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ISBN 978-93-82655-01-5

Ministry of Health & Family Welfare

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 List of Contributors

1 Ms. Anuradha Gupta AS&MD (NRHM), MoHFW

2 Dr. Rakesh Kumar JS, RCH, MoHFW
3 Mr Manoj Jhalani JS, Policy, MoHFW
4 Dr. Himanshu Bhushan DC (I/c MH), MoHFW
5 Dr. Manisha Malhotra DC (MH), MoHFW
6 Dr. Dinesh Baswal DC (MH), MoHFW
7 Dr. S.K. Sikdar DC ( I/c FP), MoHFW
8 Dr. P.K. Prabhakar DC (CH), MoHFW
9 Dr. Poonam Varma Shivkumar Prof. of OBGY, MGIMS, Wardha
10 Dr. R. Rajendran State Nodal Officer, Anaesthesia, Tamil Nadu
11 Dr. Arvind Mathur WHO, SEARO
12 Dr. Dinesh Agarwal UNFPA
13 Dr. Pavitra Mohan UNICEF
14 Dr. Neerja Bhatla Prof of OBGY, AIIMS, New Delhi
15 Dr. Somesh Kumar Jhpiego
16 Dr. Archana Mishra DD (MH), GoMP
17 Dr. Ritu Agrawal UNICEF
18 Dr. Aparajita Gogoi CEDPA, India
19 Dr. Sridhar R.P. State Health Consultant (MCH), Gujarat
20 Dr. Pushkar Kumar Lead Consultant, MH, MoHFW
21 Mr. Nikhil Herur Consultant MH, MoHFW
22 Dr. Rajeev Agarwal Sr. Mgt. Consultant, MH, MoHFW
23 Dr. Ravinder Kaur Senior Consultant, MH, MoHFW
24 Dr. Renu Srivastava SNCU Co-ordinator, CH, MoHFW
25 Dr. Anil Kashyap Consultant NRHM, MoHFW
26 S. Chandrashekhar JD(QA & IEC, KHSDRP, Karnataka
27 Ms. Jyoti Verma DD & Nodal Officer, QA, Govt. of Bihar
28 Ms. Laura Barnitz CEDPA, India
29 Ms. Priyanka Mukherjee CEDPA, India
NHSRC Team
1 Dr. T Sundararaman ED, NHSRC
2 Dr. J N Srivastava Advisor – QI, NHSRC
3 Dr. P. Padmanaban Advisor (PHA Div.), NHSRC
4 Mr. Prasanth K.S. Sr. Consultant (PHA Div.), NHSRC
5 Dr. Nikhil Prakash Consultant NHSRC (QI Div)
6 Dr. Deepika Sharma Consultant NHSRC (QI Div)

List of Contributors iii

 Maharashtra Team
1 Shri Vikas Kharage Ex MD, NRHM, Govt. of Maharashtra
2 Dr. Satish Pawar Director, Health Services, Govt. of Maharashtra
3 Dr. M. S. Diggikar Ex Principal, Public Health Institute, Nagpur, Maharashtra
4 Mr. Shridhar Pandit PO, NRHM, Govt. of Maharashtra
Standard Review Committee - 2016
1 Dr. J.N. Srivastava Advisor Quality Improvement, NHSRC-Chairperson
2 Prof. Sangeeta Sharma Prof. & Head, Neruropsychopharmacology, IHBAS, New Delhi
3 Prof. M. Mariappan Prof. & Chairperson, Centre for Hospital Management, TISS, Mumbai
4 Prof. Avinash Supe Dean, KEN Medical College Hospitals, Mumbai
5 Prof. Urmila Thatte Prof. & Head, Dept. of Pharmacology, Seth GS Medical College, Mumbai
6 Dr. Munindra Srivastava President, AHA, Noida
7 Dr. Sandip Sanyal Deputy Director of Health Services, Hospital Administration Branch, Kolkata
8 Dr. Parminder Gautam Senior Consultant, Quality Improvement, NHSRC
9 Dr. Nikhil Prakash Senior Consultant, Quality Improvement, NHSRC
10 Dr. Deepika Sharma Consultant, Quality Improvement, NHSRC
Expert Consultation Committee-2017
Group I – Focus on Maternal Health Components
1 Dr. Dinesh Baswal DC (Maternal Health- I/C), MoHFW
2 Dr. J.N. Srivastav NHSRC
3 Dr. Paul Francis/ Dr. Amrita Kansal WHO
4 Dr. AsheberGaym UNICEF
5 Dr. NeeleshKapoor IPE Global
6 Dr.VikasYadav/ Deepti Singh Jhpiego
7 Nikhil Prakash NHSRC
8 Dr. Anil Kandukuri NHSRC
9 Dr. Salima Bhatia, Sr. Consultant MoHFW
10 Dr. Tarun Singh Sodha, Consultant MoHFW
11 Dr. JyotiBaghel, JrConsultant MoHFW
12 Additional Experts (as nominated by MH Division)
Group II – Focus on Child Health Components
1 Dr. Ajay Khera DC (Child Health- I/C), MoHFW
2 Dr. J.N. Srivastav NHSRC
3 Dr. Prabhakar DC (Child Health), MoHFW
4 Dr. Paul Francis/ Dr. Amrita Kansal WHO
5 Dr. Gagan Gupta UNICEF
6 Dr. Harish Kumar IPE Global
7 Dr. RenuSrivastav IPE Global
8 Dr. VikasYadav/ Deepti Singh Jhpiego
9 Nikhil Prakash NHSRC

iv National Quality Assurance Standards for Public Health Facilities | 2018

 Table of Contents

National Quality Assurance Standards for District Hospital 1

Introduction to National Quality Assurance Standards 3
National Quality Assurance Standards for district hospital 5
Components of Quality Measurement System and their Intent 9
Assessment Protocol  11
Intent of Standards & Measurable Elements 17
Intent of standards and Measurable elements for District Hospital 19
Bibliography 51
Index 57

Table of Contents v
National Quality Assurance
Standards for District Hospital

National Quality Assurance Standards for District Hospital 1

 Introduction to National Quality
Assurance Standards

Often, measuring the quality in health facilities has never been easy, more so, in Public Health Facilities. We have
had quality frame-work and Quality Standards & linked measurement system, globally and as well as in India. The
proposed system has incorporated best practices from the contemporary systems, and contextualized them for
meeting the needs of Public Health System in the country.
The system draws considerably from the guidelines (more than one hundred fifty in number), Standards and Texts
on the Quality in Healthcare and Public health system, which ranges from ISO 9001 based system to healthcare
specific standards such as JCI, IPHS, etc. Operational Guidelines for National Health Programmes and schemes
have also been consulted.
We do realise that there would always be some kind of ‘trade-off’, when measuring the quality. One may have
short and simple tools, but that may not capture all micro details. Alternatively one may devise all-inclusive
detailed tools, encompassing the micro-details, but the system may become highly complex and difficult to apply
across Public Health Facilities in the country.
Another issue needed to be addressed is having some kind of universal applicability of the quality measurement
tools, which are relevant and practical across the states. Therefore, proposed system has flexibility to cater for
differential baselines and priorities of the states.
Following are salient features of the proposed quality system :
1. Comprehensiveness – The proposed system is all inclusive and captures all aspects of quality of care
within the eight areas of concern. The departmental check-lists transposed within Quality Standards, and
commensurate measurable elements provide an exhaustive matrix to capture all aspects of quality of care
at the Public Health Facilities.
2. Contextual – The proposed system has been developed primarily for meeting the requirements of the
Public Health Facilities; since Public Hospitals have their own processes, responsibilities and peculiarities,
which are very different from ‘for-profit’ sector. For instance, there are standards for providing free drugs,
ensuring availability of clean linen, etc. which may not be relevant for other hospitals.
3. Contemporary – Contemporary Quality standards such as NABH, ISO and JCI, and Quality improvement
tools such as Six Sigma, Lean and CQI have been consulted and their relevant practices have been
incorporated.
4. User Friendly – The Public Health System requires a credible Quality system. It has been endeavour
of the team to avoid complex language and jargon. So that the system remains user-friendly to enable
easy understanding and implementation by the service providers. Checklists have been designed to be
user-friendly with guidance for each checkpoint. Scoring system has been made simple with uniform
scoring rules and weightage. Additionally, a formula fitted excel sheet tool has been provided for the
convenience, and also to avoid calculation errors.
5. Evidence based – The Standards have been developed after consulting vast knowledge resource available
on the quality. All respective operational and technical guidelines related to RMNCH+A and National
Health Programmes have been factored in.

Introduction to National Quality Assurance Standards 3

 6. Objectivity – Ensuring objectivity in measurement of the Quality has always been a challenge. Therefore
in the proposed quality system, each Standard is accompanied with measurable elements & Checkpoints
to measure compliance to the standards. Checklists have been developed for various departments, which
also captures inter-departmental variability for the standards. At the end of assessment, there would be
numeric scores, bringing out the quality of care in a snap-shot, which can be used for monitoring, as well
as for inter-hospital/ inter-state(s) comparison.
7. Flexibility – The proposed system has been designed in such a way that states and Health Facilities can
adapt the system according to their priorities and requirements. State or facilities may pick some of the
departments or group of services in the initial phase for Quality improvement. As baseline differs from
state to state, checkpoints may either be made essential or desirable, as per availability of resources.
Desirable checkpoints will be counted in arriving at the score, but this may not withhold its certification,
if compliance is still not there. In this way the proposed system provides flexibility, as well as ‘road-map’.
8. Balanced – All three components of Quality – Structure, process & outcome, have been given due
weightage.
9. Transparency – All efforts have been made to ensure that the measurement system remains transparent,
so that assessee and assessors have similar interpretation of each checkpoint.
10. Enabler – Though standards and checklists are primarily meant for the assessment, it can also be used
as a ‘road-map’ for improvement.

4 National Quality Assurance Standards for Public Health Facilities | 2018

 NATIONAL QUALITY ASSURANCE Standards
for district hospital

Area of Concern - A: Service Provision

Standard A1 The facility provides curative services

Standard A2 The facility provides RMNCHA services

Standard A3 The facility provides diagnostic services

Standard A4 The facility provides services as mandated in National Health Programmes/State Scheme.

Standard A5 The facility provides support services

Standard A6 Health services provided at the facility are appropriate to community needs.

Area of Concern - B: Patient Rights

Standard B1 The facility provides information to care seekers, attendants & community about the available services
and their modalities.

Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are
no barriers on account of physical economic, cultural or social reasons.

Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient
related information.

Standard B4 The facility has defined and established procedures for informing patients about the medical condition,
and involving them in treatment planning, and facilitates informed decision making.

Standard B5 The facility ensures that there are no financial barriers to access, and that there is financial protection
given from the cost of hospital services.

Standard B6 The facility has defined framework for ethical management including dilemmas confronted during
delivery of services at public health facilities.

Area of Concern - C: Inputs

Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the
prevalent norms.

Standard C2 The facility ensures the physical safety of the infrastructure.

Standard C3 The facility has established Programme for fire safety and other disaster.

Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the
current case load.

Standard C5 The facility provides drugs and consumables required for assured list of services.

Standard C6 The facility has equipment & instruments required for assured list of services.

Standard C7 The facility has a defined and established procedure for effective utilization, evaluation and augmentation
of competence and performance of staff

Introduction to National Quality Assurance Standards 5

 Area of Concern - D: Support Services

Standard D1 The facility has established Programme for inspection, testing and maintenance and calibration of
Equipment.

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in
pharmacy and patient care areas.

Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.

Standard D4 The facility has established Programme for maintenance and upkeep of the facility.

Standard D5 The facility ensures 24 X 7 water and power backup as per requirement of service delivery, and support
services norms.

Standard D6 Dietary services are available as per service provision and nutritional requirement of the patients.

Standard D7 The facility ensures clean linen to the patients.

Standard D8 The facility has defined and established procedures for promoting public participation in management
of hospital transparency and accountability.

Standard D9 Hospital has defined and established procedures for Financial Management.

Standard D10 The facility is compliant with all statutory and regulatory requirement imposed by local, state or central
government.

Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and
standards operating procedures.

Standard D12 The facility has established procedure for monitoring the quality of outsourced services and adheres to
contractual obligations.

Area of Concern - E: Clinical Services

Standard E1 The facility has defined procedures for registration, consultation and admission of patients.

Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the
patients.

Standard E3 The facility has defined and established procedures for continuity of care of patient and referral.

Standard E4 The facility has defined and established procedures for nursing care.

Standard E5 The facility has a procedure to identify high risk and vulnerable patients.

Standard E6 The facility follows standard treatment guidelines defined by state/Central government for prescribing
the generic drugs & their rational use.

Standard E7 The facility has defined procedures for safe drug administration.

Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records
and their storage.

Standard E9 The facility has defined and established procedures for discharge of patient.

Standard E10 The facility has defined and established procedures for intensive care.

Standard E11 The facility has defined and established procedures for Emergency Services and Disaster
Management.

Standard E12 The facility has defined and established procedures of diagnostic services.

Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and
Transfusion.

6 National Quality Assurance Standards for Public Health Facilities | 2018

Standard E14 The facility has established procedures for Anaesthetic Services.

Standard E15 The facility has defined and established procedures of Operation theatre services.

Standard E16 The facility has defined and established procedures for end of life care and death.

Maternal & Child Health Services

Standard E17 The facility has established procedures for Antenatal care as per guidelines.

Standard E18 The facility has established procedures for Intranatal care as per guidelines .

Standard E19 The facility has established procedures for postnatal care as per guidelines .

Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines.

Standard E21 The facility has established procedures for abortion and family planning as per government guidelines
and law.

Standard E22 The facility provides Adolescent Reproductive and Sexual Health services as per guidelines.

National Health Programmes

Standard E23 The facility provides National health Programme as per operational/Clinical Guidelines.

