MEDICAL ADMINISTRATIVE

INSTRUCTIONS (MAI)

8 0
:2 3
14 .
6
01/2023
02 2
.
3
/0 .0
/2
20 5

NATIONAL QUALITY ASSURANCE STANDARDS :

2
13

IMPLEMENTATION PROGRAMME

Issued by

Directorate General of Medical Services (Army)

Adjutant General‟s Branch
Integrated Headquarters of MoD (Army)

Auth: B/75346/NQAS/DGMS-3E Dated: 09 Jan 2023

DGMS-3E
 2

Dte Gen of Med Services (Army)

Adjutant General‟s Branch
Integrated Headquarters of MoD (Army)
3rd Floor, A Block
Defence Offices Complex, KG Marg
New Delhi – 110001

09 Jan 2023

MEDICAL ADMINISTRATIVE INSTRUCTIONS 01/2023

NATIONAL QUALITY ASSURANCE STANDARDS: IMPLEMENTATION PROGRAMME

1. Medical Administrative Instructions 01/2023 „National Quality Assurance Standards :

Implementation Programme‟ as per guidelines promulgated by MoH&FW, GoI, are being

8 0
issued for adoption by all hospitals of IA.

:2 3
2. I am sanguine that adoption of these standards will improve the quality of care
14 .
provided to our clientele. The report on the sub will be submitted by hospitals as an
6
addendum to the Dept Insp report.
02 2
.
3
/0 .0
/2
20 5
2

(Daljit Singh)
13

Lt Gen
DGMS (Army)
 IMPLEMENTATION PROGRAMME:
NATIONAL QUALITY ASSURANCE STANDARDS

Ref:-
(A) Manual of Inspection 1982
(B) Regulations for the Army 1987
(C) National Quality Assurance Standards for Public Health Facilities 2020

Introduction

1. Armed Forces Medical Service (AFMS) has been continuously striving towards
improving the quality of services in its hospitals. Based on the emerging requirements and
responses to newer initiatives in the healthcare sector, there have been significant

8 0
advancements in the scope for improving the quality of services at National and
International levels.

:2 3
National Health Policy 14 .
6
2. The objective of National Health Policy (NHP) 2017 is to improve the health status
02 2

through concerted policy action in all sectors and to expand preventive, promotive, curative,
palliative and rehabilitative services provided through the public health services. In
.
3

accordance with the NHP 2017, these operational guidelines are being promulgated with an
/0 .0

aim to strengthen and improve quality of care across all Military Hospitals.
/2
20 5

Current Policy
2
13

3. At present, Departmental Inspections are carried out by the respective Heads of

Arms and Services at the formation HQs to assess the technical efficiency of the units
under them, in terms of the „Manual of Inspection 1982 and Regulations for the Army 1987‟.
The aim of departmental inspection is to ascertain: -

(a) Functional and technical efficiency of the unit.

(b) Efficiency as regards training.
(c) Administrative efficiency.

4. The current system of Departmental Inspection is designed primarily to assess

whether hospital/medical unit is carrying out its role of patient related activities adequately
or not, the unit personnel are trained and aware of their role/duties and to identify problem
areas, if any, related to stores and equipment.

5. SWOT Analysis of Current Policy

(a) Strengths

(i) Easily adopted assessment system.

(ii) Based on overall performance of the hospital.
 2

(b) Weaknesses

(i) Quantification of assessment not possible.

(ii) Lack of focus and assessment of quality.
(iii) No methodology to identify areas of improvement.
(iv) Lack of assessment of Key Performance Indicators (KPI).

(c) Opportunities

(i) Provides an opportunity to align with the National Standards.

(ii) Standardisation of the inspection process.
(iii) Ability to judge hospitals with a quality perspective.
(iv) Identify areas of improvement in Structure, Processes and Output.
(v) Quantification through Key Performance Indicators (KPI).

(d) Threats

8 0
:2 3
(i) Outdated quality inspection parameters.
(ii) Risk to patient safety in absence of KPI.
(iii)
14 .
Reduced patient satisfaction.
6
(iv) Limited scope for improvement for hospitals.
02 2

NQAS
.
3
/0 .0

6. National Quality Assurance Standards (NQAS) for Public Health Facilities 2020
delineates structured guidelines to improve the quality standards in service delivery at
/2
20 5

hospitals not only to meet present day needs, but also to prepare to be future ready. These
2

guidelines have internationally recognized standards, measurement system and quality

13

improvement interventions at par with universal quality and safety goals.

Need for Adoption of NQAS

7. There is a need for adoption of NQAS in the current policy of Departmental

Inspection of Military Hospitals, in view of the advancements in the scope for improving the
quality of services globally. There is a need to improve the quality of care by addressing the
gaps in understanding, measuring and improving quality in healthcare. To continue the
momentum of building quality health systems in Mil Hosps a comprehensive understanding
and implementation of GoI issued NQAS is required across all departments in all hospitals.

Aim

8. The aim of the document is to align the conduct of Dept Insp of Military Hospitals of
IA with NQAS, to strengthen and improve quality standards of hospital care.

Objectives

(a) To strengthen and improve Quality of care in Military Hospitals, which incl:-

(i) Adoption of the Standards.

(ii) Implement a system of continuous assessment of hospitals.
 3

(iii) Action planning for identification and closure of gaps.

(iv) Sp supervision and external assessment of the facilities for validation.

(b) To boost the Quality system by defining evidence based, internationally

recognized/accepted standards, measurement system and quality improvement
interventions in congruence with universal quality and safety goals.

(c) To deploy a credible Quality Management System, so that hospitals not only
ensure availability of services, but also ensure that the services meet verifiable and
objective quality and safety standards.

(d) To enable authorities to identify areas where intervention is required and set
out a clear road map for achieving high quality standards of care.

Scope

9. These guidelines define the overall understanding of Quality, ensure quality is

8 0
integrated across health functions, build capacity in ongoing quality activities, establish

:2 3
reporting and learning system for quality and safety and ensure monitoring for quality-of-
care results. The scope covers all activities, undertaken at different levels for ensuring
14 .
sustained safe, effective, patient centric, timely and efficient healthcare delivery.
6
Dimensions of Quality of Care
02 2

The Institute of Medicine defines Quality of Care as “the degree to which health care
.
10.
3
/0 .0

services for individuals and populations increase the likelihood of desired health outcomes
and are consistent with current professional knowledge”.
/2
20 5

According to „Crossing the Quality Chasm: A New Health System for the 21st
2

11.
Century (2001) Report‟ and subsequent modification (2018) “Quality of Care” has six basic
13

dimensions described as under: -

(a) Safety. Avoiding harm to patients from the care intended to help them.

(b) Effectiveness. Providing services based on scientific knowledge to all

who could benefit and refraining from providing services to those not likely to benefit
(i.e. avoiding both overuse of inappropriate care and underuse of effective care).

(c) Person Centeredness. Providing care that is respectful of and responsive

to individual preferences, needs, and values and ensuring that people‟s values guide
all clinical decisions. Care transitions and coordination should not be centered on
health care providers, but on recipients.

(d) Accessibility, Timeliness, Affordability. Reducing unwanted waits and

harmful delays for both those who receive and those who give care, reducing access
barriers and financial risk for patients, families, and communities and promoting care
that is affordable for the system.

(e) Efficiency. Avoiding waste of equipment, supplies, ideas, energy and

waste resulting from poor management.

(f) Equity. Providing care that does not vary in quality because of personal
characteristics.
 4

Quality in Health Care

12. Quality in Health Systems has two components: -

(a) Technical Quality. Has a bearing on outcome of services delivered. It
concerns the service providers (doctors, nurses and para-medical staff).
(b) Service Quality. Has bearing on patient experience including satisfaction. It
concerns the patient‟s experience of facility-based care and services.

13. Quality Perception by Stakeholders

(a) Patients. Patient‟s experiences, personal or shared, have a major

impact in their decision of seeking the services at a facility. Patients perceive quality
as fulfillment of following expectations: -
(i) Clean and inviting atmosphere

8 0
(ii) Courteous and respectful behaviour
(iii) Personalised approach

:2 3
(iv) Psychological well being
14 .
6
(v) Quality care without variation
02 2

(vi) Correct, speedy, low cost and lasting treatment

(vii) Emergency response
.
3
/0 .0

(viii) No new diseases

(ix) No harmful procedure/ complication
/2
20 5
2

(x) No overuse of unnecessary/ ineffective care

13

(b) Healthcare Providers. Quality of care is equated with achieving desired

outcomes i.e. reduction in morbidity, mortality and disability limitation. For example,
doctor‟s expectation of quality services is that investigation reports are available on
time, drugs are available in the dispensary, and patients are getting cured timely.

(c) Administration. Quality is perceived in terms of optimal and rational

utilization of resources, maximum satisfaction by the users of health facility, delivery
of all components under the health programmes, compliance to treatment guidelines
& clinical protocols, and improvement in the health status of population.

Quality Measurement

14. The main pillars of quality measurement systems are Quality Assessment Standards
(Appx ‘A’). The standards have been grouped within the eight „Areas of Concern‟. Each
standard further has specific „Measurable Elements‟ (Appx ‘B’). These standards and
measurable elements are to be checked in each dept of hosp through dept specific
Checkpoints. All Checkpoints for a dept are collated, and together they form assessment
tool called „Checklist‟. Scored/ filled-in Checklists generate scorecards.

15. Empanelment of Internal Assessors. A pool of NHSRC certified NQAS Internal

Assessors will be created, maintained and posted to hosps. Training of Medical Officers
and MNS as Internal Assessors will be planned by OPP, DGMS (Army) in consultation with
 5

HQ Comd (Med Br). Internal Assessors will carry out IEC activities for all departments in the
hospitals.

