AADIYOGI CONSULTING SERVICES LLP

Name Of Organization –

Location-

Date-

SPOC Name & Signature-

NABH APPLICATION DETAILS

Sr No Particulars Status Remarks
1 Hospital Name (as registered with regulatory agencies)
2 Hospital Photograph( Upload photograph of Hospital Building with name display
and Reception Area)
3 Applied for
4 Hospital specialities
5 Name of the Building* ( Mention Hospital Name if not available)
6 Address (same address will be printed on the certificate)
7 Nearby Landmark
8 Country
9 State
10 District
11 City
12 Pin Code
13 Email
14 Contact number
15 Hospital Website
16 Telephone(s) with STD Codes
17 Fax
18 Location Type
19 Does the Hospital have a split location(s) ?
20 Sanctioned Beds
21 Operational Beds
22 Bed occupancy*(Average of past 06 months (in %))
23 ICU*(Average of past 06 months (in %))
24 WARDS*(Average of past 06 months (in %))
25 Inpatient Beds*(excluding emergency, day-care, recovery room beds etc.)
26 In Patient beds (Non ICU)
27 In Patient beds (ICU)
28 Emergency beds
29 Day-care beds
30 Recovery room beds
31 Labour room beds
32 Dialysis
33 Major OTs
34 Minor OTs
35 Does the hospital provide treatment through alternative medicines ?(other than
allopathic medicine)
36 Name of the CEO
Designation
Email ID
Contact
37 Name of the MD
Designation
Email ID
Contact
38 Accreditation Coordinator Name ( Not needed if Co-ordinator & SPOC are same)
Designation
Email ID
Contact
39 Establishment year of the hospital
40 Under which of the following body is the hospital registered ?
1.State or local statutory hospital registering body
2.Clinical establishment act
3.Shop and establishment act
41 Month and Year of Clinical Functions started
42 Ownership Type
1.Public limited
2.Private limited
3.LLP
4.Partnerships between doctors
5.Partnerships includes non-medico person
6.Propreitory Doctor owned
7.Propreitory (non-medical)
8.Charitable trust
 9.Cooperative society
10.Section 25 Company
11.Central Govt
12.State Govt
43 Is the Hospital registered with Local Authorities ?
44 Under which of the schemes Hospital is already empanelled with ?*

Railways

State Government Health Scheme

Others

None

Ayushman Bharat

CGHS

ECHS

Public Health Insurance Schemes

45 Social Media (Facebook/Linkedin/Twitter)

46 Hospital staff Details
1.Consultant Details
2.Other Consultant Details
3.Medical Officer Details
4.Non Allopathic Doctor Details
5.Nurse Details
6.Para Medical Staff
(Refer Templates For all)
47 Registration under Clinical Establishment Act (or equivalent state act)
48 Registration under Shops and Establishments Act
49 Registration with Local Authorities e.g. City Corporation, Municipality, Village
Panchayat
50 Bio-medical Waste Management and Handling Authorization from Pollution
Control Board
51 Consent under Water (Prevention and Control of Pollution) Act
52 Consent under Air (Prevention and Control of Pollution) Act
53 Authorization under Hazardous Wastes (Management and Handling) Rules, 1989
54 Clinical department availability
1.Blood bank
2.Blood storage Centre
3.License for MTP
4.Registration for Transplantation

55 Facility management
1. Fire (NOC)
2. Building Occupancy / Completion Certificate
3. Approval for Electrical Installations
4. License for Diesel Storage
5. License to Store Compressed Gas from the Petroleum and Explosives
Safety Organization (PESO)
6. Registration for Boiler
7. Sanction/ License for Lifts
56 Radiology Oncology
1. License to operate Radiation Therapy Department
2. License to Procure Source/radioactive material
3. RSO Level III

57 Pharmacy
1. Drugs-Bulk license(s)
2. Drugs-Retail license(s)
3. Narcotic license

58 Canteen/ F & B license

59 License for Possession and Use of Methylated Spirit, Denatured spirit and Methyl
alcohol
60 License for Possession of Rectified Spirit and ENA
61 Broad speciality
Anaesthesiology
Bio-chemistry
Dermatology and Venereology
Emergency Medicine
Family Medicine
General Medicine
Geriatrics
General Surgery
General Surgery including Laparoscopic surgery

