Kayakalp Assessment Checklist - Tertiary Care Institutions

Name of the Instituion _

Date of Assessment _
Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
A HOSPITAL UPKEEP 130
A1 Level of Illumination (Lighting) in various areas 10

Check Adequate lighting in

A1.1
Adequate illumination in
Circulation and Support area OB
Adequate illumination in
Outdoor & Indoor Patient Care
A1.2 Areas
waiting area/ lobby, corridors,
elevators, lift landing area, 2
staircase, toilets, administrative
offices. Minimum -100 Lux,
Check for Adequate lighting
arrangements through Natural
Light or Electric Bulbs. 2

OB Minimum 150 lux

Check for Adequate lighting
arrangements in OT, Labour
A1.3 Room, Laboratory, Pharmacy. 2
Adequate illumination in Minimum Illumination should
Procedure Areas OB be 300 Lux

In the night, sufficient street

A1.4 Adequate illumination in front lights and focus lights for 2
of hospital , access road and hospital front, access road,
open areas OB open areas , parking etc.

A1.5 Check use of energy Efficient 2

Use of energy efficient bulbs OB LED Bulbs for Illumination

A2 Hospital Appearance - Painting & Whitewashing 10

Check Hospital Name Board

clean and clearly visible from
A2.1 distance. Hospital façade clean 2
and well maintained. Entry gate
painted and not rusted
Hospital front is maintained OB

Page 1
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d

Check that outer wall plaster is

not chipped-off and the
building is painted/
whitewashed in uniform colour
A2.2 2
and Paint has not faded away.
Check there are no unwanted ,
outdated poster bills /
Outer walls painted and free posters/wall writing occupying
of posters/bills OB outer walls

Interior walls and roof of the

A2.3
Interior of patient care areas
are plastered & painted
A2.4
Information display and
signage are maintained
outdoor and indoor area are
plastered and painted in
2
soothing colour. The Paint has
not faded away. Check there
are no unwanted , outdated
poster bills / posters/wall
OB writing occupying outer walls
Information signage are inside
the premises are clean , well
2
maintained and not fading
OB away

Check Dado and skirting are

A2.5 2
Dado and skirting's are well well demarcated, intact
maintained and clean OB painted, clean and maintained

A3 10
Landscaping, Gardening & Greenery

Open areas of the facility has

A3.1 been maintained with grass 2
Availability of lawns and green beds, trees, Garden, etc. and it
areas within the premises OB has an aesthetic appearance
Check indoor plants have been
placed in public areas such as
waiting areas, internal
A3.2 pathways etc. in aesthetic 2
Indoor plants placed in public manner .Plants are healthy and
areas OB well maintained

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Check that wild vegetation does
not exist. Shrubs and Trees are
well maintained. Grass trimmed
A3.3 and well maintained. Over 2
grown branches of plants/ tree
have been trimmed regularly.
Green Areas/ Parks are well Dry leaves and green waste are
maintained OB removed on daily basis.

Check that there is no over

A3.4 grown shrubs, weeds, moss, 2
No unwanted vegetation or any other vegetation in hospital
weeds in the premises OB premises
Check if the facility maintains a
A3.5 herbal garden for the medicinal 2
Provision of Herbal Garden OB/SI plants
A4 Maintenance of Open Areas 10

Check pathways are clearly

demarcated and paved. No
A4.1 potholes/ broken tiles on the 2
pathways. Direction boards are
Pathways are well defined and available and easily visibl.No
Maintained OB blind turns in pathways

Check that there is a

A4.2
Adequate and well defined
parking areas
A4.3
No water logging in premises
A4.4
No thoroughfare / general
traffic in hospital premises
demarcated space for parking
of the vehicles of staff and 2
visitors as well as for the
Ambulances . Check vehicles
OB are parked systematically
in open areas because of faulty
drainage, leakage from the
2
pipes, rain water accumulation
OB etc.
Check that the facility premises
are not being used as
2
‘thoroughfare’ by the general
OB public

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Check for hospital premises and
no unauthorized occupation access road have not been
A4.5 within the facility, nor there is encroached by the vendors, 2
encroachment on Hospital unauthorized shops/ occupants,
land OB/SI etc.
A5 Infrastructure Maintenance 10
No major cracks, seepage,
A5.1 Hospital Infrastructure is well chipped plaster & floors in the 2
maintained OB hospital
Hospital has a system for Check the records for
periodic maintenance of preventive maintenance of the
A5.2 2
infrastructure at pre-defined building. It should be done at
interval OB least annually.
Manholes are covered &
A5.3 Sewage and drains are not 2
Drainage System is maintained OB overflowing

Check to ensure that there are

A5.4 2
Electric wiring and Fittings are no loose hanging wires, open or
maintained OB broken electricity panels

Check that there is a proper

A5.5 Hospital has intact boundary boundary wall of adequate 2
wall and functional gates at height without any breach. Wall
entry OB is painted in uniform colour
A6 10
Maintenance of Furniture and Fixture
Window and doors are OB Check, if Window panes are
maintained intact, and provided with Grill/
A6.1 Wire Meshwork. Doors are 2
intact and painted /varnished.

Patient Beds & Mattresses are OB Check that Patient beds are not
in good condition rusted and are painted.
A6.2 2
Mattresses are clean and not
torn
Trolleys, Stretchers, Wheel OB Check that Trolleys, Stretcher,
A6.3 Chairs, etc. are well wheel chairs are intact, painted 2
maintained and clean Wheels of stretcher

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Furniture at the nursing OB Check the condition of
station, staff room, furniture at nursing station,
administrative office are duty room, office, etc. The
A6.4 2
maintained furniture is not broken/having
loose joints, wobbling
/painted/polished and clean.
There is a system of preventive SI/RR Check if hospital has an annual
A6.5 maintenance of furniture and preventive maintenance 2
fixtures programmed for furniture and
fi l i
A7 10
Mechanism for removal of Junk Material regularly
No junk material in patient OB Check if unused/ condemned 2
care areas articles, and outdated records
A7.1
are kept in the Nursing stations,
OPD clinics, wards, etc.
No junk material in Open OB Check, if unused/ condemned 2
Areas and corridors equipment, vehicles, etc. are
A7.2 kept in the corridors, pathways,
under the stairs, open areas,
No junk material in critical OB f if unused
Check b l articles, and 2
service area old records are kept in the
A7.3 Labor room, OT, Injection
room, ICU, Emergency etc.

Hospital has demarcated OB/SI Check for availability of a 2

space for keeping condemned demarcated & secured space
A7.4 junk material for collecting and storing the
junk material before its disposal
Hospital has documented and SI/RR Check if Hospital has drafted its 2
implemented Condemnation condemnation policy or have
policy got one from the state. Check
A7.5
whether they are complying
with it

A8 10
Pest Management & Stray Animal Control
No stray animals within the OB Observe for the presence of 2
facility premises stray animals such as dogs, cats,
A8.1 cattle, pigs, etc. within the
premises. Also discuss with the
facility staff.

