Tools for Cleanliness Assessment

Hospital Upkeep
Sanitation and Hygiene
Waste Management
Infection Control
Support Services
Hygiene Promotion

Vikaspedia

Hospital Upkeep

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A1.	Pest & Animal Control
A1.1	No stray animals within the facility premises	OB/SI	Observe for the presence of stray animals such as dogs, cats, cattle, pigs, etc. within the premises. Also discuss with the facility staff	.
A1.2	Cattle-trap is installed at the entrance	OB	Check at the entrance of facility that cattle trap has been provided. Also look at the breach, if any, in the boundary wall
A1.3	Pest Control Measures are implemented in the facility	SI/RR	Ask the facility administration about pest control measures to control rodents and insect. Check records of engaging a professional agency for the same	.
A1.4	Anti-termite Treatment of the wooden furniture and fixtures is undertaken periodically	RR/SI	Check if the facility has a scheduled programme for anti-termite treatment at least once in a year
A1.5	Measures for Mosquito free environment are in place	OB/SI /PI	Check for a. Usage of Mosquito nets by the patients b. Availability of adequate stock of Mosquito nets c. Wire Mesh in windows d. Desert Coolers (if in use) are cleaned regularly/ oil is sprinkled e. No water collection for mosquito breeding within the premise	.

A2.	Landscaping & Gardening
A2.1	Facility’s front area is landscaped	OB	Frontage of the facility has been maintained with grass beds, trees, Garden, etc. and it has an aesthetic appearance
A2.2	Green Areas/ Parks/ Open spaces are well maintained	OB	Check that wild vegetation does not exist. Shrubs and Trees are well maintained. Over grown branches of plans/ tree have been trimmed regularly. Dry leaves and green waste are removed on daily basis.
A2.3	Internal Roads, Pathways, waiting area, etc. are uneven and clean	OB	Check that pathways, corridors, courtyards, waiting area, etc. are clean and land landscaped.
A2.4	Gardens/ green area are secured with fence	OB	Barricades, fence, wire mesh, Railings, Gates, etc. have been provided for the green area.
A2.5	Provision of Herbal Garden	OB/SI	Check if the facility maintains a herbal garden for the medicinal plants

