Kayakalp Clean Hospital Awards

Checklist for Assessment PHC

The Cleanliness Score Card

Name of Facility Level of Assessment

76.7%
Grading Improvement

Thematic Scores

A. PHC Upkeep B. Sanitation & Hygiene C. Waste Management

50 46 42

D. Infection Control E. Support Services F. Hygiene Promotion

42 26 24
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

A. PHC UPKEEP
A1 Pest & Animal Control 4

A1.1 No stray animals within the OB/SI Observe for the presence of stray 2
facility premises animals such as dogs, cats, cattle, pigs,
etc. within the premises. Also discuss
with the facility staff.
Check at the entrance of the facility that
cattle trap has been provided.

A1.2 Pest Control Measures are SI/RR/ OB Check for the evidence at the facility 1
implemented in the facility (Presence of Pests, Record of Purchase of
Pesticides and availability of the rat trap)
and Interview the staff about its usage

A1.3 Measures for Mosquito free OB/SI /PI Check for 1

environment are in place a. Wire
Mesh in windows b.
Desert Coolers (if in use) are cleaned
regularly/ oil is sprinkled
c. No water collection to
prevent mosquito breeding within the
premises
d. Gambusia fish cultivation
e. Usage of Mosquito nets by the
admitted patients
f. Availability of adequate stock of
Mosquito nets( If Applicable)

A2 Landscaping & Gardening 3

A2.1 Front area/ Parks/ Open OB Check that wild vegetation does not 1
spaces are well maintained exist. Shrubs and Trees are well
maintained. Over grown branches of
plants/ tree have been trimmed
regularly. Dry
leaves and green waste are removed on
daily basis.
Gardens/ green area are secured with
fence

A2.2 Internal Roads, Pathways, OB Check that pathways, corridors, 2

etc. are uneven and clean courtyards, etc. are clean and
landscaped.

A 2.3 Provision of Herbal Garden OB/SI Check if the facility maintains a herbal 0
garden for the medicinal plants

A3 Maintenance of Open Areas 6

A3.1 There is no abandoned / OB Check for presence of any ‘abandoned 2

dilapidated building within building’ within the facility premises
the premises

A3.2 No water logging in open OB Check for water accumulation in open 2

areas areas because of faulty drainage, leakage
from the pipes, etc.

A3.3 There is no unauthorised OB/SI Check for PHC premises and access road 2
occupation within the have not been encroached by the
facility, nor there is vendors, unauthorized shops/ occupants,
encroachment on PHC land No thoroughfare / general traffic in PHC
premises etc.

A4 PHC Appearance 6
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

A4.1 Name of the PHC is OB Name of the PHC is prominently 2

prominently displayed at the displayed as per state’s policy.
entrance The name board of the facility is well
illuminated / florescent to have visibility
in night

A4.2 Walls are well-plastered and OB Check that wall (Internal and External) 2
painted plaster is not chipped-off and the
building is painted/ whitewashed in
uniform approved colour and Paint has
not faded away.
Check for presence of any outdated
Posters

A4.3 Uniform signage system in OB All signage's (directional & departmental) 2

the PHC are in local language and follow uniform
colour scheme.

A5 Infrastructure Maintenance 4

A5.1 PHC Infrastructure is well OB/ RR/ SI No major cracks, seepage, chipped 1
maintained plaster & floors is seen within the
building.
The Building is periodically maintained

A5.2 PHC has intact boundary OB Check that there is a proper boundary 2
wall and functional gates at wall of adequate height without any
entry breach. The Wall is painted in uniform
colour

A.5.3 PHC has adequate facility for OB Check that there is a demarcated space 1
parking of vehicles for parking of the vehicles as well as for
the Ambulances and vehicles are parked
systematically

A6 Illumination 6

A6.1 Adequate illumination inside OB Check for Adequate lighting 2

the building arrangements through Natural Light or
Electric Bulbs inside PHC

A6.2 Adequate illumination in OB Check that PHC front, entry gate and 2
Outside of the PHC access road are well illuminated

