DISTRICT

HOSPITAL GAP ANALYSIS REPORT

HARDOI

Submitted By:

G -27,Lower Ground, Kailash Colony

New Delhi (India) - 110048
Telefax: +91-11-41658335
 FOREWORD

Gap Analysis is the first step towards implementing a Quality Management System in an
organization. It involves mapping the “as is” vis a vis comparing to the “to be”.
However the process intends to find the gaps in the Structure, Process and Outcomes in a
hospital like organization.
In the context of conducting a Gap Analysis of 117 district hospitals in the state of Uttar Pradesh,
our endeavor is to find out the Gaps in the context of NABH Accreditation in the land, building,
equipments, manpower, licenses, relevant hospital processes and their outcomes.
The exercise is being carried out by experienced hospital and healthcare managers who are
trained in the subject and have a proven track record in the same.
.

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 ACKNOWLEDGEMENT

The Gap Analysis Study in District Hospital Hardoi,(Uttar Pradesh)has been successfully
conducted. It was an outcome of the dedicated& collective initiative of Uttar Pradesh Health
Systems Strengthening Project (UPHSSP) and the Government of UP.

Our gratitude to the Project Director and his team in UPHSSP for initiating this wonderful
effort

The team of Octavo Solutions Pvt. Ltd., New Delhi wants to express their profound thanks to all
the distinguished leaders in the District Hospital Hardoi who provided their untiring support in
facilitating and guiding our team in the process of the gap analysis study.

The courtesy extended by Dr. P.N. Singh (CMS), District Hospital Hardoi needs to be
appreciated. It was his leadership that enabled our team to complete the study within the
specified time.

Lastly, we express our gratitude to all those, whose name has not been mentioned but who
contributed at any point towards the successful completion of the gap analysis study.

DH-HARDOI
 INDEX
1. LIST OF ABBREVIATIONS ........................................................................................ 6

2. EXECUTIVE SUMMARY ............................................................................................. 7

3. AIM AND OBJECTIVES ............................................................................................. 9

4. SCOPE AND APPROACH ........................................................................................... 9

5. HOSPITAL INTRODUCTION .................................................................................... 10

6. KEY INDICATORS ................................................................................................. 11

7. SIGNAGE SYSTEM ................................................................................................ 12

8. STATUTORY REQUIREMENTS ................................................................................. 13

9. BED DISTRIBUTION .............................................................................................. 13

10. STRUCTURAL DETAILS ........................................................................................ 14

11. DEPARTMENTAL GAPS ......................................................................................... 15

11.1 EMERGENCY .................................................................................................. 15

11.2 AMBULANCE .................................................................................................. 17
11.3 OPD ............................................................................................................. 17
11.4 LABORATORY................................................................................................. 19
11.5RADIOLOGY& IMAGING.................................................................................... 21
11.6 WARDS ......................................................................................................... 22
11.7 ICU .............................................................................................................. 24
11.8 OT ............................................................................................................... 28
11. 9 BLOOD BANK ............................................................................................... 30
11. 10 PHARMACY ................................................................................................. 32
11. 11 BIOMEDICAL WASTE MANAGEMENT ............................................................... 33
11. 12 HOSPITAL INFECTION CONTROL ................................................................... 34
11. 13 CSSD ......................................................................................................... 36
11. 14 BIOMEDICAL ENGINEERING ......................................................................... 37
11. 15 ENGINEERING AND MAINTENANCE ................................................................ 38
11. 16 STORE ...................................................................................................... 40
11. 17 KITCHEN/DIETARY...................................................................................... 41
11.18 HUMAN RESOURCE ...................................................................................... 42
11.19 MEDICAL RECORDS DEPARTMENT .................................................................. 43
11.20 LINEN/LAUNDRY ......................................................................................... 45
11. 21 HOUSEKEEPING .......................................................................................... 46
11. 22 SECURITY ................................................................................................... 47
11.23 MORTUARY .................................................................................................. 47

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12. EQUIPMENT ....................................................................................................... 48

13. MANPOWER ....................................................................................................... 53

14. PERSONS INTERACTED DURING DATA COLLECTION ............................................... 57

15. RECOMMENDATIONS ........................................................................................... 58

Annexure-

1. Score Sheet
2. Cost sheet
3. Lay out
4. Pictorial Evidences
5. Time Bound Action Plan (TBAP)

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1. LIST OF ABBREVIATIONS

Abbreviations Full Form

ABC Always Better Control
AERB Atomic Energy Regulatory Board
ALS Advance Life Support
ADR Adverse Drug Reaction
BLS Basic Life Support
BMW Bio Medical Waste
BMWM Bio Medical Waste Management
BME Bio-Medical Engineer
CSSD Central Sterile Supply Department
CT Scan Computerized Tomography Scan
CPR Cardio Pulmonary Resuscitation
ECG Electro Cardiogram
EQAS External Quality Assurance System
FIFO First In First Out
GRN Good Receipt Note
HAI Hospital Acquired Infection
HCO Health Care Organization
HVAC Heat, Ventilation, Air condition
ICU Intensive Care Unit
IPD In Patient Department
IPHS Indian Public Health Standards
MLC Medico Legal Cases
NABH National Accreditation Board for Hospitals and Healthcare Providers
OPD Out Patient Department
OT Operation Theatre
PPE Ppersonal Protective Equipments
RSO Radiation Safety Officer
TSSU Theatre Sterile Supply Unit
USG Ultra-Sonography
VED Vital Essential Desirable

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2. EXECUTIVE SUMMARY

Gap Analysis is a tool to analyse the degree of compliance to any standard. Herein, this
assignment the given district hospitals are analysed with reference to the NABH Standard (3 rd
edition).

UPHSSP under the aegis of World Bank has taken a step in the right direction to assess the
current level of quality adhered by the district hospitals in delivering healthcare services to the
community, in the state of Uttar Pradesh.

This assignment would guide the State in understanding the existing deficiencies/gaps in
healthcare delivery services thereby enabling the policy makers to formulate a strategy to fulfil
such deficiencies/gaps and strive towards further improvement.

The Octavo Solutions Private Limited, New Delhi has put all efforts to ensure that all
components with respect to NABH Standard (3rd edition) are covered and relevant deficiencies
are accordingly addressed.

To conclude, the actions to be taken for compliance with the Accreditation standards of NABH
(3rd edition) at District Hospital Hardoi are likely to impact the delivery of healthcare services
positively, ensuring quality services, efficient outcomes with economy, risk management with
patients, staff and visitors safety and above all equity in healthcare services for all the citizens.

Major Findings:
The „Gap Analysis Report‟ includes assessment of documentation and implementation with
respect to Structure (Manpower, equipment, infrastructure and Statutory
requirements),Processes (Clinical & Administrative)and Outcome against NABH Standard (3 rd
edition).
Standardized and pre tested data collection and analysis tools have been used for the onsite
assessment and analysis. This includes all departments exist in the hospitals.

The whole report is prepared as under:

1. Scope of Services in District Hospital Hardoi.
2. Identifies the significant gaps in terms of Structure, Process and Outcome observed in
all the concerned areas.
3. The data on status of the existing Manpower, Equipment and Statutory requirements.
4. Any other data or information as deemed necessary.

