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1 | Page OCTAVO SOLUTIONS PVT LTD G-27, LOWER GROUND, KAILASH COLONY NEW DELHI - 110048 TEL: 011-41658335, Email:[email protected] GAP REPORT DISTRICT HOSPITAL GOPESWAR, CHAMOLI UTTRAKHAND
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OCTAVO SOLUTIONS PVT LTD G-27, LOWER GROUND, KAILASH
COLONY NEW DELHI - 110048 TEL: 011-41658335,
Email:[email protected]
GAP REPORT
DISTRICT HOSPITAL
GOPESWAR, CHAMOLI
UTTRAKHAND
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LATE SHREE NARENDRA SINGH BHANDARI MEMORIAL DISTRICT
HOSPITAL, GOPESWAR-CHAMOLI ( UTTARAKHAND)
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FOREWORD
Quality Management System and the Accreditation process in compliance with standards are tools
for quality assurance and quality improvement for hospitals which in turn help to ensure quality
healthcare services, standardized output and aim for the best possible outcome. Spin offs of the
system include economy, effectiveness, leadership amongst peer institution, confidence of the
citizens in the establishment and a culture of team work with a focus on service quality.
The Quality Council of India is an autonomous body under the Government of India; which has the
National Accreditation Board for Hospitals and Healthcare Providers (NABH) amongst several
other boards under its fold. The NABH standards place emphasis on patient, staff, visitor and
environment safety, infection control practices and quality of patient care.
With this Octavo Solutions Pvt. Ltd., The Health & Hospital Consultants wish the DISTRICT
HOSPITAL , GOPESWAR (CHAMOLI)-UTTARAKHAND Under UKHSDP all the very best
in their voyage towards implementing the quality management system and accreditation of the
hospital with the Entry Level NABH.
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LIST OF ABBREVIATION
1. NABH National Accreditation Board for Hospitals and
Healthcare Providers
2. UKHSDP Uttrakhand health system Development project
3. BMW Biomedical Waste
4. OT Operation theatre
5. OPD Outpatient department
6. NOC No objection certificate
7. PNDT Prenatal diagnostic techniques
8. AERB Atomic energy regulatory board
9. HCO Healthcare organization
10. KVA Kilo volt ampere
11. DG Diesel Generator
12. UPS Uninterrupted Power Supply
13. HVAC Heat Ventilation Air Conditioning
14. ICU Intensive care unit
15. NBSU New Born Stabilization Unit
16. UHID Unique Hospital Identification
17. USG Ultrasonography
18. B.P Blood pressure
19. BLS Basic life support
20. PA system Public announcement system
21. TAT Turnaround time
22. ACLS Advance Cardiac life support
23. MLC Medico legal case
24. PPE Personal protective equipment
25. HIV Human Immune Deficiency Virus
26. TLD Thermo Luminescent Dosimeter
27. PAC Pre Anesthetic Checkup
28. FRU First Referral Unit
29. ADR Adverse drug reaction
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30. APGAR Appearance Pulse Grimace Activity Respiration
31. LAMA Leave against medical advice
32. ICD International codification of disease
33. MRD Medical record department
34. HIC Hospital Infection Control
35. UTI Urinary Tract Infection
36. VAP Ventilator Associated Pneumonia
37. SSI Surgical Site Infection
38. CPR Cardio pulmonary resuscitation
39. FIFO First in first out
40. GRN Goods Receipt Notes
41. SOP Standard Operating Procedure
42. CSSD Central Sterile Supply Department
43. TSSU Theater Sterile Supply Unit
44. HR Human resource
45. PWD Public Welfare Department
46. BME Biomedical engineering
47. ECG Electrocardiography
48. ANM Auxiliary Nurse Midwifery
49. AMC Annual Maintenance Contract
50. ANC Ante natal check-ups
51. PNC Pre- natal check-ups
52. ICCU Intensive Cardiac Care Unit
53. PPE Personnel Protective Equipment
54. HAZMAT hazardous materials
55. GRN Good Receipt Not
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Contents EXECUTIVE SUMMARY ................................................................................................................................. 9
MAJOR FINDINGS ...................................................................................................................................... 10
HOSPITAL INTRODUCTION ........................................................................................................................ 12
KEY INDICATORS ........................................................................................................................................ 13
SIGNAGE SYSTEM ...................................................................................................................................... 14
STATUTORY REQUIREMENTS ..................................................................................................................... 15
BED DISTRIBUTION .................................................................................................................................... 16
STRUCTURAL DETAILS ................................................................................................................................ 17
MANPOWER REQUIREMENT ...................................................................................................................... 18
1. EMERGENCY .......................................................................................................................................... 22
2. AMBULANCE .......................................................................................................................................... 23
3. OUT PATIENT DEPARTEMENT ................................................................................................................ 24
4. OPERATION THEATER ............................................................................................................................ 25
5. PHARMACY STORE ................................................................................................................................. 27
6. TSSU/AUTOCLAVE FACILITY.................................................................................................................... 28
7. ENGINEERING AND MAINTENANCE DEPARTMENT ................................................................................. 29
8. MEDICAL RECORD DEPARTMENT ........................................................................................................... 30
9. NBSU (New Born Stabilisation Unit) ....................................................................................................... 30
10.WARDS ................................................................................................................................................. 32
11. HUMAN RESOURCE DEPARTMENT ....................................................................................................... 33
12. KITCHEN .............................................................................................................................................. 33
13. IMAGING DEPARTMENT ....................................................................................................................... 34
14. ICU (INTENSIVE CARE UNIT) ................................................................................................................. 34
15. INFECTION CONTROL PROGRAMME..................................................................................................... 35
16. LINEN/LAUNDARY ................................................................................................................................ 36
17. LABORATORY ....................................................................................................................................... 37
18. BIOMEDICAL ENGINEERING DEPARTMENT ........................................................................................... 37
LABOUR ROOM ......................................................................................................................................... 38
BIO-MEDICAL WASTE MANAGEMENT ........................................................................................................ 40
SECURITY ................................................................................................................................................... 40
HOUSEKEEPING DEPARTMENT .................................................................................................................. 41
MORTUARY ............................................................................................................................................... 41
STORE........................................................................................................................................................ 42
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EXISTING EQUIPMENT LIST ........................................................................................................................ 43
RECOMMENDATIONS ................................................................................................................................ 48
INFRASTRUCTURE ...................................................................................................................................... 49
REGISTRATION &OUT PATIENT DEPARTEMENT .......................................................................................... 50
OPERATION THEATRE ................................................................................................................................ 51
PHARMACY STORE ..................................................................................................................................... 52
AUTOCLAVE FACILITY................................................................................................................................. 53
ENGINEERING AND MAINTENANCE ........................................................................................................... 53
MEDICAL RECORD DEPARTMENT ............................................................................................................... 54
NBSU (NEW BORN STABILISATION UNIT) ................................................................................................... 54
WARDS ...................................................................................................................................................... 55
HUMAN RESOURCE DEPARTMENT ............................................................................................................. 56
KITCHEN .................................................................................................................................................... 56
ICU ............................................................................................................................................................ 57
INFECTION CONTROL ................................................................................................................................. 57
LINEN/LAUNDARY...................................................................................................................................... 58
BIOMEDICAL ENGINEERING DEPARTMENT ................................................................................................ 58
LABOUR ROOM ......................................................................................................................................... 59
BLOOD BANK ............................................................................................................................................. 59
BIOMEDICAL WASTE MANAGEMENT ......................................................................................................... 59
MORTUARY ............................................................................................................................................... 60
STORE........................................................................................................................................................ 60
GAPS PRIORITIZATION ............................................................................................................................... 76
REGISTRATION & OUT PATIENT DEPARTEMENT ........................................................................... 80
TSSU/ AUTOCLAVE FACILITY ............................................................................................................. 86
NBSU (NEW BORN STABILISATION UNIT) ........................................................................................ 89
INFECTION CONTROL .......................................................................................................................... 95
LINEN/LAUNDARY ................................................................................................................................ 97
LABORATORY........................................................................................................................................ 97
LABOUR ROOM...................................................................................................................................... 98
BLOOD BANK ......................................................................................................................................... 98
BIOMEDICAL WASTE MANAGEMENT ............................................................................................... 99
SECURITY ............................................................................................................................................... 99
MORTUARY .......................................................................................................................................... 100
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STORE.................................................................................................................................................... 101
ANNEXURE ..................................................................................................... Error! Bookmark not defined.
LEGAL DOCUMENTS –LETTER SIGNED BY HOSPITAL AUTHORITY .......................................................... 103
APPROVED EXISTING MANPOWER LIST ................................................................................................ 106
APPROVED EXISTING EQUIPMENT LIST ................................................................................................ 109
SUPPORTIVE EVIDENCE OF IDENTIFIED GAPS ....................................................................................... 115
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EXECUTIVE SUMMARY
Gap Analysis is a tool to analyze the degree of compliance to any standard. Herein, this assignment
the given district hospitals are analyzed with reference to the NABH pre entry level Standard
UKHSD under the aegis of World Bank has taken a step in the right direction to assess the current
level of quality adhered by the district hospitals in delivering healthcare services to the community,
in the state of Uttrakhand.
This assignment would guide the State in understanding the existing deficiencies/gaps in healthcare
delivery services thereby enabling the policy makers to formulate a strategy to fulfill such
deficiencies/gaps and strive towards further improvement.
The Octavo Solutions Private Limited, New Delhi has put all efforts to ensure that all components
with respect to NABH Pre entry level Standards are covered and relevant deficiencies are
accordingly addressed.
To conclude, the actions to be taken for compliance with the Accreditation standards of NABH Pre
entry level at District Hospital, Gopeswar (Chamoli) are likely to impact the delivery of healthcare
services positively, ensuring quality services, efficient outcomes with economy, risk management
with patients, staff and visitors safety and above all equity in healthcare services for all the citizens.
Hence, the demands of good governance dictate that the core values of health care service delivery
are equitable regardless whether services are provided to a prince or pauper. This ideal state of
affair can be achieved by the institution of a quality management system that focuses on
compliance with the Accreditation standards of NABH. The standards for compliance are dynamic
and seek to raise the bar continually; as well as to remain contemporary and applicable to the
situation obtaining in a region.
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MAJOR FINDINGS
The ‘Gap Analysis Report’ includes assessment of documentation and implementation with respect to Structure (Manpower, equipment, infrastructure and Statutory requirements), Processes (Clinical & Administrative) and Outcome against NABH Pre entry level Standard in Standardized and pre tested data collection and analysis tools have been used for the onsite assessment and analysis. This includes all departments exist in the hospitals.
The whole report is prepared as under:
1. The scope of services provided by District Hospital, Gopeswar (Chamoli) has been reviewed and represented accordingly.
2. Identifies the significant gaps in terms of Structure, Process and Outcome observed in all the concerned areas.
3. The data on status of the existing Manpower, Equipment and Statutory requirements.
4. Any other data or information as deemed necessary.
The Key Findings identified are as follows:
1. Biomedical Waste segregation is not as per the Biomedical Waste Handling Rules 2016 at all places and foot operated bins with Biohazard Symbol are not available.
2. Mortuary Chamber area is not marked and nearby area of the Mortuary are is very dirty. Cow was sitting in front of the unit.
3. Safety Belts are not available in stretcher& Wheel chairs.
4. Hand Railing is not available on the Ramps
5. Equipment is not under AMC and is not calibrated.
6. In digital X-ray room there is no Red Bulbs on the door that indicated Work/X-ray is going on.
7. Condemn Equipment were not placed inside the Room demarcated for same like non functional X-ray Machine was present inside the X-ray room.
8. No demarcated areas in sterilization Room like Receiving area, Sterilization Area, Storage Area, Issue area etc.
9. No Zoning in OT.
10. All Signages were not bilingual.
11. Crash cart with defibrillator is not available in Emergency department and other wards.
12. Nursing Staff is not trained in BLS.
13. Disposable delivery kits are not available.
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14. All the Sanctioned posts are not filled up. Required posts like Speciality Doctors, Surgeons, Medical Officer, Nurses, Radiologist, Dietician, Medical Records Technician, quality manager, CSSD technician, ANM, OT technician, security staffs are not included in the sanctioned posts.
15. The hospital does not comply with the necessary statutory & regularity requirements (except PNDT). All other relevant statutory requirement like biomedical waste handling rules (under renewal), building occupancy certificate, approved fire exit plan etc is not complained.
16. There is no provision of Central Medical gas Supply. Currently oxygen cylinders and oxygenators are used in areas like OT, labour room, ICU, ICCU and NBSU etc.
17. Hospital infection control practices are not evident. There is no dedicated infection control nurse. Culture sensitivity test not carried out in critical areas like OT.
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HOSPITAL INTRODUCTION
SCOPE OF SERVICES
Sl. No. Name of Services/ Department Availability (Yes/No/NA)
Remarks
GROUP A – CLINICAL SERVICES
01 General Medicine Yes
02 Obstetrics and Gynecology Yes
03 Peadiatrics and Neonatology No
04 Orthopedics Yes
05 Ophthalmology Yes
06 Anesthesiology Yes
07 General Surgery Yes
08 Dentistry Yes
09 ENT Yes
10 Dermatology No
Other
11 Ayurvedic clinic Yes
12 Homeopathy clinic Yes
GROUP B: CLINICAL SUPPORT SERVICES
13 Laboratory Yes
14 Radiology & Imaging Yes
15 Blood Bank Yes
16 Dialysis No
17 Physiotherapy Yes
GROUP C: SUPPORT SERVICES
18 Pharmacy Yes
19 General Store Yes
20 Kitchen & Dietary Yes
21 Laundry Yes Outsourced
22 CSSD/TSSU Yes
23 Medical Records Yes
24 Ambulance & Transport Yes
25 Security Services Yes Outsourced
26 Housekeeping Services Yes Outsourced
27 Biomedical engineering No
28 Maintenance Yes On Call
29 Mortuary services Yes
GROUP D: ADMINISTRATIVE SERVICES
30 General Administration Yes
31 Account & Finance Yes
GROUP E:NATIONAL PROGRAMS
32 Jananisurakshayojana Yes
33 RCH Yes
34 RMNCH Yes
35 PradhanMantriBhartiya Jan AushadhiYojana Yes
36 National Immunization program Yes
37 National family planning programme Yes
38 National STDs control programme Yes
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KEY INDICATORS
INDICATORS November-
2018
October-
2018
September-
2018
August-
2018
July-
2018
June-
2018
IP
Admissions
448 309 480 648 744 648
OPD 4786 3432 4297 5486 5607 5718
SURGERIES
(Minor)
10 15 16 23 30 15
SURGERIES
(Major)
11 19 02 04 01 03
X-RAYS 576 476 608 808 921 797
USG 391 397 380 424 625 669
LAB 1888 2621 3380 4511 5282 4974
BIRTH 56 43 59 66 63 59
DEATH 08 02 07 06 04 02
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SIGNAGE SYSTEM
Signage's Displayed
(Yes / No /
NA)
Bilingual
(Yes / No /
NA)
Pictorial
(Yes / No /
NA)
Remarks
(if any)
Citizen Charter Yes Yes NA Citizen
Charter is
displayed but
not in a
required
format it is
only Patient
Rights and
Responsibility
Mission No No NA
Vision No No NA
Patients Rights& Responsibilities Yes No NA
Scope of Services Yes No No Digitally
displayed
inside the
hospital
premises
Tariff List Yes No No
Doctors list along with their
Specialties and Qualifications
Yes No No Qualification
not displayed
OPD Schedule of Doctors (Specialty,
Timings and Day of Availability)
Yes No No
Biohazard Symbols Yes No No
Fire Exit Plan No No No
Floor Directory Yes Yes No
Wash Rooms (Differently Able) No No No
Toilets Yes No No
Ambulance Parking Area Yes Yes No
Drinking Water Yes No No
Health Education Related Signage
(HIV & Immunization)
Yes No No
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STATUTORY REQUIREMENTS
Licenses Available
YES/NO
Building Occupancy/Completion Certificate No
Clinical Establishment Act Certificate No
Approved Fire Exit Plan Yes (Applied
for Renewal
License under Bio- medical Management and handling Rules, 1998. Yes
Vehicle Registration Certificate for Ambulance Yes
PNDT Certificate Yes
Site & Type Approval for X-Ray from AERB No (Applied)
License for Blood Bank No (Applied)
A = Applicable NA = Not Applicable
Note: The hospital does not comply with the necessary statutory & regularity requirements
(except PNDT and Biomedical Waste Management Licence, Vehicle Registration Certificate for
Ambulance). All other relevant statutory requirement like Building occupancy certificate,
approved fire exit plan, Clinical Establishment Act Certificate, & Type Approval for X-Ray from
AERB&License for Blood Bank need to be acquired.
