Assessors Guidebook For Quality Assurance in Community Health Centres First Referral Unit

Assessor’s Guidebook for Quality Assurance in Community Health Centres (FRU)
Assessor’s Guidebook for

Quality Assurance in
Community Health Centres
(First Referral Unit)
2014
National Health Mission

Ministry of Health and Family Welfare
Government of India
Government of India
2014

Government of India
© 2014, National Health Mission, Ministry of Health and 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 978-93-82655-09-1

Government of India
Nirman Bhawan, New Delhi, India
Disclaimer
The Quality Standards and its measurement System including the check-lists given in this book are meant to
assess a CHC, which is functioning as the first referral unit (FRU). The contents and check-lists are not to be used
for making decisions for patient care.
Designed by: Silverline Communication and printed by:

MESSAGE
Large sections of the people in our country, especially those living in the
rural areas or those faced with financial barriers, depend upon the Public Health
Institutions for their health care needs. For mitigation of suffering of masses, we are
committed to provide universal health coverage with assurance of quality standards
in treatment and diagnosis to all citizens of the country. We intend to ensure that
Health Facilities in the Public Sector should become the ‘first choice’ of healthcare
seekers. The available services should be of such quality that not only poor but all
sections of society develop trust and faith in such services.
Indian Public Health Standards (IPHS) Guidelines brought out by this Ministry are good tools
for normative planning. However, delivery of care entails processes & sub-processes, which need to be
undertaken for diagnosis & treatment of patients. For optimum satisfaction of patients, such processes
need to ensure that other than providing treatment and drugs, patients’ privacy & confidentiality are
maintained and patients’ rights are respected, more so for women and those from the vulnerable sections,
in all settings including outreach services. The most important aspect of Quality is how the services are
perceived by the users
Our Prime Minister has recently launched “Swachh Bharat Abhiyan” with the aim of achieving
all around sanitation & cleanliness in the country by the year 2019. Public Hospitals are expected to lead
by example. Presently, there is much to be done in improving level of cleanliness at public hospitals. A
villager cannot be motivated to use a sanitary latrine at home if he/she sees dirty and unhygienic toilets in a
Hospital. Our Hospitals should be impeccably clean, waste should be segregated properly, robust infection
control practices should be in place, and workers must be protected. Then only can we create a role-model
for the community to follow.
I am sure that the attainment of Quality Standards for Primary Health Centres and Community
Health Centres would not only ensure delivery of appropriate care of high standards, but that those
standards would also strengthen equity and accessibility of healthcare. These standards are the minimum
requirements which public health facilities should meet. The States can strengthen them by adding a few
more standards, as per their capacity.
I urge all States and service providers across the country to adopt these quality standards at their
institutions and contribute towards achieving “Sarve Bhavantu Sukhina, Sarve Santu Niramaya”.
Place: New Delhi.

Date: 25.10.2014. (Dr. Harsh Vardhan)
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VII
IX
XI
XIII
Assessor’s Guidebook for Quality Assurance in CHCs
LIST OF CONTRIBUTORS
Government of India Officials
1 Mr. C. K. Mishra AS and MD(NRHM), MoHFW
2 Mr. Manoj Jhalani JS (Policy), MoHFW
3 Dr. Rakesh Kumar JS (RCH), MoHFW
4 Dr. Himanshu Bhushan DC (I/c MH), MoHFW
5 Dr. S. K. Sikdar DC (I/c FP), MoHFW
6 Dr. Dinesh Baswal DC (MH), MoHFW
7 Dr. P. K. Prabhakar DC (CH), MoHFW
8 Dr. Teja Ram DC (FP), MoHFW
9 Mr. R. C. Danday Director, NHM, MoHFW
10 Dr. Renu Shrivastava SNCU Coordinator, MoHFW
11 Dr. Pushkar Kumar Lead Consultant, MoHFW
12 Dr. Rajeev Agarwal Sr. Consultant, MoHFW
13 Dr. Anil Kashyap Consultant - NHM, MoHFW
14 Dr. Ajay Patte Consultant, MoHFW
Development Partners and International Agencies

15 Dr. Arvind Mathur WHO, SEARO
16 Dr. Nigel Livesley URC - ASSIST

17 Dr. Rajeev Gera IPE Global
18 Dr. Devina Bajpayee IPE Global
19 Dr. Ritu Agarwal CMNH, LSTM, UK
20 Dr. Gagan Gupta UNICEF
21 Dr. Bulbul Sood Country Director , JHPIEGO
22 Dr. Vivek Yadav JHPIEGO
23 Dr. Neerja Arora URC - ASSIST
24 Dr. Arunabh Ray BTAST, Bihar
Institutional Numbers
25 Dr. Neerja Bhatla Professor, OBGY AIIMS
26 Dr. Sushma Nangia Professor, Pediaterics, AIIMS
27 Dr. Vidushi Kulshrestha Asst. Professor, OBGY AIIMS
28 Dr. Manju Chhuggani Principal, Nursing School, Jamia
XIV
List of Contributors
NHSRC Team
29 Dr. Sanjiiv Kumar Dixit, Executive Director
30 Dr. J. N. Srivastava Advisor, Quality Improvement
31 Dr. Parminder Gautam Sr. Consultant
32 Dr. Nikhil Prakash Sr. Consultant
33 Dr. J. V. Ramamurthi Consultant
34 Dr. Deepika Sharma Consultant
35 Ms. Surbhi Sharma Consultant
36 Ms. Richa Sharma Consultant
37 Mr. Rajesh Nallamothu Consultant
38 Dr. Jagjeet Singh Consultant
39 Dr. Sushant Agrawal Consultant
State Team
40 Dr. J. L. Meena NHM, Govt. of Gujarat
41 Dr. Sulbha Swaroop NHM, Govt. of UP
42 Dr. K. Sandeep NHM, Govt. of Kerala

43 Mr. Shridhar Pandit NHM, Govt. of Maharashtra
44 Dr. Neelima Singh IIH&FW, Hyderabad
45 Dr. Monika Rana DSHM, GNCT, Delhi
46 Dr. Manoj Donglikar SDH Vaijapur, Aurangabad, Maharashtra

47 Dr. Gitesh Chawda PHC Shivoor, Aurangabad, Maharashtra
48 Dr. Rajani MOiC , PHC RC Puram, Medak , Telangana
49 Dr. Srimanth AMOH, PHC C. Dabka, Bidar, Karnatka
50 Dr. Praveen Kumar AMOH, PHC Halbarga, Bidar, Karnatka
XV
List of Contributors
Table of Contents
Message.....................................................................................................................................................................III
Preface........................................................................................................................................................................VI
Foreword...................................................................................................................................................................VII
Foreword...................................................................................................................................................................IX
Foreword....................................................................................................................................................................XI
Program officers message...............................................................................................................................XIII
List of contributors.............................................................................................................................................XIV
Executive Summary..............................................................................................................................................01
A Introduction to Quality Assurance......................................................................................................02
I. Introduction to Assessor’s Guidebook.............................................................................................03
II. Framework for Quality of Care QOC...............................................................................................04
III. The Quality Measurement System.................................................................................................05
B National Quality Assurance Standards for Community Health Centre (FRU).........10
I. I. Intent of Quality Assurance Standards for CHC (FRU)..........................................................11
II. Measurable Elements for CHC Quality Assurance Standards...............................................22
C Assessment Protocols.................................................................................................................................36
I. Assessment Methodology.....................................................................................................................37
II. Scoring System. ......................................................................................................................................41
D Implementing Quality Assurance at Facility Level....................................................................44
I. Step by step Approach for Quality Assurance.............................................................................45
E Departmental Checklists...........................................................................................................................50
Checklist for Accident and Emergency...............................................................................................52
Checklist for Outdoor Department......................................................................................................82
Checklist for Labour Room....................................................................................................................118
Checklist for Inpatient Department..................................................................................................152
Checklist for New Born Stabilization Unit.....................................................................................182
Checklist for Operation Theatre..........................................................................................................210
Checklist for Laboratory.........................................................................................................................240
Checklist for Radiology...........................................................................................................................262
Checklist for Pharmacy and Stores....................................................................................................278
Checklist for Blood Storage Centres.................................................................................................296
Checklist for Auxillary Services...........................................................................................................312
Checklist for General Administration...............................................................................................330
Annexure...............................................................................................................................................................368
Key Performance Indicators.................................................................................................................369
Suggestive Format for Standard Operating Procedures...........................................................371
Inpatient Feedback Format.................................................................................................................. 373
OPD patient Feedback Format.............................................................................................................375
List of Abbreviations................................................................................................................................376
Bibliography................................................................................................................................................381
Index .............................................................................................................................................................385
National Quality Assurance Standards for CHC (FRU)
Executive Summary
Community Health Centres in the country are first port of call for availing specialised services in
the Public Health System. Patients and beneficiaries being treated at Public Health Facilities should
ideally get specialised services at these health facilities. However, due to various factors including
vacancies not being filled, shortage of specialists, most of the CHCs at present are not providing
specialised services. Nevertheless some of the CHCs, where blood transfusion facilities are available,
provide Emergency Obstetric Care services, including Newborn Stabilisation Units (NBSUs), Caesarean
Sections, and others.
However, quality of care provided at such facilities has been a cause of concern. Concerted efforts
are required for improving the quality of care, so that the community is assured of a minimum level
of quality, while availing the services.
First step in such efforts is to assess Community Health Centres, so that the gaps at health
facilities are known, and a time-bound action plan for the gap closure is developed. Subsequent
assessments by various stakeholders – facility incharges, district health administration, state and
external certification body, would need to be undertaken using same tools, so that there is clarity on
expectation and objectivity in assessment is maintained. This ensures in-house ownership, which is
important for sustainability of Quality Assurance Initiative.
An ‘All-in-One’ approach has been adopted in developing this guide book. The guidebook also has
both ‘What’ and ‘How’ components. What needs to be done to improve the quality at CHCs and how
to do it? Therefore, the book can be used for assessment as well as implementation. For convenience
of calculating different scores, the guidebook also contains a formula based excel sheet.
The ‘Assessor’s Guidebook for Quality Assurance in Community Health Centres’ contains Quality
Standards for a CHC, measurable elements for each of the standards and check-points for the
verification. A total of sixty-five quality standards in the book is organised around eight areas of
concern, viz. Service provision, Structure, Clinical Care, Patient Rights, Infection Control, Support
Services, Quality Management and Outcome. The Quality Standards for a CHC have a total of 252
measurable elements (ME), which are specific attributes of the standards, and should be looked into
for assessing the degree of compliance to a particular standard.
Checkpoints for each ME have been arranged into twelve check-lists – Accident and Emergency
Department, OPD, IPD, Labour Room, Operation Theatre, Blood Storage Unit, Laboratory, NBSU,
Pharmacy and Stores, Radiology, Auxiliary Services and General Administration. Evidence of
compliance to each checkpoint would be gathered either by direct observation by the assessor or
interviewing staff of the health facility or review of records available at the CHC or patient interview
or a combination of all such methodologies. Compliance to each checkpoint would be decided in
term of full compliance, partial compliance or no compliance and the checkpoint would be awarded
two, one or zero marks respectively.
Thus, the assessment process would generate a score for the health facility, as well as departmental
score, and also score against each area of concern. The score would be used as an objective
parameter for assessing progress of Quality Assurance implementation at the health facility, as
well as for comparing two similar health facilities and inter-district and inter-state comparison.
Similar yardstick would be used for assessing the health facility for external quality certification by
independent assessors with no conflict of interest.
The guidebook will help in improving the quality of services at Community Health Centres, optimal
utilisation of resources and building a credible, sustainable and intrinsic Quality Management System
(QMS) within the system.
1
Section
Introduction to
Quality Assurance
I. Introduction to Assessor’s Guidebook
Public Health System in India has been organised at three levels, namely primary, secondary and
tertiary. While Primary Health Care is being provided at PHCs and Subcentres, the secondary health
care is being provided at Community Health Centres (CHCs) and other higher level facilities such
as Sub-District Hospitals (SDH) and District Hospitals (DH). The CHCs are expected to function
as First Referral Unit (FRU), thereby providing referral linkage to the Primary Health Centres and
Subcentres. A FRU should have facilities for Emergency Obstetric Care including facilities for LSCS
and Anaesthesia, Blood Storage Unit and NBSU.
Indian Public Health Standards (IPHS) guidelines divide services at CHC into two categories -
Essential and Desirable. A CHC is expected to have 30-beds and provide specialist care in Medicine,
Surgery, Obstetricsand Gynaecology, Paediatrics, Dental and AYUSH.
Providing an equitable, accessible and affordable primary healthcare, which is of an assured

quality, would be a mandatory pre-requisite before the dream of ‘Health for All’ can be realized.
The successful implementation of NRHM, which has since then transformed into the National
Health Mission (NHM), is evident by many fold increase in OPD, IPD and other services at Public
Health Facilities, 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.
Quality Standards for a health facility would be all inclusive, encompassing full range of
conditions such as Emergency care, Emergency care to Pregnant Women and Newborn under RCH
programme, prevention and management of Communicable and Non-Communicable diseases,
availability of essential medicines. The level of care at CHC not only meets technical criteria, but
also adequately meets community’s expectations. Past experiences have shown that an in-built
system of quality assurance addresses not only such requirements, but is sustainable as well.
Therefore, an in-house quality management system needs to be built into the design of each
facility, which will regularly measure its quality, take corrective active and promote the quality of
care culture. Incentivisation of the quality initiative may be planned.
Measurement is the first step that leads to assurance and eventually to improvement. If you can’t
measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you
can’t control it, you can’t improve it.
Hence to measure the quality of services at public health facilities, and to help states in building
an in-house credible quality management system into the design of Public health facilities,
‘Operational Guidelines for Quality Assurance in Public Health Facilities’ and accompanying
compendium of check-lists for District Hospitals were released in the year 2013 by the Ministry
of Health andFamily Welfare. It is now felt that similar guidelines and standards are required for
PHCs and CHCs.
The current “Assessor’s Guidebook for Quality Assurance for CHC” is applicable those CHCs, which
are functioning as FRU.
3
Introduction to Quality Assurance
II. Framework of Quality of Care (QOC)
Quality has been described differently in its context. The Quality Management Guru, Juran in 1974 has described ‘Quality is fitness for
use’ and Crosby in1979 ‘Quality means conformance to Requirements’. The Webster dictionary states ‘Quality is a degree of excellence’.
Quality is meeting the “stated” and “implied” needs of the customer. Quality is also perceived as totality of features and characteristics
of a product or service that bear on its ability to satisfy given needs.
Quality is not achieved by doing different things; it is achieved by doing things differently.
The most accepted frame-work for assessing the quality of care is the ‘Donabedian model’, which classifies QOC in terms of three
aspects – structure, process, and outcome.
a. Structure – Structural aspect of QOC includes material resources like infrastructure, drugs and equipment; and human
resources such as availability of adequate number of personnel, who have requisite knowledge and skills. Evaluation of the
quality that relies on such structural elements implicitly assumes that well qualified people working in well-organized settings
would ensure delivery of high quality of care. However, it is not always true. Also, it is acknowledged that in the Public Health
System, it may not always be possible to meet fully the infrastructure and HR norms. However, a public health facility having
minimum infrastructure and HR norms does not preclude from delivering quality of care, which is possible within the means
of available resources. The proposed quality system strives to provide QOC within these constraints.
b. Process – Care can also be evaluated in terms of processes and sub-processes, required for delivery of care. This refers to
what takes place during delivery of healthcare and its sub-components – for example, how quickly registration of a patient
is done, and s/he is attended, courteous behaviour of the service providers, conduct of examination with respect to privacy,
confidentiality and other patients’ rights, etc.
c. Outcome – The other aspect of quality of care can be assessed in terms of outcome measurements, which denote to what
extent goals of the care have been achieved.
All three aspects of the QOC have different connotations to different stakeholders, viz. Patients, Service Providers and Health System,
as given in Table 2.1.
Table 2.1: QOC IN TERM OF INPUTS, PROCESSES and OUTCOME

Inputs Processes Outcome
Patients’ • Availability of services • Minimal waiting time and • No out of pocket
Expectations Prompt referral, if required expenditure
• Availability of drugs and
consumables • Good behaviour by service • Availability of guaranteed
providers services
• Prompt and courteous
services • Privacy andconfidentiality • High Patient Satisfaction
• Clean and Inviting environment • Grievance Redressal • Treatment and Cure
at the health facility
• Access to Information and
• Barrier Free Access involvement in decision
making for the care
• No exclusion on the basis of
caste and socio-economic
status
4
Inputs Processes Outcome

Service Providers • Adequate and planned • Adherence to clinical • Low Mortality, Morbidity,
Requirements infrastructure Protocols complications, and Referrals,
etc.
• Serviceable and calibrated • Infection Control Practices
Equipment • Efficiency in care in term
• Training and Skill
of average length of stay,
• Availability of Quality Drugs Development
bed occupancy, etc.
• Human Resources-numerical • Safe and effective Nursing
• Adverse drug reactions and
adequacy with knowledge care
Hospital acquired infection
and skills
• High staff satisfaction
• Enabling Work Environment
• Measurable deliverables of
Health Systems • Allocation of adequate • Efficient logistics
programmes
Requirements resources management
• Improvement in Health
• Facilities provide full range of • Monitoring and Supervision
Indicators
services
• Effective implementation of
• Enhanced Productivity in
• Adequate Technical Support programmes
terms of volume
In order to have a unified approach for Quality of care, the MoHFW, Government of India has introduced Quality Assurance Framework
at all levels (National, state, District and Facility level). Some of the salient features of the institutional arrangement for Quality
Assurance are-
1. Unified Quality Assurance Structures (QA Committees and Units) at Facility, District and State level.
2. Appointment of full time quality professionals at District and State level.
3. Defining quality standards for public health facilities and tools for assessing them.
4. Mechanism of continual quality assessment, scoring and improvement of public health facilities through internal and external
assessments.
5. Provision of certification of public health facilities.
6. Promoting Quality Assurance through financial and non-financial incentives linked with Quality Scores and Incentives.
Service providers and quality assurance committees in various states are using quality standards and assessment tools for district
hospitals in the country.
Expanding the same quality framework, this manual provides the Quality Assurance Standards for Community Health Centres as well
as basic guide how to improve services at the facilities.
5
III. The Quality Measurement System
Measuring quality of care at health facilities has never been easy, more so, in Public Health Facilities. We have had quality fame-work
and quality standards and 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. It
is realized 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.
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 six departmental check-sheets transposed within fifty standards, and commensurate measurable elements provide a
reasonable 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 other health facilities,
such as ‘for-profit’, corporate, NGO, etc. For instance, the system described in this manual has quality standards for providing free
drugs, ensuring availability of clean linen, etc. which may not be relevant for non-public 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 lessons included.
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 for easy understanding and implementation by the service providers.
Scoring system has been made simple with uniform scoring rules and weightage. Additionally, a formula fitted excel sheet tool
has been provided for convenience, and also to minimise calculation errors.
5. Evidence based – The system draws considerably from existing guidelines, standards and available literature on the Quality in
Healthcare and Public Health System. Additionally, Operational Guidelines for National Health Programmes and schemes have also
been consulted.
6. Objectivity – In the proposed quality system, each standard is accompanied with measurable elements and checkpoints to measure
compliance to the standards. Checklists have been developed for various departments, which also captures interdepartmental
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. Balanced – All three components of Quality – Structure, process and outcome, have been given due weightage. Similarly due
weightage have been provided to preventive and promotive services and National Health Programs.
QUALITY ASSURANCE STANDARDS FOR CHC
Quality Assurance Standards for CHC given in this book are in congruence with “Operational Guidelines for Quality Assurance for Public
Health Facilities“. There are sixty-five Standards, categorized into 8 area of concern. Each standard further has specific measurable
elements (in total 252 ME). These standards and Measurable Elements are assessed through twelve departmental checklists for CHC
- Accident and Emergency Department, OPD, IPD, Labour Room, Operation Theatre, Blood Storage Unit, Laboratory, NBSU, Pharmacy
and Stores, Radiology, Auxiliary Services and General Administration. Completed checklists would generate scorecards for a facility,
area of concern, and department.
6
Figure 4.1: Relationship between Standard, Measurable Elements and Departmental checklists
Departmental
FRU
Following is the brief outline of Areas of Concerns, under which Quality standards for Primary Health Centre are presented in this
manual -
A. Service Provision – This area of concern has six standards, which measures availability of the Curative, RMNCH+A, Diagnostics
services, and also the services under National Health Programmes.
B. Patients’ Rights – This area of concern also has five standards. These standards measures different aspects of patients’ rights
i.e. Availability of information, Physical access, Ensuring Privacy andConfidentiality, Availability of mandated free services,
and provision of incentive schemes at CHCs.
C. Inputs - This area of concern has five standards, which measure Availability of required infrastructure, Physical safety, Skilled
human resources, Drugs, Consumables, Equipment and Instruments.
D. Support services – There are total of ten standards in this area of concern. These standards are related with processes
required for equipment maintenance, inventory management, and auxiliary services such as laundry, diet, housekeeping and
power backup. This area of concern also contains standards for Financial Management, Community Monitoring, and Human
Resource Management.
E. Clinical services – This area of concern has 22 standards that measure quality of clinical services at a CHC. This includes
standards on the consultation, admission, assessment and reassessment, continuity of care, nursing care, medication safety,
High risk and vulnerable patients, usage of standard treatment guidelines (STGs), safe drug administration, emergency
services, laboratory services, medical records and discharge process. Last six standards under the area of concern pertains to
those clinical processes related to antenatal care, intranasal care, post-natal care, new-born care, child health, adolescent
health, family planning and clinical services, and the National Health Programmes.
F. Infection Control - There are six standards pertaining to infection control programme, hand-washing facilities, personal
protection, instrument processing, environment control and Biomedical waste management under this area of concern.
G. Quality Management – This area of concern encompasses four standards related to Quality team, Internal and external
quality assurance, Patient satisfaction survey and Standard Operating Procedures.
H. Outcome – This area of concern has four standards related with measuring performance of CHC in terms of productivity,
efficiency, clinical care and service quality.
7
Departmental Checklists: There are twelve checklists, namely –Accident and Emergency, Outpatient Department, Labour Room,
Inpatient Department, Operation Theatre, Pharmacy, Laboratory, Radiology, Blood Storage, NBSU, and General Administration and
Auxiliary Services, which are given in this publication. Brief description of each check-list is given below -
1. Accident andEmergency – This checklist is applicable to Accident and Emergency department of a CHC. The checklist has been
designed to assess all aspects of dedicated emergency services, which a CHC should provide. If emergency department is shared
with OPD, then both the checklists are required to be used independently.
2. Outdoor Department – This checklist is applicable to outdoor department of a CHC. It includes OPD services, ICTC, ANC clinics,
Family planning and Support areas like immunization room, dressing room, and waiting area. Similarly dispensary has been
included in the Pharmacy check list. It may be possible that OPD services are dispersed geographically, for example ANC Clinic
and Immunisation clinic may not be located in the main OPD complex. However, all such facilities should be visitedand assessed as
a part of assessment of OPD.
3. Labour Room- This checklist is applicable to the labour room and its auxiliary area like nursing station, waiting area and recovery
area. It also includes septic labour room (if available).
4. Inpatient Department – This is a common checklist for indoors wards including male and female wards. As facilities of indoor
wards are shared by all the departments in the CHC, IPD requirements of Medicine, Gynaecology and Obstetrics, Paediatrics, and
Surgery have been included in the same Checklist.
5. Newborn Stabilization Unit - This checklist is applicable to a functional Level NBSU,located at the CHC.
6. Operation Theatre - This checklist is applicable for OT in the CHC. As TSSU is collocated with OT, are also included in the
Checklist.
7. Laboratory - This checklist is meant for main clinical laboratory of a CHC, which would include routine biochemistry, haematology,
serology, etc. Essential tests for OPD and IPD patients including ANC and National Health Programs are covered under this
checklist
8. Radiology - This checklist covers X-Ray and Ultrasound facility available in the CHC.
9. Pharmacy and Stores - This checklist is applicable to Drug store, Cold Chain storage and Drug dispensing counter.
10. Blood Storage - The checklist is meant for Blood storage facility in the facility. Although some component of parent blood bank
e.g. valid registration is included in the checklist, this checklist is not applicable to Blood Bank.
11. General Administration - The checklist covers checkpoints related to general administration of CHC. It would essentially cover
policy level issues, and cross-cutting processes, which are followed at a CHC. This checklist is complimentary to other ten
checklists. Assessment Protocols and scoring methodology for this system will be same as Quality Assurance Standards for District
Hospitals.
12. Auxiliary Services - This checklist covers Laundry, Kitchen, and Medical records. 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, pond or
food supplied by charitable/religious institutions does not constitute having hospital laundry/kitchen per se. House-keeping
services are being assessed under the Hospital Infection Prevention and Control of each department.
8
Section
National Quality Assurance

standards for
Community Health Centre (FRU)
I. Intent of Quality Assurance

Standards for CHC (FRU)
I. Area of Concern A – Services Provision

Community Health Centres constitute the First referral Units (FRUs) and are designed to provide referral health care for cases
from the Primary Health Centres level and for cases in need of specialist care approaching the centre directly. Indian Public
Health Standards (IPHS) defines minimum assured services, which should to be available at a Community Health Centre.
Recently launched RMNCH+A initiative has also defined service availability norms for Reproductive, Maternal, Neonatal, and
Child and Adolescent health services at a CHC.
Community Health Centre is an important link between PHC and District Hospital. CHC is a 30-bedded Hospital providing
specialist care in Medicine, Surgery, Obstetrics and Gynaecology, Paediatrics, Dental and AYUSH.
This area of concern measures availability of services. “Availability” of functional services means service is available to end-
users because mere presence of infrastructure and human resources does not always ensure availability of the services. For
example an Operation Theatre, Surgeon and Anaesthetist may be available, but no LSCS are being conducted due to varied
reasons. Compliance to these standards and measurable elements should be checked, preferably by observing delivery of the
services, review of records for utilization of services and interviewing the users to know, whether the services were provided to
them or not.
There are six standards in this area of concern. Compliance to following standards ensures that the health facility is addressing
this area of concern.
Standard A1–The Facility Provides Curative Services.
This standard includes availability of OPD consultation, Indoor services and Surgical procedures and Emergency Care under
different specialities e. g. Medicine, Surgery, 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
and Emergency department, availability of General surgery clinic at OPD, and Availability of surgical procedures in Operation
theatre.
Standard A2– The Facility provides RMNCH+A Services.
This standard measures availability of Reproductive, Maternal, Newborn, Child and Adolescent services in different departments
of the hospital. Each aspect of RMNCH+A services is covered by one measurable element of this standard.
Standard A3 –The facility provides Diagnostics Services.
It covers availability of Laboratory, Radiology and other diagnostics services in the respective departments.
Standards A4 – The facility provides services as mandated in national Health Programmes /State
Scheme.
This standard measures availability of the services under different National Health Programmes such as RNTCP, NVBDCP, etc.
One Measurable element has been assigned to each National Health Programme.
Standard A5 – The facility provides Support services and Administrative Services.
The standard measures availability of support services like dietary, laundry and housekeeping services at the facility.
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National Quality Assurance standards for Community Health Centre (FRU)
Standard A6 – Health services provided at the facility are appropriate to community needs.
The standard mandates availability of the services according to specific local health needs. Different geographical area may
have certain health problems, which are prevalent locally, e. g. Kala-azar, Dengue, Arsenic Poisoning, AES, etc.
Area of Concern – B: Patients’ 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 - Health services provided at the facility are appropriate to community needs.
This standard measures availability of the information about the services and their modalities of availing them. Measurable
elements under this standard check for availability of user-friendly signages, display of available services and user charges,
citizen charter, enquiry desk and access to his/her clinical records.
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.
This standard ensures that the services are sensitive to gender, cultural and religious needs. This standard also measures
the physical access and disable-friendliness of the services, such as availability of ramps and disable friendly toilets. Last
measurable element of this standard mandates for provision for affirmative action for vulnerable and marginalized patients
like orphans, destitute, terminally ill patients, victims of rape and domestic violence so they can avail health care service with
dignity and confidence at public hospitals
Standard B3 - The facility maintains privacy, confidentiality and dignity of patient, and has a system
for guarding patient related information.
This standard measures the patient friendliness of the services in terms of ensuring privacy, confidentiality and dignity.
Measurable elements under this standard check for provisions of screens and curtains, confidentiality of patients’ clinical
information, behaviour of service providers, and also ensuring specific precautions to be taken, while providing care to patients
with HIV infection, abortion, teenage pregnancy, etc.
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.
This standard mandates that health facility has procedures for informing patients about their rights, and actively involves them
in the decision-making about their treatment. Measurable elements in this standard look for practices such informed consent,
dissemination of patient rights and how patients are communicated about their clinical conditions and options available. This
standard also measures for procedure for grievance redressal. Compliance to these standards can be checked through review of
records for consent, interviewing staff about their awareness of patients’ rights, interviewing patients whether they had been
informed of the treatment plan and available options.
Standard B5 – The facility ensures that there are no financial barriers to access, and that there is
financial protection given from the cost of hospital services.
This standard majorly checks that there are no financial barriers for the community, more so those belong to BPL category,
vulnerable in available the services. Measurable elements under this standard check for availability of drugs, diagnostics
and transport free of cost under different schemes, and timely payment of the entitlements under JSY and Family planning
incentives.
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Area of concern C – Inputs

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 and 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 30-bedded CHC having 40% bed occupancy may not have same requirements as another CHC 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 in arriving at a just decision for compliance.
Standard C1 - The facility has infrastructure for delivery of assured services, and available
infrastructure meets the prevalent norms.
The standard measures adequacy of infrastructure in terms of space, patient amenities, layout, circulation area, communication
facilities, service counters, etc. It also looks into the functional aspect of the structure, whether it commensurate with the
process flow of the facility or not.
Minimum requirement for space, layout and patient amenities are given for some of the departments, but assessors would be
expected to use his discretion to conclude whether available space 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 - The facility ensures the physical safety including Fire safety of the infrastructure.
The standard deals with Physical safety of the infrastructure. It includes seismic safety, safety of lifts, electrical safety, and
general condition of hospital infrastructure. It also covers fire safety of the facility. Measurable elements in this standard look
for implementation of fire prevention, availability of adequate number of firefighting equipment and preparedness of the
facility for fire disaster in terms of mock drill and staff training.
Standard C3 - The facility has adequate qualified and trained staff, required for providing the
assured services to the current caseload.
The standard measures the numerical adequacy and skill sets of the staff. It includes availability of doctors, nurses, paramedics
and support staff. It also ensures that the staffs have been trained as per their job description and responsibilities. There are
two components while assessing the staff adequacy - first is the numeric adequacy, which can be checked by interaction
with in charge of the CHC and review of records. Second is to access human resources in term of their availability within the
department. For instance, a CHC may have four SBA trained nurses, but if none of them is available in the night to conduct
deliveries, then the intent of standard is not being complied with.
Standard C4 - The facility provides drugs and consumables required for assured services.
This standard measures availability of drugs and consumables in the user departments. Assessor may check availability of
drugs under the broad group such as antibiotics, IV fluids, dressing material, and make an assessment that drugs for treatment
majority of normal patients and critically ill patients are getting treated at the health facility.
Standard C5 - The facility has equipment and instruments required for assured list of services.
This standard is concerned with availability of instruments in various departments and service delivery points. Equipment and
instruments have been categorized into sub-groups as per their use, and measurable elements have 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.
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Area of Concern D – Support services

Support services are backbone of health care facilities. 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.
Standard D1 - The facility has established Programme for inspection, testing and maintenance and
calibration of Equipment.
The standard is concerned with equipment maintenance processes, such as AMC, daily and breakdown maintenance processes,
calibration and availability of operating instructions. Equipment records should be reviewed to ensure that valid AMC is
available for critical equipment and preventive / corrective maintenance is being 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 - The facility has defined procedures for storage, inventory management and dispensing
of drugs in pharmacy and patient care areas.
This standard is concerned with safe storage of drugs and scientific management of the inventory, so drugs and
consumables are available in adequate quantity in patient care area. Measurable elements of this standard look into
processes of indenting, procurement, storage, expired drugs management, inventory management, stock management
at patient care areas, including storage at optimum temperature. While assessing drug management system, these
practices should be looked into each clinical department, especially at the nursing stations and its complementary
process at drug stores/Pharmacy.
Standard D3 - The facility has established Programme for maintenance and upkeep of the facility to
provide safe, secure and comfortable environment to staff, patients and visitors.
This standard is concerned with adequacy of facility management processes. This includes appearance of facility, cleaning
processes, infrastructure maintenance, removal of junk and condemned items and control of stray animals and pest control
at the facility. This standard is also concerned with providing safe, secure and comfortable environment to patients as well
to service providers. The measurable elements under this standard have two aspects, - firstly, provision of comfortable work
environment in terms of adequate illumination and temperature control in patient care areas and work stations. It would
be preferable that assessment of adequacy of illumination is undertaken by Lux-meter (not a very expensive devise) and
compared against BIS Standards of illumination in Hospital. Second part pertains to 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 The facility ensures 24x7 water and power backup as per requirement of service
delivery, and support services norms.
The standard covers processes to ensure water supply (quantity and quality), power back up and medical gas supply. All
departments should be assessed for availability of water and power back up. Some critical area like OT and ICU may require
two-tire power backup in terms of UPS and Invertors. Availability of central oxygen and vacuum supply should especially be
assessed in critical area like OT and ICU.
Standard D5 - The facility ensures availability of Diet as per nutritional requirement of the patients
and clean Linen to all admitted patients.
The standard is concerned with processes ensuring availability of nutritious food, as per requirement of different
category of patients. The food is served in an appealing and hygienic manner. This includes nutritional assessment
of patients, availability of different types of diets and standard procedures for preparation and distribution of food,
including hygiene and sanitation in the kitchen. Patients / staff may be interacted for knowing their perception about
quality and quantity of the food.
This standard also covers laundry processes. It includes availability of adequate quantity of clean and usable linen, process
of providing and changing bed sheets in-patient care area and process of collection, washing and distributing the linen.
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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 D6 - The facility has defined and established procedures for promoting public participation
in management of hospital transparency and accountability.
The standards measures processes related to functioning of Rogi Kalyan Samiti (RKS), equivalent to Hospital Development
Society (HDS) and community participation in facility management. RKS records should be reviewed to assess frequency of
the meetings, and issues discussed there. Participation of non-official members like community/NGO representatives in such
meetings should be checked.
Standard D7 - Hospital has defined and established procedures for Financial Management.
The standard is concerned with the financial management of the funds/grants, received from different sources including
NRHM. Assessment of financial management processes by no means should be equated with financial or accounts 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 D8 - The facility is compliant with all statutory and regulatory requirement imposed by
local, state or central government.
This standard is concerned with compliances to statuary and regulatory requirements. It includes availability of requisite
licenses, updated copies of acts and rules, and adherence to the legal requirements as applicable to Public Health Facilities.
Standard D9 - Roles and Responsibilities of administrative and clinical staffs are determined as per
govt. regulations and standards operating procedures.
This standard is concerned with processes regarding staff management and their deployment in the departments of a facility.
This includes availability of Job descriptions for different cadre, processes regarding preparation of duty rosters and staff
discipline. The facility staff can be interviewed to assess about their awareness of job description. It should be assessed by
observation and review of the records. Adherence to dress code should be observed during the assessment.
Standard D10 - The facility has established procedure for monitoring the quality of outsourced
services and adheres to contractual obligations.
This standard measures the processes related to outsourcing and contract management. This includes monitoring of outsourced
services, adequacy of contact documents and tendering system, timely payment for the availed services and provision for
action in case for inadequate/ poor quality of services. Assessor should review the contract records related to outsourced
services, and interview hospital administration about the management of outsources 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 six standards are concerned with specific clinical and therapeutic processes including emergency care,
diagnostic services, Blood storage and transfusion services, anaesthesia, surgical services and end of life care.
Last set of seven standards under this area of concern is concerned with specific clinical processes for Maternal, Newborn,
Child, Adolescent and Family Planning services and National Health Programmes. These standards are based on the technical
guidelines published by the Government of India.
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.
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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 - The facility has defined procedures for registration, consultation and admission of
patients.
This standard is concerned with the registration and admission processes in hospitals. It also covers OPD consultation processes.
The Assessor should review the records to verify that details of patients have been recorded, and patients have been given
unique identification number. OPD consultation 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. The facility staff should be interviewed to know,
whether there is any fixed admission criteria especially in critical care department.
Standard E2 - The facility has defined and established procedures for clinical assessment and
reassessment of the patients.
This standard pertains to clinical assessment of the patients. It includes initial assessment as well as reassessment of admitted
patients.
Standard E3 - The facility has defined and established procedures for continuity of care of patient
and referral.
The standard is concerned with continuity of care for the patient’s ailment. It includes process of inter-departmental
transfer, referral to another facility, deputation of staff for the care, and linkages with higher institutions. The staff
should be interviewed to know the referral linkages, how they inform the referral hospital about the referred patients
and arrangement for the vehicles and follow-up care. Records should be reviewed for confirming that referral slips
have been provided to the patients.
Standard E4 - The facility has defined and established procedures for nursing care.
This standard measures adequacy and quality of nursing care for the patients. It includes processes for identification of
patients, timely and accurate implementation of treatment plan, nurses’ handover processes, maintenance of nursing records
and monitoring of the patients. The 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 and nursing notes should be done.
Standard E5 - The facility has a procedure to identify high risk and vulnerable patients.
This standard is concerned with identification of vulnerable and High-risk patients. Review of records and staff interaction
would be helpful in assessing how High-risk patients are given due attention and treatment.
Standard E6 - The facility follows standard treatment guidelines defined by state/Central

government for prescribing the generic drugs and their rational use.
The standard is concerned with assessing that patients are prescribed drugs according standard treatment guidelines and
protocols. Patient records are assessed to ascertain that prescriptions are written in generic name only.
Standard E7 - The facility has defined procedures for safe drug administration.
The standard is concerned with the safety of drug administration. It includes administration of high alert drugs, legibility of
medical orders, process for checking drugs before administration and processes related to self-drug 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 - The facility has defined and established procedures for maintaining, updating of
patients’ clinical records and their storage.
This standard is concerned with the processes of maintaining clinical records systematically and adequately. Compliance to this
standard can be assessed by comprehensive review of the patients’ record.
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Standard E9 - The facility has defined and established procedures for maintaining, updating of
patients’ clinical records and their storage.
This standard measures adequacy of the discharge process. It includes pre-discharge assessment, adequacy of discharge
summary, pre-discharge counselling and adherence to standard procedures, if a patient is leaving against medical advice
(LAMA) or is found absconding. Patients’ records should also be reviewed for adequacy of the discharge summary.
Standard E10 - The facility has defined and established procedures for Emergency Services and
Disaster Management.
This standard is concerned with emergency clinical processes and procedures. It includes triage, adherence to emergency clinical
protocols, disaster management, processes related to ambulance services, handling of medico-legal cases, etc. Availability of
the buffer stock for medicines and other supplies for disaster and mass casualty needs to be found out. Interaction with the
staff and hospital administration should be done to asses overall disaster preparedness of the health facility.
Standard E11 - The facility has defined and established procedures of diagnostic services.
This standard deals with the procedures related to diagnostic services. The standard is majorly applicable for laboratory and
radiology services. It includes pre-testing, testing and post-testing procedures. It needs to be observed that samples in the
laboratory are properly labelled, and instructions for handling samples 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 E12 - The facility has defined and established procedures for Blood Storage Management
and Transfusion.
This standard is concerned with functioning of blood storage and transfusion services. The measurable elements under this
standard are processes for transport of blood from parent blood bank, storage procedures, cross matching, issuing, transfusion
and monitoring of transfusion reaction. The assessor should observe the functioning, and interact with the staff to know
adherence to standard procedures for blood transport storage and issue of blood as per standard protocols. Records of
temperature maintained in different storage units should be checked. Records should be reviewed for assessing processes of
monitoring transfusion reactions.
Standard E13 - The facility has established procedures for Anaesthetic Services.
This standard is concerned with the processes related to safe anaesthesia practices. It includes pre-anaesthesia, monitoring
and post-anaesthesia processes. Records should be reviewed to assess, how Pre-anaesthetic check-up is done and records are
maintained. Interact with Anaesthetist and OT technician/Nurse for adherence to protocols in respect of anaesthesia safety,
monitoring, recording and reporting of adverse events, maintenance of anaesthesia notes, etc.
Standard E14 - The facility has defined and established procedures of Operation theatre and surgical
services.
This standard is concerned with processes related with Operation Theatre. It includes processes for OT scheduling, pre-operative,
Post-operative practices of surgical safety. Interaction with the surgeon(s) and OT staff should be done to 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 and protocol for instrument count, suture material, etc. may be undertaken.
Standard E 15 - The facility has defined and established procedures for end of life care and death.
This is concerned with end of life care and management of death. Records should be reviewed for knowing adequacy of the
notes. Interact with the facility staff to know how news of death is communicated to relatives, and kind of support available
to family members.
Standard E16 - The facility has established procedures for Antenatal care as per guidelines.
The standard includes processes that ensure adequacy and quality of antenatal care provided at the facility. It includes
measurable elements for ANC registration, processes during check-up, identification of High Risk pregnancy, 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
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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 E17 - The facility has established procedures for Antenatal care as per guidelines.
This standard measures the quality of intra-natal care. It includes clinical process for normal delivery as well management
of complications and C-Section surgeries. The concerned staff can be interviewed to know their skill and practices regarding
management of different stages of labour, especially Active Management of Third stage of labour. Demonstration of resuscitation
and essential newborn care may be asked. Competency of the staff for managing obstetric emergencies, interpretation of
partograph, APGAR score should also be assessed.
Standard E18 - The facility has established procedures for postnatal care as per guidelines.
The standard is concerned with adherence to post-natal care of mother and newborn within the hospital. Observe if postnatal
protocols for prevention of Hypothermia and breastfeeding are adhered to. Mother may be interviewed to know that proper
counselling has been provided.
Standards E19 - The facility has established procedures for care of new born, infant and child as per
guidelines.
This standard is concerned with adherence to clinical protocols for newborn and child health. It covers immunization,
management of new-born and childhood illnesses like neonatal asphyxia, low birth weight, neo-natal jaundice, malnutrition
and diarrhoea. Immunization services are majorly 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 E20 - The facility has established procedures for abortion and family planning as per
government guidelines and law.
The standard is concerned with providing safe and quality family planning and abortion services. This includes standard
practices and procedures for Family planning, counselling, spacing methods, family planning surgeries and counselling and
procedures for abortion. Quality and adequacy of counselling services can be assessed by exit interview with the clients.
Staff at family planning clinic may be interacted to assess adherence to the protocols for IUD insertion, precaution and
contraindication for oral pills, family planning surgery, etc.
Standard E21 - The facility provides Adolescent Reproductive and Sexual Health services as per
guidelines.
This standard is concerned with services related to adolescent, Reproductive and Sexual health (ARSH) guidelines. It includes
promotive, preventive, curative and referral services under the ARSH. Staff should be interviewed, and records should be
reviewed.
Standard E22 - The facility provides services as per National Health Programmes’ Operational/
Clinical Guidelines.
The standard is concerned with adherence to clinical guidelines under the National Health Programmes. For each national
health programme, availability of clinical services as per respective guidelines should be assessed.
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
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Standard F1 - The facility has Infection Control Programme, and there are procedures in place for
prevention and measurement of Hospital Associated Infections.
This standard is concerned with the implementation of Infection control programme at the facility. It includes existence
of functional infection control committee, microbiological surveillance, measurement of hospital acquired infection
rates, periodic medical check-up and immunization of staff and monitoring of Infection control Practices. Hospital
administration should be interacted to assess the functioning of infection control committee. Records should be
reviewed for confirming the culture surveillance practices, monitoring of Hospital acquired infection, status of staff
immunization, etc. Implementation of antibiotic policy can be assessed though staff interviews, perusal of patient
record and usage pattern of antibiotic.
Standard F2 - The facility has defined and Implemented procedures for ensuring hand hygiene
practices and antisepsis.
This standard is concerned with practices of hand washing and antisepsis. Availability of Hand washing facilities with soap and
running water should be observed at the point of use. Technique of hand washing for assessing the practices, and effectiveness
of training may be observed.
Standard F3 - The facility ensures availability of material for personal protection, and facility staff
follows standard precaution for personal protection.
This standard is concerned with usage of Personal Protection Equipment (PPE) such as gloves, mask, apron, etc. Interaction with
staff may reveal the adequacy of supply of PPE.
Standard F4 - The facility has standard procedures for processing of equipment and instruments.
This standard is concerned with standard procedures, related to processing of equipment and instruments. It includes adequate
decontamination, cleaning, disinfection and sterilization of equipment and instruments. These practices should be observed
and staff should be interviewed for compliance to certain standard procedures.
Standard F5 - The facility has standard procedures for processing of equipment and instruments
The standard pertains to environment cleaning. It assesses whether the layout and arrangements of processes are conducive
for the infection control or not. Environment cleaning processes like mopping, especially in critical areas like OT and ICU should
be observed for the adequacy and technique.
Standard F6 - The facility has defined and established procedures for segregation, collection,
treatment and disposal of Bio-medical and hazardous Waste.
This standard is concerned with Management of Biomedical waste management including its segregation, transportation,
disposal and management of sharps. Availability of equipment and practices of segregation can be directly observed. Staff
should be interviewed about the procedure for management of the needle stick injuries. Storage and transportation of waste
should be observed and records are verified.
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 - The facility has established organizational framework for quality improvement.
This standard is concerned with creating a Quality Team at the facility and making it functional. Assessor may review the
document and interact with Quality Team members to know how frequently they meet and responsibilities have been delegated
to them. Quality team meeting records may be reviewed.
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Standard G2 - The facility has established system for patient and employee satisfaction.
The standard is concerned with having a system of measurement of patient and employees’ satisfaction. This includes periodic
patients’ satisfaction survey, analysis of the feedback and preparing action plan. Assessors should review the records pertaining
to patient satisfaction and employee satisfaction survey to ascertain that feedback of the patients, from a scientifically drawn
sample, is taken at prescribed intervals.
Standard G3 - The facility have established internal and external quality assurance Programmes
wherever it is critical to quality.
The standard is concerned with implementation of internal quality assurance programmes within departments such as EQAS
of diagnostic services, daily round and use of departmental checklists, External Quality Assurance Service (EQUAS) records at
laboratory, etc. Interview with Matron, Hospital Mangers, Nurse in-charges, OT technician, etc. may give information about
how they conduct daily round of departments and usage of checklists.
Standard G4 - The facility has established documented implemented and maintained Standard
Operating Procedures for all key processes.
This standard is concerned with availability and adequacy of Standard operating procedures and work instructions with the
respective process owners. Display of work instructions and clinical protocols should be observed during the assessment.
Standard G5 - The facility has established system of periodic review as internal assessment, medical
and death audit and prescription audit.
This standard pertains to the processes of internal assessment, medical and death audit at a defined periodicity. Review of
Internal assessment and clinical audit records may reveal their adequacy and periodicity.
Standard G6 - The facility has defined and established Quality Policy and Quality Objectives.
This standard is concerned with establishment and dissemination of quality policy and objectives in the hospital. The staff may
be interviewed regarding their awareness of Quality policy and Objectives. Review of records should be done for assessing that
Quality objectives meet SMART criteria, and have been reviewed periodically.
Standard G7 - The facility seeks continual improvement by practicing Quality tool and method.
This standard is regarding using Quality tools and methods like Process mapping, control charts, 5-‘S’, etc. The Assessor should
look for any specific methods and tools practiced for quality improvement.
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, and 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 - The facility measures Productivity Indicators and ensures compliance with State/
National benchmarks.
This standard is concerned with the measurement of Productivity indicators and meeting the benchmarks. This includes
utilization indicators like bed occupancy rate and C-Section rate. Assessor should review these records to ensure that theses
indictors are getting measured at the health facility.
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Standard H2 - The facility measures Efficiency Indicators and ensures compliance with State/
This standard pertains to measurement of efficiency indicators and meeting benchmark. This standard contains indicators that
measure efficiency of processes, such as turnaround time, and efficiency of human resource like surgery per surgeon. Review
of records should be done to assess that these indicators have been measured correctly.
Standard H3 - The facility measures Clinical Care and Safety Indicators and tries to reach State/
This standard is concerned with the indicators of clinical quality, such as average length of stay and death rates. Record review
should be done to see the measurement of these indicators.
Standard H4 - The facility measures Service Quality Indicators and endeavours to reach State/
This standard is concerned with indicators measuring service quality and patient satisfaction like Patient satisfaction score and
waiting time and LAMA rate.
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II. Measurable Elements for CHC Quality Assurance Standards

Area of Concern - A: Service Provision
Standard A1 The facility provides Curative Services
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 and Gynecology Services
ME A1.4 The facility provides Pediatric Services
ME A1.5 The facility provides Ophthalmology Services (at least 4 days in a month)
ME A1.6 The facility provides Dental Treatment Services
ME A1.7 The facility provides AYUSH Services
ME A1.8 The facility provides services for OPD
ME A1.9 Services are available for the time period as mandated
ME A1.10 The facility provides Accident and Emergency Services
ME A1.11 The facility provides Blood Storage and transfusion services
Standard A2 The facility provides RMNCHA 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 Newborn Health Services
ME A2.4 The facility provides Child Health Services
ME A2.5 The facility provides Adolescent Health Services
Standard A3 The facility Provides diagnostic 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
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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 and 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 Deafness
ME A4.11 The facility provides services under Universal Immunization Programme (UIP) as per guidelines
ME A4.12 The facility provides services under National Tobacco Control Programme as per guidelines
ME A4.13 The facility provides services under National Iodine Deficiency Programme as per guidelines
ME A4.14 The facility provides services as per State specific health programmes
Standard A5 Facility provides support services and Administrative services.

