GAP REPORT DISTRICT HOSPITAL ALMORA UTTRAKHAND · SOP Standard Operating Procedure 42. CSSD Central...
84
1 | Page OCTAVO SOLUTIONS PVT LTD G-27, LOWER GROUND, KAILASH COLONY NEW DELHI - 110048 TEL: 011-41658335, Email:[email protected] GAP REPORT DISTRICT HOSPITAL ALMORA UTTRAKHAND
Transcript of GAP REPORT DISTRICT HOSPITAL ALMORA UTTRAKHAND · SOP Standard Operating Procedure 42. CSSD Central...
1 | P a g e
OCTAVO SOLUTIONS PVT LTD G-27, LOWER GROUND, KAILASH
COLONY NEW DELHI - 110048 TEL: 011-41658335,
Email:[email protected]
GAP REPORT DISTRICT
HOSPITAL ALMORA
UTTRAKHAND
2 | P a g e
Table of Contents LIST OF ABBREVIATION ....................................................................................................................................... 3
EXECUTIVE SUMMARY ........................................................................................................................................ 5
HOSPITAL SERVICES ............................................................................................................................................ 8
KEY INDICATORS ................................................................................................................................................. 9
SIGNAGE SYSTEM ............................................................................................................................................. 10
STATUTORY REQUIREMENTS ............................................................................................................................ 11
BED DISTRIBUTION: .......................................................................................................................................... 12
STRUCTURAL DETAILS ....................................................................................................................................... 13
MANPOWER REQUIREMENT............................................................................................................................. 14
EMERGENCY DEPARTMENT .................................................................................................................. 18
DEPARTMENTAL GAPS ...................................................................................................................................... 17
AMBULANCE ............................................................................................................................................ 19
OUT PATIENT DEPARTMENT ................................................................................................................. 20
RADIOLOGY AND IMAGING DEPARTMENT ........................................................................................ 20
WARDS ....................................................................................................................................................... 21
LABORATORY DEPARTMENT ................................................................................................................ 23
OPERATION THEATRE ............................................................................................................................. 24
INFECTION CONTROL ........................................................................................................................................ 29
KITCHEN .................................................................................................................................................... 30
PHARMACY ............................................................................................................................................... 31
BLOOD BANK ............................................................................................................................................ 32
ENGINEERING AND MAINTENANCE..................................................................................................... 33
EXISTING EQUIPMENT LIST ............................................................................................................................... 34
RECOMMENDATIONS ....................................................................................................................................... 34
SELF ASSESSMENT TOOLKIT .............................................................................................................................. 34
SUPPORTIVE DOCUMENT ................................................................................................................................. 34
3 | P a g e
LIST OF ABBREVIATION
1. NABH National Accreditation Board for Hospitals and
Healthcare Providers
2. UKHSDP Uttrakhand health system Development project
3. BMW Biomedical Waste
4. OT Operation theatre
5. OPD Outpatient department
6. NOC No objection certificate
7. PNDT Prenatal diagnostic techniques
8. AERB Atomic energy regulatory board
9. HCO Healthcare organization
10. KVA Kilo volt ampere
11. DG Diesel Generator
12. UPS Uninterrupted Power Supply
13. HVAC Heat Ventilation Air Conditioning
14. ICU Intensive care unit
15. NBSU New Born Stabilization Unit
16. UHID Unique Hospital Identification
17. USG Ultrasonography
18. B.P Blood pressure
19. BLS Basic life support
20. PA system Public announcement system
21. TAT Turnaround time
22. ACLS Advance Cardiac life support
23. MLC Medico legal case
24. PPE Personal protective equipment
25. HIV Human Immune Deficiency Virus
26. TLD Thermo Luminescent Dosimeter
27. PAC Pre Anesthetic Checkup
28. FRU First Referral Unit
29. ADR Adverse drug reaction
4 | P a g e
30. APGAR Appearance Pulse Grimace Activity Respiration
31. LAMA Leave against medical advice
32. ICD International codification of disease
33. MRD Medical record department
34. HIC Hospital Infection Control
35. UTI Urinary Tract Infection
36. VAP Ventilator Associated Pneumonia
37. SSI Surgical Site Infection
38. CPR Cardio pulmonary resuscitation
39. FIFO First in first out
40. GRN Goods Receipt Notes
41. SOP Standard Operating Procedure
42. CSSD Central Sterile Supply Department
43. TSSU Theatre Sterile Supply Unit
44. HR Human resource
45. PWD Public Welfare Department
46. BME Biomedical engineering
47. ECG Electrocardiography
48. ANM Auxiliary Nurse Midwifery
49. AMC Annual Maintenance Contract
50. ANC Ante natal check-ups
51. PNC Pre- natal check-ups
52. ICCU Intensive Cardiac Care Unit
53. PPE Personnel Protective Equipment
54. HAZMAT hazardous materials
55. GRN Good Reciept Not
5 | P a g e
EXECUTIVE SUMMARY
Gap Analysis is a tool to analyze the degree of compliance to any standard. Herein, this assignment the
given district hospitals are analyzed with reference to the NABH pre entry level Standard
UKHSD under the aegis of World Bank has taken a step in the right direction to assess the current level
of quality adhered by the district hospitals in delivering healthcare services to the community, in the
state of Uttarakhand.
This assignment would guide the State in understanding the existing deficiencies/gaps in healthcare
delivery services thereby enabling the policy makers to formulate a strategy to fulfill such
deficiencies/gaps and strive towards further improvement.
The Octavo Solutions Private Limited, New Delhi has put all efforts to ensure that all components with
respect to NABH Pre entry level Standards are covered and relevant deficiencies are accordingly
addressed.
To conclude, the actions to be taken for compliance with the Accreditation standards of NABH Pre
entry level at District Hospital Almora Uttrakhand are likely to impact the delivery of healthcare
services positively, ensuring quality services, efficient outcomes with economy, risk management with
patients, staff and visitors safety and above all equity in healthcare services for all the citizens. MAJOR
FINDINGS
The ‘Gap Analysis Report’ includes assessment of documentation and implementation with
respect to Structure (Manpower, equipment, infrastructure and Statutory requirements), Processes
(Clinical & Administrative) and Outcome against NABH Pre entry level Standard in Standardized and
pre tested data collection and analysis tools have been used for the onsite assessment and analysis.
This includes all departments exist in the hospitals.
The whole report is prepared as under:
1. The scope of services provided by District Hospital Alomar Uttrakhand has been reviewed and
represented accordingly.
2. Identifies the significant gaps in terms of Structure, Process and Outcome observed in all the
concerned areas.
3. The data on status of the existing Manpower, Equipment and Statutory requirements.
4. Any other data or information as deemed necessary.
6 | P a g e
The Key Findings identified are as follows:
1. All the Sanctioned posts are not filled up. Required posts like Dietician, Medical Records Technician,
quality manager, CSSD technician, OT technician, are not included in the sanctioned posts.
2. The hospital does not comply with the necessary statutory & regularity requirements. All other relevant
statutory requirement like biomedical waste handling rules (under renewal), Type and site approval by
AERB, building occupancy certificate, approved fire exit plan etc need to be acquired.
3. The Hospital provides Dietary services but the kitchen is not functioning in appropriate manner. The
kitchen does not have demarcated area such as receiving, washing, chopping /cutting, cooking, storing etc.
There is no dietician posted in the hospital. Staff working in this department does not undergo any
regular health check up, etc. the area outside the kitchen is unclean, and the door of kitchen was
broken.
4. There is sufficient number of toilets for patient and visitors but the Toilets and bathrooms were
found unclean. There is no provision of dedicated toilets for the differently able people.
5. There is no dedicated, functioning CSSD in the hospital. The instruments are being washed.
Autoclave is available in OT complex which takes care of the sterilization activities for OT. There
is no dedicated person to perform sterilization activities, ward boy currently performs it.
6. The hospital does not have ICU facility for keeping trauma and post operative patient. The
monitoring of post operative cases is not evident.
7. The Emergency of the Hospital was found reasonably busy throughout the day but there were no
arrangements for dealing with common type of emergencies. The department has only beds. The
necessary equipments for performing the examination, crash cart, dressing trolley.
8. Inventory control management is not done in the stores (Medical and General). There is no Drug &
Therapeutic Committee in the Hospital. Temperature monitoring not evident in any of the
refrigerators inspected during the visit such as Medicine Store, Operation Theatres etc. Staff not
aware on addressing Adverse Drug Reactions. “Look alike and Sound alike” drugs are not stored
separately.
9. The hospital has 3 operation theatres. There was lack of necessary anaesthesia and surgery
equipment (multi Para-monitor, anaesthesia work station, CPR kit etc.) for carrying out surgery.
7 | P a g e
The infection control practices were not evident e.g. changing of clothes before entering in OT, no
arrangements of PPE, restricted entry to the zones, the washing area for clothes is in sterile zone.
10. The laundry and linen practices are not being followed; the infected and soiled linens are mixed
and washed collectively. No sluicing is not being performed. There is no protocol for washing of
HIV Infected linen. There is no trolley for carrying linen. The department does not have proper
layout like receiving, segregation area, sluicing, washing, drying, calendaring etc.hte department
has only a semi automated washing machine.
11. Fire extinguishers (ABC type) have been installed in all the areas of the hospital however there is
no approved fire exit plan and provision of other fire detecting devices such as smoke detectors,
fire alarm etc.
12. Dedicated department for equipment management not evident. Purchase dept. currently addresses
the issues relating to medical equipment maintenance. All major equipments are not covered under
AMC/CMC and calibration is not done for any of the equipments.
13. There is lack of Necessary life saving equipments in hospital like Ventilator, defibrillator and crash
cart were not available in the OT and emergency.
14. There is no department for keeping Medical Records. The records are stored in boxes with scrap
material. The Coding, Indexing, and Filing of records were not evident. The medical records are
not stored securely and away from rodents. There is not designated person i.e. medical record
technician for taking care of medical records. The records does not have all relevant forms &
formats like Nurses Records, Medication chart, Intake /Output chart, TPR chart, etc.
8 | P a g e
HOSPITAL SERVICES
SCOPE OF SERVICES
Sl.
No.
Name of Services/ Department Availability
(Yes/No/NA)
Remarks
GROUP A – CLINICAL SERVICES
01 General Medicine Yes
02 Obstetrics and Gynaecology No
03 Paediatrics and Neonatology Yes
04 Orthopaedics Yes
05 Ophthalmology Yes
06 Anaesthesiology Yes
07 General Surgery Yes
08 Dentistry Yes
09 ENT Yes
10 Dermatology No
GROUP B: CLINICAL SUPPORT SERVICES
11 Laboratory Yes
12 Radiology & Imaging Yes
13 Blood Bank Yes
14 Dialysis No
15 Physiotherapy Yes
GROUP C: SUPPORT SERVICES
16 Pharmacy Yes
17 General Store Yes
18 Kitchen & Dietary Yes
19 Laundry Yes
20 CSSD/TSSU Yes
21 Medical Records Yes
22 Ambulance & Transport Yes
23 Security Services Yes
24 Housekeeping Services Yes
25 Biomedical engineering No
26 Maintenance No
27 Mortuary services Yes
GROUP D: ADMINISTRATIVE SERVICES
28 General Administration Yes
29 Account & Finance Yes
9 | P a g e
KEY INDICATORS
INDICATORS November-
2018
October-
2018
September-
2018
August-
2018
July-
2018
June-
2018
IP Admissions 81 140 196 166 223 174
OPD 7002 7822 9879 10007 10309 10585
SURGERIES(Minor) 08 03 03 13 23 18
SURGERIES(Major) 12 66 0 07 14 17
X-RAYS 434 366 571 622 734 676
USG 675 820 924 873 859 751
LAB 2,466 3,735 4738 5072 5,552 5226
BIRTH NA NA NA NA NA NA
DEATH 02 04 02 01 03 0
10 | P a g e
SIGNAGE SYSTEM
Signage's Displayed
(Yes / No /
NA)
Bilingual
(Yes / No /
NA)
Pictorial
(Yes / No /
NA)
Remarks
(if any)
Citizen Charter Yes No No No
Mission No No No No
Vision No No No No
Patients Rights & Responsibilities No No No No
Scope of Services No No No No
Tariff List Yes No No No
Doctors list along with their Specialties and
Qualifications
No No No No
OPD Schedule of Doctors (Specialty, Timings and
Day of Availability)
No No No No
Biohazard Symbols Yes No No No
Fire Exit Plan No No No No
Floor Directory No No No No
Wash Rooms (Differently Able) No No No No
Toilets Yes No No No
Ambulance Parking Area Yes No No No
Drinking Water Yes No No No
Although the hospital has quite good signage system , IEC activity are properly implemented but the some
signage’s need to be placed according to NABH requirement and all signage’s need to be bilingual, pictorial
and permanent in nature.