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Cattle-trap is installed at the OB Check at the entrance of facility 2
entrance that cattle trap has been
A8.2 provided. Also look at the
breach, if any, in the boundary
wall

Pest Control Measures are OB/RR Ask the facility administration 2

implemented in the facility about pest control measures to
A8.3 control rodents and insect.
Check records of engaging a
professional agency for the
Anti-termite Treatment of the OB/RR Check if the facility has a 2
wooden furniture and fixtures scheduled programmed for anti-
A8.4 is undertaken periodically termite treatment at least once
in a year

Measures for Mosquito free OB/RR Check for 2

environment are in place a. Usage of Mosquito nets by
the patients
b. Availability of adequate stock
of Mosquito nets
A8.5 c. Wire Mesh in windows
d. Desert Coolers (if in use) are
cleaned regularly/ oil is
sprinkled
e. No water collection for
mosquito breeding within the
premises
A9 10
Water Sanitation practices (Safe drinking water/ Rooftop Tanks)

Check Taps and sinks are clean,

A9.1 No fungal growth around 2
deinking water areas
Water taps and sinks area is RO system has been installed
kept clean OB for drinking water taps

Check potable drinking water

A9.2 2
Adequate no. of drinking facility have been provided in
water taps are available OB all patient care areas

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d

Check No fungal or algae

A9.3 2
Water Storage tanks are growth in or around the tanks
maintained OB or drinking water areas

Check for leaking taps, pipes,

A9.4 Water supply system is
maintained in the Hospital
A9.5
Cleaning schedule of tanks
maintained and adhered to
A10 Water Conservation Practices
Hospital promotes water
A10.1
conservation
over-flowing tanks and 2
OB/SI dysfunctional cisterns
been prepared in advance and
tanks have been cleaned on
2
defined interval as per schedule
OB/RR
10
Awareness posters in place for
2
OB conserving water

Check if Hospital Infrastructure

A10.2
Hospital has a functional rain
water harvesting system
A10.3 Water supply system is
maintained in the Hospital
2
and drain system are fitted with
rain water harvesting system
OB/SI with sufficient storage capacity
Check for leaking taps, pipes,
over-flowing tanks and 2
OB dysfunctional cisterns

A10.4
Water conservation Practices
are implemented in Hospitals OB
Check for
2
Water sprinklers used in lawns
Dual flush installed in toilets
Recycling of waste RO water
Usage of STP water

A10.5 Sensor based / Auto Stop taps 2

are installed at washbasins OB Check for availability

A11 10
Availability and adequacy of signage in hospital areas

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Check for uniform bilingual
departmental signage have
been provided in all the
A11.1 departments 2
Lift landing areas to have floor
All wards and departments are number mentioned in big and
clearly marked and defined OB bright colors

Check Direction boards are

A11.2
Directional siganges have been
provide at relevant areas
A11.3 Service availability information
has been prominently
displayed
available for locating 2
departments, offices, public
OB toilets drinking water facilities.
Check for doctors available,
visiting hours , services
available, user charges etc.
information has been 2
prominently displayed
OB

Check floor wise department

A11.4
Floor directory and wayfinding
maps are displayed
A11.5 Exit signage system is
established
discerption and layout of the
hospital with locational aid has 2
been displayed at entry, OPD,
Emergency or any other
OB relevant area
Check All emergency exits are
well marked with radium/ 2
OB reflector boards

A12 Maintenance of administrative offices ,Records Management & Work 20

Place Management
General Cleaning:
A12.1 Administrative offices well 2
maintained OB

Door Cleaning: All the doors

clean, door handles free of
A12.2 2
stains and clean, door joints in
place, no creaking noise, well
painted OB

A12.3 Floor: Floor free of litter and 2

dust balls, free of stains OB

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Window: Windows clean and
free of stains, window panes
A12.4 2
not broken, window ledge
clean OB

Wall: Walls are free of stain or

spit marks, Walls are painted
A12.5 2
properly. If tiled, then tiles are
not broken; dado and skirting
clean OB
Staff periodically sort useful SI/OB
A12.6 and unnecessary articles at 2
work station
The Staff arrange the useful SI/OB
A12.7 articles, records in systematic 2
manner
Staff label the articles in SI/OB
A12.8 identifiable manner 2

Work stations are clean and SI/OB

A12.9 free of dirt/dust 2

There is establish retention SI/OB

A12.10 and disposal policy for records 2

B SANITATION & HYGIENE 150

B1 10
Cleanliness of Circulation areas/ Compound Wall - outside & inside)
No dirt/Grease/Stains in the OB Check that floors and walls of 2
Circulation area Corridors, Waiting area, stairs,
B1.1 roof top for any visible or
tangible dirt, grease, stains, etc.
No Cobwebs/Bird Nest/ Dust OB Check that roof, walls, corners 2
on walls and roofs of corridors of Corridors, Waiting area,
B1.2 stairs, roof top for any Cobweb,
Bird Nest, etc.
Corridors are cleaned at least SI/RR Ask cleaning staff about 2
twice in the day with wet mop frequency of cleaning in a day.
B1.3 Verify with Housekeeping
records

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Corridors are rigorously SI/RR Ask the staff about cleaning 2
B1.4 cleaned with scrubbing / schedule and activities
flooding once in a month
Surfaces are conducive of OB Check if surfaces are smooth 2
B1.5 effective cleaning enough for cleaning

B2 Cleanliness of Wards , ICU, CCU 20

B2.1 No dirt/Grease/ Stains/ OB Check that floors and walls of 2
Garbage in wards indoor department for any
visible or tangible dirt, grease,
stains, etc.

B2.2 No Cobwebs/Bird Nest/ OB Check for the roof, corners of 2

Dust/Seepage on walls and
roofs of wards
B2.3 Wards are cleaned at least
thrice in the day with wet mop
ward for any Cobweb, Bird
Nest, Dust etc.
OB Ask cleaning staff about 2
frequency of cleaning in a day.
Verify with Housekeeping
records

B2.4 Patient Furniture, Mattresses, OB Check for visible dirt, dust, 2

Fixtures are without grease grease etc. Check if the items
and dust are wiped/dusted daily

B2.5 Floors, walls, furniture and OB Ask cleaning staff about 2

fixture are thoroughly cleaned frequency of cleaning in a day.
once in a week. Verify with Housekeeping
records if available

B2.6 OB
Door: Entrance door to wards
2
clean and free of stains, doors
Doors at ward are clean well maintained
B2.7 OB
Electrical: fans, lights, switch
boards clean and well 2
Electric Fixtures are clean maintained
B2.8 Windows clean and well OB
maintained Windows: Clean and well 2
maintained, Window panes not
broken, Window ledges clean

