Manual for Recommissioning of hospitals up to 100 beds
Item
- Title
-
Manual for Recommissioning of
hospitals up to 100 beds - extracted text
-
■
Government of Karnataka
Manual for Recommissioning of
hospitals upto 100 beds
5
1
Karnataka Health Systems Development Project
Health & Family Welfare Department
Bangalore
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Government of Karnataka
Manual for Recommissioning of
hospitals upto 100 beds
Karnataka Health Systems Development Project
Health & Family Welfare Department
Bangalore
“I
y
Introduction
>’
J
e KHSDP has taken up the task of upgrading 201 secondary hospitals with the
assistance from the World Bank. As on August 1999 the civil works are complete in 60
comnlernd URUt yiPtr0JrettS
decIared comPlete when once the major civil works are
completed. But a lot of things are not attended for a long time even after the completion of the
cwil work n the result the upgraded facility would not be of greater use. In order to see that
nroUnre ThIS
ProPerly the KHSDP has evolved a definite recommissioning
f procedures maintained in this booklet are applicable to hospitals with less than
or bigger hospitals a separate booklet for recommissioning is available.
The purpose of issuing this recommissioning booklet is to see that all facilities are laid
own properly at the hospitals so that it can work at its best. It is hoped that this booklet would
be a guiding principle for the Administrative Medical Officer to know what are the issues that he
has to look into for proper functioning of the hospital. This recommissioning manual will be
used for routine inspections and also for grading the performance of the hospital annually. ;
i, PL6
three components in this booklet. The first component relates to civil works
only and they are one time test procedures to be adopted before commissioning. As these things
vvould not change within a short period it is enough if they are checked once a year. The civil
foundation1 f°r
h°Spital W°Uld be checked by the quality auditors namely M/s. TOR Steel
v,ell laid out and made to function in a hospital. At the outset the Administrative Medical
th hosn^l0™ PUty SireCt°;0f KHSPD would jointly take up the work of recommissioning
the hospital. They would see that the right sign boards are put up at the right places the
equipment required are laid out properly as indicated in the manual. Over a period of time this
nual would act something like annual stock verification certificate, a facility audit report
eaTfinanchl011
w h "
f°r evaIuating the Perf°nnance of the hospital at the end of
financial year. We hope that periodical inspection of each and every point would help the
hospital authorities to reset their hospitals from deviations once in two months.
The third component deals with administration and outreach activities of the hospital
outreach activities of the hospital.
e^rcSTTf111 I'65
t^ management aCtivity Which is
- administrative
problem KHSDP
m 13
manUaI 'S SeIf exPlanatory- Should there be a
La t m S?P
be g ad y Wllling t0 assist the Administrative Medical Officer in
understanding the recommissioning manual for proper recommissioning of the hospital.
1
I
■i
Civil Works Component
2
»•
Civil Work Component
Check list for completion reports
Please fill in the columns as indicated in the brackets :
SL
No
Item
1
Location of the site. (Indicate the place and position)
2
Bed Capacity as per KHSDP norms.
3
Dates of inspection.
4
Inspection in the presence of KHSDP Officers.
5
Inspection in the presence of Contractor.
Response
(Note : Refer specifications of BOQ and Special specifications in tender)
6
SI. No.
Items of Work completion
1
Units of constructions
a.
b.
c.
d.
e.
f.
Note : Please add additional sheets of paper if required.
1
Foundation :
Response
a. Observation of settlement.
b. Pointing.
c. Flagging.
2
Dimensional checks of all rooms .
(If changes are found indicate reasons for change)
Doors and windows :
a. Sections of frame & shatters used.'
Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
t
•M
b. Dimensions of doors and windows.
c. Quality of joinery.
d. Quality of fittings used.
e. Quality of painting. (Please check all exposed surfaces)
f. Easing test for shatters.
g. Checking ofcracks around the frame with masonry work.
4
Tiled Flooring :
a. General level.
b. Pointing ofjoints.
c. Exposure of chips in mosaic flooring.
d. Skirting levels.
e. Colour variations in tiles.
f. Quality of polishing.
5
Dadooing on walls (Glazed tiles)
a. Top level dadooing and finishing materials used.
b. Colour / shade variations of tiles.
c. Pointing of joints.
d. Evenness of surface finish.
6
Ceiling plastering
a. Evenness of surface finish.
~
b. Joints with wall.
c. Bottom line of beams (to be horizontal may please be verified)
7
Wall Plastering
——————
a. Evenness of surface finish
b. Joints with RCC members
(i)
Provision of grooves
(ii)
Fixing of mesh
c. Plastering ofjams (level and plumb) of doors and windows.
8
W.P.C.
- ------------------------------ -----------
a. Cracks in surface.
* Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
4
r*
•j
b. Joints with parapet walls.
3
c. Outlet aprons.
i
d. Ponding test.
e. How are they draining water from Overhead tank.
f. Vegetation in roof area.
9
Sunken slabs
a. Check leakages / dampness
10
Water supply system
a. Source of supply.
b. System of storage : Sump tank / Overhead tank.
c. Piping system checking for leakage / has pressured test done
before plastering.
d. Do the fittings confirm to tender specifications.
11
Sanitary system
a. No. of closets in operation.
b. No. of wash basins.
c. System of disposal
drainage system.
:
Septic tank / Soak pit / Municipal
d. No. of chambers.
e. Do the fittings confirm to tender specifications.
