NABH – ASSESSOR CHECKLIST_ENTRY LEVEL HOSPITAL

CHECKLIST FOR NABH

ASSESSORS
Entry Level Hospital
19/6/2017

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AREA WISE CHECKLIST

Introduction
The area wise checklist of what to look for during the assessment on the basis of priority has 2
levels of requirements:

i. Primary: Most vital and essential requirements for an area

ii. Secondary: General requirements for an area

Some standards apply across the hospital and can be checked at any point/ place.

This checklist can be used for practical guidance. The assessor should not limit the assessment only
to this checklist and can check other applicable standards based on his/her own initiative and as
per assessment schedule.

Staff and Patient Interview checklist is provided at the end of the document, however, this can be
applied in the various areas and modified as per the department being assessed.

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CONTENTS

Clinical Areas

S. No Department/Area Page Number

1. Emergency and Ambulance 5

2. Out Patient Department 7
3. Wards 9
4. Specialized wards 12
5. Palliative Care 13
6. Dialysis Unit 14
7. Intensive Care, Neonatal/ Paediatric ICU and High 16
Dependency Units
8. Operation Theatre 19
9. Recovery Room 21
10. Endoscopy 22
11. Imaging: X Ray/ USG/ CT Scan/ MRI 24
12. Nuclear Medicine 25
13. Cardiac Catheterization lab 27
14. Laboratory: Haematology/ Biochemistry/ Pathology/ 30
Microbiology
15. Blood Bank 32
16. Radiation therapy/Radioactive drugs 33
17. Nutrition 34
18. Hospital Infection Control 35

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Non Clinical Areas

S. No Department/Area Page Number

1. Document Review 36
2. Quality Management 37
3. Management/Administration 38
4. Committees 40
5. Human Resource Department 41
6. Medical Record Department (MRD) 44
7. Hospital Information System(HIS) 47
8. Front office: Registration, Admission and Billing counters 48
9. Biomedical Equipment Management: Equipment, Medical 49
Gases, Vacuum System etc.
10. Medication Management: Pharmacy and Pharmacy Store 50
11. Purchase 52
12. Facility Management: Engineering and Maintenance 53
13. Safety Program 56
14. Housekeeping 57
15. Laundry and Linen 58
16. Kitchen/Canteen 59
17. Mortuary 60
18. CSSD 61

Interviews

S. No Department/Area Page Number

1. Patient and family interview 62

2. Staff interview-Care of patients 62
3. Staff interview-HR 63
4. Staff interview-Safety 63

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Clinical Areas

1. Emergency Room and Ambulance

Emergency Room: Primary

COP 2a-e  Policies/procedure/protocols for emergency care
 Procedure for handling MLC case (including capturing identification
marks and police intimation)
 Emergency care/ admission/ discharge documentation
 Triage, contents of triage policy: categories, ask for demo/ policy on
handling of mass casualties (reference guidebook for entry level SHCO)
FMS 4 d  Mock drills of disaster management (internal disasters like fire)
COP 2 b  Training in CPR – BLS/ ALS, triage
AAC 2 a –b  Registration of emergency patients 24 x 7
/ COP 6a  Patient admission/ time for admission request completion
 Availability of registration form and consent for admission
 Transfer out form and transfer out record
 check stability/unstable/transfer notes.
 Referral of patients
 Staff awareness regarding the same
 Managing non availability of beds
AAC 2 b  Admission criteria and priorities for ICU
AAC 3 a –d  Predefined initial assessment
 Time frame for doing and documenting initial assessment
 Initial Nursing assessment
 Staff awareness regarding the same
AAC 3 b  Staff qualification – Doctors – MBBS and PG in various specialities
 Nurses – GNM/B.Sc Nursing / M.Sc Nursing (Diploma , degree and PG in
nsg) – Reference guidebook for SHCO entry level 1st ed)
AAC 1b,  Signposting and Directional signage’s (which language) from approach
FMS 1a , road
COP 2a  Adequacy of access to Emergency (easy and unobstructed). Flow of

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patients, unobstructed
COP 1a  Care records and treatment is signed and dated by concerned doctor
 Adherence to clinical practice guidelines
COP 5 a,c  Scope of obstetrics services – obstetric emergencies
 Transport of neonates (staff awareness)
COP 6 a  Scope of paediatric services
 Staff awareness regarding same
COP 10a  IV sedatives in emergency: conscious sedation, monitoring, consent
MOM 2 a,b  Safe storage of medications
MOM 2 e  Emergency drug management, expiry of medications, LASA , high risk
storage,
MOM 3a-d  Prescription of medicines
 Legibility of handwriting
 SOP on prescription of high risk medications
MOM 5a-e  Medication administration
 Staff interview on the methodology of administration
 Patient identification prior to medication administration
 Storage, prescription of narcotics – if applicable
 Medication administration documentation

Emergency Room: Secondary

 Patient interview
PRE 1a-g  Patients charter display and awareness among staff
AAC2a, COP  Informed consent for admission, procedures, anaesthesia and surgery
7e, COP 8b
HIC 2a  Availability of hand washing facilities
HIC 2 b  Adequacy of supplies
HIC 2 c  PEP protocol staff awareness
HIC 3 b  Segregation of bio-medical waste
COP 3 a –e  Rational use of blood and blood products – Policy and procedure
 Informed consent
 Monitoring transfusion reactions

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 Staff awareness on above policies

COP6 d  Code Pink – staff awareness if neonatal and obstetrics emergencies are
routed through ER
MOM 5 a-e  Medication administration, identification of patient prior to
administration

Ambulance: Primary
COP 2a  Adequacy of parking for Ambulances
COP 3d  Communication system of Ambulance
COP 3d  Check list of Ambulance, drugs and equipment
COP 3e  Ambulance: adequate equipment in working order
COP 2 b  Training of personnel on BLS/ACLS
ROM 1b  Statutory requirements
o RC book
o License of driver (s)
o Yellow Badge of driver
o Insurance
o Emission check
o Fitness Certificate
Secondary

ROM 3 a  Formal documented agreement (MOU) for outsourced ambulance

services, if any
 Monitoring of the quality of the outsourced ambulance services
 Patient interview
 Staff interview

