Ayushman Bharat Niramayamayushmanbharat.mp.gov.in/uploads/media/Non-NABH... · 2020. 1. 4. · (Annexure 1). D. All the required information and documents will need to be uploaded

Ayushman Bharat "Niramayam"Government of Madhya Pradesh

GUIDELINES FOR THE EMPANELMENT OF NONNABH S I NG LE lMU LTISPECIALITY

/SUPERSPECIALITY HOSPITALS

Deen Dayal Swasthya Suraksha ParishadIEC Bureau, JP Hospital Campus, Bhopal, M.P 462003

Phone Number: 07 55-27 62582Helpline Number: 18002332085, 14555

Emai I : ayushman .bhar at@mp. gov. inWebs ite : r,vt'rv. *).'u sh{n *nhha rat. n:::. €l*rv. i l:r

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GUIDELINES FOR THE EMPANELMENT OF NON NABH

SINGLE /MULTISPECIALITY /SUPERSPECIALITY HOSPITALS

l.l. Basic Principles:

For providing the benefits envisaged under the Mission, the State Health Agency (SHA)through State Empanelment Committee (SEC) will empanel or cause to empanelNonNABH private health care service providers and facilities as per these guidelines.

1.2. Inclusions:

Sin gle/Nlulti s peciality/ S up er Specialities

General Surgery, ENT, Opthalmology,Obstetrics& Gynaecology, Orthopaedics,CardioThoracic Surgery, Paediatric surgery, Genitourinary Surgery (Urology), Neuro Surgery,Surgical Oncology, Medical Oncology, Radiation Oncology, Burns,Plastic& reconstructiveSurgery, Polytrauma, Dental Surgery, Paediatric Cancer, Cricital Care, General Medicine,Paediatrics, Neonatology, Cardiology, Nephrology, Neurology, Chest diseases andrespiratory medicine(Pulmonology).

Super Specialities Centres:

Super Speciality centres are the centres which reflect requirement of DMAvICH/DNB orequivalentqualifi ed personnel.

1.3. Process of Empanelment for Non NABH SingleilVlulti speciality/ SuperSpecialitiesprivate health care ssrvice providers:

A. Hospitals can apply for the empanelment throughthe portal only, as a first step forgetting empanelled in the programmehttps:ii.!:or:ililglSd:gli+y-.9*v.i:r .

B. Hospital should have ROHINI provided by Insurance Information Bureau (IIB).C. Hospital need to fulfiI the criteria for various types of specialties catered by the hospitals

(Annexure 1).D. All the required information and documents will need to be uploaded and submitted by

the hospital through the web portal.E. Hospitalsneed to attain quality milestones by having at least NABII pre-entry level

accreditation to be attained within I year with 2 extensions af one year each.F. Criteria for empanelment has been divided into two broad categories as given below.

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process for empanelment after 3 year to determine

application30 days of

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Physical verification team :-

The mode of verification of empanelment application, conducting the physical verificationwill be done by through a team with two members of State Healthlg.n.y(SHA)nominatedby CEO, Ayushman Bharat "Niramayam"lthree member team from District including onemember nominated by CMHO (Should be from CMHO office, Minimum qualification isMBBS)' one member from DQAC&District Epidemiologist, under the broid mandate ofthe instructions provided in these guidelines.The State Government may also require theInsurance Company to mandatorily provide a medical representative to assist the SEC in itsactivities.

Alternatively, the SHA may continue with any existing institution under the respective stateschemes that may be vested with the powers and responsibilities of SEC u, p., theseguidelines.

The Physical verification team will be responsible for:o Getting the field verification done along with the submission of the verification reports

to the SEC.o The Team will physically inspect the premises of the hospital and verify the physical

presence of the details entered in the empanelment application, including but noi limitedto equipment, human resources, service standards and quality and submit a report in asaid format through real time monitoring using an Appby geotagging the phoiographs

2lPage Deen Dayat Swasthya iuraksha parishad



through the portal along with supporting pictures/videos/document scans which shall beexamined by the officers at the State Health Agency.

o The Physical verification team will also be responsible for recommending, ifapplicable, any relaxation in empanelment criteria that may be required to ensure thatsufficient number of empanelled facilities are available in the district.

o Final approval of relaxation will lie with SEC.o The SEC will consider, among other things, the reports submitted by the physical

verification team and recommendation approve or deny or return to the hospital theempanelment request.

The SHAs through state Empanelment committee (sEC) shall ensure:

. Empanelment within the stipulated timeline.

. The empanelled provider meets the minimum criteria as defined by the guidelines fornon NABH multispecialty private health care service providers;

. Time-bound processing of all applications; and

. Time-bound escalation of appeals.

. In case of refusal, the SEC will record in writing the reasons for refusal and either directthe hospital to remedy the deficiencies, or in case of egregious emissions from theempanelment request, either based on documentary or physical verification, direct thehospital to submit a fresh request for empanelment on the online portal.

. In case the hospital chooses to withdraw from the scheme, it will only be permitted to e-enter/get re-empanelled under the scheme after a period of 6 months.

1.4. Awareness Generation and Facilitation:

The SHA shall ensure that maximum number of eligible hospitals participate in the scheme,and this need to be achieved through IEC campaigns, collaboration with and district,subdistrict and block level workshops.

The state and district administration should strive to encourage all eligible hospitals in theirrespective jurisdictions to apply for empanelment under Ayushman Bharat 'Niramayam'.The SHA shall organize a district workshop to discuss the details of the Mission (includingempanelment criteria, packages and processes) with the hospitals and address any querythat they may have about the mission.

Annexure 1: Detailed Empanelment Criteria

Minimum Criteria:



A Hospital would be empanelled as a network private hospital with the approval of therespective State Health Authorityl if it adheres with the following minimum criteria:

1. In order to facilitate the effective implementation of PMRSSM, State Govemments shallset up the State Health Authority (SHA) or designate this function under any existingagencyl trust designated for this pu{pose, such as the state nodal agency or a trust set upfor the state insurance program.

2. Qualified doctor is a MBBS approved as per the Clinical Establishment AcV Stategovernment rules & regulations as applicable from time to time.

3. Qualified nurse per unit per shift shall be available as per requirement laid down by theNursing Councili Clinical Establishment Act/ State government rules & regulations asapplicable from time to time.

4. Should have at least 50 inpatient beds at district level and 30 inpatient beds atsubdivision level with adequate infrastructure, spacing and supporting staff as pernonns.

o Exemption may be given for the hospitals in Aspirational districts/ Tribal districts,for non-profitable trust hospitals and single-specialty hospitalsexcept whereMedical College Hospitals are situated.

