GAP REPORT DISTRICT HOSPITAL RUDRAPRAYAG ......GAP REPORT DISTRICT HOSPITAL RUDRAPRAYAG UTTRAKHAND OCTAVO SOLUTIONS PVT LTD G-27, LOWER GROUND, KAILASH COLONY NEW DELHI - 110048 TEL:

1 | P a g e

GAP REPORT DISTRICT

HOSPITAL RUDRAPRAYAG

UTTRAKHAND

OCTAVO SOLUTIONS PVT LTD G-27, LOWER GROUND, KAILASH

COLONY NEW DELHI - 110048 TEL: 011-41658335,

Email:[email protected]

2 | P a g e

Table of Contents ABBREVIATION ................................................................................................................................................. 4

EXECUTIVE SUMMARY ..................................................................................................................................... 5

MAJOR FINDINGS ............................................................................................................................................. 5

HOSPITAL INTRODUCTION ............................................................................................................................... 7

KEY INDICATORS ............................................................................................................................................... 8

SIGNAGE SYSTEM ............................................................................................................................................. 9

STATUTORY REQUIREMENTS ......................................................................................................................... 10

BED DISTRIBUTION ......................................................................................................................................... 11

STRUCTURAL DETAILS .................................................................................................................................... 12

MANPOWER DETAILS ..................................................................................................................................... 13

DEPARTMENTAL GAPS ................................................................................................................................... 15

Emergency Department ................................................................................................................................. 16

OUT PATIENT DEPARTMENT .......................................................................................................................... 16

LABORATORY .................................................................................................................................................. 17

RADIOLOGY AND IMAGING (X-RAY AND ULTRASOUND) ............................................................................... 18

WARDS ........................................................................................................................................................... 18

LABOR ROOM ................................................................................................................................................. 19

OPERATION THEATRE ..................................................................................................................................... 20

BLOOD BANK .................................................................................................................................................. 21

PHARMACY STORE ......................................................................................................................................... 22

AUTOCLAVE FACILITY ..................................................................................................................................... 22

ENGINEERING AND MAINTENANCE DEPARTMENT ....................................................................................... 23

MEDICAL RECORD DEPARTMENT ................................................................................................................... 24

HUMAN RESOURCE DEPARTMENT ................................................................................................................ 24

KITCHEN (OUTSOURCED) ............................................................................................................................... 25

LAUNDRY (OUTSOURCED) .............................................................................................................................. 25

INFECTION CONTROL ..................................................................................................................................... 25

EXISTING EQUIPMENT LIST ............................................................................................................................ 26

RECOMMENDATIONS ..................................................................................................................................... 30

Self-Assessment Toolkit ................................................................................................................................. 41

PRIORITY GAPS ............................................................................................................................................... 54

3 | P a g e

SUPPORTIVE DOCUMENTS ............................................................................................................................. 65

4 | P a g e

ABBREVIATION

AMC – Annual Maintenance Contract

CMC – Comprehensive maintenance Contract

AERB- Atomic Energy Regulatory Board

UHID-Unique Hospital Identification Number

BLS- Basic life Support

OPD- Out patient Department

TLD- Thermoluminescent dosimeter,

LASA- Look alike Sound alike

BMW- Biomedical Waste

ECG- Electro Cardio Graph

MSDS- Material safety Data sheet

TPR- Temperature, Pulse and Respiration

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 Rudraprayag 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 Rudraprayag 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 Physician, Lab attendant

, Lab Technician ,Blood Bank Officer are vacant

2. There is acute shortage of nurses in wards especially in evening and night shift (i.e. 1

nurse in hospital )

3. Required Equipment like Defibrillator , Cardiac monitor ,crash cart are not available

in Emergency department

4. All required equipment are not under AMC /CMC

5. All required equipment are not calibrated

6. There is no demarcated triage area in emergency department for triaging of patients

7. Biomedical waste segregation is not according to the BMW Management Rule at all

places.

8. Foot operated Bins are not available at all places

9. In inpatient files all required forms and formats like Initial assessment form, Pre

anesthesia checkup form, Care Plan, Nursing assessment sheet are not available.

10. Safety belts are not available in wheel chairs and stretchers.

11. UHID No. is not generated while registering the patient .Only Registration number is

generated that is valid for 15 days.

12. Tested and untested blood bags are not marked separately

13. X-ray Room does not have Type and site approval from AERB

14. All the signage in the hospital are not bilingual

15. Biohazard signage are not available on all the BMW Bins

16. Emergency staff are not trained in BLS

17. There is issue with respect to drainage in the hospital. There is no proper sewerage

outlet. Mosquitoes were seen over the open drainage.

18. There is no provision of dedicated toilets for the differently able people

19. Hospital infection control practices are not evident uniformly. There is no dedicated

infection control nurse. Culture sensitivity test not carried out in critical areas like OT.

20. 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 checkup, etc. the

area outside the kitchen is unclean.

21. There is no dedicated Medical Record Department. Files are stored at nursing station

in cartons. The Coding, Indexing, and Filing of records are not evident.

22. In central store medicines are not stored alphabetically and all racks are not marked.

23. There is no dedicated person to perform sterilization activities, ward boy currently

performs it

7 | P a g e

HOSPITAL INTRODUCTION

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 Yes

03 Paediatrics and Neonatology Yes

04 Orthopaedics Yes 05 Ophthalmology Yes

06 Anesthesiology 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 Outsourced 19 Laundry Yes Outsourced

20 CSSD/TSSU Yes Sterilization room 21 Medical Records Yes Records are stored at

nursing station 22 Ambulance & Transport Yes

23 Security Services Yes 24 Housekeeping Services Yes

25 Biomedical engineering No

26 Maintenance No 27 Mortuary services Yes Only Postmortem

house

GROUP D: ADMINISTRATIVE SERVICES 28 General Administration Yes

29 Account & Finance Yes

8 | P a g e

KEY INDICATORS

INDICATORS November-

2018

October-

2018

September-

2018

August-

2018

July-

2018

June-

2018

IP

Admissions

312 234 254 516 365 394

OPD 6904 5210 6475 7578 1717 8507

SURGERIES

(Minor)

06 03 10 07 11 20

SURGERIES

(Major)

03 - 03 07 05 19

X-RAYS 424 371 435 442 326 443

USG 470 300 146 367 493 404

LAB 2136 2003 2315 2998 3125 2892

BIRTH 101 66 80 100 100 103

DEATH 02 01 01 - - 01

9 | 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 NA Only patient’s responsibilities

Mission No NA

Vision No NA

Patients Rights& Responsibilities Yes No NA Only responsibilities

Scope of Services Yes No No Tariff List Yes No NA

Doctors list along with their Specialties and Qualifications

No No NA

OPD Schedule of Doctors (Specialty, Timings and Day of Availability)

Yes No NA

Biohazard Symbols Yes NA Yes Fire Exit Plan Yes No No

Floor Directory Yes No No Not on all floors

Wash Rooms (Differently Able) No No No Toilets Yes No No

Ambulance Parking Area Yes No No Drinking Water Yes No No

Health Education Related Signage (HIV & Immunization)

Yes No No

10 | P a g e

STATUTORY REQUIREMENTS

Licenses Available YES/NO

Building Occupancy/Completion Certificate No

Clinical Establishment Act Certificate No

Approved Fire Exit Plan Yes

License under Bio- medical Management and handling Rules, 1998. No (Under Renewal)

PNDT Certificate Yes

Site & Type Approval for X-Ray from AERB No

License for Blood Bank Yes

11 | P a g e

BED DISTRIBUTION

Class/Department Beds

Labor Ward 9

Post-operative ward 4 Ortho ward 9

Surgical Ward 9

Medicine Ward 9

Buffer Ward 9 Isolation Ward 2

VIP Room 2

Total 53

Sanctioned Beds = 75

Actual Beds = 53

12 | P a g e

STRUCTURAL DETAILS

Category

A. Land (not available)

B. Building 28777.50 Sqft

C. HVAC Availability of HVAC system No

Number Capacity

D. Electricity

Transformer 1 63 KVA

DG set 2 40 KVA 62.5 KVA

UPS 0.5 KVA (2) 1 KVA (3) 3 KVA (1) 2 KVA (1)