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2. Out Patient Department

OPD- Primary

AAC 1 a  Scope of services displayed bilingually

 Staff orientation about scope of services

AAC 2 a  Policy and procedure of registration of patient – OP, IP

ROM 2d  Availability of the billing process requirements ( Administrative

department)
 display of the billing tariff
AAC 3a-d  Predefined initial assessment and re-assessment
 Time frame for doing and documenting initial assessment
 Initial assessment to include nursing assessment .
 Documented plan of care including preventive aspects of the care
COP 5a,c  Care of high risk obstetrical patients – display, maternal nutrition
assessment, antenatal records
COP 6a-e  Care of paediatric patients
o display the scope
o provisions for special care of children
o detailed nutritional, growth, psychosocial and immunization
assessment
o parent education on nutrition, immunization and safe parenting
and documentation of the same.
 Staff awareness on above policies
 Patient interview
MOM 1a  Documented policies and procedures on prescription of medications
MOM 2 a-e  Storage of vaccines, LASA, high risk medications,
 Expiry dates of medications
MOM 3 a -d  Minimum requirements of a prescription
 Check who writes prescription orders
 Orders are written in a uniform location in the medical records
 Medication orders are clear, legible, dated, timed, named and signed

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 Medication orders contain the name of the medicine, route of

administration, dose to be administered and frequency/time of
administration

Secondary
AAC 2a  Patient admission from OPD
AAC 2b  Managing non availability of beds
 Patient transfer
 Referral of patients
PRE 1d  General consent for treatment
 Patient and/or his family members interview for the scope of general
consent
PRE 2 a  Cost of treatment discussed with patient / relatives
HIC 2a,b  Hand washing facilities, adequate gloves, masks, soaps, and disinfectants

HIC 3b  Bio-medical waste segregation

 Staff Interview – Care of Patients
 Staff interview – HR
 Staff Interview – Safety
 Staff interview - billing procedure, scope of services
 Patient Interview

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3. Wards

Primary: Patients’ case file

AAC 3a –d  Predefined initial assessment and re-assessment
 Time frame for doing and documenting initial assessment - finished
within 24 hours
 Initial Nursing Assessment
AAC 4b-d  Reassessment – frequency of reassessment, documentation of response
to treatment, plan for further treatment or discharge
AAC 4ª  Qualified individual identified as responsible for care – Qualification of
working nurses and doctors
AAC 2b  Transfer of patients between departments/units/ out of hospital
 Transfer note
 Referral of patients to other departments/specialties, referral form
AAC 4d ,  Discharge planning in coordination with various departments, Check
AAC 7a-b for discharge summary including medico-legal cases / LAMA/ discharge
at request
AAC 7c-e  Content of discharge summary
COP 1a-b  Care and treatment orders are signed, named, timed and dated by the
doctor
 Plan of care countersigned by the clinician in charge within 24 hours
(optional)
 Clinical practice guidelines
COP 2b,  CPR – Policy and procedure, staff trained in BLS/ALS,
COP 3a,c,d,e  Rational use of blood and blood products - Policy and procedure,
informed consent, patient and family education about donation,
monitoring transfusion reactions
COP 8a-c  Care of patients undergoing surgical procedures - Policy and procedure,
preoperative assessment and provisional diagnosis documented prior
to surgery, informed consent obtained by a surgeon, documented
policies and procedures to prevent adverse events, surgical safety
checklist
COP 7 b-g  Pre-anaesthesia assessment, anaesthesia plan, immediate pre-operative

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re-evaluation, informed consent, anaesthesia monitoring form, pain

assessment and management
MOM 1a  Documented policies and procedures on prescription of medications
MOM 2 a-e  Storage of medications, LASA, high risk medications,
 Expiry dates of medications
MOM 3 a -d  Minimum requirements of a prescription
 Check who writes prescription orders
 Orders are written in a uniform location in the medical records
 Medication orders are clear, legible, dated, timed, named and signed
 Medication orders contain the name of the medicine, route of
administration, dose to be administered and frequency/time of
administration
MOM5e  Narcotic drugs procedure
 Storage
 Handling
 Documentation

Secondary
PRE 1a-g,  Patients and families are informed of their rights and responsibilities in
a format and language that they can understand
 Staff awareness on protecting patient and family rights
PRE 1d  General consent for treatment
 Consent for procedure
 Patient and/or his family members interview for the scope of general
consent
PRE 2 a-b  Patient and family education on following aspects in the language that
they understand
o Plan of care
o Preventive aspects
o Possible complications
o Medications
o Expected cost of treatment
o Expected result

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PRE 1a  Patient privacy protected

 Cleanliness and general hygiene,
HIC 1a-d  cleaning and disinfection protocols
 Sterilized sets: expiry dates, storage conditions
HIC 2a-b  Check hand washing facilities for staff in all care area, instructions for
proper hand washing
 Check Adequate soap, masks, gloves and disinfectants are available
HIC 3b  Segregation of bio-medical waste
FMS 4b  Signage
 Fire exit ,fire extinguishers, signs etc.
 Floor plans
FMS 3c,e  All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 4c  Gas and vacuum supply / Storage of oxygen cylinders/Condition of
Humidifiers
FMS 2 b  Preventive and breakdown maintenance
IMS 1a,c,d  Medical record unique no. / Dated and timed entry / author are clear
IMS 2 a-b  up-to-date and chronological order of case records
 information regarding reasons for admission, diagnosis and plan of care
 Patient interview
 Staff interview

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4. Specialized Wards

Paediatric

Primary
COP 6a-e  Care of paediatric patients - display the scope,
 age specific competency,
 provisions for special care of children,
 detailed nutritional, growth, psychosocial and immunization assessment,
 provision for preventing child/neonate abduction and abuse
 Parent education on nutrition, immunization and safe parenting and
documentation of the same

Secondary: Checklist of ward

OBG and Labour Room

Primary
COP 5 a-c  Care of obstetrical patients –
o Display of scope of obstetric services stating whether high risk
obstetric cases can be cared for or not
o Assessment of maternal nutrition
o Competence of staff handling high risk obstetrical patients
o Ante –natal check –up records
o Post-natal care
o Facilities to take care of neonates of high risk pregnancies,
NICU/PICU with proper equipment and staff to take care of
neonates of high risk obstetric cases

Secondary: Checklist of ward

Chemotherapy Unit (NA) No special standard on this exists however if it is in the

scope of services of organization then can be treated as high risk medications
administration

Primary
MOM 3d  Chemotherapeutic drug procedure – for indenting, prescribing, list of
medications stated under high risk medications
MOM5a-e  Preparation, administration and disposal of chemotherapy drugs

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 Staff training

Secondary: Checklist of ward

5. Palliative Care – No specific standard for this but if HCO has this under scope then
can consider the same under clinical practice guidelines

Primary
COP 1b  Define the group of patients for whom palliative care is applicable
 Appropriate assessment and management of pain
 Patient and family education on various pain management techniques
 End of life care – Documented policies and procedures, unique needs
identification, autopsy/ organ donation process
 Staff awareness on end of life care