Area of Concern - F: Infection Control

Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement
of hospital associated infection.

Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and
antisepsis.

Standard F3 The facility ensures standard practices and materials for Personal protection.

Standard F4 The facility has standard procedures for processing of equipment and instruments.

Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention.

Standard F6 The facility has defined and established procedures for segregation, collection, treatment and disposal
of Bio Medical and hazardous Waste.

Area of Concern - G: Quality Management

Standard G1 The facility has established organizational framework for quality improvement.

Standard G2 The facility has established system for patient and employee satisfaction.

Standard G3 The facility has established internal and external quality assurance Programmes wherever it is critical
to quality.

Standard G4 The facility has established, documented implemented and maintained Standard Operating Procedures
for all key processes and support services.

Standard G5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding
activities and wastages

Standard G6 The facility has established system of periodic review as internal assessment, medical & death audit and
prescription audit.

Standard G7 The facility has defined Mission, Values, Quality policy and Objectives, and prepares a strategic plan to
achieve them.

Introduction to National Quality Assurance Standards 7

Standard G8 The facility seeks continually improvement by practicing Quality methods and tools.

Standard G9 The facility has defined, approved and communicated Risk Management framework for existing and
potential risks.

Standard G10 The facility has established procedures for assessing, reporting, evaluating and managing risk as per
Risk Management Plan

Area of Concern - H : Outcome Indicator

Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks.

Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark.

Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark.

Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National benchmark.

8 National Quality Assurance Standards for Public Health Facilities | 2018

 Components of Quality Measurement
System and their Intent

The main pillars of Quality Measurement Systems are Quality Standards. These standards have been defined for
various level of facilities. The Standards have been grouped within the eight Areas of Concern. Each Standard further
has specific Measurable Elements. These standards and measurable elements are checked in each department of
a health facility through department specific Checkpoints. All Checkpoints for a department are collated, and
together they form assessment tool called ‘Checklist’. Scored/ filled-in Checklists would generate scorecards.
Functional relationship between quality standards, measurable elements, check-points and check-list is shown in
Figure1.
Figure 1: Functional Relationship between Components of Quality Measurement System

Departmental
Checklists

Checkpoint Score
Measurable
Elements card
Checkpoint Departmental
Standard &
Checkpoint Facility
Area of Concern Measurable
Elements
Checkpoint
Standard

Following are the area of concern in a health facility:

1. Service Provision
2. Patient Rights
3. Inputs
4. Support Services
5. Clinical Services
6. Infection Control
7. Quality Management
8. Outcome

Components of Quality Measurement System and their Intent 9

 Assessment Protocol

A. General Principles
Assessment of the Quality at Public Health Facilities is based on general principles of integrity, confidentiality,
objectivity and Replicability -
1. Integrity – Assessors and persons managing assessment programmes should
yy Perform their work with honesty, diligence and responsibility
yy Demonstrate their competence while performing assessment
yy Performance assessment in an impartial manner
yy Remain fair and unbiased in their findings
2. Fair Presentation - Assessment findings should represent the assessment activities truthfully and accurately. Any
unresolved diverging opinion should between assessors and assesses should be reported.
3. Confidentiality- Assessors should ensure that information acquired by them during the course of assessment is not
shared with any authorised person including media. The information should not be used for personal gain.
4. Independence- Assessors should be independent to the activity that they are assessing and should act in a manner
that is free from bias and conflict of interest. For internal assessment, the assessor should not assess his or her own
department and process. After the assessment, assessor should handhold to guide the service providers for closing the
gap and improving the services.
5. Evidence based approach – Conclusions should be arrived based on evidences, which are objective, verifiable and
reproducible.

B. Planning Assessment Activities

Following assessment activities are undertaken at different level -
1. Internal Assessment at the facility level– A continuous process of assessment within the facility by internal assessors.
2. Assessment by District and State Quality Assurance Units
3. Accreditation assessment – Assessment by national assessors for the purpose for certification/ accreditation.

Internal Assessment- Internal assessment is a continuous process and integral part of facility based Quality assurance
program. Assessing all departments in a health facility every month may not be possible. The hospital should prepare
a quarterly assessment schedule. It needs to be ensured that every department would be assessed and scored at least
once in a quarter. This plan should be prepared in consultation with respective departments. Quality team at the
facility can also prioritize certain departments, where quality of services has been a cause of concern.
For internal assessment, the Hospital Quality Team should appoint a coordinator, preferably the hospital manager or
quality manger, whose main responsibilities are given below -
1. Preparing assessment plan and schedule
2. Constitute an assessment team for internal assessment
3. Arrange stationary (forms & formats) for internal assessment
4. Maintenance of assessment records
5. Communicating and coordinating with departments

Components of Quality Measurement System and their Intent 11

 6. Monitor & review the internal assessment programme
7. Disseminate the findings of internal assessment
8. Preparation of action plan in coordination with quality team and respective departments.

Assessment by DQAU/SQAU – DQAU and SQAU are also responsible for undertaking an independent quality
assessment of a health facility. Facilities having poor quality indicators would have priority in the assessment
programme. Visit for the assessment should also be utilised for building facility level capacity of quality assurance and
handholding. Efforts should be made to ensure that all departments of the hospital have been assessed during one
visit. Assessment process is shown in Figure 2.
Figure 2: Assessment Process

Assessment Plan
& Schedule and its Constitution of Conducting Conclusion & Dissmenination and
communication Assessment Team Assessment scoring Action Planing

C. Constituting assessment team

Assessment team should be constituted according to the scope of assessment i.e. departments to be assessed. Team
assessing clinical department should have at least one person form clinical domain preferably a doctor, assessing
patient care departments. Indoor departments should also have one nursing staff in the team. It would be preferable
to have a multidisciplinary team having at least one doctor and one nurse during the external assessment. As DQAU/
SQAU may not have their own capacity for arranging all team members internally, a person form another hospital
may be nominated to be part of the assessment team. However, it needs to be ensured that person should not assess
his/her own department and there is no conflict of interest. For external assessment, the team members should have
undergone the assessors’ training.

D. Preparing assessment schedule

Assessment schedule is micro-plan for conducting assessment. It constitutes of details regarding departments, date,
timing, etc. Assessment schedule should be prepared beforehand and shared with respective departments.

E. Performing Assessment –
i. Pre-assessment preparation – Team leader of the assessment team should ensure that assessment schedule has been
communicated to respective departments. Team leader should assign the area of responsibility to each team member,
according to the schedule and competency of the members.
ii. Opening meeting – A short opening meeting with the assessee’s department or hospital should be conducted for
introduction, aims & objective of the assessment and role clarity.
iii. Reviewing documents – The available records and documents such as SOPs, BHT, Registers, etc should be reviewed.

F. Communication during assessment

Behaviours and communication of the assessors should be polite and empathetic. Assessment should be fact finding
exercise and not a fault finding exercise. Conflicts should be avoided.

12 National Quality Assurance Standards for Public Health Facilities | 2018

 G. Using checklists
Checklists are the main tools for the assessment. Hence, familiarity with the tools would be important -

Figure 3: Sample checklist*.

a
Checklist for Accident & Emergency
Reference Measurement Checkpoint Compli- Assess- Means of Verification
No. Element ance ment
Method
b
Standard A1
Area of Concern - A Service Provision
The facility provides Curative Services
d
ME A1.1. The facility provides Availability of Emergency SI/OB Poisoning, Snake Bite, CVA,

c
General Medicine Medical Procedures g Acute MI, ARF, Hypovolumic
services
e f h Shock, Dysnea, Unconsious
Patients
h
ME A1.2. The facility provides Availability of Emergency SI/OB Appendicitis, Rupture spleen,
General Surgery Surgical Procedures Intestinal Obstruction, Assault
services Injuries, perforation, Burns
ME A1.3. the facility provides Availability of Emergency SI/OB APH, PPH, Eclampsia,
Obstetrics & Obstertics & Gynaecology Obstructed labour, Septic
Gynaecology Services Procedures abortion, Emergency
Contraceptives
ME A1.4. Availability of emergency SI/OB ARI, Diarrheal diseases,
Pediatric procedures Hypothermia, PEM, reucitation
* - ME denotes measurable elements of a standard, for which details have been provided in the Annexure ‘A’.
a) Header of the checklist denotes the name of department for which checklist is intended.
b) The horizontal bar in grey colour contains the name of the Area of concern for which the underlying standards belong.
c) Extreme left column of checklist in blue colour contain the reference no. of Standard and Measurable Elements, which can used for the identification
and traceability of the standard. When reporting or quoting, reference no of the standard and measurable element should also be mentioned.
d) Yellow horizontal bar contains the statement of standard which is being measured. There are a total of seventy standards, but all standards may not
be applicable to every department, so only relevant standards are given in yellow bars in the checklists.
e) Second column contains text of the measurable element for the respective standard. Only applicable measurable elements of a standard are shown in
the checklists. Therefore, all measurable elements under a standard are not there in the departmental check-lists. They have been excluded because
they are not relevant to that department.
f) Next right to measurable elements are given the check points to measure the compliance to respective measurable element and the standard. It is the
basic unit of measurement, against which compliance is checked and the score is awarded.
g) Right next to Checkpoint is a blank column for noting the findings of assessment, in term of Compliance – Full, Partial or and Non Compliance.
h) Next to compliance column is the assessment method column. This denotes the ‘HOW’ to gather the information. Generally, there are four primary
methods for assessment - SI means staff interview, OB means observation, RR means record review & PI - Patient Interview.
i) Column next to assessment method contains means of verification. It denotes what to see at a Checkpoint. It may be list of equipment or procedures
to be observed, or question you have to ask or some benchmark, which could be used for comparison, or reference to some other guideline or legal
document. It has been left blank, as the check point is self-explanatory.

Assessor should gather information and evidences to assess compliance to the requirement of measurable element
and checkpoints at Health Facility being assessed. Information can be gathered by following four methods
i. Observation– Compliance to many of the measurable elements can be assessed by directly observing the articles, processes
and surrounding environment. Few examples are given below -
a) Enumeration of articles like equipment, drugs, etc
b) Displays of signages, work instructions, important information
c) Facilities - patient amenities, ramps, complaint-box, etc.
d) Environment – cleanliness, loose-wires, seepage, overcrowding, temperature control, drains, etc
e) Procedures like measuring BP, counselling, segregation of biomedical waste,

Components of Quality Measurement System and their Intent 13

ii. Record Review – It may not be possible to observe all clinical procedures. Records also generate objective evidences, which
need to be triangulated with finding of the observation. For example on the day of assessment, drug tray in the labour room
may have adequate quantity of Oxytocin, but if review of the drug expenditure register reveals poor consumption pattern of
Oxytocin, then more enquiries would be required to ascertain on the adherence to protocols in the labour room. Examples
of the record review are given below -
a) Review of clinical records - delivery note, anaesthesia note, maintenance of treatment chart, operation notes, etc.
b) Review of department registers like admission registers, handover registers, expenditure registers, etc.
c) Review of licenses, formats for legal compliances like Blood bank license and Form ‘F’ for PNDT
d) Review of SOPs for adequacy and process
e) Review of monitoring records – TPR chart, Input/output chart, culture surveillance report, calibration records, etc
f) Review of department data and indicators
iii. Staff interview –Interaction with the staff helps in assessing the knowledge and skill level, required for performing job functions.
Examples -
a) Competency testing – Quizzing the staff on knowledge related to their job
b) Demonstration – Asking staff to demonstrate certain activities like hand-washing technique, new born resuscitation, etc.
c) Awareness - Asking staff about awareness off patients’ right, quality policy, handling of high alerts drugs, etc.
d) Attitude about patient’s dignity and gender issues.
e) Feedback about adequacy of supplies, problems in performing work, safety issues, etc.
iv. Patient / Client Interview– Interaction with patients/clients may be useful in getting information about quality of services
and their experience in the hospital. It gives us users’ perspective. It should include -
a) Feedback on quality of services staff behaviour, food quality, waiting times, etc.
b) Out of pocket expenditure incurred during the hospitalisation
c) Effective of communication like counselling services and self drug administration

Assessor may use one these method to asses certain measurable element. Suggestive methods have been given in the
Assessment method column against each checkpoint Means of verification has been given against each checkpoint.
Normal flow of gathering information assessment would be as given in Figure 4 -

Figure 4: Flow of Information

Familiarise with Measurable element and Checkpoint

Understand the Assesment method and Means of

verification

Gather the information & Evidence

Compare with checkpoint and means of verification

Arrive at a conclusion for compliance

14 National Quality Assurance Standards for Public Health Facilities | 2018

H. Assessment conclusion
After gathering information and evidence for measurable elements, assessors should arrive at a conclusion for extent
of compliance - full, partial or non-compliance for each of the checkpoints. If the information and evidence collected
gives an impression of not fully meeting the requirements, it could be given ‘Partial compliance’, provided there some
evidences pointing towards the complaince. Non-compliance should be given of none or very few of the requirements
are being met.
After arriving on conclusion, assessor should mark ‘C’ for compliance, ‘P’ for partial compliance and ‘N’ for non-
compliance in Compliance column.

