NQAS SCORE CARD-DISTRICT HOSPITAL

Hospital Score Card (Department wise)

Accident & Emergency OPD Labour Room Maternity Ward Paediatrics OPD

Hospital Score
89% #DIV/0! #DIV/0! #DIV/0! 84%
Paediatrics Ward SNCU NRC OT M- OT

#DIV/0!
82% 86% 0% 97% 82%
PP Unit ICU IPD Blood Bank Lab

LaQshya
85% 92% #REF! 94% 84% Score
Radiology Pharmacy Auxiliary Mortuary Haemodialysis Centre

83% 90% 93% #REF! 85%

General Administration
#DIV/0!

50%

HOSPITAL QUALITY SCORE CARD AREA OF CONCERN WISE MUSQAN QUALITY SCORE CARD AREA OF CONCERN WIS
Service Provision Patient Rights Inputs Support Services Service Provision Patient Rights

89% 90% 85% #REF! 85% 82%

Hospital Score Hospital Score

#DIV/0! 84%
 Clinical Services Infection Control Quality Management Outcome Clinical Services Infection Control

#REF! 91% 78% 98% 88% 83%

Reference No Area of Concern & Standards NQAS Score

Area of Concern A- Service Provision

Standard A1. Facility Provides Curative Services 92%
Standard A2 Facility provides RMNCHA Services 88%
Standard A3. Facility Provides diagnostic Services 84%
Standard A4 Facility provides services as mandated in National Health Programmes/ State Scheme 93%
Standard A5. Facility provides support services 90%
Standard A6. Health services provided at the facility are appropriate to community needs. 80%
Area of Concern B- Patient Rights
Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities 90%

Services are delivered in a manner that is sensitive to gender, religious, and cultural needs, and there are no barrier on account of
Standard B2. 76%
physical economic, cultural or social reasons.
Standard B3. Facility maintains the privacy, confidentiality & Dignity of patient, and has a system for guarding patients related information 92%
Facility has defined and established procedures for informing patients about the medical condition,and involving them in treatment
Standard B4. 94%
planning, and facilitate informed decision making patient.
Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of hospital
Standard B5. 96%
services.
Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health
Standard B6 88%
facilities
Area of Concern C - Inputs
Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms 80%

Standard C2. The facility ensures the physical safety of the infrastructure. 81%
Standard C3. The facility has established Programme for fire safety and other disaster 90%

Standard C4. The facility has adequate qualified and trained staff, required for providing the assured services to the current case load 75%

Standard C5. Facility provides drugs and consumables required for assured list of services. 97%
Standard C6. The facility has equipment & instruments required for assured list of services. 88%
Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and
Standard C7 82%
performance of staff

Area of Concern D- Support Services

Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment. 77%
The facility has defined procedures for storage, inventory management and dispensing of medicines and consumables in pharmacy
Standard D2. 91%
and patient care areas
Standard D3. The facility provides safe, secure and comfortable environment to staff, patients and visitors. 82%
Standard D4. The facility has established Programme for maintenance and upkeep of the facility 77%
Standard D5. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms 75%
StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients. 91%
Standard D7. The facility ensures clean linen to the patients 93%
The facility has defined and established procedures for promoting public participation in management of hospital transparency and
Standard D8 #DIV/0!
accountability.
Standard D9 Hospital has defined and established procedures for Financial Management 100%

Standard D10. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government 88%

Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating
Standard D11. 95%
procedures.

Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations 70%

Area of Concern E- Clinical Services

Standard E1. The facility has defined procedures for registration, consultation and admission of patients. 97%

Standard E2. The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation. 97%

Standard E3. Facility has defined and established procedures for continuity of care of patient and referral 90%
Standard E4. The facility has defined and established procedures for nursing care 94%
Standard E5. Facility has a procedure to identify high risk and vulnerable patients. 92%

Standard E6. Facility ensures rationale prescribing and use of medicines 82%

Standard E7. Facility has defined procedures for safe drug administration 92%

Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage 93%

Standard E9. The facility has defined and established procedures for discharge of patient. 98%
Standard E10. The facility has defined and established procedures for intensive care. 93%
Standard E11. The facility has defined and established procedures for Emergency Services and Disaster Management 82%
Standard E12. The facility has defined and established procedures of diagnostic services 95%
Standard E13. The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion. 98%
Standard E14 Facility has established procedures for Anaesthetic Services 94%
Standard E15. Facility has defined and established procedures of Operation theatre services 94%
Standard E16. The facility has defined and established procedures for the management of death & bodies of deceased patients 95%
Standard E17 Facility has established procedures for Antenatal care as per guidelines 100%
Standard E18 Facility has established procedures for Intranatal care as per guidelines 93%
Standard E19 Facility has established procedures for postnatal care as per guidelines 67%
Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines 88%
Standard E21 Facility has established procedures for abortion and family planning as per government guidelines and law 90%
Standard E22 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines 90%
Standard E23 Facility provides National health program as per operational/Clinical Guidelines 78%
Standard E24 The facility has defined and established procedure for Haemodialysis Services 100%
Area of Concern F- Infection Control
Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection 78%
Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis 94%
Standard F3. Facility ensures standard practices and materials for Personal protection 95%
Standard F4. Facility has standard Procedures for processing of equipment and instruments 94%
Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention 87%
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous
Standard F6. 92%
Waste.

Area of Concern G- Quality Control

Standard G1 The facility has established organizational framework for quality improvement 78%
Standard G2 Facility has established system for patient and employee satisfaction 85%
Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality. 89%
Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and
Standard G4. 94%
support services.
Standard G5. Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages 58%
Standard G6. The facility has defined Mission, values, Quality policy and objectives, and prepares a strategic plan to achieve them 71%
Standard G7. Facility seeks continually improvement by practicing Quality method and tools. 53%
Standard G8. Facility has de defined, approved and communicated Risk Management framework for existing and potential risks. 88%
Standard G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan 64%
Standard G10. The facility has established clinical Governance framework to improve quality and safety of clinical care processes 65%

Area of Concern H- Outcome

Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks 99%
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark 97%
Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark 100%
Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark 96%
 Version:
DH/NQAS-2020
Revision-00

Hospital Score

#DIV/0!

MusQan
Score

84%

CORE CARD AREA OF CONCERN WISE

Inputs Support Services

84% 80%
ospital Score

84%
Quality Management Outcome

75% 96%

LaQshya Score MusQan Score

67% 89%
100% 79%
100% 86%
NA 92%
NA 88%
NA 75%

50% 85%

100% 56%

70% 83%

100% 96%

100% 94%
NA 50%

80% 75%

60% 78%
83% 85%

80% 83%

82% 97%
81% 95%

50% 80%

70% 77%

83% 89%

75% 87%
 50% 65%
88% 86%
NA 72%
75% 80%

NA NA

NA NA

NA 83%

100% 88%

NA 75%

#DIV/0! 100%

100% 95%

50% 88%
100% 83%
75% 92%

60% 79%

86% 88%

81% 91%

NA 95%
NA 67%
50% 75%
100% 100%
90% 89%
92% NA
88% NA
100% 83%
NA NA
93% NA
67% NA
NA 88%
NA NA
 NA NA
NA 75%
NA NA

70% 70%
92% 84%
100% 75%
93% 83%
68% 77%

72% 93%

100% 67%
#DIV/0! 83%
92% 78%

100% 95%
50% 83%
33% 67%
50% 69%
NA NA
50% 67%
92% 57%

100% 97%
88% 96%
100% 100%
100% 85%
Checklist 1 Accident Emergency
Version: DH/NQAS-
Version - NHSRC/3.0
National Quality Assurance Standards for District Hospitals 2020/00
Checklist for Accident & Emergency 1
Assessment Summary
Name of the Hospital GHQH Erode Date of Assessment Mar-25
Names of Assessors Names of Assessee
Type of Assessment (Internal/External) Internal Action plan Submission Date
Accident & Emergency Score Card
Area of Concern wise Score Accident & Emergency Score
A Service Provision 90%
B Patient Rights 91%
C Inputs 86%
D
E
Support Services
Clinical Services
79%
94% 89%
F Infection Control 95%
G Quality Management 78%
H Outcome 100%

Major Gaps Observed

1
2
3
4
5
Strengths / Good Practices
1
2
3
4
5
Recommendations/ Opportunities for Improvement
1
2
3
4
5
Signature of Assessors
Date

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Area of Concern - A Service Provision

Standard A1. Facility Provides Curative Services
Poisoning, Snake Bite, CVA, Acute MI, ARF,
ME A1.1. The facility provides General Availability of Emergency Medical 2 SI/OB Hypovolemic Shock , Dyspnoea, Unconscious
Medicine services Procedures Patients

ME A1.2. The facility provides General Availability of Emergency Surgical 2 SI/OB Appendicitis, Rupture spleen, Intestinal
Surgery services Procedures Obstruction, Assault Injuries, perforation, Burns

ME A1.4. The facility provides paediatrics Availability of emergency Paediatric 2 SI/OB ARI, Diarrhoeal diseases, Hypothermia,
services procedures PEM,resustication

ME A1.5. The facility provides Availability of Emergency 2 SI/OB Foreign body and injuries
Ophthalmology Services Ophthalmology procedures

ME A1.6. The facility provides ENT Services Availability of Emergency ENT 2 SI/OB Epitasis, foreign body
procedures

ME A1.7. The facility provides Orthopaedics Availability of Emergency Orthopaedic 2 SI/OB Fracture, RTA, Poly trauma
Services procedures

ME A1.9. The facility provides Psychiatry Availability of Emergency Psychiatric 2 SI/OB Conversion Reactions, other Psychiatric
Services procedures emergencies Hysteria, mania, psychosis

ME A1.13. The facility provides services for Availability of Dressing room facility 2 SI/OB Drainage, dressing, suturing
OPD procedures

Availability of injection room facilities 2 SI/OB Injection room facility with ARV, ASV and
emergency drugs

ME A1.14. Services are available for the time 24X7 availability of dedicated 2 SI/RR
period as mandated emergency Services
Defibrillation, CPR, Mobilization, Chest Tube,
ME A1.16. The facility provides Accident & Availability of Emergency procedures 2 SI/OB Intubations, Tracheotomy, Mechanical
Emergency Services Ventilation
Standard A2 Facility provides RMNCHA Services

(a) Primary management of Severe pelvic pain,

severe vaginal bleeding, vulvar abscesses & toxic
ME A2.2 The facility provides Maternal Availability of Emergency Gynaecology 0 SI/OB shock syndrome etc.
health Services procedure (b) Emergency laparotomy - Due to uterine
perforation, septic abortion, pelvic abscess,
ectopic pregnancy

ME A2.4 The facility provides Child health Triage and emergency management of 2 SI/OB
Services paediatric cases
Standard A3 Facility Provides diagnostic Services
ME A3.1. The facility provides Radiology Availability / Linkage to X-ray & USG 2 SI/OB
Services services

Radiology Services are functional 24X7 2 SI/OB Check services are functional at night
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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

ME A3.2. The facility Provides Laboratory Availability of Emergency diagnostic 2 SI/OB HB%, CPC, Blood Sugar, RDK, Urine Protein,
Services tests 24x7 Electrolyte (Na+K)

ME A3.3. The facility provides other Availability of Functional ECG Services 2 SI/OB
diagnostic services, as mandated
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme

The facility provides services

under National Programme for
ME A4.8 Prevention and control of Cancer, Availability emergency services 2 SI/OB
Acute chest pain, Acute /chronic hypertension,
Diabetes, Cardiovascular diseases cardiovascular diseases & cerebro pulmonary oedema, congestive cardiac failure &
& Stroke (NPCDCS) as per vascular attack acute arrhythmias
guidelines

Standard A5. Facility provides support services

ME A5.3. The facility provides security Availability of Police post 0 SI/OB
services

ME A5.7. The facility has services of medical Availability of Medico-legal record 2 SI/OB
record department services
Standard A6. Health services provided at the facility are appropriate to community needs.
The facility provides curatives & Ask for the specific local health frequent
ME A6.1. preventive services for the health Availability of specific procedures for 2 SI/OB emergencies. See if emergency is ready for it or
problems and diseases, prevalent local prevalent emergencies not.
locally.
Area of Concern - B Patient Rights
Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1. The facility has uniform and user- Availability departmental signage's . 2 OB Emergency department board is prominently
friendly signage system displayed with facility of illumination in night.

Availability of Directional Signage's. 0 OB Direction is displayed from main gate to direct.

The facility displays the services

ME B1.2. and entitlements available in its List of services including emergencies 2 OB
departments that are managed at the facility

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
ambulance, blood bank , police and 2 OB
referral centres displayed

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

language and easy to understand in local language

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The facility provides information Enquiry services may be provided by registration

ME B1.7. to patients and visitor through an Enquiry services are available 24X7. 2 OB clerk/Nurse in a small set up. For large and busy
exclusive set-up. emergency departments there should be
dedicated enquiry counter

The facility ensures access to

ME B1.8 clinical records of patients to Treatment note/discharge note is given 2 RR/OB
entitled personnel to patient

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 economic, cultural or social reasons.
ME B2.1. Services are provided in manner Separate room for examination of rape 2 OB
that are sensitive to gender victims
Availability of sexual assault forensic 2 OB
evidence kit
Availability of protocols /guidelines for
collection of forensic evidence in case 1 OB /RR
of rape victim
Counselling services are available for 1 OB/RR
rape victim and domestic violence
Availability of female staff if a male 2 OB/SI
doctor examine a female patients
Separate toilets for male and females 2 SI/OB
Demarcated male and female 2 OB
observation areas

Access to facility is provided

ME B2.3. without any physical barrier & and Availability of Wheel chair/ stretcher 2 OB
friendly to people with disabilities for emergency

Emergency is located at ground floor 2 OB At least 120 cm width, gradient not steeper than
with availability of ramp and railing 1:12
No vehicle parked on the way /in front of
Ambulance has direct access to the 2 OB emergency entrance. Access road to emergency
receiving/triage area of the emergency. is wide enough for streamline moment of
emergency
Availability of specially abled friendly 2 OB
toilet
Standard B3. Facility maintains the privacy, confidentiality & Dignity of patient, and has a system for guarding patients related information
ME B3.1. Adequate visual privacy is Screens provided at emergency 2 OB At the examination and procedure area.
provided at every point of care

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

1. No information regarding patient / parent

Confidentiality of patients records Confidentiality of patient record identity is displayed
ME B3.2. and clinical information is 2 SI/OB 2. Records are not shared with anybody without
maintained
maintained written permission of parents & appropriate
hospital authorities

MLC cases are kept in secure place 2 SI/OB

beyond access of general public

The facility ensures the behaviours

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

The facility ensures privacy and

confidentiality to every patient, Privacy and confidentiality of HIV,
ME B3.4. especially of those conditions Rape, suicidal cases, domestic violence 2 SI/OB
having social stigma, and also and psychotic cases
safeguards vulnerable groups
Standard B4. Facility has defined and established procedures for informing patients about the medical condition, and involving them in treatment planning, and facilitate informed decision
making patient.
There is established procedures
ME B4.1. for taking informed consent Consent is taken for invasive 2 SI/RR
before treatment and procedures emergency procedures

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

rights and responsibilities responsibilities.

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

The facility has defined and Availability of complaint box and display
ME B4.5. established grievance redressal of process for grievance redressal and 0 OB
system in place whom 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.
The facility provides cashless Emergency services are free for all
ME B5.1 services to pregnant women, including pregnant woman, neonate 2 PI/SI
mothers and neonates as per and children
prevalent government schemes

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The facility ensures that drugs Check that patient party has not spent
ME B5.2. prescribed are available at on purchasing drugs or consumables 2 PI/SI
Pharmacy and wards from outside.
It is ensured that facilities for the
ME B5.3. prescribed investigations are Check that patient party has not spent 2 PI/SI
available at the facility on diagnostics from outside.

The facility provide free of cost

ME B5.4. treatment to Below poverty line Free Emergency Consultation for BPL 2 PI/SI/RR
patients without administrative patients
hassles
Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities

The policy clearly defines the procedures for

managing critical cases in the ward, HDU/ICU,
brain-dead patients, conscious patients with
serious diseases like motor neurons and
brought-in dead cases. It also includes:
(a) Patient and family have the right to be
ME B6.6 There is an established procedure End of life policy & procedure are 2 SI/RR informed about their condition and make
for ‘end-of-life’ care available and followed choices about the treatment
(b) Withhold or withdraw life-sustaining
treatment
(c ) Organ donation as per NOTTO &India's
Governing organ donation law
(d) All the decisions should be transparent and
documented

Staff is educated & trained for end of 1 SI/RR

life care
The patient's Relatives informed clearly
about the deterioration in the health 2 SI/RR Periodic update on the patient's condition is
condition of Patient. given to the family.

Hospital has documented policy for 2 SI/OB

pain management

Screening of the patient for pain 2 SI/RR Symptomatic treatment is given to the patient to
prevent complications to extent possible

Pain alleviation measures or medication

is initiated & titrated as per need and 2 SI/RR
response

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

There is an established procedure

for patients who wish to leave Declaration is taken from the LAMA Consequences of LAMA are explained to
ME B 6.7 hospital against medical advice or patient 2 RR/SI
patient/relative
refuse to receive specific c
treatment
Area of Concern - C Inputs
Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms

ME C1.1. Departments have adequate space Adequate space for accommodating 2 OB 1000 square meters per 100 patient daily loads
as per patient or work load emergency load

Availability of adequate waiting area 2 OB

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

per patient load the waiting area
Availability of cold Drinking water 0 OB
Availability of functional toilets 2 OB

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

demarcated areas as per functions

Demarcated receiving /triage areas 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 mortuary/ Post
bodies. mortem room
All the fixture and furniture are movable to
Lay out is flexible 2 OB rearrange the different areas in case of mass
casualty
Dedicated Minor OT 0 OB
Shaded porch for ambulance 2 OB
availability of clean and dirty utility 2 OB
room

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The facility has adequate Corridors at Emergency are broad

ME C1.4. circulation area and open spaces enough for easy moment of stretcher 2 OB 2-3 meter
according to need and local law and trolley

The facility has infrastructure for

ME C1.5. intramural and extramural Availability of functional telephone and 0 OB
communication Intercom Services

The ambulance(s) has a proper

communication system(at least cell 2 OB
phone)

ME C1.6. Service counters are available as Availability of emergency beds as per 2 OB 5% of the total beds
per patient load load
Availability of buffer beds for handling 2
mass causality and disaster

The facility and departments are

planned to ensure structure Receiving/Triage-Resuscitation-observation
ME C1.7. follows the function/processes Unidirectional flow of services. 1 OB
beds- Procedures area. There is no crises cross
(Structure commensurate with the
function of the hospital)

Separate entrance for emergency 2 OB Entrance of Emergency should not be shared

department with OPD and IPD
Emergency has functional linkage with
Major OT , ICU and labour room , 2 OB/SI
Indoors and laboratories
Emergency is located near to the entry 1 OB
of the hospital
Standard C2. The facility ensures the physical safety of the infrastructure.

Check for fixtures and furniture like cupboards,

ME C2.1 The facility ensures the seismic Non structural components are 2 OB cabinets, and heavy equipment , hanging objects
safety of the infrastructure properly secured are properly fastened and secured

Emergency department does not have

ME C2.3. The facility ensures safety of temporary connections and loosely 2 OB
electrical establishment hanging wires

ME C2.4. Physical condition of buildings are Floors of the Emergency are non 2 OB
safe for providing patient care slippery and even

Windows have grills and wire 2 OB

meshwork
Standard C3. The facility has established Programme for fire safety and other disaster

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Emergency has sufficient fire exit to

ME C3.1. The facility has plan for prevention permit safe escape to its occupant at 1 OB/SI
of fire time of fire
Check the fire exits are clearly visible
and routes to reach exit are clearly 1 OB
marked.
Emergency has installed fire
ME C3.2. The facility has adequate fire Extinguisher that is Class A , Class B, C 2 OB
fighting Equipment type or ABC type

Check the expiry date for fire

extinguishers are displayed on each 2 OB/RR
extinguisher as well as due date for
next refilling is clearly mentioned

The facility has a system of

periodic training of staff and Check for staff competencies for
ME C3.3. 2 SI/RR
conducts mock drills regularly for operating fire extinguisher and what to
fire and other disaster situation do in case of fire

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

ME C4.1. The facility has adequate specialist Availability of specialist Doctor 2 OB/RR Check for specialist on call/ full time
doctors as per service provision

The facility has adequate general

ME C4.2. duty doctors as per service Availability of emergency medical 2 OB/RR
provision and work load officer

The facility has adequate nursing

ME C4.3. staff as per service provision and Availability of Nursing staff 2 OB/RR/SI At least 2 in day and 1 in night
work load
The facility has adequate
ME C4.4. technicians/paramedics as per Availability of dresser /paramedic 2 OB/SI
requirement

ME C4.5. The facility has adequate support / Dedicated 24X7 house keeping staff 2 SI/RR
general staff
availability of dedicated security guards 2 SI/RR
24X7
Availability of registration clerk 2 SI/RR
Availability of Drivers for Ambulance 2 SI/RR 103/108/State specific ambulance services
24X7
Standard C5. Facility provides drugs and consumables required for assured list of services.

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Availability of
ME C5.1. The departments have availability Analgesics/Antipyretics/Anti 2 OB/RR Tracers as per State's EML
of adequate drugs at point of use Inflammatory

Availability of Anti-Infective/Antibiotics 2 OB/RR Tracers as per State's EML

Availability of Solutions Correcting

Water, Electrolyte Disturbances and 2 OB/RR Tracers as per State's EML
Acid-Base Disturbances
Availability of Drugs acting on 2 OB/RR Tracers as per State's EML
Cardiovascular System
Availability of drugs action on Central
nervous system and peripheral nervous 2 OB/RR Tracers as per State's EML
system
Availability of dressing material and 2 OB/RR Tracers as per State's EML
antiseptics
Availability of drugs for Respiratory 2 OB/RR Tracers as per State's EML
System
Availability of Hormonal Preparation 2 OB/RR Tracers as per State's EML
Availability of emergency drugs in 0 OB/RR Tracers as per State's EML
ambulance
Availability of drugs for obstetric 2 OB/RR Magnesium sulphate, Oxytocin, Plasma
emergencies Expanders
Availability of Medical gases 2 OB/RR Availability of Oxygen Cylinders
Availability of Immunological/vaccines 2 OB/RR Polyvalent Anti snake Venom, Anti tetanus
Human Immunoglobin
Availability of Antidotes and Other 2 OB/RR Activated charcoal, Anti-snake venom
Substances used in Poisoning

ME C5.2. The departments have adequate Resuscitation Consumables / Tubes 2 OB/RR Masks, Ryles tubes, Catheters, Chest Tube, ET
consumables at point of use tubes etc

Availability of disposables at dressing 2 OB/RR

room
Availability of consumables in 2 OB/RR Dressing material / Suture material
ambulance

Emergency drug trays are

ME C5.3. maintained at every point of care, Emergency Drug Tray/ Crash Cart is 2 OB/RR
where ever it may be needed maintained at emergency

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

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Availability of equipment & Availability of functional Equipment

ME C6.1. instruments for examination & &Instruments for examination & 1 OB BP apparatus, Multiparameter Torch, hammer ,
monitoring of patients Monitoring Spot Light

Availability of Monitoring equipment in 2 OB

ambulance
Availability of equipment &
ME C6.2. instruments for treatment Availability of dressing tray for 2 OB
procedures, being undertaken in Emergency procedures
the facility
Dressing tray are in adequate numbers 2 OB
as per load
Availability of instruments for 0 OB
emergency Gynae procedure
Availability of equipment &
ME C6.3. instruments for diagnostic Availability of Point of care diagnostic 1 OB Glucometer, ECG and HIV rapid diagnostic kit
procedures being undertaken in devices
the facility

Availability of equipment and

instruments for resuscitation of Availability of functional Instruments Ambu bag, defibrillator, layrngo scope, nebulizer,
ME C6.4. patients and for providing 2 OB
for Resuscitation. suction apparatus , LMA
intensive and critical care to
patients

Availability of resuscitation equipment 0 OB

in ambulance

ME C6.5. Availability of Equipment for Availability of equipment for storage for 2 OB Refrigerator, Crash cart/Drug trolley, instrument
Storage drugs trolley, dressing trolley
Availability of functional
ME C6.6 equipment and instruments for Availability of equipment for cleaning 2 OB Buckets for mopping, mops, duster, waste
support services and sterilization trolley, Deck brush, Boiler

Departments have patient

ME C6.7. furniture and fixtures as per load Availability of patient beds with prop up 2 OB Hospital graded Mattress, IV stand, bed rails, Bed
and service provision facility, attachments and accessories pan

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

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Check objective checklist has been prepared for

Criteria for Competence Check parameters for assessing skills assessing competence of doctors, nurses and
ME C7.1 assessment are defined for clinical and proficiency of clinical staff has been 1 SI/RR paramedical staff based on job description
and Para clinical staff defined defined for each cadre of staff. Dakshta checklist
issued by MoHFW can be used for this purpose.

Competence assessment of Check for records of competence assessment

ME C7.2 Clinical and Para clinical staff is Check for competence assessment is 1 SI/RR including filled checklist, scoring and grading .
done on predefined criteria at done at least once in a year Verify with staff for actual competence
least once in a year assessment done

The Staff is provided training as

ME C7.9 per defined core competencies Triage and Mass Casualty Management 1 SI/RR
and training plan
Basic life support (BLS)/ Advance life 2 SI/RR
support (ALS)

Infection control & prevention training 2 SI/RR Bio medical Waste Management including Hand
Hygiene
Training on Quality Management 1
System
Patient Safety 1

There is established procedure for Check supervisors make periodic rounds of

utilization of skills gained thought Staff is skilled for emergency department and monitor that staff is working
ME C7.10 2 SI/RR according to the training imparted. Also staff is
trainings by on -job supportive procedures
supervision provided on job training wherever there is still
gaps

Check supervisors make periodic rounds of

Staff is skilled for resuscitation and use department and monitor that staff is working
1 SI/RR according to the training imparted. Also staff is
defibrillator
provided on job training wherever there is still
gaps

Check supervisors make periodic rounds of

Staff is skilled for maintaining clinical department and monitor that staff is working
2 SI/RR according to the training imparted. Also staff is
records
provided on job training wherever there is still
gaps

Area of Concern - D Support Services

Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The facility has established system 1. Check with AMC records/

ME D1.1. for maintenance of critical All equipment are covered under AMC 0 SI/RR Warranty documents
Equipment including preventive maintenance 2. Staff is aware of the list of equipment covered
under AMC.

There is system of timely corrective [Link] for breakdown & Maintenance record in
break down maintenance of the 2 SI/RR the log book
equipment 2. Staff is aware of contact details of the
agency/person in case of breakdown.

There has system to label

Defective/Out of order equipment and 2 OB/RR
stored appropriately until it has been
repaired

(1) Staff is trained for use, preventive

maintenance and trouble shooting of equipment
Staff is skilled for trouble shooting in such as radiant warmers, infusion pump, oxygen
1 SI/RR concentrator, bag &mask, weighting machine,
case equipment malfunction
phototherapy unit.
(2) There is procedure to check timely
replacement of lights in Phototherapy unit.

The facility has established

ME D1.2. procedure for internal and All the measuring equipment/ 0 OB/ RR
external calibration of measuring instrument are calibrated
Equipment

Operating and maintenance

ME D1.3. instructions are available with the Operating instructions for critical 2 OB/SI
users of equipment equipment are available

Standard D2. The facility has defined procedures for storage, inventory management and dispensing of medicines and consumables in pharmacy and patient care areas
There is established procedure for Stock level are daily updated
ME D2.1 forecasting and indenting drugs There is established system of timely 2 SI/RR Indents are timely placed
and consumables indenting of consumables and drugs

Drugs are stored in

ME D2.3. The facility ensures proper storage containers/tray/crash cart and are 2 OB Labelled with drug name, drug strength and
of drugs and consumables labelled expiry date

Empty and filled cylinders are labelled 2 OB

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

No expired drug found 2 OB/RR

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Records for expiry and near expiry Check register/DVDMS/other supply chain
drugs are maintained for drug stored at 2 RR software for record of stock of expired and near
department expiry drugs
The facility has established
ME D2.5. procedure for inventory There is practice of calculating and 2 SI/RR
management techniques maintaining buffer stock in Emergency

Department maintained stock register Record of drug received, issued and balance
of drugs and consumables in 1 RR/SI stock of drug in hand
Emergency

There is practice of calculating and 2 SI/RR

maintaining buffer stock in ambulance

Department maintained stock register

of drugs and consumables in 1 RR/SI Check record of drug received, issued and
ambulance balance stock in hand

There is a procedure for There is established procedure for

ME D2.6. periodically replenishing the drugs replenishing drug tray emergency crash 2 SI/RR
in patient care areas cart
There is established procedure for
replenishing drug tray emergency crash 2 OB/SI
cart in ambulance
Random stock check of some essential
There is no stock out of drugs 2 SI/RR medicines. E.g. Paracetamol, Atenolol,
Amlodipine, Azithromycin, etc.

There is process for storage of Temperature of refrigerators are kept

ME D2.7. vaccines and other drugs, as per storage requirement and 2 OB/RR Check for refrigerator/ILR temperature charts.
requiring controlled temperature records twice a day and are maintained Charts are maintained and updated twice a day

There is a procedure for secure

ME D2.8. storage of narcotic and Narcotics and psychotropic drugs are 1 OB/SI
psychotropic drugs kept separately in lock and key

Standard D3. The facility provides safe, secure and comfortable environment to staff, patients and visitors.
The facility provides adequate
ME D3.1. illumination level at patient care Adequate illumination at procedure 2 OB Resuscitation area, dressing room and
areas area examination area

Adequate illumination at receiving and 2 OB

triage area
The facility has provision of
ME D3.2. restriction of visitors in patient Visitors are restricted at resuscitation 2 OB/SI
areas and procedure area

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The facility ensures safe and Fans/ Air

ME D3.3 comfortable environment for Temperature control and ventilation in 1 PI/OB conditioning/Heating/Exhaust/Ventilators as per
patients and service providers patient care area environment condition and requirement
Fans/ Air
Temperature control and ventilation in 2 SI/OB conditioning/Heating/Exhaust/Ventilators as per
nursing station/duty room environment condition and requirement
There are set procedures for handling
ME D3.4. The facility has security system in mass situation and violence in 2 SI/OB See for linkage to police, self protection form
place at patient care areas emergency staff

Hospital has sound security system to 0 OB/SI

manage overcrowding in emergency

The facility has established

ME D3.5 measure for safety and security of Ask female staff whether they feel 2 SI
female staff secure at work place

Standard D4. The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior of the facility building is Building is painted/whitewashed in 2 OB
maintained appropriately uniform colour
Interior of patient care areas are 2 OB
plastered & painted
Floors, walls, roof, roof topes, sinks
ME D4.2. Patient care areas are clean and patient care and circulation areas are 1 OB All area are clean with no dirt,grease,littering
hygienic Clean and cobwebs

Surface of furniture and fixtures are 2 OB

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

ME D4.3. Hospital infrastructure is Check for there is no seepage , Cracks, 2 OB

adequately maintained chipping of plaster
Window panes , doors and other 2 OB
fixtures are intact
Patients beds are intact and painted 1 OB Mattresses are intact and clean

ME D4.5. The facility has policy of removal No condemned/Junk material in the 1 OB

of condemned junk material Emergency

The facility has established

ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds 0 OB
animal control
Standard D5. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The facility has adequate

ME D5.1. arrangement storage and supply Availability of 24x7 running and potable 2 OB/SI
for portable water in all functional water
areas

The facility ensures adequate

ME D5.2. power backup in all patient care Availability of power back in Emergency 2 OB/SI
areas as per load
Availability of UPS 0 OB/SI
Availability of Emergency light 0 OB/SI

Critical areas of the facility ensures

ME D5.3. availability of oxygen, medical Availability of Centralized /local piped 2 OB
gases and vacuum supply Oxygen and vacuum supply

Standard D7. The facility ensures clean linen to the patients

The facility has adequate
ME D7.1. availability of linen for meting its Clean Linens are provided at 2 OB/RR
need. observation beds

The facility has established

ME D7.2. procedures for changing of linen in Linen are changed after change shift of 2 OB/RR
patient care areas each patient or whenever it get soiled

The facility has standard There is system to check the

ME D7.3 procedures for handling , cleanliness and Quantity of the linen 2 SI/RR
collection, transportation and received from laundry
washing of linen

Standard D10. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government

The facility has requisite licences

ME D10.1. and certificates for operation of Valid licences for ambulances are 2 RR/SI
hospital and different activities available

The facility ensure relevant

ME D10.3. processes are in compliance with Staff is aware of requirements of 2 SI
statutory requirement medico legal cases

Standard D11. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

Staff is aware of their role and

ME D11.1. The facility has established job responsibilities 2 SI
description as per govt guidelines

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The facility has a established Check for system for recording time of reporting
ME D11.2. procedure for duty roster and There is procedure to ensure that staff 2 RR/SI and relieving (Attendance register/ Biometrics
deputation to different is available on duty as per duty roster etc)
departments
There is designated in charge for 2 SI
department
The facility ensures the adherence
ME D11.3. to dress code as mandated by its Doctor, nursing staff and support staff 0 OB
administration / the health adhere to their respective dress code
department

Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

There is established system for There is procedure to monitor the Verification of outsourced services (cleaning/
ME D12.1 contract management for out quality and adequacy of outsourced 1 SI/RR Dietary/Laundry/Security/Maintenance)
sourced services services on regular basis provided are done by designated in-house staff

Area of Concern - E Clinical Services

Standard E1. The facility has defined procedures for registration, consultation and admission of patients.
The facility has established Unique identification number is given
ME E1.1. procedure for registration of to each patient during process of 2 RR
patients registration
Patient demographic details are 2 RR Check for that patient demographics like Name,
recorded in admission records age, Sex, Address, Chief complaint, etc.
There is established criteria for
ME E1.3. There is established procedure for admission through emergency 2 SI/RR
admission of patients department
There is establish procedure for
admission of MLC cases as per 2 SI/RR
prevalent laws
There is establish procedure for 2 SI/RR
prisoners as per prevalent local laws
Admission is done by written order of a 2 SI/RR
qualified doctor
There is no delay in treatment because 2 SI/RR
of admission process
Time of admission is recorded in patient 2 RR
record
There is no delay in transfer of patient
to respective department once 2 SI/RR
admission is confirmed

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Emergency department is aware of 2 SI/RR Like ICU, SNCU, Burn cases

admission criteria to critical care units

Staff is aware of cases that can not be

admitted at the facility due to 2 SI
constraint in scope of services

There is established procedure for The is provision of extra beds, trolley

ME E1.4. managing patients, in case beds beds in case of high occupancy or mass 0 OB/SI
are not available at the facility casualty

Standard E2. The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.

Assessment criteria of different kind of Use of standard criteria of assessment like

ME E2.1. There is established procedure for medical emergencies is defined and 2 SI/RR Glasgow comma scale, Poly trauma, MI, burn
initial assessment of patients practiced patient, paediatric patient, pain assessment
criteria etc.

Initial assessment and treatment is

provided immediately 2 OB/RR

Initial assessment is documented 2 RR

preferably within 2 hours
There is established procedure for There is fixed schedule for
ME E2.2. follow-up/ reassessment of reassessment of patient under 2 RR/SI
Patients observation
There is system in place to identify and Criteria is defined for identification, and
manage the changes in Patient's health 2 SI/RR management of high risk patients/ patient
status whose condition is deteriorating
Check the re assessment sheets/ Case sheets
Check the treatment or care plan is 2 SI/RR modified treatment plan or care plan is
modified as per re assessment results documented

There is established procedure to Assessment includes physical assessment,

plan and deliver appropriate Check healthcare needs of all history, details of existing disease condition (if
ME E2.3 treatment or care to individual as hospitalised patients are identified 2 SI/RR any) for which regular medication is taken as
per the needs to achieve best through assessment process well as evaluate psychological ,cultural, social
possible results factors

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

(a) According to assessment and investigation

findings (wherever applicable).
(b) Check inputs are taken from patient or
Check treatment/care plan is prepared 2 RR relevant care provider while preparing the care
as per patient's need plan.

Care plan include:, investigation to be

Check treatment / care plan is 2 RR conducted, intervention to be provided, goals to
documented achieve, timeframe, patient education, ,
discharge plan etc
Check care is delivered by competent 2 SI/RR Check care plan is prepared and delivered as per
multidisciplinary team direction of qualified physician
Standard E3. Facility has defined and established procedures for continuity of care of patient and referral

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

There is a procedure consultation of

the patient to other specialist with in 2 SI/RR
the hospital

Facility provides appropriate

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

Availability of referral linkages to higher 2 SI/RR Check how patient are referred if services are
centres. not available
Advance communication is done with 2 SI/RR
higher centre
Referral vehicle is being arranged 2 SI/RR
Referral in or referral out register is 2 RR
maintained
Facility has functional referral linkages 0 SI/RR
to lower facilities
1. Check referral out record is maintained
Check for if there is any system of 1 RR 2. Check randomly with the referred cases
follow up (contact them) for completion of treatment or
follow up.

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

ME E3.3. A person is identified for care Doctor and nurse is designated for each 2 SI/RR
during all steps of care patient admitted to emergency ward

Standard E4. The facility has defined and established procedures for nursing care
Procedure for identification of There is a process for ensuring the
ME E4.1. patients is established at the identification before any clinical 2 OB/SI Patient id band/ verbal confirmation/Bed no. etc.
facility procedure

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

There is a process to ensure the (1) Check system is in place to give telephonic
2 SI/RR orders & practised
accuracy of verbal/telephonic orders
(2) Verbal orders are verified by the ordering
physician within defined time period

There is established procedure of

ME E4.3. patient hand over, whenever staff Patient hand over is given during the 2 SI/RR
duty change happens change in the shift

Nursing Handover register is 2 RR

maintained
Hand over is given bed side 2 OB/SI
ME E4.4. Nursing records are maintained Nursing notes are maintained 2 RR/SI Check for nursing note register. Notes are
adequately adequately written

ME E4.5. There is procedure for periodic Patient Vitals are monitored and 2 RR/SI Check for TPR chart, IO chart, any other vital
monitoring of patients recorded periodically required is monitored
Critical patients are monitored 2 RR/OB Check for use of cardiac monitor/multi
continually parameter
Standard E5. Facility has a procedure to identify high risk and vulnerable patients.
Vulnerable patients are identified and
ME E5.1. The facility identifies vulnerable measures are taken to protect them 2 OB/SI Unstable, irritable, unconscious. Psychotic and
patients and ensure their safe care from any harm serious patients are identified

The facility identifies high risk High risk medical emergencies are
ME E5.2. patients and ensure their care, as identified and treatment given on 2 OB/SI
per their need priority
Standard E6. Facility ensures rationale prescribing and use of medicines

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Check for:
Facility ensured that drugs are Check for BHT if drugs are prescribed 1. No. of medicines prescribed
ME E6.1. 2 RR 2. High-end antibiotics are not prescribed
prescribed in generic name only under generic name only
3. polypharmacy
4. Medicines are prescribed from EML

Check for that relevant Standard

ME E6.2. There is procedure of rational use treatment guideline are available at 1 RR
of drugs point of use
Check staff is aware of the drug regime 0 SI/RR Check BHT that drugs are prescribed as per STG
and doses as per STG
Availability of drug formulary at 2 SI/OB
emergency
There are procedures defined for Check complete medication history including
ME E6.3 medication review and Complete medication history is 2 RR/OB over-the- counter medicines is taken and
optimization documented for each patient documented
Standard E7. Facility has defined procedures for safe drug administration

There is process for identifying Electrolytes like Potassium chloride,opiods,

ME E7.1. and cautious administration of High alert drugs available in 2 SI/OB Neuro muscular blocking agent, Anti
high alert drugs department are identified thrombolytic agent, insulin, warfarin, Heparin,
Adrenergic agonist etc.

Value for maximum doses as per age, weight and

Maximum dose of high alert drugs are 0 SI/RR diagnosis are available with nursing station and
defined and communicated doctor
A system of independent double check before
There is process to ensure that right 2 SI/RR administration, Error prone medical
doses of high alert drugs are only given abbreviations are avoided
Every Medical advice and procedure is
ME E7.2. Medication orders are written accompanied with date , time and 2 RR
legibly and adequately signature
Check for the writing, It 1 RR/SI
comprehendible by the clinical staff

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

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

Check for separate sterile needle is 2 OB

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

Any adverse drug reaction is recorded 2 RR/SI Adverse drug event trigger tool is used to report
and reported the events
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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Administration of medicines done after

ME E7.4. There is a system to ensure right ensuring right patient, right drugs , right 2 SI/OB
medicine is given to right patient route, right time
Patient is advice by doctor/
ME E7.5. Patient is counselled for self drug Pharmacist /nurse about the dosages 2 SI/PI
administration and timings .
Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
All the assessments, re-
ME E8.1. assessment and investigations are Assessment findings are written on BHT 2 RR Day to day progress of patient is recorded in BHT
recorded and updated (Manually/e-records)

All treatment plan

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

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

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

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

ME E8.6. Register/records are maintained Emergency Records are maintained 2 OB/RR Emergency register, death register, MLC register,
as per guidelines are maintained
All register/records are identified and 1 OB/RR
numbered
The facility ensures safe and
ME E8.7. adequate storage and retrieval of Safe keeping of MLC records 2 OB/SI
medical records
Standard E9. The facility has defined and established procedures for discharge of patient.
See if there is any procedure/protocol for
Discharge is done after assessing Assessment is done before discharging discharging the patient if the condition of patient
ME E9.1. 2 SI/RR improves in emergency itself.
patient readiness patient from emergency
What is the procedure for discharge for short
stay / day care patients

Discharge is done by a responsible and 2 SI/RR

qualified doctor
Patient / attendants are consulted 2 PI
before discharge

Treating doctor is consulted/ informed 2 SI/RR

before discharge of patients

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Case summary and follow-up

ME E9.2. instructions are provided at the Discharge summary is provided 2 RR/PI See for discharge summary, referral slip
discharge provided.

Discharge summary adequately

mentions patients clinical condition, 2 RR
treatment given and follow up
Discharge summary is give to patients 2 SI/RR
going in LAMA/Referral
Counselling services are provided
ME E9.3. as during discharges wherever Counselling services are provided 2 SI/PI
required wherever it is required

Standard E11. The facility has defined and established procedures for Emergency Services and Disaster Management

ME E11.1. There is procedure for Receiving Emergency has a implemented system 2 SI/OB As care provider how they triage patient-
and triage of patients of sorting the patients immediate, delayed, expectant, minimal, dead

Triage area is marked 2 OB/SI

Triage protocols are displayed 1 OB

Responsibility of receiving and shifting 2 SI

the patient from vehicle is defined

ME E11.2. Emergency protocols are defined Emergency protocols are available at 2 OB See for protocols of head injury, snake bite,
and implemented point of use poisoning, drawing etc.
Staff is aware of Clinical protocols 2 SI/RR
There is procedure for CPR 2 SI/RR
ME E11.3. The facility has disaster Lines of authority is defined 2 SI/RR
management plan in place
Procedure for internal communication 2 SI/RR
defined
There is procedure for setting up 2 SI/RR
control room
Disaster buffer stock of medicines and 2 SI/RR
other supplies maintained
Role and responsibilities of staff in 2 SI/RR
disaster is defined
Staff is aware of disaster plan 2 SI/RR

The facility ensures adequate and

ME E11.4. timely availability of ambulances Check for how ambulances are called 2 SI/RR
services and mobilisation of and patient is shifted
resources, as per requirement
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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Ambulances are equipped 2 OB

If the patient is stable then he is
transferred in ambulance with the 2 SI/RR
trained driver and one staff from
hospital.

If the patient is serious (as decided by

the Doctor), then trained driver and 2 SI/RR
one paramedical staff is mandatory to
accompany him.
The Patient’s rights are respected 2 SI/RR
during transport.
Ambulance appropriately equipped for 2 OB/RR
BLS with trained personnel

There is a daily checklist of all 2 RR

equipment and emergency medications

Ambulance has a log book for the

maintenance of vehicle and daily 2 RR
vehicle checklist

Transfer register is maintained to 2 RR

record the detail of the referred patient

ME E11.5. There is procedure for handling Medico legal cases are identified by on 2 RR/SI
medico legal cases patient records
MLC cases are not delayed because of 2 SI/OB/RR
police proceedings

There is procedure for informing police 2 SI/RR Discharge is not done before police consent

Emergency has criteria for defining 2 SI/RR Criteria is defined based on cases and when to
medico legal cases do MLC

Standard E12. The facility has defined and established procedures of diagnostic services

ME E12.1. There are established procedures Container is labelled properly after the 2 OB
for Pre-testing Activities sample collection

ME E12.3. There are established procedures Nursing station is provided with the 2 SI/RR
for Post-testing Activities critical value of different tests

Standard E13. The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

ME E13.8 There is established procedure for There is a procedure for issuing the 2 RR/SI
issuing blood blood promptly for life saving measures

ME E13.9 There is established procedure for Consent is taken before transfusion 2 RR

transfusion of blood
Patient's identification is verified before 2 SI/OB
transfusion
Blood is kept on optimum temperature 2 RR
before transfusion
Blood transfusion is monitored and 2 SI/RR
regulated by qualified person
Blood transfusion note is written in 2 RR
patient record
There is a established procedure Any major or minor transfusion
ME E13.10 for monitoring and reporting reaction is recorded and reported to 2 RR
Transfusion complication responsible person

Standard E15. Facility has defined and established procedures of Operation Theatre Services

ME E15.1. Facility has established procedures There is procedure for emergency 2 SI/RR See surgeon is available on call/on duty
OT Scheduling surgeries

Procedure for arranging logistics 2 Responsibilities are defined and patient is shifted
SI
promptly
Standard E16. The facility has defined and established procedures for the management of death & bodies of deceased patients
Death of admitted patient is
ME E16.1. adequately recorded and Facility has a standard procedure to 2 SI
communicated decent communicate death to relatives

Death note is written on patient record 2 RR

The facility has standard

ME E16.2. procedures for handling the death Past history and sign of any medico 2 RR Check what is policy for registering brought in
in the hospital legal cause is looked for dead, death cases as 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
Area of Concern - F Infection Control
Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Facility has provision for Passive

ME F1.2. and active culture surveillance of Surface and environment samples are 0 SI/RR Swab are taken from infection prone surfaces
critical & high risk areas taken for microbiological surveillance

There is Provision of Periodic

ME F1.4. Medical Check-ups and There is procedure for immunization of 2 SI/RR Hepatitis B, Tetanus Toxic etc
immunization of staff the staff

Periodic medical check-ups of the staff 2 SI/RR

Facility has established procedures

ME F1.5. for regular monitoring of infection Regular monitoring of infection control 2 SI/RR Hand washing and infection control audits done
control practices practices at periodic intervals

ME F1.6 Facility has defined and Check for Doctors are aware of Hospital 2 SI/RR
established antibiotic policy Antibiotic Policy
Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
ME F2.1. Hand washing facilities are Availability of hand washing Facility at 1 OB Check for availability of wash basin, elbow
provided at point of use Point of Use operated tap near the point of use

Availability of running Water 2 OB/SI Ask to Open the tap. Ask Staff water supply is
regular

Availability of antiseptic soap with soap 2 OB/SI Check for availability/ Ask staff if the supply is
dish/ liquid antiseptic with dispenser. adequate and uninterrupted

Availability of Alcohol based Hand rub 2 OB/SI Check for availability/ Ask staff for regular
supply.
Display of Hand washing Instruction at 2 OB Prominently displayed above the hand washing
Point of Use facility , preferably in Local language

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

Staff aware of when to hand wash 2 SI

ME F2.3. Facility ensures standard practices Availability of Antiseptic Solutions 2 OB

and materials for antisepsis

Proper cleaning of procedure site with 2 OB/SI like before giving IM/IV injection, drawing blood,
antisepsis putting Intravenous and urinary catheter

Standard F3. Facility ensures standard practices and materials for Personal protection
Facility ensures adequate personal
ME F3.1. protection equipment as per Clean gloves are available at point of 2 OB/SI
requirements use
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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

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, Masks, 2 OB/SI

personal protection practices caps and aprons.
Compliance to correct method of 2 SI Gloves, Masks, Cap, Aprons etc
wearing and removing the PPE
Standard F4. Facility has standard Procedures for processing of equipment and instruments

Facility ensures standard practices Ask staff about how they decontaminate the
ME F4.1. and materials for decontamination Decontamination of operating & 2 SI/OB procedure surface like Examination table ,
and cleaning of instruments and Procedure surfaces dressing table, Stretcher/Trolleys etc.
procedures areas (Wiping with 0.5% Chlorine solution

Ask staff how they decontaminate the

Decontamination of instruments after instruments like ambubag, suction cannula,
2 SI/OB Airways, Face Masks, Surgical Instruments
use
(Soaking in 0.5% Chlorine Solution, Wiping with
0.5% Chlorine Solution or 70% Alcohol as
applicable

Contact time for decontamination is 2 SI/OB 10 minutes

adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with detergent and running
decontamination water after decontamination
Proper handling of Soiled and infected 2 SI/OB No sorting ,Rinsing or sluicing at Point of use/
linen Patient care area
Staff know how to make chlorine 2 SI/OB
solution
Facility ensures standard practices Equipment and instruments are
ME F4.2. and materials for disinfection and sterilized after each use as per 2 OB/SI Autoclaving/HLD/Chemical Sterilization
sterilization of instruments and requirement
equipment's

High level Disinfection of

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

Chemical sterilization of
instruments/equipment is done as per 2 OB/SI Ask staff about method, concentration and
protocols contact time 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

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Layout of the department is

ME F5.1. conducive for the infection control Facility layout ensures separation of 2 OB
practices general traffic from patient traffic

Facility ensures availability of

ME F5.2. standard materials for cleaning Availability of disinfectant as per 2 OB/SI Chlorine solution, Glutaraldehyde, carbolic acid
and disinfection of patient care requirement
areas
Availability of cleaning agent as per 2 OB/SI Hospital grade phenyl, disinfectant detergent
requirement solution

Facility ensures standard practices

ME F5.3. followed for cleaning and Staff is trained for spill management 2 SI/RR
disinfection of patient care areas

Cleaning of patient care area with 2 SI/RR

disinfectant detergent solution
Staff is trained for preparing cleaning 2 SI/RR
solution as per standard procedure
Standard practice of mopping and 2 OB/SI Unidirectional mopping from inside out
scrubbing are followed
Cleaning equipment like broom are not 2 OB/SI Any cleaning equipment leading to dispersion of
used in patient care areas dust particles in air should be avoided
Emergency department define list of
ME F5.4. Facility ensures segregation infectious diseases require special 2 OB/SI
infectious patients precaution and barrier nursing
Staff is trained for barrier nursing 2 OB/SI
Standard F6. Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

Facility Ensures segregation of Bio

ME F6.1. Medical Waste as per guidelines Availability of colour coded bins at 2 OB Adequate number. Covered. Foot operated.
and on-site management of waste point of waste generation
is carried out as per guidelines

Availability of colour coded non 2 OB

chlorinated plastic bags

Human Anatomical waste, Items contaminated

Segregation of Anatomical and soiled with blood, body fluids, dressings, plaster casts,
2 OB/SI cotton swabs and bags containing residual or
waste in Yellow Bin
discarded blood and blood components.

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Items such as tubing, bottles, intravenous tubes

Segregation of infected plastic waste in 2 OB and sets, catheters, urine bags, syringes (without
red bin needles and fixed needle syringes) and
vacutainer's with their needles cut) and gloves

Display of work instructions for

segregation and handling of Biomedical 2 OB Pictorial and in local language
waste
There is no mixing of infectious and 2
general waste

ME F6.2. Facility ensures management of Availability of functional needle cutters 2 OB See if it has been used or just lying idle
sharps as per guidelines

Should be available nears the point of

Segregation of sharps waste including generation. Needles, syringes with fixed needles,
Metals in white (translucent) Puncture needles from needle tip cutter or burner,
proof, Leak proof, tamper proof 2 OB scalpels, blades, or any other contaminated
containers sharp object that may cause puncture and cuts.
This includes both used, discarded and
contaminated metal sharps

Availability of post exposure 2 SI/OB Ask if available. Where it is stored and who is in
prophylaxis charge of that.
Staff knows what to do in case of shape injury.
Staff knows what to do in condition of 2 SI Whom to report. See if any reporting has been
needle stick injury done

Contaminated and broken Glass are

disposed in puncture proof and leak 2 OB Vials, slides and other broken infected glass
proof box/ container with Blue colour
marking

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

Disinfection of liquid waste before 0 SI/OB

disposal
Transportation of bio medical waste is 2 SI/OB
done in close container/trolley

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Check for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to locate mercury beads
5. Use syringe without a needle/eyedropper and
sticky tape to suck the beads
6. Collection of beads in leak-proof bag or
Staff is aware of mercury spill container
2 SI/RR 7. Sprinkle sulphur or zinc powder to remove any
management
remaining mercury
8. All the mercury spill surfaces should be
decontaminated with 10% sodium thiosulfate
solution
9. All the bags or containers containing items
contaminated with mercury should be marked as
“Hazardous Waste, Handle with Care”
10. Collected mercury waste should be handed
over to the CBMWTF

Area of Concern - G Quality Management

Standard G1 The facility has established organizational framework for quality improvement
1. Check if the quality circle has been constituted
ME G1.1 The facility has a quality team in Quality circle has been formed in the 2 SI/RR and is functional
place Emergency 2. Roles and Responsibility of quality circle has
been defined
Standard G3. Facility have established internal and external quality assurance programs.
There is system daily round by
Facility has established internal matron/hospital manager/ hospital
ME G3.1 quality assurance program at superintendent/ Hospital Manager/ 2 SI/RR
relevant departments Matron in charge for monitoring of
services

Inhouse ambulance check is done by designated

There is system for periodic check up of hospital staff OR ambulance belonging to the
Ambulances by designated hospital 2 SI/RR
agency- the daily checklist is filled, displayed and
staff updated by the designated person

Facility has established external There is periodic assessment of

ME G3.2 assurance programs at relevant preparedness for disaster by competent 2 SI/RR
departments authority

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

1. NQAS assessment toolkit is used to conduct an

Facility has established system for Internal assessment is done at periodic internal assessment
ME G3.3 use of check lists in different 2 RR/SI 2. SaQushal assessment toolkit is used for safety
interval
departments and services audits.

Departmental checklist are used for 2 SI/RR Staff is designated for filling and monitoring of
monitoring and quality assurance these checklists

Non-compliances are enumerated and 2 RR Check the non compliances are presented &
recorded discussed during quality team meetings
Actions are planned to address Check action plans are prepared and Randomly check the details of action,
ME G3.4 gaps observed during quality implemented as per internal 2 RR responsibility, time line and feedback
assurance process assessment record findings mechanism

Planned actions are implemented Check PDCA or revalent quality method Check actions have been taken to close the gap.
ME G3.5 through Quality Improvement is used to take corrective and 2 SI/RR It can be in form of action taken report or
Cycles (PDCA) preventive action Quality Improvement (PDCA) project report

Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
Standard operating procedure for
ME G4.1. Departmental standard operating department has been prepared and 2 RR
procedures are available approved
Current version of SOP are available 2 OB
with process owner
Work instruction/clinical protocols are 2 OB Triage, CPR, Medical clinical protocols like Snake
displayed bite and poisoning
Standard Operating Procedures Emergency has documented procedure
ME G4.2. adequately describes process and for Registration and patient calling 0 RR
procedures system
Department has documented 2 RR
procedure for triaging
Department has documented 2 RR
procedure for taking consent
Department has documented
procedure for initial screening of 2 RR
patient
Department has documented 2 RR
procedure for nursing care
Department has documented
procedure for admission and transfer of 2 RR
the patient to ward

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Emergency has documented procedure 2 RR

for Handling medical records

Department has documented

procedure for maintaining records in 2 RR
Emergency
Department has documented
procedure to handle brought in dead 2 RR
patient
Department has documented
procedure for storage, handling and 2 RR
release of dead body

Department has documented

procedure for storage and replenishing 2 RR
the medicine in emergency

Department has documented

procedure for equipment preventive 2 RR
and break down maintenance
Department has documented 1 RR
procedure for Disaster management
Staff is trained and aware of the
ME G4.3. standard procedures written in Check Staff is a aware of relevant part 2 SI/RR
SOPs of SOPs

Standard G 5. Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

ME G5.1. Facility maps its critical processes Process mapping of critical processes 2 SI/RR
done
Facility identifies non value adding
ME G5.2. activities / waste / redundant Non value adding activities are 2 SI/RR
activities identified

ME G5.3 Facility takes corrective action to Processes are rearranged as per 2 SI/RR
improve the processes requirement
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
Mission, Values, Quality policy and Interview with staff for their awareness. Check if
ME G6.5 objectives are effectively Check of staff is aware of Mission , 2 SI/RR Mission Statement, Core Values and Quality
communicated to staff and users Values, Quality Policy and objectives Policy is displayed prominently in local language
of services at Key Points

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Review the records that action plan on quality

objectives being reviewed at least once in month
Facility periodically reviews the Check time bound action plan is being by departmental in charges and during the
ME G6.7 progress of strategic plan towards reviewed at regular time interval 2 SI/RR
quality team meeting. The progress on quality
mission, policy and objectives objectives have been recorded in Action Plan
tracking sheet

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
ME G7.1. Facility uses method for quality Basic quality improvement method 2 SI/OB PDCA & 5S
improvement in services

Advance quality improvement method 0 SI/OB Six sigma, lean.

ME G7.2. Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used in each
improvement in services department

Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan

Periodic assessment for Check periodic assessment of Verify with the records. A comprehensive risk
ME G9.6 Medication and Patient care safety medication and patient care safety risk 1 SI/RR assessment of all clinical processes should be
risks is done as per defined is done using defined checklist done using pre define criteria at least once in
criteria. periodically three month.

Periodic assessment for potential

risk regarding safety and security SaQushal assessment toolkit is used for 1. Check that the filled checklist and action taken
ME G9.7 of staff including violence against safety audits. 1 SI/RR report are available
service providers is done as per 2. Staff is aware of key gaps & closure status
defined criteria

ME G9.7 Risks identified are analysed Identified risks are analysed for severity 1 SI/RR Action is taken to mitigate the risks
evaluated and rated for severity

Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

Check parameter are defined & implemented to

review the clinical care i.e. through Ward round,
Clinical care assessment criteria The facility has established process to peer review, morbidity & mortality review,
ME G10.3 have been defined and 2 SI/RR
review the clinical care processes patient feedback, clinical audit & clinical
communicated outcomes.

(1) Both critical and stable patients

Check regular ward rounds are taken to 2 SI/RR (2) Check the case progress is documented in
review case progress BHT/ progress notes-
Check the patient /family participate in 2 SI/PI Feedback is taken from patient/family on health
the care evaluation status of individual under treatment

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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

System in place to review internal referral

Check the care planning and co- 2 SI/RR process, review clinical handover information,
ordination is reviewed review patient understanding about their
progress

Check medical audit records

(a) Completion of the medical records i.e.
Medical history, assessments, re assessment,
investigations conducted, progress notes,
interventions conducted, outcome of the case,
Facility conducts the periodic patient education, delineation of responsibilities,
ME G10.4 clinical audits including There is procedure to conduct medical 1 SI/RR discharge etc.
prescription, medical and death audits (b) Check whether treatment plan worked for
audits the patient
(C) progress on the health status of the patient
is mentioned
(d) whether the goals defined in treatment plan
is met for the individual cases
(e) Adverse clinical events are documented
(f) Re admission

(1) All the deaths are audited by the committee.

(2) The reasons of the death is clearly mentioned
(3) Data pertaining to deaths are collated and
There is procedure to conduct death trend analysis is done
2 SI/RR (4) A through action taken report is prepared
audits
and presented in clinical Governance Board
meetings / during grand round (wherever
required)

(1) Random prescriptions are audited

(2) Separate Prescription audit is conducted foe
both OPD & IPD cases
There is procedure to conduct 2 RR (3) The finding of audit is circulated to all
prescription audits concerned
(4) Regular trends are analysis and presented in
Clinical Governance board/Grand round
meetings

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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

All non compliance are enumerated 1 SI/RR Check the non compliances are presented &
recorded for medical audits discussed during clinical Governance meetings

All non compliance are enumerated 1 SI/RR Check the non compliances are presented &
recorded for death audits discussed during clinical Governance meetings

All non compliance are enumerated 1 SI/RR Check the non compliances are presented &
recorded for prescription audits discussed during clinical Governance meetings

Clinical care audits data is Check action plans are prepared and
ME G10.5 analysed, and actions are taken to implemented as per medical audit 1 SI/RR Randomly check the actual compliance with the
close the gaps identified during record findings actions taken reports of last 3 months
the audit process

Check action plans are prepared and

implemented as per death audit 1 SI/RR Randomly check the actual compliance with the
record's findings actions taken reports of last 3 months

Check action plans are prepared and

implemented as per prescription audit 1 SI/RR Randomly check the actual compliance with the
record findings actions taken reports of last 3 months

Check the data of audit findings are 1 RR Check collected data is analysed & areas for
collated improvement is identified & prioritised
Check the critical problems are regularly
Check PDCA or revalent quality method 1 SI/RR monitored & applicable solutions are duplicated
is used to address critical problems in other departments (wherever required) for
process improvement

Facility ensures easy access and

use of standard treatment Check standard treatment guidelines / Staff is aware of Standard treatment protocols/
ME G10.7 guidelines & implementation tools protocols are available & followed. 0 SI/RR guidelines/best practices
at
point of care

Check treatment plan is prepared as 0 SI/RR Check staff adhere to clinical protocols while
per Standard treatment guidelines preparing the treatment plan
Check the drugs are prescribed as per 0 SI/RR Check the drugs prescribed are available in EML
Standards treatment guidelines or part of drug formulary
Check when the STG/protocols/evidences used
Check the updated/latest evidence are 0 SI/RR in healthcare facility are published.
available Whether the STG protocols are according to
current evidences.
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Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

The gaps in clinical practices are identified &

Check the mapping of existing clinical 2 SI/RR action are taken to improve it. Look for
practices processes is done evidences for improvement in clinical practices
using PDCA
Area of Concern - H Outcome
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1. Facility measures productivity No. of trauma cases treated per 1000 2 RR
Indicators on monthly basis emergency cases
No. of poisoning cases treated per 1000 2 RR
emergency cases
No. of cardiac cases treated per 1000 2 RR
emergency cases
No of resuscitation done per thousand 2 RR Resuscitation should include: Chest
population Compression, Airway and Breathing
Number of emergency cases treated at 2 RR Check at lease last 3 month data
night per month
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1. Facility measures efficiency Response time for ambulance 2 RR
Indicators on monthly basis
Proportion of cases referred 2 RR
Sum of time taken for initial assessment of all
Response time at emergency for initial 2 RR patients who accessed emergency services in a
assessment period/Total number of patients who accessed
emergency services in that period

Average Turn Around Time 2 RR Average time a patient stays at emergency

observation bed
Proportion of patient referred by state
ME H2.2 owned/108 ambulance per 1000 2 RR
referral cases
Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

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

ME H4.1. Facility measures Service Quality LAMA Rate 2 RR No of LAMA X 100/ No of Patients seen at
Indicators on monthly basis emergency

Absconding rate 2 RR No of Absconding X 100/ No of Patients seen at

emergency
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Checklist 1 Accident Emergency Version - NHSRC/3.0

Reference No. Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks
Method

Response Time in Emergency 2 RR The time from entry of patient at emergency

department department to admission/transfer-out/discharge

Percentage of emergency patients for (Number of patients in emergency for whom the
whom the initial assessment was 2 RR initial assessment was completed within a
completed within defined timeframe defined time frame / total number of patients
admitted) x 100

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Checklist No - 2 Outdoor Department Version - NHSRC/ 3.0

Version: DH/NQAS-
National Quality Assurance Standards for District Hospitals 2020/00
Checklist for Outdoor Patient Department 2
Assessment Summary
Name of the Hospital GHQH Erode Date of Assessment
Names of Assessors Names of Assessee
Type of Assessment (Internal/External) Internal Action plan Submission Date

OPD Score Card

Area of Concern wise Score OPD Score

A Service Provision #DIV/0!
B Patient Rights #DIV/0!
C Inputs #DIV/0!
D
E
Support Services
Clinical Services
#DIV/0!
#DIV/0! #DIV/0!
F Infection Control #DIV/0!
G Quality Management #DIV/0!
H Outcome #DIV/0!

Major Gaps Observed

1
2
3
4
5
Strengths / Good Practices
1
2
3
4
5
Recommendations/ Opportunities for Improvement
1
2
3
4
5
Signature of Assessors
Date

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Checklist No - 2 Outdoor Department Version - NHSRC/ 3.0

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Checklist No - 2 Outdoor Department Version - NHSRC/ 3.0

Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services

ME A1.1 The facility provides General Availability of functional General SI/OB Dedicated General speciality Medicine Clinic
Medicine services Medicine Clinic

ME A1.2 The facility provides General Surgery Availability of functional General Surgery SI/OB Dedicated General speciality Surgical Clinic
services Clinic

(a) Dedicated speciality Obstetrics &

Gynaecology Clinic.
ME A1.3 The facility provides Obstetrics & Availability of Functional Obstetrics & SI/OB (b) High-risk pregnancy cases are referred
Gynaecology Services Gynaecology Clinic from the ANC clinic and consulted.

(a) Dedicated clinic of PMSMA

Availability of Pradhan Mantri Surakshit (b) Availability MO & ObG specialist
Matritva Abhiyan (PMSMA) services (c ) 9th of every month - for all pregnant
women in 2-3 trimester

(a) PAP smear & biopsy, Cervical VIA

Availability of daycare Gynaecology staining, Endometrial aspiration, Bartholin
SI/OB cyst excision.
procedure
(b) MTP (Medical & surgical Method)

Availability of Paediatric Clinic (1) Dedicated Paediatric Clinic for diagnosis

and treatment for common childhood
ailments
ME A1.4 The facility provides Paediatric SI/OB (2) Screening for admission
Services (3) Follow up for care & care after discharge

Availability of services for early Established linkage with DEIC (inhouse or

identification and intervention of 4 D's SI/OB referral)

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

1. Dedicated ENT providing consultation

services
2. Foreign Body Removal (Ear and
ME A1.6 The facility provides ENT Services Availability of Functional ENT Clinic for SI/OB Nose),Stitching of CLW’s, Dressings,
adult and paediatrics Syringing of Ear, Chemical Cauterization
(Nose & Ear), Eustachian Tube Function Test,
Vestibular Function Test/Caloric Test

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
(a) Dedicated clinical for Orthopaedic
ME A1.7 The facility provides Orthopaedics Availability of Functional Orthopaedic SI/OB consultation
Services Clinic (b) Plaster room to conduct Orthopaedic
procedure

ME A1.8 The facility provides Skin & VD Availability of functional Skin & VD Clinic SI/OB Dedicated Clinic providing consultation
Services services
Dedicated Clinic providing consultation
ME A1.9 The facility provides Psychiatry Availability of functional Psychiatry Clinic SI/OB services/ provision of private psychiatrist 2-
Services 3 days /week

ME A1.10 The facility provides Dental Availability of functional Dental Clinic SI/OB Dedicated Clinic providing consultation
Treatment Services services
Accompanied by dental lab. Extraction,
Availability of OPD Dental procedure SI/OB scaling, tooth extraction, denture and
Restoration.

ME A1.11 The facility provides AYUSH Services Availability of Functional AYUSH clinic SI/OB AYUSH clinic accompanied by dispensary

Pain Management with cryotherapy, Pain

ME A1.12 The facility provides Physiotherapy Availability of Functional Physiotherapy SI/OB Management with deep heat therapy
Services Unit (SWD), Increase range of motion with
mobilization,

ME A1.13 The facility provides services for OPD Availability of Dressing facilities at OPD SI/OB Dressing, Suturing and drainage
procedures
Availability of Injection room facilities at SI/OB
OPD

ME A1.14 Services are available for the time At least 6 Hours of OPD Services are SI/RR
period as mandated available

PMSMA is conducted 9th of every month SI/RR

ME A1.15 The facility provides services for Availability of functional Cardiology clinic SI/OB
Super specialties, as mandated
Availability of functional gastro SI/OB
entomology clinic

Availability of functional nephrology clinic SI/OB

Availability of functional Neurology clinic SI/OB

Availability of functional endocrinology SI/OB

Clinic is available

Availability of functional Oncology Clinic SI/OB

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Checklist No - 2 Outdoor Department Version - NHSRC/ 3.0

Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Standard A2 Facility provides RMNCHA Services

ME A2.2 The facility provides Maternal health Availability of functional ANC clinic SI/OB
Services

ME A2.3 The facility provides Newborn health Availability of Functional immunization SI/OB
Services clinic

ME A2.4 The facility provides Child health Availability Functional IYCF clinic SI/OB
Services
Availability of promotion services of
overall growth and development of SI/OB
children as per RBSK

(a) Screening & Counselling on Nutrition,

puberty-related concerns, HIV,
Contraceptives, Substance abuse, Learning
problems, Stress, Depression, Suicidal
Tendency, healthy lifestyle, and risky
The facility provides Adolescent behaviour.
ME A2.5 Availability of Functional AFHCs SI/OB (b)Treatment & management for RTI/ STI,
health Services
ANC for pregnant adolescents, Abortion,
Violence, Sexual Abuse, Mental Health
Issues, Management of Menstrual problems,
Management of Iron deficiency Anaemia,
(c) Linkages with de-addiction centres and
referrals.

Standard A3 Facility Provides diagnostic Services

ME A3.2 The facility Provides Laboratory Availability of Sample collection Centre SI/OB
Services

ME A3.3 The facility provides other diagnostic Functional ECG Services are available SI/OB
services, as mandated
Availability of TMT services SI/OB
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme

The facility provides services under

ME A4.1 National Vector Borne Disease Availability of OPD Services Under NVBDCP SI/RR OPD Management of Malaria, Kala Azar,
Control Programme as per guidelines Dengue

The facility provides services under

ME A4.2 national tuberculosis elimination Availability of Functional DOTS clinic SI/OB
programme as per guidelines.

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Checklist No - 2 Outdoor Department Version - NHSRC/ 3.0

Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
The facility provides services under
ME A4.3 National Leprosy Eradication Availability of OPD services under NLEP SI/RR
Programme as per guidelines
Assessment of Disability Status SI/RR
Supply of Customized Foot wear SI/RR
The facility provides services under
ME A4.4 National AIDS Control Programme as Availability of Functional ICTC SI/OB
per guidelines

Availability of HIV Testing and Counselling SI/RR

PPTCT Services for HIV positive Pregnant SI/OB

Women
Availability of Functional ART Centre SI/OB
Availability of CD4 testing facility SI/OB
The facility provides services under
ME A4.5 National Programme for prevention Screening and early detection of visual SI/RR Refraction, syringing and probing, foreign
and control of Blindness as per impairment and refraction body removal, Tonometry and retinoscopy
guidelines

Syringing and probing, foreign body removal

Availability of OPD procedures SI/OB , Tonometry ,Perimetry, Retinoscopy,
Retrobulbar Injection

The facility provides services under (a) Acute/ chronic headache Epilepsy,
ME A4.6 Mental Health Programme as per Availability of services under MHP Dementia , Vertigo.
guidelines (b) Anxiety disorders, Substance abuse

Availability of counselling centre for SI/OB

Suicide prevention

(a)Dedicated OPD services for geriatric

patients
The facility provides services under daily
ME A4.7 National Programme for the health Dedicated Geriatric Clinic SI/OB
(b) Lab investigation & medicine for geriatric
care of the elderly as per guidelines cases

The facility provides services under (a) Diagnosis & management of cases of
National Programme for Prevention hypertension, diabetes, CVD, Stroke &
ME A4.8 and control of Cancer, Diabetes, Functional NCD clinic is available SI/OB cancer
Cardiovascular diseases & Stroke (b) Follow up chemotherapy cases
(NPCDCS) as per guidelines ( c) Rehabilitation and physiotherapy

The facility provide services under

ME A4.10 National health Programme for Management of case referred from SI/RR
deafness PHC/CHC directly reported to Hospital

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

ME A4.11 The facility provides services as per Availability of OPD services as per State SI/RR
State specific health programmes Health Programs
The facility provided services as per Screening and early detection of 4 Ds Linkage with lower facilities, MMU, school
ME A 4.12 Rashtriya bal swasthya Karykram SI/RR health programme for management of 4 D's

Availability of DEIC Facility for Occupational therapy & Physical

therapy, Psychological services, Cognition
SI/RR services, Audiology, Speech-language
pathology,vision,etc

(a) Screening of the suspected cases of HBV

& HCV
(b) Confirmation of cases - Referral/ Linkage
The facility provides services as per (c ) Treatment of uncomplicated cases
ME A4.14 Availability of services under NVHCP SI/RR (d) Referral of complicated cases to Medical
National Viral Hepatitis Program
college/ Model Hepatitis Treatment Centre
(e) Follow-up visits - after starting the
treatment

The facility provide services under

ME A4.15 National Programme for palliative Availability of palliative care OPD SI/RR Frequency as mandated the state
care
Standard A6 Health services provided at the facility are appropriate to community needs.

The facility provides curatives & Ask for the specific local health problems/
ME A6.1 preventive services for the health Special Clinics are available for local SI/OB diseases .i.e.. Kala azar, Swine Flue, arsenic
problems and diseases, prevalent prevalent endemics poisoning etc.
locally.
Area of Concern - B Patient Rights
Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities

Facility provides the information to

Standard B1 care seekers, attendants & ###
community about the available
services and their modalities

ME B1.1 The facility has uniform and user- Availability departmental signage's OB (Numbering, main department and internal
friendly signage system sectional signage
Display of layout/floor directory OB
The facility displays the services and
ME B1.2 entitlements available in its List of OPD Clinics are available OB
departments
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Method
Names of doctor on duty is displayed and OB
updated
Timing for OPD are displayed OB
Entitlements applicable are Displayed OB Entitlement under, PMJAY, JSY , JSSK, NSSK
and other schemes
Important numbers like ambulance are OB
displayed

ME B1.3 The facility has established citizen Display of citizen charter OB

charter, which is followed at all levels

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

Patients & visitors are sensitised and

ME B1.5 educated through appropriate IEC / IEC Material is displayed OB PMSMA, JSSK, JSY, PMJAY etc
BCC approaches
Education material for counselling are OB
available in Counselling room

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

language and easy to understand local language
The facility provides information to
ME B1.7 patients and visitor through an Availability of Enquiry Desk with dedicated OB
exclusive set-up. staff

The facility ensures access to clinical

ME B1.8 records of patients to entitled OPD slip with UID is given to the patient RR/OB
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 economic, cultural or social reasons.

ME B2.1 Services are provided in manner that Separate queue for female at registration OB
are sensitive to gender
Separate Female general OPD OB
Separate toilets for male and female OB
Availability of female staff if a male doctor OB
examination a female patients
Availability of Breast feeding corner OB
Access to facility is provided without
ME B2.3 any physical barrier & and friendly to Availability of Wheel chair or stretcher for OB
people with disabilities easy access to the OPD

Emergency is located at ground floor with OB At least 120 cm width, gradient not steeper
availability of ramp and railing than 1:12

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Method
Measure are taken to reduce the
There is no chaos and over crowding in the OB overcrowding like appointment
OPD system/chaos/token system

Availability of specially abled friendly toilet OB

Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient, and has a system for guarding patients related information
ME B3.1 Adequate visual privacy is provided at Availability of screen at Examination Area OB
every point of care
One Patient is seen at a time in clinics OB
Privacy at the counselling room is OB
maintained

ME B3.2 Confidentiality of patients records Confidentiality of HIV reports at ICTC SI/OB

and clinical information is maintained

The facility ensures the behaviours of

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

The facility ensures privacy and

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

Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it is required.

There is established procedures for

ME B4.1 taking informed consent before Informed consent for before HIV testing at SI/RR
treatment and procedures ICTC

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

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

Pre and Post test counselling is given at SI/PI/RR

ICTC

The facility has defined and Availability of complaint box and display of
ME B4.5 established grievance redressal process for grievance re redressal and OB
system in place whom 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.

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Method
The facility provides cashless services
ME B5.1 to pregnant women, mothers and Free OPD Consultation / ANC Check-ups PI/SI For JSSK entitlement
neonates as per prevalent
government schemes

The facility ensures that Medicines Check that patient party has not spent on
ME B5.2 prescribed are available at Pharmacy purchasing Medicines or consumables PI/SI
and wards from outside.
It is ensured that facilities for the
ME B5.3 prescribed investigations are available Check that patient party has not spent on PI/SI
at the facility diagnostics from outside.

The facility provide free of cost

ME B5.4 treatment to Below poverty line Free OPD Consultation for BPL patients PI/SI/RR
patients without administrative
hassles

The facility ensures timely

ME B5.5 reimbursement of financial If any other expenditure occurred it is PI/SI/RR
entitlements and reimbursement to reimbursed from hospital
the patients
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
ME C1.1 Departments have adequate space as Clinics has adequate space for OB Adequate Space in Clinics (12 sq. ft)
per patient or work load consultation and examination
Waiting area at the scale of 1 sq. ft per
Availability of adequate waiting area OB average daily patient with minimum 400 sq.
ft of area

ME C1.2 Patient amenities are provide as per Availability of seating arrangement in OB As per average OPD at peak time
patient load waiting area
Availability of sub waiting at for separate OB For clinics has high patient load
clinics
Availability of cold Drinking water OB See if its is easily accessible to the visitors
Urinals 1 per 50 person
Availability of functional toilets OB water closet and wash basins 1 per 100
person
Availability of patient calling system OB
ME C1.3 Departments have layout and There is designated area for registration OB
demarcated areas as per functions
Dedicated clinic for each speciality OB
One clinic is not shared by 2 doctors at OB
one time
Dedicated examination areas is provided OB
with each clinics

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Method
Demarcated dressing area /room OB
Demarcated injection room OB
Demarcated immunization room for OB
pregnant women and children
OPD has separate entry and exit from IPD OB
and Emergency

availability of clean and dirty utility room OB

Demarcated trolley/wheelchair bay OB
The facility has adequate circulation
ME C1.4 area and open spaces according to Corridors at OPD are broad enough to OB
need and local law manage stretcher and trolleys

The facility has infrastructure for

ME C1.5 intramural and extramural Availability of functional telephone and OB
communication Intercom Services

Availability of Registration counters as Average Time taken for registration would

ME C1.6 Service counters are available as per per Patient load OB be 3-5 min so number of counter required
patient load would be worked on scale of 12-20
patient/hour per counter

Layout of OPD shall follow functional flow of

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

All OPD clinics and related auxiliary

services are co located in one functional OB
area
OPD is located near to the entry of the OB
hospital
Standard C2 The facility ensures the physical safety of the infrastructure.
Check for fixtures and furniture like
ME C2.1 The facility ensures the seismic safety Non structural components are properly OB cupboards, cabinets, and heavy equipment ,
of the infrastructure secured hanging objects are properly fastened and
secured

ME C2.3 The facility ensures safety of electrical OPD building does not have temporary OB
establishment connections and loosely hanging wires

ME C2.4 Physical condition of buildings are Floors of the OPD are non slippery and OB
safe for providing patient care even

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Method

Windows have grills and wire meshwork OB

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

ME C3.1 The facility has plan for prevention of OPD has sufficient fire exit to permit safe OB/SI
fire escape to its occupant at time of fire

Check the fire exits are clearly visible and OB

routes to reach exit are clearly marked.

ME C3.2 The facility has adequate fire fighting OPD has installed fire Extinguisher that is OB
Equipment Class A , Class B C type or ABC type
Check the expiry date for fire extinguishers
are displayed on each extinguisher as well OB/RR
as due date for next refilling is clearly
mentioned

The facility has a system of periodic Check for staff competencies for operating
ME C3.3 training of staff and conducts mock fire extinguisher and what to do in case of
drills regularly for fire and other fire
disaster situation
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
(a) Check for specialist are available at
ME C4.1 The facility has adequate specialist Availability of specialist Doctor at OPD OB/RR scheduled time
doctors as per service provision time (b) 1 OBG specialist per 100 ANC - regular
or private - for PMSMA

The facility has adequate general duty

ME C4.2 doctors as per service provision and Availability of General duty doctor at OB/RR
work load Screening Clinic

Availability of General duty doctor at OB/RR

PMSMA

ME C4.3 The facility has adequate nursing staff Availability of Nursing staff OB/RR/SI At Injection room/ OPD Clinic as Per
as per service provision and work load Requirement

The facility has adequate

ME C4.4 technicians/paramedics as per Availability of dresser/paramedic at OB/SI
requirement dressing room

Counsellor for ICTC SI/RR Full Time

Lab technician for ICTC SI/RR Full time
Counsellor for AFHS clinic SI/RR
Availability of ECG technician SI/RR
Availability of Audiometrician SI/RR
Availability of Ophthalmic assistant SI/RR

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Method
Availability of Physiotherapist SI/RR
Availability of Dental technician SI/RR
Availability of rehabilitation therapist SI/RR
ME C4.5 The facility has adequate support / availability of dedicated security guard for SI/RR
general staff OPD
Availability of registration clerks as per SI/RR
load
Availability of housekeeping staff SI/RR
Standard C5 Facility provides Medicines and consumables required for assured list of services.

ME C5.1 The departments have availability of Availability of injectables at injection room OB/RR ARV, TT
adequate Medicines at point of use

Availability of drugs for management of Metformin & insulin

GDM

ME C5.2 The departments have adequate Availability of disposables at dressing OB/RR Examination gloves, Syringes, Dressing
consumables at point of use room and clinics material , suturing material
HIV testing Kits I, II and III at ICTC OB/RR
Availability of glucometer & OGTT for screening of GDM
Emergency Medicine trays are
ME C5.3 maintained at every point of care, Emergency Medicine Tray is maintained at OB/RR
where ever it may be needed injection room & immunization room

Standard C6 The facility has equipment & instruments required for assured list of services.
Availability of equipment & Availability of functional Equipment BP apparatus, thermometer, weighting
ME C6.1 instruments for examination & &Instruments for examination & OB machine, torch, stethoscope, Examination
monitoring of patients Monitoring table

Availability of equipment & Availability of functional

ME C6.2 instruments for treatment Instruments/Equipment for Gynae and OB PV examination kit, Inch tape, fetoscope,
procedures, being undertaken in the obstetric Weighting machine, BP apparatus etc.
facility

Availability of functional
Equipment/Instruments for Orthopaedic OB X ray view box, Equipment for plaster room
Procedures
Retinoscope, refraction kit, tonometer,
Availability of functional Instruments / OB perimeter, distant vision chart, Colour vision
Equipment for Ophthalmic Procedures chart.
Audiometer, Laryngoscope, Otoscope, Head
Availability of Instruments/ Equipment OB Light, Tuning Fork, Bronchoscope,
Procedures for ENT procedures Examination Instrument Set
Availability of functional Instruments/ OB Dental chair, Air rotor, Endodontic set,
Equipment for Dental Procedures Extraction forceps

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Method
Availability of functional
Equipment/Instruments of Physiotherapy OB Traction, Wax bath, Short Wave Diathermy,
Procedures Exercise table Etc .

Availability of equipment &

ME C6.3 instruments for diagnostic procedures Availability of Equipment for ICTC lab OB Micropipettes, Centrifuge, Needle destroyer,
being undertaken in the facility Refrigerators

ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for OB Refrigerator, Crash cart/Medicine trolley,
Medicines instrumental trolley, dressing trolley

ME C6.6 Availability of functional equipment Availability of equipment for cleaning OB Buckets for mopping, mops, duster, waste
and instruments for support services trolley, Deck brush

Availability of equipment for sterilization OB Boiler

and disinfection
Departments have patient furniture
ME C6.7 and fixtures as per load and service Availability of Fixtures OB Spot light, electrical fixture for equipment, X
provision ray view box

Doctors Chair, Patient Stool, Examination

Availability of furniture at clinics OB Table, Attendant Chair, Table, Footstep,
cupboard
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

Check objective checklist has been prepared

for assessing competence of doctors, nurses
Criteria for Competence assessment Check parameters for assessing skills and and paramedical staff based on job
ME C7.1 are defined for clinical and Para proficiency of clinical staff has been RR/SI
description defined for each cadre of staff.
clinical staff defined Dakshta checklist issued by MoHFW can be
used for this purpose.

Competence assessment of Clinical Check for records of competence

ME C7.2 and Para clinical staff is done on Check for competence assessment is done RR/SI assessment including filled checklist, scoring
predefined criteria at least once in a at least once in a year and grading . Verify with staff for actual
year competence assessment done

The Staff is provided training as per

ME C7.9 defined core competencies and Infection control & prevention training SI/RR Bio medical Waste Management including
training plan Hand Hygiene

Training on Quality Management System SI/RR

Patient Safety SI/RR
ICTC Team Training SI/RR
Induction and refresher training for ICTC SI/RR
counsellor

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Method
Induction and refresher training for ICTC SI/RR
lab technician

There is established procedure for Check supervisors make periodic rounds of

utilization of skills gained thought Check the competency of staff to use OPD department and monitor that staff is
ME C7.10 SI/RR working according to the training imparted.
trainings by on -job supportive equipment like BP apparatus etc
supervision Also staff is provided on job training
wherever there is still gaps

Check supervisors make periodic rounds of

At ANC clinic staff is skilled to identify high department and monitor that staff is
SI/RR working according to the training imparted.
risk pregnancies
Also staff is provided on job training
wherever there is still gaps

Check supervisors make periodic rounds of

department and monitor that staff is
Counsellor is skilled for counselling SI/RR working according to the training imparted.
Also staff is provided on job training
wherever there is still gaps

Check supervisors make periodic rounds of

Staff is skilled for maintaining clinical department and monitor that staff is
SI/RR working according to the training imparted.
records
Also staff is provided on job training
wherever there is still gaps
Area of Concern - D Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
1. Check with AMC records/
ME D1.1 The facility has established system for All equipment are covered under AMC SI/RR Warranty documents
maintenance of critical Equipment including preventive maintenance 2. Staff is aware of the list of equipment
covered under AMC.

[Link] for breakdown & Maintenance

There is system of timely corrective break SI/RR record in the log book
down maintenance of the equipment 2. Staff is aware of contact details of the
agency/person in case of breakdown.

The facility has established procedure

ME D1.2 for internal and external calibration of All the measuring equipment/ instrument OB/ RR BP apparatus, thermometer are calibrated
measuring Equipment are calibrated

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

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Method

ME D2.3 The facility ensures proper storage of Medicines are stored in OB Labelled with Medicine name, Medicine
Medicines and consumables containers/tray/crash cart and are labelled strength and expiry date

Empty and filled cylinders are labelled OB

ME D2.4 The facility ensures management of Medicines expiry dates' are maintained at OB/RR
expiry and near expiry Medicines emergency Medicine tray

No expired Medicine found OB/RR

Records for expiry and near expiry Check register/DVDMS/other supply chain
Medicines are maintained for Medicine RR software for record of stock of expired and
stored at department near expiry Medicines
The facility has established procedure
ME D2.5 for inventory management There is established system of calculating SI/RR
techniques and maintaining buffer stock

Department maintained stock register of SI/RR Check record of drug received, issued and
drugs and consumables balance stock in hand and are updated
There is a procedure for periodically
ME D2.6 replenishing the Medicines in patient There is established procedure for SI/RR
care areas replenishing drug tray /crash cart

Random stock check of some essential

There is no stock out of drugs SI/RR medicines. E.g. Paracetamol, Atenolol,
Amlodipine, Azithromycin, etc.
There is process for storage of Temperature of refrigerators are kept as Check for refrigerator/ILR temperature
ME D2.7 vaccines and other Medicines, per storage requirement and records OB/RR charts. Charts are maintained and updated
requiring controlled temperature twice a day and are maintained twice a day

Check for four conditioned Ice packs are

Cold chain is maintained at immunization OB/RR placed in Carrier Box,
room DPT, DT, TT and Hep B Vaccines are not
kept in direct contact of Frozen Ice pack
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
The facility provides adequate
ME D3.1 illumination level at patient care Adequate Illumination in clinics OB Examination table
areas

Adequate Illumination in procedure area OB Dressing room, injection room and

immunization room

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

Limited number of attendant/ relatives are OB/SI

allowed with patient

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Method
Medical representative are restricted in OB/SI
OPD timings

The facility ensures safe and Fans/ Air

ME D3.3 comfortable environment for patients Temperature control and ventilation in PI/OB conditioning/Heating/Exhaust/Ventilators as
and service providers waiting areas per environment condition and requirement

Fans/ Air
Temperature control and ventilation in SI/OB conditioning/Heating/Exhaust/Ventilators as
clinics per environment condition and requirement

ME D3.4 The facility has security system in Hospital has sound security system to OB/SI
place at patient care areas manage overcrowding in OPD

ME D3.5 The facility has established measure Ask female staff whether they feel secure SI
for safety and security of female staff at work place

Standard D4 The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior of the facility building is Building is painted/whitewashed in OB
maintained appropriately uniform colour
Interior of patient care areas are plastered OB
& painted
Floors, walls, roof, roof topes, sinks
ME D4.2 Patient care areas are clean and patient care and circulation areas are OB All area are clean with no
hygienic Clean dirt,grease,littering and cobwebs

Surface of furniture and fixtures are clean OB

Toilets are clean with functional flush and OB

running water

ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , Cracks, OB

maintained chipping of plaster
Window panes , doors and other fixtures OB
are intact
Patients beds are intact and painted OB
Mattresses are intact and clean OB
ME D4.5 The facility has policy of removal of No condemned/Junk material lying in the OB
condemned junk material OPD
The facility has established
ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds OB
animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

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Method

The facility has adequate

ME D5.1 arrangement storage and supply for Availability of 24x7 running and potable OB/SI
portable water in all functional areas water

The facility ensures adequate power

ME D5.2 backup in all patient care areas as per Availability of power back up in OPD OB/SI
load
StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.

ME D6.1 The facility has provision of Nutritional assessment of patient done as RR/SI
nutritional assessment of the patients required and directed by doctor

Standard D7 The facility ensures clean linen to the patients

ME D7.1 The facility has adequate sets of linen Availability of linen in examination area OB

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

Staff is aware of their role and

ME D11.1 The facility has established job responsibilities SI
description as per govt guidelines

The facility has a established Check for system for recording time of
ME D11.2 procedure for duty roster and There is procedure to ensure that staff is RR/SI reporting and relieving (Attendance register/
deputation to different departments available on duty as per duty roster Biometrics etc)

There is designated in charge for SI

department
The facility ensures the adherence to
ME D11.3 dress code as mandated by its Doctor, nursing staff and support staff OB
administration / the health adhere to their respective dress code
department
Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

There is established system for There is procedure to monitor the quality Verification of outsourced services
ME D12.1 contract management for out sourced and adequacy of outsourced services on SI/RR (cleaning/Laundry/Security/Maintenance)
services regular basis provided are done by designated in-house
staff
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

ME E1.1 The facility has established procedure Unique identification number is given to RR
for registration of patients each patient during process of registration

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Method
Patient demographic details are recorded RR Check for that patient demographics like
in OPD registration records Name, age, Sex, Address etc.

Patients are directed to relevant clinic by PI/SI

registration clerk based on complaint

Registration clerk is aware of categories of SI/RR

the patient exempted from user charges

Patient is called by Doctor/attendant as per

ME E1.2 The facility has a established There is procedure for systematic calling OB his/her turn on the basis of “first come first
procedure for OPD consultation of patients one by one examine” basis.
Patient History is taken and recorded RR Check OPD records for the same

Check details of the physical examination,

Physical Examination is done and recorded OB/RR provisional diagnosis and investigations (if
wherever required any) is mentioned in the OPD ticket

Provisional Diagnosis is recorded OB/RR Check treatment plan and confirmed

diagnosis is recorded
Proper seating arrangement for the patient
No Patient is Consulted in Standing OB and parent- attendant is there. Care is
Position provided in a dignified way.
Clinical staff is not engaged in OB/SI During OPD hours clinical staff is not
administrative work engaged in other administrative tasks

ME E1.3 There is established procedure for There is establish procedure for admission SI/RR
admission of patients through OPD
There is establish procedure for day care SI/RR
admission
Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.
ME E2.1 There is established procedure for There is screening clinic for initial OB
initial assessment of patients assessment of the patients

ME E2.2 There is established procedure for There is fixed schedule for reassessment SI/RR
follow-up/ reassessment of Patients of patient under observation

There is system in place to identify and Criteria is defined for identification, and
manage the changes in Patient's health SI/RR management of patient as per disease
status condition
Check the re assessment sheets/OPD tickets
Check the treatment or care plan is SI/RR modified, treatment plan or care plan is
modified as per re assessment results documented

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Method

(a) According to assessment and

There is established procedure to investigation findings (wherever applicable).
plan and deliver appropriate (b) Check inputs are taken from patient or
ME E2.3 treatment or care to individual as per Check treatment/care plan is prepared as SI/RR relevant care provider while preparing the
the needs to achieve best possible per patient's need care plan.
results

Care plan include:, investigation to be

Check treatment / care plan is RR conducted, intervention to be provided,
documented goals to achieve, timeframe, patient
education, , discharge plan etc
Check care is delivered by competent SI/RR Check care plan is prepared and delivered as
multidisciplinary team per direction of qualified physician
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral
Facility has established procedure for Facility has established procedure for
ME E3.1 continuity of care during handing over of patients during SI/RR
interdepartmental transfer departmental transfer
There is a procedure consultation of the
patient to other specialist with in the SI/RR
hospital

Facility provides appropriate referral

linkages to the patients/Services for Availability of referral linkages for OPD (a) Check how patient are referred if
ME E3.2 RR/OB services are not available
transfer to other/higher facilities to consultation.
assure their continuity of care. (b) Check the referral linkage for PMSMA

Facility has functional referral linkages to SI/RR

higher facilities
Facility has functional referral linkages to SI/RR
lower facilities
1. Check referral out record is maintained
There is a system of follow up of referred RR 2. Check randomly with the referred cases
patients (contact them) for completion of treatment
or follow up.
ICTC has functional Linkages with ART and RR/SI
state reference Labs
Facility is connected to medical
ME E3.4 colleges through telemedicine Telemedicine service are used for RR/SI
services consultation

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Method
Patient records are maintained for the RR/PI Check the records for completion.
cases availing the telemedicine services
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.
The facility identifies high risk For any critical patient needing urgent
ME E5.2 patients and ensure their care, as per attention queue can be bypassed for OB/SI
their need providing services on priority basis
Standard E6 Facility ensures rationale prescribing and use of medicines

Check for:
1. No. of medicines prescribed
Facility ensured that Medicines are Check for OPD slip if Medicines are 2. High-end antibiotics are not prescribed
ME E6.1 RR 3. polypharmacy
prescribed in generic name only prescribed under generic name only
4. No of multivitamins prescribed
5. No of injectables prescribed
6. Medicines are prescribed from EML

A copy of Prescription is kept with the RR

facility
Check for that relevant Standard
ME E6.2 There is procedure of rational use of treatment guideline are available at point RR
Medicines of use
Check staff is aware of the Medicine SI/RR Check OPD ticket that Medicines are
regime and doses as per STG prescribed as per STG
Availability of Medicine formulary SI/OB
Check complete medication history including
ME E6.3 There are procedures defined for Complete medication history is RR/OB over-the- counter medicines is taken and
medication review and optimization documented for each patient documented

1. Medication Reconciliation is carried out

by a trained and competent health
professional during the patient's admission,
Established mechanism for Medication SI/RR interdepartmental transfer or discharged
reconciliation process 2. Medicine reconciliation includes
Prescription and non-prescription (over-the-
counter) medications, vitamins, nutritional
supplements.

Medicines are optimised as per individual

Medicine are reviewed and optimised as SI/RR treatment plan for best possible clinical
per individual treatment plan outcome specially in chronic cases, Non
communicable diseases etc
Clinician counsel the patient on medication
Patients are engaged in their own care PI/SI safety using "5 moments for medication
safety app"
Standard E7 Facility has defined procedures for safe Medicine administration
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Method
Every Medical advice and procedure is
ME E7.2 Medication orders are written legibly accompanied with date , time and RR
and adequately signature
Check for the writing, It comprehendible RR/SI
by the clinical staff
There is a procedure to check
ME E7.3 Medicine before administration/ Medicines are checked for expiry and OB/SI Check in Injection room
dispensing other inconsistency before administration

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

Check for separate sterile needle is used OB In multi dose vial needle is not left in the
every time for multiple dose vial septum
Any adverse Medicine reaction is recorded RR/SI Adverse drug event trigger tool is used to
and reported report the events

ME E7.5 Patient is counselled for self Medicine Patient is advice by doctor/ Pharmacist SI/PI
administration /nurse about the dosages and timings .
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
All the assessments, re-assessment Patient History, Chief Complaint and
ME E8.1 and investigations are recorded and Examination Diagnosis/ Provisional RR (Manually/e-records)
updated Diagnosis is recorded in OPD slip

ME E8.2 All treatment plan prescription/orders Written RR (Manually/e-records)

are recorded in the patient records. Prescription Treatment plan is written

ME E8.4 Procedures performed are written on Any dressing/injection, other procedure RR (Manually/e-records)
patients records recorded in the OPD slip

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

ME E8.6 Register/records are maintained as OPD records are maintained OB/RR OPD register, ANC register, Injection room
per guidelines register etc
All register/records are identified and OB/RR
numbered
The facility ensures safe and
ME E8.7 adequate storage and retrieval of Safe keeping of OPD records OB/SI
medical records
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.3 The facility has disaster management Staff is aware of disaster plan SI/RR
plan in place
Role and responsibilities of staff in disaster SI/RR
is defined

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Method

Standard E12 The facility has defined and established procedures of diagnostic services

ME E12.1 There are established procedures for Container is labelled properly after the OB
Pre-testing Activities sample collection

ME E12.3 There are established procedures for Clinics is provided with the critical value of SI/RR
Post-testing Activities different tests
Maternal & Child Health Services
Standard E17 Facility has established procedures for Antenatal care as per guidelines

There is an established procedure for

ME E17.1 Registration and follow up of Facility provides and updates “Mother and RR/SI Line listing
pregnant women. Child Protection Card”.

Records of each ANC check-ups is

Records are maintained for ANC registered RR maintained in Mother and child protection
pregnant women card

There is an established procedure for

ME E17.2 History taking, Physical examination, ANC check-ups is done by Qualified RR/SI
and counselling for each antenatal personnel
visit.
At ANC clinic, Pregnancy is confirmed by RR/SI
performing urine test
Last menstrual period (LMP) is recorded
and Expected date of Delivery (EDD) is RR/SI
calculated

Assessment of Clinical condition of Gestational Age, general & systemic

pregnant women & foetus during all ANC RR/SI examination including breast examination ,
Check-up medical, surgical & personal history etc

Weight & Blood pressure measurement RR/SI

Pallor, oedema and icterus. RR/SI
Abdominal palpation for foetal growth, RR/SI
foetal lie
Auscultation for foetal heart sound RR/SI
PV examination during 4th ANC RR/SI to check pelvic adequacy - in 37 weeks
4 ANC & 1 PMSMA check-ups of women is RR/SI
done

(a) Confirm hypertension & identify the

Identification & Management of RR/SI pregnant women with severe PE/E
hypertensive disorders (b) Manage hypertension as per guidelines

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Method

(a) Treatment as per the guidelines

Management of the Syphilis reactive RR/SI (b) Quantitative & qualitative RPR/VDRL test
pregnant women (c ) Test/treat the spouse/partner

Management of the Syphilis non reactive RR/SI Retest high-risk women in third trimester or
high risk pregnant women soon after delivery

(a) Medical Nutrition Therapy (MNT) &

Physical exercise for 2 weeks
(b) After 2 weeks of MNT & physical exercise
- 2hrs PPBS
- if 2hrs PPBS is less than 120mg/dl- repeat
Management of pregnant women with the test as per protocol- one test every
GDM month during 2nd & 3rd trimesters
- if 2hrs PPBS is more 120mg/dl - medical
management (metformin or insulin therapy
to be started as per guidelines
(c ) Foetal surveillance - Foetal auscultation
in Antenatal visit

(a) Screening of high-risk Pregnant women

(Areas with moderate to severe iodine
deficiency, obesity, history - of thyroid
dysfunction/ surgery, to first-degree
Identification & management of relatives, mental retardation, autoimmune
hypothyroidism disease, frequent miscarriage, pre-term
delivery etc.)
(b) Hormonal assay - TSH & FT4
(c ) Treatment as per guidelines-
Levothyroxine

Facility ensures availability of Check for Haemoglobin, urine albumin,

ME E17.3 diagnostic and Medicines during Diagnostic test under ANC check up are RR/SI urine sugar, blood group and Rh
antenatal care of pregnant women prescribed by ANC clinic factor ,Syphilis (VDRL/RPR) HIV, blood sugar,
malaria & Hepatitis B

(a) Universal screening of all pregnant

Oral glucose tolerance test (OGTT) is done women at the time of first antenatal
RR/SI contact.
for all pregnant women
(b) if the first test is negative second test -
24-28 week of gestation

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Method

There is an established procedure for (a) PIH, GDM, Malaria, HIV, syphilis, APH,
identification of High risk pregnancy High risk pregnant women are referred to (b) From ANC clinic to PMSMA
ME E17.4 RR/SI (c ) Sticker indicating the risk factor/
and appropriate treatment/referral as specialist
per scope of services. condition of the pregnant woman - placed in
MCP card in PMSMA

There is an established procedure for

ME E17.5 identification and management of Line listing of pregnant women with RR/SI
moderate and severe anaemia moderate and sever anaemia

Provision for Injectable Iron Treatment for RR/SI

moderate anaemia
Counselling of pregnant women is
ME E17.6 done as per standard protocol and Nutritional counselling RR/PI
gestational age
Nutrition & Rest Iron, folic acid & calcium supplementation
Recognizing danger sign of labour RR/PI
Breast feeding RR/PI
Institutional delivery RR/PI
Arrangement of referral transport RR/PI
Birth preparedness RR/PI
Family planning RR/PI
Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines

ME E20.1 The facility provides immunization Availability of diluents for Reconstitution RR/SI
services as per guidelines of measles vaccine

Check diluents are kept under cold chain at

Recommended temperature of diluents is least before 24 hours before reconstitution
RR/SI Diluents are kept in vaccine carrier only at
insured before reconstitution
immunization clinic but should not be in
direct contact of ice pack

Ask staff about when BCG, measles and JE

Reconstituted vaccines are not used after RR/SI vaccines are constituted and till when these
recommended time are valid for use. Should not be used beyond
4 hours after reconstitution
Time of opening/ Reconstitution of vial is RR Check for records
recorded
Staff checks VVM level before using SI Ask staff how to check VVM level and how
vaccines to identify discard point
Staff is aware of how check freeze damage SI Ask staff to demonstrate how to conduct
for T-Series vaccines Shake test for DPT, DT and TT

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Method
Check for no expired, frozen or with VVM
Discarded vaccines are kept separately SI/OB beyond the discard point vaccine stored in
clod chain

Check for DPT, DT, Hep Band TT vials are SI/OB

not kept in direct contact of ice pack

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

Staff knows correct use AD syringe SI Ask for demonstration , How to peel, how to
remove air bubble and injection site
Check for AD syringes are not reused OB
Injection site is not cleaned with spirit OB/SI
before administering vaccine dose

Vaccine recipient is asked to stay for half

an hour after vaccination to observer any SI/RR
Adverse effect following immunization

Antipyretic medicines available SI/RR

Availability of Immunization card SI/RR
Counselling on side effects and follow up SI/RR
visits done(CEI)
Staff is aware of how to handle minor and SI
serious advise events (AEFI)
Staff knows how to manage any SI
immediate serious reaction/anaphylaxis

1. Ask the staff to enumerate categories or

Staff is aware of different categories of whether he/she can differentiate between
OB/SI minor & severe AEFI
AEFI
2. The case definition list of severe/serious
AEFI is available with provider

1. Verify weekly report of AEFI cases

Person responsible for notifying & SI/RR 2. Nil reporting in case of no AEFI cases
reporting of the AEFI is identified 3. Verify HMIS report of previous month
Process of reporting and route is SI/RR Ask staff to whom the cases are reported
communicated to all concerned and how
Triage, Assessment & Management of
ME E20.2 newborns having Check for adherence to clinical protocols SI/RR
emergency signs are done as per
guidelines

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Method

Management of children presenting

ME E20.7 with fever, cough/ breathlessness is Check for adherence to clinical protocols SI/RR
done as per guidelines

Management of children with severe

ME E20.8 Acute Malnutrition is done as per Screening of children coming to OPDs SI/RR
guidelines using weight for height and/or MUAC

ME E20.9 Management of children presenting Check for adherence to clinical protocols SI/RR
diarrhoea is done per guidelines

Availability of ORT corner SI/RR

Standard E22 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines

Nutritional Counselling, contraceptive

ME E22.1 Facility provides Promotive ARSH Provision of Antenatal natal check up for SI/RR counselling, Couple counselling ANC check-
Services pregnant adolescent ups, ensuring institutional delivery
Counselling and provision of emergency SI/RR Check for the availability of Emergency
contraceptive pills Contraceptive pills (Levonorgestrel)
Counselling and provision of reversible RR/SI Check for the availability of Oral
Contraceptives Contraceptive Pills, Condoms and IUD

Availability and Display of IEC material OB Poster Displayed, Reading Material

handouts etc.

Advice on topic related to Growth and

development,puberty,sexuality cancers,
Information and advice ob. sexual and SI/RR myths & misconception, pregnancy, safe
reproductive health related issues sex, contraception, unsafe abortion,
menstrual disorders,anemia, sexual
abuse ,RTI/STI's etc.

ME E22.2 Facility provides Preventive ARSH Services for Tetanus immunization SI/RR TT at 10 and 16 year
Services

Services for Prophylaxis against Nutritional SI/RR Haemoglobin estimation, weekly IFA tablet,
Anaemia and treatment for worm infestation

Nutrition Counselling SI/RR

Services for early and safe termination of
pregnancy and management of post SI/RR MVA procedure for pregnancy up to 8 week
abortion complication Post abortion counselling

Privacy and Confidentiality, treatment

ME E22.3 Facility Provides Curative ARSH Treatment of Common RTI/STI's SI/RR Compliance, Partner Management, Follow
Services up visit and referral

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Method
Treatment and counselling for Menstrual SI/RR Symptomatic treatment , counselling
disorders

Treatment and counselling for sexual SI/RR

concern for male and female adolescents

Management of sexual abuse amongst SI/RR ECP, Prophylaxis against STI, PEP for HIV and
Girls Counselling

ME E22.4 Facility Provides Referral Services for Referral Linkages to ICTC and PPTCT SI/RR
ARSH
Screens and curtains for visual
Privacy and confidentiality maintained at SI/RR privacy,confidentaility policy displayed, one
ARSH clinic client at a time

Standard E23 Facility provides National health program as per operational/Clinical Guidelines

Facility provides service under As per Clinical Guidelines for Treatment of

ME E23.1 National Vector Borne Disease Ambulatory care of uncomplicated P. SI/RR Malaria
Control Program as per guidelines Vivax malaria

Ambulatory care of uncomplicated P. SI/RR As per Clinical Guidelines for Treatment of

Falciparum Malaria Malaria
Ambulatory care of Medicine resistant SI/RR As per Clinical Guidelines for Treatment of
malaria Malaria

Cough >2 weeks, fever >2 weeks,

significant weight loss, haemoptysis,
any abnormalities in chest radiography.
Facility provides service under Addition, contact of microbiologically
ME E23.2 National TB Elimination Program as Staff is aware of symptoms or signs SI/RR confirmed
per guidelines Presumptive pulmonary TB as per revised TB patients, PL HIV, diabetics, malnourished,
guidelines cancer
patients, patients on immunosuppressive
therapy

Organ specific symptoms and signs like

Staff is aware of Signs and symptoms of swelling of lymph nodes, pain & swelling in
SI/RR joints, neck stiffness, disorientation, etc or
Extra pulmonary Tuberculosis
constitutional symptoms like weight loss,
fever> 2 weeks night sweat

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Method

Child with persistent fever and/ or cough for

more than 2 weeks. Unexplained Loss of
Staff is aware of signs and symptoms of weight/no weight gain in past 3
presumptive paediatric TB cases as per SI/RR months/here loss of body
revised guidelines weight loss of >5% body weight as
compared to highest weight recorded in the
last
3 months.

(1)TB patients who have failed treatment

with first‑line
anti‑ tubercular Medicines (ATD).
(2)Paediatric TB non‑responded.
Staff is aware of presumptive DRTB cases (3)TB patients who are contacts of DRTB.
SI/RR (4)TB patients who are found positive on
as per revised guidelines
any follow‑up sputum smear examination
during treatment with
first‑line ATD.
(5) Previously treated TB cases
(6)TB patients with HIV co‑infection

1. Mono resistance (MR) – Biological

specimen of TB Patient resistant to one first
line anti TB Medicine only.
2. Poly resistance (PDR) – Biological
specimen resistant to more than one anti TB
Medicine, other than INH & Rifampicin.
3. Multi‑ Medicine resistance (MDR) –
Biological specimen resistant to both INH
Staff is aware of classification done on the and Rifampicin or with or without resistance
basis of Medicine resistance as per revised SI/RR to other first line ATD
guidelines 4. Rifampicin resistance (RR) – Resistance
to Rifampicin detected by phenotypic or
genotypic method with or without resistant
to other ATD excluding INH. Patient with RR
manged as if MDR-TB case.
5. Extensive Medicine resistance-
MDR TB case whose biological specimen
resistant to Fluroquinolone (FQ)
and a second‑line injectable ATD

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Method

All the presumptive TB cases undergo

sputum smear examination (spot early
morning or spot-spot). If first sputum is
positive not at risk of DRTB, it is
microbiologically confirmed.
Treatment of New Cases:
Treatment in IP will consist of 8weeks of
Diagnosis and treatment of Presumptive RR/SI INH, Rifampicin, Pyrazinamide and
pulmonary TB as per revised guidelines Ethambutol in daily dose as per weight band
categories.
Only Pyrazinamide will be stopped in CP rest
3 Medicines will be continue for 16 weeks.
(Daily regimen with administration of daily
fixed dose combination of first line ATD as
per weight band)

Cartridge based Nucleic Acid Amplification

test (CBNAAT) performed to rule out
Rifampicin resistance and categorized as
microbiologically confirmed Medicine
Diagnosis and treatment of smear positive sensitive TB or RIF resistant.
and presumptive multi Medicine Treatment:
resistance TB (MDR-TB) as per revised RR/SI IP will be of 12 weeks, where injection
guidelines Streptomycin will be stopped after 8 weeks
and remaining four Medicines in daily dose
for another 4 weeks as per weight band.
At CP, Pyrazinamide will be stopped while
rest of Medicines will be continue for
another 20 weeks as daily dosage

Diagnostic algorithm for pulmonary, extra

pulmonary and paediatric TB as per RR/SI Check algorithm for all the three cases are
revised guidelines are readily available available.

The CP in both new and previously treated

Management of extra pulmonary TB cases cases may be extended 3-6 months in cases
RR/SI such as CNS, skeletal etc.
as per revised guidelines
ATD given in fixed dose on daily basis as per
weight band

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Method

6-9 months of IP with Kanamycin,

Management of MDR/RRTB(without Levofloxacin, Ethambutol, Pyrazinamide,
additional resistance) as per revised RR/SI Ethionamide, And Cyclomerize. !8 month of
guidelines CP with Levofloxacin, Ethambutol,
Ethionamide, And Cyclomerize

Management of Paediatric Tuberculosis SI/RR As per revised RNTCP Technical Guidelines

Management of Patients with HIV SI/RR As per revised RNTCP Technical Guidelines
infection and Tuberculosis

Educate patient and family about disease,

Patient and family is counselled before dose schedule, duration, common side
SI/PI/RR effects, methods of prevention,
initiating TB treatment
consequence of irregular treatment or
premature cessation of treatment

Treatment card and TB identity card is PI/RR Treatment card will be issued in duplication
given if required

Clinical follow up:

Should be at least monthly – the patient
may visit the clinical facility or medical
officer call for review may even visit the
house of patient.
Laboratory follow up: Sputum smear
Monitoring and follow up of patient done SI/RR examination at the end of IP & end of
as per protocols treatment (for every patient)
Long term follow up: After completion of
treatment, the patient should be followed
up at the end of 6, 12, 18 and 24 months.
Any clinical symptoms and/or cough,
sputum microscopy and/or culture should
be considered.

There is functional Linkage between DMC SI/RR

and ICTC
Facility provides service under
ME E23.3 National Leprosy Eradication Program Validation and Diagnosis of Referred and SI/RR As per Operation/ Clinical Guidelines of
as per guidelines Directly Reported Cases NLEP

Treatment of all diagnosed cases including SI/RR As per Operation/ Clinical Guidelines of
Reaction and Neuritis NLEP

Assessment of Disability Status SI/RR As per Operation/ Clinical Guidelines of

NLEP

Management of Lepra Reactions SI/RR As per Operation/ Clinical Guidelines of

NLEP

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Method

Management of Complicated Ulcers SI/RR As per Operation/ Clinical Guidelines of

NLEP

Management of Eye Complications SI/RR As per Operation/ Clinical Guidelines of

NLEP
Physiotherapy including Pre and Post SI/RR As per Operation/ Clinical Guidelines of
Operative Care NLEP

Follow-up of cases treated at tertiary Level SI/RR As per Operation/ Clinical Guidelines of
NLEP

Supply of Customized Foot wear SI/RR As per Operation/ Clinical Guidelines of

NLEP

Self care Counselling SI/RR As per Operation/ Clinical Guidelines of

NLEP

Outreach Services to Leprosy Clinics SI/RR As per Operation/ Clinical Guidelines of

NLEP

Screening of Cases of RCS SI/RR As per Operation/ Clinical Guidelines of

NLEP

basic information and benefits of HIV testing

potential risks such as discrimination. The
client is also informed about their right to
Facility provides service under Pre Test Counselling is done as per refuse, follow-up services . Pregnant
ME E23.4 National AIDS Control program as per protocols SI/RR
women are given additional information on
guidelines nutrition, hygiene, the importance of an
institutional delivery and HIV testing so as to
avoid HIV transmission from mother to child.

window period, a repeat test is

recommended, clients with suspected
tuberculosis are referred to the nearest
microscopy centre. In case of a positive test
result, the counsellor assists the client to
understand the
Post test counselling given as per protocol SI/RR implications of the positive test result and
helps in coping with the test result. The
counsellor also ensures access to treatment
and care, and supports disclosure of the HIV

status to the spouse.

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Method
Diagnosis and treatment of opportunistic SI/RR As per NACO guidelines
Infections
Screening of PLHA for initiating ART SI/RR As per NACO guidelines
Monitoring of patients on ART and SI/RR As per NACO guidelines
management of side effects
Counselling and Psychological support for SI/RR As per NACO guidelines
PLHA

(a) Management of the acute psychosis,

obsession, anxiety, depression, neurosis &
Facility provides service under Mental Identification and treatment of mental epilepsy
ME E23.6 (b)Ensure availability medicines & regular
Health Program as per guidelines illness as per guidelines
follow up
(c ) Referferal of the cases as per
requirement

Identification of the cases for substance SI/RR Treat/ refer to the de addiction centre
abuse

(a) Basic psycho education about treatment

adherence
(b) Motivation enhancement
Psychosocial support is provided SI/RR (c ) Reduction of high risk behaviour
(d) Relapse prevention
(e ) Counselling for occupational rehab.
(d) Patient support group / individual
counselling

Facility provides service under (a) Linkage with specialists like medicine,
ME E23.7 National programme for the health Geriatric Care is provided as per Clinical SI/RR ortho, health., ENT services
care of the elderly as per guidelines Guidelines (b) Referral services to Regional Geriatric
centre/MC

Facility provides service under Screening of persons above age of 30 -

National Programme for Prevention Opportunistic screening for diabetes, History of tobacco examination, BP
ME E23.8 and Control of cancer, diabetes, SI/RR
hypertension, cardiovascular diseases Measurement and Blood sugar estimation
cardiovascular diseases & stroke Look for records at NCD clinic
(NPCDCS) as per guidelines

Screen women of the age group 30-69 SI/RR for early detection of cervix cancer and
years approaching to the hospital breast cancer

Increased intake of healthy foods, Increased

Health Promotion through IEC and physical activity through sports, exercise,
OB etc.;
counselling
Avoidance of tobacco and alcohol; stress
management & warning signs of cancer etc

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Method

Council the patient for monitoring of their

Counselling the identified cases for self PI/RR BP (using digital BP apparatus) , sugar (using
care glucometer) , self care for ulcer etc

(a) Submitted to District surveillance officer

ME E23.9 Facility provide service for Integrated Weekly reporting of Presumptive cases on SI/RR (b) Data is submitted manually or through
disease surveillance program form "P" from OPD clinic IHIP (integrated health information
platform)

Facility provide services under

ME E23.10 National program for prevention and Early detection and screening for SI/RR As per Clinical guidelines
control of deafness detection of deafness

(a) Routine assessment of HBsAg & LFT

(b) Assessment of the severity of liver
Facility provides services under disease
ME E23.11 National Viral Hepatitis Control Assessment & treatment of uncomplicated SI/RR (c) Management of the cases with evidence
Programme cases of Viral Hepatitis of compensated or decompensated
cirrhosis- as per guidelines

(a) Medication refill- after 25 days

(b) Educate the patient on adherence &
regular follow up
Follow up of the cases of the Viral SI/RR (c ) Check for side effects & investigate as
Hepatitis per requirements & guidelines
(d) Update the investigation in the
treatment card

(a) Assessment, treatment plan &

prescription for cases
ME E 23.12 Facility provide services under Clinical assessment by trained & SI/RR (b) Pain Management
National program for palliative care competent physician (c ) Counselling & psycho social
interventions

Area of Concern - F Infection Control

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 There is procedure for immunization of SI/RR Hepatitis B, Tetanus Toxic etc
Check-ups and immunization of staff the staff

Periodic medical check-ups of the staff SI/RR

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

ME F1.6 Facility has defined and established Check for Doctors are aware of Hospital SI/RR
antibiotic policy 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 Availability of hand washing Facility at OB Check for availability of wash basin, elbow
at point of use Point of Use operated tap near the point of use

Availability of running Water OB/SI Ask to Open the tap. Ask Staff water supply
is regular
Availability of antiseptic soap with soap OB/SI Check for availability/ Ask staff if the supply
dish/ liquid antiseptic with dispenser. is adequate and uninterrupted

Availability of Alcohol based Hand rub OB/SI Check for availability/ Ask staff for regular
supply.
Prominently displayed above the hand
Display of Hand washing Instruction at OB washing facility , preferably in Local
Point of Use language

ME F2.2 Staff is trained and adhere to Adherence to 6 steps of Hand washing SI/OB Ask of demonstration
standard hand washing practices
Staff aware of when to hand wash SI
ME F2.3 Facility ensures standard practices Availability of Antiseptic Solutions OB
and materials for antisepsis
like before giving IM/IV injection, drawing
Proper cleaning of procedure site with OB/SI blood, putting Intravenous and urinary
antisepsis catheter
Standard F3 Facility ensures standard practices and materials for Personal protection
Facility ensures adequate personal
ME F3.1 protection equipment as per Clean gloves are available at point of use OB/SI
requirements
Availability of Masks OB/SI
ME F3.2 Staff is adhere to standard personal No reuse of disposable gloves, Masks, caps OB/SI
protection practices and aprons.
Compliance to correct method of wearing SI Gloves, Masks, Cap, Aprons etc
and removing the gloves
Standard F4 Facility has standard Procedures for processing of equipment and instruments

Facility ensures standard practices Ask staff about how they decontaminate the
ME F4.1 and materials for decontamination Decontamination of operating & SI/OB procedure surface like Examination table ,
and cleaning of instruments and Procedure surfaces dressing table, Stretcher/Trolleys etc.
procedures areas (Wiping with 0.5% Chlorine solution

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Method

Ask staff how they decontaminate the

Proper Decontamination of instruments instruments like Stethoscope, Dressing
SI/OB Instruments, Examination Instruments,
after use
Blood Pressure Cuff etc
(Soaking in 0.5% Chlorine Solution, Wiping
with 0.5% Chlorine Solution

Contact time for decontamination is SI/OB 10 minutes

adequate
Cleaning of instruments after SI/OB Cleaning is done with detergent and running
decontamination water after decontamination
Proper handling of Soiled and infected SI/OB No sorting ,Rinsing or sluicing at Point of
linen use/ Patient care area

Staff know how to make chlorine solution SI/OB

Facility ensures standard practices

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

High level Disinfection of

instruments/equipment is done as per OB/SI Ask staff about method and time required
protocol for boiling

Autoclaved dressing material is used OB/SI

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

Clinics for infectious diseases are located OB Preferably in remote corner with
away from main traffic independent access
Sitting arrangement in TB clinic is as per OB
guideline
Facility ensures availability of
ME F5.2 standard materials for cleaning and Availability of disinfectant as per OB/SI Chlorine solution, Glutaraldehyde, carbolic
disinfection of patient care areas requirement acid

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

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

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Method
Staff is trained for preparing cleaning SI/RR
solution as per standard procedure
Standard practice of mopping and OB/SI Unidirectional mopping from inside out
scrubbing are followed
Any cleaning equipment leading to
Cleaning equipment like broom are not OB/SI dispersion of dust particles in air should be
used in patient care areas avoided
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins at point of OB
Medical Waste as per guidelines waste generation
Availability of colour coded non OB Adequate number. Covered. Foot operated.
chlorinated plastic bags

Human Anatomical waste, Items

contaminated with blood, body fluids,
Segregation of Anatomical and soiled OB/SI dressings, plaster casts, cotton swabs and
waste in Yellow Bin bags containing residual or discarded blood
and blood components.

Items such as tubing, bottles, intravenous

Segregation of infected plastic waste in tubes and sets, catheters, urine bags,
OB syringes (without needles and fixed needle
red bin
syringes) and vacutainers' with their
needles cut) and gloves

Display of work instructions for

segregation and handling of Biomedical OB Pictorial and in local language
waste
There is no mixing of infectious and
general waste

ME F6.2 Facility ensures management of Availability of functional needle cutters OB See if it has been used or just lying idle
sharps as per guidelines

Should be available nears the point of

Segregation of sharps waste including generation. Needles, syringes with fixed
Metals in white (translucent) Puncture needles, needles from needle tip cutter or
proof, Leak proof, tamper proof OB burner, scalpels, blades, or any other
containers contaminated sharp object that may cause
puncture and cuts. This includes both used,
discarded and contaminated metal sharps

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

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
Staff knows what to do in case of shape
Staff knows what to do in condition of SI injury. Whom to report. See if any reporting
needle stick injury has been done

Contaminated and broken Glass are

disposed in puncture proof and leak proof OB Vials, slides and other broken infected glass
box/ container with Blue colour marking

ME F6.3 Facility ensures transportation and Check bins are not overfilled SI/OB
disposal of waste as per guidelines
Transportation of bio medical waste is
done in close container/trolley

Check for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to locate mercury beads
5. Use syringe without a needle/eyedropper
and sticky tape to suck the beads
6. Collection of beads in leak-proof bag or
container
Staff is aware of mercury spill SI/RR 7. Sprinkle sulphur or zinc powder to
management remove any remaining mercury
8. All the mercury spill surfaces should be
decontaminated with 10% sodium
thiosulfate solution
9. All the bags or containers containing
items contaminated with mercury should be
marked as “Hazardous Waste, Handle with
Care”
10. Collected mercury waste should be
handed over to the CBMWTF

Area of Concern - G Quality Management

Standard G1 The facility has established organizational framework for quality improvement

There is a designated departmental nodal 1. Check if the quality circle has been
ME G1.1 The facility has a quality team in place person for coordinating Quality Assurance SI/RR constituted and is functional
activities 2. Roles and Responsibility of quality circle
has been defined
Standard G2 Facility has established system for patient and employee satisfaction
ME G2.1 Patient Satisfaction surveys are OPD Patient satisfaction survey done on RR
conducted at periodic intervals monthly basis
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

There is system daily round by

Facility has established internal matron/hospital manager/ hospital
ME G3.1 quality assurance program at relevant superintendent/ Hospital Manager/ SI/RR
departments Matron in charge for monitoring of
services

Internal Quality Assurance is established at SI/RR

ICTC lab
Facility has established external
ME G3.2 assurance programs at relevant External Quality assurance program is SI/RR
departments established at ICTC lab

Facility has established system for use 1. NQAS assessment toolkit is used to
ME G3.3 of check lists in different departments Internal assessment is done at periodic RR/SI conduct internal assessment
and services interval 2. SaQushal assessment toolkit
Departmental checklist are used for SI/RR Staff is designated for filling and monitoring
monitoring and quality assurance of these checklists

Non-compliances are enumerated and RR Check the non compliances are presented &
recorded discussed during quality team meetings

Actions are planned to address gaps Check action plans are prepared and Randomly check the details of action,
ME G3.4 observed during quality assurance implemented as per internal assessment RR responsibility, time line and feedback
process record findings mechanism

Planned actions are implemented Check PDCA or revalent quality method is Check actions have been taken to close the
ME G3.5 through Quality Improvement Cycles used to take corrective and preventive SI/RR gap. It can be in form of action taken report
(PDCA) action or Quality Improvement (PDCA) project
report
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
Standard operating procedure for
ME G4.1 Departmental standard operating department has been prepared and RR
procedures are available approved
Current version of SOP are available with OB/RR
process owner
Work instruction/clinical protocols are OB Relevant protocols are displayed like Clinical
displayed Protocols for ANC check-ups
Standard Operating Procedures
ME G4.2 adequately describes process and OPD has documented procedure for RR
procedures Registration

OPD has documented procedure for RR

patient calling system in OPD clinics
OPD has documented procedure for RR
receiving of patient in clinic

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
OPD has documented process for OPD RR
consultation
OPD has documented procedure for RR
investigation
OPD has documented procedure for RR
prescription and Medicine dispensing
OPD has documented procedure for RR
nursing process in OPD
OPD has documented procedure for RR
patient privacy and confidentiality
OPD has documented procedure for
conducting, analysing patient satisfaction RR
survey
OPD has documented procedure for
equipment management and maintenance RR
in OPD
Department has documented procedure
for Administrative and non clinical work at RR
OPD

Department has documented procedure RR

for No Smoking Policy in OPD

OPD has documented procedure for duty

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

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

Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

ME G5.1 Facility maps its critical processes Process mapping of critical processes done SI/RR

Facility identifies non value adding

ME G5.2 activities / waste / redundant Non value adding activities are identified SI/RR
activities

ME G5.3 Facility takes corrective action to Processes are rearranged as per SI/RR
improve the processes requirement
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Check short term valid quality objectivities

have been framed addressing key quality
Facility has de defined quality Check if SMART Quality Objectives have issues in each department and cores
ME G6.4 objectives to achieve mission and SI/RR
framed services. Check if these objectives are
quality policy Specific, Measurable, Attainable, Relevant
and Time Bound.

Mission, Values, Quality policy and Interview with staff for their awareness.
ME G6.5 objectives are effectively Check of staff is aware of Mission , Values, SI/RR Check if Mission Statement, Core Values and
communicated to staff and users of Quality Policy and objectives Quality Policy is displayed prominently in
services local language at Key Points

Review the records that action plan on

quality objectives being reviewed at least
Facility periodically reviews the Check time bound action plan is being once in month by departmental in charges
ME G6.7 progress of strategic plan towards SI/RR
reviewed at regular time interval and during the quality team meeting. The
mission, policy and objectives progress on quality objectives have been
recorded in Action Plan tracking sheet

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 Facility uses method for quality Basic quality improvement method SI/RR PDCA & 5S
improvement in services
Advance quality improvement method SI/OBSix sigma, lean.
ME G7.2 Facility uses tools for quality 7 basic tools of Quality SI/RR Minimum 2 applicable tools are used in each
improvement in services department
Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan

Periodic assessment for Medication Check periodic assessment of medication Verify with the records. A comprehensive
ME G9.6 and Patient care safety risks is done and patient care safety risk is done using SI/RR risk assessment of all clinical processes
as per defined criteria. defined checklist periodically should be done using pre define criteria at
least once in three month.

Periodic assessment for potential risk

regarding safety and security of staff SaQushal assessment toolkit is used for 1. Check that the filled checklist and action
ME G9.7 including violence against service SI/RR taken report are available
safety audits.
providers is done as per defined 2. Staff is aware of key gaps & closure status
criteria

ME G9.8 Risks identified are analysed Identified risks are analysed for severity SI/RR Action is taken to mitigate the risks
evaluated and rated for severity

Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Check parameter are defined &

implemented to review the clinical care i.e.
ME G10.3 Clinical care assessment criteria have The facility has established process to SI/RR through Ward round, peer review, morbidity
been defined and communicated review the clinical care & mortality review, patient feedback, clinical
audit & clinical outcomes.

(1) Both critical and stable patients

Check regular ward rounds are taken to SI/RR (2) Check the case progress is documented
review case progress in BHT/ progress notes-

Check the patient /family participate in the SI/PI Feedback is taken from patient/family on
care evaluation health status of individual under treatment

System in place to review internal referral

Check the care planning and co- ordination SI/RR process, review clinical handover
is reviewed information, review patient understanding
about their progress

(1) Random prescriptions are audited

(2) Separate Prescription audit is conducted
Facility conducts the periodic clinical foe both OPD & IPD cases
ME G10.4 audits including prescription, medical There is procedure to conduct prescription SI/RR (3) The finding of audit is circulated to all
and death audits audits concerned
(4) Regular trends are analysis and
presented in Clinical Governance
board/Grand round meetings

All non compliance are enumerated SI/RR Check the non compliances are presented
recorded for prescription audits & discussed during clinical Governance
meetings

Clinical care audits data is analysed, Check action plans are prepared and Randomly check the actual compliance
ME G10.5 and actions are taken to close the implemented as per medical audit record SI/RR with the actions taken reports of last 3
gaps identified during the audit findings months
process

Check action plans are prepared and Randomly check the actual compliance
implemented as per prescription audit SI/RR with the actions taken reports of last 3
record findings months

Check the data of audit findings are RR Check collected data is analysed & areas for
collated improvement is identified & prioritised

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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Check the critical problems are regularly

Check PDCA or revalent quality method is SI/RR monitored & applicable solutions are
used to address critical problems duplicated in other departments (wherever
required) for process improvement

Facility ensures easy access and use

of standard treatment guidelines & Check standard treatment guidelines / Staff is aware of Standard treatment
ME G10.7 protocols are available & followed. SI/RR protocols/ guidelines/best practices
implementation tools at
point of care

Check treatment plan is prepared as per SI/RR Check staff adhere to clinical protocols while
Standard treatment guidelines preparing the treatment plan
Check the drugs are prescribed as per SI/RR Check the drugs prescribed are available in
Standards treatment guidelines EML or part of drug formulary

Check when the STG/protocols/evidences

Check the updated/latest evidence are SI/RR used in healthcare facility are published.
available Whether the STG protocols are according to
current evidences.

The gaps in clinical practices are identified &

Check the mapping of existing clinical SI/RR action are taken to improve it. Look for
practices processes is done evidences for improvement in clinical
practices using PDCA
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Proportion of follow-up patients RR
Indicators on monthly basis
No of ANC done per thousand RR
ICTC OPD per thousand RR
ART patient load per thousand RR
ARSH OPD per thousand RR
Immunization OPD per thousand RR
No. of Geriatric cases admitted in geriatric RR
Ward
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators Medicine OPD per Doctor RR
on monthly basis
Surgery OPD per Doctor RR
Paediatric OPD per Doctor RR
OBG OPD per Doctor RR
Dental OPD per Doctor RR
Ophthalmology OPD per doctor RR
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Reference [Link] Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
Skin & OPD per doctor RR
TB/DOT pod per doctor RR
ENT OPD per doctor RR
Psychiatry OPD per doctor RR
AYUSH OPD per doctor RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Consultation time at ANC Clinic RR Time motion study
Safety Indicators on monthly basis
Consultation time at General Medicine RR
Clinic
Consultation time for General Surgery RR
Clinic
Consultation time for paediatric clinic RR
Proportion of High risk pregnancy RR No of High Risk Pregnancies X100/ Total no
detected during ANC PW used ANC services in the month
Proportion of severe anaemia cases RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality Patient Satisfaction Score RR
Indicators on monthly basis
Waiting time at registration counter RR
Waiting time at ANC Clinic RR
Waiting time at general OPD RR
Waiting time at paediatric Clinic RR
Waiting time at surgical clinic RR
Average door to Medicine time RR

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Checklist No. 3 Labour Room Version - NHSRC/NQAS2016

Version: DH/NQAS-
National Quality Assurance Standards for District Hospitals 2020/00
Checklist for Labour Room 3
Assessment Summary
Name of the Hospital GHQH Erode Date of Assessment
Names of Assessors Names of Assessees
Type of Assessment (Internal/Peer/External) Internal Action plan Submission Date
Labour room Score Card
Area of Concern wise Score LaQshya Labour Room Score
A Service Provision #DIV/0!
B Patient Rights #DIV/0!
C Inputs #DIV/0!
D
E
Support Services
Clinical Services
#DIV/0!
#DIV/0! #DIV/0!
F Infection Control #DIV/0!
G Quality Management #DIV/0!
H Outcome #DIV/0!

Major Gaps Observed

1
2
3
4
5
Strengths / Good Practices
1
2
3
4
5
Recommendations/ Opportunities for Improvement
1
2
3
4
5
Signature of Assessors
Date

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Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
Area of Concern - A Service Provision

Standard A1 The facility provides Curative Services

ME A1.14 Services are available for the time Labour room service is functional 24X7 SI/RR Verify with records that deliveries have
period as mandated been conducted in night on regular basis

Standard A2 The facility provides RMNCHA Services

ME A2.1 The facility provides Reproductive Availability of Post Partum IUD insertion SI/RR Verify with records that PPIUD services
health Services services have been offered in labour room

ME A2.2 The facility provides Maternal health Availability of Vaginal Delivery services SI/RR Normal vaginal & assisted (Vacuum /
Services Forceps ) delivery
Check if pre term delivery are being
Availability of Pre term delivery services SI/RR conducted at facility and not referred to
higher centres unnecessarily

Management of Postpartum Haemorrhage SI/RR Check if Medical /Surgical management

of PPH is being done at labour room

Check staff manages retained placenta

Management of Retained Placenta SI/RR cases in labour room . Verify with
records

Check if infected delivery cases are

Septic Delivery & Delivery of HIV positive SI/RR managed at labour room and not
Pregnant Women referred to higher centres unnecessarily

Check services for management of PIH/

Management of PIH/Eclampsia/ Pre SI/RR Eclampsia are being proved at labour
eclampsia room
Check if labour room has a functional
ME A2.3 The facility provides Newborn health Availability of New born resuscitation SI/OB New born resuscitation services available
Services in labour room

Check essential newborn care provisions

such as Keeping baby on mother's
abdomen, immediate drying of baby,
Availability of Essential new born care SI/OB Skin to skin contact, delayed chord
clamp, initiation of breast feeding,
recording of vitals and Vit. K are
provided

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Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Standard A3 The facility Provides diagnostic Services

ME A3.2 The facility Provides Laboratory 24 *7 Availability of point of care SI/OB HIV, Hb% , Random blood sugar , Protein
Services diagnostic tests Urea Test
Area of Concern - B Patient Rights

Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities

Numbering, main department and

The facility has uniform and user- internal sectional signage, Restricted
ME B1.1 Availability of departmental signage's OB area signage displayed. Directional
friendly signage system
signages are given from the entry of the
facility

The facility displays the services and Name of doctor and Nurse on duty are
ME B1.2 entitlements available in its Necessary Information regarding services OB displayed and updated. Contact details
departments provided is displayed of referral transport / ambulance
displayed

Patients & visitors are sensitised and Breast feeding, kangaroo care, family
ME B1.5 educated through appropriate IEC / IEC Material is displayed OB planning etc (Pictorial and chart ) in
BCC approaches circulation & waiting area

ME B1.6 Information is available in local Signage's and information are available in OB Check all information for patients/
language and easy to understand local language visitors are 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 physical economic, cultural or social reasons.

Pregnant woman, her birth companion,

ME B2.1 Services are provided in manner that Only on duty staff is allowed in the labour OB doctor, nurse/ANM on duty, and other
are sensitive to gender room when it is occupied support staff only, is allowed in the
labour room

Access to facility is provided without

ME B2.3 any physical barrier & friendly to Availability of Wheel chair or stretcher for OB
people with disabilities easy Access to the labour room

If not located on the ground floor

Availability of ramps and railing & Labour OB availability of the ramp / lift with person
room is located at ground floor for shifting

There is no discrimination on basis of Discrimination may happen because of

ME B2.4 social and economic status of the Check care to pregnant women is not OB/PI religion, caste, ethnicity, cast, language,
patients denied or differed due to discrimination paying capacity and educational level.

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

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Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
Screens / Partition has been provided
ME B3.1 Adequate visual privacy is provided Availability of screen/ partition at delivery OB from three side of the delivery table or
at every point of care tables Cubicle for ensuring visual privacy
Check all the windows are fitted with
Curtains / frosted glass have been OB frosted glass or curtains have been
provided at windows provided

Check that observation beds and delivery

No two women are treated on common OB/PI tables are not shared by multiple women
bed/ Delivery Table at the same time because of any reason

Check records are not lying in open and

Confidentiality of patients records Patient Records are kept at secure place there is designated space for keeping
ME B3.2 and clinical information is SI/OB records with limited access. Records are
beyond access to general staff/visitors
maintained not shared with anybody without
permission of hospital administration

Check that labour staff is not providing

The facility ensures the behaviour of Behaviour of labour room staff is dignified care in undignified manner such as
ME B3.3 staff is dignified and respectful, while and respectful OB/PI yelling, scolding , shouting, blaming and
delivering the services using abusive language, unnecessary
touching or examination

Check that care providers are attentive

Pregnant women is not left unattended or OB/PI and empathetic to the pregnant women
ignored during care in the labour room at no point of care they are left alone.

Check if the physical abuse practices

Care provided at labour room is free from OB/PI such as pinching, slapping, restraining ,
physical abuse or harm pushing on the abdomen, extensive
episiotomy etc.

Check if care providers verbally inform

Pregnant women is explicitly informed OB/PI the pregnant women before touching,
before examination and procedures examination or starting procedure.

The facility ensures privacy and Check if HIV status of pregnant women is
confidentiality to every patient, HIV status of patient is not disclosed not explicitly written on case sheets and
ME B3.4 especially of those conditions having except to staff that is directly involved in SI avoiding any means by which they can
social stigma, and also safeguards care be identified in public such as labelling or
vulnerable groups allocating specific beds.

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Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and involving them in treatment planning, and facilitates informed
decision making

There is established procedure for

ME B4.1 taking informed consent before Consent is taken before delivery and or SI/RR Check the labour room case sheet for
treatment and procedures shifting consent has been taken

Check if pregnant women and her family

Information about the treatment is Labour room has system in place to members have been informed and
ME B4.4 shared with patients or attendants, involve patient's relative in decision PI
consulted before shifting the patient for
regularly making about pregnant women treatment C-Section or referral to higher centre

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.

Check if there are no user charges of any

The facility provides cashless services services in labour room .
to pregnant women, mothers and Check all services including drugs, Ask Pregnant women and their
ME B5.1 consumables, diagnostics and blood are PI/SI
neonates as per prevalent attendants if they have not paid for any
government schemes free of cost in labour room services or any informal fees to service
providers

Area of Concern - C Inputs

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
Labour tables should be placed in a way
Departments have adequate space that there is a distance of at least 3 feet
ME C1.1 Adequate space as per delivery load OB from the sidewall, at least 2 feet from
as per patient or work load
head end wall, and at least 6’ from the
second table

Dedicated Toilets for Labour Room area

and Staff Rooms. LDR concept for Labour
Room should have attached toilet with
ME C1.2 Patient amenities are provided as Availability of patients amenities such as OB each LDR unit . Toilets are provided with
per patient load Drinking water, Toilet & Changing area western style toilet seats. Drinking water
Facility within labour room
For Pregnant women & companion

Labour Room and associated services are

arranged according to Labour-Delivery-
ME C1.3 Departments have layout and Labour Room layout is arranged in LDR OB Recovery Concepts with each LDR unit
demarcated areas as per functions concept comprising of 4 Labour Beds and
dedicated Nursing Station and New Born
Corner

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Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Dedicated reception and registration

Availability of Registration Area & Waiting area the entry of Labour Room Complex
OB with registration desk and seating
area
arrangement for 30 people in waiting
area

Dedicated Triage & Examination room

with two examination beds for
Availability of Triage and Examination Area OB segregation of High & Low Risk patients
Entry to the labour room should not be
direct. Check if there is any buffer area

One common Nursing station for

Dedicated nursing station and Duty Rooms OB Conventional Labour Room
Dedicated Nursing station for Each unit if
LDR concept is followed

A dedicated sub store with cabinets and

storage racks for storing supplies
Availability of Storage Area OB Separate Clean room & Dirty Utility room
for Storing Sterile and Used goods
respectively

One Dedicated Newborn care area for

each four tables. In case of LDR
dedicated NBCA for each unit. There
should be no obstruction between
Availability of Newborn Care area OB labour table and Newborn corner for
swift shifting of newborn requiring
resuscitation Radiant Warmer Should
have free space from three sides

Dedicated rooms for Nursing staff and

Availability of Staff Room & Doctor's Duty OB Doctors provided with beds, storage
Room furniture and attached toilets
The facility has adequate circulation Corridors connecting labour room are Corridor should be wide enough that 2
ME C1.4 area and open spaces according to broad enough to manage stretcher and OB stretcher can pass simultaneously
need and local law trolleys without any hassle
The facility has infrastructure for
ME C1.5 intramural and extramural Availability of functional telephone and OB Check availability of functional telephone
communication Intercom Services and intercom connections

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Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks

Method

Less than 20 Deliveries/ Month -1

20-99 Deliveries/ Month - 2
100- 199 Deliveries/Month -4
Service counters are available as per Availability of labour tables as per delivery 200- 499 Deliveries/Month -6
ME C1.6 OB More than 500 Deliveries-
patient load load
Conventional Labour Room - Monthly
Delivery Cases X 0.014
(Labour- Delivery-Recovery) LDR format
- Monthly Delivery Cases X.028

Check labour room is located in the

The facility and departments are proximity of Maternity OT and SNCU/
planned to ensure structure follows Labour room is in Proximity and function NICU in one block only with means of
ME C1.7 the function/processes (Structure OB swift shifting of patients in case of
linkage with OT & SNCU
commensurate with the function of emergency. If located on different floor
the hospital) lift/ ramp with manned trolley should be
provided

Labour room lay out and arrangement of

Unidirectional flow of care OB services are designed in a way, that
there is no criss cross movement of
patient, staff, supplies & equipment
Standard C2 The facility ensures the physical safety of the infrastructure.
Check for fixtures and furniture like
ME C2.1 The facility ensures the seismic Non structural components are properly OB cupboards, cabinets, and heavy
safety of the infrastructure secured equipment , hanging objects are
properly fastened and secured

Switch Boards other electrical

ME C2.3 The facility ensures safety of Labour room does not have temporary OB installations are intact. Check adequate
electrical establishment connections and loosely hanging wires power outlets have been provided as per
requirement of electric appliances

The floor of the labour room complex

should be made of anti-skid material.
ME C2.4 Physical condition of buildings are Check if safety features have been OB Each window have 2-panel sliding
safe for providing patient care provided in infrastructure doors. The outside panel be fixed The
second panel should be moving with
frosted glass and a lock.

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

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Reference No Measurable Element Checkpoint Compliance Assessment Means of Verification Remarks

Method
Labour room has sufficient fire exit to
ME C3.1 The facility has plan for prevention permit safe escape to its occupant at time OB/SI Check the fire exits are clearly visible and
of fire of fire routes to reach exit are clearly marked.

Class A , Class B, C type or ABC type.

ME C3.2 The facility has adequate fire fighting Labour room has installed fire OB
Check the expiry date for fire
Equipment Extinguishers & expiry is displayed on each extinguishers are displayed on each
fire extinguisher extinguisher as well as due date for next
refilling is clearly mentioned

The facility has a system of periodic Check for staff competencies for operating Check staff is aware of RACE (Rescue-
ME C3.3 training of staff and conducts mock fire extinguisher and what to do in case of SI/RR Alarm-Contain-Extinguish) method for in
drills regularly for fire and other fire case of fire and confident in using fire
disaster situation extinguisher.
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
100-200 Deliveries -1 (OBG/EMOC)
ME C4.1 The facility has adequate specialist Availability of Ob&G specialist OB/RR 200 - 500 Deliveries - 1 OBG (Mandatory
doctors as per service provision + 4 (OBG/EMOC)
>500 3 OBG + 4 EMOC
Availability of Paediatrician OB/RR At least 1 paediatrician
The facility has adequate general
ME C4.2 duty doctors as per service provision Availability of General duty doctor OB/RR At least 4 Medical Officers
and work load

The facility has adequate nursing Deliveries Per month-

ME C4.3 staff as per service provision and Availability of Nursing staff /ANM OB/RR/SI 100-200- 8
work load 200-500 -12
> 500 - 16

Housekeeping Staff as per delivery load

100-200- 4
200-500 - 8
ME C4.5 The facility has adequate support / Availability of house keeping staff & SI/RR Security Guards as per Delivery Load
general staff Security Guards > 500 - 12
100-200- 4
200-500 - 6
> 500 - 8

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

ME C5.1 The departments have availability of Availability of uterotonic medicine OB/RR Inj Oxytocin 10 IU (to be kept in fridge)
adequate medicine at point of use Tab Misoprostol 200mg

Availability of Anti-infective medicine OB/RR Cap Ampicillin 500mg, Tab

Metronidazole 400mg, Inj Gentamicin

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Method
Nifedipine, Methyldopa, Inj
Availability of Antihypertensive , analgesic OB/RR Hydralazine, Tab Paracetamol, Tab
and antipyretic and Anesthetic medicine Ibuprofen, Inj Xylocaine 2%,

Availability of IV Fluids OB/RR IV fluids, Normal saline, Ringer lactate,

Availability of Vitamins OB/RR Vit K

Gauze piece and cotton swabs, sanitary

The departments have adequate Availability of dressings material and Napkins (2 for Each Delivery), Sanitary
ME C5.2 OB/RR Pads (4 for each delivery, needle (round
consumables at point of use Sanitary pads
body and cutting), chromic catgut no. 0,
antiseptic solution

Availability of syringes and IV Sets /tubes OB/RR Paediatric IV sets,urinery catheter,

and consumables for newborn Gastric tube and cord clamp, Baby ID tag

Inj Magsulf 50%, Inj Calcium gluconate

10%, Inj Dexamethasone, inj
Hydrocortisone Succinate, Inj Ampicillin,
Emergency drug trays are Inj Gentamicin, inj metronidazole, , Inj
ME C5.3 maintained at every point of care, Emergency Drug Tray is maintained OB/RR diazepam, inj Pheniramine maleate, inj
wherever it may be needed Corboprost, Inj Pentazocine, Inj
Promethazine, Betamethasone, Inj
Hydralazine, Nifedipine,
Methyldopa,ceftriaxone

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

One set of Digital BP apparatus,

Stethoscope, Adult Thermometer , Baby
Availability of equipment & Availability of functional Equipment Thermometer, baby forehead
ME C6.1 instruments for examination & &Instruments for examination & OB thermometer, Handheld Fetal Doppler ,
monitoring of patients Monitoring Fetoscope, baby weighting scale,
Measuring Tape for four labour tables or
at least two sets., Wall clock

Availability of equipment & Cord Cutting Scissor, Artery forceps, Cord

ME C6.2 instruments for treatment Availability of instrument arranged in OB clamp, Sponge holder, speculum, kidney
procedures, being undertaken in the Delivery trays tray, bowl for antiseptic lotion are
facility present in tray
Delivery kits are in adequate numbers as OB One autoclaved delivery tray for each
per load table plus 4 extra trays

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Method
Episiotomy scissor, kidney tray, artery
Availability of Instruments arranged for OB forceps, allis forceps, sponge holder,
Episiotomy trays toothed forceps, needle holder, thumb
forceps, are present in tray

Two pre warmed towels/sheets for

wrapping the baby, mucus extractor, bag
Availability of Baby tray OB and mask (0 &1 no.), sterilized thread for
cord/cord clamp, nasogastric tube are
present in tray

Speculum, anterior vaginal wall

Availability of instruments arranged for retractor, posterior wall retractor,
OB sponge holding forceps, MVA syringe,
MVA/EVA tray
cannulas, MTP, cannulas, small bowl of
antiseptic lotion, are present in tray

PPIUCD insertion forceps, CuIUCD

Availability of instruments arranged for OB 380A/Cu IUCD375 in sterile package are
PPIUCD tray present in tray

Availability of Radiant Warmers OB 1 Functional Radiant warmer for each

four tables
Availability of equipment &
ME C6.3 instruments for diagnostic Availability of Diagnostic Instruments OB At least 2 Glucometers, Protein Urea
procedures being undertaken in the Test Kit , HB Testing Kits, HIV Kits.
facility

Availability of equipment and Availability of Neonatal Resuscitation Kit

instruments for resuscitation of Availability of resuscitation Instruments Paediatric resuscitator bag (volume 250
ME C6.4 OB ml) with masks of
patients and for providing intensive for Newborn & Mother
and critical care to patients 0 and 1 size for each Radiant warmer
Adult Resuscitation Kit

Refrigerator, Movable Crash cart/Drug

ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for OB trolley, instrument trolley, dressing
drugs trolley

Buckets for mopping, Separate mops for

ME C6.6 Availability of functional equipment Availability of equipment for cleaning & OB labour room and circulation area duster,
and instruments for support services sterilization waste trolley, Deck brush, Autoclave

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Method

Each labour bed should be have

following facilities
Departments have patient furniture Adjustable side rails, Facilities for
ME C6.7 and fixtures as per load and service Availability of Labour Beds with OB Trendelenburg/reverse positions,
provision attachment/accessories Facilities for height adjustment, Stainless
steel IV rod, wheels & brakes ,Steel
basins attachment, Calf support,
handgrip, legs support.

Mattress should be in three parts and

Availability of Mattress for each Labour seamless in each part with a thin
OB cushioning at the joints, detachable at
Beds
perineal end. It should be washable and
water proof with extra set.
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

Criteria for Competence assessment Check parameters for assessing skills and Check objective checklist such OSCE
ME C7.1 are defined for clinical and Para proficiency of clinical staff has been SI/RR (Onsite Clinical Examination) defined
clinical staff defined Dakshta program are available at the
labour room

Competence assessment of Clinical Check for records of competence

and Para clinical staff is done on Check for competence assessment is done assessment using OSCE including filled
ME C7.2 SI/RR checklist, scoring and grading . Verify
predefined criteria at least once in a at least once in a year
year with staff for actual competence
assessment done

The Staff is provided training as per

ME C7.9 defined core competencies and Navjat Shishu Surkasha Karyakarm (NSSK) SI/RR Check training records
training plan training & Skilled birth Attendant (SBA)

Biomedical Waste Management& Infection SI/RR Check training records

control and hand hygiene ,Patient safety

Training on Quality Management SI/RR Assessment, action planning, PDCA, 5S &

use of checklist
Training on Respectful Maternal Care SI/RR Check training records

Check with training records the labour

room staff have been provided refresher
There is established procedure for training at lest once in every 12 month
ME C7.10 utilization of skills gained thought Labour room staff is provided refresher SI/RR on Intrapartum care, Identification and &
trainings by on -job supportive training management of obstetric emergencies
supervision and Essential Newborn care & Breast
feeding support

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Method
Area of Concern - D Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
The facility has established system
ME D1.1 for maintenance of critical All equipment are covered under AMC SI/RR Check with AMC records/ Warranty
Equipment including preventive maintenance documents

There is system of timely corrective break SI/RR Check for breakdown & Maintenance
down maintenance of the equipment record in the log book

The facility has established BP apparatus, thermometers, weighing

ME D1.2 procedure for internal and external All the measuring equipment/ instrument OB/ RR scale , radiant warmer etc are
calibration of measuring Equipment are calibrated calibrated . Check for records
/calibration stickers

Operating and maintenance Up to date instructions for operation and Check operating and trouble shooting
ME D1.3 instructions are available with the maintenance of equipment are readily OB/SI instructions of equipment such as
users of equipment available with labour room staff. radiant warmer are available at labour
room
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas

There is established procedure for Stock level are daily updated

ME D2.1 forecasting and indenting medicine There is established system of timely SI/RR Requisition are timely placed well before
and consumables indenting of consumables and medicine reaching the stock out level.
Check with stock and indent registers.