A3.	Maintenance of Open Areas
A3.1	There is no abandoned / dilapidated building within the premises	OB	Check for presence of any ‘abandoned building’ within the facility premises
A3.2	No water logging in open areas	OB	Check for water accumulation in open areas because of faulty drainage, leakage from the pipes, etc.
A3.3	No thoroughfare / general traffic in hospital premises	OB/SI	Check that the facility premises are not being used as ‘thoroughfare’ by the general public	.
A3.4	Open areas are well maintained	OB	Check that there is no over grown shrubs, weeds, grass, potholes, bumps etc. in open areas
A3.5	There is no unauthorised occupation within the facility, nor there is encroachment on Hospital land	OB/SI	Check for hospital premises and access road have not been encroached by the vendors, unauthorized shops/ occupation, etc.	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A4	Hospital Appearance
A4.1	Walls are well-plastered and painted	OB	Check that wall plaster is not chipped-off and the building is painted/ whitewashed in uniform colour and Paint has not faded away.	.
A4.2	Interior of patient care areas are plastered & painted	OB	Interior walls and roof of the outdoor and indoor area are plastered and painted in soothing colour. The Paint has not faded away
A4.3	Name of the hospital is prominently displayed at the entrance	OB	Name the Hospital is prominently displayed as per state’s policy and convenience of beneficiaries. The name board of the facility is well illuminated in night	.
A4.4	Uniform signage system in the Hospital	OB	All signages (directional & departmental) are in local language and follow uniform colour scheme.
A4.5	No unwanted/Outdated posters	OB	Check, facility’s external and internal walls are not studded with irrelevant and out dated posters, slogans, wall writings, graffiti, etc.	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A5	Infrastructure Maintenance
A5.1	Hospital Infrastructure is well maintained	OB	No major cracks, seepage, chipping plaster, chipped floors in the hospital	.
A5.2	Hospital has a system for periodic maintenance of infrastructure at pre-defined interval	SI/RR	Check the records for preventive maintenance of the building. It should be done at least annually
A5.3	Electric wiring and Fittings are maintained	OB	Check to ensure that there are no loose hanging wires, open or broken electricity panels,	.
A5.4	Hospital has intact boundary wall and functional gates at entry	RR/SI	Check that there is a proper boundary wall of adequate height without any breach. Wall is painted in uniform colour
A5.5	Hospital has adequate facility for parking of vehicles	OB	Check that there is a demarcated space for parking of the vehicles as well as for the Ambulances and vehicles are parked systematically	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A6	Illumination
A6.1	Adequate illumination in Circulation Area	OB	Check Adequate lighting arrangements through Natural Light or Electric Bulbs.	.
A6.2	Adequate illumination in Indoor Areas	OB	Check Adequate lighting arrangements through Natural Light or Electric Bulbs. The illumination should be 150-300 Lux at Nursing station and 100 Lux in the wards.
A6.3	Adequate illumination in Procedure Areas (Labour Room/ OT)	OB	Check Adequate lighting arrangements The illumination should be 300 Lux in procedure areas. Toilets should have at least 100 lux light.	.
A6.4	Adequate illumination in front of hospital and access road	RR/SI	Check hospital front, entry gate and access road are well illuminated
A6.5	Use of energy efficient bulbs	OB	Check hospital uses energy efficient bulb like CFL or LED for lighting purpose within the Hospital Premises	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A7	Maintenance of Furniture & Fixture
A7.1	Window and doors are maintained	OB	Check, if Window panes are intact, and provided with Grill/ Wire Meshwork. Doors are intact and painted /varnished	.
A7.2	Patient Beds & Mattresses are in good condition	OB	Check that Patient beds are not rusted and are painted. Mattresses are clean and not torn
A7.3	Trolleys, Stretchers, Wheel Chairs, etc. are well maintained	OB	Check Trolleys, Stretcher, wheel chairs are intact, painted and clean. Wheels of stretcher and wheel chair are aligned and properly lubricated	.
A7.4	Furniture at the nursing station, staff room, administrative office are maintained	OB	Check condition of furniture at nursing station, duty room, office, etc. The furniture is not broken, painted/polished and clean
A7.5	There is a system of preventive maintenance of furniture and fixtures	SI/RR	Check if hospital has any annual preventive maintenance programme for furniture and fixtures, at least once in a year.	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A8	Removal of Junk Material
A8.1	No junk material in patient Care areas	OB	Check if unused/ condemned articles, and outdated records are kept in the Nursing station, OPD clinics, wards, etc.	.
A8.2	No junk material in Open Areas and corridors	OB	Check, if unused/ condemned equipment, vehicles etc. are kept in the corridors, pathways, under the stairs, open areas, roof tops, balcony, etc.
A8.3	No junk material in critical service area	OB	Check if unused articles, and old records are kept in the Labour room, OT, Injection room, Dressing room etc.	.
A8.4	Hospital has demarcated space for keeping condemned junk material	OB/SI	Check availability of a demarcated & secured space for collecting and storing the junk material before its disposal
A8.5	Hospital has documented and implemented Condemnation policy	SI/RR	Check if Hospital has drafted their condemnation policy or have got one from the state. Check whether they are complying with it	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A9	Water Conservation
A9.1	Water supply is adequate in Quantity & Quality	OB/SI/RR	Check the quantity of water including reservoir and record of its quality	.
A9.2	Water supply system is maintained in the Hospital	OB	Check for leaking taps, pipes, over-flowing tanks and dysfunctional cisterns
A9.3	There is a system of periodical inspection for water wastage	OB	Check if staff have been assigned duty for periodical inspection of leaking taps, etc.	.
A9.4	Hospital promotes water conservation	SI/OB	Check if IEC is displayed for water conservation, and staff & users are made aware of its importance
A9.5	Hospital has a functional rain water harvesting system	OB/SI	Check if Hospital Infrastructure and drain system are fitted with rain water harvesting system with sufficient storage capacity	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
A10	Work Place Management
A10.1	Staff periodically sort useful and unnecessary articles at work station	SI/OB	Ask the staff, how frequently they sort and remove unnecessary articles from their work place like Nursing station, work bench, dispensing counter in Pharmacy, etc. Check for presence of unnecessary articles.
A10.2	The Staff arrange the useful articles, records in systematic manner	SI/OB	Check if drugs, instruments, Records are not lying in haphazard manner and kept near to point of use in arranged manner. The place has been demarcated for keeping different articles
A10.3	Staff label the articles in identifiable manner	SI/OB	Check that drugs, instruments, records, etc. are labelled for facilitating easy identification.	.
A10.4	Work stations are clean and free of dirt/dust	SI/OB	Check nursing station, dispensing counter, lab benches, etc. are clean and shining
A10.5	Staff has been trained for work place management	SI/RR	Check, if the facility staff has got any formal/hands on training for managing the workplace (e. g. 5’s’)	.

Sanitation and Hygiene

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B1.	Cleanliness of Circulation Area
B1.1	No dirt/Grease/Stains in the Circulation area	OB/SI	Check floors and walls of Corridors, Waiting area, stairs, roof top for any visible or tangible dirt, grease, stains, etc.	.
B1.2	No Cobwebs/Bird Nest/ Dust on walls and roofs of corridors	OB	Check roof, walls, corners of Corridors, Waiting area, stairs, roof top for any Cobweb, Bird Nest, etc.
B1.3	Corridors are cleaned at least twice in the day with wet mop	SI/RR	Ask cleaning staff about frequency of cleaning in a day. Verify with Housekeeping records	.
B1.4	Corridors are rigorously cleaned with scrubbing / flooding once in a mont	SI/RR	Ask the staff about cleaning schedule and activities
B1.5	Surfaces are conducive of effective cleaning	OB/SI /PI	Check surfaces are smooth enough for cleaning	.

