Checklist for Assessment of Phase I, 50 critical indicators at Teaching Hospitals:

MSD Respo
S
S nse
r Indic Indicator Compliance Requirement Scoring Key Score Remarks
Y/N/N
# ator # A
Continuous Quality Improvement
1. A documented Continuous Quality
Improvement Program is available that
includes at least:
a. Multi-disciplinary committee with
[Y] 1 [No] 0
TORs
b. Methodology to be used for CQI [Y] 1 [No] 0
c. Reporting structure of CQI results [Y] 1 [No] 0
d. Requirement for minutes of
[Y] 1 [No] 0
Committee meetings
e. Defined responsibilities and
authorities of the CQI committee and [Y] 1 [No] 0
individual committee members
2. Department wise KPIs with
The quality [Y] 5 [No] 0
benchmarks defined
improvement
3. Focal persons of all departments
program is [Y] 5 [No] 0
notified
developed,
4. CQI coordinator is notified [Y] 5 [No] 0
1 93 implemented
and maintained 5. Data collection from all departments
[Y] 5 [No] 0
by a multi- is evident
disciplinary 6. Frequency of CQI meetings is
[Y] 5 [No] 0
committee defined
7. Record of minutes of meeting of
[Y] 5 [No] 0
CQI committee is available
8. Analysis of KPIs against benchmarks
[Y] 5 [No] 0
is evident
9. Corrective measures for non-
[Y] 5 [No] 0
compliant KPIs are recorded
10. Responsibilities are assigned for
[Y] 5 [No] 0
corrective measures
11. Corrective measures activities are
[Y] 5 [No] 0
time lined
12. Mechanism exist for sharing the
[Y] 5 [No] 0
minutes of meeting
(attach all evidences)
Compliant/
Total Non-
60 Compliant
The designated a. SOPs on training/orientation
CQI program is regarding CQI program, of all senior
[Y] 4 [No] 0
communicated leaders, all Department Heads and
and relevant employees, are available
coordinated b. Communication/Orientation of all
2 97 amongst all the senior leaders, regarding CQI Program [Y] 1 [No] 0
employees of is evident
the c. Relevant Staff understand and
organization show examples of impact of CQI [Y] 1 [No] 0
through a programme, verified through interviews
proper training d. Communication/Orientation of all [Y] 4 [No] 0
 Department Heads, regarding CQI
mechanism. Program is evident
Compliant/
Total 10 Non-
Compliant
Total 70
Hospital Infection Prevention & Control
The hospital HIPC Plan is available, covering at
infection least the following essential
prevention and components :
control (HIPC) a. Surveillance activities (Active and
[Y] 3 [No] 0
plan is Passive)
documented b. Notified IPC committee with
3 84
which aims at authorities and responsibilities of the [Y] 2 [No] 0
preventing and committee
reducing risk c. Hand /Respiratory Hygiene and use [Y] 2.5 [No]
of healthcare of PPEs 0
associated d. Isolation, Sterilization and Waste [Y] 2.5 [No]
infections management 0
Compliant/
Total 10 Non-
Compliant
The hospital a. IPC Committee is constituted and
has a multi- notified with representation from all [Y] 4 [No] 0
disciplinary relevant departments
Infection b. TORs of Committee defining roles,
prevention and responsibilities and authorities are [Y] 3 [No] 0
4 85
Control available
Committee/ c. Minutes of the last IPC Committee
Environmental meeting , at least on quarterly basis
[Y] 3 [No] 0
Safety containing issues and the recommended
Committee actions
Compliant/
Total 10 Non-
Compliant
a. Hospital waste management
[Y] 2 [No] 0
(HWM) plan is available
b. Notification and composition of
HWM team in line with the PHWM [Y] 1 [No] 0
Rules
The
establishment c. HWM facilities/arrangements for
has appropriate the following are available:
consumables, [Y] 0.5 [No]
i. Segregation
collection and 0
handling [Y] 0.5 [No]
5 88 ii. Collection
systems, 0
equipment and [Y] 0.5 [No]
iii. Transportation
facilities to 0
manage the [Y] 0.5 [No]
control of iv. Storage
0
infections [Y] 0.5 [No]
v. Disposal/ Minimization
0
[Y] 0.5 [No]
vi. Documentation/Record keeping
0
d. All the requirements of HWM, [Y] 4 [No] 0
 segregation, collection, transportation
and disposal are being complied
Compliant/
Total 10 Non-
Compliant
a. Purpose built CSSD or Dedicated
[Y] 2.5 [No]
area for sterilization of instruments and
0
separate washing area, is available
There is b. There is adequate separation
adequate space [Y] 2.5 [No]
(physical barrier) between dirty and
6 90 available for 0
clean areas
sterilization c. Clean area for storage for sterilized
activities [Y] 3 [No] 0
instruments is available
