaise, pelvic pain, pain,
swelling and pus discharge
from laceration or episiotomy
or incision. Conduct
appropriate lab.
investigations, Prescribes IV
fluids and broad spectrum
antibiotics for seven days &
advises perennial care

Delivery of infectious cases HIV 1 SI/RR

positive PW
ME E17.4 There is an established procedure Recording date and Time of 1 SI/RR Check the records
for new born resuscitation and Birth, Weight
new-born care.

Dried and put on mothers 1 SI/OB With a clean towel from head
abdomen to feet, discards the used
towel and covers baby
including head in a clean dry
towel

Vitamin K for low birth weight 1 SI/RR Given to all new born (1.0 mg
IM in > 1500 gms and 0.5 mg
in < 1500 gms

Warmth 1 SI/RR Check use of radiant warmer

Care of Cord and Eyes 1 SI/RR Delayed Cord Clamping,

Clamps & Cut the cords by
sterile instruments within 1-3
minutes of Birth
Clean baby's eyes with sterile
cotton/Gauge

APGAR Score 1 SI/RR Check practice of maintaining

APGAR Score, Nurse has
requisite skills

Kangaroo Mother Care 1 SI/RR Observe /Ask staff about the

practice
New born Resuscitation 1 SI/RR Ask Nursing staff to
demonstrate Resuscitation
Technique

Standard E18 The facility has established procedures for postnatal care as per guidelines 6 12
ME E18.1 Post partum Care is provided to Prevention of Hypothermia of new 1 SI/RR
the mothers born
Initiation of Breastfeeding with in 1 PI
1 Hour
Mother is monitored as per post 1 RR/SI Check for records of Uterine
natal care guideline contraction, bleeding,
temperature, B.P, pulse,
Breast examination, (Nipple
care, milk initiation)

Check for perennial washes 1 PI

performed
ME E18.3 There is an established procedure Labour room has procedure to 1 PI/SI Breast feeding and
for Post partum counselling of provide post partum Counselling prevention of hypothermia
mother
ME E18.4 The facility has established There is established criteria for 1 SI/RR
procedures for shifting new-born to NBSU
stabilization/treatment/referral of
post natal complications

Standard E20 Facility has established procedures for abortion and family planning as per government guidelines and law 13 26
ME E20.2 Facility provides spacing method IUD insertion is done as per 1 SI/RR
No touch technique,
of family planning as per guideline standard protocol Speculum and bimanual
examination, sounding of
uterus and placement
Staff is aware of case selection 1 SI/RR 22-49 year age
criteria for family planning Married
at least having one year old
baby and Spouse has not
undergone for sterilization

ME E20.3 Facility provides limiting method Assessment of client done before 1 SI/RR Physical examination and
of family planning as per guideline surgery for any Delay, refer of Medical History taken,
caution signs

Consent is confirmed before the 1 RR Informed consent is taken,

procedure which is verified by checking
records and confirming with
patients

Client is informed about post 1 SI/RR/PI

operative care, complication and
follow up
 Follow up visits done as per GoI
guidelines
1 SI/RR/PI Visit after 48 hours, first
follow up visit on 7th day and
semen analysis after 3
months, emergency follow
up

ME E20.4 Facility provide counselling Pre procedure Counselling is 1 SI/RR/PI

services for abortion as per provided
guideline
Post procedure Counselling 1 SI/RR/PI As per national guidelines
provided
Counselling on the follow-up visit 1 SI/RR/PI

ME E20.5 Facility provide abortion services MVA procedures are done as per 1 SI/RR
for 1st trimester as per guideline guidelines

Medical termination of pregnancy 1 SI/RR

is done as per guidelines

ME E20.6 Facility provide abortion services Surgical Procedure are done as per 1 SI/RR Dilation and evacuation
for 2nd trimester as per guideline guidelines

Medical termination of pregnancy 1 SI/RR ethacridine lactate extra

done as per guidelines amniotic instillation

Area of Concern - F Infection Control 67 134

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital
4 8
associated infection
ME F1.2 The facility has provision for 1
Surface and environment samples SI/RR Swab are taken from
Passive and active culture are taken for microbiological infection prone surfaces
surveillance of critical & high risk surveillance
areas

ME F1.4 There is Provision of Periodic There is a procedure for 1 SI/RR Hepatitis B, Tetanus Toxoid
Medical Check-up and immunization of the staff etc.
immunization of staff
Periodic medical check-ups of the 1 SI/RR
staff
ME F1.5 The facility has established Regular monitoring of infection 1 SI/RR Hand washing and infection
procedures for regular monitoring control practices control audits done at
of infection control practices periodic intervals

Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 13 26
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB Check the availability of wash
provided at point of use Facility at Point of Use basin near the point of use

Availability of running Water 1 OB/SI Open the tap. Ask the Staff,
water is available 24*7

Availability of antiseptic soap with 1 OB/SI Check for availability/ Ask

soap dish/ liquid antiseptic with staff if the supply is adequate
dispenser and uninterrupted

Availability of Alcohol based Hand 1 OB/SI Check for availability/ Ask

rub staff for regular supply. Hand
rub dispenser are provided
adjacent to bed

Display of Hand washing 1 OB Prominently displayed above

Instruction at Point of Use the hand washing facility ,
preferably in Local language

Availability of elbow operated taps 1 OB

Hand washing sink is wide and 1 OB

deep enough to prevent splashing
and retention of water

ME F2.2 The facility staff is trained in hand Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
washing practices and they washing
adhere to standard hand washing
practices

Staff is aware of occasion for hand 1 SI

washing
ME F2.3 The facility ensures standard Availability of Antiseptic Solutions 1 OB
practices and materials for
antisepsis
Proper cleaning of procedure site 1 OB/SI like before giving IM/IV
with antiseptics injection, drawing blood,
putting Intravenous and
urinary catheter

Proper cleaning of perennial area 1 SI

before procedure with antisepsis

Check Shaving is not done during 1 SI

part preparation/delivery cases

Standard F3 The facility ensures standard practices and materials for Personal protection 9 18
ME F3.1 The facility ensures adequate Availability of Masks 1 OB/SI
personal protection Equipment as
per requirements
Availability of Sterile s gloves 1 OB/SI
Use of elbow length gloves for 1 OB/SI
obstetrical purpose
Availability of gown/ Apron 1 OB/SI
Availability of Caps 1 OB/SI
Heavy duty gloves and gum boats 1 OB/SI
for housekeeping staff
Personal protective kit for 1 OB/SI
delivering HIV patients
ME F3.2 The facility staff adheres to No reuse of disposable gloves, 1 OB/SI
standard personal protection Masks, caps and aprons.
practices
Compliance to correct method of 1 SI
wearing and removing the gloves

Standard F4 The facility has standard procedures for processing of equipment and instruments 14 28
ME F4.1 Facility ensures standard practices Decontamination of Procedure 1 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate work benches
and cleaning of instruments and (Wiping with 0.5% Chlorine
procedures areas solution)
 Proper Decontamination of 1 SI/OB Decontamination of
instruments after use instruments and reusable of
glassware are done after
procedure in 1% chlorine
solution/ any other
appropriate method

Proper handling of Soiled and 1 SI/OB No sorting ,Rinsing or sluicing

infected linen at Point of use/ Patient care
area

Contact time for decontamination 1 SI/OB 10 minutes

is adequate
Cleaning of instruments after 1 SI/OB Cleaning is done with
decontamination detergent and running water
after decontamination

The Staff knows how to make 1 SI/OB

chlorine solution
ME F4.2 The facility ensures standard Equipment and instruments are 1 OB/SI Autoclaving/HLD/Chemical
practices and materials for sterilized after each use as per Sterilization
disinfection and sterilization of requirement
instruments and equipment

High level Disinfection of 1 OB/SI Ask staff about method and

instruments/equipment is done time required for boiling
as per protocol

Autoclaving of instruments is done 1 OB/SI Ask staff about temperature,

as per protocols pressure and time

Chemical sterilization of 1 OB/SI Ask staff about method,

instruments/equipment is done as concentration and contact
per protocols time required for chemical
sterilization

Autoclaved linen are used for 1 OB/SI

procedure
Autoclaved dressing material is 1 OB/SI
used
There is a procedure to ensure the 1 OB/SI
traceability of sterilized packs

Sterility of autoclaved packs is 1 OB/SI Sterile packs are kept in

maintained during storage clean, dust free, moist free
environment.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 12 24
ME F5.1 Layout of the department is Labour Room is located in a 1 OB
conducive for the infection control secluded place, away from the
practices internal main traffic of the CHC

ME F5.2 The facility ensures availability of Availability of disinfectant as per 1 OB/SI Chlorine solution,
standard materials for cleaning and requirement Gluteraldehye, carbolic acid
disinfection of patient care areas

Availability of cleaning agent as 1 OB/SI Hospital grade phenyl,

per requirement disinfectant detergent
solution

ME F5.3 The facility ensures standard The Staff is trained in spill 1 SI/RR
practices are followed for the management
cleaning and disinfection of patient
care areas

Cleaning of patient care area with 1 SI/RR

detergent solution
Staff is trained for preparing 1 SI/RR
cleaning solution as per standard
procedure

Standard practice of mopping and 1 OB/SI Unidirectional mopping from

scrubbing are followed inside out
Cleaning equipment like broom 1 OB/SI Any cleaning equipment
are not used in patient care areas leading to dispersion of dust
particles in air should be
avoided

Use of three bucket system for 1 OB/SI

mopping
Fumigation/carbolization as per 1 SI/RR
schedule
External foot wares are restricted 1 OB

ME F5.4 The facility ensures segregation of Isolation and barrier nursing 1 OB/SI
infectious patients procedure are followed for septic
cases

Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and
15 30
hazardous 1Waste.OB
ME F6.1 The facility Ensures segregation of Availability of colour coded bins at
Bio Medical Waste as per point of waste generation
guidelines and 'on-site'
management of waste is carried
out as per guidelines

Availability of plastic colour coded 1 OB

plastic bags
Segregation of different category 1 OB/SI
of waste as per guidelines

Display of work instructions for 1 OB

segregation and handling of
Biomedical waste

There is no mixing of infectious 1 OB

and general waste
ME F6.2 Facility ensures management of Availability of functional needle 1 OB Verify its usage
sharps as per guidelines cutters
Availability of puncture proof box 1 OB Should be available nears the
point of generation like
nursing station and injection
room

Disinfection of sharp before 1 OB/SI Disinfection of syringes is not

disposal done in open buckets
Staff is aware of contact time for 1 SI 30 minutes
disinfection of sharps
Availability of post exposure 1 OB/SI Ask if available. Where it is
prophylaxis stored and who is in charge
of that.

Staff knows procedure in event of 1 SI/RR Staff knows what to do in

needle stick injury case of sharp injury & Whom
to report. See if any reporting
has been done
ME F6.3 The facility ensures transportation Check that bins are not overfilled 1 SI
and disposal of waste as per
guidelines
Disinfection of liquid waste before 1 SI/OB
disposal
Transportation of bio medical 1 SI/OB
waste is done in closed
container/trolley

Staff is aware of mercury spill 1 SI/RR

management

Area of Concern - G Quality Management 37 74

Standard G1 The facility has established organizational framework for quality improvement 1 2
ME G1.1 The facility has a quality team in There is a designated 1 SI/RR Preferably Obstetrician
place departmental nodal person for
coordinating Quality Assurance
activities

Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 3 6
ME G3.1 The facility has established There is system daily round by 1 SI/RR
internal quality assurance matron/hospital manager/
programme in key departments hospital superintendent/ Hospital
Manager/ Matron in charge for
monitoring of services

ME G3.3 The facility has established Departmental checklists are 1 SI/RR

system for use of check lists in used for monitoring and quality
different departments and assurance
services

Staff is designated for filling and 1 SI

monitoring of these checklists

Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key
20 40
processes and support services.
ME G4.1 Departmental standard operating Standard operating procedure for
1 RR
procedures are available department has been prepared
and approved

Current version of SOP's are 1 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures The Department has documented 1 RR
adequately describes process and procedure for receiving and
procedures assessment of the patient for
delivery

The Department has documented 1 RR

procedure for Emergency obstetric
care

The Department has documented 1 RR

procedure for management of
high risk pregnancy

The Department has documented 1 RR

procedure for rapid initial
assessment

The Department has documented 1 RR

procedure for requisition of
diagnosis and receiving of the
reports

The Department has documented 1 RR Intrapartum care includes

procedure for intra partum care Management of 1st stage of
labour, 2nd stage of labour
and 3rd stage of labour

The Department has documented 1 RR

immediate post partum care

The Department has documented 1 RR

essential new born care

The Department has documented 1 RR

procedure for neonatal
resuscitation

The Department has documented 1 RR

procedure for admission, shifting
and referral of the patient

The Department has documented 1 RR Labour room management

procedure for arrangement of include maintenance and
intervention for labour room calibration of equipment and
inventory management etc.

The Department has documented 1 RR

procedure for blood transfusion

The Department has documented 1 RR

criteria for distinguish between
new-born death and still birth

The Department has documented 1 RR

procedure for environmental
cleaning and processing of the
equipment

The Department has documented 1 RR

procedure for maintenance of
rights and dignity of pregnant
women

The Department has documented 1 RR

procedure for record Maintenance
including taking consent

ME G4.3 Staff is trained and aware of the Check if staff are aware of relevant 1 SI/RR
procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 1 OB AMSTL, PPH,Infection
Point of use are displayed control,Eclamsia, New born
resuscitation, kangaroo care

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription
4 8
audit
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps time bound Action plan is 1 RR/SI
found in the assessment / audit prepared for improvement
process
ME G5.5 Corrective and preventive actions Corrective and preventive action 1 RR/SI
are taken to address issues, taken
observed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objective for Labour Room 1 RR/SI
quality objectives and key are defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check if staff is aware of quality 1 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services

5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 17 34
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 6 12
ME H1.1 Facility measures productivity Normal Deliveries per 1000 1 RR
Indicators on monthly basis population
Proportion of deliveries conducted 1 RR
at night
Proportion of complicated 1 RR
cases managed
Proportion of assisted delivery 1 RR
conducted
% PPIUCD inserted against 1 RR
total IUCD
ME H1.2 The Facility measures equity Proportion of BPL Deliveries 1 RR
indicators periodically
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 4 8
ME H2.1 Facility measures efficiency Proportion of cases referred to OT 1 RR
Indicators on monthly basis
Proportion of cases referred to 1 RR
Higher Facilities
% of new-born's required 1 RR
resuscitation out of total live
births

% of new-born's required 1 RR
resuscitation out of total live
births

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 6 12
ME H3.1 Facility measures Clinical Care & Proportion of Cases Partograph 1 RR
Safety Indicators on monthly basis Maintained

Episiotomy site infection rate 1

No of adverse events per thousand 1 RR
patients
Culture Surveillance sterility rate 1 RR % of environmental swab
culture reported positive

Proportion of cases of different 1 RR PPH, Eclampsia, obstructed

complications labour etc.
Rational oxytocin usage Index 1 RR No. of Oxytocin doses
used /No. of normal
deliveries conducted Source: NICE
Kerala Standard
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 1 2
ME H4.1 Facility measures Service Quality Patient satisfaction 1 RR
Indicators on monthly basis

Labour room Score Card

Labour room
Score
50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50

Obtained Maximum Percent 3

A 15 30 50
B 26 52 50
C 78 156 50
D 48 96 50
E 103 206 50
F 67 134 50
G 37 74 50
H 17 34 50
Total 391 782 50
 National Quality Assurance Standards for CHC 0 1 2

Checklist for IPD 4

Measurable Element Checkpoints Compliance Assessment Means of verification
Reference No Method
Remarks
Area of Concern - A Service Provision 14 28
Standard A1 The facility provides Curative Services 2 4
Availability of admission 1 SI/OB Correlate with Night
ME A1.9 Services are available for the time facilities 24X7 admission rate
period as mandated
Availability of accident & 1 SI/OB
ME A1.10 The facility provides Accident & trauma beds.
Emergency Services
Standard A2 The facility provides RMNCHA Services 7 14
Availability of indoor services 1 SI/OB Separate beds for
for Antenatal cases, Normal delivery cases in female
ME A2.2 delivery and LSCS ward.
The facility provides Maternal
health Services
Indoor Management of Severe 1 SI/RR
ME A2.4 Diarrhoea with dehydration
The facility provides Child health
Services
Indoor Management of Acute 1 SI/RR
Respiratory Infections

Seizers and convulsions 1 SI/RR

Shock 1 SI/RR
Accidental poisoning 1 SI/RR
Services Under RSBY 1 SI/RR
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme 4 8
The facility provides services Availability of Indoor services 1 SI/RR Malaria Kalazar Dengue
under National Vector Borne for Management of vector & Chikungunya
Disease Control Programme as per borne diseases AES/Japanese
ME A4.1 guidelines Encephalitis as prevalent
locally

The facility provides services Indoor treatment of TB 1 SI/RR

under Revised National TB Control patients requiring
ME A4.2 Programme as per guidelines hospitalization

The facility provides services Inpatient Management of 1 SI/RR

under National Leprosy severely ill cases
ME A4.3 Eradication Programme as per
guidelines

The facility provides services Inpatient care for cases 1 SI/RR

under National AIDS Control requiring hospitalization
ME A4.4
Programme as per guidelines

Standard A6 Health services provided at the facility are appropriate to community needs. 1 2
The facility provides curatives & Availability of indoor Services 1 SI/RR
preventive services for the health as per local prevalent disease
ME A6.1 problems and diseases, prevalent
locally.

Area of Concern - B Patient Rights 41 82

Standard B1
The facility provides the information to care seekers, attendants & community about the available services and
8 16
their modalities
Availability departmental 1 OB (Numbering Rooms, main
signage's department and inter-
The facility has uniform and user- sectional signage)
ME B1.1
friendly signage system

Visiting hours and visitor 1 OB

policy are displayed

The facility displays the services Entitlements under different 1 OB

National Health Programmes
ME B1.2 and entitlements available in its are displayed
departments
Contact details of referral 1 OB
transport / ambulance
displayed

User charges are displayed and User charges if any are 1 OB

displayed
ME B1.4 communicated to patients
effectively
Relevant IEC material 1 OB Kangaroo mother care,
Patients & visitors are sensitised displayed in wards Breast feeding,
ME B1.5 and educated through appropriate immunization & PPIUCD
IEC / BCC approaches

Signage's and information are 1 OB

Information is available in local available in local language
ME B1.6
language and easy to understand

The facility ensures access to Discharge summary is given 1 RR/OB

to the patient
ME B1.8 clinical records of patients to
entitled personnel
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no
10 20
barrierSeparate
on account of physical , economic,
male & female 1 OB
cultural orWhere
socialever
status.
male and
wards female are kept in same
Services are provided in manner wards male and female
ME B2.1 area are demarcated
that are sensitive to gender

Male and female toilets are 1 OB/SI

demarcated
Access to toilet should not go 1 OB
through opposite sex patient
care area

Male attendants are not 1 OB/SI

allowed to stay in night in
Female ward

There is no discrimination 1 SI/PI

with transgender patients
No unnecessary /non- 1 SI/PI/RR
essential disclosure of a
person’s transgender status

Cots in Female ward are large 1

enough for stay of mother
with child
 Availability of Wheel chair or 1 OB
stretcher for easy Access to
ME B2.3 Access to facility is provided the ward
without any physical barrier & and
friendly to people with disabilities
Availability of ramps with 1 OB
railing
Availability of disable friendly 1 OB
toilet
Standard B3
The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related
8 16
Availability of Screens /
information.
1 OB Bracket screen
Adequate visual privacy is
ME B3.1 Curtains
provided at every point of care
Examination/ Dressing of 1 OB
patient is done in enclosed
area

No two patients are treated 1 OB

on one bed
Partitions separating men and 1 OB
women are robust enough to
prevent casual overlooking
and overhearing

Patient Records are kept in a 1 SI/OB

Confidentiality of patients records secure places beyond access
ME B3.2 and clinical information is to general staff/visitors
maintained

No information regarding 1 SI/OB

patient identity and details
are unnecessary displayed on
BHT/case sheet/case paper/
Case sheet

Behaviour of staff is 1 OB/PI

The facility ensures the behaviours empathetic and courteous
ME B3.3 of staff is dignified and respectful,
while delivering the services

HIV status of patient is not 1 SI/OB

The facility ensures privacy and disclosed except to staff that
confidentiality to every patient, is directly involved in care
ME B3.4 especially of those conditions
having social stigma, and also
safeguards vulnerable groups
Standard B4
The facility has defined and established procedures for informing patients about the medical condition, and
3 6
involving them in treatment planning, and 1facilitates
General Consent is taken SI/RR
informed decision making
There is established procedures before admission
ME B4.1 for taking informed consent
before treatment and procedures

Patient is informed about 1 PI

Information about the treatment clinical condition and
ME B4.4 is shared with patients or treatment being provided
attendants, regularly

The facility has defined and Availability of complaint box 1 OB

established Grievance Redressal and display of process for
ME B4.5 System in place grievance redressal and with
contact detail.

Standard B5
The facility ensures that there are no financial barrier to access, and that there is financial protection given from
the cost of hospital services. 12 24
Stay in wards is free for 1 PI/SI
The facility provides cashless entitled patients under NHP
services to pregnant women, and as per state schemes
ME B5.1
mothers and neonates as per
prevalent government schemes
Drugs and consumables under 1 PI/SI
NHP are freely available to
entitled personnel

Availability of free diagnostics 1

to entitled Personnel

Availability of Free drop back 1

The facility ensures that drugs
ME B5.2 prescribed are available at
Pharmacy and wards
to entitled Personnel
Availability of Free diet to 1
mother
Availability of Free patient 1
transport
Availability of Free Blood 1
Availability of Free drugs 1
Check that parents & 1 PI/SI
attendant's have not spent
money on purchasing drugs
and consumables from
outside.

Check that parents & 1 PI/SI

It is ensured that facilities for the attendants have not spent
ME B5.3 prescribed investigations are money on diagnostics from
available at the facility outside.

If any other expenditure has 1 PI/SI/RR

The facility provide free of cost been incurred, then it is
treatment to Below poverty line reimbursed from hospital
ME B5.4
patients without administrative
hassles
The facility ensure Cashless treatment been 1 SI/RR
implementation of health provide to smart card holders
ME B5.6 insurance schemes as per National
/state scheme

Area of Concern - C Inputs 62 124

Standard C1
The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent
norms 21 42
The Departments has adequate Adequate space in wards with 1 OB Distance between
ME C1.1 space as per patient or work load no cluttering of beds centres of two beds –
2.25 meter

Patient amenities are provided as Functional toilets with 1 OB 1:12 Male & 1:8 Female
per patient load running water and flush are
available as per strength and
ME C1.2 patient load of ward
 Functional bathrooms with 1 OB
running water are available as
per strength and patient load
of ward

Availability of drinking water 1 OB

Patient/ visitor Hand washing 1 OB

area
Separate toilets for visitors 1 OB

TV for entertainment and IEC 1 OB

activities
Adequate shaded waiting area 1 OB
is provided for attendants of
patient

The Departments has layout and Availability of Dedicated 1 OB

ME C1.3 demarcated areas as per functions nursing station

Availability of Examination 1 OB
room
Availability of Treatment room 1 OB

Availability of Doctor's Duty 1 OB

The facility has adequate
circulation area and open spaces
according to need and local law
ME C1.4
room
Availability of Nurse Duty
room
Availability of Store
Availability of Dirty utility
room
There is sufficient space
between two bed to provide
bed side nursing care and
movement
1 OB
1 OB Drug & Linen store
1 OB
1 OB Space between two beds
should be at least 4 ft.
and clearance between
head end of bed and wall
should be at least 1 ft.
and between side of bed
and wall should be 2 ft.

Corridors are wide enough for 1 OB Corridor should be at

patients, visitors and trolley/ least 3 metres wide
equipment movement

The facility has infrastructure for Availability of functional 1 OB

intramural and extramural telephone and Intercom
ME C1.5 Services
communication
Service counters are available as There is separate nursing 1 OB
ME C1.6 per patient load station for each ward
The facility and departments are Indoor beds have functional 1 OB
planned to ensure structure linkages with OT and labour
follows the function/processes room.
ME C1.7 (Structure commensurate with the
function of the hospital)

Location of nursing station 1 OB

and patients beds enables
easy and direct observation of
patients

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 9 18
The facility ensures seismic safety Non structural components 1 OB Check for fixtures and
of the infrastructure are properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging
ME C2.1 objects are properly
fastened and secured

The facility ensures safety of IPD ward does not have 1 OB Switch Boards other
ME C2.2 electrical establishment temporary connections and electrical installations are
loosely hanging wires intact

Physical condition of buildings is Floors of the ward are non 1 OB

safe for providing patient care slippery and even surpad
ME C2.3

Windows have grills and wire 1 OB

meshwork
The facility has plan for prevention Ward has fire exit to permit 1 OB/SI
ME C2.4. of fire safe escape of its occupant at
time of fire

Check the fire exits are clearly 1 OB

visible and routes to reach exit
are clearly marked.

The facility has adequate fire IPD has installed fire 1 OB

fighting Equipment Extinguisher that are capable
ME C2.5 of fighting A,B & C Type of
fire.

Check the expiry date for fire 1 OB/RR

extinguisher is displayed on
each extinguisher as well as
due date for next refilling is
clearly mentioned

The facility has a system of Check for staff competencies 1 SI/RR

periodic training of staff and for operating fire extinguisher
conducts mock drills regularly for and what to do in case of fire
ME C2.6. fire and other disaster situation

Standard C3
The facility has adequate qualified and trained staff, required for providing the assured services to the current
case load 10 20
The facility has adequate specialist Availability of specialist doctor 1 OB/RR
ME C3.1 doctors as per service provision. on call

The facility has adequate general Availability of at least one 1 OB/RR

duty doctors as per service doctor at all time
ME C3.2
provision
 The facility has adequate nursing Availability of Nursing staff 1 OB/RR/SI As per patient load
ME C3.3 staff as per service provision and
work load
The facility has adequate support / Availability of ward attendant/ 1 SI/RR
ME C3.5. general staff Ward boy/Aya
Availability of Security staff 1 SI/RR

The staff has been provided Biomedical waste 1 SI/RR

ME C3.6. required training / skill sets management
Infection control and hand 1 SI/RR
hygiene
CPR/Resuscitation 1
Patient Safety 1 SI/RR
The Staff is skilled as per job Nursing staff is skilled for 1 SI/RR
ME C3.7. description maintaining clinical records

Standard C4 The facility provides drugs and consumables required for assured services. 11 22
The departments have availability Availability of 1 OB/RR
ME C4.1 of adequate drugs at point of use Analgesics/Antipyretics/Anti
Inflammatory

Availability of Antibiotics 1 OB/RR

Availability of Infusion Fluids 1 OB/RR

Availability of Drugs acting on 1 OB/RR

CVS
Availability of drugs action on 1 OB/RR
CNS/PNS
Drugs for Respiratory System 1 OB/RR

Availability of Medical gases 1 OB/RR Availability of Oxygen

Cylinders
The departments have adequate Availability of dressing 1 OB/RR
consumables at point of use material and antiseptic lotion
ME C4.2

Availability of syringes and IV 1 OB/RR

Sets /Ryle's Tube/Foley's
Catheter

Availability of Antiseptic 1 OB/RR Betadine

Solutions
Emergency drug trays are Availability of emergency drug 1 OB/RR Inj Dopamine, Inj
maintained at every point of care, tray Hydrocortisone, Inj
ME C4.3 where ever it may be needed Adrenaline

Standard C5 The facility has equipment & instruments required for assured list of services. 11 22
Availability of equipment & Availability of functional 1 OB BP apparatus,
instruments for examination & Equipment &Instruments Thermometer,
monitoring of patients for examination & foetoscope, baby and
ME C5.1 Monitoring adult weighing scale,
Stethoscope ,
Glucometer

Availability of equipment & Availability of dressing tray 1 OB

instruments for treatment
ME C5.2 procedures, being undertaken in
the facility

Availability of equipment & Availability of Point of care 1 OB Lumber Puncture set in

instruments for diagnostic diagnostic instruments Paediatric ward
ME C5.3 procedures being undertaken in
the facility

Availability of equipment and Availability of functional 1 OB Ambu bag and mask

instruments for resuscitation of Instruments for (adult and paediatric),
patients and for providing Resuscitation. Oxygen, Suction
intensive and critical care to machine, Airway,
patients Nebulizer, Suction
ME C5.4 apparatus ,
Laryngoscope,
Endotracheal tube

Availability of Equipment for Availability of equipment 1 OB Refrigerator, Crash

Storage for storage for drugs cart/Drug trolley,
ME C5.5 instrument trolley,
dressing trolley

Availability of functional Availability of equipment 1 OB Buckets for mopping,

equipment and instruments for
ME C5.6
support services
Departments have patient
furniture and fixtures as per load
ME C5.7
and service provision
for cleaning mops, duster, waste
trolley, Deck brush
Availability of equipment 1 OB Steriliser
for sterilization and
disinfection
Availability of patient beds 1 OB
with prop up facility
Availability of attachment/ 1 OB Hospital grade mattress,
accessories with patient bed Bed side locker , IV stand,
Bed pan

Availability of Fixtures 1 OB Spot light, electrical

fixture for equipment
like suction, X ray view
box

Availability of furniture 1 OB Cupboard, Nursing

counter, Table for
preparation of
medicines, Chair

Area of Concern - D Support Services 46 92

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 3 6
The facility has established system All equipment are covered 1 SI/RR
for maintenance of critical under AMC including
ME D1.1 preventive maintenance
Equipment
There is system of timely 1 SI/RR
corrective break down
maintenance of the
equipment
 The facility has established All the measuring equipment/ 1 OB/ RR BP apparatus, Weighing
procedure for internal and instrument are calibrated Machine etc. are
ME D1.2 external calibration of measuring calibrated
Equipment

Standard D2
The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and
patient care areas 9 18
There is established procedure for There is established system of 1 SI/RR Stock level are daily
forecasting and indenting of drugs timely indenting of updated
and consumables consumables and drugs at Requisition are timely
ME D2.1 nursing station placed

The facility ensures proper storage Drugs are stored in 1 OB

of drugs and consumables containers/tray/crash cart and
ME D2.3 are labelled

Empty and filled cylinders are 1 OB

labelled
The facility ensures management Expiry dates are maintained at 1 OB/RR
of expiry and near expiry drugs emergency drug tray
ME D2.4

No expiry drug found 1 OB/RR

There is a procedure for periodically There is procedure for 1 SI/RR
ME D2.6 replenishing the drugs in patient care replenishing drug tray /crash
areas cart

There is no stock out of drugs 1 OB/SI

There is process for storage of Temperature of refrigerators 1 OB/RR Check for temperature
vaccines and other drugs, are kept as per storage charts are maintained
requiring controlled temperature requirement and records are and updated periodically
ME D2.7 maintained

There is a procedure for secure Narcotic and psychotropic 1 OB/SI Separate prescription for
storage of narcotic and drugs are identified and narcotic and
ME D2.8 stored in lock and key psychotropic drugs
psychotropic drugs

Standard D3
The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and
comfortable environment to staff, patients and visitors. 18 36
Exterior of the facility building is Building is 1 OB
maintained with landscaping in painted/whitewashed in
ME D3.1 uniform colour
the open area
Interior of patient care areas 1 OB
are plastered & painted

Hospital infrastructure is Check for there is no seepage , 1 OB

ME D3.2 adequately maintained Cracks, chipping of plaster

Window panes , doors and 1 OB

other fixtures are intact
Patients beds are intact and 1 OB
painted
Mattresses are intact and 1 OB
clean
Patient care areas are clean and Floors, walls, roof, roof tops, 1 OB All area are clean with
hygienic sinks in patient care and no dirt,grease,littering
ME D3.3 circulation areas are Clean and cobwebs

Surface of furniture and 1 OB

fixtures are clean
Toilets are clean with 1 OB
functional flush and running
water

The facility has policy of removal No condemned/Junk material 1 OB

of condemned junk material found in the ward
ME D3.4.

The facility has established No stray animal/rodent/birds 1 OB

ME D3.5 procedures for pest, rodent and
animal control
The facility provides adequate Adequate Illumination at 1 OB 100 Lux of Illumination
illumination level at patient care nursing station
ME D3.6
areas
Adequate illumination in 1 OB 150 Lux of Illumination
patient care areas
The facility has provision of Visiting hour are fixed and are 1 OB/PI
restriction of visitors in patient observed.
ME D3.7.
areas
One family members is 1 OB/SI
allowed to stay with the
patient

The facility ensures safe and
comfortable environment for
patients and service providers
ME D3.8
Temperature control and
ventilation in patient care
area
1 PI/OB Fans/ Air
conditioning/Heating/Ex
haust/Ventilators as per
environment condition
and requirement

Temperature control and 1 SI/OB Fans/ Air

ventilation in nursing conditioning/Heating/Ex
station/duty room haust/Ventilators as per
environment condition
and requirement

The facility has established measure Ask female staff weather they 1 SI
ME D3.10 for safety and security of female staff feel secure at work place

Standard D4
The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services
norms 3 6
The facility has adequate Availability of running and 1 OB/SI
arrangement storage and supply potable water on 24*7 basis
ME D4.1. for portable water in all functional
areas

The facility ensures adequate Availability of power back up 1 OB/SI

power backup in all patient care in patient care areas
ME D4.2
areas as per load
ME D4.3 Critical areas of the facility ensures Availability of Oxygen 1 OB
availability of oxygen, medical gases cylinders and vacuum suction
and vacuum supply
Standard D5
The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all
admitted patients. 9 18
The facility has provision of Appropriate diet as per 1 RR/SI
nutritional assessment of the nutritional requirement of the
ME D5.1 patients patients is prescribed by the
treating doctor

The facility provides diets Check for the adequacy and 1 OB/RR Check that all items fixed
according to nutritional frequency of diet as per in diet menu is provided
ME D5.2 requirements of the patients nutritional requirement to the patient

Check for the Quality of diet 1 PI/SI Ask patient & check the
provided record
Hospital has standard procedures for There is procedure of 1 RR/SI Normal, Semi-solid,
preparation, handling, storage and requisition of different type of Liquid diet, diet for
distribution of diets, as per diet from ward to kitchen diabetic patients, low salt
ME D5.3 requirement of patients and high protein diet etc.

The facility has adequate sets of Clean Linens are provided for 1 OB/RR
ME D 5.4. linen all occupied bed
Gown are provided to the 1 OB/RR
cases going for surgery or
delivery

Availability of Blankets, draw 1 OB/RR

sheet, pillow with pillow cover
and mackintosh

The facility has established ward has facility to provide 1 OB/RR

procedures for changing of linen sufficient and clean linen for
ME D5.5. in patient care areas each patient

The facility has standard procedures There is system to check the 1 SI/RR
for handling , collection, cleanliness and quantity of the
ME D5.6. transportation and washing of linen linen received from laundry

Standard D9
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
operating procedures. 4 8
The facility has established job Staff is aware of their role and 1 SI
ME D9.1 description as per govt guidelines responsibilities

The facility has a established
procedure for duty roster and
deputation to different
ME D9.2 departments
There is procedure to ensure
that staff is available on duty
as per duty roster
1 RR/SI Check for system for
recording time of
reporting and relieving
(Attendance register/
Biometrics etc.)

There is designated in charge 1 SI

for department
The facility ensures the adherence Doctor, nursing staff and 1 OB
to dress code as mandated by its support staff adhere to their
ME D9.3 administration / the health respective dress code
department

Area of Concern - E Clinical Services 109 218

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 6 12
The facility has established Unique identification number 1 RR
procedure for registration of is given to each patient
ME E1.1 during registration
patients
Patient demographic details 1 RR Check for that patient
are recorded in admission demographics like Name,
records Age, Sex,Provisional
Diagnosis etc.

There is established procedure for There is no delay in admission 1 SI/RR/OB

ME E1.3 admission of patients of patient
Admission is done by written 1 SI/RR/OB
order of a facility's doctor

Time of admission is recorded 1 RR

in patient record
There is established procedure for There is provision of extra 1 OB/SI
managing patients, in case beds Beds
ME E1.4 are not available at the facility

Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 8 16
There is established procedure for Initial assessment's of all 1 RR/SI The assessment criteria
initial assessment of patients admitted patient done as per for different clinical
standard protocols conditions are defined
ME E2.1 and measured in
assessment sheet

Patient History is taken and 1 RR

recorded
Physical Examination is done 1 RR
and recorded wherever
required

Provisional Diagnosis is 1 RR
maintained
Initial assessment and 1 RR/SI
treatment is provided
immediately

Initial assessment is 1 RR
documented preferably within
2 hours

There is established procedure for There is fixed schedule for 1 RR/OB

follow-up/ reassessment of assessment of stable patients
ME E2.2
Patients
For critical patients admitted 1 RR/OB
in the ward there is provision
of reassessment as per need

Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 8 16
 The facility has established Facility has established 1 SI/RR
procedure for continuity of care procedure for handing over of
during interdepartmental transfer patients from one department
ME E3.1 to other department

There is a procedure for 1 RR/SI

consultation of the patient
with other specialist with-in
the hospital

The facility provides appropriate Patients are referred with 1 RR/SI

referral linkages to the referral slip
patients/Services for transfer to
ME E3.2 other/higher facilities to assure the
continuity of care.

Advance intimation is given to 1 RR/SI

higher centre
Referral vehicle is being 1 SI/RR
arranged
Referral in or referral out 1 RR
register is maintained
Facility has functional 1 SI/RR Check for referral cards
referral linkages to lower filled from lower facilities
facilities
There is a system of follow 1 RR
up of referred patients

Standard E4 The facility has defined and established procedures for nursing care 9 18
Procedure for identification of There is a process for 1 OB/SI Patient id band/ verbal
patients is established at the ensuring the identification confirmation/Bed no.
ME E4.1 facility before any clinical procedure etc.

Procedure for ensuring timely and
accurate nursing care as per
treatment plan is established at the
ME E4.2 facility
Treatment chart are 1 RR Check for treatment
maintained chart are updated and
drugs given are marked.
Co relate it with drugs
and doses prescribed.

There is a process to ensue 1 SI/RR Verbal orders are

the accuracy of rechecked before
verbal/telephonic orders administration

There is established procedure of Patient hand over is given 1 SI/RR

ME E4.3 patient hand over, whenever staff during the change of the shift
duty change happens
Nursing Handover register is 1 RR
maintained
Bed side Hand over is given 1 SI/RR

Nursing records are maintained Nursing notes are maintained 1 RR/SI Check for nursing note
adequately register. Notes are
ME E4.4 adequately written

There is procedure for periodic Patient's Vitals are 1 RR/SI Check for TPR chart, IO
monitoring of patients monitored and recorded chart, any other vital
ME E4.5 periodically required is monitored

Critical patients are 1 RR/SI

monitored continuasly
Standard E5 The facility has a procedure to identify high risk and vulnerable patients. 2 4
The facility identifies vulnerable Vulnerable patients are 1 OB/SI Unstable, irritable,
patients and ensure their safe care identified and measures are unconscious. Psychotic
taken to protect them from and serious patients are
ME E5.1 any harm identified

The facility identifies high risk High risk patients are 1 OB/SI
ME E5.2 patients and ensure their care, as per identified and treatment given
their need on priority

Standard E6
The facility follows standard treatment guidelines defined by state/Central government for prescribing the
generic drugs & their rational use. 4 8
The facility ensured that drugs are Check for BHT/case 1 RR
prescribed in generic name only sheet/case paper if drugs are
ME E6.1 prescribed under generic
name only

There is procedure of rational use of Check for that relevant 1 RR

drugs Standard Treatment Guideline
ME E6.2 are available at point of use

Check if staff are aware of the 1 SI/RR

drug regime and doses as per
Standard treatment guidelines
(STG)

Check BHT/case sheet/case 1 RR

paper that drugs are
prescribed as per STG

Standard E7 The facility has defined procedures for safe drug administration 11 22
There is process for identifying High alert drugs are identified 1 SI/OB Electrolytes like
and cautious administration of in the department. Potassium chloride,
high alert drugs Opioids, Neuro muscular
blocking agent, Anti
thrombolytic agent,
Insulin, Warfarin,
ME E7.1 Heparin, Adrenergic
agonist etc.

