AAC 1A

Score
(0/5/10)
EVIDENCE
CONTENT
The services being provided are clearly
defined and are in consonance with the
needs of the community.
10

INTERPRETATION
The organization shall define this
keeping in mind the scope of services
applied for.

REMARKS
The needs of the community should be
considered especially when planning a
new organization or adding new
services. The same could be captured
through the feedback mechanism.

SERVICES

AAC 6B
Score
(0/5/10)
EVIDENCE
CONTENT
The Infrastructure (physical and
manpower) is adequate to provide for
its defined scope of services.(For Labs)
10
INTERPRETATION
The available equipment and manpower
should be able to effectively deliver its
laboratory services.

REMARKS
Reports should not get delayed due to
lack of adequate equipment or
manpower (including people authorized
to report results).

Manpower
Summary

COP -1C
Score
(0/5/10)
EVIDENCE
CONTENT
These reflect (Uniform Care Policy) applicable
laws, regulations and guidelines.
0
INTERPRETATION
Self explanatory. Where applicable, the
organization shall adhere to the norms laid down
by government by relevant legislations like clinical
establishment act or any such similar legislation.

REMARKS
For example, consent before surgery, providing
first aid to emergency patients and police
intimation in cases of medico-legal cases.

DEFICIENCY

COP- 3D
Score
(0/5/10)
EVIDENCE
CONTENT
Ambulance(s) are manned by trained
personnel.
10
INTERPRETATION
The ambulance should be manned by a
trained driver, technician/nurse and/or
doctor depending on the situation.
Personnel shall be trained in BLS and/or
ACLS.

REMARKS
Driver shall have a valid driving license


COP -3E
Score
(0/5/10)
EVIDENCE
CONTENT Ambulance(s) is checked on a
daily basis
10
INTERPRETATION Self-explanatory.

REMARKS The check shall clearly
indicate the functioning
status of the ambulance like
lights, siren, beacon lights etc.
In addition, the ambulance
shall undergo servicing as per
the set schedule


COP-3F Score
(0/5/10)
EVIDENCE
CONTENT Equipment are checked on
a daily basis using a
checklist
10
INTERPRETATION Self-explanatory
REMARKS The check shall clearly
indicate the functioning
status of the equipment


COP-3G Score
(0/5/10)
EVIDENCE
CONTENT
Emergency medication are
checked daily and prior to dispatch
using checklist
10
INTERPRETATION
Self explanatory .This also includes
checking expiry dates of drugs.

REMARKS
In case of rapid turnaround of the
ambulance is required , only
medication used could be topped
up or the organization could keep
an additional set of drugs as stand
by.


COP-8D Score
(0/5/10)
EVIDENCE
CONTENT Adequate staff and equipment(In ICUs)are
available
10
INTERPRETATION The ICU should be equipped with all necessary
life-saving and monitoring equipment as well as
suitably manned by trained staff. The exact
requirements shall be decided by the
organization based on the scope and
complexity of its services. However, the
organization is expected to follow best clinical
practices

REMARKS A good reference guide for nursing manpower
is the Indian Nursing Council recommendations.

Equipment
List
Nurse patient
Ratio

COP 8G
Score
(0/5/10)
EVIDENCE
CONTENT A quality assurance programme(Critical Care) is
documented and implemented
5

INTERPRETATION These could be developed individually or it could be a
part of the organizations quality-assurance
programme. The organization shall ensure that the
programme is in consonance with good clinical
practices.

REMARKS Good clinical practices include monitoring infection
rates, re-admission rates, re-intubation rates etc.
Further a good starting point could be various national
and international critical care society guidelines.

Antibiotic
Policy
Infection
Rate
Deficiency

COP -9A
Score
(0/5/10)
EVIDENCE
CONTENT Policies and procedures (Vulnerable) are
documented and are in accordance with the
prevailing laws and the national and
international guidelines
10
INTERPRETATION At a minimum, it shall incorporate as to who the
vulnerable patients are, who is responsible for
identifying these patients, risk management in
these patients and monitoring of these patients
(at least twice a day). All these patients shall be
assessed for risk of falls and the same
documented.

REMARKS Refer to disability act, mental act.

Policy
Fall
Assessment
Fall Risk
Assessment Tool

COP- 11B
Score
(0/5/10)
EVIDENCE
CONTENT The organization defines and displays the
scope of its paediatric services
5
INTERPRETATION The scope shall also include neonatal
services, if any.

REMARKS The display should be in a prominent
location (either near the entrance or
registration counter or near the OPD)
Refer to AAC 1b also.

Services
Deficiency

COP- 14D
Score
(0/5/10)
EVIDENCE
CONTENT Documented policies and procedure exist to
prevent adverse events like wrong site, wrong
patient and wrong surgery.*
10
INTERPRETATION Procedure should be available for preventing
adverse events like wrong patients, wrong site by a
suitable mechanism.

REMARKS The organization should be able to demonstrate
methods to prevent these events, e.g.
identification tags, badges, cross-checks, time-out
etc. Refer to WHO Safe surgery saves lives
initiative.

Policy
SSC
WHO SAFE
SURGERY

COP -16D
Score
(0/5/10)
EVIDENCE
CONTENT The organization respects and supports
management of pain for such patients.
5
INTERPRETATION Self explanatory. In case the hospital
does not have facilities for pain
management it could refer such
patients to centres specializing in pain
management.

REMARKS Pain management includes medical,
surgical and anaesthesia techniques.

ASSESSEMENT
FORM
PERCENTAGE

COP -17E
Score
(0/5/10)
EVIDENCE
CONTENT
Rehabilitative services are
provided by a multidisciplinary
team
10
INTERPRETATION
The team shall have a treating
doctor, a rehabilitation therapist,
rehabilitation nurses and other
professional experts.

REMARKS


Physiotherapy
Qualification

COP-18 B
Score
(0/5/10)
EVIDENCE
CONTENT The organization has an ethics
committee to oversee all research
activities.
10
INTERPRETATION An ethics committee should be
framed in the hospital to monitor
activities undertaken by various
providers. The committee has the
powers to discontinue a research trial
when risks outweigh the potential
benefits.

REMARKS Refer to schedule Y of drugs and
cosmetics Act and to ICMR guidelines


COMMITTEES
DRUGS AND
COSMETICS
ICMR

MOM 1C
Score
(0/5/10)
EVIDENCE
CONTENT A multidisciplinary committee guides the formulation
and implementation of these policies and
procedures.
10
INTERPRETATION This shall be representative of major clinical
departments, administration and shall include a
pharmacist/ clinical pharmacologist. The objective of
this committee, its composition, frequency of
meetings, quorum required and the minutes of the
meeting shall be documented. At a minimum the
committee shall meet once in three months.

REMARKS For example pharmaco-therapeutic committee.

COMMITTEES

PRE 1A
Score
(0/5/10)
EVIDENCE
CONTENT Patient and family rights and responsibilities are
documented and displayed.*
10
INTERPRETATION Organization should respect Patients rights and
inform them of their responsibilities. All the rights
of the patients should be displayed in the form of a
citizens charter, which should also give information
of the charges and grievance redressal mechanism.