ME A5. 1 Facility provides Dietary services.
ME A5.2 Facility provides Laundry services
ME A5.3 Facility provides Security services.
ME A5.4 Facility provides Housekeeping services
ME A5.5 Facility ensures Maintenance services.
ME A5.6 Facility provides Pharmacy and store services.
ME A5.7 Facility has services for Medical Records
ME A5.8 The facility provides Administrative Services for the Block
Standard A6 Health services provided at the facility are appropriate to community needs.
ME A6.1 The facility provides curatives and 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’s Rights

The facility provides the information to care seekers, attendants and community about the available
Standard B1
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 and visitors are sensitized 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
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Services are delivered in a manner that is sensitive to gender, religious, gender and cultural needs,
Standard B2
and there are no barrier on account of physical access, social, economic, cultural or social status.
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 and friendly to people with disability.
ME B2.4 There is no discrimination on basis of social and economic status of the patients
ME B2.5 There is affirmative action to ensure that vulnerable sections can access services
The facility maintains privacy, confidentiality and dignity of patient, and has a system for guarding
Standard B3 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 behaviors of staff is dignified and respectful, while delivering the services
The facility ensures privacy and confidentiality to every patient, especially of those conditions having social
ME B3.4 stigma, and also safeguards vulnerable groups
The facility has defined and established procedures for informing patients about the medical condition,
Standard B4 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
The facility ensures that there is no financial barrier to access, and that there is financial
Standard B5 protection given from the cost of hospital services.
ME B5.1 The facility provides cashless services to pregnant women, mothers and neonates and for other patients on
payment 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
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Area of Concern - C: Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the
prevalent norms
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)
Standard C2 The facility ensures the physical safety including fire safety of the infrastructure.
ME C2.1 The facility ensures the seismic safety of the infrastructure
ME C2.2 The facility ensures safety of electrical establishment
ME C2.3 Physical condition of buildings are safe for providing patient care
ME C2.4 The facility has plan for prevention of fire
ME C2.5 The facility has adequate firefighting equipment
ME C2.6 The facility has a system of periodic training of staff and conducts mock drills regularly for fire and other
disaster situation
The facility has adequate qualified and trained staff, required for providing the assured services
Standard C3
to the current case load
ME C3.1 The facility has adequate specialist doctors as per service provision.
ME C3.2 The facility has adequate general duty doctors as per service provision and work load
ME C3.3 The facility has adequate nursing staff as per service provision and work load
ME C3.4 The facility has adequate technicians/paramedics as per requirement
ME C3.5 The facility has adequate support / general staff
ME C3.6 The staff has been provided required training / skill sets
ME C3.7 The staff is skilled as per job description
Standard C4 The facility provides drugs and consumables required for assured services.
ME C4.1 The departments have availability of adequate drugs at point of use
ME C4.2 The departments have adequate consumables at point of use
ME C4.3 Emergency drug trays are maintained at every point of care, where ever it may be needed
Standard C5 The facility has equipment and instruments required for assured list of services.
ME C5.1 Availability of equipment and instruments for examination and monitoring of patients
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ME C5.2 Availability of equipment and instruments for treatment procedures, being undertaken in the facility
ME C5.3 Availability of equipment and instruments for diagnostic procedures being undertaken in the facility
ME C5.4 Availability of equipment and instruments for resuscitation of patients and for providing intensive and
critical care to patients
ME C5.5 Availability of equipment for storage
ME C5.6 Availability of functional equipment and instruments for support services
ME C5.7 Departments have patient furniture and fixtures as per load and service provision
Area of Concern - D: Support Services

The facility has established programme for inspection, testing and maintenance
Standard D1
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
The facility has defined procedures for storage, inventory management and dispensing of drugs in
Standard D2
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 established 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
The facility has established program for maintenance and upkeep of the facility to provide safe, secure
Standard D3 and comfortable environment to staff, patients and visitors.
ME D3.1 Exterior of the facility building is maintained with landscaping in open area.
ME D3.2 Patient care areas are clean and hygienic
ME D3.3 Hospital infrastructure is adequately maintained.
ME D3.4 The facility has policy of removal of condemned junk material
ME D3.5 The facility has established procedures for pest, rodent and animal control
ME D3.6 The facility provides adequate illumination level at patient care areas
ME D3.7 The facility has provision of restriction of visitors in patient areas
ME D3.8 The facility ensures safe and comfortable environment for patients and service providers
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ME D3.9 The facility has security system in place at patient care areas
ME D3.10 The facility has established measure for safety and security of female staff
delivery, and support services norms
ME D4.1 The facility has adequate arrangement storage and supply for portable water in all functional areas
ME D4.2 The facility ensures adequate power backup in all patient care areas as per load
ME D4.3 Critical areas of the facility ensure availability of oxygen, and medical gases.
The facility ensures availability of diet as per nutritional requirement of the patients
Standard D5
and clean linen to all admitted patients
ME D5.1 The facility has provision of nutritional assessment of the patients
ME D5.2 The facility provides diets according to nutritional requirements of the patients
ME D5.3 Hospital has standard procedures for preparation, handling, storage and distribution of diets, as per
requirement of patients
ME D5.4 The facility has adequate sets of linen
ME D5.5 The facility has established procedures for changing of linen in patient care areas
ME D5.6 The facility has standard procedures for handling , collection, transportation and washing of linen
The facility has defined and established procedures for promoting public participation
Standard D6 in management of hospital with transparency and accountability
ME D6.1 The facility has established process for management of activities of Rogi Kalyan Samitis
ME D6.2 The facility has established procedures for community based monitoring of its services
Standard D7 The facility has defined and established procedures for promoting public participation
in management of hospital with transparency and accountability
ME D7.1 The facility ensures the proper utilization of fund provided to it
ME D7.2 The facility ensures proper planning and requisition of resources based on its need
Standard D8 The facility is compliant with all statutory and regulatory requirement imposed
by local, state or central government
ME D8.1 The facility has requisite licenses and certificates for operation of hospital and different activities
ME D8.2 Updated copies of relevant laws, regulations and government orders are available at the facility
ME D8.3 The facility ensure relevant processes are in compliance with statutory requirement
Roles and Responsibilities of administrative and clinical staff are determined as per
Standard D9
ME D9.1 The facility has established job description as per govt guidelines
ME D9.2 The facility has an established procedure for duty roster and deputation to different departments
ME D9.3 The facility ensures the adherence to dress code as mandated by its administration / the health department
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Standard D10 The facility has established procedure for monitoring the quality of outsourced
services and adheres to contractual obligations
ME D10.1 There is established system for contract management for out sourced services
ME D10.2 There is a system of periodic review of quality of out sourced services
Area of Concern - E: Clinical Services

Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
ME E1.1 The facility has established procedure for registration of patients
ME E1.2 The facility has an 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
The facility has defined and established procedures for clinical assessment
Standard E2
and reassessment of the patients.
ME E2.1 There is established procedure for initial assessment of patients
Standard D3 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 D3.9 The facility has security system in place at patient care areas
ME D3.10 The facility has established measure for safety and security of female staff
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
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients and ensure their safe care
ME E5.2 The facility identifies high risk patients and ensure their care, as per their need
The facility follows standard treatment guidelines defined by state/central government

Standard E6
for prescribing the generic drugs and their rational use.
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
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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
The facility has defined and established procedures for maintaining, updating of
Standard E8
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
Standard E9 The facility has defined and established procedures for discharge of patient
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 Counseling 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 D10 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E10.1 There is procedure for receiving and triage of patients
ME E10.2 Emergency protocols are defined and implemented
ME E10.3 The facility has disaster management plan in place
ME E10.4 The facility ensures adequate and timely availability of ambulances services and mobilization of resources, as
per requirement
ME E10.5 There is procedure for handling medico legal cases
Standard E11 The facility has defined and established procedures for diagnostic services
ME E11.1 There are established procedures for Pre-testing Activities
ME E11.2 There are established procedures for Testing Activities
ME E11.3 There are established procedures for Post-testing Activities
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Standard E12 The facility has defined and established procedures for Blood Storage Management and Transfusion.
ME 12.1 There is established procedure for transport of blood from parent blood bank.
ME E12.2 There is established procedure for storage of blood
ME E12.3 There is established procedure for cross matching of blood
ME E12.4 There is established procedure for issuing blood
ME E12.5 There is established procedure for transfusion of blood
ME E12.6 There is an established procedure for monitoring and reporting transfusion complication
Standard E13 The facility has established procedures for Anesthetic Services
ME E13.1 The facility has established procedures for Pre-Anesthetic Checkup and maintenance of records
ME E13.2 The facility has established procedures for monitoring during Anaesthesia and maintenance of records
ME E13.3 The facility has established procedures for Post-Anaesthesia care
Standard E14 The facility has defined and established procedures of operation theatre and surgical services.
ME E14.1 The facility has established procedures for OT Scheduling
ME E14.2 The facility has established procedures for Pre-operative care
ME E14.3 The facility has established procedures for Surgical Safety
ME E14.4 The facility has established procedures for Post-operative care
Standard E15 The facility has defined and established procedures for end of life care and death
ME E15.1 Death of admitted patient is adequately recorded and communicated
ME E15.2 The facility has standard procedures for handling the death in the hospital
ME E15.3 The facility has standard operating procedure for end of life support
ME E15.4 The facility has standard procedures for conducting/referring for post-mortem, its recording and meeting its
obligation under the law
Maternal and Child Health Services

Standard E16 The facility has established procedures for Antenatal care as per guidelines
ME E16.1 There is an established procedure for registration and follow up of pregnant women.
ME E16.2 There is an established procedure for history taking, physical examination, and counseling of each antenatal
woman, visiting the facility.
ME E16.3 The facility ensures availability of diagnostic and drugs during antenatal care of pregnant women
ME E16.4 There is an established procedure for identification of High risk pregnancy and appropriate treatment/referral
as per scope of services.
ME E16.5 There is an established procedure for identification and management of moderate and severe anaemia
ME E16.6 Counseling of pregnant women is done as per standard protocol and gestational age
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Standard E17 The facility has established procedures for Intranasal care as per guidelines
ME E17.1 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 E17.2 There is an established procedure for assisted and C-section deliveries per scope of services.
ME E17.3 There is established procedure for management/referral of obstetrics emergencies as per scope of services.
ME E17.4 There is an established procedure for new born resuscitation and newborn care.
Standard E18 The facility has established procedures for postnatal care as per guidelines
ME E18.1 Post-partum care is provided to the mothers
ME E18.2 The facility ensures adequate stay of mother and newborn in a safe environment as per standard protocols.
ME E18.3 There is an established procedure for Post-partum counseling of mother
ME E18.4 The facility has established procedures for stabilization/treatment/referral of post natal complications
ME E18.5 There is established procedure for discharge and follow up of mother and newborn.
Standard E19 The facility has established procedures for care of new born, infant and child as per guidelines
ME E19.1 The facility provides immunization services as per guidelines
ME E19.2 Triage, Assessment and Management of newborns having emergency signs are done as per guidelines
ME E19.3 Management/referral of low birth weight newborns is done as per guidelines
ME E19.4 Management of neonatal asphyxia, jaundice and sepsis is done as per guidelines
ME E19.5 Management of children presenting with fever, cough/ breathlessness is done as per guidelines
ME E19.6 Management/referral of children with severe Acute Malnutrition is done as per guidelines
ME E19.7 Management of children presenting diarrhoea is done per guidelines
The facility has established procedures for Medical Termination of Pregnancy and family planning as
Standard E20
per government guidelines and law
ME E20.1 Family planning counseling services provided as per guidelines
ME E20.2 The facility provides spacing method of family planning as per guidelines
ME E20.3 The facility provides limiting method of family planning as per guidelines
ME E20.4 The facility provide counseling services for abortion as per guidelines
ME E20.5 The facility provide abortion services for 1st trimester as per guidelines
ME E20.6 The facility provide abortion services for 2nd trimester as per guidelines
Standard E20 The facility provides Adolescent Reproductive and Sexual Health services as per guidelines
ME 21.1 The facility provides promotive ARSH services.
ME 21.2 The facility provides preventive ARSH services.
Me 21.3 The facility provides curative ARSH services
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Me 21.4 The facility provides referral services for ARSH.
National Health Programmes

The facility provides National health Programme as per operational/Clinical
Standard E23 Guidelines of the Government.
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 and 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

The facility has infection control programme and procedures in place for prevention, control and
Standard F1
measurement of hospital associated infection
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 and 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
Standard F1 The facility has defined and Implemented procedures for ensuring hand hygiene practices
and antisepsis
ME F2.1 Hand hygiene facilities are provided at point of use
ME F2.2 The facility staff is trained in hand washing and hand rub practices and they adhere to standard hand washing
and hand rub 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
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Standard F4 The facility has standard disinfection and sterilization 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 isolation of infectious patients
ME F5.5 The facility ensures air quality of high risk area
The facility has defined and established procedures for segregation, collection, treatment
Standard E6
and disposal of bio medical and hazardous Waste
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
The facility has established internal and external quality assurance programmes
Standard G3
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
The facility has established, documented implemented and maintained Standard

Standard G4
ME G4.1 Departmental standard operating procedures are available
ME G4.2 Standard Operating Procedures adequately describes process and procedures
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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
The facility has established system of periodic review as internal assessment,

Standard G5
medical and death audit and prescription audit
ME G5.1 The facility conducts periodic internal assessment
ME G5.2 The facility conducts the periodic prescription/ medical/death audits
ME G5.3 The facility ensures non compliances are enumerated and recorded adequately
ME G5.4 Action plan is made on the gaps found in the assessment / audit process
ME G5.5 Corrective and preventive actions are taken to address issues, observed in the assessment and audit

Standard G6
ME G6.1 The facility defines its quality policy
ME G6.2 The facility periodically defines its quality objectives and key departments have their own objectives
ME G6.3 Quality policy and objectives are disseminated and staff is aware of that
ME G6.4 Progress towards quality objectives is monitored periodically
The facility seeks continual improvement by practicing quality tool

Standard G7
and methods
ME G7.1 The facility uses methods for quality improvement in services
ME G7.2 The facility uses tool for quality improvement
Area of Concern - H: Outcomes

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity 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 Benchmarks
ME H2.1 Facility measures efficiency indicators on monthly basis
ME H2.2 Facility ensures compliance of key efficiency indicators with national/state benchmarks
Standard H3 The facility measures Clinical Care and Safety Indicators and tries to reach State/National benchmarks
ME H3.1 Facility measures clinical care and safety indicators on monthly basis
ME H3.2 Facility ensures compliance of key clinical care and safety with national/state benchmarks
Standard H4 The facility measures Service Quality Indicators and endeavors to reach State/National benchmarks
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
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Standard H4 The facility measures service quality indicators and endeavors to reach State/National 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
35
Section
Assessment
Protocols
I. Assessment Methodology
1. General Principles
Assessment of a CHC is undertaken on general principles of an assessment protocol. Adherence to these principles is a prerequisite for
arriving at objective and unbiased conclusion that is useful for the service providers as well for other stake-holders such as District
Health Administration and Health Department. Following are the key principles of an assessment –
1. Integrity – Assessors and persons managing assessment programs should
• Perform their work with honesty, diligence and responsibility
• Demonstrate their competence while performing assessment
• Make assessment in an impartial manner
• Remain fair and unbiased in their findings
• Be sensitive to any influence that may be exerted while carrying out assessment
2. Fair Presentation - Assessment findings should truthfully and accurately represent the assessment activities. Any unresolved
diverging opinion between assessors and assesses should be brought-out. Communication should be truthful, accurate, objective,
timely, clear and complete.
3. Confidentiality- Assessors should ensure that information acquired by them during the assessment kept confidential and should
not be shared with un-authorised personnel. The information must not be used for personal gain.
4. Independence- Assessors should be independent to the activity they are assessing and should be in all cases act in manner that is
free from biases and conflict of interest. For internal assessment, an assessor should not assess his or her own department and
process.
5. Evidence based approach – Conclusion should be based on evidence which is verifiable and reproducible.
2. Planning Assessment Activities
Following assessment activities are undertaken at different level -
1. Internal Assessment – A continuous process of assessment within the facility by internal assessors.
2. External Assessment- Assessment by District Quality Assurance Unit (DQAU) and State Quality Assurance Unit (SQAU)
3. Assessment for Certification – Assessment by the assessors, deputed by the Ministry of Health and Family Welfare or an organisation
on behalf of the MoHFW
Internal Assessment- Internal assessment is a continuous process and forms an integral part of facility based Quality Assurance
Programme. Assessing all departments in a health facility every month may not be feasible. The facility should prepare a quarterly
assessment plan. It needs to be ensured that every department is 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, thereby requiring more attention. For example if Labour room services is much critical
to quality. It could be assessed more frequently.
37
Assessment Protocols
For internal assessment, a nodal person at the PHC may be designated as the coordinator, whose main responsibilities are
given below -
1. Preparing assessment plan and schedule
2. Constitute the assessment team for internal assessment
3. Arrange stationary (forms and formats) for internal assessment
4. Maintenance and safe keeping of assessment records
5. Communicating and coordinating with departments
6. Monitor and 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.
External Assessment –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 assessment also provides
opportunity of building facility level capacity of quality assurance and handholding. It needs to be ensured that all departments and
work processes have been assessed at PHC.
3. Constituting assessment team
Assessment team should be constituted according to the scope of assessment i. e. department to be assessed. Team assessing clinical
department should have at least one person form clinical domain preferably a doctor, assessing patient care department specially
indoor department should also have one nursing staff in team. It would be preferable to have a multidisciplinary team having at least
one doctor and one nurse for external assessment. As DQAU/SQAU may not have their own capacity for arranging all team members
internally, they may nominate a person form other health facility to be a part of the assessment team. However, it needs to be ensured
that person should not assess his/her area of work in internal assessment. Similarity for external assessment none of the team member
should be from same health facility. For external assessment, the team members should have undergone the assessors’ training.
4. 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 should be shared with respective departments.
5. Performing Assessment –
i. Pre assessment preparation – Team leader of the assessment team should ensure that assessment schedule has been communicated
to all concerned staff of the health facility. Stationary for the assessment including Checklists are available in adequate numbers.
Team leader should assign responsibility to different team members according to assessment schedule and competence of
different staff members.
ii. Opening meeting – A short opening meeting with the staff should be conducted for introduction, aims and objective of the
assessment and role clarity.
6. 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. All type conflicts should be avoided. In event of conflict department head or assessment coordinator should
be contacted to mediate and resolve the conflict.
7. Using Checklists for assessment
Checklists are the main tools for the assessment. Assessors should familiarise themselves with the check-lists beforehand. Lay-out of
the check-lists in this manual is given below -
38
a) Title of the checklist denotes the name of department for which checklist is intended.
b) Extreme left column of checklist in blue colour contains the reference number of Standard and Measurable Elements. The
Reference number helps in identification and traceability of a standard.
c) The horizontal bar in grey colour contains the name of the area of concern for which the underlying standards belong.
d) Yellow horizontal bar contains the statement of standard which is being measured. There are total sixty five standards but all
standards may not be applicable to each departments, so only relevant standards are given in yellow bars
e) Second column contains text of the measurable element for the respective standard. Only applicable measurable elements of a
standard are shown in checklist. You may not find all measurable elements under a standard in departmental check-list. They
have been excluded because they are not relevant to that department.
f) The column next to measurable elements on right side has check-points for measuring compliance to respective measurable
element and the standard. Check-point is the basic unit of measurement, against which compliance is checked and the score is
awarded.
g) Next right to Checkpoint a blank column is available where finding of assessment in term of Compliance, Partial Compliance and
Non Compliance should be written.
h) Next right to compliance column is the assessment method column. This denotes the ‘HOW’ to gather the information. Generally,
there are four primary methods for assessment - SI means staff interview, OB means observation RR means record review and PI
Patient Interview.
i) Column next to assessment method contains means of verification. It denotes what to see in a particular Check-point. It may be
list of equipment or procedures to be observed, OR example question may be asked to interviewee or some benchmark, which
could be used for comparison, OR reference to some other guideline OR legal document. It may be left blank as check point may
be self-explanatory.
Assessor should read measurable elements and checkpoints; and try to gather information and evidence to assess the compliance to
the requirement of measurable element and checkpoint. Information can be gathered by four methods
I. Observation –Compliance to many of the measurable elements can be assessed by directly observing the articles, process and
surrounding environment. Few examples are given below -
a) Enumeration of articles like equipment, drugs
b) Displays like signage, work instructions, important information
c) Facilities such as patient amenities, ramps, complaint box, etc.
d) Environment like seepage, overcrowding, temperature control, cleanliness
e) Procedures like measuring BP, counselling, segregation of biomedical waste,
ii. Record Review – As all processes especially clinical procedures cannot be observed. Review of records may generate more objective
evidence and triangulate the finding of the observation. For example on the day of assessment, a drug tray at the labour room
may have adequate quantity of Oxytocin, but review of drug expenditure register would reveal consumption pattern of Oxytocin.
Based on load of deliveries, it can be assessed that the drug was available or not. Examples of record review are given below -
a) Review of clinical records for assessing adequacy of processes like delivery note, anaesthesia note, maintenance of treatment
chart, assessment of patients,etc.,
b) Review of department registers like admission registers, handover registers, expenditure registers, etc.
c) Review of license, formats for legal compliances like Blood Storage Centre, authorisation certificate under the BMW Rules 1998
d) Review of SOPs for adequacy and processes
39
e) Review of monitoring records like temperature monitoring charts, culture surveillance report and calibration records
f) Review of department data and indicators
iii. Staff interview –Interaction with the staff help in assessing the knowledge and skill level, required for performing job functions.
Examples -
a) Competency testing - Asking staff how do they perform certain procedures.
b) Demonstration – Asking staff to demonstrate certain activities like hand washing technique or new born resuscitation.
c) Awareness- Asking staff about awareness off patient right or quality policy of hospital, high alerts drugs.
d) Attitude -about issues about patient 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 user’s perspective. It should include -
a) Feedback on quality of services staff behaviour, food quality, waiting times, etc.
b) Out of pocket expenditure occurred during the treatment
c) Effective of communication like counselling services and self-drug administration
Assessor may use one these method to asses certain measurable element. Suggestive methods are also 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 below -
Flow of gathering information during assessment

is given below -
Read Mesurable element
Read checkpoits against it
Read the Assesment method and

Means of verification
Gather the information

and Evidence
Compare with chceckpint and

means of verification
Arrive on a conslusion
H. Assessment conclusion
After gathering information and evidence for measurable elements, assessors can conclude Compliance, Partial compliance or Non-
compliance for each of the checkpoints. If the information and evidence collected gives an impression of not fully meeting the
requirement, it could be given ‘Partial compliance’, provided some evidences are available. Non-compliance should be given if none or
very few of the requirements are being met.
After arriving at a conclusion, assessor should mark C for Compliance, P for Partial compliance and N for Non-compliance in
Compliance column.
40
II. Scoring System
After assessing all the measurable elements, checkpoints and marking compliance, scores of the department/ facility can be
calculated.
Rules of Scoring
2 marks for each compliance
1 mark for each partial-compliance
0 Marks for every Non-Compliance
All checkpoints have equal weightage to keep scoring simple.

Once scores have been assigned to each checkpoint, department wise scores can be calculated for department and standards by
adding the individual scores for each 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 checkpoints 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 scores and
dash boards.
The assessment scores can be presented in following ways
1. Departmental Score card – Depicting the score card in the individual score .This score card is generated automatically in
the excel tool, provided with this manual.
2. Standard wise score card depicting standard wise score card
3. Aggregate score care
4. Thematic score card like area of concern wise, National Health Program Wise etc.
41
Sample of filled in Departmental Score Card
Sample Scorecard of a Hospital with Departmental Score
Sample Scorecard of Hospital with Area of Concern Score

42
Section
Implementing Quality Assurance

at Facility Level
I. Step by Step Approach for Quality Assurance
Many challenges could be faced in implementation of Quality Assurance Programme. Few such examples are given below -
l Changing Attitude of Staff, Visitors (Patients and attendants) and Community.
l Identifying the ‘Change-agents’ which could act as catalyst in the improvement process.
l Channelizing resources required from higher authorities.
l Mid-term review and mid-course correction.
A suggestive approach and methodology is explained here. Some of the steps are iterative in nature e.g. Assessment and Gap Analysis.
At the same time, following activities could be initiated simultaneously –
l Patient Satisfaction Surveys
l Employee satisfaction surveys,
l Initiating a complaint management system
l Calibration of equipment
e
Step 1 - Sensitisation of Service Providers for Quality
Quality can be achieved through collective efforts only. It is always prudent to make the facility staff aware about what they are
expected to do for the quality assurance. They should be communicated the benefits of improving quality for patients and staff
themselves. A formal half-day workshop can be organized at the facility, where, the facility in charge or representative from District
Quality Assurance Committee (DQAC) should orient the staff about quality assurance programme, quality standards, assessment
process and incentives linked to quality in brief.
All staff members of facility including clinical, nursing, administrative and support staff should be encouraged to attend this meeting.
Participants should be also encouraged to share their perception of quality and how the quality can be improved.
Step 2 - Setting up the Quality Team

Implementation of Quality Assurance Programme requires performing set of defined activities in a planned manner. There are always
advantages in working through team, as mentioned below -
a) Members of team can exchange view and information to bring collective wisdom, group deliberation and judgement
to bear upon subjects of discussion and tasks.
b) The team generate ideas for change and overall quality improvement.
c) A well organized team enables its members to perform at a high level of cooperation and commitment.
Hence for timely and effective implementation of quality assurance, a team should be constituted at facility. This team should have
representation from all cadres of staff. Preferably facility in charge should head the team and there should be at least one member
each from nursing, paramedic, administrative and support staff.
The role and responsibility of each member should be well defined. Main functions of the team are given below -
45
Steps in Implementing Quality Assurance at Facility Level
a) Defining the road-map for Quality assurance for the facility.
b) Defining quality policy and objectives and periodic monitoring on them
c) Dissemination and orientation for Quality Standards and Standard Operating Procedures (SOP) among the facility staff.
d) Assuring that services being provided to defined quality standards and clinical protocols.
e) Performing baseline as well as subsequent periodic quality assessment against defined standards with support from district
quality assurance committee.
f) Measurement, reporting and review of the key performance indicators
g) Providing hands on training and guidance to facility staff for meeting quality standards
h) Facilitating change ideas and focus interventions for Quality Improvement.
Quality team should meet every month on to review the progress on quality assurance against defined road map and action plan.
Minutes of meeting and action points should be recorded.
Step 3 - Baseline Assessment
Before starting the journey of quality assurance, first we should know the start point. Initially assessment of all the departments
using the departmental checklists given in this assessors’ guidebooks should be undertaken. The assessment would also generate
scores, using MS Excel based tool given in accompanying CD with this book. In subsequent periodic assessments, the scores would be
compared with baseline scores to judge the quality improvement.
Step 4 - Action Planning and Prioritising
Based on the finding of baselines assessment, the gaps can be identified and enumerated for each department. These gaps can be
categorized on the basis of severity of gap and level of support required, as given below -
Level of support required Severity ranking

a) Gaps that could be traversed at facility level a) High: gaps affecting patient care directly
b) Gaps requiring support from district authorities. b) Medium: gaps indirectly affecting patient care.
c) Gaps requiring state support. c) Low: Gaps not affecting patient care but quality at PHC.
For all the enumerated gaps, a time bound action-plan should be prepared in consultation with process owners and departmental in
charges. It may be possible that all the gaps could not be traversed in ‘one-go’. Hence prioritisation of gaps is important to best value
of the investment.
Step 5 - Measuring Key Performance Indicators (KPI)
A system of measurement needs to be put in place to measure the different aspects of facility performance and quality of care. A set
of indicators have been defined for each level of facility. These Indicators are categorized into four classes –
a) Productivity
b) Efficiency
c) Clinical Care/Safety and
d) Services quality
While productivity indicators reflect volumes and adequacy of the services provided, efficiency indicators measure utilization of the
services within given resources. It also reflects on the proficiency of service providers.
46
Clinical care indicators directly or directly indicate the quality of a particular clinical process or out come. Service quality indicators are
assigned to perception of users about quality of services, their comfort and satisfaction level. Facility should measure these indicators
on monthly basis and report to DQAC. These indicators should also be utilized by facility for taking evidence based management
decisions.
Step -6 Patient Satisfaction Survey
The first and foremost definition of quality is to meet the user’s expectations. The best way to know the users perception about the
quality of services is to conduct regular periodic patient satisfaction survey at the facility, asking users to rate the services as per
their experience. These surveys should be at least done quarterly. The feedback should be analysed to know the services or attributes
of services with which the users are not satisfied. Results of the feedback can be then discussed in monthly quality team meeting to
decide on actions to be taken for enhancing customers’ satisfaction.
Step 7- Setting Quality Policy and Quality Objectives
Quality Policy needs to be framed by the facility in consultation the staff and other stakeholders like members of Rogi Kalyan Samities
(RKS). Quality policy is a broad statement that describes what and how the facility intends to improve the quality of its services.
Quality policy should always acknowledge user satisfaction as key component of its policy. It should be formulated in local language
and displayed at critical places for better understanding.
An example of Quality Policy
“We shall strive to provide preventive, promotive and primary level of curative healthcare services to the people in the PHC
------ with sustained efforts to ensure that it is equitable, affordable, accountable and responsive to the people needs, within
limitation of its resources.
We ensure to provide referral linkages to patients visiting us.
We are committed to delight the end users of our services by efficient service delivery. “
Quality objective are tangible short terms goals that facility intend to achieve. The objective should be in sync. with the Quality Policy.
These objectives should be SMART. i.e. Specific, Measurable, Attainable, Reviewable, and Time-bound. Quality objectives should be set
for the facility and for each department.
Example of Quality objectives:
Facility Level Increasing patient satisfaction Level by X% in y Months
Increasing facility quality score from X% to Y% in Z months
Department Level Reduction of postpartum infection rates from X% to y% in Z months.
Increase average length of stay from X days to Y days in Z months
Step 8 - Implementation of Standard Operating Procedures
Quality is about doing things right, for first time and every time, thereafter. To archive this objective, all key clinical and support process
should be standardized. Standard Operating Procedures (SOPs) is a tested and tried tool for standardizing the processes in various
setups. Facility should document all its processes those are critical to quality service delivery in with the standard specification and
flow in which these should be delivered. These Standard operating procedures should be complied department wise and distributed to
the respective process owners. Hand-on training on these SOPs should be provided to respective service providers.
47
Step 9 - Periodic Assessments and Improvement
The next step is to check whether processes and services are in accordance to quality standards and SOPs. Therefore, a system of
periodic internal assessment should be implemented at the facilities. Assessment can be carried out using the departmental checklists,
which are given in this book. The frequency of internal assessment can be variable according criticality of departments, but at least all
the departments should be assessed once in a quarter.
For specific clinical process medical, death and prescription audit should be conducted every month.
Findings of these assessment and audits should be complied and discussed during the monthly quality team meeting. The quality
team with support of process owners should do the root cause analysis to identify the action points. On these action points again a
time bound action plan should be prepared. Follow-up on the Action Plan is meticulously done to traverse the gaps and improve the
quality score of your facility. Quality team would be responsible for ensuring corrective and preventive action taken in time.
Step 10 - Certification
Keep on repeating afore-mentioned Steps 1 to 9 would certainly improve the quality score of facility. Once facility is confident
that quality score has been reached a threshold level (70%), it can inform DQAC (District Quality Assurance Committee) for starting
certification process. Members of DQAU (District Quality Assurance Unit) verify the score by undertaking independent verification. If
facility gets the required score, it would be recommended for Assessment to the SQAC (State Quality Assurance Committee).
Then, the State Quality Assurance Unit (SQAU), which is implementation arm of the SQAC, will carry out the Assessment. If facility gets
the required score, a state level certification would be provided to the facility. Simultaneously, actions would be taken for obtaining
the National Certification.
48
Section
Departmental
Checklists
Reference Measurable Element Checkpoint Comp- Assessment Means of

No. liance Method Verification
NATIONAL QUALITY ASSURANCE

STANDARDS FOR CHC
Checklist for Accident and
Emergency
52
Checklist for Accident and Emergency

Area of Concern - A Service Provision
Standard A1 Facility Provides Curative Services
ME A1.1 The facility provides Facility for managing SI/OB Dengue Haemorrhagic
General Medicine services emergency cases in medical fever, Cerebral Malaria,
Poisoning, Snake Bite,
congestive heart failure,
Pneumonia, status
epilepticus, status
Asthamaticous, acute
gastroenteritis and severe
drug reaction
ME A1.2 The facility provides Availability of Emergency SI/OB -Pyocele

General Surgery services management of acute surgical
condition -Renal colic
-Fractures
-RTA
-Lacerated wound
- Foreign body in ear/nose
- Acute abdomen
- Strangulated Hernia
ME A1.3 The facility provides Availability of Emergency SI/OB APH, PPH, Eclampsia ,
Obstetrics and Obstetrics and Gynaecology Obstructed Labour, Septic
Gynaecology Services Procedures Abortion, Emergency
Contraceptives
ME A1.4 The facility provides Availability of emergency SI/OB ARI, Diarrhoeal Diseases,
paediateric services Paediatric procedures Hypothermia, Convulsions/
Seizures
ME A1.8 The facility provides services Availability of Dressing room SI/OB Drainage, dressing,
for OPD procedures facility suturing
Availability of injection room SI/OB Injection room facility

facilities with ARV and Emergency
drugs
ME A1.9 Services are available 24X7 availability of dedicated SI/RR Check for emergency
for the time period as emergency Services register
mandated
ME A1.10 The facility provides Availability of Emergency SI/OB CPR, Mobilization,

Accident and Emergency procedures Intubations, Tracheotomy,
Services Cervical immobilisation
Mechanical Ventilation
53

Standard A3 Facility Provides diagnostic Services
ME A3.1 The facility provides Availability / Linkage to X-ray SI/OB

Radiology Services and USG services
On call Radiology Services are SI/OB Check services are

avaialable 24x7 functional at night
ME A3.2 The facility Provides Availability of point of care SI/OB Hb%, Blood Sugar, RDK,
Laboratory Services diagnostics in emergency 24x7 Urine Protein,
on call facility for conducting

Emergency diagnostic tests 24x7
ME A3.3 The facility provides other Availability of Functional ECG SI/OB

diagnostic services, as Services
mandated
Standard A5 Facility provides support services

ME A5.3 The facility provides Availability of Home Guard/ SI/OB At least one per shift.
security services Security Guard
ME A5.7 The facility has services Availability of Medico-legal SI/OB

of medical record Record service
department
ME A6.1 The facility provides Availability of specific SI/OB Ask for specific local
curatives and preventive procedures for local prevalent health emergencies
services for the health emergencies encountered frequently.
problems and diseases, See if emergency is ready
prevalent locally. for it or not. e.g. cerebral
malaria, RTA
Area of Concern - B Patient Right
Standard B1 Facility provides the information to care seekers, attendants and community about
the available services and their modalities
ME B1.1 The facility has uniform Availability departmental OB Emergency department

and user-friendly signage signage’s board is prominently
system displayed with facility of
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 that are OB

the services and managed at the facility
entitlements available
in its departments
Names of doctor and nursing OB

staff on duty are displayed
and updated
54

List of drugs available are OB
displayed
Important numbers including OB

ambulance, blood bank, police
and referral centres displayed
ME B1.6 Information is available Signage’s and information are OB

in local language and available in local language
easy to understand
ME B1.8 The facility ensures Treatment note/discharge RR/OB

access to clinical records note is given to patient
of patients to entitled
personnel
Standard B2 Services are delivered in a manner that is sensitive to gender, religious, and cultural needs,
and there are no barrier on account of physical economic, cultural or social reasons.
ME B2.1 Services are provided Arrangement for examination OB
in manner that are of rape victims
sensitive to gender
Availability of protocols / OB /RR

guidelines for collection of
forensic evidence in case of
rape victim OB/RR
Counselling services are

available for rape victim and OB/SI
domestic violence
Availability of female staff if a

male doctor examine a female RR/SI
patients
Emergency contraceptive pill

and antibiotics are provided to OB
all rape victims
ME B2.3 Access to facility is Availability of Wheel chair/ OB

provided without any stretcher for emergency
physical barrier and friendly patient
to people with disability.
Availability of ramps with OB No vehicle parked

railing on the way /in front
of emergency entrance.
Ambulance has direct access Access road to
to the receiving/triage area emergency is wide
of the emergency. enough for streamline
moment of emergency
55

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

patients records and record maintained
clinical information is
maintained
MLC case records are kept in a SI/OB

secure place with limited access
to essential persons
ME B3.3 The facility ensures Behaviour of staff is OB/PI

the behaviours of empathetic and courteous
staff is dignified and
respectful, while
delivering the services
ME B3.4 The facility ensures Privacy and confidentiality SI/OB

privacy and of HIV, Rape, suicidal cases,
confidentiality to every domestic violence and
patient, especially of psychotic cases are maintained
those conditions having
social stigma, and
also safeguards
vulnerable groups
Standard B4 The facility has defined and established procedures for informing patients about the medical condition,
and involving them in treatment planning, and facilitates informed decision making
ME B4.1 There is established Consent is taken for invasive SI/RR - Lumbar puncture
procedures for taking emergency procedures - Catheterisation
informed consent before - PR and PV exam
treatment and procedures
ME B4.2 Patient is informed Display charter which OB

about his/her rights and includes patient rights and
responsibilities responsibilities.
ME B4.3 Staff are aware Staff is aware of patient rights SI

of Patients rights and responsibilities
responsibilities
ME B4.4 Information about the Patient/attendent/next of kin PI Ask patients about

treatment is shared with is informed about her clinical what they have been
patients or attendants, condition and treatment been communicated about the
regularly provided treatment plan
ME B4.5 The facility has defined Availability of complaint box OB Check for complaint
and established grievance and display of process for register and follow up its
redressal system in place grievance redresaal and whom closure loop
to contact is displayed
56

Standard B5 The facility ensures that there are no financial barrier to access, and that there is
ME B5.1 The facility provides Emergency services are free for PI/SI
cashless services to all including pregnant woman,
pregnant women, mothers neonate children and BPL
and neonates as per population as per government
prevalent government order / scheme
schemes
ME B5.2. The facility ensures that Check that patient party has PI/SI
drugs prescribed are not spent on purchasing drugs
available at Pharmacy and or consumables from outside.
wards
ME B5.3. It is ensured that facilities Check that patient party has PI/SI
for the prescribed not spent on diagnostics from
investigations are outside.
available at the facility
Area of Concern - C Inputs

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

provide as per patient load arrangement in the waiting area
Availability of Drinking water
Availability of functional toilets OB Dry with regular supply

of water
ME C1.3 Departments have layout Demarcated trolley bay OB

and demarcated areas as
per functions
Demarcated receiving /triage OB

area
Demarcated Nursing station OB
Demarcated duty room for OB

doctor /nurse
Demarcated resuscitation area OB
Demarcated observation area/ OB

beds
Demarcated dressing area /room OB
Demarcated injection room OB
57

Demarcated area for keeping OB
serious patient for intensive
monitoring
Demarcated areas for keeping OB Separate room or linkage

dead bodies. with mortuary/ Post
mortem room
Lay out is flexible OB All the fixture and

furniture are movable to
re-arrange the different
areas in case of mass
casualty
Dedicated Minor OT OB
Shaded porch for ambulance OB
Availability of clean and dirty OB

utility room
ME C1.4 The facility has adequate Corridors at Emergency are OB 2-3 meter
circulation area and open broad enough for easy moment
spaces according to need of stretcher and trolley
and local law
ME C1.5 The facility has Availability of functional OB

infrastructure for telephone and Intercom
intramural and extramural Services
communication
The ambulance(s) has a proper OB

communication system
(at least cell phone)
ME C1.6 Service counters Availability of emergency OB Atleast 4 beds.

are available as per beds as per expected load
patient load
ME C1.7 The facility and Unidirectional flow of OB Receiving/Triage-

departments are planned services. Resucitation-observtion
to ensure structure beds- Procedures area.
follows the function/
processes (Structure
commensurate with the
function of the hospital)
Separate entrance for OB Entrance of Emergency

emergency department should not be shared
with OPD and IPD
Emergency is located near OB

to the entarance of the hospital
58

Standard C2 The facility ensures the physical safety including Fire safety of the infrastructure.
ME C2.1 The facility ensures the Non structural components are OB Check for fixtures and
seismic safety of the properly secured furniture like cupboards,
infrastructure cabinets, and heavy
equipments, hanging
objects are properly
fastened and secured
ME C2.2 The facility ensures Emergency department does OB

safety of electrical not have temporary connections
establishment and loosely hanging wires
ME C2.3 Physical condition of Floors of the Emergency are OB

buildings are safe for non slippery and even
providing patient care
ME C2.4 The facility has plan for Windows have grills and wire OB/SI
prevention of fire meshwork
Emergency has sufficient fire OB

exit to permit safe escape to its
occupant at time of fire
ME C2.5 The facility has adequate Emergency has installed fire OB

fire fighting Equipment Extinguishers of type A B C
Check the expiry date for fire OB/RR

extinguishers are displayed on
each extinguisher as well as due
date for next refilling is clearly
mentioned
ME C2.6 The facility has a system Check for staff competencies SI/RR
of periodic training of for operating fire extinguisher
staff and conducts mock and what to do in case of fire
drills regularly for fire and
other disaster situation
Standard C3 The facility has adequate qualified and trained staff, required for providing the
assured services to the current case load
ME C3.1 The facility has adequate Specialsits are avaiable with in OB/RR
specialsit docotors as per reasonable period
service provision. for emergency cases
ME C3.2 The facility has adequate Availability of atleast OB/RR

general duty doctors as one Doctor 24x7
per service provision and
work load
ME C3.3 The facility has adequate Availability of trained Nursing OB/RR/SI At least 2 in day
nursing staff as per staff and 1 in night
service provision and
work load
59

ME C3.4 The facility has adequate Availability of dresser / OB/SI
technicians/paramedics as paramedic
per requirement
ME C3.5 The facility has adequate Availability of Drivers for SI/RR Driver may be on call
support / general staff Ambulance 24X7 for emergency.
ME C3.6 The staff has been provided Triage and Mass Casualty SI/RR
required training / skill sets Management
Basic life support (BLS)/ SI/RR

Advance life support (ALS)
Bio Medical waste Management SI/RR
Care of uncounscious patient SI/RR
Infection control and hand SI/RR

hygiene
Patient Safety SI/RR
ME C3.7 The Staff is skilled as per The staff is skilled for SI/RR
job description emergency procedures
The staff is skilled for SI/RR

resuscitation and use
defibrillator

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

Antibiotics
Availability of Infusion Fluids OB/RR Tracers as per State EDL
Availability of Drugs acting on OB/RR Tracers as per State EDL

CVS
Availability of drugs action OB/RR Tracers as per State EDL

on CNS/PNS
Availability of dressing material OB/RR Tracers as per State EDL

and antiseptic lotion
Drugs for Respiratory System OB/RR Tracers as per State EDL
Availability of drugs for OB/RR Tracers as per State EDL

obstetric emergencies
60

Availability of emergency OB/RR Megsulf, Oxytocin, Plasma
drugs in ambulance Expanders
Availability of Medical gases OB/RR Availability of Oxygen

Cylinders
Availability of Immunological OB/RR Polyvalent Anti snake

drugs Venom, Anti tetanus
Human Immunoglobin
Antidotes and Other Substances OB/RR Inj. Atropine Sulphate

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

dressing room
Availability of consumables in OB/RR Dressing material / Suture

ambulance material
ME C4.3 Emergency drug trays Emergency Drug Tray/ Crash OB/RR

are maintained at every Cart is maintained at
point of care, where ever emergency
it may be needed
ME C5.1 Availability of equipment Availability of functional OB BP apparatus,

and instruments for Equipment and Instruments for Multiparameter, Torch,
examination and examination and Monitoring hammer, Spot Light,
monitoring of patients. Stethoscope, thermometer
Availability of Monitoring OB -Artery forcep

equipments in ambulance - Vene Section Kit
ME C5.2 Availability of equipment and Availability of dressing tray for OB

instruments for treatment Emergency procedures
procedures, being undertaken
in the facility
Availability of instruments for OB - Speculum

emergency obstetrics procedure - D and E Set
Availability of equipment Availability of Point of care OB Glucometer, ECG and HIV

ME C5.3 and instruments for diagnostic devices rapid diagnostic kit
diagnostic procedures being
undertaken in the facility
ME C5.4 Availability of equipment Availability of functional OB Ambu bag, defibrillator,

and instruments for Instruments for Resuscitation. layrngo scope with spare
resuscitation of patients batteries, nebulizer,
and for providing intensive suction apparatus, LMA
and critical care to patients
61

ME C5.5 Availability of Equipment Availability of equipment for OB Refrigerator, Crash cart/
for Storage storage for drugs Drug trolley, instrument
trolley, dressing trolley
ME C5.6 Availability of functional Availability of equipment for Steam Steriliser /

equipment and sterilization and disinfection OB Autoclave
instruments for support
services
ME C5.7 Departments have patient Availability of patient beds with

furniture and fixtures prop up facility and wheels OB
as per load and service
provision
Availability of attachment/ OB Hospital graded Mattress,

accessories with patient bed IV stand, bed rails, Bed pan
for male and female
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 equipment are covered No unservicable

established system for under AMC including preventive SI/RR equipment/instrument in
maintenance of critical maintenance emergency room
Equipment
There is system of timely SI/RR

corrective break down
maintenance of the equipments
The staff is skilled for trouble SI/RR

shooting in case equipment
malfunction
ME D1.2 The facility has established All the measuring equipments/ OB/ RR
procedure for internal instrument are calibrated
and external calibration of
measuring Equipment
ME D1.3 Operating and Operating instructions OB/SI Suction machine,

maintenance instructions for critical equipments are Multipara monitor,
are available with the available defebrillator.
users of equipment
62

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

labelled
ME D2.4 The facility ensures Expiry dates’ are maintained at OB/RR

management of expiry emergency drug tray
and near expiry drugs
No expiry drug is found OB/RR
ME D2.5 The facility has established The Department maintained RR/SI

procedure for inventory stock and expenditure register
management techniques of drugs and consumables in
Emergency
ME D2.6 There is a procedure for There is procedure for SI/RR

periodically replenishing replenishing drug tray
the drugs in patient emergency crash cart
care areas
There is procedure for eplenishing OB/SI

drug tray emergency crash cart in
ambulance
There is no stock out of drugs SI/RR
ME D2.7 There is process for Temperature of refrigerators OB/RR Check for temperature
storage of vaccines and are kept as per storage charts are maintained
other drugs, requiring requirement and records are and updated periodically
controlled temperature maintained
ME D2.8 There is a procedure for Narcotics and psychotropic OB/SI

secure storage of narcotic drugs are kept in lock and key
and psychotropic drugs
Standard D3 The facility has established Program for mainntenance and upkeep of the faciity to provide
safe, secure and comfortable environment to staff, patients and visitors.
ME D3.2 Hospital infrastructure is Floors, walls, roof, roof topes, sinks OB All area are clean with no
adequately maintained patient care and circulation dirt,grease,littering and
areas are Clean cobwebs
Surface of furniture and fixtures OB

are clean
ME D3.3 Patient care areas are Check for there is no seepage , OB

clean and hygienic Cracks, chipping of plaster
Window panes , doors and other OB

fixtures are intact
Patients beds are intact and painted OB
63

Mattresses are intact and clean OB
ME D3.4 The facility has policy of No condemned/Junk material in OB

removal of condemned the Emergency
junk material
ME D3.5 The facility has established No stray animal/rodent/birds/ OB

procedures for pest, rodent termites
and animal control
ME D3.6 The facility provides Adequate illumination at OB 200 Lux (Minimum)

adequate illumination procedure area.
level at patient care areas
ME D3.7 The facility has provision Visitors are restricted at OB/SI Resuscitation area,
of restriction of visitors in resuscitation and procedure dressing room and
patient areas area examination area
ME D3.8 The facility ensures Temperature control and PI/OB Fans/ Air conditioning/
safe and comfortable ventilation in the emergency. Heating/Exhaust/
environment for patients Ventilators as per
and service providers environment condition
and requirement
ME D3.9 The facility has security There are set procedures for SI/OB See for linkage to police,
system in place at patient handling mass situation and procedure for protection
care areas violence in emergency of staff
Hospital has sound security OB/SI

system to manage overcrowding
in emergency
ME 3.10 The facility has established Ask female staff whether they SI
measure for safety and feel secure at work place
security of female staff
The facility ensures 24X7 water and power backup as per requirement of service
Standard D4
ME D4.1 The facility has adequate Availability of 24x7 running and OB/SI
arrangement storage and potable water
supply for potable water
in all functional areas
ME D4.2 The facility ensures Availability of power back in OB/SI

adequate power backup Emergency, which can take load
in all patient care areas as of equipment running
per load
Availability of UPS OB/SI
Availability of Emergency light OB/SI
ME D4.3 Critical areas of the facility Availability of Oxygen cylinders OB

ensures availability of and vacuum suction
oxygen, medical gases and
vacuum supply
64

The facility ensures avaialblity of Diet as per nutritional requirement of the patients and
Standard D5
clean Linen to all admitted patients.
ME D5.4 The facility has adequate Clean Linen is provided on OB/RR
sets of linen observation beds
ME D5.5 The facility has established Linen is changed every day or OB/RR
procedures for changing whenever it get soiled
of linen in patient care
areas
Facility is compliant with all statutory and regulatory requirement imposed
Standard D8
ME D8.1. The facility has requisite Valid licences for ambulances RR/SI
licences and certificates and PUC are available
for operation of hospital
and different activities
ME D8.3. The facility ensure Staff is aware of procedure and SI

relevant processes are in protocal of management of
compliance with statutory of medico legal cases
requirement
Roles and Responsibilities of administrative and clinical staff are determined as per govt.
Standard D9
regulations and standards operating procedures.
ME D9.1. The facility has established “Staff is aware of their roles SI
job description as per and responsibilities
govt guidelines
ME D9.2. The facility has a There is procedure to ensure RR/SI Check for system of
established procedure that staff is available on duty as recording time of
for duty roster and per duty roster reporting and relieving
deputation to different (Attendance register/
departments Biometrics etc)
ME D9.3. The facility ensures Doctor, nursing staff and OB

the adherence to dress support staff adhere to their
code as mandated by its respective dress code
administration / the health
department
Area of Concern - E Clinical Services

ME E1.1. The facility has established Unique identification number RR
procedure for registration is given to each patient during
of patients registration
Patient demographic details RR Check for that patient

are recorded in admission demographics like Name,
records age, Sex, Address, Chief
complaint, etc.
ME E1.3. There is established There is established criteria for SI/RR

procedure for admission admission through emergency
of patients department
65

There is established procedure SI/RR
for admission of MLC cases as
per prevalent laws

for prisoners as per prevalent
local laws
Admission is done by written SI/RR

order of a qualified doctor
There is no delay in treatment RR

because of admission process
Time of admission is recorded in RR

patient record
There is no delay in transfer of SI/RR

patient to respective department
once admission is confirmed and
clinically patient is stable to be
transfered
The staff is aware of procedures, SI

if patients cannot be admitted at
the facility due to constraint in
scope of services
ME E1.4 There is established The is provision of extra beds, OB/SI

procedure for managing trolley beds in case of high
patients, in case beds occupancy or mass casualty
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 Assessment criteria of different SI/RR Use of standard criteria
procedure for initial kind of medical emergencies is of assessment like
assessment of patients defined and practiced Glasgow coma scale, Poly
trauma, MI, burn patient,
paediatric patient, pain
assessment criteria etc.
Initial assessment and treatment OB/RR

is provided immediately
Initial assessment is RR
documented preferably within
two hours
ME E2.2 There is established There is fixed schedule for RR/SI

procedure for follow-up/ reassessment of patient under
reassessment of Patients observation
66

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

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

with higher centres. referred if services are
not available
Advance communication is SI/RR

done with higher centre
Referral vehicle is being SI/RR

arranged
Referral in or referral out RR

register is maintained
Facility has functional referral SI/RR

linkages to lower facilities
Check for if there is any system RR Check for referral cards

of follow up filled from lower facilities
ME E4.1 Procedure for identification There is a process for ensuring OB/SI Patient id band/ verbal
of patients is established the identification before any confirmation/Bed no. etc.
at the facility clinical procedure
ME E4.2 Procedure for ensuring Treatment charts are maintained RR Check for treatment chart
timely and accurate are updated and drugs
nursing care as per given are marked. Co
treatment plan is relate it with drugs and
established at the facility doses prescribed.
There is a process to ensure the SI/RR Verbal orders are

accuracy of verbal/telephonic rechecked before
orders administration
ME E4.3 There is established Patient hand over is given SI/RR

procedure of patient hand during the change in the shift
over, whenever staff duty
change happens
67

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

continously 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 identified OB/SI Unstable, irritable,
vulnerable patients and and measures are taken to protect unconscious. Psychotic
ensure their safe care them from any harm and serious patients are
identified
ME E5.2 The facility identifies high High risk medical emergencies OB/SI MI,Head injury, Spinal
risk patients and ensure are identified and treatment injury, Abdominal injuries,
their care, as per given on priority fractures.
their need
Facility follows standard treatment guidelines defined by state/Central government

Standard E6
ME E6.1 Facility ensured that drugs Check for BHT/Case sheet/Case RR

are prescribed in generic paper if drugs are prescribed
name only under generic name only
ME E6.2 There is procedure of Check for that relevant Standard RR

rational use of drugs Treatment Guideline (STG) are
available at point of use
Check staff is aware of the drug SI/RR

regime and doses as per STG
Check BHT/Case sheet/Case RR

paper that drugs are prescribed
as per STG
Standard E7 Facility has defined procedures for safe drug administration

ME E7.1 There is process for High alert drugs available in SI/OB Electrolytes like Potassium
identifying and cautious department are identified chloride,opiods, Neuro
administration of high muscular blocking agent,
alert drugs Anti thrombolytic agent,
Insulin, Warfarin, Heparin,
Adrenergic agonist etc.
Maximum dose of high SI/RR Value for maximum doses

alert drugs are defined and as per age, weight and
communicated diagnosis are available
with nursing station
and doctor
68

There is process to ensure that SI/RR A system of independent
right doses of high alert drugs double check before
are only given administration,
Error prone medical
abbreviations are avoided
ME E7.2 Medication orders are Every Medical advice and RR

written legibly and procedure is accompanied with
adequately 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 for expiry OB/SI Turbidity, Leakage, Colour
to check drug before and other inconsistency before change, fungus.
administration/ dispensing administration
Check single dose vial are not OB Check for any open single
used for more than one dose dose vial with left over
content indented to be
used later on
Check for separate sterile needle OB In multi dose vial needle

is used every time for multiple is not left in the septum”
dose vial
Any adverse drug reaction is RR/SI

recorded and reported
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 Patient is advice by doctor/ SI/PI

self drug administration Pharmacist /nurse about the
dosages and timings
Facility has defined and established procedures for maintaining, updating of patients’
Standard E8 clinical records and their storage
ME E8.1 All the assessments, Assessment findings are written RR Day to day progress of
re-assessment and on BHT/Case sheet/Case paper patient is recorded in BHT/
investigations are Case sheet/Case paper
recorded and updated
ME E8.2 All treatment plan Treatment plan, first orders are RR Treatment prescribed in
prescription/orders are written on BHT/Case sheet/Case nursing records
recorded in the patient paper
records.
ME E8.3 Care provided to each Maintenance of treatment RR Treatment given is

patient is recorded in the chart/treatment registers recorded in treatment
patient records chat
69

ME E8.4 Procedures performed are Any procedure performed is written RR CPR, Dressing,
written on patients records on BHT/Case sheet/Case paper mobilization etc
ME E8.5 Adequate form and Availability of form formats for OB/SI MLC, Lab /X-ray requisition,
formats are available at emergency death certificate, Initial
point of use 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 identified OB/RR

and numbered
ME E8.7 The facility ensures safe Safe keeping of MLC records OB/SI
and adequate 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 before SI/RR “See if there is any
after assessing patient discharging patient from procedure/protocol for
readiness 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 are PI

consulted before discharge
ME E9.2 Case summary and Discharge summary is provided RR/PI See for discharge
follow-up instructions are summary, referral slip
provided at the discharge provided.
Discharge summary adequately RR

mentions patients clinical
condition, treatment given and
follow up
Discharge summary is give to SI/RR

patients going in LAMA/Referral
ME E9.3 Counselling services are Counselling services are SI/PI

provided as during discharges provided wherever it is required
wherever required
ME E9.4 The facility has established Declaration is taken from the RR/SI
procedure for patients LAMA patient
leaving the facility
against medical advice,
absconding, etc
70

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

shifting the patient from vehicle
is defined
ME E10.2 Emergency protocols are Emergency protocols are OB See for protocols of
defined and implemented available at point of use head injury, snake bite,
poisoning, drawing etc.
Staff is aware of Clinical SI/RR

protocols
There is procedure for CPR SI/RR
ME E10.3 The facility has disaster Line of authority is defined SI/RR

management plan in place
Procedure for internal SI/RR

communication defined
There is procedure for setting up SI/RR

control room
Disaster buffer stock of medicines SI/RR

and other supplies maintained
Role and responsibilities of staff SI/RR

in disaster is defined
Staff is aware of disaster plan SI/RR
ME E10.4 The facility ensures Check for how ambulances are OB

adequate and timely called and patients are shifted
availability of ambulances
services and mobilisation
of resources, as per
requirement
Ambulances are equipped SI/RR
Stable patients are transferred in

ambulance with staff
All serious patients are SI/RR

transferred in ambulance with
trained staff
71

Ambulance is appropriately OB/RR
equipped for BLS with trained
personnel
There is a daily checklist of all RR

equipment and emergency
medications
Ambulance has a log book for RR/SI

the maintenance of vehicle and
daily vehicle checklist
Transfer register is maintained to RR

record the detail of the referred
patient
ME E10.5 There is procedure for Medico legal cases are identified SI/OB/RR
handling medico legal by patient records
cases
Treatment of MLC cases are SI/RR

not delayed because of police
proceedings
There is a established procedure SI/RR Discharge is not done

for informing police, as per before police consent
government guidelines
Emergency has criteria for Criteria is defined based on

defining medico legal cases cases and when to do MLC
Standard E11 The facility has defined and established procedures of diagnostic services
ME E11.1 There are established Container is labelled properly OB
procedures for Pre-testing after the sample collection
Activities
ME E11.3 There are established Nursing station is provided with SI/RR

procedures for Post- the critical value of different
testing Activities tests
Standard E14 The facility has defined and established procedures of operation theatre and surgical services
Facility has established
ME E14.1 There is procedure for SI/RR See surgeon is available
procedures OT Scheduling emergency surgeries on call/on duty

Procedure for arranging SI Responsibilities are
logistics defined and patient is
shifted promptly
ME E15.1 Death of admitted patient Facility has a standard SI
is adequately recorded procedure of communicating
and communicated death to relatives decently.
Death note is written on patient RR

record
72

ME E15.2 The facility has standard Past history and sign of any RR Check what is policy for
procedures for handling medico legal cause is looked for registering brought in
the death in the hospital dead, death cases as MLC
There is criteria for declaring SI/RR ask form how death

death is declared - Physical
examination or ECG is
done
Procedure for handing over the SI

dead body
Death certificate is issued SI/RR

.
ME E15.3 The facility has standard Patients Relatives are informed PI/SI
operating procedure for clearly about the deterioration
end of life support in health condition of Patients
There is a standard procedure of SI/RR Check about the policy

removal of life support as per and practice for removing
law life support
There is a procedure to allow SI/OB

patient relative/Next of Kin to
observe patient in last hours
Area of Concern - F Infection Control

Facility has infection control program and procedures in place for prevention and
Standard F1
ME F1.4 There is Provision of There is procedure for SI/RR Hepatitis B, Tetanus Toxic
Periodic Medical Checkups immunization of the staff etc
and immunization of staff
Periodic medical checkups of

the staff SI/RR
ME F1.5 Facility has established Regular monitoring of infection SI/RR Hand washing and
procedures for regular control practices infection control audits
monitoring of infection done at periodic intervals
control practices
ME F1.6 Facility has defined and Check for Doctors are aware of SI/RR
established antibiotic Hospital Antibiotic Policy
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 washing OB Check for availability of
are provided at point of Facility at Point of Use wash basin near the point
use of use
Availability of running Water OB/SI Ask to Open the tap. Ask