9 KVA

Total Load Sanctioned 60 KVA

E. Water Water Tanks (Sump) 1000 Litre (2) 500 Litre (13)

8500 liters

Water Tanks (Overhead) 2 5000 liters

Sources of water Jal sansthan Rudraprayag

13 | P a g e

MANPOWER DETAILS

S.NO. DESIGNATION SANCTIONED ACTUAL VACANT

1. Chief Medical Superintendent

1 1 0

2. Senior Medical Officer

1 1 0

3. Senior Gynecologist 1 1 0 4. Dental Surgeon 1 1 0

5. Orthopedician 1 1 0

6. Radiologist 1 1 0

7. Pathologist 1 1 0

8. Gynaecologist 2 1 1 9. ENT Surgeon 1 1 0

10. Cardiologist 1 1 0 11. EMO Male 3 3 0

12. EMO Female 2 2 0 13. Physician 1 0 1

14. Surgeon 1 1 0

15. Pediatrician 1 1 0 16. Anesthetist 1 1 0

17. GDMO Male 1 1 0

18. GDMO Female 1 1 0

Total 22 20 2 19. Physiotherapist 1 1 0

20. Assistant Matron 1 1 0

21. Sister 5 5 0 22. Nursing Staff 11 9 2

23. Pharmacy officer 1 0 1 24. Chief Pharmacist 3 3 0

25. Pharmacist 6 5 1 26. Nursing assistant 1 1 0

27. Dental Hygienist 1 1 0

28. Lab technician 1 1 0

29. X-ray technician 1 1 0

30. Chief Administrative officer

1 0 1

31. Administrative officer

1 1 0

32. Senior Assistant 1 1 0

33. Clerk 1 3 0 34. Dark room assistant 1 1 0

35. Lab attendant 1 0 1

36. Ward Boy 11 9 2

37. Blood Bank officer 1 0 1

14 | P a g e

38. Lab Technician 2 0 2

39. Staff nurse 1 0 1 40. Lab attendant 1 0 1

41. Sweeper 1 0 1

Total 55 41 14 42. Driver 2 2 0

43. Peon 2 2 0 44. Choukidar 1 1 0

Total 82 66 16

Sanctioned Post – 82

Actual Filled – 66

Vacant- 16

15 | P a g e

DEPARTMENTAL GAPS

16 | P a g e

Emergency Department

S

T

R

U

C

T

U

R

E

• There is no demarcated Triage area for triaging of patients • Nurse is not available round the clock for emergency care of patient, Ward

nurse takes care of emergency patients and pharmacist is available round the clock

• Crash cart with defibrillator, emergency drugs and cardiac monitor is not available

• X-ray view box is not available in consultant’s room • Safety belts are not available in wheel chairs and stretchers • List of all staff that contain Name , contact details and designation is not

available • All Signage are not bilingual • Emergency signage is not visible from the road with proper lightning and signs •

P

R

O

C

E

S

S

• Documented policies and procedures are not available • Standardized Forms and formats are not available • Triaging of patient is not done • BMW is not segregated and handled properly • Staff are not trained in BLS/ALS • Near Expiry date medicines were available in the injection room. Medicine

expiring in Jan 2019 was available in the injection room. • In injection Room on sterilization drums date of sterilization and expiry was

not mentioned O U T C O M E

• Time for initial assessment of the patient not monitored

• Monitoring of No. of Patients returned to emergency within 72 Hrs is not done

OUT PATIENT DEPARTMENT

S T R U C T U R E

• Separate Queue for differently abled is not available

• Separate and functional toilet for differently abled is not available

• Patient privacy screen is not available in all the OPDs

• Weighing machine is not present in all the OPDs. (ortho OPD)

• BP apparatus , weighing machine, Height Scale and thermometer are not

calibrated

• Safety belts are not available in Wheel chair and stretchers

17 | P a g e

• All Signage are not bilingual and directional signage are not available

• Mission and vision of the hospital is not displayed

P R O C E S S

• Documented policy and procedures are not available • UHID number is not generated for all the patients • No separate registration for old and new OPDs

O U T C O M E

• Waiting time is not monitored

• OPD Patient satisfaction survey is not conducted

LABORATORY

S T R U C T U R E

• No demarcated area for sample collection

• Laboratory equipment are not under AMC/CMC

• Equipment are not calibrated

• Signage are not bilingual

P R O C E S S

• Scope of services are not defined and displayed • No documented procedure to guide collection , identification ,handling ,safe

transportation ,processing and disposal of specimen • Critical results are not intimated immediately to the concerned person • Laboratory tests not available in the organization are not outsourced • Temperature monitoring of refrigerator is not done •

O U T C O M E

• Turnaround time is not monitored

• Number of reporting errors per 1000 investigation are not monitored

• Percentage of adherence to safety precautions

• Percentage of redo’s

18 | P a g e

RADIOLOGY AND IMAGING (X-RAY AND ULTRASOUND)

S T R U C T U R E

• X-ray unit has no site and Type approval from AERB

• There is no changing room for patients

• TLD Badges are not available

• Lead aprons are available but not placed is the right manner

• Gonad shield and thyroid shields are not available

• Critical results are not defined, reported and documented.

• Working Indicator (Red Bulb) is not on the x-ray door to show that x-ray is

ongoing.

• X-ray machine and ultrasound machine are not under AMC/CMC.

P R O C E S S

• There is no documented policy and procedures for radiology and imaging department.

O U T C O M E

• Turnaround time is not monitored

• Number of reporting errors per 1000 investigation are not monitored

• Percentage of adherence to safety precautions

• Percentage of redo’s

WARDS

S T R U C T U R E

• Emergency crash cart with defibrillator is not available

• Nurses are not adequate for each shift

• Racks are not available to store linens

• X-ray view box is not available at nursing station.

• Weighing machine is not available at nursing station

• Refrigerator Temperature is not monitored thrice a day on temperature sheet

• Foot operated Biomedical waste bins are not available

• Grab bar in the toilets are not available.

P • Documented policies and procedures are not available

19 | P a g e

R O C E S S

• Required forms and formats are not available (Pre anesthesia checkup form , Plan of care

• Vitals are checked but are not documented in each file • Staff is not trained in BLS • All staff is not aware of transfer IN/OUT System. • Discharge process is not defined and documented. • The content of discharge summary is not appropriate. It does not include

when and how to obtained urgent care.

• The blood transfusion consent is not present. The transfusion record is not

available and the reporting of transfusion reaction is not being done.

• Look alike, sound alike medicines is not identified and stored separately. • Multi-use open vials do not have labels of date of opening and date of expiry. • Proper identification of patient before carrying out any patient care Activity is

not being done. • High risk medicines is not identified and stored separately. • The 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 •

O U T C O M E

The quality indicators are not be monitored. These are- • Percentage of Patients receiving high risk medications developing adverse drug

event. • 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, Incidence of blood body fluid

exposures, Incidence of needle stick injuries • Patient satisfaction rate of the ward.

LABOR ROOM

S T R U C T U R E

• Separate areas are not demarcated for septic and aseptic deliveries

• Changing room is not available

• Crash cart with defibrillator is not available

• ECG Monitor is not available

• Disposable HIV Kits are not available as per the load

• Scope of services are not displayed

20 | P a g e

P R O C E S S

• There is no documented procedure to guide the care of obstetrical and Gynecology patients

• No of labor room instruments counted before and after use but are not documented

O U T C O M E

• Maternal Mortality rate is not monitored

• Still birth rate is not monitored

OPERATION THEATRE

S T R U C T U R E

• One OT has more than one OT table that table is not used for operation.

