Overview of National quality assurance standard

Nqas in gujarati of health facilities

1. Key concepts of Quality & an overview of NQAS Quality & Patient Safety NHSRC

2. Introduction Outline of the training programme Introduction to various materials(all the assessors guidebook) Operational Guidelines NQAS 2020 QPS Microsite NHM Website Outline of the presentation Disclaimer: HWC-SC to be read & considered as Ayushman Arogya Mandir-Sub Centre

3. What is Quality Definition Perspective: Patient & their attendants Staff/service providers External stakeholders Donabedian Model : Structure Process Outcome

4. Ev olution : Quality of Care Framework-NQAS Recommendations: Evidence based Sustainable Public health specific Low cost of implementation

5. NQAS Framework Patient Safety Caption 5 LaQshya Caption 2 MusQan Caption 3 NQAS Caption 1 Kayakalp Caption 4 NQAS Framework Focus based DH/SDH/CHC/PHC/UPHC/AAM Care around birth & child-friendly scheme

6. Buzz words/Key words . Standards Area of Concerns . Checkpoints Measurable Elements The grip of the programme/NQAS Checklist Means of verifications/Tracers

7. A B C E D F H G Area of Concerns Service Provision Patients Rights Inputs Support Services Clinical Services Infection Control Quality Management Outcome Indicators A B C D E F G H

8. SERVICE PROVISION PATIENT RIGHTS INPUTS SUPPORT SERVICES CLINICAL SERVICES INFECTION CONTROL Quality Management OUTCOME Outcome Outcome Structure Process Process Process Process Process

9. A-Service Provision Curative Services RMNCH+A Services Diagnostic Services National Health Programs Support Services Services as per local Needs A1 A2 A3 A4 A5 A6

10. AREA OF CONCERN A SERVICE PROVISION - STANDARDS Not applicable to AAM-SHCs Promotive, preventive services are included in UPHC Not applicable to AAM-SHCs Dugs – included in AAM-SHCs(A2) Not applicable to AAM-SHCs Not applicable to AAM-SHCs Not applicable to PHC & AAM-SHCs A2 RMNCH+A Services

11. Area of Concern A- Service Provision     DH CHC PHC UPHC AAM-SHC Standard A1. Facility Provides Curative Services       Promotive, preventive   Standard A2 Facility provides RMNCHA Services           Standard A3. Facility Provides diagnostic Services         Drugs+diagnostic Standard A5. Facility provides support services       Standard A4 Facility provides services as mandated in national Health Programs/ state scheme           Standard A6. Health services provided at the facility are appropriate to community needs.             The facility provides Comprehensive Primary Healthcare Services           S ummary

12. B-Patients Rights B1 Patient Information Free Services and Entitlements Access and Non Discrimination Privacy and Confidentiality Ethical Issues in Healthcare Patient Participation B2 B5 B6 B3 B4

13. Patient Rights- Standards Area of Concern B B1 Patient Information B2 Access & Non Discrimination B3 Privacy & Confidentiality B4 Patient Participation B5 Free Services & Entitlemen ts B6 Ethical Issues in Healthcare Applicable to all HCF Included as B1 in UPHC (Accesibility) Mentioned as B2 in UPHC (Acceptability) Not applicable to AAM-SHCs Included as B1 in UPHC ( Accesibility ) Mentioned as B3 in UPHC (Affordability) Not applicable to CHC, PHC, UPHC & AAM-SHCs

14. Area of Concern B- Patient Rights     DH CHC PHC UPHC AAM-SHC Standard B1. Facility provides the information to care seekers, attendants & community about the available services and their modalities       Accessible     Standard B4. Facility has defined and established procedures for informing and involving patient and their families about treatment and obtaining informed consent wherever it is required.       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.         Standard B3. Facility maintains the privacy, confidentiality & Dignity of patient and related information.       Acceptable   Standard B5. Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.       Affordable   Standard B6 Facility has defined framework for ethical management including dilemmas confronted during delivery of services at public health facilities             S ummary

15. C-Inputs C1-Infrastructure Adequacy C2- Physical Safety C7- Competency Assessment C3- Fire Safety C6- Instruments and Equipment C5- Drugs and Consumables C4- Human Resource Adequacy

16. Input - Standards Area of Concern C C 1 Infrastructure Adequacy C2 Physical Safety C3 Fire Safety C4 Human Resource Adequacy C5 Drugs & Consumables C6 Instruments & Equipment C7 Competence Assessment Not applicable to CHC, PHC & UPHC

