Reference No.

Measurable Elements Checkpoints Compliance Assessment Method Means of Verification

Area of Concern - Service Provision
Standard A1 The facility provides Comprehensive Primary Healthcare Services
Services for early registration, screening
The facility provides care in Pregnancy & child Availability of functional ANC services with including lab investigation ,counselling &
ME A1.1 birth services minimum 4 ANC check-ups RR/SI identification of high risk and danger signs
APH, PIH, Pre eclampsia, Severe Anaemia, IUGR,
Multiple pregnancies, Gestational Diabetes ,
First aid, referral & follow up services for high Hypothyroidism, Syphilis and bad obstetric
risk pregnancies are provided RR/SI history
New Born: Low birth weight newborn
<1800gms, Preterm, Sepsis, Birth asphyxia,
Congenital anomalies Infant: ARI, Diarrhoea,
The facility provides Neonatal & Infant Health Identification, primary management & prompt Jaundice, anaemia & malnutrition,
ME A1.2 services referral of sick new born & infant RR/SI developmental delays

Anaemia, malnutrition, Vaccine preventable

diseases, ARI, Diarrhoea, Fever, ENT problems,
The facility provides Childhood & Adolescent Identification, primary management, referral & Skin infections, Worm infestations, Poisoning,
ME A1.3 health services follow up services for Childhood ailments RR/SI injuries/ accidents, 4D's,Sickle cell anaemia.

Prevention & treatment of anaemia and other

deficiencies, Counselling on life style, menstrual
Education, Counselling and referral services for hygiene, harmful effects of tobacco/substance
Adolescent health PI/SI abuse and sex education
Provision of contraceptive including ECP,OCP,
ME A1.4 The facility provides Family Planning services Availability of family planning services RR/SI Injectables, condom, IUCD.
The facility provides services for promotion,
prevention and treatment of communicable Community engagement, facilitate referral,
diseases as mandated under National Health promote treatment completion & reducing
ME A1.5 Program/state scheme Preventive & promotive measures under NLEP SI stigma
Case detection, treatment, referral & follow up
of cases under NVHCP RR/SI Diagnostic services, referral & follow up

Early identification, link with designed

Case detection, treatment, referral & follow up microscopy centre, referral & follow up of
of cases under NTEP RR/SI complicated cases, & medication compliance
Availability of functional services under
IDSP/IHIP RR/SI Weekly reporting & surveillance
Referral & follow up of cases under NACP RR/SI Compliance to ART & follow up

(1) Diagnostic services, primary management,

referral & follow up of complicated cases. (2)
Case detection, treatment, referral & follow up Mass drug administration in case of filarasis &
of cases under NVBDCP RR/SI immunization in JE
Diagnostic services, primary management,
Case detection, treatment, referral & follow up referral & follow up of complicated cases, &
of cases under NLEP RR/SI medication compliance
Community engagement/ peer support,
facilitate referral, promote treatment
completion, Convergence with other
Preventive & promotive measures under NVHCP SI departments
Malaria, Dengue, Chinguniya, Filariasis,
Preventive & promotive services under NVBDCP RR/SI KalaAzar, Japanese Encephalitis
Prevention & promotion among high risk
behaviour groups, support to patient living with
Preventive & promotive services under NACP SI HIV/AIDS
Fever, URIs, ARIs, Diarrhoea, Scabies, Rashes/
Urticaria, Abscess, Cholera, Dysentery, Typhoid,
The facility provide services for acute Simple Identification, management and referral of Helminthiasis, Headache, Body aches, Joint
ME A1.6 illness & minor aliments acute illness & minor aliments RR/SI aches.

Water born diseases (diarrhoea, dysentery,

Preventive & promotive measures for acute enteritis) Helminthiasis, rabies,musculosketal
illness SI disorders (osteoporosis, arthritis, aches )
The facility provides services for promotion,
prevention and treatment of Non- Oral, Breast, Cervical Cancers. Screening, linking
communicable diseases as mandated under with the specialist, 2 way referral& follow up
ME A1.7 National Health Program/state scheme Availability of Services for Cancers RR/SI treatment compliance and complications

Community engagement to promote healthy life

style & address risk factor. Counselling and IEC
Preventive & promotive services under NCD SI activities regarding harmful effects of NCDs
Screening, early identification , treatment
compliance and follow up of all diagnosed cases,
referral and follow up for complications , refill of
Availability of services for Epilepsy RR/SI drugs
 Screening, early identification , treatment
compliance and follow up of all diagnosed cases,
referral and follow up for complications , refill of
Availability of services for respiratory diseases RR/SI drugs for diseases such as COPD & Asthma.

Screening, Diagnosis, treatment compliance and

follow up of all diagnosed cases, referral &
Availability of services for Diabetes RR/SI follow up for complications and refill of drugs

Screening, treatment compliance and follow up

of all positive cases, referral & follow up for
Availability of services for Hypertension RR/SI complications and refill of drugs

Screening, treatment compliance and follow up

Availability of services for Nonalcoholic fatty of all positive cases, referral & follow up for
liver disease (NAFLD) RR/SI complications and refill of drugs
Awareness generation, vit A prophylaxis for eye
The facility provides services for common eye Preventive & promotive services under for (6month -5yr), eye examination for pre term
ME A1.8 aliments Ophthalmic PI/SI (less than 32 weeks)

1. Screening & referral of Blindness, Refractive

errors, Visual Acuity, Cataract 2. Identification
and primary treatment of Conjunctivitis, dry
Eye, Trachoma, foreign body, eye injuries 3.
Follow up medicines for chronic eye disease
Availability of Ophthalmic Services RR/SI such as Cataract and glaucoma
Identification, primary management and
referral( if required) for Common Cold, , URI,
Tonsillitis, Pharyngitis, Laryngitis and Sinusitis ,
Epistaxis, Otomycosis, Otitis Externa, ASOM ,
The facility provides services for common ENT removal of foreign bodies, /Injuries, thyroid
ME A1.9 aliments Availability of ENT Services RR/SI swelling.
Awareness generation about causes &
prevention of ENT problem viz. Protection from
excessive noise, Safe listening (< 85db),
improving acoustic environment, avoid self
medication and not to attempt foreign body
Preventive & promotive services under for ENT SI removal at home
Gum diseases (Gingivitis, Periodontitis), Dental
caries and dental emergencies (Tooth ache,
The facility provides service for oral health Availability of symptomatic management & Tooth injuries , uncontrolled bleeding and
ME A1.10 aliments referral services for oral Health conditions RR/SI abscess)
Irregular arrangement of teeth & Jaws
(Malocclusion) , Dental Fluorosis, Cleft lip &
Availability of early identification & referral palate, Abnormal growth , patch or ulcers, oral
services for oral Health conditions RR/SI cancers

Awareness generation, oral health education &

Preventive & promotive services under oral prevention of common oral diseases through
health SI dietary advice & tobacco cessation

(1) General Awareness about -Healthy life style,

social security scheme for elderly and promote
active & healthy aging , identification of age
related aliments and increase supportive
environment in families (2) Mapping of elderly
Population (3)Comprehensive Geriatric
The facility provide Elderly & Palliative care assessment by Primary health Care team (4)
ME A1.11 services Availability of services for elderly care RR/SI Domiciliary visits to bed ridden patients

(1) Population enumeration & empanelment of

cases requiring palliative care (2) Palliative care
assessment (3) Home visit for psycho- social
support and basic nursing care (4) Dispense
Availability of services for palliative care RR/SI drugs & consumables as per requirement

1. Stabilization and referral services for minor

injuries, animal bites, poisoning, burn,
Respiratory arrest, cardiac arrest, fractures,
shock, chocking, fits, drowning, haemorrhage,
cellulitis, Acute gastro-intestinal conditions &
Genito- urinary conditions 2. Identification &
referral for Cysts, Lipoma, , haemorrhoids,
The facility provides emergency medical care, Availability of services for Medical Emergencies hernia, hydrocele, varicose veins, bed ulcers,
ME A1.12 including for trauma and burn including trauma & burns RR/SI phimosis etc.
 Identification, counselling & referral for Anxiety,
The facility provides services for Screening & hysteria, Depression, Neurosis, Dementia,
ME A1.13 Management of Mental Health illness Availability of services for mental health RR/SI Mental Retardation, Autism
Awareness generation ,stigma & discrimination
reduction ,community engagement, patient
Preventive & promotive services under mental support, facilitate referral, promote treatment
health SI completion etc
As per scope of services defined by state. Give
The facility provides services for health full compliance in case separate AYUSH centre
ME A1.14 promotion activities & wellness Provision of AYUSH services RR/SI (as per state policy)
Check counselling services for : (1) Eat Healthy:
(a) Nutrition during first 1000 days of Life (b)
Balanced diet (c) Food fortification (d) Food to
avoid (2) Eat Safe: (a) Hygiene & Sanitation (b)
Food Safety & Safe food practices (c) Food
Provision of counselling services for Eat Right SI Adulteration
Provision of wellness services through Yoga and Periodic scheduling of yoga session, Health
other activities SI education for life style modification
Standard A2 The facility provides drugs and diagnostic services as mandated
The facility provides services for drug dispensing
ME A2.2 including medicine refills Availability of drugs for refill for chronic cases RR/SI As per scope of service provided
Availability of drugs as per EML RR/SI As per scope of services provided
Area of Concern - Patients Right
Standard B1 The facility provides information to care seeker, attendants & community about available services & their modalities
Information about the treatment and Primary healthcare team provide information to JSY, JSSK, RBSK, RMNCHAN, PM JAY/ state
entitlements are shared with patients or beneficiaries or families regarding their insurance scheme etc Also support beneficiaries
ME B1.3 attendants entitlements SI to seek services
Standard B2 Facility ensures services are accessible to care seekers and visitors including those required some affirmative action
Check for Outreach session plan - targeted
The facility is accessible from community and population covered & implementation as per
ME B2.1 referral centre Check outreach sessions are conducted RR/SI plan.
(1) Ensure care is provided within 30 minutes,
provision MMU for hard to reach area (Give full
compliance for MMU if area is not hard to
Ayushman Arogya Mandir is located closer to reach) (2) Preferably within 1-2 Kms of Referral
community SI Centre