Page 10

Ref.
Criteria
No.
B2.9 Curtains are clean
B2.10 Nursing Stations are clean
B3
Cleanliness of Procedure Areas
No dirt/Grease/ Stains/
Garbage in Procedure Areas
B3.1
No Cobwebs/Bird Nest/ OB
Seepage in OT & Labour Room
B3.2
OT/Labour Room floors and
procedures surfaces are
B3.3 cleaned at least twice a day /
after every surgery
OT & Labour Room Tables are OB
without grease, body fluid and
B3.4 dust
Floors, walls, furniture and
fixture are thoroughly cleaned
B3.5
once in a week.
B4
Cleanliness of Ambulatory Areas (OPD, Emergency, Lab, Radiology )
No dirt/Grease/Stains / OB
Garbage in Ambulatory Area
B4.1
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
OB
Check curtains, screens, blinds
2
etc. are clean, free of stains and
intact
OB Check counters , furniture,
fixtures , drug cabinets , drug
2
trolleys etc. at nursing stations
are clean
10
OB Check that floors and walls of 2
Labour room, OT, Dressing
room for any visible or tangible
dirt, grease, stains etc.
Check for roof, walls, corners of 2
Labour Room, OT, Dressing
Room for any Cobweb, Bird
Nest, Seepage, etc.
SI/RR Ask cleaning staff about 2
frequency of cleaning in a day.
Verify with Housekeeping
records.
Check that Top, side and legs of 2
OT Tables, Dressing Room
Tables, Labour Room Tables for
dirt, dried human tissue, body
fluid etc.
SI/RR Ask cleaning staff about 2
frequency of cleaning day.
Verify with Housekeeping
records if available.
10
Check for floors and walls of 2
OPD, Emergency, Laboratory,
Radiology for any visible or
tangible dirt, grease, stains, etc.
Page 11
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
No Cobwebs/Bird Nest/ OB Check for roof , walls, corners 2
Seepage on walls and roofs of of OPD, Emergency, Laboratory,
B4.2 ambulatory area Radiology for any Cobweb, Bird
Nest, Dust, Seepage, etc.
Ambulatory Areas are cleaned SI/RR Ask cleaning staff about 2
at least thrice in the day with frequency of cleaning in a day.
B4.3
wet mop Verify with Housekeeping
records
Furniture, & Fixtures are OB/SI Observe and ask the staff about 2
B4.4 without grease and dust and frequency for cleaning
cleaned daily

Floors, walls, furniture and SI/RR Ask staff about schedule of 2

fixture are thoroughly cleaned cleaning and verify with records
B4.5
once in a week.

B5 Cleanliness of Auxiliary areas 10

No dirt/Grease/ Stains/
Garbage in Auxiliary Area
B5.1
OB Check for the floors and walls 2
of Pharmacy, Kitchen, Laundry,
Mortuary, Administrative
offices, for any visible or
tangible dirt, grease, stains, etc.

No Cobwebs/Bird Nest/ OB Check the roof , walls, corners 2

Seepage on walls and roofs of of Pharmacy, Kitchen, Laundry,
B5.2 Auxiliary Area Mortuary, Administrative
offices for any Cobweb, Bird
Nest, Seepage, etc.

Auxiliary Areas are cleaned at SI/RR Ask cleaning staff about 2

least twice in the day with wet frequency of cleaning in a day.
B5.3 mop Verify with Housekeeping
records.

Furniture & Fixtures are OB/SI Observe and ask the staff about 2
B5.4 without grease and dust and frequency for cleaning
cleaned daily

Floors, walls, furniture and SI/RR Ask staff about schedule of 2

fixture are thoroughly cleaned cleaning and verify with records
B5.5
once in a month

B6 Cleanliness of Toilets 30

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
No dirt/Grease/Stains/ OB Check some of the toilets 2
Garbage in Toilets randomly in indoor and
B6.1 outdoor areas for any visible
dirt, grease, stains, water
accumulation in toilets
No foul smell in the Toilets OB Check some of the toilets 2
randomly in indoor and
B6.2
outdoor areas for foul smell

Toilets have running water and OB Ask cleaning staff to operate 2

B6.3 functional cistern cistern and water taps

Sinks and Cistern are cleaned
B6.4 every two hours or whenever
required
Floors of Toilets are Dry
B6.5
SI/RR Ask cleaning staff for frequency 2
of cleaning and verify it with
house keeping records
OB Check some of the toilets 2
randomly for dryness of floors
and without residue water
accumulation

Toilet prominently marked and

B6.6 2
visible OB
Separate signage for ladies
B6.7 2
and gents toilet OB
Doors and door handles clean
B6.8 2
and well maintained OB

B6.9 Dado, walls and skirting clean 2

and free of stain or spit marks OB
Taps not leaking or
B6.10 2
overflowing OB
Soap dispensers clean and
B6.11 2
properly stocked OB

B6.12 2
Mirror clean and tarnish free OB
Toilet seat clean and free of
B6.13 2
stains OB
Urinal clean, free of stain and
B6.14 2
not overflowing OB

All lights are in working

B6.15 2
condition, switch boards clean
and in working condition OB

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d

B7 10
Use of standard materials for cleaning
Availability of Detergent SI/OB/ Check for good quality Hospital 2
Disinfectant solution / Hospital RR cleaning solution preferably a
Grade Phenyl for Cleaning ISI mark. Composition and
B7.1 purpose concentration of solution is
written on label. Check with
cleaning staff if they are getting
d t l V if th
Cleaning staff uses correct SI/RR Check, if the cleaning staff is 2
concentration of cleaning aware of correct concentration
solution and dilution method for
B7.2 preparing cleaning solution. Ask
them to demonstrate. Verify it
with the instruction given
solution bottle.
Availability of carbolic Acid/ SI/RR Check for adequacy of the 2
B7.3 Basaloid for surface cleaning in supply. Verify with the records
procedure areas- OT, Labour of stock outs, if any
Room
Availability of Buckets and SI/RRCheck if adequate numbers of 2
carts for Mopping Buckets and carts are available.
B7.4
General and critical areas
should have separate bucket
Availability of Cleaning SI/OB Check the availability of mops, 2
Equipment brooms, collection buckets etc.
as per requirement. Hospital
B7.5 with a size of more than 300
beds should have mechanized
mopping machine.

B8 10
Use of standard methods of cleaning
Use of Three bucket system SI/OB Check if cleaning staff uses 2
for cleaning three bucket system for
cleaning. One bucket for
B8.1 Cleaning solution, second for
plain water and third one for
wringing the mop. Ask the
cleaning staff about the process

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Use unidirectional method and SI/OB Ask cleaning staff to 2
out word mopping demonstrate the how they
apply mop on floors. It should
B8.2 be in one direction without
returning to the starting point.
The mop should move from
inner area to outer area of the
room
No use of brooms in patient SI/OB Check if brooms are stored in 2
care areas patient care areas. Ask cleaning
staff if they are using brooms
B8.3 for sweeping in wards, OT,
Labour room. Brooms should
not be used in patient care
Use of separate mops for SI/OB Check if cleaning staff is using 2
critical and semi critical areas same mop for outer general
and procedures surfaces areas and critical areas like OT
and labor room. The mops
should not be shared between
B8.4 critical and general area. The
clothes used for cleaning
procedure surfaces like OT
Table and Labour Room Tables
should not be used for mopping
the floors.
Disinfection and washing of SI/OB Check if cleaning staff disinfect, 2
B8.5 mops after every cleaning clean and dry the mop before
cycle using it for next cleaning cycle.