Quality Assessment Cell (QAC)

16. As a mechanism to build and ensure quality culture, Quality Assessment Cells
(QAC) will be est at Hosps, Comds and Line Dte. QACs will be entrusted to plan, guide and
maint Quality Assessment Standards in the hospitals. HQ Comds will identify Sr Advisors of
respective specialities, Medical Offrs and MNS, certifed as NQAS Internal Assessors under
Comd AoR, as Member Secys of QACs. Composition of QACs will be as under:-

QAC Level Composition

Hospital (a) Chairman: Dy Comdt/ Sr Registrar Hosp
(b) Members: HsOD/ MNS (as approved by Comdt/ CO)
(c) Member Secy: NQAS certified Internal Assessors (where avl)
Comd (a) Chairman: Brigs Med (Comd)

8 0
(c) Member Secy: Sr Advisors of respective specialities/ NQAS
Certified Internal Assessors (where avl)

:2 3
Line Dte (a) Chairman: ADGMS (Army)
14 .
(b) Members: Brig Med (OPP), Col Med (Proj)
6
(c) Member Secy: GSO1 Med (Hosp Proj)
02 2

17. Responsibilities of QAC. Fwg will be the responsibilities of QAC: -

.
3
/0 .0

(a) Preparation of assessment plan and schedule.

(b) Maintenance of assessment records.
/2
20 5

(c) Communicating Assessment Protocol and coordinating with departments.

2

(d) Monitor & review the Internal Assessment Programme.

13

(e) Disseminate the findings of internal assessment.

(f) Preparation of action plan in coordination with respective departments.

Pre-Assessment Preparation

18. OIC Dept/ HoD should ensure education and training staff on NQAS. Each staff
member should be assigned areas of responsibility according to the schedule and
competency of the staff. A briefing for the department should be conducted for introduction,
aims & objective of the assessment and role clarity. The available records and documents
such as SOPs, Registers, etc. should be reviewed.

19. Modalities for Assessment. The MS Excel Sheet as promulgated by NQAS will
be used for the conduct of assessment (uploaded on JUST IN/ DGMS (Army) website). To
further the green initiative, physical printouts must be avoided. The assessment by different
auth may be carried out on the given MS Excel sheet and final report submitted as per
format att.

20. Scoring System. After assessment, the QAC should arrive at a conclusion for
extent of compliance - full, partial or non-compliance for each of the checkpoints. If the
information and evidence collected gives an impression of not fully meeting the
requirements, it could be given „Partial Compliance‟, provided there is some evidence
pointing towards compliance. Non-compliance should be given if none or very few of the
 6

requirements are being met. After arriving at a conclusion, assessor should mark „C‟ for
compliance, „P‟ for partial compliance and „N‟ for noncompliance in the Compliance
Column. Scoring system for compliance is as under:-

Remark Score
Compliance (C) 0
Partial Compliance (P) 1
Non-Compliance (N) 2

21. All the checkpoints have equal weightage to keep scoring simple. Once scores have
been assigned to each checkpoint, department wise and standard wise scores can be
calculated. The final score should be given in percentage, so that it can be compared with
other groups and departments. Scores can be entered into excel sheets already fwd to get
the score card. All scores should be in percentages to have uniform unit for inter-
departmental and inter-hospital comparison.

22. The assessment scores can be presented in three ways:-

8 0
(a) Departmental Scorecard. It presents the quality scores of a

:2 3
department as well as the area of concern in terms of percentages. The scorecard
can be generated automatically after filling a score for all checkpoints using the excel
14 .
6
tool.
(b) Hospital Quality Scorecard. This scorecard depicts departmental and
02 2

overall quality score of hospital at a glance

.
3

(c) Area of Concern Wise Scorecard. These are calculated by taking

/0 .0

average of areas of concern scores of all departments.

/2
20 5

23. Internal Assessment. QAC should gather information and evidences to assess
2

compliance to the requirement of Measurable Elements and Checkpoints. Information can

13

be gathered by following four methods to asses certain Measurable Elements: -

(a) Observation. Compliance with many of the Measurable Elements can

be assessed by directly observing the articles, processes and surrounding
environment. Few examples are as under: -

(i) Enumeration of articles like equipment, drugs, etc.

(ii) Display of signage, work instructions, important information.
(iii) Facilities - patient amenities, ramps, complaint-box, etc.
(iv) Environment - cleanliness, loose wires, seepage, overcrowding,
temperature control, drains, etc.
(v) Procedures like measuring BP, counseling, segregation of BMW.

(b) Records Review. Records generate objective evidences, which need to be

triangulated with finding of the obsns. Examples of the record review are as under: -

(i) Review of clinical records - delivery note, anaesthesia notes,

maintenance of treatment chart, operation notes etc.
(ii) Review of department registers like admission registers, handover
registers, expenditure registers, etc.
 7

(iii) Review of applicable licenses, formats for legal compliances like Blood
bank license and Form „F‟ for PNDT.
(iv) Review of SOPs for adequacy and process.
(v) Review of monitoring records - TPR chart, input/output chart, culture
surveillance report, calibration records, etc.
(vi) Review of department data and indicators.

(c) Staff Interviews. Interaction with the staff helps in assessing the
knowledge and skill level, reqd for performing job functions. Examples are as under:-
(i) Competency testing - Quizzing staff on knowledge related to their job.
(ii) Demonstration - Asking staff to demonstrate certain activities like hand
washing technique, new born resuscitation, etc.
(iii) Awareness - Asking staff about awareness off patients‟ right, quality
policy, handling of high alerts drugs etc.
(iv) Attitude towards patient‟s dignity and gender issues.

8 0
(v) Feedback on adequacy of supplies, problems while performing duties,

:2 3
safety issues, etc.
14 .
6
(d) Patient Interviews. Interaction with patients may be useful in getting
information about quality of services and their experience in the hospital and
02 2

provides user‟s perspective. It should include:-

.
(i) Feedback on service quality, staff behavior, food quality, waiting time
3
/0 .0

etc.
(ii) Effective commn like counseling services and instrs on self-drug admn.
/2
20 5
2

24. External Assessment. MGs Med HQ Comds will prepare a plan for external
13

assessment of hospital on an annual basis, in sync with Dept Insp pgme. The consolidated
NQAS report as per format att (Appx ‘C’) will be submitted by HQ Comds to the Dte Gen
for perusal, along with Dept Insp [Link] assessment will verify compliance with
National Standards and identify areas of concern which are to be addressed to Dte Gen for
consideration. The external assessment as per standards will be carried out by certified
NQAS Internal Assessors and/or Senior Advisors of concerned specialties.

25. Dte Gen will select one hosp per Comd to be assessed. The same will be at short
notice. Dte Gen may pool in resources available at the disposal for conduct of the
assessment. The BOO so detailed will validate the hospital and submit the report to the Dte
Gen.

26. Actions Post Assessment. Fwg actions will be undertaken at various levels after
completion of assessment:-

(a) Actions at the level of Depts

(i) Take note of end points.
(ii) Assess & rate the current status based on end points as per standards.
(iii) Analyse gaps.
(iv) Take necessary action to bridge the gaps.
(v) Action plan with timelines.
(vi) Review at regular intervals.
(vii) Identify points to be addressed for action by hosp.
 8

(b) Actions at the level of Hosp

(i) Assimilation of points by dept post self-assessment.
(ii) Cross verification/ assessment by other depts.
(iii) Identify gaps.
(iv) Identify actions to be taken by dept/ hosp.
(v) Define Key Improvement Objectives.
(vi) Change management.
(vii) Implementation and review.
(viii) Identify points to be addressed for action by higher fmns.

(c) Actions at the level of Fmn/ Line Dte. HQ Comds/ Line Dte will evaluate
the internal and external assessment and define the fwg:-
(i) Identify areas where intervention is required.
(ii) Actions to be taken to resolve the issues.
(iii) Financial aspects of the above.

8 0
(iv) Define timelines for implementation

:2 3
27. Implementation. Internal as well as external assessments will be carried out as
under:-
14 .
02 2
6
Assessment Schedule
Phase Hospitals
Internal External
.
3
/0 .0

Ph I (a) AH (R&R) Jan to Mar 2023 Apr to Jun 2023

(b) All Comd Hosps
/2

(c) BH DC
20 5
2

(d) AICTS Pune

13

(e) Hospitals posted with Certified

NQAS Internal Assessors
Ph II Four hospitals per Comd# Jul to Sep 2023 Oct to Dec 2023
Ph III Balance of hospitals* Jan to Jun 2024 Jul to Dec 2024

# HQ Comds (Med Br) to identify the hospitals under intimation to the Dte Gen.
*Notwithstanding the above, all hospitals may initiate necessary actions for
compliance to NQAS before the above mentioned timelines.

Key Performance Indicators (KPI)

28. A large no of KPIs have been defined in the mentioned guidelines. The same have
not been included currently in the scope of Tech Inspection due the complexities in collation
of data. The same will be included in the Hosp Info system (HIS) when implemented.

Prescription Audit

29. Prescription audit is a part of the holistic clinical audit and is a quality improvement
process through a systematic review of care against explicit criteria. Prescription audit
guidelines based on the guiding document issued by MoH&FW is being promulgated
separately for adoption and implementation by Military Hospitals.
 9

Patient Safety

30. Safety of patient during the provision of quality health services is of paramount
importance for strengthening health care systems. SaQushal, a self assessment tool for
health facilities on patient safety and quality, developed by NHSRC, is being promulgated
as separate document to all hospitals. Hospitals may put in place internal systems to adopt
and implement SaQushal guidelines.

Patient Satisfaction Survey

31. Patient satisfaction surveys are an integral part of Quality Improvement program. It
gives the valuable information about patient perception and experience about the quality
services, which guide service providers to further improve the processes and service
delivery.

PDCA Methodology

8 0
32. A comprehensive PDCA methodology is followed for the measurement of patient
satisfaction in hospitals by using pre-defined Patient Satisfaction Survey (PSS) formats

:2 3
(both OPD and IPD). Patient feedback is collected, data is analysed, and action is taken on
14 .
lowest performing attributes. Following illustration shows the process and steps of Patient
6
Satisfaction Improvement Program:-
02 2
.
3
/0 .0

Calcutate the
sample size
/2

for OPD &

20 5

IPD as per
2

case load Take patient

13

feedback on
Plan PSS for
PSS format
next quarter
continous
basis

PLAN DO
Analyse the
Corrective
collected
and
data on
preventive
quarterly
actions
basis
ACT CHECK

Identify
Root cause lowest two
analysis performing
attributes
Discuss the
findings of in
quality team
meeting
 10

33. Patient Satisfaction Improvement Program

(a) Plan. Zonal hospitals may conduct patient satisfaction survey on monthly
basis. Mid zonal and peripheral hospitals may conduct the survey on quarterly basis.
A designated team from the hospital may be given the responsibility to collect the
feedback. Fwg table lays down guidance on appropriate sample size of patients for
collecting feedback. It should not be less than 30 for being statistically valid.

