National Quality Assurance Stand

Health & Wellness Centre -Sub Ce

Name of HWC Ariyapadi

Name of Assesssors K.NITHIYA -CHO

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

2 Neonatal & Infant Health Services Mandatory

Childhood & adolescent Health

3 Mandatory
Services
4 Family Planning Mandatory
Management of Communicable
5 Mandatory
diseases
Management of Simple illness
6 Mandatory
including Minor Elements

HWC -HSC Overall Score & Ar

C_HSC Overall Score Card

Service Provision Patient Rights

91% 77%
 HWC_HSC Overall S
Inputs Support Services

Theme Wise Score 80% 82%

Theme Wis
Care in pregnancy & Childbirth 97%
Neonatal & Infant Health Services 97%
Childhood & adolescent Health 96%
Services
Family Planning 92%
Management of Communicable 85%
diseases
Management of Non 83%
Communicable Diseases

Reference No. Area of Concern/ Standards

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

Standard A2 The facility provides drugs and diagnostic services as mandated

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

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

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

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

The facility has adequate qualified and trained staff required for providing the assured
Standard C2 services as per current case load
 Facility has a defined and established procedure for effective utilization, evaluation and
Standard C3 augmentation of competence and performance of staff

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

Standard C5 Facility has adequate functional equipment and instruments for assured list of services
Area of Concern -D-

Standard D1 The facility has established Programme for maintenance and upkeep of the facility

The facility has defined procedures for storage, inventory management and dispensing
Standard D2 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 -
The facility has defined procedures for registration, consultation, clinical assessment and
Standard E1 reassessment of the patients
The facility has defined and established procedures for continuity of care through two
Standard E2 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.

Standard E5 The facility follows standard treatment guidelines and ensures rational use of 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 ophthalmic, ENT
Standard E8 and Oral aliments as per operational/ clinical guidelines
The facility has defined & established procedure for screening & basic management of
Standard E9 Mental Health ailments as per Operational/ clinical guidelines

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

The facility has defined & established procedures for management of non-communicable
Standard E11 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-I
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 equipment and
Standard F4 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
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 Operating
Standard G3 Procedures for all key processes and support services.
The facility has established system of periodic review of clinical, support and quality
Standard G4 management processes
Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to
Standard G5 achieve them.
Area of Concern
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
y Assurance Standards
ess Centre -Sub Centre
Date of Assessment
11.09.2024
Name of Assessee
DR.GANAGURU

Action Plan submission date

11.10.2024
ervices Provided At HWC_HSC
Management of Non
7 Mandatory
Communicable Diseases
Care for Common Ophthalmic
0
and ENT
0 Oral health care.
0 Elderly and Palliative health care
0 Emergency Medical Services
Management of Mental health
0
ailments.

Overall Score & Area of Concern wise Scores

Clinical Services
Overall Score of
HWC -HSC 89%
 Quality
Management
85% System

81%

Theme Wise Score

97% Care for Common Ophthalmic 0%
and ENT
97% Oral health care. 0%
96% Elderly and Palliative health care 0%
92% Emergency Medical Services 0%
85% Management of Mental health 0%
ailments.
83% Drugs & Diagnostics 84%

Score Obtained Maximum Scores

Area of Concern -A - Service Provision
es 63 68

d 6 8
Area of Concern -B- Patient Rights
community about available
25 28

tors including those

12 18

, religious & cultural needs

al reasons 13 16

nt 8 12

users 7 10
Area of Concern -C- Inputs

f assured services as per

sers 21 32

or providing the assured

12 14
 tilization, evaluation and
15 16

or assured services 51 60

or assured list of services 3 6

Area of Concern -D- Support Services

pkeep of the facility 20 24

agement and dispensing

25 28

ecords and data

29 32
l transparency and
21 30

activities through
43 54

ment 7 8
Area of Concern -E- Clincal Care
on, clinical assessment and
24 28
uity of care through two
12 14

diagnostic services. 5 8

n. 15 16

rational use of drugs 16 18

care. 14 16
ency care 6 10
ment of ophthalmic, ENT
0 0
& basic management of
0 0

ment of communicable
39 48

ment of non-communicable
48 58
 delines 0 0
nfant and child as per
67 68
per government guidelines

Health services as per 18 20

4 4

er guidelines 49 50
re as per guidelines 0 0
4 4
Area of Concern -F-Infection Control
ention and control 5 6
ring hand hygiene
8 8

onal protection 4 6
zation of equipment and
7 12
ation, collection,
26 30
Area of Concern -G- Quality Management Systems
ty improvement.
12 14

ployee satisfaction 5 6
pdated Standard Operating
11 14
l, support and quality
13 16
ves, and approved plan to
6 6
Area of Concern -H- Outcome
12 14
14 14
16 20
6 6
Infection Control

81%
 Output

89%

0%
0%
0%
0%
0%
84%

Percentage

93%

75%

89%

67%

81%

67%

70%

66%

86%
 94%

85%

50%

83%

89%

91%

70%

80%

88%

86%

86%

63%

94%

89%

88%
60%
#DIV/0!

#DIV/0!

81%

83%
#DIV/0!

99%

90%

100%
98%
#DIV/0!
100%

83%

100%

67%

58%

87%

86%

83%

79%

81%

100%

86%
100%
80%
100%
 National
Health &
Name of HWC
Name of Assesssors

Type of Assessment (Internal/

State/External)

Reference No Measurable Elements

Standard A1 The

ME A1.1

The facility provides care in Pregnancy & child birth

services

ME A1.2

The facility provides Neonatal & Infant Health services

ME A1.3
The facility provides Childhood & Adolescent health
services

ME A1.4

The facility provides Family Planning services

The facility provides services for promotion,

prevention and treatment of communicable diseases
ME A1.5
as mandated under National Health Program/state
scheme
ME A1.6
The facility provide services for acute Simple illness &
minor aliments
 The facility provides services for promotion,
prevention and treatment of Non-communicable
ME A1.7
diseases as mandated under National Health
Program/state scheme
 The facility provides services for health promotion
ME A1.14
activities & wellness

Standard A2 The

ME A2.1

The facility provides laboratory services as mandated

The facility provides services for drug dispensing

ME A2.2
including medicine refills
Standard B1 The facility provides informati

ME B1.1 The facility displays its services and entitlements

Patients & visitors are sensitized and educated

ME B1.2
through appropriate IEC / BCC approaches
 Information about the treatment and entitlements
ME B1.3
are shared with patients or attendants

Standard B2 Facility ensures services are

The facility is accessible from community and

ME B2.1
referral centre

Access to facility is provided without any physical

ME B2.2
barrier & friendly to people with disability.
 There is affirmative action to ensure that vulnerable
ME B2.3
and marginalized sections can access services

Standard B3 Services are delivered in a manner that are sensitive

Services are provided in manner that are sensitive to

ME B3.1
gender religious & cultural need
MEB3.2 Staff is aware of Patients rights and responsibilities

The facility has defined and established procedure

ME B3.3
grievance redressal system in place

Standard B4 The

Adequate visual privacy is provided at every point of

ME B4.1
care

Confidentiality of patients’ records and clinical

ME B4.2
information is maintained
ME B4.3 The facility ensures behaviours of its staff is dignified
and respectful, while delivering the services

Standard B5 The

ME B5.1 The facility provides free of cost services as per

prevalent government schemes/ norms.

The facility has adequate and safe infrastructure

Standard C1
Facility has adequate infrastructure, space and
amenities as per patient or work load

ME C1.1
 The facility ensures physical safety including
ME C1.2
electrical and fire safety of infrastructure

ME C1.3 The facility ensures availability of information &

communication technologies

Standard C2 The facility has adequate quali

The facility ensures availability of Community Health

ME C2.1
officer

The facility have adequate frontline health workers

ME C2.2
and support staff as requirement

ME C2.3 The facility has established procedure for duty roster

for facility and community staff
Standard C3 Facility has a defined and established proc

ME C3.1 Competence assessment and performance

evaluation of all staff is done on predefined criteria

ME C3.2 The staff is provided training as per defined core

competencies and training plan

Standard C4 The faci

ME C4.1 The facility have availability of adequate drugs
ME C4.2 The facility have adequate consumables as per
requirement

Standard C5 Facility has ad

 The facility ensures availability of equipment and
ME C5.1 instruments for examination and monitoring of
patients

The facility have adequate furniture and fixture as

ME C5.2
per service provision

Standard D1 The facility h

The facility has established system for infrastructure

ME D1.1
maintenance

ME D1.2 The facility has established system for maintaining

sanitation and hygiene
Standard D2 The facility has defi
There is established procedure for estimation and
ME D2.1 indenting of drugs and consumables as per
requirement

ME D2.2 The facility ensures proper storage of drugs and

consumables

ME D2.3 The facility ensure management of expiry and near

expired drugs

Standard D3 The facility has defined and establishe

Information regarding ambulatory care &

management, public health and managerial
ME D3.1
functions are recorded and updated through IT
platforms
ME D3.2 The facility ensures safe storage, maintenance and
retrieval of information & records of services

ME D3.3 The facility has established procedure for providing

consultation using tele medicine
Standard D4 The facility has defi
ME D4.1 The facility has established procedure for
management of activities of Jan Arogya Samiti

The facility has established procedures for

ME D4.2 community based monitoring of its services through
social audits

The facility has established procedure for supporting

ME D4.3 and monitoring activities of Community health
workers
Standard D5 The facility ensures hea

ME D5.1
The HWC facilitate planning & implementation of health
promotion and disease prevention activities through
community level interventions
ME D5.2
The facility has Patient Support Groups(PSG) as per the
issues/ diseases in its catering population
 The facility ensure multisectoral convergence for
ME D5.3
health promotion and primary prevention

Standards D6 The

ME D6.1 The facility ensures its processes are in compliance

with statutory and legal requirement
Standard E1 The facility has defined proced

The facility has established procedure for

ME E1.1 empanelment & registration of individual and
families

The facility has established procedure for

ME E1.2
registration & consultation in HWC
 The facility has established procedure for follow up/
ME E1.3
re-assessment of patients

Standard E2 The facility has defin

ME E2.1 The facility has established procedure for continuity
of care

The facility has established procedure for undertaking

ME E2.2 referred in & referred out of the cases

Standard E3 The faci

The facility has established procedure for laboratory

ME E3.1
diagnosis as per guidelines
Standard E4 The

Facility follows protocols for safe drug

ME E4.1
administration

There is process for identifying and cautious

ME E4.2
administration of high alert drugs

Standard E5 The facility f

ME E5.1 There is procedure of rational use of drugs

ME E5.2 Facility has system in place to periodically monitor
the treatment provided by CHO

Standard E6 The f
ME E6.1 There is established procedure for identification &
periodic monitoring of the patients

ME E6.2 Prescribed treatment plan and procedure

performed are recorded in patient's record

Adequate forms, formats and records are available

ME E6.3
as per services mandate

Standard E7 The fa

ME E 7.1 Emergency protocols are defined and implemented

ME E 7.2 The facility has disaster management plan in place

Standard E8 The facility has defined & established proc

Standard E9 The facility has defined & established procedu

Standard E10 The facility has defined & established
The facility provides services under National vector
ME E10.1 Borne disease control programme as per guidelines
as per guidelines

ME E10.2 The facility provides services under National

Tuberculosis Elimination Program (NTEP)

ME E10.3 The facility provides services under National Leprosy

Eradication Program as per guidelines

ME E10.4 The facility provides services under National AIDS

Control Program as per guidelines

The facility provides services under Integrate Disease

ME E10.5 surveillance as per guidelines

ME E10.6
The facilities provide services for National Viral Hepatitis
Control Programme (NVHCP)

Standard E11 The facility has defined & established p

ME E11.1 The facility provides services for hypertension as per

guidelines

ME E11.2 The facility provides services for Diabetes as per

guidelines
ME E11.3 The facility provides services for cancer screening
and referral as per guidelines

ME E11.4 The facility provides services for de addiction, and

locally prevalent health diseases as per guidelines

ME E11.5 The facility promotes services for health & wellness

Standard E12 Elderl

Standard E13 The facility has es

ME E13.1 Post natal visit & counselling for new born & infant
care is provided as per guideline

ME E13.2 The facility provides immunization services as per

guideline
ME E13.3 Management of children for ARI, diarrhoea,
malnutrition and other illness

Standard E14 The facility has esta

ME E14.1 Family planning counselling services are provided as
per guidelines

ME E14.2 The facility provides spacing methods for family

planning as per guidelines

The facility provides limiting methods for family

planning as per guidelines
ME E14.3

Standard E15 The facility prov

ME E15.1 The facility provides promotive, preventive &

curative service for adolescent

Standard E16 The facil

There is an established procedure for registration and
ME E16.1 follow up of pregnant women.

There is an established procedure for History taking,

ME E16.2 Physical examination, and counselling of each antenatal
woman, visiting the facility.

The facility ensures of drugs & diagnostics are prescribed

ME E16.3 as per protocol

There is an established procedure for identification of

ME E16.4 High risk pregnancy and appropriate & timely referral.
 Counselling of pregnant women is done as per standard
ME E16.5 protocol and gestational age

Standard E17 The faci

Standard E18
ME E18.1 Post partum Care is provided to the mothers
There is a established procedures for Postnatal visits &
ME E18.2 counselling of Mother and Child

Standard F1 The fac

ME F1.1 Facility ensures that staff is working as team and
monitor the infection control practices

Standard F2 The facility has

ME F2.1 Hand Hygiene facilities are provided at point of use

& ensures adherence to standard practices

Standard F3 The facilit

The facility ensures availability of personal

ME F3.1 protection equipment and ensures adherence to
standard practices

Standard F4 The facility has stand

 The facility ensures availability of material and
adherence to Standard Practices for
ME F4.1
decontamination and cleaning of instruments and
followed by procedure/ patient care areas.

The facility ensures standard practices and materials

ME F4.2 for disinfection and sterilization of instruments and
equipment

Standard F5 The facility has defined and established p

The facility ensures segregation and storage of Bio

ME F5.1
Medical Waste as per guidelines
 The facility ensures management of sharps as per
ME F5.2
guidelines

The facility ensures management of hazardous &

ME F5.3
general waste

ME F5.4 The facility ensures transportation & disposal of

waste as per guidelines
Standard G1 The facility

ME G1.1 The facility has a quality improvement team and it

review its quality activities at periodic intervals

Standard G2 The fac

The facility ensures mechanism for conducting

ME G2.1
patient satisfaction survey

Standard G3 The facility has established, documented, i

MEG3.1 Updated work instructions for all key clinical

processes are available

Standard G4 The facility has establishe

ME G4.1 Handholding support and supervision is provided to

HWC by PHC, block/ district/state teams
ME G4.2 The facility conducts periodic internal assessment
The facility ensures non compliances are recorded
ME G4.3 adequately and action plan is made on the gaps
found in the assessment/review process using
quality improvement methods

Standard G5 Facility has defined M

ME G5.1 The facility has defined Quality policy and quality

objectives

Standard H1
ME H1.1 The facility measures productivity indicators
services on monthly basis

Standard H2
ME H2.1 The facility measures efficiency indicators on
monthly basis

Standard H3
ME H3.1 The facility measures clinical care indicators on
monthly basis

Standard H4
ME H4.1 The facility measures service quality indicators on
monthly basis

Obtained
69
65
102
145
321
50
47
48
847

1 97%
2 97%
3 96%

4 92%

5 85%

6 83%
7 0%

8 0%

9 0%
10 0%
11 0%
12 84%
 National Quality Assurance Standards
Health & Wellness Centre -Sub Centre
Ariyapadi Date of Assessment
NITHIYA.K -CHO Name of Assessee

Internal Action Plan submission date

Checkpoints Means of Verification

Area of Concern A: Service Provision

The facility provides Comprehensive Primary Healthcare Services

Services for early registration, screening including lab

Availability of functional ANC services with
investigation ,counselling & identification of high risk and
minimum 4 ANC check-ups
danger signs

APH, PIH, Pre eclampsia, Severe Anaemia, IUGR, Multiple

pregnancies, Gestational Diabetes , Hypothyroidism,
Syphilis and bad obstetric history
First aid, referral & follow up services for high
risk pregnancies are provided

New Born: Low birth weight newborn <1800gms, Preterm,

Identification, primary management & prompt Sepsis, Birth asphyxia, Congenital anomalies
referral of sick new born & infant Infant: ARI, Diarrhoea, Jaundice, anaemia & malnutrition,
developmental delays
 Complete immunization schedule & reporting of AEFI both
Availability of Immunization Services
from Sub centre & Outreach

Anaemia, malnutrition, Vaccine preventable diseases, ARI,

Identification, primary management, referral & Diarrhoea, Fever, ENT problems, Skin infections, Worm
follow up services for Childhood ailments infestations, Poisoning, injuries/ accidents, 4D's,Sickle cell
anaemia.

Prevention & treatment of anaemia and other deficiencies,

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

Provision of contraceptive including ECP,OCP, Injectables,

Availability of family planning services condom, IUCD.

(1)Provide Information about Family planning options to

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

Identification ,management & referral (if required)

Dysmenorrhoea, Vaginal Discharge, Mastitis, Breast lump,
Identification and referral for Obstetric and Pelvic Pain and Pelvic Organ Prolapse, Identification and
Gynaecological Conditions management for RTI/STI

Preventive & promotive services under NVBDCP

Malaria, Dengue, Chinguniya, Filariasis, KalaAzar,

Japanese Encephalitis

(1) Diagnostic services, primary management, referral &

Case detection, treatment, referral & follow follow up of complicated cases.
up of cases under NVBDCP (2) Mass drug administration in case of filarasis &
immunization in JE
Preventive & promotive measures under NTEP
Community engagement, facilitate referral, promote
treatment completion & reducing stigma

Case detection, treatment, referral & follow Early identification, link with designed microscopy centre,
referral & follow up of complicated cases, & medication
up of cases under NTEP compliance

Preventive & promotive measures under NLEP

Community engagement, facilitate referral, promote
treatment completion & reducing stigma

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

Preventive & promotive services under NACP

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

Preventive & promotive measures under NVHCP Community engagement/ peer support, facilitate referral,
promote treatment completion, Convergence with other
departments
Case detection, treatment, referral & follow Diagnostic services, referral & follow up
up of cases under NVHCP

Availability of functional services under IDSP Weekly reporting & surveillance

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

Identification, management and referral of
Urticaria, Abscess, Cholera, Dysentery, Typhoid,
acute illness & minor aliments
Helminthiasis, Headache, Body aches, Joint aches.

Water born diseases (diarrhoea, dysentery, enteritis)

Preventive & promotive measures for acute
Helminthiasis, rabies,musculosketal disorders
illness
(osteoporosis, arthritis, aches )
 Screening, treatment compliance and follow up of all
Availability of services for Hypertension positive cases, referral & follow up for complications and
refill of drugs

Screening, Diagnosis, treatment compliance and follow up

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

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

Oral, Breast, Cervical Cancers.

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

Screening, early identification , treatment compliance and

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

Screening, early identification , treatment compliance and

Availability of services for Epilepsy follow up of all diagnosed cases, referral and follow up for
complications , refill of drugs

Early identification, referral, & follow up care for disease

such as Pneumoconiosis, Dermatitis, Lead Poisoning,
Availability of services for locally prevalent
Fluorosis etc. & for substance abuse such as tobacco,
health diseases & substance abuse
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
HWC undertakes health promotion and VHSNC/Self help group/ Patient support groups,
disease prevention activities through Health promotion campaign and multisectoral
Community level resources convergence

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

Provision of AYUSH services As per scope of services defined by state.

Check counselling services for :

(1) Eat Healthy: (a) Nutrition during first 1000 days of
Life (b) Balanced diet (c) Food fortification (d) Food to
Provision of counselling services for Eat Right
avoid
(2) Eat Safe: (a) Hygiene & Sanitation (b) Food Safety
& Safe food practices (c) Food Adulteration

The facility provides drugs and diagnostic services as mandated

Point of care diagnostics including RDKs as per Service

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
Availability of basic diagnostic services including testing for faecal contamination & chlorination, HBs Ag for
NHP hepatitis B, filariasis ( endemic areas), Syphilis (RTK)

Linkages with the Central diagnostic units (Hub &

spoke) As per scope of services provided

Availability of drugs as per EDL

As per scope of services provided

Availability of drugs for refill for chronic cases

As per scope of service provided
 Area of Concern B: Patients Right
The facility provides information to care seeker, attendants & community about available services & their m
Name of the facility & list of services (1) Name of the HWC, Service Packages and time
available are displayed prominently mandate is displayed.
(2) Check the name of HWC is visible at night also

Branding of HWC-HSC is done as per (1) Outer surface of the building is yellow with specified
guidelines
Citizen charter is displayed shade.
(1) In local language
HWC displays entitlements available as per scope (2) Service
Under Provided,
all NHP contact
including details
RMNCHA andofPMJAY
fire, police
of ambulance. Name & contact detail of CHW and nearest
Listservices
of Available drugs prominently displayed Updatedcentre.
referral as per current stock
All signages are of uniform colour, user friendly & Information is available in local language and easy to
in local language understand

Directional signages are displayed in the Check prominent signage are displayed to reach HWC
catchment area -SC
(1) Service specific relevant IEC is displayed
(2) Check availability of the updated IEC material
(3) Check no outdated information is displayed in HWC
(4) Check audio visual aids are used to display the IEC/
information
IEC Material is displayed as per services provided

(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 various
HWC promotes wellness through EAT right
activities viz: 3 D food pyramid, food fortification
campaign
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
Health Promotion activities are undertaken using & follow up care Viz. GATHER (Greet, Ask, tell, help, Explain
various BCC approach & return (FP), TALK : Tell, advise, Lead & Know (Health
promotion for NCD, 5 A's (Ask, advice, assess, assist,
arrange) ( Tobacco & alcohol cessation)
 Check patients is explained about - diagnosis, treatment
Patient is informed about clinical condition and
plan (dosage, period etc), special instructions, referral &
treatment plan
follow up

Consent is taken before procedure for conditions Staff is aware of the conditions where consent is taken
(wherever required) before procedure

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

HWC team provide support for linkage with

PM- JAY to avail the scheme benefits Facilitate identification & registration of families for PM-
JAY

Facility ensures services are accessible to care seekers and visitors including those required some affirmati
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)
(2) Preferably within 1-2 Kms of Referral Centre

Check for Outreach session plan - targeted population

Check outreach sessions are conducted covered & implementation as per plan.
The services are available for the time period, HWC is functional for at least six hours per day
as mandated
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 ophthalmic & ENT
The facility provides access to expanded problems, Oral health, elderly & palliative care, Emergency
range of services medical services & Mental health aliments

Check HWC premises is free from any Availability of Wheel chair/stretcher, ramp with railing ( At
physical barrier least 120 cm width, Gradient not be steeper than 1:12 )
 (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 individuals (3) Ramps and stairs with handrails.
(4) Ramps & staircases with hip lip (20mm) on exposed side
to prevent slipping of cane/ crutches/ wheelchair

(1) Tactile signs with good contrast between letters &

background.
Check HWC premises is obstacle free for sight (2) One or two rows of tactile guiding blocks along the
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

Check for special precaution is taken for HIV, Leprosy , Abortion, domestic Violence, psychotic
maintaining privacy & confidentiality of cases cases, GBV, abuses etc
having social stigma

There are linkages of care , Counselling and Victims of Violence including domestic violence/ Gender
Protection of vulnerable and marginalized Based Violence, terminally ill patients, orphan, elderly etc.
section Linkage and support for treatment, counselling & Legal
Support

rvices are delivered in a manner that are sensitive to gender, religious & cultural needs and there is no discrimination on accou

Availability of female staff / attendant, if a male

CHO examines a female patients

Cultural and religious preferences of patients are honoured

Religious and cultural preferences of patients
and their attendants are taken 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 economic
There is no discrimination based religion, status
ethnicity, socio economic status, cast, gender (4) Check there is no discrimination due to ethnicity &
& language etc language

Check Staff is aware of Patient rights and Display of patient rights and responsibilities through citizen
responsibilities charter.

Check community is aware of services provided, grievance

Check community is aware of Patient's rights and redressal mechanism, contact details of higher centre,
responsibilities contact details of ambulances by HWC-HSC.

Check staff & community is aware of

Existing state grievance system/ 104.
grievance redressal system

Complaint Box/ Complaint register/ facility specific IT

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
The facility maintains privacy, confidentiality & dignity of patient
Availability of screen/ curtains in examination Screen/ curtain/ frosted glass on windows
area and in windows

One Patient is seen at a time by CHO Clinic is not shared by two patients at a time

Patient records are kept in safe custody

Family folders, CBAC form, NCD portal information, HIV,

RTI/STI, OPD registers etc
Patient records are kept at safe place beyond access of
general patient flow
 (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 details
Check patient and their kin's have access to are provided. (IT system- have option for print)
clinical records
Care is free from any physical & verbal abuse. Vulnerable
or marginalized patients
is not left unattended/ignored.
Behaviour of staff is empathetic and courteous to Ask thethe
Check status separately in labour room if delivery
patient about in
their
patients and services are provided SC experience of care
Behaviour of visitors
staff is dignified & respectful

The facility ensures all services are provided free of cost to its users
(1) As per service package or
HWC provide free of cost access to all the
The facility provides free of cost screening RMNCHA, CD, NCD, Eye, ENT, Oral, Mental Health,
services
and investigations services as per Elderly,
All Pallative,Emergency
screening medical
services and required services
diagnostic etc are
services
The facility
requirement provides free of cost essential provided free of cost
Check all drugs in the HWC-EDL are provided free of cost
medicines and refills as per treatment plan
Availability of Free referral /ambulance services Through 102/108 or any other
Availability of free teleconsultation services
Area of concern C: Inputs
The facility has adequate and safe infrastructure for delivery of assured services as per prevalent norms and it provides optim

Well ventilated & illuminated clinic room with (1) Check demarcated area for examination (privacy
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 areas)

Availability of adequate patient waiting area Covered waiting area which can accommodate 20-25
Demarcated space for Laboratory / diagnostics Chairs.
Lab. space is adequate for carrying out Lab. activities
Adequate
Demarcated space/room for Yogaout
area for carrying activities
immunization within HWC or its premises
activities
Demarcated area of storage (1) Storage space for storing medicines ,Consumables &
Availability of functional telephone/Mobile (1) equipment
CUG
etc.of Portable emergency light ,
Availability
numbers/ Landline and internet connectivity
and internet services
Availability of regular & uninterrupted generators/inverters/solar panel/ for power back up (2)
electricity supply Use of energy efficient bulbs for lighting

(1) Potable drinking water supply is available for patients,

Adequate water supply with storage facility visitor & staff
(2) Piped water supply/ tube well with fitted water pump/
other alternate source.
(3) Water Storage facility- Minimum 3 days
(4) Periodic chlorination & Quality testing of water is done
 (1) Check toilets are functional with running water facility.
Availability of separate toilets for male & female (2) Check the toilets are disable friendly

Check boundary is of adequate height and it is not broken

from anywhere
HWC premises has intact boundary wall
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
(4) Check exists are clutter free

(1)Check for fixtures & furniture like Almirah/ Cabinets,

hanging objects are properly fastened & secured
SafeBuilding
installation, use &
of appropriateof wires &for
MCB , Use of
HWC does not have temporary connections and (2) (1) Check
AV regulator
bye laws
availability
( for of instructions
Smartphones/
regulating the
NBC
Tablets
fluctuations)
seismic
and
loosely hangingcomponents
wires safety is followed
Non structural are properly secured Laptop/desktops, internet connectivity (2mbps).
(2) For tele medicine services,check desktop/ Laptop have
HWC has adequate ICT hardware for efficient headphone , HD web camera & printer connected with it
delivery
HWC hasofadequate
services ICT software for efficient
delivery of services
Check availability of functional & updated Portals or
applications viz RCH portal, HWC portal, NCD portal,
ANMOL, DVDMS, NIKSHAY, e-sanjeevani, HMIS etc. and
any state specific application.

The facility has adequate qualified and trained staff required for providing the assured services as per curren

As per eligibility criteria.

Availability of Community Health Officer Staff is aware of their role and responsibilities

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

2 ANM (Essential, one may be staff nurse) - Only for SC
Availability of ANM type-B
Staff is aware of their role and responsibilities

1 Female and 1 Male

Staff is aware of their role and responsibilities for HWC and
Availability of Multipurpose Worker community
Availability of ASHA & ASHA facilitator 1 ASHA per 1000 population / ASHA per 500 population for
Check duty roster is prepared prepared, updated tribal and hilly area.
& followed
Check for all
field visit cadres
plans are prepared, updated &
followed by primary healthcare team
 All staff adhere to their respective dress code (1) Staff adhere to their respective dress code
(2) Staff on duty is wearing their ID card

(1) Check objective checklist has been prepared for

assessing competence of staff based on job description
Facility has a defined and established procedure forand effective
assessment utilization,
is done evaluation
at least onceand in aaugmentation
year (2) Check of competence an
Check parameters for assessing skills and who
(1) 6 did
Verify therecords
with
month assessment
certificatethat -performance
At least
program in PHC- MO/ Competence
appraisal
Community has been
health,
proficiency of staff has evaluation
Check for performance been defined
is done at least Matrix
done
(2) 3 at
dayis prepared
least
IT once
training for
in aeach
year
including category
and verify
Tele of staffstaff for actual
with
medicines
MPW- (F) : (1)4-5 days training in IUCD insertion, NSSK,
once in a year assessment
(3)
HBNC daysdone
5-7Supervision,
supplementary
Management training on new health
of Childhood illness, (2)
programs, new skills (if applicable)
21 days of SBA training. (Wherever applicable)
(4)
MPW refresher every year
(All)-induction
National (if applicable)
Health Programmes, 3 days training6&
(1)
(5) 8 days
Basic physiotherapy training,
( where20 ever
days elderly
training &ofpalliative
module
on
CheckNCD, 1 day
training joint
need training with ASHA for NCD screening ,
7,
care
3
5 days
dayspackagesNCD module.
training are
on available) and receiving information &
are
reporting
identified at defined intervals
Check actions are taken for all the identified gaps adequate
(2)
(6) skill
Supplementary
Training are provided
& refresher kittraining for 15 days/year. (if
CHO is trained as per mandate using digitalon
applicable)
Eat right
applications tool
& basic nursing care training (esp.
for
(3) elderly & palliativeiscare),
ASHA facilitatory trained training on physiotherapy
for Basic Eat right tool kit
MPW is trained as per mandate (Bio
where everwaste
elderly & palliative care packages are
medical
(1) Through accessmanagement,
to Job aids/ Infection
MOOC Prevention,
(massive open
AHSA is trained as per mandate available),Training
patient safety, internalon Eat right toolkit
assessment, BLS, Methods of QA viz
online courses)/ ECHO etc
Staff
CheckisHWC
provided
use with Quality assurance
IT platforms for regulartraining PSS, 5S, PDCA
(2) Check how etcmany capacity building training/workshop
continuous learning & capacity building attended by primary healthcare team in last quarter
The facility provides drugs and consumables required for assured services
Availability of Anaesthetics agents Oxygen & Lignocaine topical (5%)

Levocetirizine tablet (5mg) , Levocetirizine Oral liquid ,

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

Aspirin tab 75, Diclofenac tab 50mg, Diclofenac injection

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

Amoxicillin Capsule 250 & 500 mg

Phenytoin Tablet
Amoxicillin 50 mg
Oral liquid 250& 300 mg, Sodium
mg/5ml, valporate
Amoxicillin dispersible
Tablet
tab 250200,
mg,500 mg & Sodium
Gentamycin inj 10&valporate
80 mg/ Syrup each
ml, Ciprofloxacin
200mg/5ml,
Tablet 500 mg, Phenobarbitone
Ciprofloxacin Oral tab 30 & 60250
liquid mg,mg/5ml,
Phenobarbitone Syrup 20 mg/5ml, Midazolam
Ciprofloxacin Inj., Tab Co-trimoxazole [Sulphamethoxazol nasal spray,
Diazepam
80 tab 5 & 10 mg,
mg +Trimethoprim 400Magnesium
mg] sulphate Inj (50%
Availability on Anticonvulsants /Anti epileptics sol
Tab )-Co-trimoxazole
2ml Tablet 400
Albendazole [Sulphamethoxazole
mg, Albendazole 100 Oralmg + 200
liquid
Availability of Intestinal Anti Helminthes Trimethoprim
mg/5 ml 20 mg ] Co-trimoxazole Oral liquid
Diethylcarbamazine
([Sulphamethoxazole Tablet
200 100
mg mg
+ Trimethoprim 40 mg/5ml),
Availability of Antifilarial Clofazimine Capsule 50
Diethylcarbamazine
Chloroquine, Oralmgliquid 120 mg/5 ml
Doxycycline
Clofazimine 100mg,
Capsule Metronidazole 200 & 400
100 mg, Dapsone Tablet 25(B), mg,
mg,
Availability of Anti Bacterial Artesunate
Norfloxacin
Ferrous salt(A)+
tab/ Sulphadoxine-
oral
100 50
mg + Folic acidPyrimethamine
500 mcg Tablet
Dapsone
Combipack Tablet
(A+B) mg,
Availability of Anti leprosy Ferrous
Dapsone salt 20 mg
Tablet +mg
1002.5 Folic acid 100 mcg Tablet, Ferrous salt
Primaquine
60 mg + Folic Tablet
acid 500 mg
mcg, Ferrous salt 45mg + Folic acid
Availability of Anti Malarial Primaquine
100 Tablet
mcg , Ferrous salt+mg
7.5 Folic5mg
acidtab,
Syrup, Folic acid Tablet 5
Isosorbide- 5-mononitrate Isosorbide dinitrate
Availability of anti Anaemic drug mg and 400 mcg, Vit K inj 1mg/ml,
5mg, Atenolol 50mg, Metoprolol 25mg, Metoprolol SR
Availability of Cardiovascular medicines 25mg
Amlodipine Tablet 2.5 & 5 mg, Telmisartan Tablet 40 mg,
Availability of drugs for Hypertension Enalapril 5mg, Hydrochlorothiazide 12.5 & 25 mg
Availability of drugs for Hypolipidemic Atorvastatin Tablet 10 mg
Clotrimazole Cream, Miconazole oint. ,tab fluconazole 150
mg , Silver sulphadiazine Cream 1%, Betamethasone
Availability of Dermatological & antifungal cream 0.05%, Calamine Solution, Benzyl -benzoate oint/lot,
Medicines Mupirocin, KMnO4 -0.1%, Zinc oxide cream 10%,

Ranitidine Tablet 150 mg, Ranitidine inj, Omeprazole,

Availability of Diuretics Ondansetron
Furosemide Injtab, oral40
& tab liquid
mg and inj, Ispaghula granules/
Husk/ powder, Oral rehydration salts (ORS),Zinc Sulphate
Syrup & tablet, Dicyclomine Tablet & Inj, Dioctyl sulfo
succinate Sodium, Magnesium Hydroxide liquid, Senna
Availability of Gastroinstinal medicines Powder, Domperidone Tab & Syrup

Ethinylestradiol (A) + Levonorgestrel Tablet 0.03 mg (A) +

0.15 mg (B),Condom,
Salbutamol Tablet 2 mg IUCD 380 A Copper bearing
intrauterine, Ormeloxifene
Salbutamol Oral liquid 2 mg/5Tabml
30mg, ECP( Levonorgestrel
Availability of Contraceptives 1.5mg), Medroxy
Salbutamol
Metformin SR progesterone
Respirator
Tablet 500 solution Acetate
for use ininjection,
mg, Metformin nebulizer
Tab 500mg,
Availability of drugs for diabetes Mellitus 5mg/ml, Budesonide
Glimepiride Tab 2mg, Respirator solution
Glibenclamide Tab for &
2.5 use in
5 mg
Levothyroxine Tablet Normal
nebulizer 0. 5mg/ml, 25, 50 & 100 mcg
Saline drops,
Availability of drugs for Thyroid Dextromethorphan oral syrup, Hyoscinebutylbromide Tab
Availability of medicines for Tespiratory tract 10 mg
Ringer
Calciumlactate Injection,
Carbonate Sodium
Tablet chloride
500 mg, injection
Vit C tab 100mg,0.9%,
Availability of IV Fluids Dextrose 5% & 25%
Cholecalciferol Tab 60,000 IU, Pyridoxine tab 25,50 &
Availability of Vitamins and Minerals 100mg, Vit A oral liquid 1,00,000 IU/ml, B complex tab

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

Availability of injectables Anti rabies vaccine, Inj. Tetanus Toxoid,

Availability of Emergency Drug Tray / injectables Inj. Adrenaline, Inj. Hydrocortisone, Inj. Dexamethasone ,
at injection room Haemoglobin
Glyceryl scaleSublingual
trinitrate- test with talquist paper,
mg Urine
tab 0.5Povidone
Hydrogen
Pregnancy peroxide,
rapid test,Gentian
Rapid violet,
Kits for Malaria Iodine,
and Dengue,
Availability of Anti septic Splints, Syringe
Framycetin (10cc,ointment
sulphate 5cc, 2cc) and AD Syringe (0.5ml and
Urine
0.1ml) Dip
for Stick for
injection,albumin
Suture and
with Sugar,
needleGlucometer
holder & with
artery
Availability of Rapid Diagnostic Kits Mucus extractor,
glucosticks, Sputum Wooden
Cups, Spatula, Disposable Cord clamp,
forceps,
DisposableDisposable gloves,
Sterile Urethral Disposable12fr,
Catheter( Swabs,
14fr)Disposable
, Foleys
Availability of disposables for Dressing / Lancets, Mackintosh Sheets
Emergency management catheter , IV Cannula and Sets, Interdental Cleaning Aids,
Availability of disposables at Clinics cold pack, cotton and envelopes for drug dispensing

Vit A prophylaxis, Glucosticks, Syringes, Pregnancy kits, HIV

Rapid Test and STI Screening Test kits, Kit for testing
residual chlorine in Water. Vision screening care for 6/18
Availability of Drugs and Consumables for VHNDs vision, measuring tape (6m), reading module.
or camps
Facility has adequate functional equipment and instruments for assured list of services
 BP apparatus, Torch, stethoscope ,peak flow meter 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 at Examination
Ambu bag with Lamp,
Mask,Cheatle's
Suction forceps,
Machine,Sponge
OxygenHolder,
cylinder
Clinic Artery forceps.
with Administrative equipment (Keys),Mouth Gag ,
Availability of Emergency functional equipment Nebulizer. AED (Automated External Defibrillator)

Table, Doctor chair, Patient Stool, Examination table,

Attendant Chair, Foot Step, Screen Separators with Stand,
IV stand, Wall clock, refrigerator (For storage of drugs &
Availability of furniture & fixture at Clinics vaccines)
Area of Concern D: Support Services

The facility has established Programme for maintenance and upkeep of the facility

HWC Building is painted/whitewashed in uniform Check building is white washed both from inside & outside
colour & its branding done as per the guideline

Check building & its premises is well maintained

1. No seepage, cracks and chipping of plaster from wall,
HWC has system for periodic maintenance of roof, windows
1. Check etcof building, patient amenities
records
Building including patient amenities maintenance and schedules.
2. Pest or rodent control measures are taken at least once
in 6 months
No condemned/Junk material in HWC (corridors, HWC remove its junk periodically as per condemnation
roof, administrative area , backyard) policy.

There is system of timely corrective & preventive Check staff is skilled to undertake the trouble shooting
break E.g. Weighing machine, BP apparatus, the status is re
All the down maintenance
measuring of the
equipment/ equipment
instrument are checked At least once in six months.
calibrated 1. Check that floors and walls for any visible or tangible
Check all the areas are clean & hygienic
Check there is no foul smell in HWC dirt,
Check grease,
toiletsstains, etc.and there is no overflowing/clogged
are clean
Check availability of adequate supply of cleaning drains
(1) Availability of mops, 2- buckets system, good quality
material
Check staff is aware of use of 2 bucket system & cleaning
One bucketsolution preferably
for Cleaning a ISI mark.
solution, second for
disinfection of mop after cleaning
HWC has a system for safe disposal of general wringing the mop.
No garbage piles in and around HWC.
waste No signs of burning of waste in HWC
Clean and adequate linen is available Check Examination bed, table cloth etc are clean.
There is system in place for washing of linen

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

HWC has a process to consolidate and calculate Check forecasting of drugs & consumables is done
the consumption
Check Drugs and consumables forecasting and scientifically based on
Linkage with portal/ consumption .Reorder & buffer
DVDMS
indenting is IT enabled levels are defined

Check there is established system to timely (1) Timely indenting the drugs for common aliments &
indent the drugs as per services package emergency
(1) For HWC,cases
campaigns and home based care.
Check there is no stock out of essential & (2) Check staff is aware of any stock out
vital drugs

(1) Check list of VED categorisation

Check drugs are categorised in Vital, Essential (2) Check updated stock registers of the last 6 months for
vital & essential drugs
and desirable

There is specified place to store medicines in Drugs and consumables are stored away from water /
HWC dampness
Check drugs are kept in racks and shelves with Drugs are not andstored
sourcesat of direct
floor heatitems
,Heavy & sunlight etc. at
are stored
proper labelling
LASA ( Look alike and Sound alike ) are stored lower shelves/racks and fragile items are not kept on the
separately edges
Check heat and light sensitive drugs are stored as (1) Medications that are considered light-sensitive will be
per manufacturers
Check instructions
process followed to maintain the stored in closed drawers.
(1) Temperature chart is maintained
First expiry first
temperature out (FEFO)used
of refrigerator system is followed (2) De frosting is done (in case household freeze is used)
for drugs/
vaccine/
for drugslab kits
dispensing
There is system in place to maintain expiry & Check all near expiry drugs are shifted back to PHC/
near expiry of drugs
No expired drug is found in HWC referral centre/ facility where it is urgently required based
In
on dispensing area as(that
inventory turnover well is-
as drug storage
Fast, slow area
or non moving
There is an established process for discard the (1) Staff
drugs) is aware about how to discard expired drugs and
expired drugs are not stored in HWC
The facility has defined and established procedure for clinical records and data management with progressive use o
Information regarding illness and minor aliments (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
(2) Randomly, select at least 5 cases (or all cases if less
than 5) and check for details

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

Information regarding cases of Non- (1) Check family folder, CBAC form are filled and complete
communicable diseases are recorded & updated details are updated in portal.
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
(3) Randomly, select at least 5 cases (or all cases if less
than 5) and check for details

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
Give partial compliance if information is only available in
paper.

Functional platform/s and updated digital records Population enumeration, coverage, screening, referral &
to assess the
Functional coverageand
platform/s andupdated
measuredigital
outcomes follow ups generation- daily, weekly & missed task,
Work plan
of healthcare
records facility
forplatform/s
work/ taskand
management
Functional updated digital records reminders to team
Daily reporting of allfor
thescheduling
activities ,appointments
IT support to ,follow
generateup
for reporting and monitoring of the of home visits and outreach activities, Special
performance matrix of Service Providers, calculating days etc
performance of health care provider performance based incentive, Support for staff monitoring
& maintenance of their credentials

HWC has established procedure for safe (1) Secure place to keep records and registers
keeping
HWC has&established
retrieval ofprocedure
paper based
for records
access & (2)
(1) Check
Systemrecords
clearly are easywho
define to retrieve
all are authorized to access
retrieval of electronic records the patient electronic information
HWC has policy for retention period for different As per State policy
information & records
Hubs are identified for tele consultation Staff is aware
(1) Arrange of functional
consultation hubs
with & skilled
PHC- MO orto use the as
Specialist
Cases are identified for tele consultation for software
per requirement.
specialist & non specialist consultation (2) Check how many cases were consulted using tele
medicine in preceding 3 months
Co ordination with specialist / super
As per roster - send the patient to PHC
specialist for tele consultation

(1) Pre appointment, location for consultation

Co ordination with patient & creating
(2) Check reminder / SMS alerts are sent for
awareness about tele consultation services
appointments/ referral/ follow up cases
Dispense drugs as per prescription received As per e-prescription
through tele consultation
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.
Committee members are aware of its roles & Chairperson- Sarpanch,
A. (1) Maintenance Co -Chairperson-
of HWC - cleanliness, MO- PHCsafe
hygiene, and
responsibilities Member
drinking Sect. - CHO.
water, clean toilet, BMW disposal & clear signage.
JAS meetings are held at defined intervals (1) Monthly.
Check JAS supports HWC to mobilize (2)
BothMinutes of meeting
monetary and nonare recorded
monetary from PRIs/ CSR/Govt.
resources/funds schemes and program /donation etc
Timely planning & utilization of untied funds Timely submission of Utilization certificate as per
Check JAS provide support for Health promotion state/NHM norms
& prevention activities

Organize camps, VHSNC meetings, multisectoral

convergence, formation of PSGs etc.
Check JAS facilitate Public hearing or Jan Sunwais Check when was last public hearing was undertaken. HWCs
undertake Jan sunwais bi annually

Check social audits are done at periodic intervals At least once in a year. Check when last social audit was
undertaken

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 audits
teams

Gaps closure plan is prepared & status is assessed atleast

once in quarter or as per decided timeline
Check JAS committee has prepared action
plan along with HWC

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.

(1) At least once in a month

(2) Assess the progress on coverage of beneficiaries &
Check CHO conducts periodic meetings with any knowledge or skill gap
MPW
Check & ASHA
CHO provide on job mentoring & (3) Identify common issues & problems faced by
(1) Check CHO
Frontline provide on job mentoring & support to
workers
supervision household
Check CHO provide on visits
job mentoring & frontline workers (ASHA/
(4) Check
(1) Actions
CHOtaken onMPW)
thereafter
provide job mentoring & support to
supervision for VHSND or campaign etc. frontline workers (ASHA/ MPW)
 (1) Monthly review of service delivery & performance
Check PHC -MO provide supportive
of HWC
supervision & monitoring for HWC activities
(2) Supportive supervision for HWC staff

The facility ensures health promotion and disease prevention activities through community mobilizati

Check HWC is aware of community level

approaches for health promotion and disease
prevention VHSNC, VHNDs, ASHA, AWW and Monthly campaign etc

(1) Regular meetings are being conducted

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

Check frontline workers part of VHSNC are able to

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

(1) Check agenda points and minutes of meeting of

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

Check number of VHSNC meeting attended by

CHO in preceding quarter At least 2 VHSNC per month

(1) Check the list of VHND planned & conducted

Check number of VHND planned & conducted in (2) List of AWC under HWC & name of the AWC where
CHO's catering area in preceding quarter VHNDs conducted
 (1) Check advance communication regarding date & 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 expected to
Micro planning to conduct VHND is done by attend VHND are calculated in advance
HWC staff & frontline workers (4) Check the coverage against estimation
(1) Identify the individual with health risk
(2) Community mobilization for screening
(3) Holding or Support village meetings or campaigns for
awareness
(1) Awarenessgeneration
generation& life
forstyle modification
various Health program
Check functional equipment, instrument and (4)
(2) Support
Need basedtreatment compliance
counselling for pregnant women,
& interventions
adequate
Check the consumables
health promotionare available
& diseaseto conduct new born,the
(3) Check NCDlist&ofacute of chronic
topics coveredconditions
during VHNDsas per
in
VHND
presentation activities are performed during As per service
service
proceding provision
provision
quarter
Check primary healthcare team perform (5) Check number of newenumeration,
individuals identified with health
VHNDs
advocacy with community influencers for giving (1) Viz.Based on of
Benefits Population
immunization, family village health
planning, ANCs,
risk & mobilized
register,check-up
CBAC, ASHA for screening in proceding quarter
key messages
Check for health promotion prevention regular and diary,
Yoga forVHSNC
NCDsrecords,
etc. RCH registers
Check the
the health
processpromotion
followed to& identify
disease key (6)
etc Check number of individual supported treatment
activities
challengesare performed
and by ASHA
list of priorities for monthly compliance
(2) Based oninsocial
proceding quarter
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 are organized
per year. Viz. WASH, Eat right/eat safe, Nutrition
(1) Prepared
screening, draft campaign
deaddiction plan & define
& substance abuse,responsibilities
Indoor and
of primary care team
outdoor pollution, Case detection for NCD & CD, childhood
Check Annual calendar is prepared for monthly (2) Conduct
illness meeting
diarrhoea of HWC team
& pneumonia, & other stakeholders
prevention of childhood
campaign based on situational analysis i.e. panchayat,
marriage, GBV ICDS etc
etc
Check health promotion campaign are (3) Gather/PreparedIEC or IPC material requiredconducted
Check number of health promotion campaign
conducted as per planning
Check the involvement of HWC in planning & out of planned
(4) Engage in proceding
community quarter
volunteer, support & supervise
falcitation of monthly campaign activities them
There is a system of taking feedback from ASHAs
/ VHNSCs/ VHND to improve the services

For ensuring treatment compliance, reduce stigma,

HWC have created Patient support groups for increase acceptance toward disease, reduce stress &
various issues/ disease conditions anxiety & increase self understanding

(1) Based on issues/diseases with high prevalence in area

Check the process followed to create PSGs using data &information collected
 (1) Identify the potential member & encourage them to
join by explaining them the advantages of joining
(2) Friends, relatives, frontline workers and patients
suffering from same disease conditions.
(3) PSGs meetings should be open to all community
Check staff is aware of guiding principles to be members
followed to constitute PSGs

(1) Sharing the knowledge & experience with other

(2) Work together to solve the problems
(3 Helping health functionaries in health promotion (as
Check members of PSGs aware of their roles convenient)
No. of planned PSGs & how many actually conducted
(1) Flexible location, - in house of group member, arranged
after VHNSC/ VHNDs, SHC, AWW - preferable near to
Check the frequency , location & timing of PSG marginalized or distant hamlets
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
Primary health care team/worker is aware of (4) Inform group about content, date , time & place for
their role in conducting PSGs next meeting
(1) Education, WCD, ICDS, rural development/
HWC engage other allied departments for municipal bodies, FSSAI &ICDS etc.
intersectoral convergence (2) Check VHSNC provide platform for multisectoral
convergence

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

HWC organize training sessions &

With support of Ayushman ambassadors
competitions for school children

HWC promotes wellness & health promotion

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

The facility is compliant with statutory and regulatory requirement

Authorization for Bio Medical waste Prior approval from Pollution control board (if HWC is using
Management
No Smoking sign is displayed at the prominent deep burial &
Both inside pit)
outside the building
places
Any positive report of notifiable disease is
intimated copies
Updated of relevant
to designated laws, regulations
authorities BMW rules, fire safety, electrical installations and any
and Govt orders are available other as per state mandate
Area of Concern E: Wellness & Clinical Services
 The facility has defined procedures for registration, consultation, clinical assessment and reassessment of th

(1) There is established procedure to collect the

HWC is aware of constitution of its catering demographic composition
Check no. of pregnant women, no. of life births, pregnant
population
HWC periodically estimates & updates number (2) No. of individuals of different
mother with complications, agecouple,
eligible groupssick new born
of beneficiaries for RMNCHA services are estimated

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

HWC periodically estimates & updates number

of (1) per
Check family folders are maintained
ratesfor entire
Allbeneficiaries forfamilies
individuals and CDs are empanelled under As incidence rates/ prevalence
registered population in facility's coverage area.
H WC (2) Check data base is updated regularly for new entrants
and exits (annually) & their illness.
Check Unique health ID is given to all individuals and
Unique identification number is given to each families .
patient

Check all the patients visiting HWC are registered & their
Patient demographic details are recorded in OPD demographic details like Name, age, Sex and Address etc
register/portal are maintained
Chief Complaint, Patient History, Physical
The facility has established procedure for examination, requisite diagnostics, provisional
OPD Consultation diagnosis, primary management & referral (if
required)
Through tele health/ tele consultation with MO PHC
Facility has system to undertaken opinion /identified hubs/ clinical decision making -IT tool
/consultation from higher centre

All the empanelled individuals are screened Through fix day/routine OPD consultation
Facilities provide follow up/re assessment for
cases under RMNCHA Reassessment /follow up as per schedule for all cases
including
Reassessmentcritical /highup
/follow risk patients.
Reassessment
Follow
(1) Eye,up /follow
includes
ENT, oral, - up asas
Treatment
elderly
per schedule
percompliance,
schedule
&patients.
palliative,
for
mental
all
all cases
forreview
cases
health ofetc.
including
including critical
critical /high
/high risk
risk patients.
parameters,
Follow up includes - Treatment compliance, review oflife
Give full monitoring
compliance if anyof side effect,
services is adherence
not given as to
per
style modification,
service mandate
parameters, timelyofdetection
monitoring of adherence
complication
side compliance,
effect, and
toof
life
Follow up
continuity
(2) Follow includes
and - Treatment
adequacy
up includes of
-timely treatment.
Treatment review
compliance, monitoring
style modification
Facilities provide follow up/re assessment for parameters, and detection of complication
of
andside effect,monitoring
continuity adherence
andand
adequacy
of
to side
life
of
effect,
style adherence and
modification
treatment.
to life
cases under Communicable diseases style modification timely detection
Facilities provide follow up/re assement for timely detection of complication and continuity and of complication
cases under
Facilities non communicable
provide diseasesfor and
follow up/re assement
continuity
adequacy and adequacy of treatment.
of treatment.
other clinical conditions
The facility has defined and established
CHW ensures procedures
home visit,forcounselling/
continuity of care through two way referra
supportive
Facility ensures continuity of care at activities for risk
Dispensation factor modification,
of medicines, provide as
repeat diagnostic
community/household reminder for follow up at HWC & collection
level at Health & wellness required/ as per treatment plan, identification of drugs.
of
Continuity of care is ensured Linkage with MMU/RBSK mobile unit
centre complication , facilitating referrals, organizing tele
Continuity of care is ensured at referral Examination,
consultations,development/modification
maintenance of records of treatment
Centre/higher centre plan, instruction forprimary
Early case detection, patient,management/stabilisation,
note to CHO by
Facility has defined
Check availability ofprotocols
separate for referral
colour codedout MO/Specialist.
Complete details of case records/care provided - use of
referal slip for easy identification in referral centre
referral slip
Facility has defined protocols for referral in Check records for treatment plan, periodic assessment,
medicine refill
(1) Referral slip,and referred
referral in ortoout
further higher centre
register/portal, (if
Advance
required)/ regular follow up at referring centre
communication , prior appointment with specialist, referral
vehicle (if required) & follow up.
(2) IT system to track upward & downward referrals to
ensure the continuity of care
Facility has referral procedure in place to ensure
continuity of care

The facility has defined and established procedures of diagnostic services.

Point of care diagnostics services are available as Check staff is aware of Quality Control method for various
per mandate tests (RDKs)

Central hub/diagnostic units are identified &

linkage has established for tests not done at For Both laboratory/other diagnostic test. Check how much
HWC patient has to travel for getting diagnostic services

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

results from PHC/referral centre or identified hub results.
HWC has system for timely reporting, retaining & (2) Biological reference intervals for laboratory tests are
prompt retrieval of diagnostic result available in HWC
Check there is no irrational prescription of Check OPD ticket for any irrational prescription of Lab
Diagnostic test test/USG/ X ray etc

The facility has defined procedures for safe drug administration.

Medication orders are written legibly and

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

(1) Drugs are checked for expiry and other inconsistency

There is procedure to check the drugs before before administration, single dose vial /ampule are not
administration and dispensing 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
Patients are counselled for self drug (1) Medication calendars /schedules, specify the time to
administration take medications, medicine related information sheets,
specific packaging’s such as pill boxes/ envelope,
indicating the time/ frequency of dose.
(2) Check patient is aware of 5 moments of medication
safety

Check high alerts drugs are identified & its

maximum dose are defined High alert drugs such as Nonsteroidal anti-inflammatory,
anti convulsant/antiepileptics, Hypertensive, oral
(1) Right patient,
hypoglycaemic right drug, right route, right time, right
etc.
Check staff is aware of right dose of high alert Value
dose &ofright
maximum dose as per age, weight and diagnosis is
documentation.
drugs available with CHO.
(2) Check system in place to verify the verbal orders given
Check staff follows 6 Rs of drug
with staff if any untoward drug events has by
administration
Check MO
Minimum information model (MIMPS) for medication
ever
Checkoccurred
any untoward/adverse drug events are safety is followed & used for reporting & subsequent
recorded and reported actions planning
Check the cases in which CHO has prescribed medicines/
The facility follows standard treatment
antibiotics. Check if guidelines
the drugs areand ensures
either rational
prescribed use of drugs
more
than required dose /quantity or on more occasion
Check availability of STG/clinical algorithm/ Clinical than
Check staff is aware of rational use of drugs necessary.
decision making tool (IT based), Staff is aware of drug
Check
Check medication review is scheduled for regular regime
STG/ clinical algorithm is followed At leastand
oncedoses
in a year
chronic cases with PHC MO/ Physician of referral facility
 Check OPD ticket if drugs are prescribed under generic
Check drugs are prescribed with generic name Well
namedefined
only and standardized format is used to assess the
quality and accuracy of treatment provided. Valid sample
Check HWCprovided
Treatment has antibiotic
by CHOpolicy
is monitored Check
is takenstaff is aware ofofantibiotic
& frequency monitoringpolicy
process is defined and
regularly followed
Check
Check monitoring
medication is done by
orders/ qualifiedispersonnel
procedure written Preferably
Check medicalMO advise
of Mother PHC/referralwith
is accompanied sitedate, time &
legibly & comprehendible signature

(1) Non compliances ( viz over prescription, irrational use

of antibiotics, drugs, vitamins, vaccines, diagnostics etc)
are enumerated , (2) Action plan is prepared & Primary
health care team is hand holded & guided for
Action taken on non compliances improvement
The facility has defined
Both in HWC and established
& home procedures for nursing care.
based care.
There is process for ensuring the identification of Investigations, refill the medicines, performing minor
patient before any procedure procedure, administrating vaccine etc

Chronic cases/ critical patient referred from higher

There is process in place to identify non Patients who are
centre/Home notcare
based oftently following
patient/ their treatment
bed ridden/ elderly cases
compliant
Patient's patient
vital in chronic disease
are monitored and recorded plan or taking the medicines as recommended
Check Patient vital like BP, weight, TPR, Blood sugar etc are
Prescribed Treatment plan , procedure
periodically in follow up
performed are written in case sheet/OPD maintained as per
Treatment plan disease, medication
followed conditions administered are
ticket/Portal
Day to day progress of patient is recorded where documented
Progress is monitored & documented as per schedule
ever required/ critical/ chronic cases prescribed
HWC, home based care/ home visits, patient self
managements
OPD slip, family folders, referral slips , Disease specific
forms & formats (any hard /soft copy)
Standard forms & formats are available Registers & records are maintained as per guidelines/range
Updated Registers & records
All the register/records are available
are identified and of services
Check provided
the master listby
&H WC (SC)
unique identification number is
numbered followed to identify records

The facility hasProtocols

defined and established
for snake procedures
bite, poisoning, for Emergency
drowning, trauma, care
burn,
Checkfits,
staffcardiac or of
is aware respiratory arrest
steps of BLS and, haemorrhoids,
also ask about how
Emergency protocols for first aid and stabilization rectal
to recognize the signs for sudden cardiac arrest is
(SCA),
are available (1) Check hernia,
prolapse, how ambulances
hydrocele,are called & patient
appendicitis shifted.
etc. obstruction
heart attack, stroke, and foreign-body airway
(2) Transfer register is maintained to record the details of
Staff
HWC isensures
aware of procedure
timely for CPR
availability of ambulances (FBAO)
the refferred patient
services for emergency cases

Staff is aware of district disaster management team, staff

is aware of their roles, basic emergency management kit is
Emergency care
Staff is aware of isprocess
given inofcase of disaster
sorting the patients available
Staff is aware of triage protocols in case of referral
in case of mass causalty/ outbreak required

The facility has defined & established procedures for management of ophthalmic, ENT and Oral aliments as per operatio

The facility has defined & established procedure for screening & basic management of Mental Health ailments as per Opera
 Source reduction,
(1) Fortnightly Home personal
visit &protection,
testing people environment
with current/
management, Biological control
recent fever & chills in past 14 days using RDT. ( Larvivorus fish) &
chemical control (larvicide / Adulticide)
(2) Malaria detection in cases presenting with fever . Staff is involved
at
in
HWCintersectoral convergence with other departments like
DODWS (Department of Drinking
(3) Detection by using RDT/Microscopy. (Microscopy- Water and Sanitation
under Ministry
result should beofmade
Jal Shakti, MOHUA
available within(Ministry
24 hrs) of Housing
The facility has defined & established procedures and
(4) for management
Urban
Negative Affairs),
RDT cases of communicable
strongly suspected ofdiseases
malaria as per operational/
cross
Primary care team is aware of vector born (1) Treatment should
Municipalities etc) & be
carrystarted
out within cleanliness
weekly 24 hrs of detection.
drive in
checked
(2) P. Vivax by -microscopy
Chloroquine/ 3days and Primaquine/14 days.
disease control strategies village
(5) through
Check HWC is in VHSNC
aware of confirmedor malaria cases in its
(Contraindicated
Persistence of fever pregnant
even afterfemale 48 hrs ofinfant
treatment,or G6PD
Case detection is done for Malaria catchment
(1) Diagnostic-
deficiency/ area
P- RDK
falciparum- ACT dehydration, change in
continuous
(2) Management- vomiting, Bed headache,
rest,& diagnosis
Staff is aware of Malaria treatment protocols (3) Algorithm
sensorium, for treatment
convulsions, bleeding is available
& clotting disorders,
cold sponging,& symptomatic treatment.
Staff is aware of Malaria referral protocols
Staff is aware of diagnostic & management of severe
(3) Check anaemia, Jaundice
HWCisismaintained
aware of dengue& hypothermia
cases reporting
in its catchment
Check register & updated, in form
dengue as per protocols area
M 1 (ASHA/SC), M2 (if using slides), M4- fortnight complied
RDT kits , clean slides, needles, swabs, ACT, CQ, PQ etc.
NVBDCP
Facilities register & records
have adequate areofmaintained
stock commodities & report
Check how of malaria
kits havesurveillance
been storedsubmitted
& near by SC drugs are
expiry
(1)Provision of DOTS at Sub-centre, proper
drugs
Staff is aware of sign & symptoms of prevalent not available
documentation
Chikungunya, KA,andJE,follow-up,
LF home based support,
etc. to designated
Refer
regular allscreening
presumptive oftheircases
cases for common Microscopy
vector born
Identification diseases
of in area
presumptive case & their Any of
centre. the cases
Sputum in
collection catchment
and areaadverse
transport of
effects,
sputum of
HWC support, supervision & manage ensure compliance & completeness of course
referral
presumptive, confirmed & on treatment cases samples
(2) CheckisHWC supported
is aware in of
hard/difficult
presumptive, areas.
confirmed & on
including DR- TB patients
Staff is aware of follow up protocol after treatment cases in its catchment area
(1) Pale & reddish patches on the skin, skin thickness, shiny
treatment completion 6,12, 18 , 24
& reddish, month follow
numbness up after
& tingling, treatment
painful tendercompletion
nerves,
weakness of hands, feet or eyelid, swelling & lumps in the
face & ear lobes impaired sensation.
(2) Sensory testing for screening: touching the tip of pen on
patch
Ensuretodelivery/
feel sensation
availability2 times (once
of 2nd with
dose eyes &drugs,
onward 2nd with
Referral
closed slip, Patients
eyes) treatment card (if CHW is supporting
NTEP register & records are maintained pulse dose toTBbenotification
treatment), given in presence register of ANM/MPW,
Primary
Check the healthcare team
availability identify
/ delivery of and ensure
subsequent (3) Referral of
completion of suspected
treatment,cases to higherofcentre.
identification signs of First dose
neuritis,
referral of suspected cases of Leprosy
doses of MDT and follow up of persons under initiated at higher centre
reactions etc for treatment cases. Referral in case MCR
treatment Health
footwear education
Identification if required/ to community
& referral referral
of forregarding
suspected complications
cases, signs
Condomand
Maintain
symptoms & update
of leprosy, case its card (ULF01),
complications, Update
curability the &
NLEP register & awareness
records areabout
maintained Promotion
treatment & distribution
registered when among
visitinghigh
therisk
PHC groups & help
Facility provide leprosy & availability
HIV cases for of receiving
free of cost treatment,
& adhering to self
ART.care & encourage
availability of its treatment the
IEC patient
for
HIV/STI to bring his/her
STI,HIV/AIDS
Counselling, Awareness
Screening contacts to check-up
generation
(consent) and, identification
referral
HWC-HSC is aware of their roles in NACP of
in peer
Type support
B groups
Sub-centres in for
highHRG- PLHIV,
prevalence encourage
districts for
HWC -SC has linkage for management of Linkage with Microscopy
index testing, support centre for adherence,
in treatment HIV -TB, for PPTCT
HIV/AIDS complications Fever,
services Cough less than 2 weeks duration, acute flaccid
Staff is aware of promotional &supportive arrangement
paralysis more forthan
counselling/
15 yrs. psycho
of age, therapies,
diarrhoea community
NACP under surveillance (1) (1)Information
Preliminary is collected from women
Home visit (foror
(3 above
activities done under
Staff is aware of syndrome follow
more loose
described stoolanalysis
up to support
syndrome)/day), & reporting
HIV pregnant
Jaundice,
& from SC- OPD
of collected
Raise the signaldata
& for
in IDSPprocess to collect information in form to MO-inPHC
action caseon every
ofdata Monday
for any unusualfor
health event /death
Check (2)
(2) Check any action hasRegister
Collation of in Syndromic
been undertaken using IDSP
SCheck Analysis & reporting of information Surveillance
data
for syndromic surveillance is done

Awareness generation & behaviour change

Availability of diagnostic & treatment RDT for Hep B & immunization
communication, Hep C & referral forfor
Hepconfirmation
B (Birth dose, &
services further management
high risk group & healthcare worker) , injection safety
Staff is aware of preventive measures for NVH (1) Population
& safe
Interview drinking enumeration
patients water -filling of CBAC form for
for: & sanitation.
all
(1) Regular & adequate availability ofat
above 30Yrs of age- Screening HWC onasfixed
medicines per day
The facility has defined & established procedures for management
approach-referral
treatment plan ofofsuspected
non-communicable
cases to higherdiseasescentreas per operationa
for His/her
(2) Consultation - followabout
understanding up of dosage
those who are life style
schedule,
Staff is aware of process of population Systolic/ Diastolic BP ofrestriction
over 140 /Over 90that
mmthey of Hg.
diagnosed
medication, with
Awareness generation hypertension
any dietary & ensuring
and
- (a)Risk factors: awareness
overweight about
&
identification
CHO is awareand referral
of sign for hypertension
& symptoms of Severe
next Headache,
follow up visit fatigue,
date nausea, sweating, feeling
adhere
(1)
obesity, to treatment
Population
Physical plan-
enumeration
inactivity & identify
-filling
stress warning
of
(b) CBAC
Healthy signs
form
life of
for
style:
HWC ensures frequency of follow up & supply of Interview
Hypertension faint
(3) &
Annual
complication
all above
patients
confusion,
30Yrs&
for:
consultation
refervision
with
to problem,
specialist
higher
of age-availability
Screening chest
centre.
atat NCD pain,
HWC(con clinic
fixed
required medicines
diet,
(1) exercise,
Regular
shortness
avoidance
& adequate
of
tobacco &ofalcohol,
medicines ) as per day
Staff is aware of promotional &supportive (2)
Counselling forbreath.
Re screening
approach-referral
treatment plan ofofpopulation
Lifestyle modification
suspected (new and
(d)
cases old) at centre
importance
to higher of
activities for Hypertension Counselled
periodic
regular follow about
intervals
& -not
every
compliance to miss/skip
year
to meal, take up
medication
for
(2) consultation
His/her
Random
frequent blood
and - follow
understanding
sugar
small upincrease
about
140mg/dl
meals, of dosage
those who areactivity
schedule,
and physical
mg/dl. life style
Staff is aware of process of population
diagnosed
medication,
Frequent
and side with
any hypertension
dietary
urination,
effects ofdateincreased
anti &
restriction ensuring
and
drugs. that
awareness
diabetichunger,excessive they
about
thirst,
identification
CHO is awareand referral
of sign for diabetes
& symptoms of next follow up visit
adhere to
unexplained treatment
Hypoglycaemia: weight plan-
loss,
Symptoms; identify
extreme
tremors, warning
tiredness, signs
blurred
nervousness, of
diabetes
HWC ensures frequency of follow up & supply of (3) Annual consultation
complication & refer with
to specialist
higher centre at NCD clinic
required medicines vision, slow
anxiety, woundirritability,
sweating, healing numbness
confusion, orHeart
tingling beat
Check Patient is counselled about identification & (2)
handsRe screening
increase,or feet of population
& sexual
headache etcproblems (new and old) at
immediate management hypoglycaemia periodic
Management:intervalsTake -every year Mishri/1 table spoon
5-6 toffees/
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.
 (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)
● Family H/O diabetes, hypertension, heart diseases
and cancers
● Obesity
Awareness (BMI>=25kg/m2)
generation - (a)Risk factors: overweight &
● Oedema
obesity, examination
Physical inactivity & stress (b) Healthy life style:
(3) Referal
diet, to avoidance
exercise, PHC for management
tobacco & alcohol, (c )
Counselling for Life style modification (d) Importance of
HWC is aware of risk factors of Nonalcoholic regular follow & compliance tofor medication (e) Counselling
fatty liver disease (NAFLD) & supportive (1) At SC/ outreach/screening Breast, cervix & oral
Staff is aware of promotional about
cancer. diabetes related complication viz. Retinopathy,
activities for diabetes neuropathy
(2) Screening&iskidney undertakenfailurebyetc. trained personnel (LHV/Staff
Check cancer screening services are provided Vaginal bleeding
nurse/MO) can bebetween
done in periods,
outreachmenses longer or day.
session/screening
through HWC about sign & symptom of cervical heavier than usual, post menopausal bleeding, bleeding &
Staff is aware (3) Screening of cervical cancer is conducted on site
cancer Lump
pain
where inprivacy
breast/under
during/after sexual
& facility arm area,
intercourse,
for thickening
sterilization smelly or swelling of
vaginal
is available
Staff is aware about sign & symptom of Breast Difficulty in chewing or swallowing
cancer
breath,
discharge,
(4) Repeat
(1) puckering
pain
Visual Inspection /dimpling
during
screening -every urination
by- (1)Risk
Acetic5yrsAcid for cervical,ulcers
of breath
etc , mouth
skin, redness (2) in
Oral
Staff is aware about sign & symptom of Oral Awareness
persist
nipple for
area, generation
more
nipple than
discharge3 weeks, factors:
/blood, persistent smoking,
constant pain,
pain multiple
lump,
etc
Visual
sexual Examination
partner, for
unprotected oral cancer
sex, family (3) clinical
history, breast
Cancer
Check with staff about methodology followed for Forthickening
cancers
examination in cheek,
offor
the oralwhite/red
Breast .and breast, patch
the first on level
gums/ of referral
overweight,
tongue/tonsil
Staff
theisCHC
aware
is(4)Discuss lack
5A of
etc, physical
approach
/interpretation
SDH/ DH and then activity
- Ask, toadvise,(2)
theif DH Healthy
assess, life style:
Assist
forata SC/outreach
biopsy &
for
cancer screening
Check CHW is aware of referral centre for all diet, exercise, avoidance of results
tobacco & done
alcohol, (3 )
arrange
confirmed cases. day
session/screening
types
Staff isofaware
cancerof promotional & supportive Counselling for Life style modification
(1)
ForHistory
cervicaltakingcancer, and referral
if VIA refer(4)
to identified
positive, toimportance
de addiction
higher centreof
activities for diabetes regular
centre. follow
offering colposcopy & compliance to medication
Confirmation and referral of cases for
(2)
(1) Advise to quite in
For Withdrawal cleat, strong
symptoms andstyle
(2) Life personalized
support
Tobacco/alcohol/ substance abuse
Promotional & supportive activities for manner
changes (3) Engagement/ linkage with patient support
Tobacco/alcohol/ AskAttempt
for localto prevalent (4) disease
Involve viz. Pneumoconiosis , lead
Check Screening &substance abuseprevalent
referral locally (3)
groups (4) Support Quit encouragement family by &family
friends, & remove
friends
poisoning,
Check
substancesstaff fluorosis
counsel
from etc.
mother's
their Give full
adjacent for compliance
nutritious
area, Arrange iffollow
diet no such
during upfirst
diseases Through trainer Yoga instructor (ASHA/ Asha facilitator/
Check HWC is providing Yoga services disease
1000
visit days
(5) exists
of
motivate life by re enforcing & intense follow up
Yoga
(1)
1. Checkteacher/
Stage 1 (During
roster physical instructor
Pregnancy)
is available, from
: Balance
updated school)
& nutritious diet
& displayed
Check Yoga sessions are conducted regularly including important nutrients
One
2. day fixed
Community Ayurveda
is aware yogalike
ofclinic for iodine,
diet
sessions folic acid, by
counselling,
conducted iron, vit
HWC
Check Ayurveda services are available B12 etc.
management of chronic aches & pains & elderly care.
Check counselling of mother's for nutrition & (2) CheckStage 2about
( Period
availability offrom
Ayurveda birth of child to&1with
physician yr.): household
medicinesEarly
Check
hygiene staff counsel and
maintenance guideEat
under mother's (1)
theright (1) Guide
Generate
initiation of
household
awareness
exclusive aboutmeasurement
breastfeeding 4 major for food
initial groups
6 months,(food
utensils
pyramid) - a. Cereals & millets
about household preparation of initiation
(2) Awarenessof Complementary feeding on & completion ofof6
Check Primary health
complementary care team generate
feeds b. Vegetables
months
(1) with
Awareness
Awareness &on ingredients,
fruits,
continued
ongeneration
benefits of &quantity
c.Breastfeeding
Milk about animal
fortified logos
food
frequency
products
on packed d. Fats/food
awareness in community complementary nutsfeeding for children up to 2 yrs.
Check Primary health careabout
teambalanced
generate diet oils, sugar3 &
(3)Stage
Awareness (Period
(2) Identification
viz. fssai, generation
ISI, +F, ofbetweenabout
fortified
green and 12 month
maintaining
food
red tofor
available
dots 24 inmonths
personal
market
vegetarian &of(+Fchild
and
Check Primary health care team generate (2)
age):Limit
environmental
awareness in community about food fortification logo) the
Complementaryconsumption
hygiene feeding
whileof foods
& its
cooking high in
preparation
food fats,
(viz. sugar
with &
right
non
salts vegetarian food items.
consistency, quantity, frequency,
awareness in community about Eat safe handwashing,
(2) Safe storage regular bathing,
of perishable &density
wearingnon clean & variety.
perishable clothes, food
Check Primary health care team generate
practices keeping kitchen clean, taking pest control measures, waste
awareness in community about food safety (3) Precautions to be taken while cooking & serving
disposal, using kitchen waste for compositing etc)
the meals.
(4) Awareness
Elderly & palliative about
health care common
services tests for as
are provided food
per guidelines
adulteration (Key ring test)

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, Jaundice,
CHO & CHW are aware of danger signs of new
pustules, hypothermia,
Staff practice unableStabilization
ETAT protocol. to pass stool/urine, fever,
per disease
born & infant
Primary management & prompt referral of sick diarrhoea, indrawing of the chest (2-12 months-50
condition.
Exclusive breast feeding, cord care, maintenance of
new born & infants breaths/min & 12-5yrs-40 breaths/min)
Staff is aware of post natal care Counselling DPT, DT, Hep promoting
temperature, B ,TT vials & diluents
hygiene are notsupport
practise, kept in direct
for high
Check for vaccines & diluents are kept as per the contact of ice pack , Discarded medicines are kept
risk babies
recommendation of guidelines separately
 (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 reconstitution.
Reconstituted vaccines are not used after
(2) Vials should be kept in plastic box with label ' NOT TO
recommended time
BE USED' & discarded after 48 hrs/ before the next
session, whichever is earlier.

Staff checks VVM level before using vaccines and Staff is aware of how check freeze damage for T-Series
identify discard
Parents are point for informing any
counselled vaccines
Observe interaction at session site and interview parents
untoward
Antipyretic drugs are provided wherever required /care
event of concern following vaccination Observegiver
session site and interview parents /care giver
Beneficiary is asked to stay for half an hour after To observe any AEFI, Staff is aware of minor & serious AEFI
vaccination
Vaccinator is aware about how to manage any with its management,
Ask the vaccinator what reporting
steps toof AEFI
take Counselling
in case on
of serious
immediate serious reaction/anaphylaxis side effects and follow up visits (CEI)
Check the availability of anaphylaxis kit with ANM reaction/anaphylaxis
Kit constitute of job-aid, dose chart for adrenaline as per
at session site
Check adrenaline is not expired in kit age
Give(1non
ml compliance
ampoule -3 ifno.),
kit isTuberculin syringe (1ml-3 no.),
not available
24H/25G needle- 3 no, swabs-3 no. updated contact
information of DIO, MO PHC/CHC & local ambulance

Check for injection site is not cleaned with spirit Cleaning of injection site with spirit swab is not
before
Check thatadministering
Staff knowsvaccine
how todose
use AD Syringe recommended
Ask for demonstration , How to peel, how to remove air
Staff is aware of the shelf life of Vit A once it is bubble
Shelf lifeand
6-8injection site mention of opening date is
weeks. Check
opened
ANM/CHW andisensures it is not given
aware segregation afterafter
policy shelf life marked on bottle
1. Segregate use & unused vials, Kept in sealed/zipper bag
completion
Staff is aware ofof
immunization session
Open vial policy in the vaccine carrier cold
OVP is not applicable chain (reverse
to opened cold chain)
reconstituted vials of&
picked by AVD
measles, BCG & JE
Check for HWC -SHC micro plan for immunization
& its is
Staff adequacy
aware of how to calculate the number of Estimating the beneficiaries & logistic. Preparing due list of
beneficiaries,
HWC -SC maintain quantity of vaccines
tracking & syringes
bag/ tickler box expected beneficiaries
Counter foil are updatedincluding number
& utilized of beneficiaries
for follow up &
wastage/dosage per multidose vials
Check Vaccinator is aware of different categories 1. Ask the staff to enumerate categories or whether he/she
of AEFIperson responsible for notifying &
Check can differentiate
Ask the between
staff regarding the minor & severefor
responsibility AEFI.
notifying and
reporting of the AEFI is identified reporting the AEFI

Process of reporting and route is communicated Ask staff to whom the cases are reported & how
to all concerned
Reporting of AEFI cases is ensured by ANM 1.Verify weekly report of AEFI cases.
Frontline workers & Health supervisor is aware of 2.Nil
Verifyreporting in case
with current ofguidelines
AEFI no AEFI case.
his/her roles
Vaccinator is & responsibility
aware about how fortoAEFI surveillance
prevent Ask vaccinator how to prevent immunization related
Programme
Primary healthcare
immunization team communicate
error related reactions the reactions the
Observe fromsession interaction/ interview the
occurring
benefits of RI at VHND sessions beneficiaries
(1)
ARI:Give
Assessment for identification of ARI, diarrhoea, Chestfirst dose of oral
indrawing Amoxicillin
difficulty and injectable
in breathing ,coughing,
malnutrition andidentification Gentamycin.
Other Illnessof possible serious
fever, fast breathing
Assessment for Young
(2) Treatinfant- Not able
or prevent lowtosugar
feed(breastfeed/
or convulsionage or appropriate
fast
bacterial
Managementinfections among young
of diarrhoea is doneinfant (0-59
as per breathing
Symptomatic >60/ min or
treatment,severe chest
Paracetamol indrawing
for or
fever,
ORS, Zn, LotO of fluids, & treatment with Cotrimoxazole.
feed) axillaryof
plenty
days) & children
protocols (2 -59 months) temp
fluids,37.5
keep
Counselling
(3) Warm the C or
child
and more
& giveor
referral
young movement
normal only when stimulated
if temp is less than 35.5& Oreferral
if required
infant diet . Counselling C.
Management of ARI is done as per protocols if required
(4) Advise mother to keep young infant warm & refer
Management of Possible serious bacterial urgently to hospital
infection
Managementas per
ofprotocols
Malnutrition is up
done
Screening,
protocols
referral and follow of as per
Counselling for nutrition & referral
children
for anomalies, disabilities and developmental Functional linkage with RBSK team, referral & follow up
delays
The facility has established procedures for family planning as per government guidelines and law
The client is given full information about family Importance of FP, Options available- ( limiting & spacing
planning methods
Staff is aware of Method specific counselling method), time for initiation & advantages of various
approaches available methods. For Limiting method -counselled &
referred to higher centre
BRAIDED Approach: Benefits of method, risk, consequence
of failure, alternatives, inquiries, decision to withdraw,
explanation of method chosen & document of session