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BED DISTRIBUTION
Floor
Class/Department Beds
Ground Floor Emergency Ward (Emergency Block) 02
Ortho Ward (Male) 08
Surgical Ward-1 08
Surgical Ward-2 08
General Medical Ward 14
Peadiatrics Ward 08
Burn Ward 06
Private Ward 01
Semi Private Ward 05
Dengue/ Isolation Ward 08
Accidental Ward 10
First Floor Surgical Female Ward 08
Gynecological Ward 08
Geriatric Ward 06
ANC ward 04
PNC Ward 05
Eye Ward 12
ICU 03
ICCU 03
NBSU 04
TOTAL
131
Total Beds: 131
Functional Beds = 131
‘
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STRUCTURAL DETAILS
Category
A. Land 131200 Sq.ft.
B. Building -
C. HVAC Availability of HVAC system No
Quantity
(No)
Capacity
D. Electricity
Transformer 01 250 KVA
DG set 03 40 KVA,32 KVA,20
KVA=92 KVA
Inverter 06 15 KVA
UPS 15 15 KVA
Solar Panel 01 30 KVA
Total Load Sanctioned 200 KVA
E. Water Water Tanks (Overhead) 3 (10000
each)
30,000liters
Water Tanks
(underground)
- -
Sources of water Main Source – Uttrakhand Jal
Sansthan
Alternative Source- No
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MANPOWER REQUIREMENT
S.No Designation Sanctioned Actual Vacant
1 Chief medical Superintendent
1 0 1
2 Assistant Medical Superintendent
1 0 1
3 Gynecologist 1 1 0
4 Pediatrician 1 0 1
5 Anesthetist 3 1 2
6 Physician 2 1 1
7 Orthopedician 1 1 0
8 Cardiologist 1 1 0
9 Dermatologist 1 0 1
10 Surgeon 8 3 5
11 Medical Officer 5 4 1
12 Dentist 1 0 1
13 EMO 6 2 4
14 Pathologist 1 1 0
15 Radiologist 3 1 2
16 Blood Bank Officer 1 0 1
17 Physiotherapist 1 1 0
18 Matron 1 0 1
19 Sister Incharge 9 7 2
20 Staff Nurse 28 18 10
21 Tutor 3 0 3
22 Nursing Assistant 1 0 1
23 Chief Pharmacy Officer 1 0 1
24 Chief pharmacist 3 3 0
25 Pharmacist 3 3 0
26 Dresser 1 0 1
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27 Lab Technician 5 1 4
28 X-Ray Technician 2 1 1
29 Ophthalmic Assistant 2 2 0
30 Dark Room Assistant 1 1 0
31 Electrician 1 0 1
32 Electrician Cum Engine Repairer
1 0 1
33 Chief administrative officer 1 0 1
34 Assistant administrative officer
1 0 1
35 Sr. Administrative Officer 1 0 1
36 Administrative Officer 1 1 0
37 Chief Assistant 1 1 0
38 Senior Assistant 1 1 0
39 Junior Assistant 2 2 0
40 Storekeeper Cum Clerk 1 1 0
41 MSW 2 0 2
42 Health Inspector 1 1 0
43 Female Health Worker 2 2 0
44 Housekeeper 2 0 2
55 Lab Attendant 1 0 1
46 Driver 2 1 1
47 Ward Boy 12 7 5
48 Ward aaya 3 2 1
49 Plumber 1 1 0
50 Servant 3 0 3
51 Chukidar 2 2 0
52 Cleaner 2 1 1
53 Mali 1 1 0
54 Group D Worker 1 1 0
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55 Kook 1 1 0
56 Kahar 1 0 1
57 Bearer 1 1 0
58 Water-Carrier 1 0 1
Sanctioned Post – 147
Actual Filled - 79
Vacant Post –68
Note: All the Sanctioned Post Need to Be Filled and Some More Positions like ANM, quality
manager, nurses, security guard, Dietician, Microbiologist Need to Be Appointed.
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DEPARTMENTAL GAPS
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1. EMERGENCY
S
T
R
U
C
T
U
R
E
Triage area not Demarcated in Emergency Department.
Emergency Signage not visible from the road with proper lighting and signs.
P
R
O
C
E
S
S
There is no on call system to review all imaging by a radiologist within 24 hours.
Crash cart not checked daily regarding regular Testing because no availability of Crash Cart.
Triaging of Patient not done because no defined Triage area in the department.
Written Clinical Protocol on Commonly seen Emergency not available.
No defined Procedure for receiving and triage available.
No defined Procedure for Disaster Management.
Initial assessment of the patient not done in proper format.
Nurse’s initial assessment was not being carried out.
O U T C O M E
No monitoring of Time for initial assessment of emergency patient.
No Monitoring of No. of Patients returned to emergency within 72 Hrs.
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2. AMBULANCE
S
T
R
U
C
T
U
R
E
Required Medicines are not available in the ambulance.
P
R
O
C
E
S
S
Policy and procedures for ambulance services not defined & documented.
Medication and equipment checklist not maintained in the Ambulance.
Infection control practices not followed properly.
O U T C O M E
Monitoring of response time for ambulance services not done
Monitoring of availability and utilization of ambulance services not done.
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3. OUT PATIENT DEPARTEMENT
Identified gaps:
STR
UC
TU
RE
There is no enquiry counter in OPD.
PR
OC
ESS
UHID is not generated for all patients.
No separate registration done for Old and New Patients.
Procedure to admission or refer of Patient from OP Chamber is not available.
OU
TC
OM
E OPD utilization is not done & monitored.
Recording Waiting time for patients in OPD is not done.
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4. OPERATION THEATER
IDENTIFIED GAPS:
S
T
R
U
C
T
U
R
E
Window A/c is being used in OT and there was no evidence of regular cleaning
of a/c filters and air culture record thus, having convenient pockets for microbial
growth.
The temperature, humidity of the OT was not as per the requirement. i.e. 55%
humidity, 21 0c
P
R
O
C
E
S
S
The WHO surgical safety checklist is not being followed for patient.
Immediate pre-operative check-up before wheeling in patient in operation
room from pre-operative ward was not performed.
The surgery and anesthesia consent is not present. The consent is being
taken in hand written format.
Preoperative checklist not followed.
Patient undergoing surgery is not being screened for HIV. There was no
evidence of HIV consent and HIV test of patient undergoing surgery.
The plan of care is not documented. The desired result of treatment is not
documented.
No defined criteria are being used to decide shifting of patient from post-
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operative ward. The post operative monitoring is not being carried out.
Look alike, sound alike medicines are not stored separately.
Multi-use open vials to have a label of date of opening and expiry
High risk medicines are not stored separately.
Monitoring of patient during surgical procedure (at minimum heart rate,
cardiac rhythm, respiratory rate, blood pressure, and oxygen saturation and
level sedation) is not being documented.
Infection control practices not being followed in appropriate manner.
All staff is not aware on OT specific infection control practices (scrubbing,
sterility maintenance, use of PPE etc.)
Each operation room is not monitored for humidity and temperature on
daily basis.
Biomedical Waste management practices not followed properly in Inside the
OT.
Each operation room is not monitored for filter integrity, at-least once in six
month.
Regular environmental surveillance for microbes is not done in each OT and
other areas to identify forming of any colonies of bacteria.
Defined criteria to decide shifting of patient from post-operative ward is not
being followed.
O U T C O M E
The quality indicators like
% modification of anaesthesia plan % of unplanned ventilation following anaesthesia. % of adverse anaesthesia events % of rescheduling of surgeries % of adverse events like wrong patient, wrong site, wrong surgery. OT utilization rate % of cases received antibiotic prophylaxis within defined time frame is
not being monitored.
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5. PHARMACY STORE
S T R U C T U R E
Medicines are not stored in a condition as described by manufacturer. No Refrigerator available for storing medicine does not have a temperature monitoring system. The temperature of the refrigerator is not recorded at-least 3 times a day.
All items storage areas are not ladled and marked. There is no demarcated are for Receiving area, Segregation area and storing
area.
P R O C E S S
The medicines are not labelled& arranged as per alphabetical order. Look alike and sound alike (LASA) medicines are not identified and a list is not
available. Staffs are not aware on what to do if temperature of refrigerator is not within
the defined limit. (Time limit within which medicines to be shifted to another refrigerator)
High risk medicines are not identified and a list is not available. Pharmacists are not aware on policy on verbal order of prescription
medicine. Adverse drug reactions are not being analyzed. Staff at pharmacy is not aware of situation when medicine recall is
warranted and the procedure of recall. List of all hazardous materials stored in pharmacy is not available. MSDS for
each hazardous material are not kept available for ready reference of staff.
O U T C O M E
Percentage of stock out of drugs
Percentage of stock out of emergency drugs
Percentage of stock out of V and E category drugs
Percentage of medicines procured through local purchase.
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6. TSSU/AUTOCLAVE FACILITY
S T R U C T U R A L
The area layout do not have well demarcated zones, which includes
Collection zone (or soiled zone) where the soiled and used items should be received and
sorted.
Cleaning zone where washing, cleaning and packaging of items should be done.
Sterilization zone where the actual sterilization of packages should be done.
Storage – This can be considered a part of sterilization zone, where sterilized packs are
stored till its distribution.
The zones do not lead to unidirectional movement of people and supplies. There is no bacteriological/chemical surveillance test being performed for sterilization
authenticity & validation. No Hypochlorite solution not present for decontamination of equipments only bleaching
available.
Transport trolley not available inside the unit. No adequate racks present in the department.
P R O C E S S
SOP is not documented for each activity done in CSSD.
Procedure of sterilization (separate SOP for each type of sterilization, Procedure of
cleaning, Procedure of packing, Procedure of disinfection, Procedure of storage and
issue, Safety precautions and guidelines, Processing required before reuse of the items,
A policy is not there on reusable devices/items which specify List of items that can be
re-used .The department is not maintaining record of all validation test reports.
There is no procedure of recalling items in case of sterilization breakdown.
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7. ENGINEERING AND MAINTENANCE DEPARTMENT
S T R U C T U R A L
There is no designated person handling the medical equipments related issues.
P R O C E S S
There is no safety committee (including representatives from facility management,
clinicians, administrator, nursing and paramedical staff) to coordinate development,
implementation and monitoring of safety plans.
The organization does not identify the potential emergencies and not prepared for
emergencies like earthquake, major fire, flood, etc. as there is no documented
disaster management plans and mock drills are not being carried out for emergency
codes.
The periodic facility inspection is not being carried out to identify the environmental
hazards and risk.
O U T C O M E
No monitoring done for response time.
Number of variations observed during mock drills not monitored.
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8. MEDICAL RECORD DEPARTMENT
P
R
O
C
E
S
S
There is not designated person for taking care of medical records.
The records do not have all relevant forms & formats like Nurses Records, Initial
assessment form, etc. There is not like unique identifier at each page, policy
authorizing medical record entries in medical record.
Entry in the medical record is not named, signed, dated and timed.
The organization does not have an effective process for document control e.g. the
forms and formats which is being used is not standardized and do not have
identification code.
The retrieval of the records is not easy. Deficiency checklist is not followed.
O
U
T
C
O
M
E
The outcome indicators like % of missing records, % of records with ICD
codification done is not being monitored.
9. NBSU (New Born Stabilisation Unit)
No of beds: 4 beds
P R O C E S S
Fumigation is being practiced which is not acceptable. There was no protocol for
terminal cleaning and disinfection.
The admission and discharge criteria for NBSU are not defined.
No documented policy for initial assessment and re-assessment of patient.
The continuous monitoring of the patient condition is not being done. The patient and
family are not educated on change in the condition.
The evidence based practice is not being followed for the treatment of the patient
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although the protocols are available in the department but the compliance is not being
monitored.
No Hospital Acquired Infection rate monitored and action taken report not documented.
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10.WARDS
S
T
R
U
C
T
U
R
E
Adequate privacy arrangement for patient (especially applicable in multi-bed
wards not made available.
There is lack of Separate or segregated storage area for clean and dirty supplies.
P
R
O
C
E
S
S
The reporting of adverse patient events is not being followed.
A nurse initial assessment was not being carried out.
The time frame for initial assessment of the patient is not defined and the
assessment conducted by the doctors is not counter signed by Incharge clinician.
Emergency medicines are not checked regularly.
The blood transfusion consent is present. The transfusion record is not
available and the reporting of transfusion reaction is not being done.
Patients are not regularly reassessed by treating physician and
reassessment is not documented.
The content of discharge summary is not appropriate. It does not include
when and how to obtained urgent care.
Medications errors, near miss events are not identified and recorded.
O
U
T
C
O
M
E
The quality indicators are not be monitored. These are-
Percentage of Patients receiving high risk medications developing adverse drug
event.
Percentage of admissions with adverse drug reactions (s) (Adverse drug
reactions per 100 separations)
Incidence of medication errors (Medication errors per patient days)
Appropriate handovers during shift change (To be done separately for doctors
and nurses per patient per shift).
Incidence of hospital associated pressure ulcers after admission (Bed sore per
1000 patient days)
Incidence of falls
Catheter associated Urinary tract infection rate, Incidence of blood body fluid
exposures, Incidence of needle stick injuries.
