Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download iii. clinical management priority areas
Document related concepts
no text concepts found
Transcript
HOSPITAL QUALITY SUPERVISION CHECKLIST February 2016 Date received by ______________________________________ For RBF use: % Structural score (35%Weight): ………….... % Management & planning score % Clinical care score (65% weight): ……….... Final Combined Score from Database: …….... HOSPITAL QUALITY SUPERVISION CHECKLIST Questionnaire for a Provincial/District/Mission Hospital Quality Review Province: _______________________________________________________________________________ District: ________________________________________________________________________________ Hospital: _______________________________________________________________________________ Number of beds: ________ Catchment area population: __________________________________________ Date of supervision: ______________________________________________________________________ Name of supervisors and designation No. Name of supervisor 1 2 3 4 5 Designation 1 I. Hospital Staffing STAFF Establishment In post District Medical Officer Government Medical Officer Clinical Officer Health Promotion Officer District Nursing Officer Matron Sister in Charge Sister in Charge Community Principal State Certified Nurse Sister General State Certified Nurse District TB Coordinator District Environmental Health Officer Environmental Health Officer Environmentla Health Technician Pharmacist Pharmacy Technician Dispensary Assistant Nutritionist Assistant Nutritionist Radiographer X-ray Operator Dark Room Assistant Physiotherapist Medical Laboratory Scientist District Health Service Administrator Human Resource Officer Health Information Assistant Accountant Accounting Assistant Government Dental Officer Dental Therapist Dental Surgery Assistant Rehabilitation Technician CCSD Packer Nurses with midwifery Up skilled PCN PCN Operating theatre nurses Nurse anaesthetist Nurse aides General hands Non-medical staff or unqualified staff : Cook, , Non-medical staff or unqualified staff : driver Non-medical staff or unqualified staff : Laundry Hand , Senior Hand) 2 Vacant Duration of vacancy ASSESSMENT SUMMARY I. STRUCTURAL SECTION General Structure and auxiliary services Structure in clinical departments TOTAL II, MANAGEMENT & PLANNING SECTION Administration, finance, planning Infection control Emergency services Operating theatre Laboratory Pharmacy Radiological services Outpatient department (OPD) Family and Child Health (FCH) Extended Program Immunization (EPI) Maternity ward HMIS TOTAL III. CLINICAL MANAGEMENT SECTION OPD/ consultation area TB management ANC-PNC Best practices Maternity waiting home HIV-PMTCT Ambulatory management diarrhoea, pneumonia Delivery best practices Management obstetric complications Inpatient Pediatric best practices Inpatient management diarrhea, pneumonia Postoperative infection control Quality Improvement/Assuranc e TOTAL Available Points 11 Number of composite indicators 6 43 20 44 Available Points 26 Number of composite indicators 17 8 7 12 19 13 28 9 10 4 5 6 10 11 4 3 7 2 17 7 17 14 7 4 170 71 Available Points Number of composite indicators 3 4 18 24 54 6 30 9 1 5 48 66 54 28 28 12 8 11 8 4 4 2 22 384 7 66 3 Applicable valid points this quarter Number of applicable composite indicators this quarter Total points scored Applicable valid points this quarter Number of applicable composite indicators this quarter Total points scored Applicable valid points this quarter Number of applicable composite indicators this quarter Total points scored I. STRUCTURAL SECTION I.1 Structural indicators in the general compound of the Hospital, mortuary, Operating theatre and maternity waiting home *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 1S Outside appearance (when arriving at hospital): 1S.1 -Visible sign post 1S.2 -Fence/wall without holes and a gate that can be closed 1S.3 -Functional guard room with boom gate and functional light at the gate? 1S.4 -Direction signs with visiting times displayed 2S Maintenance of the ground: 2S.1 -Clean ground and grass cut 2S.2 2S.3 -Garden well maintained with flower beds, trees or lawn, resting places (benches in shade),and with no animal excrement, no litter or dangerous objects such as needles, syringes, gloves, used cotton wool, etc, -Sufficient parking area with clean pavements 3S Waste water drainage system 3S.1 -Connected to local sewage system (if not, septic tank must be available) 4S Incinerator within the premises: 4S.1 -Available, functional, fenced and being used 5S Waste pit for non-contaminated objects: 5S.1 -Waste pit with hole of minimum 3 metres depth fenced, without infected non decomposable (non – biodegradable) objects available (Waste pit is only required in hospitals where the city municipality is not collecting the non-contaminated objects) 6S Lighting system 6S.1 -Electricity for at 24 hours a day, and 7 days a week (Source of electricity: ZESA with backup system of either generator or solar energy and/or inventors). Total points this quarter (MAXIMUM AVAILABLE Points: 11 POINTS) 4 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded I.2 Structural Indicators in Selected Departments: Indicat ors Randomly select one department each quarter for indicators listed below. Please vary the department to be selected quarterly *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators *if you write N/A for an indicator in a selected department, please deduct the points for the indicator from the maximum available points 7S Outside appearance of buildings 7S.1 7S.2 8S -External appropriate wall finishing( painting, bricks or rough plastering) -Roof intact with well-maintained gutters, window panes Inside appearance of building and its cleanliness 8S.1 -Walls and Floors- Clean, without cracks and floors-polished ( if required) and Ceiling / roof intact without leaks neither cobwebs 8S.2 -Doors with locks and closing properly 9S Firefighting System: 9S.1 9S.2 -Functional and serviced fire extinguishers with or without water hoses available and accessible -Fire exits clearly marked and is there a clearly marked firefighting assembly area and evacuation plan: Ask staff member on firefighting plan 10S Garbage bins in ground 10S.1 -Bins with lids and plastic lining available and not more than ¾ full without hazardous waste (e.g. sharps, used cotton wool e.t.c) at accessible points 11S Presence of sufficient well maintained latrines/toilets 11S.1 11S.2 11S.3 12S -One water closet for every 6 inpatients or One water closet for every 20 outpatients -The toilet entries should be clearly marked for each sex and the male toilets should also have a urinal -Recently cleaned without visible faecal matter or urine Water and soap for hand washing: 12S.1 -Hand washing facilities with running water and soap available at accessible points 13S Waste collection 13S.1 13S.2 -Waste collected and disposed daily or within 4 to 5 hours ( only for maternity ward) (Ask staff member) Waste segregated with colour coding: -Red/yellow for non-sharp infectious waste and sharp objects 5 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded N/A: if the indicator is not applicable in the selected department Please select one department among the following four departments ( encircle the selected department) and assess indicators 7S-16S 1. OPD 2. FCH 3. Maternity Ward 4. Paediatric Ward -Black for communal non-sharp non-infectious wastes and/or service area *the bins and/or sharp boxes should not be more than ¾ full 14S 14S.1 14S.2 Protective clothing and disinfectant use by cleaners: * Ask the available cleaners during the assessment period -Cleaners have appropriate protective clothing (Heavy duty gloves, Uniforms, Dustcoats, Gumboots, Face Mask) -Cleaners know how to appropriately use disinfectants? (1 part jik (sodium hypochlorite industrial) to 9 parts water for general cleaning and 1 part jik to 4 parts for spillages i.e. blood and mainly body fluids) 15S Professional staff appropriately dressed : 15S.1 -Clean with standard uniform, identification tag and lace up shoes. 