d. Dedicated person for supervising the
[Y] 2 [No] 0
sterilization activities is notified
Compliant/
Total 10 Non-
Compliant
a. Procedure to verify that sterilization
process, along with list of types of [Y] 3 [No] 0
validation tests to be used, is available
Regular b. Evidence that validation of
validation tests sterilization is employed for All
for sterilization “batches”, verified by reviewing the [Y] 3 [No] 0
7 91
are carried out record and physical assessment of
and sterilized sets (randomly picked)
documented c. Marking date of sterilization and
expiry (as per the packing material
[Y] 4 [No] 0
used) on each sterilized item /batch is
evident
Compliant/
Total 10 Non-
Compliant
Total 50
Emergency Care
8 15 Policies and 1. Emergency Department SOPs are
procedures for available covering following areas:
emergency care [Y] 0.5 [No]
are a. Admission / Registration
0
documented b. Un hindered Facility Entrance
[Y] 0.25 [No]
providing easy access supported by
0
signage
c. Estimated waiting time for initial [Y] 0.25 [No]
assessment 0
[Y] 0.5 [No]
d. Triage
0
[Y] 0.5 [No]
e. Initial Screening
0
[Y] 0.25 [No]
f. Consent
0
g. Clinical Laboratory & Radiology [Y] 0.5 [No]
Services 0
h. Operating / Procedure Room, if [Y] 0.25 [No]
required 0
 [Y] 0.5 [No]
i. ICU/ CCU care
0
[Y] 0.5 [No]
j. Patients Discharge
0
[Y] 0.5 [No]
k. Continuous Training of ER Staff
0
[Y] 0.5 [No]
l. Management of Medico legal Cases
0
[Y] 0.5 [No]
m. Patients Record
0
n. Patient transfer from emergency
[Y] 0.5 [No]
department to inpatient areas or to
0
another organization
2. Emergency guidelines are available [Y] 2 [No] 0
3. Emergency Management Clinical
[Y] 2 [No] 0
Protocols/ guidelines available
Compliant/
Total 10 Non-
Compliant
a. Emergency care provision is in
accordance with the SOPs, as evident [Y] 2 [No] 0
from emergency staff interviews
The patients b. Documented evidence of
[Y] 4 [No] 0
receive care in implementation of policies is available
9 17 consonance c. Names of the staff on duty
with the including the consultants (onsite or on
policies [Y] 2 [No] 0
call) is displayed on the roster
preferably on the LED screen
d. Round the clock coverage of
[Y] 2 [No] 0
specialized care is evident
Compliant/
Total 10 Non-
Compliant
a. Staff orientation on available
Policies and Triage SOPs is evident from training [Y] 2 [No] 0
procedures record
guide the triage
1 b. Staff orientation on Triage SOPs is
18 of patients for [Y] 2 [No] 0
0 evident from staff interviews
initiation of
appropriate c. Evidence that the documented
care SOPs and triage process is practiced [Y] 6 [No] 0
and implemented
Compliant/
Total 10 Non-
Compliant
1. Staff (EMO/CMO) and others on
Staff members duty are trained on the SOPs related to
are familiar care of emergency patients evidenced
with the through:
policies and a. attendance record [Y] 2 [No] 0
1
19 trained on the b. Staff interview [Y] 2 [No] 0
1
procedures for 2. Documentary evidence of training
care of of staff on BLS, ACLS, ATLS and [Y] 1 [No] 0
emergency ALSO etc. is available accordingly
patients
3. Evidence is available that the [Y] 1 [No] 0
 policies and procedures have been
implemented
4. Documentary evidence of training
on Emergency guidelines of emergency [Y] 4 [No] 0
staff is available
Compliant/
Total 10 Non-
Compliant
Admission or Record of the patients, reported in the
discharge to emergency department has information
home or regarding, Admission, Diagnosis,
1 [Y] 10 [No]
20 transfer to Treatment given, Final disposal, from
2 0
another emergency department, i.e., Admission
organization is in Indoor, Referred, Discharged,
documented Expired, LAMA, Received Dead, etc.
Compliant/
Total 10 Non-
Compliant
Total 50
Blood Transfusion
1. Documented
Policies/guidelines/SOPs for rational
use of blood and blood products are [Y] 3 [No] 0
available and being implemented
accordingly with documented record
2. Policies/guidelines/SOPs cover the
following applicable legal
requirements:
a. Donor screening for blood donations,
[Y] 1 [No] 0
testing/ collection
Documented
b. Blood Processing [Y] 1 [No] 0
policies and
procedures are c. Storage of blood, performing
1 compatibility tests before issuance of
21 used to guide
3 blood and blood components, [Y] 1 [No] 0
rational use of
blood and distribution and transport for
blood products transfusion
