Reference No.

Measurable Elements Checkpoints Compliance Assessment Method Means of Verification

Area of Concern - Patients Right
Standard B1 The facility provides information to care seeker, attendants & community about available services & their modalities

(1) In local language (2) Service Provided,

contact details of fire, police ambulance. Name
& contact detail of CHW and nearest referral
centre. (3) Details of grievance re addressal
mechanism (4) Citizen rights and responsibilities
(5) Citizen entitlements as per scope of services-
ME B1.1 The facility displays its services and entitlements Citizen charter is displayed 2 RR/SI all NHP including RMNCHA and PMJAY

(1) Name of the Ayushman Arogya Mandir,

Service Packages and time mandate is
displayed. (2) Check the name of Ayushman
Name of the facility, list of services and drugs Arogya Mandir is visible at night also (3) List of
available are displayed prominently 2 RR/SI available drugs and its stock status is displayed

(1) HWC is renamed as Ayushman Arogya

Mandir with its tag line "Arogyam Paramam
Dhanam" (2) Check the translation of regional
language correspond with designated name. (3)
Check the tagline is transliterated only. (4)
Check no flex or banner is used Flex affixed on
metal frame is only allowed for a rental building.
Give non complaince if it is still named as HWC,
Name of AAM is written in regional language 2 RR/SI painted or flex or electronic

(1) Outer surface of the building is metallic

yellow . (mistmatch in olour require prior
approval from MOHFW) (2) Windows and their
frame in brown with specified shade. (3) Six
illustrations are drawn on the façade and are
prominently displayed (4) HWC is renamed as
Ayushman Arogya Mandir with its tag line
"Arogyam Paramam Dhanam" (5) Logo of NHM
and Ayushman Bharat. (6). Check electronic
display of boards of the services. Give non
Branding of Ayushman Arogya Mandir is done as complaince if it is still named as HWC, painted or
per guidelines 2 RR/SI flex or electronic

(1) Service specific relevant IEC is displayed (2)

Check availability of the updated IEC material (3)
Check no outdated information is displayed in
Patients & visitors are sensitized and educated IEC Material is displayed as per services Ayushman Arogya Mandir (4) Check audio visual
ME B1.2 through appropriate IEC / BCC approaches provided 1 RR/SI aids are used to display the IEC/ information

(1) Check relevant poster are displayed (2)

Check staff engages the community in
disseminating key messages in outreach as well
as Ayushman Arogya Mandir related to nutrition
& sanitation through various activities viz: 3 D
food pyramid, food fortification pocket flyer, +F
logo puzzle, waste management, hand washing,
food adulteration etc. (3) Check AV aids are
Ayushman Arogya Mandir promotes wellness played in waiting area as well as during EAT right
through EAT right campaign 2 RR/SI campaign
Standard B2 Facility ensures services are accessible to care seekers and visitors including those required some affirmative action
Access to facility is provided without any Availability of Wheel chair/stretcher, ramp with
physical barrier & friendly to people with Check Ayushman Arogya Mandir premises is railing ( At least 120 cm width, Gradient not be
ME B2.2 disability. free from any physical barrier 2 RR/SI steeper than 1:12 )
(1) Passage is wide enough for wheel chair and
crutches/canes/stick users. (2) Floors are non
slippery. (3) Ramps and stairs with handrails. (4)
Check Ayushman Arogya Mandir premises is Ramps & staircases with hip lip (20mm) on
obstacle free for ambulatory and semi exposed side to prevent slipping of cane/
ambulatory individuals 2 RR/SI crutches/ wheelchair
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

