Sunday, December 29, 2013

Check List for Hospital Inspection /Accreditation/ Monitoring / Logistics Management/ Quality assessment at public health Care institutions

Check List for Hospital Inspection /Accreditation/ Monitoring / Logistics Management/ Quality assessment at public health Care institutions

No.
ITEM
Marks
Score
1
OUT PATIENT DEPARTMENT (TOTAL MARKS 100)


a)
Reception Counter : (Marks-5)


i)
Posting of knowledgeable MSW or Staff Nurse as a Receptionist with a board "May I Help You?"
3

ii)
All sections of the OPD numbered and depicted on flow chart near reception counter.
1

iii)
Boards indicating days of Special Services and Hospital timings near reception counter.
1

b)
Registration : (Marks - 5)


i)
Separate registration windows with railing arrangements for Male/Female,
Old/New, Freedom Fighters & Govt. Servants.
2

ii)
Board indicating hospital fees for various services provided for OPD & IPD
2

iii)
Glow sign with changing messages exhibited at prominent places.
1

c)
O P D Sections : (Marks - 20)


i)
Every OPD section should have : separate register for diagnosis, complete examination tray with B P Apparatus, torch and hammer, X-ray view box, examination table with foot steps, writing table, stool for patients, wash basin adequate sitting arrangement for waiting O P D patients, appropriate Health Education Material displayed.
8

ii)
In addition to above



Medical OPD :
CNS examination tray, tuning fork, ECG Machine
2


Surgical OPD
PR examination tray with proctoscope and gloves, Kidney trays, Tongue depressor
2


Gynaec. OPD :
PS & PV exam. Tray, IUD tray, Kidney tray, Weighing machine, pap smear tray, exam. Table with lithotomy facility, table lamp.
2


Pediatric OPD :
Paed. Weighing machine, Measuring Tape, Height and Weight Scale,
2


Ophthalmic OPD :
Near and Distant vision charts, Refraction set Opthalmoscope, Dark room facilities for Retinoscopy,
2


Ear, Nose & Throat OPD :
Head light mirror, Indirect laryngoscopes, Tongue depressor, nasal & ear speculum, electric sterilizer, tuning fork, Audiometry, diagnostic ENT set, audiometry, wax syringe, etc.
2










No.
ITEM
Marks
Score
d)
Dental OPD (Marks 7)


i)
Dental surgeon and Dental hygienist services are adequately utilized. (Activities carries out other than OPD hours such as evening OPD attendance)
2

ii)
Apart from Dental extraction and scaling other procedures like silver filling, mandibular wiring, dental alignment etc. are done
2

iii)
Involvement of dental surgeon and dental hygienist in outreach activity of school health survey of caries, cancer detection camp, creating awareness of tobacco related cancer, oral health etc.
1

iv)
Efforts made by staff to keep dental x-ray unit, motor in order, continuous water supply, staff nurse posting, denture preparation (prosthesis), Biosafety measures adopted etc.
2

e)
Dressing Room (Marks 5)


i)
Autoclaved material used
1

ii)
Separate dressing rooms for male and female patient
1

iii)
Dressing table, sink for hand washing available, soap
1

iv)
Dresser wears Plastic apron, face mask, gloves etc. While doing dressings.
1

v)
Antiseptic lotions and dressing materials and foot operated dustbins are adequately
available, with color coding of containers
1

f)
Injection Room (Marks 10)


i)
Separate rooms for male and female available
1

ii)
Staff nurse is trained in management of Injection reactions.
2

iii)
Updated emergency drug tray and Availability of Oxygen Cylinder with accessories, Suction Machine (electric & foot operated), Cot & Mattresses with arrangement for head low position, venesection tray, Chart of management of Anaphylactic reaction, Availability of wash basin, Bio safety measures adopted, Inventory maintained.
3

iv)
Sufficient No. of autoclaved syringes & needles depending upon OPD load.
2

v)
Availability of wash collection bags/containers for sharp with color codes & emblemt
2

g)
Dispensing Room (Marks 7)


i)
Availability of Male, Female & Govt. Servants windows separately with railings arrangements and free treatment board.
2

ii)
Daily accounting of drugs kept? (Any proof of checking of inventory)
2

iii)
Surprise check by MO/RMO for actual dispensing against prescription.
1

iv)
Drugs are dispensed in plastic bags, paper packets
1

v)
Morbidity statistics kept up to date (Verify the record)
1








No.
ITEM
Marks
Score
h)
Physiotherapy (Marks 7)


i)
Availability short wave diathermy, infrared facilities for Myalagia
1

ii)
Availability of Lumbar/Cervical traction for Spondylitis
1

iii)
Shoulder mobilization wheels, walking bars available
1

iv)
Wax bath and Muscle stimulator available
1

v)
Services of Physiotherapist are adequately utilized for patients especially for orthopedic ward, burns ward etc.
3

i)
Minor Operation theater and Plaster Room (Marks 12)


i)
Availability of Anaesthetic apparatus, shadow less lamp, operation table,
suction apparatus (electric and foot operated) fumigation apparatus,
2

ii)
Availability for wash basin, sleepers, cap, mask, gown, sleepers etc
2

iii)
Availability of autoclaved linen material, dressing drums, minor surgery instruments, life saving drugs and anaesthetic agents etc.
2

iv)
Availability of plaster room, plaster material & plaster cutting saw etc.
2

v)
Availability of waste collection bags/Containers for different type of waste
2

vi)
Maintenance of records and registers of minor OT, dead stock etc.
2

J)
O R T Corner (Marks 3)


i)
Availability of all Health Education material and demonstration sets.
1

ii)
Knowledge of staff about ORT
1

iii)
No. of diarrhoea cases treated in OPD & mothers educated. Verify records.
1

K)
Drinking Water Facilities (Marks 1)