Aspirational districts Tribal districtsDamoh AlirajpurBarwani AnuppurVidisha Barwani

Singrauli BetulKhandwa Dhar

Chhatarpur DindoriGuna Jhabua

Rajgarh KhargoneMandlaUmaria

5. It should havephysically in

adequate andcharge round

qualified medical andthe clock; (necessary

nursing staff (doctors2 & nurses3),certificates to be produced during

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6. Fully equipped and engaged in providing Medical and Surgical services, commensurateto the scope of service/ available specialities and number of beds.o Round-the-clock availability (or on-call) of a Surgeon and Anaesthetist where

surgical services/ day care treatments are offered.o Round-the-clock availability of specialists (or on-call) in the concerned specialties

having sufficient experience where such services are offered.

7. Hospital should have adequate arrangements for round-the-clock support systemsrequired for the above services like Pharmacy, Blood Bank, Laboratory, Dialysis unit,Endoscopy investigation support, Post op ICU care with ventilator support (mandatoryfor providing surgical packages), X-ray facility etc., either 'In-House' or with'Outsourcing arrangements' with appropriate agreements and in nearby vicinity.

8. Round-the-clock Ambulance facilities (own or tie-up).

9. 24 hours emergency services managed by technically qualified staff whereveremergency services are offered.

l0.Casualty should be equipped with Monitors, Defibrillator, Nebulizer with accessories,Crash Cart, Resuscitation equipment, Oxygen cylinders with flow meter/tubing/catheter/face mask/nasal prongs, Suction apparatus etc. and with attached toiletfacility.

ll.Mandatory for hospitals wherever surgical procedures are offered:. Fully equipped Operation Theatre of its own with qualified nursing staff under its

employment round the clock.o Post-op ward with ventilator and other required facilities.

l2.Wherever intensive care services are offered it is mandatory to be equipped with anIntensive Care Unit (For medicaVsurgical ICUAIDU) with requisite staffo The unit is to be situated in close proximity of operation theatre, acute care medical

and surgical ward units.o Suction, oxygen supply and compressed air should be provided for each bed.o Further High Dependency Unit (HDU) - where such packages are mandated should

have the following equipment:1) Piped gases2) Multi-signMonitoringequipment3) Infusion of ionotropic support4) Equipment for maintenance of body temperature


SINGLT /MULTISPECIALITY /SUPERSPECIALITY HOSPITALS

6. Fully equipped and engaged in providing Medical and Surgical services, commensurateto the sCope of seryice/ available specialities and number of beds.

o Round-the-clock availability (or on-call) of a Surgeon and Anaesthetist wheresurgical services/ day care treatments are offered'

. Round-the-clock availability of specialists (or on-call) in the concerned specialtieshaving sufficient experience where such services are offered.

Z. Hospital should have adequate arrangements for round-the-clock support systemsrequired for the above serviies like Pharmacy, Blood.Bank, Laboratory, Dialysis unit,

Endoscopy investigation support, Post op ICU care with ventilator support (mandatory

for ptouiOing suigical paikages), X-ray facility etc., either 'In-House' or with.Outsourcing-arrangements' with appropriate agreements and in nearby vicinity.

8. Round-the-clock Ambulance facilities (own or tie-up).

g, 24 hours emergency services managed by technically qualified staff whereveremergency services are offered.

L0.Casualty should be equipped with Monitors, Defibrillator, Nebulizer with accessories,

Crash Cart, Resusiitation equipment, Oxygen cylinders with flow meter/tubing/cath eterlface mask/nasal prongs, Suction apparatus etc. and with attached toiletfacility.

ll.Mandatory for hospitals wherever surgical procedures are offered:o Fully equipped Operation Theatre of its own with qualified nursing staff under its

employment round the clock.o Post-op ward with ventilator and other required facilities.

L2.Wherever intensive care services are offered it is mandatory to be equipped with anIntensive Care Unit (For medical/surgical ICU/HDU) with requisite staff. The unit is to be situated in close proximity of operation theatre, acute care medical

and surgical ward units.o Suction, oxygen supply and compressed air should be provided for each bed.o Further High Dependency Unit (HDU) - where such packages are mandated should

have the following equiPment:1) Piped gases2) Multi-signMonitoringequipment3) Infusion of ionotroPic suPPort4) Equipment for maintenance of body temperature

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5) Weighing scale6) Manpower for 24x7 monitoring

o ICU should also be equipped with all the equipment and manpower as per HDUnoffns, plus paediatric ventilator(s).

l3.Records Maintenanoe: Maintain complete records as required on day-to-day basis and isable to provide necessary records of hospital I patients to the Society/Insurer or hisrepresentative as and when required.. Wherever automated systems are used it should comply with NHA EHR guidelines

(as and when they are enforced and updated)o All Ayushman Bharat cases must have complete records maintained.

l.4.Legalrequirements as applicable by the local/state health authority.

l5.Adherence to Standard treatment guidelines/ Clinical Pathways for procedures asmandated by NHA from time to time.

l6.Registration with the Income Tax Department.

l7.NEFT enabled bank account

l8.Telephone/Fax

I 9. Safe drinking water facilities.

20.Unintemrpted (24 hour) supply of electricity and generator facility with requiredcapacity suitable to the bed strength of the hospital.

2l.Waste management support services (General and Bio Medical) - in compliance withthe biomedical waste management act.

22, Appr opri ate fi re-s afety measures.

23.Provide space for a separate kiosk for Ayushman Bharat beneficiary management at thehospital reception.

24.[insure a dedicated medical officer to work as a medical co-ordinator towards Ayushmanllharat beneficiary management (including records for follow-up care as prescribed)

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25.Ensure appropriate promotion of Ayushman Bharat in and around the hospital (display

bannerso btorhur.r .tr.; to*utds effective publicity of the scheme in co-ordination withthe SHA team.

26,IT Hardware requirements (desktopilaptop with internet, printer, webcam, scanner/ fax,

biometric device etc.) as mandated by the NHA.

27.Summary of mandatory documents(own or tie-up)

Name of approval Issuing Authority

PAN card Separate PAN number

Building plan approval Municipal Commissioner/ Executive Officer Panchayat

Occupancy certificate Municipal Commissioner/ Executive Offi cer Panchayat

D&Otradelicence Municipal Commissioner/ Executive Offi cer Panchayat

Fire department clearance certificate Fire Services Authority

Nursing Home Registration CM&HO

PCPNDT act Registration CM&HO

Blood bank license Director Drug Control administration (DCA)(own or tie-up)

Pharmacy license Director Drug Control administration (DCA)

Transplantation of human organs registration

certification

Director of Medical Education Committee

Pollution control board certifi cate Pollution Control Board

Registration certificate of Ambulance Regional Transport Authority(own or tie-up)

Licence for surgical sPirit Excise Authority

Licence for morphine Excise Authority

Licence for opium Excise Authority

Bio medical waste management as per rules Authorization of Pollution Control Board

Registration for operation of medical diagnostic x-ray equipment

Atomic energy regulatory board (AERB) certification

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Criteria for Non-NABH Super Specialtv Hospital Assessment Sheet

| 1 | Keylnputs | 10 | 40 I

o Each checkpoint is accompanied by means of verification in next column.r The process of assessment will take place in three steps-

1. Under all the categories, there are mandatory requirements which are to be fulfilled compulsorily2, Means of verifications which require to be assessed on basis of the scoring system as mentioned below

as mlnlmum quality standards.