Secondary
MOM 5 b  Check labelling prior to making a secondary medicine
 Check patient is identified before administering medication, verified from
the order/ dosage route/ timing
MOM 5e  Procedure for handling narcotics/ license/
 documentation of usage/ disposal/
 handled by competent staff
 Patient interview
 Staff interview
 Staff training

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6. Dialysis Unit

Primary
HIC 1b-d,  Overall adherence to infection control
2a-b  Re-use policy of tubes, how safely it was kept and the labelling
requirement to prevent exchange/ensure patient’s safety.
 Check Adequate soap, masks, gloves and disinfectants are available
FMS 3 a  Quality of RO water
PRE 1d  Policy on consent. Who can give consent when patient is incapable
FMS 2 b  All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records

Secondary
 Patient interview
 Staff interview
COP 2 b  Training in CPR – BLS/ ALS
MOM 2 e  Emergency drug management
HIC 2d  Sterilized sets: expiry dates, storage conditions
HIC 2 a-b  Check hand washing facilities for staff in all care area, instructions for
proper hand washing
 Check Adequate soap, masks, gloves and disinfectants are available
HIC 3 b  Segregation of bio-medical waste
FMS 4d  Documented plan for maintenance of medical gas and vacuum system
 SOP on handling, storage, usage and replenishment of medical gases
 Medical gases handling, storage and usage safely
 Medical gas and vacuum supply / Storage of oxygen
cylinders/Condition of Humidifiers
FMS 4 a-b  Documented plan for handling fire and non-fire emergencies
 Safe Exit plan in case of fire and non-fire emergencies
 Signage pertaining to fire exits
 Open and easily accessible fire exits without any obstruction
 Smoke detectors, fire alarms, fire alarm control panel etc. (where

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applicable)
 Fire exit, fire extinguishers, no smoking signs etc.
FMS 1 c  Identification of hazardous materials
 Implementation of the processes for sorting, labelling, handling,
storage, transporting and disposal of hazardous materials
 Spills management plan of hazardous materials
 Staff awareness
 Patient interview
 Staff interview

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7. Intensive Care, Neonatal/ Paediatric ICU and High Dependency Units

Primary
COP 4a-b  Policy on admission. If they have written about admission and
discharge criteria for ICU/HDU/NICU/PICU then to check for adherence
or else just a general check on which types of patients are admitted
 Adherence to infection control practices
 Adequacy of staff and equipment
AAC 2b  Policy for Bed shortage in ICU
AAC 3a,c,d  Predefined initial assessment
 Time frame for doing and documenting initial assessment
AAC 4b,d  Reassessment – frequency of reassessment, documentation of response
to treatment, plan for further treatment or discharge
COP 2 b  Documented policies and procedures on use of resuscitation /CPR/
adequate trained staff and equipment
COP 3a-e  Rational use of blood and blood products - Policy and procedure,
informed consent, patient and family education about donation,
monitoring transfusion reactions
COP 6b  Age specific competency in case of Paediatric and Neonate population
COP 6c  Nutritional assessment
 Growth assessment
 Immunization assessment
MOM 2 e  Emergency drug management
MOM 3a-c  Medicine orders are written in a uniform location clear, legible, dated,
timed, named, signed
 Written order for high risk medication
MOM 5a-e  Medication administration
 Medication administration documentation
MOM 6a-b  Patient monitoring after medication administration
 Knowledge to pick adverse drug events and reporting of the same
MOM 5e  Narcotic drug procedure
 Handling

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 Documentation
HIC 1  Collection of Infection control data
 Availability of various HAI rates of that area and action taken based on
this
FMS 1d  Layout of beds, spacing, visual privacy (optional / unless gross
problems in spacing between the beds)
FMS 2b  All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 3c, 4c  Gas and vacuum supply / Storage of oxygen cylinders/Condition of
Humidifiers
PRE 2a  Patient interview
o Explanation of plan of care, preventive aspects, possible
complications, medications, expected results and cost of care

Secondary
AAC 3a-d  Initial assessment, nursing assessment
IMS2b  Documented plan of care
AAC 4a  Qualified individual identified as responsible for care
 Referral of patients to other departments/specialties
AAC 4b-d  Re assessment documented
AAC 4d ,  Discharge planning in coordination with various departments,
AAC 7 a including medico-legal cases / LAMA, discharge summary to all
AAC 7c-f  Content of discharge summary / death summary
COP 1a-b  Care and treatment orders are signed, named, timed and dated by the
concerned doctor – consultant
 Clinical practice guidelines followed
HIC 2 a-b  Check hand washing facilities for staff in all care area instructions for
proper hand washing
 Check if adequate soap, masks, gloves and disinfectants are available
Hand washing
HIC 3 b  Bio-medical waste
PRE 1d  Policy on consent. Who can give consent when patient is incapable/

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Informed consent situations/ performing doctor’s name.

FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.
IMS 1a-e,  Medical record unique no. / dated and timed entry / author is clear,
 up-to-date and chronological.
IMS 1 e
 Patient / family interview
 Staff interview

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8. Operation Theatre

Primary
COP 71a-i  Pre-Anaesthesia assessment and immediate pre-operative assessment
 Consent for anaesthesia and surgery
 Monitoring during and post anaesthesia
 Criteria for discharge to recovery area
 Monitoring of adverse anaesthesia events
COP 8a-e  Care of patients undergoing surgical procedures - procedure
 Preoperative assessment and provisional diagnosis documented prior
to surgery
 Informed consent obtained by a surgeon
 Qualified persons perform the procedures that they are entitled to
perform(privileging based on credentials)
 Documented procedures to prevent adverse events
 Operating notes and post-operative plan of care
 Surgical safety checklist
COP8f-g  Availability of appropriate facilities and
equipments/appliances/instrumentation in OT
 Patient, staff and material flow conforms to infection control
practices(Layout of OT - no mix of sterile and un sterile)
COP8 f  Surveillance of OT environment
 Monitoring of SSI (optional) / wrong site, wrong patient, wrong
surgeries
MOM 2a-e  Storage of medications
 Expiry dates, clean safe storage, LASA, high risk medications storage
 Emergency drug management
MOM 5 e  Narcotic drug procedure
 Handling
 Documentation
MOM 1b  Procedure for procuring and using implants