The signage need to be displayed are Vision and mission of hospital, scope of service, patient rights and
responsibility in all patient areas, floor directory, list of doctors, fire exit plan etc.
11 | P a g e
STATUTORY REQUIREMENTS
SNO LICENSES
AVAILABLE
YES/NO
1 Building Occupancy/Completion Certificate No
2 Approved fire exit plan No
3 License under Bio- medical Management and handling Rules, 1998. No
5 Vehicle registration certificates for Ambulances. Yes
7 PNDT Certificate Yes
8 Site & Type Approval for X-Ray from AERB Applied
9 License for Blood Bank Yes
A = Applicable NA = Not Applicable
Note: The hospital does not comply with the necessary statutory & regularity requirements (except
PNDT, vehicle registration, blood bank). All other relevant statutory requirement like biomedical waste
handling rules (under renewal), building occupancy certificate, approved fire exit plan etc. need to be
acquired.
12 | P a g e
BED DISTRIBUTION:
Class/Department Functional Beds
EYE/ENT 6
MEDICAL WARD 6
SURGICAL WARD 6
ORTHO WARD 6
ISOLATION WARD 6
FEMALE WARD 6
PAEDIATRIC WARD 6
EMERGENCY WARD 5
NRC( NUTRITION REBH WARD ) 6
PRIVATE WARD 6
TOTAL 59
Functional beds: 59 beds
NRC – 6 beds(6 non-functional )
Sanctioned Beds: 60beds
13 | P a g e
STRUCTURAL DETAILS
Category
A. Land 16000 sq feet
B. Building 11000 sq feet
C. HVAC Availability of HVAC system No
Quantity
(No)
Capacity
D. Electricity
Transformer 1 250 KVA
DG set 1 125 KVA
UPS (Invertors) 3 8.5 KVA
Total Load Sanctioned 100 KVA
E. Water Water Tanks (Overhead) 1 20000 liters
Water Tanks (underground) 1
5
10
5000 liters
2000 liters
500 liters
Sources of water Main Source – Jal Sansthan" water
supply
Alternative Source- BORE WELL
14 | P a g e
MANPOWER REQUIREMENT
Sl.
No
Designations Sanctioned Actual Vacant
DOCTORS
1 Chief Medical Superintendent 1 1 0
2 Medical Specialist (General Medicine) 2 2 0
3 General Surgery Specialists 05 03 02
4 Obstetrics & Gynaecology specialist NA NA NA
5 Dermatologist /Venereologist) 1 0 1
6 Paediatrician 1 1 0
7 Anaesthesiologist 1 1 0
8 ENT Surgeon 1 1 1
9 Ophthalmologist 1 1 0
10 Orthopedician 1 1 0
11 Radiologist 1 1 0
12 Pathologist & Blood Bank In-charge 02 02
13 Medical Officer 08 07 1
14 Dental Surgeon 1 1 0
15 AYUSH 1 1 0
SUB TOTAL 27 22 5
NURSING STAFF
1 Matron/Nursing Superintendent 1 1 0
2 Nursing In-charge 5 6 --
3 Staff Nurse 12 10 2
4 Nursing Orderly 01 01 0
SUB TOTAL 19 18 1
PARAMEDICAL STAFF
1 Dental Mechanic 1 1 0
2 OT Technician 1 1 0
3 OT assistant 1 00 1
4 Lab Supervisor 1 1 0
5 Laboratory Technician (Lab
+BB)
5 4 1
6 Laboratory Attendant (Hospital Worker)
1 0 1
15 | P a g e
7 Radiographer 1 1 1
8 Dark Room Assistant 1 00 1
9 ECG Technician 1 1 0
10 Optometrist NA NA NA
11 Physiotherapist 1 1 0
12 CSSD Technician 1 0 1
13 Ophthalmic Assistant 2 2 0
SUB TOTAL 17 11 6
PHARMACIST
1 Pharmacist 7 5 2
SUB TOTAL 7 5 2
KITCHEN
1 Dietician 1 0 1
2 Cook 1 1 0
3 Cook Assistant 1 1 0
4 Cook Bearer 1 0 1
SUB TOTAL 4 2 2
ADMINISTRATIVE
1 Bio Medical Engineer 1 0 1
2 Engineer 1 0 1
3 Office Superintendent 3 3 0
4 Accountant/Asst. accountant 2 2 0
5 Office Clerk 3 1 2
6 Registration Clerk 2 1 1
7 Store keeper 1 1 0
8 Medical Records Clerk 1 0 1
9 Mortuary Attendant 1 0 1
10 Electrician 1 0 1
11 Plumber 1 0 1
12 Sr. Assistants 18 15 3
SUB TOTAL 35 23 12
CLASS 4
1 Mali 2 1 1
2 Choukidar 3 3 0
3 Dhobi 1 0 1
16 | P a g e
4 Tailor 1 0 1
5 Housekeeping Supervisor 1 1 0
6 Class IV 8 9 0
7 Driver 1 2 0
8 Security 8 8 0
SUB TOTAL 25 24 3
TOTAL 127 100 17
17 | P a g e
DEPARTMENTAL GAPS
18 | P a g e
EMERGENCY DEPARTMENT
IDENTIFIED GAPS
ST
RU
CT
UR
AL
No triage area present in OT Department
Departments do not have layout and demarcated areas as per functions viz trolley bay area, receiving
and triage area.
No demarcated area for resuscitation
Non availability of essential life saving equipment’s in Emergency .i.e. Crush cart, defibrillators, Bp
apparatus, ECG machine etc.
No. of Trolleys and wheelchairs is not commensurate to the needs.
Trolleys and wheelchairs is not having patient safety belt
No appropriate qualified staff member is scheduled to manage triage activities.
Staffs are not trained in BLS/ACLS.
Emergency department not have separate entrance
PR
OC
ES
S
Policy and procedure for the Emergency Service is not available.
Crash cart are not checked daily regarding regular testing.
Initial assessment of the patient not done in proper format.
Disaster management plan not prepared by the HCO.
There is no system to review all imaging by a radiologist within 24 hours
Not ability to perform acute blood test and receive results within one hour for Arterial blood gases,
Full blood picture, urea and electrolytes, plasma, glucose, Blood levels for common overdose
medication/agents, Coagulation studies.
Electrical equipment (e.g. defibrillator) is not present
Is BMW is not segregated and handled properly.
Are the separate registers maintained for medico legal cases, discharge, admissions to ward?
OU
TC
OM
E
No Monitoring of Time for initial assessment of Emergency patient.
19 | P a g e
AMBULANCE
The Ambulance service is available in the hospital however the ambulances are not fully equipped. There are two
Ambulances in the Hospital.
AMBULANCE REQUIREMENTS:
The basic life support vehicle should have two compartments: driver’s cabin & patient’s cabin.
DRIVERS CABIN
Communication System ( Wireless / Mobile Phones)
NOT AVAILBLE
Siren & Light Switch NOT AVAILBLE
PA system NOT AVAILBLE
PATIENTS CABIN
Room height of at least 6 1/2 feet NOT AVAILBLE
Two stretchers with one Trolley NOT AVAILBLE
Railing for Iv suspension NOT AVAILBLE
Oxygen cylinder NOT AVAILBLE
Suction machine ( foot operator) NOT AVAILBLE
ET tube NOT AVAILBLE
Ambu Bag NOT AVAILBLE
Laryngoscope NOT AVAILBLE
Suction catherters NOT AVAILBLE
Foley’s catheter NOT AVAILBLE
EMERGENCY DRUGS
Atropine, Adrenaline NOT AVAILBLE
Sodabicarbonate, Digoxin NOT AVAILBLE
Decadron NOT AVAILBLE
Dopamine, 25% Dextrose NOT AVAILBLE
IV fluids NOT AVAILBLE
IDENTIFIED GAPS
S
T
R
U
C
T
U
R
E
The ambulance does not have a proper communication system connected with the
organization’s control room by wireless/ mobile phones.
Required medication is not present in ambulance
Calibration of equipment is not present
The ambulance was not equipped with Basic Life Support,
P
R
O
C
E
S
S
The functioning status of the ambulance like lights, siren, beacon lights was not checked
regularly and there was no servicing record for the ambulance.
The equipments and emergency medications was not present
Infection control practice was not followed in the ambulance like hand rubbing and liquid soap
was not present.
The staffs were not trained in Basic Life Support
O
U
T
C
O
Monitoring of Turnaround Time (TAT) for Ambulance service is not done.
20 | P a g e
M
E
OUT PATIENT DEPARTMENT
IDENTIFIED GAPS
ST
RU
CT
UR
AL
Availability of complaint box and display of process for grievance redressal and whom to contact is
not displayed.
The vision mission, citizen charter is not displayed at OPD.
Scope of service is not displaced
No separate queue for differently able.
No calibration of BP apparatus, weighing machine and thermometer
PR
OC
ES
S
Written Policy and Procedure for OPD Service is not available
UHID is not generated in proper manner (each time new UHID no is generated )
Procedure to admission or refer of Patient from OP Chamber is not available
Content of the initial assessment of the Patient is not defined and hence not followed.
OU
TC
OM
E Recording Waiting time for patients in OPD is not done.
RADIOLOGY AND IMAGING DEPARTMENT Identified Gaps:
GAPS
Radiology department is not having AERB (SITE/TYPE approval) licence
Changing room for patient is not available in proper condition
TLD badges is not available for any staff
Radiation safety devices like Lead glass, Lead apron, gonad shield, thyroid shield is not available in radiology department
Radiation hazard symbols were not displayed
S
T
R
U
C
T
U
R
E
21 | P a g e
The staffs of the department are not wearing the TLD batches.
The radiation safety devices are not in a good condition and sufficient in numbers there is no evidence of quality assurance test of lead aprons.
The calibration record of radiology equipment is not available.
The staffs are not aware about radiation safety precautions.
The quality assurance program is not documented and implemented.
The critical test results are not defined, reported and documented.
Radiology reports are not signed by radiologist
No define time frame for dispatching reports
turnaround time is not monitored
P
R
O
C
E
S
S
The outcome of the department like –
No of reporting errors per 1000 investigation
% of reports having clinical correlation with provisional diagnosis
% of adherence to safety precaution.
% of redos is not being monitored
O
U
T
C
O
M
E
WARDS Identified Gaps
S
T
R
U
C
T
U
R
E
Only one nursing station between all wards
Nurse patient ration is not maintained
Hand washing area is not equipped with liquid soap and paper towel.
There is lack of fire-fighting equipment and accessibility to the equipment is also difficult.
Crash cart placed at a location from where it could be immediately accessed when
required.
Patient’s washroom is not having safety arrangements (anti-skid mats, emergency call
button, grab bars, disable friendliness, door opening outside, latch type locking which can
be opened from outside).
There is inadequate privacy arrangement for patient. There is lack of sufficient no of
screens.
There is lack of availability of all necessary patient care equipment. E.g. proper oxygen,
suction facility, crush cart, defibrillators etc.
There is lack of Separate or segregated storage area for clean and dirty supplies.
Nurses were not trained in Basic life support.
Look alike, sound alike medicines is not identified and stored separately.