A6.3 Use of energy efficient bulbs OB Check that PHC uses energy efficient 2
bulb like CFL or LED for lighting purpose
within the PHC Premises

A7 Maintenance of Furniture & Fixture 6

A7.1 Window and doors are OB Check, if Window panes are intact, and 2
maintained provided with Grill/ Wire Mesh. Doors
are intact and painted /varnished

A7.2 Patients' furniture are in OB Check that Patient beds are not rusted 2
good condition and are painted. Mattresses are clean
and not torn
Trolleys, Stretchers, Wheel Chairs, etc.
are well maintained( As applicable)

A7.3 Furniture at the nursing OB Check the condition of furniture at 2

station, staff room, nursing station, duty room, office, etc.
administrative office are The furniture is not broken,
maintained painted/polished and clean.

A8 Removal of Junk Material 5

A8.1 PHC has documented and SI/RR Check if PHC has drafted its 2
implemented States' condemnation policy or have got one
Condemnation policy from the state. Check whether it has
been complied.
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

A8.2 No junk material within the OB Check if unused/ condemned articles, 2

PHC premises and outdated records are kept in the
Nursing stations, OPD clinics, Labour
Room , Injection Room , Dressing Room,
Wards, stairs, open areas, roof tops,
balcony etc.
No condemned vehicles are parked

A8.3 PHC has demarcated space OB/SI Check for availability of a demarcated & 1
for keeping condemned junk secured space for collecting and storing
material the junk material before its disposal

A9 Water Conservation 4

A9.1 Water supply system is OB Check for leaking taps, pipes, over- 2
maintained in the PHC flowing tanks and dysfunctional cisterns

A9.2 Preventive measures are SI/OB Check self closing taps are installed 2
taken to reduce wastage and Reuse of water for activities like
reuse of water gardening.

A 9.3 PHC has a functional rain OB/SI If the such system is available, please 0
water harvesting system check is functionality

A10 Work Place Management 6

A10.1 The Staff periodically sorts SI/OB Ask the staff about the frequency of 2
useful and unnecessary sorting and removal of unnecessary
articles at work stations articles from their work place like
Nursing stations, work bench, dispensing
counter in Pharmacy, etc.
Check for presence of unnecessary
articles.

A10.2 Useful articles, records, SI/OB Check if drugs, instruments, records, 2

drugs, etc. are arranged have been kept systematically near their
systematically usage points in demarcated areas. They
are not lying in haphazard manner.

A10.3 Articles are labelled for easy SI/OB Check that drugs, instruments, records, 2
recognition and easy etc. are labelled for facilitating easy
retrieval. identification.

B Sanitation & Hygiene

B1 Cleanliness of Circulation Area 6

B1.1 No dirt/Grease/Stains/ OB Check that floors and walls of Corridors, 2

Cobwebs/Bird Nest/ Dust/ Waiting area, stairs, roof top for any
vegetation on the walls and visible or tangible dirt, grease, stains, etc.
roof in the PHC's circulation Check that roof, walls, corners of
area Corridors, Waiting area, stairs, roof top
for any Cobweb, Bird Nest, etc.

B1.2 Corridors are cleaned at SI/RR Ask cleaning staff about frequency of 2
least twice in a day with wet cleaning in a day. Verify with
mop Housekeeping records.
Corridors are rigorously cleaned with
scrubbing / flooding once in a month

B1.3 Surfaces are conducive for OB Check if surfaces are smooth for cleaning 2
effective cleaning Check the floors and walls for cracks,
uneven or any other defects which may
adversely impact the cleaning procedure
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

B2 Cleanliness of Wards 6

B2.1 No dirt/Grease/Stains/ OB Check the floors and walls of wards for 2

Cobwebs/Bird Nest/ Dust/ any visible or tangible dirt, grease, stains,
vegetation on the walls and etc.
roof in the PHC's ward Check the roof, walls, corners of wards
for any Cobweb, Bird Nest, etc.