12 Campus drainage
a. Surface drainage system.
b. How drainage of court yards planned.
13 Campus roads
a. Type of roads.
b. Side drains.
14 Chajjas / canopy slabs
a. System of disposal of water
b. System adopted for top finish.
c. Provision of drip moulds.
* Wherever the matter is complied put a 1V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
5
J
15 Fire safety arrangement
a. Any system exits.
b. If so, details
c. Fire Alarm system.
d. Any system proposed. 33
16 Waste disposal arrangement
Present system adopted for disposal of:
a. Medical waste.
b. General waste
17 Non-destructive tests
a. Already conducted.
b. Proposed.
18
Tests reports
a. Test reports furnished already.
b. Test reports pending.
c. Fresh tests contemplated.
19
Electrification
a. Power requirement (details unit-wise may please be provided)
b. Transformer capacity (If existing, what is the capacity)
c. No. of motors installed / capacity.
d. No. of Generators / capacity.
e. Earthing details (whether installed or not ? )
f. Types of wiring used (test certificates may please be verified).
g. Types of fixtures used.
h. Tube lights used with power factor condenser.
i. Have the fixtures got ISI mark.
j- Do they confirm to tender specification.
k. Is there separate earthing points for lighting and power points.
1.
Safety gadgets provided with details, i.e., Circuit breakers /
others
* Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
6
i
20
Drawings
a. Layout drawing of drainage system.
b. Layout drawing of water supply system.
c. Layout of electrical circuit diagram.
21
Overhead tanks
a. Type of storage structure
b. Type of access to Overhead tank.
c. Source of water to Overhead tank.
d. Details of bore well (dia, depth, installed pumping arrangement)
22
Expansion joints
a. Type ofjoints (ceiling / walls).
b. Method adopted for sealing these joints.
23 Operation theatre
a. No. of door openings (prepared one).
b. Type of openings in OT
(i)
towards sterilization room.
(ii)
Towards medical waste room.
c. Type of flooring used (with details of materials used).
24
General Observations :
* Wherever the matter is complied put a 1V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
7
y
4
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<1
Clinical Component
8
No.
ITEM
1
a)
i)
4
Response as on date of visit (Y/N) *
Date
Date
Date Date
OUT PATIENT DEPARTMENT______________
Reception Counter / Enquiry :__________
Posting of knowledgeable MSW or Staff Nurse as a
Receptionist with a board "May I help You?"
ii) All sections of the OPD numbered and depicted on flow
chart near reception counter
iii) Boards indicating days of Special Services and Hospital
timings near reception counter.
b) Registration /OPD ticket issuing counter:____________
i)
Board indicating hospital fees for various services provided
for OPD & IPD — Inpatient counter for admission_________
ii) Glow sign with changing messages exhibited at prominent
places.______
__ 2 OPP SECTIONS (MOP, SOP, POP, POP, GyOP):
i)
Every OPD section should have : separate register for
diagnosis, Complete examination tray with B P Apparatus,
torch and hammer, X ray view box, examination table with
foot steps, writing table, stool for patients, wash basin
adequate sitting arrangement for waiting OPD Patients,
appropriate Health Education material displayed. Waste
collection , coloured baskets with instructions about the
kind of waste to be installed in all the rooms
ii)
In addition to above,
iii)
Medical OPD :
~
CNS examination tray, tuning fork, ECG Machine
iv)
Surgical OPD :
““
PR examination tray with proctoscope and gloves, Kidney
trays. Tongue depressor, torch, xylocaine jelly
v)
Gynaec. OPD :
~
PS & PV exam. Tray, IUD tray, Kidney tray, clean gloves,
Weighing machine, pap smear tray, exam. Table with
lithotomy facility, table lamp, jelly or cream, torch, view
light
vi)
Pediatric OPD :
Paed. Weighing machine, Measuring Tape, Height and
Weight Scale.
Ophthal OPD---------------------------Torch, eye drops, eye charts, sterile bins with dressings,
lotion________
1NT OPD---------------------------Head light, torch, ENT instruments tray, antiseptic lotions,
jongue depressor, foreign body removal set (nose and ear)
- ----------------------__ dl Dental OPD
i) ____ Dental Surgeon available
ii)
Apart from Dental extraction and scaling other procedures
like silver filling, mandibular wiring, dental alignment etc.
are done.
iii)
Efforts made by staff to keep dental x-ray unit, motor in
order, continuous water supply, staff nurse' posting, denture
preparation (prosthesis), Biosafety measures adopted. Etc.
e Dressing Room.
~
* Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
9
No.
i)
ii)
iii)
ITEM
Response as on date of visit (Y/N) *
Date
Date
Date Date
Autoclaved material used (bandages, dressings, towels,
swabs)
Dressing table, antiseptic lotion, sink for hand washing
available____________
Dresser wears Plastic apron, face mask, gloves
etc., while doing dressings
______
iv)
v) __
vi)
vii)
Antiseptic lotions and dressing materials kept in bins______
Dustbins are available with waste collection instructions.
