Area of Concern -

Inputs

Dr. Ajay Arya

Consultant, Quality & Patient Safety
Area of Concerns
 Standards and MEs under
QPS-NHSRC

Inputs

District
Checklists CHC PHC UPHC HWC-SC
Hospital

Standards 7 5 5 4 5

ME 40 30 25 20 12

10/01/2023
Area of Concern - Inputs

C1 C2 C3
Adequate Physical Safety Fire Safety
Infrastructure

C4
C5 C6 C7
Adequate
Drugs & Instruments & Competence
Human
Consumables Equipment Assessment
Resource

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Standard
The facility has infrastructure for delivery of assured
C1 services, and available infrastructure meets the

prevalent norms.
Measurable Elements – 07

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Standard The facility has infrastructure for delivery of assured services, and
C1
available infrastructure meets the prevalent norms.

ME C1.1 Departments have adequate space as per

Adequate All Departments
patient or workload.
Space

ME C1.2 Patient amenities are provided as per patient

All Patient Care
Patient
load. Areas
Amenities

Departments have layout and demarcated

ME C1.3
All Departments
Layout areas as per functions.

ME C1.4 The facility has adequate circulation area and

Circulation All Departments
open spaces according to need and local law.
Area
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Standard The facility has infrastructure for delivery of assured services, and
C1
available infrastructure meets the prevalent norms.

ME C1.5
Communica The facility has infrastructure for intramural and All Departments
tion extramural communication.

ME C1.6 Service counters are available as per patient

Service All Departments
Counters load.

ME C1.7 The facility and departments are planned to

Functional All Departments
Relationship ensure structure follows the function/processes

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 The facility ensures the physical safety of the
Standard
C2 infrastructure.

Measurable Elements – 04

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Standard The facility ensures the physical safety of the infrastructure.
C2

ME C2.1 The facility ensures the seismic safety of the

Seismic All Departments
safety infrastructure.

ME C2.2 The facility ensures safety of lifts and lifts have General/
Lifts Safety required certificate from the designated bodies/ board. Administration

All Departments &

ME C2.3 The facility ensures safety of electrical Special focus on
Electrical departments having
Safety establishment. additional electrical safety
e.g. SNCU & ICU

ME C2.4 Physical condition of buildings are safe for

Building All Departments
Safety providing patient care.
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Standard The facility has established Program for fire safety and other

C3 disaster

Measurable Elements – 03

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 The facility has established Program for fire safety and other
Standard
C3 disaster

All Departments &

ME C3.1
The facility has plan for prevention of fire Hospital wide issues in
Fire Safety
General/Administratio
Plan
n

ME C3.2 The facility has adequate fire fighting

Fire Fighting All Departments
Equipment Equipment.

The facility has a system of periodic training of staff

ME C3.3
Fire Safety and conducts mock drills regularly for fire and other All Departments
Training disaster situation

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 OPD Checklist-DH

01/10/2023 QPS-NHSRC
 Standard
The facility has adequate qualified and trained staff, required
C4
for providing the assured services to the current case load.

Measurable Elements – 05

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Standard The facility has adequate qualified and trained staff, required for
C4
providing the assured services to the current case load

ME C4.1 The facility has adequate specialist doctors as

All Clinical
Specialist
per service provision. Departments
Doctors

ME C4.2
General The facility has adequate general duty doctors as All Clinical
Duty Departments
per service provision and workload.
Doctors

ME C4.3 The facility has adequate nursing staff as per

All Clinical
Nursing
service provision and workload. Departments
Staff

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Standard The facility has adequate qualified and trained staff, required
C4
for providing the assured services to the current case load.

ME C4.4 All Clinical

Paramedic/ The facility has adequate technicians/paramedics as Departments except
Technician per requirement. labour room & NRC

ME C4.5 The facility has adequate support/general staff.