• Crash cart with defibrillator is not available

• Required equipment are not under AMC/CMC

• There is no designated Nursing staff for OT .(OT Nurse) ward nurse assist the

doctors/surgeons

• Patient ,personnel and material flow do not confirm to infection control

practices

P R O C E S S

• No documented procedure to guide the care of patients undergoing surgical procedures

• No documented policy and procedure for administration of anaesthesia • Pre anaesthesia check-up do not result in formulation of an documented

anaesthesia plan • Immediate preoperative re-evaluation is not documented • The WHO surgical safety checklist is not being followed for patient. • Immediate pre-operative check-up before wheeling in patient in operation

room from pre-operative ward was not performed. • 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 to have a label of date of opening and expiry • High risk medicines are not stored separately. • Each operation room is not monitored for humidity and temperature on daily

basis.

https://expresshealthcaremanagement.blogspot.in/2018/04/criteria-discharge-of-patients-from-OT-recovery.html

21 | P a g e

• All areas of OT are not kept clean from dust all the time. • Regular environmental surveillance for microbes is not done in each OT and

other areas to identify forming of any colonies of bacteria. O U T C O M E

• % 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.

BLOOD BANK

S T R U C T U R E

• There is no designated staff nurse for blood bank

• Signage are not bilingual

• Scope of services are not displayed

• There is no separate counseling section

• Equipment are not under AMC/CMC

• Required equipment are not calibrated

• Tested and untested blood are not marked separately

P R O C E S S

• Policies and procedures for blood bank are not available • Blood transfusion reaction forms are not available and used.

O U T C O M E

• Turnaround time for issue of blood is not monitored

• Percentage of blood wastage is not monitored

22 | P a g e

PHARMACY STORE

S T R U C T U R E

• There is no marking of receiving area , segregation area and storing area

• There is lack of sufficient racks for storage of medicine. Medicines are stored on floor

• There is no list of LASA Drugs and are not stored separately

• There is no provision for storage of narcotic drugs (double lock and key

system)

• Refrigerator temperature is not monitored thrice a day in a register.

P R O C E S S

• Departmental policies and procedures are not available • Items are not labeled and arranged as per alphabetical order • Look alike and sound alike (LASA) medicines are not identified and a list is not

available. • Staffs are 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)

• High risk medicines are not identified and a list is not available. • Pharmacists are not aware on what to do if prescription is not clear or legible

(policy of confirmation of medicine from the prescribing doctor). • Narcotics were not stored under double lock and key. • Pharmacists are not aware on policy on verbal order of prescription medicine. • Staff at pharmacy was not aware on practice of preventing expiry of medicine

(FIFO method, identifying near expiry medicine, identifying medicine with short shelf life).

• Staff at pharmacy is not aware of situation when medicine recall is warranted and the procedure of recall.

• List of all hazardous materials stored in pharmacy is not available. MSDS for each hazardous material are not kept available for ready reference of staff

O U T C O M E

• Percentage of stock outs are not monitored

• Percentage of variation from the procurement process is not monitored

AUTOCLAVE FACILITY

• Layout does not follow the functional flow. areas are not demarcated as mentioned below:

▪ Receiving area ▪ Washing area ▪ Decontamination area

23 | P a g e

I D E N T I F I E D G A P S

▪ Drying ▪ Packing ▪ Loading area ▪ Unloading ▪ Storing ▪ Issuing area.

• Calibration of pressure meter is not done • Racks are not available • Sterilization is done by ward boy there is no technician • Recall system of items is not followed • Transport trolley for sterile items is not available • Documented Reuse policy is not available

ENGINEERING AND MAINTENANCE DEPARTMENT


• Up-to-date drawing, layouts and escape route are not maintained. • There was evidence of seepage on the walls, chipping of plasters, visible cracks

on the walls and roofs, broken flooring, slippery floors, fungus on the walls, bulges, and peeling of paint.

• There is no grab bars, safety belts on stretchers and wheelchairs, alarm system, call bells and fire detection devices available.

• There is no safety committee (including representatives from facility management, clinicians, administrator, nursing and paramedical staff) to coordinate development, implementation and monitoring of safety plans.

• The stray animals were roaming in hospital.(at disposal site) • There were no florescent strips in the stairs. Floor wise fire evacuation plan is

not displayed • The organization does not identify the potential emergencies and not prepared

for emergencies like earthquake, major fire, flood, etc. • There is no documented disaster management plans and mock drills are not

being carried out for emergency codes. • Hazardous materials was not labelled and stored at appropriate place. Material

Safety Data Sheet was not displayed. • Equipment are not periodically inspected and calibrated. • Regular rounds of biomedical engineer are not conducted. There is no

designated person handling the medical equipment related issues. • The periodic facility inspection is not being carried out to identify the

environmental hazards and risk.

24 | P a g e

MEDICAL RECORD DEPARTMENT


• The hospital does not have any department for keeping Medical Records. The records are stored in boxes with at nursing station. The Coding, Indexing, and Filing of records are 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, Pre anesthesia checkup form Intake /Output chart, TPR chart, etc.

• Entry in the medical record is not named, signed, dated and timed. The author of Entry in the medical record is not named, signed, dated and timed. The contents of a patient medical record are not identified and defined e.g. admission order, face sheet, IP sheets does not have a proper format.

• The patient file does not provide a complete, up-to-date and chronological account of patient. The organization does not have an effective process for document control e.g. the forms and formats which is being used is not standardized and do not have identification code.

• The retrieval of the records is not easy. Deficiency checklist is not followed. The hospital does not have retention policy for documents. The outcome indicators like % of missing records, % of records with ICD codification done, Percentage of medical records not having discharge summary, Percentage of medical records not having consent form, % of records with ICD codification done, Percentage of medical records not having discharge summary, Percentage of medical records not having consent form is not being monitored.

HUMAN RESOURCE DEPARTMENT

I D E N T I F I E D G A

• The employees are not aware of their rights, responsibilities • There is no training program when job responsibilities changes and when

new equipment gets installed. • There is no documented training and development manual present for

employees. • No evidence of training Need Analysis • Employee’s satisfaction survey is not done and analyzed • There is no feedback mechanism for improvement of training and

development program.

25 | P a g e

P S

KITCHEN (OUTSOURCED)

I

D

E

N

T

I

F

I

E

D

G

A

P

S

• No qualified dietician is available to supervise the functioning of the

department.

• Patient & family members are not educated regarding the limitations of diet.

• The kitchen does not have demarcated area such as receiving, washing,

chopping /cutting, cooking, storing etc.

• Staff working in this department does not undergo any regular health check up.

• 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.

• No monitoring of indicators like no of complains received food wastage etc.

LAUNDRY (OUTSOURCED)

• Site inspection of washing area is not done by hospital staff • There is no documented policy and procedure • Racks to store washed linen are not available. Washed linen are stored in a

safe with other documents

INFECTION CONTROL

I

1. There is no documented infection prevention and control programme. 2. The organization does not adhere to standard precautions at all times. 3. There is no cleaning protocol for equipment. 4. There is no antibiotic policy established. 5. There is 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.