High risk medicines is not identified and stored separately.
22 | P a g e
P
R
O
C
E
S
S
Multi-use open vials do not have labels of date of opening and date of expiry.
There is no protocol for storage of narcotics. It is not stored under lock and key.
Proper identification of patient before carrying out any patient care activity is not being
done.
Reporting of adverse patient events is not being followed.
List of hazardous materials in the ward is not identified and MSDS sheet for them is not
available.
Fridge has no checklist and food items were present inside the fridge.
A nurse initial assessment was not being carried out. Nurse’s medication chart is not
signed.
The time frame for initial assessment of the patient is not defined and the assessment
conducted by the doctors is not counter signed by in charge clinician.
Emergency medicines are not checked regularly.
There was no policy for taking verbal order and vulnerable patient care.
The blood transfusion consent is present. The transfusion record is not available and the
reporting of transfusion reaction is not being done.
Patient and family members are not being educated about the plan of care, prognosis,
length of stay etc.
The screening of nutritional assessment is not being carried out. There is no qualified
professional for conducting the nutritional assessment.
There was no feedback form available for conducting IPD patient’s satisfaction survey.
Patients are not regular reassessment by treating physician. The reassessment is not
documented.
The known drug allergy is not ascertained before prescribing the drug.
The content of discharge summary is not appropriate. It does not include all contents
needed
No of equipments is not adequate in wards like sphygmomanometers, thermometers,
weighing scale.
The prepared drug is not labelled if loaded but not administered at same time.
Medications errors, near miss events are not identified and recorded.
The quality indicators are being monitored but not analysed on regular basis. These are-
Percentage of Patients receiving high risk medications developing adverse drug event.
23 | P a g e
O
U
T
C
O
M
E
Percentage of admissions with adverse drug reactions (s) (Adverse drug reactions per 100
separations)
Incidence of medication errors (Medication errors per patient days
Appropriate handovers during shift change (To be done separately for doctors and nurses)-
(per patient per shift).
Incidence of hospital associated pressure ulcers after admission (Bed sore per 1000 patient
days)
Incidence of falls
Catheter associated Urinary tract infection rate
Ventilator associated Pneumonia rate
Incidence of needle stick injuries
Incidence of blood body fluid exposures
Incidence of missing medical records
Percentage of non-compliance observed related to infection control practices
Patient satisfaction rate of the ward (Checkout a sample form)
Time taken for discharge.
LABORATORY DEPARTMENT
Identified Gap
P
R
O
C
E
S
S
the scope of services is not defined
maintenance of laboratory equipments is not done
laboratory equipments are not calibrated
laboratory staff is not aware about the safety precautions while handling samples
Critical results are not defined, reported, and documented.
No surveillance for lab test being carried out
EQAS is not being monitored
labelling of sample is not done
time frame defined for dispatching lab reports is not defined
turnaround time for lab reports is not monitored
No MOU available for outsourced tests
temperature monitoring of refrigerator is not done
O
U
T
C
O
M
Number of reporting errors per 1000 investigations
% of reports having clinical correlation with provisional diagnosis
% of adherence to safety precautions
% of redo's
24 | P a g e
E
OPERATION THEATRE
Identified Gaps
S
T
R
U
C
T
U
R
E
OT structure is not as per the defined layout. The zoning in the OT is not present. There is no
separation between the zones. The entry was not regulated to clean zone and beyond..
HVAC System is not present in OT
OT light is not in working condition.
Phenol is using for washing
Doctor and nurses changing room is not present.
The roof of the OT was not adequate breakage was in some places. No anti-static flooring, walls
and is porous, not smooth, seamless without corners (coving) and not easily cleanable. E.g. the
plaster of the walls of the OT was clipping off.
The door of the OT is not automated, hermetically sealed.
The scrub area was not clean; There was no liquid soap for hand-washing.
There was mixing of sterile and unsterile items. There is no separate space for string the sterile
and unsterile items.
Accessibility of fire-fighting equipment, in all areas of OT is not adequate.
There was not sufficient PPE for the OT, dresses & gowns .
There was no security guard present at the entrance of the OT.
The preoperative area is not properly equipped. There is no monitor in the preoperative area.
The temperature, humidity and pressure of the OT is not as per the requirement. i.e. positive
pressure, 55% humidity, 21 0c.
All staff to be trained in BCLS.
The manpower is not sufficient in the OT
P
R
O
C
E
S
S
The equipment in OT is not calibrated and does not have the label of calibration date and status.
Infection control practices is not being followed
Number of instrument is not counted before and after surgery.
The WHO surgical safety checklist is not being followed for each patient.
Immediate pre-operative check-up before wheeling in patient in operation room from pre-
operative ward was not performed.
The anesthesia consent is not present in a definite format (hand written consent are being taken
from patient).
25 | P a g e
Patient undergoing surgery is not being screened for HIV. There was no evidence of HIV consent
and HIV test of patient undergoing surgery.
The plan of care is not documented. The desired result of treatment is not documented.
No defined criteria are being used to decide shifting of patient from post-operative ward. The
post operative monitoring is not being carried out.
Look alike, sound alike medicines are not stored separately.
Multi-use open vials do not have a label of date of opening and expiry.
High risk medicines are not stored separately.
Monitoring of patient during surgical procedure (at minimum heart rate, cardiac rhythm,
respiratory rate, blood pressure, and oxygen saturation and level sedation) is not being
documented.
Documentation of type of anesthesia and anaesthetic medication in patient’s medical record is not
being done.
All staff is not aware on OT specific infection control practices (scrubbing, sterility maintenance,
use of PPE etc.)
Each operation room is not monitored for humidity and temperature on daily basis.
Each operation room is not monitored for filter integrity, at-least once in six month.
All areas of OT are not kept clean from dust all the time. Proper terminal cleaning and dusting
was not done.
O
U
T
C
O
M
E
The quality indicators like are being captured but not analysed on regular basis.
% modification of anaesthesia plan
% of unplanned ventilation following anaesthesia.
% of adverse anaesthesia events
% of rescheduling of surgeries
% of adverse events like wrong patient, wrong site, wrong surgery.
OT utilization rate
% of cases received antibiotic prophylaxis within defined time frame is not being monitored.
26 | P a g e
AUTOCLAVE ROOM There is no proper department in hospital as CSSD. The hospital has only a autoclave in which all sterilization
related activities has been carried out.
Identified Gaps
S
T
R
U
C
T
U
R
E
The CSSD is not located in a delineated area where there is less or no external traffic
movement. The department is situated in OT department
The sterile items are not transported in closed trolley.
Entry to CSSD is not restricted to only staff working in CSSD.
The CSSD layout do not have well demarcated zones, which includes
The zones do not lead to unidirectional movement of people and supplies.
No proper storage for equipment.
There is no bacteriological/chemical surveillance test being performed for sterilization
authenticity & validation.
Entry to sterile zone is not taking necessary infection control precautions such as hand
washing, wearing of gowns/aprons, gloves etc. e.g. The staff is not using any PPE and
not changing their shoes while entering to the CSSD room.
The sterilization zone (especially storage) is not having a higher air pressure to prevent
outside air to enter in this area.
Emergency exit route is not identified and displayed.
The handling the department is not qualified for handling the department.
No CSSD technician available for CSSD ward boy is performing all sterilization process
No recall system of items is followed.
Cidex is used for sterilization
SOP is not documented for each activity done in CSSD. These activities include-
Procedure of cleaning
Procedure of packing
Procedure of disinfection
Procedure of sterilization (separate SOP for each type of sterilization equipment)
Procedure of storage and issue
27 | P a g e
P
R
O
C
E
S
S
Safety precautions and guidelines
A policy is not there on reusable devices/items which specifies following
List of items that can be re-used (items not in list should automatically be
considered, non-reusable)
Number of times it can be re-used
On whom can it be re-used (like on same patient or on different patient)
Processing required before reuse of the items
Sterilization equipment is not calibrated at a regular interval. A preventive maintenance
checklist is not available for each equipment.
Labelling of drum in CSSD is not done
Each sterilization equipment is not having an identification number, which should be
displayed on the equipment
Each pack that is being sterilized is not labelled with following information
Date of sterilization
Date of expiry
Equipment number in which it was sterilized
Load number in which it was loaded for sterilization
Record of each load sterilized in CSSD is not maintained. The record which contains
date, load number, description of contents that were included, Temperature, pressure
and time-record chart is not available.
Validation tests are not done in CSSD. The validation tests which include
Physical/Chemical test – should be done for each load
Biological spore test – at-least weekly basis for each equipment
The CSSD is not maintaining record of all validation test reports
There is no procedure of recalling items in case of sterilization breakdown.
List of hazardous chemicals in CSSD is not available.
MSDS of each hazardous chemical is not available.
O
U
T
C
O
Quality Indicators for CSSD is not being monitored. These are-
% of HAI happening due to instrument/devices used on patients
Number of times of sterilization failure
28 | P a g e
M
E % re-sterilization required due to improper storage
% of non-compliance to sterilization practices
29 | P a g e
INFECTION CONTROL
GAPS
1. There is no documented infection prevention and control programme.
2. There is an infection control committee but the chairman of the committee is not a microbiologist.
3. The organization does not adhere to standard precautions at all times.
4. There is no cleaning protocol for equipment.
5. There was no antibiotic policy established.
6. There was no appropriate engineering control to prevent infections which includes design of patient care
areas (optimum spacing between beds), operating rooms, air quality and water supply.
7. There was no evidence of proper air conditioning as per the required guidelines and cleaning of AC, ducts
/filters.
8. The infection control surveillance data is not being collected.
9. The organization does not have appropriate hand hygiene facilities across the patient care areas viz no elbow
operated taps, soap solution
10. The CSSD has only has only 1 auto clave machine.
11. Brooming and dry dusting is evident which is not acceptable.
12. The disinfectant which is being used in the hospital is not undergone any sterility test. Phenyl is being used
as disinfectant.
13. The sterilized and disinfectant equipment sets were not stored in appropriate manner across the organization
including CSSD.
14. Regular validation tests for sterilization like physical and chemical test , daily, weekly biological tests, steam
processing, and ETO processing is not being followed.
15. There was no established recall procedure for breakdown identified in the sterilization system.
16. The organization does not conduct infection control training of all staff.
17. Antibiotic audit is not carried out to ensure adherence to antibiotic policy.
18. Equipment cleaning & sterilization practices need to be strengthened.
19. The biomedical waste bins is not foot operate and there is no labelling of biohazard symbol in BMW
buckets.
The outcome is not being monitored-
Catheter associated urinary tract infection rate
Ventilator associated pneumonia rate
Central line associated blood stream infection rate
Surgical site infection rate
Percentage of staff provided pre- exposure prophylaxis
Incidence of blood body fluid exposures
Compliance to hand hygiene practice
Percentage of adherence to safety precautions by Employees working in diagnostics.
30 | P a g e
KITCHEN Identified Gaps
GAPS
Kitchen layout was not defined as receiving, storage, preparation, distribution, and cleaning
area.
No dedicated food storage area present in kitchen
No fire fighting equipment were installed in department
No qualified dietician is available for supervising the functioning of the department.
The plaster of the walls of kitchen is chipping off.
S
T
R
U
C
T
U
R
E
Patient & family members are not educated regarding the limitations of diet.
Patient and family members are not educated on food & drug interactions.
Food evaluation is not done before serving to patient.
Nutritional assessment is not being done.
No cleaning schedule for the kitchen available.
There is no documented policy for storage, preparation, distribution & disinfection
processes.
Infection control practice is not been followed
Patient case sheet are not checked by doctor and dietician
P
R
O
C
E
S
S
No monitoring of indicators like no of complains received food wastage etc. O
U
T
C
O
M
E
31 | P a g e
HOUSE KEEPING DEPARTMENT:
GAPS
G
A
P
S
There is manpower gap in housekeeping staff.
Hazardous materials are not identified.
Master cleaning schedule is not available.
The dilution factor of disinfectants is not known to housekeeping staff.
