comments on management section -...

REFERRAL HOSPITAL

ASSESSMENT TOOL

PREFACE

This Assessment tool for Referral Hospitals in Cambodia has been developed by the Ministry of Health's Quality Assurance Office in collaboration with USAID-HSSC/URC and other health partners. The purpose of the tool is to assist Referral Hospitals identify problems within their hospital that require improvement. It can also be used by the central department, donors and other health partners who will benefit from information collected and be able to target appropriate resources where needed.

The tool has been developed using the CPA guidelines and other MoH documents developed for Referral Hospitals. The tool tests Hospital Management, Administration, infrastructure and equipment, organization of wards and departments, documentation and recording of information, referral system, staff satisfaction and general hygiene. There are fourteen sections which need to be completed (more if the hospital is CPA 3).

Over an 18 month period, the tool has been used successfully in 8 referral hospitals. A baseline assessment identified weaknesses which then formed the basis of a quality improvement plan for each hospital tested. Reassessment after 12 months showed hospitals had used the initial assessment results to formulate a plan to improve their services.

Due to the success of the tool, it has been decided to nationalize this tool so that all hospitals have the opportunity to improve their performance. It is recommended that external assessors assess hospitals on an annual basis. Hospitals can also use the tool for self assessment to identify problems and weaknesses and work on these to improve their services.

I expect that this tool will not only be used as a baseline tool to improve the quality of the hospital but it will strengthen our health system especially in improving the Cambodian people’s health.

Phnom Penh, 02 March 2007

Instructions and Recommendations for use of Hospital Assessment Tool

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TABLE OF CONTENTS

1. COMPONENTS OF TOOL..........................................................................................................42. SCORING:......................................................................................................................................53. DOCUMENTS REQUIRED TO PERFORM THE HOSPITAL ASSESSMENT.............................................54. STRENGTHS OF THE TOOL............................................................................................................75. WEAKNESSES OF THE TOOL.........................................................................................................76. RECOMMENDATIONS FOR ASSESSORS..........................................................................................97. INSTRUCTIONS FOR USING THE TOOL................................................................................118. VERIFICATION OF DIFFERENT QUESTIONS BETWEEN WARDS AND DEPARTMENTS.....................189. ASSESSMENT TOOLS..............................................................................................................21

1. Hospital Management................................................................................................................232. Paediatric Ward.........................................................................................................................393. Obstetric Ward...........................................................................................................................494. Medical Ward.............................................................................................................................595. Surgical Ward.............................................................................................................................686. TB Ward.....................................................................................................................................777. Operating Room and Sterilising Area.......................................................................................858. OPD............................................................................................................................................909. Laboratory..................................................................................................................................9810. Pharmacy................................................................................................................................10711. Radiology................................................................................................................................11012. Referral System.......................................................................................................................11213. Staff Questions........................................................................................................................11414. Hospital Indicators.................................................................................................................11715. Summary.................................................................................................................................120

10. ANNEX 1 LIST OF DOCUMENTS REQUIRED TO PERFORM HOSPITAL ASSESSMENT.........12111. ANNEX 2 PRACTICE PRE TB WARD ASSESSMENT................................................12312. Annex 3 Verification of questions between wards and departments................................129


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1. COMPONENTS OF TOOL 13 components have been developed and form this hospital assessment tool (see attached). Another component (standard MOH hospital indicators) has also been included to gain more information about the overall functioning of the hospital.

Departments to be tested include:

Management (with the following sections included) Administration Hospital committees Infrastructure and logistics Finance Health information systems

Wards o Paediatric Wardo Obstetric Wardo Medical Wardo Surgical Wardo TB Ward

Outpatient Department Operating Room and Central Sterilising Department

The wards, OPD and OR are divided into the following categories:

Organisation and presentation of staff and ward Equipment and supplies Quality of documentation and procedures Patient verification General hygiene

Laboratory Pharmacy Radiology Referral System Staff interviews

Each area is not checked thoroughly as some activities won’t be measurable with this type of tool e.g. no technical procedures are tested such as surgical skills, delivery skills, dressing skills. These will need to be assessed using a different strategy. A second tool focussing more on quality issues will be developed and used once hospitals have reached a certain level on this tool.

All equipment included in the assessment which is to be checked comes from the CPA equipment list for that ward. Drugs (including dosage) and supplies are on the essential drug list therefore all should be available at the hospitals.


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Once all sections have been assessed, the assessor should check the standard MOH CPA indicators for the past year using the HIS data provided by the hospital.

The hospital assessment tool does not yet include assessment of the following areas:

Staff allocation Dental Department Specialty departments such as Mental Health, ENT,

Ophthalmology Emergency ward/ICU Gynaecology Ward Ultrasound or other imaging such as endoscopy HIV specific care Detailed section on maintenance

2.SCORING: Scoring errs on the tough side. The maximum points that can be achieved is often 5 or 10 but if only some possibilities are achieved, the amount received is 1 or 2 i.e. less than half. In some cases, there is no intermediate score as without all factors in place, the system cannot work e.g. if the ambulance is available, has petrol in it, the emergency kit is in place, staff are available to accompany the driver but the driver is not available then the ambulance cannot function and no score should be given. Some tasks should be done correctly rather than half done!In addition to receiving points, there are a few places where points will be lost e.g. if sharps containers are not kept away from the general public then they should lose points. If needles or other contaminated waste is found in general rubbish bins points should be lost. There are a few questions where hospitals can earn additional points for hospital specific initiatives.

3.DOCUMENTS REQUIRED TO PERFORM THE HOSPITAL ASSESSMENT 1

The following documents and information should be provided by hospitals to assist with the assessment. Please inform the hospitals ahead of time so documents are available on arrival

Basic information about the hospital e.g. list of all hospital departments/services offered at the hospital, no. beds, no. staff

1 Please see Annex 1 for a list which can be printed out and given to Referral Hospital prior to assessment


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Hospital annual work plan, current monthly or quarterly plan and any amendments. This may need to also include the last years annual work plan if assessment is taking place early in the year when no review has been done

Review of hospital work plan e.g. 3 or 6 monthly review or review from the past year as well as annual review of work plan if assessment carried out early in the following year when no review has been performed

Minutes of meetings for past 6 months for the following (indeed if they have minutes):

o Hospital managemento Financing Committeeo Monitoring and Evaluation sub-committeeo Procurement and Logistics sub-committeeo Morning meetingso Technical committee o Disciplinary committeeo General hospital meetingo Death audit meetingso Any other meetings which are regular/irregularo Meetings with HC Chiefs (if possible)

Terms of Reference for all above committees and any other committees which exist in the hospital

Intergrated supervision reports for the past 6 months Staff Schedule for current month (day and night for all staff) Organisational chart Up to date staff list with positions held (including details of

any staff away for extended training) Staff daily attendance book(s) and ward daily attendance

books if available at that hospital Copy of staff regulations Copy of any disciplinary measures taken (meeting with staff,

evidence of reduction in salary, position in hospital changed, letter to PHD to take action etc)

Job descriptions of Director, Vice, Administrator, Chief of Service, Chief of Ward, Chief Nurse, Laboratory technician, cook, cleaner, driver

User Fee distribution criteria (details on how 60% is divided between staff and how remaining 39% is used)

Price of services for OPD, IPD, ambulance, all investigations and any other fees charged at the hospital

Exemption criteria for those unable to pay user fees Previous month’s financial report and receipt books (may be

recorded by service/dept) Yearly expenditure for User Fees and other budgets if

available HIS for the past six months i.e. monthly data so you can

check certain months if necessary HIS for the past year (to check indicators)


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Essential Drug List for hospitals Rational Drug Use Supervision visits Referral Hospital Treatment Guidelines National Referral Guidelines (which includes Ambulance

Emergency Kit contents) Updated 6 month TB treatment guideline Malaria treatment guidelines CPA guidelines second edition (for reference) Health Centre Manual (includes treatment guidelines) Laboratory Quality Control reports – both internal and

external (CNM, CENAT, NIPH, other) Maintenance schedule for x-ray and sterilising department

and records of maintenance performed Ambulance log book and maintenance schedule Other hospital maintenance schedules

4.STRENGTHS OF THE TOOL Despite the length of the tool it is easy to use if assessors are appropriately chosen and trained well. Few problems have been encountered during assessments. Often they have been due to assessors’ lack of knowledge about hospitals. The tool will assist the Hospital Management team, Ward and Department Chiefs to identify problem areas. In addition, it should be easy to see from the tool what areas are in need of improvement.

5.WEAKNESSES OF THE TOOL

1) The length of the tool and the time taken is extensive. It is estimated that the following time is required:

Management - one full day Wards/OPD - 2-3 hours.

It may take more time to check the TB ward as checking the registration and patient cards is time consuming and often difficult and confusing.

Operating Room - 2 hours Lab - 2 – 3 hours X-ray - 1 hour Pharmacy - 3 hours Referral system - 1 - 2 hours Staff interviews can be included in the departments e.g. one

or two staff per department/ward. This should take a maximum of ten minutes per staff member i.e. 1.5 hours total time

Indicators - 2 – 4 hours


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The total time taken is estimated to be at least five days if there is one assessment team only and (with hospital hours being limited) possibly longer. If there are two or more teams, the total time may be reduced to three days (see below for recommendations about this). (Please consider that hospital “working hours” are often 0830-1130 and 1430-1700 which is not a full day).

2) As mentioned above, not all departments are included in this tool2. There are many activities that could be added however it may not provide additional information. It is possible that some topics could be removed, or only parts of them completed e.g. if the hospital management team is not working efficiently then it is unlikely that committees will be established or functioning well. Likewise, if the administration does not have copies of staff schedules then it is possible that the wards are also not very astute at keeping schedules.

3) There is no information provided throughout the tool regarding staff numbers i.e. appropriate/insufficient, qualifications etc however this will be available from the RH e.g. the ISC tool.

4) As mentioned there are no questions assessing procedures i.e. examination and assessment of patients, sterile technique, surgical technique, anaesthetic technique etc. It would be better to assess these by observation.

5) Assessment must be carried out by appropriately chosen staff otherwise accurate data will not be obtained – see recommendations below for suitable assessors.

6) Hospitals that have little activity may score proportionately higher than those that are busy and therefore look like they are functioning better. This is because some questions are dependent on checking five patient files and performing five patient interviews. If there are few patients, the average score is taken so as not to penalise hospitals where some wards are not busy at the time of assessment. Likewise, for laboratory, if few tests are performed the overall score might be quite high. This tool tests mostly inputs rather than processes or quality of care. The second tool will focus mostly on quality related issues.

2 There is no section to assess Mental Health, Ophthalmology, Ear, Nose and Throat or Dental departments


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6. RECOMMENDATIONS FOR ASSESSORS

If there are teams of assessors, they should include at least one medical person per team familiar with the RH Treatment guidelines, MOH Essential Drug List and clinical practices as they will be required to assess patient files (appropriate history, examination, investigations, diagnosis and treatment). They should also be familiar with TB categories and treatment and Obstetric care.

In addition, the assessors should also be knowledgeable on how to operate certain equipment (oxygen concentrator, ventouse, steriliser etc). They should be familiar with sterile technique, operating room procedures, laboratory equipment, x-ray procedures (including developing of films and equipment required) and waste management.

The assessors should be familiar with the CPA guidelines e.g. know how often committees meet, be aware of how additional hospital drugs are purchased, how user fees should be used, know the services offered by the hospitals and the expected variations between hospitals.

Two assessors should work together initially (for the entire section not separate during the ward) until they are familiar with the tool (this might mean doing each section of the tool at least twice). Once they are familiar, the assessor could easily manage to test the departments alone (or with assistance from hospital management).

It is important that assessors follow the tool completely e.g. drugs and supplies are often mentioned and it is important to ensure correct dosage is checked or size of equipment is as written e.g. if Amoxycillin 250 mg should be in place, 500mg as a substitute is not sufficient particularly for children. Likewise, hospitals should have an array of syringes so that if 1 or 2 ml syringes are included in the tool, then the hospital should have these. It is not possible to accurately draw up 0.5ml in a 10ml syringe.

To ensure efficiency, it is recommended that those assessing the tool obtain as many hospital forms as possible prior to the assessment to become familiar with the sections that should be checked e.g. TB patient card, TB patient register, partogram, hospital admission sheets, referral forms, lab and other investigation forms. These documents could be marked with the salient features that are to be checked.


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Prior to the assessment, the assessment teams should discuss the tool at length to ensure assessors are clear about the questions to ask. Preferably, each question in each section should be clarified

At the end of each day of the assessment there needs to be a discussion between all assessors to ensure consistency in the assessing e.g. If the Management section and Obstetric and Medical Wards have been completed then verification between the different questions should be checked (see check list of questions that need to be verified below). Modification of scores may be required. Please note that those questions that should be verified are marked with ** in the column on the left. A comment has also been placed at the end of the question to remind the assessment team that verification is required. The Management section can only be completed (verified) after all other wards and departments have been completed (see below) e.g. water back up needs to be verified by the ward information regarding back up supply; availability for water for patients and relatives needs to be verified by patient verification questions from wards; food being provided by hospital kitchen needs to be verified by patients, availability of relative kitchen needs to be verified by patients etc. The Referral and OPD section results need to be verified as there are many topics that are similar

At the end of the assessment further discussions need to be held to summarise the entire assessment i.e. go through each department and ward and discuss whether the results appear consistent with what the assessors thought whilst performing the assessment.


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7.INSTRUCTIONS FOR USING THE TOOL

How many points to give?The points given should be the points that are indicated rather than others. If you do think that there should be another score than the options presented, you need to provide explanations as to why they have received a different amount in the comments box.

Comments boxPlease give as many comments as you can as this will be useful for analysis as well as the future assessment - it isn’t possible to have too much in the comments box! Please use it e.g. if you see that there are very dirty instruments being used in the ward, please comment. If the container housing the sponge forceps has no disinfectant, please comment. If needles are reused to draw up drugs, please comment. If drugs are given to patients in one container i.e. different drugs mixed up together, please comment.

What should be done if there is more than one Medical Ward or more than one hospital Pharmacy?There are some hospitals that have more than one ward for the same specialty e.g. there may be two or more Medical, Obstetrics, TB or Paediatric Wards. Some hospitals may divide their Obstetric patients from their Gynaecology patients and some may divide their surgical patients into (immediately) post-operative and non-operative/some days post operative. Some hospitals may have different OPDs e.g. one for ‘HC’ type patients and the other for more complicated cases that couldn’t be managed by MPA OR they may have an OPD for specialty patients (ENT, Mental Health, Ophthalmology) which is kept separate from other OPD patients OR they may have a registration book for outpatients and a different registration book for those that are admitted. Some hospitals may have different pharmacies – one supplying outpatients and the other providing drugs to inpatients only. Some hospitals still have different laboratories e.g. General laboratory, STI/HIV, TB, Blood Bank. It is recommended that prior to each hospital assessment, information is gathered about the number of each ward and department so the assessment team can be prepared with the correct number of assessment sheets. If there is more than one ward which manages the same type of patient e.g. Medicine, then EACH ward should be assessed. A new tool should be used for each ward e.g. if there are two Obstetric Wards i.e. on different floors and there is a different chief for each ward, then there should be two assessments. If there is one chief responsible for two different wards then they could be assessed together (providing the registration procedures and data collected are identical).


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Surgical Ward (post-operative/surgical wards)For those hospitals with a post-operative ward and surgical ward, please assess them separately. The current surgical tool could be used for both with comments for those questions that are not applicable. A new tool may be developed for the surgical ward at a later date.

Obstetric/Gynaecology wardsIf the hospital separates Obstetric and Gynaecology wards, then the Obstetric ward should be assessed using the Obstetric tool and the surgical tool should be used for the Gynaecology ward (until a specific tool has been developed).

OPD wardsIf there is more than one OPD, please assess both using the same tool. Some of the questions will not be relevant – please mark those which are not applicable e.g. for those hospitals who have a separate register for admitted patients, there may be no record of the number of drugs provided to the patient therefore please comment

ICU wardPlease use Medicine Ward tool

Emergency WardPlease use Medicine Ward tool

Operating RoomIf there is more than one operating room e.g. one for general operations and one for Obstetric or VSC, each should be assessed using the same tool

PharmacyIf there is an OPD and an IPD pharmacy, they should both be assessed using the same tool for both

LaboratoryIf there is more than one laboratory, each laboratory should be checked and assessed. It is important to establish whether the laboratories have been integrated i.e. whether lab staff can work in all areas rather than some allocated to blood bank, others allocated to VCCT etc.

Management Section 1 Qu. 1 to 4


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These questions relate to the annual plan. They may seem similar but they are checking for 1) availability of a plan, 2) whether the plan is reviewed, 3) whether the plan is realistic and 4) if it is up to date. Five definitive objectives have been chosen to check during the assessment - 1) BOR, 2) no. hospital deliveries, 3) % patients receiving Antibiotics, 4) % patients referred from HC and 5) mortality rate. Four are from CPA guidelines, the fifth (number of deliveries) is a standard indicator used by hospitals. If the hospital does not have all five objectives in their plan they score zero.

HIS data that should be usedPrior to starting the assessment it should be decided by the team, the month of HIS data that will be collected for Qu 2 (7) Paediatric, Obstetric, Medical, Surgical wards and Qu 3 (2) TB ward so data is consistent between wards. If the assessment is conducted before the 20th day of the month, data should be collected from 2 months earlier i.e. if you are conducting the assessment on November 10th you would choose September data to give the best chance of all patients admitted in September being discharged. If you conduct the assessment on November 21st, choose the HIS data for October. All teams must collect data from the same month. It is also important to ascertain the collection dates i.e. hospitals will usually not collect data from 1st day to last day of the month, rather from say 22nd of previous month to 21st of next month. It must be clear to all involved in the assessment which days are used to ensure consistency when checking registration books.. Checking Ward registration books for monthly dataPlease be careful when you are doing the HIS section of the wards (Section 3). Each ward may have a summary of admissions, discharges, deaths, referrals recorded in their registration book at the end of the month. Please do not copy this summary but rather, go through the book yourself and count up the different categories i.e. admissions, discharges, referrals in, referrals out. Please be sure to do this section or record why you are unable if that is the case. If one ward is missed it will affect the entire HIS section of the Management assessment (section 5).

DefinitionsAdmissions = all those admitted during the month you are checkingReferrals in = referrals from HC or other health facility NOT transfers between wards. If the ward doesn’t referrals into hospital separately then please document in comments boxDischarges = all those leaving the ward – doesn’t matter how they go i.e. discharged home, unauthorised discharge, death, referral to another hospital or HC, transfer between ward. You have to add ALL together. In addition to checking the month you have selected


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you should also check the month before to see whether any admitted in the previous month were discharged in the month you are checking. HIS data checks for all discharged in a month which is why you need to check the previous month. You DON’T need to record the number of patients who are still admitted at the end of the monthReferrals out = those referred to another health facility i.e. HC or RH NOT those transferred within the hospital. If the ward doesn’t record them separately then please document in the comments box.

The relevance for collecting this data is:Admission and referral in data will be used to work out the number of inpatients that have been referred. This is a measure of how successful the referral system and recording system isThe discharge data measures the accuracy of the HIS data (HIS records discharges rather than admissions)Referral out data will be compared with referral in to ascertain whether the hospital has more referrals in that out i.e. again a measure of success of the referral system, recording system and overall function of the hospital

Central registerThere should be a central register for each hospital which records ALL patients to the hospital and categorises them as referred, admitted etc. For the OPD and Referral section, please ensure you find out whether there are additional registers i.e. whether patients can bypass the OPD and go directly to ward without being registered at triage, OPD, cashier etc.. Some questions will not be able to be scored if there is not a central register. OPD and Referral sections are closely linked and verification is required to ensure accurate scoring (see table below).

Underlining of answers givenPlease underline the answer i.e. the option you have chosen e.g.

Copy of government rules for workers or copy of hospital disciplinary schedule and

evidence of disciplinary action (e.g. reduced salary, change of position)

No disciplinary schedule/criteria but disciplinary action has been taken

No evidence or not clear if implemented

10

50

10

Water is piped and reliable but back up water exists (storage containers at sinks which are

full; labour room and operating room have large back up storage)

Water is piped but unreliable, reliable back up routinely exists

Water is unreliable and no back up existsWater is unreliable and storage is not routine

10

100

0

10


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UNDERLINE THE OPTION

or sufficientTold where toilet/bathroom is, (or in ward

and very obvious), not locked when want to use it, water always available for

bathing/washing Told where toilet/bathroom is, (or in ward

and very obvious) but can’t use it all the time because locked or water not always available

Not told where toilet/bathroom is or not in ward and not obvious

TOTAL 5 points per patient

5

0

0

0

i.e. for question 1 (9) Hospital Administration (first example above), the answer was ‘copy of hospital disciplinary schedule’ therefore it was underlined to give info that this was what scored the ten points. For Qu 3 (6) the answer was ‘water is piped but unreliable but back up routinely exists’. This might mean that the town piped supply is unreliable and often goes off but the hospital has an alternative way to pipe water or containers are routinely kept and filled at ALL sinks.Example three indicates that patients knew where toilets/bathroom was but couldn’t use it at all times because water was not available. Being locked is another option. (No water and being locked are 2 very different reasons to score zero so underlying will help to decide what action is required).If two of the answers are correct e.g. in the first example e.g. copy of hospital disciplinary schedule and evidence of disciplinary action then please underline both.

Job DescriptionsFor the question on Job Descriptions (Management Section 1 (10) please underline those Job descriptions that you have seen. They can be used as a check for the next assessment e.g.

Do all positions have job descriptions? Director, Vice-Director, Admin, Chief of Service, Chief of Ward, Chief Nurse, Laboratory technician, cook, cleaner, driver. Check each job description and underline those that the hospital has a job description for

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A variety of positions have been chosen to ascertain the importance placed on all staff members

Questions regarding staff schedulesThis question (Section 1, Qu 2 all wards and OPD) appears to be a contentious question as many hospitals don’t have schedules for day shift as it is assumed all staff work except if they have worked night duty the previous night. However this question is included for two reasons:


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1) All wards and departments should have a schedule for both day and night i.e. they should actually be on one schedule so that it is clear to whoever goes to the ward or department, who should be on duty at the time.2) Some hospitals do not have sufficient staff to cover each ward/department each night therefore some wards or departments will share their duty roster with other wards/departments e.g. the on call night duty team may cover OPD at night which would leave OPD staff free to work in other areas on night duty. In this case the OPD staff would have the day off following night duty perhaps requiring a staff member from another ward to cover their position in OPD the following day. In this case it must be clearly written who is covering the day or night schedule otherwise it is possible that no one will be assigned to work.

If there is no up to date staff schedule in the ward then the question following regarding whether staff are present for that day is irrelevant (i.e. no schedule to verify) therefore this second question should score zero.If the hospital has a yearly schedule, this is not sufficient. An up to date weekly or monthly schedule is required to reflect the real situation i.e. if staff are away at workshops, additional staff should be rostered on to cover them.

2 Is there an up to date staff schedule - day and night? (Often staff is required to work day shift Mon to Fri in their department with the exception of the day following their night duty when they are scheduled off. However, in some hospitals where staff is lacking it is possible that staff will work in more than one ward/department either for night duty (if there are insufficient regular staff for the night duty) or to cover the day shift when the staff are off post night duty. In this case, there should be a clear schedule for each ward/dept for both day and night rather than just a night schedule so it is clear to anyone checking who should be on duty at any given time during the week or month). If the answer is zero, please score zero on next question as you will be unable to verify whether all staff are present

3 Is all staff present today that should be? (Check today’s schedule) If the staff member is not present and you are told that they have official permission to be away, you must verify this with the Chief of ward or Administration

If staff is absent with permission, then this needs to be verified with Chief of Ward or Administration (do not just take the other staff’s word for it)

Likewise, for the question on Management section regarding staff schedules (Section 1, Qu 6) the Administration should have schedules of all wards and departments i.e. this includes cleaners, gardeners, drivers, cooks etc. If not, then the score is zero.The Management Section cannot obtain full points (10) unless all wards, OR and OPD have scored 5 points.


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Question regarding PEPEach hospital should have a PEP policy kept by Administration i.e. if a staff member has a needle stick injury it is the responsibility of the Administration to ensure the person is tested, given prophylaxis, followed up etc NOT the ward alone. Therefore the documentation should be in the Administration. If it is only in one ward e.g. Medical or HIV ward then the hospital scores zero.

Question regarding IVsPlease count the number of IVs and record (in left column). If there are no IV lines in the ward at the time of assessment, please put this in the comments box

EquipmentDon’t forget to check whether the equipment is in good working order. If not, they only score one point.For Paediatric question regarding cups for ORS, availability of spoon has also been added. If water is available then it should be in a place where patients have access to it. If the water is in the nurses’ station then is it available for patients to get at any time? Do the patients know that water is available? Are they able to get it to make up ORS? If not, they should not score points. Confirm by asking any patients with vomiting or diarrhoea whether they have been given ORS and water.

Back up electricity and water supplyPlease check whether the back-up supply works i.e. check the generator is working (turn it on and go to the areas where it should be working – OR, laboratory etc) (and not just sitting in a room unattended, not hooked up etc). Check whether water containers are in the crucial areas e.g. operating scrub room, maternity ward etc

Area to wash linenPlease check the area where hospital linen is washed to see whether animals and general public are kept out. Check for the water supply, drainage etc

TB ward assessment The TB assessment is complicated and takes a lot of time particularly Qu 3, (1) where one must go through all the patients admitted to the programme 6 months ago. It is not easy to check this and it will take two people to go through it thoroughly to ensure sputums are recorded and up to date.The patient cards also take time to check (Qu 3 (5). Please be meticulous when checkingA sample TB registration book has been provided with the tool and assessors of the TB ward should do this practice test before going to the TB ward for assessment (see Annex 2).


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List of contact numbers for doctors on callThere should not be a list of doctor’s phone numbers visible to the general public i.e. the list should be in the nurses’ station only rather than in a public place

Patient verification of drugs being given (Section 4 wards)Regarding drugs being provided/explanations on how to take them, please only ask patients who have been prescribed oral medications. For patients on the surgical ward, only ask those who are able to eat i.e. able to take oral intake post operatively rather than those still in their early recovery stage who may only be in IV fluids). The time of asking this question is important – if you ask before 10am the patient should have had drugs from the day before i.e. they should have taken the drugs early in the morning. If you ask after 10am they should have been given drugs by this time (and if not, then the procedure to get drugs from the pharmacy post ward round is very slow and should be quicker to ensure patients are given drugs in a timely manner).

Question regarding food for patientsIf the patients complain that the food given is insufficient in quantity or not nutritious, please record it in the comments box (e.g. some hospital kitchens receive a fixed amount of money per day regardless of patient numbers).If the hospital kitchen receives a fixed amount of money per day for patients (regardless of number of inpatients), please record this.

Availability of EMERGENCY drugs after hoursThe question regarding after hours drugs is directed at the pharmacist. S/he should know whether drugs are provided to the wards for after hours on a routine basis. If so, then the pharmacist should have a list of what drugs are sent to each ward. If there is only a few drugs per ward and an inadequate record then the score should only be 2 (only some drugs of emergency stock available in some wards) or 4 (emergency stock available in some wards only). The idea of the assessment is to identify gaps and rectify them and this is one area where many hospitals are likely to need improvement. It is not necessary to make a list of emergency drugs per ward – the pharmacist will know if there is a list existing for each ward.

Question regarding purchasing of additional drugs for hospitalIt is the mandate of the Technical Committee to decide on the drugs that the hospital will purchase (CPA guidelines) therefore be careful at Qu 9 Pharmacy regarding this answer (verify with Management 2 (15) (see table below).