REMARKS Display should be at least bi-lingual (English and the
State language/language spoken by the majority of
people in the area). The documented patient rights
shall include all the points mentioned in PRE 2. For
example of patient responsibility refer to glossary

BOARD
POLICY

PRE- 1B
Score
(0/5/10)
EVIDENCE
CONTENT Patients and families are informed of
their rights and responsibilities in a
format and language that they can
understand.
10

INTERPRETATION Self explanatory.
REMARKS This could be done in the form of
permanent displays at strategic
locations within the organization.
Pamphlets could be provided regarding
the same
BOARD
PAMPHLETS

PRE -1C
Score
(0/5/10)
EVIDENCE
CONTENT The organizations leaders
protect patients rights.
10
INTERPRETATION Protection also includes
addressing patients grievances
w.r.t rights.

REMARKS

PAMPHLETS
CITIZEN
CHARTER

PRE -1E
Score
(0/5/10)
EVIDENCE
CONTENT Violation of patient rights is reviewed and
corrective/preventive measures taken.
5
INTERPRETATION Where patients' rights have been infringed upon,
management must keep records of such violations, as also a
record of the consequences, e.g. corrective actions to prevent
recurrences. The organization shall have a mechanism to
capture the same

REMARKS The organization could develop an indicative list of such items
and train the staff accordingly. For example, repeated
examinations, no examination soliciting money. The patient
feedback form (by incorporating patient rights worded
appropriately) could be used as a tool to capture violation of
patient rights

DEFICIENCY

PRE-2A
Score
(0/5/10)
EVIDENCE
CONTENT Patient and family rights address
any special preferences, spiritual
and cultural needs.
10
INTERPRETATION This could include dietary
preferences and worship
requirements

REMARKS
Prayer Room
DIETRY
PREFERENCE

PRE- 2B
Score
(0/5/10)
EVIDENCE
CONTENT Patient rights include respect for personal dignity and
privacy during examination, procedures and treatment.
10
INTERPRETATION During all stages of patient care, be it in examination or
carrying out a procedure, hospital staff shall ensure that
patients privacy and dignity is maintained. The
organization shall develop the necessary guidelines for
the same. During procedures the organization shall
ensure that the patient is exposed just before the actual
procedure is undertaken. With regards to
photographs/recording procedures; the organization
shall ensure that consent is taken and that the patients
identity is not revealed.

REMARKS
NURSING
POLICY

PRE- 2C
Score
(0/5/10)
EVIDENCE
CONTENT Patient and family rights include
protection from physical abuse or
neglect.
10
INTERPRETATION Self explanatory. Special precautions
shall be taken especially w.r.t vulnerable
patients e.g. elderly, neonates etc.

REMARKS Examples of this falling from the
bed/trolley due to negligence, assault,
repeated internal examinations,
manhandling etc

Sentinel Event
OPD
IPD FORM

PRE- 2D
Score
(0/5/10)
EVIDENCE
CONTENT Patient and family rights include treating
patient information as confidential
10
INTERPRETATION Self explanatory. Statutory requirements
w.r.t. privileged communication shall be
followed at all times. Confidential
information including HIV status shall not be
revealed without patients permission. It
shall not be written / pasted on the cover of
the medical record.

REMARKS Examples of privileged communications
include MTP, patients of tuberculosis or any
other infectious disease

NURSING MANUAL
MRD Manual


PRE -2G
Score
(0/5/10)
EVIDENCE
CONTENT Patient and family rights include right
to complain and information on how
to voice a complaint
5

INTERPRETATION Grievance redressal mechanism must
be accessible and transparent.
Displayed information must be
clearly available on how to voice a
complaint.

REMARKS
Deficiency
CITIZEN
CHARTER

PRE -2H Score
(0/5/10)
EVIDENCE
CONTENT Patient and family rights
include information on
the expected cost of the
treatment
10
INTERPRETATION Self explanatory
REMARKS Refer PRE 6c
ESTIMATE BILL
CITIZEN
CHARTER

PRE -2J Score
(0/5/10)
EVIDENCE
CONTENT
Patient and family rights include
information on plan of care,
progress and information on their
health care needs.
5
INTERPRETATION
Self explanatory

REMARKS
Refer AAC 4g and PRE 5

Percentage
DEFICIENCY
DEFICIENCY PRE 2J
Only 16.6% of Care Plan is Documented and countersigned by consultant.

PRE- 3E
Score
(0/5/10)
EVIDENCE
CONTENT The care plan respects and where
possible incorporates patients
and/or family concerns and
requests.
10
INTERPRETATION The religious, cultural and spiritual
views of the patients and/or family
shall be considered during the
process of care delivery.

REMARKS Incorporating patient and/or family
requests shall be limited by the
statutory requirements.

DIETRY
PRAYER ROOM

PRE-6A Score
(0/5/10)
EVIDENCE
CONTENT There is uniform pricing policy
in a given setting (out-patient
and ward category).
10
INTERPRETATION There should be a billing policy
which defines the charges to
be levied for various activities

REMARKS
BILLING POLICY
CITIZEN
CHARTER

PRE- 6B
Score
(0/5/10)
EVIDENCE
CONTENT The tariff list is available to patients. 10
INTERPRETATION The organization shall ensure that there is
an updated tariff list and that this list is
available to patients when required. The
organization shall charge as per the tariff
list. Any additional charge should also be
enumerated in the tariff and the same
communicated to the patients. The tariff
rates should be uniform and transparent.

REMARKS
SCREEN SHOT OF
BILLING SOFTWARE
ESTIMATE BILL
CITIZEN
CHARTER

PRE -6C
Score
(0/5/10)
EVIDENCE
CONTENT The patient and/or family members are
explained about the expected costs
10
INTERPRETATION Patients should be given an estimate of
the expenses on account of the
treatment preferably in a written form.

REMARKS The estimate shall be prepared on the
basis of the treatment plan. It could be
prepared by the OPD / Registration /
Admission staff in consultation with
treating doctor.

ESTIMATE BILL
CITIZEN
CHARTER

PRE -6D Score
(0/5/10)
EVIDENCE
CONTENT Patient and/or family are informed
about the financial implications when
there is a change in the patient
condition or treatment setting

INTERPRETATION When patients are shifted from one
setting to another, typically to and
from ICUs, the financial implications
must be clearly conveyed to them

REMARKS

PRE- 7A Score
(0/5/10)
EVIDENCE
CONTENT The organization has a documented complaint
redressal procedure.*
5
INTERPRETATION This shall incorporate the mechanism for lodging
complaints (including verbal or telephonic
complaints), method of compiling them,
analysing complaints including the time frame,
the person(s) responsible and documenting the
action taken.

