10/12/2025
Dated-10/12/2025
External Assessment of District Hospital Mangan on: 08/12/2025
Assessment Team:
Ms. Sandhya Rai, Joint Director – Sanitation
Ms. Krishna Sharma, District Quality Consultant – Pakyong/Coordinator STNM
Ms. Prasansamani Rai, District Quality Consultant – Gangtok
An external Kayakalp assessment of District Hospital (DH) Mangan was conducted on 8 December 2025 by the designated assessment team. The purpose of the visit was to evaluate the hospital's adherence to Kayakalp thematic areas, review progress from previous assessments, identify gaps, and suggest actionable improvements aimed at enhancing cleanliness, infection control, and overall quality of public healthcare services.
The assessment followed the standard Kayakalp external assessment checklist, covering the six core thematic areas:
Hospital Upkeep
Sanitation & Cleanliness
Waste Management
Infection Control
Support Services
Hygiene Promotion
The team conducted:
Facility walkthroughs
Interaction with staff and beneficiaries
Verification of records and maintenance logs
Observation of practices in critical areas (OT, Labour Room, IPD, OPD, CSSD, BMW areas)
Key Observations
Hospital Upkeep
Overall infrastructure was maintained adequately, with functional lighting, ventilation, and basic amenities.
Minor repairs required in certain corridors and outpatient areas.
Signage system present but needs clearer directional indicators in a few zones.
Sanitation & Cleanliness
Regular cleaning schedules were observed, and housekeeping staff were aware of protocols.
Toilets were generally clean, though some required improved odor control and more frequent refilling of consumables (handwash, tissues).
Outdoor premises were mostly clean, with minor littering noted near the boundary area.
Waste Management
Segregation at source largely adhered to; colour-coded bins available in clinical areas.
Biomedical waste storage area maintained, but the team recommended improved labeling and routine internal audits.
Sharp waste pits and deep burial pits were functional and compliant.
Infection Control
Hand hygiene practices were being followed, though compliance varied among departments.
Infection Control Committee functional; records of meetings and surveillance maintained.
Use of PPE was appropriate; however, certain wards required replenishment of stock.
Disinfection protocols were in place, but monitoring checklists need more consistent updating.
Support Services
Laundry services functional, with segregation and cleaning processes in place.
Water supply adequate; drinking water points operational.
Dietary services maintained acceptable hygiene standards.
Hygiene Promotion
IEC materials displayed in prominent locations.
Staff awareness good; patient awareness activities ongoing.
Public areas had functional handwashing stations.
Strengths Noted
Motivated hospital administration and staff cooperation during assessment.
Good documentation of infection control and sanitation activities.
Effective waste segregation and operational BMW management system.
Visible improvement in cleanliness in comparison to previous review inputs. Gaps Identified
Inconsistent documentation in monitoring checklists.
Need for moderate civil repairs and repainting in specific areas.
Toilets requiring improved odor control and maintenance of consumables.
Stock gaps in PPE in some departments.
Boundary area cleanliness needs more stringent monitoring.
Recommendations
Undertake minor infrastructure repairs and repainting where required.
Strengthen monitoring of sanitation checklists and ensure daily countersignature.
Improve hand hygiene compliance through periodic micro-observations and feedback.
Ensure consistent availability of PPE and essential consumables.
Regular cleaning and surveillance of outdoor premises and peripheral zones.
Conduct refresher orientation for housekeeping and nursing staff on BMW and infection control.
Conclusion
The external assessment team observed that District Hospital Mangan has made substantial progress in maintaining cleanliness, hygiene, and infection control in alignment with the Kayakalp standards. While certain operational and documentation gaps persist, the hospital demonstrates strong administrative commitment and potential for higher scoring with focused follow-up.
The team appreciates the cooperation extended by the hospital administration and staff during the assessment.
