National Quality Assurance Standards

Health & Wellness Centre -Sub Centre

Name of HWC HWC Gaddo bajitpur Date of Assessment

Name of Assesssors Ravi Kumar Name of Assessee

Type of Assessment
(Internal/ Internal Action Plan submissi
State/External)
Details of Services Provided At HWC
1 Care in pregnancy & Childbirth Mandatory 7

Neonatal & Infant Health

2 Mandatory 0
Services
Childhood & adolescent
3 Mandatory 0
Health Services

4 Family Planning Mandatory 0

Management of
5 Mandatory 0
Communicable diseases
Management of Simple
6 illness including Minor Mandatory 0
Elements

HWC -HSC Overall Score & Area of

SC Overall Score Card

Service Provision Patient Rights

Overall Sco
HWC -H
 HWC_HSC Overall Score Ca
Overall Sco
96% 90%
HWC -H

Inputs Support Services

92%
93% 94%

Theme Wise Sco

Theme Wise Score

Care in pregnancy & Childbirth 96%

Neonatal & Infant Health

94%
Services
Childhood & adolescent
100%
Health Services
Family Planning 92%
Management of
91%
Communicable diseases
Management of Non
94%
Communicable Diseases

Reference No. Area of Concern/ Standards

Area of Concern -A - Service Pro
Standard A1 The facility provides Comprehensive Primary Healthcare Services

Standard A2 The facility provides drugs and diagnostic services as mandated

Area of Concern -B- Patient R
The facility provides information to care seeker, attendants & community about
Standard B1 available services & their modalities

Facility ensures services are accessible to care seekers and visitors including
Standard B2 those required some affirmative action

Services are delivered in a manner that are sensitive to gender, religious &
cultural needs and there is no discrimination on account of economic or social
Standard B3 reasons

Standard B4 The facility maintains privacy, confidentiality & dignity of patient

Standard B5 The facility ensures all services are provided free of cost to its users
Area of Concern -C- Input

The facility has adequate and safe infrastructure for delivery of assured services
Standard C1 as per prevalent norms and it provides optimal care and comfort to users

The facility has adequate qualified and trained staff required for providing the
Standard C2 assured services as per current case load

Facility has a defined and established procedure for effective utilization,

Standard C3 evaluation and augmentation of competence and performance of staff

Standard C4 The facility provides drugs and consumables required for assured services

Facility has adequate functional equipment and instruments for assured list of
Standard C5 services
Area of Concern -D- Support Se
The facility has established Programme for maintenance and upkeep of the
Standard D1 facility

The facility has defined procedures for storage, inventory management and
Standard D2 dispensing of drugs

The facility has defined and established procedure for clinical records and data
Standard D3 management with progressive use of digital technology
The facility has defined and established procedures for hospital transparency and
Standard D4 accountability.

The facility ensures health promotion and disease prevention activities through
Standard D5 community mobilization

Standards D6 The facility is compliant with statutory and regulatory requirement

Area of Concern -E- Clincal C
The facility has defined procedures for registration, consultation, clinical
Standard E1 assessment and reassessment of the patients
The facility has defined and established procedures for continuity of care
Standard E2 through two way referral

Standard E3 The facility has defined and established procedures of diagnostic services.

Standard E4 The facility has defined procedures for safe drug administration.

The facility follows standard treatment guidelines and ensures rational use of
Standard E5 drugs

Standard E6 The facility has defined and established procedures for nursing care.
Standard E7 The facility has defined and established procedures for Emergency care
 The facility has defined & established procedures for management of
Standard E8 ophthalmic, ENT and Oral aliments as per operational/ clinical guidelines
The facility has defined & established procedure for screening & basic
Standard E9 management of Mental Health ailments as per Operational/ clinical guidelines

The facility has defined & established procedures for management of

Standard E10 communicable diseases as per operational/ clinical guidelines

The facility has defined & established procedures for management of non-
Standard E11 communicable diseases as per operational/ clinical guidelines
Standard E12 Elderly & palliative health care services are provided as per guidelines
The facility has established procedures for care of new born, infant and child as
per guidelines
Standard E13
The facility has established procedures for family planning as per government
guidelines and law.
Standard E14 The facility provides Adolescent Reproductive and Sexual Health services as per
Standard E15 guidelines.

Standard E16 The facility has established procedures for Antenatal care as per guidelines
Standard E17 The facility has established procedure for intranatal care as per guidelines
Standard E18 The facility has established procedure for post natal Care
Area of Concern -F-Infection Co
Standard F1 The facility has established program for infection prevention and control
The facility has defined and Implemented procedures for ensuring hand hygiene
Standard F2 practices

Standard F3 The facility ensures standard practices and equipment for Personal protection
The facility has standard procedures for disinfection and sterilization of
Standard F4 equipment and instruments.
The facility has defined and established procedures for segregation, collection,
Standard F5 treatment and disposal of Bio Medical and hazardous Waste.
Area of Concern -G- Quality Managem
The facility has established organizational framework for quality improvement.
Standard G1

Standard G2 The facility has established system for patient and employee satisfaction
The facility has established, documented, implemented and updated Standard
Standard G3 Operating Procedures for all key processes and support services.
The facility has established system of periodic review of clinical, support and
Standard G4 quality management processes
Facility has defined Mission, Values, Quality policy and Objectives, and approved
Standard G5 plan to achieve them.
Area of Concern -H- Outcom
Standard H1 The facility measures Productivity Indicators
Standard H2 The facility measures efficiency Indicators.
Standard H3 The facility measures Clinical Care Indicators.
Standard H4 The facility measures Service Quality Indicators
ance Standards
tre -Sub Centre
ate of Assessment
12/5/2024
ame of Assessee
priyam Kumari, Renu Kumari & Sima Kumari

ction Plan submission date

12/7/2024
rovided At HWC_HSC
Management of Non
Mandatory
Communicable Diseases
Care for Common Ophthalmic
and ENT

Oral health care.

Elderly and Palliative health

care

Emergency Medical Services

Management of Mental
health ailments.

Score & Area of Concern wise Scores

Clinical Services Infection Control

Overall Score of
HWC -HSC
 Overall Score of
HWC -HSC 93% 76%

Quality
Management Output
92% System

95% 93%

heme Wise Score

Care for Common Ophthalmic
0%
and ENT

Oral health care. 0%

Elderly and Palliative health

0%
care
Emergency Medical Services 0%
Management of Mental
0%
health ailments.

Drugs & Diagnostics 96%

Score Obtained Maximum Scores Percentage

a of Concern -A - Service Provision
65 68 96%

8 8 100%
rea of Concern -B- Patient Rights
86%
24 28

89%
16 18

94%
15 16
92%
11 12
 100%
10 10
Area of Concern -C- Inputs

88%
28 32

100%
14 14

81%
13 16

97%
58 60

100%
6 6
ea of Concern -D- Support Services

96%
23 24

100%
28 28

94%
30 32
83%
25 30

100%
54 54
75%
6 8
Area of Concern -E- Clincal Care
96%
27 28
100%
14 14

6 8 75%

88%
14 16

100%
18 18
88%
14 16
6 10 60%
 #DIV/0!
0 0
#DIV/0!
0 0

90%
43 48

91%
53 58
0 0 #DIV/0!

97%
66 68

90%
18 20
4 4 100%
98%
49 50
0 0 #DIV/0!
4 4 100%
ea of Concern -F-Infection Control
5 6 83%

0%
0 8
83%
5 6
67%
8 12
97%
29 30
oncern -G- Quality Management Systems
93%
13 14

5 6 83%

100%
14 14
94%
15 16
100%
6 6
Area of Concern -H- Outcome
14 14 100%
14 14 100%
16 20 80%
6 6 100%
 National Quality Assurance Standards
Health & Wellness Centre -Sub Centre
Name of HWC HWC Gaddo Bajitpur Date of Assessment 12/5/2024
priyam Kumari, Renu
Name of Assesssors Ravi Kumar Name of Assessee Kumari & Sima
Kumari
Type of Assessment (Internal/
State/External) Internal Action Plan submission date 12/7/2024

Reference No Measurable Elements Checkpoints Means of Verification Assessment Compliance

Method
Area of Concern A: Service Provision

Standard A1 The facility provides Comprehensive Primary Healthcare Services

Services for early registration, screening including lab

Availability of functional ANC services with
ME A1.1 minimum 4 ANC check-ups
investigation ,counselling & identification of high risk SI/ RR 2
and danger signs
The facility provides care in Pregnancy & child birth
services
APH, PIH, Pre eclampsia, Severe Anaemia, IUGR,
Multiple pregnancies, Gestational Diabetes ,
Hypothyroidism, Syphilis and bad obstetric history SI/ RR 2
First aid, referral & follow up services for
high risk pregnancies are provided

New Born: Low birth weight newborn <1800gms,

Identification, primary management & Preterm, Sepsis, Birth asphyxia, Congenital anomalies
ME A1.2 prompt referral of sick new born & infant Infant: ARI, Diarrhoea, Jaundice, anaemia &
SI/ RR 2
malnutrition, developmental delays
The facility provides Neonatal & Infant Health
services

Complete immunization schedule & reporting of AEFI

Availability of Immunization Services
both from Sub centre & Outreach
SI/ RR 2

Anaemia, malnutrition, Vaccine preventable

Identification, primary management, referral diseases, ARI, Diarrhoea, Fever, ENT problems, Skin
ME A1.3 & follow up services for Childhood ailments infections, Worm infestations, Poisoning, injuries/
SI/ RR 2
The facility provides Childhood & Adolescent health accidents, 4D's,Sickle cell anaemia.
services

Prevention & treatment of anaemia and other

Education, Counselling and referral services deficiencies, Counselling on life style, menstrual
for Adolescent health hygiene, harmful effects of tobacco/substance abuse
SI/ PI 2
and sex education

Provision of contraceptive including ECP,OCP,

ME A1.4 Availability of family planning services Injectables, condom, IUCD. SI/ RR 2

The facility provides Family Planning services

(1)Provide Information about Family planning

options to eligible clients (2) Motivate families
for spacing b/w 2 children (3) Counselling to support
Education, Counselling and referral services couple in choosing the FP methods, Provide correct
for family planning services & appropriate information about chosen method. (4)
SI/CI 2
Post abortion contraceptive counselling
(5) Referral & support for sterilization, Abortions &
GBV

SI/ RR 2
Identification ,management & referral (if required)
Dysmenorrhoea, Vaginal Discharge, Mastitis, Breast
Identification and referral for Obstetric and lump, Pelvic Pain and Pelvic Organ Prolapse,
Gynaecological Conditions Identification and management for RTI/STI

The facility provides services for promotion,

ME A1.5 prevention and treatment of communicable Preventive & promotive services under
SI/ RR 2
diseases as mandated under National Health NVBDCP
Program/state scheme Malaria, Dengue, Chinguniya, Filariasis, KalaAzar,
Japanese Encephalitis

(1) Diagnostic services, primary management, referral

Case detection, treatment, referral & & follow up of complicated cases.
SI/ RR 2
follow up of cases under NVBDCP (2) Mass drug administration in case of filarasis &
immunization in JE

Preventive & promotive measures under

NTEP
CI/SI 2
Community engagement, facilitate referral, promote
treatment completion & reducing stigma

Case detection, treatment, referral & Early identification, link with designed microscopy
centre, referral & follow up of complicated cases, & SI/ RR 1
follow up of cases under NTEP medication compliance
 Preventive & promotive measures under
NLEP
SI/ CI 2
Community engagement, facilitate referral, promote
treatment completion & reducing stigma

Case detection, treatment, referral & Diagnostic services, primary management, referral &
follow up of complicated cases, & medication SI/ RR 2
follow up of cases under NLEP compliance

Preventive & promotive services under NACP SI/ CI 2

Prevention & promotion among high risk behaviour
groups, support to patient living with HIV/AIDS

Referral & follow up of cases under NACP Compliance to ART & follow up SI/ RR 1

Preventive & promotive measures under

NVHCP Community engagement/ peer support, facilitate SI/ CI 2
referral, promote treatment completion,
Convergence with other departments
Case detection, treatment, referral & Diagnostic services, referral & follow up SI/ RR 2
follow up of cases under NVHCP

Availability of functional services under IDSP Weekly reporting & surveillance SI/ RR 2

Fever, URIs, ARIs, Diarrhoea, Scabies, Rashes/

ME A1.6 Identification, management and referral Urticaria, Abscess, Cholera, Dysentery, Typhoid, SI/ RR 2
of acute illness & minor aliments Helminthiasis, Headache, Body aches, Joint
The facility provide services for acute Simple illness aches.
& minor aliments

Preventive & promotive measures for Water born diseases (diarrhoea, dysentery,
enteritis) Helminthiasis, rabies,musculosketal SI/ CI 2
acute illness disorders (osteoporosis, arthritis, aches )

The facility provides services for promotion,

prevention and treatment of Non- Screening, treatment compliance and follow up of all
ME A1.7 Availability of services for Hypertension positive cases, referral & follow up for complications SI/RR 2
communicable diseases as mandated under and refill of drugs
National Health Program/state scheme

Screening, Diagnosis, treatment compliance and

Availability of services for Diabetes follow up of all diagnosed cases, referral & follow up SI/RR 2
for complications and refill of drugs

Availability of services for Nonalcoholic Screening, treatment compliance and follow up of all
positive cases, referral & follow up for complications SI/RR 2
fatty liver disease (NAFLD) and refill of drugs

Oral, Breast, Cervical Cancers.

Availability of Services for Cancers Screening, linking with the specialist, 2 way referral& SI/ RR 1
follow up treatment compliance and complications

Screening, early identification , treatment

Availability of services for respiratory compliance and follow up of all diagnosed cases,
diseases referral and follow up for complications , refill of
SI/RR 2
drugs for diseases such as COPD & Asthma.

Screening, early identification , treatment

compliance and follow up of all diagnosed cases,
Availability of services for Epilepsy
referral and follow up for complications , refill of
SI/ RR 2
drugs

Early identification, referral, & follow up care for

disease such as Pneumoconiosis, Dermatitis, Lead
Availability of services for locally prevalent
health diseases & substance abuse
Poisoning, Fluorosis etc. & for substance abuse such RR/ CI 2
as tobacco, Alcohol & others.

