A Quick Guide on How to Achieve Gold /

Silver Quality Certificate in

AB PM-JAY Empaneled Hospitals
 Gold Quality Certificate
for AB PM-JAY
Gold Quality Certificate is the highest level of Ayushman Bharat Quality
Certification which signifies that the certified hospital is complying with most of the
healthcare protocols to ensure best quality of services and patient care. Gold Quality
Certificate is revised terminology for already existing outcome -based incentivization
structure i.e. NABH Full / JCI Accreditation to AB PM-JAY Gold Quality Certification.
Silver Quality Certified hospital can directly apply for this certification. Gold Quality
Certified hospitals will get additional and higher financial benefits over and above the
‘Hospital benefit plans’.

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3
 Silver Quality Certificate
for AB PM-JAY
Silver Quality Certificate is the second level of Ayushman Bharat Quality
Certification which is revised terminology for already existing outcome -based
incentivization structure i.e. Entry level NABH/NQAS Certification. It indicates that
hospital has better quality of services and patient care but need to focus next on
organization centered standards in terms of responsibility of management system
among others. It is intended to motivate hospitals to keep increasing the level of
quality in their services. Bronze Quality Certified hospital can directly apply for this
certification. Silver Quality Certified hospitals will get additional financial benefits
over and above the ‘Hospital benefit plans’.

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5
 1. Are 'scope of services' registered under AB PM-JAY
clearly defined and displayed at prominent place (e.g.
Hospital entrance, Registration area, Waiting area, etc.) ?
2. Are 'scope of services' registered under AB PMJAY
displayed bilingually (one local language and another
Hindi or English)?
3. Is the hospital staff aware of 'scope of services'
registered under AB PMJAY?
4. Is there a dedicated kiosk/ counter for AB PMJAY
at prominent place in the hospital?
 5. Is the kiosk/ counter manned by Pradhan Mantri
Arogya Mitra (PMAM)/ trained staff during the
operational hours (e.g. Arogya Mitra & its Duty list) ?
Duty from 30-09-2019 to 03-11-2019
Day Date harshad tejalben akshay devendra mukesh Nisha Jayesh
Monday 30-09-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Tuesday 01-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Wednesday 02-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Thursday 03-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Friday 04-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Saturday 05-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Sunday 06-10-19 9 to 5 week off wk off wk off wk off wk off wk off
Monday 07-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Tuesday 08-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Wednesday 09-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Thursday 10-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Friday 11-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Saturday 12-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Sunday 13-10-19 wk off 9 to 5 wk off wk off wk off wk off wk off
Monday 14-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Tuesday 15-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Wednesday 16-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Thursday 17-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Friday 18-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Saturday 19-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Sunday 20-10-19 wk off wk off 9 to 5 wk off wk off wk off wk off
Monday 21-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Tuesday 22-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Wednesday 23-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Thursday 24-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Friday 25-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Saturday 26-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Sunday 27-10-19 wk off wk off wk off 9 to 5 wk off wk off wk off
Monday 28-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Tuesday 29-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Wednesday 30-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Thursday 31-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Friday 01-11-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Saturday 02-11-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Sunday 03-11-19 wk off wk off wk off wk off 9 to 5 wk off wk off
6. Are required equipment’s provided to Arogya
Mitra for AB PMJAY beneficiary identification?
7. Does the hospital have a dedicated team for
AB PMJAY?

Yes / No
 8. Does the hospital have at least one Pradhan Mantri Arogya
Mitra (PMAM)/ dedicated person per shift appointed for looking
after the work of Ayushman Bharat Scheme?
9.Does the nominated AB PMJAY team have
doctor(s) engaged?
10. Does the nominated AB PMJAY team have
a member from administration department?
 11. Does the hospital have AB PMJAY specific IEC
materials near hospital entry and at prominent areas?
12. Does the AB PMJAY kiosk/ counter has IEC
materials pertaining to AB PMJAY on or near it?
 13. Has hospital conducted any promotional activity
(like camping) for spreading awareness regarding the
AB PMJAY scheme?
14. Is hospital’s scope of services mapped with
hospital’s Manpower/Human Resources?
15. Do the hospitals maintain proper medical records
maintained for AB PMJAY patients?
16. Is AB PMJAY claim process documented in the
hospital's policies?
17. Does the hospital charge any extra money
from AB PMJAY beneficiaries?