General Surgery including Bariatric Surgery

General Surgery including Laparoscopic & Bariatric Surgery
Infectious Disease
 Medical Genetics
Microbiology
Obstetrics and Gynaecology
Ophthalmology
Orthopaedic Surgery
Orthopaedic Surgery including joint replacement
Arthroscopic Surgery
Otorhinolaryngology
Paediatrics
Pathology
Psychiatry
Radiology
Respiratory Medicine
Sports Medicine
Transfusion Medicine
Day Care Services
Immuno-haematology

62 Super Specialities
Cardiac Anaesthesia
Cardiology
Cardiothoracic Surgery
Clinical Haematology
Critical Care
Clinical Immunology
Speciality ICU
Medicine
Cardiac
Surgery
NICU
PICU
Endocrine Surgery
Endocrinology
Haematology
Hand Surgery
Hemato-pathology
Hepatology
Hepato-Pancreato-Biliary Surgery
Medical Gastroenterology
Immunology
Neonatology
Nephrology
Neurology
Neuroanaesthesia
Neuro-Radiology
Neurosurgery
Nuclear Medicine
Organ Transplant Anaesthesia
Paediatric Anaesthesia
Paediatric CTVS
63 Transplant Services
Kidney transplant
Liver transplant
Cornea transplant
Bone marrow transplant
64 Oncology
65 Other speciality
Endo vascular Interventions
Interventional Radiology
Interventional Neurology
66 Professions allied to Medicine
(Inhouse, Outsourced, NA)
Ambulance

Blood Bank/ transfusion services

Dietetics
Psychology
Rehabilitation
Occupational Therapy
Physiotherapy
Speech and Language Therapy
67 Diagnostic Services
Bone Densitometry
CT Scanning
DSA Lab
Gamma Camera
Mammography
MRI
PET
X-Ray
Ultrasound
Blood Transfusion Services
Clinical Bio-Chemistry
Laboratory Service
Clinical Microbiology and Serology
 Clinical Pathology
Cytopathology
Genetics
Haematology
Histopathology
Molecular Biology
Toxicology
68 Other diagnostic services
Audiometry
2D Echo
EEG
EMG/EP
Scopy (Bronchoscopy, Endoscopy, Colonoscopy, Sigmoidscopy)
Holter Monitoring
Barium studies
Spirometry
Urodynamic Studies
Tread Mill Testing

69 Non clinical and administrative services

Bio-medical Engineering
Catering and Kitchen Services
Community Service
General Administration
CSSD
Housekeeping
Human Resources
Information Technology
Laundry
Maintenance/Facility Management
Management of Bio-medical Waste
Mortuary Services
Security
Social Service
Supply Chain Management/Material Management

