DistrictHospitalsAssessorguidebookVolume 1 PDF

Volume - I | Assessor’s Guidebook for Quality Assurance in District Hospitals | 2013
Assessor’s Guidebook for

Quality Assurance in
District Hospitals
2013
Volume - I
Maternal Health Division

Ministry of Health and Family Welfare
Government of India
© 2013, National Health Mission, Ministry of Health & family Welfare, Government of India
Reproduction of any excerpts from this document does not require permission from the publisher so long
as it is verbatim, is meant for free distribution and the source is acknowledged
ISBN 978-93-82655-02-2
Ministry of Health & Family Welfare

Government of India
Nirman Bhavan, New Delhi, India
Designed by: Macro Graphics & Printed by: Royal Press
DISCLAIMER
The check-lists given in Volume I & II have been developed after review of Indian Public Health Standards (IPHS), Guidelines
of Ministry of Health & Family Welfare, National Health Programmes, Standard Text Books, Journals & Periodicals, etc. The
check-lists are to be used as tools for the Quality Improvement. While taking patient and clinical care related decisions
these check-lists may not be used.
Keshav Desiraju Hkkjr ljdkj
Secretary LokLF; ,oa ifjokj dY;k.k foHkkx
Tel.: 23061863 Fax: 23061252 LokLF; ,oa ifjokj dY;k.k ea=kky;
E-mail : secyhfw@nic.in fuekZ.k Hkou] ubZ fnYyh & 110011
k.desiraju@nic.in Government of India
Department of Health and Family Welfare
Nirman Bhawan, New Delhi - 110011
PREFACE
The National Rural Health Mission (NRHM) Strives to Provide Quality Health care to all
citizens of the country in an equitable manner. The 12th five year plan has re-affirmed
Government of India’s commitment – “All government and publicly financed private
health care facilities would to expected to achieve and maintain Quality Standards.
An in-house quality management system will be built into the design of each facility,
which will regularly measure its quality achievements.”
Indian Pubic Health Standards (IPHS) developed during 11th Five Year Plan describe norms for health facilities
at different levels of the Public Health System. However, It has been observed that while implementing
these Standards, the focus of the states has been mostly on creating IPHS specified infrastructure and
deploying recommended Human Resources. The requirement of national programmes for ensuring quality
of the services and more importantly use’s perspective are often overlooked.
The need is to create an inbuilt and sustainable quality for Public Health Facilities which not only delivers
good quality but is also so perceived by the clients. The guidelines have been prepared with this perspective
defining relevant quality standards, a robust system of measuring these standards and institutional
framework for its implementation.
These operational guidelines and accompanying compendium of cheek-lists are intended to support the
efforts of states in ensuring a credible quality system at Public Health Facilities. I do hope states would take
benefit of this painstaking work.
(Keshav Desiraju)
Hkkjr ljdkj
LokLF; ,oa ifjokj dY;k.k ea=kky;
fuekZ.k Hkou] ubZ fnYyh & 110011
Government of India
Department of Health and Family Welfare
Anuradha Gupta, IAS Ministry of Health and Family Welfare
Additional Secretary & Nirman Bhawan, New Delhi - 110011
Mission Director, NRHM
Telefax : 23062157
E-mail : anuradha–gupta@outlook.com
FOREWORD
The successful implementation of NRHM since its launch is 2005 is clearly evident by
the many fold increase in OPD, IPD and other relevant services being delivered in the
Public health institutions, however, the quality of services being delivered still remains
an issue. The offered services should not only be judged by its technical quality but also
from the perspective of service seekers. An ambient and bright environment where
the patients are received with dignity and respect along with prompt care are some of
the important factors of judging quality from the clients’ perspective.
Till now most of the States’ approach toward the quality is based on accreditation of Public Health Facilities
by external organizations which at times is hard to sustain over a period of time after that support is
withdrawn. Quality can only be sustained, if there is an inbuilt system within the institution along with
ownership by the providers working in the facility As Aristotle said “Quality is not as act but a habit”
Quality Assurance (QA) is cyclical process which needs to be continuously monitored against defined
standards and measurable elements. Regular assessment of health facilities by their own staff and state
and ‘action-planning’ for traversing the observed gaps is the only way in having a viable quality assurance
prgramme in Public Health. Therefore, the Ministry of Health and Family welfare (MOHFW) has prepared
a comprehensive system of the quality assurance which can be operationalzed through the institutional
mechanism and platforms of NRHM.
I deeply appreciate the initiative taken by Maternal Health division and NHSRC of this Ministry in preparing
these guidelines after a wide range of consultations. It is hoped that States’ Mission Directors and
Programme Officers will take advantage of these guidelines and initiate quick and time bound actions as
per the road map placed in the guidelines.
(Anuradha Gupta)
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Government of India
Manoj Jhalani, IAS Nirman Bhawan, New Delhi 110011
Joint Secretary
Telefax : 23063687
E-mail : manoj.jhalani@nic.in
FOREWORD
The National Rural Health Mission (NRHM) was launched in the year 2005 with aim to
provide affordable and equitable access to public health facilities. Since then Mission
has led to considerable expansion of the health services through rapid expansion of
infrastructure, increased availability of skilled human resources; greater local level
flexibility in operations, increased budgetary allocation and improved financial
management. However, improvement in Quality of health services at every location
is still not perceived, generally.
Perceptions of poor quality of health care, in fact, dissuade patients from using the available services
because health issues are among the most salient of human concerns. Ensuring quality of the services
will result in improved patient/client level outcomes at the facility level
Ministry of Health and Family Welfare, Government of India is committed to support and facilitate a
Quality Assurance Programme, which meets the need of Public Health system in the country which
is sustainable. The present guidelines on Quality Assurance has been prepared with a focus on both
the technical and perception of service delivery by the clients. This would enhance satisfaction level
among users of the Government Health Facilities and reposing trust in the Public Health System.
The Operational guidelines along-with standards and checklist are expected to facilitate the states in
improving and sustaining quality services beginning with RMNCH-A services at our Health facilities so
as to bring about a visible change in the services rendered by them. The guideline is broad based and
has a scope for extending the quality assurance in disease control and other national programme. It is
believed that states will adopt it comprehensively and extend in phases for bringing all services under
its umbrella. Feedback from the patients about our services is single-most important parameter to
assess the success of our endeavour.
I acknowledge and appreciate the contribution given by NRHM division and NHSRC to RCH division
of this Ministry in preparing and finalizing the guidelines. I especially acknowledge proactive role and
initiative taken by Dr. Himanshu Bhushan, Deputy Commissioner and I/C of Maternal Health Division,
Dr. SK Sikdar Deputy Commissioner and I/C of family planning Division and Dr. JN Srivastava of NHSRC
in framing these guidelines.
(Manoj Jhalani)
Joint Secretary (Policy)
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Government of India
Dr. Rakesh Kumar, I.A.S Nirman Bhawan, New Delhi - 110011
JOINT SECRETARY
Telefax : 23061723
E-mail : rk1992uk@gmail.com
E-mail : rkumar92@hotmail.com
ACKNOWLEDGEMENT
The Operational Guidelines for Quality Assurance have been developed by the
Ministry of Health and family welfare GOI, under the guidance and support of
Shri Keshav Desiraju, Secrelary, Health & Family Welfare, Gol. The contribution and
insightful inputs given by Ms. Anuradha Gupta, Additional Secretary & Mission
Director NRHM helped in firming up the guidelines within a set time period.
I must appreciate the efforts and initiatives of the entire team of Maternal Health, Family Planning &
Child health Divisions, especially Dr. Himanshu Bhushan (DC MH I/C), Dr S K Sikdar (DC FP I/C), and
Dr PK Prabhakar (DC CH), who have coordinated the process of developing these Operational
Guidelines besides making substantial technical contributions in it.
The technical contribution by Dr J.N Srivastava, Head of QI Division and their team members
Dr. Nikhil Prakash and Dr. Deepika Sharma of NHSRC need a special mention for their robust and
sound contribution and collating all available information.
I would like to express my sincere gratitude to Mr. Vikas Kharge, Mission Director & Dr. Satish Pawar, DG
(Health), Govt. of Maharashtra for their inputs and continued support. I would also like to place on record
the contribution of development partners like WHO, UNICEF, UNFPA particularly Dr. Arvind Mathur,
Dr Malalay, Dr. Ritu Agarwal and Dr. Dinesh Agarwal.
I would like to convey my special thanks to all the experts, particularly Dr. Poonam Shivkumar
from MGIMS, Wardha, Dr. Neerja Bhatla from AIIMS, Dr. R Rajendran, Institute of OBGYN, Chennai,
Dr R.P. Sridhar from MCH Gujart Dr. P. Padmanaban and Mr. Prashanth from NHSRC, MH Division
Consultants Dr. Pushkar Kumar, Mr Nikhil Herur, Dr. Rajeev Agarwal and Dr. Anil Kashyap for putting
their best efforts in preparing several drafts and final guidelines. Since it is difficult to acknowledge
all those who contributed a list of contributors is attached in the guidelines.
I hope these Operational Guidelines and accompanying compendium of check-lists facilitate to build a
sound and credible quality system at Public Health facilities at-least in provision of RMNCH-A services
to start with.
(Dr. Rakesh Kumar)

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Government of India
Dr. H. Bhushan Nirman Bhawan, New Delhi - 110008
Deputy Commissioner (MH)
Telefax : 23062930
E-mail : drhbhushan@gmail.com
Date: 24th October, 2013
Program Officer’s Message

‘Quality’ is the core and most important aspect of services being rendered at any health
facility. The Clinicians at the health facility particularly public health facilities mostly
deliver their services based on their clinical knowledge. Mostly client’s expectations goes
beyond only cure & includes courtesy, behavior of the staff, cleanliness of the facility &
delivery of prompt & respectful service. Few of these clinician’s also take care of clients
perspective however in many cases, it is overlooked. Those who can afford, can go to a
private facility but the large mass particularly the poor and those living in rural areas do
not have such means neither they have the voices which can be heard.
Government System particularly the policy makers, planners and programme officers have this responsibility
to act upon the needs of the people, who cannot raise voices but needs equal opportunity, at par with
those who can afford. Fulfilling the needs of sick and ailing is the responsibility of public health service
provider.
We have several stand alone guidelines from IPHS to Technical aspects of service delivery but there is no
standard guideline defining quality assurance and its different parameters. The present set of guidelines
have been prepared comprehensively beginning with areas of concerns, defining its standards, measurable
elements and checkpoints both from service provider and service seekers aspect. There is a prudent mix of
technical, infrastructural and clients perspective while framing these guidelines.
The programme divisions of RCH, NRHM, NHSRC and other experts along with team from Govt. of
Maharashtra, representative from Govt. Of Karnataka, Gujarat, Tamil Nadu and Bihar along with institutional
experts had extensive deliberations before firming up each and every aspects of these guidelines.
It is an earnest request to all the States and District Programme Officers to utilize these guidelines for
placing the services as per the expectations of those who do not have means to afford treatment and
services from a private health facility. Protecting the dignity and rendering timely services with competency
to the clients is our moral duty but we also need to assess the quality of services sitting on the opposite
side of the chair. Implementing these guidelines in letter and spirit will help us in achieving our desired
outcomes.
Ensuring standard practices and adherence to the technical protocols, changing behavior and attitude of
a staff is not an easy task. It needs rigorous monitoring, continuous support and encouragement by the
supervisors and most importantly the ownership of the staff working at the facility for implementation
and sustainability of quality efforts. The guidelines are only a tool and its success will depend upon actions
envisaged under these guidelines.
(Dr. Himanshu Bhushan)

List of Contributors
1 Ms. Anuradha Gupta AS&MD (NRHM), MoHFW

2 Dr. Rakesh Kumar JS, RCH, MoHFW
3 Mr Manoj Jhalani JS, Policy, MoHFW
4 Dr. Himanshu Bhushan DC (I/c MH), MoHFW
5 Dr. Manisha Malhotra DC (MH), MoHFW
6 Dr. Dinesh Baswal DC (MH), MoHFW
7 Dr. S.K. Sikdar DC ( I/c FP), MoHFW
8 Dr. P.K. Prabhakar DC (CH), MoHFW
9 Dr. Poonam Varma Shivkumar Prof. of OBGY, MGIMS, Wardha
10 Dr. R. Rajendran State Nodal Officer, Anaesthesia, Tamil Nadu
11 Dr. Arvind Mathur WHO, SEARO
12 Dr. Dinesh Agarwal UNFPA
13 Dr. Pavitra Mohan UNICEF
14 Dr. Neerja Bhatla Prof of OBGY, AIIMS, New Delhi
15 Dr. Somesh Kumar Jhpiego
16 Dr. Archana Mishra DD (MH), GoMP
17 Dr. Ritu Agrawal UNICEF
18 Dr. Aparajita Gogoi CEDPA, India
19 Dr. Sridhar R.P. State Health Consultant (MCH), Gujarat
20 Dr. Pushkar Kumar Lead Consultant, MH, MoHFW
21 Mr. Nikhil Herur Consultant MH, MoHFW
22 Dr. Rajeev Agarwal Sr. Mgt. Consultant, MH, MoHFW
23 Dr. Ravinder Kaur Senior Consultant, MH, MoHFW
24 Dr. Renu Srivastava SNCU Co-ordinator, CH, MoHFW
25 Dr. Anil Kashyap Consultant NRHM, MoHFW
26 S. Chandrashekhar JD(QA & IEC, KHSDRP, Karnataka
27 Ms. Jyoti Verma DD & Nodal Officer, QA, Govt. of Bihar
28 Ms. Laura Barnitz CEDPA, India
29 Ms. Priyanka Mukherjee CEDPA, India
NHSRC Team
1 Dr. T Sundararaman ED, NHSRC
2 Dr. J N Srivastava Advisor – QI, NHSRC
3 Dr. P. Padmanaban Advisor (PHA Div.), NHSRC
4 Mr. Prasanth K.S. Sr. Consultant (PHA Div.), NHSRC
5 Dr. Nikhil Prakash Consultant NHSRC (QI Div)
6 Dr. Deepika Sharma Consultant NHSRC (QI Div)
Maharashtra Team
1 Shri Vikas Kharage Ex MD, NRHM, Govt. of Maharashtra
2 Dr. Satish Pawar Director, Health Services, Govt. of Maharashtra
3 Dr. M. S. Diggikar Ex Principal, Public Health Institute, Nagpur, Maharashtra
4 Mr. Shridhar Pandit PO, NRHM, Govt. of Maharashtra
How to use Assessor’s Guidebook
Assessor’s Guidebook contains tools for Internal and External Assessment of a District Hospital (and equivalent health
facility). Volume I contains guidelines for Assessment and nine departmental checklists. Volume II of this guidebook have
another nine departmental checklist. CD provided with volume I contains a formula fitted MS-Excel tool with can be used
for reproducing these checklist and for generating score cards.
List of check-lists given in Assessor’s Guidebook is given below –
Volume I Volume II
1 Accident & Emergency Department 10 Intensive Care Unit (ICU)
2 Out Patient Department 11 Indoor Patient Department
3 Labour Room 12 Blood Bank
4 Maternity Ward 13 Laboratory Services
5 Paediatrics Ward 14 Radiology & USG
6 Sick Newborn Care Unit (SNCU) 15 Pharmacy
7 Nutritional Rehabilitation Center (NRC) 16 Auxiliary Services
8 Operation Theatre 17 Mortuary
9 Post Partum Unit 18 General Administration
table of Contents
Preface�� iii
Foreword�� v
Foreword�� vii
Acknowledgement�� ix
Program officer’s Message�� xi
List of Contributors for Quality Assurance Guidelines��xiii

How to use Assessor’s Guidebook............................................................................................................................................................................xv
Part A: Guidelines for Assessment ............................................................................................................................................................................. 1
I. Introduction to Quality Measurement System...................................................................................................................................... 3
II. Components of Quality Measurement System and their intent..................................................................................................... 5
III. Introduction to departmental checklist – tool for assessment......................................................................................................17
IV. Assessment Protocol.....................................................................................................................................................................................19
V. Scoring System................................................................................................................................................................................................24
Part B: Departmental Checklists...............................................................................................................................................................................27
Accident & Emergency Department..............................................................................................................................................................29
Out Patient Department.....................................................................................................................................................................................61
Labour room...........................................................................................................................................................................................................95
Maternity Ward................................................................................................................................................................................................... 131
Paediatrics Ward................................................................................................................................................................................................. 163
Sick New Born Unit............................................................................................................................................................................................ 193
Nutrition Rehabilitation Centre.................................................................................................................................................................... 227
Operation Theatre.............................................................................................................................................................................................. 261
Post Partum Unit................................................................................................................................................................................................ 293
Annexure- Measurable Elements.......................................................................................................................................................................... 325
Abbreviation................................................................................................................................................................................................................. 338
Bibliography.................................................................................................................................................................................................................. 343
Index................................................................................................................................................................................................................................ 347
Part-A
Guidelines for
assessment
i Introduction to Quality Measurement System
Often, measuring the quality in health facilities has never been easy, more so, in Public Health Facilities. We have had quality
fame-work and Quality Standards & linked measurement system, globally and as well as in India. The proposed system has
incorporated best practices from the contemporary systems, and contextualized them for meeting the needs of Public
Health System in the country.
The system draws considerably from the guidelines (more than one hundred fifty in number), Standards and Texts on the
Quality in Healthcare and Public health system, which ranges from ISO 9001 based system to healthcare specific standards
such as JCI, IPHS, etc. Operational Guidelines for National Health Programmes and schemes have also been consulted.
We do realise that there would always be some kind of ‘trade-off’, when measuring the quality. One may have short and simple
tools, but that may not capture all micro details. Alternatively one may devise all-inclusive detailed tools, encompassing
the micro-details, but the system may become highly complex and difficult to apply across Public Health Facilities in the
country.
Another issue needed to be addressed is having some kind of universal applicability of the quality measurement tools,
which are relevant and practical across the states. Therefore, proposed system has flexibility to cater for differential baselines
and priorities of the states.
Following are salient features of the proposed quality system -
1. Comprehensiveness – The proposed system is all inclusive and captures all aspects of quality of care within
the eight areas of concern. The eighteen departmental check-sheets transposed within seventy standards, and
commensurate measurable elements provide an exhaustive matrix to capture all aspects of quality of care at the
Public Health Facilities.
2. Contextual – The proposed system has been developed primarily for meeting the requirements of the Public
Health Facilities; since Public Hospitals have their own processes, responsibilities and peculiarities, which are very
different from ‘for-profit’ sector. For instance, there are standards for providing free drugs, ensuring availability of
clean linen, etc. which may not be relevant for other hospitals.
3. Contemporary – Contemporary Quality standards such as NABH, ISO and JCI, and Quality improvement tools such
as Six Sigma, Lean and CQI have been consulted and their relevant practices have been incorporated.
4. User Friendly – The Public Health System requires a credible Quality system. It has been endeavour of the team
to avoid complex language and jargon. So that the system remains user-friendly to enable easy understanding
and implementation by the service providers. Checklists have been designed to be user-friendly with guidance for
each checkpoint. Scoring system has been made simple with uniform scoring rules and weightage. Additionally, a
formula fitted excel sheet tool has been provided for the convenience, and also to avoid calculation errors.
5. Evidence based – The Standards have been developed after consulting vast knowledge resource available on the
quality. All respective operational and technical guidelines related to RMCH+A and National Health Programmes
have been factored in.
6. Objectivity – Ensuring objectivity in measurement of the Quality has always been a challenge. Therefore in the
proposed quality system, each Standard is accompanied with measurable elements & Checkpoints to measure
compliance to the standards. Checklists have been developed for various departments, which also captures inter-
departmental variability for the standards. At the end of assessment, there would be numeric scores, bringing
out the quality of care in a snap-shot, which can be used for monitoring, as well as for inter-hospital/ inter-state(s)
comparison.
7. Flexibility – The proposed system has been designed in such a way that states and Health Facilities can adapt
the system according to their priorities and requirements. State or facilities may pick some of the departments or
group of services in the initial phase for Quality improvement. As baseline differs from state to state, checkpoints
may either be made essential or desirable, as per availability of resources. Desirable checkpoints will be counted
Assessor’s Guidebook for Quality Assurance in District Hospitals | 3

in arriving at the score, but this may not withhold its certification, if compliance is still not there. In this way the
proposed system provides flexibility, as well as ‘road-map’.
8. Balanced – All three components of Quality – Structure, process & outcome, have been given due weightage.
9. Transparency – All efforts have been made to ensure that the measurement system remains transparent, so that
assessee and assessors have similar interpretation of each checkpoint.
10. Enabler – Though standards and checklists are primarily meant for the assessment, it can also be used as a ‘road-
map’ for improvement.
4 | Assessor’s Guidebook for Quality Assurance in District Hospitals

ii Components of Quality Measurement System
and their intent
The main pillars of Quality Measurement Systems are Quality Standards. There are Seventy standards, defined under the
proposed quality measurement system. The standards have been grouped within the eight areas of concern. Each Standard
further has specific measurable elements. These standards and measurable elements are checked in each department of a
health facility through department specific checkpoints. All Checkpoints for a department are collated, and together they
form assessment tool called ‘Checklist’. Scored/ filled-in Checklists would generate scorecards.
Functional relationship between quality standards, measurable elements, check-points and check-sheet is shown in
Figure1.
Figure 1: Functional Relationship between Components of Quality Measurement System
Departmental
Checklists
Checkpoint
Mesurable Score card
Elements
Checkpoint Departmental
Standard &
Hospital
Checkpoint
Mesurable
Area of Concern
Elements
Checkpoint
Standard
Following are the area of concern in a health facility –
1. Service Provision 5. Clinical Services

2. Patient Rights 6. Infection Control
3. Inputs 7. Quality Management
4. Support Services 8. Outcome
Categorization of standards within the eight areas of concern is in line with the Quality of Care model - Structure, Process
and Outcome. Summary of each area of concern is given in succeeding paragraphs -

Area of Concern - A: Service Provision
Apart from the curative services that district hospitals provides, Public hospitals are also mandated to provide preventive
and promotive services. Reproductive and Child Health services are now grouped as RMCH+A, which are major chunk of
the services. These services are also priority for the government, so as to have direct impact on the key indicators such as
MMR and IMR.
This area of concern measures availability of services. “Availability” of functional services means service is available to
end-users because mere availability of infrastructure or human resources does not always ensure into availability of the
services. For example, a facility may have functional OT, Blood Bank, and availability of Obstetrician and Anaesthetist,
but it may not be providing CEmOC services on 24x7 basis. The facility may have functional Dental Clinic, but if there
are hardly any procedures undertaken at the clinic, it may be assumed that the services are either not available or non-
accessible to users. Compliance to these standards and measurable elements should be checked, preferably by observing
delivery of the services, review of records and checking utilisation of the service.
Compliance to following standards ensures that the health facility is addressing this area of concern.
Standard A1: The standard would include availability of OPD consultation, Indoor services
The facility provides Curative and Surgical procedures, Intensive care and Emergency Care under different
Services specialities e. g. Medicine, Surgery, Orthopaedics, Paediatrics etc. Each measurable
element under this standard measures one speciality across the departments.
For Example, ME A1.2 measures availability of emergency surgical procedures in
Accident & Emergency department, availability of General surgery clinic at OPD,
Availability of surgical procedures in Operation theatre and availability of indoors
services for surgery patients in wards.
Standard A2: This standard measures availability of Reproductive, Maternal, Newborn, Child
The facility provides RMNCHA and Adolescent services in different departments of the hospital. Each aspect of
Services RMNCH+A services is covered by one measurable element of this standard.
Standard A3: It covers availability of Laboratory, Radiology and other diagnostics services in the
The facility Provides respective departments.
diagnostic Services
Standard A4: This standard measures availability of the services at health facility under
The facility provides services different National Health Programmes such as RNTCP, NVBDCP, etc. One
as mandated in national Measurable element has been assigned to each National Health Programme.
Health Programmes/ state
scheme
Standard A5: The standard measures availability of support services like dietary,
The facility provides support laundry and housekeeping services at the facility.
services
Standard A6: The standard mandates availability of the services according to specific
Health services provided at local health needs. Different geographical area may have certain health
the facility are appropriate to problems, which are prevalent locally.
community needs.

Area of Concern – B: Patient Rights
Mere availability of services does not serve the purpose until the services are accessible to the users, and are provided
with dignity and confidentiality. Access includes Physical access as well as financial access. The Government has launched
many schemes, such as JSSK, RBSK and RBSY, for ensuring that the service packages are available cashless to different
targeted groups. There are evidences to suggest that patients’ experience and outcome improves, when they are involved
in the care. So availability of information is critical for access as well as enhancing patients’ satisfaction. Patients’ rights also
include that health services give due consideration to patients’ cultural and religious preferences.
Brief description of the standards under this area of concern are given below –
Standard B1: Standard B1 measures availability of the information about services and their
The facility provides the modalities to patients and visitors. Measurable elements under this standard
information to care seekers, check for availability of user-friendly signages, display of services available and
attendants & community user charges, citizen charter, enquiry desk and access to his/her clinical records.
about the available services
and their modalities
Standard B2 Standard B2 - This standard ensure that the services are sensitive to gender,
Services are delivered in cultural and religious needs. This standard also measures the physical access,
a manner that is sensitive and disable-friendliness of the services, such as availability of ramps and disable
to gender, religious and friendly toilets. Last measurable element of this standard mandates for provision
cultural needs, and there are for affirmative action for vulnerable and marginalized patients like orphans,
no barriers on account of destitute, terminally ill patients, victims of rape and domestic violence so they can
physical economic, cultural avail health care service with dignity and confidence at public hospitals.
or social reasons.
Standard B3 Standard B3 - This standard measures the patient friendliness of the services in
The facility maintains privacy, terms of ensuring privacy, confidentiality and dignity. Measurable elements
confidentiality & dignity of under this standard check for provisions of screens and curtains, confidentiality
patient, and has a system for of patients’ clinical information, behaviour of service providers, and also ensuring
guarding patient related specific precautions to be taken, while providing care to patients with HIV
information. infection, abortion, teenage pregnancy, etc.
Standard B4 Standard B4 - This standard mandates that health facility has procedures of
The facility has defined and informing patients about their rights, and actively involves them in the decision-
established procedures for making about their treatment. Measurable elements in this standards look for
informing patients about practices such informed consent, dissemination of patient rights and how patients
the medical condition, and are communicated about their clinical conditions and options available. This
involving them in treatment standard also measures for procedure for grievance redressal. Compliance to these
planning, and facilitates standards can be checked through review of records for consent, interviewing
informed decision making staff about their awareness of patients’ rights, interviewing patients whether they
had been informed of the treatment plan and available options.
Standard B5 Standard B5 – This standard majorly checks that there are no financial barriers to
The facility ensures that the services. Measurable elements under this standard checks for availability of
there is no financial barrier drugs, diagnostics and transport free of cost under different schemes, and timely
to access, and that there is payment of the entitlements under JSY and Family planning incentives.
financial protection given
from the cost of hospital
services.

Area of concern C – Input
This area of concern predominantly covers the structural part of the facility. Indian Public Health Standards (IPHS)
defines infrastructure, human resources, drugs and equipment requirements for different level of health facilities. Quality
standards given in this area of concern take into cognizance of the IPHS requirement. However, focus of the standards
has been in ensuring compliance to minimum level of inputs, which are required for ensuring delivery of committed
level of the services. The words like ‘adequate’ and ‘as per load‘ has been given in the requirements for many standards &
measurable elements, as it would be hard to set structural norms for every level of the facility that commensurate with
patient load. For example, a 100-bedded hospital having 40% bed occupancy may not have same requirements as the
similar hospital having 100% occupancy. So structural requirement should be based more on the utilization, than fixing
the criteria like beds available. Assessor should use his/her discretion to arrive at a decision, whether available structural
component is adequate for committed service delivery or not.
Following are the standards under this area of concern –
Standard C1 Standard C1 measures adequacy of infrastructure in terms of space, patient

The facility has amenities, layout, circulation area, communication facilities, service counters, etc.
infrastructure for delivery It also looks into the functional aspect of the structure, whether it commensurate
of assured services, and with the process flow of the facility or not.
available infrastructure Minimum requirement for space, layout and patient amenities are given in
meets the prevalent norms some of departments, but assessors should use his discretion to see whether
space available is adequate for the given work load. Compliance to most of the
measurable elements can be assessed by direct observation except for checking
functional adequacy, where discussion with staff and hospital administration may
be required to know the process flow between the departments, and also within
a department.
Standard C2 Standard C2 deals with Physical safety of the infrastructure. It includes seismic
The facility ensures the safety, safety of lifts, electrical safety, and general condition of hospital
physical safety of the infrastructure.
infrastructure.
Standard C3 Standard C3 is concerned with fire safety of the facility. Measurable elements in
The facility has established this standard look for implementation of fire prevention, availability of adequate
Programme for fire safety number of fire fighting equipment and preparedness of the facility for fire disaster
and other disaster in terms of mock drill and staff training.
Standard C4 Standard C4 measures the numerical adequacy and skill sets of the staff. It includes
The facility has adequate availability of doctors, nurses, paramedics and support staff. It also ensures that
qualified and trained staff, the staff have been trained as per their job description and responsibilities. There
required for providing are two components while assessing the staff adequacy - first is the numeric
the assured services to the adequacy, which can be checked by interaction with hospital administration and
current case load review of records. Second is to access human resources in term of their availability
within the department. For instance, a hospital may have 20 security guards, but
if none of them is posted at the labour room, then the intent of standard is not
being complied with.
Skill set may be assessed by reviewing training records and staff interview
and demonstration to check whether staff have requisite skills to perform the
procedures.
Standard C5 Standard C5 measures availability of drugs and consumables in user departments.
The facility provides drugs Assessor may check availability of drugs under the broad group such as antibiotics,
and consumables required IV fluids, dressing material, and make an assessment that majority of normal
for assured services. patients and critically ill patients are getting treated at the health facility.
Standard C6 Standard C6 is also concerned with availability of instruments in various
The facility has equipment departments and service delivery points. Equipment and instruments have been
& instruments required for categorized into sub groups as per their use, and measurable elements have
assured list of services. been assigned to each sub group, such as examination and monitoring, clinical
procedures, diagnostic equipment, resuscitation equipment, storage equipment
and equipment used for non clinical support services. Some representative
equipment could be used as tracers and checked in each category.

Area of Concern D – Support services
Support services are backbone of every health care facility. The expected clinical outcome cannot be envisaged in absence
of sturdy support services. This area of concern includes equipment maintenance, calibration, drug storage and inventory
management, security, facility management, water supply, power backup, dietary services and laundry. Administrative
processes like RKS, Financial management, legal compliances, staff deputation and contract management have also been
included in this area of concern.
Brief description of the standards under this area of concern are given below -
Standard D1 Standard D1 is concerned with equipment maintenance processes, such as AMC,

The facility has established daily and breakdown maintenance processes, calibration and availability of
Programme for inspection, operating instructions. Equipment records should be reviewed to ensure that valid
testing and maintenance and AMC is available for critical equipment and preventive / corrective maintenance
calibration of Equipment. is done timely. Calibration records and label on the measuring equipment should
be reviewed to confirm that the calibration has been done. Operating instructions
should be displayed or should readily available with the user.
Standard D2 Standard D2 is concerned with safe storage of drugs and scientific management
The facility has defined of the inventory, so drugs and consumables are available in adequate quantity
procedures for storage, in patient care area. Measurable elements of this standard look into processes
inventory management of indenting, procurement, storage, expired drugs management, inventory
and dispensing of drugs in management, stock management at patient care areas, including storage at
pharmacy and patient care optimum temperature. While assessing drug management system, these practices
areas should be looked into each clinical department, especially at the nursing stations
and its complementary process at drug stores/Pharmacy.
Standard D3 Standard D3 - This standard is concerned with providing safe, secure and
The facility provides safe, comfortable environment to patients as well service providers. The measurable
secure and comfortable elements under this standard have two aspects, - firstly, provision of comfortable
environment to staff, patients work environment in terms of illumination and temperature control in patient
and visitors. care areas and work stations, and secondly, arrangement for security of patients
and staff. Availability of environment control arrangements should be looked
into. Security arrangements at patient area should be observed for restriction of
visitors and crowd management.
Standard D4 Standard D4 - This standard is concerned with adequacy of facility management
The facility has established processes. This includes appearance of facility, cleaning processes, infrastructure
Programme for maintenance maintenance, removal of junk and condemned items and control of stray animals
and upkeep of the facility and pest control at the facility.
Standard D5 Standard D5 covers processes to ensure water supply (quantity & quality),
The facility ensures 24X7 power back-up and medical gas supply. All departments should be assessed for
water and power backup as availability of water and power back-up. Some critical area like OT and ICU may
per requirement of service require two-tire power backup in terms of UPS. Availability of central oxygen and
delivery, and support services vacuum supply should especially be assessed in critical area like OT and ICU.
norms
Standard D6 Standard D6 is concerned with processes ensuring timely and hygienic dietary
Dietary services are available services. This includes nutritional assessment of patients, availability of different
as per service provision and types of diets and standard procedures for preparation and distribution of food,
nutritional requirement of including hygiene & sanitation in the kitchen. Patients / staff may be interacted for
the patients. knowing their perception about quality and quantity of the food.
Standard D7 Standard D7 is concerned with the laundry processes. It includes availability of
The facility ensures clean adequate quantity of clean & usable linen, process of providing and changing bed
linen to the patients sheets in-patient care area and process of collection, washing and distributing the
linen. Besides direct observation, staff interaction may help in knowing availability
of adequate sets of linen and work practices. An assessment of segregation and
disinfection of soiled laundry should be undertaken. Observation should be
recorded if laundry is being washed at some public water body like pond or river.

Standard D8 Standard D8 measures processes related to functioning of Rogi Kalyan Samiti
The facility has defined and (RKS; equivalent to Hospital Management Society) and community participation
established procedures in Hospital Management. RKS records should be reviewed to assess frequency of
for promoting public the meetings, and issues discussed there. Participation of non-official members
participation in management like community/NGO representatives in such meetings should be checked.
of hospital transparency and
accountability.
Standard D9 Standard D9 is concerned with the financial management of the funds/grants,
Hospital has defined and received from different sources including NRHM. Assessment of financial
established procedures for management processes by no means should be equated with financial or accounts
Financial Management audit. Hospital administration and accounts department can be interacted to
know process of utilization of funds, timely payment of salaries, entitlements and
incentives to different stakeholders and process of receiving funds and submitting
utilization certificates. An assessment of resource utilisation and prioritisation
should be undertaken.
Standard D10 Standard D10 is concerned with compliances to statuary and regulatory
The facility is compliant with requirements. It includes availability of requisite licenses, updated copies of acts
all statutory and regulatory and rules, and adherence to the legal requirements as applicable to Public Health
requirement imposed by local, Facilities.
state or central government
Standard D11 Standard D11 is concerned with processes regarding staff management and
Roles & Responsibilities of their deployment in the departments of a facility. This includes availability of Job
administrative and clinical descriptions for different cadre, processes regarding preparation of duty rosters
staff are determined as and staff discipline. Staff can be interviewed to assess about their awareness of
per govt. regulations job description. It should be assessed by observation and review of the records.
and standards operating Adherence to dress-code should be observed during the assessment.
procedures.
Standard D12 Standard D12 This standard measures the processes related to outsourcing and
The facility has established contract management. This includes monitoring of outsourced services, adequacy
procedure for monitoring of contact documents and tendering system, timely payment for the availed
the quality of outsourced services and provision for action in case for inadequate/ poor quality of services.
services and adheres to Assessor should review the contract records related to outsourced services, and
contractual obligations interview hospital administration about the management of outsource services.

Area of Concern- E Clinical Care
The ultimate purpose of existence of a hospital is to provide clinical care. Therefore, clinical processes are the most critical
and important in the hospitals. These are the processes that define directly the outcome of services and quality of care.
The Standards under this area of concern could be grouped into three categories. First, nine standards are concerned with
those clinical processes that ensure adequate care to the patients. It includes processes such as registration, admission,
consultation, clinical assessment, continuity of care, nursing care, identification of high risk and vulnerable patients,
prescription practices, safe drug administration, maintenance of clinical records and discharge from the hospital.
Second set of next seven standards are concerned with specific clinical and therapeutic processes including intensive
care, emergency care, diagnostic services, transfusion services, anaesthesia, surgical services and end of life care.
The third set of seven standards are concerned with specific clinical processes for Maternal, Newborn, Child, Adolescent
& Family Planning services and National Health Programmes. These standards are based on the technical guidelines
published by the Government of India on respective programmes and processes.
It may be difficult to assess clinical processes, as direct observation of clinical procedure may not always be possible at
time of assessment. Therefore, assessment of these standards would largely depend upon review of the clinical records
as well. Interaction with the staff to know their skill level and how they practice clinical care (Competence testing) would
also be helpful. Assessment of theses standard would require thorough domain knowledge.
Following is the brief description of standards under this area of concern.
Standard E1 Standard E1 -This standard is concerned with the registration and admission
The facility has defined processes in hospitals. It also covers OPD consultation processes. The Assessor
procedures for registration, should review the records to verify that details of patients have been recorded,
consultation and admission and patients have been given unique identification number. OPD consultation
of patients. may be directly observed, followed by review of OPD tickets to ensure that
patient history, examination details, etc. have been recorded on the OPD ticket.
Staff should be interviewed to know, whether there is any fixed admission criteria
especially in critical care department.
Standard E2 Standard E2 -This standard pertains to clinical assessment of the patients. It
The facility has defined and includes initial assessment as well as reassessment of admitted patients.
established procedures for
clinical assessment and
reassessment of the patients.
Standard E3 Standard E3 is concerned with continuity of care for the patient’s ailment. It
The facility has defined and includes process of inter-departmental transfer, referral to another facility,
established procedures for deputation of staff for the care, and linkages with higher institutions. Staff should
continuity of care of patient be interviewed to know the referral linkages, how they inform the referral hospital
and referral about the referred patients and arrangement for the vehicles and follow-up car.
Records should be reviewed for confirming that referral slips have been provided
to the patients.
Standard E4 Standard E4 measures adequacy and quality of nursing care for the patients.
The facility has defined and It includes processes for identification of patients, timely and accurate
established procedures for implementation of treatment plan, nurses’ handover processes, maintenance
nursing care of nursing records and monitoring of the patients. Staff should be interviewed
and patients’ records should be reviewed for assessing how drugs distribution/
administration endorsement and other procedures like sample collection and
dressing have been done on time as per treatment plan. Handing-over of patients
is a critical process and should be assessed adequately. Review BHT for patient
monitoring & nursing notes should be done.
Standard E5 Standard E5 is concerned with identification of vulnerable and High-risk patients.
The facility has a procedure Review of records and staff interaction would be helpful in assessing how High-
to identify high risk and risk patients are given due attention and treatment.
vulnerable patients.
Standard E6 Standard E6 is concerned with assessing that patients are prescribed drugs
The facility follows standard according standard treatment guidelines and protocols. Patient records are
treatment guidelines defined assessed to ascertain that prescriptions are written in generic name only.
by state/Central government
for prescribing the generic
drugs & their rational use.

Standard E7 Standard E7 concerns with the safety of drug administration. It includes
The facility has defined administration of high alert drugs, legibility of medical orders, process for checking
procedures for safe drug drugs before administration and processes related to self-drug administration.
administration Patient’s records should be reviewed for legibility of the writing and recording
of date and time of orders. Safe injection practices like use of separate needle for
multi-dose vial should be observed.
Standard E8 Standard E8 is concerned with the processes of maintaining clinical records
The facility has defined and systematically and adequately. Compliance to this standard can be assessed by
established procedures for comprehensive review of the patients’ record.
maintaining, updating of
patients’ clinical records and
their storage
Standard E9 Standard E9 measures adequacy of the discharge process. It includes pre-discharge
The facility has defined and assessment, adequacy of discharge summary, pre-discharge counselling and
established procedures for adherence to standard procedures, if a patient is leaving against medical advice
discharge of patient. (LAMA) or is found absconding. Patients’ record should also be reviewed for
adequacy of the discharge summary.
Standard E10 Standard E10 is concerned with processes related to intensive care treatment of
The facility has defined and patients, availability and adherence to protocols related to pain management,
established procedures for sedation, intubation, etc.
intensive care.
Standard E11 Standard E11 is concerned with emergency clinical processes and procedures. It
The facility has defined and includes triage, adherence to emergency clinical protocols, disaster management,
established procedures for processes related to ambulance services, handling of medico-legal cases, etc.
Emergency Services and Availability of the buffer stock for medicines and other supplies for disaster
Disaster Management and mass casualty needs to be found out. Interaction with staff and hospital
administration should be done to asses overall disaster preparedness of the
health facility.
Standard E12 Standard E12 deals with the procedures related to diagnostic services. The standard is
The facility has defined and majorly applicable for laboratory and radiology services. It includes pre-testing, testing
established procedures of and post-testing procedures. It needs to be observed that samples in the laboratory
diagnostic services are properly labelled, and instructions for handling sample are available. The process
for storage and transportation of samples needs to be ensured. Availability of critical
values and biological references should also be checked.
Standard E13 Standard E13 is concerned with functioning of blood bank and transfusion services.
The facility has defined and The measurable elements under this standard are processes for donor selection,
established procedures collection of blood, testing procedures, preparation of blood components,
for Blood Bank/Storage labelling and storage of blood bags, compatibility testing, issuing, transfusion and
Management and Transfusion. monitoring of transfusion reaction. The assessor should observe the functioning,
and interact with the staff to know regarding adherence to standard procedures
for blood collection and testing, including preparation of blood components,
storage practices, as per standard protocols. Record of temperature maintained in
different storage units should be checked. The staff should also be interacted to
know how they mange if certain blood is not available at the blood bank. Records
should be reviewed for assessing processes of monitoring transfusion reactions.
Standard E14 Standard E14 is concerned with the processes related with safe anaesthesia
The facility has established practices. It includes pre-anaesthesia, monitoring and post-anaesthesia processes.
procedures for Anaesthetic Records should be reviewed to assess how Pre-anaesthesia check-up is done and
Services records are maintained. Interact with Anaesthetists and OT technician/Nurse for
adherence to protocols in respect of anaesthesia safety, monitoring, recording &
reporting of adverse events, maintenance of anaesthesia notes, etc.
Standard E15 Standard E15 is concerned with processes related with Operation Theatre. It
The facility has defined and includes processes for OT scheduling, pre-operative, Post-operative practices of
established procedures of surgical safety. Interaction with the surgeon(s) and OT staff should be done to
Operation theatre services assess processes - preoperative medication, part preparation and evaluation of
patient before surgery, identification of surgical site, etc. Review of records for
usage of surgical safety checklist & protocol for instrument count, suture material,
etc may be undertaken.

Standard E16 Standard E 16 concerned with end of life care and management of death. Records
The facility has defined and should be reviewed for knowing adequacy of the notes. Interact with the facility
established procedures for staff to know how news of death is communicated to relatives, and kind of support
end of life care and death available to family members.
Standard E17 Standard E17 is concerned with processes ensuring that adequate and quality
The facility has established antenatal care is provided at the facility. It includes measurable elements for ANC
procedures for Antenatal registration, processes during check-up, identification of High Risk pregnancy,
care as per guidelines management of serve anaemia and counselling services. Staff at ANC clinic
should be interviewed and records should be reviewed for maintenance of MCP
cards and registration of pregnant women. For assessing quality and adequacy
of ANC check-up, direct observation may be undertaken after obtaining requisite
permission. ANC records can be reviewed to see findings of examination and
diagnostic tests are recorded. Review the line listing of anaemia cases and how
they are followed. Client and staff can be interacted for counselling on the
nutrition, birth preparedness, family planning, etc.
Standard E18 Standard E18 measures the quality of intra-natal care. It includes clinical process
The facility has established for normal delivery as well management of complications and C-Section surgeries.
procedures for Intranatal Staff can be interviewed to know their skill and practices regarding management
care as per guidelines of different stages of labour, especially Active Management of Third stage of
labour. Staff may be interacted for demonstration of resuscitation and essential
newborn care. Competency of the staff for managing obstetric emergencies,
interpretation of partograph, APGAR score should also be assessed.
Standard E19 Standard E19 is concerned with adherence to post-natal care of mother and
The facility has established newborn within the hospital. Observe that postnatal protocols of prevention of
procedures for postnatal Hypothermia and breastfeeding are adhered to. Mother may be interviewed to
care as per guidelines know that proper counselling has been provided.
Standard E20 Standards E20 is concerned with adherence to clinical protocols for newborn and
The facility has established child health. It covers immunization, emergency triage, management of newborn
procedures for care of new and childhood illnesses like neonatal asphyxia, low birth weight, neo-natal
born, infant and child as per jaundice, sepsis, malnutrition and diarrhoea. Immunization services are majorly
guidelines assessed at immunization clinic. Staff interview and observation should be done
to assess availability of diluents, adherence to protocols of reconstitution of
vaccine, storage of VVM labels and shake test. Adherence to clinical protocols for
management of different illnesses in newborn and child should be done through
interaction with the doctors and nursing staff.
Standard E21 Standard 21 is concerned with providing safe and quality family planning and
The facility has established abortion services. This includes standard practices and procedures for Family
procedures for abortion palling counselling, spacing methods, family planning surgeries and counselling
and family planning as per and procedures for abortion. Quality and adequacy of counselling services can
government guidelines and be assessed by exit interview with the clients. Staff at family planning clinic may
law be interacted to assess adherence to the protocols for IUD insertion, precaution &
contraindication for oral pills, family planning surgery, etc.
Standard E22 Standard E22 is concerned with services related to adolescent Reproductive and
The facility provides Sexual health (ARSH) guidelines. It includes promotive, preventive, curative and
Adolescent Reproductive and referral services under the ARSH. Staff should be interviewed, and records should
Sexual Health services as per be reviewed.
guideline
Standard E23 Standard E23 pertains to adherence for clinical guidelines under the National
The facility provides National Health Programmes. For each national health programme, availability of clinical
health Programme as per services as per respective guidelines should be assessed
operational/Clinical Guidelines

Area of concern F – Infection Control
The first principle of health care is “to do no harm”. As Public Hospitals usually have high occupancy, the Infection control
practices become more critical to avoid cross-infection and its spread. This area of concern covers Infection control
practices, hand-hygiene, antisepsis, Personal Protection, processing of equipment, environment control, and Biomedical
Waste Management.
Following is the brief description of the Standards within this area of concern
Standard F1 Standard F1 is concerned with the implementation of Infection control programme

The facility has infection at the facility. It is includes existence of functional infection control committee,
control Programme and microbiological surveillance, measurement of hospital acquired infection rates,
procedures in place for periodic medical check-up and immunization of staff and monitoring of Infection
prevention and measurement control Practices. Hospital administration should be interacted to assess the
of hospital associated functioning of infection control committee. Records should be reviewed for
infection confirming the culture surveillance practices, monitoring of Hospital acquired
infection, status of staff immunization, etc. Implementation of antibiotic policy
can be assessed though staff interview, perusal of patient record and usage
pattern of antibiotic.
Standard F2 Standard F2 is concerned with practices of hand-washing and antisepsis.
The facility has defined and Availability of Hand washing facilities with soap and running water should be
Implemented procedures observed at the point of use. Technique of hand-washing for assessing the
for ensuring hand hygiene practices, and effectiveness of training may be observed.
practices and antisepsis
Standard F3 Standard F3 is concerned with usage of Personal Protection Equipment (PPE)
The facility ensures standard such as gloves, mask, apron, etc. Interaction with staff may reveal the adequacy
practices and materials for of supply of PPE.
Personal protection
Standard F4 Standard F4 is concerned with standard procedures, related to processing of
The facility has standard equipment and instruments. It includes adequate decontamination, cleaning,
procedures for processing of disinfection and sterilization of equipment and instruments. These practices
equipment and instruments should be observed and staff should be interviewed for compliance to certain
standard procedures.
Standard F5 Standard F5 pertains to environment cleaning. It assesses whether lay out
Physical layout and and arrangement of processes are conducive for the infection control or not.
environmental control of Environment cleaning processes like mopping, especially in critical areas like OT
the patient care areas ensures and ICU should be observed for the adequacy and technique.
infection prevention
Standard F6 Standard F6 is concerned with Management of Biomedical waste management
The facility has defined and including its segregation, transportation, disposal and management of sharps.
established procedures for Availability of equipment and practices of segregation can be directly observed.
segregation, collection, Staff should be interviewed about the procedure for management of the needle
treatment and disposal of stick injuries. Storage and transportation of waste should be observed and records
Bio Medical and hazardous are verified.
Waste.

Area of concern G Quality Management
Quality management requires a set of interrelated activities that assure quality of services according to set standards and
strive to improve upon it through a systematic planning, implementation, checking and acting upon the compliances.
The standards in this area concern are the opportunities for improvement to enhance quality of services and patient
satisfaction. These standards are in synchronization with facility based quality assurance programme given in ‘Operational
Guidelines’.
Following are the Standards under this area of Concern.
Standard G1 Standard G1 is concerned with creating a Quality Team at the facility and making
The facility has established it functional. Assessor may review the document and interact with Quality Team
organizational framework members to know how frequently they meet and responsibilities have been
for quality improvement delegated to them. Quality team meeting records may be reviewed.
Standard G2 Standard G2 is concerned with having a system of measurement of patient and
The facility has established employee satisfaction. This includes periodic patients’ satisfaction survey, analysis
system for patient and of the feedback and preparing action plan. Assessors should review the records
employee satisfaction pertaining to patient satisfaction and employee satisfaction survey to ascertain
that Patient feedback is taken at prescribed intervals and adequate sample size
is adequate.
Standard G3 Standard G3 is concerned with implementation of internal quality assurance
The facility has established programmes within departments such as EQAS of diagnostic services, daily round
internal and external quality and use of departmental check-lists, EQUAS records at laboratory, etc. Interview
assurance Programmes with Matron, Hospital Mangers etc may give information about how they conduct
wherever it is critical to daily round of departments and usage of checklists.
quality.
Standard G4 Standard G4 is concerned with availability and adequacy of Standard operating
The facility has established, procedures and work instructions with the respective process owners. Display
documented implemented of work instructions and clinical protocols should be observed during the
and maintained Standard assessment.
Operating Procedures for all
key processes and support
services.
Standard G 5 Standard G5 concerns the efforts’ made for the mapping and improving processes.
The facility maps its key Records should be checked to ensure that the critical processes have been
processes and seeks to mapped, wastes have been identified and efforts are made to remove them to
make them more efficient by make processes more efficient.
reducing non value adding
activities and wastages
Standard G6 Standard G6 pertains to the processes of internal assessment, medical and death
The facility has established audit at a defined periodicity. Review of Internal assessment and clinical audit
system of periodic review as records may revel their adequacy and periodicity.
internal assessment , medical
& death audit and prescription
audit
Standard G7 7.7 Standard G7 is concerned with establishment and dissemination of quality
The facility has defined and policy and objectives in the hospital. The staff may be interviewed regarding their
established Quality Policy & awareness of Quality policy and Objectives. Review of records should be done for
Quality Objectives assessing that Quality objectives meet SMART criteria, and have been reviewed
periodically.
Standard G8 7.8 Standard G8 is concerned with the practice of using Quality tools and
The facility seeks continually methods like control charts, 5-‘S’, etc. The Assessor should look for any specific
improvement by practicing methods and tools practiced for quality improvement.
Quality method and tools.

Area of Concern H Outcome
Measurement of the quality is critical to improvement of processes and outcomes. This area of concern has four standard
measures for quality- Productivity, Efficiency, Clinical Care and Service quality in terms of measurable indicators. Every
standard under this area has two aspects – Firstly, there is a system of measurement of indicators at the health facility;
and secondly, how the hospital meets the benchmark. It is realised that at the beginning many indictors given in
these standards may not be getting measured across all facilities, and therefore it would be difficult to set benchmark
beforehand. However, with the passage of time, the state can set their benchmarks, and evaluate performance of health
facilities against the set benchmarks.
Following is the brief description of the Standards in this area of concern
Standard H1 Standard H1 is concerned with the measurement of Productivity indicators and

The facility measures meeting the benchmarks. This includes utilization indicators like bed occupancy
Productivity Indicators and rate and C-Section rate. Assessor should review these records to ensure that theses
ensures compliance with indictors are getting measured at the health facility.
State/National benchmarks
Standard H2 Standard H2 pertains to measurement of efficiency indicators and meeting
The facility measures benchmark. This standard contains indicators that measure efficiency of
Efficiency Indicators and processes, such as turnaround time, and efficiency of human resource like surgery
ensure to reach State/ per surgeon. Review of records should be done to assess that these indicators
National Benchmark have been measured correctly.
Standard H3 Standard H3 is concerned with the indicators of clinical quality, such as average
The facility measures Clinical length of stay and death rates. Record review should be done to see the
Care & Safety Indicators and measurement of these indicators.
tries to reach State/National
benchmark
Standard H4 Standard H4 is concerned with indicators measuring service quality and patient
The facility measures Service satisfaction like Patient satisfaction score and waiting time and LAMA rate.
Quality Indicators and
endeavours to reach State/
National benchmark
Complete list of standard wise measurable elements are given in Annexure ‘A’.

iii Introduction to departmental checklist –
tool for assessment
As we discussed earlier, Checklist are the tools for measuring compliance to the Standards. We may also recall that “standards
are statement of requirements for that are critical for delivery of quality services”.
These are cross sectional themes that may apply to all or some of the departments. Assessing every standard independently
in each department may take lot of time and hence not practicable. Therefore for the convenience sake, all the applicable
standards and measurable elements for one department have been collated in the checklists. It enables measurement of
all aspect of quality of care in a department in one go. After assessing the departments on the checklist, their scores can be
calculated to see compliance to different standards in the department.
There are eighteen checklists given in these Assessors Guidebooks (Volume I & II). Following is a brief description of
checklists -
1. Accident &Emergency – This checklist is applicable to Accident& Emergency department of a Hospital. The
checklist has been designed to assess all aspect of dedicated emergency department. If emergency department is
shared with OPD infrastructure than two checklists should be used independently.
2. Outdoor department – This checklist is applicable to outdoor department of a hospital. It includes all clinics and
support areas like immunization room, dressing room, waiting area and laboratory’s sample collection centre,
located there, except for Family planning Clinic (if co-located in OPD), which has been included in the post partum
unit. Similarly dispensary has been included in the Pharmacy check list. This checklist also includes ICTC and ANC
clinics. It may be possible that OPD services are dispersed geographically, for example ANC Clinic may not be
located in the main OPD complex. Therefore, all such facilities should be visited.
3. Labour Room- This checklist is applicable to the labour room(s) and its auxiliary area like nursing station, waiting
area and recovery area. It also includes septic labour room and eclampsia room.
4. Maternity ward – This checklist is meant for assessment of indoor obstetric department including wards for
Antenatal care, and Post-partum wards (including C-Section). The auxiliary area for these wards like nursing station,
toilets and department sub stores are also included in this check-list. However, general female wards or family
planning ward are not covered within the purview of maternity ward.
5. Indoor Department – This is a common checklist for other indoors wards including Medical, Surgical, Orthopaedics,
etc. In subsequent years, separate checklist for each ward may be included. However, as of now, this checklist
should be used for all such departments.
6. Nutritional Rehabilitation Centre – This checklist is applicable to NRC functioning within the health facility.
However, it may not be relevant, if management of malnourished patients is done in the paediatric wards.
7. Paediatric ward- This checklist meant for a dedicated paediatric ward. If, there is no such ward in the hospital and
paediatric patients are treated in other wards, then this checklist is not applicable at such health facilities.
8. Sick Newborn Care Unit – This checklist is applicable to a functional Level II SNCU, located in the Hospital. It
includes auxiliary area like waiting area for relatives, side laboratory and duty rooms for the staff. This checklist is
not meant for lower level of facilities like Newborn Stabilization units and Newborn corner.
9. Intensive Care Unit – This checklist is meant for assessing level II ICUs, which are recommended for District
Hospitals. The ICU should have ventilators.
10. Operation Theatre- This checklist is applicable for OT complex including General OT, Obstetrics & Gynaecology OT,
Orthopaedics OT, Ophthalmic OT and any other facility for undertaking the surgeries(if available). Family planning/
Postpartum OT is excluded from this checklist, which will be assessed through postpartum checklist. This checklist
also includes CSSD /TSSU, either co-located within the OT complex or located separately.
11. Postpartum Unit – This checklist is applicable to Family Planning clinic, separate OT used for Family planning
surgeries & abortion cases and separate indoor ward available to admit any such cases. Assessment of Post partum
unit would be undertaken through this checklist.

12. Blood Bank– This checklist is applicable to Blood bank available within the premises of the hospital. This checklist
also use covers the blood component services. This checklist is not meant for blood storage unit.
13. Laboratory – This checklist is meant for main clinical laboratory of the hospital and also includes the laboratory for
testing TB and malaria cases under respective National Health programme. This does not include ICTC lab for HIV
testing which is part of OPD checklist.
14. Radiology – This checklist is applicable on X-ray and Ultrasound departments. This checklist does not cover
technical checkpoints for CT Scan and MRI.
15. Pharmacy – This checklist is applicable on Drug store, Cold Chain storage and Drug dispensing counter. General
store and Drug warehouse are not covered within ambit of this checklist.
16. Auxiliary Services – This checklist covers Laundry ,Dietary and medical record department. If these departments
are outsourced and even located outside the premises, then also this checklist can be used. Washing hospital linen
in public water body like river or pond or food supplied by charitable/religious institutions does not constitute
having Hospital laundry / kitchen per se.
17. Mortuary – This checklist is applicable to Mortuary and post-mortem room located at the hospital
18. General Hospital Administration– This checklist covers medical superintendent (equivalent) and hospital
manager offices and processes related to their functioning. This also covers hospital policy level issues and hospital
wide cross cutting processes. This checklist is complimentary to all other checklist. So if a hospital wants to choose
only of some of the department for quality assurance initially, then this check list should always be included in the
assessment programme.

iv Assessment Protocol
A. General Principles
Assessment of the Quality at Public Health Facilities is based on general principles of integrity, confidentiality, objectivity
and Replicability -
1. Integrity – Assessors and persons managing assessment programmes should
yy Perform their work with honesty, diligence and responsibility
yy Demonstrate their competence while performing assessment
yy Performance assessment in an impartial manner
yy Remain fair and unbiased in their findings
2. Fair Presentation - Assessment findings should represent the assessment activities truthfully and accurately. Any
unresolved diverging opinion should between assessors and assesses should be reported.
3. Confidentiality- Assessors should ensure that information acquired by them during the course of assessment is
not shared with any authorised person including media. The information should not be used for personal gain.
4. Independence- Assessors should be independent to the activity that they are assessing and should act in a
manner that is free from bias and conflict of interest. For internal assessment, the assessor should not assess his or
her own department and process. After the assessment, assessor should handhold to guide the service providers
for closing the gap and improving the services.
5. Evidence based approach – Conclusions should be arrived based on evidences, which are objective, verifiable
and reproducible.
B. Planning Assessment Activities

Following assessment activities are undertaken at different level -
1. Internal Assessment at the facility level– A continuous process of assessment within the facility by internal
assessors.
2. Assessment by District and State Quality Assurance Units
3. Accreditation assessment – Assessment by national assessors for the purpose for certification/ accreditation.
Internal Assessment- Internal assessment is a continuous process and integral part of facility based Quality assurance
program. Assessing all departments in a health facility every month may not be possible. The hospital should prepare a
quarterly assessment schedule. It needs to be ensured that every department would be assessed and scored at least once
in a quarter. This plan should be prepared in consultation with respective departments. Quality team at the facility can also
prioritize certain departments, where quality of services has been a cause of concern.
For internal assessment, the Hospital Quality Team should appoint a coordinator, preferably the hospital manager or quality
manger, whose main responsibilities are given below -
1. Preparing assessment plan and schedule
2. Constitute an assessment team for internal assessment
3. Arrange stationary (forms & formats) for internal assessment
4. Maintenance of assessment records
5. Communicating and coordinating with departments
6. Monitor & review the internal assessment programme
7. Disseminate the findings of internal assessment
8. Preparation of action plan in coordination with quality team and respective departments.