B9 Application of mechanized cleaning 10

Electrical scrubber drier OB/SI Check availability and
B9.1 2
functionality
Mechanical Sweepers OB/SI Check availability and
B9.2 2
functionality
Vacuum Cleaner wet & dry OB/SI Check availability and
B9.4 2
functionality
High Pressure Jet OB/SI Check availability and
B9.5 Cleaners/Washer &S team functionality 2
Cleaner
Spray pump for pest control OB/SI Check availability and
B9.6 as per IPCA functionality 2
recommendations

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
B10 Monitoring Mechanism for Cleanliness Activities 10
Use of Housekeeping Checklist OB/RR Check that Housekeeping 2
in Toilets Checklist is displayed in Toilet
B10.1
and updated. Check
Housekeeping records if
Use of Housekeeping Checklist OB/RR Check that Housekeeping 2
B10.2 in Patient Care Areas Checklist is displayed in OPD,
IPD, Lab, etc. Check
OB/RR Check cleaning schedule for
each areas has been prepared,
B10.3 2
Cleaning schedule for each approved and disseminated to
area available the concerned persons
OB/RR Check duty rooster for cleaning
/SI & housekeeping staff has been
B10.4 prepared and cleaning staff is 2
Duty roster made and adhered available as per schedule
to prepared
A person is designated for SI/RR Check if a staff-member from
monitoring of Housekeeping the hospital has been
Activities designated to monitor the
B10.5 housekeeping activities and 2
verify them with counter
signature on housekeeping
h kli t
B11 10
Drainage and Sewage Management
Availability of closed drainage OB Check if there is any open drain 2
system in the hospital premises.
Hospital should have a closed
drainage system. If, the
B11.1 hospital’s infrastructure is old
and it is not possible create
closed draining system, the
open drains should properly
covered
Availability of Sewage OB/RR Check if functional sewage 2
B11.2 Treatment Plant treatment plant is available at
the facility
Records maintained of
B11.3 cleaning of drains and sewage Check records regarding 2
maintained. RR cleaning schedule

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Gradient of Drains is OB Check that the drains have 2
B11.4 conducive for adequate for adequate slope and there is no
maintaining flow accumulation of water or debris
No blocked/ over-flowing OB Check with the cleaning staff 2
B11.5 drains in the facility about the frequency of cleaning
of drains. Verify with the
B12 Maintenance of equipment for cleaning 10

B12.1 All mechanical equipment 2

have warranty cards available RR
No naked or dangling wires in
B12.2 2
any equipment OB
Storage area for cleaning
B12.3 2
equipment is clean and dry OB

Equipment should be cleaned

B12.4 2
and emptied of water, garbage
or chemical after use OB/SI

Routine maintenance schedule

B12.5 2
available and adhered to for
all mechanical equipment SI/RR

C 40
HOSPITAL SUPPORT SERVICES
C1 Laundry services and Linen Management 10
Check the stock position and its
turn-over during last one year
in term of demand and
C1.1 availability. At least 5 sets per 2
bed should be available
Periodic stock taking is done
Adequate linen required for all and records are maintained for
beds SI/RR the same
Bed-sheets and pillow cover are
C1.2 stain free and clean in wards , 2
Hygiene/ Wash quality of linen OB Linen not torn or damaged
Check, if the bedsheets and
pillow cover have been changed
C1.3 daily or whenever get soiled . 2
Bedsheets are changed daily Please interview the patients as
or whenever required SI/PI well.

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Laundry machines are Availability of washer,
C1.4 available as per requirement hydroroextratcer, Dryer, 2
and are well maintained OB/SI Calendaring machine, Sluicer
Soiled linen and clean linen is Check soiled/ infected linen and
C1.5 transported in separate clean linen are segregated and 2
trolleys OB/SI transported in separate trolleys
C2 Kitchen Services 10
Food to patients is distributed OB Check that adequate number of 2
through covered trolleys and trolleys are available and are in
C2.1 patients utensils are not use. Look for the condition of
dented or chipped - off patients crockery and utensils.

Staff observes meticulous OB Check that the Staff uses cap 2

personal hygiene
C2.2
Kitchen facility clean and well OB
maintained, pest free
C2.3
C2.4 Dish washing area is clean and
well maintained
The Kitchen has provision to OB
store dry ration and fresh
ration separately.
C2.5
C3 Security Services
The main gate of premises,
Hospital building, wards, OT
and Labour room are secured
C3.1
and kitchen dress, while
cooking. Nails & hair are
trimmed. Ill staff is not allowed
to work in kitchen. Toilet
facilities are available for the
staff Nail brush is available
There is proper ventilation in
the kitchen. Doors and
Windows arefly-proofed.No fly 2
nuisance is noticed inside the
kitchen.
OB 2
Dry ration is stored on pellet, 2
away from wall in closed
containers. Vegetables are
stored at appropriate
temperature. Milk, curd and
other perishable items are
stored in the fridge, which is
cleaned and defrosted
l l
10
OB
Check for the presence of
security personnel at critical
2
locations. DFMD is present and
condition camera are available
in all strategic places

Page 18
 Assess
Ref. ment
Criteria
No. Metho
d
The security personal are OB
meticulously dressed and
C3.2 smartly turned-out.
There is a robust crowd OB
management system.
C3.3
Security personal reprimands OB
attendants, who found
indulging into unhygienic
C3.4 behavior - spitting, open field
urination & defecation, etc.
Un-authorized vendors are not OB/SI/ Check, entry of vendors is
present inside the campus. PI
C3.5 Waste storage is secured and
there is no plastic items, card
board etc.
C4 Outsource Service Management
There is valid contract for out- RR
sourced services, like house-
C4.1 keeping, BMW management,
security, etc.
The Contract has well defined RR
measurable deliverables
C4.2
The contract has penalty RR/ SI Look for the penalty clause in
clause and it has been evoked
C4.3 in the event of non-
performance or sub-standard
performance
Complia
Means of Verification Remarks
nce
Check if Security personnel 2
themselves observe the
commensurate behavior such
no spitting, no chewing of
tobacco, non-smoker, etc.
Crowd in OPD has waiting 2
place, seats, etc. Dust bins are
available and there is adequate
ventilation for the patients and
their attendants.
Check, if security personnel 2
watch behavior of patients and
their attendants, particularly in
respect of hygiene, sanitation,
etc. and take appropriate
actions, as deemed.
2
controlled or not. Unauthorized
entry of rag-pickers should not
be there.
10
Please check contract 2
document of all out-sourced
services
Check the contract documents 2
to see, whether the deliverables
of the out-sourced organization
have been well defined in term
of the work to be done and
how it would be verified
2
the contract and how often it
has been used
Page 19
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Services provided by the out- RR Check if Performance of the 2
sourced organization are vendors have been evaluated
measured periodically and and recorded
C4.4
performance evaluation is
formally recorded.