Dressing tray with medicines and bandages ________
Electric steriliser for instruments and suture removal set
__ 0 Injection Room
i) ___
Syringe destroyer installed and being used
ii)
Colour waste collection bins installed with instructions for
use______________
iii) —Staff nurse is trained in management of Injection reactions
iv)
Updated emergency drug tray and Availability of Oxygen
Cylinder with accessories, Suction Machine (electric and
foot operated), Cot and mattresses with arrangement for
head low position, vensection tray,
v)
Chart of management of Anaphylactic reaction,
classification of dogbite wounds and dosage schedule of
ARV, rabipur._______________
vi)
Availability of Wash basin, Biosafety measures adopted,
Inventory maintained.
vii)
Sufficient number of autoclaved syringes & needles
depending upon OPP load.
g) Pharmacy________
i)
Proper display of all the available drugs in the pharmacy to
build a proper public image
ii)
Daily accounting of drugs kept? (Any proof of checking of
inventory)_________
iii)
Surprise check by MO / RMO for actual dispensing against
prescription.
iv)
Drugs are dispensed in paper packets
v) __
Morbidity statistics kept up-to-date (Verify the record)
vi)
Is the fire extinguisher installed at the pharmacy__________
__ hl Minor Operation Theater and Plaster Room
i)
Availability of shadowless lamp, operation table, suction
apparatus (electric and foot operated) fumigation apparatus,
ii)
Availability for wash basin, slippers, cap, mask, gown, etc
iii)
Availability of autoclaved linen material, dressing drums,
minor surgery instruments, life saving drugs and anaesthetic
agents’ etc.__________
iv)
Maintenance of records and registers of minor OT,
condemned articles etc.
v)
Water coolers available with 4 number of taps for OPD
vi)
Separate well maintained arrangements of toilet for male &
female patients & relatives?
vii)
Is it clean?_____________
viii)
Separate stand for vehicles.
ix)
Availability of functioning telephone for public
Wherever the matter is complied put a “V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
10
No.
ITEM
x)
xi)
/
_ Film show arrangements made for OPP patients_________
Suggestions book in OPD. Action taken, if any for valid
suggestions made.
xii)
Waste collection basket installed at appropriate places
xiii)
Availability of wheelchairs & stretchers for shifting Pt.
_ From OPD to Ward.
2) EMERGENCY
SERVICE
DEPARTMENT.
(CASUALITY)
iL
MedicalOfficer available round the clock ~
ii)
Glow sign board indicating “Emergency Services” [
Department]
■ii)
Ward well equipped with Fowler's bed,
iv)
Emergency tray with essential drugs
v)
Catheter tray, Ryles' tubes / Stomach tube, flatus tube,_____
vi)
Venesection tray, tracheotomy set, L P tray, Suturing tray,
vii)
Emergency light / Generator,
viii)
BP Apparatus, Torch, Thermometer, weighing machine,
hammer,_______ ■x)
Refrigerator, stationary & forms (medico-legal stationary)
x)
Availability of ARV services 24 hours. Board displayed
accordingly.__________
xi)
Knowledge of M Os in classification of dogbite wounds and
their management training in giving ARV.
xii)
Proper documentation of case sheet and MLC, treatment
card and records / registers.
xiii)
_Uninterrupted Stock of ARV, Check the stock book.
xiv)
Medico-legal register in prescribed register with I
commencing and closing dates and number on the book,
j
XV)
Store room with sufficient stock of essential and life saving
drugs.______________
I
xvi)
Availability of transport facilities (Ambulance) round the
clock, drivers duty chart
xvii)
Waste collection at appropriate places
I
xviii)
Emergency resuscitation kit available and functional
4)
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
Response as on date of visit (Y/N) *
Date
Date
Date Date
CLINICAL LABORATORIES
Qualified Pathologist available.
Examination of special tests like widal, serum bilirubin, L F
T, V D R L, B S for M P., stool examinations, semen
analysis, electrolyte study, blood gas analysis, kidney
function tests, C S F examination etc.
Reports, monthly abstract drawn and verified by CMO
Use of aprons by laboratory technicians
Availability of sufficient wash basins, sinks for staining
Proper disposal of the spoiled containers after
decontamination.
Use of only autoclaved syringes & needles / Disposable
needles.______________
Appropriate tests carried out as per indication
Observance of bio safety measures in waste management
Wherever the matter is complied put a “V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
11
*
No.
X)
xi)
I
ITEM
Regular availability of staining material and their inventory
maintenance__________
Status of following equipment
Total No. Working
Under
Pen
Available
Condition Repairs
ding
for
Con
dem
Microscopes
Monocular
Centrifuge
Refrigerator
Water bath
Hot air oven
a)
bl
c)
dl
e)
Response as on date of visit (Y/N) *
Date
Date
Date Date
nati
on
61 RADIOLOGY
---------------X-ray technician is available, if not efforts made for getting
the post filled in or any suitable alternative arrangement
made for day to day supervision
ii) Status of X-ray Machines available
Total No. Working
iii)
Under
Pen
Available Condition Repairs ding
for
Con
dem
nati
on
X-ray Machine
“
iv)
Availability of dark room safe light, film drying cabinet xray illuminators (view box) etc.,
v)
Use of bulps and are they regularly sent to BARC for
checking and steps taken on reports________
vi)
Availability of all life saving drugs, oxygen cylinder,
suction apparatus etc., to tackle the anaphylactic reaction
vii)
X-ray films and hypo solutions are preserved/Disposed as
per Rules.