26 | P a g e

D E N T I F I E D G A P S

6. The infection control surveillance data is not being collected. 7. Brooming and dry dusting is evident which is not acceptable. 8. The disinfectant which is being used in the hospital is not undergone any sterility

test. Phenyl/Lysol is used as disinfectant. 9. There is no established recall procedure for breakdown identified in the

sterilization system. 10. Antibiotic audit is not carried out to ensure adherence to antibiotic policy. 11. Equipment cleaning & sterilization practices need to be strengthened. 12. The biomedical waste bins are not foot operates and there is no labeling of

biohazard symbol in BMW buckets. 13. 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

27 | P a g e

EXISTING EQUIPMENT LIST

Area Equipment Quantity Functional

Radiology Ultrasound 1 1

X-Ray (Fixed) 1 1

Cassettes X-Ray 9 9

Lead Apron 2 2

Baby Incubator 1 1

Phototherapy Unit 1 1

Emergency Resuscitation Kit Baby 1 1

Weighing Machine Adult 1 1

Syringe Infusion Pump 1 1 Radiant Warmer 1 1

Slit Lamp 1 1

Vision Drum 1 1

IOL Open Set 1 1

Ophthalmic Surgical Instrument 1 1

Eye Microscopy 1 1

Dental Air Rotors 1 1

Dental Unit Motor 1 1 X-ray 1 1

Laboratory

HaematologyAnalyser 22 Parameter 1 1

Micro Pippetes of Different Volume Y Y

Hot Air Oven 1 1

Lab Incubator 1 1

Electric Centrifugal Top 1 1

Counting Chamber 1 1

Haemoglobino meter 1 1

TC DC Count Apparatus 1 1

ESR Stand Tubes Y Y

Test Tubes Stand Y Y

Alarm Clock 1 1

Operation Theatre

Operation Table Hydraulic 5 4

28 | P a g e

Shadow less Lamp Ceiling Type 5 5

Suction Apparatus 4 4

Apparatus trolley 6 6

C arm 1 1

Pulse oxymeter 5 5

Diagnostic Laparoscope 1 1

Gastro scope 1 1

Cautery 1 1

Defibrillator 1 1

Boyel’s Apparatus 3 3

Multipara Monitor 3 3

Diathermy 1 1

Autoclave Room

Auto. Steam sterilizer 2 2

Physiotherapy

CPM machine 1 1

Trans-cutaneous electrical nerve stimulator 1 1

Mobile ultrasound therapy unit 1 1

Standard tilt table for physiotherapy 2 2

Microcontroller stimulator 1 1

Short wave diathermy unit 1 1

Electrical stimulator 1 1 Peripheral pulse Doppler

Blood Bank

Blood bank refrigerator 2 2

binocular microscope 1 1

Microprocessor based centrifuge 1 1

Automated immunoassay analyser 1 1

Blood bag tube sealer 1 1

Blood collection monitor 1 1

29 | P a g e

OPD Stethoscope 6 6

Sphygmomanometer 6 6

X-ray View box 6 6

Thermometer 1 1

Weighing Machine (Adult) 1 1

Weighing Machine (Paed) 1 1

Screen 5 5

Wards(Gen) Stethoscope 1 1

Sphygmomanometer 1 1

Thermometer 1 1

Weighing Machine 1 1

Medicine/Dressing Trolley 1 1

Emergency

ECG 1 1

Sthetho 1 1

Sphygmo 1 1

Thermometer 1 1

Pulse oximeter 1 1

Drug/Dressing Trolley 1 1

Suction Apparatus 1 1

Nebulizer 1 1

Glucometer 1 1

30 | P a g e

RECOMMENDATIONS

31 | P a g e

1. Emergency

• Triage area should be marked for triaging of patients

• Round the clock nursing staff should be available in the emergency department

• Crash cart with defibrillator should be available.

• X-ray view box should be fixed in the consultant’s room

• Emergency staff should be trained in a BLS/ALS

• Safety belts should be provided in the stretcher and wheelchairs for the safety of the

patients

• All the signages should be bilingual

• Foot operated biomedical waste bins should be provided

• Biomedical waste segregation should strictly follow the BMW Management rule.

• Time for initial assessment of the patient should be monitored

• Emergency department signage should be visible from the road with proper lightning

(glow signage)

• Near Expiry date medicines should be removed /Replaced

2. Out Patient Department

• Separate Queue for differently abled should be provided

• Separate and functional toilet for differently abled should be provided

• Patient privacy screen should be available in all the OPDs

• Weighing machine should be present in all the OPDs.

• BP apparatus , weighing machine, Height Scale and thermometer should be calibrated

• Safety belts should be available in Wheel chair and stretchers

• All Signage should be bilingual and directional signage are should be displayed

• Mission and vision of the hospital should be finalized and displayed

• Documented policy and procedures should be finalized

• UHID number should be generated for all the patients

• Record for separate registration for old and new OPDs

• Waiting time should be monitored

• OPD Patient satisfaction survey should be conducted by collection the patient

feedback forms.

3. Laboratory

• sample collection area should be marked

• All the required Laboratory equipment should be under AMC/CMC

• All the required Equipment should be calibrated

• All the Signage should be bilingual

• Scope of services should be defined and displayed

32 | P a g e

• Documented procedure to guide collection , identification ,handling ,safe

transportation ,processing and disposal of specimen should be available

• Critical results should be intimated immediately to the concerned person/Pathologist

• Laboratory tests not available in the organization should be outsourced

• Temperature monitoring of refrigerator should be done

• Turnaround time should be monitored

• Number of reporting errors per 1000 investigation should be monitored

• Percentage of adherence to safety precautions should be monitored

• Percentage of redo’s should be monitored

• Foot operated bins should be provided

4. Radiology and Imaging

• X-ray unit should have site and Type approval from AERB

• changing room for patients should be provided

• TLD Badges should be available for each technician

• Lead aprons should be hanged on a hanger and placed is the right manner

• Gonad shield and thyroid shields should be provided

• Critical results should be defined, reported and documented.

• Working Indicator (Red Bulb) should be fixed on the x-ray door to show that x-ray is

ongoing.

• X-ray machine and ultrasound machine should be under AMC/CMC.

• Documented policy and procedures should be available for radiology and imaging

department.

• Turnaround time should be monitored

• Number of reporting errors per 1000 investigation should be monitored

• Percentage of adherence to safety precautions should be monitored

• Percentage of redo’s should be monitored

5. WARDS

• Emergency crash cart with defibrillator should be provided

• Adequate nursing staff should be available in each shift

• Racks should be provided to store clean linen

33 | P a g e

• X-ray view box should be available at nursing station.

• Weighing machine should be available at nursing station

• Refrigerator Temperature should be monitored thrice a day on temperature

monitoring sheet

• Foot operated Biomedical waste bins should be available

• Grab bar should be fixed in the toilets .

• Documented policies and procedures should be available

• Required forms and formats should be available (Pre anesthesia checkup form , Plan

of care

• Vitals should be checked and documented in each file

• Staff should be trained in BLS

• Staff should be aware of transfer IN/OUT System.

• Discharge process should be defined and documented.

• The content of discharge summary should be appropriate. It should include

when and how to obtained urgent care.

• The blood transfusion consent should be available and taken where required.

• Look alike, sound alike medicines should be identified and stored separately.

• Multi-use open vials should have labels of date of opening and date of expiry..

• The recording of patient condition like vital signs monitoring, physical examinations etc should be documented.

• High risk medicines should be identified and stored separately.

• The reporting of adverse patient events should be done.

• Percentage of Patients receiving high risk medications developing adverse drug event should be monitored

• Percentage of admissions with adverse drug reactions (s) should be monitored

• Incidence of medication errors (Medication errors per patient days) should be monitored

• Appropriate handovers during shift change should be taken (To be done separately for doctors and nurses per patient per shift).

• List of hazardous materials in the ward should be identified and MSDS sheet should

be displayed.

• Incidence of hospital associated pressure ulcers after admission (Bed sore per 1000 patient days) should be monitored

• Incidence of falls should be monitored

34 | P a g e

• Catheter associated Urinary tract infection rate, Incidence of blood body fluid exposures, Incidence of needle stick injuries should be monitored

• Patient satisfaction rate of the ward should be monitored

6. Labor Room

• Separate areas should be demarcated for septic and aseptic deliveries

• Changing room should be available

• Crash cart with defibrillator should be available

• ECG Monitor should be provided

• Disposable HIV Kits should be provided in adequate no.