16S 16S.1 16S.2 16S.3 16S.4 Staff duty roster, staff leave calendar and clock in register (per department) including maintenance and cleaning duty roster with timeline and signature column for cleaner and supervisor: -Duty roster clearly visible including assigned nurse(s) and doctors(s) covering each ward for each shift, including night and weekend coverage - The DOCTOR, NURSES actually present in the ward (Check the person/s on duty on the day of visit) -Staff leave calendar complete and up to date, and displayed where all staff can see -Clock in register including maintenance and cleaning with timeline and supervisor signature column Sub-total points ( maximum available sub-total points: 20) Please select one department among the following two departments ( encircle the selected department) and assess indicators 17S-20S 1. OPD 2. FCH 17S Good conditions in waiting area, meeting minimum standards: 17S.1 -With sufficient benches and / or chairs (according to daily attendance): calculate the average daily attendance from the weekly attendance - Well/adequately ventilated with sufficient light adequate ventilation of waiting area: If Open space with a shade or roof supported by brick or metal pillars or If closed space: windows should measure at least 1/10 of floor area and at least ½ of window area should be openable. Consultancy rooms in good condition, meeting minimum standards -Windows with curtains or non-transparent glass and screen around bed 17S.2 18S 18S.1 18S.2 -Functional doors with lock 18S.3 -Furniture (at least one chair and table for nurse/doctor, one chair for patient) 18S.4 -Hand washing facility 18S .5 -Examination bed in good condition and covered with clean linen 19S OPD fees, and medical aid companies: 6 19S1 -OPD fees and list of accepted medical aid companies accepted displayed in local vernacular (when applicable) and easily visible for patients 20S Hygienic and aseptic conditions in wound dressing: 20S.1 -Bench and foot rest covered with Macintosh available 20S.2 -Bins for infected and contaminated objects with lid, plastic lining and foot pedal available and not more than ¾ full -Sharp box well positioned and not more than ¾ full? 20S.3 Sub- total points (maximum sub-total points: 11) Please select one department among the following two departments ( encircle the selected department) and assess indicators 21S-26S 1. Maternity Ward 2. Paediatric Ward 21S Availability and status of furniture and other items 21S.1 -Beds, and mattresses with sheets, blankets, bedside lockers, benches on bed side available and in good state (not broken, torn and clean) -Mosquito nets (in malaria endemic areas) available and in good state ( Not Applicable in Non-Malaria Endemic area) 21S.2 21S.3 -Fan and heater available when required 22S Bucket or basin for dirty linen: 22S.1 -Bins covered with a lid and not overflowing 23S Hygienic condition, access to water and space: 23S.1 -Clean and regular cleaned ( ask staff member or look at the weekly plan for cleaning) 23S.2 -Safe drinking water available and accessible 23S.3 -Enough space between beds (at least 1m between beds) 23S.4 -Well ventilated without bad smells 23S.5 24S -Shower with running water, and/ or container with at least 100 litres for patients to bath with hot water available during winter? Movable lockable drug trolleys: 24S.1 -Available with working locks? 24S.2 -Dangerous drugs cupboard (double locked) each with a different lock available 24S.3 -DDA registers available Sub-total ( maximum sub-total available points: 12) Total points this quarter (MAXIMUM AVAILABLE Points: 43 POINTS) 7 II. MANAGEMENT AND PLANNING: STAFF, POLICY, GUIDELINES, Medicines & SUPPLIES and Vaccines II.1 ADMINISTRATION, FINANCE AND PLANNING Indicat ors *Assess at District Medical officer’s office/Administration and/or Finance Department /Matron office *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 1M Mission statement , Vision, Values and patient charter 1M.1 -Displayed in public places and clearly visible 2M 2M.2 Catchment area map, spot map, monitoring graphs, demographic data:* Assess the indicator in the office of the DMO/Matron or administrator office -Catchment area maps with current catchment population target population for services calculated correctly and displayed -Spot map showing recent or suspected out breaks with clear markings displayed 2M.3 -Monitoring graphs for different services displayed 3M Documentation of activities/ Operational Plan 3M.1 -Staff minute book/file available, well filed and up to date 3M.2 4M.1 -Quarterly review reports, annual operational plan and annual progress report ( of previous year) available, well filed and up to date Management book, inventory register, maintenance book, returns( human, material and finance) - Available and up to date? 5M Service and maintenance plan for hospital equipment and vehicles 5M.1 -Plan available and being followed (Ask for reports and cross check with the plan) 6M Purchasing of medicines, equipment and consumables 6M.1 -MoHCC tender and procurement procedure documents available? 6M.2 -Functional CBU and PTC available 6M.3 -Medicines, equipment and consumables purchased as per the procedure? (ask the procurement committee to provide the documents for an item which was purchased and cross check whether it was bought as per the MoHCC procedures) Finance and accounting system 2M.1 4M 7M 7M.1 7M.2 -Financial and accounting documents available and well-kept in clearly labelled files including bank statements, payment vouchers with attached support documents. -Document showing budget and revenues (GoZ, HSF, RBF, Donations) available 7M.4 -Managed by qualified staff (accountant/ accounts assistants)? 7M.5 8M -Financial reports which show expenditure of proper utilization of funds according to statutory requirements and minutes of finance meetings available Ambulance and communication systems 8M.1 -The hospital has a functional (24/7) ambulance 8 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded 8M.2 -The hospital has a functional communication system (land line/cell phone/radio) Total points this quarter: (Maximum Available Points: 17) II.2 . INFECTION CONTROL *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators *If N/A, please deduct the points for the indicator from the maximum available points 9M Infection control committee *Assess the indicator by asking the infection control committee/focal person -The hospital has a functional infection control committee ( check for the minutes of meetings) -Infection control guideline available 9M.1 9M.2 9M.3 10M 10M.1 10M.2 11M 11M.1 12M 12M.1 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded -The committee assesses implementation of infection control guidelines and taking measures according to the guideline? ( check in reports/minutes) Sterilization of instruments: Assess the indicator at CSSD (Central Steam Sterilizing Department) as all sterilizations are done in this department. -Functional Autoclave/ Steam steriliser available Sensitive tape available on sterilized packs and cords not used to tie packs ( check at least two packs) Guidelines -Guidelines available and utilized (Ask a staff member at CSSD and compare the response with the guideline Regular training of kitchen staffs on food handling: Check for training reports from Hospital Food Services Supervisor and ask two kitchen staff members -Kitchen staff members receiving regular in house training (quarterly) on food handling Total points this quarter: (Maximum Available Points: 7) II.3 EMERGENCY SERVICES Indicat ors *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators * 13M. Staff Duty Roster for On call Medical doctor and support staff 13M.1 -Duty roster fully completed and posted in public place for medical and support staff on call through the month (doctor, lab, x-ray, anaesthetist, theatre nurse and observed on the day of the visit)? -Response time for staff on call displayed and a review of calls made to ascertain response time SUPPLIES 13M.2 9 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded 14M Are the following emergency airway equipment available and functional? 14M.1 -Suction machine, adult and paediatric laryngoscope, bag and mask (ambubag) (adult and paediatric), oxygen. - If not functional was a report made? *Equipment should be easily accessible not stored under lock and key. Emergency tray: 14M.2 15M 15M.1 15M.2 15M.3 -With all the necessary drugs (as from EDLIZ). 