d. Administration /use of blood and
[Y] 1 [No] 0
blood products
e. Identification and analysis of real or
suspected transfusion reactions in the [Y] 1 [No] 0
donor and the recipient
f. Disposal of blood and related
[Y] 1 [No] 0
products
g. Record keeping for traceability of
processes/actions at all steps in the [Y] 1 [No] 0
blood chain
Compliant/
Total 10 Non-
Compliant
Total 10
Anesthesia Services
1 31 There is a 1. Documented SOPs for administration
4 documented of anaesthesia are available, being
policy and implemented accordingly and cover at
procedure for least the following:
 a. Staff responsibilities in provision of [Y] 0.2 [No]
anaesthesia care 0
b. Safe handling and storage of [Y] 0.2 [No]
anesthetic medicines and agents 0
[Y] 0.2 [No]
c. Equipment maintenance
0
d. Pre-anesthesia assessment (in line [Y] 0.2 [No]
with the ASA scoring) 0
[Y] 0.2 [No]
e. Pre-induction re-evaluation
0
f. Documented intra-operative [Y] 0.2 [No]
monitoring of the anesthetized patients 0
g. Recording of any complication/ [Y] 0.2 [No]
adverse anesthesia events 0
[Y] 0.2 [No]
h. Post anesthesia monitoring
0
i. Criteria for shifting of patients from [Y] 0.2 [No]
anesthesia care 0
2. All the relevant staff members are [Y] 1.2 [No]
aware of and implementing the same 0
3. Record of the at least ten randomly
selected patients, who received
[Y] 1 [No] 0
anaesthesia, contain documented pre-
anaesthesia assessment
4. Record of the at least ten randomly
selected patients, who received
the anaesthesia, contain documented [Y] 1 [No] 0
administration anaesthesia plan based on pre-
of anaesthesia anaesthesia assessment
5. Record of the at least ten randomly
selected patients, who received
anaesthesia, contain documented Pre-
[Y] 1 [No] 0
induction re-evaluation including at
least the record of vital signs and
change of anaesthesia plan if required
6. Record of the at least ten randomly
selected patients, who received
anaesthesia, contain informed consents
for anaesthesia, the contents of which [Y] 1 [No] 0
accommodate all patient levels of
understanding, duly signed by
patient/attendant and doctor
7. Record of at least ten randomly
selected patients, who received
anaesthesia, contain filled checklist for [Y] 1 [No] 0
confirming the identity of patient for
which staff is conversant
8. Record of at least ten randomly
selected patients, who received
anaesthesia, contain post-anaesthetic [Y] 1 [No] 0
monitoring of the patients including at
least the following:
9. Record of at least ten randomly
selected patients, who received [Y] 1 [No] 0
anaesthesia, contain shifting notes from
 the recovery area, documented by
qualified individual
Compliant/
Total 10 Non-
Compliant
During Record of at least ten randomly selected
anesthesia, patients, who received anaesthesia,
monitoring contain documented during anaesthesia
includes monitoring, covering at least the
regular and following,
periodic i. Heart rate [Y] 2 [No] 0
recording of ii. Blood pressure [Y] 2 [No] 0
heart rate,
iii. Cardiac rhythm [Y] 2 [No] 0
1 cardiac rhythm,
36 iv. Respiratory rate [Y] 2 [No] 0
5 respiratory
rate, blood v. Oxygen saturation [Y] 2 [No] 0
pressure, vi. Airway security and patency [Y] 2 [No] 0
oxygen
saturation,
airway security
and patency
and level of
anesthesia.
Compliant/
Total 10 Non-
Compliant
Total 20
Surgical Services
1. Surgery-related policies/SOPs are
available, being implemented and cover
the following:
a. Pre-operative assessment [Y] 1 [No] 0
b. Pre-operative provisional diagnosis [Y] 1 [No] 0
c. Obtaining informed consent by a
qualified medical member of the [Y] 1 [No] 0
The surgery- surgical team prior to the procedure
related policies d. Prevention of adverse events like;
1
41 and procedures wrong patient, wrong surgery, or wrong [Y] 1 [No] 0
6
are site
documented e. Writing operative note by the
[Y] 1 [No] 0
surgeon or a doctor of the surgical team
f. Documenting Post-operative Care
plan prior to transferring the patient out [Y] 1 [No] 0
of the recovery area
2. All relevant staff members are aware
of the policies and procedures and their [Y] 4 [No] 0
applicability
Compliant/
Total 10 Non-
Compliant
1 44 Documented Record of the at least ten randomly [Y] 6 [No] 0
7 policies and selected patients, who underwent
procedures surgery, contain evidence of calling
exist to prevent “time out”, in form of filled checklists,
