HM Medical Clinic

Nsi.edu.np

Hospital Management Strengthening Program (HMSP) Checklist
To Identify the Gaps in Minimum Service Standards
Government of Nepal
Ministry of Health and Population
Contents

Section 1: Governance Section 2: Organizational Management Section 3: Human Resource Management Section 4: Financial Management Section 5: Information Management Section 6: Quality Management Section 7: Clinical Management 7.4. Clinical Laboratory 7.5. Nursing/ Inpatient Services 7.6. Maternity Services 7.7. Dressing and Injections, Routine Procedures 7.8 Surgical Services 7.9 Anesthesia Services 7.10. Diagnostic Services 7.11. Specialized Services Section 8: Hospital Support Services Management 8.3. Housekeeping 8.4. Repair and Maintenance 8.5. Hospital Waste Management 8.6 Power System 8.7 Safety and Security 8.8 Transportation and Communication 8.9 Hospital Medical Store 8.10. Hospital Canteen 8.11. Information, Education and Communication (IEC) Materials 15 List of Annexes

Annex 1: List of Staff Annex 3: Emergency Room Annex 4: List of Essential Drugs and Supplies for Pharmacy Annex 5: Clinical laboratory Annex 6: Inpatient Services Annex 7: Dressing & Injection, Routine Procedures Annex 8: Surgical Services Annex 9: Anesthesia Annex 11: Central Sterile Supply Department (CSSD) Annex 12: Laundry Annex 13: Housekeeping Annex 14: Safety and Security Annex 15: Hospital Canteen Background
There are number of specific standards, guidelines and tools developed to address the need to improve and strengthen the government based hospitals of Nepal. Some of them provide the infrastructure standards while others focus on specific technical competencies of the service providers. This checklist for ‘Minimum Service Standards for District Hospital' has been
developed to bring together all the previous standards, guidelines, tools and other
documents that are related to the hospital quality. Some hospitals that are practicing a
desired level of management practices were also observed to make this checklist
realistic. Moreover, some additional criteria have been added up in order make it more
contemporary and practical. This checklist intends to focus more on ‘Service Standards'
that expects to demand the resources including human, infrastructure, and supplies
required to establish a hospital fulfilling the ‘Minimum Service Standards'.
Given below is a list of references taken to develop this checklist: 1. /fli6«o :jf:Yo gLlt, @)&! 2. :jf:Yo ;+:yf :yfkgf, ; rfng tyf :t/f]Gglt dfkb08 ;DaGwL lgb]{lzsf, @)&) c:ktfn ljsf; ;ldlt u7g cfb]zx? ;'zf;g -Joj:yfkg tyf ;+rfng_ P]g, @) $ g]kfn :jf:Yo ;]jf lgodfjnL, @)%% lghfdtL ;]]jf lgodfjnL, @)%) :jf:Yo ;]jf ljefusf] sfo{ljlw, @) * cfly{s sfo{ljlw lgodfjnL, @) $ n]vfkfng tyf ah]6 lgoGq0f k 0ffnL (TABUCS) k of]ustf{ k'l:tsf, @)&) 10. :jf:Yo If]qsf nflu ;fdflhs k/LIf0f sfo{ ; rfng lgb]{lzsf, @)&) 11. :jf:Yo Joj:yfkg ;"rgf k 0ffnL clen]v tyf k ltj]bg;DaGwL lgb]{lzsf, @)&) 12. u'0f:t/Lo :jf:Yo ;]jf ;DaGwL gLlt, @) $ 13. :jf:Yo ;]jfsf] u'0f:t/ ;'wf/ k4lt sfof{Gjog lgb]{lzsf, @) 14. c:ktfn kmfd]{;L ;]jf lgb]{lzsf, @)&) 15. ;+qmd0f /f]syfdsf nflu ;Gbe{ k'l:tsf -lhNnf c:ktfn tyf :jf:Yo ;+:yfx?sf] nflu_, @) 16. If]qLo :jf:Yo lgb]{zgfno / lhNnf :jf:Yo ÷ hg:jf:Yo sfof{nox?df sfo{/t sd{rf/Lx?sf] sfo{ljj/0f, @)&) 17. National medical standard for reproductive health, Vol. III, 2007 18. National Safe Motherhood and Newborn Health Program District Maternal and Neonatal Health Need Assessment Tool Kit Vol. 1,Hospital, 2006 19. National list of essential medicines,(Draft) 2010 20. Hospital QI Tools, NSI 21. Hospital management practices observed in a. Primary Health Care and Resource Center, Chapagaun, Lalitpur b. Gorkha Hospital, Gorkha c. Lamjung Community District Hospital, Lamjung There are eight sections in this checklist; 1. Governance 2. Organizational Management 3. Human Resources Management 4. Financial Management 5. Information Management 6. Quality Management 7. Clinical Management 8. Hospital Support Services Management In the ‘Clinical Management' there are eleven sub-sections;
Emergency Service Clinical Laboratory Nursing/inpatient Services Maternity Services Dressing and Injections, Routine Procedures Surgical Services Anesthesia Services 7.10. Diagnostic Services 7.11. Specialized Services
In the ‘Hospital Support Services', there are eleven specific sub-sections;
Repair & Maintenance Hospital Waste Management Safety and Security Transportation and Communication Hospital Medical Store 8.10. Hospital Canteen 8.11. Information, Education and Communication (IEC)
How to Use This Checklist

