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HEALTH CENTER/CLINIC QUALITY SUPERVISION CHECKLIST

February 2016

HEALTH CENTER/CLINIC QUALITY SUPERVISION CHECKLIST

Province: _______________________________________________________________________________District: ________________________________________________________________________________Health facility: ___________________________________________________________________________Number of beds: ________ Catchment area population: __________________________________________Date of supervision: ______________________________________________________________________

Name of supervisors and designationNo. Name of supervisor Designation12345

I. Facility Staffing

STAFF Establishment In post Vacant Duration of vacancyRGNRGN with midwifery PCN EHTNurse aidesGeneral handsOther (Non-medical staff or unqualified staff)

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Date received by

For RBF use:% Structural score and % Management & planning score (35% of Weight)

% Clinical care score (65% weight): ………....

Final Combined Score from Database: ……....

ASSESSMENT SUMMARY

I. STRUCTURAL SECTION

Available Points

Number of composite indicators

Applicable valid points this quarter

Number of applicable composite indicators this quarter

Total points scored

Structural indicators in general compound of the clinic

21 11

Structure indicators in OPD, Labour ward/Maternity and Inpatient/Observation departments

29 8

TOTAL 50 19II, MANAGEMENT & PLANNING SECTION

Available Points




Total points scored

Administration, finance and planning

14 6

Community services 5 3Environmental health services 10 4Infection control and waste management

11 5

Pharmacy 32 4Outpatient department (OPD) 12 4Extended Program Immunization (EPI)

17 8

Maternity ward 11 7Observation/in patients services 1 1Health Information Management System

14 4

TOTAL 127 46III. CLINICAL MANAGEMENT SECTION

Available Points




Total points scored

1C.OPD/ consultation area 18 32C. ANC-PNC Best practices 60 103C. Maternity waiting home 6 14C. HIV-PMTCT 24 45C. Ambulatory management diarrhoea, pneumonia 48 86C. Delivery best practices 66 117C. Management obstetric complications 42 7TOTAL 264 44

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I. STRUCTURAL SECTION

Indicators

I.1. Structural indicators in the general compound of the clinic

*Please give a score for each of the criteria under each indicator as per the criteria in the left column*N.B. The items highlighted in bold are the indicators

Score:1: if all criterion have been met/ recorded0: if all criterion have not been met/ not recorded

1S Outside appearance (when arriving at the clinic ):

1S.1 -Visible sign post

1S.2 -Fence/wall: in good condition and gate with clearly written emergency contact number/s and service hours

1S.3 -A bell available and national flag displayed and in good state

2S Maintenance of the ground:

2S.1 -Ground clean with no litters and/or stagnant water and the grass cut

2S.2 -No waste and dangerous objects in courtyard such as needles – syringes –gloves – used cotton wool, etc

3S Outside appearance of buildings:

3S.1 -External appropriate wall finishing (painting/bricks/rough plastering)

3S.2 -Roof intact, presence of well-maintained rain gutters and,

4S Availability of a garbage bin in ground:

4S.1 -Bin with lid accessible to clients and not more than ¾ full

5S Presence of sufficient and clean latrines/toilets:

5S.1 -Minimum of 3 toilets: 1 male, 1 female, 1 staff offering privacy

5S.2 -Recently clean without visible fecal material and without smell

5S.3 -Hand washing facility with soap available near the toilets

6S Lighting system

6S1 -Electricity for 24 hours a day, and 7 days a week:Source of electricity: ZESA with backup system of either generator or solar energy and/or inventors.

7S Firefighting System:7S.1 -Fire extinguishers available, accessible, functional and serviced

7S.2 -A clearly marked firefighting assembly point and procedure: Ask staff member on firefighting procedure

8S Waste Management system: Fenced and lockable disposal area

8S.1 -Ottoway pit with lid, not full and functional

8S.2 -Incinerator ( lined with bricks) and functional

8S.3 -Rubbish pit: 2-3 metres deep without infected non decomposable objects (non – biodegradable)

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Indicators

I.1. Structural indicators in the general compound of the clinic


Score:1: if all criterion have been met/ recorded0: if all criterion have not been met/ not recorded

9S Bathing facilities and waste water drainage system

9S.1 Appropriate drainage of waste water (presence of septic tank or connected to local sewage)

9S.2 Shower with either running water or container of at least 100 litres

10S Referral service-Availability of means of communication:

10S.1 -Radio or mobile phone with airtime or landline for communication

11S Transport plan for emergency referrals:

11S.1 -Transport plan for emergency referrals and/or contingency plan (in case of unavailability of ambulances from hospitals) included in the planTOTAL POINTS THIS QUARTER: (MAXIMUM AVAILABLE POINTS: 21)

Indicators

I.2. STRUCTURAL Indicators In OPD, Maternity/Labour ward and Inpatient/Observation Departments

Score 1: if all criterion have been met/ recorded0: if all criteria have not been met/ not recorded


OPD

12S Good conditions in waiting area, meeting minimum standards:

12S.1 -With sufficient benches and / or chairs (according to average daily attendance calculated using attendance over a week)

12S.2 -Adequate ventilation of waiting area:

If open space: with a shade or roof supported by brick or metal pillars orIf closed space: windows should measure at least 1/10 of floor area and at least ½ of window area should be openable.