Assessment by DQAU/SQAU – DQAU and SQAU are also responsible for undertaking an independent quality assessment
of a health facility. Facilities having poor quality indicators would have priority in the assessment programme. Visit for the
assessment should also be utilised for building facility level capacity of quality assurance and handholding. Efforts should
be made to ensure that all departments of the hospital have been assessed during one visit. Assessment process is shown
in Figure 2.
Figure 2: Assessment Process
Assessment Plan
& Schedule and its Constitution of Conducting Conclusion & Dissmenination and
communication Assessment Team Assessment scoring Action Planing
C. Constituting assessment team

Assessment team should be constituted according to the scope of assessment i.e. departments to be assessed. Team
assessing clinical department should have at least one person form clinical domain preferably a doctor, assessing patient
care departments. Indoor departments should also have one nursing staff in the team. It would be preferable to have a
multidisciplinary team having at least one doctor and one nurse during the external assessment. As DQAU/SQAU may not
have their own capacity for arranging all team members internally, a person form another hospital may be nominated to be
part of the assessment team. However, it needs to be ensured that person should not assess his/her own department and
there is no conflict of interest. For external assessment, the team members should have undergone the assessors’ training.
D. Preparing assessment schedule

Assessment schedule is micro-plan for conducting assessment. It constitutes of details regarding departments, date, timing,
etc. Assessment schedule should be prepared beforehand and shared with respective departments.
E. Performing Assessment –
i. Pre-assessment preparation – Team leader of the assessment team should ensure that assessment schedule has
been communicated to respective departments. Team leader should assign the area of responsibility to each team
member, according to the schedule and competency of the members.
ii. Opening meeting – A short opening meeting with the assessee’s department or hospital should be conducted for
introduction, aims & objective of the assessment and role clarity.
iii. Reviewing documents – The available records and documents such as SOPs, BHT, Registers, etc should be
reviewed.
F. Communication during assessment

Behaviours and communication of the assessors should be polite and empathetic. Assessment should be fact finding
exercise and not a fault finding exercise. Conflicts should be avoided.
G. Using checklists
Checklists are the main tools for the assessment. Hence, familiarity with the tools would be important -

Figure 3: Sample checklist*.
a
Checklist for Accident & Emergency
Reference Measurement Checkpoint Compli- Assess- Means of Verification
No. Element ance ment
Method
b
Standard A1
Area of Concern - A Service Provision
The facility provides Curative Services
d
ME A1.1. The facility provides Availability of Emergency SI/OB Poisoning, Snake Bite, CVA,
c
General Medicine Medical Procedures g Acute MI, ARF, Hypovolumic
services
e f h Shock, Dysnea, Unconsious
Patients
h
ME A1.2. The facility provides Availability of Emergency SI/OB Appendicitis, Rupture spleen,
General Surgery Surgical Procedures Intestinal Obstruction, Assault
services Injuries, perforation, Burns
ME A1.3. the facility provides Availability of SI/OB APH, PPH, Eclampsia,
Obstetrics & Emergency Obstertics & Obstructed labour, Septic
Gynaecology Services Gynaecology Procedures abortion, Emergency
Contraceptives
ME A1.4. Availability of emergency SI/OB ARI, Diarrheal diseases,
Pediatric procedures Hypothermia, PEM, reucitation
* - ME denotes measurable elements of a standard, for which details have been provided in the Annexure ‘A’.
a) Header of the checklist denotes the name of department for which checklist is intended.
b) The horizontal bar in grey colour contains the name of the Area of concern for which the underlying standards belong.
c) Extreme left column of checklist in blue colour contain the reference no. of Standard and Measurable Elements, which can used for the iden-
tification and traceability of the standard. When reporting or quoting, reference no of the standard and measurable element should also be
mentioned.
d) Yellow horizontal bar contains the statement of standard which is being measured. There are a total of seventy standards, but all standards may
not be applicable to every department, so only relevant standards are given in yellow bars in the checklists.
e) Second column contains text of the measurable element for the respective standard. Only applicable measurable elements of a standard are
shown in the checklists. Therefore, all measurable elements under a standard are not there in the departmental check-lists. They have been
excluded because they are not relevant to that department.
f) Next right to measurable elements are given the check points to measure the compliance to respective measurable element and the standard.
It is the basic unit of measurement, against which compliance is checked and the score is awarded.
g) Right next to Checkpoint is a blank column for noting the findings of assessment, in term of Compliance – Full, Partial or and Non Compli-
ance.
h) Next to compliance column is the assessment method column. This denotes the ‘HOW’ to gather the information. Generally, there are four pri-
mary methods for assessment - SI means staff interview, OB means observation, RR means record review & PI - Patient Interview.
i) Column next to assessment method contains means of verification. It denotes what to see at a Checkpoint. It may be list of equipment or
procedures to be observed, or question you have to ask or some benchmark, which could be used for comparison, or reference to some other
guideline or legal document. It has been left blank, as the check point is self-explanatory.
Assessor should gather information and evidences to assess compliance to the requirement of measurable element and
checkpoints at Health Facility being assessed. Information can be gathered by following four methods
i. Observation– Compliance to many of the measurable elements can be assessed by directly observing the articles,
processes and surrounding environment. Few examples are given below -
a) Enumeration of articles like equipment, drugs, etc
b) Displays of signages, work instructions, important information
c) Facilities - patient amenities, ramps, complaint-box, etc.
d) Environment – cleanliness, loose-wires, seepage, overcrowding, temperature control, drains, etc
e) Procedures like measuring BP, counselling, segregation of biomedical waste,
ii. Record Review – It may not be possible to observe all clinical procedures. Records also generate objective evidences,
which need to be triangulated with finding of the observation. For example on the day of assessment, drug tray in
the labour room may have adequate quantity of Oxytocin, but if review of the drug expenditure register reveals poor

consumption pattern of Oxytocin, then more enquiries would be required to ascertain on the adherence to protocols
in the labour room. Examples of the record review are given below -
a) Review of clinical records - delivery note, anaesthesia note, maintenance of treatment chart, operation notes, etc.
b) Review of department registers like admission registers, handover registers, expenditure registers, etc.
c) Review of licenses, formats for legal compliances like Blood bank license and Form ‘F’ for PNDT
d) Review of SOPs for adequacy and process
e) Review of monitoring records – TPR chart, Input/output chart, culture surveillance report, calibration records, etc
f) Review of department data and indicators
iii. Staff interview –Interaction with the staff helps in assessing the knowledge and skill level, required for performing job
functions.
Examples -
a) Competency testing – Quizzing the staff on knowledge related to their job
b) Demonstration – Asking staff to demonstrate certain activities like hand-washing technique, new born resuscita-
tion, etc.
c) Awareness - Asking staff about awareness off patients’ right, quality policy, handling of high alerts drugs, etc.
d) Attitude about patient’s dignity and gender issues.
e) Feedback about adequacy of supplies, problems in performing work, safety issues, etc.
iv. Patient / Client Interview– Interaction with patients/clients may be useful in getting information about quality of
services and their experience in the hospital. It gives us users’ perspective. It should include -
a) Feedback on quality of services staff behaviour, food quality, waiting times, etc.
b) Out of pocket expenditure incurred during the hospitalisation
c) Effective of communication like counselling services and self drug administration
Assessor may use one these method to asses certain measurable element. Suggestive methods have been given in the
Assessment method column against each checkpoint Means of verification has been given against each checkpoint. Normal
flow of gathering information assessment would be as given in Figure 4 -
Figure 4: Flow of Information
Familiarise with Measurable element and

Checkpoint
Understand the Assesment method and Means of

verification
Gather the information & Evidence
Compare with checkpoint and means of verification
Arrive at a conclusion for compliance

H. Assessment conclusion
After gathering information and evidence for measurable elements, assessors should arrive at a conclusion for extent of
compliance - full, partial or non-compliance for each of the checkpoints. If the information and evidence collected gives
an impression of not fully meeting the requirements, it could be given ‘Partial compliance’, provided there some evidences
pointing towards the complaince. Non-compliance should be given of none or very few of the requirements are being met.
After arriving on conclusion, assessor should mark ‘C’ for compliance, ‘P’ for partial compliance and ‘N’ for non-compliance
in Compliance column.

v Scoring System
After assessing all the measurable elements and checkpoints and marking compliance, scores of the department/ facility
can be calculated.
Rules of Scoring
yy 2 marks for full compliance
yy 1 mark for partial compliance
yy 0 Marks for Non Compliances
All checkpoints have equal weightage to keep scoring simple.
Once scores have been assigned to each checkpoint, department wise scores can be calculated for the departments, and
also for standards by adding the individual scores for the checkpoints.
The final score should be given in percentage, so it can be compared with other groups and department.
Calculation of percentage is as follows
Score obtained X 100
No of checkpoint in checklist X 2
Scores can be calculated manually or scores can be entered into excel sheet given in the accompanying soft copy to get
score card. All scores should be in percentages to have uniform unit for inter-departmental and inter-hospital comparison.
The assessment scores can be presented in three ways
1. Departmental Scorecard – This score-card presents the Quality scores of a department. It shows the overall
quality score of the department as well as the area of concern wise score in term of percentages. This score card
can be generated by two way
a. If calculations are done manually departmental score can be calculated by simple formula given above, and
filled-in score card format given at the end of checklist.
b. If using excel tool given with this guide book, the scorecard will be generated automatically after filling a score
for all checkpoints
Figure 5 is an example of a filled in score-card after assigning and calculating scores. Score given in the yellow box denotes
the overall quality score of the department in percentage.
Scores given in blue label are area of concern wise scores of the department in percentage.
Figure 5: Sample of filled-in Score card for Labour Room
Labour Room Score Card
Labour Room Score 70%
Area of Concern wise score
1. Service Provision 78 %
2. Patient Rights 52 %
3. Inputs 55 %
4. Support Services 50 %
5. Clinical services 77 %
6. Infection control 85 %
7. Quality Management 90 %
8. Outcome 73 %

2. Hospital Quality Score care
This scorecard depicts departmental and overall quality score of hospital in a snapshot. Another variant depicts area of
Concern wise scores of the Hospital.
Figure 6 is an example of hospital score card generated after calculation of scores for all departments in the hospital.
Yellow label depicts the overall score of the hospital in percentage by taking average of departmental scores. Rest of
the boxes in blue label shows individual scores of the departments.
Figure 6: Sample Scorecard of a Hospital with Departmental Score
Hospital Quality Score Card

Department wise
Accident & Emergency OPD Labour room Maternity Ward Indoor Department
45% 58% 70% 67% 78%
NRC
Paediatric ward SNCU ICU
68%
85% 57% 68%
Hospital
Score
Operation Theatre Post Partum Unit
70% Blood Bank Laboratory
82% 49% 85% 50%
Radiology Pharmacy Auxiliary Services Mortuary General Administration
35% 72% 65% 25% 60%
Figure 7 gives a sample score card for each of eight areas of concern. These have been calculated by taking average of area
of concern score of all departments. Yellow label shows the overall score of Hospital.
Figure 7: Sample Scorecard of a Hospital with Area of Concern Score

Hospital score Card
(Area of Concern Wise)
Service Provision Patient Rights Inputs Support Services
72% 66% 78% 59%
Hospital Score
70%
Quality
Clinical Services Infection Control Outcome
Management
85% 75% 70% 55%
3. Apart from these scorecards, the tool provided in the accompanying CD provides flexibility to present scores according
to your choice. You can choose some of the area and themes like RMNCHA, Patient Safety, etc, as per requirement.
There are endless possibilities they way you can represent your quality scores.

part - B
DEPARTMENTal
checklists
Checklist–1
Accident & Emergency
DEPARTMENT
Version: 1/2013
National Quality Assurance Standards

Checklist–1
Checklist for Accident & Emergency DEPARTMENT
Reference Measure Element Checkpoint Compli- Assessment Means of Verification

No. ance Method
Standard A1. Facility Provides Curative Services
ME A1.1. The facility provides Availability of Emergency SI/OB Poisoning, Snake Bite,
General Medicine Medical Procedures CVA, Acute MI, ARF,
services Hypovolumic Shock ,
Dyspnoea, Unconscious
Patients
ME A1.2. The facility provides Availability of Emergency SI/OB Appendicitis, Rupture
General Surgery Surgical Procedures spleen, Intestinal
services Obstruction, Assault
Injuries, perforation, Burns
ME A1.3. The facility provides Availability of SI/OB APH, PPH, Eclampsia ,
Obstetrics & Emergency Obstetrics Obstructed labour, Septic
Gynaecology Services &Gynaecology abortion, Emergency
Procedures Contraceptives
ME A1.4. The facility provides Availability of emergency SI/OB ARI, Diarrhoeal
Paediatric Services Paediatric procedures diseases, Hypothermia,
PEM,resustication
ME A1.5. The facility provides Availability of Emergency SI/OB Foreign body and injuries
Ophthalmology Ophthalmology
Services procedures
ME A1.6. The facility provides Availability of Emergency SI/OB Epitasis, foreign body
ENT Services ENT procedures
ME A1.7. The facility provides Availability of SI/OB Fracture, RTA, Poly trauma
Orthopaedics Services Emergency Orthopaedic
procedures
ME A1.9. The facility provides Availability of Emergency SI/OB Conversion Reactions,
Psychiatry Services Psychiatric procedures other Psychiatric
emergencies Hysteria,
mania, psychosis
ME A1.13. The facility provides Availability of Dressing SI/OB Drainage, dressing,
services for OPD room facility suturing
procedures Availability of injection SI/OB Injection room facility
room facilities with ARV, ASV and
emergency drugs
ME A1.14. Services are available 24X7 availability of SI/RR
for the time period as dedicated emergency
mandated Services
ME A1.16. The facility provides Availability of Emergency SI/OB Defibrillation, CPR,
Accident & Emergency procedures Mobilization, Chest Tube,
Services Intubations, Tracheotomy,
Mechanical Ventilation
Standard A2 Facility provides RMNCHA Services
ME A2.2 The facility provides Availability of SI/OB
Maternal health Emergency Obstetrics &
Services Gynaecology procedure
No. ance Method
ME A2.4 The facility provides Triage and emergency SI/OB
Child health Services management of
paediatric cases
Standard A3. Facility Provides diagnostic Services
ME A3.1. The facility provides Availability / Linkage to SI/OB
Radiology Services X-ray & USG services
Radiology Services are SI/OB Check services are
functional 24X7 functional at night
ME A3.2. The facility Provides Availability of Emergency SI/OB HB%, CPC, Blood Sugar,
Laboratory Services diagnostic tests 24x7 RDK, Urine Protein,
Electrolyte (Na+K)
ME A3.3. The facility provides Availability of Functional SI/OB
other diagnostic ECG Services
services, as mandated
Standard A5. Facility provides support services
ME A5.3. The facility provides Availability of Police post SI/OB
security services
ME A5.7. The facility has Availability of Medico- SI/OB
services of medical legal record services
record department
Standard A6. Health services provided at the facility are appropriate to community needs.
ME A6.1. The facility provides Availability of specific SI/OB Ask for the specific
curatives & preventive procedures for local local health frequent
services for the health prevalent emergencies emergencies. See if
problems and diseases, emergency is ready for it
prevalent locally. or not.
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 Availability OB Emergency department
uniform and user- departmental signage’s . board is prominently
friendly signage displayed with facility of
system illumination in night.
Availability of Directional OB Direction is displayed
Signage’s. from main gate to direct.
ME B1.2. The facility displays List of services including OB
the services and emergencies that are
entitlements available managed at the facility
in its departments Names of doctor and OB
nursing staff on duty are
displayed and updated
List of drugs available are OB
displayed
Important numbers OB
including ambulance,
blood bank , police and
referral centres displayed
ME B1.5 Patients & visitors are IEC Material is displayed
sensitised and educated
through appropriate
IEC / BCC approaches
ME B1.6. Information is Signage’s and OB
available in local information are available
language and easy to in local language
understand
32 | Checklist for Accident & Emergency Department

No. ance Method
ME B1.7. The facility provides Enquiry services are OB Enquiry services may be
information to patients available 24X7. provided by registration
and visitor through an clerk/Nurse in a small set
exclusive set-up. up. For large and busy
emergency departments
there should be dedicated
enquiry counter
ME B1.8 The facility ensures Treatment note/ RR/OB
access to clinical discharge note is given to
records of patients to patient
entitled personnel
Standard B2. Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and
there are no barrier on account of physical, social, economic, cultural or social reason.
ME B2.1. Services are provided Separate room for OB
in manner that are examination of rape
sensitive to gender victims
Availability of sexual OB
assault forensic evidence
kit
Availability of protocols / OB /RR
guidelines for collection
of forensic evidence in
case of rape victim
Counselling services are OB/RR
available for rape victim
and domestic violence
Availability of female staff OB/SI
if a male doctor examine
a female patients
Separate toilets for male SI/OB
and females
Demarcated male and OB
female observation areas
ME B2.3. Access to facility is Availability of Wheel chair/ OB
provided without any stretcher for emergency
physical barrier & and Availability of ramps with OB
friendly to people with railing
disabilities Emergency is located at OB
ground floor
Ambulance has direct OB No vehicle parked on
access to the receiving/ the way /in front of
triage area of the emergency entrance.
emergency. Access road to emergency
is wide enough for
streamline moment of
emergency
Availability of disable OB
friendly toilet
Standard B3. Facility maintains the privacy, confidentiality & Dignity of patient and related information.
ME B3.1. Adequate visual Screens provided at OB At the examination and
privacy is provided at emergency procedure area.
every point of care
ME B3.2. Confidentiality of Confidentiality of patient SI/OB
patients records and record maintained
clinical information is MLC cases are kept in SI/OB
maintained secure place beyond
access of general public
Checklist for Accident & Emergency Department | 33

No. ance Method
ME B3.3. The facility ensures Behaviour of staff OB/PI
the behaviours of is empathetic and
staff is dignified and courteous
respectful, while
delivering the services
ME B3.4. The facility ensures Privacy and SI/OB
privacy and confidentiality of HIV,
confidentiality to every Rape, suicidal cases,
patient, especially domestic violence and
of those conditions psychotic cases
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.
ME B4.1. There is established Consent is taken for SI/RR
procedures for taking invasive emergency
informed consent procedures
before treatment and
procedures
ME B4.2. Patient is informed Display of patient rights OB
about his/her rights and responsibilities.
and responsibilities
ME B4.3. Staff are aware Staff is aware about SI
of Patients rights patient rights and
responsibilities responsibilities
ME B4.4. Information about the Patient is informed about PI Ask patients about
treatment is shared her clinical condition and what they have been
with patients or treatment been provided communicated about the
attendants, regularly treatment plan
ME B4.5. The facility has defined Availability of complaint OB
and established box and display of
grievance redressal process for grievance
system in place redresaal 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 care.
ME B5.1 The facility provides Emergency services are PI/SI
cashless services to free for all including
pregnant women, pregnant woman,
mothers and neonates neonate and children
as per prevalent
government schemes
ME B5.2. The facility ensures Check that patient PI/SI
that drugs prescribed party has not spent
are available at on purchasing drugs
Pharmacy and wards or consumables from
outside.
ME B5.3. It is ensured Check that patient PI/SI
that facilities for party has not spent on
the prescribed diagnostics from outside.
investigations are
available at the facility
ME B5.4. The facility provide Free Emergency PI/SI/RR
free of cost treatment Consultation for BPL
to Below poverty patients
line patients without
administrative hassles

No. ance Method
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 for OB 1000 square meters per
adequate space as per accommodating 100 patient daily loads
patient or work load emergency load
Availability of adequate OB
waiting area
ME C1.2. Patient amenities are Availability of seating OB
provide as per patient arrangement in the
load waiting area
Availability of cold OB
Drinking water
Availability of functional OB
toilets
ME C1.3. Departments have Demarcated trolley bay OB
layout and demarcated Demarcated receiving / OB
areas as per functions triage areas
Demarcated Nursing OB
station
Demarcated duty room OB
for doctor /nurse
Demarcated resuscitation OB
area
Demarcated observation OB
area/beds
Demarcated dressing OB
area /room
Demarcated injection OB
room
Demarcated area for OB
keeping serious patient
for intensive monitoring
Demarcated areas for OB Separate room or linkage
keeping dead bodies. with mortuary/ Post
mortem room
Lay out is flexible OB All the fixture and
furniture are movable to
rearrange the different
areas in case of mass
casualty
Dedicated Minor OT OB
Shaded porch for OB
ambulance
availability of clean and
dirty utility room
ME C1.4. The facility has Corridors at Emergency OB 2-3 meter
adequate circulation are broad enough for
area and open spaces easy moment of stretcher
according to need and and trolley
local law

No. ance Method
ME C1.5. The facility has Availability of functional OB
infrastructure telephone and Intercom
for intramural Services
and extramural The ambulance(s) has a OB
communication proper communication
system(at least cell
phone)
ME C1.6. Service counters are Availability of emergency OB 5% of the total beds
available as per patient beds as per load
load Availability of buffer
beds for handling mass
causality and disaster
ME C1.7. The facility and Unidirectional flow of OB Receiving/Triage-
departments are services. Resucitation-observtion
planned to ensure beds- Procedures area.
structure follows There is no crises cross
the function/ Separate entrance for OB Entrance of Emergency
processes (Structure emergency department should not be shared with
commensurate with OPD and IPD
the function of the
hospital) Emergency has OB/SI
functional linkage with
Major OT , ICU and labour
room , Indoors and
laboratories
Emergency is located OB
near to the entry of the
hospital
Standard C2. The facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the Non structural OB Check for fixtures and
seismic safety of the components are properly furniture like cupboards,
infrastructure secured cabinets, and heavy
equipments , hanging
objects are properly
fastened and secured
ME C2.3. The facility ensures Emergency department OB
safety of electrical does not have
establishment temporary connections
and loosely hanging
wires
ME C2.4. Physical condition of Floors of the Emergency OB

buildings are safe for are non slippery and even
providing patient care Windows have grills and OB
wire meshwork
Standard C3. The facility has established Programme for fire safety and other disaster
ME C3.1. The facility has plan for Emergency has sufficient OB/SI
prevention of fire fire exit to permit safe
escape to its occupant at
time of fire
Check the fire exits are OB
clearly visible and routes
to reach exit are clearly
marked.

No. ance Method
ME C3.2. The facility has Emergency has installed OB
adequate fire fighting fire Extinguisher that is
Equipment Class A , Class B, C type or
ABC type
Check the expiry date OB/RR
for fire extinguishers
are displayed on each
extinguisher as well as
due date for next refilling
is clearly mentioned
ME C3.3. The facility has a Check for staff SI/RR
system of periodic competencies
training of staff and for operating fire
conducts mock drills extinguisher and what to
regularly for fire and do in case of fire
other disaster 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 Availability of specialist OB/RR Check for specialist on
adequate specialist Doctor call/ full time
doctors as per service
provision
ME C4.2. The facility has Availability of emergency OB/RR
adequate general duty medical officer
doctors as per service
provision and work load
ME C4.3. The facility has Availability of Nursing OB/RR/SI At least 2 in day and 1 in
adequate nursing staff staff night
as per service provision
and work load
ME C4.4. The facility has Availability of dresser / OB/SI
adequate technicians/ paramedic
paramedics as per
requirement
ME C4.5. The facility has Dedicated 24X7 house SI/RR
adequate support / keeping staff
general staff
availability of dedicated SI/RR
security guards 24X7
Availability of registration SI/RR
clerk
Availability of Drivers for SI/RR
Ambulance 24X7
ME C4.6. The staff has been Triage and Mass Casualty SI/RR
provided required Management
training / skill sets
Basic life support (BLS)/ SI/RR
Advance life support
(ALS)
Bio Medical waste SI/RR
Management
Infection control and SI/RR
hand hygiene
Patient Safety

No. ance Method
ME C4.7. The Staff is skilled as Staff is skilled for SI/RR
per job description emergency procedures
Staff is skilled for SI/RR
resuscitation and use
defibrillator
maintaining clinical
records
Standard C5. Facility provides drugs and consumables required for assured list of services.
ME C5.1. The departments Availability of Analgesics/ OB/RR Tracers as per State EDL
have availability of Antipyretics/Anti
adequate drugs at Inflammatory
point of use Availability of Antibiotics OB/RR Tracers as per State EDL
Availability of Infusion OB/RR Tracers as per State EDL
Fluids
Availability of Drugs OB/RR Tracers as per State EDL
acting on CVS
Availability of drugs OB/RR Tracers as per State EDL
action on CNS/PNS
Availability of dressing OB/RR Tracers as per State EDL
material and antiseptic
lotion
Drugs for Respiratory OB/RR Tracers as per State EDL
System
Hormonal Preparation OB/RR Tracers as per State EDL
Availability of emergency OB/RR Tracers as per State EDL
drugs in ambulance
Availability of drugs for OB/RR Megsulf, Oxytocin, Plasma
obstetric emergencies Expanders
Availability of Medical OB/RR Availability of Oxygen
gases Cylinders
Availability of OB/RR Polyvalent Anti snake
Immunological Venom, Anti tetanus
Human Immunoglobin
Antidotes and Other OB/RR Inj. Atropine Sulphate
Substances used in
Poisonings
ME C5.2. The departments Resuscitation OB/RR Masks, Ryles tubes,
have adequate Consumables / Tubes Catheters, Chest Tube, ET
consumables at point tubes etc
of use Availability of disposables OB/RR
at dressing room
Availability of OB/RR Dressing material / Suture
consumables in material
ambulance
ME C5.3. Emergency drug trays Emergency Drug Tray/ OB/RR
are maintained at every Crash Cart is maintained
point of care, where at emergency
ever it may be needed
Standard C6. The facility has equipment & instruments required for assured list of services.
ME C6.1. Availability of Availability of functional OB BP apparatus,
equipment & Equipment &Instruments Multiparameter Torch,
instruments for for examination & hammer , Spot Light
examination & Monitoring
monitoring of patients Availability of Monitoring OB
equipments in
ambulance

No. ance Method
ME C6.2 Availability of Availability of dressing OB
equipment & tray for Emergency
instruments for procedures
treatment procedures, Dressing tray are in OB
being undertaken in adequate numbers as per
the facility load
Availability of instruments OB
for emergency obstetrics
procedure
ME C6.3. Availability of Availability of Point of OB Glucometer, ECG and HIV
equipment & care diagnostic devices rapid diagnostic kit
instruments for
diagnostic procedures
being undertaken in
the facility
ME C6.4. Availability of Availability of functional OB Ambu bag, defibrillator,
equipment and Instruments for layrngo scope, nebulizer,
instruments for Resuscitation. suction apparatus , LMA
resuscitation of Availability of OB
patients and for resuscitation equipments
providing intensive in ambulance
and critical care to
patients
ME C6.5. Availability of Availability of equipment OB Refrigerator, Crash cart/
Equipment for Storage for storage for drugs Drug trolley, instrument
trolley, dressing trolley
ME C6.6 Availability of Availability of OB Buckets for mopping,
functional equipment equipments for cleaning mops, duster, waste
and instruments for trolley, Deck brush
support services Availability of equipment OB Boiler
for sterilization and
disinfection
ME C6.7. Departments have Availability of patient OB
patient furniture and beds with prop up facility
fixtures as per load and wheels
and service provision Availability of OB Hospital graded Mattress,
attachment/accessories IV stand, bed rails, Bed
with patient bed pan
Availability of fixtures OB Spot light, electrical
fixture for equipments
like suction, monitor and
defibrillator, X ray view
box
Availability of furniture at OB Doctors Chair, Patient
emergency Stool, Examination Table,
Chair, Table, Footstep,
cupboard
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 All equipments are SI/RR
established system for covered under AMC
maintenance of critical including preventive
Equipment maintenance

No. ance Method
There is system of timely SI/RR
corrective break down
maintenance of the
equipments
trouble shooting in case
equipment malfunction
ME D1.2 The facility has All the measuring OB/ RR
established procedure equipments/ instrument
for internal and are calibrated
external calibration of
measuring Equipment
ME D1.3 Operating and Operating instructions OB/SI
maintenance for critical equipments
instructions are are available
available with the
users of equipment
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 There is established SI/RR Stock level are daily
procedure for system of timely updated
forecasting and indenting of Requisition are timely
indenting drugs and consumables and drugs placed
consumables
ME D2.3 The facility ensures Drugs are stored in OB
proper storage containers/tray/crash
of drugs and cart and are labelled
consumables Empty and filled OB
cylinders are labelled
ME D2.4 The facility ensures Expiry dates’ are OB/RR
management of expiry maintained at
and near expiry drugs emergency drug tray
No expiry drug found OB/RR
Records for expiry and RR
near expiry drugs are
maintained for drug
stored at department
ME D2.5 The facility has There is practice SI/RR
established procedure of calculating and
for inventory maintaining buffer stock
management in Emergency
techniques Department maintained RR/SI
stock and expenditure
register of drugs
and consumables in
Emergency
There is practice SI/RR
of calculating and
maintaining buffer stock
in ambulance
Department maintained RR/SI
register of drugs
and consumables in
ambulance

No. ance Method
ME D2.6 There is a procedure There is procedure for SI/RR
for periodically replenishing drug tray
replenishing the drugs emergency crash cart
in patient care areas There is procedure for OB/SI
replenishing drug tray
emergency crash cart in
ambulance
There is no stock out of SI/RR
drugs
ME D2.7 There is process for Temperature of re- OB/RR Check for temperature
storage of vaccines and frigerators are kept as per charts are maintained and
other drugs, requiring storage requirement and updated periodically
controlled temperature records are maintained
ME D2.8 There is a procedure Narcotics and OB/SI
for secure storage psychotropic drugs are
of narcotic and kept in lock and key
psychotropic drugs
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
ME D3.1 The facility provides Adequate illumination at OB Resuscitation area,
adequate illumination procedure area dressing room and
level at patient care examination area
areas Adequate illumination at OB
receiving and triage area
ME D3.2 The facility has Visitors are restricted OB/SI
provision of restriction at resuscitation and
of visitors in patient procedure area
areas
ME D3.3 The facility ensures Temperature control and PI/OB Fans/ Air conditioning/
safe and comfortable ventilation in patient care Heating/Exhaust/
environment for area Ventilators as per
patients and service environment condition
providers and requirement
Temperature control and SI/OB Fans/ Air conditioning/
ventilation in nursing Heating/Exhaust/
station/duty room Ventilators as per
environment condition
and requirement
ME D3.4 The facility has security There are set procedures SI/OB See for linkage to police,
system in place at for handling mass self protection form staff
patient care areas situation and violence in
emergency
Hospital has sound OB/SI
security system to
manage overcrowding in
emergency
ME D3.5 The facility has Ask female staff whether SI
established measure they feel secure at work
for safety and security place
of female staff
Standard D4. The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior of the facility Building is painted/ OB
building is maintained whitewashed in uniform
appropriately colour
Interior of patient care OB
areas are plastered &
painted

No. ance Method
ME D4.2 Patient care areas are Floors, walls, roof, roof OB All area are clean with no
clean and hygienic topes, sinks patient care dirt,grease,littering and
and circulation areas are cobwebs
Clean
Surface of furniture and OB
fixtures are clean
Toilets are clean with OB
functional flush and
running water
ME D4.3. Hospital infrastructure Check for there is OB
is adequately no seepage , Cracks,
maintained chipping of plaster
Window panes , doors and OB
other fixtures are intact
Patients beds are intact OB
and painted
Mattresses are intact and OB
clean
ME D4.5. The facility has policy of No condemned/ OB
removal of condemned Junk material in the
junk material Emergency
ME D4.6 The facility has No stray animal/rodent/ OB
established procedures birds
for 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
ME D5.1. The facility has Availability of 24x7 OB/SI
adequate arrangement running and potable
storage and supply for water
portable water in all
functional areas
ME D5.2. The facility ensures Availability of power OB/SI
adequate power back in Emergency
backup in all patient Availability of UPS OB/SI
care areas as per load
Availability of Emergency OB/SI
light
ME D5.3. Critical areas of Availability of OB
the facility ensures Centralized /local piped
availability of oxygen, Oxygen and vacuum
medical gases and supply
vacuum supply
Standard D7. The facility ensures clean linen to the patients
ME D7.1. The facility has Clean Linens are provided OB/RR
adequate sets of linen at observation beds
ME D7.2. The facility has Linen are changed after OB/RR
established change shift of each
procedures for patient or whenever it
changing of linen in get soiled
patient care areas
ME D7.3 The facility There is system to check SI/RR
has standard the cleanliness and
procedures for Quantity of the linen
handling, collection, received from laundry
transportation and
washing of linen

No. ance Method
Standard Facility is compliant with all statutory and regulatory requirement imposed by local, state or
D10 central government
ME D10.1 The facility has Valid licences for RR/SI
requisite licences ambulances are available
and certificates for
operation of hospital
and different activities
ME D10.3 The facility ensure Staff is aware of SI
relevant processes are requirements of medico
in compliance with legal cases
statutory requirement
Standard Roles & Responsibilities of administrative and clinical staff are determined as per govt.
D11 regulations and standards operating procedures.
ME D11.1 The facility has Staff is aware of their role SI
established job and responsibilities
description as per govt
guidelines
ME D11.2 The facility has a There is procedure RR/SI Check for system for
established procedure to ensure that staff is recording time of
for duty roster and available on duty as per reporting and relieving
deputation to different duty roster (Attendance register/
departments Biometrics etc)
There is designated in SI
charge for department
ME D11.3 The facility ensures Doctor, nursing staff and OB
the adherence to dress support staff adhere to
code as mandated by their respective dress
its administration / the code
health department
Standard Facility has established procedure for monitoring the quality of outsourced services and adheres
D12 to contractual obligations
ME D12.1 There is established There is procedure to SI/RR Verification of outsourced
system for contract monitor the quality and services (cleaning/
management for out adequacy of outsourced Dietary/Laundry/Security/
sourced services services on regular basis Maintenance) 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 Unique identification RR
established procedure number is given to each
for registration of patient during process of
patients registration
Patient demographic RR Check for that patient
details are recorded in demographics like Name,
admission records age, Sex, Address, Chief
complaint, etc.
ME E1.3 There is established There is established SI/RR
procedure for criteria for admission
admission of patients through emergency
department
There is establish SI/RR
procedure for admission
of MLC cases as per
prevalent laws

No. ance Method
There is establish SI/RR
procedure for prisoners
as per prevalent local
laws
Admission is done SI/RR
by written order of a
qualified doctor
There is no delay in SI/RR
treatment because of
admission process
Time of admission is RR
recorded in patient record
There is no delay in SI/RR
transfer of patient to
respective department
once admission is
confirmed
Emergency department is SI/RR Like ICU, SNCU, Burn cases
aware of admission criteria
to critical care units
Staff is aware of cases that SI/RR
can not be admitted at the
facility due to constraint in
scope of services
ME E1.4. There is established The is provision of extra OB/SI
procedure for beds, trolley beds in case
managing patients, of high occupancy or
in case beds are not mass casualty
Standard E2. The facility has defined and established procedures for clinical assessment and reassessment of
the patients.
ME E2.1. There is established Assessment criteria of SI/RR Use of standard criteria of
procedure for initial different kind of medical assessment like Glasgow
assessment of patients emergencies is defined comma scale, Poly trauma,
and practiced MI, burn patient, paediatric
patient, pain assessment
criteria etc.
Initial assessment and OB/RR
treatment is provided
immediately
Initial assessment is RR
documented preferably
within 2 hours
ME E2.2 There is established There is fixed schedule RR/SI
procedure for follow- for reassessment
up/ reassessment of of patient under
Patients observation
Standard E3 Facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 Facility has There is procedure for SI/RR Check for how hand over
established procedure hand over for patient is given from emergency
for continuity transfer from emergency to ward, ICU, SNCU etc.
of care during to IPD /OT
interdepartmental There is a procedure SI/RR
transfer consultation of the
patient to other specialist
with in the hospital

No. ance Method
ME E3.2 Facility provides Patient referred with SI/RR
appropriate referral referral slip
linkages to the patients/ Availability of referral SI/RR
Services for transfer to linkages to higher
other/higher facilities to centres. Check how
assure their continuity patient are referred if
of care. services are not available
Advance communication SI/RR
is done with higher
centre
Referral vehicle is being SI/RR
arranged
Referral in or referral out RR
register is maintained
Facility has functional SI Check for referral cards
referral linkages to lower filled from lower facilities
facilities
Check for if there is any SI/RR
system of follow up
ME E3.3. A person is identified Doctor and nurse is SI/RR
for care during all designated for each
steps of care patient admitted to
emergency ward
Standard E4. The facility has defined and established procedures for nursing care
ME E4.1. Procedure for There is a process OB/SI Patient id band/ verbal
identification of for ensuring the confirmation/Bed no. etc.
patients is established identification before any
at the facility clinical procedure
ME E4.2. Procedure for ensuring Treatment chart are RR Check for treatment chart
timely and accurate maintained are updated and drugs
nursing care as per given are marked. Co
treatment plan is relate it with drugs and
established at the doses prescribed.
facility There is a process to SI/RR Verbal orders are
ensure the accuracy of rechecked before
verbal/telephonic orders administration
ME E4.3. There is established Patient hand over is SI/RR
procedure of patient given during the change
hand over, whenever in the shift
staff duty change Nursing Handover RR
happens register is maintained
Hand over is given bed OB/SI
side
ME E4.4. Nursing records are Nursing notes are RR/SI Check for nursing note
maintained maintained adequately register. Notes are
adequately written
ME E4.5. There is procedure for Patient Vitals are RR/SI Check for TPR chart, IO
periodic monitoring of monitored and recorded chart, any other vital
patients periodically required is monitored
Critical patients are RR/OB Check for use of cardiac
monitored continually monitor/multi parameter
Standard E5. Facility has a procedure to identify high risk and vulnerable patients.
ME E5.1. The facility identifies Vulnerable patients are OB/SI Unstable, irritable,
vulnerable patients identified and measures unconscious. Psychotic
and ensure their safe are taken to protect them and serious patients are
care from any harm identified

No. ance Method
ME E5.2. The facility identifies High risk medical OB/SI
high risk patients and emergencies are
ensure their care, as identified and
per their need treatment given on
priority
Standard E6. Facility follows standard treatment guidelines defined by state/Central government for
prescribing the generic drugs & their rational use.
ME E6.1. Facility ensured that Check for BHT if drugs RR
drugs are prescribed in are prescribed under
generic name only generic name only
ME E6.2. There is procedure of Check for that relevant RR
rational use of drugs Standard treatment
guideline are available at
point of use
Check staff is aware of SI/RR
the drug regime and
doses as per STG
Check BHT that drugs are RR
prescribed as per STG
Availability of drug SI/OB
formulary at emergency
Standard E7. Facility has defined procedures for safe drug administration
ME E7.1. There is process High alert drugs available SI/OB Electrolytes like Potassium
for identifying in department are chloride, Uploads, Neuro
and cautious identified muscular blocking agent,
administration of high Anti thrombolytic agent,
alert drugs insulin, warfarin, Heparin,
Adrenergic agonist etc.
Maximum dose of high SI/RR Value for maximum doses
alert drugs are defined as per age, weight and
and communicated diagnosis are available
with nursing station and
doctor
There is process to SI/RR A system of independent
ensure that right doses of double check before
high alert drugs are only administration,
given Error prone medical
abbreviations are avoided
ME E7.2. Medication orders are Every Medical advice RR
written legibly and and procedure is
adequately accompanied with date ,
time and signature
Check for the writing, It RR/SI
comprehendible by the
clinical staff
ME E7.3. There is a procedure Drugs are checked OB/SI
to check drug before for expiry and other
administration/ inconsistency before
dispensing administration
Check single dose vial are OB Check for any open single
not used for more than dose vial with left over
one dose content indented to be
used later on
Check for separate sterile OB
needle is used every time In multi dose vial needle is
for multiple dose vial not left in the septum

No. ance Method
Any adverse drug RR/SI
reaction is recorded and
reported
ME E7.4. There is a system to Administration of SI/OB
ensure right medicine medicines done after
is given to right ensuring right patient,
patient right drugs , right route,
right time
ME E7.5 Patient is counselled Patient is advice by SI/PI
for self drug doctor/ Pharmacist /
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
ME E8.1. All the assessments, Assessment findings are RR Day to day progress of
re-assessment and written on BHT patient is recorded in BHT
investigations are
recorded and updated
ME E8.2. All treatment plan Treatment plan, first RR Treatment prescribed in
prescription/orders are orders are written on BHT nursing records
recorded in the patient
records.
ME E8.3. Care provided to each Maintenance of RR Treatment given is
patient is recorded in treatment chart/ recorded in treatment
the patient records treatment registers chat
ME E8.4. Procedures performed Any procedure RR CPR, Dressing,
are written on patients performed written on mobilization etc
records BHT
ME E8.5. Adequate form and Availability of form OB/SI MLC,PIB, Lab /X-ray re-
formats are available formats for emergency quisition, death certificate,
at point of use Initial assessment format,
referral slip etc.
ME E8.6. Register/records are Emergency Records are OB/RR Emergency register, death
maintained as per maintained register, MLC register, are
guidelines maintained
All register/records are OB/RR
identified and numbered
ME E8.7. The facility ensures Safe keeping of MLC OB/SI
safe and adequate records
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 Assessment is done SI/RR See if there is any
after assessing patient before discharging procedure/protocol for
readiness patient from emergency discharging the patient if
the condition of patient
improves in emergency
itself.
What is the procedure for
discharge for short stay /
day care patients
Discharge is done by a SI/RR
responsible and qualified
doctor
Patient / attendants PI
are consulted before
discharge

No. ance Method
Treating doctor is SI/RR
consulted/ informed
before discharge of
patients
ME E9.2. Case summary and Discharge summary is RR/CI See for discharge
follow-up instructions provided summary, referral slip
are provided at the provided.
discharge Discharge summary RR
adequately mentions
patients clinical
condition, treatment
given and follow up
Discharge summary is SI/RR
give to patients going in
LAMA/Referral
ME E9.3 Counselling services Counselling services are SI/PI
are provided as during provided wherever it is
discharges wherever required
required
ME E9.4 The facility has Declaration is taken from RR/SI
established procedure the LAMA patient
for patients leaving the
facility against medical
advice, absconding,
etc
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster
Management
ME E11.1 There is procedure for Emergency has a SI/OB As care provider how they
Receiving and triage of implemented system of triage patient- immediate,
patients sorting the patients delayed, expectant,
minimal, dead
Triage area is marked OB/SI
Triage protocols are OB
displayed
Responsibility of SI
receiving and shifting the
patient from vehicle is
defined
ME E11.2 Emergency protocols Emergency protocols are OB See for protocols of
are defined and available at point of use head injury, snake bite,
implemented poisoning, drawing etc.
Staff is aware of Clinical SI/RR
protocols
There is procedure for SI/OB
CPR
ME E11.3 The facility has disaster Lines of authority is SI/RR
management plan in defined
place Procedure for internal SI/RR
communication defined
There is procedure for SI/RR
setting up control room
Disaster buffer stock of OB/SI
medicines and other
supplies maintained

No. ance Method
Role and responsibilities of SI/RR
staff in disaster is defined
Staff is aware of disaster SI/RR
plan
ME E11.4. The facility ensures Check for how OB/RR
adequate and ambulances are called
timely availability of and patient is shifted
ambulances services Ambulances are equipped OB
and mobilisation
of resources, as per If the patient is stable SI/RR
requirement then he is transferred
in ambulance with the
trained driver and one
staff from hospital.
If the patient is serious (as SI/RR
decided by the Doctor),
then trained driver and
one paramedical staff is
mandatory to accompany
him.
The Patient’s rights SI/RR
are respected during
transport.
Ambulance appropriately OB/RR
equipped for BLS with
trained personnel
There is a daily checklist RR
of all equipment and
emergency medications
Ambulance has a log book RR
for the maintenance of
vehicle and daily vehicle
checklist
Transfer register is RR
maintained to record
the detail of the referred
patient
ME E11.5. There is procedure for Medico legal cases are RR/SI
handling medico legal identified by on patient
cases records
MLC cases are not SI/OB/RR
delayed because of
police proceedings
There is procedure for SI/RR Discharge is not done
informing police before police consent
Emergency has criteria SI/RR Criteria is defined based
for defining medico legal on cases and when to do
cases MLC
Standard The facility has defined and established procedures of diagnostic services
E12.
ME E12.1. There are established Container is labelled OB
procedures for Pre- properly after the sample
testing Activities collection
ME E12.3. There are established Nursing station is SI/RR
procedures for Post- provided with the
testing Activities critical value of different
tests

No. ance Method
Standard The facility has defined and established procedures for Blood Bank/Storage Management and
E13. Transfusion.
ME E13.8 There is established There is a procedure RR/SI
procedure for issuing for issuing the blood
blood promptly for life saving
measures
ME E13.9 There is established Consent is taken before RR
procedure for transfusion
transfusion of blood Patient’s identification SI/OB
is verified before
transfusion
Blood is kept on RR
optimum temperature
before transfusion
Blood transfusion is SI/RR
monitored and regulated
by qualified person
Blood transfusion note is RR
written in patient record
ME E13.10 There is a established Any major or minor RR
procedure for transfusion reaction is
monitoring and recorded and reported to
reporting Transfusion responsible person
complication
Standard E15 Facility has defined and established procedures of Surgical Services
ME E15.1 Facility has established There is procedure for SI/RR See surgeon is available
procedures OT emergency surgeries on call/on duty
Scheduling Procedure for arranging SI Responsibilities are
logistics defined and patient is
shifted promptly
Standard The facility has defined and established procedures for end of life care and death
E16.
ME E16.1 Death of admitted Facility has a standard SI
patient is adequately procedure to decent
recorded and communicate death to
communicated relatives
Death note is written on RR
patient record
ME E16.2. The facility has Past history and sign of RR Check what is policy for
standard procedures any medico legal cause is registering brought in
for handling the death looked for dead, death cases as MLC
in the hospital There is criteria for SI/RR ask form how death
declaring death is declared - Physical
examination or ECG is
done
Procedure for handing SI
over the dead body
Death certificate is issued SI/RR
ME E16.3 The facility has Patients Relatives are PI/SI
standard operating informed clearly about
procedure for end of the deterioration in health
life support condition of Patients

No. ance Method
There is a standard SI/RR Check about the policy
procedure of removal of and practice for removing
life sustaining treatment life support
as per law
There is a procedure to SI/OB
allow patient relative/
Next of Kin to observe
patient in last hours
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 Surface and environment SI/RR Swab are taken from
for Passive and active samples are taken infection prone surfaces
culture surveillance of for microbiological
critical & high risk areas surveillance
ME F1.4. There is Provision There is procedure for SI/RR Hepatitis B, Tetanus Toxic
of Periodic Medical immunization of the staff etc
Checkups and Periodic medical SI/RR
immunization of staff checkups of the staff
ME F1.5 Facility has established Regular monitoring SI/RR Hand washing and
procedures for regular of infection control infection control audits
monitoring of infection practices done at periodic intervals
control practices
ME F1.6 Facility has defined Check for Doctors SI/RR
and established are aware of Hospital
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 Availability of hand OB Check for availability of
are provided at point washing Facility at Point wash basin near the point
of use of Use of use
Availability of running OB/SI Ask to Open the tap. Ask
Water Staff water supply is
regular
Availability of antiseptic OB/SI Check for availability/
soap with soap dish/ liquid Ask staff if the supply
antiseptic with dispenser. is adequate and
uninterrupted
Availability of Alchol OB/SI Check for availability/ Ask
based Hand rub staff for regular supply.
Display of Hand washing OB Prominently displayed
Instruction at Point of above the hand washing
Use facility , preferably in
Local language
ME F2.2 Staff is trained and Adherence to 6 steps of SI/OB Ask of demonstration
adhere to standard Hand washing
hand washing Staff aware of when to SI
practices hand wash
ME F2.3 Facility ensures Availability of Antiseptic OB/SI
standard practices and Solutions
materials for antisepsis Proper cleaning of OB like before giving IM/IV
procedure site with injection, drawing blood,
antisepesis putting Interavenous and
urinary catheter

No. ance Method
Standard F3 Facility ensures standard practices and materials for Personal protection
ME F3.1 Facility ensures Clean gloves are available OB/SI
adequate personal at point of use
protection equipments Availability of Masks OB/SI
as per requirements
Personal protective kit for OB/SI HIV kit
infectious patients
ME F3.2 Staff is adhere to No reuse of disposable OB/SI
standard personal gloves, Masks, caps and
protection practices aprons.
Compliance to correct SI
method of wearing and
removing the gloves
Standard F4 Facility has standard Procedures for processing of equipments and instruments
ME F4.1 Facility ensures Decontamination of SI/OB Ask stff about how
standard practices operating & Procedure they decontaminate
and materials for surfaces the procedure surface
decontamination like Examination table ,
and clean ing of dressing table, Stretcher/
instruments and Trolleys etc.
procedures areas (Wiping with .5% Chlorine
solution
Decontamination of SI/OB Ask staff how they
instruments after use decontaminate the
instruments like
ambubag, suction
cannula, Airways,
Face Masks, Surgical
Instruments
(Soaking in 0.5% Chlorine
Solution, Wiping with
0.5% Chlorine Solution or
70% Alcohal as applicable
Contact time for SI/OB 10 minutes
decontamination is
adeqaute
Cleaning of instruments SI/OB Cleaning is done
after decontamination with detergent and
running water after
decontamination
Proper handling of Soiled SI/OB No sorting ,Rinsing or
and infected linen sluicing at Point of use/
Patient care area
Staff know how to make SI/OB
chlorine solution
ME F4.2. Facility ensures Equipment and OB/SI Autoclaving/HLD/
standard practices instruments are sterlized Chemical Sterlization
and materials for after each use as per
disinfection and requirement
sterilization of High level Disinfection OB/SI Ask staff about method
instruments and of instruments/ and time required for
equipments equipments is done as bioling
per protocol
Chemical sterilization of OB/SI Ask staff about method,
instruments/equipments concentration and
is done as per protocols contact time requied for
chemical sterilization
Autoclaved dressing OB/SI
material is used

No. ance Method
Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention
ME F5.1. Layout of the Facility layout ensures OB
department is separation of general
conducive for the traffic from patient traffic
infection control
practices
ME F5.2. Facility ensures Availability of OB/SI Chlorine solution,
availability of standard disinfectant as per Gluteraldehye, carbolic
materials for cleaning requirement acid
and disinfection of Availability of cleaning OB/SI Hospital grade phenyle,
patient care areas agent as per requirement disinfectant detergent
solution
ME F5.3. Facility ensures Staff is trained for spill SI/RR
standard practices management
followed for cleaning Cleaning of patient care SI/RR
and disinfection of area with disinfectant
patient care areas detergent solution
Staff is trained for SI/RR
preparing cleaning
solution as per standard
procedure
Standard practice of OB/SI Unidirectional mopping
mopping and scrubbing from inside out
are followed
Cleaning equipments like OB/SI Any cleaning equipment
broom are not used in leading to dispersion of
patient care areas dust particles in air should
be avoided
ME F5.4. Facility ensures Emergency department OB/SI
segregation infectious define list of infectious
patients diseases require special
precaution and barrier
nursing
Staff is trained for barrier
nursing
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 Availability of color OB
segregation of Bio coded bins at point of
Medical Waste as per waste generation
guidelines Availability of color OB
coded plastic bags
Segregation of different OB/SI
category of waste as per
guidelines
Display of work OB
instructions for
segregation and
handling of Biomedical
waste
There is no mixing of
infectious and general
waste

No. ance Method
ME F6.2. Facility ensures Availability of functional OB See if it has been used or
management of sharps needle cutters just lying idle
as per guidelines Availability of puncture OB Should be available nears
proof box the point of generation
like nursing station and
injection room
Disinfection of sharp OB/SI Disinfection of syringes is
before disposal not done in open buckets
Staff is aware of contact
time for disinfection of
sharps
Availability of post OB/SI Ask if available. Where it
exposure prophylaxis is stored and who is in
charge of that.
Staff knows what to do in SI Staff knows what to do
condition of needle stick in case of shape injury.
injury Whom to report. See if
any reporting has been
done
ME F6.3. Facility ensures Check bins are not SI
transportation and overfilled
disposal of waste as Disinfection of liquid SI/OB
per guidelines waste before disposal
Transportation of bio SI/OB
medical waste is done in
close container/trolley
Staff aware of mercury SI/RR
spill management
Area of concern - G : quality management
Standard G1 The facility has established organizational framework for quality improvement
ME G1.1 The facility has a There is a designated SI/RR
quality team in place departmental nodal
person for coordinating
Quality Assurance
activities
Standard G3. Facility have established internal and external quality assurance programs wherever it is critical
to quality.
ME G3.1. Facility has established There is system daily SI/RR
internal quality round by matron/
assurance program at hospital manager/
relevant departments hospital superitendant/
Hospital Manager/
Matron in charge for
monitoring of services
There is system for SI/RR
periodic check up
of Ambulances by
designated hospital staff
ME G3.2. Facility has established There is periodic SI/RR
external assurance assessment of
programs at relevant preparedness for disaster
departments by competent authority
ME G3.3. Facility has established Departmental checklist SI/RR
system for use of are used for monitoring
check lists in different and quality assurance
departments and Staff is designated for SI
services filling and monitoring of
these checklists

No. ance Method
Standard G4. Facility has established, documented implemented and maintained Standard Operating
Procedures for all key processes and support services.
ME G4.1. Departmental Standard operating RR
standard operating procedure for
procedures are department has been
available prepared and approved
Current version of OB
SOP are available with
process owner
ME G4.2. Standard Operating Emergency has RR
Procedures adequately documented procedure
describes process and for receiving the patient
procedures in emergency
Department has RR
documented procedure
for triaging
Department has RR
for taking consent
Department has do- RR
cumented procedure for
initial screening of patient
Department has RR
for nursing care
Department has RR
for admission and
transfer of the patient to
ward
Emergency has RR
for Handling medical
records
Department has RR
for maintaining records
in Emergency
Department has RR
to handle brought in
dead patient
Department has RR
for storage, handling and
release of dead body
Department has RR
for storage and
replenishing the
medicine in emergency
Department has RR
for equipment preventive
and break down
maintenance

No. ance Method
Department has RR
for Disaster management
ME G4.3. Staff is trained and Check Staff is a aware of SI/RR
aware of the standard relevant part of SOPs
procedures written in
SOPs
ME G4.4. Work instructions are Work instruction/clinical OB Triage, CPR, Medical
displayed at Point of protocols are displayed clinical protocols like
use Snake bite and poisoning
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 SI/RR
processes critical processes done
ME G5.2. Facility identifies non Non value adding SI/RR
value adding activities activities are identified
/ waste / redundant
activities
ME G5.3 Facility takes corrective Processes are rearranged SI/RR
action to improve the as per requirement
processes
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 Internal assessment is RR/SI
periodic internal done at periodic interval
assessment
ME G6.2 The facility conducts There is procedure to RR/SI
the periodic conduct Medical Audit
prescription/ medical/ There is procedure to RR/SI
death audits conduct Prescription
audit
There is procedure to RR/SI
conduct Death audit
ME G6.3 The facility ensures Non Compliance are RR/SI
non compliances enumerated and
are enumerated and recorded
recorded adequately
ME G6.4. Action plan is made Action plan prepared RR/SI
on the gaps found in
the assessment / audit
process
ME G6.5. Corrective and Corrective and RR/SI
preventive actions preventive action taken
are taken to address
issues, observed in the
assessment & audit
Standard G7. The facility has defined and established Quality Policy & Quality Objectives
ME G7.2. The facility periodically Quality objective for RR/SI
defines its quality emergency defined
objectives and key
departments have
their own objectives
ME G7.3. Quality policy and Check of staff is aware SI
objectives are of quality policy and
disseminated and staff objectives
is aware of that

No. ance Method
ME G7.4 Progress towards Quality objectives are SI/RR
quality objectives is monitored and reviewed
monitored periodically periodically
Standard G8. Facility seeks continually improvement by practicing Quality method and tools.
ME G8.1. Facility uses PDCA SI/RR
method for quality 5S SI/OB
improvement in
Mistake proofing SI/OB
services
Six Sigma SI/RR
ME G8.2. Facility uses tools for 6 basic tools of Quality SI/RR
quality improvement
in services
Area of Concern - H Outcome
Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National
benchmarks
ME H1.1. Facility measures No of Emergency cases RR
productivity Indicators per thousand population
on monthly basis No of trips per ambulance RR
No. of trauma cases RR
treated per 1000
emergency cases
No. of poisoning cases RR
treated per 1000
emergency cases
No. of cardiac cases RR
treated per 1000
emergency cases
No. of obstetric cases RR
treated per 1000
emergency cases
No of resuscitation done RR Resuscitation should
per thousand population include: Chest
Compression, Airway and
Breathing
Proportion of Patients RR
attended in Night
ME H1.2. The Facility measures Proportion of BPL RR
equity indicators Patients
periodically
Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1. Facility measures Response time for RR
efficiency Indicators ambulance
on monthly basis Proportion of cases RR
referred
Response time at RR
emergency for initial
assessment
Average Turn Around RR Average time a patient
Time stays at emergency
observation bed
Proportion of patient RR
referred by state
owned/108 ambulance
per 1000 referral cases

No. ance Method
Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National
benchmark
ME H3.1. Facility measures No of adverse events per RR
Clinical Care & Safety thousand patients
Indicators on monthly Death Rate RR No of Deaths in
basis 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 LAMA Rate RR No of LAMA X 100/
Service Quality No of Patients seen at
Indicators on monthly emergency
basis Absconding rate RR No of Absconding X 100/
No of Patients seen at
emergency