33 | P a g e
11. HUMAN RESOURCE DEPARTMENT
There is no specific Human Resource department located in the Hospital but activities are taken care by few dedicated administrative staff. There is a need of development of Human Resource department so as to implement all the necessary policies and procedures relating to various standards and objective elements.
S T R U C T U R A L
There is not Training Incharge present in the hospital.
P R O C E S S
There is no training programme when job responsibilities changes and when new
equipment gets installed.
HR induction and training programme was not documented after joining.
No evidence of training Need Analysis is being done.
Employee’s satisfaction survey was not being done and analyzed
There were no feedback mechanisms for improvement of training and
development programme.
12. KITCHEN
The Hospital provides Dietary services but the department is not having demarcated areas
such as receiving area, storage area, washing cutting cooking, distribution and cleaning area
etc.
S
T
R
U
C
T
U
R
A
L
There is no demarcation in the kitchen.
P
R
O
C E
S
S
Patient & family members are not educated regarding the limitations of diet.
No cleaning schedule for the kitchen available.
Diet sheet, Nutritional, Food evaluation is not prepared by dietician because dietician
not available.
Infection control practices not followed in appropriate manner.
34 | P a g e
13. IMAGING DEPARTMENT
IDENTIFIED GAPS
ST
RU
CT
UR
AL
TLD badge for staff is not available.
Type & Site approval for X-Ray is not available
PR
OC
ES
S Surveillance of imaging results is not being carried out.
OU
TC
OM
E Safety & Quality programme for the department is not being monitored viz. No.
of reporting errors/1000 investigations, % of Re-dos, % of reports co relating
with clinical diagnosis & % adherence to safety precautions by employees
working in diagnostics.
14. ICU (INTENSIVE CARE UNIT)
Note: Well Equipped ICU and ICCU is Available but there is no trained manpower
available for functioning of the department.
35 | P a g e
15. INFECTION CONTROL PROGRAMME
There is no infection control program established in the hospital. The surveillance activities are not being carrying out in the hospital.
S T R U C T U R A L
No designated and qualified infection control nurse is present. No Designated Infection Control officer is present.
P R O C E S S
There is no documented infection prevention and control programme. The organization does not adhere to standard precautions at all times. There is no cleaning protocol for equipment. There was no antibiotic policy established. No monitoring done of HAI rate and Housekeeping Effectiveness... Hospital does not adhere laundary and linen management processes because Laundry
was outsourced. The infection control surveillance data is not being collected. No documented procedures present for identifying an outbreak. No Training Session conducted for all staff at least once in a year. The organization does not have appropriate hand hygiene facilities across the all patient
care areas viz no elbow operated taps, soap solution. Phenyl is being used as disinfectant. 1. Regular validation tests for sterilization like physical test , daily, weekly biological tests,
steam processing, is not being followed. The outcome is not being monitored-
Catheter associated urinary tract infection rate Surgical site infection rate Percentage of staff provided pre- exposure prophylaxis Incidence of blood body fluid exposures Compliance to hand hygiene practice
36 | P a g e
16. LINEN/LAUNDARY
S T R U C T U R A L
The department does not have demarcated areas like receiving, segregation area,
sluicing, washing, drying, calendaring etc.
The department has only one semi automated washing machine.
P R O C E S S
Segregation of soiled and contaminated linen is not being carried out.
There is no disinfectant while washing contaminated linens.
No Separate storage area for dirty and clean linens.
Hospital does not adheres laundry and linen management processes because Laundry
was outsourced.
The HCO does not adhere to kitchen sanitation and food handling issues of Outsource
Kitchen.
The HCO does not adhere Mortuary practices in appropriate manner.
There was no appropriate engineering control to prevent infections which includes
design of patient care areas (optimum spacing between beds), operating rooms, air
quality and water supply.
The infection control surveillance data is not being collected.
The organization does not have appropriate hand hygiene facilities across the all
patient care areas viz no elbow operated taps, soap solution.
The disinfectant which is being used in the hospital is not undergone any sterility test.
Phenyl is being used as disinfectant.
Regular validation tests for sterilization like physical test , daily, weekly biological
tests, steam processing, is not being followed.
O U T C O M E
The outcome is not being monitored-
Catheter associated urinary tract infection rate Surgical site infection rate
Percentage of staff provided pre- exposure prophylaxis
Incidence of blood body fluid exposures
Compliance to hand hygiene practice
37 | P a g e
17. LABORATORY
ST
RU
CT
UR
AL
Separate Sample Collection area is not available in the Laboratory .
Periodically maintenance & Calibration of Equipment is not evident.
No adequate no. of Personal protective devices such as aprons, masks, gloves
etc..
Fire exit signage & plan is not displayed.
Foot Operated BMW bins are not available.
Non availability of HAZMAT Kit in the department.
PR
OC
ES
S
Lab surveillance is not being done.
Quality Assurance program of lab is not established (Internal & External).
Laboratory staff not aware about safety precautions while handling samples.
Critical Result not defined and documented in laboratory department.
No Monitoring of Turn-around Time for Laboratory.
Temperature Monitoring of Refrigerator not done.
OU
TC
OM
E
No Monitoring of Outcome indicator such as:
Number of reporting errors per 1000 investigations.
% of reports having clinical correlation with provisional diagnosis.
% of adherence to safety precautions.
% of Redo’s
18. BIOMEDICAL ENGINEERING DEPARTMENT
There is no Biomedical Engineering department in the hospital. All the equipment is maintained
and repaired by the workmen on call basis as per requirement. There is no qualified person for
managing the department.
38 | P a g e
LABOUR ROOM
Labour room which acts as an emergency functions 24 hourly. Emergency cases are received
and treated in Labour Room.. Sterilization facilities are also inadequate. There is no provision for
Septic and aseptic deliveries separately in Labour Rooms.
IDENTIFIED GAPS
ST
RU
CT
UR
AL
Unavailability of separate areas for septic and aseptic deliveries.
Department’s layout is not demarcated as per functions viz receiving area,
Examination room, Pre-delivery room, delivery room, post delivery observation
room, Nursing station, dirty utility and clean utility, area for medication and
injection preparation, Pre-Eclampsia area etc
No separate Changing Room available for Doctors and Nurses.
Scope of high risk obstetrics care is not displayed.
ECG monitor, Disposable delivery kits in required quantities, Crash cart with
defibrillator is not available in the unit.
PR
OC
ES
S
Work Instructions are not displayed prominently.
No documented Obstetrics & Gynecology policy available.
Staff is not trained on the policies.
Staff is not trained on infection Control practices
OU
TC
OM
E Quality indicators like maternal death rate, fetal deaths, incidence of unexpected
complications is not monitored.
Incidence of theft/swapping babies is not being monitored.
39 | P a g e
BLOOD BANK
IDENTIFIED GAPS
ST
RU
CT
UR
AL
No Crash cart and defibrillator available in the department
No Qualified and Trained nurse deputed in Blood Bank.
Signage displayed is not bilingual.
Equipment of Blood Bank is not calibrated uniformly.
Transfusion reaction is not capturing. Analysis of transfusion reactions.
There is no full time qualified Blood Bank In-Charge available to manage the
blood collection/distribution department.
No Blood bank technician available in this department.
PR
OC
ES
S
Separate counseling section is not present in this unit.
Bilingual consent for blood donation is not available.
There is no screening of donors prior to blood donation in appropriately.
No evidence is present for cross marched ,labeled, recipient identified,
compatibility level noted, unit dispensed.
List of department staffs is not displayed in this unit.
No Blood Transfusion committee exists in the HCO.
No documentation for monitoring of adverse drug reaction and data are not
collected, analyzed and reported .
Documented policy for issue and collection of blood is not available.
Blood bank policy is not available
Temperature of the refrigerator is not being monitored and recorded.
Staff is not trained on the Blood Bank policy
Informed consent viz. Blood transfusion & HIV consent forms is not available.
OU
TC
OM
E Quality Indicators is not being monitored viz. % of transfusion reactions, % of
wastage of blood & blood products, Turnaround time for issue of Blood &
Blood components.
40 | P a g e
BIO-MEDICAL WASTE MANAGEMENT
IDENTIFIED GAPS
ST
RU
CT
U
RA
L
Foot operated BMW bins were not available.
Signage for Bio-hazard was not displayed.
PR
OC
ES
S Segregation of BMW at point of Generation not done at all areas.
There is no separate route defined for transportation of waste from the general
traffic area.
SECURITY
IDENTIFIED GAPS
ST
RU
CT
UR
AL
No system of telephone connectivity from Emergency Room.
No separate security guard available for emergency and labor room.
PR
OC
ES
S No outgoing items checked and entered on a register.
OU
TC
OM
E Monitoring of security related incidents and thefts was not done in the hospital
premises.
41 | P a g e
HOUSEKEEPING DEPARTMENT
IDENTIFIED GAPS
ST
RU
CT
UR
AL
No basic facilities available like(Toilet/Drinking water/change room) for
housekeeping staff.
PR
OC
ES
S Daily Cleaning & Master cleaning schedule was not available.
Material Safety Data Sheet was not available.
Pest control method was not practiced.
OU
TC
OM
E
Effectiveness of housekeeping services was not monitored.
MORTUARY
Mortuary Chamber area is not marked and nearby area of the Mortuary are is very dirty. Cow was sitting in front of the unit.
IDENTIFIED GAPS
ST
RU
CT
UR
AL
Calibration and maintenance is not done regularly.
Fire detection/Fire fighting system such as: Fire Extinguisher not installed in
this unit.
PR
OC
ES
S Temperature not being monitored regular basis.
42 | P a g e
STORE
IDENTIFIED GAPS
ST
RU
CT
UR
AL
Layout of the store was not appropriate. There was no dedicated receiving,
quality check, labeling, Store and Issue area identified.
No adequate Racks are available in Store cartons lying on floor.
PR
OC
ES
S
Inventory control practices were not followed.
Frequently used items are not arranged and located in most easily accessible
area.
Documented policy for Store & Purchase department was no available.
Documented condemnation policy was not available.
OU
TC
OM
E
Monitoring of indicators like percentage of local purchase, Stock turnover
details, incidence of variation from the procurement process and percentage of
goods rejected before preparation of GRN, was not done.
43 | P a g e
EXISTING EQUIPMENT LIST
Area Equipments Quantity
(nos)
Functional
Remarks
Radiology Ultrasound 3 1
Mammography System 0 0
X-Ray (Fixed) 02 1
X-Ray (Mobile) 1 1
Defibrillator 0 0
X-Ray Developing Tank 2 2
Safe Light X-Ray Dark Room 2 2
Cassettes X-Ray 5 5
Lead Apron 3 3
Gonad Shield 0 0
Thyroid Shield 0 0
TLD badges 0 0
NBSU Baby Incubator 1 1
Phototherapy Unit 1 1
Emergency Resuscitation Kit
Baby 1 1
Multi Para monitors 3 3
Nebulizer Kit Baby 1 1
Weighing Machine Adult 1 1
Syringe Infusion Pump 2 2
Defibrillator 0 0
Ventilator 0 0
Infant Warmer/Resuscitation
Unit 5 1
Transport Monitor- Critical Care 0 0
Portable X ray Unit – Multi
mobile 0 0
Pulse Oximeter With Pediatric
Sensor
1 1
ECG Machine 0 0
Glucometer 0 0
Suction Machine 0 0
Ear, Nose,
Throat (ENT)
Head Light Ordinary 1 1
ENT Operation Set Including
Lead Light Transits 1 1
44 | P a g e
Head Light (Cold Light ) 1 1
Tracheostomy Set 1 1
Tuning Tank 1 1
EYE Ophthalmoscope Direct 2 1
Slit Lamp 2 2
Vision Drum 1 1
IOL Open Set 1 1
Ophthalmic Surgical Instrument 1 1
Eye Microscopy 1 1
Dental Air Rotors 2 2
Dental Unit Motor 1 1
Laboratory ELISA Reader Cum Washer 0 0
Blood gas Analyzer 0 0
Electrolyte Analyzer 0 0
HaematologyAnalyser 22
Parameter 1 1
Laboratory Autoclave 0 0
Micro Pipettes of Different
Volume 1 1
Hot Air Oven 2 1
Lab Incubator 2 1
Distilled Water Plant 1 1
Electric Centrifugal Top 3 2
Counting Chamber 1 1
Glucometer 0 0
Haemoglobino meter 2 1
TC DC Count Apparatus 0 0
ESR Stand Tubes 1 1
Test Tubes Stand 5 5
Test Tubes Rack 5 5
Spirit Lamp 1 1
Alarm Clock 0 0
ELISA Reader Cum Washer 0 0
Blood gas Analyzer 0 0
Electrolyte Analyzer 0 0
Operation
Theatre
Operation Table Hydraulic 2 2
Operation Table Non Hydraulic 2 1
45 | P a g e
Field type
Shadow less Lamp Ceiling Type 2 1
Suction Apparatus 1 1
Apparatus trolley 1 1
C arm 1 1
Pulse oximeter 2 1
Ventilator 1 0
Cystoscope 0 0
Diagnostic Laparoscope 2 2
Gastro scope 0 0
Hysteroscope 0 0
Auto mist 0 0
Video calposcopy 0 0
Cautery 1 1
Defibrillator 1 1
Boyel’s Apparatus 1 1
Multipara Monitor 1 1
Diathermy 0 0
Crash cart 0 0
ICU
ECG Machine 1 1
Multi-Para Monitor 3 3
Defibrillators 2 2
Crash cart 0 0
Ventilator 1 1
Syringe infusion pump 0 0
Volumetric pump 0 0
Blood / infusion warmer 0 0
Pulse oximeter 1 0
Transport monitor 0 0
Glucometer 1 1
Suction Machine 1 1
CSSD
Incubator (for test vials) 0 0
Ultrasonic cleaner / washer unit 0 0
46 | P a g e
ETO sterilizer 0 0
Dry heat sterilizer – hot air
Owen 0 0
Ultrasonic cleaner – single tank 0 0
Auto. Steam sterilizer 3 3
Rotary sealing machine 0 0
Physiotherapy
ECB pulse controlled ergo meter 0 0
body wave therapy unit 0 0
CPM machine 0 0
Trans-coetaneous electrical
nerve stimulator 1 1
Mobile ultrasound therapy unit 1 1
Standard tilt table for
physiotherapy 0 0
Microcontroller stimulator 0 0
Short wave diathermy unit 1 1
Electrical stimulator 1 1
Blood Bank
Plasma expresser 0 0
Refrigerated centrifuge 1 1
plasma freezer 0 0
Laminar air flow – clean zone
unit
0 0
Platelet agitator incubator 0 0
Blood bank refrigerator 4 3
Water bath shaker (thawing
bath) 1 1
Hi-speed cold centrifuge 0 0
Blood warming / thawing bath 1 1
binocular microscope 1 1
Microprocessor based centrifuge 0 0
Automated immunoassay
analyzer 0 0
Micro typing system (blood
grouping etc) 0 0
Plasma snap freezer 0 0
HB analyzer 1 1
Flash steam sterilizer 0 0
Blood bag tube sealer 1 1
Blood collection monitor 2 2
Plasma thawing bath 0 0
47 | P a g e
OPD Stethoscope 20 20
Sphygmomanometer 20 20
X-ray View box 20 20
Thermometer 4 4
Weighing Machine (Adult) 7 7
Weighing Machine (Paed) 2 2
Screen 4 4
Wards(Gen) Stethoscope 3 0
Sphygmomanometer 3 0
X-ray View box 2 0
Thermometer 1 1
Weighing Machine 2 2
Crash Cart 0 0
Medicine/Dressing Trolley 1 1
Emergency
ECG 1 1
Stethoscope 2 2
Sphygmo 2 2
Thermometer 2 2
Pulse oximeter 1 1
Syringe pump 0 0
Crash cart 0 0
Defibrillator 1 1
Multipara monitor 3 3
Drug/Dressing Trolley 2 2
X-ray view box 0 0
Suction Apparatus 1 1
Nebulizer 2 2
Glucometer 2 2
48 | P a g e
RECOMMENDATIONS
49 | P a g e
INFRASTRUCTURE
Grab bars, safety belts on stretchers and wheelchairs, alarm system and fire safety devices should
be available.