B2.2 Wards are cleaned at least SI/RR Ask cleaning staff about frequency of 2
thrice in a day with wet mop cleaning in a day. Verify with the
Housekeeping records

B2.3 Surfaces are conducive for OB Check if surfaces are smooth for cleaning 2
effective cleaning Check the floors and walls for cracks,
uneven or any other defects which may
adversely impact the cleaning procedure

B3 Cleanliness of Procedure Areas 5

B3.1 No dirt/Grease/Stains/ OB Check that floors and walls of Procedure 2

Cobwebs/Bird Nest/ Dust/ area like Labour Room, OT, Dressing
vegetation on the walls and Room, Immunization Room etc. (As
roof in the procedure area. Applicable) for any visible or tangible
dirt, grease, stains, etc.
Check that roof, walls, corners of these
area for any Cobweb, Bird-nest,
vegetation, etc.

B3.2 Procedure area are cleaned SI/RR Ask cleaning staff about frequency of 1
at least twice in a day/ after cleaning in a day. Verify with
every procedure (as Housekeeping records
applicable) areas are rigorously cleaned with
scrubbing / flooding once in a week

B3.3 Surfaces are conducive for OB Check if surfaces are smooth for ensuring 2
effective cleaning cleaning
Check the floors and walls for cracks,
uneven or any other defects which may
affect cleaning procedure

B4 Cleanliness of Ambulatory & Diagnostic Areas 6

B4.1 No dirt/Grease/Stains and OB Check that floors and walls of OPD, Lab, 2
Cobwebs/Bird Nest/ Dust on X-ray etc. (If available) for any visible or
walls and roof in Ambulatory tangible dirt, grease, stains, etc.
& Diagnostic area Check that roof, walls, corners of these
area for any Cobweb, Bird Nest, etc.

B4.2 Ambulatory and Diagnostic SI/RR Ask cleaning staff about frequency of 2
areas are cleaned at least cleaning in a day. Verify with
twice in a day with wet mop Housekeeping records

B4.3 Surfaces are conducive of OB Check if surfaces are smooth for ensuring 2
effective cleaning cleaning
Check the floors and walls for cracks,
uneven or any other defects which may
affect cleaning procedure

B5 Cleanliness of Auxiliary Areas 5

Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

B5.1 No dirt/Grease/Stains and OB Check that floors and walls of Pharmacy, 2

Cobwebs/Bird Nest/ Stores, Cold chain Room, Meeting Room
Vegetation/ Dust on walls etc. (As applicable) for any visible or
and roof in Auxiliary area tangible dirt, grease, stains, etc.
Check that roof, walls, corners of these
area for any Cobweb, Bird Nest, etc.

B5.2 Auxiliary areas are cleaned SI/RR Ask cleaning staff about frequency of 1
at least twice in a day with cleaning in a day. Verify with
wet mop Housekeeping records
Areas are rigorously cleaned with
scrubbing / flooding once in a month

B5.3 Surfaces are conducive of OB Check if surfaces are smooth enough for 2
effective cleaning cleaning check floors and walls for
cracks, uneven or any other defects
which may affect cleaning procedure

B6 Cleanliness of Toilets 5

B6.1 No dirt/Grease/Stains/ OB Check some of the toilets randomly in 2

Garbage in Toilets indoor and outdoor areas for any visible
dirt, grease, stains, water accumulation
in toilets

B6.2 No foul smell in the Toilets OB Check some of the toilets randomly in 2
and its dry indoor and outdoor areas for the foul
smell and dryness of floor.

B6.3 Toilets have running water OB/SI Please operate cistern and water taps 1
and functional cistern

B7 Use of standards materials and Equipment for Cleaning 3

B7.1 Availability of Detergent SI/OB/RR Check for good quality PHC cleaning 1
Disinfectant solution / solution preferably a ISI mark.
Hospital Grade Phenyl for Composition and concentration of
Cleaning purpose solution is written on label.
Check with cleaning staff if they are
getting adequate supply. Verify the
consumption records.
Check, if the cleaning staff is aware of
correct concentration and dilution
method for preparing cleaning solution.