i)
Water coolers available with adequate number of taps for OPD.
1

L)
Sanitary Blocks : Marks 2)


i)
Separate well maintained arrangements of toilet for male & female
patients & relatives ?
1

ii)
Separate toilets & wash basins for staff members ?
1

M)
Cycle/Scooter stand with shed for parking. (Marks 2)


i)
Separate stand for staff/Public vehicles.
1

ii)
Management of parking on contract basis by floating tender or otherwise
1

N)
R.M.O.Office (Marks 7)


i)
Availability of telephone for RMO and public.
1

ii)
Film show arrangements made for OPD patients verify the register.
1

iii)
Suggestion book in OPD action taken, if any valid suggestions made.
1











No.
ITEM
Marks
Score
iv)
Availability of RMO during entire OPD period and musters of interns class III
and para medical are available in RMO'S Chamber.
2

v)
Availability of wheelchairs & stretchers for shifting Pts. from OPD to Ward.
2

O)
Verifications of adequacy of treatment (Minimum 5 case papers should be checked) (Marks 5)


i)
Clinical notes, Diagnosis, Investigations and Legible hand writing
1

ii)
Proper prescription of drugs with dose schedule
1

iii)
Views of the patients regarding treatment and their satisfaction
1

iv)
Familogram, Smear for MP, Sputum for AFB are stamped or not
1

v)
Clear concept of Malaria Clinic and Knowledge of Management of PV & PF cases to MOs
1

2)
EMERGENCY SERVICE DEPTT. (CASUALTY) (MARKS 60)


I)
Separate Medical Officer (CMO) available round the clock
1

ii)
Continuous availability of D.M.O.(Indoor M O ) during night hours.
2

iii)
Board displaying doctors on call, Specialist and other staff on duty
2

iv)
Glow sign board indicating 'Emergency Services Department'
2

v)
Casualty Department annexed with Emergency ward with adequate number of
beds and attached toilets facilities.
3

vi)
Ward well equipped with Fowler's bed, Oxygen Cylinder with Accessories,
Suction apparatus electric-foot operated, Emergency tray with essential
drugs with Catheter tray, Ryles' tubes / stomach tube, flatus tube, Venesection tray, Tracheotomy set, L P tray, Suturing tray, Ambu bag, Laryngoscope, Tourniquet, Splints-Thomus splint, Bohler's splint, Crammer wire splints Emergency light/Generator, BP Apparatus, Torch, Thermometer, Weighing machine, hammer, Refrigerator, Stationary & Forms.
10

vii)
Trained staff posted in Emergency department & availability of SIERON
2

viii)
Boards displayed regarding management of snake bite, common poisoning,
Anaphylactic reaction, Cardio respiratory arrest etc.
3

ix)
Availability of ARV Services 24 hours. Board displayed accordingly.
2

x)
Knowledge of MOs in classification of dogbite wounds and their management
training in giving ARV.
5

xi)
Proper documentation of treatment card and records/registers.
1

xii)
Medicolegal register in prescribed format either central or individual.
2







No.
ITEM
Marks
Score
xiv)
Call book is in prescribed format and calls are attended promptly. Any time checked by CS/RMO. Verify
2

xv)
Availability of Disaster Management Plan and disaster drill conducted regularly. (Verify the record and stock)
3

xvi)
Retiring room for MO and Interns with attached toilet lockers, cooler, fan and drinking water arrangements.
5

xvii)
Night super nurse on duty should be available in emergency ward after night rounds.
2

xviii)
Treatment room cum minor operation theater with all necessary instruments, equipment, trolleys, tables and trays.
5

xix)
Availability of separate telephone for Casualty Department. as well as for public.
1

xx)
Store room with sufficient stock of essential and life savings drugs.
2

xxi)
Availability of sufficient number of wheel chairs and stretcher trolleys.
2

xxii)
Availability of transport facilities (Ambulance) round the clock.
2

xxiii)
Availability of public outpost chowky adjacent to CMO room 
1

3)
INTENSIVE CARDIAC CARE UNIT (MARKS 15)


I)
Existence of I C U with AC, bedside monitor, central monitors, defibrillators, ventilators, fowlers beds etc. and round the clock availability of qualified and trained staff.
4

ii)
Equipment in working condition & history book maintained
2

iii)
Space availability, cleanliness, generator facilities etc.
2

iv)
Adequate no. of Trained Med. Officer & Nursing Staff.
2

v)
Record keeping of patients treated so far.
2

vi)
Availability of central oxygen, suction machine and life saving drugs.
3

4)
CLINICAL LABORATORIES (MARKS 25)


i)
Qualified Pathologist available, if not efforts made for getting the post filled in or suitable alternative arrangements made.
2

ii)
Examination of special tests like widal, serum bilirubin, LFT, VDRL, BS for M.P.,stool examinations, semen analysis, electrolyte study, blood gas analysis, kidney function tests, CSF examination etc.
3

iii)
Accuracy of reports, monthly abstract drawn and verified by pathologist
2

iv)
Availability of round the clock laboratory services
2

v)
Use of aprons by laboratory technicians
1

vi)
Availability of sufficient wash basins, sinks for staining.
1

vii)
Proper dispose off of the spoiled containers after decontamination.
2

viii)
Use of only autoclaved syringes & needles/disposable needles.
2

ix)
Availability of waste sharp & other waste collection bags/containers
2







No.
ITEM
Marks
Score
x)
Appropriate tests carried out as per indication.
1

xi)
Observance of bio safety measures


xii)
Regular availability of staining material and their inventory maintenance.
2

xiii)
Status of following equipment
5


.         
Total No. Available
Working Condition
Under Repairs
Pending for Condemnation


a)
Microscopes Monocular






b)
Flame photometer





c)
Centrifuge





d)
Auto Analyzer





f)
Refrigerator





g)
Water bath





h)
VDRL Rotator





i)
Hot air oven





j)
Calorimeter









5)
BLOOD BANKS (MARKS 25)