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 Entry of batch and serial number in patient’s case file & master log book
PRE 1d, PRE  Consent
2 a-b o Name of procedure
o Name of doctor
o Explanation of risks, benefits and alternatives if any
o Language (that the patient understands) used for taking consent
o Completeness of the consent form in all aspects
HIC1c  Cleaning and disinfection practices defined and monitored
 Equipment cleaning (if any)
HIC 1d  Sterilization/disinfection activities being performed
 Sterilized sets: expiry dates, storage conditions
HIC 1e  Linen disinfection (if any) in OT
HIC 2 a-b  Check hand washing facilities for staff in all care area, instructions for
proper hand washing
 Check Adequate soap, masks, gloves and disinfectants are available
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.
FMS 2b  Documented operational and maintenance (preventive and
breakdown)plan
 All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 3c, 4c  Gas and vacuum supply / Storage of oxygen cylinders/Condition of
Humidifiers

Secondary
COP 2 b  CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of
events during CPR, Communication of corrective and preventive
measures
COP 3a-e  Rational use of blood and blood products - Policy and procedure,
informed consent, patient and family education about donation,
monitoring transfusion reactions
HIC 3 b  Segregation of bio-medical waste

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 Patient interview
 Staff interview

9. Recovery Room

Primary
COP 7g-h  Discharge criteria
 Patient monitoring post anaesthesia
COP 8e  Operating notes and post-operative plan of care

Secondary
 Staff interview
MOM 3a-d  Medicine orders are written in a uniform location clear, legible, dated,
timed, named, signed
 Verbal orders(optional)
 Written order for high risk medication
MOM 5a-d  Medication administration
 Staff interview on the methodology of administration
 Medication administration documentation
 Patient’s self-administration of medicines (optional)
 Management of medications got from outside (optional)
MOM 6a-b  Patient monitoring after medication administration
 Knowledge to pick adverse drug events and reporting of the same
MOM 5e  Narcotic drug procedure
 Handling
 Documentation
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.

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10. Endoscopy (No specific standard for this but if it is in the scope of services of HCO,
then to follow following)

Primary
COP 7a  Sedation policy implementation
 Check who gives sedation and who monitors patient
 Documentation of monitoring activities
 Availability of equipment and manpower
MOM 2 e  Emergency drug management
PRE 1d,  Consent
PRE 2a-b o Name of procedure
o Name of doctor
o Explanation of risks, benefits and alternatives if any
o Language (that the patient understands) used for taking consent
o Completeness of the consent form in all aspects
 Equipment cleaning (if any)
HIC 1d
 Sterilized sets: expiry dates, storage conditions
HIC 2 a-b  Check hand washing facilities for staff in all care area, instructions for
proper hand washing
 Check Adequate soap, masks, gloves and disinfectants are available
FMS2b  All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 4c  Gas and vacuum supply / Storage of oxygen cylinders/Condition of
Humidifiers

Secondary
AAC 4a  Qualified individual identified as responsible for care – Qualification of
working nurses and doctors
COP 2 b  CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of
events during CPR, Communication of corrective and preventive
measures

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COP 3a-e  Rational use of blood and blood products – Policy and procedure,
informed consent, patient and family education about donation,
monitoring transfusion reactions
COP 8b,c,d  Documented procedures on prevention of adverse events like wrong
site, wrong patient and wrong procedure
 Informed consent taken by the doctor performing the procedure
COP8 e  Documentation of the procedures in the patient record
HIC 3 b  Segregation of bio-medical waste
MOM 3a-d  Medicine orders are written in a uniform location clear, legible, dated,
timed, named, signed
 Verbal orders(optional)
 Written order for high risk medication
MOM 5a-d  Medication administration
 Staff interview on the methodology of administration
 Medication administration documentation
 Patient’s self-administration of medicines (optional)
 Management of medications got from outside (optional)
MOM 6a-b  Patient monitoring after medication administration
 Knowledge to pick adverse drug events and reporting of the same
MOM 5e  Narcotic drug procedure
 Handling
 Documentation
 Patient interview
 Staff interview
FMS 2b  Documented operational and maintenance (preventive and
breakdown)plan
 All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.

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11. Imaging: X Ray/ USG/ CT Scan/ MRI

Primary
AAC 6a-d  Scope of imaging services - Radiation hazard, PC-PNDT act etc.
 Display of imaging signages
 Performing and reporting of tests
 Technician qualified as per AERB
 Turnaround time - Check results are available in defined time frame
 Critical results intimation
 Radiation safety programme including usage of safety equipment and
TLD badges
 Adherence to standard precautions and safe practices
 Staff trained in safe practice; staff have safety equipment/ fire
extinguisher/ dressing materials/ etc.
 Safety devices periodically checked
 Availability of safety equipment
FMS 2b  Documented operational and maintenance (preventive and
breakdown)plan
 All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator

Secondary
MOM 2 e  Emergency drug management
PRE 1d  Policy on consent. Who can give consent when patient is incapable/
Informed consent situations/ performing doctor’s name
FMS 2b  All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.

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 Patient interview
 Staff interview

12. Nuclear Medicine

Primary
AAC 6a-d  Scope of imaging services - Radiation hazard, PC-PNDT act
 Display of imaging signages
 Performing and reporting of tests
 Technician qualified as per AERB
 Turnaround time - Check results are available in defined time frame
 Critical results intimation
 Radiation safety programme including usage of safety equipment and
TLD badges
 Adherence to standard precautions and safe practices
 Staff trained in safe practice; staff have safety equipment/ fire
extinguisher/ dressing materials/ etc.
 Safety devices periodically checked
 Availability of safety equipment
FMS 2b  Documented operational and maintenance (preventive and
breakdown)plan
 All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
MOM 7a-b  Documented procedures on usage of radioactive drugs
 Storage, preparation, handling, distribution and disposal of radioactive
drugs
 Staff, patient and visitor education on safety precautions

Secondary
MOM 2 e  Emergency drug management
PRE 1d  Policy on consent. Who can give consent when patient is incapable/
Informed consent situations/ performing doctor’s name

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FMS 2b  All equipment are inventoried and log maintained / calibrated

 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.