Assessment Summary
A. Score Card
Accident & Emergency Department Score Card
Accident & Emergency Department Score
1. Service Provision
2. Patient Rights
3. Inputs
4. Support Services
5. Clinical services
6. Infection control
7. Quality Management
8. Outcome
B. Major Gaps observed
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
C StrengthS/Best Practices
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
D. RecommendationS/ OpportunityS for Improvement
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Names and Signature of Assessors
Date ________________

Checklist–2
Out Patients
Department (OPD)
Version: 1/2013

Checklist–2
Checklist for Out Patients Department (OPD)
Reference Measure Element Checkpoint Com- Assessment Means of

No. pliance Method Verification
Standard A1 Facility Provides Curative Services
ME A1.1 The facility provides Availability of functional SI/OB Dedicated General
General Medicine General Medicine Clinic speciality Medicine
services Clinic
ME A1.2 The facility provides Availability of functional SI/OB Dedicated General
General Surgery services General Surgery Clinic speciality Surgical
Clinic
ME A1.3 The facility provides Availability of Functional SI/OB Dedicated speciality
Obstetrics & Gynaecology Obstetrics & Gynaecology Obstetrics &
Services Clinic Gynaecology Clinic.
High risk pregnancy
cases are referred
from ANC clinic and
consulted.
ME A1.4 The facility provides Availability of Paediatric SI/OB Dedicated Paediatric
Paediatric Services Clinic speciality Clinic
ME A1.5 The facility provides Availability of functional SI/OB Dedicated
Ophthalmology Services Ophthalmology Clinic ophthalmology
clinic providing
consultation
services
ME A1.6 The facility provides ENT Availability of Functional ENT SI/OB Dedicated
Services Clinic ENT providing
consultation
services
Availability of OPD ENT SI/OB Foreign Body
procedures Removal (Ear and
Nose),Stitching of
CLW’s, Dressings,
Syringing of
Ear, Chemical
Cauterization (Nose
& Ear), Eustachian
Tube Function Test,
Vestibular Function
Test/Caloric Test
ME A1.7 The facility provides Availability of Functional SI/OB Dedicated clinical
Orthopaedics Services Orthopaedic Clinic for Orthopaedic
consultation
Availability of OPD SI/OB plaster room
Orthopaedic procedure procedure
ME A1.8 The facility provides Skin Availability of functional Skin SI/OB Dedicated
& VD Services & VD Clinic Clinic providing
consultation
services
Psychiatry Services Psychiatry Clinic Clinic providing
consultation
services
Dental Treatment Dental Clinic Clinic providing
Services consultation services
Availability of OPD Dental SI/OB Accompanied
procedure by dental lab.
Extraction, scaling,
tooth extraction,
denture and
Restoration.
ME A1.11 The facility provides Availability of Functional SI/OB AYUSH clinic
AYUSH Services Ayush clinic accompanied by
dispensary
ME A1.12 The facility provides Availability of Functional SI/OB Pain Management
Physiotherapy Services Physiotherapy Unit with cryotherapy,
Pain Management
with deep heat
therapy (SWD),
Increase range
of motion with
mobilization,
ME A1.13 The facility provides Availability of Dressing SI/OB Dressing, Suturing
services for OPD facilities at OPD and drainage
procedures Availability of Injection room SI/OB
facilities at OPD
ME A1.14 Services are available At least 6 Hours of OPD SI/RR
for the time period as Services are available
mandated
ME A1.15 The facility provides Availability of functional SI/OB
services for Super Cardiology clinic
specialties, as mandated Availability of functional SI/OB
gastro entomology clinic
Availability of functional SI/OB
nephrology clinic
Neurology clinic
endocrinology Clinic is
available
Oncology Clinic
nuclear medicine clinic is
available
ME A2.2 The facility provides Availability of functional ANC SI/OB
Maternal health Services clinic
ME A2.3 The facility provides Availability of Functional SI/OB
Newborn health Services immunization clinic
ME A2.4 The facility provides Child Availability Functional IYCF SI/OB
health Services clinic
Services under RBSY SI/OB
64 | Checklist for Out Patients Department (OPD)

Adolescent health ARSH clinic
Services
Standard A3 Facility Provides diagnostic Services
ME A3.2 The facility Provides Availability of Sample SI/OB
Laboratory Services collection Centre
ME A3.3 The facility provides Functional ECG Services are SI/OB
other diagnostic services, available
as mandated Availability of TMT services SI/OB
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme
ME A4.1 The facility provides Availability of OPD Services SI/RR OPD Management
services under National Under NVBDCP of Malaeria, Kala
Vector Borne Disease Azar, Dengue
Control Programme as
per guidelines
services under Revised DOTS clinic
National TB Control
Programme as per
guidelines
ME A4.3 The facility provides Availability of OPD services SI/RR
services under National under NLEP
Leprosy Eradication Assessment of Disability
Programme as per Status
guidelines Supply of Customized Foot
wear
ME A4.4 The facility provides Availability of Functional ICTC SI/OB
services under National Availability of HIV Testing and SI/RR
AIDS Control Programme Counselling
as per guidelines PPTCT Services for HIV SI/OB
positive Pregnant Women
Availability of Functional ART SI/OB
Centre
Availability of CD4 testing SI/OB
facility
ME A4.5 The facility provides Screening and early SI/RR Refraction, syringing
services under National detection of visual and probing, foreign
Programme for impairment and refraction body removal,
prevention and control Tonometery and
of Blindness as per retinoscopy
guidelines Availability of OPD SI/OB Syringing and
procedures probing, foreign
body removal
, Tonometry
,Perimetry,
Retinoscopy,
Retrobulbar
Injection
ME A4.6 The facility provides Availability of counselling SI/OB
services under Mental centre for Suicide prevention
Health Programme as
per guidelines
ME A4.7 The facility provides Dedicated Geriatric Clinic SI/OB
services under National
Programme for the health
care of the elderly as per
guidelines
Checklist for Out Patients Department (OPD) | 65

ME A4.8 The facility provides Functional NCD clinic is SI/OB
services under National available
Programme for
Prevention and control
of Cancer, Diabetes,
Cardiovascular diseases &
Stroke (NPCDCS) as per
guidelines
ME A4.10 The facility provide Management of case referred SI/RR
services under National from PHC/CHC directly
health Programme for reported to Hospital
deafness
ME A4.11 The facility provides Availability of OPD services as
services as per per State Health Programs
State specific health
programmes
Standard A6 Health services provided at the facility are appropriate to community needs.
ME A6.1 The facility provides Special clinics are available SI/OB Ask for the specific
curatives & preventive for local prevalent endemics local health
services for the health problems/ diseases
problems and diseases, .i.e.. Kala azar,
prevalent locally. Swine Flue, arsenic
poisoning etc.
Standard B1 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and
ME B1.1 The facility has uniform Availability departmental OB (Numbering, main
and user-friendly signage signage’s department and
system internal sectional
signage
Display of layout/floor OB
directory
ME B1.2 The facility displays List of OPD Clinics are OB
the services and available
entitlements available in Names of doctor on duty is OB
its departments displayed and updated
Timing for OPD are displayed OB
Entitlement under JSY , JSSK OB
and other schemes
Important numbers like OB
ambulance are displayed
ME B1.3 The facility has Display of citizen charter OB
established citizen
charter, which is followed
at all levels
ME B1.4 User charges are User charges for services are OB
displayed and displayed
communicated to
patients effectively
ME B1.5 Patients & visitors are IEC Material is displayed OB
sensitised and educated Education material for OB
through appropriate IEC / counselling are available in
BCC approaches Counselling room
ME B1.6 Information is available in Signage’s and information OB
local language and easy are available in local
to understand language

ME B1.7 The facility provides Availability of Enquiry Desk OB
information to patients with dedicated staff
and visitor through an
exclusive set-up.
ME B1.8 The facility ensures OPD slip is given to the RR/OB
access to clinical records patient
of patients to entitled
personnel
Standard B2 Services are delivered in a manner that is sensitive to gender, religious, gender and cultural needs,
and there are no barrier on account of physical access, social, economic, cultural or social status.
ME B2.1 Services are provided in Separate queue for female at OB
manner that are sensitive registration
to gender Separate Female general OPD OB
Separate toilets for male and OB
female
Availability of female staff if OB
a male doctor examination a
female patients
Availability of Breast feeding OB
corner
ME B2.3 Access to facility is Availability of Wheel chair or OB
provided without any stretcher for easy Access to
physical barrier & and the OPD
friendly to people with Availability of ramps with OB
disabilities railing
There is no chaos and over OB
crowding in the OPD
Availability of disable friendly OB
toilet
Standard B3 Facility maintains the privacy, confidentiality & Dignity of patient and related information.
ME B3.1 Adequate visual privacy Availability of screen at OB
is provided at every point Examination Area
of care One Patient is seen at a time OB
in clinics
Privacy at the counselling OB
room is maintained
ME B3.2 Confidentiality of patients Confidentiality of HIV reports SI/OB
records and clinical at ICTC
information is maintained
ME B3.3 The facility ensures the Behaviour of staff is PI/OB
behaviours of staff is empathetic and courteous
dignified and respectful,
while delivering the
services
ME B3.4 The facility ensures privacy Privacy and confidentiality of SI/OB Check in RTI/STI
and confidentiality to HIV, Leprosy Patients clinic
every patient, especially of
those conditions having
social stigma, and also
safeguards vulnerable
groups
Standard B4 Facility has defined and established procedures for informing and involving patient and their
ME B4.1 There is established Informed consent for before SI/RR
procedures for taking HIV testing at ICTC
informed consent
before treatment and
procedures

ME B4.2 Patient is informed Display of patient rights and OB
about his/her rights and responsibilities.
responsibilities
ME B4.4 Information about the Patient is informed about PI Ask patients
treatment is shared with her clinical condition and about what
patients or attendants, treatment been provided they have been
regularly communicated
about the treatment
plan
Pre and Post test counselling SI/PI/RR
is given at ICTC
ME B4.5 The facility has defined Availability of complaint box OB
and established and display of process for
grievance redressal grievance re redressal 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
ME B5.1 The facility provides Free OPD Consultation / ANC PI/SI For JSSK entitlement
cashless services to Checkups
pregnant women,
mothers and neonates
as per prevalent
government schemes
ME B5.2 The facility ensures that Check that patient party PI/SI
drugs prescribed are has not spent on purchasing
available at Pharmacy drugs or consumables from
and wards outside.
ME B5.3 It is ensured that facilities Check that patient party PI/SI

for the prescribed has not spent on diagnostics
investigations are from outside.
ME B5.4 The facility provide free of Free OPD Consultation for PI/SI/RR
cost treatment to Below BPL patients
poverty line patients
without administrative
hassles
ME B5.5 The facility ensures If any other expenditure PI/SI/RR
timely reimbursement occurred it is reimbursed
of financial entitlements from hospital
and reimbursement to
the patients
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets
the prevalent norms
ME C1.1 Departments have Clinics has adequate OB Adequate Space in
adequate space as per space for consultation and Clinics (12 sq ft)
patient or work load examination
Availability of adequate OB Waiting area at the
waiting area scale of 1 sq ft per
average daily patient
with minimum 400
sq ft of area
ME C1.2 Patient amenities are Availability of seating OB As per average OPD
provide as per patient arrangement in waiting area at peak time
load

Availability of sub waiting at OB For clinics has high
for separate clinics patient load
Availability of cold Drinking OB See if its is easily
water accessible to the
visitors
Availability of functional OB Urinals 1 per 50
toilets person water closet
and wash basins 1
per 100 person
Availability of patient calling OB
system
Availability of public OB
telephone booth
ME C1.3 Departments have layout There is designated area for OB
and demarcated areas as registration
per functions Dedicated clinic for each OB
speciality
One clinic is not shared by 2 OB
doctors at one time
Dedicated examination areas OB
is provided with each clinics
Demarcated dressing area / OB
room
Demarcated injection room OB
Demarcated immunization OB
room for pregnant women
and children
OPD has separate entry and OB
exit from IPD and Emergency
availability of clean and dirty OB
utility room
Demarcated trolley/ OB
wheelchair bay
ME C1.4 The facility has adequate Corridors at OPD are broad OB
circulation area and open enough to manage stretcher
spaces according to need and trolleys
and local law
ME C1.5 The facility has Availability of functional OB
and extramural
communication
ME C1.6 Service counters are Availability of Registration OB Average Time taken
available as per patient counters as per Patient load for registration
load would be 3-5 min so
number of counter
required would be
worked on scale of
12-20 patient/hour
per counter
ME C1.7 The facility and Unidirectional flow of OB Layout of OPD shall
departments are planned services follow functional
to ensure structure flow of the patients,
follows the function/ e.g.:Enquiry
processes (Structure Registration Waiting
commensurate with the Sub-waiting Clinic
function of the hospital) Dressing room/
Injection Room
Diagnostics (lab/X-
ray)Pharmacy Exit

All OPD clinics and related OB
auxiliary services are co
located in one functional area
OPD is located near to the OB
entry of the hospital
Standard C2 The facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the Non structural components OB Check for fixtures
seismic safety of the are properly secured and furniture
infrastructure like cupboards,
cabinets, and
heavy equipments ,
hanging objects are
properly fastened
and secured
ME C2.3 The facility ensures OPD building does not have OB
safety of electrical temporary connections and
establishment loosely hanging wires
ME C2.4 Physical condition of Floors of the OPD are non OB
buildings are safe for slippery and even
providing patient care Windows have grills and wire OB
meshwork
Standard C3 The facility has established Programme for fire safety and other disaster
ME C3.1 The facility has plan for OPD has sufficient fire exit OB/SI
prevention of fire to permit safe escape to its
occupant at time of fire
Check the fire exits are clearly OB
visible and routes to reach
exit are clearly marked.
ME C3.2 The facility has adequate OPD has installed fire OB
fire fighting Equipment Extinguisher that is Class A ,
Class B C type or ABC type
Check the expiry date for fire OB/RR
extinguishers are displayed
on each extinguisher as well
as due date for next refilling
ME C3.3 The facility has a system Check for staff competencies SI/RR
of periodic training of for operating fire
staff and conducts mock extinguisher and what to do
drills regularly for fire and in case of fire
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services
ME C4.1 The facility has adequate Availability of specialist OB/RR Check for specialist
specialist doctors as per Doctor at OPD time are available at
service provision scheduled time
ME C4.2 The facility has adequate Availability of General duty OB/RR
general duty doctors as doctor at Screening Clinic
per service provision and
work load
ME C4.3 The facility has adequate Availability of Nursing staff OB/RR/SI At Injection room/
nursing staff as per OPD Clinic as Per
service provision and Requirement
work load

ME C4.4 The facility has adequate Availability of dresser/ OB/SI
technicians/paramedics paramedic at dressing room
as per requirement Counsellor for ICTC SI/RR Full Time
Lab technician for ICTC SI/RR Full time
Counsellor for ARSH clinic SI/RR
Availability of ECG technician SI/RR
Availability of Audiometrician SI/RR
Availability of Ophthalmic SI/RR
assistant
Availability of Physiotherapist SI/RR
Availability of Dental SI/RR
technician
Availability of rehabilitation SI/RR
therapist
ME C4.5 The facility has adequate availability of dedicated SI/RR
support / general staff security guard for OPD
Availability of registration SI/RR
clerks as per load
Availability of housekeeping SI/RR
staff
ME C4.6 The staff has been Bio Medical waste SI/RR
provided required Management
training / skill sets Infection control and hand SI/RR
hygiene
Patient Safety SI/RR
ICTC Team Training SI/RR
Induction and refresher SI/RR
training for ICTC counsellor
Induction and refresher SI/RR
training for ICTC lab
technician
ME C4.7 The Staff is skilled as per Check the competency of SI/RR
job description staff to use OPD equipment
like BP apparatus etc
At ANC clinic staff is skilled to SI/RR
identify high risk pregnancies
Counsellor is skilled for SI/RR
counselling
Staff is skilled for maintaining SI/RR
clinical records
Standard C5 Facility provides drugs and consumables required for assured list of services.
ME C5.1 The departments have Availability of injectables at OB/RR ARV, TT
availability of adequate injection room
drugs at point of use Availability of vaccine as OB/RR
per National Immunization
Program
ME C5.2 The departments have Availability of disposables at OB/RR examination gloves,
adequate consumables at dressing room and clinics Syringes, Dressing
point of use material , suturing
material
HIV testing Kits I, II and III at OB/RR
ICTC

ME C5.3 Emergency drug trays are Emergency Drug Tray is OB/RR
maintained at every point maintained at injection room
of care, where ever it may & immunization room
be needed
Standard C6 The facility has equipment & instruments required for assured list of services.
ME C6.1 Availability of equipment Availability of functional OB BP apparatus,
& instruments for Equipment &Instruments for thermometer,
examination & examination & Monitoring weighting machine,
monitoring of patients torch, stethoscope,
Examination table
ME C6.2 Availability of equipment Availability of functional OB PV examination kit,
& instruments for Instruments/Equipments for Inch tape, fetoscope,
treatment procedures, Gynae and obstetric Weighting machine,
being undertaken in the BP apparatus, etc.
facility Availability of functional OB X ray view box,
Equipment/Instruments for Equipment for
Orthopaedic Procedures plaster room
Availability of functional OB Retinoscope, refrac-
Instruments / Equipments for tion kit, tonometer,
Ophthalmic Procedures perimeter, distant
vision chart, Colour
vision chart.
Availability of Instruments/ OB Audiometer,
Equipments Procedures for Laryngoscope,
ENT procedures Otoscope, Head
Light, Tuning Fork,
Bronchoscope,
Examination
Instrument Set
Availability of functional OB Dental chair, Air
Instruments/ Equipments for rotor, Endodontic
Dental Procedures set, Extraction
forceps
Availability of functional OB Traction, Wax
Equipment/Instruments of bath, Short Wave
Physiotherapy Procedures Diathermy, Exercise
table Etc .
ME C6.3 Availability of equipment Availability of Equipments for OB Micropipettes,
& instruments for ICTC lab Centrifuge,
diagnostic procedures Needle destroyer,
being undertaken in the Refrigerators
facility
ME C6.5 Availability of Equipment Availability of equipment for OB Refrigerator, Crash
for Storage storage for drugs cart/Drug trolley,
instrumental trolley,
dressing trolley
ME C6.6 Availability of functional Availability of equipments for OB Buckets for
equipment and cleaning mopping, mops,
instruments for support duster, waste trolley,
services Deck brush
Availability of equipment for OB Boiler
sterilization and disinfection
ME C6.7 Departments have Availability of Fixtures OB Spot light,
patient furniture and electrical fixture for
fixtures as per load and equipments, X ray
service provision view box

Availability of furniture at OB Doctors Chair,
clinics Patient Stool,
Examination Table,
Attendant Chair,
Table, Footstep,
cupboard
of Equipment.
ME D1.1 The facility has All equipments are covered SI/RR
established system for under AMC including
maintenance of critical preventive maintenance
Equipment There is system of timely SI/RR
maintenance of the
equipments
ME D1.2 The facility has All the measuring OB/ RR BP apparatus,
established procedure equipments/ instrument are thermometer are
for internal and external calibrated calibrated
calibration of measuring
Equipment
ME D2.1 There is established There is process indenting SI/RR Stock level are daily
procedure for forecasting consumables and drugs in updated
and indenting drugs and injection/ dressing room Requisition are
consumables timely placed

proper storage of drugs containers/tray/crash cart
and consumables and are labelled
Vaccine are kept at OB
recommended temperature
at immunization room
ME D2.4 The facility ensures Expiry dates for injectables OB/RR
management of expiry are maintained at injection
and near expiry drugs and immunization room
maintained for drug stored at
department
ME D2.5 The facility has There is practice of SI/RR
established procedure for calculating and maintaining
inventory management buffer stock
techniques Department maintained SI/RR
register of drugs and
consumables
ME D2.6 There is a procedure for There is procedure for SI/RR
periodically replenishing replenishing drug tray /crash
the drugs in patient care cart
areas There is no stock out of drugs SI/RR

ME D2.7 There is process for Temperature of refrigerators OB/RR Check for
storage of vaccines and are kept as per storage temperature charts
other drugs, requiring requirement and records are are maintained
controlled temperature maintained and updated
periodically
Cold chain is maintained at OB/RR Check for four
immunization room conditioned Ice
packs are placed in
Carrier Box,
DPT, DT, TT and
Hep B Vaccines are
not kept in direct
contact of Frozen
Ice pack
ME D3.1 The facility provides Adequate Illumination in OB Examination table
adequate illumination clinics
level at patient care areas Adequate Illumination in OB Dressing room,
procedure area injection room and
immunization room
ME D3.2 The facility has provision Only one patient is allowed OB/SI
of restriction of visitors in one time at clinic
patient areas Limited number of OB/SI
attendant/ relatives are
allowed with patient
Medical representative are OB/SI
restricted in OPD timings
ME D3.3 The facility ensures Temperature control and PI/OB Fans/ Air
safe and comfortable ventilation in waiting areas conditioning/
environment for patients Heating/Exhaust/
and service providers Ventilators as
per environment
condition and
requirement
Temperature control and SI/OB Fans/ Air
ventilation in clinics conditioning/
Heating/Exhaust/
Ventilators as
per environment
condition and
requirement
ME D3.4 The facility has security Hospital has sound OB/SI
system in place at patient security system to manage
care areas overcrowding in OPD
ME D3.5 The facility has Ask female staff whether they SI
established measure for feel secure at work place
safety and security of
female staff
Standard D4 The facility has established Programme for maintenance and upkeep of the facility
Interior of patient care areas OB
are plastered & painted
ME D4.2 Patient care areas are Floors, walls, roof, roof OB All area are
clean and hygienic topes, sinks patient care and clean with no
circulation areas are Clean dirt,grease,littering
and cobwebs

fixtures are clean
functional flush and running
water
ME D4.3 Hospital infrastructure is Check for there is no seepage OB
adequately maintained , Cracks, chipping of plaster
Patients beds are intact and OB
painted
clean
ME D4.5 The facility has policy of No condemned/Junk material OB
removal of condemned lying in the OPD
junk material
ME D4.6 The facility has No stray animal/rodent/birds OB
established procedures
for pest, rodent and
animal control
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and
ME D5.1 The facility has adequate Availability of 24x7 running OB/SI
arrangement storage and and potable water
supply for portable water
in all functional areas
ME D5.2 The facility ensures Availability of power back up OB/SI
adequate power backup in OPD
in all patient care areas as
per load
Standard D6 Dietary services are available as per service provision and nutritional requirement of the patients
ME D6.1 The facility has provision Nutritional assessment of RR/SI
of nutritional assessment patient done as required and
of the patients directed by doctor
Standard D7 The facility ensures clean linen to the patients
ME D7.1 The facility has adequate Availability of linen in OB
sets of linen examination area
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 Staff is aware of their role and SI
established job responsibilities
guidelines
ME D11.2 The facility has a There is procedure to ensure RR/SI Check for system
established procedure that staff is available on duty for recording time
for duty roster and as per duty roster of reporting and
deputation to different relieving (Attendance
departments register/ Biometrics
etc)
There is designated in charge SI
for department
the adherence to dress support staff adhere to their
code as mandated by respective dress code
its administration / the
health department

Standard D12 The facility has established procedure for monitoring the quality of outsourced services and
adheres to contractual obligation
ME D12.1 There is established There is procedure to SI/RR Verification of
system for contract monitor the quality and outsourced services
management for out adequacy of outsourced (cleaning/ Dietary/
sourced services services on regular basis Laundry/Security/
Maintenance)
provided are done
by designated in-
house staff
established procedure for number is given to each
registration of patients patient during process of
registration
Patient demographic RR Check for
details are recorded in OPD that patient
registration records demographics like
Name, age, Sex,
Address etc.
Patients are directed to PI/SI
relevant clinic by registration
clerk based on complaint
Registration clerk is aware SI/RR
of categories of the patient
exempted from user charges
ME E1.2 The facility has a There is procedure for OB Patient is called by
established procedure for systematic calling of patients Doctor/attendant
OPD consultation one by one as per his/her turn
on the basis of “first
come first examine”
basis.
Patient History is taken and RR
recorded
Physical Examination is done OB/RR
and recorded wherever
required
Provisional Diagnosis is OB/RR
recorded
No Patient is Consulted in OB
Standing Position
Clinical staff is not engaged OB/SI
in administrative work
ME E1.3 There is established There is establish procedure SI/RR
procedure for admission for admission through OPD
of patients There is establish procedure SI/RR
for day care admission
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of
the patients.
ME E2.1 There is established There is screening clinic for OB
procedure for initial initial assessment of the
assessment of patients patients
ME E2.2 There is established Procedure for follow up of old OB/RR
procedure for follow-up/ patients
reassessment of Patients

ME E3.1 Facility has established Facility has established SI/RR
procedure for continuity procedure for handing
of care during over of patients during
interdepartmental departmental transfer
transfer There is a procedure SI/RR
consultation of the patient
to other specialist with in the
hospital
ME E3.2 Facility provides Availability of referral RR/OB Check how patient
appropriate referral linkages for OPD are referred if
linkages to the patients/ consultation. services are not
Services for transfer to available
other/higher facilities to
assure their continuity of
care.
ME E3.4 Facility is connected to Facility has functional referral SI/RR
medical colleges through linkages to higher facilities
telemedicine services Facility has functional referral SI/RR
linkages to lower facilities
There is a system of follow up RR
of referred patients
ICTC has functional Linkages RR/SI
with ART and state reference
Labs
Telemedicine service are used RR/SI
for consultation
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.
ME E5.2 The facility identifies high For any critical patient RR
risk patients and ensure needing urgent attention
their care, as per their queue can be bypassed for
need providing services on priority
basis
Standard E6 Facility follows standard treatment guidelines defined by state/Central government for
ME E6.1 Facility ensured that Check for OPD slip if drugs RR
drugs are prescribed in are prescribed under generic
generic name only name only
A copy of Prescription is kept RR
with the facility
ME E6.2 There is procedure of Check for that relevant RR
rational use of drugs Standard treatment guideline
are available at point of use
Check staff is aware of the SI/RR
drug regime and doses as per
STG
Check OPD ticket that drugs RR
are prescribed as per STG
Availability of drug formulary SI/OB
Standard E7 Facility has defined procedures for safe drug administration
ME E7.2 Medication orders are Every Medical advice and RR
written legibly and procedure is accompanied
adequately with date , time and signature
clinical staff

ME E7.3 There is a procedure Drugs are checked for expiry OB/SI Check in Injection
to check drug before and other inconsistency room
administration/ before administration
dispensing Check single dose vial are not OB Check for any open
used for more than one dose single dose vial with
left over content
intended to be used
later on
Check for separate sterile OB In multi dose vial
needle is used every time for needle is not left in
multiple dose vial the septum
Any adverse drug reaction is RR/SI
recorded and reported
ME E7.5 Patient is counselled for Patient is advice by doctor/ SI/PI
self drug administration Pharmacist /nurse about the
dosages and timings .
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’ clinical
ME E8.1 All the assessments, Patient History, Chief RR
re-assessment and Complaint and Examination
investigations are Diagnosis/ Provisional
recorded and updated Diagnosis is recorded in OPD
slip
ME E8.2 All treatment plan Written RR
prescription/orders are Prescription Treatment plan
recorded in the patient is written
records.
ME E8.4 Procedures performed Any dressing/injection, other RR
are written on patients procedure recorded in the
records OPD slip
ME E8.5 Adequate form and Check for the availability of OB/SI
formats are available at OPD slip, Requisition slips etc.
point of use
ME E8.6 Register/records are OPD records are maintained OB/RR OPD register, ANC
maintained as per register, Injection
guidelines room register etc
All register/records are OB/RR
ME E8.7 The facility ensures safe Safe keeping of OPD records OB/SI
and adequate storage
and retrieval of medical
records
Management
ME E11.3 The facility has disaster Staff is aware of disaster plan SI/RR
management plan in
place Role and responsibilities of SI/RR
Standard E12 The facility has defined and established procedures of diagnostic services
ME E12.1 There are established Container is labelled OB
procedures for Pre- properly after the sample
testing Activities collection
ME E12.3 There are established Clinics is provided with the SI/RR
procedures for Post- critical value of different tests
testing Activities

Maternal & Child Health Services
Standard E17 Facility has established procedures for Antenatal care as per guidelines
ME E17.1 There is an established Facility provides and updates RR/SI Line listing
procedure for “Mother and Child Protection
Registration and follow Card”.
up of pregnant women. Records are maintained for RR Records of each
ANC registered pregnant ANC checkups
women is maintained in
Mother and child
protection card
ME E17.2 There is an established ANC checkups is done by RR/SI
procedure for History Qualified personnel
taking, Physical At ANC clinic, Pregnancy is RR/SI
examination, and confirmed by performing
counselling for each urine test
antenatal visit.
Last menstrual period (LMP) RR/SI
is recorded and Expected
date of Delivery (EDD) is
calculated
Weight measurement RR/SI
blood pressure, RR/SI
respiratory rate RR/SI
pallor, oedema and icterus. RR/SI
abdominal palpation for RR/SI
foetal growth, foetal lie
auscultation for foetal heart RR/SI
sound
breast examination RR/SI
History of past illness / RR/SI
pregnancy complication is
taken and recorded
4 ANC checkups of women is RR/SI
confirmed
ME E17.3 Facility ensures Diagnostic test under ANC RR/SI Check for
availability of diagnostic check up are prescribed by Haemoglobin, urine
and drugs during ANC clinic albumin urine sugar
antenatal care of blood group and
pregnant women Rh factor Syphilis
(VDRL/RPR) HIV
blood sugar malaria
Hepatitis B
ME E17.4 There is an established High risk pregnant women RR/SI
procedure for are referred to specialist
identification of High
risk pregnancy and
appropriate treatment/
referral as per scope of
services.
ME E17.5 There is an established Line listing of pregnant RR/SI
procedure for women with moderate and
identification and sever anaemia
management of Provision for Injectable Iron RR/SI
moderate and severe Treatment for moderate
anaemia anaemia

ME E17.6 Counselling of pregnant nutritional counselling RR/PI
women is done as per recognizing danger sign of RR/PI
standard protocol and labour
gestational age
breast feeding RR/PI
institutional delivery RR/PI
arrangement of referral RR/PI
transport
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 Availability of diluents for RR/SI
immunization services as Reconstitution of measles
per guidelines vaccine
Recommended temperature RR/SI Check diluents are
of diluents is insured before kept under cold
reconstitution chain at least before
24 hours before
reconstitution
Diluents are kept in
vaccine carrier only
at immunization
clinic but should not
be in direct contact
of ice pack
Reconstituted vaccines are RR/SI Ask staff about
not used after recommended when BCG, measles
time and JE vaccines are
constituted and till
when these are valid
for use. Should not
be used beyond
4 hours after
reconstitution
Time of opening/ RR Check for records
Reconstitution of vial is
recorded
Staff checks VVM level before SI Ask staff how to
using vaccines check VVM level
and how to identify
discard point
Staff is aware of how check SI Ask staff to
freeze damage for T-Series demonstrate how to
vaccines conduct Shake test
for DPT, DT and TT
Discarded vaccines are kept SI/OB Check for no
separately expired, frozen or
with VVM beyond
the discard point
vaccine stored in
clod chain
Check for DPT, DT, Hep Band SI/OB
TT vials are not kept in direct
contact of ice pack

AD syringes are available as SI/OB Check for 0.1 ml AD
per requirement syringe for BCG and
0.5 ml syringe for
others are available
Staff knows correct use AD SI Ask for
syringe demonstration ,
How to peel, how to
remove air bubble
and injection site
Check for AD syringes are not OB
reused
Vaccine recipient is asked SI/RR
to stay for half an hour after
vaccination to observer any
Adverse effect following
immunization
Antipyretic medicines SI/RR
available
Availability of Immunization SI/RR
card
Counselling on side effects SI/RR
and follow up visits done(CEI)
Staff is aware of how to minor SI
and serious advise events
(AEFI)
Staff knows what to do in SI
case of anaphylaxis
ME E20.2 Triage, Assessment Check for adherence to SI/RR
& Management of clinical protocols
newborns having
emergency signs are
done as per guidelines
ME E20.5 Management of children Check for adherence to SI/RR
presenting clinical protocols
with fever, cough/
breathlessness is done as
per guidelines
ME E20.6 Management of children Screening of children coming SI/RR
with severe to OPDs using weight for
Acute Malnutrition is height and/or MUAC
ME E20.7 Management of children Check for adherence to SI/RR
presenting clinical protocols
diarrhoea is done per availability of ORT corner SI/RR
guidelines
Standard E22 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines
ME E22.1 Facility provides Provision of Antenatal natal SI/RR Nutritional
Promotive ARSH Services check up for pregnant Counselling,
adolescent contraceptive
counselling, Couple
counselling ANC
checkups, ensuring
institutional delivery

Counselling and provision SI/RR Check for the
of emergency contraceptive availability of
pills Emergency
Contraceptive pills
(Levonorgesterol)
Counselling and provision of RR/SI Check for the
reversible Contraceptives availability of Oral
Contraceptive Pills,
Condoms and IUD
Availability and Display of IEC OB Poster Displayed,
material Reading Material
handouts etc.
Information and advice of SI/RR Advice on topic
sexual and reproductive related to Growth
health related issues and development,
puberty, sexuality
cancers, myths &
misconception,
pregnancy, safe
sex, contraception,
unsafe abortion,
menstrual
disorders, anemia,
sexual abuse, RTI/
STI’s etc.
ME E22.2 Facility provides Services for Tetanus SI/RR TT at 10 and 16 year
Preventive ARSH Services immunization
Services for Prophylaxis SI/RR Haemoglobin
against Nutritional Anaemia estimation, weekly
IFA tablet, and
treatment for worm
infestation
Nutrition Counselling SI/RR
Services for early and safe SI/RR MVA procedure for
termination of pregnancy pregnancy up to 8
and management of post week Post abortion
abortion complication counselling
ME E22.3 Facility Provides Curative Treatment of Common RTI/ SI/RR Privacy and
ARSH Services STI’s Confidentiality,
treatment
Compliance, Partner
Management,
Follow up visit and
referral
Treatment and counselling SI/RR Symptomatic
for Menstrual disorders treatment ,
counselling
Treatment and counselling SI/RR
for sexual concern for male
and female adolescents
Management of sexual abuse SI/RR ECP, Prophylaxis
amongst Girls against STI, PEP for
hIV and Counselling
ME E22.4 Facility Provides Referral Referral Linkages to ICTC and SI/RR
Services for ARSH PPTCT
Privacy and confidentiality SI/RR Screens and curtains
maintained at ARSH clinic for visual privacy,
confidentaility
policy displayed,
one client at a time

National Health Programs
Standard E23 Facility provides National health program as per operational/Clinical Guidelines
ME E23.1 Facility provides Ambulatory care of SI/RR As per Clincal
service under National uncomplicated P. Vivax Guidelines for
Vector Borne Disease malaria Treatment of
Control Program as per Maleria
guidelines
Ambulatory care of SI/RR As per Clincal
uncomplicated P. Falciparum Guidelines for
Malaria Treatment of
Maleria
Ambulatory care of drug SI/RR As per Clincal
resistant malaria Guidelines for
Treatment of
Maleria
ME E23.2 Facility provides service Diagnosis and Management SI/RR As per RNTCP
under Revised National of Pulmonary Tuberculosis Technical Guidelines
TB Control Program as Diagnosis and Management SI/RR As per RNTCP
per guidelines of Extra pulmonary Technical Guidelines
Tuberculosis
Management of Paediatric SI/RR As per RNTCP
Tuberculosis Technical Guidelines
Management of Patients SI/RR As per RNTCP
vith HIV infection and Technical Guidelines
Tuberculosis
Drug administration for SI/RR Check for filled
Intensive and Continuation treatment Cards
done as per RNTCP treatment
protocol
Protocols for treatment for TB SI/RR Discontinuation of
during pregnancy and Post Streptomycin
natal Period is adhered Chemoprophylaxis
of baby in case
of smear positive
mother
Monitoring and follow up of SI/RR Check for records/
patient done as per protocols Protocols
There is functional Linkage SI/RR
between DMC and ICTC
ME E23.3 Facility provides service Validation and Diagnosis SI/RR As per Operation/
under National Leprosy of Referred and Directly Clincal Guidelines of
Eradication Program as Reported Cases NLEP
per guidelines Treatment of all diagnosed SI/RR As per Operation/
cases including Reaction and Clincal Guidelines of
Neuritis NLEP
Assessment of Disability SI/RR As per Operation/
Status Clincal Guidelines of
NLEP
Management of Lepra SI/RR As per Operation/
Reactions Clincal Guidelines of
NLEP
Management of Complicated SI/RR As per Operation/
Ulcers Clincal Guidelines of
NLEP

Management of Eye SI/RR As per Operation/
Complications Clincal Guidelines of
NLEP
Physiotherapy including Pre SI/RR As per Operation/
and Post Operative Care Clincal Guidelines of
NLEP
Follow-up of cases treated at SI/RR As per Operation/
tertiary Level Clincal Guidelines of
NLEP
Supply of Customized Foot SI/RR As per Operation/
wear Clincal Guidelines of
NLEP
Self care Counselling SI/RR As per Operation/
Clincal Guidelines of
NLEP
Outreach Services to Leprosy SI/RR As per Operation/
Clinics Clincal Guidelines of
NLEP
Screening of Cases of RCS SI/RR As per Operation/
Clincal Guidelines of
NLEP
ME E23.4 Facility provides service Pre Test Counselling is done SI/RR basic information
under National AIDS as per protocols and benefits of HIV
Control program as per testing potential
guidelines risks such as
discrimination.
The client is also
informed about
their right to refuse,
follow-up services.
Pregnant women
are given additional
information on
nutrition, hygiene,
the importance
of an institutional
delivery and
HIV testing so
as to avoid HIV
transmission from
mother to child.
Post test counselling given as SI/RR window period,
per protocol 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
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.

Diagnosis and treatment of SI/RR As per NACO
opportunistic Infections guidelines
Screening of PLHA for SI/RR As per NACO
initiating ART guidelines
Monitoring of patients on SI/RR As per NACO
ART and management of side guidelines
effects
Counselling and SI/RR As per NACO
Psychological support for guidelines
PLHA
ME E23.6 Facility provides Treatment of Menal illnesses SI/RR
service under Mental as per clinical guidelines
Health Program as per
guidelines
ME E23.7 Facility provides Geriatic Care is provided as SI/RR
service under National per Clinical Guidelines
programme for the
health care of the elderly
as per guidelines
ME E23.8 Facility provides Opportunistic screening for SI/RR Screening of
service under National diabetes, persons above
Programme for hypertension, cardiovascular age of 30 - History
Prevention and Control diseases of tobacco
of cancer, diabetes, examination, BP
cardiovascular diseases & Measurement
stroke (NPCDCS) as per and Blood sugar
guidelines estimation
Look for records at
NCD clinic
screen women of the SI/RR
age group 30-69 years
approaching to the hospital
for early detection of cervix
cancer and breast cancer.
Health Promotion through OB increased intake
IEC and counselling of healthy foods
increased physical
activity through
sports, exercise, etc.;
avoidance of
tobacco and
alcohol; 24
stress management
warning signs of
cancer etc
ME E23.9 Facility provide service Weekly reporting of SI/RR
for Integrated disease Presumptive cases on form
surveillance program “P” from OPD clinic
ME E23.10 Facility provide services Early detection and screening SI/RR As per Clinical
under National program for detection of deafness guidelines
for prevention and
control of deafness
Standard F1 Facility has infection control program and procedures in place for prevention and measurement
ME F1.4 There is Provision There is procedure for SI/RR Hepatitis B, Tetanus
of Periodic Medical immunization of the staff Toxic etc
Checkups and Periodic medical checkups of SI/RR
immunization of staff the staff

ME F1.5 Facility has established Regular monitoring of SI/RR Hand washing and
procedures for regular infection control practices infection control
monitoring of infection audits done at
control practices periodic intervals
ME F1.6 Facility has defined and Check for Doctors are aware SI/RR
established antibiotic of Hospital Antibiotic Policy
policy
antisepsis
ME F2.1 Hand washing facilities Availability of hand washing OB Check for availability
are provided at point of Facility at Point of Use of wash basin near
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 OB/SI Check for
soap with soap dish/ liquid availability/ Ask
antiseptic with dispenser. staff if the supply
is adequate and
uninterrupted
Availability of Alcohol based OB/SI Check for
Hand rub availability/ Ask
staff for regular
supply.
Display of Hand washing OB Prominently
Instruction at Point of Use displayed above
the hand washing
facility , preferably
in Local language
ME F2.2 Staff is trained and Adherence to 6 steps of Hand SI/OB Ask of
adhere to standard hand washing demonstration
washing practices Staff aware of when to hand SI
wash
ME F2.3 Facility ensures standard Availability of Antiseptic OB
practices and materials Solutions
for antisepsis Proper cleaning of procedure OB/SI like before giving
site with antisepsis IM/IV injection,
drawing blood,
putting Intravenous
and urinary catheter
ME F3.1 Facility ensures adequate Clean gloves are available at OB/SI
personal protection point of use
equipments as per
requirements
Availability of Masks OB/SI
removing the gloves

ME F4.1 Facility ensures standard Decontamination of SI/OB Ask staff about how
practices and materials operating & Procedure they decontaminate
for decontamination and surfaces the procedure
cleaning of instruments surface like
and procedures areas Examination table
, dressing table,
Stretcher/Trolleys
etc.
(Wiping with .5%
Chlorine solution
Proper Decontamination of SI/OB
instruments after use Ask staff how they
decontaminate
the instruments
like Stethoscope,
Dressing
Instruments,
Examination
Instruments, Blood
Pressure Cuff etc
(Soaking in 0.5%
Chlorine Solution,
Wiping with 0.5%
Chlorine Solution
decontamination is
adequate
Cleaning of instruments after SI/OB Cleaning is done
decontamination with detergent and
running water after
decontamination
Proper handling of Soiled and SI/OB No sorting ,Rinsing
infected linen or sluicing at Point
of use/ Patient care
area
chlorine solution
ME F4.2 Facility ensures Equipment and instruments OB/SI Autoclaving/
standard practices and are sterilized after each use HLD/Chemical
materials for disinfection as per requirement Sterilization
and sterilization of High level Disinfection of OB/SI Ask staff about
instruments and instruments/equipments is method and time
equipments done as per protocol required for boiling
Autoclaved dressing material OB/SI
is used
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
ME F5.1 Layout of the department Facility layout ensures OB
is conducive for the separation of general traffic
infection control from patient traffic
practices Clinics for infectious diseases OB Preferably in
are located away from main remote corner with
traffic independent access
Sitting arrangement in TB OB
clinic is as per guideline

ME F5.2 Facility ensures Availability of disinfectant as OB/SI Chlorine solution,
availability of standard per requirement Glutaraldehyde,
materials for cleaning and carbolic acid
disinfection of patient Availability of cleaning agent OB Hospital grade
care areas as per requirement phenyl, disinfectant
detergent solution
ME F5.3 Facility ensures standard Staff is trained for spill SI/RR
practices followed for management
cleaning and disinfection Cleaning of patient care area SI/RR
of patient care areas with detergent solution
Staff is trained for preparing SI/RR
cleaning solution as per
standard procedure
Standard practice of OB/SI Unidirectional
mopping and scrubbing are mopping from
followed inside out
Cleaning equipments like OB/SI Any cleaning
broom are not used in equipment leading
patient care areas to dispersion of
dust particles in air
should be avoided
Standard F6 Facility has defined and established procedures for segregation, collection, treatment and
ME F6.1 Facility Ensures Availability of colour coded OB
segregation of Bio bins at point of waste
Medical Waste as per generation
guidelines Availability of plastic colour OB
coded plastic bags
guidelines
Display of work instructions OB
for segregation and handling
of Biomedical waste
There is no mixing of OB
infectious and general waste
ME F6.2 Facility ensures Availability of functional OB See if it has been
management of sharps as needle cutters used or just lying
per guidelines idle
Availability of puncture proof OB Should be available
box nears the point
of generation like
nursing station and
injection room
Disinfection of sharp before OB/SI Disinfection of
disposal syringes is not done
in open buckets
Staff is aware of contact time SI
for disinfection of sharps
Availability of post exposure OB/SI Ask if available.
prophylaxis Where it is stored
and who is in charge
of that.
Staff knows what to do in SI Staff knows what to
condition of needle stick do in case of shape
injury injury. Whom to
report. See if any
reporting has been
done

ME F6.3 Facility ensures Check bins are not overfilled SI/OB
transportation and Transportation of bio medical SI/OB
disposal of waste as per waste is done in close
guidelines container/trolley
Staff aware of mercury spill SI/RR
management
Area of Concern - G Quality Management
ME G1.1 The facility has a quality There is a designated SI/RR
team in place departmental nodal person
for coordinating Quality
Assurance activities
Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient Satisfaction OPD Patient satisfaction RR
surveys are conducted at survey done on monthly
periodic intervals basis
Standard G3 Facility have established internal and external quality assurance programs wherever it is critical
to quality.
ME G3.1 Facility has established There is system daily round SI/RR
internal quality assurance by matron/hospital manager/
program at relevant hospital superintendent/
departments Hospital Manager/ Matron
in charge for monitoring of
services
Internal Quality Assurance is SI/RR
established at ICTC lab
ME G3.2 Facility has established External Quality assurance SI/RR
external assurance program is established at
programs at relevant ICTC lab
departments
ME G3.3 Facility has established Departmental checklist are SI/RR
system for use of used for monitoring and
check lists in different quality assurance
departments and services Staff is designated for filling SI
and monitoring of these
checklists
Standard G4 Facility has established, documented implemented and maintained Standard Operating
ME G4.1 Departmental standard Standard operating RR
operating procedures are procedure for department
available has been prepared and
approved
Current version of SOP are OB/RR
available with process owner
ME G4.2 Standard Operating OPD has documented RR
Procedures adequately procedure for Registration
describes process and OPD has documented RR
procedures procedure for patient calling
system in OPD clinics
OPD has documented RR
procedure for receiving of
patient in clinic
process for OPD consultation

procedure for investigation
procedure for prescription
and drug dispensing
procedure for nursing
process in OPD
procedure for patient privacy
and confidentiality
procedure for conducting,
analysing patient satisfaction
survey
procedure for equipment
management and
maintenance in OPD
Department has documented RR
procedure for Administrative
and non clinical work at OPD
Department has documented RR
procedure for No Smoking
Policy in OPD
procedure for duty roaster,
punctuality, dress code and
identity for OPD staff
ME G4.3 Staff is trained and Check Staff is a aware of SI/RR
SOPs
ME G4.4 Work instructions are Work instruction/clinical OB Relevant protocols
displayed at Point of use protocols are displayed are displayed like
Clinical Protocols for
ANC checkups
Standard G 5 Facility maps its key processes and seeks to make them more efficient by reducing non value
ME G5.1 Facility maps its critical Process mapping of critical SI/RR
processes processes done
ME G5.2 Facility identifies non Non value adding activities SI/RR
value adding activities are identified
/ waste / redundant
activities
ME G5.3 Facility takes corrective Processes are rearranged as SI/RR
action to improve the per requirement
processes
Standard G6 The facility has established system of periodic review as internal assessment , medical & death
ME G6.1 The facility conducts Internal assessment is done RR/SI
periodic internal at periodic interval
assessment
ME G6.2 The facility conducts the There is procedure to RR/SI
periodic prescription/ conduct Medical Audit
medical/death audits There is procedure to RR/SI
conduct Prescription audit

non compliances enumerated and recorded
are enumerated and
recorded adequately
ME G6.4 Action plan is made Action plan prepared RR/SI
process
ME G6.5 Corrective and preventive Corrective and preventive RR/SI
actions are taken to action taken
address issues, observed
in the assessment & audit
Standard G7 The facility has defined and established Quality Policy & Quality Objectives
ME G7.1 The facility defines its
quality policy
ME G7.2 The facility periodically Quality objective for OPD RR/SI
defines its quality defined
objectives and key
departments have their
own objectives
ME G7.3 Quality policy and Check of staff is aware of SI
objectives are quality policy and objectives
disseminated and staff is
aware of that
ME G7.4 Progress towards quality Quality objectives are SI/RR
objectives is monitored monitored and reviewed
periodically periodically
Standard G8 Facility seeks continually improvement by practicing Quality method and tools.
ME G8.1 Facility uses method for PDCA SI/RR
quality improvement in 5S SI/OB
services
Six Sigma SI/RR
ME G8.2 Facility uses tools for 6 basic tools of Quality SI/RR
quality improvement in Prateo / Prioritization SI/RR
services

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National
benchmarks
ME H1.1 Proportion of follow-up RR
patients
No of ANC done per RR
thousand
ICTC OPD per thousand RR
ART patient load per RR
thousand
ARSH OPD per thousand RR
Immunization OPD per RR
thousand
ME H1.2 The Facility measures Proportion of BPL patients RR
equity indicators
periodically

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures Medicine OPD per Doctor RR
efficiency Indicators on Surgery OPD per Doctor RR
monthly basis
Paediatric OPD per Doctor RR
OBG OPD per Doctor RR
Dental OPD per Doctor RR
Ophthalmology OPD per RR
doctor
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 Consultation time at ANC RR Time motion study
Care & Safety Indicators Clinic
on monthly basis
Consultation time at General RR
Medicine Clinic
Consultation time for General RR
Surgery Clinic
Consultation time for RR
paediatric clinic
Proportion of High risk RR No of High Risk
pregnancy detected during Pregnancies X100/
ANC Total no PW used
ANC services in the
month
Proportion of severe anaemia RR
cases
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National
benchmark
ME H4.1 Facility measures Service Patient Satisfaction Score RR
Quality Indicators on Waiting time at registration RR
monthly basis counter
Waiting time at ANC Clinic RR
Waiting time at general OPD RR
Waiting time at paediatric RR
Clinic
Waiting time at surgical clinic RR
Average door to drug time RR

Assessment Summary
A. Score Card
Out patients department (opd) Score Card
Out Patients Department (opd) Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Checklist–3
Labour Room
Version: 1/2013

Checklist–3
Checklist for Labour Room
Reference Measure Element Checkpoint Compli- Assessment Means of

No. ance Method Verification
Standard A1 The facility provides Curative Services
ME A1.3 The facility provides Obstetrics Availability of SI/OB
& Gynaecology Services comprehensive
obstetric services
ME A1.14 Services are available for the Labour room service SI/RR
time period as mandated are functional 24X7
Standard A2 The facility provides RMNCHA Services
ME A2.1 The facility provides Availability of Post SI/OB PPIUD insertion
Reproductive health Services partum sterilization
services
ME A2.2 The facility provides Maternal Vaginal Delivery SI/OB Term, post Date
health Services and pre term
Assisted Delivery SI/OB Forceps delivery
and vacuum
delivery
Management SI/OB Medical /Surgical
of Postpartum
Haemorrhage
Management of SI/OB
Retained Placenta
Septic Delivery SI/OB
Delivery of HIV SI/OB
positive PW
Management of SI/OB
PIH/Eclampsia/pre
Eclampsia
Initial Diagnosis and SI/OB
management of MTP
and Ectopics
ME A2.3 The facility provides Newborn Availability of New SI/OB
health Services born resuscitation
Availability of Essential SI/OB
new born care
Standard A3 The facility Provides diagnostic Services
ME A3.1 The facility provides Radiology Availability of SI/OB
Services dedicated services for
USG
ME A3.2 The facility Provides Availability of point of SI/OB HIV, Hb% ,
Laboratory Services care diagnostic test Random blood
sugar /as per
state guideline
Standard B1 The facility provides the information to care seekers, attendants & community about the available
ME B1.1 The facility has uniform and Availability OB (Numbering,
user-friendly signage system departmental main
signage’s department and
internal sectional
signage
Directional signage OB Direction is
for department is displayed from
displayed main gate to
direct.
Restricted area signage OB
displayed
ME B1.2 The facility displays the Entitlements under OB
services and entitlements JSSK Displayed
available in its departments Entitlement under JSY OB
displayed
Name of doctor and OB
Nurse on duty are
Contact details of OB
referral transport /
ambulance displayed
Services provision OB
of labour room are
displayed at the
entrance
ME B1.5 Patients & visitors are IEC Material is OB Breast feeding,
sensitised and educated displayed kangaroo care,
through appropriate IEC / BCC family planning
approaches etc (Pictorial and
chart )
ME B1.6 Information is available in Signage’s and OB
local language and easy to information are
understand available in local
language
ME B1.7 The facility provides Availability of Enquiry OB Enquiry desk
information to patients and Desk with dedicated serving both
visitor through an exclusive staff maternity ward
set-up. and labour
ME B2.1 Services are provided in Only on duty staff is OB
manner that are sensitive to allowed in the labour
gender room when it is
occupied
Availability of female OB/SI
staff if a male doctor
examine a female
patients
98 | Checklist for Labour Room

ME B2.3 Access to facility is provided Availability of Wheel OB
without any physical barrier chair or stretcher for
& and friendly to people with easy Access to the
disabilities labour room
Availability of ramps OB
and railing
Labour room is located OB If not located on
at ground floor the ground floor
availability of the
ramp / lift
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/ OB
provided at every point of care partition at delivery
tables
Curtains / frosted glass OB
have been provided at
windows
ME B3.2 Confidentiality of patients Patient Records are SI/OB
records and clinical kept at secure place
information is maintained beyond access to
general staff/visitors
ME B3.3 The facility ensures the Behaviour of staff OB/PI
behaviours of staff is dignified is empathetic and
and respectful, while courteous
ME B3.4 The facility ensures privacy HIV status of patient is SI/OB
and confidentiality to every not disclosed except
patient, especially of those to staff that is directly
conditions having social involved in care
stigma, and 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
ME B4.1 There is established General consent is SI/RR
procedures for taking taken before delivery
informed consent before
treatment and procedures
ME B4.4 Information about the Labour room has PI
treatment is shared with system in place to
patients or attendants, involve patient relative
regularly in decision making
about pregnant
women treatment
ME B4.5 The facility has defined Availability of OB
and established grievance complaint box and
redressal system in place display of process for
grievance re redressal
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 Drugs and PI/SI
services to pregnant women, consumables under
mothers and neonates as JSSK are available free
per prevalent government of cost
schemes
Checklist for Labour Room | 99

ME B5.2 The facility ensures that drugs Check that patient PI/SI
prescribed are available at party has not spent
Pharmacy and wards on purchasing drugs
or consumables from
outside.
ME B5.3 It is ensured that facilities for Check that patient PI/SI
the prescribed investigations party has not spent
are available at the facility on diagnostics from
outside.
ME B5.5 The facility ensures If any other PI/SI/RR
timely reimbursement of expenditure occurred
financial entitlements and it is reimbursed from
reimbursement to the patients hospital
the prevalent norms
ME C1.1 Departments have adequate Adequate space as per OB One labour
space as per patient or work delivery load table requires
load 10X10 sqft of
space, Every
labour table
should have
space for vertical
trolley with
space for six
trays
Availability of Waiting OB
area for attendants/
ASHA
ME C1.2 Patient amenities are provide Attached toilet and OB
as per patient load bathroom facility
available
Availability of Hot OB
water facility
Availability of Drinking OB
water
Availability of OB
Changing area
ME C1.3 Departments have layout Delivery unit has OB
and demarcated areas as per dedicated Receiving
functions area
Availability of OB
Examination Room
Availability of Pre OB
delivery room
Availability of Delivery OB
room
Availability of Post OB
delivery observation
room
Dedicated nursing OB
station within or
proximity labour room

Area earmarked for OB
newborn care Corner
Dedicated Eclampsia OB
room available
Dedicated Septic OB
Labour Room with
NBCC
Preparation of OB
medicine and injection
area
Availability of dirty OB
utility room
Availability of store OB
ME C1.4 The facility has adequate Corridors connecting OB
circulation area and open labour room are broad
spaces according to need and enough to manage
local law stretcher and trolleys
ME C1.5 The facility has infrastructure Availability of OB
for intramural and extramural functional telephone
communication and Intercom Services
ME C1.6 Service counters are available Availability of labour OB At least 2
as per patient load tables as per delivery labour table for
load 100 deliveries
per month
(Minimum 4)
ME C1.7 The facility and departments Labour room is in OB
are planned to ensure Proximity and function
structure follows the linkage with OT
function/processes (Structure Labour room is in OB
commensurate with the proximity a proximity
function of the hospital) and functional linkage
with SNCU
Unidirectional flow of OB
care
ME C2.1 The facility ensures the seismic Non structural OB Check for
safety of the infrastructure components are fixtures and
properly secured furniture like
cupboards,
cabinets,
and heavy
equipments ,
hanging objects
are properly
fastened and
secured
ME C2.3 The facility ensures safety of Labour room does OB Switch Boards
electrical establishment not have temporary other electrical
connections and installations are
loosely hanging wires intact
Stabilizer is provided OB
for Radiant warmer
ME C2.4 Physical condition of buildings Floors of the labour OB
are safe for providing patient room are non slippery
care and even
Windows have grills OB
and wire meshwork

ME C3.1 The facility has plan for Labour room has OB/SI
prevention of fire sufficient fire exit to
permit safe escape to
its occupant at time
of fire
Check the fire exits OB
are clearly visible and
routes to reach exit are
clearly marked.
ME C3.2 The facility has adequate fire Labour room OB
fighting Equipment has installed fire
Extinguisher that is
Class A , Class B, C type
or ABC type
extinguisher as well
as due date for next
refilling is clearly
mentioned
ME C3.3 The facility has a system of Check for staff SI/RR
periodic training of staff and competencies
conducts mock drills regularly for operating fire
for fire and other disaster extinguisher and what
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
ME C4.1 The facility has adequate Availability of Ob&G OB/RR
specialist doctors as per specialist on duty and
service provision on call paediatrician
ME C4.2 The facility has adequate Availability of General OB/RR at least One per
general duty doctors as per duty doctor at all time shift
service provision and work at labour room
load
ME C4.3 The facility has adequate Availability of Nursing OB/RR/SI at least Three per
nursing staff as per service staff /ANM shift
ME C4.5 The facility has adequate Availability of labour SI/RR at least 1
support / general staff room attendants/ Birth sanitary worker
Companion and 1 ayah per
shift
Availability of SI/RR
dedicated female
security staff
ME C4.6 The staff has been provided Navjat Shishu Surkasha SI/RR
required training / skill sets Karyakarm (NSSK)
training
Skilled birth Attendant SI/RR
(SBA)
Biomedical Waste SI/RR
Management
hand hygiene
Patient safety SI/RR