Sample Size (Number of patients to be surveyed)

Margin of Margin of Margin of Margin of
Population Error -10% Error -10% Error Error
(OPD/ IPD) Confidence Confidence -5% -5%
Level -90% Level -95% Confidence Confidence
Level -90% Level -95%
10 9 9 10 10

8 0
20 16 17 19 20

:2 3
50 29 34 43 45
100 41 14 . 50 74 80
6
200 51 66 116 132
02 2

300 56 73 143 169

500 60 81 176 218
.
3
/0 .0

1000 64 88 214 257

3000 67 94 249 278
/2
20 5
2

5000 67 95 257 341

13

10000 68 96 264 370

15000 68 96 266 375
20000 68 96 268 377
30000 68 96 269 380
50000 68 96 270 382
100000 68 96 270 383

(b) Do. All depts should be covered, with special focus on those with high case
load like ANC clinic, Maternity ward etc. Exit feedback should be preferred from
those patients who have already availed the services e.g. at dispensary counter for
OPD and at the time of discharge in IPD. Filled up forms should be collected and
submitted to the coordinator.
(c) Check. Feedback collected should be collated and analysed. Analysis
should generate overall as well as area/ attribute wise score. Lowest performing two
attributes should be identified and root cause analysis should be done for them.
(d) Act. Action plan should be prepared on causes identified during root cause
analysis including corrective and preventive action to be taken, timeline and person
responsible for taking action. Compliance to action should be reviewed monthly.
Sample OPD and IPD feedback forms are given as under:-
 11

OPD PATIENT FEEDBACK FORMAT

Very
Poor Fair Good Excellent
S No Attributes Good
(1) (2) (3) (5)
(4)
1 Availability of sufficient information in
Hospital (Direction & location
signages, Registration Counter,
Laboratory, Radiology Department,
Dispensary etc.)
2 Waiting time at the registration counter

3 Behaviour and attitude of Hospital

Staff
4 Amenities in waiting area (chairs, fans,
drinking water and cleanliness of
bathrooms & toilets)

8 0
5 Attitude & communication of Doctors

:2 3
6 Time spent on consulting, examination
and counselling 14 .
6
7 Availability of Lab and Radiology
investigation facilities within the
02 2

hospital
8 Promptness at medicine distribution
.
3

counter
/0 .0

9 Availability of prescribed drugs at the

hospital dispensary
/2
20 5

10 Your overall satisfaction during the

2

visit to the hospital

13

1. What improvement would you like to see in the hospital?

2. What made you come to this hospital for treatment?
3. Would you like to return to this hospital next time for treatment?
4. Your valuable suggestions

Date __________ Clinic ___________ Age _________ Sex ______________

 12

INPATIENT FEEDBACK FORMAT

Very
Poor Fair Good Excellent
S No Attributes Good
(1) (2) (3) (5)
(4)
1 Availability of sufficient information at
registration/ admission counters
(Direction & location signages,
Registration Counter, Laboratory,
Radiology Department, Dispensary
etc.)
2 Waiting time at the Registration/
Admission counter
3 Behaviour and attitude of Hospital
Staff at the registration/admission
counter
4 Your feedback on discharge process

8 0
5 Cleanliness of the ward

:2 3
6 Cleanliness of Bathrooms & toilets
7 Cleanliness of Bed sheets, pillow- 14 .
6
covers etc.
8 Cleanliness of surroundings and
02 2

campus drains
9 Regularity of Doctor‟s attention
.
3
/0 .0

10 Attitude and communication of

Doctors
/2

11 Time spent for examination of

20 5

patient and counselling

2

12 Promptness in response by Nurses/

13

ward boys or girls in the ward

13 Round the clock availability of
Nurses/ ward boys or girls in the
ward
14 Attitude and communication of
Nurses/ ward boys or girls
15 All prescribed drugs were made
available from Hospital supply
16 Availability of Diagnostics
17 Timeliness of supply of the diet and
its quality
18 Your overall satisfaction during the
treatment as an in-patient

1. What improvement would you like to see in the hospital?

2. What made you come to this hospital for treatment?
3. Would you like to return to this hospital next time for treatment?
4. Your valuable suggestions

Date _________ Ward _______ Age _______Sex ________ Date of Admission _________
 13

Summary

34. The guidelines will help the inspecting authorities to work on requirements, specific
to the scope of services and role and responsibilities of the Military Hospitals to achieve
desired quality standards. The guidelines will also delineate roles and responsibilities of
different stakeholders for building the quality systems.

35. Inspecting authorities and hospitals need to utilise these guidelines in planning and
operationalizing the institutional framework in a meaningful manner and creating a culture
of quality services delivery in all Military Hospitals. The new guidelines will assist the
hospitals and the authorities in identification of gaps, planning, implementation of new
initiatives where necessary and plugging such gaps through better utilisation of existing
resources.

8 0
:2 3
14 .
02 2
6
.
3
/0 .0
/2
20 5
2
13
 14

Appx ‘A’

QUALITY ASSESSMENT STANDARDS

Area of Concern ‘A’: Service Provision

Standard A1 The facility provides curative services.
Standard A2 The facility provides RMNCHA services.
Standard A3 The facility provides diagnostic services.
Standard A4 The facility provides services as mandated in National Health
Programmes.
Standard A5 The facility provides support services.
Standard A6 Health services provided at the facility are appropriate to community needs.
Area of Concern ‘B’: Patient Rights

8 0
Standard B1 The facility provides information to care seekers, attendants & community
about the available services and their modalities.

:2 3
Standard B2 Services are delivered in a manner that is sensitive to gender, religious
14 .
and cultural needs, and there are no barriers on account of physical
6
economic, cultural or social reasons.
02 2

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a
system for guarding patient related information.
.
3
/0 .0

Standard B4 The facility has defined and established procedures for informing patients
about the medical condition, and involving them in treatment planning, and
/2

facilitates informed decision making.

20 5
2

Standard B5 The facility ensures that there are no financial barriers to access, and that
13

there is financial protection given from the cost of hospital services.

Standard B6 The facility has defined framework for ethical management including
dilemmas confronted during delivery of services at public health facilities.
Area of Concern ‘C’: Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and
available infrastructure meets the prevalent norms.
Standard C2 The facility ensures the physical safety of the infrastructure.
Standard C3 The facility has established Programme for fire safety and other disaster.
Standard C4 The facility has adequate qualified and trained staff, required for providing
the assured services to the current case load.
Standard C5 The facility provides drugs and consumables required for assured list of
services.
Standard C6 The facility has eqpt & instruments required for assured list of services.
Standard C7 The facility has a defined and established procedure for effective
utilization, evaluation and augmentation of competence and performance
of staff.
Area of Concern ‘D’: Support Services
Standard D1 The facility has established Programme for inspection, testing and
maintenance and calibration of Equipment.
 15

Standard D2 The facility has defined procedures for storage, inventory management and
dispensing of drugs in pharmacy and patient care areas.

Standard D3 The facility provides safe, secure and comfortable environment to staff,
patients and visitors.
Standard D4 The facility has established programme for maint and upkeep of the facility.
Standard D5 The facility ensures 24 X 7 water and power backup as per requirement of
service delivery, and support services norms.
Standard D6 Dietary services are available as per service provision and nutritional
requirement of the patients.
Standard D7 The facility ensures clean linen to the patients.
Standard D8 The facility has defined and established procedures for promoting public
participation in management of hospital transparency and accountability.
Standard D9 Hospital has defined and established procedures for Financial
Management.

8 0
Standard D10 The facility is compliant with all statutory and regulatory requirement
imposed by local, state or central government.

:2 3
Standard D11 Roles & Responsibilities of administrative and clinical staff are determined
14 .
as per govt regulations and standards operating procedures.
6
Standard D12 The facility has established procedure for monitoring the quality of
outsourced services and adheres to contractual obligations.
02 2

Area of Concern ‘E’: Clinical Services

.
3
/0 .0

Standard E1 The facility has defined procedures for registration, consultation and
admission of patients.
/2

The facility has defined and established procedure for clinical assessment
20 5

Standard E2
2

and preparation of the treatment plan.

13

Standard E3 The facility has defined and established procedures for continuity of care of
patient and referral.
Standard E4 The facility has defined and established procedures for nursing care.
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
Standard E6 Facility ensures rationale prescribing and use of medicines
Standard E7 The facility has defined procedures for safe drug administration.
Standard E8 The facility has defined and established procedures for maintaining,
updating of patients‟ clinical records and their storage.
Standard E9 The facility has defined and established procedures for discharge of patient.
Standard E10 The facility has defined and established procedures for intensive care.
Standard E11 The facility has defined and established procedures for Emergency
Services and Disaster Management.
Standard E12 The facility has defined and established procedures of Diagnostic Services.
Standard E13 The facility has defined and established procedures for Blood Bank/Storage
Management and Transfusion.
Standard E14 The facility has established procedures for Anaesthetic Services.
Standard E15 The facility has defined and established procedures of Operation Theatre
services.
 16

Standard E16 The facility has defined and established procedures for End of Life Care and
Death.
Maternal & Child Health Services
Standard E17 The facility has established procedures for Antenatal Care as per
guidelines.
Standard E18 The facility has established procedures for Intranatal Care as per
guidelines.
Standard E19 The facility has established procedures for Postnatal Care as per
guidelines.
Standard E20 The facility has established procedures for care of new born, infant and
child as per guidelines.
Standard E21 The facility has established procedures for abortion and family planning
as per government guidelines and law.
Standard E22 The facility provides Adolescent Reproductive and Sexual Health services

8 0
as per guidelines.
National Health Programmes

:2 3
Standard E23 The facility provides National Health Programmes as per
14 .
Operational/Clinical guidelines.
6
Area of Concern ‘F’: Infection Control
02 2

Standard F1 The facility has infection control Programme and procedures in place for
.
3

prevention and measurement of hospital associated infection.