 Patient interview
 Staff interview

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13. Cardiac Catheterization lab

Primary
AAC 6-d  Scope of imaging services - Radiation hazard, PC-PNDT act
 Display of imaging signages
 Performing and reporting of tests
 Technician qualified as per AERB
 Turnaround time - Check results are available in defined time frame
 Critical results intimation
 Radiation safety programme including usage of safety equipment and
TLD badges
 Adherence to standard precautions and safe practices
 Staff trained in safe practice; staff have safety equipment/ fire
extinguisher/ dressing materials/ etc.
 Safety devices periodically checked
 Availability of safety equipment
MOM 1a-b  Procedure for procuring and using implants
 Entry of batch and serial number in patient’s case file and master log
book
PRE 1d  Process for taking informed consent
 Who can give consent when patient is incapable
 Staff awareness on informed consent procedure
 Informed consent taken by the doctor performing the procedure
 Consent
o Name of procedure
o Name of doctor
o Explanation of risks, benefits and alternatives if any
o Language (that the patient understands) used for taking consent
 Completeness of the consent form in all aspects
HIC 1c  Equipment cleaning and disinfection

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 Equipment cleaning (if any)

HIC 1d  Sterilization/disinfection activities being performed
 Sterilized sets: expiry dates, storage conditions
HIC 1e  Linen disinfection (if any) in cath lab
HIC 2 a-b  Check hand washing facilities for staff in all care area, instructions for
proper hand washing
 Check Adequate soap, masks, gloves and disinfectants are available



Secondary
COP 2 b  CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of
events during CPR, Communication of corrective and preventive
measures
MOM 2 e  Emergency drug management
MOM 3a-d  Medicine orders are written in a uniform location clear, legible, dated,
timed, named, signed
 Verbal orders(optional)
 Written order for high risk medication
MOM 5a-d  Medication administration
 Staff interview on the methodology of administration
 Medication administration documentation
 Patient’s self-administration of medicines (optional)
 Management of medications got from outside (optional)
MOM 6a-b  Patient monitoring after medication administration
 Knowledge to pick adverse drug events and reporting of the same
MOM 5e  Narcotic drug procedure
 Handling
 Documentation
FMS 2b  Documented operational and maintenance (preventive and
breakdown)plan
 All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration

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records/Refrigerator
FMS 3c, 4c  Gas and vacuum supply / Storage of oxygen cylinders/Condition of
Humidifiers
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.
 Patient interview
 Staff interview

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14. Laboratory: Haematology/ Biochemistry/ Pathology/ Microbiology

Primary
AAC 5a-f  Standard operating procedures
 Appropriate use of logos (e.g. NABL) and scope of lab accreditation (if
accredited)
 Technician qualified
 Turn-around time - Results are available in defined time frame
 Procedures for collection, identification, handling, safe transportation,
processing and disposal of specimens
 Alert and Panic levels - Critical results intimated immediately
 Documented procedures of out sourcing test
 Measurement uncertainties
 Signatures
 Outsourcing and controls
AAC 5e  Documented lab safety programme
 Documented policies and procedures for disposal of infectious and
hazardous materials
 Awareness of safety among employees - Staff trained in safe practice
Staff have safety equipment / fire extinguisher / dressing materials / etc.
 Usage of gloves
 Reagent storage
 Handling spills

Secondary
HIC 3 b  Segregation of bio-medical waste
FMS 2b  Documented operational and maintenance (preventive and
breakdown)plan
 All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration

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records/Refrigerator
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.
 Patient interview
 Staff interview

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15. Blood Bank

Primary
COP 3a-e  Blood bank license and adherence to its terms and conditions
 Adherence to part X B and Schedule F of part XII B and/or XII C of drugs
and cosmetics rules
 Informed consent
 Staff awareness on above
 Transfusion reactions documentation and reporting

Secondary
PRE 1d  Informed consent on HIV
MOM 2e  Emergency medication management
HIC 3 b  Segregation of bio-medical waste
 Patient interview on blood donation
 Staff interview
FMS 1a  Signage
FMS 4 A-B  Fire exit ,fire extinguishers, no smoking signs etc.
FMS 2b  Documented operational and maintenance (preventive and
breakdown)plan
 All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
FMS 3c, 4c  Gas and vacuum supply / Storage of oxygen cylinders/Condition of
Humidifiers

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16. Radiation therapy/Radioactive drugs

Primary
AAC 6a-d  Comply with BARC/AERB legal requirements
 Scope of imaging services
 Performing and reporting of tests
 Technician qualified as per AERB
 Turnaround time - Check results are available in defined time frame
 Critical results intimation
 Safety programme including usage of safety equipment and TLD badges
 Use of personal protective equipment
 Isolation barriers for radioactive areas
 Adherence to standard precautions and safe practices
 Staff trained in safe practice
 Safety equipment/ fire extinguisher/ dressing materials/ etc.
 Safety devices periodically checked
 Imaging signage - Radiation hazard
MOM 7a-b  Documented procedures on usage of radioactive drugs
 Storage, preparation, handling, distribution and disposal of radioactive
drugs/ isotopes (Iv 192, Cs XX, Co 60)
 Staff, patient and visitor education on safety precautions

Secondary
MOM 2 e  Emergency drug management
PRE 1d  Policy on consent. Who can give consent when patient is incapable/
Informed consent situations/ performing doctor’s name
FMS 2b  All equipment are inventoried and log maintained / calibrated
 Preventive maintenance/service labels on Equipment/calibration
records/Refrigerator
 Patient interview

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 Staff interview

17. Nutrition Therapy

Primary
COP 6 b  Maternal nutrition assessment
COP 7c  Nutritional assessment of children
COP 7 e  Family education on child’s nutrition

Secondary
 Patient interview

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18. Hospital Infection Control (HIC)

Primary
HIC 1  Documented Infection Control Programme – HIC manual
 HIC committee and team
 Qualified HIC nurse (optional)
 Identified methods of surveillance
HIC 1a-e  Adherence to
o standard precautions
o hand hygiene guidelines
o equipment cleaning and sterilization practices
o disinfection and sterilization practices
o laundry and linen management
 Effectiveness of housekeeping services
HIC 2a-b  Facilities for hand washing, Monitoring of hand washing
 Adequacy of supplies like gloves, masks, soaps, and disinfectants
HIC 2c  Pre and post exposure prophylaxis
HIC 3a-e  Authorization for generation of bio-medical waste
 Adherence to various conditions of the act
 Usage of appropriate personal protective equipment
 Visit by the hospital authorities to the disposal site
HRM 2a,  Training - Induction and in service training on occupational health
HRM 4 b hazards, risks in hospital environment
 Pre and post exposure prophylaxis

Secondary
 Staff interview

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Non Clinical Areas

1. Document Review

Primary
 NABH Application contents,
 Internal assessment report,
 Scope of the organization
CQI 1a,b  Documented Quality Improvement programme (QIP)
 Committees-composition and functioning
 Records: Attendance, minutes etc.
ROM 1a  Organization structure
ROM 2 a  Vision and mission, strategic plans
 Manuals of all departments
FMS 1b  List of statutory applicable acts/rules
 Licenses
 Other certificates/correspondence to meet statutory obligations