Check medicine and consumables are

The facility ensures proper storage medicine are stored in kept at allocated space in Crash cart/
ME D2.3 OB Drug trolleys and are labelled. Look alike
of medicine and consumables containers/tray/crash cart and are labelled
and sound alike medicine are kept
separately

Empty and filled cylinders are kept

Empty and filled cylinders are labelled and OB separately and labelled, flow meter is
updated working and pressure/ flow rate is
updated in the checklist

Expiry dates against medicine are

ME D2.4 The facility ensures management of Expiry dates' are maintained at emergency OB/RR mentioned crash cart/ emergency drug
expiry and near expiry medicine drug tray / Crash cart tray
No expiry drug found

At least one week of minimum buffer

The facility has established There is practice of calculating and stock is maintained all the time in the
ME D2.5 procedure for inventory SI/RR labour room. Minimum stock and
maintaining buffer stock
management techniques reorder level are calculated based on
consumption in a week accordingly

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Method
Department maintained stock and
expenditure register of medicine and RR/SI Check stock and expenditure register is
consumables adequately maintained

There is a procedure for periodically

ME D2.6 replenishing the medicine in patient There is procedure for replenishing drug SI/RR/OB There is no stock out of medicine
care areas tray /crash cart

Check for temperature charts are

There is process for storage of Temperature of refrigerators are kept as maintained and updated periodically.
ME D2.7 vaccines and other medicine, per storage requirement and records are OB/RR Refrigerators meant for storing medicine
requiring controlled temperature maintained should not be used for storing other
items such as eatables
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
The facility provides adequate
ME D3.1 illumination level at patient care Adequate Illumination at delivery table & OB Labour Area - 500 Lux
areas observation area Support Area - 150 Lux

Visitors are restricted at labour room.

ME D3.2 The facility has provision of There is no overcrowding in labour room OB One birth companion is allowed to stay
restriction of visitors in patient areas with the Pregnant women

Temperature of the labour room should

be kept around 26-28 degree C ,labour
The facility ensures safe and Temperature control and ventilation in complex should have split ACs with
ME D3.3 comfortable environment for PI/OB
patient care area tonnage = (square root of area)/10 and
patients and service providers one ceiling mounted fan for every labour
table . Area should be drought free

Dedicated security guards preferably

ME D3.4 The facility has security system in Security arrangement in labour room OB female security staff. CCTV Camera at
place at patient care areas entrance / circulation areas

Check adequate security measures have

ME D3.5 The facility has established measure Ask female staff whether they feel secure SI been taken for safety and security of
for safety and security of female staff at work place staff working in labour room

Standard D4 The facility has established Programme for maintenance and upkeep of the facility

Wall and Ceiling of Labour Room are

Exterior & Interior of the facility Interior & exterior of patient care areas painted in white colour. The walls of the
ME D4.1 OB
building is maintained appropriately are plastered & painted & building are labour room complex should be made of
white washed in uniform colour white wall tiles, with seamless joint, and
extending up to the ceiling.

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Method
All area are clean with no
ME D4.2 Patient care areas are clean and Floors, walls, roof, roof topes, sinks patient OB dirt,grease,littering and cobwebs.
hygienic care and circulation areas are Clean Surface of furniture and fixtures are
clean

Check toilet seats, floors, basins etc are

Toilets are clean with functional flush and OB clean and water supply with functional
running water cistern has been provided.
Check for there is no seepage , Cracks,
ME D4.3 Hospital infrastructure is adequately chipping of plaster Window panes , doors OB Check for delivery as well as auxiliary
maintained and other fixtures are intact areas

Observe for any signs for rusting or

Delivery table are intact and without rust OB accumulation of dirt/ grease/ encrusted
& Mattresses are intact and clean body fluid
Check of any obsolete article including
ME D4.5 The facility has policy of removal of No condemned/Junk material in the OB equipment, instrument, records, drugs
condemned junk material Labour room and consumables
The facility has established
ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds OB Check for no stray animal in and around
animal control labour room

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
The facility has adequate
ME D5.1 arrangement storage and supply for Availability of 24x7 running and portable OB/SI Availability of 24X7 Running water & hot
portable water in all functional areas water water facility.

The facility ensures adequate power Check for 24X7 availability of power
ME D5.2 backup in all patient care areas as Availability of power back up in labour OB/SI backup including Dedicated UPS and
per load room emergency light
Standard D7 The facility ensures clean linen to the patients
Clean Delivery gown is provided to
ME D7.1 The facility has adequate sets of Availability & use of clean linen OB/RR Pregnant Women &
linen sterile drape for baby.

The facility has standard procedures Quantity of linen is checked before

ME D7.3 for handling , collection, There is system to check the cleanliness SI/RR sending it to laundry. Cleanliness &
transportation and washing of linen and Quantity of the linen Quantity of linen is checked received
from laundry. Records are maintained

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

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Method

The facility has an established Check for system for recording time of
ME D11.2 procedure for duty roster and There is procedure to ensure that staff is RR/SI reporting and relieving (Attendance
deputation to different departments available on duty as per duty roster register/ Biometrics etc)

Staff posted in the labour room should not RR/SI Check with the duty roster
be rotated outside the labour room
The facility ensures the adherence to
ME D11.3 dress code as mandated by its Doctor, nursing staff and support staff OB As per hospital administration or state
administration / the health adhere to their respective dress code policy
department
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

The facility has established Unique identification number & patient

ME E1.1 procedure for registration of demographic records are generated RR Check for demographics like Name, age,
patients during process of registration & admission Sex, Chief complaint, etc.

ME E1.3 There is established procedure for There is procedure for admitting Pregnant SI/RR/OB Admission is done by written order of a
admission of patients women directly coming to Labour room qualified doctor

Co relate the time admission with &

There is no delay in admission of pregnant OB/SI/RR clinical intervention (vital chart ,
women in labour pain partograph, medication given etc.)
There is established procedure for Check how service provider cope with
ME E1.4 managing patients, in case beds are shortage of delivery tables due to high OB/SI Provision of extra tables.
not available at the facility patient load
Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.

Recording of vitals and FHR. immediate

Rapid Initial assessment of Pregnant sign if following danger sign are present -
There is established procedure for Women to identify complication and difficulty in breathing, fever, sever
ME E2.1 Prioritize care RR/SI/OB
initial assessment of patients abdominal pain, Convulsion or
unconsciousness, Severe headache or
blurred vision

Recording of women obstetric History

including
Recording and reporting of Clinical History RR/SI LMP and EDD Parity, Gravid status, h/o
CS, Live birth, Still Birth, Medical History
(TB, Heart diseases, STD etc) HIV status
and Surgical History

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Method

Time of start, frequency of contractions,

Recording of current labour details RR time of bag of water leaking, colour and
smell of fluid and baby movement

Recording of Vitals , shape & Size of

Physical Examination RR/SI abdomen , presence of scars, foetal lie
and presentation. & vaginal examination

ME E2.2 There is established procedure for There is fixed schedule for reassessment of SI/RR
follow-up/ reassessment of Patients patient under observation

There is system in place to identify and Criteria is defined for identification, and
manage the changes in Patient's health SI/RR management of high risk patients/
status patient whose condition is deteriorating

Check the re assessment sheets/ Case

Check the treatment or care plan is SI/RR sheets modified treatment plan or care
modified as per re assessment results plan is documented

Assessment includes physical

There is established procedure to assessment, history, details of existing
plan and deliver appropriate Check healthcare needs of all hospitalised disease condition (if any) for which
ME E2.3 treatment or care to individual as patients are identified through SI/RR
regular medication is taken as well as
per the needs to achieve best assessment process evaluate psychological ,cultural, social
possible results factors

(a) According to assessment and

investigation findings (wherever
applicable).
(b) Check inputs are taken from patient
Check treatment/care plan is prepared as RR or relevant care provider while preparing
per patient's need the care plan.

Care plan include:, investigation to be

Check treatment / care plan is SI/RR conducted, intervention to be provided,
documented goals to achieve, timeframe, patient
education, , discharge plan etc

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Method
Check care plan is prepared and
Check care is delivered by competent delivered as per direction of qualified
multidisciplinary team physician
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral

Hand over from Labour Room to the

destination department is given while
The facility has established There is procedure of handing over shifting the Mother & Baby. Shifting to
ME E3.1 procedure for continuity of care patient / new born from labour room to SI/RR
ward should be done at least two hours
during interdepartmental transfer OT/ Ward/SNCU after delivery in case of conventional LR
and 4 hours in case of LDR

There is a procedure for consultation of check if there are linkages and

the patient to other specialist with in the SI/RR established process for calling other
hospital specialist in labour room if required

Verify with referral records that reasons

for referral were clearly mentioned and
rational. Referral is authorized by
The facility provides appropriate Gynaecologist or Medical officer on duty
referral linkages to the Reason for referral is clearly stated and after ascertaining that case can not be
ME E3.2 patients/Services for transfer to referral is authorized competent person RR managed at the facility
other/higher facilities to assure the (Gynaecologist or Medical Officer on duty) Labour room staff confirms the
continuity of care. suitability of referral with higher centres
to ascertain that case can be managed at
higher centre and will not require further
referrals

Check for availability of following -

Referral Pathway
Essential information regarding referral Names, Contact details and duty
RR/OB schedules for responsible persons higher
facilities are available at labour room
referral centres
Name , Contact details, duty schedule of
Ambulance services

The information regarding the case,

Advance communication regarding the expected time of arrival and special
patient's condition is shared with the SI/RR facilities such as specialist, blood,
higher centre intensive care may be required is
communicated to the higher centre

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Method

A referral slip/ Discharge card is provided

to patient when referred to another
health care facility. Referral slip includes
demographic details, History of woman,
Patient referred with referral slip RR/SI examination findings, management done
, drugs administered, any procedure
done, reason for referral, detail of
referral centre including whom to
contact and signature of approving
medical officer

Check labour room staff facilitates

arrangement of ambulance for
transferring the patient to higher
centre . Patient attendant are not asked
Referral vehicle is being arranged SI/RR to arrange vehicle by their own
Check if labour room staff checks
ambulance preparedness in terms of
necessary equipment, drugs,
accompanying staff in terms of care that
may be required in transit

Referral check list is filled before referral

to ensure all necessary steps have been
taken for safe referral including advance
communication, transport arrangement,
Referral checklist & Referral in/ Out accompanying care provider, referral slip
RR , time taken for referral etc. regarding
register is maintained all referred cases
referral cases including demographics,
date & time of admission, date & time of
referral, diagnosis at referral and follow
up of outcome is recorded in referral
register

Check that labour room staff follow up of

referred cases for timely arrival and
Follow-up of referral cases is done SI/RR appropriate care provided at higher
centre. Outcome and deficiencies if any
should be recorded in referral out
register.

ME E3.3 A person is identified for care during Nurse is assigned for each pregnant RR/SI Check for nursing hand over
all steps of care women

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Method
Standard E4 The facility has defined and established procedures for nursing care

ME E4.1 Procedure for identification of There is a process for ensuring the OB/SI Identification tags for mother and baby
patients is established at the facility identification before any clinical procedure

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

There is established procedure of

ME E4.3 patient hand over, whenever staff Patient hand over is given during the RR/SI Nursing Handover register is maintained
duty change happens change in the shift

Handover is given during the shift

Hand over is given bed side SI/RR/OB change beside the pregnant women
explaining the condition, care provided
and any specific care if required

Check for BP, pulse,temp,Respiratory

ME E4.5 There is procedure for periodic Patient Vitals are monitored and recorded RR/SI rate FHR,dilation Uterine Contractions,
monitoring of patients periodically blood loss any other vital required is
monitored and recoded in case sheet

Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
Vulnerable patients are identified and
ME E5.1 The facility identifies vulnerable measures are taken to protect them from OB/SI Check the measure taken to prevent new
patients and ensure their safe care any harm born theft, sweeping and baby fall

List of cases identified as High Risk is

The facility identifies high risk High Risk Pregnancy cases are identified available with labour room staff . Check
ME E5.2 patients and ensure their care, as OB/SI for the frequency of observation: Its
and kept in intensive monitoring
per their need stage :half an hour and 2nd stage: every
5 min
Standard E6 Facility ensures rationale prescribing and use of medicines
Check all the drugs in case sheet and
ME E6.1 The facility ensured that drugs are Check for case sheet if drugs are RR discharge slip are written in generic
prescribed in generic name only prescribed under generic name only name only.

Intrapartum care, Essential new-born

ME E6.2 There is procedure of rational use of Check for that relevant Standard RR
care, Newborn Resuscitation, Pre-
drugs treatment protocols are available at point Eclampsia, Eclampsia, Postpartum
of use haemorrhage , Obstructed Labour,
Management of preterm labour

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Method
Check BHT that drugs are prescribed as
Check staff is aware of the drug regime SI/RR per treatment protocols &Check for
and doses as per STG rational use of uterotonic drugs
Standard E7 The facility has defined procedures for safe drug administration

There is process for identifying and Check high alert drugs such as Magsulf,
ME E7.1 cautious administration of high alert High alert drugs available in department SI/OB Oxytocin, Carbopost, Adrenaline are
drugs are identified identified in the labour room

Value for maximum doses as per age,

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

Every Medical advice and procedure is

ME E7.2 Medication orders are written legibly accompanied with date , time and RR Verify case sheets of sample basis
and adequately signature
Check for the writing, It comprehendible RR/SI Verify case sheets of sample basis
by the clinical staff
Check for any open single dose vial with
ME E7.3 There is a procedure to check drug Drugs are checked for expiry and other OB/SI left over content intended to be used
before administration/ dispensing inconsistency before administration later on. In multi dose vial needle is not
left in the septum

Check if adverse drug reaction form is

Any adverse drug reaction is recorded and RR/SI available in labour room and reporting is
reported in practice

Administration of medicines done after

ME E7.4 There is a system to ensure right Check Nursing staff is aware 7 Rs of SI/RR ensuring right patient, right drugs , right
medicine is given to right patient Medication and follows them route, right time, Right dose , Right
Reason and Right Documentation

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
All the assessments, re-assessment
ME E8.1 and investigations are recorded and Progress of labour is recorded RR Partograph
updated
All treatment plan
ME E8.2 prescription/orders are recorded in Treatment prescribed in nursing records RR Medication order, treatment plan, lab
the patient records. investigation are recoded adequately

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Method

Outcome of delivery, date and time,

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

Did baby cry, Essential new born care,

Baby note is adequate RR resuscitation if any, Sex, weight, time of
initiation of breast feed, birth doses,
congenital anomaly if any.

Availability of standardized labour room

ME E8.5 Adequate form and formats are Standard Formats are available RR/OB case sheets including partograph and
available at point of use safe Birthing checklist

Labour room register, OT register, MTP

Register/records are maintained as Registers and records are maintained as register, Maternal death register and
ME E8.6 RR records, lab register, referral in /out
per guidelines per guidelines
register, internal & PPIUD register , NBCC
register, handover register

All register/records are identified and RR Check records are numbered and
numbered labelled legibly

Standard E12 The facility has defined and established procedures of diagnostic services

ME E12.3 There are established procedures Nursing station is provided with the critical SI/RR Check for list of critical values is available
for Post-testing Activities value of different test at nursing station

Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.

blood is kept on room temperature (28

ME E13.9 There is established procedure for Protocol of blood transfusion is monitored RR degree C) before transfusion. Blood
transfusion of blood & regulated transfusion is monitored and regulated
by qualified person
Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients

Maternal and neonatal death are

recorded as per MDR guideline. Death
note including efforts done for
ME E16.2 The facility has standard procedures Death note is written as per mother & RR resuscitation is noted in patient record.
for handling the death in the hospital neonatal death review guidelines Death summary is given to patient
attendant quoting the immediate cause
and underlying cause if possible

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Method
There is established criteria for Every still birth is examined, classified by
distinguishing between new-born death SI/RR paediatrician before declaration &
and still birth record is maintained

Standard E18 The facility has established procedures for Intranatal care as per guidelines

Ensures 'six cleans' are followed during

Facility staff adheres to standard Ensures 'six cleans' are followed during delivery
ME E18.1 procedures for management of SI/OB Clean hands, Clean Surface, clean blade,
delivery
second stage of labour. clean cord tie, clean towel & clean cloth
to wrap mother

Allows spontaneous delivery of head SI/OB By flexing the head and giving perineal
support

Manages cord round the neck; assists

Delivery of shoulders and Neck delivery of shoulders and body; delivers
SI/OB baby on mother's abdomen

Check with records and interview with

Check no unnecessary episiotomy SI/RR staff if they are still practicing routine
performed episiotomy.

Check uterotonics such as oxytocin and

misoprostol is not used for routine
induction normal labour unless clear
Unnecessary augmentation and induction SI/RR medical indication and the expected
of labour is not done using uterotonics benefits outweigh the potential harms
Outpatient induction of labour is not
done

Facility staff adheres to standard

ME E18.2 procedure for active management of Rules out presence of second baby by SI Check staff competence
third stage of labour palpating abdomen

Administration of 10 IU of oxytocin IM
immediately after Birth . Check if there is
Use of Uterotonic Drugs SI/RR practice of preloading the oxytocin inj
for prompt administration after birth.

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Method
Control Cord Traction SI/RR Only during Contraction
Uterine tone assessment SI/RR Check staff competence
After placenta expulsion , Checks
Checks for completeness of placenta SI/RR Placenta & Membranes for
before discarding Completeness
Facility staff adheres to standard Wipes the baby with a clean pre-warmed
ME E18.3 procedures for routine care of new- towel and wraps baby in second pre- SI/OB Check staff competence through
born immediately after birth warmed towel; demonstration or case observation

Performs delayed cord clamping and SI/OB Check staff competence through
cutting (1-3 min); demonstration or case observation

Initiates breast-feeding soon after birth SI/OB Check staff competence through
demonstration or case observation
Records birth weight and gives injection SI/OB Check staff competence through
vitamin K demonstration or case observation
There is an established procedure
ME E18.4 for assisted and C-section deliveries Staff is aware of Indications for referring SI Ask staff how they identify slow progress
per scope of services. patient for to Surgical Intervention of labour , How they interpret Partogram

Diagnosis obstructed labour based on

data registered from the partograph, Re-
hydrates the patient to maintain normal
plasma volume, check vitals, gives broad
Management of Obstructed Labour SI/RR spectrum antibiotics, perform bladder
catheterization and takes blood for Hb &
grouping, Decides on the mode of
delivery as per the condition of mother
and the baby

Facility staff adheres to standard

ME E18.5 protocols for identification and Records BP in every case SI/RR Check staff competence through
management of Pre Eclampsia / checks for proteinuria demonstration or case observation
Eclampsia
identifies danger signs of severe PE and SI/RR Check staff competence through
convulsions; demonstration or case observation
Administers injection magnesium sulphate SI/RR Check staff competence through
appropriately; demonstration or case observation
provides nursing care & ensures specialist SI/RR Check staff competence through
attention. demonstration or case observation
Facility staff adheres to standard
ME E18.6 protocols for identification and Checks uterine tone and bleeding PV SI/OB Check staff competence through
management of PPH. regularly demonstration or case observation

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Method
Assessment of bleeding (PPH if >500 ml
Identifies PPH SI?OB/RR or > 1 pad soaked in 5 Minutes or any
bleeding sufficient to cause signs of
hypovolemia in patient.

starts IV fluids, manages shock if present,

Manages PPH as per protocol SI/OB/RR gives uterotonic, identifies causes,
performs cause specific management.

Initial Dose: Infuse 20 IU in 1 L NS/RL at

60 drops per minute
Staff knows the use of oxytocin for SI/OB/RR Continuing dose: Infuse 20 IU in 1 L
Management of PPH NS/RL at 40 drops per minute
Maximum Dose: Not more than 3 L of IV
fluids containing oxytocin

Administration of another dose of

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

Facility staff adheres to standard

ME E18.7 protocols for Management of HIV in Provides ART for seropositive mothers/ SI/RR Check case records and Interview of staff
Pregnant Woman & Newborn links with ART centre

Provides syrup Nevirapine to newborns of SI/RR Check case records and Interview of staff
HIV seropositive mothers

Assessment and evaluation to confirm

gestational age, administration of
Facility staff adheres to standard Correctly estimates gestational age to corticosteroid and tocolytics for 24-34
ME E18.8 protocol for identification and SI/RR
confirm that labour is preterm weeks
management of preterm delivery. Magnesium sulphate given to preterm
labour < 32 weeks

identifies conditions that may lead to SI/RR (severe PE/E, APH, PPROM);
preterm birth
administers antenatal corticosteroids in
pre term labour and conditions leading to SI/RR Review case records
pre term delivery (24-34 weeks);
Records mother' s temperature at
ME E18.9 Staff identifies and manages admission and assesses need for SI/RR Review case records
infection in pregnant woman antibiotics

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Method
Administers appropriate antibiotics to SI/RR Review case records
mother
There is Established protocol for Facility staff adheres to standard protocol Performs initial steps of resuscitation
ME 18.10 newborn resuscitation is followed at for resuscitating the newborn within 30 SI/OB within 30 seconds: immediate cord
the facility. seconds. cutting and PSSR at radiant warmer.

Initiates bag and mask ventilation using

Facility staff adheres to standard protocol room air with 5 ventilator breaths and
for preforming bag and mask ventilation SI/OB
continues ventilation for next 30 seconds
for 30 seconds if baby is still not breathing. if baby still does not breathe.

Facility staff adheres to standard protocol If baby still not breathing/ breathing
for taking appropriate actions if baby does SI/OB well, continues ventilation with oxygen,
not respond to bag and mask ventilation calls or arranges for advanced help or
after golden minute. referral.

Facility ensures Physical and Women are encouraged and counselled

ME E18.11 emotional support to the pregnant for allowing birth companion of their PI/SI
women means of birth companion of choice
her choice
Orientation session and information is PI/SI
available for Birth companion

Standard E19 The facility has established procedures for postnatal care as per guidelines

Facility staff adheres to protocol for Check for records of Uterine contraction,
assessment of condition of mother Performs detailed examination of mother bleeding, temperature, B.P, pulse, Breast
ME E19.1 SI/RR/PI examination, (Nipple care, milk
and baby and providing adequate
postpartum care initiation), Check for perineal washes
performed

Looks for signs of infection in mother and OB/SI Staff Interview

baby
Skin to skin contact with mother, regular
Looks for signs of hypothermia in baby and RR/SI/PI monitoring and specialist attention as
provides appropriate care required

Facility staff adheres to protocol for Counsels on danger signs to mother at

counselling on danger signs, post- time of discharge; Counsels on post
ME E19.2 Staff counsels mother on vital issues PI/SI partum family planning to mother at
partum family planning and exclusive
breast feeding discharge; Counsels on exclusive breast
feeding to mother at discharge

Facility staff adheres to protocol for

ME E19.3 ensuring care of newborns with Facilitates specialist care in newborn SI/RR Facilitates specialist care in newborn
small size at birth <1800 gm <1800 gm (seen by paediatrician)

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Method
Facilitates assisted feeding whenever SI/RR/PI
required
Facilitates thermal management including SI/RR/PI Facilitates thermal management
kangaroo mother care including kangaroo mother care
The facility has established
ME 19.4 procedures for There is established criteria for shifting SI/RR Check if criteria has been defined and in
stabilization/treatment/referral of newborn to SNCU practice by labour room staff
post natal complications
Area of Concern - F Infection Control
Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection

The facility has provision for Passive Swab are taken from infection prone
ME F1.2 and active culture surveillance of Surface and environment samples are SI/RR surfaces such as delivery tables , door,
critical & high risk areas taken for microbiological surveillance handles, procedure lights etc.

There is Provision of Periodic

ME F1.4 Medical Check-up and immunization There is procedure for immunization & SI/RR Hepatitis B, Tetanus Toxic .
of staff medical check up of the staff

The facility has established

ME F1.5 procedures for regular monitoring of Regular monitoring of infection control SI/RR Hand washing and infection control
infection control practices practices audits done at periodic intervals

Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Check for availability of wash basin near
ME F2.1 Hand washing facilities are provided Availability of hand washing with running OB the point of use Ask to Open the tap.
at point of use Water Facility at Point of Use Ask Staff water supply is regular
Check for availability/ Ask staff if the
Availability of antiseptic soap with soap OB/SI supply is adequate and uninterrupted.
dish/ liquid antiseptic with dispenser. Availability of Alcohol based Hand rub
Prominently displayed above the hand
Display of Hand washing Instruction at OB washing facility , preferably in Local
Point of Use language

Availability of elbow operated taps &

Handwashing station is as per specification OB Hand washing sink is wide and deep
enough to prevent splashing and
retention of water

The facility staff is trained in hand Ask for demonstration of six steps &
ME F2.2 washing practices and they adhere Staff is aware of when and how to hand SI/OB check staff awareness five moments of
to standard hand washing practices wash handwashing

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Method

like before giving IM/IV injection,

The facility ensures standard drawing blood, putting Intravenous and
ME F2.3 Availability & Use of Antiseptics OB urinary catheter &Proper cleaning of
practices and materials for antisepsis
perineal area before procedure with
antisepsis

Check Shaving is not done during part SI Staff Interview

preparation/delivery cases
Standard F3 The facility ensures standard practices and materials for Personal protection

The facility ensures adequate Check if staff is using PPEs

ME F3.1 personal protection Equipment as Availability of Masks , caps and protective OB/SI/ RR Ask staff if they have adequate supply
per requirements eye cover Verify with the stock / Expenditure
register

Check if staff is using PPEs

Sterile gloves are available at labour room OB/SI /RR Ask staff if they have adequate supply
Verify with the stock / Expenditure
register

Check if staff is using PPEs

Use of elbow length gloves for obstetrical OB/SI /RR Ask staff if they have adequate supply
purpose Verify with the stock / Expenditure
register

Check if staff is using PPEs

Availability of disposable gown/ Apron OB/SI /RR Ask staff if they have adequate supply
Verify with the stock / Expenditure
register

Check if staff is using PPEs

Heavy duty gloves and gum boots for OB/SI /RR Ask staff if they have adequate supply
housekeeping staff Verify with the stock / Expenditure
register
Personal protective kit for delivering HIV OB/SI Cap & Mask, protective Eye cover,
cases Disposable apron

ME F3.2 The facility staff adheres to standard No reuse of disposable gloves, Masks, caps OB/SI
personal protection practices and aprons.

Entry to the labour Room is only after OB

change of shoes and wearing Mask & Cap

Standard F4 The facility has standard procedures for processing of equipment and instruments

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Method
The facility ensures standard
ME F4.1 practices and materials for Disinfection of operating & Procedure SI/OB Cleaning of delivery tables tops after
decontamination and cleaning of surfaces each delivery with 2% carbolic acid
instruments and procedures areas
Proper handling of Soiled and infected SI/OB No sorting ,Rinsing or sluicing at Point of
linen use/ Patient care area

Cleaning of instruments SI/OB Cleaning is done with detergent and

running water after use
The facility ensures standard
ME F4.2 practices and materials for Equipment and instruments are sterilized OB/SI Autoclaving
disinfection and sterilization of after each use as per requirement
instruments and equipment

Ask staff about temperature, pressure

Autoclaving of delivery kits is done as per OB/SI and time. Ask staff about method,
protocols concentration and contact time required
for chemical sterilization

There is a procedure to ensure the

traceability of sterilized packs & their OB/SI Sterile packs are kept in clean, dust free,
storage moist free environment.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Layout of the department is
ME F5.1 conducive for the infection control Facility layout ensures separation of routes OB
practices for clean and dirty items

The facility ensures availability of Chlorine solution, Glutaraldehyde,

ME F5.2 standard materials for cleaning and Availability of disinfectant & cleaning OB/SI Hospital grade phenyl, disinfectant
disinfection of patient care areas agents as per requirement detergent solution

The facility ensures standard

ME F5.3 practices are followed for the Spill management protocols are SI/RR spill management kit staff training,
cleaning and disinfection of patient implemented protocol displayed
care areas
Cleaning of patient care area with SI/RR Staff is trained for preparing cleaning
detergent solution solution as per standard procedure

Unidirectional mopping from inside out.

Standard practice of mopping and Cleaning protocols are available /
scrubbing are followed & three bucket OB/SI displayed
system is followed Cleaning equipment like broom are not
used in patient care areas
Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

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Method

The facility Ensures segregation of

ME F6.1 Bio Medical Waste as per guidelines Availability of colour coded bins & Plastic OB Adequate number. Covered. Foot
and 'on-site' management of waste bags at point of waste generation operated.
is carried out as per guidelines

Human Anatomical waste, Items

contaminated with blood, body fluids,
Segregation of Anatomical and soiled OB/SI dressings, plaster casts, cotton swabs
waste in Yellow Bin and bags containing residual or
discarded blood and blood components.

Items such as tubing, bottles,

intravenous tubes and sets, catheters,
Segregation of infected plastic waste in red OB urine bags, syringes (without needles
bin and fixed needle syringes) and
vacutainers' with their needles cut) and
gloves

Display of work instructions for

segregation and handling of Biomedical OB Pictorial and in local language
waste

Availability of functional needle cutters &

ME F6.2 The facility ensures management of puncture proof, leak proof, temper proof OB See if it has been used or just lying idle.
sharps as per guidelines white container for segregation of sharps

Ask if available. Where it is stored and

Availability of post exposure prophylaxis & who is in charge of that. Also check PEP
OB/SI issuance register
Protocols
Staff knows what to do in condition of
needle stick injury

Contaminated and broken Glass are

disposed in puncture proof and leak proof OB Includes used vials, slides and other
box/ container with Blue colour marking broken infected glass

The facility ensures transportation

ME F6.3 and disposal of waste as per Check bins are not overfilled OB/SI Bins should not be filled more than 2/3
guidelines of its capacity

Area of Concern - G Quality Management

Standard G1 The facility has established organizational framework for quality improvement

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Method

ME G1.1 The facility has a quality team in Quality circle has been formed in the SI/RR Check if quality circle formed and
place Labour Room functional in the Labour Room
Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient satisfaction surveys are Client satisfaction survey done on monthly RR
conducted at periodic intervals basis

ME G2.2 The facility analyses the patient feed Analysis of low performing attributes of RR
back, and root-cause analysis client feedback is done
The facility prepares the action plans
ME G2.3 for the areas, contributing to low Action plan prepared is prepared to RR
satisfaction of patients address the areas of low satisfaction

Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.

Facility In charge should visit at least

There is system of daily round by twice in a week. OBG In charge should
The facility has established internal matron/hospital manager/ hospital visit Labour room at least twice a day,
ME G3.1 quality assurance programme in key superintendent/ Hospital Manager/ SI/RR Matron/Nursing supervisor should visit
departments Matron in charge for monitoring of at once in each shift
services Findings/instructions during the visits are
recorded

Facility has established system for

ME G3.3 use of check lists in different Internal assessment is done at periodic RR/SI NQAS assessment toolkit is used to
departments and services interval conduct internal assessment

Departmental checklist are used for SI/RR Staff is designated for filling and
monitoring and quality assurance monitoring of these checklists

Non-compliances are enumerated and RR Check the non compliances are

recorded presented & discussed during quality
team meetings

Actions are planned to address gaps Check action plans are prepared and Randomly check the details of action,
ME G3.4 observed during quality assurance implemented as per internal assessment RR responsibility, time line and feedback
process record findings mechanism

Planned actions are implemented Check PDCA or prevalent quality method is Check actions have been taken to close
ME G3.5 through Quality Improvement Cycles used to take corrective and preventive SI/RR the gap. It can be in form of action taken
(PDCA) action report or Quality Improvement (PDCA)
project report
Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
Standard operating procedure for
ME G4.1 Departmental standard operating department has been prepared and RR Check if SOPs available at labour room
procedures are available approved are formally approved

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Method

Current version of SOP are available with OB/RR Check current version of SOP is available
process owner with all staff members of labour room

clinical protocols for Intrapartum care Clinical Protocols on AMSTL, Preparing

and Management of obstetric emergency OB Partograph, , PPH, Eclampsia, Infection
are Displayed control, Referral, Infection Control

Clinical protocols on Newborn Care are OB Clinical Protocols on Essential Newborn

displayed Care, New born resuscitation

1. No routine enema
2. No routine shaving
3. No routine induction/augmentation of
labour
4. No place for routine suctioning of the
Don'ts/ Harmful Activities are Displayed at OB baby
labour Room 5. No pulling of the baby.
6. No routine episiotomy
7. No fundal pressure
8. No immediate cord cutting
9. No immediate bathing of the newborn
10. No routine resuscitation on warmer

Standard Operating Procedures Department has documented procedure Review the Labour Room SOPs for
ME G4.2 adequately describes process and for ensuring patients rights including RR description of processes pertaining to
procedures consent, privacy, confidentiality & ensuring privacy, confidentiality,
entitlement respectful maternity care and consent

Review the Labour Room SOPs for

Department has documented procedure RR inclusion for processes to Physical as well
for safety & risk management as patient safety, assessment of risks and
their timely mitigation

Review the Labour Room SOPs for

Department has documented procedure process description of support services
for support services & facility RR such as equipment maintenance ,
management. calibration, housekeeping, security,
storage and inventory management

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Method

Review Labour room SOPS for processes

Department has documented procedure of triage, assessment, admission,
RR identification of high risk patients,
for general patient care processes
Referral , Medication management and
maintenance of clinical records

Review Labour room SOPs for process of

Department has documented procedure intrapartum care, management of
RR complications, immediate postpartum
for specific processes to the department
care , Natural Birthing Process and Birth
Companion

Review Labour room SOPs for process

description of Hand Hygiene, personal
protection, environmental cleaning,
instrument sterilization, asepsis, Bio
Department has documented procedure Medical Waste management ,
for infection control & bio medical waste RR
surveillance and monitoring of infection
management control practices, Periodic quality review
such as Maternal Death Audit, Newborn
Death Audit, Referral audit and Near
miss audit.

Review Labour room SOPs for process

description of function of quality circles,
internal quality assessment, Quality
Department has documented procedure RR improvement using PDCA cycle client
for quality management & improvement satisfaction surveys, processes
improvement , Maternal Death Audit,
Newborn Death Audit, Referral Death
Audit and Near Miss audits.

Review Labour room SOPs for

Department has documented procedure description of process related to
for data collection, analysis & use for RR collection of data & quality indicators ,
improvement their analysis and use for quality
improvement

ME G4.3 Staff is trained and aware of the Check Staff is aware of relevant part of SI/RR Interview labour room staff for their
procedures written in SOPs SOPs awareness about content of SOPs
Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

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Method
Critical process are the ones where is
ME G5.1 The facility maps its critical processes Process mapping of critical processes done SI/RR some problem-delays, errors, cost, time,
etc. and improvement will make our
process effective and efficient.

Facility identifies non value adding Non value adding activities are wastes. In
ME G5.2 activities / waste / redundant Non value adding activities are identified SI/RR these steps resources are expended,
activities delays occur, and no value is added to
the service.

ME G5.3 Facility takes corrective action to Processes are improved & implemented SI/RR Look for the improvements made in the
improve the processes critical process.
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Check short term valid quality objectives

have been framed addressing key quality
ME G6.4 Facility has defined quality objectives Check if SMART Quality Objectives have SI/RR issues in each department and cores
to achieve mission and quality policy framed services. Check if these objectives are
Specific, Measurable, Attainable,
Relevant and Time Bound.

Mission, Values, Quality policy and Interview with staff for their awareness.
objectives are effectively Check of staff is aware of Mission , Values, Check if Mission Statement, Core Values
ME G6.5 SI/RR and Quality Policy is displayed
communicated to staff and users of Quality Policy and objectives
services prominently in local language at Key
Points
Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 The facility uses method for quality Basic quality improvement method SI/OB PDCA & 5S
improvement in services

ME G7.2 The facility uses tools for quality 7 basic tools of Quality SI/RR Minimum 2 applicable tools are used in
improvement in services each department
Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
Verify with the records. A
Periodic assessment for Medication Check periodic assessment of medication comprehensive risk assessment of all
ME G9.6 and Patient care safety risks is done and patient care safety risk is done using SI/RR clinical processes should be done using
as per defined criteria. defined checklist periodically pre define criteria at least once in three
month.

Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

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Method

Check parameter are defined &

implemented to review the clinical care
Clinical care assessment criteria have The facility has established process to i.e. through Ward round, peer review,
ME G10.3 SI/RR morbidity & mortality review, patient
been defined and communicated review the clinical care
feedback, clinical audit & clinical
outcomes.

(1) Both critical and stable patients

Check regular ward rounds are taken to SI/RR (2) Check the case progress is
review case progress documented in BHT/ progress notes-
Feedback is taken from patient/family on
Check the patient /family participate in the SI/PI health status of individual under
care evaluation treatment

System in place to review internal

Check the care planning and co- ordination SI/RR referral process, review clinical handover
is reviewed information, review patient
understanding about their progress

(1) Random referral slips are audited

(2) The reasons of the referral is clearly
mentioned
(3) Referral is written by authorized
Facility conducts the periodic clinical There is procedure to conduct referral competent person
ME G10.4 audits including prescription, SI/RR
audits (4) A through action taken report is
medical and death audits prepared and presented in clinical
Governance Board meetings / during
grand round (wherever required)

(1) All the deaths are audited by the

committee.
(2) The reasons of the death is clearly
mentioned
There is procedure to conduct maternal (3) Data pertaining to deaths are collated
SI/RR and trend analysis is done
death audits
(4) A through action taken report is
prepared and presented in clinical
Governance Board meetings / during
grand round (wherever required)

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Method

(1) All the deaths are audited by the

committee.
(2) The reasons of the death is clearly
mentioned
There is procedure to conduct neonatal (3) Data pertaining to deaths are collated
RR and trend analysis is done
death audits
(4) A through action taken report is
prepared and presented in clinical
Governance Board meetings / during
grand round (wherever required)

All non compliance are enumerated SI/RR Check the non compliances are
recorded for referral audits presented & discussed during clinical
Governance meetings

All non compliance are enumerated SI/RR Check the non compliances are
recorded for maternal death audits presented & discussed during clinical
Governance meetings

All non compliance are enumerated SI/RR Check the non compliances are
recorded for neonatal death audits presented & discussed during clinical
Governance meetings

Clinical care audits data is analysed, Check action plans are prepared and Randomly check the actual compliance
ME G10.5 and actions are taken to close the implemented as per referral audit record SI/RR with the actions taken reports of last 3
gaps identified during the audit findings months
process

Check action plans are prepared and Randomly check the actual compliance
implemented as per maternal death audit SI/RR with the actions taken reports of last 3
record findings months
Check action plans are prepared and Randomly check the actual compliance
implemented as per neonatal death audit SI/RR with the actions taken reports of last 3
record's findings months
Check collected data is analysed & areas
Check the data of audit findings are RR for improvement is identified &
collated prioritised

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Method

Check the critical problems are regularly

Check PDCA or prevalent quality method monitored & applicable solutions are
SI/RR duplicated in other departments
is used to address critical problems
(wherever required) for process
improvement

Facility ensures easy access and use

ME G10.7 of standard treatment guidelines & Check standard treatment guidelines / SI/RR
Staff is aware of Standard treatment
implementation tools at protocols are available & followed. protocols/ guidelines/best practices
point of care

Check treatment plan is prepared as per SI/RR Check staff adhere to clinical protocols
Standard treatment guidelines while preparing the treatment plan

Check the drugs are prescribed as per SI/RR Check the drugs prescribed are available
Standards treatment guidelines in EML or part of drug formulary

Check when the

Check the updated/latest evidence are STG/protocols/evidences used in
SI/RR healthcare facility are published.
available
Whether the STG protocols are
according to current evidences.

The gaps in clinical practices are

Check the mapping of existing clinical SI/RR identified & action are taken to improve
practices processes is done it. Look for evidences for improvement
in clinical practices using PDCA

Area of Concern - H Outcome

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Percentage of deliveries conducted at RR
Indicators on monthly basis night
Percentage of complicated RR
cases managed
% PPIUCD inserted against RR
total number of normal delivery
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Percentage of cases referred to OT RR
Indicators on monthly basis
% of newborns required
resuscitation out of total live RR
births

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Method
No of drugs stock out in the month RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Percentage of deliveries conducted using RR
Safety Indicators on monthly basis real time partograph
Percentage of deliveries conducted using RR
safe birth checklist
No of adverse events per thousand RR
patients

The percentage of Women, administered

Oxytocin, immediately after birth. RR

Intrapartum stillbirth rate RR

Percentage newborn breastfed within 1 RR

hour of birth
No. of cases of Neonatal asphyxia RR
No. of cases of Neonatal Sepsis RR

Percentage of antenatal corticosteroid RR

administration in case of preterm labour

No. of cases of Maternal death related to RR

APH/ PPH
No of cases pf maternal death related to RR
Eclampsia/ PIH
OSCE Score RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality Percentage of Deliveries attended by Birth RR
Indicators on monthly basis Companion
Client Satisfaction Score RR

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method
Area of Concern - A Service Provision

Standard A1 The facility provides Curative Services

(a) IPD services for Obstetric Cases

(General & post Surgical cases)
(b) IPD Services for Gynae cases
The facility provides Obstetrics & Availability of Obs and Gynaecology ( General & post-surgical cases)
ME A1.3 Gynaecology Services indoor services SI/OB (c ) 250-500 Deliveries - 8-bedded HDU
or 500-1000 deliveries - 8 bedded hybrid
ICU (6 HDU & 2 ICU beds or more 1000
Deliveries- 4 bed ICU & 8-bed HDU

ME A1.14 Services are available for the time Availability of nursing services 24X7 SI/RR
period as mandated

ME A1.18 The facility provides Blood bank & Availability of blood transfusion services SI/OB Availability/ linkage with blood bank
transfusion services

Standard A2 The facility provides RMNCHA Services

ME A2.2 The facility provides Maternal Availability of indoor services for SI/OB Antenatal ward- Clean Ward
health Services Antenatal cases
Availability of indoor services for normal SI/OB Postnatal ward -Normal delivery
delivery

Availability of indoor services for C section SI/OB Postnatal ward -C-section delivery

Availability of indoor services for Septic SI/OB Septic ward

cases
Availability of indoor services for SI/OB Eclampsia room
Eclampsia cases

Availability of Gynae Services SI/RR Hysterectomy & mastectomy services as

per disease indication

ME A2.3 The facility provides Newborn Prevention of hypothermia and initiation SI/OB
health Services of breast feeding

ME A2.4 The facility provides Child health Screening of New born for Birth Defects SI/OB
Services

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method

Standard A3 The facility Provides diagnostic Services

ME A3.1 The facility provides Radiology Availability / linkage for Radiology and SI/OB
Services USG

ME A3.2 The facility Provides Laboratory Availability / linkage with laboratory SI/OB
Services
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme
The facility provides services
ME A4.1 under National Vector Borne Treatment of Malaria in pregnancy SI/OB check the records for management of
Disease Control Programme as per cases in last one year
guidelines

The facility provide services under Referral of child born of High Risk
ME A4.10 National health Programme for pregnancy showing features suggestive of SI/OB
prevention and control of hearing impairment
deafness
Area of Concern - B Patient Rights
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 The facility has uniform and user- Availability departmental signage's OB (Numbering, main department and
friendly signage system internal sectional signage
Visiting hours and visitor policy are OB
displayed
The facility displays the services
ME B1.2 and entitlements available in its Entitlements applicable are Displayed OB JSSK, JSY and PM JAY
departments
List of drugs available are displayed and OB
updated
Contact details of referral transport / OB
ambulance displayed

Patients & visitors are sensitised Breast feeding and care of breast,
ME B1.5 and educated through appropriate IEC Material is displayed OB kangaroo care, family planning, Danger
IEC / BCC approaches signs, PN advice, Information material
about PCPNDT etc
Counselling aids like flip chart etc are OB
available for post partum counselling

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

language and easy to understand local language

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The facility provides information
ME B1.7 to patients and visitor through an Availability of Enquiry Desk with dedicated OB Enquiry desk serving both maternity
exclusive set-up. staff ward and labour

Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of physical economic, cultural or
Standard B2 social reasons.

ME B2.1 Services are provided in manner No Male attendant allowed to stay in OB/SI
that are sensitive to gender female wards at night
Availability of female staff if a male doctor OB/SI
examine a female patients
Availability of Breast feeding corner OB

Access to facility is provided

ME B2.3 without any physical barrier & and Availability of Wheel chair or stretcher for OB
friendly to people with disabilities easy Access to the ward

Availability of ramps and railing OB

Availability of disable friendly toilet OB
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Adequate visual privacy is Availability of screen at Examination Area OB Bracket screen
provided at every point of care

Curtains have been provided at windows OB

Patients are dressed/covered while

shifting the patients from one department OB
to other
No two patients are treated on one bed OB

1. No information regarding patient /

Confidentiality of patients records Patient Records are kept at secure place parent identity is displayed
ME B3.2 and clinical information is beyond access to general staff/visitors SI/OB 2. Records are not shared with anybody
maintained without written permission of parents &
appropriate hospital authorities

The facility ensures the behaviours

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

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The facility ensures privacy and

confidentiality to every patient, HIV status of patient is not disclosed
ME B3.4 especially of those conditions except to staff that is directly involved in SI/OB
having social stigma, and also care
safeguards vulnerable groups

Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and involving them in treatment planning, and facilitates
informed decision making

There is established procedures

ME B4.1 for taking informed consent General Consent is taken before SI/RR
before treatment and procedures admission

Information about the treatment Patient and their attendant is informed

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

The facility has defined and Availability of complaint box and display
ME B4.5 established grievance redressal of process for grievance redressal and OB
system in place whom to contact is 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 services.

The facility provides cashless

ME B5.1 services to pregnant women, Availability of Free drugs PI/SI
mothers and neonates as per
prevalent government schemes
Stay and diet provided in ward is free of PI/SI
cost
Availability of free diagnostic PI/SI
Availability of Free drop back PI/SI
Availability of Free referral PI/SI
vehicle/Ambulance services
Availability of Free Blood PI/SI
The facility ensures that drugs Check that patient party has not spent on
ME B5.2 prescribed are available at purchasing drugs or consumables from PI/SI
Pharmacy and wards outside.

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

The facility ensures timely

ME B5.5 reimbursement of financial If any other expenditure occurred it is PI/SI/RR
entitlements and reimbursement reimbursed from hospital
to the patients
JSY Payment is done before discharge PI/SI/RR

Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities

The policy clearly defines the procedures

for managing critical cases in the ward,
HDU/ICU, brain-dead patients, conscious
patients with serious diseases like motor
neurons and brought-in dead cases. It
also includes:
(a) Patient and family have the right to
ME B6.6 There is an established procedure End of life policy & procedure are SI/RR be informed about their condition and
for ‘end-of-life’ care available and followed make choices about the treatment
(b) Withhold or withdraw life-sustaining
treatment
(c ) Organ donation as per NOTTO
&India's Governing organ donation law
(d)
All the decisions should be transparent
and documented

Staff is educated & trained for end of life SI/RR

care
The patient's Relatives informed clearly
about the deterioration in the health SI/RR Periodic update on the patient's
condition of Patient. condition is given to the family.

Policy & procedures like DNR , DNI etc Patient right "Do not resuscitate" or "
for critical cases are in consonance with SI/RR Do not intubate"/ allow natural death
legal requirement are respected

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There is a procedure to allow patient
relative/Next of Kin to observe patient in SI/OB
last hours

(a) a patient living with or diagnosed

with life-limiting illness
(b) a patient who is likely to die in the
short or medium term is admitted, or
deteriorates during their admission
(c) a patient is dying where Patient (or
Staff is aware of events indicating that family member, if the patient lacks
conversations about end-of-life care need RR/SI capacity)
to start with patient or family expresses interest in discussing end-of-
life care
(d) a previously well person who has
suffered an acute life-threatening event
or illness is admitted
(e) unexpected, significant physical
deterioration occurs

Hospital has documented policy for pain SI/OB

management
Symptomatic treatment is given to the
Screening of the patient for pain SI/RR patient to prevent complications to
extent possible
Pain alleviation measures or medication is
initiated & titrated as per need and SI/RR
response

There is an established procedure

for patients who wish to leave Declaration is taken from the LAMA Consequences of LAMA are explained to
ME B 6.7 hospital against medical advice or patient RR/SI patient/relative
refuse to receive specific c
treatment
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms

ME C1.1 Departments have adequate space Adequate space in wards with no OB Distance between centres of two beds –
as per patient or work load cluttering of beds 2.25 meter

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Functional toilets with running water and
ME C1.2 Patient amenities are provide as flush are available as per strength and OB one toilet for 12 patients
per patient load patient load of ward
Functional bathroom with running water
are available as per strength and patient OB one toilet for 12 patients
load of ward
Availability of drinking water OB
Patient/ visitor Hand washing area OB
Separate toilets for visitors OB
TV for entertainment and health OB
promotion
Adequate shaded waiting area is provide OB
for attendants of patient

ME C1.3 Departments have layout and Availability of Dedicated nursing station OB

demarcated areas as per functions

Availability of Examination room OB

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

Corridors are wide enough for patient, OB Corridor should be 3 meters wide
visitor and trolley/ equipment movement

The facility has infrastructure for

ME C1.5 intramural and extramural Availability of functional telephone and OB
communication Intercom Services

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1. ANC, PNC, C-Section ward. Depending

upon Wards available for maternity
Service counters are available as There is separate nursing station for each cases
ME C1.6 per patient load ward OB
2. Location of nursing station and
patients beds enables easy and direct
observation of patients

Availability of adequate beds as per OB 10 beds for 100 delivery per month
delivery load

The facility and departments are

planned to ensure structure Prepartum and post partum wards are in
ME C1.7 follows the function/processes proximity and functional linkage with OB
(Structure commensurate with the labour room
function of the hospital)

Postpartum ward and SNCU are in OB

proximity and functional linkage
C section ward is in Proximity and has OB/SI
functional linkage with OT
Standard C2 The facility ensures the physical safety of the infrastructure.
Check for fixtures and furniture like
ME C2.1 The facility ensures the seismic Non structural components are properly OB cupboards, cabinets, and heavy
safety of the infrastructure secured equipment , hanging objects are
properly fastened and secured

Switch Boards other electrical

ME C2.3 The facility ensures safety of IPD building does not have temporary OB installations are intact. There is proper
electrical establishment connections and loosely hanging wires earthing

ME C2.4 Physical condition of buildings are Floors of the maternity ward are non OB
safe for providing patient care slippery and even

Windows have grills and wire meshwork OB

Standard C3 The facility has established Programme for fire safety and other disaster
Maternity ward has sufficient fire exit to
ME C3.1 The facility has plan for prevention permit safe escape to its occupant at time OB/SI
of fire of fire

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Check the fire exits are clearly visible and OB

routes to reach exit are clearly marked.

Maternity ward has installed fire

ME C3.2 The facility has adequate fire Extinguisher that is either Class A , Class OB
fighting Equipment B, C type or ABC type

Check the expiry date for fire

extinguishers are displayed on each OB/RR
extinguisher as well as due date for next
refilling is clearly mentioned

The facility has a system of

periodic training of staff and Check for staff competencies for operating
ME C3.3 conducts mock drills regularly for fire extinguisher and what to do in case of SI/RR
fire and other disaster situation fire

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

ME C4.1 The facility has adequate specialist Availability of Bog specialist on duty and OB/RR
doctors as per service provision on call paediatrician

The facility has adequate general

ME C4.2 duty doctors as per service Availability of General duty doctor at all OB/RR
provision and work load time

The facility has adequate nursing 6 for 100-200 Deliveries/Month

ME C4.3 staff as per service provision and Availability of Nursing staff OB/RR/SI 8 for More than 200 deliveries per
work load month
The facility has adequate
ME C4.4 technicians/paramedics as per Availability of RMNCH counsellor OB/SI Counsellor available for postpartum
requirement counselling of mothers

Availability of dresser for C section ward SI/RR

ME C4.5 The facility has adequate support / Availability of ward attendant SI/RR Availability of mamta/ ayahs and
general staff Sanitary worker
Availability Security staff SI/RR
Standard C5 The facility provides drugs and consumables required for assured services.

ME C5.1 The departments have availability Availability of Uterotonic Drugs OB/RR Tocolytic agent, Isoxsuprine
of adequate drugs at point of use

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Availability of Anti - Infective - Antibiotics, OB/RR Tab. Metronidazole 400mg, Gentamicin,
Antifungal

Availability of Antihypertensive OB/RR Tab. Misprostol 200mg, Labetalol Discussion

required

Availability of analgesics and antipyretics OB/RR Tab. Paracetamol, Tab. Ibuprofen,

Piroxicam
Availability of IV Fluids OB/RR IV fluids, Normal saline, Ringer lactate,
Tab. Ritodrine, Misoprostol, Carboprost,
Availability of other emergency drugs OB/RR steroid as Hydrocortisone,
dexamethasone, iron, calcium, and folic
acids tablets

Inj. Vit K 10mg, Vaccine OPV, Hepatitis B,

BCG, paracetamol syrup/drops, Syp
Calcium with Vit D, Multivitamin drops,
Availability of drugs for newborn OB/RR Simethicone + Fennel Oil + Dill Oil drops,
Nevirapine drops (for HIV + ve mother
born children), gentian Violet (0.50%)

gauze piece and cotton swabs, sanitary

ME C5.2 The departments have adequate Availability of dressings and Sanitary pads OB/RR pads, needle (round body and cutting),
consumables at point of use chromic catgut no. 0,
Paediatric iv sets, urinary catheter with
Availability of syringes and IV Sets /tubes OB/RR bag, Foyle's catheter Nasogastric tube,
Syringe A/D
Availability of Antiseptic Solutions OB/RR Povidone Iodine Solution
Availability of consumables for new born OB/RR gastric tube and cord clamp, dressing
care pad

Emergency drug trays are

ME C5.3 maintained at every point of care, Availability of emergency drug tray in OB/RR
where ever it may be needed Maternity ward

Standard C6 The facility has equipment & instruments required for assured list of services.
Availability of equipment & Availability of functional Equipment BP apparatus, Thermometer,
ME C6.1 instruments for examination & &Instruments for examination & OB foetoscope, baby and adult weighing
monitoring of patients Monitoring scale, Stethoscope, Doppler

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Availability of equipment & Availability of functional Dressing and suture removal kit,
ME C6.2 instruments for treatment Equipment/Instruments Gynae & OB speculum, Anterior vaginal wall
procedures, being undertaken in Obstetric Procedures retractor.
the facility

Availability of equipment &

ME C6.3 instruments for diagnostic Availability of Point of care diagnostic OB Glucometer and HIV rapid diagnostic kit
procedures being undertaken in instruments
the facility

Availability of equipment and

instruments for resuscitation of Adult and baby bag and mask, Oxygen,
ME C6.4 patients and for providing Availability of resuscitation equipments OB Suction machine, Airway, Laryngoscope,
intensive and critical care to ET tube
patients

ME C6.5 Availability of Equipment for Availability of equipment for storage for OB Refrigerator, Crash cart/Drug trolley,
Storage drugs instrument trolley, dressing trolley
Availability of functional
ME C6.6 equipment and instruments for Availability of equipments for cleaning OB Buckets for mopping, mops, duster,
support services waste trolley, Deck brush

Availability of equipment for sterilization OB Boiler

and disinfection
Departments have patient
ME C6.7 furniture and fixtures as per load Availability of patient beds with prop up OB
and service provision facility

Availability of attachment/ accessories OB Hospital graded mattress, Bed side

with patient bed locker , IVstand, Bed pan

Availability of Fixtures OB Spot light, electrical fixture for

equipments like suction, X ray view box

Availability of furniture OB cupboard, nursing counter, table for

preparation of medicines, chair.

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

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Check objective checklist has been

prepared for assessing competence of
Criteria for Competence Check parameters for assessing skills and doctors, nurses and paramedical staff
ME C7.1 assessment are defined for clinical proficiency of clinical staff has been RR/SI based on job description defined for
and Para clinical staff defined each cadre of staff. Dakshta checklist
issued by MoHFW can be used for this
purpose.

Competence assessment of Check for records of competence

Clinical and Para clinical staff is Check for competence assessment is done assessment including filled checklist,
ME C7.2 done on predefined criteria at at least once in a year RR/SI scoring and grading . Verify with staff for
least once in a year actual competence assessment done

The Staff is provided training as

ME C7.9 per defined core competencies Infant and young Child Feeding ( IYCF) SI/RR
and training plan practices

Infection control & prevention training SI/RR Bio medical Waste Management
including Hand Hygiene
Infection control and hand hygiene SI/RR
Patient Safety SI/RR
Training on Quality Management System

There is established procedure for Check supervisors make periodic rounds

utilization of skills gained thought Nursing staff is skilled identificaton and of department and monitor that staff is
ME C7.10 trainings by on -job supportive managing complication SI/RR working according to the training
supervision imparted. Also staff is provided on job
training wherever there is still gaps

Check supervisors make periodic rounds

Staff is skilled for maintaining clinical of department and monitor that staff is
records SI/RR working according to the training
imparted. Also staff is provided on job
training wherever there is still gaps

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Check supervisors make periodic rounds

Counsellor is skilled for postnatal of department and monitor that staff is
counselling SI/RR working according to the training
imparted. Also staff is provided on job
training wherever there is still gaps

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

The facility has established system 1. Check with AMC records/

ME D1.1 for maintenance of critical All equipments are covered under AMC SI/RR Warranty documents
Equipment including preventive maintenance 2. Staff is aware of the list of equipment
covered under AMC.

[Link] for breakdown & Maintenance

There is system of timely corrective break record in the log book
down maintenance of the equipments SI/RR 2. Staff is aware of contact details of the
agency/person in case of breakdown.

The facility has established

ME D1.2 procedure for internal and All the measuring equipments/ instrument OB/ RR BP apparatus, thermometers etc are
external calibration of measuring are calibrated calibrated
Equipment
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of medicines in pharmacy and patient care areas
There is established procedure for There is established system of timely Stock level are daily updated Indents are
ME D2.1 forecasting and indenting indenting of consumables and medicine SI/RR timely placed
medicine and consumables at nursing station

medicine are stored in medicine are stored in separate

ME D2.3 The facility ensures proper storage containers/tray/crash cart and are OB containers, trays and carts and labelled
of medicine and consumables labelled with drug name, drug strength and
expiry date
Empty and filled cylinders are labelled OB
Check medicine are arranged in tray as
ME D2.4 The facility ensures management Expiry dates' are maintained at emergency OB/RR per First Expiry and First Out (FEFO) and
of expiry and near expiry medicine drug tray expiry date are mentioned against the
drug.
No expired drug found OB/RR

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Records for expiry and near expiry Check register/DVDMS/other supply
medicine are maintained for drug stored RR chain software for record of stock of
at department expired and near expiry medicine
The facility has established
ME D2.5 procedure for inventory There is established system of calculating SI/RR
management techniques and maintaining buffer stock

Check record of drug received, issued

Department maintained stock register of RR/SI and balance stock in hand and are
medicine and consumables updated
There is a procedure for
ME D2.6 periodically replenishing the There is procedure for replenishing drug SI/RR
medicine in patient care areas tray /crash cart

There is no stock out of medicine OB/SI Random stock check of some medicine

Check for refrigerator/ILR temperature

charts. Charts are maintained and
There is process for storage of Temperature of refrigerators are kept as updated twice a day. Refrigerators
ME D2.7 vaccines and other medicine, per storage requirement and records OB/RR meant for storing medicine should not
requiring controlled temperature twice a day and are maintained be used for storing other items such as
eatables.

There is a procedure for secure Separate prescription for narcotic and

ME D2.8 storage of narcotic and Narcotics and psychotropic medicine are OB/SI psychotropic medicine by a registered
psychotropic medicine kept separately in lock and key medical practioner
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
The facility provides adequate
ME D3.1 illumination level at patient care Adequate Illumination at nursing station OB
areas
Adequate illumination in patient care OB Spot light is available
areas
The facility has provision of
ME D3.2 restriction of visitors in patient Visiting hour are fixed and practiced OB/PI
areas
There is no overcrowding in the wards OB
during to visitors hours

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Optimal temperature and warmth is

The facility ensures safe and Temperature control and ventilation in ensured Fans/ Air
ME D3.3 comfortable environment for patient care area PI/OB conditioning/Heating/Exhaust/Ventilator
patients and service providers s as per environment condition and
requirement

Fans/ Air
Temperature control and ventilation in SI/OB conditioning/Heating/Exhaust/Ventilator
nursing station/duty room s as per environment condition and
requirement

ME D3.4 The facility has security system in New born identification band and foot OB/RR
place at patient care areas prints are in practice

Security arrangement in maternity ward OB/SI

The facility has established

ME D3.5 measure for safety and security of Ask female staff weather they feel secure SI
female staff at work place

Standard D4 The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior of the facility building is Building is painted/whitewashed in OB
maintained appropriately uniform colour
Interior of patient care areas are plastered OB
& painted
Floors, walls, roof, roof topes, sinks
ME D4.2 Patient care areas are clean and patient care and circulation areas are OB All area are clean with no
hygienic Clean dirt,grease,littering and cobwebs

Surface of furniture and fixtures are clean OB

Toilets are clean with functional flush and OB

running water

ME D4.3 Hospital infrastructure is Check for there is no seepage , Cracks, OB

adequately maintained chipping of plaster
Window panes , doors and other fixtures OB
are intact
Patients beds are intact and painted OB Mattresses are intact and clean

ME D4.5 The facility has policy of removal No condemned/Junk material in the ward OB
of condemned junk material

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The facility has established
ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds OB
animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
The facility has adequate
ME D5.1 arrangement storage and supply Availability of 24x7 running and potable OB/SI
for portable water in all functional water
areas
Availability of hot water OB/SI
The facility ensures adequate
ME D5.2 power backup in all patient care Availability of power back in ward OB/SI
areas as per load
StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.
The facility has provision of Nutritional assessment of patient done
ME D6.1 nutritional assessment of the specially for high risk pregnancy and other RR/SI For hypertensive patient, diabetic cases.
patients specified cases Check nutrition advice from records

The facility provides diets

ME D6.2 according to nutritional Check for the adequacy and frequency of OB/RR Check that all items fixed in diet menu is
requirements of the patients diet as per nutritional requirement provided to the patient

Check for the Quality of diet provided PI/SI Ask patient/staff weather they are
satisfied with the Quality of food

Hospital has standard procedures

for preparation, handling, storage There is procedure of requisition of diet for diabetic patients, low salt and
ME D6.3 and distribution of diets, as per different type of diet from ward to kitchen RR/SI high protein diet etc
requirement of patients

Standard D7 The facility ensures clean linen to the patients

ME D7.1 The facility has adequate sets of Clean Linens are provided for all occupied OB/RR
linen bed
Gown are provided at least to the cases OB/RR
going for surgery

Availability of Blankets, draw sheet, pillow OB/RR

with pillow cover and mackintosh

The facility has established

ME D7.2 procedures for changing of linen in Linen is changed every day and whenever OB/RR
patient care areas it get soiled

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The facility has standard There is system to check the cleanliness
ME D7.3 procedures for handling , and Quantity of the linen received from SI/RR
collection, transportation and laundry
washing of linen

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

ME D11.1 The facility has established job Staff is aware of their role and SI
description as per govt guidelines responsibilities

The facility has a established Check for system for recording time of
ME D11.2 procedure for duty roster and There is procedure to ensure that staff is RR/SI reporting and relieving (Attendance
deputation to different available on duty as per duty roster register/ Biometrics etc)
departments
There is designated in charge for SI
department
The facility ensures the adherence
ME D11.3 to dress code as mandated by its Doctor, nursing staff and support staff OB
administration / the health adhere to their respective dress code
department
Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

Verification of outsourced services

There is established system for There is procedure to monitor the quality (cleaning/
ME D12.1 contract management for out and adequacy of outsourced services on SI/RR Dietary/Laundry/Security/Maintenance)
sourced services regular basis provided are done by designated in-
house staff
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
The facility has established
ME E1.1 procedure for registration of Unique identification number is given to RR
patients each patient during process of registration

Patient demographic details are recorded RR Check for that patient demographics like
in admission records Name, age, Sex, Chief complaint, etc.

ME E1.3 There is established procedure for There is no delay in treatment because of SI/RR/OB
admission of patients admission process

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Admission is done by written order of a SI/RR/OB
qualified doctor
There is separate counter for admission of OB/RR
patients
Time of admission is recorded in patient RR
record

There is established procedure for

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

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

ANC history of pregnant women is RR/SI

reviewed and recorded

Assesses general condition, including:

Physical Examination is done and vital signs, conjunctiva for pallor and
recorded wherever required RR jaundice, and bladder and bowel
function, conducts breast examinations

Examines the perineum for

inflammation, status of
Dangers signs are identified and recorded RR/SI episiotomy/tears, lochia for colour,
amount, consistency and odour, Checks
calf tenderness, redness or swelling

Initial assessment and treatment is

provided immediately RR/SI

Initial assessment is documented RR

preferably within 2 hours
There is established procedure for
ME E2.2 follow-up/ reassessment of There is fixed schedule for assessment of RR/OB
Patients stable patients

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For critical patients admitted in the ward
there is provision of reassessment as per RR/OB
need

There is system in place to identify and Criteria is defined for identification, and
manage the changes in Patient's health SI/RR management of high risk patients/
status patient whose condition is deteriorating

Check the re assessment sheets/ Case

Check the treatment or care plan is SI/RR sheets modified treatment plan or care
modified as per re assessment results plan is documented

Assessment includes physical

There is established procedure to assessment, history, details of existing
plan and deliver appropriate Check healthcare needs of all hospitalised disease condition (if any) for which
ME E2.3 treatment or care to individual as patients are identified through SI/RR regular medication is taken as well as
per the needs to achieve best assessment process evaluate psychological ,cultural, social
possible results factors

(a) According to assessment and

investigation findings (wherever
applicable).
(b) Check inputs are taken from patient
Check treatment/care plan is prepared as RR or relevant care provider while preparing
per patient's need the care plan.

Care plan include:, investigation to be

Check treatment / care plan is conducted, intervention to be provided,
documented RR goals to achieve, timeframe, patient
education, , discharge plan etc

Check care plan is prepared and

Check care is delivered by competent SI/RR delivered as per direction of qualified
multidisciplinary team physician
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral

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The facility has established Facility has established procedure for

ME E3.1 procedure for continuity of care handing over of patients from maternity SI/RR to OT/labour room/USG
during interdepartmental transfer ward

There is a procedure for consultation of

the patient to other specialist with in the SI/RR
hospital

The facility provides appropriate

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

Advance communication is done with RR/SI

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

ME E3.3 A person is identified for care Duty Doctor and nurse is assigned for RR/SI
during all steps of care each patients
Standard E4 The facility has defined and established procedures for nursing care
Procedure for identification of There is a process for ensuring the Identification tags for mother and baby /
ME E4.1 patients is established at the identification before any clinical OB/SI foot print are used for identification of
facility procedure newborns

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

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(1) Check system is in place to give

There is a process to ensue the accuracy telephonic orders & practised
of verbal/telephonic orders SI/RR (2) Verbal orders are verified by the
ordering physician within defined time
period

There is established procedure of

ME E4.3 patient hand over, whenever staff Patient hand over is given during the SI/RR
duty change happens change in the shift

Nursing Handover register is maintained RR

Hand over is given bed side SI/RR
ME E4.4 Nursing records are maintained Nursing notes are maintained adequately RR/SI Check for nursing note register. Notes
are adequately written

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

Critical patients are monitored continually RR/SI

Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
Vulnerable patients are identified and
ME E5.1 The facility identifies vulnerable measures are taken to protect them from OB/SI Check the measure taken to prevent new
patients and ensure their safe care any harm born theft, sweeping and baby fall

The facility identifies high risk High risk cases : Eclampsia, Sepsis,
ME E5.2 patients and ensure their care, as High Risk Pregnancy cases are identified OB/SI diabetic, cardiac diseases and
per their need and kept in intensive monitoring Intrauterine growth retardation

Standard E6 Facility ensures rationale prescribing and use of medicines

ME E6.1 The facility ensured that drugs are Check for BHT if drugs are prescribed RR
prescribed in generic name only under generic name only

Check for that relevant Standard

ME E6.2 There is procedure of rational use treatment guideline are available at point RR
of drugs of use
Check staff is aware of the drug regime SI/RR Check BHT that drugs are prescribed as
and doses as per STG per STG
Availability of drug formulary SI/OB
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There are procedures defined for Check complete medication history
ME E6.3 medication review and Complete medication history is RR/OB including over-the- counter medicines is
optimization documented for each patient taken and documented

1. Medication Reconciliation is carried

out by a trained and competent health
professional during the patient's
Established mechanism for Medication admission, interdepartmental transfer or
reconciliation process SI/RR discharged
2. Medicine reconciliation includes
Prescription and non-prescription (over-
the-counter) medications, vitamins,
nutritional supplements.

Medicines are optimised as per

Medicine are reviewed and optimised as SI/RR individual treatment plan for best
per individual treatment plan possible clinical outcome

1. Discharge summary includes known

drug allergies and reactions to medicines
or their ingredients, and the type of
Complete medication history is reaction experienced
documented and communicated for each SI/RR 2. Changes in prescribed medicines,
patient at the time of discharge including medicines started or stopped,
or dosage changes, and reason for the
change are clearly documented in the
case sheet and case summary"

"1. Clinician/Nurse counsel the patient

on medication safety using ""5 moments
for medication safety app""
Patients are engaged in their own care PI/SI 2. Nurse highlights the medications to be
taken by the patient at home and
counsel the patient and family on drug
intake as per treatment plan for
discharge"

Standard E7 The facility has defined procedures for safe drug administration

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There is process for identifying
ME E7.1 and cautious administration of High alert drugs available in department SI/OB Magsulf (to be kept in fridge) ,
high alert drugs are identified Methergine

Value for maximum doses as per age,

Maximum dose of high alert drugs are SI/RR weight and diagnosis are available with
defined and communicated nursing station and doctor

A system of independent double check

There is process to ensure that right doses SI/RR before administration, Error prone
of high alert drugs are only given medical abbreviations are avoided

Every Medical advice and procedure is

ME E7.2 Medication orders are written accompanied with date , time and RR
legibly and adequately signature
Check for the writing, It comprehendible RR/SI
by the clinical staff

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

Check for any open single dose vial with

Check single dose vial are not used for OB left over content kept to be used later
more than one dose on

Check for separate sterile needle is used OB In multi dose vial needle is not left in the
every time for multiple dose vial septum
Any adverse drug reaction is recorded and RR/SI Adverse drug event trigger tool is used
reported to report the events
Administration of medicines done after
ME E7.4 There is a system to ensure right ensuring right patient, right drugs , right SI/OB
medicine is given to right patient route, right time

ME E7.5 Patient is counselled for self drug Patient is advice by doctor/ Pharmacist RR/SI
administration /nurse about the dosages and timings .
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
All the assessments, re-
ME E8.1 assessment and investigations are Day to day progress of patient is recorded RR
recorded and updated in BHT

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

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

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

General order book (GOB), report book,

Admission register, lab register,
Register/records are maintained Registers and records are maintained as Admission sheet/ bed head ticket,
ME E8.6 as per guidelines per guidelines RR discharge slip, referral slip, referral
in/referral out register, OT register, FP
register, Diet register, Linen register,
Drug indent register

All register/records are identified and RR

numbered
The facility ensures safe and
ME E8.7 adequate storage and retrieval of Safe keeping of patient records OB
medical records
Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing Assessment is done before discharging SI/RR
patient readiness patient

Primary illness is resolved, All infections

Maternity ward has established criteria SI/RR and other medical complications have
for discharge been treated, vitals are stable, etc.

Discharge is done by a responsible and

qualified doctor after assessment in SI/RR Discharge is done in consultation with
consultation with treating doctor treating doctor

Patient / attendants are consulted before PI/SI Time of discharge is communicated to

discharge patient in prior
Case summary and follow-up
ME E9.2 instructions are provided at the Discharge summary is provided RR/PI See for discharge summary, referral slip
discharge provided.

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Discharge summary adequately mentions
patients clinical condition, treatment RR
given and follow up
Discharge summary is give to patients SI/RR
going in LAMA/Referral

Advice includes the information about

Counselling services are provided the nearest health centre for further
ME E9.3 as during discharges wherever Patient is counselled before discharge SI/PI follow up. Counsel mother for
required treatment, follow up, feeding, discharge
timings are explained prior

Advice includes the information about the RR/SI

nearest health centre for further follow up

Time of discharge is communicated to PI/SI

patient in prior

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management

ME E11.3 The facility has disaster Staff is aware of disaster plan SI/RR
management plan in place
Role and responsibilities of staff in SI/RR
disaster is defined

Standard E12 The facility has defined and established procedures of diagnostic services

ME E12.1 There are established procedures Container is labelled properly after the OB
for Pre-testing Activities sample collection

ME E12.3 There are established procedures Nursing station is provided with the SI/RR
for Post-testing Activities critical value of different tests

Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.

ME E13.9 There is established procedure for Consent is taken before transfusion RR

transfusion of blood
Patient's identification is verified before SI/OB
transfusion
blood is kept on optimum temperature RR
before transfusion

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Blood transfusion is monitored and SI/RR
regulated by qualified person
Blood transfusion note is written in RR
patient recorded
There is a established procedure Any major or minor transfusion reaction is
ME E13.10 for monitoring and reporting recorded and reported to responsible RR
Transfusion complication person

Standard E14 The facility has established procedures for Anaesthetic Services

The facility has established

ME E14.1 procedures for Pre-anaesthetic Pre anaesthesia check up is conducted for SI/RR
Check up and maintenance of elective / Planned surgeries
records

Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients

Death of admitted patient is

ME E16.1 adequately recorded and Facility has a standard procedure to SI
communicated decent communicate death to relatives

Death note is written on patient record RR

The facility has standard Death summary is given to patient
ME E16.2 procedures for handling the death attendant quoting the immediate cause SI/RR Maintenance of records as per guideline
in the hospital and underlying cause if possible
Death note including efforts done for RR Maternal and neonatal death
resuscitation is noted in patient record

Standard E17 The facility has established procedures for Antenatal care as per guidelines

There is an established procedure

ME E17.1 for Registration and follow up of Facility provides and updates “Mother and RR/SI
pregnant women. Child Protection Card”.

There is an established procedure

for identification of High risk
ME E17.4 pregnancy and appropriate Management of PIH/Eclampsia RR/SI
treatment/referral as per scope of
services.
Management of sepsis RR/SI
Management of diabetic pregnant mother RR/SI

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Management of cardiac cases RR/SI
Management of IUGR RR/SI

There is an established procedure

ME E17.5 for identification and management Management of of severe anaemia RR/SI Blood Transfusion services available for
of moderate and severe anaemia anaemic patients

Standard E19 The facility has established procedures for postnatal care as per guidelines

Facility staff adheres to protocol Maintains hand hygiene, keeps the baby
for assessment of condition of wrapped (maintains temperature),
ME E19.1 mother and baby and providing Post Partum Care of Newborn SI/RR Checks weight, temperature, respiration,
adequate postpartum care heart rate, colour of skin and cord stump

Checks and discusses with the mother on

breastfeeding pattern, emphasising
Initiation of Breastfeeding with in 1 Hour PI exclusive and on demand feeding.
Demonstrates the proper positioning
and attachment of the baby

Check uterine contraction, bleeding as

Post partum care of mother PI per treatment plan, check for TPR and
output chart, Breast examination and
milk initiation and perineal washes

Facility staff adheres to protocol Counsels on danger signs to mother at

for counselling on danger signs, time of discharge; Counsels on post
ME E19.2 post-partum family planning and Staff counsels mother on vital issues PI/SI partum family planning to mother at
exclusive breast feeding discharge; Counsels on exclusive breast
feeding to mother at discharge

Facility staff adheres to protocol

ME E19.3 for ensuring care of newborns Facilitates specialist care in newborn SI/RR Facilitates specialist care in newborn
with small size at birth <1800 gm <1800 gm (seen by paediatrician)

Facilitates assisted feeding whenever SI/RR/PI

required
Facilitates thermal management including SI/RR/PI
kangaroo mother care

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The facility has established
ME E19.4 procedures for There is established criteria for shifting SI/RR
stabilization/treatment/referral of newborn to SNCU
post natal complications

The facility ensure adequate stay

ME E19.5 of mother and new born in a safe 48 Hour Stay of mothers and new born
environment as per standard after delivery
protocols

There is established procedure for Check patient is explained about follow up

ME E19.6 discharge and follow up of mother visits, advice and counselling is done RR/PI
and newborn. before discharge

Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines

ME E20.1 The facility provides immunization Zero dose vaccines are given RR Check for records BCG, Hepatitis Band
services as per guidelines OPV 0 given to New born

Premature and LBW babies are

identified: Weight less than 2500 g for
Management of Low birth weight low birth weight babies, gestation of
ME E20.3 newborns is done as per Care of Low Birth Weight and Premature SI/RR less than 37 weeks for prematurely,
guidelines babies Kangaroo Mother Care (KMC) is
implemented for Low Birth
Weight/Prematurely and assisted
feeding arranged, if required

Area of Concern - F Infection Control

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection
Patients are observed for any sign and
ME F1.3 The facility measures hospital There is procedure to report cases of SI/RR symptoms of HAI like fever, purulent
associated infection rates Hospital acquired infection discharge from surgical site .
There is Provision of Periodic
ME F1.4 Medical Check-up and There is procedure for immunization of SI/RR Hepatitis B, Tetanus Toxoid etc
immunization of staff the staff

Periodic medical check-ups of the staff SI/RR

The facility has established

ME F1.5 procedures for regular monitoring Regular monitoring of infection control SI/RR Hand washing and infection control
of infection control practices practices audits done at periodic intervals

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ME F1.6 The facility has defined and Check for Doctors are aware of Hospital SI/RR
established antibiotic policy Antibiotic Policy
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
ME F2.1 Hand washing facilities are Availability of hand washing Facility at OB Check for availability of wash basin near
provided at point of use Point of Use the point of use

Availability of running Water OB/SI Ask to Open the tap. Ask Staff water
supply is regular
Availability of antiseptic soap with soap OB/SI Check for availability/ Ask staff if the
dish/ liquid antiseptic with dispenser. supply is adequate and uninterrupted

Availability of Alcohol based Hand rub OB/SI Check for availability/ Ask staff for
regular supply.
Prominently displayed above the hand
Display of Hand washing Instruction at OB washing facility , preferably in Local
Point of Use language

The facility staff is trained in hand

ME F2.2 washing practices and they adhere Adherence to 6 steps of Hand washing SI/OB Ask of demonstration
to standard hand washing
practices
Staff aware of when to hand wash SI
The facility ensures standard
ME F2.3 practices and materials for Availability of Antiseptic Solutions OB
antisepsis
like before giving IM/IV injection,
Proper cleaning of procedure site with OB/SI drawing blood, putting Intravenous and
antisepsis urinary catheter
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate
ME F3.1 personal protection Equipment as Clean gloves are available at point of use OB/SI
per requirements
Availability of Masks OB/SI
The facility staff adheres to
ME F3.2 standard personal protection No reuse of disposable gloves, Masks, OB/SI
practices caps and aprons.

Compliance to correct method of wearing SI

and removing the gloves
Standard F4 The facility has standard procedures for processing of equipment and instruments

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The facility ensures standard Ask staff about how they decontaminate
practices and materials for Decontamination of operating & the procedure surface like Examination
ME F4.1 decontamination and cleaning of Procedure surfaces SI/OB table , Patients Beds Stretcher/Trolleys
instruments and procedures areas etc.
(Wiping with 0.5% Chlorine solution

Ask staff how they decontaminate the

instruments like Stethoscope, Dressing
Proper Decontamination of instruments SI/OB Instruments, Examination Instruments,
after use Blood Pressure Cuff etc
(Soaking in 0.5% Chlorine Solution,
Wiping with 0.5% Chlorine Solution or
70% Alcohol as applicable

Contact time for decontamination is SI/OB 10 minutes

adequate
Cleaning of instruments after SI/OB Cleaning is done with detergent and
decontamination running water after decontamination
Proper handling of Soiled and infected SI/OB No sorting ,Rinsing or sluicing at Point of
linen use/ Patient care area

Staff know how to make chlorine solution SI/OB

The facility ensures standard

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

High level Disinfection of

instruments/equipment is done as per OB/SI Ask staff about method and time
protocol required for boiling

Autoclaved dressing material is used OB/SI

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
The facility ensures availability of
ME F5.2 standard materials for cleaning Availability of disinfectant as per OB/SI Chlorine solution, Glutaraldehyde,
and disinfection of patient care requirement carbolic acid
areas
Availability of cleaning agent as per OB/SI Hospital grade phenyl, disinfectant
requirement detergent solution

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The facility ensures standard
ME F5.3 practices are followed for the Staff is trained for spill management SI/RR
cleaning and disinfection of
patient care areas
Cleaning of patient care area with SI/RR
detergent solution
Staff is trained for preparing cleaning SI/RR
solution as per standard procedure
Standard practice of mopping and OB/SI Unidirectional mopping from inside out
scrubbing are followed
Any cleaning equipment leading to
Cleaning equipment like broom are not OB/SI dispersion of dust particles in air should
used in patient care areas be avoided

ME F5.4 The facility ensures segregation Isolation and barrier nursing procedure OB/SI
infectious patients 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.

The facility Ensures segregation of

Bio Medical Waste as per Availability of colour coded bins at point Adequate number. Covered. Foot
ME F6.1 guidelines and 'on-site' of waste generation OB operated.
management of waste is carried
out as per guidelines

Availability of colour coded non OB

chlorinated plastic bags

Human Anatomical waste, Items

contaminated with blood, body fluids,
Segregation of Anatomical and soiled dressings, plaster casts, cotton swabs
waste in Yellow Bin OB/SI and bags containing residual or
discarded blood and blood components.

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Items such as tubing, bottles,

intravenous tubes and sets, catheters,
Segregation of infected plastic waste in urine bags, syringes (without needles
red bin OB and fixed needle syringes) and
vacutainers' with their needles cut) and
gloves

Display of work instructions for

segregation and handling of Biomedical OB Pictorial and in local language
waste
There is no mixing of infectious and OB
general waste

ME F6.2 The facility ensures management Availability of functional needle cutters OB See if it has been used or just lying idle.
of sharps as per guidelines

Should be available nears the point of

Segregation of sharps waste including generation. Needles, syringes with fixed
Metals in white (translucent) Puncture needles, needles from needle tip cutter
proof, Leak proof, tamper proof OB or burner, scalpels, blades, or any other
containers contaminated sharp object that may
cause puncture and cuts. This includes
both used, discarded and contaminated
metal sharps

Availability of post exposure prophylaxis SI/OB Ask if available. Where it is stored and
who is in charge of that.
Staff knows what to do in case of shape
Staff knows what to do in condition of SI injury. Whom to report. See if any
needle stick injury reporting has been done

Contaminated and broken Glass are

disposed in puncture proof and leak proof OB Vials, slides and other broken infected
box/ container with Blue colour marking glass

The facility ensures transportation

ME F6.3 and disposal of waste as per Check bins are not overfilled SI/OB
guidelines
Transportation of bio medical waste is
done in close container/trolley

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Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to locate mercury
beads
5. Use syringe without a
needle/eyedropper and sticky tape to
suck the beads
6. Collection of beads in leak-proof bag
Staff is aware of mercury spill SI/RR or container
management 7. Sprinkle sulphur or zinc powder to
remove any remaining mercury
8. All the mercury spill surfaces should
be decontaminated with 10% sodium
thiosulfate solution
9. All the bags or containers containing
items contaminated with mercury should
be marked as “Hazardous Waste, Handle
with Care”
10. Collected mercury waste should be
handed over to the CBMWTF
Area of Concern - G Quality Management
Standard G1 Facility has established organizational framework for quality improvement
There is a designated departmental nodal
ME G1.1 Facility has a quality team in place person for coordinating Quality Assurance SI/RR
activities
Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient satisfaction surveys are Client/Patient satisfaction survey done on RR
conducted at periodic intervals monthly basis
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.
There is system daily round by
The facility has established matron/hospital manager/ hospital
ME G3.1 internal quality assurance superintendent/ Hospital Manager/ SI/RR
programme in key departments Matron in charge for monitoring of
services

Facility has established system for

ME G3.3 use of check lists in different Internal assessment is done at periodic RR/SI NQAS assessment toolkit is used to
departments and services interval conduct internal assessment

Departmental checklist are used for SI/RR Staff is designated for filling and
monitoring and quality assurance monitoring of these checklists

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Non-compliances are enumerated and RR Check the non compliances are

recorded presented & discussed during quality
team meetings

Actions are planned to address Check action plans are prepared and Randomly check the details of action,
ME G3.4 gaps observed during quality implemented as per internal assessment RR responsibility, time line and feedback
assurance process record findings mechanism

Planned actions are implemented Check PDCA or prevalent quality method Check actions have been taken to close
ME G3.5 through Quality Improvement is used to take corrective and preventive SI/RR the gap. It can be in form of action taken
Cycles (PDCA) action report or Quality Improvement (PDCA)
project report

Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Standard operating procedure for

ME G4.1 Departmental standard operating department has been prepared and RR
procedures are available approved
Current version of SOP are available with OB/RR
process owner
Patient safety, Identification of danger
Work instruction/clinical protocols are OB sign, postnatal care and counselling, new
displayed born care etc

Standard Operating Procedures Department has documented procedure

ME G4.2 adequately describes process and for receiving and initial assessment of the RR
procedures patient in Maternity ward

Department has documented procedure

for admission, shifting and referral of RR
pregnant mother

Department has documented procedure RR

for shifting the mother to labour room

Department has documented procedure

for requisition of diagnosis and receiving RR
of the reports

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Department has documented procedure
for preparation of the patient for surgical RR
procedure

Department has documented procedure RR

for transfusion of blood in maternity ward

Department has documented procedure

for maintenance of rights and dignity of RR
pregnant women
Department has documented procedure
for record Maintenance including taking RR
consent
Department has documented procedure
for discharge of the patient from RR
maternity ward

Department has documented procedure RR

for post natal inpatient care of mother

Department has documented procedure RR

for post natal inpatient care of new born

Department has documented procedure RR

for payment/ incentives of beneficiary

Department has documented procedure

for counselling of the patient at the time RR
of discharge
Maternity ward has documented
procedure for environmental cleaning and RR
processing of the equipment
Maternity ward has documented
procedure for arrangement of RR
intervention for maternity ward
Maternity ward has documented
procedure for sorting, cleaning and RR
distribution of clean linen to patient

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Maternity ward has documented
procedure for providing free diet to the RR
patient as per their requirement
Department has documented procedure RR
for end of life care

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

Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

ME G5.1 The facility maps its critical Process mapping of critical processes SI/RR
processes done
The facility identifies non value
ME G5.2 adding activities / waste / Non value adding activities are identified SI/RR
redundant activities

ME G5.3 The facility takes corrective action Processes are rearranged as per SI/RR
to improve the processes requirement
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Check short term valid quality

objectivities have been framed
Facility has de defined quality Check if SMART Quality Objectives have addressing key quality issues in each
ME G6.4 objectives to achieve mission and framed SI/RR department and cores services. Check if
quality policy these objectives are Specific,
Measurable, Attainable, Relevant and
Time Bound.

Mission, Values, Quality policy and Interview with staff for their awareness.
objectives are effectively Check of staff is aware of Mission , Values, Check if Mission Statement, Core Values
ME G6.5 communicated to staff and users Quality Policy and objectives SI/RR and Quality Policy is displayed
of services prominently in local language at Key
Points

Review the records that action plan on

quality objectives being reviewed at least
Facility periodically reviews the once in month by departmental in
ME G6.7 progress of strategic plan towards Check time bound action plan is being SI/RR charges and during the quality team
mission, policy and objectives reviewed at regular time interval meeting. The progress on quality
objectives have been recorded in Action
Plan tracking sheet

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Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 The facility uses method for Basic quality improvement method SI/OB PDCA & 5S
quality improvement in services
Advance quality improvement method SI/OB Six sigma, lean.
ME G7.2 The facility uses tools for quality 7 basic tools of Quality SI/RR Minimum 2 applicable tools are used in
improvement in services each department
Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan

Periodic assessment for Verify with the records. A

Medication and Patient care safety Check periodic assessment of medication comprehensive risk assessment of all
ME G9.6 risks is done as per defined and patient care safety risk is done using SI/RR clinical processes should be done using
criteria. defined checklist periodically pre define criteria at least once in three
month.

Periodic assessment for potential 1. Check that the filled checklist and
risk regarding safety and security SaQushal assessment toolkit is used for action taken report are available
ME G9.7 of staff including violence against safety audits. SI/RR 2. Staff is aware of key gaps & closure
service providers is done as per status
defined criteria

ME G9.8 Risks identified are analysed Identified risks are analysed for severity SI/RR Action is taken to mitigate the risks
evaluated and rated for severity

Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

Check parameter are defined &

implemented to review the clinical care
Clinical care assessment criteria The facility has established process to i.e. through Ward round, peer review,
ME G10.3 have been defined and review the clinical care SI/RR morbidity & mortality review, patient
communicated feedback, clinical audit & clinical
outcomes.

(1) Both critical and stable patients

Check regular ward rounds are taken to SI/RR (2) Check the case progress is
review case progress documented in BHT/ progress notes-
Feedback is taken from patient/family on
Check the patient /family participate in SI/RR health status of individual under
the care evaluation treatment

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Reference no Measurable Element Checkpoints Compliance Assessment Means of verification Remarks

method
System in place to review internal
Check the care planning and co- SI/RR referral process, review clinical handover
ordination is reviewed information, review patient
understanding about their progress

Check medical audit records

(a) Completion of the medical records
i.e. Medical history, assessments, re
assessment, investigations conducted,
progress notes, interventions conducted,
outcome of the case, patient education,
delineation of responsibilities, discharge
Facility conducts the periodic etc.
ME G10.4 clinical audits including There is procedure to conduct medical SI/RR (b) Check whether treatment plan
prescription, medical and death audits worked for the patient
audits (C) progress on the health status of the
patient is mentioned
(d) whether the goals defined in
treatment plan is met for the individual
cases
(e) Adverse clinical events are
documented
(f) Re admission

(1) All the deaths are audited by the

committee.
(2) The reasons of the death is clearly
mentioned
There is procedure to conduct death (3) Data pertaining to deaths are collated
audits SI/RR and trend analysis is done
(4) A through action taken report is
prepared and presented in clinical
Governance Board meetings / during
grand round (wherever required)

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Reference no Measurable Element Checkpoints Compliance Assessment Means of verification Remarks

method

(1) Random prescriptions are audited

(2) Separate Prescription audit is
conducted foe both OPD & IPD cases
There is procedure to conduct SI/RR (3) The finding of audit is circulated to all
prescription audits concerned
(4) Regular trends are analysis and
presented in Clinical Governance
board/Grand round meetings

All non compliance are enumerated SI/RR Check the non compliances are
recorded for medical audits presented & discussed during clinical
Governance meetings

All non compliance are enumerated SI/RR Check the non compliances are
recorded for death audits presented & discussed during clinical
Governance meetings

All non compliance are enumerated SI/RR Check the non compliances are
recorded for prescription audits presented & discussed during clinical
Governance meetings

Clinical care audits data is Check action plans are prepared and Randomly check the actual compliance
ME G10.5 analysed, and actions are taken to implemented as per medical audit record SI/RR with the actions taken reports of last 3
close the gaps identified during findings months
the audit process

Check action plans are prepared and Randomly check the actual compliance
implemented as per death audit record's SI/RR with the actions taken reports of last 3
findings months
Check action plans are prepared and Randomly check the actual compliance
implemented as per prescription audit SI/RR with the actions taken reports of last 3
record findings months
Check collected data is analysed & areas
Check the data of audit findings are SI/RR for improvement is identified &
collated prioritised

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method

Check the critical problems are regularly

Check PDCA or revalent quality method is monitored & applicable solutions are
used to address critical problems SI/RR duplicated in other departments
(wherever required) for process
improvement

Facility ensures easy access and

use of standard treatment Check standard treatment guidelines / Staff is aware of Standard treatment
ME G10.7 guidelines & implementation tools protocols are available & followed. SI/RR protocols/ guidelines/best practices
at
point of care

Check treatment plan is prepared as per SI/RR Check staff adhere to clinical protocols
Standard treatment guidelines while preparing the treatment plan

Check the drugs are prescribed as per SI/RR Check the drugs prescribed are available
Standards treatment guidelines in EML or part of drug formulary

Check when the

Check the updated/latest evidence are STG/protocols/evidences used in
available SI/RR healthcare facility are published.
Whether the STG protocols are
according to current evidences.

The gaps in clinical practices are

Check the mapping of existing clinical identified & action are taken to improve
practices processess is done SI/RR it. Look for evidences for improvement
in clinical practices using PDCA

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method
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Bed Occupancy Rate for normal delivery RR
Indicators on monthly basis ward
Bed Occupancy Rate for C section ward
Proportion of Severe anaemia cases RR
treated with blood transfusion
The proportion of high-risk pregnancies RR GDM, hypothyroidism & syphilis
managed
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Referral Rate RR
Indicators on monthly basis
Bed Turnover rate RR
Discharge rate RR
No. of drugs stock out in the ward RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

ME H3.1 Facility measures Clinical Care & Average length of stay for normal delivery RR
Safety Indicators on monthly basis

Average length of stay for Surgical Cases RR (a) C Section Cases

(b) Hysterectomy Cases
Newborns Breastfed within 1 hr of Birth RR
Maternal Death per 1000 deliveries RR
No of adverse events per thousand RR
patients
Proportion of mother given postnatal RR
counselling
Time taken for initial assessment RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

ME H4.1 Facility measures Service Quality LAMA Rate RR

Indicators on monthly basis

Patient Satisfaction Score RR

Proportion of mothers given drop back RR
facility

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National Quality Assurance Standards for District Hospitals

Checklist for Paediatric Outdoor Patient Department

Assessment Summary
Name of the Hospital GHQH Erode
Names of Assessors [Link], Merina Unice S/N
Type of Assessment (Internal/External) Internal
Paediatric
OPD Score
Card Area of Concern wise Score
A Service Provision 83%
B Patient Rights 75%
C Inputs 83%
D Support Services 80%
E Clinical Services 88%
F Infection Control 88%
G Quality Management 79%
Outcome
H 97%

Major Gaps Observed

1 There is no chaos and over crowding in the OPD

2 Patient records are maintained for the cases availing the telemedicine services
3 Emergency protocols for management of paediatric conditions are available
4 Privacy at the counselling room is maintained
5 Functional toilets with running water and flush are available
Strengths / Good Practices

2
3
4
5
Recommendations/ Opportunities for
1 Improvement
2
3
4
5
Signature of Assessors
Date

Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Area of Concern - A Service Provision

Standard A1 Facility Provides Curative Services

ME A1.4 The facility provides Paediatric Services Availability of Paediatric Clinic SI/OB
2

Availability of services for early identification and SI/OB

intervention of 4 D's 2
ME A1.5 The facility provides Ophthalmology Services Availability of functional Ophthalmology Clinic SI/OB
2

ME A1.6 The facility provides ENT Services Availability of Functional ENT Clinic SI/OB
2

Availability of OPD ENT procedures SI/OB

ME A1.7 The facility provides Orthopaedics Services Availability of Functional Orthopaedic Clinic SI/OB
1

Availability of OPD Orthopaedic procedure SI/OB

2

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

ME A1.8 The facility provides Skin & VD Services Availability of functional Skin & VD Clinic SI/OB
2

ME A1.10 The facility provides Dental Treatment Services Availability of functional Dental Clinic SI/OB
2

Availability of OPD Dental procedure SI/OB

1

ME A1.11 The facility provides AYUSH Services Availability of Functional Ayush clinic SI/OB
1

ME A1.12 The facility provides Physiotherapy Services Availability of Functional Physiotherapy Unit SI/OB
2

ME A1.13 The facility provides services for OPD procedures Availability of Dressing facilities at OPD 1 SI/OB
Availability of Injection room facilities at OPD 2 SI/OB
ME A1.14 Services are available for the time period as mandated Check OPD Services are available at least for 6 hours SI/RR
2

Check emergency services are provided to paediatric SI/RR

cases even after OPD hrs

ME A1.16 The facility provides Accident & Emergency Services Availability of services for ETAT 1 SI/OB
Availability of services for sexually assaulted child SI/OB
2
Standard A2
Facility provides RMNCHA Services
ME A2.3 The facility provides Newborn health Services Availability of immunization services 2 SI/OB
ME A2.4 The facility provides Child health Services Availability of Functional IYCF clinic SI/OB
1
Availability of promotion services of overall growth and SI/OB
development of children 1

Standard A3
Facility Provides diagnostic Services
ME A3.1 The facility provides Radiology Services Availability of Functional Radiology Services SI/OB
2
ME A3.2 The facility Provides Laboratory Services Availability of functional laboratory services SI/OB
2
Standard A4
Facility provides services as mandated in national Health Programs/ state scheme
ME A4.12 The facility provides services as per Rashtriya Bal Swasthya Screening and early detection of 4 Ds SI/RR
Karykram 2
Availability of DEIC SI/RR
2

Standard A5
Facility provides support services
ME A5.3 The facility provides security services Availability of security services 1 SI/OB
ME A5.4 The facility provides housekeeping services Availability of Housekeeping services 2 SI/OB
ME A5.6 The facility provides pharmacy services Availability of drug storage and dispensing services 2 SI/OB
Standard A6
Health services provided at the facility are appropriate to community needs.
ME A6.1 The facility provides curatives & preventive services for Special Clinics are available for local prevalent diseases/ SI/OB
the health problems and diseases, prevalent locally. endemics
1

Area of Concern - B Patient Rights

Standard B1
Facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 OB

1
The facility has uniform and user-friendly signage
system Availability of departmental & directional signages
OB
1
Display of layout/floor directory
ME B1.2 OB

The facility displays the services and entitlements

available in its departments Information regarding services are displayed
OB
1
Names of doctor on duty is displayed and updated
Entitlement under JSSK , RBSK, PMJAY and other OB
2
schemes are displayed

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

ME B1.3 OB

The facility has established citizen charter, which is

followed at all levels Display of citizen charter in OPD complex
ME B1.4 OB

2
User charges are displayed and communicated to
patients effectively User charges for services are displayed
ME B1.5 OB
Patients & visitors are sensitised and educated through 1
appropriate IEC / BCC approaches IEC Material is displayed
Education material for counselling are available in OB
1
Counselling room
No display of poster/ placards/ pamphlets/videos in any OB
part of the Health facility for the promotion of breast
2
milk substitute , feeding bottles, teats or any product as
mentioned under IMS Act
OB
No display of items and logos of companies that produce
breast milk substitute, feeding bottles, teats or any 2
product as mentioned under IMS Act

OB
No information, counselling and educational material is
0
provided to mothers and families on Formula Feed

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

2
understand Signages and information are available in local language
ME B1.7 The facility provides information to patients and visitor OB/SI
2
through an exclusive set-up. Availability of Enquiry Desk with dedicated staff
ME B1.8 The facility ensures access to clinical records of patients RR/OB
2
to entitled personnel OPD slip with UID is given to the patient
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 economic, cult
ME B2.1 Services are provided in manner that are sensitive to OB
2
gender Availability of Breast feeding corner
Availability of female staff if a male doctor examines a OB
female patient
2

OB
0
Separate toilets for male and female
ME B2.3 OB
1
Access to facility is provided without any physical
barrier and friendly to people with disabilities Dedicated registration counter for paediatric cases
OB
2
Registration to drug processes are hassle free.
Availability of Wheel chair or stretcher for easy Access to OB
1
the OPD
Availability of ramps with railing 2 OB
There is no chaos and over crowding in the OPD 0 OB
OB
0
Availability of differently abled toilet
Availability of children friendly toilet OB

Standard B3 Facility maintains the privacy, confidentiality &

Dignity of patient, and has a system for
guarding patients related information
ME B3.1 Adequate visual privacy is provided at every point of OB
2
care Availability of screen/curtain at Examination Area
Availability of screen/curtain at breastfeeding corner OB

OB
0
One Patient is seen at a time in clinics
OB
2
Privacy at the counselling room is maintained
ME B3.2 Confidentiality of patients records and clinical Records are placed at secure place beyond access to SI/OB
information is maintained general staff and visitor
2

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

ME B3.4 The facility ensures privacy and confidentiality to every Privacy and confidentiality of health conditions having PI/OB
patient, especially of those conditions having social social stigma are maintained
stigma, and also safeguards vulnerable groups
2

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Reference No. Measurable Element Checkpoint Assessment Method

Facility has defined and established Compliance
procedures for informing patients about the
Standard B4 medical condition, and involving them in
treatment planning, and facilitate informed
decision making patient.
ME B4.1 RR /PI
There is established procedures for taking informed 2
Informed consent is taken from parent/guardian before
consent before treatment and procedures any investigation
ME B4.2 Patient is informed about his/her rights and OB
2
responsibilities Display of patient rights and responsibilities.
ME B4.4 Parent- attendant is informed about the clinical PI
condition and treatment been provided

Information about the treatment is shared with patients

or attendants, regularly
Pre and Post procedure counselling is given PI/RR

ME B4.5 The facility has defined and established grievance OB

Availability of complaint box and display of process for 2
redressal system in place grievance redressal and whom 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.
ME B5.1 Free OPD Consultation PI/SI

The facility provides cashless services to pregnant 2

women, mothers and neonates as per prevalent
government schemes
ME B5.2 Check that patient party has not spent on purchasing PI/SI
drugs or consumables from outside.

The facility ensures that drugs prescribed are available

at Pharmacy and wards
ME B5.3 It is ensured that facilities for the prescribed Check that patient party has not spent on diagnostics PI/SI
from outside. 1
investigations are available at the facility
ME B5.4 Free OPD Consultation for BPL patients PI/RR
The facility provide free of cost treatment to Below 2
poverty line patients without administrative hassles
ME B5.5 If any other expenditure occurred it is reimbursed from PI/RR
The facility ensures timely reimbursement of financial hospital
2
entitlements and reimbursement to the patients
Standard B6
Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facil
ME B6.9 There is an established procedure to issue of medical Check hospital has documented policy for issuing RR/PI
certificates and other certificates medical certificates

Check hospital has documented policy for issuing RR/PI

disability certificates under RBSK

Area of Concern - C Inputs

Standard C1
The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
ME C1.1 Departments have adequate space as per patient or Clinic has adequate space for consultation and OB
work load examination 2
Availability of adequate waiting area OB

ME C1.2 Patient amenities are provide as per patient load Availability of seating arrangement in waiting area OB

Availability of sub waiting for separate clinics OB

0

Availability of Drinking water 2 OB

Functional toilets with running water and flush are OB
available
0

ME C1.3 Departments have layout and demarcated areas as per Dedicated examination area is provided with each clinics OB
functions 2
Demarcated area for the assessment and OB
examination of medico-legal cases 2
Demarcated dressing area /room & injection room 2 OB
OB
Dedicated IYCF Counselling Centre 1
Dedicated immunization room for children 2 OB
OPD has separate entry and exit from IPD and OB
Emergency 2

Availability of clean and dirty utility room 1 OB

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Demarcated Drug dispensing counter for paediatric OB

patients 2
Check paediatric complex/services are away from OB
isolation and restricted areas 1
Demarcated trolley/wheelchair bay 0 OB
ME C1.4 The facility has adequate circulation area and open Corridors at OPD are broad enough to manage stretcher OB
spaces according to need and local law and trolleys 1
ME C1.5 The facility has infrastructure for intramural and Availability of functional telephone and Intercom OB
extramural communication Services in clinics 2
ME C1.7 The facility and departments are planned to ensure Unidirectional flow of services OB
structure follows the function/processes (Structure
commensurate with the function of the hospital)

All clinics and related auxiliary services are co located in OB

one functional area
2

Standard C2
The facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the seismic safety of the Non structural components are properly secured OB
infrastructure 1

ME C2.3 The facility ensures safety of electrical establishment OPD building does not have temporary connections and OB
loosely hanging wires

ME C2.4 Physical condition of buildings are safe for providing Floors of the department is non slippery and even OB
patient care
2

Paediatric OPD is safe and secure OB

Windows have grills and wire meshwork 2 OB

Standard C3
The facility has established Programme for fire safety and other disaster
ME C3.1 The facility has plan for prevention of fire OPD has sufficient fire exit to permit safe escape to its OB
occupant at time of fire

ME C3.2 The facility has adequate fire fighting Equipment OPD has installed fire Extinguisher that is Class A , Class OB
B, C type or ABC type
2

ME C3.3 The facility has a system of periodic training of staff and Check for staff competencies for operating fire SI/RR
conducts mock drills regularly for fire and other disaster extinguisher and what to do in case of fire
situation 1

Standard C4
The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
ME C4.1 The facility has adequate specialist doctors as per Availability of paediatric specialist at OPD time OB/RR
service provision 2

ME C4.2 The facility has adequate general duty doctors as per Availability of General duty doctor OB/RR
service provision and work load 2

Availability of Dentist OB/RR

2
ME C4.3 The facility has adequate nursing staff as per service Availability of Nursing staff OB/RR/SI
provision and work load 2

ME C4.4 The facility has adequate technicians/paramedics as per Availability of paramedical staff OB/SI
requirement

Availability of staff for lab SI/RR

2

Availability of Nutrition Counsellor SI/RR

Availability of technician/ Assistant SI/RR

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Availability of Physiotherapist & rehabilitation therapist SI/RR

Availability of dedicated staff for DEIC as per RBSK SI/RR

guideline

ME C4.5 The facility has adequate support / general staff Availability of house keeping staff & security guards 1 SI/RR
Availability of registration clerks as per load 1 SI/RR
Standard C5
Facility provides drugs and consumables required for assured list of services.
ME C5.1 The departments have availability of adequate medicine OB/RR
at point of use Availability of injectables at injection room 2

Analgesics/ Antipyretics/Anti inflammatory 2 OB/RR

Antibiotics 2 OB/RR
Anti Diarrhoeal 2 OB/RR
Antiseptic lotion 2 OB/RR
Dressing material 2 OB/RR
IV fluids 2 OB/RR
Eye and ENT drops 2 OB/RR
Anti allergic 2 OB/RR
medicine acting on Digestive system 2 OB/RR
medicine acting on cardio vascular system 2 OB/RR
medicine acting on central/Peripheral Nervous system 2 OB/RR
medicine acting on respiratory system 2 OB/RR
Other medicine and materials 2 OB/RR
Availability of vaccine as per National Immunization OB/RR
Program 2
ME C5.2 The departments have adequate consumables at point Availability of disposables at dressing room and OB/RR
of use clinics 2
ME C5.3 Emergency drug trays are maintained at every point of Emergency Drug Tray is maintained at immunization OB/RR
care, where ever it may be needed room

Emergency Drug Tray is maintained at injection cum OB/SI

treatment room in OPD

Standard C6
The facility has equipment & instruments required for assured list of services.
ME C6.1 Availability of equipment & instruments for Availability of functional Equipment &Instruments OB/RR
examination & monitoring of patients for examination & Monitoring
2

ME C6.2 Availability of equipment & instruments for treatment Availability of functional equipment &Instruments for OB/RR
procedures, being undertaken in the facility paediatric clinic

Availability of functional equipment &Instruments for OB/RR

IYCF nutrition counselling

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Availability of functional Equipment/Instruments for OB/RR

emergency Procedures

Availability of functional Equipment/Instruments for OB

Orthopaedic Procedures
2

Availability of functional Instruments / Equipment OB

for Ophthalmic Procedures
2

Availability of Instruments/ Equipment Procedures OB

for ENT procedures 2

Availability of functional Instruments/ Equipment OB

for Dental Procedures 2

Availability of functional Equipment/Instruments for OB

Physiotherapy Procedures 2

ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for drugs OB
2
Availability of equipment for maintenance of cold OB
chain 2
ME C6.6 Availability of functional equipment and instruments for Availability of equipment for cleaning & disinfection OB
support services 2

Availability of equipment for sterilization 2 OB

ME C6.7 Departments have patient furniture and fixtures as per Availability of Fixtures OB
load and service provision 2
Availability of furniture at clinics OB
2

Standard C7

Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance o

ME C7.1 Criteria for Competence assessment are defined for clinical Check parameters for assessing skills and proficiency of SI/RR
and Para clinical staff clinical staff has been defined 2

ME C7.2 Check for competence assessment is done at least once SI/RR

in a year 2
Competence assessment of Clinical and Para clinical staff is
done on predefined criteria at least once in a year
ME C7.9 The Staff is provided training as per defined core Training on Infection prevention & patient safety SI/RR
1
competencies and training plan
Training on IYCF SI/RR

Training for RBSK 1 SI/RR

Training on F-IMNCI 1 SI/RR
Training on Quality Management SI/RR
1
ME C7.10 There is established procedure for utilization of skills gained Check facility has system of on job monitoring and SI/RR
thought trainings by on -job supportive supervision training
1

Area of Concern - D Support Services

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

There is system of timely corrective break down SI/RR

maintenance of the equipment
2

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

Standard D2
The facility has defined procedures for storage, inventory management and dispensing of Medicines in pharmacy and patient care are
ME D2.1 There is established procedure for forecasting and There is process for indenting consumables and drugs in SI/RR
indenting drugs and consumables injection/ dressing and immunisation room

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Check drugs are available in paediatric OB/RR

doses/formulation

Forecasting of drugs and consumables is done RR/SI

1
scientifically based on consumption and disease load
ME D2.3 The facility ensures proper storage of drugs and Drugs are stored in emergency tray and drugs dispensing OB
consumables counter and are labelled
2

Vaccine are kept at recommended temperature at OB

immunization room
2

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

Expiry dates' are maintained at OB/RR

emergency drug tray and drug dispensing counter 2

No expired drug found 2 OB/RR

ME D2.5 The facility has established procedure for inventory There is practice of calculating and maintaining buffer SI/RR
management techniques stock 1
Department maintains stock and expenditure register of SI/RR
drugs and consumables 2
ME D2.6 There is a procedure for periodically replenishing the drugs There is no stock out of vital and essential drugs SI/RR
in patient care areas 2
ME D2.7 There is process for storage of vaccines and other drugs, Temperature of refrigerators are kept as per storage OB/RR
requiring controlled temperature requirement and records are maintained
2

Cold chain is maintained at immunization room OB/RR

Standard D3
The facility provides safe, secure and comfortable environment to staff, patients and visitors.
ME D3.1 The facility provides adequate illumination level at Adequate Illumination in clinics & procedure area OB
patient care areas 2

ME D3.2 The facility has provision of restriction of visitors in Only one patient is allowed at a time in clinic OB/SI
patient areas 1
Limited number of attendant/ relatives are allowed with OB/SI
patient 1
ME D3.3 The facility ensures safe and comfortable environment Temperature control and ventilation in clinics & waiting PI/OB
for patients and service providers areas 2
ME D3.4 The facility has security system in place at patient care Hospital has sound security system to manage OB/SI
areas overcrowding in OPD
1

ME D3.5 The facility has established measure for safety and security Ask female staff whether they feel secure at work place SI
of female staff 2
Standard D4
The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior & Interior of the facility building is maintained Interior & exterior of patient care areas are plastered , OB
appropriately painted & building are white washed in uniform colour

Ambience of paediatric OPD is bright and child friendly OB

ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof tops, sinks, patient care and OB
circulation areas are Clean
1

Toilets are clean with functional flush and running water OB

1
ME D4.3 Hospital infrastructure is adequately maintained Check for there is no seepage , Cracks, chipping of OB
plaster 1
Patients Examination couch / beds are intact and OB
painted 2
ME D4.4 Hospital maintains the open area and landscaping of Gardens and child zone are well maintained OB
them
0

ME D4.5 The facility has policy of removal of condemned junk No condemned/Junk material lying in the OPD OB
material 2

ME D4.6 The facility has established procedures for pest, rodent No stray animal/rodent/birds OB
and animal control 0

Standard D5
The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
ME D5.1 The facility has adequate arrangement storage and Availability of 24x7 running and potable water OB/SI
supply for portable water in all functional areas 2
ME D5.2 The facility ensures adequate power backup in all Availability of power back up in OPD OB/SI
patient care areas as per load 2
StandardD6
Dietary services are available as per service provision and nutritional requirement of the patients.

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

ME D6.1 The facility has provision of nutritional assessment of Nutritional assessment of patient done as required and RR/SI
the patients directed by doctor
1

Standard D7
The facility ensures clean linen to the patients
ME D7.1 The facility has adequate sets of linen Availability of linen in examination area OB/RR
1
ME D7.2 The facility has established procedures for changing of Cleanliness & Quantity of washed linen is checked. OB/RR
linen in patient care areas 2
Standard D10
Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
ME D10.2 Updated copies of relevant laws, regulations and IMS Act 2003 OB/ RR
government orders are available at the facility

Protection of children from Sexual offenses Act 2012 & OB/ RR

guidelines 2013

Code of Medical ethics 2002 2 OB/ RR

ME D10.3 The facility ensure relevant processes are in compliance No information, counselling and educational PI
with statutory requirement material is provided to mothers and families on 2
Formula Feed for children
Standard D11
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedure
ME D11.2 The facility has a established procedure for duty roster There is procedure to ensure that staff is available on RR/SI
and deputation to different departments duty as per duty roster 2
There is designated in charge for department 2 SI
ME D11.3 The facility ensures the adherence to dress code as Doctor, nursing staff and support staff adhere to their OB
mandated by its administration / the health department respective dress code
2

Standard D12
Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
ME D12.1 There is procedure to monitor the quality and adequacy SI/RR
of outsourced services on regular basis 1
There is established system for contract management for out
sourced services
Area of Concern - E Clinical Services
Standard E1
The facility has defined procedures for registration, consultation and admission of patients.
ME E1.1 The facility has established procedure for registration of Unique identification number & patient demographic RR
patients records are generated during process of registration & 2
admission
Patients are directed to relevant clinic by registration PI/SI
clerk 2
Registration clerk is aware of categories of the patient SI/RR
exempted from user charges 2
ME E1.2 The facility has a established procedure for OPD There is procedure for systematic calling of patients one OB
consultation by one

Patient History is taken and recorded 2 RR

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

Check OPD records for the treatment plan 2 OB/RR

No Patient is Consulted in Standing Position OB
2
Clinical staff is not engaged in administrative work OB/SI
2

ME E1.3 There is established procedure for admission of patients There is establish procedure for admission through OPD SI/RR

There is establish procedure for day care admission SI/RR

2

Standard E2
The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.
ME E2.1 There is established procedure for initial assessment of There is screening clinic for initial assessment of the OB
patients patients

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Compliance

ME E2.2 There is established procedure for follow-up/ Procedure for follow up of patients OB/RR
reassessment of Patients

There is fixed schedule for reassessment of patient

2
under observation SI/RR
There is system in place to identify and manage the
1
changes in Patient's health status SI/RR
Check the treatment or care plan is modified as per re
2
assessment results SI/RR

There is established procedure to plan and deliver

Check treatment/care plan is prepared as per patient's
ME E2.3 appropriate treatment or care to individual as per 2
need
the needs to achieve best possible results

RR

Check treatment / care plan is documented 1

RR
Check care is delivered by competent multidisciplinary
2
team SI/RR
Standard E3
Facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 Facility has established procedure for continuity of care There is a procedure for consultation of the patient SI/RR
during interdepartmental transfer to other specialist with in the hospital 2
ME E3.2 Facility provides appropriate referral linkages to the Facility has defined criteria for referral SI/RR
patients/Services for transfer to other/higher facilities to
assure their continuity of care. 2

Facility has functional referral linkages to higher SI/RR

facilities

Facility has functional referral linkages to lower SI/RR

facilities 2

There is a system of follow up of referred patients RR/PI

2

ICTC has functional Linkages with ART and state RR/SI

reference Labs
2

ME E3.4 Facility is connected to medical colleges through Telemedicine service are used for consultation RR/SI
telemedicine services
0

Patient records are maintained for the cases availing the RR/PI
telemedicine services 0
Standard E5
Facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients and ensure their Vulnerable cases are identified and safe care is given SI/RR/OB
safe care
2

ME E5.2 The facility identifies high risk patients and ensure their For any critical patient needing urgent attention queue OB/SI
care, as per their need can be bypassed for providing services on priority basis 2
Standard E6
Facility ensures rationale prescribing and use
of medicines
ME E6.1 Facility ensured that drugs are prescribed in generic name Check for OPD slip if drugs are prescribed under generic RR
only name only 1
A copy of Prescription is kept with the facility 2 RR
ME E6.2 There is procedure of rational use of drugs Check for that relevant Standard treatment guideline are RR
available at point of use 2

Check staff is aware of the drug regime and doses as per SI/RR
STG 2
Check of drug formulary is available SI/OB
2

ME E6.3
There are procedures defined for medication review and Complete medication history is documented for each
2 RR/OB
optimization patient

Established mechanism for Medication reconciliation

2 SI/RR
process

Medicine are reviewed and optimised as per individual

1 SI/RR
treatment plan

Patients are engaged in their own care 0 PI/SI

Standard E7
Facility has defined procedures for safe drug administration
ME E7.2 Medication orders are written legibly and adequately Every Medical advice and procedure is accompanied RR
with date , time and signature 1
Check for the writing, It is comprehendible by the RR/SI
concerned staff 2

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

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

Any adverse drug reaction is recorded and reported RR/SI

2

Any adverse event following immunisation is recorded RR/SI

and reported 2

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

Check drugs are not given in hand PI/RR

Standard E8
Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re-assessment and investigations Patient History, Chief Complaint and Examination RR
are recorded and updated Diagnosis/ Provisional Diagnosis is recorded in OPD slip 1
ME E8.2 All treatment plan prescription/orders are recorded in Treatment plan and follow up is written RR/PI
the patient records.
2

ME E8.4 Procedures performed are written on patients records Any dressing/injection, other procedure recorded in the RR
OPD slip 2
ME E8.5 Adequate form and formats are available at point of use Check for the availability of OPD slip, Requisition slips OB/SI
etc.
2

ME E8.6 Register/records are maintained as per guidelines OPD records are maintained OB/RR
2
All register/records are identified and numbered 2 OB/RR
ME E8.7 The facility ensures safe and adequate storage and Safe keeping of OPD records OB/SI
retrieval of medical records 2

Standard E11
The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.1 There is procedure for Receiving and triage of patients Emergency & OPD has established & implemented SI/OB
system for sorting of the paediatric patients

Triage area is earmarked OB

Check the procedure is established to identify children SI/OB

with emergency signs in OPD queue 2

Responsibility of receiving & shifting the patient is SI/OB

defined
1

ME E11.2 Emergency protocols are defined and implemented Emergency protocols for management of paediatric SI/RR
conditions are available
0

Check physician follows clinical protocols 1 SI/RR

All the emergency paediatric cases are closely monitored SI/RR

No patient is transferred to ward/ HDU without primary PI/RR

management & stabilization 2

Staff follows stabilisation protocols SI/RR

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Check availability of protocols /guidelines for collection SI/RR

of forensic evidences in case of sexual assault/rape
2

ME E11.3 The facility has disaster management plan in place Staff is aware of disaster plan SI/RR
1

Standard E12
The facility has defined and established procedures of diagnostic services
ME E12.1 There are established procedures for Pre-testing Container is labelled properly after the sample collection OB
Activities

ME E12.3 There are established procedures for Post-testing Clinics are provided with the critical value of different SI/RR
Activities tests
2

Standard E20
The facility has established procedures for care of new born, infant and child as per guidelines
ME E20.1 The facility provides immunization services as per Availability of diluents for Reconstitution of measles RR/SI
guidelines vaccine
2

Recommended temperature of diluents is insured RR/SI

before reconstitution

Reconstituted vaccines are not used after recommended RR/SI

time
2

Time of opening/ Reconstitution of vial is recorded 2 RR

Staff checks VVM level before using vaccines SI
2
Staff is aware of how check freeze damage for T-Series SI
vaccines 2

Staff is aware of applicability of OVP vaccines SI

2

Discarded vaccines are kept separately SI/OB

2
Check for DPT, TT, IPV, HepB, PCV and Penta vaccines SI/OB
vials are not kept in direct contact of ice pack
2

AD syringes are available as per requirement SI/OB

2

Staff knows correct use AD syringe SI

2
Check for AD syringes are not reused 2 OB
Check for injection site is not cleaned with spirit before OB/SI
administering vaccine dose 2
Vaccine recipient is asked to stay for half an hour after OB/PI
vaccination

Check the availability of anaphylaxis kit OB

Check adrenaline is not expired in kit OB

Check person responsible for notifying & reporting of OB

the AEFI is identified

Process of reporting and route is communicated to all OB

concerned

Reporting of AEFI cases is ensured by ANM/ Staff nurse/ SI/RR

person providing immunization

Antipyretic medicines available 2 SI/RR

Availability of Immunization card 2 SI/RR

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Counselling on side effects and follow up visits done 2 SI/RR

Staff is aware of minor and serious adverse events (AEFI) SI
2
Staff knows what to do in case of anaphylaxis 2 SI
ME E20.7 Management of children presenting Staff is able to identify the babies with respiratory SI/RR
with fever, cough or respiratory distress is done as per distress
guidelines
2

Staff is aware of common causes of respiratory distress SI/RR

in new-born

Staff is aware of sign & symptoms of severe pneumonia SI/RR

in children 2 month to 5 yrs.

Staff is aware of assessment & grading of hypothermia SI/RR

Staff is aware of clinical conditions in which baby can SI/RR

exhibit signs of hypothermia

Staff is aware of common causes of hyperthermia SI

Staff is aware of management protocols for SI/RR

hyperthermic babies

Staff is aware of the therapeutic doses of Vitamin D and SI/RR

Calcium Supplementation

ME E20.8 Management of children with severe Screening of children coming to OPDs using weight SI/RR
Acute Malnutrition is done as per guidelines for height and/or MUAC
2

All the children reporting to healthcare facility for any SI/RR

illness are routinely assessed for anaemia

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Staff is aware of categorise of anaemia on basis of HB SI/RR

level among the children

Staff is aware of management of anaemia on basis of Hb SI/RR

Staff is aware of dose of IFA syrup for anaemic children SI/RR

(6 months–5 years)

Staff is aware of clinical manifestation for severe SI/RR

anaemia in children (from 6 month to 10 yrs.)

Staff is aware of indications for blood transfusion due SI/RR

severe anaemia

ME E20.9 Management of children presenting Check for adherence to clinical protocols SI/RR
diarrhoea is done per guidelines
2

Check parents are guided for diarrhoea management SI/RR

Availability of ORT corner SI/RR

2
ME E20.10 Facility ensures optimal breast feeding practices for Availability of services for Assessment of physical growth SI/RR
new born & infants as per guidelines & development of children attending OPD 2
Communication and counselling on optimal infant & SI/RR
young child feeding practices

Communication and counselling of mothers with less SI/RR

breast milk & sick babies on optimal feeding practices

Check staff is aware and follow the protocol for SI/RR

management of cracked nipples and engorged breast
2

Check staff is aware and follow the protocol for SI/RR

management of abscess and inverted nipple
2

Breast milk substitutes are not promoted for newborn or SI/RR

infant unless medically indicated 1

Advise & prescription is given for micronutrient SI/RR

2
supplements (Vitamin A and iron syrup)

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

ME E20.11 The facility provide services under Rashtriya Bal Swasthya Screening of newborns SI/RR
Karyakram (RBSK)

Providing referral services to children for confirmation SI/RR

of diagnosis and treatment 2

Area of Concern - F Infection Control

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-ups and There is procedure for immunization & periodic check- SI/RR
immunization of staff up of the staff 2
ME F1.5 Facility has established procedures for regular Regular monitoring of infection control practices SI/RR
monitoring of infection control practices 1
ME F1.6 Facility has defined and established antibiotic policy Check for Doctors are aware of Hospital Antibiotic Policy SI/RR
2

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 Availability of handwash basin with running water OB/SI
facility at Point of Use
2

Availability of antiseptic soap with soap dish/ liquid OB/SI

antiseptic with dispenser.
1

Display of Hand washing Instruction at Point of Use OB

Handwashing Station is as per specification OB

2
ME F2.2 Staff is trained and adhere to standard hand washing Staff is aware of when and how to handwash SI/OB
practices 2
ME F2.3 Facility ensures standard practices and materials for Availability and Use of Antiseptic Solution OB
antisepsis 1
Standard F3
Facility ensures standard practices and materials for Personal protection
ME F3.1 Facility ensures adequate personal protection Availability of PPE (Gloves, mask, apron & caps ) OB/SI /RR
equipment as per requirements
2

ME F3.2 Staff is adhere to standard personal protection practices No reuse of disposable gloves, Masks, caps and aprons. OB/SI
1
Compliance to correct method of wearing and removing SI/OB
the gloves and masks 2
Standard F4
Facility has standard Procedures for processing of equipment and instruments
ME F4.1 Facility ensures standard practices and materials for Decontamination of Procedural surfaces SI/OB
decontamination and cleaning of instruments and
procedures areas
2

Cleaning of instruments SI/OB

2

Proper handling of Soiled and infected linen SI/OB

2
Staff knows how to make chlorine solution 2 SI/OB
ME F4.2 Facility ensures standard practices and materials for Equipment and instruments are sterilized after each use RR/SI
disinfection and sterilization of instruments and equipment as per requirement

There is a procedure to ensure the traceability of OB/SI

sterilized packs &their storage

Autoclaved dressing material is used 2 OB/SI

Standard F5
Physical layout and environmental control of the patient care areas ensures infection prevention
ME F5.1 Functional area of the department are arranged to ensure Facility layout ensures separation of general traffic from OB
infection control practices patient traffic 1
Clinics for infectious diseases are located away from OB
main traffic
2

ME F5.2 Facility ensures availability of standard materials for Availability of disinfectant as per requirement OB/SI
cleaning and disinfection of patient care areas 1
Availability of cleaning agent as per requirement 2 OB/SI
ME F5.3 Facility ensures standard practices followed for cleaning and Spill management protocols are implemented SI/RR
disinfection of patient care areas 2
Cleaning of patient care area with detergent solution 2 SI/RR
Standard practice of mopping and scrubbing are followed OB/SI

Standard F6
Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Was

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

ME F6.1 Facility Ensures segregation of Bio Medical Waste as per Availability of colour coded bins at point of waste OB
guidelines generation 2
Availability of Non chlorinated plastic, colour coded OB
plastic bags 2
Segregation of Anatomical and soiled waste in Yellow OB/SI
Bin 2
Segregation of infected plastic waste in red bin 2 OB/SI
Display of work instructions for segregation and handling OB
of Biomedical waste 2
There is no mixing of infectious and general waste 2 OB
ME F6.2 Facility ensures management of sharps as per guidelines Availability of functional needle cutters and puncture OB
proof box 2

Availability of post exposure prophylaxis OB/SI

Glass sharps and metallic implants are disposed in Blue OB

colour coded puncture proof box 2
ME F6.3 Facility ensures transportation and disposal of waste as Check bins are not overfilled & staff is aware of when to SI/OB
per guidelines empty the bin
2

Transportation of bio medical waste is done in close SI/OB

container/trolley 2
Staff aware of mercury spill management SI/RR
2

Area of Concern - G Quality Management

Standard G1
The facility has established organizational framework for quality improvement
ME G1.1 The facility has a quality team in place Quality circle has been constituted SI/RR
1

ME G1.2 The facility reviews quality of its services at periodic intervals Review meetings are done regularly SI/RR
2
Standard G2
Facility has established system for patient and employee satisfaction
ME G2.1 Patient Satisfaction surveys are conducted at periodic Client satisfaction survey is done on monthly basis SI/RR
intervals
2

ME G2.2 Facility analyses the patient feed back and do root Analysis of low performing attributes is undertaken SI/RR
cause analysis 2
ME G2.3 Facility prepares the action plans for the areas of low Action plan is prepared and improvement activities are SI/RR
satisfaction undertaken 2
Standard G3
Facility have established internal and external quality assurance programs wherever it is critical to quality.
ME G3.1 Facility has established internal quality assurance There is a system of daily round by matron/hospital SI/RR
program at relevant departments manager/ hospital superintendent for monitoring of
services
2

ME G3.3 Facility has established system for use of check lists in Internal assessment is done at periodic interval RR/SI
different departments and services

Departmental checklist are used for monitoring and SI/RR

quality assurance

Non-compliances are enumerated and recorded RR

ME G3.4 Actions are planned to address gaps observed during

quality assurance process

Check action plans are prepared and implemented as

2
per internal assessment record findings

RR
ME G3.5 Planned actions are implemented through Quality
Improvement Cycles (PDCA)

Check PDCA or revalent quality method is used to take

2
corrective and preventive action

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

Current version of SOP are available with process owner OB/RR

2

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Work instruction/clinical protocols are displayed OB

ME G4.2 Standard Operating Procedures adequately describes Paediatric OPD has documented procedure for RR
process and procedures Registration and patient calling system 2

Paediatric OPD has documented procedure for receiving RR

of patient in clinic
2

Paediatric OPD has documented process for RR

consultation
2

Paediatric OPD has documented procedure for RR/PI

investigation

Paediatric OPD has documented procedure for RR/PI

prescription and drug dispensing

Paediatric OPD has documented procedure for nursing RR

process in OPD including initial investigation

Paediatric OPD has documented procedure for patient RR

privacy and confidentiality

Paediatric OPD has documented procedure for data RR

collection , analysis and undertaking improvement
activities
2

Paediatric OPD has documented procedure for support RR

services and facility management
2

Paediatric OPD has documented procedure for infection RR

control and biomedical waste management

Paediatric OPD has RR

established & documented policy for IYCF 2
Paediatric OPD has RR
documented procedure for safety
& risk management 2

ME G4.3 Staff is trained and aware of the standard procedures Check Staff is aware of relevant part of SOPs SI/RR
written in SOPs 2
Standard G 5
Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
ME G5.1 Facility maps its critical processes Process mapping of critical processes done SI/RR
2
ME G5.2 Facility identifies non value adding activities / waste / Non value adding activities are identified SI/RR
redundant activities 2

ME G5.3 Facility takes corrective action to improve the processes Processes are improved and implemented SI/RR
2

Standard G6
The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
ME G6.4 Facility has de defined quality objectives to achieve mission Check SMART Quality Objectives have framed SI/RR
and quality policy

ME G6.5 Mission, Values, Quality policy and objectives are effectively Check of staff is aware of Mission , Values, Quality Policy SI/RR
communicated to staff and users of services and objectives 2

Standard G7
Facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 Facility uses method for quality improvement in Basic quality improvement method are used SI/OB
services 2
ME G7.2 Facility uses tools for quality improvement in services 7 basic tools of Quality are used for quality SI/RR
improvement in Pead. OPD 2
Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

ME G9.6 Periodic assessment for Medication and Patient care safety Check periodic assessment of medication and patient SI/RR
risks is done as per defined criteria. care safety risk is done using defined checklist 1
periodically

Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

Clinical care assessment criteria have been The facility has established process to review
ME G10.3 defined and communicated the clinical care
0

SI/RR

Check regular ward rounds are taken to

0
review case progress
SI/RR
Check the patient /family participate in the
0
care evaluation SI/RR

Check the care planning and co- ordination is

0
reviewed
SI/RR

Facility conducts the periodic clinical audits There is procedure to conduct prescription
ME G10.4 including prescription, medical and death audits audits
2

SI/RR

All non compliance are enumerated recorded

2
for prescription audits
SI/RR
Clinical care audits data is analysed, and actions Check action plans are prepared and
ME G10.5 are taken to close the gaps identified during the implemented as per prescription audit record 0
audit process findings SI/RR
Check the data of audit findings are collated 0
SI/RR

Check PDCA or revalent quality method is

0
used to address critical problems

SI/RR

Facility ensures easy access and use of standard Check standard treatment guidelines /
ME G10.7 treatment guidelines & implementation tools at protocols are available & followed. 1 SI/RR
point of care

Check treatment plan is prepared as per

1 SI/RR
Standard treatment guidelines
Check the drugs are prescribed as per
1 SI/RR
Standards treatment guidelines

Check the updated/latest evidence are

1 SI/RR
available

Check the mapping of existing clinical

1 SI/RR
practices processes is done

Area of Concern - H Outcome

Standard H1
The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Indicators on monthly basis Number of cases in paediatric OPD per month RR
2
Number of follow-up cases per month RR
2
Immunization OPD per month 2 RR
Number of cases screened under RBSK per month RR
2
Proportion of cases being given IYCF counselling per RR
month 2
Proportion of cases being referred per month RR
2
No. of cases disease wise 2 RR
Proportion of cases being referred disease wise 2 RR
Proportion of BPL patients 2 RR
Standard H2
The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators on monthly basis Paediatric OPD per Doctor 2 RR
No. of Stock out days for essential medicines RR
2
Drop out rate for Pentavalent vaccination 2 RR
IYCF counselling sessions per counsellor 2 RR
No. of paediatric Cases seen per paediatrician 2 RR
Standard H3
The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Indicators on RR
monthly basis 2
No. of needle stick injuries reported
Percentage of AEFI cases reported 2 RR
Consultation time at Clinic 2 RR
Number of children with diarrhoea treated with ORS and RR
Zinc 2
Number of anaemia cases treated successfully 2 RR
Number of children with Pneumonia treated 2 RR
Proportion of cases requiring DEIC services out of RR
screened 2
Percentage of children on exclusive breastfeeding RR
attending OPD
2

Number of children with severe & moderate anaemia RR

treated 2
Standard H4
The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality Indicators on monthly basis Patient Satisfaction Score RR
2
Waiting time at nutrition counselling centre 0 RR
Waiting time at paediatric clinic 2 RR
waiting time at drug dispensing counter dedicated for RR
paediatric OPD 2

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Reference No. Measurable Element Checkpoint Assessment Method

Compliance

Waiting time at registration counter 2 RR

Average door to drug time 2 RR

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Hospitals Version: DH/NQAS-2020/00

ment 5

Date of Assessment May-24

Names of Assesses
Action plan Submission Date

Paediatric OPD Score

84%

er crowding in the OPD

ases availing the telemedicine services
of paediatric conditions are available
ng room is maintained
water and flush are available

Means of Verification Remarks

Service Provision

urative Services
(1) Dedicated Paediatric Clinic for diagnosis and treatment for
common childhood ailments
(2) Screening for admission
(3) Follow up for care & care after discharge

Established linkage with DEIC (inhouse or referral)

1. Ophthalmology Clinic providing Paediatrics consultation

services (shared with main hospital)
2. Check records for no. of paediatric cases seen in past three
months

1. ENT clinic providing paediatrics consultation services (shared

with main hospital)
2. Check records for no. of paediatric cases seen in past three
months

1. Check records for no. of paediatric cases seen in past three

months
2. Foreign Body Removal (Ear and Nose),Stitching of CLW’s,
Dressings, Syringing of Ear, Chemical Cauterization (Nose &
Ear), Eustachian Tube Function Test, Vestibular Function Test
etc.

1. Orthopaedic Clinic providing Paediatric consultation services

(shared with main hospital)
2. Check records no. of paediatric cases seen in past three
months

1. Check records for no. of paediatric cases seen in past three

months
2. Plaster room procedure

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Means of Verification Remarks

1. Skin & VD Clinic providing consultation paediatrics services

(shared with main hospital)
2. Check records for no. of paediatric cases seen in past three
months

1. Dental Clinic providing consultation services (shared with

main hospital)
2. Check records no. of paediatric cases seen in past three
months

1. Check records for no. of paediatric cases seen in past three

months
2. Accompanied by dental lab. Extraction, scaling, tooth
extraction, denture and Restoration.

1. AYUSH Clinic providing Paediatrics consultation services

(shared with main hospital)
2. Check records for no. of paediatric cases seen in past three
months

1. Physiotherapy Clinic providing Paediatric consultation

services (shared with main hospital)
2. Check records for no. of paediatric cases seen in past three
months

(1) Functional linkage with SNCU for all newborns (upto 28

days)
(2)Functional linkage with emergency department for
paediatric triage - assessment & stabilization

Linkage with emergency department and inpatient services

Provide first aid services , medical treatment & inform the police

MNCHA Services
Availability of Functional immunization clinic
Assessment of physical growth & immunisation status and age-
appropriate nutritional counselling services
Provision of health
education, health & nutrition counselling

agnostic Services
Hassle free diagnostic services are available for paediatric cases

Availability of a dedicated Lab technician for sample collection

of paediatric cases

national Health Programs/ state scheme

Linkage with lower facilities, MMU, school health programme
for management of 4 D's
Facility for Occupational therapy & Physical therapy,
Psychological services, Cognition services, Audiology, Speech-
language pathology,vision,etc

upport services
Dedicated staff for paediatric OPD
Dedicated staff for paediatric OPD
Dedicated drug dispensing counter for paediatric OPD

are appropriate to community needs.

Ask for the specific local health problems/ diseases .i.e.

arsenic poisoning, endosulfane, hameophilia,Acute
encephalitis Syndrome (AES) in children, followup
for Birth defects etc.
B Patient Rights

ommunity about the available services and their modalities

1. Numbering, main department and internal sectional signage

are placed.
2. Directional signages are available clearly indicating the
paediatric OPD and its ancillary areas vis a vis counselling room,
immunization room , breastfeeding corner, lab etc.

The layout should indicate the paediatric services vis a vis

examination room, consultation room, immunisation, IYCF
counselling, drugs dispensing , lab, imaging, emergency, SNCU,
paediatric wards etc very clearly

1. List of available Paediatric OPD Clinic/s

2. Timing for OPD (opening and closing)
3. Important numbers like ambulance ,blood bank etc
4. Turn around time for investigation,
5. grievance re addressal
are displayed
Name of doctor, Nurse and Counsellor on duty are displayed
and updated.
Relevant national or state guidelines are followed for provision
of diagnostics, drugs, treatment of children.

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Means of Verification Remarks

Check Citizen charter is shared with main OPD complex, it

includes information on:
1. Services available at the facility
2. Timings of different services available
3. Rights of Patients
4. Responsibilities of Patients and Visitors
5. Beds available
6. Complaints and Grievances Mechanism
7. Mention of Services available on payment if any
8. Help desk number
9. Cycle time for Critical Processes

User charges if any, are displayed and communicated to parent-

attendants.
Breastfeeding, Immunization schedule, Management of
diarrhoea using Zn & ORS, SAANS campaign, nutrition
requirement of children , KMC and hand washing etc
Education material, job aids, dolls, mama's breasts model etc
are available for lactation and nutrition Counselling

Check in Immunization, paediatric OPDs , waiting areas etc.

1. Check in Immunization, paediatric OPDs , waiting areas etc.

2. Check staff is not using pen, note pad, pen stand etc. which
have logos of companies' producing breast milk substitute etc.

During counselling Mothers and families has been specially

educated about Ill effects of breast milk substitutes.

Check all information are available in local language

Enquiry /help desk is available with staff fluent in local language
and well versed with hospital layout and processes

s, and there are no barrier on account of physical economic, cultural or social reasons.

Safe, secure, clean, calm environment and privacy is

maintained for breastfeeding

1. Due care is taken in examining older female child (she should

be examined in the presence of a parent/ relative or a female
staff.
2. Examination of mother for lactation support is also provided
ensuring complete privacy and dignity
Separate toilets for parent accompanying the
children/attendant

Facility takes effort to ensure hassle free registration.

Have dedicated counter/ separate counter in centralized OPD
registration (provision of dedicated que for school going
children)

Check computerised
registration, token system for queuing and patient calling
system with electronic display are available to systematise
outpatient consultation.
Dedicated wheelchair /stretchers are available for paediatric
patients.
At least 120 cm width, gradient not steeper than 1:12
Preferably have digital public calling system for patients
Wide , placed at lower level, supported with bars & door of
toilet is opening outside
Children friendly- two WC and a washbasin should be reserved
for children visiting the OPD and fitted accordingly (low WC
seats; washbasins at appropriate height, lever operated taps).

###

Curtain/screen are available in examination area

(1) Secondary curtain/ screen is used to create a visual barrier
in breastfeeding area
(2) Curtains/frosted glasses at windows for maintaining privacy

Only patient and the parent- attendant are permitted inside the
clinic
Privacy (verbal and visual) of mother/parent is ensured while
providing counselling services
1. No information regarding patient / parent identity is
displayed
2. Records are not shared with anybody without written
permission of parents & appropriate hospital authorities

Check staff is not providing care in undignified manner such as

yelling, scolding, shouting and using abusive language for
patient or parent-attendant

Check if HIV/leprosy/abuse case etc is not explicitly written on

case sheets/slips and avoiding any means by which they can be
identified in public

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Means of Verification Remarks

###

Explained about the whole process

Patient 's rights & responsibilities are displayed (may be shared
with main hospital)
Ask parent attendants/guardians about what they have been
communicated about the clinical condition and treatment plan .

Parent attendant/guardians are counselled before conducting a

test, imaging, immunisation or any procedure. Ask parents if
they have been counselled about the process and requirement.

check the completeness of the Grievance redressal mechanism ,

from complaint registration till its resolution

###
For JSSK, RBSK, PMJAY entitlement or any relevant national and
state guideline

Ask parent attendants/guardians if they purchased any

drug/consumable from outside

Ask parent attendants/guardians if they got any diagnostic

investigation done from outside

mmas confronted during delivery of services at public health facilities

1. Check for policy
2. Who can issue certificates
3. Formats which shall used
4. Record keeping of issued certificate
procedures for issuing duplicate certificates
5. Check turn around time to issue certificate

1. Check for policy

2. Who can issue certificates
3. Formats which shall used
4. Record keeping of issued certificate
procedures for issuing duplicate certificates
5. Check turn around time to issue certificate

rn - C Inputs

s, and available infrastructure meets the prevalent norms

a. Adequate Space in Clinic, ample space to seat 4-5 people
b. The room has handwashing facility .
a. Waiting area has adequate space and is adjacent or close to
the paediatric clinic
b. check ambience of the waiting area is child friendly vis a vis
cartoon/animals/flowers painting on the wall, child play zone
with safe toys, puzzles, blocks, stacking bottle tops and swings.

a. As per average OPD at peak time

b. separate , movable, safe and comfortable chairs for children
are available

Separate seating arrangement for immunisation , IYCF

Counselling centre, etc.
See if water cooler is easily accessible to the visitors

Two WC and a washbasin should be reserved for children

visiting the
OPD and fitted accordingly (low WC seats; washbasins at
appropriate height, lever operated taps).
Examination table along with foot steps

Such as rape/sexual assault survivors in OPD / Linkage with

emergency
Can be shared with main OPD
Check availability of IYCF room

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Means of Verification Remarks

Separate pharmacy/ Separate dispensing counter at OPD

pharmacy
TB clinic, isolation room, radiology etc.

Available separately for children

Corridor should be wide enough so that 2 stretchers can pass
simultaneously
Check availability of functional telephone and intercom
connections
Layout of OPD shall follow functional flow of the
patients, e.g.:
Enquiry→Registration→Waiting→Sub-waiting→
Clinic→Dressing room/Injection Room/immunisation→
Diagnostics (lab/X-ray)→Pharmacy→Exit

Paediatric OPD clinic, emergency, immunisation room, IYCF

counselling centre, Pharmacy/drug dispensing counter and any
other

l safety of the infrastructure.

Check for fixtures and furniture like cupboards, cabinets, and
heavy equipment , hanging objects are properly fastened and
secured
a. Switch Boards other electrical installations are intact.
B. Check adequate power outlets have been provided as per
requirement of electric appliances and
c. Electrical points are out of reach of children / covered

Open spaces are properly secured to prevent fall and injury

me for fire safety and other disaster

Check the fire exits are clearly visible and routes to reach exit
are clearly marked. Check there is no obstruction in the route of
fire exits. Staff is aware of assembly points .

Check the expiry date for fire extinguishers are displayed as

well as due date for next refilling is clearly mentioned.

Staff is aware of RACE (Rescue, Alarm, Confine & Extinguish) &

PASS (Pull, Aim, Squeeze & Sweep)

for providing the assured services to the current case load

a. As per patient load
b. 1 for every 50-60 cases;
c. Check for specialist are available at scheduled time
a. As per patient load
b. Trained in paediatric
care

As per patient load

a. As per patient load

At Injection room, OPD Clinics, immunisation room, IYCF
Counselling room DEIC as Per Requirement
1 with each doctor where children are weighed & weight is
correctly recorded, immunisation status is checked, children
< five years are screened for SAM using MUAC, and those with
emergency and priority signs are triaged.
Check dedicated staff is also available with IYCF counselling
centre

A dedicated Lab technician for sample collection of paediatric

cases

A Nutrition Counsellor/ IYCF counsellor

is appointed to manage this centre and is available for fixed
hours (coinciding with timing of outpatient services) to counsel
and address referral cases.

Audiometrician, Ophthalmic assistant, Dental technician (As

per patient load & Shared with main hospital)
a. Check services are available for paediatric cases ,
b. Check record how many paediatric cases have availed
services in last three months

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Means of Verification Remarks

a. Check services are available for paediatric cases ,

b. Check record how many paediatric cases have availed
services in last three months
(As per patient load & Shared with main hospital)

Availability of dedicated staff under RBSK:

1. Paediatrician
2. Medical Officer
3. Dentist
4. Physiotherapist / Occupational therapist / Early
Interventionist
with Physiotherapy/ Occupational therapy background
5. Clinical Psychologist/ Rehabilitation Psychologist
6. Paediatric Optometrist
7. Paediatric Audiologist & Speech pathologist / Early
Interventionist with Paediatric Audiology & Speech pathology
background
[Link] Educator
9. Lab Technician
10. Dental Technician
11. Manager
12. DEO
13. Counsellor

Dedicated for paediatric opd

Dedicated for paediatric opd

s required for assured list of services.

ARV & TT

As per State EML

As per State EML
As per State EML
As per State EML
As per State EML
As per State EML
As per State EML
As per State EML
As per State EML
As per State EML
As per State EML
As per State EML
As per State EML

As per Immunization schedule

Examination gloves, Syringes, Dressing material , suturing
material etc.
AEFI Kit - 1 mL ampoule of adrenaline (1:1000) – 3 nos., 1 mL
tuberculin syringes / 40 unit insulin syringes without fixed
neEMLes, 24/25 G neEMLes of 1 inch length, Swabs.
New-born resuscitation kit - Suction catheter (5F, 6F, 8F, 10F) ,
bag and mask, laryngoscope, endotracheal tubes(2.5, 3, 3.5, 4
and stylets, umbilical catheters , three way stop check

Normal Saline (NS),Glucose 25%,Ringer Lactate (RL),Dextrose

5%,Potassium Chloride,Calcium Gluconate,Sodium
Bicarbonate,Inj Pheniramine,Inj Hydrocortisone Hemisuccinate/
Hydrocortisone Sodium Succinate ,Inj Phenobarbitone,Inj
Phenytoin,Inj Diazepam,Inj Midazolam,Salbutamol
Respiratory,Ipratropium Respirator solution for use in
nebulizer,Inj Dopamine,I.V Infusion set,I.V Cannula
(20G/22G/24G/26G) & Nasal Cannula(Infant, Child, Adult) &
oxygen

ts required for assured list of services.

Non-invasive blood pressure monitoring (Paediatric and adult
cuffs) -1 each, thermometer, Weighing scales (digital) for
infants and children (1 each), stethoscope (paediatric),
Stadiometer, Infant meter , Measuring tape

Spatula (disposable) -multiple

torch
Stethoscope (paediatric)
Otoscope
Resuscitation kit
Direct Ophthalmoscope
Paediatric Auroscope
Ear speculum
Magnifying glass
Knee hammer

Digital weighing scales for infants & children, Stadiometer,

Infantometer WHO growth standards (Charts)
MUAC tapes, Mother Child Protection Card, Dolls and breast
models (such as for demonstrating expression of breastmilk),
Steel bowl, spoon

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Means of Verification Remarks

Self-inflating bags & mask with oxygen

reservoir: newborn (250 ml), infant (500) & paediatric (750 mL),
Newborn, Infant, child masks (00,0,1,2), Oxygen concentrator (if
assured power
supply) or oxygen cylinder (as backup) with regulator, pressure
gauge and flow meter, Suction pumps (electric & foot
operated),Nebuliser, Infusion pump, Laryngoscope handle and
blades: curved 2,3; straight 1,2; handle 0 size, Pulse oximeter
(adult / paediatric probes),Noninvasive blood pressure
monitoring
(infant, child cuffs)

X ray view box, Equipment for plaster room - Traction etc.

Retinoscope, refraction kit, tonometer, perimeter, distant vision

chart, Colour vision chart.
Audiometer, Laryngoscope, Otoscope, Head Light, Tuning Fork,
Bronchoscope, Examination Instrument Set

Dental chair, Air rotor, Endodontic set, Extraction forceps

Traction, Short Wave Diathermy, Exercise table etc .

Refrigerator, Crash cart/Drug trolley, instrument trolley,
dressing trolley
Deep freezer and ILR , insulated carrier boxes with ice packs

Buckets for mopping, mops, duster, waste trolley, Deck brush

Autoclave
Spot light, electrical fixture for equipment, X ray view box

Doctors Chair, Patient Stool, Examination Table, Attendant

Chair, Table, Footstep, cupboard, wheelchair, trolley, Almirah/
wall mounted cabinets (for storage of consumables, records)
etc.

evaluation and augmentation of competence and performance of staff

Check objective checklist has been prepared for assessing

competence of doctors, nurses and paramedical staff based on
job description defined for each cadre of staff.
Check for records of competence assessment including filled
checklist, scoring and grading . Verify with staff for actual
competence assessment done
Biomedical Waste Management & Infection control and hand
hygiene ,Patient safety
Especially for lactation failure or breast problems like
engorgement, mastitis etc, and provide special
counselling to mothers with less breast milk, low birth weight
babies, sick new-born, undernourished
children, adopted baby, twins and babies born to HIV positive
mothers.
At least two service providers trained in advanced lactation
management and IYCF counselling skills should be available to
deal with difficult and referred cases.

screening, diagnosis , management and referral

Emergency triage, Resuscitation, monitoring & stabilization
Triage, Quality Assessment & action planning, PDCA, 5S & use
of checklist for quality improvement

Check supervisors make periodic rounds of department and

monitor that staff is working according to the training imparted.
Also staff is provided on job training wherever there is still gaps
Support Services

esting and maintenance and calibration of Equipment.

1. Check with AMC records/
Warranty documents
2. Staff is aware of the list of equipment covered under AMC.

[Link] for breakdown & Maintenance record in the log book

2. Staff is aware of contact details of the agency/person in case
of breakdown.

[Link] apparatus, thermometers, weighing

scale etc. are calibrated.
[Link] for calibration records and next due date

nt and dispensing of Medicines in pharmacy and patient care areas

1. Requisition are timely placed (check with registers)
2. Monthly vaccine utilization including wastage report is
updated
3. Stock level are daily updated

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Means of Verification Remarks

Staff is trained to forecast the requirement using scientific

system
1. Check drugs and consumables are kept at allocated space in
emergency tray and drugs dispensing counter
2. Drug shelves are labelled.
3. Look alike and sound alike drugs are kept separately
[Link] EXPIRY FIRST OUT (EEFO) is practised

1. Daily cleanliness of cold chain equipment;

2. Twice daily temperature recording

Records for expiry and near expiry drugs are maintained for
stored drugs

Expiry dates against drugs are mentioned at emergency drug

tray and drug dispensing counter

At drug dispensing counter and emergency tray

Minimum reorder level is defined and buffer stock is kept

Check stock and expenditure register is

adequately maintained
There is procedure for replenishing drugs in emergency tray
and drug dispensing counter
1. Check for temperature charts are maintained and updated
periodically
2. Refrigerators meant for storing drugs should not be used for
storing other items such as eatables

Check for four conditioned Ice packs are placed in Carrier Box,
DPT, DT, TT and Hep B Vaccines are not kept in direct contact
of Frozen Ice line

le environment to staff, patients and visitors.