/0 .0

Standard F2 The facility has defined and Implemented procedures for ensuring hand
hygiene practices and antisepsis.
/2
20 5

Standard F3 The facility ensures standard practices and materials for personal
2

protection.
13

Standard F4 The facility has standard procedures for processing of equipment and
instruments.
Standard F5 Physical layout and environmental control of the patient care areas
ensures infection prevention.
Standard F6 The facility has defined and established procedures for segregation,
collection, treatment and disposal of Bio Medical and Hazardous Waste.
Area of Concern ‘G’: Quality Management
Standard G1 The facility has established organizational framework for Quality
Improvement.
Standard G2 The facility has established system for patient and employee satisfaction.
Standard G3 The facility has established internal and external Quality Assurance
programs.
Standard G4 The facility has established, documented implemented and maintained
Standard Operating Procedures for all key processes and support
services.
Standard G5 The facility maps its key processes and seeks to make them more efficient
by reducing non-value adding activities and wastages.
Standard G6 The facility has defined mission, values, Quality policy & objectives &
prepared a strategic plan to achieve them.
 17

Standard G7 The facility seeks continually improvement by practicing quality method

and tools.
Standard G8 The facility has defined, approved and communicated Risk Management
framework for existing and potential risks.
Standards G9 The facility has established procedures for assessing, reporting, evaluating
and managing risk as per Risk Management Plan.
Standard G10 The facility has established Clinical Governance framework to improve the
quality and safety of clinical care processes.
Area of Concern ‘H’: Outcome Indicators
Standard H1 The facility measures „Productivity Indicators‟ and ensures compliance with
National benchmarks.
Standard H2 The facility measures „Efficiency Indicators‟ and ensures to reach National
benchmarks.
Standard H3 The facility measures „Clinical Care & Safety Indicators‟ and tries to reach

8 0
National benchmarks.
Standard H4 The facility measures „Service Quality Indicators‟ and endeavours to reach

:2 3
National benchmarks.
14 .
02 2
6
.
3
/0 .0
/2
20 5
2
13
 18

Appx ’B’

MEASURABLE ELEMENTS

Area of Concern ‘A’: Service Provision

Standard A1 The facility provides Curative Services
ME A1.1 The facility provides General Medicine services
ME A1.2 The facility provides General Surgery services
ME A1.3 The facility provides Obstetrics & Gynaecology Services
ME A1.4 The facility provides Paediatric Services
ME A1.5 The facility provides Ophthalmology Services
ME A1.6 The facility provides ENT Services
ME A1.7 The facility provides Orthopaedic Services
ME A1.8 The facility provides Skin & VD Services
ME A1.9 The facility provides Psychiatry Services

8 0
ME A1.10 The facility provides Dental Treatment Services

:2 3
ME A1.11 The facility provides AYUSH Services
ME A1.12 The facility provides Physiotherapy Services
14 .
6
ME A1.13 The facility provides services for OPD procedures
ME A1.14 Services are available for the time period as mandated
02 2

ME A1.15 The facility provides services for Super specialties, as mandated

.
3

ME A1.16 The facility provides Accident & Emergency Services

/0 .0

ME A1.17 The facility provides Intensive care Services

ME A1.18 The facility provides Blood bank & transfusion services
/2
20 5

Standard A2 The facility provides RMNCHA Services

2

ME A2.1 The facility provides Reproductive health Services

13

ME A2.2 The facility provides Maternal health Services

ME A2.3 The facility provides Newborn health Services
ME A2.4 The facility provides Child health Services
ME A2.5 The facility provides Adolescent health Services
Standard A3 The facility provides Diagnostic Services
ME A3.1 The facility provides Radiology Services
ME A3.2 The facility provides Laboratory Services
ME A3.3 The facility provides other diagnostic services, as mandated
Standard A4 The facility provides services as mandated in National Health Programmes
ME A4.1 The facility provides services under National Vector Borne Disease Control
Programme as per guidelines
ME A4.2 The facility provides services under National TB Elimination Programme as per
guidelines
ME A4.3 The facility provides services under National Leprosy Eradication Programme as per
guidelines
ME A4.4 The facility provides services under National AIDS Control Programme as per
guidelines
ME A4.5 The facility provides services under National Programme for Control of Blindness as
per guidelines
 19

ME A4.6 The facility provides services under Mental Health Programme as per guidelines
ME A4.7 The facility provides services under National Programme for the health care of the
elderly as per guidelines
ME A4.8 The facility provides services under National Programme for Prevention and control
of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS) as per
guidelines
ME A4.9 The facility provides services under Integrated Disease Surveillance Programme as
per guidelines
ME A4.10 The facility provides services under National health Programme for Deafness
ME A4.11 The facility provides services as per State specific health programmes
ME A4.12 The facility provides services as per Rashtriya Bal Swasthya Karyakram
Standard A5 The facility provides Support Services
ME A5.1 The facility provides dietary services
ME A5.2 The facility provides laundry services
ME A5.3 The facility provides security services

8 0
ME A5.4 The facility provides housekeeping services

:2 3
ME A5.5 The facility ensures maintenance services
ME A5.6 14 .
The facility provides pharmacy services
6
ME A5.7 The facility has services of medical record department
ME A5.8 The facility provides mortuary services
02 2

Standard A6 Health Services provided at the facility are appropriate to community needs
.
3

ME A6.1 The facility provides curatives & preventive services for the health problems and
/0 .0

diseases, prevalent locally

/2

ME A6.2 There is a process for consulting community/or their representatives when planning
20 5

or revising scope of services of the facility

2

Area of Concern ‘B’: Patient Rights

13

Standard B1 The facility provides the information to care seekers, attendants & community
about the available services and their modalities
ME B1.1 The facility has uniform and user-friendly signage system
ME B1.2 The facility displays the services and entitlements available in its departments
ME B1.3 The facility has established citizen charter, which is followed at all levels
ME B1.4 User charges are displayed and communicated to patients effectively
ME B1.5 Patients & visitors are sensitised and educated through appropriate IEC/BCC
approaches
ME B1.6 Information is available in local language and easy to understand
ME B1.7 The facility provides information to patients and visitor through an exclusive set-up
ME B1.8 The facility ensures access to clinical records of patients to entitled personnel
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and
cultural needs, and there are no barriers on account of physical economic,
cultural or social reasons
ME B2.1 Services are provided in manner that are sensitive to gender
ME B2.2 Religious and cultural preferences of patients and attendants are taken into
consideration while delivering services
ME B2.3 Access to facility is provided without any physical barrier & friendly to people with
disbility
 20

ME B2.4 There is no discrimination on basis of social & economic status of patients

ME B2.5 There is affirmative action to ensure that vulnerable sections can access services
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a
system for guarding patient related information
ME B3.1 Adequate visual privacy is provided at every point of care
ME B3.2 Confidentiality of patients records and clinical information is maintained
ME B3.3 The facility ensures the behaviours of staff is dignified and respectful, while
delivering the services
ME B3.4 The facility ensures privacy and confidentiality to every patient, especially of those
conditions having social stigma, and also safeguards vulnerable groups
Standard B4 The facility has defined and established procedures for informing patients
about the medical condition, and involving them in treatment planning, and
facilitates informed decision making
ME B4.1 There is established procedures for taking informed consent before treatment and
procedures

8 0
ME B4.2 Patient is informed about his/her rights and responsibilities

:2 3
ME B4.3 Staff are aware of patients‟ rights responsibilities
ME B4.4 Information about the treatment is shared with patients or attendants, regularly
14 .
6
ME B4.5 The facility has defined and established grievance redressal system in place
Standard B5 The facility ensures that there is no financial barrier to access, and that there
02 2

is financial protection given from the cost of hospital services

.
3

ME B5.1 The facility provides cashless services to pregnant women, mothers and neonates
/0 .0

as per prevalent government schemes

ME B5.2 The facility ensures that drugs prescribed are available at Pharmacy and wards
/2
20 5

ME B5.3 It is ensured that facilities for the prescribed investigations are available at the facility
2

ME B5.4 The facility provide free of cost treatment to Below poverty line patients without
13

administrative hassles
ME B5.5 The facility ensures timely reimbursement of financial entitlements and
reimbursement to the patients
ME B5.6 The facility ensure implementation of health insurance schemes as per National
/state scheme
Standard B6 The facility has defined framework for ethical management including
dilemmas confronted during delivery of services at public health facilities
ME B6.1 Ethical norms and code of conduct for medical and paramedical staff have been
established
ME B6.2 The facility staff is aware of code of conduct established
ME B6.3 The facility has an established procedure for entertaining representatives of drug
companies and suppliers
ME B6.4 The facility has an established procedure for medical examination and treatment of
individual under judicial or police detention as per prevalent law and government
directions
ME B6.5 There is an established procedure for sharing of hospital/patient data with
individuals and external agencies including non-governmental organization
ME B6.6 There is an established procedure for „end-of-life‟ care
ME B6.7 There is an established procedure for patients who wish to leave hospital against
 21

medical advice or refuse to receive specific treatment

ME B6.8 There is an established procedure for obtaining informed consent from the patients
in case facility is participating in any clinical or public health research
ME B6.9 There is an established procedure to issue of medical certificates and other
certificates
ME B6.10 There is an established procedure to ensure medical services during strikes or any
other mass protest leading to dysfunctional medical services
ME B6.11 An updated copy of code of ethics under Indian Medical council act is available with
the facility
ME B6.12 Facility has established a framework for identifying, receiving, and resolving ethical
dilemmas‟ in a time-bound manner through ethical committee
Area of Concern ‘C’: Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available
infrastructure meets the prevalent norms

8 0
ME C1.1 Departments have adequate space as per patient or work load
ME C1.2 Patient amenities are provide as per patient load

:2 3
ME C1.3 Departments have layout and demarcated areas as per functions
ME C1.4 14 .
The facility has adequate circulation area and open spaces according to need and
6
local law
ME C1.5 The facility has infrastructure for intramural and extramural communication
02 2

ME C1.6 Service counters are available as per patient load

.
3

ME C1.7 The facility and departments are planned to ensure structure follows the
/0 .0

function/processes (Structure commensurate with the function of the hospital)