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Staff interviews Please organise prior to starting the assessment, which staff will be interviewed i.e. each assessor should know how many staff s/he should interviewPlease record the staff you interview on the record sheet. Do not interview more than one staff member per ward or department. Include floating staff e.g. cleaner, ambulance driver, so that you get a cross section of staff.If staff indicate that they are aware of staff having been disciplined, please try and obtain information about why they were disciplined

IndicatorsThe assessment team should work out all indicators as listed for each hospital i.e. they should not just copy from the annual performance record but work it out for themselves from the HIS and other data provided by the hospital to ensure accuracy (last section of tool). This will be important in analysis of hospital functioning and future assessments.


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8.VERIFICATION OF DIFFERENT QUESTIONS BETWEEN WARDS AND DEPARTMENTS 3

Please verify answers to various questions at the end of each assessment day (see above) using the following table

Assessing for Sections to Verify – Check A against BA B

Staff schedules i.e. Admin should not have an up to date copy of the schedules (10 pts) if all wards do not have copies of schedules

Management section 1 Qu (6)

Paediatric Section1 Qu (2)Obstetric Section1 Qu (2)Medical Section1 Qu (2)Surgical Section1 Qu (2)TB Section1 Qu (2)Operating Room Section1 Qu (2)OPD Section1 Qu (4)Laboratory Section 1 (Qu 4)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Attendance records of staff - cannot score 5 pts on Management Section 1, Qu 7 (Daily register is up to date today and corresponds to schedule) UNLESS wards scored 5 pts on previous question above regarding staff schedules up to date AND staff are all present at time of ward visit


Above questions and the following:

Paediatric Section1 Qu (3)Obstetric Section1 Qu (3)Medical Section1 Qu (3)Surgical Section1 Qu (3)TB Section1 Qu (3)Operating Room Section1, Qu (3)OPD Section1 Qu (6)And if additional wards assessed e.g. post op, gynae,

3 See Annex 3 for a verification list that can be printed out to be used during the assessment


21

ER/ICU please verify with them too

Disciplinary action Management section 1 Qu (9)

Staff Question no. 8

Technical Committee deciding on which drugs to purchase for hospital

Management Section 2 Qu (15)

Pharmacy Qu 9

Water storage available for back up - CAN’T score 10 on management section if one of the wards does not have back up supply

Management Sect 3 Qu (6)

Paediatric Section 5 Qu (3)Obstetric Section 5 Qu (3)Medical Section 5 Qu (3)Surgical Section 5 Qu (3)TB Section 5 Qu (4)OPD Section 5 Qu (3)Operating Room Section 5 Qu (4)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Adequate water supply for patients and relatives e.g. for toilets and washing clothes - CANNOT score 10 if patients say there is inadequate water supply

Management Sec 3 Qu (7)

Paediatric S 4 Qu (7) Obstetric S 4 Qu (6)Medical S 4 Qu (8)Surgical S 4 Qu (8)TB S 4 Qu (7)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Hospital kitchen available and in use

Management Sect 3 Qu(8)

Paediatric S 4 Qu (9) Obstetric S 4 Qu (7)Medical S 4 Qu (9)Surgical S 4 Qu (9)TB S 4 Qu (8)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Relative kitchen available and in use

Management Sec 3 Qu(9)

Paediatric S 4 Qu (10)


22

Obstetric S 4 Qu (8)Medical S 4 Qu (10)Surgical S 4 Qu (10)TB S 4 Qu (9)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Provision of receipts to patients


Paediatric S 4 Qu (12) Obstetric S 4 Qu (11)Medical S 4 Qu (13)Surgical S 4 Qu (13)OPD S 4 Qu (3)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Receipts provided to patients – CANNOT score 10 in Management if not verified by all wards


Paediatric S 4 Qu (12) Obstetric S 4 Qu (10)Medical S 4 Qu (12)Surgical S 4 Qu (12)OPD S 4 Qu (3)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Exemption of patients - CANNOT score 10 in management section if patients do not verify exemptions were explained


Paediatric S 4 Qu (11) Obstetric S 4 Qu (9)Medical S 4 Qu (11)Surgical S 4 Qu (11)TB S 4 Qu (10)OPD S 4 Qu (2)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Distribution of user fees to staff


Staff Qu 3 to 4

HIS data and recording of referrals to wards


OPD S 1, Qu (2)OPD S 1, Qu (13)OPD Qu 3 (2) and (4)Referral Qu 2 and 3


23

Paediatric Se 3 Qu (4)Obstetric Se 3 Qu (4)Medical Se 3 Qu (4)Surgical Se 3 Qu (4)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

HIS data and all referrals to hospital


OPD S 1, Qu (13)OPD Se 3 Qu (2) and (4)Referral Qu 3

New Admission sheets- ward may say that only have admission sheets in OPD but in fact some wards may have them (and each ward should have them e.g. Obstetric patients may go directly to Obst ward if in labour)

OPD Sec 1 Qu (12) Paediatric Section1 Qu (7)Obstetric Section1 Qu (7)Medical Section1 Qu (7)Surgical Section1 Qu (7)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Recording of referrals to RH in OPD central register

OPD Sec 1 Qu (13) Referral Qu 2

HIS data of referrals to each ward. If there is no score at 3 (7) then there should also be no score at 3 (15) option 2 regarding registration book having referral documented

Paediatric Sec 3 Qu(7)

Paediatric Sect 3 Qu (15)

If there is no score at 3 (7) then there should also be no score at 3 (17) option 2 regarding registration book having referral documented

Obstetric Sec 3 Qu(7)

Obstetric Sec 3 Qu(17)

If there is no score at Medical Sec 3 Qu Medical Sect 3 Qu


24

3 (7) then there should also be no score at 3 (16) option 2 regarding registration book having referral documented

(7 ) (16)And if this tool is used for ICU and ER assessments check these tools also


Surgical Sec 3 Qu (7) Surgical Sec 3 Qu(17) And if this tool is used for Post op and Gynae ward, please check these tools also


TB section 3 Qu (2) TB Sect 3 Qu(7)

Toilets locked and with water – if the toilets are locked then the next question, whether there is enough water is not relevant

Paediatric Sect 5 Qu (4)Obstetric Sect 5 Qu (4)Medical Sect 5 Qu (4)Surgical Sect 5 Qu (4)TB Sect 5 Qu (5)And if this tool is used for Post op and Gynae ward, please check these tools also

Paediatric Sect 5 Qu (5)Obstetric Sect 5 Qu (5)Medical Sect 5 Qu (5)Surgical Sect 5 Qu (5)TB Sect 5 Qu (6)And if additional wards assessed e.g. post op, gynae, ER/ICU please verify with them too

Verify with finance section whether funds have been spent on refreshments for blood donors

Laboratory tool Section 7, Qu 7

Finance section

Verify with laboratory staff that they distil water and provide it to the steriliser

OR/CSSD section 4, Qu 4

Laboratory staff/records of distilling


25

9.ASSESSMENT TOOLS

The following section is comprised of 12 assessment tools (Management, Wards, Departments) as well as questions for staff and a selection of hospital indicators.A summary page follows.Below is a list of all tools which are currently available to use for the hospital assessment.

1) Management 2) Paediatric Ward3) Obstetric Ward4) Medical Ward5) Surgical Ward6) TB Ward7) Operating Room and Sterilisation8) Outpatient Department9) Laboratory10) Pharmacy11) Radiology12) Referral System13) Staff Questions14) Indicators15) Summary Sheet


26

1. HOSPITAL MANAGEMENT Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

1. ADMINISTRATION (Interview should be conducted with Director, Vice-Director and/or chief of admin bureau with many documents available to check at the time or thereafter)

The first four questions relate to the hospital’s annual plan. They may seem quite similar but they are checking for 1) presence of an annual plan 2) whether there has been a review after analysis of achievements 3) whether the plan is realistic or not and 4) whether it is up to date

1 Does the hospital have an annual work plan and is it complete i.e. typical MOH format, covering all MOH priority areas and all categories/(objectives) filled in? Ask for any amendments. If the hospital doesn’t have the MoH format for annual plan, but only have activity plan or a financial plan, no score is given

work plan 5

Work plan is readily available and completeWork plan is available but difficult to find or incomplete

No work plan or unable to find the plan or they only have an activity plan or separate financial plan

51

0

2 Has there been any review of the work plan i.e. 3 or 6 monthly written review? Is so, please check it. Has there been any analysis of the results achieved or amendment of the plan after review of achievements? There may be a quarterly or six month plan – if so, check this and compare to the original annual plan. Problems may be stated but they must be specific and not such things as “strengthen management”, “strengthen service delivery” etc. There needs to be clear evidence that the hospital responds to obvious needs

Work plan and

review of work plan

(may include prev yr

review if asst done early in

the year)

10

3 or 6 monthly review of hospital achievements is available and subsequent amendment of the plan has been made if

required (or new quarterly or six monthly plan is available and is updated) or review shows no amendment necessary

3 or 6 monthly review of hospital achievements is available but no analysis of achievements or no change to targets despite

needing to amend someNo review available or no amended plan

10

10

3 Please check five indicators 1) BOR 2) no. deliveries 3) % patients receiving Antibiotics 4) % patients referred from HC 5) mortality rate Are the targets MOH targets or hospital specific targets? Are the targets realistic i.e. could they attain those targets or are they set too high? e.g. if current BOR is only 35% and target for this year is 65% it would seem unlikely that it will be achieved during one year. Likewise if the number of deliveries per month averaged only 10 in the previous year, 100 per month would seem unrealistic unless there are many activities that would lead to this increase e.g. tour of Obst ward for all TBAs and HC midwives in the OD, surgical services are now available and advertised, women obtain free deliveries in the hospital etc

work plan and

review of work plan,

may include

previous yrs annual performan

ce

5

Work plan targets for all 5 objectives look to be realistic i.e. they are set for the hospital rather than using MOH targets and

look to be achievableWork plan uses MOH targets only and targets look to be too

ambitious to achieve in 12 monthsOR work plan does not mention all objectives mentioned

OR review doesn’t specify achievements made

5

0

4 Check activities of above five indicators) and ask if they are up to date with work plan. Check against the HIS if possible i.e. for delivery rates, BOR, mortality rate, no. referrals from HC. Use the rational drug use supervision report to check the ABc usage. Compare between the year before, the plan and the review

R/v and current Wk

plan, recent and

last yrs HIS,

(quarterly or 6

10 Up to date with all five categories or on schedule to achieve target

Up to date with 1 - 4 categories or on scheduleNot up to date with any of the five categories

1020

Hospital Assessment Tool 27

mthly), rat drug use s’vn rpt

Verified by

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TOTAL

SCORE

COMMENTS

5 Is there an up to date hospital organisational chart publicly displayed? (Check with current staff list or on sheet for receiving user fees which has signatures. Go through each person and check whether still working/in position on chart)

Organ. chart,

staff list, user fee receipts for staff

5

Chart up to date and in a public areaChart up to date but not publicly displayed

Chart not up to date or not publicly displayed Chart not up to date and not displayed or No organisational

chart

5210

6**

Is there a monthly staff schedule for all wards and departments? (Administration should have a copy of schedules for each ward and department i.e. including floating staff (cleaners, drivers, gardeners, cooks etc) as well as pharmacy, laboratory, imaging, OPD etc. Please check for both day and night schedules)(Often staff are required to work day shift Mon to Fri in their department with the exception of the day following their night duty when they are scheduled off. However, in some hospitals where staff are lacking it is possible that staff will work in more than one ward/department either for night duty (if there are insufficient regular staff for the night duty) or to cover the day shift when the staff are off post night duty. In this case, there should be a clear schedule for each ward/dept for both day and night rather than just a night schedule so it is clear to anyone checking who should be on duty at any given time during the week or month). A yearly schedule is not adequate – a monthly schedule is required for each ward and department to reflect the real situationIf the answer is zero, please score zero on next questionVerify with Qu 1 (2) Paediatric, Obstetric, Medical, Surgical, TB and OR, Qu 1 (4) OPD and Qu 1 (1) Lab

Check admin for

all schedules

10

All wards, medical departments, non-medical departments (including floating staff) have day and night duty schedule for

the current monthAdmin only has schedules for some wards/medical

departments or only day or night schedules i.e. not complete schedule for 24 hour period

No up to date schedules/not complete for all departments

10

10

7**

Is there a register book for staff daily attendance kept at administration? Do the wards/departments have daily attendance books also? Check all attendance books for today and compare with schedules seen above. Check for at least 3 departments on 2 different daysIf the answer to this is 5, please verify with Qu 1 (2 and 3) for Paed, Obst, Med, Surg, TB, OR, Qu 1 (4 and 6) for OPD and Lab 1 (2)

Check register books at admin and

wards, staff

schedule

5Daily register is up to date today and corresponds to schedule

Today’s register not up to dateNo daily register or no schedule to verify

510


Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

8 Are there staff regulations and are they issued to each staff or available on display? Get a copy of regulations and any documents related to disciplinary action

Check regs/ask admin for

other docs

5

Staff regulations in place, in a position for all staff to read or staff have been supplied

Staff regulations allegedly in place but not seenNo staff regulations visible

OR ask two staff if they have ever received the regulations

Both have received them Only one has received themNeither have received them

OR

Each staff member has signed a sheet stating that they are aware of the hospital regulations and agree with the

disciplinary action that may be takenSome staff members have signed a sheet stating they are

aware of the hospital regulations and agree with the disciplinary action that may be taken

510

510

5

19**

Do staff not coming to work or not obeying staff regulations get disciplinary action (verbal, written warning letter, reduction of incentive, other)? Is there a schedule to explain consequences? Please detail any disciplinary measures they takePlease verify the answer to this question with Qu 8 of staff questions

Schedule, finance rpts and

staff interviews

10

Copy of government rules for workers or copy of hospital disciplinary schedule and evidence of disciplinary action (e.g.

reduced salary, change of position)No disciplinary schedule/criteria but disciplinary action has

been takenNo evidence or not clear if implemented

10

50

10 Do all positions have job descriptions? Director, Vice-Director, Admin, Chief of Service, Chief of Ward, Chief Nurse, Laboratory technician, cook, cleaner, driver. Check each job description and underline those that the hospital has a job description for

Job desc 20

Twenty points for all post listed (BUT only if JD actually read and confirmed that tasks are listed i.e. if not seen, no point

and has to have a list of tasks and responsibilities)If JD are available for others that are not listed only or not all

positions listed have JD

20

011 Is there a regular and fixed meeting with all staff where

hospital problems are discussed and suggestions for solving the problems documented? OR a meeting organised with senior staff who then have meetings with all in their department to disseminate information? Obtain minutes of the past 6 months of any general meetings or other meetings the hospital considers to be important for problem solving (may be only 1 or 2 mtgs)

Minutes general meeting, minutes

other staff meetings

10

Regular minutes of staff meetings from past 6 months available and include problems/complaints brought up by staff

which are followed up (need to show link between minutes)Irregular meetings but problems/complaints brought up by staff

which are followed up or regular meeting but not all follow upMinutes of meetings but only announcements by management;

problems not followed up or no link between minutesNo minutes of meetings in past 6 months

10

4

10

12 Is there a regular way to disseminate information to staff e.g. weekly meetings between Senior Management and Chief of Services/Wards, handouts or circulars, morning meetings etc?

Minutes of meetings, copies of

docs

10 Evidence of regular way to disseminate information i.e. minutes and includes information which is to be passed on to

other staff or handouts or circulars are providedHospital say there is a regular meeting and problems

10


givendiscussed but no minutes kept or hospital say have handouts

but no evidence No regular meeting or newsletter for all hospital staff

20

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

13 Are unskilled floating staff included in the general meetings or specific meetings with wards? Check one ward and document which ward you checked.

Attendance lists for meetings

10

Unskilled floating staff are named on the list of participants for general meeting or ward meeting

Unskilled floating staff are not named on list of participants to general or ward meeting

10

014 Is there a morning meeting held daily and recording of

discussions? Obtain meeting book/minutes Minutes morning meeting

10

Meeting book and records available, meetings Mon-Sunday and public holidays

Meeting book available, meetings Mon-Fri onlyMeeting book available but irregular meetings/recordings

No meeting book available

10410

15 Are patient files of deaths kept in a central place and discussions held regularly? Check number of deaths in last month’s HIS report and compare with number of files in central place. Need to find minutes of meetings (may be death audit meetings, morning meetings, technical committee meetings) HIS, pt

files, death audit mtgs

10

No. deaths on HIS = no. dead patient files, minutes of death audit show discussion of all deaths in the past month

No. deaths on HIS is not equal to no. dead patient files but minutes show discussion of some deaths

ORNo. deaths on HIS = no. dead patient files but no evidence

(minutes) of death audit / discussion of any deaths in the past month

Mention of some deaths at morning meetings or technical meetings but informal and not detailed or number of deaths

does not add up to HIS formNo minutes found of any death audits (including in technical

meeting minutes)

10

3

2

0

16 Does hospital have mechanism for reporting accidental exposure to blood or bodily fluids, including needle stick injury in place? There should be an incident report form or log book with a record of procedures performed since the injury. Have the staff members followed PEP procedure? Check to see whether it is all documented, drugs been given AND the records are kept in a central location e.g. Hospital Administration should be responsible for this rather than a ward, lab etc

Check PEP policyStaff

interview

10

Mechanism for reporting accidental exposure to blood and body fluid, needle injury, all in place i.e. all documentation can

be found in hospital Administration

Hospital has policy, staff may have been trained, but no central documentation (i.e. may find info on one ward only but

not in central location)

No mechanism in place

10

1

0

TOTAL 145


2. COMMITTEES (Interview should be conducted with Director, Vice-Director and/or chief of admin bureau)

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

1 Is there a Hospital Management Committee? Obtain last 6 months minutes. If zero, go to question 5. Minutes 2

Committee established, able to give names of members easilyCommittee established but not able to give names of

committee members easilyNot established

2

10

2 Are there TOR for all committee members? (need to see the written TOR) TOR 2

TOR for Hospital Management Committee clear and conciseTOR available but not really clear or not really TOR e.g. may

only be list of committee membersNo TOR available or unable to find them

2

10

3 Are there regular monthly meetings? Check minutes of meetings (CPA guidelines stipulated monthly)

Minutes 2

Frequency of meetings matches what is in the TOR for past 6 mths

Minutes but meetings not as frequent as should be for past 6 months

Say that there are regular meetings but no minutes found or no minutes taken or last minutes greater than 6 months ago

2

1

0

4 Do the topics discussed at the meeting reflect any problems mentioned in the previous minutes? i.e. are problems followed up

Minutes 10

Problems are identified and recorded in minutes; subsequent minutes report on progress

Problems are identified, recorded but not all are followed up/mentioned in subsequent minutes

Problems are identified and recorded in minutes but no progress of solving the problem appears in later minutes

No problems mentioned in mtg minutes or no minutes of mtg

10

3

10

5 Is there a Hospital Financing Committee? Obtain minutes from past 6 months (should have been elected). If zero, go to question 9. Minutes 2

Committee established by election, able to give names of members easily or a list of staff

Committee established (elected or selected) but not able to give names of committee members easily

Not established

2

10

6 Are there TOR for all committee members? (need to see the written TOR) (It is possible that they follow the TOR as written in CPA Guidelines) TOR 2

TOR for Hospital Financing Committee clear and conciseTOR available but not really clear/not really TOR e.g. may only

be list of committee membersNo TOR available or unable to find them

2

10

7 Are there regular monthly meetings? Are there minutes of each meeting? Minutes 2

Frequency of mtg matches what is in the TOR for past 6 mthsMinutes but not as frequent as should be for past 6 months

Say regular meetings but no minutes found or no minutes taken or last minutes greater than 6 months ago

21

0



Minutes 10

Problems are identified and recorded in minutes; subsequent minutes report the progress of all problems mentioned

Problems are identified, recorded but not all are followed up/mentioned in subsequent minutes

Problems are identified and recorded in minutes but no progress of solving the problem appears in later minutes

No problems mentioned in minutes of meetings or no minutes of meeting

10

3

1

0

Verified by

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ESCORING

TOTAL

SCORE

COMMENTS

9 Are there two financing sub-committees? (Monitoring and Evaluation of User Fee Scheme and Logistics and Procurement) Do they have TOR for both committees>? (need to see the written TOR and obtain minutes of past 6 months)

Minutes 4

M & E committeeTOR for Monitoring and Evaluation Committee clear and

conciseTOR available but not really clear/not really TOR e.g. may only


Logistics/ProcurementTOR for Logistics and Procurement Committee clear and

conciseTOR available but not really clear/not really TOR e.g. may only


2

10

2

10

10 Is there evidence that the Monitoring and Evaluation Committee is active?

Minutes 10

Minutes show that problems of financing scheme are discussed, hospital has a way to monitor scheme and ensure exemptions occur, method to receive formal complaints from

general public is in place (and documented)Meetings occur but problems are not discussed or solved

No minutes of meetings or no meetings

1020

11 Is there a Technical committee? Obtain minutes of past 6 months. If zero, go to question 18. Minutes 2

Committee established, able to give names of members easilyCommittee established but not able to give names of

committee members easilyNot established

2

10

12 Are there TOR for all committee members? (need to see the written TOR) TOR 2

TOR for Hospital Technical Committee clear and conciseTOR available but not really clear/not really TOR e.g. may only


2

10

13 Are there regular meetings? Are there minutes of each meeting?If there are no minutes at all for Technical Committee then the next 4 questions (14 to 17) should score zero as there is no way to verify that Tech committee is involved in discussions/decisions about drug purchase, death audits, HIS

Minutes 2

Frequency of mtgs matches what is in the TOR for past 6 mthsMinutes but not as frequent as should be for past 6 months

Say regular meetings but no minutes found or no minutes taken or last minutes greater than 6 months ago

21

0


Minutes 10 Problems are identified and recorded in minutes; subsequent minutes report on progress

Problems are identified, recorded but not all are followed 10


If score for qu 13 is zero, check zero for this questionup/mentioned in subsequent minutes

Problems are identified and recorded in minutes but no record of progress to solve the problem appears in later minutes

No problems mentioned in minutes of meetings or no minutes

3

10

15**

Does the technical committee decide on the drugs that need to be purchased for the hospital? (Procurement committee should purchase them but Technical committee should decide on the list to purchase)Please verify this answer with Qu 9 of Pharmacy assessment. If score for qu 13 is zero, check zero for this question

Minutes 10

Evidence that there is discussion about drugs purchased i.e. the need for purchasing them, the quantity

No evidence that there is discussion about drugs which hospital purchases (no minutes)

10

0

Verified by

MAXSCOR

ESCORING

TOTAL SCORE

COMMENTS

16 Do any of the minutes reflect discussion on deaths including maternal deaths, treatment of complicated cases, % pts given IV fluids/antibiotics, length of stay etcIf score for qu 13 is zero, check zero for this question

Minutes 10

Minutes show discussion on deaths frequently e.g. each meeting, treatment of complicated cases

Minutes rarely show discussion about deaths, rarely discuss indicators of hospital HIS data

No minutes

10

20

17 Is there any evidence of discussion about HIS data in any minutes of meetings (except morning meeting) (check last 6 months)If score for qu 13 is zero, check zero for this question

Minutes 8

Monthly statistics are discussed and recorded in at least two monthly minutes

Monthly statistics have not been recorded in minutes of past 6 months or no minutes

8

0

18 Are there any other committees or regular meetings which the hospital has organised that are not part of CPA guidelines? e.g. weekly meeting with chief of Services. If so please specify in the comments box

Minutes 10

Yes – committee or regular meeting established by hospital in response to needs

No additional committees100

TOTAL 100

3. INFRASTRUCTURE AND LOGISTICS (Completed after observing taking a detailed tour of the hospital – preferably at the end of the assessment)

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

1 Check the incinerator(s) (for general waste) and surrounding area. Is the incinerator full? Is the rubbish old or recent looking? Are there piles of rubbish or burnt piles close to incinerator? Does it look used? There may be incinerators for each ward therefore you need to look at all of them and note how many are

Observe 10 Incinerator looks to be used regularly (no piles of rubbish around incinerator or throughout the hospital, part full (rubbish

looks recent not old) or emptyIncinerator looks as though it is used sometimes but not

regularly with piles of rubbish close to the incinerator but not throughout the hospital

10

2


functional and how many are not. Please note the no. of incinerators checked

Incinerator not used often (may be full of old rubbish or empty) or piles of rubbish throughout the hospital or near incinerator 0

2 Check the incinerator that is used for disposing of needles and syringes

Observe 10

Incinerator looks to be used regularly, part full (rubbish looks recent not old) or empty, no needles or syringes around the

incinerator that have been dumpedIncinerator looks as though it is used sometimes, not regularly Incinerator not used often (may be full of old rubbish or empty)

or needles and syringes seen around the hospital ground or full sharps containers kept in a public place

101

03 Cleanliness of hospital grounds. Take note of bins as

you walk around and whether there are piles of rubbish around Observe 10

No piles of rubbish seen around the hospital, bins have lids and none full or over flowing

Evidence of piles of rubbish having been burnt throughout the hospital

Piles of rubbish and animals going through rubbish (chickens, dogs, pigs etc) or piles not burnt, bins with no lids or bins full

10

2

0

Verified by

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ESCORING

TOTAL

SCORE

COMMENTS

4 General appearance of hospital. Underline what is present e.g. grass cut

Observe 10

Grass well kept, no rubbish lying around, bins in use, flowers and trees well kept

Grass partly cut, no rubbish lying around, bins in use, flowers and trees partly kept

Grass not cut or rubbish lying around or bins not in use or garden unkempt

10

4

0

5 Electricity supply (Need to ask what happens if power shortage. Have they wired priority areas to generator)

Observe 10

24 hour electricity (town supply or generator permanently on or available) but has a functioning back up generator for

emergency areas (operating room, steriliser, fridges (blood bank, lab, vaccines), pharmacy storage, night lights)

back up to only some of those mentioned above e.g. O RoomReliable supply (town or generator) but no functioning back up

supply or not wired to priority areasSupply not reliable, generators in poor condition or insufficient

fuel, no reliable back up

10

4

0

6**

Water supply for hospital (Need to ask where source is from and be astute during ward visits to check whether water storage is readily available if piped water stops).Need to verify the answer to this question with Qu 5 (3) in Paediatric, Obstetric, Medical, Surgical and OPD assessments, Qu 5 (4) in TB ward and Qu 4 (4) in Oper Room 4 (4)

Observe 10

Water is piped and reliable but back up water exists (storage containers at sinks/roof tanks which are full; labour room and

operating room have large back up storage) or water is piped but unreliable, reliable back up routinely exists

Water is reliable but no back existsWater is unreliable and no back up exists or water is unreliable

and storage is not routine or sufficient

104

0

7**

Water supply for patients and relatives (Verify with Administration and patient interviews)Need to verify the answer to this question with Qu 4 (7) in Paediatric and TB assessment, Qu 4 (6) in Obstetric assessment and Qu 4 (8) in Medical and Surgical

Observe and

patient interview

10 Reliable water supply for patients and relatives to bathe, wash clothes etc (piped or well or water containers or dam)

Water available but not 24 hours per day (some containers not filled routinely)

Some toilets/bathrooms locked or water not available at all or

10

2


assessments all containers completely empty 0

8**

Hospital Kitchen (Verify when do patient interviews). It is possible that patients get two meals but it may not be nutritious i.e. just rice and little else. If so please make comments in the comments box on the right. It is also possible that the kitchen does not get 1000B per patient per day but a set amount regardless of patient numbers. If so, please record it.Verify with Paediatric, Medical and Surgical Qu 4 (9), Obstetric Qu 4 (7)and TB Qu 4, (8)

Observe and

patient interview

10

Hospital kitchen available and in use with patients receiving 2 meals per day (verified by patients in wards)

Hospital kitchen available but patients don’t receive 2 meals regularly

No hospital kitchen

10

20

9**

Patient Relative kitchen (visit and check)

Verify with Paediatric, Medical and Surgical Qu 4 (10), Obstetric Qu 4 (8)and TB Qu 4, (9)

Observe 10

Relative kitchen(s) available and in useRelative kitchen available but not used or some relatives cook

outside patient roomNo relative kitchen or all relatives cook wherever they like

10

20

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

10 Laundry (visit and check)

Observe 10

Laundry and washing machine available and used regularly for washing surgical/obstetric linen, area clean, soap powder

available, contaminated and clean linen separatedLaundry available but not used frequently

No laundry or not used or not clean; contaminated and clean linen not separated

ORNo laundry but washing done by hand in area free from the general public, cleaners protected from contaminated linen

(wear gloves), clean and dirty linen separated, soap powder available

Washing of linen in public area (well or toilets) or cleaners not protected

10

20

10

011 Staff parking Observe 10

Staff cars and motos kept in parking area during day timeSome cars and motos kept in parking area

Motos close to/ in wards during day or no area for staff parking

1020

12 Visibility and signage for emergency

Observe 10

Sign pointing to emergency area visible to hospital visitors (on road outside hospital and within hospital)

Sign only on the outside of the hospitalNo adequate sign showing where emergency area is or no

sign

102

013 Storeroom (Ask administration and observe throughout

hospital assessment) Observe 10

Hospital has at least one storage area, no old, broken down equipment lying around

Storage area exists but full and/or broken equipment stored in other places alsoNo storage area

10

20


14 Was there evidence when walking around the grounds and wards that there is a significant infection control problem e.g. sharps containers found in public place (waiting to be burnt perhaps), needles and IV lines on the ground or in rubbish bins rather than sharps containers?