I)
Trained or qualified medical officer posted as BTO
2

ii)
Round the clock availability of trained staff and services
1

iii)
Checking of cross matching by BTO
1

iv)
Proper maintenance of cold room and refrigerators
1

v)
Australia antigen, V D R L , Malaria parasite and HIV tests are carried out on every blood bottle of donor. Verify the record.
2

vi)
Fulfillment of average requirement of 5 blood bottles per bed per year.
1

vii)
Ratio of blood collections through voluntary organizations: replacement donor 60:40 followed.
1

viii)
Service charges recovered for blood bottles given to outsiders and amount collected and blood bottles given matches
1

ix)
Issue of donor cards, certificate of appreciation (Verify the records)
1

x)
Proper documentation and examination of donors.
1

xi)
Efforts made for getting Elisa reader repaired and alternative arrangements made for HIV testing.
2

xii)
Exhibition of posters and health education materials in the blood bank
1

xiii)
Availability of adequate quantity of Sera and Anti sera reagents
1









No.
ITEM
Marks
Score
xiv)
Adequate stock of PVC bags & Transfusion sets.
1

xv)
Renewal of blood bank/HIV license as per DCO rules & Records
2

xvi)
Disposal of HIV positive blood bags & Biosafety measures undertaken
2

xvii)
Transfusion feed back, and record maintenance of untoward incidences
1

xviii)
Maintenance of inventory of various sera, reagent and consumables. Verify.
2

6
RADIOLOGY DEPARTMENT : 25


i)
Radiologist in available, if not efforts made for getting the post filled in or any suitable alternative arrangement made for day to day supervision.
1

ii)
Status of X-ray Machines available.
4

iii)

Total No. Available
Working Condition
Under Repairs
Pending for Condemnation



X-ray Machines






iv)
Availability of dark room safe light, film drying cabinet x-ray illuminators
(weaving box) etc.
1

v)
Use of dosimeter and are they regularly sent to BARC for checking and steps taken on reports.
1

vi)
Special, investigations like IVP, barium swallow or barium studies,
Hystosalphingography etc.
2

vii)
Availability of necessary contrast media for special investigations (Verify)
1

viii)
Round the clock x-ray services by making x-ray Technicians available
1

ix)
Availability of all life savings drugs , oxygen cylinder, suction apparatus etc. to tackle the anaphylactic reaction
2

x)
Separate X-ray register for M L C and recording of signature or thumb impressions along with identification mark etc.
2

xi)
Maintenance of logbook of X-ray Machines.
1

xii)
Accurate records, register and inventory, checked by Radiologist or RMO
1

xiii)
X-ray films and hypo solutions are preserved/Disposed as per rules
1

xiv)
Availability and use of protection device like lead apron, lead gloves, goggles, badges and dosimeter etc. by the staff working in Radiology department.
2

xv)
X-ray diagnosis entered in the register and checked/reported by Radiologist.
1

xvi)
Availability of Sanitary block in X-ray department
1

xvii)
Availability of dental X-ray facilities.
1

xvi)
Availability of Sonography facility & trained Radiologist/Gynecologist posted for optimum utilization of equipment
2









No.
ITEM
Marks
Score
7)
OPERATION THEATER:  (50)


I)
Availability of staff in O T as per norms
1

ii)
Concept of clean, neutral and sterile zone followed by providing various self closing double doors or air curtain etc.
3

iii)
Dimensions of operation theater are measured and dose of potassium
permanganate (KMno 4) and formaldehyde calculated for doing fumigation on fixed day or as and when indicated. Verify the record
2

iv)
Availability of separate O T for septic and infected cases.
1

v)
Swabs from O T are send for culture and action taken on unfavorable
report. Verify the documents.
2

vi)
Pre operative waiting room with toilet facilities available
1

vii)
Availability of well equipped post operative ward (Recovery Room) with
adequate no. of beds and resucoitation measures.
3

viii)
Up to date maintenance of O T records like O T registers, emergency OT,
monthly abstract etc. Maintenance of operation postponement register.
3

ix)
Proper steps taken for disposal of O T waste (Operated specimens etc)
2

x)
Emergency light or generator facilities provided to or (Verify)
2

xi)
OT staff nurses available round the clock and OT allowances paid
2

xii)
House keeping and bio safety measures adopted in O T
2

xiii)
Status of following equipment
10

xiv)

Total No. Available
Under Repairs
Pending for Condemnation


a)
Boyles Apparatus





b)
Hydraulic O Table





c)
Shadow less lamp





d)
O T care





e)
Suction apparatus





f)
Air Conditioner





g)
Minor Operation Tables





h)
Electric cautery





i)
Refrigerator



























No.
ITEM
Marks
Score


Total No. Available
Under Repairs
Pending for Condemnation


j)
Electric sterilizers





k)
Autoclaves





l)
Laparoscope





m)
Bronchoscope fibro optic/rigid





n)
Gastroscope fibro optic/rigid





o)
Cystoscope fibro optic/rigid





xv)
Province of color coded waste collection containers / begs
2

xvi)
Availability of portable mobile X-ray machines in OT along with dark room.
2

xvii)
Regular condemnation of unserviceable articles twice a year done.
2

xviii)
Inventory register maintained and checked by Anesthetist/RMO
2

xix)
Check list attached to the patient posted for operation
3

xx)
Arrangement of transport of patient from O T to ward
1

xxi)
Availability of separate changing room for doctors, nurses with attached
toilet and locker facilities and entire staff use OT attire.
1