Staff water supply is
regular
73

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

rub staff for regular supply.
Display of Hand washing OB Prominently displayed

Instruction at Point of Use above the hand washing
facility , preferably in
Local language
ME F2.2 Staff is trained and adhere Adherence to 6 steps of Hand SI/OB Ask of demonstration
to standard hand washing washing
practices
Staff aware of when to hand SI

wash
ME F2.3 Facility ensures standard Availability of Antiseptic OB

practices and materials for Solutions
antisepsis
Proper cleaning of procedure OB/SI like before giving IM/IV

site with antisepesis injection, drawing blood,
putting Interavenous and
urinary catheter
Standard F3 Facility ensures standard practices and materials for Personal protection
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
Personal protective kit for OB/SI

infectious patients
ME F3.2 Staff is adhere to standard No reuse of disposable gloves, OB/SI

personal protection Masks, caps and aprons.
practices
Compliance to correct method SI

of wearing and removing the
gloves
74

Standard F4 Facility has standard Procedures for processing of equipments and instruments
ME F4.1 Facility ensures standard Decontamination of operating SI/OB “Ask stff about how
practices and materials and Procedure surfaces they decontaminate
for decontamination and the procedure surface
clean ing of instruments like Examination table ,
and procedures areas dressing table, Stretcher/
Trolleys etc. (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 after SI/OB Cleaning is done

decontamination with detergent and
running water after
decontamination
Proper handling of Soiled and SI/OB No sorting ,Rinsing or

infected linen sluicing at Point of use/
Patient care area
Staff know how to make SI/OB

chlorine solution
ME F4.2 Facility ensures standard Equipment and instruments are OB/SI Autoclaving/HLD/Chemical
practices and materials sterlized after each use as per Sterlization
for disinfection requirement
and sterilization of
instruments and
equipments
High level Disinfection of OB/SI Ask staff about method

instruments/equipments is and time required for
done as per protocol boiling
Chemical sterilization of OB/SI Ask staff about method,

instruments/equipments is done concentration and contact
as per protocols time requied for chemical
sterilization
Autoclaved dressing material OB/SI

is used
75

ME F5.1 Layout of the department Facility layout ensures separation OB
is conducive for the of general traffic
infection control practices from patient traffic
ME F5.2 Facility ensures availability Availability of disinfectant as per OB/SI Chlorine solution,
of standard materials for requirement Gluteraldehye, carbolic
cleaning and disinfection acid
of patient care areas
Availability of cleaning agent as OB/SI Hospital grade phenyle,

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

with disinfectant detergent
solution
The staff is trained for preparing SI/RR

cleaning solution as per standard
procedure
Standard practice of mopping OB/SI Unidirectional mopping

and scrubbing are followed from inside out
Cleaning equipments like broom OB/SI Any cleaning equipment

are not used in patient care leading to dispersion of
areas dust particles in air should
be avoided
ME F5.4 Facility ensures Emergency department define OB/SI

segregation infectious list of infectious diseases require
patients special precaution and barrier
nursing
The staff is trained for barrier

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

plastic bags OB
Segregation of different OB/SI

category of waste as per
guidelines
76

Display of work instructions for OB
segregation and handling of
Biomedical waste
There is no mixing of infectious OB

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

box the point of generation
like nursing station and
injection room
Disinfection of sharp before OB/SI Disinfection of syringes is

disposal 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. Where it

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 injury in case of shape 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
of waste as per guidelines
Disinfection of liquid waste SI/OB

before disposal
Transportation of bio medical SI/OB

waste is done in close container/
trolley
Staff aware of mercury spill SI/RR

management
Area of Concern - G Quality Management

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 superitendant/ Hospital
departments Manager/ Matron in charge for
monitoring of services
There is system for periodic SI/RR

check up of Ambulances by
designated hospital staff
77

ME G3.2 Facility has established There is periodic assessment SI/RR
external assurance of preparedness for disaster by
programs at relevant competent authority
departments
ME G3.3 Facility has established Departmental checklist are SI/RR

system for use of used for monitoring and quality
check lists in different 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
Procedures for all key processes.
ME G4.1 Departmental standard Standard operating procedure RR

operating procedures are for department has been
available prepared and approved
Current version of SOP are OB

available with process owner
ME G4.2 Standard Operating Emergency has documented RR

Procedures adequately procedure for receiving the
describes process and patient in emergency
procedures Department has documented
procedure for triage
The department has documented RR

procedure for taking consent
The department has RR

documented procedure for
initial screening of patient

procedure for nursing care

procedure for admission and transfer
of the patient to ward

procedure for maintaining records
in Emergency

documented procedure to
handle brought in dead patient

procedure for storage, handling
and release of dead body
78

procedure for storage and
replenishing the medicine in
emergency

procedure for equipment
preventive and break down
maintenance

procedure 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 use protocols are displayed clinical protocols like
snake bite and poisioning
Standard G6 The facility has defined and established Quality Policy and Quality Objectives
ME G6.2 The facility periodically Quality objective for emergency RR/SI
defines its quality defined
objectives and key
departments have their
own objectives
ME G6.3 Quality policy and objectives Check of staff is aware of SI

are disseminated and staff is quality policy and objectives
aware of that
Progress towards quality Quality objectives are monitored SI/RR

ME G6.4 objectives is monitored and reviewed periodically
periodically
Area of Concern - H Outcomes

Standard G3 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures No of Emergency cases per RR
productivity Indicators on thousand population
monthly basis
No of trips per ambulance RR
No. of trauma cases treated per RR

1000 emergency cases
No. of poisoning cases treated RR

per 1000 emergency cases
No. of cardiac cases treated per RR

1000 emergency cases
79

ME H1.2 No. of obstetric cases treated RR
per 1000 emergency cases
No of resuscitation done per RR Resuscitation should

thousand population include: Chest
Compression, Airway and
Breathing
The Facility measures Proportion of Patients attended RR

equity indicators in Night
periodically
Proportion of BPL Patients RR
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H3.1 Facility measures Clinical Response time for ambulance RR
Care and Safety Indicators (Between receipt of call and
on monthly basis dispatch of ambulance)
Proportion of cases referred RR
Response time at emergency for RR

initial assessment
Average Turn Around Time of RR Average time a patient

patient stays at emergency
observation bed
Proportion of patient referred RR

by state owned /108 ambulance
per 1000 referral cases
Standard H3 The facility measures Clinical Care and Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical No of adverse events per RR
Care and Safety Indicators thousand patients
on monthly basis
Death Rate RR No of Deaths in

Emergency/ Total no of
emergency attended
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark
ME H4.1 Facility measures 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
80


STANDARDS FOR CHC
Checklist for Outdoor
Department
82
Checklist for Outdoor Department

Area of Concern - A Service Provider
ME A1.1 The facility provides Availability of functional SI/OB Dedicated General
General Medicine services General Medicine Clinic Medicine 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 and Obstetrics and Gynaecology Obstetrics and Gynaecology
Gynaecology Services Clinic Clinic. High risk pregnancy
cases are referred from PHC
and SC
Availablity of IUD insertion room SI/OB
ME A1.4 The facility provides Availability of Paediatric Clinic SI/OB Dedicated Paediatric
Paediatric Services speciality Clinic
ME A1.5 The facility provides Availability of functional SI/OB Dedicated ophthalmology

Ophthalmology Services Ophthalmology Clinic clinic providing
consultation services
Availability of OPD eye care SI/OB vision testing, early

services detection of visual
impairment
Intraocular pressure
measurement.
ME A1.6 The facility provides Availability of functional SI/OB Dedicated Clinic providing
Dental Treatment Services Dental Clinic consultation services
Availability of OPD Dental SI/OB Extraction, scaling, tooth

procedure extraction, denture and
Restoration.
ME A1.7 The facility provides Availability of Functional Ayush SI/OB AYUSH clinic accompanied
AYUSH Services clinic by dispensary
ME A1.8 The facility provides Availability of Dressing SI/OB Dressing, Suturing and
services for OPD facilities at OPD drainage
procedures
Availability of Injection room
facilities at OPD SI/OB
83

Services are available At least 6 Hours of OPD
ME A1.9 for the time period as Services are available SI/RR
mandated
Standard A2 Facility provides RMNCHA Services

ME A2.1 The facility provides Availability of Spacing methods SI/OB IUCD, OCP, ECP and
Reproductive health of family planning Condoms, Progestrone
Services only Pill (POP)
Availability of Female Limiting SI/OB Tubectomy (Minilap and

Methods of family Planning Laparoscopic)
Availability of Male Limiting SI/OB NSV/Conventional

Method for Family Planning
Availability of Post partum SI/OB Tubal Ligation and PPIUD

sterilization services
Availability of dedicated Family SI/OB Should provide

Planning clinic. Counselling and
Promotive services
Abortion and Contraception SI/OB

services for Ist and 2nd trimester
ME A2.2 The facility provides Availability of functional ANC SI/OB

Maternal health Services clinic
Availability of post natal SI/OB

counselling and follow up
services
Provision of TT and IFA SI/OB
Nutrition and health counselling. SI/OB
Identification and management SI/OB PIH, Pre-eclampsia, Bad

of danger signs during obstetric history, severe
pregnancy anaemia, IUGR, multiple
pregnancy.
ME A2.3 The facility provides Availability of Functional SI/OB

Newborn health Services immunization clinic
ME A2.4 The facility provides Child Routine and emergency care of SI/OB
health Services sick children.
Services under RBSK SI/OB
ME A2.5 The facility provides Availability of Functional ARSH

Adolescent health Services clinic
84

ME A3.3 The facility provides other Functional ECG Services are SI/OB
diagnostic services, as available
mandated
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 of
services under National Under NVBDCP Malaeria, Kala Azar,
Vector Borne Disease Dengue
Control Programme as per
guidelines
ME A4.2 The facility provides Availability of Functional DOTS SI/OB

services under Revised 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
Programme as per
guidelines
Assessment of Disability Status SI/RR
ME A4.4 The facility provides Availability or linkage to a SI/OB

services under National Functional ICTC
AIDS Control Programme
as per guidelines
Availability of HIV Testing and SI/RR

Counselling
PPTCT Services for HIV positive SI/OB

Pregnant Women
Availability of linkage with ART SI/OB

Centre
Availability of CD4 testing facility SI/OB
ME A4.5 The facility provides Screening and early detection SI/RR Refraction, field of vision
services under National of visual impairment and and and retinoscopy
Programme for prevention refraction
and control of Blindness
as per guidelines
Availability of OPD procedures SI/OB Syringing and probing,

foreign body removal ,
Tonometry.
ME A4.6 The facility provides Availability of counselling SI/OB

services under Mental facility for Suicide prevention
Health Programme as per
guidelines
85

ME A4.7 The facility provides Geriatric Clinic,twice a week. SI/OB
services under National
Programme for the health
care of the elderly as per
guidelines
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 and Stroke
(NPCDCS) as per
guidelines
ME A4.10 The facility provide services Management of case referred SI/RR

under National health from PHC/SC directly reported
Programme for deafness to Hospital
ME A4.15 The facility provides Availability of OPD services as SI/RR

services as per State per State Health Programs /
specific health Scheme
programmes
ME A6.1 The facility provides Special Clinics are available for SI/OB Ask for the specific
curatives and preventive local prevalent diseases local health problems/
services for the health diseases .i.e.. Kala azar,
problems and diseases, arsenic poisoning etc.
prevalent locally.
Area of Concern - B Patient Rights
ME B1.1 The facility has uniform Availability departmental OB (Numbering rooms, main
and user-friendly signage signage’s department and inter
system sectional signage
Display of layout/floor directory OB
ME B1.2 The facility displays the List of OPD Clinics are available OB
services and entitlements
available in its
departments
Names of doctor on duty is OB

displayed and updated
Timing for OPD are displayed OB
Entitlements under JSY , JSSK OB

and other schemes
Important numbers like OB

ambulance are displayed
86

ME B1.3 The facility has established Display of citizen charter OB
citizen charter, which is
followed at all levels
ME B1.4 User charges are displayed User charges for services are OB
and communicated to displayed
patients effectively
ME B1.5 Patients and visitors are IEC Material is displayed OB

sensitised and educated
through appropriate IEC /
BCC approaches
ME B1.6 Information is available in Signage’s and information are OB

local language and easy available in local language
to understand
ME B1.7 The facility provides Availability of Enquiry Desk with OB

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

female
Availability of female staff if a OB

male doctor examines 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 the
physical barrier and and OPD
friendly to people with
disabilities
Availability of ramps with railing OB
There is no over crowding OB

during OPD hours
Availability of disable friendly OB

toilets
87

The facility maintains privacy, confidentiality and dignity of patient, and has a system
Standard B3
ME B3.1 Adequate visual privacy Availability of screen in OB
is provided at every point Examination Area
of care
One Patient is seen at a time in OB

clinics
Privacy at the counselling room OB

is maintained
ME B3.2 Confidentiality of patients Confidentiality of HIV reports. SI/OB

records and clinical
information is maintained
ME B3.3 The facility ensures that Behaviour of staff is empathetic PI/OB

behaviours of staff is and courteous
dignified and respectful,
while delivering the
services
ME B3.4 The facility ensures privacy Privacy and confidentiality of TB, SI/OB Check in RTI/STI clinic
and confidentiality to every Leprosy Patients
patient, especially of those
conditions having social
stigma, and also safeguards
vulnerable groups
Facility has defined and established procedures for informing and involving patient and their families
Standard B4
about treatment and obtaining informed consent wherever it is required.
ME B4.1 There is established Informed consent prior to ER SI/RR check for filled consent
procedures for taking procedure is taken, forms of minor
informed consent before
Informed consent for IUD SI/RR

insertion
Informed consent on prescribed SI/RR

form C for abortion
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 her PI Ask patients about
treatment is shared with clinical condition and treatment what they have been
patients or attendants, being provided, possible communicated about the
regularly outcomes, and risks involved. treatment plan
Pre and Post test counselling is SI/PI/RR

given at ICTC
88

ME B4.5 The facility has defined Availability of complaint box, OB
and established grievance display of grievance redressal
redressal system in place process, and details of person to
contact is displayed
Facility ensures that there are no financial barrier to access and that there is financial
Standard B5
protection given from cost of hospital services.
ME B5.1 The facility provides Free OPD Consultation / ANC PI/SI For JSSK entitlement
cashless services to Checkups/Investigations.
pregnant women, mothers
and neonates as per
prevalent government
schemes
ME B5.2 The facility ensures that Check that patient/attendants PI/SI

drugs prescribed are have not spent money
available at Pharmacy on purchasing drugs and
consumables from outside.
ME B5.3 It is ensured that facilities Check that patient/attendants PI/SI

for the prescribed party have not spent money on
investigations are diagnostics from outside.
ME B5.4 The facility provide free of Free OPD Consultation for BPL PI/SI/RR
cost treatment to Below patients
poverty line patients
without administrative
hassles
ME B5.5 The facility ensures If any other expenditure PI/RR

timely reimbursement has been incurred, then it is
of financial entitlements reimbursed from hospital
and reimbursement to the
patients

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

area 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 at

provide as per patient load arrangement in waiting area peak time
Availability of sub waiting areas OB For clinics having high

at separate clinics patient load
89

Availability of Drinking water OB See if its is easily
accessible to the visitors
Availability of functional toilets OB Urinals 1 per 50 person

water closet and wash
basins 1 per 100 person.
Dry Tiolet with running
water
Availability of patient calling OB

system
Availability of public telephone OB

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
Demarcated dressing area /room OB
Demarcated injection room OB
Demarcated immunization OB
room for pregnant women and
children
availability of clean and dirty OB

utility room
Demarcated trolley/wheelchair OB
bay
ME C1.4 The facility has adequate Corridors at OPD are broad OB

circulation area and open enough foe moment of
spaces according to need stretcher, trolleys, patients and
and local law visitors
ME C1.5 The facility has OB

infrastructure for Availability of functional
intramural and extramural telephone and Intercom
communication Services
ME C1.6 Service counters are OB Average Time taken for

available as per patient registration would be 3-5
load Availability of Registration min so number of counter
counters as per Patient load required would be worked
on scale of 12-20 patient/
hour per counter
90

ME C1.7 The facility and OB “Layout of OPD shall
departments are planned Unidirectional flow of services follow functional flow of
to ensure structure the
follows the function/ patients, e.g.:Enqu
processes (Structure iry→Registration
commensurate with the →Waiting→Sub-
function of the hospital) waiting→Clinic→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 entry OB

of the CHC
seismic safety of the properly secured. Building bye- furniture like cupboards,
infrastructure laws and instructions of NBC cabinets, and heavy
(National Building Code) for equipments , hanging
seismic safety are followed. objects are properly
ME C2.2 The facility ensures safety OPD building does not have OB
of electrical establishment temporary connections and
loosely hanging wires.
Safe installation, use of

apprpriate wires and MCBs,
display of Danger notice,
availability of tools and PPE
(personal protective equipments),
and periodic inspections.
ME C2.3 Physical condition of Floors of the OPD are non OB

the building is safe for slippery and even
Windows and vents if any are OB

intact and sealed
ME C2.4 The facility has a plan for OPD has sufficient fire exits OB/SI
prevention of fire to permit safe escape of its
occupant in case of fire
Fire exits are clearly visible and OB

routes to reach exit are clearly
marked.
ME C2.5. The facility has adequate OPD has installed fire OB

fire fighting Equipment Extinguisher to fight type A/B/C
of fire
91

expiry date of fire extinguishers OB/RR
are displayed on each
extinguisher as well as due
mentioned
ME C2.6. The facility has a system Check for staff competencies for
of periodic training of operating fire extinguisher and
staff and conducts mock what to do in case of fire
The facility has adequate qualified and trained staff, required for providing the assured
Standard C3
services to the current case load
ME C3.1 The facility has adequate Availability of specialist Doctor OB/RR Check for specialist are
specialist doctors as per during OPD time available at scheduled
service provision time
ME C3.3. The facility has adequate Availability of Nursing staff OB/RR/SI At Injection room/ OPD
nursing staff as per service Clinic as Per Requirement
provision and work load
ME C3.4 The facility has adequate Availability of dresser/paramedic OB/SI Full Time
technicians/paramedics as at dressing room
per requirement
Counsellor for ICTC SI/RR Full time
Lab technician for ICTC SI/RR
Counsellor for ARSH clinic SI/RR
Availability of ECG technician SI/RR
Availability of Ophthalmic SI/RR

assistant
Availability of Dental technician SI/RR
ME C3.5 The facility has adequate availability of security guard SI/RR

support / general staff for OPD
Availability of housekeeping SI/RR

staff
ME C3.6 The staff has been IMEP Training SI/RR

provided required training
/ skill sets
SBA Training SI/RR
IMNCI Training SI/RR
92

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

to identify high risk pregnancies
Counsellor is skilled for SI/RR

counselling
Staff is skilled for maintaining SI/RR

clinical records
ME C4.1 The departments have Availability of injectables in OB/RR ARV, TT
availability of adequate injection room
Availability of vaccine as per OB/RR

National Immunization Program
ME C4.2 The departments have Availability of disposables at OB/RR examination gloves,

adequate consumables at dressing room and clinics Syringes, Dressing material ,
point of use suturing material
HIV testing Kits I, II and III at ICTC OB/RR
ME C4.3 Emergency drug trays are Emergency Drug Tray is OB/RR Verify presence of
maintained at every point maintained in injection room following drugs
of care, where ever it may and immunization room -Inj Dopamine
be needed - Inj Adrenaline etc.
ME C5.1 Availability of equipment Availability of functional OB BP apparatus, thermometer,
and instruments for Equipment andInstruments for weighting machine, torch,
examination and examination and Monitoring stethoscope, Examination
monitoring of patients table
ME C5.2 Availability of equipment Availability of functional OB PV examination kit,

and instruments for Instruments/Equipments for measuring tape, fetoscope,
treatment procedures, being Gynae and obstetric Weighing machine, BP
undertaken in the facility apparatus etc.
Availability of functional OB Retinoscope, refraction

Instruments / Equipments for kit, tonometer,perimeter,
Ophthalmic Procedures distant vision chart, Colour
vision chart.
Availability of functional OB Dental chair, Air rotor,

Instruments/ Equipments for Endodontic set, Extraction
Dental Procedures forceps

for Storage storage for drugs Drug trolley, instrumental
93

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

sterilization and disinfection Autoclave
ME C5.7 Departments have patient Availability of Fixtures OB Spot light, electrical

furniture and fixtures fixture for equipments, X
as per load and service ray view box
provision
Availability of furniture at clinics OB Doctors Chair, Patient

Stool, Examination Table,
Attendant Chair, Table,
Footstep, cupboard

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 covered SI/RR
system for maintenance of under AMC including preventive
critical Equipment maintenance
ME D1.2 The facility has established All the measuring equipments/ OB/ RR BP apparatus, weighing
procedure for internal instrument are calibrated scale are calibrated
measuring Equipment
The facility has defined procedures for storage, inventory management and
Standard D2
dispensing of drugs in pharmacy and patient care areas
ME D2.1 There is established There is process for indenting SI/RR Stock level are weekly
procedure of forecasting consumables and drugs in updated
and indenting drugs and injection/ dressing room Requisition are timely
consumables placed

consumables
Vaccine are kept at OB

recommended temperature at
immunization room
ME D2.4 The facility ensures Expiry dates for injectables are OB/RR
management of expiry maintained at injection and
and near expiry drugs immunization room
ME D2.5 The facility has established There is practice of calculating SI/RR

procedure for inventory and maintaining buffer stock
management techniques
94

Department maintained stock SI/RR
and expenditure register of
drugs and consumables

periodically replenishing replenishing drug tray /crash
the drugs in patient care cart/Emergency Tray
areas
There is no stock out of drugs SI/RR
ME D2.7 There is process for Temperature of refrigerators are OB/RR Check for temperature
storage of vaccines and kept as per storage requirement charts are maintained and
other drugs, requiring and records are maintained updated periodically
controlled temperature
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 “
The facility has established Program for mainntenance and upkeeto of the faciity to provide
Standard D3
ME D3.1 Exterior of the facility Building is painted/whitewashed OB
building is maintained in uniform colour
appropriately
Interior of patient care areas are OB

plastered and painted
ME D3.2 Hospital infrastructure is Check to ensure that there is no OB

adequately maintained seepage, Cracks, chipping of plaster
Window panes, doors and other OB

fixtures are intact
Patients beds are intact and OB

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

are clean
Toilets are clean with functional OB

flush and running water
95

ME D3.4 The facility has policy of No condemned/Junk material is OB
removal of condemned junk in the OPD
material
ME D3.5 The facility has established No stray animal/rodent/birds OB

procedures for pest,
rodent and animal control
ME D3.6 The facility provides Adequate Illumination in clinics OB 100 lux in General area
adequate illumination
Adequate Illumination in OB 150 lux in injection room

procedure area
ME D3.7 The facility has provision Only one patient is allowed one OB/SI Fans/ Air conditioning/
of restriction of visitors in time at clinic Heating/Exhaust/
patient areas Ventilators as per
environment condition
and requirement
ME D3.8 The facility ensures Temperature control and PI/OB Fans/ Air conditioning/
safe and comfortable ventilation in waiting areas Heating/Exhaust/
and requirement
Temperature control and SI/OB

ventilation in clinics
ME D3.9 The facility has security Hospital has sound security OB/SI
system in place at patient system to manage crowd in OPD
care areas
ME D3.10 The facility has established Ask female staff whether they SI
The facility ensures 24X7 water and power backup as per requirement of service
Standard D4
ME D4.2 The facility ensures Availability of power back up in OB/SI

adequate power backup OPD
in all patient care areas as
per load
96

The facility ensures avaialblity of Diet as per nutritional requirement of the
Standard D5
patients and clean Linen to all admitted patients.
ME D5.4 The facility has adequate Availability of linen in OB
sets of linen examination area
Standard D9
ME D9.1 The facility has established Staff is aware of their role and SI
job description as per govt responsibilities
guidelines
ME D9.2 The facility has a There is procedure to ensure RR/SI Check for system for
ME D9.3 The facility ensures There is designated in charge SI

the adherence to dress for department
code as mandated by its
department
Doctor, nursing staff and OB

support staff adhere to their
respective dress code

ME E1.1 The facility has established Unique identification number RR
Patient demographic details are RR Check for that patient

recorded in OPD registration demographics like Name,
records age, Sex, Address etc.
Patients are directed to relevant PI/SI

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 systematic OB Patient is called by Doctor/
established procedure for calling of patients one by one attendant as per his/her
OPD consultation turn on the basis of “first
come first examine” basis.
Patient History is taken and RR

recorded
97

Physical Examination is done and OB/RR
recorded wherever required
Provisional Diagnosis is recorded OB/RR
No Patient is Consulted in OB
Standing Position
Clinical staff is not engaged in OB/SI

administrative work
ME E1.3 There is established There is establish procedure for SI/RR

procedure for admission admission through OPD
of patients
There is establish procedure for SI/RR

day care admission
ME E3.1 Facility has established There is a procedure for SI/RR

procedure for continuity consultation of the patient
of care during to other specialist with in the
interdepartmental transfer hospital
Availability of referral linkages RR/OB Check how patient are

for OPD consultation. referred if services are not
available
ME E3.2 Facility provides appropriate The facility has functional SI/RR

referral linkages to the referral linkages to higher
patients/Services for facilities
continuity of care.
The facility has functional referral SI/RR

linkages to lower facilities
There is a system of follow up of RR

referred patients
Standard E5 Facility has a procedure to identify high risk and vulnerable patients
ME E5.2 The facility identifies high For any critical patient needing OB/SI
risk patients and ensure urgent attention queue can be
their care, as per their bypassed for providing services
need on priority basis

Standard E6
for prescribing the generic drugs and their rational use
ME E6.1 Facility ensured that Check for OPD slip if drugs are RR
drugs are prescribed in prescribed under generic name
generic name only only
98

A copy of Prescription is kept RR
with the facility
ME E6.2 There is procedure of Check that relevant Standard RR

rational use of drugs treatment guideline are
Check if staff is aware of the SI/RR

drug regime and doses as per
STG
Availability of Essential Drug SI/OB

List

written legibly and procedure are accompanied with
Check for the writing to ensure RR/SI

that it is comprehendible by the
clinical staff
ME E7.3 There is a procedure Drugs are checked for expiry OB/SI

to check drug before and other inconsistency before
Check single dose vial are not OB Check in Injection room

used for more than one dose Check for any open single
dose vial with left over
content intended to be
used later on
ME E7.5 Patient is counselled for Check for separate sterile needle OB In multi dose vial needle is
self drug administration is used every time for multiple not left in the septum”
dose vial
Patient is advice by doctor/ SI/PI

Pharmacist /nurse about the
dosages and timings .
Standard E8
clinical records and their storage
ME E8.1 All the assessments, Patient History, Chief Complaint RR
re-assessment and and Examination Diagnosis/
investigations are Provisional Diagnosis are
recorded and updated recorded in OPD slip
ME E8.2 All treatment plan Written Prescription and RR

prescription/orders are Treatment plan are written
recorded in the patient
records.
99

ME E8.4 Procedures performed are Any dressing/injection, other RR
written on patients records procedure recorded in the OPD slip
ME E8.5 Adequate form and Check for the availability of OPD OB/SI
formats are available at slip, Requisition slips etc.
point of use
ME E8.6 Register/records are OPD records are maintained OB/RR OPD register, ANC register,
maintained as per guidelines Injection room register etc
All register/records are identified OB/RR

and numbered
The facility ensures safe Safe keeping of OPD records OB/SI

ME E8.7 and adequate storage and
All reegistered and records are OB/SI

identified and numbered
ME E10.3 The facility has disaster Staff is aware of disaster plan SI/RR
Roles and responsibilities of SI/RR

staff in disaster are defined
ME E11.1 There are established The container are labelled OB
procedures for Pre-testing properly after the sample
Activities collection
ME E11.3 There are established Clinics are provided with the SI/RR
procedures for Post- critical value of different tests
testing Activities
Maternal and Child Health Services

Standard E16 Facility has established procedures for Antenatal care as per guidelines
ME E16.1 There is an established Facility provides and updates RR/SI Line listing
procedure for Registration “Mother and Child Protection
and follow up of pregnant Card”.
women.
Records are maintained for ANC RR Records of each ANC

registered pregnant women checkups is maintained in
Mother and child protection
card /ANC register
ME E16.2 There is an established History of past illness / RR/SI

procedure for History taking, pregnancy complication is taken
Physical examination, and recorded
and counselling for each
antenatal visit.
ANC checkups is done by the RR/SI

qualified personnel
100

At ANC clinic, Pregnancy is RR/SI/PI
confirmed by performing urine
test
Last menstrual period (LMP) is RR/SI

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 foetal RR/SI

growth, foetal lie
Breast examination RR/SI
4 ANC checkups of women is RR/SI <12 weeks - 1 Visit, <26

confirmed weeks -2 visits, < 34 -3
visits and >34 weeks to
term -5 visits
ME E16.3 Facility ensures availability Diagnostic test under ANC RR/SI Check for Haemoglobin,
of diagnostic and drugs check up are prescribed at ANC urine albumin urine sugar
during antenatal care of clinic blood group and Rh
pregnant women factor Syphilis (VDRL/RPR)
HIV blood sugar malaria
Hepatitis B
IFA tablets are given to ANC RR/SI

cases
ME E16.4 There is an established High risk pregnant women are RR/SI Anaemia, Bad obstetrical
procedure for identified, initial Management history, CPD, PIH,
identification of High and referred to specialist Medical disorder
risk pregnancy and complicating pregnancy,
appropriate treatment/ Malpresentation,
referral as per scope of Obstructued labour, Rh
services. negative
ME E16.5 There is an established Line listing of pregnant women RR/SI

procedure for with moderate and severe
identification and anaemia
management of moderate
and severe anaemia
Provision for Injectable Iron RR/SI

Treatment for moderate
anaemia
101

ME E16.6 Counselling of pregnant Nutritional counselling RR/PI
women is done as per
standard protocol and
gestational age
Breast feeding RR/PI
Institutional delivery RR/PI
Arrangement of referral transport RR/PI
Birth preparedness RR/PI
Pregnant women are counselled PI Swelling, oedema, bleeding

for recognizing danger signs PV ( even spoting), blurred
during pregnancy vision, headach, pain
abdomen, vomiting,
pyrexia,watery foul smelling,
discharge and yellow urine
Family planning RR/PI PPIUCD and vesectomy
ME E19.1 The facility provides Availability of diluents for RR/SI Match no. of dilutant with
immunization services as reconstitution of Measles no. of measles vials
per guidelines vaccine
Recommended temperature RR/SI “Check diluents are

of diluents is ensured before kept under cold chain
reconstitution at least 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 not RR/SI Check when the vials are
used after recommended period opened and constituted .
Should not be used beyond
4 hrs after reconstitution
Time of opening/ Reconstitution RR Check for records

of vial is recorded on the vial
Staff checks VVM level before SI White square in side the violet
using vaccines circle changes the colour
Staff is aware of how to check SI Ask staff to demonstrate

freeze damage for T-Series how to conduct Shake test
vaccines for DPT, DT and TT
Discarded vaccines are kept SI/OB Check for expired, frozen

separately or with VVM beyond the
discard point vaccine
stored seperately
102

Check for DPT, DT, Hep Band TT SI/OB Check for 0.1 ml AD syringe
vials are kept in basket in upper for BCG and 0.5 ml syringe
section of ILR for others are available
AD syringes are available as per SI/OB

requirement
Vaccine recipient is asked to SI/RR

stay for half an hour after
vaccination to observe any
Adverse effect following the
immunization
Antipyretic medicines are available SI/RR
Availability and updation of SI/RR

Immunization card
Counselling on adverse effects SI/RR

and follow up visits done(CEI)
Staff is aware of how to manage SI

and report minor and serious
advise events (AEFI)
Staff knows what to do in case SI

of anaphylaxis
ME E19.2 “Triage, Assessment and Check for adherence to clinical SI/RR

Management of newborns protocols
having emergency signs are
done as per guidelines”
ME E19.5 “Management of children Check for adherence to clinical SI/RR

presenting with fever, protocols
cough/ breathlessness is
done as per guidelines “
ME E19.6 Management of children Screening of children coming to SI/RR

with Severe Acute OPDs using weight for height
Malnutrition is done as per and/or MUAC and further
guidelines management
ME E19.7 Management of children Check for adherence to clinical SI/RR

presenting with diarrhoea protocols
is done per guidelines
Availability of ORT corner SI/RR
103

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

available options for family
planning
The client is informed that use PI/SI

of condoms prevent sexually
transmitted infections (STIs)
and HIV
ME E20.2 Facility provides Oral Pills is given only to SI/RR Contraindication of

spacing method of those who meet the Medical COC in Breastfeeding
family planning as per Eligibility Criteria mothers within 6week and
guideline hypertension
The client is given full PI/SI

information about the risks,
advantages, and possible
side effects before OCPs are
prescribed for her.
The staff is aware of what to SI/RR

advice if dose of contraceptive
is missed by a lady
Staff is aware of indication SI/RR within 72 hours, second

and method of administration dose 12 hours after first
of ECP dose
IUD insertion is done as per SI/RR No touch technique,

standard protocol Speculum and bimanual
examination, sounding of
Uterus and placement
Client is informed about SI/PI Cramping, vaginal

the adverse effect that can discharge, heavy
happen and their remedy menstruation, checking
of IUD
Follow up services are SI/RR Removal of IUD,

provided as per protocols Instructions for when to
return
Staff is aware of case selection SI/RR 22-49 year age

criteria for family planning Married at least having
one year old and Spouse
has not undergone for
sterilization
104

Standard E21 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines
ME E21.1 Facility provides Provision of Antenatal SI/RR Nutritional Counselling,
Promotive ARSH Services natal check up to pregnant contraceptive counselling,
adolescent Couple counselling ANC
checkups, ensuring
institutional delivery
Counselling and provision of SI/RR Check for the availability

emergency contraceptive pills of Emergency
Contraceptive pills
(Levonorgesterol)
Counselling and provision of RR/SI Check for the availability

reversible Contraceptives of Oral Contraceptive Pills,
Condoms and IUD
Availability and Display of IEC OB Poster are displayed, Reading

material Material handouts etc.
Information and advice on SI/RR Advice on topic related to

sexual and reproductive health Growth and development,
related issues puberty, sexuality, myths
and misconception,
pregnancy, safe sex,
contraception, unsafe
abortion, menstrual
disorders,anemia, sexual
abuse, RTI/STI’s etc.
ME E21.2 Facility provides Services for Tetanus SI/RR TT at 10 and 16 year

Preventive ARSH Services immunization
Services for Prophylaxis against SI/RR Haemoglobin estimation,

Nutritional Anaemia 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 and pregnancy up to 8 weeks
management of post abortion Post abortion counselling
complication
ME E21.3 Facility Provides Curative Treatment of Common RTI/STI’s SI/RR Privacy and
ARSH Services Confidentiality, treatment
Compliance, Partner
Management, Follow up
visit and referral
Treatment and counselling for SI/RR Symptomatic treatment ,

Menstrual disorders counselling
Treatment and counselling for SI/RR

sexual concern for male and
female adolescents
105

Management of sexual abuse SI/RR ECP, Prophylaxis against
amongst Girls STI, PEP for hIV and
Counselling
ME E21.4 Facility provides Referral Referral Linkages to ICTC and SI/RR

Services for ARSH PPTCT
Privacy and confidentiality SI/RR Screens and

maintained at ARSH clinic curtains for visual
privacy,confidentaility
policy displayed, one
client at a time
Standard E22 Facility provides National health program as per operational/Clinical Guidelines
ME E22.1 Facility provides service Ambulatory care of SI/RR As per Clincal Guidelines
under National Vector uncomplicated P. Vivax malaria for Treatment of Maleria
Borne Disease Control
Program as per guidelines
Ambulatory care of SI/RR As per Clincal Guidelines

uncomplicated P. Falciparum for Treatment of Maleria
Malaria
Care of drug resistant malaria SI/RR As per Clincal Guidelines

for Treatment of Maleria
ME E22.2 Facility provides service Diagnosis and Management of SI/RR As per RNTCP Technical
under Revised National Pulmonary Tuberculosis Guidelines
TB Control Program as per
guidelines
Management of Paediatric SI/RR As per RNTCP Technical

Tuberculosis Guidelines
Management of Patients vith SI/RR As per RNTCP Technical

HIV infection and Tuberculosis Guidelines
Drug administration for SI/RR Check for filled treatment

Intensive and Continuation done Cards
as per RNTCP treatment protocol
Protocols for treatment for TB SI/RR Discontinuation of

during pregnancy and Post natal Streptomycin
Period is adhered Chemoprophylaxis of
babies in case of smear
positive mother
Monitoring and follow up of SI/RR Check for records/

patient done as per protocols Protocols
106

ME E22.3 Facility provides service Validation and diagnosis of SI/RR As per Operation/ Clincal
under National Leprosy Referred and Directly Reported Guidelines of NLEP
Eradication Program as per Cases
guidelines
Treatment of all diagnosed cases SI/RR As per Operation/ Clincal

including Reaction and Neuritis Guidelines of NLEP
Assessment of Disability Status SI/RR As per Operation/ Clincal

Guidelines of NLEP
Management of Complicated SI/RR As per Operation/ Clincal

Ulcers Guidelines of NLEP
Management of Eye SI/RR As per Operation/ Clincal

Complications Guidelines of NLEP
Follow-up of cases treated at SI/RR As per Operation/ Clincal

tertiary Level Guidelines of NLEP
Self care Counselling SI/RR As per Operation/ Clincal

Guidelines of NLEP
Outreach Services to Leprosy SI/RR As per Operation/ Clincal

Clinics Guidelines of NLEP
Screening of Cases of RCS SI/RR As per Operation/ Clincal

Guidelines of NLEP
ME E22.4 Facility provides service Pre Test Counselling is done as SI/RR Basic information and
under National AIDS per protocols benefits of HIV testing
Control program as per potential risks such as
guidelines 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.
Screening of PLHA for initiating SI/RR As per NACO guidelines

ART
Monitoring of patients on ART SI/RR As per NACO guidelines

and management of side effects
Counselling and Psychological SI/RR As per NACO guidelines

support for PLHA
ME E22.6 Facility provides service Treatment of Mental illnesses as SI/RR

under Mental Health per clinical guidelines
Program as per guidelines
107

ME E22.7 Facility provides service Geriatic Care is provided as per SI/RR
under National programme Clinical Guidelines
for the health care of the
elderly as per guidelines
ME E22.8 Facility provides service “Opportunistic screening SI/RR Screening of persons

under National Programme for diabetes, hypertension, above age of 30 - History
for Prevention and Control cardiovascular diseases” of tobacco examination,
of cancer, diabetes, BP Measurement and
cardiovascular diseases and Blood sugar estimation
stroke (NPCDCS) as per Look for records at NCD
guidelines clinic
screen women of the age group SI/RR

30-69 years approaching to the
hospital for early detection of
cervix cancer and breast cancer.
Health Promotion through IEC OB increased intake of

and counselling healthy foods
increased physical
activity through
sports, exercise,
etc.; avoidance of
tobacco and
alcohol; stress
management
warning signs of cancer
etc
ME E22.9 Facility provide service Weekly reporting of Presumptive SI/RR

for Integrated disease cases on form “P” from OPD
surveillance program clinic As per Clinical guidelines
ME E22.10 Facility provide services Early detection and screening for SI/RR
under National program detection of deafness
for prevention and control
of deafness
Standard F1 Facility has infection control program and procedures in place for prevention
and measurement of hospital associated infection
ME F1.4 There is Provision of There is a procedure for SI/RR Hepatitis B, Tetanus Toxoid
Periodic medical check-ups of SI/RR

the staff
control practices
108

ME F1.6 Facility has defined and Check if Doctors are aware of SI/RR
policy
use of use
Availability of running Water OB/SI Open the tap. Ask the

staff water is 24x7
Availability of antiseptic soap OB/SI Check for availability/ Ask

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

Hand rub staff for regular supply.

Local language
Adherence to 6 steps of Hand SI/OB Ask for demonstration

washing
ME F2.2 Staff is trained and adhere Staff is aware of occassion for SI

to standard hand washing hand washing
practices

practices and materials Solutions
for antisepsis
equipments as per
requirements
ME F3.2 Staff is adhere to standard No reuse of disposable gloves,

personal protection practices Masks, caps and aprons. OB/SI
ME F4.1 Facility ensures Decontamination of operating SI/OB Ask staff about how
standard practices and Procedure surfaces they decontaminate the
and materials for procedure surface like
decontamination and Examination table,
cleaning of instruments dressing table, Stretcher/
and procedures areas Trolleys etc. (Wiping with
.5% Chlorine solution)”
109

Proper Decontamination of SI/OB Ask staff how they
instruments like
Stethoscope, Dressing
Instruments, Examination
Instruments, Blood
Pressure Cuff etc
0.5% Chlorine Solution “

decontamination is adequate

running water after
decontamination

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

instruments/equipments is done and time required for
as per protocol boiling
Autoclaved dressing material is OB/SI

used
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
Clinics for infectious diseases are OB Preferably in remote

located away from main traffic corner with independent
access
Sitting arrangement in TB clinic OB

is as per guideline
ME F5.2 Facility ensures availability Availability of disinfectant as OB/SI Chlorine solution,

of standard materials for per requirement Glutaraldehyde, carbolic
Availability of cleaning agent as OB/SI Hospital grade phenyl,

solution
110

ME F5.3 Facility ensures standard Staff is trained for spill SI/RR Blood and body fluid spill
practices followed for management management and Mercury
cleaning and disinfection spill

with detergent solution
Staff is trained for preparing SI/RR

cleaning solution as per
standard procedure


are not used in patient care leading to dispersion of
be avoided
Facility has defined and established procedures for segregation, collection, treatment
Standard F6
and disposal of Bio Medical and hazardous Waste.
ME F6.1 Facility Ensures Availability of colour coded bins OB

Availability of plastic colour OB

coded plastic bags

guidelines

Biomedical waste

and general waste
per guidelines

injection room


charge of that.
111

Whom to report. See if
any reporting has been
done
ME F6.3 Facility ensures Check bins are not overfilled SI/OB

transportation and
disposal of waste as per
guidelines

waste is done in close
container/trolley

management
Area of Concern - Q Quality Management

ME G1.1 The facility has a quality There is a designated SI/RR Preferably Medical Officer
team in place departmental nodal person for in charge
coordinating Quality Assurance
activities
Standard G2 Facility has established system for patient and employee satisfaction
ME G2.1 Patient Satisfaction OPD Patient satisfaction RR
surveys are conducted survey done on monthly
at 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 by SI/RR
internal quality assurance matron/hospital in-charge/ for
program at relevant monitoring of services
departments
ME G3.2 Facility has established External Quality assurance SI/RR

external assurance program is established at ICTC
programs at relevant lab
departments

Staff is designated for filling SI

and monitoring of these
checklists
112

Current version of SOP are OB/RR
ME G4.2 Standard Operating OPD has documented procedure RR

Procedures adequately for Registration
describes process and
procedures
OPD has documented procedure RR

for patient calling system in
OPD clinics

for receiving of patient in clinic

for prescription and drug
dispensing

for nursing process in OPD

for patient privacy and
confidentiality

for conducting, analysing
patient satisfaction survey

for equipment management
and maintenance in OPD
Department has documented RR

procedure for Administrative
and non clinical work at OPD

procedure for No Smoking
Policy in OPD

for duty roaster, punctuality,
dress code and identity for OPD
staff
ME G4.3 Staff is trained and aware Check Staff is aware of relevant SI/RR
of the standard procedures part of SOPs
written in SOPs
ME G4.4 Work instructions are Work instruction/clinical OB Relevant protocols are

displayed at Point of use protocols are displayed displayed like Clinical
Protocols for ANC
checkups
113

The facility has established system of periodic review as internal assessment ,
Standard G5 medical and death audit and prescription audit
ME G5.1 The facility conducts Internal assessment is done at RR/SI
periodic internal assessment periodic interval
ME G5.2 The facility conducts the There is procedure to conduct

periodic prescription/ Medical Audit RR/SI
medical/death audits
There is procedure to conduct RR/SI

Prescription audit
ME G5.3 The facility ensures non Non Compliance are RR/SI

compliances are enumerated enumerated and recorded
and recorded adequately
ME G5.4 Action plan is made on Action plan prepared RR/SI

the gaps found in the
assessment / audit process
ME G5.5 Corrective and preventive Corrective and preventive RR/SI

actions are taken to action taken
address issues, observed in
the assessment and audit
ME G6.2 The facility periodically Quality objective for OPD RR/SI
objectives and key
own objectives

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

objectives is monitored and reviewed periodically
periodically
ME G7.1 Facility uses method for PDCA SI/RR
quality improvement in
services
5S SI/OB
Process Mapping SI/OB
Any other method of QA SI/RR
ME G7.2 Facility uses tools for quality 6 basic tools of Quality SI/RR
improvement in services
Pareto / Prioritization SI/RR
114

ME H1.1 Facility measures Proportion of follow-up patients RR
productivity Indicators on
monthly basis
General OPD/1000 population RR
Medicine OPD/1000 Population RR
Surgical OPD/1000 Population RR
Opthalmic OPD/1000 population RR
Paediatric OPD/1000 population RR
AYUSH OPD/1000 Population RR
No of ANC done per thousand RR
ICTC OPD per thousand RR
Immunization OPD per thousand RR
ME H1.2 The Facility measures Proportion of BPL patients RR

equity indicators
periodically
ME H2.1 Facility measures efficiency OPD per Doctor RR
Indicators on monthly
basis
ME H3.1 Facility measures Clinical Consultation time at ANC Clinic RR Time motion study
Care and Safety Indicators
on monthly basis
Consultation time at General RR

Medicine Clinic
Consultation time for paediatric RR

clinic
Proportion of High risk RR No of High Risk

pregnancy detected during ANC Pregnancies X100/ Total
no PW used ANC services
in the month
Proportion of severe anaemia RR

cases
115

ME H4.1 Facility measures Service Patient Satisfaction Score RR
Quality Indicators on
monthly basis
Waiting time at registration RR

counter
Waiting time at ANC Clinic RR
Waiting time at general OPD RR
Waiting time at paediatric Clinic RR
Waiting time at surgical clinic RR
Average door to drug time RR
116


STANDARDS FOR CHC
Checklist for Labour Room
118

ME A1.3 The facility provides Availability of comprehensive SI/OB LSCS, Blood storage,
Obstetrics and obstetric services Anesthesia.
Gynaecology Services
ME A1.9 Services are available Labour room services are SI/RR

for the time period as functional on 24x7 basis
mandated

ME A2.1 The facility provides Availability of Post partum SI/OB PPIUD insertion
Reproductive health sterilization services
Services
ME A2.2 The facility provides Vaginal Delivery SI/OB Term, post Date and pre
Maternal health Services term
Assisted Delivery SI/OB Forceps delivery and

vacuum delivery
Caesarean section SI/OB Medical /Surgical
Management of Postpartum SI/OB

Haemorrhage
Management of Retained SI/OB

Placenta
Delivery of septic and HIV SI/OB

positive PW
Management of PIH/Eclampsia/ SI/OB

Pre eclampsia
ME A2.3 The facility provides Initial Diagnosis and management SI/OB

Newborn health Services of MTP and Ectopics
Availability of Essential new born

care SI/OB
Availability of New born SI/OB

resuscitation
Standard A3 The facility Provides diagnostic Services
ME A3.1 The facility provides Availability or functional linkage SI/OB
Radiology Services for USG services.
ME A3.2 The facility Provides Availability of point of care SI/OB HIV, Hb% , Random
Laboratory Services diagnostic test blood sugar /as per state
guideline
119

Area of Concern - B Patient’s Right
Standard B1 The facility provides information to care seekers, attendants and community about
ME B1.1 The facility has uniform Availability departmental OB Numbering rooms, main
and user-friendly signage signage’s department and inter-
Directional signage for OB Direction is displayed

department is displayed from main gate to direct.
ME B1.2 The facility displays the Restricted area signage OB

services and entitlements displayed
available in its department
Entitlements under JSSK are OB

displayed
Entitlement under JSY is displayed OB
Name of doctor and Nurse on OB

duty are displayed and updated
Contact details of referral OB

transport / ambulance displayed
Services provision of labour OB

room are displayed at the
entrance
ME B1.5 Patients and visitors are IEC Material is displayed OB Breast feeding, kangaroo
sensitised and educated care, family planning
through appropriate IEC / (Pictorial and chart ),
BCC approaches Immunization schedule
in circulation area

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

male doctor examine a female
patient/mother
ME B2.3 Access to facility is Availability of Wheel chair or OB

provided without any stretcher for easy Access to the
physical barrier and and labour room
disabilities
120

Availability of ramps and railing OB
Labour room is located on OB

ground floor; or avaialbility of
the ramp/lift with person for
shifting
Standard B3
ME B3.1 Adequate visual privacy Availability of screen/ partition OB
is provided at every point at delivery tables
of care
Curtains / frosted glass have OB

been provided at windows
ME B3.2 Confidentiality of patients Patient Records are kept at SI/OB

records and clinical secure place beyond access to
information is maintained general staff/visitors
ME B3.3 The facility ensures the Behaviour of staff is empathetic OB/PI

behaviours of staff is and curteous
while delivering the services
ME B3.4 The facility ensures privacy HIV status of patient is not SI/OB
and confidentiality to every disclosed except to staff that is
patient, especially of those directly involved in care
vulnerable groups
Standard B4
ME B4.1 There is established General consent is taken SI/RR
procedures for taking before delivery
informed consent
before treatment and
procedures
ME B4.4 Information about the Labour room has system PI

treatment is shared in place to involve patient
with patients or relative in decision making
attendants, regularly about pregnant women
treatment
The facility ensures that there are no financial barrier to access, and that there is financial
Standard B5
protection given from the cost of hospital services.
ME B5.1 The facility provides Drugs and consumables under PI/SI
cashless services to JSSK are available free of cost
and neonates as per
schemes
121

ME B5.2 The facility ensures that Check that patient and PI/SI
drugs prescribed are attendents have not spent
available at Pharmacy money on purchasing drugs and
and wards consumables from outside.
ME B5.3 It is ensured that facilities Check that patient and PI/SI

for the prescribed attendents have not spent
investigations are available money on diagnostics from
at the facility outside.
ME B5.5 The facility ensures If any other expenditure PI/RR

and reimbursement to
the patients
Standard C1 The facility has infrastructure for delivery of assured services, and available
ME C1.1 The departments has Adequate space as per delivery OB One labour table requires
adequate space as per load 10X10 sqft of space, Every
patient or work load labour table should have
space for vertical trolley
with space for six trays
Availability of Waiting area for OB

attendants/ASHA
ME C1.2 Patient amenities are Attached toilet facility available OB

provides as per patient
load
Availability of Drinking water OB
Availability of Changing area OB
ME C1.3 The departments have Delivery unit has dedicated OB

layout and demarcated Receiving area
areas as per functions
Availability of Examination Room OB
Availability of Pre delivery room OB
Availability of Delivery room OB
Availability of Post delivery OB

observation room
Dedicated nursing station within OB

or proximity of labour room
Area earmarked for newborn OB

care Corner
Dedicated Isolation room OB For septic cases.
122

Preparation of medicine and OB
injection space.
Availability of dirty utility room OB
Availability of store OB
ME C1.4 The facility has adequate Corridors connecting labour OB

circulation area and open room are broad enough to
spaces according to need facilitate stretcher and trolleys
and local law movements
ME C1.5 The facility has OB

infrastructure for Availability of functional
intramural and extramural telephone and Intercom Services
communication
ME C1.6 Service counters are Availability of labour tables as OB At least 2 labour table for
available as per patient per delivery load 100 deliveries per month
load
ME C1.7 The facility and Labour room is in Proximity and OB

departments are planned function linkage with OT
to ensure structure
Labour room is in proximity and OB

functional linkage with NBSU
Unidirectional flow of care OB
equipments , hanging
ME C2.2 The facility ensures safety Labour room does not have OB Switch Boards other
of electrical establishment temporary connections and electrical installations are
loosely hanging wires intact
Stabilizer is provided for Radiant OB

warmer
ME C2.3 Physical condition of Floors of the labour room are OB

the building is safe for non slippery and even
123

ME C2.4. The facility has plan for Window and vents have grills OB
prevention of fire and wire meshwork
Labour room has sufficient fire OB/SI

exit to permit safe escape of its
Check the fire exits are clearly OB

visible and routes to reach exit
are clearly marked.
ME C2.5. The facility has adequate Labour room has installed fire OB
fire fighting Equipment Extinguishers that are capable of
fighting A, B, and C type of fire

extinguisher is displayed on
mentioned
ME C2.6. The facility has a system Check for staff competencies for SI/RR
The facility has adequate qualified and trained staff, required for providing the
Standard C3
ME C3.1 The facility has adequate Availability of ObandG specialist OB/RR paediatrician or trained
specialist doctors as per and paediatrician on call. MO, Obstetrician or
service provision trained MO
ME C3.2. The facility has adequate Availability of atleast one OB/RR/SI

general duty docotors as doctor 24x7 in the facility
work load
ME C3.3 The facility has adequate Availability of SBA trained SI/RR At least Three per shift
nursing staff as per service Nursing staff.
ME C3.5 The facility has adequate Availability of labour room SI/RR At least 1 sanitary worker
support / general staff attendants/ Birth Companion and 1 ayah per shift
Availability of dedicated SI/RR

security staff
ME C3.6 The staff has been provided Navjat Shishu Surkasha SI/RR
required training / skill sets Karyakarm (NSSK) training
Skilled birth Attendant (SBA) SI/RR
IMEP training. SI/RR
124

BEmOC training for MO SI/RR
PPIUCD training SI/RR
ME C3.7 The Staff is skilled as per Nursing staff is skilled for SI/RR check staff is awae of
job description operating radiant warmer optimal temperature, how
to set temperature, how
to use probes, and how
to interpret alarms and
trouble shooting.
Nursing staff is skilled for SI/RR Check the staff know how
resuscitation to set the temperature,
how to put the probe,
duration and interpetation
of alarms
Nursing staff is skilled SI/RR Check how staff interpret

identifying and managing different alarming sign like
complication excessive bleeding, shock ,
obstructed labour
Counsellor is skilled for SI/RR

postnatal counselling
Nursing Staff is skilled for Check staff know what

maintaining clinical records to fill different section of
including partograph partograph and how to
interpetate alert and action
ME C4.1 The departments have Availability of uterotonic Drugs OB/RR Inj Oxytocin 10 IU (to be
availability of adequate kept in fridge)
Availability of Antibiotics OB/RR Cap Ampicillin 500mg, Tab

Metronidazole 400mg, Inj.
Gentamicin,
Availability of Antihypertensive OB/RR Tab Misprostol 200 mcg,

Nefedipine,
Availabity of analgesics and OB/RR Tab Paracetamol, Tab

antipyretics Ibuprofen
Availability of IV Fluids OB/RR IV fluids, Normal saline,

Ringer’s lactate, Dextrose
Availability of local anaesthetics OB/RR Inj Xylocaine 2%,
Availability of tocolytics OB/RR Inj. Labetolol, Inj.