Check community is aware of services provided,

grievance redressal mechanism, contact details
Staff is aware of Patients rights and Check Staff and community is aware of Patient of higher centre, contact details of ambulances
ME B3.2 responsibilities rights and responsibilities 2 RR/SI by Ayushman Arogya Mandir.
(1) Complaint Box/ Complaint register/ facility
specific IT system. Defined period for resolving
The facility has defined and established the complaints (2) Corrective and preventive
ME B3.3 procedure grievance redressal system in place Availability of complaint reporting system 2 RR/SI action taken
Standard B4 The facility maintains privacy, confidentiality & dignity of patient
 Adequate visual privacy is provided at every Availability of screen/ curtains in examination
ME B4.1 point of care area and in windows 2 RR/SI (Screen/ curtain/ frosted glass on windows
Family folders, CBAC form, NCD portal
information, HIV, RTI/STI, OPD registers etc
Confidentiality of patients? records and clinical Patient records are kept at safe place beyond
ME B4.2 information is maintained Patient records are kept in safe custody 2 RR/SI access of general patient flow
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
Facility has adequate infrastructure, space and Adequate space/room for Yoga and
ME C1.1 amenities as per patient or work load immunization activities 2 RR/SI within Ayushman Arogya Mandiror its premises
(1) Lab. space is adequate for carrying out Lab.
activities (2) (Storage space for storing
medicines ,Consumables & equipment etc. (3)
Demarcated space for Laboratory/diagnostics, Check the availability of racks/ Almirahs/ shelf
drugs storage 2 RR/SI etc

(1) Potable drinking water supply is available for

patients, visitor & staff (2) Piped water supply/
tube well with fitted water pump/ other
alternate source. (3) Water Storage facility-
Minimum 3 days (4) Periodic chlorination &
Adequate water supply with storage facility 1 RR/SI Quality testing of water is done
(1) Availability of Portable emergency light ,
generators/inverters/solar panel/ for power
Availability of regular & uninterrupted electricity back up (2) Use of energy efficient bulbs for
supply 2 RR/SI lighting

(1) Check demarcated area for examination

(privacy maintained), consultation and
administrative/record keeping (2) Availability of
Well ventilated & illuminated clinic room with adequate Natural Light/ Illumination (150 Lux in
examination space 2 RR/SI OPD area & 300 Lux in drug dispensing areas)

(1) Adequate waiting space: Covered waiting

area accommodating 20-25 Chairs. (2)
Availability of separate toilets for male & female
(3) (Check toilets are functional with running
water facility. (4) Check that the toilets are
Availability of adequate patient amentities 1 RR/SI friendly for specially-abled patients
(1) Fire extinguisher ABC type (2) Check expiry
date & refill date is displayed (3) PASS- Pull the
pin, A- Aim at base of fire, S- Squeeze the lever,
The facility ensures physical safety including Ayushman Arogya Mandir has installed fire S -Sweep side to side (4) Check exists are clutter
ME C1.2 electrical and fire safety of infrastructure extinguisher and staff know how to operate it 2 RR/SI free
Ayushman Arogya Mandir does not have Safe installation, use of appropriate wires &
temporary connections and loosely hanging MCB , Use of AV regulator ( for regulating the
wires 2 RR/SI fluctuations)
Standard C4 The facility provides drugs and consumables required for assured services