adverse events ensuring agreement of ALL members of
 the surgical team that:
i. This is the correct patient [Y] 1 [No] 0
like wrong site, ii. This is the correct procedure for this
[Y] 1 [No] 0
wrong patient patient
and wrong iii. This is the correct site and side (if
[Y] 1 [No] 0
surgery. relevant)
iv. All documents like x-rays,
medical/diagnostic reports and the [Y] 1 [No] 0
needed equipment is available
Compliant/
Total 10 Non-
Compliant
Record of the at least ten randomly
selected patients, who underwent
surgery, containing operation notes
including atleast the following , prior to
transfer of patient:
• Name of the surgeon [Y] 1 [No] 0
A brief • Assistant/team [Y] 1 [No] 0
operative note
is documented • Anesthetist [Y] 1 [No] 0
by the surgeon • Type of anesthesia [Y] 1 [No] 0
or a doctor in • Procedure performed [Y] 1 [No] 0
1
46 the surgical • Findings [Y] 1 [No] 0
8
team prior to • Any specimen removed for biopsy [Y] 1 [No] 0
transferring the
• Blood loss/transfusion [Y] 1 [No] 0
patient out of
the recovery • Any uneventful development [Y] 1 [No] 0
area. • Patient’s condition at the conclusion
[Y] 1 [No] 0
of the procedure
Note: in case of procedure in
the body cavity (abdomen, pelvis or
chest etc. will also mention that all the
sponges and instruments used have
been removed and counted)
Compliant/
Total 10 Non-
Compliant
a. Documented Quality Assurance
[Y] 3 [No] 0
Program is available
b. QA Program covers holding periodic
meetings of surgical quality assurance
committee/OT management committee
A quality
or Surgical Department meeting for
assurance [Y] 3 [No] 0
monitoring the quality indicators of
1 program is
48 Surgical Services and invasive
9 followed for
procedures, and is evident from minutes
the surgical
of meeting
services.
c. There is evidence that the
documented QA Program is monitored
by surgical quality assurance committee [Y] 4 [No] 0
with adequate composition of
committee on monthly basis
Compliant/
Total 10 Non-
Compliant
 1. The surgical quality assurance
committee monitors the following and
is evident from minutes of meetings:
a. Cleaning and Disinfection of
operating rooms, along with the record [Y] 1 [No] 0
of cleaning in between surgeries
b. Cleaning and disinfection of the [Y] 0.5 [No]
medical equipment 0
c. Periodic Preventive maintenance and [Y] 0.5 [No]
calibration of OT equipment 0
The surgical d. Taking culture swabs from the
quality following sites as per guidelines / as
assurance indicated:
program [Y] 0.25
2 i. Operation table
49 includes [No] 0
0 [Y] 0.5 [No]
surveillance of ii. Floor and walls
the operation 0
theatre [Y] 0.5 [No]
iii. Instrument trolley
environment. 0
[Y] 0.25
iv. Air conditioner Vent
[No] 0
[Y] 0.5 [No]
v. Air
0
[Y] 0.5 [No]
vi. Operation Light
0
[Y] 0.5 [No]
vii. Anaesthesia machine
0
2. Evidence of corrective actions as per
[Y] 5 [No] 0
surveillance report/s, if indicated, is
[NA] NA
available
Compliant/
Total 10 Non-
Compliant
a. SOPs to monitor surgical site
[Y] 4 [No] 0
infection rate are available
The plan also b. Regular calculation of infection rates
includes on monthly basis, is evident from [Y] 3 [No] 0
2
50 monitoring of record
1
surgical site c. Analysis of the infection rates on
infection rates monthly basis, with evidence that
[Y] 3 [No] 0
remedial actions were initiated,
available in documented record
Compliant/
Total 10 Non-
Compliant
Informed Record of the at least ten randomly
consent selected patients, contains informed
includes consent duly signed by the
information on patient/attendant and the doctor,
2 covering at least
74 risks, benefits,
2 i. Type of procedure/s [Y] 2 [No] 0
and alternatives
and as to who ii. Risks [Y] 2 [No] 0
will perform iii. Benefits [Y] 2 [No] 0
the requisite iv. Alternatives [Y] 2 [No] 0
 v. Who will perform the procedure [Y] 2 [No] 0
procedure in a
language that
Compliant/
Total 10 Non-
Compliant
Total 70
Gynecological/Obstetric Services
a. Availability of
[Y] 2 [No] 0
Pediatrician/neonatologist (as per duty
[NA] NA
roster/requirement) is evident
b. Availability of competent nursing
[Y] 2 [No] 0
staff trained in neonatal resuscitation, is
[NA] NA
evident
c. Availability of the following essential
items/ equipment:
i. Neonatal resuscitation and emergency [Y] 0.5 [No]
drugs 0 [NA] NA
[Y] 0.5 [No]
ii. Ambo bag
0 [NA] NA