B2.	Cleanliness of Wards
B2.1	No dirt/Grease/ Stains/ Garbage in wards	OB	Check floors and walls of indoor department for any visible or tangible dirt, grease, stains, etc.
B2.2	No Cobwebs/Bird Nest/ Dust/Seepage on walls and roofs of wards	OB	Check roof, corners of ward for any Cobweb, Bird Nest, Dust
B2.3	Wards are cleaned at least thrice in the day with wet mop	OB	Ask cleaning staff about frequency of cleaning in a day. Verify with the Housekeeping records
B2.4	Patient Furniture, Mattresses, Fixtures are without grease and dust	OB	Check for visible dirt, dust, grease etc. Check if the items are wiped/dusted daily
B2.5	Floors, walls, furniture and fixture are thoroughly cleaned once in a week.	OB/SI	Ask cleaning staff about frequency of cleaning in a day. Verify with Housekeeping records if available

B3.	Cleanliness of Procedure Areas
B3.1	No dirt/Grease/ Stains/ Garbage in Procedure Areas	OB	Check floors and walls of Labour room, OT, Dressing room for any visible or tangible dirt, grease, stains etc.
B3.2	No Cobwebs/Bird Nest/ Seepage on walls of OT & Labour Room	OB	Check roof, walls, corners of Labour Room, OT, Dressing Room for any Cobweb, Bird Nest, Seepage, etc.
B3.3	OT/Labour Room floors and procedures surfaces are cleaned at least twice a day / after every surgery	SI/RR I	Ask cleaning staff about frequency of cleaning in a day. Verify with Housekeeping records	.
B3.4	OT & Labour Room Tables are without grease, body fluid and dust	OB	Check Top, side and legs of OT Tables, Dressing Room Tables, Labour Room Tables for dirt, dried human tissue, body fluid etc
B3.5	Floors, walls, furniture and fixture are thoroughly cleaned once in a week.	SI/RR	Ask cleaning staff about frequency of cleaning day. Verify with Housekeeping records if available	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B4	Cleanliness of Ambulatory Area (OPD, Emergency, Lab)
B4.1	No dirt/Grease/Stains / Garbage in Ambulatory Area	OB	Check floors and walls of OPD, Emergency, Laboratory, Radiology for any visible or tangible dirt, grease, stains, etc.	.
B4.2	No Cobwebs/Bird Nest/ Seepage on walls and roofs of ambulatory area	OB	Check roof , walls, corners of OPD, Emergency, Laboratory, Radiology for any Cobweb, Bird Nest, Dust, Seepage, etc.
B4.3	Ambulatory Areas are cleaned at least thrice in the day with wet mop	SI/RR	Ask cleaning staff about frequency of cleaning in a day. Verify with Housekeeping records	.
B4.4	Furniture, & Fixtures are without grease and dust and cleaned daily	OB/SI	Observe and ask the staff about frequency for cleaning
B4.5	Floors, walls, furniture and fixture are thoroughly cleaned once in a week.	SI/RR	Ask staff about schedule of cleaning and verify with records	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B5	Cleanliness of Ambulatory Area (OPD, Emergency, Lab)
B5.1	No dirt/Grease/Stains / Garbage in Ambulatory Area	OB	Check floors and walls of OPD, Emergency, Laboratory, Radiology for any visible or tangible dirt, grease, stains, etc.	.
B5.2	No Cobwebs/Bird Nest/ Seepage on walls and roofs of ambulatory area	OB	Check roof , walls, corners of OPD, Emergency, Laboratory, Radiology for any Cobweb, Bird Nest, Dust, Seepage, etc.
B5.3	Auxiliary Areas are cleaned at least twice in the day with wet mop	SI/RR	Ask cleaning staff about frequency of cleaning in a day. Verify with Housekeeping records	.
B5.4	Furniture, & Fixtures are without grease and dust and cleaned daily	OB/SI	Observe and ask the staff about frequency for cleaning
B5.5	Floors, walls, furniture and fixture are thoroughly cleaned once in a week.	SI/RR	Ask staff about schedule of cleaning and verify with records	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B6	Cleanliness of Toilets
B6.1	No dirt/Grease/Stains/ Garbage in Toilets	OB	Check some of the toilets randomly in indoor and outdoor areas for any visible dirt, grease, stains, water accumulation in toilets	.
B6.2	No foul smell in the Toilets	OB	Check some of the toilets randomly in indoor and outdoor areas for foul smell
B6.3	Toilets have running water and functional cistern	OB	Ask cleaning staff to operate cistern and water taps	.
B6.4	Sinks and Cistern are cleaned every two hours or whenever required	SI/RR	Ask cleaning staff for frequency of cleaning and verify it with house keeping records
B6.5	Floors of Toilets are Dry	OB	Check some of the toilets randomly for floors are dry and without and residue water accumulation	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B7	Use of standards materials and Equipment for Cleaning
B7.1	Availability of Detergent Disinfectant solution / Hospital Grade Phenyl for Cleaning purpose	SI/OB/RR	Check for good quality Hospital cleaning solution preferably a ISI mark. Composition and concentration of solution is written on label. Check with cleaning staff if they are getting adequate supply. Verify the consumption records	.
