CHECKLIST FOR ESIC/ESIS HOSPITALS

S. No. Description Information

1. Name of the ESI Hospital / Institution

2. Whether a teaching Institution (or attached to) (Yes / No)

3. Whether Super-Specialty service is available (Yes / No)
4. Statistical Data for The Month and Year of:
5. Sanctioned Bed Strength
6. Commissioned Bed Strength for the month1
7. Total No. of In-patient service days for the month2
8. Total No. of Discharges in the month3
9. Total No. of Deaths in the month4
10. Total Length of Stay for All Patients discharged/ died in the month5
11. Total Cost/ Expenditure (excluding Capex6) during the month

12. Cost of Medical Items procured during the month through Local Purchase
(LP)7

13. Date of Reporting

14. Key Human Resource Status
Description In-Position Vacancy w.r.t. Present Commissioned Bed
a. Teaching Faculty
b. Specialist
c. Medical Officer
d. Nurses
e. Technicians
f. Pharmacists

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Sr. No. Parameter Comments

15. Swatchta Abhyan

16. VIBGYOR Sheets
17. Availability of adequate washrooms. Status of cleanliness with
hourly check list for housekeeping staff.
18. Safe drinking water
19. A) Hospital pharmacy for OPD patients
B) Adequacy of drugs and dressing for OPD & IPD patients
C) Adequacy of consumables for hospital services
20. Present status of all laboratory Services
21. Status of radiology services. If radiology services are not
operational, mention the hindrances in the order of priority.
22. Status of Labour Room facilities, nursery and Neonatal ICU
facilities. If not operational, mention the hindrances in the order
of priority.
23. Status of OT facilities. If OT facilities are not operational, mention
the hinderances in the order of priority.
24. Status of HDU/ICU services
25. Availability of emergency services and life-saving equipment in
the emergency wards.
26. Number of well-equipped operational ambulances available and
additional requirement, if any.
27. Status of Fire NOC, fire safety measures such as operational
firefighting equipment, fire extinguishers and sensors. Date of
last fire drill.
28. All statutory compliances available or not
29. Status of payment of salaries to contract workers

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30. Condemnation
31. Any other problem being faced in the delivery of services and
suggestion for its resolution.
32. In view of the existing sanctioned bed strength and occupancy
rate in the hospital, if any, need for review of the existing norms,
specifically with regard to the existing infrastructure.
33. Suggest measures for simplification of procedures in service
delivery for instance operationalizing of token system for OPD
registration, making the hospital disabled-friendly, reducing the
waiting time of consultation, diagnostic and other procedures,
simplifying the referral system etc. in order to improve the
overall patient experience and convenience.
34. Cordial and polite behaviour by the doctors and staff towards the
patients
35. Suggest measures for developing an IP feedback system to gain
knowledge of the satisfaction level of the IPs
36. Suggest measures for increasing the awareness among the IPs of
the facilities available to them under the scheme
37. Any other suggestion or comment for improving service delivery sss
of ESI Hospital and enhancing patient experience in:
Pathology/laboratory
Radiology services
ICU services
Labour room and Neo-Natal ICU facilities
OT facilities.
38. Any other suggestion or comment

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Capex – Capital Expenditure such as building, equipment etc.

Commissioned Bed Strength for the month1

Total No. of In-patient service days for the month2
Total No. of Discharges in the month3
Total No. of Deaths in the month4
Total Length of Stay for All Patients discharged/ died in the month5
Total Cost/ Expenditure (excluding Capex6) during the month
Cost of Medical Items procured during the month through Local Purchase (LP)7

STATISTICS OF External Referral of Patients to any institution for SST/Tertiary /Secondary/Primary Care from ESIC Hospital REFERRALS VIS-À-VIS PATIENT
ATTENDANCE
External Referrals (Primary/Secondary/Tertiary/SST) to any Institution (Other ESI,
Patient Attendance
Government & Private)
External External Referral for External Referral for
Total Total In- External Referral for
Sl. Month Total OPD Grand Total Referral all Diagnostic tests treatment /
Casualty / Patient treatment / procedure Total External
No. /Year Attendance /
Emergency Admissio
Patient from Out- (Investigations from procedure /
/ consultation from In- Referrals
[Link] Attendance Patient OPD, IPD, Casualty, consultation from
Attendance ns Patient
Depts Lab, Imaging, etc.) Casualty /Emergency
(A) (B) (C) (A+B+C) (D) (E) (F) (G) (D+E+F+G)

Increase in Commissioned Bed Strength/Count during the

From Date
month, If any
Decrease in Commissioned Bed Strength/Count during the
From Date
month, If any