50% dextrose, adrenaline, lignocaine, diazepam, atropine, -Emergency tray book up to date, signed daily, no expired drugs 16M -The tray is labelled? (should be including the drugs and accessories, with clearly legible and durable labels) Important Accessories: 16M.1 -Cannula, syringes and needles, specimen bottles, 16M.2 -Swabs, strapping, disinfectant, gloves, face mask 16M.3 -Functional laryngoscope 17M IV fluids and blood : 17M.1 -Ringer lactate, 5% dextrose, and normal saline available and not expired and giving sets, drip stand Blood and blood products 17M.2 Total points this quarter: (Maximum Available Points: 12) II.4. OPERATING THEATRE Indicat ors *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators *If N/A, please deduct the points for the indicator from the maximum available points 18M 18M.1 Structure and Ventilation system, and register -Walls of durable material and easily washable walls, Non transparent windows and functional doors with floor paved with vinyl/ ceramic tiles without cracks, ceiling in good state -Good appropriate air ventilation system: small meshed windows to let air in ( if only natural ventilation is used) and/or air conditioner fitted without/with sealed windows ( if mechanical ventilation is used), and doors to the aisle closed -Surgical register available and up to date? 18M.2 18M.3 SUPPLIES 19M Operating table 19M.1 -In good state with easy to clean mattress covered with waterproof material? 19M.2 - Functional hand rests with handcuffs & stir ups? 19M.3 -The table can be tilted and raised 20M Basic equipment and consumables: -Are the following basic equipment & consumables available? 10 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded N/A: not applicable 20M.1 20M.5 Anaesthetic machine with :Patient monitor, ECG and ETCO2, Ambu Bag, Laryncoscope size 0-4 and O2 cylinder for back up, functional failure alarm and7 ventilator Air way equipment: Endotracheal tubes size 3.5-8.5, Laryngeal mask sizes 2-5, Oral air way sizes 00-6, Intubating intruder and all range sizes of face masks Efficient suction machine, fluid warmer, pressure pump infusion gadget, all range sizes of cannulas, syringes and needles and defibrillator Medicines: ketamin, pethidine/morphine, metclorpromide, suxamethanium, atracurium, ephedrine, neostigmine, diclophenac IM/supporitory Emergency drugs: adrenaline, atropine, NaHCO3, hydrocortisone, promethazine 20M.6 Inhalation anaesthetic agents: halothane and/or isoflurane , N2O and O2 cylinder 21M Movable lockable drug trolleys 21M.1 -Available with working locks? 21M.2 -Dangerous drugs cupboard (double locked) each with a different lock, with DDA registers available? Emergency surgical packs (general and caesarean ): 20M.2 20M.3 20M.4 22M 22M.1 -At least 5 kits for each of the packs i.e. general and caesarean available 23M Gowning area and theatre clothing: 23M.1 -Available and has adequate washing and scrubbing space? 23M.2 -Has Pedal or elbow tap with disinfection device? 23M.3 - Running water and anti-septic available? 23M.4 -Surgical blouse, trousers, masks, hats, sandals and gumboots, goggles and gowning packs available Total points this quarter: (Maximum Available Points: 19) II.5. LABORATORY SERVICES Indicat ors *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 24M Staffing of Laboratory: 24M.1 -Qualified (certified) staff (laboratory technician and/or lab scientist)? 25M Functionality of Laboratory after working hours:- 25M.1 -Functional and available for emergencies after working hours? * Verify after hour activities in the laboratory register for the last quarter Recording of results: 26M 26M.1 -Laboratory register correctly and completely filled: Check record of any month in the last quarter 27M Washing dirty pipettes: 11 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded 27M.1 28M 28M.1 -Lab personnel wash dirty pipes in containers with antiseptic (except disposable pipettes)? Internal and External quality assurance services: 29M -Internal and external quality controls done *Check for copy of report of internal and External quality assurance assessment report ( by ZINQAP) c SUPPLIES Parasite demonstration on plastic paper, in a colour book, or put on wall 29M.1 Blood smear: Vivax, Oval, Falciparum, Malariae 29M.2 Stools: Ascaris, entamoebae, ankylostome, schistosome 30M 30M.1 Microscope: -Available and in working condition (functional) with functional objectives immersion oil – mirror or electricity and – blades, cover glass, slides, GIEMSA Equipment: 31M 31M.1 32M.2 -Centrifuge, full blood count machine, chemistry analyser machine, incubator and fume cup board (also serviced) available and serviced and functional: ( Check in the maintenance register if the assessments were done monthly and signed for) Reagents -Available for the equipment mentioned under 30M.1 and 31M.1? (Check stocks against minimum levels) -No expired stocks 32M.3 -Expiry and disposal register available 33M 33M.1 Are the following items available? -Gloves, specimen containers, appropriate protective clothing 32M 32M.1 Total points this quarter: (Maximum Available Points: 13) II.6. PHARMACY (MEDICINES AND SUNDRIES STOCK MANAGEMENT) Indicato rs *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 34M Staffing and Specimen Signature: 34M.1 -Pharmacy being manned by qualified staff (Pharmacist and/or Pharmacy technician)? -Specimen signatures for prescribers available at pharmacy? 34M.2 35M Statutory instruments: 35M.1 -Medicines and Allied Substances Act available 35M.2 -Dangerous Drugs Act available 36M Availability of essential medicines: -Availability for at least 90 days. 12 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded 36M.1 Magnesium sulphate 36M.2 Gentamycin, Amoxicillin : select one and check its availability 36M.3 Oxytocin 36M.4 36M.5 Contraceptives (implant, injectable, post-operative IUD, progestone- oral contraceptive, combined oral contraceptive pills)* select one among the list and check its availability RHZE: rifampicin + isoniazid + pyrazinamide+Ethambutol 36M.6 Hydrochlorthiazide, Metformin, Insulin: select one and check its availability 37M HIV and AIDS medicines: Availability for at least 90 days. Adult first line ART: Preferred: TDF +3TC+NVP, alternate: TDF+3TC+EFV or ZDV+3TC+EFV/NVP ( could available in Dual or triple FDCs) Paediatric first line ART: Preferred:AZT+3TC+NVP (3-10 yr old), AZT+3TC+LPV/r ( <3 yrs) 37M.1 37M.2 37M.3 38M.1 Adult Second line: AZT + 3TC + ATV/r or LPV/r or TDF + 3TC + ATV/r or LPV/r Paediatric Second line: ABC+3TC+LPV/r VEN medicinesPlease ask for the MIS report for any one month in the last quarter and then check in the report whether the VEN medicines were available as required V Medicines available at 100% in the last three months 38M.2 E Medicines available at 80% in the last three months 38M.3 N Medicines available at 60% in the last three months 39M Stock Cards: 39M.1 39M.2 -Monthly physical counts conducted with min, max and emergency order levels recorded and updated - The physical stock level corresponds with that on the stock card 40M Storage of drugs: 40M.1 -Stored correctly in a locked secured storeroom (e.g burglar bars on windows and doors)? -Clean place, well ventilated with cupboards, labelled shelves, no incident light 37M.4 38M 40M.2 41M.3 41M -Medicines stored in alphabetical order also observing the First Expiry First Out rule Expired products: 41M.1 -Separated from stock 41M.2 -Expired medical items disposed according to guidelines(Check for the presence of expired medicine register disposal register and certificate. verify randomly 3 medicines and 2 consumables (check stock cards) Prescriptions: * check last 3 prescriptions from OPD register and compare with EDLIZ 42M 13 42M.1 43M 43M.1 44M 44M.1 -Prescriptions made according to latest edition of EDLIZ Adverse events report:*Ask the DMO or at the pharmacy -The hospital sent adverse drug reaction report to PHE and/or MCAZ/MoHCC HQ in the last quarter (Check for presence of copy of adverse event) ( if there was no adverse event, check for the presence of the reporting forms) Average number of antibiotics prescribed to a patient •Assessment: measured by considering the previous 30 patients/prescription/T12 (pharmacy register) and then tallying the number of antibiotics per prescription and divide by 30. (Acceptable range is 2-3) *Source of data: Pharmacy register -The average number of antibiotics prescribed to a patient is less than two-three antibiotics in any one month in the last quarter Total points this quarter: (Maximum Available Points: 28) II.7 Indicato rs RADIOLOGICAL SERVICES *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 45M Staffing of Radiological department: 45M.1 -Manned by qualified staff? (radiographer or x-ray operator 46M Registration and monitoring of staff for exposure:- 46M.1 -Radiology department registered with radiation authority of Zimbabwe 46M.2 -Staffs monitored for radiological exposure SUPPLIES 47M Radiological equipment: 47M.1 - X-ray machine Available and working 47M.2 48M -Ultrasound scan