Components of Quality Measurement System and their Intent 15

Intent of Standards &
Measurable Elements

Intent of Standards & Measurable Elements 17

 Intent of standards AND Measurable
elements for District Hospital

Area of Concern - A : Service Provision

Overview
Apart from the curative services that district hospitals provides, Public hospitals are also mandated to provide
preventive and promotive services. Reproductive and Child Health services are now grouped as RMNCH+A,
which are major chunk of the services. These services are also priority for the government, so as to have direct
impact on the key indicators such as MMR and IMR.
This area of concern measures availability of services. “Availability” of functional services means service is available
to end-users because mere availability of infrastructure or human resources does not always ensure into availability
of the services. For example, a facility may have functional OT, Blood Bank, and availability of Obstetrician and
Anaesthetist, but it may not be providing CEmOC services on 24x7 basis. The facility may have functional Dental
Clinic, but if there are hardly any procedures undertaken at the clinic, it may be assumed that the services are either
not available or non-accessible to users. Compliance to these standards and measurable elements should be checked,
preferably by observing delivery of the services, review of records and checking utilisation of the service.
Compliance to following standards ensures that the health facility is addressing this area of concern:

Standard A1 The standard would include availability of OPD consultation, Indoor services
The facility provides Curative and Surgical procedures, Intensive care and Emergency Care under different
Services specialities e. g. Medicine, Surgery, Orthopaedics, Paediatrics etc. Each measurable
element under this standard measures one speciality across the departments.
For Example, ME A1.2 measures availability of emergency surgical procedures in
Accident & Emergency department, availability of General surgery clinic at OPD,
Availability of surgical procedures in Operation theatre and availability of indoors
services for surgery patients in wards.
Standard A2 This standard measures availability of Reproductive, Maternal, Newborn, Child
The facility provides RMNCHA and Adolescent services in different departments of the hospital. Each aspect of
Services RMNCH+A services is covered by one measurable element of this standard.
Standard A3 It covers availability of Laboratory, Radiology and other diagnostics services in
The facility Provides the respective departments.
diagnostic Services
Standard A4 This standard measures availability of the services at health facility under different
The facility provides services National Health Programmes such as RNTCP, NVBDCP, etc. One Measurable
as mandated in national element has been assigned to each National Health Programme.
Health Programmes/ state
scheme
Standard A5 The standard measures availability of support services like dietary, laundry
The facility provides support and housekeeping services at the facility.
services
Standard A6 The standard mandates availability of the services according to specific
Health services provided at local health needs. Different geographical area may have certain health
the facility are appropriate to problems, which are prevalent locally.
community needs

Intent of Standards & Measurable Elements 19

Measurable Elements
Area of Concern - A: Measurable Elements Service Provision
Standard A1 The facility provides Curative Services
ME A1.1 The facility provides General Medicine services
ME A1.2 The facility provides General Surgery services
ME A1.3 The facility provides Obstetrics & Gynaecology Services
ME A1.4 The facility provides Paediatric Services
ME A1.5 The facility provides Ophthalmology Services
ME A1.6 The facility provides ENT Services
ME A1.7 The facility provides Orthopaedics Services
ME A1.8 The facility provides Skin & VD Services
ME A1.9 The facility provides Psychiatry Services
ME A1.10 The facility provides Dental Treatment Services
ME A1.11 The facility provides AYUSH Services
ME A1.12 The facility provides Physiotherapy Services
ME A1.13 The facility provides services for OPD procedures
ME A1.14 Services are available for the time period as mandated
ME A1.15 The facility provides services for Super specialties, as mandated
ME A1.16 The facility provides Accident & Emergency Services
ME A1.17 The facility provides Intensive care Services
ME A1.18 The facility provides Blood bank & transfusion services
Standard A2 The facility provides RMNCHA Services
ME A2.1 The facility provides Reproductive health Services
ME A2.2 The facility provides Maternal health Services
ME A2.3 The facility provides Newborn health Services
ME A2.4 The facility provides Child health Services
ME A2.5 The facility provides Adolescent health Services
Standard A3 The facility provides diagnostic Services
ME A3.1 The facility provides Radiology Services
ME A3.2 The facility provides Laboratory Services
ME A3.3 The facility provides other diagnostic services, as mandated
Standard A4 The facility provides services as mandated in National Health Programmes/State Scheme
ME A4.1 The facility provides services under National Vector Borne Disease Control Programme as per
guidelines
ME A4.2 The facility provides services under Revised National TB Control Programme as per guidelines
ME A4.3 The facility provides services under National Leprosy Eradication Programme as per guidelines
ME A4.4 The facility provides services under National AIDS Control Programme as per guidelines

20 National Quality Assurance Standards for Public Health Facilities | 2018

ME A4.5 The facility provides services under National Programme for control of Blindness as per guidelines
ME A4.6 The facility provides services under Mental Health Programme as per guidelines
ME A4.7 The facility provides services under National Programme for the health care of the elderly as per
guidelines
ME A4.8 The facility provides services under National Programme for Prevention and control of Cancer,
Diabetes, Cardiovascular diseases & Stroke (NPCDCS) as per guidelines
ME A4.9 The facility provides services under Integrated Disease Surveillance Programme as per Guidelines
ME A4.10 The facility provides services under National health Programme for deafness
ME A4.11 The facility provides services as per State specific health programmes
ME A4.12 The facility provides services as per Rashtriya Bal Swasthya Karykram
Standard A5 The facility provides support services
ME A5.1 The facility provides dietary services
ME A5.2 The facility provides laundry services
ME A5.3 The facility provides security services
ME A5.4 The facility provides housekeeping services
ME A5.5 The facility ensures maintenance services
ME A5.6 The facility provides pharmacy services
ME A5.7 The facility has services of medical record department
ME A5.8 The facility provides mortuary services
Standard A6 Health services provided at the facility are appropriate to community needs
ME A6.1 The facility provides curatives & preventive services for the health problems and diseases, prevalent
locally.
ME A6.2 There is a process for consulting community/or their representatives when planning or revising
scope of services of the facility.

Intent of Standards & Measurable Elements 21

 Area of Concern - B : Patient Rights

Overview
Mere availability of services does not serve the purpose until the services are accessible to the users, and
are provided with dignity and confidentiality. Access includes Physical access as well as financial access. The
Government has launched many schemes, such as JSSK, RBSK and RBSY, for ensuring that the service packages
are available cashless to different targeted groups. There are evidences to suggest that patients’ experience and
outcome improves, when they are involved in the care. So availability of information is critical for access as well
as enhancing patients’ satisfaction. Patients’ rights also include that health services give due consideration to
patients’ cultural and religious preferences.
Brief description of the standards under this area of concern are given below:

Standard B1 Standard B1 measures availability of the information about services and their
The facility provides the modalities to patients and visitors. Measurable elements under this standard
information to care seekers, check for availability of user-friendly signages, display of services available
attendants & community about and user charges, citizen charter, enquiry desk and access to his/her clinical
the available services and their records.
modalities
Standard B2 Standard B2 This standard ensure that the services are sensitive to gender,
Services are delivered in a cultural and religious needs. This standard also measures the physical access,
manner that is sensitive to and disa ble-friendliness of the services, such as availability of ramps and
gender, religious and cultural disable friendly toilets. Last measurable element of this standard mandates
needs, and there are no barriers for provision for affirmative action for vulnerable and marginalized patients
on account of physical economic, like orphans, destitute, terminally ill patients, victims of rape and domestic
cultural or social reasons. violence so they can avail health care service with dignity and confidence at
public hospitals.
Standard B3 Standard B3 This standard measures the patient friendliness of the services
The facility maintains privacy, in terms of ensuring privacy, confidentiality and dignity. Measurable elements
confidentiality & dignity of under this standard check for provisions of screens and curtains, confidentiality
patient, and has a system for of patients’ clinical information, behaviour of service providers, and also
guarding patient related ensuring specific precautions to be taken, while providing care to patients
information with HIV infection, abortion, teenage pregnancy, etc.
Standard B4 Standard B4 This standard mandates that health facility has procedures
The facility has defined and of informing patients about their rights, and actively involves them in the
established procedures for decision-making about their treatment. Measurable elements in this standards
informing patients about the look for practices such informed consent, dissemination of patient rights and
medical condition, and involving how patients are communicated about their clinical conditions and options
them in treatment planning, and available. This standard also measures for procedure for grievance redressal.
facilitates informed decision Compliance to these standards can be checked through review of records
making for consent, interviewing staff about their awareness of patients’ rights,
interviewing patients whether they had been informed of the treatment plan
and available options.
Standard B5 Standard B5 This standard majorly checks that there are no financial barriers
The facility ensures that there to the services. Measurable elements under this standard check for availability
is no financial barrier to access, of drugs, diagnostics and transport free of cost under different schemes,
and that there is financial and timely payment of the entitlements under JSY and Family planning
protection given from the cost of incentives.
hospital services

22 National Quality Assurance Standards for Public Health Facilities | 2018

Standard B6 Public Health faculties have been instituted for providing health care services for the
Facility has defined larger good and welfare of community. Apart from providing health care services,
framework for ethical the public health facilities have a statutory obligation to conduct medico-legal
management including examinations, post-mortems, facilitate dispensation justice as required by the law,
dilemmas confronted issuing medical certificates and implement government health policies. It is of utmost
during delivery of services importance that public health facilities portray highest standards for ethical practices
at public health facilities in clinical care and governance.
This standard requires the facility to adhere to Ethical norms, and a pre-defined code of
conduct is followed by its staff. Preferably code of conducts should be communicated
to the staff in form of written instructions. This may include do’s and don’t while
performing their duties. These norms should broadly encompass provider’s duty
to sick, doing ‘no-harm’, keeping privacy, confidentiality and autonomy of patients,
non-discrimination and equity. Ethical norms should be in consonance with Code of
Medial Ethics and Code of Nursing ethics released by the Indian Medical Council and
Indian Nursing Council respectively.
While providing the services, the providers may confront ethical dilemmas. These
may arise from patient’s refusal to receive treatment, withdrawal of life support,
prescribing drugs that doctor found more effective but are not part of essential
drug list, entertaining representatives of pharmaceuticals companies at workplace,
sharing data with research purposes where consent has not been taken from
patients, etc. to address these ethical dilemmas effectively and within the legal
parameters, the health facility should develop and implement a framework to
address ethical dilemmas.
Initially the facility should identify the situations, where ethical dilemma usually arise
or have potential to arise. Second facility should appoint a person or group that
will address such issues of ethical dilemma, and will endeavour to timely resolve
it. The mechanism of referral of such issues to appointed person on group should
be defined and effectively communicated to concerned staff. These standards are
targeted for secondary and primary care public hospital; those are not usually not
involved research activities. However, if any health care facility is involved in clinical
or public health research activity, it should take formal approval for research ethics
committee.

Intent of Standards & Measurable Elements 23

 Area of Concern - B: Measurable Elements Patient Rights
Standard B1 The facility provides the information to care seekers, attendants & community about the
available services and their modalities.
ME B1.1 The facility has uniform and user-friendly signage system.
ME B1.2 The facility displays the services and entitlements available in its departments.
ME B1.3 The facility has established citizen charter, which is followed at all levels.
ME B1.4 User charges are displayed and communicated to patients effectively.
ME B1.5 Patients & visitors are sensitised and educated through appropriate IEC/BCC approaches.
ME B1.6 Information is available in local language and easy to understand.
ME B1.7 The facility provides information to patients and visitor through an exclusive
set-up.
ME B1.8 The facility ensures access to clinical records of patients to entitled personnel.
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and cultural needs,
and there are no barriers on account of physical economic, cultural or social reasons.
ME B2.1 Services are provided in manner that are sensitive to gender.
ME B2.2 Religious and cultural preferences of patients and attendants are taken into consideration while
delivering services.
ME B2.3 Access to facility is provided without any physical barrier & friendly to people with disability.
ME B2.4 There is no discrimination on basis of social & economic status of patients.
ME B2.5 There is affirmative action to ensure that vulnerable sections can access services.
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for
guarding patient related information.
ME B3.1 Adequate visual privacy is provided at every point of care.
ME B3.2 Confidentiality of patients records and clinical information is maintained.
ME B3.3 The facility ensures the behaviours of staff is dignified and respectful, while delivering the services.
ME B3.4 The facility ensures privacy and confidentiality to every patient, especially of those conditions having
social stigma, and also safeguards vulnerable groups.
Standard B4 The facility has defined and established procedures for informing patients about the medical
condition, and involving them in treatment planning, and facilitates informed decision
making.
ME B4.1 There is established procedures for taking informed consent before treatment and procedures.
ME B4.2 Patient is informed about his/her rights and responsibilities.
ME B4.3 Staff are aware of Patients rights responsibilities.
ME B4.4 Information about the treatment is shared with patients or attendants, regularly.
ME B4.5 The facility has defined and established grievance redressal system in place.
Standard B5 The facility ensures that there is no financial barrier to access, and that there is financial
protection given from the cost of hospital services.
ME B5.1 The facility provides cashless services to pregnant women, mothers and neonates as per prevalent
government schemes.
ME B5.2 The facility ensures that drugs prescribed are available at Pharmacy and wards.

24 National Quality Assurance Standards for Public Health Facilities | 2018

ME B5.3 It is ensured that facilities for the prescribed investigations are available at the facility.
ME B5.4 The facility provide free of cost treatment to Below poverty line patients without administrative
hassles.
ME B5.5 The facility ensures timely reimbursement of financial entitlements and reimbursement to the
patients.
ME B5.6 The facility ensure implementation of health insurance schemes as per National /state scheme.
Standard B6 The facility has defined framework for ethical management including dilemmas confronted
during delivery of services at public health facilities.
ME B6.1 Ethical norms and code of conduct for medical and paramedical staff have been established.
ME B6.2 The facility staff is aware of code of conduct established.
ME B6.3 The facility has an established procedure for entertaining representatives of drug companies and
suppliers.
ME B6.4 The facility has an established procedure for medical examination and treatment of individual under
judicial or police detention as per prevalent law and government directions.
ME B6.5 There is an established procedure for sharing of hospital/patient data with individuals and external
agencies including non governmental organization.
ME B6.6 There is an established procedure for ‘end-of-life’ care.
ME B6.7 There is an established procedure for patients who wish to leave hospital against medical advice or
refuse to receive specific treatment.
ME B6.8 There is an established procedure for obtaining informed consent from the patients in case facility is
participating in any clinical or public health research.
ME B6.9 There is an established procedure to issue of medical certificates and other certificates.
ME B6.10 There is an established procedure to ensure medical services during strikes or any other mass protest
leading to dysfunctional medical services.
ME B6.11 An updated copy of code of ethics under Indian Medical council act is available with the facility.