Scorlnr.for Qualltv Standards -

Followlng general principles may be given following numerical score.

Full Compliance-lf the information gathered gives the impression that all the requirements ofCheckpoints and means of verification are being met, full compliance i.e. Marks-2 should beprovided for that check point.

Partial Compliance- For providing partial compliance at least 5O% or more requirements should be met. Forpartial compliance a score of 1 mark should be given

Non-Compliance- Non-compliance is assigned to when facility fails to meet at least 50% of the requirementgiven in a checkpoints and corresponding means of verification. ln this case score 0 is given

Total Score Score Achieved Percentage

t72

3. Based on the super specialty service for which the facility has to be empanelled, the minimum criteriafor respective super speciality have to be fulfilled by the facility.

A Focility should fulfill all the mandatory criterio ond the criterio for super speciolty for which they hove applied ond should at least score

more thon 70% under qualitystondord criterio to be eligible for emponelment under Ayushman Bhorot "Niramoyom"

1 | State Health Agency, Ayushman Bharat "Niramayam"-l\

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O Criteria 1- Key Inputs

This section of key inputs broadly covers the structural part of the hospital.

The certification criteria given in this category take into consideration the -o facilityinfrastructureo human resources requirements and trainingo appropriate space in hospital for patient movement. proper lighting facility in the hospitalr medical instruments and equipment requirements and maintenanceo fire-fightingequipmento Basic amenities like drinking water, waiting area, canteen, suitable toilets for men and

women etc.

Mandatorv Criteria -

Code Criteria Intemretation Means of Verification YAI

KI 1

Physical facility ofthe building andhospitalenvironment shallbe developed andmaintained for thesafety of Patients,visitors. and staff

This standard guides theprovision ofsafe andsecure environmentforpatients, visitors andstaff.To ensure this, thehospital premises musthmto haci n oc c enli nl ili o c

There should be no cattle or strav animals within theoremisesThe facility should have a guard avulable 24*7

The hospital boundary should be intact and notbrokenHospital (Building(s)) should be well maintained i.e.walls are well plastered (no cracks or seepage) andpainted

of infrastructure andshqll have annualmaintenance planforinfrastructuredevelopment. Thisincludes appearance ofthefacility, cleaningpr o c es s es, infr as tructur em aint enanc e an d c ontr o Iof stray animals at the

facility.

Windows and doors are intact and have erill/ wiremeshworkThe facility should have an annual maintenance planfor its infrastructureNon-structural components such as cupboards,cabinets and other heavy equipment or hangingobiects should be properly fastened and securedHospital building should not have wire hanginglooselyThere should be no stains, grease, cobwebs and birdnest on walls and roofs of the hospitalThere should be a closed drainage system with nodirect contact with the environment

Code Criteria Interpretation Means of Verification YAI

KI2Hospital should haveadequate space forambulance and patientmovement

This standard requires thatfacility should ensureadequate space for smbulancemovement and parking. Theaccess to the emergency/receiving area should besmooth and spaciousfor theease of patient movement andsafe handling.

Ambulance should have direct access tothe emergency/ receiving/ triage areaand access road to emergency should bewide enough to streamline themovement of the patient till theemergency/ receiving areaNo vehicle should be parked on the wayor in front ofthe emergency entrance

Dedicated parking area for theambulance

2 | State Health Agency, Ayushman Bharat "Niramayam"-t ^\

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oCode Criteria Intemretation Means of Verification YAI

KI3

Access to the hospitalshould be providedwithout any physicalbarrier and friendly topeople with disabilities

Prwisions should beav ailabl e for phys icallychal I enge d/ vulner abl eperson to make the entranceaccessible with ramps andgrab bars. Thefocility shouldh n e facil ity of wheelchair,stretcher and trolleys withs afety b elts for immediatesuDDort ofthe natient.

Availability of wheelchair,stretcher for emergency with strapsto protect the patient from fallingThe wheelchair, stretcher andtrolleys should be clean,operational and their wheelsshould be properly alienedAvailability of ramps with railingsat the entrance of the facilitv

Code Criteria Intemretation Means of Verification YA{

KI4

Basic amenitiesshould be providedfor all patients,hospital staff andvisitors

The hospital must hove anappropriate w aiting are a withs e ating arr qngemen| drinkingwater, clean toilets sensitive togender and plrysically challengedvisitors and staf personnel shouldbe present within the premises.

Availability of seating arrangementin the waiting area(s) within thehospital premises for attendantsAvailability of potable drinkingwater on each floor (functionalRO/filters)There should be a provision ofcanteen facility for visitors & staffinside the premises

Every floor should have at least onetoilet for hospital staffand visitorsAvailability of clean and functionaltoilets with no foul smell in andaround the toilet along withfunctional water tapsThe toilets floor should be dry andno drain should be overflowinsAvailability of disabled friendlytoilet with bars or railings and isaccessible throueh a rampAvailability of24*7 workingtelephone help line in hospital foreffective communication

Code Criteria Interpretation Means of Verification YA{

KI5

The hospital shouldensure that all medicalstaff is adequatelycredentialed as per the

The organization shall ensurethat the medical professionalswho have requiredqual i/i c ation, tr aining,exp er i en c e and cons onanc ewith the law are permitted toprovide the seryices and suchinformation should beappr opr i at ely v er iJi e d.Also, the facility shouldmaintain an adequate numberand mix of staf to meet the

Doctor/ Nurse/ Paramedic StafflAdmin & Support Staff along withthe current designation, educationalqualification, registration council ofname and the associated registrationnumber along with the date ofj oining and arealworkingdeoartrnent

statutorv nonns Organization should plan humanresource with adequate number andwith mix and credentials of staffasper the statutory norms

3 | St.t. Health AgencvAushman Bharat "Niramayam"

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t care. treqtment and servicesneeds ofpatients.

Hospital has dedicated staff(3members) foTAYUSHMANBHARAT "NIRAMAYAM"

Code Criteria lntemretation Means of Verification YAT

KI6

Hospital shouldhave fire detectionand fire-fightingequipmentinstalled as per firesafety nonns alongwith staff training

The facility should have plan andprovisions for early detection,abatement and containment offire

suah snh

Check if fire extinguisher,fnelsmoke detectors are installed inpatient care areas with firepanel

fire exit plan and trained sta/f,. Theperiodic training shall includeinformation, demonstration to use Jireextinguisher and mock drills

Check for date of expiry on fireextinguisher which should be thebeyond current date

The organization has a documentedsafe exit plan in case of fire andnon-fire emergenciesPeriodic training with mock drill isprovided for using fireextinguishers

Oualitv Stundnrds Criteria -Code Criteria lntemretation Means of Verification Score

KI 7

'fhe indoor andoutdoor areas ofthefacility should bewell-lit

In order to provide safe,secure and comfortableenvironment to patients andstaffthe hospital should haveprwis ion of comfort abl eenvironment in terms ofillumination either thr oughelectric bulbs andtubes qt allthe places, accompanied bynatural source of light. Also,thefront, entry and exit areasshould also be well lit.