machine available and working ( if it is available in maternity ward, consider it as available, but check its functionality) Protective clothing and necessary safety precautions: 48M.1 -Available for each X-Ray room and in place 49M Consumables : minimum level 49M.1 -X-ray films 49M.2 X ray fixers available 49M.3 X ray developers available Total points this quarter: (Maximum Available Points: 9) 14 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded II.8. OUTPATIENT DEPARTMENT (OPD) Indicato rs *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 50M Staffing 50M.1 -Consultations are done by appropriately qualified staff NURSE (RGN)/DOCTOR 51M Guidelines/protocols 51M.1 National Malaria guidelines for diagnosis and treatment of uncomplicated and severe malaria -On wall, accessible to staff and up to date PEP policy and guidelines: -Available in OPD Opportunistic Infection and ART guidelines: -AVAILABLE AND ACCESSILBE in all consultation rooms STI Management protocol: -Displayed in all consultation rooms and up to date IMNCI guidelines: -Available and flowcharts displayed in all consultation areas SUPPLIES 51M.2 51M.3 51M.4 51M.5 52M Equipment and PEP kit 52M.1 Adult weighing scale and Standard Paediatric Weighing (SALTER) Scale available and functional , height meter, BMI calculator, glucometers and strips, peak flow meter, ophthalmoscope, otoscope, stethoscope, otoscope, sphygmomanometer, HC meter Functional thermometer and OPD register in place 52M.2 52M.3 52M.4 PEP kit readily available in the event of a needle stick injury or other accidents Total points this quarter: (Maximum Available Points: 10) II.9 53M 53M.1 53M.2 53M.3 53M.4 54 M 54M.1 FAMILY AND CHILD HEALTH (FCH) Guidelines/protocols, medicines and equipment Focused ANC protocol in ANC care area: -Available, displayed and up to date PMTCT guidelines and charts : -Available and accessible PMTCT medicine: -Available according to guidelines? Standard Paediatric Weighing (SALTER) Scale, length/height board and MUAC tape -Available and functional Availability of functional OTP equipped with ( outpatient therapeutic center at health facility ) OTP register and case sheet 15 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded 54M.2 54M.3 RUTF ( ready to use therapeutic food ) ( adequate for at least three months: based on previous records/admissions/utilization) Trained health worker on IMAM ( Integrated Management of Acute Malnutrition) Total points this quarter: (Maximum Available Points:7) II.10. EXPANDED PROGRAM ON IMMUNIZATION (EPI) Indicato rs *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators * N.B. Please assess once all the indicators requiring opening of the refrigerator in order to avoid frequent opening of the refrigerator 55M POLICY & GUIDELINES 55M.1 -Surveillance line listing and case definitions displayed 55M.2 -Updated EPI schedule, and a contingency plan displayed 55M.3 55M.4 -EPI graphs showing trends displayed and staff member is able to interpret the graphs -EPI reference materials: EPI Policy, (e.g. multi dose vial policy (MDVP) and EPI modules available and easily accessible SUPPLIES & STORAGE 56M Cold Chain Mechanism: 56M.1 -Fridge with a temperature booklet available and filled twice a day 56M.2 -The temperature is within the recommended range of + 2 and+ 8 degrees Celsius (Supervisor should verify functionality of thermometer) Availability of vaccines: 57M 57M.1 57M.2 58M 58M.1 -The following antigens are available: BCG, MR ( measles and Rubella), polio, Penta, tetanus, pneumococcal and rota virus vaccine -The physical stock and the amount in the stock cards match ( Supervisor verifies physical stock in the fridge by selecting three different vaccines quarterly) Vaccines storage 58M.2 -Correctly stored in fridge with compartments as follows in fridges with compartments: -Freezing compartment: ice packs well frozen -None freezing compartment: top shelf BCG, OPV, measles -Lower shelf: DPT+HEPB, TT, etc N.B. the new type of refrigerator i.e. Dometic fridge do not have compartments and the live vaccines are stored in the lower tray ( colder zone) -No expired vaccines 58M.3 -The Vaccine Vial Monitor (VVM )status is kept 58M.4 -There are readable labels on vials with matching diluents 59M Syringes: 16 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded 59M.1 -The number of syringes available matches the number of vaccines in the stock cards 60M Sharps boxes: 60M.1 61M.1 -Sharps boxes available in immunisation room/corner/area and not more than 3/4 full) EPI accessories:: the following EPT accessories should be available and functional -Vaccine carriers, cold box, gas regulator, gas cylinder and scissors 62M Forms: 62M.1 - AEFI investigation forms, case investigation forms for EPI targeted diseases and vaccine wastage monitoring forms available -Vaccine order forms and stock cards available 61M 62M.2 Total points this quarter: (Maximum Available Points: 17) II.11 MATERNITY Paediatric Services ; LABOUR, DELIVERY POST-NATAL CARE FOR MOTHER AND NEWBORS and Children Indicators *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 63M 63M.1 63M.2 Medicines on Emergency tray: Are the following medicines available on the emergency tray and not expired? -IV fluids (ringer lactate, 5% dextrose, normal saline) and giving sets 63M.3 -Adrenaline, lignocaine, diazepam, oxytocin, ergometrine, Magnesium Sulphate, calcium gluconate -Cannula, syringes and needles, drip stand, swabs, strapping, disinfectant 63M.4 -At least 10 pairs of sterile gloves available, face mask, specimen bottles 64M PPH kit ( please open one kit and check for its completeness) 64M.1 -PPH kits available and complete: please refer to the annex section in the checklists guideline for list of items that should be available in the PPH kit *refer annex section in the checklist guideline for the list of items in PPH kit Eclampsia kit ( please open one kit and check for its completeness) 65M 65M.1 66M.1 Eclampsia kit available and complete: please refer to the annex section in the checklists guideline for list of items that should be available in the eclampsia kit *refer annex section in the checklist guideline for the list of items in Eclampsia kit Equipment/supplies for care of newborn and monitoring FHB: Are the following equipment available? -Fetoscope, baby blanket, Baby scale and tape measure 66M.2 -Sterile cord clamps/ties for umbilical cord, Eye ointment ( Tetracycline) 66M.3 -Neonatal bag and mask, penguin suction, resuscitator and suction bulb (at 66M 17 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded least two sets) in a “ready newborn resuscitation” area next to delivery bed 66M.4 Electric heater, and wall clock: 67M Obstetric sterilised delivery packs: ( open one pack to see whether all the items are present and check for expiry date ) -At least 5 obstetric sterilized delivery standard packs with -2 wrapping towels, 6 drapes, A galipot with 10 swabs, 5 gauze swabs, A receiver, 2 Artery Forceps, Cord Scissor, Episiotomy Scissor, Drying towel for hands, Gown, Cord ties, sanitaory pads available Delivery bed: 67M.1 68M 68M.1 69M -All beds in the maternity ward/delivery room are in good state (not broken, mattress not torn) and covered with a clean sheet Availability of functional equipped KMC ( Kangaroo Mother Care) unit 69M.1 KMC bed 69M.2 Heat source 69M.3 KMC wrap for baby ( mbereko) 69M.4 Clothes for baby ( hat, nappy and socks) 69M.5 KMC register Total points this quarter: (Maximum Available Points: 17) II12 . HEALTH INFORMATION MANAGEMENT SYSTEM Indicato rs *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators 70M Referral and feedback system: 70M.1 * review referral made in any one month in the last quarter ( if there was no referral made in the selected month, extend the period of assessment to any of the two months in the last quarter) -Standard referral forms (at least 10) available 70M.2 - 71M T Series forms and timely reporting : Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded N/A: Not applicable Referral register available and properly filled ( Applicable only if there was referral in the last quarter) * check the following two items in in any one month in the last quarter 71M.1 -The T Series forms are available and fully completed (T1, T2, T3, T5, T6, T11, and T12) 71M.2 -The T5 and HS3/5completed and sent timely (by the 21st of the following month) for previous months (Please check for the hard copies of the report at PMD office) For the following two indicators requiring review of registers and/or reported figures/indicators: Score each register/reported figure as: 1: if all criterion that have been met/ recorded 0: if the criteria has not been met/ not recorded And then give an overall score as shown below: 5 Points: if 5 (100%) of registers/reported figures are complete and/or correct/accurate 3 Points: If 3-4( 60-80%) of registers are complete and/or correct/accurate 18 0 Point: if ≤2 (≤40%) of registers are complete and/or correct/complete 72M Completeness and correctness of information in registers : *Randomly select 5 registers to assess the indicators below 72M.1 *Please review the annex section of the checklist guideline for the list of registers available in a hospital setting Are the information in each column of the selected registers complete and correct in any one month in the last quarter ( Select different registers quarterly)? 