Community engagement to promote healthy life style

& address risk factor. Counselling and IEC activities
Preventive & promotive services under NCD regarding harmful effects of NCDs SI/ CI 2

The facility provides services for health HWC undertakes health promotion and VHSNC/Self help group/ Patient support groups,
ME A1.14 disease prevention activities through Health promotion campaign and multisectoral CI/ RR 2
promotion activities & wellness Community level resources convergence

SI/ CI 2
Provision of wellness services through Yoga Periodic scheduling of yoga session, Health education
and other activities for life style modification

SI/ RR 2
Provision of AYUSH services As per scope of services defined by state.
 Check counselling services for :
(1) Eat Healthy: (a) Nutrition during first 1000
Provision of counselling services for Eat days of Life (b) Balanced diet (c) Food
fortification (d) Food to avoid SI/CI 2
Right (2) Eat Safe: (a) Hygiene & Sanitation (b) Food
Safety & Safe food practices (c) Food
Adulteration

Standard A2 The facility provides drugs and diagnostic services as mandated

ME A2.1 Point of care diagnostics including RDKs as per Service CI/ RR 2

delivery
Hb, UPT, Urine dip stick (albumin & Sugar) , Blood
sugar, Malaria -RCT, RCT for dengue, collection of
sputum sample for TB, HIV RCT, VIA test, Test for
Iodine in salt (kit), Water testing for faecal
The facility provides laboratory services as Availability of basic diagnostic services contamination & chlorination, HBs Ag for hepatitis B,
mandated including NHP filariasis ( endemic areas), Syphilis (RTK)

Linkages with the Central diagnostic units SI/ RR 2

(Hub & spoke) As per scope of services provided

ME A2.2 The facility provides services for drug Availability of drugs as per EDL SI/ RR 2
dispensing including medicine refills
As per scope of services provided

Availability of drugs for refill for chronic cases SI/ RR 2

As per scope of service provided
Area of Concern B: Patients Right
Standard B1 The facility provides information to care seeker, attendants & community about available services & their modalities
Name of the facility & list of services (1) Name of the HWC, Service Packages and time
available are displayed prominently mandate is displayed.
ME B1.1 The facility displays its services and (2) Check the name of HWC is visible at night also
OB
entitlements
2
Branding of HWC-HSC is done as per (1) Outer surface of the building is yellow with
guidelines specified shade.
(2) Windows & their frame in the brown with
specified shade.
(3) Six illustrations drawn on the façade. (4) Logo
of NHM and Ayushman Bharat. OB
(5). Check electronic display of boards of the services

1
Citizen charter is displayed (1) In local language
(2) Service Provided, contact details of fire, police
ambulance. Name & contact detail of CHW and
nearest referral centre.
(3) Details of grievance re addressal mechanism OB
(4) Citizen rights and responsibilities

1
HWC displays entitlements available as per Under all NHP including RMNCHA and PMJAY
scope of services OB
2
List of Available drugs prominently displayed Updated as per current stock
OB/RR
2
All signages are of uniform colour, user Information is available in local language and easy to OB
friendly & in local language understand 2

Directional signages are displayed in the Check prominent signage are displayed to reach OB
catchment area HWC -SC
2
(1) Service specific relevant IEC is displayed
(2) Check availability of the updated IEC material
(3) Check no outdated information is displayed in
HWC
ME B1.2 Patients & visitors are sensitized and educated IEC Material is displayed as per services (4) Check audio visual aids are used to display the
OB
through appropriate IEC / BCC approaches provided IEC/ information

(1) Check relevant poster are displayed

(2) Check staff engages the community in
disseminating key messages in outreach as well
as HWC related to nutrition & sanitation through
HWC promotes wellness through EAT various activities viz: 3 D food pyramid, food OB/CI
right campaign fortification pocket flyer, +F logo puzzle, waste
management, hand washing, food adulteration
etc.
(3) Check AV aids are played in waiting area as
well as during EAT right campaign

Staff is aware of various BCC approaches for risk

factor identification, life style modification, treatment
compliance & follow up care Viz. GATHER (Greet, Ask,
Health Promotion activities are undertaken
tell, help, Explain & return (FP), TALK : Tell, advise, SI/ CI
using various BCC approach
Lead & Know (Health promotion for NCD, 5 A's (Ask,
advice, assess, assist, arrange) ( Tobacco & alcohol
cessation)
1

Information about the treatment and Check patients is explained about - diagnosis,
Patient is informed about clinical condition
ME B1.3 entitlements are shared with patients or and treatment plan
treatment plan (dosage, period etc), special CI/ RR
attendants instructions, referral & follow up
2
 Consent is taken before procedure for Staff is aware of the conditions where consent is SI/ RR
conditions (wherever required) taken before procedure
1

Primary healthcare team provide JSY, JSSK, RBSK, RMNCHAN, PM JAY/ state
information to beneficiaries or families insurance scheme etc CI/SI
regarding their entitlements Also support beneficiaries to seek services
2

HWC team provide support for linkage

with PM- JAY to avail the scheme SI/ CI
benefits Facilitate identification & registration of families for
PM- JAY
2
Standard B2 Facility ensures services are accessible to care seekers and visitors including those required some affirmative action
HWC is located closer to community (1) Ensure care is provided within 30 minutes,
provision MMU for hard to reach area (Give full
compliance for MMU if area is not hard to reach)
ME B2.1 The facility is accessible from community and (2) Preferably within 1-2 Kms of Referral Centre
CI/SI
referral centre

Check outreach sessions are conducted Check for Outreach session plan - targeted SI/RR
population covered & implementation as per plan. 2
The services are available for the time HWC is functional for at least six hours per day
CI/RR
period, as mandated 2
Care in pregnancy & child birth, Neonatal & infant
healthcare services, childhood & adolescent
healthcare services, family planning & reproductive
healthcare services, communicable diseases including
NHPs, Common communicable disease & out patient
care, Non communicable diseases, common
The facility provides access to expanded ophthalmic & ENT problems, Oral health, elderly & CI/RR
range of services palliative care, Emergency medical services & Mental
health aliments

Access to facility is provided without any Check HWC premises is free from any Availability of Wheel chair/stretcher, ramp with
ME B2.2 physical barrier & friendly to people with railing ( At least 120 cm width, Gradient not be OB
disability. physical barrier steeper than 1:12 )
0

(1) Passage is wide enough for wheel chair and

crutches/canes/stick users.
Check HWC premises is obstacle free for (2) Floors are non slippery.
ambulatory and semi ambulatory (3) Ramps and stairs with handrails. OB
individuals (4) Ramps & staircases with hip lip (20mm) on
exposed side to prevent slipping of cane/ crutches/
wheelchair
2

(1) Tactile signs with good contrast between letters &

background.
Check HWC premises is obstacle free for (2) One or two rows of tactile guiding blocks along the OB
sight and hearing disable individuals entire length of the proposed accessible route
(3) Check there is no poles or uneven surfaces along
the route traversed by the guiding blocks

2
Check for special precaution is taken for HIV, Leprosy , Abortion, domestic Violence, psychotic
There is affirmative action to ensure that maintaining privacy & confidentiality of cases, GBV, abuses etc
ME B2.3 vulnerable and marginalized sections can cases having social stigma SI/ RR
access services
2
There are linkages of care , Counselling and Victims of Violence including domestic violence/
Protection of vulnerable and marginalized Gender Based Violence, terminally ill patients,
section orphan, elderly etc. Linkage and support for
treatment, counselling & Legal Support SI/ RR

Standard B3 Services are delivered in a manner that are sensitive to gender, religious & cultural needs and there is no discrimination on account of economic or social reasons

ME B3.1 Services are provided in manner that are Availability of female staff / attendant, if a
SI/CI 2
sensitive to gender religious & cultural need male CHO examines a female patients

Cultural and religious preferences of patients are

Religious and cultural preferences of honoured
patients and their attendants are taken OB/SI 2
into consideration, while delivering
services

(1) Check there is no discrimination due to religion,

cast and tribe
(2) Check there is no discrimination due to gender
(3) Check there is no discrimination due to socio
There is no discrimination based religion, economic status
ethnicity, socio economic status, cast, (4) Check there is no discrimination due to ethnicity & CI/OB 2
gender & language etc language
MEB3.2 Staff is aware of Patients rights and OB/SI 2
responsibilities
Check Staff is aware of Patient rights and Display of patient rights and responsibilities through
responsibilities citizen charter.

CI/OB 2
Check community is aware of services provided,
grievance redressal mechanism, contact details of
Check community is aware of Patient's rights higher centre, contact details of ambulances by HWC-
and responsibilities HSC.

ME B3.3 The facility has defined and established Check staff & community is aware of Existing state grievance system/ 104. SI/CI 2
procedure grievance redressal system in place grievance redressal system

Complaint Box/ Complaint register/ facility specific IT OB/ RR 1

Availability of complaint reporting system system. Defined period for resolving the complaints
Corrective and preventive action taken Mechanism to report the patient on action taken SI/ RR 2
Standard B4 The facility maintains privacy, confidentiality & dignity of patient
Availability of screen/ curtains in Screen/ curtain/ frosted glass on windows
Adequate visual privacy is provided at every examination area and in windows
ME B4.1 OB
point of care
1
One Patient is seen at a time by CHO Clinic is not shared by two patients at a time
OB
2
Patient records are kept in safe custody

ME B4.2 Confidentiality of patients’ records and clinical Family folders, CBAC form, NCD portal information, OB/ SI
information is maintained HIV, RTI/STI, OPD registers etc
Patient records are kept at safe place beyond access
of general patient flow 2
(1) Check HWC has policy in place regarding access of
clinical information & records. (2)
Staff is aware of it
(3) Need based individual's summary & prescription
Check patient and their kin's have access details are provided. (IT system- have option for SI/ RR
to clinical records print)

2
The facility ensures behaviours of its staff is Behaviour of staff is empathetic and
courteous to patients and visitors
ME B4.3 dignified and respectful, while delivering the CI
services Ask the patient about their experience of care 2
Behaviour of staff is dignified & respectful
Care is free from any physical & verbal abuse.
Vulnerable or marginalized patients
is not left unattended/ignored. CI
Check the status separately in labour room if
delivery services are provided in SC
2

Standard B5 The facility ensures all services are provided free of cost to its users

(1) As per service package or

ME B5.1 The facility provides free of cost services as per HWC provide free of cost access to all RMNCHA, CD, NCD, Eye, ENT, Oral, Mental CI/ RR
prevalent government schemes/ norms. the services Health, Elderly, Pallative,Emergency medical
services etc 2
The facility provides free of cost All screening services and required diagnostic services
screening and investigations services as are provided free of cost CI/ SI
per requirement 2
The facility provides free of cost essential Check all drugs in the HWC-EDL are provided free of
cost
medicines and refills as per treatment CI/ SI
plan 2
Availability of Free referral /ambulance
services CI/ SI
Through 102/108 or any other 2
Availability of free teleconsultation services
CI/SI
2
Area of concern C: Inputs
The facility has adequate and safe infrastructure for delivery of assured services as per prevalent norms and it provides optimal care and comfort to users
Standard C1
Facility has adequate infrastructure, space and Well ventilated & illuminated clinic room (1) Check demarcated area for examination (privacy
amenities as per patient or work load with examination space maintained), consultation and administrative/record
keeping
(2) Availability of adequate Natural Light/ Illumination
(150 Lux in OPD area & 300 Lux in drug dispensing
ME C1.1 areas) OB

2
Availability of adequate patient waiting area Covered waiting area which can accommodate 20-25
Chairs.
Check space is adequate to maintain Physical OB
distancing
1
Demarcated space for Laboratory / Lab. space is adequate for carrying out Lab.
diagnostics OB
activities 2
Adequate space/room for Yoga activities within HWC or its premises OB 2
Demarcated area for carrying out OB
immunization activities 2
(1) Storage space for storing medicines ,Consumables
& equipment etc.
Demarcated area of storage (2) Check the availability of racks/ Almirahs/ shelf etc OB

Availability of functional OB
telephone/Mobile and internet services CUG numbers/ Landline and internet connectivity
1
 Availability of regular & uninterrupted (1) Availability of Portable emergency light ,
generators/inverters/solar panel/ for power back up SI/ OB
electricity supply
(2) Use of energy efficient bulbs for lighting 1

(1) Potable drinking water supply is available for

Adequate water supply with storage patients, visitor & staff
(2) Piped water supply/ tube well with fitted water OB/ SI
facility
pump/ other alternate source.
(3) Water Storage facility- Minimum 3 days
(4) Periodic chlorination & Quality testing of water is
done 1

(1) Check toilets are functional with running water OB

Availability of separate toilets for male & facility.
female (2) Check the toilets are disable friendly 2

Check boundary is of adequate height and it is not OB

broken from anywhere
HWC premises has intact boundary wall 2
HWC has installed fire extinguisher and staff (1) Fire extinguisher ABC type
know how to operate it (2) Check expiry date & refill date is displayed
(3) PASS- Pull the pin, A- Aim at base of fire, S-
Squeeze the lever, S -Sweep side to side
ME C1.2 The facility ensures physical safety including (4) Check exists are clutter free OB/ SI
electrical and fire safety of infrastructure

2
HWC does not have temporary connections
and loosely hanging wires OB/ SI
Safe installation, use of appropriate wires & MCB ,
Use of AV regulator ( for regulating the fluctuations) 2
Non structural components are properly
secured
(1)Check for fixtures & furniture like Almirah/
Cabinets, hanging objects are properly fastened &
secured OB/ SI
(2) Building bye laws & instructions of NBC for seismic
safety is followed
2
HWC has adequate ICT hardware for
efficient delivery of services (1) Check availability of Smartphones/ Tablets and
ME C1.3 The facility ensures availability of information & Laptop/desktops, internet connectivity (2mbps). SI/ RR
communication technologies (2) For tele medicine services,check desktop/ Laptop
have headphone , HD web camera & printer
connected with it 2
HWC has adequate ICT software for
efficient delivery of services
Check availability of functional & updated Portals or
applications viz RCH portal, HWC portal, NCD portal, RR/ SI
ANMOL, DVDMS, NIKSHAY, e-sanjeevani, HMIS etc.
and any state specific application.
2
Standard C2 The facility has adequate qualified and trained staff required for providing the assured services as per current case load

ME C2.1 The facility ensures availability of Community SI/ RR

Health officer
As per eligibility criteria.
Availability of Community Health Officer Staff is aware of their role and responsibilities 2

2ANM (1 essential & 1 Desirable)- SC type -A

The facility have adequate frontline health 2 ANM (Essential, one may be staff nurse) - Only
ME C2.2 Availability of ANM for SC type-B SI/ RR
workers and support staff as requirement Staff is aware of their role and responsibilities

2
1 Female and 1 Male
Staff is aware of their role and responsibilities for SI/ RR
Availability of Multipurpose Worker HWC and community 2
1 ASHA per 1000 population / ASHA per 500
population for tribal and hilly area.
1 ASHA facilitator/20,000 population
Staff is aware of their role and responsibilities for SI/ RR
HWC & community
Availability of ASHA & ASHA facilitator 2
The facility has established procedure for duty Check duty roster is prepared prepared,
ME C2.3 updated & followed for all cadres SI/ RR
roster for facility and community staff 2
Check field visit plans are prepared, updated
& followed by primary healthcare team SI/ RR
2
All staff adhere to their respective dress (1) Staff adhere to their respective dress code
code (2) Staff on duty is wearing their ID card
OB

Standard C3 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

(1) Check objective checklist has been prepared for

Competence assessment and performance assessing competence of staff based on job
ME C3.1 evaluation of all staff is done on predefined description and assessment is done at least once in a RR/ SI
criteria year (2) Check who did the assessment - At least PHC-
Check parameters for assessing skills and MO/ Competence Matrix is prepared for each
proficiency of staff has been defined category of staff 2
Verify with records that performance appraisal has
Check for performance evaluation is done at been done at least once in a year and verify with staff RR/ SI
least once in a year for actual assessment done 2