Yes / No
18. Are the deployed staff members trained for HEM
portal?
19. Are the deployed staff members trained for TMS
portal?
20. Are the deployed staff members trained for BIS
portal?
 21. Does the hospital maintain proper records
for AB PMJAY referred beneficiaries?
SR NO MONTH Visit No. Patient Registrati Admit NEW IPD Patient Gender Age Age ADULT/PE Birth Date Unit Marital Mother Address Village Taluka District State 123 STATEE COUNTRY
HIRALAL
IPD/2019/ UNM- MANGILA
01/04/197 Cardiology WARD NO- TARAKHE MADHYA OTHER MADHYA
1 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD L Male 49y 40Y - 60Y ADULT Married Gujarati Jaora Ratlam INDIA
0 Unit - 2 17 DI PRADESH STATE PRADESH
19 025045 PRAJAPAT
I

VANITABE
IPD/2019/ UNM- 585/3691,
FOLLOW N 24/07/197 Cardiology AHMEDAB AHMEDAB AHMEDAB
2 APRIL 04/00090 2018-07- 24-07-18 01-04-19 Female 40y 8m 40Y - 60Y ADULT Married Gujarati G.H.B.,BA GUJARAT GUJARAT GUJARAT INDIA
UP BALKISHA 8 Unit - 1 AD AD AD
26 058187 PUNAGAR
N NORA

SHAKARIB
IPD/2019/ UNM- EN
FOLLOW 18/03/194 Cardiology NR. BAL HIMATNA SABARKA
3 APRIL 04/00090 2019-03- 18-03-19 01-04-19 BHULESH Female 70y >= 60Y ADULT Widow Gujarati kankanol GUJARAT GUJARAT GUJARAT INDIA
UP 9 Unit - 2 MANDIR GAR NTHA
28 021286 WARBHAI
DARJI
B/H
RAILWAY
CROSSING
, NEW
CHAMUN
MANJULA DA SOC-
IPD/2019/ UNM-
BEN 01/04/196 Cardiology 36, NR. AHMEDAB AHMEDAB AHMEDAB
4 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD Female 52y 40Y - 60Y ADULT Married Gujarati GUJARAT GUJARAT GUJARAT INDIA
MAHESHB 7 Unit - 2 NAVRANG AD AD AD
53 025122
HAI JADAV HIGH
SCHOOL ,
JAGATPUR
ROAD,
CHANDKH
EDA

MANGILA
IPD/2019/ UNM-
FOLLOW L 16/03/196 CVTS Unit - MADHYA OTHER MADHYA
5 APRIL 04/00090 2019-03- 16-03-19 01-04-19 Male 56y 40Y - 60Y ADULT Married Hindi - SARSOD Daloda Mandsaur INDIA
UP RAMLALJI 3 1 PRADESH STATE PRADESH
63 021083
DHANGAR