• Scope of services should be displayed

• Documented procedure to guide the care of obstetrical and Gynaecology patients

should be available

• No of labor room instruments counted before and after use should be documented

• Maternal Mortality rate should be monitored

• Still birth rate should be monitored

7. Operation Theatre

• One OT should not have more than one OT table

• Crash cart with defibrillator should be available

• All required equipment should be under AMC/CMC

• There should be designated Nursing staff for OT .(OT Nurse)

• Patient ,personnel and material flow should confirm to infection control practices

• Documented procedure to guide the care of patients undergoing surgical procedures

should be available

• Documented policy and procedure for administration of anaesthesia shoul be

available

• Pre anaesthesia check-up should result in formulation of an documented anaesthesia

plan

• Immediate preoperative re-evaluation should be documented

• The WHO surgical safety checklist should be followed for patient.

• Immediate pre-operative check-up before wheeling in patient in operation room from

pre-operative ward should be performed.

• The plan of care should be documented. The desired result of treatment should be

documented.

• Defined criteria should be used to decide shifting of patient from post-operative ward.

The post-operative monitoring should be carried out.

• Look alike, sound alike medicines should be stored separately.

https://expresshealthcaremanagement.blogspot.in/2018/04/criteria-discharge-of-patients-from-OT-recovery.html

35 | P a g e

• Multi-use open vials should have a label of date of opening and expiry

• High risk medicines should be stored separately.

• Each operation room should be monitored for humidity and temperature on daily

basis.

• All areas of OT are not kept clean from dust all the time.

• Regular environmental surveillance for microbes should be done in each OT and

other areas to identify forming of any colonies of bacteria.

• Percentage of modification of anaesthesia plan should be monitored • Percentage of unplanned ventilation following anaesthesia should be monitored • Percentage of adverse anaesthesia events should be monitored • Percentage of rescheduling of surgeries should be monitored • Percentage of adverse events like wrong patient, wrong site, wrong surgery should be

monitored • OT utilization rate should be monitored. • Percentage of cases received antibiotic prophylaxis within defined time frame should

be monitored.

8. Blood Bank

• Designated staff nurse should be available for blood bank

• All Signage should be bilingual

• Scope of services should be displayed

• Separate counseling section should be marked

• Equipment should be under AMC/CMC

• Required equipment should be calibrated

• Tested and untested blood should be marked separately

• Policies and procedures for blood bank should be available

• Blood transfusion reaction forms should be available and analysed.

• Turnaround time for issue of blood should be monitored

• Percentage of blood wastage should be monitored

9. Pharmacy Store

• Marking should be done for receiving area , segregation area and storing area

• sufficient racks for storage of medicine should be provided

• List of LASA Drugs should be available and are not stored separately

• Narcotic drugs should be stored separately (double lock and key system)

• Refrigerator temperature should be monitored thrice a day in a register/temperature

monitoring sheet.

36 | P a g e

• Departmental policies and procedures are not available

• Items are not labeled and arranged as per alphabetical order

• Look alike and sound alike (LASA) medicines are not identified and a list is not

available.

• Staffs should be 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)

• High risk medicines should be identified and a list should available.

• Pharmacists should be aware on what to do if prescription is not clear or legible

(policy of confirmation of medicine from the prescribing doctor).

• Pharmacists should be aware on policy on verbal order of prescription medicine.

• Staff at pharmacy should be aware on practice of preventing expiry of medicine (FIFO

method, identifying near expiry medicine, identifying medicine with short shelf life).

• Staff at pharmacy should aware of 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 should be available .

• Percentage of stock outs should be monitored

• Percentage of variation from the procurement process should be monitored

10. Autoclave Facility

• Layout should follow the functional flow. areas should be demarcated as mentioned below:

▪ Receiving area

▪ Washing area

▪ Decontamination area

▪ Drying

▪ Packing

▪ Loading area

▪ Unloading

▪ Storing

▪ Issuing area.

• Calibration of pressure meter should be done • Racks for storage of sterile material should be available • Sterilization should be done by technician/trained staff • Recall system of items should be followed • Transport trolley for sterile items should be available

37 | P a g e

• Documented Reuse policy should be available

11. Engineering and Maintenance Department

• Up-to-date drawing, layouts and escape route should be maintained.

• There should not be any evidence of seepage on the walls, chipping of plasters, visible cracks on the walls and roofs, broken flooring, slippery floors, fungus on the walls, bulges, and peeling of paint.

• Grab bars, safety belts on stretchers and wheelchairs, alarm system, call bells should be available

• Safety committee (including representatives from facility management, clinicians, administrator, nursing and paramedical staff) to coordinate development, implementation and monitoring of safety plans should be constituted.

• Stray animals should not roaming in hospital.(at disposal site)

• Florescent strips in the stairs should be pasted. Floor wise fire evacuation plan should be displayed

• The organization should identify the potential emergencies and prepared for emergencies like earthquake, major fire, flood, etc.

• Documented disaster management plans should be available and mock drills should be conducted for emergency codes. (Code Red , Code Blue , Code Pink etc)

• Hazardous materials should be labelled and stored at appropriate place. • Equipment should be periodically inspected and calibrated. • Regular rounds of biomedical engineer should be conducted. There should be

designated person handling the medical equipment related issues. • The periodic facility inspection should be carried out to identify the environmental

hazards and risk.

12. Medical Record Department

• The hospital should have department for keeping Medical Records.. The Coding,

Indexing, and Filing of records should be done. The medical records should be stored

securely and away from rodents.

• Designated person i.e. medical record technician for taking care of medical records

should be available .The patient records should have all relevant forms & formats

like Nurses Records, Medication chart, Pre anesthesia checkup form Intake /Output

chart, TPR chart, etc.

• Entry in all medical record should be named, signed, dated and timed. The author of

Entry in the medical record should be named, signed, dated and timed. The contents

38 | P a g e

of a patient medical record should be identified and defined e.g. admission order,

face sheet, IP sheets does not have a proper format.

• The patient file should provide a complete, up-to-date and chronological account of

patient. The organization does not have an effective process for document control

e.g. the forms and formats which is being used is not standardized and do not have

identification code.

• The retrieval of the records should be easy. Deficiency checklist should be followed.

The hospital should have retention policy for documents. The outcome indicators

like % of missing records, % of records with ICD codification done, Percentage of

medical records not having discharge summary, Percentage of medical records not

having consent form, , Percentage of medical records not having discharge summary,

Percentage of medical records not having consent form should be monitored.

13. Human Resource Department

• All employees should be aware of their rights & responsibilities • Training program should be conducted when job responsibilities change and when

new equipment is installed and same should be documented • Documented training and development manual should be present for employees. • Training Need Analysis should be done • Employee’s satisfaction survey should be done and analyzed • There should be feedback mechanisms for improvement of training and development

program.

14. Kitchen (Outsourced)

• Qualified dietician should be available to supervise the functioning of the

department.

• Patient & family members should be educated regarding the limitations of diet.

• The kitchen should have demarcated areas such as receiving, washing, chopping

/cutting, cooking, storing etc.

• Staff working in this department should undergo regular health check up . Record for

the same should be maintained

• Patient and family members should be educated on food & drug interactions.

• Food evaluation should be done before serving to patient.

• Nutritional assessment should be done.

• Cleaning schedule for the kitchen should be available.

39 | P a g e

• Documented policy for storage, preparation, distribution & disinfection processes

should be available.

• Indicators like no of complains received food wastage etc should be monitored

15. Laundry (Outsourced)

• Site inspection of washing area should be done by hospital staff • Documented policy and procedure should be available for the department • Racks to store washed linen should be available.

16. Hospital Infection Control

• Documented infection prevention and control program should be available

• The organization should adhere to standard precautions at all times.