No documented SOPs for housekeeping service.
Staffs are not trained on handling of hazardous materials & spill management.
Efficacy test for disinfectant is not done periodically.
PHARMACY Identified Gap
S
T
R
U
C
T
U
R
E
Room and area used for medicine storage is not clean, cluttered.
Medicines are stored on floor.
All items storage area are not marked and labelled
Medicine are not stored in proper temperature (2-8 degree c)
Appropriate security arrangement (like CCTV, restricted entry) is in place to prevent
pilferage of medicines.
Fire safety arrangements are not appropriate in pharmacy and store (such as fire
extinguisher within inspection date, emergency evacuation route.
Medicines are not stored in a condition as described by manufacturer (temperature,
humidity, sunlight etc.)
Refrigerator used for storing medicine do not have a temperature monitoring system. The
temperature of the refrigerator is not recorded at-least 3 times a day.
Staff is not aware on what to do if temperature of refrigerator is not within the defined
limit. (Time limit within which medicines to be shifted to another refrigerator)
Inside refrigerator, location of storing various medicines is not specified. (for eg.
Vaccines should be stored in the location most appropriate temperature is maintained).
Look alike and sound alike (LASA) medicines are not identified and a list is available.
Pairs of LASA medicines are not stored separately, or are colour coded to avoid any
confusion. (including inside refrigerator)
High risk medicines are not identified and a list is available
32 | P a g e
High risk medicines are not stored in a protected place to avoid wrongly dispensing it to
patient.
Medicine being sold does not have a label clearly mentioning its name, dose and expiry
date. This is specifically required if pharmacy sells loose medicines, cut strip medicines,
or prepared formulations of certain medicines.
Pharmacists are not aware on what to do if prescription is not clear or legible (policy of
confirmation of medicine from the prescribing doctor)
Pharmacists are not aware on policy on verbal order of prescription medicine
Staffs at pharmacy are not aware of situation when medicine recall is warranted and the
procedure of recall.
P
R
O
C
E
S
S
Records of purchase and Goods Receipt Notes are not available.
Pest control measure are not under taken
There is no proper drug and therapeutic committee in hospital
O
U
T
C
O
M
E
Percentage of wastage of drugs (in terms of financial loss)
Percentage of medicine expiring in a period
Percentage of stock out of drugs
Percentage of medicines procured through local purchase
Percentage of drugs rejected before preparation of goods receipt number
Percentage of variation from standard procurement process
BLOOD BANK
GAPS
There is no full time qualified blood bank in charge manager available for collection
/distribution
No policy and procedure for blood bank.
No blood transfusion committee exist.
No facility for blood component segregation only whole blood is been provide
Data collection regarding recipient adverse reaction is collated , analysed and reported
is done only for positive cases
Working instruction are not visible in blood bank
% of blood and blood product wastage is not monitored
G
A
P
S
33 | P a g e
% of component usage is not monitored
ENGINEERING AND MAINTENANCE GAPS
G
A
P
S
Various statutory requirements such as (Fire, Diesel storage, Water (ETP/STP),) is
not available
No Designated individual for maintenance is present
staff round the clock for emergency for repairs is not conducted.
No preventive and break down plan is available
response time and breakdown hours is not monitored
Facility inspection rounds twice a year in patient care areas and once in non-patient
care areas is not been conducted
Safety education program for all staff is not been followed
Documentation of facility inspection report is not available.
Safety committee is not present.
staff training is not done for disaster management and fire management
The mock drills are not conducted at periodic intervals and documented
34 | P a g e
EXISTING EQUIPMENT LIST
AREA EQUIPMENTS QUANITY
(NOS)
FUNCTIONAL
(YES / NO)
REMARKS
Radiology Ultrasound 1 Yes
Mammography System 0
X-Ray (Fixed) 2 Yes
X-Ray (Mobile) 1 Yes
Multi-slice CT Scanner 0
Defibrillator 0
X-Ray Developing Tank 1 Yes
Safe Light X-Ray Dark Room 1 Yes
Cassettes X-Ray 10 Yes
Lead Apron 5 Yes
Gonad Shield 0
Thyroid Shield 0
TLD badges 0
Ear, Nose,
Throat (ENT)
Head Light Ordinary 1 Yes
ENT Operation Set Including Lead
Light Trasits 1 Yes
Head Light (Cold Light ) 1 Yes
Tracheostomy Set 1 Yes
Tuning Tank 1 Yes
Yes
EYE Ophthalmoscope Direct 1 Yes
Slit Lamp 1 Yes
Vision Drum 1 Yes
IOL Open Set 2 Yes
Ophthalmic Surgical Instrument 10 Yes
Eye Microscopy 1 Yes
Dental Air Rotors 1 Yes
Dental Unit Motor 1 Yes
Dental Chair 1 Yes
Dental X_ray 1 Yes
Laboratory ELISA Reader Cum Washer 2 1 functional
Blood gas Analyser 0
Electrolyte Analyser 0
Haematology Analyser 22 Parameter 1 Yes
Laboratory Autoclave 1 Yes
Micro Pippetes of Different Volume 4 Yes
35 | P a g e
Hot Air Oven 2 Yes
Lab Incubator 2 Yes
Distilled Water Plant 0 Yes
Electric Centrifugal Top 3 Yes
Counting Chamber 1 Yes
Glucometer 0
Haemoglobino meter 2 Yes
TC DC Count Apparatus 1 Yes
ESR Stand Tubes 2 Yes
Test Tubes Stand 1 Yes
Test Tubes Rack 1 Yes
Spirit Lamp 0
Alarm Clock 0
ELISA Reader Cum Washer 1 Yes
Blood gas Analyser 1 Yes
Electrolyte Analyser 0
Haematology Analyser 22 Parameter 0
Laboratory Autoclave 0
Operation Theatre
Operation Table Hydraulic 2 Yes
Operation Table Non Hydraulic Field
type 0
Shadow less Lamp Ceiling Type 2
Suction Apparatus 2 Yes
Apparatus trolley 1 Yes
C arm 1 Yes
Pulse oxymeter 1 Yes
Ventilator 1 Yes
Cystoscope 0
Diagnostic Laparoscope 0
Gastro scope 0
Hysteroscope 0
Auto mist 0
Video calposcopy 0
Cautery 2 Yes
Defibrillator 0
Boyel’s Apparatus 1
Multipara Monitor 2 Yes
36 | P a g e
Diathermy 0
Crashcart 0
CSSD
Incubator (for test vials) 0
Ultrasonic cleaner / washer unit 0
ETO sterilizer 0
Dry heat sterilizer – hot air Owen 0
Ultrasonic cleaner – single tank 0
Auto.steam sterilizer 0
Automated steam sterilizer (mf) 1 Yes
Rotary sealing machine 1 Yes
Physiotherapy
ECB pulse controlled ergo meter 0
body wave therapy unit 0
CPM machine 0
Trans-cutaneous electrical nerve
stimulator 1 Yes
Mobile ultrasound therapy unit 1 Yes
Standard tilt table for physiotherapy 0
Microcontroller stimulator 0
Short wave diathermy unit 2 Yes
Electrical stimulator 0
Blood Bank
Plasma expressor 2 Yes
Refrigerated centrifuge 0
plasma freezer 0
Laminar air flow – clean zone unit 0
Hot Air Oven 2 1 functional
Platelet agitator incubator
Blood bank refrigerator 3 1 functional
Water bath shaker (thawing bath) 1 Yes
Hi-speed cold centrifuge 0
Blood warming / thawing bath 0
binocular microscope 3 Yes
Microprocessor based centrifuge 0
Automated immunoassay analyser 0
Micro typing system (blood grouping
etc) 0
Plasma snap freezer 0
HB analyser 2 Yes
37 | P a g e
Flash steam sterilizer 1 Yes
Blood bag tube sealer 3 Yes
Blood collection monitor 4 Yes
Plasma thawing bath 0
OPD Stethoscope 8 Yes
Sphygmomanometer 8 Yes
X-ray View box 8 Yes
Thermometer 8 Yes
Weighing Machine (Adult) 7 Yes
Weighing Machine (Paed) 1 Yes
Screen 2 Yes
Wards(Gen) Stethoscope 1 Yes
Sphygmomanometer 1 Yes
X-ray View box 0
Thermometer 1 Yes
Weighing Machine 1 Yes
Crash Cart 0
Medicine/Dressing Trolley 1 Yes
Nebulizer 1 Yes
Oxygen generator 1 Yes
Emergency 1 Yes
ECG 1 Yes
Sthetho 1 Yes
Sphygmo 1 Yes
Thermometer 1 Yes
Pulse oximeter 1 Yes
Syringe pump 0
Crash cart 0
Defibrillator 0
Multipara monitor 0
Drug/Dressing Trolley 0
X-ray view box 0
Suction Apparatus 1 Yes
Nebulizer 1 Yes
Glucometer 1 Yes
Oxygen Cylinder 1 Yes
Oxygen generator 1 Yes
38 | P a g e
RECOMMENDATIONS
39 | P a g e
EMERGENCY DEPARTMENT
RECOMMANDATION:
A dedicated Emergency Department need to be earmarked such as: trolley bay area, receiving and triage
area.
Demarcated area for resuscitation& keeping serious patient for intensive monitoring and Broad dead
patients’ needs to be earmarked.
A dedicated Stretcher & Wheel chair bay needs to be earmarked.
A dedicated triage area needs to be formed
Emergency Equipment viz. Multi-Para monitors, Defibrillators, Oxygen Cylinders should be procured and
installed.
Essential life saving equipment’s needs to be available in Emergency department.
No. of Trolleys and wheelchairs needs to be available in Emergency department.
Appropriate qualified staff member needs to be scheduled to manage triage activities.
Cardiac Monitor needs to be available in Emergency department
Disaster cupboard need to be available in the department.
Disaster cards & Triage bands need to be procured and made available.
Crash Cart need to be procured and made in the department.
Dedicated staff needs to be provided for manning the department round the clock.
Staff needs to be trained in BLS/ACLS.
mock drill needs to be conducted periodically viz. Code Yellow & Code Blue
Structured emergency assessment form needs to developed and printed.
Disaster management plan needs to be prepared by the HCO.
Policy & procedure for emergency needs to be developed & distributed.
Clinical Protocols for emergency treatment needs to be developed & displayed in the department.
Policies viz. Triage, Disaster etc. needs to be developed & distributed.
Staff needs to be trained on Emergency policies & procedures periodically.
Time taken for emergency assessment done by doctors & nurses needs to be monitored regularly.
Time for initial assessment of Emergency patient needs to be monitored.
Patients returned to emergency within 72 Hrs. needs to be monitored.
AMBULANCE
RECOMMENDATION:
There is to be a dedicated Basic Life Support category of ambulance for hospital.
There should be a control room and ambulance parking facility near emergency.
40 | P a g e
Ambulances need to be appropriately equipped with equipments and medications.
The functioning status of the ambulance need to be checked regularly and equipments needs to be checked
on daily basis using standard checklist.
Ambulance need to be manned by trained BLS personnel’s.
Turnaround Time for ambulance service needs to be monitored regularly.
OUT PATIENT DEPARTMENT
RECOMMENDATIONS:
Floor wise Fire exit plan need to be designed & displayed at appropriate locations.
Adequate facilities for differently able Patient needs to be available viz trolley bay area, differently able
toilet facility with Grab Bars.
Fire escape routes are to be highlighted appropriately.
OPD & Services Available Policy needs to be developed and distributed to the user end.
Staff need to be trained appropriately in all policies & procedures manual
Content of the assessment is to be defined and followed.
Out patient satisfaction needs to be monitored regularly.
Waiting time for patients in OPD needs to be monitored regularly.
Scope of service need to be displaced
Calibration of equipment need to be done.
RADIOLOGY AND IMAGING DEPARTMENT
RECOMMANDATIONS:
The AERB license (type and site approval) needs to be acquired.
The radiation safety devices like gonad sheet, lead aprons, and thyroid collar need to be made available
in sufficient number.