GOPAL
IPD/2019/ UNM-
RODUJI 05/06/198 Cardiology RAHIMGA MADHYA OTHER MADHYA
6 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD Male 36y 9m 18Y - 40Y ADULT Married Gujarati - Sitamau Mandsaur INDIA
SURYAVA 2 Unit - 2 RH PRADESH STATE PRADESH
68 025070
NSHI
PUSHPAB
IPD/2019/ UNM- EN BIHAND
01/01/197 CVTS Unit - MANDSA MADHYA OTHER MADHYA
7 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD PRAKASH Female 42y 3m 40Y - 60Y ADULT Married Gujarati SANSAD Mandsaur Mandsaur INDIA
7 1 UR PRADESH STATE PRADESH
78 025095 BHAI BHAVAN
DHOBI
NATVARL
IPD/2019/ UNM- AL OD
FOLLOW 07/07/194 CVTS Unit -
8 APRIL 04/00090 2019-03- 01-03-19 01-04-19 MOHANL Male 69y 8m >= 60Y ADULT Married Gujarati VAS,BUKD PATAN PATAN PATAN GUJARAT GUJARAT GUJARAT INDIA
UP 9 2
85 016731 AL I ROAD
SOLANKI
RASIKBHA
I
IPD/2019/ UNM-
MOHANB 01/04/196 Cardiology BAHADUR BHAVNAG
9 APRIL 04/00091 2019-04- 01-04-19 01-04-19 NEW IPD Male 55y 40Y - 60Y ADULT Married Gujarati - PALITANA GUJARAT GUJARAT GUJARAT INDIA
HAI 4 Unit - 2 PUR AR
07 025431
MAKWAN
A
 22. Number of AB PMJAY beneficiaries
referred to AB PMJAY hospitals in last 6 month

Only
Number..
 23. Number of AB PMJAY In-Patient
Department (IPD) census for last 6 months

Only
Number..
24. Does the hospital collect feedback during
discharge from AB PMJAY beneficiaries?
25. AB PM-JAY quality audit checklist filled
regularly in HEM portal?
 25. Guidelines for Monthly Self
Assessment Quality Audit Checklist
(Link:- https://hospitals.pmjay.gov.in )

• Self Assessment Quality Audit Checklist to be performed for all 20

parameters.
• Each parameter to be assessed based on compliance to required
evidences.
• A method of self Assessment includes - Direct observation, Patient
Interview, Staff Interview and Record Review required as per parameter.
• Scoring is 0 (Zero), 5 (Five) and 10 (Ten) based on compliance with the
evidences
• Empaneled hospitals have to perform an online self assessment every
month and average score will be considered as yearly assessment score.

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 Quality Policy
 We are committed to ensure that the beneficiary should get right
treatment in right time at right place by empanelled hospitals under
ABPM-JAY in India and also to monitor the quality of care provided to the
beneficiary by working with other stakeholders.
 We shall endeavor to constantly and actively collaborate with all
healthcare providers to build confidence of beneficiary and stakeholders.
 Also aim to wide spread the network of empanelled hospital which can be
easily accessible to patient/beneficiary for getting the free treatment
under ABPM-JAY.
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“What is Quality ???”
 Standards Environment, Standards
Treatment as per Standard Treatment
Protocol Guideline and Satisfaction of
Both Clients as well as Providers.
AS A PATIENT WHAT QUALITY LEVELS WOULD
YOU ACCEPT FROM YOUR HEALTH SERVICES?

90%
95%
96%

98%
99%

99.9%
 IF 99.9% IS ACCEPTABLE TO YOU, THEN…

•YOUR HEART FAILS * 20,000 WRONG

TO BEAT 32,000 DRUG
TIMES EACH YEAR PRESCRIPTIONS
MADE EVERY YEAR
* 500 SURGICAL
OPERATIONS ARE * 19,000
BABIES ARE
PERFORMED DROPPED BY
WRONGLY DOCTORS
EVERY WEEK AT BIRTH
 Well....
“ THERE IS ONLY A 1 %

DIFFERENCE IN THE DNA

GENETIC CODE BETWEEN A

CHIMPANZEE AND A

HUMAN BEING”
•IN OUR PROFESSION THERE IS NO SCOPE FOR ERROR.
FOR ANY ERROR COMMITTED THE DIFFERENCE LIES
BETWEEN LIFE AND DEATH, BETWEEN RELIEF AND
DISABILITY.