Maximum dose of high alert 1 SI/RR Value for maximum

drugs are defined and doses as per age, weight
communicated and diagnosis are
available with nursing
station and doctor
 There is process to ensure
that right doses of high alert
drugs are only given
1 SI/RR A system of independent
double check before
administration, Error
prone medical
abbreviations are
avoided

Medication orders are written Every Medical advice and 1 RR

legibly and adequately procedure are accompanied
ME E7.2 with date , time and
signature

Check for the writing to 1 RR/SI

ensure that it is
comprehendible by the clinical
staff

There is a procedure to check drug Drugs are checked for 1 OB/SI

before administration/ dispensing expiry and other
ME E7.3 inconsistency before
administration

Check single dose vial are not 1 OB Check for any open
used for more than one dose single dose vial with left
over content intended to
be used later on

Check for separate sterile 1 OB

needle is used every time for In multi dose vial needle
multiple dose vial is not left in the septum

Any adverse drug reaction is 1 RR/SI

There is a system to ensure right
medicine is given to right patient
ME E7.4
recorded and reported
Administration of medicines 1 SI/OB
done after ensuring right
patient, right drugs , right
route, right time

Patient is counselled for self drug Patient is advice by doctor/ 1

administration Pharmacist /nurse about the
ME E7.5 dosages and timings .

Standard E8
The facility has defined and established procedures for maintaining, updating of patients’ clinical records and
their storage 8 16
All the assessments, re- Day to day progress of 1 RR
assessment and investigations are patients is recorded in
ME E8.1 recorded and updated BHT/case sheet/case paper

All treatment plan Treatment plan, first orders 1 RR Treatment prescribed Inj
prescription/orders are recorded are written on BHT/case nursing records
ME E8.2 in the patient records. sheet/case paper

Care provided to each patient is Maintenance of treatment 1 RR Treatment given is

recorded in the patient records chart/treatment registers recorded in treatment
ME E8.3 chat

Procedures performed are written Any procedure performed is 1 RR Dressing, mobilization

ME E8.4 on patients records
Adequate form and formats are
available at point of use
ME E8.5
written on case sheet etc.
Standard Format for bed head 1 RR/OB Availability of formats for
ticket/ Patient case sheet is Treatment Charts, TPR
available as per state Chart , Intake Output
guidelines Chat Etc.

Register/records are maintained Registers and records are 1 RR General order book
as per guidelines maintained as per guidelines (GOB), report book,
Admission register, lab
register, Admission
sheet/ bed head ticket,
discharge slip, referral
slip, referral in/referral
out register, OT register,
ME E8.6 Diet register, Linen
register, Drug intend
register

All register/records are 1 RR

identified and numbered
The facility ensures safe and Safe keeping of patient 1 OB
ME E8.7 adequate storage and retrieval of records
medical records

Standard E9 The facility has defined and established procedures for discharge of patient. 10 20
Discharge is done after assessing Assessment is done before 1 SI/RR
ME E9.1 patient readiness discharging patient
Discharge is done by a 1 SI/RR
authorized doctor
Patient / attendants are 1 PI/SI
consulted before discharge

Treating doctor is consulted/ 1 SI/RR

informed before discharge of
patients

Case summary and follow-up Discharge summary is 1 RR/PI See for discharge
instructions are provided at time provided summary, referral slip
ME E9.2 provided.
of discharge
Discharge summary mentions 1 RR
adequately patients clinical
condition, treatment given
and follow up

Discharge summary is given to 1 SI/RR

patients going on
LAMA/Referral

Counselling services are provided Patient is counselled before 1 SI/PI

as during discharges wherever discharge
ME E9.3
required
 Time of discharge is 1 PI/SI
communicated to patient in
prior

The facility has established Declaration is taken from the 1 RR/SI

procedure for patients leaving the LAMA patient
ME E9.4 facility against medical advice,
absconding, etc.

Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 2 4
The facility has disaster Staff is aware of disaster plan 1 SI/RR
ME E10.3 management plan in place
Roles and responsibilities of 1 SI/RR
the staff in disaster are
defined

Standard E11 The facility has defined and established procedures of diagnostic services 2 4
There are established procedures Container is labelled properly 1 OB
for Pre-testing Activities after the sample collection
ME E11.1

There are established procedures Nursing station is provided 1 SI/RR

for Post-testing Activities with the critical value of
ME E11.3 different tests

Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 7 14
There is established procedure for Consent is taken before 1 RR
ME E12.5 transfusion of blood transfusion
Patient's identification is 1 SI/OB
verified before transfusion

blood is kept on optimum 1 RR

temperature before
transfusion

Blood transfusion is 1 SI/RR

monitored and regulated by
qualified person

Blood transfusion note is 1 RR

written in patient's record
Paediatric blood bags are 1 RR/SI
available as per requirement

There is a established procedure Any major or minor 1 RR

for monitoring and reporting transfusion reaction is
ME E12.6 Transfusion complication recorded and reported to
responsible staff

Standard E13
The facility has established
procedures for Pre-anaesthetic
ME E13.1 Check up and maintenance of
records
The facility has established procedures for Anaesthetic Services 1 2
Pre anaesthesia check up is 1 SI/RR
conducted for elective /
Planned surgeries

Standard E15 The facility has defined and established procedures for end of life care and death 7 14
Death of admitted patient is Facility has a standard 1 SI
adequately recorded and procedure to decent
ME E15.1 communicated communication of death to
relatives

Death note is written in 1 RR

patient record
Death note including efforts 1
done for resuscitation is noted
in patient record

The facility has standard Death summary is given to 1 SI/RR

procedures for handling the death patient attendant quoting the
in the hospital immediate cause and
ME E15.2 underlying cause if possible

The facility has standard All the deaths where Post- 1 RR

procedures for referring for post- mortem is mandatory, dead
mortem, its recording and bodies are referred to a
ME E15.4 meeting its obligation under the facility as per state's guideline
law

1 OB/RR

Facility has system for

storage/transfer of unclaimed
body for fixed duration as per
state guideline
1 RR

Facility has system for

disposal of unclaimed bodies
as per state guideline
Maternal Health and Child health Services.
Standard E16 The facility has established procedures for Antenatal care as per guidelines 5 10
There is an established procedure Facility provides and 1 RR/SI
ME E16.1 for Registration and follow up of updates “Mother and Child
pregnant women. Protection Card”.
There is an established procedure Management of PIH and 1 RR/SI Loading dose of
for identification of High risk referral of Eclampsia cases Magnesium sulphate is
pregnancy and appropriate given before referral
ME E16.4 treatment/referral as per scope of
services.

Management of sepsis 1 RR/SI

Initial Management & Referral 1 RR/SI
of diabetic pregnant mother

There is an established procedure Management of severe 1 RR/SI Blood Transfusion

for identification and management anaemia & referral services available for
ME E16.5 of moderate and severe anaemia anaemic patients

Standard E18 The facility has established procedures for postnatal care as per guidelines 7 14
 Post partum Care is provided to Post Partum Care of New-born 1 SI/RR Maintaining hand
the mothers hygiene, keeps the baby
wrapped (maintains
temperature), Checks
weight, temperature,
respiration, heart rate,
ME E18.1 colour of skin and cord
stump

Initiation of Breastfeeding 1 PI Verify with mother

with in one Hour regarding a)Counselling
on Breast Feeding b)Time
Period between delivery
and first feed c)Advice in
position of baby

Post partum care of mother 1 PI/RR Ask mother about

Checking uterine
contraction, bleeding,
checking for TPR and
output chart, Breast
examination and milk
initiation and perineal
washes

The facility ensures adequate stay 48 Hour Stay of mothers and 1 SI/RR
of mother and new-born in a safe new born after delivery
ME E18.2 environment as per standard
Protocols.

There is an established procedure Counselling provided for Post 1 PI/SI Nutrition ,Contraception
for Post partum counselling of partum care ,Breastfeeding ,Registrati
mother on of Birth ,IFA
ME E18.3 Supplement ,Danger
Signs.

The facility has established There is established criteria 1 SI/RR

procedures for for shifting new-born to NBSU
ME E18.4 stabilization/treatment/referral of and referring to SNCU
post natal complications

There is established procedure for Counselling is done before 1 RR/PI Danger Sign for Mother:
discharge and follow up of mother discharge, Patient is explained Bleeding, Pain abdomen,
and new-born. about follow up visits Severe Headache, Visual
disturbance, Breathing
difficulties, Fever and
Chills, Difficulty in
Urination, Foul smelling
discharge. Danger sign
for Baby: Fast & difficult
breathing, Fever,
ME E18.5 Unusual Cold, Does not
accept feed, Less active
& yellow discoloration of
skin

Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 11 22
The facility provides immunization Zero dose vaccines are given 1 RR Check for records BCG,
services as per guidelines Hepatitis-B and OPV-0
ME E19.1 given to New-born

Triage, Assessment & Management Assessment Protocols are 1 SI/RR Airway, Breathing,
of new-borns having available Circulation, Coma,
emergency signs are done as per Convulsion, and
ME E19.2 guidelines Dehydration

Triage Protocols are available 1 SI/RR Emergency, priority and

can wait
Staff is aware and practices 1 SI/RR
ETAT protocols
Staff is skilled in basic life 1 SI/RR
support for Infants and
children

ETAT checklist is available and 1 SI/RR

practiced
Management of Low birth weight Care of Low Birth Weight and 1 SI/RR Premature and LBW
new-born's is done as per Premature babies babies are identified:
guidelines Weight less than 2500 g
for low birth weight
babies, gestation of less
than 37 weeks for
prematurely, Kangaroo
Mother Care (KMC) is
implemented for Low
Birth
ME E19.3 Weight/Prematurely and
assisted feeding is
arranged, if required

Management of children Differential diagnosis 1 SI/RR

presenting algorithm are available
with fever, cough/ breathlessness
ME E19.5 is done as per guidelines

Weight chart is maintained 1 RR

Start-up and catch formula 1 SI/RR check for composition
made as per guidelines
Management of children Assessment of dehydration 1 SI/RR
presenting done as per protocols
ME E19.7 diarrhoea is done per guidelines

National Health Program

Standard E22 The facility provides National health Programme as per operational/Clinical Guidelines
The facility provide service for
Integrated disease surveillance
ME E22.9
Programme
The facility has infection control Programme and procedures in place for prevention and measurement of
Standard F1
The facility measures hospital
associated infection rates
ME F1.3
There is Provision of Periodic
Medical Check-up and
ME F1.4
immunization of staff
The facility has established
procedures for regular monitoring infection control practices
ME F1.5 of infection control practices
The facility has defined and
ME F1.6 established antibiotic policy
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are
provided at point of use
ME F2.1
The facility staff is trained in hand Adherence to 6 steps of Hand
washing practices and they adhere washing
ME F2.2 to standard hand washing
practices
The facility ensures standard
practices and materials for
ME F2.3
antisepsis
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate
ME F3.1 personal protection Equipment as point of use
per requirements
The facility staff adheres to
standard personal protection
ME F3.2
practices
Standard F4 The facility has standard procedures for processing of equipment and instruments
The facility ensures standard
practices and materials for
decontamination and cleaning of
ME F4.1 instruments and procedures areas
1 2
Weekly reporting of 1 SI/RR
Presumptive cases on form
"P" from IPD
Area of Concern - F Infection Control 40 80
hospital associated infection 5 10
There is a procedure to report 1 SI/RR Patients are observed for
cases of Hospital acquired any sign and symptoms
infection of HAI like fever,
purulent discharge from
surgical site .
There is a procedure for 1 SI/RR Hepatitis B, Tetanus
immunization of the staff Toxoid etc.
Periodic medical check-ups of 1 SI/RR
the staff
Regular monitoring of 1 SI/RR Hand washing and
infection control audits
done at periodic intervals
Check if Doctors are aware of 1 SI/RR
Hospital Antibiotic Policy
9 18
Availability of hand washing 1 OB FNBC guideline: Each
Facility at Point of Use unit should have at least
1 wash basin for every 5
beds
Availability of running Water 1 OB/SI Open the tap. Ask the
Staff, water is available
24*7
Availability of antiseptic soap 1 OB/SI Check for availability/
with soap dish/ liquid Ask staff if the supply is
antiseptic with dispenser. adequate and
uninterrupted
Availability of Alcohol based 1 OB/SI Check for availability/
Hand rub Ask staff for regular
supply. Hand rub
dispenser are provided
adjacent to bed
Display of Hand washing 1 OB Prominently displayed
Instruction at Point of Use above the hand washing
facility , preferably in
Local language
1 SI/OB Ask for demonstration
Staff is aware of occasion for 1 SI
hand washing
Availability of Antiseptic 1 OB
Solutions
Procedure for proper cleaning 1 OB/SI e.g. before giving IM/IV
of site with antisepsis injection, drawing blood,
putting Intravenous and
urinary catheter
4 8
Clean gloves are available at 1 OB/SI
Availability of Masks 1 OB/SI
No reuse of disposable gloves, 1 OB/SI
Masks, caps and aprons.
Compliance to correct method 1 SI
of wearing and removing the
gloves
9 18
Decontamination of 1 SI/OB Ask staff about how they
Procedure surfaces decontaminate work
benches
(Wiping with 0.5%
Chlorine solution)
Proper Decontamination of 1 SI/OB Decontamination of
instruments after use instruments and reusable
of glassware are done
after procedure in 1%
chlorine solution/ any
other appropriate
method
Contact time for 1 SI/OB 10 minutes
decontamination is adequate
Cleaning of instruments after 1 SI/OB Cleaning is done with
decontamination detergent and running
water after
decontamination
Proper handling of Soiled and 1 SI/OB No sorting ,Rinsing or
infected linen sluicing at Point of use/
Patient care area
The Staff knows how to make 1 SI/OB
chlorine solution
 The facility ensures standard Equipment and instruments 1 OB/SI Autoclaving/HLD/
practices and materials for are sterilized after each use Chemical Sterilization
ME F4.2 disinfection and sterilization of as per requirement
instruments and equipment

High level Disinfection of 1 OB/SI Ask staff about method

instruments/equipment is and time required for
done as per protocol boiling

Autoclaved dressing material 1 OB/SI

is used

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 8 16
The facility ensures availability of Availability of disinfectant as 1 OB/SI Chlorine solution,
standard materials for cleaning and per requirement Gluteraldehye, carbolic
ME F5.2 disinfection of patient care areas acid

Availability of cleaning agent 1 OB/SI Hospital grade phenyl,

as per requirement disinfectant detergent
solution

The facility ensures standard Staff is trained for spill 1 SI/RR

practices are followed for the management
ME F5.3 cleaning and disinfection of patient
care areas

Cleaning of patient care area 1 SI/RR

with detergent solution

Staff is trained for preparing 1 SI/RR

cleaning solution as per
standard procedure

Standard practice of mopping 1 OB/SI Unidirectional mopping

and scrubbing are followed from inside out

Cleaning equipment like 1 OB/SI Any cleaning equipment

broom are not used in patient leading to dispersion of
care areas dust particles in air
should be avoided

The facility ensures segregation Isolation and barrier nursing 1 OB/SI

ME F5.4 infectious patients procedure are followed for
septic cases

Standard F6
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio
Medical and hazardous Waste. 14 28
The facility Ensures segregation of Availability of colour coded 1 OB
Bio Medical Waste as per bins at point of waste
guidelines and 'on-site' generation
ME F6.1 management of waste is carried
out as per guidelines

Availability of plastic colour 1 OB

coded plastic bags
Segregation of different 1 OB/SI
category of waste as per
guidelines

Display of work instructions 1 OB

for segregation and handling
of Biomedical waste

There is no mixing of 1 OB
infectious and general waste

The facility ensures management Availability of functional 1 OB Verify its usage

of sharps as per guidelines needle cutters
ME F6.2

Availability of puncture proof 1 OB Should be available nears

box the point of generation
like nursing station and
injection room

Disinfection of sharp before 1 OB/SI Disinfection of syringes is

disposal not done in open buckets

Staff is aware of contact time 1 SI

for disinfection of sharps

Availability of post exposure 1 OB/SI Ask if available. Where it

prophylaxis is stored and who is in
charge of that.

Staff knows procedure in 1 SI/RR Staff knows what to do in

event of needle stick injury case of sharp injury and
whom to report. See if
any reporting has been
done

The facility ensures transportation Check bins are not overfilled 1 SI/OB
ME F6.3 and disposal of waste as per
guidelines
Transportation of bio medical 1 SI/OB
waste is done in close
container/trolley

Staff aware of mercury spill 1 SI

management

Area of Concern - G Quality Management 36 72

Standard G1 Facility has established organizational framework for quality improvement 1 2
Facility has a quality team in place There is a designated 1 SI/RR
departmental nodal person
for coordinating Quality
ME G1.1 Assurance activities

Standard G2 The facility has established system for patient and employee satisfaction 1 2
Patient satisfaction surveys are Patient satisfaction survey 1 RR
ME G2.1 conducted at periodic intervals done on monthly basis

Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 3 6
 The facility has established
internal quality assurance
programme in key departments
ME G3.1
There is system daily round by 1 SI/RR
matron/hospital
superintendent/ Hospital
Manager for monitoring of
services

The facility has established system Departmental checklist are 1 SI/RR

for use of check lists in different used for monitoring and
ME G3.3 departments and services quality assurance

Staff is designated for filling 1 SI

and monitoring of these
checklists

Standard G4
The facility has established, documented implemented and maintained Standard Operating Procedures for all
key processes. 15 30
Departmental standard operating Standard operating procedure 1 RR
procedures are available for department has been
ME G4.1 prepared and approved

Current version of SOP are 1 OB/RR

available with process owner

Standard Operating Procedures The Department has 1 RR

adequately describes process and documented procedure for
ME G4.2 procedures receiving and initial
assessment of the patient

The Department has 1 RR

documented procedure for
admission, shifting and
referral of patient

The Department has 1 RR

documented procedure for
requisition of diagnosis and
receiving of the reports

The Department has 1 RR

documented procedure for
preparation of the patient for
surgical procedure

The Department has 1 RR

documented procedure for
transfusion of blood

The Department has 1 RR

documented procedure for
maintenance of rights and
dignity of Patient

The Department has 1 RR

documented procedure for
record maintenance including
taking consent

The Department has 1 RR

documented procedure for
counselling of the patient at
the time of discharge

The Department has 1 RR

documented procedure for
environmental cleaning and
processing of the equipment

The Department has 1 RR

documented procedure for
sorting, and distribution of
clean linen to patient

The Department has 1 RR

documented procedure for
end of life care

Staff is trained and aware of the Check if staff is aware of 1 SI/RR

ME G4.3 procedures written in SOPs relevant part of SOPs
Work instructions are displayed at Work instruction/clinical 1 OB Patient safety, CPR
ME G4.4 Point of use protocols are displayed

Standard G5
The facility has established system of periodic review as internal assessment , medical & death audit and
prescription audit 7 14
The facility conducts periodic Internal assessment is done at 1 RR/SI
ME G5.1 internal assessment periodic interval
The facility conducts the periodic There is procedure to conduct 1 RR/SI
ME G5.2 prescription/ medical/death audits Medical Audit

There is procedure to conduct 1 RR/SI

Prescription audit
There is procedure to conduct 1 RR/SI
Death audit
The facility ensures non Non Compliance are 1 RR/SI
ME G5.3 compliances are enumerated and enumerated and recorded
recorded adequately
Action plan is made on the gaps Action plan is prepared 1 RR/SI
ME G5.4 found in the assessment / audit
process
Corrective and preventive actions Corrective and preventive 1 RR/SI
are taken to address issues, action taken
ME G5.5 observed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
The facility periodically defines its Quality objective for IPD are 1 RR/SI
quality objectives and key defined
ME G6.2 departments have their own
objectives

Quality policy and objectives are Check if staff is aware of 1 SI

ME G6.3 disseminated and staff is aware of quality policy and objectives
that
 Progress towards quality Quality objectives are 1 SI/RR
objectives is monitored monitored and reviewed
ME G6.4 periodically
periodically

Standard G7 The facility seeks continually improvement by practicing Quality method and tools. 6 12
The facility uses methods for PDCA 1
ME G7.1 quality improvement in services

5S 1 SI/OB
Mistake proofing 1 SI/OB
Six Sigma 1 SI/RR
The facility uses tools for quality 6 basic tools of Quality 1 SI/RR
ME G7.2 improvement in services

Pareto / Prioritization 1 SI/RR

Area of Concern - H Outcome 11 22
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 2 4
Facility measures productivity Bed Occupancy Rate of Male 1 RR
ME H1.1 Indicators on monthly basis Ward
Bed Occupancy Rate for 1 RR
Female ward
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 4 8
Facility measures efficiency Indicators Referral Rate 1 RR
ME H2.1 on monthly basis
Bed Turnover rate 1 RR
Discharge rate 1 RR
No. of drugs stock out in the 1 RR
ward
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 3 6
Facility measures Clinical Care & Average length of stay for 1 RR
ME H3.1 Safety Indicators on monthly basis Male wards

Average length of stay for 1 RR

Female ward
Time taken for initial 1 RR
assessment
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 4
Facility measures Service Quality LAMA Rate 1 RR
ME H4.1 Indicators on monthly basis
Patient Satisfaction Score 1 RR

IPD Card
IPD Score 50
Area of Concern wise Score
A Service Provision 50

B Patient Rights 50

C Inputs 50

D Support Services 50

E Clinical Services 50

F Infection Control 50

G Quality Management 50

H Outcome 50

Obtained Maximum Percent 4

A 14 28 50
B 41 82 50
C 62 124 50
D 46 92 50
E 109 218 50
F 40 80 50
G 36 72 50
H 11 22 50
Total 359 718 50
 National Quality Assurance Standards for CHC 0 1 2
Checklist for NBSU 5
Reference no. Measurable Element Checkpoint Compliance Assessment Means of verification Remarks
Method
Area of Concern - A Service Provision 12 24
Standard A1 Facility Provides Curative Services 2 4
ME A1.4 The Facility Provides Paediatric Availability of functional NBSU 1 SI/OB At least 4 beds.
Services
ME A1.9 Services are available for the time Availability of nursing care services 1 SI/RR
period as mandated at NBSU (24X7)
Standard A2 Facility provides RMNCHA Services 8 16
ME A2.3 The Facility provides New-born Management of low birth weight 1 SI/RR
health Services infants > or =1800 gm with no
other complication

Weighing the new-born. 1 SI/RR

Resuscitation 1 SI/RR
Prevention of infection including 1 SI/RR
management of new-born sepsis

Provision of Warmth 1 SI/RR

Phototherapy for new born 1 SI/RR
Breast feeding/feeding support 1 SI
and Kangaroo Mother care (KMC)

ME A2.4 The Facility provides child health Screening of New born for 1 SI/RR
Services congenital Birth Defects
Standard A3 Facility Provides diagnostic Services 2 4
ME A3.1 The Facility provides Radiology Functional linkage for USG and 1 SI/OB In house/Parent hospital/
Services X- ray services Outsourced
ME A3.2 The Facility Provides Laboratory NBSU has Linkage for laboratory 1 SI/OB 24x7 linkage with outside
Services investigations laboratory for critical tests like
Blood Count, Platelets, Plasma
glucose, Serum creatinine,
Blood count, Platelet, C
reactive protein, Prothrombin
time,etc.

Area of Concern - B Patient Rights 26 52

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 9 18
ME B1.1 The facility has uniform and user- Availability departmental 1 OB (Numbering Rooms, main
friendly signage system signage's department and inter-
sectional signage)

Directional signage for 1 OB

ME B1.2 The facility displays the services
and entitlements available in its
departments
department are displayed
Restricted area signage 1 OB
displayed
Entitlements under JSSK displayed 1 OB
Information about Nurse on duty 1 OB
is displayed and updated
Contact information in respect of 1 OB
NBSU referral services are
displayed

ME B1.5 Patients & visitors are sensitised Display of information for 1 OB Display of pictorial
and educated through education of mother /relatives information/ chart regarding
appropriate IEC / BCC approaches expression of milk/ techniques
for assisted feeding , KMC,
immunization, complimentary
feeding etc.

ME B1.6 Information is available in local Signage's and information are 1 OB

language and easy to understand available in local language

ME B1.8 The facility ensures access to Discharge summary is given to the 1 OB

clinical records of patients to patient
entitled personnel
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information. 3 6
ME B3.1 Adequate visual privacy is Privacy is maintained in breast 1 OB
provided at every point of care feeding room/corner
ME B3.2 Confidentiality of patients records new-born Records are kept at a 1 SI/OB
and clinical information is secure place beyond access to
maintained general staff/visitors

ME B3.3 The facility ensures that Behaviour of staff is empathetic 1 OB/PI

behaviour of staff is dignified and and courteous
respectful, while delivering the
services
The facility has defined and established procedures for informing patients about the medical condition, and involving
Standard B4 them in treatment planning, and facilitates informed decision making 4 8
ME B4.1 There is a established procedure NBSU has a system in place to take 1 SI/RR
for taking informed consent informed consent from new-born
before treatment and procedures relative, whenever required

ME B4.4 Information about the treatment NBSU has a system in place to 1 PI

is shared with patients or involve new-born relatives in
attendants, regularly decision making of new-born
treatment

NBSU has system in place to 1 PI/SI

provide communication on new-
born condition to parents/
relatives at least once in day

ME B4.5 Facility has defined and Availability of complaint box and 1 OB

established grievance redressal display of process for grievance
system in place redressal and with contact detail.

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital services. 10 20
ME B5.1 The facility provides cashless Availability of Free diagnostics 1 PI/SI
services to pregnant women,
mothers and neonates as per
prevalent government schemes

Availability of Free diet to 1 PI/SI

beneficiaries
Availability of Free Diet to mother 1 PI/SI
 Availability of Free new-born 1 PI/SI
transport including drop back
facility

Availability of Free Blood 1 PI/SI

Availability of Free drugs 1 PI/SI
Availability of free stay to mother 1 PI/SI

ME B5.2 The facility ensures that drugs Check that new-born parents & 1 PI/SI
prescribed are available at attendant's have not spent money
Pharmacy and wards on purchasing drugs and
consumables from outside.

ME B5.3 It is ensured that facilities for the Check that new-born parents & 1 PI/SI
prescribed investigations are attendants have not spent money
available at the facility on diagnostics from outside.

ME B5.5 The facility ensures timely If any other expenditure has been 1 PI/RR
reimbursement of financial incurred, then it is reimbursed
entitlements and reimbursement from hospital
to the patients

Area of Concern - C Inputs 43 86

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 8 16
ME C1.1 The Departments has adequate Adequate space as per new-born 1 OB Approximately 40-50 square
space as per new-born care work care units feet per bed where 4 radiant
load warmer can be kept.

ME C1.3 The Departments has layout and Availability of nursing station 1 OB

demarcated areas as per
functions
Hand washing and gowning area 1 OB

Mother's area for expression of 1 OB NBSU has system in place to

breast milk/ breast feeding call mother's of baby for
feeding

ME C1.4 The facility has adequate Availability of adequate circulation 1 OB

circulation area and open spaces area for easy moment of staff and
according to need and local law equipment

ME C1.5 The facility has infrastructure for Availability of functional Intercom 1 OB

intramural and extramural Services & Telephone Services
communication
ME C1.7 The facility and departments are NBSU is easily accessible from 1 OB
planned to ensure structure labour room, maternity ward and
follows the function/processes OT
(Structure commensurate with
the function of the hospital)

Location of nursing station and 1 OB

patients beds enables easy and
direct observation of patients

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging objects
are properly fastened and
secured

ME C2.2 The facility ensures safety of NBSU does not have temporary 1 OB Switch Boards other electrical
electrical establishment connections and loosely hanging installations are intact
wires

10 central Voltage stabilizer 1 OB/RR 50% 0f each should be 5amp

outlets are available with each and 50% should be 15 amp to
warmer in main NBSU. handle equipment

NBSU has earthling system 1 OB/RR Dedicated earthling pit

available system available
ME C2.3 Physical condition of building is Floors of the NBSU are non 1 OB
safe for providing new-born care slippery and even

Windows and vents if any are 1 OB

intact and sealed
ME C2.4. The facility has a plan for NBSU has fire exit to permit safe 1 OB/SI
prevention of fire escape of its occupant at time of
fire

ME C2.5 The facility has adequate fire NBSU has installed fire 1 OB
fighting Equipment Extinguisher that are capable of
fighting A,B & C Type of fire.

Check the expiry date for fire 1 OB/RR

extinguisher is displayed on each
extinguisher as well as due date
for next refilling is clearly
mentioned

ME C2.6. The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation

Standard C3 Facility has the appropriate number of staff with the correct skill mix required for providing the assured services to the current case load 10 20
ME C3.1 The facility has adequate Availability of On call 1 OB/RR
specialist doctors as per service Paediatrician/trained FIMNCI MO.
provision
ME C3.3 The facility has adequate nursing Availability of one Nursing staff per 1 OB/RR/SI
staff as per service provision and shift
work load
ME C3.6 The staff has been provided Facility based New Born Care 1 SI/RR To all Medical Officers and
required training / skill sets (FBNC) training Nursing Staff posted at NBSU

IMEP training. 1 SI/RR

Training on Bio Medical waste 1 SI/RR
Management
New-born Safety 1 SI/RR
ME C3.7 The Staff is skilled as per job Nursing staff is skilled for 1 SI/RR
description operation of equipment
The Staff is skilled for 1 SI/RR
resuscitation of New Born
 Nursing staff is skilled in 1 SI/RR
identifying and managing
complications

Nursing Staff is skilled for 1 SI/RR

maintaining clinical records
Standard C4 Facility provides drugs and consumables required for assured list of services. 10 20
ME C4.1 The department has availability of Availability of Antibiotics 1 OB/RR Inj. Ampicillin with Cloxacillin,
adequate drugs at point of use Inj. Ampicillin
Inj. Cefotaxime
Inj. Gentamycin, Inj. Amikacin,
Amoxycillin-Clavulanic
Suspension

Availability of Antipyretics 1 OB/RR Paracetamol

Availability of IV Fluids 1 OB/RR 5%, 10% and 25% Dextrose
Normal saline
Availability of other emergency 1 OB/RR Inj.Adrenaline (1:10000)
drugs Inj. Naloxone
Inj. Calcium gluconate, Inj.
Phenytoin, Injection
Aminophylline
Phenobarbitone (Injection
+oral)
Injection Hydrocortisone, Inj.
Phenytoin

Availability of drugs for new-born 1 OB/RR Vit K ,

ME C4.2 The department has adequate
consumables at point of use
Availability of dressings material 1 OB/RR Gauze piece and cotton swabs,
and diapers Diapers,
Availability of syringes and IV 1 OB/RR Neoflon 24 G , micro drip set
Sets /tubes with &without burette, BT set,
Suction catheter, PT tube,
feeding tube

Availability of Antiseptic Solutions 1 OB/RR Antiseptic lotion

Others 1 OB/RR Baby ID tag, cord clamp,

mucus sucker,
ME C4.3 Emergency drug trays are Emergency Drug Tray is maintained 1 OB/RR
maintained at every point of care,
where ever it may be needed

Standard C5 Facility has equipment & instruments required for assured list of services. 5 10
ME C5.1 Availability of equipment & Availability of functional 1 OB Thermometer, Weighing
instruments for examination & Equipment &Instruments for scale, pulse oxy meter2,
monitoring of patients examination & Monitoring Multipara metre. Stethoscope

ME C5.4 Availability of equipment and
instruments for resuscitation of
patients and for providing
intensive and critical care to
patients
Functional Critical care Equipment 1 OB Infusion pumps, Oxygen
cylinder/Oxygen concentrator,
oxygen hood,etc

Functional Resuscitation 1 OB Bag and mask, laryngoscope,

equipment ET tubes, Foot-suction

ME C5.7 The Department has furniture
and fixtures as per load and
service provision
Availability of Fixtures
Availability of furniture
1 OB Electrical panel with each unit,
X ray view box.
1 OB Cupboard, nursing counter,
table for preparation of
medicines, chair, furniture at
breast feeding room.

Area of Concern - D Support Services 44 88

Standard D1 Facility has established program for inspection, testing and maintenance and calibration of equipment. 4 8
ME D1.1 The facility has established All equipment are covered under 1 SI/RR Functional Radiant warmer,
system for maintenance of critical AMC including preventive suction machine, Oxygen
Equipment maintenance concentrator, pulse oximeter/
Multipara monitor and their
AMC

There is procedure to check timely 1

replacement of lights in
Phototherapy unit.

ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of measuring
Equipment

ME D1.3 Operating and maintenance Up to date instructions for 1 OB/SI

instructions are available with the operation and maintenance of
users of equipment equipment are readily available
with NBSU staff.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and new-born care areas 9 18
ME D2.1 There is established procedure There is established system of 1 SI/RR Stock level are daily updated
for forecasting and indenting of timely indenting of consumables Requisition are timely placed
drugs and consumables and drugs at nursing station

ME D2.3 The facility ensures proper Drugs are stored in 1 OB

storage of drugs and consumables containers/tray/crash cart and are
labelled

Empty and filled cylinders are 1 OB

labelled
ME D2.4 The facility ensures management Expiry dates are maintained at 1 OB/RR
of expiry and near expiry drugs emergency drug tray

No expiry drug found 1 OB/RR

ME D2.5 The facility has established Department maintain stock and 1 RR/SI
procedure for inventory expenditure register of drugs and
management techniques consumables

ME D2.6 There is a procedure for periodically There is procedure for replenishing 1 SI/RR
replenishing the drugs in new-born Emergency drug tray.
care areas

There is no stock out of drugs 1 OB/SI

ME D2.7 There is process for storage of Temperature of refrigerators are 1 OB/RR Check for temperature charts
vaccines and other drugs, kept as per storage requirement are maintained and updated
requiring controlled temperature and records are maintained periodically

Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and
18 36
ME D3.2 Hospital infrastructure is
comfortable environment to staff,
Check for there is no seepage , 1
patients
OB
and visitors.
adequately maintained Cracks, chipping of plaster
Window panes , doors and other 1 OB
fixtures are intact
 Patients beds are intact and 1 OB
painted
Mattresses are intact and clean 1 OB

ME D3.3. Patient care areas are clean and Floors, walls, roof, roof tops, sinks 1 OB All area are clean with no
hygienic new-born care and circulation dirt,grease,littering and
areas are Clean cobwebs

Surface of furniture and fixtures 1 OB

are clean
ME D3.4 The facility has policy of removal No condemned/Junk material in 1 OB
of condemned junk material the NBSU

ME D3.5 The facility has established No stray animal/rodent/birds 1 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate Illumination at each 1 OB
illumination level at patient care basinet.
areas
ME D3.7 The facility has provision of Entry to NBSU is restricted 1 OB
restriction of visitors in new-born
areas
Visiting hour are fixed and are 1 OB/PI
observed.
ME D3.8 The facility ensures safe and NBSU has a system to control 1 SI/RR Temperature inside main
comfortable environment for temperature and humidity, and NBSU should be maintained at
patients and service providers record of same is maintained (Air (22-26OC), round O clock
conditioning). preferably by thermostatic
control. Relative humidity of
30-60% should be maintained

NBSU has procedure to check the
temperature of radiant
warmer ,phototherapy units, etc.
1 SI/RR Each equipment used should
have servo controlled devices
for heat control with cut off to
limit increase in temperature
of radiant warmers beyond a
certain temperature or
warning mechanism for
sounding alert/alarm when
temp increases beyond certain
limits

NBSU has system to control the 1 SI/RR Background sound should not
sound producing activities and be more than 45 db and peak
gadgets (like telephone sounds, intensity should not be more
staff area and equipment) than 80db.

NBSU has functional room 1 SI/RR 1 for each new-born care room
thermometer and temperature is
regularly maintained

ME D3.9 The facility has a security system New born identification band are 1 OB/RR
in place at patients care area used and foot prints of babies are
taken.

There is procedure for handing 1 SI

over the baby to
mother/father/Legal Guardian

Security arrangement in NBSU are 1 OB

robust.
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 5 10
ME D4.1 The facility has arrangement for Availability of 24x7 running and 1 OB/SI
adequate storage and supply for potable water
potable water in all functional
areas

ME D4.2 The facility ensures adequate Availability of power back up in 1 OB/SI

power backup in all new-born new-born care areas
care areas as per load
Availability of UPS 1 OB/SI
Availability of Emergency light 1 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Oxygen and vacuum 1 OB
availability of oxygen, medical gases suction
and vacuum supply

Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean linen to all admitted
5 10
patients.
ME D5.2 The facility provides diet Check for the adequacy and 1 OB/RR
according to nutritional frequency of feed as per
requirements of the patients nutritional requirement

ME D5.3 Hospital has standard procedures for Facility to prepare feeds is 1 RR/SI
preparation, handling, storage and available near NBSU.
distribution of diets, as per
requirement of patients

ME D5.4 The facility has adequate sets of NBSU has facility to provide 1 OB/RR
linen available. sufficient and clean linen for each
patient

ME D5.5. The facility has established Linen is changed every day and 1 OB/RR
procedures for changing of linen whenever it get soiled
in new-born care areas
ME D5.6. The facility has standard procedures There is a system to check the 1 SI/RR
for handling , collection, cleanliness and Quantity of the
transportation and washing of linen linen received from laundry

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
3 6
ME D9.1 The facility has established job
operating procedures.
The Staff is aware of their role
1 SI
description as per govt guidelines and responsibilities

ME D9.2 The facility has a established There is a procedure to ensure 1 RR/SI Check for system for recording
procedure for duty roster and that staff is available on duty as time of reporting and relieving
deputation to different per duty roster (Attendance register/
departments Biometrics etc.)

ME D9.3 The facility ensures the Doctor, nursing staff and support 1 OB
adherence to dress code as staff adhere to their respective
mandated by its administration / dress code
the health department

Area of Concern - E Clinical Services 81 162

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 5 10
ME E1.1 The facility has established Unique identification number is 1 RR
procedure for registration of given to each New-born at time of
patients Registration

ME E1.3 There is a established procedure Admission criteria for NBSU are 1 SI/RR
for admission of patients defined & followed

There is no delay in admission of 1 SI/RR/OB

patient
Time of admission is recorded in 1 RR
new-born record
ME E1.4 There is established procedure Procedure to cope with surplus 1 OB/SI
for managing patients, if beds are new-born load
not available at the facility
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients. 2 4
ME E2.1 There is established procedure Initial assessment of all new-born's 1 RR/SI Defined criteria for assessment
for initial assessment of patients is done as per standard protocols like Silverman Anderson Score
and Down score

ME E2.2 There is established procedure There is fixed schedule for periodic 1 RR/OB
for follow-up/ reassessment of assessment of new-born's
Patients
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral 6 12
ME E3.1 The facility has established There is a procedure of taking 1 RR/SI Check continuity of care is
procedure for continuity of care over of new born from labour maintained while
during interdepartmental transfer Room OT/ Ward to NBSU transferring/ handover the
new-born

ME E3.2 The facility provides appropriate New-born referred with referral 1 RR/SI
referral linkages to the slip
patients/Services for transfer to
other/higher facilities to assure the
continuity of care.