(1) Ayushman Arogya Mandir is functional for at

The full range of services are available for the least six hours per day (2) Ayushman Arogya
time period, as mandated RR Mandir- provide services for all 12 packages
There is affirmative action to ensure that Check for special precaution is taken for
vulnerable and marginalized sections can access maintaining privacy & confidentiality of cases HIV, Leprosy , Abortion, domestic Violence,
ME B2.3 services having social stigma RR/SI psychotic cases, GBV, abuses etc
Standard B3 Services are delivered in a manner that are sensitive to gender, religious & cultural needs and there is no discrimination on account of economic or social reasons

Services are provided in manner that are Availability of female staff / attendant, if a male
ME B3.1 sensitive to gender religious & cultural need CHO examines a female patients SI

The facility has defined and established Check staff & community is aware of grievance
ME B3.3 procedure grievance redressal system in place redressal system SI Existing state grievance system/ 104.
Standard B4 The facility maintains privacy, confidentiality & dignity of patient

(1) Check Ayushman Arogya Mandir has policy in

place regarding access of clinical information &
records. (2) Staff is aware of it (3) Need based
Confidentiality of patients? records and clinical Check patient and their kin's have access to individual's summary & prescription details are
ME B4.2 information is maintained clinical records RR/SI provided. (IT system- have option for print)
Standard B5 The facility ensures all services are provided free of cost to its users

The facility provides free of cost services as per Availability of free teleconsultation and
ME B5.1 prevalent government schemes/ norms. diagnostic services SI
(1) As per service package or RMNCHA, CD,
NCD, Eye, ENT, Oral, Mental Health, Elderly,
Pallative, Emergency medical services etc (2)
Ayushman Arogya Mandir provide free of cost Screening and investigation services are
services RR provided free of cost
The facility provides free of cost essential Check all drugs in the Ayushman Arogya Mandir-
medicines and refills as per treatment plan SI EDL are provided free of cost
Area of Concern - Inputs
Standard C1 The facility has adequate and safe infrastructure for delivery of assured services as per prevalent norms and it provides optimal care and comfort to users

(1) Availability of internet connnectivity (2)

Check availability of functional & updated
Portals or applications viz RCH portal, Ayushman
Arogya Mandir portal, NCD portal, ANMOL,
The facility ensures availability of information & Ayushman Arogya Mandir has adequate ICT DVDMS, NIKSHAY, e-sanjeevani, HMIS etc. and
ME C1.3 communication technologies software for efficient delivery of services RR/SI any state specific application.
 (1) Check availability of Smartphones/ Tablets
and Laptop/desktops, internet connectivity
(2mbps). (2) For tele medicine services,check
desktop/ Laptop have headphone , HD web
Ayushman Arogya Mandir has adequate ICT camera & printer connected with it (3)
hardware for efficient delivery of services RR/SI Availablity of telphone/Mb for communication
Standard C2 The facility has adequate qualified and trained staff required for providing the assured services as per current case load
(1) As per eligibility criteria. (2) Staff is aware of
their role and responsibilities (3) Staff adhere to
The facility ensures availability of Community their respective dress code and wearing their ID
ME C2.1 Health officer Availability of Community Health Officer RR/SI card
1 ASHA per 1000 population / ASHA per 500
population for tribal and hilly area. 1 ASHA
facilitator/20,000 population Staff is aware of
The facility have adequate frontline health their role and responsibilities for Ayushman
ME C2.2 workers and support staff as requirement Availability of ASHA & ASHA facilitator RR/SI Arogya Mandir & community

(1) 2ANM (1 essential & 1 Desirable)- SC type -A

2 ANM (Essential, one may be staff nurse) - Only
for SC type-B (2) Staff is aware of their role and
responsibilities (3) Staff adhere to their
Availability of ANM RR/SI respective dress code and wear their ID card
(1) 1 Female and 1 Male (2) Staff is aware of
their role and responsibilities for Ayushman
Arogya Mandir and community (3) Staff adhere
to their respective dress code and wearing their
Availability of Multipurpose Worker RR/SI ID card
Standard C3 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

(1) Verify with records that performance

appraisal has been done at least once in a year
and verify with staff for actual assessment done
(2) Check training needs are identified based on
performance evaluations & adequate skills are
provided (3) Check IT platforms are used for
regular continuous learning & and capacity
Competence assessment and performance building (4) Check how many capacity building
evaluation of all staff is done on predefined Check for performance evaluation is done at training/workshop attended by primary
ME C3.1 criteria least once in a year RR/SI healthcare team in last quarter

(1) Check objective checklist has been prepared

for assessing competence of staff based on job
description and assessment is done at least
once in a year (2) Check who did the assessment
Check parameters for assessing skills and - At least PHC- MO/ Competence Matrix is
proficiency of staff has been defined RR/SI prepared for each category of staff

(1) 6 month certificate program in Community

health, (2) 3 day IT training including Tele
medicines (3) 5-7 days supplementary training
on new health programs, new skills (if
applicable) (4) refresher every year (if
applicable) (5) Basic physiotherapy ( where ever
The staff is provided training as per defined core elderly & palliative care packages are available)
ME C3.2 competencies and training plan CHO is trained as per mandate RR/SI (6) Training on Eat right tool kit

Bio medical waste management, Infection

Prevention, patient safety, internal assessment,
Staff is provided with Quality assurance training RR/SI BLS, Methods of QA viz PSS, 5S, PDCA etc
Area of Concern - Support Services
Standard D1 The facility has established Programme for maintenance and upkeep of the facility
No condemned/Junk material in Ayushman
The facility has established system for Arogya Mandir (corridors, roof, administrative Ayushman Arogya Mandir remove its junk
ME D1.1 infrastructure maintenance area , backyard) OB/RR periodically as per condemnation policy.
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs
(1) Timely indenting the drugs for common
aliments & emergency cases (2) Timely
indenting of Drugs of new or regular chronic
There is established procedure for estimation patients under Ayushman Arogya Mandir (3)
and indenting of drugs and consumables as per Check there is established system to timely Check the adequacy of the available drugs
ME D2.1 requirement indent the drugs as per services package RR/SI (Demand & supply)
Check forecasting of drugs & consumables is
Ayushman Arogya Mandir has a process to done scientifically based on consumption
consolidate and calculate the consumption RR/SI .Reorder & buffer levels are defined
 (1) Check all near expiry drugs are shifted back
to PHC/ referral centre/ facility where it is
urgently required based on inventory turnover
(that is- Fast, slow or non moving drugs) (2)
The facility ensure management of expiry and There is system in place to maintain expiry & Check there is demarcated space/ shelf to keep
ME D2.3 near expired drugs near expiry of drugs OB/SI expired drugs away from main dispensing area
No expired drug is found in Ayushman Arogya
Mandir OB In dispensing area as well as drug storage area
Standard D3 The facility has defined and established procedure for clinical records and data management with progressive use of digital technology
(1) Diagnosis, assessments, treatment plan,
drugs prescribed, follow up , referral in and
referral out etc are recorded & updated for all
Information regarding ambulatory care & cases by HSC (2) Randomly, select at least 5
management, public health and managerial cases (or all cases if less than 5) and check for
functions are recorded and updated through IT Information regarding illness and minor aliments details Give partial compliance if information is
ME D3.1 platforms are recorded & updated using IT platform RR/SI only available in paper.
(1) Arrange consultation with PHC- MO or
Specialist as per requirement. (2) Check how
The facility has established procedure for Cases are identified for tele consultation for many cases were consulted using tele medicine
ME D3.3 providing consultation using tele medicine specialist & non specialist consultation RR/SI in preceding 3 months
Dispense drugs as per prescription received
through tele consultation RR As per e-prescription

(1) As per roster - send the patient to PHC (2)

Pre appointment, location for consultation (3)
Co ordination with specialist / super specialist Check reminder / SMS alerts are sent for
and patient for tele consultation RR/SI appointments/ referral/ follow up cases
Staff is aware of functional hubs & skilled to use
Hubs are identified for tele consultation OB/RR the software
Standard D4 The facility has defined and established procedures for hospital transparency and accountability.