B7.2 Availability of carbolic Acid/ SI/RR Check for adequacy of the supply. Verify 0
Reputed compound with the records for stock-outs, if any
(Aldehyde & other chemicals
e.g. Bacillocid) for surface
cleaning in procedure areas-
Labour Room, OT (As
Applicable)

B7.3 Availability of Cleaning SI/OB Check the availability of mops, brooms, 2

Equipment collection buckets etc. as per
requirement.

B8 Use of Standard Methods for Cleaning 3

B8.1 Use of Three bucket system SI/OB Check if cleaning staff uses three bucket 1
for cleaning system for cleaning. (One bucket for
Cleaning solution, second for plain water
and third one for wringing the mop.) Ask
the cleaning staff about the process.
Disinfection and washing of mops after
every cleaning cycle need to be
undertaken.
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

B8.2 Use unidirectional method SI/OB Ask the cleaning staff to demonstrate, 1
and outward mopping how they apply mop on floors. It should
be in one direction without returning to
the starting point. The mop should move
from inner area to outer area of the
room. Separate mop is used for the
Procedure area.

B8.3 No use of brooms in patient SI/OB Check if brooms are stored in patient 1
care areas care areas. Ask cleaning staff if they use
brooms for sweeping in wards, OT,
Labour room. Brooms should not be used
in patient care areas.

B9 Monitoring of Cleanliness Activities 3

B9.1 Use of Housekeeping OB/RR Check that Housekeeping Checklist is 1

Checklist displayed in PHC and updated. Check
Housekeeping records if checklists are
daily updated

B9.2 Periodic Monitoring of SI/RR Periodic Monitoring is done by MOIC or 1

Housekeeping activities another person designated. Please check
record of such monitoring

B9.3 Monitoring of adequacy and SI/RR Check if there is any system of 1

quality of material used for monitoring that adequate concentration
cleaning of disinfectant solution is used for
cleaning. PHC administration take
feedback from cleaning staff about
efficacy of the solution and take
corrective action if required.

B10. Drainage and Sewage Management 4

B10.1 Availability of closed OB/SI Check, PHC should have a closed 1

drainage system with drainage system Or else drains should be
adequate gradient properly covered.

B10.2 Availability of connection OB/SI Check if PHC sewage has a connection 2

with Municipal Sewage with municipal system.
System/ soak pit/ septic tank If there is no access to municipal system,
there should be septic tank. Check
condition of septic tank e. g. Periodicity
of cleaning, mosquito proofing of
manhole, etc.

B10.3 No blocked/ over-flowing OB/SI Observe that the drains are not 1
drains in the facility overflowing or blocked
All the drains are cleaned once in a week

C Waste Management
C1 Segregation of Biomedical Waste 6

C1.1 Segregation of BMW is done OB/SI Anatomical waste and soiled dressing 2
as per BMW management material are segregated in Yellow Bin
rule,2016 General and infectious waste are not
mixed

C1.2 Display of work instructions OB Check for instructions for segregation of 2

for segregation and handling waste in different colour coded bins are
of Biomedical waste displayed at point of use.

C1.3 Check if the staff is aware of SI Ask staff about the segregation protocol. 2
segregation protocol
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

C2 Collection and Transportation of Biomedical Waste 4

C2.1 The facility has linkage with OB/ RR/ SI Check record for functional linkage with 0
a CWTF Operator or has a CWTF
deep burial pit (with prior In absence of such linkage, check
approval of the prescribed existence of deep burial pit, which has
authority) approval of the prescribed authority.

C2.2 Biomedical waste bins are OB Check that bins meant for bio medical 2
covered waste are covered with a lid

C2.3 Transportation of biomedical OB/SI Check if transportation of waste from 2

waste is done in closed clinical areas to storage areas is done in
container/trolley covered trolleys / Bins. Trolleys used for
patient shifting should not be used for
transportation of waste.

C3 Sharp Management 6

C3.1 Disinfection of Broken / OB/SI/ RR Check if such waste is either pre-treated 2

Discarded Glassware is done with 10% Sodium Hypochlorite (having
as per recommended 30% residual chlorine) for 20 minutes or
procedure by autoclaving/ microwave/ hydroclave,
followed storage in Blue Cardboard box
for re-cycling.