Examination table, Dressing room, injection room, circulation
area, counselling room, immunization room, drugs dispensing
counter and waiting area
1. Adequate seating for parent - patient
2. One clinic is not shared by 2 doctors at one time
As per hospital policy

Fans/ Air conditioning/Heating/Exhaust/Ventilators as per

environment condition and requirement
1. Dedicated security guards.
2. Functional CCTV at all entrance, all exit and circulation areas
(may be shared with main hospital)

maintenance and upkeep of the facility

1. Building is painted/whitewashed in uniform colour
2. Paediatric OPD is easy to identify

Check walls are painted with cartoon characters/ animals/

plants/ under water/ jungle themes etc
1. All area are clean with no dirt, grease, littering and cobwebs.
2. Surface of furniture and fixtures are clean
3. Cleanliness and maintenance of child zone including their
swings and toys is ensured

Check toilet seats, floors, basins etc are clean and water supply
with functional cistern
Window panes , doors and other fixtures are intact

Mattresses are intact and clean

1. No overgrown bushes /trees

2. Bushes / trees are shaped as animal/birds/child friendly
topiaries

Check if any obsolete

article including equipment, instrument, records, drugs and
consumables
(1) No lizard, cockroach, mosquito, flies, rats, bird nest etc.
(2) Anti Termite treatment on wooden items on defined
intervals

quirement of service delivery, and support services norms

1. Check for availability of power backup

2. Uninterrupted power supply for cold chain maintenance

ion and nutritional requirement of the patients.

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Means of Verification Remarks

All children below two years are directed from outpatients to

the counselling centre for assessment of physical growth &
immunisation status (if not already done in the Paediatric Clinic)
and age-appropriate counselling services

n linen to the patients

1. Adequate linen is available in examination area.
2. Child friendly bright coloured and soft linen is used
(1) A person is dedicated for management of OPD laundry.
(2) Records are maintained

irement imposed by local, state or central government

1. Check staff is able to explain the key messages of IMS Act
(At-least 3 messages)
(a) Prohibition from any kind of promotion and advertisement
of infant milk substitutes, (b) prohibition of providing free
samples and gifts to pregnant women or mother, (c) prohibit
donation of free or subsided free samples,
(d) prohibit any contact of manufacturer or distributor with
staff

2. Hoarding describing the provision of IMS act is displayed in

the facility

Check staff is aware of key points of medical examination of

sexually assaulted child
(1) Take written Consent from parents / guardian
(2) Document the question asked
(3) Ensure adequate privacy
(4) Ask the child whom they would like to accompany them
during physical examination
(5) If child resist, examination may be deferred
(6) If the victim is girl child assessment shall be conducted by
women doctor

mined as per govt. regulations and standards operating procedures.

Check for system of recording time of reporting and relieving
(Attendance register/ Biometrics etc)

As per hospital administration or state

policy

f outsourced services and adheres to contractual obligations

Verification of outsourced services
(cleaning/Laundry/Security/Maintenance) provided are done
by designated in-house staff

Clinical Services

tion, consultation and admission of patients.

Check for patient demographics like baby Name,
father's/mother's name , age, Sex, Chief complaint, etc. are
clearly recorded
Registration clerk are well versed with hospital processes and
lay out
JSSK, RBSK , ABPMJAY , BPL or any other state specific schemes

Patient is called by Doctor/attendant as per his/her turn on the

basis of “first come first examine” basis. However, in case of
emergency out of turn consultation is provided.

Check OPD records for the same

Check details of the physical examination, provisional diagnosis
and investigations (if any) is mentioned in the OPD ticket

Check treatment plan and confirmed diagnosis is recorded

Proper seating arrangement for the patient and parent-
attendant is there. Care is provided in a dignified way.
During OPD hours clinical staff is not engaged in other
administrative tasks

Check the linkage between OPD , emergency and IPD services.

Staff is aware about linkage and no time is wasted in the
admission process.

Patients requiring day care services receive the care hassle free

assessment, reassessment and treatment plan preparation.

Initial screening is done for all paediatric patients. They are
weighed & weight is correctly recorded, immunisation status is
checked, children < five years are screened for SAM using
MUAC and those with emergency and priority signs are triaged.

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Means of Verification Remarks

1. Patients (inborn and out born) are followed up for nutritional

status and the completion of the treatment & immunisation .
[Link] for follow up at lower level healthcare facilities
vis a vis CHC , PHC and HWC.
3. Provisioning for tele consultation (give compliance if
state does not have telemedicine facility)

Criteria is defined for identification, and management of high

risk patients/ patient whose condition is deteriorating
Check the re assessment sheets/ Case sheets modified
treatment plan or care plan is documented

(a) According to assessment and investigation findings

(wherever applicable).
(b) Check inputs are taken from patient or relvent care provider
while preparing the care plan.

Care plan include:, investigation to be conducted, intervention

to be provided, goals to achieve, timeframe, patient education,
, discharge plan etc
Check care plan is prepared and delivered as per direction of
qualified physician

for continuity of care of patient and referral

Check the established procedure for intradepartmental refer to
other specialist if required
1. Referral criteria are defined as per FBNC and state specific
guidelines
2. Referral criteria clearly mention the cases referred to the
higher and lower centre for treatment/follow up

1. Details of Referral linkages are clearly displayed in OPD

2. Verify with referral records that reasons for referral were
clearly mentioned and rational.
3. Referral is authorized by paediatrician or Medical officer on
duty after ascertaining that case can not be managed at the
facility.

Referral linkage to lower down facility for the compliance of

the treatment and further follow up.

1. Check referral out record is maintained

2. Check randomly with the referred cases (contact them) for
completion of treatment or follow up.

1. Telemedicine services are available on a fixed day for

paediatric cases (for both old and new cases)
2. There is a system in place to give the prior appointment

Check the records for completion.

high risk and vulnerable patients.

[Link] cases who are left unattended , orphan/lawaaris
are identified and care is provided
2. Police is informed in such cases
3. Appropriate arrangement is made with local NGOs etc.

In case of emergency out of turn consultation is provided.

###

Check all the drugs in case

sheet and slip are written in generic name only
Check records
STG for management of pneumonia, AEFI management ,
management of diarrhoea, new-born resuscitation etc. are
available and are followed
Check OPD slips that drugs are prescribed as per STG

(1) Check On duty doctor is aware of status of drugs available in

pharmacy.
(2) Updated list of available drugs is provided by pharmacy
Check complete medication history including over-the- counter
medicines is taken and documented

1. Medication Reconciliation is carried out by a trained and

competent health professional during the patient's admission,
interdepartmental transfer or discharged
2. Medicine reconciliation includes Prescription and non-
prescription (over-the-counter) medications, vitamins,
nutritional supplements.

Medicines are optimised as per individual treatment plan for

best possible clinical outcome specially in chronic cases, Non
communicable diseases etc
Clinician counsel the patient on medication safety using "5
moments for medication safety app"

for safe drug administration

Verify with prescriptions/OPD slips on sample basis

Verify with prescriptions/OPD slips on sample basis

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Means of Verification Remarks

Check for any open single dose vial with left over content
intended to be used later on. In multi dose vial needle is not left
in the septum

1. Check availability of formats for reporting and

2. Monthly reporting (nil reporting too)

1. Check availability of formats for reporting and

2. Monthly reporting (nil reporting too)
Drugs and dosages are well explained by the doctor/nurses or
pharmacists

(1) Check drugs are given in envelop

(2) Check envelops are patient friendly having representation of
morning, afternoon evening.
(3) Check representations are ticked as per prescription for
better understanding

ing, updating of patients’ clinical records and their storage

Check prescriptions/OPD slips for completion of records

[Link] treatment and follow up plan is written and is also

explained to the parent-attendant
2. Check with parent/guardian are able to explain information
received from doctor

Details are written and is also explained to the parent-

attendant
Check availability of OPD slip, investigation requisition slip ,
investigation reporting format

OPD register, immunisation records, counselling register,

Injection room register etc
Check the facility has quality management system in place
(1) Facility ensure safe keeping and easy retrieval of the OPD
registers, OPD tickets (as per state guidelines). (2) Electronic
patient recording system is available

or Emergency Services and Disaster Management

A. EMERGENCY SIGNS -who require immediate emergency
treatment.
B. PRIORITY SIGNS- indicating that they should be given priority
in the queue,
so that they can rapidly be assessed and treated without delay.
C. NON-URGENT cases- children can wait their turn in the
queue for assessment and treatment.

(1) Check triage protocols are displayed

(2) All children attending an emergency/OPD are visually
assessed immediately (within 30sec) upon arrival by
paramedics /support staff positioned in the emergency
and in OPD
(3) Triage is completed within 15 minutes of arrival or
registration by a competent and appropriately trained nurse or
doctor &and receive an initial triage assessment

Quickly be directed to
a place where treatment can be provided immediately, e.g. the
emergency room or ward equipped ETAT /SNCU
All staff such as gatemen, record clerks, cleaners, janitors who
have early patient contact are trained
in triage for emergency signs and know where to send children
for immediate management.

(1) Protocols for management of trauma, surgical,

orthopaedics, poisoning, drowning , dyspnoea, unconscious,
shock & burn
(2) Drug dosage charts are available

As per disease condition

(1) Ensure vitals are stable and the child is in no immediate

danger of deteriorating.
(2) The paediatrician on call assess the child before the transfer
is made.
to ward/ HDU/referred

Check emergency department is conducting initial assessment -

provide primary treatment, not only registering the patient &
transferring
Stabilisation include some or all:
(1) Securing the airway.
(2) Establishing secure venous access.
Correcting poor perfusion and acidaemia.
(3) Obtaining a full history.
(4) Carrying out a full physical examination.
(5) Performing baseline investigations, e.g.; a chest X-ray,
electrolytes or glucose.
(6) Performing acute ‘aetiological’ investigations, e.g.; blood
culture before giving antibiotics.
(7) Initial treatment of the causative pathology, e.g.;
bronchodilators for asthma and antibiotics for sepsis.
(8) Deciding on the location of continuing care.
(9) Arranging transfer to an appropriate unit (like paediatric
ward) or health facility.

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Means of Verification Remarks

(1) Check staff is aware & follow the protocols.

(2) Sexual assault forensic evidence kit is available
(3) Check provisioning of ECP (pubertal child) prophylaxis
against STI, HIV etc
(4) Counselling service are available for victim

[Link] and responsibilities of staff in disaster is defined

2. Mock drills have been conducted
3. Assembly point and exit points are defined

d procedures of diagnostic services

1. Preferably a personnel has been dedicated for sample
collection from Paediatric OPD
2. Labelling is done correctly
3. Pre testing instructions are given properly to the parent-
attendant

1. Reporting mechanism is explained to the parent-attendant;

the process should be hassle free
[Link] are displayed in the consultation room.
3. Staff is aware normal reference values
4. System in place for urgent reporting of critical cases

of new born, infant and child as per guidelines

Use diluent provided by the manufacturer with the vaccine

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

Ask staff about when Rotavirus vaccine, BCG, Measles/MR and

JE vaccine are constituted and till when these are valid for use.
Should not be used beyond 4 hours after reconstitution.

Check for records

Ask staff how to check VVM level and how to identify discard
point
Ask staff to demonstrate how to conduct Shake test for DPT, TT,
HepB, PCV and Penta vaccines
Shake Test is not applicable for IPV
DPT, TT, Hep B, OPV, Hib containing pentavalent vaccine
(Penta), PCV and injectable inactivated poliovirus vaccine (IPV).

Check for no expired, frozen or with VVM beyond the discard

point vaccine stored in cold chain

Check for 0.1 ml AD syringe for BCG and 0.5 ml syringe for
others are available

Ask for demonstration , How to peel, how to remove air bubble

and injection site

Cleaning of injection site with spirit swab is not recommended

To observer any Adverse effect following immunization

Kit constitute of job-aid, dose chart for adrenaline as per age (1

ml ampoule -3 no.), Tuberculin syringe (1ml-3 no.), 24H/25G
needle- 3 no, swabs-3 no. updated contact information of DIO,
local ambulance services and adrenaline administration record
slip.

Give non compliance if kit is not available

Ask the staff regarding the responsibility for notifying and

reporting the AEFI

Ask staff to whom the cases are reported & how

1. Verify weekly report of AEFI cases.

2. Nil reporting in case of no AEFI case.
3. Verify HMIS report of previous months

Paracetamol Syrup
Immunisation card is available and updated

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Means of Verification Remarks

(1) RR >60 breaths per min

(2) Severe chest in drawing
(3) Grunting
(4) Apnoea or gasping

(1) Pre Term : RDS, Congenital pneumonia, hypothermia &

hypoglycaemia
(2) Term: Transient tachypnoea of new-born (TTNB), meconium
aspiration, pneumonia, asphyxia
(3) Surgical cases: Diaphragmatic hernia, Tracheo - oesophageal
fistula, B/L choanal atresia
(4) other causes: Congenital heart disease, acidosis, inborn
errors of metabolism

Cough or difficulty in breathing in children with at least one of

the following condition :
(1) Central Cyanosis or oxygen saturation <90%
(2) Severe respiratory distress (laboured of very fast breathing
(RR<70 per minute) or severe lower chest indrawing or head
nodding or stridor or grunting)
(3) Sign of pneumonia with general danger sign (inability to
breastfed or lethargy or reduced level of consciousness or
convulsions)

Normal Axillary temp- 36.5 -37.5 OC

Cold Stress- 36.4- 36OC
Moderate Hypothermia- 35.9- 32OC
Severe Hypothermia- <32OC.
Assessment through Axillary temp., Skin temperature (using
radiant warmer probe) and Human touch.

LBW, preterm babies, hypoglycemia,sclerema, DIC and internal

bleeding
Hypothermic babies show signs of lethargy, irritability, poor
feeding, tachypnoea/apnoea etc

(1) Sepsis
(2) Envt. too hot for baby
(3) Wrapping the baby in too many layers of clothes, esp. in hot
humid climate
(4) Keeping new-born close to heater/hot water bottle
(5) Leaving the under heating devices i.e. radiant warmer,
incubator, phototherapy that is not functioning properly and/to
not check regularly
Examine every hyperthermic baby for infection (1) If temp. is
above 39OC, the neonate should be undressed and sponged
with tepid water at app. 35OC until temperature is below is
below 38 OC
(2) If temp. is 37.5- 39OC- Undressing & exposing to room temp
is usually all that is necessary.
(3) If due too envt. temperature: move baby into colder
environment & using loose & light clothes.
(4) If due to device- remove the baby from source of heat
(5) Give frequent breastfeeds to replace fluids. if the baby
cannot breastfeed, give EBM. If does not tolerate feeds, IV
fluids may be given
(6) Measures the temp. hourly till it become normal

1. For neonates and infants till 1 year of age, daily 2000 IU of

vitamin D with 500 mg of calcium for a 3-month period is
recommended. At the end of 3 months, response to treatment
should be reassessed
2. From one year onwards till 18 years of age, 3000-6000
IU/day of vitamin D along with calcium intake of 600-800
mg/day is recommended for a minimum of 3 months.
3. Staff is aware of side-effects of excessive administration of
Vitamin - D can lead to hypervitaminosis, particularly in infants.
Screening is done and the cases are referred to NRC for
appropriate treatment

All the clinically suspected anaemic children (reported for any

illness) undergo Hb estimation
All the children referred from field due to palmer pallor-
undergo HB level estimation before initiation of treatment.

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Means of Verification Remarks

Among children between 6 month and 5 yrs.)

>11 gm/dl- No anaemia
10-10.9 gm/dl- Mild anaemia
7-9.9gm/dl-Moderate anaemia
<7gm/dl- Severe Anaemia
Among children between 5 yrs-10 yrs.
11–11.4 gm/dl- Mild anaemia
8–10.9 gm/dl- Moderate anaemia
<8 gm/dl- Severe anaemia

No anaemia- 20 mg of elemental iron in 100 mcg folic acid in

biweekly regimen
Mild & Moderate Anaemia-3mg of iron/kg/day for two months-
follow up every 14 days, HB estimation after 2 months.
After completion of treatment of anaemia and documenting Hb
level >11 gm/dl, the IFA
supplementation to be resumed.
6-12month (6-10kg)--1 ml of IFA syrup, once a day
1yr -3 yrs. (10-14kg)--1.5 ml of IFA syrup, once a day
3yrs-5yrs(14-19yrs)-- 2ml of IFA syrup, once a day

H/O- Duration of symptoms, Usual diet (before the current

illness), Family circumstances (to understand the child’s
social background), Prolonged fever, Worm infestation,
Bleeding from any site, Any lumps in the body, Previous blood
transfusions and Similar illness in the family (siblings)
Examination for- Severe palmar pallor,
Skin bleeds (petechial and/or purpuric
spots),Lymphadenopathy,Hepato-splenomegaly, Signs of heart
failure (gallop rhythm, raised
JVP, respiratory distress, basal crepitations)
Investigation- Full blood count and
examination of a thin film for
cell morphology, Blood films for malaria
parasites, Stool examination for ova, cyst
and occult blood

All children with Hb ≤4 gm/dl,

Children with Hb 4–6 gm/dl with
any of the following:
– Dehydration
– Shock
– Impaired consciousness
– Heart failure
– Deep and laboured breathing
– Very high parasitaemia
(>10% of RBC)

1. Give ORS to all children with Diarrhoea

[Link] Zinc for 14 days, even if diarrhoea stops

1. Continue feeding, including breast feeding in those children

who are being breastfed
2. Make a habit of regular hand washing with soap
3. Use clean drinking water

Check ORS is freshly prepared. Mother's are counselled to

prepare ORS
Maintenance and updating of growth chart

1. Facility supports mothers to maintain breastfeeding and

manage its common difficulties
2. Awareness is generated for exclusive breastfeeding till 6
months of age
3. Awareness is generated for complementary feeding from 6
months of age till two years of age

One to one counselling

session should be conducted with the mother/caregiver for
children born prematurely or with low birth weight,
undernourished
children, adopted baby, twins and babies born to HIV positive
mothers, of mothers producing less milk.
Also ensure follow up visits to the facility/ referral centre

(1) Cracked Nipples- Apply hind milk

2. Engorged breast- encourage the mother to let baby suck
without causing too much discomfort. Putting a warm compress
on the breast may relieve breast engorgement

(1) If an abscess is suspected in one breast, advise the mother

to continue feeding from the other breast & refer for
consultation
(2) Inverted/flat nipple- corrected using syringe

Ask Parents about the counselling

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Means of Verification Remarks

(1) All newborns delivered at the District Hospital or from

outside but admitted in SNCU, postnatal and children wards
irrespective of their sickness are screened for hearing, vision,
congenital heart disease.
(2) In case DEIC is not associated with the facility- appropriate
linkage is established for the screening , diagnosis and
treatment.

Screened cases are referred to DIEC or tertiary care centre for

diagnosis and treatment.
Infection Control

r prevention and measurement of hospital associated infection

Hepatitis B, Tetanus Toxoid etc

Handwashing and infection control audits are done at periodic

intervals
Antibiotic policy is available and staff is aware about it

or ensuring hand hygiene practices and antisepsis

1. Check for availability of wash
basin and running water at point of use.
2. Ask Staff about regularity of water supply.

Check for availability/ Ask staff if the supply is adequate and

uninterrupted. Availability of Alcohol based Hand rub

Prominently displayed above the hand washing facility ,

preferably in Local language

Availability of taps & Hand washing sink which is wide and

deep enough to prevent splashing and retention of water
Ask for demonstration of 6 steps of Hand washing and
knowledge among staff about moments of handwash

d materials for Personal protection

[Link] if staff is using PPEs.
2. Ask staff if they have adequate supply. 3. Verify with the
stock/Expenditure register

cessing of equipment and instruments

Ask staff about how they decontaminate the procedural surface

like Examination table , Patients Beds Stretcher/Trolleys etc.
(Wiping with 1% Chlorine solution)
Cleaning is done with detergent and running water after
decontamination

No sorting ,Rinsing or sluicing at Point of use/ Patient care area

1. Ask staff about temperature, pressure and time for

autoclaving.
2. Ask staff about method, concentration and contact time
required for chemical sterilization.
[Link] records

1. Sterile packs are kept in dry, clean, dust free, moist free
environment
2. separate from unsterilised items- no mixing with unsterile
items

patient care areas ensures infection prevention

General patient flow doesn’t pass through paediatric OPD

Preferably away from main OPD with independent access, with

no access through paediatric OPD

Chlorine solution, Glutaraldehyde, carbolic acid

Hospital grade disinfectant
Check availability of Spill management kit ,staff is trained for
managing small & large spills , check protocols are displayed
Three bucket system is followed

Unidirectional mopping is followed. Staff is trained for

preparing cleaning solution as per standard procedure. Cleaning
equipment like broom are not used in patient care areas

ction, treatment and disposal of Bio Medical and hazardous Waste.

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Means of Verification Remarks

Check if needle cutter has been used or just lying idle, it should
be available near the point of generation like nursing station

1. Staff knows what to do in

condition of needle stick
injury.
2. Ask if PEP is available. Where it is stored and who is in-charge
of that.
3. Also check PEP issuance register
Includes used vials, slides and other broken infected glass

Bins should not be filled more than 2/3 of its capacity

Check whether department is replacing mercury products with

digital products (Aspire for mercury free)
uality Management

al framework for quality improvement

1. Check if the quality circle has been constituted and is
functional
2. Roles and Responsibility of team has been defined
Check minutes of meeting and monthly measurement &
reporting of indicators

patient and employee satisfaction

Survey is done amongst parents/guardians

assurance programs wherever it is critical to quality.

Findings /instructions during the visit are recorded and actions
are taken

NQAS assessment toolkit is used to conduct internal assessment

Staff is designated for filling and monitoring of these

checklists

Check the non compliances are presented & discussed during

quality team meetings

Randomly check the details of action, responsibility, time line

and feedback mechanism

Check actions have been taken to close the gap. It can be in

form of action taken report or Quality Improvement (PDCA)
project report

dard Operating Procedures for all key processes and support services.
Check that SOP for management of OPD services has been
prepared and is formally approved

Check current version is available with all staff of Paediatric OPD

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Means of Verification Remarks

Relevant protocols are displayed like management of

pneumonia, Summary of the 10 steps to successful
breastfeeding is displayed, lactation position and milk
expression protocol are displayed in breastfeeding corner and
OPD

Review the SOP for procedure being followed for registration of

cases. Paediatric cases should be registered on priority. It is
preferable to have separate counter for paediatric cases .
Review the SOP for receiving the patient in clinic . OPD must be
equipped to handle emergency cases, in- case a patient seeking
emergency care reaches OPD , the triage and transfer process is
defined and implemented

Review the process for consultation including examination

process, counselling etc.

Review the SOP for procedure for conducting investigation. A

specific lab personnel is designated for collection of blood
samples in children. All other investigations are facilitated and
are made hassle free

1. Review the SOP for procedure for legible and rational

prescription writing . 2. For drug dispensing , a separate
pharmacy or a Drug Dispensing Counter for children is made
functional.
3. Pharmacists/nurse explain the drug dosage and route clearly
to the parents/guardians (ask patients)

Review the SOP for procedure for initial assessment of children

( weighed & weight correctly recorded, immunisation status,
children < five years are screened for SAM using MUAC, and
those with emergency and priority signs are
triaged).

Review the SOP for ensuring Privacy and confidentiality.

Review SOP for various processes which circle undertakes to

measure quality of service ( client satisfaction form, checklists ,
audits , performance indicators etc.) , analysis of the data ,
identification of low attributes, Root cause analysis and
improvement activities using PDCA methodology

Review the SOP for process

description of support services such as equipment
maintenance, calibration,
housekeeping, security, storage and inventory management

Review SOP for process description of Hand Hygiene,

personal protection, environmental cleaning, instrument
sterilization,
asepsis, Bio Medical Waste
management, surveillance and monitoring of infection control
practices

Check breastfeeding policy is part of or linked with IYCF policy

1. Check the availability of updated Risk Management

Framework. 2. Check the components of physical, fire,
operational and pt safety are covered. 3. Review the updated
mitigation plan.

fficient by reducing non value adding activities and wastages

Critical processes are identified and mapped. Value and non
value adding processes/ activities are listed.
Non value adding activities are wastes. MUDAS in terms of
waste, delays, waiting, motion, over processing , over
production etc are identified
Check the non value adding activities are removed and
processes are made lean. Improvement is sustained over a
period of time

objectives & prepared a strategic plan to achieve them

Check short term valid quality objectivities have been framed
addressing key quality issues . Check if these objectives are
Specific, Measurable, Attainable, Relevant and Time Bound.

Interview with staff for their awareness. Check if Mission

Statement, Core Values and Quality Policy is displayed
prominently in local language at Key Points

y practicing Quality method and tools.

PDCA & 5S

Minimum 2 applicable tools are used

valuating and managing risk as per Risk Management Plan

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Means of Verification Remarks

Verify with the records. A comprehensive risk assessment of all

processes should be done using pre define criteria at least once
in three month.

k to improve quality and safety of clinical care processes

Check parameter are defined & implemented to
review the clinical care i.e. through Ward round,
peer review, morbidity & mortality review, patient
feedback, clinical audit & clinical outcomes.

(1) Both critical and stable patients

(2) Check the case progress is documented in BHT/
progress notes-
Feedback is taken from patient/family on health
status of individual under treatment
System in place to review internal referral process,
review clinical handover information, review
patient understanding about their progress
(1) Random prescriptions are audited
(2) Separate Prescription audit is conducted foe
both OPD & IPD cases
(3) The finding of audit is circulated to all
concerned
(4) Regular trends are analysis and presented in
Clinical Governance board/Grand round meetings

Check the non compliances are presented &

discussed during clinical Governance meetings

Randomly check the actual compliance with the

actions taken reports of last 3 months

Check collected data is analysed & areas for

improvement is identified & prioritised

Check the critical problems are regularly monitored

& applicable solutions are duplicated in other
departments (wherever required) for process
improvement

Staff is aware of Standard treatment protocols/

guidelines/best practices

Check staff adhere to clinical protocols while

preparing the treatment plan
Check the drugs prescribed are available in EML or
part of drug formulary
Check when the STG/protocols/evidences used in
healthcare facility are published.
Whether the STG protocols are according to current
evidences.
The gaps in clinical practices are identified & action
are taken to improve it. Look for evidences for
improvement in clinical practices using PDCA
- H Outcome

ures compliance with State/National benchmarks

Total and age group wise (neonate, 1 month to 6 months,

6months to 1 year, 1 -2 year , 2 - 5 years)
Total and age group wise (neonate, 1 month to 6 months,
6months to 1 year, 1 -2 year , 2 - 5 years )

Total and age group wise (neonate, 1 month to 6 months,

6months to 1 year, 1 -2 year , 2 - 5 years )
Total and age group wise (neonate, 1 month to 6 months,
6months to 1 year, 1 -2 year , 2 - 5 years )
Total and age group wise (neonate, 1 month to 6 months,
6months to 1 year, 1 -2 year , 2 - 5 years )
Diarrhoea, pneumonia, fever etc.
Diarrhoea, pneumonia, fever etc.

ensure to reach State/National Benchmark

check for pharmacy/drug dispensing counter dedicated to

paediatric OPD

ors and tries to reach State/National benchmark

Time motion study

up to 6 months of age

endeavours to reach State/National benchmark

Parent- attendant group only

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Means of Verification Remarks

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Checklist No. 5 Paediatrics Ward Version- NHSRC/3.0

National Quality Assurance Standards for District Hospitals

Checklist for Paediatrics Ward
Assessment Summary
Date of Assessment
Name of the Hospital GHQH Erode

Names of Assessors [Link], Vanitha S/N Names of Assesses

Type of Assessment (Internal/External) Internal Action plan Submission Date

Paediatrics Ward Score Card

Area of Concern wise Score
MusQan Paediatrics Ward Score
Service Provision
A 84%
Patient Rights
B 87%
Inputs
C 82%
Support Services

82%
D 71%
Clinical Services
E 84%
Infection Control
F 81%
Quality Management
G 79%
Outcome
H 94%

Major Gaps Observed

The facility has established process to review the clinical care

1

Management of child presenting with uncomplicated malaria

2

3 Availability of certificate of inspection of electrical installation

4 Assessment & Management of airway due to breathing obstructions/failure

5 Indoor Management of Severe Acute Malnutrition

Strengths / Good Practices

Recommendations/ Opportunities for Improvement

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Signature of Assessors

Date

Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
Area of Concern - A Service Provision

Standard A1 The facility provides Curative Services

ME A1.4 The facility provides Paediatric Services Availability of dedicated paediatric ward (1)Assessment, investigation & treatment of admitted sick
children.
(2) Monitoring and supportive care for sick children
(3) Early identification & referral of children at higher centre (for
services not covered under the scope of DH)
Give non compliance if paediatric care is given in general male/
2 SI/OB female ward

Availability of diarrhoea treatment unit (1) Assessment for dehydration

(2) Management according to degree of
dehydration
(3)Rational use of drugs in children with
2 SI/OB diarrhoea/dysentery
(4) Counselling on feeding, danger signs,
prevention of diarrhoea

Availability of isolation rooms Segregation and management of children

2 SI/OB with infectious diseases (source isolation)

ME A1.14 Services are available for the time period as mandated Availability of nursing care service 24*7
2 SI/PI

ME A1.17 The facility provides Intensive care Services Availability of High dependency unit

(1) Close , monitoring and treatment to children who have

2 SI/OB potential to be physiologically unstable
(2) Management of children requiring constant oxygen therapy,
cardiorespiratory monitoring, inotropic support.
(3) Hospital has established linkage for referral and management
with tertiary care unit (Paediatric Intensive Care Unit; PICU) if the
condition of child deteriorates
ME A1.18 The facility provides Blood bank & transfusion services Availability of blood transfusion services
2 SI/RR

Standard A2 The facility provides RMNCHA Services

ME A2.4 The facility provides Child health Services Indoor Management of Acute respiratory ARI/Bronchitis, Asthmatics, Pneumonia
infections 2 SI/RR
Indoor Management of Severe Diarrhoea 2 SI/RR Severe dehydration & shock
Indoor Management of childhood illness Meningitis, Liver diseases, convulsions disorders, childhood
malignancies, vision & hearing impairment, severe anaemia,
1 SI/RR Goitre, Pyrexia of unknown reason.

Indoor Management of Severe Acute Including vitamin & micronutrient deficiency

Malnutrition 0 SI/RR

Management of bones & joints conditions Subluxation of elbow, Rickets, Developmental dysplasia of hip,
open & close reduction of bones
1 SI/RR

Management of emergency conditions in Accidental poisoning, Comma, convulsions, stings, bites, poisoning,
children 2 SI/RR paediatric surgical conditions
Standard A3
The facility Provides diagnostic Services
ME A3.1 The facility provides Radiology Services Availability of X ray services (1) Check for functional X ray services for indoor patients
(2) Check services are available at night
(3) Check records no. of paediatric cases seen in past three
2 OB/RR months to avail X-Ray services for Chest, Skull, Spine, Abdomen,
bones & Dental etc

Availability of USG services (1) Check for functional USG services

(2) Check records no. of paediatric cases seen in past three
months to avail USG services
2 OB/RR (3)Availability of USG services for neonatal head- using probe for
anterior fontanel to check oedema

ME A3.2 The facility Provides Laboratory Services Availability of laboratory services Complete blood profile, CSF analysis, urine & stool analysis
(Routine & Microscopy), sickle cell anaemia, thalassemia, culture
sensitivity, Wilda ,Elisa, RA factor, LFT ,KFT, serum electrolyte,
serum calcium, serum bilirubin, BUN, Elisa for TB, Immunoglobin
profile, Clotting time etc.
1 RR/OB

ME A3.3 The facility provides other diagnostic services, as Availability of services for Lumber puncture
mandated & fundoscopy
1 RR/SI

Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme
ME A4.1 The facility provides services under National Vector Borne Indoor management of Vector Borne Indoor management of malaria, Chikungunya in endemic areas.
Disease Control Programme as per guidelines Diseases Check the records for management of cases in last one year

2 SI/RR

ME A4.2 The facility provides services under national tuberculosis Indoor management of paediatric
elimination programme as per guidelines. tuberculosis
1 SI/RR

ME A4.12 The facility provides services as per Rashtriya Bal Swasthya Availability of management services of 4 D's 1. Linkages with DEIC for rehabilitative care
Karykram (Defects at birth, Deficiencies, Childhood 2 SI/RR 2. Management of developmental dysplasia of hip, congenital
diseases, Developmental delays & cataract, severe anaemia, Goitre, skin conditions, Otitis Media,
Standard A5 Disabilities) convulsions, vision impairment, hearing impairment, club foot
The facility provides support services

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
ME A5.1 The facility provides dietary services
2 SI/OB
Availability of dietary services
ME A5.2 The facility provides laundry services
2 SI/OB
Availability of laundry services
ME A5.3 The facility provides security services

1 SI/OB

Availability of functional security services

ME A5.4 The facility provides housekeeping services including waste disposal
2 SI/OB
Availability of Housekeeping services
ME A5.7 The facility has services of medical record department
2 SI/OB
Availability of services for maintenance &
storage of clinical records
Standard A6
Health services provided at the facility are appropriate to community needs.
ME A6.1 The facility provides curatives & preventive services for Availability of indoor services as per local Acute encephalitis Syndrome (AES), endosulfane, arsenic
the health problems and diseases, prevalent locally. prevalent disease poisoning ,haemophilia etc in children.
2 SI/RR Give full compliance if no such disease exist in area

Area of Concern - B Patient Rights

Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 Availability departmental &directional Numbering, main department and internal sectional signage.
The facility has uniform and user-friendly signage system signage 2 OB Directional signages are given from the entry of the facility
ME B1.2 The facility displays the services and entitlements Information regarding services are displayed Visiting hours and visitor policy are displayed, Entitlement under
2 OB RBSK, PMJAY or any state specific scheme are displayed,
available in its departments
Necessary Information regarding services Name of doctor and Nurse on duty are displayed and updated.
provided is displayed 2 OB Contact details of referral transport / ambulance displayed
ME B1.4 User charges for services are displayed User charges if any, are displayed and communicated to parent-
User charges are displayed and communicated to patients 2 OB
attendants.
effectively

ME B1.5 IEC Material is displayed Breast feeding, immunization schedule, Management of diarrhoea
Patients & visitors are sensitised and educated through using Zn & ORS, Pneumonia prevention, nutrition requirement of
2 OB children, hand washing, Eat Healthy & Eat safe etc
appropriate IEC / BCC approaches

Check Paediatric ward, HDU, waiting areas etc.

No display of poster/ placards/
pamphlets/videos in any part of the Health
facility for the promotion of breast milk 2 OB
substitute , feeding bottles, teats or any
product as mentioned under IMS Act

No display of items and logos of companies

1. Check in paediatric wards , waiting areas, HDU etc.
that produce breast milk substitute, feeding
2 OB 2. Check staff is not using pen, note pad, pen stand etc. which
bottles, teats or any product as mentioned
have logos of companies' producing breast milk substitute etc.
under IMS Act

No information, counselling and educational

During counselling Mothers and families has been specially
material is provided to mothers and families 2 PI/SI
educated about ill effects of breast milk substitutes/ formula feed
on Formula Feed
ME B1.6 Information is available in local language and easy to Signages and information are available in Check all information for patients/ visitors are available in local
local language 2 OB language
understand
ME B1.8 Discharge summary is given to the patient Check discharge summary provides
1. Information on follow up
2. Diet to be followed at home
The facility ensures access to clinical records of patients to 1 RR/OB 3. Contact number for emergency
entitled personnel 4. Collaboration for community based care

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 economic, cultural or social reasons.
ME B2.1 Services are provided in manner that are sensitive to Cots in Paed .ward are large enough for stay Check Paediatric size cots are not used, As mother/ care giver has
of mother with child 2 OB to stay along with baby through out the treatment days
gender
Availability of Breast feeding corner Check availability of demarcated area for breastfeeding corner
2 OB along with curtains for privacy & seating arrangement
ME B2.3 Availability of Wheel chair /stretcher for easy
access to paed. Ward
1 OB
Access to facility is provided without any physical barrier
& and friendly to people with disabilities
Availability of ramps and railing
If not located on the ground floor availability of the ramp / lift
1 OB If ramp is available check it is at least 120 cm width, gradient not
steeper than 1:12

Availability of disable friendly toilet Wide , placed at lower level, supported with bars & door of toilet
1 OB is opening outside

Availability of children friendly toilet Children friendly- low WC seats; washbasins at appropriate height,
0 OB lever operated taps

ME B2.4 Check care to child is not denied or deferred

due to religion, caste, ethnicity, language,
There is no discrimination on basis of social and economic paying capacity, educational level & disease 2 OB/PI
status of the patients conditions

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Bracket screen
Adequate visual privacy is provided at every point of care Availability of screen at examination room 2 OB
/area
Availability of screen/curtain at (1) Secondary curtain/ screen is used to create a visual barrier in
breastfeeding corner 2 OB breastfeeding area

Curtains / frosted glass have been provided Check all the windows are fitted with frosted glass or curtains have
at windows 1 OB been provided
ME B3.2 Patient Records are kept at secure place (1) Check records are not lying in open and there is designated
Confidentiality of patients records and clinical information beyond access to general staff/visitors 1 SI/OB
space for keeping records with limited access.
(2) Records are not shared with anybody without permission of
is maintained parents & appropriate hospital authorities

No information regarding patient's identity Specially HIV or any such cases

and details are unnecessary displayed on 2 SI/OB
records
ME B3.3 Behaviour of staff is empathetic and Check that staff is not providing care in undignified manner such
The facility ensures the behaviours of staff is dignified and courteous 2 PI/OB as yelling, scolding , shouting, blaming and using abusive language
respectful, while delivering the services etc
Child is not left unattended or ignored Check that children are left alone at any point of care. Either HCW
during care 2 OB/PI or their parents/ guardian are available with them
ME B3.4 HIV status of child is not disclosed except to Check if HIV status is not displayed / written at bed side or
staff that is directly involved in care records etc
The facility ensures privacy and confidentiality to every
patient, especially of those conditions having social 2 PI/ OB
stigma, and also safeguards vulnerable groups

Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it is required.
ME B4.1 Check General Consent is taken in case sheet
There is established procedures for taking informed Paed. ward has system in place to take
informed consent from patient relative 2 PI/RR
consent before treatment and procedures
whenever required
ME B4.4
Information about the treatment is shared with patients Check parents/ relatives of admitted baby is communicated
Parents/ relatives are communicated about 2 PI about child condition, treatment plan and any changes at least
or attendants, regularly
child condition to at least once in day once in day

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
ME B4.5 The facility has defined and established grievance Availability of complaint box and display of
redressal system in place process for grievance re addressal and whom 2 OB Check the completeness of the Grievance redressal mechanism ,
to contact is displayed from complaint registration till its resolution

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.
ME B5.1 The facility provides cashless services to pregnant women, Indoor treatment is free For RBSK, PMJAY or any state specific scheme patient
mothers and neonates as per prevalent government 2 PI/SI
schemes
For JSSK, RBSK patient etc
2 PI/SI
Availability of free blood, diagnostic & drugs
Availability of free transport services 2 PI/SI Availability of Free referral vehicle/Ambulance services.
(1) For both parent-attendant & Child
1 PI/SI (2) Availability two meals per
paediatric bed per shift (breakfast, lunch & dinner).
Availability of free stay & Diet
ME B5.2 Check that patient party has not spent on
The facility ensures that drugs prescribed are available at purchasing drugs or consumables from 2 PI/SI
Pharmacy and wards outside.
ME B5.3 It is ensured that facilities for the prescribed investigations Check that patient party has not spent on 2 PI/SI
are available at the facility diagnostics from outside.
ME B5.5 If any other expenditure occurred it is
reimbursed from hospital
The facility ensures timely reimbursement of financial 2 PI/RR
entitlements and reimbursement to the patients

Area of Concern - C Inputs

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
ME C1.1 Departments have adequate space as per patient or work Adequate space in wards as per patient load (1) Check there is no cluttering of beds
load (2) The space between 2 rows of beds is 5 feet and space between
1 OB two beds 3.5-4.00 feet. Clearance of bedhead from the wall is 1
feet and 2 feet from the opposite bed.

ME C1.2 Patient amenities are provide as per patient load Functional toilets with running water and 1 Water Closet for every 6 Indoor beds & 2 washbasin up to 24
2 OB persons
flush are available
Functional bathroom with running water are 1 bathroom for every 6 indoor beds
1 OB
available
Availability of potable drinking water 2 OB In paediatric ward /in its vicinity
TV for entertainment and health promotion 0 OB
Availability of sitting arrangement for patient Availability shaded waiting area for attendant with functional
1 OB toilet & hand washing facility
attendant
Switches for all beds with indicator lights and
1 OB location indicator in the nurses’ duty station specially if cubicle
arrangement is followed
Availability of bedside lockers & call bell
ME C1.3 Departments have layout and demarcated areas as per
functions 2 OB
Availability of dedicated nursing station
Demarcated area for Examination & 2 OB
Treatment
Availability of Diarrhoea In the ward area, preferably adjacent to
treatment unit 2 OB paediatric ward or in emergency area
Availability of isolation room 2 SI/OB Separate room/s, preferably close to paediatric ward
Designated of play room / area 2 OB
Availability of Doctor's & nurses Duty room 2 OB
Availability of ancillary area 2 OB Stores, dirty utility areas
ME C1.4 The facility has adequate circulation area and open spaces Availability of adequate circulation area for of both staff and equipment
according to need and local law easy moment 1 OB

Corridors are wide enough for patient, visitor 2 OB

and trolley/ equipment movement Corridor should be 3 meters wide
ME C1.5 The facility has infrastructure for intramural and Availability of functional telephone and
extramural communication 2 OB
Intercom Services
ME C1.6 Service counters are available as per patient load Availability of IPD beds as per case load (1) 8-10% of hospital beds are allocated for paediatric ward
2 OB
ME C1.7 The facility and departments are planned to ensure Location of nursing station & patient beds
structure follows the function/processes (Structure enables easy & direct observation of patient
1 OB
commensurate with the function of the hospital)

Arrangement of different section ensures 1 OB

unidirectional flow Unidirectional flow of goods and services.

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

ME C2.1 The facility ensures the seismic safety of the infrastructure Non structural components are properly Check for fixtures and furniture like cupboards, cabinets, and
secured 1 OB heavy equipment , hanging objects are properly fastened and
secured
ME C2.2 The facility ensures safety of lifts and lifts have required Check functional lift is available (1) Ward located preferably close to the lift.
certificate from the designated bodies/ board Give full compliance if ward is at ground floor
0 OB

ME C2.3 The facility ensures safety of electrical establishment Paediatric building does not have temporary a. Switch Boards other electrical installations are intact.
connections and loosely hanging wires B. Check adequate power outlets have been provided as per
2 OB requirement of electric appliances and
c. Electrical points are out of reach of children/ covered

ME C2.4 Physical condition of buildings are safe for providing Check physical infrastructure of the 1. Windows have grills and wire meshwork
patient care paediatric ward is safe & secure for children 2 OB 2. Paediatric wards are non-slippery and even
3. Open spaces are properly secured to prevent fall and injury

Standard C3 The facility has established Programme for fire safety and other disaster
ME C3.1 The facility has plan for prevention of fire Paediatric ward has sufficient fire exit to Check the fire exits are clearly visible and routes to reach exit are
permit safe escape to its occupant at time of 2 OB/SI clearly marked. Check there is no obstruction in the route of fire
fire exits. Staff is aware of assembly points .
ME C3.2 The facility has adequate fire fighting Equipment Paediatric ward has installed fire Check the expiry date for fire extinguishers are displayed on each
Extinguisher that is either Class A , Class B, C extinguisher as well as due date for next refilling is clearly
type or ABC type 2 OB mentioned

ME C3.3 The facility has a system of periodic training of staff and Check for staff competencies for operating Staff is aware of RACE (Rescue, Alarm, Confine & Extinguish) &
conducts mock drills regularly for fire and other disaster fire extinguisher and what to do in case of PASS (Pull, Aim, Squeeze & Sweep)
situation fire 1 SI/RR

Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
ME C4.1 The facility has adequate specialist doctors as per service Availability of Paediatrician Check for on call during evening and night shifts also.
provision 2 OB/RR

ME C4.2 The facility has adequate general duty doctors as per Availability of general duty doctor Trained for managing paediatric cases & providing paediatric care
service provision and work load 2 OB/RR

ME C4.3 The facility has adequate nursing staff as per service Availability of nursing staff As per patient load (One nurse for 4-6 functional beds)
provision and work load 1 OB/RR

ME C4.5 The facility has adequate support / general staff Availability of ward attendant & security Availability of mamta/ ayahs, Sanitary worker & security guard
guard 1 SI/RR

Standard C5 The facility provides drugs and consumables required for assured services.
ME C5.1 The departments have availability of adequate medicines Availability of antibiotics Ampicillin, Gentamicin, ,Cefotaxime, Ceftriaxone, benzyl
at point of use pencillin,cloxacillin, cephalosporin, ciprofloxacin cotrimoxazole,
2 OB/RR Doxycycline,Metrindazol, Albendazole

Availability of oral medicines Syrup Chloroquine, artesunate (Anti malarial medicines),

Paracetamol, Vitamin A, IFA tablets, Salbutamol,
Frusemide tablets, Anti TB medicines, Iron syrup, adrenaline,
2 OB/RR calcium gluconate , digoxin, Manitol,Nebuliser solution of
salbutamol

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
Availability of parental medicines Ringer’s lactate, normal saline , glucose 5%, 10 % & 25%,
corticosteroid IV,Furosemide IV, diazepam IM/ IV, cephalosporins
IV, Calcium gluconate, Vit K, Potassium chloride, Sodium
bicarbonate, Magnesium sulphate inj, Antihistaminic inj,
2 OB/RR Ranitidine inj.

ME C5.2 The departments have adequate consumables at point of Consumables for Paediatric ward Plastic / disposable syringes
use · IV cannulas (22G and 24G)
· Scalp vein set No. 22 and 24
· IV infusion sets (micro infusion), infusion pump for drip, simple
2 OB/RR rubber catheter, Nasal prongs, masks

Resuscitation consumables Nasogastric tube (8,10,12FG)

Suction catheter (6,8,10 FG)
Uncuffed tracheal tube (all sizes)
Oropharyngeal airway, self inflating bags for resuscitation
2 OB/RR 250&500ml

ME C5.3 Emergency drug trays are maintained at every point of Emergency Drug Tray is maintained Normal Saline (NS),Glucose 25%,Ringer Lactate (RL),Dextrose
care, where ever it may be needed 5%,Potassium Chloride,Calcium Gluconate,Sodium Bicarbonate,Inj
Pheniramine,Inj Hydrocortisone Hemisuccinate/ Hydrocortisone
Sodium Succinate ,Inj Phenobarbitone,Inj Phenytoin,Inj
Diazepam,Inj Midazolam,Salbutamol Respiratory,Ipratropium
2 OB/RR Respirator solution for use in nebulizer,Inj Dopamine,I.V Infusion
set,I.V Cannula (20G/22G/24G/26G) & Nasal Cannula(Infant, Child,
Adult) & oxygen

Standard C6 The facility has equipment & instruments required for assured list of services.
ME C6.1 Availability of equipment & instruments for examination Availability of functional Equipment Weighing machine( infant & adult), Stadiometer for height,
& monitoring of patients &Instruments for examination & Infantometer for length, paediatric & adult stethoscope, plus
Monitoring oximeter.
2 OB BP apparatus with paediatric cuff, multipara monitor,
Thermometer, torch ,

ME C6.2 Availability of equipment & instruments for treatment Availability of instrument for treatment & Nebulizer, spacer with mask for administration of metered doses,
procedures, being undertaken in the facility procedures otoscope, ophthalmoscope, dressing tray, nebulizer
2 OB

ME C6.3 Availability of equipment & instruments for diagnostic Availability of Point of care diagnostic Glucometer, Urine Dipsticks, RDT for malaria, Typhoid, Dengue &
procedures being undertaken in the facility instruments portable x ray (may be shared with main hospital)
2 OB

ME C6.4 Availability of equipment and instruments for Availability of functional Instruments for Face masks (3 type; Neonate, Infant and paediatric type)
resuscitation of patients and for providing intensive and Resuscitation. Self-inflating ventilation bag (all sizes), Laryngoscope,
critical care to patients 2 OB Suction machines Oxygen supply, ET tube (different sizes)

ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for Refrigerator, Crash cart/Drug trolley, instrument trolley, dressing
drugs 2 OB trolley
ME C6.6 Availability of functional equipment and instruments for Availability of equipment for cleaning & Buckets for mopping, mops, duster, waste trolley, Deck brush,
support services disinfection 2 OB

ME C6.7 Departments have patient furniture and fixtures as per Availability of patient beds with attachments
load and service provision &accessories
2 OB
Prop up facility Hospital graded mattress, Bed side locker ,
IVstand, Bed pan, bed rail
Availability of Fixtures Electrical fixture for equipment like suction, X ray view box, cool
1 OB white fluorescent light/CFL or LED ,

2 OB Cupboard, nursing counter, table for preparation of medicines,

Availability of furniture chair, Call bell

Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff
ME C7.1 Criteria for Competence assessment are defined for clinical
and Para clinical staff Check objective checklist has been prepared for assessing
Check parameters for assessing skills and 1 SI/RR competence of doctors, nurses and paramedical staff based on job
proficiency of clinical staff has been defined description defined for each cadre of staff.
ME C7.2 Check for competence assessment is done at Check for records of competence assessment including filled
least once in a year checklist, scoring and grading . Verify with staff for actual
competence assessment done
1 SI/RR
Competence assessment of Clinical and Para clinical staff is
done on predefined criteria at least once in a year
ME C7.9 Training on child Care
The Staff is provided training as per defined core competencies 2 OB/RR Infant and young Child Feeding ( IYCF) practices, ETAT, FIMNCI,
and training plan Immunization, Effective communication skills
Training on Infection prevention & patient
safety 2 SI/RR Biomedical Waste Management& Infection control and hand
hygiene ,Patient safety
2 SI/RR
Training on Quality Management Assessment, action planning, PDCA, 5S & use of checklist
ME C7.10 There is established procedure for utilization of skills gained Check facility has system of on job 1. Check supervisors make periodic rounds of department and
thought trainings by on -job supportive supervision monitoring and training monitor that staff is working according to the training imparted.
1 SI/RR 2. Also staff is provided with on job training wherever there is still
gaps

Area of Concern - D Support Services

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

There is system of timely corrective break

down maintenance of the equipment
(1) Check log book is maintained & it shows time taken to repair
equipment.
2 SI/RR (2) Backup of critical equipment such as suction machine,
nebuliser & pulse oximeter is available
(3) Check staff is aware of Contact details of the agencies/ person
responsible for maintenance

ME D1.2 The facility has established procedure for internal and All the measuring equipment/ instrument BP apparatus, thermometers weighting scale etc. are calibrated.
external calibration of measuring Equipment are calibrated Check for calibration stickers & records
1 OB/ RR

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas
ME D2.1 There is established procedure for forecasting and
indenting medicines and consumables There is established system of timely
indenting of consumables and medicines at 2 SI/RR 1. Stock is updated on defined intervals
nursing station 2. Requisition are timely placed based on consumption pattern
medicines are intended in Paediatric 1 OB/RR
dosages/formulations only
Forecasting of medicines and consumables
is done scientifically based on consumption 2 RR/SI
and disease load Staff is trained for forecast the requirement using scientific system
ME D2.3 The facility ensures proper storage of medicines and medicines are stored in
consumables containers/tray/crash cart and are labelled 1 OB

Empty and filled cylinders are labelled & 1. Flow meter, humidifier, cylinder keys & updated data sheet is
kept separately 1 OB available with in use of cylinders.
ME D2.4 The facility ensures management of expiry and near expiry Expiry dates' of medicines are maintained Records for expiry and near expiry medicines are maintained for
medicines 2 OB/RR drug stored in department & emergency tray
No expired drug found 2 OB/RR Check drug sub store & emergency tray
ME D2.5 The facility has established procedure for inventory There is practice of calculating and Minimum stock and reorder level are calculated based on
management techniques maintaining buffer stock in paediatric ward 1 SI/RR consumption
Minimum buffer stock is maintained all the time

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
Department maintained stock and Check stock and expenditure register is adequately maintained
expenditure register of medicines and 2 RR/SI
consumables

ME D2.6 There is a procedure for periodically replenishing the medicines There is no stock out of vital and essential There is procedure for replenishing medicines in emergency tray
in patient care areas medicines 2 SI/RR and sub stores maintained in department

ME D2.7 There is process for storage of vaccines and other Temperature of refrigerators are kept as per Check for temperature charts are maintained and updated
medicines, requiring controlled temperature storage requirement and records are periodically.
maintained 2 OB/RR Refrigerators meant for storing medicines should not be used for
storing eatables

ME D2.8 There is a procedure for secure storage of narcotic and Check narcotic and psychotropic medicines
psychotropic medicines are kept in lock & key
1 OB/RR

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
ME D3.1 The facility provides adequate illumination level at patient Adequate illumination at nursing station & 150 Lux at patient bedside along with Provision of natural light.
care areas patient care areas Illumination of 100 Lux in ward. Illumination level at nursing
2 OB station- 150-300 Lux.

ME D3.2 The facility has provision of restriction of visitors in patient Visitor policy is defined & implemented (1) Only one female/ family members allowed to stay with the
areas child, Visiting hour are fixed and practiced
2 OB/PI (2) There is no overcrowding in the ward

ME D3.3 The facility ensures safe and comfortable environment for Temperature control and ventilation in Room kept between 25° - 30° C (to the extent possible) Fans/ Air
patients and service providers patient care area nursing station/duty room conditioning/Heating/Exhaust/Ventilators as per environment
1 PI/OB condition and requirement

Safe measures used for re-warming children Check availability of Blankets to cover the children/ functional
1 SI/OB room heaters
Side railings has been provided to prevent
fall of patient 2 OB
ME D3.4 The facility has security system in place at patient care Identification band for all children 1. Identification band for all children admitted in Paediatric ward
areas 2. Identification band specially for children below 5 years and their
parent / attendant
2 OB

Functional CCTV is installed (may be shared with main hospital)

1 OB/SI
Security arrangement in Paediatric Ward
ME D3.5 The facility has established measure for safety and security of Ask female staff whether they feel secure at
female staff work place 2 SI

Standard D4 The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior & Interior of the facility building is maintained Building is painted/whitewashed in uniform Check building is plastered, painted/ whitewashed in uniform
appropriately colour 1 OB colour
Interior walls of ward are brightly painted Check walls are painted with cartoon characters/ animals/ plants/
and decorated 1 OB under water/ jungle themes etc
ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof tops, sinks, patient 1. All area are clean with no dirt,grease,littering and cobwebs.
care and circulation areas are Clean 2. Surface of furniture and fixtures are clean
3. Cleanliness and maintenance of child zone including their
1 OB swings and toys is ensured

Toilets are clean with functional flush and Check toilet seats, floors, basins etc are clean and water supply
running water 1 OB with functional cistern
ME D4.3 Hospital infrastructure is adequately maintained Check for there is no seepage , Cracks, Window panes , doors and other fixtures are intact
chipping of plaster 1 OB

Mattresses are Intact and clean

1 OB
Patients beds are intact and painted
ME D4.5 The facility has policy of removal of condemned junk No condemned/Junk material in the ward Check if any obsolete
material article including equipment, instrument, records, drugs and
2 OB consumables

ME D4.6 The facility has established procedures for pest, rodent No stray animal/rodent/birds (1) No lizard, cockroach, mosquito, flies, rats, bird nest etc.
and animal control 0 OB (2) Anti Termite treatment on wooden items on defined intervals

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
ME D5.1 The facility has adequate arrangement storage and supply Availability of 24x7 running and potable Check for round the clock piped water supply with overhead tank
for portable water in all functional areas water
1 OB/SI

ME D5.2 The facility ensures adequate power backup in all patient Availability of power back up in patient care Check availability of power back with 1-2 outlets connected to
care areas as per load areas 2 OB/SI generator supply, check for functional UPS /emergency lights

StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.
ME D6.1 The facility has provision of nutritional assessment of the Nutritional assessment of all children done 1. Check nutritional Assessment is done to provide age
patients specially high risk cases appropriate diet by dietician/ nutrition counsellor / doctor.
2. Special nutritional advice is given for cases like diarrhoea, mild
under nutrition & disease conditions / specific food intolerance
etc
3. Check caregiver/ mother of all children below two years are
1 RR/SI directed to the counselling centre for breastfeeding & age-
appropriate counselling.

ME D6.2 The facility provides diets according to nutritional Check the procedure for requisition of (1) Check dietary requirement of children of various ages are taken
requirements of the patients different type of diet from ward to kitchen into consideration in menu/ diet chart of the hospital
(2) Check the menu includes
2 OB/RR choices that are appropriate to the different cultural needs of
children and their families

Check for the adequacy and frequency of Ask attendant/ patient whether they are satisfied with the Quality
diet as per nutritional requirement 1 OB/PI & quality of food provided

Check for Two meals / paediatric bed/ shift is ordered

1 PI/RR
Check facility provide diet for child parents/
guardian staying along with baby
ME D6.3 Hospital has standard procedures for preparation, handling, Check paediatric ward is not Give non compliance if same adult food is provided to children in
storage and distribution of diets, as per requirement of patients supplied with the same food as adults 2 PI/SI paediatric ward
1. Check food is transported in covered trolley from
Check standard procedures are followed for kitchen/pantry to ward,
transportation & distribution of diet 2. Food is distributed away from clinical area,
3. Distribution staff adhere to their PPE
4. Check utensil provided are not broken & chipped off.
1 RR/SI 5. Check the condition of trolley whether it is clean and free from
pests.
6. Check the frequency and method of cleaning of food trolley
from inside.

Standard D7 The facility ensures clean linen to the patients

ME D7.1 The facility has adequate sets of linen Clean Linens are provided for all occupied Check adequate availability of Blankets, draw sheet, bed sheets,
1 OB/RR
bed pillow with pillow cover and mackintosh.
Child friendly bright coloured and soft linen 2 OB/RR Check linen used in paediatric ward is having cartoon characters/
is used animals/ plants/ jungle themes etc.
ME D7.2 The facility has established procedures for changing of Linen is changed every day and whenever it Ask parents whether the linen is changed as soon as it gets soiled
linen in patient care areas get soiled
2 PI/RR

ME D7.3 The facility has standard procedures for handling , collection, There is system to check the cleanliness and 1. Check linen is clean, stains free & not torn,
transportation and washing of linen Quantity of the linen received from laundry 2. Check what action is taken in case the linen is torn/ still
1 SI/RR
stained/ unclean.

Standard D10 The facility is compliant with all statutory and regulatory requirement imposed by local, state or central government

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
The facility has requisite licences and certificates for Availability of valid No objection Certificate Shared with main hospital building
operation of hospital and different activities from fire safety authority
ME D10.1 2 RR

Availability of authorization for handling Bio Shared with main hospital building
Medical waste from pollution control board
2 RR

Availability of certificate of inspection of Shared with main hospital building

electrical installation 0 RR
Availability of licence for operating lift 0 RR Shared with main hospital building
Updated copies of relevant laws, regulations and IMS Act 2003 1. Check staff is able to explain the key messages of IMS Act
government orders are available at the facility (Atleasr 3 messages)
(a) Prohibition from any kind of promotion and advertisement of
infant milk substitutes, (b) prohibition of providing free samples
and gifts to pregnant women or mother, (c) prohibit donation of
free or subsided free samples,
(d) prohibit any contact of manufacturer or distributor with staff
ME D10.2 2 OB/ RR 2. Hoarding describing the provision of IMS act is displayed in the
facility

Protection of children from Sexual offenses Check staff is aware of key points of medical examination of
Act 2012 & guidelines 2013 sexually assaulted child
(1) Take written Consent- Either child/ parents
(2) Document the question asked
(3) Ensure adequate privacy
(4) Ask the child whom they would like to accompany them during
physical examination
2 OB/ RR (5) If child resist, examination may be deferred
(6) If the victim is girl child assessment shall be conducted by
women doctor

2 OB/ RR
Code of Medical ethics 2002
The facility ensure relevant processes are in compliance No information, counselling and
with statutory requirement educational material is provided to
ME D10.3 mothers and families on Formula Feed 2 PI
for children

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
ME D11.1 The facility has established job description as per govt Job description is defined and Regular + contractual
guidelines communicated to all concerned staff 1 RR

ME D11.2 The facility has a established procedure for duty roster There is procedure to ensure that staff is Check for system for recording time of reporting and relieving
and deputation to different departments available on duty as per duty roster (Attendance register/ Biometrics etc)
1 RR/SI

ME D11.3 The facility ensures the adherence to dress code as Doctor, nursing staff and support staff As per hospital dress code
mandated by its administration / the health department adhere to their respective dress code
2 OB

Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
ME D12.2 There is a system of periodic review of quality of out sourced There is procedure to monitor the quality Verification of outsourced services
services and adequacy of outsourced services on (cleaning/Laundry/Security/Maintenance) provided are done by
regular basis 1 SI/RR designated in-house staff.

Check the penalty clause if no services / non satisfactory services

are provided
Area of Concern - E Clinical Services

Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
ME E1.1 The facility has established procedure for registration of Unique identification number is given to Check for that patient demographics like Name, age, Sex, UID
patients each patient during process of registration & Chief complaint, etc. are recorded in admission records
admission 2 RR

ME E1.3 There is established procedure for admission of patients There is established criteria for admission Check the criteria is defined for admission based on age, clinical
2 SI/RR sign & symptoms , patient condition, etc & followed
There is no delay in treatment because of Admission is done by written order of a qualified doctor. Time of
admission process 2 SI/RR/OB admission is recorded in patient record.

ME E1.4 There is established procedure for managing patients, in

case beds are not available at the facility 2 OB/SI
1. Check for provision of extra beds
Procedure to cope with surplus patient load 2. Check no two children are treated at one bed

Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.
ME E2.1 There is established procedure for initial assessment of (1) Check process of initial assessment, triage, identification of
patients emergency, priority & non urgent signs are defined & followed.
(2) Check time for initial assessment done is recorded in BHT
2 RR/SI
Criteria for initial assessment is defined &
practiced

Check BHT :-
1. General condition including vital signs are documented
2. Patient H/O is taken & documented
2 RR 3. Provisional diagnosis is made & written
Patient History, Physical Examination & 4. Initial treatment to start is recorded
Provisional Diagnosis is done and recorded
Initial assessment is documented preferably within 2 hours
Initial assessment and treatment is provided
immediately 2 RR/SI

ME E2.2 There is established procedure for follow-up/ Check BHT for adherence on frequency of assessment
reassessment of Patients 2 RR/OB
There is fixed schedule for assessment of
stable & critical patient
There is system in place to identify and
Criteria is defined for identification, and management of high risk
manage the changes in Patient's health 2 SI/RR
patients/ patient whose condition is deteriorating
status

Check the treatment or care plan is modified Check the re assessment sheets/ Case sheets modified treatment
2 SI/RR
as per re assessment results plan or care plan is documented

There is established procedure to plan and deliver Check healthcare needs of all hospitalised Assessment includes physical assessment, history, details of
ME E2.3 appropriate treatment or care to individual as per the patients are identifed through assessment 2 SI/RR existing disease condition (if any) for which regular medication is
needs to achieve best possible results process taken as well as evaluate psychological ,cultural, social factors
(a) According to assessment and investigation findings (wherever
applicable).
Check treatment/care plan is prepared as (b) Check inputs are taken from patient or relevant care provider
2 RR
per patient's need while preparing the care plan.

Care plan include:, investigation to be conducted, intervention to

Check treatment / care plan is documented 2 RR be provided, goals to achieve, timeframe, patient education, ,
discharge plan etc
Check care is delivered by competent Check care plan is prepared and delivered as per direction of
2 SI/RR
multidisciplinary team qualified physician

Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 The facility has established procedure for continuity of Facility has established procedure for
care during interdepartmental transfer handing over of patients during
departmental transfer 2 SI/RR
Check process followed to transfer/ handover the patient to &
from OT, HDU, NRC, emergency etc

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
There is a procedure for consultation of the
patient to other specialist with in the Check the process followed in case child require referral to any
hospital 2 RR/SI speciality including DEIC

Children requiring close supervision, monitoring & supervision,

significant potential for physiologically unstable, management of
children requiring consent oxygen supply, cardio respiratory
monitoring, inotropic support etc
2 RR/SI
Paediatric ward/ emergency has established
criteria for discharge/transfer to High
dependency unit
ME E3.2 The facility provides appropriate referral linkages to the
patients/Services for transfer to other/higher facilities to A referral slip/card is provide to patient when referred to another
2 RR/SI health care facility.
assure the continuity of care.
Patient referred with referral slip Check reason for referral are clearly mentioned.
1. Referral vehicle is arranged
2 RR/SI 2. Referral in and out register is maintained
Advance communication is done with higher
centre
There is a system of follow up of referred Referred paediatric cases are followed up for appropriate care,
patients
1 SI/RR completion of treatment & outcome
(1) Check for referral cards filled from lower facilities
(2) ANM of nearby PHC/HWC is informed about discharge follow
Facility has functional referral linkages with ups
1 RR
lower facilities

ME E3.3 A person is identified for care during all steps of care

Duty Doctor and nurse is assigned for each 2 RR/SI
patients

Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of patients is established at There is a process for ensuring the
the facility identification before any clinical procedure (1) Identification tags are used for children less than 5 yrs.
2 OB/SI (2) There is system in place to identify the patient before drug
administration or performing any clinical procedure
ME E4.2 Procedure for ensuring timely and accurate nursing care as per Treatment chart are maintained Check treatment chart are updated and drugs given are marked in.
treatment plan is established at the facility 2 RR Co relate it with drugs and doses prescribed. Dispensing feed, time
of oral drugs, supervision of intravenous fluids etc is recorded

There is a process to ensure the accuracy

of verbal/telephonic orders 1 SI/RR (1) Check system is in place to give telephonic orders & practised
(2) Verbal orders are verified by the ordering physician within
defined time period
ME E4.3 There is established procedure of patient hand over, Patient hand over is given during the change Nursing Handover register is maintained
whenever staff duty change happens in the shift
2 SI/RR

Hand over is given bed side Check staff follows SBAR protocol (situation, background,
assessment and recommendation)
1 SI/RR

ME E4.4 Nursing records are maintained Nursing notes are maintained adequately Check for nursing note register. Notes are adequately written
1 RR/SI
ME E4.5 There is procedure for periodic monitoring of patients Patient Vitals for stable & critical patients are Check for TPR chart, I/O chart, any other vital required is
monitored and recorded periodically monitored viz lower chest indrawing, coma score or level of
2 RR/SI consciousness [AVPU: [Alert, Responding to voice, responding to
pain, unconscious], temperature and body weight

Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients and ensure their safe Vulnerable patients are identified and Check the measure taken to prevent new born theft,
care measures are taken to protect them from 1 OB/ SI sweeping ,baby fall, adverse events following drugs/vaccine etc.
any harm
ME E5.2 The facility identifies high risk patients and ensure their care, High risk patients are identified and Triage is done and provide emergency
as per their need treatment given on priority treatment keeping in mind the ABCD steps: Airway, Breathing,
2 OB/SI Circulation, Coma, Convulsion, and Dehydration.

Standard E6 Facility ensures rationale prescribing and use of medicines

ME E6.1 The facility ensured that drugs are prescribed in generic name Check for BHT if drugs are prescribed under Check all the drugs in case sheet and discharge slip are written in
only 1 RR generic name only. of Pneumonia, Diarrhoea, ARI/Bronchitis
generic name only STG for Management
ME E6.2 There is procedure of rational use of drugs Check for that relevant Standard treatment Asthmatic, Severe acute malnutrition, vitamin
guideline are available at point of use deficiencies and micronutrient deficiencies, Haematological
2 RR Disorders, Poisoning, Sting, Bites, Paediatric Surgical Emergencies,
Liver Disorders etc
Check staff is aware of the drug regimen and Check BHT that drugs are prescribed as per treatment protocols
doses as per STG 2 SI/RR &Check for rational use of antibiotics

Availability of drug formulary 2 SI/OB Staff is aware of formulary

ME E6.3 There are procedures defined for medication review and Complete medication history is documented 1 RR/OB Check complete medication history including over-the- counter
optimization for each patient medicines is taken and documented
Established mechanism for Medication 1 SI/RR 1. Medication Reconciliation is carried out by a trained and
reconciliation process competent health professional during the patient's admission,
interdepartmental transfer or discharged
2. Medicine reconciliation includes Prescription and non-
prescription (over-the-counter) medications, vitamins, nutritional
supplements.

Medicine are reviewed and optimised as per 2 SI/RR Medicines are optimised as per individual treatment plan for best
individual treatment plan possible clinical outcome
Complete medication history is documented 1 SI/RR 1. Discharge summary includes known drug allergies and reactions
and communicated for each patient at the to medicines or their ingredients, and the type of reaction
time of discharge experienced
2. Changes in prescribed medicines, including medicines started or
stopped, or dosage changes, and reason for the change are clearly
documented in the case sheet and case summary"

Patients are engaged in their own care 1 PI/SI "1. Clinician/Nurse counsel the patient on medication safety using
""5 moments for medication safety app""
2. Nurse highlights the medications to be taken by the patient at
home and counsel the patient and family on drug intake as per
treatment plan for discharge"

Standard E7 The facility has defined procedures for safe drug administration
ME E7.1 There is process for identifying and cautious High alert drugs available in department are Electrolytes like Potassium chloride, Opioids, Neuro muscular
administration of high alert drugs identified blocking agent, Anti thrombolytic agent, insulin, warfarin, Heparin,
Adrenergic agonist & primaquine not to be given to infants etc
2 SI/OB

Maximum dose of high alert drugs are Value for maximum doses as per age, weight and diagnosis are
defined and communicated 2 SI/RR available with nurses and doctor.
ME E7.2 Medication orders are written legibly and adequately There is process to ensure that right doses of A system of independent double check before administration,
drugs are only given Error prone medical abbreviations are avoided
2 SI/RR

Every Medical advice and procedure is Verify case sheets of sample basis
accompanied with date , time and 1 RR
signature
Check medication orders are legible & easily Verify case sheets of sample basis
comprehendible by the clinical staff 1 RR/SI

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

Any adverse drug reaction is recorded and Check

reported 1. Staff is aware of ADR
2 RR/SI 2. Check for availability of ADR formats
3. Check when is the last ADR reported /Nil reporting

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Assessment Method
Full/Partial/No
ME E7.4 There is a system to ensure right medicine is given to right IV Fluid and drug dosages are calculated Check for calculation chart
patient according to body weight 2 SI/RR

Drip rate and volume is calculated and Check the nursing staff how they calculate Infusion and monitor it
monitored 2 SI/RR
Check Staff follows 6Rs's practice
Right patient, Right drugs , Right route, Right time, Right Dosage
and after administration, Right documentation.
2 SI/OB
Administration of medicines done after
ensuring 6R's
ME E7.5 Patient is counselled for self drug administration Patient attendant's are advice by Dose & advice is described in vernacular. It is not given directly in
doctor/nurse about the dosages and 2 PI/SI hand of relative/patient
timings .

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re-assessment and investigations are Day to day progress of patient is recorded in Check at least 2 times/ day notes are recorded in case sheet
recorded and updated 1 RR
BHT
ME E8.2 All treatment plan prescription/orders are recorded in the Treatment plan, first orders are written on
patient records. BHT
2 RR Check treatment is prescribed in Case records and nursing records
(Medication orders, treatment plan, lab investigations)

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

ME E8.4 Procedures performed are written on patients records Procedures performed are written on 1. Procedures performed (If any) are well explained prior to the
patients records patient attendant like ryles tube insertion/ drainage bag
maintenance/ nebulization/ Resuscitation, blood transfusion etc
2 RR 2. Procedure performed viz. Nebulization, Resuscitation, blood
transfusion etc are documented

ME E8.5 Adequate form and formats are available at point of use Standard Format for bed head ticket/ Patient TPR chart, IO chart, Growth chart , BHT, continuation sheet,
case sheet available as per state guidelines Discharge card, Facility specific child death review format -
2 RR/OB 1. Check for adequate availability of the forms
2. Check for completeness in the filled forms

ME E8.6 Register/records are maintained as per guidelines

General order book (GOB), report book, Admission register, lab
1 RR register, Admission sheet/ bed head ticket, discharge slip, referral
slip, referral in/referral out register, OT register, Diet register,
Registers and records are maintained as per Linen register, Drug intend register, Patient Attendant record that
guidelines is staying with the patient, Handover register etc
All register/records are identified and Unique identification number is given & staff is able to retrieve
numbered 2 RR previous register/records
ME E8.7 The facility ensures safe and adequate storage and Safe keeping of patient records (1) Records of discharged cases are kept in MRD/ department sub
retrieval of medical records store
(2) Check records are retrieval in case of re admission
2 OB (3) Copy of records is given to next kin only with permission from
authorised staff only

Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing patient readiness Paed. HDU has established criteria to Criteria for transfer to step down: Respiratory distress improves,
transfer to step down 2 SI/RR babies on antibiotics for completion of therapy, children who are
otherwise stable.

Primary illness is resolved, All infections and other medical

2 SI/RR complications have been treated, baby maintain temp, baby is
accepting mothers milk/feed, Child is provided with
Paediatric ward has established criteria for micronutrients
discharge Immunization is updated etc
Discharge is done by a responsible and Discharge is done in consultation with treating doctor
qualified doctor after assessment in 2 SI/RR
consultation with treating doctor
Time of discharge is communicated to patient in prior
Patient / attendants are consulted before 2 PI/SI
discharge
ME E9.2 Case summary and follow-up instructions are provided at Discharge summary adequately mentions See for discharge summary, referral slip provided.
the discharge patients clinical condition, treatment given,
Nutritional status and follow up 2 RR/PI

Discharge summary is give to all patients 2 SI/RR Including LAMA/Referral patient

ME E9.3 Counselling services are provided as during discharges Patient is counselled before discharge Advice includes the information about the nearest health centre
wherever required 2 SI/PI for further follow up. Counsel mother for treatment, follow up,
feeding, discharge timings are explained prior
ME E9.4 The facility has established procedure for patients leaving Declaration is taken from the LAMA patient
the facility against medical advice, absconding, etc
2 RR/PI

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
Emergency protocols are defined and implemented Staff is aware of process & steps for (1) Triage - ETAT protocol - keeping in mind ABCD steps
emergency management of sick children (2) Ascertaining the group of baby - Emergency, Priority and non
urgent.
(2) After identification of emergency & priotize sign- prompt
ME E11.2 1 SI/RR emergency treatment is to be given to stabilize before transfer to
ward/HDU or refer

ME E11.3 The facility has disaster management plan in place Staff is aware of disaster plan Role and responsibilities of staff in disaster are defined
2 SI/RR Mock drills have conducted from time to time

Standard E12 The facility has defined and established procedures of diagnostic services
ME E12.1 There are established procedures for Pre-testing Activities Container is labelled properly after the Protocols are defined & followed for sample collection & transfer
sample collection 2 OB
timely from ward to lab for testing
ME E12.3 There are established procedures for Post-testing Nursing station is provided with the critical
Activities value of different tests
2 SI/RR (1) Critical values are defined and intimated timely to treating
medical officer
(2) List of Normal reference ranges are available in Paed. Ward

Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
ME E13.9 There is established procedure for transfusion of blood Patient's identification is confirmed & Check whether staff follows the protocol for patient identification
Consent is taken before transfusion 2 RR and cross validates it with written advice

Protocol of blood transfusion is monitored & Blood is kept on optimum temperature before transfusion. Blood
regulated transfusion is monitored and regulated by qualified person
2 RR

Blood transfusion note is written in patient Blood bag details sticker is pasted in case file, patient monitoring
records status is recorded in case sheet
1 RR

Check for adequate availability and utilization of paediatric blood

Paediatric blood transfusion bags are used 1 RR bags
for transfusion
ME E13.10 There is a established procedure for monitoring and Check -
reporting Transfusion complication Staff is aware of the protocol to be followed in case of any
2 RR transfusion reaction
Any major or minor transfusion reaction is
recorded and reported to responsible person

Standard E15 The facility has defined and established procedures of Operation theatre services
ME E15.2 The facility has established procedures for Preoperative Vitals , Patients fasting status etc. is managed & informed to OT.
care
2 RR/SI
Patient evaluation before surgery is
coordinated and recorded

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
The facility has established procedures for Post operative Staff is aware of the care protocol of children 1. Staff frequently assess the surgical site in case of any redness,
care returned back from surgery discharge the case in charge is informed immediately.
2. Staff counsel the mother on the techniques of feeding infant
post surgery
3. Diet - Soft, mashed diet to be provided to children post surgery.
Do not give hard, crunchy foods

In cases of cleft lip and cleft palate: General & Specific care
ME E15.4 1 SI/RR directed by Orthodontics viz. Mouth care is maintained post
surgery use gauze lock and mouthwash for cleaning. Don't use
brush for 3 weeks . Use the arm string/ restrain to avoid thumb/
finger sucking etc

The facility has defined and established procedures for the management of death & bodies of deceased patients
Standard E16

ME E16.1 Death of admitted patient is adequately recorded and Facility has a standard procedure to Bad news/adverse event/ poor prognosis are disclosed in quite &
communicated decent communicate death to relatives private setting
1 SI

ME E16.2 The facility has standard procedures for handling the

death in the hospital

2 RR Child death are recorded as per CDR guideline. Death note

including efforts done for resuscitation. Death summary is given to
Death note is written as per child death patient attendant quoting the immediate cause and underlying
review guidelines cause if possible
Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines

ME E20.1 The facility provides immunization services as per Immunization services are provided as
Check MCP card is available & updated. Mother /care provider is
guidelines immunization schedule 2 SI/RR
counselled and directed to immunize the child
ME E20.2 Triage, Assessment & Management of new-borns, infant & Triage of sick children is done as per Screening of sick child is done to prioritize management as per
children having emergency signs are done as per guidelines protocols classification : Emergency sign, priority sign & non urgent sign.
2 SI/RR All emergency & priority sign are stabilize and child is referred to
HDU / higher centre for management

Staff is aware of emergency signs in Sick child Obstructed or absent breathing, severe respiratory distress,
central cyanosis,
signs of shock (cold hands, capillary refill time longer than 3 s,
high heart
1 SI/RR rate with weak pulse, and low or unmeasurable blood
pressure),coma, convulsions
signs of severe dehydration in a child with diarrhoea

Staff is aware of priority signs in Sick child Tiny infant: any sick child aged < 2 months, Temperature: child is
very hot, Trauma or other urgent surgical condition, severe
Pallor , Poisoning ,severe Pain ,Respiratory distress, Restless,
2 SI/RR continuously irritable or lethargic, visible severe wasting, Oedema
of both feet & major burn

Assessment & Management of airway due Assess airway & breathing- severe respiratory distress, central
to breathing obstructions/failure cyanosis & obstructed/absent breathing (any of sign positive)-
Check (1) if foreign body aspirated.
Manage airway in choking child. Check staff is aware of
management of choking child, by back slap, chest thrust (infant)
back blow (child >1 yr.) (2) If no
1 SI/RR foreign body is aspirated -Manage air way, give oxygen & keep
child warm.
Proceed for full investigation & treatment

Assessment & management of hypoxaemia (1) Early signs confusion, restlessness & shortness of breath.
(2) Determine oxygen level using pulse oximeter.
(3) Oxygen supplementation - when child is in respiratory distress
& SPo2 is <90%.
Child with emergency signs but with out respiratory distress
2 SI/RR receive oxygen therapy- if SPo2 is <94%.
(4) Investigate for underlying cause - viz. Asthma, Pneumonia,
Anaemia, ARDS etc

Assessment & management of circulation Cold body with capillary refill longer than 3 sec/ fast & weak pulse.
failure cases Any sign positive.
Check for any bleeding, give oxygen & keep child warm.
If malnourishment seen: child is lethargic /unconscious- Insert IV
2 SI/RR line & Give IV glucose, if child is not lethargic & unconscious- give
glucose orally/nasogastric tube, proceed for full investigation &
further treatment.

Management of coma/convulsion in Coma/convulsion: Manage the airway, if convulsing, give diazepam

children 2 SI/RR rectally,Postion the child (if head & neck trauma is suspected), give
IV glucose
ME E20.7 Management of children presenting Management of Child with Bronchial Asthma Initial Treatment
with fever, cough/ breathlessness is done as per Salbutamol inhalation 2.5 mg/dose (5 mg/ml solution), by
guidelines nebuliser every 20 minutes x 3
/ Salbutamol inhalation by MDI-Spacer
4 puffs (100mcg/puff) at 2-3 min interval. This course is repeated
every 20 minutes x3
/ Inj Adrenaline 0.01 ml/kg (maximum
of 0.3 ml) of 1:1000 solution
subcutaneous every 20 minutes x 3
In case of Moderate to Severe attack Additional -
Oxygen Start Steroids; Prednisolone 2mg/kg/day in divided doses
1 SI/RR Reassess 30-60 mins If not improve -
Continue bronchodilator 1-2 hly
and Ipratropium 8hly; Continue
steroids, Give one dose of Mag. Sulph,
/aminophylline

Cough or difficulty in breathing in children with at least one of the

following condition :
(1) Central Cyanosis or oxygen saturation <90%
1 SI/RR (2) Server respiratory distress (laboured of very fast breathing
(RR<70 per minute) or severe lower chest indrawing or head
nodding or stridor or grunting)
(3) Sign of pneumonia with general danger sign (inability to
Staff is aware of sign & symptoms of severe breastfed or lethargy or reduced level of consciousness or
pneumonia in children 2 months to 5 yrs. convulsions)

Antibiotics: Ampicillin 50mg/kg or Benzyl penicillin 50,000U/Kg IM

or IV every 6 hrs.
Gentamicin7.5 mg/Kg IM or IV once in a day
2 SI/RR Give Cloxacillin or Amoxicillin+ clavulanic acid if Staphylococcal
infection is suspected ( presence of skin pustules or boil)
Give Ceftriaxone with vancomycin in case of septic shock)
If child does not show signs of improvement with in 48hrs,switch
to Gentamicin7.5 mg/Kg IV once in a day combined with
Ceftriaxone 100mg/kg IV divided in to 2 doses or cloxacillin
50mg/kg IV 8 hrly.
Shift to oral dose as soon as child is able to take it orally, except
those with shock or complicated pneumonia where longer
parenteral therapy is advised.
Management of Severe pneumonia in Duration_ Clinical response with in 48 hrs- 7 days
children 2 month to 5 yrs. Clinical response after 48 hrs- 10days

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No

Oxygen saturation <90% - give oxygen to all children or <94% with

other emergency sign like shock etc.)
1 SI/RR Use nasal prongs as preferred method of oxygen delivery to young
infant.
Use pulse oximeter to guide the oxygen therapy (keep oxygen
Staff is aware of Oxygen therapy given for saturation >90%). If pulse oximeter is not available- continue the
severe pneumonia in children 2 months to 5 oxygen until clinical sign of hypoxia (inability to breastfed or
yrs. breathing rate > or equal to 70/min) are no longer present.
Management of child presenting with severe Give a blood transfusion to: all children with an EVF ≤ 12% or Hb ≤
anaemia 4 g/dl & less severely anaemic children (EVF > 12–15%; Hb 4–5
g/dl) with any of the condition: shock, impaired consciousness,
respiratory acidosis (deep, laboured breathing),heart failure, very
high parasitaemia (> 20% of red cells parasitized).
Give 10 ml/kg packed cells or 20 ml/kg whole blood over 3–4 h.
Check the respiratory rate and pulse rate every 15 min. If one of
them rises, transfuse more slowly. If there is fluid overload, give IV
1 SI/RR furosemide (1–2 mg/kg) up to a
maximum total of 20 mg.
Give a daily iron–folate tablet or iron syrup for 14 days

All children with Hb ≤4 gm/dl,

Children with Hb 4–6 gm/dl with
any of the following:
1 SI/RR – Dehydration
– Shock
– Impaired consciousness
– Heart failure
– Deep and laboured breathing
Staff is aware of indications for blood – Very high parasitaemia
transfusion due to severe anaemia (>10% of RBC)
2 SI/RR If packed cells are available, give 10 ml/kg over 3–4 hours
Staff is aware of blood transfusion protocols preferably. If not, give whole blood 20 ml/kg over 3–4 hours.
Management of children with seizures (1) Children presenting with acute seizures IV diazepam or IV
lorazepam may be used. In case, IV access is not available non-
parenteral routes of administration of benzodiazepines is used.
Options include rectal diazepam, oral or intranasal midazolam and
rectal or intranasal lorazepam. (2) In
children with established status epilepticus, i.e. seizures persisting
after two doses of benzodiazepines, IV valproate, IV phenobarbital
1 SI/RR or IV phenytoin can be used, with appropriate monitoring.

(3) Check continuous anticonvulsant medications (phenobarbital

or valproate) is not used for febrile seizures.

ME E20.8 Management of children with severe Management of child presented in shock (1) Insert IV line, weight the child, give IV fluid 15ml/kg over 1 hr.
Acute Malnutrition is done as per guidelines with severe malnourishment Use one of the following solutions : – Ringer’s lactate with 5%
glucose (dextrose); – Half-strength Darrow’s solution with 5%
glucose (dextrose); – 0.45% NaCl plus 5% glucose (dextrose).

(2)Measure the pulse rate, volume and breathing rate at every 5–

10 min.
(3) If there are signs of improvement (pulse rate falls, pulse
volume increases or respiratory rate falls) and no evidence of
1 RR pulmonary oedema – repeat IV infusion at 15 ml/kg over 1 h; then
– switch to oral or nasogastric rehydration & initiate re-feeding
with starter F-75./ If the child fails to
improve after two IV boluses of 15 ml/kg, – give maintenance IV
fluid (4 ml/kg per h) initiate re-feeding with starter F-75 & start IV
antibiotic treatment

ME E20.9 Management of children presenting Assessment & Management severe Diarrhoea plus two of signs are positive viz. lethargy, sunken eyes,
diarrhoea is done per guidelines dehydration cases very slow skin pinch & unable to drink or drink very less.
if no severe malnutrition give fluids rapidly & start diarrhoea
treatment.
If severe malnourishment do not insert IV, proceed for full
2 SI/RR assessment & treatment.

Treatment of child presenting with severe

dehydration
(1) Start IV fluids immediately. While the drip is being set up, give
ORS solution if the child can drink.
2 SI/RR (2) Start isotonic solutions: Ringer’s lactate solution and normal
saline solution (0.9% NaCl) is given. Give 100 ml/kg of the chosen
solution. If age <12 month: first give 30ml/kg in 1 hr & repeat if
radial pulse is weak & then 70ml/kg in 5 hrs.
If age is more than or equal to 12 month, first give 30ml/kg in
30min & repeat if radial pulse is weak & then 70ml/kg in 2.5 hrs)
Staff is aware of Care of children with
Developmental Dysplasia of Hip

1. Management in child up to 4 months - Application of Pavlik

1 SI/RR Harness
2. Management of Child above 4 years - Closed Reduction and hip
spica application
3. Follow-up with the patient referred back from tertiary hospitals
4. Frequent Skin care
ME E20.10 Facility ensures optimal breast feeding practices for new Communication and counselling the mothers 1. Staff support the mother by providing adequate privacy and
born & infants as per guidelines for exclusive breastfeeding up to 6 months explaining the benefits of exclusive breastfeeding
2 PI/OB 2. Staff is aware and follow the protocol for management of
cracked nipples, inverted nipples engorged breast etc.

Staff counsel the mother for complementary Awareness is generated for complementary feeding from 6
feeding as per IYCF guidelines 2 PI/OB months of age till two years of age

Communication and counselling on optimal For children born prematurely or with low birth weight, one to
infant & young child feeding practices for one counselling
sick babies 2 PI/SI session should be conducted with the mother/caregiver and follow
up visits to the centre requested.

Breast milk substitutes are not promoted for Ask Parents about the counselling
newborn or infant unless medically indicated 2 PI/OB

Standard E23 The facility provides National health Programme as per operational/Clinical Guidelines

ME E23.1 The facility provides services under National Vector Borne Management of child presenting with For P. vivax, give a 3-day course of artemisinin-based combination
Disease Control Programme as per guidelines uncomplicated malaria therapy.
For P. falciparum (with the exception of artesunate plus
sulfadoxine–pyrimethamine) combined with primaquine at 0.25
mg base/
1 SI/RR kg, taken with food once daily for 14 days.
Give oral chloroquine at a total dose of 25 mg base/kg,
combined with primaquine.

Admission criteria is defined for dengue cases 1. Child having high fever, poor oral intake, or any danger signs
(Bleeding, red spots or patches on the skin, bleeding from nose or
gums, black-coloured stools, heavy menstruation/vaginal bleeding,
Frequent vomiting, Severe abdominal pain, Drowsiness, mental
confusion or seizures, pale, cold or clammy hands and feet,
2 SI/RR Difficulty in breathing)
2 If platelet count < 100,000 /[Link] or rapidly decreasing trend.
3 If haematocrit is rising trend.

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Assessment Method
Full/Partial/No
Staff follows the management protocol for 1. Encourage oral fluids. If not tolerated, start intravenous isotonic
Dengue management. fluid therapy with or without dextrose at maintenance. Give only
isotonic
solutions. Start with 5 ml/kg/hour for 1–2 hours, then reduce by
2ml/kg/hour every 2 hours till 2ml/kg/hr provided there is clinical
improvement and haematocrit is appropriately improving. IV
fluids are usually required for 1-2 days.
2. Reassess the clinical status and repeat the haematocrit after 2
hours. If the haematocrit remains the same, continue with the
same rate for another 2–4 hours and reassess. If the vital
signs/haematocrit is worsening increase the fluid rate and refer
2 SI/RR immediately.
3. Switch to oral as soon as tolerated, total fluid therapy usually
24-48 hrs,
titrated to adequate urine output.

Staff frequently assess the child during the 1. Temperature, Pulse, blood pressure and respiration-
management every hour (or more often) until stable subsequently 2 hourly.
2. Hourly fluid balance sheet recording the type of
fluid and the rate and volume of its administration to evaluate the
2 SI/RR adequacy of fluid replacement.
3. Chest X-ray, ultrasound abdomen, electrolytes 12-24 hrly as
when clinically indicated

Discharge criteria is defined for dengue cases 1. Absence of fever for at least 24 hrs.
2. Return of appetite.
3. Clinical improvement.
4. Good urine output.
2 SI/RR 5. Stable haematocrit.
6. 2 days after recovery from shock
7. No respiratory distress from pleural effusion and ascites

ME E23.11 The facility provide services under National viral Hepatitis Staff is aware of clinical presentation of Signs of Jaundice, unexplained weight loss, loss of appetite, fatigue
Control Programme Acute Hepatitis etc
Acute case - elevations in the concentration of alanine and
aspartate aminotransferase levels (ALT and AST); values up to
1000 to 2000 international units/L are typically seen during the
2 SI/RR acute phase with ALT being higher than AST.
Chronic is clinically salient

Staff is aware of the treatment regimen of Entecavir (in children 2 years of age or older and weighing at least
HBV Chronic Infection 10kg. the oral solution should be
given to children with a body weight up to 30kg)
Recommended once-daily dose of oral solution (mL)
Body weight (kg) Treatment –naïve persons*
10 to 11 - 3
>11 to 14 - 4
>14 to 17 - 5
>17 to 20 6
>20 to 23- 7
>23 to 26- 8
1 SI/RR >26 to 30 - 9
>30 to - 10mL (0.5 mg) / 0.5 mg tablet once daily

Renal function should be monitored annually

in persons on long-term tenofovir or entecavir therapy, and
growth monitored carefully in children

Staff is aware of the treatment regimen for Children with cirrhosis compensated- (pugh A) Sofosbuvir(400mg)
HCV + Velpatasvir(100mg) for 84 days(12 wks.) once a day.
Children with cirrhosis (Pugh B and C) - decompensated-
Sofosbuvir(400mg) + Velpatasvir
(100mg) & Ribavirin(600-1200mg**)
for 84 days(12 wks.) once a day
0 SI/RR Ribavirin based on body weight

Area of Concern - F Infection Control

The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection
Standard F1

The facility has functional infection control committee Infection control committee is in place
ME F1.1 2 SI/RR
Shared with main hospital. Check paediatrician is part of the
committee
The facility has provision for Passive and active culture Surface and environment samples are taken Swab are taken from infection prone surfaces such as examination
surveillance of critical & high risk areas for microbiological surveillance tables, injection tray, isolation wards etc.
ME F1.2 1 SI/RR

The facility measures hospital associated infection rates There is procedure for collection & reporting
of incidences of HAI cases

(1) Patients are observed for any sign and symptoms of HAI &
1 SI/RR reported
(2) Check there are defined criteria and format for reporting HAI &
staff is aware of it
(3) Check there is system at place to collate & analyse the data &
feed is given to departments
ME F1.3
There is Provision of Periodic Medical Check-up and There is procedure for immunization &
immunization of staff periodic check-up of the staff
2 SI/RR
ME F1.4 Hepatitis B, Tetanus Toxoid etc
The facility has established procedures for regular Regular monitoring of infection control (1) Hand washing and infection control audits done at periodic
monitoring of infection control practices practices intervals
1 SI/RR (2) There is designated person for coordinating infection control
activities
ME F1.5
The facility has defined and established antibiotic policy Check for Doctors are aware of Hospital (1) There is system for reporting Anti Microbial Resistance with in
Antibiotic Policy the facility
(2) Policy Includes Rational Use of Antibiotics
1 SI/RR (3) Check facility measure antibiotic consumption rate & paediatric
ward is aware of it
ME F1.6
The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Standard F2

Hand washing facilities are provided at point of use Availability of hand washing with running 1. Check for availability of wash basin near the point of use.
Water Facility at Point of Use 2 OB 2. Check the regularity of water supply.
ME F2.1
Availability of antiseptic soap with soap dish/
liquid antiseptic with dispenser. 1. Check for availability/ Ask staff if the supply is adequate and
1 OB/SI uninterrupted.
2. Availability of Alcohol based Hand rub
Display of Hand washing Instruction at Point Prominently displayed above the hand washing facility , preferably
of Use 2 OB
in Local language
Availability of elbow operated taps & Hand Check wash basin is wide and deep enough to prevent splashing
washing sink 2 OB
and retention of water
The facility staff is trained in hand washing practices and Adherence to 6 steps of Hand washing
they adhere to standard hand washing practices 2 SI/OB
Ask of demonstration & check staff awareness about when to
ME F2.2 wash the hands
Mothers are aware of importance of washing
hands Mothers are aware of importance of washing hands .Washing
2 SI/PI
hands after using the toilet/ changing diapers and before feeding
children.
Mothers/care giver adhere to hand washing Ask for demonstration
practices with soap 2 PI/OB

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
The facility ensures standard practices and materials for Availability Use of Antiseptic Solutions
antisepsis 1 OB
ME F2.3
The facility ensures standard practices and materials for Personal protection
Standard F3

The facility ensures adequate personal protection [Link] if staff is using PPEs.
Equipment as per requirements 2. Ask staff if they have adequate supply.
1 RR/SI 3. Verify with the stock/Expenditure register
Availability of PPE (Gloves, mask, apron &
ME F3.1 caps )
The facility staff adheres to standard personal protection
practices 2 OB/SI
ME F3.2 No reuse of disposable PPE No reuse of gloves, Masks, caps and aprons etc.
Compliance to correct method of wearing 1 SI
and removing the gloves & Other PPEs Ask for demonstration.
The facility has standard procedures for processing of equipment and instruments
Standard F4

The facility ensures standard practices and materials for Decontamination of examination and Ask staff how they decontaminate Examination table , Patients
decontamination and cleaning of instruments and procedures procedural surfaces 2 SI/OB Beds Stretcher/Trolleys/ Examination table etc.
areas (Wiping with 1% Chlorine solution)
ME F4.1

Ask staff how they decontaminate the instruments like

2 SI/OB Stethoscope, Dressing Instruments, Examination Instruments,
Blood Pressure Cuff etc
(Soaking in 1 % Chlorine Solution, Wiping with 1% Chlorine
Proper Decontamination of instruments after Solution or 70% Alcohol as applicable
use Contact time for decontamination of instruments
1 SI/OB
Proper handling of Soiled and infected linen No sorting ,Rinsing or sluicing at Point of use/ Patient care area
Cleaning of instruments
1 SI/OB Cleaning is done with detergent and running water after
decontamination
Staff know how to make chlorine solution 2 SI/OB
Toys washed regularly, and after each child
uses 1 SI/OB
Check records for decontamination and washing of toys
The facility ensures standard practices and materials for Equipment and instruments are sterilized 1. Ask staff about temperature, pressure and time for autoclaving.
disinfection and sterilization of instruments and equipment after each use as per requirement 2. Ask staff about method, concentration and contact time
required for chemical sterilization.
1 OB/SI [Link] records

ME F4.2
Check staff is aware of how long autoclaved items can be stored.
Also, autoclaved items are stored in dry, clean, dust free, moist
2 OB/SI free environment
Staff is aware of storage time for autoclaved
items
Physical layout and environmental control of the patient care areas ensures infection prevention
Standard F5

The facility ensures availability of standard materials for Availability of disinfectant & cleaning as per
cleaning and disinfection of patient care areas requirement 2 OB/SI
ME F5.2 Chlorine solution, Glutaraldehyde, carbolic acid
Availability of cleaning agent as per
requirement 2 OB/SI
Hospital grade disinfectant & detergent solution
The facility ensures standard practices are followed for the Spill management protocols are
cleaning and disinfection of patient care areas implemented
1 SI/RR 1. Check availability of Spill management kit ,
2. Staff is trained for managing small & large spills ,
ME F5.3 3. Check protocols are displayed
Cleaning of patient care area with detergent Three bucket system is followed
solution 2 SI/RR
Standard practice of mopping and scrubbing
are followed 1. Unidirectional mopping from inside out is followed.
2 OB/SI 2. Staff is trained for preparing cleaning solution as per standard
procedure.
3. Cleaning equipment like broom are not used in patient care
areas
The facility ensures segregation infectious patients Isolation and barrier nursing procedure are
followed
1. Check there is a separate area for infectious patients like
chicken pox, measles, diarrhoea cases .
1 OB/SI
2. Check staff is aware of barrier and reverse barrier nursing
Give non compliance if Diarrhoea or infectious disease cases are
ME F5.4 kept in corridors or with general patients
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
Standard F6

The facility Ensures segregation of Bio Medical Waste as

per guidelines and 'on-site' management of waste is
carried out as per guidelines 2 OB
Availability of colour coded bins at point of
ME F6.1 waste generation
Availability of Non chlorinated colour coded 2 OB
plastic bags
Segregation of Anatomical and soiled waste 2 OB/SI
in Yellow Bin
Segregation of infected plastic waste in red 2 OB
bin
Pictorial and in local language
Display of work instructions for segregation 2 OB
and handling of Biomedical waste
There is no mixing of infectious and general
waste 2 OB

The facility ensures management of sharps as per Availability of functional needle cutters and (1) Check if needle cutter has been used or just lying idle. (2) it
guidelines puncture proof box should be available near the point of generation like nursing
2 OB station

ME F6.2
Availability of post exposure prophylaxis
1. Staff knows what to do in case of needle stick injury.
1 OB/SI 2. Staff is aware of whom to report
3. Check if any reporting has been done
4. Also check PEP issuance register
Glass sharps and metallic implants are Includes used vials, slides and other broken infected glass
disposed in Blue colour coded puncture
proof box 2 OB

The facility ensures transportation and disposal of waste Check bins are not overfilled & staff is aware Bins should not be filled more than 2/3 of its capacity
as per guidelines of when to empty the bin
2 SI/OB
ME F6.3
Transportation of bio medical waste is done
in close container/trolley 2 SI/OB

Staff aware of mercury spill management Check whether department is replacing mercury products with
1 SI/RR
digital products (Aspire for mercury free)
Area of Concern - G Quality Management
The facility has established organizational framework for quality improvement
Standard G1

ME G1.1 The facility has a quality team in place Quality circle has been constituted 1. Check if the quality circle has been constituted and is functional
2. Roles and Responsibility of team has been defined
2 SI/RR

ME G1.2 The facility reviews quality of its services at periodic intervals Review meetings are done regularly Check minutes of meeting and monthly measurement & reporting
1 SI/RR of indicators
The facility has established system for patient and employee satisfaction
Standard G2

ME G2.1 Patient satisfaction surveys are conducted at periodic Client satisfaction survey is done on monthly Feedback is taken from parents/guardians
intervals basis 2 SI/RR

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No
ME G2.2 The facility analyses the patient feed back, and root-cause Analysis of low performing attributes is
analysis undertaken 2 SI/RR

ME G2.3 The facility prepares the action plans for the areas, Action plan is prepared and improvement
contributing to low satisfaction of patients activities are undertaken
1 SI/RR

The facility have established internal and external quality assurance Programmes wherever it is critical to quality.
Standard G3

ME G3.1 The facility has established internal quality assurance There is a system of daily round by Findings /instructions during the visit are recorded and actions are
programme in key departments matron/hospital manager/ hospital taken
superintendent for monitoring of services 1 SI/RR

ME G3.3 Facility has established system for use of check lists in Internal assessment is done at periodic NQAS assessment toolkit is used to conduct internal assessment
different departments and services interval

2 RR/SI

Departmental checklist are used for Staff is designated for filling and monitoring of these
monitoring and quality assurance checklists

2 SI/RR

Non-compliances are enumerated and

recorded

1 RR Check the non compliances are presented & discussed during

quality team meetings

ME G3.4 Actions are planned to address gaps observed during

quality assurance process
Check action plans are prepared and
Randomly check the details of action, responsibility, time line and
implemented as per internal assessment 1 RR
feedback mechanism
record findings

ME G3.5 Planned actions are implemented through Quality

Improvement Cycles (PDCA)
Check actions have been taken to close the gap. It can be in form
Check PDCA or revalent quality method is
1 SI/RR of action taken report or Quality Improvement (PDCA) project
used to take corrective and preventive action
report

The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
Standard G4

ME G4.1 Departmental standard operating procedures are available Standard operating procedure for Check that SOP for management of departmental services has
department has been prepared and 2 RR been prepared and is formally approved
approved

Current version of SOP are available with Check current version is available with the departmental staff
process owner 1 OB/RR
Child safety, formula for calculation of paediatric doses , CPR,
nutritional requirements with growth charts, Appropriate feeding
practices, Summary of the 10 steps of successful breastfeeding,
1 OB lactation position and milk expression protocol, etc. are displayed
Work instruction/clinical protocols are
displayed
ME G4.2 Standard Operating Procedures adequately describes Review the SOP has adequately cover procedure for reception,
process and procedures triage initial assessment, admission & investigation of the patient
Department has documented Procedure for 2 RR
receiving and initial assessment of the
patient
Review the SOP has adequately cover procedure for reassessment,
Department has documented procedure for follow up and referral of patient
reassessment of the patient as per clinical 2 RR
condition
Department has documented procedure for Review the SOP has adequately cover procedure of management
general patient care processes of hypothermia, hypoglycaemia, dehydration, electrolyte
imbalance, feeding recommendation as per IMNCI, micronutrient
supplementation.
2 RR
SOP also cover protocols to be used for paediatric dose
preparation as per defined criteria

Department has documented procedure for Department has documented procedure for emergency triage,
specific processes to the department assessment and treatment. Documented procedure for
Management of fever, cough, breathlessness, pneumonia,
diarrhoea and malnutrition, documented procedure for blood
2 RR transfusion, documented procedure for requisition and reporting
of diagnostics, documented procedure for end of life care

Department has documented procedure for Review the SOP has adequately cover procedure of nutritional
support services & facility management. assessment & age appropriate diet, provision of micronutrient
supplementation etc. SOP also covers support services such as
equipment maintenance, calibration, housekeeping, security,
2 RR storage and inventory management etc

Department has documented procedure for Check availability of risk management record/register to identify
safety & risk management 2 RR risk & action taken to mitigate them
Department has documented procedure for Check availability of documented procedure for taking consent,
ensuring patients rights including consent, maintenance of privacy during physical examination. Due care is
privacy confidentiality & entitlement taken in examining older female child (she should be examined in
the presence of a relative or a female staff even if it is not a
2 RR medico legal case), confidentiality & entitlements various Health
Schemes

Department has documented procedure for Review SOP adequately cover description of Hand Hygiene,
infection control & bio medical waste personal protection, environmental cleaning, instrument
management sterilization,
asepsis, Bio Medical Waste
2 RR management, surveillance and monitoring of infection control
practices

Department has documented procedure for Review SOP for procedure to constitute quality circles, their
quality management & improvement regular meetings, development of quality objectives, steps to be
2 RR take to achieve objectives and their monitoring & measurement
mechanisms

Department has documented procedure for 1. Check the availability of updated Risk Management Framework.
data collection, analysis & use for 2. Check the components of physical, fire, operational and pt
improvement safety are covered. 3. Review the updated mitigation plan.
2 RR

ME G4.3 Staff is trained and aware of the procedures written in

SOPs 1 SI/RR
Check staff is aware of relevant part of SOPs
The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
Standard G 5

ME G5.1 The facility maps its critical processes Critical processes are identified and mapped. Value and non value
2 SI/RR adding processes/ activities are listed.
Process mapping of critical processes done
ME G5.2 The facility identifies non value adding activities / waste / Non value adding activities are wastes. MUDAS in terms of waste,
redundant activities delays, waiting, motion, over processing , over production etc are
2 SI/RR identified
Non value adding activities are identified
ME G5.3 The facility takes corrective action to improve the Processes are improved & implemented Check the non value adding activities are removed and processes
processes 2 SI/RR are made lean. Improvement is sustained over a period of time

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No

Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
ME G6.4

1 SI/RR
Check short term valid quality objectivities have been framed
addressing key quality issues in department and for core services.
Facility has de defined quality objectives to achieve mission and Check SMART Quality Objectives have Check if these objectives are Specific, Measurable, Attainable,
quality policy framed Relevant and Time Bound.
ME G6.5

1 SI/RR
Interview with staff for their awareness. Check if Mission
Mission, Values, Quality policy and objectives are effectively Check of staff is aware of Mission , Values, Statement, Core Values and Quality Policy is displayed prominently
communicated to staff and users of services Quality Policy and objectives in local language at Key Points
The facility seeks continually improvement by practicing Quality method and tools.
Standard G7

ME G7.1 The facility uses method for quality improvement in Basic quality improvement method are used PDCA & 5S
services 2 SI/OB

Advance quality improvement method are Six sigma, lean.

used 0 SI/OB
ME G7.2 The facility uses tools for quality improvement in services 7 basic tools of Quality are used for Minimum 2 applicable tools are used in department
2 SI/RR
quality improvement in Paed. Ward
Standard G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
ME G9.6

Check periodic assessment of medication 1 SI/RR Verify with the records. A comprehensive risk assessment of all
Periodic assessment for Medication and Patient care safety and patient care safety risks are done using clinical processes should be done using pre defined criteria at least
risks is done as per defined criteria. defined checklist periodically once in three month.
The facility has established clinical Governance framework to improve quality and safety of clinical care processes
Standard G10

Check parameter are defined & implemented to review the clinical

Clinical care assessment criteria have been defined and The facility has established process to review 0 SI/RR
care i.e. through Ward round, peer review, morbidity & mortality
ME G10.3 the clinical care review, patient feedback, clinical audit & clinical outcomes.
communicated

(1) Both critical and stable patients

Check regular ward rounds are taken to
1 SI/RR (2) Check the case progress is documented in BHT/ progress notes-
review case progress

Check the patient /family participate in the Feedback is taken from patient/family on health status of
1 SI/RR
care evaluation individual under treatment
System in place to review internal referral process, review clinical
Check the care planning and co- ordination is
1 SI/RR handover information, review patient understanding about their
reviewed
progress

(1) Random referral slips are audited

(2) The reasons of the referral is clearly mentioned
(3) Referral is written by authorized
Facility conducts the periodic clinical audits including There is procedure to conduct medical and
2 SI/RR
competent person
ME G10.4 referral audits (4) A through action taken report is prepared and presented in
prescription, medical and death audits
clinical Governance Board meetings / during grand round
(wherever required)

(1) All the deaths are audited by the committee.

(2) The reasons of the death is clearly mentioned
(3) Data pertaining to deaths are collated and trend analysis is
There is procedure to conduct child death done
2 SI/RR
audits (4) A through action taken report is prepared and presented in
clinical Governance Board meetings / during grand round
(wherever required)

(1) Random prescriptions are audited

(2) Separate Prescription audit is conducted foe both OPD & IPD
There is procedure to conduct prescription cases
2 SI/RR
audits (3) The finding of audit is circulated to all concerned
(4) Regular trends are analysis and presented in Clinical
Governance board/Grand round meetings

All non compliance are enumerated

2 SI/RR Check the non compliances are presented & discussed during
recorded for medical and referral audits
clinical Governance meetings

All non compliance are enumerated

2 SI/RR Check the non compliances are presented & discussed during
recorded for death audits
clinical Governance meetings

All non compliance are enumerated

1 SI/RR Check the non compliances are presented & discussed during
recorded for prescription audits
clinical Governance meetings
Clinical care audits data is analysed, and actions are Check action plans are prepared and
Randomly check the actual compliance with the actions taken
ME G10.5 taken to close the gaps identified during the audit implemented as per medical and referral 1 SI/RR
reports of last 3 months
process audit record findings
Check action plans are prepared and
Randomly check the actual compliance with the actions taken
implemented as per death audit record's 2 SI/RR
reports of last 3 months
findings
Check action plans are prepared and
Randomly check the actual compliance with the actions taken
implemented as per prescription audit 2 SI/RR
reports of last 3 months
record findings
Check collected data is analysed & areas for improvement is
Check the data of audit findings are collated 2 SI/RR
identified & prioritised
Check the critical problems are regularly monitored & applicable
Check PDCA or revalent quality method is
2 SI/RR solutions are duplicated in other departments (wherever
used to address critical problems
required) for process improvement
Facility ensures easy access and use of standard Check standard treatment guidelines / Staff is aware of Standard treatment protocols/
ME G10.7 treatment guidelines & implementation tools at protocols are available & followed. 2 SI/RR guidelines/best practices
point of care
Check treatment plan is prepared as per Check staff adhere to clinical protocols while preparing the
2 SI/RR
Standard treatment guidelines treatment plan
Check the drugs are prescribed as per Check the drugs prescribed are available in EML or part of
2 SI/RR
Standards treatment guidelines drug formulary
Check when the STG/protocols/evidences used in healthcare
Check the updated/latest evidence are facility are published.
1 SI/RR
available Whether the STG protocols are according to current
evidences.

The gaps in clinical practices are identified & action are taken
Check the mapping of existing clinical
1 SI/RR to improve it. Look for evidences for improvement in clinical
practices processes is done
practices using PDCA
Area of Concern - H Outcome

The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
Standard H1

ME H1.1 Facility measures productivity Indicators on monthly basis

2 RR
Total admissions
Bed Occupancy Rate
2 RR

Proportion of admissions by gender 2 RR

The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
Standard H2

ME H2.1 Facility measures efficiency Indicators on monthly basis Referral Rate

2 RR
Discharge Rate
2 RR

1 RR
Relapse rate

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Reference No. Measurable Element Checkpoint Compliance Means of verification

Assessment Method
Full/Partial/No

Percentage of children with 2 RR

emergency signs received
initial treatment in emergency
The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
Standard H3

ME H3.1 Facility measures Clinical Care & Safety Indicators on monthly Average length of Stay
basis 2 RR
Case fatality rate in Paed. Ward 2 RR
No of adverse events per thousand patients
2 RR
% of infants exclusively breastfed from
admission to discharge 2 RR
No. of cases treated for severe Anaemia
2 RR
No. of cases treated for pneumonia with
shock 2 RR
No. of cases treated for severe dehydration
2 RR
Percentage of viral hepatitis cases managed
2 RR

The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
Standard H4

ME H4.1 Facility measures Service Quality Indicators on monthly basis LAMA Rate 2 RR
Parent/caregiver Satisfaction Score 1 RR In Paed. Ward

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Version: DH/NQAS-2020/00

May-24

rics Ward Score

2%

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Remarks Obtained Marks

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###

###

###

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e

###

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Remarks Obtained Marks

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###
###
and their modalities

###
hysical economic, cultural or social reasons.

###
elated information.

###
informed consent wherever it is required.

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Remarks Obtained Marks

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he cost of hospital services.

###
###
revalent norms

###

###

###
urrent case load

###

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Remarks Obtained Marks

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ce and performance of staff

###
###
Equipment.

###
and patient care areas

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rs.

###

###
services norms

###
ents.

###

###
al government

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s operating procedures.

tractual obligations ###

###
###
ts.

###
reatment plan preparation.

###
erral

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###

###

###

###

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Remarks Obtained Marks

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and their storage

###

###
gement

###

###
ansfusion.

###

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Remarks Obtained Marks

ased patients ###

nes ###

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Remarks Obtained Marks

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ital associated infection ###

ntisepsis ###

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Remarks Obtained Marks

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ntion ###

ical and hazardous Waste. ###

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###

###

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Remarks Obtained Marks

al to quality. ###

ocesses and support services. ###

vities and wastages ###

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chieve them

###

anagement Plan ###

are processes
###

###

hmarks ###

k ###

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hmark ###

hmark ###

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Checklist No. 6 SNCU Version - NHSRC /3.0

National Quality Assurance Standards for District Hospitals Version: DH/NQAS-

2020/00
Checklist for Special Newborn Care Unit 7

Assessment Summary

Date of Assessment
Name of the Hospital GHQH Erode

Names of Assessors Names of Assesses

Type of Assessment (Internal/External) Internal Action plan Submission Date

SNCU Score Card

Area of Concern wise Score
MusQan SNCU Score
Service Provision
A 95%
Patient Rights
B 86%
Inputs
C 87%
Support Services
D 91%

E
Clinical Services
90%
86%
Infection Control
F 80%
Quality Management
G 67%
Outcome
H 97%

Major Gaps Observed

Strengths / Good Practices

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Checklist No. 6 SNCU Version - NHSRC /3.0

Recommendations/ Opportunities for Improvement

Signature of Assessors

Date

Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
Area of Concern - A Service Provision
Facility provides RMNCHA Services
Standard A2

ME A2.3 The Facility provides Newborn health Services Management of low birth weight infants <1800 gm and SI/RR
2
preterm
Prevention of infection including management of newborn SI/RR
2
sepsis
Management of Neonatal Jaundice 2 SI/RR Phototherapy for new born
Management of Neonatal Asphyxia 2 SI/RR
Emergency Management of Newborn Illnesses 2 SI/RR ETAT , Resuscitation
SI/RR Maintenance of Warmth , Breast feeding/feeding support
2 and Kangaroo Mother care (KMC)
Management of Hypothermia
SI/RR/OB Counselling, Storage, promotion & support for optimal
1 feeding practices
Lactation support & Management Services
SI/RR/OB (1) On fixed Day- for routine examination i.e.
anthropometry, growth, developmental screening
2 (2) Valid referral linkage inhouse or with higher centre
Provision for follow up of high risk babies discharged from the equipped with developmental/ interventional facilities
SNCU `
Facility Provides diagnostic Services
Standard A3

ME A3.2 The Facility Provides Laboratory Services

(1) Serum bilirubin, Plasma glucose, Serum creatinine,
Complete Blood count, Platelet, C reactive protein,
2 Prothrombin time, Blood gas analysis with PH
measurement analysis, Serum Creatinine
(2) Check availability of services specially at night.
SNCU has side lab /Linkage for laboratory investigation. SI/OB
Facility provides services as mandated in national Health Programs/ state scheme
Standard A4

ME A4.12 The facility provides services as per Rashtriya Bal Swasthya Identification of the New born for Birth Defects & referral for SI/RR (1) Neural tube defects, down's syndrome, cleft lip &
Karykram management palate, developmental dysplasia of hip, Club foot,
congenital cataract, deafness, heart diseases, retinopathy
of prematurity, Linkage with DEIC for rehabilitative care
2 (2) All the birth defects are identified and complete
accurate records are uploaded SEAR-NBBD database
(online)

Area of Concern - B Patient Rights

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 The facility has uniform and user-friendly signage system OB
(1) Numbering, main department and internal sectional
1 signage, Restricted area signage displayed.
(2) Directional signages are given from the entry of the
Availability of departmental signages facility
ME B1.2 The facility displays the services and entitlements Necessary Information regarding services provided is (1) Name of doctor and Nurse on duty are displayed and
available in its departments displayed updated.
(2) Contact details of referral transport / ambulance
2 displayed.
(3) Entitlements under JSSK, RBSK, or any relevant scheme
are displayed
OB
ME B1.5 Patients & visitors are sensitised and educated through Display of pictorial information/ chart regarding expression
appropriate IEC / BCC approaches of milk/ techniques for assisted, feeding , KMC,
2 complimentary feeding, Nutrition requirement of
Display of information for education of mother /relatives OB children , hand washing & Breastfeeding policy etc.

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
Parents/family attendants are educated for providing care to 2 As per family participatory care guidelines
their admitted sick new-born PI/OB
Audio Visual Films, Scrolls, Job Aids, mama's breast model
Counselling aids are available for education of parents/ 1 etc are available to provide counselling for lactation,
guardian OB nutrition
No display of poster/ placards/ pamphlets/videos in any part
of the Health facility for the promotion of breast milk Check in Immunization, paediatric OPDs , waiting areas/
substitute , feeding bottles, teats or any product as mentioned 2 outside SNCU etc.
under IMS Act OB
1. Check in SNCU Complex including waiting areas
No display of items and logos of companies that produce
2. Check staff is not using pen, note pad, pen stand etc.
breast milk substitute, feeding bottles, teats or any product as 2 OB which have logos of companies' producing breast milk
mentioned under IMS Act
substitute etc.
No information, counselling and educational material is During counselling Mothers and families are specially
provided to mothers and families on Formula Feed 2 OB educated about ill effects of breast milk substitutes.
ME B1.6 Information is available in local language and easy to Signages and information are available in local language Check all information for patients/ visitors are available in
understand 2 local language
OB

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 OB (1) Screens / Partition has been provided between mothers
Adequate visual privacy is provided at every point of care 1 (2) Visual privacy is maintained in milk expression area
Privacy is maintained in breast feeding and KMC room/area
ME B3.2 SI/OB (1) Check records are not lying in open and there is
Confidentiality of patients records and clinical information designated space for keeping records with limited access.
1 (2) Records are not shared with anybody without written
is maintained Patient Records are kept at secure place beyond access to permission of parents & appropriate hospital authorities
general staff/visitors
ME B3.3 Behaviour of staff is empathetic and courteous OB/PI Check staff is not providing care in undignified manner such
The facility ensures the behaviours of staff is dignified and 2 as yelling, scolding, shouting and using abusive language to
respectful, while delivering the services mother in SNCU and MNCU

Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it is required.
ME B4.1 There is established procedures for taking informed SI/RR
SNCU has system in place to take informed consent from 2 Check BHT/ Pt file General Consent form is taken and
consent before treatment and procedures parent/ guardian/ relative whenever required signed.
ME B4.2 Check mothers of inborn and outborn baby have been allotted OB/PI Also check provision for their stay and diet
Patient is informed about his/her rights and space to stay especially in case of long stay of sick newborn. 1
responsibilities
ME B4.4 PI
Information about the treatment is shared with patients Check parents/ relatives of admitted baby is
SNCU has system in place to involve patient /relatives in 2 communicated about newborn condition, treatment plan
or attendants, regularly
decision making as per Family Participatory guidelines and any changes at least once in day
ME B4.5 Facility has defined and established grievance redressal OB
system in place 2 Check the completeness of the Grievance redressal
Availability of complaint box and display of process for mechanism , from complaint registration till its resolution
grievance re addressal and whom to contact is 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 services.
ME B5.1 The facility provides cashless services to pregnant Check all services including drugs, consumables, diagnostics PI/SI
and blood are provided free of cost Ask mother or attendants if they have paid for any services
women, mothers and neonates as per prevalent 2 or any informal fees given to service providers
government schemes
Availability of free transport services PI/SI Availability of Free drop back, availability of Free referral
2
vehicle/Ambulance services
PI/SI Check with mother about stay facility (specially mother of
outborn newborn)
1 Check with mother if she is getting adequate meal at least
3 times
Availability of free stay & Diet to mother
ME B5.2 The facility ensures that drugs prescribed are available at Check that patient party has not spent on purchasing drugs or 2
PI/SI Ask parent attendants/guardians if they purchased any
Pharmacy and wards consumables from outside. drug/consumable from outside
ME B5.3 It is ensured that facilities for the prescribed Check that patient party has not spent on diagnostics from PI/SI Ask parent attendants/guardians if they got any diagnostic
outside. 2 investigation done from outside
investigations are available at the facility
ME B5.5 System of reimbursement exist in case any expenditure PI/SI/RR
The facility ensures timely reimbursement of financial incurred in the treatment
2
entitlements and reimbursement to the patients

Area of Concern - C Inputs

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

ME C1.1 Departments have adequate space as per patient or work Adequate space in SNCU without cluttering OB (1) Floor area of 50 sq. ft per bed is required for patient
load care area with additional 50 sq. ft for ancillary area.

(2) Additional space is required for step down area.

(3)Space between 2
1 adjacent beds in SNCU should be 4 ft. Space between wall
and beds is 2 ft

Adequate space in MNCU as per the load 1 OB As per MNCU guideline

ME C1.2 Patient amenities are provide as per patient load OB
Waiting areas are along with toilet, Drinking water, seating
1 arrangement, TV for entertainment & Health Promotion
Availability adequate waiting area for patient relatives activities , Tea/coffee vending machine
Availability of space for mothers of admitted sick newborn to OB Check availability of beds, bathing facility, toilets and diet
2
stay supply
ME C1.3 Departments have layout and demarcated areas as per
functions 2
SNCU has earmarked triage area OB Demarcated reception and resuscitation area
2 To accommodate at least 20 radiant warmer, separate
SNCU has newborn care area OB outborn may not required if strict asepsis is followed
SNCU has designated area for infected cases as isolation ward (1) Varicella, Diarrhoea
2 (2) Strict asepsis protocol are followed
OB
Clean area for mixing intravenous fluids and Medications/ fluid Area is clean & entry to area is restricted
2
preparation area OB
SNCU has a designated follow-up area OB For counselling during discharge and imparting FPC training
2

Mother's area for expression of breast milk/ Breast feeding, 2 SNCU has system in place to call mother's of baby for
gowning area & Handwashing area OB feeding
SNCU Complex has designated space for MNCU OB (1) Part of SNCU complex/ Area in close proximity
2 (2) Check Stepdown and KMC unit amalgamated as part of
MNCU

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
MNCU has a treatment cum examination area 2 OB To perform routine activities and keep equipment

2 Autoclaving room, washing area, change room & Dirty

Dedicated space for support services OB Utility , Dining area
Demarcated ancillary area 1 OB Doctors duty room Unit stores & Side Lab
ME C1.4 The facility has adequate circulation area and open spaces
according to need and local law 1
Availability of adequate circulation area for easy movement OB
Check entry is restricted - visitors are not allowed without
1 permission
Check availability of buffer zone beyond the door of SNCU OB
ME C1.5 The facility has infrastructure for intramural and
extramural communication 2
Availability of functional telephone and Intercom Services OB
ME C1.6 Service counters are available as per patient load Availability of adequate patient care units as per case load 2 OB
ME C1.7 The facility and departments are planned to ensure
structure follows the function/processes (Structure 1
commensurate with the function of the hospital) SNCU is easily accessible from labour room, maternity ward
Check maternity complex & SNCU is in close proximity OB and obstetric OT

1
Arrangement of different section ensures unidirectional flow OB Unidirectional flow of goods and services.
Facility ensures the physical safety of the infrastructure.
Standard C2

ME C2.1 The facility ensures the seismic safety of the infrastructure Non structural components are properly secured OB Check for fixtures and furniture like cupboards, cabinets,
1 and heavy equipment , hanging objects are properly
fastened and secured
ME C2.3 The facility ensures safety of electrical establishment SNCU does not have temporary connections and loosely OB
2
hanging wires Switch Boards other electrical installations are intact
SNCU has mechanism for periodical check / test of all OB/RR SNCU has system for power audit of unit at defined
electrical installation by competent electrical Engineer 1
intervals and records of same is maintained
10 central Voltage stabilize outlets are available with each OB/RR 50% of each should be 5amp and 50% should be 15 amp to
1
warmer in main SNCU, Step down area and triage room handle load of equipment
OB/RR (1) SNCU has three phased stabilized power supply to
protect the equipment from electrical damage.
(2) Wall mounted digital display is available in SNCU to
2 show earth to neutral voltage. (3) Earth resistance
should be measured twice in a year and logged. Normal
range 3-5 V (if exceed to report immediately)
SNCU has earthling system available
ME C2.4 Physical condition of buildings are safe for providing The floor of the SNCU complex is made of anti-skid
patient care 2
Floors of the SNCU are non slippery and even OB material.
Windows/ ventilators if any are intact and sealed 2 OB
Facility has established program for fire safety and other disaster
Standard C3

ME C3.1 The facility has plan for prevention of fire OB/SI Check the fire exits are clearly visible and routes to reach
exit are clearly marked. Check there is no obstruction in the
route of fire exits. Staff is aware of assembly points & policy
to evacuate SNCU in case of fire
SNCU has sufficient fire exit to permit safe escape to its
occupant at time of fire 2

ME C3.2 The facility has adequate fire fighting Equipment OB Check the expiry date for fire extinguishers are displayed as
well as due date for next refilling is clearly mentioned
SNCU has installed fire Extinguisher that is either Class A ,
Class B, C type or ABC type 2

OB
SNCU has electrical and automatic fire alarm system or
SNCU has provision of Smoke and heat detector & fire alarm 1 alarm system sounded by actuation of any automatic fire
extinguisher

ME C3.3 The facility has a system of periodic training of staff and Check for staff competencies for operating fire extinguisher SI/RR Staff is aware of RACE (Rescue, Alarm, Confine &
conducts mock drills regularly for fire and other disaster and what to do in case of fire Extinguish) &PASS (Pull, Aim, Squeeze & Sweep)
2
situation

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

ME C4.1 The facility has adequate specialist doctors as per service At least one paediatrician/ FBNC trained medical officer per
provision 2 shift
Availability of fulltime Paediatrician OB/RR
ME C4.3 The facility has adequate nursing staff as per service OB/RR/SI 3 per shift
provision and work load 2
Availability of Nursing staff
ME C4.4 The facility has adequate technicians/paramedics as per Availability technician for side lab OB/SI 1 technician (if side lab is available).
requirement 2 Give full compliance if there is functional linkage with
Hospital's lab and lab tech is available at night even
ME C4.5 The facility has adequate support / general staff SI/RR Availability of sanitary staff and ayahs, Security staff &
data entry operator
2
Availability of SNCU support staff
Facility provides drugs and consumables required for assured list of services.
Standard C5

ME C5.1 The departments have availability of adequate medicines OB/RR

Ampicillin, Cefotaxime, Gentamycin, Amikacin, Piperacillin,
at point of use 2
Availability of Antibiotics Meropenem
Availability of antiepileptic medicines (AEDs) 2 OB Lorazepam, Phenytoin and Phenobarbitone
Availability of analgesics and antipyretics 2 OB/RR Paracetamol
OB/RR
5%, 10%, 25% Dextrose
2 Normal saline, Inj. Potassium Chloride 15%, Isolyte-P,
distilled water.
Inj. Calcium Gluconate 10%
Availability of IV Fluids & medicines for electrolyte imbalance
Availability of Supplements 2 OB/RR Vit D, Calcium, Phosphorus, multivitamin & iron
ME C5.2 The departments have adequate consumables at point of OB/RR
Gauze piece and cotton swabs, Diapers, Baby ID tag, cord
use 2
Availability of consumables for new born care clamp, mucus sucker, Gauze piece and cotton swabs.
OB/RR
Neoflon 24 G , micro drip infusion set with &without
2 burette, BT set, Suction catheter, PT tube, feeding tube,
Availability of syringes and IV Sets /tubes pedia drip set
OB/RR Gowns (disposable /autoclavable) while entering inside
1
Availability of consumables for mother/family attendant SNCU and also while providing KMC

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
ME C5.3 Emergency drug trays are maintained at every point of Emergency Drug Tray is maintained OB/RR [Link] (1:10000)
care, where ever it may be needed Inj. Naloxone
Sodium Bicarbonate Injection Aminophylline
2 Phenobarbitone (Injection +oral)
Injection Hydrocortisone,[Link], Inj.
Phenytoin, Vit K , Caffeine citrate

Facility has equipment & instruments required for assured list of services.
Standard C6

ME C6.1 Availability of equipment & instruments for examination Availability of functional Equipment &Instruments for
& monitoring of patients examination & Monitoring Multipara monitor , Thermometer, Weighing scale, pulse
1 oximeter, Stethoscope (binaural, neonate),stethoscope
OB (paediatric), Infantometer , Measuring tape, fluxmeter
ME C6.3 Availability of equipment & instruments for diagnostic Availability of diagnostic instruments for side laboratory
procedures being undertaken in the facility Availability of services in side lab; Micro
1 hematocrit,Multistix,Bilirubinometer,Microscope,Dextrome
ter, Glucometer, test stripes, 26 gauge needle or lancet,
OB alcohol for skin preparation
ME C6.4 Availability of equipment and instruments for
resuscitation of patients and for providing intensive and
critical care to patients
2
Infusion pumps,Oxygen cylinder/central line/Oxygen
concentrator, oxygen hood, Self inflating Bag and masks
(Size 00, 0 & 1) 250 ml &500 ml, laryngoscope ( with 0 &1
Functional Critical care equipment for Resuscitation. OB size straight blades) , ET tubes, suction machine

2
20 Radiant warmers -servo controlled with oxygen &
Functional Patient care units OB suction and 6 phototherapy machine
ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for drugs Refrigerator, Crash cart/Drug trolley, instrument trolley,
2 dressing trolley
OB
ME C6.6 Availability of functional equipment and instruments for Availability of neonatal transport equipment Transport incubator with temp probes, digital
support services thermometer, oxygen cylinder with flowmeters, oxygen
tubing adapter, oxygen hood, neonatal size masks &
2 cannula, resuscitation bags, nasal prong, endotracheal
tubes, mucus suction trap, feeding tube, infusion pump etc

OB
Availability of equipment for cleaning, washing Buckets for mopping, Separate mops for ward and
sterilization and disinfection 2 circulation area, duster, waste trolley, Deck brush, washing
machine, Autoclave
OB
ME C6.7 Departments have patient furniture and fixtures as per
load and service provision Cupboard, nursing counter, table for preparation of
2 medicines, chair, furniture at breast feeding room, X ray
Availability of furniture & fixture OB view box.

Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff
ME C7.1 Criteria for Competence assessment are defined for clinical SI/RR
and Para clinical staff Check objective checklist has been prepared for assessing
Check parameters for assessing skills and proficiency of clinical 2 competence of doctors, nurses and paramedical staff based
staff has been defined on job description defined for each cadre of staff.
ME C7.2 Check for competence assessment is done at least once in a SI/RR
year Check for records of competence assessment including
Competence assessment of Clinical and Para clinical staff is 2 filled checklist, scoring and grading . Verify with staff for
done on predefined criteria at least once in a year actual competence assessment done
ME C7.9 Facility based New Born Care (FBNC) training SI/RR
To all Medical Officers and Nursing Staff posted at SNCU
The Staff is provided training as per defined core competencies 2 -4 days class room training followed by 14 days
and training plan observership at recognized collaborating centre
NRP module training for updated protocols of neonatal SI/RR
resuscitation 2
To all Medical Officers and Nursing Staff posted at SNCU
ETAT training 2 SI/RR All the staff working in SNCU
Training on IYCF SI/RR Especially for lactation failure or breast problems like
engorgement, mastitis etc, and provide special
counselling to mothers with less breast milk, low birth
weight babies, sick new-born, undernourished
children, adopted baby, twins and babies born to HIV
2 positive mothers.
At least two service providers trained in advanced lactation
management and IYCF counselling skills should be available
to deal with difficult and referred cases.

Biomedical Waste Management& Infection control and hand SI/RR

2
hygiene ,Patient safety Check training records
SI/RR Triage, Quality Assessment & action planning, PDCA, 5S &
2
Training on Quality Management use of checklist for quality improvement
ME C7.10 There is established procedure for utilization of skills gained SI/RR
thought trainings by on -job supportive supervision Check supervisors make periodic rounds of department and
1 monitor that staff is working according to the training
imparted. Also staff is provided on job training wherever
Check facility has system of on job monitoring and training there is still gaps
SNCU staff is provided with refresher training SI/RR Check with training records the SNCU staff have been
provided refresher training at least once in every 12 month
2 on care of normal and sick newborn at time of birth &
beyond & Breast feeding support

SI/ PI As per family participatory care guidelines

Nursing staff is skilled to train parent-attendants for providing

care to the sick newborn
Area of Concern - D Support Services
Facility has established program for inspection, testing and maintenance and calibration of equipment.
Standard D1

ME D1.1 The facility has established system for maintenance of All equipment are covered under AMC including preventive SI/RR
Radiant warmer, Phototherpy units suction machine,
critical Equipment maintenance 1
Oxygen concentrator, pulse oximeter/ Multipara monitor
SI/RR Check for breakdown & Maintenance record in the log
book
Back up for critical equipment. Label Defective/Out of
2 order equipment and stored appropriately until it has been
repaired.
There is system of timely corrective break down maintenance
of the equipment

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
Staff is skilled for cleaning, inspection & trouble shooting of SI/RR (1) Staff is trained for use, preventive maintenance and
the equipment malfunction trouble shooting of equipment such as radiant warmers,
infusion pump, oxygen concentrator, bag &mask, weighting
machine, phototherapy unit.
(2) There is procedure to check timely replacement of lights
in Phototherapy unit.
2

Check the skill of staff for maintenance & trouble shooting of SI/ OB Maintenance-
oxygen concentrator Coarse filter- Ensure it is dust free & wash daily
Zeolite granule- change after 20,000 hrs
Bacterial filter- change every yr.
Trouble Shooting-
Machine is too noisy- May be coarse filter is blocked- wash
filter daily.
Machine or room gets heated- Machine is near wall- Keep
away from wall or outside the room for free circulation of
air
Yellow light is not going off- desired oxygen conc. is not
reached- may be due to high humidity or flow rate is more,
so decrease flow rate.
2 Compressor heats up- Malfunctioning of compressor- Look
at fan, it may be jammed, & hence need repair.
If central oxygen supply is used - Check staff is aware of it
maintenance & trouble shooting

Check the skill of staff for maintenance & trouble shooting of SI/RR Low irradiance : Due to tubes old, flickering, black ends,
phototherapy units bulbs covered with dust or dirty reflectors )
2

ME D1.2 The facility has established procedure for internal and All the measuring equipment/ instrument are calibrated OB/ RR `
external calibration of measuring Equipment (1) BP apparatus, thermometers, weighing scale , radiant
1 warmer etc are calibrated . (2) Check for records
/calibration stickers. (3) There is system to label/ code the
equipment to indicate status of calibration/ verification
when recalibration is due.
ME D1.3 Operating and maintenance instructions are available Up to date instructions for operation and maintenance of
OB/SI Check operating and trouble shooting instructions of
with the users of equipment 2 equipment are available in SNCU
equipment are readily available with SNCU staff.
The facility has defined procedures for storage, inventory management and dispensing of medicines in pharmacy and patient care areas
Standard D2

ME D2.1 There is established procedure for forecasting and There is established system of timely indenting of SI/RR Stock level are daily updated
indenting drugs and consumables consumables and drugs Requisition are timely placed well before reaching the stock
2 out level.
Check with stock and indent registers.

Drugs are indented & supplied in Paediatric dosages only 1 OB/RR/SI Check drugs are available in paediatric doses/formulation
ME D2.3 The facility ensures proper storage of drugs and Drugs are stored in containers/tray/crash cart and are labelled OB Check drugs and consumables are kept at allocated space
consumables 2 in Crash cart/ Drug trolleys and are labelled. Look alike and
sound alike drugs are kept separately
Empty and filled cylinders are labelled and updated OB Empty and filled cylinders are kept separately and labelled,
flow meter is working and pressure/ flow rate is updated in
2 the checklist

ME D2.4 The facility ensures management of expiry and near Expiry and near expiry dates are maintained OB/RR
Records for expiry and near expiry drugs are maintained for
expiry drugs 2
emergency tray and drug stored at department
No expiry drug found 2 OB/RR In SNCU sub store as well as drug/emergency trays
ME D2.5 The facility has established procedure for inventory There is practice of calculating and maintaining buffer stock SI/RR At least once in a week- minimum buffer stock is
management techniques 2 maintained. Minimum stock and reorder level are
calculated based on consumption in a week accordingly
Department maintained stock and expenditure register of RR Check stock and expenditure register is adequately
drugs and consumables 2 maintained
ME D2.6 There is a procedure for periodically replenishing the drugs in There is procedure for replenishing drug tray /crash cart SI/RR There is no stock out of drugs and
patient care areas 2 Procedure for replenishing drug in place
ME D2.7 There is process for storage of vaccines and other drugs, OB/RR Check for temperature charts are maintained and updated
requiring controlled temperature periodically. Refrigerators meant for storing drugs should
2 not be used for storing other items such as eatables
Temperature of refrigerators are kept as per storage
requirement and records are maintained
The facility provides safe, secure and comfortable environment to staff, patients and visitors.
Standard D3

ME D3.1 The facility provides adequate illumination level at patient OB

care areas
2 200 Lux at the plane of infant bed, adjustable
Ambient lightening at least 50 to more than 600 Lux.
Illumination level at nursing station- 150-300 Lux
Adequate Illumination patient care unit & nursing station Light source is glare free or veiling reflections
ME D3.2 The facility has provision of restriction of visitors in OB/SI
patient areas (1) One trained female family member allowed to stay with
the new born in step down after undertaking all universal
2 precaution measures like bathing, wearing gowns, mask,
head cap etc.
(2) Entry to SNCU is restricted,
Visitor policy is defined & implemented (3) Visiting hour are fixed and practiced
ME D3.3 The facility ensures safe and comfortable environment for SNCU has system to control temperature and humidity and
patients and service providers record of same is maintained
2 Temperature inside main SNCU should be maintained at
(28+/- 2OC), round O clock preferably by thermostatic
SI/RR control. Relative humidity of 30-60% should be maintained

Each equipment used should have servo controlled devices

2 for heat control with cut off to limit increase in
temperature of radiant warmers beyond a certain
SNCU has procedure to check the temperature of radiant temperature or warning mechanism for sounding
warmer ,phototherapy units, baby incubators etc. SI/RR alert/alarm when temp increases beyond certain limits

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No

Control the sound producing activities and gadgets (like

telephone sounds, staff area and equipment). Should not
2 keep beeping at high volume ( Not more than 45 db and
peak intensity should not be more than 80 db)
SNCU has system to control & monitor sound level SI/RR
SNCU has system of switching off light when not performing
any activity /at night 2
OB
ME D3.4 The facility has security system in place at patient care OB/RR There is procedure for handing over the baby to
areas 2 mother/father/Legal Guardian
New born identification band and foot prints are used
OB Restriction Signage, security guard in each shift, functional
2 CCTV camera, define & practice procedure for handing over
the baby to mother/father
Check security arrangement at SNCU are robust
ME D3.5 The facility has established measure for safety and security of Ask female staff whether they feel secure at work place SI
female staff 2

The facility has established Programme for maintenance and upkeep of the facility
Standard D4

ME D4.1 Exterior & Interior of the facility building is maintained Interior & exterior of patient care areas are plastered & OB Wall and Ceiling of SNCU is painted and made of white wall
appropriately painted & building are white washed in uniform colour 1 tiles, with seamless joint, and extending up to the ceiling.

ME D4.2 Patient care areas are clean and hygienic Walls & sinks are cleaned as per schedule OB (1) At least once a day
2 (2) With hospital grade disinfectant
Mopping of SNCU is done as per schedule 2 OB/ RR (1) At least 3 times in a day
Floors, walls, roof, roof tops, sinks patient care and circulation OB All area are clean with no dirt,grease,littering and
areas are Clean 2 cobwebs. Surface of furniture and fixtures are clean
Toilets are clean with functional flush and running water OB Check toilet seats, floors, basins etc are clean and water
2 supply with functional cistern has been provided.
ME D4.3 Hospital infrastructure is adequately maintained Check for there is no seepage , Cracks, chipping of plaster 1 OB Check for patient care as well as auxiliary areas
Window panes , doors and other fixtures are intact 2 OB
ME D4.5 The facility has policy of removal of condemned junk OB Check for any obsolete article including equipment,
material 2 instrument, records, drugs and consumables
No condemned/Junk material in the SNCU
ME D4.6 The facility has established procedures for pest, rodent OB No lizard, cockroach, mosquito, flies, rats, bird nest etc.
and animal control 2
No stray animal/rodent/birds
The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
Standard D5

ME D5.1 The facility has adequate arrangement storage and supply Availability of 24x7 running and potable water OB/SI Availability of 24X7 Running water & hot water facility.
for portable water in all functional areas 2
ME D5.2 The facility ensures adequate power backup in all patient OB/SI Check for 24X7 availability of power backup including
care areas as per load 1 dedicated UPS and emergency light
Availability of power back up in patient care areas
ME D5.3 Critical areas of the facility ensures availability of oxygen, Availability of Centralized /local piped Oxygen and vacuum OB
medical gases and vacuum supply supply 2

StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.
ME D6.1 The facility has provision of nutritional assessment of the Nutritional assessment of patient done specially for mother of
patients 2
admitted baby RR/SI
ME D6.2 The facility provides diets according to nutritional
requirements of the patients (1) Check diet is provided to all mothers (both inborn or
Check for the adequacy and frequency of diet as per 2 outborn babies)
nutritional requirement OB/RR (2) Check that all items fixed in diet menu is provided

Standard D7 The facility ensures clean linen to the patients

ME D7.1 The facility has adequate sets of linen SNCU has facility to provide sufficient and clean linen for each OB/RR Check linen is clean, stains free & not torn.
2
parent -attendant
ME D7.2 The facility has established procedures for changing of OB/RR
linen in patient care areas 2
Linen is changed every day and whenever it get soiled
ME D7.3 The facility has standard procedures for handling , collection, SI/RR Quantity of linen is checked before sending it to laundry.
transportation and washing of linen 2 Cleanliness & Quantity of linen is checked received from
There is system to check the cleanliness and Quantity of the laundry. Records are maintained
linen
OB Check linen is kept closed bin & emptied regularly. Plastic
1 bag is used in dustbin & these bags are sealed before
removed & handed over
Check dedicated closed bin is kept for storage of dirty linen

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
ME D11.2 The facility has a established procedure for duty roster There is procedure to ensure that staff is available on duty as RR/SI (1) Check for system for recording time of reporting and
and deputation to different departments per duty roster relieving (Attendance register/ Biometrics etc)
2 (2) Check FPC roster of nurses for providing training to
Parent/ attendant

ME D11.3 The facility ensures the adherence to dress code as OB As per hospital administration or state policy.
mandated by its administration / the health department Check SNCU doctors and nurses follow the dress code
Doctor, nursing staff and support staff adhere to their 2
respective dress code

Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
ME D12.1 There is established system for contract management for out SI/RR Verification of outsourced services (cleaning/
sourced services 1 Dietary/Laundry/Security/Maintenance) provided are done
There is procedure to monitor the quality and adequacy of by designated in-house staff
outsourced services on regular basis
Area of Concern - E Clinical Services

Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
ME E1.1 The facility has established procedure for registration of Unique identification number & patient demographic RR Check for that patient UID & demographics like Name, age,
patients records are generated during process of registration & 2 Sex, Chief complaint, etc. are recorded
admission
ME E1.3 There is established procedure for admission of patients SI/RR Baby weight <1800 or more >4 Kg, gestation- <34 weeks,
perinatal asphyxia, apnoea, refusal to feed, respiratory
distress(Rate >60/min,severe jaundice, hypothermia <35.4
2 deg C & hyperthermia >37.5 deg C, central cyanosis, shock
(CFT>3 sec)bleeding, abdominal distension, diarrhoea &
major malformation
Admission criteria for SNCU is defined & followed
SI/RR/OB Time of admission is recorded in patient record, Admission
2 is done by written order of a qualified doctor
There is no delay in admission of patient
ME E1.4 There is established procedure for managing patients, in OB/SI
case beds are not available at the facility 2
Procedure to cope with surplus patient load

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Partial/No

Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.
ME E2.1 There is established procedure for initial assessment of Check availability & use of assessment criteria like triage of
patients sick new born, Kramer's criteria for assessment of Jaundice,
Initial assessment of all admitted patient done as per standard Silverman Anderson Score for assessment of severity of
2 respiratory distress and Ballard score for assessing
protocols
gestation of new born etc.
RR/SI
Patient History, Physical Examination & Provisional Diagnosis is RR Check bed head ticket
2
done and recorded

2
Initial assessment and treatment is provided immediately
RR/SI Initial assessment is documented preferably within 2 hours
ME E2.2 There is established procedure for follow-up/ There is fixed schedule for assessment of stable patients &
There is fix schedule of reassessment as per protocols.
reassessment of Patients 2 Reassessment finding are recorded in BHT
critical patients RR/OB

There is system in place to identify and manage the changes in Criteria is defined for identification, and management of
Patient's health status 2 high risk patients/ patient whose condition is deteriorating
SI/RR
Check the treatment or care plan is modified as per re Check the re assessment sheets/ Case sheets modified
assessment results 2 treatment plan or care plan is documented
SI/RR

There is established procedure to plan and deliver Assessment includes physical assessment, history, details of
Check healthcare needs of all hospitalised patients are existing disease condition (if any) for which regular
ME E2.3 appropriate treatment or care to individual as per the identifed through assessment process 2 medication is taken as well as evaluate
needs to achieve best possible results psychological ,cultural, social factors
SI/RR

(a) According to assessment and investigation findings

(wherever applicable).
(b) Check inputs are taken from patient or relevant care
Check treatment/care plan is prepared as per patient's need 2 provider while preparing the care plan.