Vit A prophylaxis, Glucosticks, Syringes,

Pregnancy kits, HIV Rapid Test and STI Screening
Test kits, Kit for testing residual chlorine in
The facility have adequate consumables as per Availability of Drugs and Consumables for Water. Vision screening care for 6/18 vision,
ME C4.2 requirement VHNDs or camps 2 RR/SI measuring tape (6m), reading module.
Splints, Syringe (10cc, 5cc, 2cc) and AD Syringe
(0.5ml and 0.1ml) for injection, Suture with
needle holder & artery forceps, Disposable
Availability of disposables for Dressing / gloves, Disposable Swabs, Disposable Lancets,
Emergency management 2 RR/SI Mackintosh Sheets
Haemoglobin scale test with talquist paper,
Urine Pregnancy rapid test, Rapid Kits for
Malaria and Dengue, Urine Dip Stick for albumin
and Sugar, Glucometer with glucosticks, Sputum
Availability of Rapid Diagnostic Kits 2 RR/SI Cups,
Mucus extractor, Wooden Spatula, Disposable
Cord clamp, Disposable Sterile Urethral
Catheter( 12fr, 14fr) , Foleys catheter , IV
Cannula and Sets, Interdental Cleaning Aids,
cold pack, cotton and envelopes for drug
Availability of disposables at Clinics 1 RR/SI dispensing
Standard C5 Facility has adequate functional equipment and instruments for assured list of services
The facility ensures availability of equipment
and instruments for examination and Availability of functional Equipment & Dental explorer, mouth mirror, tweezer
ME C5.1 monitoring of patients instruments for oral services 0 RR/SI Intradental brush,
 Nasal speculum, dressing/ packing forceps,
digital scope, tuning fork (512 HZ), App &
headphone for app based audiometery, LED
Availability of functional Equipment & head lamp, ear speculum, Jobson Horne probe,
instruments for ENT services 1 RR/SI Eustachian catheter
Ambu bag with Mask, Suction Machine, Oxygen
cylinder with Administrative equipment
(Keys),Mouth Gag , Nebulizer. AED (Automated
Availability of Emergency functional equipment 1 RR/SI External Defibrillator)

BP apparatus, Torch, stethoscope ,peak flow

meter and snelle's /near vision chart, Measuring
tape, Thermometer, Foetoscope,Weighing
machine, Infant weighing scale, Tongue
depressor, Stadiometer. Dressing Trays,
Availability of functional Equipment & Dressing Drums, Surgical Scissors , Examination
instruments for examination & Monitoring at Lamp, Cheatle's forceps, Sponge Holder, Artery
Clinic 2 RR/SI forceps.

Table, Doctor chair, Patient Stool, Examination

table, Attendant Chair, Foot Step, Screen
The facility have adequate furniture and fixture Separators with Stand, IV stand, Wall clock,
ME C5.2 as per service provision Availability of furniture & fixture at Clinics 2 RR/SI refrigerator (For storage of drugs & vaccines)
Area of Concern - Support Services
Standard D1 The facility has established Programme for maintenance and upkeep of the facility

1. No seepage, cracks and chipping of plaster

from wall, roof, windows etc [Link]
unwanted/outdated posters on walls of building
& boundary walls 3. Proper landscaping and
maintenance of Open Space / Gardens/ water
bodies etc (if available) 4. No leaking taps, pipes,
over-flowing tanks and dysfunctional cisterns. 5.
No water logging /marsh inside the premises 6.
Check records of building, patient amenities
maintenance and schedules. 7. Pest or rodent
The facility has established system for control measures are taken at least once in 6
ME D1.1 infrastructure maintenance Check building & its premises is well maintained 1 RR/SI months
Ayushman Arogya Mandir Building is
painted/whitewashed in uniform colour & its Check building is white washed both from inside
branding done as per the guideline 2 RR/SI & outside

(1) Availability of mops, 2- buckets system, good

quality cleaning solution preferably a ISI mark.
(2) Composition and concentration of solution is
written on label etc. (3) Staff is aware of correct
The facility has established system for Check availability of adequate supply of cleaning concentration and dilution method for preparing
ME D1.2 maintaining sanitation and hygiene material 1 RR/SI cleaning solution. (4) Verify its consumption

1. Check that floors and walls for any visible or

tangible dirt, grease, stains, etc. Check roof,
walls, corners of these area for any cobweb, bird
nest, vegetation, etc. 2. Surface of furniture and
fixtures are clean and well maintained 3. No
rusted or broken furniture 4. Schedule for
Check all the areas are clean & hygienic 2 RR/SI cleaning is defined and implemented
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs

(1) Drugs are not stored at floor ,Heavy items

are stored at lower shelves/racks and fragile
The facility ensures proper storage of drugs and Check drugs are kept in racks and shelves with items are not kept on the edges (2) LASA ( Look
ME D2.2 consumables proper labelling 2 RR/SI alike and Sound alike ) are stored separately
(1) Temperature chart is maintained (2) De
frosting is done (in case household freeze is
Check process followed to maintain the used) (3) Staff is aware of holdover time of
temperature of refrigerator used for drugs/ refrigerator (4) Freeze is not used for storing
vaccine/ lab kits 1 RR/SI eatables