C3.2 Sharp Waste is stored in OB/SI Check availability of Puncture & leak 2
Puncture proof containers proof container (White Translucent) at
point of use for storing needles, syringes
with fixed needles, needles from
cutter/burner, scalpel blade, etc.

C3.3 Staff is aware of needle stick SI/RR Ask staff immediate management of 2
injury Protocol exposure site; and Medical Officer knows
criteria for PEP.
There should be functional linkage to
DH / SDH/ CHC for PEP follow-up and
check records of such referrals and
follow-up

C4 Storage of Biomedical Waste 6

C4.1 Dedicated Storage facility is OB Check if PHC has dedicated room for 2
available for biomedical storage of Biomedical waste before
waste disposal/handing over to Common
Treatment Facility.

C4.2 No Biomedical waste is SI/RR Verify that the waste is being disposed / 2
stored for more than 48 handed over to CTF within 48 hour of
Hours generation. Check the record especially
during holidays

C4.3 Access to waste storage OB Observe the display of Biohazard symbol 2

facility is secured at storage areas
Check that the BMW storage is situated
away from the main building and is kept
under lock and key

C5 Disposal of Biomedical waste 3

Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

C5.1 PHC has adequate facility for RR/OB/SI The Health facility within 75 KM of CTF 2
disposal of Biomedical waste shall have a valid contract with a
Common Treatment facility for disposal
of Bio medical waste. Or else facility
should have Deep Burial Pit and Sharp Pit
within premises of Health facility. Such
deep burial pit should have approval of
the Prescribed Authority

C5.2 Facility manages recyclable OB/SI Check management of IV Bottles 1

waste as per approved (Plastic), IV tubes, Urine Bags, Syringes,
procedure Catheter, etc.
(Autoclaving/ Microwaving/ Hydroclaving
followed by shredding or a combination
of sterilisation and shredding. Later
treated waste is handed over to
registered vendors.)

C5.3 Deep Burial Pit is OB/RR Located away from the main PHC 0
constructed as per norms building and water source, A pit or
given in the Biomedical trench should be dug about two meters
Waste Rules 2016 deep. It should be half filled with waste,
then covered with lime within 50 cm of
the surface, before filling the rest of the
pit with soil.
Secured from animals . If waste disposed
through CTF, then a deep burial pit is not
required.(Give Full Compliance)

C6 Management Hazardous Waste 1

C6.1 Availability of Mercury Spill SI/OB Check for Mercury Spill Management Kit 0
Management Kit and Staff is and ask staff what he/she would do in
aware of Mercury Spill case of Mercury spill. (If facility is
management mercury free give full compliance)

C6.2 Disposal of used Disinfectant SI System of pre-treatment before 0

solution like Glutaraldehyde

C6.3 Disposal of Expired or SI/RR Returned back to manufacturer or 1

discarded medicine supplier
Alternatively handed over to CWTF
Operator for incineration at temperature
> 12000C

C7 Solid General Waste Management 2

C7.1 Availability of Compost pit as OB/SI Availability of compost pit for Bio 0
per specification degradable general waste.

C7.2 Disposal of General Waste OB/SI There is a mechanism of removal of 2

general waste from the facility and its
disposal.

C7.3 Innovations in managing OB/SI/ RR Look for efforts of the health facility in 0
general waste managing General Waste, such as
Recycling of paper waste,
vermicomposting, waste to energy
initiative, etc.

C8 Liquid Waste Management 5

C8.1 The laboratory has a OB/SI/ RR A copy of such protocol should be 2

functional protocol for available and staff should be aware of
managing discarded samples the same.
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

C8.2 Liquid waste is made safe OB/SI/RR Check for the procedure - staff interview 2
before mixing with other and direct observation
waste water

C8.3 Hand-washing facilities have OB/SI Check availability of soap & water for 1
been provided for patients, patients, who are handing-over Urine
handing-over Urine Samples samples in the laboratory

C9 Equipment and Supplies for Bio Medical Waste Management 6

C9.1 Availability of Bins for OB/SI One set of bins of appropriate size at 2
segregated collection of each point of generation for Biomedical
waste at point of use and General waste.