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2. Quality Management

Primary
CQI 1a-g  Documented Quality Improvement programme (QIP)
 Committee-composition and functioning
 Designed individual
 Documented Patient Safety program
 Quality assurance and risk management
 Annual update of QIP to review of QIP and identification of improvement
activities
CQI 2a-b  Data for key performance indicators that are selected by HCO
 Clinical: mortality rate, percentage of cases where preoperative antibiotic
was given, incidence of catheter-associated UTI, number of surgical site
infections, number of errors in reporting of Lab investigations.
 Nonclinical: OPD waiting time, patient satisfaction rate, number of stock
outs of emergency medications, number of errors in billing.
 Check raw data
 Verify collection methodology of data i.e Formula or sample size, and
method of data collection is determined
 Data analysis
 Indicators are discussed and measures taken to improve the quality

Secondary
 Staff interview

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3. Management/Administration

Primary
ROM 1 a  The organogram is present.
 The organogram is approved by the Top management.
 All departments are represented in the organogram.
 All management levels are represented.
 The hierarchy is accurate.
 Cross-reporting, if any, is represented.
 Involvement of department heads in quality initiatives
 Support for quality improvement activities
 Adherence to statutory requirements at least registration with
appropriate authorities
ROM 2 a-d  Displaying mission
 Ethical management
 Revealing ownership
 Billing based on standard tariff
ROM 3 a-b  Multi-disciplinary committees
o Quality and Safety Committee
o Infection Control Committee
o Pharmacy and Therapeutics Committee
o Blood Transfusion Committee
o Medical Records Committee
o CPR Committee (Optional)
ROM 4a-b  Qualification and experience of person heading the organization
PRE 1a-g  Protection of patient rights by addressing grievance
CQI 1a-c  Availability of resources
 Monitoring of KPI / QI

Secondary
HIC 1  HIC programme
HIC 2b  Resource Allocation quality improvement/ HIC

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HRM 1  Staff mix based on patient care needs

HRM 2  Training and Development program
HRM 3  Grievance handling
HRM 4  Staff health programme

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4. Committees

Primary
COP 2 b  Composition and functioning of Resuscitation committee
 Staff training on handling emergencies
ROM 3  Pharmaco-therapeutic committee or anything similar
 Development of hospital formulary
MOM 6a  Monitoring of adverse drug events
ROM 3  Quality and Safety committee composition and functioning
 Scope of programme
 Development, implementation and monitoring of safety plans
ROM 3  Infection Control committee composition and functioning
 Scope of programme
 Development, implementation and monitoring of infection control
surveillance activities
ROM 3  Blood Transfusion committee composition and functioning
 Scope of programme
 Development, implementation and monitoring of transfusion reactions
ROM 3  Medical Records committee composition and functioning
 Scope of programme
 Development, implementation and monitoring of medical records audits

Secondary
 Any other committee as required by state/local regulations

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5. Human Resource Department (HR)

Primary
HRM 1a-b  Staff planning
 SOP on recruitment
HRM 3a-c  Training procedure
 Training identification
 Training calendar
 Training records and effectiveness
 Training requirements as per the standard
o Blood and blood products (COP 3)
o Infection control (HIC 1)
o Safety Education program comprising of Fire and non-fire
emergencies, Hazardous materials, occupational Safety (FMS 1e)
o Risks within the hospital environment (HRM 2a)
o Emergency Management of patients / CPR
o Job responsibilities (HRM 2c)
o Training on introduction of new equipment (HRM 2 c)
o Training on change of job responsibilities (HRM 2 c)
o Grievance Handling (HRM 3b)
o Induction training – preferably on following
 Orientation to mission and goals (ROM 2 a)
 Policies and procedures (hospital and department) (HRM
2c )
 Rights and responsibilities-patient and employee (PRE 1)
 Service standards (optional)
HRM 3  Procedure for disciplinary action is available
 Procedure is available for addressing complaints of sexual harassment in
the workplace
 Procedure is available for addressing grievance-handling
 Grievance handling procedure is reviewed and approved by Top
management on a yearly basis
 All concerned documents and materials have the updated procedure

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 Records of disciplinary proceedings are maintained

 Records of grievance handling proceedings are maintained
 Records of proceedings that handle complaints of sexual harassment in
the workplace are maintained confidentially.
HRM 3 b  Training records
 Staff interviews
o to check staff awareness and understanding of the disciplinary
procedure
o the grievance handling procedure
o dealing with sexual harassment at the workplace
HRM 4a-b  Pre-employment medical examination
 Medical benefits for employees
 Regular health check (at least once a year) of staff involved in patient
care
 Health check of employees exposed to radiation as per statutory
requirements
 Occupational health hazards
 Employee State Insurance Act : applicability
 List of staff whose gross salary is less than Rs. 15,000 per month
Updated every month
 Eligible new staff enrolled under ESI
 Remittance of amount to ESI Monthly remittance -
 Timely remittance (within 21 days)
 Staff interview shows awareness of the provisions under ESI
HRM 4 b  Pre-exposure prophylaxis given for concerned staff
 Post-exposure prophylaxis given following an incident
 Provision of safety measures – personal protective equipment. Audited
during facility tour.
HRM 5a-b  Personal file for every employee containing information on
o Educational qualification
o Disciplinary background
o Health status

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o In service training (optional)

o Performance appraisal (optional)
 Staff interview

Secondary
AAC 1c  Staff training on scope of services – front office
AAC 5e  Training of lab personnel in safety
AAC 6d  Training of imaging personnel in safety
COP2 b  CPR training
COP 2e  BLS training to ambulance staff, ACLS training to doctors and nurses in
ER / Ambulance
COP 6b  Age specific training records of paediatric staff
COP 6 d  Code Pink training
COP 6b, 8d  Qualification of paediatric staff and surgeons
CQI 1  Training on Quality improvement (CQI 1)

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6. Medical Record Department (MRD)

Primary
IMS 1a-e  Medical record unique no
 Policy on authorized person to make entry
 Every entry is dated and timed
 Author is clear
 Contents of medical record are identified
IMS2 a  Records are up to date and chronologically arranged
IMS 2 b-f  Medical record has reason for admission / diagnosis/ plan of care/
Operative and Procedure sheet
 Transferring patients medical records have date of
transfer/reasons/name of receiving hospital (COP2c)
 Signed Discharge note/copy of death certificate with cause, date and
time of death
 Copt of clinical autopsy report (where applicable)
 Access to current and past medical record
IMS 3a-b  Security, integrity and confidentiality of data
 Usage of privileged health information
 Documented policies and procedures on how to handle MR information
requirement
 The audited sample of case sheets are well protected from loss, theft
and tampering.
 The process of retrieval of files is implemented.
 Missing files are traced.
 Adequate fire detection and fire fighting equipment is available and
mock drills are conducted.
IMS 4a-c  Retention Policy
 Maintenance of confidentiality and security at all stages
 Method for destruction of medical records
 Documented procedures are in place for retaining the patients' clinical
records, data and information.