17. Area of Concern C - Inputs     DH CHC PHC UPHC AAM-SHC Standard C1. The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms           Standard C2. The facility ensures the physical safety of the infrastructure.       Standard C3. The facility has established Programme for fire safety and other disaster   Standard C4. The facility has adequate qualified and trained staff, required for providing the assured services to the current case load           Standard C5. Facility provides drugs and consumables required for assured list of services.           Standard C6. The facility has equipment & instruments required for assured list of services.           Standard C7 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff             Summary

18. D-Support Services Equipment Maintenance Drug Storage and inventory Safety and Security Upkeep and Cleanliness Dietary Services Laundry Services Rogi Kalyan Samities and Community participation Financial Management D1 D2 D3 D4 D6 D7 D8 D9 Water and Power Supply Statutory Requirement D5 D10 1 6 2 3 4 5 8 7 10 9 11 12 HR Management Management of Outsourced Services

19. Support Services - Standards Area of Concern D D1 Equipment Maintenance D2 Drug Storage & Inventory Management D3 Safety & Security D4 Upkeep and Cleanliness D5 Water & Power Supply D6 Dietary Services Not applicable to UPHC & AAM-SHC

20. Support Services - Standards Area of Concern D D7 Laundry Services D8 Rogi Kalyan Samities & Community Participation D9 Financial Management D10 Statutory Requirements D11 HR Management D12 Management of Outsourced Services D3 in UPHC (RKS, MAS, CBM & SS of CHW) D4 in AAM-SHC (JAS, CBM & SS of CHW) Not applicable to AAM-SHC Included as D4 in UPHC Included as D4 in UPHC Included as D4 in UPHC Not applicable to AAM-SHC Included as D4 in UPHC Not applicable to AAM-SHC RKS – Rogi Kalyan Samiti MAS – Mahila Arogya Samiti CBM – Community Based Monitoring SS – Supportive Supervision JAS – Jana Arogya Samiti CHW – Community Health Worker

21. Support Services - Standards Area of Concern D D8 Monitoring & Reporting of NHP D5 Health promotion & Disease prevention Not applicable to DH & CHC Included as D3 in AAM-SHC ( Use of digital tech. for Data Management ) Only applicable to AAM-SHC

22. Area of Concern D- Support Services     DH CHC PHC UPHC AAM-SHC Standard D1. The facility has established Programme for inspection, testing and maintenance and calibration of Equipment.           Standard D3. The facility provides safe, secure and comfortable environment to staff, patients and visitors.       Standard D4. The facility has established Programme for maintenance and upkeep of the facility     Standard D5. The facility ensures 24X7 water and power backup as per requirement of service delivery, and support services norms         Standard D7. The facility ensures clean linen to the patients       StandardD6 Dietary services are available as per service provision and nutritional requirement of the patients.         Standard D2. The facility has defined procedures for storage, inventory management and dispensing of drugs in pharmacy and patient care areas           Standard D8 The facility has defined and established procedures for promoting public participation in management of hospital transparency and accountability.       RKS, CBM, MAS & SS of CHW JAS, CBM & SS of CHW Standard D9 Hospital has defined and established procedures for Financial Management       Governance & Workplace Management   Standard D12 Facility has established procedure for monitoring the quality of outsourced services and adheres to contractual obligations       Standard D10. Facility is compliant with all statutory and regulatory requirement imposed by local, state or central government         Standard D11. Roles & Responsibilities of administrative and clinical staff are determined as per govt. regulations and standards operating procedures.         Standard D8 Hospital has defined and established procedure for monitoring & reporting of National Health Program as per state specifications         Use of digital tech. for Data Management   The facility ensures health promotion and disease prevention activities through community mobilization             S ummary

23. E1-E9 E17-E22 E 24 E23 E10-E16 Area of Concern E

24. Area of Concern E E1 Registration, Consultation & Admission . E4 Nursing Care . E7 Drug Administration . E2 Clinical Assessment & Reassessment E5 Care of high risks and vulnerable patients E8 Medical Records Management . E3 Continuity of care & Referrals E6 Standard Treatment Guidelines E9 Discharge Process . General Clinical Services

25. Area of Concern E Specific Clinical Services E10 Intensive Care . E13 Blood Bank Services . E16 Management of death & bodies of deceased patients E11 Emergency and Disaster management . E14 Anaesthetic Services . . E12 Diagnostic Services . E15 Surgical Services . E18