xxii)
Availability of fire fighting equipment's and knowledge to use them.
3





8)
CENTRAL STERILE SUPPLY DEPARTMENT (MARKS 15)


i)
Minimum two H P H S in working condition. If not efforts made.
2

ii)
Trained O T Attendant under supervision of O T staff nurse performs the
autoclaving. (Interrogate and confirm knowledge and procedure)
2

iii)
A detail chart showing how to operate HPHS displayed in Hindi
2

iv)
Wall clock made available for noting the time during autoclaving process
1

v)
All autoclave tape should be preserved and pasted on register date wise
3

vi)
Efforts made to get out of order equipment's repaired or condemned.
2

vii)
Anesthetist/Pathologist as incharge of CSSD
1

viii)
Knowledge of staff nurse for disaffection of fiber optic scopes, rubber catheter, Linen, sharp instruments, etc.
2



















No.
ITEM
Marks
Score
9)
LABOUR ROOM & P.B.U. (MARKS 40)


I)
Separate Labor Room with automatic double door for clean and septic cases available
2

ii)
Minimum 2 labor tables in Clean labor room with plastic curtain partition
1

iii)
Facilities available such as : Wall Clock, baby weighing machine, facility for headless position, baby resuscitation kit, mucus aspirator, suction, apparatus (electric or foot operated) along with set of catheter, oxygen cylinder with accessories for baby and mother, emergency light/generator connection, exhaust fan, coolers/fan, episiotomy tray and venesection tray, shadow less lamp, forceps low, fetal monitor, vaccume extractor, BP apparatus, instrument sterilizer, plastic aprons, sleepers, cap, mask, apron, foam mattress on table, Kit of all life saving drugs.
7

iv)
Same discipline as that of O T is also followed for labor room i.e. Use of gown, cap, mask etc. before entering in labor room & PBU
2

v)
Availability of deep freeze or wooden box with lock and key for preservation of still born, Placenta, till they are disposed off.
1

vi)
Enough No. of aluminum/plastic badges for identification of baby & mother.
1

vii)
Regular washing and fortnightly fumigation of labor room. Verify record
2

viii)
Observance of proper housekeeping.
1

ix)
Proper writing of delivery notes including the foot prints of baby thumb
impression of mother with attestation of nurse conducting delivery.
2

x)
Maintenance of call book in prescribed format & attendance of calls in time.
1

xi)
Interview of 5 Mothers delivered recently about their experience regarding facilities, behavior of staff and sanitation in Labor Room.
5

xii)
Availability of attached toilet facility near Labor Room.
1

xiii)
Arrangement to resuscitate new born and to keep baby warm
1

xiv)
Availability of well equipped premature Baby Unit with minimum 6 beds.
2

xv)
Availability of separate incubators for Hospital delivery cases and Home Delivery referred new borns.
2

xvi)
Staff trained in premature baby care.
2

xvii)
Arrangement for prevention of hypothermia
1

xviii)
Availability of Photo therapy unit, Oxygen hoods.
2

xix)
Proper maintenance of record, registers of new borns.
1

xx)
Precautionary measures adopted to prevent sepsis like barrier nursing,
change of cloths by staff working in PBU
2

xxi)
Written instructions about operation of incubator displayed.
1





No.
ITEM
Marks
Score
Paed
Med
Sur
Gye
Iso/TB
Total







10)
WARDS : (25 Marks each* 5 Wards i.e. Medicine, Surgery, Obst.
Gyn., Pediatrics and T.B. Ward.)


1
Satisfactory cleanliness of the wards.
1

2
Satisfactory condition of the sanitary blocks
2

3
If, floor beds in the wards present (Analyze the reason)
1

4
Satisfactory upkeepment of Cots, Mattresses, Bedside lockers, Linen etc.
2

5
Availability of Suction apparatus (electric and foot operated), oxygen cylinder with accessories, venesection tray, emergency tray, emergency light,  BP apparatus, equipments for sterilization, wheel chairs, stretcher trolley and stationers, forms etc.
2

6
Availability of poor fund boxes, sealed with last date of opening.
(Verify by checking PLA Account and Registers)
2

7
Suggestion book in wards & cognizance taken.
1

8
Adequate steps taken to carry out the repairs/replacement of out of order
equipment, sanitary wears.
2

9
Concept of progressive patient care i.e. serious patients on fowler's bed
with all presence of work collection color coded containers, 4 waste segregation
2

10
Display of name at head end of patients.
1

11
Adequacy and working of fans and tubes.
1

12
Scrutinize 4 indoor papers and ascertain adequacy of notes, prescriptions ,  Provisional and final diagnosis, Operation and anesthesia notes, documentation of investigations, Information to relatives about seriousness of the patient. Evidence of cases seen by Civil Surgeon. Patients and relatives satisfaction.
4

13
Satisfaction of patients about type of diet, quality & quantity
2

14
Has the C.S./ RMO checked the call book any time and took corrective steps.
1


Total Marks
25


No.
ITEM
Marks
Score
11)
DIET AND KITCHEN FACILITY  (Marks 30)