There should be proper lighting inthe indoor areas through natural lightand by using sufficient electric bulbs

The facility's front, entry gate andaccess road are well illuminated

Codc Criteria lnternretation Means of Verification Score

KI 8

The facility hasfunctional equipmentand instruments as perscope ofservices

The hospital must have all theequipment and instrumentsaccording to the scope of servicesthey are offering. Basic functionaldiagnostic equipment should alsobe readv available.

Availability for examination andmonitoring of patients - BP apparatus,Multiparameter Torch, hammer, aninstrument to measure height, weightand Blood Pressure (BP) to conduct ageneral examination

Codc Criteria Intemretation Means of Verification Score

KI9Staff involved in

direct patient careshall be trained in

The organization shall provideregular training to the sta/fproviding direct patient care. Ifthefacility has a CPR team (e.g. code

Training Records for Basic LifeSupport (BLS)

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, Cardio PulmonaryResuscitation (CPR)and Basic LifeSupport (BLS) alongwith a display of thesame in all criticalcare areas

blue team) it shall ensure that it istrained in advancedc ardi opulmonary r e s us c it ati on(adult, pediatric and neonatal) and

There should be a code blue protocolin the organization

,D yrctvr,a att ut, tra,Jtt. 1,t aand nurses working in ICU/ HDUs h ould unde r go appr opr iat etraining and display the CPRalg.orithm at all the critical areas

Check the display of CPR algorithmin or near ICU, Clinical area andEmergency areas.

Check the records for CPR events &CPR Mock drill along with thecorrective & Preventive measurestaken

Code Criteria Intemretation Means of Verification Score

KI 10

Annual Training Planshould be prepared forall staff covering alltraining needs

The hospital should docamentplan and prepare a trainingcalendar to ensure staffis ableto identify the patient's rightsand r e sp ons i biliti es, p ot enti alhaz ar ds, m aint ain r equir e dqualtty and take appropriateactions during any disaster

Facility prepares training calendar asper training need assessment, trainingfeedback records - Training onDisaster Management, Patient safetyand rights, facility level QualityAssurance

AYUSHMANBHARAT"NIRAMAYAM" specifi c training(e.g. BIS, TMS, mM & SupportPortal, etc) to all concerned staff.

Criteria 2 - Clinical Services

These are the processes that determine the outcome of services and quality of care.

These standards include processes such as -

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' o Consultationo clinical assessmento continuity of careo nursing careo identification of high risk and vulnerable patientso prescriptionPracticeso safe drug administrationo blood bank requiremento antibiotic PolicYo Maintenance of clinical records etc'

Assessment of these standards would largely depend upon a review of the clinical records and

documents.


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Code Criteria Intemretation Means of Verification YA{

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l)uticnts privacYshoulcl b0nruitttuincd in Outl'nticnt DePartment(Olf l)) and InPatientl)cpartment (IPD)

During all the stages oJpatient care, be itexamination or carrying outa procedure, hosPital staffshqll ensure that thepatient's privacY and dignitYis maintained. There shouldbe a provision ofscreensand curtains to ensureprecautions are taken whileproviding care to Pqtients'

Check availability for privacy screensor curtains in OPD and wards formaintaining visual privacy for thepatients

Criteria

b diagnosticls. whether inttr outsourced,I br: as per theol'scrvices

Intemretation Means of Verification YAIThe facility should have MoU/Agreernent for the out-sourcedlaboratory services, whichi nc or p or ate s qual itY as suranc e

and requirements of thisstandard. Also, a list of sewicesprovided by the hosPital oroutsourced should be available.Ifthe services are outsourced,ihen the hospital should ensure

safe and timely transqortation

ofspecimens,

List the number of in-house labservices

List the number of outsourced labservices with their scoPe of work.

In the case ofoutsourced services, isthere a sample collection room and aprocedure to monitor the quality andadequacy of these services

There should be a system in place forthe daily round by matron/trospitalmanager/ hospital superintendent/Hospital Manager/ Matron in charge ofmonitoring diagnostic services

!q_scrvicesshull be

Interpretation Means of Verification YAIThe blood bank should be

functioning and adhere tostandards procedures for bloodcollection and testing. In case

Blood bank services are available inhouse or outsourced. Ifoutsourced thenadequate supPlY/storage shall be

ensured from a nearby authorized

-Strto Hoalth Agency, Ayushman B-lrarat "Niramayam"

'6\6

Tnotpitot doesn't have theblood bank it shall have a

MoU with the blood bank or the

organization having a blood

binkwhich has a valid license'

IEC materialfor blooddonation should also be

displaYed at all strategiclocations.

statutory/regulatoryBlood bink has a talid license under

Rule 122(G) Drug and cosmetic act

Btoodian-;;facttttYof bloodcollection and storage along with

lEGffitatls dGptaYed in bloodbank and nearbY area to Provideinformation and Promote blood

efr6l for availabilitY of adequatefunctional equiPment for bloodproducts - Biood bags refrigerator with

ihermograph and alarm device,

insutatJa ianier boxes with ice packs'

Blood bag weighing machine and deep

M"rtts of Verification YA{InterpretationCode Critena Cleafito ,es, aprons and masks are

available at the Point of useffiAAW /bodYParts of staffand patlenis, attendants should

be adhered to bY usingprotective devices and

equiPment, alongwith ^

orecautions as Per law Jor'radiation safetY. The facilitY

should also ensure standard

I practices, usage andsuPPlY ofI' P ers onal P r otective EquiPment

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The hosPital should

adherc to the

radiation safetyprocautions as per

tho rogulatorYroquircments

TLD b"dg.t-thould be Provided to

each staffmember in the radiation

roomLil aprons, thfoid shields and otherradiation proteition devices should be

provided ior the staff in the radiation

held. These should be tested once in 2

vears as Per AERB r!qm--i;Ai;6i6;rm services

of ve4fig4gq-InterPretatto> Scoretu

M-eu"-t of Verification YA{T6+ar6raf qflrlnCodo I ul!!gll3

I O1'comPlex should

cs5 li;.';ilil[,f0"I roquircmcnts

v P.p"il.#Ald;'the followingareas: Protective zone, clean zone'

sterileione and disposal zone . -

The organization shall ensure

that the oPeration theater has

facilities for demarcated areas'seDarote changing rooms Jormales and females along with

pr oper illumination and

fumPerature

AGililitffifi ignage stating that theentry to OT is restricted

Fr€{perative and post-operative area

should be well-lit

efranse t"omt *" a"tlable for male*i fJ*uf. staff; entry in OT should beallowed only after change in attire

ffip-erature and humiditY aremainiained and record of same is kept

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CS6

Intensive Care unit(ICU) servicesshould be availableas per the scope ofservices along withthe requiredinfrastructure andmanpower

The ICU should beequippedwith necessqrymonitoring equipment al ongwith the suitably manned bytrained staff. The hospitalshould provide proper andsafe ercvironment to theinfected patients andnecessqry proceduress houl d b e follow e d for thesame.