/2

Standard C2 The facility ensures the physical safety of the infrastructure

20 5
2

ME C2.1 The facility ensures the seismic safety of the infrastructure

13

ME C2.2 The facility ensures safety of lifts and lifts have required certificate from the
designated bodies/ board
ME C2.3 The facility ensures safety of electrical establishment
ME C2.4 Physical condition of buildings are safe for providing patient care
Standard C3 The facility has established Programme for fire safety and other disaster
ME C3.1 The facility has plan for prevention of fire
ME C3.2 The facility has adequate firefighting Equipment
ME C3.3 The facility has a system of periodic training of staff and conducts mock drills
regularly for fire and other disaster situation
Standard C4 The facility has adequate qualified and trained staff, required for providing the
assured services to the current case load
ME C4.1 The facility has adequate specialist doctors as per service provision
ME C4.2 The facility has adequate general duty doctors as per service provision and work
load
ME C4.3 The facility has adequate nursing staff as per service provision and work load
ME C4.4 The facility has adequate technicians/paramedics as per requirement
ME C4.5 The facility has adequate support/general staff
Standard C5 The facility provides drugs and consumables required for assured services
ME C5.1 The departments have availability of adequate drugs at point of use
ME C5.2 The departments have adequate consumables at point of use
 22

ME C5.3 Emergency drug trays aremaintained at every point of care, where ever it may be
needed
Standard C6 The facility has equipment & instruments required for assured list of services
ME C6.1 Availability of equipment & instruments for examination & monitoring of patients
ME C6.2 Availability of equipment & instruments for treatment procedures, being undertaken
in the facility
ME C6.3 Availability of equipment & instruments for diagnostic procedures being undertaken
in the facility
ME C6.4 Availability of equipment and instruments for resuscitation of patients and for
providing intensive and critical care to patients
ME C6.5 Availability of Equipment for Storage
ME C6.6 Availability of functional equipment and instruments for support services
ME C6.7 Departments have patient furniture and fixtures as per load and service provision
Standard C7 The facility has a defined and established procedure for effective utilization,
evaluation and augmentation of competence and performance of staff

8 0
ME C7.1 Criteria for Competence assessment are defined for clinical and Para clinical staff

:2 3
ME C7.2 Competence assessment of Clinical and Para clinical staff is done on predefined
criteria at least once in a year
14 .
6
ME C7.3 Criteria for performance evaluation clinical and para clinical staff are defined
ME C7.4 Performance evaluation of clinical and para clinical staff is done on predefined
02 2

criteria at least once in a year

.
3

ME C7.5 Criteria for performance evaluation of support and administrative staff are defined
/0 .0

ME C7.6 Performance evaluation of support and administration staff is done on predefined

criteria at least once in a year
/2
20 5

ME C7.7 Competence assessment and performance assessment includes contractual,

2

empanelled, and outsourced staff

13

ME C7.8 Training needs are identified based on competence assessment and performance
evaluation and facility prepares the training plan
ME C7.9 The Staff is provided training as per defined core competencies and training plan
ME C7.10 There is established procedure for utilization of skills gained thought trainings by on
the job supportive supervision
ME C7.11 Feedback is provided to the staff on their competence assessment and performance
evaluation
Area of Concern ‘D’: Support Services
Standard D1 The facility has established Programme for inspection, testing and
maintenance and calibration of Equipment
ME D1.1 The facility has established system for maintenance of critical Equipment
ME D1.2 The facility has established procedure for internal and external calibration of
measuring equipment
ME D1.3 Operating and maintenance instructions are available with the users of equipment
Standard D2 The facility has defined procedures for storage, inventory management and
dispensing of drugs in pharmacy and patient care areas
ME D2.1 There is established procedure for forecasting and indenting drugs and
consumables
ME D2.2 The facility has established procedure for procurement of drugs
 23

ME D2.3 The facility ensures proper storage of drugs and consumables

ME D2.4 The facility ensures management of expiry and near expiry drugs
ME D2.5 The facility has established procedure for inventory management techniques
ME D2.6 There is a procedure for periodically replenishing the drugs in patient care areas
ME D2.7 There is a process for storage of vaccines and other drugs, requiring controlled
temperature
ME D2.8 There is a procedure for secure storage of narcotic and psychotropic drugs
Standard D3 The facility provides safe, secure and comfortable environment to staff,
patients and visitors
ME D3.1 The facility provides adequate illumination at patient care areas
ME D3.2 The facility has provision of restriction of visitors in patient areas
ME D3.3 The facility ensures safe and comfortable environment for patients and service
providers
ME D3.4 The facility has security system in place in patient care areas
ME D3.5 The facility has established measure for safety and security of female staff

8 0
Standard D4 The facility has established Programme for maintenance and upkeep of the

:2 3
facility
ME D4.1 14 .
Exterior and interior of the facility building is maintained appropriately
6
ME D4.2 Patient care areas are clean and hygienic
ME D4.3 Hospital infrastructure is adequately maintained
02 2

ME D4.4 Hospital maintains open areas and landscaped of them

.
3

ME D4.5 The facility has policy of removal of condemned junk material

/0 .0

ME D4.6 The facility has established procedures for pest, rodent and animal control
/2

Standard D5 The facility ensures 24 × 7 water and power backup as per requirement of
20 5

service delivery, and support services norms

2
13

ME D5.1 The facility has adequate arrangement storage and supply for potable water in all
functional areas
ME D5.2 The facility ensures adequate power backup in all patient care areas as per load
ME D5.3 Critical areas of the facility ensures availability of oxygen, medical gases and
vacuum supply
Standard D6 Dietary services are available as per service provision and nutritional
requirement of the patients
ME D6.1 The facility has provision of nutritional assessment of the patients
ME D6.2 The facility provides diets according to nutritional requirements of the patients
ME D6.3 Hospital has standard procedures for preparation, handling, storage and distribution
of diets, as per requirement of patients
Standard D7 The facility ensures clean linen to the patients
ME D7.1 The facility has adequate availability of linen for meeting its need
ME D7.2 The facility has established procedures for changing of linen in patient care areas
ME D7.3 The facility has standard procedures for handling, collection, transportation and
washing of linen
Standard D8 The facility has defined and established procedures for promoting public
participation in management of hospital transparency and accountability
ME D8.1 The facility has established a procedure for management of activities of Rogi Kalyan
Samiti
 24

ME D8.2 The facility has established procedures for community-based monitoring of its
services.
Standard D9 Hospital has defined and established procedures for Financial Management
ME D9.1 The facility ensures proper utilization of the fund provided to it
ME D9.2 The facility ensures proper planning and requisition of resources based on its need
Standard D10 The facility is compliant with all statutory and regulatory requirement imposed
by local, state or central government
ME D10.1 The facility has requisite licences and certificates for operation of hospital and its
different activities
ME D10.2 Updated copies of relevant laws, regulations and government orders are available at
the facility
ME D10.3 The facility ensures relevant processes are in compliance with the statutory
requirements
Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as
per govt. regulations and standards operating procedures

8 0
ME D11.1 The facility has established job description as per govt guidelines

:2 3
ME D11.2 The facility has a established procedure for duty roster and deputation to different
departments 14 .
6
ME D11.3 The facility ensures adherence to dress code as mandated by the administration
Standard D12 The facility has established procedure for monitoring the quality of
02 2

outsourced services and adheres to contractual obligations

.
3

ME D12.1 There is established system of contract management for the out sourced services
/0 .0

ME D12.2 There is a system of periodic review of quality of out-sourced services

Area of Concern ‘E’: Clinical Services
/2
20 5
2

Standard E1 The facility has defined procedures for registration, consultation and
13

admission of patients
ME E1.1 The facility has established procedure for registration of patients
ME E1.2 The facility has a established procedure for OPD consultation
ME E1.3 There is established procedure for admission of patients
ME E1.4 There is established procedure for managing patients, in case beds are not
available at the facility
Standard E2 The facility has defined and established procedure for clinical assessment
and preparation of the treatment plan
ME E2.1 There is established procedure for initial assessment of patients
ME E2.2 There is established procedure for follow-up/ reassessment of patients
ME E2.3 There is an established procedure to document treatment or care plan involving
individual patient to achieve the best possible results
Standard E3 The facility has defined and established procedures for continuity of care of
patient and referral
ME E3.1 The facility has established procedure for continuity of care during
interdepartmental transfer
ME E3.2 The facility provides appropriate referral linkages to the patients/Services for
transfer to other/ higher facilities to assure the continuity of care
ME E3.3 A person is identified for care during all steps of care
ME E3.4 The facility is connected to medical colleges through telemedicine services
 25

Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of patients is established at the facility
ME E4.2 Procedure for ensuring timely and accurate nursing care as per treatment plan is
established at the facility
ME E4.3 There is established procedure of patient hand over, whenever staff duty change
happens
ME E4.4 Nursing records are maintained
ME E4.5 There is procedure for periodic monitoring of patients
Standard E5 The facility has a procedure to identify high risk and vulnerable patients
ME E5.1 The facility identifies vulnerable patients and ensure their safe care
ME E5.2 The facility identifies high risk patients and ensure their care, as per their need
Standard E6 Facility ensures rationale prescribing and use of medicines
ME E6.1 The facility ensured that drugs are prescribed in generic name only
ME E6.2 There is procedure of rational use of drugs
ME E6.3 There are procedures defined for medication review and optimization

8 0
Standard E7 The facility has defined procedures for safe drug administration

:2 3
ME E7.1 There is process for identifying and cautious administration of high alert drugs (to
check) 14 .
6
ME E7.2 Medication orders are written legibly and adequately
ME E7.3 There is a procedure to check drug before administration/dispensing
02 2

ME E7.4 There is a system to ensure right medicine is given to right patient

.
3

ME E7.5 Patient is counseled for self-drug administration

/0 .0

Standard E8 The facility has defined and established procedures for maintaining, updating
of patients’ clinical records and their storage
/2
20 5

ME E8.1 All the assessments, re-assessment and investigations are recorded and updated
2
13

ME E8.2 All treatment plan prescription/orders are recorded in the patient records
ME E8.3 Care provided to each patient is recorded in the patient records
ME E8.4 Procedures performed are written on patient‟s records
ME E8.5 Adequate form and formats are available at point of use
ME E8.6 Register/records are maintained as per guidelines
ME E8.7 The facility ensures safe and adequate storage and retrieval of medical records
Standard E9 The facility has defined and established procedures for discharge of patient
ME E9.1 Discharge is done after assessing patient readiness
ME E9.2 Case summary and follow-up instructions are provided at the discharge
ME E9.3 Counselling services are provided as during discharges wherever required
Standard E10 The facility has defined and established procedures for intensive care
ME E10.1 The facility has established procedure for shifting the patient to step-down/ward
based on explicit assessment criteria
ME E10.2 The facility has defined and established procedure for intensive care
ME E10.3 The facility has explicit clinical criteria for providing intubation & extubation, and
care of patients on ventilation and subsequently on its removal
Standard E11 The facility has defined and established procedures for Emergency Services
and Disaster Management
ME E11.1 There is procedure for Receiving and triage of patients
ME E11.2 Emergency protocols are defined and implemented
 26