73M Accuracy and correctness of reported figures: 73M.1 Are the figures reported in any one month of the last quarter correct according to the HMIS age groups in the T5 and HS3/5? * Randomly select five indicators , verify for accuracy and correctness (selected different indicators quarterly) Total points this quarter: (Maximum Available Points: 14) 19 R1 R2 R3 R4 R5 Com plete regist ers Over all score i1 i2 i3 i4 i5 Accu rate and corre ct figur es Over all score III.CLINICAL MANAGEMENT PRIORITY AREAS 1C OPD/CONSULTATION AREA 1C1 1C2 1C3 1C4 For indicator 1C1: assess by reviewing 5 files of patient who visited the clinic during the day of assessment. If there are no enough records, assess files of patients who visited the clinic in the last month. Score each file as 1or 0 as per the criterion and then give an over score/points for the indicator For indicator 1C2: assess by asking at least half of RGNs on duty during the day of assessment. Score each criterion as 1 or 0 as per the response of the health care provider and then give an over score/point for the indicator. For indicator 1C3: assess by review OPD register and/or TB presumptive register *Source of data: OPD register and OPD patient cards *Observation of triage process *Health provider question Triaging of patients at OPD waiting area during all clinic shift: -Patients are classified into three groups and given due attention accordingly: Assess by reviewing patient files if patients are available at OPD during the day of assessment. If not, assess by asking the nurses on how they conduct triaging of patients ( their answers should match with the points listed below) Emergency signs requiring immediate attention Priority signs (requiring priority in the queue Non-urgent cases % of hospital OPD provider(s) that can correctly state at least 4 adult TB symptom screening criteria (providers on shift day of assessment) • Assessment: Ask at least half of the facility provider/s at OPD to name criteria for TB testing. Answer must include at least 4 of the following 5 symptoms and/or a known TB contact exposure: 1) Weight loss 2) fever for more than 3 weeks 3) cough for more than 14 days 4) cough in HIV+ patients 5) TB contact exposure. % of TB presumptive (TB symptom positive) that have sputum results documented in any month in the last quarter AMBULATORY MANAGEMENT OF TB *Source of data: TB Register *Review TB register and select 5 cases with TB in the any one month in the last quarter. If more than 5 cases found, randomly select 5 cases for each disorder. If the number of cases is not enough extend the search to the last quarter to gather 5 cases for each disorder. If less than 5 cases in the last quarter assess the cases found *Write Not Applicable (N/A) if there are no TB cases for review * Indicators 1C4-7 should be assessed at TB clinic and/or OI/ART clinic % of TB patients (SS + and SS-) that have HIV test results documented in any month in the last quarter 20 PATIENT’S RECORDS Or TB Symptom screening 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded N/A: not applicable if there is no record for review 1 2 3 4 5 5 records /symptoms (100%): 6 points 4 records /symptoms (80%): 4 points 3 records /symptoms (60%): 2 points ≤2 records /symptom (≤40%): 0 points Complete records POINTS 1C5 % TB patients diagnosed in any one month in the last quarter that are receiving correct treatment with DOTS, 1C6 % TB patients diagnosed in any one month in the last quarter that were TB notified 1C7 % TB patients diagnosed in any one month in the last quarter that TB contact tracing was conducted SUBTOTAL Points – ( Maximum available points:42 ) 2C 2C1 2C1.1 2C1.2 2C1.3 2C1.4 FAMILY AND CHILD HEALTH (FCH) AMBULATORY (ANC, PNC) BEST PRACTICES Source of Data: *ANC register for ANC Best Practise indicators * PNC register for PNC/Postpartum best practise indicators *Assess 10 cases/records in any one month in the last quarter. *If there are no enough cases for review, please extend the review period to a quarter. *If there are less than 10 cases for review after extending the review period to a quarter, assess the available cases/records. * If there are more than 10 cases for review, select 10 cases by using either simple/systematic random sampling *If there no records for review/the indicator is not applicable in the set up being assessed, please do not assess and not score the indicator; rather write N/A and deduct the available points for the indicator from the maximum available points. ANC BEST PRACTICES PATIENT’S RECORDS/Registers 1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recorded N/A: not applicable: if there are no records for review *Score each case/record as 1 or 0 and then give a score for items per patient record, when applicable. * At last, please write the number of records with complete information as required and give an over score/points as the per the criteria in the right column 1 % of first visit ANC bookings in any one month in last quarter who had documented: BP Height Weight measurements Fundal height measurements (if pregnancy >16 weeks of gestation) ALL ITEMS PER PATIENT RECORD % of first visit ANC bookings in any one month in last quarter who received the standard laboratory test according to the ANC guideline: Blood group and RH HIV test Haemoglobin RPR (Rapid plasma regain for syphilis diagnosis) ALL ITEMS PER PATIENT RECORD % of first visit ANC bookings with ≤ 16 weeks of gestation in any one month in last quarter who had documented pregnancy test results % of first ANC visits in any one month in last quarter who received TT vaccine 21 2 3 4 5 6 7 8 9 10 9-10 records (≥90%): 6 points 8 records (80%): 4 points 7 records (70%): 2 points ≤6 records (≤60%): 0 points Complet Points e records 2C1.5 2C1.6 2C2 2C2.1 2C2.3 2C2.4 2C2.5 3C % of first ANC visits in any one month in last quarter who received iron supplementation % of first ANC visits in any one month in last quarter who received IPTp (if pregnancy >16 weeks of gestation if women living in malaria area) * Write Not-Applicable (N/A) if it is not a malaria endemic area POSTNATAL AND/OR POSTPARTUM BEST 1 PRACTICES *Source of data: PNC register for indicators % PNC visits in any one month in last quarter documenting assessment for the following conditions of the infant: General condition of the infant; Passage of urine and/or stool by asking parents ALL ITEMS PER PATIENT RECORD % PNC visits in any one month in last quarter documenting assessment for the following conditions of the mother: General condition ,Pulse rate, B/P and temperature NAD recorded if abnormality was not detected ALL ITEMS PER PATIENT RECORD % PNC visits in any one month in last quarter documenting infant feeding (BF) status (exclusive, mixed or not BF) % women post-partum counselled and offered any of the modern FP method (below)at follow up PNC visit within 6 weeks of delivery in any one month within the last quarter POP (progesterone-only contraceptive safe with BF) injectable, Implant IUCD Tubal ligation Decline SUBTOTAL: ( Maximum available points: 54) 2 3 4 5 6 7 8 9 10 MATERNITY WAITING HOME PATIENT’S RECORDS Follow up of pregnant mothers in maternity waiting home 1: All criterion have *Write Non-Applicable (N/A) in clinics without maternity waiting homes been met/ recorded): 0: if all criterion have and/or if there are no mothers in maternity waiting homes during the assessment period and deduct the available points for the indicator from not been met/ recorded N/A: if there are no the maximum available points. *If there are less than 5 mothers in the maternity waiting home,, assess mothers in the maternity waiting indicator with mothers available during the day of assessment home ANC Best