Flooring ofthe ICU should be non-slipperv and smoothWindows/ air vents if any should beintact and sealedComfortable temperature & humidityshould be maintainedAvailability of general duty doctor,nursing staff, paramedic and securitystaff as Der requirementsCritical care equipment is availableand maintained- Refrigerator, CrashcartlDrug trolley, instrument trolley,dressing trolley, Ventilator, Infusionpump, C-PAP, tray, monitors,Electrical panel with a bed, bedheadpanel with an outlet for Oxygen andvacuum, X-ray view box. defibrillatorAvailability of isolated area forinfectious oatientIsolation and banier nursingprocedures are followed for septicczNes


CS7

Look-alike andsound-alikemedicines need to beidentified and storedseparately to avoidany dispensing andadministrationeffors.

The drug store should arrangethe stock in alphabetic/unifu r m/ s t andardiz e d orde rand storage requirement ofthedrugs should be adhered to.The overall cleanliness andtemperature ofthe storage area

Product of similar name and differentstrength (look alike and sound alikedrugs) should be stored separately.Medicine storage shall be in a clean,well lit, and in a safe environment inaccordance with the applicable lawsand regulations

should be maintained. One lookalilre should be stored apartfron its other look alilee

Stock is ananged neatly in alphabeticorder with the name facing the frontand labels must have drug name,strength and frequency

Drug store has inventory managementsoftware


CS8

Policies andprocedures foridentification, safedispensing andadministration of allhigh-risk medicinesshould bedocumented andimplemented

Clear policies to be laid downfor dispensing of high-riskmedicines and the list of suchmedicines should be availableat the drug store. The narcoticsdrugs should be stored insecure manner

Documented procedure incorporatingstorage, prescription and dispensing ofmedicationsNarcotic medicines are kept in doublelock

Pharmacy has a list of high-risk drugsavailable with it


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CS9

The facility hasdefined andestablished antibioticpolicy

The Hospital must have ane st ab I is he d ant ib i ot i c p o li cyensuring rational use ofantibiotic/drug.

Facility should ensure the rationalusage of antibioticV drugs and policyfor the same is in place andimplemented.


CS l0

Pre-operative, Intra-operative andpostoperativeassessment shouldbe done anddocumented byappropriatelyqualified staff instandardized format

All the patients undergoingsurgery should be assessed pre-operative, intra-operative andpost-operative by the trainedstafr, which should bedocumented in a standardized

format. Also, a documentedprocedure should be available

for preventing adverse likewrong site, wrong patient andwrong surgery

There is a procedure for pre-operativeand intra-operative assessment -Physical examination, result of labinvestigation, diagnosis and proposedsurserv (3 samoles)Patient reports with post-operativenotes that should contain vital sigrs,pain control, urine and gastrointestinalfluid output, other medications andLaboratory investigations (3 samples)Documented procedure to address theprevention ofadverse events likewrong site, wrong patient and wrongsurgery.


CS 11

Pre-Anesthesiaassessments, type ofAnesthesia and PostAnesthesia statusshould beDocumented

The pre-anesthesia, poslanesthesia and type of

Department has documented procedurefor pre-operative anesthesia checkup

anestnesta snould oe monrtore'and documented in astandardized format. Also thepatient records must containregular and periodicmonitoring records of patients

Anesthesia plan is documented beforeentering into OT

Post anesthesia status is monitored andrecorded

who are under obseryation PostOper ative /Ane s t he s i a for thepurpose of tadng correctiveand preve ntive act i ons.

Post-Operative/Anesthesia monitoringincludes regular and periodic recordingofheart rate, cardiac rhythm,respiratory rate, blood pressure,oxygen saturation, airway security andDatencv

Criteria 3- Support Services

Support services are fundamental foundation of every healthcaredepartrnents things run smoothly.

It includes paftrmeters to evaluate -o Cleanlinesso Sterilizationo infection control practiceso security and facility managemento water and power supply

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These standards also cover some of the administrative processes like legal and statutorycompliances, contract management, Bio-Medical waste disposal etc.


Code Criteria Interpretation Means of Verification YAJ

SS1

The hospital shouldhave arrangement ofwater storage andshould be testedperiodically as perrequirement

The hospital shall ensure thatthere is sfficient water supplyto meet the requirements at allpoint ofuse round the clock.Alternate source of water

At least 200 liters of water per bed perday is available on a daily 24x7 basis.Adequate backup for continuous watersupply should be available (checkaltemate sources also)

should be available as backup

for anyfailure or shortage andsame should be tested onregular basis. The results ofthetests should be documented

Water is available at all points of usefor hand washing, OT, Labor room,wards, Patients toilet & bathroom.All water tanks are kept tightly closedto ensure safety

Check the records for periodic tests ofthe quality of water from the source(municipal supply, borewell, etc.) forbacterial and chemical content as perthe zuidelines


SS2

The hospital shouldhave24 hourssupply of electricityeither through direcisupply or from othersources

Hospital should haveavailability of power back up inthe form ofemergency lights,DG sets, solar energt, UPS,noiseless generators or anyother suitable source. The staffinvolyed in maintenance ofelectricity must have rubbermats, gloves and bootsfor safeworking and prevention fromanv mis- haooenins.

Check the availability of power backup, availability of UPS, emergencylights or noiseless generators

Rubber mats are available in theelectrical room below the panels andrubber gloves, boots and safety gearsare provided to the electrical staff


SS3

Medical gases andvacuum shall bemade available all thetime and storedsafely. Compressedair should be madeavailable as per thescope of services

Maniftld room should beaccessible and have adequateback up of orygen cylinders.Availability of central orygenand vacuum supply shouldespecially be assessed incritical area like OT and ICUwith standardized colourcoding ofcylinders andpipelines. A promptreplacement procedure andalarm system should beavailable to indicate any

The manifold room should be locatedon the ground floor and entry to theroom is prohibited for theunauthorized people.

The manifold room should have atleast 3 days ofoxygen and othermedical gases stoclg that is chainedaoorooriatelvColor of the gas pipeline (ifapplicable) and the gas cylinder has tobe as per the standardsThe alarm system should beoperational to indicate any abnormalpressure chanse

the room. The instructions foroperating dffirent equipment'sin manifuld room should bedisplayed clearly.