ME C4.7 The Staff is skilled as per job Nursing staff is skilled SI/RR
description for operating radiant
warmer
Nursing staff is skilled SI/RR Newborn as well
for resuscitation as Mother
Nursing staff is SI/RR
skilled identifying
and managing
complication
postnatal counselling
Nursing Staff is skilled SI/RR
for maintaining clinical
records including
partograph
Standard C5 The facility provides drugs and consumables required for assured services.
ME C5.1 The departments have Availability of OB/RR Inj Oxytocin 10
availability of adequate drugs uterotonic Drugs IU (to be kept in
at point of use fridge)
Availability of OB/RR Cap Ampicillin
Antibiotics 500mg, Tab
Metronidazole
400mg,
Gentamicin,
Availability of OB/RR Tab Misprostol
Antihypertensive 200mg,
Nefedipine,
Availabity of analgesics OB/RR Tab Paracetamol,
and antipyretics Tab Ibuprofen
Availability of IV Fluids OB/RR IV fluids, Normal
saline, Ringer
lactate,
Availability of local OB/RR Inj Xylocaine 2%,
anaesthetics
Others OB/RR Tab B complex, Inj
Betamethasone,
Inj Hydralazine,
methyldopa,
(Nevirapine and
other HIV drugs)
Availability of OB/RR Inj Magsulf 50%,
emergency drugs Inj Calcium glu-
conate 10%, Inj
Dexamethasone,
inj Hydrocorti-
sone, Succinate,
Inj diazepam,
inj Pheniramine
maleate, inj
Corboprost,
Inj Fortwin, Inj
Phenergen,
Betamethasone,
Inj Hydralazine,
Nefedipine,
Methyldopa,
ceftriaxone
Availability of drugs for OB/RR Vit K
newborn

ME C5.2 The departments have Availability of OB/RR gauze piece
adequate consumables at dressings and Sanitary and cotton
point of use pads swabs, sanitary
pads, needle
(round body and
cutting), chromic
catgut no. 0,
Availability of syringes OB/RR Paediatric iv
and IV Sets /tubes sets,urinery
catheter,
Availability of OB/RR Antiseptic lotion
Antiseptic Solutions
Availability of OB/RR gastric tube and
consumables for new cord clamp, Baby
born care ID tag
ME C5.3 Emergency drug trays are Emergency Drug Tray OB/RR
maintained at every point of care, is maintained
where ever it may be needed
ME C6.1 Availability of equipment & Availability of OB BP apparatus,
instruments for examination & functional Equipment stethoscope
monitoring of patients &Instruments for Thermometer,
examination & foetoscope/
Monitoring Doppler, baby
weighting
scale, Wall clock
(tracers)
ME C6.2 Availability of equipment & Availability of OB Scissor, Artery
instruments for treatment instrument arranged in forceps,
procedures, being undertaken Delivery treys Cord clamp,
in the facility Sponge holder,
speculum,
kidney tray,
bowl for
antiseptic lotion,
Delivery kits are in OB As per delivery
adequate numbers as load and
per load cycle time for
processing of
instrument
Availability of OB Episiotomy
Instruments arranged scissor, kidney
for Episiotomy trays tray, artery
forceps, allis
forceps, sponge
holder, toothed
forceps, needle
holder,thumb
forceps,
Availability of Baby OB Two pre warmed
tray towels/sheets
for wrapping
the baby, mucus
extractor, bag
and mask (0 &1
no.), sterilized
thread for cord/
cord clamp,
nasogastric tube,

Availability of OB Speculum,
instruments arranged anterior vaginal
for MVA/EVA tray wall retractor,
posterior wall
retractor, sponge
holding forceps,
MVA syringe,
cannulas, MTP,
cannulas, small
bowl of antiseptic
lotion,
Availability of OB PPIUCD insertion
instruments arranged forceps,
for PPIUCD tray CuIUCD 380A/
Cu IUCD375 in
sterile package
ME C6.3 Availability of equipment & Availability of Point OB Glucometer,
instruments for diagnostic of care diagnostic Doppler and HIV
procedures being undertaken instruments rapid diagnostic
in the facility kit
ME C6.4 Availability of equipment and Availability of OB Oxygen, Suction
instruments for resuscitation resuscitation machine/
of patients and for providing Instruments for mucus sucker ,
intensive and critical care to Newborn Care radiant warmer,
patients laryngoscope
Availability of OB Suction
resuscitation machine,
instrument for mother Oxygen, Adult
bag and mask,
mouth gag,
ME C6.5 Availability of Equipment for Availability of OB Refrigerator,
Storage equipment for storage Crash cart/
for drugs Drug trolley,
instrument
trolley, dressing
trolley
ME C6.6 Availability of functional Availability of OB Buckets for
equipment and instruments equipments for mopping,
for support services cleaning Separate mops
for labour room
and circulation
area duster,
waste trolley,
Deck brush
Availability of OB Boiler/Autocalve
equipment for
sterilization and
disinfection
ME C6.7 Departments have patient Availability of Delivery OB Steel Top
furniture and fixtures as per tables
load and service provision
Availability of OB Hospital graded
attachment/ Mattress, IV
accessories with stand, Kelly’s
delivery table pad, support for
delivery tables,
Macintosh, foot
step, Bed pan

Availability of fixture OB Wall clock with
Second arm
Lamps- wall
mounted /side,
electrical fixture
for equipments
like radiant
warmer, suction.
Availability of Furniture OB Cupboard, Table,
chair, Counter.
Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of
Equipment.
ME D1.1 The facility has established All equipments are SI/RR
system for maintenance of covered under AMC
critical Equipment including preventive
maintenance
There is system of SI/RR
timely corrective
break down
maintenance of the
equipments
ME D1.2 The facility has established All the measuring OB/ RR BP apparatus,
procedure for internal and equipments/ thermometers,
external calibration of instrument are weighing scale ,
measuring Equipment calibrated radiant warmer
Etc are calibrated
ME D1.3 Operating and maintenance Up to date instructions OB/SI
instructions are available with for operation and
the users of equipment maintenance of
equipments are readily
available with labour
room staff.
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 There is established SI/RR Stock level are
for forecasting and indenting system of timely daily updated
drugs and consumables indenting of Requisition are
consumables and drugs timely placed
ME D2.3 The facility ensures proper Drugs are stored in OB
storage of drugs and containers/tray/crash
consumables cart and are labelled
Empty and filled OB
management of expiry and maintained at
near expiry drugs emergency drug tray
maintained for drug
ME D2.5 The facility has established There is practice SI/RR
procedure for inventory of calculating and
management techniques maintaining buffer stock
Department RR/SI
maintained stock
and expenditure
consumables

periodically replenishing the replenishing drug tray
drugs in patient care areas /crash cart
There is no stock out of OB/SI
drugs
ME D2.7 There is process for storage Temperature of OB/RR Check for
of vaccines and other refrigerators are temperature
drugs, requiring controlled kept as per storage charts are
temperature requirement and maintained
records are maintained and updated
periodically
ME D2.8 There is a procedure for Narcotics and SI/RR
secure storage of narcotic and psychotropic drugs are
psychotropic drugs kept in lock and key
ME D3.1 The facility provides adequate Adequate Illumination OB
illumination level at patient at delivery table
care areas Adequate Illumination OB
at observation area
ME D3.2 The facility has provision of There is no OB
restriction of visitors in patient overcrowding in
areas labour room
One female family OB/SI
members allowed to
stay with the PW
Visitors are restricted OB/SI
at labour room
ME D3.3 The facility ensures safe and Temperature control PI/OB Optimal
comfortable environment for and ventilation in temperature
patients and service providers patient care area and warmth
is ensured
at labour
room. Fans/
Air conditioning/
Heating/
Exhaust/
Ventilators as
per environment
condition and
requirement
Temperature control SI/OB Fans/ Air
and ventilation in conditioning/
nursing station/duty Heating/
room Exhaust/
Ventilators as
per environment
condition and
requirement
ME D3.4 The facility has security system Lockable doors in OB
in place at patient care areas labour room
Security arrangement OB/SI Preferably
in labour room female security
staff
New born OB/RR
identification band
and foot prints are in
practice

ME D3.5 The facility has established Ask female staff SI
measure for safety and weather they feel
security of female staff secure at work place
ME D4.1 Exterior of the facility building Building is painted/ OB
is maintained appropriately whitewashed in
uniform colour
painted
ME D4.2 Patient care areas are clean Floors, walls, roof, roof OB All area are clean
and hygienic topes, sinks patient with no dirt,
care and circulation grease, littering
areas are Clean and cobwebs
Surface of furniture OB
and fixtures are clean
running water
ME D4.3 Hospital infrastructure is Check for there is OB
adequately maintained no seepage , Cracks,
chipping of plaster
Window panes , doors OB
and other fixtures are
intact
Delivery table are OB
intact and without
rust
Mattresses are intact OB
and clean
ME D4.5 The facility has policy of No condemned/Junk OB
removal of condemned junk material in the Labour
material room
ME D4.6 The facility has established No stray animal/ OB
procedures for pest, rodent rodent/birds
and animal control
ME D5.1 The facility has adequate Availability of 24x7 OB/SI
arrangement storage and running and potable
supply for portable water in all water
functional areas Availability of hot OB/SI
water
ME D5.2 The facility ensures adequate Availability of power OB/SI
power backup in all patient back up in Labour
care areas as per load room
Availability of UPS OB/SI
Availability of OB/SI
Emergency light
ME D5.3 Critical areas of the facility Availability of OB
ensures availability of oxygen, Centralized /local
medical gases and vacuum piped Oxygen and
supply vacuum supply

ME D7.1 The facility has adequate sets Availability of clean OB/RR
of linen Drape, Macintosh on
the Delivery table,
Gown are provided in OB/RR
labour room
Availability of Baby OB/RR
blanket, sterile drape
for baby
ME D7.3 The facility has standard There is system to SI/RR
procedures for handling , check the cleanliness
collection, transportation and and Quantity of the
washing of linen linen received from
laundry
Standard Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations
D11 and standards operating procedures.
ME D11.1 The facility has established Staff is aware of SI
job description as per govt their role and
guidelines responsibilities
ME D11.2 The facility has a established There is procedure RR/SI Check for system
procedure for duty roster to ensure that staff is for recording
and deputation to different available on duty as time of reporting
departments per duty roster and relieving
(Attendance
register/
Biometrics etc)
ME D11.3 The facility ensures Doctor, nursing OB
the adherence to dress staff and support
code as mandated by its staff adhere to their
administration / the health respective dress code
department
Standard The facility has established procedure for monitoring the quality of outsourced services and
D12 adheres to contractual obligations
ME D12.1 There is established system for There is procedure to SI/RR Verification of
contract management for out monitor the quality outsourced
sourced services and adequacy of services
outsourced services on (cleaning/
regular basis Dietary/Laundry/
Security/
Maintenance)
provided
are done by
designated in-
house staff
ME E1.1 The facility has established Unique identification RR
procedure for registration of number is given to
patients each patient during
process of registration
details are recorded in that patient
admission records demographics
like Name,
age, Sex, Chief
complaint, etc.

ME E1.3 There is established procedure There is procedure for SI/RR/OB
for admission of patients admitting Pregnant
women directly
coming to Labour
room
Admission is done SI/RR/OB
qualified doctor
There is no delay in OB/SI/RR
admission of pregnant
women in labour pain
recorded in patient
record
ME E1.4 There is established procedure Check how service OB/SI
for managing patients, in case provider cope with
beds are not available at the shortage of delivery
facility tables due to high
patient load
the patients.
ME E2.1 There is established procedure Rapid Initial RR/SI/OB Assessment and
for initial assessment of assessment of immediate sign
patients Pregnant Women to if following dan-
identify complication ger sign are pres-
and Prioritize care ent - difficulty in
breathing, fever,
sever abdominal
pain, Convulsion
or unconscious-
ness, Severe
headache or
blurred vision
Recording and RR/SI Recording of
reporting of Clinical women obstetric
History History including
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
Recording of current RR Time of start,
labour details frequency of
contractions,
time of bag of
water leaking,
colour and smell
of fluid and baby
movement
Physical Examination RR/SI Recording of
Vitals , shape &
Size of abdomen,
presence of
scars, foetal lie
and presentation.
& vaginal
examination

ME E2.2 There is established procedure There is fixed schedule RR/OB There is fix
for follow-up/ reassessment of for reassessment of schedule of
Patients Pregnant women as reassessment as
per standard protocol per protocols
Partograph is used and RR/OB All step are
updated as per stages recorded in
of labour timely manner
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 The facility has established There is procedure of SI/RR
procedure for continuity of handing over patient /
care during interdepartmental new born form labour
transfer room to OT/ Ward/
SNCU
There is a procedure SI/RR
for consultation of
the patient to other
specialist with in the
hospital
ME E3.2 The facility provides Patient referred with RR/SI A referral slip/
appropriate referral linkages referral slip Discharge card
to the patients/Services for is provide to
transfer to other/higher patient when
facilities to assure the referred to
continuity of care. another health
care facility
Advance RR/SI
communication is
done with higher
centre
Referral vehicle is RR/SI
being arranged
Referral in or referral SI/RR
out register is
maintained
Facility has functional RR Check for referral
referral linkages to cards filled from
lower facilities lower facilities
There is a system of SI/RR
follow up of referred
patients
ME E3.3 A person is identified for care Nurse is assigned for RR/SI Check for
during all steps of care each patients nursing hand
over
Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of There is a process OB/SI Identification
patients is established at the for ensuring the tags for mother
facility identification before and baby / foot
any clinical procedure print are used for
identification of
newborns
ME E4.2 Procedure for ensuring There is a process to SI/RR Verbal orders
timely and accurate nursing ensue the accuracy are rechecked
care as per treatment plan is of verbal/telephonic before
established at the facility orders administration

ME E4.3 There is established procedure Patient hand over RR/SI
of patient hand over, is given during the
whenever staff duty change change in the shift
happens
Nursing Handover RR
Hand over is given bed SI/RR
side
ME E4.5 There is procedure for periodic Patient Vitals are RR/SI Check for BP,
monitoring of patients monitored and pluse, temp,
recorded periodically Respiratory rate
FHR, Uterine
contraction
Contractions,
any other vital
required is
monitored
Critical patients RR/SI Check for BP,
are monitored pluse, temp,
continuously Respiratory rate
FHR, Uterine
contraction
Contractions,
any other vital
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 OB/SI Check the
vulnerable patients and are identified and measure taken
ensure their safe care measures are taken to to prevent new
protect them from any born theft,
harm sweeping and
baby fall
ME E5.2 The facility identifies high risk High Risk Pregnancy OB/SI Check for the
patients and ensure their care, cases are identified frequency of
as per their need and kept in intensive observation: Ist
monitoring stage :half an
hour and 2nd
stage: every 5
min
Standard E6 The facility follows standard treatment guidelines defined by state/Central government for
ME E6.1 The facility ensured that drugs Check for BHT if drugs RR
are prescribed in generic are prescribed under
name only generic name only
ME E6.2 There is procedure of rational Check for that relevant RR
use of drugs Standard treatment
guideline are available
at point of use
the drug regime and
doses as per STG
Check BHT that drugs RR Check for
are prescribed as per rational use of
STG uterotonic drugs
formulary

Standard E7 The facility has defined procedures for safe drug administration
ME E7.1 There is process for identifying High alert drugs SI/OB Magsulf (to be
and cautious administration of available in kept in fridge) ,
high alert drugs department are Methergine
identified
Maximum dose of high SI/RR Value for
alert drugs are defined maximum
and communicated doses as per
age, weight and
diagnosis are
available with
nursing station
and doctor
There is process to SI/RR A system of
ensure that right doses independent
of high alert drugs are double
only given check before
administration,
Error prone
medical
abbreviations
are avoided
ME E7.2 Medication orders are written Every Medical advice RR
legibly and adequately and procedure is
accompanied with
date , time and
signature
Check for the writing, RR/SI
It comprehendible by
the clinical staff
ME E7.3 There is a procedure to check Drugs are checked OB/SI
drug before administration/ for expiry and other
dispensing inconsistency before
administration
Check single dose vial OB Check for any
are not used for more open single
than one dose dose vial with
left over content
intended to be
used later on
Check for separate OB
sterile needle is used In multi dose vial
every time for multiple needle is not left
dose vial in the septum
reaction is recorded
and reported
ME E7.4 There is a system to ensure Administration of SI/OB
right medicine is given to right medicines done after
patient ensuring right patient,
right drugs , right
route, right time
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical
ME E8.1 All the assessments, re- Progress of labour is RR Partograph Full
assessment and investigations recorded compliance and
are recorded and updated on bed head
ticket partial
compliance

ME E8.2 All treatment plan Treatment prescribed RR Medication
prescription/orders are in nursing records order, treatment
recorded in the patient plan, lab
records. investigation
are recoded
adequately
ME E8.4 Procedures performed are Delivery note is RR Outcome of
written on patients records adequate delivery, date
and time,
gestation
age, delivery
conducted by,
type of delivery,
complication if
any ,indication
of intervention,
date and time of
transfer, cause of
death etc
Baby note is adequate RR Did baby cry,
Essential new
born care,
resuscitation if
any, Sex, weight,
time of initiation
of breast feed,
birth doses,
congenital
anomaly if any.
ME E8.5 Adequate form and formats Standard Formats RR/OB Availability of
are available at point of use available BHT, Partograph,
etc.
ME E8.6 Register/records are Registers and records RR labour room
maintained as per guidelines are maintained as per register, OT
guidelines register, MTP
register,
FP register,
Maternal death
register and
records, lab
register, referral
in /out register,
internal& PPIUD
register etc.
All register/records RR
are identified and
numbered
Standard The facility has defined and established procedures for Emergency Services and Disaster
E11 Management.
ME E11.3 The facility has disaster Staff is aware of SI/RR
management plan in place disaster plan
Role and SI/RR
responsibilities of staff
in disaster is defined
procedures for Pre-testing properly after the
Activities sample collection

ME E12.3 There are established Nursing station is SI/RR
procedures for Post-testing provided with the
Activities critical value of
different test
Standard The facility has defined and established procedures for Blood Bank/Storage Management and
E13 Transfusion.
ME E13.9 There is established procedure Consent is taken RR
for transfusion of blood before transfusion
Patient’s identification SI/OB
is verified before
transfusion
blood is kept on RR
optimum temperature
before transfusion
Blood transfusion SI/RR
is monitored and
regulated by qualified
person
Blood transfusion note RR
is written in patient
record
procedure for monitoring transfusion reaction is
and reporting Transfusion recorded and reported
complication to responsible person
Standard The facility has defined and established procedures for end of life care and death
E16
ME E16.1 Death of admitted patient Facility has a standard SI
is adequately recorded and procedure to decent
communicated communicate death to
relatives
Death note is written RR
on patient record
ME E16.2 The facility has standard Death note including RR Maternal and
procedures for handling the efforts done for neonatal death
death in the hospital resuscitation is noted are recorded
in patient record as per MDR
guideline
There is established SI/RR Every still
criteria for distinguish record/ birth is
between newborn examined by
death and still birth paediatrician
before
declaration
Death summary SI/RR
is given to patient
attendant quoting the
immediate cause and
underlying cause if
possible
Standard The facility has established procedures for Antenatal care as per guidelines
E17
ME E17.1 There is an established Facility provides and RR/SI
procedure for Registration and updates “Mother and
follow up of pregnant women. Child Protection Card”.
ME E17.3 The facility ensures availability Tests for Urine RR/SI
of diagnostic and drugs albumin,
during antenatal care of haemoglobin, blood
pregnant women grouping

Standard E18 The facility has established procedures for Intranatal care as per guidelines
ME E18.1 Established procedures Management of 1st SI/OB Check progress
and standard protocols for stage of labour: is recorded,
management of different Women is
stages of labour including allowed to give
AMTSL (Active Management birth in the
of third Stage of labour) are position she
followed at the facility wants , Check
progress is
recorded on
partograph
Management of 2nd SI/OB Allows the
stage of labour: spontaneous
delivery of
head , gives
Perineal support
and assist in
delivering baby.
Check progress
is recorded on
partograph
Active Management of SI/OB Palpation
Third stage of labour of mother’s
abdomen to rule
out presence of
second baby
Use of Uterotonic SI/RR Administration
Drugs of 10 IU of
oxytocin IM with
in 1 minute of
Birth
Control Cord Traction SI/RR Only during
Contraction
Uterine Massage SI/RR After placenta
expulsion,
Checks Placenta
& Membranes for
Completeness
ME E18.2 There is an established Staff is aware of SI Ask staff how
procedure for assisted and Indications for they identify
C-section deliveries per scope refereeing patient slow progress
of services. for to Surgical of labour , Hoe
Intervention they interpret
Partogram
ME E18.3 There is established procedure Management and SI/RR Monitors of
for management/Referral of follow up of PIH/ BP, tests for
Obstetrics Emergencies as per Eclampsia \Pre proteinuria
scope of services. Eclampsia in cases of
eclampsia—
administers
loading dose
of Magnesium
Sulphate
(MgSO4) and
refers/ calls
for specialist
attention;

continues
maintenance
dose of MgSO4-
5 g of MgSO4
IM in alternate
buttocks every
four hours,
for 24 hours
after birth/last
convulsion,
whichever is
later
Management SI/RR Assessment of
of Postpartum bleeding (PPH
Haemorrhage if >500 ml or >
1 pad soaked
in 5 Minutes. IV
Fluid, bladder
catheterization,
measurement
of urine output,
Administration of
20 IU of Oxytoc in
in 500 ml Normal
Saline or RL at
40-60 drops per
minute. Performs
Bimanual
Compression of
Uterus
Management of SI/RR Administration
Retained Placenta of another dose
of Oxytocin 20IU
in 500 ml of RL at
40-60 drops/min
an attempt to
deliver placenta
with repeat
controlled cord
traction. If this
fails performs
manual removal
of Placenta
Management of SI/RR Vigorous Uterine
Uterine Atony massage, gives
Oxytocin 20
IU in 500 ml of
R/L 40 to 60
drops/minute
(Continue to
administer
Oxytocin upto
maximum of 3
litres of solution
with Oxytocin)
If still bleeding
perform bi
manual uterine
compression
with palpation of
femoral pulse

Management of SI/RR Diagnoses
Obstructed Labour obstructed labour
based on data
registered from
the partograph,
Re-hydrates
the patient to
maintain normal
plasma volume,
check vitals, gives
broad 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
Management of SI/RR Conduct
Puerperal sepsis appropriate lab.
investigations,
Prescribes
IV fluids and
broad spectrum
antibiotics for
seven days &
advises perineal
care
Delivery of infectious SI/RR
cases HIV positive PW
ME E18.4 There is an established Recording date and SI/RR Check the
procedure for new born Time of Birth, Weight records
resuscitation and newborn Dried and put on SI/OB With a clean
care. mothers abdomen towel from head
to feet, discards
the used towel
and covers baby
including head in
a clean dry towel
Vitamin K for low birth SI/RR Given to all new
weight born (1.0 mg IM
in > 1500 gms
and 0.5 mg in <
1500 gms
Warmth SI/RR Check use of
radiant warmer
Care of Cord and Eyes SI/RR Delayed Cord
Clamping,
Clamps & Cut the
cords by sterile
instruments
within 1-3
minutes of Birth
Clean baby’s
eyes with sterile
cotton/Gauge

APGAR Score SI/RR Check practice
of maintaining
APGAR Score,
Nurse is skilled
for it
Kangaroo Mother Care SI/RR Observe /Ask
staff about the
practice
New born SI/RR Ask Nursing staff
Resuscitation to demonstrate
Resuscitation
Technique
Standard E19 The facility has established procedures for postnatal care as per guidelines
ME E19.1 Post partum Care is provided Prevention of SI/RR
to the mothers Hypothermia of new
born
Initiation of PI
Breastfeeding with in
1 Hour
Mother is monitored RR/SI Check for
as per post natal care records of
guideline Uterine
contraction,
bleeding,
temperature,
B.P, pulse, Breast
examination,
(Nipple care,
milk initiation)
Check for perineal PI
washes performed
ME E19.3 There is an established Labour room PI/SI Breast feeding
procedure for Post partum has procedure to and prevention
counselling of mother provide post partum of hypothermia
Counselling
ME E19.4 The facility has established There is established SI/RR
procedures for stabilization/ criteria for shifting
treatment/referral of post newborn to SNCU
natal complications
Standard F1 The facility has infection control Programme and procedures in place for prevention and
measurement of hospital associated infection.
ME F1.2 The facility has provision for Surface and SI/RR Swab are taken
Passive and active culture environment from infection
surveillance of critical & high samples are taken prone surfaces
risk areas for microbiological
surveillance
ME F1.4 There is Provision of Periodic There is procedure for SI/RR Hepatitis B,
Medical Check-up and immunization of the Tetanus Toxic etc
immunization of staff staff
Periodic medical SI/RR
checkups of the staff
ME F1.5 The facility has established Regular monitoring SI/RR Hand washing
procedures for regular of infection control and infection
monitoring of infection practices control audits
control practices done 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 Availability of hand OB Check for
provided at point of use washing Facility at availability of
Point of Use wash basin near
the point of use
Availability of running OB/SI Ask to Open the
Water tap. Ask Staff
water supply is
regular
Availability of OB/SI Check for
antiseptic soap with availability/ Ask
soap dish/ liquid staff if the supply
antiseptic with is adequate and
dispenser. uninterrupted
Availability of Alcohol OB/SI Check for
based Hand rub availability/ Ask
staff for regular
supply.
Display of Hand OB Prominently
washing Instruction at displayed
Point of Use above the hand
washing facility
, preferably in
Local language
Availability of elbow OB
operated taps
Hand washing sink is OB
wide and deep enough
to prevent splashing
and retention of water
ME F2.2 The facility staff is trained in Adherence to 6 steps SI/OB Ask of
hand washing practices and of Hand washing demonstration
they adhere to standard hand Staff aware of when to SI
washing practices hand wash
ME F2.3 The facility ensures standard Availability of OB
practices and materials for Antiseptic Solutions
antisepsis Proper cleaning of OB/SI like before
procedure site with giving IM/
antiseptics IV injection,
drawing
blood, putting
Intravenous and
urinary catheter
Proper cleaning of SI
perineal area before
procedure with
antisepsis
Check Shaving is not SI
done during part
preparation/delivery
cases

Standard F3 The facility ensures standard practices and materials for Personal protection
ME F3.1 The facility ensures Availability of Masks OB/SI
adequate personal Sterile s gloves are OB/SI
protection Equipment as per available at Labour
requirements room
Use of elbow length OB/SI
gloves for obstetrical
purpose
Availability of gown/ OB/SI
Apron
Availability of shoe OB/SI
cover/gum boots
Availability of Caps OB/SI
Heavy duty gloves OB/SI
and gum boats for
housekeeping staff
Personal protective OB/SI
kit for delivering HIV
patients
ME F3.2 The facility staff adheres to No reuse of disposable OB/SI
standard personal protection gloves, Masks, caps
practices and aprons.
method of wearing
and removing the
gloves
Standard F4 The facility has standard procedures for processing of equipment and instruments
ME F4.1 The facility ensures standard Decontamination of SI/OB Ask stff about
practices and materials operating & Procedure how they
for decontamination and surfaces decontaminate
cleaning of instruments and the procedure
procedures areas surface like
Delivery Table,
Stretcher/
Trolleys etc.
(Wiping with .5%
Chlorine solution
Proper SI/OB Ask staff
Decontamination of how they
instruments after use decontaminate
the instruments
like ambubag,
suction cannula,
Delivery
Instruments
(Soaking in
0.5% Chlorine
Solution,
Wiping with
0.5% Chlorine
Solution or
70% Alcohol as
applicable

Proper handling of SI/OB No sorting,
Soiled and infected Rinsing or
line sluicing at Point
of use/ Patient
care area
decontamination is
adequate
Cleaning of SI/OB Cleaning is done
instruments after with detergent
decontamination and running wa-
ter after decon-
tamination
Proper handling of SI/OB No sorting,
Soiled and infected Rinsing or
linen sluicing at Point
of use/ Patient
care area
Staff know how to SI/OB
make chlorine solution
ME F4.2 The facility ensures standard Equipment and OB/SI Autoclaving/
practices and materials for instruments are HLD/Chemical
disinfection and sterilization of sterilized after each Sterilization
instruments and equipment use as per requirement
High level Disinfection OB/SI Ask staff about
of instruments/ method and
equipments is done time required for
as per protocol boiling
Autoclaving of delivery OB/SI Ask staff about
kits is done as per temperature,
protocols pressure and time
Chemical sterilization OB/SI Ask staff about
of instruments/ method,
equipments is done as concentration
per protocols and contact
time required
for chemical
sterilization
Autoclaved linen are OB/SI
used for procedure
material is used
There is a procedure to OB/SI
ensure the traceability
of sterilized packs
Sterility of autoclaved OB/SI Sterile packs
packs is maintained are kept in
during storage clean, dust
free, moist free
environment.
ME F5.1 Layout of the department is Facility layout ensures OB
conducive for the infection separation of routes
control practices for clean and dirty
items

ME F5.2 The facility ensures availability Availability of OB/SI Chlorine
of standard materials for disinfectant as per solution,
cleaning and disinfection of requirement Gluteraldehye,
patient care areas carbolic acid
Availability of OB/SI Hospital
cleaning agent as per grade phenyl,
requirement disinfectant
detergent
solution
ME F5.3 The facility ensures standard Staff is trained for spill SI/RR
practices are followed for the management
cleaning and disinfection of Cleaning of patient SI/RR
patient care areas care area with
detergent solution
preparing cleaning
solution as per
standard procedure
Standard practice OB/SI Unidirectional
of mopping and mopping from
scrubbing are followed inside out
Cleaning equipments OB/SI Any cleaning
like broom are not equipment
used in patient care leading to
areas dispersion of
dust particles
in air should be
avoided
Use of three bucket OB/SI
system for mopping
Fumigation/ SI/RR
carbolization as per
schedule
External footwares are OB
restricted
ME F5.4 The facility ensures Isolation and barrier OB/SI
segregation infectious nursing procedure
patients are followed for septic
cases
Standard F6 The facility has defined and established procedures for segregation, collection, treatment and
ME F6.1 The facility Ensures Availability of colour OB
segregation of Bio Medical coded bins at point of
Waste as per guidelines and waste generation
‘on-site’ management of waste Availability of plastic OB
is carried out as per guidelines colour coded plastic
bags
Segregation of OB/SI
different category of
waste as per guidelines
Display of work OB
instructions for
segregation and
waste
waste

ME F6.2 The facility ensures Availability of OB See if it has been
management of sharps as per functional needle used or just lying
guidelines cutters idle
Availability of OB Should be
puncture proof box available nears
the point of
generation like
nursing station
and injection
room
Disinfection of sharp OB/SI Disinfection of
before disposal syringes is not
done in open
buckets
Staff is aware of SI
contact time for
disinfection of sharps
Availability of post OB/SI Ask if available.
exposure prophylaxis Where it is stored
and who is in
charge of that.
Staff knows what to do SI Staff knows
in condition of needle what to do in
stick injury case of shape
injury. Whom to
report. See if any
reporting has
been done
ME F6.3 The facility ensures Check bins are not SI
transportation and disposal of overfilled
waste as per guidelines Disinfection of liquid SI/OB
waste before disposal
medical waste is done
in close container/
trolley
spill management
ME G1.1 The facility has a quality team There is a designated SI/RR
in place departmental
nodal person for
coordinating Quality
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 There is system SI/RR
internal quality assurance daily round by
programme in key matron/hospital
departments manager/ hospital
superintendent/
Hospital Manager/

ME G3.3 The facility has established Departmental SI/RR
system for use of check lists checklist are used for
in different departments and monitoring and quality
services assurance
Staff is designated for SI
filling and monitoring
of these checklists
Standard G4 The facility has established, documented implemented and maintained Standard Operating
operating procedures are procedure for
available department has
been prepared and
approved
Current version of OB/RR
process owner
ME G4.2 Standard Operating Department has RR
Procedures adequately documented
describes process and procedure for
procedures receiving and
assessment of the
patient of delivery
Labour room RR
has documented
procedure for
Emergency obstetric
care
Department has RR
documented
procedure for
management of high
risk pregnancy
Department has RR
documented
procedure for rapid
initial assessment
Department has RR
documented
procedure for
requisition of diagnosis
and receiving of the
reports
Department has RR Intrapartum
documented care includes
procedure for intra Management
partum care of 1st stage
of labour, 2nd
stage of labour
and 3rd stage of
labour
Department has RR
documented
immediate post
partum care

Department has RR
documented essential
new born care
Department has RR
documented
procedure for neonatal
resuscitation
Department has RR
documented
procedure for
admission, shifting and
referral of the patient
Department has RR Labour room
documented management
procedure for include
arrangement of maintenance
intervention for labour and calibration
room of equipments
and inventory
management etc
Labour room RR
has documented
procedure for blood
transfusion
Labour room has RR
documented criteria
for distinguish
between newborn
death and still birth
Labour room RR
has documented
procedure for
environmental
cleaning and
processing of the
equipment
Labour room RR
has documented
procedure for
maintenance of
rights and dignity of
pregnant women
Department has RR
documented
procedure for record
Maintenance including
taking consent
ME G4.3 Staff is trained and aware of Check Staff is a aware SI/RR
the procedures written in of relevant part of
SOPs SOPs
ME G4.4 Work instructions are Work instruction/ OB AMSTL,
displayed at Point of use clinical protocols are PPH,Infection
displayed control,Eclamsia,
New born
resuscitation,
kangaroo care

Standard The facility maps its key processes and seeks to make them more efficient by reducing non value
G5 adding activities and wastages
ME G5.1 The facility maps its critical Process mapping of SI/RR
ME G5.2 The facility identifies non Non value adding SI/RR
value adding activities / waste activities are identified
/ redundant activities
ME G5.3 The facility takes corrective Processes are SI/RR
action to improve the rearranged as per
processes requirement
ME G6.1 The facility conducts periodic Internal assessment RR/SI
internal assessment is done at periodic
interval
ME G6.3 The facility ensures non Non Compliance are RR/SI
compliances are enumerated enumerated and
and recorded adequately recorded
ME G6.4 Action plan is made on the Action plan prepared RR/SI
gaps found in the assessment
/ audit process
ME G6.5 Corrective and preventive Corrective and RR/SI
actions are taken to address preventive action
issues, observed in the taken
assessment & audit
ME G7.2 The facility periodically defines Quality objective RR/SI
its quality objectives and key for labour room are
departments have their own defined
objectives
ME G7.3 Quality policy and objectives Check of staff is aware SI
are disseminated and staff is of quality policy and
aware of that objectives
ME G7.4 Progress towards quality Quality objectives SI/RR
objectives is monitored are monitored and
periodically reviewed periodically
Standard G8 The facility seeks continually improvement by practicing Quality method and tools.
ME G8.1 The facility uses method PDCA SI/RR
for quality improvement in 5S SI/OB
services
Six Sigma SI/RR
ME G8.2 The facility uses tools for 6 basic tools of Quality SI/RR
quality improvement in Pareto/Prioritization SI/RR
services
benchmarks
ME H1.1 Facility measures productivity Normal Deliveries per RR
Indicators on monthly basis 1000 population
Proportion of RR
deliveries conducted
at night
Proportion of RR
complicated
cases managed

Proportion assisted RR
delivery conducted
% PPIUCD inserted RR
against
total IUCD
ME H1.2 The Facility measures equity Proportion of BPL RR
indicators periodically Deliveries
ME H2.1 Facility measures efficiency Proportion of cases RR
Indicators on monthly basis referred to OT
Proportion of cases RR
referred to Higher
Facilities
% of newborns RR
required
resuscitation out of
total live
births
% of newborns RR
required resuscitation
out of total live births
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 RR
& Safety Indicators on monthly cases partograph
basis maintained
Episiotomy site RR
infection rate
No of adverse events RR
per thousand patients
Culture Surveillance RR % of
sterility rate environmental
swab culture
reported
positive
Proportion of cases of RR PPH, Eclampsia,
different complications obstructed
labour etc.
Rational oxytocin RR No. of Oxytocin
usage Index doses used /
No. of normal
deliveries
conducted
benchmark
ME H4.1 Facility measures Service Patient satisfaction RR
Quality Indicators on monthly
basis

Assessment Summary
A. Score Card
Labour room Score Card
Labour Room Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Checklist–4
Maternity Ward
Version: 1/2013

Checklist–4
Checklist for Maternity Ward

ME A1.3 The facility provides Availability of Gynaecology SI/OB For obstetric
Obstetrics & Gynaecology indoor services indoor services
Services kindly refer to
ME A2.2
ME A1.14 Services are available for the Availability of nursing SI/RR
time period as mandated services 24X7
ME A1.18 The facility provides Blood Availability/ linkage with SI/OB
bank & transfusion services blood bank
ME A2.2 The facility provides Maternal Availability of indoor SI/OB Antenatal ward-
health Services services for Antenatal cases Clean Ward
Availability of indoor SI/OB Postnatal
services for normal delivery ward -Normal
delivery
Availability of indoor SI/OB Postnatal ward
services for C section -C-section
delivery
Availability of indoor SI/OB Septic ward
services for Septic cases
Availability of indoor SI/OB Eclampsia room
services for Eclampsia cases
ME A2.3 The facility provides Newborn Prevention of hypothermia SI/OB
health Services and initiation of breast
feeding
ME A2.4 The facility provides Child Screening of New born for SI/OB
health Services Birth Defects
ME A3.1 The facility provides Availability / linkage with SI/OB
Radiology Services Radiology
ME A3.2 The facility Provides Availability / linkage with SI/OB
Laboratory Services laboratory
Standard A4 The facility Provides services as mandated in national Health Programmes/State Scheme
ME A4.1 The facility provides services Treatment of Malaria in SI/OB check the
under National Vector Borne pregnancy records for
Disease Control Programme management of
as per guidelines cases in last one
year
ME A4.10 The facility provide services Referral of child born SI/OB
under National health of High Risk pregnancy
Programme for prevention & showing features suggestive
control of deafness of hearing empairment
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 Availability departmental OB (Numbering,
user-friendly signage system signage’s main
department
and internal
sectional
signage
Visiting hours and visitor OB
policy are displayed
ME B1.2 The facility displays the Entitlements under JSSK OB
services and entitlements Displayed
available in its departments Entitlement under JSY OB
displayed
List of drugs available are OB
Contact details of referral OB
transport / ambulance are
displayed
ME B1.5 Patients & visitors are IEC Material is displayed OB Breast feeding
sensitised and educated and care
through appropriate IEC / BCC of breast,
approaches kangaroo care,
family planning,
Danger signs,
PN advice,
Information
material about
PCPNDT etc
Counselling aids like flip OB
chart etc are available for
post partum counselling
local language and easy to are available in local
understand language
ME B1.7 The facility provides Availability of Enquiry Desk OB Enquiry desk
information to patients and with dedicated staff serving both
visitors through an exclusive maternity ward
set-up. and labour
ME B1.8 The facility ensures access to Discharge summery is given RR/OB
clinical records of patients to to the patient
entitled personnel
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 Services are provided in No Male attendant is OB/SI
manner that are sensitive to allowed to stay in female
gender wards at night
Availability of female staff OB/SI
if a male doctor examine a
female patients
Availability of Breast feeding OB
corner
134 | Checklist for Maternity Ward

ME B2.3 Access to facility is provided Availability of Wheel chair or OB
without any physical barrier stretcher for easy Access to
& and friendly to people with the ward
disabilities Availability of ramps and OB
railing
friendly toilet
ME B3.1 Adequate visual privacy is Availability of screen in OB Bracket screen
provided at every point of Examination Area
care Curtains have been OB
provided at windows
Patients are dressed/ OB
covered while been shifted
from one department to
other
No two patients are treated OB
on one bed
ME B3.2 Confidentiality of patients Patient Records are kept SI/OB
records and clinical at secured place beyond
information is maintained access to general staff/
visitors
No information regarding SI/OB
patient identity and details
are unnecessary displayed
ME B3.3 The facility ensures the Behaviour of staff is OB/PI
behaviour of staff is dignified empathetic and courteous
and respectful, while
ME B3.4 The facility ensures that HIV status of patient is not SI/OB
privacy and confidentiality disclosed except to staff
to every patient, especially of that directly involved in care
those conditions having social
stigma, and also safeguards
vulnerable groups
ME B4.1 There is established General Consent is taken SI/RR
procedure for taking informed before admission
consent before treatment and
procedures
ME B4.4 Information about the Patient and/ or attendant PI
treatment is shared with are informed about her
patients or attendants, clinical condition and
regularly treatment being provided
ME B4.5 The facility has defined Availability of complaint OB
and established grievance box and display of process
redressal system in place for grievance redresaal
and whom to contact is
displayed
Checklist for Maternity Ward | 135

ME B5.1 The facility provides cashless Stay in ward is free of cost PI/SI
services to pregnant women, Availability of Free Diet PI/SI
mothers and neonates as
per prevalent government Availability of Free drop PI/SI
schemes back
Availability of Free referral PI/SI
vehicle/Ambulance services
Availability of Free Blood PI/SI
Availability of Free drugs PI/SI
Availability of free PI/SI
diagnostics
ME B5.2 The facility ensures that drugs Check that patient does PI/SI
prescribed are available at not spentd on purchasing
Pharmacy and wards drugs or consumables from
outside.
ME B5.3 It is ensured that facilities for Check that patient does not PI/SI
the prescribed investigations spentd on diagnostics from
are available at the facility outside.
timely reimbursement incurred it is reimbursed
and reimbursement to the JSY Payment is done before PI/SI/RR
patients discharge
ME B5.6 The facility ensure
implementation of health
insurance schemes as per
National /state scheme
the prevalent norms
ME C1.1 Departments have adequate Adequate space in wards OB Distance
space as per patient or work with no cluttering of beds between
load centres of two
beds – 2.25
meter
ME C1.2 Patient amenities are provide Functional toilets with OB One toilet for 12
as per patient load running water and flush are patients
available as per strength
and patient load in ward
Functional bathroom with OB One toilet for 12
running water are available patients
as per patient load in ward
Availability of drinking water OB
Patient/ visitor Hand OB
washing area
Separate toilets for visitors OB
TV for entertainment and OB
health promotion
Adequate shaded waiting OB
area is provided for
attendants of patient

ME C1.3 Departments have layout Availability of Dedicated OB
and demarcated areas as per nursing station
functions Availability of Examination OB
room
Availability of Treatment OB
room
Availability of Doctor’s Duty OB
room
Availability of Nurse Duty room OB
Availability of Store OB Drug &Linen
store
Availability of Dirty room OB
ME C1.4 The facility has adequate There is sufficient space OB Space between
circulation area and open between two beds to two beds
spaces according to need and provide bed side nursing should be at
local law care and movement least 4 ft and
clearance
between head
end of bed and
wall should be
at least 1 ft and
between side
of bed and
wall should
be 2 ft
Corridors are wide enough OB Corridor should
for patients, visitors be 3 meters
and trolleys/ equipment wide
movement
ME C1.5 The facility has infrastructure Availability of functional OB
for intramural and extramural telephone and Intercom
communication Services
ME C1.6 Service counters are available There is separate nursing OB
as per patient load station in each ward
Availability of adequate OB 10 beds for 100
beds as per delivery load deliveries per
month
ME C1.7 The facility and departments Prepartaum and post OB
are planned to ensure partum wards are in
structure follows the proximity and have
function/processes (Structure functional linkage with
commensurate with the labour room
function of the hospital) Postpartum ward and SNCU OB
are in proximity and have
functional linkage
C section ward is in OB/SI
Proximity and has functional
linkage with the OT
Location of nursing station OB
and patients beds enables
easy and direct observation
of patients

ME C2.1 The facility ensures the Non structural components OB Check for
seismic safety of the are properly secured fixtures and
infrastructure furniture like
cupboards,
cabinets,
and heavy
equipment,
hanging objects
are properly
fastened and
secured
ME C2.3 The facility ensures safety of IPD building does not have OB Switch Boards
electrical establishment temporary connections and other electrical
loosely hanging wires installations are
intact, there is
proper earthing
ME C2.4 Physical condition of Floors of the maternity ward OB
buildings are safe for are non slippery and even
providing patient care Windows have grills and OB
wire meshwork
ME C3.1 The facility has plan for Maternity ward has OB/SI
prevention of fire sufficient fire exits to permit
safe escape to its occupant
in emergency
Fire exits are clearly visible OB
and routes to reach exit are
clearly marked.
ME C3.2 The facility has adequate fire Maternity ward has installed OB
fighting equipment fire Extinguisher that are
Class A , either B, C type or
ABC type
Expiry date for fire OB/RR
extinguishers displayed on
each extinguisher as well as
due date for next refilling is
clearly mentioned
periodic training of staff and competencies for operating
conducts mock drills regularly fire extinguisher and what
for fire and other disaster to do in case of fire
situation
to current case load
ME C4.1 The facility has adequate Availability of Ob&G OB/RR
specialist doctors as per specialist on duty and on
service provision call paediatrician
ME C4.2 The facility has adequate Availability of General duty OB/RR
general duty doctors as per doctor at all time
service provision and work
load
ME C4.3 The facility has adequate Availability of Nursing staff OB/RR/SI 6 for 100-200
nursing staff as per service Deliveries/
provision and work load Month
8 for More than
200 deliveries
per month

ME C4.4 The facility has adequate Availability of RMNCH OB/SI Counsellor
technicians/paramedics as counsellor available for
per requirement postpartum
counselling of
mothers
Availability of dresser for C SI/RR
section ward
ME C4.5 The facility has adequate Availability of ward SI/RR Availability of
support / general staff attendant mamta/ ayahs
and Sanitary
worker
Availability of Security staff SI/RR
ME C4.6 The staff has been provided Infant and young Child SI/RR
required training / skill sets Feeding ( IYCF) practices
Biomedical waste SI/RR
management
Infection control and hand SI/RR
hygiene
ME C4.7 The Staff is skilled as per job Nursing staff is skilled in SI/RR
description identification and managing
complications
maintaining clinical records
ME C5.1 The departments have Availability of Uterotonic OB/RR Tocolytics,
availability of adequate drugs Drugs Isoxsuprine
at point of use Availability of Antibiotics OB/RR Tab
Metronidazole
400mg, Inj.
Gentamicin,
Availability of OB/RR Labetalol
Antihypertensive
Availability of analgesics OB/RR Tab
and antipyretics Paracetamol,
Tab Ibuprofen,
Availability of IV Fluids OB/RR IV fluids,
Normal saline,
Ringer is
lactate,
Availability of other OB/RR Tab Retrodrine,
emergency drugs Misoprostol,
Prostodin, ste-
roid as Hydro-
cortison Dex-
amethasone,
iron, Calcium,
and Folic acids
tablets

Availability of drugs for OB/RR Inj Vit K 10mg,
newborn Vaccine OPV,
Hep B, BCG,
Paracetamol
syrup/drops,
Syp Calcium
with Vit D,
Multivitamin
drops,
Nevirapine
drops (for HIV
+ ve mother
born children),
Gentian Violet
(0.50%)
ME C5.2 The departments have Availability of dressings and OB/RR Gauze piece
adequate consumables at Sanitary pads and Cotton
point of use swabs, Sanitary
pads, needle
(round body
and cutting),
chromic catgut
no. 0,
Availability of syringes and OB/RR Paediatric iv
IV Sets /tubes sets, Urinary
catheter with
bag, Foyley
is catheter
Nasogastric
tube, Syringe
A/D
Availability of Antiseptic OB/RR Betadine
Solutions
Availability of consumables OB/RR Gastric tube
for new born care and cord clamp,
dressing pad
ME C5.3 Emergency drug trays are Availability of emergency OB/RR
maintained at every point of drug tray in Maternity ward
care, where ever it may be
needed
ME C6.1 Availability of equipment & Availability of functional OB BP apparatus,
instruments for examination Equipment &Instruments Thermometer,
& monitoring of patients for examination & Foetoscope,
monitoring baby and adult
weighing scale,
Stethoscope,
Doppler
ME C6.2 Availability of equipment & Availability of functional OB Dressing and
instruments for treatment Equipment/Instruments suture removal
procedures, being undertaken Gynae & Obstetric kit, speculum,
in the facility Procedures Anterior vaginal
wall retractor.
ME C6.3 Availability of equipment & Availability of Point of care OB Glucometer
instruments for diagnostic diagnostic instruments and HIV rapid
procedures being undertaken diagnostic kit
in the facility

ME C6.4 Availability of equipment and Availability of resuscitation OB Adult and baby
instruments for resuscitation equipment bag and mask,
of patients and for providing Oxygen, Suction
intensive and critical care to machine,
patients Airway,
Laryngoscope,
ET tube
ME C6.5 Availability of Equipment for Availability of equipment OB Refrigerator,
Storage for storage for drugs Crash cart/
Drug trolley,
instrument
trolley, dressing
trolley
ME C6.6 Availability of functional Availability of equipment for OB Buckets for
equipment and instruments sterilization and disinfection mopping, mops,
for support services duster, waste
trolley, Deck
brush
Availability of equipment OB Boiler
for cleaning
ME C6.7 Departments have patient Availability of patient beds OB
furniture and fixtures as per with prop up facility
load and service provision Availability of attachment/ OB Hospital graded
accessories with patient mattress, Bed
bed side locker ,
IVstand, Bed
pan
Availability of Fixtures OB Spot light,
electrical fixture
for equipment
like suction,
machine X ray
view box
Availability of furniture OB cupboard,
nursing
counter, table
for preparation
of medicines,
chair.
Standard D1 The facility has established Programme for inspection, testing, maintenance and calibration of
Equipment.
ME D1.1 The facility has established All equipment are covered SI/RR
system for maintenance of under AMC including
critical Equipment preventive maintenance
There is a system of SI/RR
timely corrective break
down maintenance of the
equipment
procedure for internal and equipments/ instrument Oxygen flow
external calibration of are calibrated meter etc are
measuring Equipment calibrated

ME D2.1 There is established There is established system SI/RR Stock level are
procedure for forecasting of timely indenting of daily updated
and indenting of drugs and consumables and drugs at Requisition are
consumables nursing station timely placed
storage of drugs and containers/tray/crash cart
consumables and are labelled
Empty and filled cylinders OB
are labelled
ME D2.4 The facility ensures Expiry dates’ are maintained OB/RR
management of expiry and at emergency drug tray
near expiry drugs No expiry drug found OB/RR
maintained for drug stored
at department
ME D2.5 The facility has established There is practice of SI/RR
procedure for inventory calculating and maintaining
management techniques buffer stock
consumables
ME D2.6 There is a procedure for There is a procedure for SI/RR
periodically replenishing the replenishing drug tray /
drugs in patient care areas crash cart
There is no stock out of drugs OB/SI
ME D2.7 There is process for storage Temperature of refrigerators OB/RR Check for
of vaccines and other are kept as per storage temperature
drugs, requiring controlled requirement and records charts are
temperature are maintained maintained
and updated
periodically
ME D2.8 There is a procedure for Narcotics and psychotropic OB/SI Separate
secure storage of narcotic and drugs are kept in lock and prescription for
psychotropic drugs key narcotic and
psychotropic
drugs
ME D3.1 The facility provides adequate Adequate Illumination at OB
illumination level in patient nursing station
care areas Adequate illumination in OB
patient care areas
ME D3.2 The facility has provision Visiting hour are fixed and OB/PI
of restriction of visitors in practiced
patient area There is no overcrowding OB
in the wards during visitors
hours

ME D3.3 The facility ensures safe and Temperature control and PI/OB Optimal
comfortable environment for ventilation in patient care temperature
patients and service providers area and warmth
is ensured
Fans/ Air
conditioning/
Heating/
Exhaust/
Ventilators
as per
environment
condition and
requirement
ventilation in nursing conditioning/
station/duty room Heating/
Exhaust/
Ventilators
as per
environment
condition and
requirement
ME D3.4 The facility has security Recording of New-born OB/RR
system in place at patient care identification band and foot
areas prints are in practice
Security arrangement in OB/SI
maternity ward
ME D3.5 The facility has established Ask female staff weather SI
the measures for safety and they feel secure at work
security of female staff place
ME D4.2 Patient care areas are clean Floors, walls, roof, roof OB All area are
and hygienic tops, sinks patient care and clean with no
circulation areas are Clean dirt, grease,
littering and
cobwebs
fixtures are clean
functional flush and running
water
ME D4.3 Hospital infrastructure is Check if there is seepage, OB
adequately maintained Cracks, chipping of plaster
painted
Mattresses are Intact and OB
clean

removal of condemned junk material in the ward
material
ME D4.6 The facility has established No stray animal/rodent/ OB
procedures for pest, rodent birds
and animal control
arrangement for storage and and potable water
supply for portable water in Availability of hot water OB/SI
all functional areas
ME D5.2 The facility ensures adequate Availability of power back OB/SI
power backup in all patient in ward
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 RR/SI For
nutritional assessment of the patient is done specially for hypertensive
patients high risk pregnancy and patient, diabetic
other specified cases cases. Check
nutrition advice
from records
ME D6.2 The facility provides diet Check for the adequacy OB/RR Check that all
according to nutritional and frequency of diet as per items fixed in
requirements of the patients nutritional requirement diet menu are
provided to the
patient
Check for the Quality of diet PI/SI Ask patient/staff
provided weather they
are satisfied
with the Quality
of food
ME D6.3 Hospital has standard There is procedure of RR/SI Diet for diabetic
procedures for preparation, requisition of different type patients, low
handling, storage and of diet from ward to kitchen salt and high
distribution of diets, as per protein diet etc
requirement of patients
ME D7.1 The facility has adequate sets Clean Linens are provided OB/RR
of linen for all occupied bed
Gowns are provided to the OB/RR
cases going for surgery
Availability of Blankets, draw OB/RR
sheet, pillow with pillow
cover and mackintosh
ME D7.2 The facility has established Linen is changed every day OB/RR
procedures for changing of and whenever it get soiled
linen in patient care area
ME D7.3 The facility has standard There is system to check SI/RR
procedures for handling , the cleanliness and Quantity
collection, transportation and of the linen received from
washing of linen laundry

ME D11.1 The facility has established Staff is aware of their role SI
job description as per govt and responsibilities
guidelines
ME D11.2 The facility has a established There is procedure to RR/SI Check for
procedure for duty roster ensure that staff is available system for
and deputation to different on duty as per duty roster recording time
departments of reporting
and relieving
(Attendance
register/
Biometrics etc)
code as mandated by its respective dress code
administration / the health
department
adheres to contractual obligations.
ME D12.1 There is established system There is procedure to SI/RR Verification of
for contract management for monitor the quality and outsourced
out sourced services adequacy of outsourced services
services on regular basis (cleaning/
Dietary/
Laundry/
Security/
Maintenance)
provided
are done by
designated in-
house staff
procedure for registration of number is given to each
patients patient during process of
registration
Patient demographic details RR Check for
are recorded in admission that patient
records demographics
like Name,
age, Sex, Chief
complaint, etc.
ME E1.3 There is established There is no delay in SI/RR/OB
procedure for admission of treatment because of
patients admission process
Admission is done by SI/RR/OB
written order of a qualified
doctor
There is separate counter for OB/RR
admission of patients

ME E1.4 There is established There is provision of extra OB/SI
procedure for managing Beds
patients, in case beds are not
the patients.
ME E2.1 There is established Initial assessment of all RR/SI/OB The assessment
procedure for initial admitted patients done as criteria for
assessment of patients per standard protocols different clinical
conditions are
defined and
measured in
assessment
sheet
ANC history of pregnant RR/SI
women is reviewed and
recorded
Physical Examination RR Assesses
is done and recorded general
wherever required condition,
including:
vital signs,
conjunctiva
for pallor and
jaundice, and
bladder and
bowel function,
conducts breast
examinations
Dangers signs are identified RR/SI Examines the
and recorded perineum for
inflammation,
status of
episiotomy/
tears, lochia for
colour, amount,
consistency and
odour, Checks
calf tenderness,
redness or
swelling
Initial assessment and RR/SI
immediately
within 2 hours
ME E2.2 There is established There is fixed schedule RR/OB
procedure for follow-up/ for assessment of stable
reassessment of Patients patients
For critical patients RR/OB
admitted in the ward there
is provision of reassessment
as per need

ME E3.1 The facility has established Facility has established SI/RR
procedure for continuity of procedure for handing over
care during interdepartmental of patients from maternity
transfer ward to OT/labour room
There is a procedure for SI/RR
to other specialist with in
the hospital
ME E3.2 The facility provides Patient are referred with RR/SI
appropriate referral linkages referral slips
to the patients/Services for Advance communication is RR/SI
transfer to other/higher done with higher centre
facilities to assure the
continuity of care. Referral vehicle are RR/SI
arranged
Referral in or referral out SI/RR
Facility has functional RR Check for
referral linkages to lower referral cards
facilities filled from lower
facilities
Functional linkage with RR
higher facilities
There is a system of follow SI/RR
up of referred patients
ME E3.3 A person is identified for care Duty Doctor and nurse are RR/SI
during all steps of care assigned for each patients
ME E4.1 Procedure for identification of There is a process for OB/SI Identification
patients is established at the ensuring the identification tags for mother
facility before any clinical and baby /
procedure foot print
are used for
identification of
newborns
ME E4.2 Procedure for ensuring Treatment chart are RR Check that
timely and accurate nursing maintained treatment chart
care as per treatment plan is are updated
established at the facility and drugs given
are marked. Co
relate it with
drugs and doses
prescribed.
There is a process to ensue SI/RR Verbal orders
the accuracy of verbal/ are rechecked
telephonic orders before
administration
of drug
ME E4.3 There is established Patient hand over is given SI/RR
procedure of patient hand during the change in the
over, whenever staff duty shift
change happens Nursing Handover register is RR
maintained
Hand over is given bed side SI/RR

ME E4.4 Nursing records are Nursing notes are RR/SI Check that
maintained maintained adequately nursing note
register. Notes
are adequately
written
ME E4.5 There is procedure for Patient Vitals are monitored RR/SI Check that TPR
periodic monitoring of and recorded periodically chart, IO chart,
patients any other vital
are is monitored
Critical patients are RR/SI
monitored continually
ME E5.1 The facility identifies Vulnerable patients are OB/SI Check the
vulnerable patients and identified and measures are measure taken
ensure their safe care taken to protect them from to prevent new
any harm born theft,
sweeping and
baby fall
ME E5.2 The facility identifies high risk High Risk Pregnancy cases OB/SI High risk cases
patients and ensure their care, are identified and kept in : Eclampsia,
as per their need intensive monitoring Sepsiss,
diabetic, cardiac
diseases and
Intrauterine
growth
retardation
ME E6.1 The facility ensured that drugs Check for BHT if drugs are RR
are prescribed in generic prescribed under generic
name only name only
ME E6.2 There is procedure of rational Check that relevant RR
point of use
Check if staff is aware of the SI/RR
drug regime and doses as
per STG
formulary
ME E7.1 There is process for High alert drugs for SI/OB Magsulf (to be
identifying and cautious department are identified kept in fridge) ,
administration of high alert Methergine
drugs Maximum dose of high SI/RR Value for
alert drugs are defined and maximum
communicated doses as per
age, weight and
diagnosis are
available with
nursing station
and doctor

There is process to ensure SI/RR A system of
that right doses of high alert independent
drugs are only given double
check before
administration,
Error prone
medical
abbreviations
are avoided
ME E7.2 Medication orders are written Every Medical advice and RR
legibly and adequately procedure are accompanied
with date , time and
signature
clinical staff
ME E7.3 There is a procedure to check Drugs are checked for expiry OB/SI
drug before administration/ and other inconsistency
dispensing before administration
Check single dose vial are OB Check for any
not used for more than one open single
dose dose vial
with left over
content kept to
be used later on
Check for separate sterile OB In multi dose
needle is used every time vial needle is
for multiple dose vial not left in the
septum
ME E7.4 There is a system to ensure Administration of medicines SI/OB
right medicine is given to done after ensuring right
right patient patient, right drugs , right
route, right time
ME E7.5 Patient is counselled for self Patient is advised by doctor/ RR/SI
drug administration Pharmacist /nurse about the
ME E8.1 All the assessments, re- Day to day progress of RR
assessment and investigations patient is recorded in BHT
are recorded and updated
ME E8.2 All treatment plan Treatment plan, first orders RR Treatment
prescription/orders are are written on BHT prescribed &
recorded in the patient nursing records
records.
ME E8.3 Care provided to each patient Maintenance of treatment RR Treatment given
is recorded in the patient chart/treatment registers is recorded in
records treatment chat
ME E8.4 Procedures performed are Any procedure performed RR Dressing,
written on patients records written on BHT mobilization etc
ME E8.5 Adequate form and formats Standard Format for bed RR/OB Availability
are available at point of use head ticket/ Patient case of formats for
sheet are available as per Treatment
state guidelines Charts, TPR
Chart , Intake
Output Chat Etc.