Advance intimation is given to 1 RR/SI

higher centre
Referral vehicle is arranged 1 SI/RR
Referral in or referral out register 1 RR
is maintained
There is a system of follow up 1 RR
of referred patients
Standard E4 The facility has defined and established procedures for nursing care 7 14
ME E4.1 Procedure for identification of Identification tags are used for 1 OB/SI
patients is established at the identification of new-born's
facility
ME E4.2 Procedure for ensuring timely and Treatment chart are maintained 1 RR Check that treatment charts
accurate nursing care as per are updated and drugs given
treatment plan is established at the are marked. Co -relate it with
facility drugs and doses prescribed.

There is a process to ensue the 1 SI/RR Verbal orders are rechecked

accuracy of verbal/telephonic before administration
orders
ME E4.3 There is established procedure of new-born hand over is given 1 SI/RR
new-born hand over, whenever during the change in the shift
staff duty change happens

Nursing Handover register is 1 RR

maintained
ME E4.4 Nursing records are maintained Nursing notes are maintained 1 RR/SI Check for nursing note register
adequately and adequacy of notes.

ME E4.5 There is procedure for periodic Vitals of new-borns are 1 RR/SI Check for TPR chart,
monitoring of patients monitored and recorded Phototherapy chart, any other
periodically vital are monitored and
recorded.

Standard E6 The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic
4 8
ME E6.1 The facility ensures that drugs are
drugs & their rational
Check for BHT if drugs are 1
use.
RR
prescribed in generic name only prescribed under the generic
name only

ME E6.2 There is procedure of rational use of Check for that relevant Standard 1 RR
drugs treatment guideline are available
at point of use

Check staff is aware of the drug 1 SI/RR

regime and doses as per STG

Check BHT that drugs are 1 RR

prescribed as per STG
Standard E7 The facility has defined procedures for safe drug administration 12 24
ME E7.1 There is process for identifying High alert drugs are identified in 1 SI/OB Electrolytes like Potassium
and cautious administration of the department. chloride, Insulin etc. as
high alert drugs applicable

Maximum dose of high alert drugs 1 SI/RR Value for maximum doses as
are defined and communicated per age, weight and diagnosis
are available with nursing
station and doctor

ME E7.2 Medication orders are written
legibly and adequately
There is process to ensure that
right doses of high alert drugs are
only given
1 SI/RR A system of independent
double check before
administration, Error prone
medical abbreviations are
avoided

Every Medical advice and 1 RR

procedure are accompanied
with date , time and signature

Check for the writing to ensure 1 RR/SI

that it is comprehendible by the
clinical staff

ME E7.3 There is a procedure to check Drugs are checked for expiry
drug before administration/ and other inconsistency before
dispensing administration
Check single dose vial are not used
for more than one dose
1 OB/SI
1 OB Check for any open single dose
vial with left over content
intended to be used later on

Check for separate sterile needle is 1 OB

used every time for multiple dose In multi dose vial needle is not
vial left in the septum
 Any adverse drug reaction is 1 RR/SI
recorded and reported
ME E7.4 There is a system to ensure right Fluid and drug dosages are 1 SI/RR Check for calculation chart
medicine is given to right new- calculated according to body
born weight

Drip rate and volume are 1 SI/RR Check the nursing staff how
calculated and monitored they calculate Infusion and
monitor it

Administration of medicines is 1 SI/OB

done after ensuring right patient,
right drugs , right dose, right route,
right time

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their
8 16
storage
ME E8.1 All the assessments, re- 1
New-born progress is recorded as RR
assessment and investigations are per defined assessment schedule
recorded and updated
ME E8.2 All treatment plan Treatment plan are written on BHT 1 RR
prescription/orders are recorded and all drugs are written legibly in
in the new-born records. case sheet.

ME E8.3 Care provided to each new-born's Maintenance of treatment 1 RR Treatment given is recorded in
recorded in the new-born records chart/treatment registers the treatment chat

ME E8.4 Procedures performed are Procedure performed are 1 RR Mobilization, resuscitation etc.
written on patients records recorded in BHT
ME E8.5 Adequate forms and formats are Standard Formats are available 1 RR/OB Availability of formats for
available at point of use Treatment Charts, TPR Chart ,
Intake Output Chart,
Community follow up card,
BHT, continuation sheet,
Discharge card Etc.

ME E8.6 Register/records are maintained Registers and records are 1 RR General order book (GOB),
as per guidelines maintained as per guidelines report book, Admission
register, lab register,
Admission sheet/ bed head
ticket, discharge slip, referral
slip, referral in/referral out
register, OT register, Diet
register, Linen register, Drug
intend register

All register/records are identified 1 RR

and numbered
ME E8.7 The facility ensures safe and Safe keeping of new-born records 1 OB
adequate storage and retrieval of
medical records
Standard E9 The facility has defined and established procedures for discharge of patient. 12 24
ME E9.1 Discharge is done after assessing NBSU has established criteria for 1 SI/RR New-born's shifted to
new-born readiness discharge of the new-born ward/step down after
assessment

Assessment is done before 1 SI/RR

discharging new-born
Discharge is done by a responsible 1 SI/RR Preferably Paediatrician. Or
and qualified doctor Doctor on duty in consultation
with paediatrician

New-born/ attendants are 1 PI/SI

consulted before discharge
Treating doctor is consulted/ 1 SI/RR
informed before discharge of
patients

ME E9.2 Case summary and follow-up
instructions are provided at time
of discharge
Discharge summary is provided 1 RR/PI See for discharge summary,
referral slip provided.
Discharge summary mentions 1 RR
adequately patients clinical
condition, treatment given and
follow up

Discharge summary is given to 1 SI/RR

patients going on LAMA/Referral

There is a procedure for clinical 1 RR/SI

follow up of the new born by local
PHC (Community health care
worker)/ASHA

ME E9.3 Counselling services are provided Counselling of mother before 1 PI/SI For care of new born and
as during discharges wherever discharge breastfeeding, treatment and
required follow up counselling

Time of discharge is 1 PI/SI

communicated to the attendant
prior to discharge

ME E9.4 The facility has established Declaration is taken from the 1 RR/SI
procedure for patients leaving the LAMA new-born
facility against medical advice,
absconding, etc.

Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 9 18
ME E10.1 There is procedure for receiving Triaging of new born as per 1 SI/RR
and triage of patients guidelines

ME E10.3 The facility has disaster Staff is aware of disaster plan 1 SI/RR
management plan in place
ME E10.4 The facility ensures adequate and There is a System for coordination 1 SI/RR
timely availability of ambulances of ambulances
services and mobilisation of
resources, as per requirement

NBSU has provision of Ambulance 1 SI/RR

to refer the case to higher centre

Ambulance has provision/ method 1 SI/RR

for maintenance of Warm chain
while referred to higher centre

Ambulance/transport vehicle have 1 OB/RR

adequate arrangement for Oxygen
 Ambulance/transport vehicle have 1 OB/RR
dedicated rescue kit including "
essential supplies kit", emergency
drug kit

NBSU has system to periodic check 1 SI/RR

of ambulances/transport vehicle
by driver/paramedic staff and
counter checked by NBSU staff

Transfer of new-born's Ambulance 1 SI/RR

/new-born transport vehicle is
accompanied by trained Medical
Practitioner

Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 6 12
ME E12.5 There is established procedure Consent is taken before 1 RR
for transfusion of blood transfusion
Patient's identification is verified 1 SI/OB
before transfusion
Blood is kept at optimum 1 RR
temperature before transfusion

Blood transfusion is monitored 1 SI/RR

and regulated by qualified person

Blood transfusion note is written in 1 RR

new-born record
ME E12.6. There is a established procedure Any major or minor transfusion 1 RR The event is communicated to
for monitoring and reporting reaction is recorded and reported Paediatrician Incharge as well
Transfusion complication at BSU as to the in charge of concern
Blood storage unit.

Standard E15 The facility has defined and established procedures for end of life care and death 8 16
ME E15.1 Death of admitted patient is Facility has a standard 1 SI
adequately recorded and procedure which respects
communicated sensitivities & sentiments to
communicate death to relatives

NBSU has system for conducting 1 RR/SI

grievance counselling of parents in
case of new-born mortality

Death note is written on new-born 1 RR

record
ME E15.2 The facility has standard Death note including efforts done 1 SI/RR
procedures for handling the for resuscitation is noted in new-
death in the hospital born record

Procedure to declare death for 1 SI/RR

brought in dead cases exists in
facility.

Death summary is given to new- 1 SI/RR

born attendant quoting the
immediate cause and underlying
cause if possible

ME E15.3 The facility has standard operating Patients Relatives are informed 1 SI/RR
procedure for end of life support clearly about the deterioration in
health condition of Patients

There is a procedure to allow new- 1 SI/OB

born relative/Next of Kin to
observe new-born in last hours

Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines 2 4
ME E19.3 Management of Low birth weight Adherence to clinical protocol 1 SI/RR Competence testing
new-born's is done as per
guidelines

ME E19.4 Management of neonatal Adherence to clinical protocol 1 SI/RR Competence testing

asphyxia, jaundice and sepsis is
done as per guidelines

Area of Concern - F Infection Control 61 122

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital
4 8
ME F1.4 There is Provision of Periodic There is a procedure for
associated infection
1 SI/RR Hepatitis B, Tetanus Toxoid etc.
Medical Check-up and immunization of the staff
immunization of staff
Periodic medical check-ups of the 1 SI/RR
staff
ME F1.5 The facility has established Regular monitoring of infection 1 SI/RR Hand washing and infection
procedures for regular monitoring control practices control audits are done at
of infection control practices periodic intervals

ME F1.6 The facility has defined and Check if Doctors are aware of 1 SI/RR
established antibiotic policy Hospital Antibiotic Policy
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 12 24
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB FNBC guideline: Each unit
provided at point of use Facility at Point of Use should have at least 1 wash
basin for every 5 beds

Availability of running Water 1 OB/SI Open the tap. Ask the Staff,
water is available 24*7

Availability of antiseptic soap with 1 OB/SI Check for availability/ Ask staff
soap dish/ liquid antiseptic with if the supply is adequate and
dispenser. uninterrupted

Availability of Alcohol based Hand 1 OB/SI Check for availability/ Ask

rub staff for regular supply. Hand
rub dispenser are provided
adjacent to bed

Display of Hand washing 1 OB Prominently displayed above

Instruction at Point of Use the hand washing facility ,
preferably in Local language

Availability of elbow operated taps 1 OB

Hand washing sink is wide and 1 OB

deep enough to prevent splashing
and retention of water
ME F2.2 The facility staff is trained in Adherence to 6 steps of Hand 1 SI/OB Ask for demonstration
correct hand washing practices washing
and they adhere to standard hand
washing practices

Staff is aware of occasion for hand 1 SI

washing
Mothers are practicing wash hand 1 PI/OB
washing with soap
ME F2.3 The facility ensures standard Availability of Antiseptic Solutions 1 OB
practices and materials for
antisepsis
Procedure for proper cleaning of 1 OB/SI e.g. before giving IM/IV
site with antisepsis injection, drawing blood,
putting Intravenous and
urinary catheter

Standard F3 The facility ensures standard practices and materials for Personal protection 7 14
ME F3.1 The facility ensures adequate Clean gloves are available at point 1 OB/SI Hand washing between each
personal protection Equipment as of use new-born & change of gloves
per requirements
Availability of Mask 1 OB/SI
Availability of gown/ Apron 1 OB/SI Staff and visitors
Availability of shoe cover 1 OB/SI Staff and visitors
Availability of Caps 1 OB/SI Staff and visitors
ME F3.2 The facility staff adheres to No reuse of disposable gloves, 1 OB/SI
standard personal protection masks, caps and aprons.
practices
Compliance to correct method of 1 SI
wearing and removing the gloves

Standard F4 The facility has standard procedures for processing of equipment and instruments 13 26
ME F4.1 The facility ensures standard Cleaning & Decontamination of 1 SI/OB Cleaning of Radiant warmers
practices and materials for new-born care Units and Bassinets with detergent
decontamination and cleaning of and water
instruments and procedure areas

Proper Decontamination of 1 SI/OB Decontamination for

instruments after use Thermometer, Stethoscope,
Suction Apparatus, Ambu bag
with 70% Alcohol or detergent
& water, as applicable

Contact time for decontamination 1 SI/OB 10 minutes

is adequate
Cleaning of instruments after 1 SI/OB Cleaning is done with
decontamination detergent and running water
after decontamination

Proper handling of Soiled and 1 SI/OB No sorting ,Rinsing or sluicing

infected linen at Point of use/ new-born care
area

Staff is aware of correct procedure 1 SI/OB

of making chlorine solution

ME F4.2 The facility ensures standard Equipment and instruments are 1 OB/SI Autoclaving/HLD/Chemical
practices and materials for sterilized after each use as per Sterilization
disinfection and sterilization of requirement
instruments and equipment

High level Disinfection of 1 OB/SI Ask staff about method and

instruments/equipment is done time required for boiling
as per protocol

Autoclaving of instruments is done 1 OB/SI Ask staff about temperature,

as per protocols pressure and time

Chemical sterilization of 1 OB/SI Ask staff about method,

instruments/equipment is done as concentration and contact
per protocols time required for chemical
sterilization

Autoclaved dressing material is 1 OB/SI

used
There is a procedure to ensure the 1 OB/SI
traceability of sterilized packs

Sterility of autoclaved packs is 1 OB/SI Sterile packs are kept in clean,

maintained during storage dust free, moist free
environment.

Standard F5 Physical layout and environmental control of the new-born care areas ensures infection prevention 11 22
ME F5.1 Layout of the department is Floors and wall surfaces of NBSU 1 OB
conducive for the infection control are easily cleanable
practices

ME F5.2 The facility ensures availability of Availability of disinfectant as per 1 OB/SI Chlorine solution,
standard materials for cleaning and requirement Gluteraldehye, carbolic acid
disinfection of new-born care areas

ME F5.3 The facility ensures standard Staff is trained for spill 1 SI/RR
practices are followed for the management
cleaning and disinfection of new-
born care areas

Cleaning of new-born care area 1 SI/RR

with detergent solution
Staff is trained for preparing 1 SI/RR
cleaning solution as per standard
procedure

Standard practice of mopping and 1 OB/SI Unidirectional mopping from

scrubbing are followed inside out
Cleaning equipment like broom 1 OB/SI Any cleaning equipment
are not used in new-born care leading to dispersion of dust
area. particles in air should not be
used.

Use of three bucket system for 1 OB/SI

mopping
External foot wares are restricted 1 OB

ME F5.4 The facility ensures segregation Isolation and barrier nursing 1 OB/SI
infectious patients procedure are followed for septic
cases
ME F5.5 The facility ensures air quality of NBSU has system to maintain 1 OB Ventilation can be provided in
high risk area ventilation and its environment two ways: exhaust only and
should be dust free supply-and-exhaust. Exhaust
fans pull stale air out of the
unit while drawing fresh air in
through cracks, windows or
fresh air intakes. Exhaust-only
ventilation is a good choice for
units that do not have existing
ductwork to distribute heated
or cooled air

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and
14 28
ME F6.1
hazardous Waste.
Facility Ensures segregation of Bio Availability of colour coded bins at
1 OB
Medical Waste as per guidelines point of waste generation

Availability of plastic colour coded 1 OB

plastic bags
Segregation of different category 1 OB/SI
of waste as per guidelines

Display of work instructions for 1 OB

segregation and handling of
Biomedical waste

There is no mixing of infectious 1 OB

ME F6.2 Facility ensures management of
sharps as per guidelines
and general waste
Availability of functional needle 1 OB
cutters
Availability of puncture proof box 1 OB Should be available nears the
point of generation like
nursing station and injection
room

Disinfection of sharp before 1 OB/SI Disinfection of syringes is not

disposal done in open buckets
Staff is aware of contact time for 1 SI
disinfection of sharps
Availability of post exposure 1 OB/SI Ask if available. Where it is
prophylaxis stored and who is in charge of
that.

Staff knows procedure in event of 1 SI/RR Staff knows what to do in case

needle stick injury of sharp injury & Whom to
report. See if any reporting has
been done

ME F6.3 Facility ensures transportation Check that bins are not overfilled 1 SI
and disposal of waste as per
guidelines
Disinfection of liquid waste before 1 SI/OB
disposal
Staff aware of mercury spill 1 SI
management
Area of Concern - G Quality Management 38 76
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality. 3 6
ME G3.1 The facility has established There is system daily round by 1 SI/RR
internal quality assurance Paediatrician/matron/ hospital in
programme in the departments charge for monitoring of services

ME G3.3 The facility has established Departmental checklist is used 1 SI/RR

system for use of check lists in for monitoring and quality
the department and services assurance
Staff is designated for filling and 1 SI
monitoring of these checklists

Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key
21 42
processes.
ME G4.1 Departmental standard operating Standard operating procedure for
1 RR
procedures are available department has been prepared
and approved

Current version of SOP are 1 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures NBSU has documented procedure 1 RR
adequately describes process and for receiving and assessment of
procedures the patient

NBSU has documented procedure 1 RR

for admission of the new born

NBSU has documented procedure 1 RR

for discharge of the new-born
from unit

NBSU has documented procedure 1 RR

for triage of new born

NBSU has documented procedure 1 RR

for assessment and treatment of
new born emergency signs

NBSU has documented procedure 1 RR

for neonatal transportation and
referral

NBSU has documented procedure 1 RR

for clinical assessment and
reassessment of the new-born and
doctor follows it

NBSU has documented procedure 1 RR

for key clinical protocols

NBSU has documented procedure 1 RR

for preventive- break down
maintenance and calibration of
equipment

NBSU has documented system for 1 RR

storage, retaining ,retrieval of
NBSU records

NBSU has documented procedure 1 RR

for Maintenance of infrastructure
of NBSU
 NBSU has documented procedure 1 RR
for thermoregulation of new born

NBSU has documented procedure 1 RR

for drugs,intravenous,and fluid
management and nutrition
management of new born's

NBSU has documented procedure 1 RR

for resuscitation of new born if
required

NBSU has documented procedure 1 RR

for infection control practices

NBSU has documented procedure 1 RR

for inventory management

NBSU has documented procedure 1 RR

for entry of parents /visitor

ME G4.3 Staff is trained and aware of the Check if staff are aware of relevant 1 SI/RR
procedures written in SOPs part of SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 1 OB STP for phototherapy, Grading
Point of use are displayed and management of
hypothermia, Expression of
milk\, Monitoring of babies
receiving I/V, Precaution for
phototherapy, Management of
Hypoglycaemia, housekeeping
protocols, Administration of
commonly used drugs,
assessment of neonatal sepsis,
Assessment of Jaundice,
Temperature maintenance etc.

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription
5 10
ME G5.1 The facility conducts periodic Internal assessment is done at
audit1 RR/SI
internal assessment periodic interval
ME G5.2 The facility conducts the periodic There is a procedure to conduct 1 RR/SI
prescription/ medical/death New born Death audit
audits
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive actions Corrective and preventive action 1 RR/SI
are taken to address issues, taken
observed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objective for NBSU are 1 RR/SI
quality objectives and key defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check if staff is aware of quality 1 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services

5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 16 32
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 8
ME H1.1 Facility measures productivity Bed Occupancy Rate 1 RR
Indicators on monthly basis
ME H1.2 The Facility measures equity Proportion of female babies 1 RR
indicators periodically admitted
Male: Female LAMA ratio 1 RR
Proportion of BPL Patients 1 RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 6 12
ME H2.1 Facility measures efficiency Proportion of low birth weight 1 RR No. of low birth weight babies
Indicators on monthly basis babies (< 2500 gm but not < 1800 gm)

Down time of Critical Equipment 1 RR

Bed Turnover Rate 1 RR

Referral Rate 1 RR
Survival rate 1 RR
No. of drug stock out in NBSU 1 RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 5 10
ME H3.1 Facility measures Clinical Care & Average waiting time for initial 1 RR
Safety Indicators on monthly basis assessment of new-born

Proportion of new-born deaths 1 RR

Average length of stay 1 RR

No. of Adverse events reported 1 RR Baby theft, wrong drug
administration, needle stick
injury, absconding patients
etc.

No of New-born Resuscitated 1 RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 1 2
ME H4.1 Facility measures Service Quality LAMA Rate 1 RR
Indicators on monthly basis

NBSU Score Card

NBSU Score 50
Area of Concern wise Score
A Service Provision 50
B Patient's Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50

Obtained Maximum Percent 5

A 12 24 50
B 26 52 50
C 43 86 50
D 44 88 50
E 81 162 50
F 61 122 50
G 38 76 50
H 16 32 50
Total 321 642 50
 National Quality Assurance Standards for CHC 0 1 2
Checklist for Operation Theatre 6
Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Area of Concern - A Service Provision 9 18

Standard A1 Facility Provides Curative Services 4 8
ME A1.2 The facility provides General Availability of General Surgery 1 SI/OB Incision and drainage, Hernia,
Surgery services procedures Hydrocele, Appendicitis,
Haemorrhoids, Fistula and stitching
of injuries.

ME A1.3 The facility provides Obstetrics & Availability of Gynaecology 1 SI/OB D & E, LSCS, Hysterectomy.
Gynaecology Services procedures
ME A1.9 Services are available for the time OT Services are available 24X7 1 SI/RR
period as mandated
ME A1.10 The facility provides Accident & OT services are available for 1 SI/OB
Emergency Services emergency cases.
Standard A2 Facility provides RMNCHA Services 5 10
ME A2.1 The facility provides Reproductive Availability of Post partum 1 SI/OB Tubal ligation
health Services sterilization services
Availability of Abortion services. 1 SI/OB

ME A2.2 The facility provides Maternal Availability of C-section services 1 SI/OB

health Services
ME A2.3 The facility provides New-born Availability of New born 1 SI/OB
health Services resuscitation
Availability of essential new born 1 SI/OB
care

Area of Concern - B Patient Rights 21 42

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities 4 8
ME B1.1 The facility has uniform and user- Availability of departmental 1 OB (Numbering, main department and
friendly signage system signage's internal-section signage)
Signage for restricted area are 1 OB
displayed
Zones of OT are marked 1 OB
ME B1.6 Information is available in local Signage's and information are 1 OB
language and easy to understand available in local language

Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of
3 6
physical, economic,1cultural or social status.
ME B2.1 Services are provided in manner
Availability of female staff if a male OB/SI Availability of female staff in pre
that are sensitive to gender doctor examination/ conduct and post operative room
surgery of a female patient

ME B2.3 Access to facility is provided Availability of Wheel chair or 1 OB

without any physical barrier & stretcher for easy Access to the OT
and friendly to people with
disabilities

Availability of ramps with railing 1 OB

Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information. 5 10
ME B3.1 Adequate visual privacy is Availability of screen between OT 1 OB
provided at every point of care table
Patients are properly 1 OB
draped/covered before and after
procedure.

ME B3.2 Confidentiality of patients records Patient Records are kept at secure 1 SI/OB
and clinical information is place beyond access to general
maintained staff/visitors

ME B3.3 The facility ensures the Behaviour of staff is empathetic 1 PI/OB

behaviours of staff is dignified and and courteous
respectful, while delivering the
services

ME B3.4 The facility ensures privacy and Privacy and Confidentiality of HIV 1 SI/OB
confidentiality to every patient, cases
especially of those conditions
having social stigma, and also
safeguards vulnerable groups

Privacy and Confidentiality of 1

Hysterectomy cases
Standard B4 Facility has defined and established procedures for informing and involving patient about medical condtion and involving them 4 8
ME B4.1 in treatement
There is established procedures Informed/Written planning,
consent is taken and facilitates
1 informed decision making
SI/RR
for taking informed consent before any surgery
before treatment and procedures

Anaesthesia Consent for OT 1 SI/RR

ME B4.4 Information about the treatment Patients attendant is informed 1 PI/SI
is shared with patients or about clinical condition and
attendants, regularly treatment being provided

Patient/Attendant is informed 1 PI/SI

about Possible outcomes/risks
involved/alternatives available of
surgery

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital
5 10
ME B5.1 The facility provides cashlessAll surgical procedures are free of
services.
1 PI/SI JSSK
services to pregnant women, cost for JSSK beneficiaries
mothers and neonates as per
prevalent government schemes

All drugs and consumables are free 1

ME B5.2 The facility ensures that drugs
prescribed are available at
Pharmacy and wards
for JSSK beneficiaries
Check that patient/attendants 1 PI/SI
have not spent money on
purchasing drugs & consumable's
from outside.

ME B5.3 It is ensured that facilities for the Check that patient/attendants 1 PI/SI
prescribed investigations are have not spent money on
available at the facility Diagnostic from outside.

ME B5.4 The facility provide free of cost Surgical services are free for BPL 1 PI/SI/RR
treatment to Below poverty line patients
patients without administrative
hassles

Area of Concern - C Inputs 81 162

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 17 34
ME C1.1 Departments have adequate Adequate space for 1 OB
space as per patient or work load accommodating surgical load

Waiting area for attendants 1 OB

ME C1.2 Patient amenities are provide as Seating arrangement for patient 1 OB
per patient load attendant
ME C1.3 Department has layout and Demarcated Protective Zone 1 OB
demarcated areas as per
functions
Demarcated Clean Zone 1 OB
Demarcated sterile Zone 1 OB
Demarcated disposal Zone 1 OB
Availability of Changing Rooms 1 OB
Availability of Pre Operative/Post 1 OB
operative Room

Availability of Scrub area 1 OB

Availability of earmarked area for 1 OB
new-born Corner
Availability of Autoclave room/ 1 OB
TSSU
Availability of dirty utility area 1 OB
Availability of store 1 OB
ME C1.4 The facility has adequate Corridors are wide enough for 1 OB 2-3 meters
circulation area and open spaces movement of trolleys
according to need and local law

ME C1.5 The facility has infrastructure for Availability of functional telephone 1 OB

intramural and extramural and Intercom Services
communication
ME C1.7 The facility and department are Unidirectional flow of goods and 1 OB No criss cross of infectious and
planned to ensure structure services sterile goods
follows the function/processes
(Structure commensurate with
the function of the hospital)

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and furniture like
safety of the infrastructure properly secured cupboards, cabinets, and heavy
equipment , hanging objects are
properly fastened and secured

ME C2.2 The facility ensures safety of OT does not have temporary 1 OB

electrical establishment connections and loosely hanging
wires

ME C2.3 Physical condition of the buildings Floors of the OT are non slippery 1 OB
is safe for providing patient care and even

Walls and floor of the OT covered 1 OB

with joint less tiles
Windows and vents if any in the OT 1 OB
are intact and sealed
ME C2.4 The facility has plan for OT has fire exit to permit safe 1 OB/SI
prevention of fire escape to its occupant at time of
fire

Check the fire exits are clearly 1 OB

visible and routes to reach exit are
clearly marked.

ME C2.5 The facility has adequate fire OT room has installed fire 1 OB
fighting Equipment Extinguisher that are capable of
fighting A,B,C Type of Fire

Check the expiry date for fire 1 OB/RR

extinguisher is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned

ME C2.6 The facility has a system of Check for staff competencies for 1 SI/RR
periodic training of staff and operating fire extinguisher and
conducts mock drills regularly for what to do in case of fire
fire and other disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 19 38
ME C3.1 The facility has adequate Availability of Obs & Gynae 1 OB/RR As per case load
specialist doctors as per service Surgeon
provision
Availability of trained surgeon for 1 OB/RR Minilap - MBBS trained in
Minilap/ Laparoscopic/NSV procedure
Laparoscopic

Availability of anaesthetist 1 OB/RR As per case load

ME C3.3 The facility has adequate nursing Availability of Nursing staff 1 OB/RR/SI As per patient load , at least two
staff as per service provision and
work load
ME C3.4 The facility has adequate Availability of OT 1 OB/SI
technicians/paramedics as per attendant/assistant
requirement
ME C3.6 The staff has been provided Advance Life support 1 SI/RR
required training / skill sets
OT Management 1 SI/RR
IMEP training. 1 SI/RR
Infection control and hand hygiene 1 SI/RR

Training on processing/sterilization 1 SI/RR

of equipment

Patient Safety 1 SI/RR

PPIUCD insertion 1 SI/RR
Family planning counselling 1 SI/RR
Laparoscopic surgery/Minilap 1 SI/RR
NSV 1 SI/RR
ME C3.7 The Staff is skilled as per job Staff is skilled for resuscitation and 1 SI/RR
description intubation
Nursing Staff is skilled for 1 SI/RR
maintaining clinical records
Staff is Skilled to operate OT 1 SI/RR
equipment
Staff is skilled for processing and 1 SI/RR
packing instrument
Standard C4 Facility provides drugs and consumables required for assured list of services. 15 30
ME C4.1 The departments have availability Availability of medical gases 1 OB/RR Availability of Oxygen Cylinders
of adequate drugs at point of use /Nitrogen Gas supply

Availability of Uterotonic Drugs 1 OB/RR

Availability of Antibiotics 1 OB/RR Inj Ampicillin, Inj. metronidazole Inj

Gentamycin,
Availability of Antihypertensive 1 OB/RR Injectable Hydralazine

Availability of analgesics and 1 OB/RR Tab Paracetamol Ibuprofen, Inj

antipyretics
Availability of IV Fluids
Availability of anaesthetics
Diclofenac, Sodium
1 OB/RR IV fluids, Normal saline, Ringer's
lactate,
1 OB/RR Halothane, Thiopentone,
Lignocaine, Succinylcholine,
Ketamine, Nitrous Oxide, Sodium

Availability of emergency drugs
1 OB/RR Inj Adrenaline, Inj Magsulf 50%, Inj
Calcium gluconate 10%, Inj
Hydrocortisone, Succinate, Inj
Diazepam, Inj Pheniramine
maleate, inj Cerboprost, Inj Fort
win, Inj Phenergan,
Betamethasone, Inj Hydralazine,
Nifidepin, Methyldopa

Availability of drugs for new-born 1 OB/RR Vitamin K

ME C4.2 The departments have adequate Availability of dressings and 1 OB/RR

consumables at point of use Sanitary pads

Availability of syringes and IV Sets 1 OB/RR

Availability of Antiseptic Solutions 1 OB/RR

Availability of consumables for 1 OB/RR

new born care
Availability of personal protective 1 OB/RR
equipment
ME C4.3 Emergency drug trays are Emergency drug tray is maintained 1 OB/RR
maintained at every point of care, in OT/pre and post operative room
where ever it may be needed

Standard C5 The facility has equipment & instruments required for assured list of services. 20 40
ME C5.1 Availability of equipment & Availability of functional 1 OB BP apparatus, Thermometer, Pulse
instruments for examination & Equipment &Instruments for Oxy meter, Multipara meter , PV
monitoring of patients examination & Monitoring Set

ME C5.2 Availability of equipment & Availability of functional 1 OB LSCS Set, Cervical Biopsy Set, MVA
instruments for treatment instruments for Gynae and set, D&C Set, Defibrillator,
procedures, being undertaken in obstetrics Nebulizers
the facility

Availability of functional 1 OB Radiant warmer, Baby tray with

equipment/ Instruments for New Two pre warmed towels/sheets for
Born Care wrapping the baby, mucus
extractor, bag and mask (0 &1 no.),
sterilized thread for cord/cord
clamp, nasogastric tube

Availability of functional General 1 OB General Surgical Instruments for

surgery equipment Piles, Fistula, & Fissures. Surgical
set for Hernia & Hydrocele, Cautery

Operation Table with 1 OB

Trendelenburg facility
Minilap instruments 1 OB
Laparoscopic set 1 OB
NSV sets 1 OB
Instruments for Laparoscopy 1 OB
ME C5.3 Availability of equipment & Availability of Point of care 1 OB Portable X-Ray Machine,
instruments for diagnostic diagnostic instruments Glucometer, HIV rapid diagnostic
procedures being undertaken in kit. Uristix.
the facility

ME C5.4 Availability of equipment and
instruments for resuscitation of
patients and for providing
intensive and critical care to
patients
Availability of functional 1 OB Ambu bag, Oxygen, Suction
Instruments for Resuscitation machine , laryngoscope, ET Tube,
defibrillator

Availability of functional 1 OB Boyles apparatus, Bains Circuit or

anaesthesia equipment Soda lime absorbent in close circuit

ME C5.5 Availability of Equipment for Availability of equipment for 1 OB Crash cart/Drug trolley, instrument
Storage storage for drugs trolley, dressing trolley

Availability of equipment for 1 OB Instrument cabinet and racks for

storage of sterilized items storage of sterile items (not inside
OT)

ME C5.6 Availability of functional Availability of equipment for 1 OB Buckets for mopping, Separate
equipment and instruments for cleaning mops for patient care area and
support services circulation area duster, waste
trolley, Deck brush

Availability of equipment for 1 OB Autoclave

ME C5.7 Departments have patient
furniture and fixtures as per load
and service provision
TSSU
Availability of functional OT light 1 OB Shadow less , Ceiling and Stand
Model, Focus Lamp
Availability of attachment/ 1 OB Hospital grad mattress , IV stand,
accessories with OT table Bed pan
Availability of Fixtures 1 OB Electrical panel for anaesthesia
machine, cautery, monitors etc., X-
ray view box

Availability of furniture 1 OB Cupboard, table for preparation of

medicines, chair, racks,

Area of Concern - D Support Services 52 104

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 8 16
ME D1.1 The facility has established All equipment are covered under 1 SI/RR
system for maintenance of critical the AMC including preventive
Equipment maintenance
 There is system of timely 1 SI/RR
corrective break down
maintenance of the equipment

There has system to label 1 OB/RR

Defective/Out of order equipment
and stored appropriately until it
has been repaired

Staff is skilled for trouble shooting 1 SI/RR

in case equipment malfunction

Periodic cleaning, inspection and 1 SI/RR

maintenance of the equipment is
done by the operator

ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR Boyles apparatus, cautery, BP
procedure for internal and instrument are calibrated apparatus, autoclave etc.
external calibration of measuring
Equipment

There is system to label/ code the 1 OB/ RR

equipment to indicate status of
calibration/ verification when
recalibration is due

ME D1.3 Operating and maintenance Up to date instructions for 1 OB/SI

instructions are available with the operation and maintenance of
users of equipment equipment are readily available
with staff.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care 12 24
ME D2.1 1areas SI/RR
There is established procedure for There is established system of Stock level are daily updated
forecasting and indenting of drugs timely indenting of consumables Requisition are timely placed
and consumables and drugs

ME D2.3 The facility ensures proper Drugs are stored in 1 OB

storage of drugs and consumables containers/tray/crash cart and are
labelled

Empty and filled cylinders are 1 OB

labelled
ME D2.4 The facility ensures management Expiry dates are maintained at 1 OB/RR
of expiry and near expiry drugs emergency drug tray, crash cart,
anaesthesia drug trolley.

No expired drug is found 1 OB/RR

ME D2.5 The facility has established
procedure for inventory
management techniques
There is practice of calculating and 1 SI/RR
maintaining buffer stock
Department maintained stock and 1 RR/SI
expenditure register of drugs and
consumables

ME D2.6 There is a procedure for periodically There is procedure for replenishing 1 SI/RR
replenishing the drugs in patient care drug tray /crash cart
areas

There is no stock out of drugs 1 OB/SI

ME D2.7 There is process for storage of Temperature of refrigerators are 1 OB/RR Check for temperature charts are
vaccines and other drugs, kept as per storage requirement maintained and updated
requiring controlled temperature and records are maintained periodically

ME D2.8 There is a procedure for secure
storage of narcotic and
psychotropic drugs
Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable
ME D3.2 Hospital infrastructure is
adequately maintained
Narcotic and psychotropic drugs 1 OB/SI
are kept in lock and key
Anaesthetic agents are kept at 1 OB/SI
secured place
18 36
environment to staff, patients and visitors.
Interior of patient care areas are 1 OB
plastered & painted
Check to ensure that there is no 1 OB
seepage , cracks, chipping of
plaster

Window panes , doors and other 1 OB

fixtures are intact
OT Table are intact and without 1 OB
rust
Mattresses are intact and clean 1 OB
ME D3.3 Patient care areas are clean and Floors, walls, roof, roof tops, sinks 1 OB All area are clean with no
hygienic patient care and circulation areas dirt,grease,littering and cobwebs
are Clean

Surface of furniture and fixtures 1 OB

are clean
Toilets are clean with functional 1 OB
flush and running water

ME D3.4. The facility has policy of removal No condemned/Junk material in 1 OB

of condemned junk material the OT

ME D3.5. The facility has established No pests are noticed 1 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate Illumination at OT table 1 OB 100000 lux
illumination level at patient care
areas
Adequate Illumination at pre 1 OB General area 300 Lux
operative and post operative area

ME D3.7 The facility has provision of Entry to OT is restricted 1 OB

restriction of visitors in patient
areas
Warning light is provided outside 1 OB/SI
OT and its been used when OT is
functional

ME D3.8 The facility ensures safe and Temperature is maintained and 1 SI/RR 20-250C, ICU has functional room
comfortable environment for record of same is kept thermometer and temperature is
patients and service providers regularly maintained

Humidity is maintained at desirable 1 SI/RR 50-60%

level
Positive pressure is maintained in 1 SI/RR
OT
ME D3.9 The facility has security system in Security arrangement at OT 1 OB
place at patient care areas

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 6 12
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for potable water in all functional
areas

Availability of Hot water supply 1 OB/SI

ME D4.2 The facility ensures adequate Availability of power back up in OT 1 OB/SI 2 tier backup with UPS
power backup in all patient care
areas as per load
Availability of UPS 1 OB/SI
Availability of Emergency light 1 OB/SI
ME D4.3 Critical areas of the facility ensures Availability of Centralized /local 1 OB
availability of oxygen, medical gases piped Oxygen, nitrogen and
and vacuum supply vacuum supply

Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patients and clean Linen to all admitted patients. 4 8
ME D5.4 The facility has adequate sets of OT has facility to provide sufficient 1 OB/RR Drape, draw sheet, cut sheet and
linen and clean linen for surgical patient gown

OT has facility to provide linen for 1 OB/RR

staff
ME D5.5 The facility has established Linen is changed after each 1 OB/RR
procedures for changing of linen procedure
in patient care areas
ME D5.6 The facility has standard procedures There is system to check the 1 SI/RR
for handling , collection, cleanliness and Quantity of the
transportation and washing of linen linen received from laundry

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating 4 8
ME D9.1 The facility has established job procedures.
Staff is aware of their roles and
1 SI
description as per govt guidelines responsibilities

ME D9.2 The facility has a established There is procedure to ensure that 1 RR/SI Check for system for recording
procedure for duty roster and staff is available on duty as per time of reporting and relieving
deputation to different duty roster (Attendance register/ Biometrics
departments etc.)