26. Area of Concern E RMNCHA+NHP+HAEMODIALYSIS E18 Intra natal Care E21 . 07 E19 E22 E20 E23 09 E24 Hemodialysis Unit National Health Programs Adolescent Health Family Planning New born and Child Care Post natal Care E17 Antenatal Care

27. General Clinical Services - Standards Area of Concern E E1 Registration, consultation & Admission E2 Clinical Assessment & Reassessment E3 Continuity of Care / Referrals E4 Nursing Care E5 Care of High Risk & Vulnerable Patients E6 Standard Treatment Guidelines E7 Drug Administration E8 Medical Records Management E9 Discharge Process Only registration & consultation included in UPHC Not applicable in UPHC Not applicable in PHC, UPHC & AAM-SHC Not applicable in UPHC, AAM-SHC Included as D4 in AAM-SHC

28. Specific Clinical Services - Standards Area of Concern E E10 Intensive Care E11 Emergency & Disaster Management E12 Diagnostic Services E13 Blood Bank Services E14 Anesthesia Services E15 Surgical Services E16 Management of death & bodies of deceased patients Applicable only in DH Not applicable in PHC, UPHC & AAM-SHC Not applicable in PHC, UPHC & AAM-SHC Not applicable in PHC, UPHC & AAM-SHC Not applicable in PHC, UPHC & AAM-SHC

29. RMNCH+A Clinical Services - Standards Area of Concern E E17 Antenatal Care E18 Intra-natal Care E19 Postnatal Care E20 Newborn & Childcare E21 Family Planning E22 Adolescent Health E23 National Health Programs All the above 3 are included under E 5 (maternal health care) in UPHC E 24-Haemodialysis Unit

30. Clinical Services – Exclusive Standards of AAM-SHC Area of Concern E E 9 Mental health ailments E 11 NCD E 10 Communicable diseases E 12 Elderly & Palliative Care tal Care tal Care E 8 Opthalmic, ENT & Oral Care

31. Area of Concern E- Clinical Services     DH CHC PHC UPHC AAM-SHC Standard E1. The facility has defined procedures for registration, consultation and admission of patients.       Registration & consultation   Standard E2. The facility has defined and established procedures for clinical assessment and reassessment of the patients.         Standard E3. Facility has defined and established procedures for continuity of care of patient and referral       Standard E8. Facility has defined and established procedures for maintaining, updating of patients’ clinical records and their storage       (Standard D4) with progressive use of digital technology Standard E11. The facility has defined and established procedures for Emergency Services and Disaster Management         Standard E4. The facility has defined and established procedures for nursing care           Standard E5. Facility has a procedure to identify high risk and vulnerable patients.           Standard E6. Facility follows standard treatment guidelines defined by state/Central government for prescribing the generic drugs & their rational use.           Standard E7. Facility has defined procedures for safe drug administration       Standard E9. The facility has defined and established procedures for discharge of patient.             Summary

32. Area of Concern E- Clinical Services     DH CHC PHC UPHC AAM-SHC Standard E10. The facility has defined and established procedures for intensive care.           Standard E12. The facility has defined and established procedures of diagnostic services           Standard E13. The facility has defined and established procedures for Blood Bank/Storage Management and Transfusion.           Standard E14 Facility has established procedures for Anaesthetic Services           Standard E15. Facility has defined and established procedures of Surgical Services           Standard E16. The facility has defined and established procedures for end of life care and death           Standard E17 Facility has established procedures for Antenatal care as per guidelines       Maternal Health care   Standard E18 Facility has established procedures for Intranatal care as per guidelines         Standard E19 Facility has established procedures for postnatal care as per guidelines           Level –wise Arrangement of Standard

33. Area of Concern E- Clinical Services     DH CHC PHC UPHC AAM-SHC Standard E20 The facility has established procedures for care of new born, infant and child as per guidelines           Standard E21 Facility has established procedures for abortion and family planning as per government guidelines and law           Standard E22 Facility provides Adolescent Reproductive and Sexual Health services as per guidelines           Standard E23 Facility provides National health program as per operational/Clinical Guidelines             The facility has defined & established procedures for management of ophthalmic, ENT and Oral aliments as per operational/ clinical guidelines           The facility has defined & established procedure for screening & basic management of Mental Health ailments as per Operational/ clinical guidelines           The facility has defined & established procedures for management of communicable diseases as per operational/ clinical guidelines           The facility has defined & established procedures for management of non-communicable diseases as per operational/ clinical guidelines           Elderly & palliative health care services are provided as per guidelines           Level –wise Arrangement of Standard

34. Area of Concern F Infection Control Programme Hand Hygiene Personal Protection Instrument processing & autoclaving Environmental Control Bio-Medical Waste Management 1 2 3 4 5 6 1 4 2 5 6 3

35. Infection Control- Standards Area of Concern F F1 Infection Control Program F2 Hand Hygiene F3 Personal Protection F4 Instrument Processing & Autoclaving F5 Environmental Control F6 Biomedical Waste Management Not applicable in UPHC Not applicable in UPHC

36. Area of Concern F- Infection Control     DH CHC PHC UPHC HWC(SC) Standard F1. Facility has infection control program and procedures in place for prevention and measurement of hospital associated infection           Standard F5. Physical layout and environmental control of the patient care areas ensures infection prevention         Standard F2. Facility has defined and Implemented procedures for ensuring hand hygiene practices and antisepsis           Standard F3. Facility ensures standard practices and materials for Personal protection           Standard F4. Facility has standard Procedures for processing of equipments and instruments           Standard F6. Facility has defined and established procedures for segregation, collection, treatment and disposal of Bio Medical and hazardous Waste.             S ummary

37. Area of Concern G Quality Team PSS & ESS Internal & External Quality Assurance Programme Standard Operating Procedures Quality Policy, Quality Objective, Vision & Mission Quality Tools & Methods Risk Management Framework Risk Management Process 1 2 3 4 6 7 8 9 Process Mapping Clinical Governance 5 10 1 6 2 3 4 5 8 7 10 9

38. Quality Management Standards Area of Concern G G1 Quality Team G2 Patient Satisfaction survey G3 Quality Assurance Program G4 Standard Operating Procedures G5 Process Mapping & Improvement G6 Quality Policy , Objective, Vision, Mission G7 Quality Tools & Methods G8 Risk Management Framework Applicable only to DH Not applicable to AAM-SHC Applicable only to DH

39. Quality Management Standards Area of Concern G G9 Risk Management Process G10 Clinical Governance G4 Review of clinical support & Quality management process Applicable only to DH Applicable only to AAM-SHC

40. Area of Concern G- Quality Control     DH CHC PHC UPHC HWC(SC) Standard G1 The facility has established organizational framework for quality improvement           Standard G7. The facility has defined Mission, values, Quality policy and objectives, and prepares a strategic plan to achieve them       Standard G3. Facility have established internal and external quality assurance programs wherever it is critical to quality.         Standard G6. The facility has established system of periodic review as internal assessment , medical & death audit and prescription audit     Standard G2 Facility has established system for patient and employee satisfaction           Standard G4. Facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services.           Standard G8. Facility seeks continually improvement by practicing Quality method and tools.       Standard G5. Facility maps its key processes and seeks to make them more efficient by reducing non value adding activities and wastages           Standard G9 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.           Standard G10. Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan             The facility has established system of periodic review of clinical, support and quality management processes             S ummary

41. Area of Concern H Clinical Care & Safety Productivity Service Quality Efficiency H1 H2 H4 H3

42. Outcome - Standards Area of Concern H H1 Productivity H2 Efficiency H3 Clinical Care/ Safety H4 Service Quality All these 4 standards are merged & mentioned as H1 in UPHC H2 Meet Benchmark Mentioned exclusively as H2 in UPHC Included internally in all standards under H in DH, CHC, PHC & AAM-SHC

43. Area of Concern H- Outcome     DH CHC PHC UPHC AAM-SHC Standard H1 . The facility measures Productivity Indicators and ensures compliance with State/National benchmarks           Standard H2 . The facility measures Efficiency Indicators and ensure to reach State/National Benchmark         Standard H3. The facility measures Clinical Care & Safety Indicators and tries to reach State/National benchmark         Standard H4. The facility measures Service Quality Indicators and tries to reach State/National benchmark           Facility endeavours to improve its performance to meet bench marks H1, H2,H3 & H4 H1, H2,H3 & H4 H1, H2,H3 & H4   H1, H2,H3 & H4   S ummary

44. Comprehensive example from CHC(FRU): Identify the AoCs For example purpose only, not to be quoted anywhere

45. To be continued…..

46. Measurement System under National Quality Assurance Standards Quality & Patient Safety, NHSRC

47. Component District Hospital CHC PHC UPHC AAM -SC Area of Concern 8 8 8 8 8 Standards 75 65 50 35 48 (A)/50 (B) Measurable Element 380 297 250 200 126 (A)/ 129 (B) Checklist 21 12 6 12 1 Measurement System at Various level of HCF

48. Quality is all about Improvement and Measurement is the first step If you can’t measure something, you can’t understand it If you can’t understand it, you can’t control it If you can’t control it, you can’t improve it

49. Areas of Concern Broad area/ themes for assessing different aspects for quality like Service provision, Patient Rights, Infection Control Standards 8 Statement of requirement for particular aspect of quality 75 Measurable Element Specific attributes of a standards which should be looked into for assessing the degree of compliance to a particular standard 380 Checkpoint Tangible measurable checkpoints are those, which can be objectively observed and scored. 400 Quality Measurement System

50. Areas of Concern Infection Control Standards Hand Hygiene Measurable Element Hand washing Facility Checkpoint Availabiity of Soap Clinical Care Intrapartum Care Active Management of third stage of Labour (AMSTL ) Admnistration of Oxytocin within 1 Min. of Birth Patient Rights Privacy & confidentiality Visual privacy Availabilty of Screen and curtains 1X 5X 10X 100X Quality Measurement System

51. Area of Concern Statement of Standard Measurable Element Checkpoint Assessment Method Means of Verification Compliance Reference No. Anatomy of Checklist

52. OBSERVATION ( OB ) STAFF INTERVIEW ( SI ) RECORD REVIEW ( RR ) PATIENT INTERVIEW ( PI ) Assessment Method CI: Client Interview

53. Observation (OB) Compliance to many of the measurable elements can be assessed by directly observing the articles, processes and surrounding environment

54. Examples of Observation to assess compliance of ME 1 2 3 4 5 6 Enumeration of articles like equipment, drugs, etc Displays of signages, work instructions, important information Facilities - patient amenities, ramps, complaint-box, etc Procedures like measuring BP, counseling, segregation of biomedical waste Environment – cleanliness, loose-wires, seepage, overcrowding, temperature control, drains, etc Availability of drinking water, hand washing facilities and toilets etc

55. Staff interview (SI) Interaction with the staff helps in assessing the knowledge and skill level, required for performing job functions

56. Examples of Staff interviews to assess knowledge, skills, etc. 1 2 3 4 5 Competency testing – Quizzing the staff on knowledge related to their job Competency testing – Quizzing the staff on Demonstration – Asking staff to demonstrate certain activities like hand-washing technique, new born resuscitation , etc Awareness - Asking staff about awareness off patients’ right, quality policy, handling of high alerts drugs etc Attitude about patient’s dignity and gender issues Feedback about adequacy of supplies, problems in performing work, safety issues, etc

57. Record Review (RR) It may not be possible to observe all clinical procedures. Records also generate objective evidences, which need to be triangulated with finding of the observation. For example on the day of assessment, drug tray in the labour room may have adequate quantity of Oxytocin, but if review of the drug expenditure register reveals poor consumption pattern of Oxytocin, then more enquiries would be required to ascertain on the adherence to protocols in the Labour room

58. Examples of Record Review 1 2 3 4 5 6 Review of clinical records - delivery note, anaesthesia note, maintenance of treatment chart, operation notes, etc Review of department registers like admission registers, handover registers, expenditure registers, etc Review of licenses, formats for legal compliances like Blood bank license and Form ‘F’ for PNDT Review of SOPs for adequacy and process Review of monitoring records – TPR chart, Input/output chart, culture surveillance report, calibration records, etc Review of department data and indicators

59. Client Interview (CI)   Interaction with patients/clients may be useful in getting information about quality of services and their experience in the hospital. It gives us users’ perspective

60. Examples of Client Interviews 1 2 3 4 6 Feedback on quality of services, staff behavior, food quality, waiting times, etc Out of pocket expenditure Effective of communication like counseling services Satisfaction of the clients/individuals attending VHND, meetings, PSG meetings etc

61. COMPLIANCE AND SCORING THE THREE GOLDEN RULES CRITERIA TO BE USED FULL COMPLIANCE (2) PARTIAL C O M P L I AN C E (1) NON COMPLIANCE (0) CHECK POINT ALL REQUIREMENTS OF CHECK POINTS ARE MET HALF OF THE REQUIREMENTS OF CHECKPOINT ARE MET NONE OF THE R E Q U I R EME N T S MET RULE NO: 1 (checkpoints without MOV or MOV are explanatory in nature ) RULE NO:2 ( Checkpoints with enumerated MOV) CRITERIA TO BE USED FULL COMPLIANCE (2) PARTIAL C O M P L I A N CE (1) NON COMPLIANCE (0) MEANS OF V E R I FI C A T I ON 100% 50% TO 99% LESS THAN 50% RULE NO:3 (Not as routine) Only when you are Not able to score using Rule 1 and Rule 2 It seems the checkpoint is not applicable. Going beyond obvious Always look for INTENT in relation to the ME and Standard CRITERIA TO BE USED FULL COMPLIANCE (2) PARTIAL C O M P L I A N CE (1) NON COMPLIANCE (0) INTENT FULLY MET PARTIALY MET NOT MET

62. Name of Checklists-DH Accident & Emergency NRC Laboratory OPD IPD Radiology Labour Room ICU Pharmacy Maternity Ward OT Auxiliary Services SNCU PP Unit Mortuary Pediatric Ward Blood Bank General/Admin Maternity OT Paed OPD Haemodialysis unit List of DH Level & UPHC Checklists Name of Checklists-UPHC General Clinic Maternal Health Newborn & Child Health Immunization Family Planning Communicable Diseases Non-Communicable Diseases Dressing & Emergency Pharmacy Laboratory Outreach General Administration

63. Departmental Checklists

64. Documents for the certification process & Certification Criteria

65. Documents for DH/SDH Filled application form along with Hospital data sheet No. & Names of the Department to be assessed Latest State Assessment Report & Scores. Minutes of last Quality Team Meeting(MOM) Departmental SOPs Quality Improvement Manual Copy of Hospital Wide Policies/ Procedures Vision, Mission, Values, Strategic Plan & Quality Policy Condemnation Policy Antibiotic policy End of Life Care policy Privacy, Dignity & Confidentiality policy of policy Consent Policy Referral policy Policy of timely reimbursement of entitlements & compensations Grievance Redressal policy Free treatment to BPL patient’s procedural/ policy Scores of Last 3 Patient Satisfaction Surveys & Subsequent Corrective and Preventive Actions undertaken Last 3 months data of Key Performance Indicators(KPI) Prescription/ Medical Audit Analysis with Corrective and Preventive Action(CAPA). Statutory/ Regulatory Compliance Authorization for handling the Bio-Medical Waste from the State Pollution Control Board Fire Safety NOC Certificate of inspection of electrical Installation License for Operating lift (if applicable) X-ray Layout Approval from AERB License of Blood Bank Copy of registration under PCPNDT Act

66. Documents for CHC/UCHC Filled application form along with hospital data sheet No & names of departments to be assessed Latest state assessments reports & scores Minutes of last Quality Team Meeting(MOM) Departmental SOPs Quality Improvement manual Policies/ Procedures of the facilitie s Condemnation Policy Antibiotic Policy Social, Culture & Religious Equality policy Privacy, Dignity & Confidentiality policy of policy Consent Policy Referral policy Policy of timely reimbursement of entitlements & compensations Quality policy Scores of last 3 Patient Satisfaction Surveys and subsequent Corrective & Preventive actions Last 3 months data of Key Performance Indicators Prescription Audit Analysis with Corrective and Preventive Action (CAPA) report Statutory / Regulatory Compliance Authorization for handling the Bio medical waste from Pollution Control Board Fire Safety NOC Certificate of inspection of electrical Installation License for operating lift (if applicable) X ray layout approval form AERB License of Blood Storage Unit Copy of registration under PCPNDT Act (if applicable)

67. Documents for PHC/UPHC Filled application form along with hospital data sheet Latest state assessment report and scores Minutes of last Quality Team Meeting (MOM) Departmental SOPs Quality Improvement Manual Copy of Hospital Wide Policies/ Procedures. Quality Policy Condemnation Policy Maintaining of Patients Record, its security, sharing of information and safe disposal Referral Policy Scores of Last 3 Patient Satisfaction Surveys and Subsequent Corrective and actions undertaken Last 3 months data of Key Performance Indicators (KPI) Prescription Audit Analysis with Corrective and Preventive Action(CAPA) Statutory/ Regulatory Compliance Authorization for handling the Bio medical Waste form Pollution Control Board Pre-authorization from SPCB for sharp & deep burial pits in remote PHCs ( if applicable) Fire safety NOC

68. National level certification criteria for NQAS Certification for DH Criterion 1- Aggregate score of the health facility ≥ 70% Criterion 2- Scores of each department of the healthy facility ≥ 70% Criterion3- Segregated scores in each Area of concern( Service Provision, Patient’s Right, Inputs, Support Services, Clinical services, Infection Control, Quality Management, outcome Indicators) ≥ 70% Criterion 4- Scores of Standard A2, Standard B5 & Standard D10 is ≥ 70% in each applicable department Standard A2 states “the facility provides RMNCHA services” Standard B5 states “the facility ensures that there are no financial barriers to access and that there is financial protection given from the cost of hospital services” Standard D10 states “the facility is compliant with all statutory and regulatory requirement imposed by local, state pr central government” Criterion 5- Individual Standard wise scores ≥ 50% Criterion 6- Patient Satisfaction score of 70% in the preceding Quarter or more (Satisfied & Highly Satisfied on Mera- Aspataal ) or score of 3.5 on Likert scale.

69. National level certification criteria for NQAS Certification for CHC/U-CHC Criterion 1- Aggregate score of the health facility ≥ 70% Criterion 2- Scores of each department of the healthy facility ≥ 70% Criterion3- Segregated scores in each Area of concern( Service Provision, Patient’s Right, Inputs, Support Services, Clinical services, Infection Control, Quality Management, outcome Indicators) ≥ 70% Criterion 4- Scores of Standard A2, Standard B5 & Standard D8 is ≥ 70% in each applicable department Standard A2 states “the facility provides RMNCHA services” Standard B5 states “the facility ensures that there are no financial barriers to access and that there is financial protection given from the cost of hospital services” Standard D8 states “the facility is compliant with all statutory and regulatory requirement imposed by local, state pr central government” Criterion 5- Individual Standard wise scores ≥ 50% Criterion 6- Patient Satisfaction score of 65% in the preceding Quarter or more (Satisfied & Highly Satisfied on Mera- Aspataal ) or score of 3.2 on Likert scale.

70. National level certification criteria for NQAS Certification for PHC/U-PHC Criterion I - Aggregate score of the health facility ≥ 70% Criterion II – Segregated score in each Area of Concern ≥ 60% Criterion III – Score of Standard A2, Standard B4 and Standard F6 (PHC)/F4 (U-PHC ) is >60% in each applicable department. z Standard A2 (PHC/U-PHC) states “The facility provides RMNCHA services”. Standard B4 (PHC) states that “the facility ensures that there are no financial barriers to access, and that there is financial protection given from the cost of hospital services ”. OR B3 (U-PHC ) states that “The Services provided are affordable”. Standard F6 (PHC)/F4 (U-PHC) states “the facility has defined and established procedures for segregation, collection, treatment and disposal of Biomedical & Hazardous Waste”. Criterion IV - Individual Standard wise score ≥ 50% Criterion V – Patient Satisfaction Score of 60% in the preceding Quarter or more (Satisfied & Highly Satisfied on Mera- Aspataal ) or Score of 3.0 on Likert Scale.

71. National level certification criteria for NQAS Certification for Ayushman Arogya Mandir- Health Sub Centre Criterion 1- Aggregate score of the health facility ≥ 70% Criterion 2- Scores of each service package of the health facility ≥ 70% Criterion3- Segregated scores in each Area of concern( Service Provision, Patient’s Right, Inputs, Support Services, Clinical services, Infection Control, Quality Management, outcome Indicators) ≥ 60% Criterion 4- Scores of Standard ≥ 60% Standard A1 -The facility provides Comprehensive Primary Healthcare Services. Standard D3 - The facility has defined and established procedure for clinical records and data management with progressive use of digital technology. Standard D4 -The facility has defined and established procedures for hospital transparency and accountability. Standard D5- The facility ensures health promotion and disease prevention activities through community mobilization. Standard G2- The facility has established system for patient and employee satisfaction. Criterion 5-Individual Standard wise score ≥ 50% Criterion 6- Patient/Client Satisfaction Score- 60% or score of 3.0 on Likert Scale separately.

72. Recertification of NQAS Certified Facilities

73. Virtual Certification under NQAS