The quality assurance test of lead aprons need to conducted regularly.
The calibration of radiology equipment needs to be done.
The staffs need to be trained about radiation safety precautions.
The critical test results need to be defined, reported and documented.
WARDS
RECOMMENDATION:
Hand washing facilities needs to be equipped with liquid soap and paper towel and hand rubs need to be
made available.
Staff need to follow all BMW and PPE practice
The proper fire-fighting equipment need to be made available.
Crash cart trolley need to be purchase and equipped with proper emergency drugs and CPR equipments.
Patient’s washroom need to have safety arrangements (anti-skid mats, emergency call button, grab bars,
disable friendliness, door opening outside, latch type locking which can be opened from outside).
Proper privacy arrangement for patient need to be available.
41 | P a g e
The all necessary patient care equipment needs to be made available. E.g. proper oxygen, suction facility,
crush cart, defibrillators etc.
There should be Separate area for storage area for clean and dirty supplies.
Nurses need to be trained in Basic life support.
The storage space for the linen need to be made available.
Look alike, sound alike and high risk medicines needs to be identified and stored separately. Narcotics need
to be stored under lock and key.
Policies and procedure for ward regarding the Reporting of adverse patient events List of hazardous
materials in the ward, nurse initial assessment, policy for taking verbal order and vulnerable patient care,
blood transfusion, Patient and family education etc need to be developed.
The proper equipments in wards like sphygmomanometers, thermometers, weighing scale need to be
available.
Medications errors, near miss events need to be identified and recorded.
LABORATORY DEPARTMENT
RECOMMENDATION:
The scope of services of lab need to be defined and displayed.
Preventive maintenance and calibration of laboratory equipments needs to be conducted on regular basis.
Laboratory staff training should be done for safety precautions while handling samples.
Critical results need to be defined, reported, and documented and Surveillance for lab test needs to be
carried out.
Labelling of sample need to be done.
Time frame need to define for dispatching lab reports and turnaround time for lab reports need to be
monitored.
MOU need to be available for outsourced tests and Temperature monitoring of refrigerator need to done.
OPERATION THEATRE
RECOMMENDATIONS:
The roof and walls of the OT need to be repaired.
The scrub area of OT need to be cleaned and elbow operated taps need to be installed and adequate hand
washing items need to be available.
There should be a separate storage area for sterile and unsterile items.
Adequate fire-fighting equipment need to be installed in OT.
Sufficient PPE, dresses & gowns need to be available in OT.
One security guard should be present at the entrance of the OT.
The post operative area need to be arranged properly with proper life saving equipment like crush cart,
monitors, defibrillators etc. The storage items should be removed from post operative area.
42 | P a g e
The temperature, humidity and pressure of the OT should be maintained and monitored as per the
requirement. I.e. positive pressure, 55% humidity, 21 0c.
All staff needs to be trained in BCLS.
The equipment in OT needs to be calibrated.
The WHO surgical safety checklist should be followed for each patient.
Immediate pre-operative check-up before wheeling in patient in operation room from pre-operative ward
need to be performed.
INFECTION CONTROL
RECOMMENDATIONS
The infection prevention and control programme need to be documented.
The organization need to adhere to standard precautions at all times.
The cleaning protocol for equipment need to be developed and followed.
The antibiotic policy need to be established and the anti-biogram need to be formed.
The appropriate engineering control to prevent infections which includes design of patient care areas
(optimum spacing between beds), operating rooms, air quality and water supply need to be developed.
Soap bars need to be replaced with liquid hand washes and hand towels with tissue paper.
Induction & in-service training should be provided uniformity to all staff.
Antibiotic audit needs to be carried out to ensure adherence to antibiotic policy.
Monitoring of outcome indicators need to be done on regular basis.
The disinfectant which is being used in the hospital need to undergone sterility test.
The members of infection control committee need to be revised and including the members of
maintenance, biomedical engineering, clinicians, intensivist, nursing superintendent, infection control
nurse, housekeeping in charge, CSSD in charge etc.
KITCHEN
RECOMMENDATIONS:
A qualified dietician should be deputed in the department for supervising the functioning of the
department.
Documented polices need to be developed regarding storage, preparation, distribution & disinfection
processes.
Nutritional assessment for the patient should be performed and the diet should be given according to the
patient nutritional need.
Patient and family need to be educated on food drug interactions and limitation of diet.
Monitoring of indicator need to be done regularly.
Infection control practises need to be followed
Fire fighting equipment need to be installed in department
43 | P a g e
HOUSE KEEPING DEPARTMENT:
RECOMMANDATIONS:
The sufficient number of in housekeeping staff needs to be appointed.
Hazardous materials should be identified and store in proper manner.
Master cleaning schedule should be developed and implemented.
The dilution factor of disinfectants should be known to housekeeping staff.
Staffs should be trained on handling of hazardous materials & spill management.
Efficacy test for disinfectant should be done periodically.
PHARMACY
RECOMMENDATION
Room and area used for medicine storage should be clean.
There should be proper space for storage of medications and Medicines should not be stored on floors.
The medicine should be arranged properly using either bin card system or mentioning a index on the
racks should be done.
The tablets, syrup, injections should be stored separately and labelled.
There should be appropriate security arrangement (like CCTV, restricted entry) is in place to prevent
pilferage of medicines.
Fire safety arrangements such as fire extinguisher within inspection date, emergency evacuation route
should be appropriate in pharmacy and store.
Refrigerator used for storing medicine should have a temperature monitoring system and should be
recorded at-least 3 times a day.
Inside refrigerator, location of storing various medicines should be specified.
Look alike and sound alike (LASA) medicines should be separately stored and labelling; colour coding
should be done on the racks to avoid confusion.
High risk medicines are to be stored in a protected place to avoid wrongly dispensing it to patient.
Medicine being should have a label clearly mentioning its name, dose and expiry date.
Pharmacists should be aware on policy on verbal order of prescription medicine, situation when
medicine recall is warranted and the procedure of recall.
List of all hazardous materials stored in pharmacy should be available. MSDS for each hazardous
material is to be kept available for ready reference of staff.
Quality Indicators for pharmacy like Percentage of wastage of drugs, Percentage of medicine expiring in
a period, Percentage of stock out of drugs, Percentage of stock out of emergency drugs, , Percentage of
44 | P a g e
medicines procured through local purchase, Percentage of drugs rejected before preparation of goods
receipt note, Percentage of variation from standard procurement process should be monitored.
BLOOD BANK
RECOMMANDATIONS:
Full time qualified blood bank in charge manager available for collection /distribution need to be hire.
Policy and procedure for blood bank needs to be formed and followed
blood transfusion committee have to be formed
facility for blood component segregation need to be provide
Data collection regarding recipient adverse reaction is collated , analysed and report need to be done for
all cases
Working instruction need to be display in blood bank
Outcome such as (% of blood and blood product wastage is not monitored ,% of component usage)
should be monitored
ENGINEERING AND MAINTENANCE
RECOMMANDATIONS:
A Designated individual for maintenance need to be designated.
Staff round the clock for emergency for repairs needs to be hire.
The preventive maintenance and break down plan for equipment should be available and response time
need to be monitored
Facility inspection rounds twice a year in patient care areas and once in non-patient care areas need to be
conducted.
Safety education program for all staff is not been followed
Documentation of facility inspection report need to be formed and Safety committee should be formed.
staff training need to be done for disaster management and fire management
The mock drills need to be conducted at periodic intervals and documented.
45 | P a g e
SELF ASSESSMENT
TOOLKIT
46 | P a g e
Self Assessment Toolkit
Organization is required to provide self assessment report in the format 'Self Assessment Toolkit' given below. All the entries are to be properly filled up. Regarding scoring following criteria would be applicable.
Compliance to the requirement: 10
Partial compliance to the requirement: 5 (if any of the sample is
found to be noncomplying out of total samples selected) Non-
compliance to the requirement: 0
Not Applicable: NA
Evaluation Criteria:
• Overall score of minimum 50% in all standards
• Overall score of minimum 50% in each chapter
(Name & Address of the Hospital)
47 | P a g e
DISTRICT HOSPITAL ALMORA
Elements
Scores (0/ 5/ 10)
Total Score 3.45
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC) 3.68
AAC.1: The organization defines and displays the services that it can provide. 5
a The services being provided are clearly defined. 0
b The defined services are prominently displayed. 5
c The staff is oriented to these services. 5
AAC.2: The organization has a documented registration, admission and transfer process. 5
a. Process addresses emergency patients.
registering and admitting out-
patients,
in-
patients
and 5
b. Process addresses mechanism for transfer or referral of patients who do not match the organizational resources.
5
AAC.3 Patients cared for by the organization undergo an established initial assessment. 0
a. The organization defines the content of the assessments for the out-patients, in- patients and emergency patients.
0
b. The organization determines who can perform the assessments. 0
c. The initial assessment for in-patients is documented within 24 hours or earlier. 0
d. Initial assessment of inpatients includes nursing assessment which is done at the time of admission and documented.
0
48 | P a g e
AAC.4 Patient care is continuous and all patients cared for by the organization undergo a regular reassessment.
2.5
a. During all phases of care, there is a qualified individual identified as responsible for the patient’s care who coordinates the care in all the settings within the organization.
5
b. All patients are reassessed at appropriate intervals. 5
c. Staff involved in direct clinical care document reassessments. 0
d. Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.
0
AAC.5 Laboratory services are provided as per the scope of the hospital’s services and laboratory safety requirements.
4.16
a. Scope of the laboratory services are commensurate to the services provided by the organization.
0
b. Procedures guide collection, identification, handling, safe transportation, processing and disposal of specimens.
0
c. Laboratory results are available within a defined time frame and critical results are intimated immediately to the concerned personnel.
0
d. Adequately trained personnel perform, supervise & interpret the investigations. 10
e. Laboratory personnel are trained in safe practices and are provided with appropriate safety equipment/ devices.
10
f. Laboratory tests not available in the organization are outsourced. 5
AAC.6 Imaging services are provided as per the scope of the hospital’s services and established radiation safety programme.
2.5
a. Scope of the imaging services are commensurate to the services provided by the organization.
0
b. Imaging signages are prominently displayed in all appropriate locations. 5
c. Imaging results are available within a defined time frame and critical results are intimated immediately to the concerned personnel.
0
49 | P a g e
d. Imaging personnel are trained in safe practices and are provided with appropriate safety equipment/ devices.
5
AAC.7 The organisation has a defined discharge process. 1.66
a. Process addresses discharge of all patients including Medico-legal cases and patients leaving against medical advice.
5
b. A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice).
5
c. Discharge summary contains the reasons for admission, significant findings, investigation results, diagnosis, procedure performed (if any), treatment given and the patient’s condition at the time of discharge.
0
d. Discharge summary contains follow up advice, medication and other instructions in an understandable manner.
0
e. Discharge summary incorporates instructions about when and how to obtain urgent care.
0
f. In case of death the summary of the case also includes the cause of death. 0
Chapter 2: CARE OF PATIENTS (COP) 2.12
COP.1: Care of patients is guided by accepted norms & practice. 7.5
a The care and treatment orders are signed and dated by the concerned doctor.
10
b Critical Practice Guidelines are adopted to guide patient care wherever
possible.
5
COP.2: Emergency services including ambulance are guided by documented procedures.
0
a Documented procedures address care of patients arriving in the emergency including handling of medico-legal cases.
0
b Staff should be well versed in the care of emergency patients in consonance with the scope of the services of hospital.
0
50 | P a g e
c Admission or discharge to home or transfer to another organization is also documented.
0
d Ambulance is appropriately equipped. 0
e Ambulance(s) is manned by trained personnel. 0
COP.3: Documented procedures define rational use of blood and blood products. 2
a Documented policies and procedures are used to guide the rational use of blood and blood products.
0
b Documented procedures govern transfusion of blood and blood products. 0
c The transfusion services are governed by the applicable laws and regulations.