Intent of Standards & Measurable Elements 25

 Area of concern - C : Input

Overview
This area of concern predominantly covers the structural part of the facility. Indian Public Health Standards
(IPHS) defines infrastructure, human resources, drugs and equipment requirements for different level of health
facilities. Quality standards given in this area of concern take into cognizance of the IPHS requirement. However,
focus of the standards has been in ensuring compliance to minimum level of inputs, which are required for
ensuring delivery of committed level of the services. The words like ‘adequate’ and ‘as per load‘ has been given
in the requirements for many standards & measurable elements, as it would be hard to set structural norms for
every level of the facility that commensurate with patient load. For example, a 100-bedded hospital having 40%
bed occupancy may not have same requirements as the similar hospital having 100% occupancy. So structural
requirement should be based more on the utilization, than fixing the criteria like beds available. Assessor should
use his/her discretion to arrive at a decision, whether available structural component is adequate for committed
service delivery or not.
Following are the standards under this area of concern:

Standard C1 Standard C1 measures adequacy of infrastructure in terms of space, patient amenities,

The facility has layout, circulation area, communication facilities, service counters, etc. It also looks
infrastructure for into the functional aspect of the structure, whether it commensurate with the process
delivery of assured flow of the facility or not.
services, and available
infrastructure meets the Minimum requirement for space, layout and patient amenities are given in some of
prevalent norms departments, but assessors should use his discretion to see whether space available
is adequate for the given work load. Compliance to most of the measurable elements
can be assessed by direct observation except for checking functional adequacy, where
discussion with staff and hospital administration may be required to know the process
flow between the departments, and also within a department.
Standard C2 Standard C2 deals with Physical safety of the infrastructure. It includes seismic safety,
The facility ensures the safety of lifts, electrical safety, and general condition of hospital infrastructure.
physical safety of the
infrastructure.
Standard C3 Standard C3 is concerned with fire safety of the facility. Measurable elements in this
The facility has established standard look for implementation of fire prevention, availability of adequate number
Programme for fire safety of fire fighting equipment and preparedness of the facility for fire disaster in terms of
and other disaster mock drill and staff training.
Standard C4 Standard C4 measures the numerical adequacy and skill sets of the staff. It includes
The facility has adequate availability of doctors, nurses, paramedics and support staff. It also ensures that the
qualified and trained staff, staff have been trained as per their job description and responsibilities. There are
required for providing the two components while assessing the staff adequacy - first is the numeric adequacy,
assured services to the which can be checked by interaction with hospital administration and review of
current case load records. Second is to access human resources in term of their availability within
the department. For instance, a hospital may have 20 security guards, but if none
of them is posted at the labour room, then the intent of standard is not being
complied with.
Skill set may be assessed by reviewing training records and staff interview
and demonstration to check whether staff have requisite skills to perform the
procedures.
Standard C5 Standard C5 measures availability of drugs and consumables in user departments.
The facility provides drugs Assessor may check availability of drugs under the broad group such as antibiotics,
and consumables required IV fluids, dressing material, and make an assessment that majority of normal patients
for assured services and critically ill patients are getting treated at the health facility.

26 National Quality Assurance Standards for Public Health Facilities | 2018

Standard C6 Standard C6 is also concerned with availability of instruments in various departments
The facility has equipment and service delivery points. Equipment and instruments have been categorized into
& instruments required for sub groups as per their use, and measurable elements have been assigned to each
assured list of services sub group, such as examination and monitoring, clinical procedures, diagnostic
equipment, resuscitation equipment, storage equipment and equipment used for non
clinical support services. Some representative equipment could be used as tracers
and checked in each category.
Standard C7 Human resources are the most critical asset of a healthcare organization. Public health
Facility has a defined facilities serve volumes of patients and sometime feel constrained by limited human
and established resources. For being a facility providing quality and safe healthcare services, it is
procedure for effective indispensable to ensure that the staff engaged in patient care and auxiliary activities
utilization, evaluation have requisite knowledge and skills to accomplish their task in the expected manner.
and augmentation It is also very important to ensure that workforce is working at optimal level and their
of competence and performance is evaluated periodically.
performance of staff
This standard and related measurable elements requirethat public health facility
should have defined staff’scompetency and have a system for assessing it periodically
at pre-defined interval, and takes actions for maintaining it. These criteria should
be based on job description as defined in Standard D-10. These defined criteria
can be converted into simple checklist that can work as tools for the competency
assessment e. g. Checklist for competency assessment of Labour room nurse, Lab
technician, Security guard, Hospital manager, etc. The Ministry of Health & Family
Welfare, Government of India also has prepared checklist for competence assessment.
In addition there are explicit requirement spelled by the professional bodies such
as Medical Council of India, Nursing Council of India, Dental Council of India, etc.
These can also be used after local customization. This standard also requires that
performance evaluation criteria should also be defined for each cadre of staff. These
criteria may have some indicators measuring productivity and efficiency of the staff
as well. Based on these defined criteria the competence and performance of staff
should be evaluated at least once in a year though it may be more frequent ongoing
activity. Competence assessment program and performance evaluation program
should include contractual staff, staff working in hospital premises through outsources
agencies, empanelled doctors providing services for specific duration. Based on these
assessment and evaluation, the training needs of each staff are identified and training
plan is prepared. Staff should be trained according to the training plan. Facility should
also ensure that skills gained through training are retained and utilized and feedback
is given to individual staff on their competence and performance.

Intent of Standards & Measurable Elements 27

 Area of Concern - C: Measurable Elements Inputs
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure
meets the prevalent norms.
ME C1.1 Departments have adequate space as per patient or work load.
ME C1.2 Patient amenities are provide as per patient load.
ME C1.3 Departments have layout and demarcated areas as per functions.
ME C1.4 The facility has adequate circulation area and open spaces according to need and local law.
ME C1.5 The facility has infrastructure for intramural and extramural communication.
ME C1.6 Service counters are available as per patient load.
ME C1.7 The facility and departments are planned to ensure structure follows the function/processes
(Structure commensurate with the function of the hospital).
Standard C2 The facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the seismic safety of the infrastructure.
ME C2.2 The facility ensures safety of lifts and lifts have required certificate from the designated bodies/
board.
ME C2.3 The facility ensures safety of electrical establishment.
ME C2.4 Physical condition of buildings are safe for providing patient care.
Standard C3 The facility has established Programme for fire safety and other disaster.
ME C3.1 The facility has plan for prevention of fire.
ME C3.2 The facility has adequate fire fighting Equipment.
ME C3.3 The facility has a system of periodic training of staff and conducts mock drills regularly for fire and
other disaster situation.
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured
services to the current case load.
ME C4.1 The facility has adequate specialist doctors as per service provision.
ME C4.2 The facility has adequate general duty doctors as per service provision and work load.
ME C4.3 The facility has adequate nursing staff as per service provision and work load.
ME C4.4 The facility has adequate technicians/paramedics as per requirement.
ME C4.5 The facility has adequate support/general staff.
Standard C5 The facility provides drugs and consumables required for assured services.
ME C5.1 The departments have availability of adequate drugs at point of use.
ME C5.2 The departments have adequate consumables at point of use.
ME C5.3 Emergency drug trays are maintained at every point of care, where ever it may be needed.
Standard C6 The facility has equipment & instruments required for assured list of services.
ME C6.1 Availability of equipment & instruments for examination & monitoring of patients.
ME C6.2 Availability of equipment & instruments for treatment procedures, being undertaken in the facility.
ME C6.3 Availability of equipment & instruments for diagnostic procedures being undertaken in the facility.
ME C6.4 Availability of equipment and instruments for resuscitation of patients and for providing intensive
and critical care to patients.

28 National Quality Assurance Standards for Public Health Facilities | 2018

ME C6.5 Availability of Equipment for Storage.
ME C6.6 Availability of functional equipment and instruments for support services.
ME C6.7 Departments have patient furniture and fixtures as per load and service provision.
Standard C7 The facility has a defined and established procedure for effective utilization, evaluation and
augmentation of competence and performance of staff
ME C7.1 Criteria for Competence assessment are defined for clinical and Para clinical staff.
ME C7.2 Competence assessment of Clinical and Para clinical staff is done on predefined criteria at least once
in a year.
ME C7.3 Criteria for performance evaluation clinical and para clinical staff are defined.
ME C7.4 Performance evaluation of clinical and para clinical staff is done on predefined criteria at least once
in a year
ME C7.5 Criteria for performance evaluation of support and administrative staff are defined.
ME C7.6 Performance evaluation of support and administration staff is done on predefined criteria at least
once in a year.
ME C7.7 Competence assessment and performance assessment includes contractual, empanelled, and
outsourced staff.
ME C7.8 Training needs are identified based on competence assessment and performance evaluation and
facility prepares the training plan.
ME C7.9 The Staff is provided training as per defined core competencies and training plan.
ME C7.10 There is established procedure for utilization of skills gained thought trainings by on -job supportive
supervision.
ME C7.11 Feedback is provided to the staff on their competence assessment and performance evaluation.

Intent of Standards & Measurable Elements 29

 Area of Concern - D : Support services

Overview
Support services are backbone of every health care facility. The expected clinical outcome cannot be envisaged
in absence of sturdy support services. This area of concern includes equipment maintenance, calibration, drug
storage and inventory management, security, facility management, water supply, power backup, dietary services
and laundry. Administrative processes like RKS, Financial management, legal compliances, staff deputation and
contract management have also been included in this area of concern.
Brief description of the standards under this area of concern are given below:

Standard D1 Standard D1 is concerned with equipment maintenance processes, such as AMC,

The facility has established daily and breakdown maintenance processes, calibration and availability of operating
Programme for inspection, instructions. Equipment records should be reviewed to ensure that valid AMC is
testing and maintenance available for critical equipment and preventive / corrective maintenance is done
and calibration of timely. Calibration records and label on the measuring equipment should be reviewed
Equipment to confirm that the calibration has been done. Operating instructions should be
displayed or should readily available with the user.
Standard D2 Standard D2 is concerned with safe storage of drugs and scientific management of
The facility has defined the inventory, so drugs and consumables are available in adequate quantity in patient
procedures for storage, care area. Measurable elements of this standard look into processes of indenting,
inventory management procurement, storage, expired drugs management, inventory management, stock
and dispensing of drugs in management at patient care areas, including storage at optimum temperature.
pharmacy and patient care While assessing drug management system, these practices should be looked into
areas each clinical department, especially at the nursing stations and its complementary
process at drug stores/Pharmacy.
Standard D3 Standard D3 This standard is concerned with providing safe, secure and
The facility provides safe, comfortable environment to patients as well service providers. The measurable
secure and comfortable elements under this standard have two aspects, - firstly, provision of comfortable
environment to staff, work environment in terms of illumination and temperature control in patient
patients and visitors care areas and work stations, and secondly, arrangement for security of patients
and staff. Availability of environment control arrangements should be looked
into. Security arrangements at patient area should be observed for restriction of
visitors and crowd management.
Standard D4 Standard D4 This standard is concerned with adequacy of facility management
The facility has established processes. This includes appearance of facility, cleaning processes, infrastructure
Programme for maintenance, removal of junk and condemned items and control of stray animals and
maintenance and upkeep of pest control at the facility.
the facility
Standard D5 Standard D5 covers processes to ensure water supply (quantity & quality), power
The facility ensures 24X7 back-up and medical gas supply. All departments should be assessed for availability
water and power backup as of water and power back-up. Some critical area like OT and ICU may require two-tire
per requirement of service power backup in terms of UPS. Availability of central oxygen and vacuum supply
delivery, and support should especially be assessed in critical area like OT and ICU.
services norms
Standard D6 Standard D6 is concerned with processes ensuring timely and hygienic dietary
Dietary services are services. This includes nutritional assessment of patients, availability of different types
available as per service of diets and standard procedures for preparation and distribution of food, including
provision and nutritional hygiene & sanitation in the kitchen. Patients / staff may be interacted for knowing
requirement of the their perception about quality and quantity of the food.
patients

30 National Quality Assurance Standards for Public Health Facilities | 2018

Standard D7 Standard D7 is concerned with the laundry processes. It includes availability of
The facility ensures clean adequate quantity of clean & usable linen, process of providing and changing bed
linen to the patients sheets in patient care area and process of collection, washing and distributing the
linen. Besides direct observation, staff interaction may help in knowing availability
of adequate linen and work practices. An assessment of segregation and disinfection
of soiled laundry should be undertaken. Observation should be recorded if laundry is
being washed at some public water body like pond or river.
Standard D8 Standard D8 measures processes related to functioning of Rogi Kalyan Samiti (RKS;
The facility has defined equivalent to Hospital Management Society) and community participation in Hospital
and established Management. RKS records should be reviewed to assess frequency of the meetings,
procedures for promoting and issues discussed there. Participation of non-official members like community/
public participation in NGO representatives in such meetings should be checked.
management of hospital
transparency and
accountability
Standard D9 Standard D9 is concerned with the financial management of the funds/grants,
Hospital has defined and received from different sources including NHM. Assessment of financial management
established procedures for processes by no means should be equated with financial or accounts audit. Hospital
Financial Management administration and accounts department can be interacted to know process of
utilization of funds, timely payment of salaries, entitlements and incentives to different
stakeholders and process of receiving funds and submitting utilization certificates. An
assessment of resource utilisation and prioritisation should be undertaken.
Standard D10 Standard D10 is concerned with compliances to statuary and regulatory requirements.
The facility is compliant It includes availability of requisite licenses, updated copies of acts and rules, and
with all statutory and adherence to the legal requirements as applicable to Public Health Facilities.
regulatory requirement
imposed by local, state or
central government
Standard D11 Standard D11 is concerned with processes regarding staff management and
Roles & Responsibilities of their deployment in the departments of a facility. This includes availability of Job
administrative and clinical descriptions for different cadre, processes regarding preparation of duty rosters and
staff are determined as staff discipline. The staff can be interviewed to assess about their awareness of their
per govt. regulations own job description. It should be assessed by observation and review of the records.
and standards operating Adherence to dress-code should be observed during the assessment.
procedures
Standard D12 Standard D12 This standard measures the processes related to outsourcing and
The facility has established contract management. This includes monitoring of outsourced services, adequacy of
procedure for monitoring contact documents and tendering system, timely payment for the availed services and
the quality of outsourced provision for action in case for inadequate/ poor quality of services. Assessor should
services and adheres to review the contract records related to outsourced services, and interview hospital
contractual obligations administration about the management of outsource services.