B7.2	Cleaning staff uses correct concentration of cleaning solution	SI/RR	Check, if the cleaning staff is aware correct concentration and dilution method for preparing cleaning solution. Ask them to demonstrate. Verify it with the instruction given solution bottle.
B7.3	Availability of carbolic Acid/ Bacilocid for surface cleaning in procedure areas- OT, Labour Room	SI/RR	Check for adequacy of the supply. Verify with the records of stock outs, if any	.
B7.4	Availability of Buckets and carts for Mopping	SI/RR	Check if adequate numbers of Buckets and carts are available. General and critical areas should have separate bucket and carts.
B7.5	Availability of Cleaning Equipment	SI/OB	Check availability of mops, brooms, collection buckets etc. as per requirement. Hospital with a size of more than 300 beds should have mechanized mopping machine. .	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B8	Use of Standard Methods Cleaning
B8.1	Use of Three bucket system for cleaning	SI/OB	Check if cleaning staff uses three bucket system for cleaning. Only bucket for Cleaning solution, one for plain water and third one for wringing the mop. Ask the cleaning staff about the process	.
B8.2	Use unidirectional method and out word mopping	SI/OB	Ask cleaning staff to demonstrate the how they apply mop on floors. It should be in one direction without returning to the starting point. The mop should move from inner area to outer area of the room
B8.3	No use of brooms in patient care areas	SI/OB	Check if brooms are stored in patient care areas. Ask cleaning staff if they are using brooms for sweeping in wards, OT, Labour room. Brooms should not be used in patient care areas.	.
B8.4	Use of separate mops for critical and semi critical areas and procedures surface	SI/OB	Check if cleaning staff is using same mop for outer general areas and critical areas like OT labour room. The mops should not be shared between critical and general area. The clothes used for cleaning procedure surfaces like OT Table and Labour Room Tables should not be used for mopping the floors.
B8.5	Disinfection and washing of mops after every cleaning cycle	SI/OB	Check if cleaning staff disinfect, clean and dry the mop before using it for next cleaning cycle.	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B9	Monitoring of Cleanliness Activities
B9.1	Use of Housekeeping Checklist in Toilets	OB/RR	Check that Housekeeping Checklist is displayed in OPD, IPD, Lab, etc. Check Housekeeping records if checklists are daily updated for at least last one month	.
B9.2	Use of Housekeeping Checklist in Patient Care Areas	OB/RR	Check Housekeeping Checklist is displayed in Labour room, OT Dressing room etc. Check Housekeeping records if checklist are daily updated for at least last one month
B9.3	Use of Housekeeping Checklist in Procedure Areas	OB/RR	Use of Housekeeping Checklist in Procedure Areas .	.
B9.4	A person is designated for monitoring of Housekeeping Activities	SI/RR	Check if a staff-member from the hospital has been designated to monitor the housekeeping activities and verify them with counter sign on housekeeping checklist.
B9.5	Monitoring of adequacy and quality of material used for cleaning	SI/RR	Check if there is any system of monitoring that adequate concentration of disinfectant solution is used for cleaning. Hospital administration take feedback from cleaning staff about efficacy of the solution and take corrective action if it is not effective	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
B10	Drainage and Sewage Management
B10.1	Availability of closed drainage system	OB	Check if there is any open drain in the hospital premises. Hospital should have a closed drainage system. If, the hospital’s infrastructure is old and it is not possible create close draining system, the open drains should properly covered.
B10.2	Gradient of Drains is conducive for adequate for maintaining flow	SI/OB	Check if there is any open drain in the hospital premises. Hospital should have a closed drainage system. If, the hospital’s infrastructure is old and it is not possible create close draining system, the open drains should properly covered.
B10.3	Availability of connection with Municipal Sewage System/ Or Soak Pit	SI/OB	Check that the drains have adequate slope and there is no accumulation of water or debris in it	.
B10.4	No blocked/ over-flowing drains in the facility	OB	Observe that the drains are not overflowing or blocked
B10.5	No blocked/ over-flowing drains in the facility	OB	Observe that the drains are not overflowing or blocked	.

