Quality Assurance Program



The Quality Assurance Programme is being implemented in the state since Nov 2014 as per the operational guidelines for Quality Assurance in public Health facilities 2013. Quality Assurance is a cyclical process which needs to be continuously monitored against defined standards and measurable elements laid down in the guidelines. Measurement and compliance to 70 standards will be mandatory for a district level facility to get National level certification including the certification for RMNCH+A services under Quality Assurance Programme. Regular assessment of public health facilities by their own staff and state level assessors, action planning for traversing the observed gaps is the only way in having a viable Quality Assurance Programme.

The facilities which get National certification for the quality and have been retained such status during subsequent assessment shall be incentivized.

Organizational framework:

Following committee/units have been constituted for effective implementation of the programme.

State Quality Assurance Committee.

State Quality Assurance Unit.

District Quality Assurance Cell.

District Quality Assurance Unit.

Quality Team-STNM hospital and four district hospital.

The Quality Assurance cell is located at Annexure Building, HC, HS& FW Deptt. and headed by Additional Director cum SHO and supported by officers and staff of Sanitation cell, and External Assessor (I/ C Emergency) District Hospital Singtam.

Activities conducted during 2015-16:

Mrs. Madhukala Mishra went for Internal assessment at Disrict Hospital Namchi under QAP. 26th-27th May 2015

Dr. D. C. Sharma, District Medical Superintendent –District Hospital Namchi, went for 2nd Batch External Assessors Training under Quality Assurance Programme from 13th– 17th July 2015 at New Delhi.

Orientation workshop on Kayakalpat Guwahati and Awareness workshop on Kayakalp at New Delhi 29th June 2015 was attended by Dr.Sarita Lama, Addl. Director cum SHO, Dr. RinzingLhamu, Joint Director, Mrs. Madhukala Mishra, District Hospital Singtam and Mrs. VijayaLakhsmiRai-DPHN-District Hospital Namchi.

One Day Sensitization training on Kayakalp at Gangtok was held on 1st August 2015.

Orientation workshop on External Assessment for Kayakalp and Model Health District Initiative was held at Guwahati.


Internal Assessment of District Hospital Singtam from 18th to 20th June 2015.

Internal Assessment of Four District Hospitals and STNM Hospital under KayakalpProgramme.

State level and District level Assessors visited District Hospital Namchi, DH Singtam and DH Gyalshing from 9th Sept’ for Peer assessment of the health facilities for KayakalpProgramme.

External assessment of District Hospital Namchi and District Hospital Singtam was conducted on 22nd and 23rd Sept 2015 under KayakalpProgramme

Fund released to District Hospital Namchiand Singtamfor traversing the gaps under Quality AssuranceProgramme.

Purchase of stationery items under Quality Assurance Programme.

Printing of guidebooks for Quality Assurance Programme and Kayakalp.

State level assessment of District Hospital Namchi under Quality Assurance Programmew.e.f 28th -30th January 2016 (Score-68.57%).

State level assessment of District Hospital Singtam under Quality Assurance Programme during 10th -12th February 2016 (Score-78.25%).

Assessment of District Hospital Singtam by District Quality Assurance Unit under Quality Assurance Programmew.e.f. 15th-17th January 2016(Score-72.64%).

Dr. D. C. Sharma, Mrs. Madhukala Mishra & Mrs. MonmoyuriDutta attended one day orientation workshop at Guwahati on 18th September 2015 for all NE States on Model Health District initiative.

Dr. Pramila Kothari, JD cum Nodal Officer Urban Health Centre and Mrs. MadhukalaMishra, went for one day orientation workshop on quality assurance guidelines and implementation of quality assurance programme under National Urban Health Mission on 18th Feb 2016 at New Delhi.

District Hospital Singtam received 1stKayakalp Award and District Hospital Namchi received 2nd commendation award.