There is designated in charge for 1 SI

department
ME D9.3 The facility ensures the Doctor, nursing staff and support 1 OB
adherence to dress code as staff adhere to their respective
mandated by its administration / dress code
the health department

Area of Concern - E Clinical Services 75 150

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 2 4
ME E3.1 Facility has established procedure There is procedure of handing over 1 SI/RR
for continuity of care during while receiving patient from OT to
interdepartmental transfer indoor and ICU

There is a procedure for 1 RR/SI

consultation of the patient with
other specialists with in the
hospital

Standard E4 The facility has defined and established procedures for nursing care 5 10
ME E4.1 Procedure for identification of There is a process for ensuring the 1 OB/SI Patient id band/ Patient ID
patients is established at the identification before any clinical No./verbal confirmation etc.
facility procedure

ME E4.2 Procedure for ensuring timely and There is a process to ensue the 1 SI/RR Verbal orders are rechecked before
accurate nursing care as per accuracy of verbal/telephonic administration
treatment plan is established at the orders
facility

ME E4.3 There is established procedure of Patient hand over is given during 1 SI/RR
patient hand over, whenever staff the change in the shift
duty change happens
Handover register is maintained 1 RR

ME E4.5 There is procedure for periodic
monitoring of patients
Standard E5
ME E5.1 The facility identifies vulnerable
patients and ensure their safe care
Patient Vitals are monitored and 1 RR/SI Check for use of multi parameter
recorded periodically
Facility has a procedure to identify high risk and vulnerable patients. 2 4
Vulnerable patients are identified 1 OB/SI Check the measure taken to
and measures are taken to protect prevent new born theft, baby
them from any harm sweeping and baby fall

ME E5.2 The facility identifies high risk High risk patients are identified 1 OB/SI HIV, Infectious cases
patients and ensure their care, as per and treatment given on priority
their need

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their
rational use. 3 6
ME E6.1 Facility ensured that drugs are Check for BHT if drugs are 1 RR
prescribed in generic name only prescribed under generic name
only

ME E6.2 There is procedure of rational use of Check staff is aware of the drug 1 SI/RR
drugs regime and doses as per STG

Check BHT that drugs are 1 RR

prescribed as per STG
Standard E7 Facility has defined procedures for safe drug administration 10 20
ME E7.1 There is process for identifying High alert drugs available in 1 SI/OB Electrolytes like Potassium
and cautious administration of department are identified chloride, Opioids, Neuro muscular
high alert drugs blocking agent, Anti thrombolytic
agent, insulin, warfarin, Heparin,
Adrenergic agonist etc. as
applicable

Maximum dose of high alert drugs 1 SI/RR Value for maximum doses as per
are defined and communicated age, weight and diagnosis are
available with nursing station and
doctor

There is process to ensure that 1 SI/RR A system of independent double

right doses of high alert drugs are check before administration, Error
only given prone medical abbreviations are
avoided

ME E7.2 Medication orders are written Every Medical advice and 1 RR

legibly and adequately procedure is accompanied with
date , time and signature

Check for the writing, is it 1 RR/SI

comprehendible by the clinical
staff
ME E7.3 There is a procedure to check Drugs are checked for expiry 1 OB/SI Check for availability of magnifying
drug before administration/ and other inconsistency before glass.
dispensing administration
Check single dose vial are not used 1 OB Check for any open single dose vial
for more than one dose with left over content intended to
be used later on

Check for separate sterile needle is 1 OB

used every time for multiple dose In multi dose vial needle is not left
vial in the septum

Any adverse drug reaction is 1 RR/SI

recorded and reported
ME E7.4 There is a system to ensure right Administration of medicines 1 SI/OB
medicine is given to right patient done after ensuring right
patient, right drugs , right dose,
right route, right time

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 8 16
ME E8.1 All the assessments, re- Records of Monitoring/ 1 RR PAC, Intraoperative monitoring
assessment and investigations are Assessments are maintained
recorded and updated
ME E8.2 All treatment plan Treatment plan, first orders are 1 RR Treatment prescribed in nursing
prescription/orders are recorded written on BHT records
in the patient records.

ME E8.4 Procedures performed are written Operative Notes are Recorded 1 RR Name of person in attendance
on patients records during procedure, Pre and post
operative diagnosis, Procedures
carried out, length of procedures,
estimated blood loss, Fluid
administered, specimen removed,
complications etc.

Anaesthesia Notes are Recorded 1 RR

ME E8.5 Adequate form and formats are Standard Formats available 1 RR/OB Consents, surgical safety check list
available at point of use
ME E8.6 Register/records are maintained Registers and records are 1 RR OT Register, Schedule, Infection
as per guidelines maintained as per guidelines control records, autoclaving
records etc.

All register/records are identified 1 RR

and numbered
ME E8.7 The facility ensures safe and Safe keeping of patient records 1 RR
adequate storage and retrieval of
medical records
Standard E12 The facility has defined and established procedures for Blood Storage Management and Transfusion. 7 14
ME E12.4 There is established procedure for Availability of blood units in case of 1 RR/SI The blood is ordered for the patient
issuing blood emergency with out replacement according to the MSBOS (Maximum
Surgical Blood Order Schedule)

ME E12.5 There is established procedure for Patient's identification is verified 1 SI/OB

transfusion of blood before transfusion
Blood is kept on optimum 1 RR
temperature before transfusion

Blood transfusion is monitored and 1 SI/RR

regulated by qualified staff

Blood transfusion note is written in 1 RR

patient's record
ME E12.6 There is a established procedure Any major or minor transfusion 1 RR
for monitoring and reporting reaction is recorded and reported
Transfusion complication to responsible staff

Staff is competent to identify 1 RR/SI

transfusion reaction and its
management

Standard E13 Facility has established procedures for Anaesthetic Services 10 20

ME E13.1 Facility has established There is procedure to ensure that 1 RR/SI
procedures for Pre Anaesthetic PAC has been done before surgery
Check up and maintenance of
records

There is procedure to review 1 RR/SI

findings of PAC
ME E13.2 Facility has established Anaesthesia plan is documented 1 RR
procedures for monitoring during before entering into OT
anaesthesia
Food intake status of Patient is 1 RR/SI
checked
Patients vitals are recorded during 1 RR Heart rate , cardiac rate , BP, O2
anaesthesia Saturation,
Airway security is ensured 1 RR/SI Breathing system is securely and
correctly assembled
Potency and level of anaesthesia is 1 RR/SI
monitored
Anaesthesia notes are recorded 1 RR Check for the adequacy

Any adverse Anaesthesia Event is 1 RR

recorded and reported
ME E13.3 Facility has established Post anaesthesia status is 1 RR/SI
procedures for Post Anaesthesia monitored and documented
care
Standard E14 Facility has defined and established procedures for Operation Theatre and Surgical Services 12 24
ME E14.1 Facility has established There is procedure OT Scheduling 1 RR/SI Schedule is prepared in
procedures OT Scheduling consonance with available OT
house and patients requirement

ME E14.2 Facility has established Patient evaluation before surgery 1 RR/SI Vitals , Patients fasting status etc.
procedures for Preoperative care is done and recorded

Antibiotic Prophylaxis given as 1 RR/SI

indicated
Tetanus Prophylaxis is given if 1 RR/SI
Indicated
There is a process to prevent 1 RR/SI Surgical Site is marked before
wrong site and wrong surgery entering into OT
Surgical site preparation is done as 1 RR/SI Cleaning , Asepsis and Draping
per protocol
ME E14.3 Facility has established Surgical Safety Check List is used 1 RR/SI Check for Surgical safety check list
procedures for Surgical Safety for each surgery has been used for surgical
procedures

ME E14.4 Facility has established
procedures for Post operative
care
Standard E17
ME E17.2 There is an established procedure pre operative care
for assisted and C-section
deliveries per scope of services.
ME E17.3 There is established procedure for Management of PIH/Eclampsia
management of Obstetrics
Emergencies as per scope of
services.
ME E17.4 There is an established procedure Recording Time of Birth
for new born resuscitation and
new-born care.
Standard E18
ME E18.1 Post partum Care is Provided to
Mother
ME E18.4 The facility has procedures for
Stabilization/treatment/referral
of post natal complication
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection
ME F1.2 Facility has provision for Passive Surface and environment samples
and active culture surveillance of are taken for microbiological
critical & high risk areas
ME F1.3 Facility measures hospital
associated infection rates
ME F1.4 There is Provision of Periodic
Medical Check-up's and
immunization of staff
ME F1.5 Facility has established
procedures for regular monitoring control practices
of infection control practices
ME F1.6 Facility has defined and
established antibiotic policy
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
ME F2.1 Hand washing facilities are
provided at point of use
Sponge and Instrument Count
Practice is implemented
Adequate Haemostasis is ensured
during surgery
Appropriate suture material is used
for surgery as per requirement
Post operative monitoring is done
before discharging to ward
Post operative notes and orders
are recorded
Facility has established procedures for Intranatal care as per guidelines
Proper selection of Anaesthesia
Intraoperative care
Post operative care
Postpartum Haemorrhage
Management of shock.
Ruptured Uterus
Vitamin K
Care of Cord and Eyes
APGAR Score
New born Resuscitation
Facility has established procedures for postnatal care as per guidelines
Prevention of Hypothermia
Initiation of Breastfeeding with-in 1
Hour
There is established criteria for
shifting new-born to NBSU/SNCU
Area of Concern - F Infection Control
surveillance
There is procedure to report cases
of Hospital acquired infection
There is procedure for
immunization of the staff
Periodic medical check-up of the
staff
Regular monitoring of infection
Check for Doctors are aware of
Hospital Antibiotic Policy
Availability of hand washing
Facility at Point of Use
Availability of running Water
Availability of antiseptic soap with
soap dish/ liquid antiseptic with
dispenser.
Availability of Alcohol based Hand
rub
Display of Hand washing
Instruction at Point of Use
Availability of elbow operated taps
1 RR/SI Instrument, needles and sponges
are counted before beginning of
case, before final closure and on
completing of procedure
1 RR/SI Check for Cautery and suture
legation practices
1 RR/SI Check for what kind of sutures
used for different surgeries .
Braided Biological sutures are not
used for dirty wounds, Catgut is
not used for closing facial layers of
abdominal wounds or where
prolonged support is required
1 RR/SI Check for post operative operation
ward is used and patients are not
immediately shifted to wards after
surgery
1 RR/SI Post operative notes contains Vital
signs, Pain control, Rate and type
of IV fluids, Urine and
Gastrointestinal fluid output, other
medications and Laboratory
investigations
13 26
1 SI/RR Check for Haemoglobin level is
estimated , and arrangement of
Blood, IV line established,
Catheterization, Demonstration of
Antacids
1 SI/RR Check Both General and Spinal
Anaesthesia Options are available.
Ask for what are the criteria for
using spinal and GA
1 SI/RR Check for measures taken to
prevent Supine Hypotension (Use
of pillow/Sandbag to tilt the
uterus), Technique for Incision,
Opening of Uterus, Delivery of
Foetus and placenta, and closing of
Uterine Incision
1 SI/RR Monitoring of vitals I/O charting,
uterine contraction, bleeding
1 SI/RR Ask for how to secure airway and
breathing, Loading and
Maintenance dose of Magnesium
sulphate , Administration of
Hypertensive Drugs
1 SI/RR
1 SI/RR
1 SI/RR
1 RR
1 SI/RR
1 SI/RR
1 SI/RR
1 SI/RR
3 6
1 SI/RR
1 PI/SI
1 SI/RR
81 162
6 12
1 SI/RR Swab are taken from infection
prone surfaces
1 SI/RR Patients are observed for any sign
and symptoms of HAI like fever,
purulent discharge from surgical
site .
1 SI/RR Hepatitis B, Tetanus Toxoid etc.
1 SI/RR
1 SI/RR Hand washing and infection control
audits done at periodic intervals
1 SI/RR
15 30
1 OB Check for availability of wash basin
near the point of use
1 OB/SI Open the tap. Ask the staff, water
is 24*7
1 OB/SI Check for availability/ Ask staff if
the supply is adequate and
uninterrupted
1 OB/SI Check for availability/ Ask staff for
regular supply.
1 OB Prominently displayed above the
hand washing facility , preferably in
Local language
1 OB
 Hand washing sink is wide and 1 OB
deep enough to prevent splashing
and retention of water

ME F2.2 The Facility Staff is trained in Adherence to 6 steps of Hand 1 SI/OB Ask for demonstration
correct Hand washing practices washing
and they adhere to standard hand
washing practices

Adherence to Surgical scrub 1 SI/OB Procedure should be repeated

method several times so that the scrub lasts
for 3 to 5
minutes. The hands and forearms
should be dried with a sterile towel
only.

Staff is aware of occasions for hand 1 SI

washing
ME F2.3 Facility ensures standard practices Availability of Antiseptic Solutions 1 OB
and materials for antisepsis

Procedure for proper cleaning of 1 OB/SI E.g.. before giving IM/IV injection,
site with Antisepsis drawing blood, putting Intravenous
and urinary catheter

Proper cleaning of perineal area 1 SI

before procedure with antisepsis

Check Shaving is not done during 1 SI

part preparation/delivery cases

Check sterile field is maintained 1 OB/SI Surgical site covered with sterile
during surgery drapes, sterile instruments are kept
within the sterile field.

Standard F3 Facility ensures standard practices and materials for Personal protection 9 18
ME F3.1 Facility ensures adequate Clean gloves are available at point 1 OB/SI
personal protection equipment as of use
per requirements
Availability of Masks 1 OB/SI
Sterile gloves are available in OT 1 OB/SI
and Critical areas
Use of elbow length gloves for 1 OB/SI
obstetrical purpose
Availability of gown/ Apron 1 OB/SI
Availability of Caps 1 OB/SI
Personal protective kit for 1 OB/SI HIV kit
infectious patients
ME F3.2 Staff is adhere to standard No reuse of disposable gloves, 1 OB/SI
personal protection practices Masks, caps and aprons.
Compliance to correct method of 1 SI
wearing and removing the gloves

Standard F4 Facility has standard Procedures for processing of equipment and instruments 18 36
ME F4.1 Facility ensures standard practices Decontamination of operating 1 SI/OB Ask staff about how they
and materials for decontamination surfaces decontaminate the procedure
and cleaning of instruments and surface like OT Table,
procedures areas Stretcher/Trolleys etc.
(Wiping with 0.5% Chlorine
solution

Proper Decontamination of 1 SI/OB

instruments after use Ask staff how they decontaminate
the instruments like ambubag,
suction cannula, Surgical
Instruments
(Soaking in 0.5% Chlorine Solution,
Wiping with 0.5% Chlorine Solution
or 70% Alcohol as applicable

Contact time for decontamination 1 SI/OB 10 minutes

is adequate
Cleaning of instruments after 1 SI/OB Cleaning is done with detergent
decontamination and running water after
decontamination

Proper handling of Soiled and 1 SI/OB No sorting ,Rinsing or sluicing at

infected linen Point of use/ Patient care area

Staff know how to make chlorine 1 SI/OB

solution
ME F4.2 Facility ensures standard practices Equipment and instruments are 1 OB/SI Autoclaving/HLD/Chemical
and materials for disinfection and sterilized after each use as per Sterilization
sterilization of instruments and requirement
equipment

High level Disinfection of 1 OB/SI Ask staff about method and time
instruments/equipment is done required for boiling
as per protocol

Chemical sterilization of 1 OB/SI Ask staff about method,

instruments/equipment is done as concentration and contact time
per protocols required for chemical sterilization

Formaldehyde or glutaraldehyde 1 OB/SI

solution replaced as per
manufacturer instructions

Autoclaved linen are used for 1 OB/SI

procedure
Autoclaved dressing material is 1 OB/SI
used
Instruments are packed according 1 OB/SI
for autoclaving as per standard
protocol

Autoclaving of instruments is done 1 OB/SI Ask staff about temperature,

as per protocols pressure and time
Regular validation of sterilization 1 OB/SI/RR
through biological and chemical
indicators

Maintenance of records of 1 OB/SI/RR

sterilization
There is a procedure to ensure the 1 OB/SI/RR
traceability of sterilized packs
 Sterility of autoclaved packs is 1 OB/SI Sterile packs are kept in clean, dust
maintained during storage free, moist free environment.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 18 36
ME F5.1 Layout of the department is Facility layout ensures separation 1 OB Faculty layout ensures separation
conducive for the infection control of general traffic from patient of general traffic from patient
practices traffic traffic

Zoning of High risk areas 1 OB

Facility layout ensures separation 1 OB
of routes for clean and dirty items

Floors and wall surfaces of OT are 1 OB

easily cleanable
CSSD/TSSU has demarcated 1 OB
separate area for receiving dirty
items, processes, keeping clean
and sterile items

ME F5.2 Facility ensures availability of Availability of disinfectant as per 1 OB/SI Chlorine solution, Gluteraldehye,
standard materials for cleaning and requirement carbolic acid
disinfection of patient care areas

Availability of cleaning agent as per 1 OB/SI Hospital grade phenyl, disinfectant

requirement detergent solution
ME F5.3 Facility ensures standard practices Staff is trained for spill 1 SI/RR
followed for cleaning and management
disinfection of patient care areas

Cleaning of patient care area with 1 SI/RR

detergent solution
Staff is trained for preparing 1 SI/RR
cleaning solution as per standard
procedure

Standard practice of mopping and 1 OB/SI

scrubbing are followed
Cleaning equipment like broom are 1 OB/SI
not used in patient care areas

Use of three bucket system for 1 OB/SI

mopping
Fumigation/carbolization as per 1 SI/RR
schedule
External foot wares are restricted 1 OB

ME F5.4 Facility ensures segregation Isolation and barrier nursing 1 OB/SI

infectious patients procedure are followed for septic
cases

ME F5.5 Facility ensures air quality of high Positive Pressure in OT 1 OB/SI

risk area
Adequate air exchanges are 1 SI/RR
maintained
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous
Waste. 15 30
ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins at 1 OB
Medical Waste as per guidelines point of waste generation

Availability of plastic colour coded 1 OB

plastic bags
Segregation of different category 1 OB/SI
of waste as per guidelines

Display of work instructions for 1 OB

segregation and handling of
Biomedical waste

There is no mixing of infectious 1 OB

and general waste
ME F6.2 Facility ensures management of Availability of functional needle 1 OB See if it has been used or just lying
sharps as per guidelines cutters idle
Availability of puncture proof 1 OB Should be available nears the point
container of generation like nursing station
and injection room

Disinfection of sharp before 1 OB/SI Disinfection of syringes is not done

disposal in open buckets
Staff is aware of contact time for 1 SI
disinfection of sharps
Availability of post exposure 1 OB/SI Ask if available. Where it is stored
prophylaxis and who is in charge of that.

Staff knows what to do in condition 1 SI Staff knows what to do in case of

of needle stick injury shape injury. Whom to report. See
if any reporting has been done

ME F6.3 Facility ensures transportation Check bins are not overfilled 1 SI

and disposal of waste as per
guidelines
Disinfection of liquid waste before 1 SI/OB
disposal
Transportation of bio medical 1 SI/OB
waste is done in close
container/trolley

Staff aware of mercury spill 1 SI/RR

management

Area of Concern - G Quality Management 31 62

Standard G1 The facility has established organizational framework for quality improvement 1 2
ME G1.1 The facility has a quality team in There is a designated 1 SI/RR Preferably Anaesthetist or surgeon
place departmental nodal person for
coordinating Quality Assurance
activities

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 3 6
ME G3.1 Facility has established internal There is system daily round by 1 SI/RR
quality assurance program at Surgeon/Matron/Hospital
relevant departments manager/ Hospital
Superintendent/for monitoring of
services

ME G3.3 Facility has established system for Departmental checklist are used 1 SI/RR
use of check lists in different for monitoring and quality
departments and services assurance

Staff is designated for filling and 1 SI

monitoring of these checklists

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 14 28
ME G4.1 Departmental standard operating Standard operating procedure for 1 RR
procedures are available department has been prepared
and approved

Current version of SOP are 1 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures The Department has documented 1 RR
adequately describes process and procedure for scheduling the
procedures Surgery and its booking

The Department has documented 1 RR

procedure for pre operative
procedure

The Department has documented 1 RR

procedure for pre operative
anaesthetic check up

The Department has documented 1 RR

procedure for in process check
during surgery

The Department has documented 1 RR

procedure for post operative care
of the patient

The Department has documented 1 RR

procedure for operation theatre
asepsis and environment
management

The Department has documented 1 RR

procedure for OT documentation.

The Department has documented 1 RR

procedure for reception of dirt
packs and issue of sterile packs
from TSSU

The Department has documented 1 RR

procedure for maintenance and
calibration of equipment

The Department has documented 1 RR

procedure for general cleaning of
OT and annexes

ME G4.3 Staff is trained and aware of the Check staff if aware of relevant 1 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 1 OB Processing and sterilization of
Point of use are displayed equipment,
Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit 4 8
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and and recorded
recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive actions Corrective and preventive actions 1 RR/SI
are taken to address issues, are taken
observed in the assessment &
audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objective for OT are 1 RR/SI
quality objectives and key defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check of staff is aware of quality 1 SI
disseminated and staff is aware of policy and objectives
that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services

5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 18 36
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 8
ME H1.1 Facility measures productivity C-Section Rate 1 RR
Indicators on monthly basis
Proportion of C-Sections done in 1 RR
night
Proportion of other emergency 1 RR
surgeries done in the night
No. of Major surgeries done per 1 1 RR
lakh population
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 5 10
ME H2.1 Facility measures efficiency Downtime of critical equipment 1 RR
Indicators on monthly basis
No of major surgeries per surgeon 1 RR

Proportion of elective C-Sections 1 RR

Proportion emergency surgeries 1 RR

Cycle time for instrument 1 RR

processing
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 8 16
ME H3.1 Facility measures Clinical Care & Surgical Site infection Rate 1 RR No. of observed surgical site
Safety Indicators on monthly basis infections*100/total no. of Major
surgeries

No of adverse events per thousand 1 RR

patients
 Incidence of re-exploration of 1 RR
surgery
% of environmental swab culture 1 RR
reported positive
Perioperative Death Rate 1 RR Deaths occurred from pre
operative procedure to discharge
of the patient

Proportion of General Anaesthesia 1 RR

to spinal anaesthesia

Proportion of PAC done out of 1 RR

total surgeries
No. of autoclave cycle failed in 1 RR
Bowie dick test out of total
autoclave cycle

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 1 2
ME H4.1 Facility measures Service Quality Operation Cancellation rates 1 RR No. of cancelled operation*1000
Indicators on monthly basis /total operation done

Planned operations
cancelled due to any
reason like clinical,
non clinical (theatre),
or by patient

Operation Theatre Score

Card
Operation 50
Theatre
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50

Obtained Maximum Percent 6

A 9 18 50
B 21 42 50
C 81 162 50
D 52 104 50
E 75 150 50
F 81 162 50
G 31 62 50
H 18 36 50
Total 368 736 50

0
 National Quality Assurance Standards for CHC 0 1 2

Checklist for Laboratory 7

Reference Measurable Element Checkpoint Complian Assessment Means of Verification
No. ce Method
Full/ Remarks
Partial/
No
Area of Concern - A Service Provision 14 28

Standard A3 Facility Provides diagnostic Services 8 16

ME A3.2 The facility Provides All lab services are available in 1 SI/RR
Laboratory Services routine working hours

Emergency lab services are 1 SI/RR Facility for on call laboratory

available technician
Availability of Haematology 1 SI/OB Hb, TLC, DLC, AEC, Reti count,
services ESR, PBS, Malaria/Filaria,
Platelets count, PCV, Blood
grouping, Rh typing.

Availability of Bio chemistry 1 SI/OB B. sugar, B urea, LFT, KFT, lipid

services profile
Availability of Microbiology 1 SI/OB Smear for AFB, KLB, Gram stain
services for throat Swab, Sputum etc.

Availability of urine analysis 1 SI/OB Urine for Albumin, Sugar,

services Deposits, Bile salts, Bile
pigments, Ketone Bodies, spc.
Gravity, pH.

Availability of stool analysis 1 SI/OB Stool for ova/cyst (EH), Occult

blood.
Availability of sputum 1 SI/OB
cytology
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 5 10

ME A4.1 The facility provides services Tests for Diagnosis of malaria 1 SI/OB
under National Vector (Smear and RDTK)
Borne Disease Control
Programme as per
guidelines

Tests for Kala Azar, Dengue, 1 SI/OB As per prevalent endemic

JE, Chikunganya
ME A4.2 The facility provides services Availability of Designated 1 SI/OB
under Revised National TB Microscopy Centre (AFB)
Control Programme as per
guidelines

ME A4.3 The facility provides services Availability of Skin Smear 1 SI/OB

under National Leprosy Examination
Eradication Programme as
per guidelines

ME A4.8 The facility provides services Haemogram, BT CT, 1 SI/RR

under National Programme Fasting/PP Sugar, Lipid Profile,
for Prevention and control Blood Urea , LFT Kidney
of Cancer, Diabetes, Function Test
Cardiovascular diseases &
Stroke (NPCDCS) as per
guidelines

Standard A6 Health services provided at the facility are appropriate to community needs. 1 2

ME A 6.1 The facility provides Laboratory provides specific 1 SI/RR

curatives & preventive test for local health
services for the health problems/ diseases e.g..
problems and diseases, Dengue, Kalazar etc.
prevalent locally.

Area of Concern - B Patient Rights 18 36

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their 6 12
modalities
ME B1.1 The facility has uniform and Availability departmental 1 OB (Numbering of rooms, main
user-friendly signage system signage's department and inter- sectional
signage)

ME B1.2 The facility displays the List of services available are 1 OB

services and entitlements displayed at the entrance
available in its departments

Timing for collection of 1 OB

sample and delivery of reports
are displayed

ME B1.4 User charges are displayed User charges in r/o laboratory 1 OB

and communicated to services are displayed
patients effectively

ME B1.6 Information is available in Signage's and information are 1 OB

local language and easy to
understand
ME B1.8 The facility ensures access
to clinical records of
patients to entitled
personnel
available in local language
Lab Reports are provided to 1 OB
Patient in proper printed
format

Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no 2 4
barrier on account of physical , economic, cultural or social status.
ME B2.1 Services are provided in Separate queue for female 1 OB
manner that are sensitive to patients at lab
gender
ME B2.3 Access to facility is provided Check the availability of ramp 1 OB
without any physical barrier in lab building area /sample
& and friendly to people collection area
with disabilities

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 3 6
information.
ME B3.2 Confidentiality of patients Laboratory has a system to 1 SI/OB Laboratory staff do not discuss
records and clinical ensure the confidentiality of the lab result and reports are
information is maintained the reports generated kept in secure place

ME B3.3 The facility ensures the Behaviour of staff is 1 PI/OB

behaviours of staff is empathetic and courteous
dignified and respectful,
while delivering the services

ME B3.4 The facility ensures privacy HIV positive 1 SI/OB

and confidentiality to every
patient, especially of those
conditions having social
stigma, and also safeguards
vulnerable groups
reports/pregnancy reports are
communicated as per NACO
guidelines

Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and 2 4
involving them in treatment planning, and facilitates informed decision making
ME B4.1 There is established Informed Consent is taken 1 SI/RR Before testing for HIV patient is
procedures for taking before HIV testing, Biopsy informed the that test is
informed consent before and any other invasive voluntary and result will be
treatment and procedures procedure disclosed to him/her only

ME B4.4 Information about the Pre test counselling is done 1 PI/SI/RR

treatment is shared with before HIV testing
patients or attendants,
regularly

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost 5 10
of care.
ME B5.1 The facility provides Free Diagnostic tests for 1 PI/SI
cashless services to Pregnant women & Infant
pregnant women, mothers
and neonates as per
prevalent government
schemes

ME B5.2 The facility ensures that Check that patient has not 1 PI/SI
drugs prescribed are incurred expenditure on
available at Pharmacy and purchasing consumables from
wards outside.

ME B5.3 It is ensured that facilities Check that patient party not 1 PI/SI
for the prescribed incurred expenditure on
investigations are available diagnostics from outside.
at the facility

ME B5.4 The facility provide free of Tests are free of cost for BPL 1 PI/SI/RR
cost treatment to Below patients
Poverty Line(BPL) patients
without administrative
hassles

ME B5.5 The facility ensures timely Cashless investigation by 1 PI/SI/RR

reimbursement of financial empanelled lab for JSSK
entitlements and beneficiaries for the test
reimbursement to the which are not available within
patients the facility

Area of Concern - C Inputs 40 80

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent 10 20
norms
ME C1.1 Departments have adequate Laboratory space is adequate 1 OB Adequate area for sample
space as per patient or work for carrying out activities collection, waiting, performing
load test, keeping equipment and
storage of drugs and records

ME C1.2 Patient amenities are Availability of adequate 1 OB

provide as per patient load waiting area

Availability of functional 1 OB
toilets
Availability of drinking water 1 OB
near laboratory.
ME C 1.3 Departments have layout Demarcated sample collection 1 OB
and demarcated areas as area
per functions
Demarcated testing area 1 OB
Designated report writing area 1 OB

Demarcated washing and 1 OB

waste disposal area
ME C 1.5 The facility has Availability of functional 1 OB
infrastructure for intramural telephone and Intercom
and extramural Services
communication

ME C 1.7 The facility and Unidirectional flow of services 1 OB Sample collection- Sample
departments are planned to processing- Analytical area-
ensure structure follows the reporting.
function/processes
(Structure commensurate
with the function of the
hospital)
Standard C 2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20

ME C2.1 The facility ensures the
seismic safety of the
infrastructure
Non structural components
are properly secured
1 OB Check for fixtures and furniture
like cupboards, cabinets, and
heavy equipment , hanging
objects are properly fastened
and secured

ME C2.2 The facility ensures safety of Laboratory does not have 1 OB

electrical establishment temporary connections and
loose hanging wires

Adequate electrical sockets 1 OB/RR

are provided for safe and
smooth operation of lab
equipment

ME C2..3 Physical condition of Work benches are chemical 1 OB

buildings are safe for
providing patient care
resistant
Floors of the Laboratory are 1 OB
non slippery and even its
surface is acid resistant

Windows have grills and wire 1 OB

ME C2.4. The facility has plan for
prevention of fire
meshwork
Laboratory has plan for safe 1 OB/SI
storage and handling of
potentially flammable
materials.

ME C2.5. The facility has adequate Lab has installed fire 1 OB/RR
fire fighting Equipment Extinguishers to handle fire
ABC type

Check if expiry date for fire 1 OB/RR

extinguishers are displayed on
each extinguisher as well as
due date for next refilling is
clearly mentioned

ME C2.6. The facility has a system of Check for staff competencies 1 SI/RR
periodic training of staff and for operating fire extinguisher
conducts mock drills and what to do in case of fire
regularly for fire and other
disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current 8 16
case load
ME C3.4 The facility has adequate Availability of Lab. technicians 1 OB/RR Two Lab technicians
technicians/paramedics as
per requirement
ME C3.6. The staff has been provided Training on automated 1 SI/RR
required training / skill sets Diagnostic Equipment like
semi auto analyser

Bio Medical waste 1 SI/RR

Management
Infection control and hand 1 SI/RR
hygiene
Training on Internal and 1 SI/RR
External Quality Assurance
Laboratory Safety 1 SI/RR
ME C3.7 The Staff is skilled as per job Staff is skilled to run 1 SI/RR
description automated equipment like
semi auto analyser.

Staff is skilled for maintaining 1 SI/RR

Laboratory records

Standard C 4 Facility provides drugs and consumables required for assured list of services. 3 6

ME C4.2 The departments have
adequate consumables at
point of use
Regular availability of supplies
for Laboratory
1 OB/RR Clean slides, slide markers,
gloves, transport medium, test
tubes, vials, swabs, culture
bottles, Zeil Neelsen Acid Fast
stain, sealing material etc.

Availability of RD kits. 1 OB/RR RDK for malaria/typhoid and

faecal contamination of water.

ME C4.3 Emergency drug trays are Emergency Drug Tray is 1 OB/RR

maintained at every point of maintained
care, where ever it may be
needed

Standard C5 The facility has equipment & instruments required for assured list of services. 9 18

ME C 5.1 Availability of equipment & Availability of functional 1 OB BP apparatus, Stethoscope at

instruments for examination Equipment &Instruments sample collection area
& monitoring of patients for examination &
Monitoring

ME C 5.3 Availability of equipment & Availability of functional 1 OB Micropipettes , Spirit lamp,

instruments for diagnostic equipment for sample Centrifuge, Water Bath, Hot air
procedures being collection and processing oven.
undertaken in the facility

Availability of equipment for 1 OB Ice box, stool transport carrier,

storage and transfer of test tube rack, refrigerator,
samples smear transporting box, sterile
leak proof containers.

Availability of functional 1 OB Binocular Micro scope , FNAC,

Microscopy equipment staining rack
Availability of equipment 1 Photocalorie meter, semi
for testing & analysis autoanalyzer, glucometer.
ME C5.6 Availability of functional Availability of equipment 1 OB Buckets for mopping, mops,
equipment and instruments for cleaning duster, waste trolley, Deck
for support services brush

Availability of equipment 1 OB Autoclave/Boiler

ME BC 5.7 The Department have
patient furniture and
fixtures as per load and
service provision
for sterilization and
disinfection
Availability of fixtures at lab
1 OB Illumination at work stations,
Electrical fixture for lab
equipment and storage
equipment

Availability of furniture 1 OB Lab stools, Work bench's, rack

and cupboard for storage of
reagent ,Patient stool, Chair
table

Area of Concern - D Support Services 34 68

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 10 20

ME D 1.1 The facility has established All equipment are covered 1 SI/RR Agency/ is identified for
system for maintenance of under the AMC including maintenance of the equipment
critical Equipment preventive maintenance

There is a system of timely 1 SI/RR

corrective break down
maintenance of the
equipment

There is a system to label 1 OB/RR

Defective/Out of order
equipment and they are
stored appropriately until its
repair

The Staff is skilled for trouble 1 SI/RR

shooting in case equipment
malfunction

Periodic cleaning, inspection 1 SI/RR

and maintenance of the
equipment is done by the
operator

ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment

There is system to label/ code 1 OB/ RR

the equipment to indicate
status of calibration/
verification when recalibration
is due

Laboratory has a system to 1 SI/RR

update correction factor after
calibration of equipment (if
required)

Each lot of reagents matched 1 SI/RR

against earlier tested in-use
reagent lot or with suitable
reference material before
being put in service and
result's are recorded.

ME D1.3 Operating and maintenance Up to date instructions for 1 OB/SI

instructions are available operation and maintenance of
with the users of equipment equipment are readily
available with staff.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and 8 16
patient care areas
ME D2.1 There is a established There is established system of 1 SI/RR Stock level are daily updated
procedure for forecasting timely indenting of Requisition are timely placed
and indenting of drugs and consumables and reagents
consumables

ME D2.3 The facility ensures proper Reagents and consumables 1 OB/RR

storage of drugs and are kept away from water and
consumables sources of heat,
direct sunlight

Reagents are labelled 1 OB/RR Reagents label contain name,

appropriately concentration, date of
preparation/opening, date of
expiry, storage conditions and
warning

ME D2.4 The facility ensures No expired reagent found 1 OB/RR

management of expiry and
near expiry drugs
ME D2.5 The facility has established Department maintains stock 1 RR/SI
procedure for inventory and expenditure register of
management techniques reagents

There is no stock out of 1 OB/SI

ME D2.7 There is process for storage
of vaccines and other drugs,
requiring controlled
temperature
reagents
Temperature of refrigerators 1 OB/RR Check, if temperature charts are
are kept as per storage maintained and updated
requirement and records are periodically
maintained

Regular Defrosting is done 1 SI/RR

Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and 10 20
comfortable environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Floors, walls, roof, roof tops, 1 OB All area are clean with no
adequately maintained. sinks in patient care and dirt,grease,littering and
circulation areas are Clean cobwebs

Surface of furniture and 1 OB

fixtures are clean
ME D3.3 Patient care areas are clean Check for there is no seepage , 1 OB
and hygienic Cracks, chipping of plaster

Window panes , doors and 1 OB

other fixtures are intact
ME D3.4. The facility has a policy of No condemned/Junk material 1 OB
removal of condemned junk found in the lab
material
ME D3.5 The facility has established No stray animal/rodent/birds 1 OB
procedures for pest, rodent
and animal control

ME D3.6 The facility provides Adequate illumination in the 1 OB

adequate illumination level laboratory.
at patient care areas

ME D3.8 The facility ensures safe and Temperature control and 1 SI/RR Fans/ Air
comfortable environment ventilation in the laboratory. conditioning/Heating/Exhaust/V
for patients and service entilators as per environment
providers condition and requirement

Availability of Eye washing 1 OB

facility
ME D3.10. The facility has established Ask female staff weather they 1 SI
measure for safety and feel secure at work place
security of female staff

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services 2 4
norms
ME D4.1 The facility has adequate Availability of running and 1 OB/SI
arrangement storage and potable water on 24*7 basis
supply for potable water in
all functional areas

ME D4.2 The facility ensures Availability of power back up 1 OB/SI

adequate power backup in in laboratory
all patient care areas as per
load

Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 1 2

ME D8.3 The facility ensure relevant Any positive report of 1 RR/SI

processes are in compliance notifiable disease is intimated
with the statutory to designated authorities
requirements within the stipulated time-
limit

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 3 6
operating procedures.
ME D9.1 The facility has established Staff is aware of their role 1 SI
job description as per govt and responsibilities
guidelines

ME D9.2 The facility has a established There is procedure to ensure 1 RR/SI Check for system of recording
procedure for duty roster that staff is available on duty time of reporting and relieving
and deputation to different as per duty roster (Attendance register/
departments Biometrics etc.)

ME D9.3 The facility ensures Technician and support staff 1 OB

adherence to dress code as adhere to their respective
mandated by its dress code
administration / the health
department

Area of Concern - E Clinical Services 27 54

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 2 4

ME E1.1 The facility has established Unique laboratory 1 RR

procedure for registration of identification number is given
patients to each patient sample

Patient demographic details 1 RR Check for that patient

are recorded in laboratory demographics like Name, Age,
records Sex,Provisional Diagnosis etc.

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 2 4

ME E3.2 Facility provides appropriate Laboratory has referral linkage 1 RR/SI

referral linkages to the for test, which are not
patients/Services for transfer available at the facility
to other/higher facilities to
assure their continuity of care.

Facility gets referred patients 1 RR/SI e.g.: linkage for disease

from lower level of facility surveillance and water testing

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their 5 10
storage
ME E8.5 Adequate form and formats Standard Formats are 1 RR/OB Printed formats for requisition
are available at point of use available and reporting are available

ME E8.6 Register/records are Lab records are labelled and 1 RR

maintained as per indexed
guidelines
 Records are maintained for 1 RR Test registers, IQAS/EQAS
the laboratory Registers, Expenditure registers,
Accession list etc.