5
d Informed consent is obtained for donation and transfusion of blood and blood products.
5
e Procedure addresses documenting and reporting of transfusion reactions. 0
COP.4: Documented procedures guide the care of patients as per the scope of services provided by hospital in Intensive care and high dependency unit.
0
a Care of patients is in consonance with the documented procedures. 0
b Adequate staff and equipment are available. 0
COP.5: Documented procedures guide the care of obstetrical patients as per the scope
of services provided by hospital.
a The organization defines the scope of obstetric services. NA
b Obstetric patient’s care includes regular ante-natal check ups, maternal nutrition and post-natal care.
NA
c The organization has the facilities to take care of neonates. NA
51 | P a g e
COP.6: Documented procedures guide the care of pediatric patients as per the scope of services provided by hospital.
a The organization defines the scope of its pediatric services. NA
b Provisions are made for special care of children by competent staff. NA
c Patient assessment includes detailed nutritional, growth, and immunization assessment.
NA
d Procedure addresses identification and security measures to prevent child/ neonate abduction and abuse.
NA
e The children’s family members are educated about nutrition and
immunization
NA
COP.7: Documented procedures guide the administration of anesthesia. 3.33
a. There is a documented policy & procedure for the administration of
anesthesia.
0
b. All patients for anesthesia have a pre-anesthesia assessment by a qualified/ trained anesthetist.
10
c. The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented.
0
d. An immediate preoperative re-evaluation is documented. 0
e. Informed consent for administration of anesthesia is obtained by the anesthetist.
5
f. Anesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and patency and End tidal carbon dioxide.
5
g. Each patient’s post-anesthesia status is monitored and documented. 5
h. Defined criteria are used to transfer the patient from the recovery area. 5
i. Adverse anesthesia events are recorded and monitored. 5
52 | P a g e
COP.8: Documented procedure guides the care of patients undergoing surgical procedures.
4.2
a. Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery.
5
b. An informed consent is obtained by a surgeon prior to the procedure. 5
c. Documented procedure addresses the prevention of adverse events like wrong site, wrong patient and wrong surgery.
0
d. Qualified persons are permitted to perform the procedures that they are entitled to perform.
10
e. The operating surgeon documents the operative notes and post-operative plan of care.
5
f. The operation theatre is adequately equipped and monitored for infection control practices.
0
g. Patients, personnel and material flow conform to infection control practices.
5
Chapter 3: MANAGEMENT OF MEDICATION (MOM) 2
MOM.1: Documented procedures guide the organization of pharmacy services and usage of medication.
5
a Documented procedure shall incorporate purchase, storage, prescription and dispensation of medications.
5
b Documented procedures address procurement and usage of implantable prostheses.
5
MOM.2: Documented policies & procedures guide the storage of medications. 1
a Documented policies and procedures exist for storage of medication 0
b Medications are stored in a clean, safe and secure environment, and incorporate manufacturer’s recommendations.
5
c Sound alike and look alike medications are stored separately. 0
53 | P a g e
d Beyond expiry date medications are not stored/used. 0
e List of emergency medicines is defined, stored, and available all the
time.
0
MOM.3: Documented procedures guide the prescription of medications. 2.5
a The organization determines who can write orders. 0
b Orders are written in a uniform location in the medical records. 5
c Medication orders are clear, legible, dated and signed. 5
d The organization defines a list of high risk medication & process to
prescribe them.
0
MOM.4: Poilicies & procedures guide the safe dispensing of medications. 2.5
a Medications are checked prior to dispensing, including the expiry date to ensure that they are fit for use.
5
b High risk medication orders are verified prior to dispensing. 0
MOM.5: There are defined procedures for medication administration. 3
a Medications are administered by trained personnel. 10
b Prior to administration medication order including patient, dosage, route and timing are verified.
5
c Prepared medication is labelled prior to preparation of a second drug. 0
d Medication administration is documented. 0
e A proper record is kept of the usage, administration and disposal of narcotics and psychotropic medications.
0
MOM.6: Adverse drug events are monitored.
54 | P a g e
a Adverse drug events are defined & monitored. 0
b Adverse drug events are documented and reported within a
specified time frame.
0
MOM.7: Documented policies & procedures govern usage of radioactive drugs. NA
a Documented policies and procedures govern usage of radioactive drugs.
NA
b Policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs.
NA
Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE) 1.4
PRE.1: Patient rights are documented displayed and support individual beliefs, values and involve the patient and family in decision making processes.
1.4
a. Patient rights include respect for personal dignity and privacy during examination, procedures and treatment.
5
b. Patient rights include protection from physical abuse or neglect. 5
c. Patient rights include treating patient information as confidential. 0
d. Patient rights include obtaining informed consent before carrying out procedures.
0
e. Patient rights include information on how to voice a complaint. 0
f. Patient rights include information on the expected cost of the
treatment.
0
g. Patient has a right to have an access to his / her clinical records. 0
PRE.2: Patient and families have a right to information and education about their
healthcare needs.
0
a Patients and families are educated on plan of care, preventive aspects, possible complications, medications, the expected results and cost as applicable.
0
55 | P a g e
b Patients are taught in a language and format that they can understand. 0
Chapter 5: HOSPITAL INFECTION CONTROL (HIC) 6.4
HIC.1: The hospital has an infection control manual, which is periodically updated and conducts surveillance activities.
3
a It focuses on adherence to standard precautions at all times. 5
b Cleanliness and general hygiene of facilities will be maintained and
monitored.
0
c Cleaning and disinfection practices are defined and monitored as
appropriate.
5
d Equipment cleaning, disinfection and sterilization practices are
included.
5
e Laundry and linen management processes are also included 0
HIC.2: The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees.
8.33
a Hand hygiene facilities in all patient care areas are accessible to health care providers.
5
b Adequate gloves, masks, soaps, and disinfectants are available and used correctly.
10
c Appropriate pre and post exposure prophylaxis is provided to all concerned staff members.
10
HIC.3: Bio-medical Waste (BMW) management practices are followed.
8
a The hospital is authorised by prescribed authority for the management and handling of Bio-Medical Waste.
5
b Proper segregation and collection of Bio-Medical Waste from all patient care areas of the hospital is implemented and monitored.
5
c Bio-Medical Waste treatment facility is managed as per statutory provisions (if in- house) or outsourced to authorised contractor(s).
10
d Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.
10
56 | P a g e
e Appropriate personal protective measures are used by all categories of staff handling Bio-Medical Waste.
10
Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI) 2.5
CQI.1: There is a structured quality improvement, patient safety and continuous monitoring programme in the organization.
0
a There is a designated individual for coordinating and implementing the quality improvement and patient safety programme.
0
b The quality improvement and patient safety programme is a continuous process and updated at least once in a year.
0
c Hospital Management makes available adequate resources required for quality improvement and patient safety programme.
0
CQI.2: The organization identifies key indicators to monitor the structures, processes and outcomes which are used as tools for continual improvement.
5
a Organization may identify the appropriate key performance indicators in both clinical and managerial areas.
5
b These indicators shall be monitored. 5
Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)
ROM.1: The responsibilities of the management are defined 3.33
a The organization has a documented organogram. 5
b The organization is registered with appropriate authorities as applicable.
5
c The organization has a designated individual(s) to oversee the hospital wide quality and safety programme.
0
ROM.2: The organization is managed by the leaders in an ethical manner. 5
57 | P a g e
a The management makes public the mission statement of the
organization.
5
b The leaders/management guide the organization to function in an ethical
manner.
5
c The organization discloses its ownership. 5
d The organization's billing process is accurate and ethical. 5
ROM.3: The organization has set up multi-disciplinary committees to oversee specific areas of quality and patient safety.
5
a These committees include Quality and Safety, Infection Control, Pharmacy and Therapeutics, Blood Transfusion, and Medical Records.
5
b The membership, responsibilities, and periodicity of meetings shall be
defined.
5
Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS) 4.5
FMS.1: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.
4
a Internal and External Signage’s shall be displayed in a language understood by the patients and families.
10
b Maintenance staff is contactable round the clock for emergency repairs. 0
c There the hospital has a system to identify the potential safety and security risks including hazardous materials.
0
d Facility inspection rounds to ensure safety are conducted periodically. 0
e There is a safety education programme for relevant staff. 10
FMS.2: The organization has a program for clinical and support service equipment management.
2.5
58 | P a g e
a The organization plans for equipment in accordance with its services. 5
b There is a documented operational and maintenance (preventive and breakdown) plan.
0
FMS.3: The organization has provisions for safe water, electricity, medical gas and vacuum systems.
6.66
a Potable water and electricity are available round the clock. 10
b Alternate sources are provided for in case of failure and tested
regularly.
10
c There is a maintenance plan for medical gas and vacuum systems. 0
FMS.4: The organization has plans for fire and non-fire emergencies within the facilities.
5
a The organization has plans and provisions for detection, abatement and containment of fire and non-fire emergencies.
0
b The organization has a documented safe exit plan in case of fire and non-fire emergencies.
5
c There is a maintenance plan for medical gas and vacuum systems. 0
d Mock drills are held at least twice in a year. 10
Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM) 5.4
HRM.1: The organization has staffing commensurate with patient care needs. 7.5
a The mix of staff is commensurate with the volume and scope of the services.
5
b Staff recruitment process is well defined. 10
HRM.2: There is an ongoing programme for professional training and development
of the staff.
1.66
a All staff is trained on the relevant risks within the hospital environment.
5
59 | P a g e
b Staff members can demonstrate and take actions to report, eliminate/ minimize risks.
0
c Training also occurs when job responsibilities change/ new equipment is introduced.
0
HRM.3: The organization has a well-documented disciplinary and grievance handling procedure.
3.33
a A documented procedure with regard to these is in place. 0
b The documented procedure is known to all categories of employees in the organization.
0
c Actions are taken to redress the grievance. 10
HRM.4: The organization addresses the health needs of the employees 5
a Health problems of the employees are taken care of in accordance with the organization’s policy.
5
b Occupational health hazards are adequately addressed. 5
HRM.5: There is documented personal record for each staff member 10
a Personal files are maintained in respect of all employees. 10
b The personal files contain personal information regarding the employees qualification, disciplinary actions and health status. The disciplinary procedure is in consonance with the prevailing laws.
10
Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS) 2.1
IMS.1: The organization has a complete and accurate medical record for every patient
1
a Every medical record has a unique identifier. 0
60 | P a g e
b Organization identifies those authorized to make entries in medical
record.
5
c Every medical record entry is dated and timed. 0
d The author of the entry can be identified. 0
e The contents of medical record are identified and documented. 0
IMS.2: The medical record reflects continuity of care. 5
a The record provides an up-to-date and chronological account of patient
care.
5
b The medical record contains information regarding reasons for admission, diagnosis and plan of care.
5
c Operative and other procedures performed are incorporated in the medical record.
5
d The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel.
5
e In case of death, the medical records contain a copy of the death certificate indicating the cause, date and time of death.
5
f Care providers have access to current and past medical record. 5
IMS.3: Documented policies and procedures are in place for maintaining confidentiality, integrity and security of records, data and information.
2.5
a a. Documented procedures exist for maintaining confidentiality, security and integrity of information.
0
b Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient's authorization.
5
IMS.4: Documented procedures exist for retention time of records, data and information.
0
a Documented procedures are in place on retaining the patient’s clinical records, data and information.
0
b The retention process provides expected confidentiality and security. 0
c The destruction of medical records, data and information is in accordance with the laid down procedure.
0
61 | P a g e
PRIORITY
District hospital Almora
S.no Gap statement Action plan Priority
A Hospital wide major gap
1 The hospital does not comply with the necessary statutory & regularity
requirements.
All other relevant statutory requirement like biomedical waste handling rules (under
renewal), type and site approval by aerb,
building occupancy certificate, approved fire exit plan etc need to be acquired.