There is defined time-line for RR/Int Check the record for the time 2
release of payment to the erview taken in releasing the payment
C4.5 contractors for the services with due to the out-sourced
delivered by the organization. vendor organization

D WASTE MANAGEMENT 100

D1 10
Segregation practices of Biomedical Waste
OB/SI Check in departments like labor 2
Anatomical waste & Soiled room, OT that anatomical
D1.1
waste is segregated in as per waste is in Yellow bin
BMW 2016 guideline
OB/SI Wastes generated 2
from disposable items
such as tubing, bottles,
intravenous tubes and
sets, catheters, urine
D1.2 bags, syringes (without
needles and fixed needle
syringes) and
Solid infectious waste (recycle) vacutainers with their
are segregated as per BMW needles cut) and gloves are put
2016 guideline in Red bin
OB/SI Needles, syringes with 2
fixed needles, needles
from needle tip cutter or
burner, scalpels, blades,
or any other
contaminated sharp
D 1.3 object that may cause
puncture and cuts are
Used, discarded in white translucent
discarded and container. Glassware are
contaminated metals sharps & disposed in blue intercept
Glassware are disposed in cytotoxic waste.
appropriate bin.

Page 20

Ref.
Criteria
No.
Work instructions for
D1.4
segregation and handling of
Biomedical waste has been
displayed prominently
D1.5 Biomedical waste bins are
covered
D2
Collection, Storage and Transportation of Bio-medical waste
D 2.1 Dedicated Storage facility is
available for biomedical waste
and its has biohazard symbol
displayed
D2.2 The Storage facility is located
away from the patient area
and has connectivity of a
motor able road & facility has
hand-washing facilities for the
workers
The Storage facility is secured
D2.3
against pilferage and reach of
animal and rodents.
D2.4
No Biomedical waste is stored
for more than 48 Hours
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
OB Check availability of 2
instructions for segregation of
waste in different colour coded
bins and instructions are
displayed at point of use.
OB Check that bins meant for bio 2
medical waste are covered with
lids
10
OB Check if the health facility has 2
dedicated room for storage of
Biomedical waste before
disposal/handing over to
Common Treatment Facility.
OB Look at the location and its 2
connectivity through a road for
CWTF vehicle to reach the
storage area un-hindrance.
Check availability of soap,
running water in vicinity of
storage facility
The storage area does not pose
any threat to patients, indoor &
outdoor both.
OB Check the security (Lock and 2
key) and rodent proofing of the
storage area
SI/RR Verify that the waste is 2
disposed / handed over to CTF
within 48 hour of generation.
Check the record especially
during holidays
Page 21

Ref.
Criteria
No.
D2.5
Transportation of biomedical
waste is done in closed
container/trolley
D3 Disposal of Biomedical waste
D3.1
The Health Facility has
adequate arrangements for
disposal of Biomedical waste
D3.2
Recyclable waste is disposed
as per procedure given in the
BMW Rules 2016
The facility has linkage with a OB/
D3.3
CWTF Operator
Disposal of Expired or
D3.4 discarded medicine is done as
per protocol given in Schedule
I of BMW Rules 2016
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
OB/SI Check, transportation of waste 2
from clinical areas to storage
areas is done in covered trolleys
/ Bins. Trolleys used for patient
shifting should not be used for
transportation of waste.
10
RR/OB The Health facility within 75 KM 2
/SI of CTF have a valid contract
with a Common Treatment
facility for disposal of Bio
medical waste. Or The facility
should have Deep Burial Pit and
Sharp Pit within premises of
Health facility. Such deep burial
pit should approved by the
Prescribed Authority
OB/SI/ Check if Recyclable waste 2
RR (catheter, syringes, gloves, IV
tubes, Ryle's tube, etc.) is
shredded / mutilated after
treatment (options
autoclaving/microwave/hydrocl
ave) and then sent back to
registered recyclers.
Alternatively it can also be sent
for energy recovery or road
construction.
Ascertain that waste is never
sent for incineration or land-fill
site.
Check record for functional 2
RR/ SI linkage with a CWTF
OB/SI/ Check, if there is a system of 2
RR sending discarded medicines
back to manufacturer or
disposed by incineration.
Page 22

Ref.
Criteria
No.
D3.5
Discarded / contaminated
linen is disposed as per
procedure given in the BMW
Rules 2016
D4
Equipment and Supplies for Bio Medical Waste Management
D 4.1 Availability of Bins and liners
for segregated collection of
waste at point of use
Availability of Needle/ Hub
D4.2 cutter and puncture proof
boxes
D4.3
Availability and supply of
personal protective equipment
D4.4 Availability of Sodium
Hypochlorite Solution
Availability of trolleys for
D4.5 waste collection and
transportation
D5 Sharp Management
D 5.1 Disinfection of Broken /
Discarded Glassware is done
as per recommended
procedure
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
OB/SI/ Check that discarded linen, 2
RR mattresses & bedding
contaminated with blood or
body fluid is subjected to
disinfection by non-chlorinated
disinfection (e.g. Hydrogen
Peroxide) followed by
incineration.
Alternatively it can be shredded
or mutilated.
10
OB/SI/ One set of bins and liners of 2
RR appropriate size at each point
of generation for Biomedical
and General waste and its
supply record
OB/SI At each point of generation of 2
sharp waste
OB/SI/ Please look at availability of PPE 2
RR (cap, mask, gloves, boots,
goggles) for waste handlers and
its supply record
OB/SI/ Please look at availability of 2
RR Sodium Hypochlorite and its
supply record
OB/SI Number and size would depend 2
upon the size of facility and
waste inventory
10
OB/SI/ Check if such waste is pre- 2
RR treated either with 10% Sodium
Hypochlorite (having 30%
residual chlorine) for 20
minutes or by autoclaving/
microwave/ hydroclave,