DH-HARDOI
The key findings identified at District Hospital Hardoi are as follows:

1. Citizen charter and scope of services are not displayed.

2. Emergency drug list is not displayed in emergency department.

3. Fire extinguisher is not available in OT, MRD, and pharmacy store and in some wards.

4. Separate changing room for doctors and nurses is not available in OT.

5. Document regarding calibration/AMC of lab equipment is not available.

6. PPE is not used in radiology department as well radiation hazard symbol is not present.

7. Windows were not lead covered and opened while performing X-ray test.

8. Narcotic drugs were not in double lock system in pharmacy store.

9. Medicines were not kept in alphabetically manner in pharmacy store.

10. Temperature monitoring is not in practice in pharmacy store.

11. Seepage of walls in some areas i.e. OPD, MRD, OT, pharmacy store and in imaging
department.

12. HVAC is available in major OT but not functional.

13. Security guard system is not available round the clock in hospital campus.

14. Hospital‟s own ambulance facility is not functional.

15. Freezer is not available for dead bodies in mortuary facility.

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3. AIM AND OBJECTIVES

3.1 AIM:
To assess District Hospital Hardoi as per National Accreditation Board for Hospitals &
Healthcare Providers (NABH) standard.

3.2 OBJECTIVES:
 To assess the existing service delivery system
 To suggest alterations in Structural Designs of the facilities to meet the requirement
 To recommend on areas of improvement with defined Action Plan
 To provide an estimated cost required to overcome the deficiencies

4. SCOPE AND APPROACH

4.1 Scope:
 To assess the following aspects at the District Hospital Hardoi for their compliance
with NABH standard (3rd edition):
o Infrastructure
o Manpower
o Equipment
o Licenses
 To carry out a gap analysis between desired and existing level
 To suggest recommendations for streamlining the processes
 To develop further course of action which will lead to compliance with accreditation
standards of the NABH standard
 To plan the activities for action subsequent to the Gap analysis.

4.2 Approach:
 Collection of primary data and secondary data from the hospital for assessing the
Structure (civil work, manpower, equipment, licenses), Process (Policies and procedures)
and Outcome so that gaps can be identified.
 Structural works have been evaluated as per the minimum requirement of NABH.
 Manpower for the hospitals has been compared with the work load.
 Equipment gaps have been assessed on the basis of their utilization and available
standards and guidelines.
 The system and processes are assessed through inspection, interviews, discussions and
observations on ground using the NABH standards as a yardstick.

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5. HOSPITAL INTRODUCTION

SCOPE OF SERVICES
Sl. Name of Services/ Department Availability Remarks
No. (Yes/No/NA)
GROUP A – CLINICAL SERVICES
01 General Medicine Yes
02 Paediatrics Yes
03 Orthopaedics Yes
04 Ophthalmology Yes
05 Anaesthesiology Yes
06 General Surgery Yes
07 Dentistry Yes
08 ENT Yes
09 Dermatology No
GROUP B: CLINICAL SUPPORT SERVICES
10 Laboratory Yes
11 Radiology & Imaging Yes
12 Blood Bank Yes
13 Physiotherapy No
GROUP C: SUPPORT SERVICES
14 Pharmacy Yes
15 General Store Yes
16 Kitchen & Dietary Yes
17 Laundry Yes Out Sourced
18 CSSD No Autoclave available
19 Medical Records Yes
20 Ambulance & Transport Yes
21 Security Services No
22 Housekeeping Services Yes
23 Biomedical engineering No
24 Maintenance No AD to JE Level
25 Mortuary services Yes
GROUP D: ADMINISTRATIVE SERVICES
28 General Administration Yes
29 Account & Finance Yes

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6. KEY INDICATORS

INDICATORS August 2013 Sept 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014

IP Admissions 4556 4044 3894 3423 3735 3688

OPD 48140 50088 42128 38249 37253 34229

SURGERIES
92 85 149 96 163 100
(Minor)

SURGERIES
48 70 424 201 495 597
(Major)

X-RAYS 2294 2223 2006 2550 1616 2044

USG 168 139 178 164 146 181

LAB 6345 5804 5095 5039 4282 3653

DEATH 78 86 54 53 49 39

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7. SIGNAGE SYSTEM

Signage's Displayed Bilingual Pictorial Remarks

(Yes / No / (Yes / No / (Yes / No / (if any)
NA) NA) NA)

Citizen Charter No No NA

Mission No No NA

Vision No No NA

Patients Charter & Citizen Charter No No NA

Scope of Services Yes No NA

Tariff List Yes No NA

Doctors list along with their Yes No NA

Specialities and Qualifications

OPD Schedule of Doctors (Speciality, Yes No NA

Timings and Day of Availability)

Biohazard Symbols No No No

Fire Exit Plan No No No

Floor Directory Yes No NA

Wash Rooms (Differently Able) No No No

Toilets Yes No Yes

Ambulance Parking Area No No No

Drinking Water Yes No No

Health Education Related Signage Yes No Yes

(HIV & Immunization)

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8. STATUTORY REQUIREMENTS

Licenses Status Available

*(A / NA) YES/NO
Building Occupancy/Completion Certificate A No
Fire License A No
License under Bio- medical Management and handling Rules, 1998. A Yes
NOC for Air & Water from State Pollution Control Board A No
Excise permit to store Spirit. A No
Narcotics and Psychotropic substances Act and License. A No
Vehicle registration certificates for Ambulances. A Yes
Retail drug license (Pharmacy) A No
PNDT Certificate A Yes
Site & Type Approval for X-Ray from AERB A No
License for Blood Bank A Yes
Noise & Air pollution certificate for Diesel Generators A No
A = ApplicableNA = Not Applicable

9. BED DISTRIBUTION

Floor Class/Department Beds

Emergency Ward 26
Ortho Ward 20
Burn Ward 08
General Ward 18
T.B. Ward 06
Male Medical Ward 23
Ground Floor Male Surgical 25
Pvt Ward 04
Female Medical Ward 11
Female Surgical 10
ICCU 02
Children Medical 12
Eye Ward 20

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 Cardiac Ward 16
TOTAL 201

Note: Total number of sanctioned beds is 184 and functional beds is 201

10. STRUCTURAL DETAILS

Category
A. Land 12602.56 sq. meter

B. Building 9102.56 sq. meter

C. HVAC Availability of HVAC system Yes Yes/No

Number Capacity

D. Electricity
DG set 2 62.2 KVA
50 KVA
Inverters 11 600 VA each
Total Load Sanctioned 126.906 KVA
E. Water
Water Tanks (Overhead) 25000 litres
Sources of water Underground (boring)

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11. DEPARTMENTAL GAPS

11.1 EMERGENCY
Checklist for Emergency
S. No. Yes No Remarks
STRUCTURE
1. Whether the triage area is marked separately √
2. Does the Emergency department have a √
separate entrance?
3. Is the Emergency signage visible from the road √
with proper lighting and signs?
4. Is the doctor available round the clock for √
emergency care of patients?
5. Is there a nurse available round the clock for √
emergency care of patients?
6. Does the number of trolleys and wheelchairs
commensurate to the needs? √
7. Does the emergency room retain a list of all √
staff that contains Name, Contact details,
Designation?
8. Is Doctor‟s name and contact number kept √
posted at all times in the emergency room?
9. Is there an appropriate waiting area for the √
relatives of the patient?
10. An appropriately qualified staff member is √
scheduled to manage triage activities.
11. Is Emergency Crash Cart available? √
12. Defibrillator √
13. Cardiac Monitor √
14. Emergency drugs √
15. Resuscitation bags ( i.e. AMBU ) of various √
sizes
16. Oral Airways of various sizes √
17. Laryngoscope with various blades √
18. Laryngoscope replacement batteries and bulbs. √
19. Endotracheal tubes of various sizes. √
PROCESS
20. Is there a system to review all imaging by a √
radiologist within 24 hours

