6 Maternity OT Laqshya Assessment Toolkit (2).xlsx

	A	B	C	D	E	F	G	J
1	National Quality Assurance Standards 2016
2	Checklist for Maternity Operation Theatre
3	Assessment Summary
4	Name of the Hospital					Date of Assessment
5	Names of Assessors					Names of Assesses
6	Type of Assessment (Internal/External)					Action plan Submission Date
7	Operation Theatre Score Card
8	Area of Concern wise Score			Operation Theatre Score
9	A	Service Provision	50%	50%
10	B	Patient Rights	50%
11	C	Inputs	50%
12	D	Support Services	50%
13	E	Clinical Services	50%
14	F	Infection Control	50%
15	G	Quality Management	50%
16	H	Outcome	50%
17
18		Major Gaps Observed
19	1
20	2
21	3
22	4
23	5
24		Strengths / Good Practices
25	1
26	2
27	3
28	4
29	5
30		Recommendations/ Opportunities for Improvement
31	1
32	2
33	3
34	4
35	5
36		Signature of Assessors
37		Date
38
39
40
41	Checklist for Operation Theatre
42	Reference No.	ME Statement	Checkpoint	Compliance	Assessment Method	Means of Verification	Remarks	%
43		Area of Concern - A Service Provision						50
44	Standard A1	Facility Provides Curative Services						50
58	ME A1.14	Services are available for the time period as mandated	OT Services are available 24X7	1	SI/RR	Check with OT records that OT services were functional in 24X7 and surgeries are being conducted in night hours
60	ME A1.16	The facility provides Accident & Emergency Services	Availability of Emergency OT services as and when required	1	SI/OB
61	ME A1.17	The facility provides Intensive care Services	Availability of Maternity HDU/ICU services in the facility	1	SI/OB
63	Standard A2	Facility provides RMNCHA Services						50
64	ME A2.1	The facility provides Reproductive health Services	Availability of Post partum sterilization services	1	SI/OB	tubal ligation
65	ME A2.2	The facility provides Maternal health Services	Availability of Elective C-section services	1	SI/RR	Check services are available and are being utilized
66			Availability of Emergency C-section services	1	SI/RR	Check services are available and are being utilized
67			Management of MTP	1	SI/OB	Surgical management
68	ME A2.3	The facility provides New-born health Services	Availability of New born resuscitation& essential new born care	1	SI/OB	Dedicated Functional New born Care services in Operation theatre
70	Standard A3	Facility Provides diagnostic Services						50
72	ME A3.2	The facility Provides Laboratory Services	Availability of point of care diagnostic test	1	SI/OB	Glucometer, RDK , Blood grouping
99		Area of Concern - B Patient Rights						50
100	Standard B1	Facility provides the information to care seekers, attendants & community about the available services and their modalities						50
101	ME B1.1	The facility has uniform and user-friendly signage system	Availability of departmental signage's	1	OB	Numbering, main department and internal sectional signage, Restricted area signage displayed. Directional signages are given from the entry of the facility
102	ME B1.2	The facility displays the services and entitlements available in its departments	Information regarding services are displayed	1	OB	Display doctor/ Nurse on duty and updated OT schedule displayed
108	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.						50
110	ME B2.3	Access to facility is provided without any physical barrier & and friendly to people with disabilities	OT is easily accessible	1	OB	Availability of Wheel chair or stretcher for easy Access. Door is wide enough for passage of trolley and staff.
113	Standard B3	Facility maintains the privacy, confidentiality & Dignity of patient and related information.						50
114	ME B3.1	Adequate visual privacy is provided at every point of care	Patients are properly draped/covered before and after procedure	1	OB	Look patients are covered while transferred from ward to OT and vice-versa.
115			Visual Privacy is maintained between two OT Tables	1	OB	Preferably only one OT table should be placed in theatre, if it is not possible because of high case load adequate visual privacy should be provided through screens of multiple patients are present in same OT
116	ME B3.2	Confidentiality of patients records and clinical information is maintained	Patient Records are kept at secure place beyond access to general staff/visitors	1	SI/OB	In drawers/Amirah; preferably with lock facility.
117	ME B3.3	The facility ensures the behavior of staff is dignified and respectful, while delivering the services	Behaviour of OT staff is dignified and respectful	1	OB/PI	Check that OT staff is not providing care in undignified manner such as yelling, scolding , shouting, blaming and using abusive language
118	ME B3.4	The facility ensures privacy and confidentiality to every patient, especially of those conditions having social stigma, and also safeguards vulnerable groups	Pregnant women is not left unattended or ignored during care in the OT	1	OB/PI	Check that care providers are attentive and empathetic to the pregnant women at no point of care they are left alone.
119	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.						50
120	ME B4.1	There is established procedures for taking informed consent before treatment and procedures	Consent is taken for surgical procedures	1	SI/RR	written consent with details of the procedure with potentials risks and complication. Should be signed by patient/next of kin and one witness
121			Separate consent is taken for Anesthesia procedure	1	SI/RR	written consent with details of the anaesthesia with potentials risks and complication. Should be signed by patient/next of kin and one witness
126	Standard B5	Facility ensures that there are no financial barrier to access and that there is financial protection given from cost of care.						50
127	ME B5.1	The facility provides cashless services to pregnant women, mothers and neonates as per prevalent government schemes	All surgical procedure are free of cost for JSSK beneficiaries	1	PI/SI	free drugs, consumables , blood, referral etc.
142		Area of Concern - C Inputs						50
143	Standard C1	The facility has infrastructure for delivery of assured services, and available infrastructure meets the prevalent norms						50
144	ME C1.1	Departments have adequate space as per patient or work load	Adequate space for accommodating surgical load	1	OB	OT around 40 Square meter. Two OT tables are not kept in one OT
146	ME C1.3	Departments have layout and demarcated areas as per functions	Demarcated Protective Zone	1	OB	Reception, waiting area, stretcher/Trolley bay, Pre and post operative rooms,
147			Demarcated Clean Zone	1	OB	Doctor's and Nurse's room, Anesthesia room, equipment room, emergency exit.
148			Demarcated sterile Zone	1	OB	Operating room, Scrub station, Anesthesia station,
149			Demarcated disposal Zone	1	OB	Disposal corridor, janitor closet
150			Availability of Changing Rooms	1	OB	Separate for male and females
151			Availability of demarcated Pre & post Operative Room /area	1	OB	Can be in a single room with a partition.
152			Availability of earmarked area for new born Corner	1	OB	Functional warmer, resuscitation apparatus, suction/mucous extractor, O2 cylinder, weighing scale and sterile gloves.
153			Availability of Scrub Area	1	OB	Height around 96 cm with elbow taps/sensors, both hot and cold water available. Sink is deep and wide enough to avoid spoiling. Scrub area should not be inside the OT room.
154			Availability of TSSU /CSSD	1	OB	Dedicated areas with provision of Washing, Packing , Autoclaving the instruments and linen
155			Availability of store	1	OB
156	ME C1.4	The facility has adequate circulation area and open spaces according to need and local law	Corridors are wide enough for movement of trolleys	1	OB	7 to 10 feet.
157	ME C1.5	The facility has infrastructure for intramural and extramural communication	Availability of functional telephone and Intercom Services	1	OB	Intercom should connects Operation theatre to key areas like ICU, Blood Bank, SNCU, Lab, Accident and emergency, wards, Administration
158	ME C1.6	Service counters are available as per patient load	OT tables are available as per load	1	OB	Hydraulic OT Tables As per case load at least two
159	ME C1.7	The facility and departments are planned to ensure structure follows the function/processes (Structure commensurate with the function of the hospital)	Unidirectional flow of goods and services	1	OB	Services are designed in a way, that there is no criss cross in moment of sterile & no sterile supplies & equipment etc.
160	Standard C2	The facility ensures the physical safety of the infrastructure.						50
161	ME C2.1	The facility ensures the seismic safety of the infrastructure	Non structural components are properly secured	1	OB	Check for fixtures and furniture like cupboards, cabinets, and heavy equipment , hanging objects are properly fastened and secured
163	ME C2.3	The facility ensures safety of electrical establishment	OT does not have temporary connections and loosely hanging wires	1	OB	No extension cord or multi-plugs
164			Availability of three phase electricity supply	1	SI/OB	Check electricity bill or Power Distribution Board. Meter have three wires coming out (with one neutral).
165	ME C2.4	Physical condition of buildings are safe for providing patient care	Walls and floor of the OT covered with joint less tiles	1	OB	made of anti-skid & Epoxy flooring
166			Windows/ ventilators if any in the OT are intact and sealed	1	OB	No broken glass, gap or cracks in window/ventilator.
167	Standard C3	The facility has established Programme for fire safety and other disaster						50
168	ME C3.1	The facility has plan for prevention of fire	OT has sufficient fire exit to permit safe escape to its occupant at time of fire	1	OB/SI	Check the fire exits are clearly visible and routes to reach exit are clearly marked
169	ME C3.2	The facility has adequate fire fighting Equipment	Labour room has installed fire Extinguishers & expiry is displayed on each fire extinguisher	1	OB	Class A , Class B, C type or ABC type. Check the expiry date for fire extinguishers are displayed on each extinguisher as well as due date for next refilling is clearly mentioned
170	ME C3.3	The facility has a system of periodic training of staff and conducts mock drills regularly for fire and other disaster situation	Check for staff competencies for operating fire extinguisher and what to do in case of fire	1	SI/RR	staff should be able to demonstrate how to open the extinguisher and operate it. PASS (Pull the pin, Aim at the base of fire, Sway from side to side)
171	Standard C4	The facility has adequate qualified and trained staff, required for providing the assured services to the current case load						50