70 AAC
1. Are the healthcare services provided, clearly defined and in consonance
with the needs of the community? *
Defined Scope of Service (Photo of display, font size, Contrast and of
being of permanent in nature, and bilingual)
2.
Does each service in scope, have diagnostic backup and consultant for
OPD, IPD, Emergency, and diagnostic cover? *
Document of scope of lab, imaging & relevant manpower of inhouse or
outsourced (including MOU) .
3. Is scope of health care services for each department defined? *
Scope of health care services defined for all the departments.
4. Does the organisation use written guidance for registering and
admitting patients? *
Guideline for registration and admission of patients
5. Is there a written guidance which addresses managing patients during
non-availability of beds? *
Guideline for the referral of the patients
6. Is access to the healthcare services in the organisation being prioritised
according to the clinical needs of the patient? *
Document of access prioritization
7. Does the HCO have a documented guidance for appropriate transfer-in
of patients to the organization and it being implemented? *
Guideline for appropriate transfer-in of the patients
8. Is transfer-out /referral of unstable patients to another facility being
done appropriately? *
1. Guideline for appropriate transfer-out of the patients. 2. Photograph
of referral and transfer register 3. Training record of staff for BLS, ALS
etc.
9. Are the initial assessment of the out–patients, day care, in-patients and
emergency patients being done? *
Initial assessment forms for OP, IP and Emergency patients
10. Is initial assessment performed by qualified personnel? *
Initial assessment forms for OP, IP and Emergency patients
11. What is the time of performing initial assessment after triaging? *
Defined time frame for initial assessment
12. Is requisition for tests, collection, identification, handling, safe
transportation, processing and disposal of specimens being performed
according to the written guidance? *
Guideline
13. Are the laboratory results available within a defined time frame? *
Documentation of turnaround time of lab result for all modalities.
14. Are critical results intimated to the person concerned at the earliest? *
Documentation of critical results for lab tests for all modalities, and
defined time frames and personnel
15. Is the practice to address recall/amendment of reports whenever
applicable as per documented guidance being done? *
Guideline for recall/amendment of reports
16. Is the MOU of outsourced lab based on quality assurance system of the
outsourced lab? *
 1. MOU documents of outsourced lab 2. Quality assurance system of
the outsourced lab.
17. Does the HCO have a laboratory quality assurance programme? *
Documented laboratory quality assurance programme
18. Does the Lab perform verification and / or validation of test
methods? *
Verification and Validation of reports
19. Does the hospital have internal quality controls and EQAS
programme? *
1.INQUAS records 2. EQAS records
20. Is the calibration and maintenance of equipments available? *
1. Calibration and traceability records 2. Maintenance records of the
equipment
21. Has CAPA been done for non compliance to lab quality assurance
programme? *
1. CAPA of INQUAS records 2. CAPA of EQAS records
22. Is the documented laboratory safety programme is implemented? *
Documented laboratory safety programme.
23. Is the laboratory safety programme aligned with organisation‘s safety
programme? *
Review of laboratory safety program vis-à-vis organisation‘s safety
programme
24. Is Patient transported in a safe and timely manner to and from the
imaging services? *
Transfer Policy/ protocol to imaging services
25. Are the imaging results being available within a defined time frame? *
Documentation of turnaround time of imaging result for all modalities.
26. When Critical results are intimated to the person concerned? *
Documentation of critical results for imaging tests for all modalities,
and defined time frames and personnel
27. Is there any mechanism in place to address recall / amendment of
reports whenever applicable? *
Guideline for recall/amendment of reports
28. Are imaging tests outsourced to organisation(s) based on their quality
assurance system? *
1. MOU of outsourced lab 2. Quality assurance document of the
outsourced lab
29. Does the organisation have quality assurance programme for imaging
services? *
Documented Imaging quality assurance programme
30. Does Quality assurance programme include tests for imaging
equipment? *
Quality test results for imaging equipment.
31. Does the organisation have a quality assurance programme for imaging
protocols? *
Quality Assurance Programme document for imaging protocol.
32. Is programme includes periodic calibration and maintenance of all
equipment? *
Review of Calibration and traceability records Review of maintenance
records
33. Is the programme includes the documentation of corrective and
preventive actions? *
Document of CAPA for Imaging QA results.
34. Is radiation-safety programme implemented as per AERB? *
Documented radiation safety programme
35. Is radiation – safety programme aligned with the organisation‘s safety
programme? *
Review of imaging safety program vis-à-vis organisation‘s safety
programme
36. Are Radiation-safety and monitoring devices periodically tested and
results are documented? *
Documented periodically testing result of radiation-safety and
monitoring devices with action taken report.
37. Are imaging and ancillary personnel trained in imaging safety practices
and radiation-safety measures? *
Training documents.
38. Does the organisation follow the guidelines for referral of patients to
other departments/specialties? *
Guideline for the referral of the patients to other departments
39. Is the discharge process coordinated among various departments and
agencies involved (including medico-legal and absconded cases)? *
Policy for Transfer / Discharge of Patients
40. Does written guidance govern the discharge of patients leaving against
medical advice? *
1. Guideline for the discharge of patients 2. Medical record review
41. Does the organisation confirm to defined timeframe for discharge and
makes continual improvement for the same? *
Document defining timeframe for discharge and improvement process