Since this checklist is developed to measure the existing situation of the hospital against
the standards, it will help you to understand the standard gaps and make a plan to fulfill
those gaps in order for your hospital to reach to a standard level. Reaching to the
standard means that your hospital has become able to render the specified health
services maintaining quality.
Group Discussion
 Go to your hospital team  Read the checklist and think if your hospital really meets the given indicators o This can be done either in a large group, or making smaller groups of your hospital and working in the specific sections of the checklist
Filling the Checklist
 Read each sections carefully
 There are list of standards and the supporting indicators for each standards
 If your hospital meets the indicators, please mark ‘1' in the column of ‘Score'
 Complete this process to all the indicators
Scoring the checklist
 Now in each section, add the total score and convert it into total percentage, as
Section 5: Information Management
Standards
Verification Criteria
Obtained
Managing Medical Records
Patient registration Computerized patient registration is done using a standard software Patient referral Referral records are kept using the standard form and register Adequate Infrastructure
Adequate space for 5.3 There is a separate room and adequate space to store the medical records All patients' records are kept in individual folders in racks/ kept digitally maintaining privacy Computer/Printers There is a set of functional computer and printer to store the medical records Working tables and 5.6 There is at least a set of one table and one chair per staff in the room. Section 5
Total Score
Percentage = Total Score ( 4 )/7 X
 In the section 7 and 8, add the scores of each sub-sections, and calculate the average score of the section  Finally, calculate the average percentage of eight sections and this gives you the existing score of your hospital
Section 1: Governance
Standards
Verification criteria
Obtained
Formation of
There is Hospital Development Committee as Hospital
per the HDC formation order. Development
The hospital has its own mission and vision Committee
Capacity
All HDC members have received an orientation building
on HDC functions activities for
HDC members have participated in some kind of capacity building training. HDC members have received refresher orientation at least once in the last year. Carrying out the HDC Functions
The HDC conducts meetings at least 3 times at least 3 times per year. Mandatory Hospital services and utilization Hospital's financial issues Patient rights issues HR issues Infrastructure issues Coordination issues with DHO/DoHS/MoHP Meeting agenda is circulated/made known to all the members before the meeting. agenda Hospital's A written form of hospital's annual plan is available and approved by HDC. developed and approved. Establishment There is a separate locker for HDC locker for HDC documents. The hospital is Updated citizen/patient charter is available. Separate notice board of the HDC is available. The complaint box is kept in a visible place in the hospital main lobby. Specific person is designated to record the complaints weekly and brings this to MS to Annual Report from HDC is available within 3 months of the end of the fiscal year Annual Report Conduct social 1.21 Social audit is conducted every year. Section 1
Total Score
Percentage=Total Score( )/21 X100
Section 2: Organizational Management
Standards
Verification criteria
Obtained
List of specific department showing detailed structure of
list of services/ organogram is displayed. hospital
departments
Work division
A written statement is available specifying certain person to have been delegated the delegation of
roles, responsibilities and authorities of head authorities
of department/unit. Maintaining
A clear channel of client flow system within the client flow
hospital has been developed (shown in a map) and practiced accordingly. Maintaining effective team work environment
Hand over meetings are conducted daily. Department/unit meetings are conducted every Senior staff meetings are conducted twice a month led by the DHO and/or Medical Superintendent and minutes are kept. A staff meeting including all staff is conducted at least once in a month and decisions are Section 2
Total Score
Percentage=Total Score ( )/7X100
Section 3: Human Resource Management
Standards
Verification criteria
Obtained
Practicing the
Personnel administration policy of HDC is personnel
available (for locally hired staff) and practiced of the staff
recruited by
the HDC
Maintaining
Individual records of all staff (including all contract staff) are maintained and updated All staff have job description description
Review of
The half-yearly review of performance of all Performance
staff is done by the line managers. Performance feedback meeting is conducted by the line managers half-yearly. Adequate
Hospital has fulfilled all the staff required to number staff
deliver the specific services (See Annex 1)
in the hospital
Motivating the
There is some instance of hospital carrying out activities to motivate staff (staff retreat, rewards, recognition of performances etc.) at least once in a year Section 3
Total Score
Percentage =Total Score ( )/9 X100

Section 4: Financial Management
Standards
Verification criteria
Obtained
Formulation
An annual hospital budget is developed and approval
incorporating the revenue from services, of Annual
government grants, and supports provided by Hospital
other organizations Internal income is reviewed during budgeting every year. Service fees
The service fees of the hospital are fixed by HDC every year. Daily income
Daily income is deposited in the bank every Financial
Financial and physical progress review is done at least in each trimester (once in every 4 Financial audit 4.6
Externally audited accounts are available for Electronic database
Hospital uses central Electronic Billing system software for all financial and Hospital uses TABUCS for accounting Financial reports
Hospital produces monthly financial report produces all financial Trimesterly financial report is produced. (every Annual financial report is submitted to HDC. Auction is done yearly. Clearing
Clearance of financial irregularities is done financial
Inventory
Inventory inspection is done twice a year. inspection
Section 4
Total Score
Percentage =Total Score ( )/14X100
Section 5: Information Management
Standards
Verification criteria
Obtained
Managing Medical Records
Computerized patient registration is done using a standard software Patient referral Referral records are kept using the standard form and register Adequate Infrastructure
There is a separate room and adequate space to store the medical records records Filing racks All patients' records are kept in individual folders in racks/ kept digitally maintaining privacy There is a set of functional computer and printer to store the medical records There is at least a set of one table and one chair per staff in the room. Developing
Hospital services utilization reports are developed and reported using the standard HMIS form (HMIS 9.4) Utilizing
Hospital services utilization statistics are information
analyzed at least every trimester (once in 4 Conduction of 5.9
Social marketing activities are being conducted (Billboards, ads in FM,TV, pamphlets, banners, marketing
mobilization of FCHVs, via websites etc.) to promote hospital services Information to
A separate help desk/reception is available A separate staff to run the help desk is available Information
An information officer is specified to communicate with patients, their relatives, media and other stakeholders. Signs for
There are appropriate signs to show the directions
directions of service delivery rooms. Section 5
Total Score
Percentage = Total Score ( )/13X100
Section 6: Quality Management
Standards
Verification criteria
Obtained
Hospital QI committee
Formation of
Hospital QI committee is formed hospital QI
committee
Meetings of QI 6.2
QI committee meetings are held at least every 4 committee
Addressing
The hospital has a statement of patient rights and patient rights
responsibilities, which is posted in public places in Hospital has a formal decision to give priority to the children and senior citizens, and is being Conducting
The hospital monitors patients' experiences through patient satisfaction surveys or focus interview
group discussions conducted at least annually. Assessing
Hospital has assessed the hospital quality using hospital
the standard QI tools at least every 4 months Planning
Hospital has developed specific plans to improving
improving quality based on the QI assessment Hospital has implemented the specific activities based on the QI plan Morbidity and
Morbidity and mortality records are kept securely. mortality
records
Each mortality in hospital is investigated and report is kept. Section 6
Total Score
Percentage =Total Score ( )/10 X 100

Section 7: Clinical Management
Standards
Verification criteria
Obtained Maxi mum
7.1 OPD Service
Adequate time 7.1.1 OPD is open from 10 AM to 3 PM Adequate numbers of health care workers are available in OPD (at least 1 doctor and 1 mid- level health worker treating 60 patients per day.) Appropriate techniques have been used to ensure the patient privacy (separate rooms, curtains hung, maintaining queuing of patients etc) Counseling is done to patients about the type of treatment being given and its consequences. Instruments and equipments to carry out the OPD works are available and functioning (See Annex
Adequate rooms and space for the practitioners and patients are available Light and ventilation are adequately maintained The required furniture are available (See Annex
Duty rosters of OPD are developed regularly and available in appropriate location Comfortable waiting space with sitting arrangement is available for at least 50 persons in Safe drinking water is available in waiting lobby throughout the day There is at least four toilets with hand washing facilities (2 for male and 2 for female) Hand washing facilities is available for patients. Masks and gloves are available There are colored bins for waste disposal Hand washing facility with running water and soap is available for practitioners Needle/sharps disposal container is used Chlorine solution is available and utilized Total Score
Percentage = Total Score ( )/22X 100
Standards
Verification criteria
Obtained Maximum
7.2 Emergency Service
Adequate time 7.2.1 ER is open 24 hours Doctors/health workers/nurses are available in ER (1 health worker and 1 nurse with a doctor on- Hospital maintains a triage system in the ER Appropriate methods have been used to ensure the patient privacy (separate rooms, curtains hung, maintaining queuing of patients etc) Instruments and equipments to carry out the ER works are available and functioning (See Annex
10% of the total hospital beds are allocated and Light and ventilation are adequately maintained Adequate furniture are available as per annex.
(See Annex 3.2)
Adequate medicines and supplies to carry out the ER works are available and functioning (See
Annex 3.3)
Hospital is equipped and able to provide Primary Hospital has maintained security system for ER Hospital has mass casualty management protocol, and all staff are updated Hospital carries out at least one mock drill once a year Referral decisions are made by doctors Duty rosters of ER are developed regularly and available in appropriate location Separate inventories for medicines, medical supplies, and narcotics are maintained. Narcotic drugs are kept separately and securely. Safe drinking water is available for 24 hours. There is at least one toilet with hand washing facilities Staff wear mask and gloves at work There are colored bins for waste disposal Hand washing facility with running water and soap is available and being practiced by staff Needle/sharps disposal container is used Chlorine solution is available and utilized Total Score
Percentage =Total Score ( )/30 X 100
Standards
Verification criteria
Obtained Maximum
7.3 Pharmacy
All of the free medicines provided by government are available in pharmacy. (See Annex 4.1)
Display of list of 7.3.2 The list of free medicines is displayed in a clearly There is a list of authorized OPD medicines other than the free drugs, and are made available in the pharmacy (See Annex 4.2)
There is a list of authorized injections other than the free ones, and are made available in pharmacy (See Annex 4.3)
There is a list of authorized medical supplies other than the free ones, and are made available in the pharmacy (See Annex 4.4)
All the medicines and supplies are displayed in the clean racks maintaining alphabetical orders and generic names Information to 7.3.7 Information regarding the medicines are provided to the patients Each medicine is given with written instructions on how to take them. A daily use record of each medicine and supplies is maintained. Expiry 7.3.10 FEFO system is maintained using standard stock book/cards Every month, all medicines and supplies are counted, out- of-date discarded, and tallied with the medical store of 7.3.12 Medicines are bought following the prevailing procurement rules. Total Score
Percentage =Total Score ( )/18 X 100
Standards
Verification criteria
Obtained
Clinical Laboratory
All investigations mentioned in the standard list are available round the clock (See Annex 5.1)
At least three months buffer stock of laboratory supplies is available Recording and 7.4.3 Standard reporting sheets are being used and all reports are recorded in a standard register All physical instruments and equipments required to conduct all parameters of tests are available and functioning (See Annex 5.2)
Staff wear mask and gloves at work There are colored bins for waste disposal Hand washing facility with running water and soap is available and being practiced All sample containers are disposables Needle/sharps disposal container is used Chlorine solution is available and utilized Laboratory has safety box for sputum AFB Communication 7.4.12 Reports are being disbursed to the patients in the same day the test is completed (except AFB Total Score
Percentage =Total Score ( )/16X100
Standards
Verification criteria
Obtained
7.5 Nursing Services (Inpatient Services)
Separate space for nurses' work station is available There is a set of one table and three chairs in the nursing station. Medicines rack is available Telephone facility is available Admission and discharge register are available and are being filled completely (HMIS 8.1 and Furniture and instruments/equipments are
available (See Annex 6.1)
Medical supplies for ward is provided (See
Annex 6.2)
There are adequate lighting and ventilation in the There are adequate toilets for patients (1 for 6 patients) Safe drinking water is available 24 hours Separate space is available for patient visitors (Kuruwa Ghar) Communication 7.5.12 Basic information regarding admitted patients are displayed in a separate board Mask and gloves are available and used whenever required There are colored bins for waste disposal Hand washing facility with running water and soap is available and being practiced Needle/sharps disposal container is used Chlorine solution is available and utilized Total Score
Percentage =Total Score ( )/21 X 100
Standards
Verification criteria
Obtained
Maternity Services
A separate prelabor ward is available A standard partograph chart is being used for clinical decision making A labor room is equipped with equipments and
instruments,supplies are available (See Annex
Normal and complicated deliveries (vacuum, forceps, induction etc) are conducted 24 hours Separate postnatal ward is available Baby bath is done after 24 hours of delivery A formally signed standard birth certificate is issued. Postnatal counseling is done prior to discharge Safe drinking water is available 24 hours Separate toilet is present in labor room Mask and gloves are available and used whenever required There are colored bins for waste disposal Hand washing facility with running water and soap is available and being practiced Needle/sharps disposal container is used Chlorine solution is available and utilized Total Score
Percentage =Total Score ( )/17 X100
Standards
Verification criteria
Obtained
7.7 Dressing and Injections, Routine Procedures
A separate room for routine dressing and injection service is available Adequate furniture are available (See Annex
Adequate items of disposable supplies and medicines are available (See Annex 7.2)
Sterile supplies Adequate quantity of sterilized packs for wound
dressing are available (See Annex 7.3)
Separate containers for sterile gauge and cotton balls are available List of minimum 7.7.6 A list of minimum dressing services and routine procedures are available (See Annex 7.4)
Separate colored waste bins are available Chlorine solution is available Needle/sharps disposal container is used Hand washing facility with running water and soap is available and being practiced Chlorine solution is available and utilized Proper records of all procedures are kept and Total Score
Percentage = Total Score ( )/20 X100
Standards
Verification criteria
Obtained
7.8 Surgical Services
The operating room has adequate physical facilities, equipments & instruments. (See
Annex 8.1)
Medicines and supplies are available (See
Annex 8.2)
List of surgical Listed types of surgical procedures under local, regional, spinal, and general anesthesia are done (See Annex 8.3)
Adequate and appropriate furniture for patient
and staff are available (See Annex 8.4)
Recording is done for all surgeries Fumigation is done at least once a week in the High Level Disinfection (e.g. Cidex) facility is available and being practiced High dusting is done at least twice a week in Separate colored waste bins are available Mask and gloves are available and used whenever required Needle/sharps disposal container is used Hand washing facility with running water and soap is available and being practiced Chlorine solution is available and utilized Total Score
Percentage =Total Score ( )/21X100
Standards
Verification criteria
Obtained
Anesthesia Services
Adequate instruments and equipments are available (See Annex 9.1)
Anesthetic drugs are available (See Annex 9.2)
Records of all anesthetic procedures are kept and reported Total Score
Percentage = Total Score ( )/12X100
Standards
Verification criteria
Obtained
Diagnostic Services
X-ray service with minimum of 100 mA machine
is provided round the clock (See Annex 10)
Lead barriers are available and used Working table and chairs are available Obstetrical (including emergencies) and abdominal scanning is done USG report is provided in the same day. ECG facility is available for OPD and ER Separate ECG facility is available in wards Total Score
Percentage = Total Score ( )/9X100
Standards
Verification criteria
Obtained
Specialized services
Gyne/Obs service including Caesarian Section is available At least one specialized service is available (eye, ENT, dental etc) Round the clock postmortem service is available Separate room for mortuary is available Postmortem and mortuary rooms are disinfected and kept clean Mortuary van is accessible for hospital use Total Score
Percentage = Total Score ( )/6 X 100
Section 7
Section 7's Grand Total Score
Section 7's Average Percentage =
Grand total Score ( )/ 192 X 100
Section 8: Hospital Support Services Management
Standards
Verification criteria
Obtained
Separate CSSD service is available There are separate rooms for dirty and clean utility. Adequate equipments and supplies are available for sterilization (See Annex 11)
Gauge, cotton balls, bandages are prepared All used instruments and linens are cleaned using proper chemical/detergents in a separate All instruments and equipments are dried in a separate room. All instruments are packed in wrappers All wrapped Instruments are indicated with thermal indicator tape and autoclaved in a All sterile packs are stored in separate cupboards in a separate room. Sterile supplies are distributed using a proper method (basket supply system or on-demand All instruments and linens are recorded and inventory maintained Staff wear mask and gloves at work There are colored bins for waste disposal Hand washing facility with running water and soap is available and being practiced Chlorine solution is available and utilized 8.2 Laundry
Separate room for laundry is available Adequate equipments and supplies are available for laundry (See Annex 12)
All linens are washed using washing machine of capacity of at least 10 KG is available. All linens are dried in direct sunlight All linens are ironed and packed properly Linens are properly stored in separate cup board All linens are distributed using a proper method (basket supply system or on-demand supply All linens are recorded and inventory maintained Total Score
Percentage = Total Score ( )/27X 100
Standards
Verification criteria
Obtained
Basic supplies are available (See Annex 13)
Hospital premises are visibly clean. There is no litter in the hospital premises. All Hospital toilets are clean, have no offensive smell, and stains and cleaned at least three All doors and windows of hospital are dust free, stain free and cleaned once a day. All floors of hospital are stain free and cleaned twice a day. All walls of hospital are clean and stain free and are painted with enamel up to 4 ft. Hospital maintains a garden and retains beauty Cleaning log book is maintained in every service Repair & Maintenance
Hospital has regular preventive maintenance practices (calibration, servicing of equipments) While doing medical equipment repair and maintenance, biomedical engineer or person trained in biomedical equipment is there. Hospital Waste Management
Waste bins are available within the hospital premises Hospital has incinerator and burial space for Staff use mask, gloves, boot, gown while collecting waste Information regarding proper use of waste bins are displayed in public places Power System
Hospital has main-grid power supply with three Hospital has alternate power generator of at least 50 KVA Proper inventory of fuel is maintained Hospital has solar system installed (at least for administrative functions) Total Score
Percentage = Total Score ( )/20 X100
Standards
Verification criteria
Obtained
8.7 Safety and Security
Hospital has security personnel round the clock Security personnel are oriented about the hospital security procedures A separate office for security with communication system is available Hospital has done insurance of its buildings and major equipments Basic amenities are available (See Annex 14)
Hospital has replaced all mercury apparatus with other appropriate technologies Hospital has fire extinguisher in all blocks Hospital has installed safety alarm system Retro fitting has been done in all buildings (if Hospital has prevented lightening by ensuring earthing system in electrification Disaster preparedness orientation has been given to all staff at least every six months Disaster mock drill is practiced at least once a Exit signs to escape during disaster are available in all places An assembly zone has been specified for Transportation and Communication
24 hour ambulance service is available Hospital has access to utility van Communication 8.8.3 Hospital has telephone with intercom (EPABX) network Internal communication (paging) system has been installed in all major service stations Hospital has installed safety alarm system A notice board is available and being utilized There is a list of important phone numbers in reception, ER, admin etc. Total Score
Percentage =Total Score ( )/23 X100
Standards
Verification criteria
Obtained
Hospital Medical Store
Buffer stock in 8.9.1 A separate hospital medical store with 3-months buffer stock is available Electronic database system available in hospital medical store Hospital Canteen
Hospital has a canteen in its premises A list of food items with price list approved by HDC is available and opening hours should be Separate dish washing area is available and for 8.10.4 The inpatients are provided with food at least twice a day and the food contains carbohydrate, fats, proteins and at least one vegetable item. Utensils are available as given in the annex. (Annex 15)
All furniture and dining space is clean Inventory of all assets is kept and counted once in every four months Information, Education and Communication (IEC) materials
A separate space for IEC corner is available near to main patient area The corner has adequate and updated materials The corner is used by the clients Total Score
Percentage = Total Score ( )/14X 100
Section 8
Section 8's Grand Total Score
Section 8's Average Percentage =
Grand total Score ( )/ 84 X 100
Grand Total Score of All Sections
Existing Standard of Hospital =Grand Total ( )/350 X 100
ANNEX 1: List of Staff
Required
Department
Designation
Available
available
Health Assistant/SAHW Pharmacy Assistant Anesthesia Assistant Nursing Officer/Sister Medical Recorder Housekeeping Worker Cook's Assistant Accounts Officer Total Required
Total Available
Total Available Percentage = Total Available/46 X 100
Scoring Chart
Total available staff %
Final Score
Standard 3.6 Score
Staff Structure
Medical Superintendent - 1 Medical Officer - 4 Nursing Officer (BN) - 1 Administrator - 1 Accounts Officer - 1 Medical Recorder - 1 Lab Technician - 1 Laundry Worker - 1 Asst. Radiographer Office Support Asst - Pharmacy Asst - 1 Security Guard - 2 Anesthesia Asst - 1 Total Staff
Medical Department
Nursing Department Administration Department : 15 Finance Department Total : 46
ANNEX 2: OPD
Annex 2.1: Equipments and Instruments
Required No.
For each practitioner Sphygmomanometer (non- For each practitioner Thermometer (digital) Disposable wooden tongue Examination gloves Total Score
Total Percentage = Total Score/12 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.1.5 Score
Annex 2.2: Furniture and General Supplies
General Items
Required No.
2. Working Chairs 3. Patient chairs 4. Examination table 5. Curtain separator for examination beds 6. Examination lamp 10. Shelves for papers 11. Reference books with shelve 12. Weighing scale 13. Snellen's Chart 14. Measuring tape Total Score
Total Percentage = Total Score/14 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.1.8 Score
ANNEX 3: Emergency Room
Annex 3.1: Equipments and instruments
Required No.
Suction Machine (each treatment room) Suture set (each treatment room) Ambu bag (Resuscitation bag with Oxygen (each treatment room) BP set and Stethoscope (each treatment room) Cart (Trolley) with medicines for emergency Intraoscious Canulation Set Venous section set Water sealed drainage set N/G tube Aspiration set Foot suction (Non-electric) Gastric Lavage Set Oxygen Tubes and Masks Hard Cervical Collar Ear Irrigation Equipments Spinal backboard Total Score
Total Percentage = Total score/31 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.2.5 Score

Annex 3.2: Furniture and General Supplies
Required
Furniture and General Supplies
Quantity
Information board Medical Exam Bed Sharp Disposal Bin Reference Books with cupboard Total Score
Total Percentage = Total Score/15 X 100

Each row gets a score of 1 if all the required quantity is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.2.8 Score
Annex 3.3: Medicines and Supplies
Atropine Injection Local Anesthetic Injections Adrenaline Injection Antihistamine Injection Hydrocortisone Injection Ranitidine/Omeperazole Injection Frusemide Injection Diclofenac Injection Hyoscine Butylbromide Injection Diazepam injection Morphine Injection Dexamethasone Injection Dopamine injection IV Catheters 16, 18, 20, 22, 24, 26 Disposable syringes 1 ml, 3 ml, 5 ml, 10 ml, 30 ml, 50 ml Disposable Gloves 6, 6.5, 7, 7.5 Magnesium Sulphate injection Calcium Gluconate injection Total Score
Total Percentage = Total Score/27 X100
Each row gets a score of 1 if available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.2.9 Score
ANNEX 4: List of Essential Drugs and Supplies for Pharmacy
Annex 4.1: List of free essential medicines*
Name of drugs
S.N. Forms
Strength
1 % with/ without Injection, 30 ml adrenaline, 2% w/v Chlorpheniramine Eye/ ear drop, 5ml Sulfamethoxazole + 120 DT, 480 and 960 Ferrous Sulphate 60 mg elemental Iron Vitamin B complex Therapeutic dose Compound solution of Ringers' Lactate Sodium lactate Sodium chloride Dextrose Solution Hydrochlorothiazide hexachloride Povidine lodine Aluminium hydroxide + Magnesium hydroxide Hyoscine butylbromide Oral Rehydration Solutions Metoclorpropamide Hydrochloride Charcol activated Benzoic acid + Salicylic acid 56. Ointment, tube, 30g Pralidoxim sodium 100mg / vial with Powder for injection Silver Sulphadiazine Skin Cream, 25 g Total Score
Total Percentage = Total Score/ 83 X 100

* There are 83 items for 70 essential medicines provided for free by the government.
Each row gets a score of 1 if the mentioned medicines are available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.3.1 Score
Annex 4.2: List of OPD Medicines for Pharmacy

Category
Name of drugs
Strength/ Form
Analgesics, Antipyretics, Ibuprofen+Paracetamol 400mg+500 mg, Syp Ampicillin+Cloxacilin 500mg, 250mg, Syp 400mg, 200mg, Syp 480mg, 960mg, Syp 250mg, 500mg, Syp Antitubercular Medicines
Ethambutol tablet 400mg (hydrochloride) Isoniazid+Ethambutol tablet 150mg+ 75mg+ 275mg +Ethambutol tablet Isoniazid tablet 60 mg+ 30 mg, 150mg Rifampicin+Isoniazid tablet 60 mg+ 30 mg+150 mg Rifampicin capsule or tablet Streptomycin powder for injection 1 g (as sulfate) in vial Antileprosy
Diethylcarbamazipine 25mg, 50mg, 100mg 100000 IU Lozenge Diloxanide Furoate 150mg, Syp, Inj. 7.5mg, 15mg, Syp 250mg+250mg, Syp Hydroxide+Magnesium Hydroxide Gastrointestinal 5mg, Suppository Magnesium Sulphate Digestive Enzyme Benzyl Benzoate Lotion Silversulfadizene Cream Benzyl Peroxide Cream Pividine Iodine Cream Whitefield's Cream Fluticasone Cream 120mg, 180mg, Syp Ferrous Sulphate + Folic Acid Calcium Carbonate+Vit D3 Potassium Chloride Chlordiazepoxide Psychotherapeutic Lithium Carbonate Combined Oral Contraceptives Intrauterine Device Methylergometrine Mefipristone+Misoprostol Combi Chlorhexidine Gargle Bclomethasonme E/E Drop Acyclovir ointment 25mg/250mg/400mg Lamivudine+Zidovudine Lopinavir+Ritonavir Lopinavir+Ritonavir 200mg/50mg per 5ml Stavudine+Lamivudine Tenofovir+Lamivudine 300mg+300mg+600mg Zidovudine+Lamivudine Zidovudine + Lamivudine + Total Score
Total percentage = Total Score/80 X 100
*(For ART site)Total percentage = Total Score/107 X 100
* For ART hospital site only Each row gets a score of 1 if the mentioned medicines are available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.3.3 Score
Annex 4.3: List of Injections for Pharmacy

Name of Medicine
Score S.N
Name of Medicine
1. Adrenaline 1mg 37. Mannitol 20% 2. Aminophylline 250mg 38. Mephenteramine 3. Ampicillin inj 39. Metochlopramide 10 mg 4. Anti D Immunoglibin 40. Metronidazole Inj 41. Morphine 10mg 42. Neurobin forte Inj Benzathine Penicillin 12 8. Benzathine Penicillin 6 Lakh 9. Calcium Gluconate 45. Oxytocin 5lU/ml 10. Ceftriaxone 250mg 46. (Pentazocine) 11. Ceftriaxone 1 gm 47. Pantoparazole 40 mg 12. Ciprofloxacin Injection 48. Paracetamol 300mg 13. Cloxacillin Inj 49. Pethidine 50mg/ml 14. Dexamethasone sodium 4mg 15. Dextrose 10% 51. (Promethagine) 16. Dextrose 25% 52. Phenobarbitone 18. Diazepam 10 mg 54. Potassium Chloride 19. Diclofenac Sodium 75mg 55. 12.5mg/ml( Stemetil) 20. Digoxin 0.25mg 22. Dopamine 200mg 58. Soda Bicarbonate 59. Tetanus Toxoid 0.5ml 60. Thiamine 50mg 25. Ergometrine Inj 61. Tramadol 50mg 26. Frusemide 20mg 62. Triamcinolone 40mg 27. Gentamycin 80mg 28. Haloperidol 5mg 64. Water for Injection 5 ml 65. 1/2 NS+5% Dextrose 30. Hydrocortisone 100mg Total Score
Hyoscine Bultylbromide 20 Total Percentage =
Total Score/65X100
32. Ketamine 10 ml Scoring Chart
33. Lignocaine 1% Total Percentage
34. Lignocaine 2% 35. Lignocaine 2% +Adrenaline 36. Magnesium Sulphate 1gm Standard 7.3.4 Score
Annex 4.4: List of Medical Supplies for Pharmacy
Name of medical supply
I/V Canula 16, 18, 20, 22, 24, 1. Adhesive Tape 2. Adhesive Handy Plast 22. IV Infusion Set Tube L.P Needle (Spinal Needle Betadine Solution 4. Butterfly Needle 23 G 24. Lignocaine Jelly 5. Butterfly Needle 24 G 25. NG Tube 10, 12, 18 6. Cervical Collar 26. Nylon Suture Thread 3-0 7. Chromic 0, 1-0, 2-0, 3-0, 4-0 8. Clinical Thermometer 28. Peri Pads Rolls 29. Phenyle Solution 10. Cotton Roll 400 mg 30. POP Bandage 3", 4", 6" Disposable Needle 18, 20, 22, 31. Pregnancy Test Kit Disposable Syring 1ml, 3ml, 32. Proliene 0, 1-0, 2-0, 3-0, 4-0 12. 5ml, 10ml, 20ml, 50ml 33. Suction Catheter 13. Distilled Water 500 ml 34. Use and Throw Mask 14. Easyfix Plast 35. Use and Throw Gloves 15. Endotracheal Tube (ET Tube) Vaginal Ring Pessary Size 2.5, 16. Female Catheter 17. Surgical Blade 10, 11, 15 37. Vaginal Ring Pessary Size 3 18. Surgical Gloves 6.5, 7, 7.5 Total Score
Foleye Catheter 14, 16, 18, 20, Total percentage = Total Score/38
Each row gets a score of 1 if the mentioned medical supplies are available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.3.5 Score
ANNEX 5: Clinical Laboratory
Annex 5.1: List of Essential Laboratory Tests
1. Hematology
Hemoglobin or Hematocrit 1.12. Group and Rh Type 1.13. Stick Blood Sugar (For ER) 2. Immunology
3. Biochemistry
3.10. Lipid Profile 3.10.1. Cholesterol 3.11.1. Bilirubin T/D 3.11.2. Alk. Phosphatase 4. Bacteriology
Culture & Sensitivity 5. Parasitology
6. Virology
7. Stool Exam
Stool for Occult Blood 8. Urine Exam
HCG (Pregnancy Test) 9. Miscellaneous
Total Score
Total Percentage = Total Score/ 52 X 100

Each row gets a score of 1 if the mentioned test is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.4.1 Score
Annex 5.2: List of Major Lab Equipments/Instruments
Required
Name of Instruments
Quantity
2. Semi Auto Analyzer (Bio Chemistry) 4. Chemical Balance 5. Electrolyte Analyzer 9. Counting Chamber 11. Pipettes, Glassware/kits 12. Computer with printer 14. Disposable test tubes Total Score
Total Percentage = Total Score/14 X 100
Each row gets a score of 1 if all the required quantity is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.4.4 Score
ANNEX 6: Inpatient Services
Annex 6.1: Furniture and supplies per bed
General Items
Required No.
1. Patient Beds (Metal bed, raisable head, mechanical ratchet, 3 X 6 ft.) 5. Blanket with cover 6. Bed site table 10. Medicine trolley 11. Medicine Trey 12. Cardex files 13. Working table 19. Torch with extra batteries and bulb 20. Inpatient register 21. Inventory Records Equipment/ Instruments
22. BP set and stethoscope (Non-mercury) 23. Body thermometer 24. Fetal stethoscope 25. Baby weighing scale 26. Self-inflating bag air mask - neonatal size 27. Mucus extractor with suction tube 28. Suction machine 29. Oxygen supply 31. Sponge forceps Total Score
Total Percentage = Total Score/32 X 100
Each row gets a score of 1 if all the required quantity is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.5.6 Score
Annex 6.2: Medicines and supplies
Medicines and Supplies
Required No.
5. Distilled Water 6. IV Infusion Set 7. IV Catheter 18G,20G,22G,24G,26G 9. Mask, Cap, Gowns 10. Disposable syringes 1 ml, 3 ml, 5 ml, 10 ml, 30 11. Needle 18-25 Total Score
Total Percentage = Total Score/11 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.5.7 Score
Annex 6.3: Instruments/Equipments and Supplies for Labor Room
Required No.
General Items
calculated as
per the average
no. of deliveries)
2. Clean bed linen 3. Curtains if more than one bed 4. Clean surface (for alternative delivery position) 5. Resuscitation table 8. Room thermometer Waste Management
9. Container for sharps disposal 10. Receptacle for soiled linens 11. Bucket for soiled pads and swabs 12. Bowl and plastic bag for placenta Miscellaneous
14. Torch with extra batteries and bulb 15. Log book (Maternity register Equipment
17. BP Set and Stethoscope (Non-Mercury) 18. Body thermometer 19. Fetal stethoscope 21. Self-inflating bag air mask - neonatal size 22. Mucus extractor with suction tube Sterile Delivery Instrument Set (Check each
25. Cord cutting Scissors 26. Artery forceps or clamp (Straight 8-10 cm) 27. Gally pot Small 28. Sponge forceps 29. Vaginal speculum (Sims) 30. Rubber sheet 31. Plain catheter 32. Placenta bowel Suture set (Check each set)
33. Needle holder 34. Sponge holder 35. Suture cutting scissors 36. Dissecting forceps (tooth and plain) Episiotomy set (Check each set)
37. Episiotomy scissor 38. Needle holder 39. Suture cutting scissor 40. Dissecting forceps(tooth and plain) Supplies
41. Utility Gloves 42. Sterile Gloves 43. Long plastic apron 44. Urinary catheter 45. Syringes and needles 47. Sutures for tear or episiotomy repair 48. Antiseptic solution (iodophors or chlorhexidine) 49. Spirit (70% alcohol) 51. Bleach (chlorine-base compound) 52. Clean (plastic) sheet to place under mother 53. Sanitary pads 54. Clean towels for drying and wrapping the baby 55. Cord ties (sterile) 56. Blanket for the baby 57. Baby feeding cup 58. Impregnated bed net 59. Inj. Oxytocin 60. Inj. Ergometrine 61. Inj. Magnesium sulphate 62. Inj. Calcium gluconate 63. Inj. Diazepam 64. Inj. Hydralazine 65. Inj. Ampicillin 66. Inj. Gentamycin 67. Inj. Metronidazole 68. Inj. Benzathine penicillin 69. Inj. Nevirapine or Zidovudine 70. Inj. Lignocaine 71. Inj. Adrenaline 72. Inj. Ringer lactate 73. Inj. Normal saline 0.9% 74. Inj. Dextrose 5% 75. Water for injection 76. Eye antimicrobial (1% silver nitrate or 2.5% 77. povidone iodine) 78. Tetracycline 1% eye ointment Total Score
Total Percentage = Total Score/80 X 100

Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.6.3 Score
ANNEX 7: Dressing & injection, Routine Procedures
Annex 7.1: Furniture and general supplies
General Items
Required No.
Mattress, pillow Bucket with chlorine solution Bucket with soap water Colored waste bins with lid Sharp disposal bin Total Score
Total Percentage = Total Score/13 X 100

Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.7.2 Score

Annex 7.2: Disposable supplies/Medicines
Supplies
Required No.
Disposable syringes 1 ml, 3 ml, 5 ml, 10 ml Lignocaine Hydrochloride 1% Lignocaine Hydrochloride 2% Lignocaine Hydrochloride 2% with adrenaline Lignocaine hydrochloride 4% Hydrogen Peroxide Disposable Gloves Polypropylene (Prolene) 2-0, 3-0, 4-0 Total Score
Total Percentage = Total Score/15 X 100

Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.7.3 Score
Annex 7.3: Sterile supplies
General items
Required No.
1. Sterile Dressing Set (must be in wrapper) 2. Sterile Suture Sets (must be in wrapper) 3. Sterile Suture Removal Set (must be in 4. Sterile Cheetle Forcep 5. Sterile Forcep Jar 6. Sterile cotton balls in steel drum 7. Sterile gauze pieces in steel drum 8. Sterile gauze pads 9. Sterile extra instruments in separate trey Total Score
Total Percentage = Total Score/9 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.7.4 Score
Annex 7.4: List of Minimum Services for Dressing and Routine Procedures
Categories
1. Simple dressing change 2. Skin Suture removals 4. Multiple wound requiring additional sterile gauzes 5. Large wound requiring paddings 6. Dressing change under LA 7. Burns up to 9% Total Score
Total Percentage = Total Score/7 X 100
Each row gets a score of 1 the mentioned service is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.7.6 Score
ANNEX 8: Surgical Services
Annex 8.1: Equipments and Instruments for OT
Standard
General Equipments for OT
Quantity
1. Wheel chair foldable, adult size 3. Patient trolley 4. OT table with stirrups 5. Wedge to position the patient 6. Mattresses w/ water proof cover 7. Pillows w/ water proof cover 9. Revolving Stool 12. Instrumental Trolley 14. Lamp operating, fixed 8 lamp unit 15. Lamp operating portable 16. Emergency Light 18. Wall clock that can be seen easily 19. Refrigerator/ cold box 21. Pump, suction, surgical, 200V, 2 bottles, w/access 22. Electrosurgical Cautery 23. Cardiac Monitor 24. Neonatal Radiant Warmer 26. BP apparatus (Non-Mercury) 28. Rectal Thermometer 29. Drums for gloves 30. Jar w/cover (for swabs) 31. Tourniquet, latex rubber, 75cm 32. Kidney Tray (600cc) 33. Dressing Tray 34. Cheattle Forceps w/jar, stainless steel 36. Appendectomy Set 39. Laprotomy set 40. Minor Surgery Set Total Score
Total Percentage = Total Score/40 X 100
Each row gets a score of 1 if the required standard quantity is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.8.1 Score

Annex 8.2: Medicines and Supplies for OT

Emergency Drugs (including neonates)
Standard Quantity for
1 patient
Calcium Gluconate (inj) 10ml X 2 ampules Magnesium sulphate (inj) Dextrose (25%) (inj) Adrenaline (inj.) Aminophyline (inj) Atropine sulphate (inj) Chloropheniramine Mephentine (inj) Ergometrine (inj) IV Fluids- Ringer Lactate / Normal Saline Hydralizine injection Total Score
Total Percentage = Total Score/19 X 100


Each row gets a score of 1 if the required standard quantity is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.8.2 Score

Annex 8.3: List of Minimum Surgical Procedures
Categories
1. Catheterization (Plain and Foley's) 3. POP + Immobilization 4. Breast Abscess Aspiration 5. Lumbar Puncture 6. Nasal Packing 7. Debridement wound 9. Skin suture <5cm size 10. Foreign body removal 11. Gastric lavage 12. Joint aspiration 1. POP and reduction 2. Excision of ganglion, lump, cyst, corn, lipoma under LA 3. Foreign body removal under LA 4. Debridement under LA 5. Cleaning and Dressing under sedation 6. Skin suture >5 stitches 7. Skin traction 8. Gallows traction 1. POP (Colle's, SC) 2. Tendon Repair 3. Chest Tube insertion 5. Amputation under LA and sedation 7. Ear Lobe Repair 8. Webbed finger repair 9. Volar flap repair 10. Debridement <20 % under sedation (Burn) 12. Repair of perineal tear 13. Marsupilisation 14. I +D under Ket (GA) Breast,Deep, Perineal 15. Reduction of dislocation under Ket (GA) plus sedation 16. Excision of cyst,lipoma, lump under GA 17. Tongue tie under Ket 18. Skeletal Traction 1. Obstructed hernia Repair 3. Debridement (burn) >20 % under Ket (GA) 4. Amputation (life saving) under GA 1. Explorative Laporotomy 2. Appendicectomy Total Score
Total Percentage = Total Score/45 X 100
Each row gets a score of 1 the mentioned service is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.8.3 Score
Annex 8.4: Furniture for OT
Standard
Furniture for OT
Quantity
Cabinets with glass for drugs/instruments Table for recording and reporting notes Total Score
Total Percentage = Total Score/4 X 100
Each row gets a score of 1 the standard quantity is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.8.4 Score
ANNEX 9: Anesthesia
Annex 9.1: Instruments and Equipments for Anesthesia
Standard Qty.
Oxford Miniature Vaporizer (OMV) Oxygen Attachment Kit Corrugated, Anti-static, Breathing tube/Anesthetic hose 105cm Breathing Tube Connectors, Male Breathing Tube Connectors, Female Pediatric Bellows Ambu E Valves (adults and child) Tool Kit (EMO and OMV) Anesthetic mobile Trolley, ss, 3 drawers, 2 trays, fitted with height adjustable twin hook loop and oxygen cylinder, electric lamp holder,960mmL X 500mm W X 1545mm H Anesthetic Face Masks  Rendall Backer (pediatric) size 0, 1, 2, 3  Clear "ohmeda" or "ambu size 0, 1, 2, 3, 4, 5  Black, antistatic size 3, 4, 5 Endotracheal tube (ETT) of different sizes Brushes for ETT (Small, Medium, Large) Magill Forceps (adult and child) Airways, reusable rubber sizes 0- 4 oral; 5-9 Nasal Bougie (adult and child) Oxygen Tubing (clear green) Spinal set (set of spinal needles 18 -25 gauge, small bowl, small 5 - 10 ml syringe needle, sponge holding forceps, kidney tray) Combined Pulse Oximeter/ECG monitor Oxygen cylinder with regulator and flow meter Electric pump suction, 220V Oxygen Concentrator Suction catheter (newborn Fr 10 or 12 size and adult 16 size) Laryngoscope set Total Score
Total Percentage = Total Score/27 X 100
Each row gets a score of 1 the standard quantity is available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.9.1 Score
Annex 9.2: Anesthetic Drugs and Emergency Drugs
Aluminum Hydroxide or Magnesium Trisilicate Injection Ranitidine Injection Metoclopropamide Atropine injection Bupivacaine 0.5% heavy Lidocaine 5% heavy Lidocaine 2% with adrenaline and plain Calcium Gluconate Ephedrine / Mephenteramine Sodium Bicarbonate Beta-Blockers ( Metoprolol, Labatolol) Promethazine HCL Total Score
Total Percentage = Total Score/26 X 100
Each row gets a score of 1 if the mentioned drugs are available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.9.2 Score
ANNEX 10: X-ray
List of X-ray supplies
Description
1. X-Ray Film and cassettes 8 x 10 2. X-Ray Film and cassettes 10 x 12 3. X-Ray Film and cassettes 12 x 15 4. X-Ray Developer 6. Magnetic Gown Total Score
Total Percentage = Total Score/6 X 100

Each row gets a score of 1 if the given supplies are available otherwise 0.
Scoring Chart
Total Percentage
Standard 7.10.1 Score
ANNEX 11: Central Sterile Supply Department (CSSD)
List of Equipments and Supplies
Required No.
1. Autoclave Machine 2. Working Table 3. Thermal Indicator Tape 7. Trolley for Transportation 9. Storage Shelves 11. Cap, Mask, Gown 13. Cotton Rolls 14. Cotton Gauze Total Score
Total Percentage = Total Score/15 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 8.1.3 Score
ANNEX 12: Laundry
List of Equipments and Supplies
Required No.
Stirrer (wooden) Cap, Mask, Gowns Trolley for Transportation Chlorine Solution Total Score
Total Percentage = Total Score/13 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 8.2.2 Score
ANNEX 13: Housekeeping
List of Supplies
General Items
Required No.
Housekeeping Storage Room Additional Bed Covers for Replacement Additional Pillow Window screens (jaali) Personal Protective Items Log Book for Records Working Table and Chair Total Score
Total Percentage = Total Score/26 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 8.3.1 Score
ANNEX 14: Safety and Security
List of Basic Amenities
General Items
List of Important Phone Numbers Fire extinguisher Total Score
Total Percentage = Total Score/6 X 100
Each row gets a score of 1 if all the mentioned items are available otherwise 0.
Scoring Chart
Total Percentage
Standard 8.7.5 Score
ANNEX 15: Hospital Canteen
List of Basic Amenities
General Items
Required No.
1. Dining Plate (Thaal) 2. Bowl (Kachaura) 6. Pressure cooker (5 liter and 3 liter) 7. Karai (2 with different sizes) 8. Bata (3 with different sizes) 9. Stove (Gas or Wood) - smokeless Buckets (3 with different sizes) Taps with running water facility Lighting system (Main line or Solar) Fire Extinguisher Dish washing place Total Score
Total Percentage = Total Score/26 X 100
Each row gets a score of 1 if all the required number is available otherwise 0.
Scoring Chart
Total Percentage
Standard 8.10.5 Score
Supported By
PO Box 8975 EPC 1813
Sanepa, Lalitpur, Nepal
T +977 1 5551978
F +977 1 5544179

Source: http://nsi.edu.np/web-images/Minimum_Service_Standards_March_18.pdf