RR/ SI
Check actions are taken for all the identified Check training need are identified at defined intervals
gaps & adequate skill are provided 2
 (1) 6 month certificate program in Community health,
(2) 3 day IT training including Tele medicines
ME C3.2 The staff is provided training as per defined CHO is trained as per mandate (3) 5-7 days supplementary training on new health RR/ SI
core competencies and training plan programs, new skills (if applicable)
(4) refresher every year (if applicable)
(5) Basic physiotherapy ( where ever elderly &
palliative care packages are available)
(6) Training on Eat right tool kit
1

MPW- (F) : (1)4-5 days training in IUCD insertion,

NSSK, HBNC Supervision, Management of Childhood
illness, (2) 21 days of SBA training. (Wherever
MPW is trained as per mandate applicable) RR/ SI
MPW (All)- National Health Programmes, 3 days
training on NCD, 1 day joint training with ASHA for
NCD screening , 3 days training on reporting and
receiving information using digital applications &
basic nursing care training (esp. for elderly &
palliative care), training on Eat right tool kit
2

(1) 8 days induction training, 20 days training of

module 6& 7, 5 days NCD module. RR/ SI
(2) Supplementary & refresher training for 15
days/year. (if applicable)
(3) ASHA facilitatory is trained for Basic
physiotherapy ( where ever elderly & palliative care
AHSA is trained as per mandate packages are available),Training on Eat right toolkit 1
Bio medical waste management, Infection
Staff is provided with Quality assurance Prevention, patient safety, internal assessment, BLS, RR/ SI
training Methods of QA viz PSS, 5S, PDCA etc 1

(1) Through access to Job aids/ MOOC (massive open

online courses)/ ECHO etc RR/ SI
(2) Check how many capacity building
Check HWC use IT platforms for regular training/workshop attended by primary healthcare
continuous learning & capacity building team in last quarter 2
Standard C4 The facility provides drugs and consumables required for assured services

ME C4.1 The facility have availability of adequate drugs OB/RR

Availability of Anaesthetics agents Oxygen & Lignocaine topical (5%) 0

Levocetirizine tablet (5mg) , Levocetirizine Oral OB/RR

liquid , Hydrocortisone Succinate injection 100mg,
Availability of Anti-allergic Pheniramine inj 22.75mg/ml, Adrenaline inj 1mg/ml 2

Aspirin tab 75, Diclofenac tab 50mg, Diclofenac OB/RR

injection 25mg/ml, Paracetamol tab 250mg,
Availability of Analgesics, Anti Pyretic, Paracetamol Syrup 125mg/5ml, Paracetamol
NSAIDS, Syrup250 mg/5 ml, Ibuprofen tab 200mg 2

Phenytoin Tablet 50 mg & 300 mg, Sodium valporate

Tablet 200, 500 mg & Sodium valporate Syrup each OB/RR
200mg/5ml, Phenobarbitone tab 30 & 60 mg,
Phenobarbitone Syrup 20 mg/5ml, Midazolam nasal
Availability on Anticonvulsants /Anti spray, Diazepam tab 5 & 10 mg, Magnesium sulphate
epileptics Inj (50% sol )- 2ml 2
Albendazole Tablet 400 mg, Albendazole Oral liquid OB/RR
Availability of Intestinal Anti Helminthes 200 mg/5 ml 2
Diethylcarbamazine Tablet 100 mg OB/RR
Availability of Antifilarial Diethylcarbamazine Oral liquid 120 mg/5 ml 2

Amoxicillin Capsule 250 & 500 mg

Amoxicillin Oral liquid 250 mg/5ml, Amoxicillin
dispersible tab 250 mg, Gentamycin inj 10& 80 mg/
ml, Ciprofloxacin Tablet 500 mg, Ciprofloxacin Oral
liquid 250 mg/5ml, OB/RR
Ciprofloxacin Inj., Tab Co-trimoxazole
[Sulphamethoxazol 80 mg +Trimethoprim 400 mg]
Tab Co-trimoxazole [Sulphamethoxazole 100 mg +
Trimethoprim 20 mg ] Co-trimoxazole Oral liquid
([Sulphamethoxazole 200 mg + Trimethoprim 40
mg/5ml), Doxycycline 100mg, Metronidazole 200 &
Availability of Anti Bacterial 400 mg, Norfloxacin tab/ oral 2

Clofazimine Capsule 50 mg OB/RR

Clofazimine Capsule 100 mg, Dapsone Tablet 25 mg,
Dapsone Tablet 50 mg,
Availability of Anti leprosy Dapsone Tablet 100 mg 2

Chloroquine,
Artesunate (A)+ Sulphadoxine- Pyrimethamine (B), OB/RR
Combipack (A+B)
Primaquine Tablet 2.5 mg
Availability of Anti Malarial Primaquine Tablet 7.5 mg 2

Ferrous salt 100 mg + Folic acid 500 mcg Tablet

Ferrous salt 20 mg + Folic acid 100 mcg Tablet,
Ferrous salt 60 mg + Folic acid 500 mcg, Ferrous salt OB/RR
45mg + Folic acid 100 mcg , Ferrous salt+ Folic acid
Syrup, Folic acid Tablet 5 mg and 400 mcg, Vit K inj
Availability of anti Anaemic drug 1mg/ml, 2
Isosorbide- 5-mononitrate 5mg tab, Isosorbide
dinitrate 5mg, Atenolol 50mg, Metoprolol 25mg, OB/RR
Availability of Cardiovascular medicines Metoprolol SR 25mg 2

Amlodipine Tablet 2.5 & 5 mg, Telmisartan Tablet 40 OB/RR

Availability of drugs for Hypertension mg, Enalapril 5mg, Hydrochlorothiazide 12.5 & 25 mg 2
 OB/RR
Availability of drugs for Hypolipidemic Clotrimazole Cream,10Miconazole
Atorvastatin Tablet mg oint. ,tab fluconazole 2
150 mg , Silver sulphadiazine Cream 1%,
Betamethasone cream 0.05%, Calamine Solution,
Availability of Dermatological & antifungal Benzyl -benzoate oint/lot, Mupirocin, KMnO4 -0.1%, OB/RR
Medicines Zinc oxide cream 10%, 2
Ranitidine Tablet 150 mg, Ranitidine inj,
Omeprazole, Ondansetron tab, oral liquid and inj, OB/RR
Availability of Diuretics Ispaghula
Furosemidegranules/
Inj & tabHusk/
40 mgpowder, Oral rehydration 2
salts (ORS),Zinc Sulphate Syrup & tablet, Dicyclomine
Tablet & Inj, Dioctyl sulfo succinate Sodium,
Magnesium Hydroxide liquid, Senna Powder, OB/RR
Availability of Gastroinstinal medicines Domperidone Tab & Syrup 2

Ethinylestradiol (A) + Levonorgestrel Tablet 0.03 mg

(A) + 0.15 mg (B),Condom, IUCD 380 A Copper OB/RR
bearing intrauterine, Ormeloxifene Tab 30mg,
ECP( Levonorgestrel 1.5mg), Medroxy progesterone
Availability of Contraceptives Acetate injection, 2

Metformin SR Tablet 500 mg, Metformin Tab 500mg, OB/RR

Availability of drugs for diabetes Mellitus Glimepiride Tab 2mg, Glibenclamide Tab 2.5 & 5 mg 2
Levothyroxine Tablet 25, 50 & 100 mcg OB/RR
Availability of drugs for Thyroid 2

Salbutamol Tablet 2 mg
Salbutamol Oral liquid 2 mg/5 ml
Salbutamol Respirator solution for use in nebulizer OB/RR
5mg/ml, Budesonide Respirator solution for use in
nebulizer 0. 5mg/ml, Normal Saline drops,
Dextromethorphan oral syrup, Hyoscinebutylbromide
Availability of medicines for Tespiratory tract Tab 10 mg 2
Ringer lactate Injection, Sodium chloride injection OB/RR
Availability of IV Fluids 0.9%, Dextrose 5% & 25% 2

Calcium Carbonate Tablet 500 mg, Vit C tab 100mg,

Cholecalciferol Tab 60,000 IU, Pyridoxine tab 25,50 & OB/RR
100mg, Vit A oral liquid 1,00,000 IU/ml, B complex
Availability of Vitamins and Minerals tab 2

OB/RR

Availability of Antidotes Activated Charcoal, Atropine 1 mg/ml . 2

Availability of injectables Anti rabies vaccine, Inj. Tetanus Toxoid, OB/RR 2

Inj. Adrenaline, Inj. Hydrocortisone, Inj. OB

Availability of Emergency Drug Tray / Dexamethasone , Glyceryl trinitrate- Sublingual tab
injectables at injection room 0.5 mg 2
Hydrogen peroxide, Gentian violet, Povidone Iodine, OB/RR
Availability of Anti septic Framycetin sulphate ointment 2

The facility have adequate consumables as per Haemoglobin scale test with talquist paper, Urine
ME C4.2 Pregnancy rapid test, Rapid Kits for Malaria and OB/RR
requirement Dengue, Urine Dip Stick for albumin and Sugar,
Availability of Rapid Diagnostic Kits Glucometer with glucosticks, Sputum Cups, 2
Availability of disposables for Dressing /
Emergency management
Splints, Syringe (10cc, 5cc, 2cc) and AD Syringe (0.5ml OB/RR
and 0.1ml) for injection, Suture with needle holder &
artery forceps, Disposable gloves, Disposable Swabs,
Disposable Lancets, Mackintosh Sheets 2
Availability of disposables at Clinics
Mucus extractor, Wooden Spatula, Disposable Cord
clamp, Disposable Sterile Urethral Catheter( 12fr, OB/RR
14fr) , Foleys catheter , IV Cannula and Sets,
Interdental Cleaning Aids, cold pack, cotton and
envelopes for drug dispensing 2

Vit A prophylaxis, Glucosticks, Syringes, Pregnancy

kits, HIV Rapid Test and STI Screening Test kits, Kit for OB/RR
testing residual chlorine in Water. Vision screening
care for 6/18 vision, measuring tape (6m), reading
Availability of Drugs and Consumables for module.
VHNDs or camps 2
Standard C5 Facility has adequate functional equipment and instruments for assured list of services

The facility ensures availability of equipment

ME C5.1 and instruments for examination and BP apparatus, Torch, stethoscope ,peak flow meter OB
monitoring of patients and snelle's /near vision chart, Measuring tape,
Thermometer, Foetoscope,Weighing machine, Infant
weighing scale, Tongue depressor, Stadiometer.
Availability of functional Equipment & Dressing Trays, Dressing Drums, Surgical Scissors ,
instruments for examination & Monitoring Examination Lamp, Cheatle's forceps, Sponge
at Clinic Holder, Artery forceps. 2

Ambu bag with Mask, Suction Machine, Oxygen

cylinder with Administrative equipment OB
Availability of Emergency functional (Keys),Mouth Gag , Nebulizer. AED (Automated
equipment External Defibrillator) 2

ME C5.2 The facility have adequate furniture and fixture Table, Doctor chair, Patient Stool, Examination table, OB
as per service provision Attendant Chair, Foot Step, Screen Separators with
Stand, IV stand, Wall clock, refrigerator (For storage
Availability of furniture & fixture at Clinics of drugs & vaccines) 2
Area of Concern D: Support Services

Standard D1 The facility has established Programme for maintenance and upkeep of the facility
 HWC Building is painted/whitewashed in Check building is white washed both from inside &
uniform colour & its branding done as per outside
the guideline

ME D1.1 The facility has established system for OB

infrastructure maintenance

2
Check building & its premises is well 1. No seepage, cracks and chipping of plaster from
maintained wall, roof, windows etc
2.No unwanted/outdated posters on walls of building
& boundary walls
3. Proper landscaping and maintenance of Open
Space / Gardens/ water bodies etc (if available)
4. No leaking taps, pipes, over-flowing tanks and
dysfunctional cisterns. OB
5. No water logging /marsh inside the premises

2
HWC has system for periodic maintenance of 1. Check records of building, patient amenities
Building including patient amenities maintenance and schedules.
2. Pest or rodent control measures are taken at least SI/ RR
once in 6 months 2
No condemned/Junk material in HWC HWC remove its junk periodically as per
(corridors, roof, administrative area , condemnation policy.
backyard) RR/ OB
2
There is system of timely corrective & Check staff is skilled to undertake the trouble
preventive break down maintenance of the shooting SI/ OB
equipment
2
All the measuring equipment/ instrument E.g. Weighing machine, BP apparatus, the status is re
are calibrated RR/ OB
checked At least once in six months. 2
1. Check that floors and walls for any visible or
tangible dirt, grease, stains, etc.
Check roof, walls, corners of these area for any
cobweb, bird nest, vegetation, etc.
2. Surface of furniture and fixtures are clean and well
ME D1.2 The facility has established system for Check all the areas are clean & hygienic maintained OB
maintaining sanitation and hygiene 3. No rusted or broken furniture
4. Schedule for cleaning is defined and implemented

2
Check there is no foul smell in HWC Check toilets are clean and there is no
overflowing/clogged drains OB
2
Check availability of adequate supply of (1) Availability of mops, 2- buckets system, good
cleaning material quality cleaning solution preferably a ISI mark.
(2) Composition and concentration of solution is
written on label etc.
(3) Staff is aware of correct concentration and
dilution method for preparing cleaning solution. OB/ RR
(4) Verify its consumption

1
Check staff is aware of use of 2 bucket One bucket for Cleaning solution, second for
system & disinfection of mop after cleaning wringing the mop.
Ask the cleaning staff about the process, Disinfection ,
washing & keeping mops for drying after every OB/ SI
cleaning cycle
2
HWC has a system for safe disposal of No garbage piles in and around HWC.
general waste No signs of burning of waste in HWC OB
2
Clean and adequate linen is available Check Examination bed, table cloth etc are clean.
There is system in place for washing of linen OB/ RR
2

Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs

There is established procedure for estimation HWC has a process to consolidate and Check forecasting of drugs & consumables is done
ME D2.1 and indenting of drugs and consumables as per calculate the consumption scientifically based on consumption .Reorder &
buffer levels are defined
SI/ RR
requirement 2
Check Drugs and consumables forecasting Linkage with portal/ DVDMS
and indenting is IT enabled
RR/SI
2
(1) Timely indenting the drugs for common aliments
& emergency cases
(2) Timely indenting of Drugs of new or regular
chronic patients under HWC
Check there is established system to (3) Check the adequacy of the available drugs
timely indent the drugs as per services (Demand & supply) RR/SI
package

2
(1) For HWC, campaigns and home based care.
Check there is no stock out of essential & (2) Check staff is aware of any stock out RR/ Ci
vital drugs
2
(1) Check list of VED categorisation
Check drugs are categorised in Vital, (2) Check updated stock registers of the last 6 months
for vital & essential drugs RR/SI
Essential and desirable
2
There is specified place to store medicines in Drugs and consumables are stored away from
ME D2.2 The facility ensures proper storage of drugs and HWC water / dampness and sources of direct heat & OB
consumables sunlight etc.
2
Check drugs are kept in racks and shelves Drugs are not stored at floor ,Heavy items are stored
with proper labelling at lower shelves/racks and fragile items are not kept OB
on the edges
2
LASA ( Look alike and Sound alike ) are
stored separately OB
2
 Check heat and light sensitive drugs are (1) Medications that are considered light-sensitive
stored as per manufacturers instructions will be stored in closed drawers.
(2) Check process in place for storage of drugs,
laboratory kits & vaccines etc requiring controlled OB/SI
temperature
2
Check process followed to maintain the (1) Temperature chart is maintained
temperature of refrigerator used for drugs/ (2) De frosting is done (in case household freeze is
vaccine/ lab kits used)
(3) Staff is aware of holdover time of refrigerator OB/RR
(4) Freeze is not used for storing eatables
2