I)
Availability of different types of diets
2

ii)
Physical verification of dietary articles done any time. Verify
2

iii)
Availability of diet charts for adult, pediatric and special diet.
2

iv)
Steps taken to prevent pilferage of diet & dietary articles
2

v)
Arrangements for washing vegetable and vegetable cutting platform.
2

vi)
Satisfactory cleanliness of kitchen.
1

vii)
Satisfactory arrangements for preventing rat nuisance.
1

viii)
Availability of modern gadgets like mixer grinder, chapati puffer, hot case, tea urns, bulk cooker, refrigerators, atta needing machines.
2

ix)
Availability of stainless steel with copper based utensils for cooking
1

x)
Satisfactory arrangements for storing the utensils.
1

xi)
Satisfactory arrangement for storing for foodgrains.
1

xii)
Utilization of dietitian's services for ANC/PNC clinics, Pediatric ward.
2

xiii)
Regular medical check up of food handlers (Verify the records)
1

xiv)
Availability of food testing register and remarks.
2

xv)
Sending of samples of dietary articles for P A F studies and action taken on results
2

xvi)
Availability of lactometer measuring unit, weighing machine and weight.
2

xvii)
Action taken on substandard supply of dietary articles.
2

xviii)
Kitchen work storage & disposal
2

12)
LINEN & LAUNDRY SERVICES (MARKS 30)


i)
Availability of Linen Keeper or efforts made to fill up the posts / Satisfactory alternative arrangements.
1

ii)
Condemnation carried out by every Six months.
2

iii)
Yearly requirement prepared on the basis of last three years consumption and buffer stock. (Verify the records)
2

iv)
Availability of linen as per norms.
2

v)
Availability of buffer stock of linen to face Disaster Emergencies.
2

vi)
Upkeep of linen register.
2

vii)
Hospital linen stamped by Dhobi ink.
2


















No.
ITEM
Marks
Score
viii)
Regular disposal of condemned linen materials.
2

ix)
Services of tailor utilized adequately for making new OT wears ete.
shade and mending the torn cloths etc.
2

x)
A practice of Dirty/spoiled linen being decontaminated/washed and given
to Dhobi followed.
2

xi)
O T Linen is kept separately and washed separately.
1

xii)
Paramedical uniforms
2

xiii)
Class IV Uniforms
2

xiv)
Concept of Central Linen Supply System implemented.
2

13)
MEDICAL / NON MEDICAL STORES (MARKS 45)


I)
Suitability of location for all sections of Hospital and adequate space
for medical store
2

ii)
Restriction of entry for unauthorized personnel's and medical representatives.
1

iii)
Stall Knowledgeable in materials management, system of FiFo,
bin card, lead time, buffer stock reorder level are followed
3

iv)
Inspection of stores by the Civil Surgeon/R M O (CI) in last six months verify the stock book.
2

v)
Availability of Vital, essential and desirable drugs sufficient to last for at least three months.
2

vi)
Upkeep of expiry date register and its regular inspection by RMO.
2

vii)
Efforts made to redistribute large stock of slow moving drugs for its
utilization or redistribution.
2

viii)
Check a few A B C drugs from the stock book to ascertain the correctness of balance quantity
2

ix)
Proper arrangements of the drugs as per ABC/VED Category and
storage of rubber goods as per guidelines.
2

x)
Knowledge of minimum levels for each drug to store keeper by bin card system.
2

xi)
Appropriate steps taken to prevent pilferage of drugs.
2

xii)
All ampoules are stamped with hospital name.
2














No.
ITEM
Marks
Score
xiii)
Entries of donations taken in Donation Register on the same day.
2

xiv)
Separate system for issuing costly drugs.
2

xv)
Satisfactory storage of drugs with reference to temperature, sunlight protection from moisture, availability of refrigerators and exhaust fans.
2

xvi)
Sending of samples to chemical laboratory to check it as per specification and standard & action taken thereon.
2

xvii)
Every parcel is opened within 48 hours and checked the quantity as per order. Communication of any shortages/damages to firm.
2

xviii)
Maintenance of separate Register for the batches declared unfit for use.
1

xix)
Availability of licenses for spirit, morphine, opium.
2

xx)
Circulation of lists of available drugs to all the MOs, OPD & Wards.
2

xxi)
Submission of certified bills to office for release of payments within three days. (Verify the register)
2

xxii)
Arrangement of regular auction to clear the empty material from store.
2

xxiii)
Availability of Fire Fighting equipment and knowledge to operate.
1

xxiv)
Prevention of drugs and non drugs items from rat nuisance.
1

14)
MEDICAL RECORDS, AUDIT & BIOSAFETY (MARKS 60)


i)
Availability of Medical Record Room with enough number of racks and cupboards etc.
3

ii)
Knowledge of staff in keeping the medical records in desired fashion.
2

iii)
Regular reporting of births & deaths to the appropriate authority (Verify)
2

iv)
Regular WHO classification of diseases.
2

v)
Quarterly submission of the morbidity, mortality reports
(Check the report of the last month to assess the correctness,)
2

vi)
Give the following rates for this hospital (calculated/record) month wise.



Bed occupancy 80 to 90% - marks  Less than 80%   -1
3


Bed turn over rate 2 days  -  marks, 3 days  - 1
3


Case flow rate 45 to 50/bed/year : 3 marks, <45 1="" :="" marks="" o:p="">

3























No.
ITEM
Marks
Score

LSCS rate 5% to 15% : 3 marks, above 15% : 1 mark
3


Average length of stay
3


Total death Rate <3 -="" 3="" marks="" nbsp="">3%  - 1 mark
3


Net death rates <2 -="" .5="" 3="" marks="" nbsp="">2.5%  -  1 marks
3


Post operative deaths <1 -="" 1="" 3="" mark="" marks="" nbsp="">1% - 1 Mark
3


Anesthesia deaths <0 -1="" .25="" 3="" mark="" marks="" nbsp="" o:p="">

3


Infection rate <2 -="" 3="" marks="" nbsp="">-2%  -  1 marks
3


Infant rate < 2% - 3 Marks    < 2%  -  1 Mark.