Danger zone marked or not with red paint
viii)
Availability and use of protection devices like lead apron,
lead gloves, goggles, badges and dosimeter etc by the staff
working in Radiology.
i)
__ Z1 OPERATION THEATER
i) ___
ii)
iii)
Availability of staff in O T as per norms / Duty roster chart
Concept of clean, neutral and sterile zone followed by
providing various self-closing double doors or air curtain
etc, and marked_________
Dimensions of operation theater are measured and dose of
potassium permanganate (KMnO4) and formaldehyde
calculated for doing fumigation on fixed day or as and when
indicated. Verify the fumigation register record.__________
* Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
12
No.
iv)
v)
vi)
7
vii)
viii)
ix)
x)
xi)
a)
ITEM
Response as on date of visit (Y/N) *
Date
Date
Date Date
Swabs from O T are sent for culture and action taken on
unfavourable report. Verify the documents._____________
Pre operative waiting room with toilet facilities available
Availability of well equipped postoperative ward (Recovery
room) with adequate No. of beds and resuscitation measures
Uptodate maintenance of O T records like O T registers
(elective), emergency O T, monthly abstract etc.
Proper steps taken for disposal of 0 T waste (Operated
specimens etc.)
Emergency light or generator facilities provided to O T
(Verify)
Status of following equipment
Total No. Under
Pending
Available Repairs
for
condem
nation
Boyles Apparatus
Hydraulic O T
___ £1 Shadowless lamp
___ d). O T care
_
Suction
Apparatus
______
___£1
Conditioner
Air
___ 0
'
'
___ g) Minor Operation Tables
___ i)_ Refrigerator_______
___ jl Electric Sterilizers______
___ k) Autoclaves________
~
~
~
xii)
Regular condemnation of unserviceable articles twice a year
done________
xiii)
Inventory register maintained and checked by Anaesthetist /
RMO
xiv)
Availability of separate changing room for doctors, nurses
with attached toilet and locker facilities and entire staff uses
O T dress and separate slippers
xv)
Availability of the fire fighting equipment and knowledge
to use them_________
xvi)
Oxygen cylinder available & quantity checked periodically
____ b)
CENTRAL
STERILE SUPPLY DEPARTMENT
81
i)
ii)
iii)
iv)
A detailed chart showing how to operate H P H S displayed
in Kannada
Wall clock made available for noting the time during
autoclaving process
All autoclave tape should be preserved and pasted on
register datewise which is to be signed by Staff Nurse and
checked by Anaesthetist (Verify the register)
Efforts made to get out of order equipment’s repaired or
condemned (Verify the register)
LABPOUR
ROOM & PREMATURE BABY UNIT
21
Wherever the matter is complied put a “V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
13
No.
i)
ii)
J
iii)
iv)
V)
vi)
vii)
viii)
ix)
x)
xi)
xii)
xiii)
xiv)
xv)
xvi)
xvii)
xviii)
ITEM
Separate Labour Room with automatic double door for
clean and septic cases available.
____________
Minimum 2 labour tables in Clean labour room with plastic
curtain partition.
Facilities available such as : Wall Clock, baby weighing
machine, facility for headlow position, baby resuscitation
kit, mucus aspirator, suction apparatus (electric or foot
operated) alongwith set of catheter, oxygen cylinder with
accessories for baby and mother, emergency light /
generator connection, exhaust fan, coolers / fan, episiotomy
tray and venesection tray, shadowless lamp, forceps low, B
P apparatus, instrument sterilizer, plastic aprons, slippers,
cap, mask, apron, foam mattress on table, Kit of all life
saving drugs,__________
Same discipline as that of O T is also followed for labour
room i.e., use of gown, cap, mask etc. before entering in
labour room & PBU______
Availability of deep freeze or plastic containers with ice
cubes for preservation of still born, Placenta, till they are
disposed off.___________
Regular washing and fortnightly fumigation of labour room.
Verify record.
Duty roaster of staff of labour room and attendance
displayed or not
Proper writing of delivery notes including the foot prints of
baby, thumb impression of mother with attestation of nurse
conducting delivery.
Availability of attached toilet facility near Labour Room
Arrangement to resuscitate new bom and to keep baby
warm__________
Availability of functioning incubators
Staff trained in premature baby care.
Arrangement for prevention of hypothermia______________
Availability of Photo therapy unit, Oxygen hoods
Proper maintenance of record, registers of new bom
Precautionary measures adopted to prevent sepsis like
barrier nursing, change of cloths by staff working PBU
Written instructions about operation of incubator displayed.
Duty roster of staff on duty.
Paed F Med
10
WARDS
Sur
Gye
Post
op
Emergency
Casual
-ity
Response as on date of visit (Y/N) *
Date
Date
Date Date
Toca
I
Satisfactory
T~~ cleanliness
of the
2.
3?
4.
5.
sanitary blocks.
If, floor beds in
the wards present.
Satisfactory
upkeepment
of
Cots., Mattresses,
Bedside lockers.
Linen etc.____
Use of hospital
uniforms by all
patients_________
Availability
of
Suction Apparatus
* Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
14
No.
(electric and foot
operated), oxygen
cylinder
with
accessories,
venesection tray,
emergency tray.
emergency light,
BP
apparatus,
equipments
for
sterilization,
wheel
chairs,
stretcher trolly and
stationaries, forms
etc, without man_________
Maintenance
of
records (incoming,
outgoing
and
death
reports),
CARDEX (ward
round book)____________
Adequacy
and
working of fans
and tube lights___________
Availability of hot
water____________
/
6.
7.
8.
11)
i) ___
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
xi)
xii)
xiii)
xiv)
xv)
H)
IL
ii)
iii)
iv)
V)
vi)
vii)
ITEM
Response as on date of visit (Y/N) *
Date
Date
Date Date
DIET AND KITCHEN FACILITY
Availability of diet_______
Physical verification of dietary articles done any time.