72 COP
Is uniform care provided to patients? *
Uniform care of patient guidelines
Is care delivery uniform across different settings? *
Treatment guidelines/ protocols.
Is telemedicine facility provided safely? *
Guidelines of MOU for telemedicine
Are crowd management measures implemented? *
1. Policy for crowd management. 2. Number of ED footfalls
Is emergency care provided in consonance with statutory requirements and as per
written guidance? *
Protocols for five common emergencies included adult and paediatric
Are MLCs handled appropriately? *
Policy on Handling MLC Cases
Is triage followed? *
Triage policy
Is a Quality assurance program implemented for emergency dept? *
1. Quality assurance program for emergency debt 2. Indicators relevant to
emergency debt, and CAPA (past 6 months)
Is a system in place for management of patients found dead on arrival/ who die
within a few minutes of arrival? *
Guidelines for dead on arrival and dying on arrival.
Is ambulance equipment checked? *
Daily ambulance equipment checklist
Does the hospital have a proper communication system? *
Daily ambulance medication checklist
Are disasters identified? *
Disaster manual/plan
Are disasters managed as per plan? *
Disaster manual/plan
Is the disaster plan tested? *
1. Evidence of disaster drill 2. Mock drill/table top exercise report including CAPA
Are resuscitation services available to patients at all times? *
Guidelines for CPR, including defined teams and committee
Is there a written guidance for nursing services? *
Guidelines for nursing services
Are nursing practice guidelines implemented? *
Defined nursing clinic are care guidelines/pathways
Is there a written guidance for clinical procedures? *
Guidelines for clinical procedures, and department manuals
Is care taken to prevent adverse events like wrong patient wrong procedure and
wrong site? *
Policy on adverse events
Is Blood/components transfusion done safely? *
1. Document of blood transfusion record [pre-transfusion medications (if any),
record of verification of cross matching, label of the transfused blood product,
monitoring of patient during the transfusion (at least 3)]. 2. Transfusion guidelines
Are Blood/ Components used rationally? *
1. Guidelines of rational use of blood Data Ratio of Blood and Blood products
transfusions in (past 3 months), 2. Evidence of Issue register from Blood bank 3.
Quality indicator on Blood component usage.
Is TAT for emergency Blood/ Blood Components defined and monitored? *
1. List of TAT for Emergency Blood/ Blood Components. 2. Evidence of monitoring
of TAT
Are Blood transfusion Reaction Forms collected, and reactions identified and
analysed for CAPA? *
MOM of blood transfusion committee
Is there a Quality assurance Programme for Blood/ blood Components Transfusion
services and Blood Bank ? *
QAP Guideline for Blood bank.
Is there a ICU manual for Care of patients in the intensive care and high dependency
units? *
ICU manual
Are admission and discharge criteria for its intensive care and high dependency
units implemented? *
Admission and discharge guideline
Is procedure for bed shortage followed? *
Policy for Bed shortage/ transferring of patients to other HCO.
Are infection control practices documented and being followed for ICU and
HDU? *
Guideline for infection control practices in ICU and HDU
Is quality assurance programme of ICU documented? *
clinical Practice Guideline/SOP for transplant
Are obstetrics services organized and provided safely? *
1. Guidelines for management of obstetric patient . 2. Photo of Display of Scope of
Obstetric Services mentioning whether High Risk Obstetric Cases are included or
excluded. 3. Delivery record in Labour Room and Caesarean Sections in OT.
Are antenatal services appropriately provided? *
Guideline for Antenatal services
Are Pediatric services organized and provided safely? *
1. Guideline for paediatric services including STGs. 2. Scope of paediatric services
Is neonatal care in consonance with national/international guidelines? *
Guideline on neonatal treatment, e.g. NICU manual for doctors and nurses
Does organization have measures to prevent child/neonatal abduction and abuse? *
Guideline on prevent child/neonatal abduction and abuse
Is procedural sedation administered in a consistent manner ? *
Procedural sedation guideline
Are patients discharged from the observation/recovery area using defined criteria? *
Patients discharged guideline
Are anesthesia services administered in a consistent manner? *
Guideline for sound clinical to govern anaesthesia services
Are patients transferred from the observation/recovery area using defined criteria? *
Defined criteria of patients transferred from recovery area
 Is Written Guidance available for Surgical services? *
Guidelines on Surgical services
Is there a system in place to prevent adverse events like wrong site, wrong patient
and wrong surgery in place? *Is there a documented Quality Assurance Programme
for OT services? *
1.Document for QAP which includes Intra-operative mishaps, pre-operative events,
pre-operative preparation, Antibiotic Prophylaxis, Methods to prevent adverse
events etc. 2.QAP for surgical services and evidence monitoring of relevant KPI
Surgical safety Checklist, Identification tags, badges etc.
Does the documented Quality Assurance Programme for OT services include
Surviellance of the OT Environment? *
1. Daily record of temperature, Humidity, Pressure Differential, OT cleaning,
disinfection processes and monitoring of its efficacy 2. Monthly Swab reports and
Air sample reports 3. Monitoring Record of integrity of the OT filter (past 6
months)
Is the care of transplant patients guided by the Clinical Practice Guidelines? *
Clinical Practice Guideline/SOP for transplant
Are vulnerable patients identified and managed accordingly? *
Guidelines for vulnerable patients
Is any tool used to identify and manage patients who are at risk of fall? *
Fall risk scoring sheet (E.g., MORSE Fall risk assessment)
Is any tool used to identify and manage patients who are at a risk of developing /
worsening of pressure ulcers? *
Pressure ulcer scoring sheet (E.g., Braden Scale)
Is any tool used to identify and manage patients who are at a risk of developing deep
vein thrombosis? *
DVT assessment tool
Which tool is used to identify and manage patients who need restraints? *
Guidelines for identifying restraint management.
Are patients in pain managed effectively? *
Guidelines on sound pain management
Are the scope of rehabilitation services defined? *
Document detailing Rehabilitation Services (Physiotherapy, Occupational Therapy
etc)
Are patients screened for nutritional risk? *
Nutritional assessment form
Is end of life care provided in the organizationin a consistent manner? *
Document for the end-of-life based on national guidelines.