Hydralazine, Inj. Isoprene.
125

Availability of emergency drugs OB/RR Inj Magsulf 50%, Inj
Calcium gluconate 10
mg, Inj Dexamethasone,
inj Hydrocortisone,
Succinate, Inj Diazepam,
inj Pheniramine
maleate, inj Corboprost,
Inj Pentazocine,
Inj Promethazine,
Betamethasone, Inj
Hydralazine, Nefedipine,
Methyldopa,Ceftriaxone,
Inj. Adrenaline.
Availability of drugs for newborn OB/RR Vit K1 1 mg.
ME C4.2 The departments have Availability of dressings and OB/RR Gauze pieces and cotton
adequate consumables at Sanitary pads swabs, sanitary pads,
point of use needle (round body and
cutting), chromic catgut
no. 0,
Availability of syringes and IV OB/RR Paediatric iv sets,urinery

Sets /tubes catheter,
Availability of Antiseptic OB/RR Antiseptic lotion

Solutions
Availability of consumables for OB/RR Gastric tubes and cord

new born care clamp, Baby ID tag,
mucous sucker.
ME C4.3 Emergency drug trays are Emergency Drug Tray is OB/RR

maintained at every point maintained
of care, where ever it may
be needed
ME C5.1 Availability of equipment Availability of functional OB BP apparatus, stethoscope
and instruments for Equipment andInstruments for Thermometer, foetoscope/
examination and examination and Monitoring Doppler, baby weighting
monitoring of patients scale, Wall clock.
ME C5.2 Availability of equipment Availability of instrument OB Scissors, Artery forceps,

and instruments for arranged in Delivery trays Cord clamp, Sponge
treatment procedures, holder, Speculum, Kidney
being undertaken in the tray, Bowl for antiseptic
facility lotion,
Delivery kits are in adequate OB As per delivery load and

numbers as per load cycle time for processing
of instruments
126

Availability of Instruments OB Episiotomy scissors, Kidney
arranged for Episiotomy trays tray, Artery Forceps, Allis
forceps, Sponge holder,
Toothed forceps, Needle
holder,Thumb forceps,
Availability of Baby tray OB Two pre warmed towels/

sheets for wrapping the
baby, mucus extractor, bag
and mask (0 and1 no.),
sterilized thread for cord/
cord clamp, nasogastric
tube,
Availability of instruments OB Speculum, anterior

arranged for MVA/EVA tray vaginal wall retractor,
posterior wall retractor,
sponge holding forceps,
MVA syringe, cannulas,
MTP, cannulas, small bowl
of antiseptic lotion,
Availability of instruments OB Sim’s speculum, PPIUCD

arranged for PPIUCD tray insertion forceps, CuIUCD
380A/Cu IUCD375 in
sterile package
ME C5.3 Availability of equipment Availability of Point of care OB Glucometer, Doppler and

and instruments for diagnostic instruments HIV rapid diagnostic kit,
diagnostic procedures being Uristix.
ME C5.4 Availability of equipment Availability of resuscitation OB Bag and mask (Newborn

and instruments for Instruments for Newborn Care resucitator), Oxygen,
resuscitation of patients Suction machine/ mucus
and for providing sucker , radiant warmer,
intensive and critical care laryngoscope, ET tube 2.5
to patients and 3.5 sizes.
Availability of resuscitation OB Suction machine, Oxygen

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


equipment and cleaning Separate mops for labour
instruments for support room and circulation area
services duster, waste trolley, Deck
brush
Availability of equipment for OB Steam sterlizer and

sterilization and disinfection Autocalve
127

ME C5.7 Departments have patient Availability of Delivery tables OB Steel Top
furniture and fixtures
provision
Availability of attachment/ OB Hospital graded Mattress,

accessories with delivery table IV stand, Kelly’s pad,
support for Delivery
tables, Macintosh, Foot
step, Bed pan
Availability of fixture OB Wall clock with Second

arm, Wall mounted lamp,
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 equipment are covered SI/RR Radiant warmer, Suction
system for maintenance of under the AMC including machine, Doppler.
critical Equipment preventive maintenance

maintenance of the equipment
ME D1.2 The facility has established All the measuring equipment/ OB/ RR BP apparatus,
procedure for internal and instrument are calibrated thermometers, weighing
external calibration of scale , radiant warmer Etc
measuring Equipment are calibrated
ME D1.3 Operating and Up to date instructions for OB/SI

maintenance instructions operation and maintenance of
are available with the equipments are readily available
users of equipment with labour room staff.
Standard D2
ME D2.1 There is established There is established system of SI/RR Stock level are daily
procedure for forecasting timely indenting of consumables updated
and indenting of drugs and drugs Requisition are timely
and consumables placed

consumables

labelled
128

ME D2.4 The facility ensures Record of Expiry date’s are OB/RR
management of expiry maintained at emergency drug
and near expiry drugs tray
Records for expiry and near RR

expiry drugs are maintained for
drug store at the department

management technique
Department maintained stock RR/SI


periodically replenishing replenishing drug tray/crash cart
the drugs in patient care
areas
There is no stock out of drugs OB/SI
Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide
safe, secure and comfortable environment to the staff, patients and visitors.


fixtures are intact
Delivery table are intact and OB

without rust
clean and hygienic tops, sinks patient care and dirt, grease, littering and

are clean


removal of condemned the Labour room
junk material
129

ME D3.6 The facility provides Adequate Illumination at OB 400 lux.

adequate illumination delivery table
Adequate Illumination at OB 300 Lux.

observation area
ME D3.7 The facility has provision There is no overcrowding in OB

of restriction of visitors in labour room
patient areas
One female family member OB/SI

allowed to stay with the PW
Entry of visitors is restricted in OB/SI

the labour room
ME D3.8 The facility ensures Temperature control and PI/OB Optimal temperature and
safe and comfortable ventilation in Labour room warmth is ensured at
environment for patients labour room. Fans/ Air
and service providers conditioning/Heating/
Exhaust/Vents as per
environment condition
and requirement
ME D3.9 The facility has security Lockable doors in labour room OB

system in place at patient
care areas
New born identification band are
used and foot prints of babies OB/RR
are taken
ME D3.10 The facility has established Ask female staff weather they SI
The facility ensures 24x7 water and power backup as per requirement of service
Standard D4
Availability of hot water OB/SI

adequate power backup labour room
per load
130

ME D4.3 Critical areas of the Availability of Oxygen cylinders OB

facility ensures availability and vacuum suction
of oxygen, medical gases
and vacuum supply

Standard D5
ME D5.4 The facility has adequate Availability of clean Drape, OB/RR

sets of linen Macintosh on the Delivery table,
Gown are provided in labour OB/RR

room
Availability of Baby blanket, OB/RR

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

Standard D9
per govt. regulations and standards operating procedures.
ME D9.1 The facility has established Staff is aware of their roles and SI
guidelines
There is designated in charge SI

for department
ME D9.3 The facility ensures Doctor, nursing staff and OB

adherence to the dress support staff adhere to their
code as mandated by its respective dress code
department
Area of Concern - E clinical Services

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
131

recorded in admission records demographics like Name,
age, Sex, Provisional
diagnosis, etc.
ME E1.3 There is established There is a procedure for SI/RR/OB

procedure for admission admitting Pregnant women
of patients directly to Labour room
Admission is done on written SI/RR/OB

order of a qualified doctor

patient record
ME E1.4 There is established Check how service provider cope OB/SI

procedure for managing with shortage of delivery tables
patients, in case beds are due to high patient load
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 Rapid Initial assessment of RR/SI/OB Assessment and immediate
procedure for initial Pregnant Women to identify treatment following
assessment of patients complication and Prioritization danger sign are present
of care - difficulty in breathing,
fever, sever abdominal
pain, Convulsion or
unconsciousness, Severe
headache or blurred vision
RR/SI Recording of women

Recording and reporting of obstetric History including
Clinical History LMP and EDD Parity,
Gravida status, h/o CS, Live
birth, Still Birth, Medical
History (TB, Heart diseases,
STD etc, HIV status and
Surgical History)
Recording of current labour RR Time of start, frequency

details of contractions, time of
water bag leaking, colour
and smell of fluid and baby
movement
Physical Examination RR/SI Recording of Vitals, shape

and Size of abdomen,
presence of scars, foetal
lie and presentation. and
vaginal examination
ME E2.2 There is established There is fixed schedule for RR/OB There is a fixed schedule
procedure for follow-up/ reassessment of Pregnant of reassessment as per
reassessment of Patients women as per standard protocol protocols
132

Partograph is used and RR/OB All step are recorded in
updated as per stages of timely manner
labour
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 The facility has There is procedure of handing SI/RR
established procedure for over patient / new born from
continuity of care during labour room to OT/ Ward/NBSU
There is a procedure for SI/RR

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

higher centre
Referral vehicle is arranged RR/SI
Referral in or referral out SI/RR

Facility has functional referral RR Check for referral cards

linkages to lower facilities filled from lower facilities
There is a system of follow up of SI/RR

referred patients
ME E4.1 Procedure for There is a process for ensuring OB/SI Identification tags
identification of patients the identification before any for mother and baby /
is established at the clinical procedure foot print are used for
facility identification of newborns
ME E4.2 Procedure for ensuring There is a process to ensue SI/RR Verbal orders are
timely and accurate accuracy of verbal/telephonic rechecked before
nursing care as per orders administration
treatment plan is
established at the facility
ME E4.3 There is established Patient hand over is given RR/SI

procedure of patient hand during the change of the shift
change happens
133

maintained
Hand over is given bed side SI/RR
ME E4.5 There is procedure for Patient Vitals are monitored and RR/SI
periodic monitoring of recorded periodically Check for BP,
patients pluse,temp,Respiratory
rate FHR, Uterine
contraction Contractions,
any other vital required is
monitored
Critical patients are monitored RR/SI
continuously Check for BP,
pluse,temp,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 are identified OB/SI Check the measure taken
vulnerable patients and and measures are taken to protect to prevent new born theft,
ensure their safe care them from any harm swaping and baby fall
ME E5.2 The facility identifies high High Risk Pregnancy cases are OB/SI Check for the frequency of
risk patients and ensure identified and kept in intensive observation: Ist stage :half
their care, as per their monitoring an hour and 2nd stage:
need every 5 min
The facility follows standard treatment guidelines defined by state/Central government

Standard E6
ME E6.1 The facility ensures that Check for BHT if drugs are RR
drugs are prescribed in prescribed under the generic
generic name only name only

rational use of drugs Treatment Guideline are
Check if staff are aware of the SI/RR

drug regime and doses as per STG
Check BHT that drugs are RR Check for rational use of

prescribed as per STG uterotonic drugs
ME E7.1 There is process for identifying High alert drugs are identified SI/OB Magsulf (to be kept in
and cautious administration in the department fridge), Methergine
of high alert drugs

communicated diagnosis are available with
nursing station and doctor
134

are only given administration, Error prone
medical abbreviations are
avoided

written legibly and procedure are accompanied with

clinical staff

used later on
Check for separate sterile needle OB In multi dose vial needle is

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

ME E7.4 There is a system to Administration of medicines SI/OB

ensure right medicine is done after ensuring right
given to right patient patient, right drugs, right dose,
right route, right time
The facility has defined and established procedures for maintaining, updating of patients’
Standard E8
ME E8.1 All the assessments, Progress of labour is recorded RR Partograph fully
re-assessment and compliance/bed head
investigations are ticket partial compliance
ME E8.2 All treatment plan Treatment prescribed in nursing RR Medication order,

prescription/orders are records treatment plan, lab
recorded in the patient investigation are recoded
records. adequately
ME E8.4 Procedures performed Delivery notes are adequate RR Outcome of delivery, date
are written on patients and time, gestation age,
records delivery conducted by,
type of delivery,
complication if any
,indication of intervention,
date and time of transfer,
cause of death etc
135

Baby note is adequate RR Cry of baby, Essential new
born care, Resuscitation if any,
Sex, Weight, Time of initiation
of breast feed, Birth doses,
Congenital anomaly if any,
APGAR Score.
ME E8.5 Adequate form and Standard Formats available RR/OB Availability of BHT,
formats are available at Partograph, etc.
point of use
ME E8.6 Register/records are Registers and records are RR labour room register, OT
maintained as per maintained as per guidelines register, MTP register,FP
guidelines register, Maternal death
register and records,
lab register, referral in /
out register, internaland
PPIUD register etc.
All register/records are identified RR

and numbered
Roles and responsibilities of staff SI/RR

in disaster are defined

Activities

procedures for Post- the critical value of different test
testing Activities
Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion
ME E12.5 There is established Consent is taken before RR
procedure for transfusion transfusion
of blood
Patient’s identification is verified SI/OB

before transfusion
Blood is kept on optimum RR

temperature before transfusion
Blood transfusion is monitored SI/RR

and regulated by qualified staff
136

Blood transfusion note is RR
written in patient record
ME E12.6. There is a established Any major or minor transfusion RR

procedure for monitoring reaction is recorded and
and reporting Transfusion reported to Blood Bank/
complication designated personnel
ME E16.1 There is an established Facility provides and updates RR/SI
procedure for Registration “Mother and Child Protection
and follow up of pregnant Card”.
women.
ME E16.3 The facility ensures Tests for Urine albumin, RR/SI

availability of diagnostic haemoglobin, blood grouping
and drugs during
antenatal care of
pregnant women
Standard E17 The facility has established procedures for Intranatal care as per guidelines
ME E17.1 Established procedures Management of 1st stage of SI/OB Check progress is recorded,
and standard protocols labour Women is allowed to give
for management of birth in the position she
different stages of labour wants , Check progress is
including AMTSL (Active recorded on partograph
Management of third
Stage of labour) are
followed at the facility
Management of 2nd stage of SI/OB Allows the spontaneous

labour delivery of head , gives
Perineal support and assist
in delivering baby. Check
progress is recorded on
partograph
Active Management of Third SI/OB Palpation of mother’s

stage of labour abdomen to rule out
presence of second baby
Use of Uterotonic Drugs SI/RR Administration 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
and Membranes for
Completeness
ME E17.2 There is an established Staff is aware of Indications for SI Ask staff how they
procedure for assisted and referring patient for Surgical identify slow progress of
C-section deliveries per Intervention labour, how they interpret
scope of services. Partogram
137

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

Haemorrhage last convulsion, whichever
is later
If BP is >160/110 mmHg
or more, give appropriate
anti-hypertensive
(Hydralazine/Methyl Dopa/
Nifedipine) “
Assessment of bleeding
(PPH if >500 ml or
> 1 pad soaked in
5 Minutes. IV Fluid,
bladder catheterization,
measurement of urine
output, Administration of
20 IU of Oxytocin in 500
ml Normal Saline or RL at
40-60 drops per minute
. Performs Bimanual
Compression of Uterus
Management of Retained SI/RR Administration of another

Placenta 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
138

Management of Uterine Atony SI/RR Vigorous Uterine 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 Obstructed SI/RR Diagnose obstructed

Labour labour based on data
registered from the
partograph, Re-hydrate
the patient to maintain
normal plasma volume,
check vitals, give broad
spectrum antibiotics,
perform bladder
catheterization and
take blood for Hb and
grouping, Decide on the
mode of delivery as per
the condition of mother
and the baby
Management of Puerperal sepsis SI/RR Diagnose puerperal sepsis

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

positive PW
ME E17.4 There is an established Recording date and Time of SI/RR Check the records
procedure for new Birth, Weight
born resuscitation and
newborn care.
139

Dried and put on mothers SI/OB With a clean towel from
abdomen head to feet, discards the
used towel and covers
baby including head in a
clean dry towel
Vitamin K for low birth weight SI/RR Given to all new 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 and 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 has requisite skill set
Kangaroo Mother Care SI/RR Observe /Ask staff about

the practice
New born Resuscitation SI/RR Ask Nursing staff to

demonstrate Resuscitation
Technique
ME E18.1 Post partum Care is Prevention of Hypothermia of SI/RR
provided to the mothers new born
Initiation of Breastfeeding with PI

in 1 Hour
Mother is monitored as per post RR/SI Check for records of

natal care guideline Uterine contraction,
bleeding, temperature, B.P,
pulse, Breast examination,
(Nipple care, milk
initiation)
Check for perineal washes PI

performed
ME E18.3 There is an established Labour room has procedure PI/SI Breast feeding
procedure for Post partum to provide post partum and prevention of
counselling of mother Counselling hypothermia
ME E18.4 The facility has established There is established criteria for SI/RR
procedures for stabilization/ shifting newborn to NBSU
treatment/referral of post
natal complications
140

Standard E20 Facility has established procedures for abortion and family planning as per government guidelines and law
ME E20.2 Facility provides spacing IUD insertion is done as per SI/RR No touch technique,
method of family standard protocol Speculum and bimanual
planning as per guideline examination, sounding of
uterus and placement
Staff is aware of case selection SI/RR 22-49 year age

criteria for family planning Married at least having
one year old baby and
Spouse has not under
gone sterilization
ME E20.3 Facility provides limiting Assessment of client done SI/RR Physical examination and
method of family before surgery for any Delay, Medical History taken,
planning as per guideline refer of caution signs
Consent is confirmed before the RR Informed consent is

procedure taken, which is verified
by checking records and
confirming with patient
Client is informed about post SI/RR/PI

operative care, complication and
follow up
Follow up visits done as per GoI SI/RR/PI Visit after 48 hours, first
guidelines follow up visit on 7th day
and semen analysis after
3 months, emergency
follow up
ME E20.4 Facility provide Pre procedure Counselling SI/RR/PI

counselling services for provided
abortion as per guideline
Post procedure Counselling is SI/RR/PI As per National

provided Guidelines
Counselling on the follow-up SI/RR/PI

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

pregnancy is done as per
guidelines
ME E20.6 Facility provide abortion Surgical Procedures are done as SI/RR Dilation and evacuation
services for 2nd trimester per guidelines
as per guideline
141

Medical termination of SI/RR ethacridine lactate extra
pregnancy done as per amniotic instillation
guidelines

The facility has infection control Programme and procedures in place for prevention and
Standard F1
ME F1.2 The facility has provision Surface and environment SI/RR Swab are taken from
for Passive and active samples are taken for infection prone surfaces
culture surveillance of microbiological surveillance
critical and high risk areas
ME F1.4 There is Provision of There is a procedure for SI/RR Hepatitis B, Tetanus Toxic
Periodic Medical Check-up immunization of the staff etc
Periodic medical checkups of the SI/RR

staff is done
ME F1.5 The facility has established Regular monitoring of infection SI/RR Hand washing and
control practices
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
use of use
Availability of running Water OB/SI Open the tap, ask the staff
if water supply is 24x7

uninterrupted


Local language
Availability of elbow operated OB

taps
Hand washing sink is wide OB

and deep enough to prevent
splashing and retention of water
142

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

hand washing
ME F2.3 The facility ensures Availability of Antiseptic OB

standard practices and Solutions
materials for antisepsis
Procedure for proper cleaning of OB/SI E.g. before giving IM/IV

site with antisepetics injection, drawing blood,
putting Intravenous and
urinary catheter
Proper cleaning of perineal area SI

before procedure with antisepsis
Check Shaving is not done SI

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
protection Equipment as
per requirements
Availability of Sterile s gloves OB/SI
Use of elbow length gloves for OB/SI

obstetrical purpose
Availability of gown/ Apron OB/SI
Availability of Caps OB/SI
Heavy duty gloves and gum OB/SI

boats for housekeeping staff
Personal protective kit for OB/SI

delivering HIV patients
ME F3.2 Staff adheres to standard No reuse of disposable gloves, OB/SI

personal protection Masks, caps and aprons.
practices

gloves
143

Standard F4 The facility has standard procedures for processing of equipment and instruments
ME F4.1 The facility ensures Decontamination of operating SI/OB Ask stff about how they
standard practices and Procedure surfaces decontaminate the
decontamination and Delivery Table, Stretcher/
cleaning of instruments Trolleys etc.
and procedures areas (Wiping with 0.5%
Chlorine solution

suction cannula, Delivery
Instruments
Solution, Wiping with 0.5%
Chlorine Solution or 70%
Alcohol as applicable

infected line sluicing at Point of use/
Patient care area


running water after
decontamination

Patient care area

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

instruments/equipments is done and time required for
Autoclaving of delivery kits is OB/SI Ask staff about temperature,

done as per protocols pressure and time

instruments/equipments is done concentration and
as per protocols contact time required for
chemical sterilization
144

Autoclaved linen are used for OB/SI
procedure

used
There is a procedure to ensure OB/SI

the traceability of sterilized
packs
Sterility of autoclaved packs is OB/SI Sterile packs are kept in

maintained during storage clean, dust free, moist
free environment.
ME F5.1 Layout of the department Labour room is loacted in a OB
is conducive for the secluded place, away from
infection control practices internal main traffic of the CHC
ME F5.2 The facility ensures Availability of disinfectant as OB/SI Chlorine solution,

availability of standard per requirement Gluteraldehye, carbolic
materials for cleaning and acid
disinfection of patient
care areas

solution
ME F5.3 The facility ensures that Staff is trained in spill SI/RR

standard practices are management
followed for the cleaning
and disinfection of patient
care areas


standard procedure


are not used in patient care leading to dispersion
areas of dust particles in air
should be avoided
Use of three bucket system for OB/SI

mopping
Fumigation/carbolization as per SI/RR

schedule
145

External footwares are restricted OB
ME F5.4 The facility ensures Isolation and barrier nursing OB/SI

segregation of infectious procedure are followed for
patients septic cases
Standard F6 The facility has defined and established procedures for segregation, collection, treatment
ME F6.1 The facility Ensures Availability of colour coded bins OB
and ‘on-site’ management
of waste is carried out as
per guidelines
Availability of colour coded OB

plastic bags
Segregation of different category OB/SI


Biomedical waste

and general waste
ME F6.2 The facility ensures Availability of functional needle OB Verify its usage
management of sharps as cutters
per guidelines

injection room
Disinfection of sharps before OB/SI Disinfection of syringes is



charge of that.
Staff knows procedure in event SI/RR Staff knows what to do in

of needle stick injury case of sharp injury and
ME F6.3 The facility ensures Check that bins are not SI

transportation and overfilled
guidelines
146

before disposal

waste is done in closed
container/trolley
Staff is aware of mercury spill SI

management

ME G1.1 The facility has a quality There is a designated departmental SI/RR Preferably Obstetrician
team in place nodal person for coordinating
Quality Assurance activities
Standard G3 The facility have established internal and external quality assurance Programmes
ME G3.1 The facility has There is system daily round SI/RR

established internal by matron/hospital manager/
quality assurance hospital superintendent/
programme in key Hospital Manager/ Matron
departments in charge for monitoring of
services
ME G3.3 The facility has Departmental checklists are SI/RR

established system for use used for monitoring and quality
of check lists in different assurance
Staff is designated for filling and SI

monitoring of these checklists
The facility has established, documented implemented and maintained Standard Operating
Standard G4 Procedures for all key processes and support services.

Current version of SOP’s are OB/RR

ME G4.2 Standard Operating Department has documented RR

Procedures adequately procedure for receiving and
describes process and assessment of the patient for
procedures delivery
Labour room has documented RR

procedure for Emergency
obstetric care

procedure for management of
high risk pregnancy
147

procedure for rapid initial
assessment

procedure for requisition of
diagnosis and receiving of the
reports
The department has documented RR Intrapartum care includes

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

immediate post partum care

essential new born care

procedure for neonatal
resuscitation

procedure for admission, shifting
and referral of the patient
The department has documented RR Labour room management

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

procedure for blood transfusion

criteria for distinguish between
newborn death and still birth

procedure for environmental
cleaning and processing of the
equipment

procedure for maintenance of
rights and dignity of pregnant
women

record Maintenance including
taking consent
148

ME G4.3 Staff is trained and aware Check if 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 AMSTL, PPH,Infection

displayed at Point of use protocols are displayed control,Eclamsia, New
born resuscitation,
kangaroo care

Standard G5
periodic internal periodic interval
assessment
ME G5.3 The facility ensures Non Compliance are enumerated RR/SI

non compliances are and recorded
enumerated and recorded
adequately
ME G5.4 Action plan is made on Time bound Action plan is RR/SI

the gaps found in the prepared for improvement

ME G6.2 The facility periodically Quality objective for labour RR/SI
defines its quality room are defined
objectives and key
own objectives
ME G6.3 Quality policy and objectives Check if staff is aware of quality SI

are disseminated and staff is policy and objectives
aware of that

periodically
Standard G7 Facility seeks continually improvement by practicing Quality method and tools.
services
5S SI/OB
149

ME G7.2 Facility uses tools for 6 basic tools of Quality SI/RR
services
Area of Concern - H Outcome

ME H1.1 Facility measures Normal Deliveries per 1000 RR
productivity Indicators on population
monthly basis
Proportion of deliveries RR
conducted at night
Proportion of complicated RR
cases managed
Proportion of assisted delivery RR

conducted
% PPIUCD inserted against RR

total IUCD
ME H1.2 The Facility measures Proportion of BPL Deliveries RR

equity indicators
periodically
ME H2.1 Facility measures Proportion of cases referred to RR
efficiency Indicators on OT
monthly basis
Proportion of cases referred to RR

Higher Facilities
% of newborns required RR
resuscitation out of total live
births
% of newborns required RR
resuscitation out of total live
births
ME H3.1 Facility measures Clinical Proportion of cases partograph RR
Care and Safety Indicators maintained
on monthly basis
Episiotomy site infection rate RR
No of adverse events per RR

thousand patients
150

Culture Surveillance sterility rate RR % of environmental swab
culture reported positive
Proportion of cases of different RR PPH, Eclampsia,

complications obstructed labour etc.
Rational oxytocin usage Index RR No. of Oxytocin doses

used /No. of normal
deliveries conducted
ME H4.1 Facility measures Service Patient satisfaction RR
monthly basis
151


STANDARDS FOR CHC
Checklist for Inpatient
Department
152
Checklist for Inpatient Department

ME A1.9 Services are available Availability of admiossion SI/OB Co-relate with night
for the time period as facilities 24x7 admission rate
mandated
ME A1.10 The facility provides Availability of accident and SI/OB

Accident and Emergency trauma beds.
Services
ME A2.2 The facility provides Availability of indoor services SI/OB Separate beds for delivery
Maternal health Services for Antenatal cases, Normal cases in female ward.
delivery and LSCS
ME A2.4 The facility provides Child Indoor Management of Severe SI/RR

health Services Diarrhoea with
dehydration
Indoor Management of Acute SI/RR

Respiratory Infections
Seizers and convulsions SI/RR
Shock SI/RR
Accidental poisoning SI/RR
Services Under RSBY SI/RR
Standard A4 The facility provides services as mandated in national Health Programmes/ state scheme
ME A4.1 The facility provides Availability of Indoor services SI/RR Malaria, Kalaazar,
services under National for Management of vector Dengue and Chikunguna
Vector Borne Disease borne diseases AES/Japanese
Control Programme as per Encephalitis as prevelant
guidelines locally
ME A4.2 The facility provides services Indoor treatment of SI/RR

under Revised National TB TB patients requiring
Control Programme as per hospitalization
guidelines
ME A4.3 The facility provides services Inpatient Management of SI/RR

under National Leprosy severly ill cases
Eradication Programme as
per guidelines
ME A4.4 The facility provides services Inpatient care for cases SI/RR
under National AIDS Control requiring hospitilization
Programme as per guidelines
153

ME A6.1 The facility provides Availability of indoor Services SI/RR
curatives and preventive as per local prevalent disease
services for the health
problems and diseases,
prevalent locally.
Area of Concern - B Patient’s Rights

Standard B1 The facility provides information to care seekers, attendants and community about
ME B1.1 The facility has uniform Availability departmental OB Numbering rooms, main
and user-friendly signage signage’s department Male and
system female and inter-sectional
signage
Visiting hours and visitor policy OB

are displayed
ME B1.2 The facility displays the Entitlements under National OB

services and entitlements Health Programmes are
available in its departments displayed
Contact details of referral OB

transport / ambulance displayed
ME B1.4 User charges are displayed User charges if any are OB

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

to understand
ME B1.8 The facility ensures Discharge summary is given to RR/OB

access to clinical records the patient
personnel
Standard B2
and there are no barrier on account of physical , economic, cultural or social status.
ME B2.1 Services are provided in Separate male and female wards OB Where ever male and
manner that are sensitive female are kept in same
to gender wards male and female
area are demarcated
Male and female toilets are OB/SI

demarcated
Access to toilet should not go through OB

opposite sex patient care area
154

Male attendants are not allowed OB/SI
to stay in night in Female ward
There is no discrimination with SI/PI

transgender patients
No unnecessary /non-essential SI/PI/RR

disclosure of a person’s trans-
gender status
Cots in Female ward are large OB

enough for stay of mother with
child
Access to facility is Availability of Wheel chair or OB

ME B2.3 provided without any stretcher for easy Access to the
physical barrier and and ward
disabilities
Availability of disable friendly OB

toilet
Standard B3 The facility maintains privacy, confidentiality and dignity of patient, and has a system
ME B3.1 Adequate visual privacy Availability of screens / Curtains OB Bracket screen
is provided at every point
of care
Examination/ Dressing of OB
patient is done in enclosed area
No two patients are treated on OB

one bed
Partitions separating men and OB

women are robust enough to
prevent casual overlooking and
overhearing
ME B3.2 Confidentiality of patients Patient Records are kept in a SI/OB

records and clinical secure place, beyond access to
No information regarding SI/OB

patient identity and details are
unnecessary displayed on BHT/
casesheet/case paper/ Case sheet
ME B3.3 The facility ensures the Behaviour of staff is empathetic OB/PI

services
155

ME B3.4 The facility ensures HIV status of patient is not SI/OB
privacy and confidentiality disclosed except to staff that is
to every patient, especially directly involved in care
of those conditions having
social stigma, and also
safeguards vulnerable
groups
Standard B4
ME B4.1 There is established General Consent is taken before SI/RR

procedures for taking admission
ME B4.4 Information about the Patient is informed about PI

treatment is shared with clinical condition and treatment
patients or attendants, being provided
regularly
ME B4.5 The facility has defined Availability of complaint box OB

and established grievance and display of process for
redressal system in place grievance redressal and with
contact details
The facility ensures that there are no financial barrier to access, and that there is
Standard B5
ME B5.1 The facility provides Stay in wards is free for entitled PI/SI
cashless services to patients under NHP and as per
pregnant women, mothers state schemes
and neonates as per
schemes
Drugs and consumables under PI/SI

NHP are frely available to
entitled personal
Availability of free diagnostics PI/SI

to entitled personal
Availablity of Free drop back to PI/SI

entitled personal
Availablity of Free diet to PI/SI

beneficiaries mother
Availablity of Free patient PI/SI

transport facility including drop
back
Availabliity of Free Blood PI/SI
Availablity of Free drugs PI/SI
156

ME B5.2 The facility ensures that Check that patient and PI/SI
drugs prescribed are attendents have not spent
available at Pharmacy and money on purchasing drugs or
wards consumables from outside.
ME B5.3 It is ensured that facilities Check that patient and PI/SI

for the prescribed attendents have not spent
investigations are money on diagnostics from
available at the facility outside.
ME B5.4 The facility provide free of All treatments are free of cost PI/SI/RR
cost treatment to Below for BPL Patients
hassles
ME B5.6 The facility ensure Cashless treatment been provide SI/RR

implementation of health to smart card holders
insurance schemes as per
National /state scheme
ME C1.1 The departments has Adequate space in wards with OB Distance between centres
adequate space as per no cluttering of beds of two beds – 2.25 meter
ME C1.2 Patient amenities are Functional toilets with running OB 1:12 Male and 1:8 Female
provided as per patient water and flush are available as
load per strength and patient load
of ward
Functional bathrooms with OB

running water are available as
per strength and patient load
of ward
Availability of drinking water OB
Patient/ visitor Hand washing OB

area
Separate toilets for visitors OB
TV for entertainment and IEC OB

activities
Adequate shaded waiting area is OB

provided for attendants of patient
ME C1.3 The department has Availability of Dedicated nursing OB

layout and demarcated station
157

Availability of Examination room OB
Availability of Treatment room OB
Availability of Doctor’s Duty OB

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

patient and visitors and trolley/ 3 metre wide
equipment movement

infrastructure for telephone and Intercom Services
intramural and extramural
communication
ME C1.6 Service counters are There is separate nursing OB

available as per patient station for each ward
load
ME C1.7 The facility and Indoor beds have functional OB

departments are planned linkages with OT and labour
to ensure structure room.
Location of nursing station and OB

patients beds enables easy and
direct observation of patients
ME C2.1 The facility ensures Non structural components are OB Check for fixtures and
158

ME C2.2 The facility ensures safety IPD ward does not have OB Switch Boards other
of electrical establishment temporary connections and electrical installations are
loosely hanging wires intact
ME C2.3 Physical condition of Floors of the ward are non OB

the building is safe for slippery and even surpad
Windows and vents if aany are OB

intact and sealed
ME C2.4 The facility has a plan for Ward has sufficient fire exit OB/SI
prevention of fire to permit safe escape of its

are clearly marked.
ME C2.5 The facility has adequate IPD has installed fire OB

fire fighting Equipment Extinguishers that are capable
of fighting A,B and C type of fire

mentioned
ME C2.6. The facility has a system Check for staff competencies SI/RR
The facility has adequate qualified and trained staff, required for providing the assured
Standard C3
ME C3.1 The facility has adequate Availability of specialist doctor OB/RR
specialsit docotors as per on call
service provision.
ME C3.2 The facility has adequate Availability of at least one OB/RR

general duty doctors as doctor at all time
per service provision
ME C3.3 The facility has adequate Availability of Nursing staff OB/RR/SI As per patient load
nursing staff as per service
ME C3.5. The facility has adequate Availability of ward attendant/ SI/RR

support / general staff Ward boy/Aya
Availability of Security staff SI/RR
ME C3.6. The staff has been provided Biomedical waste management SI/RR
required training / skill sets
159

hygiene
Resuscitation (CPR) SI/RR
ME C3.7 The Staff is skilled as per Nursing staff is skilled for

job description maintaining clinical records SI/RR
ME C4.1 The departments have Availability of Analgesics/ OB/RR
availability of adequate Antipyretics/Anti Inflammatory
Availability of Antibiotics OB/RR
Availability of Infusion Fluids OB/RR
Availability of Drugs acting on OB/RR

CVS
Availability of drugs action on OB/RR

CNS/PNS
Drugs for Respiratory System OB/RR
Availability of Medical gases OB/RR Availability of Oxygen

Cylinders
Availability of dressing material OB/RR
ME C4.2 The departments have Availability of syringes and IV OB/RR

adequate consumables at Sets /tubes
point of use
Availability of Antiseptic OB/RR Betadine

Solutions
Availability of dressing material OB/RR
ME C4.3 Emergency drug trays are Availability of emergency drug OB/RR E.g. Inj Dopamine
maintained at every point tray Inj Hydro Cortisone
of care, where ever it may Succinate Inj Adrenaline
be needed
and instruments for Equipment andInstruments for Thermometer, Foetoscope,
examination and examination and Monitoring Baby and Adult weighing
monitoring of patients scale, Stethoscope
160

ME C5.2 Availability of equipment Availability of dressing tray OB
and instruments for
treatment procedures, being
ME C5.3 Availability of equipment Availability of Point of care OB Glucometer

and instruments for diagnostic instruments
diagnostic procedures being
ME C5.4 Availability of equipment Availability of functional OB Ambu bag and mask

and instruments for Instruments for Resuscitation. (adult and paediatric),
resuscitation of patients Oxygen, Suction machine,
and for providing intensive Airway, Nebulizer, Suction
and critical care to patients apparatus, Laryngoscope,
Endotrachial Tube


equipment and cleaning mops, duster, waste
instruments for support trolley, Deck brush
services
Availability of equipment for OB Sterilizer

sterilization and disinfection
ME C5.7 Departments have patient Availability of patient beds with OB

furniture and fixtures as per prop up facility
load and service provision
Availability of attachment/ OB Hospital grade mattress,

accessories with patient bed Bed side locker, IV stand,
Bed pan
Availability of Fixtures OB Spot light, electrical fixture

for equipments like suction,
X ray view box
Availability of furniture OB Cupboard, Nursing counter,

Table for preparation of
medicines, Chair.
Area of Concern - D Support Service

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

161

ME D1.2 The facility has established All the measuring equipment/ OB/ RR BP apparatus, wighing
procedure for internal instrument are calibrated scale etc are calibrated
measuring Equipment
Standard D2
ME D2.1 There is established There is established system SI/RR Stock level are daily
procedure for forecasting of timely indenting of updated
and indenting of drugs consumables and drugs at Requisition are timely
and consumables nursing station placed

consumables

labelled
ME D2.4 The facility ensures Expiry dates’ are maintained at OB/RR

No expiry drug found OB/RR

the drugs in patient care cart
areas
controlled temperature Separate prescription for
narcotic and psychotropic
drugs
ME D2.8 There is a procedure for Narcotic and psychotropic OB/SI

secure storage of narcotic drugs are identified and stored
and psychotropic drugs in lock and key
The facility has established Program for maintenance and upkeep of the faciity to provide
Standard D3
ME D3.1 Exterior of the facility Building is painted/whitewashed OB
building is maintained in uniform colour
appropriately
Interior of patient care areas are OB

plastered and painted
ME D3.2 Hospital infrastructure is Check to ensure that there is OB

adequately maintained no seepage, Cracks, chipping of
plaster
162

fixtures are intact
Patients beds are in good OB

condition and painted
ME D3.3 Patient care areas are Floors, walls, roof, roof tops, sink OB All area are clean with no
clean and hygienic in patient care and circulation dirt,grease,littering and
areas are clean cobwebs

are clean

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

removal of condemned the ward
junk material

procedures for pest, rodent
and animal control
ME D3.6 The facility provides Adequate Illumination at OB

adequate illumination nursing station
Adequate illumination in OB
patient care areas
ME D3.7. The facility has provision Visiting hour are fixed and are OB/PI
of restriction of visitors in observed
patient areas
One family members is allowed

to stay with the patient
ME D3.8 The facility ensures Temperature control and OB/SI Fans/ Air conditioning/
safe and comfortable ventilation in patient care area Heating/Exhaust/Ventilators
environment for patients as per environment
and service providers condition and requirement
Temperature control and PI/OB Fans/ Air conditioning/

ventilation in nursing station/ Heating/Exhaust/Ventilators
duty room as per environment
condition and requirement
ME D3.10 The facility has established Ask female staff weather they SI/OB
163

The facility ensures 24x7 water and power backup as per requirement of
Standard D4
service delivery, and support services norms
arrangement for storage potable water
and supply for potable
water in all functional areas

adequate power backup patient care areas
per load
ME D4.3 Critical areas of the Availability of Oxygen cylinders OB

facility ensures availability and vacuum suction
and vacuum supply
The facility ensures avaialblity of Diet as per nutritional requirement of the patients
Standard D5
ME D5.1 The facility has provision Appropriate diet as per nutriational RR/SI
of nutritional assessment requirement of the patients are
of the patients precribed by the treating doctor
ME D5.2 The facility provides diets Check for the adequacy and OB/RR Check that all items fixed
according to nutritional frequency of diet as per in diet menu is provided
requirements of the patients nutritional requirement to the patient
Check for the Quality of diet PI/SI Ask patient and check the
provided record
ME D5.3 Hospital has standard There is procedure of requisition RR/SI Normal, Semi-solid, Liquie
procedures for preparation, of different type of diet from dite, diet for diabetic
handling, storage and ward to kitchen patients, low salt and high
distribution of diets, as per protein diet etc
ME D 5.4. The facility has adequate Clean Linens are provided for all OB/RR
sets of linen occupied bed
Gown are provided to the cases OB/RR

going for surgery or delivery
Availability of Blankets, draw OB/RR

sheet, pillow with pillow cover
and mackintosh
ME D5.5. The facility has established Linen is changed daily / OB/RR

procedures for changing of whenever it get soiled
ME D5.6. The facility has standard There is a system to check the SI/RR
procedures for handling , cleanliness and Quantity of the
164

Standard D9
ME D9.1 The facility has Staff is aware of their role and SI
established job description responsibilities
as per govt guidelines

for department

code as mandated by respective dress code
its administration / the
health department

ME E1.1 The facility has established Unique identification number RR

recorded in admission records demographics like Name,
Age, Sex, provisional
diagnosis, etc.
ME E1.3 There is established There is no delay in admission of SI/RR/OB

procedure for admission patient
of patients
Admission is done by written SI/RR/OB

order of a facilitys doctor

patient record
ME E1.4 There is established There is provision of extra Beds OB/SI

procedure for managing
patients, in case beds are
Standard E2 The facility has defined and established procedure for clinical assessment and reassessment of patients
ME E2.1 There is established Initial assessment of all RR/SI The assessment criteria for
procedure for initial admitted patient is done as per different clinical conditions
assessment of patients standard protocols are defined and measured in
assessment sheet
Patient History is taken and RR

recorded
165

Physical Examination is done RR
and recorded wherever required
Provisional Diagnosis is RR
maintained
Initial assessment and treatment RR/SI

is provided immediately
Initial assessment is documented RR

preferably within 2 hours
ME E2.2 There is established There is fixed schedule for RR/OB

procedure for follow-up/ assessment of stable patients
reassessment of Patients
For critical patients admitted in RR/OB

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 over of
continuity of care during patients from one department to
interdepartmental transfer other department
There is a procedure for RR/SI

consultation of the patient
with other specialist with in the
hospital
ME E3.2 The facility provides Patients are referred with RR/SI

appropriate referral referral slip
linkages to the patients/
Services for transfer to
assure the continuity of
care.

higher centre
Referral vehicle is arranged SI/RR

Facility has functional referral SI/RR Check for referral cards

linkages to lower facilities filled from lower facilities

referred patients
166

ME E4.1 Procedure for identification There is a process for ensuring OB/SI Patient id band/ verbal
of patients is established at the identification before any confirmation/Bed no. etc.
the facility clinical procedure
ME E4.2 Procedure for ensuring Treatment chart are maintained RR Check for treatment chart
timely and accurate are updated and drugs
nursing care as per given are marked. Co
treatment plan is relate it with drugs and
established at the facility doses prescribed.
There is a process to ensue the SI/RR Verbal orders are

accuracy of verbal/telephonic rechecked before
orders administration

procedure of patient hand during the change of the shift
change happens

maintained
Bed side hand oven is given SI/RR
maintained adequately register. Notes are
adequately written
ME E4.5 There is procedure for Patients vital are monitored and RR/SI Check for TPR chart, IO
periodic monitoring of recorded periodically chart, any other vital
patients required is monitored
Critical patients are monitored RR/SI

continually
Standard E5 The 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 and identified and measures are unconscious. Psychotic
ensure their safe care taken to protect them from any and serious patients are
harm identified
ME E5.2 The facility identifies high High risk patients are identified OB/SI
risk patients and ensure and treatment given on priority
their care, as per their
need

Standard E6
ME E6.1 The facility ensured that Check for BHT/casesheet/case RR
drugs are prescribed in paper if drugs are prescribed
generic name only under generic name only
167

rational use of drugs Treatment Guideline are
Check if staff are aware of the drug SI/RR

regime and doses as per Standard
Treatment Guidelines (STG)
Check BHT/casesheet/case paper RR

that drugs are prescribed as per
STG
ME E7.1 There is process for High alert drugs are identified in SI/OB Electrolytes like Potassium
identifying and cautious the department chloride, insulin etc. as
administration of high applicable
alert drugs

with nursing station and
doctor

Error prone medical


clinical staff

used later on
Check for separate sterile needle OB In multi dose vial needle

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

168

given to right patient patient, right drugs , right route,
right time
ME E7.5 Patient is counselled for Patient is advice by doctor/

self drug administration Pharmacist /nurse about the
dosages and timings .
Standard E8 The facility has defined and established procedures for maintaining, updating of
ME E8.1 All the assessments, Day to day progress of patients RR

re-assessments and is recorded in BHT/casesheet/
investigations are case paper
ME E8.2 All treatment plan Treatment plan, first orders are RR Treatment prescribed and
prescription/orders are written on BHT/casesheet/case nursing records
recorded in the patient paper
records.

patient is recorded in the chart/treatment registers recorded in treatment
patient records chat
ME E8.4 Procedures performed Any procedure performed is RR Dressing, Mobilization etc

are written on patients written on BHT/casesheet
records
ME E8.5 Standard Format for bed head RR/OB Availability of formats

Adequate form and ticket/ Patient case sheet is for Treatment Charts,
formats are available at available as per state guidelines TPR Chart , Intake Output
point of use Chat Etc.
ME E8.6 Register/records are Registers and records are RR General order book (GOB),
maintained as per maintained as per guidelines report book, Admission
guidelines register, lab register,
Admission sheet/ bed
head ticket, discharge
slip, referral slip, referral
in/referral out register,
OT register, Diet register,
Linen register, Drug
intend register
All register/records are identified RR

and numbered
ME E8.7 The facility ensures safe Safe keeping of patient records OB

and adequate storage
and retrieval of medical
records
169

ME E9.1 Discharge is done after Assessment is done before SI/RR
assessing patients readiness discharging patient
Discharge is done by a SI/RR

authorized doctor
Patient / attendants are PI/SI

Treating doctor is consulted/ SI/RR

informed before discharge of
patients
ME E9.2 Case summary and follow- Discharge summary is provided RR/PI See for discharge
up instructions are provided summary, referral slip
at time of discharge provided.
Discharge summary mentions RR

adequately patients clinical
follow up
Discharge summary is given to SI/RR

patients going on LAMA/Referral
ME E9.3 Counselling services are Patient is counselled before SI/PI

provided as during discharges discharge
wherever required
Time of discharge is PI/SI

communicated to patient in
prior
The facility has established Declaration is taken from the RR/SI

ME E9.4 procedure for patients LAMA patient
leaving the facility
against medical advice,
absconding, etc
Roles and responsibilities of the SI/RR

Standard E11 The facility has defined and establised procedures of diagnostic services
Activities

procedures for Post- the critical value of different tests
testing Activities
170

Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion
of blood

before transfusion
blood is kept on optimum RR


Blood transfusion note is RR

written in patient’s recorded
Paediatric blood bags are RR/SI

available as per requirement
ME E12.6 There is a established Any major or minor transfusion RR

and reporting Transfusion reported to responsible staff
complication
Standard E13 The facility has established procedures for Anaesthetic Services
ME E13.1 The facility has established Pre anaesthesia check up is SI/RR
procedures for Pre- conducted for elective / Planned
anaesthetic Check up and surgeries
maintenance of records
ME E15.1 Death of admitted patient Facility has a standard procedure SI
is adequately recorded to decent communication of
and communicated death to relatives
Death note is written in patient RR

record
ME E15.2 The facility has standard Death summary is given to SI/RR

procedures for handling patient attendant quoting the
the death in the hospital immediate cause and underlying
cause if possible
Death note including efforts RR

done for resuscitation is noted
in patient record
ME E15.4 The facility has standard All the deaths where Post- RR
procedures for referring mortem is mandatory, dead
for post-mortem, its bodies are referred to a facility
recording and meeting its as per as state’s procedure
obligation under the law
171

Facility has system for storage/ OB/RR
transfer of unclaimed body
for fixed duration as per state
guideline
Facility has system for disposal RR

of unclaimed bodies as per state
guideline
ME E16.1 There is an established Facility provides and updates RR/SI

procedure for Registration Mother and Child Protection
and follow up of pregnant Card
women
ME E16.4 There is an established Management of PIH and referral RR/SI Loading dose of
procedure for identification of eclampsia cases Magnesium sulphate is
of High risk pregnancy and given before referral
appropriate treatment/
referral as per scope of
services
Management of sepsis RR/SI
Initial Management and Referral RR/SI

of diabetic pregnant mother
ME E16.5 There is an established Management of of severe RR/SI Blood Transfusion services

procedure for anaemia and referral available for anaemic
identification and patients
management of moderate
and severe anaemia
ME E18.1 Post partum Care is Post Partum Care of Newborn SI/RR Maintaining hand hygiene,
provided to the mothers keeps the baby wrapped
(maintains temperature),
Checks weight, temperature,
respiration, heart rate,
colour of skin and cord
stump
Initiation of Breastfeeding with PI Verify with mother

in 1 Hour regarding
A. Counselling in breast
feeding
B. Time period between
delivery and first feed
C. Advice in position of
body
172

Post partum care of mother PI/RR Ask mother about checking
uterine contraction,
bleeding, checking for TPR
and output chart, Breast
examination and milk
initiation and perineal
washes
ME E18.2 The facility ensures 48 Hour Stay of mothers and SI/RR

adequate stay of mother new born after delivery
and newborn in a safe
environment as per
standard Protocols.
ME E18.3 There is an established Counselling provided for Post PI/SI Nutrition ,Contraception
procedure for Post partum care ,Breastfeeding ,Registration
partum counselling of of Birth ,IFA Supplement
mother ,Danger Signs.
ME E18.4 The facility has There is established criteria for SI/RR

established procedures for shifting newborn to NBSU and
stabilization/treatment/ referring to SNCU
referral of post natal
complications
ME E18.5 There is established Patient is explained about follow RR/PI Danger Sign For Mother:
procedure for discharge up visits. Counselling is done Bleeding, pain abdomen,
and follow up of mother before discharge severe Headache, Visual
and newborn. disturbance, Breathing
difficulties, Fever and Chills,
difficulty in Urination,
foul smelling discharge.
Danger sign for Baby: Fast
and difficult breathing,
fever, unusal cold, Does not
accept feed less active and
yellow discoluration of skin
ME E19.1 The facility provides Zero dose vaccines are given RR Check for records BCG,
immunization services as Hepatitis B and OPV 0
per guidelines given to New born
ME E19.2 “Triage, Assessment and 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 available SI/RR Emergency, priority and

can wait
Staff is aware and practices SI/RR

ETAT protocols
173

Staff is skilled in basic life SI/RR
support for infants and
children
ETAT checklist is available and SI/RR

practiced
ME E19.3 “Management of Low Care of Low Birth Weight and SI/RR Premature and LBW babies
birth weight newborns is Premature babies are identified: Weight less
done as per guidelines “ 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 is arranged,
if required
ME E19.5 “Management of children Differential diagnosis algorithm SI/RR

presenting with fever, are available
cough/ breathlessness is
done as per guidelines “
Weight chart is maintained RR
Start-up and catch formula SI/RR check for composition

made as per guidelines
ME E19.7 “Management of children Assessment of dehydration done SI/RR

presenting diarrhoea is as per protocols
done per guidelines “
National Health Program The facility provides National health Programme

Standard E22
as per operational/Clinical Guidelines
ME E22.9 The facility provide service Weekly reporting of Presumptive SI/RR
for Integrated disease cases on form “P” from IPD
surveillance Programme

Standard F1 The facility has infection control Programme and procedures in place for prevention
ME F1.3 The facility measures There is a procedure to report SI/RR Patients are observed for
hospital associated cases of Hospital acquired any sign and symptoms
infection rates infection of HAI like fever, purulent
discharge from surgical site.
ME F1.4 There is Provision of There is procedure for SI/RR Hepatitis B, Tetanus Toxid
Periodic medical checkups SI/RR

of the staff
174

ME F1.5 The facility has Regular monitoring of infection SI/RR Hand washing and
established procedures control practices infection control
for regular monitoring of audits done at periodic
infection control practices intervals
ME F1.6 The facility has defined and Check if Doctors are aware of SI/RR
established antibiotic policy Hospital Antibiotic Policy
use of use
Availability of running Water OB/SI Open the tap. Ask the Staff, if
water is 24x7

uninterrupted
Display of Hand washing OB/SI Prominently displayed

Instructions at Point of Use above the hand washing
Local language
Availability of elbow operated taps OB

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

hand wash

Proper cleaning of procedure OB/SI like before giving IM/IV

site with antisepsis injection, drawing blood,
urinary catheter
ME F3.1 The facility ensures Clean gloves are available at OB/SI
adequate personal point of use
protection Equipment as
per requirements
175

ME F3.2 The facility staff adheres No reuse of disposable gloves, OB/SI

to standard personal Masks, caps and aprons.
protection practices
Compliance to correct method of SI

wearing and removing the gloves
ME F4.1 The facility ensures Decontamination of operating SI/OB Ask staff about how
standard practices and Procedure surfaces they decontaminate the
decontamination and Examination table , Patients
cleaning of instruments Beds Stretcher/Trolleys etc.
and procedures areas (Wiping with .5% Chlorine
solution
Proper Decontamination of SI/OB Decontamination of

instruments after use instruments and reusable
glassware are done after
procedure in 1% chlorine
soultion/ any other
appropriate matter


running water after
decontamination

Patient care area

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

instrument/equipment is done and time required for
Autoclaved dressing material is used OB/SI
176

materials for cleaning and acid
disinfection of patient
care areas

solution
ME F5.3 The facility ensures Staff is trained for spill SI/RR

and disinfection of
patient care areas


standard procedure


are not used in patient care leading to dispersion
areas of dust particles in air
should be avoided

segregation infectious procedure are followed for
The facility has defined and established procedures for segregation, collection, treatment
Standard F6
ME F6.1 The facility Ensures Availability of color coded bins OB
Waste as per guidelines and
‘on-site’ management of
waste is carried out as per
guidelines
Availability of plastic color OB

coded plastic bags

guidelines

Biomedical waste
177

and general waste
ME F6.2 The facility ensures Availability of functional needle OB Verify it’s usage
per guidelines

injection room



charge of that.
Staff knows procedure in event SI/RR Staff knows what to do

of needle stick injury in case of sharp injury
and Whom to report. See
if any reporting has been
done
ME F6.3 The facility ensures Check bins are not overfilled SI/OB
Disinfection of liquid wate SI/OB

before disposal
Staff aware of mercury spill SI

management

Standard G1 Facility has established organizational framework for quality improvement
ME G1.1 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 Patient satisfaction survey done RR
surveys are conducted at on monthly basis
periodic intervals
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 daily round by SI/RR
internal quality assurance matron/hospital superintendent/
programme in key Hospital Manager for
departments monitoring of services
178

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

Standard G4 The facility has established, documented implemented and maintained Standard


describes process and initial assessment of the patient
procedures

procedure for admission, shifting
and referral of patient

procedure for requisition of
diagnosis and receiving of the
reports

procedure for preparation of the
patient for surgical procedure

procedure for transfusion of
blood

rights and dignity of Patient

procedure for record maintenance
including taking consent

procedure for counselling of the
patient at the time of discharge

procedure for environmental
cleaning and processing of the
equipment
179

procedure for sorting, and
distribution of clean linen to
patient

procedure for end of life care
ME G4.3 Staff is trained and aware Check staff is a aware of SI/RR

in SOPs
ME G4.4 Work instructions are Work instruction/clinical OB Patient safety, CPR

displayed at Point of use protocols are displayed
Standard G5 The facility has established system of periodic review as internal assessment,
assessment
ME G5.2 The facility conducts the There is procedure to conduct RR/SI

periodic prescription/ Medical Audit

Prescription audit

Death audit
ME G5.3 The facility ensures Non Compliance are RR/SI

non compliances are enumerated and recorded
adequately


ME G6.2 The facility periodically Quality objective for IPD are RR/SI
objectives and key
own objectives
ME G6.3 Quality policy and objectives Check if the staff is aware of SI

is aware of that
180

ME G6.4 Progress towards quality Quality objectives are SI/RR
objectives is monitored monitored and reviewed
periodically periodically
Standard G7 The facility seeks continually improvement by practicing Quality method and tools.
ME G7.1 The facility uses method PDCA
for quality improvement
in services 5S SI/OB
Mistake proofing SI/OB
Six Sigma SI/RR
ME G7.2 The facility uses tools for 6 basic tools of Quality SI/RR
services

ME H1.1 Facility measures Bed Occupancy Rate of Male RR
productivity Indicators on Ward
monthly basis
Bed Occupancy Rate for Female ward RR

ME H2.1 Facility measures Referral Rate RR
efficiency Indicators on
monthly basis
Bed Turnover rate RR
Discharge rate RR
No. of drugs stock out in the ward RR
ME H3.1 Facility measures Clinical Average length of stay for Male RR
Care and Safety Indicators wards
on monthly basis
Average length of stay for Female ward RR
Time taken for initial assessment RR
ME H4.1 Facility measures Service LAMA Rate RR
monthly basis
Patient Satisfaction Score RR
181


STANDARDS FOR CHC
Checklist for New Born
Stabilization Unit
182
Checklist for New Born Stabilization Unit

ME A1.4 The Facility Provides Availability of functional NBSU SI/OB At least 4 beds.
Paediatric Services
ME A1.9 Services are available for the Availability of nursing care SI/RR
time period as mandated services at NBSU (24x7)

ME A2.3 The Facility provides Management of low birth SI/RR
Newborn health Services weight infants > or =1800 gm
with no other complication
Weighing the new born SI/RR
Resuscitation SI/RR
Prevention of infection including SI/RR

management of newborn sepsis
Provision of Warmth SI/RR
Phototherapy for new born SI/RR
Breast feeding/feeding support SI/RR

and Kangaroo Mother care (KMC)
ME A2.4 The Facility provides child Screening of New born for SI

health Services congenital Birth Defects

ME A3.1 The Facility provides Functional linkage for USG and SI/OB In house/ Parent hospital/
Radiology Services X-ray services Outsourced
ME A3.2 The Facility Provides NBSU has Linkage for laboratory SI/OB 24x7 linkage with outside
Laboratory Services investigations laboratory for critical tests
like bilirubin, Plasma glucose,
Serum creatnine, Blood count,
Platelet, C-reactive protein,
Prothrobin time, etc.