High
2 Although the hospital has quite good signage system , iec activity are
properly implemented but the some
signage’s need to be placed according to nabh requirement and all signage’s is
not bilingual, pictorial and permanent
in nature
The signage’s need to be placed according to nabh requirement and should be bilingual,
pictorial and permanent in nature
High
3 All the sanctioned posts are not filled up. Required posts like dietician,
medical records technician, quality
manager, cssd technician, ot technician, are not included in the sanctioned posts.
All the sanctioned posts is need to be filled and recommended number of staff need to be
appointed. High
4 The hospital has 3 operation theatres.
There was lack of necessary anaesthesia
and surgery equipment (multi para-monitor, anaesthesia work station, cpr
kit etc.) For carrying out surgery. The
infection control practices were not evident e.g. Changing of clothes before
entering in ot, no arrangements of ppe,
restricted entry to the zones, the
washing area for clothes is in sterile zone.
The necessary anaesthesia and surgery
equipment (multi para-monitor, anaesthesia
work station, cpr kit etc.) For carrying out surgery need to be purchased and installed.
And adequate infection control practices
should be followed in ot. High
5 There is no dedicated, functioning cssd
in the hospital. The instruments are being washed. Autoclave is available in
ot complex which takes care of the
sterilization activities for ot. There is no
dedicated person to perform sterilization activities, ward boy currently performs
it.
A dedicated person to perform sterilization
activities need to be appointed.
High
6 Dedicated department for equipment management not evident. Purchase dept.
Currently addresses the issues relating
to medical equipment maintenance. All
major equipments are not covered under amc/cmc and calibration is not done for
any of the equipments.
A dedicated department for equipment management for addresses the issues relating
to medical equipment maintenance need to be
established. All major equipments should be
covered under amc/cmc and calibration should be done for all the equipments.
High
7 there is lack of necessary life saving
equipments in hospital like ventilator, defibrillator and crash cart were not
available in the ot and emergency.
The necessary life saving equipments in
hospital like ventilator, defibrillator and crash cart need to be installed
High
8 There is no department for keeping medical records. The records are stored
in boxes with scrap material. The
coding, indexing, and filing of records
were not evident. The medical records are not stored securely and away from
rodents. There is not designated person
i.e. Medical record technician for taking care of medical records. The records
does not have all relevant forms &
formats like nurses records, medication chart, intake /output chart, tpr chart, etc.
The medical record need to stored in separately in a room and free from rodents.
All relevant forms & formats like nurses
records, medication chart, intake /output
chart, tpr chart, etc. Need to be implemented.
High
9 There is insufficient number of toilets
for patient and visitors but the toilets
and bathrooms were found unclean. There is no provision of dedicated
toilets for the differently able people.
Toilets and bathrooms must be clean. There
should be provision of dedicated toilets for
the differently able people. High
10 the hospital provides dietary services
but the kitchen is not functioning in
appropriate manner. The kitchen does not have demarcated area such as
receiving, washing, chopping /cutting,
cooking, storing etc. There is no
dietician posted in the hospital. Staff working in this department does not
undergo any regular health check up,
etc. The area outside the kitchen is unclean, and the door of kitchen was
broken.
The kitchen need to be demarcated area such
as receiving, washing, chopping /cutting,
cooking, storing ,dietician need to hire ,regular health check need to be done
High
11 The hospital does not have icu facility
for keeping trauma and post operative patient. The monitoring of post
operative cases is not evident.
Icu facility for keeping trauma and post
operative patient need to be formed. The monitoring of post operative cases should be
documented. High
12 the emergency of the hospital was
found reasonably busy throughout the
day but there were no arrangements for
dealing with common type of emergencies. The department has only
beds. The necessary equipments for
performing the examination, crash cart, dressing trolley.
Arrangements for dealing with common type
of emergencies need to be done. The
necessary equipments for performing the
examination, crash cart, dressing trolley need to provided
High
13 inventory control management is not done in the stores (Alphabetically order
) There is no drug & therapeutic
committee in the hospital. Temperature
monitoring not evident in any of the refrigerators inspected during the visit
such as medicine store, operation
theatres etc. Staff not aware on addressing adverse drug reactions.
“look alike and sound alike” drugs are
not stored separately. Provision of security is not evident.
Drug & therapeutic committee need to be formed, temperature monitoring , look like
sound like drug and drug reaction need to be
formed and documented
High
14 The laundry and linen practices are not being followed; the infected and soiled
linens are mixed and washed
collectively. No sluicing is not being
performed. There is no protocol for washing of hiv infected linen. There is
no trolley for carrying linen. The
department does not have proper layout like receiving, segregation area,
sluicing, washing, drying, calendaring
etc.hte department has only a semi
automated washing machine.
Laundry and linen practises need to be followed, protocol for HIV infected linen
need to followed .linen should be carried by
trolley equipment needed for washing need to
be purchased.
High
15 The calibration of equipment is not
being performed in all department
Calibration of all equipment in hospital need
to be done and documented High
16 Hand washing area is not equipped
with liquid soap and paper towel.
Hand washing need to done by liquid hand
wash and replacement of all towels with
tissue paper. High
17 Patient’s washroom is not having safety
arrangements (anti-skid mats,
emergency call button, grab bars,
disable friendliness, door opening outside, latch type locking which can be
opened from outside).
The toilet need to equipped with safety
arrangements (anti-skid mats, emergency call
button, grab bars, disable friendliness, door
opening outside, latch type locking which can be opened from outside).
High
18 The quality indicators are not being monitored(outcome of all department )
All quality indicator need to be monitor and documented High
19 All committees according to NABH
requirements are not formed like (infection control committee, core
committee etc).
All committees according to NABH
requirements need to be formed like (infection control committee, core committee
etc).
High
20 The biomedical waste bins are not foot operate and there is no labelling of
biohazard symbol in BMW buckets.
The biomedical wastes bins need to be foot operate and labelled of biohazard symbol in
BMW buckets. Medium
21 The doctors and nurses are not trained
in BLS and ACLS.
The doctors and nurses need to be trained in
BLS and ACLS. High
Emergency
23 Policy and procedure for the
emergency service is not available.
Policy and procedure for the emergency
service need to be formed. Medium
24 Crash cart are not checked daily
regarding regular testing.
Crash cart should be checked daily regarding
regular testing. Medium
25 initial assessment of the patient not
done in proper format.
Initial assessment of the patient need to be
done in proper format. High
26 Disaster management plan not prepared
by the hco.
Disaster management plan need to be
prepared by the hco. Medium
27 There is no system to review all
imaging by a radiologist within 24
hours
System for review all imaging by a
radiologist within 24 hours need to be
arranged High
28 non ability to perform acute blood test
and receive results within one hour for
arterial blood gases, full blood picture,
urea and electrolytes, plasma, glucose, blood levels for common overdose
medication/agents, coagulation studies.
The facility to perform acute blood test and
receive results within one hour for arterial
blood gases, full blood picture, urea and
electrolytes, plasma, glucose, blood levels for common overdose medication/agents,
coagulation studies need to be available.
Medium
29 no monitoring of time for initial
assessment of emergency patient.
The time for initial assessment of emergency
patient need to be monitored and documented Low
Ambulance
31 The functioning status of the ambulance like lights, siren, beacon lights was not
checked regularly and there was no
servicing record for the ambulance.
The functioning status of the ambulance like lights, siren, beacon lights was not checked
regularly and there was no servicing record
for the ambulance need to be provided Medium
32 The equipments and emergency medications was not present
The equipments and emergency medications need to be avalible Medium
Out patient department
34 UHID is not generated in proper manner
(each time new UHID no is generated )
The prepare arrangements of UHID
generation should be done by implementing it enabled hospital information system.
High
35 Procedure to admission or refer of
patient from op chamber is not available
Procedure to admission or refer of patient
from op chamber need to be done Low
36 Content of the initial assessment of the
patient is not defined and hence not
followed
Content of the initial assessment of the
patient need to be defined and followed.
Medium
37 Recording waiting time for patients in opd is not done
Waiting time for patients in opd is need to be monitor.
Low
Radiology and imaging department
39 Changing room for patient is not
available in proper condition
Changing room for patient need to be
provided in proper condition Medium
40 TLD badges is not available for any
staff
TLD badges need to arranged for all
radiology staff. High
41 Radiation safety devices like lead glass, lead apron, gonad shield, thyroid shield
is not available in radiology department.
Radiation safety devices like lead glass, lead apron, gonad shield, thyroid shield should
be arranged in radiology department High
42 Radiation hazard symbols were not
displayed
Radiation hazard symbols need to be
displayed High
43 The staffs are not aware about radiation safety precautions.
The staffs training need to be preformed about radiation safety precautions.
Medium
44 The quality assurance program is not
documented and implemented.
The quality assurance program need to be
documented and implemented. Medium
Wards
46 Nurse patient ratio is not maintained Nurse patient ratio need to be maintained High
47 There is inadequate privacy
arrangement for patient. There is lack of sufficient no of screens.
Adequate privacy arrangement for patient
should be done
Medium
48 Look alike, sound alike medicines is not
identified and stored separately.
Look alike, sound alike medicines should be
identified and stored separately. High
49 High risk medicines is not identified
and stored separately.
High risk medicines need to be identified and
stored separately. High
50 Multi-use open vials do not have labels
of date of opening and date of expiry.
Training of staff need to be done for handling
and storage of sample
Medium
51 There is no protocol for storage of
narcotics. It is not stored under lock and
key.
Protocol for storage of narcotics needs to be
formed and documented. It should be stored
under lock and key. High
52 Proper identification of patient before
carrying out any patient care activity is not being done.
Proper identification of patient before
carrying out any patient care activity is need to be done and documented
High
53 Reporting of adverse patient events is
not being followed.
Reporting of adverse patient events is need to
be followed. High
54 List of hazardous materials in the ward is not identified and msds sheet for
them is not available.
List of hazardous materials in the ward need to be identified and MSDS sheet need to be
available
High
55 Fridge has no checklist and food items were present inside the fridge.
Fridge checklist need to be followed and regular checking of items store in fridge need
to be checked and documented daily Medium
56 Emergency medicines are not checked
regularly.
Emergency medicines need to be checked
regularly. High
57 The blood transfusion consent is
present. The transfusion record is not
available and the reporting of transfusion reaction is not being done.
reporting of transfusion reaction need to be
done and documented
High
58 Patient and family members are not
being educated about the plan of care,
prognosis, length of stay etc.
Patient and family members need to be
educated about the plan of care, prognosis,
length of stay etc. Medium
59 The screening of nutritional assessment
is not being carried out. There is no
qualified professional for conducting the nutritional assessment.
The screening of nutritional assessment in
need to be being carried out.
High
60 There was no feedback form available for conducting ipd patient’s satisfaction
survey.
Feedback for conducting ipd patient’s satisfaction survey need to be done
Low
61 Patients are not regular reassessment by
treating physician. The reassessment is not documented.
Patients reassessment by treating physician
need to be done and documented
High
62 The known drug allergy is not
ascertained before prescribing the drug.
The known drug allergy must be ascertained
before prescribing the drug. Medium
63 The content of discharge summary is
not appropriate. It does not include all
contents needed
The content of discharge summary need to be
done in appropriate manner . It should
contain all the content needed Medium
64 The prepared drug is not labelled if
loaded but not administered at same time.
Nursing staff need to be trained regarding
administration of medication
Medium
Laboratory department
66 The scope of services is not defined Scope of service need to be define and displayed Medium
67 laboratory staff is not aware about the
safety precautions while handling
samples
Staff training need to be on safety
precautions while handling samples
Medium
68 No mou available for outsourced tests Mou for outsource test need to be done. Medium
Operation theatre
70 Ot light is not in working condition. Ot light need to purchase High
71 Phenol is using for washing Phenol is using for washing should be replaced with 1% sodium hypochlorite.
High
72 Doctor and nurses changing room is not present.
Doctor and nurses changing room need to be formed
Medium
73 There was mixing of sterile and unsterile items. There is no separate
space for string the sterile and unsterile
items.
separate space for string the sterile and unsterile items need to provide
High
74 There was not sufficient PPE for the ot, dresses & gowns.
Sufficient no of PPE for the ot, dresses & gowns need to provide to all staff member
High
75 There was no security guard present at the entrance of the ot.
security guard need to be assigned at the entrance of the ot.