Support Staff
All Departments

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 Checklist – Labour Room

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Standard The facility provides drugs and consumables required for

C5 assured services

Measurable Elements – 03

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 The facility provides drugs and consumables required for
Standard
C5 assured services

ME C 5.1 The departments have availability of adequate

All Clinical
Drug
Availability drugs at point of use Departments

ME C5.2 The departments have adequate consumables at

All Clinical
Consumables
Availability point of use Departments

ME C5.3 Emergency drug trays are maintained at every

All Clinical
Emergency
Drug Tray point of care, wherever it may be needed. Departments

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 Checklist- Labour Room

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 Checklist- Labour Room

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Standard The facility has equipment & instruments required for assured

C6 list of services

Measurable Elements – 07

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 The facility has equipment & instruments required for assured
Standard
C6 list of services

ME C6.1 Availability of equipment & instruments for

Examination All Clinical
& Monitoring examination & monitoring of patients Departments
Instruments

ME C6.2
All clinical
Surgical Availability of equipment & instruments for treatment
Instruments Departments doing
procedures, being undertaken in the facility surgical procedures

ME C6.3
Availability of equipment & instruments for diagnostic All clinical
Diagnostic
Equipment departments
procedures being undertaken in the facility

ME C6.4 Availability of equipment and instruments for resuscitation

All clinical
Resuscitation of patients and for providing intensive and critical care to
Equipment Departments
patients
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 The facility has equipment & instruments required for assured
Standard
C6 list of services

ME C6.5
Storage Availability of Equipment for Storage All Departments
Equipment

ME C6.6 Availability of functional equipment and

Support
Services
All Departments
instruments for support services
Equipment

ME C6.7 Departments have patient furniture and fixtures

Furniture & All Departments
Fixtures as per load and service provision

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 Checklist – Operation Theatre

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 Checklist – Operation Theatre

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 Facility has a defined and established procedure
Standard for effective utilization, evaluation and
C7 augmentation of competence and performance
of staff
Measurable Elements – 11

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 Facility has a defined and established procedure for effective
Standard utilization, evaluation and augmentation of competence and
C7
performance of staff
ME C7.1
Criteria for Competence assessment are defined
Competence
Assessment All Departments
Criteria
for clinical and Para clinical staff.

ME C7.2 Competence assessment of Clinical

Periodic
Competence and Para clinical staff is done on All Departments
Assessment predefined criteria at least once in a year

ME C7.3 Criteria for performance evaluation clinical

Performance
Evaluation
All Departments
and para clinical staff are defined
Criteria

ME C7.4 Performance evaluation of clinical and para

Periodic clinical staff is done on predefined criteria at
Performance
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All Departments
least onceQPS-NHSRC
in a year
Evaluation .
 Facility has a defined and established procedure for effective
Standard utilization, evaluation and augmentation of competence and
C7
performance of staff

ME C7.5 Criteria for performance evaluation of

Performance
Criteria support and administrative staff are All Departments
defined.

ME C7.6 Performance evaluation of support and

Performance administration staff is done on All Departments
Evaluation
predefined criteria at least once in a year
Competence assessment and performance
ME C7.7
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Competence & assessment includes contractual,
Performance empaneled, and outsourced staff All Departments
Evaluation

QPS-NHSRC
 Facility has a defined and established procedure for effective
Standard utilization, evaluation and augmentation of competence and
C7
performance of staff

ME C7.8 Training needs are identified based on

Training competence assessment and performance All Departments
Needs & Plan evaluation and facility prepares the training plan

ME C7.9 The Staff is provided training as per

Training
All Departments
defined core competencies and training plan

There is established procedure for

ME C7.10 utilization of skills gained thought trainings
supportive All Departments
supervision
by on -job supportive supervision

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Feedback is provided to the staff on their
ME C7.11
Feedback competence assessment and performance All Departments
evaluation
QPS-NHSRC
 Checklist – General Admin

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 Checklist – General Admin

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 Checklist – General Admin

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 Checklist – General Admin

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Thank You

01/10/2023