The [Y] 0.5 [No]

iii. Neo-natal face mask
organization 0 [NA] NA
caring for high [Y] 0.5 [No]
iv. Neo-natal laryngoscope
risk obstetric 0 [NA] NA
cases has the v. A selection of Neo-natal Endo [Y] 0.5 [No]
2
29 facilities and tracheal tubes 0 [NA] NA
3
technically
competent staff [Y] 0.5 [No]
vi. Oxygen supply
to take care of 0 [NA] NA
neonates of [Y] 0.5 [No]
such cases vii. Suction machine
0 [NA] NA
[Y] 0.5 [No]
viii. Baby warmer
0 [NA] NA
[Y] 0.5 [No]
ix. Incubator
0 [NA] NA
[Y] 0.5 [No]
x. Infusion pump/micro burette
0 [NA] NA
xi. Umbilical artery cannulation tray (in
[Y] 0.5 [No]
case of in house neonatology unit) or
0 [NA] NA
some alternative/referral arrangements
xii. Exchange transfusion tray (in case
[Y] 0.5 [No]
of in house neonatology unit) or some
0 [NA] NA
alternative/referral arrangements
Compliant/
Total 10 Non-
Compliant
No treatment 1. Use of identity tag is in practice for
2 should be newborn and mothers containing:
30
4 administered [Y] 3 [No] 0
unless the a. Name of the patient/baby of……
[NA] NA
 [Y] 3 [No] 0
b. MR Number input required
[NA] NA
2. The concerned staff is familiar with
identity of the the practices of confirming identity of [Y] 4 [No] 0
patient can be patient before administering the [NA] NA
guaranteed treatment
Compliant/
Total 10 Non-
Compliant
Total 20
Management of Medication
a. Definition/description of high risk
medicines/medications including the
The
Look Alike and Sound Alike (LASA) [Y] 6 [No] 0
organization
drugs for understanding of the staff is
defines and
2 available
56 enlists the
5 b. List of high risk medicines
high-risk
including the Look Alike and Sound
medicines/med
Alike (LASA) drugs readily available [Y] 4 [No] 0
ications
to the staff and displayed at all nursing
stations and pharmacy
Compliant/
Total 10 Non-
Compliant
a. Written policy for checking expiry
Expiry dates date and near expiry medication is [Y] 4 [No] 0
are checked available
2 and b. Evidence exist that the policy for
60 [Y] 3 [No] 0
6 documented checking expiry date is practiced
prior to c. No expired drug in stock, in the
dispensing ward and pharmacy/store, reagents in [Y] 3 [No] 0
labs
Compliant/
Total 10 Non-
Compliant
1. Documented SOPs for labelling are
available including the following
requirements:
a. All I/V fluids and when the
injections are mixed with the I/V fluids, [Y] 1.5 [No]
these are labelled prior to dispensing/ 0
Labelling administration
requirements b. Multiple medications for single
are [Y] 1.5 [No]
patient such as in operating room or
2 documented 0
61 emergency
7 and c. All medications given to
implemented [Y] 1 [No] 0
outpatients
by the 2. Implementation of following
organization requirements is evident in indoor
labelling and outdoor labelling or
prescription
i. Patient’s name [Y] 1 [No] 0
ii. Medicine name [Y] 1 [No] 0
iii. Dose and route [Y] 1 [No] 0
 iv. Direction for use [Y] 1 [No] 0
v. Prescriber’s name [Y] 1 [No] 0
vi. Date of dispensing [Y] 1 [No] 0
Compliant/
Total 10 Non-
Compliant
Medications a. Authorization of staff to dispense and
are administer medicines, as per PMDC,
[Y] 5 [No] 0
2 administered PNC criteria or hospital policy, is
62 available.
8 by those who
are permitted b. Patient, medication, dosage, route &
[Y] 5 [No] 0
by law to do so time is identified prior to administration
Compliant/
Total 10 Non-
Compliant
Total 40
Laboratory Services
a. Pathologist holding qualification/s
registered with PM&DC is available for
