Checklist No.

3 Labour Room Version - NHSRC/NQAS2016

National Quality Assurance Standards Version-2

Checklist for Labour Room 3

Assessment Summary
Name of the Hospital Sadar Hospital Chatra Date of Assessment 9/28/2021
Names of Assessors MD MURSHID Names of Assessees

Type of Assessment INTERNAL Action plan Submission

(Internal/Peer/External) Date

Labour room Score Card

Area of Concern wise Score Labour Room Score
A Service Provision 95%
B Patient Rights 90%
C Inputs 87%
D
E
Support Services
Clinical Services
Infection Control
89%
93%
81%
87%
F
G Quality Management 73%
H Outcome 83%

Major Gaps Observed

1 1. LR SHIFTING

2 2. DEVELOPMENT OF TRIAGE ROOM

3 3. UNAVAILABILITY OF PAEDITRICS, ANAESTHETICS, GYNECOLOGIST

4 4. TRAINING OF ALL STAFF REQUARDING LAQSHAY

5
Strengths / Good Practices

1 1.ALL STAFF CO -OPERATIVE AND EAGER TO LEARN

2 2. POSITIVE ATTITUTE OF ALL STAFF INCLUDING MO

3 3. LIMITED RESOURCES FACILITY PROVIDING

5
Recommendations/ Opportunities for Improvement

5
Signature of Assessors

Date

Checklist for Labour Room

Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
nce Method aine imu
d m
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Checklist No. 3 Labour Room Version - NHSRC/NQAS2016

Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
nce - A Service
MethodProvision aine imu 95
Area of Concern 21
d
22
m
2 2 100
Standard A1 The facility provides Curative Services
ME A1.14 Services are available for the time period Labour room service is SI/RR Verify with records that deliveries
as mandated functional 24X7 have been conducted in night on
2 regular basis

18 18 100
Standard A2 The facility provides RMNCHA Services
ME A2.1 The facility provides Reproductive health Availability of Post Partum IUD 2 SI/RR Verify with records that PPIUD
Services insertion services services have been offered in labour
room

ME A2.2 The facility provides Maternal health Availability of Vaginal Delivery 2 SI/RR Normal vaginal & assisted (Vacuum /
Services services Forcep ) delivery

Availability of Pre term delivery 2 SI/RR Check if pre term delivery are being
services conducted at facility and not referred
to higher centres unnecessarily

Management of Postpartum 2 SI/RR Check if Medical /Surgical

Haemorrhage management of PPH is being done at
labour room

Management of Retained 2 SI/RR Check staff manages retained

Placenta placenta cases in labour room . Verify
with records

Septic Delivery & Delivery of 2 SI/RR Check if infected delivery cases are
HIV positive Pregnant Women managed at labour room and not
referred to higher centres
unnecessarily

Management of PIH/Eclampsia/ 2 SI/RR Check services for management of

Pre eclampsia PIH/ Eclampsia are being proved at
labour room
ME A2.3 The facility provides Newborn health Availability of New born 2 SI/OB Check if labour room has a functional
Services resuscitation New born resuscitation services
available in labour room

Availability of Essential new 2 SI/OB Check essential newborn care

born care provisions such as Keeping baby on
mother's abdomen, immediate drying
of baby, Skin to skin contact, delayed
chord clamp, initiation of breast
feeding, recording of vitals and Vit. K
are provided

1 2 50
Standard A3 The facility Provides diagnostic Services
ME A3.2 The facility Provides Laboratory Services 24 *7 Availability of point of 1 SI/OB HIV, Hb% , Random blood sugar , glucometer with strip
care diagnostic tests Protein Urea Test - HM

Area of Concern - B Patient Rights 36 40 90

6 8 75
Standard B1 The facility provides the information to care seekers, attendants & community about the available services and their modalities
ME B1.1 Availability of departmental 1 OB Numbering, main department and SIGNAGES WORK TO
signage's internal sectional signage, Restricted BE DONE - HM
area signage displayed. Directional
The facility has uniform and user-friendly signages are given from the entry of
signage system the facility

ME B1.2 Necessary Information 1 OB Name of doctor and Nurse on duty HM

regarding services provided is are displayed and updated. Contact
The facility displays the services and displayed details of referral transport /
entitlements available in its departments ambulance displayed

ME B1.5 IEC Material is displayed 2 OB Breast feeding, kangaroo care, family

Patients & visitors are sensitised and planning etc (Pictorial and chart ) in
educated through appropriate IEC / BCC circulation & waiting area
approaches

ME B1.6 Signage's and information are 2 OB Check all information for patients/
available in local language visitors are available in local language
Information is available in local language
and easy to understand

6 8 75
Standard B2
Services are delivered in a manner that is sensitive to gender, religious and cultural needs, and there are no barrier on account of
physical economic, cultural or social reasons.
ME B2.1 Only on duty staff is allowed in 2 OB Pregnant woman, her birth
the labour room when it is companion, doctor, nurse/ANM on
Services are provided in manner that are occupied duty, and other support staff only, is
sensitive to gender allowed in the labour room

ME B2.3 Availability of Wheel chair or 2 OB

Access to facility is provided without any stretcher for easy Access to the
physical barrier & friendly to people with labour room
disabilities
Availability of ramps and railing 0 OB If not located on the ground floor
& Labour room is located at availability of the ramp / lift with
ground floor person for shifting

ME B2.4 Check care to pregnant women 2 OB/PI Discrimination may happen because
is not denied or differed due to of religion, caste, ethnicity, cast,
There is no discrimination on basis of discrimination language, paying capacity and
social and economic status of the patients educational level.

18 18 100
Standard B3 The facility maintains privacy, confidentiality & dignity of patient, and has a system for guarding patient related information.
ME B3.1 Availability of screen/ partition 2 OB Screens / Partition has been provided
Adequate visual privacy is provided at at delivery tables from three side of the delivery table
every point of care or Cubicle for ensuring visual privacy

Curtains / frosted glass have 2 OB Check all the windows are fitted with
been provided at windows frosted glass or curtains have been
provided

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No two women are treated on nce
2 Method
OB/PI Check that observation beds and aine imu
common bed/ Delivery Table delivery tables are not shared by d m
multiple women at the same time
because of any reason
ME B3.2 Patient Records are kept at 2 SI/OB Check records are not lying in open
secure place beyond access to and there is designated space for
general staff/visitors keeping records with limited access.
Confidentiality of patients records and Records are not shared with anybody
clinical information is maintained without permission of hospital
administration

ME B3.3 Behavior of labour room staff is 2 OB/PI Check that labour staff is not
dignified and respectful providing care in undignified manner
such as yelling, scolding , shouting,
The facility ensures the behavior of staff is blaming and using abusive language,
dignified and respectful, while delivering unnecessary touching or examination
the services

Pregnant women is not left 2 OB/PI Check that care providers are
unattended or ignored during attentive and empathetic to the
care in the labour room pregnant women at no point of care
they are left alone.

Care provided at labour room is 2 OB/PI Check if the physical abuse practices
free from physical abuse or such as pinching, slapping,
harm restraining , pushing on the abdomen,
extensive episiotomy etc.

Pregnant women is explicitly 2 OB/PI Check if care providers verbally inform

informed before examination the pregnant women before touching,
and procedures examination or starting procedure.

ME B3.4 HIV status of patient is not 2 SI Check if HIV status of pregnant

disclosed except to staff that is women is not explicitly written on
The facility ensures privacy and directly involved in care case sheets and avoiding any means
confidentiality to every patient, especially by which they can be identified in
of those conditions having social stigma, public such as labelling or allocating
and also safeguards vulnerable groups specific beds.