Observe - 20 points

Yes – take OFF 20 points from the totalNo -20

TOTAL 130 Remember to take off 20 points if the last question is positive


4. FINANCE Verified by

MAX SCORE SCORING TOTAL

SCORE COMMENTS

1 Is there a User Fees system implemented? If so, are fees displayed in central location near cashier (Check area where patients pay fees) Observe 10

User fees are displayed at area where patients pay and large enough for patients to be able to see/read it, includes

exemption informationUser fees not displayed at place of payment or not large enough for patients to see clearly, no exemption criteria

documentedNo user fees on display

10

10

2 Is it clearly stated whether patients receive full service (entire length of stay) when they pay the hospital admission fee or do they have to pay for additional services e.g. lab, x-ray etc? Are they expected to pay again throughout their stay?

Observe 10

User fees clearly state what the admission fee will cover (how many days, services provided)

User fees state that patients will have to pay again after a certain number of days e.g. 3 or 7 days but it is not clear

whether they will have to pay for additional servicesUser fees are not clear

10

20

3**

Are receipts provided to all patients including those who are exempted?

Verify with Qu 4 (12) Paediatric, Medical and Surgical, Qu 4 (10) Obstetric and Qu 4 (3) OPD

Patient interviews 10

Receipts provided to all patients met including exempted patients

Receipts not given to all patients interviewed (may have no receipt of stapled to notes)

Receipts stapled to patient notes onlyNo receipts given

10

100

4**

Does the hospital have a system to exempt patients? Please check user fees board to see if it is mentioned, whether written criteria for exemption is available; check registration book to see if patients are exempt, document the number of patients who were exempted during interviews or had exemption provided, obtain information from RH financial records whether exemptions were providedVerify answer with Qu 4 (11) Paediatric, Medical and Surgical Assessments, Qu 4 (9) Obstetric, Qu 4 (10) TB assessment and Qu 4 (2) OPD

Pt interviews, user fee board, receipt books,

financial records

10

Exemptions are explained to patients, user fee board gives information, hospital documents all exemptions which is

verified by patient interviewsHospital says that they exempt patients, no record but patients

verify exemptionNo mention of exemptions on board and patients are not

aware of exemptions

10

3

0

5 Mechanism for allocating user fees is documented and is according to MOH guidelines (60% to staff, 39% to running costs). Check financial records i.e. budget lines etc for the 39%

Guidelines for

distribution10

Written guidelines are witnessed, 60% used for staff salaries and 39% used for running costs (excludes funds for night duty,

overtime etc)Written guidelines are witnessed but 39% is also used for staff

top up salaries/incentivesNo written guidelines for distribution of 60%

10

20

6**

How is the amount of money generated per month and disseminated to staff? Do they receive money from user fees monthly and are they aware of the method to decide on amount each staff member will receive? There should be guidelines not just a monthly sheet which the staff has signed. Check the financial records to get information on how the money is divided between staff Verify answer with Qu 3 to 4 of Staff Assessments

Staff interviews, financial records,

verification sheet

signed by staff

10

Staff verify that information about user fees is disseminated monthly, they receive funds regularly and in correct amountStaff verify that information about user fees is disseminated

but funds are not received monthly or not in the amount they expect or don’t know if they get correct amount

No information is given to staff about user fees generated or how dispersed between staff or do not receive the amount

they should or don’t receive it at all

10

2

0


7 Of the 60% of user fees allocated to staff, does the hospital allocate a percentage to each ward? If so are there guidelines on how the money is divided?

Financial records,

staff interviews,

hospital guidelines

10

Wards receive a % of the user fees to be used by ward or staff. Guidelines exist for their use

Wards receive a % of the user fees but no guidelines exist. Accounting is available

Wards receive a % of the user fees but no guidelines exist or accounting is not kept or wards don’t receive a % of user fees

10

2

0

8 Accounting of user fees is correct. Check receipts and financial records for a few days. (If hospitals provide departments with a % of amount earned, the financing system may be recorded daily according to department).

Receipt book and monthly financial report

10

Monthly records of user fees collected are equal to amount in receipt book

Amount collected is not equal to receipt bookNo receipt book

1020

TOTAL 80


5. HIS (need to have HO2 form for last month and also last years total report)

Verified by


SCORE COMMENTS

1. Is last months H02 report available and each section completed? HIS report 5

CANNOT score between 0 and 5 – either available or not Available and all sections completed

Not available or not completed 50

2. Check the following for accuracyAdd together different age groups of each of the following rows of hospital morbidity (diarrhoea, malaria, ARI, accidents, others) i.e. different age groups of each disease and check whether the total number written is correct.

HIS report 5 5 rows correct

2-4 rows correct 0-1 row correct

510

3. Go to Hospital Services – General Activities table. Go to discharge rows i.e. authorized d/c, unauthorized d/c, referrals, deaths. Add each row to see if total is correct.

HIS report 5

4 of 4 rows correct 2 or 3 of 4 rows correct bks

0-1 of 4 rows correct

510

4. Check hospital mortality rate for four departments separately (i.e. 4 of med, surg, paed, mat or others) i.e. check no. deaths in each dept x 100/totat no. discharges for each dept. (authorized d/c, unauthorized d/c, referrals, deaths)Then check total hospital mortality rate (add all deathsx100/all discharges (authorised/non etc)

HIS report 10 5 of 5 correct 2 - 4 correct 0 or 1 correct

1010

5. Check no. deaths in this table and compare with (1) deaths on table above (morbidity and mortality table) PLUS (2) no. maternal deaths (abortion and delivery tables further below). Should be the same number

HIS report 5 Number of deaths is the sameNumber of deaths is different

50

6. Check BOR for four departments (those used above) and total BOR (excluding TB)BOR = no. inpatient days x 100/no. beds x no. days month

HIS report 10

5 of 5 correct 2 - 4 correct 0 or 1 correct

1010

7. Check total no. deliveries (found under Obstetrical activities and births) and compare with total live births PLUS total no. stillbirths (No. should be the same if all are recorded except if there are twins/triplets born. If this is the case, it should be verified by looking at the delivery register where this would be recorded. If there is no record or twins/triplets then they should score zero)

HIS report 10

Total no. deliveries (Obstetrics section) = no. live births + stillbirths

Not equal100

8. Is there a whiteboard showing hospital statistics and is it up to date?

HIS report 10 Whiteboard up and up to dateWhiteboard but last month’s data not yet recorded

No whiteboard but some graphs showing some up to date morbidity/mortality data

Whiteboard not up to date > 1 month

103

31


No whiteboard 0

Copy here the information you have gathered from Ward assessments (Paed, Obstet, Med, Surgery Section 3 (7), OPD Sec 3 (4) and TB Sec 3 (2) as well as discharges from HO2 form. See instructions in left column. All data should be from the past month or from two months before if the assessment is carried out before the 20th day of the month. Ensure all ward assessments collect information from the same month (decide before doing the assessment). Please check with the hospital what closing date they have i.e. all wards should collect data from the same period and the HIS record should ensure that they also use the same data

HO2 form

From reg bks

MAX

9 TOTAL ADMISSIONS TO WARDS (from OPD registration book) (Check Qu 3(4) OPD)

TOTAL ADMISSIONS PAEDIATRICS (Qu 3 (7)TOTAL ADMISSIONS OBSTETRICS (Qu 3 (7)

TOTAL ADMISSIONS MEDICAL WARD (Qu 3 (7)TOTAL ADMISSIONS SURGERY (Qu 3 (7)

TOTAL ADMISSIONS TB (Qu 3 (2)TOTAL ADMISSIONS ICU WARD (Qu 3 (7)

TOTAL ADMISSIONS EMERGENCY WARD (Qu 3 (7)TOTAL ADMISSIONS POST OP (Qu 3 (7)

TOTAL ADMISSIONS GYNAE (Qu 3 (7)TOTAL ADMISSIONS TO OTHER WARDS IF

PRESENT

This data comes from the Ward assessments

N/A

N/AN/AN/AN/AN/AN/AN/AN/AN/A

N/A

Use the data collected during the ward visits to the 6 wards and transpose the data here

10. The next section refers to REFERRALS from OUTSIDE the hospital i.e. NOT transfer of patients between wards BUT referred from HC or other hospital

TOTAL REFERRALS TO PAEDIATRICS (Qu 3 (7)TOTAL REFERRALS TO OBSTETRICS (Qu 3 (7)

TOTAL REFERRALS TO MEDICAL WARD (Qu 3 (7)TOTAL REFERRALS TO SURGICAL WARD (Qu 3 (7)

TOTAL REFERRALS TO TB (Qu 3 (2)TOTAL REFERRALS TO ICU WARD (Qu 3 (7)

TOTAL REFERRALS TO EMERGENCY WARD (Qu 3 (7)

TOTAL REFERRALS TO POST OP (Qu 3 (7)TOTAL REFERRALS TO GYNAE (Qu 3 (7)

TOTAL REFERRALS TO OTHER WARDS IF PRESENT

**Please verify answer with Qu 1 (2), Qu 1 (13) and Qu 3 (2) and (4) OPD asst, Qu 2 and Qu 3Referral

assessment, Qu 3 (4) for Paediatric, Obstetric, Medical, Surgical assessments (and if ICU, ER, Gynae and Post

Op rooms) (find the column with referrals from HC or other health facility)

N/AN/AN/AN/AN/AN/AN/AN/AN/A

N/A If referrals to the hospital are not clear i.e. the registration book includes internal referrals (transfers from other wards) as well as referrals from outside hospital then please state this in the comments box on the right


USEHO2Form

11. This relates to DISCHARGES which are ALL patients leaving the hospital i.e. authorised discharges + unauthorised discharges + referrals to another hospital + deaths i.e. you need to add all of these together. Check the month you are supposed to PLUS the month before in case there is a patient admitted earlier who was admitted for a lengthy period

TOTAL DISCHARGES PAEDIATRICS (Qu3 (7) TOTAL DISCHARGES OBSTETRICS (Qu 3 (7)

TOTAL DISCHARGES MEDICAL (Qu 3 (7) TOTAL DISCHARGES SURGERY(Qu 3 (7)

TOTAL DISCHARGES TB (Qu 3 (2) TOTAL DISCHARGES ICU WARD (Qu 3 (7)

TOTAL DISCHARGES EMERGENCY WARD (Qu 3 (7)

TOTAL DISCHARGES POST OP (Qu 3 (7)TOTAL DISCHARGES GYNAE (Qu 3 (7)

TOTAL DISCHARGES TO OTHER WARDS IF PRESENT

(TOTAL = d/c, unauthorised, referrals, deaths)

10

HO2 form and registration book confer for all wards on no. total discharges

HO2 form and registration book have different no. dischargesUnable to find HO2 form

1010

12. The next section relates to REFERRALS from this ward to another hospital or HC i.e. NOT transfers within the hospital.Please note that the data may not be able to be collected

TOT REFERRALS FROM PAEDIATRICS(3 (7)TOT REFERRALS FROM OBSTETRICS(3 (7) TOT REFERRALS FROM MEDICAL (Qu 3 (7)

TOT REFERRALS FROM SURGERY (Qu 3 (7) TOTAL REFERRALS FROM TB(Qu 3 (2)

TOTAL REFERRALS FROM ICU WARD (Qu 3 (7)TOTAL REFERRALS FROM EMERGENCY WARD (Qu

3 (7)TOTAL REFERRALS FROM POST OP (Qu 3 (7)

TOTAL REFERRALS FROM GYNAE (Qu 3 (7)TOTAL REFERRALS FROM OTHER WARDS IF

PRESENT

N/AN/AN/AN/AN/AN/AN/AN/AN/AN/A

N/A

If referrals from the hospital is not clear i.e. the registration book does not differentiate

between referrals to other hospitals and internal transfers, then please state this in the

comments box on the right

13. Please work out the percentage of inpatients that have been referred in to RH (from HC or other RH or health facility i.e. not transfers between wards). Transpose data from OPD Section 3 (4)Total no. admissions =

10 >20% inpatients referred from HC10-20% inpatients referred from HC

5-10% inpatients referred from HC2-5% inpatients referred from HC<2% inpatients referred from HC

106310


Total no referred inpatients =

% inpatients referred = no. referred inpatients to RH x 100/total no. admissions

Total admissions should be recorded in a central OPD register. If there is no central register, then this % cannot be calculated unless the remaining wards have their admission numbers and no. referred patients checked also (amounts above are only some recorded above from ward registers). Please note: hospital services table in HO2 form records discharges not admissions so you cannot verify this with HO2)**Verify with OPD assessment Qu 1 (13) , Qu 3 (2) and (4) and Referral asst Qu 3

N/Aunable to quantify as don’t know total admissions

PLEASE TICK WHICHEVER APPLIES

USED OPD ADMISSION DATA

OR OBTAINED ALL DATA FROM IPD REGISTRARS

0

14. Please compare the number of referrals to and from hospital (use ward data from above). If no statistics to compare they score zero 10

No. referrals into RH is greater than the no. referrals outNo referrals in is less than the number of referrals out or there

are no statistics to compare

10

0

15. For those hospitals who have more than one ward per specialty e.g. two Medical Wards, two Obstetric Wards or more than one laboratory or OPD, is there evidence that the data collected is in the same format e.g. are the registration books set up the same, does one ward collate statistics from both wards before sending to Administration? This should be verified with the various wards/department where there is more than one building/ward before finalising this question

20

Wards/departments have the same registration book format, Chief of ward gets together with other chief of ward and combines statistics

together - 20Wards/Departments have same registration book but don’t combine

statistics prior to sending to Administration - 8Wards/departments have different registration books - 0

16. Does the hospital have a computerised system for their HO 2 form? If so and yet the data does not correspond to the Ward HIS data then 20 points should be taken away i.e. the hospital may score full marks on the first 7 questions (if computerised) yet the data entered does not correspond to the ward registration books and therefore is meaningless

Hospital has computerised system for HO2 but data does not correspond to data from ward registration book - 20

TOTAL 110Don’t forget, if there is a computerised system and the data is different to ward registration books please deduct 20points


MAX SCORE

SCORE RECEIVE

D%

1. Administration 1452. Committees 1003. Infrastructure and

Logistics130

4. Finance 805. HIS 110

TOTAL MANAGEMENT

565


Assessment of Paediatric Ward –Referral Hospital Treatment Guidelines (including malaria treatment guidelines), HIS for past month (or HIS for 2 months earlier, if assessment done before 20th of the day i.e. if you are doing the assessment on the 10th day of the month, get the HIS from two months earlier) and Essential Drug list will be required to do this assessment. If there is more than one Paediatric Ward, an assessment should be performed for both

2. PAEDIATRIC WARD

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

1. ORGANISATION AND PRESENTATION OF STAFF AND WARD (visit ward)

1 Is there an organisational chart of staff working in this ward, displayed: on the ward, in the nurse’s station or chief’s office? Is it up to date?

Spot check 3

Available and up to date Not up to date or not present

30

2 Is there an up to date staff schedule - day and night? (Often staff is required to work day shift Mon to Fri in their department with the exception of the day following their night duty when they are scheduled off. However, in some hospitals where staff is lacking it is possible that staff will work in more than one ward/department either for night duty (if there are insufficient regular staff for the night duty) or to cover the day shift when the staff are off post night duty. In this case, there should be a clear schedule for each ward/dept for both day and night rather than just a night schedule so it is clear to anyone checking who should be on duty at any given time during the week or month). A schedule should be made at least monthly. If the ward has only a yearly schedule this is not adequate

If the answer is zero, please score zero on next question as you will be unable to verify whether all staff are present

Observe and staff schedule

5

Both day and night staff schedule available and observed (or schedule shows both day and night duty on the one schedule) for

the current month Only day or night available and up to date, but not both

Nil or none up to date

510

3 Are all staff present today that should be? (Check today’s schedule) If the staff member is not present and you are told that they have official permission to be away, you must verify this with the Chief of ward or Administration


5

All staff are present (in hospital at time of visit) Half or more than half of the staff are present

Less than half of the staff are present or no schedule to check

510

4 How many staff are in their uniform and look well presented?Count the number of staff on duty. No. staff=No staff in uniform =

Spot check andObserve in ward

5

All staff wearing uniform and look well presentedHalf or more than half wearing uniform and look neat and tidy

More than half wearing uniform but it is not clean or tidy Less than half have uniform on

5210

5 How many staff have name tags? Spot 5 All staff have name tags 5


Count the number of staff on duty. No. with tags = check andObserve in ward

Half or more than half have their name tags displayed Less than half have their name tags displayed

10

6 Are there new patient files/admission sheets (include sheets for: 1-patients details, 2-history, exam, diagnosis and treatment, 3. medication, and 4. vital signs). Are they readily available and made up ready for the next admission? It is possible that the OPD will complete the admission file. If so, then record in the comments box that this hospital has a policy to have admissions completed by OPD

Spot check 5

All sheets readily available and completely made up All sheets readily available but not made up into a file

Not available or not readily available

510

7 Are there blank discharge letters available? Spot check 3 Available and easily found

Not available or not readily found 30

8 Are there forms for laboratory, x-ray, ultra sound, pharmacy on hand and easily found?

Spot check 4

Pharmacy forms available (prescription pads or ward pt form)No pharmacy form

Form for x-ray, lab, ultra sound available and has adequate space to record all results

No form or inadequate space to record resultsTOTAL 4 points

20

20

TOTAL 35

PAEDIATRIC WARD Verified by

MAXSCOR

ESCORING

TOTAL SCORE COMMENTS

2. EQUIPMENT AND SUPPLIES 1 Check for the following: thermometer, BP cuff (child cuff),

stethoscope, scales for babies, scales for older children. Is it easily found or locked in a cupboard? It must also be in good working order


10

One point for each piece of equipment and another point if that item is easily found i.e. total of 2 points per item. Nil points if broken

ThermometerBP (child cuff)

StethoscopeScales for babies

Scales for older children

1+11+11+11+11+1

2 ORS is available Spot check 5

ORS sachets are readily available on the ward i.e. can be given to a child without a prescription if needed

No ORS 50

3 clean water is available on ward to mix up ORSThe water must be readily available for patients to have 24 hour access i.e. if kept in the nurse’s station please ask patients whether they know it is available. Check any patient with vomiting and diarrhoea to see whether they have water/ORS, whether they know water is available

Spot check

5 Water is treated at source (if tap water), filtered, bottled, boiled and easily available for all patients to get at any time

No water or water is not treated/boiled or water is not always easily available or patient doesn’t know about availability of water

or patient has to provide

5

0


etc. If water is available in nurse’s station but patients do not know about it then score zero

4 cups are available for children to drink from and spoons are available for those who are too young to use a cup

Spot check 5

Clean cups and spoons stored in easily accessible place Cups available but not clean

No cups available

510

5 oxygen is available (check regulator and flow meter to

see if oxygen tank has oxygen or concentrator is working)Spot check 5

Oxygen available/concentrator working No oxygen or no oxygen concentrator in ward or not working

50

6 Mask/nasal cannula and tubing is clean; other clean masks and tubing is available

If there is no mask score zero points. Nasal cannula can only deliver a maximum of 2 litres per minute therefore if additional oxygen is required, a mask must be used

Spot check

5

Paediatric mask and nasal specs/canula) and tubing is readily available and clean; spare masks and tubing readily available

Mask and tubing available but not clean or not easily accessible No mask/tubing available on ward

510

TOTAL 35


3. QUALITY OF DOCUMENTATION AND PROCEDURES (Need RH Treatment guidelines and Essential Drug List to help with certain questions)


MAXSCOR

ESCORING


1 Check the register book. Is there one book that records admissions and discharges? Ask if there are different registration books in the ward

Register book 5

Registration book has both admissions and discharges in the same book

Ward has different registration books – one for admissions and one for discharges or other system

5

02 Check registration book for columns (see below for

columns it should have). If there are no columns skip the next questions (all get zero points) and go the questions on patient files – starting at no. 9)

3 Is the registration book up to date i.e. today's admissions and discharges are in the register book? Register

book 5

Today’s admissions entered and up to date; today’s d/c up to date Today’s admission entered -not up to date, today’s d/c not up to

date Nothing entered for today

5

10

4 Check this registration book for the following columns: running number, name, age, sex, address, date of admission, diagnosis on admission, referred from HC or other health facility, date of discharge, diagnosis on discharge, outcome (discharged, unauthorised d/c, referred (to other health facility or ward), death), no. days admitted. Are all columns included?

The hospital should record whether the patient was a referral FROM HC or other facility or internal transfer from other ward. If not then it is unsatisfactory so please check what this ward has regarding referrals into hospital

Register book 15

Give one point for each item being in the registerRunning number

NameAgeSex

AddressDate of admission

Referred from HC or other faciilityDiagnosis on admission

Date of dischargeDiagnosis on d/c

Dischargedunauthorised d/c

referred (to other health facility or ward)death

No. days admittedTotal points 15

5

Go to the first day of the previous month of the registration book and check entries for the patients on this day. If there was no one admitted on the first day, take the second day.

Register book 12

Give one point for each column mentioned above being complete for those admitted on the first day of the previous month (this should allow for all of those to now be discharged). If there is > one patient admitted check all. If all columns have been completed correctly, give 12 points (only one of four outcomes is possible hence the reason for only 12 points). If a column is incomplete for any patient they lose 1 point. If there are 5 patients, the same applies. If the registration book does not have all the above columns then the maximum number of points that can be attained is 6


6 Check every entry for the first 20 days of the previous month to see if they have an outcome recorded i.e. discharge, unauthorised discharge, death, referral (If the date of the assessment is before 20th day of month, please use the data from 2 months earlier to increase the chance of pts admitted during that month being discharged)

Register book 8

All patients admitted in the first 20 days of the previous month have an outcome recorded

One patient or more doesn’t have an outcome recordedNone have an outcome recorded

810

7**

Check no. admissions, referrals to and from RH, discharges in the past month using the registration book and complete the following (If the date of the assessment is before 20th day of month, please use the data from 2 months earlier to increase chance of pts admitted during that month being discharge):ADMISSIONS IN = all those admitted during the month you are checkingREFERRALS IN = those from outside the hospital only; DISCHARGES include ALL leaving the ward i.e. authorised and non authorised, deaths and referrals/transfers. You will have to check the month in question PLUS the month before to see whether patients admitted in the previous month were discharged in the following month.REFERRALS OUT = those referred to another health facility (RH or HC) NOT transfer within the hospitalIf the Registration book does not make this distinction then please make comments in the comments box

a) TOTAL ADMISSIONS TO PAEDIATRICS (in the past month (or 2 months)) =

The next section refers to REFERRALS from OUTSIDE the hospital i.e. NOT transfer of patients between wards BUT referred from HC or other hospital If the registration book does not differentiate please commentb) TOTAL REFERRALS IN TO PAEDIATRIC WARD (in the past month(or 2 months)) =

The next section relates to DISCHARGES which refers to ALL patients leaving the hospital i.e. authorised discharges, unauthorised discharges, referrals to another hospital and deaths i.e. you need to add all of these together to get the total no. discharges.Check the month you are supposed to PLUS the month before in case there is a patient admitted earlier who was admitted for a lengthy periodc) TOTAL DISCHARGES PAEDIATRICS (in the past month/2 mths) =

The next section relates to REFERRALS from this ward to another hospital or HC i.e. NOT transfers within the hospital. It may be difficult to get this information – if so please commentd) TOTAL REFERRALS FROM RH OF PAEDIATRIC PATIENTS (in the past month/2 mths) =

If registration book does not record referrals then leave the referral sections blank

Please transpose this information to HIS in Management section 5

8 Please work out the % of inpatients who have been referred in to paediatric ward :% = total no. referrals to Paediatric ward last month x 100/total no. admissions to Paediatric ward

Use the above data. If referrals from outside are not recorded or clear you are unable to calculate it

Register book 10

>20% inpatients referred from HC10-20% inpatients referred from HC5-10% inpatients referred from HC

2-5% inpatients referred from HC<2% inpatients referred from HC

Nil if unable to check because referrals or total admissions are unable to be retrieved

106310

0



MAXSCOR

ESCORING


9 Take 5 current patient files and check for completion of:

If less than 5 patients, multiply total score by 5 and divide by number patient files checked e.g. if 3 patients scored 15 then 15 x 5/3 is the final score to put in the box

pt1

pt 2

pt3

pt 4

pt 5

total

name, address, age, sex, date of admission, referred from (check if referral letter present – if so, they get a point)

Patient file 30

One point for each i.e. total 6 points per patient, total 30 patients if all correctly filled in

nameaddress

agesex

date of admissionreferred from

TOTAL 6 points per patients

10 Vital signs on admission completedHistory of illness, examination and diagnosis completed in admission record

Patient file 50

Vital signs: one point for completion of each i.e. T BPPRRR

History: if detailed and extensive - 2 not complete or very scant - 1

no history - 0Examination: complete/extensive - 2

not complete - 1nil - 0

Diagnosis: if fits with history and vital signs and examination - 2

if no history or vital signs missing - 0

TOTAL 10 points per patient – total 50 for 5 patients

11 Were the investigations appropriate for the symptoms/signs? (laboratory, x-ray, ultrasound) Patient

file, RH guidelines

10

If investigations warranted and fit with symptoms - 2 If investigations performed but not really warranted or

no history or examination – 0 If no investigations performed when should have - 0


12 Were the drugs prescribed on the essential drug list and according to RH treatment guidelines?

Patient file,

essential drug list,

guidelines

10

On essential drug list and treatment according to guidelines - 2

Not on essential drug list - 0 not according to guidelines - 0

TOTAL 2 points per patient13 Check the file for today's entry/recording. Is there a date,

clinical notes, examination, treatment orders, signature of doctor/MA? Patient

file 25

One point for each DateClinical notesExamination

Treatment ordersSignature of doctor/MA




MAXSCOR

ESCORING


If less than 5 patients, multiply total score by 5 and divide by number patient files checked e.g. if 3 patients scored 15 then 15 x 5/3 is the final score to put in the box

1 2 3 4 5 TO

14 Check the vital sign chart for entire admission of these current patients. Is there at least daily recording of temperature, PR, BP, RR with a signature of the person taking them? If no daily vital signs for each patient, no point is given for that item. If no vital sign chart at all, then no points

Patient file 25

One point for each vital sign (only if they have been done every day of admission) and signature. If they missed any vital sign during their admission then no point is given T everyday

BP everydayPR everydayRR everyday

Signature everydayTOTAL 5 points per patient

15**

Find 5 files of patients that were referred by a HC (see the admission sheet which should check this box) or registration book to find the patient. Check whether the referral form from the HC is stapled to the file. Check the registration book and see whether the referral has been recordedIf no referred patient is found in the current files, check last month's patient files and compared with registration book. Find at least 5 patients in total that were referredVerify this with the score for referrals into Paediatric ward at 3 (7)

Patient files 50

5 points if referral letter stapled to file5 points if registration book had referral documented

If not set up - 0 (If no referral is found then give 0 score as perhaps not

recorded


16 Take 5 files of discharged patients and check for discharge letter (may have filled front sheet of admission sheet i.e. final diagnosis. If pt not referred, this will suffice) but if referred, discharge letter is mandatory

Patient files 10

Discharge letter attached or pt not referred and admission sheet completed (final diagnosis) - 2

No discharge letter/final diagnosis not recorded on admission sheet or files not available - 0


TOTAL 265

4. PATIENT VERIFICATION (meet patients in ward)

Ask five patients who are conscious (or their parents) and have been prescribed oral medications i.e. ask each patient or check the file before the interview:

If less than 5 patients, multiply total amount scored by 5 and divide by number of patient files e.g. if 2 patients scored 4 then 4 x 5/2 is the final score 1 2 3 4 5 TO COMMENTS

1**

Have you been seen by the doctor/MA today?