13S Displaying of free service sign and/or service fee charges:

13S.1 -Free services sign or service fee charges (if any) displayed and easily visible for patients

13S.2 -Displayed in local vernacular?

OPD Labour ward

Inpatient

14S Inside appearance of building and its cleanliness14S.1 -Walls, Floors and Ceiling / roof clean and in good condition (no leaks,

cobwebs) and floors polished ( when applicable)14S.2 -Doors with locks and closing properly14S.3 -Curtains on windows or non- transparent glass and screen

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Indicators

I.2. STRUCTURAL Indicators In OPD, Maternity/Labour ward and Inpatient/Observation Departments

Score 1: if all criterion have been met/ recorded0: if all criteria have not been met/ not recorded


OPD

14S.4 -Clean and with good ventilation without bad smell?

OPD Labour ward

15S Availability of waste management supplies and their utilization:

15S.1 -Bin with plastic liners + sharps containers available and not more than ¾ full

16S Hand washing facilities:

16S.1 -Hand washing facilities with soap available at accessible points for outpatient and/or a functional water point and/or at least 50 litres reserve with soap available in delivery room

Labour ward17S Delivery bed:-

17S.1 -In good state (not broken, mattress not torn) and covered with a clean sheet and Macintosh

Labour ward Inpatient

18S Availability and status of furniture:

18S.1 -Beds, mattresses (covered in plastic), bed sheet and bed side lockers available and in good state

18S.2 -Mosquito nets available and in good state? (In malaria endemic areas)?N/A in non- malaria endemic area

19S Access to drinking water and space between beds:

19S.1 -Safe drinking water is accessible

19S.2 -Sufficient space between beds (at least 1m between beds)

\ TOTAL POINTS THIS QUARTER: (MAXIMUM AVAILABLE POINTS: 29)

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II. MANAGEMENT AND PLANNING: STAFF, POLICY, GUIDELINES, MEDICINES & SUPPLIES & Vaccines

Indicators

II.1. ADMINISTRATION, FINANCE AND PLANNING*Please give a score for each of the criteria under each indicator as per the criteria in the left column*N.B. The items highlighted in bold are the indicators

Score: 1: if all criterion have been met/ recorded 0: if all criteria have not been met/ not recorded

1M Mission statement, vision, values and patient charter

1M.1 -Displayed in accessible area and easily readable ( should be health facility specific)

2M Catchment area map, spot map, monitoring graphs, demographic data and list and mapping of community based workers:

2M.1 -Catchment area maps with current catchment population target population for services calculated correctly and displayed

2M.2 -Up to date monitoring graphs for different services showing trends displayed and health care providers know their interpretations ( ask the health care provider on duty)

2M.3 -Up to date list of community based workers (VHWs, HBC givers) showing those that are active available and displayed

3M Finance, accounting and procurement

3M.1 -Bank statements, receipts, invoices, etc available and filed in clearly labelled files

3M.2 -Procurement procedures being followed while purchasing items (Ask for one purchased item and check whether it was purchased according to the procedure)

3M.3 -Management book, inventory/asset register, maintenance book available

4M Staff duty roster, current practising certificates (nurses and EHT), staff leave calendar and clock in register:

4M.1 -Staff duty roster, staff leave calendar and clock in register complete, up to date and displayed on the wall where all staff can see

4M.2 -Current practising certificates for nurses and EHTs available in the HR files

5M Documentation of activities/ Operational Plan

5M.1 -Staff minute book/file and HCC meetings available, well filed and up to date

5M.2 -Quarterly review and annual/operational plan and annual progress report available and up to date

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6M Health education plan/ diary, and reports at the facility:

6M.1 -Health education plan/diary with clear topics, target audience (in which number of audience are clearly stated and disaggregated by sex) and dates when they will be presented available

6M.2 -Topics related to current health problems

6M.3 -Report/s on health education session delivered available

TOTAL POINTS THIS QUARTER: (MAXIMUM AVAILABLE POINTS: 14)

Indicators

II.2 COMMUNITY SERVICES


Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded

7M School health programme:

7M.1 -School health programme available

7M.2 -Reports and data on activities done available

8M VHW, HBC activity reports:

8M.1 -Monthly reports and minutes of meetings available

9M Domiciliary visits to patients:

9M.1 -Reports on visits available in register

9M.2 -Visits categorized according to patients’ condition (e.g. chronically ill, PNC and ANC)TOTAL POINTS THIS QUARTER: (MAXIMUM AVAILABLE POINTS: 5)

II.3 ENVIRONMENTAL HEALTH SERVICES

10M Participatory community health and hygiene education activities:

