Evaluation Guide for New and

Accredited Health Centers

 Mandatory Requirements

Section Penalty

Administration

1- Local authorities license

Yes

Not Available Suspension for one month + $5000

No
Available, expired $5,000

2- Medical X-ray services license

Yes

Not Available Suspension for one month + $5000

No
Available, expired $5,000

3- Director or administration office

Yes

No Not Available Suspension for one month + $5000

4- Report generation area

Yes

No Not Available Suspension for one month + $5000

5- License to practice or evidence of specialization for some healthcare practitioners

Two (2) Full time Physicians

Yes
Non-availability of 2 licensed
Suspension for one month + $5000
physicians
Only one licensed physician is
No $5,000
available
One physician license is expired $2,000

2 Evaluation Guide for New and Accredited Health Centers

 Mandatory Requirements

Section Penalty
One (1) Full time or part time Clinical pathologist
Yes
Not Available Suspension for one month + $5000
No
Expired license $5,000
One (1) Full time or part time radiologist
Yes
Not Available Suspension for one month + $5000
No
Expired license $5,000
Two (2) Full time Nurses
Yes
Non-availability of 2 licensed nurses Suspension for one month + $5000
No Only one licensed nurse is available $5,000
One nurse license is expired $2,500
Two (2) Full time laboratory technicians
Yes
There are no 2 qualified laboratory
Suspension for one month + $5000
technicians
No
Only one qualified laboratory
$5,000
technician is available
One (1) Full time Phlebotomist or qualified technician
Yes
There is no a technician qualified for
No $5,000
phlebotomy
Available, expired license or no proof
$2,500
of specialty
Two (2) Full time radiology technicians
Yes
There are no 2 qualified radiology
Suspension for one month + $5000
technicians
No
Only one qualified radiology
$5,000
technician is available
3 Evaluation Guide for New and Accredited Health Centers
 Mandatory Requirements

Section Penalty
6- Electronic verification personal identification system that includes finger print and
personal photo
Yes
Not Available Suspension for one month + $5000
Available in all sections, and not
$5,000
No totally activated
Available in all sections and partially
$2,500
activated
7- Internal electronic registration system
Yes
Not Available $5,000
No
Available, no data $2,500
Medical examination
8- Two (2) rooms for medical examination
Yes
There are no rooms for medical
No Suspension for one month + $5000
examination
There is only one room $5,000
9- Medical examination equipment
Yes
Full: All the following medical
examination equipment are not
available: Stethoscope, otoscope,
sphygmomanometer, weight and $5,000
height scale, thermometer, tongue
depressors and visual acuity testing
No device.
Partial: Any the following medical
examination equipment is not
available: Stethoscope, otoscope,
sphygmomanometer, weight and $2,500
height scale, thermometer, tongue
depressors and visual acuity testing
device.

4 Evaluation Guide for New and Accredited Health Centers

 Mandatory Requirements

Section Penalty

Laboratory

10- Fully automated Immunoassay analyzer

Yes

Semi-automatic $2,500
No
Not-automatic $5,000

11- Fully automated Chemistry Analyzer

Yes

Semi-automatic $2,500
No
Not-automatic $5,000

12- Fully automated Hematology Analyzer

Yes

Semi-automatic $2,500
No
Not-automatic $5,000

13. Medical microscope

Yes

No Not Available $5,000

Radiology

14- Digital X-Ray Machine DR or CR ≥200mA

Yes

Digital CR < 200mA $5,000

No
Non-digital Suspension for one month + $5000

15- Separate X-Ray changing room

Yes

No Not Available $5,000

5 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
The center building

Adequate, easily accessible and identifiable

Adequate building
1 2 3
Warning Verbal Guidance NONE

1. The center building is

good
1. The center building is 1. The center is very good
2. The center is a part of
under construction or old 2. The center building is
a health institution
and dilapidated separated (independent)
with shared services
2. Service sections in more 3. All service sections are in
3. Service sections in the
than one building one floor
center are in more
than one floor

1 2 3
Warning Verbal Guidance NONE

Easily accessible

1. Outside the city, on

1. Inside the city, main street
suburbs, or in informal 1. Inside the city, side
that is near to public
settlements without street that is difficult
transportation and is easy
infrastructure that are to reach
to reach
difficult to reach