If the answer is no, then score zero on next questionPatient

interview10

Yes - 2 Total 2 points per patient No - 0

2**

Did s/he speak to you, examine you?

Score zero if no score on question above

25

Spoke and examined - 5 Spoke but didn’t examine - 0

Didn’t speak and didn’t examine or hasn’t been seen - 0 TOTAL 5 points per patient


1 2 3 4 5 TO COMMENTS3 Has anyone taken your temperature, BP, PR, today?

30

Two points for each vital sign T

BPPR

TOTAL 6 points per patientThe next two questions are about oral drugs – the first is about receiving them and how to take themand the second is about taking them. Don’t confuse the answers

4 Did you get your oral drugs today? Were you told how many to take and when? Ask patient to show their drugs and explain how and when to take them. If you ask pts before 10 am, they may not have received any BUT they should have some left from yesterday). If not, they score zero. If you ask this question after 10 am, and they have not received any drugs today, score zero.

25

Received drugs, told how many to take and when, can give correct information on how often to take them - 5

Received drugs but not told how many/ time to take - 0 Not given drugs (give time of asking question) - 0

TOTAL 5 points per patient5 Have you taken your drugs as asked today? Check the

drugs.Patient

interview 25

Ask patient to tell you how many and whenIf know correctly and have already taken them - 5

If don’t know how to take them - 0 If haven’t taken them today - 0

Not given drugs - 0

TOTAL 5 points per patient6 Do you know what your diagnosis and plan for treatment

is? Patient interview 25

Know diagnosis and plan for treatment - 5 Know diagnosis but not plan for treatment - 1

Doesn’t know diagnosis - 0

TOTAL 5 points per patient 7 Is there staff here at night that you can call on if you need

to? Patient interview 25

Staff available on ward and easily contactable - 5 Staff available but not on ward or easily contacted - 1

Staff not available – 0TOTAL 5 points per patient

8 Were you told where the patient toilet/bathroom was on admission (or is it very obvious being in the same ward)? Can you use it or is it locked, is there always enough water?Is there enough water for washing clothes also?

Patient interview 25

Told where toilet/bathroom is, (or in ward and very obvious), not locked when want to use it, water always

available for bathing/washing - 5 Told where toilet/bathroom is, (or in ward and very

obvious) but can’t use it all the time because locked or water not always available - 0

Not told where toilet/bathroom is or not in ward and not obvious - 0

TOTAL 5 points per patient9 Were you told about food being provided by hospital twice

daily (or given 1000R per day for food if the hospital doesn't have a kitchen)?

Were there any comments about amount provided or quality of food? If so please record in comments box in right


Told about food/money for food and received it twice daily (food)/money daily - 5

Told about food/money but didn’t receive it twice daily (food) or money daily - 2

Told about food/money but never received it - 1 Not told about food/money for food - 0



1 2 3 4 5 TO COMMENTS10 Were you told or shown where your relatives could cook

(or the kitchen is adjacent to ward and very easily seen without explanation)? Patient

interview 10

Told or shown where relatives could cook or kitchen adjacent to ward and easily seen - 2

Not told or shown were relatives could cook/Didn’t know there was a kitchen or no kitchen available - 0


11 Were you given any explanation about the exemption scheme when you first arrived at hospital or when you were admitted? Patient

interview 25

Exemption scheme explained well - 5 Exemption mentioned but not explained well - 1

Noticed exemption mentioned on user fees board but no explanation - 1

No mention of exemption - 0 TOTAL 5 points per patient

12 Were you asked to pay additional fees after admission including drugs not available in the hospital? Please check all receipts that patient has and ask them whether they always received receipts (even if paid additional amounts during admission). For patients who are exempted e.g. monks, HIV +ve patients, EF beneficiaries, they should receive something to say they are exempt

receipt 50

Receipt from admission and no additional fees paid or have receipt for additional fees paid or have receipt and

exempted - 10 Receipt from admission but no receipt for subsequent

payments or no receipt but exempted - 1No receipt but had to pay or receipt attached to patient

file only - 0TOTAL 10 points per patient

13 Check all patients in ward. Count how many patients have IVs up – IVs up =Are there any IVs that are empty or have any of the IVs stopped i.e. no drops being visible? If there are no IVs on the ward, they can score 5 points

Patient interview 5

Count no. patients with IV and no. patients with IV stopped.

All IVs are dripping normally (or no IVs at all on the ward) - 5

At least one IV stopped or empty– 0

TOTAL 305

5. GENERAL HYGIENE1 Are there rubbish bins in the ward and in nurse's station?

If so, is there evidence that they are emptied regularly? Observe 5

Rubbish bins in nurse’s station, on ward and not over flowing/cleared regularly Not enough rubbish bins

No rubbish bins or doesn’t look emptied regularly

510

2 Is there evidence that the floor is regularly swept and mopped in patient ward? (currently clean, not much dirt/papers on the floor) Observe 5

Looks very clean and well mopped, cleaning materials may be seen

Swept but not mopped or mopped poorly Not clean

510

3**

Is there any back up storage for staff to wash hands i.e. a large container filled with water in case piped water fails?(Check with Section 3, Qu 6 Management section) Observe 5

Back up storage near sink where staff wash hands/bathroom where staff wash hands

Back up storage container but no water in itNo back up storage

510

4**

Check patient toilets Are they locked? If so the next question scores zeroIf they don’t work they don’t score points either Observe 5

Not locked Locked or not working/not able to be used

50


5 Are they cleaned (or is their evidence that they are cleaned), is there water available and a scoop (if non flush toilet)?

Observe 5Very clean, water and scoop of sufficient size available

Partly cleaned, water available, scoop available Not cleaned at all or water not available or no scoop or locked

510

6 Is there soap available? Observe 5 Soap available for patients in toilet/bathroom No soap available

50

TOTAL 30

MAX POSSIBLE

SCORE RECEIVE

D

%

1 ORGANISATION AND PRESENTATION OF STAFF AND WARD

35

2EQUIPMENT AND SUPPLIES 35

3QUALITY OF DOCUMENTATION AND PROCEDURES

265

4PATIENT VERIFICATION 305

5GENERAL HYGIENE 30

TOTAL PAEDIATRIC WARD 670


If there is more than one Obstetric Ward, an assessment should be performed for both. If there is a separate Gynaecology Ward, then the Surgical assessment should be used for this ward until a separate Gynaecology tool can be developed

3. OBSTETRIC WARD Verified by


SCORE COMMENTS

1. ORGANISATION AND PRESENTATION OF STAFF AND WARD1 Is there an organisational chart of staff working in this

ward, displayed: on the ward, in the nurse’s station or chief’s office? Is it up to date?


3


30



Observe and

schedule 5

Both day and night staff schedule available and observed (or schedule shows both day and night duty on the one schedule)

Only day or night available and up to date, but not both Nil or none up to date

510



5



510

4 How many staff are in their uniform and look well presented?Count the number of staff on duty. No. = No. in uniforms =


5



5210

5 How many staff have name tags?Count the number of staff on duty. No. with tags = Spot

check 5

All staff have name tagsHalf or more than half have their name tags displayed

Less than half have their name tags displayed

510

6 Are there new patient files/admission sheets (include Spot 5 All sheets readily available and completely made up 5


sheets for: 1-patients details, 2-history, exam, diagnosis and treatment, 3. medication, and 4. vital signs). Are they readily available and made up ready for the next admission? It is possible that the OPD will complete the admission file. If so, then record in the comments box that this hospital has a policy to have admissions completed by OPD

check

All sheets readily available but not made up into a file Not available or not readily available

10

7Are there blank discharge letters available? Spot

check 3Available and easily found

Available but not easily found Not available or not readily found

310

8

Are there forms for laboratory, x-ray, ultrasound, pharmacy on hand and easily found?

Spot check 4

Pharmacy forms available (prescription pads or ward pt form) No pharmacy form


No form or inadequate space to record results Total 4 points

20

20

TOTAL 35

2. LABOUR AND DELIVERY ROOM – EQUIPMENT AND SUPPLIES (Check Labour and Delivery Ward for these)


1 Check for the following: thermometer, BP cuff, stethoscope, scales for babies, scales for adults, doppler or Pinnard stethoscope, tape measure, long sterile gloves for manual removal of placenta, non sterile gloves, needle holder. Is it easily found or locked in a cupboard?It must also be in good working order Observe 20

One point for each item being found, another point if easily found and readily available i.e. not locked up/in a corner as they should be used daily. No point if broken Thermometer

BP cuffStethoscopeBaby scales

Umbilical clampDoppler/Pinnard

Tape measureLong sterile gloves for removal of placenta

Non sterile glovesNeedle holder

1+11+11+11+11+11+11+11+11+11+1

2Oxygen is available (check regulator and flowmeter to see if oxygen tank has oxygen or concentrator is working) Observe 10 Oxygen available/concentrator working

No oxygen or no oxygen concentrator in ward or not working 100

3

Paediatric mask, nasal canula for neonates, mask for mother and tubing is clean; other clean masks, nasal canula and tubing is available

Observe 10

Paediatric mask and nasal canula, mask for mother and tubing is readily available and clean; spare masks/nasal canula and

tubing readily available Mask and tubing available but not clean or not easily accessible

Not all masks (paediatric and adult), nasal cannula /tubing available on ward

101

0


Verified by


SCORE COMMENTS

4 delivery pack is available (sterilised and packed)Observe 10

> 1 delivery pack is easily accessible, packed and sterilisedonly one delivery pack (packed and sterilised) is available

no delivery pack is available or locked up

1010

5 suction available and working (try it out)

Observe 10

Suction available, working, power on, clean suction tip, ready to use

Suction available but not set up ready to useNo suction or no power, dirty connections

1010

6 forceps/ventouse available and working; staff can use it (Please check to see whether ventouse is working or not)

Observe 10

Forceps sterilised and readily available OR ventouse set up, connections all present, suction working, staff member on duty

who can use at least one methodForceps not sterilised or ventouse has parts missing or suction

not working or no staff on duty that can use one method

10

0

7 speculum, operating light, suture material,

Observe 15

Score 5 points for each item only if all conditions metSpeculums available, sterile and ready to use

Operating light available, working, power availableSuture material available and needle holder sterile

If not with the above conditions, 0 points

555

8 Drugs and supplies. Check for the following: hydrallazine, oxytocin or ergotamine, needle, 2 ml syringe, IV fluid, giving set

Observe 25

Score 5 points for each item only if all conditions metHydrallazine available, not expired

Oxytocin or ergometrine available, not expiredNeedles and 2ml syringes readily available

IV fluid not locked upGiving set not locked up

(If above conditions don’t exist, no points i.e. locked, or expired)

555550

9 Gloves, sharps container readily available

Observe 10

Score 5 points for each item only if all conditions metNon sterile gloves readily available (not locked)

Non sterile gloves not available or locked Sharps container easily accessible and not full (not in a corner

but easily able to be accessed)Sharps container not easily accessible or full

50

50

10 Is there any IEC materials in the ward or labour room e.g. posters on breastfeeding, nutrition, vaccinations, Family Planning; pamphlets to give to patients Observe 5

IEC materials on all topics mentioned on display and pamphlets readily available

IEC materials on a few topics only on display and pamphlets readily available

No IEC materials on display or no pamphlets available

5

10

TOTAL 125


OBSTETRIC WARD3. QUALITY OF DOCUMENTATION AND PROCEDURES (Regarding obstetrics only)

Verified by


SCORE COMMENTS

1 Check the Obstetric register book. Is there one book that records admissions and discharges? Ask if there are different registration books in the ward

Register book 5



5

0

2 Check registration book for columns (see below for columns it should have). If there are no columns skip the next questions (all get zero points) and go the questions on patient files – starting at no. 9)


book 5



5

10

4

Check registration book for the following columns: running number, name, age, sex, address, date of admission, diagnosis on admission, referred from HC or other health facility, date of discharge, diagnosis on discharge, outcome (discharged, unauthorised d/c, referred (to other health facility or ward), death), no. days admitted. Are all columns included


Register book 15


NameAge


Diagnosis on admissionReferred from HC or outside hospital

Date of dischargeDiagnosis on discharge

DischargedUnauthorised discharge

Referred (to other health facility or ward)Death

No. days admittedUser Fees

5 Go to the first day of the previous month of the registration book and check entries for the patients on this day. If there was no one admitted on the first day, take the second day.

Register book 12

Give one point for each column mentioned above being complete for those admitted on the first day of the previous month (this should allow for all of those to now be discharged). If there is > one patient admitted check all. If all columns have been completed correctly, give 12 points (only one of four outcomes is possible hence the reason for only 12 points). If a column is incomplete for any patient they lose 1 point. If there are 5 patients, the same applies. If the registration book does not have all the above columns then the maximum number of points that can be attained is 6.

6 Check every entry for the first 20 days of the last month to see if they have an outcome recorded i.e. discharge,

Register book

8 All patients admitted in the first 20 days of the last month have an outcome recorded 8


unauthorised discharge, death, referral(If the date of the assessment is before 20 th day of month, please use the data from 2 months earlier to increase the chance of pts admitted during that month being discharged)

One patient or more doesn’t have an outcome recordedNone have an outcome recorded

10

7**

Check no. admissions, referrals to and from obstetric ward of RH, discharges in the last month using the registration book and complete the following (If the date of the assessment is before 20th day of month, please use the data from 2 months earlier to increase chance of pts admitted during that month being discharge)::ADMISSIONS IN = all those admitted during the month you are checkingREFERRALS IN = those from outside the hospital only; DISCHARGES includes ALL leaving the ward i.e. authorised and non authorised, deaths and referrals/transfers. You will have to check the month in question PLUS the month before to see whether patients admitted in the previous month were discharged in the following month.REFERRALS OUT = those referred to another health facility (RH or HC) NOT transfer within the hospitalIf the Registration book does not make this distinction then please make comments in the comments box

a) TOTAL ADMISSIONS TO OBSTETRICS (in the last month (or 2 months)) =

The next section refers to REFERRALS from OUTSIDE the hospital i.e. NOT transfer of patients between wards BUT referred from HC or other hospital If the registration book does not differentiate please commentb) TOTAL REFERRALS IN TO OBSTETRIC (in the last month(or 2 months)) =

The next section relates to DISCHARGES which refers to ALL patients leaving the hospital i.e. authorised discharges, unauthorised discharges, referrals to another hospital and deaths i.e. you need to add all of these together to get the total no. discharges.Check the month you are supposed to PLUS the month before in case there is a patient admitted earlier who was admitted for a lengthy period

c) TOTAL DISCHARGES OBSTETRICS (in the last month/2 mths) (all discharges) =

The next section relates to REFERRALS from this ward to another hospital or HC i.e. NOT transfers within the hospital. It may be difficult to get this information – if so please comment

d) TOTAL REFERRALS FROM RH OF OBSTETRICS PATIENTS (in the last month/2 mths) =


Please transpose this information to HIS in Management section 5

8 Please work out the % of inpatients who have been referred in to Obstetric ward of RH :% = total no. referrals to Obstetric ward last month x 100/total no. admissions to Obstetric ward


Register book 10




106310

0

Take 5 current obstetric patient files (vaginal deliveries only) and check for completion of:

If less than 5 patients, multiply total score by 5 and divide by number patient files e.g. if 3 patients scored 15 then 15 x 5/3 is the final score to put

pt1

pt 2 pt3

pt 4

pt 5

tot


in the total box

9 name, address, age, date of admission, referred from

Patient files 25


nameaddress

agedate of admission

referred from

TOTAL 5 points per patient10 maternal vital signs (temp, PR, BP, RR) recorded on

admission

Patient files 20

Vital signs: one point for each i.e. TBPPRRR

0 if no vital sign done

TOTAL 4 points per patient11 ANC card in patient file or it has been recorded in patient

file that she has been to ANC Patient files 50

ANC card present – 10Admission mentions that pt has been to ANC – 2

Admission not mentioned that pt has been to ANC-0

12 History of presenting complaint, fundal examination (fundal height, lie, presentation, foetal heart rate, vaginal examination (if applicable)), diagnosis, treatment

Patient files 80

History current problem: if detailed and extensive - 2 not complete or very scant - 1

no history - 0Examination: general exam (lungs, heart etc) - 2

Abdominal: Fundal height - 2Lie - 2

Presentation - 2Foetal heart rate - 2

Vaginal examination - 2 Diagnosis: fits with history, vital signs, examination - 2

0 if no history or missed any of the above

TOTAL 16 points per patient13 Partograph - check for completeness (name, date, time,

vital signs, contractions (strength/length etc)

Patient files 100

Name - 1Date - 1Time - 1

Vital signs done throughout labour- 2Foetal heart rate done regularly (every hour) - 5

Contractions (strength/length) completed, correct 10Nil partogram – 0


If less than 5 patients, multiply total score by 5 and divide by number patient files e.g. if 3 patients scored 15 then 15 x 5/3 is the final score to put in the total box

pt1

pt 2 pt3

pt 4

pt 5

tot


14 Check the file for today's entry/recording. Is there a date, clinical notes, examination, treatment orders, signature of doctor/MA? Patient

file 25



TOTAL 5 points per patient15 Check the vital sign chart for the entire admission - is

there at least daily recording of temperature, PR, BP, RR, lochia, fundal height with a signature of the person taking them? If no daily vital signs for each patient, no point is given for that item. If no vital sign chart at all, then no points Patient

file 35

One point for each vital sign (only if they have been done every day of admission) and signature. If they missed any vital sign during their admission then no point is given – total 7 points per patient

T everydayBP everydayPR everydayRR everyday

Lochia everydayFundal height everyday


16 Find the file of one patient only who had a caesarean section. Check for: signed consent form, operation notes/details of operation performed, anaesthetic notes including vital signs throughout operation, post operative orders

Patient file 20

Consent form correctly filled in and signed – 5Operation notes detailing operation present -5

Anaesthetic notes including vital signs throughout operation included -5

Post operative orders -5TOTAL 20 points per patient

pt1 pt 2 pt

3pt 4

pt 5 tot

17**

Find 5 files of patients that were referred by a HC (see the admission sheet which should check this box) or registration book to find the patient. Check whether the referral form from the HC is stapled to the file. Check the registration book and see whether the referral has been recordedIf no referred patient is found in the current files, check last month's patient files and compared with registration book. Find at least 5 patients in total that were referred

Verify this with the score for referrals into Obstetric ward at 3 (7)

Patient file 50


If not set up - 0 (If no referral is found then give 0 score as perhaps

not recorded)


18 Take 5 files of discharged patients and check for discharge letter (may have filled front sheet of admission sheet i.e. final diagnosis. If pt not referred, this will suffice) but if referred, discharge letter is mandatory

Patient files 10




TOTAL 470

4. PATIENT VERIFICATION


Ask five patients: If less than 5 patients, multiply total amount scored by 5 and divide by number patient files e.g. if 2 patients scored 2 then 2 x 5/2 is the final score to put in the box

pt1

Pt 2

pt3

pt 4

pt 5 tot

1**


If the answer is no, then score zero on next question

Patient interview

10 Yes - 2 No - 0

TOTAL 2 points per patient2**





Didn’t speak and didn’t examine or hasn’t been sent yet - 0

TOTAL 5 points per patient3 Has anyone taken your temperature, BP, PR today?


Two points for each vital sign TBPPR

TOTAL 6 points per patient4 Have you been given Vitamin A and Iron tablets?

Please ask the woman to describe the tablets she received. Iron tablets are red/brown and Vitamin A capsules for lactating women are red (200,000U)


Vit A given, taken, Fe tabs given and taken today - 10Vit A and Iron given but not yet taken - 1

Nil given – 0TOTAL 10 points per patient

5 Is there staff here at night that you can call on if you need to?



Staff not available - 0 TOTAL 5 points per patient

6 Were you told where the patient toilet/bathroom was on admission (or is it very obvious being in the same ward)? Can you use it or is it locked, is there always enough water?Is there enough water for washing clothes also?







daily (or given 1000R per day for food if hospital doesn't have a kitchen)?Were there any comments about amount provided or quality of food? If so please record in comments box in right




Told about food/money but never received it - 1 Not told about food/money for food – 0

TOTAL 5 points per patient8 Were you told or shown where your relatives could cook

(or the kitchen is adjacent to ward and very easily seen without explanation)?\ Patient

interview 10



TOTAL 2 points per patient9 Were you given any explanation about the exemption

scheme when you first arrived at hospital or when you were admitted?

Patient interview

25 Exemption scheme explained well – 5 Exemption mentioned but not explained well - 1

Noticed exemption mentioned on user fees board but


no explanation - 1No mention of exemption – 0


10 Were you asked to pay additional fees after admission including drugs not available in the hospital? Please check all receipts that patient has and ask them whether they always received receipts (even if paid additional amounts during admission).

For patients who are exempted e.g. HIV +ve patients, EF beneficiaries, they should receive something to say they are exempt

Receipt 50

Receipt from admission and no additional fees paid or have receipt for additional fees paid or Receipt and

exempted – 10Receipt from admission but no receipt for subsequent

payments or no receipt but exempted - 1No receipt but had to pay – 0

Receipt attached to patient file only– 0

TOTAL 10 points per patient11 Check all patients in ward. Count how many patients

have IVs up – IVs up =Are there any IVs that are empty or have any of the IVs stopped i.e. no drops being visible? If there are no IVs on the ward, they can score 5 points

Observe 5

IV is dripping normally for all patients (or no IV for the patient) - 5

IV stopped or empty– 0

12 Has anyone discussed with you about breastfeeding and have you started breastfeeding yet? Patient

interview 50

Discussed and started – 10Not discussed but started - 1

No discussion or not started yet - 0

13 Check the newborn has a yellow card - name recorded, BCG/Hepatitis B given, weight recorded, weight plotted, date of birth recorded

Yellow card 50

All five categories listed are recorded (name, BCG/Hepatitis B given, weight recorded AND plotted,

date of birth recorded)- 10If no weight plotted but others recorded, 1 pt only - 1If only one vaccination given and weight recorded - 1

Nil plotted or no yellow card – 0

TOTAL 380

5. GENERAL HYGIENE Verified by


SCORE COMMENTS1 Are there rubbish bins in the ward, labour room and in

nurse's station? If so, is there evidence that they are emptied regularly? Observe 5

Rubbish bins in nurse’s station, on ward, in labour room and not over flowing/cleared regularly

Not enough rubbish bins No rubbish bins or doesn’t look to be emptied regularly

510




510

3**

Is there any back up storage for staff to wash hands i.e. a large container filled with water in case piped water fails?

Observe 5 Back up storage near sink where staff wash hands/bathroom where staff wash hands 5


(Check with Section 3, Qu 6 Management section) Back up storage container but no water in itNo back up storage

10

4**

Check patient toilets Are they locked? If so the next question scores zeroIf they don’t work they don’t score points either

Observe 5Not locked

Locked or not working/not able to be used 50



Partly cleaned, water available, scoop available Not cleaned at all OR Water not available OR no scoop or locked

510


50

TOTAL 30

OBSTETRIC WARD MAX POSSIBLE

SCORE RECEIVED

%

1 ORGANISATION AND PRESENTATION OF STAFF AND WARD 35

2 QUALITY OF DOCUMENTATION AND PROCEDURES 125

3 LABOUR AND DELIVERY EQUIPMENT AND SUPPLIES 470

4 PATIENT VERIFICATION 380

5 GENERAL HYGIENE 30

TOTAL OBSTETRIC WARD 1040

Assessment of Medical Ward –Referral Hospital Treatment Guidelines (including malaria treatment guidelines), HIS for the past month (or HIS for 2 months earlier, if assessment done before 20th of the day) and Essential Drug list will be required to do this


assessment. If there is more than one Medical Ward, an assessment should be performed for both with comments to clarify which wards have been assessed

4. MEDICAL WARD

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS




3


30



5



510


Observe and

schedule5



510

4 How many staff are in their uniform and look well presented?Count the number of staff on duty. No. staff=No. staff in uniform =

5

All staff wearing uniform and look well presentedHalf of more than half wearing uniform and look neat and tidy


5210

5 How many staff have name tags?Count the number of staff on duty. No. with tags=

5 All staff have name tagsHalf or more than half have their name tags displayed

51


Less than half have their name tags displayed 0


5



510

7 Are there blank discharge letters available? 3 Available and easily found Not available or not readily found

30

8

Are there forms for laboratory, x-ray, ultrasound, pharmacy on hand and easily found? 4




20

20

TOTAL 35

MEDICAL WARD Verified by

MAXSCOR

ESCORING

TOTAL SCORE

COMMENTS

2. EQUIPMENT AND SUPPLIES1

Check for the following equipment. Is it easily found or locked in a cupboard? It must also be in good working order

To score full points for needles there must be 18 G and 21 or 23 G available in the ward


20

One point for each piece of equipment and another point if that item is easily found but no point if broken Thermometer

BP (adult cuff)Stethoscope

Scales Female bedpan

Tongue depressorTendon hammerSharps container

Needles (both 18 and 21 or 23 G) Syringes

1+11+11+11+11+11+11+11+11+11+1

2 oxygen is available (check regulator and flowmeter to see if oxygen tank has oxygen or concentrator is working)


5Oxygen available/concentrator working

No oxygen or no oxygen concentrator in ward or not working 50

3mask and tubing is clean; other clean masks and tubing is available 5

mask and tubing is readily available and clean; spare masks and tubing readily available


510


TOTAL 30

3. QUALITY OF DOCUMENTATION AND PROCEDURESTOTAL SCORE

COMMENTS

1 Check the register book. Is there one book that records admissions and discharges? Ask if there are different registration books in the ward

Register book 5



5

02 Check registration book for columns (see below for

columns it should have). If there are no columns skip the next questions (all get zero points) and go the questions on patient files – starting at no. 9)

Register book


book 5

Today’s admissions entered and up to date; today’s d/c up to date Today’s admission entered but not up to date, today’s d/c not up

to date Nothing entered for today

5

10

4 Check this registration book for the following columns: running number, name, age, sex, address, date of admission, diagnosis on admission, referred from HC or other health facility, date of discharge, diagnosis on discharge, outcome (discharged, unauthorised d/c, referred (to other health facility or ward), death), no. days admitted. Are all columns included?