ME E8.6 Register/records are Registers and records RR General order
maintained as per guidelines are maintained as per book (GOB),
guidelines report book,
Admission
register, lab
register,
Admission
sheet/ bed head
ticket, discharge
slip, referral
slip, referral
in/referral out
register, OT
register, FP
register, Diet
register, Linen
register, Drug
indent register
All register/records are RR
ME E8.7 The facility ensures safe Safe keeping of patient OB
and adequate storage and records
retrieval of medical records
Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after Assessment is done before SI/RR
assessing patient readiness discharging patient
doctor
Patient / attendants are PI/SI
consulted before discharge
consulted/ informed before
discharge of patients
ME E9.2 Case summary and follow-up Discharge summary is RR/PI See for
instructions are provided at provided discharge
the discharge summary,
referral slip
provided.
Discharge summary RR
adequately mentions
patients clinical condition,
treatment given and follow
up
Discharge summary is given SI/RR
to patients going on LAMA/
Referral out
ME E9.3 Counselling services are Patient is counselled before SI/PI
provided as during discharges discharge
wherever required Advice includes the RR/SI
information about the
nearest health centre for
further follow up
prior time of discharge is PI/SI
communicated to patient

ME E9.4 The facility has established Declaration is taken from RR/SI
procedure for patients leaving the LAMA patient
the facility against medical
advice, absconding, etc
Management
ME E11.3 The facility has disaster Staff is aware of disaster SI/RR
management plan in place plan
procedures for Pre-testing properly after the sample
Activities collection
ME E12.3 There are established Nursing station is provided SI/RR
procedures for Post-testing with the critical value of
Activities different tests
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and
Transfusion.
procedure for transfusion of transfusion
blood Patient’s identification is SI/OB
verified before transfusion
Blood is kept at optimum RR
temperature before
transfusion
monitored and regulated by
qualified person
written in patient recorded
and reporting Transfusion recorded and reported to
complication responsible person
Standard E14 The facility has established procedures for Anaesthetic Services
ME E14.1 The facility has established Pre anaesthesia check up SI/RR
procedures for Pre- is conducted for elective /
anaesthetic Check up and Planned surgeries
maintenance of records
Standard E16 The facility has defined and established procedures for end of life care and death
is adequately recorded and procedure to communicate
communicated death to relatives
sympathetically
patient record
ME E16.2 The facility has standard Death summary is given to SI/RR Maintenance of
procedures for handling the patient attendant quoting records as per
death in the hospital the immediate cause and guideline
underlying cause if possible
Death note including efforts RR Maternal and
done for resuscitation are neonatal death
noted in patient record

Standard E17 The facility has established procedures for Antenatal care as per guidelines
procedure for Registration updates “Mother and Child
and follow up of pregnant Protection Card”.
women.
ME E17.4 There is an established Management of PIH/ RR/SI
procedure for identification Eclampsia
of High risk pregnancy and Management of sepsis RR/SI
appropriate treatment/
referral as per scope of Management of diabetic RR/SI
services. pregnant mother
Management of cardiac RR/SI
cases
Management of IUGR RR/SI
ME E17.5 There is an established Management of of severe RR/SI Blood
procedure for identification anaemia Transfusion
and management of services available
moderate and severe anaemia for anaemic
patients
Standard E19 The facility has established procedures for postnatal care as per guidelines
ME E19.1 Post partum Care is provided Post partum care of mother PI Check uterine
to the mothers contraction,
bleeding as
per treatment
plan, check for
TPR and output
chart, Breast
examination
and milk
initiation and
perineal washes
Initiation of Breastfeeding PI Checks and
with in 1 Hour discusses with
the mother on
breastfeeding
pattern,
emphasising
exclusive and
on demand
feeding.
Demonstrates
the proper
positioning and
attachment of
the baby
Post Partum Care of SI/RR Maintains
Newborn hand hygiene,
keeps the
baby wrapped
(maintains
temperature),
Checks weight,
temperature,
respiration,
heart rate,
colour of skin
and cord stump

ME E19.2 The facility ensures adequate 48 Hour Stay of mothers SI/RR
stay of mother and newborn and new born after delivery
in a safe environment as per
standard Protocols.
ME E19.3 There is an established Counselling provided for PI/SI Nutrition
procedure for Post partum Post partum care ,Contraception
counselling of mother ,Breastfeeding
,Registration
of Birth ,IFA
Supplement
,Danger Signs,
Contraception
ME E19.4 The facility has established There is established criteria SI/RR
procedures for stabilization/ for shifting newborn to
treatment/referral of post SNCU
natal complications
ME E19.5 There is established Check if patient is explained RR/PI
procedure for discharge and about follow up visits,
follow up of mother and advice and counselling is
newborn. done 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 Zero dose vaccines are RR Check for
immunization services as per given records BCG,
guidelines Hepatitis Band
OPV 0 given to
New born
ME E20.3 Management of Low birth Care of Low Birth Weight SI/RR Premature and
weight and Premature babies LBW babies
newborns is done as per are identified:
guidelines Weight less
than 2500 g
for low birth
weight babies,
gestation of
less than 37
weeks for
prematurely,
Kangaroo
Mother Care
(KMC) is
implemented
for Low Birth
Weight/
Prematurely and
assisted feeding
arranged, if
required
ME F1.3 The facility measures hospital There is procedure to report SI/RR Patients are
associated infection rates cases of Hospital acquired observed for
infection any sign and
symptoms
of HAI like
fever, purulent
discharge from
surgical site .

Medical Check-up and immunization of the staff Tetanus Toxoid
immunization of staff etc
Periodic medical checkups SI/RR
of the staff
ME F1.5 The facility has established Regular monitoring of SI/RR Hand washing
procedures for regular infection control practices and infection
monitoring of infection control audits
intervals
ME F1.6 The facility has defined and Check for Doctors are aware SI/RR
established antibiotic policy of Hospital Antibiotic Policy
antisepsis
ME F2.1 Hand washing facilities are Availability of hand washing OB Check for
provided at point of use Facility at Point of Use availability of
wash basin near
the point of use
Availability of running Water OB/SI Ask to Open
the tap. check
with Staff water
supply is regular
soap with soap dish/ liquid availability/
antiseptic with dispenser. Ask staff if
the supply is
adequate and
uninterrupted
staff for regular
supply.
Instruction at Point of Use displayed
above the hand
washing facility,
preferably in
local language
ME F2.2 The facility staff is trained in Adherence to 6 steps of SI/OB Ask of
hand washing practices and Hand washing demonstration
they adhere to standard hand Staff is aware when to hand SI
washing practices wash
ME F2.3 The facility ensures standard Availability of Antiseptic OB
practices and materials for Solutions
antisepsis IV injection,
drawing
blood, putting
Intravenous and
urinary catheter
ME F3.1 The facility ensures Clean gloves are available at OB/SI
adequate personal point of use
protection Equipment as per Availability of Masks OB/SI
requirements

standard personal protection gloves, Masks, caps and
practices aprons.
removing the gloves
ME F4.1 The facility ensures standard Decontamination of SI/OB Ask stff how
practices and materials operating & Procedure do they
cleaning of instruments and Examination
procedures areas table , Patients
Beds Stretcher/
Trolleys etc.
(Wiping with
.5% Chlorine
solution
Proper Decontamination of SI/OB
instruments after use Ask staff
how they
decontaminate
the instruments
like
Stethoscope,
Dressing
Instruments,
Examination
Instruments,
Blood Pressure
Cuff etc
(Soaking in
0.5% Chlorine
Solution,
Wiping with
0.5% Chlorine
Solution or
70% Alcohol as
applicable
decontamination is
adequate
Cleaning of instruments SI/OB Cleaning is
after decontamination done with
detergent and
running water
after decon-
tamination
Proper handling of Soiled SI/OB No sorting,
and infected linen Rinsing or
sluicing at Point
of use/ Patient
care area
Staff knows how to make SI/OB
chlorine solution
ME F4.2 The facility ensures standard Equipment and instruments OB/SI Autoclaving/
practices and materials for are sterilized after each use HLD/Chemical
disinfection and sterilization as per requirement Sterilization
of instruments and
equipment

High level Disinfection of OB/SI Ask staff about
instruments/equipments is method and
done as per protocol time required
for boiling
material is used
ME F5.1 Layout of the department is
conducive for the infection
control practices
ME F5.2 The facility ensures availability Availability of disinfectant OB/SI Chlorine
of standard materials for as per requirement solution,
cleaning and disinfection of Gluteraldehye,
patient care areas Carbolic acid
Availability of cleaning OB/SI Hospital
agent as per requirement grade phenyl,
disinfectant
detergent
solution
cleaning and disinfection of Cleaning of patient care SI/RR
patient care areas area with detergent solution
standard procedure
followed inside out
Cleaning equipment like OB/SI Any cleaning
broom are not used in equipment
patient care areas leading to
dispersion of
dust particles
in air should be
avoided
ME F5.4 The facility ensures Isolation and barrier nursing OB/SI
segregation infectious procedure are followed for
patients septic cases
ME F6.1 The facility Ensures Availability of color coded OB
segregation of Bio Medical bins at point of waste
Waste as per guidelines and generation
‘on-site’ management of Availability of plastic color OB
waste is carried out as per coded plastic bags
guidelines
guidelines
for segregation and
waste

waste
ME F6.2 The facility ensures Availability of functional OB Verify its usage
management of sharps as per needle cutters
guidelines Availability of puncture OB Should be
proof box available near
to point of
generation like
nursing station
and injection
room
disposal syringes is not
done in open
buckets
Staff is aware of contact SI
sharps
prophylaxis Where it is
stored and who
is in charge of
that.
Staff knows reporting SI Staff knows
processes after sharp injury what to do in
case of shape
injury. Whom
to report. See if
any reporting
has been done
ME F6.3 The facility ensures Check bins are not overfilled SI/OB
transportation and disposal of Transportation of bio SI/OB
waste as per guidelines medical waste is done in
management
Standard G1 Facility has established organizational framework for quality improvement
ME G1.1 Facility has a quality team in There is a designated SI/RR
place departmental nodal person
ME G2.1 Patient satisfaction surveys Client/Patient satisfaction RR
are conducted at periodic survey done on monthly
intervals basis
ME G3.1 The facility has established There is system daily SI/RR
internal quality assurance round by matron/hospital
programme in key manager/ hospital
departments superintendent/ Hospital
Manager/ Matron in charge
for monitoring of services

ME G3.3 The facility has established Departmental checklist are SI/RR
system for use of check lists used for monitoring and
in different departments and quality assurance
services Staff is designated for filling SI
checklists
approved
Current version of SOP OB/RR
are available with process
owner
describes process and for receiving and initial
procedures assessment of the patient in
Maternity ward
Department has RR
for admission, shifting and
referral of pregnant mother
Department has RR
for shifting the mother to
labour room
Department has RR
documented procedure for
requisition of diagnosis and
receiving of the reports
Department has RR
preparation of the patient
for surgical procedure
Department has RR
for transfusion of blood in
maternity ward
Department has RR
maintenance of rights and
dignity of pregnant women
Department has RR
for record Maintenance
including taking consent
Department has RR
discharge of the patient
from maternity ward
Department has RR
post natal inpatient care of
mother

Department has RR
post natal inpatient care of
new born
Department has RR
for payment/ incentives of
beneficiary
Department has RR
counselling of the patient at
the time of discharge
Maternity ward has RR
for environmental cleaning
and processing of the
equipment
for arrangement of
intervention for maternity
ward
Facility ensures standard Maternity ward has RR
practices and materials documented procedure
for decontamination and for sorting, cleaning and
cleaning of instruments and distribution of clean linen to
procedures areas patient
for providing free diet to
the patient as per their
requirement
Department has RR
end of life care
ME G4.3 Staff is trained and aware of Check staff is a aware of SI/RR
the procedures written in relevant part of SOPs
SOPs
ME G4.4 Work instructions are Work instruction/clinical OB Patient safety,
displayed at Point of use protocols are displayed Identification
of danger sign,
postnatal care
and counselling,
new born care
etc
Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value
ME G5.1 The facility maps its critical Process mapping of critical SI/RR
ME G5.2 The facility identifies non Non value adding activities SI/RR
value adding activities / waste are identified
ME G5.3 The facility takes corrective Processes are rearranged as SI/RR
processes

ME G6.1 The facility conducts periodic Internal assessment is done RR/SI
internal assessment at periodic interval
conduct maternal Death
audit
conduct New born Death
audit
compliances are enumerated enumerated and recorded
and recorded adequately
/ audit process
actions are taken to address action taken
assessment & audit
ME G7.2 The facility periodically Quality objective for RR/SI
defines its quality objectives Maternity ward are defined
and key departments have
services
Six Sigma SI/RR
ME G8.2 The facility uses tools for qual- 6 basic tools of Quality SI/RR
ity improvement in services Pareto / Prioritization SI/RR
benchmarks
ME H1.1 Facility measures productivity Bed Occupancy Rate for RR
Indicators on monthly basis normal delivery ward
Bed Occupancy Rate for C RR
section ward
Proportion of Severe RR
anaemia cases treated with
blood transfusion

Proportion of cases of high RR
risk pregnancy/ obstetric
complications
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 RR
ward
benchmark
ME H3.1 Facility measures Clinical Average length of stay for RR
Care & Safety Indicators on normal delivery
monthly basis Average length of Stay for RR
C-Section
Newborns Breastfed within RR
1 hr of Birth
Maternal Death per 1000 RR
deliveries
No of adverse events per RR
thousand patients
Proportion of mother given RR
Time taken for initial RR
assessment
benchmark
ME H4.1 Facility measures Service LAMA Rate RR
Quality Indicators on monthly Patient Satisfaction Score RR
basis
Proportion of JSY payment RR
done with in stay of mother
at facility
Proportion of mothers given RR
drop back facility

Assessment Summary
A. Score Card
Maternity Ward Score Card
Maternity Ward Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Checklist–5
Paediatrics Ward
Version: 1/2013

Checklist–5
Checklist for Paediatrics Ward

ME A1.4 The facility provides Availability of dedicated SI/OB
Paediatric Services paediatric ward
Availability of isolation SI/OB Particularly for
room chicken pox,
measles etc.)
ME A1.14 Services are available for the Availability of nursing care SI/RR
ME A2.4 The facility provides Child Indoor Management of SI/RR
health Services Severe Acute Malnutrition
Indoor Management of SI/RR
Severe Diarrhoea with
severe dehydration
Indoor Management of SI/RR
Meningitis
Indoor Management SI/RR
of Acute respiratory
infections
Seizers and convulsions SI/RR
Shock SI/RR
Accidental poisoning SI/RR
Services Under RBSY SI/RR
Standard A4 The facility Provides services as mandated in national Health Programmes/State Scheme
ME A4.1 The facility provides services Indoor management of SI/RR
under National Vector Borne malaria
Disease Control Programme Indoor management of SI/RR
as per guidelines Chikungunia
Indoor management of JE SI/RR
ME A4.2 The facility provides services Management of SI/RR
under Revised National TB paediateric Tuberculosis
Control Programme as per
guidelines
ME A4.10 The facility provide services Referral of child born SI/RR
under National health of High Risk pregnancy
Programme for deafness showing features
suggestive of hearing
impairment
Standard B1 The facility provides the information to care seekers, attendants & community about the available
ME B1.1 The facility has uniform and Availability departmental OB (Numbering, main
user-friendly signage system signage’s department and
internal sectional
signage
Visiting hours and visitor OB
policy are displayed
ME B1.2 The facility displays the Contact details of referral OB
services and entitlements transport / ambulance
available in its departments displayed
Entitlement under RBSY OB
are displayed
ME B1.5 Patients & visitors are IEC Material is displayed OB Breast feeding,
sensitised and educated immunization
through appropriate IEC / schedule and Zn,
BCC approaches ORS, nutrition and
hand washing etc.
understand language
ME B1.8 The facility ensures access to Discharge summery is RR/OB
clinical records of patients to given to the patient
entitled personnel
ME B2.1 Services are provided in Cots in paediatric ward are OB
manner that are sensitive to large enough for stay of
gender mother with child
ME B2.3 Access to facility is provided Availability of Wheel OB
without any physical barrier chair or stretcher for easy
& and friendly to people with Access to the ward
disabilities Availability of ramps with OB
railing
ME B3.1 Adequate visual privacy is Availability of screen OB
provided at every point of
care
ME B3.2 Confidentiality of patients Patient Records are kept SI/OB
records and clinical at secure place beyond
visitors
while delivering the services
ME B4.1 There is established General Consent is taken SI/RR
procedures for taking before admission
informed consent before
treatment and procedures
ME B4.4 Information about the Patient is informed about PI
treatment is shared with her clinical condition and
patients or attendants, treatment been provided
regularly
ME B4.5 The facility has defined Availability of complaint OB
and established grievance box and display of process
redressal system in place for grievance re addressal
displayed
166 | Checklist for Paediatrics Ward

ME B5.1 The facility provides cashless Availability of free PI/SI
services to pregnant women, diagnostics
mothers and neonates as Availability of Free drop PI/SI
per prevalent government back
schemes
Availability of Free diet to PI/SI
patient
Availability of Free Diet to PI/SI
mother
Availability of Free patient PI/SI
transport
Availability of Free Blood PI/SI
Availability of free stay in PI/SI
paediatric ward
ME B5.2 The facility ensures that Check that patient PI/SI
drugs prescribed are party has not spent on
available at Pharmacy and purchasing drugs or
wards consumbles from outside.
ME B5.3 It is ensured that facilities for Check that patient PI/SI/RR
the prescribed investigations party has not spent on
are available at the facility diagnostics from outside.
ME B5.4 The facility provide free of Treatment to BPL patient PI/RR
cost treatment to Below is free
poverty line patients without
and reimbursement to the
patients
the prevalent norms
ME C1.1 Departments have adequate Adequate space in wards OB Distance
space as per patient or work with no cluttering of beds between centres
load of two beds –
2.25 meter
ME C1.2 Patient amenities are provide Functional toilets with OB
as per patient load running water and flush
are available as per
strength and patient load
of ward
Functional bathroom OB
with running water are
available as per strength
and patient load of ward
Availability of drinking OB
water
Patient/ visitor Hand OB
washing area
Separate toilets for visitors OB
Checklist for Paediatrics Ward | 5

health promotion
Adequate shaded waiting OB
area is provide for
attendants of patient
ME C1.3 Departments have layout Availability of Dedicated OB
and demarcated areas as per nursing station
functions Availability of Examination OB
room
Availability of Treatment OB
room
Availability of Doctor’s OB
Duty room
Availability of Nurse Duty OB
room
Availability of Store OB Drug &Linen store
Availability of Dirty room OB
Availability of play room OB
circulation area and open between two bed to two beds should
spaces according to need provide bed side nursing be at least 4 ft
and local law care and movement and clearance
between head
end of bed and
wall should be
at least 1 ft and
between side
of bed and wall
should be 2 ft
Corridors are wide OB Corridor should
enough for patient, visitor be 3 meters wide
and trolley/ equipment
movement
for intramural and telephone and Intercom
extramural communication Services
ME C1.6 Service counters are Availability of IPD beds as OB
available as per patient load per load
ME C1.7 The facility and departments Location of nursing OB
are planned to ensure station and patients beds
structure follows the enables easy and direct
function/processes observation of patients
(Structure commensurate
with the function of the
hospital)
ME C2.1 The facility ensures the Non structural OB Check for fixtures
seismic safety of the components are properly and furniture
infrastructure secured like cupboards,
cabinets,
and heavy
equipments,
hanging objects
are properly
fastened and
secured

ME C2.3 The facility ensures safety of Paediatric building does OB
electrical establishment not have temporary
connections and loosely
hanging wires
ME C2.4 Physical condition of Floors of the paediatric OB
buildings are safe for wards are non slippery
providing patient care and even
Windows have grills and OB
wire meshwork
ME C3.1 The facility has plan for Paediatric Ward has OB/SI
prevention of fire sufficient fire exit to
permit safe escape to its
marked.
ME C3.2 The facility has adequate fire Paediatric ward has OB
fighting Equipment installed fire Extinguisher
that is Class A, Class B, C
type or ABC type
extinguisher as well as
due date for next refilling
periodic training of staff competencies for
and conducts mock drills operating fire extinguisher
regularly for fire and other and what to do in case of
disaster situation fire
ME C4.1 The facility has adequate Availability of OB/RR
specialist doctors as per Paediatrician on call
service provision
ME C4.2 The facility has adequate Availability of general OB/RR
general duty doctors as per duty doctor
load
ME C4.3 The facility has adequate Availability of nursing staff OB/RR As per patient
nursing staff as per service load
ME C4.5 The facility has adequate Availability of ward OB/RR availability of
support / general staff attendant/ Ward boy ayahs/ Sanitary
worker
Availability Security staff OB/RR
ME C4.6 The staff has been provided Facility based OB/RR
required training / skill sets immunization
Infant and young Child OB/RR
Feeding ( IYCF) practices
IMNCI Training OB/RR

Biomedical waste OB/RR
management
Infection control and hand OB/RR
hygiene
Patient safety OB/RR
ME C4.7 The Staff is skilled as per job Nursing staff is skilled OB/RR
description for maintaining clinical
records
Counsellor is skilled IYCF OB/RR
counselling
ME C5.1 The departments have Availability of emergency OB/RR Adrenaline
availability of adequate drugs Diazepam,
drugs at point of use Phenobarbitone
Pheniramine
(Cetirizine)
Hydrocortisone
Calcium
gluconate
Sodium
bicarbonate
Dopamine,
methasone
Availability of IV fluid OB/RR Ringer’s lactate·
Normal saline·
N/5 in 5%
Dextrose
Dextrose (10%)
Availability of antibiotics OB/RR (Ampicillin, Genta
micin,,Cefotaxime
,Ceftriaxone
Other Injectables OB/RR Quinine,
Mannitol,
Potassium
chloride(KCL),
Vitamin K,
Nebuliser solution
of salbutamol,
Artesunate
Oral Drugs 1 OB/RR ORS
Cotrimoxazole
paediatric tablets
& Syrup
Amoxicillin
tablets
Doxycycline &
Syrup Zinc tablets
Chloroquine
tablets
Paracetamol,
Metrindazol,
Albendazol
Oral Drugs 2 OB/RR Vitamin A,
IFA tablets,
Salbutamol,
Prednisolone
tablets, Frusemide
tablets

ME C5.2 The departments have Consumables for OB/RR Plastic /
adequate consumables at Paediatric ward disposable
point of use syringes· IV
cannulas (22G
and 24G)· Scalp
vein set No. 22
and 24· IV infusion
sets (adult and
paediatric),
simple rubber
catheter
Resuscitation OB/RR Nasogastric tube
consumables (8,10,12FG)
Suction catheter
(6,8,10 FG)
Uncuffed tracheal
tube (all sizes)
Oropharyngeal
airway
maintained at every point of maintained
needed
ME C6.1 Availability of equipment & Availability of functional OB Weighing
instruments for examination Equipment &Instruments machine( infant &
& monitoring of patients for examination & adult)
Monitoring · Stadiometer for
height
· Infantometer for
length
BP apparatus with
paediatric cuff,
Thermometer.
ME C6.2 Availability of equipment & Availability of dressing OB
instruments for treatment tray
procedures, being
undertaken in the facility
ME C6.3 Availability of equipment & Availability of Point of care OB Glucometer
instruments for diagnostic diagnostic instruments
procedures being
undertaken in the facility
ME C6.4 Availability of equipment Availability of functional OB Face masks (3
and instruments for Instruments for type; Neonate,
resuscitation of patients and Resuscitation. Infant and
for providing intensive and paediatric type)
critical care to patients Self-inflating
ventilation bag
(all sizes)
Laryngoscope
Nebulizer
Suction machines
Oxygen supply,
ET tube (different
sizes)

ME C6.5 Availability of Equipment for Availability of equipment OB Refrigerator,
Storage for storage for drugs Crash cart/Drug
trolley, instrument
trolley, dressing
trolley
ME C6.6 Availability of functional Availability of equipments OB Buckets for
equipment and instruments for cleaning mopping, mops,
for support services duster, waste
trolley, Deck
brush
Availability of equipment OB Boiler
disinfection
ME C6.7 Departments have patient Availability of patient beds OB
furniture and fixtures as per Availability of attachment/ OB Hospital graded
load and service provision accessories with patient mattress, Bed side
bed locker, IVstand,
Bed pan, bed rail
Availability of Fixtures OB Electrical fixture
for equipments
like suction, X ray
view box
Availability of furniture OB cupboard, nursing
counter, table for
preparation of
medicines, chair.
of Equipment.
ME D1.1 The facility has established All equipments are SI/RR
system for maintenance of covered under AMC
critical Equipment including preventive
maintenance
maintenance of the
equipments
procedure for internal and equipments/ instrument thermometers etc
external calibration of are calibrated are calibrated
measuring Equipment
ME D2.1 There is established There is established SI/RR Stock level are
procedure for forecasting system of timely indenting daily updated
and indenting drugs and of consumables and drugs Requisition are
consumables at nursing station timely placed
Drugs are intended in OB/RR/SI
Paediatric dosages only
consumables and are labeled
are labeled

management of expiry and maintained at emergency
near expiry drugs drug tray
maintained for drug
in paediatric ward
consumables
drugs
of vaccines and other refrigerators are kept as temperature
drugs, requiring controlled per storage requirement charts are
temperature and records are maintained
maintained and updated
periodically
ME D3.1 The facility provides Adequate Illumination at OB
adequate illumination level nursing station
at patient care areas Adequate illumination in OB
patient care areas
ME D3.2 The facility has provision Visiting hour are fixed and OB/PI
of restriction of visitors in practiced
patient areas There is no overcrowding OB
in the wards during
visitors hours
One female/ family OB/SI
members allowed to stay
with the child
ME D3.3 The facility ensures safe and Temperature control and PI/OB Room kept
comfortable environment ventilation in patient care between 25° - 30°
for patients and service area C (to the extent
providers possible) Fans/
Air conditioning/
Heating/Exhaust/
Ventilators as
per environment
condition and
requirement
Safe measures used for SI/OB Check availability
re-warming children of Blankets to
cover the children

station/duty room Heating/Exhaust/
Ventilators as
per environment
condition and
requirement
Side railings has been OB
provided to prevent fall of
patient
ME D3.4 The facility has security Identification band for OB
system in place at patient children below 5 years
care areas Security arrangement in OB/SI
Paediatric . Ward
measure for safety and they feel secure at work
painted
and hygienic topes, sinks patient care with no dirt,
and circulation areas are grease, littering
Clean and cobwebs
fixtures are clean
running water
ME D4.3 Hospital infrastructure is Check for there is no OB
adequately maintained seepage, Cracks, chipping
of plaster
Window panes, doors and OB
and painted
clean
removal of condemned junk material in the ward
material
and animal control
Standard D5 The facility ensures 24 × 7 water and power backup as per requirement of service delivery, and
support services norms.
arrangement storage and running and potable
supply for portable water in water
all functional areas

ME D5.2 The facility ensures adequate Availability of power back OB/SI
power backup in all patient up in patient care areas
ME D6.1 The facility has provision of Nutritional assessment of RR/SI
nutritional assessment of the patient done as required
patients and directed by doctor
ME D6.2 The facility provides diets Check for the adequacy OB/RR Check that all
according to nutritional and frequency of diet items fixed in diet
requirements of the patients as per nutritional menu is provided
requirement to the patient
Check for the Quality of PI/SI Ask patient/staff
diet provided weather they are
satisfied with the
Quality of food
ME D6.3 Hospital has standard There is procedure of RR/SI
procedures for preparation, requisition of different
handling, storage and type of diet from ward to
distribution of diets, as per kitchen
requirement of patients
ME D7.1 The facility has adequate sets Clean Linens are provided OB/RR
of linen for all occupied bed
Availability of Blankets, OB/RR
draw sheet, pillow
with pillow cover and
machintosh
ME D7.2 The facility has established Linen is changed every OB/RR
procedures for changing of day and whenever it get
linen in patient care areas soiled
procedures for handling, the cleanliness and
collection, transportation Quantity of the linen
and washing of linen received from laundry
guidelines
and deputation to different available on duty as per time of reporting
departments duty roster and relieving
(Attendance
register/
Biometrics etc)
the adherence to dress support staff adhere to
code as mandated by its their respective dress code
department

adheres to contractual obligations
for contract management for monitor the quality and outsourced
out sourced services adequacy of outsourced services
Dietary/Laundry/
Security/
Maintenance)
provided
are done by
designated in-
house staff
patients patient during process of
registration
like Name,
age, Sex, Chief
complaint, etc.
ME E1.3 There is established There is established SI/RR Age Criteria &
procedure for admission of criteria for admission clinical diagnosis,
patients all emergency
and serious cases
There is no delay in SI/RR/OB
admission of patient
doctor
ME E1.4 There is established There is provision of extra OB/SI
procedure for managing Beds
patients, in case beds are not
Standard E2 Facility has defined and established procedures for clinical assessment and reassessment of the
patients.
ME E2.1 There is established Initial assessment of all RR/SI
procedure for initial admitted patient done as
assessment of patients per standard protocols
Patient History is taken RR

and recorded
Physical Examination RR
is done and recorded
wherever required
Provisional Diagnosis is RR
recorded

immediately
within 2 hours
admitted in the ward
there is provision of
reassessment as per need
ME E3.1 The facility has Facility has established SI/RR
established procedure for procedure for handing
continuity of care during over of patients during
interdepartmental transfer departmental transfer
There is a procedure for RR/SI
to other specialist with in
the hospital
ME E3.2 The facility provides Patient referred with RR/SI Check for referral
appropriate referral linkages referral slip cards filled from
to the patients/Services for lower facilities
transfer to other/higher Advance communication RR/SI
facilities to assure the is done with higher centre
continuity of care.
Referral vehicle is being SI/RR
arranged
Facility has functional SI/RR
referral linkages to lower
facilities
There is a system of follow RR
ME E3.3 A person is identified for care Duty Doctor and nurse is RR/SI
during all steps of care assigned for each patients
ME E4.1 Procedure for identification There is a process for OB/SI Identification
of patients is established at ensuring the identification tags are used for
the facility before any clinical children less than
procedure 5 yrs
ME E4.2 Procedure for ensuring Treatment chart are RR Check for
care as per treatment plan is are updated and
established at the facility drugs given are
marked. Co relate
it with drugs and
doses prescribed.
There is a process to ensue SI/RR Verbal orders are
the accuracy of verbal/ rechecked before
telephonic orders administration

procedure of patient hand during the change in the
over, whenever staff duty shift
change happens Nursing Handover register RR
is maintained
side
ME E4.4 Nursing records are Nursing notes are RR/SI Check for
register. Notes
are adequately
written
ME E4.5 There is procedure for Patient Vitals are RR/SI Check for TPR
periodic monitoring of monitored and recorded chart, IO chart,
patients periodically weight records
any other vital
required is
monitored
Standard E5 The facility has a procedure to identify high risk and vulnerable patients
vulnerable patients and identified and measures measure taken to
ensure their safe care are taken to protect them prevent new born
from any harm theft, sweeping
and baby fall
ME E5.2 The facility identifies high High risk patients are OB/SI
risk patients and ensure their identified and treatment
care, as per their need given on priority
ME E6.1 The facility ensured that Check for BHT if drugs are RR
drugs are prescribed in prescribed under generic
point of use
per STG
formulary
ME E7.1 There is process for High alert drugs available SI/OB Electrolytes
identifying and cautious in department are like Potassium
administration of high alert identified chloride, Opioids,
drugs Neuro muscular
blocking agent,
Anti thrombolytic
agent, insulin,
warfarin, Heparin,
Adrenergic
agonist etc.

age, weight and
diagnosis are
available with
nursing station
and doctor
that right doses of high independent
alert drugs are only given double
check before
administration,
Error prone
medical
abbreviations are
avoided
adequately with date, time and
signature
clinical staff
administration
Check single dose vial are OB Check for any
not used for more than open single dose
one dose vial with left over
content intended
to be used later
on
Check for separate sterile OB
needle is used every time In multi dose vial
for multiple dose vial needle is not left
in the septum
Any adverse drug reaction RR/SI
is recorded and reported
ME E7.4 There is a system to ensure Fluid and drug dosages SI/RR Check for
right medicine is given to are calculated according calculation chart
right patient to body weight
Drip rate and volume is SI/RR Check the nursing
calculated and monitored staff how they
calculate Infusion
and monitor it
Administration of SI/OB
medicines done after
ensuring right patient,
right drugs, right route,
right time
ME E7.5 Patient is counselled for self Patient is advice by PI/SI
drug administration doctor/ Pharmacist /nurse
about the dosages and
timings .

ME E8.1 All the assessments, Day to day progress of RR
re-assessment and patient is recorded in BHT
investigations are recorded
and updated
ME E8.2 All treatment plan Treatment plan, first RR Treatment
prescription/orders are orders are written on BHT prescribed in
records.
ME E8.3 Care provided to each Maintenance of treatment RR Treatment given
patient is recorded in the chart/treatment registers is recorded in
patient records treatment chat
ME E8.4 Procedures performed are Procedures performed RR Nebulization,
written on patients records are written on patients Resuscitation etc
records
ME E8.5 Adequate form and formats Standard Format for bed RR/OB TPR chart, IO
are available at point of use head ticket/ Patient case chart, Growth
sheet available as per chart (Pre term)
state guidelines
Admission
register, lab
register,
Admission sheet/
bed head ticket,
discharge slip,
referral slip,
referral in/referral
out register, OT
register, Diet
register, Linen
register, Drug
intend register
and adequate storage and records
retrieval of medical records
ME E9.1 Discharge is done after Assessment is done before SI/RR
assessing patient readiness discharging patient
doctor
Patient / attendants PI/SI
discharge
consulted/ informed
before discharge of
patients
ME E9.2 Case summary and follow-up Discharge summary is RR/PI See for discharge
instructions are provided at provided summary, referral
the discharge slip provided.

adequately mentions
treatment given and
follow up
LAMA/Referral
ME E9.3 Counselling services Counselling the mother PI/SI
are provided as during on correct treatment and
discharges wherever feeding of the child at
required home, when to return
for follow-up care and
immunization
Time of discharge is PI/SI
in prior
ME E9.4 The facility has establishedDeclaration is taken from RR/SI
procedure for patients the LAMA patient
leaving the facility against
medical advice, absconding,
etc
Management
Role and responsibilities SI/RR
of staff in disaster is
defined
ME E12.1 There are established Container is labeled OB
procedures for Post-testing provided with the critical
Activities value of different tests
Transfusion.
ME E13.8 There is established Paediatric bags for blood RR/SI
procedure for issuing blood available
procedure for transfusion of transfusion
blood Patient’s identification is SI/OB
blood is kept on optimum RR
temperature before
transfusion
monitored and regulated
by qualified person
recorded

Standard E14 The facility has established procedures for Anaesthetic Services
ME E14.1 The facility has established Pre anaesthesia check up SI/RR
procedures for Pre- is conducted for elective /
anaesthetic Check up and Planned surgeries
maintenance of records
Standard E16 Facility has defined and established procedures for end of life care and death
relatives
patient record
ME E16.2 The facility has standard Death note including SI/RR
procedures for handling the efforts done for
death in the hospital resuscitation is noted in
patient record
Death summary is given to RR
patient attendant quoting
the immediate cause
and underlying cause if
possible
procedure for Registration updates “Mother and
and follow up of pregnant Child Protection Card”.
women.
ME E20.2 Triage, Assessment & Assessment Protocols are SI/RR Airway, Breathing,
Management of newborns available Circulation, Coma,
having emergency signs are Convulsion, and
done as per guidelines Dehydration
Triage Protocols are SI/RR Emergency,
available priority and can
wait
Staff aware and practice SI/RR
ETAT protocols
Staff is skilled for basic life SI/RR
support for young infants
and children’s
ETAT checklist is available SI/RR
and practiced
ME E20.5 Management of children Differential diagnosis SI/RR
presenting with fever, algorithm are available
cough/ breathlessness is
ME E20.6 Management of children Food/ fluid intake is chart RR
with severe Acute is maintained
Malnutrition is done as per Weight chart is RR
guidelines maintained
Start-up and catch SI/RR check for
formula made as per composition
guidelines
ME E20.7 Management of children Assessment of SI/RR
presenting diarrhoea is done dehydration done as per
per guidelines protocols

ME F1.3 The facility measures There is procedure to SI/RR Patients are
hospital associated infection report cases of Hospital observed for
rates acquired infection any sign and
symptoms
of HAI like
fever, purulent
discharge from
surgical site .
measurement of hospital associated infection
Medical Check-up and immunization of the staff Tetanus Toxid etc
immunization of staff Periodic medical checkups SI/RR
of the staff
intervals
ME F1.6 The facility has defined and Check for Doctors SI/RR
established antibiotic policy are aware of Hospital
Antibiotic Policy
antisepsis
provided at point of use washing Facility at Point availability of
of Use wash basin near
the point of use
water supply is
regular
soap with soap dish/ availability/ Ask
liquid antiseptic with staff if the supply
dispenser. is adequate and
uninterrupted
staff for regular
supply.
Instruction at Point of Use displayed above
the hand washing
facility, preferably
in Local language
ME F2.2 The facility staff is trained Adherence to 6 steps of SI/OB Ask of
in hand washing practices Hand washing demonstration
and they adhere to standard Staff aware of when to SI
hand washing practices hand wash
Mothers are practicing PI/OB After using the
wash hand washing with toilet or changing
soap diapers and
before feeding
children

procedure site with giving IM/IV
antisepsis injection, drawing
blood, putting
Intravenous and
urinary catheter
ME F3.1 The facility ensures Clean gloves are available OB/SI
adequate personal at point of use
protection Equipment as per Availability of Masks OB/SI
requirements
practices aprons.
removing the gloves
Examination
table, Patients
Beds Stretcher/
Trolleys etc.
(Wiping with .5%
Chlorine solution
Proper Decontamination SI/OB Ask staff how they
of instruments after use decontaminate
the instruments
like Stethoscope,
Dressing
Instruments,
Examination
Instruments,
Blood Pressure
Cuff etc
(Soaking in 0.5%
Chlorine Solution,
Wiping with 0.5%
Chlorine Solution
or 70% Alcohol as
applicable
decontamination is
adequate
after decontamination with detergent
and running
water after
decontamination

Proper handling of Soiled SI/OB No
and infected linen sorting,Rinsing or
sluicing at Point
of use/ Patient
care area
chlorine solution
practices and materials for instruments are sterilized HLD/Chemical
disinfection and sterilization after each use as per Sterilization
of instruments and requirement
equipment High level Disinfection of OB/SI Ask staff about
instruments/equipments method and
is done as per protocol time required for
boiling
material is used
ME F5.2 The facility ensures Availability of disinfectant OB/SI Chlorine solution,
availability of standard as per requirement Gluteraldehye,
materials for cleaning and carbolic acid
disinfection of patient care Availability of cleaning OB/SI Hospital
areas agent as per requirement grade phenyl,
disinfectant
detergent
solution
patient care areas area with detergent
solution
preparing cleaning
procedure
mopping and scrubbing mopping from
are followed inside out
dispersion of
dust particles
in air should be
avoided
segregation infectious nursing procedure are
patients followed for septic cases
ME F6.1 The facility Ensures Availability of color coded OB
segregation of Bio Medical bins at point of waste
Waste as per guidelines and generation
‘on-site’ management of
waste is carried out as per
guidelines

Availability of plastic color OB
coded plastic bags
guidelines
Display of work OB
instructions for
segregation and handling
of Biomedical waste
waste
ME F6.2 The facility ensures Availability of functional OB See if it has been
management of sharps as needle cutters used or just lying
per guidelines idle
Availability of puncture OB Should be
proof box available nears
the point of
generation like
nursing station
and injection
room
done in open
buckets
sharps
exposure prophylaxis Where it is stored
and who is in
charge of that.
Staff knows what to do in SI Staff knows
condition of needle stick what to do in
injury case of shape
injury. Whom to
report. See if any
reporting has
been done
ME F6.3 The facility ensures Check bins are not SI/OB
transportation and disposal overfilled
of waste as per guidelines Transportation of bio SI/OB
spill management
team in place departmental nodal
Quality Assurance
activities

ME G2.1 Patient satisfaction surveys Patient satisfaction survey RR
are conducted at periodic done on monthly basis
intervals
Manager/ Matron in
charge for monitoring of
services
ME G3.3 The facility has established Departmental checklist SI/RR
system for use of check lists are used for monitoring
in different departments and and quality assurance
services Staff is designated for SI
filling and monitoring of
these checklists
approved
owner
Procedures adequately documented Procedure
procedures assessment of the patient
Department has RR
for reassessment of the
patient as per clinical
condition
Department has RR
for admission, shifting and
referral of children
Department has RR
for emergency triage
assessment and treatment
Department has RR
for assessment and
management of
Emergency signs
Department has RR
for Management of fever,
cough, breathlessness,
diarrhoea and
malnutrition

Department has RR
documented discharge
process for paediatric
patient
Department has RR
for transfusion of blood in
maternity ward
Department has RR
for requisition and
reporting of diagnostics
Department has RR
for end of life care
Department has RR
for discharge of the
patient
Department has RR
for environmental
cleaning and processing
of the equipment
Department has RR
for arrangement of
intervention for Paediatric
ward
Department has RR
for sorting, cleaning and
distribution of clean linen
to patient
Department has RR
for providing free diet to
the patient as per their
requirement
ME G4.3 Staff is trained and aware of Check staff is a aware of SI/RR
the procedures written in relevant part of SOPs
SOPs
ME G4.4 Work instructions are Work instruction/clinical OB Patient safety,
displayed at Point of use protocols are displayed formula for
calculation of
paediatric doses,
CPR etc
value adding activities / activities are identified
waste / redundant activities

ME G5.3 The facility takes corrective Processes are rearranged SI/RR
processes
Standard G6 The facility has established system of periodic review as internal assessment, medical & death
ME G6.1 Facility ensures standard Internal assessment is RR/SI
practices and materials done at periodic interval
for decontamination and
cleaning of instruments and
procedures areas
conduct Death audit
compliances are enumerated enumerated and recorded
and recorded adequately
ME G6.4 Action plan is made on Action plan prepared RR/SI
the gaps found in the
assessment / audit process
actions are taken to address action taken
assessment & audit
ME G7.2 The facility periodically Quality Objectives are RR/SI
defines its quality objectives defined
services
Six Sigma SI/RR
ME G8.2 The facility uses tools for 6 basic tools of Quality SI/RR
quality improvement in Pareto / Prioritization SI/RR
services
benchmarks
ME H1.1 Facility measures Bed Occupancy Rate RR
productivity Indicators on Proportion of Mothers RR
monthly basis given nutritional
counselling
No. of paediatric RR
admission per 1000 indoor
admission

ME H1.2 The Facility measures equity Proportion of female RR
indicators periodically patient
LAMA rate for female RR
patient
Proportion of BPL patient RR
ME H2.1 Facility measures efficiency Referral Rate RR
Indicators on monthly basis Bed Turnover rate RR
No. of drug stock out in RR
the paediatric ward
Discharge Rate RR
benchmark
ME H3.1 Facility measures Clinical No of Newborn / Child RR
Care & Safety Indicators on Resuscitated
monthly basis Average length of Stay RR
Death rate RR
No of adverse events per RR
thousand patients
% of infants exclusively RR
breastfed from admission
to discharge
Time taken for initial RR
assessment
Case fatality rate RR
benchmark
Quality Indicators on Attendant Satisfaction RR
monthly basis Score

Assessment Summary
A. Score Card
Paediatrics Ward Score Card
Paediatrics Ward Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Checklist–6
sick newborn care
unit (SNCU)
Version: 1/2013

Checklist–6
Checklist for sick newborn care unit (SNCU)

ME A1.4 The Facility Provides Availability of functional SI/OB
Paediatric Services SNCU
ME A1.14 Services are available Availability of nursing care SI/RR
for the time period as services 24X7
mandated
ME A2.3 The Facility provides Management of low birth SI/RR
Newborn health Services weight infants <1800 gm
and preterm
Management of all sick SI/RR
new borns except those
requiring mechanical
ventilation and major
surgical intervention
Resuscitation SI/RR
Prevention of infection SI/RR
including management of
newborn sepsis
Provision of Warmth SI/RR
Phototherapy for new born SI/RR
Breast feeding/feeding SI/RR
support and Kangaroo
Mother care (KMC)
ME A2.4 The Facility provides child Screening of New born for SI/RR
health Services Birth Defects
ME A3.1 The Facility provides Availability for USG and SI/OB In house, Parent
Radiology Services portable X ray services hospital and
Outsourced
ME A3.2 The Facility Provides SNCU has facility /Linkage SI/OB Availability of
Laboratory Services for laboratory investigation. side laboratory:
Serum billirubin,
Plasma
glucose, Serum
creatnine, Blood
count, Platelet, C
reactive protein,
Prothrobin
time, Blood gas
analysis with PH
measurement
analysis. If
linkage with
outside lab than
give partial
compliance
Standard B1 Facility provides the information to care seekers, attendants & community about the available
ME B1.1 The facility has uniform Availability departmental OB (Numbering,
and user-friendly signage signage’s main
system department
and internal
sectional
signage
Directional signage for OB
department is displayed
Restricted area signage OB
displayed
ME B1.2 The facility displays the Services available in SNCU OB
services and entitlements are displayed
available in its departments Entitlements under JSSK OB
Displayed
Information about doctor/ OB
Nurse on duty is displayed
and updated
Contact information in OB
respect of SNCU referral
services are displayed
ME B1.5 Patients & visitors are Display of information OB Display of
sensitised and educated for education of mother / pictorial
through appropriate IEC / relatives information/
BCC approaches chart regarding
expression of
milk/ techniques
for assistive
feeding , KMC,
complimentary
feeding etc.
Counselling aids are OB
available for education of
mother
understand language
ME B1.8 The facility ensures Discharge summery is OB
access to clinical records given to the patient
of patients to entitled
personnel
ME B3.1 Adequate visual privacy is Privacy is maintained in OB
provided at every point of breast feeding room
care
ME B3.2 Confidentiality of patients Patient Records are kept at SI/OB
records and clinical secure place beyond access
information is maintained to general staff/visitors
while delivering the
services
196 | Checklist for Sick Newborn Care Unit (SNCU)

ME B4.1 There is established SNCU has system in place to SI/RR
procedures for taking take informed consent from
informed consent patient relative whenever
before treatment and required
procedures
ME B4.4 Information about the SNCU has system in place to PI
treatment is shared with involve patient relatives in
patients or attendants, decision making of patient
regularly treatment
SNCU has system in place PI/SI
to provide communication
of newborn condition to
parents/ relatives at least
once in day
ME B4.5 Facility has defined and Availability of complaint OB
established grievance box and display of process
redressal system in place for grievance re addressal
displayed
ME B5.1 The facility provides availability of Free PI/SI
cashless services to diagnostics
pregnant women, mothers Availability of free drop PI/SI
and neonates as per back
prevalent government
schemes Availability of Free diet to PI/SI
patient
Availability of Free Diet to PI/SI
mother
Availability of Free patient PI/SI
transport
Availabliity of Free Blood PI/SI
Availability of free stay to PI/SI
mother
ME B5.2 The facility ensures that Check that patient party PI/SI
drugs prescribed are has not spent on purchasing
available at Pharmacy and drugs or consumables from
wards outside.
ME B5.3 It is ensured that facilities Check that patient PI/SI
for the prescribed party has not spent on
investigations are available diagnostics from outside.
at the facility
and reimbursement to the
patients
Checklist for Sick Newborn Care Unit (SNCU) | 197

the prevalent norms
ME C1.1 Departments have Adequate space as per OB Space between
adequate space as per patient care units 2 adjacent beds
patient or work load in SNCU should
be 4 ft. Space
between wall
and beds is 2 ft
Availability of adequate OB
waiting area
ME C1.2 Patient amenities are Availability of drinking OB
provide as per patient load water
Toilets for visitors OB
health promotion
Adequate sitting area for OB
patient relative
ME C1.3 Departments have layout SNCU has separate Inborn OB
and demarcated areas as unit
per functions SNCU has separate Out born OB
unit
SNCU has separate OB
designed washing area
The rooms has been OB Patient care
separated by transparent area has 2
observation windows from interconnected
the nurses’ working place in rooms
between
Availability of nursing OB
station
Hand washing and gowning OB
area
Receiving room with OB
examination area
Clean area for mixing OB
intravenous fluids and
Medications/ fluid
preparation area
Doctors duty room, OB
Dirty utility area OB
Mother’s area for expression OB SNCU has
of breast milk/ Breast system in place
feeding to call mother’s
of baby for
feeding
Unit stores OB
Side lab. Nurses change OB
room, autoclaving room,
Counselling room
Step down area in close OB
proximity

ME C1.4 The facility has adequate Availability of adequate OB
circulation area and open circulation area for easy
spaces according to need moment of staff and
and local law equipments
infrastructure for telephone and Intercom
intramural and extramural Services
communication
ME C1.6 Service counters are Availability of adequate OB According to the
available as per patient patient care units as per delivery load
load case load (Calculation
as per GOI
guidelines)
ME C1.7 The facility and SNCU is easily accessible OB
departments are planned from labour room,
to ensure structure follows maternity ward and
the function/processes obstetric OT
(Structure commensurate Arrangement of OB Unidirectional
with the function of the different section ensures flow of goods
hospital) unidirectional flow and services.
Location of nursing station OB
and patients beds enables
easy and direct observation
of patients
Standard C2 Facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the Non structural components OB Check for
seismic safety of the are properly secured fixtures and
infrastructure furniture like
cupboards,
cabinets,
and heavy
equipments ,
hanging objects
are properly
fastened and
secured
ME C2.3 The facility ensures safety SNCU does not have OB Switch Boards
of electrical establishment temporary connections and other electrical
loosely hanging wires installations are
intact
SNCU has mechanism for OB/RR
periodical check / test of
all electrical installation
by competent electrical
Engineer
10 central Voltage stabilize OB/RR 50% 0f each
outlets are available with should be
each warmer in main SNCU, 5amp and 50%
Step down area and triage should be 15
room amp to handle
equipments
SNCU has system for power OB/RR
audit of unit at defined
intervals and records of
same is maintained
SNCU has earthling system OB/RR Dedicated
available earthling pit
system available

SNCU has dedicated OB/RR Earth resistance
earthling pit system should be
available and records of its measured twice
measurement is maintained in a year and
logged
Wall mounted digital OB Normal range
display is available in SNCU 3-5 V (if exceed
to show earth to neutral to report
voltage immediately)
Quality output of voltage OB
stabilizer is displayed in
each stabilizer as per
manufacturer guideline
Power boards are marked OB
as per phase to which it
belongs
SNCU has system to OB/RR Earth resistance
measure earth resistance at should be
defined interval measured twice
in a year and
logged
ME C2.4 Physical condition of Floors of the SNCU are non OB
buildings are safe for slippery and even
providing patient care Windows/ ventilators if any OB
in the OT are intact and
sealed
Standard C3 Facility has established program for fire safety and other disaster
ME C3.1 The facility has plan for SNCU has sufficient fire exit OB/SI
prevention of fire to permit safe escape to its
marked.
ME C3.2 The facility has adequate SNCU has installed fire OB
fire fighting Equipment Extinguisher that is Class A ,
ClassB, C type or ABC type
SNCU has provision of OB
Smoke and heat detector
SNCU has electrical and OB/RR
automatic fire alarm system
or alarm system sounded by
actuation of any automatic
fire extinguisher
extinguisher as well as due
date for next refilling is
clearly mentioned
periodic training of staff compatencies for operating
and conducts mock drills fire extinguisher and what
regularly for fire and other to do in case of fire
disaster situation

Standard C4 Facility has the appropriate number of staff with the correct skill mix required for providing the
assured services to the current case load
ME C4.1 The facility has adequate Availability of fulltime OB/RR At least one
specialist doctors as per Paediatrician paediatrician
service provision
ME C4.2 The facility has adequate Availability of 1 Medical OB/RR
general duty doctors as per officer per shift
load
ME C4.3 The facility has adequate Availability of 3 Nursing OB/RR/SI
nursing staff as per service staff per shift
ME C4.4 The facility has adequate Availability 1 technician for OB/SI
technicians/paramedics as side lab
per requirement
ME C4.5 The facility has adequate Availability of SNCU SI/RR Availability of
support / general staff attendant one sanitary
staff and ayahs
Availability Security staff SI/RR
Availability of one data SI/RR
entry operator
ME C4.6 The staff has been Facility based New Born SI/RR To all Medical
provided required training Care (FBNC) training Officers and
/ skill sets Nursing Staff
posted at SNCU
Training on infection control SI/RR
and hand hygiene
Training on Bio Medical SI/RR
waste Management
ME C4.7 The Staff is skilled as per Nursing staff is skilled for SI/RR
job description operation of equipments
resuscitation of New Born
Nursing staff is skilled SI/RR
identifying and managing
complication
Nursing Staff is skilled for SI/RR
maintaining clinical records
ME C5.1 The departments have Availability of Antibiotics OB/RR Inj. Ampicillin
availability of adequate with Cloxacillin,
drugs at point of use Inj. Ampicillin
Inj. Cefotaxime
Inj. Gentamycin
Amoxycillin-
Clavulanic
Suspension
Availability of analgesics OB/RR Paracetamol
and antipyretics
Availability of IV Fluids OB/RR 5%, 10%, 25%
Dextrose
Normal saline

Availability of other OB/RR Inj. Adrena-
emergency drugs line (1:10000)
Inj. Naloxone
Sodium Bicar-
bonate Injection
Aminophy lline
Phenobarbi
tone (Injection
+oral) Injection
Hydrocortisone,
Inj. Dexam-
ethasone, Inj.
Phenytoin
Drugs for electrolyte OB/RR Inj. Potassium
imbalance Chloride 15%
Inj. Calcium
Gluconate 10%
Inj. Magnesium
Sulphate 50%
Availability of drugs for OB/RR Vit K ,
newborn
ME C5.2 The departments have Availability of dressings OB/RR Gauze piece and
adequate consumables at material and diapers cotton swabs,
point of use Diapers,
Availability of syringes and OB/RR Neoflon 24 G ,
IV Sets /tubes microdrip set
with &without
burette, BT set,
Suction catheter,
PT tube, feeding
tube
Availability of Antiseptic OB/RR Antiseptic lotion
Solutions
Others OB/RR Baby ID tag,
cord clamp,
mucus sucker,
maintained at every point maintained
of care, where ever it may
be needed
Standard C6 Facility has equipments & instruments required for assured list of services.
ME C6.1 Availability of equipment Availability of functional OB Multiparamoni-
& instruments for Equipment &Instruments tor , Thermom-
examination & monitoring for examination & eter, Weighing
of patients Monitoring scale, pulse oxy
meter, Stetho-
scope
ME C6.3 Availability of equipment & Availability of diagnostic OB Availability of
instruments for diagnostic instruments for side services in side
procedures being laboratory lab; Micro hem
undertaken in the facility atocrit,Multisti
x,Bilirubinome
ter,Microscope
,Dextrometer,
Glucometer

ME C6.4 Availability of equipment Functional Patient care OB Radiant
and instruments for units warmers and
resuscitation of patients phototherapy
and for providing intensive machine
and critical care to patients Functional Critical care OB Infusion
Equipments pumps,Oxygen
cylinder/central
line/Oxygen
concentrator,
oxygen hood,
Functional Resuscitation OB Bag and mask,
equipments laryngoscope,
ET tubes,
suction machine
ME C6.5 Availability of Equipment Availability of equipment OB Refrigerator,
for Storage for storage for drugs Crash cart/
Drug trolley,
instrument
trolley, dressing
trolley
ME C6.6 Availability of functional Availability of equipments OB Buckets for
equipment and for cleaning mopping,
instruments for support Separate mops
services for inborn and
outborn and
circulation area,
duster, waste
trolley, Deck
brush
Availability of dedicated OB
washing machine for SNCU
Availability of equipment OB Autoclave
disinfection
ME C6.7 Departments have patient Availability of Fixtures OB Electrical panel
furniture and fixtures as per with each unit,
load and service provision X ray view box.
Availability of furniture OB Cupboard,
nursing counter,
table for
preparation of
medicines, chair,
furniture at
breast feeding
room.
Standard D1 Facility has established program for inspection, testing and maintenance and calibration of
equipments.
ME D1.1 The facility has established All equipments are covered SI/RR Radiant
system for maintenance of under AMC including warmer, suction
critical Equipment preventive maintenance machine,
Oxygen
concentrator,
pulse oximeter/
Multipara
monitor

maintenance of the
equipments
There has system to label OB/RR
Defective/Out of order
equipments and stored
appropriately until it has
been repaired
Staff is skilled for trouble SI/RR
shooting in case equipment
malfunction
Periodic cleaning, inspection SI/RR
and maintenance of the
equipments is done by the
operator
ME D1.2 The facility has established All the measuring OB/ RR
procedure for internal and equipments/ instrument
external calibration of are calibrated
measuring Equipment There is system to label/ OB/ RR
code the equipment
to indicate status of
calibration/ verification
when recalibration is due
ME D1.3 Operating and Up to date instructions for OB/SI
maintenance instructions operation and maintenance
are available with the users of equipments are readily
of equipment available with SNCU staff.
ME D2.1 There is established There is established system SI/RR Stock level are
procedure for forecasting of timely indenting of daily updated
and indenting drugs and consumables and drugs at Requisition are
consumables nursing station timely placed
consumables and are labelled
are labelled
Expressed milk is stored at OB/RR
recommended temperature
ME D2.4 The facility ensures Expiry dates’ are maintained OB/RR
management of expiry and at emergency drug tray
near expiry drugs No expiry drug found OB/RR
maintained for drug stored
at department
ME D2.5 The facility has established There is practice of SI/RR
procedure for inventory calculating and maintaining
management techniques buffer stock in SNCU
consumables
periodically replenishing replenishing drug tray /
the drugs in patient care crash cart
areas There is no stock out of drugs OB/SI

ME D2.7 There is process for storage Temperature of refrigerators OB/RR Check for
of vaccines and other are kept as per storage temperature
drugs, requiring controlled requirement and records charts are
temperature are maintained maintained
and updated
periodically
ME D3.1 The facility provides Adequate Illumination at OB Separate
adequate illumination level nursing station procedure
at patient care areas lightening
capable of
providing not
less than 200Lux
at the plane
of infant bed,
Ambient
lightening
levels in infants
spaces shall
be adjustable
through range
of at least 50 to
more than 600
Lux.
Adequate illumination in OB
patient care unit
ME D3.2 The facility has provision One female family members OB/SI
of restriction of visitors in allowed to stay with the
patient areas new born in step down
Entry to SNCU is restricted OB
Visiting hour are fixed and OB/PI
practiced
ME D3.3 The facility ensures SNCU has system to control SI/RR Temperature
safe and comfortable temperature and humidity inside main
environment for patients and record of same is SNCU should
and service providers maintained be maintained
at (22-26OC),
round O clock
preferably by
thermostatic
control. Relative
humidity of 30-
60% should be
maintained
SNCU has procedure to SI/RR Each equipment
check the temperature used should have
of radiant warmer servo controlled
,phototherapy units, baby devices for
incubators etc. heat control
with cut off to
limit increase in
temperature of
radiant warmers
beyond a certain
temperature
or warning
mechanism for
sounding alert/
alarm when
temp increases
beyond certain
limits

SNCU has system to control SI/RR Background
the sound producing sound should
activities and gadgets (like not be more
telephone sounds, staff area than 45 db and
and equipments) peak density
should not be
more than 80db.
SNCU has functional SI/RR 1 for each
room thermometer and patient care
temperature is regularly room
maintained
ME D3.4 The facility has security New born identification OB/RR
system in place at patient band and foot prints are in
care areas practice
There is procedure for SI
handing over the baby to
mother/father
Security arrangement in OB
SNCU
ME D3.5 The facility has established Ask female staff whether SI
ME D4.2 Patient care areas are clean Floors, walls, roof, roof OB All area are
and hygienic topes, sinks patient care and clean with no
circulation areas are Clean dirt, grease,
littering and
cobwebs
fixtures are clean
running water
ME D4.3 Hospital infrastructure is Check for there is no OB
adequately maintained seepage , Cracks, chipping
of plaster
painted
clean
removal of condemned material in the SNCU
junk material
and animal control

arrangement storage and and potable water
supply for portable water
in all functional areas
ME D5.2 The facility ensures Availability of power back OB/SI
adequate power backup up in patient care areas
in all patient care areas as Availability of UPS OB/SI
per load
Availability of Emergency OB/SI
light
ME D5.3 Critical areas of the facility Availability of Centralized OB
ensures availability of /local piped Oxygen and
oxygen, medical gases and vacuum supply
vacuum supply
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 RR/SI
nutritional assessment of patient done specially for
the patients mother of admitted baby
ME D6.2 The facility provides diets Check for the adequacy OB/RR Check that all
according to nutritional and frequency of diet as per items fixed in
requirements of the nutritional requirement diet menu is
patients provided to the
patient
Check for the Quality of diet PI/SI Ask patient/staff
provided weather they are
satisfied with the
Quality of food
ME D7.1 The facility has adequate SNCU has facility to provide OB/RR
sets of linen sufficient and clean linen
for each patient
Gown are provided to OB/RR
visitors/staff at the entrance
of SNCU
ME D7.2 The facility has established Linen is changed every day OB/RR
procedures for changing of and whenever it get soiled
linen in patient care areas
procedures for handling , the cleanliness and Quantity
collection, transportation of the linen received from
and washing of linen laundry
guidelines
ME D11.2 The facility has a There is procedure to RR/SI Check for system
established procedure for ensure that staff is available for recording
duty roster and deputation on duty as per duty roster time of reporting
to different departments and relieving
(Attendance
register/
Biometrics etc)

code as mandated by its respective dress code
department
for contract management monitor the quality and outsourced
for out sourced services adequacy of outsourced services
Dietary/
Laundry/
Security/
Maintenance)
provided
are done by
designated in-
house staff
procedure for registration number is given to each
of patients patient during process of
registration
Patient demographic details RR Check for
are recorded in admission that patient
records demographics
like Name,
age, Sex, Chief
complaint, etc.
ME E1.3 There is established Admission criteria for SNCU SI/RR
procedure for admission of is defined & followed
patients There is no delay in SI/RR/OB
admission of patient
doctor
ME E1.4 There is established Procedure cope with OB/SI
procedure for managing surplus patient load
patients, in case beds are
not available at the facility
the patients.
ME E2.1 There is established Initial assessment of all RR/SI Defined criteria
procedure for initial admitted patient done as for assessment
assessment of patients per standard protocols like Silverman
Anderson Score
and down score
Patient History is taken and RR
recorded

wherever required
recorded
immediately
within 2 hours
admitted in the ward there
is provision of reassessment
as per need
ME E3.1 The facility has There is procedure of taking RR/SI Check
established procedure for over of new born from continuity
continuity of care during labour OT/ Ward to SNCU of care is
interdepartmental transfer maintained
while
transferring/
handover the
patient
ME E3.2 The facility provides Patient referred with referral RR/SI
appropriate referral slip
linkages to the patients/ Advance communication is RR/SI
Services for transfer to done with higher centre
other/higher facilities to
assure the continuity of Referral vehicle is being SI/RR
care. arranged
Facility has functional SI/RR Check for
referral linkages to lower referral cards
facilities filled from lower
facilities
There is a system of follow RR
ME E3.3 A person is identified for Duty Doctor and nurse is RR/SI
care during all steps of care assigned for each patients
ME E4.1 Procedure for identification Identification tags are OB/SI
of patients is established at used for identification of
the facility newborns
timely and accurate maintained treatment chart
nursing care as per are updated
treatment plan is and drugs given
established at the facility are marked. Co
relate it with
drugs and doses
prescribed.