1 2 3
Warning Verbal Guidance NONE

Easily identifiable

1. The center entrance

through the building 1. Front entrance of the
1. The center entrance is at
main entrance. building
the side or behind the
Availability of elevator 2. Ground floor entrance
building
2. Clear but small sign 3. Clear and large sign board
2. No or unclear center’s
board making it at the entrance, making
sign board
difficult to be easily identifiable
identifiable

6 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Reception and waiting room

General appearance and the space and capacity of the waiting room

1 2 3
Warning Verbal Guidance NONE

1. Organized waiting room

1. Unorganized waiting
1. Unorganized waiting 2. Spacious, accommodating
room
room clients and allowing easy
2. Sufficient seats are
2. Small waiting room movement
available
capacity that cannot 3. Modern furniture
3. Only one port for
accommodate clients 4. Air-conditioned waiting room
registration is available
3. Not all registration 5. There are more than one port
4. Some registration
devices are available for registration
devices are not available
(computer, printer, 6. All registration devices are
(computer, printer,
scanner) available (computer, printer,
scanner)
scanner)

Public services

1 2 3
Warning Verbal Guidance NONE
1. Toilets are available, clean
1. Toilets are available and and in a good condition
adequate 2. Instructional signboards are
1. Toilets are available,
2. Instructional signboards available
old or inadequate
are available 3. Educational materials are
available
4. Drinking water is available

7 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Administration

Director’s office

1 2 3
Warning Verbal Guidance NONE

1. Separated director's office.

1. Director's office is not
2. The office is fully furnished
1. Director's office is not fully separated
and equipped. Filing
separated 2. The office is not fully
cabinets are available.
furnished or equipped.
3. Meeting room is available.

Medical reports generation area

1 2 3
Warning Verbal Guidance NONE

1. Separate room
2. Electronic door access 1. Separate room
1. Not separated place
control is available 2. Electronic door access control
2. Electronic door access
(Limited access) is available (Limited access)
control is not available
3. Not all devices are 3. All devices are available
(Limited access)
available (computer, (computer, printer, scanner)
printer, scanner)

8 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Administration

Medical waste disposal

Medical waste disposal room
1 2 3 4

2500$ Warning Verbal Guidance NONE

1. Medical waste
disposal room
1. Medical waste
size is
disposal room size
appropriate
is appropriate
2. Very well
2. Inappropriate
ventilation of the
ventilation of the
medical waste
medical waste
1. Medical waste disposal room
disposal room is
disposal room is 3. Medical waste
not
small in size disposal room is
3. Medical waste
2. Medical waste secured
disposal room is
1. Medical waste disposal room is 4. Waste bins are
secured
disposal room is not ventilated available
4. Waste bins are
not available 3. Medical waste 5. Waste bins are
available
disposal room is visibly clean, both
5. Waste bins are
not secured externally and
not visibly clean,
4. Waste bins are not internally.
both externally
available 6. Packaged waste
and internally.
bins are properly
6. Packaged waste
sealed
bins are not
7. Waste bins are
properly sealed
not overfilled
7. Waste bins are
8. Medical Waste
overfilled
Disposal Log
available

Medical waste disposal contract

1 2 3

2500$ Warning NONE

1. Medical waste disposal 1. Expired medical waste 1. Medical waste disposal

contract is not available disposal contract contract available

9 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Medical examination rooms
The Space and general appearance of examination rooms and equipments
1 2 3
Warning Verbal Guidance NONE
1. Room space accommodates
1. Room space does not
1. Room space accommodates medical furniture
accommodate medical
medical furniture 2. All medical examination
furniture and does not
2. Some medical examination equipments are available
allow easy movement of
equipments are available 3. Privacy during medical
medical staff and
3. No privacy during medical examination (curtain for the
candidates
examination (No curtain for medical examination bed is
2. Medical examination
the medical examination bed) available)
equipments are not
4. Reusable bed sheets 4. Washbasin is available
available
5. Disposable bed sheets
Visual Acuity Testing
1 2 3
$2500 Warning NONE
1. Following inappropriate
1. Following appropriate Visual
Visual Acuity Testing
Acuity Testing procedure
1. Visual Acuity Testing procedure (no proper
(proper distance, examiner’s is
procedure is not distance, examiner’s is not
familiar with the testing
available familiar with the testing
procedure)
procedure)
2. Use of electronic devices
2. Use non-electronic devices
Disposal of medical waste
1 2 3
Warning Verbal Guidance NONE
1. There are containers to separate
different types of medical waste
1. There are containers to
1. There are no containers and using appropriate method
separate different types of
to separate different 2. Written guidelines and
medical waste but using
types of medical waste educational materials on safe
inappropriate method
management of medical waste
are available
Infection control procedure
1 2 3
Warning Verbal Guidance NONE
1. Sanitizers are available
2. Washbasin is available
3. Disposable gloves are available.
1. Sanitizers are available
1. No procedure available 4. Written guidelines and
2. Washbasin is available
educational materials on
Infection control procedure and
hand hygiene are available