Waste Management

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
C1.	Segregation of Biomedical Waste
C1.1	Anatomical waste is segregated in Yellow Bin	OB/SI	Check in departments like Labour room and OT that anatomical waste is put in yellow colour Bin	.
C1.2	Soiled and Solid infectious waste (plastic) are segregated properly as per states guidelines, which are in compliance to options for segregation given the BMW (management & handling) rules 1998	OB/SI	Check soiled waste like dressings, plaster, linen are segregated as per appropriate coloured bin. Solid waste e.g.. Tubing,Catheter, Syringes are put indesignated bins as per stateprotocol for segregation
C1.3	General and Infectious waste are not mixed	OB	Check that general waste like medicine boxes, paper, food, kitchen waste are not mixed with infected wastes.	.
C1.4	Display of work instructions for segregation and handling of Biomedical waste	OB	Check for instructions for segregation of waste in different categories of colour coded bins are displayed at point of use.
C1.5	Check if the staff is aware of segregation protocols	SI	Ask staff about the segregation protocol.	.

C2.	Collection and Transportation of Biomedical Waste
C2.1	Biomedical waste bins are not over filled	OB	Check Bins meant for Biomedical waste are not filled beyond 2/3 capacity
C2.2	Biomedical waste bins are covered	OB	Check bins meant for bio medical waste are covered with a lid
C2.3	There is a defined schedule for collection of Biomedical waste from generation area	SI/RR	Ask staff how frequent bio medical waste is collected from the patient care areas. It should be collected at least twice a day or when bin is 2/3 filled
C2.4	Transportation of biomedical waste is done in closed container/trolley	OB/SI	Check transportation of waste from clinical areas to storage areas is done in covered trolleys / Bins. Trolleys used for patient shifting should not be used for transportation of waste
C2.5	Route of transportation ofbiomedical waste should be away from the general trafficof hospital.	OB/SI	Check route of transportation of waste. It should be done from the dirty corridor not used by patients and visitors. If separate route is not available in the hospital, the waste should be transferred during the lean time - Early morning or late night.

C3.	Sharp Management
C3.1	Staff uses needle cutters for cutting the syringe hub	OB/SI	Observe needle cutters are being used for cutting and disposing syringes and are not idle. Observe the procedure and containers for storing the SHARPS and syringes
C3.2	Disinfection of sharp before disposal	OB	Check if SHARPS are put in a disinfectant solution (1.0% Chlorine Solution or any other suitable disinfectant as per hospital’s policy)
C3.3	Staff uses safe method for processing and transportation of sharp	OB/SI	Check that the staff uses either double bin with sieves or puncture poof container for transportation of the sharps	.
C3.4	Staff knows what to do in condition of needle stick injury	SI/RR	Ask staff about post exposure prophylaxis (PEP) after a needle stick injury - immediate first aid, reporting format, and follow-up.
C3.5	Post exposure prophylaxis is available in the hospital	SI/RR	Check if valid PEP kit is available in the hospital and the staff is aware of them. PEP protocol is prominently displayed at work stations.	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
C4	Storage of Biomedical Waste
C4.1	Dedicated Storage facility is available for biomedical waste	OB	Check if hospital has dedicated room for storage of Biomedical waste before disposal/handing over to Common Treatment Facility.	.
C4.2	Storage facility is located away from the patient area and is secured	OB	Check that the BMW storage is situated away from the main building and is kept in lock and key
C4.3	No Biomedical waste is stored for more than 48 Hours	SI/RR	Verify that the waste is being disposed / handed over to CTF within 48 hour of generation. Check the record especially during holidays	.
C4.4	General waste is not stored with biomedical waste	OB	Check that General waste is not mixed bio medical waste in storage area
C4.5	Biohazard sign is prominently displayed at storage area	OB	observe display of Biohazard sign at storage areas	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
C5	Disposal of Biomedical waste
C5.1	Hospital has adequate facility for disposal of Biomedical waste	RR/OB	Check that the hospital has a valid contract with Common Treatment for disposal of Bio medical waste. In absence of access to CTF, the facility should have Deep Burial Pit and Sharp Pit within premises of hospital	.
C5.2	Facility disinfects and mutilates the Plastic waste before disposal	OB/SI	Gloves are cut, Plastic Syringe are shredded and disinfected with chlorine solution (prepared within 6 - 8 hours) before disposal to prevent its reuse
C5.3	Anatomical waste is disposed as per guidelines	SI/RR	Check either anatomical waste is handed over to CTF incineration or disposed in deep burial pit	.
C5.4	Deep Burial Pit is constructed as per BMW (management & handling) Rules 1998	OB/RR	Located away from the main hospital building and water source, At least two meter deep. Closed when half filled. Secured from animals and covered with a lid. If waste disposed through CTF, then a deep burial pit is not required.
C5.5	Sharp Pit constructed as per guidelines	OB/SI	Constitute structure with a funnel inlet. If Sharp are disposed through CTF give full compliance	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
C6.	Management Hazardous Waste
C6.1	Staff is aware of Mercury Spill management	SI	Ask staff what he/she would do in case of Mercury spill.	.
C6.2	Availability of Mercury Spill Management Kit	OB	Check Mercury spill management kit is readily available
C6.3	Disposal of Radiographic Developer and Fixer	SI/RR	Check how X-ray department dispose developer and fixer. It should be handed over to authorized agency and not drained in sewage	.
C6.4	Disposal of Disinfectantsolution like Glutaraldehyde	SI	Should not be drained in sewageuntreated
C6.5	Disposal of Lab reagents	SI/RR	As per instructions of manufacturer	.

C7.	Solid General Waste Management
C7.1	Recyclable and Biodegradable waste aresegregated	OB/SI	Check if there are separate general waste bins for Recyclable and Bio degradable waste
C7.2	Availability of Compost pit as per specification	OB/SI	Availability of compost pit for Bio degradable waste. If it is disposed through Municipal waste management system, give full compliance
C7.3	Availability of waste disposal services	OB/SI	Check, if hospital has access to solid waste disposal services through municipal or out sourced agencies
C7.4	There is no mixing of infectious and general waste	OB/SI	Check no infectious waste is disposed in general waste bin or storage area
C7.5	General waste from hospital is removed daily by municipal/ outsourced agency .	OB/SI/RR	Ask staff/ verify with records for daily removal of waste. Check there is no sign of burning of waste in hospital premises

C8.