Page 23

Ref.
Criteria
No.
Disinfected Glassware is
stored as per protocol given in RR
D5.2
Schedule I of the BMW Rules
2016
D 5.3 The Staff uses needle cutters
for cutting/burning the syringe
hub
D 5.4
Sharp Waste is stored in
Puncture proof containers
D 5.5
Staff is aware of needle stick
injury Protocol and PEP is
available to the staff
D6
General Solid Waste Management
D6.1 General Waste is not mixed
with infected waste
Availability of Compost Pit
D6.2
within the premises
D 6.3
The facility has introduced
innovations in managing
General Waste
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
OB/SI/ Verify that all glassware is 2
stored in a Cardboard with Blue
colored marking and later sent
for recycling
OB/SI Observe that needle cutters are 2
available at every point of
waste generation and also
being used
OB/SI Check availability of Puncture & 2
leak proof container (White
Translucent) at point of use for
storing needles, syringes with
fixed needles, needles from
cutter/burner, scalpel blade,
etc.
SI/RR Ask staff immediate 2
management of exposure site;
and Medical Officer knows
criteria for PEP.
Please check records of
reporting of Needle Stick Injury
case, PEP, and follow-up
10
OB/SI Check bins to ascertain that 2
such mixing does not take place
PI/OB Check availability of pit within 2
the premises; If a facility has
OB Check, if certain innovative 2
practices have been introduced
for managing general waste e.g.
Vermicomposting, Re-cycling of
papers, Waste to energy,
Compost Activators, etc.
Page 24

Ref.
Criteria
No.
D6.4
Recyclable and Biodegradable
Wastes have segregated
collection
The Facility Undertakes efforts RR/PI displayed at the locations,
to educate patients and
visitors about segregation of
recyclable and biodegradable
D 6.5
wastes The Facility Undertakes
efforts to educate patients and
visitors about segregation of
recyclable and biodegradable
wastes
D7 Liquid Waste Management
D 7.1.
The laboratory has a
functional protocol for
managing discarded samples
Body fluids, Secretions in
suction apparatus, blood and
D7.2 other exudates in OT, Labour
room, minor OT, Dressing
room are disposed only after
treatment
The Facility has treatment
D7.3
facility for managing infectious
liquid waste
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
OB/SI Check availability of two types 2
of bins for collecting
Recyclables and Biodegradables
- Kerb collection point, wards,
OPD, Patient Waiting Area,
Pharmacy, Office, Cafeteria
OB/SI/ Posters/ Work instructions are 2
where two types of bins have
been kept
10
OB/SI/ A copy of such protocol should 2
RR be available and staff should be
aware of the same. Discarded
Lab samples made safe before
mixing with other waste water
OB/SI Check that such secretions, 2
blood and exudates are treated
as per protocol
OB/SI
Check the availability of ETP or
2
a system for treatment with
Chlorine Solution
Page 25
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
OB/SI

Check that Sullage (waste water

from bathrooms & kitchen;
does not contain urine &
D7.4 excreta) does not stagnate 2
(causing fly & mosquito
breeding) and is connected to
Municipal system. In absence of
Sullage is managed such system, the facility should
scientifically have soakage pit for Sullage.
Runoff is drained into the OB/SI drainage system and its
D 7.5 2
municipal drain connectivity and gradient with
D8 Kitchen Waste Management 10

D8.1 Segregation of kitchen waste is 2

done in general waste bin OB
Waste is removed from
D8.2 2
kitchen after every shift OB/RR
Kitchen waste is collected
D8.3 separately & not mixed with 2
Bio medical waste OB
Kitchen waste is disposed in
composite/ taken by agency
D 8.4 2
contracted for solid waste
management RR
Check food waste is not
D 8.5 dumped in Kitchen & 2
surrounding area OB

D9 10
Management of hazardous waste (radioactive etc.)
SI Interact with the staff to 2
ascertain their awareness of
D 9.1
The Staff is aware of Mercury Mercury spill management
Spill management
Availability of Mercury Spill OB Check physical availability of 2
D 9.2
Management Kit Mercury spill management kit,

Page 26

Ref.
Criteria
No.
D9.3
Disposal of Radiographic
Developer and Fixer
D9.4 Disposal of Disinfectant
D9.5
Disposal of Lab reagents
D10
Recycling of waste & Statutory Compliances
The Health Facility has a valid
D 10.1 authorization for Bio Medical
waste Management from the
prescribed authority
D 10.2
The Health Facility submits
Annual report to pollution
control board
D 10.3 The Health Facility has a
system of review and
monitoring of BMW
Management through an
existing committee or by
forming a new committee
The Health facility maintains
D 10.4
its website and annual report
is uploaded
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
SI/RR Check in the Radiology 2
Department about the
procedure being followed for
disposal of Radiographic
developers and fixer. It should
be handed over to an
authorized agency, not
discharged in the drain
SI Should not be drained in 2
SI/RR As per instructions of the 2
manufacturer
10
RR Check for availability of the 2
authorization certificate and its
validity
RR Check the records that reports 2
have been submitted to the
prescribed authority on or
before 30th June every year.
RR/SI Check following records - 2
a. Office order for constitution
of committee or its review by
existing committee - Quality
Committee/ infection control
committee
b. Frequency of committee
meetings - at least 6 monthly
c. Minutes of meetings
RR Check, if the facility has its own 2
website and annual report
under the BMW Rules 2016 is
uploaded
Page 27
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
RR Check following records - 2
a. Yearly Health Check-up
record of all handlers
b. BMW training records of all
staff (once in year training)
c. Immunization records of all
D10.5
waste handlers
d. Records of operations of
Autoclave and other equipment
The Health Facility maintains for last five years
records, as required under the
Biomedical Waste Rules 2016
E INFECTION CONTROL 100
E1 Hand hygiene facilities 10
Availability of Sink and running OB Check for washbasin with 2
water at point of use functional tap, soap and
running water availability at all
E 1.1 points of use including nursing
stations,OPD clinics, OT, labor
room etc.

Display of Hand washing OB Check that Hand washing 2

Instructions instructions are displayed
E 1.2
preferably at all points of use

Adherence to 6 steps of Hand SI Ask facility staff to demonstrate 2

E1.3 washing 6 steps of normal hand wash

Availability of Alcohol Based SI/OB Check for availability alcohol 2

hand rub based hand-rub. Ask staff about
E1.4
its regular supply

Staff is aware of when to hand SI Ask staff about the situations, 2

wash when hand wash is mandatory
E1.5
(5 steps of hand washing).

E2 Personal Protective equipment 10

Use of Gloves during SI/OB Check, if the staff uses gloves 2
procedures and examination during examination, and while
E2.1
conducting procedures

Page 28
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Use of Masks and Head cap SI/OB Check, if staff uses mask and 2
E2.2 head caps in patient care and
procedure areas
Use of Heavy Duty Gloves and SI/OB Check, if the housekeeping staff 2
gumboot by waste handlers and waste handlers are using
E2.3
heavy duty gloves and gum
boots
Use of aprons/ Lab coat by the SI/OB Check the usage of protective 2
clinical staff attire e.g. Apron by the doctor
and nurses, lab coat by the lab
E2.4
technicians, gown in OT, etc.