The Clinical Establishment (Registration and Regulation) Act 2010 has adopted by the State Govt. of Sikkim on 31st July 2012 with the view to prescribing the minimum standards of facilities and services provided by theHealth, so that mandate of Article 47 of the constitution for the improvement in public health may be achieved. The State Govt. of Sikkim has notified and constituted the state council body comprising 15 members vide gazette notification no. 57/HC,HS & FW dated 19.04.2012 and also constituted the District Registering Authority in the District level. Vide notification no. 53/HC, HS& FW dated19.04.2012 .The Act is being implemented by the District Registering Authority constituted under four Districts & GMC Area, Gangtok. The process for renewal of the provisional will be granted two year as per the guidelines of Govt. of India, Ministry of Health & Family Welfare.

Physical verification of the clinical establishments who have been issued the provisional registration are also being conducted by a team of officers from Clinical Establishment cell, District Collectorate Office &Gangtok Municipal Corporation. The Technical Officers like Consultant Radiologist, Consultant Pathologist are also being involved wherever necessary.The Govt. health facilities are also being visited. The District Hospitals have been instructed to take action for registering all diagnostic facilities including X-Ray equipment as per Atomic Energy Regulatory Board Guidelines. The Clinical Establishment have been instructed to report on noticeable diseases like TB in coordination with State TB Cell. During the visit some of the Clinics, it was found that MTP is being conducted without taking approval of the place to conduct MTP. Hence, they have also been instructed to comply with the MTP Act. However, Clinical Establishment Cell and RCH wing (NRHM) would be working together to tackle these issues.

The permanent registration would be granted to the Clinical Establishment if only when a Clinical Establishment fulfills the prescribed standards for registration by the Central Govt. The online registration of Clinical Establishment was initiated in coordination with officials of NIC, Gangtok. However, it couldn’t be operationalized due to shortage of Office Assistant/Data Entry Operators in the cell. Online registration will be started once the post of Data Entry Operators are appointed by the central Govt.

The total provisional registration of different categories of clinical establishment has been made by the DRA Offices till 31/03/2016.


Sl.No.District/StateDistrict /State HospitalPHCsPHScsCHC
Grand Total – 178.



Sl.No.Clinical Establishment (Private)Total No.Registered as on 31/3/16
1Private Hospital11
2Allopathy Single Practitioner2828
3Ayurvedic Clinic66
4Ayurvedic Hospital11
5Homeopathy Clinic1010
6Diagnostic Centre/Lab/Poly Clinic2525
7Dental Clinic1212
8Eye Clinic44
9Rehabilitation Centre77
10Nature Care11
12Alternative Medicine (Tibetan)22
13Physiotherapy Clinic66
14Radio Diagnostic/Imagine Centre1010
Grand Total115115


Rs.50,000/- (Fifty Thousand) only/- has been earmarked underState Plan Budgetfor implementation of various activities of Clinical Establishment.However, fund has been utilized by the account section for other purpose.


To start online registration system of Clinical Establishment Act, 2010.

To regularize left out unauthorized private practitioner.

Appointment of Data Entry Operator through (NHM).

To notify and to include 3(three) other member under Clinical Establishment Act,2010 from Police Department, UDH Department, and from professional medical association for a period of two year accordance to under clause (C) of Sub Section (i) of section 10 of the Act.

To organize State Level Council meeting and meeting of District Registration Authority quarterly.

To grant permanent registration certificate of clinical establishmentsubject to fulfillment of the prescribed minimum standard of Clinical Establishment required by the central government.

Proposed Budget for 2016-17.

1State Council level meeting (Half Yearly)Rs.1,00,000/-
2Workshop and Meeting of DRA (Half Yearly)Rs.1,00,000/-
3Mobility Support (POL/TA/DA)Rs.2,00,000/-
4Advertisement Awareness Rs.50,000/-
5TA/DA to Officers for attending meetings outside StateRs.1,00,000/-
TOTAL Rs.5,50,000/-