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 The documented procedures are implemented.

 The audited sample of case sheets are well preserved
for the duration of the retention period.
 The process of destruction of medical records is defined and
implemented.
 If the process of destruction is outsourced, adequate measures are
taken to safeguard against leakage of information from these records.
AAC 7b-f  Discharge summary
o reason for admission, findings, diagnosis, condition at the time of
discharge
o investigation results, procedure performed, medication and
other treatment given
o follow up advice and medication instructions
o when and how to obtain urgent care
COP 3d, 7e,  Check for completeness of consent documents
8b, PRE 1d,  Consent for anaesthesia, blood transfusion, and surgical procedures
PRE 2b  Authorized legal representative
 General consent
 Language of consent
AAC4d,  Plan of care is present in the case files
IMS2b
AAC 7a  Medico legal case documentation
 LAMA case file has discharge summary and risks explained
Paediatric cases:
PRE 3a,  Patient assessment includes detailed nutritional, growth, psychosocial
COP 6c, e and immunization assessment
 The children’s family members are educated about nutrition,
immunization and safe parenting and this is documented in the
medical record
COP 7 b, c, d,  Pre anaesthesia assessment, anaesthesia plan , immediate pre op
f evaluation , anaesthesia monitoring,
COP 7e,  Informed anaesthesia consent

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COP 7 h,  recovery criteria

COP 8e,  Informed consent for surgery
COP 8 c d,  Surgical safety checklist,
COP 8e  Operation Notes, , post-operative plan of care

ROM 1 b Random check for statutory documents

 MTP register
 Birth and death registration
 Consent document under MTP act
 Consent document under PNDT act
 Completeness of death certificates
 Medico legal cases documentation
 Any other applicable documents

Secondary
 Staff interview

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7. Hospital Information System (HIS)

Primary
ROM 1b  License for software
 Validation of software
IMS 3a-b  Security, integrity and confidentiality of data
 Safeguarding data/ record against loss, destruction and tampering
 Usage of privileged health information
 Documented policies and procedures on how to handle MR
information requirement

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8. Front office: Registration, Admission and Billing counters

Primary
AAC 1a-c  Display of scope
 Orientation of staff with respect to available services

AAC 2a-b  Procedure for registration and admission (OP, IP and Emergency)
 Management of patients when beds are not available (given in
guidebook for SHCO)
 Awareness of staff
PRE (intent  Display of patient rights and responsibilities
of std)
PRE 1d  General consent process
ROM 2d  Uniform pricing policy in a given setting
 Availability of tariff list
ROM 2a  Display of mission

Secondary
COP 5a  Information to patients if high risk obstetric cases can be or cannot be
taken
COP 6a  Display of scope of paediatrics services
FMS 1a  Signage in local language
 Patient interview
 Staff interview

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9. Biomedical Equipment Management: Equipment, Medical Gases, Vacuum System

etc.

Primary
FMS 2a-bf  Equipment inventory , asset list review, asset tag and log
 Training of staff when new equipment is installed (HRM 2c)
 Preventive maintenance and calibration-- Review of PM tracker
 Adherence to manufacturer/ international guidelines with regard to
preventive maintenance and frequency of calibration
 Review of Preventive Maintenance record as per checklist like
Anaesthesia ventilator, IABP etc.
 Traceability of calibration report
 Preventive and breakdown maintenance plans
 Interview with bio-medical head
FMS3 c and  Documented policies and procedures on procuring, handling, storing,
FMS4c distributing and replenishing of medical gas
 Safety precautions at all levels
 Records as per legal requirements
FMS 4c  Colour coding of pipelines (given in guidebook for entry level SHCO)
 Maintenance plan
 Adherence to manufacturer/ international guidelines with regard to
maintenance

Secondary
 Scope of department
 Staff interview

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10. Medication Management: Pharmacy and Pharmacy Store

Primary
MOM 1a,b  Documented procedures on medication procurement, storage,
formulary, prescription, dispensing, administration, monitoring etc.
 Separate license for each of the pharmacies.
 Adherence to terms and conditions mentioned in the license.
 Duty roster to ensure that there is a qualified pharmacist at all times
(his/her name being mentioned in the license).
 Documented procedures for procurement and usage of implantable
prostheses
MOM 3a-e  Documented policies and procedures for storage
 Storage of medicines in clean, well lit and ventilated environment
and/or as per manufacture’s requirement
 Inventory control practices like FIFO
 Stock of medicines
 Precautions against theft
 Identification and storage of sound alike and look alike drugs
 Procedure to obtain medications when pharmacy is closed
 Availability of emergency medicines
MOM 3a-d  Prescription adheres to statutory requirements and the Code of Medical
Ethics
 Check who writes prescription orders
 Prescription orders are written in a uniform location in the medical
records
 Medication orders are clear, legible, dated, timed, named and signed
 Medication orders contain the name of the medicine, route of
administration, dose to be administered and frequency/time of
administration
 Identified high risk medicines
 Check for the procedure of prescribing High risk medications same is
available
 Procedure for dispensing these medicines

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MOM 4a-b  Policy and Procedures for dispensing

 Expiry date check before dispensing
 High risk medications are verified prior to dispensing – check process
of verification
MOM 5e  Procedure for narcotic drugs
 Storage
 Proper record
 Handling – use and disposal
MOM 6a-b  Adverse Drug events defined and monitored
 Time frame of reporting the adverse events
MOM 7 a-b  Policies and procedures for use, storage, preparation, handling,
distribution and disposal of radioactive drugs

Secondary
ROM 3a  Multidisciplinary committee
PRE 2a  Patient interview on safe and effective use of medicines

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11. Purchase

Primary
MOM 1a  Procedures for procuring implants
FMS 2a  Equipment planning
 Equipment selection

Secondary
 Scope of department
 Staff interview

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12. Facility Management: Engineering and Maintenance

Primary
ROM 1b  Various statutory requirements
o Fire
o Diesel storage
o Liquid oxygen and storage of medical cylinders.
o Boiler
o Electrical inspectorate reports.
o ETP
o DG sets
FMS 1 a,b  Signage
 Up to date drawing, layout, escape route
 Presence of staff round the clock for emergency repairs

FMS 2b  Preventive and break down maintenance plan
 Response time
 Provision of space
 Designated individual for maintenance
FMS 3a-c  Availability of potable water and electricity
 Alternate sources and their testing
 Water quality reports
FMS 1c,d.e  Hazardous material and other potential safety and security risk
identified
 Safety devices
 Facility inspection rounds twice a year in patient care areas and once in
non-patient care areas
 Documentation of facility inspection report
 CAPA , RCA for facility rounds
 Safety education program for all staff
FMS 3 c. 4c  Protocol for operating medical gas and vacuum installations shall be
managed as per policy.
 Daily, weekly, monthly and annual maintenance schedule.