Intent of Standards & Measurable Elements 31

 Area of Concern - D: Measurable Elements Support Services
Standard D1 The facility has established Programme for inspection, testing and maintenance and
calibration of Equipment.
ME D1.1 The facility has established system for maintenance of critical Equipment.
ME D1.2 The facility has established procedure for internal and external calibration of measuring Equipment.
ME D1.3 Operating and maintenance instructions are available with the users of equipment.
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of
drugs in pharmacy and patient care areas.
ME D2.1 There is established procedure for forecasting and indenting drugs and consumables.
ME D2.2 The facility has established procedure for procurement of drugs.
ME D2.3 The facility ensures proper storage of drugs and consumables.
ME D2.4 The facility ensures management of expiry and near expiry drugs.
ME D2.5 The facility has established procedure for inventory management techniques.
ME D2.6 There is a procedure for periodically replenishing the drugs in patient care areas.
ME D2.7 There is a process for storage of vaccines and other drugs, requiring controlled temperature.
ME D2.8 There is a procedure for secure storage of narcotic and psychotropic drugs.
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and
visitors.
ME D3.1 The facility provides adequate illumination at patient care areas.
ME D3.2 The facility has provision of restriction of visitors in patient areas.
ME D3.3 The facility ensures safe and comfortable environment for patients and service providers.
ME D3.4 The facility has security system in place in patient care areas.
ME D3.5 The facility has established measure for safety and security of female staff.
Standard D4 The facility has established Programme for maintenance and upkeep of the facility.
ME D4.1 Exterior and interior of the facility building is maintained appropriately
ME D4.2 Patient care areas are clean and hygienic.
ME D4.3 Hospital infrastructure is adequately maintained.
ME D4.4 Hospital maintains open areas and landscaped of them.
ME D4.5 The facility has policy of removal of condemned junk material.
ME D4.6 The facility has established procedures for pest, rodent and animal control.
Standard D5 The facility ensures 24 × 7 water and power backup as per requirement of service delivery,
and support services norms.
ME D5.1 The facility has adequate arrangement storage and supply for potable water in all functional areas.
ME D5.2 The facility ensures adequate power backup in all patient care areas as per load.
ME D5.3 Critical areas of the facility ensures availability of oxygen, medical gases and vacuum supply.
Standard D6 Dietary services are available as per service provision and nutritional requirement of the
patients.
ME D6.1 The facility has provision of nutritional assessment of the patients.
ME D6.2 The facility provides diets according to nutritional requirements of the patients.

32 National Quality Assurance Standards for Public Health Facilities | 2018

ME D6.3 Hospital has standard procedures for preparation, handling, storage and distribution of diets, as per
requirement of patients.
Standard D7 The facility ensures clean linen to the patients.
ME D7.1 The facility has adequate availability of linen for meeting its need.
ME D7.2 The facility has established procedures for changing of linen in patient care areas
ME D7.3 The facility has standard procedures for handling, collection, transportation and washing of linen.
Standard D8 The facility has defined and established procedures for promoting public participation in
management of hospital transparency and accountability.
ME D8.1 The facility has established a procedure for management of activities of Rogi Kalyan Samiti.
ME D8.2 The facility has established procedures for community based monitoring of its services.
Standard D9 Hospital has defined and established procedures for Financial Management.
ME D9.1 The facility ensures proper utilization of the fund provided to it.
ME D9.2 The facility ensures proper planning and requisition of resources based on its need.
Standard D10 The facility is compliant with all statutory and regulatory requirement imposed by local,
state or central government.
ME D10.1 The facility has requisite licences and certificates for operation of hospital and its different activities.
ME D10.2 Updated copies of relevant laws, regulations and government orders are available at the facility.
ME D10.3 The facility ensures relevant processes are in compliance with the statutory requirements.
Standard D11 Roles & Responsibilities of administrative and clinical staff are determined as per govt.
regulations and standards operating procedures.
ME D11.1 The facility has established job description as per govt guidelines.
ME D11.2 The facility has a established procedure for duty roster and deputation to different departments.
ME D11.3 The facility ensures adherence to dress code as mandated by the administration.
Standard D12 The facility has established procedure for monitoring the quality of outsourced services and
adheres to contractual obligations.
ME D12.1 There is established system of contract management for the out sourced services.
ME D12.2 There is a system of periodic review of quality of out-sourced services.

Intent of Standards & Measurable Elements 33

 Area of Concern - E : Clinical Care

Overview
The ultimate purpose of existence of a hospital is to provide clinical care. Therefore, clinical processes are the
most critical and important in the hospitals. These are the processes that define directly the outcome of services
and quality of care. The Standards under this area of concern could be grouped into three categories. First,
nine standards are concerned with those clinical processes that ensure adequate care to the patients. It includes
processes such as registration, admission, consultation, clinical assessment, continuity of care, nursing care,
identification of high risk and vulnerable patients, prescription practices, safe drug administration, maintenance
of clinical records and discharge from the hospital.
Second set of next seven standards are concerned with specific clinical and therapeutic processes including intensive
care, emergency care, diagnostic services, transfusion services, anaesthesia, surgical services and end of life care.
The third set of seven standards are concerned with specific clinical processes for Maternal, Newborn, Child,
Adolescent & Family Planning services and National Health Programmes. These standards are based on the
technical guidelines published by the Government of India on respective programmes and processes.
It may be difficult to assess clinical processes, as direct observation of clinical procedure may not always be possible
at time of assessment. Therefore, assessment of these standards would largely depend upon review of the clinical
records as well. Interaction with the staff to know their skill level and how they practice clinical care (Competence
testing) would also be helpful. Assessment of theses standard would require thorough domain knowledge.
Following is the brief description of standards under this area of concern:

Standard E1 Standard E1 This standard is concerned with the registration and admission
The facility has defined processes in hospitals. It also covers OPD consultation processes. The Assessor
procedures for registration, should review the records to verify that details of patients have been recorded, and
consultation and admission patients have been given unique identification number. OPD consultation may be
of patients directly observed, followed by review of OPD tickets to ensure that patient history,
examination details, etc. have been recorded on the OPD ticket. Staff should be
interviewed to know, whether there is any fixed admission criteria especially in
critical care department.
Standard E2 Standard E2 This standard pertains to clinical assessment of the patients. It includes
The facility has defined and initial assessment as well as reassessment of admitted patients.
established procedures for
clinical assessment and
reassessment of the patients
Standard E3 Standard E3 is concerned with continuity of care for the patient’s ailment. It includes
The facility has defined and process of inter-departmental transfer, referral to another facility, deputation of staff
established procedures for for the care, and linkages with higher institutions. Staff should be interviewed to
continuity of care of patient know the referral linkages, how they inform the referral hospital about the referred
and referral patients and arrangement for the vehicles and follow-up car. Records should be
reviewed for confirming that referral slips have been provided to the patients.
Standard E4 Standard E4 measures adequacy and quality of nursing care for the patients. It
The facility has defined and includes processes for identification of patients, timely and accurate implementation
established procedures for of treatment plan, nurses’ handover processes, maintenance of nursing records and
nursing care monitoring of the patients. Staff should be interviewed and patients’ records should
be reviewed for assessing how drugs distribution/ administration endorsement and
other procedures like sample collection and dressing have been done on time as per
treatment plan. Handing-over of patients is a critical process and should be assessed
adequately. Review BHT for patient monitoring & nursing notes should be done.
Standard E5 Standard E5 is concerned with identification of vulnerable and High-risk patients.
The facility has a procedure Review of records and staff interaction would be helpful in assessing how High-risk
to identify high risk and patients are given due attention and treatment.
vulnerable patients

34 National Quality Assurance Standards for Public Health Facilities | 2018

Standard E6 Standard E6 is concerned with assessing that patients are prescribed drugs
The facility follows standard according standard treatment guidelines and protocols. Patient records are assessed
treatment guidelines defined to ascertain that prescriptions are written in generic name only.
by state/Central government
for prescribing the generic
drugs & their rational use
Standard E7 Standard E7 concerns with the safety of drug administration. It includes
The facility has defined administration of high alert drugs, legibility of medical orders, process for checking
procedures for safe drug drugs before administration and processes related to self-drug administration.
administration Patient’s records should be reviewed for legibility of the writing and recording
of date and time of orders. Safe injection practices like use of separate needle for
multi-dose vial should be observed.
Standard E8 Standard E8 is concerned with the processes of maintaining clinical records
The facility has defined and systematically and adequately. Compliance to this standard can be assessed by
established procedures for comprehensive review of the patients’ record.
maintaining, updating of
patients’ clinical records and
their storage
Standard E9 Standard E9 measures adequacy of the discharge process. It includes pre-discharge
The facility has defined and assessment, adequacy of discharge summary, pre-discharge counselling and
established procedures for adherence to standard procedures, if a patient is leaving against medical advice
discharge of patient. (LAMA) or is found absconding. Patients’ record should also be reviewed for
adequacy of the discharge summary.
Standard E10 Standard E10 is concerned with processes related to intensive care treatment of
The facility has defined and patients, availability and adherence to protocols related to pain management,
established procedures for sedation, intubation, etc.
intensive care.
Standard E11 Standard E11 is concerned with emergency clinical processes and procedures. It
The facility has defined and includes triage, adherence to emergency clinical protocols, disaster management,
established procedures for processes related to ambulance services, handling of medico-legal cases, etc.
Emergency Services and Availability of the buffer stock for medicines and other supplies for disaster and mass
Disaster Management casualty needs to be found out. Interaction with staff and hospital administration
should be done to asses overall disaster preparedness of the health facility.
Standard E12 Standard E12 deals with the procedures related to diagnostic services. The standard is
The facility has defined and majorly applicable for laboratory and radiology services. It includes pre-testing, testing
established procedures of and post-testing procedures. It needs to be observed that samples in the laboratory are
diagnostic services properly labelled, and instructions for handling sample are available. The process for
storage and transportation of samples needs to be ensured. Availability of critical values
and biological references should also be checked.
Standard E13 Standard E13 is concerned with functioning of blood bank and transfusion services.
The facility has defined and The measurable elements under this standard are processes for donor selection,
established procedures collection of blood, testing procedures, preparation of blood components,
for Blood Bank/Storage labelling and storage of blood bags, compatibility testing, issuing, transfusion and
Management and Transfusion monitoring of transfusion reaction. The assessor should observe the functioning,
and interact with the staff to know regarding adherence to standard procedures for
blood collection and testing, including preparation of blood components, storage
practices, as per standard protocols. Record of temperature maintained in different
storage units should be checked. The staff should also be interacted to know how
they mange if certain blood is not available at the blood bank. Records should be
reviewed for assessing processes of monitoring transfusion reactions.
Standard E14 Standard E14 is concerned with the processes related with safe anaesthesia
The facility has established practices. It includes pre-anaesthesia, monitoring and post-anaesthesia processes.
procedures for Anaesthetic Records should be reviewed to assess how Pre-anaesthesia check-up is done and
Services records are maintained. Interact with Anaesthetists and OT technician/Nurse for
adherence to protocols in respect of anaesthesia safety, monitoring, recording &
reporting of adverse events, maintenance of anaesthesia notes, etc.