•THERE IS NO SECOND CHANCE

“Quality comes from your Heart. ”
“Quality is a Team Work, it’s never
achieved by Single Person. ”
 “Self Assessment is the Best
Assessment for Improvement. ”
 1. All the services being provided by AB – PMJAY Empanelled
Hospitals, patient rights and responsibilities are clearly defined &
display at prominent place in understandable language.

Evidence Method of Available evidence

Response sheet Mark
Required Assessment (Photo to be uploaded)

If all options available:

a) Scope of service displayed at the entrance and
Scope of service
visible to the patient and visitors 10
is clearly defined
b) Bilignual languages
and displayed at
c) Staff aware of scope of services
prominent place
(e.g. Hospital If any options Incomplete:
Photo of Scope of
entrance, Direct a) Scope of service displayed at the entrance and
Service in AB PMJAY,
Registration area, observation & visible to the patient and visitors 5
Patient rights &
Waiting area, Staff interview b) Bilignual languages
responsibility.
etc.) in two c) Staff aware of scope of services
language (one If all options not available:
local language
a) Scope of service displayed at the entrance and
and another Hindi
visible to the patient and visitors 0
or English).
b) Bilignual languages
c) Staff aware of scope of services 42
 1. All the services being provided by AB – PMJAY Empanelled
Hospitals, patient rights and responsibilities are clearly defined &
display at prominent place in understandable language.

43
 1. All the services being provided by AB – PMJAY Empanelled
Hospitals, patient rights and responsibilities are clearly defined &
display at prominent place in understandable language.

44
 2. Hospital has displayed the IEC pertaining to
Ayushman Bharat at prominent place

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

100% compliance of all

a) The banner or poster of AB- 10
three evidences.
PMJAY is displayed at
prominent place (e.g. Hospital
if any of the three AB PM-JAY
entrance, Registration area,
Direct evidence is found to be 5 Banner displayed
Waiting area, etc.)
observation & non-compliant. at prominent
b) The banner or poster of AB-
Staff interview place in hospital
PMJAY is visible to patient or
premsis.
visitors
Non-compliance of all
c) Staff aware about the AB- 0
three evidences.
PMJAY
45
2. Hospital have displayed the IEC pertaining to Ayushman Bharat
at prominent place

46
 3. The initial assessment by doctors for in-patients is documented
within 24 hours or earlier and the Patient record file have care and
treatment orders which is signed, named, timed and dated by the
concerned doctor.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

See minimum 5 in-patients files of

existing (admitted) patient record 100% compliance of all
10
and check for: four evidences.
a) Availability of Initail assesment
form
Doctor's initial
b) Initial assemnent form filled by if any of the four
Record review & assessment form
concerned personal evidence is found to be 5
Staff interview and Nursing initial
c) Time of admission ,Time of initial non-compliant.
assessment form.
assessment , Initial assesment start
and completion time.
d) Treatment orders are signed, Non-compliance of all
named, timed and dated by the 0
four evidences.
concerned doctor 47
3. The initial assessment by doctors for in-patients is documented
within 24 hours or earlier and the Patient record file have care and
treatment orders which is signed, named, timed and dated by the
concerned doctor.

48
3. The initial assessment by doctors for in-patients is documented
within 24 hours or earlier and the Patient record file have care and
treatment orders which is signed, named, timed and dated by the
concerned doctor.

49
 4 . The results of the diagnostic (Laboratory, Radiology, etc.) tests
should be made available in defined time frame and intimated
about the critical results to the concerned personnel immediately.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

100% compliance of all three

10
a) Time frame of diagonostic evidences.
results are displayed in Turn around
diagnostic department and Time, Critical
followed. Direct if any of the three evidence is value Chart are
5
b) See minimum five cases of observation, found to be non-compliant. displayed in
Critical value and check for: Record review, Diagnostic area.
i) Critical result value Patient interview Registry
identification time and informed & Staff interview maintained for
time to concerned personnel. Non-compliance of all three TAT and Critical
ii) Appropriate action taken by 0 value
evidences.
the concerned person for the
critical result. 50
 4. The results of the diagnostic (Laboratory, Radiology, etc.) tests
should be made available in defined time frame and intimated
about the critical results to the concerned personnel immediately.