Adequate back-up of B-type cylindersin critical areas like ICU, OT and forpatient transfer DumoseThe procedure being followed forprompt replacement of empty

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ficvlinders with filled cvlindersInstruction for operating differentequipment in the manifold roomshould be clearlv displayed


SS4

The facility shouldadhere to thepractices specifiedunder statutorycompliances as perthe scope ofservices- Licenses withCertificate number,date of issue and dateof expiry

Hospital should adhere to the

Fire Department Clearance Certificate

NOC from Pollution Control Board forair and water nollutionLift License (if applicable)

Hospital Registration Certifi cate

s tatutory norms / c omp lianceslaid down by government asper the scope of services andmust provide certificates/licenses for the same

Bio-Medical Waste Management

PCPNDT Act Reeistration

AERB

Pharmacy License & Narcotics DrugsLicense (if applicable)Ambulance Registration Certifi cate,insurance Policy, pollution control andDriver License (if in house oroutsourced)

Code Criteria Interoretation Means of Verification YA{

SS5

Hospital shouldensure Bio-MedicalWaste managementpractices as per thestatutory noffns(BMW(Amendment) Rules,2018)

The organization shall beauthorized by the appropriateauthority for management ofbiomedical waste. The wasteshould be segregated andcollected in dffirent colorcoded bags and containers asper statutory norms and sameshould be available at all thepoint of waste generation.Manage m e nt of b i o me di c a Iwaste including its segregation,

Availability of color-coded bins at thepoint of waste generation along withthe display of work instructions forsegregation and handling ofBiomedical wasteThe waste should be handed over to anauthorized agency and not dischargedin any drain. Ifoutsourced, check thecontract document of outsourcedservices. Register with the weight ofwaste collected from different coloredbass should be maintainec

tr a nsp or t at t on, manageme ntand disposal ofwaste should bedone by an authorized agencywith a designated place forwaste collection andsegregation near the premises.

Facility has secured designated placefor segregation and storage ofBio-Medical waste before disposal at thewaste collection siteTransportation of bio-medical wasteshould be done in a closedcontainer/trollev

Oualitv Standards Criteria -


SS6Hospital should beclean and have wellmanaged flooring

The flooring of the hospitalshould be well managed andhave adequate cleaningprocesses like mopping,scrubbing etc. conducive for theinfection control.

The floor should be non-slippery anddry

The floor surface should be smoothenough for effective cleaning andwalkineThe facility should be cleaned at leasttwice in the day with a wet mop andare also rigorously cleaned withscrubbing at least once in a month.Check cleanins records for resular and

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SS7

Temperature controland ventilationshould bemaintained in patientcare and nursingarea

Ar r ange me nt for c omfort ab I ework environment in terms oftemperature control should beavailable in patient care areasand work stations.

Availability of fans/ air conditioning/heating/ exhaust/ air vents as per therequirement and weather condition.


12 | state Health Agency, Ayushman Bhara(Niramayam"

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SS8

The hospital shouldensure thatappropriate infectioncontrol practices ilebeing followed alongwith hand hygienepractices

The hospital infection controland prevention process should

Availability of wash basin near thepoint of use along with antiseptic soapwith soap dish/ liquid antiseptic withdispenserAvailability of alcohol-based hand rub

Availability of disinfectant/cleaningaeent as ner reouirement

be documented which aims atpreventing and reducing risk ofhealthcare associatedinfe c t i on. The organiz at i onshall also adhere to handhygie ne, cle aning, dis infecti onand s terilization guide line s.

Check if infection control manualshowing periodic update andsurveillance activities available/monitoring takes placeThe facility should follow standardpractices and materials for disinfectionand sterilization of instruments/equipmentStaff should be trained for all infectioncontrol practices, hand hygieneguideline, occupational risk and itsorevention.

Code Criteria lntemretation Means of Verification Score

SS9

Hospital shouldensure that servicesi.e. (Laundry,Housekeeping,Dietary, security,Ambulance,Mortuary, CentralSterile SupplyDepartment (CSSD)etc. are available (in-house oroutsourced).

The services lilce laundry,houselreeping, dietary, security,mortuary, ambulance CSSDetc. should be available in-house or out-sourced. Thehospital shall ensure that theyestablish adequate controls byhaving a policy to ntonitor/audit these semices. If theseservices are outsourced, thenthey should have MoU/agreement for the same.

Checklist for Desktop Assessment -Availability YesA.lo & If outsourced,MoU should be available for the same.

Intemal audits of the services to beconducted on regular intervals

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SS 10

Sexual harassmentand grievancehandling procedureshould be available

There should be disciplinaryand grievance handlingprocedures in place with ade dic at e d c omnit t e e /t e an

Committee against sexual harassmentis constituted at the facility

against sexual harassment andvarious other prievances.

Documented disciplinary andgrievance handling procedure

Criteria 4- Patient Care

Giving quality patient care have a positive effect on patient outcomes and recovery experience.Patients' rights are also an integral part of patient caxe. The important patient rights includeinformed consent, confidentiality of medical records, legible prescription etc.

Standards to be assessed are-

o uniform user-friendly signageo IEC for educating patientso patient-friendly admission and referral processo consent policieso retaining of medical recordo Education of patients

Mandatorv Criteria -Code Criteria Intemretation Means of Verification YAI

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User charges aredisplayed andcommunicated topatients effectivelyat the time ofregistration,admission to theward and in case of achanee in medical

The list ofuser charges must bedisplayed at strategic places(Reception, waiting areas,lobby) in the hospital premises

for better communication topatients and to maintaintransparency. The list must beupdated in case ofany changein medical and surgical plan.

Facility prepares a comprehensive listofuser charges and display at strategicpoints in the hospital

AYUSHMANBHARAT"NIRAMAYAM" benefi ciaries areprovided cashless services


PC2

Medical recordsshould be retained asper the policies ofHospital based onnational and locallaw

Hospital must abide by thenational and local laws forretaining medical records foreach category ofrecords: Out-patient, in-patient and MLC.The retention and destructionprocess should be included inthe process to maintainconfidentiality and security ofboth manual and electronicrecords system. Also, thereshould be a documentedprocessfor medical records ofAB PMJAY schemebeneficiaries.

