Provide Quality Health Care Service in India & beyond, Only Aim to improve the Quality Health Care Service in India. Dr. J. L. Meena

1. How to achieve NABH “Process”
Standards in PHCs
Dr J L Meena
State Quality Assurance Officer
Department of Health & Family welfare
Government of Gujarat
Email:- drjlmeena@gmail.com
Web:- www.gujhealth.gov.in/quality-assurance-program.htm
149

2. SECTION – B:
Process Standards

3. 8. Access to the Facility
Objective Elements
• The facility should be easily assessable by
approachable all weather roads.
• There should be transport facility from main
road to the facility campus in case it is at
significant distance.
• Adequate sign posting to be available at various
strategic location so as to guide patients to the
facility.

4. The facility should be easily assessable by
approachable all weather roads.

5. There should be transport facility from main road to
the facility campus in case it is at significant
distance.

6. Adequate sign posting to be available at various
strategic location so as to guide patients to the
facility.

7. Objective Elements
• At least 1 medical officer and 1 nurse shall be
available at all times in the facility.
• 3 medical officers and 3 staff nurses shall be
available on-call on 24X7 basis.
• Staff shall attend to any emergency at all times
beyond the normal OPD or working hours.
• At least 1 staff member should be available at
all times to provide guidance or basic
information to the patients and their families.
9. Availability of Staff

8. At least 1 medical officer and 1 nurse shall be
available at all times in the facility.

9. 3 medical officers and 3 staff nurses shall be
available on-call on 24X7 basis.

10. Staff shall attend to any emergency at all times
beyond the normal OPD or working hours.

11. Exchange a few words with the clients
At least 1 staff member should be available at all times to
provide guidance or basic information to the patients and
their families.

12. • Facility should have Assistant Professor from
Medical College designated as its Radiological
Surveillance Officer.
• Facility should be guarded by Security
personnel 24X7.
• Available staff should be immunized and
insured for health / hospitalization.
9. Availability of Staff Cont…

13. Facility should have Assistant Professor
from Medical College designated as its
Radiological Surveillance Officer.

14. Facility should be guarded by Security personnel
24X7.

15. Available staff should be immunized and insured for
health / hospitalization.

16. Available staff should be immunized and insured for health / hospitalization.

17. Available staff should be immunized and insured for health /
hospitalization.

18. Objective Elements
• All patients to under go a unified assessment
with privacy and dignity.
• The nurse / ANM should carry out assessment
in terms of noting the vitals, height and weight
of the patient in a pre designated area of the
OPD card.
• Medical officer to documented the findings of
the patient in a definite area in the OPD card.
• Advise for medication and investigation to be
documented in predefined areas of the card.
10. Evaluation of the Patients

19. All patients to under go a unified assessment with
privacy and dignity.

20. The nurse / ANM should carry out assessment in terms of
noting the vitals, height and weight of the patient in a
pre designated area of the OPD card.

21. Medical officer to documented the findings of the
patient in a definite area in the OPD card.

22. Advise for medication and investigation to be
documented in predefined areas of the card.

23. • The documentation to be legible, timed,
dated, named and signed by the medical
officers.
• The instructions to be communicated to the
patient in an understandable (variable and
written) manner.
• The assessment of the patient is uniform in all
settings i.e. casualty, OPD, Wards etc.
• Records of all such assessments to be
maintained (for time limits as per regulations)
in the facility.
10. Evaluation of the Patients Cont…

24. The documentation to be legible, timed, dated,
named and signed by the medical officers.

25. The instructions to be communicated to the patient
in an understandable (variable and written)
manner.

26. The assessment of the patient is uniform in all
settings i.e. casualty, OPD, Wards etc.

27. Records of all such assessments to be maintained
(for time limits as per regulations) in the facility.

28. Records of all such assessments to be maintained
(for time limits as per regulations) in the facility.

29. Records of all such assessments to be maintained
(for time limits as per regulations) in the facility.

30. Objective Elements
• The staff should be courteous, humane and
empathetic.
• Care shall commensurate with the amenities
available.
• Care should be provided in manner in which
dignity and privacy of patient is maintained.
• Organization should have Care, Admission,
Referral and Discharge Policies.
• Organization should have written SOPs on care.
11. Care of Patients

31. The staff should be courteous, humane and
empathetic.

32. Care shall commensurate with the amenities
available.

33. Care should be provided in manner in which dignity
and privacy of patient is maintained.

34. Organization should have Care, Admission, Referral
and Discharge Policies.

35. Organization should have written SOPs on care.
Quality Manual
Infection Control
Manual
Policies and SPOs
Job charts of
employees
Disaster
Management
Manual
Forms and Formats

36. • Organization should have written Consent Policy.
• Care shall be comprehensive in nature i.e.
preventive, promotive, curative and
rehabilitative in nature.
• Documentation for all procedures carried out in
the facility to be mentioned in the case records.
• All the instruction by the medical officer to be
legible, dated, timed, named and signed.
• Patient admitted in the hospital to be evaluated
for their progress at least twice a day.
11. Care of Patients Cont…

37. Organization should have written Consent Policy.

38. Care shall be comprehensive in nature i.e.
preventive, promotive, curative and rehabilitative
in nature.

39. Documentation for all procedures carried out in the
facility to be mentioned in the case records.

40. All the instruction by the medical officer to be
legible, dated, timed, named and signed.

41. Patient admitted in the hospital to be evaluated for
their progress at least twice a day.

42. • Patient's condition to be communicated to the
family members.
• A discharge summary to be given to the
patients on their separation from hospital i.e.
discharge, LAMA, Referral.
• In case of death a death summary to be given
to the patients family.
• A general consent to be obtained for all
patients accepted in the facility.
11. Care of Patients Cont…

43. Patient's condition to be communicated to the family
members.

44. A discharge summary to be given to the patients on their
separation from hospital i.e. discharge, LAMA, Referral.

45. In case of death a death summary to be given to the
patients family.

46. A general consent to be obtained for all patients
accepted in the facility.

47. • An informed consent to be obtained for
patients undergoing any procedures.
• A list of procedures for which informed
consent to be obtained shall be available in
the facility.
• The consent for shall be in vernacular / local
language.
• Consent shall be obtained either by the
medical officer or the nurse.
11. Care of Patients Cont…

48. An informed consent to be obtained for patients
undergoing any procedures.

49. A list of procedures for which informed consent to
be obtained shall be available in the facility.

50. The consent for shall be in vernacular / local
language.

51. Consent shall be obtained either by the medical
officer or the nurse.

52. Objective Elements
• Organization should have written infection Control
Policy.
• Organization should have identified / ear marked
resources for infection control.
• Organization should have written protocols on cleaning
of the infection prone areas (OT, Wards and Labour
room) and equipments used in patient care.
• The center shall take all precautions to control
infection.
• Adherence to standard precautions to be maintained
by all staff.
12. Control of Infection

53. Organization should have written infection Control
Policy.
INDEX
S.
No
.
Contents Pa
ges
1. Responsibility for
implementation
4
2. Quality Core Group-IV
3. Amendment Sheets 5
4. Executive Summary
5. Part-I; General Information 7
6. Part-II; Infection control 9
7. Part-III; Bio-medical waste
handling and management
32
8. Part-IV; Sanitation, Hygiene
and potable water
39
9. Annexure 42

54. Organization should have identified / ear marked
resources for infection control.

55. Organization should have written protocols on cleaning of
the infection prone areas (OT, Wards and Labour room)
and equipments used in patient care.

56. The center shall take all precautions to control
infection.

57. Adherence to standard precautions to be maintained
by all staff.

58. • Mopping (by disinfectants) of all areas of the
center to be carried out at least twice a day.
• Carbolisation of the OT, Labour Room, Laboratory
to be carried out at least twice a day.
• Availability of running tap water for hand washing
of staff to be maintained 24 hours a day.
• The hospital environment to be kept clean from
litters, pest and stray animals.
• Adequate lighting arrangement and cross
ventilation to be present in all areas.
12. Control of Infection Cont…

59. Mopping (by disinfectants) of all areas of the center
to be carried out at least twice a day.

60. Carbolisation of the OT, Labour Room, Laboratory to
be carried out at least twice a day.

61. Availability of running tap water for hand washing of
staff to be maintained 24 hours a day.

62. The hospital environment to be kept clean from
litters, pest and stray animals.

63. Adequate lighting arrangement and cross ventilation
to be present in all areas.

64. • Sanitation of the toilets and hygiene of the staff to
be maintained.
• Adequate amount of bleaching lotion to be available
for disinfection purposes.
• The labour room, OT and ward areas to be washed
with soap and water regularly and a documentation
there of to be maintained.
• Autoclaving of all the instruments and linen uses in
the labour room, OT, dressing room to be done.
• Quality checks of the autoclave to be maintained by
using quick strips.
12. Control of Infection Cont…

65. Sanitation of the toilets and hygiene of the staff to
be maintained

66. Adequate amount of bleaching lotion to be available
for disinfection purposes

67. The labour room, OT and ward areas to be washed
with soap and water regularly and a
documentation there of to be maintained

68. Autoclaving of all the instruments and linen uses in
the labour room, OT, dressing room to be done

69. Quality checks of the autoclave to be maintained by
using quick strips.

70. Objective Elements
• Hospital waste generated shall be managed in
accordance with the Biomedical waste management
and handling rules 1998.
• General waste to be collected in Green bags.
• The yellow bags to be subjected to deep burial and a
pit for the same to be created with in the hospital
premise according to the dimensions specified by the
biomedical rules 1998.
• Facilities for syringe and needle distruction to be
available and practiced.
• Chemical treatment of plastics to be carried out by
using freshly prepared bleaching lotion.
13. Hospital Waste Management

71. S.no. Type of Waste Quantity
(Kg / day)
%
1 Infectious Waste
A Pathological & Anatomical 1.5 6
B Sharp including syringe 1 4
C Non Sharp waste 7.5 30
Total 10 40
2 General Waste
Total 15 60
Grand Total 25 100
Type of Biomedical Waste Generate 30 beds
Hospitals

72. Hospital waste generated shall be managed in
accordance with the Biomedical waste
management and handling rules 1998

73. General waste to be collected in Green bags.

74. General waste to be collected in Green bags.

75. The yellow bags to be subjected to deep burial and a
pit for the same to be created with in the hospital
premise according to the dimensions specified by
the biomedical rules 1998

76. The yellow bags to be subjected to deep burial and a
pit for the same to be created with in the hospital
premise according to the dimensions specified by
the biomedical rules 1998

77. Facilities for syringe and needle distraction to be
available and practiced

78. Chemical treatment of plastics to be carried out by
using freshly prepared bleaching lotion

80. • A site for composting of biodagradable waste to
be available with in the hospital premises.
• Annual report to be submitted to the competent
authority by 31st January every year.
• Accident spillage of waste shall be reported and
handled as per the BMW Guidelines.
• Segregation of wastes to be done in maximum of
3 bags (Black, Yellow & Blue).
• Organization should have resources to train all
health personnel on handling BMW as per
regulations.
13. Hospital Waste Management
Cont…

81. A site for composting of bio degradable waste to be
available with in the hospital premises.

82. Annual report to be submitted to the competent
authority by 31st January every year
ANNUALREPORT (FORM II)
(To be submitted to the prescribed authority by 31 January every year).
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
1 . Particulars of the applicant:
(i) Name of the authorized person( MO):-
(ii) Name of the institution:
Address
Tel. No
Fax No.
2. Categories of waste generated and quantity on a monthly average basis:
3. Brief details of the treatment facility:
In case of off-site facility:
Name & address of the operator
4. Category-wise quantity of waste treated:
5. Mode of treatment with details:
6. Any other information:
7. Certified that the above report is for the period from
Date .............TO..................
Place............... Signature
Date................ Designation

83. Annual report to be submitted to the competent
authority by 31st January every year

84. Accident spillage of waste shall be reported and
handled as per the BMW Guidelines

85. Accident spillage of waste shall be reported and
handled as per the BMW Guidelines

86. Accident spillage of waste shall be reported and
handled as per the BMW Guidelines
BIOMEDICALWASTE ACCIDENT REPORTING (FORM III)
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
1. Date and time of accident:-
2. Sequence of events leading to accident:-
3. The waste involved in accident :
4. Assessment of the effects of the accidents on human health
and the
environment:-
5. Emergency measures taken:-
6. Steps taken to alleviate the effects of accidents :-
7. Steps taken to prevent the recurrence of such an accident:-
Place............... Signature
Date................ Designation

87. Segregation of wastes to be done in maximum of 3
bags (Green, Yellow & Blue)

88. Organization should have resources to train all
health personnel on handling BMW as per
regulations.

89. Objective Elements
• The facility should have Reverse Osmosis (RO)
Plant.
• The center shall promote sanitation hygiene and
availability of potable water in the community by
involving the Panchayati Raj Institute (PRI).
• The center shall distribute chlorine tablets to the
community and educate them about their usage.
• The perils of open defecation to be informed to the
community.
14. Sanitation, Hygiene and Potable
Water

90. The facility should have Reverse Osmosis (RO) Plant.

91. The facility should have Reverse Osmosis (RO) Plant.

92. The center shall promote sanitation hygiene and
availability of potable water in the community by
involving the Panchayati Raj Institute (PRI).

93. The center shall distribute chlorine tablets to the
community and educate them about their usage.

94. The peril of open defecation to be informed to the
community.

95. • Creation of soak pit and trench lavatories to be
carried out by involving the PRI.
• Health education and maintenance of hygiene
to be done by adopting the principles of school
health and involving public opinion makers.
• A plan to combat disasters, epidemics in the
community shall be ready in the facility,
communicated to all concerned and rehearsed
at least twice a year.
14. Sanitation, Hygiene and Potable
Water Cont…

96. Creation of soak pit and trench lavatories to be
carried out by involving the PRI.

97. Health education and maintenance of hygiene to be
done by adopting the principles of school health
and involving public opinion makers.

98. A plan to combat disasters, epidemics in the
community shall be ready in the facility,
communicated to all concerned and rehearsed at
least twice a year.

99. Mock drill and training
PHC Mahuwas, Navsari

100. Mock drill and training
PHC Tankal, Kandolpada & Mahuwas, Navsari

101. Mock drill and training
PHC Tankal & Kandolpada Navsari

102. Mock drill and training
PHC Tankal, Navsari

103. Mock drill and training
DH Gandhinagar, Gandhinagar

104. Mock drill and training

105. Objective Elements
• The health workers and related staff to be
involved in counseling the community regarding
population stabilization, safe sex, hygiene, breast
feeding, anemia, nutrition, spacing of children,
Vitamin-A deficiency etc.
• Appropriate IEC tools to be available so as to
create awareness amongst the community for
availing the services of the center.
• Trust to be given for reproductive and child
health services.
15. Counseling and IEC

106. The health workers and related staff to be involved in counseling the
community regarding population stabilization, safe sex, hygiene,
breast feeding, anemia, nutrition, spacing of children, Vitamin-A
deficiency etc.

107. Appropriate IEC tools to be available so as to create
awareness amongst the community for availing
the services of the center.

108. Appropriate IEC tools to be available so as to create
awareness amongst the community for availing
the services of the center.

109. Appropriate IEC tools to be available so as to create
awareness amongst the community for availing
the services of the center.

110. Trust to be given for reproductive and child health
services

111. • Staff of the center to disseminate the plans
and programs (specific to the area) of the
Government by using all IEC tools available
e.g. posters, pamphlets, wall hangings,
paintings, audiovisual tools etc.
• Counseling shall also include knowledge about
HIV / AIDS and other communicable diseases.
• Organization should have policy of printing
"name & contact number of doctor" on the
cards (OPD & Discharge), IEC tools used.
15. Counseling and IEC Cont…

112. Staff of the center to disseminate the plans and programs (specific to
the area) of the Government by using all IEC tools available e.g.
posters, pamphlets, wall hangings, paintings, audiovisual tools etc.

113. Counseling shall also include knowledge about HIV /
AIDS and other communicable diseases

114. Organization should have policy of printing "name &
contact number of doctor" on the cards (OPD &
Discharge), IEC tools used

115. Objective Elements
• The organization shall give impetus to the
preventive aspect of health care.
• The staff (Doctors, Nurses, ANMs, LHVS,
Pharmacist, Health Educator, Health Assistants)
shall maintain open channels of communication
with the patients and their families.
• Immunization shall commensurate with the
universal immunization program.
• Expecting mothers to be given two doses of
tetanus immunization in their antenatal checkups.
16. Preventive Health

116. The organization shall give impetus to the preventive
aspect of health care.

117. The staff (Doctors, Nurses, ANMs, LHVS, Pharmacist,
Health Educator, Health Assistants) shall maintain
open channels of communication with the
patients and their families.

118. Immunization shall commensurate with the universal
immunization program

119. Expecting mothers to be given two doses of tetanus
immunization in their antenatal checkups.

121. • New borns to be immunized according to the
schedule and a card stating their immunization
status and growth pattern along with the mile
stones to be available with all parents.
• Field health workers shall educate about
adolescent health and life style management.
Organization should be involved in :
 Management of disease outbreaks-
identification, classification (water-borne,
vector-borne, vaccine ref-entable), incidence
reporting, investigation, data collation, analysis
and reporting.
16. Preventive Health Cont…

122. New borns to be immunized according to the
schedule and a card stating their immunization
status and growth pattern along with the mile
stones to be available with all parents

123. New borns to be immunized according to the schedule and a card
stating their immunization status and growth pattern along with
the mile stones to be available with all parents

124. Field health workers shall educate about adolescent
health and life style management

125. Management of disease outbreaks-identification, classification (water-
borne, vector-borne, vaccine ref-entable), incidence reporting,
investigation, data collation, analysis and reporting
“District Authority”.

126.  Water quality surveillance.
 Disaster mapping-identification,
preparedness (equipments, antidotes,
emergency care, referral services) and
networking.
• Organization should have identified resources
(equipments & drugs) for handling such
preventive programmes / actions.
16. Preventive Health Cont…

127. Water quality surveillance.

128. Disaster mapping-identification, preparedness
(equipments, antidotes, emergency care,
referral services) and networking.

129. Organization should have identified resources
(equipments & drugs) for handling such
preventive programmes / actions.

130. Objective Elements
• The center shall participate in all the National
Health programs as stated in IPHS.
• Community mobilization and their
participation to make the program successful
is responsibility of the center.
• Report of such program shall be submitted to
the authorities periodically by the MOIC.
17. Participation in National Health
Programs

131. The center shall participate in all the National Health
programs as stated in IPHS

132. Community mobilization and their participation to
make the program successful is responsibility of
the center

133. Report of such program shall be
submitted to the authorities
periodically by the MOIC.

134. 18. Referral Services
Objective Elements
• The center shall practice a bi-directional or
standardized referral system as per the policy.
• The referral cards (with contact numbers) according to
the colour coding to be available and a document
there of to be maintained.
• Patient shall be referred from the FRU / Sub-center or
referral to CHC or District Hospital.
• All such patient to be followed up for their profress by
the MOIC.
• Entries of the transferring in or out to be maintained in
register or the computer.

135. The center shall practice a bi-directional or
standardized referral system as per the policy

136. The referral cards (with contact numbers) according
to the colour coding to be available and a
document there of to be maintained

137. Patient shall be referred from the FRU / Sub-center
or referral to CHC or District Hospital

138. All such patient to be followed up for their progress
by the MOIC

139. Entries of the transferring in or out to be maintained
in register or the computer

140. Entries of the transferring in or out to be maintained
in register or the computer

141. 19. Community Mobilization with PRI
Objective Elements
• The organization shall have a continuous interaction
with the PRI.
• All meeting should be planned and that the agenda of
meeting should be area specific and / or as per the
requirements of the community.
• All meeting to be documented.
• Diseases profile along with seasonal variation to be
discussed and appropriate proactive intervention to be
planed.
• Gatekeeper approach in in mobilizing the community
shall be follow.

142. The organization shall have a continuous interaction
with the PRI “Gramsabha”

143. All meeting should be planned and that the agenda
of meeting should be area specific and / or as per
the requirements of the community

144. All meeting to be documented

145. Diseases profile along with seasonal variation to be
discussed and appropriate proactive intervention
to be planed

146. Gatekeeper approach in in mobilizing the community
shall be follow

147. 20. Social Responsibility
Objective Elements
• The center shall understand that it is an
integral part of the society.
• The center shall carry out camps, melas, and
healthy competitions etc. periodically.
• Respect to the senior citizens and active
participation in school health shall be
documented.

148. The center shall understand that it is an integral part
of the society

149. The center shall carry out camps, melas, and healthy
competitions etc. periodically

150. Respect to the senior citizens and active
participation in school health shall be
documented

151. Respect to the senior citizens and active
participation in school health shall be
documented

152. • Training to the community on household
remedies and first aid shall to be carried out
and documented.
• A sense of ownership of the facility by the
community to be created.
• Centre shall participate in all cultural activities
in the community.
20. Social Responsibility Cont…

153. Training to the community on household remedies
and first aid shall to be carried out and
documented

154. A sense of ownership of the facility by the
community to be created

155. Centre shall participate in all cultural activities in the
community

156. Health for All