Liquid Waste Management

C8.1

Lab samples are discarded after treatment only

OB/SI

Treated with chlorine solution before disposal

C8.2

Body Fluids, collection in suction apparatus, etc. are disposed after treatment

OB/SI

Treated with chlorine solution before disposal

C8.3

Hospital has treatment facility for infectious liquid waste

OB/SI

ETP or local Treatment with chlorine solution

C8.4

Facility has septic tank as per specification

If connected to sewage give full compliance

C8.5

Soak tank is maintained as per guidelines

Periodic desalting and repair of septic tank

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
C9	Equipment and Supplies for Bio Medical Waste Management
C9.1	Availability of Bins for segregation of Biomedical waste at point of use	OB/RR	One set of bins at each point of generation	.
C9.2	Availability of Bins for Collection of general waste	OB	One at each point of waste generation
C9.3	Availability of Needle/ Hub cutter and puncture proof boxes	OB/SI	At each point of generation of sharp waste	.
C9.4	Availability of Colour coded liners for Biomedical waste and general waste	OB/SI	Check all the bins are provided with chlorine free liners. Ask staff about adequacy of supply
C9.5	Availability of trolleys for waste collection and transportation	OB/RR	As per the size of the hospital	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
C10	Statuary Compliances
C10.1	Hospital has a valid authorization for Bio Medical waste Management from pollution control board	RR	Check for three record for validity of authorization	.
C10.2	Hospital submits Annual report to pollution control board	RR	Check the records that reports have been submitted before 31st January
C10.3	Hospital Keeps records of waste generated	RR	Check the records being maintained for amount of waste generated in different categories of waste	.
C10.4	There is a designated person for monitoring for Bio Medical Waste Management	SI/RR	Check for who is designated and what is his role and responsibilities
C10.5	Copy of Biomedical waste rules is available with hospital	RR	Check the records	.

Infection Control

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
D1.	Hand Hygiene
D1.1	Availability of Sink andrunning water at point of use	OB	Check for washbasin withfunctional tap, soap andrunning water availability at allpoints of use including nursingstations, OPD clinics, OT,labour room, etc.	.
D1.2	Display of Hand washingInstructions	OB	Check that Hand washing instructions are displayed preferably at all points of use
D1.3	Adherence to 6 steps ofHand washing	SI	Ask facility staff to demonstrate 6 steps of normal hand wash	.
D1.4	Availability of AlcoholBased hand rub	SI/OB	Check for availability alcohol based hand-rub. Ask staff about its regular supply
D1.5	Staff is aware of when tohand wash	SI	Ask staff about the situations, when hand wash is mandatory (5 moments of hand washing).	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
D2.	Personal Protective Equipment (PPE)
D2.1	Use of Gloves duringprocedures and examination	SI/OB	Check, if the staff uses gloves during examination, and while conducting procedures	.
D2.2	Use of Masks and Head cap	SI/OB	Check, if staff uses mask and head caps in patient care and procedure areas
D2.3	Use of Heavy Duty Gloves and gumboot by waste handlers	SI/OB	Check, if the housekeeping staff and waste handlers are using heavy duty gloves and gum boots	.
D2.4	Use of aprons/ Lab coat by the clinical staff	SI/OB	Check the usage of protective attire e.g. Apron by the doctor and nurses, lab coat by the lab technicians, gown in OT, etc.
D2.5	Adequate supply of Personal Protective Equipment (PPE)	SI/RR	Check with staff whether they have adequate supply of personal protective equipment. Verify with records for any stock outs	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
D3.	Personal Protective Practices
D3.1	The staff is aware of use of gloves, when to use (occasion) and its type	SI/OB	Check with the staff when do they wear gloves, and when gloves are not required. The Staff should also know difference between clean & sterilized gloves and when to use	.
D3.2	Correct method of wearing and removing gloves	SI/OB	Ask staff to demonstrate correct method of wearing and removing Gloves
D3.3	Correct Method of wearing mask and cap	SI/OB	Check, if the staff knows correct method of wearing mass	.
D3.4	No re-use of disposable personal protective equipment	SI/OB	Check that disposable gloves and mask are not re-used. Reusable Gloves and mask are used after adequate sterilization
D3.5	The Staff is aware of standard Precautions	SI	Ask the staff about five Standard Precautions	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
D4.	Decontamination and Cleaning of Instruments
D4.1	Staff knows how to make Chlorine solution	SI/OB	Ask the staff how to make 1% chlorine solution from Bleaching powder and Liquid Hypochlorite solution	.
D4.2	Decontamination of operating and Surface examination table, dressing tables etc. after every procedures	SI/OB	Ask staff about practice when and how they clean the operating surfaces either by chlorine solution or Disinfectant like carbolic acid
D4.3	Decontamination of instruments after use	SI/OB	Check whether instruments are decontaminated with 0.5% chlorine solution for 10 minutes	.
D4.4	Cleaning of instruments done after decontamination	SI/OB	Check instruments are cleaned thoroughly with water and soap before sterilization
D4.5	Adequate Contact Time for decontamination	SI	Ask staff about the Contact time for decontamination of instruments (10 Minutes)