4 4 100
Standard B4
The facility has defined and established procedures for informing patients about the medical condition, and involving them in
treatment planning, and facilitates informed decision making
ME B4.1 Consent is taken before delivery 2 SI/RR Check the labour room case sheet for
There is established procedure for taking and or shifting consent has been taken
informed consent before treatment and
procedures
ME B4.4 Labour room has system in 2 PI Check if pregnant women and her
place to involve patient's family members have been informed
Information about the treatment is relative in decision making and consulted before shifting the
shared with patients or attendants, about pregnant women patient for C-Section or referral to
regularly treatment higher center

2 2 100
Standard B5
The facility ensures that there are no financial barrier to access, and that there is financial protection given from the cost of hospital
services.
ME B5.1 Check all services including 2 PI/SI Check if there are no user charges of
drugs, consumables, diagnostics any services in labour room .
The facility provides cashless services to and blood are free of cost in Ask Pregnant women and their
pregnant women, mothers and neonates labour room attendants if they have not paid for
as per prevalent government schemes any services or any informal fees to
service providers

Area of Concern - C Inputs 94 108 87

19 28 68
Standard C1 The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms
ME C1.1 Departments have adequate space as per Adequate space as per delivery 1 OB Labour tables should be placed in a LR SHIFTED TO OPPOSIDE
patient or work load load way that there is a distance of at least ROOM
3 feet from the sidewall, at least 2
feet from head end wall, and at least
6’ from the second table

ME C1.2 Patient amenities are provided as per Availability of patients 2 OB Dedicated Toilets for Labour Room
patient load amenities such as Drinking area and Staff Rooms. LDR concept for
water, Toilet & Changing area Labour Room should have attached
toilet with each LDR unit . Toilets are
provided with western style toilet
seats. Drinking water Facility within
labour room
For Pregnant women & companion
ME C1.3 Departments have layout and Labour Room layout is arranged 0 OB Labour Room and associated services
demarcated areas as per functions in LDR concept are arranged according to Labour-
Delivery-Recovery Concepts with each
LDR unit comprising of 4 Labour Beds
and dedicated Nursing Station and
New Born Corner

Availability of Registration 1 OB Dedicated reception and registration

Area & Waiting area area the entry of Labour Room
Complex with registration desk and
seating arrangement for 30 people in
waiting area

Availability of Triage and 0 OB Dedicated Triage & Examination PLACE HAS BEEN
Examination Area room with two examination beds for IDENTIFIED - NEED TO
segregation of High & Low Risk IMPLIMENT
patients
Entry to the labour room should not
be direct. Check if there is any buffer
Dedicated nursing station and 1 OB One
area common Nursing station for
Duty Rooms Conventional Labour Room
Dedicated Nursing station for Each
unit if LDR concept is followed

Availability of Storage Area 2 OB A dedicated sub store with cabinets

and storage racks for storing supplies
Separate Clean room & Dirty Utility
room for Storing Sterile and Used
Availability of Newborn Care 2 OB goods
One respectively
Dedicated Newborn care area for
area each four tables. Incase of LDR
dedicated NBCA for each unit.There
should be no obstruction between
labour table and Newborn corner for
swift shifting of newborn requiring
resuscitation Radiant Warmer Should
have free space from three sides

Availability of Staff Room & 2 OB Dedicated rooms for Nursing staff

Doctor's Duty Room and Doctors provided with beds,
storage furniture and attached toilets

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
ME C1.4 The facility has adequate circulation area Corridors connecting labour nce
2 Method
OB Corridor should be wide enough that aine imu
and open spaces according to need and room are broad enough to 2 stretcher can pass simultaneously d m
local law manage stretcher and trolleys without any hassle

ME C1.5 The facility has infrastructure for Availability of functional 0 OB Check availability of functional
intramural and extramural telephone and Intercom telephone and intercom connections
communication Services

ME C1.6 Service counters are available as per Availability of labour tables as 2 OB Less than 20 Deliveries/ Month -1
patient load per delivery load 20-99 Deliveries/ Month - 2
100- 199 Deliveries/Month -4
200- 499 Deliveries/Month -6
More than 500 Deliveries-
Conventional Labour Room - Monthly
Delivery Cases X 0.014
(Labour- Delivery-Recovery) LDR
format - Monthly Delivery Cases
X.028

ME C1.7 The facility and departments are planned Labour room is in Proximity and 2 OB Check labour room is located in the
to ensure structure follows the function linkage with OT & proximity of Maternity OT and SNCU/
function/processes (Structure SNCU NICU in one block only with means of
commensurate with the function of the swift shifting of patients in case of
hospital) emergency. If located on different
floor lift/ ramp with manned trolley
should be provided

Unidirectional flow of care 2 OB Labour room lay out and arrangement

of services are designed in a way, that
there is no criss cross movement of
patient, staff, supplies & equipment

5 6 83
Standard C2 The facility ensures the physical safety of the infrastructure.
ME C2.1 The facility ensures the seismic safety of Non structural components are 2 OB Check for fixtures and furniture like
the infrastructure properly secured cupboards, cabinets, and heavy
equipment , hanging objects are
properly fastened and secured

ME C2.3 The facility ensures safety of electrical Labour room does not have 1 OB Switch Boards other electrical
establishment temporary connections and installations are intact. Check
loosely hanging wires adequate power outlets have been
provided as per requirement of
electric appliances

ME C2.4 Physical condition of buildings are safe for Check if safety features have 2 OB The floor of the labour room complex
providing patient care been provided in infrastructure should be made of anti-skid material.
Each window have 2-panel sliding
doors. The outside panel be fixed The
second panel should be moving with
frosted glass and a lock.

6 6 100
Standard C3 The facility has established Programme for fire safety and other disaster
ME C3.1 The facility has plan for prevention of fire Labour room has sufficient fire 2 OB/SI Check the fire exits are clearly visible
exit to permit safe escape to its and routes to reach exit are clearly
occupant at time of fire marked.

ME C3.2 The facility has adequate fire fighting Labour room has installed fire 2 OB Class A , Class B, C type or ABC type.
Equipment Extinguishers & expiry is Check the expiry date for fire
displayed on each fire extinguishers are displayed on each
extinguisher extinguisher as well as due date for
next refilling is clearly mentioned

ME C3.3 The facility has a system of periodic Check for staff competencies 2 SI/RR Check staff is aware of RACE (Rescue-
training of staff and conducts mock drills for operating fire extinguisher Alarm-Contain-Extinguish) method for
regularly for fire and other disaster and what to do in case of fire in case of fire and confident in using
situation fire extinguisher.

6 10 60
Standard C4 The facility has adequate qualified and trained staff, required for providing the assured services to the current case load
ME C4.1 The facility has adequate specialist Availability of Ob&G specialist 0 OB/RR 100-200 Deliveries -1 (OBG/EMOC)
doctors as per service provision 200 - 500 Deliveries - 1 OBG
(Mandatory + 4 (OBG/EMOC)
>500 3 OBG + 4 EMOC

Availability of Pediatrician 0 OB/RR At least 1 pediatrician

ME C4.2 The facility has adequate general duty Availability of General duty 2 OB/RR At least 4 Medical Officers
doctors as per service provision and work doctor
load

ME C4.3 The facility has adequate nursing staff as Availability of Nursing staff 2 OB/RR/SI Deliveries Per month-
per service provision and work load /ANM 100-200- 8
200-500 -12
> 500 - 16

ME C4.5 The facility has adequate support / Availability of house keeping 2 SI/RR Housekeeping Staff as per delivery
general staff staff & Security Guards load
100-200- 4
200-500 - 8
Security Guards as per Delivery Load
> 500 - 12
100-200- 4
200-500 - 6
> 500 - 8

16 16 100
Standard C5 The facility provides drugs and consumables required for assured services.
ME C5.1 The departments have availability of Availability of uterotonic Drugs 2 OB/RR Inj Oxytocin 10 IU (to be kept in
adequate drugs at point of use fridge) Tab Misoprostol 200mg

Availability of Anti-infective 2 OB/RR Cap Ampicillin 500mg, Tab

Drugs Metronidazole 400mg, Inj Gentamicin

Availability of Antihypertensive , 2 OB/RR Nifedipine, Methyldopa, Inj

analgesic and antipyretic and Hydralazine, Tab Paracetamol, Tab
Anesthetic drugs Ibuprofen, Inj Xylocaine 2%,
Availability of IV Fluids 2 OB/RR IV fluids, Normal saline, Ringer
lactate,

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Availability of Vitamins nce
2 Method
OB/RR Vit K aine imu
d m

ME C5.2 The departments have adequate Availability of dressings material 2 OB/RR Gauze piece and cotton swabs,
consumables at point of use and Sanitary pads sanitary Napkins (2 for Each Delivery),
Sanitary Pads (4 for each delivery,
needle (round body and cutting),
chromic catgut no. 0, antiseptic
solution