• Cleaning protocol for equipment should be available

• Antibiotic policy should be established.

• Appropriate engineering control should be available to prevent infections which include design of patient care areas (optimum spacing between beds), operating rooms, air quality and water supply checks.

• The infection control surveillance data should be collected.

• Brooming and dry dusting should not be done in the wards

• The disinfectant which is used in the hospital should undergo sterility test.

• There should be an established recall procedure for breakdown identified in the sterilization system.

• Antibiotic audit should be carried out to ensure adherence to antibiotic policy.

• Equipment cleaning & sterilization practices should be strengthened.

• The biomedical waste bins should be foot operated and biohazard symbol should be labeled on BMW buckets.

• The outcome should be monitored-

▪ Catheter associated urinary tract infection rate

▪ Ventilator associated pneumonia rate

▪ Central line associated blood stream infection rate

▪ Surgical site infection rate

40 | P a g e

▪ 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

• Foot operated bins should be provided in all the departments

• Poly bags inside the bio medical waste bin should match the color of the bin.

• Documented policy and procedures should be available

• Segregation of the biomedical waste should be as per the biomedical waste management

rule.

• Regular health checkup of staff dealing with Biomedical waste management should be

done

• Site of disposal of biomedical waste should be well maintained waste should not be lying

over the pit.

41 | P a g e

Self-Assessment Toolkit

Organisation 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

(District Hospital Rudraptayag)

42 | P a g e

Elements

Scores

(0/ 5/ 10)

TOTAL SCORE 3.61

Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC) 4.6

AAC.1: The organization defines and displays the services that it can provide.

5

a The services being provided are clearly defined.

5

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.

5

a. The organization defines the content of the assessments for the out-patients, in- patients and emergency patients.

5

b. The organization determines who can perform the assessments.

5

c. The initial assessment for in-patients is documented within 24 hours or earlier.

5

d. Initial assessment of inpatients includes nursing assessment which is done at the time of admission and documented.

5

AAC.4 Patient care is continuous and all patients cared for by the organization undergo a regular reassessment.

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

43 | P a g e

c. Staff involved in direct clinical care document reassessments. 5

d. Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.

5

AAC.5 Laboratory services are provided as per the scope of the hospital’s services and laboratory safety requirements.

4.1

a. Scope of the laboratory services are commensurate to the services provided by the organization.

5

b. Procedures guide collection, identification, handling, safe transportation, processing and disposal of specimens.

5

c. Laboratory results are available within a defined time frame and critical results are intimated immediately to the concerned personnel.

5

d. Adequately trained personnel perform, supervise & interpret the investigations.

5

e. Laboratory personnel are trained in safe practices and are provided with appropriate safety equipment/ devices.

5

f. Laboratory tests not available in the organization are outsourced. 0

AAC.6 Imaging services are provided as per the scope of the hospital’s services and established radiation safety programme.

5

a. Scope of the imaging services are commensurate to the services provided by the organization.

5

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.

5

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. 3.3

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.

5

d. Discharge summary contains follow up advice, medication and other instructions in an understandable manner.

0

44 | P a g e

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.

5

Chapter 2: CARE OF PATIENTS (COP) 3.4

COP.1: Care of patients is guided by accepted norms & practice.

5

a The care and treatment orders are signed and dated by the concerned doctor.

5

b Critical Practice Guidelines are adopted to guide patient care wherever possible.

5

COP.2: Emergency services including ambulance are guided by documented procedures.

4

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.

5

c Admission or discharge to home or transfer to another organization is also documented.

5

d Ambulance is appropriately equipped. 5

e Ambulance(s) is manned by trained personnel. 5

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.

5

a Care of patients is in consonance with the documented procedures. 5

45 | P a g e

b Adequate staff and equipment are available. 5

COP.5: Documented procedures guide the care of obstetrical patients as per the scope of services provided by hospital.

3.3

a The organization defines the scope of obstetric services. 0

b Obstetric patient’s care includes regular ante-natal check ups, maternal nutrition and post-natal care.

5

c The organization has the facilities to take care of neonates. 5

COP.6: Documented procedures guide the care of pediatric patients as per the scope of services provided by hospital.

2

a The organization defines the scope of its pediatric services. 0

b Provisions are made for special care of children by competent staff. 5

c Patient assessment includes detailed nutritional, growth, and immunization assessment.

5

d Procedure addresses identification and security measures to prevent child/ neonate abduction and abuse.

0

e The children’s family members are educated about nutrition and immunization

0

COP.7: Documented procedures guide the administration of anesthesia. 2.2

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.

5

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.

0

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. 0

46 | 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.

0

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.

5

g. Patients, personnel and material flow conform to infection control practices.

5

Chapter 3: MANAGEMENT OF MEDICATION (MOM) 2.7

MOM.1: Documented procedures guide the organization of pharmacy services and usage of medication.

0

a Documented procedure shall incorporate purchase, storage, prescription and dispensation of medications.

0

b Documented procedures address procurement and usage of implantable prostheses.

0

MOM.2: Documented policies & procedures guide the storage of medications.

3

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

d Beyond expiry date medications are not stored/used. 5

e List of emergency medicines is defined, stored, and available all the time.

5

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

47 | P a g e

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.

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. 5

MOM.5: There are defined procedures for medication administration.

6

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.

5

d Medication administration is documented. 5

e A proper record is kept of the usage, administration and disposal of narcotics and psychotropic medications.

5

MOM.6: Adverse drug events are monitored.

0

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.

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) 3.9

PRE.1: Patient rights are documented displayed and support individual beliefs, values and involve the patient and family in decision making processes.

2.8

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. 0

48 | P a g e

c. Patient rights include treating patient information as confidential. 0

d. Patient rights include obtaining informed consent before carrying out procedures.

5

e. Patient rights include information on how to voice a complaint. 5

f. Patient rights include information on the expected cost of the treatment.

5

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.

5

a Patients and families are educated on plan of care, preventive aspects, possible complications, medications, the expected results and cost as applicable.

5

b Patients are taught in a language and format that they can understand.

5

Chapter 5: HOSPITAL INFECTION CONTROL (HIC) 4.6

HIC.1: The hospital has an infection control manual, which is periodically updated and conducts surveillance activities.

5

a It focuses on adherence to standard precautions at all times. 5

b Cleanliness and general hygiene of facilities will be maintained and monitored.

5

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 5

HIC.2: The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees.

5

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.

5

c Appropriate pre and post exposure prophylaxis is provided to all concerned staff members.

5

HIC.3: Bio-medical Waste (BMW) management practices are followed.

4

49 | P a g e

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).

5

d Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.

0

e Appropriate personal protective measures are used by all categories of staff handling Bio-Medical Waste.

5

Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI) 4.1

CQI.1: There is a structured quality improvement, patient safety and continuous monitoring programme in the organization.

3.3

a There is a designated individual for coordinating and implementing the quality improvement and patient safety programme.

5

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.

5

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) 5

ROM.1: The responsibilities of the management are defined 5

a The organization has a documented organogram. 0

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.

5

ROM.2: The organization is managed by the leaders in an ethical manner.

5

50 | 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) 2.4

FMS.1: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.

1

a Internal and External Signage’s shall be displayed in a language understood by the patients and families.

5

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. 0

FMS.2: The organization has a program for clinical and support service equipment management.

0

a The organization plans for equipment in accordance with its services.

0

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.

5

a Potable water and electricity are available round the clock. 10

51 | P a g e

b Alternate sources are provided for in case of failure and tested regularly.

5

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.

3.7

a The organization has plans and provisions for detection, abatement and containment of fire and non-fire emergencies.

5

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. 5

Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM) 3.9

HRM.1: The organization has staffing commensurate with patient care needs. 5

a The mix of staff is commensurate with the volume and scope of the services.