Verify__________________
Availability of diet charts for adult, paediatric and special
diet.___________________
Arrangements for washing vegetable and vegetable cutting
platform________________
Satisfactory cleanliness of kitchen______
Satisfactory arrangements for preventing rat nuisance_____
Availability of utensils for cooking.
Satisfactory arrangements for storing the foodgrains_______
Regular medical check up of food handlers (Verify the
records)_____________
Regular organisation of diet committee meeting (Verify the
Minutes)____________
Availability of food testing register and remarks__________
Sending of samples of dietary articles for P A F studies and
action taken on results
Availability of lactometer measuring unit, weighing
machine and weights
Action taken on substandard supply of dietary articles______
Waste Disposal facility available
LINEN & LAUNDRY SERVICES
Condemnation carried out by every six months
Yearly requirement prepared on the basis of last three years
consumption and buffer stock, (Verify the records)
Availability of linen as per norms___________________
Availability of buffer stock of linen to face Disaster
Emergencies
Upkeep of linen register
Hospital linen stamped by Dhobi ink_______
I Services of tailor utilized adequately for making new O T
Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
15
a
No.
viii)
ix)
x)
xi)
xii)
xiii)
13)
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
xi)
xii)
xiii)
xiv)
xv)
xvi)
xvii)
xviii)
xix)
xx)
xxi)
ITEM
Response as on date of visit (Y/frT *
Date
Date
Date Date
wears eye shade and mending the torn cloths etc.
A practice of Dirty / spoiled linen are decontaminated /
washed and given to Dhobi is followed.________________
O T Linen is kept separately and washed separately_______
Availability of Linen as per departments guidelines such as
Woolen blanket - Red
O.T.Gown - Green
Use of aprons by Doctors
Paramedical uniforms_______
Class IV uniforms
MEDICAL / NON MEDICAL STORES______________
Suitability of location for all sections of Hospital and
adequate space for medical store, _________________
Pharmacist knowledgeable in materials ■• management,
system of bin cards, nearing expiry and expiry chart, buffer
stock are followed
Inspections of stores by the CMO in last six months verify
the stock book.
Availability of Vital, essential and desirable drugs sufficient
to last for at least three months
Upkeep of expiry date register and its regular inspection by
Efforts made to redistribute large stock of slow moving
drugs for its utilization or redistribution_________________
Check a few ABC drugs from the stock book to ascertain
the correctness of balance quantity
Proper arrangements of the drugs as per ABC / V.E.D
Category and storage of rubber goods as per guidelines
Knowledge of minimum levels for each drug to store
keeper by him card system.
Appropriate steps taken to prevent pilferage of drugs______
All ampoules are stamped with government name.
Separate system for issuing costly drugs.
Satisfactory storage of drugs with reference to temperature,
sunlight, protection from moisture, availability of
refrigerators and exhaust fans.
Sending of samples to chemical laboratory to check it as per
specification and standard & action taken thereon
Every parcel is opened within 8 hours and checked the
quantity as per order. Communication of any shortages/
damages to Firm.
Maintenance of separate Register for the batches declared
unfit for use._________
Availability of licenses for spirit, morphine, opium________
Circulation of lists of available drugs to the MOs, OPD &
Wards
Submission of certified bills to office for release of
payments within three days. (Verify the register)__________
Arrangement of regular auction to clear the empty material
from store_________
Availability of Fire Fighting equipment and knowledge to
operate
* Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
16
No.
ITEM
xxii)
xxiii)
Prevention of drugs and non drugs items from rat nuisance.
Black waste container available for waste disposal.
14)
MEDICAL RECORDS, AUDIT & BIOSAFETY
Availability of Medical Record Room with enough number
of racks and cupboards etc.
Knowledge of staff in keeping the medical records in
desired fashion
Regular reporting of births & deaths to the appropriate
authority (Verify)
Regular WHO classification of diseases________________
Quarterly submission of the morbidity, mortality reports
(Check the report
of_ the
last ----month
.
— —
to assess the
correctness)________
Monthly Death audit meetings held & minutes of meeting
recorded/ reported
Organisation of Hospital Infection Control Committee
meetings. Action taken on minutes and investigation done if
any. (Verify)
i)
ii)
iii)
iv)
v)
vi)
vii)
i)
ii)
iii)
iv)
v)
vi)
16)
i) ____
ii) ___
iii)
iv)
Response as on date of visit (Y/N *
Date
Date
Date Date
POST MORTEM FACILITY & M.L.C RECORD
Availability of the instruments required for performing Post
Mortem in order and sufficient.
Availability of prescribed P.M. and viscera forms in
mortuary_______
Arrangement for carrying out post mortem after sunset.
Availability of exhaust fans and adequate Water Supply
Proper writing of post mortem notes (Verify PM records)
Update records such as P M Register, Incoming and
outgoing dead bodies register available_________________
Bio-safety measures undertaken like cap, mask, thick
gloves while doing Post Mortem
I E C & SOCIAL ACTIVITIES_____________________
Posters and Banners displayed in OPD, Wards and premises
Arrangements of Cinema shows in OPD on fixed days.