Intent of Standards & Measurable Elements 35

 Standard E15 Standard E15 is concerned with processes related with Operation Theatre. It includes
The facility has defined and processes for OT scheduling, pre-operative, Post-operative practices of surgical safety.
established procedures of Interaction with the surgeon(s) and OT staff should be done to assess processes -
Operation theatre services preoperative medication, part preparation and evaluation of patient before surgery,
identification of surgical site, etc. Review of records for usage of surgical safety checklist
& protocol for instrument count, suture material, etc may be undertaken.
Standard E16 Standard E 16 concerned with end of life care and management of death. Records
The facility has defined and should be reviewed for knowing adequacy of the notes. Interact with the facility
established procedures for staff to know how news of death is communicated to relatives, and kind of support
end of life care and death available to family members.
Standard E17 Standard E17 is concerned with processes ensuring that adequate and quality
The facility has established antenatal care is provided at the facility. It includes measurable elements for ANC
procedures for Antenatal registration, processes during check-up, identification of High Risk pregnancy,
care as per guidelines management of serve anaemia and counselling services. Staff at ANC clinic should
be interviewed and records should be reviewed for maintenance of MCP cards and
registration of pregnant women. For assessing quality and adequacy of ANC check-
up, direct observation may be undertaken after obtaining requisite permission.
ANC records can be reviewed to see findings of examination and diagnostic
tests are recorded. Review the line listing of anaemia cases and how they are
followed. Client and staff can be interacted for counselling on the nutrition, birth
preparedness, family planning, etc.
Standard E18 Standard E18 measures the quality of intra-natal care. It includes clinical process
The facility has established for normal delivery as well management of complications and C-Section surgeries.
procedures for Intranatal Staff can be interviewed to know their skill and practices regarding management of
care as per guidelines different stages of labour, especially Active Management of Third stage of labour.
Staff may be interacted for demonstration of resuscitation and essential newborn
care. Competency of the staff for managing obstetric emergencies, interpretation
of partograph, APGAR score should also be assessed.
Standard E19 Standard E19 is concerned with adherence to post-natal care of mother and
The facility has established newborn within the hospital. Observe that postnatal protocols of prevention of
procedures for postnatal Hypothermia and breastfeeding are adhered to. Mother may be interviewed to
care as per guidelines know that proper counselling has been provided.
Standard E20 Standards E20 is concerned with adherence to clinical protocols for newborn and
The facility has established child health. It covers immunization, emergency triage, management of newborn
procedures for care of new and childhood illnesses like neonatal asphyxia, low birth weight, neo-natal jaundice,
born, infant and child as per sepsis, malnutrition and diarrhoea. Immunization services are majorly assessed
guidelines at immunization clinic. Staff interview and observation should be done to assess
availability of diluents, adherence to protocols of reconstitution of vaccine, storage
of VVM labels and shake test. Adherence to clinical protocols for management of
different illnesses in newborn and child should be done through interaction with
the doctors and nursing staff.
Standard E21 Standard 21 is concerned with providing safe and quality family planning and
The facility has established abortion services. This includes standard practices and procedures for Family
procedures for abortion palling counselling, spacing methods, family planning surgeries and counselling
and family planning as per and procedures for abortion. Quality and adequacy of counselling services can be
government guidelines and assessed by exit interview with the clients. Staff at family planning clinic may be
law interacted to assess adherence to the protocols for IUD insertion, precaution &
contraindication for oral pills, family planning surgery, etc.
Standard E22 Standard E22 is concerned with services related to adolescent Reproductive and
The facility provides Sexual health (ARSH) guidelines. It includes promotive, preventive, curative and
Adolescent Reproductive and referral services under the ARSH. Staff should be interviewed, and records should
Sexual Health services as per be reviewed.
guideline
Standard E23 Standard E23 pertains to adherence for clinical guidelines under the National
The facility provides National Health Programmes. For each national health programme, availability of clinical
health Programme as services as per respective guidelines should be assessed
per operational/Clinical
Guidelines

36 National Quality Assurance Standards for Public Health Facilities | 2018

 Area of Concern - E: Measurable Elements Clinical Services
Standard E1 The facility has defined procedures for registration, consultation and admission of
patients.
ME E1.1 The facility has established procedure for registration of patients.
ME E1.2 The facility has a established procedure for OPD consultation.
ME E1.3 There is established procedure for admission of patients.
ME E1.4 There is established procedure for managing patients, in case beds are not available at
the facility.
Standard E2 The facility has defined and established procedures for clinical assessment and
reassessment of the patients.
ME E2.1 There is established procedure for initial assessment of patients.
ME E2.2 There is established procedure for follow-up/ reassessment of Patients.
Standard E3 The facility has defined and established procedures for continuity of care of patient and
referral.
ME E3.1 The facility has established procedure for continuity of care during interdepartmental transfer.
ME E3.2 The facility provides appropriate referral linkages to the patients/Services for transfer to other/
higher facilities to assure the continuity of care.
ME E3.3 A person is identified for care during all steps of care.
ME E3.4 The facility is connected to medical colleges through telemedicine services.
Standard E4 The facility has defined and established procedures for nursing care.
ME E4.1 Procedure for identification of patients is established at the facility.
ME E4.2 Procedure for ensuring timely and accurate nursing care as per treatment plan is established at the
facility.
ME E4.3 There is established procedure of patient hand over, whenever staff duty change happens.
ME E4.4 Nursing records are maintained.
ME E4.5 There is procedure for periodic monitoring of patients.
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients and ensure their safe care.
ME E5.2 The facility identifies high risk patients and ensure their care, as per their need.
Standard E6 The facility follows standard treatment guidelines defined by state/Central government for
prescribing the generic drugs & their rational use.
ME E6.1 The facility ensured that drugs are prescribed in generic name only.
ME E6.2 There is procedure of rational use of drugs.
Standard E7 The facility has defined procedures for safe drug administration.
ME E7.1 There is process for identifying and cautious administration of high alert drugs (to check).
ME E7.2 Medication orders are written legibly and adequately.
ME E7.3 There is a procedure to check drug before administration/dispensing.
ME E7.4 There is a system to ensure right medicine is given to right patient.
ME E7.5 Patient is counselled for self drug administration.

Intent of Standards & Measurable Elements 37

 Standard E8 The facility has defined and established procedures for maintaining, updating of patients’
clinical records and their storage.
ME E8.1 All the assessments, re-assessment and investigations are recorded and updated.
ME E8.2 All treatment plan prescription/orders are recorded in the patient records.
ME E8.3 Care provided to each patient is recorded in the patient records.
ME E8.4 Procedures performed are written on patients records.
ME E8.5 Adequate form and formats are available at point of use.
ME E8.6 Register/records are maintained as per guidelines.
ME E8.7 The facility ensures safe and adequate storage and retrieval of medical records.
Standard E9 The facility has defined and established procedures for discharge of patient.
ME E9.1 Discharge is done after assessing patient readiness.
ME E9.2 Case summary and follow-up instructions are provided at the discharge.
ME E9.3 Counselling services are provided as during discharges wherever required.
Standard E10 The facility has defined and established procedures for intensive care.
ME E10.1 The facility has established procedure for shifting the patient to step-down/ward based on explicit
assessment criteria.
ME E10.2 The facility has defined and established procedure for intensive care.
ME E10.3 The facility has explicit clinical criteria for providing intubation & extubation, and care of patients
on ventilation and subsequently on its removal.
Standard E11 The facility has defined and established procedures for Emergency Services and Disaster
Management.
ME E11.1 There is procedure for Receiving and triage of patients.
ME E11.2 Emergency protocols are defined and implemented.
ME E11.3 The facility has disaster management plan in place.
ME E11.4 The facility ensures adequate and timely availability of ambulances services and mobilisation of
resources, as per requirement.
ME E11.5 There is procedure for handling medico legal cases.
Standard E12 The facility has defined and established procedures of diagnostic services.
ME E12.1 There are established procedures for Pre-testing Activities.
ME E12.2 There are established procedures for testing Activities.
ME E12.3 There are established procedures for Post-testing Activities.
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management
and Transfusion.
ME E13.1 Blood bank has defined and implemented donor selection criteria.
ME E13.2 There is established procedure for the collection of blood.
ME E13.3 There is established procedure for the testing of blood.
ME E13.4 There is established procedure for preparation of blood component.
ME E13.5 There is establish procedure for labelling and identification of blood and its product.
ME E13.6 There is established procedure for storage of blood.

38 National Quality Assurance Standards for Public Health Facilities | 2018

ME E13.7 There is established the compatibility testing.
ME E13.8 There is established procedure for issuing blood.
ME E13.9 There is established procedure for transfusion of blood.
ME E13.10 There is a established procedure for monitoring and reporting Transfusion complication.
Standard E14 The facility has established procedures for Anaesthetic Services.
ME E14.1 The facility has established procedures for Pre-anaesthetic Check up and maintenance of records.
ME E14.2 The facility has established procedures for monitoring during anaesthesia and maintenance of
records.
ME E14.3 The facility has established procedures for Post-anaesthesia care.
Standard E15 The facility has defined and established procedures of Operation theatre services.
ME E15.1 The facility has established procedures OT Scheduling.
ME E15.2 The facility has established procedures for Preoperative care.
ME E15.3 The facility has established procedures for Surgical Safety.
ME E15.4 The facility has established procedures for Post operative care.
Standard E16 The facility has defined and established procedures for end of life care and death.
ME E16.1 Death of admitted patient is adequately recorded and communicated.
ME E16.2 The facility has standard procedures for handling the death in the hospital.
ME E16.3 The facility has standard procedures for conducting post-mortem, its recording and meeting its
obligation under the law.
Maternal & Child Health Services
Standard E17 The facility has established procedures for Antenatal care as per guidelines.
ME E17.1 There is an established procedure for Registration and follow up of pregnant women.
ME E17.2 There is an established procedure for History taking, Physical examination, and counselling of each
antenatal woman, visiting the facility.
ME E17.3 The facility ensures availability of diagnostic and drugs during antenatal care of pregnant women.
ME E17.4 There is an established procedure for identification of High risk pregnancy and appropriate
treatment/referral as per scope of services.
ME E17.5 There is an established procedure for identification and management of moderate and severe
anaemia.
ME E17.6 Counselling of pregnant women is done as per standard protocol and gestational age.
Standard E18 The facility has established procedures for Intranatal care as per guidelines.
ME E18.1 The facility staff adheres to standard procedures for management of second stage of labor.
ME E18.2 The facility staff adheres to standard procedure for active management of third stage of labor
ME E18.3 The facility staff adheres to standard procedures for routine care of newborn immediately after birth.
ME E18.4 There is an established procedure for assisted and C-section deliveries per scope of services.
ME E18.5 The facility staff adheres to standard protocols for identification and management of Pre
Eclampsia/Ecalmpsia
ME E18.6 The facility staff adheres to standard protocols for identification and management of PPH.
ME E18.7 The facility staff adheres to standard protocols for Management of HIV in Pregnant Woman & Newborn

Intent of Standards & Measurable Elements 39

 ME E18.8 The facility staff adheres to standard protocol for identification and management of preterm delivery.
ME E18.9 Staff identifies and manages infection in pregnant woman
ME E18.10 There is Established protocol for newborn resuscitation is followed at the facility.
ME E18.11 The facility ensures Physical and emotional support to the pregnant women means of birth
companion of her choice
Standard E19 The facility has established procedures for postnatal care as per guidelines
ME E19.1 The facility staff adheres to protocol for assessments of condition of mother and baby and
providing adequate postpartum care
ME E19.2 The facility staff adheres to protocol for counseling on danger signs, post-partum family planning
and exclusive breast feeding
ME E19.3 The facility staff adheres to protocol for ensuring care of newborns with small size at birth
ME E19.4 The facility has established procedures for stabilization/treatment/referral of post natal
complications
ME E19.5 The facility ensures adequate stay of mother and newborn in a safe environment as per standard
Protocols
ME E19.6 There is established procedure for discharge and follow up of mother and newborn
Standard E20 The facility has established procedures for care of new born, infant and child as per
guidelines
ME E20.1 The facility provides immunization services as per guidelines
ME E20.2 Triage, Assessment & Management of newborns, infant & children having emergency signs are
done as per guidelines
ME E20.3 Management of Low birth weight newborns is done as per guidelines
ME E20.4 Management of neonatal asphyxia is done as per guidelines
ME E20.5 Management of neonatal sepsis is done as per guidelines
ME E20.6 Management of children with Jaundice is done as per guidelines.
ME E20.7 Management of children presenting with fever, cough/ breathlessness is done as per guidelines
ME E20.8 Management of children with severe acute Malnutrition is done as per guidelines
ME E20.9 Management of children presenting diarrhoea is done per guidelines
ME E20.10 The facility ensures optimal breast feeding practices for new born & infants as per guidelines
Standard E21 The facility has established procedures for abortion and family planning as per government
guidelines and law.
ME E21.1 Family planning counselling services provided as per guidelines.
ME E21.2 The facility provides spacing method of family planning as per guideline.
ME E21.3 The facility provides limiting method of family planning as per guideline.
ME E21.4 The facility provide counselling services for abortion as per guideline.
ME E21.5 The facility provide abortion services for 1st trimester as per guideline.
ME E21.6 The facility provide abortion services for 2nd trimester as per guideline.
Standard E22 The facility provides Adolescent Reproductive and Sexual Health services as per guidelines.
ME E22.1 The facility provides Promotive ARSH Services.

40 National Quality Assurance Standards for Public Health Facilities | 2018

ME E22.2 The facility provides Preventive ARSH Services.
ME E22.3 The facility provides Curative ARSH Services.
ME E22.4 The facility provides Referral Services for ARSH.
National Health Programmes
Standard E23 The facility provides National health Programme as per operational/Clinical Guidelines.
ME E23.1 The facility provides services under National Vector Borne Disease Control Programme as per
guidelines.
ME E23.2 The facility provides services under Revised National TB Control Programme as per guidelines .
ME E23.3 The facility provides services under National Leprosy Eradication Programme as per guidelines.
ME E23.4 The facility provides services under National AIDS Control Programme as per guidelines.
ME E23.5 The facility provides services under National Programme for control of Blindness as per guidelines .
ME E23.6 The facility provides services under Mental Health Programme as per guidelines .
ME E23.7 The facility provides services under National Programme for the health care of the elderly as per
guidelines .
ME E23.8 The facility provides service under National Programme for Prevention and Control of cancer,
diabetes, cardiovascular diseases & stroke (NPCDCS) as per guidelines .
ME E23.9 The facility provide service for Integrated disease surveillance Programme.
ME E23.10 The facility provide services under National Programme for prevention and control of deafness.