A. (1) Maintenance of Ayushman Arogya Mandir

- cleanliness, hygiene, safe drinking water, clean
toilet, BMW disposal & clear signage. (2)
Management of grievances (3) Ensure conduct
of social audits & public hearing (4)Coordinate
celebration of Annual health calendar days (5)
Effective implementation of community level
programmes viz. VISHWAS, SABLA, Eat right
campaign of FSSI, farmer groups, Self help
groups, women groups, Milk unions etc. B.
The facility has established procedure for Committee members are aware of its roles & Check each member is aware of their powers
ME D4.1 management of activities of Jan Arogya Samiti responsibilities RR/SI and functions

(1) Check composition of committee as per JAS

guidelines. Chairperson- Sarpanch, Co -
Chairperson- MO- PHC and Member Sect. - CHO.
(2) At least 50% of representation of women (3)
Ayushman Arogya Mandir has functional Jan Check committee has representation of all
Arogya Samiti RR/SI habitation or communities esp. vulnerable
(1) Monthly review of service delivery &
The facility has established procedure for Check PHC -MO provide supportive supervision performance of Ayushman Arogya Mandir (2)
supporting and monitoring activities of & monitoring for Ayushman Arogya Mandir Supportive supervision for Ayushman Arogya
ME D4.3 Community health workers activities RR/SI Mandir staff
Standard D5 The facility ensures health promotion and disease prevention activities through community mobilization

The Ayushman Arogya Mandir facilitate planning

& implementation of health promotion and (1) Check the list of VHND planned & conducted
disease prevention activities through Check number of VHND planned & conducted in (2) List of AWC under Ayushman Arogya Mandir
ME D5.1 community level interventions CHO's catering area in preceding quarter RR & name of the AWC where VHNDs conducted
(1) Regular meetings are being conducted , at
least 2 meetings per month (2) Community
based action plan for health is prepared (3)
Provide support to frontline workers for health
Check VHSNC are constituted & functional RR/SI related activities
(1) Identify pool of local yoga instructors (2)
Prepare & disseminate weekly/monthly
The facility ensure multisectoral convergence Ayushman Arogya Mandir promotes wellness & schedule of classes for community yoga
ME D5.3 for health promotion and primary prevention health promotion through Yoga RR/SI trainings
(1) Education, WCD, ICDS, rural development/
municipal bodies, FSSAI &ICDS etc. (2) Check
Ayushman Arogya Mandir engage other allied VHSNC provide platform for multisectoral
departments for intersectoral convergence RR/SI convergence
Area of Concern - Wellness & Clinical Services
Standard E1 The facility has defined procedures for registration, consultation, clinical assessment and reassessment of the patients
 The facility has established procedure for (1) There is established procedure to collect the
empanelment & registration of individual and Ayushman Arogya Mandir is aware of demographic composition (2) No. of individuals
ME E1.1 families constitution of its catering population RR/SI of different age groups

(1) Check no. of pregnant women, no. of life

births, pregnant mother with complications,
eligible couple, sick new born are estimated (2)
Ayushman Arogya Mandir periodically estimates Population above 30yrs , break up of men &
and updates number of beneficiaries for women above 30 yrs. (3) As per incidence rates/
RMNCHA , NCD and CD RR/SI prevalence rates
(1) Check family folders are maintained for
entire registered population in facility's
coverage area. (2) Check data base is updated
All individuals and families are empanelled regularly for new entrants and exits (annually) &
under AAM-SC RR/SI their illness.
(1) Check all the patients visiting are registered
& their demographic details like Name, age, Sex
The facility has established procedure for and Address etc are maintained . (2) Check
registration & consultation in Ayushman Arogya Patient demographic details are recorded in Unique health ID is given to all individuals and
ME E1.2 Mandir OPD register/portal with UID RR/SI families
Through tele health/ tele consultation with MO
Facility has system to undertaken opinion PHC /identified hubs/ clinical decision making -IT
/consultation from higher centre RR/SI tool
Chief Complaint, Patient History, Physical
examination, requisite diagnostics, provisional
The facility has established procedure for OPD diagnosis, primary management & referral (if
Consultation RR/SI required)

Reassessment /follow up as per schedule for all

cases including critical /high risk patients. Follow
up includes - Treatment compliance, review of
parameters, monitoring of side effect,
adherence to life style modification, timely
The facility has established procedure for follow Facilities provide follow up/re assessment for detection of complication and continuity and
ME E1.3 up/ re-assessment of patients cases under RMNCHA RR adequacy of treatment.
Standard E2 The facility has defined and established procedures for continuity of care through two way referral
(1) specially chronic cases referred for
medication review (2) Examination,
development/modification of treatment plan,
The facility has established procedure for Continuity of care is ensured at referral instruction for patient, note to CHO by
ME E2.1 continuity of care Centre/higher centre RR/SI MO/Specialist.

Dispensation of medicines, repeat diagnostic as

required/ as per treatment plan, identification
Continuity of care is ensured at Ayushman of complication , facilitating referrals, organizing
Arogya Mandir RR/SI tele consultations, maintenance of records
(1) Referral slip, referral in or out register/portal,
Advance communication , prior appointment
with specialist, referral vehicle (if required) &
The facility has established procedure for follow up. (2) IT system to track upward &
undertaking referred in & referred out of the Facility has referral procedure in place to ensure downward referrals to ensure the continuity of
ME E2.2 cases continuity of care RR/SI care
Check records for treatment plan, periodic
assessment, medicine refill and referred to
further higher centre (if required)/ regular
Facility has defined protocols for referral in RR/SI follow up at referring centre
(1) Early case detection, primary
management/stabilisation, Complete details of
case records/care provided - use of referral slip
(2) Check availability of separate colour coded
referal slip -for easy identification in referral
Facility has defined protocols for referral out RR/SI centre
Standard E3 The facility has defined and established procedures of diagnostic services.
The facility has established procedure for Check there is no irrational prescription of Check OPD ticket for any irrational prescription
ME E3.1 laboratory diagnosis as per guidelines Diagnostic test RR/SI of Lab test/USG/ X ray etc
Point of care diagnostics services are available Check staff is aware of Quality Control method
as per mandate RR/SI for various tests (RDKs)
Central hub/diagnostic units are identified & For Both laboratory/other diagnostic test. Check
linkage has established for tests not done at how much patient has to travel for getting
Ayushman Arogya Mandir SI diagnostic services
Standard E4 The facility has defined procedures for safe drug administration.
 (1) Drugs are checked for expiry and other
inconsistency before administration, single dose
vial /ampule are not used for more than one
dose & separate sterile needle is used every
time. (2) Check prescription from referral centre
is verified every time before dispensing of the
Facility follows protocols for safe drug There is procedure to check the drugs before drugs from Ayushman Arogya Mandir /in home
ME E4.1 administration administration and dispensing OB/SI visits

(1) High alert drugs such as Nonsteroidal anti-

inflammatory, anti convulsant/antiepileptics,
Hypertensive, oral hypoglycaemic etc. (2) Staff is
aware of right dose : Value of maximum dose as
There is process for identifying and cautious Check high alerts drugs are identified & its per age, weight and diagnosis is available with
ME E4.2 administration of high alert drugs maximum dose are defined RR/SI CHO.