Facility provides the information to care seekers, attendants and community about the
Standard A1
available services and their modalities
ME B1.1 The facility has uniform Availability departmental OB Numbering of rooms,
and user-friendly signage signage’s main department and
system inter-sectional signage
183

Directional signage for OB
department’s are displayed
Restricted area signage displayed OB
ME B1.2 The facility displays the Entitlements under JSSK OB

services and entitlements displayed
available in its
departments
Information about Nurse on duty OB

is displayed and updated
Contact information in respect OB

of NBSU referral services are
displayed
ME B1.5 Patients and visitors are Display of information for OB Display of pictorial
sensitised and educated education of mother /relatives information/ chart
through appropriate IEC / regarding expression
BCC approaches of milk/ techniques
for assisted feeding,
KMC, immunization,
complimentary feeding
etc.

local language and easy to available in local language
understand
ME B1.8 The facility ensures Discharge summary is given to OB

access to clinical records the patient
personnel
The facility maintains privacy, confidentiality and dignity of patient’s, and has a system
Standard B3
ME B3.1 Adequate visual privacy Privacy is maintained in breast OB
is provided at every point feeding room/corner
of care
ME B3.2 Confidentiality of patients New born records are kept at a SI/OB

ME B3.3 The facility ensures that Behaviour of staff is empathetic OB/PI

ME B4.1 There is a established NBSU has system in place to SI/RR
procedure for taking take informed consent from
informed consent before newborn’s relative, whenever
treatment and procedures required
184

ME B4.4 Information about the NBSU has a system in place to PI
treatment is shared with involve newborn relatives in
patients or attendants, decision making of new born
regularly treatment
NBSU has system in place to PI/SI

provide communication on
newborn condition to parents/
relatives at least once in day
ME B4.5 Facility has defined and Availability of complaint box and OB

established grievance display of process for grievance
redressal system in place redressal and contact details
Standard B5
ME B5.1 The facility provides Availability of Free diagnostics PI/SI
cashless services to
and neonates as per
schemes
Availability of Free diet to PI/SI

beneficiaries
Availability of Free newborn PI/SI

transport including dropback
facility
Availability of Free Blood PI/SI
Availability of Free drugs PI/SI
Availability of free stay to PI/SI

mother
ME B5.2 The facility ensures that Check that newborn parents PI/SI
drugs prescribed are and attendants have not spent
available at Pharmacy and money on purchasing drugs and
wards consumables from outside.
ME B5.3 It is ensured that facilities Check that newborn parents PI/SI

for the prescribed and attendants have not spent
investigations are money on diagnostics from
available at the facility outside.
ME B5.5 The facility ensures If any other expenditure PI/SI/RR

patients
185

Standard C1
ME C1.1 The departments has Adequate space as per newborn OB Approximately 40-50
adequate space as per care units square feet per bed
new born cases work load where 4 radiant warmer
and can be kept.
ME C1.3 The department has Availability of nursing station OB

layout and demarcated
Hand washing and gowning area OB
Mother’s area for expression of OB NBSU has system in place

breast milk/ breast feeding to call mothers of babies
for feeding
ME C1.4 The facility has adequate Availability of adequate OB

circulation area and open circulation area for easy moment
spaces according to need of staff and equipment
and local law

infrastructure for Intercom and telephone services
communication
ME C1.7 The facility and NBSU is easily accessible from OB

departments are planned labour room, maternity ward
to ensure structure and OT
Location of nursing station and OB

patients beds enables easy and
direct observation of patients
Standard C2 The facility ensures physical safety including Fire safety of the infrastructure.
ME C2.2 The facility ensures safety NBSU does not have temporary OB Switch Boards other
of electrical establishment connections and loosely electrical installations are
hanging wires intact
10 central Voltage stabilizer OB/RR 50% 0f each should be

outlets are available with each 5amp and 50% should be 15
warmer in main NBSU. amp to handle equipment
186

NBSU has earthling system OB/RR Dedicated earthling pit
available system available
ME C2.3 Physical condition of Floors of the NBSU are non OB

providing new born care
Windows and vents if any are OB

intact and sealed
ME C2.4. The facility has plan for NBSU has fire exit to permit OB/SI
prevention of fire safe escape of its occupant at
time of fire
ME C2.5 The facility has a adequate NBSU has installed fire OB

fire fighting Equipment Extinguisher that are capable of
fighting A, B and C type of fire

extinguishers is displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned
ME C2.6. The facility has a system Check for staff competencies SI/RR
staff are conducted and and what to do in case of fire
conduct mock drills
regularly for fire and
The facility has appropriate number of staff with the correct skill mix required for
Standard C3
providing the assured services to the current case load
ME C3.1 The facility has adequate Availability of On call OB/RR
specialist doctors as per Paediatrician/trained FIMNCI
service provision MO.
ME C3.3 The facility has adequate Availability of one Nursing staff OB/RR/SI
nursing staff as per service per shift
ME C3.6 The staff has been Facility based New Born Care SI/RR To all Medical Officers and
provided required training (FBNC) training Nursing Staff posted at
/ skill sets NBSU
Training on Bio Medical waste SI/RR

Management
New born Safety SI/RR
ME C3.7 The Staff is skilled as per Nursing staff is skilled for SI/RR
job description operation of equipment

resuscitation of new born
187

Nursing staff is skilled in SI/RR
identifying and managing
complications
Nursing Staff is skilled for SI/RR

ME C4.1 The department has Availability of Antibiotics OB/RR Inj. Ampicillin with
availability of adequate Cloxacillin, Inj. Ampicillin
drugs at point of use Inj. Cefotaxime
Inj. Gentamycin, Inj.
Amikacin, Amoxycillin-
Clavulanic Suspension
Availability of OB/RR Paracetamol

antipyretics
Availability of IV Fluids OB/RR 5%, 10% and 25%

Dextrose Normal saline
Availability of other emergency OB/RR Inj.Adrenaline (1:10000)

drugs Inj. Naloxone
Inj. Calcium gluonate, Inj.
Phenytoin,
Injection
Aminophylline
Phenobarbitone (Injection
+oral)
Injection
Hydrocortisone, Inj.
Phenytoin
Availability of drugs for new born OB/RR Vit K
ME C4.2 The department has Availability of dressings material OB/RR Gauze piece and cotton
adequate consumables at and diapers swabs, Diapers
point of use
Availability of syringes and IV OB/RR Neoflon 24 G, micro drip set

Sets /tubes with andwithout 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,

be needed
188

Standard C5 Facility has equipments and instruments required for assured list of services.
ME C5.1 Availability of equipment Availability of functional OB Thermometer, Weighing
and instruments for Equipment andInstruments for scale, pulse oxy meter,
examination and examination and Monitoring Multipara metre.
monitoring of patients Stethoscope
ME C5.4 Availability of equipment Functional Critical care OB Infusion pumps,Oxygen

and instruments for Equipment cylinder/Oxygen
resuscitation of patients concentrator, oxygen
and for providing hood,etc
intensive and critical care
to patients
Functional Resuscitation OB Bag and mask,

equipment Laryngoscope, ET tubes,
Foot-suction
ME C5.7 The department has Availability of Fixtures OB Electrical panel with each
furniture and fixtures as per unit, X ray view box.
load and service provision
Availability of furniture OB Cupboard, nursing counter,

table for preparation of
medicines, chair, furniture
in 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 equipment are covered under SI/RR Functional radiant
system for maintenance the AMC including preventive warmer, suction machine,
of critical Equipment maintenance Oxygen concentrator,
pulse oximeter/ Multipara
monitor and their AMC
There is procedure to check

timely replacement of lights in
Phototherapy unit.
ME D1.2 The facility has established All the measuring equipment/ OB/ RR
procedure for internal and instrument are calibrated
external calibration of
measuring Equipment

users of equipment with NBSU staff.
The facility has defined procedures for storage, inventory management and dispensing
Standard D2
of drugs in pharmacy and newborn care areas
ME D2.1 There is established There is established system SI/RR “Stock level are daily
and indenting of drugs consumables and drugs at Requisition are timely
and consumables nursing station placed
189

consumables

labelled
ME D2.4 The facility ensures Expiry dates are maintained at OB/RR

No expiry drug found OB/RR
ME D2.5 The facility has established Department maintains stock and RR/SI
procedure for inventory expenditure register of drugs
management techniques and consumables

periodically replenishing replenishing Emergency drug
the drugs in newborn care tray.
areas
Standard D3 The facility has established Program for maintenance and upkeep to of the facility to provide safe,
secure and comfortable environment to the staff, patients and visitors.
ME D3.2 Hospital infrastructure is Check to ensure that there is OB
adequately maintained no seepage , Cracks, chipping of
plaster

fixtures are intact
Patients beds are intact and OB

painted
ME D3.3. Patient care areas are Floors, walls, roof, roof tops, OB All area are clean with no
clean and hygienic sinks newborn care and dirt,grease,littering and

are clean

removal of condemned the NBSU
junk material
190

ME D3.6 The facility provides Adequate Illumination at each OB

adequate illumination basinet.
ME D3.7 The facility has provision Entry to NBSU is restricted OB

of restriction of visitors in
newbornareas
Visiting hour are fixed and are OB/PI

observed
ME D3.8 The facility ensures NBSU has a system to control SI/RR Temperature inside
safe and comfortable temperature and humidity and main NBSU should be
environment for patients record of same is maintained maintained at (22-26OC),
and service providers (Air conditioning). round O clock preferably
by thermostatic control.
Relative humidity of
30-60% should be
maintained
NBSU has procedure to check SI/RR Each equipment used

the temperature of radiant should have servo
warmer ,phototherapy units, etc. controlled devices for
heat control with cut
off to limit increase in
temperature of radiant
warmers beyond a certain
temperature or warning
mechanism for sounding
alert/alarm when temp
increases beyond certain
limits
NBSU has system to control the SI/RR Background sound should

sound producing activities and not be more than 45 db
gadgets (like telephone sounds, and peak intensity should
staff area and equipment) not be more than 80 db.
NBSU has functional room SI/RR 1 for each newborn care

thermometer and temperature room
is regularly maintained
ME D3.9 The facility has a security New born identification band OB/RR
system in place at are used and foot prints of
newborn care areas babies are taken
There is procedure for handing SI

over the baby to mother/father/
legal guardian
Security arrangement in NBSU OB

are robust
191

Standard D4
ME D4.1 The facility has Availability of 24x7 running and OB/SI
arrangements for potable water
adequate storage and
ME D4.2 The facility ensures adequate Availability of power back up in OB/SI

power backup in all newborn care areas
newborncare areas as per load
ME D4.3 Critical areas of the Availability of Oxygen and OB

facility ensures availability vacuum suction
and vacuum supply
Standard D5 The facility ensures availabilty of Diet as per nutritional requirement of the patients
and clean linen to all admitted patients.
ME D5.2 The facility provides diet Check for the adequacy and OB/RR
according to nutritional frequency of feed as per
requirements of the nutritional requirement
patients
ME D5.3 Hospital has standard Facility to prepare feeds is RR/SI

procedures for preparation, available near NBSU
handling, storage and
distribution of diets, as per
ME D5.4 The facility has adequate NBSU has facility to provide OB/RR
sets of linen available sufficient and clean linen for
each patient
ME D5.5. The facility has established Linen is changed every day and OB/RR
procedures for changing of whenever it get soiled
linen in newborn care areas
ME D5.6. The facility has standard There is a system to check the SI/RR
Standard D9
ME D9.1 The facility has The staff is aware of their role SI
established job description and responsibilities
192

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

code as mandated by respective dress code
health department

ME E1.1 The facility has Unique identification number RR
established procedure for is given to each Newborn at
registration of patients time of Registration
ME E1.3 There is a established Admission criteria for NBSU are SI/RR

procedure for admission defined and followed
of patients
There is no delay in admission of SI/RR/OB
patient

new born record
ME E1.4 There is established Procedure to cope with surplus OB/SI

procedure for managing newborn load
patients, if beds are not
The facility has defined and established procedures for clinical assessment
Standard E2
and reassessment of the patients.
ME E2.1 There is established Initial assessment of all RR/SI Defined criteria
procedure for initial newborn’s is done as per for assessment like
assessment of patients standard protocols Silverman Anderson
Score and Down score
ME E2.2 There is established There is fixed schedule for RR/OB

procedure for follow-up/ periodic assessment of
reassessment of Patients newborn’s
ME E3.1 The facility has There is a procedure of taking RR/SI Check continuity of
established procedure for over of new born from labour care is maintained while
continuity of care during Room OT/ Ward to NBSU transferring/ handover
interdepartmental transfer the newborn
ME E3.2 The facility provides Newborn referred with referral RR/SI

appropriate referral linkages slip
to the patients/Services for
facilities to assure the
continuity of care.
193

higher centre
Referral vehicle is arranged SI/RR


referred patients
ME E4.1 Procedure for identification Identification tags are used for OB/SI
of patients is established at identification of newborns
the facility
ME E4.2 Procedure for ensuring Treatment chart are maintained RR Check that treatment chart’s
timely and accurate nursing are updated and drugs given
care as per treatment plan are marked. Co relate it with
is established at the facility drugs and doses prescribed.
There is a process to ensue the SI/RR Verbal orders are rechecked

accuracy of verbal/telephonic orders before administration
ME E4.3 There is established Newborn hand over is given SI/RR

procedure of newborn hand during the change in the shift
change happens

maintained
maintained adequately register and adequacy of
notes
ME E4.5 There is procedure for Vitals of newborn’s monitored RR/SI Check for TPR chart,
periodic monitoring of and recorded periodically Phototherapy chart, any
patients other required vitals are
monitored and recorded
Standard E6 for prescribing the generic drugs and their rational use.
ME E6.1 The facility ensure that Check for BHT if drugs are RR
drugs are prescribed in prescribed under the generic
generic name only name only

rational use of drugs treatment guideline are available
at point of use
Check staff is aware of the drug SI/RR

regime and doses as per STG
Check BHT that drugs are RR

prescribed as per STG
194

ME E7.1 There is process for High alert drugs are identified in SI/OB Electrolytes like Potassium
identifying administration the department chloride, Insulin, etc. as
of high alert drugs applicable

doctor

Error prone medical

adequately date , time and signature

clinical staff

used later on

is used every time for multiple not left in the septum”
dose vial

ME E7.4 There is a system to Fluid and drug dosages are SI/RR Check for calculation
ensure right medicine is calculated according to body chart
given to right newborn weight
Drip rate and volume are SI/RR Check the nursing staff
calculated and monitored how they calculate
Infusion and monitor it
Administration of medicines SI/OB

is done after ensuring right
patient, right drugs , Right dose,
195

The facility has defined and established procedures for maintaining, updating of
Standard E8
ME E8.1 All the assessments, Newborn progress is recorded as RR

re-assessments and per defined assessment schedule
investigations are
ME E8.2 All treatment plan Treatment plan are written on RR

prescription/orders are BHT and all drugs are written
recorded in the newborn legibly in case sheet
records.

newbornis recorded in the chart/treatment registers recorded in the treatment
newborn records chart
ME E8.4 Procedures performed are Procedure performed are RR Mobilization, resuscitation

written on patients records recorded in BHT etc.
ME E8.5 Adequate forms and Standard Formats are available RR/OB Availability of formats
formats are available at for Treatment Charts,
point of use TPR Chart , Intake Output
Chart, Community follow
up card, BHT, Continuation
sheet, Discharge card, etc.
ME E8.6 Register/records are Registers and records are RR General order book (GOB),
maintained as per maintained as per guidelines report book, Admission
guidelines register, lab register,
Admission sheet/ bed
head ticket, discharge
slip, referral slip, referral
in/referral out register,
OT register, Diet register,
Linen register, Drug intend
register
All register/record are identified RR

and numbered
ME E8.7 The facility ensures safe

and adequate storage All register/records are identified RR
and retrieval of medical and numbered
records
Safe keeping of newborn OB

records
ME E9.1 Discharge is done after NBSU has established criteria for SI/RR newborn is shifted to
assessing newborn’s discharge of the newborn ward/step down after
readiness assessment
Assessment is done before SI/RR

discharging newborn
196

Discharge is done by a SI/RR Preferably Paediatrician.
responsible and qualified doctor Or Doctor on duty
in consultation with
paediatrician
newborn/ attendants are PI/SI

Treating doctor is consulted/ SI/RR

informed before discharge of
patients
ME E9.2 Case summary and follow- Discharge summary is provided RR/PI See for discharge
up instructions are provided summary, referral slip
at time of discharge provided.
Discharge summary mentions RR

adequately patients clinical
follow up
Discharge summary is give to SI/RR

patients going on LAMA/Referral
There is a procedure for clinical RR/SI

follow up of the new born by
local PHC (Community health
care worker)/ASHA
ME E9.3 Counselling services are Counselling of mother before PI/SI for care of new born and
provided as during discharges discharge breastfeeding, treatment
wherever required and follow up counselling
Time of discharge is PI/SI

communicated to the attendant
prior to discharge
ME E9.4 The facility has established Declaration is taken from the RR/SI
procedure for patients LAMA newborn
leaving the facility against
medical advice, absconding
ME E10.1 There is procedure for Triaging of new born as per SI/RR
receiving and triage of guidelines
patients
ME E10.4 The facility ensures There is a system for SI/RR

adequate and timely coordination of ambulances
availability of ambulances
services and mobilisation
of resources, as per
requirement
197

NBSU 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 vehicle OB/RR

have adequate arrangement for
Oxygen
Ambulance/transport vehicle OB/RR

have dedicated rescue kit
including “ essential supplies kit”,
emergency drug kit
NBSU has system to periodic SI/RR

check of ambulances/transport
vehicle by driver/paramedic staff
and counter checked by NBSU
staff
Transfer of newborn in SI/RR

Ambulance /newborn transport
vehicle is accompanied by
trained medical Practitioner
Standard E12 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
of blood

before transfusion
Blood is kept at optimum RR

Blood transfusion is monitored and SI/RR

regulated by qualified person
Blood transfusion note is written RR

in newborn recorded
ME E12.6. There is a established Any major or minor transfusion RR

and reporting Transfusion reported to the blood storage
complication unit
ME E15.1 Death of admitted Facility has a standard procedure SI
patient is adequately which respects sensitivities and
recorded and sentiments to communicate
communicated death to relatives
198

NBSU has system for conducting RR/SI
grievance counselling of parents
in case of newborns’ mortality
Death note is written on RR

newborn record
ME E15.2 The facility has standard Death note including efforts SI/RR
procedures for handling done for resuscitation is noted in
the death in the hospital newborn record
Procedure to declare death for SI/RR

brought in dead cases exists in
the facility
Death summary is given to SI/RR

newborn attendant quoting the
immediate cause and underlying
cause if possible
ME E15.3 The facility has standard Patients Relatives are informed SI/RR
operating procedure for clearly about the deterioration in
end of life support health condition of Patients
There is a procedure to allow SI/OB

newbornrelative/Next of Kin to
observe newborn in last hours
ME E19.3 Management of Low birth Adherence to clinical protocol SI/RR Competence testing
weight newborns is done
as per guidelines
ME E19.4 Management of jaundice Adherence to clinical protocol SI/RR Competence testing

and sepsis is done as per
guidelines

Standard F1 The facility has infection control Programme and procedures in place for prevention and
ME F1.4 There is Provision of There is a procedure for SI/RR Hepatitis B, Tetanus Toxoid
Periodic medical check-ups of SI/RR

the staff
ME F1.5 The facility has Regular monitoring of infection SI/RR Hand washing and
established procedures control practices infection control audits are
for regular monitoring of done at periodic intervals
infection control practices
ME F1.6 The facility has defined Check if Doctors are aware of SI/RR
and established antibiotic Hospital Antibiotic Policy
policy
199

ME F2.1 Hand washing facilities Availability of hand washing OB FNBC guideline: Each
are provided at point of Facility at Point of Use unit should have at least
use 1 wash basin for every 5
beds

Staff, if water is 24x7

uninterrupted

Hand rub dispenser are
provided adjacent to bed

Local language

taps

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

hand washing
Mothers are practicing wash PI/OB

hand washing with soap

Procedure for proper cleaning OB/SI E.g. before giving IM/IV

site with antisepsis injection, drawing blood,
urinary catheter
200

ME F3.1 The facility ensures Clean gloves are available at OB/SI Handwashing b/w each
adequate personal point of use newborn and change of
protection Equipment as gloves
per requirements
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
ME F3.2 The facility staff adheres No reuse of disposable gloves, OB/SI

to standard personal Masks, caps and aprons.

gloves
ME F4.1 The facility ensures Cleaning and Decontamination SI/OB Cleaning of Radiant
standard practices of newborn care Units warmers and Bassinets
and materials for with detergent and water
decontamination and
cleaning of instruments
and procedure areas
Proper Decontamination of SI/OB Decontamination

instruments after use for Thermometer,
Stethoscope, Suction
apparatus, Ambu bag with
70% Alcohol or detergent
and water as applicable


running water after
decontamination

newborn care area
Staff is aware of correct SI/OB

procedure of making chlorine
solution
201

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

Autoclaving of instruments is OB/SI Ask staff about

done as per protocols temperature, pressure and
time

as per protocols contact time required for

used
There is a procedure to ensure OB/SI

the traceability of sterilized
packs

maintained during storage clean, dust free, moist free
environment.
Standard F5 Physical layout and environmental control of the newborn care areas ensures infection prevention
ME F5.1 Layout of the department Floors and wall surfaces of OB
is conducive for the NBSU are easily cleanable
infection control practices

materials for cleaning and acid.
disinfection of newborn - change of Gluteraldehye
care areas solution after 14 days
ME F5.3 The facility ensures Staff is trained for spill SI/RR

and disinfection of
newborncare areas
Cleaning of newborn care area SI/RR


standard procedure
202

Cleaning equipment like broom OB/SI Any cleaning equipment

are not used in newborn care leading to dispersion of
not be used

mopping
External foot wares are restricted OB

segregation infectious procedures are followed for
ME F5.5 The facility ensures air NBSU has system to maintain OB Ventilation can be
quality of high risk area ventilation and its environment provided in two ways:
should be 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
Standard F6 Facility has defined and established procedures for segregation, collection, treatment

coded plastic bags


Biomedical waste

and general waste
ME F6.2 Facility ensures Availability of functional needle OB Verify it’s usage

per guidelines
203

injection room



charge of that.

ME F6.3 Facility ensures Check that bins are not SI

transportation and overfilled
guidelines

before disposal
Staff aware of mercury spill SI

management

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 daily round by SI/RR
internal quality assurance Paediatrician/matron/ hospital
programme in the in charge for monitoring of
department services
ME G3.3 The facility has established Departmental checklist is used SI/RR

system for use of check for monitoring and quality
lists in the department assurance
and services

Standard G4 The facility has established, documented implemented and maintained Standard

204

ME G4.2 Standard Operating NBSU has documented RR
describes process and assessment of the patient
procedures
NBSU has documented RR

procedure for admission of the
new born

procedure for discharge of the
newborn from unit

procedure for triage of new
borns
NBSU has documented procedure RR

for assessment and treatment of
new born emergency signs

for neonatal transportation and
referral

for clinical assessment and
reassessment of the newborn and
doctor follows it

procedure for key clinical
protocols

procedure for preventive-
break down maintenance and
calibration of equipment
NBSU has documented system RR

for storage, retaining ,retrieval
of NBSU records

procedure for Maintenance of
infrastructure of NBSU

procedure for thermoregulation
of new borns

procedure for drugs, intravenous,
and fluid management and
nutrition management of new
borns
205

procedure for resuscitation of
new born if required

procedure for infection control
practices

procedure for inventory
management

procedure for entry of parents
and visitors

in SOPs
ME G4.4 Work instructions are Work instruction/clinical OB STP for phototherapy,

displayed at Point of use protocols are displayed 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
The facility maps its key processes and seeks to make them more efficient by
Standard G5
reducing non value adding activities and wastages
ME G5.1 The facility maps its Process mapping of critical SI/RR
critical processes processes is done

Standard G5
ME G5.2 The facility conducts the There is a procedure to conduct

periodic prescription/ New born Death audit RR/SI

adequately
206

ME G5.4 Action plan is made on Action plan is prepared RR/SI

ME G6.2 The facility periodically Quality objective for NBSU are RR/SI
objectives and key
own objectives

aware of that

periodically
services
5S SI/OB

services

ME H1.1 Facility measures Bed Occupancy Rate RR
productivity Indicators
on monthly basis
ME H1.2 The Facility measures Proportion of female babies RR

equity indicators admitted
periodically
Male: Female LAMA ratio RR
Proportion of BPL Patients RR
207

ME H2.1 Facility measures Proportion of low birth weight RR No. of low birth weight
efficiency Indicators on babies babies (< 2500 gm but not
monthly basis < 1800 gm)
Down time of Critical Equipment RR
Bed Turnover Rate RR
Referral Rate RR
Survival rate RR
No. of drug stock out in NBSU RR
ME H3.1 Facility measures Clinical Average waiting time for initial RR
Care and Safety Indicators assessment of newborn
on monthly basis
Proportion of newborn deaths RR
Average length of stay RR
No. of Adverse events reported RR Baby theft, wrong drug

administration, needle
stick injury, absconding
patients etc
No of Newborn Resuscitated RR
Standard H4 The facility measures service quality indicators and endeavours to reach state/national benchmarks
ME H4.1 Facility measures Service LAMA Rate RR
monthly basis
208


STANDARDS FOR CHC
Checklist for Operation
Theatre
210
Checklist for Operation Theatre

ME A1.2 The facility provides Availability of General Surgery SI/OB Incision and drainage,
General Surgery services procedures Hernia, Hydrocele,
Appendicitis,
Haemorrhoids, Fistula and
stitching of injuries.
ME A1.3 The facility provides Availability of Gynaecology SI/OB D and E, LSCS,

Obstetrics and procedures Hysterectomy.
Gynaecology Services
ME A1.9 Services are available OT Services are available 24X7 SI/RR

for the time period as
mandated
ME A1.10 The facility provides OT services are available for SI/OB

Accident and Emergency emergency cases.
Services

ME A2.1 The facility provides Availability of Post partum SI/OB Tubal ligation
Reproductive health Services sterilization services
Availability of Abortion services
ME A2.2 The facility provides Availability of C-section services SI/OB

Maternal health Services
ME A2.3 The facility provides Availability of New born SI/OB

Newborn health Services resuscitation
Availability of essential new SI/OB

born care
ME B1.1 The facility has uniform Availability of departmental OB Numbering of rooms, main
Signage for restricted area are OB

displayed
Zones of OT are marked OB

understand
211

Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and
Standard B2
there are no barrier on account of physical, economic, cultural or social status.
ME B2.1 Services are provided in Availability of female staff if a OB/SI Availability of female staff
manner that are sensitive male doctor examination/ conduct in pre and post operative
to gender surgery of a female patient room
ME B2.3 Access to facility is provided Availability of Wheel chair or OB

without any physical barrier stretcher for easy Access to the
and and friendly to people OT
with disabilities
Standard B3 Facility maintains the privacy, confidentiality and Dignity of patient and related information.
ME B3.1 Adequate visual privacy Availability of screen between OB
is provided at every point two OT tables
of care
Patients are properly draped/covered OB

before and after procedure.
ME B3.2 Confidentiality of patients Patient Records are kept at SI/OB

ME B3.3 The facility ensures the Behaviour of staff is empathetic PI/OB

ME B3.4 The facility ensures privacy Privacy and Confidentiality of SI/OB

and confidentiality to every cases in relatively young women
patient, especially of those
vulnerable groups
Privacy and confidentiality of SI/OB
Hysterectomy
Standard B4
ME B4.1 There is established Informed/Written consent is SI/RR
procedures for taking taken before any surgery
Anaesthesia Consent for OT SI/RR
ME B4.4 Information about the Patient’s attendant is informed PI/SI

treatment is shared with about clinical condition and
patients or attendants, regularly treatment being provided
Patient/Attendant is informed about PI/SI

Possible outcomes/risks involved/
alternatives avaialable of surgery
212

Standard B5 Facility ensures that there are no financial barrier to access and that there is financial
ME B5.1 The facility provides All surgical procedures are free PI/SI JSSK
cashless services to of cost for JSSK beneficeries
and neonates as per
schemes
All drugs and consumables are

free for JSSK benefieries
ME B5.2 The facility ensures that Check that patient/attendents PI/SI

drugs prescribed are have not spent money on
available at Pharmacy and purchasing and consumables
wards from outside.
ME B5.3 It is ensured that facilities Check that patient party have PI/SI
for the prescribed not spent money on diagnostics
investigations are from outside.
ME B5.4 The facility provide free of Surgical services are free for BPL PI/SI/RR
hassles

Standard C1
ME C1.1 Departments have Adequate space for OB
adequate space as per accommodating surgical load
Waiting area for attendants OB
ME C1.2 Patient amenities are Seating arrangement for patient OB

provide as per patient load and attendants
ME C1.3 Department has layout Demarcated Protective Zone OB

and demarcated areas as
per functions
Demarcated Clean Zone OB
Demarcated sterile Zone OB
Demarcated disposal Zone OB
Availability of Changing Rooms OB
Availability of Pre Operative/ OB

Post operative Room
213

Availaility of Scrub Area OB
Availability of earmarked area OB

for newborn Corner
Availability of Autoclave room/ OB

TSSU
Availability of dirty utility area OB
Availability of store OB
ME C1.4 The facility has adequate Corridors are wide enough for OB 2-3 meters
circulation area and open movement of trolleys
spaces according to need
and local law

communication
ME C1.7 The facility and Unidirectional flow of goods and OB No cris cross of infectious
department are planned services and sterile goods
to ensure structure
ME C2.2 The facility ensures safety OT does not have temporary OB

of electrical establishment connections and loosely
hanging wires
ME C2.3 Physical condition of Floors of the ward are non OB

ME C2.4 The facility has plan for Walls and floor of the OT OB
prevention of fire covered with joint less tiles
Windows/ vents if any in the OT OB

are intact and sealed
ME C2.5 The facility has adequate OT has fire exit to permit safe OB/SI
fire fighting Equipment escape to its occupant at time
of fire
214

are clearly marked.
OT room has installed fire OB

Extinguisher to fight type A, B
and C type of fire

mentioned
ME C2.6 The facility has a system Check for staff competencies for SI/RR
Standard C3
ME C3.1 The facility has adequate Availability of Obg and Gynae OB/RR As per case load
specialist doctors as per Surgeon
service provision
Availability of trained surgeon OB/RR Minilap - MBBS trained in

for Minilap/ Laparoscopic/NSV procedure Laparoscopic
Availability of anaesthetist OB/RR As per case load
ME C3.3 The facility has adequate Availability of Nursing staff OB/RR/SI As per patient load , at
nursing staff as per service least two
ME C3.4 The facility has adequate Availability of OT attendant/ OB/SI

technicians/paramedics as assistant
per requirement
ME C3.6 The staff has been Advance Life support SI/RR

provided required training
/ skill sets
OT Management SI/RR

hygiene
Training on processing/ SI/RR

sterilization of equipments
215

PPIUCD insertion SI/RR
Family planning counselling SI/RR
Laparoscopic surgery/Minilap SI/RR
NSV SI/RR
ME C3.7 The Staff is skilled as per The staff is Skilled to operate SI/RR
job description OT equipment
The staff is skilled for processing SI/RR

and packing instrument

resuscitation and intubation
Nursing Staff is skilled for SI/RR

ME C4.1 The departments have Availability of medical gases OB/RR Availability of Oxygen
availability of adequate Cylinders /Nitrogen Gas
drugs at point of use supply
Availability of Uterotonic Drugs OB/RR
Availability of Antibiotics OB/RR Inj Ampillicin, Inj.

metronizazole Inj
Gentamycin,
Availability of Antihypertensive OB/RR Injectable Hydralagine
Availability of analgesics and OB/RR Tab Paracetamol Ibuprofen,

antipyretics inj Diclofenac, Sodium
Availability of IV Fluids OB/RR IV fluids, Normal saline,

Ringer’s lactate,
Availability of anesthetics OB/RR Halothane, Thiopenatona,

Lignocaine, Succinylcholine,
Ketamine, Nitrous Oxide,
Solium
Availability of emergency drugs OB/RR Inj Magsulf 50%, Inj Calcium

gluconate 10%, Inj Adrenalin,
inj Hydrocortisone,
Succinate, Inj diazepam, Inj
Pheneramine maleate, Inj
Corboprost, Inj Fortwin, Inj
Phenergen, Betameathazon,
Inj Hydrazaline, Nefidepin,
Methyldopa,ceftriaxone
216

Availability of drugs for newborn OB/RR Vitamin K
ME C4.2 The departments have Availability of dressings and OB/RR

adequate consumables at Sanitary pads
point of use
Availability of syringes and IV OB/RR

Sets
Availability of Antiseptic OB/RR

Solutions
Availability of consumables for OB/RR

new born care
Availability of personal OB/RR

protective equipments
ME C4.3 Emergency drug trays are Emergency drug tray is OB/RR

maintained at every point maintained in OT/pre and post
of care, where ever it may operative room
be needed
and instruments for Equipment andInstruments for Thermometer, Pulse Oxy
examination and examination and Monitoring meter, Multiparameter,
monitoring of patients PV Set
ME C5.2 Availability of equipment Availability of functional OB LSCS Set, Cervical Biopsy

and instruments for instruments for Gynae and Set, MVA set, DandC Set,
treatment procedures, obstetrics Defribilator, Megulillr
being undertaken in the
facility
Availability of functional OB Radiant warmer, Baby

equipments/ Instruments for tray with Two pre warmed
New Born Care towels/sheets for wrapping
the baby, mucus extractor,
bag and mask (0 and1 no.),
sterilized thread for cord/
cord clamp, nasogastric
tube
Availability of functional OB General Surgical

General surgery equipments Instruments for Piles,
Fistula, and Fissures.
Surgical set for Hernia and
Hydrocele, Cautery
Operation Table with OB

Trendelenburg facility
Minilap instruments OB
217

Laparoscopic set OB
NSV sets OB
Instruments for Laparoscopy OB
ME C5.3 Availability of equipment Availability of Point of care OB Portable X-Ray Machine,

and instruments for diagnostic instruments Glucometer, HIV rapid
diagnostic procedures diagnostic kit. Uristix.
facility
ME C5.4 Availability of equipment Availability of functional OB Ambu bag, Oxygen,

and instruments for Instruments for Resuscitation Suction machine ,
resuscitation of patients laryngoscope, ET Tube,
and for providing defibrilator
intensive and critical care
to patients
Availability of functional OB Boyles apparatus, Bains

anaesthesia equipment Circuit or Sodalime
absorbent in close circuit
ME C5.5 Availability of Equipment Availability of equipment for OB Crash cart/Drug trolley,

for Storage storage for drugs instrument trolley,
dressing trolley
Availability of equipment for OB Instrument cabinet and

storage of sterilized items racks for storage of sterile
items (not inside OT)

equipment and cleaning Separate mops for patient
instruments for support care area and circulation
services area duster, waste trolley,
Deck brush
Availability of equipment for OB Autoclave

TSSU
ME C5.7 Departments have patient Availability of functional OT OB Shadow less , Ceiling and
furniture and fixtures light Stand Model, Focus Lamp
provision
Availability of attachment/ OB Hospital grade mattress ,

accessories with OT table IVstand, Bed pan
Availability of Fixtures OB Electrical panel for

anaesthesia machine,
cautery, monitors etc, X-
ray view box.
Availability of furniture OB Cupboard, table for

preparation of medicines,
chair, racks,
218

ME D1.1 The facility has established All equipment are covered under SI/RR
system for maintenance of the AMC including preventive

There has system to label OB/RR

Defective/Out of order
equipment and stored
appropriately until it has been
repaired
Staff is skilled for trouble SI/RR

malfunction
Periodic cleaning, inspection and SI/RR

is done by the operator
ME D1.2 The facility has established All the measuring equipment/ OB/ RR Boyels apparatus, cautery,
procedure for internal instrument are calibrated BP apparatus, autoclave
and external calibration of etc.
measuring Equipment
There is system to label/ code OB/ RR

the equipment to indicate status
of calibration/ verification when
recalibration is due

users of equipment with staff.
Standard D2
and indenting drugs and consumables and drugs Requisition are timely
consumables placed

consumables

labelled
219

ME D2.4 The facility ensures Expiry dates are maintained at OB/RR Check for temperature
management of expiry emergency drug tray, crash cart, charts are maintained and
and near expiry drugs anesthesia drug trolley. updated periodically
No expired drug is found OB/RR

Department maintained stock RR/SI


the drugs in patient care cart
areas
ME D2.7 There is process for Temperature of refrigerators are OB/RR

storage of vaccines and kept as per storage requirement
other drugs, requiring and records are maintained
ME D2.8 There is a procedure for Narcotic and psychotropic drugs OB/SI

secure storage of narcotic are kept in lock and key
and psychotropic drugs
Anaesthetic agents are kept at OB/SI

secure place
The facility has established Program for mainntenance and upkeep of the faciity to provide
Standard D3
ME D3.2 Hospital infrastructure is Interior of patient care areas are OB
adequately maintained plastered and painted
Check to ensure that there is no OB

seepage, Cracks, chipping of plaster

fixtures are intact
OT Table are intact and without OB

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

are clean
220


removal of condemned the OT
junk material
ME D3.5 The facility has established No pests are noticed OB

ME D3.6 The facility provides Adequate Illumination at OT OB 300 lux for general area
adequate illumination table
Adequate Illumination at pre OB

operative and post operative
area
ME D3.7 The facility has provision Entry to OT is restricted OB

of restriction of visitors in
patient areas
Warning light is provided OB/SI

outside OT and its been used
when OT is functional
ME D3.8 The facility ensures Temperature is maintained and SI/RR 20-25OC, ICU has
safe and comfortable record of same is kept functional room
environment for patients thermometer and
and service providers temperature is regularly
maintained
Humidity is maintained at SI/RR 50-60%

desirable level
Positive pressure is maintained SI/RR

in OT
ME D3.9 The facility has security Security arrangement at OT OB

system in place at patient
care areas
Standard D4
Availability of Hot water supply OB/SI
ME D4.2 The facility ensures Availability of power back up OB/SI 2 tier backup with UPS
adequate power backup in OT
per load
221

ME D4.3 Critical areas of the Availability of Centralized /local OB

facility ensures availability piped Oxygen, nitrogen and
of oxygen, medical gases vacuum supply
and vacuum supply
Standard D5 The facility ensures avaialblity of Diet as per nutritional requirement of the patients
ME D5.4 The facility has adequate OT has facility to provide sufficient OB/RR Drape, draw sheet, cut
sets of linen and clean linen for surgical patient sheet and gown
OT has facility to provide linen OB/RR

for staff
ME D5.5 The facility has established Linen is changed after each OB/RR
procedures for changing of procedure
ME D5.6 The facility has standard There is system to check the SI/RR
Standard D9
guidelines
ME D9.2 The facility has a established There is procedure to ensure that RR/SI Check for system for
procedure for duty roster staff is available on duty as per recording time of reporting
and deputation to different duty roster and relieving (Attendance
departments register/ Biometrics etc)
There is designated in charge for SI

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

ME E3.1 Facility has established There is procedure of handing SI/RR
procedure for continuity over while receiving patient
of care during from OT to indoor and ICU
There is a procedure for consultation RR/SI

of the patient with other specialists
with in the hospital
222

ME E4.1 Procedure for identification There is a process for ensuring OB/SI Patient id band/ Patient ID
of patients is established at the identification before any No./verbal confirmation
the facility clinical procedure etc.
ME E4.2 Procedure for ensuring There is a process to ensue the SI/RR Verbal orders are rechecked
timely and accurate accuracy of verbal/telephonic before administration
nursing care as per orders
treatment plan is

procedure of patient hand during the change in the shift
change happens
Handover register is RR
maintained
ME E4.5 There is procedure for Patient Vitals are monitored and RR/SI Check for use of multi
periodic monitoring of recorded periodically parameter
patients
ME E5.1 The facility identifies Vulnerable patients are OB/SI Check the measure taken
vulnerable patients and identified and measures are to prevent new born theft,
ensure their safe care taken to protect them from any baby sweeping and baby
harm fall
ME E5.2 The facility identifies high OB/SI HIV, Infectious cases

risk patients and ensure High risk patients are identified
their care, as per their and treatment given on priority
need

Standard E6
for prescribing the generic drugs and their rational use
ME E6.1 Facility ensured that drugs Check for BHT if drugs are RR
are prescribed in generic prescribed under generic name
name only only
ME E6.2 There is procedure of Check staff is aware of the drug SI/RR

rational use of drugs regime and doses as per STG
Check BHT that drugs are RR

prescribed as per STG
Standard E7 Facility has defined procedure for safe drug administration
ME E7.1 There is process for High alert drugs available in SI/OB Electrolytes like Potassium
identifying and cautious department are identified chloride, Opioids, Neuro
administration of high muscular blocking agent,
alert drugs (to check) Anti thrombolytic agent,
insulin, warfarin, Heparin,
Adrenergic agonist etc. as
applicable
223

doctor

Error prone medical

Check for the writing, It RR/SI

comprehendible by the clinical
staff
ME E7.3 There is a procedure Drugs are checked for expiry OB/SI Check for avaialability of
to check drug before and other inconsistency before magnifying glass.
used later on

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


given to right patient patient, right drugs , right dose,
Standard E8 Facility has defined and established procedures for maintaining, updating of
ME E8.1 All the assessments, Records of Monitoring/ RR PAC, Intraoperative

re-assessment and Assessments are maintained monitoring
investigations are recorded
and updated
ME E8.2 All treatment plan Treatment plan, first orders are RR Treatment prescribed in
prescription/orders are written on BHT nursing records
recorded in the patient
records.
224

ME E8.4 Procedures performed Operative Notes are Recorded RR Name of person in
are written on patients 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 Recorded RR
ME E8.5 Adequate form and formats Standard Formats available RR/OB Consents, surgical safety
are available at point of use check list
ME E8.6 Register/records are Registers and records are RR OT Register, Schedule,

maintained as per maintained as per guidelines Infection control records,
guidelines autoclaving records etc
All register/records are RR

identified and numbered
ME E8.7 The facility ensures safe Safe keeping of patient records RR

and adequate storage
records
Standard E12 The facility has defined and established procedures for Blood Storage Management and Transfusion.
ME E12.4 There is established Availability of blood units in RR/SI The blood is ordered for
procedure for issuing case of emergency with out the patient according to
blood replacement the MSBOS (Maximum
Surgical Blood Order
Schedule)
ME E12.5 There is established Patient’s identification is verified SI/OB

procedure for transfusion before transfusion
of blood
blood is kept on optimum RR


Blood transfusion note is

written in patient’s record RR
ME E12.6 There is a established Any major or minor transfusion

procedure for monitoring reaction is recorded and RR
and reporting Transfusion reported to responsible person
complication
Staff is competent to identify RR/SI

transfusion reaction and its
management
225

Standard E13 Facility has established procedures for Anaesthetic Services
ME E13.1 Facility has established There is procedure to ensure RR/SI
procedures for Pre that PAC has been done before
Anaesthetic Check up and surgery
maintenance of records
There is procedure to review RR/SI

findings of PAC
ME E13.2 Facility has established Anaesthesia plan is documented RR

procedures for monitoring before entering into OT
during anaesthesia
Food intake status of Patient is RR/SI

checked
Patients vitals are recorded RR Heart rate, cardiac rate ,

during anaesthesia BP, O2 Saturation,
Airway security is ensured RR/SI Breathing system is securely

and correctly assembled
Potency and level of anaesthesia RR/SI

is monitored
Anaesthesia notes are recorded RR Check for the adequacy
Any adverse Anaesthesia Event is RR

ME E13.3 Facility has established Post anaesthesia status is RR/SI

procedures for Post monitored and documented
Anaesthesia care
Standard E14 Facility has defined and established procedures for Operation Theatre and Surgical Services
ME E14.1 Facility has established There is procedure OT RR/SI Schedule is prepared in
procedures OT Scheduling Scheduling consonance with available
OT house and patients
requirement
ME E14.2 Facility has established RR/SI Vitals , Patients fasting

procedures for Patient evaluation before status etc.
Preoperative care surgery is done and recorded
Antibiotic Prophylaxis given as RR/SI

indicated
Tetanus Prophylaxis is given if RR/SI

Indicated
There is a process to prevent RR/SI Surgical Site is marked

wrong site and wrong surgery before entering into OT
Surgical site preparation is done RR/SI Cleaning , Asepsis and

as per protocol Draping
226

ME E14.3 Facility has established Surgical Safety Check List is RR/SI Check for Surgical safety
procedures for Surgical used for each surgery check list has been used
Safety for surgical procedures
Sponge and Instrument Count RR/SI Instrument, needles and

Practice is implemented sponges are counted
before beginning of case,
before final closure and on
completing of procedure
Adequate Haemostasis is secaud RR/SI Check for Cautery and

during surgery suture legation practices
Appropriate suture material RR/SI Check for what kind of

is used for surgery as per sutures used for different
requirement surgeries . 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
ME E14.4 Facility has established Post operative monitoring is RR/SI Check for post operative
procedures for Post done before discharging to ward operation ward is used
operative care and patients are not
immediately shifted to
wards after surgery
Post operative notes and orders RR/SI Post operative notes

are recorded contains Vital signs, Pain
control, Rate and type
of IV fluids, Urine and
Gastrointestinal fluid
output, other medications
and Laboratory
investigations
Standard E17 Facility has established procedures for Intranatal care as per guidelines
ME E17.2 There is an established pre operative care SI/RR Check for Haemoglobin
procedure for assisted level is estimated , and
and C-section deliveries arrangement of Blood,
per scope of services. IV line established,
Catheterization,
Demonstration of Antacids
Proper selection of Anaesthesia SI/RR Check Both General

and Spinal Anaesthesia
Options are available. Ask
for what are the criteria
for using spinal and GA
227

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
ME E17.3 There is established Management of PIH/Eclampsia SI/RR Ask for how to secure
procedure for airway and breathing,
management of Obstetrics Loading and Maintenance
Emergencies as per scope dose of Magnesium
of services. sulphate , Administration
of Hypertensive Drugs
Postpartum Haemorrhage SI/RR
Management of shock. SI/RR
Ruptured Utreus SI/RR
ME E17.4 There is an established Recording Time of Birth RR

procedure for new born
resuscitation and newborn
care.
Vitamin K SI/RR
Care of Cord and Eyes SI/RR
APGAR Score SI/RR
New born Resuscitation SI/RR

Standard E18 Facility has established procedures for Intranatal care as per guidelines
ME E18.1 Post partum Care is Prevention of Hypothermia SI/RR
Provided to Mother
Initiation of Breastfeeding with PI/SI

in 1 Hour
ME E18.4 The facility has procedures There is established criteria for SI/RR
for Stabilization/treatment/ shifting newborn to NBSU/
referral of post natal SNCU
complication
Facility has infection control program and procedures in place for prevention and measurement
Standard F1
of hospital associated infection
ME F1.2 Facility has provision for Surface and environment SI/RR Swab are taken from
Passive and active culture samples are taken for infection prone surfaces
surveillance of critical and microbiological surveillance
high risk areas
228

ME F1.3 Facility measures hospital There is procedure to report SI/RR Patients are observed for
associated infection rates cases of Hospital acquired any sign and symptoms
infection of HAI like fever, purulent
discharge from surgical
site
Periodic medical checkup of the SI/RR

staff
control practices
ME F1.6 Facility has defined and Check for Doctors are aware of SI/RR
policy
use of use
Availability of running Water OB/SI Open the tap. Ask Staff if

water 24x7

uninterrupted


Local language

taps
Hand washing sink is wide and OB

deep enough to prevent splashing
and retention of water
practices
229

Adherence to Surgical scrub SI/OB “procedure should be
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 hand wash SI
ME F2.3 Facility ensures standard Availability of Antiseptic OB like before giving IM/IV
practices and materials Solutions injection, drawing blood,
for antisepsis putting Intravenous and
urinary catheter
Proper cleaning of procedure site OB/SI

with antisepsis
Proper cleaning of perineal area SI

before procedure with antisepsis
Check Shaving is not done during SI

part preparation/delivery cases
Check sterile field is maintained OB/SI Surgical site covered

during surgery with sterile drapes, sterile
instruments are kept
within the sterile field.
equipments as per
requirements
Sterile gloves are available in OT OB/SI

and Critical areas
Use of elbow length gloves for OB/SI

obstetrical purpose
Availability of gown/ Apron OB/SI
Availability of Caps OB/SI
Personal protective kit for OB/SI HIV kit

infectious patients
ME F3.2 Staff is adhere to No reuse of disposable gloves, OB/SI

standard personal Masks, caps and aprons.

gloves
230

ME F4.1 Facility ensures standard Decontamination of operating SI/OB Ask stff about how they
practices and materials surfaces decontaminate the
for decontamination and procedure surface like OT
clean ing of instruments Table, Stretcher/Trolleys
and procedures areas etc. (Wiping with .5%
Chlorine solution

suction canulae, Surgical
Instruments
0.5% Clorine Solution or
70% Alcohal as applicable

decontamination is adeqaute

running water after
decontamination

Patient care area

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


as per protocols contact time requied for
Formaldehyde or glutaraldehyde OB/SI

solution replaced as per
manufacturer instructions
Autoclaved linen are used for OB/SI

procedure
231

used
Instruments are packed OB/SI

according for autoclaving as per
standard protocol
Autoclaving of instruments is OB/SI Ask staff about

done as per protocols temperature, pressure and
time
Regular validation of OB/SI/RR

sterilization through biological
and chemical indicators
Maintenance of records of OB/SI/RR

sterilization
There is a procedure to enusure OB/SI/RR

the tracibility of sterilized packs

maintained during storage clean, dust free, moist free
environment.
ME F5.1 Layout of the department Facility layout ensures OB Faculty layout ensures
is conducive for the separation of general traffic separation of general
infection control practices from patient traffic traffic from patient traffic
Zoning of High risk areas OB
Facility layout ensures separation OB

of routes for clean and dirty items
Floors and wall surfaces of OT OB

are easily cleanable
CSSD/TSSU has demarcated OB

separate area for receiving dirty
items, processes, keeping clean
and sterile items

of standard materials for per requirement Gluteraldehye, carbolic

solution
ME F5.3 Facility ensures standard Staff is trained for spill SI/RR

232


cleaning solution as per standard
procedure
Standard practice of mopping OB/SI

and scrubbing are followed
Cleaning equipments like broom OB/SI

are not used in patient care areas

mopping
Fumigation/carbolization as per SI/RR

schedule
External footwares are restricted OB
ME F5.4 Facility ensures Isolation and barrier nursing OB/SI

segregation infectious procedure are followed for septic
patients cases
ME F5.5 Facility ensures air quality Positive Pressure in OT OB/SI

of high risk area
Adequate air exchanges are SI/RR

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

coded plastic bags


Biomedical waste

and general waste
per guidelines
233

container the point of generation
injection room



charge of that.

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


before disposal

trolley
Facility ensures standard Staff aware of mercury spill SI/RR

practices and materials management
for decontamination and
and procedures areas

ME G1.1 The facility has a quality There is a designated SI/RR Preferably Anaesthetist or
team in place departmental nodal person for surgeon
activities
Facility have established internal and external quality assurance programs

Standard G3 wherever it is critical to quality.
ME G3.1 Facility has established There is system daily SI/RR

internal quality assurance round by Surgeon/matron/
program at relevant hospital manager/ hospital
departments superintendent/for monitoring
of services
234


Facility has established, documented implemented and maintained Standard

Standard G4

ME G4.2 Standard Operating The department has RR

Procedures adequately documented procedure for
describes process and scheduling the Surgery and its
procedures booking

documented procedure for pre
operative procedure

documented procedure for pre
operative anaesthetic check up

documented procedure for in
process check during surgery

documented procedure for post
operative care of the patient

operation theatre asepsis and
environment management

documented procedure for OT
documentation.

reception of dirt packs and issue
of sterile packs from TSSU

maintenance and calibration of
equipments
235

The department has documented
procedure for general cleaning RR
of OT and annexes
ME G4.3 Staff is trained and aware Check staff if aware of relevant

of the standard procedures part of SOPs SI/RR
written in SOPs
ME G4.4 Work instructions are Work instruction/clinical OB processing and

displayed at Point of use protocols are displayed sterilization of
equipments,
The facility has established system of periodic review as internal assessment ,

Standard G5
assessment

adequately


actions are taken to actions are taken
ME G6.2 The facility periodically Quality objective for OT are RR/SI
objectives and key
own objectives

is aware of that

periodically
services
5S SI/OB
236


services

ME H1.1 Facility measures C-Section Rate RR
monthly basis
Proportion of C-Sections done RR

in night
Proportion of other emergency RR

surgeries done in the night
No. of Major surgeries done per RR

1 lakh population
ME H2.1 Facility measures Downtime of critical euipments RR
monthly basis
No of major surgeries per RR

surgeon
Proportion of elective C-Sections RR
Proportion emergency surgeries RR
Cycle time for instrument RR

processing
ME H3.1 Facility measures Clinical Surgical Site infection Rate RR No. of observed surgical
Care and Safety Indicators site infections*100/total
on monthly basis no. of Major surgeries

thousand patients
Incidence of re-exploration of RR
surgery
% of environmental swab RR
culture reported positive
Perioperative Death Rate RR Deaths occurred from pre

operative procedure to
discharge of the patient
237

Proportion of General RR
Anaesthesia to spinal
anaesthesia
Proportion of PAC done out of RR

total surgeries
No. of autoclave cycle failed RR

in Bowie dick test out of total
autoclave cycle
ME H4.1 Facility measures Service Operation Cancellation rates RR No. of cancelled
Quality Indicators on operation*1000 /total
monthly basis operation done
238


STANDARDS FOR CHC
Checklist for Laboratory
240

Standard A3 The facility provides diagnostic services
ME A3.2 The facility Provides All lab services are available in SI/RR
Laboratory Services routine working hours
Emergency lab services are SI/RR Facility for on call

available laboratory technician
Availability of Haematology SI/OB Hb, TLC, DLC, AEC, Reti

services count, ESR, PBS, Malaria/
Filaria, Platelets count, PCV,
Blood grouping, Rh typing.
Availability of Bio chemistry SI/OB B. sugar, B urea, LFT, KFT,

services lipid profile
Availability of Microbiology SI/OB smear for AFB, KLB,Gram

services stain for throat swab,
Sputum etc.
Availability of urine analysis SI/OB Urine for albumin, sugar,

services deposits, bile salts, bile
pigments, Ketone bodies,
spc. Gravity, PH.
Availability of stool analysis SI/OB Stool for ova/cyst (EH),

Occult blood.
Availability of sputum cytology SI/OB
ME A4.1 The facility provides Tests for Diagnosis of malaria SI/OB
services under National (Smear and RDTK)
Vector Borne Disease
guidelines
Tests for Kala Azar, Dengue, JE, SI/OB As per prevalant endemic
Chikungunya
ME A4.2 The facility provides Availability of Designated SI/OB

services under Revised Microscoy Center (AFB)
National TB Control
Programme as per
guidelines
ME A4.3 The facility provides services Availability of Skin Smear SI/OB

under National Leprosy Examination
per guidelines
241

ME A4.8 The facility provides Haemogram, BT CT, Fasting/PP SI/RR
services under National Sugar, Lipid Profile, Blood Urea ,
Programme for LFT Kidney Function Test
Prevention and control
of Cancer, Diabetes,
Cardiovascular diseases
and Stroke (NPCDCS) as
per guidelines
ME A 6.1 The facility provides Laboratory provides specific SI/RR
curatives and preventive test for local health problems/
services for the health diseases e.g.. Dengue, Kala-azar
problems and diseases, etc.
prevalent locally.