Up-to-date drawing, layouts and fire escape route needs to be maintained.
Florescent strips in the stairs should be made available.
Fire alarm system needs to be available in every department and floors of the hospital..
CCTV camera need to be installed at all areas of hospital for security reasons and a notice for the
same is to be displayed.
The sufficient number of toilets for patient and visitors need to be available .The broken taps,
seepage on walls, drainage issues in commodes, etc. need to be repaired. The provision of
dedicated toilets for the differently able people should be available.
The alternative source of water need to be arranged for dealing with the shortage of water.
Biomedical Waste segregation is not as per the Biomedical Waste Handling Rules 2016 and foot operated bins with Biohazard Symbol needs to be available at all places.
Mortuary Chamber area needs to be maintained marked and nearby area of the Mortuary are is very dirty. Cow was sitting in front of the unit.
Hand Railing needs to be available on the Ramps
Equipment needs to be calibrated and AMC.
Red Bulbs needs to be available on the door of digital X-ray room that indicated Work/X-ray is going on in imaging department.
Condemn Equipment area needs to be demarcated maintained accordingly.
Sterilization Room area needs to be demarcated like Recieving area, Sterilization Area, Storage Area, Issue area etc.
Zoning needs to be defined in OT, ICU and NBSU.
All Signages needs to make bilingual (English and Local Language).
All the Sanctioned posts need to be filled up. Required posts like Speciality Doctors, Surgeons, Medical Officer, Nurses, Radiologist, Dietician, Medical Records Technician, infection control nurse, quality manager, CSSD technician, ANM, OT technician, security staffs needs to be included in the sanctioned posts.
The hospital needs to be complying with the necessary statutory & regularity requirements (except PNDT). All other relevant statutory requirement like biomedical waste handling rules (under renewal), building occupancy certificate, approved fire exit plan etc should be complained.
50 | P a g e
1. EMERGENCY DEPARTMENT
Triage area needs to be demarcated in Emergency Department.
Emergency Signage should be visible from the road with proper lighting and signs.
Doctors name and contact number should be posted at all times in the emergency room.
The HCO needs to be established the System to review all imaging by a radiologist within 24 hours.
Written Clinical Protocol on Commonly seen in Emergency needs to be available.
Procedure for receiving and triage needs to be defined and documented.
Procedure for Disaster Management needs to be defined and documented.
Initial assessment of the patient should be done in proper format.
Nurse’s initial assessment needs to be carried out.
Outcome indicators such as: Time for initial assessment of emergency patient, No. of Patients returned to emergency within 72 Hrs.
2. AMBULANCE
Required Medicines needs to be available in the ambulance.
Policy and procedures for ambulance services needs to be defined & documented.
Medication and equipment checklist needs to be maintained in the Ambulance.
Infection control practices should be followed properly.
Outcome indicators such as: Monitoring of response time for ambulance services, Monitoring of availability and utilization of ambulance services needs to be done.
3. REGISTRATION &OUT PATIENT DEPARTEMENT
Enquiry counter needs to be demarked in OPD.
51 | P a g e
UHID needs to be generated for all patients.
Separate registration should be done for Old and New Patients.
Procedure needs to be defined and documented to admission or refer of Patient from OP Chamber
OPD utilization needs to be monitored.
Recording Waiting time for patients in OPD needs to be monitored.
4. OPERATION THEATRE
Window A/c is being used in OT and there was no evidence of regular cleaning of a/c filters and air
culture record thus, having convenient pockets for microbial growth.
The temperature, humidity of the OT was not as per the requirement. i.e. 55% humidity, 21 0c
Operating room committee needs to be operational; minutes needs to be recorded and retained.
List of Surgeons with contact details needs to be displayed.
Policies and procedure for OT needs to be developed & made available.
Policy for anaesthesia should be documented & made available.
The surgery and anaesthesia consent needs to be standardized and present.
Patient undergoing surgery should be screened for HIV. HIV consent and HIV test of patient
undergoing surgery needs to be documented.
Plan of care needs to be defined and documented.
Transfer Criteria needs to be defined for shifting of patient from post-operative ward.
Post operative monitoring needs to be carried out.
Look alike, sound alike medicines should be stored separately.
Multi-use open vials should be label of date of opening and expiry
High risk medicines should be stored separately.
Monitoring needs to be done for patient during surgical procedure (at minimum heart rate, cardiac
rhythm, and respiratory rate, blood pressure, and oxygen saturation and level sedation) needs to be
documented.
Biomedical Waste management practices needs to follow properly in Inside the OT.
Defined criteria to decide shifting of patient from post-operative ward is not being followed.
Policy for Sedation, Surgery & Pain management needs to be documented & made available.
Material Safety Data sheet (MSDS) needs to be defined and displayed.
Infection control practices needs to be followed properly.
Surveillance of OT should be carried out regularly.
52 | P a g e
Quality Assurance programme needs to be documented.
Number of OT instruments counted before and after operation needs to be documented.
Pre-operative checklist needs to be followed in OT.
Bio-medical waste management practices needs to be followed properly. Quality Indicators were
not monitored namely; % of modification of anaesthesia plan, % of unplanned ventilation following
anaesthesia, % of adverse anaesthesia events, anaesthesia related mortality rate, % of unplanned
return to OT, % of rescheduling of surgeries, % of cases where the organisation’s procedure to
prevent adverse events like wrong site, wrong patient, wrong surgery have been adhered to, % of
cases who received appropriate prophylactic antibiotics within the specified time frame, OT
utilization was not monitored, Re Exploration rate and Re scheduling of surgeries.
5. PHARMACY STORE
Medicines need to be stored in a condition as described by manufacturer. Refrigerator used for
storing medicine should have a temperature monitoring system. The temperature of the
refrigerator should be recorded at-least 3 times a day.
Receiving area, Segregation area and storing area needs to be demarcated.
Inside refrigerator, location of storing various medicines should be specified.
Look alike and sound alike (LASA) medicines need to be identified and a list should be
available.
List of all hazardous materials stored in pharmacy needs to be available. MSDS for each
hazardous material are not kept available for ready reference of staff.
Staffs need to be trained on what to do if temperature of refrigerator is not within the defined
limit. (Time limit within which medicines to be shifted to another refrigerator)
High risk medicines need to be identified and a list should be available.
Recall Policy needs to be documented and followed.
Narcotics need to be stored under double lock and key.
Staff at pharmacy needs to be trained on practice of preventing expiry of medicine (FIFO
method, identifying near expiry medicine, and identifying medicine with short shelf life).
The outcome indicators like Percentage of stock out of drugs, Percentage of stock out of emergency
drugs, Percentage of stock out of V and E category drugs, Percentage of medicines procured through
local purchase need to be monitored.
53 | P a g e
6. AUTOCLAVE FACILITY
There should be a separate department for carrying out sterilization activities for the hospital.
The area layout should have well demarcated zones, which includes
Collection zone (or soiled zone) where the soiled and used items should be received and
sorted.
Cleaning zone where washing, cleaning and packaging of items should be done.
Sterilization zone where the actual sterilization of packages should be done.
Storage – This can be considered a part of sterilization zone, where sterilized packs are
stored till its distribution.
The protocol for washing of equipments, Procedure of sterilization (separate SOP for each type
of sterilization, Procedure of cleaning, Procedure of packing, Procedure of disinfection,
Procedure of storage and issue, Safety precautions and guidelines, Processing required before
reuse of the items, need to be developed.
The bacteriological/chemical surveillance test needs to be performed for sterilization
authenticity & validation.
The department should maintain record of all validation test reports.
Adequate no. of Racks needs to be present in the department
Hypochlorite solution should be present for decontamination of equipments.
Transport trolley needs to be available inside the unit.
Biological and bowie-dick Validation tests need to be done for autoclave. The validation tests
which include bowie-dick and Biological spore test – at-least weekly basis for each equipment.
Procedure of recalling items in case of sterilization breakdown needs to be defined and
documented.
7. ENGINEERING AND MAINTENANCE
Designated person needs to be appointed for handling the medical equipments related issues.
There should be a safety committee which should include representatives from facility
management, clinicians, administrator, nursing and paramedical staff to coordinate
development, implementation and monitoring of safety plans.
Regular inspection of fire extinguisher need to be done and the organization should identify
their potential emergencies and should prepare for disasters like earthquake, major fire, flood,
etc and should maintain policies for disaster management.
54 | P a g e
The periodic facility inspection needs to be carried out to identify the environmental hazards
and risk.
Response time needs to be monitored and documented...
Number of variations observed during mock drills needs to be monitored.
8. MEDICAL RECORD DEPARTMENT
There should be a designated person i.e. medical record technician for taking care of medical
records.
The records should have all relevant forms & formats like Nurses Records, Initial assessment
form, etc.
There should be unique identifier at each page, policy authorizing medical record entries in
medical record.
Entry in the medical record should be named, signed, dated and timed.
The policy for retrieval of the records and record retention needs to be developed. Deficiency
checklist should be followed.
The outcome indicators like % of missing records, % of records with ICD, etc needs to be monitored.
9. NBSU (NEW BORN STABILISATION UNIT)
Fumigation practice need to replace with terminal cleaning by 1% sodium hypo-chloride (any other
disinfectant) and proper cleaning and disinfection practices need to be follow as per CDC guidelines.
The floor disinfectant need to be replaced with sodium hypo-chloride.
The swab culture from different areas of NBSU like patient bed, floor, walls etc need to be taken
regularly for the monitoring of microbial flora and if any microbial growth found in NBSU the
appropriate measure need to be taken and corrective action taken need to be documented.
Policy for initial assessment and re-assessment of patient needs to be documented.
Reassessment frequency needs to be defined and followed by the staff.
Nutritional screening of the patient need to be done by qualified dietician .
The staff of NBSU needs to be trained about care bundles to be followed for infection control and
policies related to patient care in NBSU.
The continuous monitoring of the patient condition need to be done and same need to be reflected on
patient records.
All the outcome indicators related to NBSU need to be monitored and reviewed on regular basis.
55 | P a g e
The admission and discharge criteria for NBSU are needs to be defined & documented.
Infection control & quality assurance programme for NBSU needs to be established.
Hospital Acquired Infection rate needs to be monitored and action taken report needs to be
documented.
10. WARDS
Adequate privacy arrangement for patient (especially applicable in multi-bed wards)
need to be made.
There should be a Separate or segregated storage area for clean and dirty supplies.
Reporting of adverse patient events should be done.
Nurse initial assessment need to be carried out. Nurse’s medication chart should be
implemented.
The time frame for initial assessment of the patient should be defined and the assessment
conducted by the doctors should be counter signed by in-charge clinician.
All emergency medicines should be available as per defined quantity and checked
regularly.
The blood transfusion consent needs to be taken. The transfusion record must be
prepared and the reporting of transfusion reaction need to be done.
Patients should be regularly reassessed by treating physician and reassessment should
be documented.
The content of discharge summary should be defined.
Medications errors, near miss events should be identified and recorded.
Quality indicators need to be monitored. This are-
Percentage of Patients receiving high risk medications developing adverse drug event.
Percentage of admissions with adverse drug reactions (s) (Adverse drug reactions per
100 separations)
Incidence of medication errors (Medication errors per patient days)
Appropriate handovers during shift change (To be done separately for doctors and
nurses per patient per shift).
Incidence of hospital associated pressure ulcers after admission (Bed sore per 1000
patient days)
56 | P a g e
Incidence of falls
Catheter associated Urinary tract infection rate, Incidence of blood body fluid exposures,
Incidence of needle stick injuries
11. HUMAN RESOURCE DEPARTMENT
There should be a dedicated department for dealing with the staff and training and
development related activity.
There should be a continuous training programme when job responsibilities changes and
when new equipment gets installed.
HR induction and training programme should be documented after joining.
Employee’s satisfaction survey needs to be done and analysed.
The training Need Analysis of the employee needs to be conducted.
There should be feedback mechanisms for improvement of training and development
programme.
12. KITCHEN
The space should be sufficient to effectively carry out all functions of kitchen. The sub-areas within kitchen should comprise of following,
o Raw material receiving and storage area (includes cold storage)
o Preparation area – for preparing raw materials (peeling, cutting, slicing etc.) before cooking
o Cooking area – where the actual cooking takes place
o Special diet area – here special diets such as soft diet, diabetic diet etc. are prepared
o Servicing area – here the plates are prepared with food and laid on
o Washing area – for pots, cutleries and trolleys
o Garbage collection area
o Administrative areas
Patient and family members should be educated regarding the limitations of diet.
There should be a proper cleaning schedule for the kitchen.
There should a dedicated dietician for diet sheet, nutritional and food evaluation.
Infection control practices needs to be followed in appropriate manner.
Policies and Procedures for Kitchen/Dietary department Needs to be developed, documented and followed by the staffs.
13. RADILOGY AND IMAGING DEPARTMENT
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Red Bulbs needs to be available on the door of digital X-ray room that indicated Work/X-ray is going on in imaging department.
Gonad shield & Thyroid shield needs to be available.
TLD badge for staff is should be available.
Type & Site approval for X-Ray should be available
Procedure should be defined and documented for checking of tubes to monitor leakage of radiation.
Procedure of regular examination of technicians exposed to radiation needs to be defined and
documented.
Surveillance of imaging results needs to be done.
Safety & Quality programme for the department needs to be monitored viz. No. of reporting
errors/1000 investigations, % of Re-dos, % of reports co relating with clinical diagnosis & %
adherence to safety precautions by employees working in diagnostics.
14. ICU
Note: Well Equipped ICU and ICCU is Available but Lack of Manpower such as: Specialist
Doctors, Nurses, Anesthetics needs to be Sectioned and appointed for functioning the
department.
15. INFECTION CONTROL
The Hospital should adheres laundry and linen management processes.