10M.1 -Availability of plan11M.2 -Report of any sessions of education conducted with available

11M Epidemics and disease surveillance:

11M.1 -Contact tracing forms, and disease surveillance protocols available

11M.2 -Spot map showing recent or suspected out breaks with clear markings displayed

11M.3 -Follow ups and contact tracing (look in registers) on possible or confirmed outbreaks made: Compare reports with weekly statistics (RDNS)

13M Inspections for public premises (including clinics and hospitals) and trading places:

13M.1 -Inspections done (Check availability of inspection reports)

14M Water and sanitation activities:

14M.1 -Coverage statistics displayed

14M.2 -Community health clubs formed

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14M.3 - Were water tests conducted: check for reports


Indicators

II 4. INFECTION CONTROL AND WASTE MANAGEMENT Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded

15M Infection control guideline:

15M.1 -Available and staff members know about it: Ask a staff member about it

16M Sterilisation of instruments:

16M.1 -Functioning steam steriliser

16M.2 -Guidelines for sterilization of instruments available

16M.3 -Sensitive tape available on sterilized packs and are cords not used to tie packs

17M Hygienic and aseptic conditions in wound dressing and injection room:

17M.1 -Bench and foot rest covered with macintosh

17M.2 -Bins for infected and contaminated objects with lid, plastic lining and foot pedal available and not more than ¾ full

17M.3 -Sharp box well positioned and not more than ¾ full

18M Protective clothing and disinfectant use by cleaners:

18M.1 -Cleaners have appropriate protective clothing (Heavy duty gloves, Uniforms, Dustcoats, Gumboots, Face Mask)

18M.2 -Cleaners know how to appropriately use disinfectants? (1 part jik (sodium hypochlorite industrial) to 9 parts water for general cleaning and 1 part jik to 4 parts for spillages i.e. blood and mainly body fluids): Ask the available cleaners during the assessment period and check the presence of the above mentioned items

19M Appropriate dressing of consulting staff:

19M.1 -Dressed with clean standard uniform (princess liner, Brown lace up shoes), and functioning nurses watch


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Indicators

II 5. PHARMACY (MEDICINES AND SUNDRIES STOCK MANAGEMENT)

Score: 1: if all criterion have been met/ recorded 0: if the criterion have not been met/ not recorded

20M Stock Management:20M.1 -Monthly physical counts conducted with min, max and emergency order

levels recorded and updated in stock cards20M.2 -The physical stock level corresponds with that on the stock card: supply on

stock card corresponds with physical count, (use sample of three medicines)20M.3 -Staff completes and send MIS forms to district each month (check for

copies remaining at institution)21M Storage of drugs:21M.1 -Stored correctly in a locked secured storeroom (e.g burglar bars on

windows and doors)21M.2 -Clean place, well ventilated with cupboards, labelled shelves, no incident

light21M.3 -Medicines stored in alphabetical order also observing the First Expiry First

Out rule22M Expired products:

22M.1 -Expired Medicine Register available

22M.2 -No expired products in stock: supervisor verifies randomly 3 medicines and 2 consumables (check stock cards)

23M VEN Medicines (according to EDLIZ) adequately stocked 3-6 months’ supply

23M.1 Doxycycline capsules 100mg23M.2 Ciprofloxacin tablets 500mg23M.3 Metronidazole tablets 200mg Oral23M.4 Diazepam injection 5mg/ml23M.5 Benzathine Penicillin injection23M.6 Benzyl Penicillin 23M.7 Amoxycillin suspension 125mg/5ml ( dispersible tablets)23M.8 Ferrous sulphate tablets/Folic Acid23M.9 Zinc Sulphate tabs23M.10 Paracetamol 500mg tablets23M.11 Paracetamol syrup or dispersible tablets23M.12 Dispensing envelopes23M.13 Latex gloves23M.14 Oxytocin 10IU/ml Injection, 1ml Ampoule.23M.15 Magnesium Sulphate 500mg/ml Injection, 2ml Ampoule23M.16 Gentamycin 40mg/ml Injection, 2ml Ampoule23M.17 Artemether 20mg + Lumefantrine 120mg Tablets, 24's

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Indicators

II 5. PHARMACY (MEDICINES AND SUNDRIES STOCK MANAGEMENT)

Score: 1: if all criterion have been met/ recorded 0: if the criterion have not been met/ not recorded

23M.18 Depo Medroxyprogesterone 150mg/Ml Injection, 1Vial23M.19 Levonorgestrel + Ethinyl Oestradiol (0.15+0.03)mg, 28Tablets, 100 Cycles23M.20 Lignocaine 23M.21 PEP kits available and accessible:

Contents of PEP kit: Zidovudine 300 mg + lamivudine 300 mg +Atazanavir (300 mg)/Ritonavir (100mg)

23M.22 Lockable trolleys available with working lock23M.23 Adult first line ART:

Preferred: TDF +3TC+NVP, alternate: TDF+3TC+EFV or ZDV+3TC+EFV/NVP ( could available in Dual or triple FDCs)