Facility provides the information to care seekers, attendants and community
Standard B1
about the available services and their modalities
ME B1.1 The facility has uniform Availability of departmental OB Numbering of rooms, main
and user-friendly signage signages department and inter-
ME B1.2 The facility displays the List of services available are OB

services and entitlements displayed at the entrance
available in its departments
Timing for collection of sample OB

and delivery of reports are
displayed
ME B1.4 User charges are displayed User charges in r/o laboratory OB

and communicated to services are displayed

understand
ME B1.8 The facility ensures Lab Reports are provided to OB

access to clinical records Patient in proper printed format
personnel
Services are delivered in a manner that is sensitive to gender, religiousand cultural needs, and
Standard B2
there are no barrier on account of physical , economic, cultural or social status.
ME B2.1 Services are provided in Separate queue for female OB
manner that are sensitive patient’s
to gender
ME B2.3 Access to facility is Check the availability of ramp OB

provided without any in lab building area /sample
physical barrier and collection area
disabilities
242

Standard B3 The facility maintains privacy, confidentiality and dignity of patient, and has a system
ME B3.2 Confidentiality of patients Laboratory has a system to SI/OB Laboratory staff do not
records and clinical ensure the confidentiality of the discuss the lab results and
information is maintained reports generated reports are kept in secure
place
ME B3.3 The facility ensures the Behaviour of staff is empathetic PI/OB

services
ME B3.4 The facility ensures HIV positive reports/pregnancy SI/OB

privacy and reports are communicated as
confidentiality to every per NACO guidelines
patient, especially of
those conditions having
social stigma, and also
safeguards vulnerable
groups
ME B4.1 There is established Informed Consent is taken SI/RR Before testing for HIV, the
procedures for taking before HIV testing, Biopsy and patient is informed that
informed consent before any other invasive procedure the test is voluntary and
treatment and procedures result will be disclosed to
him/her only
ME B4.4 Information about the Pre test counselling is done PI/SI/RR

treatment is shared with before HIV testing
patients or attendants,
regularly
Facility ensures that there are no financial barrier to access and that there is
Standard B5
financial protection given from cost of care.
ME B5.1 The facility provides Free Diagnostic tests for PI/SI
cashless services to Pregnant women and Infant
and neonates as per
schemes
ME B5.2 The facility ensures that Check that patient has not PI/SI
drugs prescribed are incurred expenditure on
available at Pharmacy and purchasing consumables from
wards outside.
ME B5.3 It is ensured that facilities Check that patient has not PI/SI
for the prescribed incurred expenditure on
investigations are available diagnostics from outside.
243

ME B5.4 The facility provide free of Tests are free of cost for BPL PI/SI/RR
Poverty Line (BPL) patients
hassles
ME B5.5 The facility ensures Cashless investigation by PI/SI/RR

timely reimbursement empanelled lab for JSSK
of financial entitlements beneficiaries for the test which
and reimbursement to the are not available within the
patients facility

The facility has infrastructue for delivery of assured services and available
Standard C1
infrastructure meets the prevalant norms
ME C1.1 Departments have Laboratory space is adequate for OB Adequate area for sample
adequate space as per carrying out activities collection, waiting,
patient or work load performing test, keeping
equipment and storage of
drugs and records
ME C1.2 Patient amenities are Availability of adequate waiting OB

provide as per patient load area
Availability of functional toilets OB
Availability of drinking water OB

near laboratory.
ME C 1.3 Departments have layout Demarcated sample collection OB

and demarcated areas as area
per functions
Demarcated testing area OB
Designated report writing area OB
Demarcated washing and waste OB

disposal area
ME C 1.5 The facility has Availability of functional OB

communication
ME C 1.7 The facility and Unidirectional flow of services OB Sample collection- Sample
departments are planned processing- Analytical
to ensure structure follows area- reporting.
the function/processes
(Structure commensurate
with the function of the
hospital)
244

ME C2.2 The facility ensures safety Laboratory does not have OB

loose hanging wires
Adequate electrical sockets are OB/RR

provided for safe and smooth
operation of lab equipment
ME C2..3 Physical condition of Work benches are chemical OB

building is safe for resistant
Floors of the Laboratory are non OB

slippery and even its surfaces is
acid resistent
Windows have grills and wire OB

meshwork
ME C2.4. The facility has plan for Laboratory has plan for safe OB/SI
prevention of fire storage and handling of
potentially flammable materials.
ME C2.5. The facility has adequate Lab has installed fire OB/RR
fire fighting Equipment Extinguishers to handle A, B and
C type of fire
Check if expiry date for fire OB/RR

extinguishers are displayed on each
extinguisher as well as due date for
next refilling is clearly mentioned
Standard C3
ME C3.4 The facility has adequate Availability of Lab. technicians OB/RR Two Lab technicians
technicians/paramedics as
per requirement
ME C3.6. The staff has been Training on automated SI/RR

provided required training Diagnostic Equipments like semi
/ skill sets auto analyzer
245

Bio Medical waste Management SI/RR

hygiene
Training on Internal and External SI/RR

Quality Assurance
Laboratory Safety SI/RR
ME C3.7 The Staff is skilled as per Staff is skilled to run automated SI/RR
job description equipment like semi auto
analyser.

Laboratory records
ME C4.2 The departments have Regular avaialability of supplies OB/RR Clean slides, slide markers,
adequate consumables at for Laboratory gloves, transport medium,
point of use test tubes, vials, swabs,
culture bottles, Zeil
Neelsen Acid Fast stain,
sealing material etc.
Availability of RD kits. OB/RR RDK for malaria/typhoid

and faecal contimination
of water.

be needed
ME C 5.1 Availability of equipment Availability of functional OB BP apparatus, Stethoscope
and instruments for Equipment andInstruments for at sample collection area
examination and examination and Monitoring
monitoring of patients
ME C 5.3 Availability of equipment Availability of functional OB Micropipettes , Spirit lamp,

and instruments for equipments for sample Centrifuge, Water Bath,
diagnostic procedures being collection and processing Hot air oven.
Availability of equipment for OB Ice box, stool transport

storage and transfer of samples carrier, test tube rack,
refrigerator, smear
transporting box, sterile
leak proof containers.
Availability of functional OB Binocular Micro scope ,

Microscopy equipments FNAC, staining rack
246

Availability of equipment for Photocalorie meter,
testing and analysis semi autoanalyzer,
glucometer.
ME C5.6 Availability of functional Availability of equipment for OB

equipment and cleaning Buckets for mopping,
instruments for support mops, duster, waste
services trolley, Deck brush
Availability of equipment for OB

sterilization and disinfection Autoclave/Boiler
ME BC 5.7 The department have Availability of fixtures at lab OB Illumination at work

patient furniture and stations, Electrical fixture
fixtures as per load and for lab equipment and
service provision storage equipment
Availability of furniture OB Lab stools, Work bench’s,

rack and cupboard
for storage of reagent
Patient stool, Chair table

ME D 1.1 The facility has established All equipment are covered under SI/RR Agency/ is identified
system for maintenance the AMC including preventive for maintenance of the
of critical Equipment maintenance equipment
There is a system of timely SI/RR

There is a system to label OB/RR

equipment and these are stoud
till its appropriately
repaired
The staff is skilled for trouble SI/RR

malfunction

measuring Equipment

of calibration/ verification, when
247

The laboratory has a system to SI/RR
update correction factor after
calibration of equipment (if required)
Each lot of reagents has to be

checked against earlier tested in SI/RR
use reagent lot or with suitable
reference material before being
placed in service and result
should be recorded.
ME D1.3 Operating and Up to date instructions for

maintenance instructions operation and maintenance of OB/SI
are available with the equipment are readily available
Standard D2
ME D2.1 There is a established There is established system of SI/RR Stock level are daily
procedure for forecasting timely indenting of consumables updated
and indenting of drugs and reagents Requisition are timely
and consumables placed
ME D2.3 The facility ensures proper Reagents and consumables OB/RR

storage of drugs and are kept away from water and
consumables sources of heat, direct sunlight
Reagents are labelled OB/RR Reagents label contain

appropriately name, concentration, date
of preparation/opening,
date of expiry, storage
conditions and warning
ME D2.4 The facility ensures No expired reagent is found OB/RR

management of expiry
ME D2.5 The facility has established Department maintain stock and RR/SI
procedure for inventory expenditure register of reagents
There is no stock out of reagents OB/SI
ME D2.7 There is process for Temperature of refrigerators are OB/RR Check if temperature
Regular Defrosting is done SI/RR
Standard D3
ME D3.2 Patient care areas are Check for there is no seepage , OB
clean and hygienic Cracks, chipping of plaster
248

fixtures are intact
ME D3.3 Hospital infrastructure is Floors, walls, roof, roof tops, OB All area are clean with
adequately maintained. sinks in patient care and no dirt,grease,littering
circulation areas are Clean and cobwebs

are clean
ME D3.4 The facility has a policy No condemned/Junk material is OB

of removal of condemned found in the lab
junk material

and animal control
ME D3.6 The facility provides Adequate illumination in the OB

adequate illumination laboratory.
ME D3.8 The facility ensures Temperature control and SI/RR Fans/ Air conditioning/
safe and comfortable ventilation in the laboratory. Heating/Exhaust/
and requirement
Availability of Eye washing OB

facility
ME D3.10 The Facilities has Ask female staff weather they SI

established measure for feel secure at work place
safety amd security of
female staff
Standard D4
ME D4.1 The facility has adequate Availability of running and OB/SI

arrangement storage and potable water on 24x7 basis

adequate power backup laboratory
per load
Standard D8 Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government
ME D8.3 The facility ensure Any positive report of notifiable RR/SI
relevant processes are disease is intimated to
in compliance with the designated authorities with in
statutory requirements stipulated time limit
249

Standard D9
guidelines
ME D9.2 The facility has a There is procedure to ensure that RR/SI Check for system of
established procedure for staff is available on duty as per recording time of
duty roster and deputation duty roster reporting and relieving
to different departments (Attendance register/
Biometrics etc)
ME D9.3 The facility ensures Technician and support staff OB

adherence to dress code adhere to their respective dress
as mandated by its code
department

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

recorded in laboratory records demographics like Name,
Age, Sex, Provisional
diagnosis, etc.
ME E3.2 Facility provides Laboratory has referral linkage RR/SI
appropriate referral for tests which are not available
linkages to the patients/ at the facility
assure their continuity of
care.
Facility gets referred patients RR/SI e.g.: linkage for disease

from lower level of facility surveillance and water
testing
250

Standard E8
ME E8.5 Adequate form and Standard Formats are available RR/OB Printed formats for
formats are available at requisition and reporting
point of use are available
ME E8.6 Register/records are Lab records are labelled and RR

maintained as per indexed
guidelines
Records are maintained for the RR Test registers, IQAS/EQAS

laboratory Registers, Expenditure
registers, Accession list
etc.
ME E8.7 The facility ensures safe and Laboratory has adequate facility OB
adequate storage and easy for storage of the records.
There is system of retrieval of OB May ask for retrival of

record sample records
ME E10.3 The facility has Disaster The staff is aware of Disaster plan SI/RR
Management Plan (DMP)
in place
Roles and responsibilities of the SI/RR

ME E10.5 There is a procedure for Samples of medico legal SI/RR Requisition and reports are
handling medico legal cases are identified, secured, marked with MLC and the
cases preserved and processed reports are handed over to
authorized personnel only
ME E11.1 There are established Requisition of all laboratory test RR/OB Request form contains
procedures for Pre-testing are received on designated and relevant information:
Activities approved forms Name and identification
number of patient, name
of authorized requester,
type of primary sample,
examination requested,
date and time of primary
sample collection and date
and time of receipt of
sample by laboratory,
Instructions for collection and RR/SI

handling of primary samples
are communicated to those
responsible for collection
Laboratory has system in place RR/SI

to label the primary samples
251

Laboratory has system to RR/SI
trace the primary sample from
requisition form
Laboratory has system in place RR/SI Transportation of

to monitor transportation of sample includes: Time
the sample frame, temperature and
carrier specified for
transportation
ME E11.2 Testing procedure are readily OB/RR

available at work station and
staff is aware of the same
Laboratory has Biological OB/RR

reference interval for its
examination of various results
Laboratory has identified RR/SI

critical intervals for which
immediate notification is done
to concerned physician
ME E11.3 There are established Laboratory has a system to review RR/SI

procedures for testing the results of examination by
Activities authorized person before release
of the report
Laboratory has format for RR/OB

reporting of results
Laboratory has system to provide RR/SI

the reports within defined cycle
time/ for each category of patient
-routine and emergency
Laboratory results written in RR/SI

reports are legible without error
in transcription
Laboratory has defined the RR/SI

retention period and disposal of
used sample
Laboratory has a system to RR/SI

retain the copies of reported
results, which are promptly
retrieved when required
Standard E22 Facility provides National health program as per operational/Clinical Guidelines
ME E22.9 The facility provide service Weekly reporting of Confirmed SI/RR
for Integrated Disease cases on form “L” from
Surveillance Programmes laboratory
(IDSP)
252

Standard F1
Periodic medical check up of the SI/RR

staff is undertaken
control practices
use of use

Staff if water is 24x7

uninterrupted

Local language

taps

practices
Staff aware of when to hand SI

wash

practices and materials for Solutions
antisepsis
Proper cleaning of procedure site OB/SI before drawing blood,

with antisepsis
253

equipment as per
requirements
Availability of lab aprons/coats OB/SI
ME F3.2 Staff adheres to standard No reuse of disposable gloves OB/SI

personal protection and Masks.
practices
ME F4.1 Facility ensures standard Decontamination of Procedure SI/OB Ask staff about how they
practices and materials surfaces decontaminate work
for decontamination and benches
clean ing of instruments (Wiping with .5% Chlorine
and procedures areas solution)
Proper Decontamination of SI/OB Decontamination of

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


running water after
decontamination
The staff know how to make SI/OB

chlorine solution
ME F4.2 Facility ensures standard Disinfection of reusable SI/OB Disinfection by hot air
practices and material for glassware oven at 160 oC for 1 hour
disinfection and sterilization
of instruments and
equipments
of standard materials for per requirement Gluteraldehye, Carbolic
of patient care areas - If Gluteraldehye-Check
for its activation period
Availability of cleaning agent as OB/SI Hospital grade Phenyl,

solution
254



standard procedure


are not used in laboratory leading to dispersion of
dust particles in air should
be avoided
ME F5.4 Facility ensures Precaution with infectious OB/SI

segregation infectious patients like TB
patients
Standard F6

coded plastic bags


Biomedical waste

and general waste
per guidelines

injection room

255


charge of that.

done
ME F6.3 Facility ensures Disinfection of liquid waste SI/OB

transportation and before disposal
guidelines
Disposal of sputum cups as per SI/OB

guidelines
Check bins are not overfilled SI

trolley

management

ME G1.1 The facility has a quality There is a designated SI/RR
team in place departmental nodal person for
activities
ME G2.1 Patient Satisfaction There is system to take feed RR
surveys are conducted at back from clinician about
periodic intervals quality of services
ME G3.1 Facility has established Internal Quality assurance SI/RR
internal quality assurance programme is in place
program at relevant
departments
Standards are run at defined SI/RR

interval
Control charts are prepared and SI/RR

outliers are identified.
256

Corrective action is taken on the SI/RR
identified gaps
Internal Quality Control for SI/RR Routine checking of

RNTCP Lab. is in place equipments, new lots of
regent, smear preparation,
grading etc
ME G3.2 Facility has established Cross Validation of Lab tests are SI/RR
external assurance done and records are maintained
programs at relevant
departments
Corrective actions are taken on SI/RR

abnormal values
External quality assurance SI/RR “Onsite evaluation done

program is implemented as per Monthly
RNTCP program Random Blinded
rechecking (RBRC) done
Monthly”
External quality assurance SI/RR

program is implemented for
NVBDCP
External quality assurance under SI/RR

NACP


Facility has established, documented implemented and maintained Standard Operating

Standard G4
Procedures for all key processes and support services.
ME G4.1 Departmental standard Standard operting procedure RR
operating procedures are for the department has been
Current version of SOP are available OB/RR

with the respective process owner
ME G4.2 Standard Operating Laboratory has documented RR

Procedures adequately process for Collection and
describes process and handling of primary sample
procedures
Laboratory has documented RR

procedure for transportation
of primary sample with
specification about time frame,
temperature and carrier
257

process on acceptance and
rejection of primary samples

procedure on receipt, labeling,
processing and reporting of
primary sample’
Laboratory has documented system RR

for storage of examined samples
Laboratory has documented

system for repeat tests due to RR
analytical failure

validated procedure for RR
examination of samples

biological reference intervals RR

critical reference values and RR
procedure for immediate
reporting of results

procedure for release of reports RR
including details of personal
authorised to release the result and
details of receipients of the reports

internal quality control system
to verify the quality of results

External Quality assurance
program

procedure for calibration of
equipments

procedure for validation of
results of reagents ,stains , media
and kits etc. wherever required

system of resolution of
complaints and other feedback
received from patients, clinicians
and RKS members
258

procedure for examination by
referral laboratories

system for storage, retaining and
retrieval of laboratory records,
primary sample, Examination
sample and reports of results.

system for control of its
documents

procedure for preventive and
break down maintenance

procedure for internal audits

procedure for purchase of
External services and supplies

of the standard procedures relevant part of SOPs
written in SOPs
ME G4.4 Work instructions are Work instruction/clincal OB Work instruction for

displayed at Point of use protocols are displayed Internal Quality control,
Standard G5 The facility has established system of periodic review as internal assessment,
assessment

adequately

ME G5.5 Corrective and Preventive Corrective and preventive RR/SI

259

ME G6.2 The facility periodically Quality Objectives are defined RR/SI
defines its quality
objectives and key
own objectives
ME G6.3 Quality policy and Check for staff is aware of SI

objectives are disseminated quality policy and objectives
and staff is aware of that

periodically
services
5S SI/OB

services
Control charts SI/RR

ME H1.1 Facility measures Lab test done per patients in RR
productivity Indicators on OPD
monthly basis
No. of HB test done per 1000 RR

population
No. of Blood Smear Examined RR

per 1000 population
No. of AFB Examined per 1000 RR

population
No. of HIV test done per 1000 RR

population
No. of VDRL test done per 1000 RR

population
260

ME H1.2 The Facility measures Percentage of lab investigations RR
equity indicators for BPL, IPD patients out of total
periodically investigations for IPD patients
ME H2.1 Facility measures No of test not matched in RR
efficiency Indicators on validation
monthly basis
Z score for biochemistry or RR

equivalent
Z score for haematology or RR

equivalent
Down time of critical RR

equipment
Turn around time for routine lab RR

investigations
Turn around time for emergency RR

lab investigations
ME H3.1 Facility measures Clinical % of critical values reported RR
Care and Safety Indicators within one hour
on monthly basis

thousand patients
Report correlation rate RR Proportion of lab report

co related with clinical
examination
Proportion of false positive / RR For Rapid diagnostic Kit

false negative test
ME H4.1 Facility measures Service Waiting time at sample RR
Quality Indicators on collection area
monthly basis
Number of stock out incidences RR

of reagents
261


STANDARDS FOR CHC
Checklist for Radiology
262

ME A3.1 The facility provides Availability of X ray services SI/OB for chest, bones, skull,
Radiology Services spine and abdomen.
Availability of Dental X ray SI/OB Dental X-ray.

Services
Availability/Functional linkage of SI/OB Pre natal diagnostic

ultrasound services procedure:
Ultrasonography,
Standard B1 Facility provides the information to care seekers, attendants and community about the
ME B1.1 The facility has uniform Availability departmental OB Numbering of rooms, main
Display of PNDT Notice at USG OB “Notice in local language is

displayed at entrance of USG
department that All persons
including the employer,
employee or any other person
associated with department
shall not conduct or associate
with or help in carrying out
detection or disclosure of sex
of foetus in any manner”
Display of cautionary signage OB Radiation hazard sign

outside the X ray department and caution for pregnant
women and children
ME B1.2 The facility displays the Timing for taking X ray and OB
services and entitlements collection of reports are
available in its displayed outside the X ray
departments department
ME B1.4 User charges are displayed User charges in r/o X ray services OB
and communicated to are displayed at entrance

understand
ME B1.8 The facility ensures access Reports are provided to Patient OB

to clinical records of patients in proper printed format
to entitled personnel
263

Standard B2
ME B2.1 Services are provided in Female attendant should OB/SI
manner that are sensitive accompany female patients
to gender during radiological procedures
ME B2.3 Access to facility is Check the availability of ramp in OB

provided without any OPD/ X ray room
physical barrier and and
disabilities
Standard B3
ME B3.1 Adequate visual privacy X ray department has provision OB
is provided at every point of privacy while taking X ray.
of care
ME B3.2 Confidentiality of patients USG department has provision OB provision of screen

records and clinical of privacy during
information is maintained sonography
Radiology has system to ensure RR/SI Radiology staff do not

the confidentiality of the discuss the X-Ray/USG
reports result outside. And reports
are kept in secure place
ME B3.3 The facility ensures the Behaviour of staff is empathetic PI

services
Standard B4
ME B4.1 There is established Form F for USG under PNDT RR
procedures for taking maintained for scan of pregnant
informed consent before woman
Standard B5
ME B5.1 The facility provides Free radiology services for PI/SI USG and X ray
cashless services to Pregnant women and infant
and neonates as per
schemes
ME B5.3 It is ensured that facilities Check that patient/attendants PI/SI

for the prescribed has not incurred expenditure
investigations are on having radiological
available at the facility investigations from outside.
264

ME B5.4 The facility provide free of Tests are free of cost to BPL PI/SI
hassles
ME B5.5 The facility ensures JSSK beneficiaries get free PI/SI/RR check that enpanelled
timely reimbursement investignations even for the labs. Are providing
of financial entitlements tests not available at the facility cashless facilities.
patients

Standard C1
ME C1.1 Departments have Room Size of X ray unit is as per OB Room housing shall not
adequate space as per AERB safety code be less than 18 sq m, any
patient or work load dimension not less than
4m
ME C1.3 Departments have layout Unshielded opening for OB Unshielded opening in x

and demarcated areas as Ventilation and natural light has ray room shall be located
per functions been provided in X ray room as above height of 2 m from
per AERB safety code finished floor level outside
the X ray room
Installation of control panel of OB Control panel of X ray

X ray equipment is as Per AERB equipment operation at
safety Code 125 kVp or above shall
be installed in a separate
room located outside
contiguous to X-ray room,
with appropriate shielding,
direct viewing and oral
communication facility
Distance between control panel OB The distance between

and X ray unit is as per AERB control panel and X ray
safety code unit shall not be less than
3m
Location of dark room is as per OB Dark room is located such

AERB safety code that no significant primary
or secondary x ray reaches
inside dark room
Dark room has X ray developing OB SS processing tank to

tanks with water supply accommodate 14”X 17”
approx capacity of 13 litre
Dark room has provision of safe OB

light in dark room
265

There is separate storage area OB
for undeveloped X ray films and
personal monitoring devices
in protected area away from
radiation sources
ME C1.4 The facility has adequate Corridors are wide enough OB 2-3 meters
circulation area and open for movement of trolleys and
spaces according to need stretchers
and local law

communication
ME C1.7 The facility and Internal layout of X-ray OB No cris cross in the
departments are planned department is uni-directional movement patient traffic
to ensure structure and services flow Should
follows the function/ be near emergency
processes (Structure department
ME C2.2 The facility ensures safety X-ray - does not have temporary OB Switch Boards other
of electrical establishment connections and loosely hanging electrical installation are
wires intact
Stabilizer is provided for X-ray OB

machine
ME C2.3 Physical condition of Floors of the Radiology OB

buildings are safe for department are non slippery and
providing patient care even
Windows and door in X ray room OB

is provided with lead lining
Thickness of walls at X room are OB 15 centimeters

as AERB safety code
X ray department should not be OB

located adjacent to patient care
area
266

ME C2.5. The facility has adequate Radiology department has OB
fire fighting Equipment installed fire Extinguisher for
fighting type A, B and C fires

mentioned
Standard C3
ME C3.4 The facility has adequate Availability of Radiographer SI/RR One radiographer
per requirement
ME C3.6 The staff has been provided Training on radiation safety SI/RR
Training on infection control and SI/RR

hand hygiene
Training on Bio Medical waste SI/RR

Management
ME C3.7 The Staff is skilled as per Radiographers are skilled to SI/RR

job description operating equipment
ME C4.2 The departments have Availability Consumables OB/RR X ray films, Developer,
adequate consumables at Fixer, USG gel, printing
point of use paper
Availability of personal OB/RR Lead apron with

protective equipments hanger, lead shield
ME C4.3 Emergency drug trays are Emergency Drug Tray is OB/RR -IV fuild
maintained at every point maintained -Inj Dopamine
of care, where ever it may - Inj Adreline
be needed -Inj Hydrocortsome
- Oxygen cylinder
ME C5.1 Availability of equipment Availability of functional OB TLD badges
and instruments for Equipment andInstruments for
examination and examination and Monitoring
monitoring of patients
267

ME C5.3 Availability of equipment Availability of functional X-ray OB 300 MA X ray machine
and instruments for machines
diagnostic procedures
facility
Availability of functional Dental OB At least one

X-Ray Machine
Availability of functional OB Desirable in the facility.

Ultrasonography Otherwise functional
linkage with nearby
facility.
Availability of Accessories for OB Cassettes X ray,

X ray Intensifying screen X ray,
Lead letter (A-Z),Letter
figures (0-9) and R and L
ME C5.7 Departments have patient Availability of attachment/ OB X ray hangers, Bucky

furniture and fixtures accessories Stand
provision
Availability of fixtures at lab OB X-ray View box, Electrical

fixture for equipments
Availability of furniture OB Rack and cupboard, Chair

table

ME D1.1 The facility has established All equipments are covered SI/RR
system for maintenance of under AMC including preventive

Staff is skilled for trouble shooting SI/RR

in case equipment malfunction

ME D1.2 The facility has established All the measuring equipments/ OB/ RR
measuring Equipment

of calibration/ verification when
268

ME D1.3 Operating and Operating instructions and OB/SI
maintenance instructions factor charts are available
are available with the with the equipments
users of equipment
Standard D2
ME D2.1 There is established There is established system of SI/RR Stock level are daily
procedure for forecasting timely indenting of X ray films, updated
and indenting drugs and fixer and developers etc Requisition are timely
consumables placed
ME D2.3 The facility ensures proper “Fixers, developer and X ray films/ OB/RR Reagents label contain
storage of drugs and consumables are kept away from name, concentration, date
consumables water and sources of heat, of preparation/opening,
direct sunlight “ date of expiry, storage
Fixers and developer are labelled OB/RR

properly
ME D2.5 The facility has established Department maintain stock and RR/SI
procedure for inventory expenditure register of chemicals
management techniques and X-ray films

periodically replenishing replenishing drug tray
areas
There is no stock out of x-ray RR/SI

films
Standard D3 The facility has established Program for maintenance and upkeep of the faciity to provide
ME D3.2 Hospital infrastructure is Check for there is no seepage , OB
adequately maintained Cracks, chipping of plaster

fixtures are intact

are clean

removal of condemned the X-ray and USG
junk material
ME D3.5 The facility has No rodent/birds OB

established procedures for
pest, rodent and animal
control
269

ME D3.6 The facility provides Adequate illumination at work OB
adequate illumination level station at X ray room
at patient care areas
Adequate illumination at OB
workstation at USG
ME D3.7 The facility has provision Only one patient is allowed one OB
of restriction of visitors in time in X room
patient areas
Warning light is provided OB/SI

outside X ray room and its been
used when unit is functional
ME D3.8 The facility ensures Protective apron and gloves OB/SI

safe and comfortable are being provided to relative
environment for patients of the child patient who escort
and service providers the child for X ray examination/
immobilisation support is
provided to children
Shield for Testis to male patients OB/SI

undergoing X-ray abdomen
X ray room has been kept closed OB

at the time of radiation exposure
Lead apron and other protective OB

equipments are available with radiation
workers and they are using it
TLD badges are available with all

staff of X ray department and OB
records of its regular assessment
is done by X ray department
Temperature control and SI/RR Fans/ Air conditioning/

ventilation in X ray room Heating/Exhaust/Ventilators
as per environment
Temperature control and SI/RR Exhaust in dark room

ventilation in dark room
Temperature control and SI/RR Fans/ Air conditioning/

ventilation USG Heating/Exhaust/Ventilators
as per environment condition
and requirement
The facility ensures 24x7 water and power backup as per requirement of
Standard D5
service delivery, and support services norms
270

ME D5.2 The facility ensures Availability of power back up OB/SI
adequate power backup in Radiology and USG room
in all patient care areas
as per load
ME D8.1 The facility has requisite X-ray has vaild registration from RR
licences and certificates AERB
for operation of hospital
X-ray department has layout RR

approval from AERB
X-ray department has type RR

approval of equipment with QA
test report for X-ray machine
USG department has registration RR

under PCPNDT
Duplicate copy of Certificate OB

of registration under Form B is
displayed inside the department
ME D8.3 The facility ensure relevant USG is taken by staff Qualified RR

processes are in compliance as per PCPNDT
with statutory requirement
Records of submission of Form F to RR

appropriate district authorities
Standard D9
ME D9.1 The facility has established The staff is aware of their role SI
job description as per govt and responsibilities
guidelines
ME D9.2 The facility has a established There is procedure to ensure RR/SI Check for system for
procedure for duty roster that the staff is available on recording time of reporting
and deputation to different duty as per duty roster and relieving (Attendance
ME D9.3 The facility ensures technician and support staff OB

the adherence to dress adhere to their respective dress
code as mandated by its code
department

ME E1.1 The facility has established Unique identification number is RR Check for that patient
procedure for registration given to each patient demographics like Name, age,
of patients Sex, Chief complaint, etc.
271

Patient demographic details RR
are recorded in radiology/USG
records
ME E3.2 Facility provides There is procedure for referral of RR/SI
appropriate referral patient for which services can
linkages to the patients/ not be provided at the facility
care.
ME E5.1 The facility identifies Women in reproductive age are OB/SI/RR Notice in local language
vulnerable patients and asked for pregnancy (LMP)before is displayed at entrance of
ensure their safe care X-ray X ray department asking
every female to inform
radiographer/radiologist
whether she is likely to be
pregnant
Facility has defined and established procedures for maintaining, updating of

Standard E8
ME E8.5 Adequate form and Standard Formats available RR/OB Printed formats
formats are available at for requisition and
point of use reporting are available
ME E8.6 Register/records are Radiology records are labelled RR

maintained as per guidelines and indexed and maintained.
ME E8.7 The facility ensures safe Radiology has adequate facility OB

and adequate storage for storage of records
records
ME E11.1 There are established Requisition of all X-ray RR/OB - Provisional diagnosis
procedures for Pre-testing examination is done in request - Indication for the
Activities form investigation
X-ray department has system in RR/SI

place to label the X rays
X-ray has system to trace the X RR/SI

ray from requisition form
272

Requisition of all USG examination RR/OB
is done in request form
The USG department has system RR/SI

in place to label the USGs
Preparation of the patient is RR/SI

done as per requirement
Instructions to be followed by RR/SI

patient for USG are displayed in
local language at reception
ME E11.2 There are established The X-ray taking and processing OB/RR
procedures for testing procedure are readily available
Activities at work station and staff is
aware of it
The radiographer is aware of RR/SI

operation of X ray machine
USG of the patient is taken as OB/RR

per consultant requirement
ME E11.3 There are established The X-ray department has RR/OB

procedures for Post- format for reporting of results
testing Activities
The USG department has format RR/OB

for reporting of results

Standard F1
Periodic medical checkups of SI/RR - Peripheral blood smear

the staff - Hb
- Gonodal Atrophy
- Alopalcia
use of use
Availability of running Water OB/SI Ask to Open the tap. Ask

Staff water supply is
regular

uninterrupted
273


facility , preferably in Local
language
practices
Staff is aware of when to hand SI

wash
ME F5.2 Facility ensures availability Availability of cleaning agent as OB/SI Hospital grade phenyl,
of standard materials for per requirement disinfectant detergent
cleaning and disinfection solution



Standard F6

coded plastic bags


Biomedical waste

and general waste
ME F6.3 Facility ensures Disposal of Fixer and Developer SI/OB/RR

transportation and
guidelines
274

Area of Concern - G Quality Mangement
ME G2.1 Patient Satisfaction There is system to take feed back RR
surveys are conducted at from clinician about quality of
periodic intervals services
ME G3.2 The facility has TLD badges are analyzed at RR
established external stipulated interval
assurance programme at
relevant departments
ME G3.3 The facility has Departmental checklist are SI/RR

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

Standard G4
Procedures for all key processes.

ME G4.2 Standard Operating Procedures The department has documented RR

adequately describes process procedure for process of taking
and procedures and handling X-ray

procedure for acceptance and
rejection of X-ray taken

procedure for receipt, labelling,
Processing and reporting of X-ray

procedure for taking X-ray in
emergency conditions

procedure for quality control system
to verify the quality of results
Radiology has documented RR

system for repeat X-ray.

procedure for storage, retaining
and retrieval of department
records, and reports of results.
275

procedure preventive and break
down maintenance

procedure for purchase of
External services and supplies

procedure for inventory
management

procedure for radiation safety of
staff, patients and visitors
ME G4.3 Staff is trained and aware Check if staff is aware of SI/RR

of the standard procedures relevant parts of SOPs
written in SOPs
ME G4.4 Work instructions are Work Instructions are displayed OB Factor chart, radiation
displayed at Point of use for radiation safety safety, development for
x-ray films

Standard G5

adequately


actions are taken to action are taken
ME G6.2 The facility periodically Quality objectives for Radiology RR/SI
defines its quality objectives are defined
and key departments have
their own objectives
ME G6.3 Quality policy and objectives Check of staff is aware of quality SI

aware of that

periodically
276

ME H1.1 Facility measures X-ray done per 1000 OPD patient RR
monthly basis
X-ray done per 1000 IPD patient RR
Ultrasound done per 1000 OPD RR

patient
No. of dental X-ray per 1000 RR

dental OPD
ME H1.2 The Facility measures Proportion of BPL Patients under RR

equity indicators went X-ray exam and USG
periodically
ME H2.1 Facility measures Downtime for critical RR
efficiency Indicators on equipments
monthly basis
Turn around time for X-Ray RR

film development
Proportion of wastage of films RR
Proportion of X-ray rejected/ RR

repeated
ME H3.1 Facility measures Proportion of scans for RR
Clinical Care and Safety which F form is filled out of
Indicators on monthly pregnant women scanned
basis
No of events of over limit of RR

radiation exposure
ME H4.1 Facility measures Average waiting time at RR
Service Quality radiology
basis
Average waiting time at USG RR

Number of stock out
incidences of X-ray films RR

stock out
277


STANDARDS FOR CHC
Checklist for Pharmacy
and Stores
278
Checklist for Pharmacy and Stores

ME A1.9 Services are available Dispensary services are available SI/RR
for the time period as during OPD hours
mandated
Facility ensure access to drug SI/RR

store after OPD hours
ME A4.1 The facility provides Availability of Drugs under SI/OB Chloroquine,
services under National NVBDCP Primaquine, ACT
Vector Borne Disease (Artemisinin
Control Programme as per Combination Therapy)
guidelines
ME A4.2 The facility provides Availability of Drugs under SI/OB CAT 1, CAT II Cat IV and
services under Revised RNTCP Paediateric
National TB Control
Programme as per
guidelines
ME A4.3 The facility provides services Availability of Drugs under NLEP SI/OB Rifampicin, Clofazimine,
under National Leprosy Dapsone
per guidelines
ME A4.4 The facility provides Availability of ARV Drugs under SI/OB Zidovudine, Stavudine,
services under National NACP Lamivudine, Nevirapine
AIDS Control Programme in combination as per
as per guidelines NACO
Availability of Drugs for SI/OB Paediatric Dosages FDC

Paediatric HIV management 6, FDC 10, Efavirenz,
Cotrimoxazole
Standard A5 Facility provides support services and Administrative services
ME A5.6 The facility provides Dispensing of Medicines and SI/OB Functional dispensary
pharmacy and store services consumables for OPD Patients
Storage of drugs SI/OB
Storage of consumables SI/OB
Storage of equipments SI/OB
Storage of Stationaries. SI/OB
Cold chain management services SI/OB
Storage of Linen SI/OB
279

Standard B1
ME B1.1 The facility has uniform Availability departmental OB (Numbering, main
and user-friendly signage signage’s department and internal
ME B1.2 The facility displays the List of available Drugs displayed OB

services and entitlements at a Pharmacy
available in its departments
Status of availability of drugs is OB

updated weekly
Timings for dispensing counter OB

of pharmacy are displayed

understand
Standard B2
ME B2.1 Services are provided in Availability of separate Queue OB
manner that are sensitive for Male and female patients at
to gender dispensing counter
ME B2.3 Access to facility is Pharmacy has easy access for OB Check for availability of
provided without any moment of goods ramp and goods trolley/
physical barrier and and cart
is friendly to people with
disabilities
The facility maintains privacy, confidentiality and dignity of patient, and has a system for
Standard B3
guarding patient related information.
ME B3.3 The facility ensures the Behaviour of staff is empathetic PI
services
Standard B4
ME B4.4 Information about the Method of Administration / OB/SI
treatment is shared with taking of the medicines is
patients or attendants, informed to patient/ their
regularly relative by pharmacist as per
doctors prescription in OPD
Pharmacy
280

Standard B5
ME B5.1 The facility provides Free drugs and consumables for PI/SI
cashless services to JSSK beneficiaries
and neonates as per
schemes
ME B5.2 The facility ensures that Pharmacy supplies generic SI/OB

drugs prescribed are drugs to all hospital
available at Pharmacy and departments as per as internal
wards demand
Check that patient has PI/SI

not incurred expenditure
on purchasing drugs or
consumables from outside.
ME B5.4 The facility provides Free drugs for BPL and other PI/SI/RR As per state guideline e. g:
free of cost treatment entitled patients geriateric patient
to Below poverty
line patients without
administrative hassles
ME B5.5 The facility ensures Local purchase of stock out PI/SI/RR

timely reimbursement drugs/ Reimbursement of
of financial entitlements expenditure to the beneficiaries
patients

Standard C1
ME C1.1 Departments have The hospital has allocated space OB Minimum space
adequate space as per for Pharmacy in OPD required is 250sq F or
patient or work load 5% of average OPD X 0.8
sq m.
Dispensary has adequate OB

waiting space as per load
ME C1.2 Patient amenities are Pharmacy has patients sitting OB

provide as per patient load arrangement as per requirement
ME C1.3 Departments have layout Dedicated area for keeping OB

and demarcated areas as medical gases
per functions
Dedicated area for keeping OB Storage of sprit etc.

inflammables
Demarcated are of keeping near OB

expiry drugs
281

Demarcated area for keeping OB
instruments and consumables
Dedicated area for cold chain OB

management
ME C1.4 The facility has adequate Availability of adequate OB

circulation area and open circulation area for easy moment
spaces according to need of staff , drugs and carts
and local law

communication
ME C1.6 Service counters are Adeqauate No of drug OB

available as per patient dispensing counter as per load
load
ME C1.7 The facility and Unidirectional flow of goods in Receipt and Inspection
departments are planned the Pharmacy OB area at one side and issue
to ensure structure area on the other side
ME C2.2 The facility ensures safety Pharmacy does not have OB

loosely hanging wires
Stabilizer is provided for cold OB

chain room
ME C2.3 Physical condition of Windows of drug store have OB

buildings are safe for grills and wire meshwork
Floors of the Pharmacy OB

department are non slippery,
acid resistand and even surfaced
282

ME C2.4 The facility has plan for Pharmacy has plan for safe OB/SI
prevention of fire storage and handling of
ME C2.5 The facility has adequate Pharmacy has installed fire OB/RR
fire fighting Equipment Extinguisher for A, B and C class
of fire
Check the expiry date on fire OB/RR

extinguishers is displayed on
mentioned
ME C2.6 The facility has a system Check staff competencies for SI/RR
The facility has adequate qualified and trained staff, required for providing the assured services to the
Standard C3
current case load
ME C3.4 The facility has adequate Availability of Pharmacist SI/RR
per requirement
ME C3.6 The staff has been provided Inventory management SI/RR

Cold chain management of ILR SI/RR

and deep freezer
Rational use of drugs SI/RR
Prescription Audit SI/RR
ME C3.7 The Staff is skilled as per Staff is skilled for estimation SI/RR
job description of the requirement and proper
storage of the drugs

pharmacy records and bin cards
ME C4.1 The departments have Analgesics/ Antipyretics/Anti OB/RR As per State EDL
availability of adequate inflammatory
Antibiotics OB/RR As per State EDL
Anti Diarrhoeal OB/RR As per State EDL
Antiseptic lotion OB/RR As per State EDL
Dressing material OB/RR As per State EDL
283

IV fluids and plasma expenders OB/RR As per State EDL
Eye and ENT drops OB/RR As per State EDL
Anti allergic OB/RR As per State EDL
Drugs acting on Digestive OB/RR As per State EDL

system
Drugs acting on cardio vascular OB/RR As per State EDL

system
Drugs acting on central/ OB/RR As per State EDL

Peripheral Nervous system
Drugs acting on respiratory OB/RR As per State EDL

system
Drugs acting on uro genital OB/RR As per State EDL

system
Drugs used on Obstetrics and OB/RR As per State EDL

Gynaecology
Hormonal Preparation OB/RR As per State EDL
Other drugs and materials OB/RR As per State EDL
Vaccines and Sera OB/RR As per State EDL
Surgical accessories for Eye OB/RR As per State EDL
Vitamins and nutritional OB/RR As per State EDL

supplement
ME C4.2 The departments have Availability of Consumables OB/RR As per Sate EDL
adequate consumables at
point of use
ME C5.5 Availability of Equipment Availability of Equipment for OB ILR, Deep Freezers,
for Storage maintenance of Cold chain Insulated carrier boxes
with ice packs,

equipment and cleaning mops, duster, waste trolley,
instruments for support Deck brush
services
ME C5.7 Department have patient Storage furniture for drug store OB Racks ,Cupboards,
furniture and fixtures Sectional Drawer cabinet/
as per load and service Shelves, Work table
provision
284

ME D1.2 The facility has established All the measuring equipment/ OB/ RR Calibration of
procedure for internal instruments are calibrated thermometers at cold
and external calibration of chain room
measuring Equipment
ME D1.3 Operating and Operating instructions for ILR/ OB/SI

maintenance instructions Deep Freezers are available at
are available with the cold chain room
users of equipment
Standard D2 The facility has defined procedures for storage, inventory management and dispensing
ME D2.1 There is established Drug store has process to RR/SI
procedure for forecasting consolidate and calculate the
and indenting drugs and consumption of all drugs and
consumables consumables
Forecasting of drugs and RR/SI

consumables is done scientifically
which is realistic and based on
consumption and disease load
Staff is trained for forecast the RR/SI

requirement using scientific
system
ME D2.2 The facility has The facility has a established RR/SI

establish procedure for procedure for local purchase of
procurement of drugs drugs in emergency conditions
The facility has system for placing RR/SI

requisition to district drug store
ME D2.3 The facility ensures proper There is specified place to store OB

storage of drugs and medicines in Pharmacy and
consumables drug store
All the shelves/racks containing OB Stock is arranged neatly

medicines are labelled in in alphabetic order with
pharmacy and drug store name facing the front.
Product of similar name and OB

different strength are stored
separately
Heavy items are stored at lower OB

shelves/racks
Fragile items are not stored at OB

the edges of the shelves.
285

Sound alike and look alike OB
medicines are stored separately
in patient care area and
pharmacy
There is separate shelf /rack for OB

storage near expiry drugs
Drug store and pharmacy OB/SI

has system of inventory
Management
Drugs and consumables are stored OB/RR Medications that are

away from water and sources of considered light-sensitive will
heat, direct sunlight etc. be stored in closed drawers.
Drugs are not stored on floor OB Pallets are provided if

and adjacent to wall required to store at floor
ME D2.4 The facility ensures The dispensary has system to RR/SI

management of expiry check the expiry of drugs
Drug store has system to check RR/SI

the expiry of drugs
Drug store has system to inform RR/SI

the patient care areas about
near expiry and system of call
back of expired drugs
There is a system of periodic RR/SI

random quality testing of drugs
ME D2.5 The facility has established Physical verification of RR/SI

procedure for inventory inventory is done periodically
Facility uses bin card system RR/OB
First expiry first out system is OB

established for drugs
Stores has defined minimum RR/OB

stock for each category of
drug as per there consumption
pattern
Reorder level is defined for each RR

category of drugs
Drug store has inventory OB/RR

management software
Drugs are categorized in Vital, OB/RR

Essential and Desirable (VED)
286

ME D2.6 There is a procedure for Hospital has system of collection RR/SI
periodically replenishing of medicines from the store in
the drugs in patient care case of emergency
areas
ME D2.7 There is process for Check that vaccines are kept in OB (Top to bottom) : Hep B,
storage of vaccines and sequence DPT, DT, TT, BCG, Measles,
other drugs, requiring OPV
Work instruction for storage of OB

vaccines are displayed at point
of use
ILR and deep freezer have OB

functional temperature
monitoring devices
There is a system in place to OB Temp. of ILR: Min +2OC

maintain temperature chart of to 8Oc in case of power
ILR failure min temp. +10OC .
Daily temperature log are
maintained
There is a system in place to OB Temp. of Deep freezer

maintain temperature chart of cabinet is maintained
deep freezers between -15OC to -25OC.
Daily temperature log are
maintained
Check that thermometer in ILR OB

is in hanging position
ILR and deep freezer have SI/RR

functional alarm system
The staff is aware of hold over SI/RR

time of cold storage equipments
ME D2.8 There is a procedure for Narcotic medicines are kept in OB As per Narcotic act,
secure storage of narcotic double lock Narcotic medicines are
and psychotropic drugs kept in 2 Keys with 2
locks kept by 2 different
persons
Empty ampoules/strips are OB/RR

returned along with narcotic
administration detail sheet
Hospital has a system to discard RR/SI Discarded narcotic drugs

the expired narcotic drugs are documented with
witness.
The facility maintains the list of RR

narcotic and psychotropic drugs
available at facility
287

Standard D3
ME D3.2. Hospital infrastructure is Check for there is no seepage, OB
adequately maintained Cracks, chipping of plaster

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

are clean
ME D3.4. The facility has policy of Action for removing junk, OB

removal of condemned condemned articles are periodically
junk material taken, atleast at six monthly intervals

and animal control
ME D3.6 The facility provides Adequate Illumination inside OB

adequate illumination drug store
ME D3.8 The facility ensures Temperature control and SI/RR Fans/ Air conditioning/
safe and comfortable ventilation in pharmacy is Heating/Exhaust/
environment for patients maintained Ventilators as per
and requirement
ME D3.9 The facility has security Security arrangement at OB

system in place at patient pharmacy is robust
care areas
adequate power backup the Pharmacy
per load
Availability of power back up for OB/SI

the cold chain maintenance
ME D8.1 The facility has requisite License for storing spirit RR
licences and certificates
for operations of hospital
288

Roles and Responsibilities of administrative and clinical staff are determined as per
Standard D9
guidelines
ME D9.2 The facility has a There is a procedure to ensure RR/SI Check for system for
There is designated in charge for SI

department
ME D9.3 The facility ensures Pharmacists adhere to their OB

the adherence to dress respective dress code
code as mandated by
health department

Standard E6
ME E6.1 The facility ensured that The facility has essential drug RR/SI
drugs are prescribed in list as per State guideline
generic name only
Drugs are purchased by generic OB

name only
The facility has enabling order RR/SI

from state for writing drugs in
generic name only
The facility provide list of

drugs available to different RR/SI
departments as per essential
drug list
There is system of conducting RR/SI

periodic prescription audit to
ensure that only generic and
rational drugs are prescribed

ME E7.1 There is process for Pharmacy has list of high risk RR/SI
identifying and cautious drugs.
administration of high
alert drugs
289

Facility has defined and established procedures for maintaining, updating
Standard E8
of patients’ clinical records and their storage
ME E8.5 Adequate form and Standard Formats available RR/OB Bin cards, indent forms
formats are available at etc
point of use
ME E8.6 Register/records are Pharmacy records are labeled RR

maintained as per and indexed
guidelines
Records are maintained for RR

Pharmacy
ME E8.7 The facility ensures safe Pharmacy has adequate facility OB

and adequate storage for storage of records
records
Roles and responsibilities of staff SI/RR

in disaster are defined
Contingency/Buffer stock for SI/RR

Disaster and mass casualties.

Standard F1
ME F1.4 There is Provision of There is procedure for SI/RR Hepatitis B, Tetanus
Periodic Medical Checkups immunization of the staff Toxid etc
Periodic medical checkups of SI/RR

the staff are conducted
ME F1.6 Facility has defined and Check for Pharmacist are aware SI/RR
established antibiotic of Hospital Antibiotic Policy
policy
ME F5.2 Facility ensures availability Availability of cleaning agent OB/SI Hospital grade phenyl,
of standard materials for as per requirement disinfectant detergent
cleaning and disinfection solution
Standard F6
ME F6.1 Facility Ensures Availability of colour coded OB
segregation of Bio Medical bins and liner for disposal of
Waste as per guidelines expired drugs
290

ME F6.3 Facility ensures There is no mixing of infectious OB
transportation and disposal and general waste
Disposal of expired drugs as per SI/OB

state guidelines

ME G3.1 Facility has established Physical verification of the SI/RR
internal quality assurance inventory by Pharmacist at
program at relevant periodic intervals
departments



Standard G4 Procedures for all key processes and support services.


Procedures adequately procedure for indent the drugs
describes process and and items from district drug
procedures warehouse

procedure for local purchase of
drugs/ generic drug stores

procedure for reception of
drugs and items

procedure for storage of drugs

procedure for disposal of
expired drugs

procedure for dispensing of
medicines at Pharmacy
291

procedure of supply the drugs
to patient care area

procedure for issue of the drugs
in emergency condition

temperature of ILR/Deep freezer
/refrigerators

procedure for maintaining
near expiry drugs at store and
pharmacy

procedure for rational use of
drugs and prescription audit

procedure for storage of
narcotic and psychotropic drugs

system for periodic random
check and quality testing of
drugs
ME G4.3 Staff is trained and aware Check staff is a aware of SI/RR

of the standard procedures relevant part of SOPs
written in SOPs
ME G4.4 Work instructions are Work instruction/clinical OB Work instruction for

displayed at Point of use protocols are displayed storing drugs, Cold chain
management

Standard G5
assessment
ME G5.2 The facility conducts the Pharmacy department co- RR/SI

periodic prescription/ ordinates the prescription audit
Storage and compilation of RR/SI

records of prescription audit

adequately
292

ME 5.4 Action plan is made on Action plan is prepared RR/SI

actions are taken to actions taken
ME G6.2 The facility periodically Quality objectives for Pharmacy RR/SI
defines its quality are defined
objectives and key
own objectives

aware of that

periodically
services
5S SI/OB

services

ME H1.1 Facility measures Percentage of drugs available RR
productivity Indicators on against essential drug list
monthly basis
ME H1.2 The Facility measures Expenditure on drugs procured RR

equity indicators throughlocal purchase for BPL
periodically patient
293

ME H2.1 Facility measures efficiency Number of stock out situations RR
Indicators on monthly for Vital category of drugs/
basis consumables.
Turn Around time for dispensing RR

medicine at Dispensary
Percentage of drugs expired RR

during the months
ME H3.1 Facility measures Clinical Proportion of prescription found RR
Care and Safety Indicators prescribing non generic drugs
on monthly basis
No of advere drug reaction per RR

thosuand patients
Antibiotic rate RR No. of antibiotic

prescribed /No. of patient
admiited or consulted
Percentage of irrational use of RR

drugs/overprescription
ME H4.1 Facility measures Waiting time for Pharmacy RR
Service Quality Counter
basis
294


STANDARDS FOR CHC
Checklist for Blood Storage
Centres
296
Checklist for Blood Storage Centres

ME A1.9 These services are available Blood storage services are SI/RR Lab Technician in charge
for the time period as available 24X7 is available on call after
mandated working hours
ME A1.11 The facility provides Blood Blood storage has facility for SI/OB
storage and transfusion storage of whole blood
services
Blood storage has emergency SI/OB A, B, O (+)-5units; AB + 2

stock of blood units and 1 unit each of
A,B, and O Negative {may
be modified as per usage)

ME A3.2 The facility Provides Availability of Blood Grouping, SI/OB
Laboratory Services compatability testing and and
cross matching services
ME A4.1 The facility provides Facility to arrange for platelets SI/RR
services under National from parent blood bank for
Vector Borne Disease management of Dengue cases.
guidelines

Facility provides the information to care seekers, attendants and community about
Standard B1
ME B1.1 The facility has uniform Availability of Departmental OB Numbering of rooms,
and user-friendly signage signages main department and
system inter- sectional signage
ME B1.2 The facility displays the Blood storage has displayed OB

services and entitlements information regarding number
available in its of blood units available
departments
ME B1.4 User charges are displayed User applicable charges in OB

and communicated to r/o blood are displayed at the
patients effectively entrance
ME B1.5 Patients and visitors are IEC material is available in Blood OB

sensitised and educated storage to provide information
through appropriate IEC / and to promote blood donation
BCC approaches
297

ME B1.6 Information is available Signages and information are OB
in local language and available in local language
easy to understand
Standard B3
ME B3.3 The facility ensures that Behaviour of staff is empathetic PI/OB
the behaviours of staff is and courteous
services
Standard B5
protection given from cost of Hospital services.
ME B5.1 The facility provides Free blood for Pregnant women, PI/SI
cashless services to Mothers and New borns and
pregnant women, mothers infants.
and neonates as per
schemes
ME B5.2 The facility ensures that Check that patient party PI/SI
drugs prescribed are has not incurred expenditure on
available at Pharmacy and purchasing blood from outside.
wards
ME B5.4 The facility provide free of Free blood is provided to BPL PI/SI/RR
hassles

The facility has infrastructure for delivery of assured services and available infrastructure meets the
Standard C1
prevalent norms
ME C1.1 Departments have Blood storage has adequate OB Space required is more
adequate space as per space as per requirement than 10sq meters
ME C1.3 Departments have layout Dedicated area for Whole blood OB

and demarcated areas as and components.
per functions
Dedicated space for keeping OB

records

infrastructure for Intercom and telephonic
intramural and extramural services
communication
298

equipment, hanging
ME C2.2 The facility ensures safety Blood storage does not have OB
of electrical establishment temporary connection and
loosely hanging wires
Adequate electrical socket OB/RR

provided for safe and smooth
operations of testing equipment
ME C2.4 Physical condition of Work benches are chemical OB

buildings are safe for resistant
Blood storage has plan for OB

safe storage and handling of
ME C2.5 The facility has adequate At least one Fire Extinguisher OB/RR
fire fighting Equipment (ABC types) is available in
vicinity of blood storage.
Check the expiry date on fire OB/RR

extinguishers is displayed
as well as due date for next
refilling is also mentioned
ME C2.6 The facility has a system Check for staff competencies SI/RR
Standard C3
ME C3.1 The facility has adequate Availability of designated OB/RR MBBS doctor with 3 days
specialists doctors as per Blood storage officer. recognized training on
service provision blood storage
ME C3.4 The facility has adequate Availability of Trained SI/RR DMLT with one day
technicians/paramedics as Technician for Blood storage recognized training on
per requirement blood storage.
ME C3.6 The staff has been provided IMEP training. SI/RR

Blood storage management
299

ME C3.7 The Staff is skilled as per Staff is skilled in operating SI/RR
job description the equipment
ME C4.1 The departments have Availability of Laboratory OB/RR Pauster pipette, glass
availability of adequate materials tubes, gloves, tooth picks
drugs at point of use Glass slides, Glass marker/
paper stickers
ME C4.2 The departments have Availability of Reagents /Kits OB/RR Standard Grouping Sera
adequate consumables at and other consumables for Anti A, Anti B and Anti D,
point of use testing. Antihuman Globulin.
ME C5.3 Availability of equipment Availability of laboratory OB Microscope, RH viewer.

and instruments for equipment and instruments for
diagnostic procedures laboratory
facility
ME C5.5 Availability of Equipment Check for availability of storage OB Blood bags refrigerator
for Storage equipment for blood products with thermo graph and
alarm device, Insulated
carrier boxes with
ice packs, Blood bag
weighting machine, deep
freezer,

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

There is a system to label OB/RR

equipments and stored
appropriately until it has been
repaired
Staff is skilled for trouble SI/RR

shooting in case of equipment
malfunction

300

measuring Equipment
There is a system to label/ code OB/ RR

the equipment to indicate
status of calibration/ verification
when recalibration is due
Blood storage has a system to SI/RR Check for records

update correction factor after
calibration wherever required
Each lot of reagents is checked SI/RR

against earlier tested in use
reagent lot or with suitable
reference material before being
placed in service and result
should be recorded.

