The document provides a self-assessment toolkit for evaluating an organization's compliance with various healthcare standards. It outlines the scoring criteria for the self-assessment report, with a score of 10 for full compliance, 5 for partial compliance, 0 for non-compliance, and NA for not applicable. The evaluation will consider whether any standard received a zero score, if the average score per standard is at least 5 and per chapter at least 7, and if the overall average score exceeds 7. The toolkit then lists sample standards within chapters on access, assessment and continuity of care for the organization to self-assess.

1. Self Assessment Toolkit
Compliance to the requirement: 10
Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying out of total samples selected)
Non-compliance to the requirement: 0
Not Applicable: NA
Evaluation Criteria during final assessment:
Organisation is required to provide self assessment report in the format 'Self Assessment Toolkit' given below. All the entries are to be properly
filled up. Regarding scoring following criteria would be applicable.
• No individual standard should have more than one zero to qualify. However, no zero is accepted in the regulatory/ legal requirements.
• The average score for individual standard must not be less than 5.
• The average score for individual chapter must not be less than 7.
• The overall average score for all standards must exceed 7.

2. SELF ASSESSMENT TOOLKIT
Elements
a
b
c The defined healthcare services are prominently displayed.
d The staff are oriented to these services.
a
b
c A unique identification number is generated at the end of registration.
d Patients are accepted only if the organisation can provide the required service.
e
f
Documentation
(Yes/ No)
Implementation
(Yes/ No)
Evidence
(cross reference to
documents/
manuals etc.)
Scores
(0/ 5/ 10)
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF
CARE (AAC)
AAC.1: The organisation defines and displays the healthcare services that it
provides.
The healthcare services being provided are clearly defined and are in consonance
with the needs of the community.
Each defined service should have appropriate diagnostics and treatment facilities
with suitably qualified personnel who provide out-patient, in-patient and
emergency cover.
AAC.2: The organisation has a well-defined registration and admission
process.
Documented policies and procedures are used for registering and admitting
patients. *
The documented procedures address out-patients, in-patients and emergency
patients. *
The documented policies and procedures also address managing patients during
non-availability of beds. *
Access to the healthcare services in the organisation is prioritised according to the
clinical needs of the patient.