Complication rate <2 -="" .5="" 3="" marks="" nbsp="">2.5%  -  1 mark
3

vii)
Monthly Death audit meetings held & minutes of meeting recorded / reported.
4

viii)
Organization of Hospital Infection Control Committee Meetings.
Action taken on minutes and investigation done if any (Verify)
4

ix)
Organization of Clinical Meetings & recording of Minutes.
Involvement of IMA or NIMA etc
5

15)
POST MORTEM FACILITY & M.L.C.RECORD (MARKS 35)


I)
Mortuary cabinet/cold storage is in working condition. If not,
efforts made to get them repaired, (Verify the correspondence)
3

ii)
Availability of the instruments required for performing post Mortem in order and sufficient.
2

iii)
Availability of prescribed P.M. and viscera forms in mortuary,
2

iv)
Arrangement for carrying out post mortem in order and sufficient.
4

v)
Proper writing of post mortem notes and copy submitted to CS (Verify P.M. records)
2

vi)
Reports are checked by the Civil Surgeon/RMO (Verify)
1

vii)
Interval between inquest panchnama and starting of Post Mortem less than two hours.
3

viii)
Action taken for disposal of viscera bottles pending for more than six
months after intimation to concerned police station.
3

ix)
Updated records such as PM Register, Incoming and outgoing dead bodies register available.
2

x)
Scrutinize  PM reports and ensure that whether identification marks injuries, cause of death are recorded properly and certificates are issued promptly.
4















No.
ITEM
Marks
Score
xi)
Injury certificates issued in standard form
2

xii)
Collection of blood sample under prohibition act and submission to
Laboratory without delay.
2

xiii)
Biosafety measures undertaken like cap, mask thick gloves while doing Post Mortem.
3

xiv)
Shade for relatives with drinking water arrangements and light.
2

16)
TRAINING, CME,IEC & SOCIAL ACTIVITIES (MARKS 30)


i)
Establishment of Hospital Training Team and organization of regular clinical meeting, journal clubs and involvement of IMA
6

ii)
Training curriculum designed and training conducted under :



a) MTP/IUD/Sterilization  Training
1


b) MLC/Post Mortem Training
3


c) Trauma Care/Disaster Management drill
2


d) Burn Management
1


e) Blood Transfusion techniques
1


f) Intensive Care Unit Management
2


g) Hospital Administration and Management
1

iii)
Hospital Library with latest journals and basic text book.
3

iv)
Services of Med. Social Worker made available in OPD for IEC Activities.
1

v)
Posters and Banners displayed in OPD, Wards and Premises.
2

vi)
Arrangements of Cinema shows in OPD on fixed days.
2

vii)
Celebration of different National days and record maintenance
2

viii)
Annual Social gathering arranged for the staff
3

17)
M M U, I I E R & TELECOMMUNICATION (Total Marks 35)


a)
VEHICLES (Marks 15)


i)
Status of Vehicle                                        OOF ROAD                      ON ROAD
5


No. of Vehicles :


ii)
Availability of Garages
2

iii)
Proper maintenance of Logbooks & History books.
2

iv)
Major accidents and the procedure of inquiry completed with in 6 months.
2

v)
Efforts made to bring off road vehicle on road
2

vi)
Dispose off of the condemned vehicles by regular auction
2












No.
ITEM
Marks
Score
b)
MOBILE MAINTENANCE UNIT (Marks 5)


i)
Follow up made to fill up the posts of Service Engineer/Foreman and
supportive staff like Electrician, Mechanic, helper etc.
2

ii)
Optimum utilization of services. Verify the no. of break down Vehicles in distri8ct and efforts made for repairs.
2

iii)
Availability of shed and necessary tools needed for workshop.
2

c)
HEALTH EQUIPMENT REPAIRS UNIT (Total Marks 10)


i)
Regular visit of H E R Unit to Hospital. (Verify Tour Diary)
2

ii)
Sending of list of out of order instruments/equipment to Unit every month. Check the list
2

iii)
Efforts made to get the major instruments, equipments repaired promptly by chasing higher authorities.
2

iv)
Verify the down time of various O T and cold chain equipments like operation table, suction machine, I L Rs., refrigerators, centrifuge machines, various types of autoclaves etc.
2

v)
Repairing and enamel painting of cots, bedside lockers, saline stand locally.
2





d)
TELECOMMUNICATION ( Total marks 5 )


i)
Availability of PBX and knowledge Receptionist cum Telephone Operator with up to date maintained trunk call resister.
1

ii)
Availability of Public Phone facility in Casualty and OPD
1

iii)
Availability of functioning Intercom facility for entire hospital if not efforts made to keep in order.
1

iv)
Availability of Telephone directory and telephone numbers of Collector, Police Superintendent, Fire Brigade, Water supply, other ambulances, M S E B., and private nursing homes in emergency service department.
2























No.
ITEM
Marks
Score
18)
ACHIEVEMENT IN NATIONAL HEALTH PROGRAMMES : (Marks 75)
a)
FAMILY WELFARE, M C H , M T P & P P PROGRAMME ( 25 Marks )


i)
Completion of proportional target of Sterilization
100% - 2, 90% - 1, less than 80% - 0
2

ii)
Completion of proportionate IUD target
100% - 2, 90% - 1, less than 80% - 0
2

iii)
Maintenance of - ILR, Refrigerator or walk in cooler is satisfactory with break down of cold chain less than 2%
2

iv)
Up to date para wise, religion wise breakup of total deliveries taking place in the institute month wise.
2

v)
Conversion of 75% of OB., AB. cases with living issue 2 and above to accept Sterilization.(Achievement - 100% : 2 marks, between 100 - 80% : 1 mark and less than 80% : 0 mark.)
2

vi)
Conversion of 75% of OB., AB., with living issue less than 2 to accept IUD.  (Achievement - 100% : 2 marks, between 100 - 80% : 1 mark and less than 80% : 0 mark.)
2