ME E8.7 The facility ensures safe and Laboratory has adequate 1 OB

adequate storage and facility for storage of records
retrieval of medical records

Laboratory has a system of 1 OB Ask for retrieval of a sample

easy retrieval of record record
Standard The facility has defined and established procedures for Emergency Services and Disaster Management 3 6
E10
ME E10.3 The facility has Disaster The staff is aware of Disaster 1 SI/RR
Management Plan in place Plan

Roles and responsibilities of 1 SI/RR

the staff in disaster are
defined

ME E10.5 There is a procedure for Samples of medico legal cases 1 SI/RR Requisition and reports are
handling medico legal cases are identified, Secured, marked with MLC, and the
preserved and processed reports are handed over to
authorized personnel only

Standard The facility has defined and established procedures of diagnostic services 14 28
E11
ME E11.1 There are established Requisitions of all laboratory 1 RR/OB Request form contains relevant
procedures for Pre-testing test are received on information: Name and
Activities designated and apparent identification number of
forms. patient, name of authorized
requester, type of primary
sample, examination requested,
date and time of primary
sample collection and date and
time of receipt of sample by
laboratory,

Instructions for collection and 1 RR/SI

handling of primary samples
are communicated to those
responsible for collection

Laboratory has system in 1 RR/SI

place to label the primary
samples

Laboratory has system to 1 RR/SI

trace the primary sample from
requisition form

Laboratory has system in 1 RR/SI Transportation of sample

place to monitor includes: Time frame,
transportation of the sample temperature and carrier
specified for transportation

ME E11.2 There are established Testing procedure are readily 1 OB/RR

procedures for testing available at work station and
Activities staff is aware of the same

Laboratory has Biological 1 OB/RR

reference interval for its
examination of various results

Laboratory has identified 1 RR/SI

critical intervals for which
immediate notification is done
to concerned physician

ME E11.3 There are established Laboratory has a system to 1 RR/SI

procedures for Post-testing review the results of
activities examination by authorized
person before release of the
report

Laboratory has format for 1 RR/OB

reporting of results
Laboratory has system to 1 RR/SI
provide the reports within
defined cycle time for each
category of patient -routine
and emergency

Laboratory results written in 1 RR/SI

reports are legible without
error in transcription

Laboratory has defined the 1 RR/SI

retention period and disposal
of used sample

Laboratory has a system to 1 RR/SI

retain the copies of reported
results, which are promptly
retrieved when required

Standard Facility provides National health program as per operational/Clinical Guidelines 1 2

E22
ME E22.9 The Facility provide service Weekly reporting of 1 SI/RR
for Integrated Disease Confirmed cases on form "L"
Surveillance Programme from laboratory

Area of Concern - F Infection Control 47 94

Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital 3 6
associated infection
ME F1.4 There is Provision of There is procedure for 1 SI/RR Hepatitis B, Tetanus Toxoid etc.
Periodic Medical Check-up's immunization of the staff
and immunization of staff
 Periodic medical check-up's of 1 SI/RR
the staff is undertaken

ME F1.5 Facility has established Regular monitoring of 1 SI/RR Hand washing and infection
procedures for regular infection control practices control audits are done at
monitoring of infection periodic intervals
control practices

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 10 20

ME F2.1 Hand washing facilities are Availability of hand washing 1 OB Check for availability of wash
provided at point of use Facility at Point of Use basin near the point of use

Availability of running Water
Availability of antiseptic soap
with soap dish/ liquid
antiseptic with dispenser.
1 OB/SI Open the tap. Ask the Staff,
water is available 24*7
1 OB/SI Check for availability/ Ask staff if
the supply is adequate and
uninterrupted

Display of Hand washing 1 OB Prominently displayed above

Instruction at Point of Use the hand washing facility ,
preferably in Local language

Availability of elbow operated 1 OB

taps
Hand washing sink is wide and 1 OB
deep enough to prevent
splashing and retention of
water

ME F2.2 Staff is trained and adhere Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
to standard hand washing washing
practices
Staff aware of when to hand 1 SI
wash
ME F2.3 Facility ensures standard Availability of Antiseptic 1 OB
practices and materials for Solutions
antisepsis
Proper cleaning of procedure 1 OB/SI before drawing blood,
site with antisepsis

Standard F3 Facility ensures standard practices and materials for Personal protection 4 8

ME F3.1 Facility ensures adequate Clean gloves are available at 1 OB/SI

personal protection point of use
equipment as per
requirements

Availability of lab 1 OB/SI

aprons/coats
Availability of Masks 1 OB/SI
ME F3.2 Staff adheres to standard No reuse of disposable gloves 1 OB/SI
personal protection and Masks.
practices

Standard F4 Facility has standard Procedures for processing of equipment and instruments 6 12

ME F4.1 Facility ensures standard
practices and materials for
decontamination and clean ing
of instruments and
procedures areas
Decontamination of 1 SI/OB Ask staff about how they
Procedure surfaces decontaminate work benches
(Wiping with 0.5% Chlorine
solution)

Proper Decontamination of 1 SI/OB Decontamination of instruments

instruments after use and reusable of glassware are
done after procedure in 1%
chlorine solution/ any other
appropriate method

Contact time for 1 SI/OB 10 minutes

decontamination is adequate

Cleaning of instruments after 1 SI/OB Cleaning is done with detergent

decontamination and running water after
decontamination

The Staff knows how to make 1 SI/OB

ME F4.2 Facility ensures standard
practices and material for
disinfection and sterilization of
instruments and equipment
chlorine solution
Disinfection of reusable 1 SI/OB Disinfection by hot air oven at
glassware 160 oC for 1 hour

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 8 16

ME F5.2 Facility ensures availability of Availability of disinfectant as 1 OB/SI Chlorine solution,

standard material for cleaning per requirement Gluteraldehye, Carbolic acid(If
and disinfection of patient care Gluteraldehyde-Check for its
areas activation period.)

Availability of cleaning agent 1 OB/SI Hospital grade phenyl,

as per requirement disinfectant detergent solution

ME F5.3 Facility ensures standard Staff is trained for spill 1 SI/RR

practices followed for cleaning management
and disinfection of patient care
areas

Cleaning of patient care area 1 SI/RR

with detergent solution

Staff is trained for preparing 1 SI/RR

cleaning solution as per
standard procedure

Standard practice of mopping 1 OB/SI Unidirectional mopping from

and scrubbing are followed inside out
 Cleaning equipment like 1 OB/SI Any cleaning equipment leading
broom are not used in to dispersion of dust particles in
Laboratory air should be avoided

ME F5.4 Facility ensures segregation Precaution with infectious 1 OB/SI

infectious patients patients like TB

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical 16 32
and hazardous Waste.
ME F6.1 Facility Ensures segregation Availability of colour coded 1 OB
of Bio Medical Waste as per bins at point of waste
guidelines generation

Availability of plastic colour 1 OB

coded plastic bags
Segregation of different 1 OB/SI
category of waste as per
guidelines

Display of work instructions 1 OB

for segregation and handling
of Biomedical waste

There is no mixing of 1 OB
infectious and general waste

ME F6.2 Facility ensures Availability of functional 1 OB See if it has been used or just
management of sharps as needle cutters lying idle
per guidelines
Availability of puncture proof 1 OB Should be available nears the
box point of generation like nursing
station and injection room

Disinfection of sharp before 1 OB/SI Disinfection of syringes is not

disposal done in open buckets
Staff is aware of contact time 1 SI
for disinfection of sharps

Availability of post exposure 1 OB/SI Ask if available. Where it is

prophylaxis stored and who is in charge of
that.

Staff knows what to do in 1 SI Staff knows what to do in case

condition of needle stick of shape injury. Whom to
injury report. See if any reporting has
been done

ME F6.3 Facility ensures Disinfection of liquid waste 1 SI/OB

transportation and disposal before disposal
of waste as per guidelines

Disposal of sputum cups as 1 SI/OB

per guidelines
Check bins are not overfilled 1 SI

Transportation of bio medical 1 SI/OB

waste is done in close
container/trolley

Staff aware of mercury spill 1 SI/RR

management

Area of Concern - G Quality Management 53 106

Standard G1 The facility has established organizational framework for quality improvement 1 2
ME G1.1 The facility has a quality There is a designated 1 SI/RR
team in place departmental nodal person
for coordinating Quality
Assurance activities

Standard G2 Facility has established system for patient and employee satisfaction 1 2

ME G2.1 Patient Satisfaction surveys There is system to take feed 1 RR

are conducted at periodic back from clinician about
intervals quality of services

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 12 24

ME G3.1 Facility has established Internal Quality assurance 1 SI/RR

internal quality assurance programme is in place
program at relevant
departments

Standards are run at defined 1 SI/RR

interval
Control charts are prepared 1 SI/RR
and outliers are identified.

Corrective action is taken on 1 SI/RR

the identified gaps
Internal Quality Control for 1 SI/RR Routine checking of equipment,
RNTCP Lab. is in place new lots of regent, smear
preparation, grading etc.

ME G3.2 Facility has established Cross Validation of Lab tests 1 SI/RR

external assurance are done and records are
programs at relevant maintained
departments

Corrective actions are taken 1 SI/RR

on abnormal values
External quality assurance 1 SI/RR Onsite evaluation done Monthly
program is implemented as Random Blinded rechecking
per RNTCP program (RBRC) done Monthly

External quality assurance 1 SI/RR

program is implemented for
NVBDCP
 External quality assurance 1 SI/RR
under NACP
ME G3.3 Facility has established Departmental checklist is 1 SI/RR
system for use of check lists used for monitoring and
in different departments quality assurance
and services

Staff is designated for filling 1 SI

and monitoring of these
checklists

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key 25 50
processes and support services.
ME G4.1 Departmental standard Standard operating procedure 1 RR
operating procedures are for department has been
available prepared and approved

Current version of SOP are 1 OB/RR

available with the respective
process owners

ME G4.2 Standard Operating Laboratory has documented 1 RR

Procedures adequately process for Collection and
describes process and handling of primary sample
procedures

Laboratory has documented 1 RR

procedure for transportation
of primary sample with
specification about time
frame, temperature and
carrier

Laboratory has documented 1 RR

process on acceptance and
rejection of primary samples

Laboratory has documented 1 RR

procedure on receipt,
labelling, processing and
reporting of primary sample

Laboratory has documented 1 RR

system for storage of
examined samples

Laboratory has documented 1 RR

system for repeat tests due to
analytical failure

Laboratory has documented 1 RR

validated procedure for
examination of samples

Laboratory has documented 1 RR

biological reference intervals

Laboratory has documented 1 RR

critical reference values and
procedure for immediate
reporting of results

Laboratory has documented 1 RR

procedure for release of
reports including details of
personal, authorised to
release the results and details
of recipient's of the reports

Laboratory has documented 1 RR

internal quality control system
to verify the quality of results

Laboratory has documented 1 RR

External Quality assurance
program

Laboratory has documented 1 RR

procedure for calibration of
equipment

Laboratory has documented 1 RR

procedure for validation of
results of reagents ,stains ,
media and kits etc. wherever
required

Laboratory has documented 1 RR

system of resolution of
complaints and other
feedback received from
patients, clinicians and RKS
members.

Laboratory has documented 1 RR

procedure for examination by
referral laboratories

Laboratory has documented 1 RR

system for storage, retaining
and retrieval of laboratory
records, primary sample,
Examination sample and
reports of results.
 Laboratory has documented 1 RR
system for control of its
documents

Laboratory has documented 1 RR

procedure for preventive and
break down maintenance

Laboratory has documented 1 RR

procedure for internal audits

Laboratory has documented 1 RR

procedure for purchase of
External services and supplies

ME G4.3 Staff is trained and aware of Check, if staff is a aware of 1 SI/RR

the standard procedures relevant part of SOPs
written in SOPs

ME G4.4 Work instructions are Work instruction/clinical 1 OB Work instruction for Internal
displayed at Point of use protocols are displayed Quality control,

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and 4 8
prescription audit
ME G5.1 The facility conducts Internal assessment is done at 1 RR/SI
periodic internal assessment periodic interval

ME G5.3 The facility ensures non Non Compliance are 1 RR/SI

compliances are enumerated and recorded
enumerated and recorded
adequately

ME G5.4 Action plan is made on the Action plan prepared 1 RR/SI

gaps found in the
assessment / audit process

ME G5.5 Corrective and Preventive Corrective and preventive 1 RR/SI

actions are taken to address action taken
issues, observed in the
assessment & audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6

ME G6.2 The facility periodically Quality Objectives are 1 RR/SI

defines its quality objectives defined
and key departments have
their own objectives

ME G6.3 Quality policy and objectives Check for staff is aware of 1 SI

are disseminated and staff is quality policy and objectives
aware of that

ME G6.4 Progress towards quality Quality objectives are 1 SI/RR

objectives is monitored monitored and reviewed
periodically periodically

Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 7 14

ME G7.1 Facility uses method for PDCA 1 SI/RR

quality improvement in
services
5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services

Pareto / Prioritization 1 SI/RR

Control charts 1 SI/RR
Area of Concern - H Outcome 20 40

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 8 16

ME H1.1 Facility measures productivity No. of HIV test done per 1000 1 RR
Indicators on monthly basis population

No. of VDRL test done per 1 RR

1000 population
No. of Blood Smear Examined 1 RR
per 1000 population

No. of AFB Examined per 1000 1 RR

population
No. of HB test done per 1000 1 RR
population
Lab test done per patients in 1 RR
OPD
Lab test done per patients IPD 1 RR

ME H1.2 The Facility measures equity Percentage of Lab 1 RR

indicators periodically Investigations for BPL IPD
Patients out of total
investigations for IPD Patients

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 6 12

ME H2.1 Facility measures efficiency No of test not matched in 1 RR

Indicators on monthly basis validation

Z score for biochemistry or 1 RR

equivalent
Z score for haematology or 1 RR
equivalent
 Down time of critical 1 RR
equipment
Turn around time for routine 1 RR
lab investigations
Turn around time for 1 RR
emergency lab investigations

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 8

ME H3.1 Facility measures Clinical Care % of critical values reported 1 RR

& Safety Indicators on monthly within one hour
basis

No of adverse events per 1 RR

thousand patients
Report correlation rate 1 RR Proportion of lab report co
related with clinical examination

Proportion of false positive 1 RR For Rapid diagnostic Kit test

/false negative
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 2 4

ME H4.1 Facility measures Service Waiting time at sample 1 RR

Quality Indicators on monthly collection area
basis

Number of stock out 1 RR

incidences of reagents

Laboratory Score Card

Laboratory
Score
50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50

H Outcome 50

Obtained Maximum Percent 7

A 14 28 50
B 18 36 50
C 40 80 50
D 34 68 50
E 27 54 50
F 47 94 50
G 53 106 50
H 20 40 50
Total 253 506 50
 National Quality Assurance Standards for CHC 0 1 2
Checklist for Radiology 8
Reference no. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Area of Concern - A Service Provision 3 6

Standard A3 Facility Provides diagnostic Services 3 6
ME A3.1 The facility provides Radiology Availability of X-ray services 1 SI/OB for chest, bones, skull,
Services spine and abdomen.
Availability of Dental X-ray Services 1 SI/OB Dental X-ray.

Availability/Functional linkage of 1 SI/OB Pre natal diagnostic

ultrasound services procedure:
Ultrasonography,

Area of Concern - B Patient Rights 18 36

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their 7 14
ME B1.1 The facility has uniform and Availability departmental signage modalities
1 OB (Numbering and rooms,
user-friendly signage system main department and
inter- sectional signage )

Display of PNDT Notice at USG 1 OB Notice in local language is

displayed at entrance of
USG department that All
persons including the
employer,
employee or any other
person associated with
department shall not
conduct or associate with
or help in carrying out
detection or disclosure of
sex of foetus in any
manner

Display of cautionary signage 1 OB Radiation hazard sign and

outside the X-ray department caution for pregnant
women and children

ME B1.2 The facility displays the services Timing for taking X-ray and 1 OB
and entitlements available in its collection of reports are displayed
departments outside the X-ray department

ME B1.4 User charges are displayed and User charges in r/o X-ray services 1 OB
communicated to patients are displayed at entrance
effectively
ME B1.6 Information is available in local Signage's and information are 1 OB
language and easy to available in local language
understand
ME B1.8 The facility ensures access to Reports are provided to Patient in 1 OB
clinical records of patients to proper printed format
entitled personnel
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on
2 4
ME B2.1
account of physical, economic,
Services are provided in manner Female attendant should 1
cultural
OB/SI
or social status.
that are sensitive to gender accompany female patients during
radiological procedures

ME B2.3 Access to facility is provided Check the availability of ramp in 1 OB

without any physical barrier & OPD/ X-ray room
and friendly to people with
disabilities

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 4 8
ME B3.1 Adequate visual privacy is X-ray department has provision ofinformation.
1 OB
provided at every point of care privacy while taking X-ray.

USG department has provision of 1 OB provision of screen

privacy while taking sonography

ME B3.2 Confidentiality of patients Radiology has system to ensure 1 RR/SI Radiology staff do not
records and clinical information the confidentiality of the reports discuss the X-Ray/USG
is maintained result outside. And reports
are kept in secure place

ME B3.3 The facility ensures the Behaviour of staff is empathetic 1 PI

behaviours of staff is dignified and courteous
and respectful, while delivering
the services

Standard B4 Facility has defined and established procedures for informing patient about their medical condition and involving them 1 2
ME B4.1 There is established procedures in treatement
Form planning,
F for USG under PNDT and facilitates
1 informed
RR decision making.
for taking informed consent maintained for scan of pregnant
before treatment and woman
procedures

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of
4 8
ME B5.1 The facility provides cashless
hospital services.
Free radiology services for 1 PI/SI USG and X-ray
services to pregnant women, Pregnant women and infant
mothers and neonates as per
prevalent government schemes

ME B5.3 It is ensured that facilities for Check that patient/attendant has 1 PI/SI
the prescribed investigations are not incurred expenditure on having
available at the facility Radiological Investigation(s) from
outside.

ME B5.4 The facility provide free of cost Tests are free of cost to BPL 1 PI/SI
treatment to Below poverty line patients
patients without administrative
hassles

ME B5.5 The facility ensures timely JSSK beneficiaries get free 1 PI/SI/RR Check that empanelled
reimbursement of financial investigations even for the tests labs are providing cashless
entitlements and not available at the facility facilities.
reimbursement to the patients

Area of Concern - C Inputs 37 74

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 11 22
ME C1.1 Departments have adequate Room Size of X-ray unit is as per 1 OB Room housing shall not be
space as per patient or work AERB safety code less than 18 sq m, any
load dimension not less than
4m
ME C1.3 Departments have layout and Unshielded opening for 1 OB Unshielded opening in X-
demarcated areas as per Ventilation and natural light has ray room shall be located
functions been provided in X-ray room as per above height of 2 m from
AERB safety code finished floor level outside
the X-ray room

Installation of control panel of X- 1 OB Control panel of X-ray

ray equipment is as Per AERB equipment operation at
safety Code 125 kVp or above shall be
installed in a separate
room located outside
contiguous to X-ray room,
with appropriate shielding,
direct viewing and oral
communication facility

Distance between control panel 1 OB The distance between

and X-ray unit is as per AERB safety control panel and X-ray
code unit shall not be less than 3
m

Location of dark room is as per 1 OB Dark room is located such

AERB safety code that no significant primary
or secondary X-ray reaches
inside dark room

Dark room has X-ray developing 1 OB SS processing tank to

tanks with water supply accommodate 14"X 17"
approx. capacity of 13 litre

Dark room has provision of safe 1 OB

light in dark room
There is separate storage area for 1 OB
undeveloped X-ray films and
personal monitoring devices in
protected area away from
radiation sources

ME C1.4 The facility has adequate Corridors are wide enough for 1 OB 2-3 meters
circulation area and open spaces movement of trolleys and
according to need and local law stretchers

ME C1.5 The facility has infrastructure for Availability of functional telephone 1 OB

intramural and extramural and Intercom Services
communication
ME C1.7 The facility and departments are Internal Layout of X-ray 1 OB No criss cross in the
planned to ensure structure department is unidirectional movement patient traffic
follows the function/processes and services flow
(Structure commensurate with
the function of the hospital)

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 10 20
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment , hanging
objects are properly
fastened and secured

ME C2.2 The facility ensures safety of X-ray - does not have temporary 1 OB Switch Boards other
electrical establishment connections and loosely hanging electrical installation are
wires intact

Stabilizer is provided for X-ray 1 OB

machine
ME C2.3 Physical condition of the Floors of the Radiology 1 OB
buildings is safe for providing department are non slippery and
patient care even

Window and door in X-ray room is 1 OB

provided with lead lining

Thickness of walls at X room are as 1 OB

AERB safety code
X-ray department should not be 1 OB
located adjacent to patient care
area

ME C2.5. The facility has adequate fire Radiology department has 1 OB

fighting Equipment installed fire Extinguisher for
fighting Type A,B and C Fire

Check the expiry date for fire 1 OB/RR

extinguishers are displayed on
each extinguisher as well as due
date for next refilling is clearly
mentioned

ME C2.6. The facility has a system of
periodic training of staff and
conducts mock drills regularly
for fire and other disaster
situation
Check for staff competencies for 1 SI/RR
operating fire extinguisher and
what to do in case of fire

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case 5 10
ME C3.4 The facility has adequate Availability of Radiographer load
1 SI/RR One radiographer
technicians/paramedics as per
requirement
ME C3.6 The staff has been provided Training on radiation safety 1 SI/RR
required training / skill sets
Training on infection control and 1 SI/RR
hand hygiene
Training on Bio Medical waste 1 SI/RR
Management
ME C3.7 The Staff is skilled as per job Radiographers are skilled to 1 SI/RR
description operating equipment
Standard C4 Facility provides drugs and consumables required for assured list of services. 3 6
ME C4.2 The departments have adequate Availability Consumables 1 OB/RR X-ray films, Developer,
consumables at point of use Fixer, USG gel, printing
paper

Availability of personal protective 1 OB/RR Lead apron with hanger,

equipment lead shield
ME C4.3 Emergency drug trays are Emergency Drug Tray is maintained 1 OB/RR Verify Presence of
maintained at every point of following Drugs:-Inj
care, where ever it may be Dopamine, Inj Adrenaline,
needed Inj Hydrocortisone
Succinate, Inj
Chlorpheniramine
Maleate,Inj Ranitidine, Inj
Onendestron

Standard C5 The facility has equipment & instruments required for assured list of services. 8 16
ME C5.1 Availability of equipment & Availability of functional 1 OB TLD badges
instruments for examination & Equipment &Instruments for
monitoring of patients examination & Monitoring
ME C5.3 Availability of equipment & Availability of functional X-ray 1 OB 300 MA X-ray machine
instruments for diagnostic machines
procedures being undertaken in
the facility

Availability of functional Dental 1 OB At least one

X-Ray Machine
Availability of functional 1 OB Desirable in the facility.
Ultrasonography Otherwise functional
linkage with nearby facility.

Availability of Accessories for X- 1 OB Cassettes X-ray,

ray Intensifying screen X-ray,
Lead letter (A-Z),Letter
figures (0-9) and R & L

ME C5.7 Departments have patient
furniture and fixtures as per
load and service provision
Availability of attachment/ 1 OB X-ray hangers, Bucky Stand
accessories
Availability of fixtures at lab 1 OB X-ray View box, Electrical
fixture for equipment

Availability of furniture 1 OB Rack and cupboard , Chair

table

Area of Concern - D Support Services 42 84

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 7 14
ME D1.1 The facility has established All equipment are covered under 1 SI/RR
system for maintenance of AMC including preventive
critical Equipment maintenance

There is system of timely 1 SI/RR

corrective break down
maintenance of the equipment

Staff is skilled for trouble shooting 1 SI/RR

in case equipment malfunction

Periodic cleaning, inspection and 1 SI/RR

maintenance of the equipment is
done by the operator

ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment

There is system to label/ code the 1 OB/ RR

equipment to indicate status of
calibration/ verification when
recalibration is due

ME D1.3 Operating and maintenance Operating instructions and factor 1 OB/SI

instructions are available with charts are available with the
the users of equipment equipment

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and 6 12
ME D2.1 There is established procedure There is established system ofpatient care
1 areas
SI/RR Stock level are daily
for forecasting and indenting timely indenting of X-ray films, updated
drugs and consumables fixer and developers etc. Requisition are timely
placed

ME D2.3 The facility ensures proper Fixers, developer and X-ray films/ 1 OB/RR
storage of drugs and consumables are kept away from
consumables water and sources of heat,
direct sunlight

Fixers and developer are labelled 1 OB/RR Reagents label contain

properly name, concentration, date
of preparation/opening,
date of expiry, storage
conditions and warning

ME D2.5 The facility has established Department maintains stock and 1 RR/SI
procedure for inventory expenditure register of chemicals
management techniques and X-ray films

ME D2.6 There is a procedure for There is procedure for replenishing 1 SI/RR

periodically replenishing the drugs drug tray
in patient care areas

There is no stock out of x-ray films 1 RR/SI

Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and comfortable
17 34
ME D3.2 Hospital infrastructure is
environment to staff, patients
Check to ensure that there is no 1 OB
and visitors.
adequately maintained seepage , cracks, chipping of
plaster

Window panes , doors and other 1 OB

fixtures are intact
ME D3,3 Patient care areas are clean and Floors, walls, roof, roof tops, sinks 1 OB All area are clean with no
hygienic patient care and circulation areas dirt,grease,littering and
are Clean cobwebs

Surface of furniture and fixtures 1 OB

are clean
ME D3.4. The facility has policy of removal No condemned/Junk material in 1 OB
of condemned junk material the X-ray and USG

ME D3.5 The facility has established No rodent/birds 1 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate illumination at work 1 OB
illumination level at patient care station at X-ray room
areas
 Adequate illumination at 1 OB
workstation at USG
ME D3.7 The facility has provision of Only one patient is allowed one 1 OB
restriction of visitors in patient time in X room
areas
Warning light is provided outside 1 OB/SI
X-ray room and its been used when
unit is functional

ME D3.8 The facility ensures safe and
comfortable environment for
patients and service providers
Protective apron and gloves are 1 OB/SI
being provided to relative of the
child patient who escort the child
for X-ray examination/
immobilisation support is provided
to children

X-ray room has been kept closed at 1 OB

the time of radiation exposure

Lead apron and other protective 1 OB

equipment are available with
radiation workers and they are
using it

TLD badges are available with all 1 OB

staff of X-ray department and
records of its regular assessment is
done by X-ray department

Temperature control and 1 SI/RR Fans/ Air

ventilation in X-ray room conditioning/Heating/Exha
ust/Ventilators as per
environment condition and
requirement

Temperature control and 1 SI/RR Exhaust in dark room

ventilation in dark room
Temperature control and 1 SI/RR Fans/ Air
ventilation USG conditioning/Heating/Exha
ust/Ventilators as per
environment condition and
requirement

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and supply potable water
for potable water in all
functional areas

ME D4.2 The facility ensures adequate Availability of power back up in 1 OB/SI

power backup in all patient care Radiology and USG room
areas as per load
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 7 14
ME D8.1 The facility has requisite X-ray has valid registration from 1 RR
licences and certificates for AERB.
operation of hospital and
different activities

X-ray department has layout 1 RR

approval from AERB
X-ray department has type 1 RR
approval of equipment with QA
test report for X-ray machine

USG department has registration 1 RR

under PCPNDT
Duplicate copy of Certificate of 1 OB
registration under Form B is
displayed inside the department

ME D8.3 The facility ensure relevant USG is taken by staff qualified as 1 RR

processes are in compliance per PCPNDT
with statutory requirement
Records of submission of Form F to 1 RR
appropriate district authorities

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 3 6
ME D9.1 The Staff is aware of theiroperating
The facility has established job role procedures.
1 SI
description as per govt and responsibilities
guidelines
ME D9.2 The facility has a established There is procedure to ensure that 1 RR/SI Check for system for
procedure for duty roster and the staff is available on duty as per recording time of reporting
deputation to different duty roster and relieving (Attendance
departments register/ Biometrics etc.)

ME D9.3 The facility ensures the Technician and support staff 1 OB

adherence to dress code as adhere to their respective dress
mandated by its code
administration / the health
department

Area of Concern - E Clinical Services 22 44

Standard E1 The facility has defined procedures for registration, consultation and admission of patients. 2 4
ME E1.1 The facility has established Unique identification number is 1 RR
procedure for registration of given to each patient
patients
Patient demographic details are 1 RR Check for that patient
recorded in radiology/USG records demographics like Name,
age, Sex, Chief complaint,
etc.

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral 1 2
ME E3.2 Facility provides appropriate There is procedure for referral 1 RR/SI
referral linkages to the of patient for which services can
patients/Services for transfer to not be provided at the facility
other/higher facilities to assure
their continuity of care.

Standard E5 Facility has a procedure to identify high risk and vulnerable patients. 1 2
ME E5.1 The facility identifies vulnerable Women in reproductive age are 1 OB/SI/RR Notice in local language is
patients and ensure their safe care asked for pregnancy (LMP)before displayed at entrance of X-
X-ray ray department asking
every female to inform
radiographer/radiologist
whether she is likely to be
pregnant

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 3 6
ME E8.5 Adequate form and formats are Standard Formats available 1 RR/OB Printed formats for
available at point of use requisition and reporting
are available

ME E8.6 Register/records are maintained Radiology records are labelled and 1 RR

as per guidelines indexed and maintained.
ME E8.7 The facility ensures safe and Radiology has adequate facility for 1 OB
adequate storage and retrieval storage of records
of medical records
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management 3 6
ME E10.3 The facility has disaster Staff is aware of disaster plan 1 SI/RR
management plan in place
Role and responsibilities of staff in 1 SI/RR
disaster is defined
ME E10.5 There is procedure for handling Procedure for handling of MLC 1 SI/RR Requisition and reports are
medico legal cases marked with MLC and
reports are handed over to
authorize person

Standard E11 The facility has defined and established procedures of diagnostic services 12 24
ME E11.1 There are established Requisition of all X-ray examination 1 RR/OB Request form contain
procedures for Pre-testing is done in request form information: Name and
Activities identification number of
patient, Provisional
diagnosis, Indication for
the investigation, name of
authorized requester,
examination requested,
type of X-ray, date and
time of X-ray taken and
date and time of receipt of
X-ray from X-ray
department

X-ray department has system in 1 RR/SI

place to label the X-rays
X-ray has system to trace the X-ray 1 RR/SI
from requisition form
Requisition of all USG examination 1 RR/OB
is done in request form

The USG department has system in 1 RR/SI

place to label the USGs

Preparation of the patient is done 1 RR/SI

as per requirement
Instructions to be followed by 1 RR/SI
patient for USG are displayed in
local language at reception

ME E11.2 There are established The X-ray taking and processing 1 OB/RR
procedures for testing Activities procedure are readily available at
work station and staff is aware of it

The Radiographer is aware of 1 RR/SI

operation of X-ray machine
USG of the patient is taken as per 1 OB/RR
consultant requirement
ME E11.3 There are established The X-ray department has format 1 RR/OB
procedures for Post-testing for reporting of results
Activities
The USG department has format 1 RR/OB
for reporting of results

Area of Concern - F Infection Control 19 38

Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated 2 4
ME F1.4 There is Provision of Periodic There is procedure for infection
1 SI/RR Hepatitis B, Tetanus Toxoid
Medical Check-up's and immunization of the staff etc.
immunization of staff
Periodic medical check-up's of the 1 SI/RR For Alopecia, Gonadal
staff atrophy, Peripheral Blood
Smear

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 7 14
ME F2.1 Hand washing facilities are Availability of hand washing 1 OB Check for availability of
provided at point of use Facility at Point of Use wash basin near the point
of use

Availability of running Water 1 OB/SI Open the tap. Ask the

Staff, water is available
24X7

Availability of antiseptic soap with 1 OB/SI Check for availability/ Ask

soap dish/ liquid antiseptic with staff if the supply is
dispenser. adequate and
uninterrupted

Availability of Alcohol based Hand 1 OB/SI Check for availability/ Ask

rub staff for regular supply.

Display of Hand washing 1 OB Prominently displayed

Instruction at Point of Use above the hand washing
facility , preferably in Local
language

ME F2.2 Staff is trained and adhere to Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
standard hand washing practices washing

Staff is aware of when to hand 1 SI

wash
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 4 8
ME F5.2 Facility ensures availability of Availability of cleaning agent as per 1 OB/SI Hospital grade phenyl,
standard materials for cleaning and requirement disinfectant detergent
disinfection of patient care areas solution
ME F5.3 Facility ensures standard practices Staff is trained for spill 1 SI/RR
followed for cleaning and management
disinfection of patient care areas

Cleaning of patient care area with 1 SI/RR

detergent solution
Standard practice of mopping and 1 OB/SI Unidirectional mopping
scrubbing are followed from inside out
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and 6 12
ME F6.1 Facility Ensures segregation of Availability of colour coded bins at 1 OB
Bio Medical Waste as per point of waste generation
guidelines
Availability of plastic colour coded 1 OB
plastic bags
Segregation of different category 1 OB/SI
of waste as per guidelines

Display of work instructions for 1 OB

segregation and handling of
Biomedical waste

There is no mixing of infectious 1 OB

and general waste
ME F6.3 Facility ensures transportation Disposal of Fixer and Developer 1 SI/OB/RR
and disposal of waste as per
guidelines

Area of Concern - G Quality Management 25 50

Standard G2 Facility has established system for patient and employee satisfaction 1 2
ME G2.1 Patient Satisfaction surveys are There is system to take feed back 1 RR
conducted at periodic intervals from clinician about quality of
services

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 2 4
ME G3.2 The facility has established TLD Badges are analysed at
external assurance programmes stipulated intervals
at relevant departments

1 SI/RR
ME G3.3 Facility has established system Departmental checklist is used 1 SI/RR
for use of check lists in different for monitoring and quality
departments and services assurance

Staff is designated for filling and 1 SI

monitoring of these checklists

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key 15 30
ME G4.1 Departmental standard Standard operating procedure for processes.
1 RR
operating procedures are department has been prepared
available and approved

Current version of SOP are 1 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures The Department has documented 1 RR
adequately describes process procedure for process of taking
and procedures and handling X-ray

The Department has documented 1 RR

procedure for acceptance and
rejection of X-ray taken

The Department has documented 1 RR

procedure for receipt, labelling ,
Processing and reporting of X-ray

The Department has documented 1 RR

procedure for taking X-ray in
emergency conditions

The Department has documented 1 RR

procedure for quality control
system to verify the quality of
results

The Department has documented 1 RR

system for repeat X-ray.

The Department has documented 1 RR

procedure for storage, retaining
and retrieval of department
records, and reports of results.

The Department has documented 1 RR

procedure preventive and break
down maintenance

The Department has documented 1 RR

procedure for purchase of External
services and supplies

The Department has documented 1 RR

procedure for inventory
management

The Department has documented 1 RR

procedure for radiation safety of
staff , patients and visitors

ME G4.3 Staff is trained and aware of the Check if staff is aware of relevant 1 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4 Work instructions are displayed Work Instructions are displayed for 1 OB Factor chart, radiation
at Point of use radiation safety safety, development for x-
ray films

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription 4 8
ME G5.1 The facility conducts periodic
Internal assessment is done at audit
1 RR/SI
internal assessment periodic interval
ME G5.3 The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and recorded
and recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive Corrective and preventive action 1 RR/SI
actions are taken to address are taken
issues, observed in the
assessment & audit

Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines Quality objectives for Radiology 1 RR/SI
its quality objectives and key are defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check of staff is aware of quality 1 SI
disseminated and staff is aware policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically

Area of Concern - H Outcome 14 28

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 5 10
ME H1.1 Facility measures productivity X-ray done per 1000 OPD patient 1 RR
Indicators on monthly basis
X-ray done per 1000 IPD patient 1 RR

Ultrasound done per 1000 OPD 1 RR

patient
No. of dental X-ray per 1000 dental 1 RR
OPD
ME H1.2 The Facility measures equity Proportion of BPL Patients 1 RR
indicators periodically underwent x-ray & USG
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 4 8
ME H2.1 Facility measures efficiency Downtime for critical equipment 1 RR
Indicators on monthly basis
Turn around time for X-Ray film 1 RR
development
Proportion of wastage of films 1 RR
Proportion of X-ray 1 RR
rejected/repeated
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 2 4
ME H3.1 Facility measures Clinical Care & Proportion of scans for which F 1 RR
Safety Indicators on monthly basis form is filled out of pregnant
women scanned

No of events of over limit of 1 RR

radiation exposure
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 3 6
ME H4.1 Facility measures Service Quality Average waiting time at radiology 1 RR
Indicators on monthly basis

Average waiting time at USG 1 RR

Incidences of X- ray films stock-out 1 RR

Radiology Score Card

Radiology Score 50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50

Obtained Maximum Percent 8

A 3 6 50
B 18 36 50
C 37 74 50
D 42 84 50
E 22 44 50
F 19 38 50
G 25 50 50
H 14 28 50
Total 180 360 50
 National Quality Assurance Standards for CHC 0 1 2
Checklist for Pharmacy & Stores 9
Reference Measurable Element Checkpoint Assessment Means of
No Compliance Method Verification Remarks

Area of Concern - A Service Provision 14 28

Standard A1 Facility Provides Curative Services 2 4
ME A1.9 Services are available for the time Dispensary services are available 1 SI/RR
period as mandated during OPD hours
Facility ensure access to drug store 1 SI/RR
after OPD hours

Standard A4 Facility provides services as mandated in national Health Programs/ state scheme 5 10
ME A4.1 The facility provides services under Availability of Drugs under NVBDCP 1 SI/OB Chloroquine,
National Vector Borne Disease Primaquine, ACT
Control Programme as per (Artemisinin
guidelines Combination
Therapy)

ME A4.2 The facility provides services under Availability of Drugs under RNTCP 1 SI/OB
Revised National TB Control
Programme as per guidelines
CAT 1, CAT II CAT
IV & Paediateric
ME A4.3 The facility provides services under Availability of Drugs under NLEP SI/OB
National Leprosy Eradication
Programme as per guidelines Rifampicin,
Clofazimine,
1 Dapsone
ME A4.4 The facility provides services under Availability of ARV Drugs under NACP 1 SI/OB Zidovudine,
National AIDS Control Programme Stavudine,
as per guidelines Lamivudine,
Nevirapine in
combination as
per NACO

Availability of Drugs for Paediatric HIV 1 SI/OB Paediatric Dosages

management FDC 6, FDC 10,
Efavirenz,
Cotrimoxazole

Standard A5 Facility provides support services and Administrative services 7 14

ME A5.6 The facility provides pharmacy and Dispensing of Medicines and
store services consumables for OPD Patients Functional
1 SI/OB dispensary
Storage of drugs 1 SI/OB
Storage of consumables 1 SI/OB
Storage of equipments 1 SI/OB
Storage of Stationaries. 1 SI/OB
Cold chain management services 1 SI/OB
Storage of Linen 1 SI/OB
Area of Concern - B Patient Rights 14 28
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their
5 10
ME B1.1
modalities
Availability departmental signages 1 OB (Numbering, main
department and
internal sectional
The facility has uniform and user- signage
friendly signage system

ME B1.2 The facility displays the services and List of available drugs displayed at
Pharmacy
1 OB
entitlements available in its
departments
Status of availability of drugs is 1 OB
updated weekly
Timings for dispensing counter of 1 OB
pharmacy are displayed
ME B1.6 Information is available in local Signage's and information are 1 OB
language and easy to understand available in local language
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no
2 4
ME B2.1
barrier Availability
on account of physical, economic, cultural
of separate Queue for 1
or social status.
OB
Services are provided in manner Male and female patients at
that are sensitive to gender dispensing counter

ME B2.3 Pharmacy has easy access for 1 OB Check for

moment of goods availability of
Access to facility is provided without ramp and goods
any physical barrier and is friendly trolley/ cart
to people with disabilities
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related
1 2
ME B3.3
information. 1
Behaviour of staff is empathetic and PI
The facility ensures the behaviours courteous
of staff is dignified and respectful,
while delivering the services
The facility has defined and established procedures for informing patients about the medical condition, and
Standard B4 involving them in treatment planning, and facilitates informed decision making 1 2
ME B4.4 Method of Administration /taking of 1 OB/SI
the medicines is informed to patient/
Information about the treatment is their relatives by pharmacist as per
shared with patients or attendants, doctors prescription in OPD Pharmacy
regularly

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost
5 10
ME B5.1
of hospital services.1
Free drugs and consumables for JSSK PI/SI
The facility provides cashless beneficiaries
services to pregnant women,
mothers and neonates as per
prevalent government schemes
ME B5.2 The facility ensures that drugs Pharmacy supplies generic drugs list 1 SI/OB
to all hospital departments as per
prescribed are available at their internal demand
Pharmacy and wards
Check that patient has not incurred 1 PI/SI
expenditure on purchasing drugs or
consumables from outside.
ME B5.4 Free drugs for BPL & other entitled 1 PI/SI/RR As per state
The facility provide free of cost patients guideline e. g:
treatment to Below poverty line geriateric patient
patients without administrative
hassles
ME B5.5 Local purchase of stock out drugs/ 1 PI/SI/RR
The facility ensures timely Reimbursement of expenditure to the
reimbursement of financial beneficiaries
entitlements and reimbursement to
the patients

Area of Concern - C Inputs 51 102

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent
12 24
norms
ME C1.1 Departments have adequate space The hospital has allocated space for
Minimum space
as per patient or work load Pharmacy in OPD
required is 250sq F
or
5% of average
OPD X 0.8 sq m.
1 OB
Dispensary has adequate waiting
space as per load
1 OB
ME C1.2 Patient amenities are provide as per Pharmacy has patients sitting 1
patient load arrangement as per requirement
OB
ME C1.3 Departments have layout and Dedicated area for keeping medical
demarcated areas as per functions gases

1 OB
Dedicated area for keeping
inflammables Storage of sprit
1 OB etc.
Demarcated are of keeping near
expiry drugs
1 OB
Demarcated area for keeping
instruments and consumables
1 OB
Dedicated area for cold chain
management
1 OB
ME C1.4 The facility has adequate circulation Availability of adequate circulation 1
area and open spaces according to area for easy moment of staff , drugs
need and local law and carts
OB
ME C1.5 The facility has infrastructure for Availability of functional telephone 1
intramural and extramural and Intercom Services
communication
OB
ME C1.6 Service counters are available as per Adeqauate no. of drug dispensing 1
patient load counter as per load
OB
ME C1.7 The facility and departments are Unidirectional flow of goods in the 1 Receipt and
planned to ensure structure follows Pharmacy . Inspection area at
the function/processes (Structure one side and issue
commensurate with the function of area on the other
the hospital) side
OB
Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 9 18
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures
safety of the infrastructure properly secured and furniture like
cupboards,
cabinets, and
heavy
equipments ,
hanging objects
are properly
fastened and
secured

ME C2.2 The facility ensures safety of Pharmacy does not have temporary 1 OB
electrical establishment connections and loosely hanging wires

Stabilizer is provided for cold chain 1 OB

room
ME C2.3 Physical condition of buildings are Windows of drug store have grills and 1 OB
safe for providing patient care wire meshwork

Floors of the Pharmacy department 1 OB

are non slippery, acid resistant & even
surface

ME C2.4 The facility has plan for prevention Pharmacy has plan for safe storage 1 OB/SI
of fire and handling of potentially flammable
materials.