Availability of syringes and IV 2 OB/RR Paediatric IV sets,urinery catheter,

Sets /tubes and consumables Gastric tube and cord clamp, Baby ID
for newborn tag

ME C5.3 Emergency drug trays are maintained at Emergency Drug Tray is 2 OB/RR Inj Magsulf 50%, Inj Calcium
every point of care, wherever it may be maintained gluconate 10%, Inj Dexamethasone,
needed inj Hydrocortisone Succinate, Inj
Ampicillin, Inj Gentamicin, inj
metronidazole, , Inj diazepam, inj
Pheniramine maleate, inj Corboprost,
Inj Pentazocine, Inj Promethazine,
Betamethasone, Inj Hydralazine,
Nifedipine, Methyldopa,ceftriaxone

28 28 100
Standard C6 The facility has equipment & instruments required for assured list of services.
ME C6.1 Availability of equipment & instruments Availability of functional 2 OB One set of Digital BP apparatus,
for examination & monitoring of patients Equipment &Instruments for Stethoscope, Adult Thermometer ,
examination & Monitoring Baby Thermometer, baby forehead
thermometer, Handheld Fetal Doppler
, Fetoscope, baby weighting scale,
Measuring Tape for four labour tables
or at least two sets., Wall clock

ME C6.2 Availability of equipment & instruments Availability of instrument 2 OB Cord Cutting Scissor, Artery forceps,
for treatment procedures, being arranged in Delivery trays Cord clamp, Sponge holder, speculum,
undertaken in the facility kidney tray, bowl for antiseptic lotion
are present in tray

Delivery kits are in adequate 2 OB One autoclaved delivery tray for each
numbers as per load table plus 4 extra trays

Availability of Instruments 2 OB Episiotomy scissor, kidney tray, artery

arranged for Episiotomy trays forceps, allis forceps, sponge holder,
toothed forceps, needle holder,thumb
forceps, are present in tray

Availability of Baby tray 2 OB Two pre warmed towels/sheets for

wrapping the baby, mucus extractor,
bag and mask (0 &1 no.), sterilized
thread for cord/cord clamp,
nasogastric tube are present in tray

Availability of instruments 2 OB Speculum, anterior vaginal wall

arranged for MVA/EVA tray retractor, posterior wall retractor,
sponge holding forceps, MVA syringe,
cannulas, MTP, cannulas, small bowl
of antiseptic lotion, are present in tray

Availability of instruments 2 OB PPIUCD insertion forceps, CuIUCD

arranged for PPIUCD tray 380A/Cu IUCD375 in sterile package
are present in tray

Availability of Radiant Warmers 2 OB 1 Functional Radiant warmer for each

four tables

ME C6.3 Availability of equipment & instruments Availability of Diagnostic 2 OB Atleast 2 Glucometers, Protien Urea
for diagnostic procedures being Instruments Test Kit , HB Testing Kits, HIV Kits.
undertaken in the facility

ME C6.4 Availability of equipment and instruments Availability of resuscitation 2 OB Availability of Neonatal Resuscitation
for resuscitation of patients and for Instruments for Newborn & Kit Pediatric resuscitator bag (volume
providing intensive and critical care to Mother 250 ml) with masks of
patients 0 and 1 size for each Radiant warmer
Adult Resuscitation Kit

ME C6.5 Availability of Equipment for Storage Availability of equipment for 2 OB Refrigerator, Movable Crash cart/Drug
storage for drugs trolley, instrument trolley, dressing
trolley
ME C6.6 Availability of functional equipment and Availability of equipment for 2 OB Buckets for mopping, Separate mops
instruments for support services cleaning & sterilization for labour room and circulation area
duster, waste trolley, Deck brush,
Autoclave

ME C6.7 Departments have patient furniture and Availability of Labour Beds with 2 OB Each labor bed should be have
fixtures as per load and service provision attachment/accessories following facilities
Adjustable side rails, Facilities for
Trendelenburg/reverse positions,
Facilities for height adjustment,
Stainless steel IV rod, wheels & brakes
,Steel basins attachment, Calf support,
handgrip, legs support.

Availability of Mattress for each 2 OB Mattress should be in three parts and

Labour Beds seamless in each part with a thin
cushioning at the joints, detachable at
perineal end. It should be washable
and water proof with extra set.

Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and 14 14 100
Standard C7
performance of staff

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
ME C7.1 Criteria for Competence assessment are Check parameters for assessing nce
2 Method
SI/RR Check objective checklist such OSCE aine imu
defined for clinical and Para clinical staff skills and proficiency of clinical (Onsite Clinical Examination) defined d m
staff has been defined Dakshta program are available at the
labor room

ME C7.2 Check for competence 2 SI/RR Check for records of competence

assessment is done at least assessment using OSCE including filled
once in a year checklist, scoring and grading . Verify
with staff for actual competence
Competence assessment of Clinical and assessment done
Para clinical staff is done on predefined
criteria at least once in a year
ME C7.9 Navjat Shishu Surkasha 2 SI/RR Check training records
Karyakarm (NSSK) training &
The Staff is provided training as per Skilled birth Attendant (SBA)
defined core competencies and training
plan
Biomedical Waste 2 SI/RR Check training records
Management& Infection control
and hand hygiene ,Patient
safety

Training on Quality 2 SI/RR Assessment, action planning, PDCA,

Management 5S & use of checklist

Training on Respectful 2 SI/RR Check training records

Maternal Care

ME C7.10 There is established procedure for Labour room staff is provided 2 SI/RR
Check with training records the labour
utilization of skills gained thought refresher training room staff have been provided
trainings by on -job supportive refresher training at lest once in
supervision every 12 month on Intrapartum care,
Area of Concern - D Support Services Identification and & management of 55 62 89
obstetric emergencies and Essential
Newborn care & Breast feeding 8 8 100
Standard D1 The facility has established Programme for inspection, testing and maintenance
support and calibration of Equipment.

ME D1.1 The facility has established system for All equipments are covered 2 SI/RR Check with AMC records/ Warranty
maintenance of critical Equipment under AMC including preventive documents
maintenance

There is system of timely 2 SI/RR Check for breakdown & Maintenance

corrective break down record in the log book
maintenance of the equipments

ME D1.2 The facility has established procedure for All the measuring equipments/ 2 OB/ RR BP apparatus, thermometers,
internal and external calibration of instrument are calibrated weighing scale , radiant warmer etc
measuring Equipment are calibrated . Check for records
/calibration stickers

ME D1.3 Operating and maintenance instructions Up to date instructions for 2 OB/SI Check operating and trouble shooting
are available with the users of equipment operation and maintenance of instructions of equipment such as
equipments are readily radiant warmer are available at labour
available with labour room room
staff.

14 16 87.5
Standard D2 The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas
ME D2.1 There is established procedure for There is established system of 2 SI/RR Stock level are daily updated
forecasting and indenting drugs and timely indenting of Requisition are timely placed well
consumables consumables and drugs before reaching the stock out level.

Check with stock and indent registers.

ME D2.3 The facility ensures proper storage of Drugs are stored in 2 OB Check drugs and consumables are
drugs and consumables containers/tray/crash cart and kept at allocated space in Crash cart/
are labelled Drug trolleys and are labelled. Look
alike and sound alike drugs are kept
seprately

Empty and filled cylinders are 2 OB Empty and filled cylinders are kept
labelled and updated separately and labelled, flow meter is
working and pressure/ flow rate is
updated in the checklist

ME D2.4 The facility ensures management of Expiry dates' are maintained at 2 OB/RR Expiry dates against drugs are
expiry and near expiry drugs emergency drug tray / Crash mentioned crash cart/ emergency
cart drug tray
ME D2.5 The facility has established procedure for There is practice of calculating 2 SI/RR At
Noleast
expiryone week
drug of minimum buffer
found
inventory management techniques and maintaining buffer stock stock is maintained all the time in the
labour room. Minimum stock and
reorder level are calculated based on
consumption in a week accordingly

Department maintained stock 2 RR/SI Check stock and expenditure register

and expenditure register of is adequately maintained
drugs and consumables

ME D2.6 There is a procedure for periodically There is procedure for 2 SI/RR/OB There is no stock out of drugs
replenishing the drugs in patient care replenishing drug tray /crash
areas cart

ME D2.7 There is process for storage of vaccines Temperature of refrigerators 0 OB/RR Check for temperature charts are
and other drugs, requiring controlled are kept as per storage maintained and updated periodically.
temperature requirement and records are Refrigerators meant for storing drugs
maintained should not be used for storing other
items such as eatables

8 10 80
Standard D3 The facility provides safe, secure and comfortable environment to staff, patients and visitors.
ME D3.1 The facility provides adequate Adequate Illumination at 2 OB Labour Area - 500 Lux
illumination level at patient care areas delivery table & observation Support Area - 150 Lux
area

ME D3.2 The facility has provision of restriction of There is no overcrowding in 2 OB Visitors are restricted at labour room.
visitors in patient areas labour room One birth companion is allowed to
stay with the Pregnant women

ME D3.3 The facility ensures safe and comfortable Temperature control and 0 PI/OB Temperature of the labour room
environment for patients and service ventilation in patient care area should be kept around 26-28 degree C
providers ,labour complex should have split ACs
with tonnage = (square root of
area)/10 and one ceiling mounted fan
for every labour table . Area should be
drought free

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ME D3.4 The facility has security system in place at Security arrangement in labour nce
2 Method
OB Dedicated security guards preferably aine imu
patient care areas room female security staff. CCTV Camera at d m
entrance / circulation areas

ME D3.5 The facility has established measure for Ask female staff whether they 2 SI Check adequate security measures
safety and security of female staff feel secure at work place have been taken for safety and
security of staff working in labour
room

11 14 79
Standard D4 The facility has established Programme for maintenance and upkeep of the facility
ME D4.1 Exterior & Interior of the facility building Interior & exterior of patient 1 OB Wall and Ceiling of Labour Room are
is maintained appropriately care areas are plastered & painted in white colour. The walls of
painted & building are white the labour room complex should be
washed in uniform colour made of white wall tiles, with
seamless joint, and extending up to
the ceiling.

ME D4.2 Patient care areas are clean and hygienic Floors, walls, roof, roof topes, 2 OB All area are clean with no
sinks patient care and dirt,grease,littering and cobwebs.
circulation areas are Clean Surface of furniture and fixtures are
clean

Toilets are clean with functional 2 OB Check toilet seats, floors, basins etc
flush and running water are clean and water supply with
functional cistern has been provided.

ME D4.3 Hospital infrastructure is adequately Check for there is no seepage , 0 OB Check for delivery as well as auxiliary
maintained Cracks, chipping of plaster areas
Window panes , doors and
other fixtures are intact

Delivery table are intact and 2 OB Observe for any signs for rusting or
without rust & Mattresses are accumulation of dirt/ grease/
intact and clean encrusted body fluid

ME D4.5 The facility has policy of removal of No condemned/Junk material in 2 OB Check of any obsolete article including
condemned junk material the Labour room equipment, instrument, records,
drugs and consumables
ME D4.6 The facility has established procedures for No stray animal/rodent/birds 2 OB Check for no stray animal in and
pest, rodent and animal control around labour room
4 4 100
Standard D5 The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms
ME D5.1 The facility has adequate arrangement Availability of 24x7 running and 2 OB/SI Availability of 24X7 Running water &
storage and supply for portable water in portable water hot water facility.
all functional areas

ME D5.2 The facility ensures adequate power Availability of power back up in 2 OB/SI Check for 24X7 availability of power
backup in all patient care areas as per labour room backup including Dedicated UPS and
load emergency light

4 4 100
Standard D7 The facility ensures clean linen to the patients
ME D7.1 The facility has adequate sets of linen Availability & use of clean linen 2 OB/RR Clean Delivery gown is provided to
Pregnant Women &
sterile drape for baby.

ME D7.3 The facility has standard procedures for There is system to check the 2 SI/RR Quantity of linen is checked before
handling , collection, transportation and cleanliness and Quantity of the sending it to laundry. Cleanliness &
washing of linen linen Quantity of linen is checked received
from laundry. Records are maintained

6 6 100
Standard D11
Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating
procedures.
ME D11.2 The facility has an established procedure There is procedure to ensure 2 RR/SI Check for system for recording time of
for duty roster and deputation to that staff is available on duty as reporting and relieving (Attendance
different departments per duty roster register/ Biometrics etc)

Staff posted in the labor room 2 RR/SI Check with the duty roster
should not be rotated outside
the labor room

ME D11.3 The facility ensures the adherence to Doctor, nursing staff and 2 OB As per hospital administration or state
dress code as mandated by its support staff adhere to their policy
administration / the health department respective dress code

Area of Concern - E Clinical Services 171 184 93

8 8 100
Standard E1 The facility has defined procedures for registration, consultation and admission of patients.
ME E1.1 The facility has established procedure for Unique identification number 2 RR Check for demographics like Name,
registration of patients & patient demographic records age, Sex, Chief complaint, etc.
are generated during process
of registration & admission

ME E1.3 There is established procedure for There is procedure for 2 SI/RR/OB Admission is done by written order of
admission of patients admitting Pregnant women a qualified doctor
directly coming to Labour room

There is no delay in admission 2 OB/SI/RR Co relate the time admission with &
of pregnant women in labour clinical intervention (vital chart ,
pain partograph, medication given etc.)

ME E1.4 There is established procedure for Check how service provider 2 OB/SI Provision of extra tables.
managing patients, in case beds are not cope with shortage of delivery
available at the facility tables due to high patient load

10 10 100
Standard E2 The facility has defined and established procedures for clinical assessment and reassessment of the patients.
ME E2.1 There is established procedure for initial Rapid Initial assessment of 2 RR/SI/OB Recording of vitals and FHR.
assessment of patients Pregnant Women to identify immediate sign if following danger
complication and Prioritize care sign are present - difficulty in
breathing, fever, sever abdominal
pain, Convulsion or unconsciousness,
Severe headache or blurred vision

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
Recording and reporting of nce
2 Method
RR/SI Recording of women obstetric History aine imu
Clinical History including d m
LMP and EDD Parity, Gravid status,
h/o CS, Live birth, Still Birth, Medical
History (TB, Heart diseases, STD etc)
HIV status and Surgical History

Recording of current labour 2 RR Time of start, frequency of

details contractions, time of bag of water
leaking, colour and smell of fluid and
baby movement

Physical Examination 2 RR/SI Recording of Vitals , shape & Size of

abdomen , presence of scars, foetal
lie and presentation. & vaginal
examination

ME E2.2 There is established procedure for follow- There is fixed schedule for 2 RR/OB There is fix schedule of reassessment
up/ reassessment of Patients reassessment of Pregnant as per protocols. Assessment finding
women as per standard should be recorded in partograph
protocol

18 20 90
Standard E3 The facility has defined and established procedures for continuity of care of patient and referral
ME E3.1 The facility has established procedure for There is procedure of handing 2 SI/RR Hand over from Labour Room to the
continuity of care during over patient / new born from destination department is given while
interdepartmental transfer labour room to OT/ Ward/SNCU shifting the Mother & Baby. Shifting
to ward should be done at least two
hours after delivery in case of
conventional LR and 4 hours in case of
LDR

There is a procedure for 2 SI/RR check if there are linkages and

consultation of the patient to established process for calling other
other specialist with in the specialist in labour room if required
hospital

ME E3.2 The facility provides appropriate referral Reason for referral is clearly 2 RR Verify with referral records that
linkages to the patients/Services for stated and referral is authorized reasons for referral were clearly
transfer to other/higher facilities to competent person mentioned and rational. Referral is
assure the continuity of care. (Gynaecologist or Medical authorized by Gynaecologist or
Officer on duty) Medical officer on duty after
ascertaining that case can not be
managed at the facility
Labor room staff confirms the
suitability of referral with higher
centers to ascertain that case can be
managed at higher center and will not
require further referrals

Essential information regarding 2 RR/OB Check for availability of following -

referral facilities are available at Referral Pathway
labour room Names, Contact details and duty
schedules for responsible persons
higher referral centers
Name , Contact details, duty schedule
of Ambulance services

Advance communication 2 SI/RR The information regarding the case,

regarding the patient's expected time of arrival and special
condition is shared with the facilities such as specialist, blood,
higher center intensive care may be required is
communicated to the higher center

Patient referred with referral 2 RR/SI A referral slip/ Discharge card is

slip provided to patient when referred to
another health care facility. Referral
slip includes demographic details,
History of woman, examination
findings, management done , drugs
administered, any procedure done,
reason for referral, detail of referral
center including whom to contact and
signature of approving medical officer

Referral vehicle is being 2 SI/RR Check labour room staff facilitates

arranged arrangement of ambulance for
transferring the patient to higher
center . Patient attendant are not
asked to arrange vehicle by their own
Check if labour room staff checks
ambulance preparedness in terms of
necessary equipments, drugs,
Referral checklist & Referral in/ 2 RR accompanying staffis in
Referral check list terms
filled of care
before
Out register is maintained all that maytobe
referral required
ensure in transit steps
all necessary
referred cases have been taken for safe referral
including advance communication,
transport arrangement,
accompanying care provider, referral
slip , time taken for referral etc.
regarding referral cases including
demographics, date & time of
admission, date & time of referral,
diagnosis at referral and follow up of
Follow-up of referral cases is 0 SI/RR outcome
Check thatis labour
recorded
room in referral
staff follow
done register
up of referred cases for timely arrival
and appropriate care provided at
higher center. Outcome and
deficiencies if any should be recorded
in referral out register.

ME E3.3 A person is identified for care during all Nurse is assigned for each 2 RR/SI Check for nursing hand over
steps of care pregnant women
8 10 80
Standard E4 The facility has defined and established procedures for nursing care
ME E4.1 Procedure for identification of patients is There is a process for ensuring 0 OB/SI Identification tags for mother and
established at the facility the identification before any baby
clinical procedure

ME E4.2 Procedure for ensuring timely and There is a process to ensure the 2 SI/RR Verbal orders are rechecked before
accurate nursing care as per treatment accuracy of verbal/telephonic administration. Verbal orders are
plan is established at the facility orders documented in the case sheet

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
ME E4.3 There is established procedure of patient Patient hand over is given nce
2 Method
RR/SI Nursing Handover register is aine imu
hand over, whenever staff duty change during the change in the shift maintained d m
happens

Hand over is given bed side 2 SI/RR/OB Handover is given during the shift
change beside the pregnant women
explaining the condition, care
provided and any specific care if
ME E4.5 There is procedure for periodic Patient Vitals are monitored 2 RR/SI required
Check for BP, pulse,temp,Respiratory
monitoring of patients and recorded periodically rate FHR,dilation Uterine
Contractions, blood loss any other
vital required is monitored and
recoded in case sheet

4 4 100
Standard E5 The facility has a procedure to identify high risk and vulnerable patients.
ME E5.1 The facility identifies vulnerable patients Vulnerable patients are 2 OB/SI Check the measure taken to prevent
and ensure their safe care identified and measures are new born theft, sweeping and baby
taken to protect them from any fall
harm

ME E5.2 The facility identifies high risk patients High Risk Pregnancy cases are 2 OB/SI List of cases identified as High Risk is
and ensure their care, as per their need identified and kept in intensive available with labour room staff .
monitoring Check for the frequency of
observation: Ist stage :half an hour
and 2nd stage: every 5 min

4 6 67
Standard E6
The facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their
rational use.
ME E6.1 The facility ensured that drugs are Check for case sheet if drugs are 0 RR Check all the drugs in case sheet and
prescribed in generic name only prescribed under generic name discharge slip are written in generic
only name only.

ME E6.2 There is procedure of rational use of Check for that relevant 2 RR Intrapartum care, Essential newborn
drugs Standard treatment protocols care, Newborn Resuscitation, Pre-
are available at point of use Eclampsia, Eclampsia, Postpartum
hemorrhage , Obstructed Labour,
Management of preterm labour

Check staff is aware of the drug 2 SI/RR Check BHT that drugs are prescribed
regime and doses as per STG as per treatment protocols &Check for
rational use of uterotonic drugs

14 14 100
Standard E7 The facility has defined procedures for safe drug administration
ME E7.1 There is process for identifying and High alert drugs available in 2 SI/OB Check high alert drugs such as
cautious administration of high alert department are identified Magsulf, Oxytocin, Carbopost,
drugs Adrenaline are identified in the labour
room

Maximum dose of high alert 2 SI/RR Value for maximum doses as per age,
drugs are defined and weight and diagnosis are available
communicated & there is with nursing station and doctor. A
process to ensure that right system of independent double check
doses of high alert drugs are before administration, Error prone
only given medical abbreviations are avoided

ME E7.2 Medication orders are written legibly and Every Medical advice and 2 RR Verify case sheets of sample basis
adequately procedure is accompanied with
date , time and signature

Check for the writing, It 2 RR/SI Verify case sheets of sample basis
comprehendible by the clinical
staff

ME E7.3 There is a procedure to check drug before Drugs are checked for expiry 2 OB/SI Check for any open single dose vial
administration/ dispensing and other inconsistency before with left over content intended to be
administration used later on.In multi dose vial needle
is not left in the septum

Any adverse drug reaction is 2 RR/SI Check if adverse drug reaction form is
recorded and reported available in labour room and reporting
is in practice

ME E7.4 There is a system to ensure right Check Nursing staff is aware 7 2 SI/RR Administration of medicines done
medicine is given to right patient Rs of Medication and follows after ensuring right patient, right
them drugs , right route, right time, Right
dose , Right Reason and Right
Documentation

13 14 93
Standard E8 The facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage
ME E8.1 All the assessments, re-assessment and Progress of labour is recorded 2 RR Partograph
investigations are recorded and updated

ME E8.2 All treatment plan prescription/orders are Treatment prescribed in nursing 2 RR Medication order, treatment plan, lab
recorded in the patient records. records investigation are recoded adequately

ME E8.4 Procedures performed are written on Delivery note is adequate 2 RR Outcome of delivery, date and time,
patients records gestation age, delivery conducted by,
type of delivery, complication if any
,indication of intervention, date and
time of transfer, cause of death etc

Baby note is adequate 1 RR Did baby cry, Essential new born care,
resuscitation if any, Sex, weight, time
of initiation of breast feed, birth
doses, congenital anomaly if any.

ME E8.5 Adequate form and formats are available Standard Formats are available 2 RR/OB Availability of standardized labour
at point of use room case sheets including
partograph and safe Birthing checklist

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
ME E8.6 Register/records are maintained as per Registers and records are nce
2 Method
RR Labour room register, OT register, aine imu
guidelines maintained as per guidelines MTP register, Maternal death register d m
and records, lab register, referral in
/out register, internal & PPIUD
register , NBCC register, handover
register

All register/records are 2 RR Check records are numbered and

identified and numbered labelled legibily
2 2 100
Standard E12 The facility has defined and established procedures of diagnostic services
ME E12.3 There are established procedures for Nursing station is provided with 2 SI/RR Check for list of critical values is
Post-testing Activities the critical value of different available at nursing station
test

2 2 100
Standard E13 The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.
ME E13.9 There is established procedure for Protocol of blood transfusion is 2 RR blood is kept on room temperature
transfusion of blood monitored & regulated (28 degree C) before transfusion.
Blood transfusion is monitored and
regulated by qualified person

4 4 100
Standard E16 The facility has defined and established procedures for end of life care and death
ME E16.2 The facility has standard procedures for Death note is written as per 2 RR Maternal and neonatal death are
handling the death in the hospital mother & neonatal death recorded as per MDR guideline. Death
review guidelines note including efforts done for
resuscitation is noted in patient
record. Death summary is given to
patient attendant quoting the
immediate cause and underlying
cause if possible

There is established criteria for 2 SI/RR Every still birth is examined, classified
distinguishing between new- by paediatrician before declaration &
born death and still birth record is maintained

Maternal & Child Health Services

70 74 95
Standard E18 The facility has established procedures for Intranatal care as per guidelines
ME E18.1 2 SI/OB
Facility staff adheres to standard Ensures 'six cleans' are followed Ensures 'six cleans' are followed
procedures for management of second during delivery during delivery
stage of labour. Clean hands, Clean Surface, clean
blade, clean cord tie, clean towel &
clean cloth to wrap mother

2 SI/OB By flexing the head and giving

Allows spontaneous delivery of perineal support
head

Delivery of shoulders and Neck 2 SI/OB Manages cord round the neck; assists
delivery of shoulders and body;
delivers baby on mother's abdomen

Check no unneccessary 2 SI/RR Check with records and interview with

episiotomy performed staff if they are still practicing routine
episiotomy.

Unnecessary augmentation and 2 SI/RR Check uterotonics such as oxytocin

induction of labour is not done and mesoperstol is not used for
using uterotonics routine induction normal labour
unless clear medical indication and
the expected
benefits outweigh the potential harms
Outpatient induction of labour is not
done

ME E18.2 Facility staff adheres to standard Rules out presence of second 2 SI Check staff competence
procedure for active management of third baby by palpating abdomen
stage of labour

Use of Uterotonic Drugs 2 SI/RR Administration of 10 IU of oxytocin IM

immediately after Birth . Check if
there is practice of preloading the
oxytocin inj for prompt administration
after birth.

Control Cord Traction 2 SI/RR Only during Contraction

Uterine tone assessment 2 SI/RR Check staff competence

Checks for completeness of 2 SI/RR After placenta expulsion , Checks

placenta before discarding Placenta & Membranes for
Completeness

ME E18.3 Facility staff adheres to standard Wipes the baby with a clean 2 SI/OB Check staff competence through
procedures for routine care of new-born pre-warmed towel and wraps demonstration or case observation
immediately after birth baby in second pre-warmed
towel;
Performs delayed cord clamping 2 SI/OB Check staff competence through
and cutting (1-3 min); demonstration or case observation

Initiates breast-feeding soon 2 SI/OB Check staff competence through

after birth demonstration or case observation

Records birth weight and gives 2 SI/OB Check staff competence through
injection vitamin K demonstration or case observation
ME E18.4 There is an established procedure for Staff is aware of Indications for 2 SI Ask staff how they identify slow
assisted and C-section deliveries per referring patient for to Surgical progress of labour , How they
scope of services. Intervention interpret Partogram

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
Management of Obstructed nce
2 Method
SI/RR Diagnosis obstructed labour based on aine imu
Labour data registered from the partograph, d m
Re-hydrates the patient to maintain
normal plasma volume, check vitals,
gives broad spectrum antibiotics,
perform bladder catheterization and
takes blood for Hb & grouping,
Decides on the mode of delivery as
per the condition of mother and the
baby

ME E18.5 Facility staff adheres to standard Records BP in every case 2 SI/RR Check staff competence through
protocols for identification and checks for proteinuria demonstration or case observation
management of Pre Eclampsia /
Eclampsia
identifies danger signs of severe 2 SI/RR Check staff competence through
PE and convulsions; demonstration or case observation

Administers injection 2 SI/RR Check staff competence through

magnesium sulphate demonstration or case observation
appropriately;

provides nursing care & ensures 2 SI/RR Check staff competence through
specialist attention. demonstration or case observation

ME E18.6 Facility staff adheres to standard Checks uterine tone and 2 SI/OB Check staff competence through
protocols for identification and bleeding PV regularly demonstration or case observation
management of PPH.

Identifies PPH 2 SI?OB/RR Assessment of bleeding (PPH if >500

ml or > 1 pad soaked in 5 Minutes or
any bleeding sufficient to cause signs
of hypovolemia in patient.

Manages PPH as per protocol 2 SI/OB/RR starts IV fluids, manages shock if

present, gives uterotonic, identifies
causes, performs cause specific
management.

Staff knows the use of oxytocin 2 SI/OB/RR Initial Dose: Infuse 20 IU in 1 L NS/RL
for Management of PPH at 60 drops per minute
Continuing dose: Infuse 20 IU in 1 L
NS/RL at 40 drops per minute
Maximum Dose: Not more than 3 L of
IV fluids containing oxytocin

Management of Retained 2 SI/RR Administration of another dose of

Placenta Oxytocin 20IU in 500 ml of RL at 40-60
drops/min an attempt to deliver
placenta with repeat controlled cord
traction. If this fails performs manual
removal of Placenta

ME E18.7 Facility staff adheres to standard Provides ART for seropositive 2 SI/RR Check case records and Interview of
protocols for Management of HIV in mothers/ links with ART center staff
Pregnant Woman & Newborn

Provides syrup Nevirapine to 0 SI/RR Check case records and Interview of

newborns of HIV seropositive staff
mothers

ME E18.8 Facility staff adheres to standard protocol Correctly estimates gestational 2 SI/RR Assessment and evaluation to confirm
for identification and management of age to confirm that labour is gestational age, administration of
preterm delivery. preterm corticosteroid and tocolytoics for 24-
34 weeks
Magnesium sulphate given to preterm
labour < 32 weeks

identifies conditions that may 2 SI/RR (severe PE/E, APH, PPROM);

lead to preterm birth

administers antenatal 2 SI/RR Review case records

corticosteroids in pre term
labour and conditions leading to
pre term delivery (24-34
ME E18.9 Staff identifies and manages infection in weeks); mother' s temperature
Records 0 SI/RR Review case records
pregnant woman at admission and assesses need
for antibiotics

Administers appropriate 2 SI/RR Review case records

antibiotics to mother

There is Established protocol for newborn Facility staff adheres to 2 SI/OB Performs initial steps of resuscitation
resuscitation is followed at the facility. standard protocol for within 30 seconds: immediate cord
resuscitating the newborn cutting and PSSR at radiant warmer.
within 30 seconds.
ME 18.10
Facility staff adheres to 2 SI/OB Initiates bag and mask ventilation
standard protocol for using room air with 5 ventilator
preforming bag and mask breaths and continues ventilation for
ventilation for 30 seconds if next 30 seconds if baby still does not
baby is still not breathing. breathe.

Facility staff adheres to 2 SI/OB If baby still not breathing/ breathing

standard protocol for taking well, continues ventilation with
appropriate actions if baby does oxygen, calls or arranges for advanced
not respond to bag and mask help or referral.
ventilation after golden minute.

ME E18.11 Facility ensures Physical and emotional Women are encouraged and 2 PI/SI
support to the pregnant women means of counselled for allowing birth
birth companion of her choice companion of their choice

Orientation session and 2 PI/SI

information is available for Birth
companion

14 16 87.5
Standard E19 The facility has established procedures for postnatal care as per guidelines
ME E19.1 Facility staff adheres to protocol for Performs detailed examination 2 SI/RR/PI Check for records of Uterine
assessment of condition of mother and of mother contraction, bleeding, temperature,
baby and providing adequate postpartum B.P, pulse, Breast examination,
care (Nipple care, milk initiation), Check for
perineal washes performed

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
Looks for signs of infection in nce
2 Method
OB/SI Staff Interview aine imu
mother and baby d m

Looks for signs of hypothermia 2 RR/SI/PI Skin to skin contact with mother,
in baby and provides regular monitoring and specialist
appropriate care attention as required

ME E19.2 Facility staff adheres to protocol for Staff counsels mother on vital 2 PI/SI Counsels on danger signs to mother at
counselling on danger signs, post-partum issues time of discharge; Counsels on post
family planning and exclusive breast partum family planning to mother at
feeding discharge; Counsels on exclusive
breast feeding to mother at discharge

ME E19.3 Facility staff adheres to protocol for Facilitates specialist care in 2 SI/RR Facilitates specialist care in newborn
ensuring care of newborns with small size newborn <1800 gm <1800 gm (seen by paediatrician)
at birth

Facilitates assisted feeding 2 SI/RR/PI

whenever required

Facilitates thermal 2 SI/RR/PI Facilitates thermal management

management including including kangaroo mother care
kangaroo mother care

The facility has established procedures for There is established criteria for 0 SI/RR Check if criteria has been defined and
stabilization/treatment/referral of post shifting newborn to SNCU in practice by labour room staff
natal complications
ME 19.4
Area of Concern - F Infection Control 60 74 81

1 6 17
Standard F1 The facility has infection control Programme and procedures in place for prevention and measurement of hospital associated infection
The facility has provision for Passive and Surface and environment 0 SI/RR Swab are taken from infection prone
active culture surveillance of critical & samples are taken for surfaces such as delivery tables , door,
high risk areas microbiological surveillance handles, procedure lights etc.

ME F1.2
There is Provision of Periodic Medical There is procedure for 0 SI/RR Hepatitis B, Tetanus Toxic .
Check-up and immunization of staff immunization & medical check
up of the staff
ME F1.4
The facility has established procedures for Regular monitoring of infection 1 SI/RR Hand washing and infection control
regular monitoring of infection control control practices audits done at periodic intervals
ME F1.5 practices
14 14 100
Standard F2 The facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis
Hand washing facilities are provided at Availability of hand washing 2 OB Check for availability of wash basin
point of use with running Water Facility at near the point of use Ask to Open the
Point of Use tap. Ask Staff water supply is regular

ME F2.1
Availability of antiseptic soap 2 OB/SI Check for availability/ Ask staff if the
with soap dish/ liquid antiseptic supply is adequate and uninterrupted.
with dispenser. Availability of Alcohol based Hand rub

Display of Hand washing 2 OB Prominently displayed above the hand

Instruction at Point of Use washing facility , preferably in Local
language

Handwashing station is as per 2 OB Availability of elbow operated taps &

specification Hand washing sink is wide and deep
enough to prevent splashing and
retention of water

The facility staff is trained in hand Staff is aware of when and how 2 SI/OB Ask for demonstration of six steps &
washing practices and they adhere to to hand wash check staff awareness five moments
standard hand washing practices of handwashing
ME F2.2
The facility ensures standard practices Availability & Use of Antiseptics 2 OB like before giving IM/IV injection,
and materials for antisepsis drawing blood, putting Intravenous
and urinary catheter &Proper cleaning
of perineal area before procedure
with antisepsis
ME F2.3
Check Shaving is not done 2 SI Staff Interview
during part
preparation/delivery cases

8 16 50
Standard F3 The facility ensures standard practices and materials for Personal protection
The facility ensures adequate personal Availability of Masks , caps and 2 OB/SI/ RR Check if staff is using PPEs
protection Equipment as per protective eye cover Ask staff if they have adequate supply
requirements Verify with the stock / Expenditure
register

ME F3.1
Sterile gloves are available at 2 OB/SI /RR Check if staff is using PPEs
labour room Ask staff if they have adequate supply
Verify with the stock / Expenditure
register

Use of elbow length gloves for 0 OB/SI /RR Check if staff is using PPEs
obstetrical purpose Ask staff if they have adequate supply
Verify with the stock / Expenditure
register

Availability of disposable gown/ 0 OB/SI /RR Check if staff is using PPEs

Apron Ask staff if they have adequate supply
Verify with the stock / Expenditure
register

Heavy duty gloves and gum 1 OB/SI /RR Check if staff is using PPEs
boots for housekeeping staff Ask staff if they have adequate supply
Verify with the stock / Expenditure
register

Personal protective kit for 0 OB/SI Cap & Mask, protective Eye cover,
delivering HIV cases Disposable apron

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Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
The facility staff adheres to standard No reuse of disposable gloves, nce
2 Method
OB/SI aine imu
personal protection practices Masks, caps and aprons. d m

ME F3.2
Entry to the labour Room is only 1 OB
after change of shoes and
wearing Mask & Cap

12 12 100
Standard F4 The facility has standard procedures for processing of equipment and instruments

The facility ensures standard practices Disinfection of operating & 2 SI/OB Cleaning of delivery tables tops after
and materials for decontamination and Procedure surfaces each delivery with 2% carbolic acid
cleaning of instruments and procedures
areas
ME F4.1
Proper handling of Soiled and 2 SI/OB No sorting ,Rinsing or sluicing at Point
infected linen of use/ Patient care area

Cleaning of instruments 2 SI/OB Cleaning is done with detergent and

running water after use

The facility ensures standard practices Equipment and instruments are 2 OB/SI Autoclaving
and materials for disinfection and sterilized after each use as per
sterilization of instruments and requirement
ME F4.2 equipment
Autoclaving of delivery kits is 2 OB/SI Ask staff about temperature, pressure
done as per protocols and time. Ask staff about method,
concentration and contact time
required for chemical sterilization

There is a procedure to ensure 2 OB/SI Sterile packs are kept in clean, dust
the traceability of sterilized free, moist free environment.
packs & their storage

10 10 100
Standard F5 Physical layout and environmental control of the patient care areas ensures infection prevention
Layout of the department is conducive for Facility layout ensures 2 OB
the infection control practices separation of routes for clean
and dirty items
ME F5.1
The facility ensures availability of Availability of disinfectant & 2 OB/SI Chlorine solution, Glutaraldehyde,
standard materials for cleaning and cleaning agents as per Hospital grade phenyl, disinfectant
disinfection of patient care areas requirement detergent solution
ME F5.2
The facility ensures standard practices are Spill management protocols are 2 SI/RR spill management kit staff training,
followed for the cleaning and disinfection implemented protocol displayed
of patient care areas
ME F5.3
Cleaning of patient care area 2 SI/RR Staff is trained for preparing cleaning
with detergent solution solution as per standard procedure
Standard practice of mopping 2 OB/SI Unidirectional mopping from inside
and scrubbing are followed & out. Cleaning protocols are available /
three bucket system is followed displayed
Cleaning equipment like broom are
not used in patient care areas
15 16 94
Standard F6
The facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous
Waste.
The facility Ensures segregation of Bio Availability of colour coded bins 1 OB Adequate number. Covered. Foot
Medical Waste as per guidelines and 'on- & Plastic bags at point of waste Human
operated.Anatomical waste, Items
site' management of waste is carried out generation contaminated with blood, body
as per guidelines fluids,dressings, plaster casts, cotton
ME F6.1 swabs and bags containing residual or
Items suchblood
discarded as tubing, bottles,
and blood
Segregation of Anatomical and 2 OB/SI intravenous
soiled waste in Yellow Bin components.tubes and sets, catheters,
urine bags, syringes (without needles
Segregation of infected plastic 2 OB and fixed needle syringes) and
waste in red bin vaccutainers with their needles cut)
and gloves
Display of work instructions for 2 OB Pictorial and in local language
segregation and handling of
Biomedical waste
The facility ensures management of Availability of functional needle 2 OB See if it has been used or just lying
sharps as per guidelines cutters & puncture proof, leak idle.
proof, temper proof white
container for seggregation of
sharps

ME F6.2
Availability of post exposure 2 OB/SI Ask if available. Where it is stored and
prophylaxis & Protcols who is in charge of that. Also check
PEP issuance register
Staff knows what to do in condition of
needle stick injury

Contaminated and broken Glass 2 OB Includes used vials, slides and other
are disposed in puncture proof broken infected glass
and leak proof box/ container
with Blue colour marking

The facility ensures transportation and Check bins are not overfilled 2 OB/SI Bins should not be filled more than
disposal of waste as per guidelines 2/3 of its capacity

ME F6.3
Area of Concern - G Quality Management 51 70 73

2 2 100
Standard G1 The facility has established organizational framework for quality improvement
ME G1.1 The facility has a quality team in place Quality circle has been formed 2 SI/RR Check if quality circle formed and
in the Labour Room functional in the Labour Room

3 6 50
Standard G2 The facility has established system for patient and employee satisfaction
ME G2.1 Patient satisfaction surveys are Client satisfaction survey done 1 RR
conducted at periodic intervals on monthly basis

ME G2.2 The facility analyses the patient feed Analysis of low performing 1 RR
back, and root-cause analysis attributes of client feedback is
done

ME G2.3 The facility prepares the action plans Action plan prepared is 1 RR
for the areas, contributing to low prepared to address the areas
satisfaction of patients of low satisfaction

4 4 100
Standard G3 The facility have established internal and external quality assurance Programmes wherever it is critical to quality.

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Checklist No. 3 Labour Room Version - NHSRC/NQAS2016

Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
ME G3.1 The facility has established internal There is system of daily round nce
2 Method
SI/RR Facility Incharge should visit at least aine imu
quality assurance programme in key by matron/hospital manager/ twice in a week. OBG Incharge should d m
departments hospital superintendent/ visit Labour room atleast twice a day,
Hospital Manager/ Matron in Matron/Nursing supervisor should
charge for monitoring of visit at once in each shift
services Findings/instructions during the visits
are recorded

ME G3.3 The facility has established system for use Departmental checklist are used 2 SI/RR Daily Checklist to check labour room
of check lists in different departments for monitoring and quality preparedness and cleanliness is used
and services assurance for quality assurance
Staff is designated for filling and
monitoring of these checklists

26 28 93
Standard G4
The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and
support services.
ME G4.1 Departmental standard operating Standard operating procedure 2 RR Check if SOPs available at labour room
procedures are available for department has been are formally approved
prepared and approved

Current version of SOP are 2 OB/RR Check current version of SOP is

available with process owner available with all staff members of
labour room

ME G4.2 Standard Operating Procedures Department has documented 2 RR Review the Labour Room SOPs for
adequately describes process and procedure for ensuring patients description of processes pertaining to
procedures rights including consent, ensuring privacy, confidentiality,
privacy, confidentiality & respectful maternity care and consent
entitlement

Department has documented 2 RR Review the Labour Room SOPs for

procedure for safety & risk inclusion for processes to Physical as
management well as patient safety, assessment of
risks and their timely mitigation

Department has documented 2 RR Review the Labour Room SOPs for

procedure for support services process description of support
& facility management. services such as equipment
maintenance , calibration,
housekeeping, security, storage and
inventory management

Department has documented 2 RR Review Labour room SOPS for

procedure for general patient processes of triage, assessment,
care processes admission, identification of high risk
patients, Referral , Medication
management and maintenance of
clinical records

Department has documented 2 RR Review Labour room SOPs for process

procedure for specific processes of intrapartum care, management of
to the department complications, immediate
postpartum care , Natural Birthing
Process and Birth Companion

Department has documented 2 RR Review Labour room SOPs for process

procedure for infection control description of Hand Hygiene, personal
& bio medical waste protection, environmental cleaning,
management instrument sterilization, asepsis, Bio
Medical Waste management ,
surveillance and monitoring of
infection control practices, Periodic
Department has documented 2 RR Review Laboursuch
quality review roomasSOPs for process
Maternal Death
procedure for quality description of function
Audit, Newborn of quality
Death Audit, Referral
management & improvement circles,
audit andinternal quality
Near miss assessment,
audit.
Quality improvement using PDCA
cycle client satisfaction surveys,
processes improvement , Maternal
Death Audit, Newborn Death Audit,
Referral Death Audit and Near Miss
audits.

Department has documented 0 RR Review Labour room SOPs for

procedure for data collection, description of process related to
analysis & use for improvement collection of data & quality indicators ,
their analysis and use for quality
improvement

ME G4.3 Staff is trained and aware of the Check Staff is aware of relevant 2 SI/RR Interview labour room staff for their
procedures written in SOPs part of SOPs awareness about content of SOPs
ME G4.4 Work instructions are displayed at Point clinical protocols for 2 OB Clinical Protocols on AMSTL, Preparing
of use Intrapartum care and Partograph, , PPH, Eclampsia,
Management of obstetric Infection control, Referral, Infection
emergency are Displayed Control

Clinical protocols on Newborn 2 OB Clinical Protocols on Essential

Care are displayed Newborn Care, New born
resuscitation

Don'ts/ Harmful Activities are 2 OB 1. No routine enema

Displayed at labour Room 2. No routine shaving
3. No routine induction/augmentation
of labour
4. No place for routine suctioning of
the baby
5. No pulling of the baby.
6. No routine episiotomy
7. No fundal pressure
8. No immediate cord cutting
9. No immediate bathing of the
newborn
10. No routine resuscitation on
warmer

3 6 50
Standard G 5 The facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages

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Checklist No. 3 Labour Room Version - NHSRC/NQAS2016

Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
ME G5.1 The facility maps its critical processes Process mapping of critical nce
1 Method
SI/RR Critical process are the ones where is aine imu
processes done some problem-delays, errors, cost, d m
time, etc. and improvement will make
our process effective and efficient.

ME G5.2 Facility identifies non value adding Non value adding activities are 1 SI/RR Non value adding activities are
activities / waste / redundant activities identified wastes. In these steps resources are
expended, delays occur, and no value
is added to the service.
ME G5.3 Facility takes corrective action to Processes are improved & 1 SI/RR Look for the improvements made in
improve the processes implemented the critical process.

8 14 57
Standard G6 The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit
ME G6.1 The facility conducts periodic internal Internal assessment is done at 2 RR/SI Check for assessment records such as
assessment periodic interval circular, assessment plan and filled
checklists. Internal assessment should
be done at least quarterly

ME G6.1 Referral Audits are conducted 1 RR/SI Check for records referral audit is
on Monthly Basis being done on regular basis

Maternal Death Audits are 1 RR/SI Check for records maternal audit is
conducted on Monthly Basis being done on regular basis

Neonatal Death Audits are 1 RR/SI Check for records Neonatal audits is
conducted on Monthly Basis being done on regular basis

ME G6.3 The facility ensures non compliances are Non Compliance are 1 RR/SI Check points having scores partial and
enumerated and recorded adequately enumerated and recorded Non Compliances are listed

ME G6.4 Action plan is made on the gaps found in Action plan prepared 1 RR/SI With details of action, responsibility,
the assessment / audit process time line and Feedback mechanism.

ME G6.5 Planned actions are implemented through Check correction & corrective 1 RR/SI Check actions have been taken to
Quality improvement cycle (PDCA) actions are taken close the gap. Can be in form of
Action taken report or Quality
Improvement (PDCA) project report

2 4 50
Standard G7 The facility has defined mission, values, Quality policy & objectives & prepared a strategic plan to achieve them
Check if SMART Quality 1 SI/RR Check short term valid quality
Objectives have framed objectives have been framed
addressing key quality issues in each
department and cores services. Check
if these objectives are Specific,
ME G7.4 Measurable, Attainable, Relevant and
Time Bound.

Facility has defined quality objectives to

achieve mission and quality policy
Check of staff is aware of 1 SI/RR Interview with staff for their
Mission , Values, Quality Policy awareness. Check if Mission
and objectives Statement, Core Values and Quality
ME G7.5 Policy is displayed prominently in local
language at Key Points
Mission, Values, Quality policy and
objectives are effectively communicated
to staff and users of services
2 4 50
Standard G8 The facility seeks continually improvement by practicing Quality method and tools.
ME G8.1 The facility uses method for quality Basic quality improvement 1 SI/OB PDCA & 5S
improvement in services method
ME G8.2 The facility uses tools for quality 7 basic tools of Quality 1 SI/RR Minimum 2 applicable tools are used
improvement in services in each department
Standards G10 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan 1 2 50
ME G10.6 Check periodic assessment of 1 SI/RR Verify with the records. A
medication and patient care comprehensive risk assessment of all
safety risk is done using defined clinical processes should be done
Periodic assessment for Medication and checklist periodically using pre define criteria at least once
Patient care safety risks is done as per in three month.
defined criteria.
Area of Concern - H Outcome 33 40 82.5

4 6 67
Standard H1 The facility measures Productivity Indicators and ensures compliance with State/National benchmarks
ME H1.1 Facility measures productivity Indicators Percentage of deliveries 2 RR
on monthly basis conducted at night
Percentage of complicated 1 RR
cases managed
% PPIUCD inserted against 1 RR
total number of normal delivery

3 6 50
Standard H2 The facility measures Efficiency Indicators and ensure to reach State/National Benchmark
ME H2.1 Facility measures efficiency Indicators on Percentage of cases referred to 1 RR
monthly basis OT
% of newborns required 1 RR
resuscitation out of total live
births
No of drugs stock out in the 1 RR
month
22 24 92
Standard H3 The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark
ME H3.1 Facility measures Clinical Care & Safety Percentage of deliveries 1 RR
Indicators on monthly basis conducted using real time
partograph
Percentage of deliveries 2 RR
conducted using safe birth
checklist
No of adverse events per 1 RR
thousand patients
The percentage of Women, 2 RR
administered Oxytocin,
immediately after birth.

Intrapartum stillbirth rate 2 RR

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Checklist No. 3 Labour Room Version - NHSRC/NQAS2016

Reference No Measurable Element Checkpoint Complia Assessment Means of Verification Remarks Obt Max %
Percentage newborn breastfed nce
2 Method
RR aine imu
within 1 hour of birth d m

No. of cases of Neonatal 2 RR

asphyxia
No. of cases of Neonatal Sepsis 2 RR

Percentage of antenatal 2 RR
corticosteroid administration in
case of preterm labour
No. of cases of Maternal death 2 RR
related to APH/ PPH
No of cases pf maternal death 2 RR
related to Eclampsia/ PIH
OSCE Score 2 RR
4 4 100
Standard H4 The facility measures Service Quality Indicators and endeavors to reach State/National benchmark

ME H4.1 Facility measures Service Quality Percentage of Deliveries 2 RR

Indicators on monthly basis attended by Birth Companion
Client Satisfaction Score 2 RR

Obtained Maximum Percent 3

A 21 22 95%
B 36 40 90%
C 94 108 87%
D 55 62 89%
E 171 184 93%
F 60 74 81%
G 51 70 73%
H 33 40 83%
Total 521 600 87%

0
1
2

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