Celebration of different National days and record
maintenance _______
Annual social gathering arranged for the staffs celebration
of hospital day
17)
MOTOR VEHICLE UNIT, HEALTH EQUIPMENT
REPAIR UNIT & TELECOMMUNICATION
___ a). VEHICLES-------i)
Status of Vehicle
OFFROAD ONROAD
Date of its registration and other details_________________
ii)
Availability of Garage and tools in the vehicles.__________
iii)
Proper maintenance of Logbooks
iv)
Major accidents and the procedure of inquiry completed
within 6 months (maintenance of the repair register with the
name of the part replaced)_____
v)
Efforts made to bring off road vehicle on road
Wherever the matter is complied put a “V’ in green colour and
Wherever it is not complied put an 'X’ mark in red colour
17
No.
vi)
ITEM
Response as on date of visit (Y/N,
Date
Date
Date Date
Ambulance availability & functionality
bl MOBILE MAINTEANCE UNIT (AMBULANCE)
Maintenance of register for collection of fees for ambulance
services
c)
i)
HEALTH EQUIPMENT REPAIRS UNIT
Sending of list of out of order instruments / equipment to
Unit every month. Check the list
Efforts made to get the major instruments, equipment’s
repaired promptly by chasing higher authorities.
Repairing and enamel painting of cots, bedside lockers
saline stand locally.
ii)
iii)
dl TELECOMMUNICATION________________________
List of telephone numbers, code, fax numbers available
Telephone connection for the hospital_________________
Availability of Public Phone facility in Casualty and OPP
Availability of Telephone directory and telephone numbers
of DC, referring hospitals, Police Superintendent, Fire
Brigade, Water Supply, other ambulances, K E B., and
private nursing homes in emergency service department.
i)
ii)
iii)
18)
a)
b)
c)
Whether the following National/State Programmes
being implemented and reported
FAMILY WELFARE, MCH, MTP&PP
PROGRAMME (25 Marks)
__________________
NATIONAL
PROGRAMME:
NATIONAL
PROGRAMME
MALARIA
TUBERCULOSIS
ERADICATION
CONTROL
d)
NATIONAL PROGRAMME FOR CONTROL OF
BLINDNESS
0
PROGRAMMES
FOR
THE
DISADVANTAGED COMMUNITY
e)
NATIONAL
PROGRAMME
LEPROSY
SOCIALLY
ERADICATION
AIDS CONTROL PROGRAMME
g)
19)
i)
DISTRICT
SURVEILLANCE
INFORMATION
SERVICES
______________
If yes, please provide details
ENVIRONMENT SANITATION & WATER SUPPLY:
Efforts made by CMO to improve the general sanitation of
hospital premises by preventing open air defecation
underground drainage system keeping Dust bins at various
Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
18
No.
•D
iii)
f
v)
vii)
viii)
ix)
x)
xi)
21)
i)
ii)
iii)
iv)
v)
vi)
vii)
ITEM
places etc.,______ _________
Efforts made to prevent nuisance of stray animals like pigs,
donkeys, cows, goats in the premises by providing
compound wall and cattle trap at Entrance and Exist.
Arrangements for regular lifting of garbage with the help of
Municipality/Corporation
_____________________
Anti Smoking, Spitting boards & other Health Education
boards depicted at prominent places in Hospital Campus
Arrangement of sufficient illumination arrangements in
Hospital premises by Street light etc.,__________________
Provision of Public latrines
________________
Source of water supply is adequate, if not, then efforts made
to augment it by Borewell or dugwell etc.,
Sanitation, Cleaning and general condition of overhead
tank/sump well. Verify reports of OT test done by Sanitary
Inspectors. Cross check done by RMO (OR)_____________
Collection of water charges at domestic rate where the
supply is combine for hospital and staff quarters
CONSTRUCTION & GARDEN DEVELOPMENT
Quarters available to all essential staff, if not, efforts made
to provide or construct
Efforts made to develop hospital garden_____________
Availability of adequate water supply._________________
Arrangements to protect garden from stray animals________
Decorative arrangements in garden such as showers,
sprinkles____________
Development of Children’s park______________________
Display of Health Education slogans.____________
Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
Response as on date of visit (Y/K *
Date
Date
Date Date
19
u
g
7;
'z
Administration and outreach
activities Component
20
J
No.
23)
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
xi)
xii)
xiii)
xiv)
xv)
xvi)
xvii)
xviii
)__
xix)
xx)
24)
i)
ii)
iii)
ITEM
OFFICE ADMINISTRATION____________________
Cash Book and Cash Verification once in 3 month by CS
(Ascertain)_____________
Security Deposits collected from the staff working in
Stores, Operation Theater, Cash Section, Outward Section
etc.,_____________
Muster roll and Leave Account, Late Muster checked by
Administrative Officer/Chief Administrative Officer
Standing Order file neatly maintained_________________
Maintenance of Service Books of all cadres____________
Recurring & Non-Recurring Expenditure statements
submitted in time to higher authorities as per schedule
Efforts made to investigate the grievances and complaints
received and corrective action taken._____
Efforts made for disposal of all E B L cases (files)_______
Efforts made to settle the leave at local level and beyond
power, proposals submitted to higher authorities
Maintenance of increment registers and scrutiny of pending
advances, recovery etc.,
Efforts made to finalise the Pension cases and appointment
on compassionate grounds etc.,
Compliance of Audit & Store Verification Paras_____
Pending Confidential Reports Cl.Ill, Cl.H and Cl.I
Local Purchases in comparison with total expenditure on
Medicine not more than 5%__________
Efforts made to settle reimbursement claims, verify the
records____________
Hospital Advisory Committee formed. If not, efforts made
to constitute it.