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Performance Report of ESIS Hospitals
Name of the Hospital / Institution
Date of Inspection
Report for the Month & Year (it is the month in which physical inspection/visit is made)
Referral Statistics of the hospital used for the month of
Commissioned Bed Strength in the current month being reported upon
Whether a teaching Institution / Super Speciality Hospital (or attached to)
ESIC 2.0 REFORM INITIATIVE REVISED KEY PERFORMANCE SCORE
SCORE BY
Sl. No. PARAMETERS WEIGHTAGE
TEAM
Aadhaar Seeding Provisions (Advertisement & Counselling for Aadhaar Seeding in
1 'Panchdeep' database; Separate Counters, banners, educational material, motivational 3
initiatives)
Biomedical Waste Management & Safe Practices (Hand Washing Practices, appropriate
2 3
Segregation of Waste at Source, Colour coded bins, Appropriate Disposal Process)
Clean Hospital -Inside & Outside Premises (OPD, IPD, OT, Casualty, Diagnostic Depts, Lifts,
Stairs, Kitchen, Overhead tank, Trash Bins, Lawns, etc.; Display of cleaning schedule; White
3 3
washing/paints of exteriors & interiors - Status/ Condition; Horticulture, Gardening,
Landscaping & Ambience )
Courteousness & Hospitality (Behaviour of Staff towards Patients, Relatives & Guests,
4 3
Behavioral training provision)
Diet Management (Clean, Hygienic & Nutritious Diet; Display of Diet Chart & Plan;
5 3
Provision of Covered / packed diet)
Examination Table Etiquettes (Availability & use of Disposable, Hygienic, Clean Paper
6 3
Sheet on examination tables; Maintenance of Privacy)
Facilitation & Feedback Mechanism (Provisions & Adequate Functioning of 'May I Help
7 You' Desk/Counter; Patient Feedback Mechanism & its Review; Priority Registration 3
counter for Senior citizen, Differently-abled persons, Ladies, etc.)
Fire & Disaster Management System (Fire Fighting Provisions, Mock Drills, Training, Fire
8 3
Exits with Fluoroscent Glow Signs and Markings; Disaster Preparedness)
Green Environment Initiatives (Solar power; Rain water harvesting; Carbon Footprint
9 3
A reduction initiatives)
Indradhanush-VIBGYOR Policy (Clean, smart bed sheet arrangements; Daily change
10 3
schedule & Display)
Lighting Arrangements in Premises (Eco friendly LED Lights, Adequacy, Illumination,
11 3
Functionality)
Panchdeep Implementation (IT Infrastructure, Functioning Hardware, all out Involvement
12 3
of staff for Dhanwantri & ERP Adoption)
Patients' Relatives and Guests Amenities (Canteen, Cashless Services; ATM; Restroom
13 Facility; Waiting Room Facility; Beverage Vending Machine; Promotional, Educational and 3
Entertainment Provisions)
Potable Water Facility (Safe, Filtered & Purified cool/warm drinking water facility;
14 3
availability of disposable tumbler in OPD, IPD, Casualty etc.)
15 Quality Certification & Accolades (ISO, NABH, NABL), (Optional - GPNQ, TBEM, RGNQ, etc.) 3
Rest Room Amenities (Clean, Fresh, Hygienic & Aesthetic Toilets & Washrooms; Hourly
16 3
Cleaning & Display of schedule; Toilets for Differently-abled persons)
Seating Arrangement & Queue Management in OPD (Adequacy, Comfort, Ambience,
17 3
Amenities, Space availability & management; Efficient Queue management system)
Signage (Contents, Appropriateness, Adequacy, Size, Colour, Font, 3 Language, Aesthetics,
18 3
Glow Signs, Uniformity)
Water & Air heating/cooling facility (Hot Water, Geyser, Air Cooler, Room Heater, De-
19 3
humidifier, Air Conditioner, Air Purifier, etc.)
Website Content Management (Availability of up to date and functional website,
20 3
Uniformity, Appropriate linkages)
Quantum of Reduction of External referrals in comparison to same month previous year *
B 20
#
Sub Total 80
Quantum of Deviation of Referral % in comparison to Median of such Values of all
C 20
comparable hospitals of the group (To be awarded Centrally from Hqrs Office)
Grand Total 100
# * Please refer to Notes above.

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Signature: __________________ ______________ ______________
Name {in BLOCK): __________________ ______________ ______________
Date: __________________ ______________ ______________
Designation: __________________ ______________ ______________
Place of Posting: __________________ ______________ ______________