The HCO should adhere to kitchen sanitation and food handling issues of Outsource Kitchen.
The HCO should Mortuary practices in appropriate manner.
There should be appropriate engineering control to prevent infections.
Surveillance for infection control should be regularly carried out. The frequency of surveillance in
high risk areas should be higher. Surveillance must include both, patient surveillance and
environmental surveillance.
Staff should use appropriate hand hygiene guidelines. These guideline includes, when wash hands,
what kind of hand washing is required in different situations, proper method of hand washing (6
point or 9-point hand wash) and other measures to keep hand hygienic.
The disinfectant which is being used in the hospital should undergo sterility test.
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Regular validation tests for sterilization should be followed.
The outcome indicators must be used to determine effectiveness of infection control measures.
These are Catheter-associated urinary tract infection rates, Ventilator associated pneumonia, and
Catheter linked blood stream infections, surgical site infections etc needs to be monitored.
16. LINEN/LAUNDARY
The department should be designed as per the desired layout like receiving, segregation area, sluicing,
washing, drying, calendaring etc.
Sufficient number of washing machines needs to be purchased.
The laundry and linen practices need to be followed; the infected and soiled linens need to be washed
separately.
There segregation of soiled and contaminated linen needs to be done.
The disinfectant for washing contaminated linens should be arranged.
17. LABORATORY
Separate Sample Collection area needs to be available in the Laboratory.
HAZMAT Kit needs to be available in the department.
Lab surveillance should be done on regular basis.
Training needs to be conducted & Laboratory staff should be aware about safety precautions while
handling samples.
Critical Result should be defined and documented in laboratory department.
Turn-around Time for Laboratory needs to be defined and monitored.
Temperature Monitoring of Refrigerator needs to be done.
Outcome indicator needs to be monitored such as:
Number of reporting errors per 1000 investigations.
% of adherence to safety precautions.
% of Redo’s
18. BIOMEDICAL ENGINEERING DEPARTMENT
A dedicated department for biomedical engineering needs to be earmarked.
A dedicated Manpower (BME) should be made available.
All equipments in the hospital need to be calibrated.
Equipments files are to be maintained as per defined checklist.
Appropriate Asset code for all equipments need to be developed.
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Response time for complaints needs to be monitored and analysed.
19. LABOUR ROOM
Separate areas for septic and aseptic deliveries needs to be demarcated in Labor Room.
Department’s layout needs to be demarcated as per functions via receiving area, Examination room,
Pre-delivery room, delivery room, post delivery observation room, Nursing station, dirty utility and
clean utility, area for medication and injection preparation, Pre-Eclampsia area etc.
Separate Changing Room needs to be available for Doctors and Nurses.
Scope of high risk obstetrics care needs to be displayed.
Documented Obstetrics & Gynaecology policy needs to be available.
Staff should be trained on the policies.
Staff should be trained on infection Control practices.
Quality indicators like maternal death rate, fetal deaths, incidence of unexpected complications needs
to be monitored.
Incidence of theft/swapping babies needs to be monitored.
20. BLOOD BANK
Full time qualified Blood Bank In-Charge needs to be available to manage the blood
collection/distribution department.
Blood bank technician needs to be available in this department.
Transfusion reaction is needs to be capturing. Analysis of transfusion reactions.
Separate counseling section needs to be present in this unit.
Screening of donors prior to blood donation needs to be done in appropriately.
List of department staffs should be displayed in this unit.
Temperature of the refrigerator needs to be monitored and recorded. .
Quality Indicators needs to be monitored viz. % of transfusion reactions, % of wastage of blood &
blood products, Turnaround time for issue of Blood & Blood components.
21. BIOMEDICAL WASTE MANAGEMENT
Signage for temporary storage area for biomedical waste needs to be available.
Foot operated BMW bins should be available in all required patient care areas.
Signage for Bio-hazard needs to be displayed.
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Documented policy for BMW management should be developed, documented and available.
Segregation of BMW at point of Generation needs to be done at all areas.
Separate route needs to be defined for transportation of waste from the general traffic area.
Bio-medical waste management audit needs to be carried out.
22. SECURITY
Exit plan for fire & non fire emergencies needs to be available.
Systemic telephone connectivity from Emergency Room needs to be available.
Separate security guard should be available for emergency room.
Separate security guard should be available for labour Room.
Documented policies and procedures needs to be developed and available for hospital safety,
security, civil disturbances, emergency codes, disaster management, fire and non fire management.
Outgoing items should be checked and entered on a register.
Monitoring of security related incidents and thefts needs to be done in the hospital premises.
23. HOUSEKEEPING DEPARTMENT
Basic facilities like (Toilet/Drinking water/change room) should be available for housekeeping staff.
Daily Cleaning & Master cleaning schedule should be available and followed.
Material Safety Data Sheet should be available and displayed.
Staffs needs to be aware about preparation of cleaning solutions.
Pest control method should be practiced and documented.
Effectiveness of housekeeping services needs to be monitored.
24. MORTUARY
There should be a dedicated mortuary chamber for keeping dead bodies with safety arrangements.
The surrounding of the mortuary should be clean.
Mortuary Chamber area needs to be marked and should be Clean. Fire detection/Fire fighting system such as: Fire Extinguisher needs to be installed in this unit.
Temperature should be monitored on regular basis.
25. STORE
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Layout of the store needs to be demarcated appropriate. There should be dedicated receiving, quality
check, labeling, Store and Issue area needs to be identified.
Adequate Racks needs to be available in Store.
Frequently used items needs to be arranged and located in most easily accessible area.
Monitoring of indicators like percentage of local purchase, Stock turnover details, incidence of
variation from the procurement process and percentage of goods rejected before preparation of GRN,
needs to be done.
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SELF ASSESSMENT TOOLKIT
Elements
Scores
(0/ 5/ 10)
TOTAL SCORE OF CHAPTER
3.7
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)
3.21
AAC.1: The organization defines and displays the services that it can provide.
a The services being provided are clearly defined. 5
b The defined services are prominently displayed. 5
c The staff is oriented to these services. 5
AVERAGE SCORE 5
AAC.2: The organization has a documented registration, admission and transfer process.
a. Process addresses emergency patients.
registering and admitting out-patients, in-patients and 5
b. Process addresses mechanism for transfer or referral of patients who do not match the organizational resources.
5
AVERAGE SCORE 5
AAC.3 Patients cared for by the organization undergoes an established initial assessment.
a. The organization defines the content of the assessments for the out-patients, in- patients and emergency patients.
5
b. The organization determines who can perform the assessments. 5
c. The initial assessment for in-patients is documented within 24 hours or earlier. 5
d. Initial assessment of inpatients includes nursing assessment which is done at the time of admission and documented.
5
AVERAGE SCORE 5
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AAC.4 Patient care is continuous and all patients cared for by the organization undergo a regular reassessment.
a. During all phases of care, there is a qualified individual identified as responsible for the patient’s care who coordinates the care in all the settings within the organization.
0
b. All patients are reassessed at appropriate intervals. 0
c. Staff involved in direct clinical care document reassessments. 5
d. Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.
5
AVERAGE SCORE 2.5
AAC.5 Laboratory services are provided as per the scope of the hospital’s services and laboratory safety requirements.
a. Scope of the laboratory services are commensurate to the services provided by the organization.
0
b. Procedures guide collection, identification, handling, safe transportation, processing and disposal of specimens.
5
c. Laboratory results are available within a defined time frame and critical results are intimated immediately to the concerned personnel.
0
d. Adequately trained personnel perform, supervise & interpret the investigations. 5
e. Laboratory personnel are trained in safe practices and are provided with appropriate safety equipment/ devices.
5
f. Laboratory tests not available in the organization are outsourced. 0
AVERAGE SCORE
2.5
AAC.6 Imaging services are provided as per the scope of the hospital’s services and established radiation safety programme.
a. Scope of the imaging services are commensurate to the services provided by the organization.
5
b. Imaging Signages are prominently displayed in all appropriate locations. 5
c. Imaging results are available within a defined time frame and critical results are intimated immediately to the concerned personnel.
0
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d. Imaging personnel are trained in safe practices and are provided with appropriate
safety equipment/ devices.
0
AVERAGE SCORE 2.5
AAC.7 The organization has a defined discharge process.
a. Process addresses discharge of all patients including Medico-legal cases and patients leaving against medical advice.
5
b. A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice).
5
c. Discharge summary contains the reasons for admission, significant findings, investigation results, diagnosis, procedure performed (if any), treatment given and the patient’s condition at the time of discharge.
0
d. Discharge summary contains follow up advice, medication and other instructions in an understandable manner.
0
e. Discharge summary incorporates instructions about when and how to obtain urgent care.
0
f. In case of death the summary of the case also includes the cause of death. 5
AVERAGE SCORE 2.5
Chapter 2: CARE OF PATIENTS (COP)
3.4
COP.1: Care of patients is guided by accepted norms & practice.
a The care and treatment orders are signed and dated by the concerned doctor. 5
b Critical Practice Guidelines are adopted to guide patient care wherever possible. 5
COP.2: Emergency services including ambulance are guided by documented procedures.
a Documented procedures address care of patients arriving in the emergency including handling of medico-legal cases.
0
b Staff should be well versed in the care of emergency patients in consonance with the scope of the services of hospital.
5
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c Admission or discharge to home or transfer to another organization is also
documented.
5
d Ambulance is appropriately equipped. 5
e Ambulance(s) is manned by trained personnel. 0
AVERAGE SCORE 3
COP.3: Documented procedures define rational use of blood and blood products.
a Documented policies and procedures are used to guide the rational use of blood and blood products.
0
b Documented procedures govern transfusion of blood and blood products. 0
c The transfusion services are governed by the applicable laws and regulations. 0
d Informed consent is obtained for donation and transfusion of blood and blood products.
5
e Procedure addresses documenting and reporting of transfusion reactions. 5
AVERAGE SCORE 2
COP.4: Documented procedures guide the care of patients as per the scope of services provided by hospital in Intensive care and high dependency unit.
a Care of patients is in consonance with the documented procedures. 0
b Adequate staff and equipment are available. 5
AVERAGE SCORE 5
COP.5: Documented procedures guide the care of obstetrical patients as per the scope of services provided by hospital.
a The organization defines the scope of obstetric services. 0
b Obstetric patient’s care includes regular ante-natal checkups, maternal nutrition and post-natal care.
5
c The organization has the facilities to take care of neonates. 5
AVERAGE SCORE 3.3
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COP.6: Documented procedures guide the care of pediatric patients as per the scope of services provided by hospital.
a The organization defines the scope of its pediatric services. 0
b Provisions are made for special care of children by competent staff. 5
c Patient assessment includes detailed nutritional, growth, and immunization assessment.
0
d Procedure addresses identification and security measures to prevent child/ neonate abduction and abuse.
0
e The children’s family members are educated about nutrition and immunization 5
AVERAGE SCORE 2
COP.7: Documented procedures guide the administration of anesthesia.
a. There is a documented policy & procedure for the administration of anesthesia. 5
b. All patients for anesthesia have a pre-anesthesia assessment by a qualified/ trained anesthetist.
10
c. The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented.
5
d. An immediate preoperative re-evaluation is documented. 0
e. Informed consent for administration of anesthesia is obtained by the anesthetist. 0
f. Anesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and patency and End tidal carbon dioxide.
5
g. Each patient’s post-anesthesia status is monitored and documented. 0
h. Defined criteria are used to transfer the patient from the recovery area. 0
I. Adverse anesthesia events are recorded and monitored. 0
AVERAGE SCORE 2.7
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COP.8: Documented procedure guides the care of patients undergoing surgical procedures.
a. Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery.
5
b. An informed consent is obtained by a surgeon prior to the procedure. 5
c. Documented procedure addresses the prevention of adverse events like wrong site, wrong patient and wrong surgery.
0
d. Qualified persons are permitted to perform the procedures that they are entitled to perform.
10
e. The operating surgeon documents the operative notes and post-operative plan of care.
10
f. The operation theatre is adequately equipped and monitored for infection control practices.
5
g. Patients, personnel and material flow conform to infection control practices. 5
AVERAGE SCORE
5.7
Chapter 3: MANAGEMENT OF MEDICATION (MOM)
1.8
MOM.1: Documented procedures guide the organization of pharmacy services and usage of medication.
a Documented procedure shall incorporate purchase, storage, prescription and dispensation of medications.
0
b Documented procedures address procurement and usage of implantable prostheses.
0
AVERAGE SCORE 0
MOM.2: Documented policies & procedures guide the storage of medications.
a Documented policies and procedures exist for storage of medication 0
b Medications are stored in a clean, safe and secure environment, and incorporate manufacturer’s recommendations.
5
c Sound alike and look alike medications are stored separately. 0
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d Beyond expiry date medications are not stored/used. 5
e List of emergency medicines is defined, stored, and available all the time. 0
AVERAGE SCORE 2
MOM.3: Documented procedures guide the prescription of medications.
a The organization determines who can write orders. 5
b Orders are written in a uniform location in the medical records. 5
c Medication orders are clear, legible, dated and signed. 0
d The organization defines a list of high risk medication & process to prescribe them. 0
AVERAGE SCORE 2.5
MOM.4: Policies & procedures guide the safe dispensing of medications.
a Medications are checked prior to dispensing, including the expiry date to ensure that they are fit for use.
5
b High risk medication orders are verified prior to dispensing. 0
AVERAGE SCORE 2.5
MOM.5: There are defined procedures for medication administration.
a Medications are administered by trained personnel. 5
b Prior to administration medication order including patient, dosage, route and timing are verified.
5
c Prepared medication is labeled prior to preparation of a second drug. 5
d Medication administration is documented. 5
e A proper record is kept of the usage, administration and disposal of narcotics and psychotropic medications.
0
AVERAGE SCORE
4
MOM.6: Adverse drug events are monitored.
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a Adverse drug events are defined & monitored. 0
b Adverse drug events are documented and reported within a specified time frame. 0
AVERAGE SCORE
0
MOM.7: Documented policies & procedures govern usage of radioactive drugs.
a Documented policies and procedures govern usage of radioactive drugs. NA
b Policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs.
NA
AVERAGE SCORE NA
Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE) 4.6
PRE.1: Patient rights are documented displayed and support individual beliefs, values and involve the patient and family in decision making processes.
a. Patient rights include respect for personal dignity and privacy during examination, procedures and treatment.
5
b. Patient rights include protection from physical abuse or neglect. 0
c. Patient rights include treating patient information as confidential. 0
d. Patient rights include obtaining informed consent before carrying out procedures. 5
e. Patient rights include information on how to voice a complaint.
5
f. Patient rights include information on the expected cost of the treatment. 10
g. Patient has a right to have an access to his / her clinical records. 5
AVERAGE SCORE 4.2
PRE.2: Patient and families have a right to information and education about their healthcare needs.
a Patients and families are educated on plan of care, preventive aspects, possible complications, medications, the expected results and cost as applicable.