ME D2.3 The facility ensure management of expiry and First expiry first out (FEFO) system is OB
near expired drugs followed for drugs dispensing 2
There is system in place to maintain expiry & Check all near expiry drugs are shifted back to PHC/
near expiry of drugs referral centre/ facility where it is urgently required
based on inventory turnover (that is- Fast, slow or
non moving drugs)
2
No expired drug is found in HWC In dispensing area as well as drug storage area OB 2
There is an established process for discard (1) Staff is aware about how to discard expired drugs
the expired drugs and are not stored in HWC
(2) Check there is demarcated space/ shelf to keep SI/OB
expired drugs away from main dispensing area
2
Standard D3 The facility has defined and established procedure for clinical records and data management with progressive use of digital technology
Information regarding illness and minor (1) Diagnosis, assessments, treatment plan, drugs
aliments are recorded & updated using IT prescribed, and follow up etc are recorded & updated
platform for all cases by HSC
Information regarding ambulatory care & (2) Randomly, select at least 5 cases (or all cases if
ME D3.1 management, public health and managerial less than 5) and check for details RR/SI
functions are recorded and updated through IT
platforms

2
Information regarding RMNCHA care seekers (1) Diagnosis, assessments, treatment plan, drugs
are recorded & updated using IT platform prescribed, and follow up etc are recorded & updated
for all cases by HSC/ referral centre
(2) Randomly, select at least 5 cases (or all cases if
less than 5) and check for details RR/SI

2
Information regarding cases of (1) Diagnosis, assessments, treatment plan, drugs
communicable diseases are recorded & prescribed, and follow up etc are recorded & updated
updated using IT platform for all cases by HSC/ referral centre
(2) Randomly, select at least 5 cases (or all cases if
less than 5) and check for details RR/SI

2
Information regarding cases of Non- (1) Check family folder, CBAC form are filled and
communicable diseases are recorded & complete details are updated in portal.
updated for each case using IT platform (2) Diagnosis, assessments, treatment plan, drugs
prescribed, and follow up etc are recorded & updated
for all cases by HSC/ referral centre RR/SI
(3) Randomly, select at least 5 cases (or all cases if
less than 5) and check for details

2
Check referral in & referral out records are (1) Referral out, Assessments, re-assessments,
maintained using IT platform investigation, treatment plan and medicines
dispensed.
(2) Referral in- status at time of discharge, treatment
given, vitals medicine dispensed, follow up, any
adverse drug reaction reported, treatment plan to be
followed RR/SI
Give partial compliance if information is only
available in paper.

1
Functional platform/s and updated digital Population enumeration, coverage, screening,
records to assess the coverage and referral & follow ups RR/SI
measure outcomes of healthcare facility
2
Functional platform/s and updated digital Work plan generation- daily, weekly & missed task,
records for work/ task management reminders to team for scheduling
appointments ,follow up of home visits and outreach RR/SI
activities, Special days etc
1
Functional platform/s and updated digital Daily reporting of all the activities , IT support to
records for reporting and monitoring of the generate performance matrix of Service Providers,
performance of health care provider calculating performance based incentive, Support for
staff monitoring & maintenance of their credentials
RR/SI

2
The facility ensures safe storage, maintenance HWC has established procedure for safe (1) Secure place to keep records and registers
(2) Check records are easy to retrieve
ME D3.2 and retrieval of information & records of keeping & retrieval of paper based OB/ SI
services records 2
(1) System clearly define who all are authorized to
access the patient electronic information
HWC has established procedure for (2) Password/finger print protected Tablets
(3) Any restriction/ firewall to protect the individual's OB/ SI
access & retrieval of electronic records
information from mis-use etc
2
HWC has policy for retention period for As per State policy
different information & records RR/ SI
2

ME D3.3 The facility has established procedure for Hubs are identified for tele consultation Staff is aware of functional hubs & skilled to use OB/ RR
providing consultation using tele medicine the software 2

Cases are identified for tele consultation (1) Arrange consultation with PHC- MO or
for specialist & non specialist Specialist as per requirement. SI/ RR
consultation (2) Check how many cases were consulted using
tele medicine in preceding 3 months 2

Co ordination with specialist / super As per roster - send the patient to PHC SI/ RR
specialist for tele consultation
2
 Co ordination with patient & creating (1) Pre appointment, location for consultation
awareness about tele consultation (2) Check reminder / SMS alerts are sent for SI/ CI
services appointments/ referral/ follow up cases
2
Dispense drugs as per prescription received
through tele consultation As per e-prescription RR
2

Standard D4 The facility has defined and established procedures for hospital transparency and accountability.
HWC has functional Jan Arogya Samiti (1) Check composition of committee as per JAS
guidelines. Chairperson- Sarpanch, Co -Chairperson-
MO- PHC and Member Sect. - CHO.
ME D4.1 The facility has established procedure for (2) At least 50% of representation of women RR/SI
management of activities of Jan Arogya Samiti (3) Check committee has representation of all
habitation or communities esp. vulnerable
2
Committee members are aware of its roles & A. (1) Maintenance of HWC - cleanliness, hygiene,
responsibilities safe drinking water, clean toilet, BMW disposal &
clear signage.
(2) Management of grievances
(3) Ensure conduct of social audits & public hearing
(4)Coordinate celebration of Annual health calendar
days
(5) Effective implementation of community level
programmes viz. VISHWAS, SABLA, Eat right campaign
of FSSI, farmer groups, Self help groups, women CI/ SI/RR
groups, Milk unions etc.
B. Check each member is aware of their powers and
functions

2
JAS meetings are held at defined intervals (1) Monthly.
(2) Minutes of meeting are recorded RR
2
Check JAS supports HWC to mobilize Both monetary and non monetary from PRIs/
resources/funds CSR/Govt. schemes and program /donation etc RR/ SI
2
Timely planning & utilization of untied Timely submission of Utilization certificate as per
state/NHM norms RR/SI
funds 2
Check JAS provide support for Health
promotion & prevention activities
SI/ RR
Organize camps, VHSNC meetings, multisectoral
convergence, formation of PSGs etc. 2
Check JAS facilitate Public hearing or Jan Check when was last public hearing was undertaken.
Sunwais HWCs undertake Jan sunwais bi annually
SI/RR

2
Check social audits are done at periodic At least once in a year. Check when last social audit
intervals was undertaken
The facility has established procedures for
ME D4.2 community based monitoring of its services RR
through social audits
0
Check JAS is aware of the issues issues
emerged in Social Audits & public hearing
There is mechanism in place to improve the gaps
identified / recommendations given by social RR/SI
audits teams
0
Gaps closure plan is prepared & status is assessed
atleast once in quarter or as per decided timeline
Check JAS committee has prepared RR/SI
action plan along with HWC

2
Check social audits are conducted before Check the issues emerging out of the Social Audit are
completion of Annual planning of the gram integrated with the annual planning process of Gram
Panchayat Panchayat.
RR

(1) At least once in a month

The facility has established procedure for (2) Assess the progress on coverage of
ME D4.3 supporting and monitoring activities of Check CHO conducts periodic meetings beneficiaries & any knowledge or skill gap RR/SI
Community health workers with MPW & ASHA (3) Identify common issues & problems faced by
Frontline workers
(4) Actions taken thereafter
2
(1) Check CHO provide on job mentoring & support
to frontline workers (ASHA/ MPW)
Check CHO provide on job mentoring & (2) Visiting households requiring additional support or SI/RR
supervision household visits motivation

2
(1) Check CHO provide on job mentoring & support
to frontline workers (ASHA/ MPW)
(2) Monitoring the quality of services using checklist
Check CHO provide on job mentoring & (3) Check report is duly signed by both MPW & ASHA CI/ RR
and a copy is shared with MO- PHC
supervision for VHSND or campaign etc.

Check PHC -MO provide supportive (1) Monthly review of service delivery &
supervision & monitoring for HWC performance of HWC RR/ SI
activities (2) Supportive supervision for HWC staff
2

Standard D5 The facility ensures health promotion and disease prevention activities through community mobilization
ME D5.1 SI/ CI 2
The HWC facilitate planning & implementation of Check HWC is aware of community level
health promotion and disease prevention activities approaches for health promotion and VHSNC, VHNDs, ASHA, AWW and Monthly campaign
through community level interventions disease prevention etc

(1) Regular meetings are being conducted RR/ SI 2

(2) Community based action plan for health is
prepared
(3) Provide support to frontline workers for health
Check VHSNC are constituted & functional related activities

Check frontline workers part of VHSNC are able to

explain - Support to develop village health action
plan,
Awareness generation for Health Promotion & SI/ CI 2
disease prevention and support the community to
Check VHSNC members are aware of their raise their voice, need, experience & grievances to
roles & responsibilities towards Health & access health services or benefits
wellness centre

(1) Check agenda points and minutes of meeting of

preceding quarter
VHSNC actively involved in review of public (2) Check health & wellness activities are prioritized RR 2
services & programmes viz. ICDS, drinking (3) Check the status of planned actions & activities
water, sanitation , mid day meal including proposed for or in co ordination with health &
HWCs etc wellness centre

RR 2
Check number of VHSNC meeting attended
by CHO in preceding quarter At least 2 VHSNC per month

RR/CI 2
Check number of VHND planned & (1) Check the list of VHND planned & conducted
conducted in CHO's catering area in (2) List of AWC under HWC & name of the AWC
preceding quarter where VHNDs conducted

(1) Check advance communication regarding date & RR/CI 2

venue is given.
(2)Line listing of pregnant women requiring ANC, TB
patients, infant or children requiring immunisation,
left or drop out children & malnourished
(3) Check estimation about number of people
Micro planning to conduct VHND is done by expected to attend VHND are calculated in advance
HWC staff & frontline workers (4) Check the coverage against estimation

SI/ OB 2
Check functional equipment, instrument and
adequate consumables are available to
conduct VHND As per service provision

(1) Awareness generation for various Health program

(2) Need based counselling & interventions CI/ SI/ RR 2
Check the health promotion & disease (3) Check the list of topics covered during VHNDs in
presentation activities are performed during proceding quarter
VHNDs
Check primary healthcare team perform
advocacy with community influencers for Viz. Benefits of immunization, family planning, ANCs, CI/SI 2
giving key messages for health promotion regular check-up and Yoga for NCDs etc.

(1) Identify the individual with health risk

(2) Community mobilization for screening
(3) Holding or Support village meetings or campaigns
for awareness generation & life style modification SI/ RR 2
(4) Support treatment compliance for pregnant
women, new born, NCD & acute of chronic conditions
as per service provision
(5) Check number of new individuals identified with
health risk & mobilized for screening in proceding
quarter
Check the health promotion & disease (6) Check number of individual supported treatment
prevention activities are performed by ASHA compliance in proceding quarter

(1) Based on Population enumeration, village health

register, CBAC, ASHA diary, VHSNC records, RCH SI/ RR 2
Check the process followed to identify key registers etc
challenges and list of priorities for monthly (2) Based on social resource map - it identify location
campaigns & vulnerable section

(1) Check advance plan is available with HWC

(2) At least 30 diseases/national health program
specific awareness or health promotion campaign RR/ SI 2
are organized per year. Viz. WASH, Eat right/eat safe,
Nutrition screening, deaddiction & substance abuse,
Check Annual calendar is prepared for Indoor and outdoor pollution, Case detection for NCD
monthly campaign based on situational & CD, childhood illness diarrhoea & pneumonia,
analysis prevention of childhood marriage, GBV etc
Check health promotion campaign are Check number of health promotion campaign RR 2
conducted as per planning conducted out of planned in proceding quarter
 (1) Prepared draft campaign plan & define
responsibilities of primary care team
(2) Conduct meeting of HWC team & other RR/SI 2
stakeholders i.e. panchayat, ICDS etc
(3) Gather/PreparedIEC or IPC material required
Check the involvement of HWC in planning & (4) Engage community volunteer, support & supervise
falcitation of monthly campaign activities them
There is a system of taking feedback from
ASHAs / VHNSCs/ VHND to improve the
services SI/ RR 2

ME D5.2 For ensuring treatment compliance, reduce stigma, CI/ RR 2

The facility has Patient Support Groups(PSG) as per HWC have created Patient support groups increase acceptance toward disease, reduce stress &
the issues/ diseases in its catering population for various issues/ disease conditions anxiety & increase self understanding

SI/RR 2
(1) Identify
(1) Based onthe
issues/diseases with high
potential member prevalence
& encourage in
them
Check the process followed to create PSGs area
to using
join data &information
by explaining them thecollected
advantages of joining
(2) Friends, relatives, frontline workers and patients
suffering from same disease conditions.
(3) PSGs meetings should be open to all community SI/ CI 2
Check staff is aware of guiding principles to members
be followed to constitute PSGs

(1) Sharing the knowledge & experience with other

(2) Work together to solve the problems SI/CI 2
(3 Helping health functionaries in health promotion
Check members of PSGs aware of their roles (as convenient)
No. of planned PSGs & how many actually conducted
(1) Flexible location, - in house of group member,
arranged after VHNSC/ VHNDs, SHC, AWW - RR/CI 2
Check the frequency , location & timing of preferable near to marginalized or distant hamlets
PSG meetings facilitated by HWC (2) Time- mutually convenient
(1) Encourage participants to sit together
(2) Summarize the learnings from meeting
(3) Listening & respecting the opinion of members SI 2
Primary health care team/worker is aware of (4) Inform group about content, date , time & place
their role in conducting PSGs for next meeting
(1) Education, WCD, ICDS, rural development/
ME D5.3 The facility ensure multisectoral convergence HWC engage other allied departments municipal bodies, FSSAI &ICDS etc. RR/SI 2
for health promotion and primary prevention for intersectoral convergence (2) Check VHSNC provide platform for
multisectoral convergence

HWC support & felicitate promotion Community level education, malnutrition,

activities with their convergence sanitation drives, promotion of healthy SI/ RR 2
departments behaviour, sanitation drives etc
(1) In schools in HWC-SHC coverage area
Check Ayushman ambassador are (2) Ayushman Ambassador - 1Male & 1 female
teacher -provide age appropriate learning for SI/ RR 2
identified promotion of healthy behaviour

HWC organize training sessions & With support of Ayushman ambassadors SI/ RR 2
competitions for school children

HWC promotes wellness & health SI/ RR 2

promotion through Yoga (1) Identify pool of local yoga instructors
(2) Prepare & disseminate weekly/monthly schedule
of classes for community yoga trainings

Standards D6 The facility is compliant with statutory and regulatory requirement

The facility ensures its processes are in Authorization for Bio Medical waste Prior approval from Pollution control board (if HWC is
Management using deep burial pit)
ME D6.1 compliance with statutory and legal RR
requirement 0
No Smoking sign is displayed at the Both inside & outside the building
prominent places OB
2
Any positive report of notifiable disease is
intimated to designated authorities RR/SI
2
BMW rules, fire safety, electrical installations and any
Updated copies of relevant laws, other as per state mandate
RR
regulations and Govt orders are available
2
Area of Concern E: Wellness & Clinical Services

Standard E1 The facility has defined procedures for registration, consultation, clinical assessment and reassessment of the patients

The facility has established procedure for

ME E1.1 empanelment & registration of individual and RR/SI
families (1) There is established procedure to collect the
HWC is aware of constitution of its catering demographic composition
population (2) No. of individuals of different age groups 2
HWC periodically estimates & updates Check no. of pregnant women, no. of life births,
number of beneficiaries for RMNCHA pregnant mother with complications, eligible couple, RR/SI
services sick new born are estimated 2

RR/SI
HWC periodically estimates & updates Population above 30yrs , break up of men & women
number of beneficiaries for NCDs above 30 yrs. 2

RR/SI
HWC periodically estimates & updates
number of beneficiaries for CDs As per incidence rates/ prevalence rates 2
(1) Check family folders are maintained for entire
registered population in facility's coverage area.
RR/SI
(2) Check data base is updated regularly for new
All individuals and families are empanelled entrants and exits (annually) & their illness.
under H WC 2
ME E1.2 The facility has established procedure for Check Unique health ID is given to all individuals and
RR/CI
registration & consultation in HWC Unique identification number is given to families .
each patient 2

RR/SI
Check all the patients visiting HWC are registered &
Patient demographic details are recorded in their demographic details like Name, age, Sex and
OPD register/portal Address etc are maintained 2
Chief Complaint, Patient History, Physical
The facility has established procedure for examination, requisite diagnostics, provisional RR/SI
OPD Consultation diagnosis, primary management & referral (if
required) 2

Through tele health/ tele consultation with MO

Facility has system to undertaken opinion PHC /identified hubs/ clinical decision making -IT tool RR/SI
/consultation from higher centre 2

All the empanelled individuals are Through fix day/routine OPD consultation RR/CI
screened
2

The facility has established procedure for follow Facilities provide follow up/re Reassessment /follow up as per schedule for all cases
ME E1.3 including critical /high risk patients. CI/ RR
up/ re-assessment of patients assessment for cases under RMNCHA
Follow up includes - Treatment compliance, review of
parameters, monitoring of side effect, adherence to
life style modification, timely detection of
complication and continuity and adequacy of
treatment. 2

Reassessment /follow up as per schedule for all cases

Facilities provide follow up/re including critical /high risk patients.
assessment for cases under Follow up includes - Treatment compliance, review of CI/ RR
Communicable diseases parameters, monitoring of side effect, adherence to
life style modification and timely detection of
complication and continuity and adequacy of
treatment. 2

Reassessment /follow up as per schedule for all cases

Facilities provide follow up/re assement including critical /high risk patients.
for cases under non communicable CI/ RR
Follow up includes - Treatment compliance, review of
diseases parameters, monitoring of side effect, adherence to
life style modification and timely detection of
complication and continuity and adequacy of
treatment. 2

(1) Eye, ENT, oral, elderly & palliative, mental health

etc.
Facilities provide follow up/re assement Give full compliance if any services is not given as per CI/ RR
for other clinical conditions service mandate
(2) Follow up includes - Treatment compliance,
monitoring of side effect, adherence to life style
modification and timely detection of complication
and continuity and adequacy of treatment.
1

Standard E2 The facility has defined and established procedures for continuity of care through two way referral
Facility ensures continuity of care at
community/household level CHW ensures home visit, counselling/ supportive
ME E2.1 The facility has established procedure for activities for risk factor modification, provide CI/ RR
continuity of care reminder for follow up at HWC & collection of
drugs. Linkage with MMU/RBSK mobile unit
2
Continuity of care is ensured at Health &
wellness centre Dispensation of medicines, repeat diagnostic as
required/ as per treatment plan, identification of SI/ RR
complication , facilitating referrals, organizing
tele consultations, maintenance of records
2
Continuity of care is ensured at referral Examination, development/modification of
Centre/higher centre treatment plan, instruction for patient, note to
CHO by MO/Specialist.
RR/SI/CI

2
Early case detection, primary
The facility has established procedure for management/stabilisation, Complete details of case
ME E2.2 undertaking referred in & referred out of the cases Facility has defined protocols for referral
RR/ SI
records/care provided - use of referral slip
out 2
Check availability of separate colour coded for easy identification in referral centre
OB/SI
referal slip 2
Check records for treatment plan, periodic
assessment, medicine refill and referred to further
higher centre (if required)/ regular follow up at RR/SI
referring centre
Facility has defined protocols for referral in 2
(1) Referral slip, referral in or out register/portal,
Advance communication , prior appointment with
specialist, referral vehicle (if required) & follow up.
(2) IT system to track upward & downward referrals RR/SI
to ensure the continuity of care
Facility has referral procedure in place to
ensure continuity of care 2

Standard E3 The facility has defined and established procedures of diagnostic services.

ME E3.1 The facility has established procedure for SI/RR

laboratory diagnosis as per guidelines
Point of care diagnostics services are Check staff is aware of Quality Control method for
available as per mandate various tests (RDKs) 0
 CI/ SI
Central hub/diagnostic units are identified & For Both laboratory/other diagnostic test. Check how
linkage has established for tests not done much patient has to travel for getting diagnostic
at HWC services 2

(1) Check IT system is used for reporting of diagnostic

results from PHC/referral centre or identified hub RR
HWC has system for timely reporting, results.
retaining & prompt retrieval of diagnostic (2) Biological reference intervals for laboratory tests
result are available in HWC 2

RR/SI

Check there is no irrational prescription of Check OPD ticket for any irrational prescription of Lab
Diagnostic test test/USG/ X ray etc 2

Standard E4 The facility has defined procedures for safe drug administration.

ME E4.1 Facility follows protocols for safe drug Medication orders are written legibly and
RR/SI
administration updated (1) Every medical advice is accompanied with date,
time and signature. Check orders/ instructions are
comprehendible
(2) Ask the staff what protocols are followed in case
orders/instructions are not legible due use of
abbreviations, handwriting etc 2

(1) Drugs are checked for expiry and other

There is procedure to check the drugs before inconsistency before administration, single dose
OB/SI
administration and dispensing vial /ampule are not used for more than one dose &
separate sterile needle is used every time.
(2) Check prescription from referral centre is verified
every time before dispensing of the drugs from
HWC /in home visits 2
Patients are counselled for self drug (1) Medication calendars /schedules, specify the time
administration to take medications, medicine related information
sheets, specific packaging’s such as pill boxes/
envelope, indicating the time/ frequency of dose. CI/ SI
(2) Check patient is aware of 5 moments of
medication safety
2

ME E4.2 There is process for identifying and cautious Check high alerts drugs are identified & SI/ RR
administration of high alert drugs its maximum dose are defined High alert drugs such as Nonsteroidal anti-
inflammatory, anti convulsant/antiepileptics,
Hypertensive, oral hypoglycaemic etc. 0
Check staff is aware of right dose of high Value of maximum dose as per age, weight and SI/RR
alert drugs diagnosis is available with CHO. 2

Check staff follows 6 Rs of drug (1) Right patient, right drug, right route, right time,
right dose & right documentation. SI/RR
administration (2) Check system in place to verify the verbal orders
given by MO 2
Check with staff if any untoward drug SI/RR
events has ever occurred 2
Minimum information model (MIMPS) for medication
Check any untoward/adverse drug events safety is followed & used for reporting & subsequent RR/ SI
are recorded and reported actions planning 2

Standard E5 The facility follows standard treatment guidelines and ensures rational use of drugs

Check the cases in which CHO has prescribed

ME E5.1 There is procedure of rational use of drugs medicines/ antibiotics. Check if the drugs are either RR
prescribed more than required dose /quantity or on
Check staff is aware of rational use of drugs more occasion than necessary. 2
Check availability of STG/clinical algorithm/ Clinical
decision making tool (IT based), Staff is aware of drug RR/ SI
Check STG/ clinical algorithm is followed regime and doses 2
Check medication review is scheduled for At least once in a year RR/CI
regular chronic cases with PHC MO/ Physician of referral facility 2
Check drugs are prescribed with generic Check OPD ticket if drugs are prescribed under RR
name generic name only 2
Check HWC has antibiotic policy Check staff is aware of antibiotic policy RR/SI 2

Facility has system in place to periodically Well defined and standardized format is used to
ME E5.2 assess the quality and accuracy of treatment RR/ SI
monitor the treatment provided by CHO Treatment provided by CHO is monitored provided. Valid sample is taken & frequency of
regularly monitoring process is defined and followed 2
Check monitoring is done by qualified SI/ RR
personnel Preferably MO of Mother PHC/referral site 2
Check medication orders/ procedure is Check medical advise is accompanied with date, time RR
written legibly & comprehendible & signature 2

(1) Non compliances ( viz over prescription, irrational RR/SI

use of antibiotics, drugs, vitamins, vaccines,
diagnostics etc) are enumerated , (2) Action plan is
prepared & Primary health care team is hand holded
Action taken on non compliances & guided for improvement 2
Standard E6 The facility has defined and established procedures for nursing care.

ME E6.1 There is established procedure for identification There is process for ensuring the Both in HWC & home based care.
SI/OB
& periodic monitoring of the patients identification of patient before any Investigations, refill the medicines, performing minor
procedure procedure, administrating vaccine etc 2
 Patients who are not oftently following their SI/ RR
There is process in place to identify non treatment plan or taking the medicines as
compliant patient in chronic disease recommended 2

Chronic cases/ critical patient referred from higher

centre/Home based care patient/ bed ridden/ elderly RR/SI
cases
Patient's vital are monitored and recorded Check Patient vital like BP, weight, TPR, Blood sugar
periodically in follow up etc are maintained as per disease conditions 2

Prescribed treatment plan and procedure Prescribed Treatment plan , procedure

ME E6.2 performed are written in case sheet/OPD Treatment plan followed , medication administered RR
performed are recorded in patient's record
ticket/Portal are documented 2

Day to day progress of patient is recorded Progress is monitored & documented as per schedule RR
where ever required/ critical/ chronic cases prescribed 2
HWC, home based care/ home visits, patient self
Adequate forms, formats and records are managements
ME E6.3 OPD slip, family folders, referral slips , Disease specific RR/ OB
available as per services mandate forms & formats (any hard /soft copy)
Standard forms & formats are available 2
Registers & records are maintained as per RR
Updated Registers & records are available guidelines/range of services provided by H WC (SC) 2
All the register/records are identified and Check the master list & unique identification number OB/ RR
numbered is followed to identify records 0

Standard E7 The facility has defined and established procedures for Emergency care

Emergency protocols are defined and Protocols for snake bite, poisoning, drowning,
ME E 7.1 trauma, burn, fits, cardiac or respiratory arrest , SI/RR
implemented Emergency protocols for first aid and haemorrhoids, rectal
stabilization are available prolapse, hernia, hydrocele, appendicitis etc. 0

Check staff is aware of steps of BLS and also ask

about how to recognize the signs for sudden cardiac SI/RR
arrest (SCA), heart attack, stroke, and foreign-body
Staff is aware of procedure for CPR airway obstruction (FBAO) 2

(1) Check how ambulances are called & patient is

shifted. RR/CI
(2) Transfer register is maintained to record the
HWC ensures timely availability of details of the refferred patient
ambulances services for emergency cases 0

ME E 7.2 The facility has disaster management plan in Staff is aware of district disaster management team, SI/ OB
place staff is aware of their roles, basic emergency
Emergency care is given in case of disaster management kit is available 2

Staff is aware of process of sorting the Staff is aware of triage protocols in case of referral SI/RR
patients in case of mass causalty/ outbreak required 2

Standard E8 The facility has defined & established procedures for management of ophthalmic, ENT and Oral aliments as per operational/ clinical guidelines

Standard E9 The facility has defined & established procedure for screening & basic management of Mental Health ailments as per Operational/ clinical guidelines

Standard E10 The facility has defined & established procedures for management of communicable diseases as per operational/ clinical guidelines

Source reduction, personal protection, environment

The facility provides services under National management, Biological control ( Larvivorus fish) &
ME E10.1 vector Borne disease control programme as per chemical control (larvicide / Adulticide) . Staff is SI/ RR
guidelines as per guidelines involved in intersectoral convergence with other
departments like DODWS (Department of Drinking
Water and Sanitation under Ministry of Jal Shakti,
MOHUA (Ministry of Housing and Urban Affairs),
Primary care team is aware of vector born Municipalities etc) & carry out weekly cleanliness
disease control strategies drive in village through VHSNC 2

(1) Fortnightly Home visit & testing people with

current/ recent fever & chills in past 14 days using
RDT.
(2) Malaria detection in cases presenting with fever at RR/ SI
HWC
(3) Detection by using RDT/Microscopy. (Microscopy-
result should be made available within 24 hrs)
(4) Negative RDT cases strongly suspected of malaria
cross checked by microscopy
(5) Check HWC is aware of confirmed malaria cases in
Case detection is done for Malaria its catchment area 2

(1) Treatment should be started within 24 hrs of

detection. RR/ SI
(2) P. Vivax - Chloroquine/ 3days and Primaquine/14
days. (Contraindicated in pregnant female or infant or
G6PD deficiency/ P- falciparum- ACT
Staff is aware of Malaria treatment protocols (3) Algorithm for treatment & diagnosis is available 2

Persistence of fever even after 48 hrs of treatment, SI/RR

continuous vomiting, headache, dehydration, change
in sensorium, convulsions, bleeding & clotting
Staff is aware of Malaria referral protocols disorders, severe anaemia, Jaundice & hypothermia 2

(1) Diagnostic- RDK

(2) Management- Bed rest, SI/ RR
cold sponging,& symptomatic treatment.
Staff is aware of diagnostic & management (3) Check HWC is aware of dengue cases in its
of dengue as per protocols catchment area 1

Check register is maintained & updated, reporting in

form M 1 (ASHA/SC), M2 (if using slides), M4- RR/SI
fortnight complied report of malaria surveillance
NVBDCP register & records are maintained submitted by SC 1
 RDT kits , clean slides, needles, swabs, ACT, CQ, PQ
Facilities have adequate stock of etc. Check how kits have been stored & near expiry RR/SI
commodities & drugs drugs are not available 1
Staff is aware of sign & symptoms of Chikungunya, KA, JE, LF etc. SI
prevalent vector born diseases in area Any of the cases in their catchment area 2

ME E10.2 The facility provides services under National Refer all presumptive cases to designated Microscopy RR
Tuberculosis Elimination Program (NTEP) Identification of presumptive case & their centre. Sputum collection and transport of sputum of
referral samples is supported in hard/difficult areas. 2

(1)Provision of DOTS at Sub-centre, proper

documentation and follow-up, home based support, OB/ RR
regular screening of cases for common adverse
HWC support, supervision & manage effects, ensure compliance & completeness of course
presumptive, confirmed & on treatment (2) Check HWC is aware of presumptive, confirmed &
cases including DR- TB patients on treatment cases in its catchment area 2
Staff is aware of follow up protocol after 6,12, 18 , 24 month follow up after treatment SI/ RR
treatment completion completion 2

RR
Referral slip, Patients treatment card (if CHW is
NTEP register & records are maintained supporting treatment), TB notification register 2

(1) Pale & reddish patches on the skin, skin thickness,

shiny & reddish, numbness & tingling, painful tender
ME E10.3 The facility provides services under National nerves, weakness of hands, feet or eyelid, swelling & RR/ SI
Leprosy Eradication Program as per guidelines lumps in the face & ear lobes impaired sensation.
(2) Sensory testing for screening: touching the tip of
pen on patch to feel sensation 2 times (once with
eyes & 2nd with closed eyes)
Primary healthcare team identify and (3) Referral of suspected cases to higher centre. First
ensure referral of suspected cases of Leprosy dose initiated at higher centre 2

Ensure delivery/ availability of 2nd dose onward

drugs, pulse dose to be given in presence of
ANM/MPW, completion of treatment, identification RR
Check the availability / delivery of of signs of neuritis, reactions etc for treatment cases.
subsequent doses of MDT and follow up of Referral in case MCR footwear if required/ referral for
persons under treatment complications 2
Maintain & update case card (ULF01), Update the RR
NLEP register & records are maintained treatment registered when visiting the PHC 2

Health education to community regarding signs and

symptoms of leprosy, its complications, curability & CI/ SI
availability of free of cost treatment, self care &
Facility provide awareness about leprosy & encourage the patient to bring his/her contacts to
availability of its treatment check-up 2

ME E10.4 The facility provides services under National Identification & referral of suspected cases, Condom RR/ SI
AIDS Control Program as per guidelines Promotion & distribution among high risk groups &
help HIV cases for receiving & adhering to ART.
HIV/STI Counselling, Screening (consent) and referral
HWC-HSC is aware of their roles in NACP in Type B Sub-centres in high prevalence districts 2
HWC -SC has linkage for management of Linkage with Microscopy centre for HIV -TB, for PPTCT RR
HIV/AIDS complications services 2

IEC for STI,HIV/AIDS Awareness generation ,

identification of peer support groups for HRG- PLHIV,
encourage for index testing, support in treatment RR/ SI
adherence, arrangement for counselling/ psycho
Staff is aware of promotional &supportive therapies, community follow up to support HIV
activities done under NACP pregnant women & 2

Fever, Cough less than 2 weeks duration, acute

ME E10.5 flaccid paralysis more than 15 yrs. of age, SI/ RR
diarrhoea (3 or more loose stool /day), Jaundice,
The facility provides services under Integrate Staff is aware of syndrome under Raise the signal for action in case of for any
Disease surveillance as per guidelines surveillance in IDSP unusual health event /death 2

(1) Information is collected from Home visit (for

above described syndrome) & from SC- OPD RR
Check process to collect information in (2) Collation of data in Register for Syndromic
form S Surveillance 2

(1) Preliminary analysis & reporting of collected

data to MO- PHC on every Monday RR/ SI
Check Analysis & reporting of (2) Check any action has been undertaken using
information for syndromic surveillance is IDSP data
done 0

ME E10.6 RR
The facilities provide services for National Viral Availability of diagnostic & treatment RDT for Hep B & Hep C & referral for
Hepatitis Control Programme (NVHCP) services confirmation & further management 2

Awareness generation & behaviour change

Staff is aware of preventive measures for communication, immunization for Hep B (Birth SI/ OB
dose, high risk group & healthcare worker) ,
injection safety & safe drinking water &
sanitation. 2

Standard E11 The facility has defined & established procedures for management of non-communicable diseases as per operational/ clinical guidelines
 (1) Population enumeration -filling of CBAC form
for all above 30Yrs of age- Screening at HWC on
fixed day approach-referral of suspected cases to
Staff is aware of process of population higher centre for Consultation - follow up of
ME E11.1 The facility provides services for hypertension identification and referral for those who are diagnosed with hypertension & RR/ SI
as per guidelines hypertension ensuring that they adhere to treatment plan-
identify warning signs of complication & refer to
higher centre.
(2) Re screening of population (new and old) at
periodic intervals - every year

2
Systolic/ Diastolic BP of over 140 /Over 90 mm of
CHO is aware of sign & symptoms of Hg.
Severe Headache, fatigue, nausea, sweating, SI
Hypertension feeling faint & confusion, vision problem, chest
pain, shortness of breath.
2

Interview patients for:

(1) Regular & adequate availability of medicines as
per treatment plan RR/CI
(2) His/her understanding about dosage schedule, life
style medication, any dietary restriction and
awareness about next follow up visit date
HWC ensures frequency of follow up & (3) Annual consultation with specialist at NCD clinic
supply of required medicines 2

Awareness generation - (a)Risk factors: overweight &

obesity, Physical inactivity & stress (b) Healthy life CI/ SI
style: diet, exercise, avoidance tobacco & alcohol, (c )
Staff is aware of promotional &supportive Counselling for Lifestyle modification (d) importance
activities for Hypertension of regular follow & compliance to medication 2

(1) Population enumeration -filling of CBAC form

for all above 30Yrs of age- Screening at HWC on
fixed day approach-referral of suspected cases to
higher centre for consultation - follow up of
ME E11.2 The facility provides services for Diabetes as per Staff is aware of process of population those who are diagnosed with hypertension & RR/ SI
guidelines identification and referral for diabetes ensuring that they adhere to treatment plan-
identify warning signs of complication & refer to
higher centre
(2) Re screening of population (new and old) at
periodic intervals -every year

Random blood sugar 140mg/dl and mg/dl.

Frequent urination, increased hunger,excessive
CHO is aware of sign & symptoms of thirst, unexplained weight loss, extreme SI
diabetes tiredness, blurred vision, slow wound healing
numbness or tingling hands or feet & sexual
problems
2

Interview patients for:

(1) Regular & adequate availability of medicines as
per treatment plan RR/ CI
(2) His/her understanding about dosage schedule, life
style medication, any dietary restriction and
awareness about next follow up visit date
HWC ensures frequency of follow up & (3) Annual consultation with specialist at NCD clinic
supply of required medicines 2

Counselled about not to miss/skip meal, take up

frequent and small meals, increase physical
activity and side effects of anti diabetic drugs.
Hypoglycaemia: Symptoms; tremors,
nervousness, anxiety, sweating, irritability,
confusion, Heart beat increase, headache etc SI/ CI
Management: Take 5-6 toffees/ Mishri/1 table
spoon sugar/honey/ 2-3 teaspoon of glucose/ 3-4
tea spoon of sugar/ half cup of juice or cold drink.
If symptoms persists patient should be taken to
higher centre for further management.
Check Patient is counselled about
identification & immediate management
hypoglycaemia 2

(1) All overweight or obese cases with diabetes

or prediabetes symptoms or elevated blood lipids
or elevated blood pressure
(2) All such cases are screened for:
● Abdominal Obesity (waist circumference of ≥
90 cm in men or ≥ 80 cm in women) SI/RR
● Family H/O diabetes, hypertension, heart
diseases and cancers
● Obesity (BMI>=25kg/m2)
● Oedema examination
(3) Referal to PHC for management
HWC is aware of risk factors of
Nonalcoholic fatty liver disease (NAFLD) 0

Awareness generation - (a)Risk factors: overweight &

obesity, Physical inactivity & stress (b) Healthy life CI/ SI
style: diet, exercise, avoidance tobacco & alcohol, (c )
Counselling for Life style modification (d) Importance
of regular follow & compliance to medication (e)
Staff is aware of promotional & supportive Counselling about diabetes related complication viz.
activities for diabetes Retinopathy, neuropathy & kidney failure etc. 2
 (1) At SC/ outreach/screening for Breast, cervix & oral
cancer.
(2) Screening is undertaken by trained personnel
ME E11.3 The facility provides services for cancer Check cancer screening services are (LHV/Staff nurse/MO) can be done in outreach
RR/ SI
screening and referral as per guidelines provided through HWC session/screening day.
(3) Screening of cervical cancer is conducted on site
where privacy & facility for sterilization is available
(4) Repeat screening -every 5yrs
2
Vaginal bleeding between periods, menses longer or
Staff is aware about sign & symptom of heavier than usual, post menopausal bleeding,
SI
cervical cancer bleeding & pain during/after sexual intercourse,
smelly vaginal discharge, pain during urination etc
2
Lump in breast/under arm area, thickening or
Staff is aware about sign & symptom of swelling of breath, puckering /dimpling of breath skin,
SI
Breast cancer redness in nipple area, nipple discharge /blood,
constant pain etc
2
Difficulty in chewing or swallowing , mouth ulcers
Staff is aware about sign & symptom of Oral persist for more than 3 weeks, persistent pain,
SI
Cancer lump, thickening in cheek, white/red patch on
gums/ tongue/tonsil etc, 2

(1) Visual Inspection by Acetic Acid for cervical, (2)

Oral Visual Examination for oral cancer (3) clinical
Check with staff about methodology breast examination for Breast .
RR/ SI
followed for cancer screening (4)Discuss interpretation of results if done at
SC/outreach session/screening day
1
For cancers of the oral and breast, the first level of
referral is the CHC / SDH/ DH and then to the DH for a
Check CHW is aware of referral centre for all
biopsy for confirmed cases. SI /RR
types of cancer
For cervical cancer, if VIA positive, refer to higher
centre offering colposcopy
2

Awareness generation - (1)Risk factors: smoking,

multiple sexual partner, unprotected sex, family
history, overweight, lack of physical activity (2) CI/ SI
Healthy life style: diet, exercise, avoidance tobacco &
alcohol, (3 ) Counselling for Life style modification (4)
Staff is aware of promotional & supportive importance of regular follow & compliance to
activities for diabetes medication 2

Staff is aware 5A approach - Ask, advise, assess, Assist

& arrange
(1) History taking and referral to identified de
The facility provides services for de addiction, addiction centre.
Confirmation and referral of cases for (2) Advise to quite in cleat, strong and personalized
ME E11.4 and locally prevalent health diseases as per Tobacco/alcohol/ substance abuse manner
SI/ RR
guidelines (3) Attempt to Quit (4) Involve family & friends,
remove substances from their adjacent area, Arrange
follow up visit (5) motivate by re enforcing & intense
follow up
1
(1) For Withdrawal symptoms (2) Life style support
Promotional & supportive activities for changes (3) Engagement/ linkage with patient
CI/ SI/RR
Tobacco/alcohol/ substance abuse support groups (4) Support encouragement by family
& friends
2
Ask for local prevalent disease viz. Pneumoconiosis ,
Check Screening & referral locally prevalent
lead poisoning, fluorosis etc. Give full compliance if SI/CI
diseases
no such disease exists 2

The facility promotes services for health & Through trainer Yoga instructor (ASHA/ Asha
ME E11.5 Check HWC is providing Yoga services facilitator/ Yoga teacher/ physical instructor from SI/ RR
wellness school) 2
1. Check roster is available, updated & displayed
Check Yoga sessions are conducted regularly 2. Community is aware of yoga sessions conducted by RR/CI
HWC 1

One day fixed Ayurveda clinic for diet counselling,

Check Ayurveda services are available management of chronic aches & pains & elderly care. OB/ RR
Check availability of Ayurveda physician & medicines
2

Check staff counsel mother's for nutritious diet during

first 1000 days of life
(1) Stage 1 (During Pregnancy) : Balance & nutritious
diet including important nutrients like iodine, folic
acid, iron, vit B12 etc.
Check counselling of mother's for (2) Stage 2 ( Period from birth of child to 1 yr.): Early
nutrition & hygiene maintenance under initiation of exclusive breastfeeding for initial 6 SI/CI
Eat right months, initiation of Complementary feeding on
completion of 6 months with continued Breastfeeding
(3)Stage 3 (Period between 12 month to 24 months
of child age): Complementary feeding & its
preparation with right consistency, quantity,
frequency, density & variety.

Check staff counsel and guide the (1) Guide about household measurement with
mother's about household preparation of household utensils
(2) Awareness on ingredients, quantity & frequency
SI/CI
complementary feeds of complementary feeding for children up to 2 yrs.
2

(1) Generate awareness about 4 major food groups

(food pyramid) - a. Cereals & millets
Check Primary health care team generate
b. Vegetables & fruits, c. Milk & animal products d.
awareness in community about balanced SI/CI
Fats/ oils, sugar & nuts
diet
(2) Limit the consumption of foods high in fats, sugar
& salts
2
(1) Awareness on benefits of fortified food
Check Primary health care team generate
(2) Identification of fortified food available in market
awareness in community about food SI/CI
(+F logo)
fortification
2
 Awareness generation about maintaining personal &
environmental hygiene while cooking food (viz.
Check Primary health care team generate
handwashing, regular bathing, wearing clean clothes,
awareness in community about Eat safe SI/CI
keeping kitchen clean, taking pest control measures,
practices
waste disposal, using kitchen waste for compositing
etc)
2

(1) Awareness generation about logos on packed

food viz. fssai, ISI, +F, green and red dots for
vegetarian and non vegetarian food items.
(2) Safe storage of perishable & non perishable
Check Primary health care team generate food
awareness in community about food safety (3) Precautions to be taken while cooking & CI/SI
serving the meals.
(4) Awareness about common tests for food
adulteration (Key ring test)

Standard E12 Elderly & palliative health care services are provided as per guidelines

Standard E13 The facility has established procedures for care of new born, infant and child as per guidelines

Not able drink or breast feed, vomiting, convulsions,

lethargy Discharge from cord, pallor, cyanosis,
ME E13.1 Post natal visit & counselling for new born & CHO & CHW are aware of danger signs of Jaundice, pustules, hypothermia, unable to pass
SI/RR
infant care is provided as per guideline new born & infant stool/urine, fever, diarrhoea, indrawing of the chest
(2-12 months-50 breaths/min & 12-5yrs-40
breaths/min)
2
Staff practice ETAT protocol. Stabilization per disease
Primary management & prompt referral of
condition. SI/ RR
sick new born & infants
2
Exclusive breast feeding, cord care, maintenance of
Staff is aware of post natal care Counselling temperature, promoting hygiene practise, support for CI/ SI
high risk babies 2
DPT, DT, Hep B ,TT vials & diluents are not kept in
ME E13.2 The facility provides immunization services as Check for vaccines & diluents are kept as per direct contact of ice pack , Discarded medicines are
OB/ SI
per guideline the recommendation of guidelines kept separately
2

(1) Ask staff about when BCG, measles and JE

vaccines are constituted and till when these are valid
for use. Should not be used beyond 4 hours after
Reconstituted vaccines are not used after reconstitution.
OB/SI
recommended time (2) Vials should be kept in plastic box with label ' NOT
TO BE USED' & discarded after 48 hrs/ before the
next session, whichever is earlier.

2
Staff checks VVM level before using vaccines Staff is aware of how check freeze damage for T-
and identify discard point Series vaccines SI
2
Parents are counselled for informing any Observe interaction at session site and interview
untoward event of concern following parents /care giver OB/CI
vaccination
2
Antipyretic drugs are provided wherever Observe session site and interview parents /care
required giver OB/CI
2
Beneficiary is asked to stay for half an hour To observe any AEFI, Staff is aware of minor & serious
after vaccination AEFI with its management, reporting of AEFI
Counselling on side effects and follow up visits (CEI) CI/ OB

2
Vaccinator is aware about how to manage Ask the vaccinator what steps to take in case of
any immediate serious reaction/anaphylaxis serious reaction/anaphylaxis SI
2
Check the availability of anaphylaxis kit with Kit constitute of job-aid, dose chart for adrenaline as
ANM at session site per age (1 ml ampoule -3 no.), Tuberculin syringe
(1ml-3 no.), 24H/25G needle- 3 no, swabs-3 no.
updated contact information of DIO, MO PHC/CHC & OB
local ambulance services and adrenaline
administration record slip.
2
Check adrenaline is not expired in kit Give non compliance if kit is not available
OB
2
Check for injection site is not cleaned with Cleaning of injection site with spirit swab is not
spirit before administering vaccine dose recommended OB/SI
2
Check that Staff knows how to use AD Ask for demonstration , How to peel, how to remove
Syringe air bubble and injection site SI/OB
2
Staff is aware of the shelf life of Vit A once it Shelf life 6-8 weeks. Check mention of opening date is
is opened and ensures it is not given after marked on bottle SI/ OB
shelf life
2
ANM/CHW is aware segregation policy after 1. Segregate use & unused vials, Kept in sealed/zipper
completion of immunization session bag in the vaccine carrier cold chain (reverse cold
chain) & picked by AVD
2 Vaccine carrier/ vaccines are not kept in field , in SI/OB
exceptional cases the vial should be discarded
2
Staff is aware of Open vial policy OVP is not applicable to opened reconstituted vials of
measles, BCG & JE SI/ OB
2
Check for HWC -SHC micro plan for
immunization & its adequacy RR
2
Staff is aware of how to calculate the Estimating the beneficiaries & logistic. Preparing due
number of beneficiaries, quantity of vaccines list of expected beneficiaries including number of
& syringes beneficiaries & wastage/dosage per multidose vials
All the vaccines covered under OVP can be used up to RR/ SI
4 weeks if meeting OVP norms

2
HWC -SC maintain tracking bag/ tickler box Counter foil are updated & utilized for follow up SI/RR 2
 Check Vaccinator is aware of different 1. Ask the staff to enumerate categories or whether
categories of AEFI he/she can differentiate between minor & severe
AEFI.
2. The case definition list of severe/serious AEFI is SI/RR
available with provider
1
Check person responsible for notifying & Ask the staff regarding the responsibility for notifying
reporting of the AEFI is identified and reporting the AEFI
SI/RR
2
Process of reporting and route is Ask staff to whom the cases are reported & how
communicated to all concerned SI/RR
2
Reporting of AEFI cases is ensured by ANM 1.Verify weekly report of AEFI cases.
2.Nil reporting in case of no AEFI case. RR
3. Verify HMIS report of previous months
1
Frontline workers & Health supervisor is Verify with current AEFI guidelines
aware of his/her roles & responsibility for SI/RR
AEFI surveillance Programme
2
Vaccinator is aware about how to prevent Ask vaccinator how to prevent immunization related
immunization error related reactions reactions from occurring SI
2
Primary healthcare team communicate Observe the session interaction/ interview the OB/CI
the benefits of RI at VHND sessions beneficiaries 2
Assessment for identification of ARI, ARI: Chest indrawing difficulty in breathing ,coughing,
diarrhoea, malnutrition and Other Illness fever, fast breathing
Malnutrition: Weakness/wasting, check weight for
ME E13.3 Management of children for ARI, diarrhoea, age, check height for weight SI/RR
malnutrition and other illness Diarrhoea: Sunken eyes, lethargic, unconscious,
restless, irritable, pinch skin
2
Assessment for identification of possible Young infant- Not able to feed or convulsion or fast
serious bacterial infections among young breathing >60/ min or severe chest indrawing or
infant (0-59 days) & children (2 -59 months) axillary temp 37.5 OC or more or movement only
when stimulated
Children - General danger signs, or chest indrawing -
very severe or severe pneumonia SI/RR
Fast breathing - RR -2-11month >or equal 50/min
12-59 months> or equal 40/min- Pneumonia

2
Management of diarrhoea is done as per ORS, Zn, Lot of fluids, & treatment with
protocols Cotrimoxazole. Counselling and referral if required SI/RR
2
Management of ARI is done as per protocols
Symptomatic treatment, Paracetamol for fever,
plenty of fluids, keep child & give normal diet . SI/RR
Counselling & referral if required 2
Management of Possible serious bacterial
infection as per protocols
(1) Give first dose of oral Amoxicillin and injectable
Gentamycin.
(2) Treat or prevent low sugar (breastfeed/ age SI/RR
appropriate feed)
(3) Warm the young infant if temp is less than 35.5
O
C.
(4) Advise mother to keep young infant warm & refer
urgently to hospital 2
Management of Malnutrition is done as per
protocols CI/ SI
Counselling for nutrition & referral 2
Screening, referral and follow up of
children for anomalies, disabilities and Functional linkage with RBSK team, referral & follow
RR/SI
developmental delays up 2

Standard E14 The facility has established procedures for family planning as per government guidelines and law.
The client is given full information about Importance of FP, Options available- ( limiting &
Family planning counselling services are family planning methods spacing method), time for initiation & advantages of
ME E14.1 various available methods. For Limiting method - SI/RR
provided as per guidelines counselled & referred to higher centre
2
Staff is aware of Method specific counselling
approaches
BRAIDED Approach: Benefits of method, risk,
consequence of failure, alternatives, inquiries,
SI/CI
decision to withdraw, explanation of method chosen
& document of session
2
Care seeker is counselled about Such as risks, advantages, and possible side effects of
contraindications & adverse events of OCPs/ECP/ Injectable/IUCD/ cent chroman , what to
chosen FP methods do if dose of contraceptive is missed, method of CI/SI
administration of ECP. 2
1.Nayi Pahel Kit, Saas Bahu Samelan, Saarthi.
2. Give full compliance if facility is not covered under
Promotional activities for Family Planning MPV but undertake promotional activities. CI/ RR
are provided at facility under Mission Parivar
Vikas 2
The facility provides spacing methods for Staff is aware of case selection criteria for 15-49 yrs., married
ME E14.2 family planning methods SI/RR
family planning as per guidelines 2
Staff is aware of options, indications & (1) Hormonal (Combined oral pill) ,Non Hormonal
methods for administration for Oral (Chaya) & Emergency Contraceptives.
Contraceptives (2) Combined oral Pill taken at fixed time daily
ECP_ within 72hrs, second dose 12hrs after first dose
Centchroman: to be taken twice a week for the first
3 months followed by once a week thereafter.
Check for Chhaya/Centchroman eligibility is checked
& confirmed by MO. Dose may be started by trained SI/ RR
HCW

2
IUD insertion & follow up is done as per
standard protocol No touch technique, Speculum and bimanual
examination, sounding of uterus and placement.
Follow up : when to return / removal of IUCD. Check SI/ RR
In case of 2nd trimester abortion IUCD is provided by
Qualified Medical officer
2
 Injectable Contraceptives are given as per Check the eligibility for injectables are checked &
protocols confirmed by MO. Dose may be started/ continue by
trained HCW. Depot MPA can be given IM or
Subcutaneous, SI/ RR
IM: single dose vial with disposal syringe & needle.
Subcutaneous: Pre filled AD syringe
0
The facility provides limiting methods for Staff is aware of case selection criteria for For sterilization: 22-49 yrs.- (female) & 22-60yrs
family planning as per guidelines limiting mentors (male), married, youngest child is at least one
year & spouse has not opted for sterilization.
ME E14.3 Counselled & referred to Higher centre SI/ RR

2
HCW is supporting & encouraging the clients
for post sterilization follow up
Check adherence to GoI guidelines
Female Sterilization: Certification is issued one
month after the surgery or after the first menstrual SI/ RR
period, whichever is earlier.
Male Sterilization; Certificate is issued only after
three months once the semen examination shows no
sperm, certificate can be delayed till 6 months if the
semen shows sperm after 3 months. (A 2

Standard E15 The facility provides Adolescent Reproductive and Sexual Health services as per guidelines.

Provision of education & counselling services

The facility provides promotive, preventive & for adolescent Nutritional Counselling, advice on topic related to
ME E15.1 Growth and development, puberty, myths & CI/ SI
curative service for adolescent misconception, pregnancy, safe sex, menstrual
disorders,anemia, sexual abuse ,RTI/STI's etc. 2
Services for treatment & referral of
common RTI/STI's, Nutritional Anaemia & Haemoglobin estimation, weekly IFA tablet, and
Menstrual disorders treatment for worm infestation, Symptomatic RR/ CI
treatment , counselling , TT at 10 and 16 year.
Referral linkages to ICTC and PPTCT 2

Standard E16 The facility has established procedures for Antenatal care as per guidelines
Facility provides and updates “Mother Check Mother & Child Protection cards have been
There is an established procedure for registration and Child Protection Card” provided for each pregnant women at time of 1st
ME E16.1 and follow up of pregnant women.
RR/ CI 2
registration/ First ANC
Facility ensures early registration & line Check ANC records for ensuring that majority of ANC
listing of high risk ANC cases registration is taking place within 12 week of RR/SI 1
pregnancy in ANC register
Clinical information & records of ANC is kept Check, if there is a system of keeping copy of ANC
with HWC information like LMP, EDD, Lab Investigation
Findings , Examination findings etc. with them.
Records of each ANC check-up is maintained in ANC RR/SI 2
register

Staff has knowledge of calculating expected Check with staff the expected pregnancies in her area
pregnancies in the area / how to calculate it.(Birth Rate X Population/1000
Add 10% as correction factor (Still Birth) SI/RR 2

Tracking of Missed and left out ANC 1.Check with ANM how she tracks missed out ANC.
Use of MCTS by generating work plan and follow-up
with ASHA, AWW etc.
2. Check if there is practice of recording Mobile no. of SI/RR 2
clients/next to kin for follow up

All pregnant women get ANC check-up as 1.Ask staff about schedule of 4 ANC Visits
per recommended schedule (1st - < 12 Weeks
2nd - < 26 weeks
3rd - < 34 weeks
4th >34 to term)
2.Check ANC register whether all 4 ANC covered for SI/RR 2
most of the women (sample cases).
3.At least one ANC visit is attended by Medical Officer
(Preferably 3rd Visit -28-34 Weeks)

There is an established procedure for History taking, At ANC clinic, Pregnancy is confirmed by Check for ANC record that pregnancy has been
ME E16.2 Physical examination, and counselling of each performing urine test confirmed by using pregnancy test Kit (Nischay Kit) SI/RR 2
antenatal woman, visiting the facility.
Last menstrual period (LMP) is recorded and Check how staff confirms EDD & LMP, (EDD = Date
Expected date of Delivery (EDD) is calculated of LMP+9 Months+7 Days) How she estimates if
on first visit Pregnant women is unable to recall first day of last
menstrual cycle ('Quickening', Fundal Height) .Check SI/RR 2
ANC records that it has been written

Comprehensive Obstetric history is recorded

(1) History of pervious pregnancies including
complications and procedures done, if any, is taken.
History of current or past systemic illness like
Hypertension, Diabetes, Tuberculosis, Rheumatic
Heart Disease, Rh Incompatibility, malaria, etc. is SI/ RR 2
taken.
(2) Allergies to drugs, any treatment taken for
infertility.

Physical Examination & vitals of Pregnant Pulse, Respiratory Rate , Pallor, Oedema. Height,
Women is done on every ANC visit weight & BP- Check any 3 ANC records/ MCP card
randomly to see that weight has been measured and
recorded at every ANC visit
Observation and Correction of Flat or Inverted RR 2
Nipples
Palpation for any Lumps or Tenderness

Abdominal Examination is done as per Measurement of Fundal Height (ask staff how she
protocol correspond fundal high with Gestational Age),
Auscultation for foetal heart sound ,
Palpation for Foetal lie and Presentation Check for SI/RR 2
findings recorded in MCPcard/ANC Records
 1.Check for Haemoglobin, confirmation of pregnancy,
urine albumin & sugar blood, blood sugar, Malaria.
The facility ensures of drugs & diagnostics are
ME E16.3 prescribed as per protocol
Check randomly any 3 MCP card/ ANC record for SI/ RR 2
Haemoglobin test is done at every ANC visit and
values are recorded.
2. Haemoglobin & urine albumin & sugar test is done
Diagnostic test for every pregnant women on every ANC visit
Referral is done for the remaining ANC SI/ RR 2
diagnostics Such as blood group and Rh factor, Hepatitis B
Tetanus Toxoid (2 Dosages/ Booster) have Check randomly any 3 ANC records for confirming
been during ANC visits that TT1 (at the time of registration) and TT2 (one
month after TT1) has been given to Primi gravida &
Booster dose for women getting pregnant within SI/ RR 2
three years of previous pregnancy

Staff can recognize the cases, which would Anaemia, Bad obstetric history, CPD, PIH, APH,
There is an established procedure for identification need referral to higher centre(FRU) Medical Disorder complicating pregnancy,
ME E16.4 of High risk pregnancy and appropriate & timely Malpresentation, foetal distress, PROM, obstructed SI/ RR 2
referral. labour.

Staff is competent to identify Hypertension / Hypertension & Pre Eclampsia

Pregnancy Induced Hypertension (Hypertension - Two consecutive reading taken four
hours apart shows Systolic BP >140 mmHg and/or
Diastolic BP > 90 mmHg SI/ RR 2

Staff is competent to identify Pre-Eclampsia Pre - Eclampsia- High BP with Urine Albumin (+2)
Imminent eclampsia -BP >140/90 with positive
albumin 2++, severe headache, Blurring of vision, SI/ RR 2
epigastria pain & oliguria in Urine

Staff is competent to identify high risk cases Identification and referral of cases with
based on Abdominal examination Cephalo-pelvic presentation, Malpresentation,
medical disorder complicating pregnancy, IUFD,
amniotic fluid abnormalities. SI/ RR 2

Staff is competent to classify anaemia >11 gm% -Absence of Anaemia,10 to 11 gm% mild,
according to Haemoglobin Level 7-10 gm% Moderate Anaemia SI/ RR 2
<7 gm% Severe Anaemia
Line listing of pregnant women with Check the records whether Line-listing of severely
moderate and severe anaemia anaemic women are maintained at the HWC SI/ RR 2
Staff is aware of prophylactic & Therapeutic 1. Prophylactic - one IFA tablet per day for six months
dose of IFA & progress is monitored during ANC &PNC. 2.Therapeutic dose- double the
dose in case of anaemia. 3. Improvement in
haemoglobin label is continuously monitored and SI/ RR 2
recorded

Counselling of pregnant women is done as per Pregnant women is counselled for planning Registration, Identification of institution as per clinical
ME E16.5 standard protocol and gestational age and preparation for birth condition CI/SI 2
Pregnant women is counselled recognize Swelling (oedema), bleeding even spotting, blurred
danger signs during pregnancy vision, headache, pain abdomen, vomiting, pyrexia, CI/ SI 2
watery & foul smelling discharge & Yellow urine
Pregnant women is counselled to recognize A bloody, sticky discharge (Show) and regular painful
sign of labour & arrange for referral uterine contractions. Contact number of the SI/ CI 2
transport ambulance is communicated
Pregnant women is counselled diet, rest, 1.Increase Dietary Intake
breast feeding & family planning Diet rich in proteins, iron, vitamin A, vitamin C,
calcium and other essential micronutrients. Initiate
breastfeeding especially colostrum feeding within an
hour of birth.
2.Do not give any pre-lacteal feeds. (Sugar, water,
Honey)
3. Ensure good attachment of the baby to the breast.
4.Exclusively breastfeed the baby for six months.
5. Breastfeed the baby whenever he/she demands
milk. SI/ CI 2
6. Follow the practice of rooming in. Different Options
available including
IUCD, PPIUCD, vasectomy, long acting injectable, etc.

Standard E17 The facility has established procedure for intranatal care as per guidelines

Standard E18 The facility has established procedure for post natal Care
Post partum Care is provided to the mothers Mother is monitored as per post natal care Check for records of Uterine contraction, bleeding,
guideline temperature, B.P, pulse, Breast examination, (Nipple
ME E18.1 care, milk initiation). Check for perineal wash is RR/ SI
performed
2
Danger signs :Excessive PV bleeding, breathing
difficulty, convulsion, severe headache, abdominal
There is a established procedures for Postnatal visits
ME E18.2 & counselling of Mother and Child Check Mother is educated & counselled pain, foul smelling lochia, urine dribbling, perineal SI/ RR
about danger signs during puerperium & pain, painful & redness of breast.
during postnatal visit 2
Area of Concern F: Infection Control
Standard F1 The facility has established program for infection prevention and control
Staff is working as team to improve Person is identified to supervise the sanitation ald
Facility ensures that staff is working as team sanitation & hygiene of the facility hygiene of HWC and its surrounding area.
ME F1.1 Check staff is aware of their roles and SI/ RR
and monitor the infection control practices responsibilities in terms of sanitation & hygiene.
2
Check Records of Medical Check-up and All staff undergo medical Check-up at least once in
Immunization year and immunization with at least Hepatitis B and RR
TT
2
Facility has a system to monitor cleanliness Regular monitoring of cleanliness & hygiene
& hygiene practices OB/ RR
1

Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices
 Washbasin with functional drainage pipe, tap,
Hand Hygiene facilities are provided at point of Availability of Hand washing facilities running water, Soap (Soap bar/liquid), AHR, Display of
ME F2.1 hand washing poster (Pictorial- Local language) OB
use & ensures adherence to standard practices
0
Check Washbasin, tap & running water as Check washbasin is wide and deep enough to
per standard protocols prevent splashing and retention of water.
Check for availability of elbow operated tap
adequate running water through piped water OB/ SI
distribution system.
0
Check availability of Soap and Alcohol Hand
rub for outreach OB
0
Demonstration and random observation (Five
Staff is trained and adheres to hand Moments of handwashing , Six Steps of Hand washing SI/ OB
washing practices )
0

Standard F3 The facility ensures standard practices and equipment for personal protection
Check availability & use of PPE (1) Check adequate required gloves, mask & apron
etc is available & used
The facility ensures availability of personal (2) Check Disposable Gloves, Cap, Mask are not
ME F3.1 protection equipment and ensures adherence reused, OB/ RR
to standard practices (3) Check records for continuity of supply.
1
Compliance to correct method of wearing Staff is aware of method of donning and doffing the
and removing PPE PPE SI/ OB
2
Availability & adherence to Personal
protective kit for infectious patients/ HIV pts.
SI/ RR
2

Standard F4 The facility has standard procedures for disinfection and sterilization of equipment and instruments.
Adequate supply of decontamination and Check records of indent & Utilization
The facility ensures availability of material and cleaning agents at the point of use
ME F4.1 adherence to Standard Practices for RR/ OB
decontamination and cleaning of instruments
and followed by procedure/ patient care areas.
2
Staff is trained for the decontamination and Ask whether staff know how to make chlorine
cleaning procedure solution
OB/SI
2
Decontamination and cleaning of Observe staff about the decontamination of
instruments and surfaces instruments is done with 0.5% of chlorine solution for SI/ OB
10 min. Check instrument are cleaned thoroughly 2
Availability of disinfectants Ethyl
with alcohol
soap or 70% , Bleaching
detergent Powder/
and water. Askhypo
staff chloride
when &
solution containing not less than 30% w/w of
The facility ensures standard practices and available chlorine.
ME F4.2 materials for disinfection and sterilization of Check availability of boiler / sterilisers RR/ OB
instruments and equipment
2
Staff adhere to the process of disinfection (1) Check staff is aware of process of HLD and
sterilization
(2) Check the reusable items are free from visible
contamination & disinfected SI/ RR

0
Sterilization/HLD records are maintained To ensure the status of sterilized/HLD instruments,
equipment & materials etc
RR/SI

Standard F5 The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.

Availability of colour coded bins and non Segregation

(1)AvailabilityofofBMW
binsrules:
and non chlorinated plastic bag,
Yellow
Covered- Human Anatomical waste, Items
ME F5.1 The facility ensures segregation and storage of chlorinated plastic bags and needle cutters and Foot
contaminated
operated bins with Display of Bio
Bio Medical Waste as per guidelines at point of waste generation Hazard sign. with blood, body fluids, dressings, OB/ SI
cotton swabs and bags containing residual or proof
(2) Availability of needle/hub cutter & puncture
discarded components. etc. 2
Segregation of BMW is done as per latest boxes
Red - Items such as tubing, bottles, intravenous tubes
prevalent rules and sets, catheters, urine bags, syringes (without
needles and fixed needle syringes) and vacutainers
with their needles cut) and gloves
White - Sharps waste including Metals in
(translucent) Puncture proof, Leak proof, temper
proof containers :Needles, syringes with fixed
needles, needles from needle tip cutter or burner, OB/ SI
scalpels, blades, or any other contaminated sharp
object that may cause puncture and cuts. This
includes both used, discarded and contaminated
metal sharps.
Blue : Contaminated and broken Glass are disposed
in puncture proof and leak proof box/ container such
as Vials, slides and other broken infected glass
2
Check there is no mixing of the Biomedical &
general waste OB
2
Display of work instructions for segregation Pictorial and in local language;

OB

2
HWC has designated area for storage for (1) BMW is not stored for more than 48 hours
BMW (2) Functional linkage with CTF/ If Functional deep
burial & sharp pit is available- dispose waste on
regular basis, Check there is no scope for
unauthorized entry; Display of Bio Hazard sign at the
point of use.
OB/ SI

2
Disinfection of broken / discarded Check if such waste is pre treated with 1-2% of
The facility ensures management of sharps as Glassware is done as per recommended Sodium Hypo chloride (having 30% of residual
ME F5.2 procedure chlorine) for 20 min OB/ SI
per guidelines
2
 Sharp waste is stored in puncture proof Check availability of puncture, leak and temper OB/ SI
container proof container at point of use
2
Availability of post exposure prophylaxis Check staff is aware of what to do in case of sharp
and staff is aware what to do in such injury, Whom to report. See if any reporting has been
condition done and treatment provided
SI/ RR

1
Facility has provision for liquid waste Liquid waste is made safe before mixing with other
management waste. On site provision liquid waste disinfection set
ME F5.3 The facility ensures management of hazardous up OB/ SI
& general waste
2
Check facility is mercury free Give partial compliance if staff know how to manage
mercury spill & mercury spill kit is available SI/ OB
2
Disposal of general waste Mechanism for removal of general waste from facility OB/ RR 2
& its disposal
HWC waste is collected & transported in Check the functional linkage/records with CBWTF
ME F5.4 The facility ensures transportation & disposal of close container/bag operator or has pre approved functional deep burial RR
waste as per guidelines
2
HWC has facility for disposal of Biomedical HWC have valid contract with CTF for disposal of
waste BMW waste/ else facility should have deep burial pit
and sharp pit within premises of Health facility. Such
deep burial pit should have prior approval from
prescribed authority & meet the specified norms RR/ OB

2
Facility manages recyclable waste as per Facility hand over the plastic waste to registered
approved procedure vendor through BPHC /CHC SI/ RR
2
No burning of any category of waste
within/outside HWC OB
2
Area of Concern G: Quality Management

Standard G1 The facility has established organizational framework for quality improvement.
The HWC has Quality team in place (1) CHO, ANM/Staff nurse, MPW & ASHA.
(2) Team members are aware of their respective
responsibilities and roles viz. ensure cleaniness,
The facility has a quality improvement team and hygiene and infection control practices are followed,
ME G1.1 it review its quality activities at periodic internal audits are conducted, feedback from RR/ SI
intervals stakeholders are taken etc

2
Quality team meets monthly and review its Check the records/ Minutes of meetings
activities RR
2
HWC reviews performance of its indicators
RR
1
Review & update work plan as per
requirement RR
2
Identify the issues needed to be addressed
at PHC review meeting RR/SI
2
Results of Kayakalp and NQAS Internal Gaps are identified
/External assessments are reviewed RR
2
Progress on time bound action plan is Resolutions of meeting is effectively communicated
reviewed RR/ SI
2

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

Client satisfaction survey is done (1) On defined intervals for patient or their attendant 2
visiting HWC & Client visiting Health campaigns,
VHNDs, PSGs etc.
(2) Check Valid Sample size is taken (3) Check format
is in local language or easy to understand (4) Sample
ME G2.1 The facility ensures mechanism for conducting having representation from all sections (age, gender, RR/SI
patient satisfaction survey cast, religion etc)

Analysis of low performing attributes is done Client satisfaction survey results are analysed and 1
lowest performing attributes are identified and action RR
plan is prepared.
Actions are taken on lowest performing 2
factors RR

Standard G3 The facility has established, documented, implemented and updated Standard Operating Procedures for all key processes and support services.

Check it covers details of process of testing, 2

MEG3.1 Updated work instructions for all key clinical Instructions for using RDK are available control & interpretation. (As per Service RR/ SI
processes are available mandate)
Work instruction for RMNCHA services RR 2
Protocols and instructions for preventing, Verify protocols are displayed at session sites 2
identifying and managing AEFI are displayed OB/RR
at immunization site
WI for screening, management and HT, Diabetes Oral, cervical and breast cancer. 2
appropriate referral of NCDs Screening using acetyl salicylic acid. RR
WI for screening, management and Malaria , dengue, TB, Leprosy, HIV-AIDS and Hepatitis 2
appropriate referral of Communicable RR
disease
WI for infection prevention & Bio medical 2
waste management RR
2
WI are updated as per current practices Check with staff if they are well versed with the RR
Work Instructions

Standard G4 The facility has established system of periodic review of clinical, support and quality management processes

Handholding support and supervision is Service delivery and performance of HWC is Through monthly visits by MO PHC
reviewed regularly
ME G4.1 provided to HWC by PHC, block/ district/state SI/ RR
teams 1
 HWC performance is reviewed regularly by Quarterly -By Block nodal officer, Bi Annual - by
block/district/state nodal officer District Nodal officer RR
2
Check gaps have been identified and actions Check number gaps closed as per last quarter report
are taken RR
2
The facility conducts periodic internal Periodic assessment using NQAS checklist At least once in six months
ME G4.2 RR
assessment 2
Periodic assessment using Kayakalp checklist Quarterly
RR
2
Non Compliance found in the internal Check gaps are identified and time bound action plan
The facility ensures non compliances are Assessment using NQAS, Kayakalp and other is prepared
ME G4.3 recorded adequately and action plan is made on monitoring checklists are recorded RR
the gaps found in the assessment/review
process using quality improvement methods 2
Root cause analysis is done Using brainstorming, Fishbone analysis or why-why
analysis RR/ SI
2
HWC team improve on the identified non Using PDCA approach
compliances & action are taken RR/ SI
2

Standard G5 Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve them.

The facility has defined Quality policy and Quality policy are defined Staff is aware of Quality Policy.
ME G5.1 Quality Policy is displayed in local language RR
quality objectives 2
Quality objectives are defined for the HWC Check whether the objectives are SMART and in sync
with the Quality Policy RR
2
There is system for monitoring of
performance toward quality objectives
RR/ SI
2
Area of Concern H: Outcome
Standard H1 The facility measures productivity indicators
The facility measures productivity indicators No. of OPD Cases per month Case specific OPD of pregnant mothers, neonate,
ME H1.1 infant, children, adolescent, FP and CD RR
services on monthly basis 2
No. of follow up cases (repeat visit) per Case specific OPD of pregnant mothers, neonate,
month infant, children, adolescent, FP and CD RR
2
No. of cases referred to higher centre per Case specific referral of pregnant mothers, neonate,
month infant, children, adolescent, FP and CD RR
2
As per Service package i.e. NCD (Hypertension,
No. of Case specific OPD per month( as Diabetes & cancer), Eye, ENT, Oral Health, RR
per defined service package) elderly, palliative, Medical Emergency & Mental
Health etc 2
No. of cases referred to higher centre per
month As per Service package i.e. NCD (Hypertension,
Diabetes & cancer), Eye, ENT, Oral Health, RR
elderly, palliative, Medical Emergency & Mental
Health etc 2
As per Service package i.e. NCD (Hypertension,
No. of case specific follow up per month Diabetes & cancer), Eye, ENT, Oral Health, RR
elderly, palliative, Medical Emergency & Mental
Health etc 2
As per Service package i.e. NCD (Hypertension,
No. of drop out rate cases following Diabetes & cancer), Eye, ENT, Oral Health, RR
identification (as per service Package) elderly, palliative, Medical Emergency & Mental
Health etc 2
Standard H2 The facility measures efficiency indicators.
ME H2.1 The facility measures efficiency indicators on Percentage of women receiving all four RR
monthly basis ANCs 2
Drop out rate for Pentavalent RR
immunization 2
Drop out rate for NCDs RR 2
No. of stock out days of essential As per Service package RR
medicines 2
No. of stock out days of essential As per Service package RR
diagnostic test 2

No. of Yoga session conducted in month RR

2
No of VHNDs conducted (for vulnerable RR
population) 2
Standard H3 The facility measures clinical care indicators.
ME H3.1 The facility measures clinical care indicators on No. of high risk pregnancy identified RR
monthly basis during ANC 0
No. of AEFI cases reported RR 0
No. of Children with diarrhoea treated RR
with ORS & Zn 2
Contraceptives acceptance rate RR 2
No. of Anaemia cases treated RR
successfully 2
Treatment completion rate for RR
Tuberculosis 2
Percentage of cases on treatment RR
achieved blood pressure control 2
Percentage of cases on treatment RR
achieved blood sugar control 2
Percentage of cases screened positive for RR
cancer underwent biopsy 2
Percentage of cancer cases underwent RR
treatment for each cancer 2
Standard H4 The facility measures service quiality indicators
Client Satisfaction Score (Patients) Sum of average satisfaction score of each respondent
The facility measures service quality indicators (Average satisfaction score = sum total of scores of
ME H4.1 attributes/number of total attributes) RR
on monthly basis
2
Client Satisfaction Score (Community) Sum of average satisfaction score of each respondent
(Average satisfaction score = sum total of scores of
attributes/number of total attributes) RR

2
Percentage of chronic cases who started
treatment at PHC/above are still under As per service package RR
treatment for last 3 months 2
Remarks
odalities
action

of economic or social reasons

 Check in Both type of SC

care and comfort to users

case load

performance of staff
igital technology
n
patients
al/ clinical guidelines

onal/ clinical guidelines

nical guidelines
clinical guidelines
d hazardous Waste.
and support services.

ses
.