[Y] 2 [No] 0
overall supervision and physical
availability is evident
b. Issuance of reports by the Pathologist
[Y] 1 [No] 0
Adequately is evident
qualified and c. Qualified section head/s, in case of
trained labs providing special range of
2 laboratory tests like hematology, [Y] 1 [No] 0
2 personnel
9 histopathology, microbiology etc. are
perform and/or
supervise the notified
investigations d. Duty roster of laboratory staff for
service provision on 24/7 basis, is [Y] 1 [No] 0
available
e. Staff is available as per the duty
[Y] 1 [No] 0
roster
f. Qualified technicians available [Y] 4 [No] 0
Compliant/
Total 10 Non-
Compliant
Policies and procedures / SOPs,
regarding following are available in the
Policies and laboratory:
procedures a. Sample Collection/ phlebotomy [Y] 1 [No] 0
guide the: 1. b. Identification of patients and samples [Y] 1 [No] 0
Specimens c. Sample handling [Y] 1 [No] 0
Collection, 2.
3 Identification, d. Safe transportation of samples [Y] 1 [No] 0
3 e. Processing/ analysis of samples [Y] 1 [No] 0
0 3. Handling, 4.
Safe f. Disposal of specimens [Y] 1 [No] 0
transportation, 2. Evidence of orientation and training
5. Processing of staff on Lab Policies & procedures, [Y] 2 [No] 0
and 6. Disposal is available
of specimens 3. Awareness of staff about the policies
and procedures, is confirmed from lab [Y] 2 [No] 0
staff interviews
Total 10 Compliant/
 Non-
Compliant
a. Turnaround time frames, i.e. , defined
Laboratory time required for availability of reports,
[Y] 4 [No] 0
results are for Routine and Emergency tests are
3 available available in laboratory
4
1 within a b. 100% compliance with specified time
defined time frame is verifiable in Lab record for
[Y] 6 [No] 0
frame receipt of samples and reporting of test
results
Compliant/
Total 10 Non-
Compliant
1. List of defined critical values of the
[Y] 2.5 [No]
test results and notifiable diseases are
0
available
2. Protocols/SOPs are available for
immediate reporting of critical results
[Y] 2.5 [No]
of tests and notifiable diseases to the
0
concerned personnel/relevant
authorities
3. Critical results reported, is available
and includes the following details:
[Y] 0.5 [No]
a. Name of patient
Critical results 0
are reported [Y] 0.5 [No]
3 b. MR Number
5 immediately to 0
2 [Y] 0.5 [No]
the concerned c. Test result/s
personnel 0
[Y] 0.5 [No]
d. Date and time of result reporting
0
e. Date and time of informing the [Y] 0.5 [No]
concerned 0
[Y] 0.5 [No]
f. Identification of informing person
0
g. Identification of means of
[Y] 0.5 [No]
communication (verbal, written or
0
electronic)
h. Person/s to whom informed (The
[Y] 1.5 [No]
patient/responsible ward
0
staff/requesting doctor)
Compliant/
Total 10 Non-
Compliant
Total 40
Imaging Services
a. Qualified Radiologist having Post-
Adequately graduation in Radiology registered with
qualified and the PMDC is available, as the overall [Y] 2 [No] 0
trained supervisor/HOD and presence is
3 personnel evident
9
3 perform
b. Presence of a medical doctor, in
supervise and
cases where IV contrast is administered
interpret the [Y] 1 [No] 0
and radiation exposure by qualified
investigations
Technicians
 /radiographers/technologist/is ensured
in the absence of Radiologist
c. List of imaging staff for service
provision on 24/7 basis, is available in [Y] 1 [No] 0
department
d. Staff is available as per the duty
[Y] 2 [No] 0
roster.
e. All Radiographers/radiology
technicians have qualification registered