C9.2 Availability of Needle/ Hub OB/SI At each point of generation of sharp 2

cutter and puncture proof waste
boxes

C9.3 Availability of Colour coded OB/SI Check all the bins are provided with 2
liners for Biomedical waste chlorine free liners. Ask staff about
and general waste adequacy of supply.

C10 Statuary Compliances 3

C10.1 PHC has a valid authorization RR Check for the validity of authorization 2
for Bio Medical waste certificate
Management from the
prescribed authority

C10.2 PHC submits Annual report RR Check the records that reports have been 0 n
to pollution control board submitted to the prescribed authority on
or before 30th June every year.

C10.3 PHC maintains records, as RR Check following records - 1

required under the a. Yearly Health Check-up record of all
Biomedical Waste Rules handlers
2016 b. BMW training records of all staff (once
in year training)
c. Immunisation records of all waste
handlers

D Infection Control

D1 Hand Hygiene 6

D1.1 Availability of Sink and OB Check for washbasin with functional tap, 2
running water at point of soap and running water at all points of
use use

D1.2 Display of Hand washing OB Check that Hand washing instructions are 2
Instructions displayed preferably at all points of use

D1.3 Staff is aware of standard SI Ask facility staff to demonstrate 6 steps 2

hand washing protocol of normal hand wash and 5 moments of
hand washing

D2 Personal Protective Equipment (PPE) 4

D2.1 Use of Gloves during SI/OB Check, if the staff uses gloves during 2
procedures and examination examination, and while conducting
procedures

D2.2 Use of Masks ,Head cap and SI/OB Check, if staff uses mask head caps , Lab 1
Lab coat, Apron etc. coat and aprons in patient care and
procedure areas

D2.3 Use of Heavy Duty Gloves SI/OB Check, if the housekeeping staff and 1
and gumboot by waste waste handlers are using heavy duty
handlers gloves and gum boots

D3 Personal Protective Practices 6

Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

D3.1 The staff is aware of use of SI/OB Check with the staff when do they wear 2
gloves, when to use gloves, and when gloves are not
(occasion) and its type required. The Staff should also know
difference between clean & sterilized
gloves and when to use

D3.2 Correct method of wearing SI/OB Ask the staff to demonstrate correct 2
and removing PPEs method of wearing and removing Gloves,
caps and masks etc.

D3.4 No re-use of disposable SI/OB Check that disposable gloves and mask 2
personal protective are not re-used. Reusable Gloves and
equipment mask are used after adequate
sterilization.

D4 Decontamination and Cleaning of Instruments 6

D4.1 Staff knows how to make SI Ask the staff how to make 1% chlorine 2
Chlorine solution solution from Bleaching powder and
Hypochlorite solution

D4.2 Decontamination of SI/OB Ask staff when and how they clean the 2
operating and Surface operating surfaces either by chlorine
examination table, dressing solution or Disinfectant like carbolic acid
tables etc. after every
procedures

D4.3 Decontamination and SI/OB Check whether instruments are 2

cleaning of instruments decontaminated with 0.5% chlorine
after use solution for 10 minutes. Check
instruments are cleaned thoroughly with
water and soap before sterilization

D5 Disinfection & Sterilization of Instruments 4

D5.1 Adherence to Protocols for SI/OB/RR Check about awareness of recommended 2

sterilization temperature, duration and pressure for
autoclaving instruments - 121 degree C,
15 Pound Pressure for 20 Minutes (30
Minutes if wrapped) Linen - 121 C, 15
Pound for 30 Minutes.
Check if the staff know the protocol for
sterilization of laparoscope soaking it in
2% Glutaraldehyde solution for 10 Hours

D5.2 Adherence to Protocol for SI/OB Check with the staff process about of 0
High Level disinfection High Level disinfection using Boiling for
20 minutes with lid on, soaking in 2%
Glutaraldehyde/Chlorine solution for 20
minutes.