Practices: follow up of pregnant mothers in maternity waiting home 22 1 2 3 4 5 Complet Points e recods 5 records (100%): 6 points 4 records (80%) : 4 points 3 records (60%) : 2 points ≤2 records (≤40%): 0 points Complete POINTS record 3C1 % of mothers in maternity waiting homes monitored for BP, FHR, and assessed for danger signs daily *Source of data: ANC cards of pregnant mothers SUBTOTAL; ( Maximum available points: 6) 4C HIV–PMTCT Source of data: ANC, ART, Delivery and DNA PCR register *Review ANC register and select 5 newly identified HIV women for indicator 4C1. *Review ART/ANC register to identify pregnant women initiated on ART before 6 months or indicator 4C2 *Review delivery register and select 5 HIV exposed new-borns for indicators 4C2-4C4 in the last quarter. *If more than 5 cases found, select 5 cases using simple/systematic random sampling for each condition. If less than 5 cases in the last quarter, assess all the cases found. *N/A (Not Applicable) if there are no HIV+/HIV exposed cases for review and deduct the available points for the indicator from the maximum available points 5 records (100%): 6 points 4 records PATIENT’S RECORDS (80%) : 4 points 1: if all criterion have been 3 records met/ recorded): (60%) : 0: if all criterion have not 2 points been met/ not recorded ≤2 records N/A: not applicable: if (≤40%): there are no records for 0 points review 1 4C1 4C2 4C3 4C4 4C5 2 3 4 5 Complete POIN TS records % NEWLY IDENTIFIED HIV + pregnant women initiated on ART in MNCH (ANC) ON THE SAME DAY in the last quarter *Source: ANC and ART register % of HIV+ women retained on ART 6 months after initiation in ANC in the last quarter *Source: ART register % of infants born to HIV+ women who had a DNA PCR sample within 6-8 weeks of birth in the last quarter *source of data: delivery register, PNC register and DNA PCR register % of HIV exposed infants who had A DNA PCR SAMPLE COLLECTED within 6-8 weeks of age and received results within one month in last quarter *Source of data: DNA PCR register % of confirmed HIV positive infants initiated on ART in last quarter WITHIN 21 DAYS OF RECEIPT OF RESULTS *Source of data: DNA PCR register and ART register SUBTOTAL: ( Maximum available points: 30) 5C AMBULATORY MANAGEMENT OF DIARRHEA, PNEUMONIA, MALARIA and Severe Acute Malnutrition in CHILDREN *Source of data: OPD/ IMCI register/CMAM register *Review OPD/ IMCI register and select 5 cases with pneumonia, 5 cases with diarrhea and 5 cases with malaria in the last month. If more than 5 cases found, randomly select 5 cases for each disorder. If the number of cases is not enough extend the search to the last quarter to gather 5 cases for each disorder. If less than 5 cases in the last quarter assess the cases found *Not Applicable (N/A) if there are no cases for review 5 records (100%): PATIENT’S 6 points RECORDS 4 records (80%) : YES (all criterion 4 points that have been met/ 3 records (60%) : recorded): 2 points No (if the criteria ≤2 records (≤40%): has not been met/ not 0 points recorded) : NA (not applicable): N/A 1 5C1 % children treated as outpatient for pneumonia in any one of month in last quarter who were correctly assessed 23 2 3 4 5 Complete POINTS records 5C2 5C3 5C4 *Source of data: OPD/ IMNCI register Absence of general danger signs recorded: able to drink/feed, vomiting, consciousness Duration of fever and cough/difficult breathing and child’s age recorded Respiratory rate, and presence/absence of chest in drawing, stridor and wheezing recorded ALL ITEMS PER PATIENT RECORD % children correctly treated as an outpatient for (ambulatory) pneumonia in any one of month of the last quarter among those correctly assessed Treatment: Oral Amoxicillin 50mg/kg divided thrice per day x 5 days; caretaker counselling and follow up or admitted into hospital % children with diarrhoea correctly assessed for signs of dehydration), persistent diarrhoea and dysentery in any one of month of the last quarter Assessment of dehydration: Using IMNCI guidelines (Integrated Management of Neonatal and Childhood Illnesses) IMNCI Flow diagram available and applied, Duration of diarrhoea and presence of blood recorded General condition of the child recorded: lethargy, consciousness and/or restless or irritability Presence of sunken eyes, drinking status ( thirsty/drinking eagerly or un able to drink/drink poorly) and skin pinch ALL ITEMS PER PATIENT RECORD % Children correctly treated as an outpatient (ambulatory) for diarrhoea in any one month of the last quarter among those correctly assessed Treatment : ORS, Zinc supplements and continued feeding and advise when to return 5C5 5C6 5C7 5C8 % children diagnosed with malaria that have RDT + or laboratory confirmation in any one month of the last quarter % Children with uncomplicated malaria correctly treated according to national guidelines in any one month of the last quarter Treatment: ARTEMETHER (20mg)-LUMEFANTRINE (120mg)(C0ARTEMETHER) during 3 days (See treatment protocol in appendix 2 of the checklist guideline) % Children with severe malaria correctly treated according to national guidelines in any one month in the last quarter Treatment: PARENTERAL ARTESUNATE IS THE MEDICINE OF CHOICE at a Dose of 2.4mg/kg body weight for 7 days(See treatment protocol in appendix 2 of the checklist guideline) % of 6-59 months old children with un complicated severe acute malnutrition (SAM) who were managed as per the national protocol in any month in the last quarter A 6 to 59 months old child with any one of the following criteria is classified as SAM : Weight for height <-3SD (WHO) MUAC <115mm MUAC <125mm and HIV positive Bilateral pitting oedema Out Patient management of SAM: RUTF Routine Medicine Health and nutrition counseling and continued follow up *see annex section of checklist guideline for treatment details 24 SUBTOTAL: ( Maximum available points: 48) 6C MATERNITY SERVICES; LABOUR, DELIVERY POST-NATAL CARE FOR MOTHER AND NEWBORN DELIVERY BEST PRACTICES *Source of data: delivery register and partograms *Review delivery register and randomly select 10 deliveries in the last month. If the number of deliveries is not enough extend the search to the last quarter to gather 10 deliveries. If less than 10 deliveries in the last quarter assess the cases found. If more than 10 cases in a month/quarter then randomly select 10 deliveries and assess the partograms for the deliveries selected to assess the following indicators * Write Not Applicable (N/A) if there are no cases for review and deduct the available points for the indicator from the maximum available points. PATIENT’S RECORDS 1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recorded N/A: not applicable: if there are no records for review 1 6C1 6C2 % deliveries performed by skilled personnel in any one month in the last quarter •Assessment: Identification of the nurse/ midwife by names in the delivery register % partographs completed per guideline in any one month in the last quarter Fetal heart tones plotted every 30 minutes State of membranes every 4 hours presence/absence meconium Descent of presenting part every 4 hours Contractions plotted every 30 minutes Maternal BP every 4 hours Maternal pulse every 30 minutes Maternal temperature every 4 hours Urinalysis documented at admission ALL ITEMS PER PATIENT RECORD % total births in any one month in the last quarter documenting administration of immediate 6C3 postpartum oxytocin 10 units IM (within one minute of delivery of baby) (AMSTL: Active management of third stage of labour) % births with placental status documented at birth 6C4 in any one month in the last quarter •Assessment: complete or ragged , retained placenta % newborns BF within one hour of birth in any one 6C5 month in the last quarter •Assessment: Time of BF initiation documented % newborns received Vitamin K in the any one 6C6 month in the last quarter % newborns received eye care (Tetracycline) in the 6C7 any one month in the last quarter % newborns received first vaccination (BCG) in the 6C8 any one month in the last quarter *source of data: Delivery and PNC register % women delivered monitored in early post-partum 6C9 period (4th stage) per guideline (birth to discharge) in the any one month in the last quarter 25 2 3 4 5 6 7 8 9 10 9-10 records (≥90%): 6 points 8 records (80%): 4 points 7 records (70%): 2 points ≤6 records (≤60%): 0 points Complete records POINT S 6C10 *Source of data: partographs Vaginal bleeding, at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge Uterine contraction