RR
Care plan include:, investigation to be conducted,
Check treatment / care plan is documented 2 intervention to be provided, goals to achieve, timeframe,
RR patient education, , discharge plan etc
Check care plan is prepared and delivered as per direction
Check care is delivered by competent multidisciplinary team 2 of qualified physician
SI/RR

Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 The facility has established procedure for continuity of There is procedure of taking over of new born from labour , Check continuity of care is maintained while transferring/
care during interdepartmental transfer 2
OT/ Ward to SNCU RR/SI hand overing the patient
ME E3.2 The facility provides appropriate referral linkages to the Check pre referral stabilization is done SI/ RR/ OB (1) Check baby is stabilized w.r.t Temp. ( skin to skin care-
patients/Services for transfer to other/higher facilities to cover the baby- Transport incubator), Oxygenation: Airway
assure the continuity of care. & breathing, perfusion ( HR, CRT temp), Sugar.
2 (2) Check 1st dose of antibiotics -inj Ampicillin & gentamicin
is given. Also, Vit K is given if not administrated earlier

(1) A referral slip/ Discharge card is provide to patient when

2 referred to another health care facility . (2) Referral slip
includes demographic details, History of patient,
examination findings, management done , drugs
administered, any procedure done, reason for referral,
(3) Detail of referral centre including whom to contact and
Patient referred with referral slip RR/SI signature of approving medical officer
Reason for referral is clearly stated and referral is written by (1) Verify with referral records that reasons for referral
authorized competent person (Paediatrician or Medical Officer were clearly mentioned
on duty) (2) SNCU staff confirms the suitability of referral with
2 higher centres to ascertain that case can be managed at
higher centre and will not require further referrals
RR/ SI
(1) Check SNCU staff facilitates arrangement of ambulance
for transferring the patient to higher centre .
(2) Patient attendant are not asked to arrange vehicle by
their own
2 (3) Check if SNCU staff checks ambulance preparedness in
terms of necessary equipment, drugs, accompanying staff
in terms of care that may be required in transit
Advance communication is done with higher centre & Referral
vehicle is being arranged SI/PI/RR
Referral checklist & Referral in/ Out register is maintained for (1) Referral check list is filled before referral to ensure all
all referred cases necessary steps have been taken for safe referral
(2) Check referral records has information regarding
advance communication, transport arrangement,
2 SI/RR accompanying care provider, reason for referral , time
taken for referral etc. along with demographics, date &
time of admission, date & time of referral, and follow up

(1) Check that SNCU staff take follow up of referred cases

for timely arrival and appropriate care provided at higher
centre. (2) Outcome and deficiencies if any should be
2 SI/RR recorded in referral out register & analysed for
improvement
There is a system of follow up of referred patients
(1) Check for referral cards filled from lower facilities
2 SI/RR (2) CHW of nearby PHC/HWC is informed about discharge
for follow ups
Facility has functional referral linkages to lower facilities
ME E3.3 A person is identified for care during all steps of care RR/SI Check community health worker is assigned for the follow-
2 up post discharge
Duty Doctor and nurse is assigned for each patients

Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of patients is established at There is a process for ensuring the identification of baby OB/SI
the facility before any clinical procedure 2
Identification tags are used for new-borns
ME E4.2 Procedure for ensuring timely and accurate nursing care as per RR Check for treatment chart are updated and drugs given are
treatment plan is established at the facility 2 marked. Co relate it with drugs and doses prescribed.
Treatment chart are maintained
There is a process to ensue the accuracy of verbal/telephonic SI/RR Verbal orders are rechecked before administration. Verbal
1 orders are documented in the case sheet
orders

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
PI/SI Breastfeeding, KMC, cleaning of baby can be undertaken by
2 trained parent/attendant under the supervision of doctor/
Parent/ attendants are encouraged to provide basic care to nurse
the newborn
ME E4.3 There is established procedure of patient hand over, Patient hand over is given during the change in the shift SI/RR Nursing Handover register is maintained
whenever staff duty change happens 2
Hand over is given bed side SI/RR (1) Handover is given during the shift change explaining the
condition, care provided and any specific care if required.
(2) Check SBAR (situation, background, assessment and
2 recommendation) protocols are followed

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

Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients and ensure their safe Measures are taken to protect new born from any harm OB/SI Check the measure taken to prevent new born
care 2 theft/swapping ,baby fall, baby charring, adverse drug
events etc
ME E5.2 The facility identifies high risk patients and ensure their care, High risk patients are identified and treatment given on OB/SI New born with emergency & priority signs assessed &
as per their need priority 2 immediate treatment is given

Standard E6 Facility ensures rationale prescribing and use of medicines

ME E6.1 The facility ensured that drugs are prescribed in generic name RR Check prescriptions are not written with brand name
only 2
Check for BHT if drugs are prescribed under generic name only
ME E6.2 There is procedure of rational use of drugs Check for that relevant Standard treatment guideline are RR
available at point of use Essential newborn care, Newborn Resuscitation,
1 management of hypothermia. LBW, Fluid management,
hypoglycaemia, neonatal jaundice, ETAT etc
Check staff is aware of the drug regime and doses as per STG SI/RR Check BHT that drugs are prescribed as per protocols and
2 &Check for rational use of drugs
ME E6.3 There are procedures defined for medication review and Check complete medication history including over-the-
optimization Complete medication history is documented for each patient 2 RR/OB counter medicines is taken and documented
Medicine are reviewed and optimised as per individual 2 SI/RR Medicines are optimised as per individual treatment plan
treatment plan for best possible clinical outcome
"1. Clinician/Nurse counsel the patient on medication
safety using ""5 moments for medication safety app""
2. Nurse highlights the medications to be taken by the
Patients are engaged in their own care 2 PI/SI patient at home and counsel the patient and family on drug
intake as per treatment plan for discharge"

Standard E7 The facility has defined procedures for safe drug administration
ME E7.1 There is process for identifying and cautious High alert drugs available in department are identified SI/OB Electrolytes like Potassium chloride, Dopamine,
administration of high alert drugs (to check) dobutamine, Hydrocortisone, Phenytoin, Phenobarbitone,
2 Adrenergic agonist, Opioids, Anti thrombolytic agent etc.
as applicable

Maximum dose of high alert drugs are defined and SI/RR Value for maximum doses as per age, weight and diagnosis
communicated 2 are available with nurses and doctor.
ME E7.2 Medication orders are written legibly and adequately There is process to ensure that right doses of drugs are only SI/RR A system of independent double check before
given 2 administration, Error prone medical abbreviations are
avoided
Every Medical advice and procedure is accompanied with date RR Verify case sheets of sample basis
, time and signature 1
Check for the writing, It comprehendible by the clinical staff 1 RR/SI Verify case sheets of sample basis
ME E7.3 There is a procedure to check drug before administration/ Drugs are checked for expiry and other inconsistency before OB/SI Check for any open single dose vial with leftover content
dispensing administration 2 intended to be used later on .In multi dose vials, needle is
not left in the septum
Any adverse drug reaction is recorded and reported RR/SI Check if adverse drug reaction form is available in SNCU
2 and its reporting is in practice.
ME E7.4 There is a system to ensure right medicine is given to right Fluid, drug & dosages are calculated according to body weight SI/RR Check for calculation chart
patient 2
Drip rate and volume is calculated and monitored SI/RR Check the nursing staff how they calculate Infusion and
2 monitor it
Check Nursing staff is aware 7 R's of Medication and follows SI/OB Administration of medicines done after ensuring right
them 2 patient, right drugs , right route, right time, Right dose ,
Right Reason and Right Documentation

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re-assessment and investigations are New born's progress is recorded as per defined assessment RR Check BHT is updated following each reassessment
recorded and updated 2
schedule
ME E8.2 All treatment plan prescription/orders are recorded in the Treatment plan are written on BHT and all drugs are written RR (1) Check Medication order, treatment plan, lab
patient records. legibly in case sheet. investigation & nursing charts are recorded adequately
1 (2) Check change in treatment plan is also mentioned in
case new born's condition deteriorate

ME E8.3 Care provided to each patient is recorded in the patient Maintenance of treatment chart/treatment registers RR Treatment given is recorded in treatment chart
records 2
ME E8.4 Procedures performed are written on patients records RR
Resuscitation, blood transfusion, suctioning, phototherapy
2
Procedure performed are recorded in BHT etc
ME E8.5 Adequate form and formats are available at point of use RR/OB

Availability of formats for neonatal case sheet, Treatment

2 Charts, TPR Chart , Intake Output Chart, Investigation
sheet, Community follow up card, BHT/ newborn case
record , treatment continuation sheet, Discharge card,
nomographs, congenital anomaly if any. etc
Standard Formats are available Check forms & formats are being used
ME E8.6 Register/records are maintained as per guidelines RR

2 General order book (GOB), report book, Admission register,

lab register, Admission sheet/ bed head ticket, discharge
slip, referral slip, referral in/referral out register, Diet
Registers and records are maintained as per guidelines register, Linen register, Drug indent register etc
All register/records are identified and numbered 2 RR Check records are numbered and labelled legibly

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
ME E8.7 The facility ensures safe and adequate storage and Safe keeping of patient records OB (1) Records of discharged cases are kept in MRD/
retrieval of medical records department sub store
(2) Check records are retrieval in case of re admission
(3) Copy of records is given to next kin only with
2 permission from authorised staff only

Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing patient readiness SI/RR
Criteria for transfer to step down: Respiratory distress
2 improves & do not require oxygen supplementation, babies
on antibiotics for completion of therapy, LBW who
otherwise stable, babies with Jaundice who otherwise
SNCU has established criteria to transfer to step down / MNCU stable.
SI/RR

Checklist having information regarding babies birth weight,

2 gestational age, perinatal asphyxia, small for date,
hypoglycaemia, neonatal seizures, sepsis with meningitis,
High risk identification checklist is available & filled at time of shock requiring vasopressor support, total serum bilirubin
discharge in exchange range, suboptimal home environment etc.
SI/RR
Criteria for transfer to home: Primary illness is resolved,
baby maintain temp without radiant warmer, baby is
2 accepting mothers milk, documented weight gain for
consecutive 3 days, & wt. is more than 1.5 Kg, baby
haemodynamically stable ( normal CFT and strong
SNCU has established criteria for discharge peripheral pulses)
Discharge is done by a responsible and qualified doctor after SI/RR Discharge is done in consultation with treating doctor
2
assessment
New-born/ attendants are consulted before discharge 2 PI/SI Time of discharge is communicated to patient in prior
RR/SI Check suggested schedule along with follow up protocols is
available & used

Follow up plan for assessment & specific interventions is

scheduled after discharge of high risk babies
ME E9.2 Case summary and follow-up instructions are provided at RR/PI See for discharge summary, referral slip provided.
the discharge
2
Discharge summary adequately mentions patient clinical
condition, treatment given and follow up
Discharge summary is give to patients going in LAMA/Referral SI/RR
patient 2

There is procedure for clinical follow up of the new born by RR/SI SNCU has system in place to send communication to
1 CHW/ASHA regarding discharge of baby from SNCU
local CHW (Community health care worker)/ASHA
ME E9.3 Counselling services are provided as during discharges PI/SI Training has been given for nutrition, immunisation,
wherever required 2 understanding baby cues and addressing the issues. Ask
Parent/attendants are trained & confident to provide care parent /attendant if they have been trained
after discharge
PI Breastfeed infant exclusively, keep infant warm, keep cord
clean and dry, importance and correct method of
handwashing & danger signs*.
(*Danger signs: Refusal to feed; Fast or difficult breathing,
Cold or Hot to touch, jaundice involving palms and soles
2 Pallor/Cyanosis, Abdominal distension, Abnormal
movements, Bleeding from any site or Diarrhoea with
blood in stool)
Check with mother/attendant the key points explained during
counselling
ME E9.4 The facility has established procedure for patients leaving RR/SI
the facility against medical advice, absconding, etc 2
Declaration is taken from parent's/ guardian of the LAMA
patient

Standard E10 The facility has defined and established procedures for intensive care.
ME E10.3 The facility has explicit clinical criteria for providing RR/SI (1) To suction trachea in presence of meconium when
intubation & extubation, and care of patients on newborn is not vigorous (2) if positive pressure ventilation
ventilation and subsequently on its removal is not resulting into adequate clinical improvement (3)To
improve efficacy of ventilation after several minutes of bag
& mask ventilation or ineffective bag & mask ventilation
(4)To facilitate chest compressions and ventilation and to
2 maximize the efficiency of each ventilation (5) for special
cases like giving endotracheal medication & suspected
diaphragmatic hernia

Criteria are defined for endotracheal intubation

SI/OB Ask for demonstration
Steps to follow : (1) Stabilize the new born's head in sniffing
position, deliver free flow of oxygen during procedure
(2) Slide laryngoscope over right side of tongue, pushing
the tongue to left side of mouth & advancing the blade
until the tip lies beyond the base of the tongue. (3) Lift the
blade slightly, raise entire blade not just tip (4) Look for
landmarks, vocal cords should appear as vertical stripes of
each side of glottis or inverted 'v'
(5) Suction if required for visualization (6) Insert the tube
1 into right side of mouth with the curve of the tube lying in
horizontal plane
(7) If cords are closed, wait them to open. Insert the tip of
endotracheal tube until vocal cord guide is at the level of
cords (8) Hold the tube firmly against the babies palate
while removing laryngoscope

Staff is trained for intubating newborn

Staff is aware of indications of correct placement of SI/OB (1) Improved vital signs
endotracheal tube (2) Breath sounds over both lung fields
(3) No gastric distention
(4) Vapours in tube during exhalation
1 (5) Chest movement in each breath
(6) Direct visualization of tube passing between vocal cords

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.2 Emergency protocols are defined and implemented (1) Triage - ETAT protocol - keeping in mind ABCD steps
(2) Ascertaining the group of baby - Emergency, Priority
and non urgent.
2 (2) After identification of emergency & priotize sign-
prompt emergency treatment is to be given to stabilize.
Staff is aware of process & steps for emergency management
of sick neonate SI/RR
ME E11.3 The facility has disaster management plan in place Staff is aware of disaster plan SI/RR Role and responsibilities of staff in disaster are defined
2 Mock drills have conducted from time to time
ME E11.4 The facility ensures adequate and timely availability of SI/RR
ambulances services and mobilisation of resources, as per
requirement Check ambulance/ vehicle used for neonatal transport have
following requirements:
2 (1) Secure fixation for transport incubator
(2) Secure fastening of other equipment (e.g. Monitoring
equipment)
(3) Independent power source to supplement equipment
SNCU has provision of Ambulances to refer the case to higher batteries to ensure uninterrupted operation of the
centre equipment
SI/RR Ambulance/transport vehicle have adequate arrangement
for Oxygen therapy, mechanical ventilation, resuscitation/
2 essential supplies kit and emergency drug kit
Ambulance has provision/ method for maintenance of Warm
chain while referring baby to higher centre
Transfer of patient in Ambulance /patient transport vehicle is SI/RR Check Constant vigilance (maintaining TOPS_ temp.
2 oxygen, perfusion & sugar) during journey.
accompanied by trained medical Practitioner

Standard E12 The facility has defined and established procedures of diagnostic services
ME E12.1 There are established procedures for Pre-testing Container is labelled properly after the sample collection OB Protocols are defined & followed for sample collection.
Activities 2 Also check procedure to transfer to lab (if need to send to
inhouse/outsource lab.)
ME E12.3 There are established procedures for Post-testing SI/RR (1) Critical values are defined and intimated timely to treat
Activities medical officer
2 (2) List of Normal reference ranges as per available in NRC
SNCU has defined critical values of various lab test

Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
ME E13.9 There is established procedure for transfusion of blood Patient's identification is confirmed & Consent is taken before
RR
2
transfusion
RR Blood is kept on optimum temperature before transfusion.
2 Blood transfusion is monitored and regulated by qualified
person
Protocol of blood transfusion is monitored & regulated
RR Blood bag details sticker is pasted in case file, patient
2 monitoring status is recorded in case sheet
Blood transfusion note is written in patient records
ME E13.10 There is a established procedure for monitoring and RR Check -
reporting Transfusion complication Staff is aware of the protocol to be followed in case of any
2 transfusion reaction
Any major or minor transfusion reaction is recorded and
reported to responsible person

Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients
ME E16.1 Death of admitted patient is adequately recorded and SNCU has system for conducting grievance counselling of
SI Bad news/adverse event/ poor prognosis are disclosed in
communicated 1 quite & private setting
parents in case of newborns' mortality
ME E16.2 The facility has standard procedures for handling the RR
death in the hospital New born death are recorded as per CDR guideline. Death
2 note including efforts done for resuscitation is noted in
patient record.
Death summary is given to patient attendant quoting the
Death note is written as per new born death review guidelines immediate cause and underlying cause if possible
ME E16.3 The facility has standard operating procedure for end of life Parents/ guardians are informed clearly about the SI/RR (1) Provide clear & honest information in supporting &
support deterioration in health condition of Patients caring manner
(2) Avoid negative comments about parents, referring
2 physician.
(3) There is a procedure to allow parents to observe patient
in last hours

ME E16.4 The facility has standard procedures for conducting post- Parent's consent is taken if autopsy required PI/ SI/ RR Check there is process to call parents after a month to
mortem, its recording and meeting its obligation under explain findings of autopsy & if required to discuss the
2 possibility of the problem occurring in next baby.
the law

Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines
ME E20.1 The facility provides immunization services as per Immunization services are provided as immunization schedule
Check MCP card is available & updated. Mother /care
guidelines 2
SI/RR provider is counselled and directed to immunize the child
ME E20.2 Triage, Assessment & Management of newborns having Rapid assessment of sick neonates is done for prioritizing Staff is aware of Triage or sorting categories to prioritize
emergency signs are done as per guidelines management in SNCU management i.e EPN (Emergency sign, priority sign & non
urgent sign)
2

SI/RR
(1) Hypothermia temp.< 35.50C,
(2) Apnoea or gasping breathing, Severe
respiratory distress rate > 70/min , severe retraction, grunt,
(3) Central cyanosis, shock, cold periphery, CFT>3 sec, weak
or fast pulse,
2 (4) coma, convulsion &encephalopathy. Action: Urgent
intervention, Stabilize and admit in SNCU

Staff is aware of emergency signs in Sick new born & action

required SI/RR
(1) Weight less than 1800 g (tiny neonates) or >3800g.
(2) Temp. 36.5 OC -35.5OC, (3)
Lethargy/irritable/restless/jittery (4) refusal to feed (5)
respiratory distress rate > 60, no or minimal retraction, (6)
abdominal distention,(7) severe jaundice appear in
<24hrs/stains palms and soles/lasts >2 weeks, severe
1 pallor, (8) bleeding from any site, (9)congenital
malformation,
Action: immediate assessment, attended on priority &
need to be admitted in SNCU
Staff is aware of priority signs in Sick new born & action
required SI/RR

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
(1)Minor birth trauma, (2) superficial infection,(3) minor
malformation, (4)possetting, (5) transitional stools, (6)
2 jaundice. Action Assess & treat as per neonate's
Staff is aware of non urgent signs signs in Sick new born & requirement
action required SI/RR
Check for Temp., Airway breathing, circulation, coma or
convulsation, Severe dehydration & hypoglycaemia
(1) Cold to touch (Abdomen): Re warm under radiant
warmer, assess the temp every half an hour
(2) Apnoea or gasping breathing : Manage
airway, administer Positive pressure ventilation with bag &
mask
(3) Central cyanosis or Severe respiratory distress, lower
chest drawing, grunting& ,give oxygen, monitor oxygen
saturation with pulse oximeter
(3) Capillary filling time >3, weak or fast pulse>160: Give
10ml/kg normal saline over 20- 30 min, repeat the bolus, if
circulation does not improve, (4) Convulsion: Manage
airway, check & correct hypoglycaemia, if convulsion
continue give IV calcium, if convulsion still continue give
anticonvulsant.
1 (5) Diarrhoea plus any two sign (a) Lethargy (b) Sunken eyes
(c) Very slow skin pinch - Insert IV line & began giving fluids
rapidly, make sure neonate is warm

Staff is competent in Management of emergency signs SI/RR

(1) Provide the warmth, Position the head & clear the air
way, suction first mouth & then nose ,Reposition &
stimulate breathing , Evaluate respiration, heart rate &
oxygenation. (2) If still not breathing, use correct size mask,
ensure proper seal, squeeze 2-3 times & observe the chest
rise, if chest rise is adequate, ventilate for 30 sec & re
2 assess, if chest rise is not adequate, take step to improve
ventilation. (3) Assess heart rate after 30 sec of ventilation,
if less than 100/min & not breathing well, continue
ventilation with oxygen.

Staff is able to demonstrate steps of new born resuscitation SI/RR

ME E20.3 Management of Low birth weight Staff is able to identify Low birth weight newborn Newborn baby can be LBW : (1) Preterm(<37 weeks) & (2)
new-borns including pre term and Small for gestational SGA (if the weight is below the 10 percentile on the chart
age as per guidelines gestational age.
LBWs can be identified from LMP, USG (first trimester) &
Expended Ballard score (EBS) and other physical maturity
2 signs like skin, ear cartilage, breast nodule, sole creases and
external genetalia

SI/RR
Staff is aware of clinical presentation of LBW SI Feeding problem, asphyxia, hypothermia, RDS, Apnoeic
spells, Intraventricular haemorrhage, hypoglycaemia,
2 hyperbilirubinemia, infection and retinopathy of
prematurity (ROP) etc.

Staff is aware of management protocols of babies < 1800 gm SI/RR Use of Overhead radiant warmer or incubator to keep baby
(34 weeks) warm. Regular monitoring of axillary temp at least once
every 6-8hrs .
1 Planning the nutrition and fluids of babies considering type
of feeding, quantity , frequency and modality of feeding

Staff is aware of frequency & type of feeding to LBW SI/RR LBW babies should fed with mother's milk every 2 hrs.
starting immediately after birth.
Ensure LBW babies receive 'hind milk'.
Multi fortified breast milk should be given to pre term <32
weeks / 1500 gm, who fail to gain weight despite of
2 breastfeeding
Minimum entral feeds : Small volume of expressed
breastmilk i.e. 12 to 24 ml/kg/day given every 1-3 hours
delivered intra gastric.

Check staff is aware of importance of hind milk SI Comes towards end of feed, rich in fat content and provide
2 more energy . LBW babies with poor weight gain may fed
with expressed hind milk.
Check guidelines for mode and quantity of providing fluids SI/RR Guidelines for modes requirements (i.e. Based on Birth
and feeds to babies is available & followed weight in gm and age (weeks).
1 Guidelines for fluid requirement of neonate (ml/kg/day) _
(based on Birth weight)

Check total daily requirement is estimated as per guidelines 2 SI/RR Check quantity given is monitored & charted
Check staff skill for various techniques/modes of feeding to SI/RR Techniques: Minimum entral feeds : Small volume of
LBW expressed breastmilk i.e. 12 to 24 ml/kg/day given every 1-
3 hours delivered intra gastric.
Non nutritive sucking: In premature or small babies - to
develop sucking behaviour & improve digestion of feed
Gavage feeds: Using feeding catheter - baby is fed with 10
ml syringe (without plunger) attached toward outer end of
tube & milk is allowed to trickle by gravity. The baby should
be placed in left lateral position for 15-20min to avoid
regurgitation.
Katori Spoon Feed: Feeding with spoon or paladai, specially
neonates with gestation of 30-32 weeks or more are in
2 position to swallow. Take required amount of expressed
breast milk in katori, place the baby in semi upright
posture. Fill the spoon with milk, a little short of brim, place
it at lips of the baby and let the milk flow into babies mouth
slowly, the baby will actively swallow the milk

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Partial/No
Check fluid and nutritional supplementation is fulfilled as per OB/SI Fluid requirement: First day of fluid requirement range
requirement from 60-80 ml/kg.
Daily increment - approx. 15ml/kg till 150ml/kg is reached.
Nutritional Supplementation_ Vit K : All LBW<1000gm -
receive 0.5 mg IM of Vit K at birth & all other 1mg IM. All
LBW who are exclusively breastfed should receive 400IU
daily of vit K from first day of life to once baby start
accepting full feeds & supplementation will continue until 6
month. 800-1000IU for small babies (<1500gm)
Multivitamin drops: 0.3 ml/day from 2 week of age
All LBW receive calcium and phosphorus at 120-140
mg/kg/day & 60-90 mg/kg/day respectively. & continue till
40wk post conceptual
2 Iron Supplementation_ 2-3mg/kg/day at 6-8 wks. and as
early as 2wks in <1500gm

Check the records to monitor intake & output to prevent fluid

overload (1) IV-fluids are given are compared with prescribed
volume & recorded in fluid monitoring chart every 2 hrly.
(2) Measure blood glucose every 6-8hrs and take action for
2 low (<45mg/dl) or high (150mg/dl) blood glucose
(3) Daily monitoring : of weight, urine output, frequency of
passage of urine, sign of overhydration.
SI/RR
Staff infusion site is inspected frequently
If there is redness and swelling seen at any time stop the
2 infusion remove the cannula and establish new IV line in
SI d/f vein
Check Growth is monitored in LBW babies SI/RR Babies checked for weight (daily), head
circumference( weekly) and length (fort-nightly).
Fenton's growth chart is used for pre term babies.
1 WHO growth chart is used from corrected age of 40 weeks

Precautions are taken to protect LBW baby from hypothermia Heat loss is minimized by kangaroo-care and a cap on the
2 head and socks on the feet
SI/RR

Normal Axillary temp- 36.5 -37.5 OC

2 Cold Stress- 36.4- 36OC
Moderate Hypothermia- 35.9- 32OC
Severe Hypothermia- <32OC.
Assessment through Axillary temp., Skin temperature
Staff is aware of assessment & grading of hypothermia SI/RR (using radiant warmer probe) and Human touch.

LBW, preterm babies, hypoglycemia,sclerema, DIC and

2 internal bleeding
Staff is aware of clinical conditions in which baby can exhibit Hypothermic babies show signs of lethargy, irritability, poor
signs of hypothermia SI feeding, tachypnoea/apnoea etc
Staff is aware of management of mild hypothermia (temp
<35.5- 36.4OC)

(1) Provide KMC to re warm baby with mild hypothermia or

warm the room using radiant heater or other heating
devices if KMC is not possible.
(2) Cover adequately & ensure to replace cold clothes with
2 warm clothes
(3) Keep room warm (26-28OC) & draught free
(4) Continue breastfeeding
(5) Monitor temp . & capillary filling time during re earning.
Watch for apnoea and hypoglycaemia .
(6) Monitor axillary temp every 1/2hr till it reaches 36.5 OC,
then hourly for next 4 hrs, 2 hrly for 12 hrs thereafter 3 hrly
SI/RR as routine
Staff is aware of management of severe hypothermia (temp Remove cold clothes from baby and replace with warm
<35.5OC) clothes
Place under radiant warmer or one may use room heater or
other means to warm baby
monitor temp every 15-30 min, monitor BP, HR, temp &
glucose as needed.
Additional - Start IV 10% dextrose, if perfusion is poor, give
2 10ml/kg of ringer lactate or normal saline. Give Vit K -1mg
I/M & provide oxygen & monitor SPO2.
Assess for sepsis

SI/RR

Counsel the mother and take consent for initiating KMC.

Give mother/care taker front open loose shirt or blouse
Guide the mother/ care taker to sit in semi reclining
position on chair or bed
2 Unbutton top 2-3 buttons and slip baby with only napkin,
socks and cap on, into shirt
Ensure skin to skin contact b/w baby and care taker
Baby should be in frog like position with head turned to
one side and placed between mother's breast
Tie a string at belt level to prevent the baby from slipping
down
Staff is able to demonstrate the process of Kangaroo mother Cover mother and baby dyad with woollen or sheet
care Protocols SI Encourage frequent breastfeeding

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Partial/No

Blood glucose level less than 45mg/dl in all new-borns

Symptoms of hypoglycaemia:
(1) Jitteriness, irritability
(2) Lethargy, limpness
(3) Weak or high pitched cry
Staff is able to access the clinical definition and symptoms of (4) Poor feeding , vomiting
hypoglycaemia is new-borns 1 (5) Tachycardia (>180/min)
(6) Sweating
(7) Hypothermia
(8) Poor respiratory effort or apnoea, tachypnoea
(9) Cyanosis
(10) Seizures or coma
SI
Staff is skilled for technique of estimating blood sugar using Common site- Heel.
regent strips in neonates (1) Ensure heel is not cold. Heel can be warmed by holding
it in hand for few minutes
(2) Prepare the site with 70% Isopropyl alcohol. Allow to
dry.
(3) Make needle stick puncture of posterolateral aspect of
heel & avoid making deep puncture.
2 (4) Follow instructions on reagent strip bottle for obtaining
blood sample analysis.
(5) If blood glucose is low send blood sample to lab for
confirmation

SI
Staff is competent in management of hypoglycaemia (1)Establish IV line, infuse bolus of 2ml/kg body weight of
10% dextrose over 1min.
(2) If an IV line can not be established quickly, give 2ml/kg
body weight of 10% dextrose orogastric tube
(3) Start infusion of dextrose containing fluid at daily
maintenance volume acc. to baby's age so as to provide a
glucose infusion rate (GIR) of 6mg/kg/min
(4) If glucose remain below 45mg/dl GIR is increased in
steps of 2mg/kg/min to max. of 12mg/kg/min
(5) Check blood glucose 30 min after starting the infusion of
glucose or any GIR. if blood glucose is above 45mg/dl,
continue glucose infusion at this rate and recheck blood
glucose 1hr later. With 2 blood glucose values in normal
range, the frequency of glucose monitoring is reduced to 6
hrly.
(6) If blood glucose is less than 25mg/dl, repeat the bolus of
2 dextrose and GIR as needed.
(7) if the blood glucose b/w 25-45mg/dl, do not give
dextrose bolus but increase GIR. The upper conc. of
dextrose sol. which can be infused safely through
peripheral vein is 15%. Conc. higher than this necessitate
central line placement & referral

SI/RR
Staff is aware of frequency of blood glucose measurement (1) Every 8 hrs as long as baby require IV fluid.
after blood glucose return to normal If the baby is no longer required or is not receiving IV fluid,
1 measure blood glucose every 12 hrs for 24 hrs

SI/RR
Charts/guidelines are readily available & followed in SNCU for Infusion rates with birth weight more than or equal to
estimating glucose infusion rates in neonates 1500gm using Mixture of D10 & D25.
Infuse ion rates with birth weight less than 1500 gm using
2 mixture of D10 & D25

SI/RR
Discharge & follow up protocols are followed LBW babies

(1) Consistently demonstrate weight again for 3

consecutive days
(2) Mother should be confident in feeding the neonate
2 (3) The required nutritional supplements started
(4)BCG, Hep. B and OPV is given to baby
(5) Methods of temperature regulation viz. KMC and other
skills are taught to mother and adequately practices in
hospital
SI/RR (6) Mother/parents are available to identify danger sign
Check important information like ROP screening and hearing
evaluation is given to parents/mother of LBW babies LBW (32 weeks/<1500gm) are advised for ROP screening at
2 1 month of postnatal age and hearing evaluation at 40
SI/RR weeks corrected gestational age
ME E20.4 Management of neonatal asphyxia is done as per Staff is aware of clinical presentation of asphyxia Asphyxiated babies evolve neurological manifestation viz
guidelines seizures, hypotonia, come or Hypoxic ischemic
encephalopathy (HIE) within 72 hrs of life
Evidence of multi organ system dysfunction (manifested as
2 difficult breathing or renal failure or feeding intolerance or
hepatic dysfunction or haematological abnormalities) in
immediate neonatal period
SI
SI/RR Using Levene's grading HIE - assessment of consciousness,
tone ,seizure activities and autonomic disturbances like
sucking & respiration - Severity is decided.
1 Check sequential grading is done every 8-12 hrs to assess
the progression of HIE
Grading of hypoxic ischaemic encephalopathy (HIE) is done &
recorded on case sheet

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Partial/No
Initial stabilization & management of asphyxia cases is done SI/RR (1) Maintenance of temperature (keep the baby under
as per protocols radiant warmer & temp is maintained at normal range)
perfusion, ventilation (monitoring of oxygen saturation-
SPO2 maintained b/w 90-94%) and normal Metabolic state
including glucose, calcium and acid base balance (IV fluids,
enteral feeding, glucose monitoring, management of
hypocalcaemia & administration of vit K 1mg IM)
(2) Early detection & management of complications must
be done to prevent extension of cerebral injury
2

Clinical monitoring or bed side tests of asphyxiated babies is SI/RR (1) Levene's staging for neurological status
performed (2) Downe's Score for respiratory status
(3) Cardiovascular status- i.e. heart rate, colour, CRT,
peripheral pulses, non- investive BP
(4) Abdominal circumferences- to rule out ileus
2 (5) Urine output - to check for serum electrolytes, blood
urea & serum creatinine
(6) Monitoring of Blood surger

Clinical monitoring is performed & updated in case sheet at SI/RR (1) Levene's staging -every 8hrs
defined intervals (2) Downe's Score -every 2-3 hrs
(3) Cardiovascular status- i.e. heart rate, colour, CRT,
peripheral pulses, non- investive BP
(4) Abdominal circumferences- to rule out ileus
1 (5) Urine output - measured daily-- should not be
<1ml/kg/hr
(6) Monitoring of Blood surger every 6-8hrs during the first
24 hrs

Staff is aware of two major clinical manifestation results due SI (1) Neonatal Shock
to asphyxia (2) Neonatal Seizures
1

Staff is skilled to identify shock SI (1) Unexplained Tachycardia- (HR>160/min)

2 (2) Capillary refill time (CRT)- >3 seconds
Staff is aware of technique to check CRT & its interpretation SI/RR Gentle pressure is applied by the tip of finger on central
part of the body such as chest for 3-5 seconds by slowly
counting from 1 to 5. this result in to blanching and area
2 refill & it become pink after the tip of finger is lifted.
Normal CRP is <3 sec. A prolonged CRT indicates poor
circulation and tissue perfusion.

Staff is skilled to manage neonatal shock SI/RR (1) Supportive Care :

(a) Maintain TBAC
(b) Hypoxia: Maintain SPO2- 90-94%
(c) Hypoglycaemia- Maintain normal blood glucose- (>45
mg/dl)
(d) Hypothermia- Maintain temp _ 36.5-37.5 O C
1 (2) Fluid resuscitation: infuse fluid bolus of 10ml/kg or
normal saline over 20-30 min.
(3) Administration of Inotropes

Staff is competent to assess improvement SI/RR Check:

(1) Improvement in CRT
(2) Decrease in heart rate by at least 10 beats/min.
2 (3) Improvement in pulse volume and an increase in urine
output over next 4-6 hrs (is sign of improvement)

Staff is competent to identify when to start vasopressors SI/RR If signs for poor perfusion persists despite 2 fluid boluses-
2 Start vasopressor along with supportive care. Most
commonly used vasopressor in neonates is dopamine
Staff is aware of dose of dopamine SI/RR (1) Starting dose- 5-10 microgram/kg/min
(2) If no improvement occurs- the dose can be increased by
2 increments of 5 microgram/kg/min every 20-30 min to max
of 20microgram/kg/min

Staff is aware of next line of treatment if shock persists after SI/RR Dobutamine - Dose same as dopamine
max dose of dopamine Hydrocortisone -1mg/kg of hydrocortisone can be given as
2 initial dose and then depending upon response , it can be
given 8-12 hrly in dose of 1mg/kg/dose for 2-3 days

Staff is aware of further line of treatment in case baby is SI/RR (1) Consider blood transfusion if Hb< 12gm%
unresponsive to shock 2 (2) Consider referral after stabilization of temperature,
oxygenation and blood glucose
Staff is aware of therapeutic end points for babies suffering SI/RR CRT <3 sec, Normal Heart rate, normal pulse, warm
from neonatal shock 2 extremities, normal BP and urine output >1ml/kg/hr
Staff is competent in method of weaning from inotropes SI/RR Once hypotension improves (BP normal for 4-6hrs) & tissue
perfusion improves, inotropes should be tapered slowly
2 @5microgm/kg/min every 1-2 hrly provided neonate
maintain the list of therapeutic end point

Staff is aware of causes of neonatal Seizures SI Asphyxia (Most common), birth injuries, meningitis,
intracranial bleeding or due to metabolic problems like
2 hypoglycaemia, hypocalcaemia, and hypo or hypernatremia

Staff knows d/f in spasm due to tetanus and jitteriness SI Spasm due to tetanus: Appear after 48hrs, Involuntary
contraction of muscles, fists often persistently and tightly
clenched, Trismus opisthotonus, triggered by touch, light &
sound and Baby is conscious throughout, often crying with
pain.
1 Jitteriness: Provoked by stimulus, abolished by restraining,
Not associated with autonomic changes, examination of
neonatal is normal b/w seizure episodes & EEG is normal

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Partial/No
Staff is aware of diagnostic approach for seizure SI In sick babies: blood glucose, serum ionized calcium, serum
sodium & Sepsis screen.
Detailed history is taken and examination is done after
1 initial acute management to determine the underlying
cause.

Staff is skilled to provide treatment of neonate with seizures SI/RR 1st Step: Resuscitate if needed : In thermoneutral
environment ensure TABC. Start oxygen if required IV
access should be secured and blood sample drawn for
blood count, blood sugar, serum calcium & electrolytes
Step 2: If blood sugar less than 45mg/dl correct
hypoglycaemia by a bolus of 2ml/kg 10% dextrose followed
by maintenance infusion of 6-8 mg/kg/min
1 3rd step: Estimate calcium levels. Consider giving 10%
calcium gluconate 2ml/kg IV over 5-10min
4th Step: Anti convulsant drug (ACD); ACD given if seizures
persists even after correction of hypoglycaemia and
hypocalcaemia

Staff is aware of 1st and 2nd line ACD along with their doses SI/RR 1st Line ACD: Inj Phenobarbitone20mg/kg IV over 20min. If
baby has no further seizures don to start maintenance. If
seizures persists after initial phenobarbitone infusion,
administer boluses of 5mg/kg put total 40 mg/kg.
2nd Line ACD: Inj Phenytoin or Fosphenytoin 20mg/kgIV
over 20 min if seizures are not controlled with
Phenobarbitone. Assess seizures control after the infusion.
1 If seizures persists then Lorazepam 0.05- 0.10 mg/kg IV
may be infused. Once the seizures are controlled, start
maintenance dose of 3-4mg/kg day after 12 hrs of loading
dose of phenobarbitone and phenytoin

Staff is aware of therapeutic action for neonate with seizures SI/RR (1) Transient metabolic problem i.e. hypoglycaemia,
hypocalcaemia, dyselectrolytemia- Treat the cause , stop
ACD immediately if started
(2) Seizures controlled with 1st bolus of phenobarbitone-
No maintenance ACD, observe for 48 hrs if seizures re
occur
(3) Seizures controlled with multiple dose of
phenobarbitone- Start maintenance dose phenobarbitone.
Stop once seizure free for 48hrs
2 (4) Difficult to control seizures- Stop Phenytoin if seizures
free for 48 hrs, continue maintenance dose
phenobarbitone, Assess neurological status : if normal-Stop
phenobarbitone, If abnormal -may continue oral
maintenance phenobarbitone

Staff is competent to identify conditions when to refer the SI/RR (1) when baby need respiratory support - as PPV required
neonatal asphyxia cases to higher centre for 5min or longer
(2) Onset of seizures within 12 hrs- refractory seizures
(uncontrolled with phenobarbitone & phenytoin)
1 (3) Severe HIE & unable to restore oral feeds within 1
week-
(4) Shock unresponsive to vasopressor

Post discharge & follow up advice is given as per protocols SI/RR To attend follow up clinic for monitoring of their growth &
1 development and to identify post asphyxia sequelae and
development delays
ME E 20.5 Management of sepsis is done as per guidelines Staff is aware of classification of neonatal sepsis SI Early onset sepsis (EOS): where sign & symptoms of sepsis
appear within 72 hrs of birth due to pathogens in maternal
genital tract or delivery area, respiratory distress due to
congenital pneumonia.
Late onset of Sepsis (LOS): where sign appear after 72 hrs
2 of age due to pathogens from hospital or community. LO is
commonly presented as Septicaemia, pneumonia, or
meningitis

Staff is aware of signs of neonatal sepsis SI (1) Clinical picture is highly variable. Sign & symptom are
minimal, subtle or non specific.
(2) Clinical manifestation of neonatal sepsis : Lethargy,
refuse to suckle, poor cry or high pitched cry or excessive
cry, comatose, and. Distension, diarrhoea, vomiting,
hypothermia, poor perfusion, sclera, poor weight gain,
2 shock, bleeding, renal failure, cyanosis, tachypnoea, chest
retraction, grunt, apnoea, fever, seizures, neck retraction,
bulging fontanel etc.

Staff is competent to identify clinical manifestation of SI fever, seizures, blank look, high pitched cry to excessive
meningitis 1 crying/irritability, neck retraction & bulging fontanel
Laboratory investigations are performed to confirm neonatal SI/RR Direct method: Isolation of micro-organism from blood,
sepsis CSF, urine or pus.
Indirect method: Leukopenia (TLC< 5000/cu mm),
Neutropenia (ANC< 1800/cu mm), Immature neutrophil to
total neutrophil ratio (>0.2), Micro ESR(>15mm 1st hour)
1 positive C Protein.
Any of the 2 or more test come positive indicate sepsis.
Lumber puncture : must be performed in all cases with late
onset of sepsis

Supportive care is provided to manage new borns SI/RR Maintain TABC

Ensure SPO2 -90-94%
Maintain normoglycemia
Administer inj vit K 1mg IV , if there is active bleeding from
any site
2 Avoid enteral feed if hemodynamically compromised &
start feed as hemodynamically stable.
Consider exchange transfusion if there is sclerema

Appropriate antibiotics are given according to age and weight SI/ RR Correct dose and frequency is given as per antibiotic
of the baby therapy of neonatal sepsis
Antibiotic therapy should cover the common bacteria viz, E
1 .coli, Staphylococcus aureus and Klebsiella Pneumonia
Every new born unit must have its own antibiotic policy
based on profile of pathogen & local sensitivity pattern

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Partial/No
Staff administer antibiotic as per protocols for confirmed SI/RR 1. Give Injection ampicillin and gentamicin, as first line of
Sepsis treatment.
2. Give cloxacillin (if available) instead of ampicillin, if there
are extensive skin pustules or abscesses, as
these might be signs of Staphylococcus infection.
3. Antibiotics should be given slowly, after dissolving in 5-10
2 ml fluid using a microdrip set or infusion
pump.
4. Never mix two antibiotics in same syringe.

Check algorithm & treatment charts for management of SI/RR Antibiotic schedule & dosage including frequency, route
neonatal sepsis is available & practices 2 and duration is available & used
Staff provide antibiotic as per protocols for confirmed SI/RR Check availability charts for prescribing antibitotics for
meningitis meningitis.
Check charts reflect following information:
Weight <2kg
Inj Cefotaxime- 12 hrly ( 0-7 days of age) or 8 hrly (>7days
of age), IV, for 3 weeks
Inj Amikacin-24hrly ( 0-7 days of age) or 24 hrly (>7days of
age), IV, for 3 weeks
Weight >2kg
Inj Cefotaxime- 8 hrly ( 0-7 days of age) or 6 hrly (>7days of
age), IV, for 3 weeks
Inj Amikacin-24hrly ( 0-7 days of age) or 24 hrly (>7days of
2 age), IV, for 3 weeks.
2nd line treatment:
Inj Meropenem- 8 hrly ( 0-7 days of age) or 8 hrly (>7days
of age), IV, for 3 weeks
nj Amikacin-24hrly ( 0-7 days of age) or 24 hrly (>7days of
age), IV, for 3 weeks.

The response to treatment is monitored SI/RR Empirical upgradation can be considered if there is no
2 clinical improvement by 48hrs of institution of antibiotic or
there is sign of deterioration
SI/RR

Pneumonia in 0-59 days children - difficult to diagnose as

per clinical conditions
Possible serious bacterial infections can be pneumonia,
1 septicaemia, or meningitis.
Essential Features: (1) Baby not able to feed or (2)
Convulsion or (3) Fast breathing (RR-> 60/min) or (4) Severe
chest indrawing or (5) Axillary temp > or equal to 37.5 oC
(or feel hot to touch) (6) or Axillary tem <35.5 oC (or feel
Staff assess the clinical presentation of possible serious cold to touch) or movement only when stimulated or no
bacterial infection among children of 0-59 days movement at all
SI/RR
Hospitalise, Maintain nutrition & hydration, Give Oxygen ( if
SpO2 <90),
2 Check availability charts for prescribing antibitotics for
serious bacterial infections.
Check dose, duration, frequency is given as per indicated
Management of Possible serious bacterial infections
Staff is competent to identify conditions that do not require SI Meconium strained amniotic fluid, meconium aspiration
antibiotic for management syndrome, Mild respiratory distress, perinatal asphyxia,
2 Asymptomatic neonates with present of 1-2 risk factors of
EOS, jaundice and prematurity

Staff is competent to identify when to refer the baby SI/RR If condition worsen or no improvement after 48hrs
(1) Respiratory failure requiring mechanical ventilation
(2) Unresponsive shock
2 (3) Persistent convulsions
(4) DIC (5) Baby require exchange transfusion (& facility is
not available

ME E20.6 Management of jaundice is done as per guidelines Staff is aware of alert sign of neonatal pathological jaundice SI Clinical Jaundice in first 24 hrs of life or Total serum
bilirubin (TSB) increasing by 5mg/dl/day or 0.5mg/dl/hr or
TSB >15mg/dl to Conjugated serum bilirubin >2mg/dl or
1 clinical jaundice persisting for > 14 days in term and > 21
days in preterm infants

Staff is aware of causes of onset of Jaundice within 24 hrs of SI (1) Haemolytic disease of newborn: RH, ABO and minor
age group incompatibility,(2) Infection: Intrauterine viral-
bacterial, malaria
1 (3) G6PD deficiency

Staff is aware of causes of onset of Jaundice after 24 hrs of S Physiological, Polycythaemia, Concealed haemorrhage,
age 2 Sepsis, neonatal hepatitis, metabolic disorder
Clinical assessment of severity of Jaundiced neonate is done SI/RR Kramer's criteria: Jaundice limited to face: Serum Bilirubin-
as per Kramer's criteria about 6mg/dl, Jaundice extended to trunk- 9mg/dl,
1 Extended to abdomen-12mg/dl. Extended to legs -15mg/dl
& Extended to feet & hand-19-20mg/dl

Staff is aware of features of acute bilirubin encephalopathy SI Hypotonia, lethargy, high pitched cry, poor suck,
2 hypertonia of external muscles, irritability, fever, seizures,
opisthotonus, shrill cry, apnoea, coma
Staff is aware of Jaundice evaluation protocols SI Blood sample is taken for TSB estimation. Plotting of values
2 on AAP charts on bilirubin nomogram
Management of Jaundice is done as per protocols SI/RR Management directed toward reducing level of bilirubin &
preventing CNS toxicity.
Prevention of hyperbilirubinemia: by early & frequent
2 feeding
Reduction of bilirubin: Achieved by phototherapy and /or
exchange transfusion

Normogram is used to imitate phototherapy & exchange SI/RR Check normogram is available & practiced for new born
transfusion 2 more than 35 week
Guidelines for phototherapy & exchange transfusion is readily SI/RR For new born <35 week
available and being followed 2

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Staff is aware of precautions to be taken while giving SI/RR Baby should be naked eyes & genitals should be covered.
phototherapy to baby New born should be kept at distance of more than 45 cm
below light [Link] feeding every 2 hours 7 change
2 in posture is promoted, once under phototherapy serum
bilirubin must be monitored every 12 hrs or earlier if
required

Check baby is monitored through out the phototherapy RR/SI Check the records baby's temperature is measured every 4
hourly to monitor for hypo/hyperthermia
Check weight is taken daily
Frequent breast feeding
Increase in allowance for fluid, (if there is any evidence of
2 dehydration)
Position is changed frequently, after each feed
(Low birth weight babies can have their socks, caps and
mittens on, while under phototherapy)

Check the availability & use of fluxmeter RR Use Fluxmeter to check for and ensure optimal irradiance
2 in phototherapy units
ME E20.7 Management of children presenting Staff is aware of common causes of hyperthermia SI (1) Sepsis
with fever, cough or respiratory distress is done as per (2) Envt. too hot for baby
guidelines (3) Wrapping the baby in too many layers of clothes, esp. in
hot humid climate
(4) Keeping newborn close to heater/hot water bottle
1 (5) Leaving the under heating devices i.e. radiant warmer,
incubator, phototherapy that is not functioning properly
and/to not check regularly

Staff is aware and follow management protocols of SI Examine every hyperthermic baby for infection (1) If temp.
hyperthermia is above 39OC, the neonate should be undressed and
sponged with tepid water at app. 35OC until temperature is
below is below 38 OC
(2) If temp. is 37.5- 39OC- Undressing & exposing to room
temp is usually all that is necessary.
(3) If due too envt. temperature: move baby to colder
environment & using loose & light clothes.
2 (4) If due to device- remove the baby from source of heat
(5) Give frequent breastfeeds to replace fluids. if the baby
cannot breastfeed, give EBM. If does not tolerate feeds, IV
fluids may be given
(6) Measures the temp. hourly till it become normal

Staff is able to identify the babies with respiratory distress SI/RR (1) RR >60 breaths per min
(2) Severe chest in drawing
2 (3) Grunting
(4) Apnoea or gasping

Staff is aware of common causes of respiratory distress in SI (1) Pre Term : RDS, Congenital pneumonia, hypothermia &
newborn hypoglycaemia
(2) Term: Transient tachypnoea of newborn (TTNB),
meconium aspiration, pneumonia, asphyxia
(3) Surgical cases: Diaphragmatic hernia, Trachea -
1 oesophageal fistula, B/L choanal atresia
(4) other causes: Congenital heart disease, acidosis, inborn
errors of metabolism

Detailed antenatal & perinatal history is taken based on SI/RR H/O gestation, onset of distress, previous preterm babies
causes of respiratory distress & recorded with RDS, antenatal steroid prophylaxis, rupture of
membranes >24 hrs, intrapartum fever, meconium
2 asphyxia, maternal diabetes mellitus, poor feeding,
lethargy, convulsion, h/o excessive frothing

Objective assessment of severity of respiratory distress is done SI/RR Using Downe's score and status is recorded in BHT
& recorded 2
Staff is aware of parameters & interpretation of Downe's SI/RR Parameter: RR, Cyanosis, Air entry, Grunt and retraction.
Score 2 Score 1-6= RDS
Score >6- Impending respiratory failure
Detailed examination of babies representing with RDS is done SI/RR (1) Severity of RDS- Assessed by Downe Score
and recorded (2) Neurological status: Activity or altered sensorium
(3) CRT
(4) Hepatomegaly
2 (5) Central Cyanosis or low oxygen saturation
(6) Features of sepsis
(7) Evidences of malformation

Staff is competent to identify conditions when to order chest SI (1) All babies with moderate to severe respiratory distress-
X ray to identify underlying causes
(2) Babies with mild respiratory distress observed for few
2 hrs- if distress does not settle in 4-6 hrs or baby continues
to need supplementary oxygen

Staff follow support management protocols for all sick SI/RR (1) Maintain body temp.
newborn (2) Give Oxygen with oxygen hood or nasal prongs to
achieve appropriate oxygen saturation. Titrate oxygen
delivery, targeting oxygen saturation of 90-94%
(3) EBM by gavage feeding
2 (4) Give IV fluids if baby does not accept Breast feed
(5) Maintain blood glucose, if low treat hypoglycaemia

Staff is competent in management of apnoeic baby SI/RR (a) Maintain temperature (b)
Stimulate to breathe by rubbing the back or flicking the
sole. If does not begin to breathe, provide PPV with bag &
mask immediately (c) Check blood glucose (d) Administer
caffeine citrate/Aminophylline if baby is pre term with no
1 other evident cause of apnoea (d) If apnoeic spells are
recurrent, obtain sepsis screen along with blood culture
and initiate treatment for sepsis

Staff is competent in specific management of moderate to SI/RR Start nasal CPAP and/or organize transfer for assisted
severe respiratory distress 2 ventilation

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Staff is aware of duration to administer antibiotics SI/RR (1) If baby show clinical improvement- sepsis screen is
negative and blood culture is sterile stop antibiotic after 48
hrs
(2) if baby show clinical improvement but sepsis screen is
positive & culture is negative give antibiotic for 5-7days
(3) Id culture is positive for Gram positive cocci (GPC) give
2 antibiotic for 7 -10days & for Gram negative bacilli (GNB)
for 10-14 days
Antibiotic may be modified based in clinical response and
blood culture sensitivity pattern

Staff is skilled to provide oxygen therapy SI/RR (1) Pulse oximeter is used to check oxygen saturation -
should be maintained b/w 90-94%
(2) Saturation below 90% should be treated using oxygen
supplementation. Ensure at NO TIME babies under
supplemental oxygen should have oxygen saturation above
95%
(3) Nasal prongs & head box is used to deliver oxygen.
1 Adjust flow of oxygen 0.5-2.0 L/min with Nasal prongs to
achieve target saturation.
Adjust the flow of oxygen (3-5L/min) to achieve desired
oxygen saturation

Staff is competent in oxygen weaning protocols SI/RR Once baby's oxygen saturation on pulse oximeter is 90-
94%, gradually wean oxygen. Reduce the oxygen flow rate
by 1/2litre/min every few minutes to observe the oxygen
2 saturation. If oxygen saturation remain in normal range
gradually remove oxygen.

Staff is competent to identify when to refer the baby SI/RR (1) If baby with breathing difficulty needs CPAP or
mechanical ventilation
(2) persistent central cyanosis or low oxygen saturation
2 despite oxygen supplementation
(3) Repeated apnoeic spells
Always stabilize before referral & transport

Discharge & follow up advice is given as per protocols PI/RR Babies with respiratory distress should be seen 48hrs after
discharge, either at hospital or during home visit by ASHA.
1 Counselling of parents for exclusive breastfeeding, temp
maintenance and immunization Should be done

ME E20.10 Facility ensures optimal breast feeding practices for new SNCU promotes initiation of breastfeeding within half an hour PI/ SI Check with mother when she has provided breastmilk to
born & infants as per guidelines after birth 2 baby after delivery
Check colostrum is given to baby & staff is aware of its SI Women produce colostrum in first few days after delivery.
importance It is thick yellowish in colour & contain antibodies, white
blood cells and other anti infective proteins.
Importance: Help to fight diseases that baby is likely to be
exposed after delivery. Help to clear baby's gut of
2 meconium. Clear bilirubin from the gut & also help to
prevent hyperbilirubinemia

No ghutti, gripe water , honey or any other milk is given to OB/PI

baby 2
SNCU ensures exclusive breastfeeding to babies during their PI/SI (1) Check with mother how frequently she breastfed her
stay in SNCU unless clinically indicated 2 admitted baby ( At least 8 times per day (EBM or DHM)
(2) No formula feeding unless prescribed by doctor
SI/PI (1) By counting no. of wet diapers per day (6-8 time/day)
Check process in place to assess the milk intake among 2 (2) Weight gain (20-30 gm a day in 1st 3-4 months after
admitted babies regaining birthweight
Check records are maintained to monitor intake of babies 2 SI/RR
Staff is aware & practice assisted feeding techniques for SI/RR Gavage feeding, katori-spoon feeding /paladai feeding/
babies unable to take feed 2 gastric tube
Check SNCU provide assistance in positioning & attaching the SI/PI Check with mother if she has been taught/ guided to
baby to mother's breast 2 position & attach the baby
Check staff& mothers are aware of signs of proper position SI/PI (1) Baby's body is well supported
(2) The head, neck & body of baby are kept in same plane
2 (3) Entire body of baby faces the mother
(4) Baby's abdomen touches mother's abdomen

Check staff & mothers are aware of signs of proper SI/PI (1) Baby's mouth is wide open
attachment (2) lower lip turned outwards
2 (3) Baby's chin turned towards mother's breast
(4) Majority of areola is inside the baby's mouth

Check poster of proper positioning & attachment is displayed RR Poster explain Signs of proper positioning, attachment and
in Breastfeeding area in SNCU suckling.
2 Also explain disadvantages of not following proper
positioning & attachment

Staff is aware of breastfeeding problems & its management SI/PI (1) Inverted/flat nipples - Treatment- A 20ml plastic syringe
can be used to draw out nipple gently
(2) Sore nipple, due to incorrect attachment or frequent
washing with soap & water or pulling the baby off while he
is still sucking- Treatment- Correct positioning &
[Link] hind milk after feed & nipple should be
aired, to allow healing in between feeds. In case of fungal
infection suspected- refer to specialist or provide anti
fungal medication
(3) Breast engorgement- Treatment - Ensuring early &
frequent feeding & correct attachment. Apply local warm
water packs & analgesics (paracetamol) . Milk should be
1 gently expressed to soften the breast.
(4) Breast abscess- treatment- treated with analgesics &
antibiotics. The abscess is to incised & drained.
(5) Reduced milk supply: if baby is not gaining weight- Ask
mother to feed more frequently especially during night.
Make sure proper attachment & back massage is useful for
stimulating lactation

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
SNCU provides extra support to establish breastfeeding in SI/PI (1) SNCU ensures mother has begin the expression of milk
mother's having pre term & LBW babies within 6 hrs of delivery.
(2) Encourage the mother's to repeat expression of milk 8-
10 times per day to maintain flow of production & to feed
the baby
(3) The baby should put in breast every 2-3 hrs for feeding
or non nutritive suckling (NNS)
(4) SNCU ensures preterm milk is given to pre term babies
2

Check mother is encouraged to visit, touch and care her baby SI/PI Ask mother how often she visits her baby in SNCU
2
Check mothers are encouraged to learn milk expression SI/PI Both manual and through breast pump.
2 Check instructions are displayed in milk expression room.
Functional electrical pumps are available
SNCU has provision to collection, & storage breast milk SI/OB Check availability of milk expression room & refrigerator to
2 store milk
SNCU has system to label & identify the expressed milk or milk SI/OB (1) Unique ID of baby, date of expression of milk or Date &
received from CLMC 2 time of opening the DHM bottle
Expressed milk/ DHM is stored at recommended temperature SI/OB Milk is immediately transferred to a refrigerator at the
temperature of +2˚C to +4˚C for storage.
EBM can be kept at room temp for 8 hours & in refrigerator
2 for 24 hrs

SNCU promote feeding of breastmilk for pre term, low birth PI/RR Check Bed head tickets whether mother milk or milk
& sick new born substitute is prescribed for admitted new born. Give non
2 compliance if milk substitute is prescribed (untill clinically
indicated)

Check breastfeeding policy is displayed RR Mentioning 10 steps of successful breastfeeding. Check

2 Staff is able to explain at least 3 components of
breastfeeding policy
Check SNCU promotes breastfeeding during follow up visits RR/OB (1) Exclusive during 6 months (2) initiate complemtary
2 feeding after 6 months & (3) continue breastfeeding up to 2
yrs. and beyond
Check SNCU has linkage with Comprehensive lactation SI/PI Inhouse or outsourced for ensuring breastmilk to the
management centre 2 babies

ME E20.11 The facility provides services as per Rashtriya Bal SI/RR (1) Inhouse or at higher centre
Swasthya Karykram (2) For developmental/ interventional facilities
SNCU has functional referral linkage with DEIC 2

Area of Concern - F Infection Control ###

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection
The facility has provision for Passive and active culture Surface and environment samples are taken for
surveillance of critical & high risk areas 2
ME F1.2 microbiological surveillance SI/RR Swab are taken from infection prone surfaces
The facility measures hospital associated infection rates
1 Patients are observed for any sign and symptoms of HAI.
There is procedure to report cases of Hospital acquired HAI reporting formats are available. Staff Know whom to
ME F1.3 infection SI/RR report & action are taken on feed back.
There is Provision of Periodic Medical Check-up and There is procedure for immunization & periodic check-up of
immunization of staff the staff 1
ME F1.4 SI/RR Hepatitis B, Tetanus Toxoid etc
The facility has established procedures for regular Hand washing and infection control audits done at periodic
monitoring of infection control practices 1 intervals for Staff as well as mothers/care givers visiting
regularly
ME F1.5 Regular monitoring of infection control practices SI/RR
1
Check each person enter SNCU after hand washing & gowning OB
The facility has defined and established antibiotic policy
2
ME F1.6 Check doctors are aware of Hospital Antibiotic Policy SI/RR

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 Availability of hand washing with running Water Facility at
Point of Use 2
ME F2.1 OB At least 1 wash basin for every 5 beds
Availability of antiseptic soap with soap dish/ liquid antiseptic Check for availability/ Ask staff if the supply is adequate
with dispenser. 1
OB/SI and uninterrupted. Availability of Alcohol based Hand rub
Display of Hand washing Instruction at Point of Use Prominently displayed above the hand washing facility ,
2
OB preferably in Local language
Availability of elbow operated taps Hand washing sink is wide and deep enough to prevent
2
OB splashing and retention of water
Separate Handwashing facilities are available for parent/ Only parents who follow the hygiene practices are allowed
attendant 2
OB/SI to provide care to their sick newborn
The facility staff is trained in hand washing practices and Adherence to 6 steps of Hand washing
(1) Ask for demonstration
they adhere to standard hand washing practices 2
ME F2.2 SI/OB (2) Staff aware of when to hand wash
1 Ask for demonstration - mothers/guardian aware Steps of
Check each person enter SNCU after hand washing & gowning OB/ PI HW.
Mothers/care giver adhere to hand washing practices with
soap Mothers are aware of importance of washing
1 hands .Washing hands after using the toilet/ changing
PI/OB diapers and before feeding children.

Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate personal protection
Equipment as per requirements 2
ME F3.1 Clean gloves are available at point of use OB/SI Handwashing b/w each patient & change of gloves
Availability of Mask caps & shoe cover 1 OB/SI
Availability of gown/ Apron & mask 2 OB/SI Staff, visitors and parent/attendants
The facility staff adheres to standard personal protection
practices 2
ME F3.2 No reuse of disposable gloves, Masks, caps and aprons. OB/SI
Compliance to correct method of wearing and removing the 1
gloves & other PPEs SI Ask for demonstration.
Mother's/parents are allowed to entre SNCU after gowning
only 1
SI

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No

Standard F4 The facility has standard procedures for processing of equipment and instruments
The facility ensures standard practices and materials for Decontamination of operating & Procedure surfaces
decontamination and cleaning of instruments and procedures
areas
1 Ask staff about how they decontaminate the procedure
surface like Examination table , Patients Beds
Stretcher/Trolleys etc.
ME F4.1 SI/OB (Wiping with 1% Chlorine solution
Cleaning of instruments Cleaning is done with detergent and running water after
2
SI/OB decontamination
2 No sorting ,Rinsing or sluicing at Point of use/ Patient care
Proper handling of Soiled and infected linen SI/OB area
Staff is trained for preparing cleaning solution as per
2 standard procedure
Staff know how to make chlorine solution SI/OB
Proper handling of Soiled and infected linen SI/OB No sorting ,Rinsing or sluicing at Point of use/ new-born
2 care area
The facility ensures standard practices and materials for Disinfection of instruments is done as per protocols Achieve within 20 min contact period with 2%
disinfection and sterilization of instruments and equipment 2 glutaraldehyde
ME F4.2 SI/OB
Disinfection of individual items & utensils is done before use (1) Individual item like stethoscope, thermometer
measuring taps, probe should be done with 70% isopropyl
alcohol daily or whenever used for another baby.
1 (2) Cup spoon and paladai are boiled for at least 15 min
before use /after every feed
SI/OB
Equipment and instruments are sterilized after each use as Autoclaving/Chemical Sterilization
per requirement 2
OB/SI
Autoclaving of instruments is done as per protocols 2 OB/SI Ask staff about temperature, pressure and time
Chemical sterilization of instruments/equipment is done as Ask staff about method, concentration and contact time
per protocols 2 required for chemical sterilization(4hrs contact period), also
how long the glutaraldehyde is active once prepared
OB/SI
Check staff is aware of how long autoclaved items can be
stored.
1 Also, autoclaved items are stored in dry, clean, dust free,
moist free environment
Staff is aware of storage time for autoclaved items OB/SI
Autoclaved dressing material & linen are used for SNCU 2 OB/SI

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Functional area of the department are arranged to ensure Facility layout ensures separation of routes for clean and dirty Facility layout ensures separation of general traffic from
infection control practices 1
ME F5.1 items OB patient traffic
There is separation between in born and out born unit 1 OB
Check there is no overcrowding inside the SNCU.
2 Hospital staff without having a valid reason are not allowed
Entry in SNCU is restricted OB in SNCU
The facility ensures availability of standard materials for Availability of disinfectant as per requirement
cleaning and disinfection of patient care areas 2
ME F5.2 OB/SI Chlorine solution, Glutaraldehyde etc
Availability of cleaning agent as per requirement Hospital grade phenyl, disinfectant, detergent solution,
2
OB/SI Lysol 5% or 3% phenol
The facility ensures standard practices are followed for the Spill management protocols are implemented
cleaning and disinfection of patient care areas Check avaialbity of Spill management kit ,staff is trained for
1 managing small & large spills , check protocols are
ME F5.3 SI/RR displayed
Standard practice of mopping and scrubbing are followed
Unidirectional mopping from inside out. Use of three
2 bucket system for mopping.
OB/SI
Cleaning equipment like broom are not used in patient care Any cleaning equipment or activity leading to dispersion of
areas 0
OB/SI dust particles in air should be avoided
External foot wares are restricted 2 OB Check foot ware are changed before entry in SNCU
The facility ensures segregation infectious patients Isolation and barrier nursing procedure are followed for septic Check babies with diarrhoea, pyoderma, or any other
1
ME F5.4 cases OB/SI contagious disease should not be admitted inside SNCU
The facility ensures air quality of high risk area SNCU has system to maintain ventilation and its environment Ventilation can be provided in 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
2 fresh air intakes. Exhaust-only ventilation is a good choice
for units that do not have existing ductwork to distribute
heated or cooled air
ME F5.5 OB

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
Facility Ensures segregation of Bio Medical Waste as per
guidelines 2
ME F6.1 Availability of colour coded bins at point of waste generation OB
Availability of Non chlorinated plastic colour coded plastic 2
bags OB
Segregation of Anatomical and soiled waste in Yellow Bin 2 OB/SI
Segregation of infected plastic waste in red bin 2 OB
Display of work instructions for segregation and handling of Pictorial and in local language
2
Biomedical waste OB
There is no mixing of infectious and general waste 2 OB
Facility ensures management of sharps as per guidelines Availability of functional needle cutter & Puncture proof
container
2 (1) Check if needle cutter has been used or just lying idle.
(2) it should be available near the point of generation like
ME F6.2 OB nursing station
Availability of post exposure prophylaxis
1. Staff knows what to do in case of needle stick injury.
1 2. Staff is aware of whom to report
3. Check if any reporting has been done
OB/SI 4. Also check PEP issuance register
Glass sharps and metallic implants are disposed in Blue colour OB Includes used vials, slides and other broken infected glass
coded puncture proof box 2
Facility ensures transportation and disposal of waste as Check bins are not overfilled Bins should not be filled more than 2/3 of its capacity
per guidelines 0
ME F6.3 SI
Disinfection of liquid waste before disposal 2 SI/OB
Transportation of bio medical waste is done in close
container/trolley 2
SI/OB
Area of Concern - G Quality Management

Standard G1 The facility has established organizational framework for quality improvement

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
ME G1.1 The facility has a quality team in place Quality circle has been constituted SI/RR 1. Check if the quality circle has been constituted and is
1 functional
2. Roles and Responsibility of team has been defined
ME G1.2 The facility reviews quality of its services at periodic intervals Review meetings are done monthly RR Check minutes of meeting and monthly measurement &
1 reporting of indicators

Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient satisfaction surveys are conducted at periodic RR
intervals 2
Patient relative satisfaction survey done on monthly basis
ME G2.2 The facility analyses the patient feed back, and root-cause Analysis of low performing attributes is undertaken RR
analysis 1
ME G2.3 The facility prepares the action plans for the areas, Action plan is prepared and improvement activities are RR
contributing to low satisfaction of patients undertaken 1

Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.
ME G3.1 The facility has established internal quality assurance SI/RR Findings /instructions during the visit are recorded
programme in key departments There is system daily round by matron/hospital manager/
hospital superintendent/ Hospital Manager/ Matron in charge 1
for monitoring of services
ME G3.3 Facility has established system for use of check lists in Internal assessment is done at periodic interval RR/SI NQAS assessment toolkit is used to conduct internal
different departments and services 2 assessment
Departmental checklist are used for monitoring and SI/RR Staff is designated for filling and monitoring of these
quality assurance 2 checklists
Non-compliances are enumerated and recorded RR
1 Check the non compliances are presented & discussed
during quality team meetings
ME G3.4 Actions are planned to address gaps observed during Check action plans are prepared and implemented as per Randomly check the details of action, responsibility, time
quality assurance process internal assessment record findings 1 line and feedback mechanism
RR
ME G3.5 Planned actions are implemented through Quality Check actions have been taken to close the gap. It can be in
Improvement Cycles (PDCA) Check PDCA or revalent quality method is used to take
1 form of action taken report or Quality Improvement (PDCA)
corrective and preventive action
SI/RR project report

Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
ME G4.1 Departmental standard operating procedures are Standard operating procedure for department has been RR Check that SOP for management of services has been
available prepared and approved 2 prepared and is formally approved
Current version of SOP are available with process owner 1 OB/RR Check current version is available
OB
WI for phototherapy, Grading and management of
2 hypothermia, Expression of milk, KMC, Management of
hypoglycaemia, housekeeping protocols, Administration of
commonly used drugs, assessment of neonatal sepsis,
Work instruction/clinical protocols are displayed Assessment of Jaundice, Temperature maintenance etc
ME G4.2 Standard Operating Procedures adequately describes SNCU has documented procedure for ensuring patients rights RR Review the SOP has adequately cover procedure for taking
process and procedures including consent, privacy, confidentiality & entitlement 2 consent, maintenance of privacy, confidentiality &
entitlements
SNCU has documented breastfeeding policy RR Review the SOP has adequately explaining implementation
2 of 10 steps of breastfeeding
SNCU has documented procedure for safety & risk RR Check availability of risk management record/register to
management 2 identify risk & action taken to address them
SNCU has documented procedure for support services & RR Documented procedure for preventive- break down
facility management. maintenance and calibration of equipment, Maintenance
of infrastructure, inventory management & storage,
retaining ,retrieval of SNCU records
2

SNCU has documented procedure for general patient care RR Availability of documented criteria & procedure for triage,
processes admission, training and engagement of parent-attendants
2 in care provision, assessment & re assessment, referral &
discharge of the patient

SNCU has documented procedure for specific processes to the RR SNCU has documented procedure for key clinical processes
department including resuscitation, thermoregulation of new
2 born, ,drugs,intravenous,and fluid management and
nutrition management of new born

SNCU has documented procedure for infection control & bio RR Check availability of documented procedure for infection
medical waste management 2 control practices& BMW
SNCU has documented procedure for quality management & RR Check availability of documented procedure for
improvement departmental quality activities viz: nomination of
department Nodal officer, internal assessments, audits,
2 patient satisfaction survey, internal & external quality
assurance processes,

SNCU has documented procedure for data collection, analysis RR Check availability of documented departmental Data set
& use for improvement 2 need to be measured monthly & procedure for their
collection, analysis & improvement
ME G4.3 Staff is trained and aware of the procedures written in SI/RR
SOPs 2
Check staff is a aware of relevant part of SOPs

Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
ME G5.1 The facility maps its critical processes SI/RR Critical processes , where there is some
problem-delays, errors, cost, time, etc. and improvement
1 will make our process
effective and efficient
Process mapping of critical processes done
ME G5.2 The facility identifies non value adding activities / waste / SI/RR Non value adding activities are wastes. In these steps
redundant activities 1 resources are wasted,
delays occur, and no value is added to the service
Non value adding activities are identified
ME G5.3 The facility takes corrective action to improve the Processes are rearranged as per requirement SI/RR Check the improvement is sustained
processes 1

Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
ME G6.4 SI/RR
Check short term valid quality objectivities have been
1 framed addressing key quality issues in each department
Facility has de defined quality objectives to achieve mission and cores services. Check if these objectives are Specific,
and quality policy Check if SMART Quality Objectives have framed Measurable, Attainable, Relevant and Time Bound.

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
ME G6.5 SI/RR
Interview with staff for their awareness. Check if Mission
Mission, Values, Quality policy and objectives are effectively Check of staff is aware of Mission , Values, Quality Policy and 1 Statement, Core Values and Quality Policy is displayed
communicated to staff and users of services objectives prominently in local language at Key Points

Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 The facility uses method for quality improvement in Basic quality improvement method SI/OB PDCA & 5S
services 2
Advance quality improvement method 0 SI/OB Six sigma, lean.
ME G7.2 The facility uses tools for quality improvement in services 7 basic tools of Quality SI/RR Minimum 2 applicable tools are used
1
Standards G9
Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
ME G9.6 SI/RR
Verify with the records. A comprehensive risk assessment
Periodic assessment for Medication and Patient care safety Check periodic assessment of medication and patient care 2 of all clinical processes should be done using pre define
risks is done as per defined criteria. safety risk is done using defined checklist periodically criteria at least once in three month.
Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes
Check parameter are defined & implemented to review the
clinical care i.e. through Ward round, peer review,
Clinical care assessment criteria have been defined and The facility has established process to review the clinical care 0 morbidity & mortality reivew, patient feedback, clinical
ME G10.3
communicated audit & clinical outcomes.
SI/RR
(1) Both critical and stable patients
Check regular ward rounds are taken to review case progress 0 (2) Check the case progress is documented in BHT/
SI/RR prgoress notes-
Feedback is taken from patient/family on health status of
Check the patient /family participate in the care evalution 0 individual under treatment
SI/RR
System in place to review internal referral process, review
Check the care planning and co- ordination is reviewed 0 clinical handover information, review patient
SI/RR understanding about their progress

Check medical audit records

(a) Completion of the medical records i.e Medical history,
assessments, re assessment, investigations conducted,
progress notes, interventions conducted, outcome of the
case, patient education, delineation of responsibilities,
Facility conducts the periodic clinical audits including There is procedure to conduct medical audits 2
discharge etc.
ME G10.4 (b) Check whether treatment plan worked for the patient
prescription, medical and death audits
(C) progress on the health status of the patient is
mentioned
(d) whether the goals defined in treatment plan is met for
the individual cases
(e) Adverse clinical events are documented
(f) Re admission
SI/RR

(1) All the deaths are audited by the committee.

(2) The reasons of the death is clearly mentioned
(3) Data pertaining to deaths are collated and trend
analysis is done
There is procedure to conduct newborn death audits 2 (4) A through action taken report is prepared and
presented in clinical Governance Board meetings / during
grand round (wherever required)

SI/RR
Check for -valid sample size, data is analysed, poor
There is procedure to conduct referral audits 2 performing attributes are identified and improvement
SI/RR initiatives are undertaken

All non compliance are enumerated recorded for medical

2 Check the non compliances are presented & discussed
audits
SI/RR during clinical Governance meetings

All non compliance are enumerated recorded for newborn

2 Check the non compliances are presented & discussed
death audits
SI/RR during clinical Governance meetings

All non compliance are enumerated recorded for referral

2 Check the non compliances are presented & discussed
audits
SI/RR during clinical Governance meetings
Clinical care audits data is analysed, and actions are
Check action plans are prepared and implemented as per Randomly check the actual compliance with the actions
ME G10.5 taken to close the gaps identified during the audit medical audit record findings 0 taken reports of last 3 months
process SI/RR
Check action plans are prepared and implemented as per Randomly check the actual compliance with the actions
newborn death audit record's findings 0 taken reports of last 3 months
SI/RR
Check action plans are prepared and implemented as per Randomly check the actual compliance with the actions
referral audit record's findings 0 taken reports of last 3 months
SI/RR
Check collected data is analysed & areas for improvement
Check the data of audit findings are collated 0 is identified & prioritised
SI/RR
Check the critical problems are regularly monitored &
Check PDCA or revalent quality method is used to address
0 applicable solutions are duplicated in other departments
critical problems
SI/RR (wherever required) for process improvement
Facility ensures easy access and use of standard Check standard treatment guidelines / protocols are Staff is aware of Standard treatment protocols/
ME G10.7 treatment guidelines & implementation tools at available & followed. 2 SI/RR guidelines/best practices
point of care
Check treatment plan is prepared as per Standard Check staff adhere to clinical protocols while preparing
2 SI/RR
treatment guidelines the treatment plan
Check the drugs are prescribed as per Standards Check the drugs prescribed are available in EML or
2 SI/RR
treatment guidelines part of drug formulary
Check when the STG/protocols/evidences used in
healthcare facility are published.
Check the updated/latest evidence are available 2 SI/RR
Whether the STG protocols are according to current
evidences.

The gaps in clinical practices are identified & action are

Check the mapping of existing clinical practices processes
2 SI/RR taken to improve it. Look for evidences for
is done
improvement in clinical practices using PDCA
Area of Concern - H Outcome

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Indicators on monthly basis Percentage of babies weighting less than 1800gm are No. of babies weighting less than 1800gm admitted / Total
1
admitted to SNCU RR admission in SNCU in Month

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Reference ME Statement Checkpoint Compliance/Full/ Assessment Method Means of verification Remarks

Partial/No
Bed Occupancy Rate 2 RR
Proportion of female babies admitted 2 RR
No. of FPC sessions conducted in a month 2 RR FPC register

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators on monthly basis No. of very low birth weight babies (< 1200 gm)/No. of Low
2
Percentage of very low birth weight babies survived RR birth+ Very low birth babies
Down time Critical Equipment 2 RR
Referral Rate 2 RR
Survival rate 2 RR Discharge rate
Average waiting time for initiation of treatment 2 RR

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Indicators on monthly
basis Percentage of new-born deaths among inborn weighting
2500gm or more 2
RR
Percentage of new-born deaths among out-born weighting
1200 to 1800g 2
RR
Recovery rate 2 RR
Antibiotic use rate 2 RR
Average length of stay 2 RR

2
Percentage of new-born survived following Resuscitation RR
2 Baby theft, wrong drug administration, needle stick injury,
Adverse events are reported RR absconding patients etc

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality Indicators on monthly basis LAMA Rate 2 RR
Parent/ care giver Satisfaction Score 2 RR

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National Quality Assurance Standards for District Hospitals

Checklist for Nutrition Rehabilitation Centre

Assessment Summary
Name of the Hospital Date of Assessment
Names of Assessors Names of Assesses
Type of Assessment (Internal/External) Action plan Submission Date
NRC Score Card
Area of Concern wise Score MusQan NRC Score
A Service Provision #DIV/0!
B Patient Rights #DIV/0!
C Inputs #DIV/0!

0%
D Support Services #DIV/0!
E Clinical Services #DIV/0!
F Infection Control #DIV/0!
G Quality Management #DIV/0!
H Outcome #DIV/0!

Major Gaps Observed

1
2
3
4
5
Strengths / Good Practices
1
2
3
4
5
Recommendations/ Opportunities for Improvement
1
2
3
4
5
Signature of Assessors
Date

Reference no. Measurable Elements Checkpoint Compliance/ Assessment Method Means of verification
Full/
Partial/No
Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services
ME A1.4 The facility provides paediatric services Availability of functional NRC SI/RR 1. Availability of indoor care and continuous monitoring services
of the SAM child
2. Treatment of medical complications
3. Therapeutic feeding
4. Treatment and follow-up
5. Capacity building of mothers/other care givers for
appropriate feeding, preparation of energy dense foods,
hygiene & care practices

Give non compliance, if the above services are provided in

paediatric ward

ME A1.14 Services are available for the time period as Availability of nursing care services 24X7 SI/RR
mandated
Standard A2 Facility provides RMNCHA Services
ME A2.4 The facility provides child health Services Management of hypoglycaemia as per the
guideline SI/RR
Management of hypothermia as per the guideline
SI/RR
Management of dehydration in the children with
SAM, without shock as per the guideline SI/RR
Management of SAM child with shock as per the
guideline SI/RR
Management of electrolyte imbalance SI/RR
Management of infection is done as per the
guideline. SI/RR
Management of SAM children less than 6 month SI/RR
Management of SAM in HIV exposed/HIV infected
and TB infected children as per the guideline
SI/RR
Provision of Therapeutic feeding as per guideline SI/RR
Counselling services to mothers for IYCF practices 1. Exclusive Breastfeeding up to 6 months
PI/SI 2. Complementary feeding from six months
Standard A3 Facility Provides diagnostic Services
ME A3.2 The facility provides laboratory services Availability of lab services -inhouse/Outsourced.
NRC has facility /linkage for laboratory Blood glucose, Haemoglobin, Serum electrolyte, TLC, DLC, urine
investigation routine, urine culture, Mantoux test, HIV (after counselling) &
any other
SI/OB
Standard A5 Facility provides support services
Checklist -7 NRC Version- NHSRC/3.0

ME A5.1 The facility provides dietary services Availability of functional nutritional services SI/OB Give non compliance if kitchen is not available in NRC
ME A5.2 The facility provides laundry services Availability/linkage for laundry services SI/OB Inhouse / Outsourced ( (Shared with main hospital)
ME A5.3 The facility provides security services Availability of security guard SI/OB Inhouse/outsourced (shared with main hospital)

ME A5.7 The facility has services of medical record Availability of services for management of NRC SI/OB Shared with main hospital
department records
Standard A6 Health services provided at the facility are appropriate to community needs.
ME A6.1 The facility provides curatives & preventive Availability of services & investigation for local SI/ RR Check for the specific local health problems/ diseases like
services for the health problems and prevalent endemics coeliac disease and malaria etc. Check testing & management
diseases, prevalent locally. services are available. Give full compliance if no such issue
exists

Area of Concern - B Patient Rights

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 The facility has uniform and user-friendly OB
signage system
Numbering, main department and internal sectional signage,
Restricted area signage displayed. Directional signages are given
Availability departmental signage from the entry of the facility
ME B1.2 The facility displays the services and Service available at NRC are displayed , Visiting hours and
entitlements available in its departments visitor policy are displayed, Contact information, Entitlement
under JSSK and RBSK are displayed
Information regarding services are displayed

OB
Necessary Information regarding services provided OB Name of doctor and Nurse on duty are displayed and updated.
is displayed Contact details of referral transport / ambulance displayed

ME B1.5 Patients & visitors are sensitised and

educated through appropriate IEC / BCC
approaches Display of pictorial information/ chart regarding expression of
milk, management of SAM, Breastfeeding, kangaroo care,
Display of information for education of mother
Preparation of appropriate feed, Hand hygiene
/care taker
OB
Counselling aids are available for education of the Flip charts, AV material etc.
mother/care taker OB
ME B1.6 Information is available in local language and Signages and information are available in local Check all information for patients/ visitors are available in local
easy to understand language language

OB
ME B1.8 The facility ensures access to clinical records Discharge summary is given to the patient RR/OB Check discharge summary provides
of patients to entitled personnel 1. Information on follow up
2. Diet to be followed at home
3. Contact number for emergency
4. Collaboration for community based care

Standard B2 Services are delivered in manners that are sensitive to gender, religious, social and cultural needs and there are no barrier on account of physical access, language, cultural or social status
ME B2.1 Cots in NRC are large enough for stay of mother OB Check Paediatric size cots are not used, As mother/ care giver
with child has to stay along with baby through out the treatment days
Services are provided in manner that are
sensitive to gender

ME B2.3 OB

Access to facility is provided without any

physical barrier & and friendly to people with Availability of Wheel chair /stretcher for easy
disabilities Access to NRC
Availability of ramps and railing OB If not located on the ground floor availability of the ramp / lift
If ramp is available check it is at least 120 cm width, gradient
not steeper than 1:12
Availability of children friendly toilet OB Children friendly- low WC seats; washbasins at appropriate
height, lever operated taps

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Privacy is maintained at breast feeding area / OB 1. Screens / curtains are provided at breastfeeding area/ corner
Corner 2. Check all the windows are fitted with frosted glass or curtains
Adequate visual privacy is provided at every have been provided
point of care

ME B3.2 SI/OB (1) Check records are not lying in open and there is designated
space for keeping records with limited access.
(2) Records are not shared with anybody without permission of
parents & appropriate hospital authorities
Confidentiality of patients records and
clinical information is maintained

Patient Records are kept at secure place beyond

access to general staff/visitors
SI/ OB

No information regarding patient's identity and

details are unnecessary displayed on records Specially HIV or any such cases
ME B3.3 Behaviour of staff is empathetic and courteous PI/OB Check that staff is not providing care in undignified manner such
as yelling, scolding , shouting, blaming and using abusive
language etc
The facility ensures the behaviours of staff is
dignified and respectful, while delivering the
services

ME B3.4 PI/ OB Check if HIV status is not displayed / written at bed side

The facility ensures privacy and

confidentiality to every patient, especially of
those conditions having social stigma, and
also safeguards vulnerable groups
HIV status of neonate/ infant is not disclosed
except to staff that is directly involved in care
Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it is required.
ME B4.1 There is established procedures for taking SI/RR General Consent is taken before admission
informed consent before treatment and NRC has system in place to take informed consent
procedures from patient relative whenever required
ME B4.4 PI
Information about the treatment is shared
with patients or attendants, regularly NRC has system in place to provide Check parents/ relatives of admitted baby is communicated
communication of child condition to parents/ about child condition, treatment plan and any changes at least
relatives at least once in day once in day
ME B4.5 Facility has defined and established OB Check the completeness of the Grievance redressal
grievance redressal system in place mechanism , from complaint registration till its resolution

Availability of complaint box and process for

grievance re addressal is 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 services.
ME B5.1 The facility provides cashless services to PI/SI
pregnant women, mothers and neonates as
per prevalent government schemes Indoor treatment is provided free of cost
Availability of free blood, diagnostic & drugs PI/SI
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Availability of free stay & transport PI/SI

Availability of Free referral vehicle/Ambulance services.

PI/SI For both mother & baby

Availability of free stay & Diet

ME B5.2 The facility ensures that drugs prescribed are Check that patient party has not spent on PI/SI
available at Pharmacy and wards purchasing drugs or consumables from outside.
ME B5.3 Check that patient party has not spent on PI/SI
It is ensured that facilities for the prescribed diagnostics from outside.
investigations are available at the facility
ME B5.5 The facility ensures timely reimbursement of PI/RR
financial entitlements and reimbursement to If any other expenditure occurred it is reimbursed
the patients from hospital
PI/SI/RR As per basic daily wages of the state
NRC has system to provide Wage compensation to
mother/caregiver for the duration of the stay at
NRC
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
ME C1.1
(1) Covered area for NRC should be about 150 sq. ft per bed
Departments have adequate space as per with 30% of ancillary area.
NRC has adequate space as per guideline (2) Space between two beds should be at least 3.5- 4 ft and
patient or work load 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
OB
ME C1.2 Patient amenities are provided as per patient Functional toilets with running water and flush
load are available
OB
Availability of separate Bathing area and laundry
area for mothers OB Dedicated attached Bathrooms and Toilets for Mothers
Availability of sitting arrangement for patient
attendant OB

Availability of drinking water OB Drinking water Facility within / in close proximity to NRC
ME C1.3 Departments have layout and demarcated Location of nursing station and patients beds enables easy and
areas as per functions Availability of nursing station OB direct observation of patients

Receiving room with examination area OB

Clean area for mixing intravenous fluids and

Medications/ fluid preparation area OB
Availability of breast feeding corner/ Area for
expression of breast milk OB
NRC has designated play area and counselling
room/ area in proximity to NRC ward OB Adequate space to play with toys, AV equipment
NRC has designated kitchen & food storage area OB Enough space for cooking, feeding and demonstration
Availability of dirty utility area OB
ME C1.4 The facility has adequate circulation area and of both staff and equipment
open spaces according to need and local law
Availability of adequate circulation area for easy
moment OB
Corridors are wide enough for patient, visitor and
trolley/ equipment movement OB Corridor should be 3 meters wide
ME C1.5 The facility has infrastructure for intramural Check availability of functional telephone and intercom
and extramural communication connections
Availability of functional telephone and Intercom
Services OB
ME C1.6 Service counters are available as per patient
load 1. Check no two children are treated at one bed
Availability of adequate beds as per case load OB 2. Check for provision of extra beds to manage surplus load.
ME C1.7 The facility and departments are planned to
ensure structure follows the
function/processes (Structure commensurate Check NRC is in proximity with Paediatric/
with the function of the hospital) inpatient facility

OB
Standard C2 Facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the seismic safety of the Non structural components are properly secured OB Check for fixtures and furniture like cupboards, cabinets, and
infrastructure heavy equipment , hanging objects are properly fastened and
secured
ME C2.3 The facility ensures safety of electrical NRC does not have temporary connections and OB (1) Switch Boards other electrical installations are intact.
establishment loosely hanging wires (2) Check adequate power outlets have been provided as per
requirement

ME C2.4 Physical condition of buildings are safe for OB 1. Windows have grills and wire meshwork
providing patient care 2. NRC are non-slippery and even
Check physical infrastructure of the NRC is safe & 3. Open spaces are properly secured to prevent fall and injury
secure for children
Floor, walls are easily cleanable and windows are OB Minimize the growth of microorganisms & Wire mesh to reduce
covered with wire mesh the entry of mosquito and fly
Standard C3 Facility has established program for fire safety and other disaster
ME C3.1 The facility has plan for prevention of fire NRC has sufficient fire exit to permit safe escape OB/SI Check the fire exits are clearly visible and routes to reach exit
to its occupant at time of fire are clearly marked. Check there is no obstruction in the route of
fire exits. Staff is aware of assembly points
ME C3.2 The facility has adequate fire fighting NRC has installed fire Extinguisher that is Class A , OB Check the expiry date for fire extinguishers are displayed as well
Equipment Class B, C type or ABC type as due date for next refilling is clearly mentioned
ME C3.3 The facility has a system of periodic training Check for staff competencies for operating fire SI/RR Staff is aware of RACE (Rescue, Alarm, Confine & Extinguish) &
of staff and conducts mock drills regularly for extinguisher and what to do in case of fire
fire and other disaster situation PASS (Pull, Aim, Squeeze & Sweep)

Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
ME C4.2 The facility has adequate general duty Availability of Medical officer OB/RR
doctors as per service provision and work
load
Availability of 1 Medical officer per 10 bed
ME C4.3 The facility has adequate nursing staff as per Availability of Nursing staff OB/RR/SI
service provision and work load Availability of 4 Nursing staff for 10 bedded NRC
ME C4.5 The facility has adequate support / general Availability of nutrition counsellor SI/RR Availability of 1 Nutrition Counsellor for 10 bedded NRC
staff
Availability of support staff for NRC SI/RR 1. Availability of one cook cum care taker.
2. Availability of 1 Medical Social Worker
Availability of house keeping staff & security SI/RR
guards Availability of Sanitary worker & security guard
Standard C5 Facility provides drugs and consumables required for assured list of services.
ME C5.1 The departments have availability of OB/RR
adequate medicines at point of use Inj. Ampicillin with Cloxacillin, Inj. Ampicillin
Availability of Antibiotics Inj. Cefotaxime
Inj. Gentamicin,
Inj. Cloxacillin,
OB/RR
Availability of analgesics and antipyretics Paracetamol
OB/RR Ringer's lactate solution with 5% glucose,0.45%(half normal)
Availability of IV Fluids
saline with 5% glucose,0.9%saline(for soaking eye pads)
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OB/RR Metronidazole, Tetracycline or Chloramphenicol eye drops,

Availability of other medicines
Atropine eye drops
OB/RR
ORS, Potassium chloride, Magnesium chloride/sulphate, Iron
Electrolyte and minerals syrup, multivitamin, folic acid, Vitamin A syrup, Zinc sulphate or
dispersible Zinc tablets, Glucose(or sucrose)
OB/RR
Availability of medicines for management of SAM
in HIV exposed
Antiretroviral medicines, cotrimoxazole prophylaxis
ME C5.2 The departments have adequate OB/RR
consumables at point of use Availability of dressings material
Gauze piece and cotton swabs.
OB/RR
Availability of syringes and IV Sets /tubes
Cannulas, IV sets, paediatric nasogastric tubes
Availability of Antiseptic Solutions OB/RR Antiseptic lotion
ME C5.3 Emergency drug trays are maintained at Emergency Drug tray is maintained OB/RR Normal Saline (NS),Glucose 25%,Ringer Lactate (RL),Dextrose
every point of care, where ever it may be 5%,Potassium Chloride, Calcium Gluconate, Sodium
needed Bicarbonate, RS, Paracetamol, Inj Pheniramine,Inj
Hydrocortisone Hemisuccinate/ Hydrocortisone Sodium
Succinate ,Inj Phenobarbitone,Inj Phenytoin,Inj Diazepam,Inj
Midazolam,Salbutamol Respiratory,Ipratropium Respirator
solution for use in nebulizer,Inj Dopamine, Third generation inj
cephalosporin, I.V Infusion set,I.V Cannula (20G/22G/24G/26G)
& Nasal Cannula(Infant, Child, Adult) & oxygen

Standard C6 Facility has equipment & instruments required for assured list of services.
ME C6.1 Availability of equipment & instruments for Availability of functional Equipment
examination & monitoring of patients &Instruments for examination & Monitoring
Thermometers, Weighing scales(digital),Infantometer,
OB Stadiometer,
ME C6.3 Availability of equipment & instruments for Availability of Point of care diagnostic
diagnostic procedures being undertaken in instruments
the facility
OB Glucometer
ME C6.4 Availability of equipment and instruments Availability of functional Instruments for
for resuscitation of patients and for providing Resuscitation.
intensive and critical care to patients
Infusion pumps, Oxygen cylinder, oxygen hood, Self inflating
Bag and masks (Size 00, 0 & 1) 250 ml &500 ml, laryngoscope
OB ( worth 0 &1 size straight blades) , ET tubes, suction machine
ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for drugs OB Refrigerator, Crash cart/Drug trolley, instrument trolley,
dressing trolley
ME C6.6 Availability of functional equipment and Availability of kitchen equipment OB Cooking Gas, Dietary scales (to weigh to 5 gms.), Measuring jars,
instruments for support services Electric Blender (or manual whisks),Water Filter,Refrigrator,
Utensils (large containers, cooking utensils, feeding cups,
saucers, spoons, jugs etc.)

Availability of equipment for cleaning & Buckets for mopping, mops, duster, waste trolley, Deck brush
disinfection OB
ME C6.7 Departments have patient furniture and Availability of patient beds with accessories OB
Hospital graded mattress, Bed side locker , IVstand, Bed pan,
fixtures as per load and service provision bed rail
Availability of Fixtures OB Electrical fixture for equipment like suction, X ray view box
OB Cupboard, nursing counter, table for preparation of medicines,
Availability of furniture chair.
Availability of toys OB Washable toys such as puzzles, blocks, stacking bottle tops etc
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff
ME C7.1 Criteria for Competence assessment are defined SI/RR
for clinical and Para clinical staff Check objective checklist has been prepared for assessing
Check parameters for assessing skills and competence of doctors, nurses and paramedical staff based on
proficiency of clinical staff has been defined job description defined for each cadre of staff.
ME C7.2 Check for competence assessment is done at least SI/RR
once in a year

Competence assessment of Clinical and Para Check for records of competence assessment including filled
clinical staff is done on predefined criteria at checklist, scoring and grading . Verify with staff for actual
least once in a year competence assessment done
ME C7.9 SI/RR All medical officer & nurses

Training on Facility based care of Severe acute

The Staff is provided training as per defined core malnutrition- Incremental & complementary to F-
competencies and training plan IMNCI
Training on IYCF SI/RR Nutrition councillor, Nursing staff & medical officer
SI/RR
Refresher training All cadre
Training on Infection prevention & patient safety SI/RR Biomedical Waste Management& Infection control and hand
hygiene ,Patient safety
Training on Quality Management SI/RR Assessment, action planning, PDCA, 5S & use of checklist
Area of Concern - D Support Services
Standard D1 Facility has established program for inspection, testing and maintenance and calibration of equipment.
ME D1.1 The facility has established system for All equipment are covered under AMC including SI/RR
maintenance of critical Equipment preventive maintenance Weighting machine, Infantometer, suction machine etc

There is system of timely corrective break down SI/RR Check staff is aware of Contact details of the agencies/ person
maintenance of the equipment responsible for maintenance
ME D1.2 The facility has established procedure for All the measuring equipment/ instrument are OB/ RR
internal and external calibration of calibrated Weighting machine, Infantometer, thermometer etc. Check for
measuring Equipment calibration stickers/ records

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of medicines in pharmacy and patient care areas
ME D2.1 There is established procedure for SI/RR
forecasting and indenting drugs and
consumables (1) Stock level are daily updated
There is established system of timely indenting of (2) Requisition are timely placed based on consumption pattern
consumables ,drugs and food material
Drugs are intended in Paediatric OB/RR
dosages/formulations only
ME D2.3 The facility ensures proper storage of drugs OB
and consumables
Drugs are stored in containers/tray/crash cart and
are labelled
Empty and filled cylinders are labelled & kept OB Flow meter , humidifier, key & updated data sheet is available
separately with in use cylinders
Food items are stored at recommended OB/RR
temperature
ME D2.4 The facility ensures management of expiry Expiry dates' of drugs are maintained OB/RR
and near expiry drugs
Records for expiry and near expiry drugs are maintained for
drug stored in department & emergency tray
Check drug sub store & emergency tray

No expired drug found OB/RR

ME D2.5 The facility has established procedure for There is practice of calculating and maintaining SI/RR . Minimum stock and reorder level are calculated based on
inventory management techniques buffer stock consumption
Minimum buffer stock is maintained all the time
Department maintained stock and expenditure RR/SI Check stock and expenditure register is adequately maintained
register of drugs and consumables
ME D2.6 There is a procedure for periodically replenishing There is procedure for replenishing drug tray SI/RR There is no stock out of drugs
the drugs in patient care areas /crash cart
ME D2.7 There is process for storage of vaccines and OB/RR Check for temperature charts are maintained and updated
other drugs, requiring controlled periodically
temperature Refrigerators meant for storing drugs should not be used for
Temperature of refrigerators are kept as per storing eatables
storage requirement and records are maintained
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Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
ME D3.1 The facility provides adequate illumination Adequate Illumination at nursing station & patient
OB
level at patient care areas care areas
ME D3.2 The facility has provision of restriction of OB/PI
visitors in patient areas Visiting hour are fixed and practiced There is no overcrowding in the NRC
There is no overcrowding in the wards during to OB
visitors hours
One female/ family members allowed to stay with OB/SI
the child
ME D3.3 The facility ensures safe and comfortable Temperature control and ventilation in patient PI/OB Room kept between 25° - 30° C (to the extent possible).
environment for patients and service care area &in nursing station/duty room Fans/ Air conditioning/Heating/Exhaust/Ventilators as per
providers environment condition and requirement

Safe measures used for re-warming children SI/OB Check availability of blankets to cover the children
Side railings has been provided to prevent fall of OB
patient
Adequate ventilation to be provided especially in OB
the kitchen area.

ME D3.4 The facility has security system in place at NRC has system for using identification tags for OB
patient care areas babies

OB/SI Functional CCTV is installed (may be shared with main hospital)

Security arrangement in NRC
ME D3.5 The facility has established measure for safety Ask female staff whether they feel secure at work SI
and security of female staff place

Standard D4 The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior & Interior of the facility building is Building is painted/whitewashed in uniform colour OB Check Exterior is well plastered, painted/ whitewashed in
maintained appropriately uniform colour

Interior walls of NRC are brightly painted and OB Check walls are painted with cartoon characters/ animals/
decorated plants/ under water/ jungle themes etc
ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof tops, sinks patient care and All area are clean with no dirt,grease,littering and cobwebs.
circulation areas are Clean OB Surface of furniture and fixtures are clean
Toilets & Bathrooms are clean OB Check toilet seats, floors, basins etc are clean and there is no
foul smell in toilets & bathrooms
ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , Cracks, chipping of OB
maintained plaster
Window panes , doors and other fixtures are intact
Patients beds are intact and without rust and OB Observe for any signs for rusting or accumulation of dirt/
mattress are clean and intact grease/ encrusted body fluid
ME D4.4 Hospital maintains the open area and Open areas around NRC is well maintained OB There is no overgrown trees / plants/ Shrubs/ grass. Check
landscaping of them trees/ plants have been trimmed regularly. Dry leaves & green
waste is removed on daily basis
ME D4.5 The facility has policy of removal of OB Check of any obsolete article including equipment, instrument,
condemned junk material records etc

No condemned/Junk material in the NRC

ME D4.6 The facility has established procedures for OB No lizard, cockroach, mosquito, flies, rats, bird nest etc. in NRC
pest, rodent and animal control No stray animal/rodent/birds
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
ME D5.1 The facility has adequate arrangement Availability of 24x7 running and potable water OB/SI Availability of 24X7 water. Check availability of hot water in
storage and supply for portable water in all bathrooms
functional areas
ME D5.2 The facility ensures adequate power backup OB/SI Check for 24X7 availability of power backup including dedicated
in all patient care areas as per load UPS and emergency light

Availability of power back up in patient care areas

StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.
ME D6.1 The facility has provision of nutritional NRC has system in place to assess appetite of baby RR/SI/PI Check appetite test for SAM baby is done as per standard
assessment of the patients based on their nutritional needs guideline. Feed used for test :
(1) For children, 7-12 months - Offer 30-35 ml/kg of catchup
diet. if child takes more than 25 ml / kg then child should be
considered to have good appetite
(2) For children >12 months,- Locally prepared food may be
offered (Roasted groundnuts 1000 gms, Milk powder 1200gms,
Sugar 1120gms, coconut oil 600gms).

Staff is aware of pre requisite of appetite test RR/SI/PI (1) Do the test in a separate quiet area.
(2) Explain to the mother/caregiver how the test will be done.
(3) Ensure mother/caregiver wash her hands.
(4) Ensure mother sits comfortably with the child on her lap
and offers therapeutic food.
(5) The child should not have taken any food for the last 2 hrs.
(6)The child must not be forced to take the food offered.
When the child has finished, the amount taken is measured.

Reference value based on baby's body weight is RR/SI Check reference value chart is available & staff is aware of it.
readily available to pass the appetite test Amount of local therapeutic feed that a child with SAM should
take based on his body weight to pass the appetite test is-
Less than 4 kg should consume 15 gms or more diet ,
4-7 kg should consume 25 gms or more diet
7-10 kgs should consume 33 gms or more

NRC has system to assess feeding problems of RR/SI/PI Counselling is done by nutrition counsellor as per feeding
child and provide individual counselling to mother recommendations of IMNCI guidelines

NRC has system to access requirement and dose of RR/SI As per standard protocols.
micronutrient of SAM children as per their age

ME D6.2 The facility provides diets according to Starter diet (F-75) is given to child just after RR/SI/OB Feeding should begin as soon as possible after admission with
nutritional requirements of the patients admission. ‘Starter diet’ until the child is stabilized
Catch up diet (F-100) is started once child is RR/SI/OB Catch up diet is started when child is clinically stable and can
clinically started tolerate increased energy and protein intake .Quantity of catch
up diet given is equal to Quantity of starter diet given in
stabilization phase

Reference Charts are followed to decide volume of RR/ SI Check reference value chart is available based on weight of
starter & catch up diet child. Check the BHT diet is planned & given as per protocols

ME D6.3 Hospital has standard procedures for F-75 and F-100 made as per the guideline. SI F-75 and F-100 refers to the specific combination of calories
preparation, handling, storage and distribution of proteins, electrolytes and minerals that is given to children with
diets, as per requirement of patients SAM
The cook prepare special diet for children under SI
the supervision of the Nutrition counsellor.
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Check raw material is kept in closed air tight OB

containers
Check all perishable items are kept refrigerator OB
NRC has system to monitor the amount of food RR
served to baby as per guideline

NRC has system to monitor the amount of feed RR Check any system to record left over feed
left over as per guideline
Standard D7 The facility ensures clean linen to the patients
ME D7.1 The facility has adequate sets of linen OB/RR
Availability of Blankets, draw sheet, pillow with pillow cover and
mackintosh
Clean Linens are provided for all occupied bed
ME D7.2 The facility has established procedures for OB/RR Check extra sets are provided to the bed in case they get soiled
changing of linen in patient care areas
Linen is changed every day and whenever it get
soiled
ME D7.3 The facility has standard procedures for SI/RR Linen is checked for stains as well as ensured it is not torn.
handling , collection, transportation and washing
of linen There is system to check the cleanliness and
Quantity of the linen received from laundry
Standard D10 The facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
ME D10.2 Updated copies of relevant laws, regulations SI/ OB
and government orders are available at the
facility
Updated copy of IMS Act is available

ME D10.3 The facility ensure relevant processes are in PI Check staff can explain at least 3 relevant components of IMS
compliance with statutory requirement Act
(1) Prohibition from any kind of promotion and
No information, counselling and educational advertisement of infant milk substitutes, (2) prohibition of
material is provided to mothers and families on providing free samples and gifts to pregnant women or
Formula Feed for children mother, (3) prohibit donation of free or subsided free
samples, (4) prohibit any contact of manufacturer or
distributor with staff

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
ME D11.2 The facility has a established procedure for There is procedure to ensure that staff is available RR/SI Check system for recording time of reporting and relieving
duty roster and deputation to different on duty as per duty roster (Attendance register/ Biometrics etc)
departments
There is designated in charge for department SI
ME D11.3 The facility ensures the adherence to dress OB
code as mandated by its administration / the
health department Doctor, nursing staff and support staff adhere to
their respective dress code
Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
ME D12.1 There is established system for contract SI/RR Verification of outsourced services (cleaning/
management for out sourced services Dietary/Laundry/Security/Maintenance) provided are done by
There is procedure to monitor the quality and designated in-house staff
adequacy of outsourced services on regular basis
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
ME E1.1 The facility has established procedure for Unique identification number & patient RR Check for that patient demographics like Name, age, Sex, UID
registration of patients demographic records are generated no. & Chief complaint, etc. are recorded during admission
ME E1.3 There is established procedure for admission SI/RR NRC has established criteria for admission:
of patients Children 6-59 months:
Any of the following: MUAC <115mm with or without any grade
of oedema or
WFH < -3 SD with or without any grade of oedema or Bilateral
pitting oedema +/++ (children with oedema +++ always need
inpatient care)
WITH
Any of the following complications: Anorexia (Loss of appetite),
Fever (39 degree C) or Hypothermia (<35 C),Persistent vomiting,
Severe dehydration, Not alert, very weak, apathetic,
unconscious, convulsions
Hypoglycaemia, Severe Anaemia (severe palmar pallor),Severe
pneumonia, Extensive superficial infection
Infants < 6 months
Infant is too weak or feeble to suckle effectively (independently
of his/her weight-for-length).
or WfL (weight-for-length) <–3SD (in infants >45 cm)
or Visible severe wasting in infants <45 cm
or Presence of oedema both feet

Admission criteria for NRC is defined & followed

SI/RR Child previously discharged from in-patient care but meets
NRC has established criteria for re admission admission criteria again.
NRC has established protocols for return after SI/RR Child who returns after default (away from in-patient care for 2
default consecutive days) and meets the admission criteria.
There is no delay in treatment because of SI/RR/OB 1. Admission is done by written order of a qualified doctor.
admission process 2. Time of admission is recorded in patient record.
3. There is no delay in transfer of patient to respective
department once admission is confirmed

ME E1.4 There is established procedure for managing OB/SI

patients, in case beds are not available at the Procedure cope with surplus patient load
facility 1. Check for provision of extra beds
2. Check no two children are treated at one bed
Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.
ME E2.1 There is established procedure for initial All the SAM children are screened to identify medical conditions
assessment of patients and its severity.
Initial assessment of all admitted patient done as The finding of initial assessment are recorded
per standard protocols

RR/SI
RR/SI Check bed head ticket
H/O Recent intake of food and fluids, Usual diet, Breastfeeding,
Duration and frequency of diarrhoea and vomiting, Type of
diarrhoea (watery/ bloody), Chronic cough, Loss of appetite,
Family circumstances, Contact with tuberculosis, Recent contact
with measles, Known or suspected HIV infection &
immunization is taken & recorded.

Check details of : Shock (cold hands, slow capillary refill, weak

and rapid pulse),Palmar pallor, Eye signs of vitamin A deficiency:
Dry conjunctiva or cornea, Bitot’s spots
Corneal ulceration, Keratomalacia and
Localizing signs of infection, including ear and throat infections,
skin infection or pneumonia
Mouth ulcers, Skin changes of kwashiorkor is seen & recorded

Patient History, Physical Examination & Provisional

Diagnosis is done and recorded
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Initial assessment and treatment is provided

immediately
RR/SI Initial assessment is documented preferably within 2 hours
ME E2.2 There is established procedure for follow-up/
reassessment of Patients
There is fixed schedule for reassessment by
Medical Officer/Nutrition Counsellor RR/OB Check BHT is updated after every reassessment

There is system in place to identify and manage Criteria is defined for identification, and management of high
the changes in Patient's health status risk patients/ patient whose condition is deteriorating
SI/RR

Check the treatment or care plan is modified as Check the re assessment sheets/ Case sheets modified
per re assessment results treatment plan or care plan is documented
SI/RR
There is established procedure to plan and Assessment includes physical assessment, history, details of
deliver appropriate treatment or care to Check healthcare needs of all hospitalised patients existing disease condition (if any) for which regular medication
ME E2.3
individual as per the needs to achieve best are identifed through assessment process is taken as well as evaluate psychological ,cultural, social
factors
possible results SI/RR

(a) According to assessment and investigation findings

(wherever applicable).
(b) Check inputs are taken from patient or relevant care
Check treatment/care plan is prepared as per
provider while preparing the care plan.
patient's need

RR

Care plan include:, investigation to be conducted, intervention

Check treatment / care plan is documented to be provided, goals to achieve, timeframe, patient
education, , discharge plan etc
RR

Check care is delivered by competent Check care plan is prepared and delivered as per direction of
multidisciplinary team qualified physician
SI/RR
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 The facility has established procedure for There is a procedure for consultation of the
continuity of care during interdepartmental patient to other specialist with in the hospital
transfer Check process followed to transfer/ handover the patient from
RR/SI emergency, OT, HDU, NRC etc & vice versa
Facility has established procedure for handing over
of patients during departmental transfer Check the process followed in case child require referral to
any speciality including DEIC
RR/ SI
ME E3.2 The facility provides appropriate referral linkages
to the patients/Services for transfer to
other/higher facilities to assure the continuity of A referral slip/ Discharge card is provide to patient when
care. referred to another health care facility.
Patient referred with referral slip RR/SI Check reason for referral are clearly mentioned.
Advance communication is done with higher 1. Referral vehicle is arranged
centre RR/SI 2. Referral in and out register is maintained
Referred paediatric cases are followed up for appropriate care,
There is a system of follow up of referred patients SI/RR completion of treatment & outcome
(1) Check for referral cards filled from lower facilities.
Facility has functional referral linkages to lower (2) ANM of nearby PHC/HWC is informed about discharge for
facilities follow ups
RR
ME E3.3 A person is identified for care during all steps Duty Doctor and nurse is assigned for each RR/SI
of care patients
Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of patients is There is a process for ensuring the identification OB/SI
established at the facility before any clinical procedure
Identification tags are used for children less than 5 yrs.
ME E4.2 Procedure for ensuring timely and accurate Treatment chart are maintained RR Check for treatment chart are updated and drugs given are
nursing care as per treatment plan is established marked. Co relate it with drugs and doses prescribed.
at the facility Dispensing feed, time of oral drugs, supervision of intravenous
fluids etc is recorded

There is a process to ensure the accuracy of SI/RR Verbal orders are rechecked before administration
verbal/telephonic orders
ME E4.3 There is established procedure of patient Patient hand over is given during the change in the SI/RR Nursing Handover register is maintained
hand over, whenever staff duty change shift
happens
Hand over is given at bed side RR Hand over is given bed side and SBAR (situation, background,
assessment and recommendation) protocols are followed
ME E4.4 Nursing records are maintained Nursing notes are maintained adequately RR/SI Check for nursing note register. Notes are adequately written.
ME E4.5 There is procedure for periodic monitoring of Patient Vitals for stable & critical patients are RR/SI Check for TPR chart, I/O chart, any other vital required is
patients monitored and recorded periodically monitored.
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients and Vulnerable patients are identified and measures OB/SI Check the measure taken to prevent new born theft,
ensure their safe care are taken to protect them from any harm sweeping ,baby fall, adverse events following drugs/vaccine etc

ME E5.2 The facility identifies high risk patients and High risk patients are identified and treatment OB/SI Triage is done and provide emergency
ensure their care, as per their need given on priority treatment keeping in mind the ABCD steps: Airway, Breathing,
Circulation, Coma, Convulsion,
and Dehydration.

Standard E6 Facility ensures rationale prescribing and use of medicines

ME E6.1 The facility ensured that drugs are prescribed in Check for BHT if drugs are prescribed under RR Check all the drugs in case sheet and discharge slip are written
generic name only generic name only in generic name only.
ME E6.2 There is procedure of rational use of drugs Check for that relevant Standard treatment RR
guideline are available at point of use Protocols for management of hypoglycaemia, hypothermia,
treatment of dehydration in children with SAM with or without
shock, treatment of infection etc
Check staff is aware of the drug regime and doses SI/RR Check BHT that drugs are prescribed as per treatment protocols
as per STG &Check for rational use of antibiotics
Availability of drug formulary SI/OB
ME E6.3 There are procedures defined for medication Complete medication history is documented for Check complete medication history including over-the- counter
RR/OB medicines is taken and documented
review and optimization each patient
"1. Clinician/Nurse counsel the patient on medication safety
using ""5 moments for medication safety app""
2. Nurse highlights the medications to be taken by the patient at
home and counsel the patient and family on drug intake as per
Patients are engaged in their own care PI/SI treatment plan for discharge"

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

Maximum dose of high alert drugs are defined and SI/RR Value for maximum doses as per age, weight and diagnosis are
communicated available with nursing station and doctor.
ME E7.2 Medication orders are written legibly and There is process to ensure that right doses of drugs SI/RR A system of independent double check before administration,
adequately are only given Error prone medical abbreviations are avoided
Every Medical advice and procedure is RR Verify case sheets of sample basis
accompanied with date , time and signature
Check for the writing is comprehendible by the RR/SI Verify case sheets of sample basis
clinical staff
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ME E7.3 There is a procedure to check drug before Drugs are checked for expiry and other OB/SI Check for any open single dose vial with left over content
administration/ dispensing inconsistency before administration intended to be used later on. In multi dose vial needle is not left
in the septum
Any adverse drug reaction is recorded and RR/SI Check if adverse drug reaction form is available and reporting is
reported in practice
ME E7.4 There is a system to ensure right medicine is Fluid and drug dosages are calculated according to SI/RR Check for calculation chart
given to right patient body weight
Drip rate and volume is calculated and monitored SI/RR Check the nursing staff how they calculate Infusion and monitor
it
Check Nursing staff is aware 7 Rs of Medication SI/OB Administration of medicines done after ensuring right patient,
and follows them right drugs , right route, right time, Right dose , Right Reason
and Right Documentation
ME E7.5 Patient is counselled for self drug Mother is advice by doctor/ Pharmacist /nurse PI/SI Dose & advice is described in vernacular. It is not given directly
administration. about the dosages and timings . in hand of relative/patient

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re-assessment and RR Check BHT updated
investigations are recorded and updated Day to day progress of patient is recorded in BHT
ME E8.2 All treatment plan prescription/orders are Treatment plan, first orders are written on BHT RR Verify treatment prescribed with nursing records
recorded in the patient records.
ME E8.3 Care provided to each patient is recorded in Maintenance of treatment chart/treatment RR Treatment given is recorded in treatment chart /register
the patient records registers
ME E8.4 Procedures performed are written on Procedure performed /Management steps are
RR
10 Steps for management of SAM is recorded during
patients records recorded in BHT Stabilization and rehabilitation phase
ME E8.5 Adequate form and formats are available at RR/OB
point of use Availability of formats for Treatment Charts, Community follow
Standard Formats are available up card, BHT, continuation sheet, Discharge card Etc.
1. Check for adequate availability of the forms
2. Check for completeness in the filled forms
ME E8.6 Register/records are maintained as per RR
guidelines General order book (GOB), report book, Admission register, lab
register, Admission sheet/ bed head ticket, discharge slip,
Registers and records are maintained as per referral slip, referral in/referral out register, Diet register, Linen
guidelines register, Drug intend register etc
All register/records are identified and numbered RR Unique identification number is given & staff is able to retrieve
previous register/records
ME E8.7 The facility ensures safe and adequate Safe keeping of patient records OB (1) Records of discharged cases are kept in MRD/ department
storage and retrieval of medical records sub store
(2) Check records are retrieval in case of re admission
(3) Copy of records is given to next kin only with permission
from authorised staff only

Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing patient NRC has established criteria for discharge of the
SI/RR Discharge infants and children when they gain 15% weight and
readiness there is no signs of illness
patient
SI/RR Based on discharge criteria:
(1) Oedema has resolved
(20 Child has achieved weight gain of > 15% and has
satisfactory weight gain for 3 consecutive days (>5 gm/kg/day)
(3) Child is eating an adequate amount of nutritious food that
the mother can prepare at home
(4) All infections and other medical complications have been
treated
(5) Child is provided with micronutrients
Immunization is updated

Discharge is done by a responsible and qualified

doctor after assessment in consultation with
treating doctor
PI/SI
Ensure that parent/caregiver understands the causes of
Mother / attendants are consulted before malnutrition and how to prevent its recurrence
discharge
PI/ SI/ RR 1. Give a single dose of any one of the following anthelminthics
orally:
200 mg. albendazole for children aged 12–23 months,
400 mg albendazole for children aged 24 months or more.
100 mg mebendazole twice daily for 3 days for children aged 24
months or more

Staff is aware that helminthic infections treatment

is given to all children before discharge
ME E9.2 Case summary and follow-up instructions are RR/PI See for discharge summary, referral slip provided.
provided at the discharge Discharge summary adequately mentions patients
clinical condition, treatment given and follow up
Discharge summary is give to all patients SI/RR Including LAMA/Referral patient

Staff guides the parent for regular follow-up visits SI/ RR

1. Regular check-ups should be made at 2 weeks in first month
and then monthly thereafter until weight for height reaches -1
SD or above.
2. If a problem is detected or suspected, visit/s can be made
earlier or more frequently until the problem is resolved.
RR/SI (1) Check NRC has a complete list of PHCs, CHC, and Sub
Centres/HWC in the catchment area.
(2) Appropriate referral to local CHW (Community health care
worker)/ASHA/AWW is established
(3) Regular Follow up including enrolment of baby to Anganwadi
There is procedure for clinical follow up of the centre a
child for assessment and monitoring of growth
and development till the child recovers completely
ME E9.3 Counselling services are provided as during
discharges wherever required
(1) Preparation and feeding the child, how to give prescribed
medication, folic acid, vitamins and iron at home, how to give
Counselling of mothers/caregiver before discharge home treatment for diarrhoea, fever and acute respiratory
infections.
(2) Advice includes the information about the nearest health
centre for further follow up.
(3) Time of discharge is communicated to patient in prior.
PI/SI (4) Advice includes feeding recommendations as per IMNCI
ME E9.4 The facility has established procedure for RR/SI
patients leaving the facility against medical
advice, absconding, etc
Declaration is taken from the LAMA cases
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.1 There is procedure for Receiving and triage Triaging of sick children is done as per protocols SI/ OB Staff practice of ETAT protocol - keeping in mind ABCD steps
of patients
Staff is skilled to provide basic life support to SI/ RR/ OB
young infants and children

ME E11.3 The facility has disaster management plan in Staff is aware of disaster plan SI/RR Role and responsibilities of staff in disaster are defined
place Mock drills have conducted from time to time

Standard E12 The facility has defined and established procedures of diagnostic services
ME E12.1 There are established procedures for Pre- Container is labelled properly after the sample OB
testing Activities collection Protocols are defined & followed for sample collection & its
transfer timely from NRC to lab for testing
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ME E12.3 There are established procedures for Post- SI/RR

testing Activities

(1) Critical values are defined and intimated timely to treating

medical officer
NRC has critical values of various lab test (2) List of Normal reference ranges are available in NRC
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
ME E13.8 There is established procedure for issuing RR/SI
blood Paediatric blood bags are available If not available than how facility cope with it
ME E13.9 There is established procedure for RR
transfusion of blood

Patient's identification is confirmed & Consent is

taken before transfusion
Blood transfusion of SAM child is done as per RR Blood transfusion is required (1) Hb is less than 4 g/dl (2) or if
standard Guideline there is respiratory distress and Hb is between 4 and 6 g/dl.
RR Blood is kept on optimum temperature before transfusion.
Blood transfusion is monitored and regulated by qualified
person :Give (1) whole blood 10 ml/kg body weight slowly over
3 hours (2) furosemide 1 mg/kg IV at the start of the transfusion
Protocol of blood transfusion is monitored &
regulated
RR Blood bag details sticker is pasted in case file, patient
Blood transfusion note is written in patient records monitoring status is recorded in case sheet
SI/RR (1) Blood transfusion should not be started until the child has
begun to gain weight.(2) Following the transfusion, if the Hb
remains
less than 4 g/dl or between 4 and 6 g/dl with continuing
respiratory
distress, DO NOT repeat the transfusion within 4 days

Staff is aware of conditions in which blood

transfusion is not done/repeated
ME E13.10 There is a established procedure for RR Check -
monitoring and reporting Transfusion Staff is aware of the protocol to be followed in case of any
complication transfusion reaction
Any major or minor transfusion reaction is
recorded and reported to responsible person
Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines
ME E20.1 The facility provides immunization services as per Immunization services are provided as Check MCP card is available & updated. Mother /care provider
guidelines immunization schedule SI/RR is counselled and directed to immunize the child
ME E20.2 Triage, Assessment & Management of newborn SI/RR Assess for Emergency signs
having 1. Airway and breathing- Not breathing, or central cyanosis or
emergency signs are done as per guidelines SRD
2. Circulation - Capillary refill > 3sec and weak fast pulse
3. Coma Convulsing
4. Severe dehydration with diarrhoea - Diarrhoea + lethargy,
sunken eyes & very slow skin pinch

Triaging of sick SAM children is done based on

emergency sign
SI/RR 1. Airway and breathing- Any sign positive- Provide basic life
support, give oxygen, make sure child is warm, insert IV & begin
fluids
2. Circulation -if positive- Apply pressure to stop bleeding if
child is bleeding, give oxygen, make sure child is warm, insert IV
& begin fluids. If Child is SAM (Age less than 2months) Give
Glucose IV or orally or NG tube (depending up on condition)&
proceed for full assessment
3. Coma Convulsing- if positive- Manage Airways- Position the
child, check and correct hypothermia, If convulsions continue
give IV calcium / anticonvulsant
4. Severe dehydration due to diarrhoea: Make sure head is
warm, Insert IV line & give fluids. If age is less than 2 month -
don to start IV, proceed for full assessment

Management of sick SAM child is done based on

emergency sign
SI/RR Tiny baby (<2 months),Bleeding, Pallor (severe)
Malnutrition: Visible severe wasting, Respiratory distress,
Trauma or other urgent surgical
condition, Oedema of both feet, Temperature <36.5°C or >
38.5°C, Restless, continuously irritable, or lethargy, Poisoning &
Burns (major)
Staff is aware of the priority signs
ME E20.8 Management of children with severe Staff is aware of Principles of Hospital based SI/RR Management of SAM based in 3 Phases:
Acute Malnutrition is done as per guidelines management (1) Stabilization Phase - Children without adequate appetite
and/or medical complications are stabilized in IPD. Phase
usually lasts for 1–2 days. Began the Starter diet & maintain
electrolytic balance. Children must be carefully monitored for
signs of overfeeding or over hydration.
(2) Transition Phase- There is
gradual transition from Starter diet to Catch up diet (F 100).
(3) Rehabilitation Phase- Promote rapid weight gain, stimulate
emotional and physical development. The child progresses
when:
S/he has reasonable appetite; finishes > 90% of the feed that is
given, without a significant pause Major reduction or loss of
oedema &
No other medical problem

Staff is aware of 10 steps for management of SAM SI (1) Treat /Prevent Hypoglycaemia (2) treat and prevent
Hypothermia (3) treat and prevent dehydration (4) Correct
electrolyte imbalance (5) treat/ prevent infection (6) Correct
micro nutrient deficiency (7) Start cautious diet (8) Achieve
catch up growth (9) Provide sensory stimulation and emotional
support (10) Prepare follow up after recovery

Staff is aware of treatment of dehydration in SAM SI/ RR

children without shock

(1) Give Oral rehydration- amount based on child's weight-

every 30 min for 1st 2 hrs- 5ml/kg weight.
Further, alternate hours for up to 10 hrs- 5ml/kg ( Add 15ml of
potassium chloride to 1l ORS)
(2) Starter diet is given in alternate hours (e.g. 2, 4, 6) with
reduced osmolarity ORS (e.g. 3, 5, 7) until the child is
rehydrated.
(3) Check Signs every half hour for the first two hours, then
hourly: Respiratory rate, Pulse rate,
Urine frequency, Stool or vomit frequency &
Signs of hydration
Checklist -7 NRC Version- NHSRC/3.0

Staff is aware of sign of improved hydration & over SI/ RR

hydration
Signs of improved hydration: (any of 3)
Child is no longer thirsty
Child is less lethargic
Slowing of respiratory and pulse rates from previous high rate
Skin pinch is less slow
Child has tears
Sign of overhydration :
Increased respiratory rate and pulse.
Jugular veins engorged
Puffiness of eye
Staff is aware of treatment of hypothermia SI/ RR

(1) Assess- If axillary temp below- 35OC or rectal temp is below

35.5 OC
(2) Start feeding immediately(or start rehydration if needed).
(3) Re-warm. Give skin to skin contact: kangaroo technique) and
cover them, OR clothe the child including the head, cover with a
warmed blanket and place a heater or lamp nearby. Remove
wet clothing/bedding
(4)Feed 2-hourly (12 feeds in 24 hours).
(5) Treat hypoglycaemia,
(6) Give 1st dose of antibiotics.
(7) Take temp. every 2 hrs -stop re-warming when it rises above
36.50 C
Staff is aware of treatment of hypoglycaemia SI/ RR
(1) Estimate Blood Glucose levels
(2) If Blood glucose is low (<54mg/dl) immediately give 50 ml
bolus of 10% glucose or 10% sucrose (1 rounded teaspoon of
sugar in 3½ tablespoons of water).
If the child can drink, give the 50 ml bolus orally.
If the child is alert but not drinking, give the 50 ml by NG tube.
If the child is lethargic, unconscious, or convulsing, give 5 ml/kg
body weight of sterile 10% glucose by IV, followed by 50 ml of
10% glucose or sucrose by NG tube. If the IV dose cannot be
given immediately, give the NG dose first.
(3) Start feeding with ‘Starter diet’ half an hour after giving
glucose and give it every half-hour during the first 2 hours
(4) Keep child warm
(5) Administer antibiotics as hypoglycaemia may be due to
underlying infection

Staff is aware of correction of electrolyte SI/ RR (1) Give supplemental potassium at 3–4 meq/kg/day for at least
imbalance 2 weeks. Potassium can be given as syrup potassium chloride;
the most common preparation available has 20meq/15ml. It
should be diluted with water.
(2) On day 1, give 50% magnesium sulphate IM once (0.3 mL/kg)
up to a maximum of 2 ml. Thereafter, give extra magnesium (0.4
– 0.6 mmol/kg/daily) orally. If oral commercial preparation is
not available you can
give injection magnesium sulphate (50%); 0.2–0.3 ml/kg orally
as magnesium supplements mixed with feeds. Give magnesium
supplements for 2 weeks.
(3) Give food without added salt to avoid sodium overload.

Staff is aware of treatment of child having sign of SI/ RR (1) Weight the child.
shock and is lethargic or lost consciousness (2) Give oxygen
(3) Make sure child is warm
(4) Insert IV line & draw blood for lab investigation
(5) Give IV 10% glucose (5ml/kg)
(6) Give IV 15ml/kg over 1 hr of either lactate in 5% dextrose or
half normal saline with 5% glucose or ringer's lactate
(7) Measure pulse & RR every 5-10 min
(8) Sign for improvement - (PR & RR fall) - Repeat IV fluid
15ml/kg over 1hr then switch to oral or NG rehydration with
ORS, 10ml/kg/hr up to 10hrs & initiate feeding with starter
formula or
If child fail to improve/ if the child condition deteriorate -
Assume child is in septic shock- Give maintenance IV fluid
(4ml/kg/hr), review antibiotic treatment, start dopamine &
initiate re-feeding

Staff is aware of treatment protocols of infectious SI/RR

or other associated disease conditions

(1) If no complication - Give oral amoxicillin 15mg/kg -8 hrly for

5 days.
If child has complications select antibiotic as per Standard
protocols.
(2) Associated diseases: viz Dermatosis, Parasitic worms,
Continual diarrhoea, dysentery , meningitis and TB as per
guideline
Staff is aware of criteria for failure to respond to SI/RR
treatment and require referral

(1) Failure to regain appetite even after 4 days of treatment

(2) Failure to lose oedema even after 4 days of treatment
(3) Oedema still even after 10 days
(4) Failure to gain at least 5 g/kg/day for 3 successive days after
feeding freely on Catch-up diet.
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Micronutrients supplementation is given to SAM SI/ RR

children as per requirement

Vitamin A
1. Vitamin A in a single dose is given to all SAM children unless
there is evidence that child has received vitamin A dose in last 1
month; < 6 months - 50 000 IU, 6–12 months or if weight <8Kg-
100 000 IU, >12 months- 200 000 IU.
2. Give same dose on Day 1, 2 and 14 if there is clinical evidence
of vitamin A deficiency.

Multivitamin Supplement
1. Must contain vitamin A, C, D, E and B12 and not just vitamin
B-complex):Twice Recommended Daily Allowance

Folic Acid : 5mg on day 1, then 1mg/day

Elemental Zinc: 2mg/ kg/day
Copper: 0.3mg/kg/day

Iron
1. Start daily iron supplementation after two days of the child
being on Catch up diet.
2. Give elemental iron in the dose of 3 mg/kg/day in two divided
doses, preferably between meals. (Do not give iron in
stabilization phase.)
Staff is aware of age wise feeding SI/ RR
recommendations as per IMNCI

(1) Up to 6 months- Exclusive Breastfeeding - at least 8 times in

24 hrs. Do not give any other food or fluids
(2)6to12 months- Breastfeeding, Give at least one Katori (3
times/day if breastfeed is given & 5 times if breastfeed not
given) mashed bread in sweetened undiluted milk or bread
mixed with thick dal or khichari. Add ghee/oil & cooked
vegetables in serving or Sevian/Dalia/halwa/kheer or mashed
boiled potatoes. Also give banana/ biscuit/cheeko/mango as
snack
(3) 12month-2yrs- Breastfeed, offer food from family pot, give
at least one & half Katori (5 times/day) mashed bread in
sweetened undiluted milk or bread mixed with thick dal or
khichari. Add ghee/oil & cooked vegetables in serving or
Sevian/Dalia/halwa/kheer or mashed boiled potatoes. Also give
banana/ biscuit/cheeko/mango as snack
(4) 2 yrs. older- Give family food at 3 meals each day. Also twice
daily give nutritious food between meal i.e. banana/
biscuit/cheeko/mango as snack
Staff is aware of management of SAM children less SI/ RR
than 6 months of age

1. Feed the infant with appropriate breastmilk/ feeds for initial

recovery and metabolic stabilization.
2. Wherever possible breastfeeding or expressed milk is
preferred in place of Starter diet.
3. For no breastfed babies, give Starter diet feed prepared
without cereals.
4. In the rehabilitation phase, provide support to mother to give
frequent feeds and try to establish exclusive breast feeding. In
artificially fed without any prospects of breastfeeds, the infant
should be given diluted Catch-up diet. [Catch-up diet diluted by
one third extra water to make volume 135 ml in place of 100
ml].
5. On discharge the non-breastfed infants should be given
locally available animal milk with cup and spoon.
6. Relactation through Supplementary Suckling Technique -
Supplementary Suckling Technique (SST) is a technique which
can be used as a strategy to initiate relactation in mothers who
have developed lactation failure.
Staff is aware of Management of SAM in HIV SI/ RR 1. Start the treatment atleast two weeks before the
exposed/ HIV infected children and TB infected introduction of ART
children 2. Preferably antiretroviral treatment should be delayed until
the recovery phase is well established.
3. Children with HIV should be given co-trimoxazole prophylaxis
against pneumocystis pneumonia; amoxicillin should be given in
addition to prophylactic doses of co-trimoxazole
4. Once SAM is being treated satisfactorily, treatment for HIV
and/or TB (as indicated) should be started;
5. Cotrimoxazole prophylaxis is to be continued as per NACO
guidelines. .

Check there is structured play therapy for children SI/RR 1. Emotional and physical stimulation is given to reduce the risk
of permanent mental retardation and emotional impairment
2. Each play session should include language and motor
activities, and activities with toys.
3. Promotion of physical activities among mobile children for
development of essential motor skills & enhance growth

ME E20.10 Facility ensures optimal breast feeding

practices for new born & infants as per
guidelines Check mothers are providing exclusive breast Check mother's knowledge regarding importance of breast
PI
milk atleast for six months feeding

Counselling and supporting mother for alternate

Expressed milk is given by spoon or cup or fed by gastric
method of feeding in case of pre term /low SI/PI/RR
tube in adequate amounts according to age.
birth/ baby unable to suck the breast

Babies intake is monitored and ensure adequate Frequent feeding at least 8 times per day including night
amount as per age and disease condition is SI/RR feeding.
provided Check monitoring checklist of feeding for LBW newborn

Check mothers is aware of complimentary Check mother's knowledge regarding importance of

PI
feeding after six months up to 2 years complimentary

HIV positive mothers are counselled for the

SI/RR
options of baby feeding

Area of Concern - F Infection Control

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection
There is Provision of Periodic Medical Check- There is procedure for immunization & periodic
up and immunization of staff check-up of the staff
ME F1.4 SI/RR Hepatitis B, Tetanus Toxoid etc
The facility has established procedures for (1) Hand washing and infection control audits done at periodic
regular monitoring of infection control intervals for staff as well as mothers/care giver
practices
ME F1.5 Regular monitoring of infection control practices SI/RR
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The facility has defined and established Check for Doctors are aware of Hospital Antibiotic
ME F1.6 antibiotic policy Policy SI/RR
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are provided at point Availability of hand washing with running Water
of use facility at Point of Use
ME F2.1 OB Each unit should have at least 1 wash basin for every 5 beds
Availability of antiseptic soap with soap dish/ liquid Check for availability/ Ask staff if the supply is adequate and
antiseptic with dispenser. OB/SI uninterrupted. Availability of Alcohol based Hand rub
Display of Hand washing Instruction at Point of Prominently displayed above the hand washing facility ,
Use OB preferably in Local language
Availability of elbow operated taps & Hand Check wash basin is wide and deep enough to prevent splashing
washing sink OB and retention of water
The facility staff is trained in hand washing Adherence to 6 steps of Hand washing
practices and they adhere to standard hand
washing practices
ME F2.2 SI/OB Ask for demonstration
Staff aware of when to hand wash SI 5 moments of Hand hygiene
Mothers are aware of importance of washing
hands Mothers are aware of importance of washing hands .Washing
hands after using the toilet/ changing diapers and before
PI/OB feeding children.
Mothers/care giver adhere to hand washing Ask for demonstration
practices with soap PI/OB
The facility ensures standard practices and Availability Use of Antiseptic Solutions
ME F2.3 materials for antisepsis OB
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate personal
protection Equipment as per requirements
ME F3.1 Availability of PPE OB/SI Gloves, mask, apron & caps
The facility staff adheres to standard No reuse of disposable gloves, Masks, caps and
ME F3.2 personal protection practices aprons. OB/SI
Compliance to correct method of wearing and
removing the gloves & Other PPEs SI
Standard F4 The facility has standard procedures for processing of equipment and instruments
The facility ensures standard practices and Decontamination of operating & Procedure
materials for decontamination and cleaning of surfaces Ask staff about how they decontaminate the procedure surface
instruments and procedures areas like Examination table , Patients Beds / Cots, Stretcher/Trolleys
etc.
ME F4.1 SI/OB (Wiping with 1% Chlorine solution

Ask staff how they decontaminate the instruments like

Stethoscope, Dressing Instruments, Examination Instruments,
Blood Pressure Cuff etc
(Soaking in 1 % Chlorine Solution, Wiping with 1% Chlorine
Solution or 70% Alcohol as applicable
Proper Decontamination of instruments after use SI/OB Contact time for decontamination of instruments
Cleaning of instruments Cleaning is done with detergent and running water after
SI/OB decontamination

Proper handling of Soiled and infected linen SI/OB No sorting ,Rinsing or sluicing at Point of use/ Patient care area
Staff know how to make chlorine solution SI/OB
Toys washed regularly, and after each child uses SI/OB Check for decontamination and washing of toys
The facility ensures standard practices and Equipment and instruments are sterilized after Ask staff about temperature, pressure and time for autoclaving.
materials for disinfection and sterilization of each use as per requirement Ask staff about method, concentration and contact time
instruments and equipment required for chemical sterilization
ME F4.2 OB/SI
Check staff is aware of how long autoclaved items can be
stored.
Also, autoclaved items are stored in dry, clean, dust free, moist
Staff is aware of storage time for autoclaved items OB/SI free environment
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
The facility ensures availability of standard Availability of disinfectant as per requirement
materials for cleaning and disinfection of patient
care areas
ME F5.2 OB/SI Chlorine solution, Glutaraldehyde etc
Availability of cleaning agent as per requirement OB/SI Hospital grade phenyl, disinfectant detergent solution
The facility ensures standard practices are Spill management protocols are implemented
followed for the cleaning and disinfection of
patient care areas Check availability of Spill management kit ,staff is trained for
ME F5.3 SI/RR managing small & large spills , check protocols are displayed
Cleaning of patient care area with detergent
solution SI/RR
Standard practice of mopping and scrubbing are
followed
Unidirectional mopping from inside out. Staff is trained for
preparing cleaning solution as per standard procedure. Cleaning
OB/SI equipment like broom are not used in patient care areas
The facility ensures segregation infectious Isolation and barrier nursing procedure are List of infectious diseases require special precaution and barrier
ME F5.4 patients followed OB/SI nursing is defined

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
Facility Ensures segregation of Bio Medical Availability of colour coded bins at point of waste
ME F6.1 Waste as per guidelines generation OB
Availability of Non chlorinated colour coded
plastic bags OB
Segregation of Anatomical and soiled waste in
Yellow Bin OB/SI
Segregation of infected plastic waste in red bin OB
Display of work instructions for segregation and Pictorial and in local language
handling of Biomedical waste OB
There is no mixing of infectious and general waste
OB
Facility ensures management of sharps as Availability of functional needle cutters and OB (1) Check if needle cutter has been used or just lying idle. (2) it
per guidelines puncture proof box should be available near the point of generation like nursing
station
ME F6.2
Availability of post exposure prophylaxis
1. Staff knows what to do in case of needle stick injury.
2. Staff is aware of whom to report
3. Check if any reporting has been done
OB/SI 4. Also check PEP issuance register
Glass sharps and metallic implants are disposed in OB Includes used vials, slides and other broken infected glass
Blue colour coded puncture proof box
Facility ensures transportation and disposal Check bins are not overfilled Bins should not be filled more than 2/3 of its capacity
ME F6.3 of waste as per guidelines SI/OB
Transportation of bio medical waste is done in
close container/trolley SI/OB
Area of Concern - G Quality Management
The facility has established organizational framework for quality improvement
Standard G1

ME G1.1 The facility has a quality team in place Quality circle has been constituted SI/RR 1. Check if the quality circle has been constituted and is
functional
2. Roles and Responsibility of team has been defined
ME G1.2 The facility reviews quality of its services at Review meetings are done monthly RR Check minutes of meeting and monthly measurement &
periodic intervals reporting of indicators

Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient satisfaction surveys are conducted at Patient relative / caregiver satisfaction survey RR
periodic intervals done on monthly basis
ME G2.2 The facility analyses the patient feed back, Analysis of low performing attributes is RR
and root-cause analysis undertaken
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ME G2.3 The facility prepares the action plans for the Action plan is prepared and improvement activities RR
areas, contributing to low satisfaction of are undertaken
patients

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

ME G3.3 Facility has established system for use of Internal assessment is done at periodic interval RR/SI NQAS assessment toolkit is used to conduct internal assessment
check lists in different departments and
services

Departmental checklist are used for SI/RR Staff is designated for filling and monitoring of these
monitoring and quality assurance checklists

Non-compliances are enumerated and RR

recorded

Check the non compliances are presented & discussed during

quality team meetings

ME G3.4 Actions are planned to address gaps

observed during quality assurance process

Check action plans are prepared and implemented Randomly check the details of action, responsibility, time line
as per internal assessment record findings and feedback mechanism

RR
ME G3.5 Planned actions are implemented through
Quality Improvement Cycles (PDCA)
Check actions have been taken to close the gap. It can be in
Check PDCA or prevalent quality method is used to
form of action taken report or Quality Improvement (PDCA)
take corrective and preventive action
project report

SI/RR
Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
ME G4.1 Departmental standard operating Standard operating procedure for department has RR Check that SOP for management of services has been prepared
procedures are available been prepared and approved and is formally approved
Current version of SOP are available with process OB/RR Check current version is available
owner
OB
Appropriate feeding practices, Summary of the 10 steps of
successful breastfeeding is displayed, lactation position and milk
Work instruction/clinical protocols are displayed expression protocol, assessment and management protocols of
sick SAM child, Management of hypoglycaemia, Management
of Dehydration, housekeeping protocols, Administration of
commonly used drugs, etc
ME G4.2 Standard Operating Procedures adequately RR Review the SOP has adequately cover procedure for reception,
describes process and procedures triage initial assessment, admission & investigation of the
Department has documented Procedure for patient
receiving and initial assessment of the patient
RR Review the SOP has adequately cover procedure for
Department has documented procedure for reassessment, follow up and referral of patient
reassessment of the patient as per clinical
condition
Department has documented procedure for RR Review the SOP has adequately cover procedure of
general patient care processes management of hypothermia, hypoglycaemia, dehydration,
electrolyte imbalance, feeding recommendation as per IMNCI,
micronutrient supplementation

Department has documented procedure for RR Review the SOP has adequately cover procedure of
specific processes to the department management of SAM children with shock, infections , TB, HIV &
any other disease

Department has documented procedure for RR Review the SOP has adequately cover procedure of nutritional
support services & facility management. assessment & use of starter & catch up diet, provision of
micronutrient supplementation etc. SOP also covers support
services such as equipment maintenance, calibration,
housekeeping, security, storage and inventory management

Department has documented procedure for safety RR Review the SOP has adequately covers procedure for patient
& risk management safety risk assessments & also mechanism defined to mitigate
the identified risk

Department has documented procedure for RR Review SOP has adequately covers the points to be discussed
Counselling of mothers/ care giver during mothers/ care giver counselling. It also covers mothers
counselling for food preparation from local resources, feeding
practices, importance of play with child, and maintenance of
care & hygiene etc

Department has documented procedure for RR Review SOP for process description of Hand Hygiene,
infection control & bio medical waste personal protection, environmental cleaning, instrument
management sterilization,
asepsis, Bio Medical Waste
management, surveillance and monitoring of infection control
practices

Department has documented procedure for RR Review SOP for procedure to constitute quality circles, their
quality management & improvement regulate meetings, development of quality objectives, steps to
be take to achieve objectives and their monitoring &
measurement mechanisms

Department has documented procedure for data RR Review SOP for data collection through various activities viz.
collection, analysis & use for improvement client satisfaction form, checklists , audits , performance
indicators etc. , analysis of the data , identification of low
attributes, Root cause analysis and improvement activities
using PDCA methodology

ME G4.3 Staff is trained and aware of the procedures SI/RR

written in SOPs Check staff is a aware of relevant part of SOPs
Standard G 5
The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
ME G5.1 The facility maps its critical processes SI/RR Critical processes , where there is some
problem-delays, errors, cost, time, etc. and improvement will
make our process
effective and efficient
Process mapping of critical processes done
ME G5.2 The facility identifies non value adding SI/RR Non value adding activities are wastes. In these steps resources
activities / waste / redundant activities are wasted,
delays occur, and no value is added to the service
Non value adding activities are identified
ME G5.3 The facility takes corrective action to Processes are rearranged as per requirement SI/RR Check the improvement is sustained
improve the processes
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Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
ME G6.4 SI/RR
Check short term valid quality objectives have been framed
addressing key quality issues in each department and cores
Facility has de defined quality objectives to services. Check if these objectives are Specific, Measurable,
achieve mission and quality policy Check if SMART Quality Objectives have framed Attainable, Relevant and Time Bound.
ME G6.5 SI/RR
Mission, Values, Quality policy and objectives are Interview with staff for their awareness. Check if Mission
effectively communicated to staff and users of Check staff is aware of Mission , Values, Quality Statement, Core Values and Quality Policy is displayed
services Policy and objectives prominently in local language at Key Points
Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 The facility uses method for quality Basic quality improvement method SI/OB PDCA & 5S
improvement in services
Advance quality improvement method SI/OB Six sigma, lean.

ME G7.2 The facility uses tools for quality 7 basic tools of Quality SI/RR Minimum 2 applicable tools are used in each department
improvement in services
Standard G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
ME G9.6 SI/RR

The facility has established clinical Check periodic assessment of medication and Verify with the records. A comprehensive risk assessment of all
Governance
Periodic framework
assessment to improve
for Medication and Patient patient care safety risk is done using defined clinical processes should be done using pre define criteria at
care safety
quality risks
and is done
safety ofasclinical
per defined
carecriteria. checklist periodically least once in three month.
Standard G10 processes
Check parameter are defined & implemented to review the
clinical care i.e. through Ward round, peer review, morbidity &
Clinical care assessment criteria have been The facility has established process to review the mortality review, patient feedback, clinical audit & clinical
ME G10.3 clinical care
defined and communicated outcomes.
SI/RR
(1) Both critical and stable patients
Check regular ward rounds are taken to review
(2) Check the case progress is documented in BHT/ progress
case progress
SI/RR notes-
Check the patient /family participate in the care Feedback is taken from patient/family on health status of
evaluations SI/RR individual under treatment
System in place to review internal referral process, review
Check the care planning and co- ordination is
clinical handover information, review patient understanding
reviewed
SI/RR about their progress

Check medical audit records

(a) Completion of the medical records i.e. Medical history,
assessments, re assessment, investigations conducted, progress
Facility conducts the periodic clinical notes, interventions conducted, outcome of the case, patient
education, delineation of responsibilities, discharge etc.
ME G10.4 audits including prescription, medical and There is procedure to conduct medical audits (b) Check whether treatment plan worked for the patient
death audits (C) progress on the health status of the patient is mentioned
(d) whether the goals defined in treatment plan is met for the
individual cases
(e) Adverse clinical events are documented
(f) Re admission

SI/RR

(1) All the deaths are audited by the committee.

(2) The reasons of the death is clearly mentioned
(3) Data pertaining to deaths are collated and trend analysis is
There is procedure to conduct death audits done
(4) A through action taken report is prepared and presented in
clinical Governance Board meetings / during grand round
(wherever required)

SI/RR

All non compliance are enumerated recorded for

Check the non compliances are presented & discussed during
medical audits
SI/RR clinical Governance meetings

All non compliance are enumerated recorded for

Check the non compliances are presented & discussed during
death audits
SI/RR clinical Governance meetings
Clinical care audits data is analysed, and
Check action plans are prepared and implemented Randomly check the actual compliance with the actions taken
ME G10.5 actions are taken to close the gaps as per medical audit record findings reports of last 3 months
identified during the audit process SI/RR
Check action plans are prepared and implemented Randomly check the actual compliance with the actions taken
as per death audit record's findings SI/RR reports of last 3 months

Check the data of audit findings are collated Check collected data is analysed & areas for improvement is
SI/RR identified & prioritised
Check the critical problems are regularly monitored &
Check PDCA or prevalent quality method is used
applicable solutions are duplicated in other departments
to address critical problems
SI/RR (wherever required) for process improvement
Facility ensures easy access and use of
Check standard treatment guidelines / Staff is aware of Standard treatment protocols/
standard treatment guidelines & protocols are available & followed. SI/RR guidelines/best practices
ME G10.7
implementation tools at
point of care
Check treatment plan is prepared as per SI/RR Check staff adhere to clinical protocols while preparing the
Standard treatment guidelines treatment plan
Check the drugs are prescribed as per SI/RR Check the drugs prescribed are available in EML or part of
Standards treatment guidelines drug formulary
Check when the STG/protocols/evidences used in
Check the updated/latest evidence are SI/RR healthcare facility are published.
available Whether the STG protocols are according to current
evidences.

The gaps in clinical practices are identified & action are

Check the mapping of existing clinical practices SI/RR taken to improve it. Look for evidences for improvement in
processes is done
clinical practices using PDCA
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Indicators on
monthly basis Total admissions RR
Bed Occupancy Rate RR
Proportion of admissions by gender RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators on Percentage of children achieved target weight
monthly basis gain RR 15% weight gain
Down time Critical Equipment RR
Bed Turnover Rate RR
Referral Rate RR
Discharge Rate RR
Acceptable-<15%
Defaulter rate RR Not Acceptable->25%
Relapse rate RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Acceptable- 1-4 week
Indicators on monthly basis Average length of stay in (weeks) RR Not Acceptable-<1 and >6
Death rate following discharge from NRC Acceptable- <5% Not Acceptable- >15%

RR
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Recovery rate Acceptable- >75% Not Acceptable- <50%

RR
wrong drug administration, needle stick injury, absconding
Adverse events are reported RR patients etc
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality Indicators on LAMA Rate
monthly basis RR
Parent/ care giver Satisfaction Score

RR
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Version: DH/NQAS-
2020/00

C Score

Remarks
 Checklist -7 NRC Version- NHSRC/3.0

nd their modalities

physical access, language, cultural or social status.

elated information.

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he cost of hospital services.

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prevalent norms

current case load

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 Checklist -7 NRC Version- NHSRC/3.0

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pital associated infection

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antisepsis

ntion

cal and hazardous Waste.

 Checklist -7 NRC Version- NHSRC/3.0

cal to quality.

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achieve them

Management Plan

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Checklist No 8 Operation Theatre Version - NHSRC /3.0
Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
Area of Concern - A Service Provision

Standard A1 Facility Provides Curative Services

Appendectomy, Intestinal Obstruction, Perforation, Tongue Tie,

The facility provides General Surgery Availability of General Surgery Inguinal Hernia, haemorrhoidectomy, Abscess drainage
ME A1.2 2 SI/OB
services procedures (perianal), Liver abscess, Cholecystectomy, superficial tumour
excision.

(a) D & C, Hysterectomy, Cervical Cautery, Bartholin cyst

excision, explorative laparotomy (uterine perforation, twisted
ME A1.3 The facility provides Obstetrics & Availability of Gynaecology 2 SI/OB ovarian), sling operation, haematocolpus drainage colpotomy
Gynaecology Services procedures (b) Lump excision, Simple mastectomy, Mammary fistula
excision, Abscess drainage ( breast)

The facility provides Paediatric Availability of Paediatric Surgery I&D, Pepuceal Dilation, Meatomy, Gland Biopsy, Reduction
ME A1.4 2 SI/OB Paraphimosis, Brachial/Thyroglossal Cyst and Fistula, Inguinal
Services procedure Herniotomy, Neonatal Intestinal Obstruction

The facility provides Ophthalmology Availability of Ophthalmic Surgery Cataract Extraction with IOL, Canthotomy, Paracentesis,
ME A1.5 Services procedures 2 SI/OB Enucleation, Glaucoma surgery, Conjunctival Cyst,

Nose, Ear and Throat surgical procedures

Packing, therapeutic removal of granulation (nasal, aural,
oropharynx), Mastoid abscess, myringoplasty, endoscopic sinus
surgery,
ME A1.6 The facility provides ENT Services Availability of ENT surgical procedure 2 SI/OB Antral Puncture, Fracture Reduction, Mastoid Abscess I &
D, periauricular sinus excision, stitching of CLW (nose & ear)

The facility provides Orthopaedics Availability of Orthopaedic surgical Open and Closed Reduction, Nailing and Plating, Amputation,
ME A1.7 Services procedures 2 SI/OB Disarticulation of Hip and Shoulder
The facility provides Dental
ME A1.10 Treatment Services Availability of Oral surgery procedures 2 SI/OB Trauma Including Vehicular Accidents , Fracture Wiring
ME A1.14 Services are available for the time OT Services are available 24X7 2 SI/RR
period as mandated
The facility provides Accident & Availability of Emergency OT services Check the number of emergency surgeries conducted in last 3
ME A1.16 Emergency Services as and even when required 2 SI/OB months

Standard A2 Facility provides RMNCHA Services

ME A2.4 The facility provides Child health Availability of Paediatric surgical 2 SI/OB Developmental Dysplasia of
Services Procedure under RBSK the Hip, Congenital Cataract, cleft lip and palate
Standard A3 Facility Provides diagnostic Services

ME A3.1 The facility provides Radiology Availability of portable x-ray machine 2 SI/OB Check availability of functional C arm for 300 and above beds
Services
The facility Provides Laboratory Availability of point of care diagnostic
ME A3.2 2 SI/OB Blood gas analyser& USG
Services test
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ME Statement Checkpoint Means of Verification Remarks
No. Method

Standard A4 Facility provides services as mandated in national Health Programs/ state scheme

The facility provides services under

ME A4.3 National Leprosy Eradication Availability of Reconstructive Surgery 2 SI/OB Reconstruction of hand (tendon repair), polio surgery
Programme as per guidelines
Availability of Amputation Surgery 2 SI/OB
Area of Concern - B Patient Rights
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities

ME B1.1 The facility has uniform and user- Availability of departmental & 2 OB Numbering, main department and internal sectional signage are
friendly signage system directional signages played
Signage for restricted area are 2 OB
displayed
Zones of OT are marked 2 OB
The facility displays the services and
ME B1.2 entitlements available in its Information regarding services are 2 OB Display doctor/ Nurse on duty and updated OT schedule
displayed displayed
departments
OT schedule displayed 2 OB
Information is available in local Signage's and information are
ME B1.6 language and easy to understand available in local language 2 OB

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, economic, cultural or social reasons.

ME B2.1 Services are provided in manner that Availability

doctor
of female staff if a male
examination/ conduct surgery 2 OB/SI Availability of female staff in pre and post operative room
are sensitive to gender of a female patients
Access to facility is provided without Availability of Wheel chair or stretcher
ME B2.3 any physical barrier & and friendly to 1 OB
for easy Access to the OT
people with disabilities
Availability of ramps with railing 2 OB At least 120 cm width, gradient not steeper than 1:12

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

ME B3.1 Adequate visual privacy is provided at Availability of screen between OT 2 OB

every point of care table
Patients are properly draped/covered
before and after produce 2 OB

Confidentiality of patients records Patient Records are kept at secure

ME B3.2 and clinical information is maintained place beyond access to general 2 SI/OB
staff/visitors
No information regarding patient
identity and details are unnecessary 2 SI/OB
displayed

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
The facility ensures the behaviours of
ME B3.3 staff is dignified and respectful, while Behaviour of staff is empathetic and 2 PI/OB
courteous
delivering the services
The facility ensures privacy and
confidentiality to every patient, Privacy and Confidentiality of HIV
ME B3.4 especially of those conditions having 2 SI/OB
cases
social stigma, and also safeguards
vulnerable groups
Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it is required.

There is established procedures for Consent is taken before major

ME B4.1 taking informed consent before surgeries 2 SI/RR
treatment and procedures
Anaesthesia Consent for OT 2 SI/RR
Information about the treatment is Patient attendant is informed about
ME B4.4 shared with patients or attendants, clinical condition and treatment been 2 PI/SI
regularly provided

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.
The facility provides cashless services
ME B5.1 to pregnant women, mothers and Free medicines and consumables are 2 PI/SI JSSK
neonates as per prevalent available
government schemes
All surgical procedure are free of cost 2 PI/SI PMJAY beneficiaries/ state scheme etc
as per entitlements
The facility ensures that drugs Check that patient party has not
ME B5.2 prescribed are available at Pharmacy spent on purchasing drugs or 2 PI/SI
and wards consumables from outside.
It is ensured that facilities for the Check that patient party has not
ME B5.3 prescribed investigations are spent on diagnostics from outside. 2 PI/SI
available at the facility
The facility provide free of cost
ME B5.4 treatment to Below poverty line Surgical services are free for BPL 2 PI/SI/RR
patients without administrative patients
hassles
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms

Departments have adequate space as Adequate space for accommodating

ME C1.1 per patient or work load surgical load 1 OB

Availability of OT for elective major

2 OB 100-200 -1OT, 200-300-2, 300-400 -3
surgeries
Availability of OT for Emergency 2 OB Emergency OT 1
surgeries
Availability of OT ophthalmic/ENT 2 OB Ophthalmic/ENT- 1

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ME Statement Checkpoint Means of Verification Remarks
No. Method
Waiting area for attendants 2 OB
ME C1.2 Patient amenities are provide as per Functional toilets with running water 2 OB In the OT waiting area for patient relatives/ in the vicinity of OT
patient load and flush are available
Availability of drinking water 2 OB Check for availability of Hot water facility
Availability of seating arrangement 2 OB
Departments have layout and
ME C1.3 demarcated areas as per functions Demarcated of Protective Zone 2 OB

Demarcated Clean Zone 2 OB

Demarcated sterile Zone 2 OB
Demarcated disposal Zone 1 OB
Availability of Changing Rooms 2 OB
Availability of Pre & post Operative
Room 1 OB
Availability of Scrub Area 2 OB
Availability of Autoclave room/ TSSU 2 OB
Availability of dirty utility area 1 OB
Availability of store 2 OB
The facility has adequate circulation Corridors are wide enough for
ME C1.4 area and open spaces according to movement of trolleys 1 OB 2-3 meters
need and local law
The facility has infrastructure for
ME C1.5 intramural and extramural Availability of functional telephone 2 OB
communication and Intercom Services

Service counters are available as per Hydraulic OT Tables

ME C1.6 patient load OT tables are available as per load 2 OB As per case load at least two for 100 - 200 bedded DH and 4 for
More than 200 beds
The facility and departments are
planned to ensure structure follows Unidirectional flow of goods and
ME C1.7 the function/processes (Structure services 1 OB No cris cross of infectious and sterile goods
commensurate with the function of
the hospital)
Standard C2 The facility ensures the physical safety of the infrastructure.