Medium
76 The preoperative area is not properly equipped. There is no monitor in the
preoperative area.
Monitoring of patient need to be done in postoperative area and it should be equipped
with all the equipment High
77 Number of instrument is not counted
before and after surgery.
Number of instrument need to be counted
before and after surgery. High
78 The who surgical safety checklist is not
being followed for each patient.
The who surgical safety checklist need to be
followed for each patient. High
79 Immediate pre-operative check-up before wheeling in patient in operation
room from pre-operative ward was not
performed.
Immediate pre-operative check-up before wheeling in patient in operation room from
pre-operative ward need to be performed
High
80 The anaesthesia consent is not present in a definite format (hand written
consent are being taken from patient).
The anaesthesia consent need to taken in proper format
High
81 Patient undergoing surgery is not being
screened for hiv. There was no evidence
of hiv consent and hiv test of patient undergoing surgery.
Patient undergoing surgery need to be
screened for hiv with proper consent
High
82 The plan of care is not documented. The
desired result of treatment is not
documented.
The plan of care and desired result of
treatment need to be documented.
High
83 no defined criteria are being used to
decide shifting of patient from post-
operative ward. The post operative
monitoring is not being carried out.
Defined criteria need to be use for shifting of
patient from post-operative ward. The post
operative monitoring is should be carried out.
High
84 Monitoring of patient during surgical procedure (at minimum heart rate,
cardiac rhythm, respiratory rate, blood
pressure, and oxygen saturation and level sedation) is not being documented.
Monitoring of patient during surgical procedure (at minimum heart rate, cardiac
rhythm, respiratory rate, blood pressure, and
oxygen saturation and level sedation) is need to be implemented and documented.
High
85 Documentation of type of aesthesia and
anaesthetic medication in patient’s
medical record is not being done.
Documentation of type of anaesthesia and
anaesthetic medication in patient’s medical
record need to be implemented and documented. High
86 Each operation room is not monitored
for humidity and temperature on daily basis.
Each operation room need to be monitored
for humidity and temperature on daily basis.
Medium
87 Each operation room is not monitored
for filter integrity, at-least once in six
month.
Each operation room need to monitor for
filter integrity, at-least once in six month.
Medium
88 All areas of ot are not kept clean from
dust all the time. Proper terminal
cleaning and dusting was not done.
proper terminal cleaning and dusting need to
be done
Medium
Autoclave room
91 The sterile items are not transported in closed trolley.
The sterile items should be transport in closed trolley.
High
92 Entry to cssd is not restricted to only staff working in cssd.
Entry to cssd is needed to be restricted to only staff working in cssd. High
93 The cssd layout do not have well
demarcated zones.
The cssd layout need to be well demarcated
zones, High
94 There is no bacteriological/chemical surveillance test being performed for
sterilization authenticity & validation.
Bacteriological/chemical surveillance test being performed for sterilization authenticity
& validation need to be done High
95 Entry to sterile zone is not taking necessary infection control precautions
such as hand washing, wearing of
gowns/aprons, gloves etc. E.g. The staff
is not using any ppe and not changing their shoes while entering to the cssd
room.
Infection control practises and standard precaution need to be followed
High
96 The sterilization zone (especially
storage) is not having a higher air pressure to prevent outside air to enter
in this area.
The sterilization zone (especially storage)
should have a higher air pressure to prevent outside air to enter in this area.
High
97 Emergency exit route is not identified and displayed.
Emergency exit route is not identified and displayed.
High
98 The handling the department is not well qualified
Cssd technician need to hire for the particular department
High
99 No recall system of items is followed. No recall system of items needs to be
followed. Medium
100 Cidex is used for sterilization Cidex is used for sterilization need to be stop Medium
101 Labelling of drum in cssd is not done Labelling of drum in cssd need to be done Medium
102 Each sterilization equipment is not having an identification number, which
should be displayed on the equipment
Each sterilization equipment need to give an identification number, which should be
displayed on the equipment Medium
103 Each pack that is being sterilized is not
labelled
Each pack sterilized need to be labelled
Medium
104 The cssd is not maintaining record of all validation test reports
The cssd record of all validation test reports need to be maintained
Medium
105 List of hazardous chemicals in cssd is not available.
List of hazardous materials in the ward need to be identified and MSDS sheet need to be
available Medium
Infection control
107 The organization does not adhere to
standard precautions at all times. Standard precaution need to follow in all department Medium
108 The infection control surveillance data
is not being collected
The infection control surveillance data need
to be collected and recorded. Medium
109 Brooming and dry dusting is evident which is not acceptable.
Brooming and dry dusting is evident which is need to be stoped mopping should be done
instead of dusting and brooming Medium
110 The disinfectant which is being used in
the hospital is not undergone any
sterility test. Phenyl is being used as disinfectant.
Sterility test need to done periodically and
stop using of phenyle
Medium
111 The sterilized and disinfectant
equipment sets were not stored in
appropriate manner across the organization including cssd.
The sterilized and disinfectant equipment sets
need to be stored in appropriate manner
across the organization including cssd. Equipment cleaning & sterilization practices
need to be strengthened. High
112 Regular validation tests for sterilization like physical and chemical test , daily,
weekly biological tests, steam
Regular validation test or sterilization , steam processing, and eto processing need to be
monitored on daily basis and to be Medium
processing, and eto processing is not being followed.
documented
113 there was no established recall
procedure for recall procedure for
breakdown identified in the sterilization system.
Recall procedure for recall procedure for
breakdown identified in the sterilization
system. Need to be formed
Medium
114 The organization does not conduct
infection control training of all staff.
Infection control training of all staffs need to
be conducted Medium
115 Antibiotic audit is not carried out to
ensure adherence to antibiotic policy.
Antibiotic audit need to be carried out.
Medium
Kitchen
117 Kitchen layout was not defined as
receiving, storage, preparation,
distribution, and cleaning area.
Kitchen layout need to be specifically
defined as receiving area , storage area,
preparation area, distribution area and
cleaning area Medium
118 The plaster of the walls of kitchen is
chipping off. The walls need to repair.
Medium
119
Patient & family members are not educated regarding the limitations of
diet& drug interactions.
Patient & family members are to be
explained and educate regarding the limitations of diet as well as food& drug
reaction Medium
120 Food evaluation is not done before
serving to patient.
Food evaluation to be done before serving to
patient and to be documented. Medium
121 Nutritional assessment is not being
done.
Nutritional assessment need to be developed
and implement. High
122 No cleaning schedule for the kitchen
available.
Cleaning schedule for the kitchen need to be
prepared and followed. Medium
123
Patient case sheet are not checked by
doctor and dietician
Patient case sheet are to be checked by doctor
and dietician.
Medium
Housekeeping department:
127 Hazardous materials are not identified. Hazardous materials need to be identified and labelled Medium
128 Master cleaning schedule is not
available. Cleaning schedule need to be developed and implemented Medium
129 The dilution factor of disinfectants is
not known to housekeeping staff. Staffs are not trained on handling of hazardous
materials & spill management.
The housekeeping staff should be made
aware regarding dilution factor for disinfectants as well as regarding handling of
hazardous material and spill management by
proving training periodically Medium
130 Efficacy test for disinfectant is not done
periodically.
Efficacy test for disinfectant need to be done
periodically and documented Medium
Pharmacy
132 Room and area used for medicine
storage is not clean, cluttered.
Room for storing of medicine need to be cleaned periodically and the cluttered need to
be filled. Medium
133
Medicines are stored on floor.
Cupboard for storing medicine should be
made available and proper shelf need to
made for storing medicine Medium
134 All items storage area are not marked
and labelled
All items storage area need to be marked and
labelled. Medium
135 Medicine are not stored in proper
temperature (2-8 degree c)
Medicine need to be stored in proper
temperature (2-8 degree c) Medium
136 Appropriate security arrangement (like
cctv, restricted entry) is in place to prevent pilferage of medicines.
Appropriate security arrangement (like cctv,
restricted entry) need to be installed to prevent pilferage of medicines. Medium
137 Refrigerator used for storing medicine
do not have a temperature monitoring system. The temperature of the
refrigerator is not recorded at-least 3
times a day.
Refrigerator used for storing medicine need to have a temperature monitoring system and
the temperature of the refrigerator need to be
recorded at-least 3 times a day. Low
138 Inside refrigerator, location of storing various medicines is not specified. (for
eg. Vaccines should be stored in the
location most appropriate temperature is maintained).
Vaccines which is suppose to be stored in
refrigerator need to be specified and
temperature need be maintaine and recorded.
Medium
139 Look alike and sound alike (lasa)
medicines are not identified and a list is
available.
Look alike and sound alike (lasa) medicines
need to be specified and list to be made
available High
140
High risk medicines are notidentified
and are not stored in a protected place to avoid wrongly dispensing it to patient.
High risk medicines need to be identified
and are to be stored in a protected place to
avoid wrongly dispensing it to patient and the list to be made available High
141 Medicine being stored does not have a
label clearly mentioning its name, dose and expiry date. This is specifically
required if pharmacy sells loose
medicines, cut strip medicines, or
prepared formulations of certain medicines.
Medicine being stored must have a label clearly mentioning its name, dose and expiry
date. This is specifically required if
pharmacy sells loose medicines, cut strip
medicines, or prepared formulations of certain medicines. High
142 Staff at pharmacy are not aware on
practice of preventing expiry of medicine (fifo method, identifying near
expiry medicine, identifying medicine
with short shelf life)
training need to be conducted for the
pharmacy regarding fifo method
Medium
143 Staffs at pharmacy are not aware of situation when medicine recall is
warranted and the procedure of recall.
Staffs are to be made aware regarding the
procedure for medicine recall. Medium
144
Records of purchase and goods receipt notes are not available.
Records of purchase and goods receipt notes
are to be made available and to be documented Medium
145 Pest control measure are not under
taken Measures for pest control need to under take
High
146 There is no proper drug and therapeutic committee in hospital
There need to be a proper drug and therapeutic committee in hospital High
147 Drug formulary is not present in
hospital Drug formulary need to be present in hospital
High
148 Records of periodic stock audit, including physical verification is not in
place.
Periodic stock audit, including physical verification need to be recorded and
documented. High
Blood bank
150
No blood transfusion committee exist.
Blood transfusion committee need to
prepared High
152 Data collection regarding recipient
adverse reaction is collected , analysed
and reported is done only for positive
cases
Data collection regarding recipient adverse
reaction need to be collected , analysed for
both positive as well as for negative case and
to be reported for both the cases High
153 Working instruction are not visible in
blood bank
Working instruction for blood bank need to
be visible Low
154 % of blood and blood product wastage
is not monitored
Blood product wastage and % of blood need
to be monitored and to be documented Medium
155 % of component usage is not monitored
Monitoring of % of component should be done and need to be documented Medium
Engineering and maintenance
159 No designated individual for
maintenance is present
for maintenance an individual should be
designated . High
160 Staff round the clock for emergency for
repairs is not conducted.
Staff round the clock for emergency for
repairs need to be conducted. High
161 no preventive and break down plan is
available, response time and breakdown hours is not monitored
Response time and breakdown hours need to
be monitored should be documented. Preventive and break down plan need to be
prepared
High
162 Facility inspection rounds twice a year
in patient care areas and once in non-patient care areas is not been conducted
Facility inspection rounds need to be
conducted twice in a year at in- patient care areas and once in non-patient care areas
Medium
163 Safety education program for all staff is
not been followed
Safety education programme for all the staff
need to be scheduled and to be followed Medium
164 Documentation of facility inspection
report is not available.
Inspection report need to be documented Medium
165 The mock drills are not conducted at
periodic intervals and documented
Mock drills need to be conducted
periodically and should be documented Medium
SUPPORTIVE DOCUMENT
Supportive evidence of identified gaps
Manpower