73 MOM
Is there a medication management manual available? *
Protocols pertaining to medication management
Is there a procedure to obtain medication when the pharmacy is closed? *
SOP on procurement of medicines, if pharmacy is not functioning 24 hours
Does the organization have a system in place to communicate medication shortage,
including stockouts to relevant staff? *
SOP on process on communication for medication usage and shortage
Is the formulary available based on the list of essential medicines? *
Drug formulary
Does the organization have a procedure for acquisition of formulary medications? *
1. SOP on Procedure for acquisition of formulary medications 2. Criteria for vendor
Selection / Evaluation 3. Reorder Levels 4. List of Stock Outs
Does the organization has a defined list of high risk medications? *
list of high-risk medications
Are the high risk medications including Look Alike & Sound Alike Medications are
stored physically apart from each other? *
List of Look Alike & Sound Alike medications
Are the emergency medications defined and stored uniformly? *
1. list of emergency medicines 2. Photo of Crash Cart
Does the organization have a written guidelines and implementation of verbal orders
for safe medication? *
Guidelines on verbal orders, and approved list of medication in the formulary
Are the medication orders written by Authorised personnel? *
Guidelines on who can prescribe medications
Are the medications dispensed in a safe manner? *
Guidelines on dispensing of medication
Are the medication recalls handled effectively? *
Guidance on medication recall
Are near expiry medications handled effectively? *
1. Guidelines on near expiry medication 2. Inventory Audits record
Are the dispensed medications labelled? *
Guidance on labelling medication
Is return of medications to the Pharmacy Addressed? *
Guidance on medication return
Are there measures in place to avoid catheter & tubing mis-connections during
medication administration? *
Policy on medication administration
Are there measures in place to govern patient's self administration of Medication? *
Guidelines on patient's self-administration of medication
Are there measures in place to govern patient's Medication brought from outside the
organization? *
Guidelines on patient's self-administration of medication
Are patients being monitored after medication administration? *
Guidance on situations where monitoring is required
Are Near Miss, Medication Errors & Adverse Drug reactions being captured? *
1. Document of Near Miss, Medication Errors and Adverse Drug reactions 2.
 Quality Indicators
Are Near Miss, Medication Errors & Adverse Drug reactions being reported within
a defined time frame? *
Records of Near Miss, Medication Errors and Adverse Drug reactions
Are Narcotic drugs &Psychotropic substances, Chemotherapeutic agents and
Radioactive agents being used safely? *
Guidelines on safe usage of Narcotic drugs & Psychotropic substances,
Chemotherapeutic agents and Radioactive agents
Is there a mechanism for usage of Implantable Prosthesis & Medical Devices? *
Guidelines for procurement, storage/stocking, issuance & usage
Is recall of Implantable Prosthesis & Medical Devices handled effectively? *
1. Guidance on recall 2. List of recalls 3. Evidence of intimating Authorities
&ManufacturerDoes the Organization adhere to the defined process for aacuisition
of Medical Supplies & consumables? *
1. SOP on Procedure for acquisition of Medical Supplies & consumables 2. List of
Stock Outs
Are the medication prescriptions in consonance with good practice /guidelines for
the rational prescription of medication? *
1. Guidance Document on Prescriptions 2. Training of Doctors 3. Sample
Prescriptions 4. Prescription Audit
Are organization adhering to the determined minimum requirement of the
prescription? *
1. Guidance Document on Prescriptions 2. Training of Doctors 3. Sample
Prescriptions 4. Prescription Audit