5

b Staff recruitment process is well defined. 5

HRM.2: There is an ongoing programme for professional training and development of the staff.

3.3

a All staff is trained on the relevant risks within the hospital environment.

5

b Staff members can demonstrate and take actions to report, eliminate/ minimize risks.

5

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.

1.6 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. 5

HRM.4: The organization addresses the health needs of the employees

5

52 | P a g e

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 5

a Personal files are maintained in respect of all employees. 5

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.

5

Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS) 1.5

IMS.1: The organization has a complete and accurate medical record for every patient

2

a Every medical record has a unique identifier. 0

b Organization identifies those authorized to make entries in medical record.

0

c Every medical record entry is dated and timed.

5

d The author of the entry can be identified. 5

e The contents of medical record are identified and documented. 0

IMS.2: The medical record reflects continuity of care.

4.1 a The record provides an up-to-date and chronological account of patient care. 0

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.

0

a a. Documented procedures exist for maintaining confidentiality, security and integrity of information.

0

53 | P a g e

b Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient's authorization.

0

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

54 | P a g e

PRIORITY GAPS

GAP STATEMENT ACTION PRIORITY

MAJOR GAPS

Scope of services of the hospital, Citizen

charter , Mission, Vision, doctor’s list along

with their specification and qualification

are not displayed in the Waiting Area

/OPD Area of the hospital

Scope of services of the hospital Citizen

charter , Mission, Vision, doctor’s list along

with their specification and qualification

should be displayed in the Waiting Area

/OPD Area of the hospital

High

All the signages- Hospital signages and

departmental signages are not bilingual

All the signages should be bilingual and

Pictorial

High

Safety belts are not available in Wheel

chairs and stretchers

Safety belts should be available in the wheel

chairs and stretchers for safety of the

patients

High

Required licenses are not available Required licenses Should be obtained

/renewed (Biomedical waste management

license , Site and type approval from AERB)

High

All the Sanctioned posts are not filled up All the sanctioned post should be filled High

There is acute shortage of nurses in wards

especially in evening and night shift (i.e. 1

nurse in hospital )

Other manpower like dietician , CSSD

Technician etc. are not available

Nursing staff need to be recruited as per

patient load

(Nurse patient ratio

Ward 1:6

All the required manpower should be

recruited.

High

Foot operated BMW Bins are not available

at all places in the hospital

Foot operated BMW bins should be

provided in all the departments in the

hospital

High

Required/Essential equipment are not

available in all the departments

Essential equipment like crash cart,

Defibrillator, cardiac monitor etc. should be

purchased.

High

55 | P a g e

All the required equipment are not

calibrated.

All the required equipment should be

calibrated

High

There is no provision of dedicated toilets

for the differently able people

A dedicated toilet for differently abled

should be provided( fixing of hand grans in

existing toilets)

High

X-ray view box is not available in all the

consultant’s room and nursing station.

X-ray view box should be available in all the

consultant’s room and nursing station.

High

Near expiry medicines were available in

the injection room and OT

Near expiry date medicine should be

replaced /removed

Medium

on sterilization drums date of sterilization

and expiry was not mentioned

Date of sterilization and expiry should be

mentioned on the sterilization drums

High

Temperature of the refrigerators is not

being monitored & recorded.

Temperature of the refrigerators should be

monitored & recorded in the temperature

monitoring sheet/register.

Medium

Look alike, sound alike medicines is not

identified and stored separately

Look alike, sound alike medicines is should

be identified and stored separately

Medium

There is no PA System in the hospital PA System should be installed for

announcements in the hospital during mock

drill /disaster etc.

High

Drainage system is not well covered Drainage system should be well covered

water.

High

There was evidence of seepage on the

walls, chipping of plasters, and roofs,

broken flooring, fungus on the walls,

bulges, and peeling of paint

All the building should be painted after

removing the fungus and algae and cracks

should be filled

High

Regular Safety inspections are not carried

out as expired fire extinguishers were

available in the facility

All the fire extinguishers should be refilled

and date of filling and expiry date should be

mentioned.

High

Documented policies and procedures are Documented policies and procedures should Medium

56 | P a g e

not available for each department be available in each department according to

NABH entry level Standards

All the required forms and formats are not

available for each department including

consent forms.

All the required forms and formats should be

available for each department including

consent forms according to NABH entry level

Standards

Medium

Quality indicators are not monitored and

analyzed for each department according to


Quality indicators should be monitored and

analyzed for each department according to


Low

EMERGENCY DEPARTMENT

There is no demarcated Triage area for

triaging of patients

Triage area should be demarcated in the

emergency department

High

List of all staff that contain Name , contact

details and designation is not available

List of all staff that contain Name , contact

details and designation should be available

High

Emergency signage is not visible from the

road with proper lightning and signs

Emergency signage should be visible from

the road with proper lightning and signs

High

OUT PATIRNT DEPARTMENT

UHID number is not generated for all the

patients

UHID number should be generated for all the

patients

Medium

Separate Queue for differently abled is not

available at registration counter

Separate Queue Should Be Provided For

Differently Abled People at registration

counter

Medium

Patient privacy screen, Weighing machine

is not available in all the OPDs

Patient privacy screen, weighing machine

should be available in all the OPDs

High

57 | P a g e

LABORATORY

No demarcated area for sample collection

Sample collection area should be

demarcated

High

Critical results are not intimated

immediately to the concerned person

Critical results should be intimated

immediately to the concerned

person/pathologist

Medium

Laboratory tests not available in the

organization are not outsourced and

displayed

Laboratory tests not available in the

organization should be outsourced and

displayed.

Medium

RADIOLOGY AND IMAGING

There is no changing room for patients

Changing room should be provided for

patients

High

Lead aprons are not placed in the right

manner

Lead aprons should be hanged on the

hangers.

Medium

TLD Badges ,Gonad shield and thyroid

shields are not available

TLD Badges ,Gonad shield and thyroid

shields should be provided for the x-ray

technician and radiologist

High

Critical results are not defined, reported

and documented

All the critical results should be defined,

reported and documented.

Medium

WARDS

Racks are not available to store the clean

linen

Racks should be provided for storing the

clean linen.

High

58 | P a g e

Vitals are checked but are not documented

in each file

All the vitals should be checked daily and

should be documented in each file

Medium

The content of discharge summary is not

appropriate. It does not include when and

how to obtained urgent care

Discharge summary should contain how to

obtain urgent care

Medium

Multi-use open vials do not have labels of

date of opening and date of expiry

Multi-use open vials should have labels of

date of opening and date of expiry

Medium

The reporting of adverse patient events is

not being followed

The reporting of adverse patient events

should be reported

Low

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

should be identified and MSDS sheet for

them is not available

High

LABOR ROOM

Separate areas are not demarcated for

septic and aseptic deliveries

Separate areas should be demarcated for

septic and aseptic deliveries

High

Changing room is not available

Changing room should be available for

changing dress for before entering labor OT

High

Disposable HIV Kits for delivery are not

available in sufficient amount

Disposable HIV Kits for delivery should be

available in sufficient amount

High

No of labor room instruments counted

before and after use but are not

documented

No of instruments should be counted and

documented before and after surgery.

Medium

OPERATION THAETRE

59 | P a g e

One OT has more than one OT table that

table is not used for operation

Each OT should have only one OT table not

more than that.

High

Patient ,personnel and material flow do

not confirm to infection control practices

(Biomedical waste ,Patients and Staff

entered from the same gate )

Biomedical waste should not be taken from

the same route from where the patient and

staff enter.

High

Each operation room is not monitored for

humidity and temperature on daily basis.

Temperature ,humidity monitoring devices

should be fitted in each OT

High

Regular environmental surveillance for

microbes is not done in each OT and other

areas to identify forming of any colonies of

bacteria.

Regular environmental surveillance for

microbes should be done in each OT to

identify forming of any colonies of bacteria.