ME C2.5 The facility has adequate fire Pharmacy has installed fire 1 OB/RR
fighting Equipment Extinguisher for A,B, C class of fire

Check the expiry date on fire 1 OB/RR

extinguishers is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned

ME C2.6 The facility has a system of periodic Check staff competencies for 1 SI/RR
training of staff and conducts mock operating fire extinguisher and what
drills regularly for fire and other to do in case of fire
disaster situation

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current
7 14
ME C3.4 The facility has adequate Availability of Pharmacist
case load 1 SI/RR
technicians/paramedics as per
requirement
ME C3.6 The staff has been provided Inventory management SI/RR
required training / skill sets 1
Cold chain management of ILR and SI/RR
deep freezer
1
Rational use of drugs 1 SI/RR
Prescription Audit 1 SI/RR
ME C3.7 The Staff is skilled as per job Staff is skilled for estimation of the 1 SI/RR
description requirement and proper storage of
the drugs

Staff is skilled for maintaining 1 SI/RR

pharmacy records and bin cards
Standard C4 Facility provides drugs and consumables required for assured list of services. 20 40
ME C4.1 The departments have availability of Analgesics/ Antipyretics/Anti
adequate drugs at point of use inflammatory

1 OB/RR As per State EDL

Antibiotics 1 OB/RR As per State EDL
Anti Diarrhoeal 1 OB/RR As per State EDL
Antiseptic lotion 1 OB/RR As per State EDL
Dressing material 1 OB/RR As per State EDL
IV fluids and plasma expenders 1 OB/RR As per State EDL
Eye and ENT drops 1 OB/RR As per State EDL
Anti allergic 1 OB/RR As per State EDL
Drugs acting on Digestive system 1 OB/RR As per State EDL
Drugs acting on cardio vascular
system
1 OB/RR As per State EDL
Drugs acting on central/Peripheral
Nervous system
1 OB/RR As per State EDL
Drugs acting on respiratory system
1 OB/RR As per State EDL
Drugs acting on uro genital system
1 OB/RR As per State EDL
Drugs used on Obstetrics and
Gynaecology
1 OB/RR As per State EDL
Hormonal Preparation 1 OB/RR As per State EDL
Other drugs and materials 1 OB/RR As per State EDL
Vaccine & Sera 1 OB/RR As per State EDL
Surgical accessories for Eye 1 OB/RR As per State EDL
Vitamins and nutritional supplement
1 OB/RR As per State EDL
ME C4.2 The departments have adequate Availability of Consumables
consumables at point of use 1 OB/RR As per Sate EDL
Standard C5 The facility has equipment & instruments required for assured list of services. 3 6
ME C5.5 Availability of Equipment for Availability of Equipment for
Storage maintenance of Cold chain
ILR, Deep
Freezers, Insulated
carrier boxes with
1 OB ice packs,
ME C5.6 Availability of functional equipment Availability of equipment for 1 Buckets for
and instruments for support cleaning mopping, mops,
services duster, waste
trolley, Deck brush

OB
ME C5.7 Department have patient furniture Storage furniture for drug store
and fixtures as per load and service
provision
Racks ,Cupboards,
Sectional Drawer
cabinet/ Shelves,
1 OB Work table
Area of Concern - D Support Services 58 116
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 2 4
ME D1.2 The facility has established All the measuring equipment/ 1 OB/ RR Calibration of
procedure for internal and external instruments are calibrated thermometers at
calibration of measuring Equipment cold chain room

ME D1.3 Operating and maintenance Operating instructions for ILR/ Deep 1 OB/SI
instructions are available with the Freezers are available at cold chain
users of equipment room

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and
39 78
patient care areas 1
ME D2.1 There is established procedure for Drug store has process to consolidateRR/SI
forecasting and indenting drugs and and calculate the consumption of all
consumables drugs and consumables

Forecasting of drugs and 1 RR/SI

consumables is done scientifically
which is realistic & is based on
consumption pattern and disease load

Staff is trained for forecasting the 1 RR/SI

requirement using scientific system

ME D2.2 The facility has establish procedure The facility has a established 1 RR/SI
for procurement of drugs procedure for local purchase of drugs
in emergency conditions

The facility has a system for placing 1 RR/SI

requisition to district drug store

ME D2.3 The facility ensures proper storage There is specified place to store
of drugs and consumables medicines in Pharmacy and drug store

1 OB
All the shelves/racks containing
medicines are labelled in pharmacy
and drug store
Stock is arranged
neatly in
alphabetic order
with name facing
1 OB the front.
Product of similar name and different
strength are stored separately
1 OB
Heavy items are stored at lower
shelves/racks
1 OB
Fragile items are not stored at the
edges of the shelves.
1 OB
Sound alike and look alike medicines
are stored separately in patient care
area and pharmacy
1 OB
There is separate shelf /rack for
storage near expiry drugs
1 OB
Drug store and pharmacy has system
of inventory Management
1 OB/SI
 Drugs and consumables are stored
away from water and sources of heat,
direct sunlight etc.
Medications that
are considered
light-sensitive will
be stored in closed
1 OB/RR drawers.
Drugs are not stored on floor and
adjacent to wall Pallets are
provided if
required to store
1 OB at floor
ME D2.4 The facility ensures management of The Dispensing counter has system to 1 RR/SI
expiry and near expiry drugs check the expiry of drugs

Drug store has system to check the 1 RR/SI

expiry of drugs
Drug store has system to inform the 1 RR/SI
patient care areas about near expiry
and system of call back of Expired
drugs

There is a system of periodic random 1 RR/SI

ME D2.5 The facility has established
procedure for inventory
management techniques
quality testing of drugs
Physical verification of inventory is 1 RR/SI
done periodically
Facility uses bin card system 1 RR/OB
First expiry first out system is 1 OB
established for drugs
Stores has defined minimum stock for 1 RR/OB
each category of drug as per there
consumption pattern

Reorder level is defined for each 1 RR

category of drugs
Drug store has inventory 1 OB/RR
management software
Drugs are categorized in Vital, 1 OB/RR
Essential and Desirable (VED)
ME D2.6 There is a procedure for periodically Hospital has system of collection of 1 RR/SI
replenishing the drugs in patient care medicines from store in case of
areas emergency

ME D2.7 There is process for storage of
vaccines and other drugs, requiring sequence
controlled temperature
Check that vaccines are kept in
(Top to bottom) :
Hep B, DPT, DT,
TT, BCG, Measles,
1 OB OPV
Work instruction for storage of
vaccines are displayed at point of use
1 OB
ILR and deep freezer have functional
temperature monitoring devices
1 OB
There is a system in place to maintain
temperature chart of ILR

Temp. of ILR: Min

+2OC to 8Oc in case
of power failure
min temp. +10OC .
Daily temperature
1 OB log are maintained
There is a system in place to maintain
temperature chart of deep freezers
Temp. of Deep
freezer cabinet is
maintained
between -15OC to -
25OC.Daily
temperature log
1 OB are maintained
Check that thermometer in ILR is in
hanging position
1 OB
ILR and deep freezer have functional
alarm system
1 SI/RR
the staff is aware of hold over time of
cold storage equipments
1 SI/RR
ME D2.8 There is a procedure for secure Narcotic medicines are kept in double
storage of narcotic and psychotropic lock
drugs

As per Narcotic
act, Narcotic
medicines are kept
in 2 Keys with 2
locks kept by 2
1 OB different persons
Empty ampoules/strips are returned
along with narcotic administration
detail sheet
1 OB/RR
Hospital has a system to discard the
expired narcotic drugs Discarded narcotic
drugs are
documented with
1 RR/SI witness.
The facility maintains the list of
narcotic and psychotropic drugs
available at facility
1 RR
Standard D3 The facility has established Program for maintenance and upkeep of the faciity to provide safe, secure and
10 20
ME D3.2.
comfortable environment to staff, patients
Hospital infrastructure is adequately Check for there is no seepage , Cracks, 1
and
OB
visitors.
maintained chipping of plaster
Window panes , doors and other 1 OB
fixtures are intact
ME D3.3 Patient care areas are clean and Interior of patient care areas are 1 OB
hygienic plastered & painted
Floors, walls, roof, roof tops, sinks OB
patient care and circulation areas are
Clean
All area are clean
with no
dirt,grease,litterin
1 g and cobwebs
 Surface of furniture and fixtures are 1 OB
clean
ME D3.4. The facility has policy of removal of Actions for removing junk condemned 1 OB At least 6 month
condemned junk material articles are periodically taken interval

ME D3.5 The facility has established No stray animal/rodent/birds 1 OB

procedures for pest, rodent and
animal control
ME D3.6 The facility provides adequate Adequate Illumination inside drug
illumination level at patient care store
areas
1 OB
ME D3.8 The facility ensures safe and Temperature control and ventilation 1 Fans/ Air
comfortable environment for in pharmacy is maintained conditioning/Heati
patients and service providers ng/Exhaust/Ventil
ators as per
environment
condition and
requirement

SI/RR
ME D3.9 The facility has security system in Security arrangement at pharmacy is 1 OB
place at patient care areas robust
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services
2 4
norms
ME D4.2 The facility ensures adequate power Availability of power back up in the
1 OB/SI
backup in all patient care areas as Pharmacy
per load
Availability of power back up for the 1 OB/SI
cold chain maintenance
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 1 2
ME D8.1 The facility has requisite licences License for storing spirit 1 RR
and certificates for operation of
hospital and different activities

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
4 8
operating procedures.1
ME D9.1 The facility has established job Staff is aware of their roles and SI
description as per govt guidelines responsibilities

ME D9.2 The facility has a established There is a procedure to ensure that 1 RR/SI Check for system
procedure for duty roster and staff is available on duty as per duty for recording time
deputation to different departments roster of reporting and
relieving
(Attendance
register/
Biometrics etc)

There is designated in charge for 1 SI

department
ME D9.3 The facility ensures the adherence Pharmacist adhere to their respective 1 OB
to dress code as mandated by its dress code
administration / the health
department

Area of Concern - E Clinical Services 13 26

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic
5 10
drugs & their rational use.
ME E6.1 Facility ensured that drugs are The facility has essential drug list as 1 RR/SI
prescribed in generic name only per State guideline
Drugs are purchased by generic name 1 OB
only
The facility has enabling order 1 RR/SI
from state for writing drugs in
generic name only
The facility provide list of drugs 1 RR/SI
available to different departments
as per essential drug list

There is system of conducting 1 RR/SI

periodic prescription audit to
ensure that only generic and
rational drugs are prescribed

Standard E7 Facility has defined procedures for safe drug administration 1 2

ME E7.1 There is process for identifying and Pharmacy has list of high risk drugs. 1 RR/SI
cautious administration of high alert
drugs
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their
4 8
ME E8.5 Adequate form and formats are Standard Formats available
storage 1 RR/OB Bin cards, indent
available at point of use forms etc
ME E8.6 Register/records are maintained as Pharmacy records are labeled and 1 RR
per guidelines indexed
Records are maintained for Pharmacy 1 RR

ME E8.7 The facility ensures safe and Pharmacy has adequate facility for 1 OB
adequate storage and retrieval of storage of records
medical records
Standard E10
The facility has defined and established procedures for Emergency Services and Disaster Management
3 6
ME E10.3 The facility has disaster Staff is aware of disaster plan 1 SI/RR
management plan in place
Roles and responsibilities of staff in 1 SI/RR
disaster are defined
Contingency/Buffer stock for Disaster 1 SI/RR
and mass casualties.

Area of Concern - F Infection Control 7 14

Facility has infection control program and procedures in place for prevention and measurement of hospital
Standard F1 3 6
associated infection
There is Provision of Periodic There is a procedure for immunization
Medical Checkups and of the staff
immunization of staff Hepatitis B,
ME F1.4 1 SI/RR Tetanus Toxid etc
Periodic medical checkups of the staff
are conducted
1 SI/RR
Facility has defined and established Check for Pharmacist are aware of
antibiotic policy Hospital Antibiotic Policy
ME F1.6 1 SI/RR
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention 1 2
 Facility ensures availability of standard Availability of cleaning agent as per
materials for cleaning and disinfection requirement
of patient care areas
Hospital grade
phenyl,
disinfectant
ME F5.2 1 OB/SI detergent solution
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical
Standard F6 3 6
Facility Ensures segregation of Bio
and hazardous Waste.
Availability of colour coded bins and
Medical Waste as per guidelines liner for disposal of expired drugs

ME F6.1 1 OB
There is no mixing of infectious and
general waste
1 OB
Facility ensures transportation and Disposal of expired drugs as per
disposal of waste as per guidelines state guidelines
ME F6.3 1 SI/OB
Area of Concern - G Quality Management 35 70
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 3 6
ME G3.1 Facility has established internal Physical verification of the inventory 1 SI/RR
quality assurance program at by Pharmacist at periodic intervals
relevant departments
ME G3.3 Facility has established system for Departmental checklist are used 1 SI/RR
use of check lists in different for monitoring and quality
departments and services assurance
Staff is designated for filling and 1 SI
monitoring of these checklists

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key
17 34
ME G4.1
processes and support services.
Departmental standard operating Standard operating procedure for 1 RR
procedures are available department has been prepared and
approved

Current version of SOP are available 1 OB/RR

with process owner
ME G4.2 Standard Operating Procedures Department has documented 1 RR
adequately describes process and procedure for indent the drugs and
procedures items from district drug warehouse

Department has documented 1 RR

procedure for local purchase of drugs/
generic drug stores

Department has documented 1 RR

procedure for reception of drugs and
items

Department has documented 1 RR

procedure for storage of drugs
Department has documented 1 RR
procedure for disposal of expired
drugs

Department has documented 1 RR

procedure for dispensing of medicines
at Pharmacy

Department has documented 1 RR

procedure of supply the drugs to
patient care area

Department has documented 1 RR

procedure for issue of the drugs in
emergency condition

Department has documented 1 RR

procedure for maintenance of
temperature of ILR/Deep freezer
/refrigerators

Department has documented 1 RR

procedure for maintaining near expiry
drugs at store and pharmacy

Department has documented 1 RR

procedure for rational use of drugs
and prescription audit

Department has documented 1 RR

procedure for storage of narcotic and
psychotropic drugs

Department has documented system 1 RR

for periodic random check and
quality testing of drugs

ME G4.3 Staff is trained and aware of the Check staff is a aware of relevant part 1 SI/RR
standard procedures written in SOPs of SOPs

ME G4.4 Work instructions are displayed at Work instruction/clinical protocols 1 OB Work instruction
Point of use are displayed for storing drugs,
Cold chain
management

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and
6 12
prescription audit 1
ME G5.1 The facility conducts periodic Internal assessment is done at RR/SI
internal assessment periodic interval
ME G5.2 The facility conducts the periodic Pharmacy department co ordinates 1 RR/SI
prescription/ medical/death audits the prescription audit

Storage and compilation of records of 1 RR/SI

prescription audit
ME G5.3 The facility ensures non Non Compliance are enumerated and 1 RR/SI
compliances are enumerated and recorded
recorded adequately
ME 5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive actions Corrective and preventive actions 1 RR/SI
are taken to address issues, taken
observed in the assessment & audit
Standard G6 The facility has defined and established Quality Policy & Quality Objectives 3 6
ME G6.2 The facility periodically defines its Quality objectives for Pharmacy are 1 RR/SI
quality objectives and key defined
departments have their own
objectives

ME G6.3 Quality policy and objectives are Check if staff is aware of quality policy 1 SI
disseminated and staff is aware of and objectives
that
ME G6.4 Progress towards quality objectives Quality objectives are monitored and 1 SI/RR
is monitored periodically reviewed periodically

Standard Facility seeks continually improvement by practicing Quality method and tools.
G7
6 12
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services
5S 1 SI/OB
Process Mapping 1 SI/OB
Any other method of QA 1 SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Pareto / Prioritization 1 SI/RR
Area of Concern - H Outcome 10 20
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 2 4
ME H1.1 Facility measures productivity Percentage of drugs available against
Indicators on monthly basis essential drug list
1 RR
ME H1.2 The Facility measures equity indicators Expenditure on drugs procured
periodically through local purchase for BPL patient
1 RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 3 6
ME H2.1 Facility measures efficiency Indicators Number of stock out situations for
on monthly basis Vital category of drugs/consumables.
1 RR
Turn Around time for dispensing
medicine at Dispensary
1 RR
Percentage of drugs expired during
the months
1 RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 8
ME H3.1 Facility measures Clinical Care & Safety Proportion of prescription found
Indicators on monthly basis prescribing non generic drugs
1 RR
No of advere drug reaction per
thosuand patients
1 RR
Antibiotic rate

No. of antibiotic
prescribed /No. of
patient admitted
1 RR or consulted
Percentage of irrational use of
drugs/overprescription
1 RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 1 2
ME H4.1 Facility measures Service Quality Waiting time for Pharmacy Counter
Indicators on monthly basis
1 RR

Pharmacy Card
Pharmacy Score 50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50

Obtained Maximum Percent 9

A 14 28 50
B 14 28 50
C 51 102 50
D 58 116 50
E 13 26 50
F 7 14 50
G 35 70 50
H 10 20 50
Total 202 404 50
 National Quality Assurance Standards for CHC 0 1 2
Checklist for Blood Storage Centres 10
Reference Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
No. Method
. Area of Concern - A Service Provision 6 12
Standard A1. Facility Provides Curative Services 4 8
ME A1.9. The Services are available for Blood storage services are available 1 SI/RR Lab Technician in charge is
the time period as mandated 24X7 available after working
hour

ME A1.11. The facility provides Blood Blood storage has facility for 1 SI/OB
storage & transfusion services storage of whole blood

Blood storage has facility for 1

storage of blood components
mainly platelets.

. Blood storage has emergency stock 1 SI/OB A, B, O (+)-5units; AB + 2

of blood as per MoHFW Guideline units and 1 unit each of
A,B, & O Negative {may be
modified as per usage)

Standard A3 Facility Provides diagnostic Services 1 2

ME A3.2 The facility Provides Laboratory Availability of Blood Grouping, 1 SI/OB
Services compatability testing and cross
matching services

Standard A4 Facility provides services as mandated in National Health Programs/ state scheme 1 2
ME A4.1 The facility provides services Facility to arrange for platelets 1 SI/RR
under National Vector Borne from parent blood bank for
Disease Control Programme as management of Dengue cases.
per guidelines

. Area of Concern - B Patient Rights 9 18

Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their 5 10
ME B1.1. The facility has uniform and Availability of Departmental 1 OB (Numbering Rooms, main
user-friendly signage system signages department and inter-
sectional signage)

ME B1.2. The facility displays the services Blood storage has displayed 1 OB
and entitlements available in its information regarding number of
departments blood units available

ME B1.4. User charges are displayed and Applicable user charges of blood 1 OB
communicated to patients are displayed at the entrance
effectively
ME B1.5. Patients & visitors are sensitised IEC material is available in Blood 1 OB
and educated through Storage to provide information and
appropriate IEC / BCC to promote blood donation
approaches

ME B1.6. Information is available in local Signage's and information are 1 OB

language and easy to available in local language
understand
Standard B3. The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 1 2
ME B3.3 The facility ensures the Behaviour of staff is empathetic 1 PI/OB
behaviours of staff is dignified and courteous
and respectful, while delivering
the services

Standard B5. Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of 3 6
ME B5.1. The facility provides cashless Free blood for Pregnant women, 1 PI/SI
services to pregnant women, Mothers and New-Borns and
mothers and neonates as per infants.
prevalent government schemes

ME B5.2 The facility ensures that drugs Check that parents & attendant's 1 PI/SI
prescribed are available at have not spent money on
Pharmacy and wards purchasing bloods from outside.

ME B5.4. The facility provide free of cost Free blood is provided to BPL 1 PI/SI/RR
treatment to Below poverty line patients
patients without administrative
hassles

.
Area of Concern C: Inputs 21 42
Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent 4 8
ME C1.1. Departments have adequate Blood storage has adequate space 1 OB Space required is more
space as per patient or work as per requirement than 10sq meters
load
ME C1.3. Departments have layout and Dedicated area for Whole blood 1 OB
demarcated areas as per and components
functions
. Dedicated space for keeping records 1 OB

ME C1.5. The facility has infrastructure Availability of functional Intercom 1 OB

for intramural and extramural and telephone services
communication
Standard C2. The facility ensures the physical safety including Fire safety of the infrastructure. 8 16
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and
safety of the infrastructure properly secured furniture like cupboards,
cabinets, and heavy
equipment ,hanging
objects are properly
fastened and secured

ME C2.2 The facility ensures safety of Blood storage does not have 1 OB
electrical establishment temporary connection and loosely
hanging wires

. Adequate electrical socket 1 OB/RR

provided for safe and smooth
operations of testing equipment

ME C2.3 Physical condition of buildings Work benches are chemical 1 OB

are safe for providing patient
care
resistant
Blood storage has plan for safe 1 OB
storage and handling of potentially
flammable materials.
ME C2.5. The facility has adequate fire At least one Fire Extinguisher ABC 1 OB/RR
fighting Equipment Type is available in vicinity of blood
storage.

. Check the expiry date for fire 1 OB/RR

extinguisher is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned

ME C2.6 The facility has a system of
periodic training of staff and
conducts mock drills regularly
for fire and other disaster
situation
Check for staff competencies for 1 SI/RR
operating fire extinguisher and
what to do in case of fire

Standard C3. The facility has adequate qualified and trained staff, required for providing the assured services to the current case 5 10
ME C3.1. The facility has adequate Availability of designated Blood 1 OB/RR MBBS doctor with 3 days
specialists doctors as per storage officer. recognized training on
service provision blood storage

ME C3.4. The facility has adequate Availability of Trained Technician 1 SI/RR DMLT with one day
technicians/paramedics as per for Blood storage recognized training on
requirement blood storage.

ME C3.6. The staff has been provided IMEP training. 1 SI/RR

required training / skill sets
Blood storage management 1
ME C3.7 The Staff is skilled as per job Staff is skilled in operating the 1 SI/RR
description equipment
Standard C4. Facility provides drugs and consumables required for assured list of services. 2 4
ME C4.1. The departments have Availability of Laboratory materials 1 OB/RR Pauster pipette, glass
availability of adequate drugs at tubes, gloves, tooth picks
point of use Glass slides, Glass
marker/paper stickers

ME C4.2. The departments have Availability of Reagents /Kits and 1 OB/RR Standard Grouping Sera
adequate consumables at point other consumables for testing. Anti A, Anti B & Anti D,
of use Antihuman Globulin.

Standard C5. The facility has equipment & instruments required for assured list of services. 2 4
ME C5.3. Availability of equipment & Availability of laboratory 1 OB Microscope, RH viewer.
instruments for diagnostic equipment & instruments for
procedures being undertaken in laboratory
the facility

ME C5.5. Availability of Equipment for Check for availability of storage 1 OB Blood bags refrigerator
Storage equipment for blood products with thermo graph and
alarm device, Insulated
carrier boxes with ice
packs, Blood bag weighting
machine, deep freezer,

. Area of Concern - D Support Services 36 72

Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 10 20
ME D1.1. The facility has established All equipment are covered under 1 SI/RR Agency/ ies identified for
system for maintenance of AMC including preventive maintenance for
critical Equipment maintenance equipments

. There is system of timely corrective 1 SI/RR

break down maintenance of the
equipments

. There has system to label 1 OB/RR

Defective/Out of order equipments
and stored appropriately until it
has been repaired

Staff is skilled for trouble shooting 1 SI/RR

in case equipment malfunction

Periodic cleaning, inspection and 1 SI/RR

maintenance of the equipments is
done by the operator

ME D1.2. The facility has established All the measuring equipments/ 1 OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment

. There is system to label/ code the 1 OB/ RR

equipment to indicate status of
calibration/ verification when
recalibration is due

. Blood storage has system to update 1 SI/RR Check for records

correction factor after calibration
wherever required

. Each lot of reagents has to be 1 SI/RR

checked against earlier tested in
use reagent lot or with suitable
reference material before being
placed in service and result should
be recorded.

ME D1.3. Operating and maintenance Up to date instructions for 1 OB/SI

instructions are available with operation and maintenance of
the users of equipment equipments are readily available
with staff.

Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and 10 20
ME D2.1. There is established procedure There is established system of 1 SI/RR Stock level are daily
for forecasting and indenting timely indenting of consumables updated
drugs and consumables and reagents Requisition are timely
placed

ME D2.3 The facility ensures proper Reagents and consumables are 1 OB/RR
storage of drugs and kept away from water and sources
consumables of heat,
direct sunlight

Reagents are labelled appropriately 1 OB/RR Reagents label contain

name, concentration, date
of preparation/opening,
date of expiry, storage
conditions and warning
ME D2.4. The facility ensures Expiry dates' of the blood bags are 1 OB/RR
management of expiry and near maintained
expiry drugs
No expired blood is found in 1 OB/RR
storage
Records for expiry and near expiry 1 RR
blood are maintained
ME D2.5 The facility has established Department maintained stock and 1 SI/RR
procedure for inventory expenditure register of reagents
management techniques
ME D2.6 There is a procedure for There is no stock out of reagents 1 OB/SI
periodically replenishing the drugs
in patient care areas

ME D2.7. There is process for storage of
vaccines and other drugs,
requiring controlled
temperature
Temperature of refrigerators used
for storing lab reagents are kept as
per storage requirement and
records are maintained
1 SI/RR Check for temperature
charts are maintained and
updated periodically for
refrigerators used storing
lab reagents

. Regular Defrosting is done 1 SI/RR

Standard D3. The facility has established Program for maintenance and upkeep of the facility to provide safe, secure and 6 12
ME D3.2. Hospital infrastructure is there is no seepage , Cracks, 1 OB
adequately maintained chipping of plaster
Window panes , doors and other 1 OB
fixtures are intact
ME D3.3. Patient care areas are clean and Floors, walls, roof, sinks,are Clean 1 OB All area are clean with no
hygienic dirt,grease,littering and
cobwebs

Surface of furniture and fixtures 1 OB

are clean
ME D3.4. The facility has policy of No condemned/Junk material in 1 OB
removal of condemned junk blood storage
material
ME D3.6. The facility provides adequate Adequate illumination at blood 1 OB Illumination level of Blood
illumination level at patient care storage storage is as per
areas recommendation/
sufficient to carry out
Blood storage activities

Standard D4. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services 3 6
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI
arrangement storage and potable water
supply for portable water in all
functional areas

ME D4.2. The facility ensures adequate Availability of power back up for 1 OB/SI
power backup in all patient care blood storage
areas as per load

Availability of UPS 1 OB/SI

Standard D8. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 3 6
ME D8.1. The facility has requisite Blood storage has obtained 1 RR
licences and certificates for approval from the State/UT
operation of hospital and licensing Authority.
different activities

Facility has obtained consent from 1 RR/SI

Parent blood bank.
Parent Blood Bank has valid 1 RR
license under Rule 122(G) Drug
and cosmetic act
Standard D9. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards 4 8
ME D9.1. The facility has established job Staff is aware of their role and 1 SI
description as per govt responsibilities
guidelines
ME D9.2. The facility has a established There is procedure to ensure that 1 RR/SI Check for system for
procedure for duty roster and staff is available on duty as per recording time of reporting
deputation to different duty roster and relieving (Attendance
departments register/ Biometrics etc)

There is designated in charge for 1 SI

department
ME D9.3. The facility ensures the Doctor, technician and support 1 OB
adherence to dress code as staff adhere to their respective
mandated by its dress code
administration / the health
department

. Area of Concern - E Clinical Services 26 52

Standard E3. Facility has defined and established procedures for continuity of care of patient and referral 2 4
ME E3.2. Facility provides appropriate There is procedure for referral 1 SI/RR
referral linkages to the of cases for which requested
patients/Services for transfer to blood group is not available
other/higher facilities to assure
their continuity of care.

. Facility has functional referral 1 SI/RR

linkages to parent blood bank

Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their 4 8
ME E8.5 Adequate form and formats are Standard Formats available 1 RR/OB Format for requisition
available at point of use form, blood transfusion
reaction form, referral slip

ME E8.6. Register/records are maintained Blood storage records are labelled 1 RR

as per guidelines and indexed
. Records are maintained for Blood
storage
ME E8.7. The facility ensures safe and Safe keeping of patient records
adequate storage and retrieval
of medical records
Standard E10. The facility has defined and established procedures for Emergency Services and Disaster Management
ME E10.3. The facility has disaster Blood storage has system of coping
management plan in place with extra demand of blood in case
of disaster
Standard E12 The facility has defined and established procedures for Blood storage Management and Transfusion.
ME 12.1 There is established procedure Blood storage has standardized 1 RR/SI
for Transport of blood from procedure for transporting blood
parent blood bank. from parent blood bank.
Cold chain is maintained at all
levels i.e. from parent blood bank
to blood storage to the issue of
blood.
ME 12.2 There is established procedure Blood storage has standardized
for storage of blood procedure for receipt of blood from
parent blood bank.
Check for refrigerators or freezers
for blood storage are not used for
storing other items
Check for refrigerators used for
blood storage are kept at
recommended temperature
Storage temperature is monitored
atleast twice a day.
Alarm system has been provided
with refrigerator
Shelf life of blood and components
is adhered as per NACO protocols
. Blood storage has system to trace
of unit of blood /component from
source to final destination
ME E12.3. There is established procedure Determination of ABO group is
for the Cross matching of blood done by recommended methods
Determination of Rh (D) Type done
as per recommended method
Blood storage has system to testing
and cross matching the recipient
blood
ME E12.4 There is established procedure Blood storage has system to testing
for issuing blood and cross matching the unit before
issuing
. Blood storage has system to
confirm that information on
transfusion requisition form and
recipients blood sample label is
same
. Blood storage has system to retain
recipient and donor blood sample
for 7 days at specified temperature
(2-8 c) after each transfusion
. Blood storage has system to issue
the blood along with cross
matching report
. Blood storage has procedure to
issue the blood in case of its
emergency requirement
ME E12.6 There is a established Transfusion reaction form is
procedure for monitoring and provided when blood is issued
reporting Transfusion
complication
1 RR Records includes daily
group wise stock register,
daily temperature
recording of temperature
dependent equipment,
stock register of
consumables and non
consumables, documents
of proficiency testing,
records of equipment
maintenance, records of
recipient, compatibility
records, transfusion
reaction records, donors
records etc.
1 OB Blood storage has facility
to store records for 5 year
1 2
1 SI/RR
19 38
1 OB/SI During transportation
blood is properly packed in
cold boxes surrounded by
ice packs. Ice should not
come in contact with blood
bags.
1 RR/SI all the blood/component
units are checked for
haemolysis, turbidity, or
change in colour on receipt
from parent blood bank
1 OB Lab reagents etc.
1 OB/RR Check records that
temperature is maintained
at 4OC + 2OC
1 OB/RR Check the records
1 RR/SI
1 RR/SI
1 RR/SI Blood should be kept at
4oC to 6oC except if it is
used for component
preparation it will be
stored at 22oC until
platelet are separated
1 RR/SI Tube or Microplate or gel
technology
1 RR/SI Check for the protocol/
Algorithm followed for
determining RH + or RH-
Blood type
1 RR/SI Testing of recipient blood
includes Determination
ABO type, Rh (D) type,
detection of unexpected
antibodies etc.
1 RR/SI Testing of blood includes
Determination ABO type,
Rh (D) type, detection of
unexpected antibodies etc.
1 RR/SI
1 RR/SI
1 RR/SI
1 RR/SI
1 RR/SI
. Blood storage has system of 1 RR/SI
detection, reporting and
evaluations of transfusion errors

. Area of Concern - F Infection Control 33 66

Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital 2 4
ME F1.4. There is Provision of Periodic There is procedure for associated infection
1 SI/RR Hepatitis B, Tetanus Toxid
Medical Checkups and immunization of the staff etc
immunization of staff
.ME F1.5. Facility has established Regular monitoring of infection 1 SI/RR Hand washing and
procedures for regular control practices infection control audits
monitoring of infection control done at periodic intervals
practices

Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 7 14
ME F2.1. Hand washing facilities are Availability of hand washing Facility 1 OB Check for availability of
provided at point of use at Point of Use wash basin near the point
of use

. Availability of running Water 1 OB/SI Ask to Open the tap. Ask

Staff water supply is
regular

. Availability of antiseptic soap with 1 OB/SI Check for availability/ Ask

soap dish/ liquid antiseptic with staff if the supply is
dispenser. adequate and
uninterrupted

Display of Hand washing 1 OB Prominently displayed

Instruction at Point of Use above the hand washing
facility , preferably in Local
language

Hand washing sink is wide and 1 OB

deep enough to prevent splashing
and retention of water

ME F2.2. Staff is trained and adhere to Adherence to 6 steps of Hand 1 SI/OB Ask of demonstration
standard hand washing washing
practices
. Staff aware of when to hand wash 1 SI

Standard F3. Facility ensures standard practices and materials for Personal protection 2 4
ME F3.1. Facility ensures adequate Clean gloves are available at point 1 OB/SI All personal use gloves
personal protection equipments of use while drawing sample,
as per requirements examining and disposable
of the samples

. Availability of lab aprons/coats 1 OB/SI

Standard F4. Facility has standard Procedures for processing of equipments and instruments 5 10
ME F4.1. Facility ensures standard practices Proper Decontamination of 1 SI/OB Decontamination of
and materials for decontamination instruments after use instruments and reusable
and cleaning of instruments and of glassware are done after
procedures areas procedure in 1% chlorine
solution/ any other
appropriate method

. Contact time for decontamination 1 SI/OB 10 minutes

is adequate
Cleaning of instruments after 1 SI/OB Cleaning is done with
decontamination detergent and running
water after
decontamination

Staff know how to make chlorine 1 SI/OB

solution
ME F4.2. Facility ensures standard practices Disinfection of reusable glassware 1 SI/OB Disinfection by hot air
and materials for disinfection and oven at 160 oC for 1 hour
sterilization of instruments and
equipments

Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention 3 6
ME F5.3. Facility ensures standard practices Staff is trained for spill 1 SI/RR
followed for cleaning and management
disinfection of patient care areas

Staff is trained for preparing 1 SI/RR

cleaning solution as per standard
procedure

Standard practice of mopping and 1 OB/SI Unidirectional mopping

scrubbing are followed from inside out
Standard F6. Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical 14 28
ME F6.1. Facility Ensures segregation of Availability of colour coded bins at 1 OB
Bio Medical Waste as per point of waste generation
guidelines
. Availability of plastic colour coded 1 OB
plastic bags
. Segregation of different category of 1 OB/SI
waste as per guidelines

. Display of work instructions for 1 OB

segregation and handling of
Biomedical waste

There is no mixing of infectious and 1 OB

general waste
ME F6.2. Facility ensures management of Availability of functional needle 1 OB See if it has been used or
sharps as per guidelines cutters just lying idle
. Availability of puncture proof box 1 OB Should be available nears
the point of generation like
nursing station and
injection room

. Disinfection of sharp before 1 OB/SI Disinfection of syringes is

disposal not done in open buckets

. Availability of post exposure 1 SI Ask if available. Where it is

prophylaxis stored and who is in
charge of that.

Staff is aware of contact time for 1 OB/SI

disinfection of sharps
. Staff knows what to do in condition 1 SI Staff knows what to do in
of needle stick injury case of shape injury.
Whom to report. See if any
reporting has been done

ME F6.3. Facility ensures transportation Disinfection of liquid waste before 1 SI/OB

and disposal of waste as per disposal
guidelines
. Disposal of discarded blood bags as 1 SI/OB
per guideline
. Check that bins are not overfilled 1 SI

. Area of Concern - G Quality Management 26 52

Standard G2 Facility has established system for patient and employee satisfaction 1 2
ME G2.1 Patient Satisfaction surveys are There is system to take feed back 1 RR
conducted at periodic intervals from clinician about quality of
services

Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality. 4 8
ME G3.1. Facility has established internal Internal Quality assurance program 1 SI/RR
quality assurance program at is in place
relevant departments

. Standards are run at defined 1 SI/RR

interval
ME G3.3. Facility has established system Departmental checklist are used 1 SI/RR
for use of check lists in different for monitoring and quality
departments and services assurance

. Staff is designated for filling and 1 SI

monitoring of these checklists

Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key 13 26
ME G4.1. Departmental standard Standard operating procedure for 1 RR
operating procedures are department has been prepared and
available approved

. Current version of SOP are 1 OB/RR

available with process owner
ME G4.2. Standard Operating Procedures Blood storage has documented 1 RR
adequately describes process procedure for Transport of
and procedures Blood/components from parent
blood bank.

. Blood storage has documented 1 RR

procedure for receipt and storage
of blood/components

. Blood storage has documented 1 RR

procedure for issue of blood for
transfusion

. Blood storage has documented 1 RR

procedure for issue of blood in case
of urgent requirement

. Blood storage has documented 1 RR

procedure to address the
transfusion reactions

. Blood storage has documents 1 RR

procedure for calibration and
maintenance of equipment

. Blood storage has documented 1 RR

procedure for HAI and disposal of
BMW

. Blood storage has documented 1 RR

system for storage, retaining and
retrieval of records, and reports of
results.