Check untoward /adverse drug event is reported

: Minimum information model (MIMPS) for
Check with staff if any untoward drug events medication safety is followed & used for
has ever occurred RR/SI reporting & subsequent actions planning
(1) Right patient, right drug, right route, right
time, right dose & right documentation. (2)
Check system in place to verify the verbal orders
Check staff follows 6 Rs of drug administration RR/SI given by MO
Standard E5 The facility follows standard treatment guidelines and ensures rational use of drugs
Check medication review is scheduled for At least once in a year with PHC MO/ Physician
ME E5.1 There is procedure of rational use of drugs regular chronic cases RR of referral facility
Check OPD ticket if drugs are prescribed under
generic name only (specially drugs written by
Check that drugs are written with generic name RR CHO for minor aliments)

(1) Check the cases in which CHO has prescribed

medicines/ antibiotics. (2) Check if the drugs are
either prescribed more than required dose
/quantity or on more occasion than necessary.
(3) Check high end or more than one antibiotics
are prescribed . Give non compliance if any of
Check staff is aware of rational use of drugs RR the above (point 2 or 3 ) is yes.
Standard E6 The facility has defined and established procedures for nursing care.
Chronic cases/ critical patient referred from
higher centre/Home based care patient/ bed
ridden/ elderly cases Check Patient vital like BP,
There is established procedure for identification Patient's vital are monitored and recorded weight, TPR, Blood sugar etc are maintained as
ME E6.1 & periodic monitoring of the patients periodically in follow up RR/SI per disease conditions
Both in Ayushman Arogya Mandir & home
based care. Investigations, refill the medicines,
There is process for ensuring the identification performing minor procedure, administrating
of patient before any procedure OB/SI vaccine etc
Patients who are not oftently following their
There is process in place to identify non treatment plan or taking the medicines as
compliant patient in chronic disease RR/SI recommended
Standard E7 The facility has defined and established procedures for Emergency care

Ayushman Arogya Mandir ensures timely (1) Check how ambulances are called & patient
Emergency protocols are defined and availability of ambulances services for is shifted. (2) Transfer register is maintained to
ME E7.1 implemented emergency cases RR record the details of the refferred patient

Check staff is aware of steps of BLS and also ask

about how to recognize the signs for sudden
cardiac arrest (SCA), heart attack, stroke, and
Staff is aware of procedure for CPR RR/SI foreign-body airway obstruction (FBAO)

Protocols for snake bite, poisoning, drowning,

trauma, burn, fits, cardiac or respiratory arrest ,
Emergency protocols for first aid and haemorrhoids, rectal prolapse, hernia,
stabilization are available RR/SI hydrocele, appendicitis etc.

Staff is aware of district disaster management

The facility has disaster management plan in team, staff is aware of their roles, basic
ME E7.2 place Emergency care is given in case of disaster OB/SI emergency management kit is available
Staff is aware of process of sorting the patients Staff is aware of triage protocols in case of
in case of mass causalty/ outbreak RR/SI referral required
Standard E8 The facility has defined & established procedures for management of ophthalmic, ENT and Oral aliments as per operational/ clinical guidelines
 Awareness about contagious eye disease,
personal hygiene, cleanliness of environment to
prevent the spread of trachoma, do's & do not's
for eye care during eye infection, life style
modification, avoid myths & mis conceptions,
mobilize children for vit A prophylaxis,
The facility provides services for Ophthalmic distribution of spectacles, follow up of referral,
aliments including blindness and refractive Promotion & supportive activities for post operative and cases required long term
ME E8.1 errors as per guidelines ophthalmic care RR medications. Motivation for eye donation
Visual acuity by using Snell's chart, near vision
Staff is aware of methods for measuring the card. ASHA/ MPW is skilled assess to use vision
refractive errors RR/SI screening chart.
Blindness & visual impairment register, records
of vit A prophylaxis, listing of eye disorders,
Surveillance records of TT/TI cases as per NPCB
Staff maintain records under ophthalmic care RR/SI & VI

Ask staff about common ophthalmic aliments &

their cardinal signs & symptoms & its primary
management Conjunctivitis: Redness, itching,
watery discharge from eyes and crusting around
eyes. Trachoma: usually affect both eyes and
may include: Mild itching and irritation of the
eyes and eyelids, discharge from the eyes,
eyelid swelling, light sensitivity (photophobia).
Xeropthalmia: conjunctiva dries out, thickens,
and begins to wrinkle, inability to see in dim
light, progress lesions form cornea and deposits
of tissue are called Bitot?s spots. Redness in
eyes, removal of foreign body & allergic
reactions,, eye injury and acid/ alkaline
Staff is aware of identification & primary /chemical exposure etc Management:
management common ophthalmic conditions Symptomatic treatment, Counselling for eye
including emergencies OB/RR/SI care and referral if required.

Ask staff about common ophthalmic aliments &

their cardinal signs & symptoms Cataract:
Clouded/ blurred or difficulty with vision at
night, sensitivity to light and glare, Need for
brighter light for reading , seeing "halos" around
lights, frequent changes in eyeglass , Fading or
yellowing of colours mostly age related.
Presbyopia: having eyestrain or headaches/
fatigue after reading/ doing close work,
Glaucoma: Severe eye pain, reddening of the
eye, Sudden onset of visual disturbance- in low
Staff screen & refer cases of common light, Corneal Disease: Visual impairment,
ophthalmic aliments lead to blindness & blurred or cloudy vision, severe pain in the eye,
refractive errors RR/SI tearing, and. sensitivity to light
Check CHO is trained and using otoscopy for ear
The facility provides services for ENT aliments as Staff is trained & using diagnostic tools for discharge, Hearing test: whisper/ App based
ME E8.2 per guidelines identification of ear problems OB/RR audiometry.

Ask staff about common ear aliments & their

cardinal signs & symptoms & its primary
management Acute suppurative Otitis media:
irritability, ear pain, neck pain, fullness in ear,
lack of balance. Otitis Externa: Ear pain, itching
& irritation in & around ear, ear discharge
Otomycosis: Fullness, redness of outer ear,
itching, pain. Ear Discharge: Otoscopy.
Identification of discharge: any fluid leaking out
is ear wax. A ruptured eardrum can cause a
white, slightly bloody, or yellow discharge from
the ear. Dry crusted material on a child's pillow
is often a sign of a ruptured eardrum Ear Wax
removal : By syringing / instrumentation, foreign
body removal. Treatment: Symptomatic
Identification & primary management of treatment - analgesics & ear drops & warm
common ear problems RR/SI compression where ever required
First aid for dislodging an obstruction from a
person's windpipe. Sudden strong pressure
Check staff is trained & able to perform Heimlich applied on their abdomen between naval &
manoeuvre/ dislodge obstruction from windpipe RR/SI ribcage
 Thyroid swelling, discharge from ear, hearing
Staff is trained to identify ENT aliments require impairment & deafness, blocked nose,
referral to higher centre RR/SI hoarseness & dysphagia

(1) Educating community about healthy ENT

habits, awareness protection against excessive
noise, safe listening & improving acoustic
environment.(2) Teach for early care seeking
behaviour for allergies & common ENT problems
teach how to instil nasal/ear /eye drops, teach
how to pinch nose in case of epistaxis, perform
Heimlich manoeuvre etc (3) Follow up for
treatment compliance (4) Identified cases
requiring surgery, hearing aid fitting or
Promotion & supportive activities for ENT RR/SI rehabilitative therapy

Patency test: Check the patency of each naris by

standing directly in front of the patient and
occluding the patient's left naris with the index
finger of your right hand. Ask the patient to
breathe normally through the right naris. Repeat
by occluding the patient's right naris with the
index finger of your left hand and ask the
patient to breathe through the left naris.
Normally the patient will be able to exhale
through the unoccluded naris. Nasal obstruction
is present if the patient is unable to exhale
through the nares. Cotton wisp: Fluff of cotton is
Staff is trained & using diagnostic tools for held against each nostrils & its movements are
identification of Nose aliments OB/SI noticed when patient inhale & exhale

Ask staff about common throat aliments & their

cardinal signs & symptoms & its primary
management. Injury, pharyngitis, laryngitis, URI,
tonsillitis. Treatment: Symptomatic treatment:
Identification & primary management of throat Analgesic, antibiotic, Refer the patient if persist
aliments RR/SI more than 5 days.

(1) Community based new born screening till 6

weeks of age- through home visit/ immunization
,Children- 6 week -18 yrs. -Screening through
RBSK , Adults & elderly - through whisper test.
(2)Check opportunistic & planned screening
Screening of population for ENT aliments RR/SI form is used for early identification

Ask staff about common nose aliments & their

cardinal signs & symptoms & its primary
management. Common cold, blocked nose,
injury, sinusitis, rhinitis, epistaxis and foreign
body in anterior part of nasal cavity Treatment:
Symptomatic treatment, nasal packing in case of
nasal bleed, Analgesic, Nasal drops/spray,
Antibiotic may be deferred in children-two years
or older with mild symptoms. Refer the patient
Identification & management of nose problem OB/RR if persist for more than 5 days.
 Ask staff about common oral aliments & their
cardinal signs & symptoms & its primary
management. Tooth decay: Discoloration/ hole,
sensitivity, pain, swelling / pus. Gum Diseases:
Foul smell, bleeding, loose teeth, swollen gums
Dental Fluorosis: White/ Yellow/ brown
discoloured patched on teeth Treatment: After
symptomatic relief at H WC refer to dentist at
CHC/DH. Malocclusion : Reverse bites,
protruding/forwardly placed teeth spacing
between teeth. Treatment: Cessation of habits
such as thumb sucking, mouth breathing. Refer
to dentist at DH. Cleft lip/palate: Split lip/gap in
palate, inability to feed the baby. Refer to
dentist at DH Oral Cancer: White/red patch, non
healing ulcer, reduced mouth opening, change
in voice, lump in neck. burning sensation,
The facility provides service for oral health Staff is aware about Oral health conditions, inability to eat spicy food. Use of CBAC form is
ME E8.3 aliments primary management & referral RR/SI filled and case is referred at appropriate level
(1) Filling of CBAC form (more than 30yrs - Check
records screening is not limited up to oral
cancers it should include screening of other
dental conditions as well ) (2) Check linkage with
Screening of oral health conditions is done as RBSK (0-18 Yrs.) (3) Rest 18-29 yrs. - under
per protocol RR/SI opportunistic screening