with PMF/Technologists having [Y] 4 [No] 0
recognized qualification for technical
and support services
Compliant/
Total 10 Non-
Compliant
a. Turnaround time frames, i.e. , defined
time required for availability of reports,
Imaging results
for Routine and Emergency imaging [Y] 4 [No] 0
are available
3 investigations are available in
11 within a
4 laboratory
defined time
b. 100% compliance with specified time
frame
frame is verifiable in record for [Y] 6 [No] 0
exposure time and reporting of results
Compliant/
Total 10 Non-
Compliant
1. List of defined critical findings of the [Y] 2.5
imaging test results [No] 0
2. Protocols/SOPs are available for
immediate reporting of critical findings [Y] 2.5
of the imaging test results to the [No] 0
concerned personnel
3. Critical findings reported, is
available and includes the following
details:
[Y] 0.5
a. Name of patient
[No] 0
Critical
[Y] 0.5
imaging results b. MR Number
[No] 0
3 are intimated
12 [Y] 0.5
5 immediately to c. Imaging Test result/s
[No] 0
the concerned
[Y] 0.5
personnel d. Date and time of result reporting
[No] 0
e. Date and time of informing the [Y] 0.5
concerned [No] 0
[Y] 0.5
f. Identification of informing person
[No] 0
g. Identification of means of
[Y] 0.5
communication (verbal, written or
[No] 0
electronic)
h. Person/s to whom informed (The
[Y] 2 [No]
patient/responsible ward
0
staff/requesting doctor)
Compliant/
Total 10 Non-
Compliant
 [Y] 2 [No]
a. Quality Assurance plan, is available
0
b. Standardized request form being used
[Y] 0.5
for imaging requisition to be verified
[No] 0
from the record
c. Periodic inspections, calibration and
[Y] 1 [No]
preventive maintenance of the
0
equipment, is evident
d. Radiation hazard signs on the doors [Y] 1 [No]
are displayed 0
e. Training of the staff on radiation
[Y] 0.25
protection and monitoring for radiation
[No] 0
exposure on quarterly basis , is evident
Quality f. Provision and use of radiation
[Y] 0.5
Assurance protection apron and thyroid and
[No] 0
3 activities are gonads shields (as required)
13
6 evident in the g. SOPs regarding due care for
[Y] 0.5
Imaging radiation exposure of pregnant woman
[No] 0
Department are being practiced
h. SOPs that doctor accompanies the
[Y] 0.5
patient/s for special / interventional
[No] 0
procedures, being practiced
i. Emergency trolley / resuscitation
[Y] 0.5
facilities available in the radiology
[No] 0
department
j. Disposal of radioactive waste
[Y] 0.25
according to the Waste Management
[No] 0
Rules 2014, if applicable
k. Complete and updated record of [Y] 2 [No]
repeat investigations 0
[Y] 2 [No]
l. Dosimeters are being used
0
Compliant/
Total 10 Non-
Compliant
Total 40
Periodic Preventive Maintenance of Equipment
a. Lists of equipment being maintained
in house as well as outsourced with [Y] 3 [No] 0
frequency of maintenance, is available
Qualified and
b. MOU available in case the
trained
maintenance of equipment is [Y] 3 [No] 0
3 personnel
124 outsourced
7 operate and
c. Credentials of the staff operating
maintain the
and maintaining the equipment
equipment
demonstrating that the qualification, [Y] 4 [No] 0
experience and training of the personnel
are appropriate as required
Compliant/
Total 10 Non-
Compliant
Equipment is a. Inventory for the hospital equipment
[Y] 3 [No] 0
3 periodically is available and update
125
8 inspected, b. Written schedule for Planned
[Y] 3 [No] 0
serviced and Preventive Maintenance (PPM) is
 available