Check for fixtures and furniture like cupboards, cabinets, and

ME C2.1 The facility ensures the seismic safety Non structural components are 1 OB heavy equipment , hanging objects are properly fastened and
of the infrastructure properly secured secured

The facility ensures safety of OT does not have temporary

ME C2.3 2 OB
electrical establishment connections and loosely hanging wires

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ME Statement Checkpoint Means of Verification Remarks
No. Method
Adequate electrical socket provided
for safe and smooth operation of 2 OB Power boards are marked as per phase to which it belongs
equipment
Availability of three phase electricity
supply 2 OB

OT has mechanism for periodical

check / test of all electrical installation 2 OB
by competent electrical Engineer

Wall mounted digital display is

available in OT to show earth to 1 OB
neutral voltage
Quality output of voltage stabilizer is
displayed in each stabilizer as per 2 OB
manufacturer guideline
Physical condition of buildings are Floors of the ward are non slippery
ME C2.4 safe for providing patient care and even 2 OB

Walls and floor of the OT covered 1 OB

with joint less tiles
Windows/ ventilators if any in the OT 2 OB
are intact and sealed

Standard C3 The facility has established Programme for fire safety and other disaster
OT has sufficient fire exit to permit
ME C3.1 The facility has plan for prevention of safe escape to its occupant at time of 2 OB/SI
fire fire
Check the fire exits are clearly visible
and routes to reach exit are clearly 2 OB
marked.
The facility has adequate fire fighting OT room has installed fire
ME C3.2 Equipment Extinguisher that is Class A , Class B, C 2 OB
type or ABC type
Check the expiry date for fire
extinguishers are displayed on each 2 OB/RR
extinguisher as well as due date for
next refilling is clearly mentioned

The facility has a system of periodic Check for staff competencies' for
ME C3.3 training of staff and conducts mock operating fire extinguisher and what 2 SI/RR
drills regularly for fire and other
disaster situation to do in case of fire

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

The facility has adequate specialist

ME C4.1 Availability of Obg & Gynae Surgeon 2 OB/RR As per case load
doctors as per service provision
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ME Statement Checkpoint Means of Verification Remarks
No. Method
Availability of general surgeon 2 OB/RR As per case load
Availability of Orthopaedic Surgeon 2 OB/RR As per case load
Availability of ophthalmic surgeon 2 OB/RR As per case load
Availability of ENT surgeon 2 OB/RR As per case load
Availability of anaesthetist 2 OB/RR As per case load
The facility has adequate nursing
ME C4.3 staff as per service provision and Availability of Nursing staff 2 OB/RR/SI As per patient load , at least two
work load
The facility has adequate
ME C4.4 technicians/paramedics as per Availability of OT technician 2 OB/SI
requirement
The facility has adequate support /
ME C4.5 general staff Availability of OT attendant/assistant 2 SI/RR
Availability CSSD/ TSSU Asstt. 2 SI/RR
Availability of Security staff 1 SI/RR
Standard C5 Facility provides drugs and consumables required for assured list of services.

The departments have availability of

ME C5.1 adequate drugs at point of use Availability of Medical gases 2 OB/RR Availability of Oxygen Cylinders / Piped Gas supply, Nitrogen
Availability of Anti-Infective medicines 2 OB/RR Inj. Ampillicin, Inj. metronidazole Inj. Gentamycin,
- Antibiotics, Antifungal
Availability of Antihypertensive 2 OB/RR Injectable preparations
medicines
Availability of analgesics and 2 OB/RR Tab Paracetamol, Ibuprofen, Inj. Diclofenac, Sodium plasma
antipyretics expender
Availability of Solutions Correcting
Water, Electrolyte Disturbances and 2 OB/RR IV fluids, Normal saline, Ringer lactate,
Acid-Base Disturbances
As per the State's EML - Topical agents: Lignocaine, Xylocaine
Availability of anaesthetic agents 2 OB/RR Inhaled agents: Halothane, Nitrous oxide.
Injectable: Barbiturates (Thiopental, Thiamylal,
methohexital, Benzodiazepines)
Availability of other medicines 2 Tab B complex, Inj. Betamethasone, Inj. Hydralazine,
Methyldopa, HIV drugs
Inj. Magnesium sulphate 50%, Inj. Calcium Gluconate 10%, Inj.
Dexamethasone, Inj. Hydrocortisone Succinate, Inj. Diazepam,
Availability of emergency drugs 2 OB/RR Inj. Pheniramine maleate, Inj Corboprost, Inj. Pentazocine, Inj.
Promethazine, Betamethason, Inj. Hydrazaline, Nifedipine,
Methyldopa, Ceftriaxone

ME C5.2 The departments have adequate Availability of dressings and Sanitary 2 OB/RR
consumables at point of use pads
Availability of syringes and IV Sets 2 OB/RR
Availability of Antiseptic Solutions 2 OB/RR Ethyl Alcohol, Povidone Iodine Solution
Availability of consumables for new 2 OB/RR
born care
Availability of personal protective 2 OB/RR
equipment
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Emergency drug trays are maintained
ME C5.3 at every point of care, where ever it Emergency drug tray is maintained in
OT in pre and post operative room 2 OB/RR
may be needed

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

Availability of equipment & Availability of functional Equipment BP apparatus, Thermometer, Pulse Oxy meter, Multiparameter ,
ME C6.1 instruments for examination & &Instruments for examination & 2 OB
PV Set
monitoring of patients Monitoring

Availability of equipment & Diathermy (Unit and Bi Polar), Proctoscopy set, general Surgical
instruments for treatment Availability of functional General
ME C6.2 procedures, being undertaken in the surgery equipment 2 OB Instruments for Piles, Fistula, & Fissures. Surgical set for Hernia &
Hydrocele, Cautery
facility

Availability of functional orthopaedic C arm, check OT table is C arm compatible, Thomas Splint, IM
surgery equipment 2 OB Nailing Set, SP Nailing, Compression Plating Kit, Dislocation Hip
Screw Fixation
Availability of Ophthalmic surgery Operating Microscope, IOL Operation Set, Ophthalmoscope
equipment 2 OB Keratometer, A Scan Biometer
Availability of functional ENT surgery Operating Microscope, ENT Operation set, Mastoid Set,
2 OB
equipment Tracheotomy set, Microdrill System set
Operation Table with Trendelenburg
facility 2 OB

Availability of equipment &

instruments for diagnostic Availability of Point of care diagnostic Portable X-Ray Machine, Glucometer, HIV rapid diagnostic kit,
ME C6.3 procedures being undertaken in the instruments 1 OB USG and Blood gas analyser
facility

Availability of equipment and

ME C6.4 instruments for resuscitation of Availability of functional Instruments 2 OB Ambu bag, Oxygen, Suction machine , laryngoscope scope,
patients and for providing intensive Resuscitation Defibrillator (Paediatric and adult) , LMA, ET Tube
and critical care to patients

Availability of functional anaesthesia 2 OB Boyles apparatus, Bains Circuit or Soda lime absorbent in close
equipment circuit

ME C6.5 Availability of Equipment for Storage Availability

for drugs
of equipment for storage 2 OB Refrigerator, Crash cart/Drug trolley, instrument trolley, dressing
trolley
Availability of equipment for storage
of sterilized items 2 OB Instrument cabinet and racks for storage of sterile items

ME C6.6 Availability of functional equipment Availability of equipment for cleaning 2 OB Buckets for mopping, Separate mops for patient care area and
and instruments for support services circulation area duster, waste trolley, Deck brush

Availability of equipment for

CSSD/TSSU 2 OB Autoclave Horizontal & Vertical, Steriliser Big & Small
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Departments have patient furniture Shadow less Major & Minor, Ceiling and Stand Model, Focus
ME C6.7 and fixtures as per load and service Availability of functional OT light 2 OB
Lamp
provision
Availability of attachment/
accessories with OT table 2 OB Hospital graded mattress , IVstand, Bed pan

Trey for monitors, Electrical panel for anaesthesia machine,

Availability of Fixtures 2 OB cardiac monitor etc, panel with outlet for Oxygen and vacuum, X
ray view box.
Availability of furniture 2 OB Cupboard, table for preparation of medicines, chair, racks,

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

Criteria for Competence assessment Check parameters for assessing skills Check objective checklist has been prepared for assessing
ME C7.1 are defined for clinical and Para and proficiency of clinical staff has 2 SI/RR competence of doctors, nurses and paramedical staff based on
clinical staff been defined job description defined for each cadre of staff.

Competence assessment of Clinical

Check for records of competence assessment including filled
ME C7.2 and Para clinical staff is done on Check for competence assessment is 2 SI/RR checklist, scoring and grading . Verify with staff for actual
predefined criteria at least once in a done at least once in a year competence assessment done
year

The Staff is provided training as per

ME C7.9 defined core competencies and Advance Life support 2 SI/RR ALS and CPR by recognized agency to all category of staff.
training plan
OT scheduling, maintenance, Fumigation, Surveillance,
OT Management 2 SI/RR equipment-operation and maintenance, infection control,
surgical procedures and emergency protocols.
Infection control & prevention 2 SI/RR Bio medical Waste Management including Hand Hygiene
training
Training on processing/sterilization of 2 SI/RR
equipment
Patient Safety 2 SI/RR Assessment, action planning, PDCA, 5S & use of checklist
Training on Quality Management 2 SI/RR To all category of staff. At the time of induction and once in a
System year.
There is established procedure for
ME C7.10 utilization of skills gained thought Staff is skilled for resuscitation and 2 SI/RR
trainings by on -job supportive intubation
supervision
Nursing Staff is skilled for maintaining 2 SI/RR
clinical records
Staff is Skilled to operate OT 2 SI/RR
equipment
Staff is skilled for processing and 2 SI/RR
packing instrument

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Area of Concern - D Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

The facility has established system All equipment are covered under AMC 1. Check with AMC records/
ME D1.1 1 SI/RR Warranty documents
for maintenance of critical Equipment including preventive maintenance 2. Staff is aware of the list of equipment covered under AMC.

(1) Check log book is maintained & it shows time taken to repair
There is system of timely corrective equipment.
break down maintenance of the 2 SI/RR (2) Backup of critical equipment
(3) Check staff is aware of Contact details of the agencies/
equipment
person responsible for maintenance

There has system to label

Defective/Out of order equipment 2 OB/RR
and stored appropriately until it has
been repaired
Staff is skilled for trouble shooting in 2 SI/RR
case equipment malfunction
Periodic cleaning, inspection and
maintenance of the equipment is 2 SI/RR
done by the operator

The facility has established procedure All the measuring equipment/

ME D1.2 for internal and external calibration instrument are calibrated 1 OB/ RR Boyles apparatus, cautery, BP apparatus, autoclave etc.
of measuring Equipment

There is system to label/ code the

equipment to indicate status of 2 OB/ RR
calibration/ verification when
recalibration is due

Operating and maintenance Up to date instructions for operation

ME D1.3 instructions are available with the and maintenance of equipment are 2 OB/SI
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

There is established procedure for Stock level are daily updated

ME D2.1 forecasting and indenting drugs and There is established system of timely
indenting of consumables and drugs 2 SI/RR Indent are timely placed
consumables

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Check drugs and consumables are kept at allocated space in

Drugs are stored in Crash cart/ Drug trolleys and are labelled. Labelled with drug
The facility ensures proper storage of
ME D2.3 containers/tray/crash cart and are 2 OB name, drug strength and expiry date. Look alike and sound alike
drugs and consumables labelled drugs are kept separately from their identical one in look or
sound.

Empty and filled cylinders are Flow meter , humidifier, key & updated data sheet is available
2 OB
labelled with in use cylinders

The facility ensures management of Expiry dates' are maintained at Records for expiry and near expiry drugs are maintained for
ME D2.4 expiry and near expiry drugs emergency drug tray 2 OB/RR emergency tray FIRST EXPIRY and FIRST OUT
(FEFO) is in practice

No expired drug found 2 OB/RR Check drug sub store & emergency tray
Records for expiry and near expiry Records for expiry and near expiry drugs are maintained for drug
drugs are maintained for drug stored 2 RR stored at department FIRST
at department EXPIRY and FIRST OUT (FEFO) is in practice
The facility has established procedure There is practice of calculating and Minimum stock and reorder level are calculated based on
ME D2.5 for inventory management maintaining buffer stock 2 SI/RR consumption
techniques Minimum buffer stock is maintained all the time
Department maintained stock register Check record of drug received, issued and balance stock in hand
2 RR/SI
of drugs and consumables and are maintained
Drugs are categorized in Vital,
2 OB/RR Check all Vital drugs are available
Essential and Desirable
There is a procedure for periodically
ME D2.6 replenishing the drugs in patient care There is procedure for replenishing 2 SI/RR
areas drug tray /crash cart Procedure for replenishing drug in place

There is no stock out of drugs 2 OB/SI Random stock check of some drugs
Check for refrigerator/ILR temperature charts. Charts are
There is process for storage of Temperature of refrigerators are kept
ME D2.7 vaccines and other drugs, requiring as per storage requirement and 2 OB/RR maintained and updated twice a day. Refrigerators meant for
storing drugs should not be used for storing other items such as
controlled temperature records twice a day are maintained eatables.
There is a procedure for secure Narcotic and psychotropic drugs are Separate prescription for narcotic and psychotropic drugs by a
ME D2.8 storage of narcotic and psychotropic 2 OB/SI
drugs kept in lock and key registered medical practioner
Anaesthetic agents are kept at secure
2 OB/SI
place

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

The facility provides adequate

ME D3.1 illumination level at patient care Adequate Illumination at OT table 2 OB 100000 lux
areas
Adequate Illumination at pre
2 OB
operative and post operative area
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ME D3.2 The facility has provision of Entry to OT is restricted 2 OB

restriction of visitors in patient areas

Warning light is provided outside OT

and its been used when OT is 2 OB/SI
functional
The facility ensures safe and
ME D3.3 comfortable environment for Temperature is maintained and 2 SI/RR 20-25OC, ICU has functional room thermometer and
record of same is kept temperature is regularly maintained
patients and service providers
Humidity is maintained at desirable
level 2 SI/RR 50-60%

Positive pressure is maintained in OT 2 SI/RR

ME D3.4 The facility has security system in Security arrangement at OT 0 OB

place at patient care areas

The facility has established measure

ME D3.5 Female staff feel secure at work place 2 SI
for safety and security of female staff

Standard D4 The facility has established Programme for maintenance and upkeep of the facility

Exterior of the facility building is Building is painted/whitewashed in

ME D4.1 maintained appropriately uniform colour 2 OB

Interior of patient care areas are 2 OB

plastered & painted

Patient care areas are clean and Floors, walls, roof, roof topes, sinks
ME D4.2 patient care and circulation areas are 2 OB All area are clean with no dirt,grease,littering and cobwebs
hygienic Clean
Surface of furniture and fixtures are 2 OB
clean
Toilets are clean with functional flush
and running water 2 OB

Hospital infrastructure is adequately Check for there is no seepage , Cracks,

ME D4.3 2 OB
maintained chipping of plaster
Window panes , doors and other 2 OB
fixtures are intact

OT Table are intact and without rust 2 OB Check Mattresses are intact and clean

The facility has policy of removal of No condemned/Junk material in the

ME D4.5 2 OB
condemned junk material OT

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The facility has established
ME D4.6 procedures for pest, rodent and No pests are noticed 2 OB
animal control

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

The facility has adequate Availability of 24x7 running and

ME D5.1 arrangement storage and supply for potable water 2 OB/SI
portable water in all functional areas

Availability of Hot water supply 2 OB/SI

The facility ensures adequate power
ME D5.2 backup in all patient care areas as per Availability of power back up in OT 1 OB/SI 2 tier backup with UPS
load
Availability of UPS 1 OB/SI
Availability of Emergency light 2 OB/SI
Critical areas of the facility ensures Availability of Centralized /local piped
ME D5.3 availability of oxygen, medical gases Oxygen, nitrogen and vacuum supply 2 OB
and vacuum supply
Standard D7 The facility ensures clean linen to the patients

OT has facility to provide sufficient

ME D7.1 The facility has adequate sets of linen and clean linen for surgical patient 2 OB/RR Drape, draw sheet, cut sheet and gown

OT has facility to provide linen for 2 OB/RR

staff
Availability of Blankets, draw sheet,
pillow with pillow cover and 2 OB/RR
mackintosh
The facility has established
ME D7.2 procedures for changing of linen in Linen is changed after each procedure 2 OB/RR
patient care areas

The facility has standard procedures There is system to check the

ME D7.3 for handling , collection, cleanliness and Quantity of the linen 2 SI/RR
transportation and washing of linen received from laundry

Check dedicated closed bin is kept for Check linen is kept closed bin & emptied regularly. Plastic bag is
storage of dirty linen 2 OB used in dustbin & these bags are sealed before removed &
handed over
Standard Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
D11

The facility has established job Job description is defined and

ME D11.1 description as per govt guidelines communicated to all concerned staff 2 RR Regular + contractual

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Staff is aware of their role and 2 SI
responsibilities

The facility has a established There is procedure to ensure that Check for system for recording time of reporting and relieving
ME D11.2 procedure for duty roster and staff is available on duty as per duty 2 RR/SI (Attendance register/ Biometrics etc)
deputation to different departments roster

There is designated in charge for

department 2 SI

The facility ensures the adherence to

dress code as mandated by its Doctor, nursing staff and support staff
ME D11.3 administration / the health adhere to their respective dress code 2 OB
department

Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
There is established system for There is procedure to monitor the Verification of outsourced services (cleaning/
ME D12.1 contract management for out quality and adequacy of outsourced 2 SI/RR
Dietary/Laundry/Security/Maintenance) provided are done by
sourced services services on regular basis designated in-house staff
Area of Concern - E Clinical Services
Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.

ME E2.1 There is established procedure for There is procedure for Pre Operative 2 RR/SI Physical examination, results of lab investigation, diagnosis and
initial assessment of patients assessment proposed surgery

There is established procedure to

plan and deliver appropriate
ME E2.3 treatment or care to individual as per Check care is delivered by competent
multidisciplinary team 2 SI/RR Check care plan is prepared and delivered as per direction of
qualified physician
the needs to achieve best possible
results

Check treatment / care plan is The care plan include:, investigation to be conducted,
2 RR intervention to be provided, goals to achieve, timeframe, patient
documented education, discharge plan etc

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral

Facility has established procedure for

ME E3.1 continuity of care during There is procedure of handing over & 2 SI/RR form OT to ward and ICU/HDU
receiving patient
interdepartmental transfer
There is a procedure for consultation
of the patient to other specialist with 2 RR/SI
in the hospital

ME E3.3 A person is identified for care during Duty Doctor and nurse is assigned for 2 RR/SI
all steps of care each patients

Standard E4 The facility has defined and established procedures for nursing care

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Procedure for identification of There is a process for ensuring the

ME E4.1 patient's identification before any 2 OB/SI Patient id band/ verbal confirmation etc.
patients is established at the facility
clinical procedure

Procedure for ensuring timely and

accurate nursing care as per There is a process to ensue the (1) Check system is in place to give telephonic orders & practised
ME E4.2 2 SI/RR
treatment plan is established at the accuracy of verbal/telephonic orders (2) Verbal orders are verified by the ordering physician within
facility defined time period

There is established procedure of

Patient hand over is given during the
ME E4.3 patient hand over, whenever staff change in the shift 2 SI/RR
duty change happens
Nursing Handover register is 2 RR
maintained
There is procedure for periodic Patient Vitals are monitored and
ME E4.5 monitoring of patients recorded periodically 2 RR/SI Check for use of cardiac monitor/multi parameter

Standard E5 Facility has a procedure to identify high risk and vulnerable patients.

The facility identifies vulnerable Vulnerable patients are identified and Check the measure taken to prevent new born theft, sweeping
ME E5.1 patients and ensure their safe care measures are taken to protect them 2 OB/SI and baby fall
from any harm
The facility identifies high risk
ME E5.2 patients and ensure their care, as per High risk patients are identified and
treatment given on priority 2 OB/SI HIV, Infectious cases
their need

Standard E6 Facility ensures rationale prescribing and use of medicines

ME E6.1 Facility ensured that drugs are Check for BHT if drugs are prescribed 2 RR
prescribed in generic name only under generic name only

ME E6.2 There is procedure of rational use of Check staff is aware of the drug 2 SI/RR Check BHT that drugs are prescribed as per STG
drugs regime and doses as per STG
Availability of drug formulary 2 SI/OB
Patient's name, prescription details and medical history is taken
before surgery.
There are procedures defined for Complete medication history is Check complete medication history including over-the- counter
ME E6.3 2 RR/OB
medication review and optimization documented for each patient medicines is taken and documented

Medicine are reviewed and optimised

2 SI/RR Medicines are optimised as per individual treatment plan for the
as per individual treatment plan best possible clinical outcome"

Standard E7 Facility has defined procedures for safe drug administration

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There is process for identifying and High alert drugs available in Electrolytes like Potassium chloride, Opioids, Neuro muscular
ME E7.1 cautious administration of high alert 2 SI/OB blocking agent, Anti thrombolytic agent, insulin, warfarin,
department are identified
drugs (to check) Heparin, Adrenergic agonist etc. as applicable
Maximum dose of high alert drugs are Value for maximum doses as per age, weight and diagnosis are
defined and communicated 2 SI/RR available with nursing station and doctor
There is process to ensure that right A system of independent double check before administration,
doses of high alert drugs are only 2 SI/RR Error prone medical abbreviations are avoided
given
Every Medical advice and procedure is
Medication orders are written legibly
ME E7.2 and adequately accompanied with date , time and 2 RR
signature
Check for the writing, It 2 RR/SI
comprehendible by the clinical staff
Drugs are checked for expiry and
There is a procedure to check drug
ME E7.3 before administration/ dispensing other inconsistency before 2 OB/SI
administration

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

Check for separate sterile needle is 2 OB

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

Any adverse drug reaction is recorded

2 RR/SI Adverse drug event trigger tool is used to report the events
and reported

Administration of medicines done after ensuring right patient,

ME E7.4 There is a system to ensure right Check Nursing staff is aware 7 Rs of 2 SI/RR right drugs, right route, right time, Right dose, Right Reason and
medicine is given to right patient Medication and follows them
Right Documentation

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage

All the assessments, re-assessment Records of Monitoring/ Assessments

ME E8.1 and investigations are recorded and 2 RR PAC, Intraoperative monitoring
updated are maintained

All treatment plan

ME E8.2 prescription/orders are recorded in Treatment plan, first orders are 2 RR Treatment prescribed in nursing records (Manually/e-records)
written on BHT
the patient records.

Name of person in attendance during procedure, Pre and post

ME E8.4 Procedures performed are written on Operative Notes are Recorded 2 RR operative diagnosis, Procedures carried out, length of
patients records procedures, estimated blood loss, Fluid administered, specimen
removed, complications etc. (Manually/e-records)
Anaesthesia Notes are Recorded 2 RR (Manually/e-records)
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ME E8.5 Adequate form and formats are Standard Formats available 2 RR/OB Consents, surgical safety check list
available at point of use
Register/records are maintained as Registers and records are maintained OT Register, Schedule, Infection control records, autoclaving
ME E8.6 per guidelines as per guidelines 2 RR records etc
All register/records are identified and
2 RR
numbered
The facility ensures safe and
ME E8.7 adequate storage and retrieval of Safe keeping of patient records 2 RR
medical records
Standard
The facility has defined and established procedures for Emergency Services and Disaster Management
E11
The facility has disaster management
ME E11.3 Staff is aware of disaster plan 2 SI/RR
plan in place
Role and responsibilities of staff in 2 SI/RR
disaster is defined
Standard The facility has defined and established procedures of diagnostic services
E12

ME E12.1 There are established procedures for Container is labelled properly after 2 OB
Pre-testing Activities the sample collection
There are established procedures for OT is provided with the critical value
ME E12.3 Post-testing Activities of different test 2 SI/RR

Standard
E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.

ME E13.8 There is established procedure for Availability of blood units in case of 2 RR/SI The blood is ordered for the patient according to the MSBOS
issuing blood emergency with out replacement (Maximum Surgical Blood Order Schedule)

ME E13.9 There is established procedure for Consent is taken before transfusion 2 RR

transfusion of blood
Patient's identification is verified 2 SI/OB
before transfusion
blood is kept on optimum 2 RR
temperature before transfusion
Blood transfusion is monitored and
regulated by qualified person 2 SI/RR

Blood transfusion note is written in 2 RR

patient recorded
There is a established procedure for Any major or minor transfusion
ME E13.10 monitoring and reporting Transfusion reaction is recorded and reported to 2 RR
complication responsible person
Standard
Facility has established procedures for Anaesthetic Services
E14

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ME E14.1 Facility has established procedures There is procedure to ensure that PAC 2 RR/SI
for Pre Anaesthetic Check up has been done before surgery
There is procedure to review findings
of PAC 2 RR/SI

in emergency & life saving conditions, surgery may be started

Minimum PAC for emergency cases 2 RR/SI with General physical examination of the patient & sending the
sample for lab. Examination
Facility has established procedures Anaesthesia plan is documented
ME E14.2 for monitoring during anaesthesia before entering into OT 2 RR

Anaesthesia Safety Checklist is used

for safe administration of anaesthesia 1 RR Check use of WHO Anaesthesia Safety Checklist

Anaesthesia equipment are checked Sufficient reserve of gases. Vaporizers are connected,
before induction 2 RR Laryngoscope, ET tube and suction App are ready and clean
Food intake status of Patient is 2 RR/SI
checked
Patients vitals are recorded during 2 RR Heart rate , cardiac rate , BP, O2 Saturation,
anaesthesia
Airway security is ensured 2 RR/SI Breathing system is securely and correctly assembled
Potency and level of anaesthesia is 2 RR/SI
monitored
Anaesthesia note is recorded 2 RR Check for the adequacy
Any adverse Anaesthesia Event is 2 RR
recorded and reported

ME E14.3 Facility has established procedures Post anaesthesia status is monitored 2 RR/SI
for Post Anaesthesia care and documented
Standard Facility has defined and established procedures of Surgical Services
E15

ME E15.1 Facility has established procedures There is procedure OT Scheduling 2 RR/SI Schedule is prepared in consonance with available OT house and
OT Scheduling patients requirement

ME E15.2 Facility has established procedures Patient evaluation before surgery is 2 RR/SI Vitals , Patients fasting status etc.
for Preoperative care done and recorded
Antibiotic Prophylaxis given as 2 RR/SI
indicated
Tetanus Prophylaxis is given if 2 RR/SI
Indicated
There is a process to prevent wrong 2 RR/SI Surgical Site is marked before entering into OT
site and wrong surgery
Surgical site preparation is done as 2 RR/SI Cleaning , Asepsis and Draping
per protocol

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ME E15.3 Facility has established procedures Surgical Safety Check List is used for 2 RR/SI Check for Surgical safety check list has been used for surgical
for Surgical Safety each surgery procedures

Sponge and Instrument Count Instrument, needles and sponges are counted before beginning
Practice is implemented 2 RR/SI of case, before final closure and on completing of procedure

Adequate Haemostasis is secured 2 RR/SI Check for Cautery and suture legation practices
during surgery
Check for what kind of sutures used for different surgeries .
Appropriate suture material is used 2 RR/SI Braided Biological sutures are not used for dirty wounds, Catgut
for surgery as per requirement is not used for closing fascial layers of abdominal wounds or
where prolonged support is required
Check for suturing techniques are
applied as per protocol 2 RR/SI

Facility has established procedures Post operative monitoring is done Check for post operative operation ward is used and patients are
ME E15.4 for Post operative care before discharging to ward 2 RR/SI not immediately shifted to wards after surgery

Post operative notes and orders are Post operative notes contains Vital signs, Pain control, Rate and
recorded 2 RR/SI type of IV fluids, Urine and Gastrointestinal fluid output, other
medications and Laboratory investigations
Standard
E16 The facility has defined and established procedures for the management of death & bodies of deceased patients

Death of admitted patient is

ME E16.1 adequately recorded and Death note is written on patient 2 RR
communicated record

The facility has standard procedures Death note including efforts done for
ME E16.2 resuscitation is noted in patient 2 RR Includes both maternal and neonatal death
for handling the death in the hospital record

Death summary is given to patient

attendant quoting the immediate 2 RR/SI
cause and underlying cause if possible

Area of Concern - F Infection Control

Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

Facility has provision for Passive and Surface and environment samples are
ME F1.2 active culture surveillance of critical 2 SI/RR Swab are taken from infection prone surfaces
& high risk areas taken for microbiological surveillance

ME F1.3 Facility measures hospital associated There is procedure to report cases of 2 SI/RR Patients are observed for any sign and symptoms of HAI like
infection rates Hospital acquired infection fever, purulent discharge from surgical site .

There is Provision of Periodic Medical There is procedure for immunization

ME F1.4 Check-ups and immunization of staff of the staff 1 SI/RR Hepatitis B, Tetanus Toxoid etc

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Periodic medical check-up of the staff 2 SI/RR

Facility has established procedures

Regular monitoring of infection Hand washing and infection control audits done at periodic
ME F1.5 for regular monitoring of infection control practices 2 SI/RR intervals
control practices

ME F1.6 Facility has defined and established Check for 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

Hand washing facilities are provided Availability of hand washing Facility at

ME F2.1 at point of use Point of Use 2 OB Check for availability of wash basin near the point of use
Availability of running Water 2 OB/SI Ask to Open the tap. Ask Staff water supply is regular
Availability of antiseptic soap with
soap dish/ liquid antiseptic with 2 OB/SI Check for availability/ Ask staff if the supply is adequate and
dispenser. uninterrupted

Availability of Alcohol based Hand rub 2 OB/SI Check for availability/ Ask staff for regular supply.

Display of Hand washing Instruction at Prominently displayed above the hand washing facility ,
Point of Use 2 OB preferably in Local language
Availability of elbow operated taps 2 OB
Hand washing sink is wide and deep
enough to prevent splashing and 2 OB
retention of water
Staff is trained and adhere to
ME F2.2 standard hand washing practices Adherence to 6 steps of Hand washing 2 SI/OB Ask of demonstration

procedure should be repeated several times so that the scrub

Adherence to Surgical scrub method 2 SI/OB lasts for 3 to 5
minutes. The hands and forearms should be dried with a sterile
towel only.
Staff aware of when to hand wash 2 SI
Facility ensures standard practices
ME F2.3 Availability of Antiseptic Solutions 2 OB
and materials for antisepsis
Proper cleaning of procedure site 2 OB/SI like before giving IM/IV injection, drawing blood, putting
with antisepsis Intravenous and urinary catheter
Proper cleaning of perineal area 2 SI
before procedure with antisepsis
Check Shaving is not done during part
2 SI
preparation/delivery cases
Check sterile field is maintained Surgical site covered with sterile drapes, sterile instruments are
2 OB/SI
during surgery kept within the sterile field.

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method

Standard F3 Facility ensures standard practices and materials for Personal protection

Facility ensures adequate personal

ME F3.1 protection equipment as per Clean gloves are available at point of 2 OB/SI
use
requirements
Availability of Masks 2 OB/SI
Sterile s gloves are available at OT and
2 OB/SI
Critical areas
Use of elbow length gloves for
2 OB/SI
obstetrical purpose
Availability of gown/ Apron 2 OB/SI
Availability of Caps 2 OB/SI
Personal protective kit for infectious
2 OB/SI HIV kit
patients

ME F3.2 Staff is adhere to standard personal No reuse of disposable gloves, Masks, 2 OB/SI
protection practices caps and aprons.
Compliance to correct method of
wearing and removing the PPE 2 SI Gloves, Masks, Caps, Aprons

Standard F4 Facility has standard Procedures for processing of equipment and instruments
Facility ensures standard practices Ask staff about how they decontaminate the procedure surface
ME F4.1 and materials for decontamination Decontamination of operating & 2 SI/OB like OT Table, Stretcher/Trolleys etc.
and clean ing of instruments and Procedure surfaces (Wiping with 0.5% Chlorine solution
procedures areas

Proper Decontamination of Ask staff how they decontaminate the instruments like ambubag,
2 SI/OB suction canulae, Surgical Instruments
instruments after use (Soaking in 0.5% Chlorine Solution, Wiping with 0.5% Chlorine
Solution or 70% Alcohol as applicable

Contact time for decontamination is

2 SI/OB 10 minutes
adequate
Cleaning of instruments after 2 SI/OB Cleaning is done with detergent and running water after
decontamination decontamination
Proper handling of Soiled and infected 2 SI/OB No sorting ,Rinsing or sluicing at Point of use/ Patient care area
linen
Staff know how to make chlorine
solution 2 SI/OB

Facility ensures standard practices

Equipment and instruments are
ME F4.2 and materials for disinfection and sterilized after each use as per 2 OB/SI Autoclaving/HLD/Chemical Sterilization
sterilization of instruments and
requirement
equipment
High level Disinfection of
instruments/equipment is done as 2 OB/SI Ask staff about method and time required for boiling
per protocol Page 327
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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
Chemical sterilization of Ask staff about method, concentration and contact time
instruments/equipment is done as per 2 OB/SI
required for chemical sterilization
protocols
Formaldehyde or glutaraldehyde
solution replaced as per manufacturer 2 OB/SI
instructions
Autoclaved linen are used for
procedure 2 OB/SI

Autoclaved dressing material is used 2 OB/SI

Instruments are packed according for

2 OB/SI
autoclaving as per standard protocol
Autoclaving of instruments is done as
per protocols 2 OB/SI Ask staff about temperature, pressure and time
Regular validation of sterilization
through biological and chemical 2 OB/SI/RR
indicators
Maintenance of records of
sterilization 2 OB/SI/RR

There is a procedure to ensure the

traceability of sterilized packs 2 OB/SI/RR

Sterility of autoclaved packs is 2 OB/SI Sterile packs are kept in clean, dust free, moist free environment.
maintained during storage

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention

Layout of the department is Facility layout ensures separation of Faculty layout ensures separation of general traffic from patient
ME F5.1 conducive for the infection control general traffic from patient traffic 2 OB traffic
practices
Zoning of High risk areas 2 OB
Facility layout ensures separation of
routes for clean and dirty items 2 OB

Floors and wall surfaces of ICU are 2 OB

easily cleanable
CSSD/TSSU has demarcated separate
area for receiving dirty items,
processes, keeping clean and sterile 2 OB
items

Facility ensures availability of Availability of disinfectant as per

ME F5.2 standard materials for cleaning and requirement 2 OB/SI Chlorine solution, Glutaraldehyde, carbolic acid
disinfection of patient care areas

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
Availability of cleaning agent as per 2 OB/SI Hospital grade phenyl, disinfectant detergent solution
requirement
Facility ensures standard practices
ME F5.3 followed for cleaning and disinfection Staff is trained for spill management 2 SI/RR
of patient care areas
Cleaning of patient care area with 2 SI/RR
detergent solution

Staff is trained for preparing cleaning 2 SI/RR

solution as per standard procedure

Standard practice of mopping and

2 OB/SI
scrubbing are followed
Cleaning equipment like broom are
not used in patient care areas 2 OB/SI

Use of three bucket system for 2 OB/SI

mopping
Fumigation/carbolization as per 2 SI/RR
schedule
External footwares are restricted 2 OB
Isolation and barrier nursing
ME F5.4 Facility ensures segregation procedure are followed for septic 2 OB/SI
infectious patients cases

ME F5.5 Facility ensures air quality of high risk Positive Pressure in OT 2 OB/SI
area
Adequate air exchanges are
maintained 2 SI/RR

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

Availability of colour coded bins &

ME F6.1 Facility Ensures segregation of Bio Plastic bags at point of waste 2 OB Adequate number. Covered. Foot operated.
Medical Waste as per guidelines generation

Human Anatomical waste, Items contaminated with blood, body

Segregation of Anatomical and soiled 2 OB/SI fluids,dressings, plaster casts, cotton swabs and bags containing
waste in Yellow Bin residual or discarded blood and blood components.

Items such as tubing, bottles, intravenous tubes and sets,

Segregation of infected plastic waste 2 OB catheters, urine bags, syringes (without needles and fixed needle
in red bin syringes) and vacutainers' with their needles cut) and gloves

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
Display of work instructions for
segregation and handling of 2 OB Pictorial and in local language
Biomedical waste
There is no mixing of infectious and
general waste 2 OB

Availability of functional needle

ME F6.2 Facility ensures management of cutters & puncture proof, leak proof, 2 OB See if it has been used or just lying idle.
sharps as per guidelines temper proof white container for
segregation of sharps

Availability of post exposure Ask if available. Where it is stored and who is in charge of that.
prophylaxis & Protocols 2 OB/SI Also check PEP issuance register
Contaminated and broken Glass are Staff knows what to do in condition of needle stick injury
disposed in puncture proof and leak
2 OB Vials, slides and other broken infected glass
proof box/ container with Blue colour
Facility ensures transportation and marking
ME F6.3 disposal of waste as per guidelines Check bins are not overfilled 2 SI Not more than two-third.

Disinfection of liquid waste before

disposal 2 SI/OB Through Local Disinfection

Transportation of bio medical waste is 2 SI/OB

done in close container/trolley
Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to locate mercury beads
5. Use syringe without a needle/eyedropper and sticky tape to
suck the beads
6. Collection of beads in leak-proof bag or container
Staff aware of mercury spill
2 SI/RR 7. Sprinkle sulphur or zinc powder to remove any remaining
management
mercury
8. All the mercury spill surfaces should be decontaminated with
10% sodium thiosulfate solution
9. All the bags or containers containing items contaminated with
mercury should be marked as “Hazardous Waste, Handle with
Care”
10. Collected mercury waste should be handed over to the
CBMWTF
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for quality improvement

The facility has a quality team in Quality circle has been formed in the Check if quality circle formed and functional with a designated
ME G1.1 place OT 2 SI/RR nodal officer for quality

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method

There is system daily round by

Facility has established internal matron/hospital manager/ hospital
ME G3.1 quality assurance program at superintendent/ Hospital Manager/ 2 SI/RR Check for entries in Round Register
relevant departments Matron in charge for monitoring of
services

Facility has established external

ME G3.2 assurance programs at relevant 2
departments
Facility has established system for
Internal assessment is done at NQAS, Kayakalp, SaQushal tools are used to conduct internal
ME G3.3 use of check lists in different periodic interval 2 RR/SI assessment
departments and services
Departmental checklist are used for 2 SI/RR Staff is designated for filling and monitoring of these checklists
monitoring and quality assurance

Non-compliances are enumerated and

recorded 2 Check the non compliances are presented & discussed during
quality team meetings
Actions are planned to address gaps Check action plans are prepared and
ME G3.4 observed during quality assurance implemented as per internal 2 Randomly check the details of action, responsibility, time line and
process assessment record findings feedback mechanism
Planned actions are implemented Check PDCA or revalent quality Check actions have been taken to close the gap. It can be in form
ME G3.5 through Quality Improvement Cycles method is used to take corrective and 2 of action taken report or Quality Improvement (PDCA) project
(PDCA) preventive action report
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Standard operating procedure for

ME G4.1 Departmental standard operating department has been prepared and 2 RR
procedures are available
approved
Current version of SOP are available
with process owner 1 OB/RR

Work instruction/clinical protocols

2 OB processing and sterilization of equipment,
are displayed
Standard Operating Procedures Department has documented
ME G4.2 adequately describes process and procedure for scheduling the Surgery 2 RR
procedures and its booking
Department has documented
procedure for pre operative 2 RR
procedure, in-process check and post
operative care
Department has documented
procedure for pre operative 2 RR
anaesthetic check up

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
Department has documented
procedure for post operative care of 2 RR
the patient

Department has documented

procedure for operation theatre
asepsis and environment 2 RR
management
Department has documented 2 RR
procedure for OT documentation.

Department has documented

procedure for reception of dirt packs 2 RR
and issue of sterile packs from TSSU

Department has documented

procedure for maintenance and 2 RR
calibration of equipment
Department has documented
procedure for general cleaning of OT 2 RR
and annexes

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

Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

ME G5.1 Facility maps its critical processes Process mapping of critical processes 2 SI/RR
done
Facility identifies non value adding Non value adding activities are
ME G5.2 activities / waste / redundant 2 SI/RR
activities identified

Facility takes corrective action to Processes are rearranged as per

ME G5.3 2 SI/RR
improve the processes requirement
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
Check short term valid quality objectivities have been framed
Facility has de defined quality
ME G6.4 objectives to achieve mission and Check if SMART Quality Objectives 2 SI/RR addressing key quality issues in each department and cores
have framed services. Check if these objectives are Specific, Measurable,
quality policy Attainable, Relevant and Time Bound.

Mission, Values, Quality policy and Interview with staff for their awareness. Check if Mission
ME G6.5 objectives are effectively Check of staff is aware of Mission , 2 SI/RR Statement, Core Values and Quality Policy is displayed
communicated to staff and users of Values, Quality Policy and objectives
services prominently in local language at Key Points

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method

Review the records that action plan on quality objectives being

Facility periodically reviews the
Check time bound action plan is being reviewed at least once in month by departmental in charges and
ME G6.7 progress of strategic plan towards 2 SI/RR
mission, policy and objectives reviewed at regular time interval during the quality team meeting. The progress on quality
objectives have been recorded in Action Plan tracking sheet

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

Facility uses method for quality

ME G7.1 Basic quality improvement method 2 SI/OB PDCA & 5S
improvement in services

ME G7.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used in each department
improvement in services
Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan

Periodic assessment for Medication Check periodic assessment of Verify with the records. A comprehensive risk assessment of all
ME G9.6 and Patient care safety risks is done medication and patient care safety 2 SI/RR clinical processes should be done using pre define criteria at least
as per defined criteria. risk is done using defined checklist once in three month.
periodically

Periodic assessment for potential risk

regarding safety and security of staff SaQushal assessment toolkit is used 1. Check that the filled checklist and action taken report are
ME G9.7 including violence against service for safety audits. 2 SI/RR available
providers is done as per defined 2. Staff is aware of key gaps & closure status
criteria

Risks identified are analysed Identified risks are analysed for

ME G9.8 evaluated and rated for severity severity 2 SI/RR Action is taken to mitigate the risks

Standard
G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

Check parameter are defined & implemented to review the

The facility has established clinical care i.e. through Ward round, peer review, morbidity &
Clinical care assessment criteria have
ME G10.3 been defined and communicated procedures to review the clinical care 2 SI/RR mortality review, patient feedback, clinical audit & clinical
processes outcomes.

Check that the patient /family 2 SI/RR Feedback is taken from patient/family on health status of
participate in the care evalution individual under treatment
System in place to review internal referral process, review clinical
Check the care planning and co-
ordination is reviewed 0 SI/RR handover information, review patient understanding about their
progress

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method

Check medical audit records

(a) Completion of the medical records i.e. Medical history,
assessments, re assessment, investigations conducted, progress
Facility conducts the periodic clinical notes, interventions conducted, outcome of the case, patient
ME G10.4 audits including prescription, medical There is the procedure to conduct 2 SI/RR education, delineation of responsibilities, discharge etc.
and death audits surgical audits (b) Check whether treatment plan worked for the patient
(C) progress on the health status of the patient is mentioned
(d) whether the goals defined in treatment plan is met for the
individual cases
(e) Adverse clinical events are documented
(f) Re admission
(1) All the deaths are audited by the committee.
(2) The reasons of the death is clearly mentioned
(3) Data pertaining to deaths are collated and trend analysis is
There is procedure to conduct death 2 SI/RR done
audits (4) A through action taken report is prepared and presented in
clinical Governance Board meetings / during grand round
(wherever required)

All non compliance are enumerated 2 SI/RR Check the non compliances are presented & discussed during
and recorded for surgical audits clinical Governance meetings
All non-compliance are enumerated
2 SI/RR Check the non compliances are presented & discussed during
and recorded for death audits clinical Governance meetings
Clinical care audits data is analysed, Check action plans are prepared and
ME G10.5 and actions are taken to close the implemented as per surgical audit 2 SI/RR Randomly check the actual compliance with the actions taken
gaps identified during the audit reports of last 3 months
process record findings

Check action plans are prepared and Randomly check the actual compliance with the actions taken
implemented as per death audit 2 SI/RR
record's findings reports of last 3 months

Check the data of audit findings are 2 SI/RR Check collected data is analysed & areas for improvement is
collated identified & prioritised
Check PDCA or revalent quality Check the critical problems are regularly monitored & applicable
method is used to address critical 2 SI/RR solutions are duplicated in other departments (wherever
problems required) for process improvement
Facility ensures easy access and use Check standard treatment guidelines / Staff is aware of Standard treatment protocols/ guidelines/best
ME G10.7 of standard treatment guidelines & protocols are available & followed. 2 SI/RR practices
implementation tools at
point of care
Check treatment plan is prepared as Check staff adhere to clinical protocols while preparing the
2 SI/RR
per Standard treatment guidelines treatment plan
Check the drugs are prescribed as per Check the drugs prescribed are available in EML or part of drug
Standards treatment guidelines 2 SI/RR formulary
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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
Check the updated/latest evidence Check when the STG/protocols/evidences used in healthcare
2 SI/RR facility are published.
are available Whether the STG protocols are according to current evidences.
The gaps in clinical practices are identified & action are taken to
Check the mapping of existing clinical
practices processes is done 2 SI/RR improve it. Look for evidences for improvement in clinical
practices using PDCA

Area of Concern - H Outcome

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
Facility measures productivity No. of Major surgeries done per 1 lakh
ME H1.1 2 RR
Indicators on monthly basis population
No. of emergency surgeries done 2 RR
Proportion of other emergency
surgeries done in the night 2 RR
No. of elective surgeries performed 2 RR
CSSD/TSSU productivity index 2 RR No. of packs sterilized against the no. of surgeries
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark

ME H2.1 Facility measures efficiency Indicators Downtime critical equipment 2 RR

on monthly basis
Skin to skin time 2 RR
No of major surgeries per surgeon 2 RR
Proportion emergency surgeries 2 RR
Cycle time for instrument processing 2 RR

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

ME H3.1 Facility measures Clinical Care & Surgical Site infection Rate 2 RR No. of observed surgical site infections*100/total no. of Major
Safety Indicators on monthly basis surgeries

Proportion of cases with post surgical Complication grading using Clavien-Dindo scale.
2 All the cases with complication more than graded >2 on the
complications Clavien-Dindo scale

No of adverse events per thousand 2 RR

patients

Incidence of re-exploration of surgery 2 RR

% of environmental swab culture

reported positive 2 RR

Deaths occurred from pre operative procedure to discharge of

Perioperative Death Rate 2 RR
the patient

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Reference Compliance Assessment
ME Statement Checkpoint Means of Verification Remarks
No. Method
Proportion of General Anaesthesia to 2 RR
spinal anaesthesia
Proportion of PAC done out of total
elective surgeries 2 RR

No. of autoclave cycle failed in Bowie

2 RR
dick test out of total autoclave cycle

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

Facility measures Service Quality (a) No. of cancelled operation*1000 /total operation done
ME H4.1 Indicators on monthly basis Operation Cancellation rates 2 RR Planned operations cancelled due to any reason like clinical, non
clinical (theatre), or by patient
Average time taken to conduct the Time taken from presentation in emergency department to non-
2 RR
emergency surgery elective surgery conducted

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National Quality Assurance Standards

Checklist for Maternity Operation Theatre

Assessment Summary
Name of the Hospital GHQH Erode Date of Assessment
Names of Assessors [Link], Valarmathi S/N Names of Assesses
Type of Assessment (Internal/External) Internal Action plan Submission Date
Operation Theatre Score Card
Area of Concern wise Score Operation Theatre Score
A Service Provision 89%
B Patient Rights 77%
C Inputs 76%
D Support Services 73%
E
F
Clinical Services
Infection Control
86%
83%
82%
G Quality Management 84%
H Outcome 96%

Major Gaps Observed

1 Narcotic ,psychotropic & Anaesthetic agents are kept in lock and key
2 Availability of functional needle cutters & puncture proof, leak proof, temper proof white container for segregation of sharps
3 Hand washing sink is wide and deep enough to prevent splashing and retention of water
4 Cleaning equipment's like broom are not used in patient care areas
5 All the measuring equipment/ instrument are calibrated
Strengths / Good Practices
1
2
3
4
5
Recommendations/ Opportunities for Improvement
1
2
3
4
5
Signature of Assessors
Date

Compliance
Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Area of Concern - A Service Provision

Standard A1 Facility Provides Curative Services

Services are available for the time period OT Services are available 24X7 Check with OT records that OT services were
ME A1.14 2 SI/RR functional in 24X7 and surgeries are being
as mandated conducted in night hours

ME A1.16
The facility provides Accident & Availability of Emergency OT services
1 SI/OB
Emergency Services as and when required

ME A1.17
The facility provides Intensive care Availability of Maternity HDU/ICU
1 SI/OB
Services services in the facility

Standard A2 Facility provides RMNCHA Services

ME A2.1
The facility provides Reproductive health Availability of Post partum sterilization 2 SI/OB tubal ligation
Services services

ME A2.2
The facility provides Maternal health Availability of Elective C-section
2 SI/RR Check services are available and are being utilized
Services services
Availability of Emergency C-section
2 SI/RR Check services are available and are being utilized
services
Management of MTP 2 SI/OB Surgical management

ME A2.3
The facility provides New-born health Availability of New born
2 SI/OB
Dedicated Functional New born Care services in
Services resuscitation& essential new born care Operation theatre

Standard A3 Facility Provides diagnostic Services

Availability of point of care diagnostic

ME A3.2 The facility Provides Laboratory Services test
2 SI/OB Glucometer, RDK , Blood grouping

Area of Concern - B Patient Rights

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities

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Compliance
Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Numbering, main department and internal sectional

ME B1.1
The facility has uniform and user-friendly Availability of departmental & 1 OB
signage, Restricted area signage displayed.
signage system directional signages Directional signages are given from the entry of the
facility

ME B1.2
The facility displays the services and Information regarding services are
1 OB
Display doctor/ Nurse on duty and updated OT
entitlements available in its departments displayed schedule displayed

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, economic, cultural or soc

Access to facility is provided without any Availability of Wheel chair or stretcher for easy
ME B2.3 physical barrier & and friendly to people OT is easily accessible 2 OB Access. Door is wide enough for passage of trolley
with disabilities and staff.

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

ME B3.1
Adequate visual privacy is provided at Patients are properly draped/covered
1 OB
Look patients are covered while transferred from
every point of care before and after procedure ward to OT and vice-versa.

Preferably only one OT table should be placed in

Visual Privacy is maintained between theatre, if it is not possible because of high case load
2 OB
two OT Tables adequate visual privacy should be provided through
screens of multiple patients are present in same OT

Confidentiality of patients records and Patient Records are kept at secure

ME B3.2 place beyond access to general 1 SI/OB In drawers/Amirah; preferably with lock facility.
clinical information is maintained staff/visitors
The facility ensures the behaviour of staff Check that OT staff is not providing care in
Behaviour of OT staff is dignified and
ME B3.3 is dignified and respectful, while respectful
2 OB/PI undignified manner such as yelling, scolding ,
delivering the services shouting, blaming and using abusive language

The facility ensures privacy and

ME B3.4
confidentiality to every patient, especially Pregnant women is not left
unattended or ignored during care in 1 OB/PI
Check that care providers are attentive and
empathetic to the pregnant women at no point of
of those conditions having social stigma, the OT care they are left alone.
and also safeguards vulnerable groups

Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it i

There is established procedures for taking written consent with details of the procedure with
ME B4.1 informed consent before treatment and Consent is taken for surgical
procedures
2 SI/RR potentials risks and complication. Should be signed
procedures by patient/next of kin and one witness

written consent with details of the anaesthesia with

Separate consent is taken for
2 SI/RR potentials risks and complication. Should be signed
Anaesthesia procedure
by patient/next of kin and one witness

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.

The facility provides cashless services to

ME B5.1 pregnant women, mothers and neonates All surgical procedure are free of cost
for JSSK beneficiaries
2 PI/SI free drugs, consumables , blood, referral etc.
as per prevalent government schemes

Area of Concern - C Inputs

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

ME C1.1
Departments have adequate space as per Adequate space for accommodating 1 OB
OT around 40 Square meter. Two OT tables are not
patient or work load surgical load kept in one OT

ME C1.3
Departments have layout and Demarcated Protective Zone 1 OB
Reception, waiting area, stretcher/Trolley bay, Pre
demarcated areas as per functions and post operative rooms,
Doctor's and Nurse's room, Anaesthesia room,
Demarcated Clean Zone 2 OB
equipment room, emergency exit.

Demarcated sterile Zone 2 OB Operating room, Scrub station, Anaesthesia station,

Demarcated disposal Zone 2 OB Disposal corridor, janitor closet

Availability of Changing Rooms 1 OB Separate for male and females

Availability of demarcated Pre & post

1 OB Can be in a single room with a partition.
Operative Room /area
Functional warmer, resuscitation apparatus,
Availability of earmarked area for new
2 OB suction/mucous extractor, O2 cylinder, weighing
born Corner
scale and sterile gloves.

Height around 96 cm with elbow taps/sensors, both

hot and cold water available. Sink is deep and wide
Availability of Scrub Area 1 OB
enough to avoid spoiling. Scrub area should not be
inside the OT room.

Dedicated areas with provision of Washing,

Availability of TSSU /CSSD 2 OB
Packing , Autoclaving the instruments and linen

Availability of store 1 OB

The facility has adequate circulation area

ME C1.4 and open spaces according to need and Corridors are wide enough for
movement of trolleys
2 OB 7 to 10 feet.
local law
The facility has infrastructure for Intercom should connects Operation theatre to key
Availability of functional telephone
ME C1.5 intramural and extramural and Intercom Services
2 OB areas like ICU, Blood Bank, SNCU, Lab, Accident and
communication emergency, wards, Administration

ME C1.6
Service counters are available as per OT tables are available as per load 2 OB
Hydraulic OT Tables
patient load As per case load at least two

The facility and departments are planned

to ensure structure follows the Services are designed in a way, that there is no criss
Unidirectional flow of goods and
ME C1.7 function/processes (Structure services
2 OB cross in moment of sterile & no sterile supplies &
commensurate with the function of the equipment etc.
hospital)

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Compliance
Reference No. ME Statement Checkpoint Assessment Method Means of Verification

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

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

ME C2.3
The facility ensures safety of electrical OT does not have temporary
1 OB No extension cord or multi-plugs
establishment connections and loosely hanging wires

Check electricity bill or Power Distribution Board.

Availability of three phase electricity
2 SI/OB Meter have three wires coming out (with one
supply
neutral).

ME C2.4
Physical condition of buildings are safe Walls and floor of the OT covered with
1 OB made of anti-skid & Epoxy flooring
for providing patient care joint less tiles

Windows/ ventilators if any in the OT

1 OB No broken glass, gap or cracks in window/ventilator.
are intact and sealed

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

OT has sufficient fire exit to permit

Check the fire exits are clearly visible and routes to
ME C3.1 The facility has plan for prevention of fire safe escape to its occupant at time of 2 OB/SI
reach exit are clearly marked
fire

Class A , Class B, C type or ABC type. Check the

The facility has adequate fire fighting Labour room has installed fire
expiry date for fire extinguishers are displayed on
ME C3.2 Extinguishers & expiry is displayed on 2 OB
Equipment each fire extinguisher
each extinguisher as well as due date for next
refilling is clearly mentioned

The facility has a system of periodic

ME C3.3
training of staff and conducts mock drills Check for staff competencies for
operating fire extinguisher and what 1 SI/RR
staff should be able to demonstrate how to open
the extinguisher and operate it. PASS (Pull the pin,
regularly for fire and other disaster to do in case of fire Aim at the base of fire, Sway from side to side)
situation

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

ME C4.1
The facility has adequate specialist Availability of Obs. & Gynae Surgeon 2 OB/RR
100 beds 2, 200 beds-3, 3oo beds-4, 400 beds-5 and
doctors as per service provision 500 beds-6
Availability of anaesthetist 2 OB/RR At least One

ME C4.3
The facility has adequate nursing staff as Availability of Nursing staff 2 OB/RR/SI As per patient load , at least two
per service provision and work load
The facility has adequate
ME C4.4 technicians/paramedics as per Availability of OT technician 1 OB/SI One per shift.
requirement

ME C4.5
The facility has adequate support / Availability of OT attendant/assistant
1 SI/RR 1 each
general staff & TSSU assistant

Standard C5 Facility provides drugs and consumables required for assured list of services.

ME C5.1
The departments have availability of Availability of medical gases 2 OB/RR
Availability of Oxygen, nitrogen Cylinders / Piped
adequate drugs at point of use Gas supply.
Availability of drugs for local
1 OB/RR Procaine, lignocaine, bupivacaine, Xylocaine jelly
anaesthesia

Inhaled agents-Halothane, nitrous oxide. Injectable:

Barbiturates (Theopental, Thiamylal, methohexital,
Availability of drugs for general Benzodiazepines (diazepam, Lorazepam,
1 OB/RR
anaesthesia Midazolam), Ketamine, Etomidate, Propofol .
Neostigmine, Naloxone, Flumazenil, Sugammadex-as
per EDL/State guidelines.

Fentanyl, Sufentanil, Morphine, Buprenorphine,

Availability of opioid analgesics. 1 OB/RR Levorphanol, Methadone-As per EDL/State
guidelines.
Succinylcholine, Vecuronium, Mivacurlum,
Availability of muscle relaxants drugs 2 OB/RR
Tubocarine as per EDL/state guidelines

Inj Magsulf 50%, Inj Calcium gluconate 10%, Inj

Dexamethasone, inj Hydrocortisone, Succinate, Inj
Availability of emergency drugs 1 OB/RR diazepam, inj Pheneramine maleate, inj Corboprost,
Inj Fortwin, Inj Phenergen, Betameathazon, Inj
Hydrazaline, Nefidepin, Methyldopa,ceftriaxone

Antibiotics, Analgesics, Uterotonic drugs, IV fluids

Availability of other drugs 2 OB/RR and anithypertensive drugs as per EDL/ state
guidelines

ME C5.2
The departments have adequate Availability of dressings Material 2 OB/RR
Adequate quantity of sterile pads, gauze, bandages ,
consumables at point of use Antiseptic Solution.
Availability of syringes and IV Sets 2 OB/RR In adequate quantity as per load.
Cord Clamp, mucous sucker, airway, NG Tube,
Availability of consumables for new
2 OB/RR Suction catheter, IV cannula, paed IV set and Bag
born care
and Mask (0 & 1 no.)
Emergency drug trays are maintained at Every tray is labelled with name and number of
ME C5.3 every point of care, where ever it may be Emergency drug tray is maintained in
OT in pre and post operative room
2 OB/RR drugs and consumables along with their date of
needed expiry.

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

Availability of functional Equipment

Availability of equipment & instruments BP apparatus, Thermometer, Pulse Oxy meter,
ME C6.1 &Instruments for examination & 1 OB
for examination & monitoring of patients Multiparameter , PV Set, torch & wall clock.
Monitoring

Availability of equipment & instruments

Availability of functional instruments LSCS Set, Cervical Biopsy Set, Proctoscopy Set,
ME C6.2 for treatment procedures, being for Gynae and obstetrics
2 OB
Hysterectomy set, D&C Set
undertaken in the facility

Radiant warmer, Baby tray with Two pre warmed

Availability of functional equipment/ towels/sheets for wrapping the baby, mucus
2 OB
Instruments for New Born Care extractor, bag and mask (0 &1 no.), sterilized thread
for cord/cord clamp, nasogastric tube

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Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Availability of functional General

2 OB Diathermy (Unit and Bi Polar), Cautery
surgery equipments
Operation Table with Trendelenburg OT Table hydraulic major and OT table hydraulic
2 OB
type minor
Availability of equipment & instruments
Availability of Point of care Glucometer, HIV rapid diagnostic kit, USG, ABG
ME C6.3 for diagnostic procedures being 1 OB
diagnostic instruments machine
undertaken in the facility

Availability of equipment and instruments

for resuscitation of patients and for Resuscitation bag (Adult & paediatrics) Ambu bag,
Availability of functional Instruments
ME C6.4 2 OB Oxygen, Suction machine , laryngoscope scope,
providing intensive and critical care to Resuscitation for new born & Mother
Defibrillator (Paediatric and adult) , LMA, ET Tube
patients
Boyles apparatus, Bains Circuit or Soda lime
Availability of functional anaesthesia
1 OB absorbent in close circuit ,AGSS (Anaesthesia gas
equipment
scavenging system)

Availability of equipment for Refrigerator, Crash cart/Drug trolley, instrument

ME C6.5 Availability of Equipment for Storage storage of drugs & Instruments
1 OB trolley, dressing trolley, Instrument cabinet and
racks for storage of sterile items

Availability of functional equipment and Availability of equipments for Three Bucket system for mopping, Separate mops
ME C6.6 2 OB for patient care area and circulation area duster,
instruments for support services cleaning waste trolley, Deck brush
Autoclave Horizontal & Vertical, Steriliser Big &
Availability of equipment for TSSU 1 OB
Small

ME C6.7
Departments have patient furniture and Availability of functional OT light 2 OB
Shadow less Major & Minor, Ceiling and Stand
fixtures as per load and service provision Model, Focus Lamp

Tray for monitors, Electrical panel for anaesthesia

machine with minimum 6 electrical sockets ( 2= 15
Availability of Fixtures 2 OB
amp power point), panel with outlet for Oxygen and
vacuum, X ray view box.

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

Check objective checklist has been prepared for

Check parameters for assessing skills
Criteria for Competence assessment are assessing competence of doctors, nurses and
ME C7.1 and proficiency of clinical staff has 1 SI/RR
defined for clinical and Para clinical staff paramedical staff based on job description defined
been defined
for each cadre of staff.

Competence assessment of Clinical and Para Check for records of competence assessment
Check for competence assessment is
ME C7.2 clinical staff is done on predefined criteria at 1 SI/RR including filled checklist, scoring and grading . Verify
done at least once in a year
least once in a year with staff for actual competence assessment done

The Staff is provided training as per defined ALS and CPR by recognized agency to all category of
ME C7.9 Advance Life support 1 SI/RR
core competencies and training plan staff.
OT scheduling, maintenance, Fumigation,
Surveillance, equipment-operation and
Training on OT Management 1 SI/RR
maintenance, infection control, surgical procedures
and emergency protocols.

Biomedical Waste Management&

To all category of staff. At the time of induction and
Infection control and hand 1 SI/RR
once in a year.
hygiene ,Patient safety
Assessment, action planning, PDCA, 5S & use of
Training on Quality Management 1 SI/RR
checklist
Area of Concern - D Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

ME D1.1
The facility has established system for All equipment are covered under AMC
1 SI/RR
look for MOU and visit records of the empanelled
maintenance of critical Equipment including preventive maintenance agency.

There is system of timely corrective Back up for critical equipment. Label Defective/Out
break down maintenance of the 2 SI/RR of order equipment and stored appropriately until it
equipment has been repaired
Staff is skilled for cleaning, inspection
E.g. when to change water of batteries, when to oil,
& trouble shooting in case equipment 2 SI/RR
change fuse, replace filters etc.
malfunction

The facility has established procedure for Boyles apparatus, cautery, BP apparatus, autoclave
All the measuring equipment/ etc. There is system to label/ code the equipment to
ME D1.2 internal and external calibration of instrument are calibrated
0 OB/ RR
indicate status of calibration/ verification when
measuring Equipment recalibration is due

ME D1.3
Operating and maintenance instructions Up to date instructions for operation
and maintenance of equipment are 2 OB/SI
If operator doesn't understand English, then
are available with the users of equipment readily available with staff. instructions should be in local language.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas

There is established procedure for Stock level are daily updated

There is established system of timely
ME D2.1 forecasting and indenting drugs and indenting of consumables and drugs
2 SI/RR Requisition are timely placed
consumables

ME D2.3
The facility ensures proper storage of Drugs are stored in
2 OB
Away from direct sunlight and temperature is
drugs and consumables containers/tray/crash cart are labelled maintained as per instructions of manufacturer.

Empty and filled cylinders are labelled Each cylinder is provided with a checklist & flow
2 OB
& kept separately meter and key for opening the cylinder

The facility ensures management of Records for expiry and near expiry drugs are
Expiry dates' are maintained at
ME D2.4 2 OB/RR maintained for drug stored at department. No
expiry and near expiry drugs emergency drug tray
expired drugs found

At least one week of minimum buffer stock is

ME D2.5
The facility has established procedure for There is practice of calculating and 1 SI/RR
maintained all the time in the labour room.
inventory management techniques maintaining buffer stock Minimum stock and reorder level are calculated
based on consumption in a week accordingly

Department maintained stock and

expenditure register of drugs and 2 RR/SI Check that records are regularly updated
consumables

There is a procedure for periodically There is procedure for replenishing

ME D2.6 2 SI/RR There is no stock out of drugs
replenishing the drugs in patient care areas drug tray /crash cart

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Reference No. ME Statement Checkpoint Assessment Method Means of Verification

There is process for storage of vaccines Temperature of refrigerators are kept

Check for temperature charts are maintained and
ME D2.7 and other drugs, requiring controlled as per storage requirement and 2 OB/RR
updated periodically
temperature records are maintained

ME D2.8
There is a procedure for secure storage of Narcotic ,psychotropic & Anaesthetic 0 OB/SI Under direct supervision of anaesthetist
narcotic and psychotropic drugs agents are kept in lock and key

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

ME D3.1
The facility provides adequate Adequate Illumination at OT table 2 OB 100000 lux
illumination level at patient care areas

ME D3.2
The facility has provision of restriction of Warning light outside the OT is 2 OB/SI
Only persons required in OT are allowed to enter the
visitors in patient areas switched on when OT is functional OT

The facility ensures safe and comfortable 20-25OC, ICU has functional room thermometer and
Temperature & humidity is maintained
ME D3.3 environment for patients and service and record of same is kept
2 SI/RR temperature is regularly maintained. 50-60%
providers humidity

ME D3.4
The facility has security system in place at Security arrangement at OT 0 OB Restricted Signage, security guard, CCTV camera
patient care areas

Standard D4 The facility has established Programme for maintenance and upkeep of the facility

Exterior of the facility building is Department is painted/whitewashed

ME D4.1 in uniform colour &plastered & 1 OB Painted in soothing colours Not bright colours.
maintained appropriately painted
Floors, walls, roof, roof tops, sinks
All area are clean with no dirt,grease,littering and
ME D4.2 Patient care areas are clean and hygienic patient care and circulation areas are 1 OB
cobwebs
Clean

Surface of furniture and fixtures are Look for dirt above OT light, behind stationary
1 OB
clean equipment etc.

ME D4.3
Hospital infrastructure is adequately Check for there is no seepage , Cracks,
1 OB check corners, false ceiling.
maintained chipping of plaster

OT Table are intact and without rust 1 OB Mattresses are intact and clean

No slabs, almirah, storing unnecessary items like

drums, equipment, Instruments etc Items not
No unnecessary items in sterile zone 1
required for immediate procedures are kept out of
sterile zone

ME D4.5
The facility has policy of removal of No condemned/Junk material in the
0 OB No partial compliance.
condemned junk material OT

ME D4.6
The facility has established procedures No stray animal/rodent/birds 2 OB
Check for no stray animal in and around OT. Also no
for pest, rodent and animal control lizard, cockroach, mosquito, flies, rats etc.

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

The facility has adequate arrangement

ME D5.1 storage and supply for portable water in Availability
potable water
of 24x7 running and
2 OB/SI Availability of Hot water supply
all functional areas
The facility ensures adequate power
ME D5.2 backup in all patient care areas as per Availability of power back up in OT 1 OB/SI 2 tier backup with UPS
load

Availability of UPS & Emergency light 2 OB/SI Check their functionality.

Critical areas of the facility ensures

Availability of Centralized /local piped Cylinders are provided with trolleys to prevent fall
ME D5.3 availability of oxygen, medical gases and 2 OB
Oxygen, nitrogen and vacuum supply and injuries.
vacuum supply

Standard D7 The facility ensures clean linen to the patients

OT has facility to provide sufficient and

ME D7.1 The facility has adequate sets of linen clean linen for surgical patient
1 OB/RR Drape, draw sheet, cut sheet and gown

OT has facility to provide linen for staff 1 OB/RR OT dress, gown. Separate OT dress for OT staff.

ME D7.2
The facility has established procedures Linen is changed after each procedure 2 OB/RR Bed sheets, draw sheets and Macintosh.
for changing of linen in patient care areas

The facility has standard procedures for There is system to check the
OT tech/Nurse checks Number of linen, cleanliness,
ME D7.3 handling , collection, transportation and cleanliness and Quantity of the linen 2 SI/RR
whether it is turned or stained
washing of linen received from laundry

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

The facility ensures the adherence to

Doctor, nursing staff and support staff
ME D11.3 dress code as mandated by its adhere to their respective dress code
2 OB Check staff is wearing dress as per their dress code.
administration / the health department

Area of Concern - E Clinical Services

Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.

ME E2.1
There is established procedure for initial There is procedure for Pre Operative 2 RR/SI
Physical examination, results of lab investigation, X-
assessment of patients assessment Rays, diagnosis and proposed surgery

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Reference No. ME Statement Checkpoint Assessment Method Means of Verification

There is established procedure to plan

and deliver appropriate treatment or care Check care is delivered by competent Check care plan is prepared and delivered as per
ME E2.3 1 SI/RR
to individual as per the needs to achieve multidisciplinary team direction of qualified physician
best possible results

Care plan include:, investigation to be conducted,

Check treatment / care plan is
1 RR intervention to be provided, goals to achieve,
documented
timeframe, patient education, , discharge plan etc

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral

Facility has established procedure for There is procedure of handing over

ME E3.1 continuity of care during from OT to Maternity Ward, HDU and 1 SI/RR Transfer Register is maintained.
interdepartmental transfer SNCU

Standard E4 The facility has defined and established procedures for nursing care

ME E4.1
Procedure for identification of patients is There is a process for ensuring the
patient's identification before any 2 OB/SI
Patient id band/ verbal confirmation etc. At least
established at the facility clinical procedure
two identifiers are used.

There is established procedure of patient

ME E4.3 hand over, whenever staff duty change Patient hand over is given during the
change in the shift
2 SI/RR Handover register is maintained
happens

ME E4.5
There is procedure for periodic Patient Vitals are monitored and 2 RR/SI Check for use of cardiac monitor/multi parameter
monitoring of patients recorded periodically

Standard E5 Facility has a procedure to identify high risk and vulnerable patients.

Vulnerable patients are identified and

The facility identifies vulnerable patients and Check the measure taken to prevent new born theft,
ME E5.1 measures are taken to protect them 1 OB/SI
ensure their safe care sweeping of baby or fall
from any harm

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

Standard E6 Facility ensures rationale prescribing and use of medicines

Facility ensured that drugs are prescribed in Check for Case Sheet if drugs are
ME E6.1 1 RR Check at least 5 case sheets selected randomly
generic name only prescribed under generic name only
Check staff is aware of the drug regime Check if drugs are prescribed as per STG in at least 5
ME E6.2 There is procedure of rational use of drugs 2 SI/RR
and doses as per STG case sheets selected randomly

Check Case Sheet that drugs are Check if drugs are prescribed as per STG in at least 5
1 RR
prescribed as per STG case sheets selected randomly

There are procedures defined for medication Complete medication history is Check complete medication history including over-
ME E6.3 1 RR/OB
review and optimization documented for each patient the- counter medicines is taken and documented

Medicine are reviewed and optimised Medicines are optimised as per individual treatment
1 SI/RR
as per individual treatment plan plan for best possible clinical outcome

Standard E7 Facility has defined procedures for safe drug administration

There is process for identifying and Electrolytes like Potassium chloride, Opioids, Neuro
High alert drugs available in muscular blocking agent, Anti thrombolytic agent,
ME E7.1 cautious administration of high alert department are identified
2 SI/OB
insulin, warfarin, Heparin, Adrenergic agonist etc. as
drugs (to check) applicable

Value for maximum doses as per age, weight and

Maximum dose of high alert drugs are
diagnosis are available with nursing station and
defined and communicated & there is
2 SI/RR doctor. A system of independent double check
process to ensure that right doses of
before administration, Error prone medical
high alert drugs are only given
abbreviations are avoided

Every Medical advice and

Medication orders are written legibly and Look for pre-op, Procedure and Post op notes and
ME E7.2 procedure is accompanied with 1 RR
adequately instructions.
date , time and signature

Check for the writing, It Ask OT/Ward staff to read the orders written by
2 RR/SI
comprehendible by the clinical staff doctor.

Drugs are checked for expiry and Check for any open single dose vial with left over
There is a procedure to check drug before
ME E7.3 other inconsistency before 2 OB/SI content intended to be used later on. In multi dose
administration/ dispensing vial needle is not left in the septum
administration

Any adverse drug reaction is recorded Adverse drug event trigger tool is used to report the
1 RR/SI
and reported events, Check for ADR forms and records.

There is a system to ensure right Administration of medicines done after ensuring

Check Nursing staff is aware 7 Rs of
ME E7.4 2 SI/RR right patient, right drugs , right route, right time,
medicine is given to right patient Medication and follows them
Right dose , Right Reason and Right Documentation

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage

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Reference No. ME Statement Checkpoint Assessment Method Means of Verification

ME E8.1
All the assessments, re-assessment and Records of Monitoring/ Assessments 2 RR PAC, Intraoperative monitoring
investigations are recorded and updated are maintained

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

Name of person in attendance during procedure, Pre

Procedures performed are written on and post operative diagnosis, Procedures carried
ME E8.4 Operative Notes are Recorded 1 RR out, length of procedures, estimated blood loss,
patients records Fluid administered, specimen removed,
complications etc.

notes includes Anaesthesia type, induction, airway,

Anaesthesia Notes are Recorded 2 RR intubation, inhalation agents, epidural, spinal,
allergies, IV lines, IV fluids, regional block.

ME E8.5
Adequate form and formats are available Standard Formats are available 1 RR/OB
Consent forms, Anaesthesia form, surgical safety
at point of use check list

ME E8.6
Register/records are maintained as per Registers and records are maintained
1 RR
OT Register, Schedule, Infection control records,
guidelines as per guidelines autoclaving records etc

All register/records are identified and

2 RR Register are labelled and numbered.
numbered

ME E8.7
The facility ensures safe and adequate Safe keeping of patient records 2 RR
Records are kept in place without seepage,
storage and retrieval of medical records moisture, termite, pests.

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management

ME E11.3
The facility has disaster management plan Staff is aware of disaster plan & their
role and responsibilities of staff is 1 SI/RR Ask role of staff in case of disaster.
in place defined

Standard E12 The facility has defined and established procedures of diagnostic services

ME E12.1
There are established procedures for Container is labelled properly after
2 OB
Including Specimen for HPE & biopsy. Name, Age,
Pre-testing Activities the sample collection Sex, date, UHID

ME E12.3
There are established procedures for OT is provided with the critical value of
2 SI/RR Critical values are displayed.
Post-testing Activities different test

Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.

ME E13.8
There is established procedure for issuing Availability of blood units in case of 1 RR/SI
The blood is ordered for the patient according to the
blood emergency with out replacement MSBOS (Maximum Surgical Blood Order Schedule)

ME E13.9
There is established procedure for Consent is taken before transfusion 2 RR Duly signed by patient/next of kin
transfusion of blood
Patient's identification is verified
2 SI/OB At least two identifiers are used.
before transfusion

blood is kept on optimum temperature before

Protocol of blood transfusion is
2 RR transfusion. Blood transfusion is monitored and
monitored & regulated
regulated by qualified person

There is a established procedure for Any major or minor transfusion

After transfusion, Reaction form is returned back to
ME E13.10 monitoring and reporting Transfusion reaction is recorded and reported to 2 RR
blood bank, even when there is no reaction.
complication responsible person

Standard E14 Facility has established procedures for Anaesthetic Services

ME E14.1
Facility has established procedures for There is procedure to ensure that PAC
2 RR/SI There is procedure to review findings of PAC
Pre Anaesthetic Check up has been done before surgery

in emergency & life saving conditions, surgery may

Minimum PAC for emergency cases 1 RR/SI be started with General physical examination of the
patient & sending the sample for lab. Examination

Type of anaesthesia
ME E14.2
Facility has established procedures for Anaesthesia plan is documented
2 RR
planned-local/general/spinal/epidural. Time is
monitoring during anaesthesia before starting surgery mentioned on all entries of anaesthesia monitoring
sheet

Anaesthesia Safety Checklist is used

2 RR Check use of WHO Anaesthesia Safety Checklist
for safe administration of anaesthesia

Sufficient reserve of gases. Vaporizers are

Anaesthesia equipment are checked
2 RR connected, Laryngoscope, ET tube and suction App
before induction
are ready and clean

Food intake status of Patient is

2 RR/SI Time of last food intake is mentioned
checked

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Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Patients vitals are recorded during Heart rate , cardiac rate , BP, O2 Saturation,
2 RR
anaesthesia temperature, Respiration rate.

Breathing system of anaesthesia equipment that

Airway security is ensured 2 RR/SI delivers gas to the patient is securely and correctly
assembled and breathing circuits are clean

Potency and level of anaesthesia is

2 RR/SI Recorded in the Anaesthesia Record Form.
monitored

Check for the adequacy, signed, complete, and post

Anaesthesia note is recorded 2 RR
anaesthesia instructions.

Reduced level of consciousness, reparatory

Any adverse Anaesthesia Event is depression, malignant hyperpyrexia, bone marrow
1 RR
recorded and reported depression, life threatening pressure effect,
anaphylaxis

ME E14.3
Facility has established procedures for Post anaesthesia status is monitored
2 RR/SI
Check for anaesthetic notes & post operating
Post Anaesthesia care and documented instructions in post operative room & area

Standard E15 Facility has defined and established procedures of Surgical Services

Facility has established procedures OT Surgery list is prepared in consonance with

List of Elective Surgeries for the day is
ME E15.1 1 RR/SI availability of the OT hours and patients
Scheduling prepared and displayed outside OT.
requirement.

Day, date and time of surgeries.

Name, Age, Gender of patients.
Clear description of the procedure ( name of
Surgery list is complete in all respect 2 OB/SI
procedure which side, )
Name of the surgeon & anaesthetist.
Major or minor case.

Operation list is sent to OT well in

2 RR/SI By 12:00 hours, a day before the surgery.
advance

Surgery list is informed to surgeon and

1 RR/SI Verify the surgery register/email
ward sister.

The operation list does not exceed the This does not refer to the time during an operation
1 RR/SI
time allocated to it. of an individual patient

ME E15.2
Facility has established procedures for Patient evaluation before surgery is
2 RR/SI Vitals , Patients fasting status etc.
Preoperative care done and recorded
Antibiotic Prophylaxis and Tetanus
2 RR/SI As per instructions of surgeon/anaesthetist.
given as indicated

Surgeries planned under local

anaesthesia/Regional Block sensitivity 2 RR/SI lidocaine sensitivity test
test is done

There is a process to prevent wrong

1 RR/SI Surgical Site is marked before entering into OT
site and wrong surgery

No shaving of the surgical site 2 SI/RR Only clipping on the day of surgery in OT is done

Skin preparation before surgery is Bathing with soap and water prior to surgery in
2 SI/RR
done. ward.

Prepare the skin with antiseptic solution

(Chlorhexidine gluconate and iodine), starting in the
Skin preparation is done as per
2 RR/SI centre and moving out to the periphery. This area
protocol
should be large enough to include the entire incision
and an adjacent working area.

Scrub, gown and glove before covering the patient

with sterile drapes. Leave uncovered only the
Draping is done as per protocol 2 SI/OB
operative field and those areas necessary for the
maintenance of anaesthesia.

ME E15.3
Facility has established procedures for Surgical Safety Check List is used for
2 RR/SI
Check for Surgical safety check list has been used for
Surgical Safety each surgery surgical procedures

Instrument, needles and sponges are counted

Sponge and Instrument Count Practice
2 RR/SI before beginning of case, before final closure and on
is implemented
completing of procedure & documented

Adequate Haemostasis is secured Check for functional Cautery, use of artery forceps
2 RR/SI
during surgery and suture ligation techniques

For closing abdominal wall or ligating blood vessel

use non-absorbable sutures (braided suture, nylon,
polyester etc). absorbable sutures in urinary tract.
Appropriate suture material is used for
2 RR/SI Braided Biological sutures are not used for dirty
surgery as per requirement
wounds, Catgut is not used for closing fascial layers
of abdominal wounds or where prolonged support is
required

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Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Braided sutures for interrupted stiches. Absorbable

Check for suturing techniques are
2 RR/SI and non-absorbable monofilament sutures for
applied as per protocol
continuous stiches.

Facility has established procedures for Check for post operative operation room /area is
Post operative monitoring is done
ME E15.4 2 RR/SI used and patients are not immediately shifted to
Post operative care before discharging to ward
wards after surgery

Post operative notes contains Vital signs, Pain

Post operative notes and orders are control, Rate and type of IV fluids, Urine and
1 RR/SI
recorded Gastrointestinal fluid output, other medications and
Laboratory investigations

Information & instructions are given to

nursing staff before shifting the 2 RR/SI Instructions given by surgeon and anaesthetist.
patient to the ward from the OT

Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients

The facility has standard procedures for Includes both maternal and neonatal death. Death
Death note including efforts done for
ME E16.2 2 RR summary is given to patient attendant quoting the
handling the death in the hospital resuscitation is noted in patient record
immediate cause and underlying cause if possible

Standard E18 Facility has established procedures for Intranatal care as per guidelines

Facility staff adheres to standard procedures Wipes the baby with a clean pre-
Check staff competence through demonstration or
ME 18.3 for routine care of new-born immediately warmed towel and wraps baby in 2 SI/OB
case observation
after birth second pre-warmed towel;

Performs delayed cord clamping and Check staff competence through demonstration or
2 SI/OB
cutting (1-3 min); case observation

Initiates breast-feeding soon after Check staff competence through demonstration or

2 SI/OB
birth case observation

Records birth weight and gives Check staff competence through demonstration or
1 SI/OB
injection vitamin K case observation

There is an established procedure for Check for Haemoglobin level is estimated , and
Pre operative care and part arrangement of Blood, Catheterization,
ME E18.4 assisted and C-section deliveries per preparation
2 SI/RR
Administration of Antacids Proper cleaning of
scope of services. perineal area before procedure with antisepsis

Check Both General and Spinal Anaesthesia Options

Proper selection Anaesthesia are available. Ask for what are the criteria for using
2 SI/RR
technique spinal and GA. Regional block and epidural
anaesthesia used wherever required/indicated

Check for measures taken to prevent Supine

Hypotension (Use of pillow/Sandbag to tilt the
Intraoperative care 2 SI/RR uterus), Technique for Incision, Opening of Uterus,
Delivery of Foetus and placenta, and closing of
Uterine Incision

Frequent monitoring of vitals, Strict IO charting, Flat

Post operative care 2 SI/RR bed without pillow for SA, NPO depending on type
of anaesthesia and surgery.

Facility staff adheres to standard

protocols for identification and Ask for how to secure airway and breathing, Loading
ME 18.5 Management of PIH/Eclampsia 2 SI/RR and Maintenance dose of Magnesium sulphate ,
management of Pre Eclampsia / Administration of anti Hypertensive Drugs
Eclampsia

Facility staff adheres to standard IV fluids, parental oxytocin and antibiotics, manual
ME 18.6 protocols for identification and Postpartum Haemorrhage 2 SI/RR removal of placenta, blood transfusion, B-lynch
management of PPH. suturing, surgery

Put patient in left lateral position, maintain Airway,

Ruptured Uterus 2 SI/RR breathing and circulation, IV Fluid, antibiotics,
urgent laparotomy and hysterectomy.
Facility staff adheres to standard
Provides ART for seropositive
ME 18.7 protocols for Management of HIV in mothers/ links with ART centre
2 SI/RR Check case records and Interview of staff
Pregnant Woman & Newborn
Provides syrup Nevirapine to new-
1 SI/RR Check case records and Interview of staff
borns of HIV seropositive mothers
There is Established protocol for new-
Ask Nursing staff to demonstrate Resuscitation
ME 18.10 born resuscitation is followed at the New born Resuscitation 2 SI/RR
Technique
facility.

Standard E19 Facility has established procedures for postnatal care as per guidelines

Facility staff adheres to protocol for

Skin contact, Kangaroo mother care, radiant
ME E19.1 assessment of condition of mother and baby Prevention of Hypothermia 2 SI/RR
warmer, warm clothes.
and providing adequate postpartum care

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Compliance
Reference No. ME Statement Checkpoint Assessment Method Means of Verification
Facility staff adheres to protocol for
Initiation of Breastfeeding with in 1 Shall be initiated as early as possible and exclusive
ME E19.2 counselling on danger signs, post-partum 1 PI/SI
Hour breast feeding
family planning and exclusive breast feeding
The facility ensure adequate stay of mother
There is established criteria for shifting only the new born requiring intensive care should be
ME E19.5 and new born in a safe environment as per 1 SI/RR
new born to SNCU transferred to SNCU
standard protocols
Area of Concern - F Infection Control
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

Facility has provision for Passive and

Surface and environment samples are
ME F1.2 active culture surveillance of critical & taken for microbiological surveillance
1 SI/RR Swab are taken from infection prone surfaces
high risk areas

ME F1.3
Facility measures hospital associated There is procedure to report cases of
1 SI/RR
Patients are observed for any sign and symptoms of
infection rates Hospital acquired infection HAI like fever, purulent discharge from surgical site .

ME F1.4
There is Provision of Periodic Medical There is procedure for immunization
2 SI/RR Hepatitis B, Tetanus Toxoid etc
Check-ups and immunization of staff medical check-up of the staff

Facility has established procedures for

Regular monitoring of infection control Hand washing and infection control audits done at
ME F1.5 regular monitoring of infection control practices
1 SI/RR
periodic intervals
practices

ME F1.6
Facility has defined and established Check for Doctors are aware of
2 SI/RR
Antibiotics prescribed are in line with Antibiotic
antibiotic policy Hospital Antibiotic Policy Policy.

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis

Hand washing facilities are provided at Check for availability of wash basin near the point of
Availability of hand washing with
ME F2.1 2 OB use Ask to Open the tap. Ask Staff water supply is
point of use running Water Facility at Point of Use
regular

Availability of antiseptic soap with

Check for availability/ Ask staff if the supply is
soap dish/ liquid antiseptic with 2 OB/SI
adequate and uninterrupted.
dispenser.

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

Availability of elbow operated taps 2 OB elbow /foot operated or sensor

Hand washing sink is wide and deep

enough to prevent splashing and 0 OB Tap should be approx. 96 cm from the ground.
retention of water

Check Finger nails of staff. They should not reach

Staff is trained and adhere to standard beyond finger tip. No nail polish or artificial nails. All
Adequate preparation for surgical
ME F2.2 2 OB/SI/RR jewellery on the fingers, wrists and arms should be
hand washing practices scrub.
removed. Adjust water to a comfortable
temperature.

Procedure should be repeated several times so that

the scrub lasts for 3 to 5
Adherence to Surgical scrub method 2 SI/OB minutes. Hands must always be kept above elbow
level. The hands and forearms should be dried with
a sterile towel only.

Check adequate quantity of antibiotic

Use of antibiotic soap/liquid 2 SI/OB
soap/Chlorhexidine solution is available and used.

Staff aware of when to hand wash 2 SI Ask for 5 moments of hand washing

ME F2.3
Facility ensures standard practices and Availability of Antiseptic Solutions 2 OB Povidone iodine solution
materials for antisepsis

Proper cleaning of procedure site with like before giving IM/IV injection, drawing blood,
2 OB/SI
antisepsis putting Intravenous and urinary catheter

Check sterile field is maintained during Surgical site covered with sterile drapes, sterile
2 OB/SI
surgery instruments are kept within the sterile field.

Standard F3 Facility ensures standard practices and materials for Personal protection

Facility ensures adequate personal

Sterile gloves are available at OT and
ME F3.1 protection equipment's as per Critical areas
2 OB/SI In adequate quantity, as per load
requirements
Availability of Masks 2 OB/SI In adequate quantity, as per load

Availability of Caps & gown/ Apron 2 OB/SI In adequate quantity, as per load

Personal protective kit for infectious

2 OB/SI Disposable surgery kit for HIV patients
patients

Availability of gum boots 2 OB/SI In adequate quantity, as per load

ME F3.2
Staff is adhere to standard personal No reuse of disposable gloves, Masks,
2 OB/SI/RR Check Autoclaving/sterilization records.
protection practices caps and aprons.

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Compliance
Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Adherence to standard technique so that sterile

Compliance to correct method of
2 SI area is not in contact with unsterile at any given
wearing and removing the gloves
point of time.

Adherence to standard technique so that sterile

Compliance to standard technique of
2 SI area is not in contact with unsterile at any given
wearing and removing of gown
point of time.

Standard F4 Facility has standard Procedures for processing of equipment's and instruments

Ask staff about how they decontaminate the

Facility ensures standard practices and
Decontamination of operating & procedure surface like OT Table, Stretcher/Trolleys
ME F4.1 materials for decontamination and clean in of 1 SI/OB
Procedure surfaces etc.
instruments and procedures areas
(Wiping with 0.5% Chlorine solution)

Ask staff how they clean the instruments like

Cleaning of instruments after use 2 SI/OB ambubag, suction canulae, Surgical Instruments
(Soaking in 0.5% Chlorine Solution, Wiping with 0.5%
Chlorine Solution or 70% Alcohol as applicable )

Proper handling of Soiled and infected No sorting ,Rinsing or sluicing at Point of use/ sterile
1 SI/OB
linen area

Staff know how to make disinfectant Carbolic acid, chlorine solution, glutaraldehyde or
2 SI/OB
solution any other disinfectant used

Facility ensures standard practices and Equipment and instruments are

ME F4.2 materials for disinfection and sterilization of sterilized after each use as per 2 OB/SI Autoclaving/Chemical Sterilization
instruments and equipment's requirement

Chemical sterilization of
Ask staff about method, concentration and contact
instruments/equipment's is done as 2 OB/SI
time required for chemical sterilization.
per protocols

Date of preparation & due date of change of

Glutaraldehyde solution is changed as
2 OB/SI solution is mentioned on container and staff is
per manufacturer instructions
aware of When to change the chemical.

Autoclaved linen and Dressing are

2 OB/SI Gowns, draw sheets , Cotton, Gauze, bandages. Etc.
used for procedure

Check for Window of autoclave drum is closed,

Instruments are packed as per
2 OB/SI drum is not filled more than 3/4th, instruments are
standard protocol
not hinged,

Autoclaving of instruments is done as

2 OB/SI Ask staff about temperature, pressure and time
per protocols

Regular validation of sterilization Indicators (temperature sensitive tape) that change

2 OB/SI/RR
through chemical indicators colour after being exposed to certain temperature.

Bacillus Thermophilus spores are used, for

measuring biological performance of autoclaving
Regular validation of sterilization
2 OB/SI/RR process. Performed monthly. Label the spore
through biological indictor
ampule, place in horizontal position, kept at the
bottom or farthest part of autoclave

Autoclave Register have column: Date, Time started,

Maintenance of records of sterilization 2 OB/SI/RR Time finished, Temp, pressure, Autoclave tape,
spore test,

Each Sterilized pack is marked with Date/Time of

There is a procedure to ensure the
2 OB/SI/RR sterilization, contents, name/signature of the
traceability of sterilized packs
Technician,

Sterility of autoclaved packs is Sterile packs are kept in clean, dust free, moist free
2 OB/SI
maintained during storage environment.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention

Functional area of the department are Facility layout ensures separation of Facility layout ensures separation of general traffic
ME F5.1 2 OB
arranged to ensure infection control practices routes for clean and dirty items from patient traffic. Separate disposal zone

CSSD/TSSU has demarcated separate

area for receiving dirty items,
1 OB Sterile & unsterile store are separately.
processes, keeping clean and sterile
items

Facility ensures availability of standard

Availability of disinfectant as per Chlorine solution, Glutaraldehyde, carbolic acid ,
ME F5.2 materials for cleaning and disinfection of 1 OB/SI
requirement fumigation material
patient care areas

Availability of cleaning agent as per Hospital grade phenyl, disinfectant detergent

1 OB/SI
requirement solution

Facility ensures standard practices followed

Spill management protocols are spill management kit. staff training, protocol
ME F5.3 for cleaning and disinfection of patient care 2 SI/RR
implemented displayed
areas
Hospital should aspire to be mercury free. If used
Mercury Spill management Kit is than Hg spill management kit should be available
2 SI/OB
available with gloves, cap, mask, goggles, polybag, Plastic
container & torch.

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Compliance
Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Cleaning of patient care area with Washing of floor with luke warm water and
2 SI/RR
detergent solution detergent.

Standard practice of mopping and

1 OB/SI Use of three bucket system for mopping
scrubbing are followed

Cleaning equipment's like broom are

0 OB/SI Look in janitors closet
not used in patient care areas
check that Formalin is not used. safer commercially
Fumigation as per schedule 2 SI/RR available disinfectants such as Bacillicidal are used
for fumigation
External footwears are restricted 2 OB adequate numbers are available at the entrance

Entry to sterile zone is permitted only

only persons really required are allowed to enter the
after hand washing, change of clothes, 1 OB/SI
sterile zone
gowning & PPE

OT to have an independent air handling unit with

ME F5.5 Facility ensures air quality of high risk area Positive Pressure in OT 1 OB/SI controlled ventilation such that the lay-up room and
the OT table is under positive pressure

Adequate air exchanges are Independent AHU also allows to maintain required
1 SI/RR
maintained number of Air exchange side. 20-25.

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

Facility Ensures segregation of Bio Availability of colour coded bins &

ME F6.1 Plastic bags at point of waste 2 OB Adequate number. Covered. Foot operated.
Medical Waste as per guidelines generation
Human Anatomical waste, Items contaminated with
blood, body fluids, dressings, plaster casts, cotton
Segregation of Anatomical and soiled
2 OB/SI swabs and bags containing residual or discarded
waste in Yellow Bin
blood and blood components.
Items such as tubing, bottles, intravenous tubes and
Segregation of infected plastic waste sets, catheters, urine bags, syringes (without
2 OB
in red bin needles and fixed needle syringes) and vacutainers
with their needles cut) and gloves
Display of work instructions for
segregation and handling of 2 OB Pictorial and in local language
Biomedical waste
Availability of functional needle
ME F6.2
Facility ensures management of sharps as cutters & puncture proof, leak proof, 0 OB See if it has been used or just lying idle.
per guidelines temper proof white container for
segregation of sharps Ask if available. Where it is stored and who is in
Availability of post exposure charge of that. Also check PEP issuance register
1 OB/SI
prophylaxis & Protocols Staff knows what to do in condition of needle stick
Contaminated and broken Glass are injury
disposed in puncture proof and leak Includes used vials, slides and other broken infected
2 OB
proof box/ container with Blue colour glass
marking
ME F6.3
Facility ensures transportation and Check bins are not overfilled 2 SI Not more than two-third.
disposal of waste as per guidelines
Disinfection of liquid waste before
0 SI/OB Through Local Disinfection
disposal
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for quality improvement

Quality circle has been formed in the Check if quality circle formed and functional in the
ME G1.1 The facility has a quality team in place operation theatre
2 SI/RR
OT

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.

Facility has established internal quality There is system of daily round by

matron/hospital manager/ hospital
ME G3.1 assurance program at relevant superintendent/ OT in charge for
1 SI/RR Check for entries in Round Register.
departments monitoring of services

Facility has established system for use of

ME G3.3 check lists in different departments and Internal
interval
assessment is done at periodic
2 RR/SI
NQAS assessment toolkit is used to conduct internal
assessment
services

Departmental checklist are used for 2 SI/RR

Staff is designated for filling and monitoring of
monitoring and quality assurance these checklists

Non-compliances are enumerated 2 RR Check the non compliances are presented &
and recorded discussed during quality team meetings
Actions are planned to address gaps Check action plans are prepared and
Randomly check the details of action, responsibility,
ME G3.4 observed during quality assurance implemented as per internal 2 RR
time line and feedback mechanism
process assessment record findings

Planned actions are implemented Check PDCA or prevalent quality Check actions have been taken to close the gap. It
ME G3.5 through Quality Improvement Cycles method is used to take corrective and 2 SI/RR can be in form of action taken report or Quality
(PDCA) preventive action Improvement (PDCA) project report

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Departmental standard operating Standard operating procedure for

Can be prepared by junior surgeon and approved by
ME G4.1 department has been prepared and 2 RR
procedures are available approved
HOD/OT in charge

Current version of SOP are available

2 OB/RR Look for version.
with process owner

Work instruction/clinical protocols are

2 OB processing and sterilization of equipment's,
displayed

Standard Operating Procedures Department has documented

procedure for ensuring patients rights
ME G4.2 adequately describes process and including consent, privacy,
2 RR Check SOP for adequacy
procedures confidentiality & entitlement

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Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Department has documented

procedure for safety & risk 2 RR Check SOP for adequacy
management

Department has documented

procedure for support services & 2 RR Check SOP for adequacy
facility management.

Department has documented

procedure for general patient care 2 RR Check SOP for adequacy
processes

Department has documented

procedure for specific processes to the 2 RR Check SOP for adequacy
department

Department has documented

procedure for infection control & bio 2 RR Check SOP for adequacy
medical waste management

Department has documented

procedure for quality management & 2 RR Check SOP for adequacy
improvement

Department has documented

procedure for data collection, analysis 2 RR Check SOP for adequacy
& use for improvement

ME G4.3
Staff is trained and aware of the standard Check staff is a aware of relevant part 2 SI/RR Ask staff how they carry out a specific activity.
procedures written in SOPs of SOPs
Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
Critical process are the ones where is some
Process mapping of critical processes problem-delays, errors, cost, time, etc. and
ME G5.1 Facility maps its critical processes done
1 SI/RR
improvement will make our process effective and
efficient.

Facility identifies non value adding Non value adding activities are wastes. In these
Non value adding activities are
ME G5.2 1 SI/RR steps resources are expended, delays occur, and no
activities / waste / redundant activities identified
value is added to the service.

ME G5.3
Facility takes corrective action to improve Processes are improved & 1 SI/RR
Look for the improvements made in the critical
the processes implemented process.

Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
Check short term valid quality objectivities have
been framed addressing key quality issues in each
Facility has de defined quality objectives to Check if SMART Quality Objectives
ME G6.4 1 SI/RR department and cores services. Check if these
achieve mission and quality policy have framed
objectives are Specific, Measurable, Attainable,
Relevant and Time Bound.

Interview with staff for their awareness. Check if

Mission, Values, Quality policy and objectives
Check of staff is aware of Mission , Mission Statement, Core Values and Quality Policy is
ME G6.5 are effectively communicated to staff and 1 SI/RR
Values, Quality Policy and objectives displayed prominently in local language at Key
users of services
Points

Review the records that action plan on quality

Facility periodically reviews the progress of objectives being reviewed at least once in month by
Check time bound action plan is being
ME G6.7 strategic plan towards mission, policy and 0 SI/RR departmental in charges and during the quality team
reviewed at regular time interval
objectives meeting. The progress on quality objectives have
been recorded in Action Plan tracking sheet

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
ME G7.1
Facility uses method for quality Basic quality improvement method 1 SI/OB PDCA & 5S
improvement in services

ME G7.2
Facility uses tools for quality 7 basic tools of Quality 1 SI/RR
Minimum 2 applicable tools are used in each
improvement in services department
Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
Check periodic assessment of Verify with the records. A comprehensive risk
Periodic assessment for Medication and
medication and patient care safety risk assessment of all clinical processes should be done
ME G9.6 Patient care safety risks is done as per 1 SI/RR
is done using defined checklist using pre define criteria at least once in three
defined criteria.
periodically month.
Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes
Check parameter are defined & implemented to
Clinical care assessment criteria have review the clinical care i.e. through peer review,
The facility has established procedures
ME G10.3 been defined and communicated to review the clinical care processes
2 morbidity & mortality review, patient feedback,
clinical audit & clinical outcomes.

Check the patient /family participate Feedback is taken from patient/family on health
2 SI/RR
in the care evaluation status of individual under treatment
System in place to review internal referral process,
Check the care planning and co-
1 SI/RR review clinical handover information, review patient
ordination is reviewed
understanding about their progress
Facility conducts the periodic clinical
ME G10.4 audits including prescription, medical and There is a procedure to conduct C-
section audits
2 SI/RR Check with audit reports
death audits

All non compliance are enumerated &

2 SI/RR Check the non compliances are presented &
recorded for c-section audits
discussed during clinical Governance meetings

Clinical care audits data is analysed, and Check action plans are prepared and
Randomly check the actual compliance with the
ME G10.5 actions are taken to close the gaps implemented as per c-section audit 2 SI/RR
actions taken reports of last 3 months
identified during the audit process record's findings

Check the data of audit findings are Check collected data is analysed & areas for
2 SI/RR
collated improvement is identified & prioritised
Check the critical problems are regularly monitored
Check PDCA or prevalent quality
& applicable solutions are duplicated in other
method is used to address critical 2 SI/RR
departments (wherever required) for process
problems
improvement

Facility ensures easy access and use of

standard treatment guidelines & Check standard treatment guidelines / Staff is aware of Standard treatment protocols/
ME G10.7 protocols are available & followed. 2 SI/RR guidelines/best practices
implementation tools at
point of care
Check treatment plan is prepared as Check staff adhere to clinical protocols while
2 SI/RR
per Standard treatment guidelines preparing the treatment plan

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Compliance
Reference No. ME Statement Checkpoint Assessment Method Means of Verification

Check the drugs are prescribed as per Check the drugs prescribed are available in EML or
2 SI/RR
Standards treatment guidelines part of drug formulary
Check when the STG/protocols/evidences used in
Check the updated/latest evidence are healthcare facility are published.
2 SI/RR
available Whether the STG protocols are according to current
evidences.

The gaps in clinical practices are identified & action

Check the mapping of existing clinical
1 SI/RR are taken to improve it. Look for evidences for
practices processes is done
improvement in clinical practices using PDCA
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks

Facility measures productivity Indicators on Total LSCS done x 100/Total deliveries conducted
ME H1.1 C-Section Rate 2 RR
monthly basis (Normal +LSCS)

Percentage of C-Sections done in the Total C-Section done in night x 100/Total surgeries
2 RR
night conducted (Day Night)

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark

Sum total of time Elapsed between when equipment

Facility measures efficiency Indicators on
ME H2.1 Downtime critical equipment 1 RR had problem and when the problem is sorted out for
monthly basis
critical equipment.

Total number of C-Section done/No. of OBG

No of C-Section per OBG surgeon 2 RR
Surgeon available

No. of elective LSCS x 100/Total LSCS (Elective +

Percentage of elective C-Sections 2 RR
Emergency)

No of drug stock out in the month 2 RR

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

Facility measures Clinical Care & Safety No. of observed surgical site infections*100/total
ME H3.1 Surgical Site infection Rate 2 RR
Indicators on monthly basis no. of Major surgeries

No of adverse events per thousand No of Adverse events reported x 1000/total no of

2 RR
patients patient treated in OT
% of environmental swab culture No. of swab culture reported positive x 100/Total
2 RR
reported positive no. of swab sent for culture

Deaths occurred from pre operative procedure to

Perioperative Death Rate 2 RR
discharge of the patient

Percentage of C-Sections conducted No. of C- Section Conducted using safe surgery

2 RR
using Safe Surgery Checklist checklist *100/Total no. C-Section Conducted

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

Facility measures Service Quality Indicators No. of cancelled operation*1000 /total operation
ME H4.1 Operation Cancellation rates 2 RR
on monthly basis done

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Version: DH/NQAS-2020/00

10

May-24

heatre Score

2%

key
ntainer for segregation of sharps
ntion of water
eas

Remarks

ervices and their modalities

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Remarks

ount of physical, economic, cultural or social reasons.

patient related information.

obtaining informed consent wherever it is required.

on given from cost of care.

eets the prevalent norms

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er

es to the current case load

ces.

ices.

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competence and performance of staff

ration of Equipment.

harmacy and patient care areas

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and visitors.

facility

d support services norms

standards operating procedures.

eatment plan preparation.

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and referral

records and their storage

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ter Management

es

nt and Transfusion.

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of deceased patients

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f hospital associated infection

es and antisepsis

on

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ments

on prevention

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Bio Medical and hazardous Waste.

ment

s critical to quality.

key processes and support services.

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ding activities and wastages

tools.

k Management Plan

al care processes

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onal benchmarks

Benchmark

onal benchmark

onal benchmark

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Complianc Assessment
Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Standard A1 Facility Provides Curative Services

ME A1.14 Services are available for the OPD services are available for 2 SI/RR At least 6 hours
time period as mandated family planning
As per Fixed Day Static (FDS) strategy, twice
Days for FP Surgeries are fixed 2 SI/RR a week, FP surgeries are performed by
trained providers posted in the same facility,
Standard A2 on fixed days
Facility provides RMNCHA Services
The facility provides Availability of Spacing methods IUCD, OCP (Mala N & Chhaya), ECP,
ME A2.1 2 SI/OB
Reproductive health Services of family planning Condoms, Antara (injectables MPA)
Availability of Female Limiting 2 SI/OB Tubectomy (Mini lap and Laparoscopic)
Methods of family Planning
Availability of Male Limiting 2 SI/OB NSV/Conventional
Method for Family Planning
Availability of Post partum FP 2 SI/OB Tubal Ligation and PPIUD
services
Availability of Family Planning
Counselling and Promotive 2 SI/OB Counselling and IEC
services
Abortion and Contraception
services for Ist and 2nd 2 SI/OB
trimester
Dedicated postpartum ward for FP surgeries
Postpartum ward 2 SI/OB
and abortion clients
The facility provides Maternal Availability of post natal
ME A2.2 counselling and follow up 2 SI/OB
health Services services Check woman is taking a prophylactic dose:
if not, either provide or refer to the
A prophylactic dose of Iron folic
concerned department
acid for women of 2 SI/RR (a) Reproductive age group (20-49yrs)- non
reproductive age & lactating
mother pregnant non-lactating
(b) Lactating mother (0-6 month)
The facility provides Newborn Availability/Linkage to
ME A2.3 2 SI/OB
health Services immunization services
The facility provides Adolescent Availability of Abortion services
ME A2.5 health Services for adolescent 2 SI/OB
Availability of Contraception 2 SI/OB
services
Standard A3 Facility Provides diagnostic Services
For sterilization surgeries, availability of
The facility Provides Laboratory Availability of point of care haemoglobin, Urine pregnancy test, urine
ME A3.2 Services diagnostic test 2 SI/OB
analysis for sugar
and albumin
Area of Concern - B Patient Rights
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 The facility has uniform and Availability of departmental & 0 OB Numbering, main department and internal
user-friendly signage system directional signages sectional signage are displayed
Restricted area signage are 2 OB
displayed
The facility displays the services List of Family Planning Services
ME B1.2 and entitlements available in its available 2 OB
departments
Compensation for family 2 OB
planning indemnity scheme

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Complianc Assessment
Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Compensation for family 2 OB

planning services are displayed
Patients & visitors are sensitised IEC materials such as posters, banners, and
and educated through IEC Material regarding family handbills
ME B1.5 appropriate IEC / BCC planning displayed 2 OB available at the site and displayed
approaches
Education material for Flip charts, models, specimens, and samples
counselling are available in 2 OB of
Counselling room contraceptives available
Information is available in local Signage's and information are
ME B1.6 2 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 physical economic,
cultural or social reasons.

Services are provided in manner Availability of female staff if a

ME B2.1 that are sensitive to gender male doctor examine a female 2 OB/SI
patients

There is no over emphasis on Ask Staff/client whether they were

2 SI/PI convinced for one method or given informed
one method
choice

Access to facility is provided

without any physical barrier & Availability of Wheel chair or
ME B2.3 stretcher for easy Access to the 1 OB
and friendly to people with OT
disabilities
At least 120 cm width, gradient not steeper
Availability of ramps with railing 2 OB
than 1:12
Availability of specially abled
0 OB
toilet
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Adequate visual privacy is Availability of screens at IUD 0 OB
provided at every point of care insertion room
Availability of screens at family 2 OB
planning OT
Patients are properly
draped/covered before and 2 OB
after procedure
Privacy at the counselling room 2 OB
is maintained
Confidentiality of patients Patient Records are kept at
ME B3.2 records and clinical information secure place beyond access to 2 SI/OB
is maintained general staff/visitors
No information regarding
patient identity and details are 2 SI/OB
unnecessary displayed
The facility ensures the
behaviours of staff is dignified Behaviour of staff is empathetic
ME B3.3 and respectful, while delivering and courteous 2 PI/OB
the services
No entry shall be made in any case sheet , PT
The facility ensures privacy and register , follow-up card or any other
confidentiality to every patient,
ME B3.4 especially of those conditions Confidentiality of Abortion 2 SI/OB document, register indicating there in the
cases name of the pregnant women . Only
having social stigma, and also reference serial no. is mentioned on all the
safeguards vulnerable groups
document

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed
consent wherever it is required.
There is established procedures
ME B4.1 for taking informed consent Informed consent for IUD 2 SI/PI/RR
before treatment and insertion
procedures
Informed consent for family 2 SI/RR
planning surgeries

Informed consent on
prescribed form C for abortion 2 SI/RR

Patient is informed about his/her Display of reproductive rights

ME B4.2 rights and responsibilities of clients 2 OB

Staff are aware of Patients rights Staff about awareness

ME B4.3 2 SI
responsibilities reproductive rights of clients

Information about the treatment Client is informed about various

ME B4.4 is shared with patients or options of family planning and 2 PI/SI
attendants, regularly assisted in decision making

Availability of complaint box

The facility has defined and and display of process for
ME B4.5 established grievance redressal 1 OB
grievance re addressal and
system in place whom 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 care.
The facility provides cashless
services to pregnant women, Drugs, consumables and
ME B5.1 mothers and neonates as per contraceptives are available 2 PI/SI
prevalent government schemes free
All surgical procedure for family
2 PI/SI
planning are free of cost
The facility ensures that drugs Check that patient party has
ME B5.2 prescribed are available at not spent on purchasing drugs 2 PI/SI
Pharmacy and wards or consumables from outside.
It is ensured that facilities for the Check that patient party has
ME B5.3 prescribed investigations are not spent on diagnostics from 2 PI/SI
available at the facility outside.
The facility ensures timely If any other expenditure
reimbursement of financial
ME B5.5 entitlements and reimbursement occurred it is reimbursed from 2 PI/SI/RR
to the patients hospital
Timely payment of family
planning compensation 2 PI/SI/RR

Area of Concern - C Inputs

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
Departments have adequate Adequate Space is for
ME C1.1 space as per patient or work load counselling and examination 2 OB
Availability of dedicated OT for
Family planning surgeries in PP 2 OB
unit

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Functional toilets with running

Patient amenities are provide as water and flush are available as
ME C1.2 1 OB
per patient load per bed strength and patient
load of ward
Availability of drinking water 1 OB
Availability of seating 2 OB
arrangement
Departments have layout and
ME C1.3 demarcated areas as per Demarcated of Protective Zone 2 OB
functions
Demarcated Clean Zone 2 OB
Demarcated sterile Zone 2 OB
Demarcated disposal Zone 2 OB
Availability of Changing Rooms 2 OB
Availability of Pre and Post 2 OB
Operative Room
Availability of Scrub Area 2 OB
Availability of Autoclave room/ 2 OB
TSSU
Availability of clean and dirty 2 OB
utility area
Availability of store 2 OB
Availability of dedicated 2 OB
counselling area
Availability of examination cum
minor procedure area for IUD 0 OB
insertion
The facility has adequate Corridors are wide enough for
ME C1.4 circulation area and open spaces movement of trolleys and 2 OB
according to need and local law stretchers
The facility has infrastructure for Availability of functional
ME C1.5 intramural and extramural telephone and Intercom 2 OB
communication Services
Service counters are available as OT tables are available as per At least 2 laparoscopic OT tables (Hydraulic
ME C1.6 per patient load load 2 OB table)

The facility and departments are

planned to ensure structure
ME C1.7 follows the function/processes Unidirectional
and services
flow of goods 2 OB
(Structure commensurate with
the function of the hospital)

Standard C2 The facility ensures the physical safety of the Check

infrastructure.
for fixtures and furniture like
ME C2.1 The facility ensures the seismic Non structural components are 0 OB cupboards, cabinets, and heavy equipment's
safety of the infrastructure properly secured , hanging objects are properly fastened and
OT does not have temporary secured
ME C2.3 The facility ensures safety of connections and loosely 1 OB
electrical establishment
hanging wires
Physical condition of buildings
ME C2.4 are safe for providing patient Floors of the ward are non 2 OB
slippery and even
care
Walls and floor of the OT 1 OB
covered with joint less tiles

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Windows if any in the OT are 0 OB

intact and sealed
Standard C3 The facility has established Programme for fire safety and other disaster
OT has sufficient fire exit to
The facility has plan for
ME C3.1 permit safe escape to its 2 OB/SI
prevention of fire
occupant at time of fire
Check the fire exits are clearly
visible and routes to reach exit 2 OB
are clearly marked.
PP unit has installed fire
ME C3.2 The facility has adequate fire Extinguisher that is Class A , 2 OB
fighting Equipment Class BC type or ABC type

Check the expiry date for fire

extinguishers are displayed on
each extinguisher as well as 1 OB/RR
due date for next refilling is
clearly mentioned

The facility has a system of Check for staff competencies

periodic training of staff and
ME C3.3 conducts mock drills regularly for for operating fire extinguisher 1 SI/RR
fire and other disaster situation and what to do in case of fire

Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
The facility has adequate Minilap - MBBS trained in procedure
specialist doctors as per service Availability
of trained surgeon
ME C4.1 for Minilap/ Laparoscopic/NSV 2 OB/RR Laparoscopic- DGO,MS, MD
provision trained in laparoscopic surgery
The facility has adequate nursing
ME C4.3 staff as per service provision and Availability of Nursing staff 0 OB/RR/SI Trained in PPIUCD and IUCD insertion
work load
The facility has adequate Viability of Counsellor for RMNCHA counseller (Applicable only in High
ME C4.4 technicians/paramedics as per 2 OB/SI
requirement family planning priority districts)

Availability of OT technician 1 SI/RR

The facility has adequate support Availability of OT
ME C4.5 / general staff attendant/assistant 1 SI/RR
Availability of Security staff 1 SI/RR
Standard C5 Facility provides drugs and consumables required for assured list of services.
The departments have
ME C5.1 availability of adequate drugs at Availability of Oral
Contraceptive Pills 2 OB/RR Stock for Month
point of use
Availability of emergency
Contraceptive Pills 2 OB/RR Stock for Month
Availability of IUD devices 2 OB/RR Stock for Month
Availability of Condoms 2 OB/RR Stock for Month
Availability of Antra 2 OB/RR Stock for Month
(Injectables)
Availability of Chaaya (Weekly 2 OB/RR Stock for Month
contraceptive)
Availability of Anaesthetic 2 OB/RR As per State's EML
Agent
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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Availability of medical gases 2 OB/RR Centralized /Cylinders

Availability of drugs for MMA 2 OB/RR Mifepristone & Misoprostol

The departments have adequate Sterilized consumables in

ME C5.2 consumables at point of use dressing drum 2 OB/RR At OT
Emergency drug trays are
ME C5.3 maintained at every point of Availability of emergency drugs 2 OB/RR
care, where ever it may be tray
needed
Standard C6 The facility has equipment & instruments required for assured list of services.
Availability of equipment & Availability of functional
BP apparatus, Thermometer, Pulse
ME C6.1 instruments for examination & Equipment &Instruments for 2 OB Oximeter, Multiparameter
monitoring of patients examination & Monitoring

Availability of equipment &

Availability of
instruments for treatment
ME C6.2 procedures, being undertaken in Instruments/Equipment's for 1 OB PV examination kit
Gynae and obstetric
the facility
Availability of Sterile IUD 1 OB
insertion and removal Kits
Operation Table with
2 OB
Trendelenburg facility
Minilap instrument 0 OB
Laparoscopic set 2 OB
NSV sets 2 OB
PP IUCD tray 2 OB
Instrument for MVA 2 OB Check MVA kit (Aspirator & cannula)
Instruments for Laparoscopy 2 OB

Availability of equipment &

ME C6.3 instruments for diagnostic Availability of Point of care 2 OB Glucometer, Doppler and HIV rapid
procedures being undertaken in diagnostic instruments diagnostic kit, digital Haemoglobin meter
the facility

Availability of equipment and

instruments for resuscitation of Availability of functional Bag and mask, Oxygen, Suction machine ,
ME C6.4 patients and for providing Instruments Resuscitation 1 OB laryngoscope scope. LMA, ET Tube ,
intensive and critical care to Airway ,Defibrillator
patients

ME C6.5 Availability of Equipment for Availability of equipment for 2 OB Refrigerator, Crash cart/Drug trolley,
Storage storage for drugs instrument trolley, dressing trolley
Availability of functional Buckets for mopping, Separate mops for
equipment and instruments for Availability
of equipment's for
ME C6.6 1 OB patient care area and circulation area
cleaning
support services duster, waste trolley, Deck brush
Departments have patient
furniture and fixtures as per load Availability
of functional OT
ME C6.7 2 OB
and service provision light

Availability of attachment/ 2 OB Hospital graded mattress , IV stand, Bed pan

accessories with OT table

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks
Tray for monitors, Electrical panel for
Availability of Fixtures 2 OB anaesthesia machine, cardiac monitor etc,
panel with outlet for Oxygen and vacuum, X
ray view box.
Availability of furniture 2 OB Cupboard, table for preparation of
medicines, chair, racks,
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff
Check objective checklist has been prepared
for assessing competence of doctors, nurses
Criteria for Competence Check parameters for assessing
and paramedical staff based on job
ME C7.1 assessment are defined for skills and proficiency of clinical 1 RR/SI description defined for each cadre of staff.
clinical and Para clinical staff staff has been defined
Dakshta checklist issued by MoHFW can be
used for this purpose.

Competence assessment of Check for records of competence

Check for competence
ME C7.2 Clinical and Para clinical staff is assessment is done at least 1 RR/SI assessment including filled checklist, scoring
done on predefined criteria at and grading . Verify with staff for actual
once in a year
least once in a year competence assessment done

The Staff is provided training as

ME C7.9 per defined core competencies PPIUCDand IUD insertion 1 SI/RR
and training plan

Family planning counselling 1 SI/RR

Laparoscopic surgery/Minilap 2 SI/RR
NSV 2 SI/RR
Training on Antra (Injectable 2 SI/RR
Contraceptives)
Chhaya training (Weekly 2 SI/RR
contraceptive)
Comprehensive Abortion care 2 SI/RR Post abortion IUCD
(CAC)
Infection control & prevention 2 SI/RR Bio medical Waste Management including
training Hand Hygiene
Patient Safety 1 SI/RR
BLS training for all staff 1
Training on Quality 2 SI/RR To all category of staff. At the time of
Management System induction and once in a year.
Check supervisors make periodic rounds of
There is established procedure
for utilization of skills gained Staff is skill for counselling department and monitor that staff is
ME C7.10 thought trainings by on -job services 1 SI/RR working according to the training imparted.
Also staff is provided on job training
supportive supervision
wherever there is still gaps
Check supervisors make periodic rounds of
department and monitor that staff is
Staff is skilled for resuscitation 2 SI/RR working according to the training imparted.
Check supervisors
Also staff make
is provided periodic
on job rounds of
training
Nursing Staff is skilled for department
wherever there andismonitor that staff is
still gaps
2 SI/RR working according to the training imparted.
maintaining clinical records Check supervisors
Also staff make
is provided periodic
on job rounds of
training
department
wherever there andismonitor that staff is
still gaps
Staff is Skilled to operate OT 2 SI/RR working according to the training imparted.
equipment's Check supervisors make periodic rounds of
Also staff is provided on job training
department
wherever there andismonitor that staff is
still gaps
Staff is skilled for processing 2 SI/RR working according to the training imparted.
and packing instrument Also staff is provided on job training
Area of Concern - D Support Services
wherever there is still gaps
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks
1. Check with AMC records/
The facility has established All equipment's are covered Warranty documents
ME D1.1 system for maintenance of under AMC including 2 SI/RR
2. Staff is aware of the list of equipment
critical Equipment preventive maintenance
There is system of timely [Link]
covered for breakdown
under AMC. & Maintenance
corrective break down record in the log book
2 SI/RR
maintenance of the 2. Staff is aware of contact details of the
equipment's
There has system to label agency/person in case of breakdown.
Defective/Out of order
equipment's and stored 1 OB/RR
appropriately until it has been
repaired
The facility has established
procedure for internal and All the measuring equipment's/
ME D1.2 external calibration of measuring instrument are calibrated 2 OB/ RR
Equipment
There is system to label/ code
the equipment to indicate
status of calibration/ 2 OB/ RR
verification when recalibration
is due
Up to date instructions for
Operating and maintenance
operation and maintenance of
ME D1.3 instructions are available with 2 OB/SI Laparoscope, MVA etc
the users of equipment equipment's 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 areas
There is established procedure There is a process for timely Check FP LIMS for indent and of stock
ME D2.1 for forecasting and indenting 0 SI/RR update
indenting commodities
drugs and consumables

The facility ensures proper Contraceptives are stored away

from water and sources of Check storage condition of condom, Tubal
ME D2.3 storage of drugs and 2 OB/RR
consumables heat, ring
direct sunlight etc.

Are near expiry/expired contraceptives

ME D2.4 The facility ensures management Expiry dates' are maintained at 0 OB/RR stored away active stock Expired
of expiry and near expiry drugs emergency drug tray contraceptives destroyed to prevent resale
or other inappropriate use

No expired commodity is found 2 OB/RR Check the drug /consumables expiry of the
drug sub store

Records for expiry and near

expiry drugs are maintained for 1 RR Check the record of expiry and near expiry
drug stored at department

The facility has established There is practice of calculating

ME D2.5 procedure for inventory and maintaining buffer stock of 2 SI/RR
management techniques contraceptives

Check record of drug received, issued and

Department maintained stock 2 RR/SI balance stock in hand and are regularly
register of contraceptives
updated

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

There is a procedure for There is established system for

ME D2.6 periodically replenishing the replenishing drug tray /crash 2 SI/RR
drugs in patient care areas cart
There is no stock out of 2 OB/SI Check stock of few commodities . E.g. Antara
contraceptives injection, Mala N, Chhaya, etc.

There is process for storage of Temperature

of refrigerators
are kept as per storage Check for temperature charts are
ME D2.7 vaccines and other drugs, 0 OB/RR
requiring controlled temperature requirement and records twice maintained and updated twice a daily.
a day and are maintained

There is a procedure for secure

Anaesthetic agents are kept at
ME D2.8 storage of narcotic and 2 OB/SI
psychotropic drugs secure place

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
The facility provides adequate
ME D3.1 illumination level at patient care Adequate Illumination at OT 2 OB
table
areas
Adequate Illumination at 2 OB At IUD insertion area
procedure area in OPD
The facility has provision of
ME D3.2 restriction of visitors in patient Entry to OT is restricted 2 OB
areas
Only one client is allowed one 2 OB/SI
time at clinic
Warning light is provided
outside OT and its been used 2 SI/RR
when OT is functional
The facility ensures safe and Temperature is maintained 20-25OC, OT has functional room
ME D3.3 comfortable environment for and record of same is 0 SI/RR thermometer and temperature is regularly
patients and service providers maintained maintained
Appropriate humidity level is SI/RR
maintained
ME D3.4 The facility has security system in Security arrangement at PP unit 0 OB
place at patient care areas
The facility has established
ME D3.5 measure for safety and security Female
place
staff feel secure at work 2 SI
of female staff
Standard D4 The facility has established Programme for maintenance and upkeep of the facility
Exterior of the facility building is Building
is
ME D4.1 maintained appropriately painted/whitewashed in 1 OB
uniform colour
Interior of patient care areas 1 OB
are plastered & painted

Patient care areas are clean and Floors,

walls, roof, roof topes,
ME D4.2 sinks patient care and 1 OB All area are clean with no
hygienic dirt,grease,littering and cobwebs
circulation areas are Clean
Surface of furniture and
fixtures are clean 0 OB

Toilets are clean with functional

flush and running water 1 OB

ME D4.3 Hospital infrastructure is Check for there is no seepage , 1 OB

adequately maintained Cracks, chipping of plaster
Window panes , doors and 1 OB
other fixtures are intact

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

OT Table are intact and without

rust 2 OB Mattresses are intact and clean

ME D4.5 The facility has policy of removal No condemned/Junk material 2 OB

of condemned junk material in the PP unit
The facility has established
ME D4.6 procedures for pest, rodent and No pests are noticed 2 OB
animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
The facility has adequate
arrangement storage and supply Availability of 24x7 running and
ME D5.1 for portable water in all potable water 2 OB/SI
functional areas

Availability of Hot water supply 0 OB/SI

The facility ensures adequate

power backup in all patient care Availability
of power back up in
ME D5.2 OT 1 OB/SI
areas as per load

Availability of UPS & generator 2 OB/SI

Availability of Emergency light 1 OB/SI

Critical areas of the facility

ensures availability of oxygen, Availability of Centralized
ME D5.3 medical gases and vacuum /local piped Oxygen, nitrogen 2 OB
and vacuum supply
supply
Standard D7 The facility ensures clean linen to the patients
OT has facility to provide
ME D7.1 The facility has adequate sets of sufficient and clean linen for 2 OB/RR Drape, draw sheet, cut sheet and gown
linen
surgical patient
OT has facility to provide linen 2 OB/RR
for staff
Availability of Blankets, draw
sheet, pillow with pillow cover 2 OB/RR
and mackintosh
The facility has established
ME D7.2 procedures for changing of linen Linen is changed after each 2 OB/RR
procedure
in patient care areas
The facility has standard There is system to check the
ME D7.3 procedures for handling , cleanliness and Quantity of the 2 SI/RR
collection, transportation and linen received from laundry
washing of linen

Check linen is kept closed bin & emptied

Check dedicated closed bin is regularly. Plastic bag is used in dustbin &
2 OB
kept for storage of dirty linen these bags are sealed before removed &
handed over
Standard D10 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
The facility ensure relevant
ME D10.3 processes are in compliance with Staff is aware of legal age for
family planning beneficiaries 2 SI/RR 22-49 yrs. married only
statutory requirement

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
The facility has established job Job description is defined and
ME D11.1 description as per govt communicated to all concerned 2 RR Regular + contractual
guidelines staff
Staff is aware of their role and 2 SI
responsibilities
The facility has a established
There is procedure to ensure Check for system for recording time of
ME D11.2 procedure for duty roster and that staff is available on duty as 2 RR/SI reporting and relieving (Attendance register/
deputation to different
per duty roster Biometrics etc)
departments
There is designated in charge 2 SI
for department

The facility ensures the

adherence to dress code as Doctor, nursing staff and
ME D11.3 mandated by its administration / support staff adhere to their 2 OB
respective dress code
the health department

Standard D12 Facility has established procedure for monitoring the quality of outsourced services and of
Verification adheres to contractual
outsourced services obligations
There is established system for There
is procedure to monitor
(cleaning/
the quality and adequacy of
ME D12.1 contract management for out outsourced services on regular 1 SI/RR Dietary/Laundry/Security/Maintenance)
sourced services provided are done by designated in-house
basis staff
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

The facility has established Unique identification number

ME E1.1 procedure for registration of is given to each client during 2 RR
patients process of registration

Client demographic details are Check for that patient demographics like
recorded in admission records 2 RR Name, age, Sex, Chief complaint, etc.

There is established procedure Age criteria for family planning

ME E1.3 2 RR/SI
for admission of patients surgeries is adhered

There is established criteria for 2 RR/SI

admission of abortion cases

There is no delay in admission 2 SI/RR/OB

of patient
Admission is done by written 2 SI/RR/OB
order of a qualified doctor
Time of admission is recorded 2 RR
in patient record
There is established procedure
for managing patients, in case There is provision of extra beds
ME E1.4 beds are not available at the during fixed day family planning 2 OB/SI
surgery
facility
Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

History of illness to screen for Current medications, Last contraceptive

There is established procedure the diseases mentioned under used and when, Menstrual history: Date of
ME E2.1 2 RR/SI
for initial assessment of patients the medical last menstrual period, Current pregnancy
eligibility criteria status, etc.
Immunization status of women
2 RR/SI
for tetanus

Pulse, blood pressure, respiratory rate,

temperature, body
weight, general condition and pallor,
auscultation of heart and lungs,
Physical Examination 2 RR/SI examination
of abdomen, pelvic examination, and other
examinations as indicated by the
client’s medical history or general physical
examination.

There is established procedure There is fixed schedule for

ME E2.2 for follow-up/ reassessment of reassessment of patient under 2 RR/OB
Patients observation
There is system in place to
identify and manage the Criteria is defined for identification, and
2 SI/RR management of patient whose condition is
changes in Patient's health deteriorating
status
Check the treatment or care Check the re assessment sheets/ Case sheets
plan is modified as per re 2 SI/RR modified treatment plan or care plan is
assessment results documented
There is established procedure
to plan and deliver appropriate Check treatment / care plan is Care plan include:, investigation to be
conducted, intervention to be provided,
ME E2.3 treatment or care to individual documented 2 RR goals to achieve, timeframe, patient
as per the needs to achieve best
education, , discharge plan etc
possible results

Check care is delivered by Check care plan is prepared and delivered as

competent multidisciplinary 2 SI/RR
team per direction of qualified physician

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral
Facility has established
procedure for continuity of care Facility
has established
ME E3.1 during interdepartmental procedure for handing over 2 SI/RR
transfer form OT to ward

Facility provides appropriate

Facility has functional referral
referral linkages to the
ME E3.2 patients/Services for transfer to linkages to higher facilities for 2 RR/SI
other/higher facilities to assure cases which can not be
managed at the facility
their continuity of care.

ME E3.3 A person is identified for care A nurse /doctor is identified 2 RR/SI

during all steps of care responsible for each case
Standard E4 The facility has defined and established procedures for nursing care

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Procedure for identification of There is a process for ensuring

ME E4.1 patients is established at the the patient's identification 2 OB/SI Patient id band/ verbal confirmation etc.
facility before any clinical procedure

Procedure for ensuring timely

and accurate nursing care as per There is a process to ensue the (1) Check system is in place to give
ME E4.2 treatment plan is established at accuracy of verbal/telephonic 0 RR telephonic orders & practised
orders (2) Verbal orders are verified by the ordering
the facility physician within defined time period

There is established procedure of Patient hand over is given

ME E4.3 patient hand over, whenever 2 SI/RR
staff duty change happens during the change in the shift

Nursing Handover register is

2 RR
maintained
Hand over is given bed side 2 SI/RR
ME E4.4 Nursing records are maintained Nursing notes are maintained 2 RR/SI Check for nursing note register. Notes are
adequately adequately written

ME E4.5 There is procedure for periodic Patient Vitals are monitored 2 RR/SI
monitoring of patients and recorded periodically
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.

The facility identifies vulnerable Vulnerable

patients are
ME E5.1 patients and ensure their safe identified and measures are 2 OB/SI
taken to protect them from any
care
harm
The facility identifies high risk High risk medical emergencies
ME E5.2 patients and ensure their care, as are identified and treatment 2 OB/SI
per their need given on priority
Standard E6 Facility ensures rationale prescribing and use of medicines

Facility ensured that drugs are Check

for BHT if drugs are
ME E6.1
prescribed in generic name only prescribed
under generic name 2 RR
only

There is procedure of rational Check for that relevant

ME E6.2 Standard treatment guideline 2 RR
use of drugs are available at point of use

Check staff is aware of the drug 2 SI/RR Check BHT that drugs are prescribed as per
regime and doses as per STG STG

Availability of drug formulary 2 SI/OB

There are procedures defined for Complete medication history is 1. Check that all over-the- counter medicines
are documented while recording the medical
ME E6.3 medication review and documented for each patient 2 RR/OB history
optimization
"1. Clinician/Nurse counsels the patient on
medication safety using ""5 moments for
Patients are engaged in their medication safety app""
0 PI/SI 2. Nurse/ clinician/counseller highlights the
own care medications to be taken by the patient at
home and counsel the client and family on
drug intake
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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Standard E7 Facility has defined procedures for safe drug administration

Electrolytes like Potassium chloride, Opioids,
There is process for identifying Neuro muscular blocking agent, Anti
High alert drugs available in
ME E7.1 and cautious administration of 2 SI/OB thrombolytic agent, insulin, warfarin,
department are identified
high alert drugs (to check) Heparin, Adrenergic agonist etc. as
applicable
Maximum dose of high alert Value for maximum doses as per age, weight
drugs are defined and 2 SI/RR and diagnosis are available with nursing
communicated station and doctor
There is process to ensure that A system of independent double check
right doses of high alert drugs 2 SI/RR before administration, Error prone medical
are only given abbreviations are avoided

Every Medical advice and

Medication orders are written
ME E7.2 procedure is accompanied with 1 RR
legibly and adequately date , time and signature
Check for the writing, It
comprehendible by the clinical 2 RR/SI
staff
There is a procedure to check Drugs are checked for expiry
ME E7.3 drug before administration/ and other inconsistency 2 OB/SI
dispensing before administration

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

Check for separate sterile

needle is used every time for 2 OB In multi dose vial needle is not left in the
multiple dose vial septum
Any adverse drug reaction is 2 RR/SI Adverse drug event trigger tool is used to
recorded and reported report the events
Administration of medicines done after
There is a system to ensure right Check Nursing staff is aware 7 ensuring right patient, right drugs, right
ME E7.4
medicine is given to right patient Rs
of Medication and follows 2 SI/RR
them route, right time, Right dose, Right Reason
and Right Documentation

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

ME E7.5 Pharmacist /nurse about the 2 SI/PI Contraceptives pills
administration dosages and timings .
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
All the assessments, re- History and Physical examination are
ME E8.1 assessment and investigations Records of Monitoring/ 2 RR recorded as per FP case sheet (Manually/e-
Assessments are maintained
are recorded and updated records)

All treatment plan

prescription/orders are recorded Treatment
plan, first orders are Drugs administered are recorded
ME E8.2 2 RR
in the patient records. written on BHT (Manually/e-records)

Procedures performed are Anaesthesia and surgery note

ME E8.4 written on patients records recorded 2 RR (Manually/e-records)

ME E8.5 Adequate form and formats are Standard Formats available 2 RR/OB Check availability and recording in FP case
available at point of use sheet

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Check for availability of sterilization register,

Register/records are maintained Check for availability of eligible
ME E8.6 2 RR IUCD & PPIUCD & service delivery register,
as per guidelines couple and sterilization register
Antra- register (injectable contraceptives)

Records on family planning (FP)

(including the number follow up register, injectable &
2 RR
of clients counselled and the contraceptive register (Antra register)
number of acceptors)

Check filled and updated DMPA (Antra card)

Follow-up records for FP clients 2 RR client card and register for beneficiaries
utilizing Antra services
All register/records are 2 RR
identified and numbered
The facility ensures safe and
ME E8.7 adequate storage and retrieval Safe keeping of patient records 2 OB
of medical records
Standard E9 The facility has defined and established procedures for discharge of patient.
Discharge is done after assessing Assessment is done before
ME E9.1 2 SI/RR
patient readiness discharging patient
Discharge is done by a
responsible and qualified 2 SI/RR
doctor
Patient / attendants are 2 PI/SI
consulted before discharge
Treating doctor is consulted/
informed before discharge of 2 SI/RR
patients
Case summary and follow-up
ME E9.2 instructions are provided at the Discharge summary is provided 2 RR/PI Check FP case Sheet
discharge

Discharge summary adequately

mentions patients clinical 2 RR Check FP case Sheet
condition, treatment given and
follow up
Discharge summary is give to
patients going in 2 SI/RR
LAMA/Referral
Counselling services are provided Counselling of client before
ME E9.3 as during discharges wherever discharge 2 SI/PI
required

Advice includes the information

about the nearest health centre 2 RR/SI
for further follow up

Time of discharge is
communicated to patient in 2 PI/SI
prior

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.3 The facility has disaster Staff is aware of disaster plan 0 SI/RR
management plan in place
Role and responsibilities of staff 0 SI/RR
in disaster is defined
Standard E12 The facility has defined and established procedures of diagnostic services
There are established Container is labelled properly
ME E12.1 procedures for Pre-testing 2 OB
after sample collection
Activities
There are established Nursing station is provided with
ME E12.3 procedures for Post-testing the critical value of different 2 SI/RR
Activities test
Standard E14 Facility has established procedures for Anaesthetic Services
Facility has established
Local anaesthesia is given as
ME E14.2 procedures for monitoring per guidelines 2 SI/RR
during anaesthesia
Standard E15 Facility has defined and established procedures of Surgical Services
Facility has established FP surgeries are scheduled as
ME E15.1 procedures OT Scheduling per guidelines 2 RR/SI

Preoperative instructions given 2 RR/PI

to the client

Facility has established Part preparation is done as per

ME E15.2 2 RR/SI
procedures for Preoperative care guidelines

Facility has established Surgical Safety Check List is Check for Surgical safety check list has been
ME E15.3 2 RR/SI
procedures for Surgical Safety used for each surgery used for surgical procedures

Instrument, needles and sponges are

Sponge and Instrument Count 2 RR/SI counted before beginning of case, before
Practice is implemented final closure and on completing of procedure

Adequate Haemostasis is Check for Cautery and suture legation

secured during surgery 2 RR/SI practices
Check for suturing techniques
are applied as per protocol 2 RR/SI

Facility has established

ME E15.4 procedures for Post operative Post operative care as per 2 RR/SI
care guidelines

Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients

Death of admitted patient is Facility has a standard

ME E16.1 adequately recorded and procedure to decent 2 SI
communicated communicate death to relatives

Death note is written on 2 RR

patient record

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

The facility has standard Death note including efforts

ME E16.2 procedures for handling the done for resuscitation is noted 2 RR
death in the hospital in patient record

Death summary is given to

patient attendant quoting the
2 SI/RR
immediate cause and
underlying cause if possible
Maternal & Child Health Services
Standard E17 Facility has established procedures for Antenatal care as per guidelines
There is an established Facility provides and updates
ME E17.1 procedure for Registration and “Mother and Child Protection 2 SI/RR
follow up of pregnant women. Card”.
Standard E21 Facility has established procedures for abortion and family planning as per government guidelines and law

The client is given full

Family planning counselling information about optimal The importance of timely initiation of an FP
ME E21.1 services provided as per pregnancy spacing and 2 PI/SI method after childbirth, miscarriage,
the benefits of it as a part of FP
guidelines or abortion will be emphasized.
health education and
counselling.

Client is counselled about the

options for family planning 2 PI/SI
available

The client is informed that

condoms prevent sexually
transmitted infections (STIs) & 2 PI/SI
HIV

Facility provides spacing method Pills should be given only to

ME E21.2 of family planning as per those who meet the Medical 2 SI/RR Contraindication of COC in Breastfeeding
guideline Eligibility Criteria mothers within 6week and hypertension

The client should be given full

information about the risks,
advantages, and possible side 2 PI/SI
effects before OCPs are
prescribed for her.

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

dose of contraceptive is missed

Staff is aware of indication and Single Tablet within 72 hours unprotected

method of administration of 2 SI/RR
intercourse.
ECP
No touch technique, Speculum and bimanual
IUD insertion is done as per 1 SI/RR examination, sounding of uterus and
standard protocol
placement
Client is informed about the Cramping, vaginal discharge, heavier
adverse effect that can happen 2 SI/PI menstruation, checking of IUD
and their remedy

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Follow up services are provided Removal of IUD, Instructions for when to

as per protocols 2 SI/RR return
IUD insertion is done as per Grasp IUCD with PPIUCD forceps using no
standard protocol 2 SI/RR touch technique, apply traction on anterior
lip of cervix with ring (sponge holding)
forceps and insert IUCD in to lower uterine
wall, remove the ring forceps and move
other hand upward to women's abdomen,
PPIUD insertion is done as per
standard protocol 0 SI/RR move PPIUCD insertion forceps upward
toward fundus, feel the resistance & thrust
of instrument by hand kept on abdomen,
open PPIUCD forceps and release IUCD,
instrument is slowly withdrawn by keeping
side way
22-49 toage
year avoid dislodging of IUCD. Ensure
Staff is aware of case selection IUCD is not visible if yes remove & reinsert
Married
criteria for family planning 1 SI/RR at least having one year old
Spouse has not gone for sterilization

Facility provides limiting method Assessment of client done Physical examination and Medical History
ME E21.3 of family planning as per before surgery for any Delay, 2 SI/RR
taken,
guideline refer of caution signs
Consent is confirmed before 2 RR surgeon check for informed consent signed
the procedure and ask client for the same
Client is informed about post use of another family planning method for 3
operative care, complication 1 SI/RR/PI months only,
and follow up Visit after 48 hours, first follow up visit at
Follow up visits done as per GoI 2 SI/RR/PI 7th day and semen analysis after 3 months,
guidelines
Facility provide counselling emergency follow
As per national up
Guidelines
Pre procedure Counselling
ME E21.4 services for abortion as per 2 SI/RR/PI Transition phase after family planning
provided
guideline surgery specially vasectomy defined
Post procedure Counselling 2 SI/RR/PI As per national guidelines
provided
Counselling on the follow-up 2 SI/RR/PI
visit
Facility provide abortion services MVA procedures are done as
ME E21.5 for 1st trimester as per guideline per guidelines 2 SI/RR Allowed up to 12 weeks of gestation.
Staff is aware of gestational Allowed upto7 weeks of gestation(49 days
period for Medical Method of 2 SI/RR from the first
Abortion (MMA) First Visit (Dayday
1) -of themg
200 LMP).
Mifepristone
(oral)
MMA drug protocols are 2nd Visit (Day 3) -400 mcg Misoprostol
followed as per guidelines 2 SI/RR (sublingual/ buccal/ vaginal/oral)
3rd Visit (Day 15)- Confirm & ensure
Facility provide abortion services Surgical Procedures procedures complete abortion
ME E21.6 for 2nd trimester as per are done as per guidelines 2 SI/RR Allowed up to 12 weeks of gestation.
guideline 1. Check aspirator retains vaccum & choose
appropriate size cannula.
2. Prepare Women for procedure (form c &
pain management)
Surgical Procedures are done 3 Clean cervix twice with Antiseptic sol.
as per guidelines 2 SI/RR 4. Administer paracervical block (lignocaine)
5. Dilate Cervix using cannula
6. Suction of uterine content
7. Inspect tissue
Area of Concern - F Infection Control
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Facility has provision for Passive Surface and environment

Swab are taken from infection prone
ME F1.2 and active culture surveillance of samples are taken for 2 SI/RR
surfaces
critical & high risk areas microbiological surveillance

There is procedure to report Patients are observed for any sign and
ME F1.3 Facility measures hospital cases of Hospital acquired 2 SI/RR symptoms of HAI like fever, purulent
associated infection rates
infection discharge from surgical site .
There is Provision of Periodic
There is procedure for
ME F1.4 Medical Check-ups and immunization of the staff 2 SI/RR Hepatitis B, Tetanus Toxoid etc
immunization of staff
Periodic medical check-ups of
0 SI/RR
the staff
Facility has established
ME F1.5 procedures for regular Regular monitoring of infection 2 SI/RR Hand washing and infection control audits
monitoring of infection control control practices done at periodic intervals
practices

ME F1.6 Facility has defined and Check for 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
ME F2.1 Hand washing facilities are Availability of hand washing 2 OB Check for availability of wash basin near the
provided at point of use Facility at Point of Use point of use
Ask to Open the tap. Ask Staff water supply
Availability of running Water 2 OB/SI
is regular
Availability of antiseptic soap
with soap dish/ liquid antiseptic 2 OB/SI Check for availability/ Ask staff if the supply
with dispenser. is adequate and uninterrupted
Availability of Alcohol based 2 OB/SI Check for availability/ Ask staff for regular
Hand rub supply.
Prominently displayed above the hand
Display of Hand washing 2 OB
Instruction at Point of Use washing facility , preferably in Local
Availability of elbow operated language
0 OB
taps
Hand washing sink is wide and
deep enough to prevent 2 OB
splashing and retention of
water

Staff is trained and adhere to Adherence to 6 steps of Hand

ME F2.2 standard hand washing practices washing 2 SI/OB Ask of demonstration

procedure should be repeated several times

Adherence to Surgical scrub so that the scrub lasts for 3 to 5
method 2 SI/OB minutes. The hands and forearms should be
dried with a sterile towel only.
Staff aware of when to hand
wash 2 SI Ask of demonstration

Facility ensures standard Availability of Antiseptic

ME F2.3 practices and materials for Solutions 2 OB
antisepsis
like before giving IM/IV injection, drawing
Proper cleaning of procedure 2 OB/SI blood, putting Intravenous and urinary
site with antisepsis
catheter

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Cleaning of cervix before IUD

insertion with antiseptic 2 SI Iodine, betadine etc.
solution
Check Shaving is not done
during part 2 SI
preparation/delivery cases Surgical site covered with sterile drapes,
Check sterile filled is 2 OB/SI sterile instruments are kept within the
maintained during surgery
Standard F3 Facility ensures standard practices and materials forsterile field.
Personal protection

Facility ensures adequate

ME F3.1 personal protection equipment's Clean gloves are available at
point of use 2 OB/SI
as per requirements

Availability of Masks 2 OB/SI

Sterile s gloves are available at
OT and Critical areas 2 OB/SI

Use of elbow length gloves for

2 OB/SI
obstetrical purpose
Availability of gown/ Apron 2 OB/SI
Availability of Caps 2 OB/SI
Personal protective kit for
infectious patients 2 OB/SI HIV kit

Staff is adhere to standard No reuse of disposable gloves,

ME F3.2 2 OB/SI
personal protection practices Masks, caps and aprons.
Compliance to correct method
of wearing and removing the 2 SI Gloves, Masks, Caps and Aprons
PPE
Standard F4 Facility has standard Procedures for processing of equipment's and instruments
Facility ensures standard
Ask staff about how they decontaminate the
practices and materials for
ME F4.1 decontamination and clean ing Decontamination of operating 2 SI/OB procedure surface like OT Table,
of instruments and procedures & Procedure surfaces
Stretcher/Trolleys etc.
(Wiping with 0.5% Chlorine solution
areas

Ask staff how they decontaminate the

Proper Decontamination of instruments like Abuba, suction canulae,
2 SI/OB Surgical Instruments
instruments after use (Soaking in 0.5% Chlorine Solution, Wiping
with 0.5% Chlorine Solution or 70% Alcohol
as applicable

Contact time for

decontamination is adequate 2 SI/OB 10 minutes

Cleaning of instruments after 2 SI/OB Cleaning is done with detergent and running
decontamination water after decontamination
Proper handling of Soiled and No sorting ,Rinsing or sluicing at Point of
infected linen 2 SI/OB use/ Patient care area
Staff know how to make 2 SI/OB
chlorine solution

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Facility ensures standard Equipment and instruments are

practices and materials for
ME F4.2 sterilized after each use as per 2 OB/SI Autoclaving/HLD/Chemical Sterilization
disinfection and sterilization of
instruments and equipment's requirement
High level Disinfection of Ask staff about method and time required
instruments/equipment's is 2 OB/SI
done as per protocol for boiling
Chemical sterilization of Ask staff about method, concentration and
instruments/equipment's is 2 OB/SI contact time required for chemical
done as per protocols sterilization

Formaldehyde or
glutaraldehyde solution 2 OB/SI
replaced as per manufacturer
instructions
Autoclaved linen are used for
procedure 2 OB/SI

Autoclaved dressing material is

2 OB/SI
used
Instruments are packed
according for autoclaving as per 2 OB/SI
standard protocol
Autoclaving of instruments is Ask staff about temperature, pressure and
2 OB/SI
done as per protocols time

Regular validation of
sterilization through biological 2 OB/SI/RR
and chemical indicators

Maintenance of records of 2 OB/SI/RR

sterilization
There is a procedure to ensure
the traceability of sterilized 2 OB/SI/RR
packs
Sterility of autoclaved packs is Sterile packs are kept in clean, dust free,
maintained during storage 2 OB/SI moist free environment.
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Layout of the department is Facility layout ensures
Faculty layout ensures separation of general
ME F5.1 conducive for the infection separation of general traffic 2 OB traffic from patient traffic
control practices from patient traffic
Zoning of High risk areas 2 OB
Facility layout ensures
separation of routes for clean 2 OB
and dirty items
Floors and wall surfaces of ICU
are easily cleanable 2 OB

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

CSSD/TSSU has demarcated

separate area for receiving
2 OB
dirty items, processes, keeping
clean and sterile items

Facility ensures availability of

standard materials for cleaning Availability of disinfectant as Chlorine solution, Glutaraldehyde, carbolic
ME F5.2 and disinfection of patient care per requirement 2 OB/SI acid
areas
Availability of cleaning agent as 2 OB/SI Hospital grade phenyl, disinfectant
per requirement detergent solution
Facility ensures standard
ME F5.3 practices followed for cleaning Staff is trained for spill 2 SI/RR
and disinfection of patient care management
areas
Cleaning of patient care area 0 SI/RR
with detergent solution
Staff is trained for preparing
cleaning solution as per 2 SI/RR
standard procedure
Standard practice of mopping
1 OB/SI
and scrubbing are followed
Cleaning equipment's like
broom are not used in patient 2 OB/SI
care areas
Use of double bucket system 0 OB/SI
for mopping
Fumigation/carbonization as
2 SI/RR
per schedule
External foot wares are 2 OB
restricted
ME F5.5 Facility ensures air quality of high Adequate air exchanges are 2 SI/RR
risk area maintained
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
Facility Ensures segregation of Availability of colour coded bins
ME F6.1 Bio Medical Waste as per 2 OB Adequate number. Covered. Foot operated.
at point of waste generation
guidelines
Availability of colour coded
2 OB
non chlorinated plastic bags

Human Anatomical waste, Items

contaminated with blood, body fluids,
Segregation of Anatomical and dressings, plaster casts, cotton swabs and
2 OB/SI
soiled waste in Yellow Bin bags containing residual or discarded blood
and blood components.

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Items such as tubing, bottles, intravenous

Segregation of infected plastic tubes and sets, catheters, urine bags,
2 OB syringes (without needles and fixed needle
waste in red bin
syringes) and vacutainers' with their
needles cut) and gloves

Display of work instructions for

segregation and handling of 2 OB Pictorial and in local language
Biomedical waste
There is no mixing of infectious
and general waste 2

Facility ensures management of Availability of functional needle

ME F6.2 sharps as per guidelines cutters 2 OB See if it has been used or just lying idle.