23M.24 Paediatric first line ART: Preferred:AZT+3TC+NVP (3-10 yr old), AZT+3TC+LPV/r ( <3 yrs)


Indicators

II6. OUTPATIENT DEPARTMENT (OPD) Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded

24M Consultations:

24M.1 -Consultations being done by appropriately qualified staff: PCN and/or RGN

25M Guidelines/protocols

25M.1 National Malaria guidelines for diagnosis and treatment of uncomplicated and severe malaria

- Posted on the wall, accessible to staff and up to date25M.2 PEP policy and guidelines:

-Available in OPD: posted on the wall and up to date25M.3 Opportunistic Infection and ART guidelines:

-Available, accessible in all consultation rooms and up to date25M.4 STI Management protocol:

-Displayed in all consultation rooms and up to date25M.5 IMNCI guidelines:

-Flowcharts displayed in all consultation areas and up to date25M.6 Focused ANC protocol:

-Displayed I all consultation rooms an up to date26M SUPPLIES: Medicines in Emergency tray and Accessories

26M.1 -Emergency tray with all the necessary un expired medicines (as from EDLIZ) available: adrenaline, lignocaine, diazepam, MgSO4, atropine?

26M.2 -Un expired ringer lactate, 5% dextrose, normal saline available

26M.3 -Important Accessories: cannula, giving sets, syringes and needles,

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drip stand, swabs, strapping, disinfectant, gloves, face mask, specimen bottles available, as part of emergency service

27M Availability of equipment at OPD?

27M.1 -Adult Weighing Scale and standard pediatric scale available and functional: inspect in comparison with a known weight, after weighing the indicator should come to zero Height meter

27M.2 -BMI calculator, Gluco meters and strips and ophthalmoscope, stethoscope, sphygmomanometer, thermometer, tape measure, fetoscope


Indicators

II 7. EXPANDED PROGRAM ON IMMUNIZATION (EPI);N.B. Please assess once all the indicators requiring opening of the refrigerator in order to avoid frequent opening of the refrigerator

Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded N/A: Not applicable

28M POLICY & GUIDELINES28M.1 -Surveillance line listing and case definitions displayed

28M.2 -Updated EPI schedule, and a contingency plan displayed

28M.3 -EPI graphs showing trends displayed and staff member is able to interpret the graphs

28M.4 -EPI reference materials: EPI Policy, (e.g. multi dose vial policy (MDVP) and EPI modules available and easily accessible

29M Cold Chain Mechanism: 29M.1 -Fridge with a temperature booklet available and filled twice a day

29M.2 -The temperature is within the recommended range of + 2 and+ 8 degrees Celsius (Supervisor should verify functionality of thermometer)

30M Availability of vaccines:30M.1 -The following antigens are available: BCG, MR ( measles and Rubella),

polio, Penta, tetanus, pneumococcal and rota virus vaccine30M.2 -The physical stock and the amount in the stock cards match ( Supervisor

verifies physical stock in the fridge by selecting three different vaccines quarterly)

31M Vaccines storage31M.1 -Correctly stored in fridge with compartments as follows in fridges with

compartments:-Freezing compartment: ice packs well frozen-None freezing compartment: top shelf BCG, OPV, measles -Lower shelf: DPT+HEPB, TT, etc

N.B. the new type of refrigerator i.e. Dometic fridge do not have compartments and the live vaccines are stored in the lower tray ( colder zone)

31M.2 -No expired vaccines

31M.3 -The Vaccine Vial Monitor (VVM )status is kept

31M.4 -There are readable labels on vials with matching diluents

32M Syringes:32M.1 -The number of syringes available matches the number of vaccines in the stock

cards

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33M Sharps boxes:33M.1 -Sharps boxes available in immunisation room/corner/area and not more than

3/4 full)34M EPI accessories: the following EPT accessories should be available and

functional34M.1 -Vaccine carriers, cold box, gas regulator, gas cylinder and scissors.

35M Forms35M.1 - AEFI investigation forms, case investigation forms for EPI targeted diseases

and vaccine wastage monitoring forms available 35M.2 -Vaccine order forms and stock cards available


Indicators II8. MATERNITY SERVICES; LABOUR, DELIVERY POST-

NATAL CARE FOR MOTHER AND NEWBORN

Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded

35M Medicines on Emergency tray: the following medicines available on the emergency tray and not expired (Check expiry date when applicable)

35M.1 -IV fluids (ringer lactate, 5% dextrose, normal saline) and giving sets

35M.2 -Adrenaline, lignocaine, diazepam, oxytocin, ergometrine, Magnesium Sulphate and calcium gluconate

35M.3 -Cannula, syringes and needles, drip stand, swabs, strapping, disinfectant

36M PPH kit ( please open one kit and check for its completeness)-PPH kits available and complete: *please refer to the annex section in the checklists guideline for list of items that should be available in the PPH kit

37 M Eclampsia kit ( please open one kit and check for its completeness)37M.1 Eclampsia kit available and complete:

*please refer to the annex section in the checklists guideline for list of items that should be available in the eclampsia kit

38M Uterotonic Medicines:38M.1 -Stored at correct temperature available in delivery room or immediate

vicinity to delivery room: oxytocin requiring refrigeration at 2-8 oC and the ones that do not require refrigeration below 25 oC

39M Equipment/supplies for care of newborn and monitoring of FHB: Are the following equipment available?