74 PRE
Are Patient and Family Rights and responsibilities documented and displayed? *
Display of patient and family rights and responsibilities
Are patient and Family Rights and responsibilities actively promoted? *
Display of Patient rights and responsibility
Do Patient and family rights include respect for personal dignity and privacy during
examination, procedures, and treatment? *
Policy on Patient rights and responsibility
Has the hospital defined the situations where informed consent is required? Are the
staff trained for the same? *
1.Hospital guideline defining informed consent situations 2.Staff training document
Does the procedure describe who can give consent when patient is incapable of
independent decision making and same is implemented? *
Hospital guideline on surrogate consent
Is the relevant tariff list available to patients? *
Tariff list
Are patient complaints redressed? *
1. Hospital guideline on patient complaint redressal including time frame for
analysis 2. Complaint/feedback forms with analysis and CAPA (3 patients)
Is communication with patients/families done effectively? *
Hospital guideline on effective communication
Are special situations where enhanced communication required identified? *
Hospital guideline on effective communication
Is enhanced communication with patients done effectively? *
Hospital guideline on effective communication
76 HIC
Does the organization has a comprehensive hospital infection control programme? *
(Hospital Guideline on infection control programme)
Are the high risk activities identified? *
(Hospital Guideline on high risk activities)
Does the organization have a hospital infection control committee? *
(TOR for HIC committee, and MOM)
Does the organization have a hospital infection control team? *
(1.TOR and staff list of HIC team 2. Surveillance result document)
Does the organization have a hospital infection control officer? *
(Appointment letter HIC manual showing responsibilities of ICO)
Does the organization have a hospital infection control nurse? *
(1. Appointment letter 2. HIC manual showing responsibilities of ICN 3. Additional
training record)
Does organization adhere to standard precautions all the time? *
(Hospital guideline on standard precautions.)
Does organization adheres to hand hygiene guidelines? *
(Hospital guideline on hand hygiene)
Does organization adheres to transmission based precautions? *
(Hospital guideline on transmission based precautions)
Does organization adheres to safe injection and infusion practices? *
(Hospital guideline on safe injection and infusion practices.)
Has organization established appropriate antimicrobial usage policy? *
(1. Hospital guideline on usage of antimicrobial agents 2.List of restricted
antimicrobial agents)
Does the organization have an antibiotic stewardship programme? *
(Hospital guideline on antibiotic stewardship programme, leadership commitment,
tracking and education records)
Does the organization have appropriate engineering controls to prevent infections? *
(1.Quality testing report of Air and water 2. Maintenance record of air conditioning
plant and equipment)
Does the organization have a plan to reduce the risk of infection during construction
and renovation? *
(Validated tool for infection control practice)
Does the organization adheres to house keeping procedures? *
(Hospital guideline on housekeeping procedure Record showing frequency of
 cleaning)
Does the organization adhere to laundry and line management process? *
(Hospital policy on laundry and linen handling process)
Does the organization adhere to kitchen sanitation and food handling issues? *
(Hospital policy on kitchen sanitation and food handling issues)
Does the organization identify and takes appropriate action to control outbreaks of
infection? *
(Review of audit tool)
Is cleaning, packing, disinfection/sterilization , storage and issue done as per written
guidance? *
(1.Hospital Guideline on cleaning, packing, disinfection/sterilization, storage and
issue 2.Details on modes of sterilization followed 3.Photo of equipment)
Is reprocessing of instruments/equipment/ devices done as per written guidance? *
(Hospital guideline on reprocessing of devices including number of reuses
permissible)
Are validation tests for sterilization carried out and documented? *
(1.Hospital guideline on validation of sterilization 2.Details of validation done 3.
Photos of validation tests undertaken- physical/ chemical/ biological)
Is an established recall procedure implemented? *
(1.Hospital guideline on recall procedure 2.PHOTO of actual/mock recall event
3.PHOTO of autoclaving register showing date/time and load details)
Does the organization implement an immunization policy for its staff? *
(Hospital guideline on Immunization policy)
Has staff been provided appropriate post-exposure prophylaxis? *
(Hospital guideline on post-exposure prophylaxis for Hepatitis B and HIV.)
77 PSQ
Is a patient-safety programme developed, implemented and maintained by the
multidisciplinary safety committee? *
(Safety Manual)
Is a quality improvement programme developed, implemented and maintained by
the multidisciplinary safety committee? *
(Quality Improvement Programme)
Are all major elements of quality assurance comprehensively covered in the quality
improvement programme? *
(Quality Improvement Programme)
Is there a designated individual for coordinating and implementing the quality
improvement programme? *
(Quality Manual)
Is there a mechanism in the quality improvement programme for identifying
improvements at pre-defined intervals? *
(Quarterly audit reports, analysis of key indicators, Minutes of the review meeting,
Issues identified, Action taken report)
Are audits being conducted at regular intervals for continuous monitoring? *
(Committee Audit report)
Is there a process for monitoring and improvement in quality of nursing care ? *
(Quality Manual of nursing care)
Are clinical audits documented? *
(Clinical audit report (minimum 3, confirming documentation of clinical audit)
Does the management implement incident management system? *
(Plan for Incident management)
Does the management have a mechanism to identify sentinel events? *
(Policy for Sentinel events)
Does the organization have an established process for analysis of incidents? *
(Process for Incident management)