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 Uniform colour coding of medical gas pipelines.

 Safety signage present
 Actual storage of empty and filled cylinders
 By-pass in case of emergencies and back up
 Valves shut off in different loops
 Chained cylinders
 Mechanism of loading and unloading cylinders
 Leak detection systems
 Daily, weekly and monthly checks by operator
 Annual overhaul
 Standardized colour coding of pipelines
 Condition of the cylinders, colour coding.
 Personnel protective equipment for the staff
FMS 4 a  Fire detection systems as per norms
 Fire fighting systems as per norms
 Checking or testing records of the detection and
fighting systems
 Leak detection systems as per norms
 Emergency communication systems
 Plan for managing fire and nonfire emergencies
 Staff training
 Awareness of staff on the plan
FMS 4b  Emergency Floor Plans
 Emergency Evacuation Plan
 Green-coloured exit signage is clearly visible.
 Emergency lighting.
 Emergency floor plans are visible on all the floors
and at conspicuous places.
 An emergency evacuation plan exists.
 Staff are trained in the emergency evacuation plan.
 Staff are aware of their roles during an emergency
evacuation.

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 Mock drills are conducted to test the plan.

Secondary
HRM  Staff Interview

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13. Safety program

Primary
ROM 3  Documented plan for handling fire and non-fire emergencies which
FMS 1a includes exit plan
 Signage pertaining to fire exits
 Open and easily accessible fire exits without any obstruction
 Mock drill schedule and record - Twice a year mock drill
 Smoke detectors, fire alarms, fire alarm control panel etc. (where
applicable)
 Safety Manual
 Safety Committee - composition and functioning
FMS 4ª  Non fire emergencies (Community emergencies, epidemics and
disasters) identified
 Documented disaster management plan
 Provision of supplies
 Tested at least twice a year
FMS 1c  Identified hazardous materials
 Hazardous materials identified have documented procedure for sorting,
storing, handling etc.
 Availability of MSDS for all such material
 Spill management plan
 Staff awareness

Secondary
ROM 3b  Safety committee meeting minutes
FMS 1d,e  Facility inspection rounds
 Awareness of staff by training on patient safety program
 Staff interview on their role in case of emergencies and on safety
aspects

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14. Housekeeping

Primary
HIC 1b,c  Effectiveness of housekeeping services
 Disinfection process
FMS 1c  Identified hazardous materials
 Hazardous materials identified have documented procedure for sorting,
storing, handling etc.
 Availability of MSDS for all such material
 Spill management plan
 Staff awareness

Secondary
 Staff Interview on handling spills–safety

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15. Laundry and Linen

Primary
HIC 1e  Process flow
 Segregation of linen
 Disinfection
 Bags and labels
 Quality control system
 Quality control of outsourced activity (if outsourced) (optional)
FMS 2b  Maintenance plan of machinery
 Layout/ space
FMS 4a  Electrical safety practices
 Staff awareness on safety practices

Secondary
FMS 1c  Identified hazardous materials
 Hazardous materials identified have documented procedure for sorting,
storing, handling etc.
 Availability of MSDS for all such material
 Spill management plan
 Staff awareness
 Monitoring of terms and conditions (T & C) in case this activity is
outsourced

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16. Kitchen/Canteen ( Optional )

Primary
HIC 1c, HIC o Washing facility
2b o Hygiene and cleanliness
o Food handlers use personal protective gear

ROM 1b  License for canteen

 Any usage of domestic gas cylinders
FMS 2a,b  Maintenance plan of machinery
 Layout/ space
FMS 4 a-d  Fire safety awareness and fire-fighting equipment
 Electrical safety practices
 Staff awareness on safety practices
HRM 4a-b  Health status of employees – Immunization for Typhoid and Hepatitis
A/Stool culture and sensitivity

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17. Mortuary

Primary
HIC 1a,b,  Mortuary facilities
HIC 2b,  Cold storage and back-up power
 Staff safety and personal protective equipment
 Disinfection
FMS 2a-b  Maintenance plan of machinery
FMS 4a-d  Electrical safety practices
 Staff awareness on safety practices
 Fire safety

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18. CSSD

Primary
HIC 1d,  Space for sterilization activities
 Layout - Unidirectional flow, segregation of areas
 Shelf life of sets
FMS 2 a-b  Regular validation testing for sterilization carried out and
documented
 Recall procedure when breakdown in sterilization system
 ETO Chimney
HIC 1d  Equipment cleaning and sterilization practices
FMS 2a-b  Maintenance plan of equipment

Secondary
 Staff interview

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Interviews

1. Patient and family interview

PRE 2 a-b  Explanation on

o Proposed care – plan of care
o Expected results
o Possible complications
o Preventive aspects
o Medications
o Expected costs
COP 6e  Educated about nutrition, immunization and safe parenting
PRE 2 b  Safe and effective use of medicines
PRE 1  Awareness of rights and responsibilities
PRE1  Involvement of patient and family in decision making
CQI 2  Feedback

2. Staff interview-Care of patients

AAC 5c  Safe practices in laboratory

COP 2 a  Handling of emergencies and medico legal cases
COP 3c  Use of blood and blood products
COP 6d  Child abduction
FMS 1c  Safety training
HRM 1c  Use of equipments –specially new
HRM 1 c  Change of job description or department
FMS2b  Technicians trained in safe operation of the equipment
 Staff training on equipment handling
FMS4a  Handling of fire and non fire emergencies
MOM 5b-d  Labelling prior to making a secondary medicine
 Patient identification before administering medication
MOM 6a  Awareness of adverse drug events and reporting mechanisms
PRE 1d  Awareness on patient rights and responsibilities
HIC 1a  Infection control programme

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CQI 1b  Quality improvement programme

3. Staff interview-HR

ROM 2a  Mission, goals and service standards of organization

HRM 2c  Hospital and department policies and procedures
HRM 3a  Disciplinary procedure
HRM 3a  Grievance handling
HRM 4a-b  Organization’s policy with respect to health problems
 Occupational health hazards
HIC 2c  Pre and post exposure prophylaxis

4. Staff interview-Safety

FMS 1e  Fire and non-fire emergencies

FMS 1e  Disaster management plan

FMS 1e  Handling spills

FMS 1e  Safety education

FMS 1e  Risk management

 Incident reporting system

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