39M.1 -Fetoscope, baby blanket Baby scale and tape measure

39M.2 -Eye ointment (tetracycline), Vit K Sterile cord clamps/ties for umbilical cord

39M.3 -Penguin suction, neonatal bag and mask and suction tube in delivery room

40M Obstetric sterilised delivery packs: ( open one pack to see whether all the items are present and check for expiry date )

40M.1 -At least 2 obstetric sterilized delivery standard packs with -2 wrapping towels, 6 drapes, A galipot with 10 swabs, 5 gauze swabs, A receiver, 2 Artery Forceps, Cord Scissor, Episiotomy Scissor, Drying towel for hands, Gown, Cord ties (2: if no cord clamps), sanitary pads available

41M Sterile gloves:41M.1 -At least 5 pairs of sterile gloves should be available

TOTAL POINTS THIS QUARTER: (MAXIMUM AVAILABLE POINTS:

12

11)II9. OBSERVATION/INPATIENT SERVICES

40M In-patient register:40M.1 -Proper or improvised in patient register available and well maintained:

check whether observations documented, identity and hospital bed daysTOTAL POINTS THIS QUARTER: (MAXIMUM AVAILABLE POINTS: 1)

Indicators

II.10. HEALTH INFORMATION MANAGEMENT SYSTEM Score: 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded N/A: Not applicable

41M Referral and feedback system: review referral made in any one month in the last quarter ( if there was no referral made in the selected month, extend the period of assessment to any of the two months in the last quarter)

41M.1 -Standard referral forms (at least 10) and register available and properly filled

41M.2 - A referral feedback documented in the register for every referral made and/or referral feedback notes available ( Applicable only if there was referral in the last quarter)

42M T Series forms and timely reporting : check the following two items in in any one month in the last quarter

42M.1 -The following T Series forms available and fully completed: T1, T2, T3, T5, T6, and T12

42M.2 -T5 completed and sent timely (by the 7th of the following month) for previous month/sFor the following two indicators requiring review of registers and/or reported figures/indicators:

Score each register/reported figure as: 1: if all criterion that have been met/ recorded 0: if the criteria has not been met/ not recorded And then give an overall score as shown below:5 Points: if 5 (100%) of registers/reported figures are complete and/or correct/accurate3 Points: If 3-4( 60-80%) of registers/reported figures are complete and/or correct/accurate0 Point: if ≤2 (≤40%) of registers/reported figures are complete and/or correct/complete

43M Completeness and correctness of information in registers :Randomly select 5 registers to assess the indicators below *Please review the annex section of the checklist guideline for the list of registers available in a Healt Center setting

43M.1 -The information in each column of the selected registers is complete and correct in any one month in the last quarter: select different registers quarterly

R1 R2 R3 R4 R5 Complete registers

Overall score

44M Accuracy and correctness of reported figures:

44M.1 Are the figures reported for the last month of the last quarter correct according to the HMIS age groups in the T5?

i1 i2 i3 i4 i5 Accurate and

Overall

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* Randomly select five indicators , verify for accuracy and correctness(selected different indicators quarterly)

correct figures

score


III. CLINICAL MANAGEMENT PRIORITY AREAS

1C OPD/CONSULTATION AREA

AMBULATORY MANAGEMENT :

For indicator 1C1: assess by reviewing 5 files of patient who visited the clinic during the day of assessment. If there are no enough records, assess files of patients who visited the clinic in the last month. Score each file as 1or 0 as per the criterion and then give an over score/points for the indicator

For indicator 1C2: assess by asking one PCN/RGN on duty during the day of assessment. Score each criterion as 1 or 0 as per the response of the health care provider and then give an over score/point for the indicator.

PATIENT’S RECORDSOr TB Symptom screening 1: if all criterion have been met/ recorded 0: if all criterion have not been met/ not recorded N/A: not applicable if there is no record for review

5 records/symptoms (100%): 6 points



≤2 records/symptom (≤40%): 0 points

1 2 3 4 5 Complete records /No.of symptoms correctly identified

POINTS

1C1 Triaging of patients at OPD waiting area during all clinic shift:-Patients are classified into three groups and given due attention accordingly:Assess by reviewing patient files if patients are available at OPD during the day of assessment. If not, assess by asking the nurses on how they conduct triaging of patients ( their answers should match with the points listed below)

Emergency signs requiring immediate attention Priority signs (requiring priority in the queue Non-urgent cases

1C2 % of health center/clinic OPD provider(s) that can correctly state at least 4 adult TB symptom screening criteria (Select one provider randomly on shift day of assessment) • Assessment: Ask the facility provider/s at OPD to name criteria for TB testing.