78 ROM
Have those responsible for governance been identified and have their roles and
responsibilities been defined and documented? *
(1. Minutes of board meeting documenting organisational goal 2. Memorandum of
Article and Association 3. Minutes of board meeting documenting record of formal
orientation and education 4. Action taken report)
Have those responsible for governance lay down the organisation's vision, mission
and values? *
(1. Photograph of vision, mission and values of the organisation 2. Record of review
and updating of mission, vision and value statement)
Do those responsible for governance approve the strategic and operational plans and
the organisation's annual budget? *
(1. Document of Strategic and operational plan 2. Annual budget report)
Do the leaders establish the organisation's ethical management framework? *
(Ethical management framework)
Does the organisation have a documented annual budget plan? *
(Annual budget document including budget for HIC and QI)
Does the organisation document staff rights and responsibilities? *
(Employee Rights and responsibility Policy)
Does the organisation document its service standards? *
(Service standards Handbook)
Is proactive risk management carried out across the organisation? *
(Risk Management plan)
Is there systems in place for internal and external reporting of systems and process
failure? *
(Records of internal and external reporting and Process flow for system failure.)

79 FMS
Have initiatives been taken by the hospital towards energy efficiency and
environment friendly hospital? *
(Safety and facility manual).
 Does the hospital have a documented condemnation and disposal protocol for
materials not in use? *
(Hospital Condemnation policy)
Are hazardous materials identified and used safely? *
(HIRA audit report)
Has the Spill management plan for hazardous materials been implemented? *
(Spill Management plan for Hazardous materials.)
Does the hospital have documented and implemented operational and maintenance
(preventive and breakdown) plan? *
(1. Utility Management Plan 2. Engineering SOP)
Is downtime of critical equipment monitored from reporting to inspection and
Implementation of corrective actions? *
(List of critical equipments (DG set, lifts, UPS, etc)
Does the hospital have documented and implemented operational and maintenance
(preventive and breakdown) plan? *
(1. BME Management plan 2. BME SOP)
Is there an inspection and calibration plan for medical equipment? *
(1. BME Management plan 2. BME SOP)
Does the hospital have written guidance which supports equipment replacement and
disposal? *
(Guideline for equipment replacement and disposal)
Whether medical equipment/device related adverse events and compliance hazard
recalls are being monitored and complied? *
(1. Guideline 2. Evidence of participation in material-vigilance program of Govt of
India)
Whether written guidance for processes for medical gases, vacuum and compressed
air available? *
(Policy for Medical gases)
Is there an Operational, inspection, testing and maintenance plan for medical gases,
vacuum and compressed air systems? *
(1. Guideline for Air system 2. Service reports for manifold)
Is there a plan that covers early detection, abatement and containment of fire and
non-fire emergencies? *
(Plan document.)
Is there a maintenance plan for fire related equipment and infrastructure? *
(1. Plan document 2. Maintenance Records 3. Testing Records)