Ask staff about common dental emergencies &

its primary management. Pain, swelling/abscess,
tooth injury, non healing ulcer, uncontrolled
bleeding from gums, extraction site. Treatment:
Staff is aware of symptomatic treatment for Symptomatic relief at Ayushman Arogya Mandir
dental emergencies RR/SI & refer to dentist at CHC/DH
(1) Oral health education & dietary advise for (a)
Promotion & supportive activities for oral health SI Oral hygiene (b) Tobacco cessation
Standard E9 The facility has defined & established procedure for screening & basic management of Mental Health ailments as per Operational/ clinical guidelines

Common Mental Disorders( CMDs) : Depression,

Anxiety/panic disorders, psychosomatic
disorders Severe Mental Disorder (SMDs) :
Schizophrenia, Bipolar disorder, severe
depression Child & Adolescent Mental Health
disorder (C& AMHD): Conduct disorder,
Attention deficit disorder (ADHD), oppositional
defiant disorder Epilepsy & dementia
The facility provides services under mental Check staff is aware of MNS (Mental, (Alzheimer's disease) Substance use disorder
ME E9.1 health Program as per guidelines neurological & substance use) conditions RR/SI (SUD): Tobacco, alcohol & drug use disorder

Awareness & use of techniques for psychosocial

intervention:(1) Psychoeducation, psychological
first aid, relation techniques (breathing
exercise), basic suicide management, basic
counselling (problem solving & behaviour
activation), community based rehabilitation,
first aid for overdose/ intoxication etc. (2)
Dispensing of medicines as per prescription (3)
Review & counsel periodically Home/
community/ Ayushman Arogya Mandir and (4)
Provide adherence support for treatment (5)
Staff is competent for basic management, Side effects and toxicities for prescribed
referral & follow up of MNS RR/SI medications
Check staff is trained for emergency Administer either intranasal or intramuscular
management of Epilepsy RR/SI Midazolam. Stabilize & refer

(1) Awareness about improving mental health

literacy, understanding of common symptoms,
reduction in social stigma, technique of self care,
community based rehabilitation, Life style
modification etc (2) Awareness & advocacy
about society problems that act as risk for
mental health conditions viz. gender based
Promotion & supportive activities for mental violence, abuse, suicide ideation & substance
health SI dependence
Standard E10 The facility has defined & established procedures for management of communicable diseases as per operational/ clinical guidelines
 Persistence of fever even after 48 hrs of
treatment, continuous vomiting, headache,
The facility provides services under National dehydration, change in sensorium, convulsions,
vector Borne disease control programme as per bleeding & clotting disorders, severe anaemia,
ME E10.1 guidelines as per guidelines Staff is aware of Malaria referral protocols RR/SI Jaundice & hypothermia
Staff is aware of sign & symptoms of prevalent Chikungunya, KA, JE, LF etc. Any of the cases in
vector born diseases in area SI their catchment area

(1) Treatment should be started within 24 hrs of

detection. (2) P. Vivax - Chloroquine/ 3days and
Primaquine/14 days. (Contraindicated in
pregnant female or infant or G6PD deficiency/ P-
falciparum- ACT (3) Algorithm for treatment &
Staff is aware of Malaria treatment protocols RR/SI diagnosis is available

(1) Diagnostic- RDK (2) Management- Bed rest,

cold sponging,& symptomatic treatment. (3)
Staff is aware of diagnostic & management of Check Ayushman Arogya Mandir is aware of
dengue as per protocols RR/SI dengue cases in its catchment area

(1) Fortnightly Home visit & testing people with

current/ recent fever & chills in past 14 days
using RDT. (2) Malaria detection in cases
presenting with fever at Ayushman Arogya
Mandir (3) Detection by using RDT/Microscopy.
(Microscopy- result should be made available
within 24 hrs) (4) Negative RDT cases strongly
suspected of malaria cross checked by
microscopy (5) Check Ayushman Arogya Mandir
is aware of confirmed malaria cases in its
Case detection is done for Malaria RR/SI catchment area

Source reduction, personal protection,

environment management, Biological control (
Larvivorus fish) & chemical control (larvicide /
Adulticide) . Staff is involved in intersectoral
convergence with other departments like
DODWS (Department of Drinking Water and
Sanitation under Ministry of Jal Shakti, MOHUA
(Ministry of Housing and Urban Affairs),
Primary care team is aware of vector born Municipalities etc) & carry out weekly
disease control strategies RR/SI cleanliness drive in village through VHSNC
RDT kits , clean slides, needles, swabs, ACT, CQ,
Facilities have adequate stock of commodities & PQ etc. Check how kits have been stored & near
drugs RR/SI expiry drugs are not available

The facility provides services under National Staff is aware of follow up protocol after 6,12, 18 , 24 month follow up after treatment
ME E10.2 Tuberculosis Elimination Program (NTEP) treatment completion RR/SI completion
Refer all presumptive cases to designated
Microscopy centre. Sputum collection and
Identification of presumptive case & their transport of sputum of samples is supported in
referral RR hard/difficult areas.

Referral slip, Patients treatment card (if CHW is

NTEP register & records are maintained RR supporting treatment), TB notification register

(1)Provision of DOTS at Sub-centre, proper

documentation and follow-up, home based
support, regular screening of cases for common
adverse effects, ensure compliance &
completeness of course (2) Check Ayushman
Ayushman Arogya Mandir support, supervision Arogya Mandir is aware of presumptive,
& manage presumptive, confirmed & on confirmed & on treatment cases in its
treatment cases including DR- TB patients OB/RR catchment area

Ensure delivery/ availability of 2nd dose onward

drugs, pulse dose to be given in presence of
ANM/MPW, completion of treatment,
Check the availability / delivery of subsequent identification of signs of neuritis, reactions etc
The facility provides services under National doses of MDT and follow up of persons under for treatment cases. Referral in case MCR
ME E10.3 Leprosy Eradication Program as per guidelines treatment RR footwear if required/ referral for complications

Maintain & update case card (ULF01), Update

NLEP register & records are maintained RR the treatment registered when visiting the PHC
 (1) Pale & reddish patches on the skin, skin
thickness, shiny & reddish, numbness & tingling,
painful tender nerves, weakness of hands, feet
or eyelid, swelling & lumps in the face & ear
lobes impaired sensation. (2) Sensory testing for
screening: touching the tip of pen on patch to
feel sensation 2 times (once with eyes & 2nd
with closed eyes) (3) Referral of suspected cases
Primary healthcare team identify and ensure to higher centre. First dose initiated at higher
referral of suspected cases of Leprosy RR/SI centre

Health education to community regarding signs

and symptoms of leprosy, its complications,
curability & availability of free of cost treatment,
Facility provide awareness about leprosy & self care & encourage the patient to bring
availability of its treatment SI his/her contacts to check-up

IEC for STI,HIV/AIDS Awareness generation ,

identification of peer support groups for HRG-
PLHIV, encourage for index testing, support in
treatment adherence, arrangement for
The facility provides services under National Staff is aware of promotional &supportive counselling/ psycho therapies, community
ME E10.4 AIDS Control Program as per guidelines activities done under NACP RR/SI follow up to support HIV pregnant women &
Ayushman Arogya Mandir -SC has linkage for Linkage with Microscopy centre for HIV -TB, for
management of HIV/AIDS complications RR PPTCT services

Identification & referral of suspected cases,

Condom Promotion & distribution among high
risk groups & help HIV cases for receiving &
adhering to ART. HIV/STI Counselling, Screening
Ayushman Arogya Mandir-HSC is aware of their (consent) and referral in Type B Sub-centres in
roles in NACP RR/SI high prevalence districts
Fever, Cough less than 2 weeks duration, acute
flaccid paralysis more than 15 yrs. of age,
diarrhoea (3 or more loose stool /day), Jaundice,
The facility provides services under Integrate Staff is aware of syndrome under surveillance in Raise the signal for action in case of for any
ME E10.5 Disease surveillance as per guidelines IDSP/IHIP RR/SI unusual health event /death

(1) Preliminary analysis & reporting of collected

Check Analysis & reporting of information for data to MO- PHC on every Monday (2) Check
syndromic surveillance is done RR/SI any action has been undertaken using IDSP data
(1) Information is collected from Home visit (for
above described syndrome) & from SC- OPD (2)
Check process to collect information in form S Collation of data in Register for Syndromic
/IHIP RR Surveillance
The facilities provide services for National Viral RDT for Hep B & Hep C & referral for
ME E10.6 Hepatitis Control Programme (NVHCP) Availability of diagnostic & treatment services RR confirmation & further management
Awareness generation & behaviour change
communication, immunization for Hep B (Birth
dose, high risk group & healthcare worker) ,
Staff is aware of preventive measures for injection safety & safe drinking water &
NVHCP OB/SI sanitation.
Standard E11 The facility has defined & established procedures for management of non-communicable diseases as per operational/ clinical guidelines