There is a process to ensue SI/RR Verbal orders
the accuracy of verbal/ are rechecked
telephonic orders before
administration
procedure of patient hand during the change in the shift
over, whenever staff duty Nursing Handover register is RR
change happens maintained
Hand over is given bed side SI/RR
register. Notes
are adequately
written
ME E4.5 There is procedure for Patient Vitals are monitored RR/SI Check for
periodic monitoring of and recorded periodically TPR chart,
patients Phototherapy
chart, any other
vital required is
monitored
Critical patients are RR/SI Check for use of
monitored continually cardiac monitor/
multi parameter
vulnerable patients and identified and measures are measure taken
ensure their safe care taken to protect them from to prevent new
any harm born theft,
sweeping and
baby fall
ME E5.2 The facility identifies high High risk patients are OB/SI
risk patients and ensure identified and treatment
their care, as per their need given on priority
ME E6.1 The facility ensured that Check for BHT if drugs are RR
drugs are prescribed in prescribed under generic
ME E6.2 There is procedure of Check for that relevant RR
point of use
per STG
formulary
ME E7.1 There is process for High alert drugs available in SI/OB Electrolytes
identifying and cautious department are identified like Potassium
administration of high alert chloride, Opioids,
drugs (to check) Neuro muscular
blocking
agent, Anti
thrombolytic
agent, insulin,
warfarin,
Heparin,
Adrenergic
agonist etc. as
applicable

alert drugs are defined and maximum
communicated doses as per
age, weight and
diagnosis are
available with
nursing station
and doctor
that right doses of high alert independent
drugs are only given double
check before
administration,
Error prone
medical
abbreviations
are avoided
adequately with date , time and
signature
clinical staff
ME E7.3 There is a procedure Drugs are checked OB/SI
administration/ dispensing inconsistency before
administration
Check single dose vial are OB Check for
not used for more than one any open
dose single dose
vial with left
over content
intended to be
used later on
Check for separate sterile OB In multi dose
needle is used every time vial needle is
for multiple dose vial not left in the
septum
right medicine is given to are calculated according to calculation chart
right patient body weight
Drip rate and volume is SI/RR Check the
calculated and monitored nursing staff
how they
calculate
Infusion and
monitor it
Administration of medicines SI/OB
done after ensuring right
patient, right drugs , right
route, right time
ME E8.1 All the assessments, Patient progress is recorded RR
re-assessment and as per defined assessment
investigations are recorded schedule
and updated

ME E8.2 All treatment plan Treatment plan, first orders RR Treatment
prescription/orders are are written on BHT prescribed in
records.
ME E8.3 Care provided to each Maintenance of treatment RR Treatment given
patient is recorded in the chart/treatment registers is recorded in
patient records treatment chat
ME E8.4 Procedures performed are Procedure performed are RR Mobilization,
written on patients records recorded in BHT resuscitation etc
ME E8.5 Adequate form and Standard Formats are RR/OB Availability
formats are available at available of formats for
point of use Treatment
Charts, TPR
Chart , Intake
Output Chart,
Community
follow up
card, BHT,
continuation
sheet, Discharge
card Etc.
maintained as per are maintained as per book (GOB),
guidelines guidelines report book,
Admission
register, lab
register,
Admission
sheet/ bed head
ticket, discharge
slip, referral
slip, referral
in/referral out
register, OT
register, Diet
register, Linen
register, Drug
intend register
and adequate storage records
and retrieval of medical
records
ME E9.1 Discharge is done after SNCU has established SI/RR Patient is shifted
assessing patient readiness criteria for discharge of the to ward/step
patient down after
assessment
Assessment is done before SI/RR
discharging patient
doctor
Patient / attendants are PI/SI
consulted before discharge
consulted/ informed before
discharge of patients

ME E9.2 Case summary and Discharge summary is RR/PI See for
follow-up instructions are provided discharge
provided at the discharge summary,
referral slip
provided.
adequately mentions
treatment given and follow
up
Discharge summary is give SI/RR
to patients going in LAMA/
Referral
there is procedure for RR/SI
clinical follow up of the
new born by local CHW
(Community health care
worker)/ASHA
ME E9.3 Counselling services Counselling of mother PI/SI for care of
are provided as during before discharge new born and
discharges wherever breastfeeding,
required treatment
and follow up
counselling
in prior
procedure for patients the LAMA patient
leaving the facility
against medical advice,
absconding, etc
Standard E10 The facility has defined and established procedures for intensive care.
ME E10.3 The facility has explicit Criteria are defined for RR/SI
clinical criteria for intubation
providing intubation &
extubation, and care of
patients on ventilation
and subsequently on its
removal
Management
ME E11.1 There is procedure for Triaging of new born as per SI/RR
Receiving and triage of guidelines
patients
ME E11.4 The facility ensures System for coordinating SI/RR
adequate and timely with ambulances
availability of ambulances
services and mobilisation
of resources, as per
requirement

SNCU has provision of SI/RR
Ambulance to refer the case
to higher centre
Ambulance has provision/ SI/RR
method for maintenance of
Warm chain while referred
to higher centre
Ambulance/transport OB/RR
vehicle have adequate
arrangement for Oxygen
Ambulance/transport OB/RR
vehicle have dedicated
rescue kit including “
essential supplies kit”,
emergency drug kit
SNCU has system SI/RR
to periodic check of
ambulances/transport
vehicle by driver/paramedic
staff and counter checked
by SNCU staff
Transfer of patient in SI/RR
Ambulance /patient
transport vehicle is
accompanied by trained
medical Practitioner
ME E12.3 There are established SNCU has critical values of SI/RR
procedures for Post-testing various lab test
Activities
Transfusion.
ME E13.8 There is established Paediatric blood bags are RR/SI if not available
procedure for issuing available than how facility
blood cope with it
procedure for transfusion transfusion
of blood Patient’s identification is SI/OB
Blood is kept on optimum RR
temperature before
transfusion
monitored and regulated by
qualified person
written in patient recorded

relatives
SNCU has system for RR/SI
conducting grievance
counselling of parents in
case of newborns’ mortality
patient record
ME E16.2 The facility has standard Death note including efforts SI/RR
procedures for handling done for resuscitation is
the death in the hospital noted in patient record
Procedure to declare death SI/RR
for brought in dead cases
Death summary is given to SI/RR
patient attendant quoting
the immediate cause and
underlying cause if possible
ME E16.3 The facility has standard Patients Relatives are SI/RR
operating procedure for informed clearly about
end of life support the deterioration in health
condition of Patients
There is a procedure to SI/OB
allow patient relative/Next
of Kin to observe patient in
last hours
ME E20.1 The facility provides Immunization services as SI/RR zero dose,
immunization services as per national guidelines system of
per guidelines ensuing
immunization
ME E20.2 Triage, Assessment & Adherence to clinical SI/RR Competence
Management of newborns protocol testing
having
emergency signs are done
as per guidelines
ME E20.3 Management of Low birth Adherence to clinical SI/RR Competence
weight protocol testing
newborns is done as per
guidelines
ME E20.4 Management of neonatal Adherence to clinical SI/RR Competence
asphyxia, jaundice and protocol testing
sepsis is done as per
guidelines
ME F1.2 The facility has provision Surface and environment SI/RR Swab are taken
for Passive and active samples are taken for from infection
culture surveillance of microbiological surveillance prone surfaces
critical & high risk areas

ME F1.3 The facility measures There is procedure to report SI/RR Patients are
hospital associated cases of Hospital acquired observed for
infection rates infection any sign and
symptoms
of HAI like
fever, purulent
discharge from
surgical site .
ME F1.4 There is Provision of There is procedure for SI/RR Hepatitis B,
Periodic Medical Check-up immunization of the staff Tetanus Toxid
and immunization of staff etc
Periodic medical checkups SI/RR
of the staff
intervals
ME F1.6 The facility has defined Check for Doctors are aware SI/RR
and established antibiotic of Hospital Antibiotic Policy
policy
antisepsis
ME F2.1 Hand washing facilities are Availability of hand washing OB FNBC guideline:
provided at point of use Facility at Point of Use Each unit should
have at least 1
wash basin for
every 5 beds
Availability of running Water OB/SI Ask to Open the
tap. Ask Staff
water supply is
regular
soap with soap dish/ liquid availability/
antiseptic with dispenser. Ask staff if
the supply is
adequate and
uninterrupted
staff for regular
supply. Hand
rub dispenser
are provided
adjacent to bed
Instruction at Point of Use displayed
above the hand
washing facility
, preferably in
Local language
operated taps
to prevent splashing and
retention of water

ME F2.2 The facility staff is trained Adherence to 6 steps of SI/OB Ask of
in hand washing practices Hand washing demonstration
and they adhere to Staff aware of when to hand SI
standard hand washing wash
practices
Mothers are practicing PI/OB
wash hand washing with
soap
ME F2.3 The facility ensures Availability of Antiseptic OB
materials for antisepsis Proper cleaning of OB/SI like before
drawing
blood, putting
Intravenous and
urinary catheter
ME F3.1 The facility ensures Clean gloves are available at OB/SI Handwashing
adequate personal point of use b/w each
protection Equipment as patient &
per requirements change of
gloves
Availability of Mask OB/SI
Availability of gown/ Apron OB/SI Staff and visitors
Availability of shoe cover OB/SI Staff and visitors
Availability of Caps OB/SI Staff and visitors
Personal protective kit for OB/SI HIV kit
infectious patients
ME F3.2 The facility staff adheres No reuse of disposable OB/SI
to standard personal gloves, Masks, caps and
removing the gloves
ME F4.1 The facility ensures Cleaning & SI/OB Cleaning of
standard practices Decontamination of patient Radiant warmer,
and materials for care Units Incubators and
decontamination and Bassinets with
cleaning of instruments detergent water
and procedures areas Proper Decontamination of SI/OB Decontami-
instruments after use nation for
thermometer,
Stethoscope,
Suction appara-
tus, ambu bag
70% Alcohol or
detergent water
as applicable
decontamination is
adequate
and running wa-
ter after decon-
tamination

Proper handling of Soiled SI/OB No sorting
and infected linen ,Rinsing or
sluicing at Point
of use/ Patient
care area
chlorine solution
ME F4.2 The facility ensures Equipment and instruments OB/SI Autoclaving/
standard practices and are sterilized after each use HLD/Chemical
materials for disinfection as per requirement Sterilization
and sterilization of High level Disinfection of OB/SI Ask staff about
instruments and instruments/equipments is method and
equipment done as per protocol time required
for boiling
Autoclaving of instruments OB/SI Ask staff about
is done as per protocols temperature,
pressure and
time
Chemical sterilization of OB/SI Ask staff about
instruments/equipments is method,
done as per protocols concentration
and contact
time required
for chemical
sterilization
Autoclaved linen are used OB/SI
for procedure
material is used
There is a procedure to OB/SI
ensure the traceability of
sterilized packs
Sterility of autoclaved OB/SI Sterile packs
packs is maintained during are kept in
storage clean, dust
free, moist free
environment.
ME F5.1 Layout of the department Facility layout ensures OB
is conducive for the separation of general traffic
infection control practices from patient traffic
Facility layout ensures OB
separation of routes for
clean and dirty items
SNCU has double door OB
system
There is separation between OB by glass pane
in born and out born unit
Floors and wall surfaces of OB
SNCU are easily cleanable
ME F5.2 The facility ensures Availability of disinfectant OB/SI Chlorine
availability of standard as per requirement solution,
materials for cleaning and Gluteraldehye,
disinfection of patient care carbolic acid
areas Availability of cleaning OB/SI Hospital
agent as per requirement grade phenyl,
disinfectant
detergent
solution

ME F5.3 The facility ensures Staff is trained for spill SI/RR
standard practices are management
followed for the cleaning Cleaning of patient care SI/RR
and disinfection of patient area with detergent solution
care areas
standard procedure
followed inside out
dispersion of
dust particles
in air should be
avoided
Use of three bucket system OB/SI
for mopping
Fumigation/carbolization as SI/RR
per schedule
External foot wares are OB
restricted
ME F5.4 The facility ensures Isolation and barrier nursing OB/SI
segregation infectious procedure are followed for
patients septic cases
ME F5.5 The facility ensures air SNCU has system to OB Ventilation can
quality of high risk area maintain ventilation and be provided
its environment should be in two ways:
dust free exhaust only
and supply-and-
exhaust. Exhaust
fans pull stale air
out of the unit
while drawing
fresh air in
through cracks,
windows or
fresh air intakes.
Exhaust-only
ventilation is a
good choice for
units that do not
have existing
ductwork to
distribute
heated or
cooled air
ME F6.1 Facility Ensures segregation Availability of colour coded OB
of Bio Medical Waste as per bins at point of waste
guidelines generation
Availability of plastic colour OB
coded plastic bags

guidelines
for segregation and
waste
Facility ensures standard There is no mixing of OB
practices and materials infectious and general
for decontamination and waste
cleaning of instruments
and procedures areas
ME F6.2 Facility ensures Availability of functional OB See if it has
management of sharps as needle cutters been used or
per guidelines just lying idle
the point of
generation like
nursing station
and injection
room
disposal syringes is not
done in open
buckets
sharps
prophylaxis Where it is
stored and who
is in charge of
that.
Staff knows what to do in SI Staff knows
condition of needle stick what to do in
injury. Whom to
report. See if any
reporting has
been done
ME F6.3 Facility ensures Check bins are not overfilled SI
transportation and disposal Disinfection of liquid waste SI/OB
of waste as per guidelines before disposal
management
team in place departmental nodal person

ME G2.1 Patient satisfaction surveys Patient relative satisfaction RR
are conducted at periodic survey done on monthly
intervals basis
Manager/ Matron in charge
for monitoring of services
ME G3.3 The facility has established Departmental checklist are SI/RR
system for use of check lists used for monitoring and
in different departments quality assurance
and services Staff is designated for filling SI
checklists
approved
owner
ME G4.2 Standard Operating SNCU has documented RR
Procedures adequately procedure for receiving and
describes process and assessment of the patient
procedures SNCU has documented RR
procedure for admission of
the new born
SNCU has documented RR
procedure for discharge of
the patient from unit
procedure for triage of new
borns
procedure for assessment
and treatment of new born
emergency signs
procedure for neonatal
transportation and referral
from unit
procedure for shifting the
patient in Step down unit
procedure for collection,
transfer and reporting the
sample to side laboratory

procedure for clinical
assessment and
reassessment of the patient
and doctor follows it
procedure for key clinical
protocols
procedure for preventive-
break down maintenance
and calibration of
equipments
system for storage, retaining
,retrieval of SNCU records
procedure for purchase
of External services and
supplies
procedure for Maintenance
of infrastructure of SNCU
procedure for
thermoregulation of new
borns
procedure for
drugs,intravenous,and fluid
management and nutrition
management of new borns
procedure for resuscitation
of new born if required
procedure for infection
control practices
procedure for inventory
management
procedure for entry of
parents visitor
ME G4.3 Staff is trained and aware Check staff is a aware of SI/RR
of the procedures written relevant part of SOPs
in SOPs

ME G4.4 Work instructions are Work instruction/clinical OB STP for
displayed at Point of use protocols are displayed phototherapy,
Grading and
management
of hypothermia,
Expression
of milk\,
Monitoring
of babies
receiving I/V,
Precaution for
phototherapy,
Management of
hypoglycaemia,
housekeeping
protocols,
Administration
of commonly
used drugs,
assessment of
neonatal sepsis,
Assessment
of Jaundice,
Temperature
maintenance etc
ME G5.1 The facility maps its critical Process mapping of critical SI/RR
ME G5.2 The facility identifies non Non value adding activities SI/RR
value adding activities are identified
/ waste / redundant
activities
ME G5.3 The facility takes corrective Processes are rearranged as SI/RR
processes
ME G6.1 The facility conducts Internal assessment is done RR/SI
periodic internal at periodic interval
assessment
conduct New born Death
audit
non compliances are enumerated and recorded
enumerated and recorded
adequately
ME G6.4 Action plan is made on Action plan prepared RR/SI
the gaps found in the
assessment / audit process

actions are taken to action taken
address issues, observed in
the assessment & audit
ME G7.2 The facility periodically Quality objective for SNCU RR/SI
defines its quality are defined
objectives and key
departments have their
own objectives
ME G7.3 Quality policy and Check of staff is aware SI
disseminated and staff is objectives
aware of that
services
ME G8.2 The facility uses tools for Control Charts SI/RR
quality improvement in
services
benchmarks
ME H1.1 Facility measures Inborn admission rate RR Proportion of
productivity Indicators on inborn babies
monthly basis admitted in the
unit
Proportion of admissions RR
which are out born
Bed Occupancy Rate RR
ME H1.2 The Facility measures Proportion of female babies RR
equity indicators admitted
periodically LAMA rate for female babies RR
Proportion of BPL Patients RR
ME H2.1 Facility measures efficiency Proportion of very low birth RR No. of very low
Indicators on monthly basis weight babies birth weight
babies (< 1200
gm)/No. of Low
birth+ Very low
birth babies
Down time Critical RR
Equipments
Bed Turnover Rate RR
Referral Rate RR
Survival rate RR Discharge rate
No. of drug stock out in RR
SNCU

benchmark
ME H3.1 Facility measures Clinical Average waiting time RR
Care & Safety Indicators on for initial assessment of
monthly basis newborn
Proportion of newborn RR
deaths among
inborn
Proportion of newborn RR
deaths among
out-born
Case Fatality Rates RR Respiratory

distress
syndrome (RDS)
Meconium
aspiration
syndrome (MAS)
• Hypoxic-
ischemic
encephalophaty
(HIE/ moderate/
severe birth
asphyxia(BA)
• Sepsis/
pneumonia/
meningitis
Ma)or congenial
malformation
• Prematurely
Proportion of asphyxiated RR
newborn babies admitted
out of deliveries conducted
at facility
Antibiotic use rate RR
Average length of stay RR
Adverse events are reported RR Baby theft,
wrong drug
administration,
needle
stick injury,
absconding
patients etc
No of Newborn Resuscitated RR
% of environmental swab RR
culture reported positive
benchmark
Quality Indicators on Attendant Satisfaction Score RR
monthly basis

Assessment Summary
A. Score Card
sick newborn care unit (SNCU) Score Card
Sick Newborn Care Unit (SNCU) Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Checklist–7
Nutritional
rehabilitation centre
(nrc)
Version: 1/2013

Checklist–7
Checklist for Nutritional rehabilitation centre (nrc)

ME A1.4 The Facility Provides Paediatric Availability of functional SI/OB For detail service
Services NRC provision kindly
refer A2.4
ME A1.14 Services are available for the Availability of NRC SI/RR
ME A2.4 The Facility provides child Management of SI/RR
health services hypoglycaemia as per
the guideline
Management of SI/RR
hypothermia as per the
guideline
Management of SI/RR
dehydration in the
children with SAM,
without shock as per the
guideline
Management of SAM SI/RR
child with shock as per
the guideline
Management of SI/RR
infection is done as per
the guideline.
children less than 6
months
in HIV exposed/HIV
infected and TB infected
children as per the
guidelines
Provision of Therapeutic SI/RR/OB
feeding as per guideline
Counselling on SI/RR/OB
appropriate feeding,
care and hygiene as per
guideline
Demonstration and SI/RR/OB
practice- by -doing on
preparation of energy
dense child food using
locally available items
ME A3.2 The Facility Provides NRC has facility / SI/OB Availability
Laboratory Services Linkage for laboratory of Side lab.
investigation Blood glucose,
Haemoglobin,
Serum
electrolyte,
TLC, DLC, urine
routine, urine
culture,Mantoux
test, HIV (after
counselling) and
any specific test
based on local
and geographic
needs like
coeliac disease
and malaria.
If linkage to
outside lab
then it is partial
compliance
Standard A5 Facility provides support services
ME A5.1 The facility provides dietary Availability of functional SI/OB
services nutritional services
ME B1.1 The facility has uniform and Availability OB (Numbering,
user-friendly signage system departmental signage’s main
department
and internal
sectional
signage
Visiting hours and OB
visitor policy are
displayed
ME B1.2 The facility displays the Service available at NRC OB
services and entitlements are displayed
available in its departments Entitlement under JSSK OB
and RBSY are displayed
Information about OB
doctor/ Nurse on duty is
Contact information in OB
respect of NRC referral
services are displayed
ME B1.5 Patients & visitors are Display of information OB Display of
sensitised and educated for education of mother pictorial
through appropriate IEC / BCC /care taker information/
approaches chart regarding
expression
of milk,
management
of sick children
with SAM etc.,
230 | Checklist for Nutritional Rehabilitation Centre (nrc)

Counselling aids are OB
available for education
of the mother/care taker
ME B1.6 Information is available in Signage’s and OB
local language and easy to information are
understand available in local
language
ME B1.8 The facility ensures access to Discharge summery is RR/OB
clinical records of patients to given to the patient
entitled personnel
ME B2.1 Services are provided in Cots in NRC are large OB
manner that are sensitive to enough for stay of
gender mother with child
ME B3.1 Adequate visual privacy is Privacy is maintained at OB
provided at every point of breast feeding area
care
ME B3.2 Confidentiality of patients’ Patient Records are kept SI/OB
records and clinical at secured place beyond
visitors
ME B3.3 The facility ensures the Behaviour of staff PI/OB
behaviours of staff is dignified is empathetic and
and respectful, while courteous
ME B4.1 There is established procedure NRC has system in SI/RR
for taking informed consent place to take informed
before treatment and consent from patient
procedures relative whenever
required
ME B4.4 Information about the NRC has system in PI
treatment is shared with place to involve patient
patients or attendants, relatives in decision
regularly making of the treatment
NRC has system in PI/SI
place to provide
communication of child
condition to parents/
relatives at least once
in day
ME B4.5 Facility has defined and Availability of complaint OB
established grievance box and display of
redressal system in place process for grievance re
addressal and whom to
ME B5.1 The facility provides cashless Availability of Free PI/SI
services to pregnant women, diagnostics
mothers and neonates as
per prevalent government
schemes
Checklist for Nutritional Rehabilitation Centre (nrc) | 231

Availablity of Free drop PI/SI
back
Availablity of Free diet to PI/SI
patient
Availablity of Free Diet PI/SI
to mother
Availablity of Free PI/SI
patient transport
Availabliity of Free Blood PI/SI
Availablity of Free drugs PI/SI
Availablity of free stay PI/SI
in NRC
ME B5.2 The facility ensures that drugs Check that patient PI/SI
prescribed are available at party has not spent
Pharmacy and wards on purchasing drugs
or consumables from
outside.
ME B5.3 It is ensured that facilities for Check that patient PI/SI
the prescribed investigations party has not spent
are available at the facility on diagnostics from
outside.
timely reimbursement of expenditure occurred,
financial entitlements and it is reimbursed from
reimbursement to the patients hospital
NRC has system PI/SI/RR
to provide Wage
compensation to
mother/caregiver for the
duration of the stay at
NRC as per basic daily
wages of the state
the prevalent norms
ME C1.1 Departments have adequate NRC has adequate space OB Covered area
space as per patient or work as per guideline for NRC should
load be about 150 sq
ft per bed with
30% of ancillary
area.
ME C1.2 Patient amenities are provide Availability of drinking OB
as per patient load water
Toilets for attendant/ OB
visitor
Availability of sitting OB
arrangement for patient
attendant
Availability of separate OB
Bathing area and
laundry area for mothers

ME C1.3 Departments have layout Availability of nursing OB
and demarcated areas as per station
functions Receiving room with OB
examination area
Clean area for mixing OB
intravenous fluids and
Medications/ fluid
preparation area
Availability of Doctors OB
duty room
utility area
Availability of breast OB
feeding corner/ Area for
expression of breast milk
Availability of unit stores OB
NRC has designated OB
play area and
counselling room in
proximity to NRC ward
NRC has designated OB
kitchen area in proximity
to NRC ward
NRC has separate OB
washing area
circulation area and open between two bed to two beds should
spaces according to need and provide bed side nursing be at least 4 ft
local law care and movement and clearance
between head
end of bed and
wall should be
at least 1 ft and
between side
of bed and wall
should be 2 ft
Corridors are wide OB Corridor should
enough for patient, be 3 meters
visitor and trolley/ wide
equipment movement
for intramural and extramural telephone and Intercom
communication Services
ME C1.6 Service counters are available Availability of adequate OB
as per patient load beds as per case load
ME C1.7 The facility and departments NRC should be OB
are planned to ensure in proximity with
structure follows the Paediatric/in patient
function/processes (Structure facility
commensurate with the Location of nursing OB
function of the hospital) station and patients
beds enables easy and
direct observation of
patients

Standard C2 Facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the seismic Non structural OB Check for
safety of the infrastructure components are fixtures and
properly secured furniture like
cupboards,
cabinets,
and heavy
equipments ,
hanging objects
are properly
fastened and
secured
ME C2.3 The facility ensures safety of NRC does not have OB Switch Boards
electrical establishment temporary connections other electrical
and loosely hanging installations are
wires intact
ME C2.4 Physical condition of buildings Floors of the NRC are OB
are safe for providing patient non slippery and even
care Windows covered wire OB
mesh
Standard C3 Facility has established program for fire safety and other disaster
ME C3.1 The facility has plan for NRC has sufficient OB/SI
prevention of fire fire exit to permit safe
escape to its occupant at
in emergency
marked.
ME C3.2 The facility has adequate fire NRC has installed fire OB
fighting Equipment Extinguisher that is
Class A /B/ C type or ABC
type
mentioned
periodic training of staff and competencies
conducts mock drills regularly for operating fire
for fire and other disaster extinguisher and what
situation to do in case of fire
Standard C4 Facility has the appropriate number of staff with the correct skill mix required for providing the
assured services to the current case load
ME C4.2 The facility has adequate Availability of Medical OB/RR Availability of 1
general duty doctors as per officer Medical officer
service provision and work per 10 bed
load
ME C4.3 The facility has adequate Availability of Nursing OB/RR/SI Availability of 4
nursing staff as per service staff Nursing staff for
provision and work load 10 bedded NRC

ME C4.5 The facility has adequate Availability of nutrition SI/RR Availability
support / general staff counsellor of 1 Nutrition
Counsellor for 10
bedded NRC
Availability of cook SI/RR Availability of
one cook cum
care taker
Availability of cleaner/ SI/RR Availability of
Attendant 2 attendant/
cleaner
Availability of Medical SI/RR Availability of 1
social worker Medical Social
Worker
Availability of security SI/RR 1 Security staff
staff per shift
ME C4.6 The staff has been provided Facility based care SI/RR
required training / skill sets of Severe acute
malnutrition
hand hygiene
Management
ME C4.7 The Staff is skilled as per job Staff is skilled for SI/RR
description nutritional assessment
of baby
Nursing staff is skilled SI/RR
records
ME C5.1 The departments have Availability of Antibiotics OB/RR Inj. Ampicillin
availability of adequate drugs with Cloxacillin,
at point of use Inj. Ampicillin
Inj. Cefotaxime
Inj. Gentamicin,
Availability of analgesics OB/RR Paracetamol
and antipyretics
Availability of IV Fluids OB/RR Ringer’s lactate
solution with 5%
glucose, 0.45%
(half normal)
saline with 5%
glucose, 0.9%
saline (for soak-
ing eye pads)
Availability of other OB/RR Metronidazole,
drugs or Chloram-
phenicol eye
drops, Atropine
eye drops

Electrolyte and minerals OB/RR ORS, Potassium
chloride,
Magnesium
chloride/
sulphate,
Iron syrup,
multivitamin,
folic acid,
Vitamin A syrup,
Zinc sulphate
or dispersible
Zinc tablets,
Glucose(or
sucrose)
Availability of drugs for OB/RR Antiretroviral
management of SAM in drugs,
HIV exposed Cotrimoxazole
prophylaxis
ME C5.2 The departments have Availability of dressings OB/RR Gauze piece and
adequate consumables at material cotton swabs.
point of use
Availability of syringes OB/RR Cannulas, IV
and IV Sets /tubes sets, paediatric
nasogastric tubes
Availability of Antiseptic OB/RR Antiseptic lotion
Solutions
maintained at every point of maintained
needed
Standard C6 Facility has equipments & instruments required for assured list of services.
ME C6.1 Availability of equipment & Availability of OB Thermometers,
instruments for examination & functional Equipment Weighing scale
monitoring of patients &Instruments for s(digital),Infant
examination & ometer,Stadiom
Monitoring eter,
ME C6.3 Availability of equipment & Availability of Point OB Glucometer
instruments for diagnostic of care diagnostic
procedures being undertaken instruments
in the facility
ME C6.4 Availability of equipment and Availability of functional OB
instruments for resuscitation Instruments for
of patients and for providing Resuscitation.
intensive and critical care to
patients
ME C6.5 Availability of Equipment for Availability of OB Refrigerator,
Storage equipment for storage Crash cart/
for drugs Drug trolley,
instrument
trolley, dressing
trolley

ME C6.6 Availability of functional Availability of kitchen OB Cooking Gas,
equipment and instruments equipment Dietary scales (to
for support services weigh to 5 gms.),
Measuring jars,
Electric Blender
(or manual
whisks), Water
Filter,Refrigrator,
Utensils (large
containers,
cooking utensils,
feeding cups,
saucers, spoons,
jugs etc.)
Availability of OB Buckets for
equipment for cleaning mopping, mops,
duster, waste
trolley, Deck
brush
Availability of OB Boiler
equipment for
sterilization and
disinfection
ME C6.7 Departments have patient Availability of patient OB
furniture and fixtures as per beds
load and service provision Availability of OB Hospital graded
attachment/ accessories mattress, Bed
with patient bed side locker ,
IVstand, Bed
pan, bed rail
Availability of Fixtures OB Electrical fixture
for equipments
like suction, X-
ray view box
Availability of furniture OB cupboard,
nursing counter,
table for
preparation of
medicines, chair.
Availability of toys OB Washable toys
Standard D1 Facility has established program for inspection, testing and maintenance and calibration of
equipments.
ME D1.1 The facility has established All equipments are SI/RR Glucometer,
system for maintenance of covered under AMC Infantometer,
critical Equipment including preventive Resuscitation
maintenance equipments,
maintenance of the
equipments
ME D1.2 The facility has established All the measuring OB/ RR
procedure for internal and equipments/ instrument
external calibration of are calibrated
measuring Equipment

ME D2.1 There is established procedure There is established SI/RR Stock level are
for forecasting and indenting system of timely daily updated
drugs and consumables indenting of Requisition are
consumables ,drugs and timely placed
food material
storage of drugs and containers/tray/crash
consumables cart and are labelled
Empty and filled OB
Food items are stored OB/RR
at recommended
temperature
management of expiry and maintained at
near expiry drugs emergency drug tray
maintained for drug
Department maintaines RR/SI
consumables
drugs
of vaccines and other refrigerators are kept as temperature
drugs, requiring controlled per storage requirement charts are
temperature and records are maintained
maintained and updated
periodically
ME D3.1 The facility provides adequate Adequate Illumination at OB
illumination level at patient nursing station
care areas Adequate illumination OB
in ward

ME D3.2 The facility has provision of Visiting hour are fixed OB/PI
restriction of visitors in patient and practiced
areas There is no OB
overcrowding in the
wards during visitors
hours
One female/ family OB/SI
members allowed to
stay with the child
ME D3.3 The facility ensures safe and Temperature control and PI/OB Room kept
comfortable environment for ventilation in patient between 25°
patients and service providers care area - 30° C (to the
extent possible)
Fans/ Air
conditioning/
Heating/
Exhaust/
Ventilators as
per environment
condition and
requirement
Safe measures are used SI/OB Check
for re-warming children availability of
Blankets to cover
the children
station/duty room Heating/
Exhaust/
Ventilators as
per environment
condition and
requirement
Side railings has been OB
provided to prevent fall
of patient
ME D3.4 The facility has security system NRC has system for OB
in place at patient care areas identification tagging
for babies if baby is less
than 6 months
Security arrangement OB/SI
in NRC
ME D4.1 Exterior of the facility building Building is whitewashed OB
is maintained appropriately in uniform colour
areas are plastered
Walls of patient care area OB
are brightly painted and
decorated

and hygienic topes, sinks patient care with no dirt,
and circulation areas are grease, littering
clean and cobwebs
fixtures are clean
running water
ME D4.3 Hospital infrastructure is Check that there is OB
adequately maintained no seepage , Cracks,
chipping of plaster
intact
and painted
Mattresses are Intact and OB
clean
removal of condemned junk material in the NRC
material
and animal control
arrangement for storage and running and potable
supply for portable water in all water
functional areas
ME D5.2 The facility ensures adequate Availability of power OB/SI
power backup in all patient back up in patient care
care areas as per load areas
Emergency light
ME D6.1 The facility has provision of NRC has system in place RR/SI/PI Check appetite
nutritional assessment of the to assess appetite of test for SAM
patients baby based on their baby is done
nutritional needs as per standard
guideline
NRC has system to RR/SI/PI Counselling
assess feeding problems is done by
of child and provide nutrition
individual counselling to counsellor
mother
NRC has system to RR/SI As per standards
access requirement and guideline
dose of micronutrient
of SAM children as per
their age

ME D6.2 The facility provides diets NRC has system to RR/SI/OB Management of
according to nutritional provide a diet to SAM are based
requirements of the patients children based on on 3 phases:
their clinical condition/ Stabilization
Medical complication Phase, Transition
Phase and
rehabilitation
phase
Starter diet (F-75) is RR/SI/OB Feeding begins
given to child just after as soon as
admission. possible after
admission with
‘Starter diet’
until the child is
stabilized
Catch up diet (F-100) is RR/SI/OB Catch up diet
given to the child. is started when
child is clinically
stable and
can tolerate
increased energy
and protein
intake .Quantity
of catch up diet
given is equal
to Quantity of
starter diet given
in stabilization
phase
ME D6.3 Hospital has standard F-75 and F-100 made are SI F-75 and
procedures for preparation, as per the guideline. F-100 refers
handling, storage and to the specific
distribution of diets, as per combination of
requirement of patients calories proteins,
electrolytes
and minerals
that should be
delivered to
children with
SAM as per WHO
guidelines made
available for this
purpose.
The cook prepare special SI
diet for children under
the supervision of the
Nutrition counsellor.
Check if raw material is OB
kept in closed air tight
containers
Check if all perishable OB
items are kept
refrigerator
NRC has system to RR
monitor the amount of
food served to baby as
per guideline
NRC has system to RR Check any
monitor the amount system to left
of feed left over as per over recorded
guideline

ME D7.1 The facility has adequate sets Clean Linens are OB/RR
of linen provided for all occupied
bed
Availability of Blankets, OB/RR
draw sheet, pillow
with pillow cover and
mackintosh
ME D7.2 The facility has established Linen is changed every OB/RR
procedures for changing of day and whenever it get
linen in patient care areas soiled
procedures for handling , the cleanliness and
collection, transportation and Quantity of the linen
washing of linen received from laundry
ME D11.1 The facility has established Staff is aware of their SI
job description as per govt role and responsibilities
guidelines
and deputation to different available on duty as per time of reporting
departments duty roster and relieving
(Attendance
register/
Biometrics etc)
ME D11.3 The facility ensures adherence Doctor, nursing staff and OB
to the dress code as mandated support staff adhere to
by its administration / the their respective dress
health department code
ME D12.1 There is established system for There is procedure to SI/RR Verification of
contract management for out monitor the quality and outsourced
sourced services adequacy of outsourced services
Dietary/
Laundry/
Security/
Maintenance)
provided
are done by
designated in-
house staff

patients patient during process
of registration

like Name,
age, Sex, Chief
complaint, etc.
ME E1.2 The facility has a established Screening of children
procedure for OPD coming to OPDs using
consultation weight for height and/or
MUAC
ME E1.3 There is established procedure There is no delay in
for admission of patients admission of patient
Admission criteria SI/RR NRC has criteria
for NRC is defined & for admission of
followed children from
6-59 months
and less than
6 month as
per standard
guideline.
NRC has established SI/RR Child previously
criteria for re admission discharged
from in-patient
care but meets
admission
criteria again.
NRC has established SI/RR Child who
criteria for return after returns after
default default (away
from in-patient
care for 2
consecutive
days) and meets
the admission
criteria.
qualified doctor
recorded in patient
record
ME E1.4 There is established procedure Procedure cope with OB/SI
for managing patients, in case surplus patient load
beds are not available at the
facility
the patients.
ME E2.1 There is established procedure Initial assessment of RR/SI
for initial assessment of all admitted patient
patients done as per standard
protocols
Patient History is taken RR
and recorded
wherever required

recorded
immediately
within 2 hours
ME E2.2 There is established procedure There is fixed schedule RR/OB
for follow-up/ reassessment of for reassessment by
Patients Medical Officer/Nutrition
Counsellor
ME E3.1 The facility has established There is a procedure RR/SI
procedure for continuity of for consultation of
care during interdepartmental the patient to other
transfer specialist with in the
hospital
ME E3.2 The facility provides Patient referred with RR/SI
appropriate referral linkages referral slip
to the patients/Services for
Advance communication RR/SI
transfer to other/higher is done with higher
facilities to assure the centre
continuity of care.
Referral vehicle is being SI/RR To and back
arranged transport for the
mother and the
child with SAM
children
Facility has functional SI/RR Check for referral
referral linkages to lower cards filled from
facilities lower facilities
Linkage with higher
label facilities
There is a system of RR
follow up of referred
patients
ME E3.3 A person is identified for care Duty Doctor and nurse RR/SI
during all steps of care is assigned for each
patients
ME E4.1 Procedure for identification of There is a process OB/SI Identification
patients is established at the for ensuring the tags are used
facility identification before any for children less
clinical procedure than 5 yrs
care as per treatment plan is are updated and
established at the facility drugs given are
marked. Co relate
it with drugs and
doses prescribed.
dispensing
feed, time of
oral drugs,
supervision of
intravenous
fluids .

There is a process to SI/RR Verbal orders
ensue the accuracy of are rechecked
verbal/telephonic orders before
administration
ME E4.3 There is established procedure Patient hand over is SI/RR
of patient hand over, given during the change
whenever staff duty change in the shift
happens Nursing Handover RR
side
register. Notes
are adequately
written
ME E4.5 There is procedure for periodic Patient Vitals are RR/SI Check for TPR
monitoring of patients monitored and recorded chart, weight
periodically records any
other vital
required is
monitored
vulnerable patients and identified and measures measure taken
ensure their safe care are taken to protect to prevent new
them from any harm born theft,
sweeping and
baby fall
ME E5.2 The facility identifies high risk High risk patients are OB/SI
patients and ensure their care, identified and treatment
as per their need given on priority
ME E6.1 The facility ensured that drugs Check for BHT if drugs RR
are prescribed in generic are prescribed under
name only generic name only
point of use
the drug regime and
doses as per STG
formulary

ME E7.1 There is process for identifying High alert drugs SI/OB Electrolytes
and cautious administration of available in department like Potassium
high alert drugs are identified chloride,
Opioids, Neuro
muscular
blocking
agent, Anti
thrombolytic
agent, insulin,
warfarin,
Heparin,
Adrenergic
agonist etc. as
applicable
age, weight and
diagnosis are
available with
nursing station
and doctor
of high alert drugs are double
only given check before
administration,
Error prone
medical
abbreviations
are avoided
ME E7.2 Medication orders are written Every Medical advice RR
legibly and adequately and procedure is
accompanied with date ,
time and signature
clinical staff
administration
Check single dose vial OB Check for any
are not used for more open single
than one dose dose vial with
left over content
indented to be
used later on
Check that separate OB In multi dose vial
sterile needle is used needle is not left
every time for multiple in the septum
dose vial
reported

right medicine is given to are calculated according calculation chart
right patient to body weight
Drip rate and volume SI/RR Check the
are calculated and nursing staff
monitored how they
calculate
Infusion and
monitor it
Administration of SI/OB
medicines is done after
ensuring right patient,
right drugs , right route,
right time
ME E7.5 Patient is counselled for self Mother is adviced by PI/SI
drug administration. doctor/ Pharmacist /
nurse about the dosages
and timings .
ME E8.1 All the assessments, re- Day to day progress of RR
assessment and investigations patient is recorded in
are recorded and updated BHT
ME E8.2 All treatment plan Treatment plan, first RR Treatment
prescription/orders are orders are written on prescribed inj
recorded in the patient BHT nursing records
records.
ME E8.3 Care provided to each patient Maintenance of RR Treatment given
is recorded in the patient treatment chart/ is recorded in
records treatment registers treatment chat
ME E8.4 Procedures performed are Procedure performed RR
written on patients records are recorded in BHT
ME E8.5 Adequate form and formats Standard Formats are RR/OB Availability
are available at point of use available of formats for
Treatment
Charts,
Community
follow up
card, BHT,
continuation
sheet, Discharge
card Etc.
Admission
register,
lab register,
Admission
sheet/ bed head
ticket, discharge
slip, referral
slip, referral in/
referral out
register, OT
register, Diet
register, Linen
register, Drug
intend register

ME E8.7 The facility ensures safe and All register/records are RR
adequate storage and retrieval identified and numbered
of medical records Safe keeping of patient OB
records
ME E9.1 Discharge is done after NRC has established SI/RR Discharge
assessing patient readiness criteria for discharge of criterion for
the patient all infants and
children is 15%
weight gain
and no signs of
illness
Assessment is done SI/RR
before discharging
patient
Discharge is done SI/RR
by a responsible and
qualified doctor
Patient / attendants PI/SI
discharge
consulted/ informed
before discharge of
patients
ME E9.2 Case summary and follow-up Discharge summary is RR/PI See for discharge
instructions are provided at provided summary,
the discharge referral slip
provided.
adequately mentions
patients clinical
given and follow up
LAMA/Referral
There is procedure for RR/SI By local CHW
clinical follow up of the (Community
child for assessment and health care
monitoring of growth worker)/ASHA/
and development AWW. Follow
till the child recovers up also includes
completely enrolment
of baby to
Anganwadi
centre and
provide
Supplementary
food

ME E9.3 Counselling services are Counselling of mothers/ PI/SI Preparation
provided as during discharges caregiver before and feeding the
wherever required discharge child, how to
give prescribed
medication,
folic acid,
vitamins and
iron at home,
how to give
home treatment
for diarrhoea,
fever and acute
respiratory
infections
Advice includes the RR/SI
information about the
further follow up
communicated to
patient
procedure for patients leaving the LAMA patient
the facility against medical
advice, absconding, etc
Management
ME E11.1 There is procedure for Triaging of sick children SI/RR
Receiving and triage of as per guideline
patients
Role and responsibilities SI/RR
defined
procedures for Pre-testing properly after the
Activities sample collection
ME E12.3 There are established NRC has critical values of SI/RR
procedures for Post-testing various lab test
Activities
Transfusion.
ME E13.8 There is established procedure Paediatric blood bags RR/SI if not available
for issuing blood are available than how facility
cope with it
ME E13.9 There is established procedure Consent is taken before RR
for transfusion of blood transfusion
Patient’s identification SI/OB
is verified before
transfusion

Blood transfusion of RR Blood
SAM child is done as per transfusion is
standard Guideline required (1) Hb
is less than 4 g/
dl (2) or if there
is respiratory
distress and Hb
is between 4 and
6 g/dl.
Blood is kept on SI/RR
optimum temperature
before transfusion
Blood transfusion RR Give (1) whole
is monitored and blood 10 ml/
regulated by qualified kg body weight
person slowly over
3 hours (2)
furosemide 1
mg/kg IV at
the start of the
transfusion
recorded
Staff is aware of SI/RR (1) Blood
conditions in which transfusion
blood transfusion is not should not be
done/repeated 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
and reporting Transfusion recorded and reported
complication to responsible person
procedure for Registration and updates “Mother and
follow up of pregnant women. Child Protection Card”.
ME E20.1 The facility provides Immunization services SI/RR
immunization services as per as per national
guidelines guidelines

ME E20.2 Triage, Assessment & Adherence to clinical SI/RR Competence
Management of newborns protocol testing
having
emergency signs are done as
per guidelines
ME E20.3 Management of Low birth Adherence to clinical SI/RR Competence
weight protocol testing
newborns is done as per
guidelines
ME E20.4 Management of neonatal Adherence to clinical SI/RR Competence
asphyxia, jaundice and sepsis protocol testing
is done as per guidelines
ME E20.6 Management of children with Staff is aware and SI (1) Treat /
severe practice of 10 General Prevent
Acute Malnutrition is done as principles of routine care Hypoglycaemia
per guidelines as per guideline (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 SI/RR Competence
Emergency treatment of testing
shock and anaemia as
per guideline
Staff is aware of SI/RR Competence
treatment of associated testing
conditions like Vitamin A
deficiency, Dermatosis,
Parasitic worms,
Continual diarrhoea and
TB as per guideline
Staff is aware of criteria SI/RR Competence
for failure to respond testing
to treatment as per
guideline

Standard E23 The facility provides National health Programme as per operational/Clinical Guidelines
ME F1.3 The facility measures hospital There is procedure to SI/RR Patients are
associated infection rates report cases of Hospital observed for
acquired infection any sign and
symptoms
of HAI like
fever, purulent
discharge from
surgical site .
Medical Check-up and immunization of the Tetanus Toxoid
immunization of staff staff etc
Periodic medical SI/RR
ME F1.5 The facility has established Regular monitoring SI/RR Hand washing
procedures for regular of infection control and infection
monitoring of infection practices control audits
intervals
ME F1.6 The facility has defined and Check for Doctors SI/RR
established antibiotic policy are aware of Hospital
Antibiotic Policy
antisepsis
provided at point of use washing Facility at Point availability of
of Use wash basin near
the point of use
water supply is
regular
soap with soap dish/ availability/ Ask
liquid antiseptic with staff if the supply
dispenser. is adequate and
uninterrupted
staff for regular
supply.
Instruction at Point of displayed
Use above the hand
washing facility,
preferably in
local language
ME F2.2 The facility staff is trained in Adherence to 6 steps of SI/OB Ask of
hand washing practices and Hand washing demonstration
they adhere to standard hand Staff aware of when to SI
washing practices hand wash

Mothers are aware of PI
importance of washing
hands
Mothers are practicing PI/OB After using
wash hand washing the toilet or
with soap changing
diapers and
before feeding
children
drawing
blood, putting
Intravenous and
urinary catheter
ME F3.1 The facility ensures Clean gloves are OB/SI Hand washing
adequate personal available at point of use b/w each patient
protection Equipment as per & change of
requirements gloves
Availability of Masks OB/SI
practices aprons.
removing the gloves
Examination
table , Patients
Beds
(Wiping with
.5% Chlorine
solution
Proper Decontamination SI/OB Check for
of instruments after use availability for
0.5 chlorine
solution
Ask staff
how they
decontaminate
the instruments
after use (Should
be at least for 10
minutes

decontamination is
adequate
and running wa-
ter after decon-
tamination
Proper handling of SI/OB No sorting
Soiled and infected linen ,Rinsing or
sluicing at Point
of use/ Patient
care area
chlorine solution
Toys washed regularly, SI/OB Check for decon-
and after each child uses tamination and
washing of toys
practices and materials for instruments are HLD/Chemical
disinfection and sterilization sterilized after each use Sterilization
of instruments and equipment as per requirement
High level Disinfection of OB/SI Ask staff about
instruments/equipments method and
is done as per protocol time required for
boiling
material is used
ME F5.2 The facility ensures availability Availability of OB/SI Chlorine
of standard materials for disinfectant as per solution,
cleaning and disinfection of requirement Gluteraldehye,
patient care areas carbolic acid
Availability of OB/SI Hospital grade
cleaning agent as per phenyle,
requirement disinfectant
detergent
solution
patient care areas area with detergent
solution
preparing cleaning
procedure
mopping and scrubbing mopping from
are followed inside out
Cleaning equipments OB/SI Any cleaning
like broom are not used equipment
in patient care areas leading to
dispersion of
dust particles
in air should be
avoided

segregation of infectious nursing procedure are
patients followed for septic cases
ME F6.1 Facility Ensures segregation Availability of colour OB
of Bio Medical Waste as per coded bins at point of
guidelines waste generation
Availability of plastic OB
colour coded plastic
bags
guidelines
Display of work OB
instructions for
segregation and
waste
waste
ME F6.2 Facility ensures management Availability of functional OB See if it has been
of sharps as per guidelines needle cutters used or just lying
idle
the point of
generation like
nursing station
and injection
room
done in open
buckets
sharps
exposure prophylaxis Where it is
stored and who
is in charge of
that.
Staff knows reporting SI Staff knows
procedure after sharp what to do in
injury. Whom to
report. See if any
reporting has
been done
ME F6.3 Facility ensures transportation Check bins are not SI/OB
and disposal of waste as per overfilled
guidelines Transportation of bio SI/OB
Staff is aware of mercury SI/RR
spill management

ME G1.1 The facility has a quality team There is a designated SI/RR
in place departmental nodal
Quality Assurance
activities
ME G2.1 Patient satisfaction surveys Patient relative RR
are conducted at periodic satisfaction survey done
intervals on monthly basis
internal quality assurance round by matron/
programme in key hospital manager/
departments hospital superintendent/
Hospital Manager/
ME G3.3 The facility has established Departmental checklist SI/RR
system for use of check lists are used for monitoring
in different departments and and quality assurance
filling and monitoring of
these checklists
operating procedures are procedure for
available department has been
prepared and approved
process owner
procedures assessment of the
patient
Department has RR
for admission, shifting
and referral 0f patient
Department has RR
for requisition of
diagnosis and receiving
of the reports
Department has RR
for counselling of
Mother for feeding, care
and Hygiene

Department have RR
standard procedures
for management of
medical complications
associated with Severe
Acute Malnutrition
Department has RR
documented procedures
for feeding of Child with
SAM
Department has RR
for management of
SAM children less than 6
month of age
Department has RR
for Management of SAM
in HIV exposed /HIV
infected and TB infected
children
Department has RR
for Structures play
therapy and loving care
Department has RR
for environmental
cleaning and processing
of the equipment
Department has RR
for sorting, and
distribution of clean
linen to patient
Department has RR
documented procedures
for demonstration and
practice of energy dense
child food
Department has RR
for follow up of children
discharge from the NRC
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
ME G4.4 Work instructions are Work instruction/clinical OB Appropriate
displayed at Point of use protocols are displayed feeding
practices,
wall charts for
assessment and
management
of sick children
with SAM,
Management
of medical
complications,
Triage, 10 steps
for management
of SAM,

Grading and
management
of hypothermia,
Management of
hypoglycaemia,
Management
of Dehydration,
housekeeping
protocols,
Administration
of commonly
used drugs, etc
value adding activities / waste activities are identified
ME G5.3 The facility takes corrective Processes are rearranged SI/RR
processes
ME G6.1 The facility conducts periodic Internal assessment is RR/SI
internal assessment done at periodic interval
conduct Prescription
audit
conduct Death audit
compliances are enumerated enumerated and
and recorded adequately recorded
/ audit process
ME G6.5 Corrective and preventive Corrective and RR/SI
actions are taken to address preventive action taken
assessment & audit
defines its quality objectives NRC are defined
ME G7.3 Quality policy and objectives Check if staff is aware SI

services Mistake proofing SI/OB
ME G8.2 The facility uses tools for Control Charts SI/RR
quality improvement in
services
benchmarks
ME H1.1 Facility measures productivity Total admissions RR
Indicators on monthly basis Bed Occupancy Rate RR
ME H1.2 The Facility measures equity Proportion of admissions RR
indicators periodically by gender
Proportion of BPL RR
Patients
ME H2.1 Facility measures efficiency Achieved target RR
Indicators on monthly basis weight(15% weight
gain)
Down time Critical RR
Equipments
Bed Turnover Rate RR
Referral Rate RR
Discharge Rate RR
Defaulter rate RR Acceptable-
<15%
Not Acceptable-
>25%
Relapse rate RR
Average waiting time for RR
admission (mins)
benchmark
ME H3.1 Facility measures Clinical Average length of stay in RR Acceptable- 1-4
Care & Safety Indicators on (weeks) week
monthly basis Not Acceptable-
<1 and >6
Death rate following RR Acceptable- <5%
discharge from NRC Not Acceptable-
>15%
Recovery rate RR Acceptable-
>75%
Not Acceptable-
<50%
Adverse events are RR wrong drug
reported administration,
needle
stick injury,
absconding
patients etc
benchmark
Quality Indicators on monthly Attendant Satisfaction RR
basis Score