5
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b Patients are taught in a language and format that they can understand. 5
AVERAGE SCORE 5
Chapter 5: HOSPITAL INFECTION CONTROL (HIC) 5
HIC.1: The hospital has an infection control manual, which is periodically updated and conducts surveillance activities.
a It focuses on adherence to standard precautions at all times. 5
b Cleanliness and general hygiene of facilities will be maintained and monitored. 5
c Cleaning and disinfection practices are defined and monitored as appropriate. 5
d Equipment cleaning, disinfection and sterilization practices are included. 5
e Laundry and linen management processes are also included 0
AVERAGE SCORE 4
HIC.2: The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees.
a Hand hygiene facilities in all patient care areas are accessible to health care providers.
5
b Adequate gloves, masks, soaps, and disinfectants are available and used correctly.
5
c Appropriate pre and post exposure prophylaxis is provided to all concerned staff members.
5
AVERAGE SCORE
5
HIC.3: Bio-medical Waste (BMW) management practices are followed.
a The hospital is authorized by prescribed authority for the management and handling of Bio-Medical Waste.
5
b Proper segregation and collection of Bio-Medical Waste from all patient care areas of the hospital is implemented and monitored.
5
c Bio-Medical Waste treatment facility is managed as per statutory provisions (if in- house) or outsourced to authorized contractor(s).
10
d Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.
5
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e Appropriate personal protective measures are used by all categories of staff
handling Bio-Medical Waste.
5
AVERAGE SCORE
6
Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)
2.5
CQI.1: There is a structured quality improvement, patient safety and continuous monitoring programme in the organization.
a There is a designated individual for coordinating and implementing the quality improvement and patient safety programme.
0
b The quality improvement and patient safety programme is a continuous process and updated at least once in a year.
0
c Hospital Management makes available adequate resources required for quality improvement and patient safety programme.
0
AVERAGE SCORE
0
CQI.2: The organization identifies key indicators to monitor the structures, processes and outcomes which are used as tools for continual improvement.
a Organization may identify the appropriate key performance indicators in both clinical and managerial areas.
5
b These indicators shall be monitored. 5
AVERAGE SCORE
5
Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM) 4.6
ROM.1: The responsibilities of the management are defined
a The organization has a documented Organogram. 5
b The organization is registered with appropriate authorities as applicable. 5
c The organization has a designated individual(s) to oversee the hospital wide quality and safety programme.
5
AVERAGE SCORE 5
ROM.2: The organization is managed by the leaders in an ethical manner.
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a The management makes public the mission statement of the organization. 0
b The leaders/management guides the organization to function in an ethical manner. 5
c The organization discloses its ownership. 5
d The organization's billing process is accurate and ethical. 5
AVERAGE SCORE 3.7
ROM.3: The organization has set up multi-disciplinary committees to oversee specific areas of quality and patient safety.
a These committees include Quality and Safety, Infection Control, Pharmacy and Therapeutics, Blood Transfusion, and Medical Records.
5
b The membership, responsibilities, and periodicity of meetings shall be defined. 5
AVERAGE SCORE 5
Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS) 4.3
FMS.1: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.
a Internal and External Signage’s shall be displayed in a language understood by the patients and families.
5
b Maintenance staff is contactable round the clock for emergency repairs. 5
c There the hospital has a system to identify the potential safety and security risks including hazardous materials.
5
d Facility inspection rounds to ensure safety are conducted periodically. 5
e There is a safety education programme for relevant staff. 5
AVERAGE SCORE 5
FMS.2: The organization has a program for clinical and support service equipment management.
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a The organization plans for equipment in accordance with its services. 5
b There is a documented operational and maintenance (preventive and breakdown) plan.
5
AVERAGE SCORE 5
FMS.3: The organization has provisions for safe water, electricity, medical gas and vacuum systems.
a Potable water and electricity are available round the clock. 5
b Alternate sources are provided for in case of failure and tested regularly. 5
c There is a maintenance plan for medical gas and vacuum systems. 5
AVERAGE SCORE 5
FMS.4: The organization has plans for fire and non-fire emergencies within the facilities.
a The organization has plans and provisions for detection, abatement and containment of fire and non-fire emergencies.
0
b The organization has a documented safe exit plan in case of fire and non-fire emergencies.
0
c There is a maintenance plan for medical gas and vacuum systems. 5
d Mock drills are held at least twice in a year. 5
AVERAGE SCORE 2.5
Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)
4.7
HRM.1: The organization has staffing commensurate with patient care needs.
a The mix of staff is commensurate with the volume and scope of the services. 5
b Staff recruitment process is well defined. 5
AVERAGE SCORE 5
HRM.2: There is an ongoing programme for professional training and development of the staff.
a All staff is trained on the relevant risks within the hospital environment. 5
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b Staff members can demonstrate and take actions to report, eliminate/ minimize
risks.
5
c Training also occurs when job responsibilities change/ new equipment is introduced.
0
AVERAGE SCORE
3.3
HRM.3: The organization has a well-documented disciplinary and grievance handling procedure.
a A documented procedure with regard to these is in place. 5
b The documented procedure is known to all categories of employees in the organization.
5
c Actions are taken to redress the grievance. 5
AVERAGE SCORE
5
HRM.4: The organization addresses the health needs of the employees
a Health problems of the employees are taken care of in accordance with the organization’s policy.
0
b Occupational health hazards are adequately addressed. 5
AVERAGE SCORE
2.5
HRM.5: There is documented personal record for each staff member
a Personal files are maintained in respect of all employees. 10
b The personal files contain personal information regarding the employee’s qualification, disciplinary actions and health status. The disciplinary procedure is in consonance with the prevailing laws.
5
AVERAGE SCORE
7.5
Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS) 2.9
IMS.1: The organization has a complete and accurate medical record for every patient
a Every medical record has a unique identifier. 5
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b Organization identifies those authorized to make entries in medical record. 0
c Every medical record entry is dated and timed. 0
d The author of the entry can be identified. 5
e The contents of medical record are identified and documented. 0
AVERAGE SCORE
2
IMS.2: The medical record reflects continuity of care.
a The record provides an up-to-date and chronological account of patient care. 0
b The medical record contains information regarding reasons for admission, diagnosis and plan of care.
0
c Operative and other procedures performed are incorporated in the medical record. 5
d The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel.
0
e In case of death, the medical records contain a copy of the death certificate indicating the cause, date and time of death.
5
f Care providers have access to current and past medical record. 5
AVERAGE SCORE 2.5
IMS.3: Documented policies and procedures are in place for maintaining confidentiality, integrity and security of records, data and information.
a a. Documented procedures exist for maintaining confidentiality, security and integrity of information.
5
b Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient's authorization.
5
AVERAGE SCORE 5
IMS.4: Documented procedures exist for retention time of records, data and information.
a Documented procedures are in place on retaining the patient’s clinical records, data and information.
5
b The retention process provides expected confidentiality and security. 0
c The destruction of medical records, data and information is in accordance with the laid down procedure.
0
AVERAGE SCORE
1.6
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PRIORITIZATION OF GAPS
SR.
NO
.
GAP STATEMENT ACTION REQUIRED RESPONSIB
ILITY
PRIORITY
MAJOR STUCTURAL GAPS
1. The hospital does not comply
with the necessary statutory &
regularity requirements (except
PNDT and Biomedical Waste
Management Licence, Vehicle
Registration Certificate for
Ambulance). All other relevant
statutory requirement like
Building occupancy certificate,
approved fire exit plan, Clinical
Establishment Act Certificate ,
& Type Approval for X-Ray
from AERB & License for
Blood Bank not available.
Relevant statutory
requirement like Building
occupancy certificate,
approved fire exit plan,
Clinical Establishment Act
Certificate, & Type Approval
for X-Ray from AERB &
License for Blood Bank need
to be acquired.
HIGH
2. All the Sanctioned posts are not
filled up. Required posts like
Specialty Doctors, Surgeons,
Medical Officer, EMO, Nurses,
Infection control Nurse,
Microbiologist, Blood Bank
officer, Chief Pharmacy officer
Administrative staff,
Radiologist, Dietician, Medical
Records Technician, quality
manager, CSSD technician, OT
, Housekeeping Staffs,
technician, Attendants , Servant
, security staffs are not included
in the Required sanctioned
posts & not filled.
All the Sanctioned posts are
not filled up. Required posts
like Specialty Doctors,
Surgeons, Medical Officer,
EMO, Nurses, Infection
control Nurse,
Microbiologist, Radiologist,
Dietician, Medical Records
Technician, quality manager,
CSSD technician, OT ,
Housekeeping Staffs,
technician, Attendants ,
Servant , security staffs are
needs to be included in the
Required sanctioned posts &
should be filled.
HIGH
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3. All Required Equipments Like
Crash Cart, Defibrillator,
Thermometer, Refrigerator,
TLD Badges, Gonad Shield,
Thyroid Shield, CPR kit, Skill
Kit, Oral Airways of Various
sizes , Syringe Pump Portable
X ray , Pulse Oximeter ,
Suction Machine, ECG
Machine, Glucometer, BP
apparatus, weighing machine ,
X-ray view box, Syringe pump,
Ventilator, Multi-Para-monitors
,Refrigerator with Temperature
Monitoring Device , Required
Equipments (Stethoscope,
Sphygnometer, suction
apparatus, defibrillator,
Monitor, Oxygen Cylinder) for
ambulance. and Required
Laboratory and Blood Bank
equipments not available in
required quantities.
All Required Equipments
Like Crash Cart,
Defibrillator, Thermometer,
Refrigerator, TLD Badges,
Gonad Shield, Thyroid
Shield, CPR kit, Skill Kit,
Oral Airways of Various
sizes , Syringe Pump
Portable X ray , Pulse
Oximeter , Suction Machine,
ECG Machine, Glucometer,
BP apparatus, weighing
machine , X-ray view box,
Syringe pump, Ventilator,
Multi-Para-monitors ,
Refrigerator with
Temperature Monitoring
Device , Required
Equipments (Stethoscope,
Sphygnometer, suction
apparatus, defibrillator,
Monitor, Oxygen Cylinder)
for ambulance. and Required
Laboratory and Blood Bank
equipments needs to be
available in required
quantities.
HIGH
4. Grab bars, safety belts on
stretchers and wheelchairs, and
fire safety devices not available.
Grab bars safety belts on
stretchers and wheelchairs,
alarm system should be
available.
HIGH
5. Up-to-date drawing, layouts and
fire escape route not
maintained.
Up-to-date drawing, layouts
and fire escape route needs to
be maintained.
HIGH
6. Florescent strips in the stairs not
available.
Florescent strips in the stairs
should be made available.
HIGH
7. Fire alarm system not available
in every department and floors
of the hospital.
Fire alarm system needs to be
available in every department
and floors of the hospital.
HIGH
8. CCTV camera not installed at
all areas of hospital for security
reasons and a notice for the
same not displayed.
CCTV camera need to be
installed at all areas of
hospital for security reasons
and a notice for the same is to
be displayed.
HIGH
9. The provision of dedicated
toilets for the differently able
people not available.
The provision of dedicated
toilets for the differently able
people should be available.
HIGH
78 | P a g e
10. Biomedical Waste segregation
is not as per the Biomedical
Waste Handling Rules 2016 and
foot operated bins with
Biohazard Symbol not available
at all places.
Foot operated bins with
Biohazard Symbol needs to
be available at all Patient care
places.
HIGH
11. Hand Railing needs not
available on the Ramps
Hand Railing needs to be
available on the Ramps.
HIGH
12. All the Medical Equipments of
the Hospital not calibrated and
AMC.
All the Medical Equipments
of the hospital needs to be
calibrated and AMC.
HIGH
13. Red Bulbs not available on the
door of digital X-ray room that
indicated Work/X-ray is going
on in Imaging department.
Red Bulbs needs to be
available on the door of
digital X-ray room that
indicated Work/X-ray is
going on in Imaging
department.
HIGH
14. Condemn Equipment area not
demarcated maintained
accordingly.
Condemn Equipment area
needs to be demarcated
maintained accordingly.
HIGH
15. Sterilization Room area not
demarcated like Receiving area,
Sterilization Area, Storage
Area, Issue area etc.
Sterilization Room area needs
to be demarcated like
Receiving area, Sterilization
Area, Storage Area, Issue
area etc.
HIGH
16. Zoning not defined in OT, ICU
and NBSU.
Zoning needs to be defined in
OT, ICU and NBSU.
HIGH
17. All Signages not available in
bilingual (English and Local
Language).
All Signages needs to be
made in bilingual (English
and Local Language)
HIGH
18. All required staffs such Nurses,
Doctors of the Emergency, OT,
ICU, NBSU and Ambulance
staffs not trained in BLS.
All required staffs such
Nurses, Doctors of the
Emergency, OT, ICU and
Ambulance staffs needs to be
trained in BLS.
HIGH
79 | P a g e
19. Narcotics drugs not stored
under double lock and key.
Narcotics drugs need to be
stored under double lock and
key.
HIGH
20. Adequate no. of Racks not
present in the Pharmacy, Store,
TSSU, Nursing Station and
Laundry department to store the
inventory.
Adequate no. of Racks needs
to be present in the
Pharmacy, Store, TSSU,
Nursing Station and Laundry
department to store the
inventory.
HIGH
EMERGENCY DEPARTMENT
21. Triage area not Demarcated in
Emergency Department
Triage area needs to be
Demarcated in Emergency
Department
HIGH
22. Emergency Signage not visible
from the road with proper
lighting and signs.
Emergency Signage should
be visible from the road with
proper lighting and signs.
HIGH
23. Doctors name and contact
number are not posted at all
times in the emergency
room.
There is a on call system to
review all imaging by a
radiologist within 24 hours.
Triaging of Patient not done
because no defined Triage
area in the department.
Written Clinical Protocol on
Commonly seen Emergency
not available.
No defined Procedure for
receiving and triage
available.
No defined Procedure for
Disaster Management.
Initial assessment of the
patient not done in proper
format.
Doctors name and contact
number should be posted
at all times in the
emergency room.
The HCO needs to be
established the System to
review all imaging by a
radiologist within 24
hours.
Triaging of Patient needs
to be done.
Written Clinical Protocol
on Commonly seen in
Emergency needs to be
available.
Procedure for receiving
and triage needs to be
defined and documented.
Procedure for Disaster
Management needs to be
defined and documented.
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80 | P a g e
Nurse’s initial assessment
was not being carried out.
Initial assessment of the
patient should be done in
proper format.
Nurse’s initial assessment
needs to be carried out.
24. No monitoring of Time for
initial assessment of
emergency patient.
No Monitoring of No. of
Patients returned to
emergency within 72 Hrs.
Outcome indicators such
as: Time for initial
assessment of emergency
patient, No. of Patients
returned to emergency within
72 Hrs.
LOW
AMBULANCE DEPARTMENT
25. All the Required Medicines not
available in the ambulance.
All the Required Medicines
needs to be available in the
ambulance.
HIGH
26. Policy and procedures for
ambulance services not
defined & documented.
Medication and equipment
checklist not maintained in
the Ambulance.