Names of Members displayed in OPD and Casualty
Department
Regular meetings held as per guidelines, if not, efforts
made for__________
Action on the decisions made in the meeting or efforts
made for their fulfillment
___________
Hospital Fees Collection (user charges)
More than last three years average collection and State
average collection :
Either more than last three years average collection or state
average collection : Y/N Less than both : Y/N (Tick one)
OUTREACH ACTIVITIES____________________
Diagnostic and Operative Camps such as Yellow Card
camps, Reconstructive surgery for Leprosy and bums
patients, Dental Camps etc (except Cataract Surgery
Camps), FPO camps (TO and LTO)________________
Providing Specialist and super service to rural hospitals by
adopting one or two TH/CH centres for providing specialist
services for operative procedures on regular basis (Verify
records)___________
Inspections of Rural Hospitals (SC, PHU and PHC) in
respect of referral system and National Health Programmes
Response as on date of visit (Y/N) *
Date
Date
Date Date
Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
21
VAEALTA,
<S| ov - 11 o
o /yjz
^6
-J)
jr.
J
*
No.
25)
i)
26)
27)
ITEM
Response as on date of visit (Y/N) *
Date
Date
Date Date
needs to be inspected by CS or AMO twice a year and
corrective action taken. (Verify the records)
Inspection Proportionate target 100%: Y/N 80%: Y/N 70%
: Y/N Below 70% : Y/N (Tick one)__________________
RESEARCH ACTIVITIES________________________
Operational Research study undertaken such as Exit
Interviews of discharged patients, study undertaken to
reduce patients waiting time, efforts made to investigate
sources of infection, special ways of treating Burn cases.
Investigation of maternal, infant mortality in hospital and
remedy suggested based on the results etc or Paper
presentations in various State and National level
conferences.
INNOVATIVE ACTION In Order To Curtail The
Expenditure such as analysis on medicine/bed/year,
expenditure on diet/bed/year, linen/bed/year and corrective
actions taken thereon.______________
DONATIONS.. In Kinds and in Cash, Prizes, Awards etc.,
received by Hospitals in last two years_________________
* Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
22
MAINTENANCE OF MEDICAL RECORDS
No.
ITEM
Response as date of visit (Y/N) *
Date
Date Date Date
A
_1_
2_
3
4
_5_
6_
7
ESTABLISHMENT SECTION_____________
Attendance register________________________
Casual leave register______________________
Service registers of employees_______________
Cash book register_________________________
Encashment register_______________________
Acquittence bill
_______________________
Contingency register (Abstract contingency &
Direct contingency)________________________
8 Inventory register (for furniture, equipment,
instruments)
a. Separate register for KHSDP - Instruments,
equipment, furniture, linen, utensils, provision
b. Separate register for D H & F W
9
Library contingency (small hospital library for
quick reference work - journals, periodicals,
books)_________________
10 Telephone
directory
(District
nos./State
nos./Local emergency - police, fire, railway,
engineering, bus station, referral hospital)
Stock book with Head of Accountwise. EgKHSDP, IPP, F W & H S___________________
11 Separate stock book of drugs - KHSDP, IPP, D
H&FW
a. Nearing expiry drug register (current month)
b. Expiry drug register (yearly with date)
12 Stock book of hospital necessities (Brooms,
stationary, bulbs etc.)_______________________
13 Memo books (office order books)_____________
14 Condemnation article register for unserviceable
articles_______________
15 Electricity, telephone and water bills register or
files and receipts register
16 I Telephone call maintenance register___________
17
1 n Log book for vehicles i.e., Ambulance, Jeep, Tata
Sumo or any vehicle in the hospital (separate
book for each vehicle)
18 General receipt books (for collection of fees for
medical certificates, leave certificate, physical
fitness, inpatient certificate, discharge certificate,
user charges, x-rays, operation, special ward
charges, drugs etc. ___________
* Wherever the matter is complied put a “V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
23
No.
ITEM
Date
Response as date of visit (Y/N) *
Date
Date Date
B
RECORDS FOR CLINICAL PURPOSE
OPP services ______
1 OPP registers_____
2
OPP slips (outpatient tickets)
Inpatient services_________________
Inpatient or admission register_________________
2
General case sheets (medical, surgical, maternity,
pediatric, ortho, ENT), medico-legal cases
(accidents, poison, rape, fall, drowning, hanging,
burns, snake bite, unnatural deaths, mass
emergency disasters — medico-legal seal should
be put on the case sheets) and diet sheet.
3
Emergency and casuality services
The following registers and sheets should be
maintained.
Accident register (MLC)
Police intimation form
X-ray requisition form
Office memo
Wound certificate
Peath form and death register for brought dead
Post mortem register — Peath occurred in the
hospitals
Night report book
Written by duty CMO or duty doctor regarding
drug availability, number of cases attended_______
C STATIONARY
FOR
MATERNITY
SERVICES________ ________________________
1
Maternity case sheets______ ________
2
Antenatal cards and registers and OPP slips______
Birth register__________
7 Emergency call book_______________
5
Carolex book _____
_6_ Baby labeling______
D OPERATION THEATRE REGISTER
1
Major OT registers_____________
2
Minor OT registers
3
HPE - specimen sending book______
4
Inventory registers - equipment, instruments,
drugs, 02 cylinders, anesthetic cylinders,
operation manuals for equipment, Boyle’s
apparatus, ICC equipment, biopsy forms
Disinfection measure registers — Date, time and
schedule of fumigation_______
Wherever the matter is complied put a ‘V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
24
No.