10 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Phlebotomy Room

Independent place and general appearance

1 2 3
$2500 Verbal Guidance NONE
1. Separate room
1. Independent area for 2. The space is sufficient to
phlebotomy accommodate the
2. The space does not phlebotomy chair and
accommodate the allows easy movement of
1. No independent area for
phlebotomy chair and the phlebotomist and
phlebotomy
the movement of the candidates.
phlebotomist and 3. Excellent general
candidates is somewhat arrangement and
restricted. organization of furniture,
tools and equipment used
Phlebotomy chair

1 2 3
Warning Verbal Guidance NONE
1. There is no phlebotomy 1. Improper phlebotomy
1. Proper phlebotomy chair
chair chair

Sample tubes and containers (Blood, urine, stool)

1 2 3
$2500 Warning NONE
1. Some reusable sample
1. Reusable sample tubes 1. Disposable sample tubes
tubes and containers
and containers (Blood, and containers (Blood,
(Blood, urine, stool) are
urine, stool) are available urine, stool) are available
available
Samples labeling method

1 2 3
Warning Verbal Guidance NONE

1. Samples are 1. Samples are electronically

electronically labeled labeled
1. Samples are manually
2. Barcode Label Printer is 2. Barcode Label Printer is
labeled
not available in the available in the
phlebotomy room phlebotomy room

11 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Phlebotomy Room

Disposal of medical waste

1 2 3 4 5
$2500 $2500 Warning Verbal Guidance NONE

1. There are containers

1. There are 1. There are to separate
containers to containers to 1. There are different types of
separate separate containers to medical waste and
different types different types separate
1. No/inadequate using appropriate
of medical of medical different types of
containers to method
waste but waste and using medical waste
separate 2. Sharp containers are
using appropriate and using
different types available
inappropriate method appropriate
of medical 3. Written guidelines
method method
waste 2. Needles and educational
2. Safe needles
cutting/burning 2. Sharp containers materials on safe
disposal
device is are available management of
method is not
available medical waste are
available
available

Infection control procedure

1 2 3 4 5
$2500 Warning Verbal Guidance NONE NONE

1. Sanitizers are
available
2. Washbasin is
1. Sanitizers are available
available 3. Disposable gloves
2. Washbasin is are available
available 4. First aid kit is
1. Sanitizers are
1. Sanitizers are 3. Disposable gloves available
available
available are available 5. Procedure for
2. Washbasin is
1. No procedure 2. Washbasin is 4. First aid kit is transporting
available
available available available samples is available
3. Disposable
5. Procedure for 6. Needlestick injury
gloves are
transporting protocol is available
available.
samples is 7. Written guidelines
available and educational
materials on
Infection control
procedure and hand
hygiene are
available

12 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Laboratory

Space and general appearance

1 2 3
Warning Verbal Guidance NONE

1. Small space that limits the 1. The space allows free movement
movement of the of the technicians inside the
1. The space allows free
technicians inside the laboratory
movement of the technicians
laboratory 2. Arrangement of laboratory
inside the laboratory
2. Laboratory equipments are equipments is good
2. Arrangement of laboratory
close to each other 3. General arrangement and
equipments is good
3. Use of inappropriate organization are good
3. General arrangement and
furniture for laboratory 4. Door access control is available
organization are good
4. General arrangement and (Limited access)
4. Door access control is available
organization are 5. Washbasins are designated to
(Limited access)
inappropriate laboratories
5. Washbasins are not designated
5. There are no washbasins 6. Use of special laboratories
to laboratories
6. Door access control is not furniture
available (Limited access) 7. Laboratory sections are separated