Standard D2 dispensing of drugs in pharmacy and patient care areas
procedure for forecasting of timely indenting of updated Requisition are
and indenting drugs and consumables and reagents timely placed
consumables
ME D2.3 The facility ensures Reagents and consumables are OB/RR

proper storage of drugs kept away from water and sources
and consumables of heat, direct sunlight
Reagents are labelled OB/RR Reagents label contain

appropriately name, concentration, date
of preparation/opening,
OB/RR date of expiry, storage
ME D2.4 The facility ensures Expiry dates’ on blood bags are OB/RR
management of expiry maintained
No expired blood is found RR

in storage
Records for expiry and near SI/RR

expiry blood are maintained
ME D2.5 The facility has established Department maintains stock and OB/SI
procedure for inventory expenditure register of reagents
301

ME D2.6 There is a procedure for There is no stock out of reagents OB/RR
periodically replenishing
areas
ME D2.7 There is process for Temperature of refrigerators RR/SI Check if temperature

storage of vaccines and used for storing lab reagents are charts are maintained and
other drugs, requiring kept as per storage requirement updated periodically for
controlled temperature and records are maintained refrigerators used storing
lab reagents
Regular Defrosting is done SI/RR
Standard D3
safe, secure and comfortable environment to the staff, patients and visitors.

Window panes, doors and other OB

fixtures are intact
ME D3.3 Patient care areas are Floors, walls, roof, tops sinks OB All area are clean with no
clean and hygienic in Blood storage unit and dirt, grease, littering and
circulation area are Clean cobwebs

are clean
ME D3.4 The facility has policy of No condemned/Junk material is OB

removal of condemned kept in Blood storage unit
junk material
ME D3.6 The facility provides Adequate illumination at blood OB Illumination level of

adequate illumination storage Blood storage is as
level at patient care areas per recommendation/
sufficient to carry out
Blood storage activities
Standard D4 delivery, and support services norms
The facility ensures Availability of power back up for OB/SI

ME D4.2 adequate power backup blood storage
per load
302

Facility is compliant with all statutory and regulatory requirement imposed by
Standard D8
local, state or central government
ME D8.1 The facility has requisite Blood storage has obtained RR
licences and certificates approval from the State/UT
for operation of hospital licensing Authority.
Facility has obtained consent RR

from Parent blood bank.
Parent Blood Bank has valid RR

license under Rule 122(G) Drug
and cosmetic act
Standard D9 regulations and standards operating procedures.
ME D9.1 The facility has The staff is aware of their roles SI
established job description and responsibilities
ME D9.2 The facility has a established There is procedure to ensure RR/SI Check for system for
procedure for duty roster that staff is available on duty as recording time of reporting
and deputation to different per duty roster and relieving (Attendance

for the department
ME D9.3 The facility ensures Doctor, technician and support OB

the adherence to dress staff adhere to their respective
code as mandated by dress code
health department

ME E3.2 Facility provides appropriate There is procedure for referral SI/RR
referral linkages to the of cases for which requested
patients/Services for Blood/compenent is not
transfer to other/higher available
continuity of care.
Facility has functional referral SI/RR

linkages to parent blood bank
Standard E8 Facility has defined and established procedures for maintaining, updating of
ME E8.5 Adequate form and formats Standard Formats are available RR/OB Format for requisition
are available at point of use form, blood transfusion
reaction form, referral slip
ME E8.6 Register/records are Blood storage records are RR

maintained as per guidelines labelled and indexed
303

Records are maintained for RR Records includes daily
Blood storage group wise stock register,
daily temperature
recording of temperature
dependent equipment,
stock register of
consumables and non
consumables, documents
of proficiency testing,
records of equipment
maintenance, records of
recipient, compatibility
records, transfusion
reaction records, donors
records etc.
ME E8.7 The facility ensures safe Safe keeping of patient records OB Blood storage has facility
and adequate storage is ensured access to the records to store records for 5 year
and retrieval of medical is on need to know basis
records
Standard D10 The facility has defined and established procedures for Emergency Services and Disaster Management
ME E10.3 The facility has disaster Blood storage centre has a system SI/RR
management plan in of coping with extra demand of
place blood in case of disaster
Standard E12 The facility has defined and established procedures for Blood storage Management and Transfusion.
ME 12.1 There is established The centre has standardized RR/SI
procedure for Transport procedure for transporting blood
of blood from parent from parent blood bank.
blood bank.
Cold chain is maintained at all OB/SI During transportation blood

levels i.e. from parent blood bank to is properly packed in cold
blood storage to the issue of blood. boxes surrounded by ice
packs. Ice should not come
in contact with blood bags.
ME 12.2 There is established The Blood storage centre has RR all the blood/component
procedure for storage of standardized procedure for units are checked for
blood receipt of blood from parent haemolysis, turbidity, or
blood bank. change in colour on receipt
from parent blood bank
Check if refrigerators or freezers for OB Lab reagents etc.

blood storage are used for storing
other items or not
Check if refrigerators used OB/RR Check records that

for blood storage are kept at temperature is
recommended temperature maintained at 40c + 20C
Storage temperature is monitored OB/RR Check the records

atleast twice a day.
304

Alarm system has been provided RR/SI
with the refrigerator
Shelf life of blood and

components is adhered as per RR/SI
NACO protocols
Blood storage has a system RR/SI Blood should be kept at

to trace of unit of blood / 4oC to 6oC except if it
component from source to final is used for component
destination preparation it will be
stored at 22oC until
plateletes are separated
ME E12.3 There is established Determination of ABO group is RR/SI Tube or Microplate or gel
procedure for the Cross done by recommended methods technology
matching of blood
Determination of Rh (D) Type RR/SI Check for the protocol/

done as per recommended Algorithm followed for
method determining RH + or RH-
Blood type
Blood storage centre has system RR/SI Testing of recipient blood

to testing and cross matching includes Determination
the recipient blood ABO type, Rh (D) type,
detection of unexpected
antibodies etc.
ME E12.4 There is established Blood storage centre has system RR/SI Testing of blood includes
procedure for issuing to testing and cross matching Determination ABO type,
blood the unit before issuing Rh (D) type, detection of
unexpected antibodies etc.
Blood storage centre has system RR/SI

to confirm that information on
transfusion requisition form and
recipients blood sample label
is same

to retain recipient and donor
blood sample for 7 days at
specified temperature (2-8 c)
after each transfusion

to issue the blood along with
cross matching report
Blood storage centre has RR/SI

procedure to issue the blood
in case of its emergency
requirement
305

ME E12.6 There is a established Transfusion reaction form is RR/SI
procedure for monitoring provided when blood is issued
and reporting Transfusion
complication
Blood storage has system RR/SI

of detection, reporting and
evaluations of transfusion errors

Standard F1
ME F1.4 There is Provision of There is procedure for SI/RR Hepatitis B, Tetanus
Periodic Medical Checkups immunization of the staff Toxid etc
Facility has established Regular monitoring of infection SI/RR Hand washing and
ME F1.5 procedures for regular control practices infection control audits
control practices
use of use

Staff, if water supply 24x7

uninterrupted

Local language

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

wash
306

ME F3.1 Facility ensures adequate Clean gloves are available at OB/SI All personal use gloves
personal protection point of use while drawing sample,
equipments as per examining and disposable
requirements of the samples
Availability of lab aprons/coats OB/SI
ME F4.1 Facility ensures standard Proper Decontamination of SI/OB Decontamination of
practices and materials instruments after use instruments and reusable
for decontamination and of glassware are done
clean ing of instruments after procedure in 1%
and procedures areas chlorine solution/ any other
appropriate method


running water after
decontamination
Staff know how to make chlorine SI/OB

solution
ME F4.2 Facility ensures standard Disinfection of reusable SI/OB Disinfection by hot air
practices and materials for glassware oven at 160 oC for 1 hour
disinfection and sterilization
of instruments and
equipments
practices are followed for management

standard procedure
Standard practice of mopping and OB/SI Unidirectional mopping

scrubbing are followed from inside out
Standard F6 and disposal of Bio Medical and hazardous Waste.
ME F6.1 Facility Ensures segregation Availability of colour coded bins OB
of Bio Medical Waste as per at point of waste generation
guidelines

coded plastic bags
307


Biomedical waste

and general waste
ME F6.2 Facility ensures Availability of functional OB Verify its usage

management of sharps needle cutters
as per guidelines
Availability of puncture OB Should be available nears

proof box the point of generation
injection room

Availability of post exposure SI Ask if available. Where it

charge of that.
Staff is aware of contact time OB/SI


ME F6.3 Facility ensures Disinfection of liquid waste SI/OB

transportation and before disposal
guidelines
Disposal of discarded blood SI/OB

bags as per guideline
Check that bins are not overfilled SI

ME G2.1 Patient Satisfaction There is system to obtain feed RR
surveys are conducted at back from clinician about
periodic intervals quality of services
ME G3.1 Facility has established Internal Quality assurance SI/RR
internal quality assurance program is in place
program at relevant
departments
308

Standards are run at SI/RR
defined interval
ME G3.3 Facility has established Departmental checklist is SI/RR

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


Standard G4 Operating Procedures for all key processes.


ME G4.2 Standard Operating The blood storage centre has RR

describes process and Transport of Blood/components
procedures from parent blood bank.
The blood storage centre has RR

documented procedure for receipt
and storage of blood/components

documented procedure for issue
of blood for transfusion

documented procedure for issue of
blood in case of urgent requirement

documented procedure to address
the transfusion reactions

documents procedure for calibration
and maintenance of equipment
ME G4.3 The blood storage centre has RR

documented procedure for HAI
and disposal of BMW
ME G4.4 The blood storage centre has RR

documented system for storage,
retaining and retrieval of
records, and reports of results.
309

Staff is trained and The blood storage centre has RR
aware of the standard documented system for internal
procedures written in and external Quality control of
SOPs Equipments, reagent and tests
Work instructions are Check if staff is aware of SI/RR

displayed at Point of use relevant part of SOPs
work instruction for

Work instruction/clinical OB
screening of blood, storage
protocols are displayed
of blood, maintaining blood
and component in event of
power failure

Standard G5
assessment
ME G5.3 The facility ensures Non Compliance are RR/SI

non compliances are enumerated and recorded
adequately

Corrective and preventive Corrective and preventive RR/SI

ME G5.5 actions are taken to action taken
ME G6.2 The facility periodically Quality objectives for Blood RR/SI
defines its quality storage are defined
objectives and key
own objectives
ME G6.3 Quality policy Check if staff is aware of quality SI

and objectives are policy and objectives
disseminated and staff is
aware of that

periodically
Control charts SI/RR
310

ME H1.1 Facility measures No. of Blood unit issued per RR No. of Unit issued X1000/
productivity Indicators on thousand population Population of serving area
monthly basis
Proportions of requests refused number of units received/

by parent blood bank. Total number of requistion
made to parent blood bank.
ME H1.2 The Facility measures equity No of blood units issued RR JSSK, Thalassemia , BPL
indicators periodically free of cost
ME H2.1 Facility measures Downtime of critical equipment RR Time period for which
efficiency Indicators on equipment was out of
monthly basis order/Total no of working
hours for equipments
Percentage of Blood Units RR No of unit discarded *100/

discarded Total no of unit received.
ME H3.1 Facility measures Clinical Blood transfusion reaction rate RR No of Blood Transfusion
Care and Safety Indicators reactions 1000/ No of
on monthly basis patient blood issued
Propotion of Adverse events RR Chemical splash, Needle

identified and reported stick injuries. Major blood
transfusion reaction,
wrong cross matching,
wrong blood issue
Cross matched/ Transfused RR No of unit are cross

Ratio matched on request/ No
of unit actually transfused
Percentage of single unit RR Percentage of single use

transfusion transfusionX 100/ Total no
of units transfused
ME H4.1 Facility measures Service Time gap between issuing and RR
Quality Indicators on requisition of blood in routine
monthly basis conditions
Time gap between issuing RR

and requisition of blood in
emergency conditions
No of refusal cases RR No of requisition refused/

referred due to non
availability of blood group
or any other reason
311


STANDARDS FOR CHC
Checklist for Auxillary Services
312

Standard A5 Facility provides support services
ME A5.1 The facility provides Availability of functional SI/OB Arrangement of Kitchen
dietary services Kitchen services services inhouse or
outsourced
ME A5.2 The facility provides Availability of functional SI/OB Arrangement of laundry

laundry services laundry services services inhouse or
outsourced
ME A5.3 The facility provides Availability of functional SI/OB In-house or outsourced,

security services security services 24 X7 At least one guard per
shift
ME A5.4 The facility provides Availability of Housekeeping SI/OB In-house or outsourced,

housekeeping services services 24X7 At least 3 in morning shift
and 2 each in morning
and evening shift
Availability of waste disposal SI/OB Arrangement for disposal

services of Bio medical and
general waste Inhouse or
outsouced
The facility ensures Availability of maintenance SI/OB Includes Physical

maintenance services services infrastructure
maintenance and
equipment maintenance
ME A5.7 The facility has services Availability of dedicated space SI/OB

for medical records for storing Medical records

Facility provides the information to care seekers, attendants and community about the
Standard B1
ME B1.8 The facility ensures Medical records are provided to RR/OB

access to clinical records patient/ Next to kin on request
of patients to entitled as per state guideline
personnel
The facility maintains privacy, confidentiality and dignity of patient, and has a system for
Standard B3
guarding patient related information.
ME B3.2 Confidentiality of patients The facility has a system to SI/RR Patient records are not
records and clinical maintain Confidentiality of shared except the patient
information is maintained patient records until it is authorized
by law
313

Standard B5
ME B5.1 The facility provides Availability of free diet PI/SI

cashless services to
and neonates as per
schemes
ME B5.4 The facility provide free of Free diet is provided to BPL PI/SI
cost treatment to Below patients and JSSK beneficiaries
hassles
ME C1.1 Departments have The kitchen has adequate space OB

adequate space as per as per requirement
The laundry Department OB Minimum space

has adequate space as per requirement 10sq ft/bed
requirement
The medical record Department OB Minimum space

has adequate space as per requirement is 2.5 to 3,5
requirement sq ft per bed
ME C1.3 Departments have layout Check if Kitchen has demarcated OB Layout as per functional
and demarcated areas as areas for various activities flow that is receipt,
per functions storage, preparation and
Cooking area, Service
area, dish washing area,
Garbage collection
area and administrative
area.Minimum space
requirement 10sq ft/bed
Check laundry department has OB Layout as per functional

demarcated and dedicated area flow that is from dirty
for its various activities end (receipt) to clean end
(Issue). That is receipt,
sorting, sluicing, washing,
drying, ironing and issue
ME C1.5 The facility has All support services department OB

infrastructure for are connected with intercom
intramural and extramural and have telephones as well
communication
314

ME C2.2 The facility ensures safety Support services departments OB

of electrical establishment do not have temporary
connections and loose hanging
wires
Equipment in wet areas like OB

Laundry and Kitchen are
equipped with ground fault
protection and designed for wet
conditions
ME C2.3 Physical condition of Floors of the Support services OB

buildings are safe for are non slippery and even
providing patient care surfaced
- Kitchen floor is not chipped
ME C2.4 The facility has plan for Dietary Department has plan for OB Dietary Department
prevention of fire safe storage and handling of
ME C2.5 The facility has adequate Support services has installed OB/RR dietary department
fire fighting Equipment fire Extinguisher that is for A B and Medical record
C fire type department
Check that the expiry date on OB/RR dietary department

fire extinguishers are displayed and Medical record
on each extinguisher as well department
as due date for next refilling is
clearly mentioned
ME C2.6 The facility has a system Check for staff competencies for SI/RR
Standard C3 The facility has adequate qualified and trained staff, required for providing the assured
ME C3.5 The facility has adequate Availability of washer man SI/RR

support / general staff
Availability of Cook SI/RR
Availability of Data Entry SI/RR

operator trained in medical
records management.
315

ME C3.6 The staff has been provided Infection Control Management SI/RR
Cleaning practices SI/RR
ME C3.7 The Staff is skilled as per Training on Medical record

job description Management SI/RR
MRD Staff is skilled for indexing

and storage of Medical records SI/RR
Laundry staff is skilled for SI/RR

segregating and processing of
soiled and infectious linen
ME C4.2 The departments have Availability of consumables in OB/RR Cap, gowns, gloves,
adequate consumables at dietary department Detergent for cleaning of
point of use utensil and Soap for hand
washing
Availability of consumables in OB/RR Detergent and

laundry department disinfectant, starch, Blue,
bleach, Heavy utility
gloves, apron.
ME C5.6 Availability of functional Availability of Equipment and OB Refrigerator, LPG, food
equipment and utensils for Dietary department trolley and cooking
instruments for support utensils
services
Availability of Equipment for OB Washing machine, drier,

Laundry Iron, Separate trolley for
clean and dirty linen
Availability of Equipment for OB Computer with scanner

Medical record department
Availability of equipment for OB Buckets for mopping,

cleaning mops, duster, waste
trolley, Deck brush
ME C5.7 Departments have patient Availability of furniture and OB Exhaust fan, Storage
furniture and fixtures fixtures for Dietary department containers, Work bench/
as per load and service slab, Utensil stand
provision
Availability of furniture and OB Stand/ Hanger for drying

fixtures for Laundry Department of linen, Iron table,
Cupboard
Availability of furniture and OB Racks and cupboard,

fixtures for Medical record table, Sectional Drawer
department cabinet/ Shelves,
316

Standard D1 The facility has established programme for inspection, testing and maintenance
and calibration of equipment
ME D1.1 The facility has established All equipment are covered SI/RR
system for maintenance of under the AMC including
There is a system of timely SI/RR


are available with the equipment are readily available
Standard D3 The facility has established Program for maintenance and upkeep of the facility to provide
ME D3.2 Hospital infrastructure is Check that there is no seepage , OB Dietary department,
adequately maintained Cracks, chipping of plaster laundry and medical
record department
Window panes , doors and other OB Dietary department,

fixtures are intact laundry and medical
record department

are clean
ME D3.4 The facility has policy of No condemned/Junk material is OB Dietary department,

removal of condemned found in any of the department laundry and medical
junk material record department
ME D3.5 The facility has established No stray animal/rodent/birds/ OB Dietary department,

procedures for pest, pests laundry and medical
rodent and animal control record department
Kitchen is rodent and pest proof OB/RR
ME D3.8 The facility ensures Temperature control and SI/RR Fans/Coolers/Exhaust/

safe and comfortable ventilation in Dietary Vents/heaters as per
environment for patients department environment condition
and service providers and requirement
Temperature control and SI/RR Fans/Coolers/Exhaust/Vents/

ventilation in Laundry heaters as per environment
Temperature control and SI/RR Fans/Coolers/Exhaust/Vents/

ventilation in Medical record heaters as per environment
Department condition and requirement
317

ME D3.10 The facility has established Check if female staff feels SI
measure for safety and secure at the work place
Standard D4
ME D4.1 The facility has adequate Availability of 24x7 running OB/SI Dietary and laundry
arrangement storage and and potable water department
ME D4.2 The facility ensures Availability of power OB/SI For Laundry, Diet and
adequate power backup back up MRD department
per load
The facility ensures availability of Diet as per nutritional requirement of the patients
Standard D5
ME D5.2 The facility provides diets The facility has defined diet RR/SI
according to nutritional schedule and menu for the
requirements of the patients.
patients
The facility has Special RR/SI Normal diet, Liquid diet,

diet schedule for patients Semi-solid diet, diabetic
suffering from Heart Disease, diet, Low salt, Low fat diet
Hypertension, Diabetes,
Pregnant Women, Diarrhoea
and Renal patients
ME D5.3 Hospital has standard Dietary department has a RR/SI

procedures for system to calculate the number
preparation, handling, of diets to be prepared
storage and distribution
of diets, as per
Dietary department has OB/SI/RR Time interval for

procedure for procurement of procurement of Perishable
perishable and non perishable and non perishable items
items is fixed
Perishable items are stored at OB Like milk, cheese, butter,

cold temperatures egg, vegetables, and fruits
Non perishable items are kept OB All the food items are
in racks/ storage container, in stored above floor level.
ventilated and rodent proof
room
Food is prepared by trained staff, OB/SI

ensuring standard practices
Distribution of the food is done OB

in covered trolleys
318

Dietary department has system RR/SI There is designated person
to check the quality of food preferably nurse in Ward to
provided to patient check the Quality of food
Dietary department has OB/SI

procedure to collect and dispose
of kitchen garbage at defined
interval and place
Department maintains stock RR/SI

and expenditure register in
Kitchen
ME D5.4 The facility has adequate The facility has sufficient set of RR/SI at least 5 sets for each
sets of linen linen available per bed functional bed
ME D5.6 The facility has standard There is a system for Periodic RR/SI To check the theft and
procedures for handling , physical verification of linen pilferage
collection, transportation inventory
Separate trolley/Heavy duty OB

bags are used for collection and
distribution of clean and dirty
linen
Infectious linen are transported OB/RR

into separate containers / bags
There is a system of sorting OB/RR Soiled, infected fouled

of different category of linen type of linen
before putting in to washing
machine
The Linen department has OB/RR

procedure for sluicing of soiled
and infected and fouled linen
Linen department has procedure RR

to keep record of daily load
received from each
department
Hospital has a designated person RR/SI

to check quality of washed linen
There is a system for verifying RR/SI

the quantity of linen received
There is procedure for RR/SI

condemnation of linen
There is system to check RR/SI Security guards keep vigil

pilferage of linen from ward
319

Standard D9 Roles and Responsibilities of administrative and clinical staff are determined as per govt.
ME D9.1 The facility has established The staff is aware of their role SI
job description as per govt and responsibilities
guidelines
ME D9.3 The facility ensures The staff is adhere to their OB

the adherence to dress respective dress code
code as mandated by
health department
Standard D10 Facility has established procedure for monitoring the quality of outsourced services and
adheres to contractual obligations
ME D10.1 There is established There is procedure to monitor SI/RR Verification of outsourced

system for contract the quality and adequacy of services (cleaning/
management for out outsourced services on regular Dietary/Laundry/Security/
sourced services basis Maintenance) provided
are done by designated
in-house staff
Standard E8 Facility has defined and established procedures for maintaining, updating of patients’
ME E8.6 Register/records are Diet Registers are maintained RR

maintained as per at Kitchen
guidelines
Laundry registers are RR

maintained at laundry
ME E8.7 The facility ensures safe Hospital has procedure for RR

and adequate storage and collection, Compilation and
retrieval of medical maintenance of patient’s
records records after discharge
Thre is a system to check RR Checking the records

completion of records as per checklist for
completion
There is a system for indexing/ RR As per ICD coding /

ICD coding the records indexing name, disease,
diagnosis, physician and
surgical procedure carried
out
320

Medical record department has RR Submitting the reports
system to generate statistics for to required health
clinical and administrative use authorities (Birth death
notification, notification
of communicable diseases
etc),
There is a system for safe RR

storage of records
Medical record department RR Retention is as per state

has procedure for retention/ guideline
Preservation of records
Medical record department has RR

procedure for destruction of
old records
Medical record department has RR/SI

system for retrieval of records
Medical record department has RR/SI In case of MLC

procedure for production of
records in Courts of law when
summoned
Medical records are issued to RR/SI To patient/next kin to

authorized personnel only patient
Standard E10 The facility has defined and established procedures for Emergency Services and
Disaster Management
ME E10.3 The facility has disaster The staff is aware of SI/RR Kitchen and Laundry
management plan in disaster plan
place
Role and responsibilities SI/RR Kitchen and Laundry

of staff in disaster is defined

Facility has infection control program and procedures in place for prevention
Standard F1
ME F1.4 There is Provision There is procedure for SI/RR Hepatitis B, Tetanus

of Periodic Medical immunization of the staff Toxid etc
Checkups and
immunization of staff
Periodic medical checkups SI/RR

of the staff with food handlers
under going investigations, as
required
321

ME F2.1 Hand washing facilities are Availability of hand washing OB Preferably in preparation
provided at point of use Facility in the kitchen and cooking area
Availability of Running Water OB/SI Ask to Open the tap. Ask

(Hot and cold) Staff water supply is
regular
Availability of soap with soap OB/SI Check for availability/

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

Local language
ME F3.1 Facility ensures adequate Clean gloves are available for OB/SI
personal protection distribution of food
equipments as per
requirements
Availability of apron OB/SI
Availability of caps OB/SI
Availability of Heavy duty gloves OB/SI

for laundry
Availability of gum boots for OB/SI

laundry
ME F3.2 Staff adheres to standard No reuse of disposable gloves, OB/SI

personal protection caps and aprons.
practices
ME F4.1 Facility ensures standard Cleaning and decontamination SI/OB Ask the cleanliness and
practices and materials of food preparation surfaces like ask staff how frequent
for decontamination and cutting board they clean it
clean ing of instruments
and procedure areas
Cleaning of utensils and food SI/OB Check the cleanliness and

trolleys how frequent they clean it
Decontamination of heavily SI/OB

soiled linen
Cleaning of washing SI/OB

equipment
322

Floors are clean OB
No stray animals in the facility/ OB

Patient Care areas

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
Kitchen food samples of SI/RR

each meal are preserved in
refrigerator for 24 hours
ME G3.2 Facility has established Departmental checklist is used SI/RR

external assurance for monitoring and quality
programs at relevant assurance
departments
ME G3.3 The facility has The staff is designated for SI

established system for use filling and monitoring of these
of check lists in different checklists

Standard G4
operating procedures are for Dietary department has
available been prepared and approved

Standard operating procedure RR

for Laundry Department has
been prepared and approved

Standard operating procedure for RR

Medical record Department has
been prepared and approved

ME G4.2 Standard Operating Record Department has RR

describes process and receiving, compiling, and
procedures maintaining records
323

Record Department has RR
issuing of the records
Record Department has RR

retention of records
Record department has RR

documented procedure for pest
and rodent control
Diet department has RR

documented procedure for diet
schedule

calculation of diet required in
wards

procurement of food items

preparation and distribution of
food

documented procedure to check
the quality of food provided to
the patient

cleaning of kitchen and utensils
Diet department has documented RR

procedure for checkups of kitchen
workers at defined intervals
Linen department has documented
procedure for collection, sorting
and cleaning of linen
Linen department has RR

sluicing of the blood/ body fluid
stained linen

distribution of linen in all
patient care area
324

condemnation of linen

documented procedure
corrective and preventive
maintenance of laundry
equipments
Security department has RR

documented procedure for duty
hours

control of incoming and
outgoing items

visiting hours in patient care
area

documented procedure for fire
safety in hospital
Security department has
electrical safety

training and drills of security
staff
ME G4.3 Staff is trained and Check if staff is a aware of RR

aware of the standard relevant part of SOPs
procedures written in
SOPs
ME G4.4 Work instructions are Work instructios are displayed RR

displayed at Point of use in Dietary Department
Work instructions are displayed SI/RR

in Laundry Department
Work instructions are displayed OB

in Medical Record Department
Work instructions are displayed OB

for hospital cleaniness
325

Standard G5
ME G5.1 The facility conducts Internal assessment is done RR/SI Dietary department,
periodic internal at periodic interval laundry and medical
assessment record department
ME G5.2 The facility conducts the Storage and compilation of RR/SI

periodic prescription/ records of medical audit
Storage and compilation of RR/SI

records of death audit
ME G5.3 The facility ensures Non Compliances are RR/SI

that non compliances enumerated and recorded
are enumerated and
recorded adequately
ME G5.4 Action plan is made Action plan is prepared RR/SI

on the gaps found in
the assessment / audit
process

address issues, observed
in the assessment and
audit
ME G6.3 Quality policy Check if staff is aware of quality SI

and objectives are policy and objectives
disseminated and staff is
aware of that
ME G6.4 Progress towards quality Quality objectives are SI/RR

objectives is monitored monitored and reviewed
Standard G7 The facility seeks continual improvement by practising quality tools and methods
ME G7.1 Facility uses method PDCA SI/RR

for quality improvement
in services
5S SI/OB
326

services

ME H1.1 Facility measures No of cases for which medical RR

productivity Indicators audit done
on monthly basis
No of cases for which death RR

audit has been done
Linen Index RR No. of bed sheet washed

in a month/Patient bed
days in month
Diet Index RR No. of meals provided in

the month/no. of times
meal served in a day * bed
days
ME H2.1 Facility measures Proportion of maternal deaths RR

efficiency Indicators on audited
monthly basis
Proportion of newborn deaths RR

audited
Cycle time for laundry services RR Time elapsed between

collection of used linen
and receiving clean linen
Proportion of special diets RR No. of special diets (Liquid,

Semi-solid, Diabetic, Low
salt, low fat diet or other
diet) in the month*100/
tital no. of diets provided
in the month
ME H3.1 Facility measures Clinical Medical Audit Score RR

on monthly basis
Death Audit Score RR
327

ME H4.1 Facility measures Service Waiting time for getting RR
Quality Indicators on handicap certificate
monthly basis
Waiting time for getting death RR

certificate
Patient feedback on cleanliness RR

of linen
Patient feedback on quality of RR

food
328


STANDARDS FOR CHC
Checklist for General
Administration
330
Checklist for General Administration

ME A1.10 The facility provides Accident Availability of functional A and E SI/OB
and Emergency Services department
Availability of functional disaster SI/OB

management team
ME A1.11 The facility provides Blood Availability of functional SI/OB

bank and transfusion services Blood storage centre

ME A 2.1 The facility provides Avaialbility of dedicated SI/OB
Reproductive health Female ward
Services
ME A2.3. The facility provides Availability of functional SI/OB

Newborn health Services NBSU
ME A3.1 The facility provides Availability of X-Ray Unit SI/OB Availability of in-
Radiology Services house services. Partial
Compliance if it is
outsourced
Availability of Ultrasound SI/OB Availability of in-

services house services. Partial
Compliance if it is
outsourced
ME A3.2 The facility Provides Availability of SI/OB If lab is outsourced than

Laboratory Services In-house lab give partial compliance
ME A 3.3 The facility provides other Availability of ECG Services SI/OB

diagnostic services, as
mandated
ME A4.2 The facility provides The laboratory has facility to
services under Revised carry out sputum microscopy
National TB Control
Programme as per
guidelines
CHC functions as DOTS centre.
ME A4.3 The facility provides services Facility for Diagnosis and SI/RR
under National Leprosy treatment of Leprosy.
per guidelines
331

Facility for management of reactions SI/RR
Counceling and advise on SI/RR

prevention of disabilities
Avaiablity of separate MDT SI/RR

regimens in separate blister
packs for MB-Adult, MB-child,
PB-adult and PB child.
ME A4.4 The facility provides Availability of Functional ICTC SI/OB

AIDS Control Programme
as per guidelines
Availability of link ART centre SI/OB
ME A4.5 The facility provides services avaialbility of Refraction room

under National Programme
for control of Blindness as
per guidelines
Avaialability or Eye OT, if Eye

surgeon posted; else linkage
with higher facilities.
ME A4.7 The facility provides Availability of Geriatric Clinic SI/OB

Programme for the health
care of the elderly as per
guidelines
ME A4.8 The facility provides services Facility for early detection and SI/OB
under National Programme referral of suspected cases,
for Prevention and control
of Cancer, Diabetes,
Cardiovascular diseases and
Stroke (NPCDCS) as per
guidelines
Sreeening for cervical, breast SI/OB

and oral cancer.
Education about self SI/OB

examination of breast and oral
self examination.
ME A4.9 The facility Provides services CHC functions as peripheral SI/OB

under Integrated Disease surveilance unit
Surveillance Programme as
per Guidelines
CHC collate, analyse and report SI/OB check for IDSP reporting
informationn to District Surveilannce format and Annexure 7A,
unit on epidemic prone disease. 7B and 7C
332

Standard A5 Facility provides Support and Administrative services
ME A5.1 The facility provides Availability of dietary service SI/OB In house or outsourced
dietary services
ME A5.2 The facility provides Availability of laundry services SI/OB In house or outsourced
laundry services
ME A5.3 The facility provides Availability of security services SI/OB In house or outsourced
security services
ME A5.4 The facility provides Availability of Housekeeping SI/OB In house or outsourced

housekeeping services services
ME A5.5 The facility ensures Availability of maintenance SI/OB In house or outsourced

maintenance services services
ME A5.6 Facility provides pharmacy Availability of drug storage and SI/OB

and store services. dispensing services
Avaialbility of General stores. For storing consumables,

Stationaries, and equipments
ME A5.7 The facility has services of Availability of Medical record SI/OB

medical records services
ME A5.8 The facility provides Proper monitoring and effective SI/OB

administrative services for supervision overall aspects of
the Block Health services of the Block.
Supervisory visits to the SI/OB

attached PHCs and SCs.
Building effective Public relations and SI/OB

ensuring active people’s participation
for getting the Health Programs/
functions achieved effectively.
To make evaluation of the SI/OB

impact from time to time.
ME A 6.1 The facility provides Treatment/referral facilities are SI/RR - Kala-Azar
curatives and preventive available for health problems of - Arsenic poisoning
services for the health local community. - Snake bite
problems and diseases, - KFD
- Laptospiromis
prevalent locally.
- Fluroris
ME A 6.2 There is process for Community representative are SI/RR
consulting community/ or Consulted while revising or
their representatives when expanding the scope of service
planning or revising scope
of services of the facility
User charges, if any, are SI/RR

decided in consultation with
user groups /RKS
333

Standard B1
ME B1.1 The facility has uniform Name of the facility prominently OB
and user-friendly signage displayed at front of CHC
system building
CHC lay out with location and OB

name of the departments are
displayed at the entrance.
CHC has established directional OB

signage
List of departments are displayed OB
All signages are in uniform OB

colour scheme
Signages are user friendly and OB

pictorial
ME B1.2 The facility displays the Services, which are not available OB
services and entitlements are also mentioned with name
available in its departments of the facilities, where such
facilities are available
Availability of administrative services OB

like handicap certificate, death
certificate services are displayed.
Processing time for issuing OB

certificates and availability of
medical record are displayed
Mandatory information under OB

the RTI is displayed
ME B1.3 The facility has established Citizen charter is established in OB

citizen charter, which is the facility
followed at all levels
Citizen charter includes the OB

Services available at the facility
Citizen Charter Includes the OB

Timings of different services
available
Citizen Charter includes Rights OB

of Patients
Citizen Charter Includes OB

Responsibilities of Patients and
Visitors
334

Citizen Charters includes Beds OB
available
Citizen Charter includes the OB

Standards and Quality of
services Provided
Citizen Charters includes OB

Complaints and Grievances
redressal Mechanism
Citizen Charter includes Services that OB

are available on payment, if any.
Citizen Charter includes the OB

Cycle time for Critical Processes
ME B1.4 User charges are displayed Facility prepares a OB

and communicated to comprehensive list of user
patients effectively charges and they are displayed
at strategic point in the CHC

to understand
ME B1.7 The facility provides A dedicated facilitation counter/ OB

information to patients rogi sahayata kendra available
and visitor through an
exclusive set-up.
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and
Standard B2
there are no barrier on account of physical economic, cultural or social reasons
ME B2.1 Services are provided in CHC has defined policy for non SI/PI
manner that are sensitive discrimination according to
to gender gender
ME B2.2 Religious and cultural Availability of complaint PI/RR

preferences of patients box and display of process
and attendants are taken for grievance redresaal and
into consideration while personnel to be contacted
delivering services
Staff is respectful to patients PI/SI

religious and cultural beliefs
The facility has defined policy to RR/SI

ensure the religious and cultural
preferences of the patient
ME B2.3 Access to facility is provided Approach road to facility is OB

without any physical barrier accessible without congestion
and friendly to people with or encroachment
disability.
335

There are no open manholes/ OB
Potholes at access road and
internal pathways
Internal Pathways and corridors OB

of the facility are without any
obstruction / Protruding Objects
CHC has defined policy to provide OB

barrier free services to patient
Ramps shall have a slope of OB

conducive for use
Ramps are provide with slip OB

resistance surface
Ramps shall have adequate OB at least 120 cm

width
Warning blocks have been OB To aid people with visual

provide at beginning and end of impairment
the ramp and Stairs
Hand rails are provided with OB

stairs
The health facility has defined OB

policy for providing disable
friendly services
Parking area is earmarked for OB

People with disabilities
ME B2.4 There is no discrimination on There is no discrimination on PI/SI

basis of social and economic basis of social and economic
status of the patients status of the patients
CHC has defined policy for RR/SI

ensuring non discrimination on
basis of social and economic
status of the patient
ME B2.5 There is affirmative actions There are arrangement and RR/SI Linkage for Palliative
to ensure that vulnerable Linkages for care of terminally ill Care Hospice
sections can access services patients
There are Linkages for care, RR/SI Linkages with NGOS,

Counselling and Protection of Police Mediation Cell
Victims of Violence including
domestic violence
There are arrangements of for RR/SI Linkages with NGOS ,

adequate care and post discharge Orphan, Old age home,
support of Orphan patients Children home
including homeless children
336

Standard B3
ME B3.1 Adequate visual privacy CHC has defined policy for RR/SI
is provided at every point maintenance of privacy of
of care patients
ME B3.2 Confidentiality of patients CHC has defined policy for RR/SI

records and clinical maintenance of patient records
information is maintained and clinical information
ME B3.3 The facility ensures the CHC defines and communicate RR/SI
behaviours of staff is policy regarding decent
dignified and respectful, communication and courteous
while delivering the behaviour towards the patient
services and visitors
ME B3.4 The facility ensures privacy CHC defines the policy for RR/SI
and confidentiality to every privacy and confidentiality
patient, especially of those of the patient and condition
conditions having social related with social stigma and
stigma, and also safeguards vulnerable groups
vulnerable groups
Facility has defined and established procedures for informing and involving patient and their
Standard B4
families about treatment and obtaining informed consent wherever it is required.
ME B4.1 There is established CHC define policy for taking RR/SI
procedures for taking consent.
ME B4.2 Patient is informed Display of patient rights and OB

about his/her rights and responsibilities.
responsibilities
ME B4.3 Staff are aware of Patients The staff is aware of patients SI

rights responsibilities rights responsibilities
The staff is regularly sensitiesed SI/RR

about rights and responsibilities
of the patient
ME B4.5. The facility has defined Availability of complaint box OB

and established grievance at administrative office and
redressal system in place display of process for grievance
Redressal and whom to contact
are displayed
CHC defines policy for grievance RR/SI

redressal mechanism
There is defined frequency of RR/SI

collecting complaints from
complaint box
337

Records of patient complaints RR
and suggestion are maintained
There is system of periodic RR/SI

review of patient complaints
There is evidence of action taken RR

on complaints
Action taken is informed to the RR

complainant
Facility ensures that there are no financial barrier to access and that there is
Standard B5
financial protection given from cost of Hospital services.
ME B5.1 The facility provides CHC establish policy for RR/SI
cashless services to providing free services to
pregnant women, mothers benficieries of Central and state
and neonates as per schemes
schemes
ME B5.2 The facility ensures that CHC has established policy RR/SI
drugs prescribed are for providing all drugs in the
available at Pharmacy and EDL free of cost as per state
wards government directive
ME B5.3 It is ensured that facilities CHC has established policy for RR/SI
for the prescribed providing all diagnostics free of
investigations are cost as per state government
available at the facility directive
ME B5.4 The facility provide free of Methods for verification of PI/SI

cost treatment to Below documents of patient is user
poverty line patients friendly
hassles
CHC has established policy to RR/SI

provide free treatment to BPL
patients
ME B5.5 The facility ensures CHC has established policy RR/SI

timely reimbursement for timely reimbursement and
of financial entitlements payment to beneficiaries
patients
ME B5.6 The facility ensure Availability of dedicated RSBY OB

implementation of health help desk
insurance schemes as per
National /state scheme
338

All tests and drugs are covered RR/SI/PI
under RSBY
Services and entitlements OB

available under RSBY are
prominently displayed
Manual process is in place in RR/SI

case smart card is not working

Standard C1 infrastructure meets the prevalent norms
ME C1.1 Departments have Availability of residential OB/RR
adequate space as per quarters for clinical and support
patient or work load staff
CHC has adequate space as per OB/RR 80 to 85 sqm per bed

bed strength
ME C1.2 Patient amenities are Availability of public toilet for OB

provide as per patient load visitors
Adequate number of Staff OB/SI

toilets available in proximity to
duty area
Adequate number of Staff OB/SI

change rooms are available in
proximity to duty area
Canteen for staff and visitors OB/SI
Availability of Staff amenities at OB/SI

nursing station and duty room
ME C1.3 Departments have layout CHC has independent entry to OB

and demarcated areas as emergency and OPD
per functions
Corridors are wide enough to OB

accommodate daily traffic
The general traffic should not OB

pass through the indoor/ critical
patient care area
Ambulatory services are located OB OPD, Emergency and

in outermost zone Administrative offices are
situated in near the entry/
exit of the CHC with direct
access from approach road
Clinical support Services are OB Lab , Radiology and

located in proximity to outer zone Pharmacy
339

Indoor area are located in inner OB Wards and Nursing
zone of the CHC Units are located in
inner most area
ME C1.4 The facility has adequate Corridors are wide enough to OB

circulation area and open accommodate daily traffic
spaces according to need
and local law
Facility maintains open area as OB

per floor area ratio mandated by
authorities
ME C1.5 The facility has CHC has 24X7 functional OB

infrastructure for telephone connection and
intramural and extramural intercom facility for internal
communication communication
There is designated person to OB/SI/RR

answer the telephone enquiries
CHC has broadband internet OB

connectivity
There is established system OB/RR Records are maintained

for managing postal for received
communication and dispatched
communication
There is established system OB/RR System for

for internal movement of communicating circulars,
documents and communication notices and orders etc.
There is assigned person for OB/RR

managing internal and external
movement of documents and
communications
General notices and information OB/RR

are displayed at notice boards at
relevant points
There is system of removal of OB/RR

old notices and updating the
notice board
ME C1.6 Service counters are Availability of OPD counter as OB/RR

available as per patient per load
load
ME C1.7 The facility and departments There is no cris-cross between OB

are planned to ensure General and Patient Traffic
structure follows the
function/processes
(Structure commensurate
with the function of the
CHC)
340

ME C2.1 The facility ensures the The facility has been surveyed by OB/RR Ask for records of survey
seismic safety of the Structural engineer for seismic
infrastructure vulnerability in high risk zones
Structural Components been OB/RR Check for records of in

made earthquake proof correction has been done
to strengthen structural
components like columns,
beams, slabs, walls etc.
ME C2.2 The facility ensures safety Facility has mechanism for OB/RR
of electrical establishment periodical check / test of
all electrical installation by
competent electrical Engineer
Facility has system for power OB/RR

audit of unit at defined intervals
Danger sign is displayed at High OB

voltage electrical installation
All electrical panels are covered OB

and has restricted access
Personal protective equipments OB/SI

are available with electrician
ME C2.3 Physical condition of Windows have grills and wire OB

buildings are safe for meshwork
Building including walls, roofs, OB

floor, windows , balconies and
terraces are maintained
Terrace, roof, balconies and stair OB

case have protective railing
CHC premises has intact OB

boundary wall
CHC has functional gate with OB

provision of animal catcher
341

Access to roof and terraces is OB
restricted
ME C2.4 The facility has plan for Fire exits provide egress to OB
prevention of fire exterior of the building in open
space
Check the fire exits are free from OB

obstruction
Facility has conducted fire safety OB/RR

audit by competent authority
Facility has defined, displayed OB/RR

and implemented evacuation
plan in case of fire
No smoking sign displayed inside OB/RR

and outside the working area
ME C2.5 The facility has adequate Facility has installed fire OB

fire fighting Equipment extinguisher are capable of
fighting A, B and C type of fire
safety alarm

date for next re-filling clearly
mentioned
ME C2.6 The facility has a system of Periodic Training is provided for OB/RR
periodic training of staff using fire extinguishers
and conducts mock drills
regularly for fire and other
disaster situation
Periodic mock drills for disaster OB/RR

management are conducted
Standard C3 The facility has adequate qualified and trained staff, required for providing
the assured services to the current case load
ME C3.1 The facility has adequate Availability of General OB/RR/SI

specialists doctors as per Surgeon
service provision
Availability of Obstetric and OB/RR/SI

Gynae Specialist
Availability of General OB/RR/SI

Medicine specialist
Availability of Paediatrician OB/RR/SI
Availability of Anaesthetics OB/RR/SI
342

ME C3.2 The facility has adequate Availability of general duty OB/RR/SI
general duty doctors as doctors (as per case load)
work load
Availability of AYUSH Doctor OB/RR/SI
Availability of Dentist OB/RR/SI
ME C3.3 The facility has adequate Availability of nursing staff OB/RR/SI As per patient load
nursing staff as per service
The facility has adequate Availability Lab Tech OB/RR/SI As per patient load
ME C3.4 technicians/paramedics as
per requirement
Availability Pharmacist SI/RR As per patient load
Availability Radiographer SI/RR As per patient load
Availability ECG Tech SI/RR As per patient load
Availability Optha. Technician/ SI/RR As per patient load

Referactionist
Availability O.T. technician SI/RR As per patient load
Counsellor SI/RR As per patient load
Dental Technician SI/RR As per patient load
Rehabilitation worker SI/RR As per patient load
ME C3.5 The facility has adequate Registration Clerk SI/RR

support / general staff
Statistical Assistant/Data entry SI/RR

operator
Account Assistant SI/RR
Administrative assistant. SI/RR
ME C3.6 The staff has been The facility conduct training SI/RR
provided required training need assessment periodically for
/ skill sets all cadre of staff
The facility has program for SI/RR

continuous medical education
for doctors and nursing staff
The facility prepares training SI/RR

calendar as per training need
assessment
343

Training feed back is taken and SI/RR
records are maintained for
training
Details and Records of training SI/RR

provided are available with unit
Training on Disaster SI/RR

Management
Training on Cardio Pulmonary SI/RR

resuscitation
Training on staff Safety SI/RR
Training on Measuring CHC SI/RR

Performance Indicators
Training on facility level Quality SI/RR

Assurance
ME C3.7 The Staff is skilled as per CHC has policy for regular SI/RR
job description competence testing as per job
description.
ME C4.1 The department has CHC has policy to ensure SI/RR
availability of adequate drugs at all point of use as
drugs at point of use per state EDL
ME C5.6 Availability of functional Availability of equipment OB Equipments for
equipment and for Facility management horticulture, electrical
instruments for support repair, plumbing
services material etc
Availability of equipment for OB Autoclave and mutilator

processing of Bio medical waste
Availability of computer for

HMIS and MCTS reporting
ME C5.7 Departments have patient Availability of fixture for OB

furniture and fixtures administrative office
provision
Availability of furniture for OB

administrative office
344

Area of Concern -D Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance
ME D1.1 The facility has established Facility has contract agency for SI/RR
system for maintenance of maintenance for equipment
critical Equipment
Contact details of the agencies SI/RR

responsible for maintenance are
communicated to the staff
Asset list of all equipment are SI/RR

maintained
There is system to maintain SI/RR

records of down time of
equipment
Indexing of all equipments is SI/RR

done
All equipment are covered SI/RR

under AMC including preventive
maintenance for computers and
other IT equipments

maintenance of the for
computers and other IT
equipment
ME D1.2 The facility has established Facility has contracted an SI/RR

procedure for internal agency for calibration of
and external calibration of equipment.
measuring Equipment
Records of the calibrated RR

equipment are maintained
Standard D2
ME D2.4 The facility ensures CHC has system to ensure SI/RR
management of expiry that drugs with sufficient life
and near expiry drugs procured
CHC has a process for proper SI/RR

disposal and prevention of
unintended use of expired drugs
ME D2.5 The facility has established CHC implements scientific OB/RR/SI ABC, VED, FSN,FIFO
procedure for inventory inventory management system
management techniques according to its needs
345

ME D2.6 There is a procedure for CHC has policy that there is RR/SI
periodically replenishing no stock out of the drugs and
the drugs in patient care consumables at patient care area
areas
ME D2.8 There is a procedure for CHC has a policy for ensuring RR/SI
secure storage of narcotic proper management and
and psychotropic drugs restriction of unintended use
of narcotic substance and
psychotropic drugs as per
prevalent law
Standard D3
ME D3.1 Exterior of the facility Boundary Walls of building is OB
building is maintained plastered and whitewashed.
with landscaping in open
areas.
No unwanted/outdated posters OB
on CHC boundary and building
walls
CHC Buildings has uniform OB

colour scheme
CHC has system to whitewash OB/RR

the building periodically
Availability of parking space as OB

per requirement
Dedicated parking space for OB

ambulances
No water logging in side the OB

premises of the CHC
There is no abandoned / OB
dilapidated building in the
premises
Proper landscaping and OB

maintenance of trees, garden
No encroachment in and around OB

the CHC
CHC has rain water harvesting OB

facility
CHC has Herbal garden OB
ME D3.2 CHC infrastructure is CHC has system for periodic OB

adequately maintained maintenance of infrastructure
at defined interval
346

There is no clogged/over flowing
drains in facility
CHC sewage is linked with

municipal drainage system or it
has functional septic tanks
Facility has a closed drainage system
Intramural roads are in good

condition without potholes/
ditches
Facility has a annual

maintenance plan for its
infrastructure
ME D3.3 Patient care areas are General waste from CHC is

clean and hygienic removed daily by municipal/
outsourced agency
Every department has a OB/RR Every department has

schedule of cleaning schedule for inspection of
cleaning work
OB
ME D3.4 The facility has policy of CHC has condemnation policy
removal of condemned in place
junk material OB/SI/RR
Periodic removal of junk

material done
OB
CHC has designated covered
place to keep junk/condemned OB
material
No junk/condemned articles in
open spaces RR/SI
ME D3.5. The facility has established Pest control measures are

procedures for pest, rodent evident at facility
and animal control OB/RR
Anti termite treatment of the

wooden furniture
SI/RR
ME D3.6. The facility provides Adequate illumination in open
adequate illumination areas in night
RR/SI
Adequate illumination in Stairs, corridor and
circulation area waiting area
Adequate illumination OB/RR

in toilets
347

CHC periodically measure
illumination at different area of
the CHCs OB
Adequate illumination at
approach roads to CHC
OB
ME D3.7 The facility has provision There is restriction on entry of
of restriction of visitors in vendors and hawkers inside the
patient areas premise of the CHC RR/SI
CHC has visitor policy in place
CHC has policy for restriction of RR/SI

media person in side the CHC
CHC implement visitor pass for OB

indoor areas
ME D3.9 The facility has security CHC has in-house/outsourced

system in place at patient security system in place OB
care areas
Duty roaster is available for OB

security staff OB
Training and Drills of security

staff is done
OB
Security staff is aware of patient
right, visitor policy and disaster
Management OB
There is system for supervision

of security staff
OB/RR
Facility has a security plan for
deputation of guard at different OB/RR
location
Responsibility and timing of OB/RR

opening and closing different
department is fixed and
documented RR/SI
There is a established procedure

for safe custody of keys
RR/SI
There is procedure for handing
over the keys at the time of shift
change RR/SI
CHC has system to manage

violence /mass casualty RR/SI
348

ME D3.10 The facility has established No female staff is posted RR/SI
measure for safety and alone at night
Where ever there are male RR/SI

employees/patients female staff
are posted in pairs
Timing of the shift is arranged RR/SI

keeping in mind the safety of
female staff
Committee against sexual

harassment is constituted at the RR/SI/OB
facility
Staff has been provided RR/SI

awareness training on Gender
issues
Standard D4 The facility ensures 24X7 water and power backup as per requirement of service
ME D4.1 The facility has adequate CHC has adequate water OB/RR/SI 450-500 Litres per bed
arrangement storage and storage facility as per per day
supply for potable water in requirements
all functional areas
CHC has adequate water supply OB/SI

from municipal /under ground
source
All water tanks are kept tightly OB

closed
Periodic cleaning of water tanks OB/RR Records of cleaning is

carried out maintained
The facility periodically tests RR

the quality of water from the
source (municipal supply, bore
well etc) for bacterial and
chemical content
Chlorination of water is done as RR

per requirement
RO/ Filters are available for OB

potable drinking water
The facility ensures that the RR/SI

distribution pipelines are not
running in close vicinity of the
sewage system.
349