REMARKS It is for the organization to decide if it wants to
give credence to anonymous complaints

INDUCTION POLICY
DEFICIENCY
CITIZEN
CHARTER

PRE-7B Score
(0/5/10)
EVIDENCE
CONTENT Patient and/or family members are made
aware of the procedure for lodging
complaints.
5
INTERPRETATION Self explanatory. This shall be either by display
or providing written information.

REMARKS It is important that the organization creates an
environment of trust wherein the patient
would be comfortable to air his/her views.

CITIZEN CHARTER
DEFICIENCY

PRE- 7C Score
(0/5/10)
EVIDENCE
CONTENT All complaints are analysed. 10
INTERPRETATION The entire process shall be
documented.

REMARKS Where appropriate the patient and/or
family could be involved in the
discussions and also informed regarding
outcome.

PATIENTS FEED
BACK

PRE 7D Score
(0/5/10)
EVIDENCE
CONTENT Corrective and/or preventive
action(s) are taken based on the
analysis where appropriate
5
INTERPRETATION Self-explanatory
REMARKS
PATIENTS FEED
BACK

HIC 5D Score
(0/5/10)
EVIDENCE
CONTENT Appropriate pre and post-exposure
prophylaxis is provided to all staff
members concerned.
5
INTERPRETATION Self-explanatory. Infection control nurse
maintains documentation of all
occupational injuries and pre- and post-
exposure prophylaxis records

REMARKS For example, hepatitis B vaccination and
PEP for needle stick injury

DEFICIENY
VACCINATION
Post Exposure
Prophylaxis

HIC 9A Score
(0/5/10)
EVIDENCE
CONTENT The management makes available
resources required for the infection control
programme

INTERPRETATION The organization shall ensure that the
resources required by the personnel should
be available in a sustained manner. This
includes both men and materials.

REMARKS
HIC -9B Score
(0/5/10)
EVIDENCE
CONTENT The organization earmarks adequate funds from
its annual budget in this regard

INTERPRETATION There shall be a separate budget demarcated for
HIC activity. This shall be prepared taking into
consideration the scope of the activity and
previous years experience.

REMARKS

CQI-1A Score
(0/5/10)
EVIDENCE
CONTENT There is a structured quality improvement
and continuous monitoring programme in
the organization
5
INTERPRETATION This committee shall have representation
from management, various clinical and
support departments of the HCO. This
programme shall be developed,
implemented and maintained in a structured
manner.

REMARKS For example core committee, quality
improvement committee etc.

All task force

DEFICIENCY

CQI 1B Score
(0/5/10)
EVIDENCE
CONTENT The quality improvement programme is
documented.*
5
INTERPRETATION This should be documented as a manual.
The manual shall incorporate the
mission, vision, quality policy, quality
objectives, service standards, important
indicators as identified etc. The manual
could be stand alone and should have
cross linkages with other manuals.

REMARKS Refer to AAC 7, AAC 10, COP 8 and COP
14 also.

DEFICIENCY
SERVICES
INDUCTION
MANUAL

CQI 1C Score
(0/5/10)
EVIDENCE
CONTENT This should(Quality Improvement Program)be
documented keeping in mind requirements of OEs
d, f, g and i. It should also incorporate the various
indicators as required by CQI 3 and 4. There is a
designated individual for coordinating and
implementing the quality improvement program.
5
INTERPRETATION This should preferably be a person having a good
knowledge of accreditation standards, statutory
requirements, hospital quality improvement
principles and evaluation methodologies, hospital
functioning and operations.

REMARKS For example accreditation co-coordinator, quality
management representative, quality manager

DEFICIENCY

CQI -1D Score
(0/5/10)
EVIDENCE
CONTENT
The quality improvement programme is
comprehensive and covers all the major
elements related to quality assurance and
supports innovation.
5
INTERPRETATION
This shall preferably cover all aspects including
documentation of the programme, monitoring
it, data collection, review of policy and
corrective action. Also refer to CQI 1b.

REMARKS
Refer to glossary for definition of quality
assurance and quality improvement

DEFICIENCY

CQI -1E Score
(0/5/10)
EVIDENCE
CONTENT The designated programme is communicated and
coordinated amongst all the employees of the
organization through proper training mechanism.
10
INTERPRETATION Self explanatory.
REMARKS This could be done through a regular training
programme or printed materials

Training
Calendar
Training
Material

CQI-1F Score
(0/5/10)
EVIDENCE
CONTENT
The quality improvement programme identifies
opportunities for improvement based on review at pre-
defined intervals.
5
INTERPRETATION
As quality improvement is a dynamic process, it needs to
be reviewed at regular pre-defined intervals (as defined
by the organisation in the quality improvement manual
but at least once in four months). The review shall
include internal audits (refer to CQI 1h), organisational
performance indicators (refer to CQI 5c), analysis of key
indicators as identified and determined by the
organisation including mandatory indicators as laid down
in CQI 3 and 4. The minutes of the review meetings
should be recorded and maintained.

REMARKS
This also applies to other quality-assurance programmes
like lab imaging, ICU and surgical services.

MONTHLY
UPDATE
DEFICIENCY

CQI -1G
Score
(0/5/10)
EVIDENCE
CONTENT The quality improvement programme is a
continuous process and updated at least once in a
year.

0

INTERPRETATION Self explanatory. The inputs for updation could be
based on the review carried out by the quality
improvement committee.

REMARKS
DEFICIENCY

CQI- 1H
Score
(0/5/10)
EVIDENCE
CONTENT Audits are conducted at regular intervals as a means
of continuous monitoring
10
INTERPRETATION This audit shall be done by a multi-disciplinary team
(preferably trained in NABH standards) including all
the applicable standards and objective elements. All
the areas of the organization shall be covered. At
the end of the audit, there shall be a formal
meeting to summarise the findings and corrective
and preventive measure shall be taken and
documented.

REMARKS The assessors shall be either trained internally or
externally in NABH standards. They shall assess
areas independent of their area of work. All audits
shall be documented.

NABH
WORKSHOP
Audit Summary

CQI -1I
Score
(0/5/10)
EVIDENCE
CONTENT There is an established process in the organization
to monitor and improve quality of nursing and
complete patient care.
10
INTERPRETATION Self-explanatory.
REMARKS This could be done through clinical audits
Nursing Forms
TRAINING TIME
TABLE
SUPERVISOR
REPORTS
ANS REPORTS

CQI -2J
Score
(0/5/10)
EVIDENCE
CONTENT The organization uses at least two identifiers to
identify patients across the organization
10
INTERPRETATION This shall be used for identifying patient for all
care-related events like medication
administration, conducting procedures etc.

REMARKS One of the identifiers shall be the unique hospital
ID generated at the time of
registration/admission.

UID NO.

CQI -3J
Score
(0/5/10)
EVIDENCE
CONTENT Monitoring includes data collection to support
further improvements
10
INTERPRETATION The data could be collected at pre-defined
intervals, e.g. monthly/quarterly. This data is
analyzed for improvement opportunities and the
same are carried out. Also refer to CQI 1f.

REMARKS For example, data can be collected to study the
reasons for re-dos in surgical patients. Data
could be represented graphically, e.g. bar chart,
pie chart etc.

Audit Summary
MONTHLY
UPDATE

CQI- 3K
Score
(0/5/10)
EVIDENCE
CONTENT Monitoring includes data collection to support
evaluation of these improvements
0

INTERPRETATION
All improvement activities carried out by the
organization shall have an evaluable outcome.
The same shall be captured and analyzed.

REMARKS For example once the reasons for re-dos have
been analyzed and preventive and corrective
measures undertaken then data can be collected
to confirm that reductions have occurred in the
incidence of re-dos

DEFICIENCY

CQI -4C
Score
(0/5/10)
EVIDENCE
CONTENT Monitoring includes utilization of space, manpower and
equipment.
5
INTERPRETATION The organization shall develop appropriate key performance
indicators suitable to it. The following is however mandatory:
i. BOR & ALOS
ii. OT and ICU Utilization
iii.Crtical Equipment Downtime
iv. Nurse Patient ratio for ICU and ward

REMARKS Any equipment the failure of which could impede patient care
shall be considered critical. Some examples are ventilators,
cardiac monitors and pulse-oximeter. However every
organization shall identify its list of critical equipment and
accordingly capture the indicator. The downtime has to be
captured irrespective of whether it has a backup or not.

OT UTILIZATION
INDICATORS
SUMMARY
REPORT
NURSE PATIENT
RATIO AND
BOR/ALOS
DEFICIENCY
ICU UTILIZATION
ICU EQUIPMENT
UTILIZATION

CQI -4D
Score
(0/5/10)
EVIDENCE
CONTENT Monitoring includes patients satisfaction which also
incorporates waiting time for services
5
INTERPRETATION The organization shall develop appropriate key performance
indicators suitable to it. The following is however mandatory:
i. Out-patient satisfaction index;
ii. In-patient satisfaction index;
iii. Waiting time for services including diagnostics and out-
patient consultation;
iv. Time taken for discharge

REMARKS Waiting time implies the time taken from the time that the
patient registers to the time taken for assessment to be done
by the doctor/diagnostic procedure to be performed. Time
taken for discharge implies the time from which the doctor
writes for discharge to the time for final clearance.

INDICATORS
SUMMARY
REPORT
DEFICIENCY
OPD
SATISFACTION
IPD
SATISFACTION
DEFICIENCY CQI 4D
Time of Discharge order was not Mentioned in 83% files.
Analysis of Time Taken for Discharge is not satisfactory.




CQI -4E
Score
(0/5/10)
EVIDENCE
CONTENT Monitoring includes employees satisfaction

5
INTERPRETATION The organization shall develop appropriate key
performance indicators suitable to it. The following is
however mandatory:
i. Employee satisfaction index;
ii. Employee attrition rate;
iii. Employee absenteeism rate;
iv.Percentage of employees who are aware of
employee rights, responsibilities and welfare schemes

REMARKS
INDICATORS
SUMMARY
REPORT
Awareness
Employee
Rights/Responsi
bility/Welfare
Employee
Satisfaction

CQI -4H
Score
(0/5/10)
EVIDENCE
CONTENT Monitoring includes data collection to support
further improvement
5
INTERPRETATION The data could be collected at pre-defined
intervals, e.g. monthly/quarterly. This data is
analysed for improvement opportunities and the
same are carried out. Also refer to CQI 1f.

REMARKS For example waiting time in OPD.
INDICATORS
SUMMARY
REPORT
DEFICIENCY

CQI -4I
Score
(0/5/10)
EVIDENCE
CONTENT Monitoring includes data collection to support
evaluation of these improvements
0
INTERPRETATION All improvement activities carried out by the
organization shall have an evaluable outcome.
The same shall be captured and analysis

REMARKS
DEFICIENCY

CQI -5A
Score
(0/5/10)
EVIDENCE
CONTENT The management makes available adequate
resources required for quality improvement
programme

INTERPRETATION This shall include the men, material, machine and
method. These should be in steady supply so as to
ensure that the programme functions smoothly.

REMARKS

CQI -5B
Score
(0/5/10)
EVIDENCE
CONTENT Organization earmarks adequate funds from its
annual budget in this regard

INTERPRETATION Appropriate fund allocation is done by the
organization for the smooth functioning of the
programme

REMARKS The budget could be earmarked based on
previous years spending. If no data is available
the organization could make a beginning by
earmarking a budget but reviewing it at the end
of six months any necessary modifications.


CQI -5C
Score
(0/5/10)
EVIDENCE
CONTENT The management identifies organizational
performance improvement target.

INTERPRETATION The management shall identify organization and
department level quality objectives, set targets,
monitor them (at least once in four months) and
modify the target (at least annually)

REMARKS The targets should be shared with the faculty and
staff and regular feedback taken.


CQI -5D
Score
(0/5/10)
EVIDENCE
CONTENT The management supports and implements use
of appropriate quality improvement, statistical
and management tools in its quality improvement
programme

INTERPRETATION Self explanatory.
REMARKS For example Root Cause analysis, FMEA, Project
Evaluation and Review Technique (PERT), Critical
Path Method (CPM), Control Charts etc.


CQI- 6A
Score
(0/5/10)
EVIDENCE
CONTENT Medical and nursing staff participates in this
system
10
INTERPRETATION The organization shall identify such personnel. It
could be a mix clinicians, administrators and
nurses.

REMARKS These could be members of the core committee /
quality assurance committee etc.

All task force
NABH
WORKSHOP

CQI -6B
Score
(0/5/10)
EVIDENCE
CONTENT The parameters to be audited are defined by the
organization.
10
INTERPRETATION As these audits are retrospective / concurrent in
nature, it is imperative that this be done using
predefined parameters so that there is no bias. The
parameters could be disease based, cost based,
community based or based on morbidity (length of
stay). It shall lay down the objectives, the
parameters that are going to be captured develop a
checklist where required, sampling and data
collection guidelines and preparation of report.

REMARKS The audit shall encompass all aspects of care
including clinical and nursing.

INDICATORS
SUMMARY
REPORT

CQI -6C
Score
(0/5/10)
EVIDENCE
CONTENT Patient and staff anonymity is maintained
INTERPRETATION This means that the names of the patients and
the hospital staff who may figure in the audit
documents must not be disclosed or any
reference be made to them in public discussions /
conferences.

REMARKS This is at the stage of report preparation and
dissemination. The staff participating in the audit
shall maintain patient and staff anonymity and
not reveal names


CQI -6D
Score
(0/5/10)
EVIDENCE
CONTENT
All audits are documented.
5
INTERPRETATION
Self explanatory

REMARKS
The organization could use a checklist with the
predefined parameters and the audit findings
could be recorded on this sheet.

INDICATORS
SUMMARY
REPORT
DEFICIENCY

CQI -6E
Score
(0/5/10)
EVIDENCE
CONTENT Remedial measures are implemented. 0
INTERPRETATION All remedial measures as ascertained should be
documented and implemented and improvements
thereof recorded to complete the audit cycle.

REMARKS This should preferably be done based on root cause
analysis.

DEFICIENCY

CQI -7B
Score
(0/5/10)
EVIDENCE
CONTENT The organization has a process to collect feedback
and receive complaints.*
10
INTERPRETATION Self explanatory.
REMARKS This shall be communicated to the patients using
displays or brochures.

CITIZEN
CHARTER
INDUCTION
MANUAL
SUGGESTION
BOX

CQI -7E
Score
(0/5/10)
EVIDENCE
CONTENT Feedback about care and service is communicated
to staff.
10
INTERPRETATION At a minimum, patient satisfaction levels shall be
communicated on a monthly basis.

REMARKS This could be done using internal communication. It
is equally important that positive feedback about
care and service is communicated to staff.

FEEDBACK ON
PATIENT
SATISFACTION

CQI -8A
Score
(0/5/10)
EVIDENCE
CONTENT The organization has defined sentinel events.* 10
INTERPRETATION The sentinel events relating to system or process
deficiencies that are relevant and important to the
organization must be clearly defined. This list of the
identified and relevant sentinel events shall be
documented.

REMARKS Refer to glossary for definition of sentinel events
SENTINEL EVENT
POLICY

ROM -1A
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance lay down the
organizations vision, mission and values.*
10
INTERPRETATION It is not only the head of the HCO but the members of
the board of governors (where applicable) who need
to define it.

REMARKS For definition of mission, vision, and values refer
to glossary

INDUCTION
MANUAL

ROM 1B
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance approve the
strategic and operational plans and organisations
budget.

INTERPRETATION Self explanatory
REMARKS Refer to glossary for strategic and operational
plans. Also refer to ROM 5c,e


ROM -1C
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance monitor and
measure the performance of the organization
against the stated mission.

INTERPRETATION The Governing board and the head of organisation
shall develop quarterly (at least ) performance
reports based on strategic and operational plans.

REMARKS Performance shall be discussed in the management
review meeting and action items are regularly
followed up.


ROM 1D
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance establish the
organizations organogram.*
10
INTERPRETATION The organization shall have a well defined
organization structure / chart and this shall clearly
document the hierarchy, line of control, along with
the functions at various levels.

REMARKS Organogram is transparent and is disseminated to
all stake holders. The organogram shall incorporate
various committees.

ORGANOGRAM

ROM -1E
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance appoint the
senior leaders in the organisation.
10
INTERPRETATION Self explanatory.
REMARKS Senior leaders include the first two rungs of the
organogram. Appointment of senior leaders shall be
through selection committee.

CONSULTANT
RECRUITMENT

ROM -1F
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance support safety
initiative and quality improvement plans.

INTERPRETATION Self explanatory.
REMARKS All risk assessment and risk reduction is known and
measures to reduce are discussed for corrective
actions.


ROM -1G
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance support research
activities.

INTERPRETATION Self explanatory.
REMARKS Support in research shall include providing
resource, budget, following ethical and legal norms.


ROM -1H
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance address the
organizations social responsibility.
10
INTERPRETATION The governing board and head of the organization
shall willfully develop social responsibility policy
and accordingly address it.

REMARKS For example, free camps, outreach programmes,
adoption of villages, PHCs etc.

CAMPS

ROM -1I
Score
(0/5/10)
EVIDENCE
CONTENT Those responsible for governance inform the public
of the quality and performance of services.
0
INTERPRETATION Self explanatory
REMARKS This could be in the form of display of brochures.
This could include results of surveys done by
independent third parties and results of
benchmarking done by professional bodies.

DEFICIENCY

ROM-2A
Score
(0/5/10)
EVIDENCE
CONTENT
The management is conversant with the laws and
regulations and knows their applicability to the organization
10
INTERPRETATION
Self Explanatory. This shall include central legislations (e.g.
Drugs and Cosmetics act and MTP act, PNDT Act 1996), Bio
Medical Waste Act. Air (Prevention and Control of Pollution)
Act 1981, Atomic Energy Regulatory Body Approvals, License
under Bio-medical Management and Handling Rules, 1998,
respective of state legislations Maharashtra Maintenance of
Clinical Records act, Clinical establishment of West Bengal)
and local regulations (e.g. building byelaws).

REMARKS
A designated management functionary could be given the
responsibility to enlist the laws and regulation as applicable
to the organization. This functionary in turn could identify
the appropriate personnel in the organization who are
supposed to implement the respective laws and regulations.

HOSPITAL
LICENSE

ROM -2B
Score
(0/5/10)
EVIDENCE
CONTENT The management ensures implementation of these
requirements
10
INTERPRETATION Self explanatory
REMARKS All relevant clause under the rules and act are
abided by the organization.


ROM -2C
Score
(0/5/10)
EVIDENCE
CONTENT Management regularly updates any amendments
in the prevailing laws of the land
10
INTERPRETATION Self-explanatory
REMARKS

ROM -2D
Score
(0/5/10)
EVIDENCE
CONTENT There is a mechanism to regularly update
licenses/ registrations/certifications
10
INTERPRETATION Self explanatory.
REMARKS For example license for lifts, DG sets etc. The
organization could develop a tracker sheet for this
purpose.

HOSPITAL
LICENSE

ROM -3B
Score
(0/5/10)
EVIDENCE
CONTENT Administrative policies and procedures for each
department are maintained.*
10
INTERPRETATION This shall include all administrative procedures
like attendance leave, conduct, replacement, etc.
This shall be documented.

REMARKS It could be common for the entire organization
Attendance Record
Time Machine
Leave Performa

ROM -3C
Score
(0/5/10)
EVIDENCE
CONTENT Each organizational programme, service, site or
department has effective leadership.
10
INTERPRETATION There needs to be a minimum essential
qualification and relevant experience of the leader.
The leader should have domain knowledge of that
particular department

REMARKS
Consultant
Qualification

ROM -3D
Score
(0/5/10)
EVIDENCE
CONTENT Departmental leaders are involved in quality
improvement.
10
INTERPRETATION Self explanatory.
REMARKS The effectively implement this, each department
could have the department objective/key
performance indicators and the responsibility of
achieving them could be that of the leader

ALL TASK FORCE

ROM -4A
Score
(0/5/10)
EVIDENCE
CONTENT The leaders make public the vision, mission and
values of the organization.
5
INTERPRETATION This shall be done by displaying the same
prominently.

REMARKS For definition of mission, vision and values
refer to glossary. Only a display on its website would
not be appropriate. It is preferable that the same be
translated and displayed in the local language also

DEFICIENCY

ROM -4B
Score
(0/5/10)
EVIDENCE
CONTENT The leaders establish the organizations ethical
management.
10
INTERPRETATION The organization shall function in an ethical manner.
Transparency in its actions shall be one of its
guiding principles. Handling of complaints,
grievances, clinical care delivery and research shall
be some of the areas to address.

REMARKS A good reference guide is Code of medical ethics-
2002 published by MCI. The organizations
established ethical management shall be
documented

MANUAL LIST

ROM -4C
Score
(0/5/10)
EVIDENCE
CONTENT The organization discloses its ownership 10
INTERPRETATION The ownership of the hospital e.g. trust, private,
public has to be disclosed

REMARKS The disclosure be in the registration
certificate/quality manual etc.

LEGAL

ROM -4D
Score
(0/5/10)
EVIDENCE
CONTENT The organization honestly portrays the services
which it can and cannot provide.
5
INTERPRETATION Self explanatory. Documentation with respect of
service non-availability and its communication to
patients is maintained.

REMARKS Here portrays implies that the organization conveys
to the patients clearly what it can and cannot
provide. The services that it cannot provide could
also be conveyed verbally. Refer to AAC 1 also.

SERVICES
AVAILABLE

ROM -4E
Score
(0/5/10)
EVIDENCE
CONTENT The organization honestly portrays its affiliations and
accreditations.
10
INTERPRETATION Self explanatory
REMARKS Here implies that the organization convey is
affiliations, accreditations for specific departments or
whole hospital wherever applicable


ROM -4F
Score
(0/5/10)
EVIDENCE
CONTENT The Organization accurately bills for its services
based upon a standard billing traiff.
10
INTERPRETATION Self explanatory
REMARKS Also Refer to PRE- 6.The Traiff could be devised by
tariff committee.

Estimated Bill
Citizen charter

ROM -5A
Score
(0/5/10)
EVIDENCE
CONTENT The person heading the organization has requisite
and appropriate administrative qualifications
10
INTERPRETATION Self explanatory.
REMARKS This implies to the individual looking after the day-
to-day operations and not to the chairman of the
Board of Governors. Appropriate implies
qualification in hospital
management/administration

LEADERS

ROM -5B
Score
(0/5/10)
EVIDENCE
CONTENT The person heading the organization has requisite
and appropriate administrative experience.
10
INTERPRETATION Self-explanatory
REMARKS Appropriate implies administrative experience in a
hospital

LEADERS

ROM -5C
Score
(0/5/10)
EVIDENCE
CONTENT The organization prepares the strategic and operational
plans including long-term and short-term goals
commensurate to the organizations vision, mission and
values in consultation with the various stakeholders

INTERPRETATION The leader(s) shall define and develop the process for
strategic and operation plans so as to achieve the
organizational vision and mission statement and adhere
to the values. It shall be discussed with all stakeholders.
One of the inputs that should be considered while
financing these plans shall be the findings of the risk
management plan (refer to ROM 6a). This shall at least
be done on an annual basis

REMARKS Refer to glossary for strategic and operational plans.
Stake holders include the community the organization
services


ROM -5D
Score
(0/5/10)
EVIDENCE
CONTENT The organization coordinates the functioning with
departments and external agencies, and monitors
the progress in achieving the defined goals and
objectives.

INTERPRETATION Self-explanatory. The reasons for not achieving any
particular goal shall be analyzed and appropriate
action shall be taken.

REMARKS This could be done through management review
meetings.


ROM -5E
Score
(0/5/10)
EVIDENCE
CONTENT The organization plans and budgets for its activities
annually

INTERPRETATION Self-explanatory. Adequate budget shall also be
allocated for infection control and quality-
improvement activities.

REMARKS This could be either done on a calendar year basis
or financial year (April-March) basis. It is preferable
that every department has a budget.


ROM-5F
Score
(0/5/10)
EVIDENCE
CONTENT The performances of the senior leaders is reviewed
for their effectiveness

INTERPRETATION Self-explanatory. Key result areas of each leader can
be established or it can be done through
performance appraisal.

REMARKS This shall be done by those responsible for
governance


ROM -5G
Score
(0/5/10)
EVIDENCE
CONTENT The functioning of committees is reviewed for their
effectiveness
0
INTERPRETATION This shall be done by the management. The review
at a minimum shall include if the purpose of having
the committee is being met, if the committee is
meeting at the prescribed frequency and if the
committee is suggesting remedial measures and if
there is adequate monitoring.

REMARKS For an effective review, it is preferable that the
organization documents the scope of every
committee, the role and responsibilities assigned to
various members and the frequency of meetings.
Agenda shall be prepared for all meetings and
documentation of each committee meeting is kept.

ALL TF
MINUTES OF
MEETING
DEFICIENCY

ROM -5H
Score
(0/5/10)
EVIDENCE
CONTENT The organization documents employee rights and
responsibilities.*
10
INTERPRETATION Self-explanatory. The organization shall define the
same in consonance with statutory requirements.

REMARKS
INDUCTION
MANUAL

ROM -5I
Score
(0/5/10)
EVIDENCE
CONTENT The organization documents the service standards.* 10
INTERPRETATION Self explanatory. The organization shall develop
benchmarks for different services being provided.
This shall be based on the organizations values and
focus on development of soft skills, behavior,
attitude, communication skills etc.

REMARKS
INDUCTION
MANUAL

ROM -5J
Score
(0/5/10)
EVIDENCE
CONTENT The organization has a formal documented
agreement for all outsourced services
5
INTERPRETATION The agreement shall specify the service parameters.
REMARKS Even if a sister concern is providing services, there
shall be an agreement with that unit

AGREEMENTS

ROM -5K
Score
(0/5/10)
EVIDENCE
CONTENT The organization monitor Quality of Outsourced
services

INTERPRETATION The Frequency of Meeting shall be determined by
the organization .This shall be done keeping in mind
the criticality of the service towards providing
patient care.

REMARKS It is preferable that the monitoring be done as per
the service standards laid down or as per the
requirement of the organization.

Outsourced test

ROM -6A
Score
(0/5/10)
EVIDENCE
CONTENT Management ensures proactive risk management across the
organization
5
INTERPRETATION This shall include clinical and non-clinical (strategic, financial,
operational and hazard) risks. It shall include risk identification,
prioritization and risk alleviation. This shall be documented as a risk
management plan. It shall include the various risks identified, the
action taken for risk alleviation of each of these risks and the
mechanism for informing staff regarding the same. Further, the risk
management plan shall be monitored and reviewed for continued
effectiveness at least annually. The results of the review shall be
communicated to the relevant stakeholders in the organization.

REMARKS This could be done using a matrix. Clinical-risk assessment could
include:
i. Medication management, covering issues such as
patient/service-user allergies and antibiotic resistance;
ii. ii. Equipment risks, e.g. fire/injury risks from use of laser; and
iii. iii. Risks resulting from long-term conditions.

HIRA
DEFICIENCY

ROM -6B
Score
(0/5/10)
EVIDENCE
CONTENT Management provides resources for proactive risk
assessment and risk reduction activities
0
INTERPRETATION There shall be sufficient resources kept as
contingency to address the risk reduction activities
as and when the leaders proactively suggest. The
end-result of these shall result in preventive actions

REMARKS Refer to glossary for definition of risk assessment
and risk reduction.


ROM -6C
Score
(0/5/10)
EVIDENCE
CONTENT Management ensures implementation of systems
for internal and external reporting of system and
process failures.*

INTERPRETATION The organization has a system in place for internal
and external reporting of system and process
failures. Contingency plan shall be in place to deal
with the situation of system and process failure
anticipated within the organization.

REMARKS For example, MRI machine of the organization
breaks down. In this case internal and external
reporting to be done to the patients. The system for
reporting shall be documented


FMS -2A
Score
(0/5/10)
EVIDENCE
CONTENT Facilities are appropriate to the scope of services of
the organization
5
INTERPRETATION Self explanatory.
REMARKS
DEFICIENCY

FMS -2H
Score
(0/5/10)
EVIDENCE
CONTENT There are designated individuals responsible for the
maintenance of all the facilities
10
INTERPRETATION A person in the organization is designated to be in-
charge of maintenance of facilities. The organization
has the required number of supervisors and
tradesmen to manage the facilities. The necessary
infrastructure and tools shall be provided by the
organization.

REMARKS
ROASTER

FMS -3A
Score
(0/5/10)
EVIDENCE
CONTENT The organization plans for equipment in accordance
with its services and strategic plan.

INTERPRETATION Self explanatory. This shall also take into
consideration future requirements.

REMARKS The plans should be fully implemented and there
should be a process for periodic review of plans


FMS -3B
Score
(0/5/10)
EVIDENCE
CONTENT
Equipment is selected by a collaborative
process.
10
INTERPRETATION
Collaborative process implies that during
equipment selection there is involvement of
end user, management, finance, engineering
and bio-medical departments.

REMARKS

FMS -3D
Score
(0/5/10)
EVIDENCE
CONTENT Qualified and trained personnel operate and
maintain the equipment and utility systems
10
INTERPRETATION Self explanatory.
REMARKS The person could be qualified by experience of
training.

QUALIFICATION
SUMMARY

FMS -4A
Score
(0/5/10)
EVIDENCE
CONTENT The organization plans for equipment in accordance
with its services and strategic plan
10
INTERPRETATION Self-explanatory. This shall also take into
consideration future requirements. The equipment
shall be appropriate to its scope of services

REMARKS A good reference for minimum equipment is the
IPHS guidelines


FMS -4B
Score
(0/5/10)
EVIDENCE
CONTENT Equipment are selected, rented, updated or
upgraded by a collaborative process.
10
INTERPRETATION Collaborative process implies that during
equipment selection there is involvement of end-
user, management, finance, engineering and
biomedical departments

REMARKS Engineering / Facilities Dept..The organization could
define different financial clearance in accordance
with the policy. For example, purchase of BP
apparatus can be done by the departmental head.


HRM -1A
Score
(0/5/10)
EVIDENCE
CONTENT Human resource planning supports the
organizations current and future ability to meet the
care, treatment and service needs of the patient.*

INTERPRETATION This shall be done in a structured manner keeping in
mind the scope of services, mission and the
healthcare needs of the community that it serves. It
shall use recognized methods for determining levels
of staffing

REMARKS It shall match the strategic and operational plan of
the organization.


HRM -1B
Score
(0/5/10)
EVIDENCE
CONTENT The organization maintains an adequate number
and mix of staff to meet the care, treatment and
service needs of the patient.
10
INTERPRETATION The staff should be commensurate with the
workload and the clinical requirement of the
patient

REMARKS A good reference could be the MCI and INC
guidelines


HRM -1C
Score
(0/5/10)
EVIDENCE
CONTENT The required job specification and job description
are well defined for each category of staff.*
10
INTERPRETATION The content of each job should be well defined and
the qualifications, skills and experience required for
performing the job should be clearly laid down. The
job description should be commensurate with the
qualification.

REMARKS Refer to glossary for definition of job description
and job specification. For a job which requires the
skills of a doctor or a nurse the minimum
qualification shall be an MBBS and GNM degree
respectively.

JOB
DESCRIPTION

HRM -1D
Score
(0/5/10)
EVIDENCE
CONTENT The organization verifies the antecedents of the
potential employee with regards to
criminal/negligence background
10
INTERPRETATION Self-explanatory
REMARKS This report can be obtained from the district
magistrates office of the district where the
employee has served earlier and/or from the
previous employer. In case of fresh graduate, the
same could be obtained from the last institution
attended. In case of a doctor or a nurse, a good
standing certificate may be obtained from the
regulatory body.

VERIFICATION OF
ANTECEDANTS

HRM -2E
Score
(0/5/10)
EVIDENCE
CONTENT The induction training includes awareness on
employee rights and responsibilities
10
INTERPRETATION Self-explanatory
REMARKS
INDUCTION
TRAINING
CHECKLIST
INDUCTION
MANUAL

HRM -5A
Score
(0/5/10)
EVIDENCE
CONTENT A documented performance appraisal system exists
in the organization.*
10
INTERPRETATION Self explanatory. This shall be done for all categories
of employees starting from the person heading the
organization and including doctors who are
employees.

REMARKS For definition of performance appraisal refer to
glossary

HR MANUAL

HRM -5B
Score
(0/5/10)
EVIDENCE
CONTENT The employees are made aware of the system of
appraisal at the time of induction.
10
INTERPRETATION Self explanatory.
REMARKS This could be incorporated in the service booklet
and included in the induction training

INDUCTION
TRAINING
CHECKLIST

HRM -5C
Score
(0/5/10)
EVIDENCE
CONTENT Performance is evaluated based on the pre-
determined criteria
10
INTERPRETATION Self explanatory.
REMARKS
ACR

HRM -5D
Score
(0/5/10)
EVIDENCE
CONTENT The appraisal system is used as a tool for further
development.
5
INTERPRETATION Self explanatory. This can be done by identifying
training requirements and accordingly providing for
the same (wherever possible).

REMARKS Key result areas are identified for each staff and
training need assessment is also done

DEFICIENCY

HRM -5E
Score
(0/5/10)
EVIDENCE
CONTENT Performance appraisal is carried out at pre defined
intervals and is documented.
10
INTERPRETATION Self explanatory.
REMARKS This shall be done at least once a year

HRM -6A
Score
(0/5/10)
EVIDENCE
CONTENT Documented policies and procedures exist.* 10
INTERPRETATION Self explanatory.
REMARKS For definition of disciplinary procedure and
grievance handling refer to glossary. The
documentation shall be done keeping in mind
objective elements c, d and e.

HR MANUAL
INDUCTION
MANUAL

HRM -6B
Score
(0/5/10)
EVIDENCE
CONTENT The policies and procedures are known to all
categories of staff of the organization
10
INTERPRETATION Self-explanatory
REMARKS All the staff should be aware of the disciplinary
procedure and the process to be followed in case
they feel aggrieved

INDUCTION
MANUAL
HOSPITAL WIDE
POLICIES

HRM -6C
Score
(0/5/10)
EVIDENCE
CONTENT The disciplinary policy and procedure is based on
the principles of natural justice
10
INTERPRETATION This implies that both parties (employee and
employer) are given an opportunity to present
their case and decision is taken accordingly.

REMARKS

HRM -6D
Score
(0/5/10)
EVIDENCE
CONTENT The disciplinary procedure is in consonance with
the prevailing laws.
10
INTERPRETATION Self explanatory.
REMARKS Refer to relevant labour laws and CCS (CCA) rules.
Anti-sexual harassment committee should also be
established in the organization


HRM -6E
Score
(0/5/10)
EVIDENCE
CONTENT There is a provision for appeals in all disciplinary
cases.
10
INTERPRETATION The organization shall designate an appellate
authority to consider appeals in disciplinary cases

REMARKS Appellate authority should be higher than the
disciplinary authority


HRM -6F
Score
(0/5/10)
EVIDENCE
CONTENT The redress procedure addresses the grievance 10
INTERPRETATION Self-explanatory
REMARKS

HRM -7A
Score
(0/5/10)
EVIDENCE
CONTENT A pre-employment medical examination is
conducted on all the employees
10
INTERPRETATION Self-explanatory
REMARKS This shall however be in consonance with the law of
the land. For example performing pre-employment
HIV testing without consent is illegal

MEDICAL
EXAMINATION

HRM -7B
Score
(0/5/10)
EVIDENCE
CONTENT Health problems of the employees are taken care of
in accordance with the organizations policy
10
INTERPRETATION Self explanatory.
REMARKS This shall be in consonance with the law of the land
and good clinical practices For example employee
health and safety policy


HRM -7C
Score
(0/5/10)
EVIDENCE
CONTENT Regular health checks of staff dealing with direct
patient care are done at least once a year and the
findings / results are documented.
10
INTERPRETATION Self-explanatory. The results should be documented
in personal file.

REMARKS The organisation could define the parameters and it
could be different for different categories of
personnel. The organisation should also identify
competent individuals to perform the same. The
staff member shall not be charged for this health
check.


HRM -7D
Score
(0/5/10)
EVIDENCE
CONTENT Occupational health hazards are adequately
addressed
5
INTERPRETATION Self-explanatory. Appropriate personal protective
equipment are provided to the staff concerned and
they are educated on how to use them.

REMARKS For definition of occupational health hazard: refer
to glossary

DEFICIENCY

HRM -8A
Score
(0/5/10)
EVIDENCE
CONTENT Personal files are maintained in respect of all staff 10
INTERPRETATION Self explanatory
REMARKS

HRM -8B
Score
(0/5/10)
EVIDENCE
CONTENT The personal files contain information regarding
the staffs qualification, disciplinary background
and health status
10
INTERPRETATION Self explanatory.
REMARKS
Employee
Information

HRM -8C
Score
(0/5/10)
EVIDENCE
CONTENT All records of in-service training and education are
contained in the personal files
5
INTERPRETATION Self explanatory.
REMARKS In case of internal trainings the organization could
file a summary of all trainings attended by the
employee on an annual basis. However there shall
be supporting document to verify that the
employee has actually attended the training

Training Record
DEFICIENCY

HRM -8D
Score
(0/5/10)
EVIDENCE
CONTENT Personal files contain results of all evaluations 5
INTERPRETATION Evaluations would include performance appraisals,
training assessment and outcome of health checks

REMARKS
DEFICIENCY

IMS -1E
Score
(0/5/10)
EVIDENCE
CONTENT The organization contributes to external databases
in accordance with the law and regulations.
10
INTERPRETATION The organization shall define the system of
releasing the relevant information to the authority
as per statutory norms.

REMARKS For example, sending birth and death statistics,
notifiable diseases (refer to glossary) and acute
flaccid paralysis reporting.

NOTIFIABLE
DISEASES

IMS-2A
Score
(0/5/10)
EVIDENCE
CONTENT Formats for data collection are standardized. 10
INTERPRETATION MIS/HIS data is collected in standardised format
from all areas/services in the organization.

REMARKS This is in the context of frequency of capturing data,
namely daily, weekly, monthly, quarterly, yearly etc.
(statistical bulletin).

DATA COLLECTION
FORMAT

IMS- 2B
Score
(0/5/10)
EVIDENCE
CONTENT Necessary resources are available for analyzing
data.

INTERPRETATION The organization shall make available men,
material, space and budget.

REMARKS
DATA COLLECTION
FORMAT

IMS -2C
Score
(0/5/10)
EVIDENCE
CONTENT Documented procedures are laid down for timely
and accurate dissemination of data.*
0
INTERPRETATION Self explanatory. All timely feedback is given to
relevant stakeholders after data generation and
analysis.

REMARKS The organization could decide on which data needs
to be shared with whom and also the modalities
(e.g. memos, circulars etc.) for dissemination of
such data.

DEFICIENCY
DEFICIENCY IMS 2C
No Documented procedures are laid down for timely and accurate dissemination
of data.

IMS-2D
Score
(0/5/10)
EVIDENCE
CONTENT Documented procedures exist for storing and
retrieving data.*
10
INTERPRETATION The organization shall define data management
policy and ensure adequate safeguards for
protection of data, where ever physical or electronic
data is stored.

REMARKS Storage could be physical or electronic. Wherever
electronic storage is done the organization shall
ensure that there are adequate safeguards for
protection of data

MRD MANUAL

IMS -2E
Score
(0/5/10)
EVIDENCE
CONTENT Appropriate clinical and managerial staff
participates in selecting, integrating and using data.

INTERPRETATION They are responsible for the appropriate selection
of indicators measurement of trends and initiating
action wherever required

REMARKS This could be done by a multi-disciplinary
committee


IMS-4G
Score
(0/5/10)
EVIDENCE
CONTENT Whenever a clinical autopsy is carried out, the
medical record contains a copy of the report of the
same
NA
INTERPRETATION Self-explanatory
REMARKS For definition of autopsy refer to glossary

IMS-5B
Score
(0/5/10)
EVIDENCE
CONTENT Documented policies and procedures are in
consonance with the applicable laws.*
10
INTERPRETATION This is in the context of Indian Evidence Act, Indian
Penal Code and Code of medical Ethics.

REMARKS For example privileged communication
MRD MANUAL

IMS -5D
Score
(0/5/10)
EVIDENCE
CONTENT The organization has an effective process of
monitoring compliance of the laid down policy and
procedure

INTERPRETATION The organization carries out regular audits/rounds
to check compliance with policies.

REMARKS Refer to IMS 7

IMS -7B
Score
(0/5/10)
EVIDENCE
CONTENT The review uses a representative sample based on
statistical principles.
10
INTERPRETATION The organization shall define the principles on
which sampling is based. For example, simple
random, systemic random sampling etc. Review
shall be based on conditions of clinical and/or
community importance, total discharges including
deaths, total indoor patients, etc.

REMARKS

IMS -7C
Score
(0/5/10)
EVIDENCE
CONTENT The review is conducted by identified care
providers.
10
INTERPRETATION Self explanatory.
REMARKS The organization shall identify and authorise such
individuals

ALL TASK FORCE