ME E11.3 The facility has disaster management plan in place

ME E11.4 The facility ensures adequate and timely availability of ambulances services and
mobilization of resources, as per requirement
ME E11.5 There is procedure for handling medico legal cases
Standard E12 The facility has defined and established procedures of diagnostic services
ME E12.1 There are established procedures for Pre-testing Activities
ME E12.2 There are established procedures for testing Activities
ME E12.3 There are established procedures for Post-testing Activities
Standard E13 The facility has defined and established procedures for Blood Bank/Storage
Management and Transfusion
ME E13.1 Blood bank has defined and implemented donor selection criteria
ME E13.2 There is established procedure for the collection of blood
ME E13.3 There is established procedure for the testing of blood
ME E13.4 There is established procedure for preparation of blood component
ME E13.5 There is establish procedure for labeling and identification of blood and its product

8 0
ME E13.6 There is established procedure for storage of blood

:2 3
ME E13.7 There is established the compatibility testing
ME E13.8 14 .
There is established procedure for issuing blood
6
ME E13.9 There is established procedure for transfusion of blood
ME E13.10 There is an established procedure for monitoring and reporting transfusion
02 2

complication
.
3

Standard E14 The facility has established procedures for Anesthetic Services
/0 .0

ME E14.1 The facility has est procedures for pre-anesthetic checkup and maint of records
/2

ME E14.2 The facility has est procedures for monitoring during anaesthesia and maint of
20 5

records
2
13

ME E14.3 The facility has established procedures for post-anaesthesia care

Standard E15 The facility has defined and established procedures of OT services
ME E15.1 The facility has established procedures OT Scheduling
ME E15.2 The facility has established procedures for Preoperative care
ME E15.3 The facility has established procedures for Surgical Safety
ME E15.4 The facility has established procedures for post-operative care
Standard E16 The facility has defined and established procedures for end-of-life care and
death
ME E16.1 Death of admitted patient is adequately recorded and communicated
ME E16.2 The facility has standard procedures for handling the death in the hospital
ME E16.3 The facility has standard procedures for conducting post-mortem, its recording and
meeting its obligation under the law
Maternal & Child Health Services
Standard E17 The facility has established procedures for Antenatal care as per guidelines
ME E17.1 There is an est procedure for Registration and follow up of pregnant women
ME E17.2 There is an est procedure for History taking, Physical examination, and counselling
of each antenatal woman, visiting the facility
ME E17.3 The facility ensures availability of diagnostic and drugs during antenatal care of
pregnant women
ME E17.4 There is an est procedure for identification of High-risk pregnancy and appropriate
 27

treatment/referral as per scope of services

ME E17.5 There is an est procedure for identification and management of moderate and
severe anaemia
ME E17.6 Counseling of pregnant women is done as per standard protocol and gestational
age
Standard E18 The facility has established procedures for Intra natal care as per guidelines
ME E18.1 The facility staff adheres to standard procedures for management of second stage
of labor
ME E18.2 The facility staff adheres to standard procedure for active management of third
stage of labor
ME E18.3 The facility staff adheres to standard procedures for routine care of newborn
immediately after birth
ME E18.4 There is an established procedure for assisted and C-section deliveries per scope
of services
ME E18.5 The facility staff adheres to standard protocols for identification and management of

8 0
Pre-Eclampsia/ Ecalmpsia

:2 3
ME E18.6 The facility staff adheres to standard protocols for identification and management of
PPH 14 .
6
ME E18.7 The facility staff adheres to standard protocols for Management of HIV in Pregnant
Woman & Newborn
02 2

ME E18.8 The facility staff adheres to standard protocol for identification and management of
.
3

preterm delivery
/0 .0

ME E18.9 Staff identifies and manages infection in pregnant woman

ME E18.10 There is Established protocol for newborn resuscitation is followed at the facility
/2
20 5

ME E18.11 The facility ensures Physical and emotional support to the pregnant women means
2

of birth companion of her choice

13

Standard E19 The facility has established procedures for postnatal care as per guidelines
ME E19.1 The facility staff adheres to protocol for assessments of condition of mother and
baby and providing adequate postpartum care
ME E19.2 The facility staff adheres to protocol for counseling on danger signs, post-partum
family planning and exclusive breast feeding
ME E19.3 The facility staff adheres to protocol for ensuring care of newborns with small size at
birth
ME E19.4 The facility has established procedures for stabilization/treatment/referral of post-
natal complications
ME E19.5 The facility ensures adequate stay of mother and newborn in a safe environment as
per standard Protocols
ME E19.6 There is established procedure for discharge and follow up of mother and newborn
Standard E20 The facility has established procedures for care of new born, infant and child
as per guidelines
ME E20.1 The facility provides immunization services as per guidelines
ME E20.2 Triage, Assessment & Management of newborns, infant & children having
emergency signs are done as per guidelines
ME E20.3 Management of Low-birth-weight newborns is done as per guidelines
ME E20.4 Management of neonatal asphyxia is done as per guidelines
 28

ME E20.5 Management of neonatal sepsis is done as per guidelines

ME E20.6 Management of children with Jaundice is done as per guidelines
ME E20.7 Management of children presenting with fever, cough/ breathlessness is done as
per guidelines
ME E20.8 Management of children with severe acute malnutrition is carried out as per
guidelines
ME E20.9 Management of children presenting diarrhoea is done per guidelines
ME E20.10 The facility ensures optimal breast-feeding practices for new born & infants as per
guidelines
Standard E21 The facility has established procedures for abortion and family planning as
per government guidelines and law
ME E21.1 Family planning counseling services provided as per guidelines
ME E21.2 The facility provides spacing method of family planning as per guidelines
ME E21.3 The facility provides limiting method of family planning as per guidelines
ME E21.4 The facility provides counseling services for abortion as per guidelines

8 0
ME E21.5 The facility provides abortion services for 1st trimester as per guidelines

:2 3
ME E21.6 The facility provides abortion services for 2nd trimester as per guidelines
14 .
Standard E22 The facility provides Adolescent Reproductive and Sexual Health services as
6
per guidelines
ME E22.1 The facility provides Promotive ARSH Services
02 2

ME E22.2 The facility provides Preventive ARSH Services

.
3

ME E22.3 The facility provides Curative ARSH Services

/0 .0

ME E22.4 The facility provides Referral Services for ARSH

/2

National Health Programmes

20 5

Standard E23 The facility provides National health Programme as per operational/Clinical
2
13

Guidelines
ME E23.1 The facility provides services under National Vector Borne Disease Control
Programme as per guidelines
ME E23.2 The facility provides services under National TB elimination Programme as per
guidelines
ME E23.3 The facility provides services under National Leprosy Eradication Programme as
per guidelines
ME E23.4 The facility provides services under National AIDS Control Programme as per
guidelines
ME E23.5 The facility provides services under National Programme for control of Blindness as
per guidelines
ME E23.6 The facility provides services under Mental Health Programme as per guidelines
ME E23.7 The facility provides services under National Programme for the health care of the
elderly as per guidelines
ME E23.8 The facility provides service under National Programme for Prevention and Control
of cancer, diabetes, cardiovascular diseases & stroke (NPCDCS) as per guidelines
ME E23.9 The facility provides service for Integrated disease surveillance Programme
ME E23.10 The facility provides services under National Programme for prevention and control
of deafness.
Area of Concern ‘F’: Infection Control
 29

Standard F1 The facility has infection control Programme and procedures in place for
prevention and measurement of hospital associated infection
ME F1.1 The facility has functional infection control committee
ME F1.2 The facility has provision for Passive and active culture surveillance of critical &
high-risk areas
ME F1.3 The facility measures hospital associated infection rates
ME F1.4 There is Provision of Periodic Medical Check-up and immunization of staff
ME F1.5 The facility has established procedures for regular monitoring of infection control
practices
ME F1.6 The facility has defined and established antibiotic policy
Standard F2 The facility has defined and Implemented procedures for ensuring hand
hygiene practices and antisepsis
ME F2.1 Hand washing facilities are provided at point of use
ME F2.2 The facility staff is trained in hand washing practices and they adhere to standard
hand washing practices

8 0
ME F2.3 The facility ensures standard practices and materials for antisepsis

:2 3
Standard F3 The facility ensures standard practices and materials for Personal protection
ME F3.1 The facility ensures adequate personal protection Equipment as per requirements
14 .
6
ME F3.2 The facility staff adheres to standard personal protection practices
Standard F4 The facility has standard procedures for processing of equipment and
02 2

instruments
.
3

ME F4.1 The facility ensures standard practices and materials for decontamination and
/0 .0

cleaning of instruments and procedures areas

ME F4.2 The facility ensures standard practices and materials for disinfection and
/2
20 5

sterilization of instruments and equipment

2

Standard F5 Physical layout and environmental control of the patient care areas ensures
13

infection prevention
ME F5.1 Functional area of the department are arranged to ensure infection control practices
ME F5.2 The facility ensures availability of standard materials for cleaning and disinfection of
patient care areas
ME F5.3 The facility ensures standard practices are followed for the cleaning and disinfection
of patient care areas
ME F5.4 The facility ensures segregation infectious patients
ME F5.5 The facility ensures air quality of high-risk area
Standard F6 The facility has defined and established procedures for segregation,
collection, treatment and disposal of Bio Medical and hazardous Waste
ME F6.1 The facility Ensures segregation of Bio Medical Waste as per guidelines and 'on-
site' management of waste is carried out as per guidelines
ME F6.2 The facility ensures management of sharps as per guidelines
ME F6.3 The facility ensures transportation and disposal of waste as per guidelines
Area of Concern ‘G’: Quality Management
Standard G1 The facility has established organizational framework for quality improvement
ME G1.1 The facility has a quality team in place
ME G1.2 The facility reviews quality of its services at periodic intervals
Standard G2 The facility has established system for patient and employee satisfaction
 30