Reagents and solutions refrigerator

1 2 3 4 5
$5000 $2500 Warning Verbal Guidance NONE

1. Available and
appropriate (new
1. Available and 1. Available and
1. Available but and spacious)
appropriate appropriate
inappropriate 2. Two temperature
(new and (new and
(Old or small) monitoring
spacious) spacious)
2. Temperature devices (TMD are
2. Only one 2. Two
monitoring available
1. Not available temperature temperature
device (TMD is 3. Temperature Logs
monitoring monitoring
not available. is available
device (TMD is devices (TMD
3. Temperature available are available 4. Written SOP to
Logs is not deal with the
3. Temperature 3. Temperature
available inappropriate
Logs is available Logs is available
temperature is
available

13 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Laboratory

Results recording system

1 2 3 4 5
$5000 $2500 Warning Verbal Guidance NONE

1. Available for all

1. Available for all
tests
tests
2. An internal 1. Available for all
1. Available for 2. Some equipments
electronic tests
some tests results are linked
system is
1. Not available 2. Results are to the internal 2. All equipments
available for
electronic system; results are linked
recorded results
and other to the internal
manually recording
equipments results electronic system
(results are
are entered
entered
manually
manually).

The quality assurance program

1 2 3 4 5
$2500 Warning Verbal Guidance NONE NONE

1. Internal quality
1. Internal quality
assurance
assurance program
1. Internal quality program for
for results is
assurance results is
available
program for available
2. Internal program
1. Internal quality results is 2. Internal program
for calibrating
1. Internal assurance available for calibrating
equipment is
quality program for 2. Internal equipment is
available
assurance results is program for available
3. Standard operating
program for available calibrating 3. Standard
procedures (SOP)
results and 2. Internal equipment is operating
are available for all
results program for available procedures (SOP)
laboratory tests
validation is calibrating 3. Standard are available for
4. Validation records
not available equipment is operating all laboratory
is available for all
available procedures tests
equipments used in
(SOP) are 4. Validation
the laboratory
available for all records is
5. Uninterrupted
laboratory tests available for all
Power Supply (UPS)
equipments used
is installed
in the laboratory

14 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Laboratory

Laboratory equipments maintenance contract

1 2 3
$2500 Warning NONE

1. Not available
1. Valid maintenance contracts for 1. Valid maintenance contracts
2. Not valid maintenance
some equipments for all equipments
contracts for all equipments
(Immunoassay, chemistry, (Immunoassay, chemistry,
(Immunoassay, chemistry, hematology) are available. hematology) are available.
hematology).

Specimen's storage refrigerator

1 2 3 4 5
$5000 $2500 Warning Verbal Guidance NONE
1. Available and
appropriate
(new and
1. Available and
1. Available but spacious)
1. Available and appropriate
inappropriate 2. Two
appropriate (new (new and
(Old or small) temperature
and spacious) spacious)
2. Temperature monitoring
2. Only one 2. Two
monitoring devices (TMD are
1. Not available temperature temperature
device (TMD is available
monitoring device monitoring
not available. 3. Temperature
(TMD is available devices (TMD
3. Temperature Logs is available
3. Temperature Logs are available
Logs is not 4. Written SOP to
is available 3. Temperature
available deal with the
Logs is available
inappropriate
temperature is
available

Expired reagents

1 5
$5000 NONE

Any expired reagents are available Any expired reagents are not available

Rapid tests for viral diseases

1 5
$5000 NONE

Rapid tests for viral diseases are available Rapid tests for viral diseases are not available

15 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Laboratory

Disposal of medical waste

1 2 3 4 5
$2500 $2500 Warning Verbal Guidance NONE

1. There are 1. There are 1. There are containers

containers to containers to 1. There are to separate different
separate separate containers to types of medical
different types different types separate waste and using
of medical of medical different types appropriate method
1. No containers
waste but waste and of medical waste 2. Sharp containers are
to separate
using using and using available
different
inappropriate appropriate appropriate 3. Written guidelines
types of
method method method and educational
medical waste
2. Safe needles materials on safe
disposal 2. Needles 2. Sharp containers management of
method is not cutting/burnin are available medical waste are
available g device is available
available

