Hospital Structured Assessment Checklist

• Hospital Name

• Hospital ID

• Conducted on

  Date

• Prepared by

• Location
  Address

• Instructions:
  -------------------------------------
  1. Answer "Yes", "No", "N/A" for the questions below.
  2. Add photos and notes by clicking on the paperclip icon.
  3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date.
  4. Complete audit by providing digital signature.
  5. Share your report by exporting as PDF, Word, Excel or Web Link.

Infrastructure

• Hospital building is seismic proof (Retro-fitting)

  Yes

  No

  N/A

• Availability of functional electricity supply

  Yes

  No

  N/A

• Availability of piped water supply

  Yes

  No

  N/A

• Intact facility boundary wall

  Yes

  No

  N/A

• All sign boards/sign plates appropriately displayed

  Yes

  No

  N/A

• Facility building maintained last year

  Yes

  No

  N/A

• Enough seating available in the waiting area

  Yes

  No

  N/A

• Female OPD painted & Looks clean

  Yes

  No

  N/A

• Hospital look clean

  Yes

  No

  N/A

• Functional toilet for female patients

  Yes

  No

  N/A

• Labor room functional

  Yes

  No

  N/A

• Beds with mattresses & clean bed sheets

  Yes

  No

  N/A

• Functional Nursery

  Yes

  No

  N/A

• Functional OT sterilization room

  Yes

  No

  N/A

• Proper heating/cooling in labor room

  Yes

  No

  N/A

• Separate room/bed for management of Eclampsia

  Yes

  No

  N/A

• Functional telephone available in emergency department

  Yes

  No

  N/A

Basic Equipment

• Functional BP apparatus available in emergency department

  Yes

  No

  N/A

• Functional stethoscope available in OPDs

  Yes

  No

  N/A

• Functional Thermometer available

  Yes

  No

  N/A

• Functional weighing machine available in pediatric OPD

  Yes

  No

  N/A

• Functional small sterilizer available Emergency department

  Yes

  No

  N/A

• Functional delivery table available in labor room

  Yes

  No

  N/A

• Height Scale available

  Yes

  No

  N/A

• Fetoscope

  Yes

  No

  N/A

• Measuring tape

  Yes

  No

  N/A

• Autoclave in labor room/OT

  Yes

  No

  N/A

• Delivery Forceps

  Yes

  No

  N/A

• Fetal monitor

  Yes

  No

  N/A

• Anesthesia machine in OT

  Yes

  No

  N/A

• Incubator

  Yes

  No

  N/A

• OT lights are all functional

  Yes

  No

  N/A

• Biochemistry analyzer in laboratory

  Yes

  No

  N/A

• Suction machines in OT

  Yes

  No

  N/A

• Functional suction machines in OT

  Yes

  No

  N/A

• Functional suction machines in labor room

  Yes

  No

  N/A

• Baby Warmer

  Yes

  No

  N/A

• Nebulizer

  Yes

  No

  N/A

• Baby cot

  Yes

  No

  N/A

• Oxygen Cylinder

  Yes

  No

  N/A

• Nitrous Oxide

  Yes

  No

  N/A

• Laryngoscope

  Yes

  No

  N/A

• Anesthesia Face Mask

  Yes

  No

  N/A

• Ambu bag for Adult

  Yes

  No

  N/A

• Ambu bag for Infants

  Yes

  No

  N/A

• Please proceed to the section.

Human Resource

• Availability of medical officer in the health facility

  Yes

  No

  N/A

• Availability of lady health visitor (LHV) in the health facility

  Yes

  No

  N/A

• Availability of dispenser/MHT in the health facility

  Yes

  No

  N/A

• Availability of at least one support staff in the health facility

  Yes

  No

  N/A

• Availability of Gynecologist

  Yes

  No

  N/A

• Availability of Anesthetist

  Yes

  No

  N/A

• Availability of WMO

  Yes

  No

  N/A

• Availability of Nurse

  Yes

  No

  N/A

• Availability of Midwife

  Yes

  No

  N/A

• Availability of OT Technician

  Yes

  No

  N/A

• Availability of Blood bank Technician

  Yes

  No

  N/A

• Availability of Laboratory technician

  Yes

  No

  N/A

• Availability of Ambulance driver

  Yes

  No

  N/A

• Availability of Sanitation staff

  Yes

  No

  N/A

Essential Stocks/Material

• Availability of HIS stationary

  Yes

  No

  N/A

• Stock out of any essential (tracer) drugs

  Yes

  No

  N/A

• Availability of anesthetic gases/drugs

  Yes

  No

  N/A

• Modern FP material available

  Yes

  No

  N/A

Essential Drugs

• Availability of any type of oral antibiotic syrup for children

  Yes

  No

  N/A

• Availability of any type of oral antibiotic for adults

  Yes

  No

  N/A

• Availability of any type of antipyretic drug

  Yes

  No

  N/A

• Availability of folate/folic acid tablet

  Yes

  No

  N/A

• Availability of any type of antiseptic solution

  Yes

  No

  N/A

• Availability of any type of antihypertensive drug

  Yes

  No

  N/A

• Filled cylinders of nitrous oxide

  Yes

  No

  N/A

• Availability of any type of injectable antibiotic emergency department

  Yes

  No

  N/A

• Availability of any type of injectable analgesic in emergency department

  Yes

  No

  N/A

• Availability of functional and filled oxygen cylinder in OT

  Yes

  No

  N/A

• Availability of functional and filled oxygen cylinder in labor room

  Yes

  No

  N/A

• Availability of oral rehydration salt (ORS) sachet

  Yes

  No

  N/A

Knowledge of Service Providers

• Use pre-agreed criteria for knowledge assessment of relevant staff.

• Knowledge on Antenatal Care (ANC) service package delivery

  Yes

  No

  N/A

• Knowledge on Postnatal Care (PNC) service package delivery

  Yes

  No

  N/A

• Knowledge of LHV on normal delivery

  Yes

  No

  N/A

• Knowledge of LHV on assisted delivery

  Yes

  No

  N/A

• Knowledge of LHV on APH management

  Yes

  No

  N/A

• Knowledge on management of eclampsia/pre-eclampsia

  Yes

  No

  N/A

• Knowledge about MISP

  Yes

  No

  N/A

• Knowledge about management of excessive vaginal bleeding after delivery

  Yes

  No

  N/A

• Knowledge about puerperal Pyrexia

  Yes

  No

  N/A

• Knowledge about Management of prolonged labor

  Yes

  No

  N/A

• Knowledge of LHV on PPH management

  Yes

  No

  N/A

• Knowledge of Gynecologist/SWMO/WMO on performing C-Section

  Yes

  No

  N/A

• Knowledge on infection prevention/sterilization

  Yes

  No

  N/A

• Knowledge on post operative care

  Yes

  No

  N/A

• Knowledge of dispenser/ or MHT on drugs stock keeping

  Yes

  No

  N/A

• Please proceed to the next section.

Provision of Health Services

• Antenatal Care Services (ANC)

  Yes

  No

  N/A

• Post Natal Care Services (PNC)

  Yes

  No

  N/A

• TT Immunization

  Yes

  No

  N/A

• EPI Services

  Yes

  No

  N/A

• Hospital based normal vaginal delivery

  Yes

  No

  N/A

• Provision of contraceptives (FP material)

  Yes

  No

  N/A

• Cesarean Section

  Yes

  No

  N/A

• Management of Eclampsia

  Yes

  No

  N/A

• Medical Indoor services

  Yes

  No

  N/A

• Gynecology and Obstetrics indoor services

  Yes

  No

  N/A

• Laboratory services

  Yes

  No

  N/A

• Radiological services

  Yes

  No

  N/A

• Ultrasonography

  Yes

  No

  N/A

• Blood grouping performed

  Yes

  No

  N/A

• Blood transfusion performed

  Yes

  No

  N/A

• Parenteral antibiotics administered

  Yes

  No

  N/A

• Parenteral oxytocic drugs administered

  Yes

  No

  N/A

• Parenteral anticonvulsant administered

  Yes

  No

  N/A

• Manual removal of placenta performed

  Yes

  No

  N/A

• Removal of retained products performed

  Yes

  No

  N/A

• Assisted vaginal delivery performed

  Yes

  No

  N/A

Infection prevention/waste management

• Look for availability and functioning of the items.

• Functional autoclave

  Yes

  No

  N/A

• Functional sterilizer

  Yes

  No

  N/A

• Disposable gloves available

  Yes

  No

  N/A

• Aprons

  Yes

  No

  N/A

• Shoe covers/slippers in the LR/OT

  Yes

  No

  N/A

• Waste bins

  Yes

  No

  N/A

• Needle/sharp disposal box

  Yes

  No

  N/A

• Needle cutter

  Yes

  No

  N/A

• Antiseptic solution

  Yes

  No

  N/A

• Disposable syringes

  Yes

  No

  N/A

• Masks

  Yes

  No

  N/A

• Caps

  Yes

  No

  N/A

• Macintosh

  Yes

  No

  N/A

• Intact sewage system

  Yes

  No

  N/A

• Fly proofing

  Yes

  No

  N/A

• Inspected by:

  Sign