ME G2.1 Patient satisfaction surveys are conducted at periodic intervals

ME G2.2 The facility analyses the patient feedback, and root-cause analysis
ME G2.3 The facility prepares the action plans for the areas, contributing to low satisfaction
of patients
Standard G3 Facility have established internal and external quality assurance programs
ME G3.1 The facility has established internal quality assurance programme in key
departments
ME G3.2 The facility has established external assurance programmes at relevant
Departments
ME G3.3 The facility has established system for use of check lists in different departments
and services
ME G3.4 Actions are planned to address gaps observed during quality assurance process
ME G3.5 Planned actions are implemented through Quality improvement cycles (PDCA)
Standard G4 The facility has established, documented implemented and maintained
Standard Operating Procedures for all key processes and support services

8 0
ME G4.1 Departmental standard operating procedures are available

:2 3
ME G4.2 Standard Operating Procedures adequately describes process and procedures
ME G4.3 Staff is trained and aware of the procedures written in SOPs
14 .
6
ME G4.4 The facility ensures documented policies and procedures are appropriately
approved and controlled
02 2

Standard G5 The facility maps its key processes and seeks to make them more efficient by
.
3

reducing non value adding activities and wastages

/0 .0

ME G5.1 The facility maps its critical processes

ME G5.2 The facility identifies non value adding activities/waste/redundant activities
/2
20 5

ME G5.3 The facility takes corrective action to improve the processes

2

Standard G6 The facility has defined Mission, Values, Quality policy and Objectives, and
13

prepares a strategic plan to achieve them

ME G6.1 The facility has defined mission statement
ME G6.2 The facility has defined core values of the organization
ME G6.3 The facility has defined Quality policy, which is in congruency with the mission of
facility
ME G6.4 The facility has defined quality objectives to achieve mission and quality policy
ME G6.5 Mission, Values, Quality policy and objectives are effectively communicated to staff
and users of services
ME G6.6 The facility prepares strategic plan to achieve mission, quality policy and objectives
ME G6.7 The facility periodically reviews the progress of strategic plan towards mission,
policy and objectives
Standard G7 The facility seeks continually improvement by practicing Quality method and
tools
ME G7.1 The facility uses method for quality improvement in services
ME G7.2 The facility uses tools for quality improvement in services
Standard G8 The facility has defined, approved and communicated Risk Management
framework for existing and potential risks
ME G8.1 Risk Mgt framework has been defined incl context, scope, objectives and criteria
ME G8.2 Risk Management framework defines the responsibilities for identifying and
 31

managing risk at each level of functions

ME G8.3 Risk Management Framework includes process of reporting incidents and potential
risk to all stakeholders
ME G8.4 A compressive list of current and potential risk including potential strategic,
regulatory, operational, financial, environmental risks has been prepared
ME G8.5 Modality for staff training on risk management is defined
ME G8.6 Risk Management Framework is reviewed periodically
Standard G9 The facility has established procedures for assessing, reporting, evaluating
and managing risk as per Risk Management Plan
ME G9.1 Risk management plan has been prepared and approved by the designated
authority and there is a system of its updation at least once in a year
ME G9.2 Risk Management Plan has been effectively communicated to all the staff, and as
well as relevant external stakeholders
ME G9.3 Risk assessment criteria and checklist for assessment have been defined and
communicated to relevant stakeholders

8 0
ME G9.4 Periodic assessment for Physical and Electrical risks is done as per defined criteria

:2 3
ME G9.5 Periodic assessment for potential disasters including fire is done as per defined
criteria 14 .
6
ME G9.6 Periodic assessment for Medication and Patient care safety risks is done as per
defined criteria
02 2

ME G9.7 Periodic assessment for potential risk regarding safety and security of staff
.
3

including violence against service providers is done as per defined criteria

/0 .0

ME G9.8 Risks identified are analyzed evaluated and rated for severity
ME G9.9 Identified risks are treated based on severity and resources available
/2
20 5

ME G9.10 A risk register is maintained and updated regularly to risk records identified risks,
2

there severity and action to be taken

13

Standard G10 The facility has established clinical Governance framework to improve the
quality and safety of clinical care processes
ME G10.1 The facility has defined clinical governance framework
ME G10.2 Clinical Governance framework has been effectively communicated to all staff
ME G10.3 Clinical care effectiveness criteria have been defined and communicated
ME G10.4 Facility conducts the periodic clinical audits including prescription, medical and
death audits
ME G10.5 Clinical care audits data is analysed, and actions are taken to close the gaps
identified during the audit process
ME G10.6 Governing body of healthcare facilities ensures accountability for clinical care
provided
ME G10.7 Facility ensures easy access and use of standard treatment guidelines &
implementation tools at point of care
Area of Concern ‘H’: Outcomes
Standard H1 The facility measures Productivity Indicators and ensures compliance with
National Benchmarks
ME H1.1 The facility measures productivity Indicators on monthly basis
ME H1.2 The facility endeavors to improve its productivity indicators to meet benchmarks
Standard H2 The facility measures Efficiency Indicators and ensure to reach National
 32

Benchmark
ME H2.1 The facility measures efficiency Indicators on monthly basis
ME H2.2 The facility endeavours to improve its efficiency indicators to meet benchmarks
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach
National benchmark
ME H3.1 The facility measures Clinical Care & Safety Indicators on monthly basis
ME H3.2 The facility endeavours to improve its clinical & safety indicators to meet
benchmarks
Standard H4 The facility measures Service Quality Indicators and endeavours to reach
National benchmark
ME H4.1 The facility measures Service Quality Indicators on monthly basis
ME H4.2 The facility endeavours to improve its service Quality indicators to meet
benchmarks

8 0
:2 3
14 .
02 2
6
.
3
/0 .0
/2
20 5
2
13
 33

Appx ‘C’

8 0
:2 3
14 .
02 2
6
.
3
/0 .0

QUALITY ASSESSMENT UNDER NQAS

/2
20 5
2

FOR THE DURATION

13

FROM TO ______
CARRIED OUT BY_______
 34

EXECUTIVE SUMMARY

QUALITY ASSESSMENT UNDER NQAS FROM TO____________.

CARRIED OUT BY .

1. Gaps identified and rectified.

(To include Patient Satisfaction Survey and Prescription Audit findings and analysis)

8 0
:2 3
2. Gaps pending for action by higher Fmn.
14 .
02 2
6
.
3

3. Actions to be taken/ taken by Line Dte.

/0 .0
/2
20 5
2
13

4. Financial implications of recom/actions if any.

 35

QUALITY ASSESSMENT UNDER NQAS FROM TO .

CARRIED OUT BY .

S No Criterion Yes No Remarks

(a) Criterion 1- Aggregate score of the health facility ≥
70%
(b) Criterion 2 - Score of each department of the health
facility ≥ 70%

(c) Criterion 3 - Segregated score in each Area of

Concern (Service Provision, Patient‟s Right, Inputs,
Support Services, Clinical Services, Infection Control,
Quality Management, Outcome Indicator) ≥ 70%

(d) Criterion 4 - Score of Standard A2, Standard B5 and

8 0
Standard D10 is>70% in each applicable department.

:2 3
(i) Standard A2 States “The facility provides
RMNCHA services”. 14 .
(iii) Standard B5 states that “the facility ensures
6
that there are no financial barriers to access, and
02 2

that there is financial protection given from the

cost of hospital services”.
.
3

(iii) Standard D10 states “the facility is compliant

/0 .0

with all statutory and regulatory requirement

imposed by local, state or central government.”
/2
20 5
2
13

(e) Criterion 5- Individual Standard wise score ≥ 50%

(f) Criteria 6- Patient satisfaction Score of 70% in the

preceding six months or more (Satisfied & Highly
Satisfied) or score of 3.5 on Likert Scale

It is recommended that hospital may be awarded with ________________________.

 36

AREA OF CONCERN WISE SCORE CARD

Area of Concern Scoring Pattern

Service Provision

Patient Rights

Inputs

Support Services

Clinical Services

Infection control

8 0
:2 3
Quality Management
14 .
6
Outcomes
02 2
.
3
/0 .0
/2
20 5
2
13
 37

HOSPITAL QUALITY SCORE CARD

Accident & OPD Labour Room Maternity In-patient

Emergency Department

% % % % %

NRC Paediatrics SNCU ICU

Ward
HOSPITAL SCORE
% % % %
%
Operation Post-Partum Blood Bank Laboratory
Theatre Unit

8 0
% % % %

:2 3
Radiology Pharmacy Auxiliary Services Mortuary General
14 . Administration
6
% % % % %
02 2
.
3
/0 .0
/2
20 5
2
13
 38

STANDARD WISE SCORE CARD

Area of Concern A Area of Concern D Area of Concern E Area of Concern F

(Service Provision) (Support Services) (Clinical Services) (Infection Control)
Overall Score Overall Score Overall Score Overall Score

Standard Score Standard Score Standard Score Standard Score

Standard A1 Standard D1 Standard E1 Standard F1
Standard A2 Standard D2 Standard E2 Standard F2
Standard A3 Standard D3 Standard E3 Standard F3
Standard A4 Standard D 4 Standard E4 Standard F4
Standard A5 Standard D 5 Standard E5 Standard F5
Standard A6 Standard D6 Standard E6
Standard F6

8 0
Standard D7 Standard E7
Area of Concern B

:2 3
(Patient Rights) Area of Concern G
Overall Score Standard D8 Standard E8 (Quality Mgt)
14 . Overall Score
6
Standard B1 Standard D 9 Standard E9 Standard G1
02 2

Standard B2 Standard D10 Standard E10 Standard G2

.
3

Standard B3 Standard D 11 Standard E11 Standard G3

/0 .0

Standard B4 Standard D 12 Standard E12 Standard G4

/2
20 5

Standard B5 Standard E13 Standard G5

2

Standard E14 Standard G6

13

Area of Concern C
(Inputs) Standard E15 Standard G7
Overall Score Standard E16 Standard G8
Area of Concern H
Standard C1 Standard E17 (Outcome Indicator)
Overall Score
Standard C 2 Standard E18 Standard H1
Standard C 3 Standard E19 Standard H2
Standard C 4 Standard E20 Standard H4
Standard C 5 Standard E21

Standard E22 Standard H4

Standard C 6
Standard E23
 39

DEPARTMENT WISE SCORE CARD

Accident & Emergency

Accident & Emergency Score Card

Area of Concern Wise Score Accident & Emergency Score
(a) Service Provision 0%

(b) Patient Rights 0%

(c) Inputs 0%

(d) Support Services 0%

(e) Clinical Services 0% 0%

8 0
(f) Infection Control 0%

:2 3
(g) Quality Management 0%
14 .
6
(h) Outcome 0%
02 2

Major Gaps Observed

.
3

(a)
/0 .0
/2

(b)
20 5
2

(c)
13

Evidences (if any….)