Medium

BLOOD BANK

Tested and untested blood are not marked

separately

Tested and untested blood should be

marked separately

High

PHARMACY STORE

There is no marking of receiving area ,

segregation area and storing area

Following areas should be marked in

pharmacy store receiving area , segregation

area and storing area

High

Adequate number of racks are not

available in store as the medicine cartons

were lying on the floor

Adequate number of racks should be

provided

High

There is no provision for storage of

narcotic drugs (double lock and key

system)

Narcotics should be stored in a double lock

and key system in a separate cupboard

High

Medicines are not stored alphabetically Medicines should be stored alphabetically Medium

60 | P a g e

and not the racks are not marked and each rack should be marked

AUTOCLAVE FACILITY

Layout does not follow the functional flow.

areas are not demarcated as mentioned

below:

▪ Receiving area

▪ Washing area


▪ Drying

▪ Packing

▪ Loading area

▪ Unloading

▪ Storing

▪ Issuing area.

Layout should follow the functional flow.

Areas should be demarcated as mentioned

below

▪ Receiving area

▪ Washing area


▪ Drying

▪ Packing

▪ Loading area

▪ Unloading

▪ Storing

▪ Issuing area.

High

Racks are not available to place sterile

material

Adequate number of racks should be

provided to store sterile material

High

Transport trolley for shifting sterile

material is not available

Transport trolley for shifting sterile material

should be available

High

ENGINEERING AND MAINTENANCE DEPARTMENT

Up-to-date drawing, layouts are not

maintained.

Up-to-date drawing, layouts and escape

route should be maintained and displayed

on each floor

High

The periodic facility inspection is not being

carried out to identify the environmental

hazards and risk.

The periodic facility inspection should be

carried out to identify the environmental

hazards and risk.

Medium

61 | P a g e

MEDICAL RECORD DEPARTMENT

There is no dedicated Medical Record

Department. Files are stored at nursing

station in cartons.

A separate room should be provided for

Keeping medical records with sufficient

racks and CCTV device

High

There is no designated person i.e. medical

record technician for taking care of

medical records.

Medical record technician should be

appointed to manage the medical record in

the medical record department.

High

The records does not have all relevant

forms & formats like Nurses Records,

Medication chart, Pre anesthesia checkup

form Intake /Output chart, TPR chart, etc.

Medical record should contain all the

relevant records like Nurses Records,

Medication chart, Pre anesthesia checkup

form Intake /Output chart, TPR chart, etc.

Medium

Entry in the medical record is not named,

signed, dated and timed. The contents of a

patient medical record are not identified

and defined e.g. admission order, face

sheet, IP sheets does not have a proper

format.

Entry in the medical record should be

named, signed, dated and timed. Contents

of the patient medical record should be

defined and patient record forms should be

maintained.

Medium

The patient file does not provide a

complete, up-to-date and chronological

account of patient. The organization does

not have an effective process for

document control e.g. the forms and

formats which is being used is not

standardized and do not have

identification code

The patient file should provide a complete,

up-to-date and chronological account of

patient.

The organization should have an effective

process for document control e.g. the forms

and formats should be standardized and

have identification code

Medium

The retrieval of the records is not easy.

Deficiency checklist is not followed. The

hospital does not have retention policy for

documents.

Retrieval of record should be easy and with

prior information. Deficiency checklist for

the record should be prepared

Medium

62 | P a g e

The outcome indicators like % of missing

records, % of records with ICD codification

done, Percentage of medical records not

having discharge summary, Percentage of

medical records not having consent form,

% of records with ICD codification done,

Percentage of medical records not having

discharge summary, Percentage of medical

records not having consent form is not

being monitored.

Outcome indicators should be monitored

Low

HUMAN RESOURCE DEPARTMENT

The employees are not aware of their

rights, responsibilities

Each employee should be aware of its rights

and responsibilities

Medium

There is no training program when job

responsibilities changes and when new

equipment gets installed.

Each time when job responsibility change

and new equipment is installed trainings

should be conducted and record for the

same should be documented

Medium

No evidence of training Need Analysis

Training need analysis should be conducted

and documented to plan for the training

program.

Medium

Employee’s satisfaction survey is not done

and analyzed

Employee’s satisfaction survey should be

conducted and analyzed.

Medium

There is no feedback mechanism for

improvement of training and development

program

There should be a feedback mechanism for

improvement of training program

Medium

63 | P a g e

KITCHEN

The kitchen does not have demarcated

area such as receiving, washing, chopping

/cutting, cooking, storing etc.

Areas should be demarcated in the kitchen

as per the flow such as receiving, washing,

chopping /cutting, cooking, storing etc

High

Patient & family members are not

educated regarding the limitations of diet.

Patient & family members should be

educated regarding the limitations of diet by

dietician/doctor

Medium

Food evaluation is not done before serving

to patient.

Food evaluation should be done before

serving to patient and same should be

documented.

Medium

Nutritional assessment is not being done.

Nutritional assessment should be done by

the dietician and should be documented in

nutritional assessment form.

Medium

LAUNDRY

Site inspection of washing area is not done

by hospital staff

Site inspection of washing area should be

done by hospital staff and should be

documented.

Medium

Racks to store washed linen are not

available. Washed linen are stored in a

safe with other documents

Racks should be purchased for storing

washed linens

High

INFECTION CONTROL

The disinfectant which is being used in the

hospital is not undergone any sterility test.

Phenyl/Lysol is used as disinfectant

The disinfectant which is being used in the

hospital should undergo any sterility test.

Medium

There is no established recall procedure for

breakdown identified in the sterilization

system.

There should be established recall

procedure for breakdown identified in the

sterilization system.

Medium

64 | P a g e

The infection control surveillance data is

not being collected.

The infection control surveillance data

should be collected.

Medium

The biomedical waste bins are not foot

operated and there is no labeling of

biohazard symbol on BMW buckets

The biomedical waste bins should be foot

operated and biohazard symbol should be

available on BMW buckets

High

Antibiotic audit is not carried out to ensure

adherence to antibiotic policy.

Antibiotic audit should be carried out to

ensure adherence to antibiotic policy.

Medium

65 | P a g e

SUPPORTIVE DOCUMENTS PICTURES OF IDENTIFIED GAPS

Safety belts are not available in wheelchairs and stretchers

66 | P a g e

Near Expiry date drugs were available in the injection room and

OT

67 | P a g e

No poly bags in the dustbins

Color of poly bags do not match the color of dustbins

68 | P a g e

No separate queue for differently abled people

No Signage for drinking water

69 | P a g e

Emergency signage is not visible from road and is not a glow signage

70 | P a g e

All signage are not bilingual

71 | P a g e

No separate area for septic and aseptic deliveries

72 | P a g e

Date of sterilization and expiry date is not mentioned on the sterilization

drum

73 | P a g e

Lead aprons are not hanged properly

Fire extinguisher are expired

74 | P a g e

No segregation of clean and dirty linen and no demarcated area is available for dirty and clean

linen

75 | P a g e

Loose wired were found

Adequate racks are not available

76 | P a g e

Open drainage system

Waste lying over the dump pits

77 | P a g e

Seepage Algae on walls, Paint is peeling off

78 | P a g e

LETTERS

79 | P a g e

80 | P a g e

81 | P a g e

MANPOWER LIST

82 | P a g e

83 | P a g e

EQUIPMENT LIST

84 | P a g e

85 | P a g e

86 | P a g e

87 | P a g e

88 | P a g e

Documents

GAP REPORT DISTRICT HOSPITAL RUDRAPRAYAG ......GAP REPORT DISTRICT HOSPITAL RUDRAPRAYAG UTTRAKHAND OCTAVO SOLUTIONS PVT LTD G-27, LOWER GROUND, KAILASH COLONY NEW DELHI - 110048 TEL: