Annexure-B

Sub center- Checklist for Facility Operationalization

Name & Designation of Supervisor:……………………………………….…Date………….

Name of Sub center:……………… Name of PHC…………………….. 3. Name of Block…………………….. Name of District…………………… Population Coverage: …………………..3. Current level of service utilization:

A. No. of deliveries in last quarter: B. No. of IUCD insertions in last quarter: C. Technical Protocol of service delivery (in place/not in place): D. Maintenance of records:

Sl. no

Record Updated(Y/N)

Timeline for completion

Remarks, if any

1 Eligible couple register2 MCH register3 Stock register4 VHND plan5 Session Monitoring

plan6 Due list7 High risk PW list 8 Mamta card9 Safe motherhood

booklet10 E-Mamta Work Plan

4. Human Resource:A. No. of ANMs:B. Other staff: 1(FPW)

5. Training:Sl. no Training Trained

(Y/N)Training required (Y/N)

Remarks

18

1 SBA2 IUD3 IMNCI4 NSSK5 IYCF5 Other

6. Infrastructure: (select only those functioning in own building or in private with adequate accommodation)Sl. no

Infrastructure Available/ Functional

Required Repair/ Renovation

Timeline for completion

1 Labor room2 No. of beds3 New born care

corner4 Staff quarters5 Toilets6 Others

7 Equipments A Laboratory test B Delivery kits C Ambu bagD Warmer (what

kind of warmer-bulb, heater, radiant warmer?)

E Drugs F Others

7. Referral linkages:

Sl. no

Assured referral (PPP Model) Govt. Vehicle

Any others Free/Paid

1 Home to facility2 Intra facility

19

3Facility to Home (drop back)

8. Systemic Issues:Issues Mechanism, if exist; details thereof:Biomedical waste management Drug Availability

Equipment Maintenance

Electricity supply; (Is back up in place?)Water supply

Display of entitlements/ service guarantee

9. Service utilization: Quarterly monitoringSl.no Indicators 2012-13

(HMIS)1st

Quarter2nd

Quarter3rd Quarter

4th Quarter

1 No. of Deliveries

2 IUDs3 Referrals

MothersNewbornsSick children (0-5 years)

4. No. of ORS packets and Zn tablets distributed

5. No. of children given IFA syrup or tab.

10. VHSNC details

No of VHSNC…………… No of Meeting held during last quarter………………….

11. Fund Utilization:

20

Untied Fund Received during 2012-13……………….. Utilization till date:………………….. Annual Maintenance Grant received during 2012-13 …………….. Utilization till date:……………..

Remarks:………………………………………..

PHC - Checklist for Facility Operationalization

Name & Designation of Supervisor………………………………….Date & Time:………

Name of PHC: …………………… Name of Block: …………………… Name of District:…………………

Population Coverage:3. Current level of service utilization:

A. No. of deliveries in last quarter: a. No. of deliveries between 8pm to 8 am (night hrs): b. No. of complicated deliveries handles: c. No. of RTI/STI cases treated:d. % of women who stayed at least 48 hours in the institution after

delivery : B. No. of IUCD insertions in last quarter: C. Technical Protocol of service delivery (in place/not in place): D. No. of admissions in Child stabilization units: Inborn: Outborn:E. MTP services in last quarter: F. Tubectomy: G. Vasectomy: H. Minilap: I. Maintenance of records:

Sl.No Record Updated(Y/N) Remarks, if any Timeline for completion

21

1 OPD Register2 IPD Register3 ANC Register4 Labour Room Register 5 OT Register6 FP –Register7 Immunization Register8 Drug Stock Register9 Referral Register

4. Human Resource:Sl. no

Category Contractual(I.P)

Regular(I.P) Total Remarks if any

1 MO2 FHS3 MHS4 SNs5 ANM6 LTs7 Pharmacist8 LHV/PHN9 MPHW10 Data Entry

Operator11 Driver

5. Training:Sl. no

Training No. trained No. required

Proposed timeline for completion

1 BeMOC

2 SBA

3 MTP/MVA

4 NSV5 IMNCI

6 F- IMNCI

7 NSSK

8 Mini Lap

9 IUD10 RTI/STI11 Others

6. Infrastructure: (see detailed feedback in the checklist for Subcenter)22

Sl no

Infrastructure Available Required Repair/ Renovation

Timeline for completion

Nodal Person

1 Physical Labour room

2 No. of beds3 New Born Baby

stabilization units (NBSU) (no. of beds)

4 New born care corner

5 Staff quarters6 Toilets7 Other 8 EquipmentsA Laboratory testB Delivery kits (ask

for numbers in stock)

C Ambu bagD Radiant Warmer

E Suction Machine

F Facility for oxygen administration

G Autoclave/sterilizerH ILR

I Drugs

J FP commodities (pills, ECPs. Condoms, IUDs etc.)

k Others

7. Referral linkages:

Sl. no

Assured referral (PPP Model)

Government Vehicle

Any others Free/Paid

1 Home to facility2 Intra facility

23

3Facility to Home (drop back)

8. Systemic Issues:

Sl. no Issues Mechanism, if exist; details thereof:1 Running water2 Electricity with backup

3 Biomedical waste management

4 Laundry/washing services

5 Free Diet

6 Drug Procurement

7 Equipment Maintenance

8 Grievances Redressal

9 Display of entitlements/ service guarantee

9. Service utilization: Quarterly MonitoringSl.no

Indicators 2011-12 HMIS

Year 2012-13 no HMIS 1st

Quarter 2nd

Quarter3rd Quarter

4th Quarter

1 No. of IPD cases

2 No. of OPD cases

3 No. of Deliveries

4 No. of complicated deliveries treated

5 No. of cases of RTI/STI treated

6 Admissions to NBSUs (can be deleted!!)

7 IUD8 Minilap 9 Tubectomy10 Vasectomy11 MTPs

Conducted

24

12 Referrals (Mothers)

13 Referrals (children <5 years)

10. Key service delivery protocolsSl. No.

Indicators Remarks/Nodal Person for improvement along-with time line

I Labour Roomi Whether neat, clean & tidyii Availability of labour beds with privacyiii No of PW referred to higher facility, with referral slipsiv Availability of New born care corner ( with radiant warmer, suction &

pediatric AMBU bag - check the time the SN/ANM takes to operate the warmer)Observe the following whether:

v Functional O2 cylinder (please observe if it can be opened easily within 3 minutes – check the time SN/ANM takes to operate the Oxygen cylinder)

vi Availability of drugs (inj Oxytocin, Mg Sulph., & Antibiotics, etc)vii Partograph are maintainedviii Technical Protocols(AMTSL, PPH, Eclampsia, Sepsis, ENBC&

Resuscitation etc)ix Regular fumigation is carried out (if yes, check with records)x Infection prevention( availability of 3 colour coded dustbins)II Safe Abortion Servicesi Availability of Doctors trained in MTPii Availability of MVA equipment / MMA drugsIII RTI /STIi Availability of colour coded RTI / STI drugs ii Wet Mount test being conducted or not IV Laboratoryi Routine tests (Hb, CBC, Routine urine, blood grouping, blood sugar,

wet mount, etc) being conducted or notV WARDSi Whether neat, clean & tidyii Whether diet being given or not VI Visit post natal wards and interact with recently delivered

mothersi Initiation of breast feeding ( time after delivery)ii Zero dose BCG, OPV given or not

25

iii Counseling on Nutrition & Family Planning done or notiv Whether staying for 48 hrs v JSY payment being given by cheque before discharge

Regularity of field of MO and staff Advance tour programmes of HQ & SC staff No. of stayed 48 hrs. after delivery Skill of MO in VT/TL/MTP Disbursement of JSY money to beneficiaries Outreach RCH camps Bio Medical waste Management ILR & Deep Freezer condition Water Facility/Power backup Display of IEC Materials/Sinages Status of RKS Account (Amnt. Rec/Expenditure) Preparedness for Epidemic control

CHC- Checklist for Facility Operationalization

Name & Designation of Supervisor:……………………………….…Date………….

Name of Sub center:……………… Name of PHC…………………….. 3. Name of Block…………………….. Population Coverage: …………………..

Staffing position

SN Category Sanctioned Filled up Vacant

1 Superintendent

2 Gynecologist (PP Unit)

3 Pediatrician (PPUnit)

4 Medical officer

26

5 Staff Nurse

6 Laboratory technician

7 X ray technician

8 Pharmacist

9 Driver

II. Treatment (last 6 months)

SN Month Indoor average Referral rec’d Cases ref’d

1

2

3

4

5

6

Average

III. Investigations (last 6 months)

SN Month X rays Screenings MP Sputum Urine ANC

Hb ANC

1

2

3

4

5

6

Average

27

IV. RCH (Performance)

Activity Work loadPerformance in

month Progressive %

Sterilization

IUD

O.pills

C.C. users

Inst.Deliveries

TT(ANC)

DPT

POLIO

BCG

V. Supply

Item Available Working Item Sufficient? Remarks

O2 cylinder Linen

Refrigerators

Instruments

Vac.carriers Furniture

Suction PM set

Ambulance Medicine

Beds Space

Non serviceable / surplus items : action taken to dispose / redistribute:

VI. Grant position

Budget sent on Date: Amount Rs.

Grant received (RKS,AMG) Rs.

28

Medicines received from CMSO Y/N If no,details--

Pending audit para :

VII. RKS Meetings Conducted

Formation date _____________________ No. of meetings in last 6 months____________

Last meeting held on date_______________________

VII. Drug Position

SN Name of Drug Balance SN Balance Name of Drug

1 Tab.Paracetamol 17 Inj.Ergometrine

2 Tab.Chloroquine 18 Inj.Atropine

3 Tab.Anthamatic 19 Inj.Adrenaline

4 Tab.Metronidazole 20 Inj.Antihistamine

5 Tab.Co-trimaxazole 21 Inj.Phenargen

6 Tab. Erythromcin 22 Inj.Coticosteroid

7 Tab.Iron(adult) 23 Inj.Penthidine

8 Tab.Iron(child) 24 Inj.ARV

9 Tab.Isonex 25 Inj.ASV

10 Cap.Refampicin 26 Inj.Ringer

11 Cap.Tetracycline 27 Inj.Normal

12 Cap.Ampi/CLOXA 28 Skin ointment

13 Inj.Benzathine pen 29 Eye ointment/drop

14 Inj.Streptomycine 30 BB lotion

15 Inj.Quine HCL 31 Vitamin-A syrup

16 Inj.Aminophylline 32 ORS packets

29

Remarks of the Visiting Officer on:

Cleanliness

Water facility/Power back up

Display of IEC Materials

Status of Deep Freezer/ILR

Bio Medical Waste Management

Needle Safety follow up

Implementation of 5 “S”

E Mamta data entry

FRUs - Checklist for Facility Operationalization

Name & Designation of Supervisor:………………………………Date:…………….

Name of FRUs:Population Coverage:Current level of service utilization:A. No. of deliveries in last quarter:

No of Normal Deliveries : No. of complicated deliveries handled: No. of C sections performed: No. of RTI/STI cases treated: % of women who stayed at least 48 hours in the facility after delivery:

B. No. of IUCD insertions in last quarter:

30

C. Technical Protocol of service delivery (in place/not in place): D. No. of admissions in Child stabilization units: Inborn: Outborn: E. MTP services in last quarter: F. NSV services in last quarter: G. Tubectomy: H. VasectomyI. Maintenance of records:

Sl. No.

Record Updated(Y/N) Remarks, if any Timeline for Completion

1 OPD Register2 IPD Register3 ANC Register4 Labour Room Register 5 OT Register6 FP-Operation Register

(OT)7 FP –Register8 Immunization Register9 Drug Stock Register10 Blood Bank stock Register11 Referral Register

4. Human Resource:Sl. no

Category Contractual(I.P)

Regular(I.P )

Total Remarks if any

1. OBG2. Anesthetist3. Pediatrician4. General Surgeon5. Others

Specialists6 MOs7 SNs8 ANMs9 LTs10 Pharmacist11 LHV12 Radiographer13 Others

5. Training:

31

Sl. no

Training No. trained No. required

Proposed timeline for completion

1 EmOC2 LSAS3 BeMOC4 SBA5 MTP/MVA6 NSV7 F-IMNCI8 NSSK9 Mini Lap10 Lapro scopy11 IUCD12 Blood storage13 IMEP14 Others

6. Infrastructure: (see detailed feedback in the proforma for sub centre)Sl. no

Infrastructure Available/ Functional

Required

Repair/ Renovation

Timeline for completion

Nodal person

1. Functional OT2 Blood Bank/ Blood

storage centre3 Labour room4 No. of beds5 NBSU 6 NBCC 7 Nutritional rehabilitation

centre (or equivalent facility)(No. of beds)

8 Staff quarters9 Toilets10

Other

11

Equipments

A Laboratory (services should be specified) test

B Delivery kits (No.?)C Ambu bagD Radiant Warmer

32

E Suction MachineF Facility for oxygen

administrationG Autoclave/sterilizerH ILRI Deep freezer J Boyle’s apparatusK Drugs? (see Performa

for sub centre)L Others

7. Referral linkages:

Sl. no

Assured referral (PPP Model)

Government Vehicle

Any others Free/Paid

1 Home to facility2 Intra facility3 Facility to Home (drop back)

8. Systemic Issues:

Sl. no Issues Mechanism, if exist; details thereof:

1 Running water2 Electricity with backup

3 Biomedical waste management

4 Laundry/washing services

5 Free Diet

6 Drug Procurement

7 Equipment Maintenance

8 Grievances Redressal

9 Display of entitlements/ service guarantee

9. Service utilization: Quarterly monitoringSl. no

Indicators HMIS 2012-13

1st

Quarter

2nd

Quarter3rd Quarter

4th

Quarter

1 No. of OPD cases2 No of IPD cases

33

3 No. of normal Deliveries4 No. of complicated

deliveries treated5 No. of C sections performed6 IUDs7 RTI/STI8 Admissions to

NBSUs/SNCUsInbornOutbornNo. of children admitted with SAM

9 NSVs conducted10 Tubectomy11 Vasectomy12 MTPs Conducted13 Referrals (Mothers))

14 Referrals (Children <5 years)

10. Key Service Delivery ProtocolsSl.

No.

Indicator Remarks/Nodal Person for improvement along-with time line

I Labour Room

i Whether neat, clean & tidy

ii Availability of labour beds with privacy

iii Availability of New born care corner ( with radiant warmer,

suction & pediatric AMBU bag) ( check the time the

SN/ANM takes to operate the warmer)

iv Functional O2 cylinder (please observe if it can be opened

easily within 3 minutes - check the time SN /ANM takes to

operate the Oxygen Cylinder.)

v. No of PW referred to higher facility, with referral slips

Observe the following whether:

v Partographs are maintained

34

vi Technical Protocols(AMTSL, PPH, Eclampsia, Sepsis,

ENBC& Resuscitation etc)

vi Tips of suction tubes & O2 delivery part is clean & tidy

vii Regular fumigation is carried out (if yes, check with

records)

viii Availability of drugs (inj Oxytocin, Mg Sulph., &

Antibiotics, etc)

ix Infection prevention( availability of 3 colour coded

dustbins)

II Operation Theatre

i Whether neat, clean & tidy

ii Availability of Operation beds, functional Boyles apparatus

iii Check OT register for major surgeries conducted (CS,

Surgical procedures, etc)

iv. Regular fumigation is carried out (if yes, check with

records)

v. Infection prevention( availability of 3 colour coded

dustbins)

III Blood Bank / Blood Storage Centre

i Functional Blood Bag Refrigerators with chart for temp.

recording

ii Availability of Generator backup

iii Check register for number of blood bags issued for BT in

last quarter(Jan-11 to Mar-11)/Month

IV Safe Abortion Services

i Availability of Doctors trained in MTP

ii No of MTPs conducted in last quarter

iii Availability of EVA/MVA/MMA equipment/drugs

V RTI /STI

i Availability of colour coded RTI / STI drugs

35

ii Wet Mount test being conducted or not

iii No. of MOs trained in RTI/STI

iv No. of SNs trained in RTI/STI

v No. of ANMs trained in RTI/STI

vi No. of Lab Technicians trained in RTI/STI

VI Laboratory

i Routine tests (Hb, CBC, Routine urine, blood grouping,

blood sugar, wet mount, etc) being conducted or not

VII Wards

i Whether neat, clean & tidy

ii Whether diet being given or not

VIII Visit post natal wards and interact with recently

delivered mothers

i Initiation of breast feeding ( time after delivery)

ii Zero dose BCG, OPV given or not

iii Counseling on Nutrition & Family Planning done or not

iv Whether staying for 48 hrs

v JSY payment being given by cheque before discharge

IX SNCUs (at District Hospital) / New Born Stabilization

Unit (at CHC / FRU)

a Whether available

b If available, no. of beds

c Whether Pediatrician posted

d Whether doctor/s posted to SNCU/NBSU trained (F-IMNCI

or Facility based new born care)

e Whether SNs /ANMs posted exclusively and trained

f Please see the admission register for utilization of infants

admitted last month

g Out of these admissions, no. admitted on referral from other

institutes

36

h No. admitted from this institute

i No of deaths if any in the last quarter

j Wherever SNCUs / Child Stabilization Units are established,

please make it a point to see and observe the functionality of

labour room & also newborn care corner where the lives

have to be saved before transferring such infants to SNCUs /

CSUs. Also check Phototherapy Unit.

CHECK LIST FOR HOSPITALS TO VISITName of the Facility

Facility Incharge

Persons Interacted during the Visit

S. No. Particulars Comments/ReDOCUMENTS - QUALITY POLICY AND QUALITY OBJECTIVES

1 Quality Policy Defined and displayed DefinedLocal LanguageDisplayedStaff Aware

2 Quality Objectives FramedSMARTSyndicated Progress Tracked or Not

Patient & Satisfaction Survey1 No. of Rounds of Satisfaction Survey Conducted

2 Availability of Feed Back form in Local Language3 Sample Size Taken4. Analysis Done5 Syndicated & Action Plan Prepared 6 Corrective Action Taken7 Availability of Records (Filled forms)

Quality Documents1 Scope of Service is displayed with actual services

provided in the facility.2 Organization Chart given commensurate with actual

organization structure of the facility.37

3 Statutory Requirement and Licences list updated

RKS1 How frequently RKS meeting is held?

2 When was the last meeting

3 Minutes of Meeting of RKS

GENERAL OBSERVATIONS2 Is it located in the low terrain area?

3 How is the condition of approach road?

4 Is boundary wall present

5 Are stray animals present in hospital campus?

6 Is there any water logging inside the campus?

7 Status of infrastructure building, its maintenance, painting landscapingparking facilities

8 Condition of drainage system

9 Is the name of the hospital displayed at the entrance?

10 Is the citizen charter displayed?

11 What is the status of power back up?

12 What is the illumination level in various departments Of hospital; specially OT, LR, emergency, lab, and all the work stations?

13 Is the hospital disabled friendly? Are adequate ramps available at OPD, IPD, and Emergency?

14 Is Complaint box/Suggestion box available? Is it opened regularly?

15 Number of beds Sanctioned

Functional

16 Name of Wards

17 Are patient care areas being used for administrative/ Storage purpose?

18 Is 24 hours running water available in the hospital?

19 Is the list of all the assets available? Are the assets numbered?

20 How is the Condition of electrical wiring in the facility?

21 Is the list of all critical equipments available? Is AMC available for them

Listthem AMC

22 Is Death audit conducted? Frequency?

23 Are Medical Audits conducted? Frequency?

24 Are printed consent forms available for IPD, OT, any other?

25 Are measuring instruments calibrated regularly?

38

3 Is the updated list of doctors available in the hospital along with their room no, days & timings displayed.

OPD AND REGISTRATION

1 Availability of may I help you desk2 Is the OPD timings, schedule and fee structure displayed 3 Are there separate counters for registration for

Male/Female/Disabled/IPD4 Is there Crowding at registration desk5 Display of IEC material in the OPD waiting area6 Is there Demarcated area for breast feeding7 Availability of Amenities for patients in OPD Area Sitting space

Waiting AreaFan/coolerDrinking waterToilets M/FStretchers/ Wheel Chair

8 Patient privacy maintained. Separate rooms for doctorsCalling systemCurtains

9 Examination equipments /Instruments/Other facility Pt. Stool Examination TableBP App.ThermometerView BoxWash Basin with running wat

10 Is there overcrowding outside the OPDsEMERGENCY

1 Is the emergency operational 24x7?

Is there separate access for Emergency department?

2 Are there appropriate and adequate signages to the emergency department from the main road or street?

3 Is there sufficient space for parking of ambulances?

4 Are the doctors/staff available 24x7?

5 Is the emergency disabled friendly? Is ramp available are stretchers & wheel chairs available?

6 Is the entrance door of the emergency department wide enough to move stretchers, trolleys, and wheel chairs etc.

7 Check the availability of emergency tray (drugs and equipments)? Is the list available? Is it updated on regular basis?

8 Oxygen supply (cylinder and mask)Suction machine,

Laryngoscope with blades,Endo tracheal tubes,

Airways,Ambu Bags,Defibrillator

ECG machine

Suction machine,Laryngoscope with blades,

Endo tracheal tubes,Airways,

Ambu Bags,Defibrillator

ECG machine

39

9 Are Dressing Room/ minor OT available?

10 Are Emergency staffs trained for BLS/CPR?11 Is the following information available:

doctors on call

contact numbers of the ambulance drivers

contact numbers of the private ambulances and dead vans

List of nearest blood banks with their contact no.

doctors on call

contact numbers of the ambulance drivers

contact numbers of the private ambulances and dead vans

List of nearest blood banks with their contact no.

12 Separate security staff for emergency available 13 Triage area Specified

OT

40

1 How many OT s are available and number of OT tables Minor

Major

2 Condition of OT Tables

3 Condition of OT Lights

4 Condition of Air Conditioner

5 Number of Operations conducted on an average MinorMajor

6 Is the layout and structure of the OT ensures one way traffic flow?

7 Condition of walls and floor

8 Are infection control practices in practice FumigationCleaningCarbonization

9 Is scrub room with elbow/Foot operated tap present10 What is the status or power back up? Are UPS available?

11 Is the changing room present

12 Is Culture surveillance Practiced? Are Records Available?

12 Are slippers, caps, Mask present at the entry SlipperMaskcap

13 Are the pre operative and post operative room available? Pre operativePost Operative

14 Check the availability of:- Cardiac monitorDefibrillatorSuction machine,Emergency drugs (tray with list), Ambu bag, Laryngoscope with blades sizes Airways of different sizesOxygen/ N2OBoyel's apparatus

Cardiac monitorDefibrillatorSuction machine,Emergency drugs (tray with list), Ambu bag, Laryngoscope with blades sizes Airways of different sizesOxygen/ N2OBoyel's apparatus

14 Is there standard procedure for autoclaving? Is autoclaving strip available?

15 H th il d li t t d? I l i i b i

41

5 Condition of Air Conditioner

6 Number of delivery conducted per day on an average7 Is the radiant warmer available in labour room? Does staff

know how to operate it?Is resuscitation facility for newborn availableSuction Pump

Oxygen cylinder with mask

8 How and when placenta is disposed

Are identification tags for newborn used?

9 Pre and post delivery room adequate

10 Is here overcrowding in labour room

11 Is observation of Mothers done before and after delivery BPPartogramPV ExamVitals

12 Are Facilities for ASHA available ChairsFoodBed

13 Are emergency drugs available in Labour room.

14 Are Sterilized delivery sets used for each delivery

Are adequate consumables, instruments and equipments available?

15 How are the soiled linen treated? Is sluicing being practiced?Are work instructions and protocols displayed in delivery rooms?Is emergency obstetric care available 24X7 Normal Delivery

C-SectionDo mother stay for 48 Hrs after normal delivery and 5 days after c-section.

Normal Deliverydays after c-section. C-Section

16 Are infection control practices followed Hand WashCleaningSlipperPPE

WARD

1 Is there Nursing station in each ward.

IS SNCU/NICU present and its condition

2 Is there enough space between two beds and between two rows?

3 Check the availability and appropriateness of nurse's hand over register, treatment book, patient's BHT, TPR chart, stock register,

nurse's hand over register, treatment book, patient's BHT, TPR chart, stock register,

42

4 Is the needle destroyer available? Is it working?

5 Check the condition of beds and linen?

6 Are the toilets available? Is there system for monitoring the cleanliness of the toilets

7 Is there any arrangement for attendants to sit?

8 Is the timing for visiting hours displayed? Is it being practiced

9 Personal Protective Equipments (gloves, caps, masks) are available? Are staffs practicing?

10 Are the following available:Bed Side LockerHand washing FacilityIV standChair/stool for attendant

Bed Side LockerHand washing FacilityIV standChair/stool for attendant

LABORATORY1 Is the services in house/out sourced/PPP

Are the charges of the test displayed?

2 Is the timing for collections of sample displayed?

3 How many average daily tests are being performed?

4 Is the timing for collections of reports displayed?

5 Is there separate and demarcated areas for sample collection, sample processing, report printing and delivery

6 Are the staff using PPE (gloves, masks, aprons)

7 Is the list of equipments available?

8 Do the technicians standardize their analyser with the standards provided with the kits?

9 Are the equipments calibrated regularly?

10 Is there waiting area outside the laboratory?

11 Is the table top used for conducting tests acid and alkali proof?

12 Check the records: lab reports register, requisition slip file, stock register, indent register

43

13 Are the reagents and kits stored at a temperature recommended by the manufacturer. Is the fridge available? Does it have thermometer, is the temperature chart being maintained.

14 What is the status of power back up? Is UPS available?

15 Is Quality Assurance programme conducted

RADIOLOGY (X-Ray/CT Scan)

1 Is the service in house/out sourced/ PPP?

2 Is the department layout as per AERB Guidelines?

3 Is the department layout AERB approved?4 Is the technician qualified?

5 Are TLD badges available? Are they sent for review?

-Are they sent for review?

6 How many x-rays are performed in a day on an average?

7 How many films are wasted in a month on an average?

8 Is the lead apron available?

9 Are the signages to warn patients and their attendants of the harm full effects of radiations and for pregnant women displayed?

10 Dark room: Are the walls painted black? Is there exhaust fan? Is red lamp available?How is water disposed

Are the walls painted black? Is there exhaust fan? Is red lamp available?How is water disposed

Ultrasound

1 Is the facility PC&PNDT approved?

2 Is radiologist available (full time/ part time)

3 How many USG are performed in a day on an average?

4 PNDT guidelines being followed Warning SignRecords

Forms F

ECG1 Is there separate room for ECG?

2 Who Conducts ECG?

3 Machine is Digital/Analogue?

BLOOD BANK/STORAGE1 Is the service in house/out sourced/ PPP.

2 Is qualified blood bank officer available?

44

6 Is the data collected regarding recipient adverse reaction?

7 Is the availability of the blood groups displayed?

8 Are the equipments calibrated regularly?

9 How many blood units are wasted on average per month?

PHARMACY AND STORES1 Are there enough racks for the storage

2 What is the condition of wall, floor, doors and windows

3 Are the racks Labelled

Are all the essential drugs available as per the state list?

4 Is refrigerator available for storage of medicines?

5 Are the near expiry drugs stored separately and removed from the storage area and disposed as per rules?

6 Are there any flammable substances stored in the store?

7 Is the store secured from an unauthorized access?

8 Is the pest control being practiced?

9 Which inventory management technique is being followed? FEFO/LIFO/FSN/FIFO?

10 Is ABC analysis or VED analysis being done?11 Are records properly maintained?12 How frequently is audit done?

HOUSEKEEPING1 Is the service in house or outsourced?

2 Who supervises housekeeping activities

3 What is the overall cleanliness level? (clean, unclean, dirty)

4 Look for seepage, webs, peeling of paint.

Listen-running tap water, rustling sound of motors.

Feel -the surfaces of furniture, walls, tiles for dust or rusting.

5 Are the housekeeping staffs aware and received training on cleaning and BMW Management?

6 Is documented evidence of cleaning present?7 Is gardening and landscaping part of housekeeping? If not

then who is taking care of this?8 Check the availability of

Equipments (brooms, wiper mops, dusters, toilet cleaning brush)

Chemicals (phenyl, disinfectant, bleaching powder, acid, NA hypochlorite, detergents, etc).

9 Does the staff have and use PPE (gloves, masks)

10 Is 24 Hrs. Running water available for house keeping

DIETIARY SERVICES

45

1 Is the service in house or outsourced?

2 How is the general infrastructure of kitchen

3 How is the general cleanliness of kitchen and utensils

4 Is qualified dietician (full time or part time available)

5 Fuel used is coal/ wood/ gas/ kerosene

6 Is dedicated food storage/refrigeration area available?

7 Is the food distributed in food trolleys/ buckets, are they covered?

8 Are they covered during the transport

9 Is the collection of garbage and kitchen waste being done in covered containers and is being removed daily from the food services areas.

10 Is the food tested by competent authority (dietician/doctor/nurse) prior to distribution for quality and taste? Is the evidence available?

11 Is there provision for special diets: diabetic diet, renal diet, liquid diet, semi solid diet, low salt diet, low fat diet, high protein diet?

LINEN & LAUNDRY1 Is the service in house or out sourced?

2 How many sets of linen are available per bed? (Ideally there should be 5 sets per bed)

3 Is linen available on all the beds?

4 Is sluicing performed for soiled linen, at the point of generation, before dispatching it to laundry?

5 If in house-is there dedicated areas for collection, sorting, sluicing, washing, hydro extracting, drying, ironing, folding, delivery of clean linen, repair and mending.

6 What equipments are available in laundry?

7 Is steam generated in laundry being utilized elsewhere (kitchen or CSSD).

8 How frequently is the linen changed?

9 Who checks the quantity and quality of linen washed?

10 What is the process for purchase of new linen?

11 What is the process for condemnation of old linen?

BIO MEDICAL WASTE MANAGEMENT1 Are the staffs aware of BMW handling, its importance,

implication and standard practices?2 Has all the staff received training in BMW handling?

How effective it has been?

46

3 What is the total amount of bio medical waste generated per day?

4 Are multi colored bins (black, blue, red, yellow- foot operated and covered) available at the point of BMW generationAre liners present in the Bins

5 Are needle destroyers available? Are they functional?

6 Is segregation done appropriately?

7 Are puncture proof containers with 1% sodium hypochlorite available for collection of sharps?

8 Are printed charts with instructions for handling BMW displayed near the bins?

9 How and by whom is the BMW transported for storage?

10 Where and for how long is it being stored before final disposal?

11 Has the facility got authorization from SPCB for handling BMW?

12 If the facility is out sourced- check the daily register? How frequently is the BMW van visiting hospital?

13 If incinerator available: what is the type (electric/diesel, single chamber/double chamber)

14 Does the incinerator have license from pollution control board?

15 If dispose in pits then is it as per BMW guidelines

16 Is separate sharp pit available

Medical Records1 Is there separate room for medical records?

2 How is General Upkeep of The Department?

3 Availability and labelling of shelves adequate?

4 Pest control done Regularly?

5 Procedure of Retrieval and Issue of Records?

6 Retention period defined?

Ambulance Service

1 Number of In-house + Outsourced Ambulance in working condition

2 General condition of Ambulance

3 Availability of Emergency drugs, Oxygen cylinder, Consumables

4 Average number of trips made per day

Security and Service

1 Number Security Guards available

2 Fire Safety equipments installed and checked

3 Has the facility got NOC from fire department?

4 Entry and Exit control by security guards

47

Disaster Plan

1 Triage area defined?

2 Disaster plan available?

3 Responsibilities defined ?

Immunization Services

1 Availability of Vaccines?

2 Status of cold chain equipments?

Date:

DISTRICT PROFILE- RCH II MONITORING OF DISTRICTS

Name of the district……………………….

Name of Liaison Officer: ………………….Designation: …………………………..

1. Demographic profile (Based on 2012 report)Population

Rural Urban

Population densitySCST % of BPL populationOthers Literacy rate

2. Administrative profile (RHS 2011)No. of BlocksNo. of villages No. of Gram Panchayats

3. Health profile CBRStill births per 1000 live birthsSex Ratio at birth Sex Ratio ( 0-6)

4. Facility status (2011-12 HMIS / as per district record)SN Public Sector Total No MCH -I MCH -II MCH -III

48

I F I F I F

1 District Hospitals2 Sub Divisional Hospitals3 Other Hospitals ( please specify

category/ type of facility e.g. Referral Hospital, Women and Child Hospital etc. make separate row for each category)

4 CHC 5 Block PHCs6 PHC ( break up to be included if

24*7 PHC, Mini PHCs APHC,UGPHC)

7 Total Sub centres 8 Total number of functional

newborn care units in the district (SNCU, NBSU, NBCC)

9 Number of facilities with Nutritional Rehabilitation Centres (or its equivalent)

10 No. of licensed blood banks (include pvt)

11 No. of licensed blood storage units/centers*I; Identified, F: Functional

5. Facilities in district and service delivery

Facilities Total No.No. of normal delivery

C-sectionNo. of new born admitted

FP services

MCH-I

MCH-II

MCH-III

6. Accreditation of Private Health Facilities:SN Private Sector Accredite

d for Normal Delivery

Accredited for

Normal Delivery & LSCS

Accredited for MTP

Accredited for any other

services

1 No of Private Hospitals accredited under JSY

49

2 No of Private Hospitals accredited under any other scheme

7. Maternal Health:

Indicators 2012-13 (HMIS)2011-12 (HMIS)

1st

Quarter2nd

Quarter3rd

Quarter4th

QuarterNo. (%) No.

(%)No.

(%)No.

(%)No.

(%)Estimated pregnancies Expected deliveries Total ANC registrations (Against estimated preg)Registrations within 12 weeks, (Against estimated preg)Three ANC checkups (Against estimated preg)100 IFA tablets given (Against

estimated preg)Hypertensive cases detected

(Against estimated preg)Women having Hb less than 11 gms (Against estimated preg)Women treated for severe anaemia (Hb<7) (Against estimated preg)Total no. Institutional deliveries(Against expected deliveries)

Public (Against expected deliveries)

Private(Against expected deliveries)

Total no. home deliveries (Against expected deliveries)Unreported deliveries (Against expected deliveries)Total C section deliveries (Against institutional deliveries)

Public(Against institutional deliveries)

Private(Against institutional deliveries)

50

Total complicated cases managed. (Against total reported deliveries) Total Live births against

estimated pregnancies .

Indicators 2012-13 (HMIS)2011-12 (HMIS)

1st

Quarter2nd

Quarter3rd

Quarter4th

QuarterNo. (%) No.

(%)No.

(%)No.

(%)No.

(%)PNC within 48 hours of

delivery. (Against total reported deliveries)

Stay ( in facility) for more than 48 hours after delivery (Against institutional deliveries)Total abortions (Against estimated pregnancies)

MTP less than 12 weeks

MTP more than 12 weeks

JSY beneficiariesTotal no. of JSY beneficiariesNo. of JSY beneficiaries paid within 24 hours fm JSY Register (Against total JSY beneficiaries)No. of JSY beneficiaries paid post 24 hours fm JSY Register (Against total JSY beneficiaries)

8. Pregnancy Tracking:No. of pregnant women data entered in software (under name based information tracking system against estimated pregnancies)

No: %

Time line for achieving the data entry in software(month & year)

50% to 75%dd/mm/yy

75% to 100% dd/mm/yy

51

9. Maternal Death Review:Indicators 1st

Quarter2nd

Quarter3rd

Quarter4th

QuarterNo. of maternal deaths reported (Community & Facilities)No. of deaths reviewed

No. due to PPH No. due to Eclampsia No. due to Sepsis No. due to Obstructed labor No. due to Referral delays No due to severe anaemia No. due to Other causes

10. Child Health: Indicators 2012-13 (HMIS)

2011-12 (HMIS)

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Target

Actual

Target

Actual

Target

Actual

Target

Actual

Target

Actual

New born breastfed within one hr of birth (against live births)

No. -

within one hr of birth (against live births)

% -

Number of new born weighed less than 2.5 kgs (against live births)

No. -new born weighed less than 2.5 kgs (against live births)

% -

No of diarrhea & dehydration cases No of respiratory infection cases admitted No of functional NICU (medical college)No of functional SNCU (DH/MCH III)

52

No of functional NBSU (FRU/CHC/MCH II)No. of children admitted to NBSUNo. of referralsNo. of functional NBCCs (all levels)

11. Child Tracking:No. of children data entered in software (under name based information tracking system against live births)

No: %

Time line for achieving the data entry in software(month & year)

50% to 75%dd/mm/yy

75% to 100% dd/mm/yy

12. Infant and Child Death Review: Sl no

Infant and Child Death Review 1st

Quarter2nd

Quarter3rd

Quarter4th

Quarter1 Infant Deaths within 24 hrs of birth2 Infant Deaths between 24hrs & under 1

week3 Infant Deaths between 1 week & under 1

month (causes of death below one month and for children up to 5 years is entirely different and cannot be clubbed )

No. due to Sepsis No. due to asphyxia No. due to LBW

53

Sl no

Infant and Child Death Review 1st

Quarter2nd

Quarter3rd

Quarter4th

Quarter

No. due to preterm birth Other causes

4 Child Deaths between 1yr under 5years5 Total Infant & Child deaths

No due to Pneumonia/ARI No due to diarrhea /dehydration No due to fever ( to be deleted-

fever cannot be the cause of death, this classification has to match international classification)

No due to measles No due to Referral delays No. due to Other causes

Note:- *This data will be maintained at MoHFW13. Immunization:

A. Indicators Indicators 2012-13 (HMIS)

2011-12 (HMIS)

1st

Quarter2nd Quarter 3rd

Quarter4th Quarter

No of fully immunized children (against live births)

No of fully immunized children (against live births)

%-

B. Outreach services:Outreach services 1st

Quarter2nd

Quarter3rd

Quarter4th

QuarterNo. of Immunization sessions planned No. of Immunization sessions held No. of VHNDs planned No. of VHNDs held

14. Family Planning: Indicators 2012-13 (HMIS)

2011-12 (HMIS)

1st

Quarter2nd

Quarter3rd

Quarter4th

QuarterNo. of eligible couple (estimated) Eligible couples with unmet need

54

Total reported FP usersLimiting methods

(sterilizations)Spacing methods

IUD Condoms OCPs

15. Community Processes:Indicators 2012-13 (HMIS)

2011-12 from district record

1st

Quarter2nd

Quarter3rd

Quarter4th

Quarter

Total No. of ASHAs in placeNo. of ASHAs trained in:

Module five Module six Module seven

16. Program Management Unit:

A. Regular Technical Resource:Human Resource-District technical officers

No. Sanctioned

No. In position

No of field visits undertaken in last quarter

No. of Tour report submitted

Corrective Action taken

CMORCHOACMODMODTODIODLOOther (specify)

55

B. Other Managerial Resource:Indicators No.

SanctionedNo. In position

No of field visits undertaken in last quarter

No. of Tour report submitted

Corrective Action taken

DPMDAMDPCM&E OfficerBPMBAMBlock Data ManagerRPMRAMR M&E

17. Deployment and Performance of Human Resources under NRHM:

Human Resource

Sanctd.

No. In position

No. trained

Specify training

How many deployed at functional facilities

Performance Indicators(April, 2011 to March 2012)

position

ed training

deployed at functional facilities

N.D

C.S

Tubectomy

Vasectomy

IUD

Obs/Gyne Peads AnesthOthers(Spl.)MO(Allopathic)MO(AYUSH)ANMSNLT 56

18. Deployment of Contractual Manpower (Facility-Wise) under NRHM:Name of the Facility

Type of Facility (APHC/PHC/ FRU/DH)

No of contractual manpowerMO-SNANMLT

Posted from

Physical Achievement(April, 20101to March 2012)

N.D

C.S

No. of 3 ANCs

No. of fully immu. children

Tubectomy

Vasectomy

IUDs

MO-SNANMLTMO-SNANMLTMO-SNANMLT

Note :-Right now this type of data is not available but we have made formats for this and we will send it further in coming week.

19. Monitoring Mechanism:Monthly meetings in the last quarter

Number Periodicity

Type of personnel attended the meeting

Monthly meetings At PHC LevelMonthly meetings At Block levelMonthly meetings At District Level under DMMonitoring Meetings at District Level under CMO

57

Sectoral Meetings for convergenceLHV/DPHN/BEE and other health supervisor

20. Systemic Issues:Sl no

Issues District Mechanism Whether Free

1 Referral transport

2 Biomedical waste management

3 Drug Procurement4 Equipment

Maintenance 5. Diet

21. ARSH

No. of ARSH Clinics established and functional: Established: ______, Functional: _____

No. of clients provided service: Girls: _______, Boys: _______ Whether ARSH training modules are available in local languages: No. of Medical Officers, LHVs/ANMs, Counselors trained: MO: ____,

LHVs/ANMs: _____, Counselors: _____ Any other ARSH activity:

22. SCHOOL HEALTH PROGRAMME

No. of schools identified in the district : No. of Schools covered : No. of girls and boys covered: Girls:__________, Boys: __________ Periodicity :

23. PNDT

Whether District Appropriate Authority is formed: No. of District Appropriate Authority meetings held :

Periodicity:

58