Should be available nears the point of

Segregation of sharps waste
including Metals in white generation. Needles, syringes with fixed
(translucent) Puncture proof, needles, needles from needle tip cutter or
2 OB burner, scalpels, blades, or any other
Leak proof, tamper proof
contaminated sharp object that may cause
containers
puncture and cuts. This includes both used,
discarded and contaminated metal sharps

Availability of post exposure Ask if available. Where it is stored and who

2 SI/OB
prophylaxis is in charge of that.
Staff knows what to do in case of shape
Staff knows what to do in
condition of needle stick injury 1 SI injury. Whom to report. See if any reporting
has been done

Contaminated and broken

Glass are disposed in puncture
proof and leak proof box/ 1 OB Vials, slides and other broken infected glass
container with Blue colour
marking

Facility ensures transportation

ME F6.3 and disposal of waste as per Check bins are not overfilled 2 SI/OB
guidelines
Disinfection of liquid waste 2 SI/OB
before disposal
Transportation of bio medical
waste is done in close 2
container/trolley

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to locate mercury beads
5. Use syringe without a needle/eyedropper
and sticky tape to suck the beads
6. Collection of beads in leak-proof bag or
container
Staff is aware of mercury spill 1 SI/RR 7. Sprinkle sulphur or zinc powder to remove
management any remaining mercury
8. All the mercury spill surfaces should be
decontaminated with 10% sodium
thiosulfate solution
9. All the bags or containers containing items
contaminated with mercury should be
marked as “Hazardous Waste, Handle with
Care”
10. Collected mercury waste should be
handed over to the CBMWTF

Area of Concern - G Quality Management

Standard G1 The facility has established organizational framework for quality improvement

ME G1.1 The facility has a quality team in Quality circle has been formed 1 SI/RR Check if quality circle formed and functional
place in the Post-partum Unit with a designated nodal officer for quality

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

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.
There is system daily round by
Facility has established internal Hospital superintendent/
ME G3.1 quality assurance program at Hospital Manager/ Matron in 2 SI/RR Check for entries in Round Register
relevant departments charge for monitoring of
services

Facility has established external

ME G3.2 assurance programs at relevant 2
departments

Facility has established system Internal assessment is done at

ME G3.3 for use of check lists in different periodic interval 2 RR/SI NQAS, Kayakalp, SaQushal tools are used to
conduct internal assessment
departments and services

Departmental checklist are

used for monitoring and quality 2 SI/RR Staff is designated for filling and monitoring
of these checklists
assurance

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Non-compliances are 2 RR Check the non compliances are presented &

enumerated and recorded
discussed during quality team meetings

Check action plans are

Actions are planned to address prepared and implemented as Randomly check the details of action,
ME G3.4 gaps observed during quality 2 RR responsibility, time line and feedback
per internal assessment record
assurance process findings mechanism

Planned actions are Check PDCA or prevalent Check actions have been taken to close the
quality method is used to take gap. It can be in form of action taken report
ME G3.5 implemented through Quality corrective and preventive 2 SI/RR or Quality Improvement (PDCA) project
Improvement Cycles (PDCA)
action report
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Departmental standard Standard operating procedure

ME G4.1 operating procedures are for department has been 2 RR
available prepared and approved

Current version of SOP are

available with process owner 2 OB/RR

Work instruction/clinical
0 OB IUD insertion, Processing of instruments
protocols are displayed

Standard Operating Procedures Department has documented

ME G4.2 adequately describes process procedure for registration, 2 RR
and procedures admission and discharge

Department has documented

procedure for initial 2 RR
assessment of the patient

Department has documented

procedure for providing
2 RR
appointment/day and date for
the surgery

Department has documented

procedure for preparation of 2 RR
patient for surgery, IUD
insertion, PPIUCD insertion

Department has documented

procedure for taking consent of 2 RR
the patient for procedure
Department has documented
procedure for record 0 RR
maintenance
Department has documented
procedure for counselling of 2 RR
the patient

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Check for:
1. Male and female sterilization manual
Department has an FP manual 2 RR 2. Quality assurance for sterilisation
3. FP indemnity scheme
4. FP Anatra and Chhaya

Department has guideline for

administration of Emergency 2 RR
contraceptive
Department has standard for
various technique of 2 RR
contraception
Department has standard IEC
material for patient education 2 RR
and counselling
Staff is trained and aware of the Check staff is a aware of
ME G4.3 standard procedures written in relevant part of SOPs 1 SI/RR
SOPs

Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

ME G5.1 Facility maps its critical Process mapping of critical 0 SI/RR

processes processes done
Facility identifies non value Non value adding activities are
ME G5.2 adding activities / waste / 0 SI/RR
identified
redundant activities

ME G5.3 Facility takes corrective action to Processes are rearranged as per 0 SI/RR
improve the processes requirement
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Check quality policy of the facility has been

defined in consultation with hospital staff
Facility has defined Quality
ME G6.3 policy, which is in congruency Check if Quality Policy has been 1 SI/RR and duly approved by the head of the facility
defined and approved . Also check Quality Policy enables
with the mission of facility achievement of mission of the facility and
health department

Check short term valid quality objectivities

have been framed addressing key quality
Facility has de defined quality
ME G6.4 objectives to achieve mission Check if SMART Quality 1 SI/RR issues in each department and cores
Objectives have framed services. Check if these objectives are
and quality policy Specific, Measurable, Attainable, Relevant
and Time Bound.

Mission, Values, Quality policy Check of staff is aware of Interview with staff for their awareness.
ME G6.5 and objectives are effectively Check if Mission Statement, Core Values and
communicated to staff and users Mission
, Values, Quality Policy 1 SI/RR
Quality Policy is displayed prominently in
of services and objectives local language at Key Points

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Reference No ME Statement Checkpoint e Method Means of Verification Remarks

Verify with records that a time bound action

Facility prepares strategic plan to Check if plan for implementing plan has been prepared to achieve quality
ME G6.6 achieve mission, quality policy quality policy and objectives 1 SI/RR policy and objectives in consultation with
and objectives have prepared hospital staff . Check if the plan has been
approved by the hospital management

Review the records that action plan on

Facility periodically reviews the quality objectives being reviewed at least
Check time bound action plan is
ME G6.7 progress of strategic plan being reviewed at regular time 1 SI/RR once in month by departmental in charges
towards mission, policy and and during the quality team meeting. The
interval
objectives progress on quality objectives have been
recorded in Action Plan tracking sheet

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

Facility uses method for quality Basic quality improvement

ME G7.1 0 SI/OB PDCA & 5S
improvement in services method

Advance quality improvement

0 SI/OB Six sigma, lean.
method

ME G7.2 Facility uses tools for quality 7 basic tools of Quality 0 SI/RR Minimum 2 applicable tools are used in each
improvement in services department

Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
Periodic assessment for Check periodic assessment of Verify with the records. A comprehensive
Medication and Patient care medication and patient care risk assessment of all clinical processes
ME G9.6 safety risks is done as per safety risk is done using defined 1 SI/RR should be done using pre define criteria at
defined criteria. checklist periodically least once in three month.
Periodic assessment for potential
risk regarding safety and security SaQushal assessment toolkit is 1. Check that the filled checklist and action
ME G9.7 of staff including violence against 2 SI/RR taken report are available
service providers is done as per used for safety audits. 2. Staff is aware of key gaps & closure status
defined criteria
ME G9.8 Risks identified are analysed Identified risks are analysed for 2 SI/RR Action is taken to mitigate the risks
evaluated and rated for severity severity
Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

Check parameter are defined &

implemented to review the clinical care i.e.
Clinical care assessment criteria The facility has established through Ward round, peer review, morbidity
ME G10.3 have been defined and procedures to review the 0 SI/RR & mortality review, patient feedback, clinical
communicated clinical care processes audit & clinical outcomes.

(1) Both critical and stable patients

Check regular ward rounds are
taken to review case progress 0 SI/RR (2) Check the case progress is documented
in BHT/ progress notes-
Check the patient /family Feedback is taken from patient/family on
participate in the care 0 SI/RR
evolution health status of individual under treatment

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Complianc Assessment
Reference No ME Statement Checkpoint e Method Means of Verification Remarks

System in place to review internal referral

Check the care planning and co- process, review clinical handover
0 SI/RR
ordination is reviewed information, review patient understanding
about their progress

Facility conducts the periodic

clinical audits including There is a procedure to conduct
ME G10.4 2 SI/RR Check with audit reports
prescription, medical and death surgical audits
audits

All non compliance are

enumerated & recorded for 0 SI/RR Check the non compliances are presented
surgical audits & discussed during clinical Governance
meetings

Clinical care audits data is Check action plans are

analysed, and actions are taken prepared and implemented as Randomly check the actual compliance with
ME G10.5 to close the gaps identified per surgical audit record's 0 SI/RR the actions taken reports of last 3 months
during the audit process findings

Check the data of audit 0 SI/RR Check collected data is analysed & areas for
findings are collated improvement is identified & prioritised

Check the critical problems are regularly

Check PDCA or prevalent monitored & applicable solutions are
quality method is used to 0 SI/RR
address critical problems duplicated in other departments (wherever
required) for process improvement

Facility ensures easy access and Check standard treatment

use of standard treatment guidelines / protocols are Staff is aware of Standard treatment
ME G10.7 guidelines & implementation available & followed. 2 SI/RR protocols/ guidelines/best practices
tools at
point of care

Check treatment plan is Check staff adhere to clinical protocols while

prepared as per Standard 2 SI/RR
treatment guidelines preparing the treatment plan

Check the drugs are prescribed

as per Standards treatment 2 SI/RR Check the drugs prescribed are available in
EML or part of drug formulary
guidelines

Check when the STG/protocols/evidences

Check the updated/latest used in healthcare facility are published.
2 SI/RR
evidence are available Whether the STG protocols are according to
current evidences.
The gaps in clinical practices are identified &
Check the mapping of existing action are taken to improve it. Look for
clinical practices processes is 1 SI/RR
evidences for improvement in clinical
done
Area of Concern - H Outcome practices using PDCA
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
Facility measures productivity IUD insertion per 1000 eligible
ME H1.1 Indicators on monthly basis female 2 RR Denominator to be discussed

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Complianc Assessment
Reference No ME Statement Checkpoint e Method Means of Verification Remarks

No of First Trimester MTP 2 RR

No. of Second Trimester MTP 2 RR
No. Antara (injectable
contraceptive) user 2 RR
No. Chhaya user 2
No. of PP- FP Method 2 RR at least 10% of deliveries per facility
Proportion of users using 2 RR
limiting method
Proportion of target met for 2 RR
male sterilization surgery
Proportion of target met for
2 RR
female sterilization surgery
No. of family planning
counselling done per 1000 2 RR
client
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Skin to Skin time 2 RR
Indicators on monthly basis
Proportion of clients agreed for
family planning methods out of 2 RR
total counselled
Surgeries done/ surgeon : 30 /day. 2
FP surgeries done per surgeon 2 RR Surgeon :50 /day.
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
Facility measures Clinical Care &
ME H3.1 Safety Indicators on monthly Surgical Site Infection rate 2 RR
basis
No of adverse events per
2 RR
thousand patients
No. of complication per 1000 2 RR
male sterilization surgeries
No. of complication per 1000
2 RR
female sterilization surgeries
No. of post operative deaths 2 RR
per 1000 surgeries
No. of sterilization failure per
2 RR
1000 surgeries
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

ME H4.1 Facility measures Service Quality Client Satisfaction score 2 RR

Indicators on monthly basis

Average counselling time 2 RR

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services
Major medical cases like
ME A1.1 The facility provides General Medicine services Availability of Intensive care services for 2 SI/OB CVA,Haematomas, CAD,
medical cases Haemoptysis, Snake bite, Br.
Asthma Poisoning etc
Availability of Intensive care services for Major surgical cases including
ME A1.2 The facility provides General Surgery services Surgical cases 0 SI/OB trauma
If ICU services are not available
ME A1.3 The facility provides Obstetrics & Gynaecology Availability of Intensive care services for 1 SI/OB then facility ensure linkages
Services Gynae and obstetrics cases (Partial Compliance)
Services are available for the time period as
ME A1.14 mandated Availability of ICU services 24X7 2 SI/RR

Intubation, Tracheotomy,
Mechanical Ventilation, short term
ME A1.17 The facility provides Intensive care Services Availability of Intensive care services. 2 SI/OB cardio respiratory support,
Defibrillation, CPR, Mobilization,
Chest Tube, ventilator
Standard A3 Facility Provides diagnostic Services
ME A3.1 The facility provides Radiology Services Availability of Portable X ray services 2 SI/OB
Availability of USG services 2 SI/OB
ME A3.2 The facility Provides Laboratory Services Functional side laboratory services are 1 SI/OB ABG & Electrolyte
available

ME A3.3 The facility provides other diagnostic services, Functional ECG Services are available 2 SI/OB 12 lead ECG
as mandated
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme
The facility provides services under National
Programme for Prevention and control of
ME A4.8 Availability of cardiac care unit 2 SI/OB 5 bedded ICU
Cancer, Diabetes, Cardiovascular diseases &
Stroke (NPCDCS) as per guidelines
Area of Concern - B Patient Rights
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities
Numbering, main department and
ME B1.1 The facility has uniform and user-friendly Availability of departmental & directional 0 OB internal sectional signage are
signage system signages
displayed
Restricted area signage are displayed 2 OB
The facility displays the services and
ME B1.2 entitlements available in its departments Services provision in ICU are displayed 2 OB

Services not available in ICU are displayed 2 OB

Names of doctor and nursing staff on duty

2 OB
are displayed and updated
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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Important numbers including ambulance,

blood bank and referral centres displayed 2 OB

User charges are displayed and communicated User charges in r/o lCU services are
ME B1.4 2 OB
to patients effectively displayed

ME B1.5 Patients & visitors are sensitised and educated IEC material displayed in waiting area 2 OB
through appropriate IEC / BCC approaches

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

ME B1.8 The facility ensures access to clinical records of Discharge summary is given to the patient 2 OB
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, economic, cultural or social reasons.
Services are provided in manner that are Availability of female staff if a male doctor
ME B2.1 2 OB/SI
sensitive to gender examination a female patients
Access to facility is provided without any Availability of Wheel chair or stretcher for
ME B2.3 physical barrier & and friendly to people with easy Access to the ICU 2 OB
disabilities

ICU is connected to lift/ramp 2 OB for easy , safe and fast transport of

bed/trolley of critically sick patient

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Adequate visual privacy is provided at every Availability of screen/curtain at the 2 OB
point of care examination and procedural area

ME B3.2 Confidentiality of patients records and clinical Patient Records are kept at secure place 2 SI/OB
information is maintained beyond access to general staff/visitors

No information regarding patient identity 2 SI/OB

and details are unnecessary displayed

The facility ensures the behaviours of staff is

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

The facility ensures privacy and confidentiality

ME B3.4 to every patient, especially of those conditions Privacy and confidentiality of HIV cases 2 SI/OB
having social stigma, and also safeguards
vulnerable groups
Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it is required.
There is established procedures for taking
Admission, intubation, blood
ME B4.1 informed consent before treatment and Informed consent for ICU 2 SI/RR
transfusion
procedures
Consent for Invasive procedure 2 SI/RR

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

ME B4.3 Staff are aware of Patients rights Staff is aware of patients rights and 2 SI
responsibilities responsibilities
ICU has system in place to communicate Ask patients relative about
Information about the treatment is shared with with patient/ their family member the whether they have been
ME B4.4 2 PI/SI
patients or attendants, regularly nature and seriousness of the illness at least communicated about the
once in day treatment plan and progress

Availability of complaint box and display of

The facility has defined and established
ME B4.5 grievance redressal system in place process for grievance re addressal and 0 OB
whom 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 care.
The facility provides cashless services to
ME B5.1 pregnant women, mothers and neonates as per ICU services are free for beneficiaries 2 PI/SI PMJAY, JSSK and any other beneficiary
prevalent government schemes

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

It is ensured that facilities for the prescribed Check that patient party has not incurred
ME B5.3 investigations are available at the facility expenditure on diagnostics from outside. 1 PI/SI

The facility provide free of cost treatment to

ME B5.4 Below poverty line patients without ICU services are free for BPL patients 2 PI/SI/RR
administrative hassles
Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities

The policy clearly defines the

procedures for managing critical
cases in the ward, HDU/ICU, brain-
dead patients, conscious patients
with serious diseases like motor
neurons and brought-in dead
cases. It also includes:
(a) Patient and family have the
There is an established procedure for ‘end-of- End of life policy & procedure are available right to be informed about their
ME B6.6 life’ care and followed 2 SI/RR condition and make choices about
the treatment
(b) Withhold or withdraw life-
sustaining treatment
(c ) Organ donation as per NOTTO
&India's Governing organ
donation law
(d)
All the decisions should be
transparent and documented

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Staff is educated & trained for end of life 2 SI/RR
care
The patient's Relatives informed clearly
about the deterioration in the health 2 SI/RR Periodic update on the patient's
condition is given to the family.
condition of Patient.

Policy & procedures like DNR , DNI etc for Patient right "Do not resuscitate"
critical cases are in consonance with legal 2 SI/RR or " Do not intubate"/ allow
requirement natural death are respected

(1) Check about the policy and

The is a standard procedure for removal of practice for removing life support
2 SI/RR (2)Patient or family is involved in
life-sustaining treatment as per law decision-making, and patient's or
family's choice is respected

There is a procedure to allow patient

relative/Next of Kin to observe patient in 2 SI/OB
last hours

(a) a patient living with or

diagnosed with life-limiting illness
(b) a patient who is likely to die in
the short or medium term is
admitted, or deteriorates during
their admission
(c) a patient is dying where Patient
Staff is aware of events indicating that (or family member, if the patient
lacks capacity)
conversations about end-of-life care need 2 RR/SI
to start with patient or family expresses interest in discussing
end-of-life care
(d) a previously well person who
has suffered an acute life-
threatening event or illness is
admitted
(e) unexpected, significant physical
deterioration occurs

Hospital has documented policy for pain

management 2 SI/OB

Symptomatic treatment is given to

Screening of the patient for pain 2 SI/RR the patient to prevent
complications to extent possible

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Pain alleviation measures or medication is
initiated & titrated as per need and 2 SI/RR
response

There is an established procedure for patients

ME B 6.7 who wish to leave hospital against medical Declaration is taken from the LAMA patient 2 RR/SI Consequences of LAMA are
explained to patient/relative
advice or refuse to receive specific c treatment

Area of Concern - C Inputs

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
Space requirement in ICU is 100-
ME C1.1 Departments have adequate space as per ICU has adequate space as per requirement 2 OB 125 sq. feet area per bed in patient
patient or work load care area including space for
storage and duty room etc
Availability of adequate waiting area
2 OB

ME C1.2 Patient amenities are provide as per patient Availability of seating arrangement 2 OB
load
Availability of cold Drinking water 2 OB
Availability of functional toilets 2 OB
Departments have layout and demarcated There is no thoroughfare through
ME C1.3 areas as per functions ICU has single entry and exit 2 OB ICU
All monitors/ patients must be
Central nursing station is available in ICU 1 OB observable from nursing station
either directly or through central
monitoring station
ICU has designated Isolation room 2 OB
Ancillary area includes: Nursing
Availability of Ancillary area 2 OB station, clean and dirty utility area,
Unit stores, Hand washing and
gowning area,
Separate doctor and nurse change
ICU has dedicated change room for staff 2 OB room are available
ICU has dedicated counselling room 2 OB

ME C1.4 The facility has adequate circulation area and Corridors are wide enough for easy 2 OB 2-3 Meters
open spaces according to need and local law movement of Trolleys

There is sufficient space between two bed

to provide bed side nursing care and 2 OB
movement

ME C1.5 The facility has infrastructure for intramural Availability of functional telephone and 0 OB
and extramural communication Intercom Services

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

ME C1.6 Service counters are available as per patient Availability of ICU beds as per load 2 OB
load

The facility and departments are planned to

ensure structure follows the function/processes There is separate nursing station
ME C1.7 (Structure commensurate with the function of Unidirectional flow of services 0 OB for each ward
the hospital)

Location of nursing station and

There is a separate nursing station 1 OB patients beds enables easy and
direct observation of patients
ICU is in Proximity of OT and has functional 0 OB
linkage with OT
Standard C2 The facility ensures the physical safety of the infrastructure.
Check for fixtures and furniture
like cupboards, cabinets, and
ME C2.1 The facility ensures the seismic safety of the Non structural components are properly 2 OB heavy equipment's , hanging
infrastructure secured objects are properly fastened and
secured

ME C2.3 The facility ensures safety of electrical ICU building does not have temporary 2 OB
establishment connections and loose hanging wires
ICU has mechanism for periodical check /
test of all electrical installation by 2 OB/RR
competent electrical Engineer
ICU has dedicated earthling pit system
available 2 OB/RR

Wall mounted digital display is available in

0 OB
ICU to show earth to neutral voltage
Quality output of voltage stabilizer is
displayed in each stabilizer as per 0 OB
manufacturer guideline
Power boards are marked as per phase to
which it belongs 2 OB

ME C2.4 Physical condition of buildings are safe for Floors of the ICU are non slippery and even 2 OB
providing patient care
Windows/ ventilators if any in the OT are 2 OB
intact and sealed
Standard C3 The facility has established Programme for fire safety and other disaster
ICU has sufficient fire exit to permit safe
ME C3.1 The facility has plan for prevention of fire escape to its occupant at time of fire 0 OB/SI

Check the fire exits are clearly visible and

0 OB
routes to reach exit are clearly marked.

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

ME C3.2 The facility has adequate fire fighting OPD has installed fire Extinguisher that is 2 OB
Equipment Class A , Class B C type or ABC type
Check the expiry date for fire extinguishers
are displayed on each extinguisher as well
2 OB
as due date for next refilling is clearly
mentioned
ICU has provision of Smoke and heat
detector 2 OB/RR

ICU has electrical and automatic fire alarm

system or alarm system sounded by 2 OB/RR
actuation of any automatic fire extinguisher

The facility has a system of periodic training of Check for staff competencies for operating
ME C3.3 staff and conducts mock drills regularly for fire fire extinguisher and what to do in case of 2 SI/RR
and other disaster situation fire
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
The facility has adequate specialist doctors as
ME C4.1 per service provision Availability of full time intensivist 2 OB/RR

ME C4.2 The facility has adequate general duty doctors Availability of General duty doctor 2 OB/RR Duty doctor in 1: 5 ratio
as per service provision and work load

ME C4.3 The facility has adequate nursing staff as per Availability of Nursing staff as per 2 OB/RR/SI As per guideline
service provision and work load requirement

ME C4.4 The facility has adequate Availability of paramedic staff 2 OB/SI 1: 5 ratio
technicians/paramedics as per requirement

ME C4.5 The facility has adequate support / general staff Availability of ICU attendant 0 SI/RR
Availability Security staff 0 SI/RR 1 in each shift
Availability of housekeeping staff 2 SI/RR
Standard C5 Facility provides drugs and consumables required for assured list of services.

The departments have availability of adequate Availability of Analgesics/Antipyretics/Anti

ME C5.1 drugs at point of use Inflammatory 2 OB/RR As per State EDL

Availability of Anti Infectives -Antibiotics,

2 OB/RR As per State EDL
Antifungal, Antiprotozoal
Availability of Infusion Fluids 2 OB/RR As per State EDL
Availability of Drugs acting on 2 OB/RR As per State EDL
Cardiovascular System

Availability of drugs action on Central

2 OB/RR As per State EDL
Nervous system, Peripheral Nervous System

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Availability of dressing material and 2 OB/RR As per State EDL
antiseptic liquid/lotion
Drugs for Respiratory System 2 OB/RR As per State EDL
Hormonal Preparation and Anti- Hormonal 2 OB/RR As per State EDL
Preparation
Availability of Medical gases 2 OB/RR Availability of Oxygen Cylinders
ME C5.2 The departments have adequate consumables Availability of disposables 2 OB/RR examination gloves, Syringes,
at point of use

Resuscitation Consumables / Tubes 2 OB/RR Masks, Ryles tubes, Catheters,

Chest Tube, ET tubes etc

Emergency drug trays are maintained at every Emergency and resuscitation tray are
ME C5.3 point of care, where ever it may be needed maintained 2 OB/RR

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

Availability of equipment & instruments for Availability of functional Equipment Bed side monitor, pulse oximeter,
ME C6.1 2 OB
examination & monitoring of patients &Instruments for examination & Monitoring thermometer, BP apparatus, ECG

Availability of equipment & instruments for

ME C6.2 treatment procedures, being undertaken in the Availability of dressing tray for ICU Surgical 2 OB
facility Ward

Availability of equipment & instruments for Availability of Point of care diagnostic

ME C6.3 diagnostic procedures being undertaken in the 2 OB ABG Machine, Glucometer,
facility instruments

Availability of equipment and instruments for

ME C6.4 resuscitation of patients and for providing Availability of Functional Intensive care 2 OB Ventilator, Infusion pump, C-PAP,
equipment and instruments
intensive and critical care to patients

Bag and mask, laryngoscope, ET

tubes, fibro optic bronchoscope
Availability of Functional Resuscitation 2 OB Oxygen cylinder/central line,
equipment's oxygen hood, Trey for procedures
like central line, Defibrillator
(Ambu bag)

Refrigerator, Crash cart/Drug

ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for 2 OB trolley, instrument trolley, dressing
drugs
trolley

Buckets for mopping, Separate

Availability of functional equipment and mops for patient care area and
ME C6.6 Availability of equipment's for cleaning 2 OB
instruments for support services circulation area duster, waste
trolley, Deck brush
Departments have patient furniture and
ME C6.7 fixtures as per load and service provision Availability of specialized ICU bed 2 OB ICU bed (shock proof -fibre).

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Availability of attachment/ accessories with Over bed tables, Head end panel,
patient bed 2 OB IV stand, Bed pan, bed rail,

Trey for monitors, Electrical panel

Availability of Fixtures 2 OB with bed, bedhead panel with
outlet for Oxygen and vacuum, X
ray view box.

Cupboard, nursing counter, table

Availability of furniture 2 OB for preparation of medicines, chair.

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

Check objective checklist has been

prepared for assessing
competence of doctors, nurses and
Criteria for Competence assessment are Check parameters for assessing skills and paramedical staff based on job
ME C7.1 2 RR/SI
defined for clinical and Para clinical staff proficiency of clinical staff has been defined description defined for each cadre
of staff. Dakshta checklist issued by
MoHFW can be used for this
purpose.

Check for records of competence

Competence assessment of Clinical and Para Check for competence assessment is done assessment including filled
ME C7.2 clinical staff is done on predefined criteria at 2 RR/SI checklist, scoring and grading .
least once in a year at least once in a year Verify with staff for actual
competence assessment done

The Staff is provided training as per defined

ME C7.9 core competencies and training plan Bio Medical waste Management 2 SI/RR
Infection control and hand hygiene 2 SI/RR
Advance life support Training 2 SI/RR
Code Blue 2 SI/RR
Patient safety 2 SI/RR

Training on Quality Management System 2 SI/RR To all category of staff. At the time
of induction and once in a year.

Check supervisors make periodic

There is established procedure for utilization of rounds of department and monitor
that staff is working according to
ME C7.10 skills gained thought trainings by on -job Staff is skilled to operate ICU equipments 2 SI/RR the training imparted. Also staff is
supportive supervision
provided on job training wherever
there is still gaps

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Check supervisors make periodic

rounds of department and monitor
Staff is skilled for resuscitation and 2 SI/RR that staff is working according to
intubation the training imparted. Also staff is
provided on job training wherever
there is still gaps

Check supervisors make periodic

rounds of department and monitor
Nursing staff is skilled identifying and 2 SI/RR that staff is working according to
managing complication the training imparted. Also staff is
provided on job training wherever
there is still gaps

Check supervisors make periodic

rounds of department and monitor
Nursing Staff is skilled for maintaining 2 SI/RR that staff is working according to
clinical records the training imparted. Also staff is
provided on job training wherever
there is still gaps

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
1. Check with AMC records/
ME D1.1 The facility has established system for All equipments are covered under AMC 0 SI/RR Warranty documents
maintenance of critical Equipment including preventive maintenance 2. Staff is aware of the list of
equipment covered under AMC.

(1) Check log book is maintained &

it shows time taken to repair
equipment.
(2) Backup of critical equipment
There is system of timely corrective break such as Ventilator, Infusion pump,
2 SI/RR
down maintenance of the equipments C-PAP,etc. is available
(3) Check staff is aware of Contact
details of the agencies/ person
responsible for maintenance

There has system to label Defective/Out of

order equipments and stored appropriately 2 OB/RR
until it has been repaired

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Staff is skilled for trouble shooting in case 2 SI/RR
equipment malfunction
Periodic cleaning, inspection and
maintenance of the equipments is done by 2 SI/RR
the operator
The facility has established procedure for
ME D1.2 internal and external calibration of measuring All the measuring equipments/ instrument 0 OB/ RR
Equipment are calibrated

There is system to label/ code the

equipment to indicate status of calibration/ 2 OB/ RR
verification when recalibration is due

Up to date instructions for operation and

ME D1.3 Operating and maintenance instructions are maintenance of equipments are readily 2 OB/SI Check the down time of
available with the users of equipment equipments
available with staff.
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas
Stock level are daily updated
There is established procedure for forecasting There is established system of timely Indents are timely placed
ME D2.1 and indenting drugs and consumables indenting of consumables and drugs at 2 SI/RR
nursing station

Away from direct sunlight and

ME D2.3 The facility ensures proper storage of drugs and Drugs are stored in containers/tray/crash 2 OB temperature is maintained as per
consumables cart and are labelled instructions of manufacturer.

Empty and filled cylinders are labelled 2 OB

Records for expiry and near expiry
drugs are maintained for
The facility ensures management of expiry and Expiry dates' are maintained at emergency
ME D2.4 near expiry drugs drug tray 2 OB/RR emergency tray
FIRST EXPIRY and FIRST
OUT (FEFO) is in practice

No expired drug found 2 OB/RR Check the drug expiry of drug sub
store
Records for expiry and near expiry drugs are Check the record of expiry and
2 RR
maintained for drug stored in ICU near expiry drug

Minimum stock and reorder level

are calculated based on
ME D2.5 The facility has established procedure for There is practice of calculating and 2 SI/RR consumption
inventory management techniques maintaining buffer stock
Minimum buffer stock is
maintained all the time

Check record of drug received,

Department maintained stock register of 2 RR/SI issued and balance stock in hand
drugs and consumables
and are regularly updated

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Drugs are categorized in Vital, Essential and 2 OB/RR Check all Vital drugs are available
Desirable
There is a procedure for periodically There is established system for replenishing
ME D2.6 replenishing the drugs in patient care areas drug tray /crash cart 2 SI/RR
There is no stock out of drugs 2 OB/SI Check stock of some vital drugs
Temperature of refrigerators are kept as Check for temperature charts are
There is process for storage of vaccines and
ME D2.7 other drugs, requiring controlled temperature per storage requirement and records twice 2 OB/RR maintained and updated twice a
a day and are maintained daily.
Separately kept, away from other
ME D2.8 There is a procedure for secure storage of Narcotic ,psychotropic drugs are kept 1 OB/SI drugs and labelled
narcotic and psychotropic drugs separately in lock and key

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

ME D3.1 The facility provides adequate illumination level Adequate Illumination at nursing station 2 OB General Patient Care - 200-50 Lux
at patient care areas Procedure Spot Light - 1500 Lux

Adequate illumination in patient care unit 2 OB

ME D3.2 The facility has provision of restriction of Entry to ICU is restricted 2 OB

visitors in patient areas
Visiting hour are fixed and practiced 0 OB/PI

20-25OC, ICU has functional room

ME D3.3 The facility ensures safe and comfortable Temperature is maintained in ICU and 2 SI/RR thermometer and temperature is
environment for patients and service providers record of same is kept regularly maintained

Humidity is maintained in ICU and record of 2 SI/RR 50-60%

same is maintained

ICU has system to maintain its ventilation 2 SI/RR

and its environment is dust free

ICU has system to control the sound

producing activities and gadgets' (like
telephone sounds, staff area and 0 SI/RR
equipments)

ME D3.4 The facility has security system in place at Security arrangement at ICU 0 OB
patient care areas
Check mechanism at place to track
Identification band for all 2 OB the patient based on UID
The facility has established measure for safety
ME D3.5 Female staff feel secure at work place 1 SI
and security of female staff
Standard D4 The facility has established Programme for maintenance and upkeep of the facility
Exterior of the facility building is maintained Building is painted/whitewashed in uniform
ME D4.1 2 OB
appropriately color
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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Interior of patient care areas are plastered 2 OB
& painted

ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof topes, sinks patient 2 OB All area are clean with no
care and circulation areas are Clean dirt,grease,littering and cobwebs

Surface of furniture and fixtures are clean 2 OB

Toilets are clean with functional flush and
running water 2 OB

Hospital infrastructure is adequately Check for there is no seepage , Cracks,

ME D4.3 1 OB
maintained chipping of plaster
Window panes , doors and other fixtures 2 OB
are intact
Patients beds are intact and painted 2 OB Mattresses are intact and clean
The facility has policy of removal of condemned
ME D4.5 junk material No condemned/Junk material in the ICU 2 OB

The facility has established procedures for pest,

ME D4.6 No rodent/pests are noticed 2 OB
rodent and animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
The facility has adequate arrangement storage
ME D5.1 and supply for portable water in all functional Availability
water
of 24x7 running and potable 2 OB/SI
areas

ME D5.2 The facility ensures adequate power backup in Availability of power back up in ICU 1 OB/SI Power back for all critical
all patient care areas as per load equipments
Availability of UPS 2 OB/SI
Availability of Emergency light 2 OB/SI

Critical areas of the facility ensures availability Availability of Centralized /local piped
ME D5.3 of oxygen, medical gases and vacuum supply Oxygen and vacuum supply 2 OB

StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.
ME D6.1 The facility has provision of nutritional Nutritional assessment of patient done as 2 RR/SI
assessment of the patients required and directed by doctor
The facility provides diets according to Check for the adequacy and frequency of Check that all items are as per
ME D6.2 2 OB/RR
nutritional requirements of the patients diet as per nutritional requirement clinical advice

Ask patient/staff weather they are

Check for the Quality of diet provided in ICU 2 PI/SI satisfied with the Quality of food

Hospital has standard procedures for

There is procedure of requisition of
ME D6.3 preparation, handling, storage and distribution different type of diet from ward to kitchen 2 RR/SI
of diets, as per requirement of patients

Standard D7 The facility ensures clean linen to the patients

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

ME D7.1 The facility has adequate sets of linen Clean Linens are provided for all occupied 2 OB/RR
bed
Gown is provided to all patients 2 OB/RR
ME D7.2 The facility has established procedures for Linen is changed every day and whenever it 2 OB/RR
changing of linen in patient care areas get soiled
The facility has standard procedures for There is system to check the cleanliness
ME D7.3 handling , collection, transportation and and Quantity of the linen received from 2 SI/RR
washing of linen laundry

Check linen is kept closed bin &

emptied regularly. Plastic bag is
Check dedicated closed bin is kept for 2 OB used in dustbin & these bags are
storage of dirty linen
sealed before removed & handed
over

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

ME D11.1 The facility has established job description as Job description is defined and 1 RR Regular + contractual
per govt guidelines communicated to all concerned staff
Staff is aware of their role and 2 SI
responsibilities

The facility has a established procedure for Check for system for recording
ME D11.2 duty roster and deputation to different There is procedure to ensure that staff is 2 RR/SI time of reporting and relieving
departments available on duty as per duty roster (Attendance register/ Biometrics
etc)
There is designated in charge for 2 SI
department
The facility ensures the adherence to dress Doctor, nursing staff and support staff
ME D11.3 code as mandated by its administration / the adhere to their respective dress code 2 OB
health department
Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
Verification of outsourced services
There is procedure to monitor the quality (cleaning/
ME D12.1 There is established system for contract and adequacy of outsourced services on 2 SI/RR Dietary/Laundry/Security/Mainten
management for out sourced services regular basis ance) provided are done by
designated in-house staff
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

The facility has established procedure for Unique identification number is given to
ME E1.1 registration of patients each patient during process of registration 2 RR

Check for that patient

Patient demographic details are recorded in 2 RR demographics like Name, age, Sex,
admission records
Chief complaint, etc.

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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Criteria based on Vital sign,
There is established procedure for admission of There is established criteria for admission
ME E1.3 patients at ICU 2 SI/RR Laboratory value/ Diagnostic
values and Physical finding
There is no delay in admission of patient 2 SI/RR/OB
Admission is done on written order by 2 SI/RR/OB
authorized doctor
Time of admission is recorded in patient
record 2 RR

There is established procedure for managing

ME E1.4 patients, in case beds are not available at the Procedure cope with surplus patient load 2 OB/SI Check for admission criteria. Check
facility for linkage with higher facilities

Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.
Initial assessment of all admitted patient Assessment criteria of different
There is established procedure for initial done as per standard protocols
ME E2.1 2 RR/SI kind of medical /surgical conditions
assessment of patients is defined and practiced

Patient History is taken and recorded 2 RR

Physical Examination is done and recorded 2 RR
wherever required
Provisional Diagnosis is recorded 2 RR
Initial assessment and treatment is
provided immediately 2 RR/SI

Initial assessment is documented preferably 2 RR

within 1 hours
There is established procedure for follow-up/ There is fixed schedule for reassessment of
ME E2.2 reassessment of Patients patient under observation 2 RR/OB

For critical patients admitted in the ward

there is provision of reassessments as per 2 RR/OB
need

There is system in place to identify and Criteria is defined for

identification, and management of
manage the changes in Patient's health 2 SI/RR high risk patients/ patient whose
status condition is deteriorating

Check the treatment or care plan is Check the re assessment sheets/

modified as per re assessment results 2 SI/RR Case sheets modified treatment
plan or care plan is documented

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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Assessment includes physical

There is established procedure to plan and assessment, history, details of
Check healthcare needs of all hospitalised existing disease condition (if any)
ME E2.3 deliver appropriate treatment or care to patients are identified through assessment 2 SI/RR for which regular medication is
individual as per the needs to achieve best
possible results process taken as well as evaluate
psychological ,cultural, social
factors

(a) According to assessment and

investigation findings (wherever
applicable).
Check treatment/care plan is prepared as (b) Check inputs are taken from
2 RR patient or relevant care provider
per patient's need
while preparing the care plan.

Care plan include:, investigation to

be conducted, intervention to be
Check treatment / care plan is documented 2 RR provided, goals to achieve,
timeframe, patient education, ,
discharge plan etc

Check care is delivered by competent Check care plan is prepared and

multidisciplinary team 2 SI/RR delivered as per direction of
qualified physician
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral
Check for how hand over is given
Facility has established procedure for continuity There is procedure for hand over for patient
ME E3.1 of care during interdepartmental transfer transferred from ICU to IPD /OT/HDU 2 SI/RR from ICU to ward and vice versa
etc.

Check for the procedure for calling

Check for the procedure if patient is to be specialist on call to ICU for
consulted with other specialist 2 RR/SI opinion /advice. Is there any list of
specialist with phone no. available

Facility provides appropriate referral linkages to

ME E3.2 the patients/Services for transfer to
other/higher facilities to assure their continuity Patient referred with referral slip 2 RR/SI
of care.

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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

(1) Verify with referral records that

reasons for referral were clearly
Reason for referral is clearly stated and mentioned
(2) ICU staff confirms the suitability
referral is written by authorized competent 2 RR/ SI of referral with higher centres to
person (Medical Officer on duty) ascertain that case can be
managed at higher centre and will
not require further referrals

(1) Check ICU staff facilitates

arrangement of ambulance for
transferring the patient to higher
centre
(2) Patient attendant are not asked
Advance communication is done with to arrange vehicle by their own
higher centre & Referral vehicle is being 2 SI/PI/RR
(3) Check if ICU staff checks
arranged ambulance preparedness in terms
of necessary equipment, drugs,
accompanying staff in terms of
care that may be required in
transit

(1) Referral check list is filled

before referral to ensure all
necessary steps have been taken
for safe referral
(2) Check referral records has
Referral in or referral out register is information regarding advance
maintained 2 RR communication, transport
arrangement, accompanying care
provider, reason for referral , time
taken for referral etc. along with
demographics, date & time of
admission, date & time of referral,
and follow up

Facility has functional referral linkages to 2 SI/RR Check the mechanism of referral
facilities linkages to lower/higher facilities
There is a system of follow up of referred
patients 2 RR

A person is identified for care during all steps of Doctor and nurse is designated for each
ME E3.3 2 RR/SI Treating doctor is designated
care patient admitted to ICU ward

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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
There is established procedure for co
Duty doctor takes round with
ordination of care between duty doctor and 2 RR/SI treating doctor
treating doctor/specialist
Patient condition is reviewed during hand
2 RR/SI
over between duty doctors
Standard E4 The facility has defined and established procedures for nursing care

Procedure for identification of patients is There is a process for ensuring the patient's Patient id band/ verbal
ME E4.1 established at the facility identification before any clinical procedure 2 OB/SI confirmation/Bed no. etc.

Check for treatment chart are

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

(1) Check system is in place to give

There is a process to ensue the accuracy of 2 SI/RR telephonic orders & practised
verbal/telephonic orders (2) Verbal orders are verified by
the ordering physician within
defined time period

ME E4.3 There is established procedure of patient hand Patient hand over is given during the 2 SI/RR
over, whenever staff duty change happens change in the shift

Nursing Handover register is maintained 2 RR

Hand over is given bed side 2 SI/RR
Check for nursing note register.
ME E4.4 Nursing records are maintained Nursing notes are maintained adequately 2 RR/SI Notes are adequately written

ME E4.5 There is procedure for periodic monitoring of Patient Vitals are monitored and recorded 2 RR/SI Check for TPR chart, IO chart, any
patients periodically other vital required is monitored

Critical patients are monitored continually 2 RR/SI Check for use of cardiac
monitor/multi parameter
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.

The facility identifies vulnerable patients and Vulnerable patients are identified and Unconscious and comatose
ME E5.1 ensure their safe care measures are taken to protect them from 2 OB/SI patient, stupors patient, patient
any harm with suppressed immune system

ME E5.2 The facility identifies high risk patients and High risk patients are identified and 2 OB/SI
ensure their care, as per their need treatment given on priority
Standard E6 Facility ensures rationale prescribing and use of medicines
ME E6.1 Facility ensured that drugs are prescribed in Check for BHT if drugs are prescribed under 2 RR
generic name only generic name only

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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Check for that relevant Standard treatment

ME E6.2 There is procedure of rational use of drugs guideline are available at point of use 0 RR

Check staff is aware of the drug regime and Check BHT that drugs are
2 SI/RR
doses as per STG prescribed as per STG
Availability of drug formulary 2 SI/OB
Check complete medication history
including over-the- counter
There are procedures defined for medication Complete medication history is medicines is taken and
ME E6.3 review and optimization documented for each patient 2 RR/OB
documented

1. Medication Reconciliation is
carried out by a trained and
competent health professional
during the patient's admission,
interdepartmental transfer or
discharged
Established mechanism for Medication 2. Medicine reconciliation includes
1 SI/RR Prescription and non-prescription
reconciliation process
(over-the-counter) medications,
vitamins, nutritional supplements.

Medicines are optimised as per

Medicine are reviewed and optimised as 2 SI/RR individual treatment plan for best
per individual treatment plan
possible clinical outcome

1. Discharge summary includes

known drug allergies and reactions
to medicines or their ingredients,
and the type of reaction
Complete medication history is experienced
documented and communicated for each 2 SI/RR 2. Changes in prescribed
patient at the time of discharge medicines, including medicines
started or stopped, or dosage
changes, and reason for the
change are clearly documented in
the case sheet and case summary

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

1. Clinician/Nurse/Paramedics
counsel the patient on medication
safety using ""5 moments for
medication safety app""
Patients are engaged in their own care 2 PI/SI 2. Nurse/Pharmacist highlights the
medications to be taken by the
patient at home and counsel the
patient and family on drug intake
as per treatment plan for discharge

Standard E7 Facility has defined procedures for safe drug administration

Electrolytes like Potassium

chloride, Uploads, Neuro muscular
There is process for identifying and cautious High alert drugs available in department are blocking agent, Anti thrombolytic
ME E7.1 administration of high alert drugs (to check) identified 2 SI/OB agent, insulin, warfarin, Heparin,
Adrenergic agonist etc. as
applicable

Value for maximum doses as per

Maximum dose of high alert drugs are age, weight and diagnosis are
defined and communicated 2 SI/RR available with nursing station and
doctor

A system of independent double

There is process to ensure that right doses 2 SI/RR check before administration, Error
of high alert drugs are only given prone medical abbreviations are
not used

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

Check for the writing, It comprehendible by

the clinical staff 1 RR/SI

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

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

Check for separate sterile needle is used 2 OB In multi dose vial needle is not left
every time for multiple dose vial
in the septum
Any adverse drug reaction is recorded and 2 RR/SI Adverse drug event trigger tool is
reported used to report the events

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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Administration of medicines done

There is a system to ensure right medicine is Check Nursing staff is aware 7 Rs of after ensuring right patient, right
ME E7.4 given to right patient Medication and follows them 2 SI/RR drugs, right route, right time, Right
dose, Right Reason and Right
Documentation

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
All the assessments, re-assessment and Patient progress is recorded as per defined
ME E8.1 investigations are recorded and updated assessment schedule 2 RR (Manually/e-records)

ME E8.2 All treatment plan prescription/orders are Treatment plan, first orders are written on 2 RR Treatment prescribed in nursing
recorded in the patient records. BHT records (Manually/e-records)
Treatment given is recorded in
Care provided to each patient is recorded in the Maintenance of treatment chart/treatment
ME E8.3 patient records registers 2 RR treatment chart (Manually/e-
records)
Procedures performed are written on patients Mobilization, resuscitation etc
ME E8.4 Procedure performed are recorded in BHT 2 RR
records (Manually/e-records)
Adequate form and formats are available at Check for the availability of ICU
ME E8.5 point of use Standard Formats are available 0 RR/OB slip, Requisition slips etc.

General order book (GOB), report

book, Admission register, lab
Register/records are maintained as per Registers and records are maintained as per register, Admission sheet/ bed
ME E8.6 2 RR head ticket, discharge slip, referral
guidelines guidelines
slip, referral in/referral out
register, OT register, Diet register,
Linen register, Drug intend register

All register/records are identified and 2 RR

numbered

ME E8.7 The facility ensures safe and adequate storage Safe keeping of patient records 2 OB
and retrieval of medical records
Standard E9 The facility has defined and established procedures for discharge of patient.
Discharge is done after assessing patient ICU has established criteria for discharge of Patient is shifted to ward/step
ME E9.1 readiness the patient 2 SI/RR down after assessment
Assessment is done before discharging 2 SI/RR
patient

Discharge is done by an authorised doctor 2 SI/RR

Patient / attendants are consulted before

discharge 2 PI/SI

Treating doctor is consulted/ informed

2 SI/RR
before discharge of patients

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

ME E9.2 Case summary and follow-up instructions are Discharge summary is provided 2 RR/PI See for discharge summary,
provided at the discharge referral slip provided.
Discharge summary adequately mentions
patients clinical condition, treatment given 2 RR
and follow up
Discharge summary is give to patients going 2 SI/RR
in LAMA/Referred out
Counselling services are provided as during
ME E9.3 discharges wherever required Patient is counselled before discharge 2 PI/SI

Time of discharge is communicated to 2 PI/SI

patient before hand

Standard E10 The facility has defined and established procedures for intensive care.

The facility has established procedure for Step down of the patient is
ICU has procedure for step down of the
ME E10.1 shifting the patient to step-down/ward based 2 RR/SI planned by on duty doctor in
on explicit assessment criteria patient. consultation with treating doctor

ME E10.2 The facility has defined and established ICU has protocols for pain management 2 RR/SI
procedure for intensive care
ICU has protocol for sedation 2 RR/SI
ICU has procedure for starting Central lines 2 RR/SI

ICU has protocol for early eternal nutrition 2 RR/SI

Protocol for Care of unconscious paraplegic 2 RR/SI Prevention of decubitus in ICU

patients is available patient
ICU has protocol for management of
anaphylactic shock 2 RR/SI

The facility has explicit clinical criteria for

ME E10.3 providing intubation & extubating, and care of ICU has criteria defined for non invasive 2 RR/SI C -PEP and V -PEP
patients on ventilation and subsequently on its ventilation in case of respiratory failure
removal
Criteria for intubation 2 RR/SI
Criteria for extubating 2 RR/SI
Criteria of tracheotomy 2 RR/SI
Monitoring include subjective
ICU has protocols for care and Monitoring 2 RR/SI responses, physiological
of patient on ventilator responses, blood gas
measurement
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
The facility has disaster management plan in
ME E11.3 Staff is aware of disaster plan 2 SI/RR
place

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Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Role and responsibilities of staff in disaster 2 SI/RR
is defined

Standard E12 The facility has defined and established procedures of diagnostic services

ME E12.1 There are established procedures for Pre- Container is labelled properly after the 2 OB
testing Activities sample collection
There are established procedures for Post-
ME E12.3 testing Activities ICU has critical values of various lab test 2 SI/RR

Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.

ME E13.8 There is established procedure for issuing blood There is a procedure for issuing the blood
promptly for life saving measures 2 RR/SI

ME E13.9 There is established procedure for transfusion Consent is taken before transfusion 2 RR
of blood
Patient's identification is verified before 2 SI/OB
transfusion
Blood is kept on optimum temperature 2 RR
before transfusion
Blood transfusion is monitored and
regulated by qualified person 2 SI/RR

Blood transfusion note is written in patient 2 RR

recorded

There is a established procedure for monitoring Any major or minor transfusion reaction is
ME E13.10 and reporting Transfusion complication recorded and reported to responsible 2 RR
person
Standard E14 Facility has established procedures for Anaesthetic Services
ME E14.1 Facility has established procedures for Pre Pre anaesthesia check up is conducted for 2 SI/RR
Anaesthetic Check up elective / Planned surgeries
Maternal & Child Health Services
Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients

Death of admitted patient is adequately ICU has procedure to inform patient

ME E16.1 relatives about poor prognostic status of 2 SI
recorded and communicated inpatient
ICU has system for conducting bereavement
support of patient's relative in case of 2 RR/SI
mortality
Death note is written on patient record 2 RR
The facility has standard procedures for Death note including efforts done for
ME E16.2 2 SI/RR
handling the death in the hospital resuscitation is noted in patient record

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Death summary is given to patient
attendant quoting the immediate cause and 2 SI/RR
underlying cause if possible
The body of deceased is handled with
2 SI/RR/OB
respect and dignity
Socio-cultural beliefs of patient 's family are 2 SI/RR/OB
identified and respected
Area of Concern - F Infection Control
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 and active Surface and environment samples are taken 2 SI/RR Swab are taken from infection
culture surveillance of critical & high risk areas for microbiological surveillance prone surfaces

Patients are observed for any sign

Facility measures hospital associated infection There is procedure to report cases of and symptoms of HAI like fever,
ME F1.3 2 SI/RR
rates Hospital acquired infection purulent discharge from surgical
site .

ME F1.4 There is Provision of Periodic Medical Check- There is procedure for immunization of the 2 SI/RR Hepatitis B, Tetanus Toxoid etc
ups and immunization of staff staff
Periodic medical check-ups of the staff 2 SI/RR

Facility has established procedures for regular Regular monitoring of infection control Hand washing and infection
ME F1.5 monitoring of infection control practices practices 1 SI/RR control audits done at periodic
intervals

ME F1.6 Facility has defined and established antibiotic Check for Doctors are aware of Hospital 2 SI/RR
policy Antibiotic Policy
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis

Hand washing facilities are provided at point of Availability of hand washing Facility at Point FNBC guideline: Each unit should
ME F2.1 use of Use 2 OB have at least 1 wash basin for
every 5 beds

Availability of running Water 2 OB/SI Ask to Open the tap. Ask Staff
water supply is regular

Availability of antiseptic soap with soap Check for availability/ Ask staff if
dish/ liquid antiseptic with dispenser. 2 OB/SI the supply is adequate and
uninterrupted

Check for availability/ Ask staff for

Availability of Alcohol based Hand rub 2 OB/SI regular supply. Hand rub dispenser
are provided adjacent to bed

Prominently displayed above the

Display of Hand washing Instruction at Point
2 OB hand washing facility , preferably
of Use
in Local language
Availability of elbow operated taps 2 OB

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Hand washing sink is wide and deep enough

to prevent splashing and retention of water 2 OB

Staff is trained and adhere to standard hand

ME F2.2 Adherence to 6 steps of Hand washing 2 SI/OB Ask of demonstration
washing practices
Staff aware of when to hand wash 2 SI
Facility ensures standard practices and
ME F2.3 materials for antisepsis Availability of Antiseptic Solutions 2 OB

like before giving IM/IV injection,

Proper cleaning of procedure site with 2 OB/SI drawing blood, putting Intravenous
antisepsis and urinary catheter
Standard F3 Facility ensures standard practices and materials for Personal protection
ME F3.1 Facility ensures adequate personal protection Clean gloves are available at point of use 2 OB/SI
equipments as per requirements
Availability of Mask 2 OB/SI
Availability of gown/ Apron 2 OB/SI Staff and visitors
Availability of shoe cover 2 OB/SI Staff and visitors
Availability of Caps 2 OB/SI Staff and visitors
Personal protective kit for infectious 2 OB/SI
patients

ME F3.2 Staff is adhere to standard personal protection No reuse of disposable gloves, Masks, caps 2 OB/SI
practices and aprons.
Compliance to correct method of wearing
and removing the PPE 2 SI Gloves, Masks, Caps and Aprons
Standard F4 Facility has standard Procedures for processing of equipments and instruments

Ask staff about how they

decontaminate the procedure
Facility ensures standard practices and surface like Examination table ,
ME F4.1 materials for decontamination and clean ing of Cleaning
Units
& Decontamination of patient care 2 SI/OB Patients Beds Stretcher/Trolleys
instruments and procedures areas etc.
(Wiping with 0.5% Chlorine
solution

Ask staff how they decontaminate

the instruments like abusage,
Proper Decontamination of instruments 2 SI/OB suction cannula, Airways, Face
after use Masks, Surgical Instruments
(Soaking in 0.5% Chlorine Solution,
Wiping with 0.5% Chlorine Solution
or 70% Alcohol as applicable

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Contact time for decontamination is 2 SI/OB 10 minutes
adequate
Cleaning is done with detergent
Cleaning of instruments after 2 SI/OB and running water after
decontamination
decontamination

Proper handling of Soiled and infected linen 2 SI/OB No sorting ,Rinsing or sluicing at
Point of use/ Patient care area
Staff know how to make chlorine solution 2 SI/OB
Facility ensures standard practices and
ME F4.2 materials for disinfection and sterilization of Equipment and instruments are sterilized 2 OB/SI Autoclaving/HLD/Chemical
instruments and equipments after each use as per requirement Sterilization

High level Disinfection of

Ask staff about method and time
instruments/equipments is done as per 2 OB/SI required for boiling
protocol
Autoclaving of instruments is done as per 2 OB/SI Ask staff about temperature,
protocols pressure and time

Chemical sterilization of Ask staff about method,

instruments/equipments is done as per 2 OB/SI concentration and contact time
protocols required for chemical sterilization

Autoclaved linen are used for procedure 2 OB/SI

Autoclaved dressing material is used 2 OB/SI
There is a procedure to ensure the 2 OB/SI
traceability of sterilized packs

Sterility of autoclaved packs is maintained 2 OB/SI Sterile packs are kept in clean, dust
during storage free, moist free environment.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
ME F5.1 Layout of the department is conducive for the Facility layout ensures separation of general 2 OB
infection control practices traffic from patient traffic
Facility layout ensures separation of routes 2 OB
for clean and dirty items
Floors and wall surfaces of ICU are easily 2 OB
cleanable
Facility ensures availability of standard Availability of disinfectant as per Chlorine solution, Glutaraldehyde,
ME F5.2 materials for cleaning and disinfection of 2 OB/SI
patient care areas requirement carbolic acid

Availability of cleaning agent as per Hospital grade phenyl, disinfectant

2 OB/SI
requirement detergent solution

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

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Cleaning of patient care area with detergent 2 SI/RR
solution
Staff is trained for preparing cleaning
solution as per standard procedure 2 SI/RR

Standard practice of mopping and scrubbing 2 OB/SI Unidirectional mopping from

are followed inside out
Any cleaning equipment leading to
Cleaning equipments like broom are not
used in patient care areas 2 OB/SI dispersion of dust particles in air
should be avoided
Use of three bucket system for mopping 2 OB/SI
Fumigation/carbonization as per schedule 2 SI/RR
External foot wares are restricted 2 OB
Isolation and barrier nursing procedure are
ME F5.4 Facility ensures segregation infectious patients followed for septic cases 1 OB/SI

ME F5.5 Facility ensures air quality of high risk area Negative pressure is maintained in Isolation 0 OB/SI
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
Facility Ensures segregation of Bio Medical Availability of colour coded bins at point of Adequate number. Covered. Foot
ME F6.1 Waste as per guidelines waste generation 2 OB operated.
Availability of colour coded non 2 OB
chlorinated plastic bags

Human Anatomical waste, Items

contaminated with blood, body
Segregation of Anatomical and soiled waste fluids, dressings, plaster casts,
2 OB/SI cotton swabs and bags containing
in Yellow Bin residual or discarded blood and
blood components.

Items such as tubing, bottles,

intravenous tubes and sets,
Segregation of infected plastic waste in red catheters, urine bags, syringes
bin 2 OB (without needles and fixed needle
syringes) and vacutainers with
their needles cut) and gloves

Display of work instructions for segregation

2 OB Pictorial and in local language
and handling of Biomedical waste

There is no mixing of infectious and general 2

waste

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

ME F6.2 Facility ensures management of sharps as per Availability of functional needle cutters 2 OB See if it has been used or just lying
guidelines idle.

Should be available nears the point

of generation. Needles, syringes
with fixed needles, needles from
Segregation of sharps waste including needle tip cutter or burner,
Metals in white (translucent) Puncture 2 OB scalpels, blades, or any other
proof, Leak proof, tamper proof containers contaminated sharp object that
may cause puncture and cuts. This
includes both used, discarded and
contaminated metal sharps

Availability of post exposure prophylaxis 2 SI/OB Ask if available. Where it is stored

and who is in charge of that.

Staff knows what to do in case of

Staff knows what to do in condition of 2 SI shape injury. Whom to report. See
needle stick injury
if any reporting has been done

Contaminated and broken Glass are Vials, slides and other broken
disposed in puncture proof and leak proof 2 OB
box/ container with Blue colour marking infected glass

Facility ensures transportation and disposal of

ME F6.3 waste as per guidelines Check bins are not overfilled 2 SI/OB

Disinfection of liquid waste before disposal 2 SI/OB

Transportation of bio medical waste is done 2

in close container/trolley

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Checklist No. - 10 Intensive Care Unit Version - NHSRC/3.0
Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to locate
mercury beads
5. Use syringe without a
needle/eyedropper and sticky tape
to suck the beads
6. Collection of beads in leak-proof
bag or container
Staff is aware of mercury spill management 2 SI/RR 7. Sprinkle sulphur or zinc powder
to remove any remaining mercury
8. All the mercury spill surfaces
should be decontaminated with
10% sodium thiosulfate solution
9. All the bags or containers
containing items contaminated
with mercury should be marked as
“Hazardous Waste, Handle with
Care”
10. Collected mercury waste
should be handed over to the
CBMWTF
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for quality improvement
Check if quality circle formed and
ME G1.1 The facility has a quality team in place Quality circle has been formed in the 2 SI/RR functional with a designated nodal
Intensive Care Unit
officer for quality
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.

There is system daily round by hospital

ME G3.1 Facility has established internal quality superintendent/ Hospital Manager/ Matron 2 SI/RR Check for entries in Round Register
assurance program at relevant departments
in charge for monitoring of services

NQAS, Kayakalp, SaQushal tools

ME G3.3 Facility has established system for use of check Internal assessment is done at periodic 2 RR/SI are used to conduct internal
lists in different departments and services interval assessment
Departmental checklist are used for 2 SI/RR Staff is designated for filling and
monitoring and quality assurance monitoring of these checklists

Non-compliances are enumerated and 2 RR Check the non compliances are

recorded presented & discussed during
quality team meetings

Check action plans are prepared and Randomly check the details of
ME G3.4 Actions are planned to address gaps observed implemented as per internal assessment 2 RR action, responsibility, time line and
during quality assurance process
record findings feedback mechanism

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Check actions have been taken to

Planned actions are implemented through Check PDCA or revalent quality method is close the gap. It can be in form of
ME G3.5 used to take corrective and preventive 2 SI/RR action taken report or Quality
Quality Improvement Cycles (PDCA) action Improvement (PDCA) project
report
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
Standard operating procedure for
Departmental standard operating procedures
ME G4.1 are available department has been prepared and 2 RR
approved
Current version of SOP are available with 1 OB/RR
process owner
Work instruction/clinical protocols are Admission and discharge criteria,
displayed 1 OB Intubation protocol, CPR
Department has documented procedure for registration, consultation,
Standard Operating Procedures adequately receiving, initial assessment, admission, Procedures, assessment of
ME G4.2 2 RR
describes process and procedures clinical assessment & reassessment of patient , counselling, Monitoring
patient in icu etc.
Department has documented procedure for
discharge of the patient 2 RR

ICU has documented procedure nursing

2 RR
care for critical patient
ICU has documented procedure for
collection, transfer and reporting the 2 RR
sample to laboratory
ICU has documented procedure for
nutrition in critical illness 2 RR

ICU has documented procedure for key

2 RR
clinical protocols
ICU has documented procedure for
preventive- break down maintenance and 2 RR
calibration of equipments
ICU has documented system for storage,
retaining, retrieval of records 2 RR

ICU has documented procedure for 2 RR

purchase of External services and supplies

ICU has documented procedure for

Maintenance of infrastructure of SNCU 2 RR

ICU has documented procedure for

2 RR
thermoregulation

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
ICU has documented procedure for
drugs,intravenous,and fluid management of 2 RR
patient
ICU has documented procedure for
2 RR
counselling of the patient attendant
ICU has documented procedure for 2 RR
infection control practices
ICU has documented procedure for
inventory management 2 RR

ICU has documented procedure for entry of 2 RR

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

Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

ME G5.1 Facility maps its critical processes Process mapping of critical processes done 2 SI/RR

ME G5.2 Facility identifies non value adding activities / Non value adding activities are identified 0 SI/RR
waste / redundant activities
Facility takes corrective action to improve the Processes are rearranged as per
ME G5.3 processes requirement 0 SI/RR
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Check quality policy of the facility

has been defined in consultation
Facility has defined Quality policy, which is in Check if Quality Policy has been defined and with hospital staff and duly
ME G6.3 2 SI/RR approved by the head of the
congruency with the mission of facility approved facility . Also check Quality Policy
enables achievement of mission of
the facility and health department

Check short term valid quality

objectivities have been framed
addressing key quality issues in
ME G6.4 Facility has de defined quality objectives to Check if SMART Quality Objectives have 2 SI/RR each department and cores
achieve mission and quality policy framed services. Check if these objectives
are Specific, Measurable,
Attainable, Relevant and Time
Bound.

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Checklist No. - 10 Intensive Care Unit Version - NHSRC/3.0
Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Interview with staff for their

Mission, Values, Quality policy and objectives Check of staff is aware of Mission , Values, awareness. Check if Mission
Statement, Core Values and
ME G6.5 are effectively communicated to staff and users Quality Policy and objectives 2 SI/RR Quality Policy is displayed
of services prominently in local language at
Key Points

Verify with records that a time

bound action plan has been
Facility prepares strategic plan to achieve Check if plan for implementing quality prepared to achieve quality policy
ME G6.6 2 SI/RR and objectives in consultation with
mission, quality policy and objectives policy and objectives have prepared hospital staff . Check if the plan has
been approved by the hospital
management

Review the records that action

plan on quality objectives being
reviewed at least once in month by
Facility periodically reviews the progress of
ME G6.7 strategic plan towards mission, policy and Check time bound action plan is being 2 SI/RR departmental in charges and
objectives reviewed at regular time interval during the quality team meeting.
The progress on quality objectives
have been recorded in Action Plan
tracking sheet

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
Facility uses method for quality improvement in
ME G7.1 services Basic quality improvement method 2 SI/OB PDCA & 5S
Advance quality improvement method 0 SI/OB Six sigma, lean.
Facility uses tools for quality improvement in Minimum 2 applicable tools are
ME G7.2 7 basic tools of Quality 2 SI/RR
services used in each department
Standard G9 2
Verify with the records. A
Check periodic assessment of medication comprehensive risk assessment of
ME G9.6 Periodic assessment for Medication and Patient and patient care safety risk is done using 2 SI/RR all clinical processes should be
care safety risks is done as per defined criteria. defined checklist periodically done using pre define criteria at
least once in three month.

Periodic assessment for potential risk regarding 1. Check that the filled checklist
and action taken report are
ME G9.7 safety and security of staff including violence SaQushal assessment toolkit is used for 0 SI/RR available
against service providers is done as per defined safety audits. 2. Staff is aware of key gaps &
criteria
closure status

Risks identified are analysed evaluated and

ME G9.8 Identified risks are analysed for severity 2 SI/RR Action is taken to mitigate the risks
rated for severity
Standards G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes
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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Check parameter are defined &

implemented to review the clinical
Clinical care assessment criteria have been The facility has established procedures to care i.e. through Ward round,
ME G10.3 2 SI/RR peer review, morbidity & mortality
defined and communicated review the clinical care processes
review, patient feedback, clinical
audit & clinical outcomes.

(1) Both critical and stable patients

Check regular ward rounds are taken to (2) Check the case progress is
review case progress 2 SI/RR documented in BHT/ progress
notes-

Check the patient /family participate in the Feedback is taken from

care evaluation 2 SI/RR patient/family on health status of
individual under treatment

System in place to review internal

referral process, review clinical
Check the care planning and co- ordination 2 SI/RR handover information, review
is reviewed patient understanding about their
progress

Check medical audit records

(a) Completion of the medical
records i.e. Medical history,
assessments, re assessment,
investigations conducted, progress
notes, interventions conducted,
outcome of the case, patient
education, delineation of
Facility conducts the periodic clinical audits There is procedure to conduct medical responsibilities, discharge etc.
ME G10.4 including prescription, medical and death 2 SI/RR
audits audits (b) Check whether treatment plan
worked for the patient
(C) progress on the health status
of the patient is mentioned
(d) whether the goals defined in
treatment plan is met for the
individual cases
(e) Adverse clinical events are
documented
(f) Re admission

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

(1) All the deaths are audited by

the committee.
(2) The reasons of the death is
clearly mentioned
(3) Data pertaining to deaths are
There is procedure to conduct death audits 2 SI/RR collated and trend analysis is done
(4) A through action taken report
is prepared and presented in
clinical Governance Board
meetings / during grand round
(wherever required)

Check for -valid sample size, data is

analysed, poor performing
There is procedure to conduct referral
audits 2 SI/RR attributes are identified and
improvement
initiatives are undertaken

All non compliance are enumerated & 2 SI/RR Check the non compliances are
recorded for medical audits presented & discussed during
clinical Governance meetings

All non compliance are enumerated & 2 SI/RR Check the non compliances are
recorded for newborn death audits presented & discussed during
clinical Governance meetings

All non compliance are enumerated & Check the non compliances are
recorded for referral audits 2 SI/RR presented & discussed during
clinical Governance meetings

Clinical care audits data is analysed, and actions Check action plans are prepared and Randomly check the actual
ME G10.5 are taken to close the gaps identified during the implemented as per medical audit record 0 SI/RR compliance with the actions taken
audit process findings reports of last 3 months
Check action plans are prepared and Randomly check the actual
implemented as per death audit record's 0 SI/RR compliance with the actions taken
findings reports of last 3 months
Check action plans are prepared and Randomly check the actual
implemented as per prescription audit 1 SI/RR compliance with the actions taken
record findings reports of last 3 months
Check collected data is analysed &
Check the data of audit findings are 1 SI/RR areas for improvement is identified
collated
& prioritised

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method

Check the critical problems are

Check PDCA or revalent quality method is regularly monitored & applicable
used to address critical problems 1 SI/RR solutions are duplicated in other
departments (wherever required)
for process improvement

Facility ensures easy access and use of standard Check standard treatment guidelines / Staff is aware of Standard
treatment protocols/
ME G10.7 treatment guidelines & implementation tools at protocols are available & followed. 2 SI/RR guidelines/best practices
point of care

Check treatment plan is prepared as per Check staff adhere to clinical

Standard treatment guidelines 2 SI/RR protocols while preparing the
treatment plan

Check the drugs are prescribed as per Check the drugs prescribed are
Standards treatment guidelines 2 SI/RR available in EML or part of drug
formulary

Check when the

STG/protocols/evidences used in
Check the updated/latest evidence are 2 SI/RR healthcare facility are published.
available Whether the STG protocols are
according to current evidences.

The gaps in clinical practices are

identified & action are taken to
Check the mapping of existing clinical 0 SI/RR improve it. Look for evidences for
practices processes is done
improvement in clinical practices
using PDCA
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Indicators on Bed Occupancy Rate 2 RR
monthly basis
Proportion of BPL patients admitted 2 RR
Number of the patients screened for pain 2 RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators on Downtime critical equipments 2 RR
monthly basis
Transfer Rate 2 RR
Re admission rate 2 RR
Patient's fall rate 2 RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Average length of stay 2 RR
Indicators on monthly basis

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Compliance Assessment
Reference No ME Statement Checkpoint Means of Verification Remarks
Full/Partial/No Method
Risk Adjusted Mortality Rate/Standard 2 RR
Mortality Rate
No of Pressure Ulcer developed per
thousand cases 2 RR

Injection room : Post exposure

No of adverse events per thousand patients 2 RR prophylaxis, medication error,
patient fall.
UTI rate 2 RR
VAP rate 2 RR
Injection room : Post exposure
Adverse events are identified 2 RR prophylaxis, medication error,
patient fall.
Reintubation Rate 2 RR
% of environmental swab culture
Culture Surveillance sterility rate 2 RRreported positive
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality Indicators on LAMA Rate 2 RR
monthly basis
Patient Satisfaction Score 2 RR

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Area of Concern - A Service Provision
Standard A1 The facility provides Curative Services
The facility provides General Medicine Availability of general medicine indoor
ME A1.1 services services SI/OB
Availability of isolation ward services SI/OB
ME A1.2 The facility provides General Surgery services Availability of surgery ward/beds SI/OB
Availability of burn ward SI/OB
ME A1.5 The facility provides Ophthalmology Services Availability of ophthalmology indoor SI/OB
services
Availability of Orthopaedics indoor In IPHS 2022, beds provision is there for
ME A1.7 The facility provides Orthopaedics Services SI/OB
services Orthopaedic inpatient services

(a) Assessment by doctor, availability of doctor on

call
ME A1.9 The facility provides Psychiatry Services Availability of Psychiatry Indoor services SI/OB (b) Availability of emergency care round the clock
( c) Psycho social interventions

Physiotherapy advices for IPD patient,

Physiotherapy procedures like tractions (Lumbar &
Cervical), Short Wave Diathermy, Electrical
ME A1.12 The facility provides Physiotherapy Services Availability of Indoor Physiotherapy SI/OB stimulator with TENS, Ultra sonic therapy, Paraffin
Procedures wax bath, Infra red therapy, Ultraviolet therapy,
Electric Vibrator, Vibrator belt message, Post polio
exercises, Obesity exercises, cerebral Palsy
massage, Breathing exercises & Postural Drainage
ME A1.14 Services are available for the time period as Availability of nursing services 24X7 SI/OB
mandated
The facility provides Accident & Emergency
ME A1.16 Availability of accident & trauma ward SI/OB
Services
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme
The facility provides services under National Availability of Indoor services for Malaria Kalaazar Dengue & Chikunguna
ME A4.1 Vector Borne Disease Control Programme as Management SI/RR AES/Japanese Encephalitis as prevalent locally
per guidelines
The facility provides services under national
Indoor treatment of TB patients requires
ME A4.2 tuberculosis elimination programme as per hospitalization SI/RR
guidelines.
The facility provides services under National Inpatient Management of severely ill
ME A4.3 Leprosy Eradication Programme as per SI/RR
guidelines cases

ME A4.4 The facility provides services under National Inpatient care for cases require SI/RR
AIDS Control Programme as per guidelines hospitalization

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
The facility provides services under National
ME A4.5 Programme for prevention and control of Availabily of Ophthalmic ward SI/OB
Blindness as per guidelines
The facility provides services under National 10 bedded Geriatric Ward- 2 beds earmarked for
ME A4.7 Programme for the health care of the elderly IPD services for Geriatric cases OB
as per guidelines respite care to bedridden
(a) Assessment by doctor, availability of doctor on
call
ME A4.15 The facility provide services under National Availability of Indoor services for SI/OB (b) Availability of emergency care round the clock
Programme for pallative care pallative care
( c) Psycho social interventions
Standard A6 Health services provided at the facility are appropriate to community needs.
The facility provides curatives & preventive
ME A6.1 services for the health problems and Availability of indoor Services as per local SI/RR
diseases, prevalent locally. prevalent disease

Area of Concern - B Patient Rights

Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
Numbering, main department and internal sectional
ME B1.1 The facility has uniform and user-friendly Availability of departmental & OB signage are displayed. Directional signages are given
signage system directional signages from the entry of the facility
Display of layout/floor directory OB
Visiting hours and visitor policy are OB
displayed

All signages are in uniform colour scheme OB

The facility displays the services and

ME B1.2 entitlements available in its departments List of services available are displayed OB

Entitlement under different national

health program OB

List of drugs available are displayed and OB

updated
Contact details of referral transport /
ambulance displayed OB

User charges are displayed and

ME B1.4 communicated to patients effectively User charges if any displayed OB

Patients & visitors are sensitised and

ME B1.5 educated through appropriate IEC / BCC Relevant IEC material displayed at wards OB
approaches
Information is available in local language and Signage's and information are available
ME B1.6 OB
easy to understand in local language
The facility ensures access to clinical records Discharge summary is given to the
ME B1.8 of patients to entitled personnel patient RR/OB

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
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 , economic, cultural or social reasons.

ME B2.1 Services are provided in manner that are Separate male & female wards OB Where ever male and female are kept in same
sensitive to gender wards male and female area are demarcated
Male and female toilets are demarcated OB/SI
Access to toilet should not go through
opposite sex patient care area OB
Male attendants are not allowed to stay OB/SI
at night in female ward
There is no discrimination with SI/PI
transgender patients
No unnecessary /non-essential disclosure SI/PI/RR
of a person’s trans status
Access to facility is provided without any Availability of Wheel chair or stretcher
ME B2.3 physical barrier & and friendly to people with OB
disabilities for easy Access to the ward

At least 120 cm width, gradient not steeper than

Availability of ramps with railing OB 1:12
Availability of specially able toilet OB
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
Adequate visual privacy is provided at every
ME B3.1 Availability of screens / Curtains OB Bracket screen
point of care
Examination/ Dressing of patient is done OB
in enclosed area
Curtains / frosted glass have been OB Check all the windows are fitted with frosted glass
provided at windows or curtains have been provided

No two patients are treated on one bed OB

Partitions separating men and women

are robust enough to OB
prevent casual overlooking and
overhearing

ME B3.2 Confidentiality of patients records and clinical Patient Records are kept at secure place SI/OB
information is maintained beyond access to general staff/visitors

No information regarding patient

identity and details are unnecessary SI/OB
displayed
The facility ensures the behaviours of staff is Behaviour of staff is empathetic and
ME B3.3 dignified and respectful, while delivering the OB/PI
courteous
services

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
The facility ensures privacy and
confidentiality to every patient, especially of HIV status of patient is not disclosed
ME B3.4 those conditions having social stigma, and except to staff that is directly involved in SI/OB
care
also safeguards vulnerable groups
Standard B4 The facility has defined and established procedures for informing patients about the medical condition, and involving them in treatment planning, and facilitates informed decision
making
There is established procedures for taking General Consent is taken before
ME B4.1 informed consent before treatment and admission SI/RR
procedures

Information about the treatment is shared Patient is informed about clinical

ME B4.4 with patients or attendants, regularly condition and treatment been provided PI

The facility has defined and established Availability of complaint box and display
ME B4.5 of process for grievance re redressal and OB
grievance redressal system in place
whom to contact is 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 services.
The facility provides cashless services to
ME B5.1 pregnant women, mothers and neonates as Stay in wards is free for entitled patients PI/SI
per prevalent government schemes under NHP and state scheme

Drugs and consumables under NHP are PI/SI

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

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

The facility provide free of cost treatment to All treatments are free of cost for BPL
ME B5.4 Below poverty line patients without PI/SI/RR
administrative hassles Patients

The facility ensure implementation of health Cashless treatment been provide to

ME B5.6 insurance schemes as per National /state smart card holders SI/RR
scheme
Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities
There is an established procedure for ‘end-of- Staff is educated & trained for end of life
ME B6.6 SI/RR
life’ care care
The patient's Relatives informed clearly
about the deterioration in the health SI/RR Periodic update on the patient's condition is given
to the family.
condition of Patient.

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Policy & procedures like DNR , DNI etc
for critical cases are in consonance with SI/RR Patient right "Do not resuscitate" or " Do not
intubate"/ allow natural death are respected
legal requirement
Hospital has documented policy for pain
management SI/OB

Screening of the patient for pain intensity SI/RR Using pain assessment scales /tools

In terms of Location, frequency, duration, radiation

Check the pain characteristics SI/RR etc. - Post operating, neuralgia, arthralgia or
myalgia
Pain alleviation measures or medication
is initiated & titrated as per need and SI/RR
response
Patient & family are educated on various
pain management techniques wherever Specially in chronic cases
appropriate

There is an established procedure for patients

ME B 6.7 who wish to leave hospital against medical Declaration is taken from the LAMA RR/SI Consequences of LAMA are explained to
advice or refuse to receive specific c patient patient/relative
treatment
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
ME C1.1 Departments have adequate space as per Adequate space in wards with no OB Distance between centres of two beds – 2.25 meter
patient or work load cluttering of beds

Patient amenities are provide as per patient Functional toilets with running water
ME C1.2 load and flush are available as per strength OB one toilet for 12 patients
and patient load of ward
Functional bathroom with running water
are available as per strength and patient OB
load of ward
Availability of drinking water OB
Patient/ visitor Hand washing area OB
Separate toilets for visitors OB
TV for entertainment and health OB
promotion
Adequate shaded waiting area is provide OB
for attendants of patient
Departments have layout and demarcated
ME C1.3 Availability of Dedicated nursing station OB
areas as per functions
Availability of Examination room OB
Availability of Treatment room OB

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Availability of Doctor's and Nurse Duty
room OB
Availability of Store OB Drug &Linen store
Availability of clean and Dirty utility room OB

Space between two beds should be at least 4 ft and

ME C1.4 The facility has adequate circulation area and There is sufficient space between two
bed to provide bed side nursing care and OB clearance between head end of bed and wall should
open spaces according to need and local law be at least 1 ft and between side of bed and wall
movement should be 2 ft

Corridors are wide enough for patient,

visitor and trolley/ equipment OB Corridor should be 3 meters wide
movement

ME C1.5 The facility has infrastructure for intramural Availability of functional telephone and OB
and extramural communication Intercom Services
Service counters are available as per patient There is a separate nursing station for Location of nursing station and patients beds in
ME C1.6 load each ward OB enables easy and direct observation of patients
Availability of IPD beds as per load OB

The facility and departments are planned to

ensure structure follows the Surgical wards has functional linkages
ME C1.7 OB
function/processes (Structure commensurate with OT
with the function of the hospital)

Location of nursing station and patients

beds enables easy and direct OB
observation of patients
Standard C2 The facility ensures the physical safety of the infrastructure.
Check for fixtures and furniture like cupboards,
ME C2.1 The facility ensures the seismic safety of the Non structural components are properly OB cabinets, and heavy equipment , hanging objects
infrastructure secured
are properly fastened and secured

ME C2.3 The facility ensures safety of electrical IPD building does not have temporary OB Switch Boards other electrical installations are
establishment connections and loosely hanging wires intact

ME C2.4 Physical condition of buildings are safe for Floors of the ward are non slippery and OB
providing patient care even

Windows have grills and wire meshwork OB

Standard C3 The facility has established Programme for fire safety and other disaster
Ward has sufficient fire exit to permit
ME C3.1 The facility has plan for prevention of fire OB/SI
safe escape to its occupant at time of fire
Check the fire exits are clearly visible and
routes to reach exit are clearly marked. OB

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
The facility has adequate fire fighting IPD has installed fire Extinguisher that is
ME C3.2 OB
Equipment Class A , Class B, C type or ABC type
Check the expiry date for fire
extinguishers are displayed on each
extinguisher as well as due date for next OB/RR
refilling is clearly mentioned

The facility has a system of periodic training Check for staff competencies for
ME C3.3 of staff and conducts mock drills regularly for operating fire extinguisher and what to SI/RR
fire and other disaster situation do in case of fire

Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
The facility has adequate specialist doctors as
ME C4.1 per service provision Availability of specialist doctor on call OB/RR

The facility has adequate general duty

ME C4.2 doctors as per service provision and work Availability of General duty doctor at all OB/RR
load time

The facility has adequate nursing staff as per

ME C4.3 service provision and work load Availability of Nursing staff OB/RR/SI As per patient load

ME C4.4 The facility has adequate Availability of dresser in surgical ward OB/SI/RR
technicians/paramedics as per requirement

The facility has adequate support / general

ME C4.5 staff Availability of ward attendant/ Ward boy SI/RR
Availability Security staff SI/RR
Standard C5 The facility provides drugs and consumables required for assured services.
Availability of Non-opioid
ME C5.1 The departments have availability of Analgesics/Antipyretics/Anti OB/RR As per State's EML
adequate drugs at point of use
Inflammatory medicines
Availability of Anti - Infective Medicines - OB/RR As per State's EML
Antibiotics, Antifungal
Availability of Solutions Correcting
Water, Electrolyte Disturbance and Acid- OB/RR As per State's EML
base Disturbance
Availability of medicines acting on OB/RR As per State's EML
Cardiovascular System
Availability of medicines acting on
Central Nervous System/Peripheral OB/RR As per State's EML
Nervous System
Availability of dressing material and OB/RR As per State's EML
antiseptic liquid/cream/ lotion
Medicines for Respiratory System OB/RR As per State's EML

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Hormonal Preparation and other
Endocrine Medicines OB/RR As per State's EML
Availability of Medical gases OB/RR Availability of Oxygen Cylinders
The departments have adequate Availability of dressing material in
ME C5.2 consumables at point of use surgical wards OB/RR As per State's EML

Availability of syringes and IV Sets /tubes OB/RR

Availability of Antiseptic Solutions OB/RR As per State's EML
Emergency drug trays are maintained at
ME C5.3 every point of care, where ever it may be Availability of emergency drug tray OB/RR
needed
Standard C6 The facility has equipment & instruments required for assured list of services.
Availability of functional Equipment
ME C6.1 Availability of equipment & instruments for &Instruments for examination & OB BP apparatus, Thermometer, fetoscope, baby and
examination & monitoring of patients adult weighing scale, Stethoscope , Doppler
Monitoring
Availability of equipment & instruments for Availability of dressing tray for Surgical
ME C6.2 treatment procedures, being undertaken in Ward OB
the facility
Availability of equipment & instruments for
ME C6.3 diagnostic procedures being undertaken in Availability of Point of care diagnostic OB Glucometer
instruments
the facility

Availability of equipment and instruments for Availability of functional Instruments for Adult bag and mask, Oxygen, Suction machine,
ME C6.4 resuscitation of patients and for providing OB Airway, nebulizer, suction apparatus , LMA,
intensive and critical care to patients Resuscitation. Laryngoscope, ET tube

ME C6.5 Availability of Equipment for Storage Availability of equipment for storage for OB Refrigerator, Crash cart/Drug trolley, instrument
drugs trolley, dressing trolley
Availability of functional equipment and Buckets for mopping, mops, duster, waste trolley,
ME C6.6 instruments for support services Availability of equipment for cleaning OB Deck brush
Departments have patient furniture and Availability of attachment/ accessories Hospital graded mattress, Bed side locker , IVstand,
ME C6.7 OB
fixtures as per load and service provision with patient bed Bed pan

Availability of Fixtures OB Spot light, electrical fixture for equipment like

suction, X ray view box
cupboard, nursing counter, table for preparation of
Availability of furniture OB medicines, chair.
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method

Check objective checklist has been prepared for

Check parameters for assessing skills and assessing competence of doctors, nurses and
ME C7.1 Criteria for Competence assessment are proficiency of clinical staff has been RR/SI paramedical staff based on job description defined
defined for clinical and Para clinical staff defined for each cadre of staff. Dakshta checklist issued by
MoHFW can be used for this purpose.

Competence assessment of Clinical and Para Check for competence assessment is Check for records of competence assessment
ME C7.2 clinical staff is done on predefined criteria at done at least once in a year RR/SI including filled checklist, scoring and grading . Verify
least once in a year with staff for actual competence assessment done

The Staff is provided training as per defined Bio medical Waste Management including Hand
ME C7.9 core competencies and training plan Infection control & prevention training SI/RR Hygiene

Patient Safety SI/RR

Basic Life Support SI/RR
Training on Quality Management System SI/RR To all category of staff. At the time of induction and
once in a year.

Check supervisors make periodic rounds of

There is established procedure for utilization Nursing staff is skilled for maintaining department and monitor that staff is working
ME C7.10 of skills gained thought trainings by on -job clinical records SI/RR according to the training imparted. Also staff is
supportive supervision provided on job training wherever there is still gaps

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
1. Check with AMC records/
ME D1.1 The facility has established system for All equipment are covered under AMC SI/RR Warranty documents
maintenance of critical Equipment including preventive maintenance 2. Staff is aware of the list of equipment covered
under AMC.
[Link] for breakdown & Maintenance record in
There is system of timely corrective the log book
break down maintenance of the SI/RR 2. Staff is aware of contact details of the
equipments
agency/person in case of breakdown.
The facility has established procedure for
ME D1.2 internal and external calibration of measuring All the measuring equipments/
instrument are calibrated OB/ RR BP apparatus, thermometers etc are calibrated
Equipment
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas
There is established system of timely Stock level are daily updated
ME D2.1 There is established procedure for forecasting indenting of consumables and drugs at SI/RR Indents are timely placed
and indenting drugs and consumables
nursing station

ME D2.3 The facility ensures proper storage of drugs Drugs are stored in containers/tray/crash OB Away from direct sunlight and temperature is
and consumables cart and are labelled maintained as per instructions of manufacturer.

Empty and filled cylinders are labelled OB

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Records for expiry and near expiry drugs are
ME D2.4 The facility ensures management of expiry Expiry dates' are maintained at OB/RR maintained for emergency tray
and near expiry drugs emergency drug tray
FIRST EXPIRY and FIRST OUT (FEFO) is in practice
No expiry drug found OB/RR
Records for expiry and near expiry drugs Check the record of expiry and near expiry drug in
are maintained for drug stored at RR
department drug sub store

Minimum stock and reorder level are calculated

The facility has established procedure for There is practice of calculating and
ME D2.5 inventory management techniques maintaining buffer stock SI/RR based on consumption
Minimum buffer stock is maintained all the time
Department maintained stock register of Check record of drug received, issued and balance
drugs and consumables RR/SI stock in hand and are regularly updated

There is a procedure for periodically There is established system for

ME D2.6 replenishing the drugs in patient care areas replenishing drug tray /crash cart SI/RR

There is no stock out of drugs OB/SI Check stock of some vital drugs

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

Separate prescription for narcotic and psychotropic

ME D2.8 There is a procedure for secure storage of Narcotic ,psychotropic drugs are kept OB/SI drugs. Separately kept, away from other drugs and
narcotic and psychotropic drugs separately in lock and key labelled

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
The facility provides adequate illumination
ME D3.1 level at patient care areas Adequate Illumination at nursing station OB

Adequate illumination in patient care OB Potable spot light and it is used whenever it is
areas required
The facility has provision of restriction of
ME D3.2 visitors in patient areas Visiting hour are fixed and practiced OB/PI

There is no overcrowding in the wards OB

during to visitors hours
One family members is allowed to stay OB/SI
with the patient
The facility ensures safe and comfortable
Temperature control and ventilation in Fans/ Air conditioning/Heating/Exhaust/Ventilators
ME D3.3 environment for patients and service PI/OB
patient care area as per environment condition and requirement
providers

Temperature control and ventilation in SI/OB Fans/ Air conditioning/Heating/Exhaust/Ventilators

nursing station/duty room as per environment condition and requirement

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
The facility has security system in place at
ME D3.4 patient care areas Security arrangement in IPD OB/SI

Check mechanism at place to track the patient

Identification band for all OB based on UID
The facility has established measure for
ME D3.5 Female staff feel secure at work place SI
safety and security of female staff
Standard D4 The facility has established Programme for maintenance and upkeep of the facility
Exterior of the facility building is maintained Building is painted/whitewashed in
ME D4.1 appropriately uniform colour OB

Interior of patient care areas are

OB
plastered & painted
Floors, walls, roof, roof topes, sinks All area are clean with no dirt,grease,littering and
ME D4.2 Patient care areas are clean and hygienic patient care and circulation areas are OB cobwebs
Clean

Surface of furniture and fixtures are clean OB

Toilets are clean with functional flush

OB
and running water

ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , Cracks, OB

maintained chipping of plaster
Window panes , doors and other fixtures
are intact OB
Patients beds are intact and painted OB Mattresses are intact and clean
ME D4.5 The facility has policy of removal of No condemned/Junk material in the ward OB
condemned junk material

ME D4.6 The facility has established procedures for No stray animal/rodent/birds OB

pest, rodent and animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
The facility has adequate arrangement
Availability of 24x7 running and potable
ME D5.1 storage and supply for portable water in all water OB/SI
functional areas

ME D5.2 The facility ensures adequate power backup Availability of power back up in patient OB/SI
in all patient care areas as per load care areas
StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.

The facility has provision of nutritional Nutritional assessment of patient done

ME D6.1 RR/SI
assessment of the patients as required and directed by doctor

ME D6.2 The facility provides diets according to Check for the adequacy and frequency of OB/RR Check that all items fixed in diet menu is provided
nutritional requirements of the patients diet as per nutritional requirement to the patient
Ask patient/staff weather they are satisfied with the
Check for the Quality of diet provided PI/SI Quality of food

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Hospital has standard procedures for
preparation, handling, storage and There is procedure of requisition of diet for diabetic patients, low salt and high protein
ME D6.3 distribution of diets, as per requirement of different type of diet from ward to RR/SI diet etc
kitchen
patients
Standard D7 The facility ensures clean linen to the patients
ME D7.1 The facility has adequate sets of linen Clean Linens are provided for all OB/RR
occupied bed
Gown are provided at least to the cases
going for surgery OB/RR

Availability of Blankets, draw sheet,

OB/RR
pillow with pillow cover and mackintosh

The facility has established procedures for Linen is changed every day and whenever
ME D7.2 changing of linen in patient care areas it get soiled OB/RR

The facility has standard procedures for There is system to check the cleanliness
ME D7.3 handling , collection, transportation and and Quantity of the linen received from SI/RR
washing of linen laundry

Check dedicated closed bin is kept for Check linen is kept closed bin & emptied regularly.
storage of dirty linen OB Plastic bag is used in dustbin & these bags are
sealed before removed & handed over

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

ME D11.1 The facility has established job description as Job description is defined and RR Regular + contractual
per govt guidelines communicated to all concerned staff
Staff is aware of their role and SI
responsibilities
The facility has a established procedure for
ME D11.2 duty roster and deputation to different There is procedure to ensure that staff is RR/SI Check for system for recording time of reporting
departments available on duty as per duty roster and relieving (Attendance register/ Biometrics etc)

There is designated in charge for SI

department
The facility ensures the adherence to dress
ME D11.3 code as mandated by its administration / the Doctor, nursing staff and support staff OB
health department adhere to their respective dress code

Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

There is established system for contract There is procedure to monitor the Verification of outsourced services (cleaning/
ME D12.1 management for out sourced services quality and adequacy of outsourced SI/RR Dietary/Laundry/Security/Maintenance) provided
services on regular basis are done by designated in-house staff
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Unique identification number is given
ME E1.1 The facility has established procedure for to each patient during process of RR
registration of patients
registration
Patient demographic details are recorded Check for that patient demographics like Name,
in admission records RR age, Sex, Chief complaint, etc.

ME E1.3 There is established procedure for admission There is no delay in admission of patient SI/RR/OB
of patients
Admission is done by written order of a
qualified doctor SI/RR/OB

Time of admission is recorded in patient

RR
record
There is established procedure for managing
ME E1.4 patients, in case beds are not available at the There is provision of extra Beds OB/SI
facility
Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.

Initial assessment of all admitted patient The assessment criteria for different clinical
ME E2.1 There is established procedure for initial done as per standard protocols RR/SI conditions are defined and measured in assessment
assessment of patients
sheet

Patient History is taken and recorded RR

Physical Examination is done and
recorded wherever required RR
Provisional Diagnosis is recorded RR
Initial assessment and treatment is
provided immediately RR/SI

Initial assessment is documented

preferably within 2 hours RR

There is established procedure for follow-up/ There is fixed schedule for assessment of
ME E2.2 RR/OB
reassessment of Patients stable patients
For critical patients admitted in the ward
there is provision of reassessment as per RR/OB
need
There is system in place to identify and Criteria is defined for identification, and
manage the changes in Patient's health SI/RR management of high-risk patients and patient
status whose condition is deteriorating
Check the re assessment sheets/ Case sheets
Check the treatment or care plan is
modified as per re assessment results SI/RR modified treatment plan or care plan is
documented

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method

There is established procedure to plan and Assessment includes physical assessment, history,
Check healthcare needs of all
ME E2.3 deliver appropriate treatment or care to hospitalised patients are identified SI/RR details of existing disease condition (if any) for
individual as per the needs to achieve best through assessment process which regular medication is taken as well as
possible results evaluate psychological ,cultural, social factors

(a) According to assessment and investigation

findings (wherever applicable).
(b) Check inputs are taken from patient or relevant
Check treatment/care plan is prepared as RR care provider while preparing the care plan.
per patient's need

Care plan include:, investigation to be conducted,

Check treatment / care plan is
documented RR intervention to be provided, goals to achieve,
timeframe, patient education, , discharge plan etc

Check care is delivered by competent SI/RR Check care plan is prepared and delivered as per
multidisciplinary team direction of qualified physician
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
The facility has established procedure for Facility has established procedure for
ME E3.1 continuity of care during interdepartmental handing over of patients from one SI/RR
transfer department to other department
There is a procedure for consultation of
the patient to other specialist with in the RR/SI
hospital

The facility provides appropriate referral

linkages to the patients/Services for transfer
ME E3.2 to other/higher facilities to assure the Patient referred with referral slip RR/SI
continuity of care.
Advance communication is done with RR/SI
higher centre
Referral vehicle is being arranged SI/RR
Referral in or referral out register is
maintained RR

Facility has functional referral linkages to SI/RR Check for referral cards filled from lower facilities
lower facilities
There is a system of follow up of referred
RR
patients
A person is identified for care during all steps Duty Doctor and nurse is assigned for
ME E3.3 RR/SI
of care each patients

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Standard E4 The facility has defined and established procedures for nursing care
There is a process for ensuring the
ME E4.1 Procedure for identification of patients is patient's identification before any clinical OB/SI Patient id band/ verbal confirmation/Bed no. etc.
established at the facility procedure
Procedure for ensuring timely and accurate Check for treatment chart are updated and drugs
ME E4.2 nursing care as per treatment plan is Treatment chart are maintained RR given are marked. Co relate it with drugs and doses
established at the facility prescribed.

(1) Check system is in place to give telephonic

There is a process to ensue the accuracy
of verbal/telephonic orders SI/RR orders & practised
(2) Verbal orders are verified by the ordering
physician within defined time period

There is established procedure of patient Patient hand over is given during the
ME E4.3 hand over, whenever staff duty change change in the shift SI/RR
happens

Nursing Handover register is maintained RR

Hand over is given bed side SI/RR
ME E4.4 Nursing records are maintained Nursing notes are maintained adequately RR/SI Check for nursing note register. Notes are
adequately written

ME E4.5 There is procedure for periodic monitoring of Patient Vitals are monitored and RR/SI Check for TPR chart, IO chart, any other vital
patients recorded periodically required is monitored
Critical patients are monitored RR/SI
continually
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
Vulnerable patients are identified and
The facility identifies vulnerable patients and Unstable, irritable, unconscious. Psychotic and
ME E5.1 ensure their safe care measures are taken to protect them from OB/SI serious patients are identified
any harm
The facility identifies high risk patients and
High risk patients are identified and
ME E5.2 OB/SI
ensure their care, as per their need treatment given on priority
Standard E6 Facility ensures rationale prescribing and use of medicines
The facility ensured that drugs are prescribed Check for BHT if drugs are prescribed
ME E6.1 in generic name only under generic name only RR

Check for that relevant Standard

ME E6.2 There is procedure of rational use of drugs treatment guideline are available at point RR
of use
Check staff is aware of the drug regime SI/RR Check BHT that drugs are prescribed as per STG
and doses as per STG
Availability of drug formulary SI/OB

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method

Nurse confirms patient's name, prescription details

and medical history before drug administration at
ME E6.3 There are procedures defined for medication Complete medication history is RR/OB bed-side, during transfer of care and at the time of
review and optimization documented for each patient discharge

1. Medication Reconciliation is carried out by a

trained and competent health professional during
the patient's admission, interdepartmental transfer
Established mechanism for Medication or discharged
reconciliation process SI/RR 2. Medicine reconciliation includes Prescription and
non-prescription (over-the-counter) medications,
vitamins, nutritional supplements, potentially
interactive food items, herbal preparations, and
recreational
1. Medicationdrugs"
review is performed for some groups
like patients taking multiple medicines, people with
Medicine are reviewed and optimised as SI/RR chronic or long term conditions, older people, etc.
per individual treatment plan
2. Medicines are optimised as per individual
treatment plan for best possible clinical outcome
1. Discharge summary includes known drug allergies
and reactions to medicines or their ingredients, and
Complete medication history is the type of reaction experienced
documented and communicated for each SI/RR 2. Changes in prescribed medicines, including
patient at the time of discharge medicines started or stopped, or dosage changes,
and reason for the change are clearly documented
in the case sheet and case summary"
"1. Clinician/Nurse counsel the patient on
medication safety using ""5 moments for
medication safety app""
Patients are engaged in their own care PI/SI 2. Nurse highlights the medications to be taken by
the patient at home and counsel the patient and
family on drug intake as per treatment plan for
discharge"
Standard E7 The facility has defined procedures for safe drug administration

Electrolytes like Potassium chloride, Opioids, Neuro

ME E7.1 There is process for identifying and cautious High alert drugs available in department SI/OB muscular blocking agent, Anti thrombolytic agent,
administration of high alert drugs are identified
insulin, warfarin, Heparin, Adrenergic agonist etc.

Value for maximum doses as per age, weight and

Maximum dose of high alert drugs are SI/RR diagnosis are available with nursing station and
defined and communicated
doctor
A system of independent double check before
There is process to ensure that right SI/RR administration, Error prone medical abbreviations
doses of high alert drugs are only given are avoided
Every Medical advice and procedure is
Medication orders are written legibly and
ME E7.2 accompanied with date , time and RR
adequately
signature
Check for the writing, It comprehendible
by the clinical staff RR/SI

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method

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

Check single dose vial are not used for Check for any open single dose vial with left over
more than one dose OB content intended to be used later on
Check for separate sterile needle is used OB
every time for multiple dose vial In multi dose vial needle is not left in the septum
Any adverse drug reaction is recorded Adverse drug event trigger tool is used to report the
and reported RR/SI events

Administration of medicines done after ensuring

There is a system to ensure right medicine is Check Nursing staff is aware 7 Rs of
ME E7.4 given to right patient Medication and follows them SI/RR right patient, right drugs, right route, right time,
Right dose, Right Reason and Right Documentation

Patient is advice by doctor/

Patient is counselled for self drug
ME E7.5 administration Pharmacist /nurse about the dosages and
timings .
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
All the assessments, re-assessment and Day to day progress of patient is
ME E8.1 RR (Manually/e-records)
investigations are recorded and updated recorded in BHT

ME E8.2 All treatment plan prescription/orders are Treatment plan, first orders are written RR Treatment prescribed inj nursing records
recorded in the patient records. on BHT (Manually/e-records)
Care provided to each patient is recorded in Maintenance of treatment Treatment given is recorded in treatment chat
ME E8.3 the patient records chart/treatment registers RR (Manually/e-records)

ME E8.4 Procedures performed are written on Any procedure performed written on BHT RR Dressing, mobilization etc (Manually/e-records)
patients records
Standard Format for bed head ticket/
Adequate form and formats are available at Availability of formats for Treatment Charts, TPR
ME E8.5 point of use Patient case sheet available as per state RR/OB Chart , Intake Output Chat Etc.
guidelines

General order book (GOB), report book, Admission

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

All register/records are identified and

numbered RR

ME E8.7 The facility ensures safe and adequate Safe keeping of patient records OB
storage and retrieval of medical records
Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing patient Assessment is done before discharging SI/RR
readiness patient

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Discharge is done by a responsible and
qualified doctor after assessment in SI/RR Discharge is done in consultation with treating
doctor
consultation with treating doctor
Patient / attendants are consulted before
discharge PI/SI

ME E9.2 Case summary and follow-up instructions are Discharge summary is provided RR/PI See for discharge summary, referral slip provided.
provided at the discharge
Discharge summary adequately mentions
patients clinical condition, treatment RR
given and follow up
Discharge summary is give to patients
going in LAMA/Referral SI/RR

Advice includes the information about the nearest

ME E9.3 Counselling services are provided as during Patient is counselled before discharge SI/PI health centre for further follow up. Counsel mother
discharges wherever required for treatment, follow up, feeding, discharge timings
are explained prior
Time of discharge is communicated to PI/SI
patient in prior
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
The facility has disaster management plan in
ME E11.3 place Staff is aware of disaster plan SI/RR

Role and responsibilities of staff in SI/RR

disaster is defined
Standard E12 The facility has defined and established procedures of diagnostic services
There are established procedures for Pre- Container is labelled properly after the
ME E12.1 OB
testing Activities sample collection

ME E12.3 There are established procedures for Post- Nursing station is provided with the SI/RR
testing Activities critical value of different tests
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
ME E13.9 There is established procedure for Consent is taken before transfusion RR
transfusion of blood
Patient's identification is verified before SI/OB
transfusion
blood is kept on optimum temperature RR
before transfusion
Blood transfusion is monitored and
regulated by qualified person SI/RR

Blood transfusion note is written in

RR
patient recorded

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
There is a established procedure for Any major or minor transfusion reaction
ME E13.10 monitoring and reporting Transfusion is recorded and reported to responsible RR
complication person
Standard E14 The facility has established procedures for Anaesthetic Services
The facility has established procedures for Pre anaesthesia check up is conducted
ME E14.1 Pre-anaesthetic Check up and maintenance of for elective / Planned surgeries SI/RR
records
Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients
Facility has a standard procedure to
ME E16.1 Death of admitted patient is adequately decent communication of death to SI
recorded and communicated relatives

Death note is written on patient record RR

Death summary is given to patient

ME E16.2 The facility has standard procedures for attendant quoting the immediate cause SI/RR
handling the death in the hospital and underlying cause if possible
Death note including efforts done for
resuscitation is noted in patient record RR
National Health Program
Standard E23 The facility provides National health Programme as per operational/Clinical Guidelines

The facility provides services under Mental Management of mental illness as per (a) Treatment of mental illness symptoms &
ME E23.6 Health Programme as per guidelines guidelines SI/RR associated condition

(a) Basic psycho education about treatment

adherence
(b) Motivation enhancement
Psychosocial support is provided SI/RR (c ) Reduction of high risk behaviour
(d) Relapse prevention
(e ) Counselling for occupational rehab.
(d) Patient support group / individual counselling

The facility provides services under National Geriatric Care is provided as per Clinical (a) Linkage with specialists like medicine, ortho,
health., ENT services
ME E23.7 Programme for the health care of the elderly Guidelines SI/RR (b) Referral services to Regional Geriatric
as per guidelines centre/MC

The facility provides service under National

Programme for Prevention and Control of Management of Myocardial infarction &
ME E23.8 cancer, diabetes, cardiovascular diseases & stroke SI/RR As per treatment protocols
stroke (NPCDCS) as per guidelines
Management of admitted diabetes cases SI/RR As per treatment protocols
as per guidelines

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Chemotherapy support or services provided as per
Chemotherapy follow up in cancer cases SI/RR state mandate
Counsel the patient for monitoring of their BP
Counselling the identified cases for self (using digital BP apparatus) , sugar (using
care PI/RR glucometer) , self-care for ulcers etc

(a) Submitted to District surveillance officer

ME E23.9 The facility provide service for Integrated Weekly reporting of Presumptive cases SI/RR (b) Data is submitted manually or through IHIP
disease surveillance Programme on form "P" from IPD
(integrated health information platform)

(a) Treatment of symptoms, associated condition &

referral to the linkage
ME E 23.12 Facility provide services under National Management of pain as per guidelines SI/RR (b) Pain management by the staff trained in pain &
program for pallative care pallative care

(a) Basic psycho education about treatment

adherence
(b) Motivation enhancement
Psychosocial support is provided SI/RR (c ) Reduction of high risk behaviour
(d) Relapse prevention
(e ) Recreation facility
(d) Patient support group / individual counselling

Area of Concern - F Infection Control

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection

ME F1.3 The facility measures hospital associated There is procedure to report cases of SI/RR Patients are observed for any sign and symptoms of
infection rates Hospital acquired infection HAI like fever, purulent discharge from surgical site .

There is Provision of Periodic Medical Check- There is procedure for immunization of

ME F1.4 SI/RR Hepatitis B, Tetanus Toxoid etc
up and immunization of staff the staff
Periodic medical check-ups of the staff SI/RR
The facility has established procedures for Regular monitoring of infection control Hand washing and infection control audits done at
ME F1.5 regular monitoring of infection control practices SI/RR periodic intervals
practices
The facility has defined and establishedCheck for Doctors are aware of Hospital
ME F1.6 antibiotic policy Antibiotic Policy SI/RR
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are provided at point Availability of hand washing Facility at Check for availability of wash basin near the point
ME F2.1 OB
of use Point of Use of use along with elbow operated tap

Availability of running Water OB/SI Ask to Open the tap. Ask Staff water supply is
regular

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method

Availability of antiseptic soap with soap OB/SI Check for availability/ Ask staff if the supply is
dish/ liquid antiseptic with dispenser. adequate and uninterrupted

Availability of Alcohol based Hand rub OB/SI Check for availability/ Ask staff for regular supply.

Display of Hand washing Instruction at OB Prominently displayed above the hand washing
Point of Use facility , preferably in Local language
The facility staff is trained in hand washing
ME F2.2 practices and they adhere to standard hand Adherence to 6 steps of Hand washing SI/OB Ask of demonstration
washing practices
Staff aware of when to hand wash SI
ME F2.3 The facility ensures standard practices and Availability of Antiseptic Solutions OB
materials for antisepsis
Proper cleaning of procedure site with OB/SI like before giving IM/IV injection, drawing blood,
antisepsis putting Intravenous and urinary catheter
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate personal
ME F3.1 Clean gloves are available at point of use OB/SI
protection Equipment as per requirements
Availability of Masks OB/SI
ME F3.2 The facility staff adheres to standard personal No reuse of disposable gloves, Masks, OB/SI
protection practices caps and aprons.
Compliance to correct method of
wearing and removing the PPE SI Gloves, Masks, Caps and Aprons
Standard F4 The facility has standard procedures for processing of equipment and instruments
Ask staff about how they decontaminate the
The facility ensures standard practices and Decontamination of operating & procedure surface like Examination table , Patients
ME F4.1 materials for decontamination and cleaning SI/OB
of instruments and procedures areas Procedure surfaces Beds Stretcher/Trolleys etc.
(Wiping with 0.5% Chlorine solution

Ask staff how they decontaminate the instruments

Proper Decontamination of instruments SI/OB like Stethoscope, Dressing Instruments,
after use Examination Instruments, Blood Pressure Cuff etc
(Soaking in 0.5% Chlorine Solution, Wiping with
0.5% Chlorine Solution or 70% Alcohol as applicable

Contact time for decontamination is

adequate SI/OB 10 minutes

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

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Proper handling of Soiled and infected No sorting ,Rinsing or sluicing at Point of use/
linen SI/OB Patient care area

Staff know how to make chlorine solution SI/OB

The facility ensures standard practices and Equipment and instruments are
ME F4.2 materials for disinfection and sterilization of sterilized after each use as per OB/SI Autoclaving/HLD/Chemical Sterilization
instruments and equipment requirement
High level Disinfection of
Ask staff about method and time required for
instruments/equipments is done as per OB/SI boiling
protocol
Autoclaved dressing material is used OB/SI
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
The facility ensures availability of standard Availability of disinfectant as per
ME F5.2 materials for cleaning and disinfection of requirement OB/SI Chlorine solution, Glutaraldehyde, carbolic acid
patient care areas
Availability of cleaning agent as per Hospital grade phenyl, disinfectant detergent
requirement OB/SI solution
The facility ensures standard practices are
ME F5.3 followed for the cleaning and disinfection of Staff is trained for spill management SI/RR
patient care areas
Cleaning of patient care area with
detergent solution SI/RR

Staff is trained for preparing cleaning

SI/RR
solution as per standard procedure
Standard practice of mopping and
scrubbing are followed OB/SI Unidirectional mopping from inside out

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

ME F5.4 The facility ensures segregation infectious Isolation and barrier nursing procedure OB/SI
patients 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.
The facility Ensures segregation of Bio
ME F6.1 Medical Waste as per guidelines and 'on-site' Availability of colour coded bins at point OB Adequate number. Covered. Foot operated.
management of waste is carried out as per of waste generation
guidelines
Availability of colour coded non
chlorinated plastic bags OB
Human Anatomical waste, Items contaminated with
blood, body fluids, dressings, plaster casts, cotton
Segregation of Anatomical and soiled
OB/SI swabs and bags containing residual or discarded
waste in Yellow Bin
blood and blood components.

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Items such as tubing, bottles, intravenous tubes
Segregation of infected plastic waste in and sets, catheters, urine bags, syringes (without
red bin OB needles and fixed needle syringes) and vacutainers'
with their needles cut) and gloves
Display of work instructions for
segregation and handling of Biomedical OB Pictorial and in local language
waste
There is no mixing of infectious and
general waste
ME F6.2 The facility ensures management of sharps as Availability of functional needle cutters OB See if it has been used or just lying idle.
per guidelines

Segregation of sharps waste including Should be available nears the point of generation.
Metals in white (translucent) Puncture Needles, syringes with fixed needles, needles from
proof, Leak proof, tamper proof OB needle tip cutter or burner, scalpels, blades, or any
containers other contaminated sharp object that may cause
puncture and cuts. This includes both used,
discarded and contaminated metal sharps
Availability of post exposure prophylaxis SI/OB Ask if available. Where it is stored and who is in
charge of that.
Staff knows what to do in condition of SI Staff knows what to do in case of shape injury.
needle stick injury Whom to report. See if any reporting has been done
Contaminated and broken Glass are
disposed in puncture proof and leak
OB Vials, slides and other broken infected glass
proof box/ container with Blue colour
marking

The facility ensures transportation and

ME F6.3 Check bins are not overfilled SI/OB
disposal of waste as per guidelines
Transportation of bio medical waste is SI/OB
done in close container/trolley
Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to locate mercury beads
5. Use syringe without a needle/eyedropper and
sticky tape to suck the beads
6. Collection of beads in leak-proof bag or container
Staff is aware of mercury spill 7. Sprinkle sulphur or zinc powder to remove any
management SI/RR remaining mercury
8. All the mercury spill surfaces should be
decontaminated with 10% sodium thiosulfate
solution
9. All the bags or containers containing items
contaminated with mercury should be marked as
“Hazardous Waste, Handle with Care”
10. Collected mercury waste should be handed over
to the CBMWTF
Area of Concern - G Quality Management

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Standard G1 Facility has established organizational framework for quality improvement
Check if quality circle formed and functional with a
ME G1.1 Facility has a quality team in place Quality circle has been formed in the IPD SI/RR designated nodal officer for quality
Standard G2 The facility has established system for patient and employee satisfaction
Patient satisfaction surveys are conducted at Patient satisfaction survey done on
ME G2.1 RR
periodic intervals monthly basis
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.
There is system daily round by Hospital
ME G3.1 The facility has established internal quality superintendent/ Hospital Manager/ SI/RR Check for entries in Round Register
assurance programme in key departments Matron in charge for monitoring of
services

The facility has established external

ME G3.2 assurance programmes at relevant
departments
The facility has established system for use of
ME G3.3 check lists in different departments and Internal assessment is done at periodic RR/SI NQAS, Kayakalp, SaQushal tools are used to conduct
services interval internal assessment

Departmental checklist are used for Staff is designated for filling and monitoring of
SI/RR
monitoring and quality assurance these checklists

Non-compliances are enumerated and RR Check the non compliances are presented &
recorded discussed during quality team meetings

ME G3.4 Actions are planned to address gaps observed Check action plans are prepared and
implemented as per internal assessment RR Randomly check the details of action, responsibility,
during quality assurance process record findings time line and feedback mechanism

Check PDCA or revalent quality method is Check actions have been taken to close the gap. It
Planned actions are implemented through
ME G3.5 Quality Improvement Cycles (PDCA) used to take corrective and preventive SI/RR can be in form of action taken report or Quality
action Improvement (PDCA) project report
Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
Standard operating procedure for
ME G4.1 Departmental standard operating procedures department has been prepared and RR
are available approved
Current version of SOP are available with OB/RR
process owner
Work instruction/clinical protocols are OB Patient safety, CPR
displayed

Standard Operating Procedures adequately Department has documented procedure

ME G4.2 for receiving and initial assessment of the RR
describes process and procedures
patient

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Checklist No. 11 IPD Version - NHSRC 3.0
Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Department has documented procedure
for admission, shifting and referral 0f RR
patient
Department has documented procedure
for requisition of diagnosis and receiving RR
of the reports
Department has documented procedure
for preparation of the patient for surgical RR
procedure
Department has documented procedure
for transfusion of blood RR

Department has documented procedure

for maintenance of rights and dignity of RR
Patient
Department has documented procedure
for record eminence including taking RR
consent
Department has documented procedure
for counselling of the patient at the time RR
of discharge
Department has documented procedure
for environmental cleaning and RR
processing of the equipment
Department has documented procedure
for sorting, and distribution of clean RR
linen to patient
Department has documented procedure RR
for end of life care
Staff is trained and aware of the procedures Check staff is a aware of relevant part of
ME G4.3 SI/RR
written in SOPs SOPs

Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

Process mapping of critical processes

ME G5.1 The facility maps its critical processes done SI/RR

ME G5.2 The facility identifies non value adding Non value adding activities are identified SI/RR
activities / waste / redundant activities
The facility takes corrective action to improve Processes are rearranged as per
ME G5.3 the processes requirement SI/RR

Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method

Check quality policy of the facility has been defined

in consultation with hospital staff and duly
ME G6.3 Facility has defined Quality policy, which is in Check if Quality Policy has been defined SI/RR approved by the head of the facility . Also check
congruency with the mission of facility and approved Quality Policy enables achievement of mission of
the facility and health department

Check short term valid quality objectivities have

been framed addressing key quality issues in each
ME G6.4 Facility has de defined quality objectives to Check if SMART Quality Objectives have SI/RR department and cores services. Check if these
achieve mission and quality policy framed
objectives are Specific, Measurable, Attainable,
Relevant and Time Bound.

Mission, Values, Quality policy and objectives Check of staff is aware of Mission , Interview with staff for their awareness. Check if
Mission Statement, Core Values and Quality Policy
ME G6.5 are effectively communicated to staff and SI/RR
users of services Values, Quality Policy and objectives is displayed prominently in local language at Key
Points

Verify with records that a time bound action plan

Facility prepares strategic plan to achieve Check if plan for implementing quality has been prepared to achieve quality policy and
ME G6.6 mission, quality policy and objectives policy and objectives have prepared SI/RR objectives in consultation with hospital staff . Check
if the plan has been approved by the hospital
management

Review the records that action plan on quality

Facility periodically reviews the progress of Check time bound action plan is being objectives being reviewed at least once in month by
ME G6.7 strategic plan towards mission, policy and reviewed at regular time interval SI/RR departmental in charges and during the quality
objectives team meeting. The progress on quality objectives
have been recorded in Action Plan tracking sheet

Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 The facility uses method for quality Basic quality improvement method SI/OB PDCA & 5S
improvement in services
Advance quality improvement method SI/OB Six sigma, lean.
ME G7.2 The facility uses tools for quality 7 basic tools of Quality SI/RR Minimum 2 applicable tools are used in each
improvement in services department
Standard G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
Verify with the records. A comprehensive risk
Periodic assessment for Medication and Check periodic assessment of medication assessment of all clinical processes should be done
ME G9.6 Patient care safety risks is done as per and patient care safety risk is done using SI/RR using pre define criteria at least once in three
defined criteria. defined checklist periodically
month.

Periodic assessment for potential risk

regarding safety and security of staff SaQushal assessment toolkit is used for 1. Check that the filled checklist and action taken
ME G9.7 SI/RR report are available
including violence against service providers is safety audits. 2. Staff is aware of key gaps & closure status
done as per defined criteria

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Risks identified are analysed evaluated and
ME G9.8 rated for severity Identified risks are analysed for severity SI/RR Action is taken to mitigate the risks

Standard G10 The facility has established clinical Governance framework to improve quality and safety of clinical care processes

Check parameter are defined & implemented to

Clinical care assessment criteria have been The facility has established procedures to review the clinical care i.e. through Ward round,
ME G10.3 SI/RR peer review, morbidity & mortality review, patient
defined and communicated review the clinical care processes
feedback, clinical audit & clinical outcomes.

Check regular ward rounds are taken to (1) Both critical and stable patients
SI/RR (2) Check the case progress is documented in BHT/
review case progress progress notes-
Check the patient /family participate in SI/RR Feedback is taken from patient/family on health
the care evaluation status of individual under treatment

Check the care planning and co- System in place to review internal referral process,
SI/RR review clinical handover information, review patient
ordination is reviewed understanding about their progress

Check medical audit records

(a) Completion of the medical records i.e. Medical
history, assessments, re assessment, investigations
conducted, progress notes, interventions
conducted, outcome of the case, patient education,
Facility conducts the periodic clinical audits delineation of responsibilities, discharge etc.
ME G10.4 including prescription, medical and death There is procedure to conduct medical SI/RR (b) Check whether treatment plan worked for the
audits audits patient
(C) progress on the health status of the patient is
mentioned
(d) whether the goals defined in treatment plan is
met for the individual cases
(e) Adverse clinical events are documented
(f) Re admission

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method

(1) All the deaths are audited by the committee.

(2) The reasons of the death is clearly mentioned
(3) Data pertaining to deaths are collated and trend
There is procedure to conduct death
audits SI/RR analysis is done
(4) A through action taken report is prepared and
presented in clinical Governance Board meetings /
during grand round (wherever required)

Check for -valid sample size, data is analysed, poor

There is procedure to conduct referral performing attributes are identified and
audits SI/RR improvement
initiatives are undertaken

All non compliance are enumerated & SI/RR Check the non compliances are presented &
recorded for medical audits
discussed during clinical Governance meetings

All non compliance are enumerated &

recorded for newborn death audits SI/RR Check the non compliances are presented &
discussed during clinical Governance meetings

All non compliance are enumerated & SI/RR Check the non compliances are presented &
recorded for referral audits
discussed during clinical Governance meetings

Facility ensures easy access and use of Check standard treatment guidelines / Staff is aware of Standard treatment protocols/
standard treatment guidelines &
ME G10.7 implementation tools at protocols are available & followed. SI/RR guidelines/best practices
point of care
Check treatment plan is prepared as per SI/RR Check staff adhere to clinical protocols while
Standard treatment guidelines preparing the treatment plan
Check the drugs are prescribed as per Check the drugs prescribed are available in EML or
Standards treatment guidelines SI/RR part of drug formulary
Check when the STG/protocols/evidences used in
Check the updated/latest evidence are SI/RR healthcare facility are published.
available Whether the STG protocols are according to current
evidences.

The gaps in clinical practices are identified & action

Check the mapping of existing clinical SI/RR are taken to improve it. Look for evidences for
practices processes is done improvement in clinical practices using PDCA

Area of Concern - H Outcome

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Indicators on Bed Occupancy Rate of Medical Wards RR
monthly basis

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Assessment
Reference No/ ME Statement Checkpoints Compliance Means of verification Remarks
Method
Bed Occupancy Rate for surgical wards RR
Number of the patients screened for pain RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
Facility measures efficiency Indicators on
ME H2.1 Referral Rate RR
monthly basis
Bed Turnover rate RR
Discharge rate RR
No. of drugs stock out in the ward RR

Percentage of in-patients with complete

screening for nutritional needs RR

Patient's fall rate RR

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Average length of stay for Medical wards RR
Indicators on monthly basis
Average length for surgical wards RR
Time taken for initial assessment RR
Medication error per 1000 patient days RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
Facility measures Service Quality Indicators
ME H4.1 on monthly basis LAMA Rate RR
Patient Satisfaction Score RR

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Complianc
Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
. Area of Concern - A Service Provision
Standard A1. Facility Provides Curative Services

Services are available for the time period

ME A1.14. as mandated Blood bank services available 24X7 2 SI/RR

The facility provides Blood bank & Blood bank has facility of whole blood
ME A1.18. transfusion services collection and storage 2 SI/OB

Blood Bank has facility for Blood PRC, Platelets Concentrate, FMP, Plasma&
. 2 SI/OB
Components preparation Single donor Cryo Precipitate
. Blood bank has emergency stock of blood 2 SI/OB For A+, B+, O+ and O-
Provision of blood donation camps 2 SI/OB As per the procedure laid down by the
National Blood Transfusion Council

Standard A2 Facility provides RMNCHA Services

ME A2.2 The facility provides Maternal health Availability of transfusion services 2 SI/OB
Services
Standard A3 Facility Provides diagnostic Services

ME A3.2 The facility Provides Laboratory Services Availability

services
of screening and cross matching 2 SI/OB

Standard A4 Facility provides services as mandated in national Health Programs/ state scheme

The facility provides services under Availability of platelets for management of

ME A4.1 National Vector Borne Disease Control 2 SI/RR
Dengue cases
Programme as per guidelines

Standard A6. Health services provided at the facility are appropriate to community needs.

The facility provides curatives & Blood Bank provides blood components for
ME A6.1. preventive services for the health thalassemia, dengue, haemophilia etc. as per 1 SI/RR
problems and diseases, prevalent locally. local need

. Area of Concern - B Patient Rights

Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities

The facility has uniform and user-friendly Availability of departmental & directional Numbering, main department and internal
ME B1.1. 2 OB
signage system signages sectional signage are displayed

ME B1.2. The facility displays the services and

entitlements available in its departments List of services available are displayed
2 OB

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Complianc
Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
. Blood bank has displayed of Information 2 OB
regarding donors eligibility
Blood bank has displayed information 2 OB
regarding number of blood units available

ME B1.4. User charges are displayed and User services charges in r/o blood are 2 OB
communicated to patients effectively displayed at entrance
Patients & visitors are sensitised and IEC material is available in blood bank to
ME B1.5. educated through appropriate IEC / BCC provide information and to promote blood 2 OB
approaches donation
Information is available in local language Signage's and information are available in
ME B1.6. and easy to understand local language 2 OB

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 economic, cultural or
social reasons
Access to facility is provided without any
Availability of ramp or alternate for easy At least 120 cm width, gradient not
ME B2.3. physical barrier & and friendly to people access to the blood bank 2 OB steeper than 1:12, if ramp is available
with disabilities

Standard B3. The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

Adequate visual privacy is provided at Privacy at blood donation and counselling

ME B3.1. every point of care room 2 OB

Blood Bank has system to ensure the Blood bank staff do not discuss the lab
ME B3.2. Confidentiality of patients records and confidentiality of results of screening test 2 SI/OB result outside. reports are kept in secure
clinical information is maintained
done place
The facility ensures the behaviours of
Behaviour of staff is empathetic and
ME B3.3 staff is dignified and respectful, while 2 PI/OB
delivering the services courteous

The facility ensures privacy and

confidentiality to every patient,
ME B3.4. especially of those conditions having Confidentiality and privacy of HIV patients 2 SI/OB
social stigma, and also safeguards
vulnerable groups

Standard B4. Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it
is required.

There is established procedures for In consent form, procedure of donation is

Blood bank is taking informed consent of explained along with informing the donor
ME B4.1. taking informed consent before 2 SI/RR
donor regarding testing of blood is mandatory for
treatment and procedures safety of recipient

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Complianc
Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
ME B4.3. Staff are aware of Patients rights Awareness of staff on donor rights and 2 SI About the confidentiality and privacy of
responsibilities donor responsibilities donor information
Procedure include preparation of
Information about the treatment is
ME B4.4. shared with patients or attendants, Pre donation counselling is done before 2 PI/SI/RR venepuncture site, use of blood bags and
regularly donation anticoagulant solution, collecting sample
for laboratory test

Post donation counselling also include

. Post donation counselling for sero reactive 2 PI/SI counselling on HIV/ Hept B for which blood
donors bank may refer the donor to ICTC /SACS/
MTC

The facility has defined and established Availabilty of complaint box and display of
ME B4.5. process for grievance re addressal and 2 OB
grievance redressal system in place
whom 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 care.

The facility provides cashless services to Free blood for Pregnant woman, Mothers
ME B5.1. pregnant women, mothers and neonates and New Borns 2 PI/SI
as per prevalent government schemes

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

The facility provide free of cost

ME B5.4. treatment to Below poverty line patients Free blood for BPL patients 2 PI/SI/RR
without administrative hassles

. Area of Concern C: Inputs

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

ME C1.1. Departments have adequate space as per Blood bank has adequate space as per 2 OB Space required is more than 100 sq meters
patient or work load requirement
Availability of waiting area in blood bank 2 OB
ME C1.2. Patient amenities are provide as per Separate toilet facilities for male & female 1 OB
patient load are available
Seating arrangement in waiting area 2 OB
Departments have layout and
ME C1.3. Dedicated examination room 2 OB
demarcated areas as per functions
. Dedicated Blood collection room 2 OB

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Complianc
Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
. Dedicated transfusion transmissible 2 OB
infection (TTI) lab
. Availability of refreshment cum rest room 2 OB
. Dedicated sterilization area 2 OB

. Dedicated store cum record room 2 OB

. Availability of Duty room for staff 1 OB

The facility has adequate circulation area

Availability of adequate circulation area for
ME C1.4 and open spaces according to need and easy moment of staff and equipments 2 OB
local law
The facility has infrastructure for
ME C1.5. intramural and extramural Availability of functional telephone and 1 OB
Intercom Services
communication

ME C1.6. Service counters are available as per Adequate Donor couches/ donor units as 2 OB
patient load per load

The facility and departments are planned

to ensure structure follows the Blood bank layout ensures smooth flow of
ME C1.7. function/processes (Structure 2 OB
commensurate with the function of the donor and services
hospital)

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

Check for fixtures and furniture like

ME C2.1 The facility ensures the seismic safety of Non structural components are properly 2 OB cupboards, cabinets, and heavy
the infrastructure secured equipments , hanging objects are properly
fastened and secured
The facility ensures safety of electrical Blood bank does not have temporary
ME C2.3 1 OB
establishment connections and loosely hanging wires

Adequate electrical socket provided for safe

. and smooth operation of lab equipments 2 OB/RR

ME C2.4 Physical condition of buildings are safe Work benches are chemical resistant 2 OB
for providing patient care
Floors of the Laboratory are non slippery and 2 OB
even
Windows have grills and wire meshwork 2 OB

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Complianc
Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
Standard C3. The facility has established Programme for fire safety and other disaster

ME C3.1. The facility has plan for prevention of fire Blood bank has sufficient fire exit to permit 2 OB/SI
safe escape to its occupant at time of fire

. Check the fire exits are clearly visible and 2 OB

routes to reach exit are clearly marked.

Blood bank has plan for safe storage and 2 OB

handling of potentially flammable materials.

ME C3.2. The facility has adequate fire fighting Blood Bank has installed fire Extinguisher 2 OB/RR
Equipment that is Class A , Class BC type or ABC type
Check the expiry date for fire extinguishers
are displayed on each extinguisher as well as
. due date for next refilling is clearly 2 OB/RR
mentioned

The facility has a system of periodic

ME C3.3. training of staff and conducts mock drills Check
fire
for staff competencies for operating
extinguisher and what to do in case of 2 SI/RR
regularly for fire and other disaster fire
situation

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

The facility has adequate specialist Availability of dedicated blood bank medical
ME C4.1. 2 OB/RR MBBS doctor with one year experience
doctors as per service provision officer
The facility has adequate nursing staff as Availability of dedicated Nursing Staff
ME C4.3. per service provision and work load 2 OB/RR/SI

The facility has adequate Availability of dedicated Blood Bank

ME C4.4. technicians/paramedics as per 1 SI/RR
Technician round the clock
requirement

ME C4.5. The facility has adequate support / Availability of housekeeping staff 2 SI/RR
general staff
Availability of security staff 0 SI/RR
Standard C5. Facility provides drugs and consumables required for assured list of services.

The departments have availability of Departments have availability of adequate Inj Adrenaline,Inj Deriphylline,Inj
ME C5.1. 2 OB/RR Dexamethasone ,Inj Chlorpheniramine,Inj
adequate drugs at point of use emergency drugs at point of use Metochlorpromide

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Complianc
Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
Evacuated Blood collection tubes, Swabs,
Availability Laboratory materials 2 OB/RR Syringes, Glass slides, Glass marker/paper
stickers

Standard Grouping Sera Anti A, Anti B &

Anti D ,VDRL/RPR Kit for Syphillis,RDK/
ME C5.2. The departments have adequate Availability of Reagents /Kits for lab 2 OB/RR ELISA for Malarial Antigen, ELISA kit for
consumables at point of use Hep B &C, ELISA kit for HIV1 & 2, malarial
parasite stains

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

ME C6.1. Availability of equipment & instruments Availability of functional Equipment 2 OB Adult Weighing machine, BP apparatus ,
for examination & monitoring of patients &Instruments for examination & Monitoring clinical thermometer

Availability of equipment & instruments Availability of laboratory equipment & Microscope with water bath, ELISA reader
ME C6.3. for diagnostic procedures being 2 OB with washer, RH viewer, Sahli's
instruments for laboratory
undertaken in the facility Haemoglobino meter/Others

Availability of equipment and

ME C6.4. instruments for resuscitation of patients Availability of functional Instruments for 2 OB Adult bag and mask and Oxygen
and for providing intensive and critical Resuscitation.
care to patients

Blood bags refrigerator with thermo graph

Check for availability of storage equipments and alarm device, Insulated carrier boxes
ME C6.5. Availability of Equipment for Storage 2 OB
for blood products with ice packs, Blood bag weighting
machine, deep freezer, Platelets agitators

Availability of functional equipment and Availability of equipments for cleaning Buckets for mopping, mops, duster, waste
ME C6.6. 2 OB
instruments for support services trolley, Deck brush

Departments have patient furniture and Availability of beds/Couches in blood bank

ME C6.7. 2 OB Blood collection bed, recovery beds
fixtures as per load and service provision

Availability of attachment/ accessories 2 OB Hospital graded Mattress, bed sheet,

blanket, and bed side table

Availability of Fixtures 2 OB Electrical fixture for equipments lab and

storage equipments
cupboard, counter for issuing blood, work
Availability of furniture 2 OB
benches for lab, chair.
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

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Check objective checklist has been

prepared for assessing competence of
ME C7.1 Criteria for Competence assessment are Check parameters for assessing skills and 2 RR/SI doctors, nurses and paramedical staff
defined for clinical and Para clinical staff proficiency of clinical staff has been defined based on job description defined for each
cadre of staff. Dakshta checklist issued by
MoHFW can be used for this purpose.

Competence assessment of Clinical and Check for records of competence

Check for competence assessment is done at assessment including filled checklist,
ME C7.2 Para clinical staff is done on predefined 2 RR/SI
criteria at least once in a year least once in a year scoring and grading . Verify with staff for
actual competence assessment done

The Staff is provided training as per

Bio medical Waste Management including
ME C7.9 defined core competencies and training Infection control & prevention training 2 SI/RR Hand Hygiene
plan
Patient Safety 2 SI/RR
Basic Life Support 2 SI/RR
To all category of staff. At the time of
Training on Quality Management System 2 SI/RR induction and once in a year.

There is established procedure for Check supervisors make periodic rounds of

department and monitor that staff is
ME C7.10 utilization of skills gained thought Staff is skilled for operating the equipments 2 SI/RR working according to the training
trainings by on -job supportive
imparted. Also staff is provided on job
supervision
training wherever there is still gaps
. Area of Concern - D Support Services
Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

1. Check with AMC records/

The facility has established system for All equipments are covered under AMC Warranty documents
ME D1.1. 2 SI/RR
maintenance of critical Equipment including preventive maintenance 2. Staff is aware of the list of equipment
covered under AMC.

[Link] for breakdown & Maintenance

There is system of timely corrective break record in the log book
. down maintenance of the equipments 2 SI/RR 2. Staff is aware of contact details of the
agency/person in case of breakdown.

There has system to label Defective/Out of

. order equipments and stored appropriately 2 OB/RR
until it has been repaired

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Staff is skilled for trouble shooting in case 2 SI/RR
equipment malfunction
Periodic cleaning, inspection and
maintenance of the equipments is done by 1 SI/RR
the operator
The facility has established procedure for All the measuring equipments/ instrument
ME D1.2. internal and external calibration of 1 OB/ RR
measuring Equipment are calibrated

There is system to label/ code the

. equipment to indicate status of calibration/ 2 OB/ RR
verification when recalibration is due

Blood bank has system to update correction

. factor after calibration wherever required 0 SI/RR Check for records

Each lot of reagents has to be checked

against earlier tested in use reagent lot or
. with suitable reference material before 2 SI/RR
being placed in service and result should be
recorded.

Operating and maintenance instructions Up to date instructions for operation and

ME D1.3. are available with the users of maintenance of equipments are readily 2 OB/SI
equipment available with staff.

Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas

There is established procedure for There is established system of timely Stock level are daily updated
ME D2.1. forecasting and indenting drugs and indenting of consumables and reagents 2 SI/RR Indent are timely placed
consumables

The facility ensures proper storage of Reagents and consumables are kept away Check the storage conditions of reagents,
ME D2.3 drugs and consumables from water and sources of heat, 2 OB/RR blood,etc.
direct sunlight

Reagents label contain name,

concentration, date of
Reagents are labelled appropriately 2 OB/RR
preparation/opening, date of expiry,
storage conditions and warning

The facility ensures management of Expiry dates' of the blood bags are
ME D2.4. 2 OB/RR
expiry and near expiry drugs maintained

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No expired blood is found in storage 2 OB/RR
Records for expiry and near expiry blood are Check the record of expiry and near expiry
maintained 2 RR drug in drug substore
Minimum stock and reorder level are
ME D2.5 The facility has established procedure for There is practice of calculating and 2 SI/RR calculated based on consumption
inventory management techniques maintaining buffer stock of reagents Minimum buffer stock is maintained all
the time

Department maintained stock register of Check record of drug received, issued and
reagents 2 RR/SI balance stock in hand and are regularly
updated
There is a procedure for periodically
ME D2.6 replenishing the drugs in patient care There is established procdeure for 2 SI/RR
replenishing drug tray /crash cart
areas
There is no stock out of reagents 2 OB/SI Check some stock of reagent
Temperature of refrigerators used for
There is process for storage of vaccines storing lab reagents are kept as per storage Check for temperature charts are
ME D2.7. and other drugs, requiring controlled requirement and records twice a day are 2 OB/RR maintained and updated twice a day for
temperature maintained refrigerators used storing lab reagents

. Regular Defrosting is done 2 SI/RR

Standard D3. The facility provides safe, secure and comfortable environment to staff, patients and visitors.

Illumination level of blood bank is as per

The facility provides adequate Adequate illumination at work station in
ME D3.1. illumination level at patient care areas laboratory 2 OB recommendation/ sufficient to carry out
blood bank activities
Adequate illumination at donation area 2 OB
The facility has provision of restriction of Entry is restricted in storage and lab area of
ME D3.2. visitors in patient areas the blood bank 2 OB

Air conditioned blood collection room,

The facility ensures safe and comfortable Temperature is maintained and record of blood group serology lab, testing lab for
ME D3.3. environment for patients and service 2 SI/RR
same is kept Transfusion Transmissible Diseases,
providers refreshment cum rest room
The facility has established measure for Female staff feel secure at work place
ME D3.5 1 SI
safety and security of female staff

Standard D4. The facility has established Programme for maintenance and upkeep of the facility

Exterior of the facility building is Building is painted/whitewashed in uniform

ME D4.1 1 OB
maintained appropriately colour

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Interior of patient care areas are plastered & 1 OB
painted

ME D4.2. Patient care areas are clean and hygienic Floors, walls, roof, roof topes, sinks patient 2 OB All area are clean with no
care and circulation areas are Clean dirt,grease,littering and cobwebs

Surface of furniture and fixtures are clean 2 OB

Toilets are clean with functional flush and 2 OB
running water

ME D4.3. Hospital infrastructure is adequately Check for there is no seepage , Cracks, 2 OB

maintained chipping of plaster
Window panes , doors and other fixtures are
intact 2 OB
Patients beds are intact and painted 2 OB Mattresses are intact and clean
ME D4.5. The facility has policy of removal of No condemned/Junk material in the lab 2 OB
condemned junk material
The facility has established procedures
ME D4.6 for pest, rodent and animal control No stray animal/rodent/birds 2 OB

Standard D5. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

The facility has adequate arrangement Availability of 24x7 running and potable
ME D5.1 storage and supply for portable water in water 2 OB/SI
all functional areas
The facility ensures adequate power
ME D5.2. backup in all patient care areas as per Availability of power back up in OT 2 OB/SI
load
Availability of UPS 0 OB/SI
Standard D7 The facility ensures clean linen to the patients
ME D7.1 The facility has adequate sets of linen Blood bank provides Linen for donors 2 OB/RR Blankets
Standard D10. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government

The facility has requisite licences and

certificates for operation of hospital and Blood
bank has valid license under Rule
ME D10.1. 122(G) Drug and cosmetic act 0 RR
different activities

Standard D11. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

The facility has established job Job description is defined and

ME D11.1. description as per govt guidelines communicated to all concerned staff 2 RR Regular + contractual

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Staff is aware of their role and 2 SI
responsibilities
The facility has a established procedure There is procedure to ensure that staff is Check for system for recording time of
ME D11.2. for duty roster and deputation to 2 RR/SI reporting and relieving (Attendance
different departments available on duty as per duty roster register/ Biometrics etc)
There is designated in charge for
department 2 SI

The facility ensures the adherence to Doctor, technician and support staff adhere
ME D11.3. dress code as mandated by its 2 OB
administration / the health department to their respective dress code

Standard D12. Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

Verification of outsourced services

ME D12.1 There is established system for contract There is procedure to monitor the quality
and adequacy of outsourced services on 2 SI/RR
(cleaning/
Dietary/Laundry/Security/Maintenance)
management for out sourced services regular basis provided are done by designated in-house
staff
. Area of Concern - E Clinical Services
Standard E1. The facility has defined procedures for registration, consultation and admission of patients.

ME E1.1. The facility has established procedure for Unique identification number is given to 2 RR
registration of patients each donor during process of registration
Check for that patient demographics like
Donors demographic details are recorded 2 RR
Name, age, Sex, Address etc.

Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.

ME E2.1 There is established procedure for initial There is procedure for assessment of patient 2 RR/SI Initial assessment is recorded
assessment of patients before donation

Standard E3. Facility has defined and established procedures for continuity of care of patient and referral

Facility has established procedure for Facility has established procedure for
ME E3.1. continuity of care during handing over of patients during 2 SI/RR
interdepartmental transfer departmental transfer
There is a procedure consultation of the
. patient to other specialist with in the 2 SI/RR
hospital

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Facility provides appropriate referral
linkages to the patients/Services for There is procedure for referral of cases for
ME E3.2. transfer to other/higher facilities to which requested blood group is not available 2 SI/RR
assure their continuity of care.
Facility has functional referral linkages to
. blood storage unit 2 SI/RR

Standard E4. The facility has defined and established procedures for nursing care

There is established procedure of patient

ME E4.3 hand over, whenever staff duty change Procedure to handover test/ results during 2 RR/SI
happens shift change

Handover register is maintained 2 RR

Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage

All the assessments, re-assessment and Records of donor assessment is maintained

ME E8.1 investigations are recorded and updated 2 RR (Manually/e-records)

Format for consent, requisition form,

ME E8.5 Adequate form and formats are available Standard Formats available 2 RR/OB blood transfusion reaction form, referral
at point of use slip

ME E8.6. Register/records are maintained as per Blood bank records are labelled and indexed 2 RR (Manually/e-records)
guidelines

Records includes daily group wise stock

register, daily temperature recording of
temperature dependent equipment, stock
register of consumables and non
. Records are maintained for blood bank 2 RR consumables, documents of proficiency
testing, records of equipment
maintenance, records of recipient,
compatibility records, transfusion reaction
records, donors records etc.

The facility ensures safe and adequate Safe keeping of patient records Blood bank has facility to store records for
ME E8.7. storage and retrieval of medical records 2 OB 5 year

Standard E11. The facility has defined and established procedures for Emergency Services and Disaster Management

The facility has disaster management Blood bank has system of coping with extra
ME E11.3. plan in place demand of blood in case of disaster 2 SI/RR

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Staff is aware of disaster plan 2 SI/RR
Role and responsibilities of staff in disaster is
defined 1 SI/RR

Standard E12 The facility has defined and established procedures of diagnostic services

There are established procedures for Container is labelled properly after the
ME E12.1 Pre-testing Activities sample collection 2 OB

Standard E13. The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.

Based on Physical examination, Medical

Blood bank has defined and Blood bank has defined criteria for donor
ME E13.1. implemented donor selection criteria selection 2 RR/SI history, condition that affects safety of
recipients, donation intervals,

. Blood bank ensures that blood is taken from 2 RR/PI/SI

voluntary donors only
Pre donation counselling is done before 2 RR/PI
donation

Check for questionnaire is available in local

2 OB/RR
language for taking pre donation information

Procedure include preparation of

ME E13.2. There is established procedure for the Blood bank has standardized procedure for 2 RR/SI venepuncture site, use of blood bags and
collection of blood collection of blood from donor anticoagulant solution, collecting sample
for laboratory test

Instructions for collection and handling the

Mostly numeric or alpha numeric label
. collected blood are communicated to those 2 RR/SI
responsible for collection should be used for tracing

Blood bank has identified procedure for

. labelling of blood bag/blood component 2 RR/OB
/pilot tubes

Blood should be kept at 4oC to 6oC except

Blood bank has system to trace of unit of if it is used for component preparation it
. blood /component from source to final 2 RR/SI
will be stored at 22oC until platelet are
destination separated

Blood bank has system to maintain

. temperature of collected blood immediately 2 RR/SI
after donation

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Blood bank has system in place to monitor
. the transportation of the blood from camp 2 RR/SI
site

ME E13.3. There is established procedure for the Determination of ABO group is done by 1 RR/SI Tube or Microplate or gel technology
testing of blood recommended methods

Determination of Rh (D) Type done as per Check for the protocol/ Algorithm followed
2 RR/SI
recommended method for determining RH + or RH- Blood type

Laboratory tests for Infectious diseases done or infectious diseases (VDRL/RPR/TPHAfor

as per recommended method 2 RR/SI syphilis, ELISA/Rapid test for Hep A, Hep B,
HIV and Malaria for malarial parasite

There is provision of Quarantine Storage Check for untested blood is stored in

2 RR/OB/SI
untested blood different refrigerator
Blood units with reactive test result area 2 RR/OB/SI In dedicate secure area with biohazard sign
kept separately until disposal

Sterility of Blood units checked with Check Sterility is checked at least for 1% of
2 RR/OB/SI blood unit collected or 4 per month which
adequate sample size ever higher by appropriate culture method

Check for use of aseptic method and

ME E13.4 There is established procedure for Sterility of Blood component is insured 2 SI/RR availability of Sterile pyrogen free
preparation of blood component during processing
disposable bags and solutions
Transfusion time limits are adhered one
2 SI/RR Within 6 hours
frozen component have been thawed
Blood components are prepared as per 2 SI/RR Check availability and adherence to NACO
technical standards standards
Approximate volume of the component is
2 RR
indicated on bag
There is establish procedure for labelling Blood bank has system to ensure that final
ME E13.5. and identification of blood and its blood bags are labelled only after all 2 RR/SI
product mandatory testing is completed.
Blood bank has system of identification Blood bags are Identified with a numeric or
. traceability of its products 2 RR/SI alpha numeric system / Barcode

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Name of product, numeric information,

date of collection and expiry, amount of
Blood bank has system to the affix the anticoagulant and approximate blood
. 2 RR/SI collected, Name, address and
product information on bag, after processing manufacturing license number of collecting
facility, storage temperature and expiry
date

Instruction for transfusion are printed on 2 RR/SI

label
Blood group O -blue, Blood group A-
. Blood bank has colour coded scheme for 2 RR/SI yellow, Blood group B- Pink, Blood group
differentiate ABO groups AB- White

There is established procedure for Check for refrigerators or freezers for blood
ME E13.6 storage of blood storage are not used for storing other items 2 OB Lab reagents etc.

Check for refrigerators used for blood

storage are kept at recommended 2 OB/RR Check records that temperature is
temperature maintained at 4c + 2 C

Storage temperature is monitored at every 4 2 OB/RR Check the records

hours
Alarm system has been provided with 2 RR/SI
refrigerator

Adequate alternate storage facility available 2 RR/SI

Shelf life of blood and components is 2 RR/SI

adhered as per NACO protocols

There is established the compatibility Blood bank has system to testing and cross Testing of recipient blood includes
ME E13.7. testing matching the recipient blood 2 RR/SI Determination ABO type, Rh (D) type,
detection of unexpected antibodies etc.
Check for practice in case of ABO type
There is established procedure for selection 2 RR/SI specific groups are not available. Issue of
of blood and components for transfusion
blood to RH+ and Negative recipient
There is established procedure for re cross
matching in case of massive transfusion 2 RR/SI

Paediatric blood collection bags are available 2 RR/SI

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Testing of recipient blood includes
There is established procedure for Blood bank has system to testing and cross
ME E13.8. issuing blood matching the recipient blood 2 RR/SI Determination ABO type, Rh (D) type,
detection of unexpected antibodies etc.

Instructions for collection and handling Blood sample collection vial is label with
blood sample of recipient are Patient Name, identification no, name of
. communicated to those responsible for 2 RR/SI hospital, ward/bed number, date time ,
collection Phlebotomist signature

Blood bank has system to confirm that

. information on transfusion requisition form 2 RR/SI
and recipients blood sample label is same

Blood bank has system to retain recipient

. and donor blood sample for 7 days at 2 RR/SI
specified temperature (2-8 c) after each
transfusion
Blood bank has system to issue the blood
. 2 RR/SI
along with cross matching report
Blood bank has system to identify the person
. who is performing the cross matching test 2 RR/SI Record of same should be available
and issue the blood
Blood bank has procedure to issue the blood
. in case of its urgent requirement 2 RR/SI

There is a established procedure for Transfusion reaction form is provided when

ME E13.10. monitoring and reporting Transfusion blood is issued 2 RR/SI
complication
Blood bank has system of detection,
. reporting and evaluations of transfusion 2 RR/SI
errors
. Area of Concern - F Infection Control
Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

Facility has provision for Passive and Surface and environment samples are taken Swab are taken from infection prone
ME F1.2 active culture surveillance of critical & 2 SI/RR
high risk areas for microbiological surveillance surfaces

There is Provision of Periodic Medical There is procedure for immunization of the

ME F1.4. 1 SI/RR Hepatitis B, Tetanus Toxid etc
Checkups and immunization of staff staff
Periodic medical checkups of the staff 1 SI/RR

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Facility has established procedures for
Regular monitoring of infection control Hand washing and infection control audits
.ME F1.5. regular monitoring of infection control practices 1 SI/RR done at periodic intervals
practices

Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis

ME F2.1. Hand washing facilities are provided at Availability of hand washing Facility at Point 2 OB Check for availability of wash basin near
point of use of Use the point of use

. Availability of running Water 2 OB/SI Ask to Open the tap. Ask Staff water
supply is regular

. Availability of antiseptic soap with soap dish/ 2 OB/SI Check for availability/ Ask staff if the
liquid antiseptic with dispenser. supply is adequate and uninterrupted

. Availability of Alcohol based Hand rub 2 OB/SI Check for availability/ Ask staff for regular
supply.
Prominently displayed above the hand
Display of Hand washing Instruction at Point
of Use 2 OB washing facility , preferably in Local
language
Availability of elbow operated taps 2 OB

Hand washing sink is wide and deep enough 2 OB

to prevent splashing and retention of water

ME F2.2. Staff is trained and adhere to standard Adherence to 6 steps of Hand washing 2 SI/OB Ask of demonstration
hand washing practices
. Staff aware of when to hand wash 2 SI
Facility ensures standard practices and
ME F2.3 Availability of Antiseptic Solutions 2 OB
materials for antisepsis
like before giving IM/IV injection, drawing
Proper cleaning of procedure site with
antisepsis 2 OB/SI blood, putting Intravenous and urinary
catheter

Standard F3. Facility ensures standard practices and materials for Personal protection

Facility ensures adequate personal All personal use gloves while drawing
ME F3.1. protection equipments as per Clean gloves are available at point of use 2 OB/SI sample, examining and disposable of the
requirements samples
. Availability of lab aprons/coats 2 OB/SI
. Availability of Masks 2 OB/SI
Staff is adhere to standard personal No reuse of disposable gloves, Masks, caps
ME F3.2. 2 OB/SI
protection practices and aprons.

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Compliance to correct method of wearing 2 SI Gloves, Masks, Caps and Aprons
and removing the PPE

Standard F4. Facility has standard Procedures for processing of equipments and instruments

Facility ensures standard practices and Ask staff about how they decontaminate
ME F4.1. materials for decontamination and clean Decontamination of operating & Procedure 2 SI/OB work benches
ing of instruments and procedures areas surfaces (Wiping with 0.5% Chlorine solution

Decontamination of instruments and

Proper Decontamination of instruments reusable of glassware are done after
. after use 2 SI/OB 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 and
decontamination running water after decontamination
Staff know how to make chlorine solution 2 SI/OB
Facility ensures standard practices and
ME F4.2. materials for disinfection and Disinfection of reusable glassware 2 SI/OB Disinfection by hot air oven at 160 oC for 1
sterilization of instruments and hour
equipments

Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention

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

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

requirement detergent solution
Facility ensures standard practices
ME F5.3. followed for cleaning and disinfection of Staff is trained for spill management 2 SI/RR
patient care areas
Cleaning of patient care area with detergent 2 SI/RR
solution
Staff is trained for preparing cleaning
2 SI/RR
solution as per standard procedure
Standard practice of mopping and scrubbing
are followed 2 OB/SI Unidirectional mopping from inside out

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Any cleaning equipment leading to
Cleaning equipments like broom are not
used in patient care areas 2 OB/SI 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.

ME F6.1. Facility Ensures segregation of Bio Availability of colour coded bins at point of 2 OB Adequate number. Covered. Foot
Medical Waste as per guidelines waste generation operated.

. Availability of colour coded non 2 OB

chlorinated plastic bags

. Segregation of different category of waste as 2 OB/SI

per guidelines

Display of work instructions for segregation

. and handling of Biomedical waste 2 OB Pictorial and in local language

There is no mixing of infectious and general

waste 2 OB

ME F6.2. Facility ensures management of sharps Availability of functional needle cutters 2 OB See if it has been used or just lying idle.
as per guidelines

Should be available nears the point of

[Link], syringes with fixed
Seggregation of sharps waste including needles, needles from needle tip cutter or
Metals in white (translucent) Puncture
. proof, Leak proof, tamper proof containers 2 OB burner, scalpels, blades, or any other
contaminated sharp object that may cause
puncture and cuts. This includes both used,
discarded and contaminated metal sharps

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

Staff knows what to do in condition of Staff knows what to do in case of shape

. 2 SI injury. Whom to report. See if any
needle stick injury reporting has been done
Facility ensures transportation and
ME F6.3. disposal of waste as per guidelines Disinfection of liquid waste before disposal 2 SI/OB

Disposal of discarded blood bags as per

. guideline 2 SI/OB
. Check bins are not overfilled 2 SI
Transportation of bio medical waste is done
in close container/trolley 2 SI/OB

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Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to lacate mercury beads
5. Use syringe without a
needle/eyedropper and sticky tape to suck
the beads
6. Collection of beads in leak-proof bag or
container
Staff aware of mercury spill management 2 SI/RR 7. Sprinkle sulphur or zinc powder to
remove any remaining mercury
8. All the mercury spill surfaces should be
decontaminated with 10% sodium
thiosulfate solution
9. All the bags or containers containing
items contaminated with mercury should
be marked as “Hazardous Waste, Handle
with Care”
10. Collected mercury waste should be
handed over to the CBMWTF

. Area of Concern - G Quality Management

Standard G1. The facility has established organizational framework for quality improvement

Quality circle has been formed in the Blood Check if quality circle formed and
ME G1.1. The facility has a quality team in place 2 SI/RR functional with a designated nodal officer
Bank for quality

Standard G2 Facility has established system for patient and employee satisfaction

Patient Satisfaction surveys are There is system to take feed back from
ME G2.1 2 RR
conducted at periodic intervals clinician about quality of services
Feedback from donor are taken on periodic
basis 2 RR

Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality.