51
52
 5. Events during cardio-pulmonary resuscitation are recorded and
mock drills conducted at regular interval; sequence of CPR in
pictorial manner should be displayed.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

a) Policy for cardio-

pulmonary resuscitation 100% compliance of all four
10
b) CPR process flow chart evidences.
displayed in patient care area Documents of CPR
c) Staff aware of steps in mock drills
Direct
cardio-pulmonary if any of the four evidence is conducted at
observation, 5
resuscitation found to be non-compliant. regular intervals
record review &
d) Documentation of Regular and CPR chart
Staff interview
mock drill conducted, display in patient
variations observed in each care area.
drill and CAPA taken by Non-compliance of all four
respective personnel's. 0
evidences.
53
5. Events during cardio-pulmonary resuscitation are recorded and
mock drills conducted at regular interval; sequence of CPR in
pictorial manner should be displayed.

54
 6. Informed consent about the information on risks involved,
benefits, alternatives for the procedures, surgeon who will
perform the requisite procedure in an understandable language

Available evidence
Evidence Required Method of Assessment Response sheet Mark
(Photo to be uploaded)
a) SOP developed for taking the 100% compliance of all
informed consent from patient or 10
four evidences.
patient relative.
b) See minimum 5 in-patients files if any of the four evidence
of previous month and check is found to be non- 5
availability of: compliant.
i) Clearly defined information on
risks involved, benefits, Direct observation,
Informed consent form
alternatives for the procedures by Record review, Patient
and Post operative
surgeon who will perform the interview & Staff
notes in patient files.
requisite procedure in an interview
understandable language.
Non-compliance of all
ii) Informed consent is duly signed 0
four evidences.
by patient or patient relative and
countersigned by concerned
surgeon.
iii) Post operative notes by 55
concerned surgeon.
 6. Informed consent about the information on risks involved,
benefits, alternatives for the procedures, surgeon who will
perform the requisite procedure in an understandable language

56
 7. The regular and periodic monitoring of anaesthesia components
like recording of heart rate, cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation, airway security and patency and level
of anaesthesia should be done.
Method of Available evidence
Evidence Required Response sheet Mark
Assessment (Photo to be uploaded)
See minimum 5 post-operative
files of previous month and check 100% compliance of all three
for: 10
evidences. a) Complete
a) Availability of completely filled
documentation:
Pre-anaesthesia, during
Recording of heart
anaesthesia and post-
if any of the three evidence is rate, cardiac rhythm,
anaesthesia form in each patient 5
found to be non-compliant. respiratory rate, BP,
file.
Record review & oxygen saturation,
b) Pre-anaesthesia consent is
Staff interview airway security
duly signed by patient or patient
b) Pre-anaesthesia
relatives and countersigned by
consent duly signed
anaesthetists in each patient file..
by pt. or pt. relatives
c) Complete documentation (e.g. Non-compliance of all three
0 and countersigned by
Recording of heart rate, cardiac evidences.
anaesthetists
rhythm, respiratory rate, BP,
oxygen saturation, airway security 57
recorded ) in each patient file.
7. The regular and periodic monitoring of anaesthesia components
like recording of heart rate, cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation, airway security and patency and level
of anaesthesia should be done.

58
 8. The documented procedure is defined and adhered to, for the
prevention of adverse events like wrong site, wrong patient and
wrong surgery.

Available evidence
Evidence Required Method of Assessment Response sheet Mark (Photo to be
uploaded)

See minimum 5 post-operative 100% compliance of

files of previous month and 10
all two evidences.
check :
a) Availability of WHO safety
checklist.
if any of the two WHO safety
b) WHO safety checklist is filled
Record review & evidence is found to 5 checklist signed by
and signed by
Staff interview be non-compliant. OT Incharge,
anaesthetist(before induction of
anaesthetist and
anaesthesia), surgeon(before
surgeon
skin incision) and OT
incharge(before patient leaves Non-compliance of all
OT) 0
two evidences.
59
8. The documented procedure is defined and adhered to, for the
prevention of adverse events like wrong site, wrong patient and
wrong surgery.