Register book 15


NameAgeSex


Referred from HC or outside hospitalDiagnosis on admission

Date of dischargeDiagnosis on d/c

Dischargedunauthorised d/c

referred (to other health facility or ward)death

No. days admitted5

Go to the first day of the previous month of the registration book and check entries for the patients on this day. If there was no one admitted on the first day, take the second day.

Register book 12

Give one point for each column mentioned above being complete for those admitted on the first day of the previous month (this should allow for all of those to now be discharged). If there is > one patient admitted check all. If all columns have been completed correctly, give 12 points (only one of four outcomes is possible hence the reason for only 12 points). If a column is incomplete for any patient they lose 1 point. If there are 5 patients, the same applies. If the registration book does not have all the above columns then the maximum number of points that can be attained is 6

6 Check every entry for the first 20 days of the previous month to see if they have an outcome recorded i.e. discharge, unauthorised discharge, death, referral (If the date of the assessment is before 20th day of month,

Register book

8 All patients admitted in the first 20 days of the previous month have an outcome recorded

One patient or more doesn’t have an outcome recorded81


please use the data from 2 months earlier to increase the chance of pts admitted during that month being discharged)

7**

Check no. admissions, referrals to and from RH, discharges in the past month using the registration book and complete the following (If the date of the assessment is before 20th day of month, please use the data from 2 months earlier to increase chance of pts admitted during that month being discharge)::ADMISSIONS IN = all those admitted during the month you are checkingREFERRALS IN = those from outside the hospital only; DISCHARGES include ALL leaving the ward i.e. authorised and non authorised, deaths and referrals/transfers. You will have to check the month in question PLUS the month before to see whether patients admitted in the previous month were discharged in the following month.REFERRALS OUT = those referred to another health facility (RH or HC) NOT transfer within the hospitalIf the Registration book does not make this distinction then please make comments in the comments box

a) TOTAL ADMISSIONS TO MEDICAL WARD (in the past month (or 2 mths) = Please transpose this information to HIS in Management section 5The next section refers to REFERRALS from OUTSIDE the hospital i.e. NOT transfer of patients between wards BUT referred from HC or other hospital If the registration book does not differentiate please commentb) TOTAL REFERRALS IN TO RH (in the past month/2 mths) =

The next section relates to DISCHARGES which refers to ALL patients leaving the hospital i.e. authorised discharges, unauthorised discharges, referrals to another hospital and deaths i.e. you need to add all of these together to get the total no. discharges.Check the month you are supposed to PLUS the month before in case there is a patient admitted earlier who was admitted for a lengthy periodc) TOTAL DISCHARGES MEDICAL WARD (in the past month/2 mths) (all discharges) =

The next section relates to REFERRALS from this ward to another hospital or HC i.e. NOT transfers within the hospital. It may be difficult to get this information – if so please commentd) TOTAL REFERRALS FROM RH OF MEDICAL PATIENTS (in the past month/2 mths) =


8 Please work out the % of inpatients who have been referred in to RH :% = total no. referrals to RH last month x 100/total no. admissions to Medical ward


Register book 10




106310

09 Take 5 current patient files and check for completion

of:If less than 5 patients, multiply total score by 5 and divide by number patient files checked e.g. if 3 patients scored 75 then 75 x 5/3 is the final score to put in the box

pt1

pt 2

pt3

pt 4

pt 5 total

10 name, address, age, sex, date of admission, referred from (check if referral letter present – if so, they get a point)

Patient file

30 One point for each i.e. total 6 points per patient, total 30 patients if all correctly filled in

nameaddress

agesex




pt1

pt 2

pt3

pt 4

pt 5

total COMMENTS11 Vital signs on admission completed

History of illness, examination and diagnosis completed in admission record

Patient file 50

Vital signs: one point for completion of each i.e. T BPPRRR



incomplete - 1nil - 0


if no history or vital signs missing - 0

TOTAL 10 points per patient – total 50 for 5 patients12 Were the investigations appropriate for the

symptoms/signs? (laboratory, x-ray, ultrasound) Patient file, RH

guidelines10


no history or examination – 0 If no investigations performed when should have been 0


13 Were the drugs prescribed on the essential drug list and according to RH treatment guidelines? Pt file,

essential drug list

and guidelines

10



TOTAL 2 points per patient14 Check the file for today's entry/recording. Is there a date,


file 25



TOTAL 5 pts per patient15 Check the vital sign chart for entire admission of these

current patients. Is there at least daily recording of temperature, PR, BP, RR with a signature of the person taking them? If no daily vital signs for each patient, no point is given for that item. If no vital sign chart at all, then no points Patient

file 25

One point for each vital sign (only if they have been done every day of admission) and signature. If they missed any vital sign during their admission then no point is given – total 5 points per patient


Signature everyday

TOTAL 5 points per patient16**

Find a file of a patient that was referred by a HC (see the admission sheet which should check this box) or registration book to find the patient and check whether the

Patient files

50 5 points if referral letter stapled to file5 points if registration book had referral documented

If not set up - 0


referral form from the HC is stapled to the file. Check the registration book and see whether the referral has been recordedIf no referred patient is found in the current files, check last month's patient files and compared with registration book. Find at least 5 patients in total that were referredVerify this with the score for referrals into Medical ward at 3 (7)

(If no referral is found then give 0 score as perhaps not recorded


17 Take 5 discharged patients and check for discharge letter (may have filled front sheet of admission sheet i.e. final diagnosis. If pt not referred, this will suffice) but if referred, discharge letter is mandatory

Patient files 10




TOTAL 265


Ask five patients who are conscious and have been prescribed oral medications i.e. ask each patient or check the file before the interview:


1**



Patient interview

10Yes - 2

Total 2 points per patient No - 0

2**



25



3 Has anyone taken your temperature, BP, PR today?

30


BPPR

TOTAL 6 points per patientThe next two questions are about oral drugs – the first is about receiving them and how to take them and the second is about taking them. Don’t confuse the answers4 Did you get your oral drugs? Were you told how many to

take and when? Ask patient to show their drugs and explain how and when to take them. If you ask pts before 10 am, they may not have received any BUT they should have some left from yesterday). If not, they score zero. If you ask this question after 10 am, and they have not received any drugs today, score zero.

25




drugs.25 Ask patient to tell you how many and when

If know correctly and have already taken them - 5 If don’t know how to take them - 0


If haven’t taken them today - 0 Not given drugs - 0


is? 25


Doesn’t know diagnosis or plan for treatment - 0 TOTAL 5 points per patient

1 2 3 4 5 TO COMMENTS7 Is there staff here at night that you can call on if you need

to? 25



8 Were you told where the patient toilet/bathroom was on admission (or is it very obvious being in the same ward)? Can you use it or is it locked, is there always enough water?Is there enough water for washing clothes also? 25

Told where toilet/bathroom is, or in ward and very obvious not locked when want to use it, water always

available - 5 Told where toilet/bathroom is or in ward and very

obvious but can’t use it all the time because locked or water not always available - 0



daily (or given 1000R per day for food if hospital coesn't have a kitchen)?








interview 10




scheme when you first arrived at hospital or when you were admitted? Patient

interview 25





receipt 50

Receipt from admission and no additional fees paid or have receipt for additional fees paid or Receipt and

exempted - 10Receipt from admission but no receipt for subsequent

payments or no receipt but exempted - 1No receipt but had to pay – 0

Receipt attached to patient file only- 0TOTAL 10 points per patient

13 Check all patients in ward. Count how many patients have IVs up – IVs up =Are there any IVs that are empty or have any of the IVs

Patient interview

5 Count no. patients with IV and no. patients with IV stopped.

All IVs are dripping normally (or no IVs at all on the


stopped i.e. no drops being visible? If there are no IVs on the ward, they can score 5 points

ward) - 5 At least one IV stopped or empty– 0

TOTAL 305




No rubbish bins or doesn’t look to be emptied regularly

510




510

3**




510

4**


Observe 5Not locked





510


50

TOTAL 30


MEDICAL WARDMAX

POSSIBLE

SCORE RECEIVE

D%


2 EQUIPMENT AND SUPPLIES 303 QUALITY OF

DOCUMENTATION AND PROCEDURES 265

4 PATIENT VERIFICATION 3055 GENERAL HYGIENE 30

TOTAL MEDICAL WARD 665


Assessment of Surgical Ward. In hospitals where there are two surgical wards i.e. post operative and surgical, please assess post operative ward in preference to surgical ward) Another tool may be developed specifically for surgical ward i.e. non post op surgical patientsReferral Hospital Treatment Guidelines (including malaria treatment guidelines) HIS for past month (or HIS for 2 months earlier, if assessment done before 20th of the day) and Essential Drug list will be required to do this assessment.

5. SURGICAL WARDVerified

by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS




2Available and up to date

Not up to date or not present 20



5



510



5



510

4 How many staff are in their uniform and look well presented? Spot

5 All staff wearing uniform and look well presentedHalf or more than half wearing uniform and look neat and tidy

52


Count the number of staff on duty. No. staff=No. staff in uniforms =

check More than half wearing uniform but it is not clean or tidy Less than half have uniform on

10

5How many staff have name tags?Count the number of staff on duty. No with tags=

Spot check 5



510

SURGICAL WARD Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS


Spot check 5



510

7

Are there consent forms and operation sheets available? Spot check 7

Both consent forms and operation sheets availableOne form available only

No forms available

710

8

Are there blank discharge letters available? Spot check 2

Available and easily found Not available or not readily found

20

9

Are there forms for laboratory, x-ray, ultra sound, pharmacy on hand and easily found?

Spot check 4




20

20

TOTAL 40

2. EQUIPMENT AND SUPPLIES

1 Check for the following equipment. Is it easily found or locked in a cupboard or not easily available? It must also be in good working order

Spot check andObserve

20 One point for each piece of equipment and another point if that item is easily found. No point if broken

Thermometer 1+1


To score full points for needles there should be at least 18 and 21 or 23 G needles in the ward

in ward

BP (adult cuff)Stethoscope

Scales Female bedpan

GlovesDressing cart

Aspirator that is in good working orderSharps container

Needles (both 18 and 21 or 23 G)

1+11+11+11+11+11+11+11+11+1

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

2 oxygen is available (check regulator and flowmeter to see if oxygen tank has oxygen or concentrator is working) 5


50

3mask and tubing is clean; other clean masks and tubing is available 5



510

TOTAL 30

3. QUALITY OF DOCUMENTATION AND PROCEDURES1 Check the register book for inpatients (there may also be

a register book for minor surgery). Is there one book that records admissions and discharges? Ask if there are different registration books in the ward

Register book 5



5

0

2 Check registration book for columns (see below for columns it should have). If there are no columns skip the next questions (all get zero points) and go the questions on patient files – starting at no. 9)


book 5



5

10

4 Check registration book for the following columns: running number, name, age, sex, address, date of admission, diagnosis on admission, referred from HC or other health facility, symptoms, operation performed, date of operation, date of discharge, diagnosis on discharge, outcome (discharged, unauthorised d/c, referred (to other health facility or ward), death), no. days admitted. Are all columns included?

Register book

18 Give one point for each item being in the registerRunning number

NameAgeSex


Referred from HC or outside hospital



SymptomsDiagnosis on admission

Operation performedDate of operationDiagnosis on d/c

Date of dischargeDischarged

unauthorised d/c referred (to other health facility or ward)

deathNo. days admitted

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

5

Go to the first day of the last month of the registration book and check entries for the patients on this day. If there was no one admitted on the first day, take the second day.

Register book 15

Give one point for each column mentioned above being complete for those admitted on the first day of the last month (this should allow for all of those to now be discharged). If there is > one patient admitted check all. If all columns have been completed correctly, give 15 points (only one of four outcomes is possible hence the reason for only 15 points). If a column is incomplete for any patient they lose 1 point. If there are 5 patients, the same applies. If the registration book does not have all the above columns then the maximum number of points that can be attained is 6

6 Check every entry for the first 20 days of the previous month to see if they have an outcome recorded i.e. discharge, unauthorised discharge, death, referral (If the date of the assessment is before 20th day of month, please use the data from 2 months earlier to increase the chance of pts admitted during that month being discharged)

Register book 7

All patients admitted in the first 20 days of the last month have an outcome recorded

One patient or more doesn’t have an outcome recordedNone patient have an outcome recorded

710

7**

Check no. admissions, referrals to and from surgical ward of RH, discharges in the past month using the registration book and complete the following (If the date of the assessment is before 20 th day of month, please use the data from 2 months earlier to increase chance of pts admitted during that month being discharge):ADMISSIONS IN = all those admitted during the month you are checkingREFERRALS IN = those from outside the hospital only; DISCHARGES includes ALL leaving the ward i.e. authorised and non authorised, deaths and referrals/transfers. You will have to check the month in question PLUS the month before to see whether patients admitted in the previous month were discharged in the following month.REFERRALS OUT = those referred to another health facility (RH or HC) NOT transfer within the hospitalIf the Registration book does not make this distinction then please make comments in the comments box

a) TOTAL ADMISSIONS TO SURGICAL WARD (in the past month (or 2 months)) = Please transpose this information to HIS in Management section 5The next section refers to REFERRALS from OUTSIDE the hospital i.e. NOT transfer of patients between wards BUT referred from HC or other hospital If the registration book does not differentiate please commentb) TOTAL REFERRALS IN TO SURGICAL WARD (in the past month (or 2 months)) =


The next section relates to DISCHARGES which refers to ALL patients leaving the hospital i.e. authorised discharges, unauthorised discharges, referrals to another hospital and deaths i.e. you need to add all of these together to get the total no. discharges.Check the month you are supposed to PLUS the month before in case there is a patient admitted earlier who was admitted for a lengthy periodc) TOTAL DISCHARGES SURGICAL WARD (in the past month (or 2 months)) =

The next section relates to REFERRALS from this ward to another hospital or HC i.e. NOT transfers within the hospital. It may be difficult to get this information – if so please commentd) TOTAL REFERRALS FROM RH OF SURGICAL PATIENTS (in the past month (or 2 months)) =


SURGICAL WARD Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

8 Please work out the % of inpatients who have been referred in to Surgical ward of RH :% = total no. referrals to Surgical ward last month x 100/total no. admissions to Surgical ward


Register book 10




106310

09 Take 5 current patient files and check for completion

of:If less than 5 patients, multiply total score by 5 and divide by number patient files checked e.g. if 3 patients scored 75 then 75 x 5/3 is the final score to put in the box

pt1

pt 2

pt3

pt 4

pt 5 total

10 name, address, age, sex, , date of admission, referred from (check if referral letter present – if so, they get a point)

Patient file 30


nameaddress

agesex



11 Vital signs on admission completedHistory of illness, examination and diagnosis completed in admission record

Patient file

50 Vital signs: one point for completion of each i.e. T BPPRRR



incomplete - 1nil - 0



if no history or vital signs missing - 0 TOTAL 10 points per patient – total 50 for 5 patients

12 Were the investigations appropriate for the symptoms/signs? (laboratory, x-ray, ultrasound) Patient

file, RH guidelines

10


no history or examination – 0 If no investigations performed when should have been 0


13 Were the drugs prescribed on the essential drug list and according to RH treatment guidelines? Pt file,

essential drug list

and guidelines

10



TOTAL 2 points per patientpt1

pt 2

pt3

pt 4

pt 5

total COMMENTS14 Check the file for today's entry/recording. Is there a date,


file 25




15 Check the vital sign chart for entire admission of these current patients. Is there at least daily recording of temperature, PR, BP, RR with a signature of the person taking them? If no daily vital signs for each patient, no point is given for that item. If no vital sign chart at all, then no points Patient

file 25

One point for each vital sign (only if they have been done every day of admission) and signature. If they missed any vital sign during their admission then no point is given



16 Find 5 files of patients with operations. Did they have consent forms signed Patient

file 25

Yes all signed - 5Not all 5 signed or none had consent forms - 0


17**

Find 5 files of patients that were referred by a HC (see the admission sheet which should check this box) or registration book to find the patient. Check whether the referral form from the HC is stapled to the file. Check the registration book and see whether the referral has been recordedIf no referred patient is found in the current files, check last month's patient files and compared with registration book. Find at least 5 patients in total that were referredVerify this with the score for referrals into Surgical ward at 3 (7)

Patient file 50


If not set up - 0 (If no referral is found then give 0 score as perhaps not

recorded)


18 Take 5 files of discharged patients and check for Patient 10 Discharge letter attached or pt not referred and


discharge letter (may have filled front sheet of admission sheet i.e. final diagnosis. If pt not referred, this will suffice) but if referred, discharge letter is mandatory files

admission sheet completed (final diagnosis) - 2 No discharge letter/final diagnosis not recorded on

admission sheet or files not available - 0 TOTAL 2 points per patient

TOTAL 295



Ask five patients who are conscious and have been prescribed oral medications i.e. ask each patient or check the file before the interview. You should not interview the patients who are on nil orally i.e. immediately post op:


1**



Patient interview

10 Yes - 2 Total 2 points per patient No - 0

2**



25

Spoke and examined, looked at wound - 5 Spoke but didn’t examine - 0


3 Has anyone taken your temperature, BP, PR today?

30


BPPR

TOTAL 6 points per patientThe next two questions are about oral drugs – the first is about receiving them and how to take them and the second is about taking them. Don’t confuse the answers

4 Did you get your oral drugs? Were you told how many to take and when? Ask patient to show their drugs and explain how and when to take them If you ask pts before 10 am, they may not have received any BUT they should have some left from yesterday). If not, they score zero. If you ask this question after 10 am, and they have not received any drugs today, score zero.

25




drugs.

25

Ask patient to tell you how many and whenIf know correctly and have already taken them - 5

If don’t know how to take them - 0 If haven’t taken them today - 0

Not given drugs - 0


is?25


Doesn’t know diagnosis or plan for treatment - 0

TOTAL 5 points per patient 7 Is there staff here at night that you can call on if you need

to?25 Staff available on ward and easily contactable - 5

Staff available but not on ward or easily contacted - 1 Staff not available – 0


TOTAL 5 points per patient 1 2 3 4 5 TO COMMENTS

8 Were you told where the patient toilet/bathroom was on admission (or is it very obvious being in the same ward)? Can you use it or is it locked, is there always enough water?Is there enough water for washing clothes also? 25






daily (or given 1000R per day for food if hospital doesn't have a kitchen)?








interview 10




scheme when you first arrived at hospital or when you were admitted? Patient

interview 25





receipt 50

Receipt from admission and no additional fees paid or have receipt for additional fees paid or receipt and

exempted - 10Receipt from admission but no receipt for subsequent

payments or No receipt but exempted - 1No receipt but had to pay – 0

Receipt attached to patient file only- 0TOTAL 10 points per patient

13 Check all patients in ward. Count how many patients have IVs up – IVs up =Are there any IVs that are empty or have any of the IVs stopped i.e. no drops being visible? If there are no IVs on the ward, they can score 5 points

Patient interview 5

Count no. patients with IV and no. patients with IV stopped.

All IVs are dripping normally (or no IVs at all on the ward) - 5

At least one IV stopped or empty– 0

TOTAL 305





No rubbish bins or doesn’t look to be emptied regularly

510




510

3**




510

4**


Observe 5Not locked




Partly cleaned, water available, scoop available Not cleaned at all or water not available or no scoop or locked

510


50

TOTAL 30

SURGICAL WARDMAX

POSSIBLE

SCORE RECEIVE

D%


2 EQUIPMENT AND SUPPLIES 303 QUALITY OF DOCUMENTATION AND

PROCEDURES 2954 PATIENT VERIFICATION 3055 GENERAL HYGIENE 30

TOTAL SURGICAL WARD 700


Assessment of TB Ward –Referral Hospital Treatment Guidelines (including up to date TB treatment guidelines), HIS for past month (or HIS for 2 months earlier, if assessment done before 20th of the day) will be required to do this assessment. If there is more than one TB Ward, an assessment should be performed for both

6. TB WARD

1. ORGANISATION AND PRESENTATION OF STAFF AND WARD

Verified by

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS


Spot check and

Observe in ward

1


10

2 Is there an up to date staff schedule - day and night? (Often staff is required to work day shift Mon to Fri in their department with the exception of the day following their night duty when they are scheduled off. However, in some hospitals where staff is lacking it is possible that staff will work in more than one ward/department either for night duty (if there are insufficient regular staff for the night duty) or to cover the day shift when the staff are off post night duty. In this case, there should be a clear schedule for each ward/dept for both day and night rather than just a night schedule so it is clear to anyone checking who should be on duty at any given time during the week or month). A schedule should be made at least monthly. If the ward has only a yearly schedule this is not adequateIf the answer is zero, please score zero on next question as you will be unable to verify whether all staff are present

Observe 5



510


Observe and

schedule5



510


Observe 5



5210

5 How many staff have name tags?Count the number of staff on duty. No. staff with tags= Observe 5



510


6 Are there IEC materials visible throughout the ward and in the department e.g. posters of people covering mouth, not spitting, disposing of sputum in a container rather than the floor etc

Observe 5

IEC materials up in each ward and the general areaIEC materials up in a few wards only

No IEC materials or posters of TB throughout

510

7 Are there forms for laboratory, x-ray, ultrasound, pharmacy on hand and easily found? Spot check

andObserve in

ward

4




20

20

TOTAL 30

2. EQUIPMENT AND SUPPLIES Verified by

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

1 Check for the following: thermometer, BP cuff, stethoscope, scale, blank TB patient cards (for both ward – white and also patient – often pink but may be another colour). Is it easily found or locked in a cupboard? It must also be in good working order Observe 10

One point for item being there and one point if easily accessible i.e. not locked. No point if broken

ThermometerBP cuff

StethoscopeScales

Blank patient TB cards

1+11+11+11+11+1

2 oxygen is available (check regulator and flowmeter to see if oxygen tank has oxygen or concentrator is working) Observe 10


100

3mask and tubing is clean; other clean masks and tubing is available Observe 10



1010

TOTAL 30


3. QUALITY OF DOCUMENTATION AND PROCEDURESTOTA

L SCOR

ECOMMENTS

1 Check the TB register book for patients registered between 3 and 9 months prior to the assessment e.g. if you do the assessment in January, you would chose patients registered between April and October in the previous year. This would give the opportunity to review patients that have already finished their treatment as well as those that are still being treated.

Check it is - available i.e. not lockedup to date i.e. patients recently admitted have been registered in the registration book – check the patient cards for the most recent patients and cross check they are in the registration book- Complete

First check those patients who have been recorded as BK+ (left side of register book- column 10 or 11 depending on the age of the registration book).

Check the date treatment started (two columns to the left). Work out how many sputum controls they should have done since starting then check the columns on the right side of the register book (columns 18-21 or 19-22) to see whether they have been recorded (result and lab number needs to be recorded)

Now check the result or treatment (outcome) which should be recorded in one of the 6 columns to the right of the sputum results (cure, completed, died, failure, defaulted, transfer). Only those patients who have had 6 months treatment should have an outcome recorded

Secondly, check the Category 1 patients that are both EP or BK- who started their treatment more than 6 months earlier

Check that they have not been a relapse, return after default or failure – they must be new cases

Check that they have an outcome recorded in the columns on the right side of the page (columns 22 to 27 (or 23 to

Register book

35 Available i.e. not lockedUp to date

Completeness of registration book:BK + patients have sputums all recorded on time

BK+ patients that have finished treatment have outcome recordedCategory 1 patients (EP/BK- only) – check that the column ‘new’

has been ticked rather than relapse, return or failureCategory 1 patients (EP/BK- only) who started treatment more

than 6 months ago have outcome recordedCategory 3 patients (EP/BK- only) – check that the column ‘new’

has been ticked rather than relapse, return or failureCategory 3 patients (EP/BK- only) who started treatment more

than 6 months ago have outcome recordedCategory 2 patients have notification of why they are category 2

patients

Only the points shown can be provided i.e. one mistake then they get zero points for that section

35

55

3

3

3

3

5


28) Thirdly check the Category 3 patients that are both EP or BK- who started their treatment more than 6 months earlier

Check that they have not been a relapse, return after default or failure – they must be new cases

Check that they have an outcome recorded in the columns on the right side of the page (columns 22 to 27 (or 23 to 28)

Fourthly, check all Category 2 patients Check there is an entry in column 12

(relapse), 14 (return after default) or failure (16). There cannot be a tick in the ‘new’ column as Category 2 patients are only patients who have had treatment for TB in the past

2** Check the ward registration book for no. admissions, referrals to and from TB ward of RH, discharges in the last month using the registration book and complete the following (If the date of the assessment is

before 20th day of month, please use the data from 2 months earlier to increase chance of pts admitted during that month being discharge):ADMISSIONS IN = all those admitted during the month you are checkingREFERRALS IN = those from outside the hospital only; DISCHARGES include ALL leaving the ward i.e. authorised and non authorised, deaths and referrals/transfers. You will have to check the month in question PLUS the month before to see whether patients admitted in the previous month were discharged in the following month. If the ward uses a ward registration book then it is only necessary to check the discharges for the month that you are checking HOWEVER, if the ward uses the CENAT TB Registration book then you will have to go back 6 MONTHS from the month you are checking and go through each patient entry (in the discharge/die/default/refer/transfer section) to see if there were any discharges during the month you are checking e.g. if you are checking the month of October, then you will have to go back to May and check all patients being admitted since May to see whether they have had an outcome recorded in OctoberREFERRALS OUT = those referred to another health facility (RH or HC) NOT transfer within the hospitalIf the Registration book does not make this distinction then please make comments in the comments box Please transpose this information to HIS in Management section 5a) TOTAL ADMISSIONS TO TB WARD (in the last month) (or 2 months) =

The next section refers to REFERRALS from OUTSIDE the hospital i.e. NOT transfer of patients between wards BUT referred from HC or other hospital If the registration book does not differentiate please commentb) TOTAL REFERRALS IN TO TB WARD (in the last month (or 2 months)) =

The next section relates to DISCHARGES which refers to ALL patients leaving the hospital i.e. authorised discharges, unauthorised discharges, referrals to another hospital and deaths i.e. you need to add all of these together to get the total no. discharges.Check the month you are supposed to PLUS the month before in case there is a patient admitted earlier who was admitted for a lengthy periodc) TOTAL DISCHARGES TB WARD (in the last month (or 2 months)) (all discharges) =

The next section relates to REFERRALS from this ward to another hospital or HC i.e. NOT transfers within the hospital. It may be difficult to get this information – if so please comment


d) TOTAL REFERRALS FROM RH OF TB PATIENTS (in the last month (or 2 months)) (these will be referred because they have moved, because they seek a higher lever of treatment or because they are referred back to a HC closer to their home) = If registration book does not record referrals then leave the referral sections blank

3 Please work out the % of inpatients who have been referred in to RH :% = total no. referrals to RH last month x 100/total no. admissions to TB ward


Register book 10




106310

0

4 Take 5 current patients and check their TB card (white A4 card kept by the ward): Patient TB

cards

If less than 5 patients, multiply total amount by 5 and divide by number patient files e.g. if 2 patients scored 18 then 18 x 5/2 is the final score to put in the box

pt1

Pt 2

pt3

pt 4

pt 5 tot

5 Check for availability then check card for: place of DOTS (top of page), date starting Rx, name, age, sex, address, type of pt (Sm+/- or EP), category, weight, sputum result, treatment correct for weight, given drugs today

(Please check with chart showing correct dosage for weight to get appropriate dosage)

Patient TB cards 60

One point per item per patient Place of DOTS

Date starting treatmentName

AgeSex

AddressType of pt (Sm +/-, EP)

Category e.g. 1, 2, 3Weight

Sputum resultTreatment correct for weight

Given drugs todayTOTAL 12 points per patient

6 Find these patients in the TB register and see if the TB register is up to date with card Patient TB

cards/ and TB register

25

In register and up to date – 5In register but not up to date – 0


7**

Find 5 patient files that were referred by a HC (see the admission sheet which should record it) and check whether the referral form from the HC is stapled to the file. Be careful – some patients may have been referred but no letter is attached so check carefully. If no referred patient is found in the current files, check last month's patient files and compared with registration book. Find at least 5 patients in total that were referred

Verify this with the score for referrals into TB ward at 3 (2)

Patient TB cards/ and TB register

25

5 points if referral letter stapled to file

(If no referral is found then give 0 score)


TOTAL 155


4. PATIENT VERIFICATION COMMENTS

Ask five patients who are conscious and have been prescribed oral medications i.e. ask each patient or check the file before the interview. Don’t ask those patients who are only suspect patients – it should only be those have been diagnosed as having TB:

If less than 5 patients in the ward, multiply total amount by 5 and divide by number patient files e.g. if 4 patients scored 18 then 18 x 5/2 is the final score to put in the box

pt1

Pt 2

pt3

pt 4

pt 5 tot

1 Have you been seen by the doctor/MA or nurse today?

If score zero on this point, following question should score zero


Yes - 5 No - 0


2 Did you get your drugs? What time? (should be before breakfast)

Score zero if hasn't been seen by a doctor, medical assistant or nurse today


Received drugs and at correct time - 5Received drugs but after breakfast - 1

Haven’t received drugs yet – 0


3 Have you taken your drugs as asked today? Check if they have any tablets left to take (should be observed swallowing the tablets but sometimes they are not)


Taken drugs already - 5Haven’t taken drugs yet – 0

TOTAL 5 points per patient4 Do you know what your diagnosis is? How long should

you take tablets for? Can you stop if you are feeling better?