ME D4.2 The facility ensures Availability of noiseless OB/SI
adequate power backup generators for power back up
per load
Estimation of power RR/SI

consumption by CHCs is done
Generator has adequate RR/SI

capacity to provide 24x7 power
back up at least to critical areas
CHC has adequate power supply RR/SI 3Kw to 5Kw per bed
connection
Use of energy efficient bulbs for SI

light

Standard D5
ME D5.2 The facility provides diets There is provision of different SI/PI Normal diet, Diabetic diet,
according to nutritional types of diets as per nutritional liquied diet, Low salt/low
requirements of the patients requirements of patients fat diet
ME D5.5 The facility has Clean linen is provided to all the OB

established procedures occupied beds
for changing of linen in
patient care areas
The facility has defined and established procedures for promoting public participation
Standard D6
in management of CHC transparency and accountability.
ME D6.1 The facility has RKS or eqvivalent body is RR
established procedures for registered under societies
management of activities registration act
of Rogi Kalyan Samitis
Availability of Income tax RR

exemption certificate for
donations
RKS meeting are held at RR

prescribed interval
Minutes of meeting are recorded RR
Participation of community RR
representatives/NGO is ensured
RKS reviews the patient RR

complaint/ feedback and action
taken
RKS generates its own resources RR/SI

from donation/leasing of space
350

ME D6.2 The facility has Community based monitoring/ RR/SI
established procedures social audits are done at
for community based periodic intervals
monitoring of its services
Facility communicate updated RR/SI

information on Quality of
services
Facility conducts public hearing RR/SI

at regular intervals
Standard D7 CHC has defined and established procedures for Financial Management
ME D7.1 The facility ensures the There is a system to track and RR/SI
proper utilization of fund ensure that funds are received
provided to it on time
Funds/Grants provided are RR

utilized in specific time limit
There is no backlog in payment RR/PI E.g.; Payment for JSY and

to beneficiaries as per their Family planning
entitlement under different
schemes
Payment to ASHA is done on time RR/PI
Salaries and compensation are RR/SI

provided to contractual staff
on time
Facility provides utilization RR

certificate for funds on time
ME D7.2 The facility ensures proper Facility prioritize the resource RR/SI
planning and requisition of required
resources based on its need
Requirement for funds are RR/SI

communicable to state on time
Facility is compliant with all statutory and regulatory requirement imposed

Standard D8
ME D8.1 The facility has requisite Availability of valid No objection RR
licences and certificates Certificate from fire safety
for operation of CHC and authority
different activities
Availability of authorization RR
for handling Bio Medical waste
from pollution control board
Availability of certificate RR
of inspection of electrical
installation
351

Availability of licence for RR
operating lift
ME D8.2 Updated copies of Availability of copy of Bio RR

relevant laws, regulations medical waste management and
and government orders handling rule 1998
are available at the facility
Registration of Ultrasound
machine under PCPNDT act.
Drug and cosmetic Act 2005 RR
Safety code for Medical RR AERB safety code no.

diagnostic X ray equipment and AERB/SC/MED-2(Rev 1)
installation
Narcotics and Psychotropic RR

substances act 1985
Code of Medical ethics 2002 RR
Nursing Council Act RR
Medical Termination of RR
Pregnancy 1971
Person with disability Act 1995 RR
Pre conception pre natal RR

diagnostic test 1996
Right to information act 2005 RR
Indian Tobacco control Act 2003 RR
Roles and Responsibilities of administrative and clinical staff are determined as

Standard D9
per govt. regulations and standards operating procedures.
ME D9.1 The facility has Job description of Specialist RR Regular + contractual
established job description Doctor is defined and
as per govt guidelines communicated
Job description of General RR Regular + contractual

duty Doctor is defined and
communicated
Job description of nursing staff RR Regular + contractual

is defined and communicated
Job description of paramedic RR Regular + contractual. Lab

staff is defined and technician, X ray technician,
communicated OT technician, etc.
Job description of counsellor is RR Regular + contractual

defined and communicated
352

Job description of ward boy is RR Regular + contractual
defined and communicated
Job description of security staff RR Regular + contractual

Job description of cleaning staff RR Regular + contractual

Job description of RR Regular + Contractual MS,

Administrative staff is defined CHC Manager, supervisor,
and communicated Matron, Ward Master.
Pharmacist etc.
ME D9.2 The facility has a established Duty roster of doctors is RR/SI

procedure for duty roster prepared, updated and
and deputation to different communicated
departments
Duty roster of Nurses is RR/SI

prepared, updated and
communicated
Duty roster of Paramedics RR/SI

is prepared, updated and
communicated
Duty roster of Cleaning staff RR/SI

communicated
Duty roster of security staff RR/SI

communicated
There is provision of Rotatory RR/SI

posting of staff
Facility has established line RR/SI

of reporting for clinical and
administrative staff
ME D9.3 The facility ensures Facility has policy for dress code RR/SI
the adherence to dress for different cadre of CHC.
code as mandated by
health department
I Cards have been provided to OB

staff
Name plates have been OB

provided to staff
353

Facility has established procedure for monitoring the quality of outsourced services
Standard D10
and adheres to contractual obligations
ME D10.1 There is established system Selection of outsourced RR
for contract management agencies done through
for out sourced services competitive tendering system
Eligibility criteria is explicitly RR

defined as per term of reference
There is system to make RR Check for that Contract

payment as per adequacy and document has provision
quality of services provided by for dedication of
the vendor payment if quality of
services is not good
Payment to the outsourced RR

services are made on time
ME D10.2 There is a system of Facility has defined criteria RR

periodic review of quality for assessment of quality of
of out sourced services outsourced services
Actions are taken against non RR/SI

compliance / deviation from
contractual obligations
Records of blacklisted vendors RR

are available with facility

ME E1.3 There is established Facility ensures that there is RR/SI
procedure for admission process for admission of patients
of patients after routine working hours
ME E1.4 There is established Facility updates daily availability RR/SI/PI

procedure for managing of vacant patient beds
patients, in case beds are
Facility has established a RR/SI

procedure for accommodating
high patient load due to
situation like disaster/ mass
casualty or disease outbreak
ME E3.1 Facility has established Facility has established policy RR/SI
procedure for continuity for co ordination and handover
of care during during interdepartmental
interdepartmental transfer transfer
There is a policy for RR/SI

consultation of the patient to
other specialists with in the CHC
354

ME E3.2. Facility provides There is policy for referral of RR/SI
appropriate referral patient for which services can
linkages to the patients/ not be provided at the facility
care.
Facility maintains list of higher RR/SI

centres where patient can be
managed.
Facility ensures the referral RR/SI

patient to public healthcare
facilities
Facility defines and RR/SI

communicate referral criteria
There is system to check that RR/OB

patient are not unduly referred
for the services those can be
ME E4.1 Procedure for identification There is policy for identification RR/SI
of patients is established at of patient before any clinical
the facility procedure
ME E4.2. Procedure for ensuring There is a policy for ensuring RR/SI

timely and accurate accuracy of verbal/telephonic
nursing care as per orders
treatment plan is
ME E4.3 There is established CHC has policy for patient hand RR/SI
procedure of patient hand over during shift change
change happens
ME E4.4 Nursing records are CHC has policy for maintaining RR/SI
maintained nursing records
ME E4.5 There is procedure for There is policy for periodic RR/SI

periodic monitoring of monitoring of patient
patients
ME E5.1 The facility identifies CHC identify and communicate OB/SI
vulnerable patients and the category of patient
ensure their safe care considered as vulnerable
ME E5.2 The facility identifies high CHC identify and communicate OB/SI
risk patients and ensure the category of patient
their care, as per their considered as high risk
need
355

Standard E6
ME E6.1. Facility ensured that drugs Facility has policy and enabling RR
are prescribed in generic order for prescribing drugs by
name only generic name only
ME E6.2 There is procedure of Facility provides adequate copies SI/RR

rational use of drugs of STG to respective department
Facility maintains a list of RR

updated version of STG
Facility provides training on use SI/RR

of STG

ME E7.3 There is a procedure Facility has policy for reporting RR/SI
to check drug before of adverse drug reaction
administration/ dispensing
Facility has defined and established procedures for maintaining, updating of

Standard E8 patients’ clinical records and their storage
ME E8.7 The facility ensures safe Dedicatd space for storage RR
and adequate storage and of records.
CHC has a policy for storing RR

records in safe and secure manner.
Records are stored in a manner RR

that they could be retrieved easily.
CHC has policy for retention period RR

for different kinds of records
CHC has policy for safe disposal RR

of records
ME E10.3 The facility has disaster CHC has prepared disaster plan RR
Disaster management RR
Committee has been constituted
ME E15.1 Death of admitted patient Facility has a standard procedure SI/RR
is adequately recorded for decent communicate of
and communicated death to relatives
ME E15.3 The facility has standard Facility has established has SI/RR
operating procedure for established policy for end of life
end of life support care
356

ME E19.1 The facility provides Facility has established produce SI/RR
immunization services as for reporting and follow up of
per guidelines AEFI
Staff is trained for detecting , SI/RR

managing and reporting of AEFIs

Facility has infection control program and procedures in place for prevention
Standard E15
and measurement of CHC associated infection
ME F1.1 Facility has functional Infection control committee SI/RR
infection control (ICC) is constituted at the
committee facility
ICC is approved by appropriate SI/RR

authority
Roles and responsibilities of ICC SI/RR

are defined and communicated
to its members
ICC meets at periodic time SI/RR

interval
Records of Infection control SI/RR

activities are maintained
ME F1.2 Facility has provision for Facility has linkage with SI/RR
Passive and active culture microbiology lab for culture
surveillance of critical and surveillance
high risk areas
There is defined format for SI/RR

requisition and reporting of
culture surveillance
Reports of culture surveillance SI/RR

are collated and analyzed
Feedback is given to the SI/RR

respective departments
ME F1.3 Facility measures hospital Samples are taken for culture to SI/RR
associated infection rates detect HAI in suspected cases.
There is defined criteria and SI/RR

format for reporting HAI based
on clinical observation
Reports are collated and SI/RR

analyzed
Feedback is given to the SI/RR

respective departments
357

ME F1.4 There is Provision of Records of immunization SI/RR Infection control nurse
Periodic Medical Checkups available
Records of Medical Checkups SI/RR

are available
ME F1.5 Facility has established There is a designated person SI/RR

procedures for regular for Co coordinating infection
monitoring of infection control activities
control practices
There is defined format/checklist SI/RR

for monitoring of hand washing
and infection control practices
ME F1.6 Facility has defined and Facility has antibiotic policy in SI/RR
established antibiotic place
policy
There is system for reporting SI/RR

Anti Microbial Resistance with
in the facility
Antibiotic policy includes plan SI/RR

for identifying, transferring ,
discharging and readmitting
patients with specific
antimicrobial resistant pathogen
The policy includes Rational Use SI/RR

of Antibiotics
Standard treatment guidelines SI/RR

are followed while developing
Antibiotic Policy
Facility Measures the Antibiotic SI/RR

Consumption Rates
ME F2.1 Hand washing facilities The facility ensures uninterrupted SI/RR
are provided at point of and adequate supply of antiseptic
use soap and alcohol hand rub in all
departments
ME F2.2 Staff is trained and Check for the records that SI/RR
adhere to standard hand training have been provided
washing practices
ME F2.3 Facility ensures standard The facility ensures SI/RR

practices and materials uninterrupted and adequate
for antisepsis supply of antiseptics
358

ME F3.1 Facility ensures adequate Availability of Heavy duty gloves OB/SI
personal protection for cleaning staff
equipments as per
requirements
Availability of gum boots for OB/SI

cleaning staff
Availability of masks for OB/SI

cleaning staff
Availability of apron for OB/SI

cleaning staff
The facility ensures adequate SI/RR

and regular supply of personal
protective equipments
ME F3.2 Staff is adhere to standard There is policy for judicious SI/RR

personal protection use of personal protective
practices equipments specially sterile
gloves
ME F4.1 Facility ensures standard The facility ensure adequate SI/RR Disinfectant like
practices and materials supply of disinfectant at the hypochlorite, bleaching
for decontamination and point of use powder etc.
and procedures areas
Staff is trained for preparation SI/RR

of disinfectant solution
ME F5.2 Facility ensures availability The facility ensure the SI/RR
of standard materials for availability of good quality
cleaning and disinfection disinfectant and cleaning
of patient care areas material
ME F5.4 Facility ensures CHC has policy for SI/RR

segregation infectious identification and segregation
patients of infectious patient
Standard F6
ME F6.1 Facility Ensures segregation The facility ensures adequate SI/RR
of Bio Medical Waste as per and regular supply of colour
guidelines coded liners

for daily monitoring of proper
segregation of Bio medical
waste by a designated person
359

ME F6.2 Facility ensures The facility ensures supply of SI/RR
management of sharps as puncture proof containers and
per guidelines needle cutters
The facility ensures availability of SI/RR

post exposure prophylaxis drugs
There is system for reporting of SI/RR

needle stick injuries
ME F6.3. Facility ensures Facility has secured designated SI/OB

transportation and disposal place for storage of Bio Medical
of waste as per guidelines waste before disposal
BMW is stored in lock and key and SI/OB

unauthorized entry is prohibited
Log book /Record of waste RR

generated is maintained
No signs of burning within the OB

premises.
Check that infectious liquid OB

waste is not directly drained in
to municipal sewerage system
Disinfection and mutilation of OB

solid plastic waste before disposal
Display of Bio Hazard sign at the OB

point of use
Infectious Waste is not stored RR

for more than 48 hours
Disposal of anatomical waste as OB/SI/RR Preferably by CTWF/in-

per BMW rule house deep burial pits/
inhouse incinerator
Disposal of solid infectious OB/SI/RR Preferably by CTWF/in-

waste as per BMW rule house incinerator
Disposal of sharp waste as per OB/SI/RR Preferably by CTWF/

BMW rule disinfection followed by
mutilation/shredding
Disposal of infectious plastic OB/SI/RR Preferably by CTWF/Disposal

waste as per BMW rule as general plastic waste
after decontamination and
mutilation
Annual report to the pollution RR

control board is submitted
Biomedical waste transported in OB/SI/RR

authorized vehicle
360

ME G1.1 The facility has a quality Quality Assurance Team for SI/RR Check for Office order by
team in place CHCs is Constituted designated authority
There is designated person for SI/RR CHC Manager

co coordinating overall quality
assurance program at the facility
Team members are aware for of SI/RR

their respective responsibilities
ME G1.2 The facility reviews Quality team meets monthly SI/RR

quality of its services at and review the quality activities
periodic intervals
Minutes of meeting are recorded RR
Results for internal /External SI/RR Check the meeting records

assessment are discussed in the
meeting
CHC performance and indicators SI/RR Check the meeting records

are reviewed in meeting
Progress on time bound action SI/RR Check the meeting records

plan is reviewed
Follow up actions from previous SI/RR Check the meeting records

meetings are reviewed
Resource requirement and SI/RR Check the meeting records

support from higher level are
discussed
Quality team review that all the SI/RR

services mentioned in RMNCHA
are delivered as per guideline
Quality team reviews that all the SI/RR

services mentioned in National
Health Program are delivered as
per guideline
Resolution of the meeting are SI/RR Check how resolution are

effectively communicated to communicated to staff
CHC staff
Quality team report regularly to SI/RR

DQAC about Key Performance
Indicators
Quality Team report regularly to SI/RR

DQAC about internal assessment
results and action taken
361

ME G2.1 Patient Satisfaction There is person designated to co SI/RR
surveys are conducted at ordinate satisfaction survey
periodic intervals
Patient feedback form are RR

available in local language
Adequate sample size is taken to RR

conduct patient satisfaction
There is procedure to conduct RR

employee satisfaction survey at
periodic intervals
ME G2.2 Facility analyses the There is a procedure for RR

patient feed back and do compilation of patient feedback
root cause analysis forms
Patient feedback is analyzed on RR Overall department wise/

monthly basis attribute wise score are
calculated
Root cause analysis is done for RR

low performing attributes
Results of Patient satisfaction RR/SI

survey are recorded and
disseminated to concerned staff
There is procedure for analysis RR

of Employee satisfaction survey
There is procedure for root RR

cause analysis of Employee
satisfaction survey
ME G2.3 Facility prepares the There is procedure for preparing RR/SI

action plans for the Action plan for improving
areas, contributing to low patient satisfaction
satisfaction of patients.
There is procedure to take RR/SI

corrective and preventive action
There is procedure for preparing RR/SI

action plan for improving
employee satisfaction
ME G3.1 Facility has established Daily round schedule is defined SI/RR
internal quality assurance and practiced
program at relevant
departments
362

ME G3.2 Facility has established External Quality assurance is SI/RR
external assurance done on defined interval
programs at relevant
departments
ME G3.3 Facility has established There is system for reviewing SI/RR At departmental /CHC
system for use of departmental checklist and Level
check lists in different taking appropriate action
Standard G4 Facility has established, documented implemented and maintained Standard

ME G4.1 Departmental standard CHC has documented Quality RR
operating procedures are system manual
available
CHC has Records of distribution RR

of Standard operating procedure
CHC has system for periodic RR

review of the standard procedures
as and when required
ME G4.2 Standard Operating CHC has documented system RR

Procedures adequately for Internal audits at defined
describes process and intervals
procedures
CHC has documented procedure RR

for control of documents and
records

for defining Quality objectives

for action planning

for training and CMEs of CHC
staff at defined intervals

for monthly review meeting
ME G4.3 Staff is trained and aware Check Staff is trained for SI/RR Check for the training
of the standard procedures relevant part of SOPs records
written in SOPs
The facility has established system of periodic review as internal assessment, medical
Standard G5 and death audit and prescription audit
ME G5.1 The facility conducts Periodic internal assessment RR/SI
periodic internal assessment and plan is prepared and
followed
363

Internal Assessors are identified RR/SI
Training of internal assessors is RR/SI

done
There is process of RR/SI

communicating about the
assessment to concerned
departments
Records of internal assessment RR/SI

are maintained
Person is designed for co RR/SI

coordinating internal assessment
ME G5.2 The facility conducts the There is established committee RR/SI

periodic prescription/ for reviewing maternal death
There is established committee RR/SI

for reviewing new born death
There is established committee RR/SI

for medical and death audit
Drug and therapeutic committee RR/SI

for Prescription audits
Medical audits are conducted at RR/SI

periodic interval
Death audits are conducted at RR/SI Maternal and death audits

periodic interval are conducted as per
guideline
Prescription audits are RR/SI

conducted at periodic interval
There is predefined criteria and RR/SI

format for medical audit

format for prescription audit

format for death audit
Training has been provided for RR/SI

conducting medical and death
audits
ME G5.4 Action plan is made on Departmental Action plan is RR/SI

the gaps found in the reviewed periodically
364

ME G5.5 Corrective and preventive There is system to ensure that RR/SI
actions are taken to corrective and preventive action
address issues, observed in are taken timely
ME G6.1 The facility defines its Quality policy are defined and RR/OB
quality policy displayed in local language
Quality policy is in local RR/OB

language
ME G6.2 The facility periodically Quality objective are reviewed RR/SI

defines its quality at periodic intervals
objectives and key
own objectives
Quality Objectives are SMART RR Specific, Measurable,

Achievable, Repeatable,
and time bound
ME G6.3 Quality policy and Check to ensure that the top RR/SI
objectives are disseminated management is aware of
and staff is aware of that quality policy and objectives
ME G6.4 Progress towards quality Top management review RR/SI

objectives is monitored progress on Quality objectives
Standard G7 The facility seeks continual improvement by practicing Quality tool and method.
ME G7.1 The faclity uses methods CHC maps critical processes and RR/SI All clinical and support
for quality improvement identify non value services process that are
in services adding activities critical to quality ,e.g. OPD,
IPD, OT, LR, NBSU, Diagnostics,
Pharmacy, Blood storage,
Admin, Kitchen, Laundry,
Housekeeping etc.
The facility identifies non RR/SI Analysis of the Process

value adding activities/waste/ map is done. All non-
redundant activities. value adding activities,
waste and redundant
activities are identified.
The facility takes corrective RR The processes are

action to improve the processes. reorganized and
implemented after taking
corrective actions.
Facility implements Plan do RR

check act (PDCA) approach to
identify the critical processes
ME G7.2 The facility uses tools for 5s, Prioritization, 7 Quality tools, RR
quality improvement. Mistake proofing etc.
365

ME H1.1 Facility measures Bed Occupancy Rate RR
monthly basis
IPD per thousand population RR
OPD consultation per Thousand RR

Population
Maternal mortality per 1000 RR

deliveries
Neonatal mortality per 1000 live RR

births
Nurse to bed ratio RR
No. of meeting held under RKS RR
ME H1.2 The Facility measures Proportion of BPL patient in OPD RR

equity indicators and in indoor admissions
periodically
ME H2.1 Facility measures Overall Referral Rate RR
monthly basis
Overall discharge rate RR
Proportion of obstetric cases RR

out of total IPD
Proportion of fund/ grant RR

utilized
ME H3.1 Facility measures Clinical Average Length of Stay RR
on monthly basis
Crude mortality rate RR
Maternal mortality per 1000 RR

deliveries
Neonatal mortality per 1000 live RR

births
CHC acquired infection rate RR Surgical Site, Device

related CHC acquired
infection rate
366

ME H4.1 Facility measures Service overall LAMA Rate RR
monthly basis
Patient satisfaction Score IPD RR
Patient satisfaction Score OPD
Staff Satisfaction Score RR
Turn over rate of contractual RR

staff
367

Annexure
368
Annexure - 1
Key Performance Indicators

Community Health Center
Indicator This Month Previous Year This Benchmark

Month
Productivity
1 Bed Occupancy Rate
2 Percentage of Cases of High Risk

Pregnancy/obstetric complication out
of total registered pregnancies at FRU
3 Lab test done per thousand patients
4 Percentage of LSCS surgeries done

in night
5 Percentage of C-Section out of

Total Deliveries
6 Percentage of Newborn admitted to

NBSU out of Total live birth at facility.
7 Blood transfusion done per

100 Admissions
Efficiency
8 Percentage of referral in admitted

patients out of total admissions
9 OPD per Doctor
10 Critical Emergencies (Snake Bite,

Poisoning, Trauma, CVA) attended out
of total emergency patients registered.
11 Percentage of Stock out of Vital

drugs (RMNCH+A)
369
Annexure
Indicator This Month Previous Year This Benchmark

Month
12 Emergency call attended per specialist

per month
Clinical Care / Safety
13 Average Length of Stay
14 Surgical Site Infection Rate
15 Failure rate of sterilization surgeries
16 Complication rate including death

following sterilization
17 Percentage of normal deliveries

having partograph recorded
18 Maternal death rate at the facility
19 Percentage of AEFI cases reported
20 Percentages of DOT cases completed

successfully
Service Quality
21 Left Against Medical Advice (LAMA) rate
22 Patient Satisfaction Score (OPD)
23 Patient Satisfaction Score (IPD)
24 Consultation time (OPD)
25 Linen Index
370
Annexure
Annexure - 2
Suggestive Format for Standard Operating Procedures
SOP Number Insert Number (e.g. 1)
SOP Title Insert Title
PURPOSE
A brief description of the purpose of the SOP, it should describe why the SOP is required (e.g. compliance with MoHFW
Guidelines, State Guidelines, ensuring quality in services, compliance to National Quality Assurance Standards, etc.).
The source should be given in the reference section rather than direct quotes. If any records are generated (e.g. entry of
birth in the birth register in labour room).
INTRODUCTION
A general introduction, with a statement of rationale.
SCOPE
A statement that outlines the areas and context covered by the SOP.
If there are any areas in which this SOP specifically does NOT apply, these should also be mentioned to avoid ambiguity.
DEFINITIONS
When appropriate, a list of definitions should be included for terms used in the SOP.
PROCESS OWNER
It is should contain the designation of the person/ persons, responsible for key activities of the SOP and also responsible
for review/ amendment/ changes in the SOP.
SPECIFIC PROCEDURES
Sr no. Activities Responsibility
1.1 (SOP no.1) (Please describe the activities and sub-activities

in the present tense, e.g. An pregnant lady arrives
at the hospital for confirmation of the pregnancy
and also for undergoing Antenatal check-up)
1.2
1.3
1.4
371
Annexure
REFRENCES
(This section is used to list all references, used within the text of the SOP, sufficient for the user to find the source
document(s). (Please add/ delete numbers)
1. ...........................................................................................................................................................................................................................................................................
2. ...........................................................................................................................................................................................................................................................................
3. ...........................................................................................................................................................................................................................................................................
4. ...........................................................................................................................................................................................................................................................................
RECORDS
Insert relevant records, which may be generated and referred to during the course of assessment. (Please add/ delete the
numbers)
1. ...........................................................................................................................................................................................................................................................................
2. ...........................................................................................................................................................................................................................................................................
3. ...........................................................................................................................................................................................................................................................................
4. ...........................................................................................................................................................................................................................................................................
372
Annexure
Annexure - 3
3.1 Inpatient Feedback Format
Dear Friend
You have spent your valuable time in the hospital in connection with your / relative’s /friend’s treatment. It will help us in our
endeavour to improve the quality of service, if you share your opinion on the service attributes of this hospital enumerated in the
table below.
Please tick the appropriate box and drop the questionnaire in the Suggestion box
Sl No Attributes Poor Fair Good Very Excellent No

Good comments
1. Availability of sufficient information at
Registration/Admission counter
2. Waiting time at the Registration/ more than 10-30 mts 5-10 mts Within 5 Immediate
Admission counter 30 mts. mts
3. Behaviour and attitude of staff at the

registration/ admission counter
4. Your feedback on discharge process
5. Cleanliness of the ward
6. Cleanliness of Bathrooms and toilets
7. Cleanliness of Bed sheets/ pillow covers etc
8. Cleanliness of surroundings and

campus drains
9. Regularity of Doctor’s attention
10. Attitude and communication of Doctors
11. Time spent for examination of patient

and counselling
12. Promptness in response by Nurses

in the ward
13. Round the clock availability of Nurses in

the ward hospital
14. Attitude and communication of Nurses
373
Annexure

Good comments
15. Availability, attitude and promptness of
Ward boys/girls
16. All prescribed drugs were made available to

you free of cost.
17. Your Perception of Doctor’s knowledge
18. Diagnostics Services were provided with in

the hospital
19. Timeliness of supply of diet
20. Your overall satisfaction during the

treatment as in patient
Your valuable suggestions ( if any )
Date __________ IPD Ticket no._________Ward_________Name _______________________
374
Annexure
3.2 OPD Patient Feedback

Dear Patient
You have spent your valuable time in the hospital in connection with your / relative’s/friend’s treatment. You are requested to share
your opinion about the service attributes of this hospital which will be used for improving the services
Please tick the appropriate box and drop the questionnaire in the Suggestion box

Good comments
1. Availability of sufficient information at
registration counter
2. Waiting time at the registration counter more than 10-30 mts 5-10 mts Within 5 Immediate
30 mts. mts
3. Behaviour and attitude of staff at the

registration counter
4. Cleanliness of the OPD, Bathrooms and

toilets
5. Attitude and communication of Doctors
6. Time spent for examination and

counselling
7. Availability of Lab and radiology tests.
8. Promptness at Medicine distribution

counter
9. Availability of drugs at the hospital

dispensary
10. Your overall satisfaction during the visit

to the hospital
Your valuable suggestions ( if any )
Date __________ OPD Ticket no.____________Name ______________________________
375
Annexure
Annexure - 4
List of Abbreviations For CHC
1 AandE Accident and Emergency
2 ABC Airway, Breathing and Circulation
3 AD Syringes Auto Disable Syringes
4 AEFI Adverse Event Following Immunization
5 AERB Atomic Energy Regulatory Board
6 AES Acute Encephalitis Syndrome
7 AFB Acid Fast Bacilli
8 AIDS Acquired Immuno Deficiency Syndrome
9 AMC Annual Maintenance Contract
10 AMTSL Active Management of Third stage of Labour
11 ANC Anti Natal Check-up
12 ANM Auxiliary Nurse Midwife
13 APGAR Score Appearance, Pulse, Grimace, Activity, Respiration Score
14 ARSH Adolescent Reproductive and Sexual Health
15 ART Anti Retroviral Therapy
16 ARV Anti Rabies Vaccine
17 ASHA Accredited Social Health Activitist
18 AYUSH Ayurveda Yoga Unani Siddha and Homoeopathy
19 BCC Behavioural Change Communication
20 BCG Bacillus Chalmette-Guerin
21 BHT Bed Head Ticket
22 BMW Bio Medical Waste
23 BPL Below Poverty Line
24 BT/CT Bleeding Time/Clotting Time
25 CBWTF Common Biomedical Waste Treatment Facility
26 CHC Community Health Centre
27 CME Continuous Medical Education
28 CNS Central Nervous system
29 CPR Cardio Pulmonary Respiration
376
Annexure
30 C-Section Caesarean Section

31 CSSD Central Sterile Supply Department
32 CVS Cardio Vascular System
33 D and E Dilatation and Evacuation
34 DGO Diploma in Obstetrics and Gynaecology
35 DLC Differential Leukocyte Count
36 DMLT Diploma in Medical Laboratory Technology
37 DOTS Directly Observed Treatment (Short Course)
38 DPT Diphtheria, Pertusis and Tetanus
39 DQAC District Quality Assurance Committee
40 DT Diphtheria and Tetanus
41 ECG Electrocardiography
42 ECP Emergency Contraceptive Pills
43 EDD Expected Date of Delivery
44 EDL Essential Drug List
45 ELISHA Enzyme-Linked Immunosorbent Assay
46 ESR Erythrocyte Sedimentation Rate
47 ET Tube Endotrachial Tube
48 ETAT Emergency Triage Assessment and Treatment
49 EVA Electric Vacuum Aspiration
50 FP Family Planning
51 FBNC Facility Based New Born Care
52 FDA Food and Drug Administration
53 FHR Foetal Heart Rate
54 FIFO First in first out
55 FIMNCI Facility based Integrated Management of Newborn Childhood Illnesses
56 FNAC Fine-needle aspiration cytology
57 FSN Fast Moving slow moving and Non moving
58 GA General Anaesthesia
59 GOB General Order Book
60 GOI Government of India
61 HAI Hospital Acquired Infection
62 HIV Human immunodeficiency Virus
63 HLD High Level Disinfectant
64 HMIS Health Management Information System
65 I V Sets Intravenous Sets
66 ICC Infection Control Committee
67 ICD International Classification of Diseases
377
Annexure
68 ICTC Integrated Counselling and Testing Centre

69 ICU Intensive Care Unit
70 IDSP Integrated Disease Surveillance Programme
71 IEC Information Educational Communication
72 IFA Iron and Folic Acid
73 ILR Ice Line Refrigerator
74 IM/IV Intramuscular/Intravascular
75 IMNCI Integrated Management of Newborn Childhood Illnesses
76 IO Chart Input Out Put Chart
77 IPD Indoor Patient Department
78 IT Information Technology
79 IUCD Intrauterine Contraceptive Device
80 IUGR Intrauterine Growth Retardation
81 JE Japanese Encephalitis
82 JSSK Janani-Shishu Suraksha Karyakrama
83 JSY Janani Suraksha Yojana
84 KFT Kidney Function Test
85 KMC Kangaroo Mother Care
86 LAMA Left Against Medical Advise
87 LFT Liver Function Test
88 LMP Last Menstrual Period
89 LR Labour Room
90 LSCS Lower Segment Caesarean Section
91 MCP Card Mother and Child Protection Card
92 MCTS Mother and Child Tracking System
93 MDT Multi Drug Therapy
94 MLC Medico Legal Cases
95 MS Medical Superintendent
96 MSBOS Maximum Surgical Blood Order Schedule
97 MTP Maternal Termination of Pregnancy
98 MUAC Mid Upper arm Circumference
99 MVA Manual Vacuum Aspiration
100 NACO National Aids Control Organisation
101 NACP National Aids Control Programme
102 NBCC New Born Care Corner
103 NBSU New Born Stabilization Unit
104 NCD Clinic Non Communicable Diseases
105 NGO Non Government Organisation
378
Annexure
106 NHP National Health Programme

107 NLEP National Leprosy Elimination Programme
108 NPCDCS National Programme for Prevention and control of Cancer, Diabetes, Cardiovascular
diseases and Stroke
109 NSSK Navjat Shishu Suraksha Karyakrama
110 NSV Non Scalpel Vasectomy
111 NVBDCP National Vector Born Disease Control Programme
112 OB Observation
113 OB and G Obstetrics and Gynaecology
114 OCP Oral Contraceptive Pills
115 OPD Out Door Patient Department
116 OPG Services Orthopantomogram Services
117 Opth Ophthalmic
118 OPV Oral Polio Vaccine
119 ORT Corner Oral Rehydration Therapy Corner
120 OT Operation Theatre
121 P V Set Per Vaginal Set
122 PAC Pre-anaesthesia Check up
123 PCPNDT Pre-Conception and Pre-Natal Diagnostic Test
124 PCV Packed Cell Value
125 PDCA Plan, Do, Check, Act
126 PHC Primary Health Centre
127 PI Patient Interview
128 PIH Pregnancy Induced Hypertension
129 PLHA People living with HIV/AIDS
130 PNDT Pre-Natal Diagnostic Test
131 PNS Peripheral Nervous System
132 PPE Personal Protective Equipments
133 PPH Post Partum Haemorrhage
134 PPIUCD Postpartum Intra Uterine Contraceptive Device
135 PPTCT Prevention of Parent to child Transmission
136 PW Pregnant Women
137 RBSY Rastriya Bal Suraksha Karyakrama
138 RCS Re Constructive Surgery
139 RDTK Rapid Diagnostic Kit
140 RH Factor Rhesus Factor
141 RKS Rogi Kalyan Samiti
142 RMNCHA Reproductive, Maternal, Newborn and Child Health
379
Annexure
143 RNTCP Revised national TB Control Programme

144 RO Reverse Osmosis
145 RR Record Review
146 RSBY Rastriya Swasthya Bima Yojana
147 RTI Right to Information Act
148 SBA Skilled birth Attendant
149 SC Sub centre
150 SI Staff Interview
151 SMART Specific, Measurable, Achievable, Relevant and time bound
152 SNCU Sick New Born Unit
153 SOP Standard Operating Procedure
154 STD Sexually Transmitted Disease
155 STG Standard Treatment Guideline
156 STI Sexually Transmitted Infection
157 TB Tuberculosis
158 TLC Total Leukocyte Count
159 TLD Thermo luminescent Dosimeter
160 TPR Chart Temperature, Pulse, Respiration Chart
161 TSSU Theatre Sterile Supply Unit
162 TT Tetanus Toxoid
163 UIP Universal Immunization Programme
164 UPS Uninterrupted Power Supply
165 USG Ultrasonography
166 UT Union Territory
167 VDRL Venereal Disease Research Laboratory
168 VED Vital, Essential and Desirable
169 VVM Vaccine Vial Monitor
380
Annexure
Annexure - 5
Bibliography
1. An Introduction to Quality Assurance in Health Care, Avedis Donabedian.
2. Juran’s Quality Handbook, Joseph. M. Juran, Fifth Edition, McGraw- Hill
3. Evaluation and Quality Improvement Program (EQuIP) standards, 4th Edition, Australian Council on Healthcare Standards
4. Facility based New born Care operational Guide, Guideline for Planning and implementation, Ministry of health and Family
Welfare, Govt. of India
5. Guideline for enhancing optima Infant and Young Child feeding practices, Ministry of Health And Family welfare,
Govt. of India
6. Guideline for implementing Sevottam, Dept. of Administration reform and Public Grievance, Ministry of Personal and
Public Grievance and Pension, Govt of India
7. Guideline for Janani- Shishu Suraksha Karyakaram (JSSK), Maternal Health Division, Ministry of Health and Family welfare,
Govt. of India
8. Guidelines for Operationalising First Referral Units, Maternal Health Division, Ministry of Health and Family Welfare, Govt.
of India.
9. Guidelines for setting up Blood Storage Centres, National AIDS Control Organisation, Ministry of Health and Family
Welfare, Govt. of India.
10. Guidelines for Setting up Blood Storage Centres at First Referral Units, Maternal Health Division, Ministry of Health and
Family Welfare, Govt. of India.
11. Toolkit for Setting up Special Care New-born Units, Stabilisation Units and New-born Corners. Unicef.
12. Implementation Guide on RCH-II, Adolescent and reproductive Sexual health Strategy, for State and District Program
Manager, Ministry of Health and Family Welfare, Govt. of India
13. Indian Public Health Standards (IPHS), Guidelines for Community Health Centres, Revised 2011, Directorate General of
Health Services, Ministry of Health and Family Welfare, Govt. of India.
14. International Covenant on Social, Economic and Cultural Rights (ICESCR), 1976
15. IS 10905, Part -2, Recommendations for basic requirements of general hospital buildings: Part 2 Medical services
department buildings, 1984.
16. IS 10905, Part -3, Recommendations for Basic Requirements of General Hospital Buildings - Part 3 : Engineering Services
Department Buildings, 1984
17. IS 10905, Part-1, Recommendations for basic requirements of general hospital buildings: Part 1 Administrative and
hospital services department buildings, 1984
18. IS 12433, Part -1, Basic requirements for hospital planning: Part 1 up to 30 bedded hospitals,1988
381
Annexure
19. IS 13808 : Part 1 , Quality management for hospital services (Up to 30-bedded hospitals) Guidelines : Part 1 Out-patient
department (OPD) and Emergency Services, 1993
20. IS 13808 : Part 2, Quality Management Procedures for Diagnostic and Blood Transfusion Services - Guidelines - Part 2 : Up
to 30-Bedded Hospitals, 1993
21. IS 13808 : Part 3, Quality management for hospital services (up to 30 bedded hospitals) - Guidelines: Part 3 Wards, nursing
services and operation theatre, 1993
22. IS 15195, Performance Guidelines for Quality Assurance in Hospital Services up to 30-Bedded Hospitals, 2002
23. IS 15461, Performance Guidelines for Quality Assurance in Hospital Services up to 100-Bedded Hospitals, 2004
24. IS 4347 , Code of practice for Hospital lighting , 1967
25. ISO 15189, Medical Laboratories- Particular requirements for quality and competence, Second edition.
26. ISO 9001, Quality Management System requirement, Fourth Edition
27. Janani Suraksha Yojana, Govt of India, Ministry of Health and Family Welfare, Maternal Health Division
28. Joint Commission International Certification Standard for Hospital, 4th Edition
29. National Accreditation Board for Hospital and Healthcare Provider, 3rd Edition.
30. National Guideline for Improvement of Quality and Safety of Healthcare Institutions (For Line Ministry and Provincial
Hospital, First Edition.
31. Operational Guidelines on Maternal and Newborn Health, Ministry of Health and Family welfare, Govt of India
32. Principles of Hospital Administration, Second Edition, John R. McGibony, M.D
33. Promoting Rational Drug Use under NRHM, National Health System Resource Centre, 2009
34. Quality Assurance Services of Sterilization Services, Research Studies and Standard division, Ministry of Health and family
welfare, Govt. Of India
35. Standards for Blood Bank and Blood Transfusion Facilities, National AIDS Control Organization, Ministry of Health and
Family Welfare, Govt. of India
36. Standards for Female and Male Sterilization Services, Research Studies and Standard division, Ministry of Health and
family N, Govt. Of India
37. National List of Essential List, 2011, Ministry of Health and Family Welfare , Government of India,
38. Guidelines and Space Standards for Building Barrier Free Built Environment for disabled and elderly persons,1998 CPWD,
Ministry of Urban Affairs and Employment
39. Fundamental elements of Quality of Care, A simple framework, Judith Bruce, Studies in family planning 1990
40. Quality Management in Public Health Facilities – An Implementation Handbook, National Health Systems Resource Centre,
New Delhi
41. Quality Management in Public Health Facilities- Traversing Gaps, National Health Systems resource Centre
42. Essential Standards of Quality and Safety, Guidance about compliance, March 2010, Care Quality Commission, United
Kingdom
43. Principles of Best Practices in Clinical Audit, National Institute of Clinical Excellence, United Kingdom,
44. Operational Guidelines for Integrated Counselling and testing Centre, 2007, National AIDS Control organization
45. Operational Guidelines for ART Centres, National AIDS control organization, MoHFW, Government of India
46. Handbook for Vaccine and Cold Chain Handlers, 2010, MoHFW, Government of India
47. Twelfth Five Year Plan, Social Sectors, 2012-2017, Planning Commission, Government of India
382
Annexure
48. Quality Management in Hospitals, S. K. Joshi, Jaypee Publishers, New delhi
49. Health Care Case Laws in India, entre for Enquiry into Health and Allied Themes (CEHAT)
50. Infection Management and Environment Plan, Guidelines for Healthcare workers for waste management and infection
control in community health centres.
51. Practical Guidelines for Infection Control in Health Care Facilities, World Health Organization
52. IWA1, Quality Management Systems – Guidelines for Processes improvements in health services organizations, 2005,
International Organization for Standardization.
53. ISO 19011: 2011, Guidelines for auditing management systems, International Organization for Standardization
54. Comprehensive Abortion Care, Training and services Delivery Guidelines, 2010 MoHFW, Government of India
55. Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs/SNs, 2010 MoHFW, Government of India
56. A Handbook for Auxiliary Nurse Midwives, Lady Heath Visitors and Staff Nurses 2010, MoHFW, Government of India
57. Maternal Death review, Guidebook, MoHFW, Government of India
58. Good Pharmacy Practice, Joint FIP/WHO Guidelines on GPP : Standards for Quality of Pharmacy Services, World Health
Organization
59. Good Pharmacy Practices Guidelines, 2002, Indian Pharmaceuticals Association
60. Immunization Handbook for Medical Officers, MoHFW, Government of India
61. Quality Improvement for Emergency Obstetric Care, Tool book and Leadership Manual Engender Health
62. Operational Guidelines for Facility Based Integrated Management of Neonatal and Childhood Illness (F-IMNCI), MoHFW,
Government of India
63. Navjaat Sishu Surakasha Karyakram, Training Manual, MoHFW, Government of India
64. Technical and Operational Guidelines for TB Control, Central TB Division, MoHFW, Government of India
65. Guidelines for Diagnosis and treatment of malaria in India, 2011, National Vector Born disease control program, GoI,
MohFW
66. Operational Guidelines on National Programme For Prevention And Control Of Cancer, Diabetes, Cardiovascular Diseases
and Stroke (NPCDCS), MoHFW, Government of India
67. Training Manual for Medical Officers for Hospital Based disease Surveillance, Integrated Disease Surveillance Project,
National Centre for Disease control.
68. Disability prevention and medical rehabilitation, Guidelines for Primary, Secondary and Tertiary level care, National Leprosy
Eradication Program, MoHFW, Government
69. A strategic approach for reproductive, maternal, new born, child and adolescent health (RMNCH+A) in India, MoHFW,
Government of India
70. Rashtriya Bal Swasthya Karyakram (RBSK), Operational Guidelines, MoHFW, 2013, Government of India
71. Operational Guidelines for Rogi Kalyan Samitis, Health and Family Welfare Department, Government of West Bengal
72. Maternal and Newborn Health Kit, Maternal Health Division, Ministry of Health and Family welfare, Government of India
73. Infection Prevention Practices in Emergency Obstetric Care, Engender Health
74. Laboratory Safety Manual, Third Edition, 2004, World Health Organization
75. Crossing The Quality Chasm: A New Health System for the 21st Century, Institute on Medicine, USA
76. Accreditation of Public Health Facilities, Evaluating the impact of the initiatives taken on improving service delivery,
documenting the challenges and successful practices , 2012, Deloitte India
383
Annexure
77. Quality and Accreditation of Health Services – A Global Review, ISQUA and WHO
78. Gender Analysis in Health –A review of selected tools, World Health Organization
79. Governing Public Hospitals, Reform strategies and the movement towards institutional autonomy, 2011, World Health
Organization
80. Environmentally sound management of mercury waste in Health Care Facilities, Central Pollution Control Board
81. ICD 10 -International Statistical Classification of Diseases and Related Health problems, 2010 Edition, World Health
organization
82. Infection Prevention, Guidelines for Healthcare facilities with limited resources, JHPIEGO
83. Manual for Medical officers, dealing with child victims of trafficking and commercial sexual exploitation, UNICEF
84. Medical records Manual, A Guide for Developing Country, World Health Organization
85. Evaluating the quality of care for severe pregnancy complications, The WHO near miss approach for maternal health,
World Health Organization
86. Guidelines for Hospital Emergency Preparedness Planning, National Disaster Management Division, Ministry of Home
affairs, Government of India.
87. Diagnostic Audit Guide 2002, Guide to Indicators, Operation Theatres, Audit Commission, National Health Services, UK
88. Determinants of patient satisfaction in public hospitals and their remediabilities, Nikhil Prakash, Parminder Gautam, JN
Srivastava, BMC Proceedings 2012
89. Measuring efficiency of emergency processes using value stream maps at Sick Newborn Care unit, Nikhil Prakash, Deepika
Sharma, JN Srivastava, EMS 2013
90. Safe blood and Blood Products, Indicators and Quality of Care, World Health Organization
91. Site assessment and strengthening for maternal health and new born health programs, JHPIEGO
92. Women- Friendly health services experience in maternal care , World Health organization
93. The Quality Improvement Tool book , National Health Systems Resource Center
94. Toyota Production system, Beyond Large Scale Production, 1988 Taiichi Ohno
95. Value Stream Mapping for Healthcare Made Easy, Cindy jimerson, CRC press, New York
96. Mistake proofing : the design of Health care – AHRQ, USA
97. The Quality Tool Box, Nancy R Tague, ASQ Quality Press
98. To Err is Human : Building a safer health system , Institute of Medicine
99. Guidelines for Good Clinical Laboratory Practices (GCLP), 2008, Indian Council of Medical Research
100. Hutchinson Clinical Methods, 23rd Edition , Saunders Ltd.2012
101. Healthcare Quality Standards, Process Guide, National Institute of Clinical Excellence, United Kingdom
102. Bio Medical Waste ( Management and handling) 1998
103. Medical Termination of Pregnancy Act 1971
104. Pre Conception and Pre Natal Diagnostic Test Act 1996
105. Person with Disability act 1995
384
Annexure
Index
S.No. Key word Reference Standard & ME 43 Hand over ME E4.3
1 Abortion Standard E20 44 High alert drugs ME E7.1
2 Accident & Emergency Services ME A1.10 45 Housekeeping service ME A5. 4
3 Active Management of third ME E17.1 46 Illumination level ME D3.6
Stage of labour
47 Immunization services ME E19.1
4 Acute Malnutrition ME E19.6
48 Infection control committee ME F1.1
5 Administrative services ME A5. 8
49 Informed consent ME B4.1
6 Adolescent health Services ME A 2.5
50 Initial assessment ME E2.1
7 Adolescent Reproductive and Standard E21
51 Integrated Disease Surveillance ME A4.9 for Service Provsion and
Sexual Health
Programme ME E22.9 for Clinical Services
8 Antenatal care Standard E16
52 Internal assessment ME G5.1
9 Antibiotic policy ME F1.6
53 Internal quality assurance ME G3.1
10 Asphyxia ME E19.4 programme
11 AYUSH ME A1.7 54 Intramural and extramural ME C1.5
communication
12 Behaviours of staff ME B3.3
55 Intranatal care Standard E17
13 Bio Medical Waste Standard F6
56 Inventory management ME D2.5
14 Blood Storage Unit Standard E12
techniques
15 Blood Transfusion ME E12.5
57 Jaundice ME E19.4
16 Calibration Standard D1
58 Job description ME D9.1
17 Cashless services ME B5.1
59 Junk material ME D3.4
18 Child health Services ME A 2.4
60 Laboratory ME A3.2
19 Citizen charter ME B1.3
61 Landscaping ME D3.1
20 Clinical Care & Safety Indicators Standard H3
62 Laundry services ME A5. 2
21 Community needs Standard A6
63 Maintenance services ME A5. 5
22 Confidentiality ME B3.4
64 Maternal health Services ME A 2.2
23 Continuity of care Standard E3
65 Medical Check-up ME F1.4
24 Contract management ME D10.1
66 Medical Records ME A5. 7
25 Corrective and preventive ME G5.5
67 Medication orders ME E7.2
actions
68 Medico legal cases ME E10.5
26 Cross matching ME E12.3
69 Mental Health Programme ME A4.6 for Service Provsion and
27 C-section ME E17.2
ME E22.6 for Clinical Services
28 Curative services Standard A1
70 Mock drills ME C2.6
29 Dental Treatment ME A1.6
71 Narcotic and psychotropic ME D2.8
30 Diagnostic services Standard A3
72 National AIDS Control ME A4.4 for Service Provsion and
31 Diagnostic services ME A3.3 for Service Provision and Programme ME E22.4 for Clinical Services
Standard E11 for Clinical Services
73 National health Programme for ME A4.10 for Service Provsion and
32 Diarrhoea ME E19.7 deafness ME E22.10 for Clinical Services
33 Dietary services ME A5. 1 74 National Iodine deficiency ME A4.13
34 Disaster Management Standard E10 Programme
35 Efficiency Indicators Standard H2 75 National Leprosy Eradication ME A4.3 for Service Provsion and
36 Emergency drug tray ME C4.3
76 National Program for healthcare ME A4.14
37 External assurance programmes ME G3.2 of elderly
38 Fire fighting Equipment ME C2.5 77 National Programme for control ME A4.5 for Service Provsion and
39 General Medicine services ME A1.1 of Blindness ME E22.5 for Clinical Services
40 General Surgery services ME A1.2 78 National Programme for ME A4.8 for Service Provsion and
Prevention and control of ME E22.8 for clinical Services
41 Grievance redressal system ME B4.5
Cancer, Diabetes, Cardiovascular
42 Hand Hygiene Standard F2 diseases & Stroke
385 Index
79 National Programme for the ME A4.7 for Service Provsion and 106 Quality team ME G1.1
health care of the elderly ME E22.7 for Clinical Services
107 Radiology ME A3.1
80 National Programmes Standard A4
108 Rational use of drugs ME E6.2
81 National Tobacco Control ME A4.12
109 Referral Linkage ME E3.2
Programme
110 Reproductive health Services ME A 2.1
82 National Vector Borne Disease ME A4.1 for Service Provsion and
Control Programme ME E22.1 for Clinical Services 111 Revised National TB Control ME A4.2 for Service Provsion and
83 New born resuscitation ME E17.4
112 Rights and responsibilities ME B4.2
84 Newborn health Services ME A 2.3
113 RMNCH+A Standard A2
85 Nutritional assessment ME D5.1
114 Rogi Kalyan Samitis ME D6.1
86 Obstetrics & Gynaecology ME A1.3
115 Root-cause analysis ME G2.2
87 Obstetrics Emergencies ME E17.3
116 security services ME A5. 3
88 Ophthalmology Services ME A1.5
117 Seismic safety ME C2.1
89 OT Scheduling ME E14.1
118 Sepsis ME E19.4
90 Paediatric Services ME A1.4
119 Service counters ME C1.6
91 Patient feed back ME G2.2
120 Service Quality Indicators Standard H4
92 Personal protection Equipment Standard F3
121 Signage system ME B1.1
93 Pest, rodent and animal control ME D3.5
122 Standard Operating Procedures Standard G4
94 Pharmacy and store services ME A5. 6
123 Statutory and regulatory Standard D8
95 Physical Access ME B2.4
requirement
96 Physical safety Standard C2
124 Support services Standard A5
97 Post operative care ME E14.4
125 Surgical Safety ME E14.3
98 Post-anaesthesia care ME E13.3
126 Triage ME E19.2
99 Postnatal care Standard E18
127 Universal Immunization ME A4.11 for Service Provsion
100 Potable water ME D4.1 Programme
101 Pre-anaesthetic Check up ME E13.1
128 User charges ME B1.4
102 Productivity Standard H1
129 Vaccines ME D2.7
103 Quality improvement standard G7
130 Visual privacy ME B3.1
104 Quality objectives ME G6.2
131 Work instruction ME G4.4
105 Quality policy ME G6.1
386 Index
Assessor’s Guidebook for Quality Assurance in Community Health Centres (FRU)
2014
National Health Mission

Government of India
Government of India

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Assessor’s Guidebook for Quality Assurance in Community Health Centres (FRU)

Assessor’s Guidebook for

National Health Mission

Ministry of Health and Family Welfare

Ministry of Health and Family Welfare

Designed by: Silverline Communication and printed by:

Place: New Delhi.

2 Mr. Manoj Jhalani JS (Policy), MoHFW

3 Dr. Rakesh Kumar JS (RCH), MoHFW

4 Dr. Himanshu Bhushan DC (I/c MH), MoHFW

5 Dr. S. K. Sikdar DC (I/c FP), MoHFW

6 Dr. Dinesh Baswal DC (MH), MoHFW

7 Dr. P. K. Prabhakar DC (CH), MoHFW

8 Dr. Teja Ram DC (FP), MoHFW

9 Mr. R. C. Danday Director, NHM, MoHFW

10 Dr. Renu Shrivastava SNCU Coordinator, MoHFW

11 Dr. Pushkar Kumar Lead Consultant, MoHFW

12 Dr. Rajeev Agarwal Sr. Consultant, MoHFW

13 Dr. Anil Kashyap Consultant - NHM, MoHFW

14 Dr. Ajay Patte Consultant, MoHFW

Development Partners and International Agencies

16 Dr. Nigel Livesley URC - ASSIST

18 Dr. Devina Bajpayee IPE Global

19 Dr. Ritu Agarwal CMNH, LSTM, UK

20 Dr. Gagan Gupta UNICEF

21 Dr. Bulbul Sood Country Director , JHPIEGO

22 Dr. Vivek Yadav JHPIEGO

23 Dr. Neerja Arora URC - ASSIST

24 Dr. Arunabh Ray BTAST, Bihar

26 Dr. Sushma Nangia Professor, Pediaterics, AIIMS

27 Dr. Vidushi Kulshrestha Asst. Professor, OBGY AIIMS

28 Dr. Manju Chhuggani Principal, Nursing School, Jamia

30 Dr. J. N. Srivastava Advisor, Quality Improvement

31 Dr. Parminder Gautam Sr. Consultant

32 Dr. Nikhil Prakash Sr. Consultant

33 Dr. J. V. Ramamurthi Consultant

34 Dr. Deepika Sharma Consultant

35 Ms. Surbhi Sharma Consultant

36 Ms. Richa Sharma Consultant

37 Mr. Rajesh Nallamothu Consultant

38 Dr. Jagjeet Singh Consultant

39 Dr. Sushant Agrawal Consultant

41 Dr. Sulbha Swaroop NHM, Govt. of UP

42 Dr. K. Sandeep NHM, Govt. of Kerala

46 Dr. Manoj Donglikar SDH Vaijapur, Aurangabad, Maharashtra

I. Introduction to Assessor’s Guidebook

Providing an equitable, accessible and affordable primary healthcare, which is of an assured

II. Framework of Quality of Care (QOC)

Table 2.1: QOC IN TERM OF INPUTS, PROCESSES and OUTCOME

Inputs Processes Outcome

2. Appointment of full time quality professionals at District and State level.

5. Provision of certification of public health facilities.

III. The Quality Measurement System

Following are salient features of the proposed quality system –

QUALITY ASSURANCE STANDARDS FOR CHC

National Quality Assurance

I. Intent of Quality Assurance

I. Area of Concern A – Services Provision

Standard A1–The Facility Provides Curative Services.