Hospital has a policy of retentionperiod with respect to different kindsofrecords and their disposal

Confi dentiality of patient recordsshould be maintained by keeping themproperly in the record room or digitallysaved on a secure network

Hospital has process documentation forAYUSHMAN BHARAT'NIRAMAYAM" scheme

Ouality Standard Criteria-

14 | State Health Agency, Ayushman Bharat "Niramayam"-'I

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Code Criteria Interpretation Means of Verification Score

PC3

Hospital should haveuniform and user-friendly signagesystem in Englishand in the locallanguage understoodby Patient I familyand community

Adequate signage should bedisplayed at all strategiclocations which are permanentin nature. The semices,depart me ntal and directionalsignage, and list ofdepartments should beprominently displayed at allstrategic locations in a uniformcolor scheme, Also theessential information lilee list ofemergency c ontact numbers,list ofdoctors, patient rightsand responsibilities etc. shouldbe displayed within thehospital premises. It ispreferable that the signage isdisplayed in bilinguallanguage for the ease andu nde rs t andi ng of patie nt s.

Name of the hospital and entry-exitshould be clearly displayed outside thehospital. Entry to the emergencydepartment should also be defined anddisolaved stratesicallvHospital has directional signage with auniform color scheme.List ofdepartments (as pet scope ofservices) should be displayed inbilingual language (INCLUDINGLOCAL LANGUAGE)The scope ofservices should bedisplayed in the waiting area/ OPD/Emergency/ Reception in bilinguallanguage(INCLUDING LOCALLANGUAGE)All the services registered underAYUSHMAN BHARAT"NIRAMAYAM" are clearly defined& displayed in prominent places inunderstandable language.Display offloor layout at each floor

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Display of patients' rights andresponsibility & other related IECmaterial (outdated and tornposters/wallpapers etc. should not beput on display)Hospital has IEC specific toAYUSHMANBHARAT.NIRAMAYAM".

List ofdoctors (as per scope ofservices) with their departments andavailabilitvNo smoking signage to be Presentwithin the hospital premises

Display of hand washing instruction atthe point of use (5 moments and 7steps ofhand hygiene)Display of emergency numbersincluding ambulance, blood bank,police and referral centers

Code Criteria lnterpretation Means of Verification Score

PC4

All Signage's thoseare required bY lawshould be displayed

at all strategiclocation

All such signage which arecompulsory by law forhospitals to display such asPC&PNDT Act, AERB andradian hazard, Bio hazardsignage and Fire exit signageshould be displayed in thehospitals at all strategiclocations

Fire exit signage to be displayed at exitroute plan along with the do's anddon'ts in case of firePC&PNDT Act Signage board to bedisplayed at the waiting room andreceotion areaAERB and Radiation hazard signage

Bio-hazard signage to be present


PC5

Contact informationof key medical staffand specialist shouldbe readily availablein the emergencydepartrnent

The hospital must haveaccessible and readilyavailable contact details ofdoctors and staf members.Also, a nurse call facility and atleast one medical fficer shouldbe available at all times in thehospital in case of emergencies.

Check ifthe contact details (telephoneor residence address) of doctors/staffare readily availableNurse call facility should be availableto address any patient emergency.

At least one medical officer and anurse should be available all the timefor the emergency cases.

Code Criteria lntemretation Means of Verification Score

PC6

Service counters forthe enquiry areavailable as per thepatient load and areduly managed byhospital staff for theregistration of

There should be a dedicatedarea for enquiry as per thenumber of patients that visitsthe hospital and dedicatedkioskfor AB PMJAY mannedround the clock Hospital mustmalce sure that every Patient isgiven a unique identificationnumber at the time ofresistration of the first

Check availability ofa dedicatedenquiry area or reception

Unique identification number is givento each patient during the process ofregistration while also recordingpatient details such as name, age, sex,address and chief comPlaint etc.

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apatients interaction if the patient with

the organisation. To ensurecontinuity of care thesenumbers shall be linked to theuniaue number.

Hospital has AYUSHMAII BHAIL{T'NIRAMAYAM" Kiosk manned 24* 7


PC7

Hospital should haveestablishedprocedure foradmission ofpatients

There should be documentedprocedures for registerin( and

Admission is done by written order ofa oualified doctor

admitting the patient. Allpatients assessed in hospitalshall be registered and alladmissions must be authorizedby a doctor. The policy shouldbe defined with respect tod o cwne ntat i on and int imat i onto police in case of MedicoLegal Cases (MLC) as perstatutory requirement

There is an established criterion foradmission through the emergencydepartment

There is established procedure foradmission of Medico-Legal Cases(MLC) as per prevalent laws andprocedure to inform the police.Records for such patients are alsomaintained.

Code Criteria lnterpretation Means of Verification Score

PC8

The patient shouldbe referred to

another facilityalong with the

documented clinicalinformation, in caseof non-availabilityofservices and/or

beds.

The documented procedureaddressing the managing

patients in case ofnonavail ab i I i ty of beds.

P at ie nt s ne e di ng t ransferincluding those who have cometo the emergency but needs to

be transferred after basic first-aid, the hospital shall havedocume nted procedure for

managing patients. Thet r o n.r fe rrin s /re fe r rinq natie nt s

There is an established procedure formanaging patients in case beds are notavailable at the facility

Patient should be referred whileissuing a referral slip and should be bi-directional referral system. The recordof the same should be maintained

Adequate emergency facilities shouldbe available to provide basic first aidbefore transfer/referral

to another focility should bedone through issuing referral

slips.

AYUSHMAN BHARAT*NIRAMAYAM" Benefi ces referredto AYUSHMAN BHARAT"NIRAMAYAM"empanelledHosoitals


PC9

General Consent andInformed Consentshould be takenduring the admissionand before anyprocedures /surgeryand anesthesia/sedation

Patients and family rightsinclude that hospital shall takeinformed consent; preferably inbi-lingual and language theycan understand, signed byp at i e nt/r e I at iv e s /c a r e t alee r atthe time of admission andbefore undergoing any surgeryor procedure which discussabout all the risl


PC 10

Patient should beproperly educated onadditional care asdeemed required andall the vitalinformation shouldbe recorded forcontinuity of care

Patient should be educatedforadditional care in respect tousage and efect ofmedication,diet and nutrition which can bedone with the help of dischargesummary and growth summaryrespectively. All the vitalinformation must be recorded

for reas s e s s ment of patientsundergoing observation in thelanguage the patient/ familymembers can understand.

Patients should be educated for usageand effect of medication, diet andnutrition, immunizations and toprevent infections (as deemedappropriate)Discharge summary should contain adiagnosis, history, physicalexamination, investigation details,treatment provided and instructionsthereof in easy to understand manner(Check 3 samoles)There should be a fixed schedule forreassessment of patient underobservation based on clinical need


PC 11

Hospitals shouldensure that allmedications andassociatedinstructions arewritten in theprescription

The organization shall ensurethat the at the minimum theprescription shall have thename of the patient, uniquepatient number, name ofmedicine with thefrequency ofadministration, name andsignature of the doctor. Allhand written prescriptionshould be legible, clear andunderstandable by the patient/family member i.e. preferablyin capital letters.

Prescription should be legible, clearand be explained in the languageunderstood by the patients and iscomprehendible by the clinical staff

Every medical advice and procedure isaccompanied with date, time andsignature, unique patient number.