vii)
Adequate utilisation of field staff for outreach activities, maintenance of eligible couple registers, follow up registers etc. Verify tour dairy of field staff.
2

viii)
Organization of diagnostic camps, adoption of Primary Health Centres/Rural Hospitals for providing specially services, training of staff and officers in field.
2

ix)
Organization of MTP Training in Civil Hospital and the training curriculum is devised. (Verify the records)
2

x)
Every Taluka HQ should have at least one MTP centre. If not, efforts made to establish.
1

xi)
All recognized MTP centres ( Govt. of private) should be inspected once in a year. If 100 % : 3, 80 to 99% : 2 Below 70% :1 ( Verify the records )
3

xii)
80% of MTPs with living issue more than two should accept any of the terminal method of Family Planning. ( 80% and above : 2 marks, 80 to 70% :1, less than 70% : 0 marks.)
2

xiii)
90% MTP cases having issue less than two should accept IUD. ( 80 to 90% : 1 marks Less than 80% - 0 marks )
1

















No.
ITEM
Marks
Score
b)
NATIONAL MALARIA ERADICATION PROGRAMME : ( Marks 5 )


i)
Blood smear collection ( 15% to new OPD )
100% - 5, 90 to 100% - 3, 80 to 90% - 2, less than 80% - 0
2

ii)
Blood smear examination done in Lab. On same day & treatment given as malaria clinic.
1

iii)
Knowledge of MOs about presumptive and radical treatment of PV & PF
2

c)
NATIONAL TUBERCULOSIS CONTROL PROGRAMME : ( Marks 10 )


i)
Sputum Collection 25% of total new OPD at DTC
100% - 2, 90% to 99% - 1, less than 90% - 0
2

ii)
Sputum positively rate
10% - 2, 8 to 10% - 1, less than 8% - 0
2

iii)
Sputum conversion rate from positive to negative
80% - 2, 60 to 80% - 1, less than 80% - 0
2

iv)
Disposal of sputum cups by burning or burial.
1

v)
No. of sputum positive patients brought under Short Course Chemotherapy Dots
100% - 2, 80 to 99% - 1, less than 80% - 0
2

vi)
Maintenance of up to date and centre wise Index Register, Indexing Card, defaulters etc.
1

d)
NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS ; ( Marks 10 )


i)
Completion of prop. target of cataract cases for Hospital
100% - 2, 90% to 99% - 1, less than 90% - 0
2

ii)
Completion of Cataract targets for Camp.
100% - 2, 90% to 99% - 1, less than 90% - 0
2

iii)
Follow up study done for restoration of vision after operation
3

iv)
Other camps like kerotoplasty, squint, plastic surgery, organized
3

e)
NATIONAL LEPROSY ERADICATION PROGRAMME : ( Marks 5 )


i)
Awareness of M Os about M.D.T., Lepra reaction management
2

ii)
Reconstruction surgery camps organized
1

iii)
Sanitation and management of temporary hospital ward
2

f)
STD / AIDS CONTROL PROGRAMME ( Marks 10 )


i)
Training of Med. Officers and Para medicals in STD/HIV/AIDS
1

ii)
V D R L Screening of all STD cases done.
1

iii)
ANC Screening for VDRL Done.
1

iv)
Syndromic approach as per guidelines followed.
1









No.
ITEM
Marks
Score
v)
Condom distribution to STD cases
1

vi)
Drugs used as per National guidelines
1

vii)
Attempt made for partner notification & appropriate steps.
1

viii)
Reports sent regularly in prescribed format
1

ix)
Biosafety  measures followed in regards to prevent HIV infection
1

x)
Equipments supplied by NACO used meticulously.
1

g)
CANCER CONTROL PROGRAMME ( Marks 10 )


i)
Availability of papsmears facilities and Follow up study of positive cases.                               ( Verify the records )
2

ii)
Training of qualified Pathologist or Gynecologist & Technicians in papsmear technique and working in the section.
2

iii)
Availability of adequate equipments and uninterrupted supply of staining materials.
2

iv)
Availability of adequate reagents and chemicals for papsmear at clinic
2

v)
Organization of diagnostic camps for cancer cervix, tobacco related cancers in the Tribal and difficult area of District with the help of NGOs
2

19)
ENVIRONMENT SANITATION & WATER SUPPLY ( Marks 25 )


i)
Efforts made by CS / RMO to improve the general sanitation of hospital premises by preventing open air defection underground drainage system keeping dust bins at various places etc.
4

ii)
Efforts made to prevent nuisance of stray animals like pigs, donkeys, cows, goats in the premises by providing compound wall and cattle trap etc. at Entrance and Exist.
2

iii)
Arrangements for regular lifting of garbage with the help of Municipality / Corporation
2

iv)
A working incinerator is available ( Diesel/ Manual ) or attempts made to get it repaired or installed new.
2

v)
Anti smoking, spitting boards & other Health Education Boards depicted at prominent places in Hospital Campus
1

vi)
Cleanliness inside and outside of Canteen / Zunka Bhakar Kendra
2

vii)
Arrangement of sufficient illumination arrangements in Hospital premises by Street light etc.
1

viii)
Provision of Public latrines / toilets / Sulabha Shouchalaya etc.
1

ix)
Source of water supply is adequate, if not, then efforts made to augment it by Borewell or drugwell etc.
3











No.
ITEM
Marks
Score
x)
Sanitation, Cleaning and general Condition of overhead tank / sump well. Verify reports of OT test done by Sanitary Inspectors. Cross check done by RMO (OR).
5

xi)
Collection of water charges at domestic rate where the supply is combine for hospital and staff quarters
2