(1) Drugs and consumables are stored away

from water / dampness and sources of direct
heat & sunlight etc. (2) Medications that are
considered light-sensitive will be stored in
closed drawers. (3) Check process in place for
There is specified place to store medicines in storage of drugs, laboratory kits & vaccines etc
Ayushman Arogya Mandir 2 RR/SI requiring controlled temperature
Standard D3 The facility has defined and established procedure for clinical records and data management with progressive use of digital technology

(1) Secure place to keep records and registers

The facility ensures safe storage, maintenance Ayushman Arogya Mandir has established (2) Check records are easy to retrieve (3) Check
and retrieval of information & records of procedure for safe keeping & retrieval of paper physical record retention period is defined as
ME D3.2 services based records 2 RR/SI per state policy and staff is aware of it
Standard D6 The facility is compliant with statutory and regulatory requirement
The facility ensures its processes are in
compliance with statutory and legal No Smoking sign is displayed at the prominent
ME D6.1 requirement places 2 RR/SI Both inside & outside the building
Area of Concern - Wellness & Clinical Services
Standard E13 The facility has established procedures for care of new born, infant and child as per guidelines
DPT, DT, Hep B ,TT vials & diluents are not kept
The facility provides immunization services as Check for vaccines & diluents are kept as per the in direct contact of ice pack , Discarded
ME E13.2 per guideline recommendation of guidelines 2 RR/SI medicines are kept separately
Area of Concern - Infection Control
Standard F1 The facility has established program for infection prevention and control

Facility ensures that staff is working as team and Facility has a system to monitor cleanliness &
ME F1.1 monitor the infection control practices hygiene practices 2 RR/SI Regular monitoring of cleanliness & hygiene
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices
Check washbasin is wide and deep enough to
prevent splashing and retention of water. Check
for availability of elbow operated tap adequate
Hand Hygiene facilities are provided at point of Check Washbasin, tap & running water as per running water through piped water distribution
ME F2.1 use & ensures adherence to standard practices standard protocols 1 RR/SI system.

(1) Washbasin with functional drainage pipe,

tap, running water, Soap (Soap bar/liquid), AHR,
Display of hand washing poster (Pictorial- Local
language) (2) Check availability of Soap and
Availability of Hand washing facilities 2 RR/SI Alcohol Hand rub for outreach
Standard F3 The facility ensures standard practices and equipment for personal protection

(1) Check adequate required gloves, mask &

The facility ensures availability of personal apron etc is available & used (2) Check
protection equipment and ensures adherence to Disposable Gloves, Cap, Mask are not reused,
ME F3.1 standard practices Check availability & use of PPE 2 RR/SI (3) Check records for continuity of supply.
Standard F4 The facility has standard procedures for disinfection and sterilization of equipment and instruments.

The facility ensures availability of material and

adherence to Standard Practices for
decontamination and cleaning of instruments Adequate supply of decontamination and
ME F4.1 and followed by procedure/ patient care areas. cleaning agents at the point of use 1 RR/SI Check records of indent & Utilization
Ethyl alcohol 70% , Bleaching Powder/ hypo
The facility ensures standard practices and chloride solution containing not less than 30%
materials for disinfection and sterilization of w/w of available chlorine. Check availability of
ME F4.2 instruments and equipment Availability of disinfectants 2 RR/SI boiler / sterilisers
Standard F5 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

(1)Availability of bins and non chlorinated plastic

bag, Covered and Foot operated bins with
Availability of colour coded bins and non Display of Bio Hazard sign. (2) Availability of
The facility ensures segregation and storage of chlorinated plastic bags and needle cutters at needle/hub cutter & puncture proof boxes
ME F5.1 Bio Medical Waste as per guidelines point of waste generation 2 RR/SI (3)Check the adequacy of supply
Check there is no mixing of the Biomedical &
general waste 2 RR/SI