c. Documentary evidence available in

respect of implementation of
calibrated to scheduled/emergent inspection, planned [Y] 4 [No] 0
ensure their preventive maintenance and calibration
proper of all equipment
function. There
is a
documented
Compliant/
Total 10 Non-
Compliant
Total 20
Fire & Non-Fire Emergencies
1. Written plan of fire and non-fire
The emergencies covering the following:
organization
has plans and a. Early detection of fire [Y] 2 [No] 0
provisions for b. Containment of fire [Y] 2 [No] 0
1. Early c. Abatement of fire [Y] 2 [No] 0
3 detection, 2. 2. The following are available in
126
9 Containment adequate number in all areas of
and 3. hospital:
abatement of a. Fire extinguishers [Y] 1 [No] 0
fire and non- b. Fire hose / water source and [Y] 1 [No] 0
fire
emergencies c. Fire Alarm/Smoke detectors [Y] 1 [No] 0
d. Fire safety certificate from 1122 [Y] 1 [No] 0
Compliant/
Total 10 Non-
Compliant
Documentary record of annual mock
drill confirm
Mock drills are a. Mock Drills have been held at least [Y] 5 [No] 0
4
128 held at least once in a year
0
once in a year b. All departments/different areas
have been subjected to mock drill in all [Y] 5 [No] 0
shifts
Compliant/
Total 10 Non-
Compliant
Total 20
Human Resource
a. A well-documented appraisal
system that evaluates administrative
A well- [Y] 3 [No] 0
factors as well as actual performance
documented
targets is available
Performance
4 b. The appraisal system also
134 Appraisal
1 incorporate the results of performance
System exists [Y] 3 [No] 0
in the monitoring by the department/unit/ward
organization in charge
c. The appraisal system also [Y] 4 [No] 0
 incorporates the requirements for staff
development to address any
performance issues
Compliant/
Total 10 Non-
Compliant
Performance
appraisal is Performance appraisals of all the
4 carried out at hospital staff, should be available in HR [Y] 10 [No]
137
2 pre-defined files, as per the above mentioned 0
intervals and is criteria
documented
Compliant/
Total 10 Non-
Compliant
Total 20
Information Management System / Medical Records
a. SOPs exist to generate and use
[Y] 4 [No] 0
unique identifier for every patient
b. Use of unique identifier for
[Y] 1.5 [No]
each patient’s medical record in
0
practice in indoor
Every medical c. Use of unique identifier for
4 record has a [Y] 1.5 [No]
144 each patient’s medical record in
3 unique 0
practice in outdoor
identifier d. Use of unique identifier for
[Y] 1.5 [No]
each patient’s medical record in
0
practice in Emergency
e. Use of unique identifier for
[Y] 1.5 [No]
each patient’s medical record in
0
practice in Diagnostics.
Compliant/
Total 10 Non-
Compliant
Every medical
All the entries in the patient medical
4 record entry is [Y] 10 [No]
146 records are dated, timed, named and
4 dated and 0
signed
timed
Compliant/
Total 10 Non-
Compliant
a. All the randomly selected 10
The record patient files have up to date medical
provides an up- record depicting an account of care [Y] 7 [No] 0
4 to-date and /treatment provided in a chorological
148
5 chronological order
account of b. System for storage of records
patient care in good order and stored for a period in [Y] 3 [No] 0
compliance with the provisions
Compliant/
Total 10 Non-
Compliant
Care providers a. All the patient record should
4
155 have access to be stored properly in in record rooms, [Y] 2 [No] 0
6
current and central or unit/ward record rooms as per
 the policy
b. Every record room should
have proper & clean racks/storage [Y] 2 [No] 0
facility
c. Every record facility should
have predefined capacity and a
mechanism to shift the record to other [Y] 1 [No] 0
dedicated room, if maximum limit has
past medical
reached
records
d. All the records/patient files
should be entered in the record of
[Y] 2 [No] 0
storage facility and should be
retrievable when needed
e. Policy/SOPs on access to
[Y] 1 [No] 0
medical record are available
f. All records asked for by the
[Y] 2 [No] 0
surveyors are provided
Compliant/
Total 10 Non-
Compliant
a. Document defining the policy
/SOPs and frequency regarding review
of the medical record on regular basis is
available [Y] 4 [No] 0
The medical
b. Documentary evidence that policy
4 records are
156 to review the medical record is
7 reviewed
implemented accordingly [Y] 2 [No] 0
periodically
c. The hospital has a medical record
review process and a schedule and
evidence that it has occurred at least on
quarterly basis [Y] 4 [No] 0
Compliant/
Total 10 Non-
Compliant
a. Documentation shows that
corrective and preventive actions were
suggested in the light of findings of the
4 medical record review [Y] 6 [No] 0
162
8 b. Evidence that corrective and
preventive measures / actions were
taken by hospital administration as per
suggestions of review report [Y] 4 [No] 0
Compliant/
Total 10 Non-
Compliant
Total 60
Complaint Management
There is a 1. Documented process / SOPs are
documented available regarding complaint
process for management system including the
4 collecting, following:
81 a. Collection / receiving of
9 prioritizing, [Y] 1 [No] 0
reporting and complaints
investigating b. Prioritization [Y] 1 [No] 0
complaints, c. Reporting [Y] 1 [No] 0
 d. Investigating [Y] 1 [No] 0
e. Resolving [Y] 1 [No] 0
f. Corrective actions [Y] 1 [No] 0
which is fair 2. Evidence exist that the SOPs are
and timely implemented, for collecting,
[Y] 4 [No] 0
prioritizing, reporting, investigating the
complaints form of complaints record
Compliant/
Total 10 Non-
Compliant
Total 10
Responsibility of Management
a. Performance audit checklist
containing objective indicators for
monitoring the progress, at hospital and
Those
department/unit/ward level (template [Y] 6 [No] 0
responsible for
for ward level performance monitoring
governance
checklist attached as Annexure B) is
5 monitor and
111 available
0 measure the
b. Performance audit checklist
performance of
reflecting corrective measures (if
the
required) with the date, name and
organization [Y] 4 [No] 0
signatures etc. of responsible person
from hospital and department/unit/ward
level, who conducted it
Compliant/
Total 10 Non-
Compliant
Total 10

Grand Total 550

Summary of Inspection

Total number of indicators :

Total number of applicable indicators :

Number of indicators Not Applicable :

Number of compliant indicators :

Number of non-compliant indicators :

Percentage of compliant indicators:

Total Score :

Scoring Percentage: