nabh ,kayakalp , assessor, infection prevention & control.

1. Kayakalp- rejuvenation of
healthcare setup
Dr harshita
2019-nov

2. Assessment
Protocol

3. Assessment
Method
OBSERVATION
(OB)
STAFF
INTERVIEW(SI)
RECORD
REVIEW(RR)
PATIENT
INTERVIEW(PI)

4. Hospital
upkeep
Sanitation &
Hygiene
Support
Services.
Waste
Management
Infection
Control Hygiene promotions
100
100 100
100 50 50

5. Laund
ry Water
and
Sanitati
on
Kitchen
and
food
Securi
ty
outsou
rce

6. ThemeA–Hospital/ Facility
upkeep
Support Services

7. Pest& Animal
Control
Landscaping &
Gardening
Maintenance of
openarea
Hospital
Appearance
Illuminat
ion
Removalof Junk
Material
Water
Conservation
Maintenance of
Furniture&
Fixtures
Work Place
Management
Hospital
Upkeep
Theme
A
Infrastructure
Maintenance

8. • Records for preventive maintenance
programme for furniture and fixtures, at
least once in a year.
• Records for draft condemnation policy
(Document of draft policy)
• Records for quality of water supply in
the facility. (Document of water quality
report including parameters of quality
such as ph, TDS, hardness etc.)
• Record for cleaning of water tank at six
monthly intervals. (storage of water
tank with capacity to store 48 hours
water)
• 23. Record showing drinking water is
chlorinated with presence of free
chlorine at 0.2 ppm.
Hospital
upkeep

9. • Record of contract document for all out-
sourced services such as housekeeping,
BMW management, security etc. including
following details such as well-defined
deliverables, timeline for releasing payment
and penalty clause.
• Record for measuring the services provided
by the out-sourced organisation are
measured periodically and performance is
evaluated.
• Record for monitoring of cleaning activities
in the facility by local governance body at
pre-defined intervals.
• Record of a system to take feed- back from
patients and visitors for maintaining the
cleanliness of the facility.
• Record for dress code policy for all cadre of
staff. (Document of policy)
Cont…

10. ThemeB–Sanitation&
Hygiene

11. Clean
Circulationarea Clean
Wards
Clean
procedure area
Clean
Ambulatory area
Clean
Toilets
Standard
methods for
cleaning
Monitoring of
cleanliness
activities
Drainage and
sewage
management
Sanitation
&
Hygiene
Theme
B
CleanAuxiliary
areas
Standard
material and
equipment for
cleaning

12. Department responsible :
•
• Record for designated staff to
monitor housekeeping activities.
(Document of housekeeping
checklist with supervisor’s signature)
• Records of housekeeping to check
frequency of cleaning in corridors in
a day with wet mop.
• Records of housekeeping to check
corridors are rigorously cleaned with
scrubbing/flooding in a month.
• Records of housekeeping to check
frequency of cleaning in OT/Labour
room floors and procedures surfaces
in a day.
• Records of housekeeping to check
frequency of cleaning of floors,
walls, furniture, sinks and cisterns,
drains and in a week.
HOUSEKEEPING

13. • Records of consumption of
detergent disinfectant and its
concentration of
solution/Hospital Grade Phenyl
for cleaning purpose.
• Records of stock to check for
adequacy of the supply of
carbolic Acid/Bacilocid for
surface cleaning in procedure
areas - OT, Labour room.
(record of inventory)
• 11. Records of feedback from
cleaning staff about efficacy of
the solution.
Cont..

14. • Records for documenting Standard
Operating Procedures (SOP) for
Cleanliness and Upkeep of Facility.
• Records of housekeeping checklists
to check frequency of updating it in
a toilet in a day/month, patient Care
Ares such as OPd, IPd, Lab,Labour
room, OT dressing room etc.
• Record of stock to check for supply
of Sodium Hypochlorite Solution
(record of inventory)
Cont..

15. Store incharge
10. Records of stock to check
for adequacy of the supply of
Buckets and carts for
Mopping. (records of
inventory)
13. Records of stock during
last one year in term of
demand and availability of
linen. (records of inventory)
Linen manager

16. THEME-C

17. Segregation
Collection &
transportation
Sharp
Management
Storage of
BMW
Manageme
nt of
hazardous
waste
Liquid
waste
managem
ent
Equipment &
supplies of
BMW
Solid general
waste
management
Statuary
Compliances
Waste
Managem
ent
Theme
C
Disposal of
BMW

18. • Records to verify facility has a valid authorization
for Bio Medical waste (Colour scheme, Linkage
with CwTF or Approval for deep Burial pit and
‘On-site’ pre-treatment of laboratory waste
before handling over to the CTF operator)
Management from the prescribed authority.
(Authorization document from prescribed
authority with validity)
• Records for procurement of Bar coded bags &
containers, Non- chlorinated bags, development
of website and uploading of Annual report and
minutes for meeting emission standards as given
in BMW rules 2016.
• Record to check the existing committee or newly
constituted committee review and monitor
• BMW management at dH/CHC level. (Minutes of
meeting of all the meetings conducted in a year
and document of BMW status reviewed)
Biomedical
waste

19. • Record of autoclaving/microwave/
of Broken/discarded Glassware.
• Record of disinfected Glassware is
stored in a Cardboard with Blue
coloured marking and later sent for
recycling-old guideline
• Record for checking waste is
disposed/handed over to CTF
within 48 hour of generation.
• Record for recyclable waste
(catheter, syringes, gloves, IV
tubes, ryle's tube, etc.) is
shredded/mutilated after
treatment (options
autoclaving/microwave/
hydroclave) and then sent back to
registered recyclers- not doing so.

20. • Record for disposal of Expired or discarded
medicine is done as per protocol of sending
discarded medicines back to manufacturer or
disposed by incineration (Contract document with
manufacturer mentioned with medicine expiry
return clause, incineration record)
• Record for discarded linen, mattresses & bedding
contaminated with blood or body fluid is done as
per protocol of disinfection by non-chlorinated
disinfection (Hydrogen Peroxide)followed by
incineration/shredding/mutilated-record
• Record of stock to check for supply of one set of
bins and liners of appropriate size for segregated
collection of waste at point of use. (record of
inventory)

21. •
• Record of submitting reports to the
prescribed authority on or before 30th
June every year. (Annual report to
pollution control board)
• Record for review and monitoring of
BMW Management through an existing
committee or by forming a new
committee.
a. Office order for constitution of
committee or its review by existing
committee- Quality Committee/
infection control committee
b. Frequency of committee meetings - at
least 6 monthly
c. Minutes of meetings)

22. • 17. Record for maintaining
facility’s website and
annual report under BMW
rules 2016 is uploaded.
• 21. Record for Common
Treatment facility (CTF)
within 75 KM of Health
facility for disposal of Bio
medical waste. (Contract
document between Health
facility & CTF)

23. ThemeD–Infection
Control

24. D1Hand
Hygiene
D2:
Personal
Protectiv
e
Equipme
nt
D3: Personal
Protective
Practices
D4:
Decontaminatio
n & cleaning of
instruments
D5:
Disinfection
and
sterilization
of
instruments

25. D6: Spill
managem
ent.
D7: Isolation
and Barrier
Nursing.
D8:
Infection
Control
Program
D9: Hospital
Acquired
infection
surveillance
D10:
Environme
ntal
Control.

26. • Record for Yearly Health Check-up of all
BMW handlers, food handlers and
housekeeping staff. (Staff health record
document)
• Record for Immunisation records of all
BMW handlers (Staff immunisation record
document)
• Record for Immunization of device providers
against Hepatitis B (Staff immunisation
record document)
• Record for Infection Control Committee is
constituted and functional (minutes of the
meeting)
• Record for documented Anti biotic policy in
the facility. (Document of policy)
• Record for microbiological surveillance of
procedure areas like OT, Labour room, ICU,
SNCU etc.
•
Infection
prevention and
control team

27. • Record for measuring Healthcare
Associated Infection (HAI) rates
in the facility.
• Record for corrective Action on
occurrence of HAIs in the facility
• Records of operations of
Autoclave and other equipment
for last five years.
• Record for bacteriological
examination of water tested
periodically.
• Records for autoclaving for use
of sterilization indicators (Signal
Locks).
Cont…

28. • Records for cleanliness and
infection control committee that
includes representation of all
cadre of staff including Group ‘d’
and cleanings staff.
• Record of any cleanliness drive
conducted in the facility on
weekly basis. (Document of
minutes of meeting and
monitoring activities)
• Record for training need
assessment regarding
cleanliness and infection control
in the facility
Cont..

29. • Record of training
programme on Bio medical
waste Management training
provided to the staff.
• Record of training
programme on Infection
control training provided to
the staff.
• Records for documenting
Standard Operating
Procedures (SOP) for Bio-
Medical waste management
and Infection Control.
Cont…

30. • Records of reporting of Needle Stick
Injury case, PEP, and follow-up available
to the staff.
• Records for disposal of radiographic
developer and Fixer to the authorized
agency. (Contract document with name
of agency, name of the facility,
authoritative signature etc.)
• Records of stock to check for adequacy
of the supply Personal Protective
Equipment (PPE) (records of inventory)
• Record of protocol for managing
discarded samples in the laboratory.
(Copy of protocol document)
Cont..
laboratory

31. ThemeE-Hygiene
Promotion