Intent of Standards & Measurable Elements 41

 Area of concern - F : Infection Control

Overview
The first principle of health care is “to do no harm”. As Public Hospitals usually have high occupancy, the Infection
control practices become more critical to avoid cross-infection and its spread. This area of concern covers Infection
control practices, hand-hygiene, antisepsis, Personal Protection, processing of equipment, environment control,
and Biomedical Waste Management.
Following is the brief description of the Standards within this area of concern:

Standard F1 Standard F1 is concerned with the implementation of Infection control programme

The facility has infection at the facility. It is includes existence of functional infection control committee,
control Programme and microbiological surveillance, measurement of hospital acquired infection rates,
procedures in place for periodic medical check-up and immunization of staff and monitoring of Infection
prevention and measurement control Practices. Hospital administration should be interacted to assess the
of hospital associated functioning of infection control committee. Records should be reviewed for
infection confirming the culture surveillance practices, monitoring of Hospital acquired
infection, status of staff immunization, etc. Implementation of antibiotic policy
can be assessed though staff interview, perusal of patient record and usage
pattern of antibiotic.
Standard F2 Standard F2 is concerned with practices of hand-washing and antisepsis. Availability
The facility has defined and of Hand washing facilities with soap and running water should be observed at
Implemented procedures the point of use. Technique of hand-washing for assessing the practices, and
for ensuring hand hygiene effectiveness of training may be observed.
practices and antisepsis
Standard F3 Standard F3 is concerned with usage of Personal Protection Equipment (PPE)
The facility ensures standard such as gloves, mask, apron, etc. Interaction with staff may reveal the adequacy of
practices and materials for supply of PPE.
Personal protection
Standard F4 Standard F4 is concerned with standard procedures, related to processing of
The facility has standard equipment and instruments. It includes adequate decontamination, cleaning,
procedures for processing of disinfection and sterilization of equipment and instruments. These practices should
equipment and instruments be observed and staff should be interviewed for compliance to certain standard
procedures.
Standard F5 Standard F5 pertains to environment cleaning. It assesses whether lay out
Physical layout and and arrangement of processes are conducive for the infection control or not.
environmental control Environment cleaning processes like mopping, especially in critical areas like OT
of the patient care areas and ICU should be observed for the adequacy and technique.
ensures infection prevention
Standard F6 Standard F6 is concerned with Management of Biomedical waste management
The facility has defined and including its segregation, transportation, disposal and management of sharps.
established procedures for Availability of equipment and practices of segregation can be directly observed.
segregation, collection, Staff should be interviewed about the procedure for management of the needle
treatment and disposal of stick injuries. Storage and transportation of waste should be observed and records
Bio Medical and hazardous are verified.
Waste

42 National Quality Assurance Standards for Public Health Facilities | 2018

 Area of Concern - F: Measurable Elements Infection Control
Standard F1 The facility has infection control Programme and procedures in place for prevention and
measurement of hospital associated infection.
ME F1.1 The facility has functional infection control committee.
ME F1.2 The facility has provision for Passive and active culture surveillance of critical & high risk areas.
ME F1.3 The facility measures hospital associated infection rates.
ME F1.4 There is Provision of Periodic Medical Check-up and immunization of staff.
ME F1.5 The facility has established procedures for regular monitoring of infection control practices.
ME F1.6 The facility has defined and established antibiotic policy.
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices
and antisepsis.
ME F2.1 Hand washing facilities are provided at point of use.
ME F2.2 The facility staff is trained in hand washing practices and they adhere to standard hand washing
practices.
ME F2.3 The facility ensures standard practices and materials for antisepsis.
Standard F3 The facility ensures standard practices and materials for Personal protection.
ME F3.1 The facility ensures adequate personal protection Equipment as per requirements.
ME F3.2 The facility staff adheres to standard personal protection practices.
Standard F4 The facility has standard procedures for processing of equipment and instruments.
ME F4.1 The facility ensures standard practices and materials for decontamination and cleaning of instruments
and procedures areas.
ME F4.2 The facility ensures standard practices and materials for disinfection and sterilization of instruments
and equipment.
Standard F5 Physical layout and environmental control of the patient care areas ensures infection
prevention.
ME F5.1 Functional area of the department are arranged to ensure infection control practices
ME F5.2 The facility ensures availability of standard materials for cleaning and disinfection of patient care
areas.
ME F5.3 The facility ensures standard practices are followed for the cleaning and disinfection of patient care
areas.
ME F5.4 The facility ensures segregation infectious patients.
ME F5.5 The facility ensures air quality of high risk area.
Standard F6 The facility has defined and established procedures for segregation, collection, treatment
and disposal of Bio Medical and hazardous Waste.
ME F6.1 The facility Ensures segregation of Bio Medical Waste as per guidelines and 'on-site' management of
waste is carried out as per guidelines.
ME F6.2 The facility ensures management of sharps as per guidelines.
ME F6.3 The facility ensures transportation and disposal of waste as per guidelines.

Intent of Standards & Measurable Elements 43

 Area of concern - G : Quality Management

Overview
Quality management requires a set of interrelated activities that assure quality of services according to set
standards and strive to improve upon it through a systematic planning, implementation, checking and acting
upon the compliances. The standards in this area concern are the opportunities for improvement to enhance
quality of services and patient satisfaction. These standards are in synchronization with facility based quality
assurance programme given in ‘Operational Guidelines’.
Following are the Standards under this area of Concern:

Standard G1 Standard G1 is concerned with creating a Quality Team at the facility and making
The facility has established it functional. Assessor may review the document and interact with Quality Team
organizational framework members to know how frequently they meet and responsibilities have been
for quality improvement delegated to them. Quality team meeting records may be reviewed.
Standard G2 Standard G2 is concerned with having a system of measurement of patient and
The facility has established employee satisfaction. This includes periodic patients’ satisfaction survey, analysis of
system for patient and the feedback and preparing action plan. Assessors should review the records pertaining
employee satisfaction to patient satisfaction and employee satisfaction survey to ascertain that Patient
feedback is taken at prescribed intervals and adequate sample size is adequate.
Standard G3 Standard G3 is concerned with implementation of internal quality assurance
The facility has established programmes within departments such as EQAS of diagnostic services, daily round
internal and external quality and use of departmental check-lists, EQUAS records at laboratory, etc. Interview
assurance Programmes with Matron, Hospital Mangers etc may give information about how they conduct
wherever it is critical to daily round of departments and usage of checklists.
quality
Standard G4 Standard G4 is concerned with availability and adequacy of Standard operating
The facility has established, procedures and work instructions with the respective process owners. Display
documented implemented and of work instructions and clinical protocols should be observed during the
maintained Standard Operating assessment.
Procedures for all key
processes and support services.
Standard G5 Standard G5 concerns the efforts’ made for the mapping and improving
The facility maps its key processes. Records should be checked to ensure that the critical processes have
processes and seeks to been mapped, wastes have been identified and efforts are made to remove them
make them more efficient by to make processes more efficient.
reducing non value adding
activities and wastages
Standard G6 Standard G6 pertains to the processes of internal assessment, medical and death
The facility has established audit at a defined periodicity. Review of Internal assessment and clinical audit
system of periodic review as records may revel their adequacy and periodicity.
internal assessment , medical
& death audit and prescription
audit
Standard G7 Every organization has a purpose for its existence and what it wants to be achieve in
Facility has defined Mission, future. Public health facilities have been created not only to provide curative services,
Values, Quality policy and but also support health promotion in their target community and disease prevention.
Objectives, and prepares a Therefore public hospitals not only cater needs of sick and those in need of medical
strategic plan to achieve them care, but also provide holistic care, which includes preventive & promotive care.
With this positioning it is very important that health facilities should clearly
articulate their mission statement in consultation with internal and external
stakeholders and disseminate it effectively amongst staff, visitors& community.
The Mission statement may incorporate ‘what is the purpose of existence’,‘ who
are our users’ and ‘what do we intend to do by operating this facility’. Mission

44 National Quality Assurance Standards for Public Health Facilities | 2018

 statement should be pragmatic and simple so it can be easily understood by target
audiences and they can relate it with their work. As the public health facility
is part of larger public health system governed by State Health Department, it is
recommended the facility’s mission statement should be in congruence with mission
of the State’s Health department. Mission statement should be approved and
endorsed by administration of facility and effectively communicated in local language
through display. Caution should also be taken to keep the language simple and easily
understandable.
This standard also requires health facilities to define core value that should be part
of all policies & procedures, and are always considered while realizing the services to
the patients and community. Being public hospital, facility should have core values of
Honesty, transparency, Non–discrimination, ethical practices, Competence, empathy
and goodwill towards community. It is also of utmost importance that how hospital
administration plan and promote that these values amongst its staff so it becomes
part of their attitude and work culture.
Quality policy is overall intension and direction of an organization related to quality
as formally expressed by hospital administration. Hospital should define what they
intend to achieve in terms of quality, safety and patient satisfaction. Quality Policy
is should be aligned with the mission statement to achieve overall aim of the facility.
To achieve the mission and quality policy, the facility should define commensurate
objectives. Objectives are more tangible and short-term goals, with each objective
targeting one specific issue or aspiration of organization. Objectives should be
Specific, Measurable, Attainable, Relevant/realistic and Time-bound (SMART).
Though Mission and Quality Policy are framed at the organizational level, objectives
can be at departmental or activity level. Quality Policy and objectives should also
be disseminated effectively to staff and other relevant stakeholders. It is equally
important that hospital administration prepares a time bound plan to achieve these
objectives and provide adequate resources to achieve them.
Assessment of this standard and related measurable elements can be done by
reviewing the records pertaining to mission, quality policy and objectives. Assessors
may also interview some of the staff about their awareness of Mission, Values, Quality
Policy and objectives.
Standard G8 Standard G8 is concerned with the practice of using Quality tools and methods like
The facility seeks control charts, 5-‘S’, etc. The Assessor should look for any specific methods and tools
continually improvement practiced for quality improvement.
by practicing Quality
method and tools
Standard G9 Healthcare facilities of all level are exposed to risks from Internal and External sources,
Facility has defined, which may put attainment of Quality objective at a risk. In Public hospitals these risks
approved and may be patients’ safety issues, shortage of supplies, fall in allocation of resources,
communicated Risk man-made or natural disaster, failure to comply with statuary & legal requirements,
Management framework Violence towards service providers or even risk of getting outdated or becoming
for existing and potential obsolete. Hospitals are complex organizations and just reacting on occurred threats
risks may not alone be helpful.
This standard requires healthcare facilities to develop, implement and continuously
improve a risk management framework considering both internal and external threats.
Risk Management framework should not be isolated exercise. It should be integrated
with facilitie’s objectives and intended Quality Management System (QMS).
In this direction, the initial step is to define scope of rick management and objectives
of the framework keeping in mind the context and environment. The hospital
administration should prepare a comprehensive list of current and perceived risks. It
is also important to define the responsibility and process of reporting and managing
risks. Facility should also have provision for training of staff on risk management
framework.

Intent of Standards & Measurable Elements 45

 Assessors may verify documents that defines facilities risk management system.
Assessors should verify that potential risks has been identified in framework keeping
in accordance to context of. Assessors can also interview hospital administration and
staff for their knowledge and practice of risk management framework.
Standard G10 To implement risk management framework facility should prepare a risk management
Facility has established plan. The Plan will delineate responsibilities and timelines for risk management
procedures for assessing, activities such as assessment and risk treatment. All staff and external stakeholders
reporting, evaluating and should be made aware of the plan in general and their roles &responsibilities in
managing risk as per Risk particular. Facility should define the criteria for identifying the risk and finalise its
Management Plan assessment tools. These tools may be a simple checklist, reporting format or work
instruction for identifying risks. It may be checklist for fire safety preparedness,
infection control audit, electrical safety audit or even an open ended questionnaire
for staff on what potential threats they feel on their security at workplace. Once risks
are identified, they should be analysed and evaluated for their impact. Based on their
impact the risk should be graded - severe, moderate and low. Accordingly actions are
taken to mitigate prevent or eliminate the risks. Actions may need to be prioritized in
term of potential impact a rick may have. Facility should also establish a risk register.
This register will record the identified or reported risk, their severity and actions to
be taken.
Assessors should review relevant records for verify availability of a valid plan for risk
management and whether risk management activities have been conducted as per
plan. Assessors should also review risk register to see how facility has graded their
risks and prioritized them for action.

46 National Quality Assurance Standards for Public Health Facilities | 2018

 Area of Concern - G : Measurable Elements Quality Management
Standard G1 The facility has established organizational framework for quality improvement.
ME G1.1 The facility has a quality team in place.
ME G1.2 The facility reviews quality of its services at periodic intervals.
Standard G2 The facility has established system for patient and employee satisfaction.
ME G2.1 Patient satisfaction surveys are conducted at periodic intervals.
ME G2.2 The facility analyses the patient feedback, and root-cause analysis.
ME G2.3 The facility prepares the action plans for the areas, contributing to low satisfaction of patients.
Standard G3 The facility has established internal and external quality assurance Programmes wherever it
is critical to quality.
ME G3.1 The facility has established internal quality assurance programme in key departments.
ME G3.2 The facility has established external assurance programmes at relevant departments.
ME G3.3 The facility has established system for use of check lists in different departments and services.
Standard G4 The facility has established, documented implemented and maintained Standard Operating
Procedures for all key processes and support services.
ME G4.1 Departmental standard operating procedures are available.
ME G4.2 Standard Operating Procedures adequately describes process and procedures.
ME G4.3 Staff is trained and aware of the procedures written in SOPs.
ME G4.4 Work instructions are displayed at Point of use.
Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non
value adding activities and wastages.
ME G5.1 The facility maps its critical processes.
ME G5.2 The facility identifies non value adding activities/waste/redundant activities.
ME G5.3 The facility takes corrective action to improve the processes.
Standard G6 The facility has established system of periodic review as internal assessment , medical &
death audit and prescription audit.
ME G6.1 The facility conducts periodic internal assessment.
ME G6.2 The facility conducts the periodic prescription/medical/death audits.
ME G6.3 The facility ensures non compliances are enumerated and recorded adequately.
ME G6.4 Action plan is made on the gaps found in the assessment/audit process.
ME G6.5 Planned actions are implemenated through Quality improvement cycle (PDCA)
Standard G7 The facility has defined Mission, Values, Quality policy and Objectives, and prepares a
strategic plan to achieve them.
ME G7.1 The facility has defined mission statement.
ME G7.2 The facility has defined core values of the organization.
ME G7.3 The facility has defined Quality policy, which is in congruency with the mission of facility.
ME G7.4 The facility has defined quality objectives to achieve mission and quality policy.
ME G7.5 Mission, Values, Quality policy and objectives are effectively communicated to staff and users of
services.
ME G7.6 The facility prepares strategic plan to achieve mission, quality policy and objectives.