1) Weight loss 2) fever for more than 3 weeks 3) cough for more than 14 days

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4) cough in HIV+ patients 5) TB contact exposure.

1C3 % of TB presumptive (TB symptom positive) that have sputum results documented in any month in the last quarter*source of data: OPD register/TB suspect register

SUBTOTAL Points – ( Maximum Available points:18)

2C FAMILY AND CHILD HEALTH (FCH)AMBULATORY (ANC, PNC) BEST PRACTICESSource of Data: *ANC register for ANC Best Practise indicators* PNC register for PNC/Postpartum best practise indicators*Assess 10 cases/records in any one month in the last quarter.

*If there are no enough cases for review, please extend the review period to a quarter. *If there are less than 10 cases for review after extending the review period to a quarter, assess the available cases/records.* If there are more than 10 cases for review, select 10 cases by using either simple/systematic random sampling*If there no records for review/the indicator is not applicable in the set up being assessed, please do not assess and not score the indicator; rather write N/A and deduct the available points for the indicator from the maximum available points.

PATIENT’S RECORDS/Registers1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recordedN/A: not applicable: if there are no records for review

*Score each case/record as 1 or 0 and then give a score for items per patient record, when applicable. * At last, please write the number of records with complete information as required and give an overall score/points as the per the criteria in the left column

9-10 records (≥90%): 6 points

8 records (80%): 4 points


≤6 records (≤60%):

0 points

2C1 ANC BEST PRACTICES: 1 2 3 4 5 6 7 8 9 10 Complete records

POINTS

2C1.1

% of first visit ANC bookings in any one month in last quarter who had documented:

BP Height Weight measurements Fundal height measurements (Applicable

only if pregnancy >16 weeks of gestation)

ALL ITEMS PER PATIENT RECORD2C1.2

% of first visit ANC bookings in any one month in last quarter who received the standard laboratory test according to the ANC guideline:

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Blood group and RH HIV test Haemoglobin RPR (Rapid plasma regain for syphilis

diagnosis)ALL ITEMS PER PATIENT RECORD

2C1.3

% of first visit ANC bookings with ≤ 16 weeks of gestation in any one month in last quarter who had documented pregnancy test results

2C1.4

% of first ANC visits in any one month in last quarter who received TT vaccine

2C1.5

% of first ANC visits in any one month in last quarter who received iron supplementation

2C1.6

% of first ANC visits in any one month in last quarter who received IPTp (if pregnancy >16 weeks of gestation if women living in malaria area)* Write Non-Applicable (N/A) if it is not a malaria endemic area

2C2 POSTNATAL AND/OR POSTPARTUM BEST PRACTICES*Source of data: PNC register for indicators

1 2 3 4 5 6 7 8 9 10 Complete records

POINTS

2C2.1

% PNC visits in any one month in last quarter documenting assessment for the following conditions of the infant:

General condition of the infant; NAD recorded if abnormality was not

detected ALL ITEMS PER PATIENT RECORD

2C2.2

% PNC visits in any one month in last quarter documenting assessment for the following conditions of the mother:

General condition ,Pulse rate, B/P and temperature

NAD recorded if abnormality was not detectedALL ITEMS PER PATIENT RECORD

2C2.3

% PNC visits in any one month in last quarter documenting infant feeding (BF) status (exclusive, mixed or not BF)

2C2.4

% women post-partum counselled and offered any of the modern FP method (below)at follow up PNC visit within 6 weeks of delivery in any one month within the last quarter

POP (progesterone-only contraceptive safe with BF)

injectable, Implant IUCD Tubal ligation Decline

SUBTOTAL: ( Maximum available points: 60)

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3C MATERNITY WAITING HOME

Follow up of pregnant mothers in maternity waiting home *Write Non-Applicable (N/A) in clinics without maternity waiting homes and/or if there are no mothers in maternity waiting homes during the assessment period and deduct the available points for the indicator from the maximum available points.*If there are less than 5 mothers in the maternity waiting home,, assess indicator with mothers available during the day of assessment

PATIENT’S RECORDS

1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recordedN/A: not applicable: if there are no mothers in the maternity waiting home


4 records (80%) : 4 points


≤2 records (≤40%):

0 points3C1

ANC Best Practices: follow up of pregnant mothers in maternity waiting home

1 2 3 4 5 Complete Records

POINTS

3C1.1

% of mothers in maternity waiting homes monitored for BP, FHR, and assessed for danger signs daily*Source of data: ANC cards of pregnant mothersSUBTOTAL; ( Maximum Available Points:6)

4C HIV–PMTCT

Source of data: ANC, ART, Delivery and DNA PCR register*Review ANC register and select 5 newly identified HIV women for indicator 4C1. *Review delivery register and select 5 HIV exposed new-borns for indicators 4C2-4C4 in the last quarter. *If more than 5 cases found, select 5 cases using simple/systematic random sampling for each condition. If less than 5 cases in the last quarter, assess all the cases found. *N/A (Not Applicable) if there are no HIV+/HIV exposed cases for review and deduct the available points for the indicator from the maximum available points.

PATIENT’S RECORDS

1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recordedN/A: not applicable: if there are no records for review




≤2 records (≤40%):

0 points

1 2 3 4 5 Complete records

POINTS

4C1 % NEWLY IDENTIFIED HIV + pregnant women initiated on ART in MNCH (ANC) ON THE SAME DAY in the last quarter*Source: ANC and ART register

4C2 % of infants born to HIV+ women who had a DNA PCR sample within 6-8 weeks of birth in the last quarter*source of data: delivery register, PNC and DNA PCR registers

4C3 % of HIV exposed infants who had A DNA PCR SAMPLE COLLECTED within 6-8 weeks of age and received results within one month in last quarter *Source of data: DNA PCR register

4C4 % of confirmed HIV positive infants initiated on ART in last quarter WITHIN 21 DAYS OF RECEIPT OF RESULTS*Source of data: DNA PCR register and ART register

SUBTOTAL: ( Maximum available points: 24)

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5C AMBULATORY MANAGEMENT OF DIARRHEA, PNEUMONIA ,MALARIA and Un complicated Severe Acute Malnutrition IN CHILDREN*Source of data: OPD/ IMNCI/CMAM registers*Review OPD/ IMCI register and select 5 cases with pneumonia, 5 cases with diarrhea, 5 cases with malaria, Cases of SAM in the last month. If more than 5 cases found, randomly select 5 cases for each dis order. If the number of cases is not enough, extend the search to the last quarter to gather 5 cases for each disorder. If less than 5 cases in the last quarter assess the cases found*Write Not Applicable (N/A) if there are no cases for review and deduct the available points for the indicator from the maximum available points.

PATIENT’S RECORDS

1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recordedN/A: not applicable: if there are no records for review

5 5 records (100%): 6 points



≤2 records (≤40%):

0 points

1 2 3 4 5 Complete Records

POINTS

5C1 % children treated as outpatient for pneumonia in any one of month in last quarter who were correctly assessed *Source of data: OPD/ IMNCI registerAbsence of general danger signs recorded: able to drink/feed, vomiting, consciousnessDuration of cough/difficult breathing and child’s age recordedRespiratory rate, and presence/absence of chest in drawing, stridor and wheezing recordedALL ITEMS PER PATIENT RECORD

5C2 % children correctly treated as an outpatient for pneumonia in any one of month in the last quarter among those correctly assessed

Treatment: Oral Amoxicillin 50mg/kg divided thrice per day x 5 days; caretaker counselling and follow up specified or admitted into hospital

5C3% children with diarrhoea correctly assessed for signs of dehydration), persistent diarrhoea and dysentery in any one of month in the last quarter Assessment of dehydration: Using IMNCI guidelines (Integrated Management of Neonatal and Childhood Illnesses) IMNCI Flow diagram available and applied,Duration of diarrhoea and presence of blood recordedGeneral condition of the child recorded: lethargy, consciousness and/or restless or irritabilityPresence of sunken eyes, drinking status ( thirsty/drinking eagerly or un able to drink/drink poorly) and skin pinchALL ITEMS PER PATIENT RECORD

5C4 % children correctly treated as an outpatient (ambulatory) for diarrhoea in any one month in the last quarter among those correctly assessed

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Treatment :-ORS, Zinc supplements and continued feeding and advise when to return

5C5 % children diagnosed with malaria that have RDT + or laboratory confirmation in any one month in the last quarter

5C6 % Children with uncomplicated malaria correctly treated according to national guidelines in any one month in the last quarter

Treatment: ARTEMETHER (20mg)-LUMEFANTRINE (120mg)(C0ARTEMETHER) during 3 days (See treatment protocol in appendix 2 of the checklist guideline)

5C7 % Children with severe malaria correctly treated according to national guidelines in any one month in the last quarter

(See treatment protocol in the Annex section of the checklist guideline)5C8 % of 6-59 months old children with un complicated severe acute

malnutrition (SAM) who were managed as per the national protocol in any one month in the last quarter

A 6 to 59 months old child with any one of the following criteria is classified as SAM :

Weight for height <-3SD (WHO) MUAC <115mm MUAC <125mm and HIV positive Bilateral pitting oedema

Out Patient management of SAM: RUTF Routine Medicine Health and nutrition counseling and continued follow up

*see annex section of checklist guideline for treatment details of SAMSUBTOTAL points: ( Maximum available points: 48)

6C MATERNITY SERVICES; LABOUR, DELIVERY POST-NATAL CARE FOR MOTHER AND NEWBORN

DELIVERY BEST PRACTICES*Source of data: delivery register and partograms *Review delivery register and randomly select 10 deliveries in the last month. If the number of deliveries is not enough extend the search to the last quarter to gather 10 deliveries. If less than 10 deliveries in the last quarter assess the cases found. If more than 10 cases in a month/quarter then randomly select 10 deliveries and assess the partograms for the deliveries selected to assess the following indicators * Write Not Applicable (N/A) if there are no cases for review and deduct the available points for the indicator from the maximum available points.