20)
DHARMASHALA ( Marks 5 )


i)
Availability of Dharmashala or if not efforts made to construct it through donations.
2

ii)
If Available :


a)
Whether adequate rooms available with kitchen, platform, chulla, condition of sanitary blocks satisfactory, and electric tubes/bulbs, fans are provided in all rooms and halls.
2

b)
Rounds taken by C S / R M O and efforts made to improve facilities like water supply, kitchen & safety.
3

21)
CONSTRUCTION & GARDEN DEVELOPMENT (  Marks 30 )


i)
Efforts made to get the minor repairs through the P W D’s maintenance grants as per norms laid down per Sq. meter.
2

ii)
Efforts made to get desired and essential addition and alternations through discretionary grants from DHS & efforts for getting quality work through regular supervision of on going work
4

iii)
Master Plan for major constructions in near future and efforts made to get Administrative Approvals and D P D C Provision.
4

iv)
Priority list prepared for the minor construction to be taken in years to come.
2

v)
Quarters available to all essential staff, if not, efforts made to provide or construct.
3

vi)
Sanctioned Plan grants utilized, if not, efforts made for
2

vii)
Efforts made to develop hospital garden through our own staff or Voluntary Organization on donation.
2

viii)
Post of Mali is adequately utilized for garden work.
2

ix)
Availability of adequate water supply.
2

x)
Arrangements to protect garden from stray animals.
2

xi)
Decorative arrangements in garden such as showers, sprinkles.
2

xii)
Development of Children’s park.
2

xiii)
Display of Health Education slogans.
1











No.
ITEM
Marks
Score
22)
NURSING SCHOOL ( Marks 15 )


i)
Availability of Buildings, Lecture hall, Faculty Member rooms as per norms.
2

ii)
Availability of all teaching material including Audio / Video aids.
2

iii)
Schedule of Training / field visits planned and displayed.
2

iv)
Vehicle in good condition.
1

v)
Facility of kitchen, diet, adequate utensils for serving food to students and quality of food.    ( Verify )
2

vi)
Hostel arrangements including rooms, linen, cleanliness, availability of water supply, Bathrooms, toilets, electricity, geyser, adequate fans, tubes, recreation facility like TV, library, carom, table tennis etc.
4

vii)
Medical Examination of Candidates
1

viii)
Guest Lectures arranged, social gathering
1

23)
OFFICE ADMINISTRATION : ( Marks 60 )


i)
Cash Book and Cash Verification once in 3 month by C S (Ascertain)
3

ii)
Security Deposits collected from the staff working in Stores, Operation Theater, Cash Section, Outward Section etc.
2

iii)
Muster roll and Leave Account, Late Muster checked by Administrative
Officer/Chief Adm. Officer
2

iv)
Standing Order file neatly maintained
2

v)
Maintenance of Service Books of all cadres
2

vi)
Recurring & Non Recurring Expenditure statements submitted in time to
Higher authorities as per schedule
2

vii)
Efforts made to investigate the grievances and complaints received and corrective action taken.
3

viii)
Efforts made for disposal of all E B cases
2

ix)
Efforts made to settle the leave at local level and beyond power, proposals submitted to higher authorities.
2

x)
Maintenance of increment registers and scrutiny of pending advances, recovery etc.
2

xi)
Efforts made to finalize the Pension cases and appointment on compassionate grounds etc.
4

xii)
Compliance of Audit & Store Verification Paras
4

xiii)
Pending Confidential Reports CI.III, CI.II and CI.I
4

xiv)
Local Purchases in comparison with total expenditure on medicine not more than 5%
3











No.
ITEM
Marks
Score
xv)
Efforts made to settle pending medicine bills verify the records
3

xvi)
Hospital Advisory Committee formed. If not, efforts made to constitute it.
2

xvii)
Names of Members displayed in O P D and Casualty Deptt.
2

xviii)
Regular meetings held as per guidelines, if not, efforts made for.
2

xix)
Action on the decisions made in the meeting or efforts made for their fulfillment.
4

xx)
Hospital Fees Collection
More than last three years average collection and State average collection : 10 marks,
Either more than last three years average collection or state average collection : 7 marks
Less than both : 2 marks
10

24)
OUTREACH ACTIVITIES ( Marks 20 )


i)
Diagnostic and Operative Camps such as Plastic surgery camps, Reconstructive surgery for Leprosy patients, Dental Camps etc. ( Except Cataract Surgery Camps)
5

ii)
Providing Specially services to Rural / Cottage Hospitals by adopting one or two RH/CH for providing Specially Services for operative procedures on regular basis. ( Verify the record)
5

iii)
Inspections of Rural Hospitals / Cottage Hospitals
Rural Hospitals and Cottage Hospitals needs to be inspected by CS twice a year and corrective action taken. ( Verify the records)
Inspection Proportionate target 100% : 10 marks, 80% : 7 marks, 70% : 5 marks below 70% : 0 marks.
10

25)
RESEARCH ACTIVITIES ( Marks 20 )


i)
Operational Research study undertaken such as Exit Interviews of discharge patients, study undertaken to reduce patients waiting time, efforts made to investigate sources of infection, special ways of treating burn cases, Investigation of material, infant mortality in hospital and remedy suggested based on the results etc. or Paper presentations in various State and National level conferences.
10

26)
INNOVATIVE ACTION In order to curtail the expenditure such as analysis on medicine / bed / year, expenditure on diet / bed / year, linen / bed / year and corrective actions taken thereon.
10

27)
DONATIONS.  In kinds and in Cash, Prizes, Awards etc. received by Hospitals in last two years.
5









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1 comment:

khan said...

I am first time seen in Indian real, original, very simple, very loyal & true history of health system.

January 1, 2014 at 10:20 PM

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