Knows the diagnosis and how long should take treatment, knows can’t stop - 10

Knows diagnosis but doesn’t know how long treatment is or doesn’t know can’t stop - 2

Doesn’t know diagnosis or length or treatment, thinks can stop treatment if feeling better - 0

TOTAL 10 points per patient5 How do you prevent TB?


Cover mouth when coughing or sneezing, no spitting - 5Cover mouth when coughing only - 1

Doesn’t know – 0TOTAL 5 points per patient

6 Is there staff here at night that you can call on if you need to? Patient

interview 25



7 Were you told where the patient toilet/bathroom was on admission (or is it very obvious being in the same ward)? Can you use it or is it locked, is there always enough water?Is there enough water for washing clothes also? Patient

interview 25

obvious), not locked when want to use it, water always available for bathing/washing - 5

Told where toilet/bathroom is, (or in ward and very obvious) but can’t use it all the time because locked or

water not always available - 0 Not told where toilet/bathroom is or not in ward and not

obvious - 0 TOTAL 5 points per patient


pt1

Pt 2

pt3

pt 4

pt 5 tot COMMENTS

8 Were you told about food being provided by hospital twice daily (or given 1000R per day for food if hospital doesn't have a kitchen)?







? (or the kitchen is adjacent to ward and very easily seen without explanation)? Patient

interview 10

Told or shown where relatives could cook or very obvious and used it or kitchen adjacent to ward and

easily seen - 2 Not told or shown were relatives could cook/Didn’t know

there was a kitchen or no kitchen available - 0 TOTAL 2 points per patient

10 Were you given any explanation about the exemption scheme when you first arrived at hospital or when you were admitted? Patient

interview 25




TOTAL 260

5. GENERAL HYGIENE TOTAL SCORE COMMENTS

1 Are there rubbish bins in the ward including in nurse's station? If so, is there evidence that they are emptied regularly?

Observe 5Rubbish bins in nurse’s station, on ward and not over flowing

Not enough rubbish bins No rubbish bins or doesn’t look emptied regularly

510

2 Is there evidence that patients spit into spittoons or cups rather than on the floor. Ask patients what they do if they have sputum. Do they sometimes spit outside or out the window?

Observe 5

Patients have spittoons to spit into and always spit into themPatients use spittoons but sometimes spit out window or outside

Patients spit on floor or in bin rather than a spittoon/cup

500

3 Is there evidence that the floor is regularly swept and mopped? (currently clean, not much dirt/papers on the floor)

Observe 5



510

4**

Is there any back up storage for staff to wash hands i.e. a large container filled with water in case piped water fails?(Check with Section 3, Qu 6 Management section)

Observe 5



510

5**

Check patient toilets Are they locked? If so the next question scores zero

Observe 5 Not locked Locked or not working/not able to be used

50


If they don’t work they don’t score points either6 Are they cleaned (or is their evidence that they are

cleaned), is there water available and a scoop (if non flush toilet)?



510

7 Is there soap available?Observe 5

Soap available for patients in toilet/bathroom No soap available

50

TOTAL 35

TB WARDMAXIMU

M POSSIBLE

SCORE RECEIVED %


2 EQUIPMENT AND SUPPLIES 303 QUALITY OF DOCUMENTATION

AND PROCEDURES 155


GRAND TOTAL TB WARD 510


Assessment of Operating Room/Sterilizing Area –HIS for past month (or HIS for 2 months earlier, if assessment done before 20th

of the day) will be required to do this assessment. If there is more than one Operation Room, an assessment should be performed for both

7. OPERATING ROOM AND STERILISING AREA

Verified by

MAXSCOR

ESCORING

TOTAL SCORE

COMMENTS


1. Is there an organisational chart of staff displayed in or near the operating room? (for operating staff and sterilising staff)

Spot check 2


20

2. Is there an up to date staff schedule - day and night? (Often staff is required to work day shift Mon to Fri in their department with the exception of the day following their night duty when they are scheduled off. However, in some hospitals where staff is lacking it is possible that staff will work in more than one ward/department either for night duty (if there are insufficient regular staff for the night duty) or to cover the day shift when the staff are off post night duty. In this case, there should be a clear schedule for each ward/dept for both day and night rather than just a night schedule so it is clear to anyone checking who should be on duty at any given time during the week or month). A schedule should be made at least monthly. If the ward has only a yearly schedule this is not adequate


Observe and

schedule5



510

3. Is all staff present today that should be? (Check today’s schedule) If the staff member is not present and you are told that they have official permission to be away, you must verify this with the Chief of ward or Administration

Observe and

schedule5



510

4. How many staff are in their surgical uniform and look well presented? Are staff wearing their theatre uniform outside of theatre?Count the number of staff on duty. No. staff=No staff with surgical uniform on=No. staff with hospital uniform on =

5 All staff wearing surgical uniform, look well presented, not wearing uniform outside of theatre

More than half wearing uniform, look neat and tidy and not wearing uniform outside of theatre

More than half wearing uniform but it is not clean or tidy Less than half have uniform on or wearing surgical uniform

outside of theatre

5

21

0


5. How many staff have name tags?Count the number of staff on duty. No. with tags= 5

All staff have name tagsMore than half have their name tags displayed Less than half have their name tags displayed

510

6. Are there consent forms available?Are there operation sheets available? (to write details about the operation performed and anaesthetic provided) 8

Both consent forms and operation sheets availableOne form available only

No forms available

820

MAXSCOR

ESCORING

TOTAL SCORE

COMMENTS

7. Is there a log book for recording details about sterilising equipment? i.e. date of sterilisation, types of packs sterilised, expiry dates etc

5

Log book available of all sterilising procedures including details on packs, expiry date and up to date

Log book available but not up to dateNo log book available

510

9. Check whether the tape used for packs is working correctly. If no tape then no points 5

Changes to the tape post sterilisation are obviousNo changes are noticed post “sterilisation”

No tape available or not used

500

10. Are there instructions on how to use steriliser? Check them 5

Instructions for steriliser on wall or easily accessibleInstructions available but not easily found

No instructions

510

11. Is there a maintenance manual available? Check for a maintenance plan and schedule 5

Maintenance manual readily available, schedule of maintenance plan and log book of maintenance performed readily available and

up to dateMaintenance manual available but no schedule of maintenance or

log bookNo manual or no record of maintenance

5

10

TOTAL 50

OR/CSSD Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

2. EQUIPMENT AND SUPPLIES

1. Check for the following equipment in OR. Is it easily found or locked in a cupboard? It must also be in good working order

Spot check andObserve in ward 30

One point for each piece of equipment and another point if that item is easily found i.e. total of 2 points per item. If it is broken or expired, no point Thermometer

BP (adult cuff)BP (child cuff)

Stethoscope

1+11+11+11+1


Sterile GlovesAspirator that is in good working order

Sharps containerRubbish bin with no lid BUT plastic bad within or foot operated

rubbish binNeedles

Syringes 2 ml or 1 mlAmbubag

Masks for ambu bag (child) Masks for ambu bag (adult)

Anaesthetic machinex-ray viewer

1+11+11+1

1+11+11+11+11+11+11+11+1

Verified by

MAXSCOR

ESCORING

TOTAL

SCORE

COMMENTS

2. Oxygen is available (check regulator and flowmeter to see if oxygen tank has oxygen or concentrator is working) 5


50

3. Mask and tubing is clean; other clean masks and tubing is available 5



510

4. Check for anaesthetic drugs. Choose five and check their expiry date 10

5 different types of anaesthetic drugs are within expiry datedo not have 5 different anaesthetic drugs available or at least one

is expired

10

05. Check for the following equipment and supplies

10. If unavailable or not clean, no point. If ok, 5 each item

Tape for packs is available and working correctlyMaterial for wrapping packs is clean and available

55

6. Check for the following packs (packs must be in material i.e. not just sterilised in the metal boxes)(For those hospitals with operations available at Obstetric ward i.e. another operating room, please check for D & C set there. It would be better if in both OR and Obstetric however it should be in at least one to get full marks)

20

5 points for each being packed and readily available and not expired. If not on hand or expired, no points

Laparotomy set on handCaesarean set on hand

Dilatation and curettage set on handOrthopaedic set on hand

5555

TOTAL 80

3. QUALITY OF DOCUMENTATION AND PROCEDURES

1. Is there an operation registration book in OR which includes information on operations performed and anaesthetics given?

5

AvailableNo registration book

50

2. Check the register book for operations. Is it up to date Register 10 Today’s operation (or last operation) entered including notes


i.e. today's operations (or yesterday’s if nil today) recorded in the register book? book

about anaesthetic Today’s operation not entered or not up to date or no anaesthetic

recorded No registration book

10

10

3. Check no. abdominal, gynaecological/obstetric and amputations performed during the last month and compare it to HO2 form.

Register book and HIS form

10 No. operations for abdominal, gynaeco/obstetric and amputations = H02 form

No. abdominal, gynaeco/obstetric and amputations not equal to H02 form

No record to check

1010

TOTAL 25


4. GENERAL HYGIENE

TOTAL

SCORE

COMMENTS

1. Check for following in scrubbing up area, OR or room for dressing in theatre gowns

10

TOTAL 2 points for each if in place. Nil if not available or poorly managed

SCRUB AREASink for scrubbing before operation

Antiseptic for scrubbing in wall mounted container (use elbow to get soap) and has fluid in it

IN DRESSING ROOM OR SCRUB ROOMShoes for wearing in theatre

Sterile Surgical gowns for staffIN OPERATING ROOM FOR DEPOSIT AFTER OPERATION

Waste container for staff gowns used during operations

2

2

22

22. Check area where contaminated instruments are cleaned

10

Cleaned in different sink to that which staff scrub in, cleaning solution/disinfectant on hand to clean them

Cleaned in different sink to that which staff scrub in, no soap on hand

No special place to clean contaminated instrumentsUse same sink that staff scrub in

10

100

3. Check for the following in sterilising areaCheck for filter – if not seen then can’t get full pointsLaboratory will have to be checked for distiller. Please confirm with the laboratory staff that they provide distilled water routinely. check any records that you can to verify this

15

Filtered or distilled water available for steriliserArea for contaminated equipment is separate to the area where

packs and clean equipment is keptClean area to pack sets/fold linen

5

55

4. Is there back up water supply i.e. containers full of water at the scrubbing sink if piped water stops? Observe 10

Container full of water with a scoop adjacent to scrub sinkNo container or container has no water or no scoop to pour over

hands whilst scrubbing up

10

05. Is there evidence that the floor is regularly swept and mopped in OR, scrub room, sterilising room? (currently clean and ready for operation of packing of instruments) Observe 10

All areas look very clean and well mopped, well kept and area able to be used for operation without further cleaning

Area currently being used but looks clean enough Not clean enough for operations or

packing sets

101

0

TOTAL 55


MAX POSSIBL

E

SCORE RECEIVE

D%

1. ORGANISATION AND PRESENTATION OF STAFF AND WARD 50

2. EQUIPMENT AND SUPPLIES 803. QUALITY OF DOCUMENTATION AND PROCEDURES

25

4. GENERAL HYGIENE 55

TOTAL OPERATING ROOM AND

STERILISING AREA210


For this assessment, the HIS report for the past month, two months ago and past year is required as well as the HC and RH treatment guidelines and essential drug list.If there is more than one OPD e.g. one for those who are considered ‘HC’ or ‘ordinary’ patients and another for those who require more specialist consultation OR those who are only seen as outpatients versus those who admitted , an assessment should be performed for both

8. OPD

1. ORGANISATION AND PRESENTATION OF STAFF AND WARD Verifi

ed byMAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

1 Is there a central register for the hospital or is there more than one register book which registers patients in various departments? There could be a triage area (with or without a central register) or there could be a register in the OPD at HC (which may function as the OPD for the RH also); there may be an OPD only at RH; the emergency/reanimation may also see patients on arrival at the RH (perhaps registering them rather than at a central location). It is also possible that the situation is different after hours i.e. the patients may go to OPD during the day and Emergency after hours. Before starting the assessment be sure you are clear how this hospital operates. If there is a RH OPD then please go to this area for the assessment. Document in the section to the right what happens in this hospital

2 Is there a central triage area where patients are registered (including referrals)?If not, they score zero

10

Triage area visible, patients are registered including whether they are referred

Triage area but no referrals recordedNo triage area

1020


Spot check and

Observe in OPD

4Available and up to date

Not up to date or not present 40

4 Is there an up to date staff schedule - day and night? (Often staff is required to work day shift Mon to Fri in their department with the exception of the day following their night duty when they are scheduled off. However, in some hospitals where staff is lacking it is possible

5 Both day and night staff schedule available and observed (or schedule shows both day and night duty on the one schedule)


510


that staff will work in more than one ward/department either for night duty (if there are insufficient regular staff for the night duty) or to cover the day shift when the staff are off post night duty. In this case, there should be a clear schedule for each ward/dept for both day and night rather than just a night schedule so it is clear to anyone checking who should be on duty at any given time during the week or month).

A schedule should be made at least monthly. If the ward has only a yearly schedule this is not adequate

If the answer is zero, please score zero on question 6 as you will be unable to verify whether all staff are present

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

5 Is there a list of phone numbers of doctor's working on call? It is not a good idea to have this list in view of the public i.e. the list should be for staff only otherwise patients may contact drs directly

Spot check and

Observe in OPD

5

List readily available but not in view of general publicList but not readily available

No list or list with doctor’s phone nos. on display and able to be seen by general public

51

0


5



510

7 Is there a list of hospital fees in the OPD that is in a prominent position and easily seen by patients? This should list all services offered that may be required by the patient i.e. admission for various ailments, investigations (lab/x-ray etc), surgery, deliveries including caesarean sections, additional payments made after one week etc. Make sure all services including cost of ambulance is recorded

5

List available and easily seen by patients List available but not easily seen

Not available or incomplete information

510

8 Is there adequate signage to show patients where they should go e.g. to lab, pharmacy, OPD specialities etc? 2

Flow chart available and easily seenNo flow chart available

20

9 Are there any IEC materials present in the patient waiting area e.g. posters on the wall, pamphlets, TV showing health videos?

If no TV present, it does not matter – what is important

10 IEC materials present including posters in well kept condition, video of health education currently being played (if TV and

video available) or pamphlets readily available about different topics

IEC materials present but not in good condition, no video being played at time of assessment (TV is on instead)

10

4


is that if they have a TB, they use it for health messages, not for showing TV shows

No IEC materials on display in waiting area 0


5

All staff wearing uniform and look well presentedHalf of more than half wearing uniform and look neat and tidy


5210

11 How many staff has name tags?Count the number of staff on duty.No. staff wearing name tags= 5



510

Verified by

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

12**

Are there new patient files/admission sheets (include sheets for: 1-patients details, 2-history, exam, diagnosis and treatment, 3. medication, and 4. vital signs). Are they readily available and made up ready for the next admission? It is possible that the ward will have these admission sheets (there are questions for Paed, Obstet, Med and Surgical wards (Section 1, Qu 7) on this topic also. Make a note if the OPD says they do not do admission but the ward is responsible).

5



510

13**

Check the register to see if there have been any patients referred from HC today. Also ask any patients who are still in OPD whether they have been referred. If you find a referral (person or in the registration book), check if they have been admitted. If not, are there feedback forms written to the referring HC? Verity this with Referrals Qu 2

10

Patients referred, not admitted and feedback letter writtenPatients registered as referral but no feedback provided

despite being discharged homePatient has referral letter but not registered as referral in

registration bookNo feedback letters written despite patient being sent home or

referrals not recorded in register

10

1

0

014 Are there forms for laboratory, x-ray, ultra sound,

pharmacy on hand and easily found?

Spot check 4




20

20

TOTAL 75


2. EQUIPMENT AND SUPPLIESVerified by

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

1 Check for the following in the examining area (where patient sees dr/MA): thermometer, BP cuff adult, BP cuff child, stethoscope, scales for children, scales for adults, otoscope, tongue depressor, gloves, sharps container. Is it readily available or locked in a cupboard? It must also be in good working orderIf the scales are not in the room where the doctor examines the patient, check the files and see if they are recorded. If not they don’t get recorded, then no points for these

Spot check 20

One point for item being available and another point if readily available i.e. not locked. No point if broken Thermometer

BP cuff adultBP cuff childStethoscope

Scales for childrenScales for adults

OtoscopeTongue depressors or one tongue depressor and alcohol to

clean between patientsGloves

Sharp containers

1+11+11+11+11+11+11+1

1+11+11+1

TOTAL 20

3. QUALITY OF DOCUMENTATION AND PROCEDURES SCORING

TOTAL

SCORE

COMMENTS

1 Check registration book for columns (see below for columns it should have). If there are no columns skip the next questions (all get zero points) and go the question 6)

Register books

2 Check the register book for the following columns:

running number, name, age, sex, address, zone, date of consultation, diagnosis, referred from HC or other health facility, treatment, outcome (discharged, referred to ward, referred to another hospital, death), fee paid or

Register book

15 One point for each if in registration bookRunning number

NameAgeSex


exempt, AddressZone

Date of consultationDiagnosis

Referred from HC or other facilitytreatment

Discharged homeReferred to ward

Referred to other hospitaldeath

Fee paid/exempt

3 Is it up to date i.e. patient's seen today have information recorded? Register

book 10

Patients seen have been recorded correctly todayOnly some patients recorded (but all columns complete for

each pt)No patients recorded or not all columns completed

10

10

Verified by

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

4 Check the last month's statistics (or two months ago) from registration books and HISHow many new patients have been seen in OPDTotal no. = no. referred = no. self referred = . (Total no. should equal referred + self referred)

In addition:Check total no. patients admitted in past month (or two months ago) (total for the hospital as written in the OPD registration book)Total =Check the no. patients referred AND admitted in the past month (or two months earlier)Total =(You’ll have to go through each entry for that month to see if referred and admitted to check this)

Register book, HIS

form 10

No. new patients seen in the month and no. referred (from HC) as written in registration book = HIS form

No. recorded but not matching HIS OR no tally

Some of this information will be transferred to Management Section so be sure to record

the data necessary on the left

If you are unable to collect this data please state in comments box. If the register is not a

central register please state

100

5 Check register of the first 20 patients of last month. Check all columns are complete i.e. that all those columns that should be completed are (outcome has only one possibility i.e. admitted, discharge or death or referral or unauthorized discharge)If registration book is not set up as written in qu 2 above, score zero

Register book 10

All columns completeOnly some columns complete

100

6 Check diagnosis with treatment. Is it logical? Are the drugs on essential drug list?

Register book, HC

10 Treatment fits with diagnosis and drugs on essential drug listTreatment fits with diagnosis but drugs not on essential drug 10


and RH treatment manual, Essential drug list

listTreatment doesn’t fit with diagnosis

20

7 Now check all patients from the last month who were not admitted. (if there are more than 100, take the first 100 patients) Add total pts receiving no drug at all, one, two, three and more than 3 drugs. Add total no. pts seen. Give the % of patients who have received more than 3 drugs in the past month. (% >3 drugs = no. pts with > 3 drugs x 100/total no. patients seen in that month)No drug =1 drug =2 drugs = 3 drugs = >3 drugs =

Register book 10

<5% patients received more than 3 drugs5 – 10% patients received more than 3 drugs

>10% patients received more than 3 drugs

1020

8 Check for patient referral forms. For any patients, have any feedback forms been written? Spot check 10

Feedback forms written for all referralsNot all feedback forms written

No feedback forms written or no feedback forms seen

1020

TOTAL 75

4. PATIENT VERIFICATION 1 2 3 4 5 tot COMMENTS1 Ask 5 patients who are waiting for consultation (or X-ray

or Lab):Has anyone taken your temperature, BP, PR today?If there are no patients, state the time you are visiting OPD


One point per vital signT

BPPR


scheme when you were asked to pay?



Noticed exemption mentioned on user fee board but no mention of exemptions to patient or never heard of

exemption - 0


1 2 3 4 5 tot COMMENTS3 Check for patient’s receipt Patient

interview25 Patients has receipt and amount paid is according to

user fee board (or exempt) - 5Has receipt but not according to user fee board - 1

No receipt - 0 Receipt attached to patient file - 0


TOTAL 5 points per patient4 If you meet patients at x-ray or laboratory, please check

their papers. Have they already received their drugs i.e. prior to investigations being completed? Please confirm in the comments section whether you have seen any patients or there were none to speak to.

If you meet patients who have received drugs but are still having investigations take 20 points away for each

patient from the total

5 Ask 3 patients who have been seen by the doctor/MA (may have to meet them at pharmacy)

If less than 3 patients, multiply total amount scored by 3 and divide by number of patients e.g. if 1 patients scored 5 then 5 x3 /1 is the final score Pt 1 Pt

2Pt 3 Total

6 Did s/he speak to you, examine you?Patient

interview 15

Spoke and examined – 5Spoke but didn’t examine - 1Didn’t speak or examine – 0

TOTAL 5 points per patient7 Did anyone take your temperature, BP, PR, RR, weight

today?


One point for each TBPPRRR

Weight

TOTAL 5 points per patient8 Did you get your drugs? Were you told how many to

take and when? Were you told to buy any outside of the hospital? Please ask the patient to explain to you how they should take their drugs Patient

interview 15

Received all drugs from RH, told how many to take and when (and can now explain to you correctly) - 5

Received drugs but not told how many to take or when - 1

Haven’t received drugs yet - 0Told to buy drugs from outside hospital – 0


TOTAL 110Don’t forget to take 20 points per patient if you find they have been given their prescription before their investigations have been done or results completed

5. GENERAL HYGIENE

Verified by

MAX SCOR

E SCORING TOTAL

SCORE COMMENTS

1 Are there rubbish bins in the OPD, waiting room and in nurse's station? If so, is there evidence that they are emptied regularly? Observe 5

Rubbish bins in nurse’s station, in OPD and waiting room and not over flowing/cleared regularly

Not enough rubbish bins No rubbish bins or doesn’t look to be emptied regularly

510




510

3 Is there any back up storage for staff to wash hands i.e. Observe 5 Back up storage near sink where staff wash hands/bathroom


** a large container filled with water in case piped water fails?(Check with Section 3, Qu 6 Management section)

where staff wash handsBack up storage container but no water in it

No back up storage

510

4 Check patient toilets: are they locked?If so the next question scores zero Observe 5 Not locked

Locked 50

5 Are they cleaned (or is their evidence that they are cleaned), is there water available and a scoop (if non flush toilet)? Observe 5

Very clean, Water and scoop of sufficient size available Partly cleaned, water available, scoop available

Not cleaned at all OR Water not available OR no scoop or locked

51

06 Is there soap available?\ Observe 5 Soap available for patients in toilet/bathroom

No soap available 50

TOTAL 30

OPD MAXIMUM POSSIBLE

SCORE RECEIVED

%

1 ORGANISATION AND PRESENTATION OF STAFF AND WARD

75


2 EQUIPMENT AND SUPPLIES 203 QUALITY OF DOCUMENTATION AND

PROCEDURES 75


TOTAL OPD 310

If there is more than one building e.g. general laboratory, Blood Bank, STI, TB please state this.9. LABORATORY Verifi

ed byMAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

1. ORGANISATION OF LABORATORY AND STAFF1

Are all staff qualified 10 or 20 laboratory technicians? This can be verified with hospital administration. If no qualified staff score zero

Cite qualifications

if possible5

All staff working in laboratory are qualified 1 or 2 lab technicians No qualified staff

Take one point off for each staff not having recognised MOH pharmacy/lab qualification.

50

2Are job descriptions available for all staff? Verify by citing the job descriptions

Check documents 1

Job descriptions are available and cited for each staff member working in lab

No job descriptions or only some job descriptions are cited 10

3Are all staff wearing protective clothing? e.g. lab coat Observe 1 All staff wearing protective clothing (lab coat or other uniform)

Only some or no staff are wearing protective clothing 10

4Is there a current monthly 24 hour staff work schedule clearly visible on the wall?

Observe 1Currently monthly schedule is clearly visible

No staff schedule for the current month or schedule not hanging on the wall

1

05 Are general laboratory staff integrated with:

Blood bank (buildings can be separate but staff should be integrated and be able to work in all areas)

Observe1

Blood bank staff are integrated into general laboratoryBlood bank staff are not yet integrated into general laboratory

10

6 Are general laboratory staff integrated with: Observe 1 VCCT staff are integrated into general laboratory 1


VCCT laboratory (buildings can be separate but staff should be integrated and be able to work in all areas)

VCCT staff are not yet integrated into general laboratory 0

7 Are general laboratory staff integrated with:STD laboratory (buildings can be separate but staff should be integrated and be able to work in all areas)

Observe1

STD staff are integrated into general laboratorySTD staff are not yet integrated into general laboratory

10

8 Are general laboratory staff integrated with:TB laboratory (buildings can be separate but staff should be integrated and be able to work in all areas)

Observe1

TB lab staff are integrated into general laboratoryTB lab staff are not yet integrated into general laboratory

10

TOTAL 12


2. INFRASTRUCTURE, SAFETY AND HYGIENE

Verified by

MAX SCOR

ESCORING

TOTAL

SCORE

COMMENTS

1**

Is 24 hr mains power available to laboratory?

Verify with hospital administration and hospital management section 2, qu. 5. Score zero if no power at the time of assessment

Observation and

management section

524 hour mains power is available at laboratory and verified

mains power to laboratory is not regular or available 24 hours50

2**

Is the hospital generator connected to the laboratory?

Verify with hospital engineer/management team that the generator power automatically switches to the lab in mains power outages. Verify with Section 2, qu 5. Score zero if mains power is currently out and generator is not on

Observe, check with

hospital generator, management section

5

Hospital generator is connected to laboratory and automatically switches to this when there are mains power

outagesHospital generator is connected to laboratory but does not

automatically switch to this when there are mains power outages

Laboratory is not connected to hospital generator or mains power is out and laboratory electricity is not on

5

2

0

3**

Is running tap water available from all taps in laboratory? Check that each tap in the laboratory is working properly.

Verify with Section 2, qu 6. Score zero if one of the taps is not working

Observe all taps in labs 2

All taps in laboratory are workingSome taps are working

No taps or taps not working

210

4 Does the laboratory have glass in windows? To ensure that the laboratory can be properly air-conditioned check if all the rooms have glass windows and free from open air vents.

Observe 1

Lab has glass windows and there no air vents into the labAir vents present or no glass windows or air from outside can

easily leak into lab

1

0

5 Does the laboratory have a working air conditioner? If it is off during the assessment score 0 Observe 2

Lab has air conditioner and it is on during assessmentLab has no air conditioner or it is off during assessment

20

6 Is a safety manual available in the laboratory?This manual should include protocols for PEP, Universal precautions, chemical spills/exposure and management of fire. If not, score zero

Observe 1

Safety manual availableNo safety manual available

10

7 Is there a fire extinguisher and has it been checked within the last 12 months? Check that there is a verification date on the extinguisher. If more than 12 months old or no date score zero

Observe 1

Fire extinguisher available and checked within past 12 monthsFire extinguisher not available or has not been checked in the

past 12 months

1

0

8 Is there an unlocked first aid kit with the following items: 1. Sterile saline for eye wash 2. Antiseptic e.g betadine 3. Cotton wool 4. Bandaids 5. A cream for minor burns.

Observe 1First aid kit is available with all items and not lockedNo first aid kit or insufficient items or cabinet locked

10


If all items are not present or the cabinet is locked score zero

9 Are there supplies of disposable gloves present? Observe and check

stocks1

Disposable gloves are availableNo disposable gloves are available or they are locked up

10

10

Is there bleach (Hypochlorite) for cleaning and disinfection. Check the expiry date. If not date, smell it. If not smelling like chlorine, score zero

Observe and check

stocks1

Bleach is available and within dateBleach not available or expired or not smelling like chlorine

10

11

Is there a separate sink for staff to hand wash with soap available and tap working? If no soap available score zero

Observe and check

sink1

Separate sink available, tap working, soap availableNo separate sink or no soap or water not running

10

12

Is waste separated into the following categories?sharps container for needles and glass?Infectious e.g. anything contaminated with other human fluids or tissueNon infectious e.g. paper

Observe and check bins and

containers

3

All categories (sharps, infectious, non infectious are present in lab

Waste is not disposed of correctly (mixing of infectious/non infectious or infectious and needles)

3

0

13**

Is waste removed every working day and taken to the incinerator to be burnt?Check to see whether it looks full or emptied regularlyVerify with Management section 3 qu 1 & 2

Check bins 1

Bins look to be emptied dailySome bins don’t look to be emptied daily or are full at time of

assessment

1

0

TOTAL 25

3. QUALITY OF DOCUMENTATION

Verified by

MAX SCOR

ESCORING

TOTAL

SCORE

COMMENTS

1 Is there a laboratory request form?Check for the following

• Name• Age• ID code• Date• Ward• Name of doctor/Medical assistant• Available tests

All must be on the form to score a point

Laboratory request

form1

All items are included on the laboratory formSome items are missing from the form or no laboratory request

form available

1

0

2 Are all samples received at the lab given a lab number? Check today’s samples and verify whether they have been given a number. If there are no samples for today,

Check lab samples

1 All samples received by lab are given a numberOnly some samples are given a lab number or no numbers

are given

1

0


check yesterday’s.If not given a number score zero

3 Is every sample received at the laboratory labeled with name, ID number and date? Check twenty samples from today. If no samples received today, check yesterday’s sample. If not all are labeled correctly, score zero

Check lab samples 1

All samples received are labelled correctlySome samples received are not labelled or no samples are

labelled

1

0

4 Check the laboratory register books for the followingName

• Date of birth (or age)• Unique Identification code (ID code)• Address of patient• Date test requested• Tests requested• Doctor/medical assistant name who

requested test• Ward or clinic (or other site)

Registration books 1

All register books have a column for all categoriesSome register books do not have all items or no registration

books

10

5 Check the register books or computer for recording of results.Check yesterday’s tests to see whether the result has been recorded for each patient.Score zero if no record for at least one patient

Registration books or computer

1

All results recorded in register book/computerOnly some results or no results recorded in register book or

computer

1

0

6 Is there a laboratory report form? Check for the following:

• Patient name• Age• ID code• Date• Ward/clinic• Name of doctor/medical assistant requesting

test• results

Laboratory report form 1

Laboratory report form has all items included on formLaboratory form has only some items included on form or no

report form

1

0

8 Check the HIS results from last month and verify that the number of tests performed is equal to the number of tests recorded in each register book

HIS form from last

month and registration

books or computer

1All HIS data is equal to the register books

Some HIS data does not equal the number of tests recorded in the register books

1

0

TOTAL 7


4. EQUIPMENT, SUPPLIES AND TRAINING MATERIAL

Verified by

MAX SCOR

ESCORING

TOTAL

SCORE

COMMENTS

1 Does the laboratory have up to date inventories for:Consumables (monthly)Reagents and chemicals (monthly) Equipment (every 3 months)Glassware (every 12 months)?

Consumables, reagents and chemicals should be updated every month, equipment should be updated every three months and glassware every 12 months to score full points

Check inventories 4

Consumables, reagents and chemicals, equipment and glassware are all inventoried as written on the left

Only some inventories are up to dateNo inventories or not up to date with recommendations on

left

410

2 Are consumables clearly labeled and clean? Observe 1 Consumables are all labelled and cleanNot all consumables are labelled or kept clean

10

3 Is glassware kept in a sealed (dust free) cabinet without air vents? Observe 1 Glassware is kept in dust free cabinet

Glassware is kept in cabinet that is not dust free10

4 Are chemicals kept clean and in alphabetical order? Observe 1 Chemicals are clean and in alphabetical orderChemicals are not clean or net all kept in alphabetical order

10

5 Check reagents in use for expiry date. If all are in date score one. If any are out of date and in use (or not separated from others and therefore might be used, score zero)

Observe 1

All reagents in use are within expiry date (out of date expired reagents stored elsewhere or returned to OD

Some reagents in use are expired 10

6 Is the temperature of the room monitored daily (including weekends) and recorded on a chart?If no monitoring or not daily monitoring, score zero. If the temperature is over 28 degrees, score zero.If the chart looks to be too ‘perfect’ i.e. just a straight line, score zero

Check chart 1

Temperature of the room is monitored 7 days a week and is consistently under 28 degrees

Temperature is not monitored or not monitored daily or chart looks too perfect to be true

1

0

7 Is the temperature of the refrigerator monitored (including weekends) and recorded on a chart? Temperature should be between 2° and 8° C. If no chart or temperature not between 2° and 8° C, score zero. If the chart looks to be too ‘perfect’ i.e. just a straight line, score zero

Check chart 1

Temperature of the refrigerator is monitored 7 days a week and is consistently between 0 and 8 degrees

Temperature is not monitored or not monitored daily or chart looks too perfect to be true

1

0

8 Check for the availability following in the lab• MOH Laboratory Manual• NIPH Laboratory Manual• Malaria morphology posters• Parasitology posters

Observe documents

5 MOH Laboratory Manual presentNIPH Laboratory Manual present

Malaria morphology posters present and easily found and readable

Parasitology posters present and easily found and readable

11

11


• Haematology postersPosters do not have to be on the wall but should be easily found in the laboratory and able to be read i.e. not so old that they have faded

Haematology posters present and easily found and readable 1

9 Check the following for availabilityMOH issued or dedicated screw top plastic containers for urine/sputum/stoolIf other containers are being used e.g. old antibiotic bottles score zero

Observe 5

MOH issued or dedicated screw top plastic containers for urine/sputum/stool

No MOH issued containers or other containers are also used 50

10

Check the following for availabilityEDTA tubes Observe 5

MOH issued EDTA tubes are usedHome made EDTA tubes are used rather than MOH issued

tubesNo EDTA tubes

510

11

Check the following for availabilityPlain glass tubes with lids (no anticoagulant)

Observe 5Plain glass tubes with lids (no anticoagulant)

Plain glass tubes but no lidsNo plain glass tubes

510

12

Is there any evidence that blood is collected, stored in a syringe (with or without a needle attached) and sent to the laboratory?

Observe -10Blood filled syringe is noted in the laboratory i.e. sent from a

ward-10 Minus 10

points

13

Are the following items available in the laboratory?

If not exactly as described, score zero

9

Frosted end glass slidesYellow pipette tips

Blue pipette tips5ml plastic disposable tubes

5ml plain glass tubesplastic 1ml disposable pasteur pipettes

plain haematocrit tubes (blue tip)Heparin coated haematocrit tubes (red tip)

Coverslips for microscope slides

111111111

14

Is the following equipment available and in working order in the laboratory?Check that each item is also working. Score zero if not working

Observe and check whether in

working order

28 ComputerPrinter

RefrigeratorDistilled water apparatus

General centrifugeHaematocrit centrifuge

SerofugeWater bath

Dry heat blockRotating mixer of roller

Vortex mixerShaker/agitator

Electronic balanceDifferential counter

Electronic microscope (solar if no power)IncubatorAutoclave

Alcohol glass lamp/Bunsen burnerHand tally counter

1111111111111111111


TimerAutomatic pipette – 5-50microlitre

Automatic pipette – 50-200microlitreAutomatic pipette – 200-1000microlitre

Biohazard safety cabinet

11115

15

Does laboratory have Internal quality control reagents and control charts?Check for reagents in the fridge and that they are not expiredCheck that control charts are present for all four machines. If machine is available but no reagents or out of date or no charts, score zero

Check availability

of chemicals and charts

10

Spectrophotometer and IQCHaematology analyser and IQC

Flow cytometer and IQCElectrolyte (ionogram) analyser and IQC

control charts for each of the above machines (score zero if not all four present)

2222

2

TOTAL 77

5. TESTS PERFORMED

Verified by

MAX SCOR

ESCORING

TOTAL SCORE

COMMENTS

1**

Are the following haematology tests performed in the lab?Check the registration books for the past 6 months to verify. If no tests, score zero

Verify automated WBC with Qu 15 on IQC above. If zero above, then automated CBC should also be zero

Ask staff, Check

registration books

16

Automated CBC (score zero if no IQC)Manual WBC

Manual Haemoglobin using haemocueManual platelet count

HaematocritMay-Grunwals/Giemsa stained blood film examination

ESRReticulocyte count

Examination for blood borne parasites (malaria)Bleeding timeClotting time

ABO blood grouping

511111111111

2**

Are the following serology tests performed?Check the registration books for the past 6 months to verify. If no tests, score zero

Ask staff, Check

registration books

11 HIV1 & 2 antibodyHIV 1 & 2 antibody confirmatory test

Hepatitis B AntigenHepatitis C Antibody

Syphilis serology (TPPA/TPHA)RPR

Widal test

1111111


Verify CD4 with Qu 15 on IQC above. If no IQC, score zero

ASLOPregnancy test

Rheumatoid arthritis testCD4 counts (score zero if no IQC)

1111

3 Are the following Microbiology tests performed?Check the registration books for the past 6 months to verify. If no tests, score zero Ask staff,

Check registration

books

8

UrinalysisStool examination

Gram stainWet mount for vaginal swabs

CSF examinationBody fluid examination

KOH test for fungiAFB smears for TB

11111111

4**

Are the following biochemistry tests performed?Check the registration books for the past 6 months to verify. If no tests, score zero

Verify with Qu 15 on IQC above. If no IQC, score zero for all tests

Ask staff, Check

registration books

16

GlucoseUrea

CreatinineALT/SGPTAST/SGOTCholesterol

TriglyceridesTotal bilirubin

ProteinAlbuminUric acidCalcium

Gamma GTAmylase

MagnesiumNa+, K+, Cl- (ionogram)

score zero for all tests if no IQC

1111111111111111

5 Check Blood Bank area for cleanliness Observe 1 Looks clean and well mopped Swept but not mopped or not clean

10

6 Check donor bed/chair Observe 1 Donor bed and chair is clean and comfortableNo donor bed/chair or not clean or not comfortable

10

7**

Check whether refreshments are offered to donors. Verify with finance department that food is purchased for the donors

Ask staff and verify

with accounts

department

1

Refreshments offered, verified with finance departmentNo verification that refreshments are offered or no refreshments

offered

1

0

8 Check to see whether a certified blood bank refrigerator is in use Observe 1 Certified blood bank refrigerator is seen and in use

No refrigerator or not in use10

9 Check whether blood bank refrigerator’s Inbuilt temperature monitoring is working Observe 1 Inbuilt temperature monitoring is working

NO inbuilt temperature monitoring or not working10

10

Check whether temperature monitoring is up to date (and recorded daily). Observe 1 Temperature monitoring is recorded daily and up to date

Temperature is monitored but not up to date or not monitored10

11

Alarm on Blood bank refrigerator is in working order.Check by pushing test alarm button on the front of the refrigerator. (only blood bags should be stored in this fridge)If the alarm is turned off score zero

Observe and test alarm

1

Alarm is turned on and in working orderAlarm is not working or turned off or no alarm

10


12

Check that blood bank reagents are stored in a different refrigerator i.e. they can be stored with other reagents but not in the blood bank refrigerator Observe 1

Blood bank reagents not stored in blood bank refrigerator but are stored in another fridge

Blood bank reagents stored in blood bank fridge or not in a fridge at all

1

0

13**

Are the following tests done in the blood bank?

(If the blood bank is separate to the main laboratory, there should be a second set of reagents i.e. HIV antibody is checked at the general laboratory as well as the blood bank but it is possible that they will have two sets of equipment and reagents)Please comment in remarks box about the situation in the hospital

Verify with register books for the past 6 months

Register books 10

HIV antibodyHepatitis B antigenHepatitis C antigen

Syphilis antibodyABO and Rh blood grouping performed

Cross matching performed using AHG reagents

111115

TOTAL 69 MINUS 10 points if blood sent to laboratory in syringe

MAXIMUM POSSIBLE

SCORE RECEIVED %

1. ORGANISATION OF LABORATORY AND STAFF 12

2. INFRASTRUCTURE, SAFETY AND HYGIENE 25

3. QUALITY OF DOCUMENTATION 7

4. EQUIPMENT, SUPPLIES, AND TRAINING MATERIAL 77


5. TESTS PERFORMED 69

TOTAL SCORE LABORATORY 190


If there is more than one Pharmacy e.g. pharmacy for OPD and a separate one for IPD, an assessment should be performed for both

10. PHARMACY Verified by

MAX SCOR

E SCORING TOTAL

SCORE COMMENTS

Check with Pharmacist what method they use for recording drugs that have been dispensed i.e. do they tally and transpose the total drugs dispensed daily, every three days or every two weeks? If they transpose daily go to question 1, if not, go to question 2

1 Check whether the daily tally (consumption) sheet from two days earlier has been transposed onto the monthly tally sheet. (Please do not go back further then two days. The pharmacist should tally up the drugs daily therefore yesterdays should already be available when you do the assessment)

Daily and monthly

tally sheet10

Tally sheet from 2 days earlier summed and transposed onto monthly tally sheet

Tally sheet from 2 days earlier summed but not yet transposedYesterday’s tally sheet not yet summed

1020

2 Take all OPD prescriptions from 2 days earlier and check whether they have been transposed correctly to daily tally (consumption) sheet . (This may take some time if there have been many patients however all prescriptions need to be checked to get a daily tally). If the hospital does not do this daily, then they get zero

Prescriptions, tally sheet

10

All prescriptions have been transposed to daily tally sheet and totals are correct

one prescription has not been transposed correctlyMore than one prescription has not been transposed correctlyNot able to check as amounts not separated by day or no tally

sheet or don’t do daily

1010

03 Pharmacy has made report of expired drugs to OD

Pharmacy (report includes date of report, name of expired drug, expiry date and quantity, drugs sent to OD – check if they have been sent or are they on the shelf?)

Report to OD 10

Report seen which includes details of drug, expiry date, quantity, drugs no longer in pharmacy (i.e. send to OD)

Report not seen or no report100

4 Check ten stock cards at random (avoid first few and go for middle or end). Check the following columns are completed:

Generic name is recorded Check there is only one dosage i.e. 250mg

separate from 500mg (i.e. one page per dose) Date of entry Date of exit Remaining balance Expiry Date

Check last entry corresponds to last month. Check that amount in the stock book is what is on the shelf

Stock cards 20

All ten stock cards up to date (all columns are completed and last entry is last month) and amount in stock book corresponds with

amount on the shelf (2% error allowed for oral drugs only – IV and vials excluded)

8 or 9 stock cards up to date and complete and amount corresponds with amount on shelf (2% error allowed for oral drugs

only – IV and vials excluded)<8 stock cards are up to date or amount doesn’t correspond with

amount on shelf or incomplete (2% error allowed for oral drugs only – IV and vials excluded)

20

2

0

5 Check five of the drugs just checked above for their expiry dates (i.e. check them on the shelf) to confirm what is written Spot check 10

All drugs are within the expiry date and all expiry dates have been recorded in stock card correctly

All drugs are within expiry date but not all expiry dates have been recorded in stock book

Some drugs expired, no expiry dates recorded in book or not correct

10

2

06 Check expiry date of five additional oral drugs and five Observe 10 No drugs expired 10


additional injectables at random from shelf At least one of the ten drugs expired 0

PHARMACY Verified by

MAX SCOR

E SCORING TOTAL

SCORE COMMENTS

7 Check for the following items

Spot check 20

One point per itemFerrous sulphate or Fe/folate

ParacetamolRifampicin 150mg/Isoniazid 75 mg

PyrazinamideAmoxycillin 250 mg

ORS sachetsCombined oral contraceptive (oestrogen and progesterone)

Artesunate/Mefloquine (oral adult dose)Artesunate/Mefloquine (oral children dose)

Artemether/Artesunate injectable or suppositoryPenicillin G (or other parenteral peniciliin)

Ergotamine/OxytocinHydrallazine

Ophthalmic ointment (antibiotic not steroid)Gauze

Syringes 2 ccSyringes 5 ccNeedles 18 GNeedles 21 G

Butterfly 21 G or smaller

11111111111111111111

8 Check the procedure for availability of drugs (including IV fluids) after hours i.e. for 24 hour and weekend cover (Ask Pharmacist for the procedure i.e. the pharmacist should know whether there is an emergency stock for each ward/OPD (there often isn’t as the pharmacist may be on call instead). It s/he says that there is, then the pharmacist should have a record of what each ward has been given which could be checked i.e. the emergency stock should be separate to the daily stock that the ward asks for. If there is no record then I would choose the option with 2 or 4 points in column on right.

Ask pharmacist 10

Complete emergency stock available 24 hours at each ward and OPD/Emergency Room has complete emergency drugs with own

keys to access drugs as neededPharmacist is on call and available 24 hours (in hospital)

Emergency stock available only in some wardsDifficult to get drugs after hours

10720


9**

Check the list of drugs purchased by the hospital. Check to see whether they are on the essential drug list. Ask who requested the drugs and why they are required. Has the Technical Committee decided to purchase them or the procurement committee? Are there drugs or quantities that seem to be inconsistent with what should be prescribed?

Verify this with Qu 2 (15) of Management section regarding Technical Committee

Essential Drug list,

Mgmt section Qu

2 (15)

10

Drug list is checked by Technical committee; only essential drugs are purchased, request appears to be reasonable

Drug list is checked by Technical committee but non essential drugs are purchased

Drug list is checked by Technical committee but type of drug or quantities do not seem to be necessary/logical or amounts are

very highDrug list is signed by Technical Committee member but cannot

verify whether any discussions by committee e.g. not in minutesTechnical committee is not consulted about list of drugs

purchasedDrugs purchased don’t seem to be necessary (other drugs could

be used in preference)

10

7

2

0

00

TOTAL 110


11. RADIOLOGYVerified by

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

1Check registration book for following: date, name, age sex, site of x-ray Registration

book 5

One point for each categoryDate

NameAgeSex

Site of x-ray2 Are instructions about amount of radiation required per

anatomical site displayed on wall for easy reference for radiographer? Observe 10

Instructions in visible place for easy referencesInstructions available but not seen unless look for them

No instructions seen or found

1010

3Is the radiographer wearing the radiation exposure badge? Observe 10

YesNo (doesn’t have badge towear)

No doesn't wear badge

1000

4

Is the radiation exposure for all radiographers recorded and reported

Log book for radiation exposure, reports to

OD

5

Radiation exposure for all radiographers is recorded and reported regularly i.e. every 6 or 12 months

Radiation exposure is recorded but not reportedNo recording or reporting

510

5 Is there a manual for maintenance? Is there a log book of date of inspection/performance evaluation of the maintenance of the x-ray machine?

Manual and log book 10

Maintenance manual and log book seen and log book up to date i.e. recent (in past 12 months) maintenance

Either maintenance manual or log book found (up to date)No log book or not up to date or no manual exists

1010

6

Check for the following: x-ray machine, x-ray films, cassettes of at least two sizes, developer, alphabet and number set, flim hanger, x-ray viewer, lead apron, sign from pregnant women. Is it easily found or locked in a cupboard? It must also be in good working order

Observe 20

One point if available and one point if in working order or easily available. No point if broken or expired

x-ray machinex-ray films (at least two different sizes)cassettes of at least two different sizes

developer (and not expired)alphabet and number set

flim hangerx-ray viewer lead apron

developing room light (red light)notice informing women who may be pregnant to inform staff (1

pt) and in prominent position e.g. change area or near x-ray area – 1 pt)

1+11+11+11+11+11+11+11+11+1

1+1

7 Are x-rays filed in orderly manner e.g. x-rays have numbers, kept in envelope, filed according to name and have report attached

Observe 10 Filed orderly, have envelope, report includedFiled orderly manner but no report

No filing or no system to filing

1040


RADIOLOGY Verified by

MAX SCOR

E SCORING

TOTAL

SCORE

COMMENTS

8 Are there hand washing facilities for the technician to use after developing the x-ray? This should be in developing room or very close by and should include soap

Observe 10

In developing room, with soapClose to developing room

Not close, no soap

1010

9 Is there a functioning exhaust fan in the developing room? Observe 5 Available and working

Available but not working or not available50

10Is there evidence that the floor is regularly swept and mopped? (currently clean, not much dirt on the floor)

Observe 5


Swept but not mopped Not clean

510

TOTAL 90


12. REFERRAL SYSTEM (Need to check OPD register, IPD registers during ward visits, ambulance including log book, speak with/contact driver. May also need to discuss with triage, cashier and wards to determine the flow of patients who have been referred.

Verified by


SCORE COMMENTS

1 Is there a central register where all OPD patients are recorded (including those that are then admitted?) This register would therefore record EVERY patient who comes to the hospital – OPD, referred from HC to OPD, self referred, emergencies i.e. NO bypassing and a complete record of all patients seen at the hospital. It is possible that the “central register” is at the cashier and if so it is possible that the registration process does not record referrals.Do NOT accept that there is a central register unless you check thoroughly e.g. emergency ward, obstetric ward, triage, cashier, OPD (including HC if the HC has been integrated into RH management) etc

50 YesNo

500

2**

Are referrals from HC recorded in the OPD central register? Check last month’s register to see if any referrals are recorded and today’s OPD patient records.

If there is no central register but patients are recorded in OPD register then the maximum points that can be obtained is only 5

Verify this with OPD Qu 1 (13)

OPD register 20

Central register of ALL patients coming to hospital has referred patients recorded last month and/or patients referred today

recordedReferred patients recorded last month and/or patients referred

today have been recorded in OPD book (but this is not the central register

Only some of today’s referred patients recordedNo records in OPD book or no column to record referrals

20

510

3 Are referrals from HC that are admitted, recorded in OPD central register? Check first five days of last month and today’s OPD patients to see if “referred from” and “referred to” is complete. It is possible that this may not be able to be measured i.e. they may bypass the OPD and be admitted directly to the ward OR they may not routinely record referrals in the register

OPD register 5

Patients referred and admitted have both columns recorded in register (all today’s patients admitted are recorded)

Patients referred and admitted are recorded in OPD register but this is not central register

Only some of today’s referred patients that are admitted are recorded

No records in OPD book or no column to record admission and referred

5

2

1

04 If the OPD register is the central register then add all

referrals to the RH in the OPD in the past month. Add all OPD patients seen and work out % of referred patients are seen at OPD. (This may not be accurate if some patients bypass the OPD or there is no central register – please make comments in box on right)

OPD register

10 >10% OPD patients have been referred5-10% OPD patients have been referred

<5% OPD patients have been referredNo central register therefore data inaccurate 10

510


Referrals to RH last month = Total OPD patients seen in the last month =Total referrals to RH = no. referrals x 100/no. OPD


12. REFERRAL SYSTEM Verified by


SCORE COMMENTS

5 Ambulance – check it is in the hospital, check it has petrol, check emergency kit is available, check the driver is in the hospital (or contact him by phone or radio to see if possible to contact him easily – mock transfer)If the driver is not there it may be difficult to check whether there is petrol in the ambulance, oxygen in ambulanceCheck where the emergency kit is and whether it is possible for you to get it when you are there or is it difficult, the person with the keys is not there etc?

Observe, contact driver

25

Ambulance available, driver on hand (i.e. you speak to him), petrol in car, emergency kit ready at a ward to go with driver,

oxygen in ambulanceAmbulance available, driver not on hand but able to be contacted and at RH within 15 minutes, petrol in car, emergency kit ready at

a ward to go with driver, oxygen in ambulanceambulance not available or no ambulance or driver can’t be found

or no oxygen in ambulance, insufficient petrol to pick up/transfer patient

25

15

06 Is there a written schedule for ambulance duty? Check

whether health staff are on standby duty for 24 hrs services (you have to go and find them – no good checking the schedule – you need to know they are there and they are aware that they are on call for ambulance duty)

Check list of duty, ask partners or

HC to determine

5

Duty list/schedule and duty team availableNo duty list and duty team

50

7 Referral team training: driver(s) and health staff Check whether driver and health staff, esp. nurses were trained on first aid, check curriculum if possible

Ask hospital director and driver and health staff

5

Referral team including driver(s) and health staff, esp. nurses trained on first aid

Only some of them trainedNo training

530

8 Ambulance has communication system that is working i.e. radio installed in ambulance with frequency of various HC and other hospitals written and kept in the ambulance or driver has a phone and phone numbers of HC chief, RH Director, Emergency ward, other hospitals commonly referred to etc written and recorded and kept in ambulance

Observe, check driver 10

Ambulance has radio in the car that works or driver has a phone and a list of frequencies/numbers in the ambulance (as written in

left column)No radio or no phone or no list of phone numbers

100

9 Ambulance log book filled in correctly and up to date (date of transfer, patient name, age, sex, complaint, place of pick up, place of transfer, odometer reading, cost). Underline what they have in their log book

Log book 10

Ambulance has log book and up to dateHas log book but not up to date or not completed correctly or lack

of info collectedAmbulance has no log book

10

20

10 Are fees for ambulance advertised e.g. part of hospital user fee board. If there are different prices according to distance e.g. from HC to RH or from RH to another RH or Phnom Penh then it should be advertised

Check User fess board 10

All amounts for various ambulance trips advertised on user fee board

Only some of the fees advertisedFee not advertised

10 1 0

TOTAL 150


Please do staff questionnaires in different wards and departments e.g. one or two per ward or department only

13. STAFF QUESTIONS (Interview 10 hospital staff during hospital assessment)

Staff 1

Staff 2

Staff 3

Staff 4

Staff 5

Staff 6

Staff 7

Staff 8

Staff 9

Staff 10 TOTAL

WARD of STAFF MEMBER INTERVIEWED

1. Do you know if there are written criteria for distribution of user fees in this hospital? This question refers to how the hospital divides the money amongst staff NOT the 60% available for staff. If the answer is no you can go to Qu 3

Yes = 1No = 0

2. Have you seen them or received a copy of the criteria?Yes = 1No = 0

3. Do you think the criteria for dividing the user fees are fair? i.e. the amount you receive compared to others in this hospital do you think it is fair? If not please explain

Yes = 1No = 0

4. Do you know whether the amount you receive is correct? Yes = 1No = 0

5. If you have a complaint about the hospital or your work, do you have a way to make complaints to your supervisor or to the hospital management?