Infection control mechanisms

1 2 3 4 5
$2500 Warning Verbal Guidance NONE NONE

1. Sterilizers are
available
2. Washbasin is
1. Sterilizers are available
available 3. Disposable gloves
1. Sterilizers are 2. Washbasin is are available.
available available 4. First aid kit is
1. Sterilizers are 2. Washbasin is 3. Disposable available
1. No procedure available available gloves are 5. Spill kit is available
available 2. Washbasin is 3. Disposable available. 6. Needlestick injury
available gloves are 4. First aid kit is protocol is available
available. available 7. Written guidelines
5. Spill kit is and educational
available materials on
Infection control
procedure and hand
hygiene are
available

16 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Radiology

Space and general appearance

1 2 3
Warning Verbal Guidance NONE
1. The space does not 1. The space accommodates the 1. The space accommodates the X-ray
accommodate the X-ray X-ray machine and machine and extensions, and allows
machine and extensions, and allows easy easy movement of the technicians
extensions, and does movement of the technicians and candidates.
not allow easy and candidates. 2. The control panel is separated from
movement of the 2. The control panel is not the radiology room.
technicians and separated from the radiology 3. Educational materials for candidates
candidates. room. are available.

X-ray Films recording system

1 2 3 4
$5000 Warning Verbal Guidance NONE
1. There is more than one
electronic method to
1. There is only one
register and save the X-ray
1. X-ray films are electronic method to
films (CD and HARD DISCK)
1. Not available saved in a register and save the X-
2. X-ray films are saved in the
printed form. ray films (CD or HARD
Picture archiving and
DISCK)
communication system
(PACS)

X-ray Machine Modality and quality

1 2 3
Warning NONE NONE
1. Old CR radiology machine.
1. New CR radiology machine. 1. DR X-ray machine
(ten years or more)

X-ray changing room

1 2 3
Warning Verbal Guidance NONE

1. Separate X-ray changing room is 1. Separate X-ray changing room

available is available
1. There is only curtain inside 2. The room is connected to the X- 2. The room is connected to the
the X-ray room ray room X-ray room
2. The changing room is not 3. The space of the X-ray changing 3. The room space allows free
connected to the X-ray room does not allow free movement of candidates.
room movement of candidates. 4. Room is closed and has a door.
4. The room has no door and 5. Disposable gowns are
closed by a curtain. available.

17 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Radiology

Radiology reporting area

1 2 3
Warning Verbal Guidance NONE

1. The space allocated to

1. Independent space allocated
radiologists to review images
1. Not available to radiologists to review
and prepare reports is not
images and prepare reports
independent

Radiation protection

1 2
Warning NONE

1. X-ray protective aprons are not available for 1. X-ray protective aprons are available for
candidates and technicians. candidates and technicians.

Vaccinations (If any, according to the State)

Space and general appearance

1 2 3
Verbal Guidance Verbal Guidance NONE

1. Separate room for

vaccinations
1. Separate room for vaccinations 2. The room space
2. The room space does not accommodates the used tools
1. No separate place for accommodate the used tools and allows workers to move
vaccinations and does not allow free freely inside the room.
movement of the staff. 3. General arrangement and
organization of furniture,
tools and equipment used are
Good

18 Evaluation Guide for New and Accredited Health Centers

 Evaluation criteria
Vaccinations (If any, according to the State)

Safe Vaccine Storage

1 2 3 4 5
$5000 $2500 Warning Verbal Guidance NONE

1. Vaccine 1. Vaccine Storage

Storage 1. Vaccine Storage refrigerator is
1. Vaccine Storage
refrigerator is refrigerator is available and
refrigerator is
available and available and appropriate (new
available but
appropriate appropriate and spacious)
inappropriate
(new and (new and 2. Two temperature
(Old or small)
spacious) spacious) monitoring devices
1. No Vaccine 2. Temperature
2. Only one 2. Two (TMD are available
Storage unit monitoring
temperature temperature 3. Temperature Logs is
device (TMD is
monitoring monitoring available
not available.
device (TMD is devices (TMD 4. Written SOP to deal
3. Temperature
available are available with the
Logs is not
3. Temperature 3. Temperature inappropriate
available
Logs is Logs is available temperature is
available available

Vaccination records

1 2 3
$2500 Warning NONE

1. No vaccination record 1. Manual vaccination record 1. Electronic vaccination records

Types and quality of vaccines

1 2 3
$5000 $2500 NONE

1. Not all types of vaccinations 1. Some types of vaccinations 1. All types of vaccinations
contained in the Regulations contained in the Regulations contained in the Regulations
are available are not available are available

19 Evaluation Guide for New and Accredited Health Centers