at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge BP at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge Pulse at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge Temperature at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge ALL ITEMS PER PATIENT RECORD % newborns monitored in early post-partum period per guideline (birth to discharge) in the any one month in the last quarter *source of data: partographs 6C11 Temperature documented at least every 30 minute first 2 hours after birth then four hourly until discharge Respiratory Rate documented at least every 30 minute first 2 hours after birth then four hourly until discharge Breast feeding status documented at least every 30 minute first 2 hours after birth then four hourly until discharge Colour documented at least every 30 minute first 2 hours after birth then four hourly until discharge ALL ITEMS PER PATIENT RECORD % facility births seen for day 3 PNC visit in any one month in the last quarter *Source of data: PNC register SUBTOTAL: ( Maximum available points: 66) 7C OBSTETRIC, NEONATAL and Childhood COMPLICATIONS *Source of data: in patient and/or delivery registers. *Review in patient and/or delivery register in maternity ward and randomly select 5 cases of patients with the following conditions in the last quarter: PROM; PPH; Postpartum sepsis; and severe Preeclampsia/eclampsia, *Review in patient and/or delivery register in paediatric and randomly select 5 cases of patients with the following conditions in the last quarter: Neonatal asphyxia; neonatal sepsis; low birth weight and severe acute malnutrition *Then review their records and assess whether they were managed as per the national protocol.. * Write Not Applicable (N/A) if there are no cases for review and deduct the available points for the indicator from the maximum available points. PATIENT’S RECORDS 1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recorded N/A: not applicable: if there are no records for review 1 26 5 records (100%): 6 points 4 records (80%) : 4 points 3 records (60%) : 2 points ≤2 records (≤40%): 0 points 2 3 4 5 Complete POINTS records 7C1 % women with prolonged labor or Rupture of Membranes and without chorioamnionitis that were administered antibiotics as per protocol in the last quarter Treatment with oral erythromycin (or amoxicillin) if ROM > 6 hours or active labor > 12 hours without signs of chorioamnionitis; first dose antibiotic *Review in patient register and select those in which rupture of membrane documented > 6 hours (at any time in course of labour and delivery) or active labour >12 hours (at any time) without documentation of other signs of maternal sepsis in the last quarter (maternal fever or foul-smelling discharge) is documented 7C2 % women with PPH managed per guideline last quarter *Review in patient register and select 5 cases of PPH fulfilling the following criteria: PPH documented (EBL > 500 cc or VB and tachycardia > 100 bpm or hypotension SBP < 100 or DBP <50) and check whether they were managed according to the guideline and check whether the following three items listed below were done for each identified case 7C3 •Assessment: See annex section of checklist guideline for specific audit criteria and management of PPH 1. PPH Cause documented (atony, tear, retained placenta, other) 2,Resuscitation for all PPH cases irrespective of the cause: manage Airway, Breathing and Circulation, secure two IV lines with two 16 G cannulas or any large size available, and run normal saline (NS) or ringer lactate (RL) 3. Management according to the cause: -Uterine atony: Oxytocin 10 IU IM, massage, IV fluids, if bleeding continues 20 IU Oxytocin in 1L NS or RL solution at 60 drops/minute until uterus is firmly contracted -Retained placenta: controlled cord traction. If failed, manual removal -Vaginal/cervical laceration: sutured ALL ITEMS PER PATIENT RECORD % women with signs of intra- or post-partum sepsis :fever temperature ≥38⁰C, foul-smelling discharge, ≥38⁰C) or Membranes were ruptured for ≥18 hours before delivery that were treated per standard in last quarter *Treatment with triple antibiotic given IV: Ampicilin 2 grm IV every 6 hours Gentamicin 5 mg/kg body weight IV every 24 hours Metronidazole 500mg IV every 6 hours 7C4 ** see annex section of hospital checklist guidelines for maternal sepsis(chorioamnionitis/puerperal sepsis) case management ALL ITEMS PER PATIENT RECORD % pregnant women with severe pre-eclampsia and/or eclampsia managed according to the guideline in last quarter Review partographs of women who delivered in the last quarter and select those who fulfill the following criterion Severe Pre-eclampsia: 27 -Diastolic BP 100mm HG or more -proteinuria 3+ or more Eclampsia: -Unconsciousness or Convulsions (fits) -dBP 110 mmHg or more -Proteinuria 2+ or more in a pregnant women or a woman who has recently given birth -Check whether the following three items listed below were at least done for each identified case: *refer Annex section of the checklist guideline for details on the management of severe pre-eclampsia/eclampsia 1-Maintain airway and if she is not breathing, assist breathing using bag and mask 2-Blood pressure monitored (if diastolic blood pressure (dBP) is ≥110 mmHg, Nifedipine 10 mg provided. If inadequate response after 20 minutes following first dose: Repeat 10mg dose orally every 20 to 30 minutes until adequate dBP response is achieved, to a maximum of 40 mg given. Then 10-20 mg orally every 4-6 hours to maintain dBP 90-100 mmHg * applicable only if dBP was ≥110mm Hg 3-Magnesium sulphate 20% solution, 4gm IV over 15 minutes given. Followed promptly with 10g of 50% magnesium sulphate solution, 5gm in each buttock as deep IM injection with 1 ml of 2% lignocaine in the same syringe. 7C5 7C6 ALL ITEMS PER PATIENT RECORD % of neonates who did not cry/spontaneously breath immediately after birth for whom resuscitation was immediately initiated in last quarter *refer checklist guideline for details % neonates who did not cry/breath immediately after birth and were successfully resuscitated within 5 minutes after delivery. *refer checklist guideline for details Did the baby breathed on its own after resuscitation was done? 7C7 7C8 % neonates with possible serious bacterial sepsis managed per standard in last quarter •Assessment of possible neonatal sepsis: Review all cases of newborn sepsis (pre-discharge or re-admitted to paediatric ward) in in patient register in last quarter; and select 5 records for review that meet any of following probable sepsis criteria: -if documented temperature >380 C or < 250 C (and not warming); - RR > 60 or <30 breaths per minute; -chest in-drawing or convulsion; -no movement on stimulation; - poor feeding/sucking or -umbilical redness, *see annex section of checklist guideline criteria for chart audit and for treatment details % of low birth weight (LBW) newborns admitted to KMC unit in the last quarter 28 Definition of LBW: infant with birth weight lower than 2500gregardless of gestational age Criteria for providing Kangaroo Mother Care (KMC): LBW neonates weighing >1500 and <2500g Baby‘s condition is stable to permit KMC The mother is in good health to start KMC SUBTOTAL: ( Maximum Available Points: 48) 8C PAEDIATRIC WARD PAEDIATRIC BEST PRACTICES *Select 5 cases from registers (randomly if there are more than 5 cases) and then obtain and review patient files * Write Not Applicable (N/A) if there are no cases for review and deduct the available points for the indicator from the maximum available points. PATIENT’S RECORDS 1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recorded N/A: not applicable: if there are no records for review 1 8C1 8C2 8C3 8C4 9C 3 4 5 Complete records POINTS % hospitalized patients with correctly completed admission medical record any one month in the last quarter Admission medical record for hospitalisations available and documenting at a minimum: Vital signs (RR, HR, BP, temperature); history of illness; physical exam; laboratory/radiology results (if applicable); admission diagnosis and treatment ALL ITEMS PER PATIENT RECORD % Written record of administration of patient medications up to date any one month in the last quarter % hospitalized patients with documentation of vital signs every 6 hours and every half hour for critical patients any one month in the last quarter % hospitalized patients with documentation of daily progress note by doctor any one month in the last quarter. PAEDIATRIC COMPLICATIONS: PNEUMONIA, DIARRHEA, Review 5 cases in registers with the diagnosis of