Assessment Summary
A. Score Card
Nutritional rehabilitation centre (nrc) Score Card
Nutritional rehabilitation centre
(nrc) Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Checklist–8
Operation Theatre
Version: 1/2013

Checklist–8
Checklist for Operation Theatre

No. ance Method
ME A1.2 The facility provides Availability of General SI/OB Appendectomy,
General Surgery Surgery procedures Intestinal Obstruction,
services Perforation, Tongue Tie,
Inguinal Hernia
ME A1.3 The facility provides Availability of SI/OB D & E, Hysterectomy .
Obstetrics & Gynaecology For Obstetric procedure
Gynaecology Services procedures kindly see A2.2
ME A1.4 The facility provides Availability of SI/OB I&D, Pepuceal Dilation,
Paediatric Services Paediatric Surgery Meatomy, Gland
procedure Biopsy, Reduction
Paraphimosis, Brachial/
Thyoglossal Cyst
and Fistula, Inguinal
Herniotomy, Neonatal
Intestinal Obstruction
ME A1.5 The facility provides Availability of SI/OB Cataract Extraction
Ophthalmology Ophthalmic Surgery with IOL, Canthotomy,
Services procedures Paracentesis,
Enucleation, Glaucoma,
Cunjuctival Cyst,
ME A1.6 The facility provides Availability of ENT SI/OB Nose, Ear and Throat
ENT Services surgical procedure surgical procedures
Packing , Antral
Puncture , Fracture
Reduction, Mastoid
Abscess I & D,
Mastoidectomy
Stapedotomy,
Adenoidectomy,
Tonsillectomy
ME A1.7 The facility provides Availability of SI/OB Open and Closed

Orthopaedics Services Orthopaedic surgical Reduction, Nailing and
procedures Plating, Amputation,
Disarticulation of Hip
and Shoulder
ME A1.10 The facility provides Availability of Oral SI/OB Trauma Including
Dental Treatment surgery procedures Vehicular Accidents ,
Services Fracture Wiring
ME A1.14 Services are available OT Services are SI/RR
for the time period as Available 24X7
mandated
Accident & Emergency Emergency OT services
Services as & when required
No. ance Method
ME A2.1 The facility provides Availability of Post SI/OB tubal ligation
Reproductive health partum sterilization
Services services
ME A2.2 The facility provides Availability of C-section SI/OB
Maternal health services
Services
Management SI/OB
of obstetrics
complications
ME A2.3 The facility provides Availability of New SI/OB
Newborn health born resuscitation
Services
Availability of essential SI/OB
new born care
ME A2.4 The facility provides Availability of SI/OB Developmental
Child health Services Paediatric surgical Dysplasia of the Hip,
Procedure under RBSY Congenital Cataract
cleft lip/palate
ME A3.1 The facility provides Availability of C arm SI/OB
Radiology Services services
ME A3.2 The facility Provides Availability of point of SI/OB Blood Gas, Blood
Laboratory Services care diagnostic test Glucose, Rapid HIV
Testing
Standard A4 Facility provides services as mandated in national Health Programs/ state scheme
services under Reconstructive Surgery
National Leprosy
Availability of SI/OB
Eradication
Amputation Surgery
Programme as per
guidelines
ME B1.1 The facility has Availability OB (Numbering, main
uniform and user- departmental signage’s department and
friendly signage internal sectional
system signage
Signage for restricted OB
area are displayed
Zones of OT are OB
marked
ME B1.2 The facility displays Display doctor/ Nurse OB
the services and on duty and updated
entitlements available
OT schedule displayed OB
in its departments
ME B1.6 Information is Signage’s and OB
available in local information are
language and easy to available in local
understand language
264 | Checklist for Operation Theatre

No. ance Method
ME B2.1 Services are provided Availability of female OB/SI
in manner that are staff if a male doctor
sensitive to gender conducts surgery on
female patients &
present of female staff
in pre & post operative
room in female are
their
ME B2.3 Access to facility is Availability of Wheel OB
provided without any chair or stretcher for
physical barrier & and easy Access to the OT
friendly to people with Availability of ramps OB
disabilities with railing
ME B3.1 Adequate visual Availability of screen OB
privacy is provided at between OT table
every point of care Patients are properly OB
draped/covered before
and after produce
ME B3.2 Confidentiality of Patient Records are SI/OB
patients records and kept at secure place
clinical information is beyond access to
maintained general staff/visitors
No information SI/OB
regarding patient
identity and details are
unnecessary displayed
ME B3.3 The facility ensures Behaviour of staff PI/OB
respectful, while
ME B3.4 The facility ensures Privacy and SI/OB
privacy and Confidentiality of HIV
confidentiality to every cases
patient, especially
of those conditions
having social stigma,
and also safeguards
vulnerable groups
ME B4.1 There is established High risk consent is SI/RR
procedures for taking taken before major
informed consent surgeries
before treatment and Anaesthesia Consent SI/RR
procedures for OT
ME B4.4 Information about the Patient attendant PI/SI

treatment is shared is informed about
with patients or clinical condition
attendants, regularly and treatment been
provided
Checklist for Operation Theatre | 265

No. ance Method
ME B4.5 The facility has defined Availabilty of OB
and established complaint box and
grievance redressal display of process for
system in place grievance re addressal
and whom to contact
is displayed
ME B5.1 The facility provides Free medicines and PI/SI JSSK
cashless services to consumables are
pregnant women, available
mothers and neonates All surgical procedure PI/SI
as per prevalent are free of cost for JSSK
government schemes beneficeries
ME B5.2 The facility ensures Check that patient PI/SI
are available at money on purchasing
Pharmacy and wards drugs or consumbles
from outside.
ME B5.3 It is ensured Check that patient PI/SI
that facilities for party has not spent
the prescribed on diagnostics from
investigations are outside.
ME B5.4 The facility provide Surgical services are PI/SI/RR
free of cost treatment free for BPL patients
to Below poverty
line patients without
the prevalent norms
ME C1.1 Departments have Adequate space for OB
adequate space as per accommodating
patient or work load surgical load
Availability of OT OB 100-200 -1OT, 200-
for elective major 300-2, 300-400 -3
surgeries
Availability of OT for OB Emergency OT 1
Emergency surgeries
Availability of OT OB Ophthalmic/ENT- 1
ophthalmic/ENT
Waiting area for OB
attendants
ME C1.2 Patient amenities are Hot water facility OB
provide as per patient Toilet facility for OB
load patient attendant
Seating arrangement OB
for patient attendant

No. ance Method
ME C1.3 Departments have Demarcated of OB
layout and demarcated Protective Zone
areas as per functions Demarcated Clean OB
Zone
Demarcated sterile OB
Zone
Demarcated disposal OB
Zone
Availability of OB
Changing Rooms
Operative Room
Availability of OB
earmarked area for
newborn Corner
Operative Room
Availaility of Scrub OB
Area
Availability of OB
Autoclave room/ TSSU
utility area
ME C1.4 The facility has Corridors are wide OB 2-3 meters
adequate circulation enough for movement
area and open spaces of trolleys
according to need and
local law
ME C1.5 The facility has Availability of OB
infrastructure functional telephone
for intramural and Intercom Services
and extramural
communication
ME C1.6 Service counters are OT tables are available OB Hydrolic OT Tables
available as per patient as per load As per case load at least
load two for 100 - 200 beded
DH and 4 for More than
200 beds
ME C1.7 The facility and Unidirectional flow of OB No cris cross of
departments are goods and services infectious and sterile
planned to ensure goods
structure follows
the function/
processes (Structure
commensurate with
the function of the
hospital)

No. ance Method
ME C2.1 The facility ensures the Non structural OB Check for fixtures
seismic safety of the components are and furniture like
infrastructure properly secured cupboards, cabinets,
and heavy equipments
, hanging objects are
properly fastened and
secured
ME C2.3 The facility ensures OT does not have OB
safety of electrical temporary connections
establishment and loosely hanging
wires
ME C2.4 Physical condition of Floors of the ward are OB
buildings are safe for non slippery and even
providing patient care Walls and floor of the OB
OT covered with joint
less tiles
Windows/ ventilators if OB
any in the OT are intact
and sealed
ME C3.1 The facility has plan for OT has sufficient fire OB/SI
prevention of fire exit to permit safe
escape to its occupant
at time of fire
clearly marked.
ME C3.2 The facility has OT room has installed OB
Equipment Class A , Class B, C type
or ABC type
mentioned
ME C3.3 The facility has a Check for staff SI/RR
system of periodic compatencies
conducts mock drills extinguisher and what
regularly for fire and to do in case of fire
ME C4.1 The facility has Availability of Obg & OB/RR As per case load
adequate specialist Gynae Surgeon
doctors as per service Availability of general OB/RR As per case load
provision surgeon
Availability of OB/RR As per case load
Orthopaedic Surgeon
ophthalmic surgeon

No. ance Method
Availability of ENT OB/RR As per case load
surgeon
anaesthetist
ME C4.3 The facility has Availability of Nursing OB/RR/SI As per patient load , at
adequate nursing staff least two
staff as per service
provision and work
load
ME C4.4 The facility has Availability of OT OB/SI
adequate technicians/ technician
paramedics as per
requirement
ME C4.5 The facility has Availability of OT SI/RR
adequate support / attendant/assistant
general staff Availability CSSD/ SI/RR
TSSU Asstt.
Availability of Security SI/RR
staff
ME C4.6 The staff has been Advance Life support SI/RR
provided required OT Management SI/RR
training / skill sets
Management
hand hygiene
Training on SI/RR
processing/sterilization
of equipments
ME C4.7 The Staff is skilled as Staff is skilled for SI/RR
per job description resuscitation and
intubation
records
Staff is Skilled SI/RR
to operate OT
equipments
processing and
packing instrument
ME C5.1 The departments Availability of medical OB/RR Availability of Oxygen
have availability of gases Cylinders / Piped Gas
adequate drugs at supply, Nitrogen
point of use Availability of OB/RR Inj Oxytocin 10 IU (to
Uterotonic Drugs be kept in fridge)
Availability of OB/RR Inj. Ampillicin 500mg,
Antibiotics Inj. metronizazole
400mg, Gentamycin,
Availability of OB/RR Injectable preparations
Antihypertensive
Availability of OB/RR Inj. Diclofenac Sodiam
analgesics and
antipyretics

No. ance Method
Availability of IV Fluids OB/RR IV fluids, Normal saline,
Ringer lactate, plasma
expender
Availability of OB/RR
anesthetics
Availability of OB/RR Inj Magsulf 50%, Inj
emergency drugs Calcium gluconate 10%,
Inj Dexamethasone,
inj Hydrocortisone,
Succinate, Inj
diazepam, inj
Pheneramine maleate,
inj Corboprost, Inj
Fortwin, Inj Phenergen,
Betameathazon, Inj
Hydrazaline, Nefidepin,
Methyldopa,ceftriaxone
Availability of drugs for OB/RR Availability of Oxygen
newborn Cylinders
ME C5.2 The departments Availability of dressings OB/RR
have adequate and Sanitary pads
consumables at point Availability of syringes OB/RR
of use and IV Sets
Antiseptic Solutions
consumables for new
born care
Availability of personal OB/RR
protective equipments
ME C5.3 Emergency drug trays Emergency drug tray OB/RR
are maintained at are maintained in
every point of care, operation theater and
where ever it may be post operative room
needed
ME C6.1 Availability of Availability of OB BP apparatus,
equipment & functional Equipment Thermometer,
instruments for &Instruments for Pulse Oxymeter,
examination & examination & Multiparameter
monitoring of patients Monitoring
ME C6.2 Availability of Availability of OB LSCS Set, Cervical
equipment & functional instruments Biopsy Set, Proctoscopy
instruments for for Gynae and Set, Hysterectomy set,
treatment procedures, obstetrics D&C Set
being undertaken in Availability OB Radiant warmer,
the facility of functional Baby tray with Two
equipments/ pre warmed towels/
Instruments for New sheets for wrapping the
Born Care baby, mucus extractor,
bag and mask (0 &1
no.), sterilized thread
for cord/cord clamp,
nasogastric tube

No. ance Method
Availability of OB Diathermy (Unit and
functional General Bi Polar), Proctoscopy
surgery equipments set, general Surgical
Instruments for Piles,
Fistula, & Fissures.
Surgical set for Hernia &
Hydrocele, Cautery
Availability of OB C arm, check OT table
functional orthopaedic is C arm compatible,
surgery equipments Thomas Splint, IM
Nailing Set, SP Nailing,
Compression Plating
Kit, Sislocation Hip
Screw Fixation
Availability of OB Operating Microscope,
Ophthalmic surgery IOL Operation Set,
equipments Ophthalmoscope
Keratometer, A Scan
Biometer
Availability of OB Operating Microscope,
functional ENT surgery ENT Operation
equipments set, Mastoid Set,
Tracheotomy set,
Microdrill System set
Operation Table with OB
Trendelenburg facility
ME C6.3 Availability of Availability of Point OB Portable X-Ray
equipment & of care diagnostic Machine, Glucometer,
instruments for instruments HIV rapid diagnostic kit
diagnostic procedures Blood Gas analyzer and
being undertaken in ultrasound
the facility
ME C6.4 Availability of Availability of OB Ambu bag, Oxygen,
equipment and functional Instruments Suction machine ,
instruments for Resuscitation laryngoscope scope,
resuscitation of Defibrillator (Paediatric
patients and for and adult) , LMA, ET
providing intensive Tube
and critical care to Availability of OB Boyles apparatus, Bains
patients functional anaesthesia Circuit or Sodalime
equipment absorbent in close
circuit
ME C6.5 Availability of Availability of OB Refrigerator, Crash cart/
Equipment for Storage equipment for storage Drug trolley, instrument
for drugs trolley, dressing trolley
Availability of OB Instrument cabinet
equipment for storage and racks for storage of
of sterilized items sterile items
functional equipment equipments for Separate mops for
and instruments for cleaning patient care area and
support services circulation area duster,
waste trolley, Deck brush
Availability of OB Autoclave Horizontal &
equipment for CSSD/ Vertical, Sterlizer Big &
TSSU Small

No. ance Method
ME C6.7 Departments have Availability of OB Shadow less Major
patient furniture and functional OT light & Minor, Ceiling and
fixtures as per load Stand Model, Focus
and service provision Lamp
Availability of OB Hospital graded
attachment/ mattress , IVstand, Bed
accessories with OT pan
table
Availability of Fixtures OB Trey for monitors,
Electrical panel for
anaesthesia machine,
cardiac monitor etc,
panel with outlet for
Oxygen and vacuum, X
ray view box.
Availability of furniture OB Cupboard, table
for preparation of
medicines, chair, racks,
of Equipment.
down maintenance of
the equipments
There has system to OB/RR
label Defective/Out of
order equipments and
stored appropriately
until it has been
repaired
trouble shooting
in case equipment
malfunction
Periodic cleaning, SI/RR
inspection and
maintenance of the
equipments is done by
the operator
ME D1.2 The facility has All the measuring OB/ RR Boyels apparatus,
established procedure equipments/ cautery, BP apparatus,
for internal and instrument are autoclave etc.
external calibration of calibrated
measuring Equipment There is system OB/ RR
to label/ code the
equipment to indicate
status of calibration/
verification when
recalibration is due

No. ance Method
ME D1.3 Operating and Up to date instructions OB/SI
maintenance for operation and
instructions are maintenance of
available with the equipments are readily
users of equipment available with staff.
ME D2.1 There is established There is established SI/RR Stock level are daily
procedure for system of timely updated
forecasting and indenting of Requisition are timely
indenting drugs and consumables and placed
consumables drugs
proper storage containers/tray/crash
of drugs and cart and are labelled
consumables Empty and filled OB
management of expiry maintained at
and near expiry drugs emergency drug tray
maintained for drug
for inventory maintaining buffer
management stock
techniques Department RR/SI
maintained stock
and expenditure
consumables
for periodically replenishing drug tray
replenishing the drugs /crash cart
in patient care areas There is no stock out of OB/SI
drugs
ME D2.7 There is process for Temperature of OB/RR Check for temperature
storage of vaccines refrigerators are charts are maintained
and other drugs, kept as per storage and updated
requiring controlled requirement and periodically
temperature records are maintained
ME D2.8 There is a procedure Narcotic and OB/SI
for secure storage psychotropic drugs are
of narcotic and kept in lock and key
psychotropic drugs Anaesthetic agents are OB/SI
kept at secure place
ME D3.1 The facility provides Adequate Illumination OB 100000 lux
adequate illumination at OT table
level at patient care Adequate Illumination OB
areas at pre operative and
post operative area

No. ance Method
ME D3.2 The facility has Entry to OT is restricted OB
provision of restriction Warning light is OB/SI
of visitors in patient provided outside OT
areas and its been used
when OT is functional
ME D3.3 The facility ensures Temperature is SI/RR 20-25OC, ICU has
safe and comfortable maintained and record functional room
environment for of same is kept thermometer and
patients and service temperature is regularly
providers maintained
Humidity is maintained SI/RR 50-60%
at desired label ICU
and record of same is
maintained
Positive pressure is SI/RR
maintained in OT
ME D3.4 The facility has security Security arrangement OB
system in place at at OT
patient care areas
ME D3.5 The facility has Ask female staff SI
established measure weather they feel
for safety and security secure at work place
of female staff
building is maintained whitewashed in
appropriately uniform colour
painted
ME D4.2 Patient care areas are Floors, walls, roof, roof OB All area are clean with
clean and hygienic topes, sinks patient no dirt,grease,littering
care and circulation and cobwebs
areas are Clean
Surface of furniture OB
and fixtures are clean
running water
ME D4.3 Hospital infrastructure Check for there is OB
intact
OT Table are intact and OB
without rust
and clean
ME D4.5 The facility has No condemned/Junk OB
policy of removal material in the OT
of condemned junk
material

No. ance Method
ME D4.6 The facility has No stray pests OB
established
procedures for pest,
rodent and animal
control
ME D5.1 The facility has Availability of 24x7 OB/SI
portable water in all Availability of Hot OB/SI
functional areas water supply
ME D5.2 The facility ensures Availability of power OB/SI 2 tier backup with UPS
adequate power back up in OT
Emergency light
ME D5.3 Critical areas of Availability of OB
the facility ensures Centralized /local
availability of oxygen, piped Oxygen,
medical gases and nitrogen and vacuum
vacuum supply supply
ME D7.1 The facility has OT has facility to OB/RR Drape, draw sheet, cut
adequate sets of linen provide sufficient and sheet and gown
clean linen for surgical
patient
OT has facility to OB/RR
provide linen for staff
ME D7.2 The facility has Linen is changed after OB/RR
established each procedure
procedures for
changing of linen in
patient care areas
ME D7.3 The facility has There is system to SI/RR
standard procedures check the cleanliness
for handling and Quantity of the
, collection, linen received from
transportation and laundry
washing of linen
ME D11.1 The facility has Staff is aware of SI
established job their role and
description as per govt responsibilities
guidelines
established procedure to ensure that staff is recording time of
for duty roster and available on duty as reporting and relieving
deputation to different per duty roster (Attendance register/
departments Biometrics etc)

No. ance Method
code as mandated by staff adhere to their
its administration / the respective dress code
health department
Standard Facility has established procedure for monitoring the quality of outsourced services and adheres
D12 to contractual obligations
ME D12.1 There is established There is procedure to SI/RR Verification of
system for contract monitor the quality outsourced services
management for out and adequacy of (cleaning/ Dietary/
sourced services outsourced services on Laundry/Security/
regular basis Maintenance) provided
are done by designated
in-house staff
the patients.
ME E2.1 There is established There is procedure RR/SI Physical examination,
procedure for initial for Pre Operative results of lab
assessment of patients assessment investigation, diagnosis
and proposed surgery
ME E3.1 Facility has There is procedure of SI/RR
established procedure handing over while
for continuity receiving patient form
of care during OT to indoor and ICU
interdepartmental There is a procedure RR/SI
transfer for consultation of
the patient to other
specialist with in the
hospital
ME E3.3 A person is identified Duty Doctor and nurse RR/SI
for care during all is assigned for each
steps of care patients
ME E4.1 Procedure for There is a process OB/SI Patient id band/ verbal
identification of for ensuring the confirmation etc.
patients is established identification before
at the facility any clinical procedure
ME E4.2 Procedure for ensuring There is a process to SI/RR Verbal orders are
timely and accurate ensue the accuracy rechecked before
nursing care as per of verbal/telephonic administration
treatment plan is orders
established at the
facility
ME E4.3 There is established Patient hand over SI/RR
procedure of patient is given during the
hand over, whenever change in the shift
ME E4.5 There is procedure for Patient Vitals are RR/SI Check for use of
periodic monitoring of monitored and cardiac monitor/multi
patients recorded periodically parameter

No. ance Method
Standard E5 Facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies Vulnerable patients OB/SI Check the measure
vulnerable patients are identified and taken to prevent new
and ensure their safe measures are taken to born theft, sweeping
care protect them from any and baby fall
harm
ME E5.2 The facility identifies High risk patients OB/SI HIV, Infectious cases
high risk patients and are identified and
ensure their care, as treatment given on
per their need priority
Standard E6 Facility follows standard treatment guidelines defined by state/Central government for
ME E6.1 Facility ensured that Check for BHT if drugs RR
ME E6.2 There is procedure of Check staff is aware of SI/RR
rational use of drugs the drug regime and
doses as per STG
Check BHT that drugs RR
are prescribed as per
STG
formulary
ME E7.1 There is process High alert drugs SI/OB Electrolytes
for identifying available in like Potassium
and cautious department are chloride, Opioids,
administration of high identified Neuro muscular
alert drugs (to check) blocking agent, Anti
thrombolytic agent,
insulin, warfarin,
Heparin, Adrenergic
agonist etc. as
applicable
Maximum dose of high SI/RR Value for maximum
alert drugs are defined doses as per age,
and communicated weight and diagnosis
are available with
nursing station and
doctor
of high alert drugs are double check before
only given administration,
Error prone medical
abbreviations are
avoided
ME E7.2 Medication orders are Every Medical advice RR
adequately accompanied with
date , time and
signature
Check for the writing, RR/SI
It comprehendible by
the clinical staff

No. ance Method
Check single dose vial OB Check for any open
are not used for more single dose vial with
than one dose left over content
intended to be used
later on
sterile needle is used In multi dose vial
every time for multiple needle is not left in the
dose vial septum
reaction is recorded
and reported
ME E7.4 There is a system to Administration of SI/OB
patient right drugs , right
route, right time
ME E8.1 All the assessments, Records of Monitoring/ RR PAC, Intraoperative
re-assessment and Assessments are monitoring
investigations are maintained
ME E8.2 All treatment plan Treatment plan, first RR Treatment prescribed in
prescription/orders are orders are written on nursing records
recorded in the patient BHT
records.
ME E8.4 Procedures performed Operative Notes are RR Name of person in
are written on patients Recorded attendance during
records procedure, Pre and post
operative diagnosis,
Procedures carried out,
length of procedures,
estimated blood loss,
Fluid administered,
specimen removed,
complications etc.
Anaesthesia Notes are RR
Recorded
ME E8.5 Adequate form and Standard Formats RR/OB Consents, surgical
formats are available available safety check list
at point of use
ME E8.6 Register/records are Registers and records RR OT Register, Schedule,
maintained as per are maintained as per Infection control
guidelines guidelines records, autoclaving
records etc
are identified and
numbered
ME E8.7 The facility ensures Safe keeping of RR
safe and adequate patient records
of medical records

No. ance Method
Management
ME E11.3 The facility has disaster Staff is aware of SI/RR
management plan in disaster plan
place Role and SI/RR
responsibilities of staff
in disaster is defined
procedures for Pre- properly after the
testing Activities sample collection
ME E12.3 There are established OT is provided with SI/RR
procedures for Post- the critical value of
testing Activities different test
Transfusion.
ME E13.8 There is established Availability of blood RR/SI The blood is ordered for
procedure for issuing units in case of the patient according
blood emergency with out to the MSBOS
replacement (Maximum Surgical
Blood Order Schedule)
ME E13.9 There is established Consent is taken RR
procedure for before transfusion
transfusion of blood Patient’s identification SI/OB
is verified before
transfusion
blood is kept on RR
optimum temperature
before transfusion
Blood transfusion SI/RR
is monitored and
regulated by qualified
person
recorded
procedure for transfusion reaction is
monitoring and recorded and reported
reporting Transfusion to responsible person
complication
Standard E14 Facility has established procedures for Anaesthetic Services
ME E14.1 Facility has established There is procedure to RR/SI
procedures for Pre ensure that PAC has
Anaesthetic Check up been done before
surgery
review findings of PAC
ME E14.2 Facility has established Anaesthesia plan is RR
procedures for documented before
monitoring during entering into OT
anaesthesia Food intake status of RR/SI
Patient is checked

No. ance Method
Patients vitals are RR Heart rate , cardiac rate
recorded during , BP, O2 Saturation,
anaesthesia
Airway security is RR/SI Breathing system is
ensured securely and correctly
assembled
Potency and level RR/SI
of anaesthesia is
monitored
Anaesthesia note is RR Check for the adequacy
recorded
Any adverse RR
Anaesthesia Event is
ME E14.3 Facility has established Post anaesthesia status RR/SI
procedures for Post is monitored and
Anaesthesia care documented
ME E15.1 Facility has established There is procedure OT RR/SI Schedule is prepared
procedures OT Scheduling in consonance with
Scheduling available OT house and
patients requirement
ME E15.2 Facility has established Patient evaluation RR/SI Vitals , Patients fasting
procedures for before surgery is done status etc.
Preoperative care and recorded
Antibiotic Prophylaxis RR/SI
given as indicated
Tetanus Prophylaxis is RR/SI
given if Indicated
There is a process to RR/SI Surgical Site is marked
prevent wrong site and before entering into OT
wrong surgery
Surgical site RR/SI Cleaning , Asepsis and
preparation is done as Draping
per protocol
ME E15.3 Facility has established Surgical Safety Check RR/SI Check for Surgical
procedures for Surgical List is used for each safety check list has
Safety surgery been used for surgical
procedures
Sponge and RR/SI Instrument, needles
Instrument and sponges are
Count Practice is counted before
implemented beginning of case,
before final closure
and on completing of
procedure
Adequate Haemostasis RR/SI Check for Cautery
is secured during and suture legation
surgery practices
Appropriate suture RR/SI Check for what kind
material is used of sutures used for
for surgery as per different surgeries
requirement . Braided Biological
sutures are not used
for dirty wounds,
Catgut is not used for
closing fascial layers
of abdominal wounds
or where prolonged
support is required

No. ance Method
Check for suturing RR/SI
techniques are applied
as per protocol
ME E15.4 Facility has established Post operative RR/SI Check for post
procedures for Post monitoring is done operative operation
operative care before discharging to ward is used and
ward patients are not
immediately shifted to
wards after surgery
Post operative notes RR/SI Post operative notes
and orders are contains Vital signs,
recorded Pain control, Rate and
type of IV fluids, Urine
and Gastrointestinal
fluid output,
other medications
and Laboratory
investigations
ME E16.1 Death of admitted Death note is written RR
patient is adequately on patient record
recorded and
communicated
ME E16.2 The facility has Death note including RR Includes both maternal
standard procedures efforts done for and neonatal death
for handling the death resuscitation is noted
in the hospital in patient record
Death summary RR/SI
is given to patient
attendant quoting the
immediate cause and
underlying cause if
possible
Standard E18 Facility has established procedures for Intranatal care as per guidelines
ME E18.2 There is an established pre operative care and SI/RR Check for Haemoglobin
procedure for assisted part preparation level is estimated ,
and C-section and arrangement of
deliveries per scope of Blood, Catheterization,
services. Demonstration of
Antacids
Proper selection SI/RR Check Both General
Anaesthesia technique and Spinal Anaesthesia
Options are available.
Ask for what are the
criteria for using spinal
and GA
Intraoperative care SI/RR Check for measures
taken to prevent Supine
Hypotension (Use of
pillow/Sandbag to tilt
the uterus), Technique
for Incision, Opening
of Uterus, Delivery of
Foetus and placenta,
and closing of Uterine
Incision
Post operative care SI/RR

No. ance Method
ME E18.3 There is established Management of PIH/ SI/RR Ask for how to
procedure for Eclampsia secure airway and
management breathing, Loading and
of Obstetrics Maintenance dose of
Emergencies as per Magnesium sulphate
scope of services. , Administration of
Hypertensive Drugs
Postpartum SI/RR
Haemorrhage
Retained Placenta SI/RR
Sepsis SI/RR
Rupture uterus SI/RR
ME E18.4 There is an established Recording Time of RR
procedure for new Birth
born resuscitation and Vitamin K for low birth SI/RR
newborn care. weight
Care of Cord and Eyes SI/RR
APGAR Score SI/RR
New born SI/RR
Resuscitation
Standard E19 Facility has established procedures for postnatal care as per guidelines
ME E19.1 Post partum Care is Prevention of SI/RR
Provided to Mother Hypothermia
Initiation of PI/SI
Breastfeeding with in
1 Hour
ME E19.4 Stabilization/ There is established SI/RR
treatment/referral criteria for shifting
of post natal newborn to SNCU
complication
ME F1.2 Facility has provision Surface and SI/RR Swab are taken from
for Passive and active environment infection prone
culture surveillance samples are taken surfaces
of critical & high risk for microbiological
areas surveillance
ME F1.3 Facility measures There is procedure to SI/RR Patients are observed
hospital associated report cases of Hospital for any sign and
infection rates acquired infection symptoms of HAI
like fever, purulent
discharge from surgical
site .
ME F1.4 There is Provision There is procedure for SI/RR Hepatitis B, Tetanus
of Periodic Medical immunization of the Toxid etc
Checkups and staff
immunization of staff Periodic medical SI/RR
checkup of the staff
procedures for of infection control infection control
regular monitoring practices audits done at periodic
of infection control intervals
practices

No. ance Method
antisepsis
ME F2.1 Hand washing facilities Availability of hand OB Check for availability
are provided at point washing Facility at of wash basin near the
of use Point of Use point of use
Availability of running OB/SI Ask to Open the tap.
Water Ask Staff water supply
is regular
Availability of OB/SI Check for availability/
antiseptic soap with Ask staff if the supply
soap dish/ liquid is adequate and
antiseptic with uninterrupted
dispenser.
Availability of Alcohol OB/SI Check for availability/
based Hand rub Ask staff for regular
supply.
Display of Hand OB Prominently displayed
washing Instruction at above the hand
Point of Use washing facility ,
preferably in Local
language
operated taps
ME F2.2 Staff is trained and Adherence to 6 steps SI/OB Ask of demonstration
adhere to standard of Hand washing
hand washing Adherence to Surgical SI/OB procedure should be
practices scrub method repeated several times
so that the scrub lasts
for 3 to 5
minutes. The hands
and forearms should
be dried with a sterile
towel only.
Staff aware of when to SI
hand wash
ME F2.3 Facility ensures Availability of OB
standard practices and Antiseptic Solutions
materials for antisepsis Proper cleaning of OB/SI like before giving IM/
procedure site with IV injection, drawing
antisepsis blood, putting
Intravenous and urinary
catheter
Proper cleaning of SI
perineal area before
procedure with
antisepsis

No. ance Method
done during part
cases
Check sterile field is OB/SI Surgical site covered
maintained during with sterile drapes,
surgery sterile instruments are
kept within the sterile
field.
ME F3.1 Facility ensures Clean gloves are OB/SI
adequate personal available at point of
protection equipments use
as per requirements Availability of Masks OB/SI
Sterile s gloves are OB/SI
available at OT and
Critical areas
purpose
Apron
Personal protective kit OB/SI HIV kit
for infectious patients
standard personal gloves, Masks, caps
protection practices and aprons.
method of wearing
and removing the
gloves
ME F4.1 Facility ensures Decontamination of SI/OB Ask stff about how
standard practices operating & Procedure they decontaminate
and materials for surfaces the procedure surface
decontamination like OT Table, Stretcher/
and clean ing of Trolleys etc.
instruments and (Wiping with .5%
procedures areas Chlorine solution
Proper SI/OB
Decontamination of Ask staff how they
instruments like
ambubag, suction
canulae, Surgical
Instruments
(Soaking in 0.5%
Chlorine Solution,
Wiping with 0.5%
Clorine Solution or 70%
Alcohal as applicable
decontamination is
adeqaute

No. ance Method
Cleaning of SI/OB Cleaning is done
instruments after with detergent and
decontamination running water after
decontamination
Proper handling of SI/OB No sorting ,Rinsing or
Soiled and infected sluicing at Point of use/
linen Patient care area
Staff know how to SI/OB
make chlorine solution
ME F4.2 Facility ensures Equipment and OB/SI Autoclaving/HLD/
standard practices instruments are Chemical Sterlization
and materials for sterlized after each use
disinfection and as per requirement
equipments equipments is done bioling
as per protocol
Chemical sterilization OB/SI Ask staff about
of instruments/ method, concentration
equipments is done as and contact time
per protocols requied for chemical
sterilization
Formaldehyde or OB/SI
glutaraldehyde
solution replaced as
per manufacturer
instructions
used for procedure
material is used
Instruments are OB/SI
packed according for
autoclaving as per
standard protocol
Autoclaving of OB/SI Ask staff about
instruments is done as temperature, pressure
per protocols and time
Regular validation of OB/SI/RR
sterilization through
biological and
chemical indicators
Maintenance of OB/SI/RR
records of sterilization
There is a procedure to OB/SI/RR
enusure the tracibility
of sterilized packs
Sterility of autoclaved OB/SI Sterile packs are kept in
packs is maintained clean, dust free, moist
during storage free environment.
ME F5.1 Layout of the Facility layout ensures OB Faculty layout ensures
department is separation of general separation of general
conducive for the traffic from patient traffic from patient
infection control traffic traffic
practices Zoning of High risk OB
areas

No. ance Method
Floors and wall OB
surfaces of ICU are
easily cleanable
CSSD/TSSU has OB
demarcated separate
area for receiving
dirty items, processes,
keeping clean and
sterile items
ME F5.2 Facility ensures Availability of OB/SI Chlorine solution,
and disinfection of Availability of OB/SI Hospital grade phenyl,
patient care areas cleaning agent as per disinfectant detergent
requirement solution
ME F5.3 Facility ensures Staff is trained for spill SI/RR
followed for cleaning Cleaning of patient SI/RR
and disinfection of care area with
patient care areas detergent solution
preparing cleaning
solution as per
standard procedure
Standard practice OB/SI
of mopping and
scrubbing are followed
Cleaning equipments OB/SI
like broom are not
used in patient care
areas
Use of three bucket OB/SI
system for mopping
Fumigation/ SI/RR
schedule
restricted
ME F5.4 Facility ensures Isolation and barrier OB/SI
segregation infectious nursing procedure
patients are followed for septic
cases
ME F5.5 Facility ensures air Positive Pressure in OT OB/SI
quality of high risk Adequate air SI/RR
area exchanges are
maintained
ME F6.1 Facility Ensures Availability of colour OB
guidelines

No. ance Method
Availability of plastic OB
bags
Segregation of OB/SI
different category of
waste as per guidelines
Display of work OB
instructions for
segregation and
waste
waste
ME F6.2 Facility ensures Availability of OB See if it has been used
management of sharps functional needle or just lying idle
as per guidelines cutters
Availability of puncture OB Should be available
proof box nears the point of
generation like nursing
station and injection
room
Disinfection of sharp OB/SI Disinfection of syringes
before disposal is not done in open
buckets
Staff is aware of SI
contact time for
disinfection of sharps
Availability of post OB/SI Ask if available. Where
exposure prophylaxis it is stored and who is
in charge of that.
Staff knows about SI Staff knows what to do
reporting process after in case of shape injury.
sharp injury Whom to report. See if
any reporting has been
done
ME F6.3 Facility ensures Check bins are not SI
medical waste is done
in close container/
trolley
Facility ensures Staff aware of mercury SI/RR
standard practices spill management
and materials for
decontamination
and cleaning of
instruments and
procedures areas

No. ance Method
quality team in place departmental
nodal person for
coordinating Quality
to quality.
ME G3.1 Facility has established There is system SI/RR
internal quality daily round by
assurance program at matron/hospital
relevant departments manager/ hospital
superintendent/
Hospital Manager/
ME G3.3 Facility has established Departmental SI/RR
system for use of checklist are used for
check lists in different monitoring and quality
departments and assurance
filling and monitoring
of these checklists
ME G4.1 Departmental Standard operating RR
procedures are department has
available been prepared and
approved
process owner
ME G4.2 Standard Operating Department has RR Tracers
Procedures adequately documented
describes process and procedure for
procedures scheduling the Surgery
and its booking
Department has RR
documented
procedure for pre
operative procedure
Department has RR
documented
procedure for pre
operative anaesthetic
check up
Department has RR
documented
procedure for in
process check during
surgery

No. ance Method
Department has RR
documented
procedure for post
operative care of the
patient
Department has RR
documented
procedure for
operation theatre
asepsis and
environment
management
Department has RR
documented
procedure for OT
documentation.
Department has RR
documented
procedure for
reception of dirt packs
and issue of sterile
packs from TSSU
Department has RR
documented
procedure for
maintenance and
calibration of
equipments
Department has RR
documented
procedure for general
cleaning of OT and
annexes
ME G4.3 Staff is trained and Check staff is a aware SI/RR
aware of the standard of relevant part of SOPs
SOPs
ME G4.4 Work instructions are Work instruction/ OB processing and
displayed at Point of clinical protocols are sterilization of
use displayed equipments,
ME G5.1 Facility maps its critical Process mapping of SI/RR
ME G5.2 Facility identifies non Non value adding SI/RR
/ waste / redundant
activities
ME G5.3 Facility takes corrective Processes are SI/RR
ME G6.1 The facility conducts Internal assessment RR/SI
periodic internal is done at periodic
assessment interval

No. ance Method
recorded adequately
process
ME G6.5 Corrective and Corrective and RR/SI
preventive actions preventive action
are taken to address taken
assessment & audit
defines its quality OT are defined
objectives and key
departments have
is aware of that
ME G7.4 Progress towards Quality objectives SI/RR
quality objectives is are monitored and
monitored periodically reviewed periodically
ME G8.1 Facility uses PDCA SI/RR
improvement in
Six Sigma SI/RR
quality improvement Pareto / Prioritization SI/RR
in services
benchmarks
ME H1.1 Facility measures C-Section Rate RR
productivity Indicators Proportion of RR
on monthly basis C-Sections done in
night
Proportion of other RR
emergency surgeries
done in the night
No. of Major surgeries RR
done per 1 lakh
population
CSSD/TSSU RR No. of packs sterilized
productivity index against the no. of
surgeries

No. ance Method
ME H2.1 Facility measures Downtime critical RR
efficiency Indicators euipments
on monthly basis Skin to skin time RR
No of major surgeries RR
per surgeon
Proportion of elective RR
C-Sections
Proportion emergency RR
surgeries
Cycle time for RR
instrument processing
benchmark
ME H3.1 Facility measures Surgical Site infection RR No. of observed surgical
Clinical Care & Safety Rate site infections*100/total
Indicators on monthly no. of Major surgeries
basis No of adverse events RR
Incidence of re- RR
exploration of surgery
% of environmental RR
swab culture reported
positive
Perioperative Death RR Deaths occurred
Rate from pre operative
procedure to discharge
of the patient
Proportion of General RR
Anaesthesia to spinal
anaesthesia
Proportion of PAC RR
done out of total
elective surgeries
No. of autoclave RR
cycle failed in Bowie
dick test out of total
autoclave cycle
benchmark
ME H4.1 Facility measures Operation Cancellation RR No. of cancelled
Service Quality rates operation*1000 /total
Indicators on monthly operation done
basis

Assessment Summary
A. Score Card
Operation Theatre Score Card
Operation Theatre Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Checklist–9
PostPartum Unit
Version: 1/2013

Checklist–9
Checklist for PostPartum Unit
Reference Measure Element Checkpoint Com- Assessment Means of Verification

No. pliance Method
ME A1.14 Services are available At least 6 hours of OPD SI/RR
for the time period as services are available at
mandated Family Planning Clinic
Days for FP Surgeries SI/RR As per Operational
are fixed Guidelines for Fixed Day
Surgery ( At least one day
per week)
ME A2.1 The facility provides Availability of Spacing SI/OB IUCD, OCP, ECP & Condoms
Reproductive health methods of family
Services planning
Availability of Female SI/OB Tubectomy (Minilap and
Limiting Methods of Laparoscopic)
family Planning
Availability of Male SI/OB NSV/Conventional
Limiting Method for
Family Planning
Availability of Post SI/OB Tubal Ligation and PPIUD
partum sterilization
services
Availability of Family SI/OB Counselling and IEC
Planning Counselling
and Promotive services
Abortion and SI/OB
Contraception services
for Ist and 2nd trimester
Postpartum ward SI/OB Dedicated postpartum
ward for FP surgeries and
abortion clients
ME A2.2 The facility provides Availability of post natal SI/OB
Maternal health counselling and follow
Services up services
ME A2.3 The facility provides Availability/Linkage to SI/OB
Newborn health immunization services
Services
ME A2.5 The facility provides Availability of Abortion SI/OB
Adolescent health services for adolescent
Services Availability of SI/OB
Contraception services
ME A3.2 The facility Provides Availability of point of SI/OB For sterilization
Laboratory Services care diagnostic test surgeries, availability
of haemoglobin, urine
analysis for sugar
and albumin
No. pliance Method
ME B1.1 The facility has Availability OB (Numbering, main
uniform and user- departmental signage’s department and internal
friendly signage sectional signage
system Restricted area signage OB
are displayed
ME B1.2 The facility displays List of Family Planning OB
the services and Services available
entitlements available Compensation for OB
in its departments family planning
indemnity scheme
Compensation for OB
family planning services
are displayed
Family planning OB
insurance scheme
displayed
ME B1.5 Patients & visitors IEC Material regarding OB IEC materials such as
are sensitised and family planning posters, banners, and
educated through displayed handbills
appropriate IEC / BCC available at the site and
approaches displayed
Education material OB Flip charts, models,

for counselling are specimens, and samples of
available in Counselling contraceptives available
room
ME B1.6 Information is Signage’s and OB
available in local information are
language and easy to available in local
understand language
ME B2.1 Services are provided Availability of female OB/SI
in manner that are staff if a male doctor
sensitive to gender examines a female
client
There is no over SI/PI Ask Staff/client whether
emphasis on one they were convinced for
method one method or given
informed choice
ME B2.3 Access to facility is Availability of Wheel OB
provided without any chair or stretcher for
physical barrier & and easy Access to the OT
friendly to people with Availability of ramps OB
disabilities with railing
friendly toilet
296 | Checklist for PostPartum Unit

No. pliance Method
ME B3.1 Adequate visual Availability of screens at OB
privacy is provided at IUD insertion room
every point of care Availability of screens at OB
family planning OT
Client are properly OB
draped/covered before
and after produce
Privacy at the OB
counselling room is
maintained
ME B3.2 Confidentiality of Client Records are kept SI/OB
patients records and at secures place beyond
clinical information is access to general staff/
maintained visitors
No information SI/OB
regarding client
identity and details are
unnecessary displayed
ME B3.3 The facility ensures Behaviour of staff PI/OB
respectful, while
ME B3.4 The facility ensures Confidentiality of SI/OB No entry shall be made
privacy and Abortion cases in any case sheet , PT
confidentiality to every register , follow-up card
patient, especially or any other document,
of those conditions register indicating there in
having social stigma, the name of the pregnant
and also safeguards women . Only reference
vulnerable groups serial no. is mentioned on
all the document
ME B4.1 There is established Informed consent for SI/RR
procedures for taking IUD insertion
informed consent Informed consent SI/RR
before treatment and for family planning
procedures surgeries
Informed consent on SI/RR
prescribed form C for
abortion
ME B4.2 Patient is informed Display of reproductive OB
about his/her rights rights of clients
and responsibilities
ME B4.3 Staff are aware Check staff if about SI
of Patients rights awareness reproductive
responsibilities rights of clients
ME B4.4 Information about the Client is informed PI/SI
treatment is shared about various options
with patients or of family planning and
attendants, regularly assisted in decision
making
Checklist for PostPartum Unity | 297

No. pliance Method
ME B4.5 The facility has defined Availabilty of complaint OB
and established box and display of
grievance redressal process for grievance re
system in place addressal and whom to
ME B5.1 The facility provides Drugs, consumables PI/SI
cashless services to and contraceptives are
pregnant women, available free
mothers and neonates All surgical procedure PI/SI
as per prevalent for family planning are
government schemes free of cost
ME B5.2 The facility ensures Check that client PI/SI
are available at on purchasing drugs
Pharmacy and wards or consumables from
outside.
ME B5.3 It is ensured Check that client PI/SI
that facilities for has not spent on
the prescribed diagnostics from
investigations are outside.
timely reimbursement expenditure occurred
of financial it is reimbursed from
entitlements and hospital
reimbursement to the Timely payment PI/SI/RR
patients of family planning
compensation
the prevalent norms
ME C1.1 Departments have Adequate Space is OB
adequate space as per for counselling and
patient or work load examination
OT for Family planning
surgeries in PP unit
ME C1.2 Patient amenities are Functional toilets with OB Availability of drinking
provide as per patient running water and flush water
load are available as per bed
strength and client load
of ward
Availability of drinking OB
water
Availability of seating OB
arrangement
ME C1.3 Departments have Demarcated of
layout and demarcated Protective Zone
areas as per functions Demarcated Clean Zone
Demarcated sterile OB
Zone

No. pliance Method
Demarcated disposal OB
Zone
Availability of Changing OB
Rooms
Operative Room
Availability of OB
earmarked area for
newborn Corner
Operative Room
Availability of Scrub OB
Area
Availability of Autoclave OB
room/ TSSU
utility area
counselling area
Availability of OB
examination cum minor
procedure area for IUD
insertion
ME C1.4 The facility has Corridors are wide OB
adequate circulation enough for movement
area and open spaces of trolleys and stretchers
according to need and
local law
and extramural
communication
ME C1.6 Service counters are OT tables are available OB
available as per patient as per load
load
ME C1.7 The facility and Unidirectional flow of OB
departments are goods and services
planned to ensure
structure follows
the function/
processes (Structure
commensurate with
the function of the
hospital)
ME C2.1 The facility ensures the Non structural OB Check for fixtures and
seismic safety of the components are furniture like cupboards,
infrastructure properly secured cabinets, and heavy
equipments , hanging
objects are properly
fastened and secured

No. pliance Method
ME C2.3 The facility ensures OT does not have OB
safety of electrical temporary connections
establishment and loosely hanging
wires
ME C2.4 Physical condition of Floors of the ward are OB
buildings are safe for non slippery and even
providing patient care Walls and floor of the OT OB
covered with joint less
tiles
Windows if any in the OB
OT are intact and sealed
ME C3.1 The facility has plan for OT has sufficient fire OB/SI
prevention of fire exit to permit safe
escape to its occupant
at time of if emergency
clearly marked.
ME C3.2 The facility has PP unit has installed OB
Equipment Class A /B/C type or ABC
type
mentioned
ME C3.3 The facility has a Check for staff SI/RR
system of periodic competencies
conducts mock drills extinguisher and what
regularly for fire and to do in case of fire
ME C4.1 The facility has Availability of trained OB/RR Minilap - MBBS trained in
adequate specialist surgeon for Minilap/ procedure
doctors as per service Laparoscopic/NSV Laparoscopic- DGO,MS, MD
provision trained in laparoscopic
surgery
ME C4.3 The facility has Availability of Nursing OB/RR/SI Trained in IUCD insertion
adequate nursing staff
staff as per service
provision and work
load
ME C4.4 The facility has Viability of Counsellor OB/SI
adequate technicians/ for family planning
paramedics as per Availability of OT SI/RR
requirement technician

No. pliance Method
ME C4.5 The facility has Availability of OT SI/RR
adequate support / attendant/assistant
general staff Availability of Security SI/RR
staff
ME C4.6 The staff has been IUD insertion SI/RR
provided required Family planning SI/RR
training / skill sets counselling
Laparoscopic surgery/ SI/RR
Minilap
NSV SI/RR
Bio medical waste SI/RR
Management
Training on infection SI/RR
control and hand
hygiene
ME C4.7 The Staff is skilled as Staff is skill for SI/RR
per job description counselling services
resuscitation
records
Staff is Skilled to SI/RR
operate OT equipments
processing and packing
instrument
ME C5.1 The departments Availability of Oral OB/RR Stock for Month
have availability of Contraceptive Pills
adequate drugs at Availability of OB/RR Stock for Month
point of use emergency
Contraceptive Pills
Availability of IUD OB/RR Stock for Month
devices
Availability of Condoms OB/RR Stock for Month
anaesthetics
Availability of medical OB/RR Tracer
gases
ME C5.2 The departments Sterilized consumables OB/RR At OT
have adequate in dressing drum
consumables at point
of use
ME C5.3 Emergency drug trays Availability of OB/RR
are maintained at emergency drugs tray
every point of care,
where ever it may be
needed

No. pliance Method
ME C6.1 Availability of Availability of OB BP apparatus,
equipment & functional Equipment Thermometer, Pulse
instruments for &Instruments for Oxymeter, Multiparameter
examination & examination &
monitoring of patients Monitoring
ME C6.2 Availability of Availability of OB PV examination kit
equipment & Instruments/
instruments for Equipments for Gynae
treatment procedures, and obstetric
being undertaken in Availability of Sterile OB
the facility IUD insertion and
removal Kits
Operation Table with OB
Trendelenburg facility
Minilap instrument OB
Laparoscopic set OB
NSV sets OB
Instruments for OB
Laparoscopy
ME C6.3 Availability of Availability of Point OB Glucometer, Doppler and
equipment & of care diagnostic HIV rapid diagnostic kit
instruments for instruments
diagnostic procedures
being undertaken in
the facility
ME C6.4 Availability of Availability of OB Bag and mask, Oxygen,
equipment and functional Instruments Suction machine ,
instruments for Resuscitation laryngoscope scope.
resuscitation of LMA, ET Tube , Airway
patients and for ,Defibrillator
providing intensive
and critical care to
patients
ME C6.5 Availability of Availability of OB Refrigerator, Crash cart/
Equipment for Storage equipment for storage Drug trolley, instrument
for drugs trolley, dressing trolley
functional equipment equipments for cleaning Separate mops for patient
and instruments for care area and circulation
support services area duster, waste trolley,
Deck brush
Availability of OB Autoclave/ boiler,
equipment for
sterilization and
disinfection
ME C6.7 Departments have Availability of functional OB
patient furniture and OT light
fixtures as per load Availability of OB Hospital graded mattress ,
and service provision attachment/ accessories IVstand, Bed pan
with OT table
Availability of Fixtures OB Trey for monitors,
Electrical panel for
anaesthesia machine,
cardiac monitor etc, panel
with outlet for Oxygen and
vacuum, X ray view box.