Interview patients for: (1) Regular & adequate

availability of medicines as per treatment plan
(2) His/her understanding about dosage
schedule, life style medication, any dietary
restriction and awareness about next follow up
The facility provides services for hypertension as Ayushman Arogya Mandir ensures frequency of visit date (3) Annual consultation with specialist
ME E11.1 per guidelines follow up & supply of required medicines RR at NCD clinic

Awareness generation - (a)Risk factors:

overweight & obesity, Physical inactivity &
stress (b) Healthy life style: diet, exercise,
avoidance tobacco & alcohol, (c ) Counselling for
Staff is aware of promotional &supportive Lifestyle modification (d) importance of regular
activities for Hypertension SI follow & compliance to medication
 (1) Population enumeration -filling of CBAC form
for all above 30Yrs of age- Screening at
Ayushman Arogya Mandir on fixed day approach-
referral of suspected cases to higher centre for
Consultation - follow up of those who are
diagnosed with hypertension & ensuring that
they adhere to treatment plan- identify warning
signs of complication & refer to higher centre.
Staff is aware of process of population (2) Re screening of population (new and old) at
identification and referral for hypertension RR/SI periodic intervals - every year

Systolic/ Diastolic BP of over 140 /Over 90 mm

of Hg. Severe Headache, fatigue, nausea,
CHO is aware of sign & symptoms of sweating, feeling faint & confusion, vision
Hypertension SI problem, chest pain, shortness of breath.

Interview patients for: (1) Regular & adequate

availability of medicines as per treatment plan
(2) His/her understanding about dosage
schedule, life style medication, any dietary
restriction and awareness about next follow up
The facility provides services for Diabetes as per Ayushman Arogya Mandir ensures frequency of visit date (3) Annual consultation with specialist
ME E11.2 guidelines follow up & supply of required medicines RR at NCD clinic

Counselled about not to miss/skip meal, take up

frequent and small meals, increase physical
activity and side effects of anti diabetic drugs.
Hypoglycaemia: Symptoms; tremors,
nervousness, anxiety, sweating, irritability,
confusion, Heart beat increase, headache etc
Management: Take 5-6 toffees/ Mishri/1 table
spoon sugar/honey/ 2-3 teaspoon of glucose/ 3-
4 tea spoon of sugar/ half cup of juice or cold
Check Patient is counselled about identification drink. If symptoms persists patient should be
& immediate management hypoglycaemia SI taken to higher centre for further management.

(1) Population enumeration -filling of CBAC form

for all above 30Yrs of age- Screening at
Ayushman Arogya Mandir on fixed day approach-
referral of suspected cases to higher centre for
consultation - follow up of those who are
diagnosed with hypertension & ensuring that
they adhere to treatment plan- identify warning
signs of complication & refer to higher centre (2)
Staff is aware of process of population Re screening of population (new and old) at
identification and referral for diabetes RR/SI periodic intervals -every year

(1) All overweight or obese cases with diabetes

or prediabetes symptoms or elevated blood
lipids or elevated blood pressure (2) All such
cases are screened for: ? Abdominal Obesity
(waist circumference of ? 90 cm in men or ? 80
cm in women) ? Family H/O diabetes,
Ayushman Arogya Mandir is aware of risk hypertension, heart diseases and cancers ?
factors of Nonalcoholic fatty liver disease Obesity (BMI>=25kg/m2) ? Oedema
(NAFLD) RR/SI examination (3) Referal to PHC for management

Awareness generation - (a)Risk factors:

overweight & obesity, Physical inactivity &
stress (b) Healthy life style: diet, exercise,
avoidance tobacco & alcohol, (c ) Counselling for
Life style modification (d) Importance of regular
follow & compliance to medication (e)
Counselling about diabetes related complication
Staff is aware of promotional & supportive viz. Retinopathy, neuropathy & kidney failure
activities for diabetes SI etc.
Random blood sugar 140mg/dl and mg/dl.
Frequent urination, increased hunger,excessive
thirst, unexplained weight loss, extreme
tiredness, blurred vision, slow wound healing
numbness or tingling hands or feet & sexual
CHO is aware of sign & symptoms of diabetes SI problems
Lump in breast/under arm area, thickening or
swelling of breath, puckering /dimpling of
The facility provides services for cancer Staff is aware about sign & symptom of Breast breath skin, redness in nipple area, nipple
ME E11.3 screening and referral as per guidelines cancer SI discharge /blood, constant pain etc
 For cancers of the oral and breast, the first level
of referral is the CHC / SDH/ DH and then to the
DH for a biopsy for confirmed cases. For cervical
Check CHW is aware of referral centre for all cancer, if VIA positive, refer to higher centre
types of cancer RR/SI offering colposcopy

(1) At SC/ outreach/screening for Breast, cervix

& oral cancer. (2) Screening is undertaken by
trained personnel (LHV/Staff nurse/MO) can be
done in outreach session/screening day. (3)
Screening of cervical cancer is conducted on site
Check cancer screening services are provided where privacy & facility for sterilization is
through Ayushman Arogya Mandir RR/SI available (4) Repeat screening -every 5yrs
Vaginal bleeding between periods, menses
longer or heavier than usual, post menopausal
bleeding, bleeding & pain during/after sexual
Staff is aware about sign & symptom of cervical intercourse, smelly vaginal discharge, pain
cancer SI during urination etc

Awareness generation - (1)Risk factors: smoking,

multiple sexual partner, unprotected sex, family
history, overweight, lack of physical activity (2)
Healthy life style: diet, exercise, avoidance
tobacco & alcohol, (3 ) Counselling for Life style
Staff is aware of promotional & supportive modification (4) importance of regular follow &
activities for diabetes SI compliance to medication

Difficulty in chewing or swallowing , mouth

ulcers persist for more than 3 weeks, persistent
Staff is aware about sign & symptom of Oral pain, lump, thickening in cheek, white/red patch
Cancer SI on gums/ tongue/tonsil etc,

(1) Visual Inspection by Acetic Acid for cervical,

(2) Oral Visual Examination for oral cancer (3)
clinical breast examination for Breast .
Check with staff about methodology followed (4)Discuss interpretation of results if done at
for cancer screening RR/SI SC/outreach session/screening day
(1) For Withdrawal symptoms (2) Life style
The facility provides services for de addiction, support changes (3) Engagement/ linkage with
and locally prevalent health diseases as per Promotional & supportive activities for patient support groups (4) Support
ME E11.4 guidelines Tobacco/alcohol/ substance abuse RR/SI encouragement by family & friends

Ask for local prevalent disease viz.

Check Screening & referral locally prevalent Pneumoconiosis , lead poisoning, fluorosis etc.
diseases SI Give full compliance if no such disease exists

Staff is aware 5A approach - Ask, advise, assess,

Assist & arrange (1) History taking and referral
to identified de addiction centre. (2) Advise to
quite in cleat, strong and personalized manner
(3) Attempt to Quit (4) Involve family & friends,
remove substances from their adjacent area,
Confirmation and referral of cases for Arrange follow up visit (5) motivate by re
Tobacco/alcohol/ substance abuse RR/SI enforcing & intense follow up

1. Check roster is available, updated & displayed

The facility promotes services for health & 2. Community is aware of yoga sessions
ME E11.5 wellness Check Yoga sessions are conducted regularly RR conducted by Ayushman Arogya Mandir

(1) Generate awareness about 4 major food

groups (food pyramid) - a. Cereals & millets b.
Vegetables & fruits, c. Milk & animal products d.
Check Primary health care team generate Fats/ oils, sugar & nuts (2) Limit the
awareness in community about balanced diet SI consumption of foods high in fats, sugar & salts
 Check staff counsel mother's for nutritious diet
during first 1000 days of life (1) Stage 1 (During
Pregnancy) : Balance & nutritious diet including
important nutrients like iodine, folic acid, iron,
vit B12 etc. (2) Stage 2 ( Period from birth of
child to 1 yr.): Early initiation of exclusive
breastfeeding for initial 6 months, initiation of
Complementary feeding on completion of 6
months with continued Breastfeeding (3)Stage 3
(Period between 12 month to 24 months of child
age): Complementary feeding & its preparation
Check counselling of mother's for nutrition & with right consistency, quantity, frequency,
hygiene maintenance under Eat right SI density & variety.
Check Primary health care team generate (1) Awareness on benefits of fortified food (2)
awareness in community about food Identification of fortified food available in
fortification SI market (+F logo)

Awareness generation about maintaining

personal & environmental hygiene while
cooking food (viz. handwashing, regular bathing,
Check Primary health care team generate wearing clean clothes, keeping kitchen clean,
awareness in community about Eat safe taking pest control measures, waste disposal,
practices SI using kitchen waste for compositing etc)