Criteria 5- Health Outcomes

The importance of measuring and reporting the healthcare outcomes is to improve patientexperience of care and fosters improvement and adoption of best practices, thus furtherimproving outcomes.

The standards to be assessed under this criteria are-

. OPD and IPD census

. mortality rateo average length ofstayo Surgical Site Infectiono Urinary Tract Infectiono Blood Stream Infectiono Ventilator Associated (VAP) Infection / Hospital Acquired Pneumoniao Transfusion reactiono Bedoccupancyo Patient and employee satisfaction

1I I State Health Agency, Ayushman Bharat "Niramayam"

oo reporting of adverse eventso Theft and securitv related events etc.

Mandatory Documents-


HOI

Monthly Out-Patient Department(OPD) and In-Patient Department(IPD) census

A monthly Out-PatientDepartment (OPD) and In-Patient Department (IPD)census data can help to monitorhow nuch OPD patients areconverting into IPD, how nanypatients visited the OPD andIPD and track the trend ofOPD to IPD conversion. Therate is generally affected bypoor patient satisfaction, highcost of IPD or low motivationof doctors to admit OPDpatient.

Out Patient Department (OPD) censusfor last 6 months

In-Patient Department (IPD) census forlast 6 months

AYUSHMANBHARAT'NIRAMAYAM" In-PatientDepartment (IPD) census for last 6months

Code Criteria Intemretation Means of Verification Y/I{

HO2Mortality Rate andAverage Length ofStay (ALS)

MortaliA stufistics provide avaluable measure for assessingcommunity health status. Theimp or tanc e of m ort alitystatistics derives bothfrom thesigniJicance ofdeath in anindividual's life as well as theirpotential to improve thepublic's health when used tosystematically assess andmonitor the health status of awhole community. ALS is averyc o mm on perfornanc e ne asurewhich is used not onlyimportantfor hospitalperformance but als o forclinical quality and infectioncontrol.

Mortality Rate (from the data of last 6months): Number of Patient died/Total number of patient admitted *100

Average

Length ofStay (from the data offorlast 6 months): Sum ofdays spend byeach patient/ Total number of patientadmitted


HO3 Infection Rates

An infection rate is theprobability or risk ofinfectionin a population. It is used totneasure the frequency ofoccurrence ofnew instances of

Surgical Site Infection (from the dataof for last 6 months) = Number ofsurgical site infections/ Number ofpatients operated *100


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Code Criteria Interpretation Means ofVerification Y/NI

HO6Reporting ofAdverse events

Adverse events are usually .

deJined as an unintended injuryor complication resulting inprolonged hospital stay,disability at the time ofdischarge or death caused byhealthcare management ratherthan by the patient's underlyingdisease. A substantial part ofthese events are avoidable andit is important to report them inorder to prevent such events infuture.

Data for last 6 months

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i nfe c ti on w it hin a p opu lationduring a speci/ic time period. Itwill help to identifu if anyrecurrent infections persist andimprove infection control in thehospital.

Urinary Tract Infection (from the dataof for last 6 months) = Sum of UrinaryTract Infection Complaints/ TotalNumber of patients admitted *100

Blood Stream Infection (BSI) (fromthe data of for last 6 months) :Number of Catheter related BSI/Number of patients on IV line * 100

Ventilator Associated Pneumonia(VAP/ Hospital Acquired Pneumonia(HAP) (from the data of last 6 months): Sum of Ventilator AssociatedPneumonia/ Number of patients onventilator *100

Code Criteria Interpretation Means of Verification YA{

HO4Reporting ofTransfusionReaction

They are responsible forcompleting blood request

forms, administering blood,m o nit or i ng transfus i ons andbeing vigilant for the signs andsymptoms of adverse reactions.These guidelines are intendedto enhance the inplementationof s t andar d c I inic al tr ansfus ionpractices for inproved patientsafety.

Number of Transfusion Reactions inlast 6 months


HO5 Bed occupancy

A good hospital managementincludes an effectiveallocativeplanningfor beds in ahospital. Bedoccupancy ratesand length ofstay are themeasures that reflect thefunctional abilitv ofa hosoital.

Bed Occupancy: Inpatient days ofcare/ Total number ofbeds available* 100

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HO7Reporting of Thefts/ Security relatedincidents

Thefts of medical equipment ormedical records is a majorconcern in hospitals. Healthrecords are being digitized andhence there is the danger ofhe a I th inform ati on be c o mingcompromised or stolenoutright. It is impoftant todecrease the number ofsuchincidents by enhancing securityin the facilin.


Code Criteria Intemretation Means ofVerification YAJ

HO8Reporting of needlestick injuriesInterpretation

Needle stick injury is defined asa penetrating wound typicallyinduced by a needle point orother sharp instrument orobject which could be infectedwith another person's secretion.These injuries can lead totransmis s ion of bl ood-borneviral infections. A continuousfollow-up and reporting ofneedle stick injuries insurgeons is important toprevent future events of needlestick injuries for higher patientsafetv.


Standard Criteria-


HO9 Percentage ofPatient satisfaction

Patient satisfaction is animportant and commonly usedindicator for measuring thequality in health care. Aneasure of care quality, patientsatisfaction gives providersinsights into various aspects ofme dic i ne, inc luding t heeffectiveness of their care andtheir level of empathy.

Copy ofthe filled feedback formclearly showing the questions asked (atleast 5 samples)

Patient Satisfaction : Number ofpatients responding extremelysatisfied/ Total number of patientssurveyed *100

Code Criteria Interpretation Means ofVerification Score

HO r0Percentage ofEmployeesatisfaction

Strong employee satisfaction islinlre d w i t h s i gni/ic antirnprovements in patient careand satisfaction therefore itbecomes crucial to study the

Copy ofthe filled feedback formclearly showing the questions asked (atleast 5 samples)


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per c ent age of emPl oY e e s w ho

are satisfied and Perform to

their best ofefforts in thehospital

Ernployee Satisfaction = Number ofemployees resPonding extremelY

satisfied/ Total number of employeessurveyed *100

Interpretation Means ofVerification ScoreCode CriteriaDelay in discharge ofthepatient increases the Pressureon beds ofthe hosPital anddelay in discharge is badforboth hosPitals and the Patients.Thus it becomes imPortant tocalculate the waiting time in thehospital in order to decreasethe waiting time and increasepatient safety bY Providingprompt semices

Out-patient Oepartment Waiting Time: Sum oftime from when the Patiententered the outpatient clinic to the time

the patient actually leaves the OPD/

Total Number of OutPatients

HO 1l

Waiting time - OutPatient DePartment(OPD) andDischarge

Oischarge Waiting Time: (Total timetaken for medical record to reach thebilling department from the ward +

Total time taken in the billingdepartment)iTotal Number ofTnnatients

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