D5.3 Use of autoclave tape for OB/RR Check autoclaving records for use of 2
monitoring of sterilization sterilization indicators (signal Lock)

D6 Spill Management 4
D6.1 Staff is aware of how to SI Check for adherence to protocols 2
manage spills

D6.2 Availability of spill SI/OB Check availability of kits 0

management Kit

D6.3 Spill management protocols SI/OB Check for display 2

are displayed at points if use

D7 Isolation and Barrier Nursing 3

D7.1 Infectious patients are not OB/SI Check infectious patients are separated 1
mixed for general patients from other patients
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

D7.2 Maintenance of adequate OB A distance of 3.5 Foot is maintained 0

bed to bed distance in wards between two beds in wards

D7.3 Restriction of external foot OB/SI External foot wear are not allowed in 2
wear in critical areas labour room, OT etc.( As Applicable)

D8 Infection Control Program 5

D8.1 Infection Control Committee RR/SI Check for the enabling order and 2
is constituted and functional minutes of the meeting
in the PHC

D8.2 Antibiotic Policy is RR/SI Check if the PHC has documented Anti 1
implemented at the facility biotic policy and doctors are aware of it.

D8.3 Immunization and medical RR/SI PHC staff has been immunized against 2
check-up of Service Hepatitis B
Providers Check for the records and lab
investigations of staff

D9 Hospital Acquired Infection Surveillance 6

D9.1 Facility measures the Health RR/SI Check for monitoring of Healthcare 2
care associated infections Associated Infection that may occur in a
Primary healthcare setting like Injection
abscess, Postpartum sepsis, infection at
dressing and suturing sites etc.

D9.2 Facility reports all notifiable RR/SI Check that the facility has list of all 2
diseases and events notifiable disease needs
immediate/periodic reporting to higher
authority.
Check records that notifiable disease
have been reported in program such as
IDSP and AEFI Surveillance.

D9.3 Regular Monitoring of RR/SI Check, if there is any practice of daily 2

infection control practices monitoring of infection control practice
like hand hygiene and personal
protection

D10 Environment Control 2

D10.1 Cross-ventilation at Patient OB/SI Check availability of Fans/ air 1
Care areas (ward, labour conditioning/ Heating/ exhaust/
room and dressing room) Ventilators as per environment condition
and requirement

D10.2 Preventive measures for air OB/SI Check staff is aware, adhere and 1
borne infections has been promote respiratory hygiene and cough
taken etiquettes

D10.3 Adequate number of Air- OB/SI Please check availability and 0

exchange in Laboratory serviceability of exhaust fan in the
laboratory

E SUPPORT SERVICES

E1 Laundry Services & Linen Management 5

E1.1 The facility has adequate RR/SI Check the stock position and its turn- 1
stock (including reserve) of over during last one year in term of
linen demand and availability

E1.2 Bed-sheets and pillow cover OB/SI Observe the condition of linen in use in 2
are stain free and clean the wards and other patient care area
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

E1.3 Bed-sheets and linen are OB/SI/PI Check, if the bedsheets and pillow cover 2
changed daily have been changed daily. Please
interview the patients as well.

E2 Water Sanitation 5

E2.1 The facility receives RR/SI/PI At least 200 litres of water per bed per 1
adequate quantity of water day is available (if municipal supply). or
as per requirement the water is available on 24x7 basis at all
points of usage

E2.2 There is storage tank for the RR The PHC should have capacity to store 48 2
water and tank is cleaned hours water requirement Water tank is
periodically cleaned at six monthly interval and
records are maintained.

E2.3 Drinking Water is tested and RR Presence of free chlorine at 0.2 ppm is 2
chlorinated tested in the samples drawn at the
consumer's end.

E3 Pharmacy and Stores 5

E3.1 Medicines are arranged OB/SI Check all the shelves/racks containing 2
systematically medicines are labelled in pharmacy and
drug store
Heavy items are stored at lower
shelves/racks
Fragile items are not stored at the edges
of the shelves
Drugs and consumables are stored away
from water and sources of heat, direct
sunlight etc.
Drugs are not stored at floor and
adjacent to wall

E3.2 Cold storage equipment's OB Check ILR, Deep freezers and Ice packs 1
are clean and managed are clean
properly Check there is a practice of regular
cleaning.
Check vaccines are kept in sequence
Check work instruction for storage of
vaccines are displayed at point of use

E3.3 Cold storage equipment are OB/SI Check eatables are not kept in ILR/Deep 2
not used for storing other Freezers
items, than vaccine .