(1) Awareness generation about logos on

packed food viz. fssai, ISI, +F, green and red dots
for vegetarian and non vegetarian food items.
(2) Safe storage of perishable & non perishable
food (3) Precautions to be taken while cooking &
serving the meals. (4) Awareness about
Check Primary health care team generate common tests for food adulteration (Key ring
awareness in community about food safety SI test)

(1) Guide about household measurement with

Check staff counsel and guide the mother's household utensils (2) Awareness on
about household preparation of complementary ingredients, quantity & frequency of
feeds SI complementary feeding for children up to 2 yrs.
Standard E12 Elderly & palliative health care services are provided as per guidelines
(1) Activity of daily living (2) Geriatric depression
scale, (3) Mini mental state examination. (4)
The facility provides services for elderly Care as CHO is aware & competent to use various Check how many cases are identified & referred
ME E12.1 per guidelines geriatric tools OB/RR (if required)

(1) Health education regarding healthy aging,

environmental modifications, nutritional
requirements, life style & behaviour changes (2)
Educate family members for looking after
disabled elderly person (3) Linkage with support
Promotional & supportive activities for Geriatric group & day care centre. (4) Motivate to join
care SI annual health check-up at village level

(1) Mapping of elderly population in category of

Bed bound ,restricted & mobile elderly,
destitute, poor & single (2) Screening using
comprehensive Geriatric assessment tools (3)
Elderly population is mapped & screened RR/SI Primary management & timely referral
Check how many elderly supported by
Ayushman Arogya Mandirs for supportive aids
Ayushman Arogya Mandir -undertake viz Walking sticks, callipers, infrared lamp,
preliminary assessment for the need of assistive shoulder wheel, pully & walker (as per
devices RR requirement) through PHCs

Check sufficient number of kits are available, it

contains supplies, equipment & drugs as per
The facility provides services for Palliative care Check Home care kit is available & case sheet requirement & kits are regularly refilled. Home
ME E12.2 as per guidelines are updated RR/SI care case sheets are filled completely & legible

(1) Check palliative care team is constituted,

comprising of CHO, MPW, ASHA & volunteer. (2)
Home based palliative care services are being Check updated roster for undertaking scheduled
provided RR/SI visits. (3) Check the compliance to roster
 (1) Health education regarding needs of
palliative patients (2) Educate family members
for routine home based care (3) Linkage with
Promotional & supportive activities for palliative support group & day care centre. (4)Help in
care SI assessing various services as needed
(1) Assessment using Palliative care screening
tool by CHO./MPW (2) Scheduled visits to
patients/ families for basic nursing care/drugs or
consumables dispensing /psycho social support.
Screening, basic management & referral of (3) Referral of palliative patients based on pain
Palliative Care patient is done RR score

Patient support group comprise of care givers,

volunteer, patients & CHO. Check their
Check patient support groups are available RR/SI gathering is convened at least once in month
Standard E13 The facility has established procedures for care of new born, infant and child as per guidelines

Not able drink or breast feed, vomiting,

convulsions, lethargy Discharge from cord,
pallor, cyanosis, Jaundice, pustules,
hypothermia, unable to pass stool/urine, fever,
Post natal visit & counselling for new born & CHO & CHW are aware of danger signs of new diarrhoea, indrawing of the chest (2-12 months-
ME E13.1 infant care is provided as per guideline born & infant RR/SI 50 breaths/min & 12-5yrs-40 breaths/min)
Primary management & prompt referral of sick Staff practice ETAT protocol. Stabilization per
new born & infants RR/SI disease condition.

Exclusive breast feeding, cord care,

maintenance of temperature, promoting
Staff is aware of post natal care Counselling SI hygiene practise, support for high risk babies
ARI: Chest indrawing difficulty in breathing
,coughing, fever, fast breathing Malnutrition:
Weakness/wasting, check weight for age, check
height for weight Diarrhoea: Sunken eyes,
Management of children for ARI, diarrhoea, Assessment for identification of ARI, diarrhoea, lethargic, unconscious, restless, irritable, pinch
ME E13.3 malnutrition and other illness malnutrition and Other Illness RR/SI skin

Young infant- Not able to feed or convulsion or

fast breathing >60/ min or severe chest
indrawing or axillary temp 37.5 OC or more or
movement only when stimulated Children -
General danger signs, or chest indrawing - very
Assessment for identification of possible serious severe or severe pneumonia Fast breathing - RR -
bacterial infections among young infant (0-59 2-11month >or equal 50/min 12-59 months> or
days) & children (2 -59 months) RR/SI equal 40/min- Pneumonia
Screening, referral and follow up of children for
anomalies, disabilities and developmental Functional linkage with RBSK team, referral &
delays RR/SI follow up

(1) Give first dose of oral Amoxicillin and

injectable Gentamycin. (2) Treat or prevent low
sugar (breastfeed/ age appropriate feed) (3)
Warm the young infant if temp is less than 35.5
Management of Possible serious bacterial OC. (4) Advise mother to keep young infant
infection as per protocols RR/SI warm & refer urgently to hospital
Management of Malnutrition is done as per
protocols SI Counselling for nutrition & referral
ORS, Zn, Lot of fluids, & treatment with
Management of diarrhoea is done as per Cotrimoxazole. Counselling and referral if
protocols RR/SI required

Symptomatic treatment, Paracetamol for fever,

plenty of fluids, keep child & give normal diet .
Management of ARI is done as per protocols RR/SI Counselling & referral if required
Standard E14 The facility has established procedures for family planning as per government guidelines and law.

(1) BRAIDED Approach: Benefits of method, risk,

consequence of failure, alternatives, inquiries,
decision to withdraw, explanation of method
chosen & document of session (2) Care seeker is
Family planning counselling services are Staff is aware of Method specific counselling counselled about contraindications & adverse
ME E14.1 provided as per guidelines approaches SI events of chosen FP methods
Importance of FP, Options available- ( limiting &
spacing method), time for initiation &
advantages of various available methods. For
The client is given full information about family Limiting method -counselled & referred to
planning methods RR/SI higher centre
 (1) Hormonal (Combined oral pill) ,Non
Hormonal (Chaya) & Emergency Contraceptives.
(2) Combined oral Pill taken at fixed time daily
ECP_ within 72hrs, second dose 12hrs after first
dose Centchroman: to be taken twice a week for
the first 3 months followed by once a week
thereafter. Check for Chhaya/Centchroman
The facility provides spacing methods for family Staff is aware of options, indications & methods eligibility is checked & confirmed by MO. Dose
ME E14.2 planning as per guidelines for administration for Oral Contraceptives RR/SI may be started by trained HCW

No touch technique, Speculum and bimanual

examination, sounding of uterus and placement.
Follow up : when to return / removal of IUCD.
IUD insertion & follow up is done as per Check In case of 2nd trimester abortion IUCD is
standard protocol RR/SI provided by Qualified Medical officer
Check the eligibility for injectables are checked
& confirmed by MO. Dose may be started/
continue by trained HCW. Depot MPA can be
given IM or Subcutaneous, IM: single dose vial
Injectable Contraceptives are given as per with disposal syringe & needle. Subcutaneous:
protocols RR/SI Pre filled AD syringe
Staff is aware of case selection criteria for family
planning methods RR/SI 15-49 yrs., married

For sterilization: 22-49 yrs.- (female) & 22-60yrs

(male), married, youngest child is at least one
The facility provides limiting methods for family Staff is aware of case selection criteria for year & spouse has not opted for sterilization.
ME E14.3 planning as per guidelines limiting mentors RR/SI Counselled & referred to Higher centre

Check adherence to GoI guidelines Female

Sterilization: Certification is issued one month
after the surgery or after the first menstrual
period, whichever is earlier. Male Sterilization;
Certificate is issued only after three months
once the semen examination shows no sperm,
HCW is supporting & encouraging the clients for certificate can be delayed till 6 months if the
post sterilization follow up RR/SI semen shows sperm after 3 months. (A
Standard E15 The facility provides Adolescent Reproductive and Sexual Health services as per guidelines.