Adequate supply of Personal SI/RR Check with staff whether they 2

Protective Equipment (PPE) have adequate supply of
E2.5 personal protective equipment.
Verify the records for any stock
outs.
E3 Personal Protective Practices 10
The staff is aware of use of SI/OB Check with the staff when do 2
gloves, when to use (occasion) they wear gloves, and when
and its type gloves are not required. The
E3.1 Staff should also know
difference between clean &
sterilized gloves and when to
use
Correct method of wearing SI/OB Ask the staff to demonstrate 2
and removing gloves correct method of wearing and
E3.2
removing Gloves

Correct Method of wearing SI/OB Check, if the staff knows correct 2

E3.3 mask and cap method of wearing mask

No re-use of disposable SI/OB Check that disposable gloves 2

personal protective equipment and mask are not re-used.
E3.4 Reusable Gloves and mask are
used after adequate
sterilization.
The Staff is aware of Standard SI Ask the staff about five 2
E3.5
Precautions Standard Precautions
E4 10
Decontamination and Cleaning of Instruments

Page 29

Ref.
Criteria
No.
Staff knows how to make
Chlorine solution
E4.1
Decontamination of operating SI/OB
and Surface examination
E4.2 table, dressing tables etc. after
every procedures
Decontamination of
instruments after use
E4.3
Cleaning of instruments done SI/OB
after decontamination
E4.4
Adequate Contact Time for
E4.5 decontamination
E5
Disinfection & Sterilization of Instruments
Adherence to Protocols for
autoclaving
E 5.1
Adherence to Protocol for
High Level disinfection
E 5.2
Use of Signal Locks for
E 5.3 sterilization
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
SI/OB Ask the staff how to make 1%
chlorine solution from
2
Bleaching powder and
Hypochlorite solution
Ask staff when and how they
clean the operating surfaces 2
either by chlorine solution or
Disinfectant like carbolic acid
SI/OB
Check whether instruments are
2
decontaminated with 0.5%
chlorine solution for 10 minutes
Check instruments are cleaned
2
thoroughly with water and soap
before sterilization
SI Ask staff about the Contact
time for decontamination of 2
instruments (10 Minutes)
10
SI/OB Check about awareness of 2
recommended temperature,
duration and pressure for
autoclaving instruments - 121
degree C, 15 Pound Pressure for
20 Minutes (30 Minutes if
wrapped) Linen - 121 C, 15
Pound for 30 Minutes
SI/OB Check with the staff process 2
about of High Level disinfection
using Boiling or Chlorine
solution
OB/RR Check autoclaving records for 2
use of sterilization indicators
(signal Loc)
Page 30
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Chemical Sterilization of SI/OB Check if the staff know the 2
instruments done as per protocol for sterilization of
E 5.4 protocol laparoscope soaking it in 2%
Glutaraldehyde solution for 10
Hours
Sterility of autoclaved pack SI/OB Check if autoclaved instruments 2
maintained during storage are kept in the clean area. Their
expiry date is mentioned on the
package. Instruments are not
E 5.5
used later once instrument
pack has been opened.

E6 Spill Management 10
Staff is aware of how manage SI/OB Check for adherence to 2
E6.1
small spills protocols
Availability of spill SI/OB Check availability of kits 2
E6.2
management Kit
Staff has been trained for spill SI/RR Check for the training records 2
E6.3
management
Spill management protocols OB Check for display 2
E6.4 are displayed at points if use

Staff is aware of management SI/OB Check for adherence to 2

E6.5
of large spills protocol
E7 Isolation and Barrier Nursing 10
Provision of Isolation ward OB Check if isolation ward is 2
E7.1
available in the hospital
Infectious patients are not OB/SI Check infectious patients are 2
E7.2 mixed for general patients admitted in infectious ward
only
Maintenance of adequate bed OB A distance of 3.5 Foot is 2
E7.3 to bed distance in wards maintained between two beds
in wards
Restriction of external foot OB External foot wear are not 2
wear in critical areas allowed in labor room, OT,ICU,
E7.4
Burn ward, SNCU, etc.

Restriction of visitors to OB/Is Visitors are not allowed in 2

E7.5 Isolation Area critical areas like OT, ICU,SNCU,
Burn Ward, etc.

Page 31
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d

E8 10
Infection Control Program and Level of Sanitization/ Awareness
Infection Control Committee is RR/SI Check for the enabling order 2
constituted and functional in and minutes of the meeting
E8.1
the Hospital

Regular Monitoring of RR/SI Check, if there is any practice of 2

infection control practices
E8.2
Antibiotic Policy is
implemented at the facility
E8.3
daily monitoring of infection
control practice like hand
hygiene and personal
protection
RR/SI Check if the hospital has 2
documented Anti biotic policy
and doctors are aware of it.

Immunization of Service RR/SI Hospital staff has been 2

E8.4 Providers immunized against Hepatitis B

Regular Medical check- ups of RR/SI Check for the records and lab 2
food handlers and investigations of Food handlers
E8.5
housekeeping staff and housekeeping staff

E9 10
Hospital Acquired Infection Surveillance
Regular microbiological RR/SI Check for the records of 2
surveillance of Critical areas microbiological surveillance of
E9.1 critical areas like OT, Labour
room, ICU, SNCU etc.

Hospital measures Surgical Site RR/SI Check for the records 2

E9.2
Infection Rates
Hospital measures Device RR/SI Check for the records 2
E9.3
Related HAI rates
Hospital measures Blood RR/SI Check for the records 2
E9.4 Related and Respiratory Tract
HAI
Hospital takes corrective RR/SI Check for the records 2
E9.5 Action on occurrence of HAIs

E10 Environment Control 10

Page 32
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Maintenance of positive air OB/SI Check how positive pressure is 2
E10.1 pressure in OT and ICU maintained in OT

Maintenance of air exchanges OB/SI At least availability of air 2

E10.2
in OT and ICU conditioner
Maintenance of Layout in OT OB/SI Check for zoning of OT in 2
E10.3 protective, clean, sterile and
disposal zones
Carbolization of OT and Labour OB/SI OT and Labour room are 2
E10.4
Room carbolized daily
General and patient traffic are OB/SI Check for the layout and 2
segregated in Hospitals patient traffic . There should be
E10.5 no criss cross between general
and patient traffic.
F HYGIENE PROMOTION 80
F1 20
Community Monitoring and Patient Participation

Check areas surrounding the

F1.1 Areas around the hospital are hospital premises are clean. No 2
cleaned and free of any waste sign of dumping of hospital
materials OB waste in surrounding areas
Members Local Governance SI At least once in month. 2
bodies monitor the cleanliness
F1.2
of the hospital at pre-defined
intervals
Local NGO/ Civil Society PI Discuss with hospital 2
Organizations are involved in administration about
F1.3 cleanliness of the hospital involvement of local NGOs/Civil
society

Patients are counselled on PI/OB Check with patients, if they 2

F1.4 benefits of Hygiene
Patients are made aware of
their responsibility of keeping
the health facility clean
F1.5
have been counselled for
hygiene practices
SI/RR Ask patients about their roles& 2
responsibilities with regards to
cleanliness. Patient’s
responsibilities should be
prominently displayed

Page 33
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Hospital conducts regular SI/RR/ Check outreach sessions, 2
program to engage community PI education seminars are being
F1.6 for promoting cleanliness conduced by hospital though
PSM department for promoting
cleanliness
Hospital has been declared OB Check for signage regarding 2
Smoking/Tobacco Free zone prohibition of
smoking/consumption of
F1.7 tobacco has been placed at
relevant place along with
penalty information

Hospital regularly monitors OB/SI/ Check if there is any 2

and control the use of tobacco RR
products in the premises.
F1.8
cigarette/pan shop
within/adjoining to the
hospital. Check if any fine has
been collected from offenders.
Check if there is any
mechanism for checking of
tobacco produces for visitors

Hospital is involved in training SI/RR Check if hospital involved in 2

and capacity building of lower
level facilities for Hygiene and
F1.9 Infection Control Practices
Hospital celebrates important SI/RR
health days
F1.10
activities of training of PHCs,
CHC, District Hospitals for issues
such as waste management,
infection control, hygiene and
sanitation.
Check if hospital celebrated 2
important health days such as,
world health day, Hand Hygiene
day, Good Governance Day,
Swacchata Pakhwada etc.