Infection control practices
not followed properly.
Policy and procedures for
ambulance services needs
to be defined &
documented.
Medication and
equipment checklist
needs to be maintained in
the Ambulance.
Infection control practices
should be followed
properly.
MEDIUM
27. Monitoring of response time
for ambulance services not
done
Monitoring of availability
and utilization of ambulance
services not done.
Outcome indicators such
as: Monitoring of response
time for ambulance services,
Monitoring of availability
and utilization of ambulance
services needs to be done.
LOW
REGISTRATION & OUT PATIENT DEPARTEMENT
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28. No Enquiry counter demarked
in OPD.
Enquiry counter needs to be
demarked in OPD.
HIGH
29. UHID is not generated
for all patients.
No separate registration
done for Old and New
Patients.
Procedure to admission
or refer of Patient from
OP Chamber is not
available.
UHID needs to be
generated for all patients.
Separate registration
should be done for Old
and New Patients.
Procedure needs to be
defined and documented
to admission or refer of
Patient from OP Chamber
MEDIUM
30. OPD utilization is not done
& monitored.
Recording Waiting time for
patients in OPD is not done.
OPD utilization needs to
be monitored.
Recording Waiting time
for patients in OPD needs
to be monitored.
LOW
OPERATION THEATRE
31. Window A/c is being used
in OT and there was no
evidence of regular cleaning
of a/c filters and air culture
record thus, having
convenient pockets for
microbial growth.
The temperature, humidity
of the OT was not as per the
requirement. i.e. 55%
humidity, 21 0c
Each operation room
needs to be monitored for
filter integrity, at-least
once in six month.
Regular environmental
surveillance for microbes
needs to done in each OT
and other areas to identify
forming of any colonies
of bacteria.
HIGH
32. The WHO surgical safety
checklist is not being
followed for patient.
Immediate pre-operative
check-up before wheeling in
Operating room
committee needs to be
operational; minutes
needs to be recorded and
retained.
List of Surgeons with
82 | P a g e
patient in operation room
from pre-operative ward
was not performed.
The surgery and anesthesia
consent is not present. The
consent is being taken in
hand written format.
Preoperative checklist not
followed.
Patient undergoing surgery
is not being screened for
HIV. There was no evidence
of HIV consent and HIV test
of patient undergoing
surgery.
The plan of care is not
documented. The desired
result of treatment is not
documented.
No defined criteria are
being used to decide
shifting of patient from
post-operative ward. The
post operative monitoring is
not being carried out.
Look alike, sound alike
medicines are not stored
separately.
Multi-use open vials to have
a label of date of opening
and expiry
High risk medicines are not
contact details needs to be
displayed.
Policies and procedure for
OT needs to be developed
& made available.
Policy for anesthesia
should be documented &
made available.
The surgery and
anesthesia consent needs
to be standardized and
present.
Patient undergoing
surgery should be
screened for HIV. HIV
consent and HIV test of
patient undergoing
surgery needs to be
documented.
Plan of care needs to be
defined and documented.
Transfer Criteria needs to
be defined for shifting of
patient from post-
operative ward.
Post operative
monitoring needs to be
carried out.
Look alike, sound alike
medicines should be
stored separately.
Multi-use open vials
should be label of date of
opening and expiry
High risk medicines
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83 | P a g e
stored separately.
Monitoring of patient during
surgical procedure (at
minimum heart rate, cardiac
rhythm, respiratory rate,
blood pressure, oxygen
saturation and level
sedation) is not being
documented.
Infection control practices
not being followed in
appropriate manner.
All staff is not aware on OT
specific infection control
practices (scrubbing,
sterility maintenance, use of
PPE etc.)
Each operation room is not
monitored for humidity and
temperature on daily basis.
Biomedical Waste
management practices not
followed properly in Inside
the OT.
Each operation room is not
monitored for filter
integrity, at-least once in six
month.
Regular environmental
surveillance for microbes is
not done in each OT and
other areas to identify
forming of any colonies of
should be stored
separately.
Monitoring needs to be
done for patient during
surgical procedure (at
minimum heart rate,
cardiac rhythm,
respiratory rate, blood
pressure, oxygen
saturation and level
sedation) needs to be
documented.
Biomedical Waste
management practices
needs to follow properly
in Inside the OT.
Defined criteria to decide
shifting of patient from
post-operative ward is not
being followed.
Policy for Sedation,
Surgery & Pain
management needs to be
documented & made
available.
Material Safety Data
sheet (MSDS) needs to be
defined and displayed.
Infection control practices
needs to be followed
properly.
Surveillance of OT
should be carried out
regularly.
Quality Assurance
84 | P a g e
bacteria.
Defined criteria to decide
shifting of patient from
post-operative ward is not
being followed.
programme needs to be
documented.
Number of OT
instruments counted
before and after operation
needs to be documented.
Pre-operative checklist
needs to be followed in
OT.
Bio-medical waste
management practices
needs to be followed
properly.
33. The quality indicators like :
% modification of
anaesthesia plan
% of unplanned ventilation
following anaesthesia.
% of adverse anaesthesia
events
% of rescheduling of
surgeries
% of adverse events like
wrong patient, wrong site,
wrong surgery.
OT utilization rate
% of cases received
antibiotic prophylaxis
within defined time frame is
not being monitored.
Quality Indicators were not
monitored namely; % of
modification of anesthesia
plan, % of unplanned
ventilation following
anesthesia, % of adverse
anesthesia events, anesthesia
related mortality rate, % of
unplanned return to OT, % of
rescheduling of surgeries, %
of cases where the
organization’s procedure to
prevent adverse events like
wrong site, wrong patient,
wrong surgery have been
adhered to, % of cases who
received appropriate
prophylactic antibiotics
within the specified time
frame, OT utilization was not
monitored, Re Exploration
rate and Re scheduling of
surgeries.
LOW
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PHARMACY STORE
34. Medicines are not stored in
a condition as described by
manufacturer. No
Refrigerator available for
storing medicine does not
have a temperature
monitoring system. The
temperature of the
refrigerator is not recorded
at-least 3 times a day.
All items storage areas are
not ladled and marked.
There is no demarcated are
for Receiving area,
Segregation area and storing
area.
Medicines need to be
stored in a condition as
described by
manufacturer.
Refrigerator used for
storing medicine should
have a temperature
monitoring system. The
temperature of the
refrigerator should be
recorded at-least 3 times
a day.
Receiving area,
Segregation area and
storing area needs to be
demarcated.
Inside refrigerator,
location of storing
various medicines
should be specified.
HIGH
35 The medicines are not
labelled & arranged as per
alphabetical order.
Look alike and sound alike
(LASA) medicines are not
identified and a list is not
available.
Staffs are not aware on
what to do if temperature
of refrigerator is not within
the defined limit. (Time
limit within which
medicines to be shifted to
another refrigerator)
High risk medicines are
not identified and a list is
not available.
Pharmacists are not
aware on policy on
verbal order of
prescription
medicine.
Staff at pharmacy was
not aware on practice
of preventing expiry
of medicine (FIFO
method, identifying
near expiry medicine,
identifying medicine
with short shelf life).
Adverse drug
reactions are not
Look alike and sound
alike (LASA) medicines
need to be identified and
a list should be
available.
List of all hazardous
materials stored in
pharmacy needs to be
available. MSDS for
each hazardous material
are not kept available
for ready reference of
staff.
Staffs need to be trained
on what to do if
temperature of
refrigerator is not within
the defined limit. (Time
limit within which
medicines to be shifted
to another refrigerator)
High risk medicines
need to be identified and
a list should be
available.
Recall Policy needs to
be documented and
followed.
Narcotics need to be
stored under double
lock and key.
Staff at pharmacy
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86 | P a g e
being analyzed.
Staff at pharmacy is
not aware of
situation when
medicine recall is
warranted and the
procedure of recall.
List of all hazardous
materials stored in
pharmacy is not available.
MSDS for each hazardous
material are not kept
available for ready reference
of staff.
needs to be trained on
practice of preventing
expiry of medicine
(FIFO method,
identifying near
expiry medicine, and
identifying medicine
with short shelf life).
36. Percentage of stock out
of drugs
Percentage of stock out
of emergency drugs
Percentage of stock out
of V and E category
drugs
Percentage of medicines
procured through local
purchase.
The outcome indicators like
Percentage of stock out of
drugs, Percentage of stock
out of emergency drugs,
Percentage of stock out of V
and E category drugs,
Percentage of medicines
procured through local
purchase need to be
monitored.
LOW
TSSU/ AUTOCLAVE FACILITY
37. The area layout do not have
well demarcated zones,
which includes
Collection zone (or soiled
zone) where the soiled and
used items should be
received and sorted.
Cleaning zone where
washing, cleaning and
packaging of items should
be done.
Sterilization zone where
the actual sterilization of
packages should be done.
Storage – This can be
considered a part of
sterilization zone, where
sterilized packs are stored
till its distribution.
The zones do not lead to
The area layout should have
well demarcated zones,
which includes
Collection zone (or soiled
zone) where the soiled
and used items should be
received and sorted.
Cleaning zone where
washing, cleaning and
packaging of items
should be done.
Sterilization zone where
the actual sterilization of
packages should be done.
Storage – This can be
considered a part of
sterilization zone, where
sterilized packs are stored
till its distribution.
HIGH
87 | P a g e
unidirectional movement of
people and supplies.
38. There is no
bacteriological/chemical
surveillance test being
performed for sterilization
authenticity & validation.
The
bacteriological/chemica
l surveillance test needs
to be performed for
sterilization
authenticity &
validation.
HIGH
39. No Hypochlorite solution
not present for
decontamination of
equipments only bleaching
available.
Transport trolley not
available inside the unit.
Hypochlorite solution
present needs to be
present for
decontamination of
equipments.
Transport trolley needs to
be available inside the
unit.
HIGH
40. No adequate racks present
in the department
Adequate racks needs to be
present in the department
HIGH
41. SOP is not documented for
each activity done in CSSD.
Procedure of sterilization
(separate SOP for each type
of sterilization, Procedure of
cleaning, Procedure of
packing, Procedure of
disinfection, Procedure of
storage and issue, Safety
precautions and guidelines,
Processing required before
reuse of the items,
A policy is not there on
reusable devices/items
which specifies List of
items that can be re-used
.The department is not
maintaining record of all
validation test reports.
There is no procedure of
recalling items in case of
sterilization breakdown.
The protocol for washing
of equipments, Procedure
of sterilization (separate
SOP for each type of
sterilization, Procedure of
cleaning, Procedure of
packing, Procedure of
disinfection, Procedure of
storage and issue, Safety
precautions and
guidelines, Processing
required before reuse of
the items, need to be
developed.
The
bacteriological/chemica
l surveillance test needs
to be performed for
sterilization
authenticity &
validation.
The department should
maintain record of all
validation test reports.
The department needs to
be maintained record of
all validation test reports.
Procedure of recalling
items in case of
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88 | P a g e
sterilization breakdown
needs to be defined and
documented..
ENGINEERING AND MAINTENANCE
42. There is no designated
person handling the medical
equipments related issues.
Designated person needs
to be appointed for
handling the medical
equipments related issues.
HIGH
44. There is no safety
committee (including
representatives from facility
management, clinicians,
administrator, nursing and
paramedical staff) to
coordinate development,
implementation and
monitoring of safety plans.
The organization does not
identify the potential
emergencies and not
prepared for emergencies
like earthquake, major fire,
flood, etc. as there is no
documented disaster
management plans and
mock drills are not being
carried out for emergency
codes.
The periodic facility
inspection is not being
carried out to identify the
environmental hazards and
risk.
There should be a safety
committee which should
include representatives
from facility
management, clinicians,
administrator, nursing and
paramedical staff to
coordinate development,
implementation and
monitoring of safety
plans.
Regular inspection of fire
extinguisher need to be
done and the organization
should identify their
potential emergencies and
should prepare for
disasters like earthquake,
major fire, flood, etc and
should maintain policies
for disaster management.
The periodic facility
inspection needs to be
carried out to identify the
environmental hazards
and risk.
MEDIUM
45. No monitoring done for
response time.
Number of variations
observed during mock drills
not monitored.
Response time needs to
be monitored and
documented..
Number of variations
observed during
mock drills needs to
be monitored.
LOW
MEDICAL RECORD DEPARTMENT
89 | P a g e
47. There is not designated
person for taking care of
medical records.
The records do not have all
relevant forms & formats
like Nurses Records, Initial
assessment form, etc.
There is not like unique
identifier at each page,
policy authorizing medical
record entries in medical
record.
Entry in the medical record
is not named, signed, dated
and timed.
The organization does not
have an effective process
for document control e.g.
the forms and formats
which is being used is not
standardized and do not
have identification code.
The retrieval of the records
is not easy. Deficiency
checklist is not followed.
There should be a
designated person i.e.
medical record
technician for taking
care of medical records.
The records should have
all relevant forms &
formats like Nurses
Records, Initial
assessment form, etc.
There should be unique
identifier at each page,
policy authorizing
medical record entries in
medical record.
Entry in the medical
record should be named,
signed, dated and timed.
The policy for retrieval
of the records and record
retention needs to be
developed. Deficiency
checklist should be
followed.
MEDIUM
48. The outcome indicators
like % of missing records,
% of records with ICD
codification done is not
being monitored.
The outcome indicators
like % of missing
records, % of records
with ICD , etc need to be
monitored.
LOW
NBSU (NEW BORN STABILISATION UNIT)
51. Fumigation is being
practiced which is not
acceptable. There was no
protocol for terminal
cleaning and disinfection.
The admission and
discharge criteria for NBSU
are not defined.
No documented policy for
Fumigation
practice need to
replace with
terminal cleaning
by 1% sodium
hypo-chloride
90 | P a g e
initial assessment and re-
assessment of patient.
The continuous monitoring
of the patient condition is
not being done. The patient
and family are not educated
on change in the condition.
The evidence based practice
is not being followed for the
treatment of the patient
although the protocols are
available in the department
but the compliance is not
being monitored.
No Hospital Acquired
Infection rate monitored and
action taken report not
documented.
(any other
disinfectant) and
proper cleaning
and disinfection
practices need to
be follow as per
CDC guidelines.
The floor
disinfectant need
to be replaced
with sodium hypo-
chloride.
The swab culture
from different areas
of NBSU like
patient bed, floor,
walls etc need to be
taken regularly for
the monitoring of
microbial flora and
if any microbial
growth found in
NBSU the
appropriate
measure need to be
taken and
corrective action
taken need to be
documented.
Policy for initial
assessment and re-
assessment of patient
needs to be documented.
Reassessment frequency
needs to be defined and
followed by the staff.
Nutritional
screening of the
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91 | P a g e
patient need to be
done by qualified
dietician .
The staff of NBSU
needs to be trained
about care bundles
to be followed for
infection control
and policies related
to patient care in
NBSU.
The continuous
monitoring of the patient
condition need to be
done and same need to
be reflected on patient
records.
All the outcome
indicators related to
NBSU need to be
monitored and
reviewed on regular
basis.
The admission and
discharge criteria for
NBSU are needs to be
defined & documented.
Infection control &
quality assurance
programme for NBSU
needs to be established.
Hospital Acquired
Infection rate needs to be
monitored and action
taken report needs to be
documented.
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92 | P a g e
52. Adequate privacy arrangement
for patient (especially
applicable in multi-bed wards
not made available.
Adequate privacy
arrangement for patient
(especially applicable in
multi-bed wards) need to be
made.
HIGH
53. There is lack of Separate or
segregated storage area for
clean and dirty supplies.
There should be a Separate or
segregated storage area for
clean and dirty supplies
HIGH
54. The reporting of adverse
patient events is not
being followed.
A nurse initial
assessment was not
being carried out.
The time frame for
initial assessment of the
patient is not defined
and the assessment
conducted by the
doctors is not counter
signed by Incharge
clinician.
Emergency medicines
are not checked
regularly.
The blood
transfusion consent
is present. The
transfusion record is
not available and the
reporting of
transfusion reaction
is not being done.
Patients are not
regularly
reassessed by
treating physician
and reassessment
is not
documented.
The content of
discharge
summary is not
appropriate. It
does not include
when and how to
obtained urgent
care.
Medications
Reporting of adverse
patient events should be
done.
Nurse initial assessment
need to be carried out.
Nurse’s medication chart
should be implemented.
The time frame for initial
assessment of the patient
should be defined and the
assessment conducted by
the doctors should be
counter signed by in-
charge clinician.
All emergency medicines
should be available as per
defined quantity and
checked regularly.
The blood transfusion
consent needs to be
taken. The transfusion
record must be
prepared and the
reporting of
transfusion reaction
need to be done.
Patients should
be regularly
reassessed by
treating
physician and
reassessment
should be
documented.
The content of discharge
summary should be
defined.
Medications errors, near
miss events should be
identified and recorded.
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93 | P a g e
errors, near miss
events are not
identified and
recorded.
55. The quality indicators are not
be monitored. These are-
Percentage of Patients
receiving high risk
medications developing
adverse drug event.
Percentage of
admissions with adverse
drug reactions (s)
(Adverse drug
reactions per 100
separations)
Incidence of medication
errors (Medication
errors per patient days)
Appropriate handovers
during shift change (To
be done separately for
doctors and nurses per
patient per shift).
Incidence of hospital
associated pressure
ulcers after admission
(Bed sore per 1000
patient days)
Incidence of falls
Catheter associated
Urinary tract
infection rate,
Incidence of blood
body fluid exposures,
Incidence of needle
stick injuries
Quality indicators
need to be monitored.
This are-
Percentage of
Patients receiving
high risk
medications
developing adverse
drug event.
Percentage of admissions
with adverse drug
reactions (s) (Adverse
drug reactions per 100
separations)
Incidence of medication
errors (Medication errors
per patient days)
Appropriate handovers
during shift change (To
be done separately for
doctors and nurses per
patient per shift).
Incidence of hospital
associated pressure ulcers
after admission (Bed sore
per 1000 patient days)
Incidence of falls
Catheter associated
Urinary tract
infection rate,
Incidence of blood
body fluid
exposures,
Incidence of
needle stick
injuries
LOW
HUMAN RESOURCE MANAGEMENT
56. There is not Training Incharge
present in the hospital.
There should be a
dedicated staff for
training and
development related
activity.
HIGH
94 | P a g e
57. There is no training
programme when job
responsibilities changes
and when new
equipment gets installed.
HR induction and
training programme was
not documented after
joining.
No evidence of training
Need Analysis is being
done.
Employee’s satisfaction
survey was not being
done and analyzed
There were no feedback
mechanisms for
improvement of training
and development
programme.
There should
be a continuous
training
programme
when job
responsibilities
changes and
when new
equipment gets
installed.
HR induction
and training
programme
should be
documented
after joining.
Employee’s
satisfaction
survey needs to
be done and
analysed.
The training
Need Analysis
of the
employee
needs to be
conducted.
There should
be feedback
mechanisms
for
improvement
of training and
development
programme.
MEDIUM
KITCHEN
59. There is no demarcation in the
kitchen.
The kitchen should be
demarcated as
Preparation area
Cooking area
Special diet area
Servicing area
Washing area
Garbage collection area
Administrative areas
HIGH
95 | P a g e
62. Patient & family members
are not educated regarding
the limitations of diet.
No cleaning schedule for
the kitchen available.
Diet sheet, Nutritional, Food
evaluation is not prepared
by dietician because
dietician not available.
Infection control practices
not followed in appropriate
manner.
Patient and family
members should be
educated regarding the
limitations of diet.
There should be a proper
cleaning schedule for the
kitchen.
There should a dedicated
dietician for diet sheet,
nutritional and food
evaluation.
Infection control
practices needs to be
followed in appropriate
manner.
MEDIUM
IMAGING DEPARTMENT
64. TLD badge for staff is not
available.
TLD badge for staff is should
be available.
HIGH
65. Type & Site approval for X-Ray
is not available
Type & Site approval for X-
Ray should be available
HIGH
66. Surveillance of imaging
results is not being carried
out.
Surveillance of imaging
results needs to be done.
MEDIUM
ICU/ICCU
68. Well Equipped ICU and ICCU
is Available but there is no
trained manpower available for
functioning of the department.
There should be adequate
number of manpower for
functioning of the
department.
HIGH
INFECTION CONTROL
96 | P a g e
69. Hospital does not adhere
laundry and linen
management processes
because Laundry was
outsourced.
The HCO does not adhere to
kitchen sanitation and food
handling issues of
Outsource Kitchen.
The HCO does not adhere
Mortuary practices in
appropriate manner.
There was no appropriate
engineering control to
prevent infections which
includes design of patient
care areas (optimum spacing
between beds), operating
rooms, air quality and water
supply.
The infection control
surveillance data is not
being collected.
The organization does not
have appropriate hand
hygiene facilities across the
all patient care areas viz no
elbow operated taps, soap
solution.
The disinfectant which is
being used in the hospital is
not undergone any sterility
test. Phenyl is being used as
disinfectant.
Regular validation tests for
sterilization like physical
test , daily, weekly
biological tests, steam
processing, is not being
followed.
The Hospital should
adheres laundry and linen
management processes.
The HCO should adhere
to kitchen sanitation and
food handling issues of
Outsource Kitchen.
The HCO should
Mortuary practices in
appropriate manner.
There should be
appropriate engineering
control to prevent
infections.
Surveillance for infection
control should be
regularly carried out. The
frequency of surveillance
in high risk areas should
be higher. Surveillance
must include both, patient
surveillance and
environmental
surveillance.
Staff should use
appropriate hand hygiene
guidelines. These
guideline includes, when
wash hands, what kind of
hand washing is required
in different situations,
proper method of hand
washing (6 point or 9-
point hand wash) and
other measures to keep
hand hygienic.
The disinfectant which is
being used in the hospital
should undergo sterility test.
Regular validation tests
for sterilization should be
followed.
MEDIUM
70. The outcome is not being
monitored-
Catheter associated urinary
tract infection rate Surgical site infection rate
Percentage of staff provided
pre- exposure prophylaxis
Incidence of blood body
fluid exposures
Compliance to hand hygiene
practice
The outcome indicators
must be used to determine
effectiveness of infection
control measures. These are
Catheter-associated urinary
tract infection rates,
Ventilator associated
pneumonia, Catheter linked
blood stream infections,
Surgical site infections ETC.
LOW
97 | P a g e
LINEN/LAUNDARY
71. The department does not have
demarcated areas like receiving,
segregation area, sluicing,
washing, drying, calendaring
etc.
The department should have
a demarcated area like
receiving, segregation area,
sluicing, washing, drying,
calendaring etc.
HIGH
72. The department has only one
semi automated washing
machine.
Sufficient number of washing
machines needs to be
purchased.
HIGH
73. Segregation of soiled and
contaminated linen is not
being carried out.
There is no disinfectant
while washing
contaminated linens.
No Separate storage area
for dirty and clean linens.
There segregation of
soiled and contaminated
linen needs to be done.
The disinfectant for
washing contaminated
linens should be arranged.
There should be separate
storage area for dirty and
clean linens.
MEDIUM
LABORATORY
74. Separate Sample Collection
area is not demarcated in the
Laboratory.
Separate Sample Collection
area needs to be demarcated
in the Laboratory.
HIGH
76. Lab surveillance is not
being done.
Laboratory staff not
aware about safety
precautions while
handling samples.
Temperature Monitoring
of Refrigerator not done.
Lab surveillance
should be done on
regular basis.
Training needs to be
conducted &
Laboratory staff
should be aware about
safety precautions
while handling
samples.
Temperature Monitoring
of Refrigerator needs to
be done.
MEDIUM
98 | P a g e
LABOUR ROOM
82. Unavailability of separate areas
for septic and aseptic deliveries.
Separate areas for septic and
aseptic deliveries needs to be
demarcated in Labor Room.
HIGH
83. Department’s layout is not
demarcated as per functions viz
receiving area, Examination
room, Pre-delivery room,
delivery room, post delivery
observation room, Nursing
station, dirty utility and clean
utility, area for medication and
injection preparation, Pre-
Eclampsia area etc
Department’s layout needs to
be demarcated as per
functions viz receiving area,
Examination room, Pre-
delivery room, delivery room,
post delivery observation
room, Nursing station, dirty
utility and clean utility, area
for medication and injection
preparation, Pre-Eclampsia
area etc
HIGH
84. No separate Changing Room
available for Doctors and
Nurses.
Separate Changing Room
needs to be available for
Doctors and Nurses.
HIGH
85. Scope of high risk obstetrics
care is not displayed.
Scope of high risk obstetrics
care needs to be displayed.
MEDIUM
BLOOD BANK
88. There is no full time qualified
Blood Bank In-Charge available
to manage the blood
collection/distribution
department.
Full time qualified Blood
Bank In-Charge needs to be
available to manage the blood
collection/distribution
department.
HIGH
89. No Blood bank technician
available in this department.
Blood bank technician needs
to be available in this
department.
HIGH
90. Transfusion reaction is not
capturing. Analysis of
transfusion reactions
Separate counseling section
is not present in this unit.
Transfusion reaction is
needs to be capturing.
Analysis of transfusion
reactions.
Separate counseling
99 | P a g e
There is no screening of
donors prior to blood
donation in appropriately.
List of department staffs is
not displayed in this unit.
Temperature of the
refrigerator is not being
monitored and recorded.
section needs to be
present in this unit.
Screening of donors prior
to blood donation needs
to be done in
appropriately.
List of department staffs
should be displayed in
this unit.
Temperature of the
refrigerator needs to be
monitored and recorded.
MEDIUM
BIOMEDICAL WASTE MANAGEMENT
92. Signage for temporary storage
area for biomedical waste was
not available.
Signage for temporary
storage area for biomedical
waste needs to be available.
HIGH
93. Signage for Bio-hazard was not
displayed.
Signage for Bio-hazard needs
to be displayed.
HIGH
94. Segregation of BMW at
point of Generation not
done at all areas.
There is no separate
route defined for
transportation of waste
from the general traffic
area
Segregation of BMW at
point of Generation needs
to be done at all areas.
Separate route needs to be
defined for transportation
of waste from the general
traffic area.
MEDIUM
SECURITY
95. No system of telephone
connectivity from Emergency
Room.
System of telephone
connectivity from Emergency
Room needs to be available.
HIGH
96. No separate security guard
available for emergency and
labor room.
Separate security guard
should be available for
emergency and labor room.
HIGH
100 | P a g e
98. No outgoing items checked
and entered on a register.
Outgoing items should be
checked and entered on a
register.
MEDIUM
HOUSEKEEPING DEPARTMENT
100 No basic facilities available
like(Toilet/Drinking
water/change room) for
housekeeping staff.
Basic facilities
like(Toilet/Drinking
water/change room) should
be available for housekeeping
staff.
HIGH
101 Daily Cleaning & Master
cleaning schedule was not
available.
Material Safety Data Sheet
was not available.
Pest control method was not
practiced.
Daily Cleaning &
Master cleaning
schedule should be
available and
followed.
Material Safety Data
Sheet should be
available and
displayed.
Pest control method
should be practiced
and documented.
MEDIUM
MORTUARY
103 There is no dedicated
department for keeping
the dead bodies in the
hospital as the Mortuary
Chamber were kept in
open tin shaded area
without any safety
arrangements .there was
no security guard in the
Mortuary.
The surrounding of the
mortuary was unclean,
smelling and stinking.
Stray animals like Cow
were roaming around
the department.
There should be a dedicated
mortuary chamber for
keeping dead bodies with
safety arrangements.
The surrounding of the
mortuary should be clean.
HIGH
101 | P a g e
104 Temperature not being
monitored regular basis.
Temperature should be
monitored on regular
basis.
MEDIUM
STORE
105 Layout of the store was not
appropriate. There was no
dedicated receiving, quality
check, labeling, Store and Issue
area identified.
Layout of the store needs to
be demarcated appropriate.
There should be dedicated
receiving, quality check,
labeling, Store and Issue area
needs to be identified.
HIGH
106 No adequate Racks are
available in Store cartons lying
on floor.
Adequate Racks needs to be
available in Store.
HIGH
107 Frequently used items are
not arranged and located in
most easily accessible area.
Frequently used items
needs to be arranged and
located in most easily
accessible area.
MEDIUM
102 | P a g e
SUPPORTING DOCUMENTS
103 | P a g e
LEGAL DOCUMENTS –LETTER SIGNED BY HOSPITAL AUTHORITY
104 | P a g e
105 | P a g e
106 | P a g e
APPROVED EXISTING MANPOWER LIST
107 | P a g e
108 | P a g e
109 | P a g e
APPROVED EXISTING EQUIPMENT LIST
110 | P a g e
111 | P a g e
112 | P a g e
113 | P a g e
114 | P a g e
115 | P a g e
SUPPORTIVE EVIDENCE OF IDENTIFIED GAPS
116 | P a g e
No Temperature monitoring done of
Refrigerator and Temperature
Monitoring Not Available
Infection control Practices not
followed in Postmortem Room
Used Blood Bag Stored in the the
Emergency Department Refrigerator No
Blood Discard Protocol followed in
Proper manner
Infection control Practices not
followed, Dirty Towel used after
hand wash, Cleaning of wash basin
not done properly.
117 | P a g e
Window AC not in good condition loose wire inside
the AC.
Broken Tiles inside the Patient care area
Seepage on the roof No Cleaning of Overhead Tank
118 | P a g e
No Labeling of Medicines done in Pharmacy Store
and adequate no. of Racks and Refrigerator not
Available
Wire directly put in the Light Switch No
Facility Safety Protocol followed
Two OT Table Available in 1 OT Biomedical Waste Management
Practices not followed in proper
manner
119 | P a g e
Date of Sterilization not mention in Drum No calibration of Autoclave Presser meter