60
 9. Documented procedure for management of medication are
defined and implemented e.g. Sound alike and look alike
medications are stored separately.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

100% compliance of all a) List of sound

10
a) Defined list of sound alike three evidences. alike and look alike
and look alike medications defined and
b) Display of the sound alike displayed in all
and look alike medications list in Direct observation, if any of the three patient-care area
all patient-care area Record review & evidence is found to be 5 b) Sound alike and
c) Sound alike and look alike Staff interview non-compliant. look alike
medications are stored medications are
separately in pharmacy and all stored separately in
patient-care area pharmacy and all
Non-compliance of all patient-care area
0
three evidences.
61
9. Documented procedure for management of medication are
defined and implemented e.g. Sound alike and look alike
medications are stored separately.

62
9. Documented procedure for management of medication are
defined and implemented e.g. Sound alike and look alike
medications are stored separately.

63
 10. Listing and storage of High risk medications to be done &
orders should be verified before their dispensing.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

100% compliance of all

a) The list of High risk 10 a) List of High risk
four evidences.
medications are available medication
b) Updated legal licence b) High Risk
available if narcotics are Medications are
stored and used. Direct observation, if any of the four evidence kept under lock and
c) The high risk medications Record review & is found to be non- 5 key in separate
are stored separately in Staff interview compliant. drawer
secure enviorment (double c) Legal liscence for
lock). narcotics if
d) Check patient file for narcotics are stored
documentation verification. Non-compliance of all four and used.
0
evidences. 64
10. Listing and storage of High risk medications to be done &
orders should be verified before their dispensing.

65
10. Listing and storage of High risk medications to be done &
orders should be verified before their dispensing.

66
 11. Verification of dosage, route, timing and expiry date before
administering the medication should be done.

Method of Available evidence

Evidence Required Response sheet Mark
Assessment (Photo to be uploaded)
100% compliance of all three
a) Defined SOP for process 10
evidences.
of administration of
if any of the three evidence is found to
medication 5
be non-compliant.
b) Check minimum 5 in- a) Policy of
patients files of previous Management of
month and look for Medications
implemented process as Direct observation, b) Patient files with
defined in SOPs (dosage, Record review & Medication orders that
route, timing and expiry Staff interview are clear, legible,
date before administering Non-compliance of all three dated, named and
0
the medication) evidences. signed by the
c) Medication orders are concerned doctor.
clear, legible, dated, named
and signed by the
concerned doctor.
67
11. Verification of dosage, route, timing and expiry date before
administering the medication should be done.

68
 12. Adverse drug events are collected, analysed by the treating
doctor and practices are modified (if necessary) to reduce the
same.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

100% compliance of all

10
a) Clearly defined policy for three evidences.
the adverse drug events.
b) Adverse drug events are
reported to concerned if any of the three evidence Records of adverse
Record review &
authority and record is is found to be non- 5 drug events kept
Staff interview
available compliant. with CAPA.
b) Corrective and preventive
action taken for Adverse drug
events. Non-compliance of all
0
three evidences.
69
12. Adverse drug events are collected, analysed by the treating
doctor and practices are modified (if necessary) to reduce the
same.

70
 13. The hospital infection control committee is constituted and
functional with defined surveillance method for tracking and
analysing appropriate infection rates.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

a) Availability of infection 100% compliance of all five

10
control committee formation evidences.
letter with list of members’s. a) SOPs are
b) List of identified high risk defined for Infection
areas. if any of the five evidence is control
5
c) Defined SOP for tracking Record review & found to be non-compliant. b) Minutes of the
and analysing infection rates. Staff interview meeting of infection
d) Minutes of the meeting of control committee
infection control committee. with corrective and
e) Corrective and preventive Non-compliance of all five preventive action
0
action taken to prevent evidences.
infection. 71
13. The hospital infection control committee is constituted and
functional with defined surveillance method for tracking and
analysing appropriate infection rates.

