Kayakalp

nabh ,kayakalp , assessor, infection prevention & control.

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

2. Assessment Protocol

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

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

5. L a un d r y Water and S a n i t a t i o n Kitchen and food Security outsource

6. Theme A – Hospital / Facility upkeep Support S e r v i c e s

7. Pest & Animal Control Landscaping & Gardening Maintenance of open area Hospital Appearance Illumination Removal of Junk Material Water Conservation Maintenance of Furniture & Fixtures Work Place Management Hospital Upkeep Theme A Infrastructure Maintenance

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

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

10. Theme B – Sanitation & Hygiene

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

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

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

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

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

16. THEME- C

17. Segregation Collection & transportation Sharp Management Storage of BMW Management of hazardous waste Liquid waste mana g eme n t Equipment & supplies of BMW Solid general waste management Statuary Compliances Waste Ma n a g em e n t Theme C Disposal of BMW

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

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

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

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

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

23. Theme D – Infection Control

24. D1 Hand Hygiene D2: Personal Protective Equipment D3: Personal Protective Practices D4: Decontamination & cleaning of instruments D5: Disinfection and sterilization of instruments

25. D6: Spill ma n a g em e n t. D7: Isolation and Barrier Nursing. D8: Infection Control Program D9: Hospital Acquired infection surveillance D10: E n vi r onm e n t al Control.

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

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

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

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

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

31. Theme E -Hygiene Promotion