E4 Security Services 5

E4.1 One Security Guard per shift OB Check for the presence of one security 1
personnel at PHC every shift

E4.2 Departments are locked OB/SI Departments like OPD, Lab, 2

after working hours Administrative office etc. are locked after
working hours.

E4.3 Security personal OB/SI Check, if security personnel watch 2

reprimands attendants, who behaviour of patients and their
found indulging into attendants, particularly in respect of
unhygienic behaviour - hygiene, sanitation, etc. and take
spitting, open field urination appropriate actions, as deemed.
& defecation, etc.

E5 Outreach Services 6

E5.1 Biomedical waste generated RR/SI Check the records and ask staff 2
during outreach session are
transported to the PHC on
the same day
Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

E5.2 ASHA's are promoting SI Check for ASHA's counsel mothers for 2
cleanliness and hygiene hand hygiene, toilets, water sanitation
practices etc.

E5.3 Medical officers monitor RR/ SI Check with medical officers and records 2
cleanliness and hygiene of of monthly meeting ''Swachh Baharat
outreach sessions and sub Abhiyaan'' has been followed up during
centres. monthly meetings with extension
workers like MPW, ASHA, ANM etc.

F Hygiene Promotion

F1 Community Monitoring & Patient Participation 3

F1.1 Local community and SI/RR Members of RKS and Local Governance 1
organisations are involved in bodies monitor the cleanliness of the
monitoring and promoting PHC at pre-defined intervals
cleanliness Local NGO/ Civil Society
Organizations/Panchayati Raj Institution
are involved in cleanliness of the PHC

F1.2 Patients are made aware of PI/OB Ask patients about their roles& 1
their responsibility of responsibilities with regards to
keeping the health facility cleanliness. Patient’s responsibilities
clean should be prominently displayed

F1.3 The Health facility has a SI/RR Check if there is a feedback system for 1
system to take feed-back the patients. Verify the records
from patients and visitors for
maintaining the cleanliness
of the facility

F2 Information Education and Communication 4

F2.1 IEC regarding importance of OB Should be displayed prominently in local 2

maintaining hand hygiene is language
displayed in PHC premises

F2.2 IEC regarding Swachhta OB Should be displayed prominently in local 0

Abhiyaan is displayed within language
the facilities’ premises

F2.3 IEC regarding use of toilets is OB Should be displayed prominently in local 2

displayed within PHC language
premises

F3 Leadership and Team work 5

F3.1 Cleanliness and infection RR/SI Verify with the records 1

control committee has
representation of all cadre of
staff including Group ‘D’ and
cleanings staff

F3.2 Roles and responsibility of SI/RR Ask different members about their roles 2
different staff members have and responsibilities
been assigned and
communicated

F3.3 PHC leadership review the SI/RR Check about regularity of meetings and 2
progress of the cleanliness monitoring activities regarding
drive on weekly basis cleanliness drive

F4 Training and Capacity Building and Standardization 6

Ref. No. Criteria Assessme Means of Verification Compliance Remarks
nt Method

F4.1 Bio medical waste SI/RR Verify with the training records 2
Management training has
been provided to the staff

F4.2 Infection control Training SI/RR Check staff are trained at the time of 2
has been provided to the induction and once in every year
staff

F4.3 PHC has documented R Check availability of SOP with respective 2

Standard Operating R users
procedures for Cleanliness,
Bio-Medical waste
management and Infection
Control

F5 Staff Hygiene and Dress Code 6

F5.1 PHC has dress code policy OB/SI PHCs staff adhere to dress code 2
for all cadre of staff

F5.2 There is a regular monitoring SI/OB Check about personal hygiene and clean 2
of hygiene of staff dress of staff

F5.3 Identity cards and name OB Check staff uses I Card and name plate 2
plates have been provided
to all staff