. Blood storage has documented 1 RR

system for internal and external
Quality control of Equipments,
reagent and tests

ME G4.3. Staff is trained and aware of the Check staff is a aware of relevant 1 SI/RR
standard procedures written in part of SOPs
SOPs
ME G4.4. Work instructions are displayed Work instruction/clinical protocols 1 OB work instruction for
at Point of use are displayed screening of blood, storage
of blood, maintaining
blood and component in
event of power failure

Standard G5. The facility has established system of periodic review as internal assessment , medical & death audit and 4 8
ME G5.1. The facility conducts periodic Internal assessment is doneprescription
at audit
1 RR/SI
internal assessment periodic interval
ME G5.3. The facility ensures non Non Compliance are enumerated 1 RR/SI
compliances are enumerated and recorded
and recorded adequately
ME G5.4. Action plan is made on the gaps Action plan prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5. Corrective and preventive Corrective and preventive action 1 RR/SI
actions are taken to address taken
issues, observed in the
assessment & audit

Standard G6. The facility has defined and established Quality Policy & Quality Objectives 4 8
ME G6.2. The facility periodically defines Quality objectives for Blood storage 1 RR/SI
its quality objectives and key are defined
departments have their own
objectives

ME G6.3. Quality policy and objectives Check if staff is aware of quality 1 SI

are disseminated and staff is policy and objectives
aware of that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically
Control charts 1 SI/RR
. Area of Concern - H Outcome 12 24
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
3 6
ME H1.1. Facility measures productivity No. of Blood unit issued per 1 RR No. of Unit issued X1000/
Indicators on monthly basis thousand population Population of serving area

Proportions of requests refused by 1 number of units

parent blood bank. received/Total number of
requistion made to parent
blood bank.

ME H1.2. The Facility measures equity No of blood units issued free of cost 1 RR JSSK, Thalassemia , BPL
indicators periodically
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
2 4
ME H2.1. Facility measures efficiency Downtime of critical equipments 1 RR Time period for which
Indicators on monthly basis equipment was out of
order/Total no of working
hours for equipments

. % of Blood Units discarded 1 RR No of unit discarded *100/

Total no of unit received.

Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 4 8
ME H3.1. Facility measures Clinical Care & Blood transfusion reaction rate 1 RR No of Blood Transfusion
Safety Indicators on monthly basis reactions 1000/ No of
patient blood issued

. Propotion of Adverse events 1 RR Chemical splash, Needle

identified and reported stick injuries. Major blood
transfusion reaction,
wrong cross matching,
wrong blood issue

. Cross matched/ Transfused Ratio 1 RR No of unit are cross

matched on request/ No of
unit actually transfused

. % of single unit transfusion 1 RR % of single use

transfusionX 100/ Total no
of units transfused

Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 3 6
ME H4.1. Facility measures Service Quality Time gap between issuing and 1 RR
Indicators on monthly basis requisition of blood in routine
conditions

. Time gap between issuing and 1 RR

requisition of blood in emergency
conditions

. No of refusal cases 1 RR No of requisition refused/

referred due to non
availability of blood group
or any other reason

Blood storage Unit Score

Card
Blood storage
Score 50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50

Obtained Maximum Percent 10

A 6 12 50
B 9 18 50
C 21 42 50
D 36 72 50
E 26 52 50
F 33 66 50
G 26 52 50
H 12 24 50
Total 169 338 50
 National Quality Assurance Standards for CHC 0 1 2
Checklist for Auxillary Services 11
Reference no Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Area of Concern - A Service Provision 7 14

Standard A5 Facility provides support services 7 14
ME A5.1 The facility provides dietary Availability of functional Kitchen 1 SI/OB Arrangement of Kitchen
services services services inhouse or outsourced

ME A5.2 The facility provides laundry Availability of functional laundry 1 SI/OB Arrangement of laundry
services services services inhouse or outsourced

ME A5.3 The facility provides security Availability of functional security 1 SI/OB In-house or outsourced, At
services services 24 X7 least one guard per shift
ME A5.4. The facility provides Availability of Housekeeping 1 SI/OB In-house or outsourced, At
housekeeping services services 24X7 least 3 in morning shift & 2
each in morning & evening shift

Availability of waste disposal 1 SI/OB Arrangement for disposal of

services Bio medical and general waste
Inhouse or outsouced

A
ME A5.5 The facility ensures maintenance Availability of maintenance 1 SI/OB Includes Physical infrastructure
services services maintenance and equipment
maintenance

ME A5.7 The facility has services for Availability of dedicated space for 1 SI/OB
medical records storing Medical records

Area of Concern - B Patient Rights 4 8

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their 1 2
ME B1.8 The facility ensures access to Medical records are provided to modalities
1 RR/OB
clinical records of patients to patient/ Next to kin on request as
entitled personnel per state guideline

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related 1 2
ME B3.2 Confidentiality of patients The facility has a system to information.
1 SI/RR Patient records are not shared
records and clinical information maintain Confidentiality of patient except the patient until it is
is maintained records authorized by law

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of 2 4
ME B5.1 The facility provides cashless Availability of free diet hospital services.
1 PI/SI
services to pregnant women,
mothers and neonates as per
prevalent government schemes

ME B5.4 The facility provide free of cost Free diet is provided to BPL 1 PI/SI
treatment to Below poverty line patients and JSSK beneficiaries
patients without administrative
hassles

Area of Concern - C Inputs 32 64

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 6 12
ME C1.1 Departments have adequate The kitchen has adequate space 1 OB
space as per patient or work as per requirement
load
The Laundry Department has 1 OB Minimum space requirement
adequate space as per 10sq ft/bed
requirement

The Medical record Department 1 OB Minimum space requirement is

has adequate space as per 2.5 to 3,5 sq ft per bed
requirement

ME C1.3 Departments have layout and Check if Kitchen has demarcated 1 OB Layout as per functional flow
demarcated areas as per area for various activities that is receipt, storage,
functions preparation & Cooking
area ,Service area, dish
washing area, Garbage
collection area and
administrative area.Minimum
space requirement 10sq ft/bed

Check laundry department has 1 OB Layout as per functional flow

demarcated and dedicated area that is from dirty end (receipt)
for its various activities to clean end (Issue). That is
receipt, sorting, sluicing,
washing, drying, ironing and
issue

ME C1.5 The facility has infrastructure for All support services department 1 OB
intramural and extramural are connected with intercom &
communication have telephone as well

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure. 9 18
ME C2.1 The facility ensures the seismic Non structural components are 1 OB Check for fixtures and furniture
safety of the infrastructure properly secured like cupboards, cabinets, and
heavy equipments , hanging
objects are properly fastened
and secured

ME C2.2 The facility ensures safety of Support services departments do 1 OB

electrical establishment not have temporary connections
and loose hanging wires

Equipment in wet areas like 1 OB

Laundry and Kitchen are equipped
with ground fault protection and
designed for wet conditions

ME C2.3 Physical condition of buildings Floors of the Support services are 1 OB

are safe for providing patient
care
ME C2.4 The facility has plan for
prevention of fire
non slippery and even
Surface of Kitchen flor is not 1
chipped
Dietary Department has plan for 1 OB Dietary Department
safe storage and handling of
potentially flammable materials.

ME C2.5. The facility has adequate fire Support services has installed fire 1 OB/RR dietary department and
fighting Equipment Extinguisher for A, B, C type of fire Medical record department
 Check the expiry date on fire 1 OB/RR dietary department and
extinguishers are displayed on Medical record department
each extinguisher as well as due
date for next refilling is clearly
mentioned

ME C2.6. The facility has a system of
periodic training of staff and
conducts mock drills regularly
for fire and other disaster
situation
Check for staff competencies for 1 SI/RR
operating fire extinguisher and
what to do in case of fire

Standard C3 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 8 16
ME C3.5 The facility has adequate Availability of washer man 1 SI/RR
support / general staff
Availability of Cook 1 SI/RR
Availability of Data Entry operator 1 SI/RR
trained in medical records
management.

ME C3.6 The staff has been provided Infection Control Management 1 SI/RR
required training / skill sets
Cleaning Practices 1 SI/RR
Training on Medical record 1 SI/RR
Management
ME C3.7 The Staff is skilled as per job MRD Staff is skilled for indexing 1 SI/RR
description and storage of Medical records

Laundry staff is skilled for 1 SI/RR

segregating and processing of
soiled and infectious linen

Standard C4 Facility provides drugs and consumables required for assured list of services. 2 4
ME C4.2 The departments have adequate Availability of consumables in 1 OB/RR Cap, gowns, gloves, Detergent
consumables at point of use dietary department for cleaning of utensil and Soap
for hand washing

Availability of consumables in 1 OB/RR Detergent and disinfectant,

laundry department starch, Blue, bleach, Heavy
utility gloves, apron.

Standard C5 The facility has equipment & instruments required for assured list of services. 7 14
ME C5.6 Availability of functional Availability of Equipment & 1 OB Refrigerator, LPG, food trolley
equipment and instruments for utensils for Dietary department and cooking utensils
support services
Availability of Equipment for 1 OB Washing machine, drier, Iron,
Laundry Separate trolley for clean and
dirty linen

Availability of Equipment for 1 OB Computer with scanner

Medical record department
Availability of equipment for 1 OB Buckets for mopping, mops,
cleaning duster, waste trolley, Deck
brush

ME C5.7 Departments have patient Availability of furniture and 1 OB Exhaust fan, Storage
furniture and fixtures as per load fixtures for Dietary department containers, Work bench/slab,
and service provision Utensil stand

Availability of furniture and 1 OB Stand/ Hanger for drying of

fixtures for Laundry department linen, Iron table, Cupboard

Availability of furniture and 1 OB Racks and cupboard, table,

fixtures for Medical record Sectional Drawer cabinet/
department Shelves,

Area of Concern - D Support Services 42 84

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 3 6
ME D1.1 The facility has established All equipment are covered under 1 SI/RR
system for maintenance of AMC including preventive
critical Equipment maintenance

There is system of timely 1 SI/RR

corrective break down
maintenance of the equipment

ME D1.3 Operating and maintenance Up to date instructions for 1 OB/SI

instructions are available with operation and maintenance of
the users of equipment equipment are readily available
with staff.

Standard D3 The facility has established Program for maintenance and upkeep of the faciity to provide safe, secure and comfortable 11 22
ME D3.2 Hospital infrastructure is environment
Check that there is no seepage ,to staff, patients
1 and visitors. Dietary department, laundry
OB
adequately maintained Cracks, chipping of plaster and medical record
department

Window panes , doors and other 1 OB Dietary department, laundry

fixtures are intact and medical record
department

ME D3.3 Patient care areas are clean and Floors, walls, roof, rooftops, sinks 1 OB All area are clean with no
hygienic patient care and circulation areas dirt,grease,littering and
are Clean cobwebs

Surface of furniture and fixtures 1 OB

are clean
ME D3.4 The facility has policy of removal No condemned/Junk material is 1 OB Dietary department, laundry
of condemned junk material found in any of the department and medical record
department

ME D3.5 The facility has established No stray 1 OB Dietary department, laundry

procedures for pest, rodent and animal/rodent/birds/pests and medical record
animal control department

Kitchen is rodent & pet proof 1 OB/SI

ME D3.8 The facility ensures safe and Temperature control and 1 SI/RR Fans/Coolers/Exhaust/Vents/
comfortable environment for ventilation in dietary department heaters as per environment
patients and service providers condition and requirement

Temperature control and 1 SI/RR Fans/Coolers/Exhaust/Vents/

ventilation in Laundry heaters as per environment
condition and requirement

Temperature control and 1 SI/RR Fans/Coolers/Exhaust/Vents/

ventilation in Medical record heaters as per environment
Department condition and requirement

ME D3.10 The facility has established Check female staff feels secure at 1 SI
measure for safety and security of work place
female staff

Standard D4 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 2 4
ME D4.1 The facility has adequate Availability of 24x7 running and 1 OB/SI Dietary and laundry
arrangement storage and supply potable water department
for portable water in all
functional areas
ME D4.2 The facility ensures adequate
power backup in all patient care
areas as per load
StandardD5 The facility ensures avaialblity of Diet as per neutritional requirement of the patients and clean Linen to all admitted
ME D5.2 The facility provides diets
according to nutritional
requirements of the patients
ME D5.3 Hospital has standard procedures
for preparation, handling, storage
and distribution of diets, as per
requirement of patients
ME D5.4 The facility has adequate sets of The facility has sufficient set of
linen
ME D5.6 The facility has standard
procedures for handling ,
collection, transportation and
washing of linen
Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards
ME D9.1 The facility has established job The staff is aware of theiroperating
description as per govt
guidelines
ME D9.2 The facility has a established
procedure for duty roster and
deputation to different
departments
ME D9.3 The facility ensures the
adherence to dress code as
mandated by its administration /
the health department
Standard D10 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual
ME D10.1 There is established system for
contract management for out
sourced services
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.6 Register/records are maintained Diet Registers are maintained at
as per guidelines Kitchen
ME E8.7 The facility ensures safe and
adequate storage and retrieval
of medical records
Availability of power back up 1 OB/SI For Laundry, Diet and MRD
department
22 44
The facility has defined diet 1 RR/SI
schedule & menu for the
patients.
The facility has Special diet 1 RR/SI Normal diet, Liquid diet, Semi-
schedule for patients suffering solid diet, diabetic diet, Low
from Heart Disease, salt, Low fat diet
Hypertension, Diabetes,
Pregnant Women, diarrhoea
and renal patients
Dietary department has system to 1 RR/SI
calculate the number of diets to
be prepared
Dietary department has 1 OB/SI/RR Time interval for procurement
procedure for procurement of of Perishable and non
perishable and non perishable perishable items is fixed
items
Perishable items are stored at 1 OB Like milk, cheese, butter, egg,
cold temeperature vegetables, and fruits
Non perishable items are kept in 1 OB All the food items are stored
racks/ storage container, in above floor level.
ventilated and rodent proof room
Food is prepared by trained staff, 1 OB/SI
ensuring standard practices
Distribution of the food is done in 1 OB
covered trolleys
Dietary department has system to 1 RR/SI There is designated person
check the quality of food provided preferably nurse in Ward to
to patient check the Quality of food
Dietary department has 1 OB/SI
procedure to collect and dispose
of kitchen garbage at defined
interval and place
Department maintain stock and 1 RR/SI
expenditure register in Kitchen
1 RR/SI at least 5 sets for each
linen available per bed functional bed
There is a system for Periodic 1 RR/SI To check the theft and pilferage
physical verification of linen
inventory
Separate trolley/Heavy duty bags 1 OB
are used for collection and
distribution of clean and dirty
linen
Infectious linen are transported 1 OB/RR
into separate containers / bags
There is a system of sorting of 1 OB/RR Soiled, infected fouled type of
different category of linen before linen
putting in to washing machine
The linen department has 1 OB/RR
procedure for sluicing of soiled
&infected linen
Linen department has procedure 1 RR
to keep record of daily load
received from each department
Hospital has a designated person 1 RR/SI
to check quality of washed linen
There is a system for verifying the 1 RR/SI
quantity of linen received
There is procedure for 1 RR/SI
condemnation of linen
There is system to check pilferage 1 RR/SI Security guards keep vigil
of linen from ward
3 6
roles procedures.
1 SI
and responsibilities
There is procedure to ensure that 1 RR/SI Check for system for recording
staff is available on duty as per time of reporting and relieving
duty roster (Attendance register/
Biometrics etc)
Staff is adhere to their respective 1 OB
dress code
obligations 1 2
There is procedure to monitor 1 SI/RR Verification of outsourced
the quality and adequacy of services (cleaning/
outsourced services on regular Dietary/Laundry/Security/Main
basis tenance) provided are done by
designated in-house staff
Area of Concern - E Clinical Services 14 28
12 24
1 RR
Laundry registers are maintained 1 RR
at laundry
Hospital has procedure for 1 RR
collection, Compilation and
maintenance of patient's records
after discharge
Thre is a system to check 1 RR Checking the records as per
completion of records checklist for completion
 There is a system for indexing/ICD 1 RR As per ICD coding / indexing
coding the records name, disease, diagnosis,
physician and surgical
procedure carried out

Medical record department has 1 RR Submitting the reports to

system to generate statistics for required health authorities
clinical and administrative use (Birth death notification,
notification of communicable
diseases etc),

There is a system for safe storage 1 RR

of records
Medical record department has 1 RR Retention is as per state
procedure for guideline
retention/Preservation of records

Medical record department has 1 RR

procedure for destruction of old
records

Medical record department has 1 RR/SI

system for retrieval of records

Medical record department has 1 RR/SI In case of MLC

procedure for production of
records in Courts of law when
summoned

Medical records are issued to 1 RR/SI To patient/next kin to patient

authorized personnel only
Standard E10 The facility has defined and established procedures for Emergency Services and Disaster Management
2 4
ME E10.3 The facility has disaster The Staff is aware of disaster plan 1 SI/RR Kitchen and Laundry
management plan in place
Roles and responsibilities of staff 1 SI/RR Kitchen and Laundry
in disaster is defined
Area of Concern - F Infection Control 18 36
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated 2 4
ME F1.4 There is Provision of Periodic There is procedure for infection
1 SI/RR Hepatitis B, Tetanus Toxid etc
Medical Checkups and immunization of the staff
immunization of staff
Periodic medical checkups of the 1 SI/RR
staff with food handlers
undergoing investigations, as
required

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 4 8
ME F2.1 Hand washing facilities are Availability of the hand washing 1 OB Preferably in preparation and
provided at point of use Facility in kitchen cooking area
Availability of Running Water (Hot 1 OB/SI Ask to Open the tap. Ask Staff
and cold) water supply is regular

Availability of soap with soap 1 OB/SI Check for availability/ Ask staff
dish/ liquid antiseptic with if the supply is adequate and
dispenser uninterrupted

Display of Hand washing the 1 OB Prominently displayed above

Instructions at Point of Use the hand washing facility ,
preferably in Local language

Standard F3 Facility ensures standard practices and materials for Personal protection 6 12
ME F3.1 Facility ensures adequate Clean gloves are available for 1 OB/SI
personal protection equipments distribution of food
as per requirements

Availability of apron 1 OB/SI

Availability of caps 1 OB/SI
Availability of Heavy duty gloves 1 OB/SI
for laundry
Availability of gum boots for 1 OB/SI
laundry
ME F3.2 Staff adheres to standard No reuse of disposable gloves, 1 OB/SI
personal protection practices caps and aprons.
Standard F4 Facility has standard Procedures for processing of equipments and instruments 6 12
ME F4.1 Facility ensures standard practices Cleaning and decontamination of 1 SI/OB Ask the cleanliness and ask
and materials for decontamination food preparation surfaces like staff how frequent they clean it
and cleaning of instruments and cutting board
procedure areas

Cleaning of utensils and food 1 SI/OB Check the cleanliness and how
trolleys frequent they clean it
Decontamination of heavily soiled 1 SI/OB
linen
Cleaning of washing equipment 1 SI/OB

Floors are clean 1 OB

No stray animals in the facility/ 1 OB
Patient Care areas
Area of Concern - G Quality Management 48 96
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality. 4 8
ME G3.1 Facility has established internal There is system daily round by 1 SI/RR
quality assurance program in matron/hospital manager/
relevant departments hospital superintendent/ Hospital
Manager/ Matron in charge for
monitoring of services

ME G3.2 Facility has established external Kitchen is has system of regular 1 SI/RR Food sample of each meal are
assurance programs at relevant external inspection by Municipal/ preserved in refrigrators for 24
departments FDA authorities hours

ME G3.3 Facility has established system Departmental checklist is used 1 SI/RR

for use of check lists in different for monitoring and quality
departments and services assurance

The staff is designated for 1 SI

filling and monitoring of these
checklists
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes. 33 66
ME G4.1 Departmental standard Standard operating procedure for 1 RR
operating procedures are Dietary department has been
available prepared and approved
 Current version of SOP are 1 OB/RR
available with process owner
Standard operating procedure for 1 RR
Laundry Department has been
prepared and approved

Current version of SOP are 1 OB/RR

available with process owner
Standard operating procedure for 1 RR
Medical record Department has
been prepared and approved

Current version of SOP are 1 OB/RR

available with process owner
ME G4.2 Standard Operating Procedures Record Department has 1 RR
adequately describes process documented procedure for
and procedures receiving, compiling, and
maintaining records

Record Department has 1 RR

documented procedure for
issuing of the records

Record Department has 1 RR

documented procedure for
retention of records

Record department has 1 RR

documented procedure for pest
and rodent control

Diet department has documented 1 RR

procedure for diet schedule

Diet department has documented 1 RR

procedure for calculation of diet
required in wards

Diet department has documented 1 RR

procedure for procurement of
food items

Diet department has documented 1 RR

procedure for preparation and
distribution of food

Diet department has documented 1 RR

procedure to check the quality of
food provided to the patient

Diet department has documented 1 RR

procedure for cleaning of kitchen
and utensils

Diet department has documented 1 RR

procedure for checkups of kitchen
workers at defined intervals

Linen department has 1 RR

documented procedure for
collection, sorting and cleaning of
linen

Linen department has 1 RR

documented procedure for
sluicing of the blood/ body fluid
stained linen

Linen department has 1 RR

documented procedure for
distribution of linen in all patient
care area

Linen department has 1 RR

documented procedure for
condemnation of linen

Linen department has 1 RR

documented procedure corrective
and preventive maintenance of
laundry equipments

Security department has 1 RR

documented procedure for duty
hours

Security department has 1 RR

documented procedure for
control of incoming and outgoing
items

Security department has 1 RR

documented procedure for
visiting hours in patient care area

Security department has 1 RR

documented procedure for fire
safety in hospital

Security department has 1 RR

documented procedure for
electrical safety

Security department has 1 RR

documented procedure for
training and drills of security staff

ME G4.3 Staff is trained and aware of the Check if staff is a aware of 1 SI/RR
standard procedures written in relevant part of SOPs
SOPs
ME G4.4 Work instructions are displayed Work instructios are displayed in 1 OB
at Point of use Dietary Department

Work instructions are displayed in 1 OB

Laundry Department

Work instructions are displayed 1 OB

in Medical Record Department

Work instructions are displayed 1 OB

for hospital cleaniness

Standard G5 The facility has established system of periodic review as internal assessment , medical & death audit and prescription 6 12
ME G5.1 The facility conducts periodic Internal assessment is done at 1 RR/SI Dietary department, laundry
internal assessment periodic interval and medical record
department

ME G5.2 The facility conducts the Storage and compilation of 1 RR/SI

periodic prescription/ records medical audit
medical/death audits
Storage and compilation of 1 RR/SI
records of death audit
ME G5.3 The facility ensures non Non Compliances are 1 RR/SI
compliances are enumerated enumerated and recorded
and recorded adequately
ME G5.4 Action plan is made on the gaps Action plan is prepared 1 RR/SI
found in the assessment / audit
process
ME G5.5 Corrective and preventive Corrective and preventive action 1 RR/SI
actions are taken to address taken
issues, observed in the
assessment & audit

Standards G6 The facility has defined and established Quality Policy & Quality Objectives
2 4
ME G6.3 Quality policy and objectives are Check if staff is aware of quality 1 SI
disseminated and staff is aware policy and objectives
of that
ME G6.4 Progress towards quality Quality objectives are monitored 1 SI/RR
objectives is monitored and reviewed periodically
periodically
Standard G7 Facility seeks continually improvement by practicing Quality method and tools. 3 6
ME G7.1 Facility uses method for quality PDCA 1 SI/RR
improvement in services

5S 1 SI/OB
ME G7.2 Facility uses tools for quality 6 basic tools of Quality 1 SI/RR
improvement in services
Area of Concern - H Outcome 14 28
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 4 8
ME H1.1 Facility measures productivity No of cases for which medical 1 RR
Indicators on monthly basis audit done
No of cases for which death audit 1 RR
has done
Linen Index 1 RR No. of bed sheet washed in a
month/Patient bed days in
month

Diet Index 1 RR No. of meals provided in the

month/no. of times meal
served in a day * bed days

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 4 8
ME H2.1 Facility measures efficiency Proportion of maternal deaths 1 RR
Indicators on monthly basis audited
Proportion of newborn deaths 1 RR
audited
Cycle time for laundry services 1 RR Time elapsed between
collection of used linen and
receiving clean linen

Proportion of special diets 1 RR No. of special diets (Liquid,

Semi-solid, Diabetic, Low salt,
low fat diet or other diet) in the
month*100/tital no. of diets
provided in the month

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 2 4
ME H3.1 Facility measures Clinical Care & Medical Audit Score 1 RR
Safety Indicators on monthly basis

Death Audit Score 1 RR

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 4 8
ME H4.1 Facility measures Service Quality Waiting time for getting handicap 1 RR
Indicators on monthly basis certificate

Waiting time for getting death 1 RR

certificate
Patient feedback on cleanliness of 1 RR
linen
Patient feedback on quality of 1 RR
food

Auxiliary Services Card

Auxiliary
Services Score
50

Area of Concern wise Score

A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50
 Obtained Maximum Percent 11
A 7 14 50
B 4 8 50
C 32 64 50
D 42 84 50
E 14 28 50
F 18 36 50
G 48 96 50
H 14 28 50
Total 179 358 50
 National Quality Assurance Standards f
Checklist for General Administration
Reference No. Measurable Element Checkpoint Compliance

Area of Concern - A Service Provision

Standard A1 Facility Provides Curative Services
ME A1.10. The facility provides Accident & Availability of functional A& E 1
Emergency Services department
Availability of functional disaster 1
management team
ME A1.11. The facility provides Blood bank & Availability of functional Blood 1
transfusion services storage
Standard A2 Facility provides RMNCHA Services
ME A 2.1. The facility provides Reproductive Avaiability of dedicated Female 1
health Services ward
ME A2.3. The facility provides Newborn health Availability of functional NBSU 1
Services
Standard A3 Facility Provides diagnostic Services
ME A3.1. The facility provides Radiology Availability of X-Ray Unit 1
Services

. Availability of Ultrasound services 1

ME A3.2 The facility Provides Laboratory Availability of In-house lab 1

Services

ME A 3.3 The facility provides other diagnostic Availability of ECG Services 1

services, as mandated
Standard A4 Facility provides services as mandated in national Health Progra
ME A4.2 The facility provides services under The laboratory has facility to carry 1
Revised National TB Control out sputum microscopy
Programme as per guidelines

CHC functions as DOTS centre. 1

ME A4.3 The facility provides services under Facility for Diagnosis and 1
National Leprosy Eradication treatment of Leprosy.
Programme as per guidelines

Facility for management of 1

reactions
 Councelling and advise on 1
prevention of disabilities
Availablity of separate MDT 1
regimens in separate blister packs
for MB-Adult, MB-child, PB-adult
and PB child.

ME A4.4 The facility provides services under Availability of Functional ICTC 1

National AIDS Control Programme as
per guidelines
Availability of link ART centre 1
ME A4.5 The facility provides services under Availability of Refraction room 1
National Programme for control of
Blindness as per guidelines

Availability or Eye OT, if Eye 1

surgeon posted; else linkage with
higher facilities.

ME A4.7. The facility provides services under Availability of geriatric Clinic 1

National Programme for the health
care of the elderly as per guidelines

ME A4.8. The facility provides services under Facility for early detection and 1
National Programme for Prevention referral of suspected cases, ,
and control of Cancer, Diabetes,
Cardiovascular diseases & Stroke
(NPCDCS) as per guidelines

Sreeening for cervical, breast and 1

oral cancer
Education about self examination 1
of breast and oral self
examination.

ME A4.9 The facility Provides services under CHC functions as peripheral 1

Integrated Disease Surveillance surveillance unit
Programme as per Guidelines

CHC collate, analyse and report 1

informationn to District
Surveillance unit on epidemic
prone disease.

Standard A5 Facility provides Support and Administrative serv

ME A5.1. The facility provides dietary services 1
Availability of dietary service
ME A5.2. The facility provides laundry services 1
Availability of laundry services
ME A5.3. The facility provides security 1
services Availability of security services
ME A5.4. The facility provides housekeeping 1
services Availability of Housekeeping
services
ME A5.5. The facility ensures maintenance 1
services Availability of maintenance
services
ME A5.6. Facility provides pharmacy and store Availability of drug storage and 1
services. dispensing services
Avaialbility of General stores 1

ME A5.7. The facility has services of medical 1

records Availability of Medical record
services
ME A5.8 The facility provides administrative Proper monitoring and effective 1
services for the Block supervision overall aspects of
Health services of the Block or
designated administrative area

Supervisory visits to the attached 1

PHCs and SCs.
Building effective Public relations 1
and ensuring active people's
participation for getting the
Health Programs/functions
achieved effectively.

To make evaluation of the impact 1

from time to time.
Standard A6 Health services provided at the facility are appropriate to com
ME A 6.1. The facility provides curatives & Treatment/referral facilities 1
preventive services for the health available for health problems of
problems and diseases, prevalent local community.
locally.

ME A 6.2. There is process for consulting Community representative are 1

community/ or their representatives Consulted while revising or
when planning or revising scope of expanding the scope of service
services of the facility

User charges if any are decided in 1

consultation with user groups
/RKS

Area of Concern - B Patient Rights

Standard B1 Facility provides the information to care seekers, attendants & community abou
ME B1.1. The facility has uniform and user- modalities1
Name of the facility prominently
friendly signage system displayed at front of CHC building
. CHC lay out with location and 1
name of the departments are
displayed at the entrance.

. CHC has established directional 1

signage
. List of departments are displayed 1

All signage are in uniform colour 1

scheme
Signages are user friendly and 1
pictorial
ME B1.2 The facility displays the services and Services which are not available 1
entitlements available in its are also mentioned with name of
departments facilities, where such failicites are
available

Availability of administrative 1
services like handicap certificate,
death certificate services are
displayed.

Processing time for issuing 1

certificates & availability of
medical records are displayed

Mandatory information under RTI 1

is displayed
ME B1.3. The facility has established citizen Citizen charter is established in 1
charter, which is followed at all the facility
levels
. Citizen charter includes the 1
Services available at the facility

Citizen Charter includes the 1

Timings of different services
available

Citizen Charter includes Rights of 1

Patients
Citizen Charter includes 1
Responsibilities of Patients and
Visitors

Citizen Charters includes Beds 1

available
Citizen Charter includes the 1
Standards and Quality of services
Provided

Citizen Charters Includes 1

Complaints and Grievances
redressal Mechanism
 Citizen Charter includes Services 1
that are available on payment, if
any.

Citizen Charter includes the Cycle 1

time for Critical Processes

ME B1.4 User charges are displayed and Facility prepares a comprehensive 1

communicated to patients list of user charges and their
effectively display at strategic point in the
CHC

ME B1.6. Information is available in local Signage's and information are 1

language and easy to understand available in local language
ME B1.7. The facility provides information to A dedicated facilitation 1
patients and visitor through an counter/rogi sahayata kendra
exclusive set-up. available

Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultu
ME B2.1 on account
Services are provided in manner that CHCof physical
has access,
defined policy social, economic,
for non 1 cultural or
are sensitive to gender discrimination according to
gender

ME B2.2 Religious and cultural preferences of Availability of complaint box and 1

patients and attendants are taken display of process for grievance
into consideration while delivering redresaal and personnel to be
services contacted.

Staff is respectful to patients 1

religious and cultural beliefs
The facility has defined policy to 1
ensure the religious and cultural
preferences of the patient

ME B2.3 Access to facility is provided without Approach road to facility is 1

accessible without congestion or
any physical barrier & friendly to encroachment
people with disability.
There are no open 1
manholes/Potholes at access road
and internal pathways

Internal Pathways and corridors of 1

the facility are without any
obstruction / Protruding Objects

CHC has defined policy to provide 1

barrier free services to patient

Ramps shall have a slope of 1

conducive for use
Ramps are provide with slip 1
resistance surface
 Ramps shall have adequate width 1

Warning blocks have been provide 1

at beginning and end of the ramp
and Stairs

Hand rails are provided with stairs 1

The facility has defined policy for 1

providing disable friendly services

Parking area is earmarked for 1

People with disabilities
ME B2.4 There is no discrimination on basis There is no discrimination on basis 1
of social and economic status of the of social and economic status of
patients the patients

CHC has defined policy for 1

ensuring non discrimination on
basis of social and economic
status of the patient

ME B2.5 There is affirmative actions to There are arrangement and 1

Linkages for care of terminally ill
ensure that vulnerable sections can patients
access services
There are Linkages for care , 1
Counselling and Protection of
Victims of Violence including
domestic violence

There are arrangements of for 1

adequate care and post discharge
support of Orphan patients
including homeless children

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a sy
ME B3.1 Adequate visual privacy is provided CHC has defined policy for information.
1
at every point of care maintenance of privacy of
patients

ME B3.2 Confidentiality of patients records CHC has defined policy for 1

and clinical information is maintenance of patient records
maintained and clinical information

ME B3.3 The facility ensures the behaviours
of staff is dignified and respectful,
while delivering the services
CHC defines and communicate 1
policy regarding decent
communication and courteous
behaviour towards the patient
and visitors
ME B3.4 The facility ensures privacy and
confidentiality to every patient,
especially of those conditions having
social stigma, and also safeguards
vulnerable groups
CHC defines the policy for privacy 1
and confidentiality of the patient
and condition related with social
stigma and vulnerable groups

Standard B4 Facility has defined and established procedures for informing patient about the
ME B4.1 them
There is established procedures forin CHC
treatment planning,
define policy for takingand facilitates
1 informed deci
taking informed consent before consent.
treatment and procedures
ME B4.2 Patient is informed about his/her Display of patient rights and 1
rights and responsibilities responsibilities.
ME B4.3 Staff are aware of Patients rights The staff is aware of patients 1
responsibilities rights responsibilities
The staff is regularly sensitised 1
about rights and responsibilities of
the patient

ME B4.5. The facility has defined and Availability of complaint box at 1

established grievance redressal administrative office and display
system in place of process for grievance Redressal
and whom to contact are
displayed

CHC defines policy for grievance 1

redressal mechanism

There is defined frequency of 1

collecting complaints from
complaint box

Records of patient complaints & 1

suggestion are maintained
. There is system of periodic review 1
of patient complaints
. There is evidence of action taken 1
on complaints
. Action taken is informed to the 1
complainant
Standard B5 Facility ensures that there are no financial barrier to access and that there is fina
ME B5.1 The facility provides cashless CHC establish policy for Hospital
providing services.
1
services to pregnant women, free services to benficieries of
mothers and neonates as per Central and state schemes
prevalent government schemes

ME B5.2 The facility ensures that drugs CHC has established policy for 1
prescribed are available at Pharmacy providing all drugs in the EDL free
and wards of cost as per state directives
ME B5.3 It is ensured that facilities for the CHC has established policy for 1
prescribed investigations are providing all diagnostics free of
available at the facility cost as per state directives

ME B5.4 The facility provide free of cost Methods for verification of 1

treatment to Below poverty line documents of patient is user
patients without administrative friendly
hassles

CHC has established policy to 1

provide free treatment to BPL
patients

ME B5.5 The facility ensures timely CHC has establish policy for timely 1
reimbursement of financial reimbursement and payment to
entitlements and reimbursement to beneficiaries
the patients

ME B5.6 The facility ensure implementation Availability of dedicated RSBY help 1

of health insurance schemes as per desk
National /state scheme

Finger print verification is done 1

through a finger print scanner

All tests and drugs are covered 1

under RSBY
Services and entitlements 1
available under RSBY are
prominently displayed

Manual process is in place in case 1

smart card is not working
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available in
ME C1.1. norms 1
Departments have adequate space Availability of residential quarters
as per patient or work load for clinical and support staff

CHC has adequate space as per 1

bed strength
ME C1.2. Patient amenities are provide as per Availability of public toilet for 1
patient load visitors
Adequate number of Staff toilets 1
available in proximity to duty area

Adequate number of Staff change 1

room are available in proximity to
duty area

Canteen for staff and visitors 1

Availability of Staff amenities at 1
nursing station and duty room
ME C1.3. Departments have layout and CHC has independent entry to 1
demarcated areas as per functions emergency and OPD.

. Corridors are wide enough to 1

accommodate daily traffic.

. The general traffic should not pass 1

through the indoor/ critical
patient care area

. Ambulatory services are located in 1

outermost zone

. Clinical support Services are 1

located in proximity to outer zone

Indoor area are located in inner 1

zone of the CHC

ME C1.4. The facility has adequate circulation Corridors are wide enough to 1
area and open spaces according to accommodate daily traffic.
need and local law
Facility maintains open area as 1
per floor area ratio mandated by
authorities

ME C1.5. The facility has infrastructure for CHC has 24X7 functional 1
intramural and extramural telephone connection and
communication intercom facility for internal
communication

. There is designated person to 1

answer the telephone enquiries

. CHC has broadband internet 1

connectivity
There is established system for 1
managing postal communication

There is established system for 1

internal movement of documents
and communication
 There is assigned person for 1
managing internal and external
movement of documents and
communications

General notices and information 1

are displayed at notice boards at
relevant points

There is system of removal of old 1

notices and updating the notice
board

ME C1.6 Service counters are available as per Availability of OPD counter as per 1
patient load load
ME C1.7. The facility and departments are There is no cris-cross between 1
planned to ensure structure follows General and Patient Traffic
the function/processes (Structure
commensurate with the function of
the CHC)

Standard C2 The facility ensures the physical safety including Fire safety of t
ME C2.1. The facility ensures the seismic The facility has been surveyed 1
safety of the infrastructure by Structural engineer for
seismic vulnerability in high risk
zone

Structural Components been 1

made earthquake proof

ME C2.2. The facility ensures safety of Facility has mechanism for 1

electrical establishment periodical check / test of all
electrical installation by
competent electrical Engineer

. Facility has system for power 1

audit of unit at defined intervals

Danger sign is displayed at High 1

voltage electrical installation

All electrical panels are covered 1

and has restricted access

Personal protective equipments 1

are available with electrician
ME C2.3. Physical condition of buildings are Windows have grills and wire 1
safe for providing patient care meshwork

. Building including walls, roofs, 1

floor, windows , balconies and
terraces are maintained

. Terrace, roof, balconies and stair 1

case have protective railing

. CHC premises has intact 1

boundary wall
. CHC has functional gate with 1
provision of animal catcher
Access to roof and terraces is 1
restricted
ME C2.4. The facility has plan for prevention Fire exits provide egress to 1
of fire exterior of the building in open
space

. Check the fire exits are free from 1

obstruction
. Facility has conducted fire safety 1
audit by competent authority

Facility has defined, displayed 1

and implemented evacuation plan
in case of fire

No smoking sign displayed inside 1

and outside the working area

ME C2.5. The facility has adequate fire Facility has installed fire 1
fighting Equipment extinguisher that are capilbility of
fighting A, B & C type of fire

There is system to track the expiry 1

dates and periodic refilling of the
extinguishers

ME C2.6. The facility has a system of periodic Periodic Training is provided for 1
training of staff and conducts mock using fire extinguishers
drills regularly for fire and other
disaster situation

Periodic mock drills for diaster 1

management are conducted

Standard C3 The facility has adequate qualified and trained staff, required for providing the a
ME C3.1. The facility has adequate specialists Availability of General Surgeon load 1
doctors as per service provision
. Availability of Obstetric & Gynae 1
Specialist
Availability of General Medicine 1
specialist
. Availability of Paediatrician 1
. Availability of Anaesthetics 1
ME C3.2 The facility has adequate general Availability of General Duty 1
duty doctors as per service provision Doctors as per load
and work load
. Availability of AYUSH Doctor 1
Availability of Dentist 1
ME C3.3. The facility has adequate nursing Availability of nursing staff 1
staff as per service provision and
work load
ME C3.4. The facility has adequate Availability Lab Tech 1
technicians/paramedics as per
requirement
. Availability Pharmacist 1
. Availability Radiographer 1
. Availability ECG Tech 1
. Availability Optha. 1
Technician/Referactionist
. Availability O.T. technician 1
. Counsellor 1
. Dental Technician 1
. Rehabilitation worker 1
ME C3.5. The facility has adequate support / Registration Clerk 1
general staff
. Statistical Assistant/Data entry 1
operator
. Account Assistant 1
Administrative assistant. 1
ME C3.6. The staff has been provided required The facility conduct training need 1
training / skill sets assessment periodically for all
cadre of staff

The facility has program for 1

continuous medical education for
doctors and nursing staff

The facility prepares training 1

calendar as per training need
assessment

Training feed back is taken and 1

records are maintained for
training

Details and Records of training 1

provided are available with unit
 Training on Disaster Management 1

Training on Cardio Pulmonary 1

resuscitation
Training on staff Safety 1
Training on Measuring CHC 1
Performance Indicators
Training on facility level Quality 1
Assurance
ME C3.7. The Staff is skilled as per job CHC has policy for regular 1
description competence testing as per job
description.