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 21. Ability to perform acute blood test and receive √
results within one hour for Arterial blood gases,
Full blood picture, urea and electrolytes,
plasma, glucose, Blood levels for common
overdose medication/agents, Coagulation
studies.
22. Security staffs are immediately available when √
required in the emergency room.
23. Electrical equipment (e.g. defibrillator) is √
charged at all times.
24. Is Crash cart checked daily regarding regular √
testing?
25. The documentation from a medico-legal and √
treatment view point is detailed, professional
and accurate.
26. Are the separate registers maintained for √
medico legal cases, discharge, admissions to
ward?
27. Is BMW segregated and handled properly. √
28. Is Triaging of the patients done? √
29. Does the initial assessment of the patient take √
place?
30. Are the patients attended by attendants when √
they come or when they are transferred to
wards?
31. Is staff trained in BLS/ACLS √
OUTCOME
32. Time for initial assessment of emergency √
patient

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11.2 AMBULANCE

Checklist for Ambulance

Sl.no Check points Yes No Remarks
STRUCTURE
1 Adequate communication system exists in
ambulance √
2 Required equipments (stethoscope,
sphygmomanometer, suction app, defibrillator,
monitor, oxygen cylinder) are available in the
ambulance.
√
3 Required medicines are available in the
ambulance. √
4 Is Vehicle license available? √
5 Is driver license present? √
6 Maintenance of the medical gas (oxygen) to 90%
of the total capacity.
√
7 Calibration of Equipments present
√
PROCESS
8 Is staff trained in BLS
√
9 Is Medication and equipment checklist
maintained
√
10
Is infection control practices followed √

11.3 OPD

Checklist for OPD

Sl. No. Check Points Yes No Remarks
STRUCTURE
1 Availability of enquiry counter √
2 Availability of registration counter √

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 Availability of separate queue for Differently
3 √
able.
Availability of designated waiting area with
4 √
adequate sitting arrangement
5 Availability of drinking water facility √
Availability of separate and functional toilet for
6 √
differently able.
7 Availability of fan & lights in waiting area √
8 Is the Scope of services displayed? √
9 Is citizen charter and Patient charter displayed √
Is list of doctors along with OPD Timings
10 √
displayed
11 Are the different OPD rooms numbered √
Is there provision of patient privacy in the
12 √
consultation room
13 Is BP apparatus with stethoscope present √
14 Is weighing machine present √
15 Is thermometer present √
Is calibration of BP apparatus, weighing
16 √
machine and thermometer
MANPOWER
17 Availability of dedicated registration clerk √
Availability of nurse to direct patients to
18 √
specific OPDs
PROCESS
19 Is UHID generated for all patients √
Is separate registration done for old and new
20 √
OPD patients
Is the tariff rates defined and made aware to the
21 √
patients/ attendant
Is patient privacy maintained during
22 √
consultation time
Is the staff aware of all the information like
23 √
Doctors OPD timings, charges etc.
OUTCOME
24 Monitoring of waiting time √
25 OPD patient satisfaction survey √

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11.4 LABORATORY

Checklist for Laboratory

Sl. NO Check points Yes No Remarks
STRUCTURE
1 Is laboratory present in hospital? ( In house/ √
outsourced)
2 Specify the functional units of laboratories present √
in the hospital
3 Is there continuous water supply to this unit? √

4 Is adequate drainage system present in this unit?

√

5 Is there provision for hand washing facility in this √

unit?
6 Is there provision of personal protective devices for
staff?(if yes mention the name) √

7 Is the staff licensed and competent in knowledge and

skill? √

8 Is there separate area available for sample

collection? √
9 Is pathologist available? √
10 Are BMW bins are present in the department?
√
11
Is there power back up facility available √
PROCESS
12 Is the scope of services defined √

13 Is maintenance of laboratory equipments done? √

14 Are laboratory equipments calibrated? √

Is laboratory staff aware about the safety precautions
while handling samples?
15 √

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 Is laboratory staff taking necessary precautions
while handling samples?
16 √
Is BMW segregation done as per BMW guidelines?

17 √
Is critical results defined, reported, and documented.

18 √
Is surveillance for lab test being carried out

19 √
Is EQAS being monitored
20 √
Laboratory reports are signed by Pathologist.
21 √
Is labeling of sample done?
22 √
Is time frame defined for dispatching lab reports?

23 √
Is turnaround time for lab reports monitored?

24 √
Is MOU available for outsourced tests All tests
are in
25 √ House.
Is temperature monitoring of refrigerator is done?

26 √
OUTCOME

27 Number of reporting errors per 1000 investigations √

% of reports having clinical correlation with

28 provisional diagnosis √

29 % of adherence to safety precautions √

30 % of redo's √

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11.5RADIOLOGY& IMAGING

Checklist for Radiology & Imaging

S. No. Check points Yes No Remarks

STRUCTURE

1 Is this unit has AERB (SITE/TYPE approval) √

Are basic facilities for staff present?
2 (toilet/drinking water/change room) √
Is the staff licensed and competent in knowledge
3 and skill? √
Is there a change room available for patients?
4 √
TLD badges available (Are they sufficient in
number)
5 √
Lead glass available (Are they sufficient in
6 number) √
Lead apron available (Are they sufficient in
number)
7 √
Gonad shield available (Are they sufficient in
number)
8 √
Thyroid shield available (Are they sufficient in
9 number) √
10 Is radiologist available? √
Is critical results defined, reported, and
11 documented. √
Radiation hazard symbol is present
12 √
PNDT license is available
13 √
PROCESS

14 Is maintenance of radiology equipments done? √

15 Are radiology equipments calibrated? √

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 Is radiology staff aware about the safety
16 precautions? √
Is radiology staff taking safety measures?
17 √
Quality Assurance program is followed or not
18 √
Radiology test requisition form is signed by
doctor.
19 √
Radiology reports are signed by Radiologist.
20 √
Is time frame defined for dispatching reports?
21 √
22 Is turnaround time for reports monitored? √
OUTCOME
Number of reporting errors per 1000
23 investigations √
% of reports having clinical correlation with
24 provisional diagnosis √
25 % of adherence to safety precautions √
26 % of redo's √

11.6 WARDS

Checklist for Ward Management

SL.NO Check points Yes No Remarks
STRUCTURE
1 Is Medical Gas Facility available in the √
ward?
2 Are basic facilities for staffs present (toilet/ √
drinking water)?
3 Is needle cutter present in each ward? √

4 Emergency crash cart is present in the √ Not in

ward? each ward
5 Color coded BMW bins are present in each √
ward?

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DH-HARDOI
 6 Is there a nursing station in the ward? √

7 Is there adequate number of nurses in each √

shift?
8 Racks are present to store linen? √ Not in
each ward
9 Wash basin is present in each ward. √

10 PPE is provided in each ward? √

PROCESS
11 Is staff aware of the admission process? √
12 Does the cleaning of the department take √
place?
13 Are the vitals of the patient checked every √
day?
14 Administration of medication is done by √
qualified nurse?
15 Indent of medicines and other items is √
placed by nurses regularly?
16 PPE is used by the nurses? √
17 Are the BMW segregated at the point of √
generation?
18 Does the nurse on duty record the details √
of the patient in the BHT on a daily basis?
19 Are the nurses trained in BLS(CPR) √
20 Is infection control practices being √
followed
21 Is bio medical waste management practice √
followed
22 Is the staff aware about transfer IN/OUT √
system
23 Is cost estimate for treatment provided to √
the patient/attendant
24 Is discharge process defined and √ Mentioned
documented? in register

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11.7 ICU

Intensive Care
Remark
Sr. No Yes No s
STRUCTURE
Is the required equipments available (Crash
cart, Defibrillator, oxygen cylinder, multi Para
monitors, central line connection, ventilator, pulse
1 oximeter, oxygen concentrator √
2 Qualified and trained nurses available √

3 Is air condition available √

4 Is fowler‟s bed available √

PROCESS

Are the admission and discharge criteria for

5 ICU and high dependency units defined? √
6 Is the staff trained to apply these criteria? √
Are the infection control practices
7 documented and followed? √
Is the quality assurance
8 programmedocumented and implemented? √
Procedures for situation of bed shortages are
9 defined and followed? √
Do the policies and procedures guide the care
10 of patients under restraints? √

11 Are the reasons for restraints documented? √

Is the patient under restrain frequently
12 monitored? √
Is the staff aware about the end of life care
13 policy? √
Are the policy for initial assessment and re-
assessment of patient documented and
14 present? √

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 Does the Initial assessment include screening
15 for nutritional needs? √

Is the time frame for doing and documenting

16 initial assessment defined? √
Is the frequency of reassessment defined and
17 followed by the staff? √

Does the documented policies and procedures

18 on uniform use of resuscitation present? √
19 Is the staff trained on resuscitation? √
Are the documented policies and procedures
for rational use of blood and blood products
20 available? √
Is the informed consent obtained before Only
donation and transfusion of blood and blood before
21 products? √ donation
Are the patient and family educated about
22 donation? √
Are the post transfusion reaction monitored
and analyzed for preventive and corrective
23 actions? √
Is the scope of pediatric services defined and
24 displayed? √
Does who care for children have age specific
25 competency? √
26 Is there a written order for the diet? √

Is the nutritional therapy planned and provided

27 in a collaborative manner? √

Are emergency medications available all the

time and replenished in a timely manner when
28 used? √

Are the medication orders written in a uniform

location and are clear, legible, dated, timed,
29 named and signed? √
Is a written order for high risk medication
30 done? √

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 Do the policies and procedures guide the
monitoring of patients after medication
31 administration? √

32 Is the medication administration documented? √

Is the policy for patient‟s medications brought

33 from outside the organization available? √
Knowledge to pick adverse drug events and
34 reporting of the same? √
Does the policy and procedure guide the use
of narcotic drugs and psychotropic
35 substances? √
Are the narcotic drugs stored in a safe
36 manner? √

Is a proper record kept for the usage,

37 administration and disposal of narcotic drugs? √
Is the antibiotic policy adhered and followed
38 by the staff? √

39 Is the infection control data collected? √

Availability of various HAI rates of that area
40 and action taken report? √
Is the layout of beds, its spacing, and visual
41 privacy appropriate? √
Are all the equipments periodically inspected
42 and calibrated? √
Service labels on Equipment and calibration
43 records present? √

Is the Information exchanged and documented

44 during transfers between units/departments? √

Documented procedures guide the referral of

45 patients to other departments/ specialties? √
Qualified individual identified as responsible
46 for the patient‟s care? √

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 Is a policy in place for LAMA patients and
47 patients being discharged on request? √
Is the policy for care of vulnerable patients
48 available? √
Does the organization provide a safe and
secure environment for the vulnerable
49 patients? √
Is the informed consent obtained by a surgeon
50 prior to the procedure? √

Are the instructions for proper hand washing

51 displayed and followed by the staff? √

Are the adequate PPE like gloves, masks

52 available and used by the staff? √

53 Isolation /Barrier nursing facility available? √

Is the Segregation of bio-medical waste done
54 as per the guidelines? √

55 Is the policy for obtaining consent present? √

Does the procedure describe who can give

consent when patient is incapable of
56 independent decision making? √

OUTCOME
1 Re intubation rate √
2 ICU utilization √

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11.8 OT

Checklist for Operation Theatre

S. No. Yes No Remarks
STRUCTURE
1 Is HVAC System present inside OT √
2 Is proper Zoning concept followed( Clean √
zone, protective zone, sterile zone, and
disposal zone)
3 Is the number of OT tables present in the √
hospital appropriate for the daily load

4 If any OT has got more than one OT table √

5 Does the OT have a hand washing facility √

6 Is the firefighting system available in the √

unit
7 Is continuous water available for the unit? √

8 Is the changing room available for the √

doctors and nurses
9 Is there a continuous power back up for OT √

10 Does the OT have a crash cart √

11 Does the OT have defibrillator √
12 Does the OT have an ECG monitor √
13 Does the OT have oxygen supply √
14 Does the OT have shadow less OT light √
15 Is the staff provided with the personnel √
protective devices
16 Is scrubbing area present for the OT staff √

PROCESS
17 Is the consent for the surgery and √
anesthesia taken from the patient
18 Is the OT list prepared √
19 Is the OT booking being done √

28

DH-HARDOI
 20 Is the preparation of patient done before √
the operation
21 Does the nurse enter the patient details √
in the OT register
22 Are the number of OT instruments √
counted before and after operation
23 Is OT disinfection done after every √
procedure
24 Is the pre anesthesia checkup done by √
the anesthetists
25 Is pre, intra, post-operative notes are √
documented
26 Is infection control practices being √
followed in OT
27 Is pre-operative checklist being √
followed
28 Is bio medical waste management √
practices being followed

OUTCOME
29 Is % of anesthesia related adverse events √
being monitored
30 % of anesthesia related mortality √
31 % of modification in plan of anesthesia √

32 % of unplanned ventilation following √

anesthesia
33 Is % of Surgical site infection rate √
monitored

34 Re Exploration rate √

35 Re scheduling of surgeries √

29

DH-HARDOI
11. 9 BLOOD BANK

Checklist for Blood Bank

Si. No Description Yes No Remarks

STRUCTURE
Is the required layout available: (Reception,
Not is
examination room, bleeding room,
1 √ refreshment
refreshment room, blood separation and
room
storage area and doctors room?)
2 Is power back up available √
A full time qualified Blood Bank In-charge
3 manages the blood collection/distribution √
department.
A couch/cot is provided during
venipuncture & the correct equipment for
4 √
blood agitation/ volume measurement is
present
Refrigerators, insulated carrier boxes with
ice pack, warmers, Bio mixers, Tube scale,
5 Component separator if applicable, √
Thawing bath, Centrifuge and freezers are
in adequate quantity
Blood bank signage and schedule of charges
6 √
are displayed

7 Blood Bank Technician is present √

8 Nurse is present √
9 All sections have bilingual signage √

10 Separate counseling section is present √

PROCESS
Is bilingual consent for blood donation
11 √
available
12 If patients are educated and given counseling. √

Donors are appropriately screened prior to

13 √
blood donation.