(a)

(b)

(c)
 40

Out-patient Department
Out-patient Department Score Card
Area of Concern Wise Score Out-patient Department Score
(a) Service Provision
0%
(b) Patient Rights 0%
(c) Inputs
0%
(d) Support Services 0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%
(g) Quality Management

8 0
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 41

Labour room
Labour room Score Card
Area of Concern Wise Score Labour room Score
(a) Service Provision
0%
(b) Patient Rights 0%
(c) Inputs
0%
(d) Support Services 0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 42

Maternity Ward
Maternity Ward Score Card
Area of Concern Wise Score Maternity Ward Score
(a) Service Provision
0%
(b) Patient Rights 0%
(c) Inputs
0%
(d) Support Services 0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 43

Pediatrics ward
Pediatrics ward Score Card
Area of Concern Wise Score Pediatrics ward Score
(a) Service Provision
0%
(b) Patient Rights 0%
(c) Inputs
0%
(d) Support Services 0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%
(g) Quality
0%

8 0
Management
(h) Outcome

:2 3
0%
Major Gaps Observed
14 .
6
(a)
02 2

(b)
.
3
/0 .0

(c)
/2

Evidences (if any….)

20 5
2

(a)
13

(b)

(c)
 44

Sick Newborn Care Unit

Sick Newborn Care Unit Score Card
Area of Concern Wise Score Sick Newborn Care Unit Score
(a) Service Provision
0%
(b) Patient Rights 0%
(c) Inputs
0%
(d) Support Services 0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%
(g) Quality Management
0%

8 0
(h) Outcome

:2 3
0%
Major Gaps Observed
14 .
6
(a)
02 2

(b)
.
3
/0 .0

(c)
/2

Evidences (if any….)

20 5
2

(a)
13

(b)

(c)
 45

Nutritional Rehabilitation Centre

Nutritional Rehabilitation Centre Score Card
Area of Concern Wise Score Nutritional Rehabilitation Centre Score
(a) Service Provision
0%
(b) Patient Rights 0%
(c) Inputs
0%
(d) Support Services 0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 46

Operation Theatre
Operation Theatre Score Card
Area of Concern Wise Score Operation Theatre Score
(a) Service Provision
0%
(b) Patient Rights 0%
(c) Inputs
0%
(d) Support Services 0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 47

Post-Partum Unit
Post-Partum Unit Score Card
Area of Concern Wise Score Post-Partum Unit Score
(a) Service Provision 0%

(b) Patient Rights 0%

(c) Inputs 0%

(d) Support Services 0%

0%
(e) Clinical Services 0%

(f) Infection Control 0%

(g) Quality Management 0%

8 0
(h) Outcome 0%

:2 3
Major Gaps Observed
14 .
6
(a)
02 2

(b)
.
3
/0 .0

(c)
/2

Evidences (if any….)

20 5
2

(a)
13

(b)

(c)
 48

Intensive Care Unit

Intensive Care Unit Score Card

Area of Concern Wise Score Intensive Care Unit Score

(a) Service Provision 0%

(b) Patient Rights
0%
(c) Inputs
0%
(d) Support Services
0%
(e) Clinical Services 0%
0%
(f) Infection Control
0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 49

Indoor Patient Department

Indoor Patient Department Score Card

Area of Concern Wise Score Indoor Patient Department Score

(a) Service Provision 0%

(b) Patient Rights
0%
(c) Inputs
0%
(d) Support Services
0%
(e) Clinical Services 0%
0%
(f) Infection Control 0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 50

Blood Bank

Blood Bank Score Card

Area of Concern Wise Score Blood Bank Score

(a) Service Provision 0%

(b) Patient Rights
0%
(c) Inputs
0%
(d) Support Services
0%
(e) Clinical Services 0%
0%
(f) Infection Control 0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 51

Laboratory

Laboratory Score Card

Area of Concern Wise Score Laboratory Score

(a) Service Provision 0%

(b) Patient Rights
0%
(c) Inputs
0%
(d) Support Services
0%
(e) Clinical Services 0%
0%
(f) Infection Control 0%

8 0
(g) Quality Management
0%

:2 3
(h) Outcome
0%
14 .
6
Major Gaps Observed
(a)
02 2
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 52

Radiology
Radiology Score Card
Area of Concern Wise Score Radiology Score
(a) Service Provision 0%

(b) Patient Rights 0%

(c) Inputs 0%

(d) Support Services 0%

0%
(e) Clinical Services 0%

(f) Infection Control 0%

(g) Quality Management 0%

8 0
(h) Outcome 0%

:2 3
Major Gaps Observed
14 .
6
(a)
02 2

(b)
.
3
/0 .0

(c)
/2

Evidences (if any….)

20 5
2

(a)
13

(b)

(c)
 53

Pharmacy

Pharmacy Score Card

Area of Concern Wise Score Pharmacy Score
(a) Service Provision 0%

(b) Patient Rights 0%

(c) Inputs 0%

(d) Support Services 0%

0%
(e) Clinical Services 0%

(f) Infection Control 0%

(g) Quality Management 0%

8 0
(h) Outcome 0%

:2 3
Major Gaps Observed
14 .
6
(a)
02 2

(b)
.
3
/0 .0

(c)
/2

Evidences (if any….)

20 5
2

(a)
13

(b)

(c)
 54

Auxiliary services

Auxiliary services Score Card

Area of Concern Wise Score Auxiliary services Score

(a) Service Provision 0%

(b) Patient Rights 0%

(c) Inputs 0%

(d) Support Services 0%

0%
(e) Clinical Services 0%

(f) Infection Control 0%

(g) Quality Management 0%

8 0
(h) Outcome 0%

:2 3
14 .
Major Gaps Observed
6
(a)
02 2

(b)
.
3
/0 .0

(c)
/2
20 5

Evidences (if any….)

2

(a)
13

(b)

(c)
 55

Mortuary

Mortuary Score Card

Area of Concern Wise Score Mortuary Score

(a) Service Provision 0%

(b) Patient Rights 0%

(c) Inputs 0%

(d) Support Services 0%

(e) Clinical Services 0% 0%

(f) Infection Control 0%

8 0
(g) Quality Management 0%

:2 3
(h) Outcome 0%
14 .
6
Major Gaps Observed
02 2

(a)
.
3
/0 .0

(b)
/2

(c)
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 56

General Administration

General Administration Score Card

Area of Concern Wise Score General Administration Score

(a) Service Provision 0%

(b) Patient Rights 0%

(c) Inputs 0%

(d) Support Services 0%

(e) Clinical Services 0% 0%

(f) Infection Control 0%

8 0
(g) Quality Management 0%

:2 3
(h) Outcome 0%
14 .
6
Major Gaps Observed
02 2

(a)
.
3

(b)
/0 .0

(c)
/2
20 5
2

Evidences (if any….)

13

(a)

(b)

(c)
 57

DOCUMENT REVIEW CHECKLIST

Checklist for review of documents

Observation Yes No Remarks
Internal Assessment
Hospital has conducted internal assessment
Complete assessment scores submitted?
Details of assessment team (name &
designation) provided.
External Assessment
Assessment schedule submitted.
Details of assessment team (name &
designation) provided.
Complete assessment scores submitted?

8 0
All checklists and scores submitted?

:2 3
Quality Policy and Quality Objectives
Quality policy submitted. 14 .
6
Quality policy is approved by Comdt Hosp
02 2

Overall quality objectives of hospital

submitted?
.
3
/0 .0

Quality objectives of all departments

submitted?
/2

Quality objectives are in line with quality

20 5

policy?
2

Quality objectives are smart?

13

Is there any mechanism to monitor and track

quality objectives?
Operational Quality Team
Supporting document/office order submitted
regarding constitution of quality team?
Quality team is multi-disciplinary with
representation from all departments (clinical,
admin, support)
Records of proceedings of at least three
consecutive monthly meetings?
Standard Operating Procedures (SOP)
All required SOPs are submitted.
All SOPs are drafted and approved by
competent authority?
All SOPs adequately describe the process and
have details as per NQAS.
Quality Improvement Manual
Quality improvement manual submitted.
Manual is approved by competent authority.
Manual is complete in all respects and
 58

Checklist for review of documents

Observation Yes No Remarks
adequately describes the process as per
NQAS?
Defined Hospital Wide Policies
Condemnation policy
End of life care policy
Antibiotic policy
Visitors‟ policy
Social, Culture & Religious Quality Policy
Privacy, Dignity and Confidentiality Policy of
Patient
Maintenance of patient records its security &
sharing of information.
Linen Policy
Consent policy

8 0
Policy of PPE & PEP in case of reported sharps

:2 3
injury
Prescription by Generic name
Adverse event reporting policy 14 .
6
Consultation & Bed allocation policy
Handing over policy
02 2

Intradepartmental & Higher Centre Referral

.
3

Policy
/0 .0

Dress Code Policy

Narcotics & Psychotropic drug safety policy
/2

Availability of EDL & Stock management policy

20 5
2

Policy of timely reimbursements of entitlements

13

& Compensation
Grievance Redressal Policy
No Smoking Policy
Quality Policy
Free treatment to BPL patients‟ procedure/
policy
Regular Competence testing as per Job
Description Policy
Quality policy.
Patient Satisfaction Surveys
Analysis of at least 3 consecutive surveys
submitted
Subsequent Corrective & Preventive actions
Analysis of Key performance indicators (KPIs)
of last 3 months
Record of Death Audit of last 3 months
Analysis of Medical Audit of last 3 months and
corrective/ preventive action
Analysis of Prescription Audit of last 3 months
and corrective/ preventive action