Yes = 1No = 0

6. Does your supervisor take the complaint to the management team?

Yes = 1No = 0

7. Do you think hospital management listens to the staff and tries to solve problems? i.e. do they take action and then provide you with feedback regarding the complaint made?

Yes = 1No = 0

8. Do you know of any staff member who didn’t obey the staff regulations, who has been disciplined? Please give some reasons for disciplinary action

Yes = 1No = 0

9 (a). If so what? Have to meet supervisorYes = 1No = 0

Have to meet DirectorYes = 1No = 0


Change positionYes = 1No = 0

Reduction in incentive/user fee contributionYes = 1No = 0

No disciplinary action takenYes = 1No = 0

Warning letter(s)Yes = 1No = 0

Other

Please transpose the above totals to the table below

STAFF INTERVIEWS Verified by No. staff interviewed

TOTAL SCORE of

+ve answer% COMMENTS

1. Do you know if there are written criteria for distribution of user fees in this hospital? Staff interview

2. Have you seen them or received a copy of the criteria?Staff interview

3. Do you think the criteria for dividing the user fees are fair? i.e. the amount you receive compared to others in this hospital do you think it is fair? If not please explain Staff interview

4. Do you know whether the amount you receive is correct? Staff interview

5. If you have a complaint about the hospital or your work, do you have a way to make complaints to your supervisor or to the hospital management? Staff interview

6. Does your supervisor take the complaint to the management team?Staff interview

7. Do you think hospital management listens to the staff and tries to solve problems? i.e. do they take action and then provide you with feedback regarding the complaint made? Staff interview


8. Do you know of any staff member who didn’t obey the staff regulations, who has been disciplined? Staff interview

For those staff disciplined: No. staff knowing staff member being disciplined i.e.

answered yes at Qu. 8


Have to meet supervisorStaff interview

Had to meet Director Staff interview

Change position Staff interview

Reduction in salary Staff interview

No disciplinary action taken Staff interview

Warning letter(s) Staff interview

Other Staff interview


14. HOSPITALINDICATORS These indicators are part of the MOH RH plan i.e. each hospital should collect this data routinely every yearUsing the HO2 statistics from the previous year it is possible to work out most of these indicators however additional information will have to be provided by RH (if they collect it)Those marked with an asterisk ** may be difficult to complete without assistance from the hospital

Health Service Delivery1. No. hosp admission per 1000 = no. pts discharged x 1000/population of OD

2. No. children 0-59 months admitted per 1000 children = no. children 0-59 months discharged x 1000/no. children 0-59 months in OD (0-59 months estimated to be 12.8% of the population)

** 3. No. women admitted per 1000 women = no. women discharged x1000/no. women in OD (total women = 51.8% of population)This may be difficult to measure in some hospitals as it is likely that hospitals may not give no. of women admitted but rather total number of patients admitted/discharged. However, if registration books are set up correctly, they should be able to give the total no. discharges per month including by sex.

4. BOR excluding TB pts = no inpatient days (excluding TB) x 100/no. bed (excluding TB) x 365

5. BOR at maternity = no. inpatient days at maternity x 100/no maternity beds x 365

6. BOR at Paediatric ward= no. inpatient days at paediatrics x 100/no maternity beds x 365

7. BOR at TB ward = no inpatient days at TB ward x 100/no TB beds x 365


8. Caesarian Section rate = no C/S x 100/total no. expected pregnancies (no. expected pregnancies = 3.8% of total population)

9. No. major surgical interventions (including C/S)

10 . % pts referred from HC = no patients at RH referred from HC x 100/total no. pts at RH

Quality Improvement** 11. % pts prescribed Antibiotics = no. pts (new and old) prescribed Antibiotics x 100/total no. pt It is possible that this will be difficult or not possible to collect. Some hospitals may collect this data – try pharmacy or check MOH supervision reports

12. Mortality rate = no. deaths x 100/no patients discharged

13. Average length of stay excluding TB pts = no inpatient days (excluding TB)/no patients (excluding TB)

Human Resource Development14. Total no. technical staff (including floating staff)

15. No. qualified surgeons= no. Surgeons working in hospital

16. No. medical doctors and medical assistants working in the hospital= no Drs/MAs working in hospital

17. No. secondary midwives = no midwives working in hospital including floating staff


** 18. No. staff received clinical training during the year = no. trained including floating staff

Health Financing

19. % government budget for running costs received (cash and kind) = total income chapters 11 and 13 x 100/total RH budget for chapters 11 and 13

20. % government budget for running costs received (cash and kind) by June 30 = total income chapters 11 and 13 (cash and kind by June 30)/total RH budget for chapters 11 and 13

21. Total income from user fees (Riels)

22. % Patients exempted or fees paid by equity fund = total no. pts exempted or fee paid by equity fund x 100/total no. pts


15. SUMMARY PAGE OF HOSPITAL ASSESSMENTHOS

PMGT

PAED

OBST MED SUR

G TB OR OPD LAB PHAR RAD REF

STAFF

I/VTOTA

LADMINISTRATION x x x x x x x x x x x x

COMMITTEES x x x x x x x x x x x xINFRASTRUCTURE AND LOGISTICS x x x x x x x x x x x x

FINANCE x x x x x x x x x x x xHIS x x x x x x x x x x x xORGANISATION AND PRESENTATION OF STAFF AND WARD

x x x x x

EQUIPMENT AND SUPPLIES x x x x x

QUALITY OF DOCUMENTATION AND PROCEDURES

x x x x x

PATIENT VERIFICATION x x x x x x x

GENERAL HYGIENE x x x x x x


TOTAL POSSIBLE 565 670 1040 665 700 510 210 310 190 110 90 150 N/A 5210

TOTAL SCORED

PERCENTAGE


10. ANNEX 1 LIST OF DOCUMENTS REQUIRED TO PERFORM HOSPITAL ASSESSMENT

The following documents and information should be provided by hospitals to assist with the assessment

Basic information about the hospital e.g. list of all hospital departments/services offered at the hospital, no. beds, no. staff

Hospital annual work plan, current monthly or quarterly plan and any amendments. This may need to also include the last years annual work plan if assessment is taking place early in the year when no review has been done

Review of hospital work plan e.g. 3 or 6 monthly review or review from the past year as well as annual review of work plan if assessment carried out early in the following year when no review has been performed

Minutes of meetings for past 6 months for the following (indeed if they have minutes):

o Hospital managemento Financing Committeeo Monitoring and Evaluation sub-committeeo Procurement and Logistics sub-committeeo Morning meetingso Technical committee o Disciplinary committeeo General hospital meetingo Death audit meetingso Any other meetings which are regular/irregularo Meetings with HC Chiefs (if possible)

Terms of Reference for all above committees and any other committees which exist in the hospital

Intergrated supervision reports for the past 6 months Staff Schedule for current month (day and night for all staff) for

each ward and department Organisational chart for entire hospital (if existing) Up to date staff list with positions held (including details of any

staff away for extended training) Staff daily attendance book(s) and ward daily attendance books if

available at that hospital Copy of staff regulations Copy of any disciplinary measures taken (meeting with staff,

evidence of reduction in salary, position in hospital changed, letter to PHD to take action etc)

Job descriptions of Director, Vice, Administrator, Chief of Service, Chief of Ward, Chief Nurse, Laboratory technician, cook, cleaner, driver

User Fee distribution criteria (details on how 49% is divided between staff and how remaining 50% is used)

Price of services for OPD, IPD and all investigations

Hospital Assessment Tool Annexes 133

Exemption criteria for those unable to pay user fees Previous month’s financial report and receipt books (may be

recorded by service/dept) Yearly expenditure for User Fees and other budgets if available HIS for the past six months i.e. monthly data so you can check

certain months if necessary HIS for the past year (to check indicators) Essential Drug List for hospitals Rational Drug Use Supervision visits Referral Hospital Treatment Guidelines National Referral Guidelines (which includes Ambulance

Emergency Kit contents) Updated 6 month TB treatment guideline Malaria treatment guidelines CPA guidelines (for reference) Health Centre Manual (includes treatment guidelines) Laboratory Quality Control reports – both internal and external

(CNM, CENAT, NIPH, other) Maintenance schedule for x-ray and sterilising department and

records of maintenance performed Ambulance log book and maintenance schedule Other maintenance schedules e.g. steriliser, x-ray,

echo/ultrasound etc

These documents should be prepared by the hospital prior to assessment so the assessment can proceed smoothly and without delay.


11. ANNEX 2 PRACTICE PRE TB WARD ASSESSMENT

Assessment of TB ward is quite difficult as there is much paperwork that needs to be scrutinised. Checking the registration book can be particularly complicated as TB treatment extends over 6 months (and sometimes longer) making it difficult for the assessor to check quickly.

I recommend that ALL assessors first practice the accompanied TB mock registration book exercise to see the problems one might encounter prior to visiting and assessing the TB ward.

The question relating to the registration book in the TB assessment is Section 3, Question 1 which states:

‘Check the register book for registration of patients 6 months earlier (this is because these patients should have done at least 2 month and 6 month control sputums). If no patients registered 6 months ago, check those that registered 5 months ago.

Check the register is Available Complete – Each entry needs to be thoroughly checked i.e. if

control sputum is required, has it been completed in registration book (check the dates)? Has each column been completed for the current time?

Up to date Correct categories – check that if sputum is positive they are

categorized as smear positive TB; if smear negative, EPB or SM- Sputum recorded

If the patients should have finished treatment, have all columns been entered correctly?’

Using the mock registration book please go through each of the above sections. (In the assessment you are only supposed to do the previous 6 months but for practice, please start at number 1 and finish at number 69).


Date Pt No.

Name

AgeAddres

s

Detecting facility Rx

start date

Regimen

Type Pt

Category of Patient Result of sputum smear examination Result of treatment

pre counselling befor

e VCCT

refer

VCCT

HIV result

Cotrim

prev Rx

HBC ARV Rem

arksM F RH H

CNew

Relapse

Transfer in

RAD

Failure

Others

pre-Rx

2(3 mths) 5 6 Cure

dRx

completed

died failure

defaulted

Transferred out

28.1.04 1

35

Chrokleav

Chiphu

Bavet 2.2.04 Cat 1

BK+ √

2 bars 0 0 0

2.7.04 134 410

676

1050

19.2.04 2 Tabeb

Chiphu

Bavet

20.2.04 Cat 1 EP √

17.8.04

Lymphadenopath

y

24.2.04 3

67 Tabeb

Chiphu

Bavet

24.2.04 Cat 1 EP √

28.2.

04

Pott's disea

se

24.2.04 4

72 Tabeb

Chiphu

Bavet

26.2.04 Cat 1 EP √

1.3.04 5 49 Tabeb

Chiphu

Bavet 9.3.04 Cat 1

BK+ √

1+ 0 0 0

4.9.04 307 616

1056

2203

5.3.04 638

Srahvong

Chiphu

Bavet

16.3.04 Cat 1

BK+ √

1+ 0

2.6.04

HC Samngok

290 601

25.3.04 7

77 Tapev

Chiphu

Bavet 2.4.04 Cat 1

BK+ √

1+ 0 0

30.9.04 427 742

2346

1.4.04 8 40

Chhit Leu

Chiphu

Bavet 2.4.04 Cat 3 BK- √

0

28.9.04 X ray448

21.4.04 9

42 Tapev

Chiphu


0

30.10.0

4 X ray550

4.5.04 10 55

Trapaing Plong

Chiphu

Bavet

21.5.04 Cat 1

BK+ √

1+ 0 0 0

600 1023

2452

2630

14.6.04 11

35 Thnanh

Chiphu

Bavet

15.6.04 Cat 3 EP √

13.12.0

4 bone

16.6.04 12

59 Tabeb

Chiphu

Bavet

21.6.04 Cat 1 BK- √

0

17.12.0

4 X ray798

18.6.04 13

39

Prey Veng

Chiphu

Bavet

19.6.04 Cat 2

BK+ √

3+ 0 0 0

18.3.04 798 86

197

413

21.6.04 14

45 Takev

Chiphu

Bavet

20.6.04 Cat 1

BK+ √

2+ 0 0 18.12.

04 107 84

231

28.6.04 15

68 Tabeb

Chiphu


0

2.1.05 X ray860

5.7.04 1667 Tabeb

Chiphu

Bavet 4.5.04 Cat 1

BK+ √

2+ 0 0 0

Transfer from Chiphu RH 05.7.04

569 904

2337

2451

13.7.04 17

67

Chrokleav

Chiphu

Bavet

15.7.04 Cat 1

BK+ √

3+ 0 0 015.1.0

5 973 2210

2686

2841

13.7.0 18 6 TapevChiphu

Bavet 16.7.0 Cat 1 BK √ 1+ 0 0 0 16.1.0


4 1 4 + 5972 2274

2085

2842


DatePt No.

Name

AgeAddres

s


start date

Regimen

Type Pt



e VCCT

refer

VCCT

HIV result

Cotrim

prev Rx

HBC ARV Remar

ksM F RH H

CNew

Relapse

Transfer in

RAD

Failure

Others

pre-Rx

2(3 months)

5 6 Cured

Rx comple

teddied failu

redefaul

tedTransferred out

14.7.04 19

26 Tabeb

Chiphu

Bavet

17.7.04 Cat 1

BK+ √

2+ 0 0 017.1.0

5 1018 2272

2684

2836

13.8.04 20

28 Thnanh

Chiphu

Bavet

14.8.04 Cat 3 EP √

Lymphadenopath

y

16.8.04 21

33 Porpev

Chiphu

Bavet

25.8.04 Cat 1

BK+ √

1+ 0 0 0

X ray2142 2450

2838

230

23.8.04 22

41

Chrokleav

Chiphu

Bavet

25.8.04 Cat 1 BK- √

0

20.2.05 486

2.9.04 23 44 Tabeb

Chiphu


1+ 0 0 0

1.3.05 2204 2504 54

231

10.9.04 24 6 Kandal

Chiphu

Bavet

10.9.04 Child EP √

9.3.05

Lymphadenopath

y

14.9.04 25

20 Kandal

Chiphu

Bavet

15.9.04 Cat 1 EP √

14.3.05

Pott's disea

se

25.10.04 26

61 Tapev

Chiphu

Bavet

16.9.04 Cat 1

BK+ √ √

1+ 0 0 014.3.0

5 15 2545232

301

5.10.04 27

65

Bavet Leu

Chiphu

Bavet 8.8.04 Cat 1 BK- √ √

3.2.05 2061

17.10.04 28

40

Prey Lvea, Svay Reing

Chiphu

Bavet

18.10.04 Cat 2

BK+ √

2+ 0 0 0

174 103

261

986

21.10.04 29

41

Chrokleav

Chiphu

Bavet

29.10.04 Cat 1 BK- √

0

2454

21.10.04 30

40

Bavet Kamdal

Chiphu

Bavet

29.10.04 Cat 1

BK+ √

3+ 0 0 026.4.0

5 2455 2829

303

559

2.11.04 31

44

Thnanh Bati

Chiphu

Bavet

3.11.04 Cat 1

BK+ √

1+ 0 0 0

1.5.05 2518 2828

384

560

4.11.04 32

59 Tapev

Chiphu

Bavet

6.11.04 Cat 1

BK+ √

2+ 0 0 0

4.5.05 2525 2877

302

564

6.12.04 33

50 Thnanh

Chiphu

Bavet

8.12.04 Cat 3 BK- √

0

21.1.05 2644

6.12.04 34

62

Prey Angkon

hChiphu

Bavet

10.12.04 Cat 2

BK+ √

3+ 0 0

5.9.05 2843 2916

309

7.12.04 35

26 Takev

Chiphu

Bavet

10.12.04 Cat 1

BK+ √

2+ 0 0 0

8.6.05 2906 124

618

936

10.12. 36 3 Prey Chiphu

Bavet 15.12. Cat 1 EP √ 10.6.05


04 8 Veng 04


DatePt No.

Name

AgeAddres

s


start date

Regimen

Type Pt



e VCCT

refer

VCCT

HIV result

Cotrim

prev Rx

HBC ARV Remar

ksM F RH H

CNew

Relapse

Transfer in

RAD

Failure

Others

pre-Rx

2(3 months)

5 6 Cured

Rx comple

teddied failu

redefaul

tedTransferred out

19.12.04 37

41

Svay Rieng

Chiphu

Bavet

24.12.04 Cat 1

BK+ √

3+ 0 0 010.6.0

5 173 209

433

109

19.12.04 38

56

Kampong

ChamChiphu

Bavet

24.12.04 Cat 1 BK- √

24.12.05 39

17

Nak Leung

Chiphu

Bavet

29.12.04 Cat 3 EP √

25.12.05 40

61

Kampong Speu

Chiphu

Bavet

26.12.04

1.1.05 4149 Kampot

Chiphu

Bavet 2.1.05 Cat 2

BK+ √

2.1.05 42 51

Steung Treng

Chiphu

Bavet 4.1.05 Cat 1

BK+ √

2+ 0 0 0

2.7.05 19 149292 63

4.1.05 43 62 Tapev

Chiphu


0

15.1.

05 2775

13.1.05 44

43 Tapev

Chiphu

Bavet

14.1.05 Cat 1 BK- √

0

2784

1.2.05 4536 Tabeb

Chiphu

Bavet 1.2.05 Cat 1

BK+ √

1+ 0 0 030.7.0

5 160 433

951

1088

16.2.05 46

62 Tapev

Chiphu

Bavet

16.2.05 Cat 1 BK- √

0

14.8.05 233

21.2.05 47

32 Tabeb

Chiphu

Bavet

22.2.05 Cat 1 EP √

0

24.2.

05

Lymphadenopath

y

14.3.05 48

52 Tabeb

Chiphu

Bavet

14.3.05 Cat 1

BK+ √

2+ 0 0 0

309 736

950

1273

14.3.05 49

26

Monk, Svay Rieng

Pagoda Chiphu

Bavet

14.3.05 Cat 1 EP √

Lymphadenopath

y

14.3.05 50

35

Prey Yeay

Chiphu

Bavet

14.3.05 Cat 2

BK+ √

2+ 0 0

604 609

1023

17.3.05 51

53

Bavet Leu

Chiphu

Bavet

17.3.05 Cat 1 EP √

21.3.05 52

75 Kandal

Chiphu

Bavet

21.3.05 Cat 1 BK- √

0

378

4.5.05 53 53 Tapev

Chiphu


0

X ray2511

12.5.05 54

68

Bavet Leu

Chiphu

Bavet

14.5.05 Cat 1

BK+ √

2+ 0 0 0

708 993

1405

1577


DatePt No.

Name

AgeAddres

s


start date

Regimen

Type Pt



e VCCT

refer

VCCT

HIV result

Cotrim

prev Rx

HBC ARV Remar

ksM F RH H

CNew

Relapse

Transfer in

RAD

Failure

Others

pre-Rx

2(3 months)

5 6 Cured

Rx comple

teddied failu

redefaul

tedTransferred out

27.5.05 55

36

Bavet Leu

Chiphu

Bavet

28.5.05 Cat 1 EP √

3.6.05 5653

Bavet Leu

Chiphu


0

801

21.7.05 57

60 Tabeb

Chiphu

Bavet

20.5.05 Cat 1

BK+ √

3+ 0 0 0

754 1101

1407

1636

23.7.05 58

51 Tabeb

Chiphu

Bavet

23.7.05 Cat 1 BK- √

X ray

13.8.05 59

26

Bavet Leu

Chiphu

Bavet

13.8.05 Cat 1 BK- √

0

1162

30.8.05 60

54 Tabeb

Chiphu

Bavet

30.8.05 Cat 1 BK- √

0

1304

7.9.05 6142 Tapev

Chiphu

Bavet 7.9.05 Cat 1

BK+ √

1+

1337

14.9.05 62

69 Tapev

Chiphu

Bavet

14.09.05 Cat 1 BK- √

0

X ray

23.9.05 63

64 Tabeb

Chiphu

Bavet

23.9.05 Cat 1 BK- √

2+

1402

8.10.05 64

63 Tapev

Chiphu

Bavet

8.10.05 Cat 1 BK- √

0

1408

8.10.05 65

67 Kandal

Chiphu

Bavet

8.10.05 Cat 1 BK- √

0

1461

6.10.05 66

74

Chrokleav

Chiphu


0

991

12.10.05 67

29 Kandal

Chiphu

Bavet 3.9.05 Cat 1

BK+ √

1+

88

21.10.05 68

44 Tabeb

Chiphu

Bavet

21.10.05 Cat 1

BK+ √

3+

1533

21.10.05 69

50

Bavet Leu

Chiphu

Bavet

21.10.05 Cat 1

BK+ √

3+

1540


Once you have checked each patient, please check with the answers below.

Patient

Number

Problem

4 No completion date of treatment7 No final control sputum 10 No record of completion of treatment14 No final smear but have recorded a cure16 No cure date21 No cure date23 Incorrect category – Sputum shows positive

result but categorised as BK-27 No sputum result only code

28Category 2 patient but ticked ‘new’ rather than relapse or return after defaultNo ‘cure’ date

29 No completion date

34Category 2 but ticked ‘new’ rather than relapse or return after defaultTicked ‘cure’ but no final control sputum

38 No initial sputum40 No category

No initial sputum41 Category 2 – no sputum controls44 No completion date48 No cure date50 Category 2 patient but ticked ‘new’ patient rather

than relapse or RADNo final sputum

51 No completion of treatment54 No cure date55 No completion date56 No completion date57 No cure date58 No initial sputum61 No 2 month sputum control67 No 2 month sputum control

Using the scoring for the above question this hospital would receive the following results:

Available – 5 points Complete – 0 points as many patients don’t have their outcome

recorded Up to date – The last entry is Oct 21, 2005 therefore if it is now

October 24 or 25 and there is no entry, please check the patient TB cards. If there is a new patient then this registration book is not up to date.


Correct categories – one patient was not put in the correct category therefore 0 points

Sputum recorded – not all sputums are recorded therefore 0 points

Total points (assuming the registration book is up to date): 5 points out of 30.Please be vigilant when you check the registration book – you can’t hurry it – you must take your time!

12. ANNEX 3 VERIFICATION OF QUESTIONS BETWEEN WARDS AND DEPARTMENTS

Assessing for Sections to Verify – Check A against BA B

Staff schedules i.e. Admin should not have an up to date copy of the schedules (10 pts) if all wards do not have copies of schedules


Paediatric Section1 Qu (2)Obstetric Section1 Qu (2)Medical Section1 Qu (2)Surgical Section1 Qu (2)TB Section1 Qu (2)Operating Room Section1 Qu (2)OPD Section1 Qu (4)Laboratory Section 1 (Qu 1)

Attendance records of staff - cannot score 5 pts on Management Section 1, Qu 7 (Daily register is up to date today and corresponds to schedule) UNLESS wards scored 5 pts on previous question above regarding staff schedules up to date AND staff are all present at time of ward visit


Above questions and the following:

Paediatric Section1 Qu (3)Obstetric Section1 Qu (3)Medical Section1 Qu (3)Surgical Section1 Qu (3)TB Section1 Qu (3)Operating Room Section1, Qu (3)OPD Section1 Qu (6)Laboratory Section 1 (Qu 2)

Disciplinary action Management section 1 Qu (9)

Staff Question no. 8


Technical Committee deciding on which drugs to purchase for hospital

Management Section 2 Qu (15)

Pharmacy Qu 9

Water storage available for back up - CAN’T score 10 on management section if one of the wards does not have back up supply

Management Sect 3 Qu (6)

Paediatric Section 5 Qu (3)Obstetric Section 5 Qu (3)Medical Section 5 Qu (3)Surgical Section 5 Qu (3)TB Section 5 Qu (4)OPD Section 5 Qu (3)Operating Room Section 5 Qu (4)

Adequate water supply for patients and relatives e.g. for toilets and washing clothes - CANNOT score 10 if patients say there is inadequate water supply


Paediatric S 4 Qu (7) Obstetric S 4 Qu (6)Medical S 4 Qu (8)Surgical S 4 Qu (8)TB S 4 Qu (7)

Hospital kitchen available and in use

Management Sect 3 Qu(8)


Relative kitchen available and in use

Management Sec 3 Qu(9)


Provision of receipts to patients


Paediatric S 4 Qu (12) Obstetric S 4 Qu (11)Medical S 4 Qu (13)Surgical S 4 Qu (13)OPD S 4 Qu (3)

Receipts provided to patients – CANNOT score 10 in Management if not verified by all wards


Paediatric S 4 Qu (12) Obstetric S 4 Qu (10)Medical S 4 Qu (12)Surgical S 4 Qu (12)OPD S 4 Qu (3)

Exemption of patients - CANNOT score 10 in management section if patients do not verify exemptions were




explained OPD S 4 Qu (2)Distribution of user fees to staff


Staff Qu 3 to 4

HIS data and recording of referrals to wards


OPD S 1, Qu (2)OPD S 1, Qu (13)OPD Qu 3 (2) and (4)Referral Qu 2 and 3Paediatric Se 3 Qu (4)Obstetric Se 3 Qu (4)Medical Se 3 Qu (4)Surgical Se 3 Qu (4)

HIS data and all referrals to hospital


OPD S 1, Qu (13)OPD Se 3 Qu (2) and (4)Referral Qu 3

New Admission sheets- ward may say that only have admission sheets in OPD but in fact some wards may have them (and each ward should have them e.g. Obstetric patients may go directly to Obst ward if in labour)

OPD Sec 1 Qu (12) Paediatric Section1 Qu (7)Obstetric Section1 Qu (7)Medical Section1 Qu (7)Surgical Section1 Qu (7)

Recording of referrals to RH in OPD central register

OPD Sec 1 Qu (13) Referral Qu 2

HIS data of referrals to each ward. If there is no score at 3 (7) then there should also be no score at 3 (15) option 2 regarding registration book having referral documented

Paediatric Sec 3 Qu(7) Paediatric Sect 3 Qu (15)


Obstetric Sec 3 Qu(7) Obstetric Sec 3 Qu(17)

If there is no score at 3 (7) then there should also be no score at 3

Medical sec 3 Qu (7 ) Medical Sect 3 Qu (16)


(16) option 2 regarding registration book having referral documentedIf there is no score at 3 (7) then there should also be no score at 3 (17) option 2 regarding registration book having referral documented

Surgical Sec 3 Qu (7) Surgical Sec 3 Qu(17)


TB section 3 Qu (2) TB Sect 3 Qu(7)

Toilets locked and with water – if the toilets are locked then the next question, whether there is enough water is not relevant

Paediatric Sect 5 Qu (4)Obstetric Sect 5 Qu (4)Medical Sect 5 Qu (4)Surgical Sect 5 Qu (4)TB Sect 5 Qu (5)

Paediatric Sect 5 Qu (5)Obstetric Sect 5 Qu (5)Medical Sect 5 Qu (5)Surgical Sect 5 Qu (5)TB Sect 5 Qu (6)

Verify with finance section whether funds have been spent on refreshments for blood donors

Laboratory tool Section 7, Qu 7

Finance section

Verify with laboratory staff that they distil water and provide it to the steriliser

OR/CSSD section 4, Qu 4

Laboratory staff/records of distilling


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