Facility has established internal quality

ME G3.1. assurance program at relevant Internal Quality assurance program is in 2 SI/RR
place
departments
. Standards are run at defined interval 2 SI/RR

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Control charts are prepared and outliers are 2 SI/RR
identified.
Corrective action is taken on the identified 2 SI/RR
outliers
Facility has established external
ME G3.2. assurance programs at relevant Cross validation of lab test are done and 2 SI/RR It includes participation of laboratory in
departments reports are maintained inter laboratory comparison

Blood bank takes corrective action when

Corrective actions are taken on abnormal control criteria are not fulfilled in
. values 2 SI/RR Interlaboratory comparisons and records
of same is maintained

Facility has established system for use of

ME G3.3 check lists in different departments and Internal assessment is done at periodic 2 RR/SI NQAS, Kayakalp, SaQushal tools are used
services interval to conduct internal assessment

Departmental checklist are used for 2 SI/RR Staff is designated for filling and
monitoring and quality assurance monitoring of these checklists

Non-compliances are enumerated and

2 RR Check the non compliances are presented
recorded & discussed during quality team meetings

Actions are planned to address gaps Check action plans are prepared and Randomly check the details of action,
ME G3.4 observed during quality assurance implemented as per internal assessment 2 RR responsibility, time line and feedback
process record findings mechanism

Check actions have been taken to close the

Planned actions are implemented Check PDCA or revalent quality method is gap. It can be in form of action taken
ME G3.5 through Quality Improvement Cycles used to take corrective and preventive 1 SI/RR
(PDCA) action report or Quality Improvement (PDCA)
project report

Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Standard operating procedure for

Departmental standard operating
ME G4.1. procedures are available department has been prepared and 2 RR
approved

. Current version of SOP are available with 2 OB/RR

process owner

Work instruction/clinical protocols are work instruction for screening of blood,

2 OB storage of blood, maintaining blood and
displayed
component in event of power failure

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Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
Standard Operating Procedures Blood bank has documented procedure for
ME G4.2. adequately describes process and Donor selection and collection of blood from 2 RR
procedures donor

. Blood bank has documented procedure for 2 RR

testing of donated blood
Blood bank has documented procedure for
. preparation of blood components 2 RR

Blood bank has documented procedure for

. storage, transportations of blood and issue 2 RR
of blood for transfusion

. Blood bank has documented procedure for 2 RR

issue of blood in case of urgent requirement

. Blood bank has documented procedure to 2 RR

address the transfusion reactions

. Blood bank has documents procedure for 2 RR

calibration and maintenance of equipment

. Blood bank has documented procedure for 2 RR

HAI and disposal of BMW

Blood bank has documented system for

storage, retaining and retrieval of laboratory
. records, primary sample, Examination 2 RR
sample and reports of results.

Blood bank has documented system for

. internal and external Quality control of 2 RR
Equipments, reagent and tests
Staff is trained and aware of the standard Check staff is a aware of relevant part of
ME G4.3. procedures written in SOPs SOPs 2 SI/RR

Standard G 5. Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

ME G5.1. Facility maps its critical processes Process mapping of critical processes done 0 SI/RR

Facility identifies non value adding

ME G5.2. activities / waste / redundant activities Non value adding activities are identified 0 SI/RR

ME G5.3. Facility takes corrective action to Processes are rearranged as per 2 SI/RR
improve the processes requirement
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Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Check quality policy of the facility has been

Facility has defined Quality policy, which defined in consultation with hospital staff
ME G6.3 is in congruency with the mission of Check if Quality Policy has been defined and 2 SI/RR and duly approved by the head of the
facility approved facility . Also check Quality Policy enables
achievement of mission of the facility and
health department

Check short term valid quality objectivities

have been framed addressing key quality
ME G6.4 Facility has de defined quality objectives Check if SMART Quality Objectives have 0 SI/RR issues in each department and cores
to achieve mission and quality policy framed services. Check if these objectives are
Specific, Measurable, Attainable, Relevant
and Time Bound.

Interview with staff for their awareness.

Mission, Values, Quality policy and
objectives are effectively communicated Check
of staff is aware of Mission , Values, Check if Mission Statement, Core Values
ME G6.5 2 SI/RR
to staff and users of services Quality Policy and objectives and Quality Policy is displayed prominently
in local language at Key Points

Verify with records that a time bound

action plan has been prepared to achieve
Facility prepares strategic plan to achieve Check if plan for implementing quality policy quality policy and objectives in
ME G6.6 1 SI/RR
mission, quality policy and objectives and objectives have prepared consultation with hospital staff . Check if
the plan has been approved by the hospital
management

Review the records that action plan on

quality objectives being reviewed at least
Facility periodically reviews the progress Check time bound action plan is being onnce in month by departmnetal incharges
ME G6.7 of strategic plan towards mission, policy reviewed at regular time interval 1 SI/RR
and during the qulaity team meeting. The
and objectives progress on quality objectives have been
recorded in Action Plan tracking sheet

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

Facility uses method for quality

ME G7.1. improvement in services Basic quality improvement method 2 SI/RR PDCA & 5S

. Advance quality improvement method 0 SI/OB Six sigma, lean.

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Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
ME G7.2. Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used in
improvement in services each department
Standard G9 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.

Verify with the records. A comprehensive

Periodic assessment for Medication and Check periodic assessment of medication
ME G9.6 Patient care safety risks is done as per and patient care safety risk is done using 2 SI/RR risk asesement of all clincial processes
defined criteria. defined checklist periodically should be done using pre define critera at
least once in three month.

Periodic assessment for potential risk 1. Check that the filled checklist and action
ME G9.7 regarding safety and security of staff SaQushal assessment toolkit is used for 2 SI/RR taken report are available
including violence against service safety audits. 2. Staff is aware of key gaps & closure
providers is done as per defined criteria status

ME G9.8 Risks identified are analyzed evaluated Identified risks are analysed for severity 1 SI/RR Action is taken to mitigate the risks
and rated for severity
. Area of Concern - H Outcome
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks

ME H1.1. Facility measures productivity Indicators No. of Blood unit issued per thousand 2 RR No. of Unit issued X1000/ Population of
on monthly basis population serving area

. % of units issued for the transfusion at 2 RR No. of Unit issued for facility*100/Total no
facility of units issued in the period
No of voluntary donation done per thousand No of Voluntary Donation
. 2 RR
population X1000/Population of the serving area
. No. of units supplied to storage units 2 RR Self Explanatory
. Blood donation camps held 2 RR Self Explanatory
Proportion of blood units issued in
. emergency cases out of total unit issued in 2 RR
month

No of blood units issued for free of cost 2 RR JSSK, Thalassemia , BPL

Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark

Time period for which equipment was out

Facility measures efficiency Indicators on Downtime critical equipments
ME H2.1. monthly basis 2 RR of order/Total no of working hours for
equipments
No of unit discarded *100/ Total no of unit
. % of Blood Units discarded 2 RR collected
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Reference No. ME Statement Checkpoint e Assessmen Means of Verification Remarks
t Method
. % of unit issued against replacement 2 RR No of unit issued on replacement *100/
Total no of unit issued

. % of unit tested seroreactive 2 RR No of unit found sero reactiveX100/ No of

unit tested

Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

ME H3.1. Facility measures Clinical Care & Safety Blood transfusion reaction rate 2 RR No of Blood Transfusion reactions 1000/
Indicators on monthly basis No of patient blood issued
Chemical splash, Needle stick injuries.
. Adverse events are identifies and reported 2 RR Major blood transfusion reaction, wrong
cross matching, wrong blood issue

. Component to whole blood ratio 2 RR No of component unit issued/No of whole

blood issued
No of unit are cross matched on request/
. Cross matched/ Transfused Ratio 2 RR No of unit actually transfused
% of single use transfusion 100/ Total no of
% of single unit transfusion 2 RR units transfused
Chemical splash, Needle stick injuries.
. Number of adverse events per thousand 2 RR Major blood transfusion reaction, wrong
patients
cross matching, wrong blood issue

Standard H4. The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

ME H4.1. Facility measures Service Quality Time gap between issuing and requisition of 2 RR
Indicators on monthly basis blood in routine conditions
Time gap between issuing and requisition of
. 2 RR
blood in emergency conditions
. Donor Satisfaction Score at Blood Bank 2 RR
No of requisition refused/ referred due to
. No of refusal cases 2 RR non availability of blood group or any other
reason

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services
ME A1.14 Services are available for the time All lab services are available in 2 SI/RR
period as mandated routine working hours

Check for:
Emergency lab services are available 1. Laboratory services are available
for selected tests of Haematology, 2 SI/RR at night
Biochemistry and Serology 24X7 2. Look for number of lab tests
performed at night
Standard A3 Facility Provides diagnostic Services
ME A3.2 The facility Provides Laboratory Availability of Haematology services 2 SI/OB
Services

Availability of Biochemistry services 2 SI/OB

Availability of Microbiology services 1 SI/OB

Availability of Cytology services 0 SI/OB
Availability of Histopathology
0 SI/OB
services
Availability of Clinical Pathology
services 1 SI/OB
Availability of Serology services 2 SI/OB
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme

The facility provides services under Tests for Diagnosis of maleria (Smear
ME A4.1 National Vector Borne Disease Control and RDTK) 2 SI/OB
Programme as per guidelines

Tests for diagnosis of Dengue,

Chikengunia 2 SI/OB

The facility provides services under

ME A4.2 national tuberculosis elimination Availability of Designated Microscoy 2 SI/OB
programme as per guidelines. Center (AFB)

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Availability or Linkage with CBNAAT 2

The facility provides services under Availability of Skin Smear

ME A4.3 National Leprosy Eradication Examination 2 SI/OB
Programme as per guidelines

The facility provides services under

National Programme for Prevention Haemogram, BT CT, Fasting/PP
ME A4.8 and control of Cancer, Diabetes, Availability of blood test for NCD 2 SI/RR Sugar, Lipid Profile, Blood Urea ,
Cardiovascular diseases & Stroke LFT Kidney Function Test
(NPCDCS) as per guidelines
Standard A6 Health services provided at the facility are appropriate to community needs.
The facility provides curatives &
preventive services for the health Laboratory provides specific test for Like Dengue, swine flu, Kala Azar,
ME A 6.1 problems and diseases, prevalent local health problems/diseases 2 SI/RR Lymphatic Filariasis,etc.
locally.
Area of Concern - B Patient Rights
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities
Numbering, main department and
ME B1.1 The facility has uniform and user- Availability of departmental & 2 OB internal sectional signage are
friendly signage system directional signages displayed

Restricted area signage are displayed 2 OB

The facility displays the services and

ME B1.2 entitlements available in its List of services available are 2 OB
departments displayed at the entrance

Timing for collection of sample and 2 OB

delivery of reports are displayed

ME B1.4 User charges are displayed and User charges in r/o laboratory 2 OB
communicated to patients effectively services are displayed

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

ME B1.5 Information is available in local Signage's and information are 2 OB

language and easy to understand available in local language
The facility ensures access to clinical Lab Reports are provided to Patient
ME B1.8 records of patients to entitled in printed format 2 OB
personnel
Services are delivered in a manner that is sensitive to gender, religiousand cultural needs, and there are no barrier on account of physical , economic,
Standard B2 cultural or social reasons.
Services are provided in manner that
ME B2.1 are sensitive to gender Separate queue for females at lab 1 OB

Access to facility is provided without Check the availability of ramp in lab At least 120 cm width, gradient not
ME B2.3 any physical barrier & and friendly to 2 OB steeper than 1:12, if ramp is
people with disabilities building area /sample collection area available
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
Laboratory has system to ensure the Laboratory staff do not discuss the
Confidentiality of patients records and
ME B3.2 clinical information is maintained confidentiality of the reports 2 SI/OB lab result outside. And reports are
generated kept in secure place
The facility ensures the behaviours of
Behaviour of staff is empathetic and
ME B3.3 staff is dignified and respectful, while courteous 2 PI/OB
delivering the services

The facility ensures privacy and

confidentiality to every patient, HIV positive reports/pregnancy
ME B3.4 especially of those conditions having reports are communicated as per 2 SI/OB
social stigma, and also safeguards NACO guidelines
vulnerable groups
Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed
Standard B4 consent wherever it is required.
There is established procedures for Informed Consent is taken before Before testing HIV patient is
informed that test is voluntary and
ME B4.1 taking informed consent before HIV testing, Biopsy and any other 2 SI/RR result will be disclosed to him/her
treatment and procedures invasive procedure only

Information about the treatment is

ME B4.4 shared with patients or attendants, Pre test counselling is given before 2 PI/SI/RR
regularly HIV testing

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

The facility provides cashless services

to pregnant women, mothers and Free Diagnostic tests for Pregnant
ME B5.1 neonates as per prevalent women, Infant and Children 2 PI/SI
government schemes

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

It is ensured that facilities for the Check that patient party has not
ME B5.3 prescribed investigations are available incurred expenditure on diagnostics 2 PI/SI
at the facility from outside.
Laboratory provides complete list of
diagnostic test available to all 1 PI/SI
department of the hospital

The facility provide free of cost

treatment to Below poverty line
ME B5.4 patients without administrative Tests are free of cost for BPL patients 2 PI/SI/RR
hassles

The facility ensures timely

reimbursement of financial Cashless investigation by empanelled
ME B5.5 lab for JSSK beneficiaries for test not 2 PI/SI/RR
entitlements and reimbursement to available within the facility
the patients
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
Adequate area for sample
ME C1.1 Departments have adequate space as Laboratory space is adequate for 1 OB collection, waiting, performing
per patient or work load carrying out activities test, keeping equipment and
storage of drugs and records

Availability of adequate waiting area 1 OB

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Patient amenities are provide as per Availability of sitting arrangement of

ME C1.2 sub waiting area 1 OB
patient load

Availability of patient calling system 1 OB

at lab
Availability of functional toilets 2 OB
Availability of drinking water 2 OB
ME C 1.3 Departments have layout and Demarcated sample collection area 2 OB
demarcated areas as per functions
Demarcated testing area 2 OB
Designated report writing area 2 OB
Demarcated washing and waste
disposal area 2 OB
Availability of store 2 OB
The facility has adequate circulation Availability of adequate circulation
ME C 1.4 area and open spaces according to area for easy moment of staff and 1 OB
need and local law equipments
The facility has infrastructure for Availability of functional telephone
ME C 1.5 intramural and extramural and Intercom Services 0 OB
communication

ME C 1.6 Service counters are available as per Availability of collection counters as 1 OB

patient load per load

The facility and departments are

planned to ensure structure follows Sample collection- Sample
ME C 1.7 the function/processes (Structure Unidirectional flow of services 2 OB processing- Analytical area-
commensurate with the function of reporting.
the hospital)
Standard C 2 The facility ensures the physical safety of the infrastructure.

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Check for fixtures and furniture

like cupboards, cabinets, and
ME C2.1 The facility ensures the seismic safety Non structural components are 2 OB heavy equipments , hanging
of the infrastructure properly secured objects are properly fastened and
secured

The facility ensures safety of electrical Laboratory does not have temporary
ME C2.3 establishment connections and loose hanging wires 2 OB

Adequate electrical socket provided

for safe and smooth operation of lab 2 OB/RR
equipments

ME C2..4 Physical condition of buildings are Work benches are chemical resistant 2 OB
safe for providing patient care
Floors of the Laboratory are non
slippery and even surfaces and acid 2 OB
resistent
Windows have grills and wire
1 OB
meshwork
Standard C3 The facility has established Programme for fire safety and other disaster

The facility has plan for prevention of Laboratory has plan for safe storage
ME C3.1 fire and handling of potentially 1 OB/SI
flammable materials.
Department has sufficient fire exit
with signage to permit safe escape 2 OB
to its occupant at time of fire
Check the fire exits are clearly visible
and routes to reach exit are clearly 2 OB
marked.
Lab has installed fire Extinguisher
ME C3.2 The facility has adequate fire fighting that is Class A , Class B C type or ABC 2 OB/RR
Equipment type

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Check the expiry date for fire

extinguishers are displayed on each 2 OB/RR
extinguisher as well as due date for
next refilling is clearly mentioned

The facility has a system of periodic Check for staff competencies for
ME C3.3 training of staff and conducts mock operating fire extinguisher and what 2 SI/RR
drills regularly for fire and other
disaster situation to do in case of fire

Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
The facility has adequate specialist For 100 bed - 1 , 200-1, 300-3, 400-
ME C4.1 Availability of dedicated pathologist 0 OB/RR
doctors as per service provision 3, 500-4.
Availability of dedicated
Microbiologist 1 OB/RR For 300-500 bed -1

The facility has adequate For 100 beds- 6, 200-9, 300- 12,
ME C4.4 technicians/paramedics as per Availability of Lab Technician 24X7 0 SI/RR
requirement 400-15, 500-18

The facility has adequate support /

ME C4.5 general staff Availability of Lab assistant 1 SI/RR In-house/Out-sourced
Availability of housekeeping staff 1 SI/RR
Availability of security staff 0 SI/RR
Standard C 5 Facility provides drugs and consumables required for assured list of services.
Iodine Solution, Gram
The departments have adequate Romanowsky ,StainZiehl- neelsen,
ME C5.2 Availability of stains 2 OB/RR
consumables at point of use Acridine orange, Acridine orange
(?)

Availability of reagents 2 OB/RR Reagents for auto analyzers, ELISA

Readers
Acetone, Alcohol, distilled water,
Availability of other Chemicals 2 OB/RR Microscope gel etc.

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Evacuated Blood collection tubes,

Availability Laboratory materials 2 OB/RR Swabs, Syringes, Glass slides, Glass
marker/paper stickers

Emergency drug trays are maintained

ME C5.3 at every point of care, where ever it Emergency Drug Tray is maintained 2 OB/RR
may be needed
Standard C 6 The facility has equipment & instruments required for assured list of services.
Availability of equipment & Availability of functional Equipment BP apparatus, Stethoscope at
ME C 6.1 instruments for examination & &Instruments for examination & 2 OB sample collection area
monitoring of patients Monitoring

Availability of equipment & Availability of functional auto Auto/ Semi Auto analyzers
ME C 6.3 instruments for diagnostic procedures analyzers 2 OB according to need
being undertaken in the facility

Cell Counters/ Counting

Availability of functional 2 OB Chambers , Heamoglobinometer ,
haematology equipments
ESR stands with tubes
Availability of functional Calorie meter, Blood Gas
Biochemistry Equipment 2 OB Analyzer, Electrolyte analyzer
Availability of functional equipments Micropipettes , Centrifuge, Water
for sample processing 2 OB Bath, Hot air oven.
Availability of functional Microscopy 1 OB Binocular Micro scope , FNAC,
equipments staining rack
Availability functional 0 OB Microtome
Histopathology equipments
Availability of functional Serology
2 OB Elisa Reader, Elisa washer
Equipments
Availability of functional Incubator , Inoculators, safety
Microbiology equipments 1 OB hood and bio safety cabinet

ME C 6.5 Availability of Equipment for Storage Availability of equipment for storage 2 OB Refrigerators
of sample and reagents

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Availability of functional equipment Availability of equipments for Buckets for mopping, mops,
ME C6.6 2 OB
and instruments for support services cleaning duster, waste trolley, Deck brush

Illumination at work stations,

Departments have patient furniture Electrical fixture for lab
ME BC 6.7 and fixtures as per load and service Availability of fixtures at lab 1 OB equipments and storage
provision
equipments

Lab stools, Work bench's, rack and

Availability of furniture 1 OB cupboard for storage of
reagent ,Patient stool, Chair table

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

Check objective checklist has been

prepared for assessing
Criteria for Competence assessment Check parameters for assessing skills competence of doctors, nurses and
paramedical staff based on job
ME C7.1 are defined for clinical and Para and proficiency of clinical staff has 2 SI/RR description defined for each cadre
clinical staff been defined of staff. Dakshta checklist issued by
MoHFW can be used for this
purpose.

Check for records of competence

Competence assessment of Clinical assessment including filled
ME C7.2 and Para clinical staff is done on Check for competence assessment is 2 SI/RR checklist, scoring and grading .
predefined criteria at least once in a done at least once in a year
year Verify with staff for actual
competence assessment done

The Staff is provided training as per Training on automated Diagnostic

ME C7.9 defined core competencies and Equipments like auto analyzer 2 SI/RR
training plan
Infection control & prevention 1 SI/RR Bio medical Waste Management
training including Hand Hygiene
Training on Internal and External
2 SI/RR
Quality Assurance

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Laboratory Safety 2 SI/RR
Patient Safety 2 SI/RR
Basic Life Support 1 SI/RR

Training on Quality Management 1 SI/RR To all category of staff. At the time

System of induction and once in a year.

Check supervisors make periodic

There is established procedure for rounds of department and monitor
ME C7.10 utilization of skills gained thought Staff is skilled to run automated 2 SI/RR that staff is working according to
trainings by on -job supportive equipments the training imparted. Also staff is
supervision provided on job training wherever
there is still gaps

Check supervisors make periodic

rounds of department and monitor
Staff is skilled for maintaining that staff is working according to
Laboratory records 2 SI/RR the training imparted. Also staff is
provided on job training wherever
there is still gaps

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
1. Check with AMC records/
The facility has established system for All equipments are covered under Warranty documents
ME D 1.1 AMC including preventive 0 SI/RR
maintenance of critical Equipment maintenance 2. Staff is aware of the list of
equipment covered under AMC.

[Link] for breakdown &

Maintenance record in the log
There is system of timely corrective book
break down maintenance of the 2 SI/RR 2. Staff is aware of contact details
equipments of the agency/person in case of
breakdown.

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

There has system to label

Defective/Out of order equipments 2 OB/RR
and stored appropriately until it has
been repaired

Staff is skilled for trouble shooting in

2 SI/RR
case equipment malfunction
Periodic cleaning, inspection and
maintenance of the equipments is 2 SI/RR
done by the operator
The facility has established procedure
All the measuring equipments/
ME D1.2 for internal and external calibration of instrument are calibrated 1 OB/ RR
measuring Equipment

There is system to label/ code the

equipment to indicate status of 1 OB/ RR
calibration/ verification when
recalibration is due

Calibrators are available for

1 SI/RR
Automated haematology analyzers

Laboratory has system to update

correction factor after calibration 1 SI/RR
wherever required

Each lot of reagents has to be

checked against earlier tested in use
reagent lot or with suitable 2 SI/RR
reference material before being
placed in service and result should
be recorded.

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Operating and maintenance Up to date instructions for operation

ME D1.3 instructions are available with the and maintenance of equipments are 2 OB/SI
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
There is established procedure for There is established system of timely Stock level are daily updated
ME D2.1 forecasting and indenting drugs and indenting of consumables and 2 SI/RR Indent are timely placed
consumables reagents

The facility ensures proper storage of Reagents and consumables are kept Check the storage condition of
ME D2.3 drugs and consumables away from water and sources of 2 OB/RR reagents,etc.
heat, direct sunlight

Reagents label contain name,

concentration, date of
Reagents are labelled appropriately 2 OB/RR preparation/opening, date of
expiry, storage conditions and
warning

The facility ensures management of

ME D2.4 No expired reagent found 2 OB/RR
expiry and near expiry drugs

Records for expiry and near expiry 2 RR Check the record of expiry and
reagent are maintained near expiry drug in drug substore

Minimum stock and reorder level

The facility has established procedure There is practice of calculating and are calculated based on
ME D2.5 for inventory management techniques maintaining buffer stock of reagents 1 SI/RR consumption
Minimum buffer stock is
maintained all the time

Check record of drug received,

Department maintained stock 2 RR/SI issued and balance stock in hand
register of reagents and are regularly updated
There is a procedure for periodically
ME D2.6 replenishing the drugs in patient care There is established procedure for 2 SI/RR
areas replenishing drug tray

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
There is no stock out of reagents 1 OB/SI Check the stock of some reagents

Check for refrigerator/ILR

Temperature of refrigerators are temperature charts. Charts are
There is process for storage of maintained and updated twice a
ME D2.7 vaccines and other drugs, requiring kept as per storage requirement and 2 OB/RR day. Refrigerators meant for
controlled temperature records twice a day and are storing drugs should not be used
maintained
for storing other items such as
eatables.

Regular Defrosting is done 2 SI/RR

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

The facility provides adequate Adequate illumination at work

ME D3.1 illumination level at patient care areas station 1 OB

Adequate illumination at Collection 2 OB Testing areas, report writing area

area

The facility has provision of restriction

ME D3.2 of visitors in patient areas Entry is restricted in testing area 2 OB

The facility ensures safe and Fans/ Air

ME D3.3 comfortable environment for patients Temperature control and ventilation 1 SI/RR conditioning/Heating/Exhaust/Ven
in collection area tilators as per environment
and service providers condition and requirement

Fans/ Air
Temperature control and ventilation conditioning/Heating/Exhaust/Ven
testing area 1 SI/RR tilators as per environment
condition and requirement

In histopathology, for tissue

processing separate room with fume 0 OB
hood is available
Availability of Eye washing facility 2 OB

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

The facility has established measure Female staff feel secure at work
ME D3.5 1 SI
for safety and security of female staff place

Standard D4 The facility has established Programme for maintenance and upkeep of the facility
Exterior of the facility building is Building is painted/whitewashed in
ME D4.1 2 OB
maintained appropriately uniform colour
Interior of patient care areas are
plastered & painted 2 OB

Patient care areas are clean and Floors, walls, roof, roof topes, sinks All area are clean with no
ME D4.2 patient care and circulation areas 2 OB
hygienic are Clean dirt,grease,littering and cobwebs

Surface of furniture and fixtures are

clean 2 OB

Toilets are clean with functional 2 OB

flush and running water

ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , 2 OB

maintained Cracks, chipping of plaster
Window panes , doors and other
fixtures are intact 2 OB

The facility has policy of removal of No condemned/Junk material in the

ME D4.5 condemned junk material lab 2 OB

The facility has established

ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds 0 OB
animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

The facility has adequate

ME D5.1 arrangement storage and supply for Availability of 24x7 running and 2 OB/SI Water use for analytical purpose
portable water in all functional areas potable water should be of reagent grade

The facility ensures adequate power Availability of power back up in

ME D5.2 backup in all patient care areas as per 2 OB/SI
load laboratory

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Standard D10 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government

The facility ensure relevant processes Any positive report of notifiable

ME D10.3 are in compliance with statutory disease is intimated to designated 2 RR/SI
requirement authorities

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

The facility has established job Job description is defined and

ME D11.1 description as per govt guidelines communicated to all concerned staff 2 RR Regular + contractual

Staff is aware of their role and

2 SI
responsibilities
Check for system for recording
The facility has a established There is procedure to ensure that
ME D11.2 procedure for duty roster and staff is available on duty as per duty 2 RR/SI time of reporting and relieving
deputation to different departments roster (Attendance register/ Biometrics
etc)
There is designated in charge for 2 SI
department
The facility ensures the adherence to
ME D11.3 dress code as mandated by its Doctor, technician and support staff 2 OB
administration / the health adhere to their respective dress code
department

Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

Verification of outsourced services

There is established system for There is procedure to monitor the (cleaning/
ME D12.1 contract management for out sourced quality and adequacy of outsourced 1 SI/RR Dietary/Laundry/Security/Mainten
services services on regular basis ance) provided are done by
designated in-house staff
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

The facility has established procedure Unique laboratory identification

ME E1.1 number is given to each patient 2 RR
for registration of patients sample

Patient demographic details are Check for that patient

2 RR demographics like Name, age, Sex,
recorded in laboratory records Chief complaint, etc.
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral

Facility provides appropriate referral

linkages to the patients/Services for Laboratory has referral linkage for
ME E3.2 transfer to other/higher facilities to tests not available at the facility 2 RR/SI
assure their continuity of care.

Facility gets referred patients from e.g.: linkage for disease

lower level of facility 2 RR/SI surveillance and water testing
Standard E4 The facility has defined and established procedures for nursing care
There is established procedure of
Procedure to handover test/ results
ME E4.3 patient hand over, whenever staff during shift change 2 RR/SI
duty change happens
Handover register is maintained 2 RR
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
Adequate form and formats are Printed formats for requisition and
ME E8.5 Standard Formats available 2 RR/OB
available at point of use reporting are available
Register/records are maintained as
ME E8.6 per guidelines Lab records are labelled and indexed 2 RR

Records are maintained for Test registers, IQAS/EQAS

2 RR Registers, Expenditure registers,
laboratory Accession list etc.
The facility ensures safe and adequate
ME E8.7 storage and retrieval of medical Laboratory has adequate facility for 2 OB
records storage of records

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

ME E11.3 The facility has disaster management Staff is aware of disaster plan 1 SI/RR
plan in place
Role and responsibilities of staff in 1 SI/RR
disaster is defined
Requisition and reports are
ME E11.5 There is procedure for handling Samples of medico legal cases are 1 SI/RR marked with MLC and reports are
medico legal cases identified handed over to authorized
personnel only

Standard E12 The facility has defined and established procedures of diagnostic services

Request form contain information:

Name and identification number of
patient, name of authorized
There are established procedures for Requisition of all laboratory test is requester, type of primary sample,
ME E12.1 Pre-testing Activities done in request form 1 RR/OB examination requested, date and
time of primary sample collection
and date and time of receipt of
sample by laboratory,

Instructions for collection and

handling of primary sample are 2 RR/SI
communicated to those responsible
for collection
Laboratory has system in place to
label the primary sample 2 RR/SI

Laboratory has system to trace the

primary sample from requisition 2 RR/SI
form
Laboratory has system to record the
identity of person collecting the 2 RR/SI
primary sample

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Laboratory has system in place to Transportation of sample includes:

monitor the transportation of the 2 RR/SI Time frame, temperature and
sample carrier specified for transportation

testing procedure are readily

ME E12.2 There are established procedures for available at work station and staff is 2 OB/RR
testing Activities
aware of them
Laboratory has Biological reference
interval for its examination of 2 OB/RR
various results

Laboratory has identified critical

intervals for which immediate 2 RR/SI
notification is done to concerned
physician

Laboratory has system to review the

There are established procedures for
ME E12.3 Post-testing Activities results of examination by authorized 2 RR/SI
person before release of report

Laboratory has format for reporting

of results 2 RR/OB

Laboratory has system to provide

the reports within defined cycle
time/ or each category of patient - 1 RR/SI
routine and emergency

Laboratory results written in reports

are legible without error in 2 RR/SI
transcription

Laboratory has defined the retention

period and disposal of used sample 2 RR/SI

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Laboratory has system to retain the
copies of reported result and 2 RR/SI
promptly retrieved when required
National Health Programs
Standard E23 Facility provides National health program as per operational/Clinical Guidelines

(a) Submitted to District

surveillance officer
Facility provide service for Integrated Weekly reporting of Confirmed cases
ME E23.9 disease surveillance program on form "L" from laboratory 2 SI/RR (b) Data is submitted manually or
through IHIP (integrated health
information plateform)
Area of Concern - F Infection Control
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection
Facility has provision for Passive and Surface and environment samples Swab are taken from infection
ME F1.2 active culture surveillance of critical & are taken for microbiological 2 SI/RR prone surfaces
high risk areas surveillance

Technician is trained for taking and

2 SI/RR
processing surface and air sample

There is Provision of Periodic Medical There is procedure for immunization

ME F1.4 2 SI/RR Hepatitis B, Tetanus Toxid etc
Checkups and immunization of staff of the staff

Periodic medical checkups of the

staff 2 SI/RR

Facility has established procedures for Regular monitoring of infection Hand washing and infection
ME F1.5 regular monitoring of infection control control practices 1 SI/RR control audits done at periodic
practices intervals

ME F1.6 Facility has defined and established Check for Doctors are aware of 1 SI/RR
antibiotic policy Hospital Antibiotic Policy
Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are provided Availability of hand washing Facility Check for availability of wash basin
ME F2.1 at point of use at Point of Use 2 OB near the point of use

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Availability of running Water 2 OB/SI Ask to Open the tap. Ask Staff
water supply is regular
Availability of antiseptic soap with Check for availability/ Ask staff if
soap dish/ liquid antiseptic with 2 OB/SI the supply is adequate and
dispenser. uninterrupted
Availability of Alcohol based Hand 2 OB/SI Check for availability/ Ask staff for
rub regular supply.
Prominently displayed above the
Display of Hand washing Instruction
at Point of Use 2 OB hand washing facility , preferably
in Local language
Availability of elbow operated taps 2 OB
Hand washing sink is wide and deep
enough to prevent splashing and 2 OB
retention of water
Staff is trained and adhere to Adherence to 6 steps of Hand
ME F2.2 standard hand washing practices washing 1 SI/OB Ask of demonstration
Staff aware of when to hand wash 2 SI
Facility ensures standard practices
ME F2.3 and materials for antisepsis Availability of Antiseptic Solutions 2 OB

like before giving IM/IV injection,

Proper cleaning of procedure site 2 OB/SI drawing blood, putting Intravenous
with antisepsis and urinary catheter
Standard F3 Facility ensures standard practices and materials for Personal protection
Facility ensures adequate personal Clean gloves are available at point of
ME F3.1 protection equipments as per use 2 OB/SI
requirements
Availability of lab aprons/coats 2 OB/SI
Availability of Masks 2 OB/SI
ME F3.2 Staff is adhere to standard personal No reuse of disposable gloves and 2 OB/SI
protection practices Masks.
Compliance to correct method of
1 SI Gloves, Masks, Caps and Aprons
wearing and removing the PPE

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Standard F4 Facility has standard Procedures for processing of equipments and instruments
Facility ensures standard practices Ask staff about how they
ME F4.1 and materials for decontamination Decontamination of operating & 2 SI/OB decontaminate work benches
and clean ing of instruments and Procedure surfaces (Wiping with 0.5% Chlorine
procedures areas solution

Decontamination of instruments
and reusable of glassware are
Proper Decontamination of 2 SI/OB done after procedure in 1%
instruments after use chlorine solution/ any other
appropriate method

Contact time for decontamination is

2 SI/OB 10 minutes
adequate
Cleaning is done with detergent
Cleaning of instruments after 2 SI/OB and running water after
decontamination decontamination
Staff know how to make chlorine
solution 2 SI/OB

Facility ensures standard practices

and materials for disinfection and Disinfection by hot air oven at 160
ME F4.2 sterilization of instruments and Disinfection of reusable glassware 0 SI/OB oC for 1 hour
equipments
Autoclaving for used culture media
0 SI/OB
and other infected material
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Facility ensures availability of Availability of disinfectant as per Chlorine solution, Gluteraldehye,
ME F5.2 standard materials for cleaning and requirement 2 OB/SI carbolic acid
disinfection of patient care areas
Availability of cleaning agent as per 2 OB/SI Hospital grade phenyl, disinfectant
requirement detergent solution
Facility ensures standard practices
ME F5.3 followed for cleaning and disinfection Staff is trained for spill management 2 SI/RR
of patient care areas

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Cleaning of patient care area with 2 SI/RR
detergent solution

Staff is trained for preparing cleaning

solution as per standard procedure 2 SI/RR

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

scrubbing are followed inside out
Any cleaning equipment leading to
Cleaning equipments like broom are
not used in patient care areas 1 OB/SI dispersion of dust particles in air
should be avoided
Facility ensures segregation infectious Precaution with infectious patients
ME F5.4 1 OB/SI
patients like TB
Facility ensures air quality of high risk
ME F5.5 area Air quality in Lab 0 OB/SI Negative Pressure for microbiology
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins at 2 OB Adequate number. Covered. Foot
Medical Waste as per guidelines point of waste generation operated.
Availability of colour coded non
chlorinated plastic bags 2 OB

Human Anatomical waste, Items

contaminated with blood, body
Segregation of Anatomical and solied fluids,dressings, plaster casts,
2 OB/SI cotton swabs and bags containing
waste in Yellow Bin residual or discarded blood and
blood components.

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Items such as tubing, bottles,

intravenous tubes and sets,
Segregation of infected plastic waste catheters, urine bags, syringes
in red bin 0 OB (without needles and fixed needle
syringes) and vaccutainers with
their needles cut) and gloves

Display of work instructions for

segregation and handling of 2 OB Pictorial and in local language
Biomedical waste
There is no mixing of infectious and
2
general waste
Facility ensures management of Availability of functional needle See if it has been used or just lying
ME F6.2 sharps as per guidelines cutters 2 OB idle.

Should be available nears the point

of [Link], syringes
Seggregation of sharps waste with fixed needles, needles from
including Metals in white needle tip cutter or burner,
(translucent) Puncture proof, Leak 2 OB scalpels, blades, or any other
proof, tamper proof containers contaminated sharp object that
may cause puncture and cuts. This
includes both used, discarded and
contaminated metal sharps

Availability of post exposure 1 SI/OB Ask if available. Where it is stored

prophylaxis and who is in charge of that.

Staff knows what to do in case of

Staff knows what to do in condition 2 SI shape injury. Whom to report. See
of needle stick injury if any reporting has been done

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Contaminated and broken Glass are

disposed in puncture proof and leak Vials, slides and other broken
proof box/ container with Blue 1 OB infected glass
colour marking
Facility ensures transportation and Disinfection of liquid waste before
ME F6.3 disposal of waste as per guidelines disposal 2 SI/OB

Disposal of sputum cups as per

guidelines 2 SI/OB
Check bins are not overfilled 2 SI

Transportation of bio medical waste 2 SI/OB

is done in close container/trolley

Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to lacate
mercury beads
5. Use syringe without a
needle/eyedropper and sticky tape
to suck the beads
6. Collection of beads in leak-proof
bag or container
Staff aware of mercury spill 7. Sprinkle sulphur or zinc powder
2 SI/RR
management to remove any remaining mercury
8. All the mercury spill surfaces
should be decontaminated with
10% sodium thiosulfate solution
9. All the bags or containers
containing items contaminated
with mercury should be marked as
“Hazardous Waste, Handle with
Care”
10. Collected mercury waste
should be handed over to the
CBMWTF
Area of Concern - G Quality Management

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Standard G1 The facility has established organizational framework for quality improvement
Check if quality circle formed and
ME G1.1 The facility has a quality team in place Quality circle has been formed in the 2 SI/RR functional with a designated nodal
Laboratory
officer for quality
Standard G2 Facility has established system for patient and employee satisfaction

Patient Satisfaction surveys are There is system to take feed back

ME G2.1 from clinician about quality of 1 RR
conducted at periodic intervals services
Client/Patient satisfaction survey 1 RR
done on monthly basis
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.
Facility has established internal
ME G3.1 quality assurance program at relevant Internal Quality assurance 2 SI/RR
departments programme is in place

Standards are run at defined interval 2 SI/RR

Control charts are prepared and

outliers are identified. 1 SI/RR

Corrective action is taken on the 1 SI/RR

identified outliers
Routine checking of equipments,
Internal Quality Control for Public
Health lab is in place 2 SI/RR new lots of regent, smear
preparation, grading etc
Facility has established external For tests where Nationnal
ME G3.2 assurance programs at relevant Proficiency Test / EQUAS is done 2 SI/RR Proficiency Test program is
departments available
External / Internal split testing is 2 SI/RR For test where PT program is not
done available
Staff is aware of EQAS reporting
EQAs reporst are analysed and
evaluated 2 system, how to evaluate, and
compare

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Corrective actions are taken on 2 SI/RR
abnormal values/ Outliers

External quality assurance program Onsite evaluation done Monthly

implemented as per NTEP program 2 SI/RR Random Blinded rechecking (RBRC)
done Monthly

External quality assurance program

implemented for NVBDCP 2 SI/RR

External quality assurance under 2 SI/RR

NACP
Facility has established system for use NQAS, Kayakalp, SaQushal tools
Internal assessment is done at
ME G3.3 of check lists in different departments periodic interval 2 RR/SI are used to conduct internal
and services assessment

Departmental checklist are used for Staff is designated for filling and
monitoring and quality assurance 2 monitoring of these checklists

Non-compliances are enumerated Check the non compliances are

and recorded 2 RR presented & discussed during
quality team meetings

Actions are planned to address gaps Check action plans are prepared and Randomly check the details of
ME G3.4 observed during quality assurance implemented as per internal 0 RR action, responsibility, time line and
process assessment record findings feedback mechanism

Check actions have been taken to

Planned actions are implemented Check PDCA or revalent quality close the gap. It can be in form of
ME G3.5 through Quality Improvement Cycles method is used to take corrective 0 SI/RR action taken report or Quality
(PDCA) and preventive action Improvement (PDCA) project
report
Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.
Standard operting procedure for
ME G4.1 Departmental standard operating department has been prepared and 2 RR
procedures are available
approved

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
Current version of SOP are available 2 OB/RR
with process owner
Work instruction/clincal protocols 2 OB Work instruction for Internal
are displayed Quality control,

Look for procedure for

Standard Operating Procedures Laboratory has documented process transportation of primary sample
ME G4.2 adequately describes process and for Collection, handling, 2 RR with specification about time
procedures transportation of primary sample
frame, temperature and carrier

Laboratory has documented process

on acceptance and rejection of 2 RR
primary samples

Laboratory has documented

procedure on receipt, labeling,
2 RR
processing and reporting of primary
sample

Laboratory has documented

procedure on receipt, labeling,
2 RR
processing and reporting of primary
sample for emergency cases

Laboratory has documented system 2 RR

for storage of examined samples

Laboratory has documented system

for repeat tests due to analytical 2 RR
failure
Laboratory has documented
validated procedure for examination 2 RR
of samples
Laboratory has documented
2 RR
biological reference intervals

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Laboratory has documented critical

reference values and procedure for 2 RR
immediate reporting of results

Laboratory has documented

procedure for release of reports
2 RR
including details of who may release
result and to whom

Laboratory has documented internal

quality control system to verify the 2 RR
quality of results

Laboratory has documented

External Quality assurance program 2 RR

Laboratory has documented

procedure for calibration of 2 RR
equipments

Laboratory has documented

procedure for validation of results of
reagents ,stains , media and kits etc. 2 RR
wherever required

Laboratory has documented system

of resolution of complaints and other 2 RR
feedback received from stakeholders

Laboratory has documented

procedure for examination by 2 RR
referral laboratories

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Laboratory has documented system

for storage, retaining and retrieval of
laboratory records, primary sample, 2 RR
Examination sample and reports of
results.

Laboratory has documented system

2 RR
to control of its documents
Laboratory has documented
procedure for preventive and break 2 RR
down maintenance
Laboratory has documented
2 RR
procedure for internal audits
Laboratory has documented
procedure for purchase of External 2 RR
services and supplies

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

Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
ME G5.1 Facility maps its critical processes Process mapping of critical processes 1 SI/RR
done
Facility identifies non value adding
Non value adding activities are
ME G5.2 activities / waste / redundant identified 1 SI/RR
activities

ME G5.3 Facility takes corrective action to Processes are rearranged as per 1 SI/RR
improve the processes requirement
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Check quality policy of the facility

has been defined in consultation
Facility has defined Quality policy, with hospital staff and duly
ME G6.3 which is in congruency with the Check if Quality Policy has been 1 SI/RR approved by the head of the
mission of facility defined and approved facility . Also check Quality Policy
enables achievement of mission of
the facility and health department

Check short term valid quality

objectivities have been framed
addressing key quality issues in
Facility has de defined quality Check if SMART Quality Objectives each department and cores
ME G6.4 objectives to achieve mission and 1 SI/RR
quality policy have framed services. Check if these objectives
are Specific, Measurable,
Attainable, Relevant and Time
Bound.

Interview with staff for their

Mission, Values, Quality policy and awareness. Check if Mission
objectives are effectively Check of staff is aware of Mission , Statement, Core Values and
ME G6.5 communicated to staff and users of Values, Quality Policy and objectives 1 SI/RR Quality Policy is displayed
services prominently in local language at
Key Points

Verify with records that a time

bound action plan has been
Facility prepares strategic plan to Check if plan for implementing prepared to achieve quality policy
ME G6.6 achieve mission, quality policy and quality policy and objectives have 1 SI/RR and objectives in consultation with
objectives prepared hospital staff . Check if the plan has
been approved by the hospital
management

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

Review the records that action

plan on quality objectives being
reviewed at least onnce in month
Facility periodically reviews the Check time bound action plan is by departmnetal incharges and
ME G6.7 progress of strategic plan towards being reviewed at regular time 2 SI/RR
mission, policy and objectives interval during the qulaity team meeting.
The progress on quality objectives
have been recorded in Action Plan
tracking sheet

Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
Facility uses method for quality
ME G7.1 Basic quality improvement method 1 SI/OB PDCA & 5S
improvement in services
Advance quality improvement
method 0 SI/OB Six sigma, lean.

ME G7.2 Facility uses tools for quality 7 basic tools of Quality 1 SI/RR Minimum 2 applicable tools are
improvement in services used in each department
Standard G9 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.
Verify with the records. A
Periodic assessment for Medication Check periodic assessment of comprehensive risk asesement of
medication and patient care safety
ME G9.6 and Patient care safety risks is done as risk is done using defined checklist 2 SI/RR all clincial processes should be
per defined criteria. periodically done using pre define critera at
least once in three month.

Periodic assessment for potential risk 1. Check that the filled checklist
regarding safety and security of staff and action taken report are
ME G9.7 including violence against service SaQushal assessment toolkit is used 2 SI/RR available
providers is done as per defined for safety audits. 2. Staff is aware of key gaps &
criteria closure status

ME G9.8 Risks identified are analyzed Identified risks are analysed for 1 SI/RR Action is taken to mitigate the risks
evaluated and rated for severity severity
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No

ME H1.1 Facility measures productivity No. of HIV test done per 1000 2 RR
Indicators on monthly basis population
No. of VDRL test done per 1000 2 RR
population
No. of Blood Smear Examined per
2 RR
1000 population
No. of AFB Examined per 1000
population 2 RR

No. of HB test done per 1000 2 RR

population
Lab test done per patients in 100 2 RR
OPD
Lab test done per patients100 IPD 2 RR
Percentage of lab test done at night 2 RR

Proportion of test done for BPL 2 RR

patients
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators No of test not matched in validation 2 RR
on monthly basis
Percentage of test not matched in 2
Split test
VIS / Z scores or equivalent 1 Biochemistry & haematology
Down time of critical equipments 2
Turn around time for emergency lab
1
investigations
Turn around time for routine lab
investigations 2 RR
Lab test done per technician 2 RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & % of critical values reported within 2 RR
Safety Indicators on monthly basis one hour

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Compliance
Standard ME Statement Checkpoint Full/ Audit Method Means of Verification Remarks
Partial/No
No of adverse events per thousand 2 RR
patients
Proportion of Haematology,
Test demography 2 RR biochemistry, serology,
Microbiology, cytology, clinical
pathology
Proportion of lab report co related
Report correlation rate 2 RR with clinical examination
Proportion of false positive /false 2 RR For Rapid diagnostic Kit test
negative
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
Facility measures Service Quality Waiting time at sample collection
ME H4.1 Indicators on monthly basis area 2 RR

Number of stock out incidences of 2 RR

reagents

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No
Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services

Services are available for the time All radiology services are available in
ME A1.14 2 SI/RR
period as mandated routine working hours

Check for:
1. Radiological services are
Emergency radiology services are 2 SI/RR available at night
available for selected procedure 24X7 2. Look for number of
radiology test performed at
night

Standard A2 Facility provides RMNCHA Services

The facility provides Maternal Availability of USG services for

ME A2.2 2 SI/OB
health Services Pregnant women

Standard A3 Facility Provides diagnostic Services

The facility provides Radiology for chest, bones, skull, spine

ME A3.1 Availability of X ray services 2 SI/OB
Services and abdomen.

Barium Swallow, Barium

enema, Barium meal, MMR
Availability of special radio graph
services 2 SI/OB (Miniature mass
radiography) Chest, IVP,
Mammography, C-arm

Radio-vision-Graph (RVG)
Availability of Dental X ray Services 2 SI/OB Digital dental X-ray, OPG
services

Pre natal diagnostic

procedure: Ultrasonography
Availability of ultrasound services 2 SI/OB with colour doppler,
Fetoscopy

Availability of CT scan facility 2 SI/OB

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No
Area of Concern - B Patient Rights
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities

Numbering, main
ME B1.1 The facility has uniform and user- Availability of departmental & 2 OB department and internal
friendly signage system directional signages sectional signage are
displayed
Notice in local language is
displayed at entrance of
USG department that All
persons including the
employer,
employee or any other
Display of PNDT Notice at USG 2 OB 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 outside Radiation hazard sign and
the X ray department 2 OB caution for pregnant women
and children
The facility displays the services and List of services available are displayed
ME B1.2 entitlements available in its at the entrance 2 OB
departments
Timing for taking X ray and collection
of reports are displayed outside the X 2 OB
ray department
User charges are displayed and User charges in r/o X ray services are
ME B1.4 communicated to patients 2 OB
effectively displayed at entrance

Information is available in local Signage's and information are available

ME B1.6 language and easy to understand in local language 2 OB

The facility ensures access to Reports are provided to Patient in

ME B1.8 clinical records of patients to proper printed format 2 OB
entitled personnel

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

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 economic,
cultural or social reasons
Female attendant should accompany
ME B2.1 Services are provided in manner female patients during radiological 2 OB/SI
that are sensitive to gender procedures

Access to facility is provided Check the availability of ramp in OPD/ At least 120 cm width,
ME B2.3 without any physical barrier & and 2 OB gradient not steeper than
friendly to people with disabilities X ray room 1:12, if ramp is available

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

ME B3.1 Adequate visual privacy is provided X ray department has provision of 2 OB

at every point of care privacy while taking X ray.
USG department has provision of
2 OB provision of screen
privacy while taking sonography
Radiology staff do not
Confidentiality of patients records
ME B3.2 and clinical information is Radiology has system to ensure the 2 RR/SI discuss the lab result
maintained confidentiality of the reports generated outside. And reports are
kept in secure place

The facility ensures the behaviours

ME B3.3 of staff is dignified and respectful, Behaviour of staff is empathetic and 2 PI
courteous
while delivering the services

Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent
Standard B4 wherever it is required.
There is established procedures for Form F for USG under PNDT
ME B4.1 taking informed consent before maintained for scan of pregnant 2 RR
treatment and procedures woman

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

The facility provides cashless

services to pregnant women, Free Diagnostic tests are available as
ME B5.1 mothers and neonates as per per entitlement 2 PI/SI Pregnant women, Infant and Children
prevalent government schemes

It is ensured that facilities for the

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

The facility provide free of cost

ME B5.4 treatment to Below poverty line Tests are free of cost for BPL patients 2 PI/SI
patients without administrative
hassles

The facility ensures timely Cashless investigation by empanelled

reimbursement of financial
ME B5.5 entitlements and reimbursement to lab for JSSK beneficiaries for test not 2 PI/SI/RR
the patients available within the facility

Area of Concern - C Inputs

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

The room housing X -ray

Departments have adequate space Room Size of X ray unit is as per AERB equipment have appropriate
ME C1.1 as per patient or work load safety code 2 OB area to facilitate easy
movement of staff & proper
patient positioning.

Availability of adequate waiting area 2 OB

Patient amenities are provide as
ME C1.2 per patient load Attached toilet facility available 2 OB For USG
Waiting area with sitting facility 2 OB

Preferably one entrance with

ME C1.3 Departments have layout and Entrance of X ray room is as per AERB 2 OB door having hydraulic
demarcated areas as per functions layout guidelines mechanism to ensure that it
is closed during procedure

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Windows should be above

2m from finished floor level
Opening for Ventilation and natural outside the x ray. If no then
light has been provided in X ray room 2 OB
as per AERB layout guidelines shielding is provided is
provided on the window up
to 2 m

The chest stand should be

Positioning of chest stand as per AERB
layout guidelines 2 OB located opposite to entrance
door and control console

Control console should be

Positioning of control console as per positioned as far away as
AERB layout guidelines 2 possible from the X ray tube.

The facility has adequate circulation Corridors are wide enough for
ME C1.4 area and open spaces according to 2 OB 2-3 meters
need and local law movement of trolleys and stretchers

The facility has infrastructure for Availability of functional telephone and

ME C1.5 intramural and extramural 0 OB
communication Intercom Services

Service counters are available as Check for the adequacy X-ray

ME C1.6 per patient load No of X ray machines as per load 2 OB machines as per load

The facility and departments are No cris cross in the

planned to ensure structure follows
ME C1.7 the function/processes (Structure Unidirectional flow of goods and 2 OB movement patient traffic
commensurate with the function of services and services flow Should be
near emergency department
the hospital)

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

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Check for fixtures and

furniture like cupboards,
The facility ensures the seismic Non structural components are cabinets, and heavy
ME C2.1 1 OB
safety of the infrastructure properly secured equipment , hanging objects
are properly fastened and
secured

The facility ensures safety of X-ray - does not have temporary Switch Boards other
ME C2.3 1 OB electrical installation are
electrical establishment connections and loosely hanging wires intact
Adequate electrical socket provided for
safe and smooth operation of lab 2 OB
equipment

Stabilizer is provided for X-ray machine 2 OB

Physical condition of buildings are Floors of the Radiology department are

ME C2.4 safe for providing patient care non slippery and even 2 OB

Mobile protective barrier

should to positioned in such
Positioning of mobile protective barrier 2 OB as manner that the operator
as AERB layout guidelines is completely shielded during
exposure

The thickness is appropriate

taking into consideration of
Thickness of walls at X room are as (1) Distance from centre of
2 OB/RR patient table (2) type of
AERB layout guidelines shielding material (brick,
concrete, steel, lead or any
other material)

X ray department should not be

located adjacent to patient care area 2 OB

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

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

Radiology has sufficient fire exit to

ME C3.1 The facility has plan for prevention permit safe escape to its occupant at 2 OB/SI
of fire time of fire
Check the fire exits are clearly visible
and routes to reach exit are clearly 2 OB
marked.
Radiology department has installed
ME C3.2 The facility has adequate fire fire Extinguisher that is Class A , Class B 2 OB
fighting Equipment C type or ABC type

Check the expiry date for fire

extinguishers are displayed on each 2 OB/RR
extinguisher as well as due date for
next refilling is clearly mentioned

The facility has a system of periodic Check for staff competencies for
ME C3.3 training of staff and conducts mock operating fire extinguisher and what to 2 SI/RR
drills regularly for fire and other
disaster situation do in case of fire

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

100-200 -1
ME C4.1 The facility has adequate specialist Availability of Radiologist 2 OB/RR 200-400- 2
doctors as per service provision
>400 - 3
The facility has adequate
ME C4.4 technicians/paramedics as per Availability of Radiographer 2 SI/RR 100-2, 200-3, 300-5, 400-7,
500-9
requirement
The facility has adequate support /
ME C4.5 Availability of housekeeping staff 2 SI/RR
general staff
Availability of security staff 2 SI/RR
Standard C5 Facility provides drugs and consumables required for assured list of services.

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

The departments have adequate X ray films, Developer, Fixer,

ME C5.2 Availability Consumables 2 OB/RR
consumables at point of use USG gel, printing paper

Mobile protective barrier,

Availability of personal protective Lead apron, Rubber hanging
equipment 2 OB/RR flaps, hand glove, lead
shields.

Emergency drug trays are

ME C5.3 maintained at every point of care, Emergency Drug Tray is maintained 1 OB/RR
where ever it may be needed

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

Availability of equipment & Availability of functional Equipment

ME C6.1 instruments for examination & &Instruments for examination & 2 OB TLD badges
monitoring of patients Monitoring

Availability of equipment &

instruments for diagnostic Availability of functional X-ray 300 MA X ray machine & 100
ME C6.3 procedures being undertaken in the machines 2 OB MA X ray machine
facility

Radio-Visio-Graph (RVG) –
Availability of functional Dental X-Ray 2 OB digital dental X-Ray,
Machine
Orthopantomogram (OPG)
2 one general purpose & one
Availability of functional
Ultrasonography 1 OB for Obstetric purpose

Availability of functional Portable X-ray 60 MA X ray machine

0 OB
Machine (Mobile)
Availability of functional CT-scan
machine 2 OB

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Cassettes X ray, Intensifying

screen X ray, Lead letter (A-
Z),Letter figures (0-9) and R
Availability of Accessories for X ray 2 OB & L (Manual). Computer,
printer, x -ray
holder/positioner, (Digital)

Availability of functional equipment Buckets for mopping, mops,

ME C6.6 and instruments for support Availability of equipment for cleaning 2 OB duster, waste trolley, Deck
services brush
Departments have patient furniture
ME C6.7 and fixtures as per load and service Availability of attachment/ accessories 2 OB Bucky Stand
provision
X-ray View box, Electrical
Availability of fixtures at radiology 2 OB
fixture for equipment
rack and cupboard , Chair
Availability of furniture 1 OB table
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

Check objective checklist has

been prepared for assessing
competence of doctors,
Criteria for Competence Check parameters for assessing skills nurses and paramedical staff
ME C7.1 assessment are defined for clinical and proficiency of clinical staff has 1 based on job description
and Para clinical staff been defined defined for each cadre of
staff. Daksha checklist issued
by MoHFW can be used for
this purpose.

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Check for records of

competence assessment
Competence assessment of Clinical
and Para clinical staff is done on Check for competence assessment is including filled checklist,
ME C7.2 predefined criteria at least once in done at least once in a year 1 scoring and grading . Verify
a year with staff for actual
competence assessment
done

The Staff is provided training as per

ME C7.9 defined core competencies and Training on radiation safety 1 SI/RR
training plan
Bio medical Waste
Infection control & prevention training 1 SI/RR Management including Hand
Hygiene
Patient Safety 1 SI/RR
Basic Life Support 1 SI/RR
To all category of staff. At
Training on Quality Management 1 SI/RR the time of induction and
System
once in a year.

Check supervisors make

periodic rounds of
There is established procedure for department and monitor
utilization of skills gained thought Radiographers are skilled to operating that staff is working
ME C7.10 trainings by on -job supportive equipment 1 SI/RR according to the training
supervision imparted. Also staff is
provided on job training
wherever there is still gaps

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

1. Check with AMC records/

The facility has established system All equipments are covered under AMC Warranty documents
ME D1.1 for maintenance of critical 2 SI/RR 2. Staff is aware of the list of
Equipment including preventive maintenance equipment covered under
AMC.

[Link] for breakdown &

Maintenance record in the
There is system of timely corrective log book
break down maintenance of the 2 SI/RR 2. Staff is aware of contact
equipments details of the agency/person
in case of breakdown.

There has system to label

Defective/Out of order equipments and 2 OB/RR
stored appropriately until it has been
repaired
Staff is skilled for trouble shooting in 2 SI/RR
case equipment malfunction
Periodic cleaning, inspection and
maintenance of the equipments is 2 SI/RR
done by the operator

The facility has established

ME D1.2 procedure for internal and external All the measuring equipments/ 2 OB/ RR
instrument are calibrated
calibration of measuring Equipment

There is system to label/ code the

equipment to indicate status of
calibration/ verification when 2 OB/ RR
recalibration is due

Operating and maintenance Operating instructions and factor

ME D1.3 instructions are available with the charts are available with the 2 OB/SI
users of equipment equipments

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas

Stock level are daily updated

There is established procedure for There is established system of timely Indent are timely placed
ME D2.1 forecasting and indenting drugs and indenting of X ray films, fixer and 2 SI/RR
consumables developers etc.

There is separate storage area for

The facility ensures proper storage
ME D2.3 of drugs and consumables undeveloped X ray films and personal 2 OB/RR Check the storage area and its condition
monitoring devices

X ray films/ Fixers, developer and Storage condition - Kept

consumables are kept away from water away from direct sunlight,
and sources of heat, 2 not in contact with damp
direct sunlight wall, water, etc

X ray films, USG jelly,

ME D2.4 The facility ensures management of No expired consumables is found 2 OB/RR contrast media, plate
expiry and near expiry drugs cleaner ( fixer & developer -
manual)

Check the record of expiry

Records for expiry and near expiry are and near expiry drug in drug
2 RR
maintained sub store and are regular
update

The facility has established X ray films, USG jelly,

ME D2.5 procedure for inventory There is practice of calculation and 1 SI/RR contrast media, plate
maintaining buffer stock cleaner, print paper roll
management techniques ( fixer & developer - manual)

Check record of drug

Department maintained stock register received, issued and balance
in X ray & USG 2 RR/SI stock in hand and are
regularly updated

There is a procedure for periodically

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

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

The facility provides adequate

ME D3.1 illumination level at patient care Adequate illumination at work station 2 OB
areas at X ray room

Adequate illumination at workstation

at USG 2 OB

The facility has provision of Only one patient is allowed one time at
ME D3.2 restriction of visitors in patient 2 OB
areas X room

Warning light is provided outside X ray

room and its been used when unit is 2 OB/SI
functional

Protective apron and gloves are being

The facility ensures safe and provided to relative of the child patient
ME D3.3 comfortable environment for who escort the child for X ray 1 OB/SI
patients and service providers examination/ immobilisation support is
provided to children

X ray room has been kept closed at the 2 OB

time of radiation exposure

Lead apron and other protective

equipment's are available with 2 OB Check TLD batch is worn
below the lead apron
radiation workers and they are using it

TLD badges are available with all staff Records of its regular
2 OB assessment is done by X ray
of X ray department department

Fans/ Air
conditioning/Heating/Exhaus
Temperature control and ventilation in 2 SI/RR t/Ventilators as per
X ray room
environment condition and
requirement

Page 530
Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Fans/ Air
conditioning/Heating/Exhaus
Temperature control and ventilation 2 SI/RR t/Ventilators as per
USG environment condition and
requirement

The facility has established measure

ME D3.5 for safety and security of female Female staff feel secure at work place 0 SI
staff

Standard D4 The facility has established Programme for maintenance and upkeep of the facility

ME D4.1 Exterior of the facility building is Building is painted/whitewashed in 2 OB

maintained appropriately uniform colour
Interior of patient care areas are 1 OB
plastered & painted
Floors, walls, roof, roof topes, sinks All area are clean with no
ME D4.2 Patient care areas are clean and patient care and circulation areas are 1 OB dirt,grease,littering and
hygienic
Clean cobwebs
Surface of furniture and fixtures are
1 OB
clean
Toilets are clean with functional flush
and running water 2 OB

Hospital infrastructure is Check for there is no seepage , Cracks,

ME D4.3 adequately maintained chipping of plaster 1 OB

Window panes , doors and other 2 OB

fixtures are intact

The facility has policy of removal of No condemned/Junk material in the X-

ME D4.5 1 OB
condemned junk material ray and USG

The facility has established

ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds 2 OB
animal control

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

Page 531
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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

The facility has adequate

arrangement storage and supply for Availability of 24x7 running and potable
ME D5.1 portable water in all functional water 2 OB/SI
areas

The facility ensures adequate

ME D5.2 power backup in all patient care Availability of power back up in 2 OB/SI
areas as per load Radiology and USG room

Standard D10 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government

The facility has requisite licences

X ray department has registration from
ME D10.1 and certificates for operation of AERB. 2 RR
hospital and different activities

X ray department has layout approval 2 RR

X ray department has type approval of

equipment with QA test report for X 2 RR
ray machine
USG department has registration under
2 RR
PCPNDT
Duplicate copy of Certificate of
registration under Form B is displayed 2 OB
inside the department
The facility ensure relevant
ME D10.3 processes are in compliance with USG is taken by person Qualified as per 2 RR
PCPNDT
statutory requirement

X ray department has

X ray department has Radiological certification from AERB for
safety officer (RSO) approved by 2 RR any person discharging
competent authority
duties and functions of RSO.

Records of submission of Form F to

appropriate district authorities 2 RR

Page 532
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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

The facility has established job Job description is defined and

ME D11.1 description as per govt guidelines communicated to all concerned staff 2 RR Regular + contractual

Staff is aware of their role and 2 SI

responsibilities
The facility has a established Check for system for
ME D11.2 procedure for duty roster and There is procedure to ensure that staff 2 RR/SI recording time of reporting
deputation to different is available on duty as per duty roster and relieving (Attendance
departments register/ Biometrics etc)
There is designated in charge for 2 SI
department
The facility ensures the adherence
to dress code as mandated by its Doctor, technician and support staff
ME D11.3 administration / the health adhere to their respective dress code 2 OB
department

Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

Verification of outsourced
There is established system for There is procedure to monitor the services
ME D12.1 contract management for out quality and adequacy of outsourced 1 SI/RR (cleaning/Laundry/Security/
Maintenance) provided are
sourced services services on regular basis done by designated in-house
staff

Area of Concern - E Clinical Services

Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

The facility has established

ME E1.1 procedure for registration of Unique identification number is given 2 RR
patients to each patient

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Check for that patient

Patient demographic details are demographics like Name,
recorded in radiology/USG records 1 RR age, Sex, Chief complaint,
etc.

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral

Facility has established procedure for

Facility has established procedure
ME E3.1 for continuity of care during handing over of patients during 1 SI/RR
interdepartmental transfer transfer to X-Ray department/ USG
room

Facility provides appropriate

referral linkages to the There is procedure for referral of
ME E3.2 patients/Services for transfer to patient for which services can not be 1 RR/SI
other/higher facilities to assure provided at the facility
their continuity of care.

Standard E5 Facility has a procedure to identify high risk and vulnerable patients.

The facility identifies vulnerable Radiology/ USG department identify Check there is any system to
ME E5.1 patients and ensure their safe care vulnerable patients as per requirement 2 SI/RR give them preference for
radiographic procedure

Notice in local language is

displayed at entrance of X
The facility identifies high risk ray department asking every
Women in reproductive age are asked
ME E5.2 patients and ensure their care, as for pregnancy (LMP)before X-ray 1 OB/SI/RR female to inform
per their need 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

Printed formats for

Adequate form and formats are
ME E8.5 available at point of use Standard Formats available 2 RR/OB requisition and reporting are
available

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

ME E8.6 Register/records are maintained as Radiology records are labelled and 1 RR

per guidelines indexed
Records are maintained for radiology 2 RR
The facility ensures safe and
ME E8.7 adequate storage and retrieval of Radiology has adequate facility for 1 OB
medical records storage of records

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management

The facility has disaster

ME E11.3 management plan in place Staff is aware of disaster plan 1 SI/RR

Role and responsibilities of staff in

disaster is defined 1 SI/RR

Requisition and reports are

There is procedure for handling marked with MLC and
ME E11.5 medico legal cases Procedure for handling of MLC 2 SI/RR reports are handed over to
authorize person

Standard E12 The facility has defined and established procedures of diagnostic services

Request form contain

information: Name and
identification number of
patient, name of authorized
There are established procedures Requisition of all X ray examination is requester, examination
ME E12.1 1 RR/OB
for Pre-testing Activities done in request form 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 has system to identify 2 RR/SI

radiographer from who has taken X ray

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No
X ray department has system in place 2 RR/SI
to label X ray films
X ray department has system to trace
back the recorded X ray film from 2 RR/SI
requisition form
Records of type of X ray prescribed is 2 RR/SI
made at the time of reception
Requisition of all USG examination is
2 RR/OB
done in request form
USG department has system in place to
label the USGs 2 RR/SI

Preparation of the patient is done as

per requirement 2 RR/SI

Instructions to be followed by patient

for USG are displayed in local language 2 RR/SI
at reception

There are established procedures X ray taking and processing procedure

ME E12.2 are readily available at work station 2 OB/RR
for testing Activities and staff is aware of it

Necessary Instruction for taking X ray

and its processing are displayed at
work station in language understood by 2 OB/RR
staff

X ray department has system in place

to take X ray of patients in case of 2 RR/SI
Emergency.
Radiographer is aware of operation of X
2 RR/SI
ray machine

Necessary Instruction for USG

Examination are displayed at work 2 OB/RR
station in language understood by staff

Page 536
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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No
USG of the patient is taken as per 2 OB/RR
consultant requirement
USG department has system in place to
take sonograph of patients in case of 0 RR/SI
Emergency.

There are established procedures X ray department has format for

ME E12.3 for Post-testing Activities reporting of results 2 RR/OB

X ray department has system to

provide the reports within defined time 2 RR/SI
intervals
USG department has format for 2 RR/OB
reporting of results
USG report is signed by 2 RR/OB
Radiologist/Sonologist
USG department has system to provide
the reports within defined time 2 RR/SI
intervals
Area of Concern - F Infection Control
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

There is Provision of Periodic

ME F1.4 Medical Check-ups and There is procedure for immunization of 0 SI/RR Hepatitis B, Tetanus Toxoid
immunization of staff the staff etc

Periodic medical check-ups of the staff 0 SI/RR

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

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis

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Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Check for availability of wash

ME F2.1 Hand washing facilities are Availability of hand washing Facility at 2 OB basin near the point of use
provided at point of use Point of Use along with availability of
elbow operated tap

Ask to Open the tap. Ask

Availability of running Water 2 OB/SI Staff water supply is regular

Check for availability/ Ask

Availability of antiseptic soap with soap 1 OB/SI staff if the supply is
dish/ liquid antiseptic with dispenser.
adequate and uninterrupted

Check for availability/ Ask

Availability of Alcohol based Hand rub 2 OB/SI staff for regular supply.

Prominently displayed above

Display of Hand washing Instruction at
Point of Use 2 OB the hand washing facility ,
preferably in Local language

Staff is trained and adhere to

ME F2.2 standard hand washing practices Adherence to 6 steps of Hand washing 2 SI/OB Ask of demonstration
Staff aware of when to hand wash 2 SI
Standard F3 Facility ensures standard practices and materials for Personal protection

Facility ensures adequate personal Clean gloves are available at point of

ME F3.1 protection equipment's as per use 2 OB/SI
requirements
Availability of Masks 2 OB/SI
Staff is adhere to standard personal No reuse of disposable gloves and
ME F3.2 protection practices Masks. 2 OB/SI

Standard F4 Facility has standard Procedures for processing of equipment's and instruments

Page 538
Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Ask staff about how they

Facility ensures standard practices decontaminate the
and materials for decontamination Decontamination of operating & procedure surface
ME F4.1 2 SI/OB
and clean ing of instruments and Procedure surfaces stretcher/Trolleys etc.
procedures areas (Wiping with 0.5% Chlorine
solution

Staff know how to make chlorine 2 SI/OB

solution

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention

Facility ensures availability of

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

Hospital grade phenyl,

Availability of cleaning agent as per 2 OB/SI disinfectant detergent
requirement solution

Facility ensures standard practices

ME F5.3 followed for cleaning and Staff is trained for spill management 2 SI/RR
disinfection of patient care areas

Cleaning of patient care area with 2 SI/RR

detergent solution
Staff is trained for preparing cleaning
2 SI/RR
solution as per standard procedure
Standard practice of mopping and Unidirectional mopping from
scrubbing are followed 2 OB/SI inside out
Any cleaning equipment
Cleaning equipment's like broom are leading to dispersion of dust
not used in patient care areas 2 OB/SI 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.

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Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Facility Ensures segregation of Bio Availability of colour coded bins at Adequate number. Covered.
ME F6.1 2 OB
Medical Waste as per guidelines point of waste generation Foot operated.

Availability of colour coded non 2 OB

chlorinated plastic bags
Segregation of different category of 1 OB/SI
waste as per guidelines
Display of work instructions for
Pictorial and in local
segregation and handling of Biomedical 2 OB language
waste
There is no mixing of infectious and
2
general waste

ME F6.3 Facility ensures transportation and Disposal of Fixer and Developer 2 SI/OB/RR
disposal of waste as per guidelines

Area of Concern - G Quality Management

Standard G1 The facility has established organizational framework for quality improvement

Check if quality circle formed

The facility has a quality team in Quality circle has been formed in the and functional with a
ME G1.1 place Radiology 1 SI/RR designated nodal officer for
quality

Standard G2 Facility has established system for patient and employee satisfaction

Patient Satisfaction surveys are There is system to take feed back from
ME G2.1 conducted at periodic intervals clinician about quality of services 1 RR

Patient satisfaction survey done on 1 RR

monthly basis

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.

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Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No
Facility has established internal Internal quality Assurance program is
ME G3.1 quality assurance program at 1 SI/RR
relevant departments established in Radiology

QA to be carried out at least

Periodic QA of equipment by AERB 1 SI/RR once in 2 yrs. and also after
authorized agencies any repairs having radiation
safety implications

Facility has established system for Internal assessment is done at periodic NQAS, Kayakalp, SaQushal
ME G3.3 use of check lists in different interval 1 RR/SI tools are used to conduct
departments and services internal assessment

Departmental checklist are used for Staff is designated for filling

monitoring and quality assurance 1 SI/RR and monitoring of these
checklists

Check the non compliances

Non-compliances are enumerated and 1 RR are presented & discussed
recorded during quality team
meetings

Actions are planned to address gaps Check action plans are prepared and Randomly check the details
ME G3.4 observed during quality assurance implemented as per internal 1 RR of action, responsibility, time
process assessment record findings line and feedback
mechanism

Check actions have been

taken to close the gap. It can
Planned actions are implemented Check PDCA or revalent quality method be in form of action taken
ME G3.5 through Quality Improvement is used to take corrective and 1 SI/RR
Cycles (PDCA) preventive action report or Quality
Improvement (PDCA) project
report

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

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Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Departmental standard operating Standard operating procedure for

ME G4.1 department has been prepared and 2 RR
procedures are available approved
Current version of SOP are available 1 OB/RR
with process owner

Work Instructions are displayed for Factor chart, radiation

radiation safety 2 OB safety, development for x-
ray films

Standard Operating Procedures Department has documented

ME G4.2 adequately describes process and procedure for process of taking and 2 RR
procedures handling X ray

Department has documented

procedure for acceptance and rejection 2 RR
of X ray taken
Department has documented
procedure for receipt, labelling , 2 RR
Processing and reporting of X ray
Department has documented
procedure for taking X ray in 2 RR
emergency conditions
Department has documented
procedure for quality control system to 2 RR
verify the quality of results
Radiology has documented system for
repeat X ray. 2 RR

Department has documented

procedure for storage, retaining and
retrieval of department records, and 2 RR
reports of results.

Department has documented

procedure preventive and break down 2 RR
maintenance

Page 542
Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No
Department has documented
procedure for purchase of External 2 RR
services and supplies

Department has documented

2 RR
procedure for inventory management

Department has documented

procedure for upkeep management of 2 RR
department
Department has documented
procedure for radiation safety of staff , 2 RR
patients and visitors
Staff is trained and aware of the
ME G4.3 standard procedures written in Check staff is a aware of relevant part 1 SI/RR
SOPs of SOPs

Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

Process mapping of critical processes

ME G5.1 Facility maps its critical processes 0 SI/RR
done
Facility identifies non value adding
ME G5.2 activities / waste / redundant Non value adding activities are 0 SI/RR
activities identified

Facility takes corrective action to Processes are rearranged as per

ME G5.3 improve the processes requirement 0 SI/RR

Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Page 543
Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Check quality policy of the

facility has been defined in
consultation with hospital
Facility has defined Quality policy, Check if Quality Policy has been staff and duly approved by
ME G6.3 which is in congruency with the 0 SI/RR the head of the facility . Also
mission of facility defined and approved check Quality Policy enables
achievement of mission of
the facility and health
department

Check short term valid

quality objectivities have
been framed addressing key
Facility has de defined quality Check if SMART Quality Objectives have quality issues in each
ME G6.4 objectives to achieve mission and 0 SI/RR department and cores
quality policy framed services. Check if these
objectives are Specific,
Measurable, Attainable,
Relevant and Time Bound.

Interview with staff for their

Mission, Values, Quality policy and awareness. Check if Mission
objectives are effectively Check of staff is aware of Mission , Statement, Core Values and
ME G6.5 communicated to staff and users of Values, Quality Policy and objectives 0 SI/RR Quality Policy is displayed
services prominently in local
language at Key Points

Page 544
Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Verify with records that a

time bound action plan has
been prepared to achieve
Facility prepares strategic plan to Check if plan for implementing quality quality policy and objectives
ME G6.6 achieve mission, quality policy and 0 SI/RR
objectives policy and objectives have prepared in consultation with hospital
staff . Check if the plan has
been approved by the
hospital management

Review the records that

action plan on quality
objectives being reviewed at
Facility periodically reviews the least once in month by
ME G6.7 progress of strategic plan towards Check time bound action plan is being 0 SI/RR departmental in charges and
reviewed at regular time interval during the quality team
mission, policy and objectives meeting. The progress on
quality objectives have been
recorded in Action Plan
tracking sheet

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

ME G7.1 Facility uses method for quality Basic quality improvement method 0 SI/OB PDCA & 5S
improvement in services

Advance quality improvement method 0 SI/OB Six sigma, lean.

ME G7.2 Facility uses tools for quality 7 basic tools of Quality 0 SI/RR Minimum 2 applicable tools
improvement in services are used in each department

Standard G9 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.

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Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

Check if periodic assessment of Verify with the assessment

Periodic assessment for Physical records. Comprehensive of
ME G9.4 and Electrical risks is done as per Physical and electrical safety risk is 0 SI/RR physical and electrical safety
defined criteria done using the risk assessment should be done at least once
checklist
in three month

Verify with the records. A

Periodic assessment for Medication Check periodic assessment of comprehensive risk
medication and patient care safety risk assessment of all clinical
ME G9.6 and Patient care safety risks is done is done using defined checklist 0 SI/RR processes should be done
as per defined criteria. periodically using pre define criteria at
least once in three month.

Periodic assessment for potential 1. Check that the filled

risk regarding safety and security of SaQushal assessment toolkit is used for checklist and action taken
ME G9.7 staff including violence against 0 SI/RR report are available
service providers is done as per safety audits. 2. Staff is aware of key gaps
defined criteria & closure status

Risks identified are analysed Action is taken to mitigate

ME G9.8 evaluated and rated for severity Identified risks are analysed for severity 0 SI/RR the risks
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks

ME H1.1 Facility measures productivity X ray done per 1000 OPD patient 2 RR
Indicators on monthly basis
X ray done per 1000 IPD patient 2 RR
Ultrasound done per 1000 OPD patient 2 RR
Proportion of X ray done at night 2 RR
No. of dental X ray per 1000 dental
OPD 2 RR
Proportion of BPL Patients screened 2 RR X-ray, USG

Page 546
Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No

X-ray, USG (reason of image

repeating is related to
Percentage of re-dos in imaging 2 RR errors, mistakes or image
quality)

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark

Facility measures efficiency

ME H2.1 Downtime for critical equipment 2 RR
Indicators on monthly basis
Turn around time for X-Ray film
development 2 RR
Proportion of waste of films 2 RR
Proportion of X ray rejected/repeated 2 RR

X ray done per radiographer 2 RR

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

ME H3.1 Facility measures Clinical Care & Proportion of X rays for which report is 2 RR
Safety Indicators on monthly basis signed by radiologist

Proportion of scans for which F form is 2 RR

filled out of pregnant women scanned

Proportion of General, Chest

Examination Demography 2 RR examination and specialised
examination

Proportion of radiology
report co related with
Report correlation rate 2 RR clinical
examination/laboratory
reports out of Total X ray
reported

Page 547
Checklist No. 14 Radiology Version - NHSRC/3.0

Compliance Assessment
Reference no. ME Statement Checkpoint Full/Partial/ Method Means of Verification Remarks
No
No of adverse events per thousand 2 RR
patients
No of events of over limit of radiation 2 RR
exposure

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

ME H4.1 Facility measures Service Quality Average waiting time at radiology 2 RR

Indicators on monthly basis
Average waiting time at USG 2 RR
Number of stock out incidences of x ray 2 RR
films

Page 548
Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services

Services are available for the time Dispensary services are available in
ME A1.14 2 SI/RR
period as mandated OPD hours

Facility ensure access to medicine

store after OPD hours 2 SI/RR

Check availability and functionality

Generic medicine store is operational 2 SI/RR of Janaushadhi Kendras in the
24X7
premises

Standard A4 Facility provides services as mandated in national Health Programs/ state scheme

The facility provides services under

Chloroquine, Primaquine, ACT
National Vector Borne Disease Availability of medicines under
ME A4.1 2 SI/OB (Artemisinin Combination
Control Programme as per NVBDCP
Therapy)
guidelines

The facility provides services under

ME A4.2 national tuberculosis elimination Availability of medicines under NTEP 2 SI/OB
programme as per guidelines.

The facility provides services under

ME A4.3 National Leprosy Eradication Availability of medicines under NLEP 2 SI/OB Rifampicin, Clofazimine, Dapsone
Programme as per guidelines

The facility provides services under Zidovudine, Stavudine,

ME A4.4 Availability of ARV medicines under 2 SI/OB
National AIDS Control Programme Lamivudine, Nevirapine in
NACP
as per guidelines combination as per NACO
Availability of medicines for Paediatric Paediatric Dosages FDC 6, FDC 10,
2 SI/OB
HIV management Efavirenz, Cotrimoxazole
Standard A5 Facility provides support services

Page 549
Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

The facility provides pharmacy Dispensing of Medicines and

ME A5.6 2 SI/OB Functional dispensary
services consumables for OPD Patients

Functional jan ayushdhalya in

Generic medicine Store 2 SI/OB
premises or equivalent
Storage of medicines 2 SI/OB
Cold chain management services 2 SI/OB
Area of Concern - B Patient Rights
Standard
Facility provides the information to care seekers, attendants & community about the available services and their modalities
B1

Availability of departmental &

Numbering, main department and
The facility has uniform and user- directional signages are displayed for
ME B1.1 1 OB internal sectional signage are
friendly signage system easy access to Pharmacy/Generic
displayed
medicine store

The facility displays the services

List of medicines available displayed at
ME B1.2 and entitlements available in its 2 OB
Pharmacy
departments
Status of availability of medicines is
2 OB
updated daily
Timing for dispensing counter of
1 OB
pharmacy are displayed
User charges are displayed and User charges in r/o services are
ME B1.4 communicated to patients displayed at entrance of generic 1 OB
effectively medicine store

Information is available in local Signage's and information are

ME B1.6 2 OB
language and easy to understand available in local language

Standard Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of physical, economic,
B2 cultural or social reasons.

ME B2.1 Services are provided in manner Availability of separate Queue for Male 2 OB
that are sensitive to gender and female at dispensing counter

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Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Access to facility is provided
ME B2.3 Pharmacy has easy access for moment 1 OB Check for availability of ramp and
without any physical barrier & and
of goods goods trolley/ cart
friendly to people with disabilities

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

The facility ensures the behaviours

Behaviour of staff is empathetic and
ME B3.3 of staff is dignified and respectful, 2 PI
courteous
while delivering the services

Standard Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent
B4 wherever it is required.

Method of Administration /taking of

Information about the treatment
ME B4.4 the medicines is informed to patient/ 2 OB/SI
is shared with patients or
their relative by pharmacist as per
attendants, regularly
doctors prescription in OPD Pharmacy

Availability of complaint box and

The facility has defined and
display of process for grievance re
ME B4.5 established grievance redressal 2 OB
addressal and whom to contact is
system in place
displayed
Standard
Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.
B5
The facility provides cashless
services to pregnant women,
ME B5.1 Free medicines and consumables for all 2 PI/SI JSSK, RBSK & PMJAY beneficiaries
mothers and neonates as per
prevalent government schemes

The facility ensures that medicines

Pharmacy provides generic medicine
ME B5.2 prescribed are available at 2 SI/OB
list to all hospital department
Pharmacy and wards

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Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Check that patient party has not

incurred expenditure on purchasing
2 PI/SI
medicines or consumables from
outside.

The facility provide free of cost

treatment to Below poverty line
ME B5.4 Free medicines for BPL patients 2 PI/SI/RR
patients without administrative
hassles

The facility ensures timely

Local purchase of stock out medicines/
reimbursement of financial
ME B5.5 Reimbursement of expenditure to the 2 PI/SI/RR
entitlements and reimbursement
beneficiaries
to the patients

Area of Concern - C Inputs

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

Minimum space required is 250sq

ME C1.1 Departments have adequate space Hospital has allocated space for 2 OB F or 5% of average
as per patient or work load Pharmacy in OPD
OPD X 0.8 sq m.
Dispensary has adequate waiting
1 OB
space as per load
Patient amenities are provide as Pharmacy has patients sitting
ME C1.2 2 OB
per patient load arrangement as per requirement
Dispensary counter has provision of
2 OB If it is outside the hospital building
shade

Departments have layout and Dedicated area for keeping medical

ME C1.3 2 OB
demarcated areas as per functions gases

Dedicated area for keeping

2 OB Storage of sprit etc.
inflammables
Demarcated are of keeping near expiry
2 OB
medicines
Demarcated are of keeping expired
2 OB
medicines
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Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Demarcated area for keeping
2 OB
instruments and consumables
Dedicated area for cold chain
2 OB
management
The facility has adequate Availability of adequate circulation
ME C1.4 circulation area and open spaces area for easy moment of staff , 1 OB
according to need and local law medicines and carts
The facility has infrastructure for
ME C1.5 Availability of functional telephone and 1 OB
intramural and extramural
Intercom Services
communication
Service counters are available as Adeqauate No of medicine dispensing
ME C1.6 2 OB
per patient load counter as per load

The facility and departments are

planned to ensure structure Receipt and Inspection area at one
Unidirectional flow of goods in the
ME C1.7 follows the function/processes 2 OB side and issue area on the other
Pharmacy .
(Structure commensurate with the side
function of the hospital)

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

Check for fixtures and furniture

like cupboards, cabinets, and
The facility ensures the seismic Non structural components are
ME C2.1 2 OB heavy equipments , hanging
safety of the infrastructure properly secured
objects are properly fastened and
secured

ME C2.3 The facility ensures safety of Pharmacy does not have temporary 2 OB
electrical establishment connections and loosely hanging wires

Stabilizer is provided for cold chain

2 OB
room

ME C2.4 Physical condition of buildings are Windows of medicine store have grills 2 OB
safe for providing patient care and wire meshwork

Floors of the Pharmacy department

2 OB
are non slippery and even
Page 553
Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

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

Pharmacy has plan for safe storage

ME C3.1 The facility has plan for prevention 2 OB/SI
and handling of potentially flammable
of fire
materials.
Department has sufficient fire exit to
permit safe escape to its occupant at 2 OB
time of fire
Check the fire exits are clearly visible
and routes to reach exit are clearly 2 OB
marked.
Pharmacy has installed fire
The facility has adequate fire
ME C3.2 Extinguisher that is Class A , Class B C 2 OB/RR
fighting Equipment
type or ABC type

Check the expiry date for fire

extinguishers are displayed on each
2 OB/RR
extinguisher as well as due date for
next refilling is clearly mentioned

The facility has a system of

Check for staff competencies for
ME C3.3 periodic training of staff and 2 SI/RR
operating fire extinguisher and what to
conducts mock drills regularly for
do in case of fire
fire and other disaster situation

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

The facility has adequate

ME C4.4 technicians/paramedics as per Availability of Pharmacist 2 SI/RR
requirement
The facility has adequate support /
ME C4.5 Availability of security staff 2 SI/RR
general staff

Standard C5 Facility provides medicines and consumables required for assured list of services.

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Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
The departments have availability Non-opioid Analgesic, Anti-Pyretic and
ME C5.1 of adequate medicines at point of Nonsteroidal Anti-Inflammatory 2 OB/RR As per State's EML
use Medicines
Anti-infective medicines - Antibiotics,
2 OB/RR As per State's EML
Antifungal, Antiamoebic
Antiseptic Liquid/Cream/lotion 2 OB/RR As per State's EML

Solution Correcting Water, Electrolyte

Disturbances and Acid-Base 2 OB/RR As per State's EML
Disturbances and plasma expenders

Anti-Allergic and Medicines used in

2 OB/RR As per State's EML
Anaphylaxis
Medicines acting on Digestive system -
Anti Diarrhoeal, Anti-Ulcer, Anti -
2 OB/RR As per State's EML
Emetic, Anti Constipation, Anti-
Inflammatory
Antidote and other Substances used in
2 OB/RR As per State's EML
Poisoning
Immunosuppressive Medicines 2 OB/RR As per State's EML
Pain and Palliative Care Medicines 2 OB/RR As per State's EML
Opioid Analgesic Medicines 2 OB/RR As per State's EML
Medicines Affecting Blood 2 OB/RR As per State's EML
Dermatological medicines (Topical) 2 OB/RR As per State's EML
Ear, Nose and Throat (ENT) Medicines 2 OB/RR As per State's EML

Dental Restorative Materials and

2 OB/RR As per State's EML
Medicines
Ophthalmological Medicines 2 OB/RR As per State's EML
Availability of psychotherapeutic
2 OB/RR As per State's EML
medicines
Medicines acting on Cardiovascular
2 OB/RR As per State's EML
system
Medicines acting on Central/Peripheral
2 OB/RR As per State's EML
Nervous system
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Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Medicines acting on Respiratory
2 OB/RR As per State's EML
system

Medicines acting on Urogenital system 2 OB/RR As per State's EML

Medicines used on Obstetrics and

2 OB/RR As per State's EML
Gynaecology
Hormonal preparation and other
2 OB/RR As per State's EML
Endocrine Medicines
Immunological/Vaccine medicine and
2 OB/RR As per State's EML
logistics
Surgical accessories for Eye 2 OB/RR As per State's EML
Vitamins, Mineral and nutritional
2 OB/RR As per State's EML
supplement
Dialysis Solution 2 OB/RR As per State's EML
Prophylactic Iron, folic acid and
2 As per State's EML
deworming
The departments have adequate
ME C5.2 Availability of Consumables 2 OB/RR As per State's EML
consumables at point of use

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

ILR, Deep Freezers, Insulated

ME C6.5 Availability of Equipment for Availability of Equipment for 1 OB carrier boxes with ice packs,
Storage maintenance of Cold chain
refrigerator
Availability of functional
Buckets for mopping, mops,
ME C6.6 equipment and instruments for Availability of equipments for cleaning 2 OB
duster, waste trolley, Deck brush
support services
Departments have patient Racks ,Cupboards, Sectional
ME C6.7 furniture and fixtures as per load Storage furniture for medicine store 1 OB Drawer cabinet/ Shelves, Work
and service provision table
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

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Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Check objective checklist has been

prepared for assessing
competence of doctors, nurses
Criteria for Competence Check parameters for assessing skills
and paramedical staff based on job
ME C7.1 assessment are defined for clinical and proficiency of clinical staff has 1
description defined for each cadre
and Para clinical staff been defined
of staff. Dakshta checklist issued
by MoHFW can be used for this
purpose.

Check for records of competence

Competence assessment of Clinical
assessment including filled
and Para clinical staff is done on Check for competence assessment is
ME C7.2 1 checklist, scoring and grading .
predefined criteria at least once in done at least once in a year
Verify with staff for actual
a year
competence assessment done

The Staff is provided training as

ME C7.9 per defined core competencies Inventory management 1 SI/RR
and training plan
Cold chain management of ILR and
2 SI/RR
deep freezer
Rational use of medicines 2 SI/RR
Prescription Audit 2 SI/RR
Patient Safety 2 SI/RR
Basic Life Support 2 SI/RR

Training on Quality Management 1 SI/RR To all category of staff. At the time

System of induction and once in a year.

Check supervisors make periodic

There is established procedure for rounds of department and monitor
Staff is skilled for estimation of the
utilization of skills gained thought that staff is working according to
ME C7.10 requirement and proper storage of the 1 SI/RR
trainings by on -job supportive the training imparted. Also staff is
medicines
supervision provided on job training wherever
there is still gaps

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Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Check supervisors make periodic

rounds of department and monitor
Staff is skilled for maintaining that staff is working according to
2 SI/RR
pharmacy records and bin cards the training imparted. Also staff is
provided on job training wherever
there is still gaps

Area of Concern - D Support Services

Standard
The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.
D1
1. Check with AMC records/
The facility has established system
All equipments are covered under Warranty documents
ME D1.1 for maintenance of critical 1 SI/RR
AMC including preventive maintenance 2. Staff is aware of the list of
Equipment
equipment covered under AMC.

[Link] for breakdown &

Maintenance record in the log
There is system of timely corrective
book
break down maintenance of the 2 SI/RR
2. Staff is aware of contact details
equipments
of the agency/person in case of
breakdown.

The facility has established

procedure for internal and All the measuring equipments/ Calibration of thermometers at
ME D1.2 0 OB/ RR
external calibration of measuring instrument are calibrated cold chain room
Equipment

Operating and maintenance Operating instructions for ILR/ Deep

ME D1.3 instructions are available with the Freezers are available at cold chain 2 OB/SI
users of equipment room
Standard The facility has defined procedures for storage, inventory management and dispensing of medicines in pharmacy and patient care areas
D2
Medicine store has process to
There is established procedure for
consolidate and calculate the
ME D2.1 forecasting and indenting 2 RR/SI
consumption of all medicines and
medicines and consumables
consumables

Page 558
Checklist No. 15 Pharmacy Version - NHSRC/3.0

Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Scientifically based on
Forecasting of medicines and
2 RR/SI consumption pattern, disease
consumables is done
prevelence, seasonality
Staff is trained for forecast the
1 RR/SI
requirement using scientific system
The facility has establish Facility has a established procedures
ME D2.2 procedure for procurement of for local purchase of medicines in 2 RR/SI 10% of total budget
medicines emergency conditions
Hospital has system for placing
2 RR/SI
requisition to district medicine store
There is allocated place to store
ME D2.3 The facility ensures proper storage 1 OB
medicines in Pharmacy and medicine
of medicines and consumables
store

Stock is arranged neatly in

All the shelves/racks containing
alphabetic order/ Therapeutic
medicines are labelled in pharmacy 2 OB
category with name facing the
and medicine store
front and expiry date

Medicines of similar name and 2 OB E.g. Montelukast 5mg,

multiple strength are stored separately Montelukast 10mg

Heavy items are stored at lower Syrup cartons, reagents cartons

2 OB
shelves/racks are kept at the lower shelves
Syrup bottles, glass ampoules, vials
Fragile items are not stored at the 2 OB are not stored at the edge of the
edges of the shelves.
rack

LASA medicines kept away from

Look Alike and Sound alike medicines their identical one in look or
are stored separately in patient care 2 OB sound. Tall Man lettering method
area and pharmacy used for identification/labelling of
LASA

High alert medicines are stored

2 OB High alert medicines are stored
separately in patient care area and
separately and labelled
pharmacy

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
There is separate shelf /rack/area for
storage near expiry, expired, NSQ 2 OB
medicines in the drug store
Pharmacy has system of inventory
2 OB/SI DVDMS, E-Aushadhi, etc.
Management

Medicines and consumables are stored Medicines that are considered

away from water and sources of heat, 2 OB/RR light-sensitive are stored in closed
direct sunlight, etc. drawers.

Medicines are not stored at floor and Pallets are provided if required to
0 OB
adjacent to wall store at floor
The facility ensures management
Dispensing counter has system to
ME D2.4 of expiry and near expiry 2 RR/SI
check the expiry of medicines
medicines
Medicine store has system to check
2 RR/SI DVDMS, E-Aushadhi, etc.
the expiry of medicines
Medicine store has system to inform
the patient care areas about near 2 RR/SI
expiry/expired medicines
There is a system of periodic random
2 RR/SI
quality testing of medicines
The facility has established
Physical verification of inventory is
ME D2.5 procedure for inventory 2 RR/SI Stock audit sheet
done periodically
management techniques
Bin cards are used for each
Facility uses bin card system 2 RR/OB medicines and are updated
regularly

Storage - Near expiry medicines

First Expiry First Out (FEFO) System is
2 OB are stored in front and long expiry
established for medicines
medicines are kept in back.

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Minimum quantity/stock level of

Stores has defined minimum stock for
each category of drug is defined.
each category of medicine as per there 2 RR/OB
E.g. Paracetamol 500mg 100 strips,
consumption pattern
etc.
Reorder level is defined for each
2 RR
category of medicines
Medicine store has supply chain
software for the management of 1 OB/RR DVDMS, E-Aushadhi, etc.
innventory

Medicines are stored and

categorized in the store's shelves
as per their consumption (Vital,
Medicines are categorized and stored 1 OB/RR Essential and Desirable, Fast
Moving, slow moving)/
Alphabetically/Therapeutic
category, etc.

There is a procedure for Hospital has established system to

ME D2.6 periodically replenishing the take medicines from store in case of 2 RR/SI
medicines in patient care areas emergency or if required urgently

There is process for storage of

(Top to bottom) : Hep B, DPT, DT,
ME D2.7 vaccines and other medicines, Check vaccines are kept in sequence 2 OB
TT, BCG, Measles, OPV
requiring controlled temperature

Work instruction for storage of 2 OB

vaccines are displayed at point of use

ILR and deep freezer have functional

2 OB
temperature monitoring devices
Temp. of ILR: Min +2°C to 8°c in
There is system in place to maintain case of power failure min temp.
2 OB
temperature chart of ILR +10°C . Twice a day temperature
log are maintained

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Temp. of Deep freezer cabinet is

There is system in place to maintain maintained between -15°C to -
2 OB
temperature chart of deep freezers 25°C. Twice a day temperature log
are maintained
Check thermometer in ILR is in hanging
2 OB
position
ILR and deep freezer has functional
2 SI/RR
alarm system
Staff is aware of Hold over time of cold
2 SI/RR
storage equipments

As per Narcotic Drugs and

There is a procedure for secure
Narcotic medicines are kept separetly Psycotropic Substances (NDPS) Act
ME D2.8 storage of narcotic and 1 OB
in double lock and Rules, Narcotic medicines are
psychotropic medicines
kept in double lock.

Consumption of Narcotic drugs &

Empty ampoules/strips are returned
psychotropic substances (NDPS)
along with narcotic administration 1 OB/RR
drugs by the wards and return
detail sheet
back to the pharmacy
Hospital has system to discard the Discarded narcotic medicines are
2 RR/SI
expired narcotic medicines documented with witness.
Facility maintains the list of narcotic
and psychotropic medicines available 2 RR List of NDPS drugs are maintained
at facility
Standard
The facility provides safe, secure and comfortable environment to staff, patients and visitors.
D3
The facility provides adequate
ME D3.1 Adequate Illumination at medicine 1 OB
illumination level at patient care
store
areas
Adequate Illumination at dispensing
2 OB
counter

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Fans/ Air
The facility ensures safe and
Temperature control and ventilation in conditioning/Heating/Exhaust/Ven
ME D3.3 comfortable environment for 2 SI/RR
pharmacy tilators as per environment
patients and service providers
condition and requirement
The facility has security system in
ME D3.4 Security arrangement at pharmacy 2 OB
place at patient care areas
The facility has established
ME D3.5 measure for safety and security of Female staff feel secure at work place 2 SI
female staff
Standard
The facility has established Programme for maintenance and upkeep of the facility
D4
Exterior of the facility building is Building is painted/whitewashed in
ME D4.1 2 OB
maintained appropriately uniform colour
Interior of patient care areas are
2 OB
plastered & painted
Floors, walls, roof, roof topes, sinks
ME D4.2 Patient care areas are clean and 1 OB All area are clean with no
patient care and circulation areas are
hygienic dirt,grease,littering and cobwebs
Clean
Surface of furniture and fixtures are
2 OB
clean
Toilets are clean with functional flush
0 OB
and running water
Hospital infrastructure is Check for there is no seepage , Cracks,
ME D4.3 1 OB
adequately maintained chipping of plaster
Window panes , doors and other
2 OB
fixtures are intact
The facility has policy of removal No condemned/Junk material in the
ME D4.5 2 OB
of condemned junk material Pharmacy and medicine store
The facility has established
ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds 1 OB
animal control

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
The facility ensures adequate
ME D5.2 power backup in all patient care Availability of power back in Pharmacy 2 OB/SI
areas as per load
Availability of power back for cold
2 OB/SI
chain
Standard
Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
D10
The facility has requisite licences
ME D10.1 and certificates for operation of License for storing spirit 2 RR
hospital and different activities

Standard
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
D11

ME D11.1 The facility has established job Job description is defined and 1 RR Regular + contractual
description as per govt guidelines communicated to all concerned staff

Staff is aware of their role and

2 SI
responsibilities
The facility has a established Check for system for recording
procedure for duty roster and There is procedure to ensure that staff time of reporting and relieving
ME D11.2 2 RR/SI
deputation to different is available on duty as per duty roster (Attendance register/ Biometrics
departments etc)
There is designated in charge for
2 SI
department
The facility ensures the adherence
to dress code as mandated by its Pharmacist adhere to their respective
ME D11.3 2 OB
administration / the health dress code
department

Standard D1 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Verification of outsourced services

There is established system for There is procedure to monitor the (cleaning/
ME D12.1 contract management for out quality and adequacy of outsourced 1 SI/RR Dietary/Laundry/Security/Mainten
sourced services services on regular basis ance) provided are done by
designated in-house staff
Area of Concern - E Clinical Services
Standard Facility ensures rationale prescribing and use of medicines
E6

ME E6.1 Facility ensured that medicines are Medicines are purchased in generic 2 RR/SI
prescribed in generic name only name only

Facility has essential medicine list as

2 OB
per State guideline
Facility provide list of medicines
available to different departments as 2 RR/SI
per essential medicine list
Facility has enabling order from state
for writing medicines in generic name 2 RR/SI
only

There is system of conducting periodic

prescription audit to ensure that only 2 RR/SI
generic medicines are prescribed

There is procedure of rational use Hospital has its own medicine

ME E6.2 2 RR/SI
of medicines formulary based on EML
medicine formulary is available with
2 RR/SI
doctors and nurses/ clinical table
Hospital has system to review the
medicine formulary as per EML at 2 RR/SI
defined intervals
Hospital has system to review the
prescription as per medicine formulary 1 RR/SI
and STG

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Standard E7 Facility has defined procedures for safe medicine administration

There is process for identifying and

Pharmacy has list of high risk
ME E7.1 cautious administration of high 2 RR/SI
medicines are available
alert medicines

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage

Adequate form and formats are

ME E8.5 Standard Formats available 2 RR/OB Bin cards, indent forms etc
available at point of use
Register/records are maintained Pharmacy records are labeled and
ME E8.6 2 RR
as per guidelines indexed

Records are maintained for Pharmacy 2 RR

The facility ensures safe and

Pharmacy has adequate facility for
ME E8.7 adequate storage and retrieval of 2 OB
storage of records
medical records

Standard E1 The facility has defined and established procedures for Emergency Services and Disaster Management

The facility has disaster

ME E11.3 Staff is aware of disaster plan 2 SI/RR
management plan in place
Role and responsibilities of staff in
2 SI/RR
disaster is defined
Area of Concern - F Infection Control
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

There is Provision of Periodic

There is procedure for immunization of
ME F1.4 Medical Checkups and 2 SI/RR Hepatitis B, Tetanus Toxid etc
the staff
immunization of staff

Periodic medical checkups of the staff 1 SI/RR

Facility has defined and Check for Pharmacist are aware of

ME F1.6 1 SI/RR
established antibiotic policy Hospital Antibiotic Policy

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Pharmacist check the antibiotic
2 SI/RR
consumption periodically

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention

Facility ensures availability of

standard materials for cleaning Availability of cleaning agent as per Hospital grade phenyl, disinfectant
ME F5.2 2 OB/SI
and disinfection of patient care requirement detergent solution
areas

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins at 2 OB Adequate number. Covered. Foot
Medical Waste as per guidelines point of waste generation operated.

Availability of colour coded non

2 OB
chlorinated plastic bags

Pharmaceutical waste like

antibiotics, cytotoxic medicines
Segregation of expired or discarded including all items contaminated
2
medicines in Yellow Bin with cytotoxic medicines along
with glass or plastic ampoules,
vials etc.

There is no mixing of infectious and

2 OB
general waste

Facility ensures transportation and Disposal of expired medicines as per Either sent back to manufacturer
ME F6.3 2 SI/OB
disposal of waste as per guidelines state guidelines or disposed by incineration

Area of Concern - G Quality Management

Standard
The facility has established organizational framework for quality improvement
G1
Check if quality circle formed and
ME G1.1 The facility has a quality team in Quality circle has been formed in the 1 SI/RR functional with a designated nodal
place Pharmacy
officer for quality
Standard Facility has established system for patient and employee satisfaction
G2
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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Patient Satisfaction surveys are Patient satisfaction survey done on
ME G2.1 2 RR
conducted at periodic intervals monthly basis
Standard
Facility have established internal and external quality assurance programs wherever it is critical to quality.
G3
Facility has established internal Physical verification of the inventory by
ME G3.1 quality assurance program at Pharmacist/hospital manager at 2 SI/RR
relevant departments periodic intervals
Facility has established external
ME G3.2 Periodic and random sampling of the 2 SI/RR By medicine controller/State
assurance programs at relevant
medicines for Quality Assurance medicine quality Assurance
departments
Facility has established system for NQAS, Kayakalp, SaQushal tools
ME G3.3 Internal assessment is done at periodic 2 RR/SI
use of check lists in different are used to conduct internal
interval
departments and services assessment
Departmental checklist are used for Staff is designated for filling and
2 SI/RR
monitoring and quality assurance monitoring of these checklists

Non-compliances are enumerated and Check the non compliances are

2 RR
recorded presented & discussed during
quality team meetings

Actions are planned to address Check action plans are prepared and Randomly check the details of
ME G3.4 gaps observed during quality implemented as per internal 2 RR action, responsibility, time line and
assurance process assessment record findings feedback mechanism

Check actions have been taken to

Planned actions are implemented Check PDCA or revalent quality close the gap. It can be in form of
ME G3.5 through Quality Improvement method is used to take corrective and 1 SI/RR action taken report or Quality
Cycles (PDCA) preventive action Improvement (PDCA) project
report

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

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Current version of SOP are available
2 OB/RR
with process owner
Work instruction for storing
Work instruction/clinical protocols are 2 OB medicines, Cold chain
displayed
management

Department has documented

Standard Operating Procedures
procedure for indent the medicines
ME G4.2 adequately describes process and 2 RR
and items from district medicine
procedures
warehouse

Department has documented

procedure for local purchase of 2 RR
medicines/ generic medicine stores
Department has documented
procedure for reception and storage of 2 RR
medicines and items

Department has documented

procedure for maintaining near expiry 2 RR
medicines at store and pharmacy and
disposal of expired medicines

Department has documented

procedure for dispensing of medicines 2 RR
at Pharmacy
Department has documented
procedure of indenting the medicines 2 RR
to patient care area
Department has documented
procedure for issue of the medicines in 2 RR
emergency condition

Department has documented

procedure for maintenance of
2 RR
temperature of ILR/Deep freezer
/refrigerators

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Department has documented
procedure for storage of narcotic and 2 RR
psychotropic medicines
Department has documented system
for periodic random check and quality 2 RR
testing of medicines
Staff is trained and aware of the
Check staff is a aware of relevant part
ME G4.3 standard procedures written in 1 SI/RR
of SOPs
SOPs
Standard G
Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
5
Process mapping of critical processes
ME G5.1 Facility maps its critical processes 1 SI/RR
done
Facility identifies non value adding
ME G5.2 Non value adding activities are 1 SI/RR
activities / waste / redundant
identified
activities
Facility takes corrective action to Processes are rearranged as per
ME G5.3 1 SI/RR
improve the processes requirement
Standard
The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
G6

Check quality policy of the facility

has been defined in consultation
Facility has defined Quality policy, with hospital staff and duly
Check if Quality Policy has been
ME G6.3 which is in congruency with the 2 SI/RR approved by the head of the
defined and approved
mission of facility facility . Also check Quality Policy
enables achievement of mission of
the facility and health department

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No

Check short term valid quality

objectivities have been framed
addressing key quality issues in
Facility has de defined quality
Check if SMART Quality Objectives each department and cores
ME G6.4 objectives to achieve mission and 1 SI/RR
have framed services. Check if these objectives
quality policy
are Specific, Measurable,
Attainable, Relevant and Time
Bound.

Interview with staff for their

Mission, Values, Quality policy and awareness. Check if Mission
objectives are effectively Check of staff is aware of Mission , Statement, Core Values and
ME G6.5 2 SI/RR
communicated to staff and users Values, Quality Policy and objectives Quality Policy is displayed
of services prominently in local language at
Key Points

Verify with records that a time

bound action plan has been
Facility prepares strategic plan to prepared to achieve quality policy
Check if plan for implementing quality
ME G6.6 achieve mission, quality policy and 2 SI/RR and objectives in consultation with
policy and objectives have prepared
objectives hospital staff . Check if the plan
has been approved by the hospital
management

Review the records that action

plan on quality objectives being
reviewed at least onnce in month
Facility periodically reviews the
Check time bound action plan is being by departmnetal incharges and
ME G6.7 progress of strategic plan towards 2 SI/RR
reviewed at regular time interval during the qulaity team meeting.
mission, policy and objectives
The progress on quality objectives
have been recorded in Action Plan
tracking sheet

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

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Facility uses method for quality
ME G7.1 Basic quality improvement method 1 SI/OB PDCA & 5S
improvement in services

Advance quality improvement method 0 SI/OB Six sigma, lean.

Facility uses tools for quality Minimum 2 applicable tools are

ME G7.2 7 basic tools of Quality 2 SI/RR
improvement in services used in each department
Standard Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.
G9
Verify with the records. A
Periodic assessment for Check periodic assessment of
comprehensive risk asesement of
ME G9.6 Medication and Patient care safety medication and patient care safety risk 1 SI/RR all clincial processes should be
risks is done as per defined is done using defined checklist
done using pre define critera at
criteria. periodically
least once in three month.

Periodic assessment for potential 1. Check that the filled checklist

risk regarding safety and security and action taken report are
SaQushal assessment toolkit is used for
ME G9.7 of staff including violence against 1 SI/RR available
safety audits.
service providers is done as per 2. Staff is aware of key gaps &
defined criteria closure status

Risks identified are analyzed Identified risks are analysed for

ME G9.8 1 SI/RR Action is taken to mitigate the risks
evaluated and rated for severity severity
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks

ME H1.1 Facility measures productivity Percentage of medicines available 2 RR

Indicators on monthly basis against essential medicine list for OPD

Percentage of medicines available

2 RR
against essential medicine list for IPD

Expenditure on medicines procured

2 RR
throughlocal purchase for BPL patient

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Compliance
Reference ME Statement Checkpoint Assessment Means of Verification Remarks
Full/
No Method
Partial/No
Percentage of medicines procured
RR
locally

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark

Facility measures efficiency Number of stock out situations in Vital

ME H2.1 2 RR
Indicators on monthly basis category medicines
% of medicines expired during the
2 RR
months
Number of stock out medicines against
2 RR
EML

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

Facility measures Clinical Care & Proportion of prescription found

ME H3.1 2 RR
Safety Indicators on monthly basis prescribing non generic medicines

No of advere medicine reaction per

2 RR
thosuand patients
No. of antibiotic prescribed /No. of
Antibiotic rate 2 RR
patient admiited or consulted
Percentage of irrational use of
2 RR
medicines/overprescription

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

Facility measures Service Quality Turn Around time for dispensing

ME H4.1 2 RR
Indicators on monthly basis medicine at Pharmacy

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Reference no ME Statement Checkpoint Compliance Assessment Means of Verification Remarks

Method
Area of Concern - A Service Provision
Standard A5 Facility provides support services

Functional Kitchen within the

ME A5.1 The facility provides dietary services Availability of operational Kitchen 2 SI/OB premise of the hospital
Arrangement of laundry services
ME A5.2 The facility provides laundry services Availability of functional laundry 2 SI/OB inhouse or outsourced

ME A5.3 The facility provides security Availability of functional security 2 SI/OB

services services 24 X7

ME A5.4 The facility provides housekeeping Availability of Housekeeping 2 SI/OB

services services 24X7
Arrangement for disposal of Bio
Availability of waste disposal
ME A5.5 services 2 SI/OB medical and general waste Inhouse
or outsouced
Includes Physical infrastructure
The facility ensures maintenance Availability of maintenance services
ME A5.6 services 24X7 2 SI/OB maintenance and equipment
maintenance

ME A5.8 The facility has services of medical Availability of Medical record 2 SI/OB
record department department
Area of Concern - B Patient Rights
Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities

Availability of departmental and

ME B1.1 The facility has uniform and user- directional signage for support 1 OB Internal sectional signage are
friendly signage system service department displayed

Information is available in local Signage's and information are

ME B1.6 language and easy to understand available in local language 2 OB

The facility ensures access to clinical Medical records are provided to

ME B1.8 records of patients to entitled 2 RR/OB
personnel patient/ Next to kin on request

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

Confidentiality of patients records Patient records are not shared

ME B3.2 and clinical information is MRD has system to maintain 2 SI/RR except the patient until it is
maintained Confidentiality of patient records authorized by law
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Reference no ME Statement Checkpoint Compliance Assessment Means of Verification Remarks

Method

The facility ensures the behaviours

ME B3.3 of staff is dignified and respectful, Behaviour of staff is empathetic and 2 PI
courteous
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 care.

The facility provides cashless

services to pregnant women,
ME B5.1 Availability of free diet 2 PI/SI
mothers and neonates as per
prevalent government schemes

The facility provide free of cost

ME B5.4 treatment to Below poverty line Free diet for BPL patients 2 PI/SI
patients without administrative
hassles
Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities

Check list of agencies with which

data shared has routinely shred has
There is an established procedure been prepared . For any other
for sharing of hospital/patient data Check hospital administration has agency a formal permission is sought
ME B6.5 with individuals and external 2
agencies including non defined protocols for data sharing from competent authorities before
governmental organization sharing the data including
international agencies, press and
NGOs.

There is an established procedure

for obtaining informed consent from Check hospital ensures that
informed consent is taken from
ME B6.8 the patients in case facility is patient participating in any clinical or 2 Check for policy or practice
participating in any clinical or public public Health research
health research

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Reference no ME Statement Checkpoint Compliance Assessment Means of Verification Remarks

Method

Check for policy defines

List of certificates can be issued by
hospital
Who can issue certificates
There is an established procedure to
ME B6.9 issue of medical certificates and Check hospital has documented 2 Formats shall used for different
other certificates policy for issuing medical certificates certificates
Record keeping of issued certificate
procedures for issuing duplicate
certificates

Area of Concern - C Inputs

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

15-20 sq ft/bed space requirement

ME C1.1 Departments have adequate space Dietary Department has adequate 1 OB for 100 and more than 100 bed
as per patient or work load space as per requirement hospital.

Laundry Department has adequate 2 OB Minimum space requirement 10sq

space as per requirement ft/bed

Medical record Department has 2 OB Minimum space requirement is 2.5

adequate space as per requirement to 3,5 sq ft per bed

Layout as per functional flow that is

Check Dietary department has receipt, storage, daily storage,
ME C1.3 Departments have layout and demarcated and dedicated area for 2 OB preparation, Cooking area ,Service
demarcated areas as per functions area, dish washing area, Garbage
various activities collection area and administrative
area.

Layout as per functional flow that is

Check laundry department has from dirty end (receipt) to clean end
demarcated and dedicated area for 2 OB (Issue). That is receipt, sorting,
its various activities sluicing, washing, drying, ironing and
issue

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Reference no ME Statement Checkpoint Compliance Assessment Means of Verification Remarks

Method
Availability of complaint box and Layout as per functional flow that is
display of process for grievance 2 OB receipt, checking of completion of
redressal and whom to contact is records, indexing and filling of
displayed records, storage.

Availability of adequate circulation

The facility has adequate circulation area for easy moment of staff ,
ME C1.4 area and open spaces according to goods and food trolley in dietary 2 OB
need and local law
department

Availability of adequate circulation

area for easy moment of staff, 2 OB
equipments and carts in laundry
Availability of adequate circulation
1 OB
area in MRD
The facility has infrastructure for
ME C1.5 intramural and extramural All support services department are 2 OB
connected with intercom
communication
Service counters are available as per Unidirectional flow of goods and
ME C1.6 patient load services in dietary services 2 OB

Unidirectional flow of goods and

services in laundry services 2 OB

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

Check for fixtures and furniture like

The facility ensures the seismic Non structural components are cupboards, cabinets, and heavy
ME C2.1 safety of the infrastructure properly secured 2 OB equipments , hanging objects are
properly fastened and secured

Support services departments does

The facility ensures safety of
ME C2.3 electrical establishment not have temporary connections and 2 OB
loosely hanging wires

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Reference no ME Statement Checkpoint Compliance Assessment Means of Verification Remarks

Method
Equipments in wet areas like
Laundry and Kitchen are equipped 2 OB
with ground fault protection and
designed for wet conditions
Physical condition of buildings are Floors of the Support services are
ME C2.4 safe for providing patient care non slippery and even 2 OB

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

Building has sufficient fire exit to

ME C3.1 The facility has plan for prevention permit safe escape to its occupant at 2 OB/SI dietary department laundry and
of fire time of fire Medical record department

Check the fire exits are clearly visible

and routes to reach exit are clearly 2 OB dietary department laundry and
marked. Medical record department

Dietary Department has plan for

safe storage and handling of 2 OB Dietary Department
potentially flammable materials.

Support services has installed fire

Extinguisher that is Class A , Class B
The facility has adequate fire dietary department and Medical
ME C3.2 fighting Equipment C type or ABC type are installed in 2 OB/RR record department
adeqaute number at every strategic
points

Check the expiry date for fire

extinguishers are displayed on each 2 OB/RR dietary department and Medical
extinguisher as well as due date for record department
next refilling is clearly mentioned

The facility has a system of periodic Check for staff competencies for
ME C3.3 training of staff and conducts mock operating fire extinguisher and what 2 SI/RR
drills regularly for fire and other
disaster situation to do in case of fire

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

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Method
The facility has adequate
ME C4.4 technicians/paramedics as per Availability of Dietician 0 SI/RR
requirement

Availability of MRD technician 0 SI/RR

ME C4.5 The facility has adequate support / Availability of washer man 0 SI/RR In-house/Out-sourced
general staff
Availability of Cook 2 SI/RR In-house/Out-sourced
Availability of Data Entry operator
for MRD 0 SI/RR

Standard C5 Facility provides drugs and consumables required for assured list of services.

Cap, gowns, gloves, Detergent for

ME C5.2 The departments have adequate Availability of consumables at 2 OB/RR cleaning of utensil and Soap for hand
consumables at point of use dietary department washing
Availability of consumables at Detergent and disinfectant, Heavy
laundry department 2 OB/RR utility gloves, apron.

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

ME C6.6 Availability of functional equipment Availability of Equipments & utensils 2 OB Refrigerator, LPG, food trolley and
and instruments for support services for Dietary department cooking utensils

Washing machine, drier, Iron,

Availability of Equipments for 2 OB Separate trolley for clean and dirty
Laundry
linen
Availability of Equipments for
Medical record department 2 OB Computer with scanner

Availability of equipments for Buckets for mopping, mops, duster,

cleaning 2 OB waste trolley, Deck brush
Departments have patient furniture Availability of furniture and fixtures Exhaust fan, Storage containers,
ME C6.7 and fixtures as per load and service 2 OB
provision for Dietary department Work bench/slab, Utensil stand

Availability of furniture and fixtures Stand/ Hanger for drying of linen,

for laundry department 2 OB Iron table, Cupboard

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Method

Availability of furniture and fixtures Racks and cupboard, table, Sectional

for Medical record department 1 OB Drawer cabinet/ Shelves,

Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff
The Staff is provided training as per
ME C7.9 defined core competencies and Infection control & prevention 2 SI/RR Bio medical Waste Management
training plan training including Hand Hygiene

Training on Medical record

Management 2 SI/RR

Check supervisors make periodic

There is established procedure for rounds of department and monitor
utilization of skills gained thought MRD Staff is skilled for indexing and that staff is working according to the
ME C7.10 2 SI/RR
trainings by on -job supportive storage of Medical records training imparted. Also staff is
supervision provided on job training wherever
there is still gaps

Check supervisors make periodic

Laundry staff is skilled for rounds of department and monitor
segregating and processing of soiled 2 SI/RR that staff is working according to the
training imparted. Also staff is
and infectious linen provided on job training wherever
there is still gaps

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

The facility has established system All equipments are covered under 1. Check with AMC records/
ME D1.1 for maintenance of critical AMC including preventive 1 SI/RR Warranty documents
2. Staff is aware of the list of
Equipment maintenance equipment covered under AMC.

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Method

[Link] for breakdown &

There is system of timely corrective Maintenance record in the log book
break down maintenance of the 1 SI/RR 2. Staff is aware of contact details of
equipments the agency/person in case of
breakdown.

Operating and maintenance Up to date instructions for operation

ME D1.3 instructions are available with the and maintenance of equipments are 2 OB/SI
users of equipment readily available with staff.

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

The facility provides adequate

ME D3.1 illumination level at patient care Adequate Illumination at Kitchen 2 OB
areas
Adequate Illumination at Laundry 2 OB
Adequate Illumination at Medical 2 OB
record department
Hospital ensures unauthorised entry
The facility has provision of
ME D3.2 restriction of visitors in patient areas into dietary department is not 2 OB/SI
permitted
Hospital ensures unauthorised entry
into Laundry department is not 2 OB/SI
permitted
Hospital ensures unauthorised entry
into Medical record department is 2 OB/SI
not permitted

The facility ensures safe and Fans/ Air

Temperature control and ventilation conditioning/Heating/Exhaust/Ventil
ME D3.3 comfortable environment for in dietary department 2 SI/RR ators as per environment condition
patients and service providers and requirement

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Method
Fans/ Air
Temperature control and ventilation 2 SI/RR conditioning/Heating/Exhaust/Ventil
in Laundry ators as per environment condition
and requirement

Fans/ Air
Temperature control and ventilation conditioning/Heating/Exhaust/Ventil
in Medical record Department 2 SI/RR ators as per environment condition
and requirement

The facility has established measure

Female staff feel secure at work
ME D3.5 for safety and security of female place 2 SI
staff

Standard D4 The facility has established Programme for maintenance and upkeep of the facility

ME D4.1 Exterior of the facility building is Building is painted/whitewashed in 2 OB Dietary department, laundry and
maintained appropriately uniform colour medical record department
Interior of patient care areas are
2 OB
plastered & painted
Floors, walls, roof, roof topes, sinks
ME D4.2 Patient care areas are clean and patient care and circulation areas 2 OB All area are clean with no
hygienic dirt,grease,littering and cobwebs
are Clean
Surface of furniture and fixtures are
clean 2 OB

Toilets are clean with functional

flush and running water 2 OB

ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , 2 OB Dietary department, laundry and
maintained Cracks, chipping of plaster medical record department
Window panes , doors and other 2 OB Dietary department, laundry and
fixtures are intact medical record department
The facility has policy of removal of No condemned/Junk material in the Dietary department, laundry and
ME D4.5 2 OB
condemned junk material Diet department medical record department
No condemned/Junk material in the
Laundry 1 OB

No condemned/Junk material in the 0 OB

MRD

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Method
The facility has established Dietary department, laundry and
ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds/pests 2 OB medical record department
animal control

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

The facility has adequate

arrangement storage and supply for Availability of 24x7 running and
ME D5.1 portable water in all functional potable water 2 OB/SI Dietary and laundry department
areas

The facility ensures adequate power

ME D5.2 backup in all patient care areas as Availability of power back up 2 OB/SI For Laundry, Diet and MRD
department
per load

StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.

The facility provides diets according Hospital has defined diet schedule
ME D6.2 to nutritional requirements of the for the patients. 2 RR/SI
patients

Hospital has Special diet schedule

for the critical ill patients suffering
from Heart Disease, Hypertension, 2 RR/SI
Diabetes, Pregnant Women,
diarrhoea and renal patients

Hospital has standard procedures

Dietary department has system to
ME D6.3 for preparation, handling, storage calculate the number of diets to be 2 RR/SI
and distribution of diets, as per prepared
requirement of patients

Dietary department has procedure Time interval for procurement of

for procurement of perishable and 2 OB/SI/RR Perishable and non perishable items
non perishable items is fixed
Perishable items are stored in the 2 OB Like milk, cheese, butter, egg,
cold room or refrigerators. vegetables, and fruits
Non perishable items are kept in All the food items are stored above
racks/ storage container, in 2 OB floor level.
ventilated and rodent proof room

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Method
Food is prepared by trained staff, 2 OB/SI
ensuring standards practices
There is a procedure for the Ensure diet is supplied at defined
2 SI/RR
distribution of the diet duration.
Distribution of the food is done in
covered food trolleys 2 OB

Dietary department has system to There is designated person

check the quality of food provided to 2 RR/SI preferably nurse in Ward to check
patient the Quality of food

Dietary department has procedure

to collect and dispose of kitchen
garbage at defined interval and 2 OB/SI
place

There is practice of calculating and

maintaining buffer stock in Kitchen 2 SI/RR

Department maintained stock and

2 RR/SI
expenditure register in Kitchen
There is system to replenish raw
food material 2 RR/SI

Standard D7 The facility ensures clean linen to the patients

The facility has adequate sets of Hospital has sufficient set of linen at least 5 sets for each functional
ME D7.1 linen available per bed 2 RR/SI bed
Hospital/ department has inventory
of total linen available with category 2 RR/SI Patient, staff and bed linen
wise distribution in every area
The facility has standard procedures Linen department has system for
ME D7.3 for handling , collection, Periodic physical verification of linen 2 RR/SI To check the theft and pilferage
transportation and washing of linen inventory

Linen department has separate

trolley for distribution of clean linen 2 OB
and collection of dirty linen

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Method
Linen are transported into closed 1 OB
leak proof containers /bags
Infectious and non infectious linen
are transported into separate 2 OB/RR
containers / bags

Linen department has system of

sorting of different category of linen 2 OB/RR Soiled, infected fouled type of linen
before putting in to washing
machine

Linen department has procedure for

sluicing of soiled, infected and 2 OB/RR
fouled linen
Linen department has procedure to
keep record of daily load received 2 RR
from each department
Hospital has system/ designated
person to check quality of washed 2 RR/SI
linen

There is a fix time for collection for 2 RR/SI

dirty linen and supply of clean linen

There is a system for verifying the

quantity of linen received 2 RR/SI

There is procedure for 2 RR/SI

condemnation of linen
There is system to check pilferage of 2 RR/SI Security guards keep vigil
linen from ward

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

The facility has established job Job description is defined and

ME D11.1 description as per govt guidelines communicated to all concerned staff 2 RR Regular + contractual

Staff is aware of their role and 2 SI

responsibilities

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Method

The facility has a established There is procedure to ensure that Check for system for recording time
ME D11.2 procedure for duty roster and staff is available on duty as per duty 2 RR/SI of reporting and relieving
(Attendance register/ Biometrics
deputation to different departments roster etc)
There is designated in charge for
Laundry department 2 RR/SI

There is designated in charge for 2 RR/SI

Dietary department
There is designated in charge for 2 RR/SI
MRD department
The facility ensures the adherence
ME D11.3 to dress code as mandated by its Staff is adhere to their respective 2 OB
administration / the health dress code
department

Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

Verification of outsourced services

There is established system for There is procedure to monitor the (cleaning/
ME D12.1 contract management for out quality and adequacy of outsourced 2 SI/RR Dietary/Laundry/Security/Maintena
sourced services services on regular basis nce) provided are done by
designated in-house staff
Area of Concern - E Clinical Services
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage

Register/records are maintained as All register/records are identified

ME E8.6 per guidelines and numbered 2 RR

Diet Registers are maintained at

Kitchen 2 RR

Laundry registers are maintained at 2 RR

laundry

The facility ensures safe and Hospital has procedure for

ME E8.7 adequate storage and retrieval of collection, Compilation and 2 RR Manual/e-records
maintenance of patient's records
medical records after discharge

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Method
Medical record department has Checking the records as per checklist
system to check for completion of 2 RR for completion
records

Medical record department has As per ICD coding / indexing name,

system for ICD coding /indexing the 2 RR disease, diagnosis, physician and
records surgical procedure carried out

Submitting the reports to required

Medical record department has health authorities (Birth death
system to generate statistics for 2 RR
clinical use notification, notification of
communicable diseases etc)

Medical record department has

system to generate statistics for 2 RR Hospital information system
administrative use

Give full compliance if system is in

place for manual record
management OR
Medical record department has If the facility has e-records in place,
system for filling and safe storage of 2 RR check for
1. Password/finger print protected
records computer
2. Any restriction/firewall to protect
the individual's information from
misuse

Medical record department has

procedure for 2 RR Retention is as per state guideline
retention/Preservation of records
Medical record department has
procedure for destruction of old 0 RR
records

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Method

Give full compliance if system is in

place for manual record
management OR
Medical records department has 2 RR/SI If the facility has e-records in place,
system for retrieval of records check for
1. System is in place to define who
all are authorized to access the
patient e-records

Medical record department has

procedure for production of records 2 RR/SI In case of MLC
in Courts of law when summoned

Medical records are issued to 2 RR/SI To patient/next kin to patient

authorized personnel only

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management

ME E11.3 The facility has disaster Staff is aware of disaster plan 2 SI/RR
management plan in place
Role and responsibilities of staff in
2 SI/RR
disaster is defined
Area of Concern - F Infection Control
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

There is Provision of Periodic

ME F1.4 Medical Checkups and immunization There is procedure for immunization 2 SI/RR Hepatitis B, Tetanus Toxid etc
of staff of the staff

Periodic medical checkups of the

staff 2 SI/RR

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

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis

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Method

Hand washing facilities are provided Availability of hand washing Facility Preferably in preparation and
ME F2.1 at point of use in kitchen 2 OB cooking area along with elbow
operated tap
Availability of Running Water (Hot 2 OB/SI Ask to Open the tap. Ask Staff water
and cold) supply is regular
Check for availability/ Ask staff if the
Availability of soap with soap dish/
liquid antiseptic with dispenser 2 OB/SI supply is adequate and
uninterrupted
Prominently displayed above the
Display of Hand washing Instruction
at Point of Use 2 OB hand washing facility , preferably in
Local language

ME F2.2 Staff is trained and adhere to Adherence to 6 steps of Hand 2 OB Ask of demonstration
standard hand washing practices washing
Staff aware of when to hand wash 2 SI
Standard F3 Facility ensures standard practices and materials for Personal protection

Facility ensures adequate personal

ME F3.1 protection equipments as per Clean gloves are available for 2 OB/SI
requirements distribution of food

Availability of apron 2 OB/SI

Availability of caps 2 OB/SI
Availability of Heavy duty gloves for
laundry 1 OB/SI

Availability of gum boats for laundry 2 OB/SI

ME F3.2 Staff is adhere to standard personal No reuse of disposable gloves, caps 2 OB/SI
protection practices and aprons.

Standard F4 Facility has standard Procedures for processing of equipments and instruments

Facility ensures standard practices

and materials for decontamination Cleaning and decontamination of Ask the cleanliness and ask staff how
ME F4.1 food preparation surfaces like 2 SI/OB
and clean ing of instruments and cutting board frequent they clean it
procedures areas

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Method

Cleaning of utensils and food trolleys 2 SI/OB Check the cleanliness and how
frequent they clean it
Decontamination of heavily soiled
2 SI/OB
linen
Cleaning of washing equipments 1 SI/OB
Facility ensures standard practices
ME F4.2 and materials for disinfection and Proper cleaning of items used for 2 SI/OB
sterilization of instruments and preparation and cooking of food
equipments

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention

Layout of the department is Facility layout ensures separation of

ME F5.1 conducive for the infection control routes for clean and dirty items in 2 OB
practices kitchen
Facility layout ensures separation of
routes for clean and dirty items in 2 OB
laundry

Facility ensures availability of

ME F5.2 standard materials for cleaning and Staff is trained for spill management 2 SI/RR
disinfection of patient care areas

Cleaning of patient care area with 2 SI/RR

detergent solution

Staff is trained for preparing cleaning

solution as per standard procedure 2 SI/RR

Standard practice of mopping and 2 OB/SI Unidirectional mopping from inside

scrubbing are followed out
Any cleaning equipment leading to
Cleaning equipments like broom are
not used in patient care areas 2 OB/SI dispersion of dust particles in air
should be avoided
Facility ensures standard practices
Surface & fixtures are visibly clean
ME F5.3 followed for cleaning and with no dust or debris 2 OB
disinfection of patient care areas

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Method

Staff is trained for spill management 2 SI/RR

Floors are clean 2 OB
No stray animals in the facility/ 2 OB
Patient Care areas

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

ME F6.1 Facility Ensures segregation of Bio Availability of colour coded bins at 2 OB Adequate number. Covered. Foot
Medical Waste as per guidelines point of waste generation operated.
Availability of colour coded non 2 OB
chlorinated plastic bags
Segregation of different category of
2 OB/SI
waste as per guidelines
Display of work instructions for
segregation and handling of 2 OB Pictorial and in local language
Biomedical waste
There is no mixing of infectious and
general waste 2 OB

Facility ensures management of Availability of post exposure Ask if available. Where it is stored
ME F6.2 sharps as per guidelines prophylaxis 2 OB/SI and who is in charge of that.

Staff knows what to do in condition Staff knows what to do in case of

of needle stick injury 2 SI shape injury. Whom to report. See if
any reporting has been done

Facility ensures transportation and Disinfection of liquid waste before

ME F6.3 0 SI/OB
disposal of waste as per guidelines disposal

Daily disposal of food waste with 2 SI/OB

general waste
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for quality improvement

Check if quality circle formed and

The facility has a quality team in Quality circle has been formed in the
ME G1.1 place Auxillary 2 SI/RR functional with a designated nodal
officer for quality

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Method

Standard G2

ME G2.1 Patient Satisfaction surveys are Hospital has system to take feed 2 RR
conducted at periodic intervals back regarding quality of diet
Hospital has system to take feed
back regarding cleanliness of linen 2 RR
provided

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.

There is system daily round by

Facility has established internal matron/hospital manager/ hospital
ME G3.1 quality assurance program at superintendent/ Hospital Manager/ 2 SI/RR Check for entries in Round Register
relevant departments Matron in charge for monitoring of
services

Facility has established external Kitchen is has system of regular

ME G3.2 assurance programs at relevant external inspection by Municipal/ 2 SI/RR
departments FDA authorities
Facility has established system for Internal assessment is done at NQAS, Kayakalp, SaQushal tools are
ME G3.3 use of check lists in different periodic interval 2 RR/SI used to conduct internal assessment
departments and services

Departmental checklist are used for Staff is designated for filling and
monitoring and quality assurance 2 SI/RR monitoring of these checklists

Non-compliances are enumerated Check the non compliances are

and recorded 2 RR presented & discussed during quality
team meetings

Actions are planned to address gaps Check action plans are prepared and Randomly check the details of
ME G3.4 observed during quality assurance implemented as per internal 2 RR action, responsibility, time line and
process assessment record findings feedback mechanism

Check actions have been taken to

Planned actions are implemented Check PDCA or revalent quality close the gap. It can be in form of
ME G3.5 through Quality Improvement Cycles method is used to take corrective 2 SI/RR action taken report or Quality
(PDCA) and preventive action Improvement (PDCA) project report

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Method

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Departmental standard operating Standard operating procedure for

ME G4.1 Dietary and Laundry department has 2 RR
procedures are available been prepared and approved
Current version of SOP are available 2 OB/RR
with process owner
Standard operating procedure for
Medical record Department has 2 RR
been prepared and approved
Current version of SOP are available 2 OB/RR
with process owner
Work instruction/clinical protocols
are displayed in Dietary and Laundry 2 OB
Department
Work instruction/clinical protocols
are displayed in Medical Record 2 OB
Department
Work instructions are displayed for 2 OB
hospital cleaniness

Record Department has

Standard Operating Procedures documented procedure for indexing,
ME G4.2 adequately describes process and receiving, compiling, maintaining, 2 RR
procedures
issuing and retention of the records

Record department has documented

procedure for pest and rodent 2 RR
control

Diet department has documented

procedure for diet schedule, 2 RR
calculation of diet required in wards,
procurement of food items

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Method
Diet department has documented
procedure for preparation, 2 RR
distribution and disposal of
remaining food

Diet department has documented

procedure to check the quality of 2 RR
food provided to the patient
Diet department has documented
procedure for cleaning of kitchen 2 RR
and utensils
Diet department has documented
procedure for checkups of kitchen 2 RR
workers at defined intervals

Linen department has documented

procedure for collection, sorting,
cleaning, sluicing of the blood/bidy 2 RR
fluid stained linen and distribution of
linen

Linen department has documented

procedure for physical verification of
the linen for cleanliness or torn out 2 RR
and condemnation of linen

Linen department has documented

procedure corrective and preventive 2 RR
maintenance of laundry equipments

Security department has

documented procedure for duty 1 RR
hours, control of incoming and
outgoing items

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Method
Security department has
documented procedure for visiting 2 RR
hours in patient care area
Security department has
documented procedure for fire 1 RR
safety in hospital
Security department has
documented procedure for electrical 1 RR
safety
Security department has
documented procedure for training 0 RR
and drills of security staff

Staff is trained and aware of the Check staff is a aware of relevant

ME G4.3 2 SI/RR
standard procedures written in SOPs part of SOPs

Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

Process mapping of critical

ME G5.1 Facility maps its critical processes processes done 2 SI/RR

Facility identifies non value adding

ME G5.2 activities / waste / redundant Non value adding activities are 2 SI/RR
activities identified

Facility takes corrective action to Processes are rearranged as per

ME G5.3 improve the processes requirement 2 SI/RR

Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
Check quality policy of the facility
has been defined in consultation
Facility has defined Quality policy, Check if Quality Policy has been with hospital staff and duly
ME G6.3 which is in congruency with the 2 SI/RR approved by the head of the facility .
mission of facility defined and approved Also check Quality Policy enables
achievement of mission of the
facility and health department

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Method

Check short term valid quality

objectivities have been framed
Facility has de defined quality addressing key quality issues in each
Check if SMART Quality Objectives
ME G6.4 objectives to achieve mission and have framed 2 SI/RR department and cores services.
quality policy Check if these objectives are
Specific, Measurable, Attainable,
Relevant and Time Bound.

Mission, Values, Quality policy and Interview with staff for their
objectives are effectively Check of staff is aware of Mission , awareness. Check if Mission
ME G6.5 communicated to staff and users of Values, Quality Policy and objectives 2 SI/RR Statement, Core Values and Quality
Policy is displayed prominently in
services local language at Key Points
Verify with records that a time
bound action plan has been
Facility prepares strategic plan to Check if plan for implementing prepared to achieve quality policy
ME G6.6 achieve mission, quality policy and quality policy and objectives have 2 SI/RR and objectives in consultation with
objectives prepared hospital staff . Check if the plan has
been approved by the hospital
management
Review the records that action plan
on quality objectives being reviewed
at least onnce in month by
Facility periodically reviews the Check time bound action plan is departmnetal incharges and during
ME G6.7 progress of strategic plan towards being reviewed at regular time 2 SI/RR
mission, policy and objectives interval the qulaity team meeting. The
progress on quality objectives have
been recorded in Action Plan
tracking sheet
Standard G7 Facility seeks continually improvement by practicing Quality method and tools.

Facility uses method for quality

ME G7.1 improvement in services Basic quality improvement method 2 SI/OB PDCA & 5S

Advance quality improvement

method 0 SI/OB Six sigma, lean.

ME G7.2 Facility uses tools for quality 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used
improvement in services in each department
Standard G9 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.

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Method

Check periodic assessment of Verify with the records. A

Periodic assessment for Medication medication and patient care safety comprehensive risk asesement of all
ME G9.6 and Patient care safety risks is done 2 SI/RR clincial processes should be done
as per defined criteria. risk is done using defined checklist using pre define critera at least once
periodically in three month.

Periodic assessment for potential

1. Check that the filled checklist and
risk regarding safety and security of SaQushal assessment toolkit is used action taken report are available
ME G9.7 staff including violence against for safety audits. 2 SI/RR 2. Staff is aware of key gaps &
service providers is done as per
defined criteria closure status

Area of Concern - H Outcome

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks

ME H1.1 Facility measures productivity No of cases for which medical audit 2 RR

Indicators on monthly basis done
No of cases for which death audit is
2 RR
done
No. of bed sheet washed in a
Linen Index 2 RR month/Patient bed days in month
No. of meals provided in the
Diet Index 2 RR 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

Facility measures efficiency Proportion of maternal deaths

ME H2.1 Indicators on monthly basis audited 2 RR

Proportion of newborn deaths

audited 2 RR

Time elapsed between collection of

Cycle for laundry services 2 RR
used linen and receiving clean linen

No. of special diets (diabetic,

hypertensive, semi solid or other
Proportion of special diets 2 RR diet) in the month*100/tital no. of
diets provided in the month
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Method

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

ME H3.1 Facility measures Clinical Care & Medical Audit Score 2 RR

Safety Indicators on monthly basis
Death Audit Score 2 RR
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

Facility measures Service Quality Waiting time for getting handicap

ME H4.1 Indicators on monthly basis certificate 2 RR

Waiting time for getting death

certificate 2 RR

Patient feedback on cleanliness of 2 RR

linen

Patient feedback on quality of food 2 RR

Page 598
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Reference No. ME Statement Checkpoints Compliance Assessment Audit Support Remark

method
Area of Concern - A Service Provision
Standard A1 The facility provides Curative Services
ME A1.14 Services are available for the time Availability of services 24X7 SI/RR
period as mandated
Standard A5 The facility provides support services
ME A5.8 The facility provides mortuary Dead bodies are kept till the SI/RR
services relatives take over the bodies
Dead bodies are brought to
hospital for medico legal post SI/RR
mortem work
Unclaimed bodies are kept SI/RR
until disposal is arranged
Area of Concern - B Patient Rights
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities

The facility has uniform and user- Availability of departmental & Numbering, main department
ME B1.1 friendly signage system directional signages OB and internal sectional signage
are displayed
Restricted area signage are OB
displayed

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

language and easy to understand language and pictorial
Post mortem records of
The facility ensures access to clinical
ME B1.8 records of patients to entitled deceased are issued to OB
personnel police/next kin of deceased as
per state guideline
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of physical
Standard B2 economic, cultural or social reasons
Religious and cultural preferences of Religious and cultural
preferences of deceased and
patients and attendants are taken
ME B2.2 into consideration while delivering considerationtaken
relatives are
while
in to
handling
OB/SI
services over the body

Access to facility is provided without Availability of ramp/level At least 120 cm width, gradient
ME B2.3 any physical barrier & and friendly to ground for easy access of OB not steeper than 1:12, if ramp is
people with disabilities stretcher to mortuary/ post available
mortem room
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
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There are arrangements that Provision of curtain, screen or

ME B3.1 Adequate visual privacy is provided at Post mortem room is not in OB buffer area or any other in post
every point of care direct line of sight of general mortem room
public/ visitors

Confidentiality of patients records Confidentiality of PM records

ME B3.2 and clinical information is maintained are maintained for all MLC
cases
RR/SI

The facility ensures the behaviours of Behaviour of staff is

ME B3.3 staff is dignified and respectful, while empathetic and courteous to PI/OB
delivering the services deceased relative

The facility ensures privacy and

confidentiality to every patient,
ME B3.4 especially of those conditions having Privacy
HIV and
and confidentiality of
suicidal cases RR/SI
social stigma, and also safeguards
vulnerable groups
Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms

ME C1.1 Departments have adequate space as Adequate

Post
space to conduct the
mortem and OB
per patient or work load accommodate dead bodies

ME C1.2 Patient amenities are provide as per Availability

arrangement
of adequate seating
in waiting area OB
patient load

Availability of Drinking water OB

Availability of functional toilets

Departments have layout and Mortuary has reception and Waiting area has space of 17.5
ME C1.3 demarcated areas as per functions waiting area as per OB sq m along with toilet and
requirement drinking water facility
Mortuary has morgue freezer
for preservation of bodies as OB
per requirement

Mortuary has post mortem Post mortem room has area of

room as per requirement OB 17.5 sq m for 101-300 beds and
21 sq m for 301-500 beds
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Mortuary and post mortem has Ancillary area consist of

Ancillary area as per OB Consultant room, mortuary
requirement supervisor room and stores

Cold room and autopsy room OB Cold room should lead to

are interconnected entrance area into autopsy room

Access way connected from As protection in wet weather

hospital to mortuary is covered OB and as screen from adjoining
area
The facility has adequate circulation Corridors of Mortuary area are
ME C1.4 area and open spaces according to wide enough to allow passage OB Not less than 8 ft
need and local law of trolleys
The facility has infrastructure for Availability of telephone and
ME C1.5 intramural and extramural Intercom Services OB
communication

ME C1.6 Service counters are available as per Availability of deep freezer for OB
patient load storage as per load

The facility and departments are

planned to ensure structure follows Mortuary has functional
ME C1.7 the function/processes (Structure linkage with hospital OB
commensurate with the function of Emergency, OT and IPD etc.
the hospital)
Standard C2 The facility ensures the physical safety of the infrastructure.

Check for fixtures and furniture

The facility ensures the seismic safety Non structural components are like cupboards, cabinets, and
ME C2.1 of the infrastructure properly secured OB heavy equipments , hanging
objects are properly fastened
and secured

The facility ensures safety of Mortuary building does not

ME C2.3 electrical establishment have temporary connections OB
and loosely hanging wires

Adequate electrical socket

provided for safe and smooth OB
operation of morgue freezer
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Physical condition of buildings are Floors of the Mortuary are

ME C2.4 safe for providing patient care thick, durable and can be easily OB
cleaned

Window have wire meshwork OB

and intact window panes

Floors of the Mortuary are non OB

slippery and even
Standard C3 The facility has established Programme for fire safety and other disaster

ME C3.2 The facility has adequate fire fighting AFire

,
Extinguisher that is Class
Class C type or ABC type are OB
Equipment installed in mortuary

Check the expiry date for fire

extinguishers are displayed on
each extinguisher as well as OB/RR
due date for next refilling is
clearly mentioned

The facility has a system of periodic Check for staff competencies

ME C3.3 training of staff and conducts mock for operating fire extinguisher SI/RR
drills regularly for fire and other and what to do in case of fire
disaster situation
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load

The facility has adequate specialist Availability of specialist/MO to

ME C4.1 doctors as per service provision conduct autopsy as per state OB/RR
norms
The facility has adequate Availability of post mortem
ME C4.4 technicians/paramedics as per technician/assistant as per SI/RR
requirement state guideline

ME C4.5 The facility has adequate support / Availability of sweeper in SI/RR

general staff Mortuary
Availability of security staff in SI/RR
mortuary
Standard C5 The facility provides drugs and consumables required for assured services.
Thread, needle, cotton wool,
ME C5.2 The departments have adequate Repairing Material OB/RR wool waste, clothes, malleable
consumables at point of use wire, polythene bag, gloves,
mask and apron
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Plastic bins OB/RR for fixing specimens

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

Weighting Mechanise. Platform

Availability of equipment & Availability of functional scale Weighting Whole body,
ME C6.1 instruments for examination & Equipment &Instruments for OB Balance to weight 100gm to 10
monitoring of patients examination & Monitoring Kg, Balance to weight 0.2 gm to
10gm

Availability of equipment & Skull Cutter, Organ Knife blade,

instruments for treatment Availability of Cutting cartilage Knife, Caltin solid, Rib
ME C6.2 procedures, being undertaken in the Instruments trays OB cutter, Brain knife, resection
facility knife, Scissor (of varying sizes),
forceps (of varying sizes)

ME C6.5 Availability of Equipment for Storage Availability of Cabinets for

storage of dead bodies OB Refrigerated body storage room,
Instrument trolley

ME C6.6 Availability of functional equipment Availability of equipments for OB Buckets for mopping, mops,
and instruments for support services cleaning duster, waste trolley, Deck brush

Departments have patient furniture Availability of Post mortem

ME C6.7 and fixtures as per load and service table OB
provision

Availability of Fixtures OB Electrical fixture for storage

cabinet
cupboard, counter for delivery
Availability of furniture OB of reports, table for preparation
of reports chair.

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

The Staff is provided training as per Infection control & prevention Bio medical Waste Management
ME C7.9 defined core competencies and training SI/RR including Hand Hygiene
training plan
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Check supervisors make periodic

There is established procedure for rounds of department and
utilization of skills gained thought Staff is skilled for preservation monitor that staff is working
ME C7.10 trainings by on -job supportive of dead bodies in the mortuary SI/RR according to the training
supervision imparted. Also staff is provided
on job training wherever there is
still gaps

Check supervisors make periodic

rounds of department and
Staff is skilled for maintaining monitor that staff is working
post mortem records SI/RR according to the training
imparted. Also staff is provided
on job training wherever there is
still gaps

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

All equipments are covered 1. Check with AMC records/

The facility has established system Warranty documents
ME D1.1 for maintenance of critical Equipment under AMC including
preventive maintenance
SI/RR 2. Staff is aware of the list of
equipment covered under AMC.

[Link] for breakdown &

There is system of timely Maintenance record in the log
corrective break down SI/RR book
maintenance of the 2. Staff is aware of contact
equipments details of the agency/person in
case of breakdown.

The facility has established procedure All the monitoring equipments

ME D1.2 for internal and external calibration are calibrated OB/ RR
of measuring Equipment

Operating and maintenance Operating instructions for

ME D1.3 instructions are available with the critical equipments are OB/SI
users of equipment available
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas
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The facility has established procedure Department maintained stock Check record of drug received,
ME D2.5 for inventory management register RR/SI issued and balance stock in hand
techniques and are regularly updated

There is process for storage of Temperature of refrigerators Check for refrigerator

ME D2.7 vaccines and other drugs, requiring are kept as per storage OB/RR temperature charts. Charts are
controlled temperature requirement and records twice maintained and updated twice a
a daily and are maintained day

Staff is aware of Hold over time SI/RR

of cold storage equipments

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
The facility provides adequate Adequate illumination at post
ME D3.1 illumination level at patient care mortem table OB
areas
Adequate illumination at OB
morgue

The facility has provision of Hospital ensures unauthorised

ME D3.2 restriction of visitors in patient areas entry into mortuary is not
permitted
OB/SI

The facility ensures safe and Fans/ Air

ME D3.3 comfortable environment for Temperature control and OB/RR conditioning/Heating/Exhaust/V
patients and service providers ventilation in Mortuary entilators as per environment
condition and requirement

The facility has security system in Hospital has sound security

ME D3.4 place at patient care areas system to manage OB
overcrowding in Mortuary

ME D3.5 The facility has established measure Female staff feel secure at SI
for safety and security of female staff work place

Standard D4 The facility has established Programme for maintenance and upkeep of the facility

Exterior of the facility building is Building is

ME D4.1 maintained appropriately painted/whitewashed in OB
uniform colour
Interior of patient care areas OB
are plastered & painted
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Patient care areas are clean and Floors, walls, roof, roof topes, All area are clean with no
ME D4.2 hygienic sinks patient care and OB dirt,grease,littering and cobwebs
circulation areas are Clean
Surface of furniture and OB
fixtures are clean
Toilets are clean with
functional flush and running OB
water

ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , OB

maintained Cracks, chipping of plaster
Window panes , doors and OB
other fixtures are intact
Post-mortem table is intact OB
and with out rust

ME D4.5 The facility has policy of removal of No condemned/Junk material OB

condemned junk material stored in the mortuary

The facility has established

ME D4.6 procedures for pest, rodent and No stray animal/rodent/birds OB
animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

The facility has adequate Availability of water in sinks,

ME D5.1 arrangement storage and supply for Availability
potable
of 24x7 running and
water OB/SI washbasin and post mortem
table should be fitted with water
portable water in all functional areas hose

The facility ensures adequate power Availability of power back in

ME D5.2 backup in all patient care areas as per mortuary OB/SI
load
Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.