72
13. The hospital infection control committee is constituted and
functional with defined surveillance method for tracking and
analysing appropriate infection rates.

73
 14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

100% compliance of all

a) Hand washing facility available 10
four evidences. a) Hand hygine
in all patient care areas
techniques are
b) Staff aware about the hand
displayed at every
hygiene practices and follows the
hand washing area.
steps of handwashing (WHO Direct observation, if any of the four
b) Training record of
handwashing steps). Record review & evidence is found to be 5
hand hygiene
c) Work instruction displayed in all Staff interview non-compliant.
trainings given to all
handwashing points at all
staff members.
patientcare areas
c) Hand hygine
d) Hand hygiene audit and CAPA
Non-compliance of all audits done
done regularly. 0
four evidences.
74
14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.

75
14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.

76
14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.

77
 14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.

Bench mark Total no. of hand hygiene opportunity - missed opportunities X100
1 Criteria Target Total no. of hand hygiene opportunities
2 % of Compliance 100 %

Jan’19 89.80 141/157

Feb’19 79.76 138/173

Mar’19 90.36 225/249

RCA – Deviation from 100 % Compliance was observed due to –

1.Heavy workload
2.Emergency situation
3.Hand hygiene done but steps not followed properly.
CAPA – 78
1. Regular training & education.
 15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis

Available evidence
Evidence Required Method of Assessment Response sheet Mark (Photo to be
uploaded)

a) The Vaccination (Inj. TT,

Hepatitis – B, Typhoid)and
medical checkup record available
of all concerned staff members
b) Hospital provided Personal
protective equipment to
concerned staff.
c) Staff uses Personal protective
equipment while conducting any
procedure/activity.
d) Display of Post exposure
prophylaxis chart in all patient
care areas
100% compliance of
10
all four evidences.
Direct observation, if any of the four
Record review & Staff evidence is found to 5 conducting any
interview be non-compliant.
Non-compliance of
0
all four evidences.
a) Staff vaccination
record.
b) PPE Equipments
used by staff while
procedure/activity.
c) Post exposure
prophylaxis chart in
patient care area.
79
15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis

80
15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis

81
15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis

82
15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis

83
 16. The proper implementation and regular monitoring of Bio-Medical
waste segregation and collection in all the patient care areas of the
hospital and staff should be trained in handling the Bio-Medical waste and
provided with all personal protective measure.

Available evidence
Evidence Required Method of Assessment Response sheet Mark
(Photo to be uploaded)
a) Updated license available for Bio- 100% compliance of all
Medical Waste Management practice 10
six evidences.
as per BMW Rule 2016
b) SOP defined for the process of if any of the six evidence
BMW as per Pollution control is found to be non- 5
a) Updated license of
guidelines. compliant.
BMW.
c) Staff follows the SOP.
b) Available
d) Waste management bins available Direct observation,
biomedical waste bins
and BMW guideline chart is displayed Record review & Staff
and displayed chart in
in all patient care area interview
patient care area.
e) Personal protective measures (e.g.
Non-compliance of all six c) Biomedical waste
gloves, mask, apron, gum boots, 0
evidences. storage area
heavy duty rubber gloves, etc.) are
used by all categories of staff
handling Bio-Medical Waste.
f) Infection control committee visits
84
common biomedical treatment facility.
 16. The proper implementation and regular monitoring of Bio-Medical
waste segregation and collection in all the patient care areas of the
hospital and staff should be trained in handling the Bio-Medical waste and
provided with all personal protective measure.

85
 16. The proper implementation and regular monitoring of Bio-Medical
waste segregation and collection in all the patient care areas of the
hospital and staff should be trained in handling the Bio-Medical waste and
provided with all personal protective measure.

86
 17. A defined mechanism to be there for regular updating of the
licences / registration / certifications.

Available evidence
Evidence Method of
Response sheet Mark (Photo to be
Required Assessment
uploaded)

All aplicable legal liscence are upto date 10

List of applicable
See the legal licences and
relevant MOU/Aggrement
Record review
statutory with date of issue
documents. If any applicable legal liscence is expired or and validity is
5
not available maintained.

Non availability of legal liscence 0

87
17. A defined mechanism to be there for regular updating of the
licences / registration / certifications.

88
17. A defined mechanism to be there for regular updating of the
licences / registration / certifications.

89
 18. Safe exit plan for fire and non-fire emergencies should be
documented and ensure the awareness amongst the hospital staff
and Fire Mock drills should be conducted at least twice in a year.

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)

a) SOP defined and 100% compliance of all four

implemented for safe exit
plan in case of fire and
non-fire emergencies.
b) Sinages displayed of Direct observation,
do's and don’t's in case of
fire
c) Display of fire exit plan
in all patient care areas.
c) Record of Mockdrill's
conducted and CAPA done
10
evidences.
a) All the signages
are displayed with
fire exit plan.
if any of the four evidence is
Record review & 5 b) Document of
found to be non-compliant.
Staff interview. mock drills
conducted at
regular intervals
Non-compliance of all four
0
evidences.
90
 18. Safe exit plan for fire and non-fire emergencies should be
documented and ensure the awareness amongst the hospital staff
and Fire Mock drills should be conducted at least twice in a year.

91
 18. Safe exit plan for fire and non-fire emergencies should be
documented and ensure the awareness amongst the hospital staff
and Fire Mock drills should be conducted at least twice in a year.

92
 18. Safe exit plan for fire and non-fire emergencies should be
documented and ensure the awareness amongst the hospital staff
and Fire Mock drills should be conducted at least twice in a year.

93
 19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.

Available
Method of evidence
Evidence Required Response sheet Mark
Assessment (Photo to be
uploaded)
See minimum 5 personal files of staffs (e.g.
Consultant RMO & Nurses, etc.) and check for their 100% compliance of
10
qualification, training and privelaging all five evidences.
a) Medical professionals are granted previlages to
admit and care of patients in consonance with their
if any of the five All files are
qualification, training, experience and registration.
evidence is found to 5 maintained by
b) Medical professionals admit and care care for
Record review & be non-compliant. HR Dept. with
patients as per their privelaging.
Staff interview all the the
c) Nursing staff is granted previlages in consonance
required
with their qualification, training, experience and
details
registration.
d) Nursing professional care for patients as per their Non-compliance of all
0
privelaging. five evidences.
e) System developed for updating the personal files
of staff. 94
19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.

95
19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.

96
19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.

97
 20. Up to date and chronological details of the patient care should
be available in the medical record including discharge summary

Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
a) SOP defined for the process of 100% compliance
a) All the files in
keeping medical record file of of all five 10
MRD section are
discharge patient, MLC and Death evidences.
arranged in
case if any of the five cronological order.
b) Staff is aware and follows the evidence is found
5 LAMA Death and
process defined in SOP to be non- MLC files are kept
c) See minimum 5 files from medical compliant.
Record review & seperately.
record (e.g. Surgery, Medicine, MLC,
Staff interview b) Checklist for
Death, LAMA, etc.) and check the
maintaining records
chronological account of patient care.
in cronological
i) Availability of checklist for Non-compliance of
0 order in patient file.
maintainaing records in chronological all five evidences. c) Summary of
order
medical record
d) Medical record audit with corrective
audit.
98
and preventive action.
20. Up to date and chronological details of the patient care should
be available in the medical record including discharge summary

99
20. Up to date and chronological details of the patient care should
be available in the medical record including discharge summary

100
 THANKS
“Want your support for Improvement”