Standard C4 Facility provides drugs and consumables required for assured

ME C4.1 The departments have availability of CHC has policy to ensure drugs at 1
adequate drugs at point of use all point of use as per state EDL

Standard C5 The facility has equipment & instruments required for assure
ME C5.6 Availability of functional equipment Availability of equipment for 1
and instruments for support services Facility management

Availability of equipment for 1

processing of Bio medical waste

Availability of computer for HMIS 1

and MCTS reporting
ME C5.7 Departments have patient furniture Availability of fixture for 1
and fixtures as per load and service administrative office
provision
Availability of furniture for 1
administrative office
Area of Concern - D Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenanc
ME D1.1. The facility has established system Facility has contract agency for 1
for maintenance of critical maintenance for equipments
Equipment
Contact details of the agencies 1
responsible for maintenance are
communicated to the staff

Asset list of all equipments are 1

maintained
There is system to maintain 1
records of down time of
equipments

Indexing of all equipments is done 1

 All equipments are covered under 1
AMC including preventive
maintenance for computers and
other IT equipments

There is system of timely 1

corrective break down
maintenance of the for
computers and other IT
equipments

ME D1.2. The facility has established Facility has contracted agency for 1
procedure for internal and external calibration of equipments.
calibration of measuring Equipment

Records of the calibrated 1

equipments are maintained
Standard D2 The facility has defined procedures for storage, inventory management and dis
ME D2.4 patient
The facility ensures management of CHC has system to ensure that care areas
1
expiry and near expiry drugs short expiry drugs are not
procured

CHC has process for proper 1

disposal and prevention of
unintended use of expired drugs

ME D2.5 The facility has established CHC implements scientific 1

procedure for inventory inventory management system
management techniques according to their needs

ME D2.6 There is a procedure for periodically CHC has policy that there is no 1
replenishing the drugs in patient care stock out of the drugs and
areas consumables at patient care area

ME D2.8 There is a procedure for secure CHC has a policy for ensuring 1
storage of narcotic and psychotropic proper management and
drugs restriction of unintended use of
narcotic substance and
psychotropic drugs as per
prevalent law

Standard D3 The facility has established Program for maintenance and upkeep of the fac
ME D3.1. Exterior of the facility building is comfortable
Boundary Wallsenvironment
of building is to staff,1 patients and vis
maintained with landscaping in open plastered and whitewashed.
areas.
. No unwanted/outdated posters 1
on CHC boundary and building
walls

. CHC Buildings are in uniform 1

colour scheme
. CHC has system to whitewash the 1
building periodically
Availability of parking space as per 1
requirement
Dedicated parking space for 1
ambulances
No water logging in side the 1
premises of the CHC
There is no abandoned 1
/dilapidated building in the
premises

Proper landscaping and 1

maintenance of trees, garden
no encroachment in and around 1
the CHC
CHC has rain water harvesting 1
facility
CHC has Herbal garden 1
ME D3.2. Hospital infrastructure is CHC has system for periodic 1
adequately maintained maintenance of infrastructure at
defined interval

. There is no clogged/over flowing 1

drain in facility
. CHC sewage is linked with 1
municipal drainage system or it
has functional septic tanks

. Facility has a closed drainage 1

system
. Intramural roads are in good 1
condition without
potholes/ditches

. Facility has a annual maintenance 1

plan for its infrastructure

ME D3.3. Patient care areas are clean and General waste from CHC is 1
hygienic removed daily by
municipal/outsourced agency

Every department has a Schedule 1

of cleaning

ME D3.4. The facility has policy of removal of CHC has condemnation policy in 1
condemned junk material place
. Periodic removal of junk material 1
done
. CHC has designated covered place 1
to keep junk/condemned material
. No junk/condemned articles in 1
open spaces
ME D3.5. The facility has established Pest control measures are evident 1
procedures for pest, rodent and at facility
animal control
. Anti Termite treatment of the 1
wooden furniture
ME D3.6. The facility provides adequate Adequate illumination in open 1
illumination level at patient care areas in night
areas
Adequate illumination in 1
circulation area
Adequate illumination in toilets 1

CHC periodically measure 1

illumination at different area of
the CHCs

Adequate illumination at 1
approach roads to CHC
ME D3.7. The facility has provision of There is restriction on entry of 1
restriction of visitors in patient areas vendors and hawkers inside the
premise of the CHC

. CHC has visitor policy in place 1

. CHC has policy for restriction of 1
media person in side the CHC

CHC implement visitor pass for 1

indoor areas
ME D3.9. The facility has security system in CHC has in-house/outsourced 1
place at patient care areas security system in place
. Duty roaster is available for 1
security staff
. Training and Drills of security staff 1
is done
. Security staff is aware of patient 1
right, visitor policy and disaster
Management

. There is system for supervision of 1

security staff
. Facility has a security plan for 1
deputation of guard at different
location

. Responsibility and timing of 1

opening and closing different
department is fixed and
documented
. There is a established procedure 1
for safe custody of keys

. There is procedure for handing 1

over the keys at the time of shift
change

. CHC has system to manage 1

violence /mass casualty
ME D3.10. The facility has established measure for No female staff is posted alone at 1
safety and security of female staff night

. Where ever there are male 1

employees/patients female staff
are posted in pairs

. Timing of the shift is arranged 1

keeping in mind the safety of
female staff

. Committee against sexual 1

harassment is constituted at the
facility

Staff has been provided 1

awareness training on Gender
issues

Standard D4 The facility ensures 24X7 water and power backup as per requirement of servi
ME D4.1. The facility has adequate norms 1
CHC has adequate water storage
arrangement storage and supply for facility as per requirements
portable water in all functional areas

. CHC has adequate water supply 1

from municipal /under ground
source

. All water tanks are kept tightly 1

closed
. Periodic cleaning of water tanks 1
carried out
The facility periodically tests the 1
quality of water from the source
(municipal supply, bore well etc)
for bacterial and chemical content

Chlorination of water is done as 1

per requirement
RO/ Filters are available for 1
potable drinking water
The facility ensures that the 1
distribution pipelines are not
running in close vicinity of the
sewage system.
ME D4.2. The facility ensures adequate power Availability of noiseless generators 1
backup in all patient care areas as for power back up
per load
Estimation of power consumption 1
by CHCs is done
Generator has adequate capacity 1
to provide 24x7 power backup at
least to critical areas

CHC has adequate power supply 1

connection
Use of energy efficient bulbs for 1
light
Standard D5 The facility ensures availability of Diet as per nutritional requirement of the patie
ME D5.2 The facility provides diets according There is provision of differentpatients. 1
to nutritional requirements of the types of diets as per nutritional
patients requirements of patients

ME D5.5 The facility has established Clean linen is provided to all the 1
procedures for changing of linen in occupied beds
patient care areas
Standard D6 The facility has defined and established procedures for promoting public parti
ME D6.1. The facility has established transparency
RKS or eqvivalent body is and accountability.
1
procedures for management of registered under societies
activities of Rogi Kalyan Samitis registration act

. Availability of Income tax 1

exemption certificate for
donations

. RKS meeting are held at 1

prescribed interval
. Minutes of meeting are recorded 1

. Participation of community 1
representatives/NGO is ensured

. RKS reviews the patient 1

complaint/ feedback and action
taken

. RKS generates its own resources 1

from donation/leasing of space

ME D6.2. The facility has established Community based 1

procedures for community based monitoring/social audits are done
monitoring of its services at periodic intervals

Facility communicate updated 1

information on Quality of services
 Facility conducts public hearing at 1
regular intervals
Standard D7 CHC has defined and established procedures for Financial M
ME D7.1. The facility ensures the proper There is system to track and 1
utilization of fund provided to it ensure that funds are received on
time

Funds/Grants provided are 1

utilized in specific time limit
. There is no backlog in payment to 1
beneficiaries as per their
entitlement under different
schemes

. Payment to ASHA done on time 1

. Salaries and compensation are 1

provided to contractual staff on
time

. Facility provides utilization 1

certificate for funds on time
ME D7.2. The facility ensures proper planning Facility prioritize the resource 1
and requisition of resources based required
on its need
. Requirement for funds are 1
communicated to state on time

Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by l
ME D8.1. The facility has requisite licences Availability of valid No objection 1
and certificates for operation of CHC Certificate from fire safety
and different activities authority

. Availability of authorization for 1

handling Bio Medical waste from
pollution control board

. Availability of certificate of 1
inspection of electrical installation

Availability of licence for 1

operating lift
ME D8.2. Updated copies of relevant laws, Availability of copy of Bio medical 1
regulations and government orders waste management and handling
are available at the facility rule 1998

Registration of Ultrasound 1
machine under PCPNDT act.
Drug and cosmetic Act 2005 1
 Safety code for Medical diagnostic 1
X ray equipment and installation

Narcotics and Psychotropic 1

substances act 1985
Code of Medical ethics 2002 1
Nursing Council Act 1
Medical Termination of Pregnancy 1
1971
Person with disability Act 1995 1

Pre conception pre natal 1

diagnostic test 1996
Right to information act 2005 1
Indian Tobacco control Act 2003 1

Standard D9 Roles & Responsibilities of administrative and clinical staff are determined as p
ME D9.1. The facility has established job operating procedures.
Job description of Specialist 1
description as per govt guidelines Doctor is defined and
communicated

Job description of General duty 1

Doctor is defined and
communicated

. Job description of nursing staff is 1

defined and communicated

. Job description of paramedic staff 1

is defined and communicated

Job description of counsellor is 1

defined and communicated
Job description of ward boy is 1
defined and communicated
Job description of security staff is 1
defined and communicated

Job description of cleaning staff is 1

defined and communicated

Job description of Administrative 1

staff is defined and communicated
ME D9.2. The facility has a established Duty roster of doctors is prepared, 1
procedure for duty roster and updated and communicated
deputation to different departments

Duty roster of Nurses is prepared, 1

updated and communicated

Duty roster of Paramedics is 1

prepared, updated and
communicated

Duty roster of Cleaning staff is 1

prepared, updated and
communicated

Duty roster of security staff is 1

prepared, updated and
communicated

There is provision of Rotatory 1

posting of staff
Facility has established line of 1
reporting for clinical and
administrative staff

ME D9.3. The facility ensures the adherence Facility has policy for dress code 1
to dress code as mandated by its for different cadre of CHC.
administration / the health
department

. I Cards have been provided to 1

staff
. Name plate have been provided 1
to staff
Standard D10 Facility has established procedure for monitoring the quality of outsourced se
ME D10.1. obligations1
There is established system for contract Selection of outsourced agencies
management for out sourced services done through competitive
tendering system

. Eligibility criteria is explicitly 1

defined as per term of reference

There is system to make payment 1

as per adequacy and quality of
services provided by the vendor

. Payment to the outsourced 1

services are made on time
ME D10.2. There is a system of periodic review of Facility has defined criteria for 1
quality of out sourced services assessment of quality of
outsourced services
 Actions are taken against non 1
compliance / deviation from
contractual obligations

Records of blacklisted vendors are 1

available with facility

Area of Concern - E Clinical Services

Standard E1 The facility has defined procedures for registration, consultation and
ME E1.3 There is established procedure for Facility ensures that there is 1
admission of patients process for admission of patients
after routine working hours

ME E1.4 There is established procedure for Facility updates daily availability 1

managing patients, in case beds are of vacant patient beds
not available at the facility

Facility has established procedure 1

for accommodating high patient
load due to situation like disaster/
mass casualty or disease outbreak

Standard E3 Facility has defined and established procedures for continuity of care
ME E3.1. Facility has established procedure Facility has established policy 1
for continuity of care during for co ordination and handover
interdepartmental transfer during interdepartmental
transfer

. There is a policy for 1

consultation of the patient to
other specialists with in the
CHC

ME E3.2. Facility provides appropriate referral There is policy for referral of 1

linkages to the patients/Services for patient for which services can
transfer to other/higher facilities to not be provided at the facility
assure their continuity of care.

. Facility maintains list of higher 1

centres where patient can be
managed.
. Facility ensures the referral 1
patient to public healthcare
facilities
. Facility defines and communicate 1
referral criteria
 There is system to check that 1
patient are not unduly referred
for the services those can be
available at the facility

Standard E4 The facility has defined and established procedures for n

ME E4.1 Procedure for identification of There is policy for identification of 1
patients is established at the facility patient before any clinical
procedure

ME E4.2. Procedure for ensuring timely and There is a policy for ensuring 1
accurate nursing care as per treatment accuracy of verbal/telephonic
plan is established at the facility orders

ME E4.3 There is established procedure of
patient hand over, whenever staff
duty change happens
ME E4.4 Nursing records are maintained
ME E4.5 There is procedure for periodic
monitoring of patients
Standard E5 Facility has a procedure to identify high risk and vulnerab
ME E5.1 The facility identifies vulnerable
patients and ensure their safe care
CHC has policy for patient hand 1
over during shift change
CHC has policy for maintaining 1
nursing records
There is policy for periodic 1
monitoring of patient
CHC identify and communicate 1
the category of patient considered
as vulnerable

ME E5.2 The facility identifies high risk patients CHC identify and communicate 1
and ensure their care, as per their need the category of patient considered
as high risk

Standard E6 Facility follows standard treatment guidelines defined by state/Central govern

ME E6.1. Facility ensured that drugs are Facility has policy drugs & their rational
and enabling 1 use.
prescribed in generic name only order for prescribing drugs by
generic name only

ME E6.2 There is procedure of rational use of Facility provides adequate copies 1

drugs of STG to respective department

Facility maintains a list of updated 1

version of STG
Facility provides training on use of 1
STG
Standard E7 Facility has defined procedures for safe drug adminis
ME E7.3 There is a procedure to check drug Facility has policy for reporting of 1
before administration/ dispensing adverse drug reaction

Standard E8 Facility has defined and established procedures for maintaining, updating of p
storage
ME E8.7 The facility ensures safe and Dedicatd space for storage of 1
adequate storage and retrieval of records.
medical records
CHC has a policy for storing 1
records in safe and secure
manner.

Records are stored in a manner 1

that they could be retrieved
easily.

CHC has policy for retention 1

period for different kinds of
records

CHC has policy for safe disposal of 1

records
Standard E10 The facility has defined and established procedures for Emergency Service
ME E10.3. The facility has disaster CHC has prepared disaster plan 1
management plan in place
. Disaster management Committee 1
has been constituted

Standard E15 The facility has defined and established procedures for end of l
ME E15.1. Death of admitted patient is Facility has a standard 1
adequately recorded and procedure for decent
communicated communicate of death to
relatives

ME E15.3 The facility has standard operating Facility has established has 1
procedure for end of life support established policy for end of life
care

Standard E19 The facility has established procedures for care of new born, infant an
ME E19.1 The facility provides immunization Facility has established produce 1
services as per guidelines for reporting and follow up of
AEFI

Staff is trained for detecting , 1

managing and reporting of AEFIs

Area of Concern - F Infection Control

Standard F1 Facility has infection control program and procedures in place for prevention an
ME F1.1. Facility has functional infection Infection control committee isinfection 1
control committee constituted at the facility
ICC is approved by appropriate 1
authority
. Roles and responsibilities of ICC 1
are defined and communicated to
its members
 ICC meet at periodic time interval 1

Records of Infection control 1

activities are maintained
ME F1.2. Facility has provision for Passive Facility has linkage with 1
and active culture surveillance of microbiology lab for culture
critical & high risk areas surveillance

There is defined format for 1

requisition and reporting of
culture surveillance

Reports of culture surveillance are 1

collated and analyzed

Feedback is given to the 1

respective departments
ME F1.3 Facility measures hospital associated Samples are taken for culture to 1
infection rates detect HAI in suspected cases.

There is a defined criteria and 1

format for reporting HAI based on
clinical observation

Reports are collated and analyzed 1

Feedback is given to the 1

respective departments
ME F1.4. There is Provision of Periodic Records of immunization available 1
Medical Checkups and immunization
of staff
. Records of Medical Checkups are 1
available
ME F1.5. Facility has established procedures There is designated person for Co 1
for regular monitoring of infection coordinating infection control
control practices activities

. There is defined format/checklist 1

for monitoring of hand washing
and infection control practices

ME F1.6. Facility has defined and established Facility has antibiotic policy in 1
antibiotic policy place
There is system for reporting Anti 1
Microbial Resistance with in the
facility

Antibiotic policy includes plan for 1

identifying, transferring ,
discharging and readmitting
patients with specific
antimicrobial resistant pathogen
 The Policy Includes Rational Use 1
of Antibiotics
Standard treatment guidelines are 1
followed while developing
Antibiotic Policy

Facility Measures the Antibiotic 1

Consumption Rates
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygi
ME F2.1 Hand washing facilities are provided Facility ensures uninterrupted and 1
at point of use adequate supply of antiseptic
soap and alcohol hand rub in all
departments

ME F2.2 Staff is trained and adhere to Check for the records that training 1
standard hand washing practices have been provided
ME F2.3 Facility ensures standard practices Facility ensures uninterrupted and 1
and materials for antisepsis adequate supply of antiseptics

Standard F3 Facility ensures standard practices and materials for Person

ME F3.1 Facility ensures adequate personal Availability of Heavy duty gloves 1
protection equipments as per for cleaning staff
requirements
Availability of gum boots for 1
cleaning staff
Availability of masks for cleaning 1
staff
Availability of apron for cleaning 1
staff
The facility ensures adequate and 1
regular supply of personal
protective equipments

ME F3.2 Staff is adhere to standard personal There is policy for judicious use of 1
protection practices personal protective equipments
specially sterile gloves

Standard F4 Facility has standard Procedures for processing of equipments

ME F4.1 Facility ensures standard practices and The facility ensure adequate 1
materials for decontamination and supply of disinfectant at the point
cleaning of instruments and of use
procedures areas

Staff is trained for preparation of 1

disinfectant solution
Standard F5 Physical layout and environmental control of the patient care areas ens
ME F5.2 Facility ensures availability of standard Facility ensure the availability of 1
materials for cleaning and disinfection good quality disinfectant and
of patient care areas cleaning material
ME F5.4 Facility ensures segregation infectious CHC has policy for identification 1
patients and segregation of infectious
patient

Standard F6 Facility has defined and established procedures for segregation, collection, trea
ME F6.1 and hazardous
Facility Ensures segregation of Bio Facility ensures adequate and Waste.
1
Medical Waste as per guidelines regular supply of colour coded
liners

There is established procedure for 1

daily monitoring of proper
segregation of Bio medical waste
by a designated person

ME F6.2 Facility ensures management of Facility ensures supply of 1

sharps as per guidelines puncture proof containers and
needle cutters

Facility ensures availability of post 1

exposure prophylaxis drugs

There is system for reporting of 1

needle stick injuries
ME F6.3. Facility ensures transportation and Facility has secured designated 1
disposal of waste as per guidelines place for storage of Bio Medical
waste before disposal

BMW is stored in lock and key and 1

unauthorized entry is prohibited

Log book /Record of waste 1

generated is maintained
No signs of burning within the 1
premises.
Check that infectious liquid waste 1
is not directly drained in to
municipal sewerage system

Disinfection & mutilation of solid 1

plastic waste before disposal

Display of Bio Hazard sign at the 1

point of use
Infectious Waste is not stored for 1
more than 48 hours
Disposal of anatomical waste as 1
per BMW rule

Disposal of solid infectious waste 1

as per BMW rule
 Disposal of sharp waste as per 1
BMW rule

Disposal of infectious plastic 1

waste as per BMW rule

Annual report to the pollution 1

control board is submitted
Biomedical waste transported in 1
authorized vehicle
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for qual
ME G1.1 The facility has a quality team in Quality Assurance Team for CHCs 1
place is Constituted

. There is designated person for co 1

coordinating overall quality
assurance program at the facility

Team members are aware for of 1

their respective responsibilities

ME G1.2. The facility reviews quality of its Quality team meets monthly and 1
services at periodic intervals review the quality activities

Minutes of meeting are recorded 1

Results for internal /External 1

assessment are discussed in the
meeting

CHC performance and indicators 1

are reviewed in meeting

Progress on time bound action 1

plan is reviewed
Follow up actions from previous 1
meetings are reviewed

Resource requirement and 1

support from higher level are
discussed

Quality team review that all the 1

services mentioned in RMNCHA
are delivered as per guideline
 Quality team review that all the 1
services mentioned in National
Health Program are delivered as
per guideline

Resolution of the meeting are 1

effectively communicated to CHC
staff

Quality team report regularly to 1

DQAC about Key Performance
Indicators

Quality Team report regularly to 1

DQAC about internal assessment
results and action taken

Standard G2 Facility has established system for patient and employee

ME G2.1. Patient Satisfaction surveys are There is person designated to co 1
conducted at periodic intervals ordinate satisfaction survey

. Patient feedback form are 1

available in local language
Adequate sample size is taken to 1
conduct patient satisfaction
There is procedure to conduct 1
employee satisfaction survey at
periodic intervals

ME G2.2. Facility analyses the patient feed There is a procedure for 1

back and do root cause analysis compilation of patient feedback
forms

Patient feedback is analyzed on 1

monthly basis

Root cause analysis is done for 1

low performing attributes
Results of Patient satisfaction 1
survey are recorded and
disseminated to concerned staff

There is procedure for analysis of 1

Employee satisfaction survey

There is procedure for root cause 1

analysis of Employee satisfaction
survey

ME G2.3. Facility prepares the action plans for There is procedure for preparing 1
the areas, contributing to low Action plan for improving patient
satisfaction of patients. satisfaction
 There is procedure to take 1
corrective and preventive action

There is procedure for preparing 1

action plan for improving
employee satisfaction

Standard G3 Facility have established internal and external quality assurance programs w
ME G3.1. Facility has established internal Daily round schedule is defined 1
quality assurance program at and practiced
relevant departments
ME G3.2. Facility has established external External Quality assurance is done 1
assurance programs at relevant on defined interval
departments
ME G3.3. Facility has established system for There is system for reviewing 1
use of check lists in different departmental checklist and taking
departments and services appropriate action

Standard G4 Facility has established, documented implemented and maintained Standard

ME G4.1. Departmental standard operating processes.1
CHC has documented Quality
procedures are available system manual
. CHC has Records of distribution of 1
Standard operating procedure

. CHC has system for periodic 1

review of the standard
procedures as and when
required

ME G4.2. Standard Operating Procedures CHC has documented system 1

adequately describes process and for Internal audits at defined
procedures intervals
CHC has documented 1
procedure for control of
documents and records
CHC has documented 1
procedure for defining Quality
objectives
CHC has documented 1
procedure for action planning

CHC has documented 1

procedure for training and
CMEs of CHC staff at defined
intervals

CHC has documented 1

procedure for monthly review
meeting
ME G4.3. Staff is trained and aware of the Check Staff is trained for relevant 1
standard procedures written in SOPs part of SOPs

Standard G5 The facility has established system of periodic review as internal assessme
ME G5.1. The facility conducts periodic prescription
Periodic internal assessment plan audit
1
internal assessment is prepared & followed
Internal Assessors are identified 1

Training of internal assessors is 1

done
There is process of 1
communicating about the
assessment to concerned
departments

Records of internal assessment 1

are maintained
Person is designed for co 1
coordinating internal assessment

ME G5.2. The facility conducts the periodic There is established committee 1

prescription/ medical/death audits for reviewing maternal death

There is established committee 1

for reviewing new born death

There is established committee 1

for medical and death audit

Drug and therapeutic committee 1

for Prescription audits

Medical audits are conducted at 1

periodic interval
Death audits are conducted at 1
periodic interval

Prescription audits are conducted 1

at periodic interval
. There is predefined criteria and 1
format for medical audit
There is predefined criteria and 1
format for prescription audit

There is predefined criteria and 1

format for death audit
Training has been provided for 1
conducting medical and death
audits
ME G5.4. Action plan is made on the gaps Departmental Action plan is 1
found in the assessment / audit reviewed periodically
process
ME G5.5. Corrective and preventive actions There is system to ensure that 1
are taken to address issues, corrective and preventive action
observed in the assessment & audit are taken timely

Standard G6 The facility has defined and established Quality Policy & Qua
ME G6.1. The facility defines its quality policy Quality policy are defined and 1
displayed in local language
Quality policy is in local language 1

ME G6.2. The facility periodically defines its Quality objective are reviewed at 1
quality objectives and key periodic intervals
departments have their own
objectives

. Quality Objectives are SMART 1

ME G6.3. Quality policy and objectives are Check if top management is 1

disseminated and staff is aware of aware of quality policy and
that objectives

ME G6.4. Progress towards quality objectives Top management review progress 1

is monitored periodically on Quality objectives periodically

standard G7 The facility seeks continual improvement by practicing Quality too

ME G7.1 The faclity uses methods for quality CHC maps critical processes and 1
improvement in services identify non value adding
activities

The facility identifies non value 1

adding activities/waste/redundant
activities.

The facility takes corrective action 1

to improve the processes.
 Facility implements Plan do check 1
act (PDCA) approach to identify
the critical processes

ME G7.2 The facility uses tools for quality 5s, Prioritization, 7 Quality tools, 1
improvement. Mistake proofing etc.

Area of Concern -H Outcome

Standard H1 The facility measures Productivity Indicators and ensures compliance with
ME H1.1. Facility measures productivity Bed Occupancy Rate 1
Indicators on monthly basis
. IPD per thousand population 1
. OPD consultation per Thousand 1
Population
. Maternal mortality per 1000 1
deliveries
. Neonatal mortality per 1000 live 1
births
. Nurse to bed ratio 1
. No. of meeting held under RKS 1

ME H1.2. The Facility measures equity indicators Proportion of BPL patient in OPD 1
periodically & Indoor admission
Standard H2 The facility measures Efficiency Indicators and ensure to reach State
ME H2.1 Facility measures efficiency Indicators Overall Referral Rate 1
on monthly basis
Overall discharge rate 1
. Proportion of obstetric cases out 1
of total IPD
. Proportion of fund/ grant utilized 1

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach
ME H3.1 Facility measures Clinical Care & Safety Average Length of Stay 1
Indicators on monthly basis
. Crude mortality rate 1
. Maternal mortality per 1000 1
deliveries
. Neonatal mortality per 1000 live 1
births
. CHC acquired infection rate 1

Standard H4 The facility measures Service Quality Indicators and endeavours to reach
ME H4.1 Facility measures Service Quality overall LAMA Rate 1
Indicators on monthly basis
. Patient satisfaction Score IPD 1
Patient satisfaction Score OPD 1
. Staff Satisfaction Score 1
. Turn over rate of contractual staff 1

Administration Score Card

Administration
Score 50
Area of Concern wise Score
A Service Provision 50
B Patient Rights 50
C Inputs 50
D Support Services 50
E Clinical Services 50
F Infection Control 50
G Quality Management 50
H Outcome 50

Obtained Maximum Percent

A 40 80 50
B 69 138 50
C 86 172 50
D 139 278 50
E 33 66 50
F 55 110 50
G 71 142 50
H 22 44 50
Total 515 1030 50

0
 Standards for CHC
tration 12
Assessment Means of Verification Remarks
Method

Service Provision 40 80
urative Services 3 6
SI/OB

SI/OB

SI/OB

MNCHA Services 2 4
SI/OB

SI/OB

gnostic Services 4 8
SI/OB Availability of in-house
services. Partial
Compliance if it is
outsourced

SI/OB Availability of in-house

services. Partial
Compliance if it is
outsourced

SI/OB If lab is outsourced than

give partial compliance

SI/OB

ational Health Programs/ state scheme 16 32

SI/RR
 SI/OB

SI/OB

SI/OB

SI/OB

SI/RR check for IDSP reporting

format and
Annexure 7A, 7B and 7C.

d Administrative services 12 24
SI/OB In house or outsourced

SI/OB In house or outsourced

SI/OB In house or outsourced

 SI/OB In house or outsourced

SI/OB In house or outsourced

SI/OB

For storing consumables,

Stationaries, and
equipments

SI/OB

SI/OB

SI/OB

SI/OB

SI/OB

re appropriate to community needs. 3 6

SI/RR Kala Azar, Arsenic
poisioning, Snake bite,
KFD, Leptospirosis &
Flurosis

SI/RR

SI/RR

B Patient Rights 69 138

ts & community about the available services and their 23 46
ties OB
OB

OB

OB

OB

OB

OB

OB

OB

OB

OB

OB

OB

OB

OB

OB

OB

OB
 OB

OB

OB

OB

OB

er, religious and cultural needs, and there are no barrier 20 40

economic,SI/PI
cultural or social status.

PI/RR

PI/SI

RR/SI

OB

OB

OB

OB

OB

OB
 OB at least 120 cm

OB To aid people with visual

impairment

OB

OB

OB

PI/SI

RR/SI

RR/SI Linkage for Palliative Care ,

Hospice

RR/SI Linkages with NGOS,

Police Mediation Cell

RR/SI Linkages with NGOS ,

Orphan , old age home,
Children home

patient, and has a system for guarding patient related 4 8

tion. RR/SI

RR/SI

RR/SI
 RR/SI

ing patient about the medical conditions and involving 11 22

litates informed
RR/SI decision making.

OB

SI

SI/RR

OB

RR/SI

RR/SI

RR

RR/SI

RR

RR

and that there is financial protection given from cost of 11 22

ervices. RR/SI

RR/SI
 RR/SI

PI/SI

RR/SI

RR/SI

OB

OB/SI/RR

RR/SI/PI

OB

RR/SI

n - C Inputs 86 172
ices, and available infrastructure meets the prevalent 25 50
ms OB/RR

OB/RR 80 to 85 sqm per bed .

OB

OB/SI

OB/SI

OB/SI
OB/SI
OB

OB

OB

OB OPD, Emergency and

Administrative offices are
situated in near the entry/
exit of the CHC with direct
access from approach
road

OB Lab , Radiology and

Pharmacy

OB Wards and Nursing Units

are located in inner most
area

OB

OB

OB

OB/SI/RR

OB

OB/RR Records are maintained

for received and
dispatched
communication

OB/RR System for communicating

circulars, notices and
orders etc.
 OB/RR

OB/RR

OB/RR

OB/RR

OB

uding Fire safety of the infrastructure. 22 44

OB/RR Ask for records of survey

OB/RR Check for records of in

correction has been done
to strengthen structural
components like columns,
beams, slabs, walls etc.

OB/RR

OB/RR

OB

OB

OB/SI
 OB

OB

OB

OB

OB

OB

OB

OB

OB/RR

OB/RR

OB/RR

OB

OB/RR

OB/RR

OB/RR

ed for providing the assured services to the current case 33 66

OB/RR/SI 1
OB/RR/SI 1

OB/RR/SI 1

OB/RR/SI 1
OB/RR/SI 1
OB/RR/SI 2

OB/RR/SI 1
OB/RR/SI 1
OB/RR/SI As per patient load

OB/RR/SI As per patient load

SI/RR As per patient load

SI/RR As per patient load
SI/RR As per patient load
SI/RR As per patient load

SI/RR As per patient load

SI/RR As per patient load
SI/RR As per patient load
SI/RR As per patient load
SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR
 SI/RR

SI/RR

SI/RR
SI/RR

SI/RR

SI/RR

required for assured list of services. 1 2

SI/RR

s required for assured list of services. 5 10

OB Equipments for
horticulture, electrical
repair, plumbing material
etc

OB Autoclave and mutilator

OB

OB

Support Services 139 278

sting and maintenance and calibration of Equipment. 9 18
SI/RR

SI/RR

SI/RR

SI/RR

SI/RR
 SI/RR

SI/RR

SI/RR

RR

management and dispensing of drugs in pharmacy and 5 10

e areas SI/RR

SI/RR

OB/RR/SI ABC, VED, FSN,FIFO

RR/SI

RR/SI

nd upkeep of the faciity to provide safe, secure and 50 100

taff, patients
OB and visitors.

OB

OB
OB/RR

OB

OB

OB

OB

OB

OB

OB

OB
OB/RR

OB

OB/SI/RR

OB

OB

RR/SI

OB/RR

SI/RR Every department has

schedule for inspection of
cleaning work

RR/SI

OB/RR

OB
OB

RR/SI

RR/SI

OB

OB Stairs, corridor and waiting

area
OB

OB

OB

OB

OB/RR
OB/RR

OB/RR

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI
 RR/SI/OB

RR/SI

RR/SI

SI

SI/RR

SI/RR

RR/SI

RR/SI

requirement of service delivery, and support services 13 26

ms OB/RR/SI 450-500 Litres per bed per
day

OB/SI

OB

OB/RR Records of cleaning is

maintained
RR

RR

OB

RR/SI
 OB/SI

RR/SI

RR/SI

RR/SI 3Kw to 5Kw per bed

SI

uirement of the patients and clean Linen to all admitted 2 4

ts. Normal diet, Diabetic diet,
liquid diet, Low salt/low
fat diet

romoting public participation in management of CHC 10 20

accountability.
RR

RR

RR

RR

RR

RR

RR/SI

RR/SI

RR/SI
 RR/SI

edures for Financial Management 8 16

RR/SI

RR

RR/PI E.g.; Payment for JSY and

Family planning

RR/PI

RR/SI

RR

RR/SI

RR/SI

rement imposed by local, state or central government 16 32

RR

RR

RR

RR

RR

RR
 RR AERB safety code no.
AERB/SC/MED-2(Rev 1)

RR

RR
RR
RR

RR

RR

RR
RR

are determined as per govt. regulations and standards 19 38

ocedures. RR Regular + contractual

RR Regular + contractual

RR Regular + contractual

RR Regular + contractual. Lab

technician, X ray
technician, OT technician,
etc.

RR Regular + contractual

RR Regular + contractual

RR Regular + contractual

RR Regular + contractual

RR Regular + Contractual MS,

CHC Manager, supervisor,
Matron, Ward Master.
Pharmacist etc.
 RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

OB

OB

lity of outsourced services and adheres to contractual 7 14

ons RR

RR

RR Check for that Contract

document has provision
for dedication of payment
if quality of services is not
good

RR

RR
 RR/SI

RR

Clinical Services 33 66
on, consultation and admission of patients. 3 6
RR/SI

RR/SI/PI

RR/SI

for continuity of care of patient and referral 7 14

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI
 RR/OB

hed procedures for nursing care 5 10

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

igh risk and vulnerable patients. 2 4

OB/SI

OB/SI

state/Central government for prescribing the generic 4 8

ational use.
RR

SI/RR

RR

SI/RR

for safe drug administration 1 2

RR/SI

aining, updating of patients’ clinical records and their 5 10

ge
 RR

RR

RR

RR

RR

or Emergency Services and Disaster Management 2 4

RR Availability of security
services
RR Availability of
Housekeeping services

ocedures for end of life care and death 2 4

SI/RR

SI/RR

f new born, infant and child as per guidelines 2 4

SI/RR

SI/RR

nfection Control 55 110

ace for prevention and measurement of CHC associated 23 46
on SI/RR

SI/RR

SI/RR
SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/RR Infection control nurse

SI/RR

SI/RR

SI/RR

SI/RR
 SI/RR

SI/RR

SI/RR

r ensuring hand hygiene practices and antisepsis 3 6

SI/RR

SI/RR

SI/RR

d materials for Personal protection 6 12

OB/SI

OB/SI

OB/SI

OB/SI

SI/RR

SI/RR

essing of equipments and instruments 2 4

SI/RR Disinfectant like
hypochlorite, bleaching
powder etc.

SI/RR

atient care areas ensures infection prevention 2 4

SI/RR
 SI/RR

ation, collection, treatment and disposal of Bio Medical 19 38

us Waste.SI/RR

SI/RR

SI/RR

SI/RR

SI/RR

SI/OB

SI/OB

RR

OB

OB

OB

OB

RR

OB/SI/RR Preferably by CTWF/in-

house deep burial pits/In
house incinerator

OB/SI/RR Preferably by CTWF/in-

house incinerator
 OB/SI/RR Preferably by
CTWF/disinfection
followed by
mutilation/shredding

OB/SI/RR Preferably by
CTWF/Disposal as general
plastic waste after
decontamination and
mutilation

RR

OB/SI/RR

uality Management 71 142

l framework for quality improvement 15 30
SI/RR Check for Office order by
designated authority

SI/RR CHC Manager

SI/RR

SI/RR

RR

SI/RR Check the meeting records

SI/RR Check the meeting records

SI/RR Check the meeting records

SI/RR Check the meeting records

SI/RR Check the meeting records

SI/RR
 SI/RR

SI/RR Check how resolution are

communicated to staff

SI/RR

SI/RR

atient and employee satisfaction 13 26

SI/RR

RR

RR

RR

RR

RR Overall department
wise/attribute wise score
are calculated

RR

RR/SI

RR

RR

RR/SI
 RR/SI

RR/SI

ssurance programs wherever it is critical to quality. 3 6

SI/RR

SI/RR

SI/RR At departmental /CHC

Level

maintained Standard Operating Procedures for all key 10 20

ses. RR

RR

RR

RR

RR

RR

RR

RR

RR
 SI/RR Check for the training
records

as internal assessment , medical & death audit and 19 38

n audit RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI Maternal and death audits

are conducted as per
guideline

RR/SI

RR/SI

RR/SI

RR/SI

RR/SI
 RR/SI

RR/SI

Quality Policy & Quality Objectives 6 12

RR/OB

RR/OB

RR/SI

RR Specific, Measurable,
Achievable, Repeatable,
and time bound

RR/SI

RR/SI

by practicing Quality tool and method. 5 10

RR/SI All clinical and support
services process that are
critical to quality ,e.g.
OPD, IPD, OT, LR, NBSU,
Diagnostics, Pharmacy,
Blood storage, Admin,
Kitchen, Laundry,
Housekeeping etc.

RR/SI Analysis of the Process

map is done. All non-value
adding activities, waste
and redundant activities
are identified.

RR The processes are

reorganized and
implemented after taking
corrective actions.
 RR/SI

RR

-H Outcome 22 44
ures compliance with State/National benchmarks 8 16
RR

RR
RR

RR

RR

RR
RR

RR

ensure to reach State/National Benchmark 4 8

RR

RR
RR

RR

ors and tries to reach State/National benchmark 5 10

RR

RR
RR

RR

RR Surgical Site, Device

related CHC acquired
infection rate

endeavours to reach State/National benchmark 5 10

RR

RR

RR
RR

12
0 1 2