The facility has established job Job description is defined and

ME D11.1 description as per govt guidelines communicated to all RR Regular + contractual
concerned staff
Staff is aware of their role and SI
responsibilities

The facility has a established There is procedure to ensure Check for system for recording
ME D11.2 procedure for duty roster and that staff is available on duty as RR/SI time of reporting and relieving
deputation to different departments per duty roster (Attendance register/ Biometrics
etc)
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There is designated in charge SI

for department
The facility ensures the adherence to Doctor and support staff
ME D11.3 dress code as mandated by its adhere to their respective OB
administration / the health dress code
department
Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations

There is procedure to monitor Verification of outsourced

There is established system for the quality and adequacy of services (cleaning/
ME D12.1 contract management for out outsourced services on regular SI/RR Dietary/Laundry/Security/Maint
sourced services basis enance) provided are done by
designated in-house staff
Area of Concern - E Clinical Services
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
The facility ensures safe and Department has process for
ME E8.7 adequate storage and retrieval of storage and retrieval of RR/SI MLC case reports etc.
medical records Medico-legal record
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E11.3 The facility has disaster management Staff is aware of disaster plan SI/RR
plan in place
Role and responsibilities of SI/RR
staff in disaster is defined
Standard E16 The facility has defined and established procedures for the management of death & bodies of deceased patients

Death of admitted patient is Facility has a standard

ME E16.1 adequately recorded and procedure to decent SI/RR
communicated communicate death to
relatives

The facility has standard procedures The body of deceased is

ME E16.2 for handling the death in the hospital dignity with respect and
handled SI/RR/OB

Socio-cultural beliefs of patient

's family are identified and SI/RR/OB
respected

Unclaimed bodies are handled/

handed over, buried or SI/RR All the unclaimed bodies are
cremated as per applicable handled with respect and dignity
laws and regulation
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The facility has standard procedures Mortuary has system for Main categorization in Non
for conducting post-mortem, its medico legal and medico legal
ME E16.3 recording and meeting its obligation categorize
before
the dead bodies
preservation.
SI/RR which is further divided into
under the law Identified and Unknown

Check Mortuary register which

contain details: Identification
number, Name, Sex, age of
deceased, date and time of
death, identification mark of
deceased and finger impression,
details of near relative, weather
autopsy is done or not, if done
Mortuary technician to then date and time of autopsy,
maintain full records of body name of autopsy surgeon, date
brought to mortuary and time when body is placed in
cold storage, length of body and
breadth across should, list of
valuables which have been
removed from body, signature
of technician, date and time of
when body is removed & Name
of relative/police collecting
body.

Identification tag should be of

Mortuary has system to plastic water proof type and
provide identification tag/wrist carry information on full
band for each stored dead RR/OB name,address,age,sex,
body registration number, date and
time of death and when body
kept for storage

Mortuary has system for

preparation of body before RR/SI
cold storage

Each cold storage door has Check identification ticket is

holder for identification ticket RR/OB available on storage cabin
containing dead body
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Name of deceased is written on

board on wall of the room RR/OB
which list each cold storage
compartment

Temperature should not be

allowed to fall below 0oC for
Cold storage room has system short duration preservation
to maintain temperature of RR/OB/SI while to preserve the body for
cabinets long time it must be deep frozen
so -20oC temp must be kept for
one compartment

Hospital has system to intimate

mortuary staff before sending SI/RR
body to mortuary

All bodies sent to mortuary is

accompanied with copy of SI/RR
death certificate issued by
hospital

Death Certificate and label is Check death certificate /dead

marked MLC in bold if medico RR/OB body.
legal cases

Mortuary/Hospital has The upper part of the body is

standard label fixed to winding RR/OB taken out of mortuary cold
cloth over upper part of body storage room i.e. head for
identification

Mortuary has system for

storage of unclaimed body for SI/RR
fixed duration as per state
guideline

Mortuary has system for

disposal of unclaimed bodies as SI/RR
per state guideline
Area of Concern - F Infection Control
Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection

ME F1.4 There is Provision of Periodic Medical There is procedure for SI/RR Hepatitis B, Tetanus Toxic etc
Check-up and immunization of staff immunization of the staff
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Periodic medical checkups of SI/RR

the staff
The facility has established Hand washing and infection
ME F1.5 procedures for regular monitoring of Regular
control
monitoring of infection
practices SI/RR control audits done at periodic
infection control practices intervals
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis

Hand washing facilities are provided Availability of hand washing Check for availability of wash
ME F2.1 at point of use Facility at Point of Use OB basin and elbow operated tap
near the point of use

Availability of running Water OB/SI Ask to Open the tap. Ask Staff
water supply is regular
Availability of antiseptic soap Check for availability/ Ask staff if
with soap dish/ liquid OB/SI the supply is adequate and
antiseptic with dispenser. uninterrupted
Availability of Alcohol based OB/SI Check for availability/ Ask staff
Hand rub for regular supply.

Display of Hand washing Prominently displayed above the

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

The facility staff is trained in hand

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

Staff aware of when to hand SI

wash
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate Clean gloves are available at
ME F3.1 personal protection Equipment as point of use OB/SI
per requirements
Availability of Masks OB/SI

ME F3.2 The facility staff adheres to standard No reuse of disposable gloves, OB/SI
personal protection practices Masks, caps and aprons.

Compliance to correct method

of wearing and removing the SI Gloves, Masks, Caps and Aprons
PPE
Standard F4 The facility has standard procedures for processing of equipment and instruments
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The facility ensures standard Ask stff about how they

practices and materials for Decontamination of mortuary decontaminate the mortuary
ME F4.1 decontamination and cleaning of table SI/OB table
instruments and procedures areas (Wiping with 0.5% Chlorine
solution)

Ask staff how they

Decontamination of instrument decontaminate the instruments
after use SI/OB (Soaking in 0.5% Chlorine
Solution, Wiping with 0.5%
Chlorine Solution or 70% Alcohol
as applicable

Contact time for SI/OB 10 minutes

decontamination is adequate

Cleaning of instruments after Cleaning is done with detergent

decontamination SI/OB and running water after
decontamination
Staff know how to make SI/OB
chlorine solution
Sterilization of mortuary SI/OB
equipment
The facility ensures standard High level disinfection by
ME F4.2 practices and materials for boiling or chemical done as SI/OB
disinfection and sterilization of per protocol at mortuary
instruments and equipment
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Layout of the department is Facility layout ensures
ME F5.1 conducive for the infection control separation of general traffic OB
practices from patient traffic

The facility ensures availability of Availability of disinfectant as Chlorine solution, Gluteraldehye,

ME F5.2 standard materials for cleaning and per requirement OB/SI carbolic acid
disinfection of patient care areas

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

per requirement disinfectant detergent solution
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The facility ensures standard

ME F5.3 practices are followed for the Staff is trained for spill SI/RR
cleaning and disinfection of patient management
care areas
Cleaning of patient care area SI/RR
with detergent solution
Staff is trained for preparing
cleaning solution as per SI/RR
standard procedure

Standard practice of mopping OB/SI Unidirectional mopping from

and scrubbing are followed inside out

Cleaning equipments like Any cleaning equipment leading

broom are not used in patient OB/SI to dispersion of dust particles in
care areas air should be avoided

Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

The facility Ensures segregation of

Bio Medical Waste as per guidelines Availability of colour coded Adequate number. Covered.
ME F6.1 and 'on-site' management of waste is generation of waste
bins at point OB Foot operated.
carried out as per guidelines

Availability of colour coded OB

non chlorinated plastic bags

Human Anatomical waste, Items

contaminated with blood, body
Segregation of Anatomical and fluids,dressings, plaster casts,
solied waste in Yellow Bin OB/SI cotton swabs and bags
containing residual or discarded
blood and blood components.
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Items such as tubing, bottles,

intravenous tubes and sets,
Segregation of infected plastic catheters, urine bags, syringes
waste in red bin OB (without needles and fixed
needle syringes) and
vaccutainers with their needles
cut) and gloves

Display of work instructions for

segregation and handling of OB Pictorial and in local language
Biomedical waste
There is no mixing of infectious
and general waste

ME F6.2 The facility ensures management of Availability of functional needle OB See if it has been used or just
sharps as per guidelines cutters lying idle.

Should be available nears the

point of [Link],
Seggregation of sharps waste syringes with fixed needles,
including Metals in white needles from needle tip cutter
(translucent) Puncture proof, OB or burner, scalpels, blades, or
Leak proof, tamper proof any other contaminated sharp
containers object that may cause puncture
and cuts. This includes both
used, discarded and
contaminated metal sharps

Availability of post exposure Ask if available. Where it is

prophylaxis SI/OB stored and who is in charge of
that.

Staff knows what to do in case of

Staff knows what to do in SI shape injury. Whom to report.
condition of needle stick injury See if any reporting has been
done

Contaminated and broken

Glass are disposed in puncture Vials, slides and other broken
proof and leak proof box/ OB infected glass
container with Blue colour
marking
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The facility ensures transportation

ME F6.3 and disposal of waste as per Check bins are not overfilled SI/OB
guidelines
Disinfection of liquid waste SI/OB
before disposal
Transportation of bio medical
waste is done in close
container/trolley
Look for:
1. Spill area evacuation
2. Removal of Jewellery
3. Wear PPE
4. Use of flashlight to lacate
mercury beads
5. Use syringe without a
needle/eyedropper and sticky
tape to suck the beads
6. Collection of beads in leak-
proof bag or container
Staff is aware of mercury spill 7. Sprinkle sulphur or zinc
management SI/RR powder to remove any
remaining mercury
8. All the mercury spill surfaces
should be decontaminated with
10% sodium thiosulfate solution
9. All the bags or containers
containing items contaminated
with mercury should be marked
as “Hazardous Waste, Handle
with Care”
10. Collected mercury waste
should be handed over to the
CBMWTF
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for quality improvement

The facility has a quality team in Quality circle has been formed Check if quality circle formed
ME G1.1 place in the Mortuary SI/RR and functional with a designated
nodal officer for quality

Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.
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There is system daily round by

The facility has established internal Hospital superintendent/ Check for entries in Round
ME G3.1 quality assurance programme in key Hospital Manager/ Matron in SI/RR Register
departments charge for monitoring of
services

Facility has established system for Internal assessment is done at NQAS, Kayakalp, SaQushal tools
ME G3.3 use of check lists in different periodic interval RR/SI are used to conduct internal
departments and services assessment
Departmental checklist are Staff is designated for filling and
used for monitoring and quality SI/RR monitoring of these checklists
assurance

Non-compliances are RR Check the non compliances are

enumerated and recorded presented & discussed during
quality team meetings

Actions are planned to address gaps Check action plans are Randomly check the details of
ME G3.4 observed during quality assurance prepared and implemented as RR action, responsibility, time line
process per internal assessment record and feedback mechanism
findings

Check PDCA or revalent quality Check actions have been taken

Planned actions are implemented method is used to take to close the gap. It can be in
ME G3.5 through Quality Improvement Cycles corrective and preventive SI/RR form of action taken report or
(PDCA) action Quality Improvement (PDCA)
project report
Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Departmental standard operating Standard operating procedure

ME G4.1 procedures are available for department has been RR
prepared and approved

Current version of SOP are OB/RR

available with process owner

Work instructions are Work Instruction for Dead body

displayed OB storage, receiving and issue of
dead body

Standard Operating Procedures Department has documented

ME G4.2 adequately describes process and procedure for death in ward RR
procedures and emergency
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Department has documented

procedure for receiving, RR
storage and tagging of the
body in mortuary

Department has documented

procedure for temperature
maintenance and its corrective RR
& preventive maintenance in
cold store

Department has documented

procedure for maintenance of RR
records

Department has documented

procedure sending the bodies RR
for autopsy

Department has documented

procedure for hand over the RR
body to deceased relatives

Department has documented

procedure for issuing the RR
records to police and patient
relatives

Department has documented

procedure for storage and send RR
the viscera/tissue for further
investigation

Department has documented

procedure for cleaning and RR
upkeep of mortuary and post
mortem room

ME G4.3 Staff is trained and aware of the Check staff is a aware of SI/RR
procedures written in SOPs relevant part of SOPs
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Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
ME G5.1 The facility maps its critical processes Process mapping of critical
processes done SI/RR

The facility identifies non value

ME G5.2 adding activities / waste / redundant Non value adding activities are
identified SI/RR
activities

ME G5.3 The facility takes corrective action to Processes are rearranged as SI/RR
improve the processes per requirement
Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Check quality policy of the

facility has been defined in
Facility has defined Quality policy, Check if Quality Policy has consultation with hospital staff
ME G6.3 which is in congruency with the been defined and approved SI/RR and duly approved by the head
mission of facility of the facility . Also check
Quality Policy enables
achievement of mission of the
facility and health department

Check short term valid quality

objectivities have been framed
Facility has de defined quality addressing key quality issues in
ME G6.4 objectives to achieve mission and Check if SMART Quality SI/RR each department and cores
quality policy Objectives have framed services. Check if these
objectives are Specific,
Measurable, Attainable,
Relevant and Time Bound.

Interview with staff for their

Mission, Values, Quality policy and Check of staff is aware of awareness. Check if Mission
ME G6.5 objectives are effectively Mission , Values, Quality Policy SI/RR Statement, Core Values and
communicated to staff and users of and objectives Quality Policy is displayed
services prominently in local language at
Key Points
Checklist - 17 Mortuary Version-NHSRC/3.0

Verify with records that a time

bound action plan has been
Facility prepares strategic plan to Check if plan for implementing prepared to achieve quality
ME G6.6 achieve mission, quality policy and quality policy and objectives SI/RR policy and objectives in
objectives have prepared consultation with hospital staff .
Check if the plan has been
approved by the hospital
management

Review the records that action

plan on quality objectives being
reviewed at least onnce in
Facility periodically reviews the Check time bound action plan month by departmnetal
ME G6.7 progress of strategic plan towards is being reviewed at regular SI/RR incharges and during the qulaity
mission, policy and objectives time interval team meeting. The progress on
quality objectives have been
recorded in Action Plan tracking
sheet

Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 The facility uses method for quality Basic quality improvement SI/OB PDCA & 5S
improvement in services method
Standard G9 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.

Verify with the records. A

Periodic assessment for Medication Check periodic assessment of comprehensive risk asesement
ME G9.6 and Patient care safety risks is done safety risk is done using SI/RR of all processes should be done
as per defined criteria. defined checklist periodically using pre define critera at least
once in three month.

Area of Concern - H Outcomes

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Proportion of non MLC cases RR
Indicators on monthly basis
Occupancy rate of cold storage RR
for dead bodies
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators Mean storage time for dead RR
on monthly basis body in cold storage
Down time Cold storage RR
equipments
Checklist - 17 Mortuary Version-NHSRC/3.0

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures Service Quality Waiting time for carrying out RR
Indicators on monthly basis post mortem
Waiting time for getting post RR
mortem report in MLC cases
 Complianc
Standard Measurable elements Checkpoints es Assessment Mean of verification Remarks
Area of Concern - A Service Provision
Standard A1 The facility Provides Curative Services

Services are available for the time period Dialysis services are available as per Check for timing of Dialysis centre as per
MEA1.14 as mandated time mandate 2 RR/OB/SI MOU/As per State mandate

ME A1.19 The facility provides Dialysis services Availability of haemodialysis services 2 RR/OB/SI

1. Hypotension
2. Dialyzer reactions (both anaphylactic reaction
and non-specific reaction)
3. Haemolysis
4. Air embolism
Availability of services to manage 5. Seizures
complications during dialysis process 1 RR/OB/SI 6. Chest pain, MI
7. Arrhythmias
8. Sudden cardiac arrest
9. Nausea, Vomiting
10. Chills, Rigors, Fevers

Availability of Nutritional Counselling Counselling may be provided by

Services 2 RR/OB/SI dietician/nephrologist/MO
Standard A3 The facility Provides diagnostic Services
ME A3.1 The facility provides Radiology Services Availability of Portable X ray Services 0 OB/SI Within centre or linkage with the main hospital

Availability of USG services 2 OB/SI Within centre or linkage with the main hospital

Within centre or linkage with the main hospital

ME A3.2 The facility Provides Laboratory Services Availability of lab services 2 OB/SI for:
Heamogram, Iron study, LFT, KFT, Hb1Ac, Viral
Marker, Vit D
Availability of Point of care diagnostic
devices 1 Hb, Blood Sugar, Blood Group, HIV, HbsAg(HBV)

The facility provides other diagnostic Within centre and staff should be trained to
ME A3.3 Functional ECG Services are available 2 OB/SI
services, as mandated operate ECG machine
Standard A4 The facility provides services as mandated in national Health Programs/ State Scheme

Availability of Haemodialysis services Economically weaker Section(EWS) certifcate

The facility provide services as per Pradhan issued by appropriate authority(District
ME A4.13 Mantri National Dialysis Programme free of cost for BPL & Economically 0 RR/PI/SI Magistrate/Revenue Ofificer not below the rank
Weaker Section(EWS) patients of Tahsildar/Sub Divisional Officer )
Area of Concern - B Patient Rights
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
The facility has uniform and user-friendly Availability of departmental and Numbering, main department and internal
ME B1.1 signage system directional signages 2 OB sectional signages
 [Link] signages at the entry & restricted
area within the dialysis centre
Signage for restricted area and safety 2. Safety Hazard and Caution
2
hazard are displayed signs, for e.g. hazards from electrical shock,
inflammables etc. shall be displayed at
appropriate places

ME B1.2 The facility displays the services and Services available and not available in 2 OB e.g.. Display of Haemodialysis for HIV or
entitlements available in its departments the dialysis centre are displayed Hepatitis B/C patients

Name of the Nephrologist/in charge Contact details & days of visits of

with registration number are 2 OB Nephrologist/in charge, Quality Managers are
displayed displayed
Blood Banks, Fire Department, Police,
Important numbers are displayed 2 OB
Ambulance Services, ICU and OT

User charges are displayed and User Charges for dialysis services are User charges(if any) are displayed at prominent
ME B1.4 2 OB places including display of free dialysis services
communicated to patients effectively displayed for BPL/EWS patients

IEC to prevent infection for patient with

Patients & visitors are sensitised and IEC materials are displayed in waiting catheters & patient with fistulas or grafts,
ME B1.5 educated through appropriate IEC / BCC 2 OB dietary advice are displayed
approaches area IEC for care
givers to manage day to day management

Relevant IEC are displayed inside Check for IEC related to fluid intake, Know
dialysis unit 2 OB about dry weight, Patient guide for access care
are displayed inside the unit

ME B1.6 Information is available in local language Signages and information are 2 OB At least in two languages with one being local
and easy to understand available in local language
Check dialysis card/Logbook is provided to the
ME B1.8 The facility ensures access to clinical Dialysis card/Logbook is provided to 2 RR/SI/OB patient and records are updated after each
records of patients to entitled personnel all patient session
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, economic, cultural or social
reasons.
Availability of female
ME B2.1 Services are provided in manner that are attendant/female staff, if a male staff 2 OB/SI Ask the staff about the adopted procedure
sensitive to gender examine, treat or manage a female
patient

Access to facility is provided without any Availability of Wheel chair and

ME B2.3 physical barrier & friendly to specially able stretcher for easy Access to the 2 OB Check availability of both wheel chair and
stretcher for the dialysis patients
people Dialysis unit
Availability of ramp with appropriate 2 A gradient of 1:8
gradient
At least one disabled-friendly toilet readily
Availability of disabled friendly toilets 0 OB/SI
accessible to the Dialysis unit
There is no discrimination on the
There is no discrimination on basis of Look for any discrepancies from the previous
ME B2.4 basis of social and economic status of 2 OB/PI
social & economic status of patients. patient records receiving the services
the patients
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
 Adequate visual privacy is provided at
ME B3.1 every point of care Availability of screen/curtains 2 OB Check for screen/curtains between the beds

Patient Records are kept at secure

Confidentiality of patients records and Confidentiality, security and integrity of records
ME B3.2 clinical information is maintained place beyond access to general 2 OB/SI shall be ensured at all times
staff/visitors
The facility ensures the behaviours of staff
ME B3.3 is dignified and respectful, while delivering Behaviour of staff is empathetic and 2 PI/OB
courteous
the services

The facility ensures privacy and HIV status of the patient is coded and not
confidentiality to every patient, especially Privacy and confidentiality of HIV displayed publicly
ME B3.4 of those conditions having social stigma, cases 2 OB/SI Internal policy to be
and also safeguards vulnerable groups checked(for maintenance of record )

Standard B4 The facility has defined and established procedures for informing and involving required.
patient and their families about treatment and obtaining informed consent wherever it is

The consent includes general condition of the

patient, treatment options, adverse reactions,
There is established procedures for taking Informed consent are obtained from consequence of missing dialysis, risk and
ME B4.1 informed consent before treatment and the patient/ next of kin/ legal 2 RR/SI complications
procedures guardian as and when required Frequency of consent: before every session
/every procedure

ME B4.2 Patient is informed about his/her rights Patients' rights and responsibilities 2 PI/OB Patients are aware of their rights and
and responsibilities. are displayed responsibilities
Staff are aware of Patients' rights and Staff is aware of patients' rights and
ME B4.3 2 SI Randomly choose any staff
responsibilities responsibilities

Dialysis Unit has a system in place to

Information about the treatment is shared communicate with patient/ their Ask the family members whether they have
ME B4.4 with patients or attendants, regularly family member regarding the nature 2 PI/SI been communicated and involved in the
treatment plan and progress
and seriousness of the illness

ME B4.4 The facility has defined and established Check availability of complaint box 2 OB/RR/SI Check when it was last open, check for
grievance redressal system in place complaint received and action taken
Availability of display of process for Check for display regarding mechanism of
grievance re addressal and whom to 2 OB/SI grievance redressal
contact is displayed
Standard B5 The facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.

All Drugs and consumables as per

The facility ensures that drugs prescribed MoU with the private Notified patients are the other poor patients
ME B5.2 are available at Pharmacy and wards partner/hospital EML are free for 2 PI/RR validated by the facility in charge of the hospital
BPL/EWS and other notified patients

It is ensured that facilities for the Check that BPL/EWS and other
notified patient has not incurred For APL Patients cost of diagnostics is included
ME B5.3 prescribed investigations are available at 2 PI/RR
expenditure on diagnostics from in the package rate
the facility
outside
 The facility provide free of cost treatment
ME B5.4 to Below poverty line patients without Dialysis services are free for BPL and 2 PI/RR/SI
other notified patients
administrative hassles

APL Patients are charged as per the The rates are inclusive of drugs, consumables
MoU rates 2 PI/RR/SI and diagnostics (Give full compliance if it is free
for all, or not applicable for the centre)

The facility ensure implementation of Dialysis sessions of BPL families Check for any duplication of payments received
ME B5.6 health insurance schemes as per registered under PMJAY/Equivalent 1 RR/SI under Pradhan Mantri National Dialysis
National /state scheme. schemes are funded by respective programme and PMJAY/equivalent schemes
scheme up to its maximum coverage

Standard B6 The facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities

Ethical norms and code of conduct for Ethical norms for Medical officers,
ME B6.1 medical and paramedical staff have been Staff nurses and technician are 2 SI/RR Ask staff about the ethical norms
established. defined and staff are aware about it

The facility has an established procedure Check that no promotional posters/activities

ME B6.3 for entertaining representatives of drug No medical representatives are 2 OB/RR/SI are encouraged for drugs and diagnostics.
allowed in the dialysis unit
companies and suppliers Ask staff about the current practice

There is an established procedure for Check list of agencies with whom the data is to
sharing of hospital/patient data with Check dialysis unit has defined be routinely shared.
ME B6.5 2 RR/SI For any other agency a formal permission is
individuals and external agencies including protocols for data sharing
non governmental organization. sought from competent authority before
sharing the data including press

Patients relatives are informed clearly

ME B6.6 There is an established procedure for ‘end- about the deterioration in health 2 SI/RR/PI
of-life’ care
condition of Patients
There is established procedure for Check the records for transfer of the patients to
transfer of patients to other facilities 2 SI/RR/PI Specialist Hospital/Tertiary Hospital /Palliative
in end stage of life Care Centres

There is an established procedure for Declaration is taken from the patient

patients who wish to leave hospital against
ME B 6.7 medical advice or refuse to receive specific seeking early termination of dialysis 2 RR/SI Check for filled declaration form
treatment and the consequences are explained

Check for policy defines

List of certificates can be issued by the dialysis
There is an established procedure to issue
ME B 6.9 of medical certificates and other Check hospital has documented 0 RR/SI centre, Who can issue certificates, Formats shall
certificates. policy for issuing medical certificates used for different certificates, Record keeping
of issued certificate, Procedures for issuing
duplicate certificates
 (a) Check the adequacy of the framework. It
address the ethical issues and decision making
Facility has established a framework for in clinical care
identifying, receiving, and resolving ethical Check facility has defined its ethical (b) Check facility's ethical management
ME B6.12 dillemas' in a time-bound manner through issues management framework 0 SI/RR framework address issues like admission,
ethical committee discharge, transfer, disclosure of information or
any professional conflict which may not be in
patient's best interest

Facility's supporting human subject research

activities/ publishing the scientific papers/
supporting medical students in thesis writing/
running any course where patient data is
collected and used for above mentioned
actvities - an ethical committee is constititued
and approval are taken before publication.
Check facility has ethical committee or
or person designated to address the Facility may collaborate with the institutions
ethical issues confronted by medical 0 SI/RR where there are ethical committee is present
professionals while delivering the and appropriate approvals, guided by applicable
services laws and regulations is taken.
or
the facilties where they are not involved in
research actvities, to address the ethical
dielamma's a person or group is appointed to
address the dilemmas effectively within legal
parameter

Check when the list was last updated. Engage

Check the list of ethical issues is with the available medical professionals to
0 RR/SI check what type of ethical dilemmas they are
available and regularly updated
facing while performing their job & how they
are dealing with dielmma's.

Check the facility has defined

mechanism identification and
reporting of the ethical issues/ 2 SI/RR Check staff is aware of reporting mechanism
dilemmas confronted during services
delivery

Check regular review of identified

and reported ethical issue is done by Check the timely resolution of the identified
0 RR/SI
appointed personnel /group/ and reported ethical issues is done
committee
 Check all the decisions related to
ethical dilemma's are communicated 0 SI Check information regarding ethical dilemma's
& its handling is also given to new joinee's
to all concerned
Area of Concern C: Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms.
Availability of adequate space for
ME C1.1 Departments have adequate space as per Dialysis room/area/Machine area 0 OB At least 120 square feet per machine
patient or work load.

Availability of dedicated Consultation

room 0 OB

Availability of dedicated Water 1 OB/RR The area have booster pumps, particle filters,
treatment area water softener, carbon filter and RO system

Water treatment area have sufficient

space for soft curving of tubings to 1 OB
prevent right angle bends

Availability of Dual water treatment 2 OB Each water treatment system includes reverse
system osmosis membrane

Availability of administrative area 0 OB This area includes registration, medical records

and billing / insurance

Check the followings:

1. A work bench with sink having side board
& drainage.
[Link] work bench is supplied with treated as
Availability of dedicated Dialyzer 2 OB well as untreated water which are separately
Reprocessing room/area
marked.
[Link] sinks for the work bench
[Link] space for at
least two persons working simultaneously.

[Link] the dry storage area is capable of

storing 3months supply of dialyzers, tubings,
Availability of dedicated Storage area hemodialysis concentrate solutions, IV fluids. It
(both dry & wet) 1 OB should also have space for stationery, linen etc.
[Link] dialyzers & tubings are being
stored in the wet storage

The centre shall have waiting area with

ME C1.2 Patient amenities are provided as per Availability of seating arrangement in 0 OB sufficient seating arrangement for patients and
patient load. Waiting area and Drinking water visitors
Availability of functional Toilets
2 OB
separate for male & female

ME C1.3 Departments have layout and demarcated Demarcated stretcher & trolley bay 2 OB Check the corridor is wide enough for easy
areas as per functions. movement of stretcher/trolley
 Location of nursing station should be such that
Dedicated nursing station 0 OB the patients are under direct and easy
observation
Demarcated changing area for staffs 0 OB Separate male & female changing room
with adequate privacy
Demarcated area for Infectious
2 OB
patients (HBV,HCV,HIV etc)

Demarcated dirty utility room/area 1 OB For cleaning and storage of housekeeping

consumables
The facility has adequate circulation area Corridors at Dialysis unit are broad
ME C1.4 and open spaces according to need and enough for easy moment of stretcher 2 OB Corridors are around 3 meter wide
local law. and trolley

ME C1.5 The facility has infrastructure for Availability of functional telephone/ 0 OB/RR Please ask the staff about the availability of
intramural and extramural communication. Intercom Services /CUG intra/extramural communication

Waiting time for scheduling session is not more

Service counters are available as per Availability of adequate no. of than 24hrs.
ME C1.6 1 OB/RR
patient load. machines At least one machine is dedicated for infectious
patients
Check the directional flow as follows:
1. entry
The facility and departments are planned
to ensure structure follows the 2. reception & registration
ME C1.7 function/processes (Structure Unidirectional flow of services. 1 OB 3. Admission, and Discharge
commensurate with the function of the
hospital). 4. Procedure
5. Ancillary area (water treatment, dialyzer
reprocessing, toilets and stores)

Functional linkage and access to 2 OB Dialysis has functional linkage with ICU ,
critical departments laboratories, Blood Bank, Emergency dept, OT

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

The facility ensures safety of lifts and lifts Measures are being taken for safety If the dialysis centre is at ground floor or
ME C2.2 have required certificate from the of lifts 2 OB/RR accessible through ramp, give full compliance
designated bodies/board

Dialysis room does not have Check there is no multi plug system
The facility ensures safety of electrical mechanism for periodical check/test of all
ME C2.3 establishment. temporary connections and loosely 1 OB electrical installation by competent electrical
hanging wires Engineer
Each dialysis machine has in-built UPS 0 OB/RR
or supplied with a UPS
Physical condition of buildings are safe for Floors of the Dialysis room are non
ME C2.4 2 OB Easily cleanable and acid, alkaline proof
providing patient care. slippery and even
Windows have grills and wire
2 OB
meshwork
Standard C3 The facility has established Programme for fire safety and other disaster.
 Dialysis Centre has sufficient fire exit
ME C3.1 The facility has plan for prevention of fire. to permit safe escape to its occupant 1 OB Check the fire exits are clearly visible and routes
to reach exit are clearly marked
at time of fire

ME C3.2 The facility has adequate fire fighting Fire Extinguisher ABC type are 2 OB Expiry date and due date for next refilling is
equipment installed clearly mentioned
The facility has a system of periodic
training of staff and conducts mock drills Check for staff competencies for Randomly ask one of the staff to operate fire
ME C3.3 regularly for fire and other disaster operating fire extinguisher and what 2 OB/SI extinguisher
situation. to do in case of fire

Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load.
Qualified Nephrologist / MD Medicine with one
The facility has adequate specialist doctors Availability of Nephrologist or year dialysis training from recognized centre
ME C4.1 2 OB/RR
as per service provision. equivalent performing one visit every fortnight and clinical
review for all patients

The facility has adequate general duty

Medical Officers (on duty) – One doctor (MBBS)
ME C4.2 doctors as per service provision and work Availability of duty medical officer 2 OB/RR per shift
load.

1. One dedicated staff nurse/technician for 3

patients
ME C4.3 The facility has adequate nursing staff as Availability of Nursing staff / dialysis 2 OB/RR/SI 2. One dedicated staff nurse/technician for each
per service provision and work load. technician infectious patient
3. One of the staff nurse/technician trained in
CPR is available in each shift

The facility has adequate Availability of Dialysis Unit With management/medicine/quality

ME C4.4 technicians/paramedics as per Manager/in-charge for day to day 2 OB/RR
requirement management background

ME C4.5 The facility has adequate support/general Availability of housekeeping staff and 1 OB/SI/RR At least one housekeeping staff and one
staff. other support staff hospital attendant per shift
Availability of dedicated security
guard 0 OB/RR At least one security guard per shift
Standard C5 The facility provides drugs and consumables required for assured services.
The departments have availability of All the drugs and consumables are As per MoU with the private partner/hospital
ME C5.1 adequate drugs at point of use. available at point of use 2 OB/RR EML

Dialysate prepared either commercially or on-

Availability of adequate quantity of site on daily basis meeting standards or
2 OB/RR/SI regulatory requirements (ISO 23500:2014, ISO
dialysate as per requirement 13958:2014, ISO 11663:2014)

Availability of medical gases 2 OB/RR Oxygen cylinders and suction machine or

through piped supply

Adequate quantity of disposable consumables

like Blood tubing set, Fistula needle(16 G),
The departments have adequate Availability of consumables,
ME C5.2 2 OB/RR Sodium Bicarbonate powder, IV sets, Dialyser
consumables at point of use. connectors, Tubing
starting kit, , Double lumen catheter set
12F(curved), etc. are available
 Every patient is provided with either a new
Availability of adequate quantity of dialyser or a reprocessed dialyser of the same
functional dialyser as per 2 OB/RR/SI
patient. All reprocessed dialysers must meet
requirement
the standard norms for test of performance

Emergency drug trays are maintained at Emergency Drug Tray/Crash Cart is Inj. Adrenaline, Atropine, Hydrocortisone,
ME C5.3 every point of care, where ever it may be maintained at dialysis unit 2 OB/RR Dexamethasone, Warfarin, Erythropoietin, ET
needed. Tube, Ambu Bag with Mask, Laryngoscope, etc.

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

Availability of equipment & instruments Availability of functional Equipment BP Apparatus, Stethoscope, Weighing Scale,
ME C6.1 &Instruments for examination & 1 OB Thermometer, Torch, X-ray view box, Multipara
for examination & monitoring of patients.
Monitoring monitor
Dialysis starting kit, Equipment for
dressing/bandaging/suturing, Stand-by
Availability of equipment & instruments heamodialysis machine, Equipment for water
ME C6.2 for treatment procedures, being Availability of instruments for dialysis 2 OB treatment and dialyser reprocessing, etc.
undertaken in the facility. procedure

Availability of equipment & instruments Availability of Point of care diagnostic Glucometer, ECG and HIV rapid diagnostic kit,
ME C6.3 for diagnostic procedures being devices 1 OB Blood group testing,HbsAg(HBV)
undertaken in the facility.

[Link]
[Link] tubes
Availability of equipment and instruments [Link] equipment
ME C6.4 for resuscitation of patients and for Availability of functional Instruments 2 OB [Link] spray
providing intensive and critical care to for Resuscitation. [Link] and Nasopharyngeal airways
patients. [Link] Bag- Adult &
Paediatric

Availability of equipment for storage Refrigerator, Crash cart/Emergency Drug tray,

ME C6.5 Availability of Equipment for Storage. 2 OB
for drugs instrument trolley/tray, dressing trolley/tray

Availability of functional equipment and Availability of equipments for Buckets for mopping, mops, duster, waste bins,
ME C6.6 instruments for support services. cleaning 2 OB cleaning brushes
Availability of equipment for
2 OB Autoclave
sterilization and disinfection
1. Hospital graded Mattress
2. IV stand
Departments have patient furniture and Availability of patient bed with 3. Bed rails
ME C6.7 2 OB
fixtures as per load and service provision. accessories 4. Stool
5. Footstep,
6. Bedside locker
Standard C7 The facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff
 Criteria may include skill, proficiency,
Competence assessment of Clinical and Criteria for Competence assessment knowledge and competencies required to carry
ME C7.2 Para clinical staff is done on predefined are defined for doctor, nurse, 2 SI/RR out day to day procedures and manage
criteria at least once in a year technician. complications.
Competence assessment is done at least once
in a year.

Performance evaluation of clinical and Performance based appraisal is done Appraisal is done on the basis of objective
ME C7.4 para clinical staff is done on predefined once in a year for all staff 2 SI/RR assessments and linked with renumeration
criteria at least once in a year
Risk Management, Infection Control Practices,
The Staff is provided training as per All staff are trained in skills required Bio-medical Waste Management, Patient and
Fire Safety, Quality Management
ME C7.9 defined core competencies and training for general management of the 2 SI/RR Comprehensive
plan. dialysis unit training programme for all staffs including PPP
service providers
Doctors are trained in skills required Evaluation, Initiation, Monitoring and
for clinical management of dialysis 2 SI/RR Termination of Dialysis session including
unit prevention and management of complication
Doctors, Nurses/Technicians are Self-care, do's and don'ts, diet and
trained in general counselling of 2 SI/RR
psychological counselling
patients
Basic life support (BLS)/ Advance life support
All staff are trained for life-saving 2 SI/RR (ALS) Doctors, nurses/technicians are
skills trained for life saving skills
Periodic refresher training are 1 SI/RR As mentioned in above checkpoints for different
provided for all staff categories of staff
Area of Concern D: Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

The facility has established system for All equipment are covered under Haemodialysis (HD) machine & all the
ME D1.1 maintenance of critical Equipment. AMC including preventive 1 SI/RR assessories including alarms
maintenance.
AMC/CMC of Water treatment 0 SI/RR
system with reverse osmosis

1. Maintenance for all the major equipmemts

There is system of timely corrective including process of periodic inspection
break down maintenance of the 1 SI/RR 2. Cleaning and maintenance
equipment [Link] unit may have AMC/CMC for individuals
machines or collectively enrolled under BMEMP

Staff of dialysis unit is skilled for

routine trouble shooting of minor 2 SI/RR
equipment failure
Maintenance of different
components of water treatment 2 OB/SI The log book is adequately maintained
system are recorded
 The facility has established procedure for All the measuring equipment/ Dialysis machine (Blood pump, Heparin pump,
ME D1.2 internal and external calibration of 2 OB/RR Pressure monitor, Conductivity meter),
instruments are calibrated
measuring equipment. Weighing scale, Thermometer, BP Apparatus

Operating Dialysis Machine, Water Treatment

Operating and maintenance instructions Operating instructions for critical
ME D1.3 2 OB/SI System, Dialyzer Reprocessing, Preparation of
are available with the users of equipment. equipment are available Dialysate

Lay-out and flow diagram of the

water treatment system is displayed 1 OB The flow-diagram is self-explanatory and easy
in the water treatment room to comprehend

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas.
There is established procedure for
ME D2.1 forecasting and indenting drugs and There is established system of timely 2 SI/RR Forecasting or demand generation manually/IT
indenting of consumables and drugs
consumables.
The facility has established procedure for There is an established procedure for
ME D2.2 procurement of drugs. placing requisition 2 SI/RR Requisition are timely placed

Please check for records for expiry and near

ME D2.4 The facility ensures management of expiry Expiry and near expiry dates are 2 OB/SI expiry drugs are maintained for drug stored in
and near expiry drugs. maintained at emergency drug tray the department
No expired drugs or consumables
found 2 OB/SI Check expiry date of dialysate packaging

Department maintained stock and

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

There is a procedure for periodically There is no stock out of drugs &

ME D2.6 replenishing the drugs in patient care consumables 2 SI/RR
areas.
There is a process for storage of vaccines Temperature of refrigerators are kept Check for temperature charts are maintained
ME D2.7 and other drugs, requiring controlled as per storage requirement and 2 OB/SI/RR and updated periodically (Erythropoietin)
temperature. records are maintained
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors
The facility provides adequate illumination There is adequate illumination at the
ME D3.1 at patient care areas. procedure area 1 OB Provision of at least 300 lux.

There is adequate illumination at the

water treatment area 1 OB Provision of at least 300 lux.

ME D3.2 The facility has provision of restriction of Entry of visitors into the dialysis unit 2 OB/SI Visiting hours are defined, displayed & adhered
visitors in patient areas. are restricted with

The Dialysis unit shall be provided

with effective and suitable ventilation
The facility ensures safe and comfortable to maintain comfortable room Fans/ Air conditionings are available as per
ME D3.3 environment for patients and service 2 OB/SI
providers. temperature. environment condition and requirement
 Water treatment area should have
measures for noise attenuation 0 OB

There is adequate ventilation to

2 OB In dialysis unit and water treatment area
prevent over-heating
Standard D4 The facility has established Programme for maintenance and upkeep of the facility.
Hospital infrastructure is adequately
ME D4.1 Exterior and interior of the facility building maintained along with interior of 2 OB/RR
is maintained properly patient care areas are plastered &
painted
Floors, walls, roof, sinks patient care
ME D4.2 Patient care areas are clean and hygienic and circulation areas are clean 2 OB

ME D4.5 The facility has policy of removal of No condemned/junk material in the 2 OB/SI/RR
condemned junk material dialysis centre

ME D4.6 The facility has established procedures for No stray animal/rodent/birds 2 OB/SI/RR
pest, rodent and animal control
Standard D5 The facility ensures 24 × 7 water and power backup as per requirement of service delivery, and support services norms.
The facility has adequate arrangement for
ME D5.1 storage and supply of potable water in all The unit shall have 24 hour provision 2 OB Check the availability of functional water points
functional areas. of potable water for RO system for RO system

ME D5.2 The facility ensures adequate power

backup in all patient care areas as per load. Availability of genset 2 OB To meet the requirements of all machine

Check the backup of UPS is at least up to 15

Availability of UPS 0 OB minutes in case of power failure/all dialysis
machines are connected to a central servo
controlled stabiliser of adequate capacity

Critical areas of the facility ensures

ME D5.3 availability of oxygen, medical gases and Availability of Centralized /local 2 OB/RR if oxygen cylinder/oxygen concentrator is
vacuum supply. piped oxygen and vacuum supply available, then full compliance will be given

480 Litres of water needed per machine (Note:

The facility has adequate arrangement for This does not include the water requirement of
ME D5.4 uninterrupted supply of RO water for The dialysis unit have sufficient 1 OB other activities of the unit such as hand washing
supply of RO water
dialysis unit )/ Water is available on 24*7 basis at all points
of usages
1. Back-flow preventer
The dialysis unit has adequate 2. Temperature blending valve
arrangements for preventing back 2 OB
flow of water 3. Booster pump and raw water tank
4. ±acid feed pump etc.
The RO plant has adequate Pre-treatment should consist of:
arrangements for pre-treatment of
1. Filtration for suspended particles.
water 0 OB/RR
[Link] carbon filtration
[Link] or deionizers
 Check for:
[Link] pipelines after
reverse osmosis system are of stainless steel
The RO plant has standardized pipes
(grade 316) or medical grade PVC.
and valves for water distribution 0 OB/RR [Link] valves joints & connectors are of the same
material.
3. Bends & blind loops must be avoided

The RO plant has adequate

arrangements for post-treatment of
water 1 OB/RR Microbial and UV filters or/and deionization

Please check for:

1. Storage tank is made up of stainless
There is adequate arrangements for steel or medical grade PVC with an air tight lid
safe storage of water 0 OB/RR [Link] tank
has de-aeration valve & drain facility at the
bottom
The facility has adequate The drains are provided with adequate
arrangements for management of 0 SI/RR gradients and adequate no. of floor traps are
drainage System available to drain excess water
Standard D6 Dietary services are available as per service provision and nutritional requirement of the patients
Ideally by a dietician else by the
ME D6.1 The facility has provision of nutritional Availability of nutritional assessment 2 OB/PI doctor(Arrangements could be made for
assessment of the patients. and counselling facility videography lecture )
Standard D7 The facility ensures clean linen to the patients.

ME D7.2 The facility has established procedures for A fresh set of linen is provided to
each patient and is changed in case of 2 OB/SI/RR/PI On a daily basis
changing of linen in patient care areas
any major spill
There is an established procedures
The facility has standard procedures for for handling dirty, soiled and clean Dirty, soiled and clean linens are collected,
ME D7.3 handling, collection, transportation and linens 2 OB/SI/RR transported and stored separately
washing of linen.
Standard D9 Hospital has defined and established procedures for Financial Management.

ME D9.1 The facility ensures proper utilization of There is no delay in payments to the 2 SI/RR Payments to the providers are made as per the
the fund provided to it. service provider MoU. If not applicable, give full compliance
Standard
D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
ME D11.1 The facility has established job description Staff is aware of their role and 2 OB/SI/RR Job descriptions/TOR are available with the
as per govt guidelines. responsibilities facility

The facility has a established procedure for There is procedure to ensure that
ME D11.2 duty roster and deputation to different staff is available on duty as per duty 2 OB/SI/RR
roster and there is designated in
departments.
charge for the department

The facility ensures adherence to dress Doctor, nursing staff and support staff All the categories of staffs are in proper dress
ME D11.3 2 OB code as assigned by the hospital
code as mandated by the administration. adhere to their respective dress code
management/administration
Standard The facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
D12
 There is established system of contract There is procedure to monitor the There is a valid MoU with outsourcing agencies
ME D12.1 quality and adequacy of outsourced 1 RR/SI
management for the out sourced services. (If not applicable, give full compliance)
services on regular basis

The
quality of services are monitored periodically
ME D12.2 There is a system of periodic review of Regular monitoring of quality of 1 SI/RR using objective criteria, process of black listing
quality of out-sourced services. services
and provision of penalties for non-
conformance(check MoU)
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
Every patient is provided with The same card/booklet may be used for
ME E1.1 The facility has established procedure for individual dialysis card/booklet with 2 RR multiple sessions
registration of patients Unique identification number during
registration

There is provision of prior Check the process for appointment & also
appointment for new & old patients 2 RR/PI advanced communication is given to the patient
in case of any cancellation/ delay

Patient details are recorded in Check for that patient details like Name, age,
Dialysis Card/Booklet 2 RR Gender, Blood group, Nephrologist details,
Dialysis start date, HBV/HCV status, etc.

There is established procedure for There is an established criteria for Criteria based on Nephrologist's
ME E1.3 admission of patients initiation of dialysis session 2 SI/RR recommendations, Dry weight/weight gain,
Vital sign, KFT results and Physical finding
Standard E2 The facility has defined and established procedures for clinical assessment, reassessment and treatment plan preparation.
Initial assessment of all patients on
dialysis is done as per standard Initial Assessment will include weight, seated
ME E2.1 There is established procedure for initial protocols 2 RR/SI blood pressure, pulse rate, temperature,
assessment of patients
respiratory rate

Dialysis history is taken and recorded 2 RR Check whether the patient has come for first
session or a follow-up session
Look for signs of
Physical Examination is done and Mobility, Pain, Skin changes, Oedema, Signs of
recorded 2 RR bruising & bleeding, Signs & symptoms of
infection

Every hour and look for safety checks as

ME E2.2 There is established procedure for follow- There is fixed schedule for
reassessment of stable and non- 1 RR/OB
Air detector/Line clamp, Dialysate Flow Rate,
Dialysate temp, Conductivity, Status of heparin
up/ reassessment of Patients infective patients pump, "A" and "B" concentrate, Concentrate
Na+, Alarm limit is set, if any
 Every half hour and look for safety checks as
There is fixed schedule for Air detector/Line clamp, Dialysate Flow Rate,
reassessment of unstable and 1 RR/OB Dialysate temp, Conductivity, Status of heparin
infective patients pump, "A" and "B" concentrate, Concentrate
Na+, Alarm limit is set, if any

There is system in place to identify Criteria is defined for identification, and

and manage the changes in Patient's 2 RR/SI management of high risk patients/ patient
health status whose condition is deteriorating
Check the re assessment sheets/ Case sheets
Check the treatment or care plan is 2 RR/SI modified treatment plan or care plan is
modified as per re assessment results documented

Assessment includes physical assessment,

There is established procedure to plan and Check healthcare needs of all history, details of existing disease condition (if
deliver appropriate treatment or care to
ME E2.3 individual as per the needs to achieve best hospitalised patients are identified 2 RR/SI any) for which regular medication is taken as
possible results through assessment process well as evaluate psychological ,cultural, social
factors

(a) According to assessment and investigation

findings (wherever applicable).
(b) Check inputs are taken from patient or
Check treatment/care plan is 2 RR/SI relevant care provider while preparing the care
prepared as per patient's need plan.

Care plan include:, investigation to be

Check treatment / care plan is 2 RR/SI conducted, intervention to be provided, goals
documented to achieve, timeframe, patient education, ,
discharge plan etc
Check care is delivered by competent Check care plan is prepared and delivered as
multidisciplinary team 2 RR/SI per direction of qualified physician
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral

Facility has established procedure for There is an established procedure for Check how hand over is given when patient is
ME E3.1 continuity of care during patient transferred from dialysis unit 2 SI/RR transferred from dialysis unit to ICU /OT/
interdepartmental transfer and referrals to ICU /OT/ Emergency and vice versa Emergency and vice versa

All patients are provided with referral card with

There is an established procedure for 2 RR/SI details of patient, details of the facility where
referral of patients to higher facility referred, treatment given, reasons for referral,
etc.
Necessary support is provided for Advance communication is done with higher
2 RR/SI
referral centre, Referral vehicle is arranged

ME E3.3 A person is identified for care during all Doctor and nurse/technician is 1 RR/SI At least one doctor is available for each shift
steps of care designated for each patient and one nurse/technician for each patient
 Patient condition is reviewed during hand over
Detailed hand over is given between 2 RR/SI between resident doctors as well as
change of the shifts
nurses/technicians
Standard E4 The facility has defined and established procedures for nursing care

Procedure for identification of patients is There is a process for ensuring the Patient id band/ verbal confirmation/Bed no.
ME E4.1 identification of the patient before 2 OB/SI
established at the facility each dialysis session etc. Any two identifiers may be used

Check for
Procedure for ensuring timely and Patient name, Age, Sex, Id no, Date, Dialysis no,
ME E4.2 accurate nursing care as per treatment Dialysis chart is maintained 2 RR Weight (Pre/Post), BP (Pre/Post), Starting and
plan is established at the facility closing time of dialysis session, Any symptoms
or medication given, etc.

Look for
ME E4.4 Nursing records are maintained General records of haemodialysis are 2 RR/SI Id on dialyzer, Dialyzer type, Dialyzer reuse no,
adequately maintained Machine no, Bed no, Dialysis duration, start and
termination time, Dialysis no

Look for
Machine rinse with RO water, Dialyzer sterilant
active, pre dialysis weight, dry weight of the
Pre-dialysis records are adequately 2 RR/SI patient, interdialytic wt. gain, UF target, pulse,
maintained BP, Temp, Anticoagulation bolus and
maintenance dose with signature of
nurse/technician commencing Haemodialysis
session

Look for
Post-dialysis records are adequately 2 RR/SI UF reading, post dialysis weight, weight
maintained loss/gain, achieved Kt/V, BP, Temp, Pulse, Inj.
EPO/Iron/Carnitine, if any
Records of the safety checks are All general, pre-dialysis and post-dialysis
2 RR/SI
adequately maintained records are duly signed by nurse/technician
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.

Hepatitis B/C, HIV positive patients, Grossly

ME E5.2 The facility identifies high risk patients and High risk patients are identified and 2 OB/SI dearranged KFT, Immuno-compromised
ensure their care, as per their need treatment given on priority patients and patients with pre-existing illnesses
e.g. Heart Failure, IHD, LVF, HTM, COPD, etc.

Standard E7 Facility has defined procedures for safe drug administration

There is process for identifying and Dialysate A & B, Electrolytes like Potassium
ME E7.1 cautious administration of high alert drugs High alert drugs and chemicals 2 SI/OB chloride, Anti thrombolytic agent, insulin,
(to check) available in department are identified warfarin, Heparin, etc.
Maximum dose of high alert drugs are Value for maximum doses are available with
2 SI/RR
defined and communicated the technician and doctor in the dialysis unit
There is process to ensure that right A system of independent double check before
doses of high alert drugs are only 2 SI/RR administration, Error prone medical
given abbreviations are not used
 Every Medical advice and procedure Check for Date, Time, name of the doctor, reg
Medication orders are written legibly and is accompanied with date, time and no, no of medicines, dosage form, strength,
ME E7.2 2 RR
adequately signature in comprehendible hand- time-duration, dosage route, signature of
writing doctor, instructions for patient, etc.

Drugs and chemicals are checked for

ME E7.3 There is a procedure to check drug before expiry and other inconsistency 2 OB/SI
administration/ dispensing
before administration
Check single dose vial are not used 2 OB Check for any open single dose vial with left
for more than one dose over content indented to be used later on
Any adverse drug reaction is recorded
and reported 2 RR/SI

Administration of medicines done

ME E7.4 There is a system to ensure right medicine after ensuring right patient, right
drug, right dose, right time, right 2 SI/OB
is given to right patient route, right reason and right
documentation
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re-assessment and Dialysis process is recorded as per 2 RR Pre, Post and Intra Dialysis processes and
investigations are recorded and updated defined assessment schedule investigations are recorded
All treatment plan prescription/orders are Each Dialysis session is planned and
ME E8.2 recorded in the patient records. documented on dialysis card 2 RR Before initiation of dialysis session

Check for the availability of Dialysis card,

ME E8.5 Adequate form and formats are available Standard Formats are available 1 RR/OB Dialysis chart, Dialysis record, Referral slip,
at point of use Consent form, Lab requisition form, etc.
Register/records are maintained as per Registers and records are maintained
ME E8.6 guidelines as per guidelines 2 RR

The facility ensures safe and adequate

ME E8.7 storage and retrieval of medical records Safe keeping of patient records 2 OB
Standard E9 The facility has defined and established procedures for discharge of patient.

ME E9.2 Case summary and follow-up instructions Dialysis card is updated at the end of 2 RR/PI Look for date of next session
are provided at the discharge each dialysis session

Counselling services are provided as during Patient is counselled before Patient is counselled for do's and don'ts, care of
ME E9.3 2 PI/SI
discharges wherever required discharge access site, diet, water intake, dry weight, etc.
Standard The facility has defined and established procedures for Emergency Services and Disaster Management
E11
ME E11.2 Emergency protocols are defined and Protocols of dialysis for emergency 0 SI/RR Acute renal failure/septicaemia in IPD/ICU
implemented cases are defined and implemented patients
Standard The facility has defined and established procedures of diagnostic services
E12
There are established procedures for Pre- Container is labelled properly after
ME E12.1 2 OB
testing Activities the sample collection

ME E12.2 There are established procedures for Facility for point of care diagnostic 2 OB/SI Blood Sugar, Blood group, HbsAg(HBV) etc.
testing Activities tests are available
Standard
E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
 There is established procedure for
ME E13.9 transfusion of blood Consent is taken before transfusion 2 RR

Patient's identification is verified

2 SI/OB
before transfusion
Blood is kept on optimum
2 RR
temperature before transfusion
Blood transfusion is monitored and 2 SI/RR
regulated by qualified person
Blood transfusion note is written in 2 RR
patient records
There is an established procedure for Any major or minor transfusion
ME E13.10 monitoring and reporting Transfusion reaction is recorded and reported to 2 RR
complication responsible person
Standard The facility has defined and established procedure for Haemodialysis Services
E24
The facility has defined and established Patient washes hand and relevant
limb (with AVF/GF) with soap and Encourage the patients to wash their hands
ME 24.1 procedure for Pre Haemodialysis water before entering the dialysis 2 OB/RR/SI themselves
assessment unit
All the patients are weighed before 2 OB/RR/SI Encourage the patients to weigh themselves
entering the dialysis unit
Pre-dialysis observations are 2 OB/RR/SI Seated blood pressure, pulse, temp, respiratory
performed and pre-recorded rate are recorded
Look for any changes since last session in
Complete assessment of the patient mobility, pain, skin state, oedema,
is done before commencement of the 2 OB/RR/SI
dialysis bruising/bleeding or any sign or symptom of
infection

Note pre and post dialysis observation of the

Information of the previous dialysis 2 OB/RR/SI previous dialysis session and any dialysis
session is reviewed variances

Baseline information is reviewed 2 OB/RR/SI Weight gain (ideally less than 5%), urine output,
blood glucose level
Plan should have details of Ultra filtration goal
Dialysis plan is documented based on 2 OB/RR/SI (amount of fluid to be removed), Ultra-filtration
observation and patient assessments rate, dialysis duration, any expected
complications
Review and prepare for pre-dialysis
2 OB/RR/SI HbSAg, HCV, HBV, HIV, MRSA
testing
Blood sample is taken for pre-dialysis 2 OB/RR/SI Hb, KFT, LFT
testing

The facility has defined and established Cleaning and disinfection with antiseptic
ME 24.2 procedure for care during Haemodialysis Prepare the access sites 2 OB/RR/SI solution
 Check that
Safety checks for Blood tubing are 2 OB/RR/SI Inserted canula is secured, check for air bubble
ensured via Air detector/Line clamps, and patency of
the circuit

Check that
Dialysis machine is disinfected and rinsed with
Safety checks for Dialysis machine are 2 OB/RR/SI RO water. Conductivity is maintained.
ensured
Alarm limit and dialysate flow rate is set

Check that
Safety checks for dialyzer and
2 OB/RR/SI Dialyzer reuse no is written, Check for Dialysate
dialysate are ensured temp and A and B concentrate

Periodic and regular monitoring of All the observations are recorded including BP,
the patient is done 2 OB/RR/SI Pulse, Respiratory Rate, Machine parameters

Patient with any comorbidity are

Blood sugar monitoring of diabetic patient and
monitored and parameters are 2 OB/RR/SI INR of patients on Warfarin
recorded periodically

Routine medications are 2 SI/RR

administered to patients as scheduled

Intervention/Medication during the Change in machine settings

session are monitored and recorded 2 OB/RR/SI Iron/Erythropoietin

Strict monitoring of the dialysis 2 OB/RR/SI Needle dislodgement and clotted circuit
related errors is done

The facility has defined and established Keep equipment ready to terminate
Swab, Tape, Bandage
ME 24.3 procedure for care after completion of the session and disconnect the 2 OB/SI
Haemodialysis patient from the machine

Take post-dialysis sample 2 OB/RR/SI For KFT or any other investigations

Disconnect the access as per the Sequence and timing of removing the cannulas
protocols 2 OB/RR/SI and tubing's

Post-dialysis observations are 2 OB/RR/SI BP, Pulse, Temp, Respiratory Rate, Blood Sugar,
recorded UF reading, weight, Inj. Iron/Erythropoietin

Water intake, Protein intake, Care of the access

Patient is counselled for self-care 2 OB/RR/SI site, do's and don't, alarming signs and when &
whom to contact in case of emergencies

Area of Concern - F: Infection Control

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection.
 The facility has provision for Passive and
ME F1.2 active culture surveillance of critical & high Dedicated person is in-charge for
infection control in the dialysis unit 2 SI/RR Doctor/Nurse/Technician may be designated
Person responsible for quality can also handle
risk areas.

Swab are taken from infection prone surfaces at

Surface and environment samples are least once in month like machine, machine
2 SI/RR control panel, dialyzer(in case of reuse), bed
taken for microbiological surveillance
railing, working bench,machine,dialysate,
RO,connectors used /supply to machine etc.

Water samples are taken for Analysis of water used for haemodialysis for
bacteria required to be done at least monthly
microbial culture and microelements 2 SI/RR and analysis for chemicals required to be done
in RO water
at least every six months

ME F1.3 The facility measures hospital associated There is procedure to report cases of 2 SI/RR The facility should develop methods to monitor,
infection rates. infection with blood borne infections review and evaluate all blood borne infections

There is provision of Periodic Medical There is procedure for immunization

ME F1.4 Check-up and immunization of staff. of the staff 1 SI/RR Hepatitis B and Tetanus Toxoid etc.

Periodic medical check-ups of the 2 SI/RR At least once in a year including housekeeping
staff and support staff
The facility has established procedures for
ME F1.5 regular monitoring of infection control Regular monitoring of infection 2 SI/RR Hand washing and infection control audits done
practices. control practices at periodic intervals

Standard F2 The facility has defined and implemented procedures for ensuring hand hygiene practices and antisepsis

ME F2.1 Hand washing facilities are provided at Availability of hand washing facility as 2 OB One hand wash basin to be provided for every
point of use. per norms 2-3 dialysis stations in the main dialysis area

Availability of running water 2 OB/SI Ask Staff if water supply is regular

Availability of antiseptic liquid soap Check for availability/ Ask staff if the supply is
2 OB/SI
with dispenser. adequate and uninterrupted

Availability of Alcohol based Hand rub 2 OB/SI One alcohol hand rub for every dialysis
machine. Ask staff for regular supply.
Display of Hand washing Instruction Prominently displayed above the hand washing
at Point of Use 2 OB facility , preferably in Local language
Availability of elbow operated taps 2 OB
Hand washing sink is wide and deep
enough to prevent splashing and 1 OB
retention of water
The facility staff is trained in hand washing
Adherence to 6 steps of Hand
ME F2.2 practices and they adhere to standard 2 SI/OB Ask for demonstration
hand washing practices washing

Staff aware of when to wash hand 2 SI Ask 5 moments for hand washing
The facility ensures standard practices and Availability of Antiseptic Solutions
ME F2.3 materials for antisepsis. 2 OB Providine iodine, Isopropyl alcohol, etc.
 Before preparing the access for
Proper cleaning of vascular access 2 OB/SI cannulation/blood tubing, before giving IM/IV
site with antiseptics injection and drawing blood (If not applicable,
give full compliance)
Standard F3 The facility ensures standard practices and materials for Personal protection.
The facility ensures adequate personal
ME F3.1 protection Equipment as per Clean gloves are available at point of 2 OB/SI
use
requirements.
Availability of Mask 2 OB/SI
Availability of gown/ Apron 2 OB/SI Staff and visitors
Availability of shoe cover 2 OB/SI Staff and visitors
Availability of Caps 2 OB/SI Staff and visitors
Personal protective kit for infectious
patients 2 OB/SI

ME F3.2 The facility staff adheres to standard No reuse of disposable gloves, Masks, 2 OB/SI
personal protection practices. caps and aprons.
Compliance to correct method of
wearing and removing the gloves 2 SI
Standard F4 The facility has standard procedures for processing of equipment and instruments.

Surfaces like dialysis bed or chair, countertops,

The facility ensures standard practices and Cleaning & Decontamination of external surfaces of dialysis machine & control
ME F4.1 materials for decontamination and dialysis machine and patient care 2 SI/OB panel etc. by wiping with .5% hypochlorite
cleaning of instruments and equipments area solution followed by removing chlorine residues
from metallic surfaces with water

Ask staff how they decontaminate the

Proper Decontamination of instruments like scissors, haemostats, clamps
instruments after use 2 SI/OB (Soaking in 0.5% Chlorine Solution), blood
pressure cuffs, stethoscopes, etc. (Wiping with
0.5% Chlorine Solution or 70% Alcohol)

Contact time for decontamination is

adequate 2 SI/OB 10 minutes

Cleaning of instruments after Cleaning is done with detergent and running

2 SI/OB
decontamination water after decontamination

Proper handling of Soiled and Sorting, Rinsing or sluicing of soiled/infected

infected linen 2 SI/OB linen is done outside the dialysis unit/ Patient
care area

Prepared chlorine solution has 500-600ppm

Staff know how to make chlorine free chlorine (e.g., 1:100 dilution of a 5.25-
2 SI/OB
solution 6.15% sodium hypochlorite provides 525-615
ppm available chlorine)
 Dialysis machines are disinfected
The facility ensures standard practices and after each session taking in to Using Citric acid in the hydraulic circuit of
ME F4.2 materials for disinfection and sterilization 2 OB/SI
account level of biofilm and haemodialysis machines
of instruments and equipments
endotoxin removal
Bottles containing unused dialysate
are disinfected after session 2 OB/SI

Opened bottles containing unused

fluid should be discarded after 24 2 OB/SI
hours
Unfinished bottles used for infected
patients must be discarded 2 OB/SI
immediately

Blood compartment is rinsed with water till the

Cleaning and disinfection of effluent is clear while hydrogen peroxide should
Hemodialysers is done as per 2 OB/SI/RR be instilled in dialysate compartment followed
protocols by rinsed out of cleaning agents from dialysate
compartment with water

Backwashing is carried out for at least 15

Backwashing or Reverse 2 OB/SI/RR minutes with periodic 1-2 minute rinsing of the
Ultrafiltration is done as per protocols blood compartment. The direction of flow
should be reversed at 5 minute intervals.

The 'Test of Performance' includes testing for

total cell volume (TCV should be more than
Only dialysers clearing the 'Test of 2 OB/SI/RR <80%), membrane integrity (should pass leak
performance' are reused test) and perform residual disinfection (shall be
checked using ‘Potency Test Strip’). Dialyser
failing 'Test of Performance' are discarded

Dialyzer should be kept in a sealed polythene

bag/leakproof box with the patients name, TCV,
Labelling and storage of Dialyzer is 2 OB/SI/RR reuse number and date marked with indelible
done appropriately ink over it. If stored for more than 7 days prior
to the subsequent use, it should be refilled with
disinfectant before use

Cleaning/Disinfection of the pipes of Distribution loop of water treatment system

2 OB/SI/RR
water management system should be cleaned preferably, once in 6 months

Autoclaved dressing material is used 2 OB/SI Ensure the traceability of sterilized packs is
maintained during storage
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Functional area of the department are Facility layout ensures separation of
ME F5.1 arranged to ensure infection control general patient from infectious 2 OB Separate bed/area for HBV, HCV and HIV cases
practices patients
 Facility layout ensures separation of
routes for clean and dirty items 0 OB

Look for non-slippery floor (or epoxy grout in

Floors and wall surfaces are easily 2 OB tiles), surfaces should be smooth & washable,
cleanable seamless and impervious with sealed or welded
joints

The facility ensures availability of standard Availability of disinfectant as per Sodium Hypochlorite solution, Citric acid,
ME F5.2 materials for cleaning and disinfection of requirement 2 OB/SI Glutaraldehyde
patient care areas
Availability of cleaning agent as per Hospital grade phenyl, disinfectant detergent
requirement 2 OB/SI solution
The facility ensures standard practices are
ME F5.3 followed for the cleaning and disinfection Staff is trained for spill management 2 SI/RR Blood spill management
of patient care areas

chair, armrests,
Cleaning of patient care area with bedside table top/counter, and drawer/
detergent solution 2 SI/RR cupboard handles) and high touch surfaces (the
exterior surfaces of the HD machine, computer
screens, and keyboards

Staff is trained for preparing cleaning 2 SI/RR

solution as per standard procedure

Standard practice of mopping and 2 OB/SI Unidirectional mopping from inside out
scrubbing are followed

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

Use of three bucket system for

mopping 1 OB/SI
External foot wares are restricted 2 OB

ME F5.4 The facility ensures segregation infectious Isolation and barrier nursing
procedure are followed for septic 2 OB/SI
patients. cases
Separate staff for infected patients 1 OB/PI Staff caring for HBV, HCV, HIV patients
ME F5.5 The facility ensures air quality of high risk Negative pressure is maintained in 0 OB/SI
area. Isolation
Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.
Facility Ensures segregation of Bio Medical
Waste as per guidelines and 'on-site' Availability of colour coded bins at
ME F6.1 management of waste carried out as per point of waste generation 2 OB Adequate number. Covered. Foot operated.
guidelines
Availability of colour coded non 2 OB
chlorinated plastic bags
 Human Anatomical waste, Dialysers after
treatment, Items contaminated with blood,
Segregation of Anatomical and soiled 2 OB/SI body fluids, dressings, plaster casts, cotton
waste in Yellow Bin swabs and bags containing residual or discarded
blood and blood components.

Items such as tubing, bottles, dialysers filters,

Segregation of infected plastic waste intravenous tubes and sets, catheters, urine
in red bin 2 OB bags, syringes (without needles and fixed
needle syringes) and vacutainers with their
needles cut) and gloves

Display of work instructions for

segregation and handling of 2 OB Pictorial and in local language
Biomedical waste
There is no mixing of infectious and 2 OB
general waste
Facility ensures management of sharps as
ME F6.2 per guidelines Availability of functional hub cutters 2 OB See if it has been used or just lying idle.

Segregation of sharps waste See availability near the point of generation.

including Metals in white Needles, needles from needle tip cutter or
(translucent) puncture proof, leak 2 OB burner, scalpels, blades, or any other
proof, tamper proof containers contaminated sharp object that may cause
puncture and cuts. This includes both used,
discarded and contaminated metal sharps

Availability of post exposure 1 SI/OB Ask if available. Where it is stored and who is in
prophylaxis charge of that.
Staff knows what to do in condition of 2 SI Look for facilities for post-exposure prophylaxis
needle stick injury
Contaminated and broken glass are
disposed in puncture proof and leak 2 OB Vials, slides and other broken infected glass
proof box/ container with Blue
colour marking

ME F6.3 Facility ensures transportation and Check bins are not overfilled 2 SI/OB
disposal of waste as per guidelines
Disinfection of liquid waste before
disposal 0 SI/OB Dialysate A and B, Discarded disinfectant

Transportation of bio medical waste 2 SI/OB

is done in close container/trolley

Area of Concern - G : Quality Management

Standard G1 The facility has established organizational framework for quality improvement.
A Quality Circle is formed and Quality circle may have
ME G1.1 The facility has a quality team in place. functional with a designated nodal 2 RR/SI nephrologist/equivalent, Technician, nurses and
officer for quality. housekeeping staff.
ME G1.2 The facility reviews quality of its services at Quality Circle meets once in a month 1 RR/SI Quality circle meets at least once in a month
periodic intervals. and review quality of services. and minutes are recorded.

Standard G2 The facility has established system for patient and employee satisfaction.
Patient satisfaction surveys are conducted Patient satisfaction survey done on
ME G2.1 2 RR/SI
at periodic intervals. monthly basis

ME G2.2 The facility analyses the patient feedback, Analysis of low performing attributes 2 RR/SI
and root-cause analysis. of patient feedback is done

The facility prepares the action plans for Action plan is prepared to address the
ME G2.3 the areas, contributing to low satisfaction areas of low satisfaction 2 RR/SI
of patients.
Action plan is implemented to 2 RR/SI
improve the patient satisfaction
Standard G3 The facility has established internal and external quality assurance Programmes wherever it is critical to quality.

The facility has established internal quality There is system of daily round by Unit In charge should visit on daily basis and the
ME G3.1 Dialysis Unit in charge for monitoring 2 SI/RR findings/instructions during the visits are
assurance programme in key departments. of services recorded

The facility has established system for use Internal assessment is done at NQAS assessment toolkit is used to conduct
ME G3.3 of check lists in different departments and periodic interval 2 RR/SI internal assessment
services.

Departmental checklist is used for 2 SI/RR Staff is designated for filling and monitoring of
monitoring and quality improvement these checklists

Non-compliances are enumerated 2 Check the non compliances are presented &
and recorded
discussed during quality team meetings

Actions are planned to address gaps Check action plans are prepared and Randomly check the details of action,
ME G3.4 implemented as per internal 2 SI/RR responsibility, time line and feedback
observed during quality assurance process assessment record findings mechanism

Check PDCA or revalent quality Check actions have been taken to close the gap.
Planned actions are implemented through
ME G3.5 Quality Improvemnet Cycles (PDCA) method is used to take corrective and 2 SI/RR It can be in form of action taken report or
preventive action Quality Improvement (PDCA) project report

Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Departmental standard operating Standard operating procedure for

ME G4.1 procedures are available. department has been prepared and 2 RR
available
Current version of SOP are available Check current version of SOP is available with
with process owner 2 RR the staff of Dialysis Unit.
Department has documented Processes pertaining to ensuring privacy,
ME G4.2 Standard Operating Procedures adequately procedure for ensuring patients rights 0 RR confidentiality, respectful maternity care and
describes process and procedures. including consent, privacy,
confidentiality & entitlement consent
 Department has documented
procedure for safety & risk 2 RR Processes related to physical safety, patient
safety and risk assessment
management

Department has documented Process description of support services such as

equipment maintenance , calibration,
procedure for support services & 1 RR housekeeping, security, storage and inventory
facility management. management

Department has documented Processes of triage, assessment, admission,

procedure for general patient care 2 RR identification of high risk patients, Referral ,
processes Medication management and maintenance of
clinical records

Department has documented Processes of physical assessment, information

2 RR related to previous dialysis session and dialysis
procedure of pre-dialysis care.
plan

Department has documented Monitoring of the patient, frequency of

observation as per their clinical status, safety
procedure of care during dialysis 2 RR measures e.g. needle dislodgement, clotted
session.
circuit, adverse drug reaction, etc.

Department has documented Protocols for post-dialysis investigations,

procedure of post-dialysis care. 2 RR disconnecting access, dressing, post-dialysis
advice and counselling

Process of Hand Hygiene, personal protection,

Department has documented environmental cleaning, instrument
procedure for infection control & bio 2 RR sterilization, asepsis, Bio Medical Waste
medical waste management management , surveillance and monitoring of
infection control practices.

Department has documented Process of internal quality assessment & gap

analysis, Root cause analysis, Change ideas to
procedure for quality management & 2 RR address the gap, implementing & monitoring
improvement
the change ideas (PDCA)

Department has documented Process related to collection of data & quality

procedure for data collection, analysis
& using the information for 2 RR indicators , their analysis and use for quality
improvement
improvement

ME G4.3 Staff is trained and aware of the Check Staff is aware of relevant part 2 SI/RR Interview dialysis Unit staff for their awareness
procedures written in SOPs. of SOPs about content of SOPs
The facility ensures the documented Standard operating procedure for
ME G4.4 policies and procedures are appropriately department is duly approved by the 2 RR
approved and controlled competent authority

Work instructions are duly approved 2 OB

 How to calculate dry weight, information on
maintaining fluid balance before, during and
Work instructions are displayed 2 OB after dialysis session, bio-medical waste
management, hand wash instructions (when
and how), diet counselling, etc.

SOP is controlled by providing unique

2 RR
identification number
Standard operating procedure for
department is reviewed periodically 2 RR At least once in a year
by quality circle

Revision history of the SOP is Date of revision, revision no, changes

2 RR suggested by, changes made, reason of change,
documented
etc.
Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
Critical processes are the ones where there are
Process mapping of critical processes some problem-delays, errors, cost, time, etc.
ME G5.1 The facility maps its critical processes. done 1 SI/RR and improvement will make our process
effective and efficient.

The facility identifies non value adding Non value adding activities are Non value adding activities are wastes. In these
ME G5.2 activities/waste/redundant activities. identified 1 SI/RR steps resources are expanded, delays occur,
and no value is added to the service.

ME G5.3 The facility takes corrective action to Processes are improved & 1 SI/RR Look for the improvements made in the critical
improve the processes. implemented process in measurable terms.
Standard G6 The facility has defined Mission, Values, Quality policy and Objectives, and prepares a strategic plan to achieve them.

Mission statement should be defined by the

implementing agency (In-house/PPP) with
ME G6.1 Facility has defined mission statement Check if mission statement has been 2 RR/SI purpose, target users and long term goal of
defined adequately dialysis unit. Mission should be aligned with the
stated mission of Pradhan Mantri National
Dialysis Program

Facility has defined Quality policy, which is Check if Quality Policy has been Check quality policy has been defined in
ME G6.3 in congruency with the mission of facility defined and approved 2 RR/SI consultation with dialysis unit staff and duly
approved by appropriate authority.

Facility has de defined quality objectives to Check if SMART Quality Objectives Check if the Quality objectives are Specific,
ME G6.4 2 RR/SI Measurable, Attainable, Relevant and Time
achieve mission and quality policy have framed Bound.

Interview with staff for their awareness. Check

Mission, Values, Quality policy and
ME G6.5 objectives are effectively communicated to Check if staff is aware of Mission ,
Values, Quality Policy and objectives 2 RR/SI if Mission Statement and Quality Policy is
displayed prominently in local language at Key
staff and users of services
Points

Verify with records that a time bound action

Facility prepares strategic plan to achieve Check if plan for implementing quality
ME G6.6 2 RR/SI plan has been prepared to achieve quality
mission, quality policy and objectives policy and objectives have prepared
policy and objectives in consultation with staff.
 Review the records that action plan on quality
Facility periodically reviews the progress of objectives being reviewed at least once in
ME G6.7 strategic plan towards mission, policy and Check time bound action plan is being 2 RR/SI month by departmental in charges and during
objectives reviewed at regular time interval the quality team meeting. The progress on
quality objectives have been recorded in Action
Plan tracking sheet

Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 Facility uses method for quality Basic quality improvement method 1 SI/OB PDCA & 5S
improvement in services
Advance quality improvement
method 0 SI/OB Six sigma, lean.

Facility uses tools for quality improvement

ME G7.2 7 basic tools of Quality 2 SI/RR Minimum 2 applicable tools are used
in services
Standard G8 Facility has defined, approved and communicated Risk Management framework for existing and potential risks.

The risk management framework should

include incident reporting related to
1. Patient: Identification, Assessment,
Diagnosis, Patient fall
2. Device related: Dialyzer identification,
Risk Management framework has been There is a well defined and Efficacy of dialyzer, Alarm failure, Clotted
ME G8.1 defined including context, scope, documented Risk Management 2 SI/RR
circuit, Short-circuit
objectives and criteria Framework 3. Process related: Haematoma, Air, Embolism,
Fluid Imbalance, Dialysis plan, Monitoring
errors, Infection control and prevention, Needle
dislodgement and Safety checks and mitigation
measures

Risk Management Framework includes Check if process of reporting risks and Responsibility of identifying the existing and
potential risks is defined amongst staff and all
ME G8.3 process of reporting incidents and hazards have been defined and 2 SI/RR the staff are aware of how to identify the risks,
potential risk to all stakeholders implemented how to report them and mitigate them

Verify with the training records . Training on risk

Modality for staff training on risk Check training on risk management management at least should be provided to
ME G8.5 management is defined has been provided to all staff 2 SI/RR person/staff responsible in haemodialysis unit
members
for indemnifying and managing risks

Risk Management Framework is reviewed Check risk management framework is Check with the records that quality circle
ME G8.6 1 SI/RR
periodically reviewed at least once in a year reviews the framework at least once in a year

Standards G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
Check if facility has prepared assessment
Risk assessment criteria and checklist for Check if risk assessment checklist is checklist for identifying risk on routine basis.
G9.3 assessment have been defined and 1 SI/RR This checklist has been disseminate to the staff
communicated to relevant stakeholders available with stakeholders members responsible for identifying and
reporting risks
 Check if periodic assessment of Verify with the assessment records.
Periodic assessment for Physical and Physical, Fire and electrical safety risk Comprehensive of physical, Fire and electrical
G9.4 Electrical risks is done as per defined 2 SI/RR
is done using the risk assessment safety should be done at least once in three
criteria
checklist month

Periodic assessment for potential risk

regarding safety and security of staff Check if Periodic assessment of Verify with records. At least once in year and
G9.7 1 SI/RR
including violence against service providers violence risks is done whenever a major incident has occurred.
is done as per defined criteria

Check if various risks identified Risk identified should be listed and evaluated
G9.8 Risks identified are analysed, evaluated during the risk assessment proceeds 1 SI/RR for their severity, frequency for occurrence and
and rated for severity are evaluated consequences.

Verify with the records that a risk priority

Identified risks are treated based on Risks are prioritized and action plan is number (RPN) is given to each identified risk.
G9.9 severity and resources available made to eliminate/mitigate the risks 1 SI/RR Risks are prioritized based on their RPN and
action plan is prepared and implemented to
eliminate/mitigate the occurrence of risks
Standard G10 The facility has established clinical governance framework to improve the quality and safety of clinical care processes
For e.g. URR (Urea Reduction Ratio), and Kt/V

ME G10.3 Clinical care effectiveness criteria has been Criteria

sessions
for effectiveness of dialysis
are defined and 2 SI/RR
(amount of fluid that is cleared of urea during
each dialysis session/volume of water a
defined and communicated
communicated person's body contains), Symptomatic
improvement

Check parameter are defined & implemented to

review the clinical care i.e. through Ward
The facility has established process to 2 RR/SI round, peer review, morbidity & mortality
review the clinical care review, patient feedback, clinical audit & clinical
outcomes.

Check regular ward rounds are taken (1) Both critical and stable patients
2 RR/SI (2) Check the case progress is documented in
to review case progress
BHT/ progress notes-
Check the patient /family participate 2 RR/SI Feedback is taken from patient/family on health
in the care evaluation status of individual under treatment
System in place to review internal referral
Check the care planning and co- process, review clinical handover information,
2 RR/SI
ordination is reviewed review patient understanding about their
progress

ME G10.4 Facility conducts the periodic clinical Periodic dialysis unit audits are 0 SI/RR Look for records. Should be conducted at least
audits including prescription, medical conducted. quarterly.
 Check medical audit records
(a) Completion of the medical records i.e.
Medical history, assessments, re assessment,
investigations conducted, progress notes,
interventions conducted, outcome of the case,
patient education, delineation of
There is procedure to conduct 1 RR/SI responsibilities, discharge etc.
medical audits (b) Check whether treatment plan worked for
the patient
(C) progress on the health status of the patient
is mentioned
(d) whether the goals defined in treatment plan
is met for the individual cases
(e) Adverse clinical events are documented
(f) Re admission

(1) All the deaths are audited by the

committee.
(2) The reasons of the death is clearly
mentioned
(3) Data pertaining to deaths are collated and
There is procedure to conduct death 1 RR/SI trend analysis is done
audits (4) A through action taken report is prepared
and presented in clinical Governance Board
meetings / during grand round (wherever
required)

(1) Random prescriptions are audited

(2) Separate Prescription audit is conducted foe
both OPD & IPD cases
There is procedure to conduct 1 RR/SI (3) The finding of audit is circulated to all
prescription audits concerned
(4) Regular trends are analysis and presented in
Clinical Governance board/Grand round
meetings

All non compliance are enumerated 1 RR/SI Check the non compliances are presented &
recorded for medical audits
discussed during clinical Governance meetings

All non compliance are enumerated

1 RR/SI Check the non compliances are presented &
recorded for death audits discussed during clinical Governance meetings
 All non compliance are enumerated 1 RR/SI Check the non compliances are presented &
recorded for prescription audits
discussed during clinical Governance meetings

Look for completeness of audit report with non-

Clinical care audit data is analysed, and Non Compliance are enumerated and compliances identified, action plan with
ME G10.5 actions are taken to close the gaps recorded, Action plan prepared, 0 SI/RR designated responsibilities, corrective and
Corrective and preventive action
identified during the audit process taken preventive plan is implemented with
measurable improvements

Check action plans are prepared and

Randomly check the actual compliance with
implemented as per medical audit 0 RR/OB
record findings the actions taken reports of last 3 months

Check action plans are prepared and Randomly check the actual compliance with
implemented as per death audit 0 RR the actions taken reports of last 3 months
record's findings
Check action plans are prepared and
Randomly check the actual compliance with
implemented as per prescription 0 RR the actions taken reports of last 3 months
audit record findings
Check the data of audit findings are 0 RR Check collected data is analysed & areas for
collated improvement is identified & prioritised
Check the critical problems are regularly
Check PDCA or revalent quality
monitored & applicable solutions are
method is used to address critical 2 RR duplicated in other departments (wherever
problems required) for process improvement

Members of the top management meet at least

quarterly, audits and PSS analysis reports are
Governing body/top management of reviewed, minutes of the meeting are recorded,
ME G10.6 healthcare facilities ensures accountability Top management review the audit
reports and PSS periodically 2 SI/RR the minutes show that data relating to audit
for clinical care provided reports and grievances are discussed, decisions
to improve quality are made and progress is
followed.

Facility ensures easy access and use of Standard norms, guidelines and other Ask staff how they adhere with norms,
ME G10.7 standard treatment guidelines and implementation tools are accessible 2 SI/RR guidelines and implementation tools during the
implementation tools at point of care to Dialysis unit's staff provision of care at Haemodialysis Unit
Check standard treatment Staff is aware of Standard treatment protocols/
guidelines / protocols are available at 2 SI/RR
point of use guidelines

Check treatment plan is prepared as Check staff adhere to clinical protocols while
2 SI/RR
per Standard treatment guidelines preparing the treatment plan

Check the drugs are prescribed as per 2 RR Check the drugs are as per EML or formulary
Standards treatment guidelines
Area of Concern - H: Outcomes
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National Benchmarks.
 The facility measures productivity Average dialysis session conducted Total no of dialysis sessions done in a month/
ME H1.1 Indicators on monthly basis per day 2 RR total no of days in a month
Percentage of dialysis session
No of dialysis session done free*100/ total no of
conducted free of cost for entitled 2 RR dialysis sessions conducted
patients
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark.
ME H2.1 The facility measures efficiency Indicators Average dialysis sessions performed 2 RR Total no of dialysis sessions performed/ total no
on monthly basis per machine of functioning dialysis machine
Downtime critical equipments/unit 2 RR

Percentage of patients shortening No of patients leaving dialysis session before

their dialysis sessions 2 RR completion of dialysis session*100/ total no of
dialysis sessions conducted
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

Dialysis complication rate Total no of complications occurring during

ME H3.1 The facility measures Clinical Care & Safety (Percentage of incidence of 2 RR dialysis session e.g. Haematoma, Needle
Indicators on monthly basis complication occurring while dialysis dislodgement, Dialyzer mismatch, Air embolism,
session) Clotted circuit/ Total no of dialysis sessions

No of adverse events per thousand 2 RR

patients

Average Urea Reduction Ratio 2 RR Average of (pre dialysis urea-post dialysis urea)
of all the patients underwent dialysis session

Average of Kt/V (1.2)(amount of fluid that is

cleared of urea during each dialysis
Average Kt/V 2 RR session/volume of water a person's body
contains) of all the patients underwent dialysis
session

Single Dialyzer
not to be used
for more than 8
times (in
Dialyser reuse rate 2 RR Total no of dialysis sessions performed/ Total reprocessing
no of dialyzer used machine) or
bundle volume
is >70% which
is earlier.

Culture Surveillance sterility rate 2 RR % of environmental swab culture reported

positive
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

The facility measures Service Quality Average days in availing follow up [Link]
ME H4.1 Indicators on monthly basis sessions 2 RR time for follow
up session
Patient Satisfaction Score 2 RR
Checklist No. 18 General Administration Version- NHSRC/3.0
Reference ME Statement Checkpoint Compliance Assessment Means of Verification Remarks
No. Method
Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services

ME A1.16. The facility provides Accident Availability of functional A& E SI/OB

& Emergency Services department

Availability of functional disaster SI/OB

management unit

ME A1.17. The facility provides Intensive Availability of functional Intensive SI/OB

care Services care unit

ME A1.18. The facility provides Blood Availability of functional Blood Bank SI/OB
bank & transfusion services

Standard A2 Facility provides RMNCHA Services

ME A 2.1. The facility provides Availability of Post Partum unit at SI/OB

Reproductive health Services the facility

ME A2.3. The facility provides Newborn Availability of functional SNCU SI/OB

health Services

ME A2.4. The facility provides Child Availability of Functional NRC SI/OB

health Services
Availability of dedicated paediatric SI/OB
ward
Availability District Early Intervention SI/OB
Centre (DEIC)

Standard A3 Facility Provides diagnostic Services

ME A3.1. The facility provides Radiology Availability of X-Ray Unit SI/OB Availability of in-house services. Partial
Services Compliance if it is outsourced

. Availability of Ultrasound services SI/OB Availability of in-house services. Partial

Compliance if it is outsourced
. Availability of CT scan SI/OB
ME A3.2 The facility Provides Availability of In-house/ outsourced SI/OB
Laboratory Services lab

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The facility provides other
ME A 3.3 diagnostic services, as Availability of ECG Services SI/OB
mandated

Standard A4 Facility provides services as mandated in national Health Programs/ state scheme

Headed by Dermatologist/ Physician

The facility provides services
along with specialists of Orthopaedics/
ME A4.3 under National Leprosy Formation of District Apex Group SI/RR General Surgery, Ophthalmology,
Eradication Programme as per
assisted by Physiotherapist and
guidelines
laboratory Technician

The facility provides services

ME A4.4 Availability Functional ICTC is SI/OB
under National AIDS Control
available
Programme as per guidelines

Availability Functional ART centre is SI/OB

available
The facility provides services
ME A4.7. under National Programme for Availability of geriatric ward/Clinic SI/OB
the health care of the elderly
as per guidelines

The facility provides services

under National Programme for
Prevention and control of
ME A4.8. Cancer, Diabetes, Availability of CCU SI/OB
Cardiovascular diseases &
Stroke (NPCDCS) as per
guidelines

The facility Provides services

Hospital has System for immediate
ME A4.9 under Integrated Disease SI/RR
reporting of any disease out break
Surveillance Programme as
authorities
per Guidelines

A Nodal person is designated for

collecting and reporting data to IDSP SI/RR
cell
Hospital disseminate the list of
conditions to be reported to all SI/RR
clinical department

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Standard A5 Facility provides support services

ME A5.1. The facility provides dietary Availability of dietary service SI/OB

services
ME A5.2. The facility provides laundry Availability of laundry services SI/OB
services

ME A5.3. The facility provides security Availability of security services SI/OB

services

ME A5.4. The facility provides Availability of Housekeeping services SI/OB

housekeeping services

ME A5.5. The facility ensures Availability of maintenance services SI/OB

maintenance services

ME A5.6. The facility provides pharmacy Availability of drug storage and SI/OB
services dispensing services

ME A5.7. The facility has services of Availability of Medical record SI/OB

medical record department services
ME A5.8 The facility provides mortuary Availability of mortuary services SI/OB
services
Standard A6 Health services provided at the facility are appropriate to community needs.

The facility provides curatives

ME A 6.1. & preventive services for the Availability of 300 indoor functional SI/RR
health problems and diseases, beds per ten lakh population
prevalent locally.

There is process for consulting

community/ or their Community representative are
ME A 6.2. representatives when planning consulted while revising or SI/RR
or revising scope of services of expanding the scope of service
the facility

User charges if any are decided in SI/RR

consultation with user groups /RKS

Area of Concern - B Patient Rights

Standard B1 Facility provides the information to care seekers, attendants & community about the available services and their modalities

Name of the facility prominently

ME B1.1. The facility has uniform and OB
displayed at front of hospital
user-friendly signage system
building

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Hospital lay out with location and

name of the
. departments are displayed at the OB
entrance.

. Hospital has established directional OB

signage
. List of departments are displayed OB
All signages are in uniform colour OB
scheme
Signages are user friendly and OB
pictorial
The facility displays the
ME B1.2 services and entitlements Services not available are displayed OB
available in its departments

Availability of administrative services

like handicap certificate, death OB
certificate services are displayed.

Processing time for issuing

documents and Medical records are OB
displayed
Mandatory information under RTI is OB
displayed
The facility has established
ME B1.3. Citizen charter is established in the OB
citizen charter, which is
facility
followed at all levels
Citizen Charter includes Mission
statement and Quality Policy of the
facility

. Citizen charter includes the services OB

available at the facility

Citizen Charter includes the days and OB

timings of different services available

Citizen Charter Includes Rights of OB

Patient

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Citizen Charter includes
Responsibilities of Patients and OB
Visitors
Citizen Charters includes Beds OB Check for display of number for General
available beds, critical care beds

Citizen Charters Includes Complaints OB

and Grievances Mechanism

Citizen Charter mention about paid OB

services, if applicable
Check for Toll free number, name,
Citizen Charter includes Grievance OB contact number and email id of
Redressal's Help Desk
designated officer for assistance

Citizen Charter include details of Check for visiting time (Morning &
visitor policy Evening), details of visiting pass system

User charges are displayed Facility prepares a comprehensive

ME B1.4 and communicated to patients list of user charges and display at OB
effectively strategic point in the hospital
Information is available in
ME B1.6. Signage's and information are OB
local language and easy to
available in local language
understand

The facility provides

ME B1.7. information to patients and A dedicated facilitation counter/Rogi OB Important contact no. are available at
visitor through an exclusive sahayata Kendra available the counter/Rogi sahayata kendra
set-up.

. Information regarding services OB

available at the counter

. A dedicated facilitation counter for OB Contact details of the PM-JAY assisting

PM-JAY officer is available at the counter

. Availability of ASHA help desk OB

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 economic, cultural
or social reasons
Services are provided in
ME B2.1 Hospital has defined policy for non SI/PI
manner that are sensitive to
discrimination according to gender
gender

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Religious and cultural

preferences of patients and Environment of the health facility
ME B2.2 attendants are taken into should be inclusive of all religious OB
consideration while delivering faiths
services

Staff is respectful to patients PI/SI

religious and cultural beliefs
Hospital has defined policy to
ensure the religious and cultural RR/SI
preferences of the patient
Access to facility is provided
Approach road to hospital is
ME B2.3. without any physical barrier & OB
accessible without congestion or
and friendly to people with
encroachment
disabilities
Internal Pathways and corridors of
the facility are without any OB
obstruction / Protruding Object

There are no open

manholes/Potholes at access road OB
and internal pathways

Hospital has defined policy to

provide barrier free services to OB
patient

At least 120 cm width, gradient not

Ramps are conducive for use OB steeper than 1:12, ramp has slip
resistance surface
Warning blocks have been provide at
beginning and end of the ramp and OB To aid people with visual impairment
Stairs

Hand rails are provided with stairs OB

Facility conducts periodic Access OB

Audits
Hospital has defined policy for OB
providing specially able facility
Parking area is earmarked for People OB
with disabilities

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Symbol of Access is displayed at the
facilities available for people with OB Ramps, Wheel Chair Bay, Lifts, Toilets
disabilities

There is no discrimination on There is no discrimination on basis of

ME B2.4 basis of social and economic social and economic status of the PI/SI
status of the patients patients

Hospital has defined policy for

ensuring non discrimination on basis RR/SI
of social and economic status of the
patient

There is affirmative actions to

ME B2.5 There are arrangement and Linkages RR/SI Linkage for Palliative Care , Hospice
ensure that vulnerable
for care of terminally ill patients
sections can access services

There are Linkages for care ,

Counselling and Protection of RR/SI Linkages with NGOS, Police Mediation
Victims of Violence including Cell
domestic violence

There are arrangements for

adequate care and post discharge RR/SI Linkages with NGOS , Orphan , old age
support of Orphan patients including home, Children home
homeless children

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.

ME B3.1 Adequate visual privacy is Hospital has defined policy for RR/SI
provided at every point of care maintenance of privacy of patients

Confidentiality of patients Hospital has defined policy for

ME B3.2 records and clinical maintenance of patient records and RR/SI
information is maintained clinical information

Hospital defines and communicate

The facility ensures the
policy regarding decent
ME B3.3 behaviours of staff is dignified RR/SI
communication and courteous
and respectful, while
behaviour towards the patient and
delivering the services
visitors

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The facility ensures privacy

and confidentiality to every Hospital defines the policy for
ME B3.4 patient, especially of those privacy and confidentiality of the RR/SI
conditions having social patient and condition related with
stigma, and also safeguards social stigma and vulnerable groups
vulnerable groups

Standard B4 Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent
wherever it is required.
There is established
ME B4.1 procedures for taking Hospital define policy for taking RR/SI
informed consent before consent.
treatment and procedures

Patient is informed about

ME B4.2 Display of patient rights and OB
his/her rights and
responsibilities.
responsibilities

ME B4.3 Staff are aware of Patients Staff is aware of patients rights SI

rights responsibilities responsibilities
Staff is regularly sensitize about
rights and responsibilities of the SI/RR
patient

Availability of complaint box at

The facility has defined and
ME B4.5. administrative office and display of OB
established grievance
process for grievance re Redressal
redressal system in place
and whom to contact is displayed

Hospital defines policy for grievance RR/SI

redressal mechanism

There is defined frequency of

collecting complaints from complaint RR/SI
box

Records of patient complaints RR

suggestion are maintained

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Check for:
1. There is evidence of action taken on
. There is system of periodic review of RR/SI complaints
patient complaints
2. Action taken are informed to the
complainant

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.

The facility provides cashless

services to pregnant women, Hospital establish policy for
ME B5.1 mothers and neonates as per providing free services for GoI and RR/SI
prevalent government state scheme
schemes

The facility ensures that drugs Hospital has established policy for
ME B5.2 prescribed are available at providing all drugs in the EDL free of RR/SI
Pharmacy and wards cost

It is ensured that facilities for

ME B5.3 Hospital has established policy for RR/SI
the prescribed investigations
providing all diagnostics free of cost
are available at the facility

The facility provide free of

ME B5.4 cost treatment to Below Methods for verification of PI/SI
poverty line patients without documents of patient is user friendly
administrative hassles

Hospital has established policy to

provide free of cost treatment to BPL RR/SI
patients

The facility ensures timely

Hospital has establish policy for
ME B5.5 reimbursement of financial RR/SI
timely Reimbursement and payment
entitlements and
to beneficiaries
reimbursement to the patients

The facility ensure Availability of a help desk/ kiosk/Arogya

ME B5.6 implementation of health Availability of dedicated PMJAY help OB Mitra Sahayta Kendra near the
insurance schemes as per desk reception area run by Pradhan Mantri
National /state scheme Aarogya Mitra (PMAM)

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Availability of 'Beneficiary Identification

System' for creation of Golden card
Finger print verification is done OB/PI/RR Give full compliance incase the
through a finger print scanner
beneficiary already holds e-card
(Golden record)

All tests and drugs are covered OB/SI/PI Treatment is free of cost for
underPMJAY hospitalised cases

Services and entitlements available The doctors have a standard template

under PMJAY are prominently RR/SI for pre-authorization form and a list of
displayed packages
The beneficiary is informed of the
Manual process is in place in case OB/PI amount of charges for diagnosis
smart card is not working
availing consultation only
Availability of functional Transaction SI/PI
Management System

Maximum time of 6 hrs, in case

approval is required from ISA/trust or
Pre-authorisation request is PI/SI/RR should be approved automatically, if no
approved timely
prior approval required from ISA
(implementation support agency)

Medicines and diagnostic services

are free of cost for 15 days post- PI/RR
discharge
Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities
Ethical norms and code of Check for any circular, policy, notice,
Check that hospital administration
ME B6.1 conduct for medical and RR/SI government order issued that explains
has defined code of conduct for
paramedical staff have been the code of conduct for staff such as
various cadre of staff
established. doctor and nurses.

ME B6.2 The Facility staff is aware of Check if staff is aware of code of RR/SI Interview doctors and nursing /
code of conduct established conduct paramedical staff on sample basis.

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Ask medical superintendent / manager

regarding any such circular /
The Facility has an established Check hospital has implemented a
instructions issued to the doctors.
ME B6.3 procedure for entertaining policy of not entertaining RR/SI Check on sample basis if doctors are
representatives of drug representative of pharma companies
aware of this policy and do not
companies and suppliers within hospital premises
entertain medical representatives in
hospital premises

The Facility has an established

procedure for medical
Check hospital administration has
examination and treatment of
ME B6.4 aware of protocols for examination RR/SI As per state law and supreme court
individual under judicial or
and treatment t of individuals direction
police detention as per
brought police
prevalent law and
government directions

Check list of agencies with which data

There is an established
shared has routinely shred has been
procedure for sharing of
prepared . For any other agency a
ME B6.5 hospital/patient data with Check hospital administration has RR/SI formal permission is sought from
individuals and external defined protocols for data sharing
competent authorities before sharing
agencies including non
the data including international
governmental organization
agencies, press and NGOs.

There is an established
ME B6.6 Facility has established has SI/RR
procedure for ‘end-of-life’
established policy of end of life care
care

There is an established
procedure for obtaining Check hospital ensures that
ME B6.8 informed consent from the informed consent is taken from SI/RR Check for policy or practice
patients in case facility is patient participating in any clinical or
participating in any clinical or public Health research
public health research

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Check for policy defines

List of certificates can be issued by
hospital
There is an established Who can issue certificates
ME B6.9 procedure to issue of medical Check hospital has documented SI/RR Formats shall used for different
certificates and other policy for issuing medical certificates certificates
certificates Record keeping of issued certificate
procedures for issuing duplicate
certificates

Check hospital administration has made

There is an established Buffer stock and alternate source pf
procedure to ensure medical Hospital has laid strategy to resume supplies for consumables
ME B6.10 services during strikes or any the basic emergency and patient SI/RR
other mass protest leading to care services during strikes Strategy and coordination with local
dysfunctional medical services disruption to maintain hospital
functions

An updated copy of code of

ME B6.11 ethics under Indian Medical Check code of conduct copies are SI/RR Check for availability of printed copies
council act is available with available at the hospital of code of conduct distributed to staff
the facility

(a) Check the adequacy of the

framework. It address the ethical issues
Facility has established a
and decision making in clinical care
framework for identifying,
(b) Check facility's ethical management
ME B6.12 receiving, and resolving ethical Check facility has defined its ethical RR/SI framework address issues like
dilemmas’ in a time-bound issues management framework
admission, discharge, transfer,
manner through ethical
disclosure of information or any
committee
professional conflict which may not be
in patient's best interest

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Facility's supporting human subject

research activities/ publishing the
scientific papers/ supporting medical
students in thesis writing/ running any
course where patient data is collected
and used for above mentioned activities
- an ethical committee is constituted
and approval are taken before
publication.
Check facility has ethical committee or
or person designated to address the Facility may collaborate with the
ethical issues confronted by medical RR/SI institutions where there are ethical
professionals while delivering the committee is present and appropriate
services approvals, guided by applicable laws
and regulations is taken.
or
the facilities where they are not
involved in research activities, to
address the ethical dilemma's a person
or group is appointed to address the
dilemmas effectively within legal
parameter

Check when the list was last updated.

Engage with the available medical
Check the list of ethical issues is RR/SI professionals to check what type of
available and regularly updated ethical dilemmas they are facing while
performing their job & how they are
dealing with dilemma's.

Check the facility has defined

mechanism identification and
RR/SI Check staff is aware of reporting
reporting of the ethical issues/
mechanism
dilemmas confronted during services
delivery

Check regular review of identified

Check the timely resolution of the
and reported ethical issue is done by RR/SI identified and reported ethical issues is
appointed personnel /group/
done
committee

Check all the decisions related to Check information regarding ethical

ethical dilemma's are communicated 1 RR/SI dilemma's & its handling is also given to
to all concerned new joinee's

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Area of Concern - C Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
Departments have adequate
ME C1.1. Residential quarters for clinical and OB/RR
space as per patient or work
support staff
load

Hospital has adequate space as per OB/RR 80 to 85 sqm per bed .

bed strength

ME C1.2. Patient amenities are provide OB

Availability of public toilet for visitors
as per patient load

. Availability of dharmshala/stay OB
facility for attendants
Adequate number of Staff toilets OB/SI
available in proximity to duty area
Adequate number of Staff change
room available in proximity to duty OB/SI
area
Separate cafeteria for patient and OB
their relatives
Cafeteria/ Recreation room for staff OB/SI
Availability of Staff amenities at OB/SI
nursing station and duty room
Departments have layout and Hospital has independent entry for
ME C1.3. demarcated areas as per emergency, OPD and support OB
functions services/staff
Corridors shall be at Wide to
. accommodate the daily traffic. OB

The general traffic should not pass

. through the indoor/ critical patient OB
care area

OPD, Emergency and Administrative

. Ambulatory services are located in OB offices are situated in near the entry/
outermost zone exit of the hospital with direct access
from approach road
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. Clinical support Services are located OB Lab , Radiology and Pharmacy

in proximity to outer zone
Procedure and Intensive Care areas
OB Operation Theatre, ICU, SNCU, Labour
are located in Middle zone of the
Room
Hospital
Indoor area are located in Inner zone OB Wards and Nursing Units are located in
of the Hospital inner most area
The facility has adequate
Corridors shall be at Wide to
ME C1.4. circulation area and open OB
accommodate the daily traffic.
spaces according to need and
local law

Facility maintains open area as per

floor area ratio mandated by OB
authorities

The facility has infrastructure

ME C1.5. Hospital has 24X7 functional OB
for intramural and extramural
telephone connection
communication

. There is designated person to OB/SI/RR

answer the telephone enquiries

. Hospital has broadband internet OB

connectivity
There is establish system for OB/RR Records are maintained for received
managing postal communication and dispatched communication
There is established system for
OB/RR System for communicating circulars,
internal movement of documents
notices and orders etc.
and communication
There is assigned person for
managing internal and external OB/RR
movement of documents and
communications
General notices and information are
displayed at notice boards at OB/RR
relevant points
There is system of removal of old
notices and updating the notice OB/RR
board
ME C1.6 Service counters are available Availability of admission counter as OB/RR
as per patient load per load

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The facility and departments

are planned to ensure
ME C1.7. structure follows the There is no crises cross between OB
function/processes (Structure General and Patient Traffic
commensurate with the
function of the hospital)

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

The facility ensures the Facility has been surveyed by
ME C2.1. seismic safety of the Structural engineer for seismic OB/RR Ask for records of survey
infrastructure vulnerability
Check for records of in correction has
Structural Components been made OB/RR been done to strengthen structural
earthquake proof components like columns, beams, slabs,
walls etc.

Check for any information available

Foundation of buildings are OB/RR about the depth of foundation. Its
adequate
should not be less the 1.5 meters

In multi story building height of the

There is no irregularity in height of OB/RR story should be of same height
different stories (Difference should not be more than
5%.

The facility ensures safety of

ME C2.2. lifts and lifts have required Lifts are installed with Automatic OB/RR
certificate from the Rescue device.
designated bodies/ board

. Every lift has Emergency Alarm OB/RR

System
. Periodic Maintenance of lift OB/RR
. Licence for lift operation OB/RR

Facility has mechanism for

ME C2.3. The facility ensures safety of periodical check / test of all electrical OB/RR
electrical establishment installation by competent electrical
Engineer

. Facility has system for power audit OB/RR

of unit at defined intervals
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Danger sign is displayed at High OB
voltage electrical installation
All electrical panels are covered and OB
has restricted access
Personal protective equipment are OB/SI
available with electrician
Physical condition of buildings
ME C2.4. Windows have grills and wire OB
are safe for providing patient
meshwork
care

. Terrace, roof, balconies and stair OB

case have protective railing

. Hospital premises has intact OB

boundary wall

. Hospital has functional gate with OB

provision of cattle trap
There is system of periodic
. inspection of patient care areas of OB
safety related issues
Hospital building including walls,
roofs, floor, windows , balconies and OB
terraces are maintained
Access to roof and terraces are OB
restricted

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

Check the fire exits provide egress

ME C3.1. The facility has plan for OB
to exterior of the building or to
prevention of fire
exterior open space

. Check the fire exits are free from OB

obstruction

. Facility has conducted fire safety OB/RR

audit by competent authority

. Evacuation plan is displayed at OB

critical areas
Facility has defined and
implemented evacuation plan in case OB/RR
of fire

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No smoking sign displayed inside and OB/RR
outside the working area

ME C3.2. The facility has adequate fire Facility has fire safety alarm OB
fighting Equipment
There is system to track the expiry
dates and periodic refilling of the OB/RR
extinguishers

The facility has a system of

periodic training of staff and
ME C3.3. Periodic Training is provided for OB/RR
conducts mock drills regularly
using fire extinguishers
for fire and other disaster
situation
Periodic mock drills are conducted OB/RR
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load

The facility has adequate

ME C4.1. specialist doctors as per Availability of General Surgeon OB/RR/SI As per patient load
service provision

. Availability of Obstetric & Gynae OB/RR/SI As per patient load

Specialist
Availability of General Medicine OB/RR/SI
specialist
. Availability of Paediatrician OB/RR/SI As per patient load
. Availability of Anaesthetics OB/RR/SI As per patient load
. Availability of Ophthalmologist OB/RR/SI As per patient load
. Availability of Orthopaedic Surgeon OB/RR/SI As per patient load
. Availability of Radiologist OB/RR/SI As per patient load
. Availability of Pathologist OB/RR/SI As per patient load
. Availability of ENT specialist OB/RR/SI As per patient load
. Availability of Dentist OB/RR/SI As per patient load
. Availability of Dermatologist OB/RR/SI As per patient load
. Availability of Psychiatrist OB/RR/SI As per patient load
. Availability of Microbiologist OB/RR/SI As per patient load
. Availability of AYUSH Doctors OB/RR/SI As per patient load

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The facility has adequate

ME C4.2. general duty doctors as per Availability of general duty doctors OB/RR/SI As per patient load
service provision and work
load

The facility has adequate

ME C4.3. nursing staff as per service Availability of nursing staff OB/RR/SI As per patient load
provision and work load
The facility has adequate
ME C4.4. technicians/paramedics as per Availability Lab Tech OB/RR/SI As per patient load
requirement
. Availability Pharmacist SI/RR As per patient load
. Availability Radiographer SI/RR As per patient load
. Availability ECG Tech/Eco SI/RR As per patient load
. Availability Audiometrician SI/RR As per patient load
. Availability Optha. SI/RR As per patient load
Technician/Referactionist
. Availability Dietician SI/RR As per patient load
. Availability Physiotherapist SI/RR As per patient load
. Availability O.T. technician SI/RR As per patient load
. Counsellor SI/RR As per patient load
. Dental Technician SI/RR As per patient load
. Rehabilitation Therapist SI/RR As per patient load
. Biomedical Engineer SI/RR As per patient load
ME C4.5. The facility has adequate SI/RR
Availability of storekeeper
support / general staff

. Availability of Housekeeping SI/RR

supervisor/In charge
. Availability of security In charge SI/RR
Standard C5 Facility provides drugs and consumables required for assured list of services.

The departments have

ME C5.1 Hospital has policy to ensure drugs SI/RR
availability of adequate drugs
at all point of use as per state EML
at point of use

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

Availability of functional
ME C6.6 Availability of equipment for Facility OB Equipment's for horticulture, electrical
equipment and instruments
management repair, plumbing material etc
for support services

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Availability of equipment for OB Autoclave and mutilator
processing of Bio medical waste
Departments have patient
ME C6.7 Availability of fixture for OB
furniture and fixtures as per
administrative office
load and service provision
Availability of furniture for OB
administrative office
Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

Check objective checklist has been

prepared for assessing competence of
Criteria for Competence Check parameters for assessing skills doctors, nurses and paramedical staff
ME C7.1 assessment are defined for and proficiency of clinical staff has RR based on job description defined for
clinical and Para clinical staff been defined each cadre of staff. Dakshta checklist
issued by MoHFW can be used for this
purpose.

Check for records of competence

Competence assessment of
assessment including filled checklist,
ME C7.2 Clinical and Para clinical staff is Check for competence assessment is RR scoring and grading . Verify with staff
done on predefined criteria at done at least once in a year
for actual competence assessment
least once in a year
done

Check if performance appraisal critical

Criteria for performance
ME C7.3 Check performance criteria for RR clinical staff has been defines as per
evaluation clinical and Para
clinical staff has been defined state service rules/ NHM Guidelines
clinical staff are defined
and job description of staff

Verify with records that performance

Performance evaluation of appraisal has been done at least once in
ME C7.4 clinical and para clinical staff is Check if annual performance RR a year for all Doctor, Nurses and
done on predefined criteria at appraisal for clinical staff is practiced paramedic staff .l. Check that
least once in a year predefined criteria has been used for
the appraisal only.

Check if performance appraisal critical

Criteria for performance
for both support/ administrative staff
ME C7.5 evaluation of support and Check performance criteria for RR has been defines as per state service
administrative staff are support staff has been defined
rules/ NHM Guidelines and job
defined
description of staff

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Verify with records that performance

Performance evaluation of appraisal has been done at least once in
Check if annual performance
ME C7.6 support and administration RR a year for all administrative and support
appraisal for support &
staff is done on predefined staff either appointed at hospital .
administration staff is practiced
criteria at least once in a year Check that predefined criteria has been
used for the appraisal only.

Verify with records that staff on

contract under NHM or any other
program, staff working through
Competence assessment and
Check staff if competence outsource agencies such as
performance assessment
ME C7.7 assessment and performance RR housekeeping and security are also go
includes contractual,
appraisal program includes staff is through the competence assessment
empanelled, and outsourced
inclusive contractual staff. along with regular staff. Also their
staff
performance appraisal is done at least
once in year by their respective
employer.

Check that hospital administration has

listed the gaps found during
Training needs are identified
competence assessment and
based on competence Check if hospital administration has
ME C7.8 RR performance appraisal exercise . These
assessment and performance a system for identifying the training
gaps in performance and competence
evaluation and facility needs and plan to address them
are factored in while developing
prepares the training plan
training plan for staff. This includes
both clinical as well as non clinical staff.

The Staff is provided training

Facility conduct training need
ME C7.9 as per defined core SI/RR
assessment periodically for all cadre
competencies and training
of staff
plan

Facility has program for continuous

medical education for doctors and SI/RR
nursing staff
Facility prepares training calendar as SI/RR
per training need assessment

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Training feed back is taking and SI/RR

records are maintained for training

Details and Records of training SI/RR

provided are available with unit
Training on Disaster Management SI/RR
Training on Cardio Pulmonary SI/RR
resuscitation
Training on staff Safety SI/RR
Training on Measuring Hospital SI/RR
Performance Indicators
Training on facility level Quality SI/RR
Assurance

Check supervisors make periodic

There is established procedure rounds of department and monitor that
Hospital has policy for regular
ME C7.10 for utilization of skills gained SI/RR staff is working according to the
competence testing as per job
thought trainings by on -job training imparted. Also staff is provided
description.
supportive supervision on job training wherever there is still
gaps

Verify with records of performance

Feedback is provided to the
Check if feedback is given after each appraisal for feedback has been written
ME C7.11 staff on their competence RR
round of competence assessment on appraisal form and shared with staff.
assessment and performance
and performance appraisal Interview staff for verification for
evaluation
feedback has been shared

Area of Concern - D Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.

The facility has established

ME D1.1. Facility has contract agency for SI/RR
system for maintenance of
maintenance for equipment
critical Equipment
Contact details of the agencies
responsible for maintenance are SI/RR
communicated to the staff
Asset list of all equipment are SI/RR
maintained

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There is system to maintain records SI/RR

of down time of equipment

Indexing of all equipment is done SI/RR

All equipment are covered under
AMC including preventive SI/RR
maintenance for computers and
other IT equipment

There has system to label

Defective/Out of order equipment OB/RR
and stored appropriately until it has
been repaired
Staff is skilled for trouble shooting in SI/RR
case equipment malfunction

There is system of timely corrective

break down maintenance of the for SI/RR
computers and other IT equipment

The facility has established

ME D1.2. procedure for internal and Facility has contracted agency for SI/RR
external calibration of calibration of equipment.
measuring Equipment
Records of the calibrated equipment RR
are maintained

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas

The facility ensures Check record of stock receipt from

ME D2.4 Hospital has system to ensure that SI/RR
management of expiry and warehouse and Local purchase
short expiry drugs are not procured
near expiry drugs purchase receipt
Hospital has process for proper
SI/RR Check policy for disposal of expired
disposal and prevention of
drugs and consumables
unintended use of expired drugs

The facility has established Hospital implements scientific Previous consumption pattern, disease
ME D2.5 procedure for inventory inventory management system OB/RR/SI burden, local disease prevalence,
management techniques according to their needs seasonality, ABC, VED, FSN

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There is a procedure for Hospital has policy that there is no
ME D2.6 RR/SI Check policy for no stock out situation,
periodically replenishing the stock out of the drugs and
stock replenishment
drugs in patient care areas consumables at patient care area

Hospital has a policy for ensuring

There is a procedure for proper management and restriction
ME D2.8 secure storage of narcotic and of unintended use of narcotic RR/SI
psychotropic drugs substance and psychotropic drugs as
per prevalent law

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

The facility provides adequate

ME D3.1. Adequate illumination in open area OB
illumination level at patient
at night
care areas
Adequate illumination in circulation OB Stairs, corridor and waiting area
area
Adequate illumination in toilets OB
Hospital periodically measure
illumination at different area of the OB
hospitals
Adequate illumination at approach OB
roads to hospital
The facility has provision of There is restriction on entry of
ME D3.2. restriction of visitors in patient vendors and hawkers inside the OB
areas premise of the hospital
. Hospital has visitor policy in place OB/RR

. Hospital has policy for restriction of OB/RR

media person in side the hospital

Hospital implement visitor pass area OB/RR

for indoor areas
The facility has security
ME D3.4. Hospital has in-house/outsourced RR/SI
system in place at patient care
security system in place
areas

. Duty roaster is available for security RR/SI

staff

. Training and Drills of security staff is RR/SI

done

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Security staff is aware of patient
. right, visitor policy and disaster RR/SI
Management

. There is system for supervision of RR/SI

security staff
Facility has a security plan for
. deputation of guard at different RR/SI
location

Responsibility and timing of opening

. and closing different department is RR/SI
fixed and documented

. There is established procedure for RR/SI/OB

safe custody of keys

. There is procedure for handing over RR/SI

the keys at the time of shift change

. Hospital has system to manage RR/SI

violence /mass situation
The facility has established
ME D3.5. No female staff is posted alone at SI
measure for safety and
night
security of female staff
Where ever there are male
. employees/patients female staff are SI/RR
posted in pairs
Timing of the shift is arranged
. keeping in mind the safety of female SI/RR
staff
Committee against sexual
. harassment is constituted at the RR/SI
facility
Staff has been provided awareness RR/SI
training on Gender issues

Standard D4 The facility has established Programme for maintenance and upkeep of the facility

ME D4.1. Exterior of the facility building Boundary Walls of building is OB

is maintained appropriately plastered and whitewashed.

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. No unwanted/outdated posters on OB
hospital boundary and building walls

. Hospital Buildings are in uniform OB

colour scheme

. Hospital has system to whitewash OB/RR

the building periodically
General waste from hospital is
ME D4.2. Patient care areas are clean OB/RR
removed daily by
and hygienic
municipal/outsourced agency
Every department has Schedule of SI/RR Every department has schedule for
cleaning inspection of cleaning work
Hospital has system for periodic
ME D4.3. Hospital infrastructure is OB/RR
maintenance of infrastructure at
adequately maintained
defined interval

. There is no clogged/over flowing OB

drain in facility

. Hospital sewage is linked with OB/SI/RR

municipal drainage system

. Facility has a closed drainage system OB

. Intramural roads are in good OB

condition without potholes/ditches

. Facility has a annual maintenance RR/SI

plan for its infrastructure

ME D4.4. Hospital maintains the open Availability of parking space as per OB

area and landscaping of them requirement

. Dedicated parking space for OB

ambulances

. No water logging in side the OB

premises of the hospital

. There is no abandoned /dilapidated OB

building in the premises

. Proper landscaping and maintenance OB

of trees, garden
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There shall be no encroachment in
. and around OB
the hospital

. Hospital has rain water harvesting OB

facility
. Hospital has Herbal garden OB
The facility has policy of
ME D4.5. Hospital has condemnation policy in RR/SI
removal of condemned junk
place
material

. Periodic removal of junk material OB/RR

done
Hospital has designated covered
. place to keep junk/condemned OB
material

. No junk/condemned articles in open OB

spaces
The facility has established
ME D4.6. Pest control measures are evident at RR/SI
procedures for pest, rodent
facility
and animal control

. Anti Termite treatment of the RR/SI

wooden furniture

Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms

The facility has adequate

ME D5.1. arrangement storage and Hospital has adequate water storage OB/RR/SI 450-500 Litres per bed per day
supply for portable water in all facility as per requirements
functional areas

Hospital has adequate water supply

. from municipal /under ground OB/SI
source

. All water tanks are kept tightly OB

closed

. Periodic cleaning of water tanks OB/RR Records of cleaning is maintained

carried out
Hospitals periodically tests the
quality of water from the source RR
(municipal supply, bore well etc) for
bacterial and chemical content

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Chlorination of water is done as per RR
requirement
RO/ Filters are available for potable OB
drinking water
Hospital ensures that the
distribution pipelines are not running RR/SI
in close vicinity of the sewage
system.

The facility ensures adequate

ME D5.2. Availability of noiseless generators OB/SI
power backup in all patient
for power back up
care areas as per load

Estimation of power consumption of

different department of hospitals is RR/SI
done
Generator has adequate capacity to
provide 24x7 power back at least RR/SI
critical areas

. Hospital has dedicated sub station OB/RR/SI

for electrical supply
Hospital has adequate power supply RR/SI 3Kw to 5Kw per bed
connection
Use of energy efficient bulbs/solar SI
panel for light
Critical areas of the facility
ME D5.3. ensures availability of oxygen, Manifold room is located on ground OB
medical gases and vacuum floor
supply

Manifold room has adequate stock OB/SI At least for three days
of Oxygen and Nitrogen Cylinders

Check for there two dedicated banks -

Cylinders banks are in duplicate OB/RR/SI Running and reserve fitted with
automatic changeover device

Colour of gas pipeline and Gas OB/RR

Cylinder are as per standards

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Alarm system has been provided to
indicate any abnormal pressure RR/SI
change
LMO storage tank has a Petroleum Also check for availability of Medical
and Explosive Safety Organisation RR/SI Gas Pipeline System (MGPS) network in
(PESO) license the hospital
LMO tank is located away from the
indoor environment or not located OB
near drain or pits

Check that
1. flammables and combustibles are not
Availability of vacant space within a
stored in near vicinity
radius of 5 meters around the tank
2. Postage of ‘No Smoking” and ‘No
Open Flames’ signages

There is procedure for prompt

replacement of empty cylinders with SI/RR/OB
filled cylinders
There is a procedure for periodic
checking of all terminal units for SI/RR
malfunctioning
Entry to Manifold room/LMO plant is OB/SI
prohibited
Instruction for operating different OB
equipment clearly displayed

Standard D7 The facility ensures clean linen to the patients

The facility has established

ME D7.2 procedures for changing of Hospital has policy to change linen RR/SI
linen in patient care areas

Standard D8 The facility has defined and established procedures for promoting public participation in management of hospital transparency and accountability.

The facility has established

Hospital Management Society/RKS is
ME D8.1. procedures for management RR
registered under societies
of activities of Rogi Kalyan
registration act
Samitis

. Availability of Income tax exemption RR

certificate for donations

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. RKS meeting are held at prescribed RR

interval
. Minutes of meeting are recorded RR
. Participation of community RR
representatives/NGO is ensured

. RKS reviews the patient complaint/ RR

feedback and action taken

. RKS generates its own resources RR/SI

from donation/leasing of space

The facility has established

ME D8.2. procedures for community Community based monitoring/social RR/SI
based monitoring of its audits are done at periodic intervals
services
Facility communicate updated RR/SI
information on Quality of services

Facility participates in Jan Sunawais RR/SI

and Jan Samvads at regular intervals

Standard D9 Hospital has defined and established procedures for Financial Management

The facility ensures the proper

ME D9.1. There is system to track and ensure RR/SI
utilization of fund provided to
that funds are received on time
it
Funds/Grants provided are utilized in RR
specific time limit

There is no backlog in payment to

. RR/PI E.g.; Payment for JSY ,Family planning &
beneficiaries as per their entitlement
ASHA
under different schemes

. Salaries and compensation are RR/SI

provided to contractual staff on time

. Facility provides utilization certificate RR

for funds on time
The facility ensures proper
ME D9.2. Facility prioritize the resource RR/SI
planning and requisition of
available
resources based on its need
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. Requirement for funds are sent to RR/SI

state on time
Standard Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
D10
The facility has requisite
ME D10.1. licences and certificates for Availability of valid No objection RR
operation of hospital and Certificate from fire safety authority
different activities

Availability of Biomedical Waste

. Management Authorisation for RR
generating BMW as per prevalent
norms/regulations

. Availability of certificate of RR
inspection of electrical installation
Availability of licence for operating RR
lift
Updated copies of relevant
Availability of copy of Bio medical
ME D10.2. laws, regulations and RR
waste management rules 2016 and
government orders are
it's subsequent amendments
available at the facility
Drug and cosmetic Act 2005 RR
Safety code for Medical diagnostic X RR AERB safety code no. AERB/SC/MED-
ray equipment and installation 2(Rev 1)
Narcotics and Psychotropic RR
substances act 1985
Code of Medical ethics 2002 RR
Nursing Council Act RR
Medical Termination of Pregnancy RR
1971 & amendments
Person with disability Act 1995 RR
Pre conception pre natal diagnostic RR
test 1996
Right to information act 2005 RR
Indian Tobacco control Act 2003 RR
Standard Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.
D11

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The facility has established job
ME D11.1. Job description of Specialist Doctor is RR Regular + contractual
description as per govt
defined and communicated
guidelines

Job description of General duty RR Regular + contractual

Doctor is defined and communicated

. Job description of nursing staff is RR Regular + contractual

defined and communicated
Regular + contractual. Lab technician, X
. Job description of paramedic staff is RR ray technician, OT technician, MRD
defined and communicated
technician etc.
Job description of counsellor is RR Regular + contractual
defined and communicated
Job description of ward boy is RR Regular + contractual
defined and communicated
Job description of security staff is RR Regular + contractual
defined and communicated
Job description of cleaning staff is RR Regular + contractual
defined and communicated
Regular + Contractual MS, Hospital
Job description of Administrative RR Manager, supervisor, Matron, Ward
staff is defined and communicated
Master. Pharmacist etc.

The facility has a established

ME D11.2. procedure for duty roster and Duty roster of doctors is prepared, RR/SI
deputation to different updated and communicated
departments
Duty roster of Nurses is prepared, RR/SI
updated and communicated
Duty roster of Paramedics is
prepared, updated and RR/SI
communicated
Duty roster of Cleaning staff is
prepared, updated and RR/SI
communicated
Duty roster of security staff is
prepared, updated and RR/SI
communicated

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There is provision of Rotatory RR/SI
posting of staff
Facility has established line of
reporting for clinical and RR/SI
administrative staff

The facility ensures the

adherence to dress code as
ME D11.3. Facility has policy for dress code for RR/SI
mandated by its
different cadre of hospital.
administration / the health
department

. I Cards have been provided to staff OB

. Name plate have been provided to OB

staff
Standard Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations
D12
There is established system for Valid contract for disposal for Bio
ME D12.1. contract management for out Medical waste with common RR
sourced services treatment facility
Selection of outsourced agencies
. done through competitive tendering RR
system
Eligibility criteria is explicitly defined RR
as per term of reference

There is system to make payment as Check for that Contract document has
. per adequacy and quality of services RR provision for dedication of payment if
provided by the vendor quality of services is not good

. Payment to the outsourced services RR

are made on time
There is a system of periodic Facility as defined criteria for
ME D12.2. review of quality of out assessment of quality of outsourced RR
sourced services services
Regular monitoring and evaluation of
staff is done according against RR
defined criteria
Actions are taken against non
compliance / deviation from RR/SI
contractual obligations
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Records of blacklisted vendors are RR
available with facility
Area of Concern - E Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

Facility ensures that there is process

ME E1.3 There is established procedure RR/SI
for admission of patients after
for admission of patients
routine working hours

There is established procedure

Facility updates daily availability of
ME E1.4 for managing patients, in case RR/SI/PI
vacant patient beds in different in
beds are not available at the
door units
facility

Facility has established plan for

accommodating high patient load RR/SI
due to situation like disaster/ mass
casualty or disease outbreak

Facility has policy for internal

adjustment of the patient within RR/SI
cold wards for accommodating
patient as extra temporary measure

Standard E3 Facility has defined and established procedures for continuity of care of patient and referral

Facility has established

Facility has established policy for co
ME E3.1. procedure for continuity of RR/SI
ordination and handover during
care during interdepartmental
interdepartmental transfer
transfer

There is a policy for consultation of

. the patient to other specialist with in RR/SI
the hospital

Facility provides appropriate

referral linkages to the There is policy for referral of patient
ME E3.2. patients/Services for transfer for which services can not be RR/SI
to other/higher facilities to provided at the facility
assure their continuity of care.

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Facility maintain list of higher
. centres where patient can be RR/SI
managed.

. Facility ensures the referral patient RR/SI

to public healthcare facilities
Facility defines and communicate
. referral criteria for different RR/SI
departments

There is system to check that patient

are not unduly referred for the RR/OB
services those can be available at the
facility

Facility is connected to
ME E3.4 There is functional telemedicine OB
medical colleges through
centre
telemedicine services
Telemedicine services are utilized for RR/SI
continual medical education

Standard E4 The facility has defined and established procedures for nursing care

Procedure for identification of

ME E4.1 There is policy for identification of RR/SI
patients is established at the
patient before any clinical procedure
facility

Procedure for ensuring timely

There is a policy for ensuring
ME E4.2. and accurate nursing care as RR/SI
accuracy of verbal/telephonic orders
per treatment plan is
established at the facility

There is established procedure

ME E4.3 of patient hand over, Hospital has policy for patient hand RR/SI
whenever staff duty change over during shift change
happens

ME E4.4 Nursing records are Hospital has policy for maintaining RR/SI
maintained nursing records
There is procedure for
ME E4.5 There is policy for periodic RR/SI
periodic monitoring of
monitoring of patient
patients

Standard E5 Facility has a procedure to identify high risk and vulnerable patients.

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The facility identifies Hospital identify and communicate
ME E5.1 vulnerable patients and the category of patient considered as OB/SI
ensure their safe care vulnerable
The facility identifies high risk Hospital identify and communicate
ME E5.2 patients and ensure their care, the category of patient considered as OB/SI
as per their need high risk

Standard E6 Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use.

Facility ensured that drugs are Facility has policy and enabling order
ME E6.1. prescribed in generic name for prescribing drugs in generic drug RR
only only

ME E6.2 There is procedure of rational Facility provides adequate copies of SI/RR

use of drugs STG to respective department
Facility maintains a list of updated RR
version of STG
Facility provides training on use of SI/RR
STG

Standard E7 Facility has defined procedures for safe drug administration

There is a procedure to check

ME E7.3 Facility has policy for reporting of RR/SI Adverse drug event trigger tool is used
drug before administration/
adverse drug reaction to report the events
dispensing

Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage

The facility ensures safe and

ME E8.7 Hospital has policy for retention RR
adequate storage and retrieval
period for different kinds of records
of medical records
Hospital has policy for safe disposal RR
of records
Standard The facility has defined and established procedures for Emergency Services and Disaster Management
E11

ME E11.3. The facility has disaster Hospital has prepared disaster plan RR
management plan in place

. Disaster management committee RR

has been constituted
Standard The facility has defined and established procedures for the management of death & bodies of deceased patients
E16

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Death of admitted patient is Facility has a standard procedure to
ME E16.1. adequately recorded and decent communicate death to SI/RR
communicated relatives

Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines

The facility provides

ME E20.1 Facility has established produce for SI/RR
immunization services as per
reporting and follow up of AEFI
guidelines
Staff is trained for detecting , SI/RR
managing and reporting of AEFIs
Area of Concern - F Infection Control
Standard F1 Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection

ME F1.1. Facility has functional Infection control committee SI/RR

infection control committee constitute at the facility
ICC is approved by appropriate SI/RR
authority
Roles and responsibilities are
. defined and communicated to its SI/RR
members
ICC meet at periodic time interval SI/RR
Records of Infection control activities SI/RR
are maintained
Facility has provision for
Facility has in-house/ linkage with
ME F1.2. Passive and active culture SI/RR
microbiology lab for culture
surveillance of critical & high
surveillance
risk areas

There is defined format for

requisition and reporting of culture SI/RR
surveillance
Reports of culture surveillance are SI/RR
collated and analysed
Feedback is given to the respective SI/RR
departments

ME F1.3 Facility measures hospital Sample are taken for culture to SI/RR
associated infection rates detect HAI in suspected cases.

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There is defined criteria and format
for reporting HAI based on clinical SI/RR
observation

Reports from different department SI/RR

are collated and analysed

Feedback is given to the respective SI/RR

departments
There is Provision of Periodic
ME F1.4. Medical Check-ups and Records of immunization available SI/RR
immunization of staff

. Records of Medical Check-ups are SI/RR

available
Facility has established
There is designated person for Co
ME F1.5. procedures for regular SI/RR Infection control nurse
coordinating infection control
monitoring of infection control
activities
practices

There is defined format/checklist for

. monitoring of hand washing and SI/RR
infection control practices

ME F1.6. Facility has defined and Facility has antibiotic policy in place SI/RR
established antibiotic policy
There is system for reporting Anti
Microbial Resistance with in the SI/RR
facility

Antibiotic policy includes plan for

identifying, transferring , discharging
and readmitting patients with SI/RR
specific antimicrobial resistant
pathogen

Policy Includes Rational Use of SI/RR

Antibiotics
Standard treatment guidelines are
followed while developing Antibiotic SI/RR
Policy
There is procedure for periodic
Laboratory Surveillance for Antibiotic SI/RR
Resistance

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Facility Measures the Antibiotic SI/RR
Consumption Rates

Standard F2 Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis

Facility ensures uninterrupted and

ME F2.1 Hand washing facilities are adequate supply of antiseptic soap SI/RR
provided at point of use and alcohol hand rub in all
departments

Staff is trained and adhere to

ME F2.2 Check for the records that training SI/RR
standard hand washing
have been provided
practices
Facility ensures standard
ME F2.3 Facility ensures uninterrupted and SI/RR
practices and materials for
adequate supply of antiseptics
antisepsis

Standard F3 Facility ensures standard practices and materials for Personal protection

Facility ensures adequate

ME F3.1 personal protection Availability of Heavy duty gloves for OB/SI
equipment as per cleaning staff
requirements
Availability of gum boats for cleaning OB/SI
staff

Availability of mask for cleaning staff OB/SI

Availability of apron for cleaning staff OB/SI

Facility ensure adequate and regular

supply of personal protective SI/RR
equipment
There is policy for judicious use of
ME F3.2 Staff is adhere to standard SI/RR
personal protective equipment
personal protection practices
specially sterile gloves

Standard F4 Facility has standard Procedures for processing of equipment and instruments

Facility ensures standard

practices and materials for
ME F4.1 Facility ensure adequate supply of SI/RR Disinfectant like hypochlorite, bleaching
decontamination and cleaning
disinfectant at the point of use powder etc.
of instruments and
procedures areas
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Staff is trained for preparation of SI/RR
disinfectant solution

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention

Facility ensures availability of

Facility ensure the availability of
ME F5.2 standard materials for SI/RR
good quality disinfectant and
cleaning and disinfection of
cleaning material
patient care areas

ME F5.4 Facility ensures segregation Hospital has policy for identification SI/RR
infectious patients and segregation of infectious patient

Standard F6 Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

Facility Ensures segregation of Facility ensures adequate and

ME F6.1 Bio Medical Waste as per regular supply of non chlorinated SI/RR
guidelines colour coded liners
Check adequacy in patient care and
Separate bins for Recyclable and
administrative areas. Also check there
biodegradable waste is available
is no mixing of waste

There is established procedure for

daily monitoring of proper SI/RR
segregation of Bio medical waste by
a designated person
Bar code system for the bags or
containers containing BMW

ME F6.2 Facility ensures management Facility ensures supply of puncture SI/RR Containers are puncture proof, leak
of sharps as per guidelines proof containers and needle cutters proof and temper proof

Facility ensures availability of post SI/RR

exposure prophylaxis drugs
There is system for reporting of SI/RR
needle stick injuries
Facility ensures transportation Facility has secured designated place
ME F6.3. and disposal of waste as per for storage of Bio Medical waste SI/OB
guidelines before disposal

BMW is stored in lock and key SI/OB Check there is no scope for
unauthorized entry

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Log book /Record of waste
RR Check records are being displayed
generated is maintained on day to
monthly on its web site
day basis
No signs of burning within the OB
premises.
Check infectious liquid waste is not
directly drained in to municipal OB
sewerage system
Display of Bio Hazard sign at the OB
point of use
Infectious Waste is not stored for RR
more than 48 hours
Preferably by CTWF/in-house deep
Disposal of anatomical waste as per OB/SI/RR burial pits/ In house incinerator with
BMW rule
prior approval

Preferably by CTWF/ Deep burial/ in

absence of above autoclaving or micro
Disposal of solid waste as per BMW OB/SI/RR waving/ hydroclaving followed by
rule
shredding or mutilation or combination
of sterlization and shredding.

Preferably by CTWF/autoclaving or dry

Disposal of sharp waste as per BMW OB/SI/RR heat sterlization followed by shredding
rule or mutilation or encapsulation in metal
contained or cement concrete

Preferably by CTWF/Autoclaving or
Disposal of contaminated waste OB/SI/RR microwaving/ hydroclaving followed by
(recyclable) as per BMW rule shredding or mutilation or combination
of sterlization and shredding

Preferably By CTWF/ disinfection (by

soaking the washed glass waste after
Disposal of Glass ware and metallic cleaning with detergent and Sodium
body implants (Blue) Hypochlorite treatment) or through
autoclaving or microwaving or
hydroclaving

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Annual report to the pollution RR
control board is submitted
Biomedical waste transported in OB/SI/RR
authorized vehicle
Area of Concern - G Quality Management
Standard G1 The facility has established organizational framework for quality improvement

ME G1.1 The facility has a quality team District Quality Team for district SI/RR Check for Office order by designated
in place hospitals are Constituted authority
There is designated person for co
. coordinating with the quality circles SI/RR Hospital Manager
and overall quality assurance
program at the facility
There is designated head of the SI/RR MS
quality team
Team members are aware for of SI/RR
there respective responsibilities
The facility reviews quality of
ME G1.2. Quality team meets monthly and SI/RR
its services at periodic
review the quality activities
intervals
Minutes of meeting are recorded RR
Results for internal /External
assessment are discussed in the SI/RR Check the meeting records
meeting
Hospital performance and indicators SI/RR Check the meeting records
are reviewed in meeting
Progress on time bound action plan SI/RR Check the meeting records
is reviewed
Follow up actions from previous SI/RR Check the meeting records
meetings are reviewed

Resource requirement and support SI/RR Check the meeting records

from higher level are discussed

Quality team review that all the

services mentioned in RMNCHA are SI/RR
delivered as per guideline

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Quality team review that all the

services mentioned in National SI/RR
Health Program are delivered as per
guideline

Resolution of the meeting are

SI/RR Check how resolution are
effectively communicated to hospital
communicated to staff
staff
Quality team report regularly to
DQAC about Key Performance SI/RR
Indicators

Quality Team DQAC about internal SI/RR

assessment results and action taken

Standard G2 Facility has established system for patient and employee satisfaction

Patient Satisfaction surveys

ME G2.1. There is person designated to co SI/RR
are conducted at periodic
ordinate satisfaction survey
intervals

. Patient feedback form are available RR

in local language
Adequate sample size is taken to RR
conduct patient satisfaction
There is procedure to conduct
employee satisfaction survey at RR
periodic intervals
Facility analyses the patient
ME G2.2. There is procedure for compilation RR
feed back and do root cause
of patient feedback forms
analysis
Patient feedback is analysed on RR Overall department wise/attribute wise
monthly basis score are calculated
Root cause analysis is done for low RR
performing attributes
Results of Patient satisfaction survey
are recorded and disseminated to RR/SI
concerned staff
There is procedure for analysis of RR
Employee satisfaction survey

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There is procedure for root cause
analysis of Employee satisfaction RR
survey
Facility prepares the action There is procedure for preparing
ME G2.3. plans for the areas of low Action plan for improving patient RR/SI
satisfaction satisfaction
There is procedure to take corrective RR/SI
and preventive action
There is procedure for preparing
action plan for improving employee RR/SI
satisfaction

Standard G3 Facility have established internal and external quality assurance programs wherever it is critical to quality.

Facility has established

ME G3.1. internal quality assurance Daily round schedule is defined and SI/RR Check for entries in Round Register
program at relevant practiced
departments

Facility has established

ME G3.2. External Quality assurance is done SI/RR
external assurance programs
on defined interval by DQAC
at relevant departments

External Quality assurance is done SI/RR

on defined interval by SQAC
Facility has established system
ME G3.3 for use of check lists in Internal assessment is done at RR/SI NQAS, Kayakalp, SaQushal tools are
different departments and periodic interval used to conduct internal assessment
services

Departmental checklist are used for SI/RR Staff is designated for filling and
monitoring and quality assurance monitoring of these checklists

Non-compliances are enumerated RR Check the non compliances are

and recorded presented & discussed during quality
team meetings

Actions are planned to address Check action plans are prepared and Randomly check the details of action,
ME G3.4 gaps observed during quality implemented as per internal RR responsibility, time line and feedback
assurance process assessment record findings mechanism

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Check actions have been taken to close

Planned actions are Check PDCA or revalent quality
ME G3.5 SI/RR the gap. It can be in form of action
implemented through Quality method is used to take corrective
taken report or Quality Improvement
Improvement Cycles (PDCA) and preventive action
(PDCA) project report

Standard G4 Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.

Departmental standard
ME G4.1. Hospital has documented Quality RR
operating procedures are
system manual
available

. Hospital has Records of distribution RR

of Standard operating procedure

Hospital has system for periodic

. review of the standard procedures RR
as and when required

Standard Operating
ME G4.2. Procedures adequately Hospital has documented system for RR
describes process and Internal audits at defined intervals
procedures

Hospital has documented procedure

for control of documents and RR
records
Hospital has documented
procedure for defining Quality RR
objectives
Hospital has documented procedure RR
for action planning

Hospital has documented procedure

for training and CMEs of hospital RR
staff at defined intervals

Hospital has documented procedure RR

for monthly review meeting

Staff is trained and aware of

ME G4.3. Check Staff is trained for relevant SI/RR Check for the training records
the standard procedures
part of SOPs
written in SOPs

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(a) Check availability of requisition

forms & formats for developing the
required documents. A system in place
The facility ensures Hospital has established procedure
to draft, review the QMS documents
ME G4.4 documented policies and for drafting, reviewing, approving RR and approval to use the documents is
procedures are appropriately the Quality Management systems
given by appropriate authority.
approved and controlled documents
(b) Check the detailed procedure is
mentioned in Quality Improvement
manual and followed

(a) Check all the QMS documents and

records (both internal & external origin)
Hospital has established procedure
RR are controlled.
for controlling & updating the QMS
(b) Check the documents are updated
documents
as and when required

(a) Check system in place to retention

and retrieval the all QMS documents
Hospitals has established system to (b) Check all documents have title,
provide identification number to the RR effective date, reference number etc
QMS documents and records and signed by competent authority
(C) Check the system is meticulously
followed in all departments

(a) Check master list of documents and

Master list of the documents and RR records is maintained.
records is available
(b) Check the list is updated.
Standard G Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages
5

ME G5.1. Facility maps its critical Process mapping of critical processes SI/RR
processes done
Facility identifies non value
ME G5.2. Non value adding activities are SI/RR
adding activities / waste /
identified
redundant activities

ME G5.3. Facility takes corrective action Processes are rearranged as per SI/RR
to improve the processes requirement

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Standard G6 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit

ME G6.1. The facility conducts periodic Internal audit plan is prepared . RR/SI
internal assessment

Internal audit schedule is prepared . RR/SI

Internal Assessors are identified RR/SI
Training of internal assessors is done RR/SI

There is process of communicating

about the assessment to concerned RR/SI
departments
Records of internal assessment are RR/SI
maintained
Person is designed for co RR/SI
coordinating internal assessment
The facility conducts the
ME G6.2. There is established committee for RR/SI
periodic prescription/
reviewing maternal death
medical/death audits
There is established committee for RR/SI
reviewing new born death
There is established committee for RR/SI
medical and death audit
Drug and therapeutic committee for RR/SI
Prescription audits
Medical audits are conducted at RR/SI
periodic interval
Death audits are conducted at RR/SI Maternal and death audits are
periodic interval conducted as per guideline
Prescription audits are conducted at RR/SI
periodic interval

. There is predefined criteria and RR/SI

format for medical audit
There is predefined criteria and RR/SI
format for prescription audit
There is predefined criteria and RR/SI
format for death audit

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Training has been provided for RR/SI

conducting medical and death audits

Action plan is made on the

ME G6.4. Departmental Action plan is RR/SI
gaps found in the
reviewed periodically
assessment / audit process

Corrective and preventive

There is system to ensure that
ME G6.5. actions are taken to address RR/SI
corrective and preventive action are
issues, observed in the
taken timely
assessment & audit

Standard G6 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them

Mission state meant should define the

purpose , target users and long term
goal of facility. Mission should be
defined in consultation with
ME G6.1 Facility has defined mission Check if mission statement has been SI/RR stakeholders and duly approved by
statement defined adequately
head of facility. Mission should be in
coherence with the stated mission of
state health department and National
Health Mission

Check if core values of organization

ME G6.2 Facility has defined core Check if core values of the facilities SI/RR such as non discrimination,
values of the organization have been defined transparency, ethical clinical practices,
competence etc have been defined

Check quality policy of the facility has

been defined in consultation with
Facility has defined Quality
ME G6.3 Check if Quality Policy has been SI/RR hospital staff and duly approved by the
policy, which is in congruency
defined and approved head of the facility . Also check Quality
with the mission of facility
Policy enables achievement of mission
of the facility and health department

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Check short term valid quality
objectivities have been framed
Facility has de defined quality addressing key quality issues in each
ME G6.4 Check if SMART Quality Objectives SI/RR
objectives to achieve mission department and cores services. Check if
have framed
and quality policy these objectives are Specific,
Measurable, Attainable, Relevant and
Time Bound.
Interview with staff for their awareness.
Mission, Values, Quality policy
Check if Mission Statement, Core
ME G6.5 and objectives are effectively Check of staff is aware of Mission , SI/RR Values and Quality Policy is displayed
communicated to staff and Values, Quality Policy and objectives
prominently in local language at Key
users of services
Points

Verify with records that a time bound

action plan has been prepared to
Facility prepares strategic plan Check if plan for implementing
ME G6.6 SI/RR achieve quality policy and objectives in
to achieve mission, quality quality policy and objectives have
consultation with hospital staff . Check
policy and objectives prepared
if the plan has been approved by the
hospital management

Review the records that action plan on

quality objectives being reviewed at
Facility periodically reviews
Check time bound action plan is least once in month by departmental in
ME G6.7 the progress of strategic plan SI/RR
being reviewed at regular time charges and during the quality team
towards mission, policy and
interval meeting. The progress on quality
objectives
objectives have been recorded in Action
Plan tracking sheet

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

Facility uses method for

ME G7.1. quality improvement in PDCA SI/RR
services
5S SI/OB
Mistake proofing SI/OB
Six Sigma SI/RR
ME G7.2. Facility uses tools for quality Basic tools of Quality SI/RR
improvement in services
Prateo/Priorization SI/RR
Gantt Chart/Project Management SI/RR
Standard G8 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.

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Review the risk management

Risk Management framework framework document. Check scope and
ME G8.1 has been defined including Check for adequacy of Risk SI/RR objectives of the framework is
context, scope, objectives and Management Framework contextual to the facility and criterion
criteria for identifying risk has been explicitly
laid out.

Review risk management framework

Risk Management framework delineation of responsibilities amongst
Check if responsibilities for
ME G8.2 defines the responsibilities for SI/RR staff for identifying the risk in their
identifying and managing risk has
identifying and managing risk work area and their management.
been defined and communicated
at each level of functions Verify with the staff members if they
are aware of their responsibilities

Risk Management Framework

Review risk management framework
ME G8.3 includes process of reporting Check if process of reporting risks SI/RR for process of reporting incidents
incidents and potential risk to and hazards have been defined
including near miss and potential risks
all stakeholders

A compressive list of current

Review risk management framework
and potential risk including
includes list of identified current and
ME G8.4 potential strategic, regulatory, Check if list of existing and potential SI/RR potential risks. These may included
operational, financial, risk have been prepared
safety, strategic, financial, statutory,
environmental risks has been
operational and environmental risks.
prepared

Verify with the training records .

Check training on risk management Training on risk management at least
ME G8.5 Modality for staff training on SI/RR
has been provided to key staff should be provided to person
risk management is defined
members responsible for indemnifying and
managing risks

Check with the records that quality

ME G8.6 Risk Management Framework Check risk management framework SI/RR team/ risk management committee
is reviewed periodically is reviewed at least once in a year reviews the framework at least once in
a year

Standard G9 Facility has defined, approved and communicated Risk Management framework for existing and potential risks.

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Risk management plan has

been prepared and approved Review the risk management plan
ME G9.1 by the designated authority Check if a valid risk management SI/RR document. Check it has been updated
and there is a system of its plan is available at the facility at lest once in a month and duly
updating at least once in a approved by the head of facility.
year

ask staff if they are aware of key

actionable points of risk management
Risk Management Plan has plan of their concerned areas. Check
been effectively Check if risk management plan has what measures hospital administration
ME G9.2 communicated to all the staff, been communicated to all stake SI/RR has taken for effective dissemination of
and as well as relevant holders risk management plan amongst staff
external stakeholders members, outsource agencies and as
well as concerned officials in district
and state health administration

Check if facility has prepared

Risk assessment criteria and
assessment checklist for identifying risk
checklist for assessment have
ME G9.3 Check if risk assessment checklist is SI/RR on routine basis. This checklist has been
been defined and
available with stakeholders disseminate to the staff members
communicated to relevant
responsible for identifying and
stakeholders
reporting risks

Check if periodic assessment of Verify with the assessment records.

Periodic assessment for
ME G9.4 Physical and electrical safety risk is SI/RR Comprehensive of physical and
Physical and Electrical risks is
done using the risk assessment electrical safety should be done at least
done as per defined criteria
checklist once in three month

Periodic assessment for

Check periodic assessment pf Check comprehensive assessment of
ME G9.5 potential disasters including SI/RR
potential disaster is done both manmade and natural potential
re is done as per de defined
periodically disaster is done at least once in year
criteria

Verify with the records. A

Periodic assessment for Check periodic assessment of
comprehensive risk assessment of all
ME G9.6 Medication and Patient care medication and patient care safety SI/RR clinical processes should be done using
safety risks is done as per risk is done using defined checklist
pre define d criteria at least once in
defined criteria. periodically
three month.

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Periodic assessment for

potential risk regarding safety
Verify with records. At least once in
ME G9.7 and security of staff including Check if Periodic assessment of SI/RR year and whenever a major incident has
violence against service violence risks is done
occurred.
providers is done as per
defined criteria

Risk identified should be listed and

evaluated for their security and
Risks identified are analysed Check if various risks identified
ME G9.8 SI/RR frequency for occurrence. A risk
evaluated and rated for during the risk assessment proceeds
severity score / grade should be give to
severity are formally evaluated
each risk identified and according gaps
should be rated. Verify with the records

Identified risks are treated

ME G9.9 Check if risk have high severe are SI/RR Check risks are prioritized base on their
based on severity and
prioritised. severity rating. Verify with the records
resources available

Check hospital administration/

A risk register is maintained responsible committee maintains a risk
ME G9.10 and updated regularly to risk Check if a risk register is maintained SI/RR register which risk identified, their
records identify ed risks, there severity, action to be taken to mitigate
severity and action to be taken risk and follow up action. Check if risk
register share been updated timely.

Standard The facility has established clinical Governance framework to improve quality and safety of clinical care processes
G10

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(a) Framework reflects facility's

commitment & accountability for
Continuous quality improvement in
their Clinical services .
(b) Framework define the
responsibilities of clinical Governance
ME G10.1 The facility has defined clinical Facility has defined framework for RR/SI board
governance framework clinical Governance (c) Framework defines the approaches
used to implement clinical Governance
in healthcare facility i.e. audits, risk
management, clinical effectiveness,
patient & public involvement,
education and training, information
management etc

(a) Check Clinical Governance

Board/Apex Committee has
representation from all the clinical
departments.
(b) Department Heads/
Facility has clinical Governance RR/SI Inchages/Representatives are identified
Board at place
or appointed
(c) Members of Apex Committee is
aware about their roles &
responsibilities

All the Clinical committee viz Infection

Clinical Governance Board/Apex control committee, medical, death and
committee prepared & approve the RR/SI prescription audit committee etc. are
facility's plan for improving clinical functioning under guidance of Clinical
quality and safety of patients Governance board

Clinical Governance Board/ Apex Board review the reports & monitor the
committee regularly receive reports RR/SI compliance to action taken reports.
on the quality and patient safety Also, provide support for the
activities compliance .
Clinical Governance board meet at RR/SI At least once in month
regular intervals

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Aggregate patient data is collected and

reviewed:
Check clinical care outcomes & RR/SI (a) Clinical Outcomes
indicators are reviewed (b) Clinical indicators
(c) Adverse/sentile events that
occurred

Check the system in place to

Decision taken in clinical Governance
RR/SI communicate the decisions of clinical
meeting are communicated to all
governance meetings to all medical
concerned staff
professionals

(1) To promote collegiality,

communication, collaboration, and
There is system in place to conduct RR/SI learning among healthcare
grand rounds regularly professionals
(2) Check how frequently the grand
rounds are conducted

Clinical Governance
ME G10.2 framework has been Check staff is aware of Clinical SI Staff is aware of role of clinical
effectively communicated to Governance framework Governance in improving quality of care
all staff
Governing body of healthcare
Hospitals has defined accountability
ME G10.6 facilities ensures RR Check hospital has defined &
& responsibility for day to day
accountability for clinical care documented organogram
operations
provided
Area of Concern - H Outcome
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks

ME H1.1. Facility measures productivity Bed Occupancy Rate RR

Indicators on monthly basis

. No. of total admissions per thousand RR

population
. IPD per thousand population RR
. OPD consultation per Thousand RR
Population
. Number of beds per 10 thousand RR
. Maternal mortality per 1000 RR
deliveries

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. Neonatal mortality per 1000 live RR

births
. Nurse to bed ratio RR
. No. of meeting held under RKS RR
Proportion of BPL patient in hospital RR

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark

ME H2.1 Facility measures efficiency Overall Referral Rate RR

Indicators on monthly basis
Overall discharge rate RR
. Proportion of obstetric cases out of RR
total IPD
. Proportion of fund/ grant utilized RR
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark

Facility measures Clinical Care

ME H3.1 & Safety Indicators on Average Length of Stay RR
monthly basis
. Crude mortality rate RR
. Maternal mortality per 1000 RR
deliveries

. Neonatal mortality per 1000 live RR

births

. Hospital acquired infection rate RR Surgical Site, Device related hospital

acquired infection rate

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark

Facility measures Service

ME H4.1 Quality Indicators on monthly Overall LAMA Rate RR
basis
. Patient satisfaction Score IPD RR

. Staff Satisfaction Score RR

. Turn over rate of contractual staff RR

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