Care seeker is counselled about contraindications Such as risks, advantages, and possible side effects of
& adverse events of chosen FP methods OCPs/ECP/ Injectable/IUCD/ cent chroman , what to do if
dose of contraceptive is missed, method of administration
of ECP.
Promotional activities for Family Planning are
provided at facility under Mission Parivar Vikas 1.Nayi Pahel Kit, Saas Bahu Samelan, Saarthi.
Staff is aware of case selection criteria for family 2. Giveyrs.,
15-49 full married
compliance if facility is not covered under MPV
planning methods but undertake promotional activities.
Staff is aware of options, indications & methods No (1) Hormonal (Combined
touch technique, oral pill)
Speculum and,Non Hormonal
bimanual (Chaya)
examination,
for
IUDadministration for Oral
insertion & follow up isContraceptives & Emergency
done as per standard sounding Contraceptives.
of uterus and placement. Follow up : when to
protocol return / removal of IUCD. Check In case of 2nd trimester
Injectable Contraceptives are given as per Check
abortiontheIUCD
eligibility for injectables
is provided are checked
by Qualified &
Medical officer
protocols confirmed by MO. Dose may be started/
Staff is aware of case selection criteria for limiting For sterilization: 22-49 yrs.- (female) & 22-60yrs continue by
trained HCW.
Check adherence Depot MPA can be given IM or
mentors (male), married, toyoungest
Subcutaneous,
GoI guidelines
child is at least one year &
Female Sterilization:
spouse has not opted Certification is issuedCounselled
for sterilization. one month & after
the surgery or after
referred to Higher centrethe first menstrual 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
HCW is supporting & encouraging the clients for sperm after 3 months. (A
post sterilization follow up
The facility provides Adolescent Reproductive
Nutritional Counselling, and Sexual
advice Health
on topic services
related as per guidelines.
to Growth
and development,
Haemoglobin puberty,
estimation, mythsIFA
weekly & misconception,
tablet, and treatment
pregnancy,
for worm safe sex, menstrual
infestation, disorders,anemia,
Symptomatic treatment , sexual
Provision of education & counselling services for abuse ,RTI/STI's etc.
adolescent counselling , TT at 10 and 16 year. Referral linkages to ICTC
Services for treatment & referral of common and PPTCT
RTI/STI's, Nutritional Anaemia & Menstrual
disorders The facility has established procedures for Antenatal care as per guidelines
Facility provides and updates “Mother and Check Mother & Child Protection cards have been provided
Child Protection
Facility Card”registration & line
ensures early for each
Check ANC pregnant
recordswomen at time
for ensuring of 1st
that registration/
majority of ANC First
ANC
registration is taking place of within 12 week
listing
Clinicalof high risk ANC
information casesof ANC is kept with
& records Check, if there is a system keeping copy ofof pregnancy
ANC in
HWC ANC register
information like LMP, EDD, Labpregnancies
Investigation
Staff has knowledge of calculating expected Check with staff the expected in Findings
her area ,/
pregnancies in the area Examination
how to calculate findings etc.
it.(Birth with
Rate them. Records
X Population/1000 of each ANC
Tracking of Missed and left out ANC 1.Check
check-up with
is ANM
maintained how she in tracks
ANC missed out ANC.Add
register Use of
10%
MCTS asbycorrection
generating factor
work (Still
plan Birth)
and follow-up with ASHA,
All pregnant women get ANC check-up as per 1.Ask staff about schedule of 4 ANC Visits
recommended schedule AWW
(1st - <etc.
12ANC Weeks
At ANC clinic, Pregnancy is confirmed by Check for record that pregnancy has been confirmed
performing urine test
Last menstrual period (LMP) is recorded and by using pregnancy
Check how staff confirms test KitEDD (Nischay
& LMP, Kit)(EDD = Date of
Expected date ofObstetric
Delivery history
(EDD) isiscalculated 1.CheckMonths+7
for Haemoglobin, confirmation of pregnancy,
if Pregnanturine
Comprehensive recorded on LMP+9
albumin &unable
sugar blood,
Days) How
blood
she estimates
sugar, Malaria. Check cycle
first visit women
(1) History is of pervious to recall first
pregnancies day of last
includingmenstrual
complications
Physical Examination & vitals of Pregnant Pulse,
randomly Respiratory
('Quickening', any 3 MCP
Fundal Rate , Pallor,
card/
Height) ANC Oedema.
record
.Check ANCforHeight, weight
Haemoglobin
records &
that it or
Women is done on every ANC visit and
BP-
test procedures
Check
is done any
at 3 done,
ANC
every if any,
records/
ANC visitisand
taken.
MCP History
card
values of current
randomly
are to
recorded. see
Abdominal Examination is done as per protocol Measurement
past systemic of Fundal
illness like Height (ask staff
Hypertension, how she
Diabetes,
that
2. weight
Haemoglobin
correspond has
fundal been
& high
urinemeasured
albumin
with and recorded
& sugar
Gestational test at
Age), is everyon
done ANC
Auscultation
Diagnostic test for every pregnant women Tuberculosis,
visit
every ANC visitRheumatic Heart Disease, Rh Incompatibility,
Referral is done for the remaining ANC for foetal heart sound ,
diagnostics Such as blood group and Rh factor, Hepatitis B
Tetanus Toxoid (2 Dosages/ Booster) have been Check randomly any 3 ANC records for confirming that TT1
during
Staff canANC visits the cases, which would need (at
recognize the time
Anaemia, Badofobstetric
registration) and CPD,
history, TT2 (one
PIH, month after TT1)
APH, Medical
referral to higher centre(FRU) has
Disorder complicating pregnancy, Malpresentation,women
been given to Primi gravida & Booster dose for foetal
getting
distress,pregnant within three
PROM, obstructed years of previous pregnancy
labour.
Staff is competent to identify Hypertension / Hypertension & Pre Eclampsia
Pregnancy Inducedto
Staff is competent Hypertension
identify Pre-Eclampsia (Hypertension
Pre - Eclampsia-- Two
Highconsecutive
BP with Urine reading taken
Albumin (+2)four hours
apart shows
Imminent Systolic
eclampsia BP >140
-BP >140/90mmHg and/or Diastolic BP >
Staff is competent to identify high risk cases Identification
90 mmHg and referral of caseswith
withpositive albumin 2+
based +, severe headache, Blurring of vision, epigastriamedical
pain &
Staff ison Abdominal
competent to examination
classify anaemia according Cephalo-pelvic
>11 presentation,
gm%in-Absence
oliguria Urine
Malpresentation,
of Anaemia,10 to 11 gm% mild,
to Haemoglobin Level disorder
7-10 complicating pregnancy, IUFD, amniotic fluid
Line listing of pregnant women with moderate Checkgm% Moderate
the records
abnormalities.
Anaemia
whether Line-listing of severely anaemic
and
Staffsevere
is awareanaemia
of prophylactic & Therapeutic dose women
1. Prophylactic - one IFA tabletHWC
are maintained at the per day for six months
of
Pregnant women isiscounselled
IFA & progress monitored for planning and during ANC &PNC. 2.Therapeutic dose- double
Registration, Identification of institution as per the dose in
clinical
preparation for birth case of
conditionanaemia. 3. Improvement in haemoglobin label is
Pregnant women is counselled recognize danger Swelling (oedema),
continuously bleeding
monitored even spotting, blurred vision,
and recorded
signs during pregnancy
Pregnant women is counselled to recognize sign headache, pain abdomen,
A bloody, sticky vomiting,
discharge (Show) andpyrexia,
regularwatery
painful& foul
of labour & arrange for referraldiet,
transport smelling
uterine discharge &
contractions. Yellow urine
Contact number of the ambulance is
Pregnant women is counselled rest, breast
1.Increase Dietary Intake
feeding & family planning communicated
Diet rich in proteins, iron, vitamin A, vitamin C, calcium and
other essential
The facility has established micronutrients.
procedure Initiate breastfeeding
for intranatal care as per guidelines
especially colostrum feeding within an hour of birth.
The facility has established procedure for post natal Care
Check
MotherMother is educated
is monitored as per&post
counselled about
natal care Check for records of Uterine contraction, bleeding,
danger signs
guideline during puerperium & during temperature, B.P, pulse,PVBreast examination,
postnatal visit Danger signs :Excessive bleeding, breathing(Nipple care,
difficulty,
milk initiation). Check for perineal wash is performed
convulsion, severe headache, abdominal pain, foul smelling
Areaurine
lochia, of Concern
dribbling,F:perineal
Infection Control
pain, painful & redness of
breast.
The facility has established program for infection prevention and control
Staff is working as team to improve sanitation & Person is identified to supervise the sanitation ald hygiene
hygiene of the facility
Check Records of Medical Check-up and of
AllHWC and its surrounding
staff undergo area. at least once in year
medical Check-up
Immunization
Facility has a system to monitor cleanliness & and immunization
Regular monitoringwith at least Hepatitis
of cleanliness B and TT
& hygiene
hygiene practices
The facility has defined and Implemented procedures for ensuring hand hygiene practices

Availability of Hand washing facilities Washbasin with functional drainage pipe, tap, running
Check Washbasin, tap & running water as per water,
Check Soap (Soapisbar/liquid),
washbasin wide and AHR,
deep Display
enoughof
tohand
prevent
standard protocols washing
splashingposter
and (Pictorial-
retention of Local language)
water.
Check availability of Soap and Alcohol Hand rub
Staff is trained and adheres to hand washing Demonstration and random observation (Five Moments of
for outreach
practices handwashing , Six Steps of Hand washing )
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
(2) Check Disposable Gloves, Cap, Mask are not reused,
(3) Check records for continuity of supply.

Compliance to correct method of wearing and Staff is aware of method of donning and doffing the PPE
removing PPE

Availability & adherence to Personal protective

kit for infectious patients/ HIV pts.

The facility has standard procedures for disinfection and sterilization of equipment and instrument
 Adequate supply of decontamination and Check records of indent & Utilization
cleaning agents at the point of use

Staff is trained for the decontamination and Ask whether staff know how to make chlorine solution
cleaning procedure

Decontamination and cleaning of instruments Observe staff about the decontamination of instruments is
and surfaces done with 0.5% of chlorine solution for 10 min. Check
instrument are cleaned thoroughly with soap or detergent
Availability of disinfectants Ethyl alcohol
and water. Ask70% , Bleaching
staff when & howPowder/ hypo chloride
they clean the surfaces
solution containing not less than 30% w/w of available
chlorine.
Check availability of boiler / sterilisers

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

Sterilization/HLD records are maintained To ensure the status of sterilized/HLD instruments,

equipment & materials etc

The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical a

Availability of colour coded bins and non (1)Availability of bins and non chlorinated plastic bag,
chlorinated plastic bags and needle cutters at Covered and Foot operated bins with Display of Bio Hazard
point of waste generation Segregation
sign. of BMW rules:
Yellow
(2) Availability ofAnatomical
- Human needle/hubwaste,
cutterItems contaminated
& puncture proof
with
boxes blood, body fluids, dressings, cotton swabs and bags
Segregation of BMW is done as per latest containing residual or discarded components. etc.
prevalent rules Red - Items such as tubing, bottles, intravenous tubes 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, 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
Check there is no mixing of the Biomedical &
general waste

Display of work instructions for segregation Pictorial and in local language;

HWC has designated area for storage for BMW (1) BMW is not stored for more than 48 hours
(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.

Disinfection of broken / discarded Glassware is Check if such waste is pre treated with 1-2% of Sodium
done as per recommended procedure Hypo chloride (having 30% of residual chlorine) for 20 min

Sharp waste is stored in puncture proof Check availability of puncture, leak and temper proof
container container at point of use
Availability of post exposure prophylaxis and Check staff is aware of what to do in case of sharp injury,
staff is aware what to do in such condition Whom to report. See if any reporting has been done and
treatment provided

Facility has provision for liquid waste Liquid waste is made safe before mixing with other waste.
management On site provision liquid waste disinfection set up

Check facility is mercury free Give partial compliance if staff know how to manage
mercury spill & mercury spill kit is available
Disposal of general waste Mechanism for removal of general waste from facility & its
disposal
HWC waste is collected & transported in close Check the functional linkage/records with CBWTF operator
container/bag
HWC has facility for disposal of Biomedical waste or
HWChashave
pre approved functional
valid contract deep
with CTF forburial
disposal of 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

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

The facility has established organizational framework for quality improvement.

The HWC has Quality team in place (1) CHO, ANM/Staff nurse, MPW & ASHA.
Quality team meets monthly and review its (2) Team
Check themembers
records/ are awareofofmeetings
Minutes their respective
activities responsibilities and roles viz. ensure cleaniness, hygiene
HWC reviews performance of its indicators and infection control practices are followed, internal audits
Review & update work plan as per requirement are conducted, feedback from stakeholders are taken etc
Identify the issues needed to be addressed at
PHC review
Results meetingand NQAS Internal /External
of Kayakalp Gaps are identified
assessments are reviewed
Progress on time bound action plan is reviewed Resolutions of meeting is effectively communicated

The facility has established system for patient and employee satisfaction

Client satisfaction survey is done (1) On defined intervals for patient or their attendant
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 having
representation from all sections (age, gender, cast, religion
etc)

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

The facility has established, documented, implemented and updated Standard Operating Procedures for all key processe

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

The facility has established system of periodic review of clinical, support and quality management proc

Service delivery and performance of HWC is Through monthly visits by MO PHC

reviewed regularly
HWC performance is reviewed regularly by Quarterly -By Block nodal officer, Bi Annual - by District
block/district/state
Check gaps have been nodal officer and actions are Nodal
identified Check officer
number gaps closed as per last quarter report
taken
Periodic assessment using NQAS checklist At least once in six months
Periodic assessment using Kayakalp checklist Quarterly
Non Compliance found in the internal Check gaps are identified and time bound action plan is
Assessment using NQAS,
Root cause analysis Kayakalp and other
is done prepared
Using brainstorming, Fishbone analysis or why-why
monitoring checklists are recorded analysis
HWC team improve on the identified non Using PDCA approach
compliances & action are taken

Facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve the

Quality policy are defined Staff is aware of Quality Policy.

Quality objectives are defined for the HWC Quality Policy isthe
Check whether displayed in local
objectives language
are SMART and in sync with
There is system for monitoring of performance the Quality Policy
toward quality objectives

Area of Concern H: Outcome

The facility measures productivity indicators
No. of OPD Cases per month Case specific OPD of pregnant mothers, neonate, infant,
No. of follow up cases (repeat visit) per month children, adolescent,
Case specific FP and CDmothers, neonate, infant,
OPD of pregnant
No. of cases referred to higher centre per month children,
Case adolescent,
specific referral FP pregnant
of and CD mothers, neonate,
As per Service package i.e. NCD (Hypertension,
No. of Case specific OPD per month( as per infant, children, adolescent, FP and CD
Diabetes & cancer),
As per Service Eye,i.e.
package ENT, Oral
NCD Health, elderly,
(Hypertension,
defined service package)
palliative,
No. of cases referred to higher centre per month Diabetes Medical Emergency
& cancer), Eye,i.e.
ENT, & Mental
Oral Health
Health, etc
elderly,
As per Service package NCD (Hypertension,
No. of case specific follow up per month palliative,
Diabetes &Medical Emergency
cancer), Eye,i.e.
ENT, & Mental
Oral Health
Health, etc
elderly,
As per Service package NCD (Hypertension,
No. of drop out rate cases following palliative,
Diabetes &Medical
cancer),Emergency & Mental
Eye, ENT, Oral Health
Health, etc
elderly,
identification (as per service Package)
palliative,
The facilityMedical
measuresEmergency
efficiency&indicators.
Mental Health etc
Percentage of women receiving all four ANCs
Drop out rate for Pentavalent immunization
Drop out rate for NCDs
No. of stock out days of essential medicines As per Service package
No. of stock out days of essential diagnostic As per Service package
test
No. of Yoga session conducted in month
No of VHNDs conducted (for vulnerable
population)
The facility measures clinical care indicators.
No. of high risk pregnancy identified during
ANC
No. of AEFI cases reported
No. of Children with diarrhoea treated with
ORS & Zn
Contraceptives acceptance rate
No. of Anaemia cases treated successfully
Treatment completion rate for Tuberculosis
Percentage of cases on treatment achieved
blood pressure
Percentage control
of cases on treatment achieved
blood sugar of
Percentage control
cases screened positive for
cancer underwent
Percentage biopsy
of cancer cases underwent
treatment for each cancer
The facility measures service quiality indicators
Client Satisfaction Score (Patients) Sum of average satisfaction score of each respondent
Client Satisfaction Score (Community) (Average satisfaction
Sum of average score =score
satisfaction sum total of scores
of each of
respondent
Percentage of chronic cases who started attributes/number of total attributes)
(Average satisfaction score = sum total of scores of
treatment at PHC/above are still under As per service package
attributes/number of total attributes)
treatment for last 3 months

Max Percentage
76 91%
84 77%
128 80%
176 82%
362 89%
62 81%
58 81%
54 89%
1000 85%

Management of Non-Communicable diseases.

Care for Common Ophthalmic and ENT

Oral health care.

Elderly and Palliative health care

Emergency Medical Services.

Management of Mental health ailments.

 11.09.2024

DR.GANAGURU

11.10.2024

Assessment Method Compliance Remarks

69

e Services
63

SI/ RR 2

SI/ RR 2

SI/ RR 2

4
SI/ RR 2

SI/ RR 2

SI/ PI 2

SI/ RR 2

SI/CI 2

SI/ RR 2

SI/ RR 1

20

SI/ RR 2
 CI/SI 2

SI/ RR 2

SI/ CI 2

SI/ RR 2

SI/ CI 2

SI/ RR 1

SI/ CI 2

SI/ RR 2

SI/ RR 2

SI/ RR 2

SI/ CI 2
SI/RR 2

14

SI/RR 2

SI/RR 2

SI/ RR 2

SI/RR 1

SI/ RR 2

RR/ CI 1

SI/ CI 2
 CI/ RR 2

SI/ CI 2

SI/ RR 2

SI/CI 1

andated
6

CI/ RR 1

SI/ RR 1

SI/ RR 2
4

SI/ RR 2
 65

vailable services & their modalities

25

OB

2 14
OB 2
OB 2
OB 2
OB/RR 2
OB 2

OB
2

OB

2 6

OB/CI

SI/ CI

2
 CI/ RR

2 5

SI/ RR
0

CI/SI

SI/ CI

2
e required some affirmative action
12

CI/SI

2 6
SI/RR 2
CI/RR 2

CI/RR

OB

1 3
 OB

OB

SI/ RR

2 3

SI/ RR

o discrimination on account of economic or social reasons

13

SI/CI 1

OB/SI 2
 CI/OB 0

OB/SI 2

CI/OB 2

SI/CI 2

6
OB/ RR 2
SI/ RR 2
of patient
8

OB
2 3

OB
1

OB/ SI

1 3
 SI/ RR

2
CI 2 2
CI 0 Check in Both type of SC

to its users
7
CI/ RR 1 7
CI/ SI 2
CI/ SI 1
CI/ SI 1
CI/SI 2
102
rms and it provides optimal care and comfort to users
21

OB

2 15
OB 1
OB 1
OB 1
OB 1
OB 2
OB 1
SI/ OB 1

OB/ SI

2
 OB
1

OB
2

OB/ SI

2 5
OB/ SI 2
OB/ SI 1
SI/ RR 0 1

RR/ SI

1
red services as per current case load
12

SI/ RR

2 2

SI/ RR

2 5
SI/ RR 2
SI/ RR 1
SI/ RR 1 5
SI/ RR 2
 OB

ntation of competence and performance of staff

15
RR/ SI 2 5
RR/ SI 2

RR/ SI
1
RR/ SI 2 10
RR/ SI 2
RR/ SI 2
RR/ SI 2
RR/ SI 2
sured services
51
OB/RR 1 43

OB/RR
2

OB/RR

OB/RR

1
OB/RR 2
OB/RR 1
OB/RR 2
OB/RR 1
OB/RR 1
OB/RR 2
OB/RR 2
OB/RR 2
 OB/RR
2

OB/RR
2

OB/RR
2

OB/RR
2

OB/RR

2
OB/RR 2
OB/RR 2
OB/RR 2
OB/RR 2
OB/RR 1

OB/RR

1
OB/RR 1

OB
1
OB/RR 2
OB/RR 2 8
OB/RR 2
OB/RR 2

OB/RR

2
sured list of services
3
 OB

1 2
OB 1

OB

1 1
145

keep of the facility

20

OB

2 10
OB 2

SI/ RR
1

RR/ OB
2
SI/ OB 1
RR/ OB 2
OB 1 10
OB 2
OB/ RR 2
OB/ SI 2
OB 1
 OB/ RR
2

and dispensing of drugs

25
SI/ RR 2 8

RR/SI
1
RR/SI 2

RR/ Ci
2

RR/SI
1
OB 2 9
OB 2
OB 2
OB/SI 1
OB/RR 2
OB 2 8
2
OB 2
SI/OB 2
nt with progressive use of digital technology
29

RR/SI

2 14

RR/SI

2
RR/SI

RR/SI

RR/SI

2
RR/SI 2
RR/SI 2

RR/SI

2
OB/ SI 2 6
OB/ SI 2
RR/ SI 2
OB/ RR 2 9
SI/ RR 2

SI/ RR

SI/ CI

1
 RR 2

rency and accountability.

21
RR/SI 1 8
CI/ SI/RR 2
RR 1
RR/ SI 1
RR/SI 1

SI/ RR

SI/RR

RR

1 5

RR/SI

RR/SI

RR

2
RR/SI 2 8
SI/RR 2
CI/ RR 2
 RR/ SI

ugh community mobilization

43

SI/ CI 1

25

RR/ SI 1

SI/ CI 2

RR 1

RR 2

RR/CI 2
 RR/CI 1

SI/ OB 1

CI/ SI/ RR 1
CI/SI 2
SI/ RR 1
SI/ RR 2

RR/ SI 2

RR 2
RR/SI 2

SI/ RR 2

CI/ RR 2
11

SI/RR 1
 SI/ CI 2

SI/CI 2

RR/CI 2

SI 2

RR/SI 2
7

SI/ RR 1

SI/ RR 2

SI/ RR 1

SI/ RR 1

quirement
7
RR 2 7
OB 2
RR/SI 2
RR 1
s 321
nt and reassessment of the patients
24

RR/SI

2 9
RR/SI 2

RR/SI

RR/SI
2
RR/SI 1

RR/CI
2 8

RR/SI

RR/SI
1

RR/SI
1

RR/CI

2
 CI/ RR

1 7
CI/ RR 2
CI/ RR 2
CI/ RR 2

through two way referral

12
CI/ RR 2 5
SI/ RR 1
RR/SI/CI 2
RR/ SI 2 7
OB/SI 2
RR/SI 1

RR/SI

ostic services.
5

SI/RR

1 5

CI/ SI

RR

1
 RR/SI

istration.
15

RR/SI

2 6

OB/SI

CI/ SI

SI/ RR

1 9
SI/RR 2
SI/RR 2
SI/RR 2
RR/ SI 2

tional use of drugs

16
RR 2 9
RR/ SI 2
RR/CI 2
 RR 1
RR/SI 2
RR/ SI 2 7
SI/ RR 2
RR 2

RR/SI

1
ursing care.
14
SI/OB 2 5

SI/ RR
2
RR/SI 1
RR 2 3
RR 1

RR/ OB

2 6
RR 2
OB/ RR 2

ergency care
6
SI/RR 1 4
SI/RR 2
RR/CI 1

SI/ OB
1 2
SI/RR 1

l aliments as per operational/ clinical guidelines

0

alth ailments as per Operational/ clinical guidelines

0
ases as per operational/ clinical guidelines
39
SI/ RR 2 14
RR/ SI 1
RR/ SI 2
SI/RR 2
SI/ RR 2
RR/SI 2
RR/SI 1
SI 2
RR 1 6
OB/ RR 1
SI/ RR 2

RR

2
RR/ SI 2 6
RR 1
RR 1
CI/ SI 2
RR/ SI 2 4
RR 1
RR/ SI 1
SI/ RR 2 5
RR 2
RR/ SI 1

RR

2 4
SI/ OB 2

seases as per operational/ clinical guidelines

48
RR/ SI 1 7
SI 2
RR/CI 2
CI/ SI 2
RR/ SI 1 11
SI 2
RR/ CI 2
SI/ CI 2
 SI/RR

2
CI/ SI 2
RR/ SI 1 11
SI 2
SI 2
SI 2
RR/ SI 1
SI /RR 1
CI/ SI 2
SI/ RR 2 4
CI/ SI/RR 1
SI/CI 1
SI/ RR 2 15
RR/CI 1
OB/ RR 2
SI/CI 2
SI/CI 2
SI/CI 2
SI/CI 1
SI/CI 2
CI/SI 1

r guidelines
0

d child as per guidelines

67
SI/RR 2 6
SI/ RR 2
CI/ SI 2
OB/ SI 2 47
 OB/SI

2
SI 2
OB/CI 2
OB/CI 2
CI/ OB 2
SI 2
OB 2

OB
2
OB/SI 2
SI/OB 2
SI/ OB 2
SI/OB 2
SI/ OB 2
RR 2
RR/ SI 2
SI/RR 2
SI/RR 2

SI/RR
2
SI/RR 1
RR 2
SI/RR 2
SI 2
OB/CI 2
SI/RR 2 14
SI/RR 2
SI/RR 2
SI/RR 2
SI/RR 2
CI/ SI 2
RR/SI 2

nment guidelines and law.

18
 SI/RR 2 6

SI/CI

CI/SI
2
CI/ RR 1
SI/RR 2 8
SI/ RR 2
SI/ RR 2
SI/ RR 2

SI/ RR

2 4
SI/ RR 2

ices as per guidelines.

4
CI/ SI 2 4
RR/ CI 2

per guidelines
49
RR/ CI 2 12
RR/SI 2
RR/SI 2
SI/RR 2
SI/RR 2
SI/RR 2
SI/RR 2 9
SI/RR 2
SI/ RR 1
RR 2
SI/RR 2
SI/ RR 2 6
SI/ RR 2
SI/ RR 2
SI/ RR 2 14
 SI/ RR 2
SI/ RR 2
SI/ RR 2
SI/ RR 2
SI/ RR 2
SI/ RR 2
CI/SI 2 8
CI/ SI 2
SI/ CI 2
SI/ CI 2
0
per guidelines

Care 4
RR/ SI 2 2
SI/ RR 2 2
50

n and control
5
SI/ RR 1 5
RR 2
OB/ RR 2

and hygiene practices

8
OB 2 8
OB/ SI 2
OB 2
SI/ OB 2

onal protection
4

OB/ RR

1 4

SI/ OB
2

SI/ RR
1

quipment and instruments.

7
 RR/ OB

1 4

OB/SI
2

SI/ OB
1

RR/ OB

1 3

SI/ RR

RR/SI

d disposal of Bio Medical and hazardous Waste.

26

OB/ SI
2 10

OB/ SI

2
 OB
2

OB

OB/ SI

OB/ SI
2 6

OB/ SI
2

SI/ RR

OB/ SI

2 5

SI/ OB
1
OB/ RR 2
RR 1 5

RR/ OB

1
SI/ RR 1
 OB 2
47

y improvement.
12
RR/ SI 2 12
RR 2
RR 2
RR 1
RR/SI 2
RR 2

RR/ SI
1

e satisfaction
5
1

RR/SI

5
RR 2
RR 2

dures for all key processes and support services.

11
RR/ SI 1 11
RR 2
OB/RR 1
RR 2
RR 1
2
RR

RR 2

quality management processes

13
SI/ RR 2 4
RR 1
RR 1
 RR 2 4
RR 2
RR 2 5
RR/ SI 1

RR/ SI
2

roved plan to achieve them.

6
RR 2 6
RR 2

RR/ SI
2
48
12
RR 1 5
RR 2
RR 2
RR 2 7
RR 1
RR 2
RR 2
14
RR 2 2
RR 2 2
RR 2 2
RR 2 2
RR 2 2
RR 2
RR 2
16
RR 2 4
RR 2 4
RR 2
RR 1
RR 2
RR 2 2
RR 1 5
RR 1
RR 1
RR 2
6
RR 2
RR 2
RR 2 2

0
0

0
 2 1 0 NA

76

68

4
 4

22
4
16
8

4
84 77%

28

14

6
 8

18

6
 4

16

6
 4

12

4
 4

10
10

128 80%

32

22
 6

14

6
16
6

10

60
52
8

6
 4

2
176 82%

24

12

12
28
10

10

32

16
 6

10
30
14

8
54

32
12
 10

8
8

362 89%
28

10

10
 8

14
6

8
16

10

18
10
 8

16
6

10
6

0
48
16

58
8

12
14

18

68
6

48
14

20
 8

4
4

50
12

10

14
 8

0
4
2
2
62 81%

6
6

8
8

12
 6

30

10
6

8
58 81%

14
14

14
14

16
6
 4

6
6

54 89%
14
6

14
2
2
2
2
2

20
4
4

2
8

6
2