Intent of Standards & Measurable Elements 47

 ME G7.7 The facility periodically reviews the progress of strategic plan towards mission, policy and
objectives.
Standard G8 The facility seeks continually improvement by practicing Quality method and tools.
ME G8.1 The facility uses method for quality improvement in services.
ME G8.2 The facility uses tools for quality improvement in services.
Standard G9 The facility has defined, approved and communicated Risk Management framework for
existing and potential risks.
ME G9.1 Risk Management framework has been defined including context, scope, objectives and criteria.
ME G9.2 Risk Management framework defines the responsibilities for identifying and managing risk at each
level of functions.
ME G9.3 Risk Management Framework includes process of reporting incidents and potential risk to all
stakeholders
ME G9.4 A compressive list of current and potential risk including potential strategic, regulatory, operational,
financial, environmental risks has been prepared.
ME G9.5 Modality for staff training on risk management is defined
ME G9.6 Risk Management Framework is reviewed periodically
Standard G10 The facility has established procedures for assessing, reporting, evaluating and managing
risk as per Risk Management Plan
ME G10.1 Risk management plan has been prepared and approved by the designated authority and there is a
system of its updation at least once in a year.
ME G10.2 Risk Management Plan has been effectively communicated to all the staff, and as well as relevant
external stakeholders.
ME G10.3 Risk assessment criteria and checklist for assessment have been defined and communicated to
relevant stakeholders
ME G10.4 Periodic assessment for Physical and Electrical risks is done as per defined criteria
ME G10.5 Periodic assessment for potential disasters including fire is done as per defined criteria
ME G10.6 Periodic assessment for Medication and Patient care safety risks is done as per defined criteria.
ME G10.7 Periodic assessment for potential risk regarding safety and security of staff including violence against
service providers is done as per defined criteria
ME G10.8 Risks identified are analyzed evaluated and rated for severity.
ME G10.9 Identified risks are treated based on severity and resources available.
ME G10.10 A risk register is maintained and updated regularly to risk records identified risks, there severity and
action to be taken.

48 National Quality Assurance Standards for Public Health Facilities | 2018

 Area of Concern - H : Outcome

Overview
Measurement of the quality is critical to improvement of processes and outcomes. This area of concern has four
standard measures for quality- Productivity, Efficiency, Clinical Care and Service quality in terms of measurable
indicators. Every standard under this area has two aspects – Firstly, there is a system of measurement of indicators
at the health facility; and secondly, how the hospital meets the benchmark. It is realised that at the beginning
many indictors given in these standards may not be getting measured across all facilities, and therefore it would
be difficult to set benchmark beforehand. However, with the passage of time, the state can set their benchmarks,
and evaluate performance of health facilities against the set benchmarks.
Following is the brief description of the Standards in this area of concern:

Standard H1 Standard H1 is concerned with the measurement of Productivity indicators and

The facility measures meeting the benchmarks. This includes utilization indicators like bed occupancy
Productivity Indicators and rate and C-Section rate. Assessor should review these records to ensure that theses
ensures compliance with indictors are getting measured at the health facility.
State/National benchmarks
Standard H2 Standard H2 pertains to measurement of efficiency indicators and meeting
The facility measures benchmark. This standard contains indicators that measure efficiency of processes,
Efficiency Indicators and such as turnaround time, and efficiency of human resource like surgery per
ensure to reach State/ surgeon. Review of records should be done to assess that these indicators have
National Benchmark been measured correctly.
Standard H3 Standard H3 is concerned with the indicators of clinical quality, such as average
The facility measures Clinical length of stay and death rates. Record review should be done to see the
Care & Safety Indicators and measurement of these indicators.
tries to reach State/National
benchmark
Standard H4 Standard H4 is concerned with indicators measuring service quality and patient
The facility measures Service satisfaction like Patient satisfaction score and waiting time and LAMA rate.
Quality Indicators and
endeavours to reach State/
National benchmark

Intent of Standards & Measurable Elements 49

 Area of Concern - H: Measurable Elements Outcomes
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National
Benchmarks.
ME H1.1 The facility measures productivity Indicators on monthly basis
ME H1.2 The facility endavours to improve its productivity indicators to meet benchmarks
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark.
ME H2.1 The facility measures efficiency Indicators on monthly basis
ME H2.2 The facility endavours to improve its efficiency indicators to meet benchmarks
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National
benchmark
ME H3.1 The facility measures Clinical Care & Safety Indicators on monthly basis
ME H3.2 The facility endavours to improve its clincal & safety indicators to meet benchmarks
Standard H4 The facility measures Service Quality Indicators and endeavours to reach State/National
benchmark
ME H4.1 The facility measures Service Quality Indicators on monthly basis
ME H4.2 The facility endavours to improve its service Quality indicators to meet benchmarks

50 National Quality Assurance Standards for Public Health Facilities | 2018

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54 National Quality Assurance Standards for Public Health Facilities | 2018

 List of Amendments done (2016)
Added
Reference No Standards (2016) Measurable Elements (2016)
1 B6 ME B6.1 – ME B6.11
2 C7 ME C7.1 – ME C7.11
3 G9 ME G9.1 – ME G9.6
4 G10 ME G10.1 – ME G10.10
Deleted
1 C4 ME C4.6 & ME C4.7
2 E9 ME E9.4
3 E16 ME E16.3
Rephrased
1 G7 ME G7.1 – ME G7.4 to ME G7.1 – ME G7.7
List of Amendments done (2018)
Added
Reference No Standards (2018) Measurable Elements (2018)
1 A4 ME A4.12
2 E18 ME E18.1, 18.2, 18.3, 18.5, 18.6, 18.7, 18.8, 18.9, 18.11
3 E19 ME E19.3
4 E20 ME E20.5, ME E20.6, ME E20.10
Deleted
1 E18 ME E18.1, ME E18.3
2 H1 ME H1.3
Rephrased
1 G6 ME G6.5
2 E18 ME E18.10
3 E19 ME E19.1, ME E19.3
4 E20 ME E20.4

Intent of Standards & Measurable Elements 55

 INDEX

S. No Key word Reference in Quality Measurement System

1 Abortion ME E21.5 & ME21.6
2 Action Plan ME G 6.4 & ME G6.5
3 Admission ME E1.2
4 Adolescent health Standard E22
5 Affordability Standard B5
6 Ambulances ME 11.4
7 Amenities ME C1.2
8 Anaesthetic Services Standard 14
9 Animals ME D4.6
10 Antenatal Care Standard E 17
11 Antibiotic Policy ME F1.5
12 Assessment Standard E2
13 Behaviour ME B3.3 for Behaviour of staff towards patients
14 Below Poverty Lime ME B 5.3
15 Bio Medical Waste Management Standard F6
16 Blood Bank Standard E12
17 Both Companion of Choice ME E18.11
18 C- Section ME E 18.2
19 Calibration ME D1.2
20 Central Oxygen and Vacuum Supply ME 5.3
21 Checklist ME G 3.3
22 Citizen Charter ME B1.3
23 Cleanliness ME D4.2
24 Clinical Indicators Standard H3
25 Cold Chain ME D2.7
26 Communication ME C1.5
27 Community Participation Area of Standard A6 for Service provision
Standard D8 for processes
28 Confidentiality ME B3.2

Intent of Standards & Measurable Elements 57

 S. No Key word Reference in Quality Measurement System
29 Consent ME B4.1
30 Continuity of care Standard E3
31 Contract Management Standard D12
32 Corrective & Preventive Action ME G6.5
33 Culture Surveillance ME F1.2
34 Competence Assessment C7.2
35 Death Standard E 16
36 Death Audit ME G6.2
37 Decontamination ME F 4.1
38 Diagnostic Equipment ME C6.3
39 Diagnostic Services Standard A4 for Service Provision
Standard E 12 for Technical Processes
40 Dietary services Standard 6
41 Disable Friendly ME B2.3
42 Disaster Management ME 11.3
43 Discharge Standard E9
44 Discrimination ME B2.4
45 Disinfection ME F4.2
46 Display of Clinical Protocols ME G4.4
47 Dress Code ME D11.3
48 Drug Safety Standard E7
49 Drugs Standard C5
50 Duty Roster ME D11.2
51 Efficiency Standard H2
52 Electrical Safety ME 2.3
53 Emergency Drug Tray ME C5.3
54 Emergency protocols ME 11.2
55 Emergency services Standard E11
56 End of life care Standard B6 ME B6.6
57 Environment control Standard F5
58 Equipment & Instrument Standard C6
59 Expiry Drugs ME D2.4
60 External Quality Assurance Program ME G3.2
61 Ethical Management Standard B6
62 Facility Management Standard D4

58 National Quality Assurance Standards for Public Health Facilities | 2018

 S. No Key word Reference in Quality Measurement System
63 Family Planning Standard E21
64 Family Planning Surgeries ME E21.2
65 Fee Drugs ME B5.2
66 Financial Management Standard D9
67 Fire Safety Standard C3
68 Form Formats ME 8.5
69 Furniture ME C6.7
70 Gender Sensitivity Standard B2
71 Generic Drugs ME E6.1
72 Grievance redressal ME B4.5
73 Hand Hygiene Standard F2
74 Handover ME E4.3
75 Help Desk ME B1.7
76 High alert drugs ME E7.1
77 High Risk Patients ME E5.2
78 HIV-AIDS ME B3.4 for Confidentiality and Privacy of People living with
HIV-AIDS
ME 23.4 for processes related to testing and treatment of
HIV- AIDS
79 Hospital Acquired infection ME F1.3
80 House keeping Standard D4
81 Human Resource Standard C4
82 Hygiene ME D4.2
83 Identification ME E4.1 for identification of patients
84 IEC/BCC ME B1.5
85 Illumination ME D3.1
86 Immunization ME E20.1
87 Indicators Area of Concern H
88 Infection Control Area of Concern F
89 Infection Control Committee ME F1.1
90 Information Standard B1 for information about services,
ME 4.2 for information about patient rights
91 Initial assessment ME E2.1
92 Inputs Area of Concern C
93 Intensive Care Standard E10
94 Internal Assessment ME G6.1

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95 Intranatal Care Standard E18
96 Inventory Management Standard D2
97 Job Description ME D11.1
98 Junk Material ME D4.5
99 Key Performance Indicators Area of Concern H
100 Landscaping ME D4.4
101 Laundry Standard D7
102 Layout ME C1.3
103 Licences ME 10.1
104 Linen ME D7.1 &7.2
105 Low Birth weight ME E20.3
106 LAMA ME B6.6
107 Maintenance Standard D1 for Equipments Maintenance
Standard D4 for Infrastructure Maintenance
108 Medical Audit ME G6.2
109 Medico Legal Cases ME 11.5
110 National Health Programs Standard A4 for Service Provision
Standard E 23 for Clinical Processes
111 New born resuscitation ME E18.4
112 Newborn Care Standard E20
113 Non Value Activities ME G5.2
114 Nursing Care Standard E4
115 Nutritional Assessment ME 6.1
116 Obstetric Emergencies ME E 18.3
117 Operating Instructions ME D1.3
118 Operation Theatre ME Standard E 15
119 Outcome Area of Concern H
120 Outsourcing Standard D12
121 Patient Records Standards E8
122 Patient Rights Area of Concern B
123 Patient Satisfaction Survey Standard G2
124 Personal Protection Standard F3
125 Physical Safety Standard C2
126 Post Mortem ME E 16.4
127 Post Partum Care ME E 19.1

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128 Post Partum Counselling ME E 19.3
129 Power Backup ME 5.2
130 Pre Anaesthetic Check up ME 14.1
131 Prescription Audit ME G6.2
132 Prescription Practices Standard E6
133 Privacy ME B3.1
134 Process Mapping Standard G5
135 Productivity Standard H1
136 Performance Evaluation C7.4
137 Quality Assurance Standard G 3
138 Quality Improvement Standard G6
139 Quality Management System Area of Concern G
140 Quality Objectives ME G 7.2
141 Quality Policy ME G 7.1
142 Quality Team ME G1.1
143 Quality Tools Standard G 8
144 Rational Use of Drugs ME E6.2
145 Referral ME E 3.2
146 Registers ME 8.6
147 Registration ME E1.1
148 Resuscitation Equipments ME C6.4
149 RMNCHA Standard A2 for Service provision
Standard E17 to E22 for Clinical Processes
150 Rogi Kalyan Samiti ME 8.1
151 Roles & Responsibilities Standard D11
152 Security ME D3.4 & 3.5
153 Seismic Safety ME 2.1
154 Service Provision Area of Concern A
155 Service Quality Indicators Standards H4
156 Sever Acute Malnutrition ME E20.8
157 Sharp Management ME F 6.2
158 Signage's ME B1.1
159 Skills Standard C6

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160 Space ME C1.1 for adequacy of space
161 Spacing Method ME E21.1
162 Standard Operating Procedures Standard G4
163 Statutory Requirements Standard D10
164 Sterilization of Equipment ME F4.2
165 Storage ME D 2.3 for Storage of drugs
ME D2.7 for Storage of Narcotic & Psychotropic Drugs
ME 8.7 for storage of medical records
166 Support Services Standard A5 for Service Provision
Area of Concern C for Support Processes
167 Surgical Services Standard 14
168 Training ME C7.9
169 Transfer ME E3.1 for interdepartmental transfer
170 Transfusion ME E 13.9 & E13.10
171 Transparency & Accountability Standard D8
172 Triage ME 11.1
173 Utilization Standard H1
174 Vulnerable ME 2.5 for Affirmative action for Vulnerable sections
ME E 5.1 for Care of Vulnerable Patients
175 Waiting Time ME H4.1
176 Water Supply ME 5.1
177 Work Environment Standard D3
178 Work Instructions ME G 4.4

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