F2 Availability of Information Education and Communication Devices/ 10

Material/ Signage
IEC regarding importance of OB Should be displayed 2
F2.1 maintaining hand hygiene is prominently in local language
displayed in hospital premises

IEC regarding Swachhata OB Should be displayed 2

F2.2 Abhiyan is displayed within the prominently in local language
facilities’ premises

Page 34
 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
IEC regarding use of toilets is OB Should be displayed 2
F2.3 displayed within hospital prominently in local language
premises
IEC regarding water sanitation OB Should be displayed 2
F2.4 is displayed in the hospital prominently in local language
premises

Hospital disseminates hygiene OB/SI/ Hygiene Kiosk, Video Messages, 2

F2.5 messages through other RR Leaflets, IEC corners etc.
innovative manners
F3 Leadership and Team Work 10
Cleanliness and Infection SI Check constitution of 2
F3.1 control committee is committee and its functioning
constituted at the facility

Cleanliness and infection RR/SI Verify with the records 2

control committee has
F3.2 representation of all cadre of
staff including Group ‘D’ and
cleanings staff
Roles and responsibility of SI/RR Ask different members about 2
different staff members have their roles and responsibilities
F3.3
been assigned and
communicated
Hospital leadership review the SI/RR Check about regularity of 2
progress of the cleanliness meetings and monitoring
F3.4 drive on weekly basis activities regarding cleanliness
drive

Hospitals leadership identifies SI Check with hospital 2

F3.5 good performing staff administration if there is any
members and departments such good practice

F4 Training and Capacity Building 10

Hospital conducts are training RR Verify with the records, if trg. 2
need assessment regarding Need assessment has been
F4.1 cleanliness and infection done
control in hospital
Bio medical waste SI/RR Verify with the training records 2
F4.2 Management training has
been provided to the staff

Page 35

Ref.
Criteria
No.
Infection control Training has
F4.3 been provided to the staff
Hospital has documented
Standard Operating
F4.4 procedures for Cleanliness and
Upkeep of Facility
Hospital has documented
Standard Operating
F4.5 procedures for Bio-Medical
waste management and
Infection Control
F5 Staff Hygiene and Dress Code
F5.1 Hospital has dress code policy
for Doctors
F5.2 Hospital has dress code policy
for Nursing Staff
Hospital has dress code policy
F5.3 for Paramedics and
Technicians
F5.4 Hospital has dress code policy
for Support Staff
F5.5 Hospital has dress code policy
for Housekeeping Staff
F5.6 Hospital has dress code policy
for Volunteers/ Other staff
F5.7 Doctors adheres to the dress
code policy established by the
hospital
F5.8 Nursing Staff adheres to the
dress code policy established
by the hospital
Assess
ment Complia
Means of Verification Remarks
Metho nce
d
SI/RR Verify with the training records 2
SI/RR Check availability of SOP with 2
the users
RR Check availability of SOP with 2
respective users
30
Ask Hospital Administration 2
about the policy. Check if it is
SI/RR documented
Ask Hospital Administration
about the policy. Check if it is 2
SI/RR documented
Ask Hospital Administration
about the policy. Check if it is 2
SI/RR documented
Ask Hospital Administration
about the policy. Check if it is 2
SI/RR documented
Ask Hospital Administration
about the policy. Check if it is 2
SI/RR documented
Ask Hospital Administration
about the policy. Check if it is 2
SI/RR documented
Check of On duty staff is
maintaining the dress code and
Personal protective 2
Equipment's as per Dress Code
OB Defined
Check of On duty staff is
maintaining the dress code and
Personal protective 2
Equipment's as per Dress Code
OB Defined
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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d
Check of On duty staff is
Paramedic/Technicians maintaining the dress code and
F5.9 adheres to the dress code Personal protective 2
policy established by the Equipment's as per Dress Code
hospital OB Defined
Check of On duty staff is
maintaining the dress code and
F5.10 Support Staff adheres to the Personal protective 2
dress code policy established Equipment's as per Dress Code
by the hospital OB Defined
Check of On duty staff is
Voluntary Personals /Other maintaining the dress code and
F5.11 staff adheres to the dress code Personal protective 2
policy established by the Equipment's as per Dress Code
hospital OB Defined
Check of On duty staff is
maintaining the dress code and
F5.12 Housekeeping Staff adheres to Personal protective 2
the dress code policy Equipment's as per Dress Code
established by the hospital OB Defined
Uniforms are clean, crisp and
F5.13 2
well maintained OB Observation
There is a regular monitoring SI/RR Check daily inspection of Food
of hygiene practices of food handlers and Housekeeping
handlers and housekeeping staff is done by their respective
F5.14 supervisors for Hygiene . Check 2
staff
if the inspection findings are
documented
F5.15 Identity cards and name plates SI/OB Observation 2
have been provided to all staff
FEEDBACK MECHANISHM
G FROM PUBLIC ON 50
CLEANLINESS

Check if Patient/User feedback

is taken either through "Mera
G1 Aspatal application of 10
Feedback c forms. Information
Mechanism in place to get regarding feedback modalities
feedback from public on are displayed prominently for
cleanliness SI/RR general public

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 Assess
Ref. ment Complia
Criteria Means of Verification Remarks
No. Metho nce
d

Feedbacks are checked

regularly/ daily and
acknowledged
G2 Check if there is any evidence 10
of corrective action taken for
Monitoring mechanism of areas of low satisfaction
follow up on such feedback identified from
received from public SI/RR feedback/complaint received. .

Mechanism to Incentivize
G3 20
sanitation staff showing
exemplary devotion to duty

Appreciation letters given to

G3.1 10
sanitation staff for positive
feedback in staff meetings SI/RR
Monetary awards, medals,
reward points, pictures on
G3.2 notice boards or any other 10
recognition for positive
feedback SI/RR
Mechanism to respond to Action taken on feedback is
G4 public on the feedback documented and 10
received SI/RR communicated

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