No. pliance Method
Availability of furniture OB Cupboard, table for
preparation of medicines,
chair, racks,
of Equipment.
down maintenance of
the equipments
There has system to OB/RR
label Defective/Out of
order equipments and
stored appropriately
until it has been
repaired
ME D1.2 The facility has All the measuring OB/ RR
established procedure equipments/ instrument
for internal and are calibrated
external calibration of There is system to label/ OB/ RR
measuring Equipment code the equipment
to indicate status of
calibration/ verification
when recalibration is
due
ME D1.3 Operating and Up to date instructions OB/SI Laparoscope, MVA etc
maintenance for operation and
instructions are maintenance of
available with the equipments are readily
users of equipment available with staff.
ME D2.1 There is established There is process SI/RR Stock level are daily
procedure for indenting consumable updated
forecasting and and drugs Requisition are timely
indenting drugs and placed
consumables
ME D2.3 The facility ensures Contraceptives are OB/RR
proper storage stored away from water
of drugs and and sources of heat,
consumables direct sunlight etc.
ME D2.4 The facility ensures Expiry dates’ are OB/RR Are expired contraceptives
management of expiry maintained at destroyed to prevent resale
and near expiry drugs emergency drug tray or other inappropriate use
maintained for drug

No. pliance Method
for inventory maintaining buffer stock
management of contraceptives
techniques Department RR/SI
maintained stock and
expenditure register of
contraceptives
for periodically replenishing drug tray /
replenishing the drugs crash cart
in patient care areas There is no stock out of OB/SI
contraceptives
ME D2.7 There is process for Temperature of OB/RR Check for temperature
storage of vaccines refrigerators are kept as charts are maintained and
and other drugs, per storage requirement updated periodically
requiring controlled and records are
temperature maintained
ME D2.8 There is a procedure Anaesthetic agents are OB/SI
for secure storage kept at secure place
of narcotic and
psychotropic drugs
ME D3.1 The facility provides Adequate Illumination OB
adequate illumination at OT table
level at patient care Adequate Illumination OB At IUD insertion area
areas at procedure area at
family planning clinic
ME D3.2 The facility has Entry to OT is restricted OB
provision of restriction Only one client is OB/SI
of visitors in patient allowed one time at
areas clinic
Warning light is SI/RR
provided outside OT
and its been used when
OT is functional
ME D3.3 The facility ensures Temperature is SI/RR 20-25OC, ICU has
safe and comfortable maintained and record functional room
environment for of same is kept thermometer and
patients and service temperature is regularly
providers maintained
Appropriate Humidity SI/RR 50-60%
label is maintained
ME D3.4 The facility has security Security arrangement at OB
system in place at PP unit
patient care areas
ME D3.5 The facility has Ask female staff weather SI
established measure they feel secure at work
for safety and security place
of female staff

No. pliance Method
painted
ME D4.2 Patient care areas are Floors, walls, roof, roof OB All area are clean with no
clean and hygienic topes, sinks patient care dirt,grease,littering and
and circulation areas cobwebs
are Clean
fixtures are clean
running water
ME D4.3 Hospital infrastructure Check for there is OB
intact
OT Table are intact and OB
without rust
and clean
ME D4.5 The facility has No condemned/Junk OB
policy of removal material in the PP unit
of condemned junk
material
ME D4.6 The facility has No pests are noticed OB
established
procedures for pest,
rodent and animal
control
ME D5.1 The facility has Availability of 24x7 OB/SI
portable water in all Availability of Hot water OB/SI
functional areas supply
ME D5.2 The facility ensures Availability of power OB/SI
adequate power back up in OT
Emergency light
ME D5.3 Critical areas of Availability of OB
the facility ensures Centralized /local piped
availability of oxygen, Oxygen, nitrogen and
medical gases and vacuum supply
vacuum supply

No. pliance Method
ME D7.1 The facility has OT has facility to OB/RR Drape, draw sheet, cut
adequate sets of linen provide sufficient and sheet and gown
clean linen for surgical
client
OT has facility to OB/RR
provide linen for staff
ME D7.2 The facility has Linen is changed after OB/RR
established each procedure
procedures for
changing of linen in
patient care areas
ME D7.3 The facility There is system to SI/RR
has standard check the cleanliness
procedures for and Quantity of the
handling, collection, linen received from
transportation and laundry
washing of linen
Standard Facility is compliant with all statutory and regulatory requirement imposed by local, state or
D10 central government
ME D10.3 The facility ensure Staff is aware of legal SI/RR 22-49 married only
relevant processes are age for family planning
in compliance with
statutory requirement
ME D11.1 The facility has Staff is aware of their SI
established job role and responsibilities
guidelines
established procedure to ensure that staff is recording time of reporting
for duty roster and available on duty as per and relieving (Attendance
deputation to different duty roster register/ Biometrics etc)
departments There is designated in SI
code as mandated by staff adhere to their
its administration / the respective dress code
health department
ME D12.1 There is established There is procedure to SI/RR Verification of outsourced
system for contract monitor the quality services (cleaning/
management for out and adequacy of Dietary/Laundry/Security/
sourced services outsourced services on Maintenance) provided
regular basis are done by designated
in-house staff
established procedure number is given to
for registration of each client during
patients process of registration

No. pliance Method
Client demographic RR Check for that client
details are recorded in demographics like Name,
admission records age, Sex, etc.
ME E1.3 There is established Age criteria for family RR/SI
procedure for planning surgeries is
admission of patients adhered
There is established RR/SI
criteria for admission of
abortion cases
There is no delay in SI/RR/OB
admission of client
qualified doctor
recorded in client record
ME E1.4 There is established There is provision of OB/SI
procedure for extra beds during fixed
managing patients, day family planning
in case beds are not surgery
the patients.
ME E2.1 There is established History of illness to RR/SI
procedure for initial screen for the diseases
assessment of patients mentioned under the
medical
eligibility criteria
Immunization status of RR/SI
women for tetanus
Current medications RR/SI
last contraceptive used RR/SI
and when
Menstrual history: Date RR/SI
of last menstrual period
current pregnancy RR/SI
status
Obstetrics history
Physical Examination RR/SI Pulse, blood pressure,
respiratory rate,
temperature, body
weight, general condition
and pallor, auscultation
of heart and lungs,
examination
of abdomen, pelvic
examination, and other
examinations as indicated
by the
client’s medical history
or general physical
examination.
procedure for follow- for assessment of client
up/ reassessment of
Patients

No. pliance Method
ME E3.1 Facility has Facility has established SI/RR
established procedure procedure for handing
for continuity over form OT to ward
of care during
interdepartmental
transfer
ME E3.2 Facility provides Facility has functional RR/SI
appropriate referral referral linkages to
linkages to the higher facilities for cases
patients/Services for can not be managed at
transfer to other/ the facility
higher facilities to
assure their continuity
of care.
ME E3.3 A person is identified A nurse /doctor is RR/SI
for care during all identified responsible
steps of care for each case
ME E4.1 Procedure for There is a process OB/SI Client id band/ verbal
identification of for ensuring the confirmation etc.
patients is established identification before any
at the facility clinical procedure
ME E4.2 Procedure for ensuring There is a process to RR Verbal orders are
timely and accurate ensue the accuracy rechecked before
nursing care as per of verbal/telephonic administration
treatment plan is orders
established at the
facility
ME E4.3 There is established Client hand over is SI/RR
procedure of patient given during the
hand over, whenever change in the shift
side
ME E4.4 Nursing records are Nursing notes are RR/SI Check for nursing note
maintained maintained adequately register. Notes are
adequately written
ME E4.5 There is procedure for Client Vitals are RR/SI
periodic monitoring of monitored and
patients recorded periodically
ME E5.1 The facility identifies Vulnerable client are OB/SI
vulnerable patients identified and measures
and ensure their safe are taken to protect
care them from any harm
ME E5.2 The facility identifies High risk medical OB/SI
high risk patients and emergencies are
ensure their care, as identified and treatment
per their need given on priority
Standard E6 The facility follows standard treatment guidelines defined by state/Central
ME E6.1 Facility ensured that Check BHT if drugs RR

No. pliance Method
ME E6.2 There is procedure of Check that relevant RR
guideline are available
at point of use
the drug regime and
doses as per STG
Check BHT that drugs RR
are prescribed as per
STG
formulary
ME E7.1 There is process High alert drugs SI/OB Electrolytes like Potassium
for identifying available in department chloride, Opioids, Neuro
and cautious are identified muscular blocking agent,
administration of high Anti thrombolytic agent,
alert drugs (to check) insulin, warfarin, Heparin,
Adrenergic agonist etc. as
applicable
Maximum dose of high SI/RR Value for maximum doses
alert drugs are defined as per age, weight and
and communicated diagnosis are available
with nursing station and
doctor
There is process to SI/RR A system of independent
ensure that right doses double check before
of high alert drugs are administration, Error prone
only given medical abbreviations are
avoided
ME E7.2 Medication orders are Every Medical advice RR
adequately accompanied with date
, time and signature
clinical staff
Check single dose vial OB Check for any open single
are not used for more dose vial with left over
than one dose content intended to be
used later on
sterile needle is used In multi dose vial needle is
every time for multiple not left in the septum
dose vial
reported
ME E7.4 There is a system to Administration of SI/OB
patient right drugs , right route,
right time

No. pliance Method
ME E7.5 Patient is counselled Client is advice by SI/PI
for self drug doctor/ Pharmacist
administration /nurse about the
ME E8.1 All the assessments, Records of Monitoring/ RR History and Physical
re-assessment and Assessments are examination are recorded
investigations are maintained
ME E8.2 All treatment plan Treatment plan, first RR Drugs administered are
prescription/orders are orders are written on recorded
recorded in the patient BHT
records.
ME E8.4 Procedures performed Anaesthesia and RR
are written on patients surgery note recorded
records
ME E8.5 Adequate form and Standard Formats RR/OB Formats for Consent etc
formats are available available available
at point of use
ME E8.6 Register/records are Check for availability RR
maintained as per of eligible couple and
guidelines sterilization register
Records on family RR
planning (FP) (including
the number
of clients counselled
and the number of
acceptors)
Follow-up records for FP RR
clients
are identified and
numbered
ME E8.7 The facility ensures Safe keeping of client OB
safe and adequate records
of medical records
Standard E9 The facility has defined and established procedures for discharge of patient
ME E9.1 Discharge is done Assessment is done SI/RR
after assessing patient before discharging
readiness client
Discharge is done SI/RR
by a responsible and
qualified doctor
Client / attendants PI/SI
discharge
consulted/ informed
before discharge of
clients

No. pliance Method
ME E9.2 Case summary and Discharge summary is RR/PI See for discharge summary,
follow-up instructions provided referral slip provided.
are provided at the Discharge summary RR
discharge adequately mentions
clients clinical
given and follow up
give to clients going in
LAMA/Referral
ME E9.3 Counselling services Counselling of client SI/PI
are provided as during before discharge
discharges wherever Advice includes the RR/SI
required information about the
further follow up
communicated to client
in prior
Management.
management plan in plan
place Role and responsibilities SI/RR
defined
Standard E12 The facility has defined and established procedures of diagnostic services.
procedures for Pre- properly after the
testing Activities sample collection
procedures for Post- provided with the
testing Activities critical value of different
test
Standard E14 Facility has established procedures for Anaesthetic Services
ME E14.2 Facility has established Local anaesthesia is SI/RR
procedures for given as per guidelines
monitoring during
anaesthesia
ME E15.1 Facility has established FP surgeries are RR/SI
procedures OT scheduled as oer
Scheduling guidelines
Preoperative RR/PI
instructions given to the
client
ME E15.2 Facility has established Part preparation is done RR/SI
procedures for as per guidelines
Preoperative care
ME E15.4 Facility has established Post operative care as RR/SI
procedures for Post per guidelines
operative care

No. pliance Method
ME E16.1 Death of admitted Facility has a standard SI
patient is adequately procedure to
recorded and communicate death to
communicated relatives
client record
ME E16.2 The facility has Death note including RR
standard procedures efforts done for
for handling the death resuscitation is noted in
in the hospital client record
Death summary is given SI/RR
to client attendant
quoting the immediate
cause and underlying
cause if possible
Standard E17 Facility has established procedures for Antenatal care as per guidelines
ME E17.1 There is an established Facility provides and SI/RR
procedure for updates “Mother and
Registration and Child Protection Card”.
follow up of pregnant
women.
Standard E21 Facility has established procedures for abortion and family planning as per government
guidelines and law
ME E21.1 Family planning The client is given full PI/SI The importance of
counselling services information about timely initiation of an FP
provided as per optimal pregnancy method after childbirth,
guidelines spacing and miscarriage,
the benefits of it as or abortion will be
a part of FP health emphasized.
education and
counselling.
Client is counselled PI/SI
about the options
for family planning
available
The client is informed PI/SI
that condoms prevent
sexually transmitted
infections (STIs) & HIV
ME E21.2 Facility provides Pills should be given SI/RR Contraindication of
spacing method of only to those who meet COC in Breastfeeding
family planning as per the Medical Eligibility mothers within 6week and
guideline Criteria hypertension
The client should be PI/SI
given full information
about the risks,
advantages, and
possible side effects
before OCPs are
prescribed for her.
Staff is aware of SI/RR
what to do if dose of
contraceptive is missed

No. pliance Method
Staff is aware of SI/RR within 72 hours, second
indication and method dose 12 hours after first
of administration of ECP dose
IUD insertion is done as SI/RR No touch technique,
per standard protocol Speculum and bimanual
examination, sounding of
uterus and placement
Client is informed about SI/PI Cramping, vaginal
the adverse effect that discharge, heavier
can happen and their menstruation, checking of
remedy IUD
Follow up services SI/RR Removal of IUD,
are provided as per Instructions for when to
protocols return
IUD insertion is done as SI/RR
per standard protocol
Staff is aware of case SI/RR 49-22 year age
selection criteria for Married
family planning at least having one year old
Spouse has not gone for
sterilization
ME E21.3 Facility provides Assessment of client SI/RR Physical examination and
limiting method of done before surgery Medical History taken,
family planning as per for any delay, refer of
guideline caution signs
Consent is confirmed RR Surgeon check for
before the procedure informed consent signed
and ask client for the same
Client is informed about SI/RR/PI use of another family
post operative care, planning method for 3
complication and follow months only,
up
Follow up visits done as SI/RR/PI Visit after 48 hours, first
per guidelines follow up visit at 7th day
and semen analysis after 3
months, emergency follow
up
ME E21.4 Facility provide Pre procedure SI/RR/PI As per National Guidelines
counselling services Counselling provided Transition phase after
for abortion as per family planning surgery
guideline specially vasectomy are
defined
Post procedure SI/RR/PI As per National Guidelines
Counselling provided
Counselling on the SI/RR/PI
follow-up visit
ME E21.5 Facility provide MVA procedures are SI/RR
abortion services for done as per guidelines
1st trimester as per Medical termination of SI/RR
guideline pregnancy done as per
guidelines
ME E21.6 Facility provide Surgical Procedures SI/RR Dilation and evacuation
abortion services for procedures are done as
2nd trimester as per per guidelines
guideline Medical termination of SI/RR ethacridine lactate extra
pregnancy done as per amniotic instillation
guidelines

No. pliance Method
ME F1.2 Facility has provision Surface and SI/RR Swab are taken from
for Passive and active environment infection prone surfaces
culture surveillance samples are taken
of critical & high risk for microbiological
areas surveillance
ME F1.3 Facility measures There is procedure to SI/RR Patients are observed for
hospital associated report cases of Hospital any sign and symptoms
infection rates acquired infection of HAI like fever, purulent
discharge from surgical
site .
ME F1.4 There is Provision There is procedure for SI/RR Hepatitis B, Tetanus Toxid
of Periodic Medical immunization of the etc
Checkups and staff
immunization of staff Periodic medical SI/RR
procedures for of infection control infection control audits
regular monitoring practices done at periodic intervals
of infection control
practices
antisepsis
ME F2.1 Hand washing facilities Availability of hand OB Check for availability of
are provided at point washing Facility at Point wash basin near the point
of use of Use of use
Availability of running OB/SI Ask to Open the tap. Ask
Water Staff water supply is
regular
Availability of antiseptic OB/SI Check for availability/
soap with soap dish/ Ask staff if the supply
liquid antiseptic with is adequate and
dispenser. uninterrupted
Availability of Alcohol OB/SI Check for availability/ Ask
based Hand rub staff for regular supply.
Display of Hand OB Prominently displayed
washing Instruction at above the hand washing
Point of Use facility , preferably in Local
language
operated taps
ME F2.2 Staff is trained and Adherence to 6 steps of SI/OB Ask of demonstration
adhere to standard Hand washing
hand washing
practices

No. pliance Method
Adherence to Surgical SI/OB procedure should be
scrub method repeated several times so
that the scrub lasts for 3
to 5
minutes. The hands and
forearms should be dried
with a sterile towel only.
Staff aware of when to SI Ask of demonstration
hand wash
ME F2.3 Facility ensures Availability of Antiseptic OB
materials for antisepsis Proper cleaning of OB/SI like before giving IM/IV
procedure site with injection, drawing blood,
antisepsis putting Intravenous and
urinary catheter
Cleaning of cervix SI
before IUD insertion
with antiseptic solution
done during part
cases
Check sterile filled is OB/SI Surgical site covered
maintained during with sterile drapes, sterile
surgery instruments are kept
within the sterile field.
ME F3.1 Facility ensures Clean gloves are OB/SI
adequate personal available at point of use
protection equipments Availability of Masks OB/SI
as per requirements
Sterile s gloves are OB/SI
available at OT and
Critical areas
purpose
Apron
Personal protective kit OB/SI HIV kit
for infectious clients
removing the gloves
ME F4.1 Facility ensures Decontamination of SI/OB Ask stff about how they
standard practices operating & Procedure decontaminate the
and materials for surfaces procedure surface like OT
decontamination Table, Stretcher/Trolleys
and clean ing of etc.
instruments and (Wiping with .5% Chlorine
procedures areas solution

No. pliance Method
Proper SI/OB
Decontamination of Ask staff how they
instruments like ambubag,
suction canulae, Surgical
Instruments
(Soaking in 0.5% Chlorine
Solution, Wiping with 0.5%
Clorine Solution or 70%
Alcohal as applicable
decontamination is
adeqaute
after decontamination with detergent and
running water after
decontamination
Proper handling of SI/OB No sorting ,Rinsing or
Soiled and infected sluicing at Point of use/
linen Patient care area
chlorine solution
ME F4.2 Facility ensures Equipment and OB/SI Autoclaving/HLD/Chemical
standard practices instruments are Sterlization
and materials for sterlized after each use
disinfection and as per requirement
equipments equipments is done as bioling
per protocol
Chemical sterilization OB/SI Ask staff about method,
of instruments/ concentration and contact
equipments is done as time requied for chemical
per protocols sterilization
Formaldehyde or OB/SI
glutaraldehyde
solution replaced as
per manufacturer
instructions
used for procedure
material is used
Instruments are OB/SI
packed according for
autoclaving as per
standard protocol
Autoclaving of OB/SI Ask staff about
instruments is done as temperature, pressure and
per protocols time
Regular validation of OB/SI/RR
sterilization through
biological and chemical
indicators

No. pliance Method
Maintenance of records OB/SI/RR
of sterilization
There is a procedure to OB/SI/RR
enusure the tracibility of
sterilized packs
Sterility of autoclaved OB/SI Sterile packs are kept in
packs is maintained clean, dust free, moist free
during storage environment.
ME F5.1 Layout of the Facility layout ensures OB Faculty layout ensures
department is separation of general separation of general
conducive for the traffic from patient traffic from patient traffic
infection control traffic
practices Zoning of High risk OB
areas
Floors and wall surfaces OB
of ICU are easily
cleanable
CSSD/TSSU has OB
demarcated separate
area for receiving
dirty items, processes,
keeping clean and
sterile items
ME F5.2 Facility ensures Availability of OB/SI Chlorine solution,
and disinfection of Availability of OB/SI Hospital grade phenyl,
patient care areas cleaning agent as per disinfectant detergent
requirement solution
ME F5.3 Facility ensures Staff is trained for spill SI/RR
followed for cleaning Cleaning of patient care SI/RR
and disinfection of area with detergent
patient care areas solution
preparing cleaning
procedure
Standard practice of OB/SI
mopping and scrubbing
are followed
Cleaning equipments OB/SI
like broom are not used
in patient care areas
Use of double bucket OB/SI
system for mopping
Fumigation/ SI/RR
schedule

No. pliance Method
restricted
ME F5.5 Facility ensures air
quality of high risk
area
Adequate air exchanges SI/RR
are maintained
ME F6.1 Facility Ensures Availability of colour OB
guidelines Availability of plastic OB
bags
guidelines
Display of work OB
instructions for
segregation and
waste
waste
ME F6.2 Facility ensures Availability of functional OB See if it has been used or
management of sharps needle cutters just lying idle
as per guidelines Availability of puncture OB Should be available nears
proof box the point of generation
like nursing station and
injection room
Disinfection of sharp OB/SI Disinfection of syringes is
before disposal not done in open buckets
sharps
Availability of post OB/SI Ask if available. Where it
exposure prophylaxis is stored and who is in
charge of that.
Staff knows about SI Staff knows what to do
reporting procuress in case of shape injury.
after sharp injury Whom to report. See if any
reporting has been done
ME F6.3 Facility ensures Check bins are not SI
spill management

No. pliance Method
quality team in place departmental nodal
Quality Assurance
activities
Standard G2 Facility has established system for patient and employee satisfaction
ME G2.1 Patient Satisfaction Client satisfaction RR
surveys are conducted survey done on monthly
at periodic intervals basis
to quality.
ME G3.1 Facility has established There is system SI/RR
internal quality daily round by
assurance program at matron/hospital
relevant departments manager/ hospital
superintendent/
Hospital Manager/
ME G3.3 Facility has established Departmental checklist SI/RR
system for use of are used for monitoring
check lists in different and quality assurance
departments and Staff is designated for SI
services filling and monitoring of
these checklists
ME G4.1 Departmental Standard operating RR
procedures are department has been
available prepared and approved
process owner
describes process and for registration,
procedures admission and
discharge
Department has RR
for initial assessment of
the client
Department has RR
for providing
appointment/day and
date for the surgery
Department has RR
for preparation of client
for surgery

No. pliance Method
Department has RR
for IUD insertion
Department has RR
for taking consent of
the client for procedure
Department has RR
for record maintenance
Department has RR
for counselling of the
client
Department has manual RR
for male and female
sterilization
for Quality assurance
for sterilization
Department has RR
guideline for
administration
of Emergency
contraceptive
Department has RR
standard for various
technique of
contraception
Department has RR
standard IEC material
for client education and
counselling
for FP indemnity
scheme
ME G4.3 Staff is trained and Check staff is a aware of SI/RR
SOPs
ME G4.4 Work instructions are Work instruction/clinical OB IUD insertion, Processing of
displayed at Point of protocols are displayed instruments
use
ME G5.1 Facility maps its critical Process mapping of SI/RR
ME G5.2 Facility identifies non Non value adding SI/RR
/ waste / redundant
activities
ME G5.3 Facility takes corrective Processes are SI/RR

No. pliance Method
ME G6.1 The facility conducts Internal assessment RR/SI
periodic internal is done at periodic
assessment interval
ME G6.2 The facility conducts There is procedure to RR/SI
the periodic conduct Medical Audit
prescription/ medical/ There is procedure to RR/SI
death audits conduct Death audit
recorded adequately
process
ME G6.5 Corrective and Corrective and RR/SI
preventive actions preventive action taken
are taken to address
assessment & audit
ME G7.2 The facility periodically Quality objective are RR/SI
defines its quality defined
objectives and key
departments have
is aware of that
ME G7.4 Progress towards Quality objectives SI/RR
quality objectives is are monitored and
monitored periodically reviewed periodically
ME G8.1 Facility uses PDCA SI/RR
improvement in
Six Sigma SI/RR
quality improvement
in services
benchmarks
ME H1.1 Facility measures IUD insertion per 1000 RR Denominator to be
productivity Indicators eligible female discussed
on monthly basis Vasectomy performed RR
Tubectomy performed RR
No of First Trimester RR
MTP

No. pliance Method
No. of Second Trimester RR
MTP
OCP Users RR
Proportion of users RR
using limiting method
Proportion of target met RR
for male sterilization
surgery
Proportion of target met RR
for female sterilization
surgery
No. of family planning RR
counselling done per
1000 client
ME H2.1 Facility measures Skin to Skin time RR
efficiency Indicators Proportion of clients RR
on monthly basis agreed for family
planning methods out
of total counselled
benchmark
ME H3.1 Facility measures Surgical Site Infection RR
Clinical Care & Safety rate
Indicators on monthly Medical Audit Score RR
basis
No of adverse events RR
No. of complication per RR
1000 male sterilization
surgeries
No. of complication per RR
1000 female sterilization
surgeries
Surgical site infection RR
rate
No. of post operative RR
deaths per 1000
surgeries
No. of sterilization RR
failure per 1000
surgeries
benchmark
ME H4.1 Facility measures Client Satisfaction score RR
Service Quality Average counselling RR
Indicators on monthly time
basis

Assessment Summary
A. Score Card
PostPartum Unit Score Card
PostPartum Unit Score
2. Patient Rights
3. Inputs
4. Support Services
8. Outcome
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
4. _________________________________________________________________________________________________
5. _________________________________________________________________________________________________
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date ________________

Annexure
Measurable
Elements
Measurable Elements
Area of Concern - A: Service Provision

ME A1.1 The facility provides General Medicine services
ME A1.2 The facility provides General Surgery services
ME A1.3 The facility provides Obstetrics & Gynaecology Services
ME A1.4 The facility provides Paediatric Services
ME A1.5 The facility provides Ophthalmology Services
ME A1.6 The facility provides ENT Services
ME A1.7 The facility provides Orthopaedics Services
ME A1.8 The facility provides Skin & VD Services
ME A1.9 The facility provides Psychiatry Services
ME A1.10 The facility provides Dental Treatment Services
ME A1.11 The facility provides AYUSH Services
ME A1.12 The facility provides Physiotherapy Services
ME A1.13 The facility provides services for OPD procedures
ME A1.14 Services are available for the time period as mandated
ME A1.15 The facility provides services for Super specialties, as mandated
ME A1.16 The facility provides Accident & Emergency Services
ME A1.17 The facility provides Intensive care Services
ME A1.18 The facility provides Blood bank & transfusion services
ME A2.1 The facility provides Reproductive health Services
ME A2.2 The facility provides Maternal health Services
ME A2.3 The facility provides Newbornhealth Services
ME A2.4 The facility provides Child health Services
ME A2.5 The facility provides Adolescent health Services
ME A3.1 The facility provides Radiology Services
ME A3.2 The facility Provides Laboratory Services
ME A3.3 The facility provides other diagnostic services, as mandated
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 Disease Control Programme as per
guidelines
ME A4.2 The facility provides services under Revised National TB Control Programme as per guidelines
ME A4.3 The facility provides services under National Leprosy Eradication Programme as per guidelines
ME A4.4 The facility provides services under National AIDS Control Programme as per guidelines
ME A4.5 The facility provides services under National Programme for control of Blindness as per guidelines

ME A4.6 The facility provides services under Mental Health Programme as per guidelines
ME A4.7 The facility provides services under National Programme for the health care of the elderly as per
guidelines
ME A4.8 The facility provides services under National Programme for Prevention and control of Cancer,
Diabetes, Cardiovascular diseases & Stroke (NPCDCS) as per guidelines
ME A4.9 The facility Provides services under Integrated Disease Surveillance Programme as per Guidelines
ME A4.10 The facility provide services under National health Programme for prevention and control of deafness
ME A4.11 The facility provides services as per State specific health programmes
Standard A5 The facility provides support services
ME A5.1 The facility provides dietary services
ME A5.2 The facility provides laundry services
ME A5.3 The facility provides security services
ME A5.4 The facility provides housekeeping services
ME A5.5 The facility ensures maintenance services
ME A5.6 The facility provides pharmacy services
ME A5.7 The facility has services of medical record department
ME A5.8 The facility provides mortuary services
Standard A6 Health services provided at the facility are appropriate to community needs
ME A6.1 The facility provides curatives & preventive services for the health problems and diseases, prevalent
locally.
ME A6.2 There is process for consulting community/ or their representatives when planning or revising scope
of services of the facility.
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-friendly signage system.
ME B1.2 The facility displays the services and entitlements available in its departments.
ME B1.3 The facility has established citizen charter, which is followed at all levels.
ME B1.4 User charges are displayed and communicated to patients effectively.
ME B1.5 Patients & visitors are sensitised and educated through appropriate IEC/BCC approaches.
ME B1.6 Information is available in local language and easy to understand.
ME B1.7 The facility provides information to patients and visitor through an exclusive
set-up.
ME B1.8 The facility ensures access to clinical records of patients to entitled personnel.
there are no barriers on account of physical economic, cultural or social reasons.
ME B2.1 Services are provided in manner that are sensitive to gender.
ME B2.2 Religious and cultural preferences of patients and attendants are taken into consideration while
delivering services.
ME B2.3 Access to facility is provided without any physical barrier & friendly to people with
disability.
ME B2.4 There is no discrimination on basis of social & economic status of patients.
ME B2.5 There is affirmative action to ensure that vulnerable sections can access services.
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 point of care.

ME B3.2 Confidentiality of patients records and clinical information is maintained.
ME B3.3 The facility ensures the behaviours of staff is dignified and respectful, while delivering the services.
ME B3.4 The facility ensures privacy and confidentiality to every patient, especially of those conditions
having social stigma, and also safeguards vulnerable groups.
condition, and involving them in treatment planning, and facilitates informed decision
making.
ME B4.1 There is established procedures for taking informed consent before treatment and procedures.
ME B4.2 Patient is informed about his/her rights and responsibilities.
ME B4.3 Staff are aware of Patients rights responsibilities.
ME B4.4 Information about the treatment is shared with patients or attendants, regularly.
ME B4.5 The facility has defined and established grievance redressal system in place.
Standard B5 The facility ensures that there is no financial barrier to access, and that there is financial
ME B5.1 The facility provides cashless services to pregnant women, mothers and neonates as per
prevalent government schemes.
ME B5.2 The facility ensures that drugs prescribed are available at Pharmacy and wards.
ME B5.3 It is ensured that facilities for the prescribed investigations are available at the facility.
ME B5.4 The facility provide free of cost treatment to Below poverty line patients without administrative
hassles.
ME B5.5 The facility ensures timely reimbursement of financial entitlements and reimbursement to the
patients.
ME B5.6 The facility ensure implementation of health insurance schemes as per National /state scheme.
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 load.
ME C1.2 Patient amenities are provide as per patient load.
ME C1.3 Departments have layout and demarcated areas as per functions.
ME C1.4 The facility has adequate circulation area and open spaces according to need and local law.
ME C1.5 The facility has infrastructure for intramural and extramural communication.
ME C1.6 Service counters are available as per patient load.
ME C1.7 The facility and departments are planned to ensure structure follows the function/processes
(Structure commensurate with the function of the hospital).
ME C2.1 The facility ensures the seismic safety of the infrastructure.
ME C2.2 The facility ensures safety of lifts and lifts have required certificate from the designated bodies/
board.
ME C2.3 The facility ensures safety of electrical establishment.
ME C2.4 Physical condition of buildings are safe for providing patient care.
Standard C3 The facility has established Programme for fire safety and other disaster.
ME C3.1 The facility has plan for prevention of fire.
ME C3.2 The facility has adequate fire fighting Equipment.

ME C3.3 The facility has a system of periodic training of staff and conducts mock drills regularly for 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.
ME C4.1 The facility has adequate specialist doctors as per service provision.
ME C4.2 The facility has adequate general duty doctors as per service provision and work load.
ME C4.3 The facility has adequate nursing staff as per service provision and work load.
ME C4.4 The facility has adequate technicians/paramedics as per requirement.
ME C4.5 The facility has adequate support/general staff.
ME C4.6 The staff has been provided required training/skill sets.
ME C4.7 The Staff is skilled as per job description.
ME C5.1 The departments have availability of adequate drugs at point of use.
ME C5.2 The departments have adequate consumables at point of use.
ME C5.3 Emergency drug trays are maintained at every point of care, where ever it may be needed.
ME C6.1 Availability of equipment & instruments for examination & monitoring of patients.
ME C6.2 Availability of equipment & instruments for treatment procedures, being undertaken in the
facility.
ME C6.3 Availability of equipment & instruments for diagnostic procedures being undertaken in the
facility.
ME C6.4 Availability of equipment and instruments for resuscitation of patients and for providing
intensive and critical care to patients.
ME C6.5 Availability of Equipment for Storage.
ME C6.6 Availability of functional equipment and instruments for support services.
ME C6.7 Departments have patient furniture and fixtures as per load and service provision.
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 critical Equipment.
ME D1.2 The facility has established procedure for internal and external calibration of measuring
Equipment.
ME D1.3 Operating and maintenance instructions are available with the users of equipment.
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 drugs and consumables.
ME D2.2 The facility has establish procedure for procurement of drugs.
ME D2.3 The facility ensures proper storage of drugs and consumables.
ME D2.4 The facility ensures management of expiry and near expiry drugs.
ME D2.5 The facility has established procedure for inventory management techniques.
ME D2.6 There is a procedure for periodically replenishing the drugs in patient care areas.
ME D2.7 There is process for storage of vaccines and other drugs, requiring controlled temperature.
ME D2.8 There is a procedure for secure storage of narcotic and psychotropic drugs.
ME D3.1 The facility provides adequate illumination level at patient care areas.

ME D3.2 The facility has provision of restriction of visitors in patient areas.
ME D3.3 The facility ensures safe and comfortable environment for patients and service providers.
ME D3.4 The facility has security system in place at patient care areas.
ME D3.5 The facility has established measure for safety and security of female staff.
Standard D4 The facility has established Programme for maintenance and upkeep of the facility.
ME D4.1 Exterior of the facility building is maintained appropriately.

ME D4.2 Patient care areas are clean and hygienic.
ME D4.3 Hospital infrastructure is adequately maintained.
ME D4.4 Hospital maintains the open area and landscaping of them.
ME D4.5 The facility has policy of removal of condemned junk material.
ME D4.6 The facility has established procedures for 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.
ME D5.1 The facility has adequate arrangement storage and supply for portable water in all functional areas.
ME D5.2 The facility ensures adequate power backup in all patient care areas as per load.
ME D5.3 Critical areas of the facility ensures availability of oxygen, medical gases and vacuum supply.
Standard D6 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 patients.
ME D6.2 The facility provides diets according to nutritional requirements of the patients.
ME D6.3 Hospital has standard procedures for preparation, handling, storage and distribution of diets, as
per requirement of patients.
Standard D7 The facility ensures clean linen to the patients.
ME D7.1 The facility has adequate sets of linen.
ME D7.2 The facility has established procedures for changing of linen in patient care areas
ME D7.3 The facility has standard procedures for handling , collection, transportation and washing of linen.
Standard D8 The facility has defined and established procedures for promoting public participation in
management of hospital transparency and accountability.
ME D8.1 The facility has established procures for management of activities of Rogi Kalyan Samiti.
ME D8.2 The facility has established procedures for community based monitoring of its services.
Standard D9 Hospital has defined and established procedures for Financial Management.
ME D9.1 The facility ensures the proper utilization of fund provided to it.
ME D9.2 The facility ensures proper planning and requisition of resources based on its need.
Standard D10 The facility is compliant with all statutory and regulatory requirement imposed by local, state
or central government.
ME D10.1 The facility has requisite licences and certificates for operation of hospital and different activities.
ME D10.2 Updated copies of relevant laws, regulations and government orders are available at the facility.
ME D10.3 The facility ensure relevant processes are in compliance with statutory requirement.
ME D11.1 The facility has established job description as per govt guidelines.
ME D11.2 The facility has a established procedure for duty roster and deputation to different departments.
ME D11.3 The facility ensures the adherence to dress code as mandated by its administration / the health
department.

ME D12.1 There is established system for contract management for out sourced services.
ME D12.2 There is a system of periodic review of quality of out-sourced services.
Area of Concern - E: Clinical Services

ME E1.1 The facility has established procedure for registration of patients.
ME E1.2 The facility has a established procedure for OPD consultation.
ME E1.3 There is established procedure for admission of patients.
ME E1.4 There is established procedure for managing patients, in case beds are not available at the
facility.
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment
of the patients.
ME E2.1 There is established procedure for initial assessment of patients.
ME E2.2 There is established procedure for follow-up/ reassessment of Patients.
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 care during interdepartmental transfer.
ME E3.2 The facility provides appropriate referral linkages to the patients/Services for transfer to other/
higher facilities to assure the continuity of care.
ME E3.3 A person is identified for care during all steps of care.
ME E3.4 The facility is connected to medical colleges through telemedicine services.
Standard E4 The facility has defined and established procedures for nursing care.
ME E4.1 Procedure for identification of patients is established at the facility.
ME E4.2 Procedure for ensuring timely and accurate nursing care as per treatment plan is established at
the facility.
ME E4.3 There is established procedure of patient hand over, whenever staff duty change happens.
ME E4.4 Nursing records are maintained.
ME E4.5 There is procedure for periodic monitoring of patients.
ME E5.1 The facility identifies vulnerable patients and ensure their safe care.
ME E5.2 The facility identifies high risk patients and ensure their care, as per their need.
ME E6.1 The facility ensured that drugs are prescribed in generic name only.
ME E6.2 There is procedure of rational use of drugs.
Standard E7 The facility has defined procedures for safe drug administration.
ME E7.1 There is process for identifying and cautious administration of high alert drugs (to check).
ME E7.2 Medication orders are written legibly and adequately.
ME E7.3 There is a procedure to check drug before administration/dispensing.
ME E7.4 There is a system to ensure right medicine is given to right patient.
ME E7.5 Patient is counselled for self drug administration.
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 recorded and updated.
ME E8.2 All treatment plan prescription/orders are recorded in the patient records.

ME E8.3 Care provided to each patient is recorded in the patient records.
ME E8.4 Procedures performed are written on patients records.
ME E8.5 Adequate form and formats are available at point of use.
ME E8.6 Register/records are maintained as per guidelines.
ME E8.7 The facility ensures safe and adequate storage and retrieval of medical records.
ME E9.1 Discharge is done after assessing patient readiness.
ME E9.2 Case summary and follow-up instructions are provided at the discharge.
ME E9.3 Counselling services are provided as during discharges wherever required.
ME E9.4 The facility has established procedure for patients leaving the facility against medical advice,
absconding, etc.
Standard E10 The facility has defined and established procedures for intensive care.
ME E10.1 The facility has established procedure for shifting the patient to step-down/ward based on
explicit assessment criteria.
ME E10.2 The facility has defined and established procedure for intensive care.
ME E10.3 The facility has explicit clinical criteria for providing intubation & extubation, and care of
patients on ventilation and subsequently on its removal.
Management.
ME E11.1 There is procedure for Receiving and triage of patients.
ME E11.2 Emergency protocols are defined and implemented.
ME E11.3 The facility has disaster management plan in place.
ME E11.4 The facility ensures adequate and timely availability of ambulances services and mobilisation of
resources, as per requirement.
ME E11.5 There is procedure for handling medico legal cases.
Standard E12 The facility has defined and established procedures of diagnostic services.
ME E12.1 There are established procedures for Pre-testing Activities.
ME E12.2 There are established procedures for testing Activities.
ME E12.3 There are established procedures for Post-testing Activities.
Transfusion.
ME E13.1 Blood bank has defined and implemented donor selection criteria.
ME E13.2 There is established procedure for the collection of blood.
ME E13.3 There is established procedure for the testing of blood.
ME E13.4 There is established procedure for preparation of blood component.
ME E13.5 There is establish procedure for labelling and identification of blood and its product.
ME E13.6 There is established procedure for storage of blood.
ME E13.7 There is established the compatibility testing.
ME E13.8 There is established procedure for issuing blood.
ME E13.9 There is established procedure for transfusion of blood.
ME E13.10 There is a established procedure for monitoring and reporting Transfusion complication.
Standard E14 The facility has established procedures for Anaesthetic Services.
ME E14.1 The facility has established procedures for Pre-anaesthetic Check up and maintenance of records.
ME E14.2 The facility has established procedures for monitoring during anaesthesia and maintenance of
records.
ME E14.3 The facility has established procedures for Post-anaesthesia care.

Standard E15 The facility has defined and established procedures of Operation theatre services.
ME E15.1 The facility has established procedures OT Scheduling.
ME E15.2 The facility has established procedures for Preoperative care.
ME E15.3 The facility has established procedures for Surgical Safety.
ME E15.4 The facility has established procedures for Post operative care.
Standard E16 The facility has defined and established procedures for end of life care and death.
ME E16.1 Death of admitted patient is adequately recorded and communicated.
ME E16.2 The facility has standard procedures for handling the death in the hospital.
ME E16.3 The facility has standard operating procedure for end of life support.
ME E16.4 The facility has standard procedures for conducting post-mortem, its recording and meeting its
obligation under the law.
Maternal & Child Health Services
Standard E17 The facility has established procedures for Antenatal care as per guidelines.
ME E17.1 There is an established procedure for Registration and follow up of pregnant women.
ME E17.2 There is an established procedure for History taking, Physical examination, and counselling of
each antenatal woman, visiting the facility.
ME E17.3 The facility ensures availability of diagnostic and drugs during antenatal care of pregnant
women.
ME E17.4 There is an established procedure for identification of High risk pregnancy and appropriate
treatment/referral as per scope of services.
ME E17.5 There is an established procedure for identification and management of moderate and severe
anaemia.
ME E17.6 Counselling of pregnant women is done as per standard protocol and gestational age.
Standard E18 The facility has established procedures for Intranatal care as per guidelines.
ME E18.1 Established procedures and standard protocols for management of different stages of labour
including AMTSL (Active Management of third Stage of labour) are followed at the facility.
ME E18.2 There is an established procedure for assisted and C-section deliveries per scope of services.
ME E18.3 There is established procedure for management/Referral of Obstetrics Emergencies as per
scope of services.
ME E18.4 There is an established procedure for new born resuscitation and newborn care.
Standard E19 The facility has established procedures for postnatal care as per guidelines.
ME E19.1 Post partum Care is provided to the mothers.
ME E19.2 The facility ensures adequate stay of mother and newborn in a safe environment as per
standard Protocols.
ME E19.3 There is an established procedure for Post partum counselling of mother.
ME E19.4 The facility has established procedures for stabilization/treatment/referral of post natal
complications.
ME E19.5 There is established procedure for discharge and follow up of mother and newborn.
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 guidelines.
ME E20.2 Triage, Assessment & Management of newbornshaving emergency signs are done as per
guidelines.
ME E20.3 Management of Low birth weightnewborns is done as per guidelines.
ME E20.4 Management of neonatal asphyxia, jaundice and sepsis is done as per guidelines.
ME E20.5 Management of children presentingwith fever, cough/ breathlessness is done as per guidelines.

ME E20.6 Management of children with severeAcute Malnutrition is done as per guidelines.
ME E20.7 Management of children presentingdiarrhoea is done per guidelines.
Standard E21 The facility has established procedures for abortion and family planning as per government
guidelines and law.
ME E21.1 Family planning counselling services provided as per guidelines.
ME E21.2 The facility provides spacing method of family planning as per guideline.
ME E21.3 The facility provides limiting method of family planning as per guideline.
ME E21.4 The facility provide counselling services for abortion as per guideline.
ME E21.5 The facility provide abortion services for 1st trimester as per guideline.
ME E21.6 The facility provide abortion services for 2nd trimester as per guideline.
Standard E22 The facility provides Adolescent Reproductive and Sexual Health services as per guidelines.
ME E22.1 The facility provides Promotive ARSH Services.

ME E22.2 The facility provides Preventive ARSH Services.
ME E22.3 The facility Provides Curative ARSH Services.
ME E22.4 The facility Provides Referral Services for ARSH.
National Health Programmes
Standard E23 The facility provides National health Programme as per operational/Clinical Guidelines.
ME E23.1 The facility provides services under National Vector Borne Disease Control Programme as per
guidelines.
ME E23.2 The facility provides services under Revised National TB Control Programme as per guidelines .
ME E23.3 The facility provides services under National Leprosy Eradication Programme as per guidelines.
ME E23.4 The facility provides services under National AIDS Control Programme as per guidelines.
ME E23.5 The facility provides services under National Programme for control of Blindness as per guidelines .
ME E23.6 The facility provides services under Mental Health Programme as per guidelines .
ME E23.7 The facility provides services under National Programme for the health care of the elderly as
per guidelines .
ME E23.8 The facility provides service under National Programme for Prevention and Control of cancer,
diabetes, cardiovascular diseases & stroke (NPCDCS) as per guidelines .
ME E23.9 The facility provide service for Integrated disease surveillance Programme.
ME E23.10 The facility provide services under National Programme for prevention and control of deafness.
Area of Concern - F: Infection Control
ME F1.1 The facility has functional infection control committee.
ME F1.2 The facility has provision for Passive and active culture surveillance of critical & high risk areas.
ME F1.3 The facility measures hospital associated infection rates.
ME F1.4 There is Provision of Periodic Medical Check-up and immunization of staff.
ME F1.5 The facility has established procedures for regular monitoring of infection control practices.
ME F1.6 The facility has defined and established antibiotic policy.
antisepsis.
ME F2.1 Hand washing facilities are provided at point of use.

ME F2.2 The facility staff is trained in hand washing practices and they adhere to standard hand washing
practices.
ME F2.3 The facility ensures standard practices and materials for antisepsis.
Standard F3 The facility ensures standard practices and materials for Personal protection.
ME F3.1 The facility ensures adequate personal protection Equipment as per requirements.
ME F3.2 The facility staff adheres to standard personal protection practices.
Standard F4 The facility has standard procedures for processing of equipment and instruments.
ME F4.1 The facility ensures standard practices and materials for decontamination and cleaning of
instruments and procedures areas.
ME F4.2 The facility ensures standard practices and materials for disinfection and sterilization of
instruments and equipment.
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 infection control practices.
ME F5.2 The facility ensures availability of standard materials for cleaning and disinfection of patient
care areas.
ME F5.3 The facility ensures standard practices are followed for the cleaning and disinfection of patient
care areas.
ME F5.4 The facility ensures segregation infectious patients.
ME F5.5 The facility ensures air quality of high risk area.
ME F6.1 The facility Ensures segregation of Bio Medical Waste as per guidelines and 'on-site'
management of waste is carried out as per guidelines.
ME F6.2 The facility ensures management of sharps as per guidelines.
ME F6.3 The facility ensures transportation and disposal of waste as per guidelines.
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.
ME G1.2 The facility reviews quality of its services at periodic intervals.
Standard G2 The facility has established system for patient and employee satisfaction.
ME G2.1 Patient satisfaction surveys are conducted at periodic intervals.
ME G2.2 The facility analyses the patient feedback, and root-cause analysis.
ME G2.3 The facility prepares the action plans for the areas, contributing to low satisfaction of patients.
Standard G3 The facility has established internal and external quality assurance Programmes wherever it is
ME G3.1 The facility has established internal quality assurance programme in key departments.
ME G3.2 The facility has established external assurance programmes at relevant departments.
ME G3.3 The facility has established system for use of check lists in different departments and services.
ME G4.1 Departmental standard operating procedures are available.
ME G4.2 Standard Operating Procedures adequately describes process and procedures.
ME G4.3 Staff is trained and aware of the procedures written in SOPs.
ME G4.4 Work instructions are displayed at Point of use.

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.
ME G5.2 The facility identifies non value adding activities/waste/redundant activities.
ME G5.3 The facility takes corrective action to improve the processes.
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 assessment.
ME G6.2 The facility conducts the periodic prescription/medical/death audits.
ME G6.3 The facility ensures non compliances are enumerated and recorded adequately.
ME G6.4 Action plan is made on the gaps found in the assessment/audit process.
ME G6.5 Corrective and preventive actions are taken to address issues, observed in the assessment &
audit.
Standard G7 The facility has defined and established Quality Policy & Quality Objectives.
ME G7.1 The facility defines its quality policy .
ME G7.2 The facility periodically defines its quality objectives and key departments have their own
objectives.
ME G7.3 Quality policy and objectives are disseminated and staff is aware of that.
ME G7.4 Progress towards quality objectives is monitored periodically.
ME G8.1 The facility uses method for quality improvement in services.
ME G8.2 The facility uses tools for quality improvement in services.
Area of Concern - H: Outcomes
Benchmarks.
ME H1.1 Facility measures productivity Indicators on monthly basis.
ME H1.2 The Facility measures equity indicators periodically.
ME H1.3 Facility ensures compliance of key productivity indicators with National/State Benchmarks.
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark.
ME H2.1 Facility measures efficiency Indicators on monthly basis.
ME H2.2 Facility ensures compliance of key efficiency indicators with National/State Benchmarks.
Benchmark.
ME H3.1 Facility measures Clinical Care & Safety Indicators on monthly basis.
ME H3.2 Facility ensures compliance of key Clinical Care & Safety with National/State Benchmarks.
Benchmark.
ME H4.1 Facility measures Service Quality Indicators on monthly basis.
ME H4.2 Facility ensures compliance of key Service Quality with National/State Benchmarks.

List of Abbreviations
A& E Accident & Emergency

ABC Airway, Breathing and Circulation
AEFI Adverse Events Following Immunization
AERB Atomic Energy Regulatory Board
AES Acute Encephalitis Syndrome
AIDS Acquired Immuno Deficiency Syndrome
ALS Advanced Life Support
AMC Annual Maintenance Contract
AMSTL Active Management of the Third Stage of Labour
ANC Anti Natal Check-up
ANM Auxiliary Nurse Midwife
APH Ante Partum Haemorrhage
ARF Acute Renal Failure
ARI Acute Respiratory Infection
ARSH Adolescent Reproductive and Sexual Health
ART Anti Retroviral Therapy
ARV Anti Rabies Vaccine
ASHA Accredited Social Health Activist
ASV Anti Snake Venom
AYUSH Ayurveda, Yoga, Unani, Sidhha & Homoeopathy
BCC Behavioural Change Communication
BCG Bacillus Calmette-Guerin
BHT Bed Head Ticket
BLS Basic Life Support
BMW Biomedical Waste
BP Blood Pressure
BPL Below Poverty Line
BT Bleeding time
CBC Complete Blood Count
CCU Coronary Care Unit
CHC Community Health Centre
CHW Community Health Worker
CLW Contused Lacerated Wound
CME Continuous Medical Education
CNS/PNS Central Nervous System / Peripheral Nervous system

C-PAP Continuous Positive Air Pressure
CPC Clinical Pathological Case

CPR Cardiopulmonary Resuscitation
CSSD Centralized Sterile Supply Department
CT Clotting Time
CBWTF Common Biomedical Waste Treatment Facility
CVA Cerebral Vascular Accident
CVS Cardio-Vascular System
D&C SET Dilatation & Curettage set
D&E Dilation & Evacuation
DEIC District Early Intervention Centre
DGO Diploma in Obstetrics & Gynaecology
DLC Differential Leukocyte Count
DMC Designated Microscopy Centre
DOTS Directly Observed Treatment (Short Course)
DPT Diphtheria, Pertussis, and Tetanus
DQAC District Quality Assurance Committee
DT Diphtheria & Tetnus
ECG Electrocardiography
ECP Emergency Contraceptive Pills
EDD Expected Date of Delivery
EDL Essential Drug List
ELISA Enzyme-Linked Immunosorbent Assay
ENT Ear Nose Throat
ET TUBE Endotracheal tube
ETAT Emergency Triage Assessment and Treatment
FBNC Facility Based Newborn Care
FHR Foetal Heart Rate
FIFO First In First Out
FMP Falciparum Malaria Parasite
FP Family Planning
FSN Fast Moving, Slow Moving , Non Moving
GOB General Order Book
GOI Government of India
HB Haemoglobin
HIE Hypoxic- Ischaemic Encephalophaty
HIV Human Immunodeficiency Virus
HLD High-Level Disinfection
I&D Incision & Drainage
ICD Intensive Care Unit
ICTC Integrated Counselling and Testing Centre
ICU Intensive Care Unit
IDSP Integrated Disease Surveillance Project
IEC Information Education Communication
IFA Iron Folic Acid
IM/IV Intra Muscular/ Intra Venous
IMNCI Integrated Management of Newborn Childhood Illnesses

IO Chart Input- output Chart
IOL Intra Ocular Lens
IPD In Patient Department
IQAS/EQAS Internal Quality Assessment Services/ External Quality Assessment Services
IUCD Intra Uterine Contraceptive Device
IUGR Intra Uterine Growth Retardation
IYCF Infant and Yong Child Feeding
JSSK Janani –Shishu Suraksha Karyakram
JSY Janani Suraksha Yojana
KMC Kangaroo Mother Care
LAMA Leave Against Medical Advice
LFT Liver Function Tests
LMA Laryngeal Mask Airway
LMP Last Menstrual Period
LSCS Lower Segment Caesarean section
MAS Meconium Aspiration Syndrome
ME Measureable Element
MI Myocardial Infarction
MLC Medico Legal Case
MMR Miniature Mass Radiography
MRD Medical Record Department
MSBOS Maximum Surgical Blood Order Schedule
MTP Medical Termination of Pregnancy
MUAC Mid-Upper Arm Circumference
MVA Manual Vaccum Aspiration
NACO National AIDS Control Organisation
NACP National AIDS Control Programme
NBCC New Born Care Corner
NCD Non Communicable Diseases
NGO Non Government Organization
NHP National Health Programme
NHSRC National Health Systems Resource Centre
NLEP National Leprosy Eradication Programme
National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases
NPCDCS & Stroke
NRC Nutritional Rehabilitation centre
NRHM National Rural Health Mission
NSSK Navjat Shishu Surkasha Karyakram
NSV No-Scalpel Vasectomy
NVBDCP National Vector Borne Disease Control Programme
OBG Obstetrics and Gynaecology
OCP Oral Contraceptive Pills
OPD Out Patient Department
OPV Oral Polio Vaccine
ORS Oral Rehydration Solution

ORT Oral Rehydration Therapy
OT Operation Theatre
PAC Pre Anaesthesia Check-up
PCPNDT Pre-Conception and Pre-Natal Diagnostic Techniques
PDCA Plan Do Check Act
PEM Protein Energy Malnutrition
PEP Post-Exposure Prophylaxis
PHC Primary Health Centre
PIB Police Information Book
PIH Pregnancy Induced Hypertension
PLHA People Living with HIV/AIDS
PPH Postpartum Haemorrhage
PPIUCD Postpartum Intra Uterine Contraceptive Device
PPTCT Prevention of Parent to Child Transmission
PRC Packed Red Cells
PV SET Per Vaginal Set
QA Quality Assurance
RBRC Random Blinded Re Checking
RCS Re Constructive Surgery
RDK Rapid Diagnostic Kit
RDS Respiratory Distress Syndrome
RFT Renal Function Tests
RMNCH Reproductive, Maternal, Newborn and Child Health
RMNCHA Reproductive Maternal Neonatal Child Health and Adolescent
RNTCP Revised National TB Control Programme
RPR KIT Rapid Plasam Reagin
RR Respiratory Rate/ Record Review
RSBY Rashtriya Swasthya Bima Yojana
RSO Radiological Safety Officer
RTA Road Traffic Accident
RTI/STI Reproductive Tract Infections / Sexually Transmitted Infections
SAM Severe Acute Malnutrition
SBA Skilled Birth Attendant
SMART Specific, Measurable, Attainable Relevant, Time Based
SNCU Sick Newborn Care Unit
SOP Standard Operating Procedure
SQAC State Quality Assurance Committee
STG Standard Treatment Guideline
SWD Short Wave Diathermy
TB Tuberculosis
TLC Total Leukocyte Count
TLD Thermoluminescent dosimeter
TMT Tread Mill Test
TPHA Treponema pallidum Hemaglutination Assay
TPR Temperature, Pulse, Respiration

TSSU Theatre Sterile Supply Unit
TT Tetanus Toxoid
TTI Transfusion Transmitted Infection
UPS Uninterrupted Power Supply
USG Ultra Sonography
VD Venereal Diseases
VDRL Venereal Disease Research Laboratory
VED Vital, Essential and Desirable
V-PEP(PAP) Variable Positive Air Pressure
VVM Vaccine Vial Monitor
WHO World Health Organization

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index
S. No Key word Reference in Quality Measurement System

1 Abortion ME E21.5 & ME21.6
2 Action Plan ME G 6.4
3 Admission ME E1.2
4 Adolescent health Standard E22
5 Affordability Standard B5
6 Ambulances ME 11.4
7 Amenities ME C1.2
8 Anaesthetic Services Standard 14
9 Animals ME D4.6
10 Antenatal Care Standard E 17
11 Antibiotic Policy ME F1.5
12 assessment Standard E2
13 Behaviour ME B3.3 for Behaviour of staff towards patients
14 Below Poverty Lime ME B 5.3
15 Bio Medical Waste Management Standard F6
16 Blood Bank Standard E12
17 C- Section ME E 18.2
18 Calibration ME D1.2
19 Central Oxygen and Vacuum Supply ME 5.3
20 Checklist ME G 3.3
21 Citizen Charter ME B1.3
22 Cleanliness ME D4.2
23 Clinical Indicators Standard H3
24 Cold Chain ME D2.7
25 Communication ME C1.5
26 Community Participation Area of Standard A6 for Service provision
Standard D8 for processes
27 Confidentiality ME B3.2
28 Consent ME B4.1
29 Continuity of care Standard E3
30 Contract Management Standard D12
31 Corrective & Preventive Action ME G6.5
32 Culture Surveillance ME F1.2
33 Death Standard E 16
34 Death Audit ME G6.2
35 Decontamination ME F 4.1
36 Diagnostic Equipment ME C6.3

37 Diagnostic Services Standard A4 for Service Provision
Standard E 12 for Technical Processes
38 Dietary services Standard 6
39 Disable Friendly ME B2.3
40 Disaster Management ME 11.3
41 Discharge Standard E9
42 Discrimination ME B2.4
43 Disinfection ME F4.2
44 Display of Clinical Protocols ME G4.4
45 Dress Code ME D11.3
46 Drug Safety Standard E7
47 Drugs Standard C5
48 Duty Roster ME D11.2
49 Efficiency Standard H2
50 Electrical Safety ME 2.3
51 Emergency Drug Tray ME C5.3
52 Emergency protocols ME 11.2
53 Emergency services Standard E11
54 End of life care Standard E16
55 Environment control Standard F5
56 Equipment & Instrument Standard C6
57 Expiry Drugs ME D2.4
58 External Quality Assurance Program ME G3.2
59 Facility Management Standard D4
60 Family Planning Standard E21
61 Family Planning Surgeries ME E21.2
62 Fee Drugs ME B5.2
63 Financial Management Standard D9
64 Fire Safety Standard C3
65 Form Formats ME 8.5
66 Furniture ME C6.7
67 Gender Sensitivity Standard B2
68 Generic Drugs ME E6.1
69 Grievance redressal ME B4.5
70 Hand Hygiene Standard F2
71 Handover ME E4.3
72 Help Desk ME B1.7
73 High alert drugs ME E7.1
74 High Risk Patients ME E5.2
75 HIV-AIDS ME B3.4 for Confidentiality and Privacy of People living with
HIV-AIDS
ME 23.4 for processes related to testing and treatment of HIV-
AIDS
76 Hospital Acquired infection ME F1.3
77 House keeping Standard D4
78 Human Resource Standard C4

79 Hygiene ME D4.2
80 Identification ME E4.1 for identification of patients
81 IEC/BCC ME B1.5
82 Illumination ME D3.1
83 Immunization ME E20.1
84 Indicators Area of Concern H
85 Infection Control Area of Concern F
86 Infection Control Committee ME F1.1
87 Information Standard B1 for information about services
ME 4.2 for information about patient rights
88 Initial assessment ME E2.1
89 Inputs Area of Concern C
90 Intensive Care Standard E10
91 Internal Assessment ME G6.1
92 Intranatal Care Standard E18
93 Inventory Management Standard D2
94 Job Description ME D11.1
95 Junk Material ME D4.5
96 Key Performance Indicators Area of Concern H
97 Landscaping ME D4.4
98 Laundry Standard D7
99 Layout ME C1.3
100 Licences ME 10.1
101 Linen ME D7.1 &7.2
102 Low Birth weight ME E20.3
103 Maintenance Standard D1 for Equipments Maintenance
Standard D4 for Infrastructure Maintenance
104 Medical Audit ME G6.2
105 Medico Legal Cases ME 11.5
106 National Health Programs Standard A4 for Service Provision
Standard E 23 for Clinical Processes
107 New born resuscitation ME E18.4
108 Newborn Care Standard E20
109 Non Value Activities ME G5.2
110 Nursing Care Standard E4
111 Nutritional Assessment ME 6.1
112 Obstetric Emergencies ME E 18.3
113 Operating Instructions ME D1.3
114 Operation Theatre ME Standard E 15
115 Outcome Area of Concern H
116 Outsourcing Standard D12
117 Patient Records Standards E8
118 Patient Rights Area of Concern B
119 Patient Satisfaction Survey Standard G2
120 Personal Protection Standard F3

121 Physical Safety Standard C2
122 Post Mortem ME E 16.4
123 Post Partum Care ME E 19.1
124 Post Partum Counselling ME E 19.3
125 Power Backup ME 5.2
126 Pre Anaesthetic Check up ME 14.1
127 Prescription Audit ME G6.2
128 Prescription Practices Standard E6
129 Privacy ME B3.1
130 Process Mapping Standard G5
131 Productivity Standard H1
132 Quality Assurance Standard G 3
133 Quality Improvement Standard G6
134 Quality Management System Area of Concern G
135 Quality Objectives ME G 7.2
136 Quality Policy ME G 7.1
137 Quality Team ME G1.1
138 Quality Tools Standard G 8
139 Rational Use of Drugs ME E6.2
140 Referral ME E 3.2
141 Registers ME 8.6
142 Registration ME E1.1
143 Resuscitation Equipments ME C6.4
144 RMNCHA Standard A2 for Service provision
Standard E17 to E22 for Clinical Processes
145 Rogi Kalyan Samiti ME 8.1
146 Roles & Responsibilities Standard D11
147 RSBY ME B5.6
148 Security ME D3.4 & 3.5
149 Seismic Safety ME 2.1
150 Service Provision Area of Concern A
151 Service Quality Indicators Standards H4
152 Sever Acute Malnutrition ME E 20.6
153 Sharp Management ME F 6.2
154 Signage's ME B1.1
155 Skills ME C4.7
156 Space ME C1.1 for adequacy of space
157 Spacing Method ME E21.1
158 Standard Operating Procedures Standard G4
159 Statutory Requirements Standard 10
160 Sterilization ME F4.2
161 Storage ME D 2.3 for Storage of drugs
ME D2.7 for Storage of Narcotic & Psychotropic Drugs
ME 8.7 for storage of medical records
162 Support Services Standard A5 for Service Provision
Area of Concern C for Support Processes

163 Surgical Services Standard 14
164 Training ME C4.6
165 Transfer ME E3.1 for interdepartmental transfer
166 Transfusion ME E 13.9 & E13.10
167 Transparency & Accountability Standard D8
168 Triage ME 11.1
169 Utilization Standard H1
170 Vulnerable ME 2.5 for Affirmative action for Vulnerable sections
ME E 5.1 for Care of Vulnerable Patients
171 Waiting Time ME H4.1
172 Water Supply ME 5.1
173 Work Environment Standard D3
174 Work Instructions ME G 4.4

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Volume - I | Assessor’s Guidebook for Quality Assurance in District Hospitals | 2013

Assessor’s Guidebook for

Maternal Health Division

Ministry of Health & Family Welfare

Designed by: Macro Graphics & Printed by: Royal Press

(Dr. Rakesh Kumar)

Program Officer’s Message

(Dr. Himanshu Bhushan)

1 Ms. Anuradha Gupta AS&MD (NRHM), MoHFW

Assessor’s Guidebook for Quality Assurance in District Hospitals | 3

4 | Assessor’s Guidebook for Quality Assurance in District Hospitals

Following are the area of concern in a health facility –

1. Service Provision 5. Clinical Services

Assessor’s Guidebook for Quality Assurance in District Hospitals | 5

6 | Assessor’s Guidebook for Quality Assurance in District Hospitals

Assessor’s Guidebook for Quality Assurance in District Hospitals | 7

Standard C1 Standard C1 measures adequacy of infrastructure in terms of space, patient

8 | Assessor’s Guidebook for Quality Assurance in District Hospitals

Standard D1 Standard D1 is concerned with equipment maintenance processes, such as AMC,

Assessor’s Guidebook for Quality Assurance in District Hospitals | 9

10 | Assessor’s Guidebook for Quality Assurance in District Hospitals

Assessor’s Guidebook for Quality Assurance in District Hospitals | 11

12 | Assessor’s Guidebook for Quality Assurance in District Hospitals

Assessor’s Guidebook for Quality Assurance in District Hospitals | 13

Standard F1 Standard F1 is concerned with the implementation of Infection control programme

14 | Assessor’s Guidebook for Quality Assurance in District Hospitals

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Standard H1 Standard H1 is concerned with the measurement of Productivity indicators and

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18 | Assessor’s Guidebook for Quality Assurance in District Hospitals

B. Planning Assessment Activities

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C. Constituting assessment team

D. Preparing assessment schedule

F. Communication during assessment

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Familiarise with Measurable element and

Understand the Assesment method and Means of

Gather the information & Evidence

Compare with checkpoint and means of verification

Arrive at a conclusion for compliance

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24 | Assessor’s Guidebook for Quality Assurance in District Hospitals

Figure 6: Sample Scorecard of a Hospital with Departmental Score

Hospital Quality Score Card

45% 58% 70% 67% 78%

82% 49% 85% 50%

Radiology Pharmacy Auxiliary Services Mortuary General Administration

35% 72% 65% 25% 60%

Figure 7: Sample Scorecard of a Hospital with Area of Concern Score

72% 66% 78% 59%

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National Quality Assurance Standards

Checklist for Accident & Emergency DEPARTMENT

Reference Measure Element Checkpoint Compli- Assessment Means of Verification

32 | Checklist for Accident & Emergency Department

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34 | Checklist for Accident & Emergency Department

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ME C2.4. Physical condition of Floors of the Emergency OB