Haemoglobin estimation, weekly IFA tablet, and

Services for treatment & referral of common treatment for worm infestation, Symptomatic
The facility provides promotive, preventive & RTI/STI's, Nutritional Anaemia & Menstrual treatment , counselling , TT at 10 and 16 year.
ME E15.1 curative service for adolescent disorders RR Referral linkages to ICTC and PPTCT

Nutritional Counselling, advice on topic related

to Growth and development, puberty, myths &
Provision of education & counselling services for misconception, pregnancy, safe sex, menstrual
adolescent SI disorders,anemia, sexual abuse ,RTI/STI's etc.
Standard E16 The facility has established procedures for Antenatal care as per guidelines
Check with staff the expected pregnancies in
her area / how to calculate it.(Birth Rate X
There is an established procedure for Staff has knowledge of calculating expected Population/1000 Add 10% as correction factor
ME E16.1 registration and follow up of pregnant women. pregnancies in the area RR/SI (Still Birth)

[Link] with ANM how she tracks missed out

ANC. Use of MCTS by generating work plan and
follow-up with ASHA, AWW etc. 2. Check if there
is practice of recording Mobile no. of
Tracking of Missed and left out ANC RR/SI clients/next to kin for follow up
[Link] staff about schedule of 4 ANC Visits (1st -
< 12 Weeks 2nd - < 26 weeks 3rd - < 34 weeks
4th >34 to term) [Link] ANC register whether
all 4 ANC covered for most of the women
(sample cases). [Link] least one ANC visit is
All pregnant women get ANC check-up as per attended by Medical Officer (Preferably 3rd Visit
recommended schedule RR/SI -28-34 Weeks)

Check Mother & Child Protection cards have

Facility provides and updates ?Mother and Child been provided for each pregnant women at
Protection Card? RR time of 1st registration/ First ANC

Check ANC records for ensuring that majority of

Facility ensures early registration & line listing of ANC registration is taking place within 12 week
high risk ANC cases RR/SI of pregnancy in ANC register
 Pulse, Respiratory Rate , Pallor, Oedema. Height,
weight & BP- Check any 3 ANC records/ MCP
card randomly to see that weight has been
There is an established procedure for History measured and recorded at every ANC visit
taking, Physical examination, and counselling of Physical Examination & vitals of Pregnant Observation and Correction of Flat or Inverted
ME E16.2 each antenatal woman, visiting the facility. Women is done on every ANC visit RR Nipples Palpation for any Lumps or Tenderness

Measurement of Fundal Height (ask staff how

she correspond fundal high with Gestational
Age), Auscultation for foetal heart sound ,
Palpation for Foetal lie and Presentation Check
Abdominal Examination is done as per protocol RR/SI for findings recorded in MCPcard/ANC Records

(1) History of pervious pregnancies including

complications and procedures done, if any, is
taken. History of current or past systemic illness
like Hypertension, Diabetes, Tuberculosis,
Rheumatic Heart Disease, Rh Incompatibility,
malaria, etc. is taken. (2) Allergies to drugs, any
Comprehensive Obstetric history is recorded RR/SI treatment taken for infertility.
Check how staff confirms EDD & LMP, (EDD =
Date of LMP+9 Months+7 Days) How she
estimates if Pregnant women is unable to recall
Last menstrual period (LMP) is recorded and first day of last menstrual cycle ('Quickening',
Expected date of Delivery (EDD) is calculated on Fundal Height) .Check ANC records that it has
first visit RR/SI been written

[Link] for Haemoglobin, confirmation of

pregnancy, urine albumin & sugar blood, blood
sugar, Malaria. Check randomly any 3 MCP card/
ANC record for Haemoglobin test is done at
every ANC visit and values are recorded. 2.
Haemoglobin & urine albumin & sugar test is
done on every ANC visit 3. Referral is done for
The facility ensures of drugs & diagnostics are the remaining ANC diagnostics: blood group and
ME E16.3 prescribed as per protocol Diagnostic test for every pregnant women RR/SI Rh factor, Hepatitis B
Check randomly any 3 ANC records for
confirming that TT1 (at the time of registration)
and TT2 (one month after TT1) has been given
to Primi gravida & Booster dose for women
Tetanus Toxoid (2 Dosages/ Booster) have been getting pregnant within three years of previous
during ANC visits RR/SI pregnancy

Hypertension & Pre Eclampsia (Hypertension -

There is an established procedure for Two consecutive reading taken four hours apart
identification of High risk pregnancy and Staff is competent to identify Hypertension / shows Systolic BP >140 mmHg and/or Diastolic
ME E16.4 appropriate & timely referral. Pregnancy Induced Hypertension RR/SI BP > 90 mmHg

1. Prophylactic - one IFA tablet per day for six

months during ANC &PNC. [Link] dose-
double the dose in case of anaemia. 3.
Staff is aware of prophylactic & Therapeutic Improvement in haemoglobin label is
dose of IFA & progress is monitored RR/SI continuously monitored and recorded
>11 gm% -Absence of Anaemia,10 to 11 gm%
mild, 7-10 gm% Moderate Anaemia <7 gm%
Severe Anaemia (2) Check the records whether
Staff is competent to classify anaemia and line Line-listing of severely anaemic women are
list the cases according to Haemoglobin Level RR/SI maintained
Anaemia, Bad obstetric history, CPD, PIH, APH,
Medical Disorder complicating pregnancy,
Staff can recognize the cases, which would need Malpresentation, foetal distress, PROM,
referral to higher centre(FRU) RR/SI obstructed labour.

Pre - Eclampsia- High BP with Urine Albumin (+2)

Imminent eclampsia -BP >140/90 with positive
albumin 2++, severe headache, Blurring of
Staff is competent to identify Pre-Eclampsia RR/SI vision, epigastria pain & oliguria in Urine
Swelling (oedema), bleeding even spotting,
blurred vision, headache, pain abdomen,
Counselling of pregnant women is done as per Pregnant women is counselled recognize danger vomiting, pyrexia, watery & foul smelling
ME E16.5 standard protocol and gestational age signs during pregnancy SI discharge & Yellow urine
(1) Registration and identification of institution
as per clinical condition (2) counselled to
Pregnant women is counselled for planning and recognize sign of labour & arrange for referral
preparation for birth SI transport
 [Link] Dietary Intake Diet rich in proteins,
iron, vitamin A, vitamin C, calcium and other
essential micronutrients. Initiate breastfeeding
especially colostrum feeding within an hour of
birth. [Link] not give any pre-lacteal feeds.
(Sugar, water, Honey) 3. Ensure good
attachment of the baby to the breast.
[Link] breastfeed the baby for six
months. 5. Breastfeed the baby whenever
he/she demands milk. 6. Follow the practice of
rooming in. Different Options available including
Pregnant women is counselled diet, rest, breast IUCD, PPIUCD, vasectomy, long acting
feeding & family planning SI injectable, etc.
Standard E18 The facility has established procedure for post natal Care
Check for records of Uterine contraction,
bleeding, temperature, B.P, pulse, Breast
Mother is monitored as per post natal care examination, (Nipple care, milk initiation). Check
ME E18.1 Post partum Care is provided to the mothers guideline RR/SI for perineal wash is performed
Danger signs :Excessive PV bleeding, breathing
difficulty, convulsion, severe headache,
Check Mother is educated & counselled about abdominal pain, foul smelling lochia, urine
There is a established procedures for Postnatal danger signs during puerperium & during dribbling, perineal pain, painful & redness of
ME E18.2 visits & counselling of Mother and Child postnatal visit RR/SI breast.
Area of Concern - Infection Control
Standard F1 The facility has established program for infection prevention and control
All staff undergo medical Check-up at least once
Facility ensures that staff is working as team and Check Records of Medical Check-up and in year and immunization with at least Hepatitis
ME F1.1 monitor the infection control practices Immunization RR B and TT
Person is identified to supervise the sanitation
Staff is working as team to improve sanitation & ald hygiene of Ayushman Arogya Mandir and its
hygiene of the facility RR/SI surrounding area.
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices

Hand Hygiene facilities are provided at point of Staff is trained and adheres to hand washing Demonstration : Six Steps of Handwashing & ask
ME F2.1 use & ensures adherence to standard practices practices OB/SI about Five Moments of handwashing
Standard F3 The facility ensures standard practices and equipment for personal protection
The facility ensures availability of personal
protection equipment and ensures adherence to Compliance to correct method of wearing and Staff is aware of method of donning and doffing
ME F3.1 standard practices removing PPE OB/SI the PPE
Standard F4 The facility has standard procedures for disinfection and sterilization of equipment and instruments.
(1) Check staff is aware of what to do in case of
sharp injury, Whom to report. See if any
The facility ensures standard practices and reporting has been done and treatment
materials for disinfection and sterilization of Check saff is aware what to do in case of provided (2) Linkage available to provide post-
ME F4.2 instruments and equipment exposure to injury or any blood/body fluid RR/SI exposure prophylaxis
Area of Concern - Quality Management
Standard G4 The facility has established system of periodic review of clinical, support and quality management processes
Handholding support and supervision is
provided to Ayushman Arogya Mandir by PHC, Service delivery and performance of Ayushman
ME G4.1 block/ district/state teams Arogya Mandir is reviewed regularly RR/SI Through monthly visits by MO PHC
Ayushman Arogya Mandir performance is
reviewed regularly by block/district/state nodal Quarterly -By Block nodal officer, Bi Annual - by
officer RR District Nodal officer
The facility conducts periodic internal
ME G4.2 assessment Periodic assessment using NQAS checklist RR At least once in six months

Periodic assessment using Kayakalp checklist RR Quarterly

Standard G5 Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve them.
The facility has defined Quality policy and Staff is aware of Quality Policy. Quality Policy is
ME G5.1 quality objectives Quality policy are defined RR displayed in local language
Major Gaps (Any)
Evidence (Any)
Strength (Any)