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
D5.	Disinfection & Sterilization of Instruments
D5.1	Adherence to Protocols for autoclaving	SI/OB	Check staff about recommended temperature, duration and pressure for autoclaving instruments Instruments - 121 degree C, 15 Pound Pressure for 20 Minutes (30 Minutes if wrapped) Linen - 121 C, 15 Pound for 30 Minutes	.
D5.2	Adherence to Protocol for High Level disinfection	SI/OB	Check with staff process of High Level disinfection using Boiling or Chlorine solution
D5.3	Use of Signal Locks for sterilization	OB/RR	Check autoclaving records for use of sterilization indicators (signal Loc)	.
D5.4	Chemical Sterilization of instruments done as per protocol	SI/OB	Check if the staff know the protocol. For sterilization of laparoscope soaking it in 2% Glutaraldehyde solution for 10 Hours
D5.5	Sterility of autoclaved packmaintained during storage	SI/OB	Check autoclaved instruments are kept in clean area. Their expiry date is mentioned on the package. Instruments are not used later once instrument pack is open

Support Services

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
E1.	Laundry Services & Linen Management
E1.1	The facility has adequate stock (including reserve) of linen	RR/SI/PI	Check the stock position and its turn-over during last one year in term of demand and availability	.
E1.2	Bed-sheets and pillow cover are stain free and clean	OB/SI/PI	Observe the condition of linen in use in the wards, Accident & Emergency Department, other patient care area, etc.
E1.3	Bed-sheets and linen are changed daily	OB/SI/PI	Check, if the bedsheets and pillow cover have been changed daily.Please interview the patients as well	.
E1.4	Soiled linen is removed, segregated and disinfected, as per procedure	SI/OB	Check, how is the soiled linen handled at the facility. It should be removed immediately and sluiced and disinfected immediately
E1.5	Patients’ dress are clean and not torn	PI/SI	Check the patients’ dresses - its cleanliness and condition .	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
E2.	Water Sanitation
E2.1	The facility receives adequate quantity of water as per requirement	RR/SI/PI	At least 200 litres of water per bed per day is available (if municipal supply). or the water is available on 24x7 basis at all points of usage	.
E2.2	There is storage tank for the water and tank is cleaned periodically	RR	The hospital should have capacity to store 48 hours water requirement Water tank is cleaned at six monthly interval and records are maintained
E2.3	Drinking Water is chlorinated	RR	Presence of free chlorine at 0.2 ppm is tested in the samples, drawn from the potable water.	.
E2.4	Quality of Water is tested periodically	RR	Periodically, the water is sent for bacteriological examination
E2.5	Water is available at all points of use	OB/SI/PI	Water is available for hand- washing, OT, Labour Room, Wards, Patients’ toilet & bath, waiting area	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
E3.	Kitchen Services
E3.1	Hospital kitchen is located in a separate building, away from patient care area and functions meticulously	OB	The Hospital kitchen is functional in a separate building with proper lay out. Cooking takes place on LPG/ PNG. No fire wood is used. Kitchen waste is collected separately and not mixed with the Biomedical waste.	.
E3.2	The Kitchen has provision to store dry ration and fresh ration separately	OB	Dry ration is stored on pellet, away from wall in closed containers. Vegetables are stored at appropriate temperature. Milk, curd and other perishable items are stored in the fridge, which is cleaned and defrosted regularly
E3.3	The Kitchen is smoke-free and fly-proofed	OB	There is proper ventilation in the kitchen. Doors and Windows are fly-proofed. No fly nuisance is noticed	.
E3.4	Staff observes meticulous personal hygiene	OB	Check that the Staff uses cap and kitchen dress, while cooking. Nails & hair are trimmed. Ill staff is not allowed to work in kitchen. Toilet facilities are available for the staff. Nail brush is available.
E3.5	Food to patients is distributed through covered trolleys and patients utensils are not dented or chipped - off	OB	Check that adequate number of trolleys are available and are in use. Look for the condition of patients crockery and utensil	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
E4.	Security Services
E4.1	The main gate of premises, Hospital building, wards, OT and Labour room are secured	OB	Check for the presence of security personnel at critical locations	.
E4.2	The security personal are meticulously dressed and smartly turned-out.	OB	Check if Security personnel themselves observe the commensurate behaviour such no spitting, no chewing of tobacco, non-smoker, etc.
E4.3	There is a robust crowd management system.	SI/OB	Crowd in OPD has waiting place, seats, etc. Dust bins are available and there is adequate ventilation for the patients and their attendants	.
E4.4	Security personal reprimands attendants, who found indulging into unhygienic behaviour -spitting, open field urination & defecation, etc.	OB	Check, if security personnel watch behaviour of patients and their attendants, particularly in respect of hygiene, sanitation, etc. and take appropriate action, as deemed.
E4.5	Un-authorised vendors are not present inside the campus. Waste storage is secured and there is no authorised collection of plastic items, card board, etc	OB/SI/PI	Check, entry of vendors is controlled or not. Unauthorised entry of rag-pickers should not be there.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
E5.	Out-sourced Services Management
E5.1	There is valid contract for out-sourced services, like house-keeping, BMW management, security, etc.	RR	Please check contract document of all out-sourced services	.
E5.2	The Contract has well defined measurable deliverables	RR	Check the contract documents to see, whether the deliverables of the out-sourced organisation have been well defined in term of the work to be done and how it would be verified
E5.3	The contract has penalty clause and it has been evoked in the event of non- performance or sub-standard performance	RR/ SI/ Interview with vendor	Look for the penalty clause in the contract and how often it has been used	.
E5.4	Services provided by the out-sourced organisation are measured periodically and performance evaluation is formally recorded.	RR	Check if Performance of the vendors have been recorded or not
E5.5	There is defined time-line for release of payment to the contractors for the services delivered by the organisation.	RR/ Interview with vendor	Check the record for the time taken in releasing the payment due to the out-sourced organisation