E
1
2
3
4
2
6
ITEM
Response as on date of visit (Y/N) *
Date
Date
Date Date
Swab culture - Done and their reports__________
LABORATORY AND BLOOD BANK_______
Inward register for receiving samples and their
nature __________
Work allotment registers____________________
Inventory book for reagents, chemicals, drugs,
equipment
___ ______________________
Log book for major equipment - auto analyser,
culture incubators, refrigerators, centrifuge,
microscopes, microtomes, date and time of
handling the equipment_____________________
Reporting register of the investigations_________
Instruction booklet for how to collect the samples
(blood, urine etc.)
F
1
RADIOLOGY DEPARTMENT RECORDS
Inventory of equipment (60, 100, 300, 500 MA xray / ultrasound scanners)___________________
2 Log book of equipment and operational manuals
2 X-ray requisition slips __________________
4 Separate register for medico-legal x-rays_______
5 X-ray report register
Ultrasound report register___________________
6 Instruction booklet for various invasive and noninvasive radiological examinations____________
2 Appointment books for various procedures
G PHARMACY SERVICES__________________
1
Stock registers__________
2 Separate issue books for each ward____________
3 Separate book for receiving empty vials and
bottles availability_______
_£ Display card of drug position — monthly, weekly
H STATIONARY
FOR
EVALUATION
PURPOSE (CLINICAL EFFECTIVENESS)
2 Flospital performance indicators______________
2 Yellow card camp reporting formats___________
3 Family planning services report formats - TO,
LTO, IUCD, contraceptives
4 Communicable disease report formats (monthly,
weekly and nil report)_______
5 Statistic report formats (daily, monthly death of
hospital attended patients)'
Wherever the matter is complied put a “V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
25
No.
ITEM
I
1
HOUSE KEEPING_______________________
Stock position of linen book - beds, pillows,
bedsheets, blankets________________________
Stock position book - OT linen, OT gowns,
patient gowns, patient sarees_________________
Labour ward linen
2
3
* Wherever the matter is complied put a “V’ in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
Response as on date of visit (Y/N) *
~~
Date
Date
Date Date
26
Waste Management Practices in 30 - 100 bedded hospitals
(To be verified every month by District Surveillance Medical Officer)
HOSPITAL:
YEAR:
ADMINISTRATIVE MEDICAL OFFICER:
SNO. _____________ _______ Indicator___________________ Jan Feb Mar Apr May Jun
1
White waste bins placed in each Consultation Room
2
White waste bins placed in the Reception
3 _ White waste bins placed in Waiting room
4
White waste bins with white coloured polythene bag
placed in X-ray room
_5
White bins with white plastic bag placed in Wards
6
7_
8
9
10
11
12
13
14
15
Jul Aug
Sep
Oct
Nov
Dec
White & Black bins with respective colour covers placed
in Pharmacy
Needle cutter being used
”
White, Blue & Yellow bins with respective colour covers
& Needle Cutter fixed in Laboratory
White. Blue & Yellow bins with respective colour covers
& Needle Cutter fixed in Inj., Dressing Room
Blue & Yellow bins with respective colour covers &
Needle Cutter fixed in Operation Theatre
White. Blue & Yellow bins with respective colour covers
& Needle Cutter fixed in Labour Room
White, Blue & Yellow bins with respective colour covers
& Needle Cutter fixed in Nurses Station
Yellow bins with yellow cover placed in Mortuary.
Waste reduction is in practice or not
Disinfection used in adequate quantity, concentration &
frequency in the bins used in Consultation, Reception,
Waiting, X-ray, Wards Lab, Pharmacy, Inj., Dressing
Room, O.T., Labour room, Nurses Station & Mortuary.
16
Plastics like catheters, IV sets, bottles, drainage tubes,
cannulas used in OBG Consultation Room, laboratory,
Inj., Dressing Room. Ward, O.T., Labour Room &
Nurses station are cut. disinfected and stored.
17
Are the injections, ampules, bottles & similar glass
artricles collected separately and stored for recycling
18
Waste paper is it being collected separately for
recycling.
Waste beign filled by the land fiii~
19
20 _ Infectious waste being put into deep burial pit
21
Are the plastic bags in which waste was collected are
being kept separately after the waste is thrown into land
fill or deep burial pit.
22
Date on which the land fill was cleared
23
Annual examination & immunisation against Tetanus,
Hepatitis-B.
__________
24
Date on which the Hospital Infection Control Committee
has met_______
25
Refresher training conducted to staff
26
Swab from OT sent for culture.
27
Equipment like wheel barrow, pump, shovel etc., being
used
28
Waste handlers wearing protective gear
29
Information - adequate availabe services
30 [Signature of the District Surveilance Officer
Signature of the Administrative Medical Officer
Note : The District Surveillance Medical Officer put (>J) mark if the activity is correctly done and put (X) in red against activities not done/
incorrectly done. He will sign against all areas verified
One of this sheet will be with the District Surveil ance Medical Officer and another copy will be with the Medicalofficer displayed in
his chamber. Inspecting officers are expected to look into this sheet during their inspection and take corrective actio
* Wherever the matter is complied put a
in green colour and
Wherever it is not complied put an ‘X’ mark in red colour
27
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