80 HRM
Is there a contingency plan to meet staff shortages? *
(Contingency plan document).
Is the Job specification job description defined for each category of staff well
defined? *
(Job specifications and job descriptions for all category staffs.)
Has the HCO defined reporting relationships for each category of staff? *
(Organogram document).
Is there a written guidance governing the process of recruitment? *
(Recruitment & Selection guidelines)
Are the administrative procedures for HR management documented? *
(Administrative procedures)
Is there a written guidance on training and development policy? *
(Training and development policy)
Is the staff trained in HCOs disaster management plan? *
(Disaster management plan and training records).
Does performance evaluation system exist in the hospital for all categories of
staff? *
(Guideline for performance management)
Is there written guidance available for disciplinary and grievance handling
mechanism? *
(Grievance redressal and disciplinary Policy)
Does the organisation address the health and safety needs of staff including
occupational hazards? *
(Policy for Health and safety needs of staffs)

81 Has the HCO identified information needs for patients, visitors, staff, management
and external agencies? *
(IMS manual)
Is there a written guidance for capture and dissemination of indentified information
and if the same is disseminated? *
(IMS manual)
Are the needs for software/hardware solutions defined and appropriate hardware and
software available? *
(Document defining needs and evidences of software/ hardware in use Licenses for
the software).
Is the HCO contributing to external data bases? If yes list databases? *
(Policy for reporting data for external agency and its list.)
Has the HCO implemented data storage and retrieval system as per its information
needs? *
(Policy for storing and retrieving medical records)
Is the content of the medical record identified and implemented? *
(1. List of identified items/components of medical record. 2. Photo of MRD
checklist)
Is the staff authorized to make entries in the medical records identified? *
(Guideline of staff list/identified)
Does the HCO maintain confidentiality, integrity and security of records, data and
information? *
(Document detailing integrity and security of records)
 Does the organization maintain integrity of records, data and information? *
(IMS Manual)
Does the organization maintain security of records, data and information? *
(IMS Manual)
Does the organization address requests for access to medical records by Patients/
Physicians and other public agencies consistently? *
(IMS Manual)
Does the organization have effective process for document control? *
(Features of document control on documents submitted by HCO.)
Does the organization retain the patient's clinical records, data and
informationaccording to its requirements? *
(Guideline for retention policy of medical records)
Is the destruction of medical records, data and information in accordance with the
written guidance? *
(Guideline for the destruction of medical records, data and information)

82 ABDM
ABHA NUMBER
Does HMIS have provision capturing ABHA number where available?
Does the hospital capture ABHA number of the patient wherever available?
Does the Hospital have consent form for issuing/sharing health information of the
user (Patient)?
Does the hospital have provision for informing the patient regarding ABHA number
in case the patient does not have the same?
Is the Hospital willing to share the data of UHID of Patient?
83 Healthcare professionals registry(HPR)
Does hospital have mechanism to inform all the healthcare professionals working in
the hospital regarding Healthcare Professional Registry?
Does hospital maintain comprehensive data of all the Healthcare professionals?
Has hospital mandated the Healthcare professionals to register with the ABDM
(Healthcare Professionals Registry)?

84 HealthCare Facility Register(HFR)

Is the Hospital willing to share facility data including equipments with the
Government of India?
Is the hospital willing to register Health Facility Registry (HFR) of ABDM?
Is the hospital willing to share the details of their infrastructure & scope of services
through HFR
Is the hospital willing to be part of Government health resource under ABDM?
85 Abha Mobile Number(PHR)
Is the Hospital creating the awareness amongst their patients regarding ABHA
mobile App (Personal health record)?
The hospital has a mechanism to create awareness about the ABHA mobile
application to its patients *

86 Unified Health Interface(UHI)

Is the Healthcare organisation willing to be part of Govt of India initiative of
ABDM
Is the hospital willing to interface their HMIS with that of the sanbox of ABDM
Is the HCO willing to share their patients’ data?