pneumonia, and 5 with diagnosis of diarrhoea. * increase the assessment period to a quarter if there are less than 5 cases in the selected month * Not Applicable (N/A) if there are no cases and deduct the available points for the indicator from the maximum points. PATIENT’S RECORDS 1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recorded N/A: not applicable: if there are no records for review 1 9C1 2 5 records (100%): 6 points 4 records (80%) : 4 points 3 records (60%) : 2 points ≤2 records (≤40%): 0 points % hospitalized children treated for pneumonia any one month in the last quarter who were correctly a for pneumonia in any one month in the last quarter 29 2 3 4 5 5 records (100%): 6 points 4 records (80%) : 4 points 3 records (60%) : 2 points ≤2 records (≤40%): 0 points Complete records POINTS Vitals: child’s age recorded; weight recorded; Temperature, respiratory rate Symptoms & duration recorded (at a minimum absence/presence and duration of fever, cough, ability to drink/feed) Pulmonary exam results recorded stridor, wheezes, chest indrawing 9C2 ALL ITEMS PER PATIENT RECORD % hospitalized children treated correctly (all criteria met) for pneumonia among those correctly assessed in any one month in the last quarter •Assessment: see checklist guideline for criteria 9C3 9C4 IV ceftriaxone 50 mg/Kg per day OR oral amoxicillin 50 mg/Kg divided TID x 7 days (if taking fluids and no severe respiratory distress Antipyretic for fever control Oxygen (per nasal cannula or paediatric mask) if : saturation < 94% Or breathing (intercostal retractions and/or respiration rate > 50, if 2months to 1 year; > 40 if 1 yr or older) % hospitalized children treated for diarrhoea in any one month in the last quarter correctly assessed for signs of severe dehydration Was general condition (abnormally sleepy or difficult to wake up, restless and irritable, or well and alert) assessed and documented? Were eyes checked for dehydration signs and documented (such as sunken and dry, sunken, normal); Was thirst assessed by offering fluid (drinks poorly or not able to drink, drinks eagerly - thirsty, drinks normally not thirsty)? Was skin turgor assessed by pinch of abdomen or thigh (goes back very slowly - longer than 2 seconds? ALL ITEMS PER PATIENT RECORD % hospitalized children treated for diarrhoea correctly (all criteria met) in any one month in the last quarter among those correctly assessed. See checklist guideline for criteria If able to drink: Low osmolarity Oral Rehydration Solution (continue breastfeeding and feeding) If unable to drink: NS (or Ringer Lactate if NS not available) IV Or If unable to drink and unable to star IVF, administer ORS via NGT Zinc 10-20 mg/kg/day x 10 days given ALL ITEMS PER PATIENT RECORD SUBTOTAL - ( Maximum available points 48 ) 10 C POST OPERATIVE INFECTION CONTROL Review operating Theatre register and randomly select 5 patients who have undergone major surgical procedures in the last quarter and review their files to assess indicators10C1-2 *If there are less than 5 cases, assess the indicators for the available number of cases. But if there are more than 5 cases for review in the last quarter, select 5 cases for review using either simple random/systematic random sampling ** Write Not Applicable (N/A) if there are no cases for review and deduct the available points for the indicator from the maximum available points. 30 PATIENT’S RECORDS 1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recorded N/A: not applicable: if there are no records for review 5 records (100%): 6 points 4 records (80%) : 4 points 3 records (60%) : 2 points ≤2 records (≤40%): 0 points *See the WHO surgical safety checklist and the definitions of surgical site infections in annex section of the checklist guideline 1 10C1 10C2 2 3 4 5 Complete records POINT S Surgical safety checklist utilization rate: -% of patients with major surgical procedures on whom safe surgical checklist was completed in the last quarter Surgical site infection: -% of post major surgical procedures free of surgical site infections in the last quarter SUBTOTAL: ( Maximum available points: 12) IV. QUALITY PROCESS MANAGEMENT 11C Quality Improvement/Assurance: *Please give a score for each of the criteria under each indicator as per the criteria in the right column *N.B. The items highlighted in bold are the indicators * Assess asking the QI focal person and/or QIC chairperson 11C1 Presence of a Quality Improvement/Assurance Committee/team (QIC) with clear structure and responsibilities: -Does the QIC have terms of reference (ToR) with the following components: Structure & leadership, known responsibilities, meeting frequency, reporting system and list of committee members? Are all service areas, including administration, represented in the committee? Presence of quality improvement plan: -Is a quality improvement (QI) plan with the following items present, as part of the overall plan of the hospital? 11C2 11C3 11C4 11C5 Action plan for improvement Targets Areas for improvement Quarterly committee meetings and reports to PHEs: -Are reports on QI activities sent to PHE? - Are processes like waiting time, staff schedule, and patient flow are discussed during the meeting? (Check in the minute) -Is the QIC meeting quarterly? (Check for the presence of minutes) - Are status of QI plan and other improvement plans discussed during the meeting? (Check in the minute) Quarterly review of patient files: * Check in the minute and/report of QIC meetings. Does the QIC review at least 10 patient files from at least each of three service areas and assess the following items? : -Completeness and correctness of the information in the reviewed patient files -Comprehensive patient management given to patients in the reviewed files -Consistency of information between the reviewed patient files and registers checked Feedback and action on quality supervision checklist assessment findings: Does the QIC receive feedback from the supervision? If so, Has the 31 Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded 11C6 11C7 QIC developed action plan for improvement to address the identified gaps from the quality supervision? And is the action plan being implemented? *Check for the presence of copy of feedback, action plan for improvement and status of implementation of the plan Feedback mechanism from Clients Quarterly client satisfaction surveys: -Does the QIC have survey tool Does the QIC conduct quarterly surveys? If so, are survey analysis reports and plan for improvement available? Suggestion box: -Does the facility have suggestion boxes? If so, it is labelled? -Is instruction on how to use the boxes posted on or above the boxes? Does the facility analyse the findings and take appropriate action? *Check for the presence of analysis report and communications given to clients on the actions taken by the health facility to address clients concerns. Clinical audit and/or maternal-perinatal mortality audit meetings: Does the hospital conduct audit meetings or maternal mortality review meetings at least once in a quarter? Is guideline for audit/mortality meetings available? Is plan developed and being implemented to address the identified gaps? *Check for guidelines for clinical audit meetings, audit meeting report, action plan for improvement and report on status of implementation of the plan Total Points- ( Maximum available points: 22) VERIFY THAT ALL QUESTIONS ARE FILLED IN Supervisor thanks the staff Signature: PHE ……………………………………………………….. DMO/MED/MATRON……………………......................... Counter verification………………………………………... 32 ASSESTMENT FEEDBACK I. Summary Comments on Results. Please note any trends, problems, exceptional or creative changes and results that you saw during your visit assessment II. Noteworthy Improvement. Please note any improvement and include a few details of what they are doing and why it is unique III. Difficulties/ Challenges. Please note any assessment area that seem to be having an especially difficult time in improving. Please include a few details about the problem, how it might be solved, and who might be involved IV. Recommendations and suggestions for improvement. Please note that the feedback is more effective when emphasizes features of the clinical task to be performed (e.g. specifies a target performance, presents information on how target performance can be attained, and address change in performance observed since previous feedback V. Follow up. Please review previous recommendations provided and assess if they were followed or not 33