Hygiene Promotion

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
F1.	Community Monitoring & Patient Participation
F1.1	Members of RKS and Local Governance bodies monitor the cleanliness ofthe hospital at pre-definedintervals	SI/RR	At least once in month.	.
F1.2	Local NGO/ Civil Society Organizations are involved in cleanliness of the hospital	SI	Discuss with hospital administration about involvement of local NGOs/ Civil society
F1.3	Patients are counselled on benefits of Hygiene	PI	Check with patients for they have been counselled for hygiene practices	.
F1.4	Patients are made aware of their responsibility of keeping the health facility clean	SI/OB	As patients about their roles & responsibilities with regards to cleanliness. Patient’s responsibilities should be prominently displayed
F1.5	The Health facility has a system to take feed-back from patients and visitors for maintaining the cleanliness of the facility	SI/RR	Check if there is any feedback system for the patients. Verify the records	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
F2.	Information Education and Communication
F2.1	IEC regarding importance of maintaining hand hygiene is displayed in hospital premises	OB	Should be displayed prominently in local language	.
F2.2	IEC regarding Swachhata Abhiyan is displayed within the facilities’ premises	OB	Should be displayed prominently in local language
F2.3	IEC regarding use of toilets is displayed within hospital premises	OB	Should be displayed prominently in local language	.
F2.4	IEC regarding water sanitation is displayed in the hospital premises	OB	Should be displayed prominently in local language
F2.5	Hospital disseminates hygiene messages through other innovative manners	SI/OB	Hygiene Kiosk, Video Messages, Leaflets, IEC corners etc.	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
F3.	Leadership and Team work
F3.1	Cleanliness and Infection control committee is constituted at the facility	SI	Ask hospital demonstration about constitution of committee and its functioning	.
F3.2	Cleanliness and infection control committee has representation of all cadre of staff including Group ‘D’ and cleanings staff	RR/SI	Verify with the records
F3.3	Roles and responsibility of different staff members have been assigned and communicated	SI/RR	Ask different members about their roles and responsibilities	.
F3.4	Hospital leadershipreview the progress of the cleanliness drive on weeklybasis	SI/RR	Check about the regular meeting and monitoring activities regarding cleanliness drive
F3.5	Hospitals leadershipidentifies good performing staff members anddepartments	SI	Check with hospital administration if there is any such good practice	.

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
F4.	Training and Capacity Building and Standardization
F4.1	Hospital conducts aretraining need assessment regarding cleanliness andinfection control in hospital	RR	Verify with records, if trg. need assessment has been done	.
F4.2	Bio medical wasteManagement training has been provided to the staff	SI/RR	Verify with the training attendance records
F4.3	Infection control Training has been provided to the staff	SI/RR	Verify with the training attendance records	.
F4.4	Hospital has documented Standard Operating procedures for Cleanliness and Upkeep of Facility	SI/RR	Check availability of SOP with users
F4.5	Hospital has documented Standard Operating procedures for Bio-Medical waste management and Infection Control	RR	Check availability of SOP with respective users

Ref.No.	Criteria	Assessment Method	Means of Verification	Compliance
F5.	Staff Hygiene and Dress Code
F5.1	Hospital has dress code policy for all cadre of staff	SI/RR	Ask staff about policy. Check if it is documented	.
F5.2	Nursing staff adhere to designated dress code	OB	Observation
F5.3	Support and Housekeeping staff adhere to their designated dress code	OB	Observation	.
F5.4	There is a regular monitoring of hygiene practices of food handlers and housekeeping staff	SI	Check with the hospital administration
F5.5	Identity cards and name plates have been provided to all staff	OB	Observation

Score
Infection Control Program	Work Environment
50.0%	50.0%
Hand Hygiene	Upkeep & Cleanliness
50.0%	50.0%
Personal Protection	Water & power Supply
50.0%	50.0%
Instrument Processing	Linen
50.0%	50.0%
Environmental Cleaning	Public Participation
50.0%	50.0%
Biomedical Waste Management	Legal Requirements
50.0%	50.0%
Overall Score	Human Resource Deployment
50.0%	50.0%
	Outsourced Services Management
	50.0%

Source: Swachhta Abhiyaan Guidelines for Public Health Facilities

Last Modified : 2/12/2020

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