30

DH-HARDOI
 Evidence is present that blood is cross
14 matched, labeled, recipient identified, √
compatibility level noted, units dispensed.
Refrigerators, warmers and freezers must
15 have temperature monitoring devices which √
are monitored daily
A list of all department staff exist and is
16 √
prominently displayed
Is Policies and procedures for blood bank
17 √
available
Appropriate disposal of blood and blood
18 products are done as per BMW management √
rules
19 A blood collection/issue register exists. √

20 Is blood transfusion committee in existence √

Donated blood is labeled appropriately with
21 √
adhesive labels.
Register of all recipient adverse reactions to
22 √
blood and blood products are maintained
Data collected regarding recipient adverse
23 reactions is collated, analyzed and reported to √
the blood transfusion committee.
Work instructions are visibly displayed and
24 √
prominent
OUTCOME
25 % of transfusion reactions √

26 % of blood and blood products wastage √

27 % of component usage √
Turnaround time for issue of blood and blood
28 √
products.

31

DH-HARDOI
11. 10 PHARMACY

Checklist for Pharmacy

Si. No Description Yes No Remarks

STRUCTURE
The racks are available in sufficient
1 √
number to store the items
There is adequate ventilation and lighting
2 √
in the department
There is a security system available at the
3 √
department
Fire detecting & firefighting systems are
4 √
available at department
5 There is no water seepage/ dampness √
All items storage areas are marked and
6 √
labeled
There is a receiving area; segregation and
7 √
storing area
Is refrigerator for storing medicines(2-8
8 √
degree C) available
9 Is qualified and trained staff available √

Provision for storage of narcotic

10 √
drugs(double lock and key system)
PROCESS
The items are labeled &arranged as per
11 √
alphabetical order.
Pest/rodent control measures are regularly
12 √
under taken
13 Is stock register maintained properly √
Verification of stock is done every six
14 √
months.
Is sound Inventory control practices Only
15 √
followed (ABC, VED, FSN,FIFO) FIFO

32

DH-HARDOI
 General items required by the hospital are
16 purchased from vendors registered by √
management

Is there a Drugs and therapeutics

17 √
committee in the hospital?

18 Is hospital drug formulary available √

19 Is adverse drug reactions are analyzed √

OUTCOME
20 % of local purchase √
21 % of stock outs √
% of variation from the procurement
22 √
process
23 % of goods rejected before GRN √

11. 11 BIOMEDICAL WASTE MANAGEMENT

Checklist for Biomedical Waste Management

Sl.No Check Points Yes No Remarks
STRUCTURE
Availability of color coded Foot operated
1
Bins at point of BMW generation √
2 Availability of colored plastic bags √
Display of work instructions at the point
3
of segregation √
4 Is needle destroyer present √
Availability of PPE(Personal Protective
5 Equipments) with biomedical waste
handlers √
Availability of sodium hypochlorite
6
solution and puncture proof boxes √
7 Availability of safe mode of transportation √
8 Is Temporary storage area available √
PROCESS

33

DH-HARDOI
 9 Is segregation of BMW at point of generation √
Is the route for transportation of waste
10
separate from the general traffic area √
Is there provision of regular health checkup
11
for staff of this unit? √
12 Usage of PPE by staff is being practiced √
13 Is Annual report submitted to UP PCB √
Is monitoring done for the amount of BMW
14
generated √

11. 12 HOSPITAL INFECTION CONTROL

Audit Checklist for HIC

S.No Yes No Remarks
INFRASTRUCTURE
A designated and qualified infection control
1 nurse(s) is present? √
Adequate and appropriate facilities for hand
2 hygiene in all patient care areas Provided? √
Are adequate and appropriate personal
protective equipment, soaps, and
3 disinfectants available? √
A designated infection control officer is
4 present? √
PROCESS
Does the hospital implements policies and/or
5 procedures to prevent infection in these areas? √
Does the organization adhere to standard
6 precautions at all times? √
Equipment cleaning, disinfection and
7 sterilization practices as polices? √
An appropriate antibiotic policy is established
8 and implemented? √
Hospital adheres to laundry and linen
9 management processes? √
Hospital adheres to kitchen sanitation and
10 food handling issues? √
11 Does the hospital have appropriate √

34

DH-HARDOI
 engineering controls to prevent infections?
Does the hospital adhere to mortuary
12 practices? √
Is the infection prevention and control
13 programme updated at least once in a year? √
Is the HIC surveillance data collected
14 regularly? √
Is the Verification of data done on a regular
15 basis by the infection control team? √
In cases of notifiable diseases, information (in
relevant format) is sent to appropriate
16 authorities? √
Tracking and analyzing of infection risks,
17 rates and trends √
Do the surveillance activities include
monitoring the effectiveness of housekeeping
18 services? √
19 HAI rates monitored? √
Appropriate feedback regarding HAI rates
provided on a regular basis to appropriate
20 personnel? √
A hospital infection control committee and
21 team are formed? √
Are the personal protective equipment used
22 correctly by the staff? √
Compliance with hand hygiene guidelines
23 monitored? √
Documented procedure for identifying an
24 outbreak present? √
25 Implementation of laid down procedure done? √
Documented procedure guides the cleaning,
packing, disinfection and/or sterilization,
26 storing and issue of items? √
Isolation / barrier nursing facilities are
27 available? √
Appropriate personal protective equipment
28 used by the BMW handlers? √
Visit by the hospital authorities to the disposal
29 site done and documented? √
30 Does the hospital makes available resources √

35

DH-HARDOI
 required for the infection control programme
Does the organization earmarks adequate
funds from its annual budget for infection
31 control activities? √
Appropriate “in-service” training sessions for
32 all staff at least once in a year conducted? √
Appropriate pre and post exposure
prophylaxis is provided to all concerned
33 staff members? √
OUTCOME
34 UTI rate √
35 VAP rate √
36 SSI rate √
Central line associated blood stream
37 infection rate √

11. 13 CSSD
Checklist for CSSD / TSSU
SL.NO CHECK POINTS Yes No Remarks
STRUCTURE
1 Is sufficient space available(0.75sq Mtrs/bed) √

2 Does the layout follow the functional flow: √

Receiving, Washing, decontamination, drying,
packing, loading, unloading, storing and issuing?

3 Autoclaves are present? √

4 Calibration of pressure meter of autoclave is √
done?
5 Racks are present in the department? √

6 Technician is present in CSSD? √

7 Sterilizer drums are present? √
8 Is decontamination solution present? √

9 Transport trolley present for items? √

36

DH-HARDOI
 PROCESS
10 CSSD sterilization register present? √
(receipt/Issue)
11 Labeling of drums in CSSD takes place? √

12 Is chemical, biological and bowie-dick test

performed √
13 If recall system of items followed √
14 If reuse policy for items available √

11. 14 BIOMEDICAL ENGINEERING

This unit is not available in the hospital

Audit Checklist for Biomedical Equipment Management:

Equipment, Medical Gases, Vacuum System etc.
SR. No Yes No Remarks
INFRASTRUCTURE
Does bio medical engineering department
1 exist √
Does the department is managed by a
2 qualified person √
Is Central supply system for bio medical
3 gases exist √

4 Is Safety devices available √

5 Is the department manned by 24 hours √

PROCESS

6 Preventive maintenance and calibration √

Review of Preventive Maintenance record
as per checklist like Anesthesia ventilator,
7 IABP etc. √
8 Traceability of calibration report √
Is there a documented procedure for
9 equipment replacement and disposal? √

37

DH-HARDOI
 Equipments are inventoried and proper
10 logs are maintained as required. √
Training of staff when new equipment is
11 installed (HRM 3b) √
Documented Preventive and breakdown
12 maintenance plans √
13 Color coding of pipelines √
OUTCOME
14 % of downtime of critical equipments √

11. 15 ENGINEERING AND MAINTENANCE

Checklist for Facility Management: Engineering and Maintenance

SR. No Check points Yes No Remarks
STRUCTURE
Various statutory requirements
o Fire
o Diesel storage
o Liquid oxygen and storage of medical
cylinders.
o Boiler
o Lift
o Water (ETP/STP)
1 o Air (DG sets) √
Up to date drawing, layout, escape route
2 present and displayed? √

3 Various required signage‟s displayed? √

Designated individual for maintenance
4 present? √
Presence of staff round the clock for
5 emergency repairs √

6 Alternative source of water and electricity √

7 Availability of (personnel) safety devices √

38

DH-HARDOI
 Availability of safety devices (Fire
Only fire
extinguishers, smoke detectors, sprinklers,
extinguis
grab bars, side rails, nurse CCTV,
hers
8 ALARMS ETC) √
PROCESS
9 Mechanism for renewing licenses √
Preventive and break down maintenance
10 plan implemented? √

11 Alternate sources and their checking done? √

12 Response time monitored? √
13 Water quality reports √
14 Are staff using safety devices √
Facility inspection rounds twice a year in
patient care areas and once in non-patient
15 care areas √

16 Documentation of facility inspection report √

17 Safety education program for all staff √

18 Safety committee present √
Is staff trained for disaster management and
19 fire management √
Are the mock drills conducted at periodic
20 intervals and documented √
OUTCOME

Number of variations observed during mock

21 drills √

39

DH-HARDOI
11. 16 STORE

CHECKLIST FOR STORE

Si.
Description Yes No Remarks
No
STRUCTURE
The racks are available in sufficient
1 √
number to store the items
There is adequate ventilation and lighting
2 √
in the department
Is there a qualified/ trained personnel
3 √
available
Fire detecting &fire fighting systems are
4 √
available at department
There is no water seepage/ damp in the
5 √
store
There is a receiving area; segregation and
6 √
storing area
PROCESS
The items are labeled &arranged at
7 √
designated place.
Items such as radiographic films, spirits
8 etc (which are inflammable) are stored in √
a separate location.
Inventory recording system is present
9 √
either computerized or on register
Frequently used items are arranged and
10 √
located in most easily accessible area.
Pest/rodent control measures are regularly
11 √
under taken
Lead time in issuing material to the
12 √
department are recorded
Stock Turnover details are calculated on a
13 √
monthly basis.
If sound inventory control practices
14 √
followed (ABC/VED/FSN/FIFO)
15 Is condemnation policy followed? √

40

DH-HARDOI
 Is there a purchase and condemnation
16 √
committee in the hospital?
A comparative list of rates of potential
17 √
suppliers maintained
OUTCOME
18 % of stock outs √
% of goods rejected before preparation of
19 √
GRN
20 % of variation from procurement process √

11. 17 KITCHEN/DIETARY

Checklist for Kitchen/Dietary Services

Sl.
Evidence
No. Check Points Yes No
STRUCTURE
Does the layout follow the functional flow:
Receiving, storage, preparation,
1 distribution and cleaning? √
Is there continuous water supply (Hot/ Normal
2 Cold) to this unit? √ water
Is adequate drainage system present in this
3 unit? √
4 Is there DG power supply to this unit? √
Dedicated refrigeration areas exist to
5 ensure food preservation √
6 Is dedicated food storage area exist √
Are measures for fire detection/firefighting
7 installed in this unit? √
8 The person responsible for this department √
is a qualified dietician or has supervision
from a consultant dietician.
PROCESS
9 Health checkup of all staff is done at least √
once a year.
10 Record maintained for food materials √
11 If nutritional Assessment done for all the √

41

DH-HARDOI
 patients
12 Diet Sheet is prepared by Dietician as per √
the treating Doctors instruction on the
patient‟s case sheet.
13 Each patient‟s Case sheet are checked by √
doctor and dietician and changes made in
their diet depending on their condition
14 Food distribution to patients occurs in √
covered trolleys
15 Is infection control practices followed √

11.18 HUMAN RESOURCE

This unit is not available
CHECKLIST FOR HUMAN RESOURCE

S. No. Check Points Yes No Remarks

STRUCTURE
1 Is the HR department present √ Managed
by
Clerk
2 Are racks available to store the √
documents?
PROCESS
3 HR Manpower planning √

4 job description and specification √

5 HR recruitment √
6 HR induction and training √
7 HR record keeping √
8 HR welfare-staff & family √
9 Performance appraisal √
10 Disciplinary procedure √
11 Staff grievance redressal √ Not
documented

42

DH-HARDOI
12 Mention the types of forms available in this No specific
department? HR related
forms
available
13 If pre-employment health checkup and √
annual health checkup is being done

14 Is Training In-charge present in the √

hospital?
15 Is regular training conducted by the √
hospital?
16 Is credentialing and privileging of doctors √
and nurses being done
17 Are records of training being maintained? √

OUTCOME
18 Employee attrition rate is monitored? √

19 Is the employee absenteeism rate √

monitored
20 % of employee provided pre exposure √
prophylaxis

Is employee satisfaction survey being

21 done and analyzed? √
% of employee who are aware of
employee rights and responsibilities and
22 welfare schemes √

11.19 MEDICAL RECORDS DEPARTMENT

CHECKLIST FOR MEDICAL RECORDS DEPARTMENT

S. No. Check Points Yes No Remarks
STRUCTURE
1 Is the sufficient space for medical record √
department available
2 Is proper ventilation present in the √
department

43

DH-HARDOI
 3 Is the firefighting system available in the √
unit
4 Is qualified and trained MRD technician √
available in the department
5 Is table and chair provided to the MRD √
technician
6 Is adequate number of racks available for √
the storage of records
PROCESS
7 Is the functional flow at MRD : √
Receiving, assembling, deficiency check,
coding, indexing , filing, issuing
8 Is ICD coding method used for complete √
and incomplete files

9 Are the MLC cases/dead cases stored √

separately under lock and key
10 Is the retrieval of the records easy √

11 Is deficiency checklist is followed √

12 Is MRD Committee available? √

13 MRD audits is being conducted √

14 Are the records kept under lock √ only

MLC
15 If the hospital has retention policy for √
documents
16 Are the forms and formats standardized √

17 Is the destruction policy for records √

available
18 Is pest control done on a regular basis √

OUTCOME
19 Is number of births/deaths monitored √

20 Is number of diseases notified to the local √

authority

44

DH-HARDOI
 21 % of missing records √

22 % of records with ICD codification done √

23 Percentage of medical records not having
discharge summary √
24 Percentage of medical records not having
consent form √

11.20 LINEN/LAUNDRY
This unit is outsourced

Checklist for Linen and Laundry Management

S. No. Check points Yes No Remarks

STRUCTURE
Number of linens as per no of beds ( 3
1 sets) √
(If laundry services are in house) Is there
2 continuous water supply to this unit? √
(If laundry services are in house) Is
adequate drainage system present in this
3 unit? √
Is disinfectant available for infected linen?
4 Specify the name √
Separate covered trolley for transporting
5 dirty linen & washed linen available? √
Heavy duty rubber gloves, mask available
6 to the linen handlers √
PROCESS
Are linen items being replenished when
7 contaminated? √
8 Are linens are changed at least once daily? √
Segregation of soiled &contaminated
9 linen is being done √
Sluicing of soiled linen is being done?
(Specify location where sluicing is being
10 done – ward or laundry) √
Packing of the soiled &contaminated
11 linens in separate bags & labeling/color √

45

DH-HARDOI
 coding is being done

The number and type of linen handed over

12 is entered on the dirty linen register √
13 Linens are transported in covered trolley √
The number and type of linen handed over
to the laundry by the ward boy is entered
14 in laundry register. √
The clean linen is handed over to the ward
boy against the received sign of Ward boy
15 in the same laundry register. √
The ward boy is handing over the clean
linen to the nurse In charge in the ward
16 against the issue register. √
Disinfection of decontaminated linen
17 (Especially high risk areas) done √
Dirty linens & clean linens are stored in
18 separate areas √
Are they following hand washing
19 practices? √
Are they using disinfectant while washing Caustic
20 contaminated linens? √ soda
PPE are used by staff while handling
21 soiled linens? √

11. 21 HOUSEKEEPING

Checklist for Housekeeping Department

Name of the Hospital:
S. No. Check Points Yes No Remarks
STRUCTURE
1 Does the housekeeping being provided √
with the personal protective
equipment(dedicated
gown/slippers/masks/gloves/head cover)
2 Does the housekeeping staff have basic √
facilities like (toilet/drinking water/change
room)
PROCESS

46

DH-HARDOI
 3 Are the hand washing and floor washing √
agent being used?
4 Is the house keeping staff being trained in √
the infection control practices
5 Is staff using PPE √
6 Is daily cleaning schedule available √
7 Are the staff aware about the preparation √
of cleaning solutions
8 Is the pest control methods being practiced √
9 Is the medical examination of staff being √
done periodically

11. 22 SECURITY
This unit is not available in the hospital

11.23 MORTUARY

Checklist for Mortuary

Sl.
No. Check Points Yes No Remarks
STRUCTURE
1 Is this unit present in the hospital? √
2 Is freezer available for dead bodies √
3 Is calibration and maintenance is done
regularly √
4 Cold storage and back-up power available? √
5 Are measures for fire detection/firefighting
installed in this unit? √
PROCESS
6 Is temperature being regularly monitored √
Is there any process of infection control
7 followed √

47

DH-HARDOI
12. EQUIPMENT

Equipment Details For Gap Analysis

Area Equipments Quantity Functional Remarks
(nos) (Yes / No)
Radiology Ultrasound 2 Yes
X-Ray (Fixed) 4 Yes 3 not in use
due to
unavailabili
ty of
required
manpower
X-Ray Developing Tank 1 Yes
Safe Light X-Ray Dark Room 1 Yes
Cassettes X-Ray 30 Yes
Lead Apron 2 Yes
Gonad Shield 0 NA 1 Required
Thyroid Shield 0 NA 1 Required
TLD badges 0 NA 1 Required

NICU Baby Incubator 1 Yes

Phototherapy Unit 1 Yes
Emergency Resuscitation Kit Baby 1 Yes
Multipara monitors 0 NA 1 Required
Nebulizer Kit Baby 1 Yes
Weighing Machine Adult 2 Yes
Syringe Infusion Pump 1 Yes
Defibrillator 0 NA 1 Required
Infant Warmer/Resuscitation Unit 0 NA 1 Required
Pulse Oximeter With Paediatric 0 NA 1 Required
Sensor

Ear, Nose, Head Light Ordinary 1 Yes

Throat (ENT) Head Light (Cold Light ) 1 Yes
Tracheostomy Set 0 NA 1 Required

48

DH-HARDOI
 Tuning Tank 1 Yes

EYE Ophthalmoscope Direct 4 Yes, 3 1 non –

Functional functional
due to
break down
Slit Lamp 2 Yes
Vision Drum 2 Yes
IOL Open Set 5 Yes
Ophthalmic Surgical Instrument 5 Yes
Eye Microscopy 2 Yes, 1 1 non –
Functional functional
due to
break down

Dental Air Rotors 3 Yes, 2 1 non –

Functional functional
due to
break down
Dental Unit Motor 3 Yes

Laboratory Binocular Microscopy 1 Yes

Chemical Balance 1 Yes
Electric Calorimeter 1 Yes
Auto Analyser 1 Yes
Semi-Auto Analyser 1 Yes
Micro Pippetes of Different 5 Yes
Volume
Hot Air Oven 1 Yes
Lab Incubator 1 Yes
Electric Centrifugal Top 1 Yes
Counting Chamber 2 Yes
Glucometer 1 Yes
Haemoglobino meter 1 Yes
TC DC Count Apparatus 1 Yes
ESR Stand Tubes 5 Yes

49

DH-HARDOI
 Test Tubes Stand 10 Yes
Test Tubes Rack 6 Yes
Spirit Lamp 5 Yes
Alarm Clock 2 No Non-
functional
due to
break down
ELISA Reader Cum Washer 1 Yes
Electrolyte Analyser 1 Yes
Laboratory Autoclave 0 NA 1 Required

Operation
Theatre Operation Table Hydraulic 3 Yes
Operation Table Non Hydraulic 2 Yes
Field type
Shadow less Lamp Ceiling Type 4 Yes
Suction Apparatus 2 Yes
Apparatus trolley 2 Yes
Pulse oximeter 2 Yes
Cautery 1 Yes
Defibrillator 0 NA 1 Required
Boyel‟s Apparatus 2 Yes
Multipara Monitor 2 Yes
Diathermy 1 Yes
Crashcart 0 NA 1 Required

ICU ECG Machine 4 Yes, 2 2 non-

Functional functional
due to
break down
Multi-para Monitor 2 Yes, 1 1non
Functional functional
due to
break down
Defibrillators 1 Yes
Crashcart 1 Yes

50

DH-HARDOI
 Blood gas analyser 0 NA 1 Required
Ventilator 0 NA 1 Required
Syringe infusion pump 1 Yes
Blood / infusion warmer 0 NA 1 Required
Pulse oximeter 1 Yes
Glucometer 0 NA 1 Required
Suction Machine 2 Yes

Blood Bank Refrigerated centrifuge 2 Yes

Laminar air flow – clean zone unit 1 Yes
Blood bank refrigerator 2 Yes
Water bath shaker (thawing bath) 1 Yes
Blood warming / thawing bath 0 NA 1 Required
binocular microscope 2 Yes
Automated immunoassay analyser 0 NA 1 Required
Micro typing system (blood 2 Yes
grouping etc.)
HB analyser 1 Yes
Blood bag tube sealer 1 Yes
Blood collection monitor 2 Yes

Stethoscope 35 Yes
OPD Sphygmomanometer 24 Yes
X-ray View box 5 Yes
Thermometer 25 Yes
Weighing Machine (Adult) 40 Yes
Weighing Machine (Paed) 2 Yes
Screen 5 Yes

Stethoscope 12 Yes
Wards(Gen) Sphygmomanometer 12 Yes
X-ray View box 2 Yes
Thermometer 12 Yes

51

DH-HARDOI
 Weighing Machine 12 Yes
Crash Cart 2 Yes
Medicine/Dressing Trolley 6 Yes

Emergency ECG 1 Yes

Stethoscope 1 Yes
Sphygmomanometer 1 Yes
Thermometer 1 Yes
Pulse oximeter 1 Yes
Syringe pump 1 Yes
Crash cart 1 Yes
Defibrillator 0 NA 1 Required
Multipara monitor 0 NA 1 Required
Drug/Dressing Trolley 1 Yes
X-ray view box 0 NA 1 Required
Suction Apparatus 1 Yes
Nebulizer 1 Yes
Glucometer 1 Yes

52

DH-HARDOI
13. MANPOWER

Acceptable
Sl. Actual/
Designations Sanctioned norms by Deficit
No Available
NABH

DOCTORS
Chief Medical
Superintendent/
1 Equivalent 1 1 1 0
Medical Specialist
2 (General Medicine) 1 1 3 2
General Surgery
3 Specialists 2 2 2 0
4 Paediatrician 2 2 3 1
5 Anaesthesiologist 2 1 2 1
6 ENT Surgeon 1 1 1 0
7 Ophthalmologist 1 1 1 0
8 Orthopedician 2 2 2 0
9 Radiologist 2 2 1 +1
Pathologist & Blood
10 Bank In-charge 2 1 2 1

11 Medical Officer 0 1 14 13
12 Dental Surgeon 1 1 1 0

Inference- There is a requirement of 2 Medical specialist (Physician), 1 Paediatrician, 1

Anaesthesiologist, 1 Pathologist& 13 Medical officer(M.B.B.S)

NURSING STAFF
Matron/Nursing
1 Superintendent 1 1 1 0
Nursing In-charge
2 (sister) 2 8 9 1
3 Staff Nurse 23 14 113 99

Inference- There is a requirement of 1 Nursing In-charge&99 additional nurses to carry out

the nursing activities.

PARAMEDICAL STAFF

53

DH-HARDOI
 1 Dental Mechanic 1 1 1 0
Laboratory Technician
2 (Lab +BB) 3 3 7 4

3 Radiographer 0 0 3 3

4 ECG Technician 0 1 1 0

5 Optometrist 1 1 2 1

6 Ophthalmic Assistant 1 1 1 0

Inference- There is a requirement of, 4 Laboratory technicians, 3Radiographer & 1

Optometrist.

PHARMACIST

1 Pharmacist 11 8 7 +1

DRIVER

1 Driver 2 3 2 +1

KITCHEN
1 Dietician 0 0 1 1
2 Cook 3 1 3 2
3 Cook Bearer/ Kahar 1 1 3 2

Inference- There is a requirement of 1 Dietician, 2 Cook & 2 Cook bearers.

ADMINISTRATIVE
1 Office Superintendent 0 0 1 1
Accountant/Asst.
2 accountant 1 1 1 0
3 Office Clerk 2 4 3 +1
4 Registration Clerk 0 0 6 6
5 Store keeper 1 1 2 1

6 Housekeeping Supervisor 1 1 1 0
7 Sr. Assistants 1 1 1 0

Inference- There is a requirement of 1 Office Superintendent,6 Registration clerk& 1

54

DH-HARDOI
Storekeeper.

CLASS 4
1 Mali 1 1 1 0
2 Choukidar/ Security 3 2 20 18
3 Dhobi 2 1 2 1
4 Ward Boy 0 0 18 18
5 Ward Aaya 0 0 18 18
6 Sweepers 15 15 15 0
7 Electrician 0 0 1 1

Inference- There is a requirement of 18 Choukidar/ Security, 1 Dhobi,18 Ward Boy, 18 Ward

Aaya&1 Electrician.
**“As Project is outsourcing the services of Mali, Gardner, Cleaner and Housekeeping staff &
Security hence these are not required and post sanctioned if available can be managed
internally”

SUMMARY- MANPOWER REQUIREMENT

S No. Designation Required

Number
1. Medical specialist (Physician) 2

2. Paediatrician 1

3. Anaesthesiologist 1

4. Pathologist 1

5. Medical officer (MBBS) 13

6. Nursing In-charge 1

7. Staff nurses 99

8. Lab technician 4

9. Radiographer 3

10. Optometrist 1

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 11. Dietician 1

12. Cook 2

13. Cook bearer/ Kahar 2

14. Office Superintendent 1

15. Registration clerk 6

16. Storekeeper 1

17. Choukidar/ Security 18

18. Dhobi 1

19. Ward Boy 18

20. Ward Aaya 18

21. Electrician 1

However additional provision should be made for Microbiologist, Bio-Medical Engineer, RSO
(Radiation Safety Officer) and Plumber (one each) over as above the list provided they could
be contractual.

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14. PERSONS INTERACTED DURING DATA COLLECTION

Sr. Name Department Contact No.

No.
1 Dr. P.N. Singh CMS / Administration 09454685686
2 Dr Indrajeet Singh Imaging 09936449656
3 Mrs. Shanti Khare Pharmacy 07275124284
4 Mr.VijayTiwari Store 09415777821
5 Mr.Ramdas& Mrs Geeta Kitchen _
6 Mr Kamalesh MRD 09450577049
7 Mr B P Kanaujia Mortuary 08400844800
8 Mr Avadhesh JE _
9 Mr Aqeel Khan Lab+ Blood Bank 09450869897
10 Mrs Padmawati Singh OT 09838747833
11 Mr AvadhVihari General Admim. 09450420368
15. RECOMMENDATIONS

1. Citizen charter and scope of services must be displayed.

2. Emergency drug list is must be displayed in emergency department.

3. Fire extinguisher must be available in OT, MRD, and pharmacy store and in some wards.

4. Separate changing room for doctors and nurses should be available in OT.

5. Document regarding calibration/AMC of lab equipment must be maintained.

6. PPE must be used in radiology department as well radiation hazard symbol must be
clearly displayed.

7. Windows must be lead covered and should not be opened while performing X-ray test.

8. Narcotic drugs must be in double lock system in pharmacy store.

9. Medicines must be kept in alphabetically manner in pharmacy store.

10. Temperature monitoring should be in practice in pharmacy store.

11. There should not be seepage of walls in anywhere especially in OPD, MRD, pharmacy
store, OT and in imaging department.

12. HVAC must be functional if installed.

13. Security guard system must be available round the clock in hospital campus.

14. Hospital‟s own ambulance facility must be functional.

15. Freezer must be available for dead bodies in mortuary facility.

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