PATIENT’S RECORDS1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recordedN/A: not applicable: if there are no records for review

9-10 records (≥90%): 6 points



≤6 records (≤60%): 0 points

1 2 3 4 5 6 7 8 9 10 Complete records

POINTS

6C1

% deliveries performed by skilled personnel in any one month in the last quarter •Skilled provider: RGN with mid wifery training/RGN/Up skilled PCN

6C2% partographs completed per guideline in any one month in the last quarter

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Fetal heart rate plotted every 30 minutes

State of membranes every 4 hours presence/absence meconium

Cervical dilatation every 4 hours Descent of presenting part every 4

hours Contractions plotted every 30 minutes Maternal BP every 4 hours Maternal pulse every 30 minutes Maternal temperature every 4 hours Urinalysis documented at admission

ALL ITEMS PER PATIENT RECORD

6C3

% total births in any one month in the last quarter documenting administration of immediate postpartum oxytocin 10 units IM (within one minute of delivery of baby) (AMSTL: Active management of third stage of labour)* administration oxytocin 10 units IM within one minute of delivery of fetus (or misoprostol or ergomertrine, if BP normal, and oxytocin unavailable)

6C4

% births with placental status documented at birth in any one month in the last quarter•Assessment: complete or ragged , retained placenta

6C5

% newborns BF within one hour of birth in any one month in the last quarter•Assessment: Time of BF initiation documented

6C6 % newborns received Vitamin K in the any one month in the last quarter

6C7% newborns received eye care (Tetracycline) in the any one month in the last quarter

6C8

% newborns received first vaccination (BCG) in the any one month in the last quarter*source of data: delivery and PNC registers

6C9

% women monitored in early post-partum period (4th stage) per guideline (birth to discharge) in any one month in the last quarter. *source of data: partographs Vaginal bleeding, at least every 30

minutes 1st 2 hrs after birth and then four hourly until discharge

Uterine contraction at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge

BP at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge

Pulse at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge

20

Temperature at least every 30 minutes 1st 2 hrs after birth and then four hourly until discharge


6C10

% newborns monitored in early post-partum period per guideline (birth to discharge) in the any one month in the last quarter *source of data: partographs Temperature documented at least every 30

minute first 2 hours after birth then four hourly until discharge

Respiratory Rate documented at least every 30 minute first 2 hours after birth then four hourly until discharge

Breast feeding status documented at least every 30 minute first 2 hours after birth then four hourly until discharge

Colour documented at least every 30 minute first 2 hours after birth then four hourly until discharge


6C11

% facility births seen for day 3 PNC visit in any one month in the last quarter*Source of data: Delivery register ( to identify list of deliveries) and PNC registerSUBTOTAL: (Maximum available points: 66)

7C OBSTETRIC & NEONATAL COMPLICATIONS

*Source of data: delivery register and partograms.*Review delivery register and randomly select 5 cases with PROM, 5 cases with PPH, and 5 cases with Postpartum sepsis, 5 cases with Pre-eclampsia/eclampsia, 5 with neonatal asphyxia and 5 with neonatal sepsis in the last quarter. If less than 5 for review in the last quarter, assess the cases found. If more than 5cases in a/quarter then randomly select 5 cases to assess the following indicators*Write Not Applicable (N/A) if there are no cases for review

PATIENT’S RECORDS

PATIENT’S RECORDS1: if all criterion have been met/ recorded): 0: if all criterion have not been met/ not recordedN/A: not applicable: if there are no records for review




≤2 records (≤40%): 0 points

* 1 2 3 4 5

Records completed

POINTS

7C1 % women with prolonged labour in last quarter referred to higher level facility -obstructed labour criteria in any one month in last quarter: active labour > 12 hours (from admission at minimum 4 cm dilation or per patient-reported labour onset if admitted > 4 cm)* Source of data: partographs and/or referral register or referral notes/

7C2 % women with prolonged labor or Rupture of Membranes and without chorioamnionitis that were administered antibiotics as per protocolTreatment with oral erythromycin (or amoxicillin) if ROM > 6 hours or active labor > 12 hours without signs of chorio-amnionitis; first dose antibiotic and referral to hospital if signs of sepsis (intra partum fever, foul-smelling discharge)

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*Review all partographs of women who delivered in last quarter and select those in which rupture of membrane documented > 6 hours (at any time in course of labour and delivery) or activelabour >12 hours (at any time) without documentation of other signs of maternal sepsis(maternal fever or foul-smelling discharge) is documented

7C3 % women with PPH managed per guideline in thelast quarter*Review all partographs of women who delivered in last quarter and select those partographs fulfilling the following criteria: PPH documented (EBL > 500 cc or VB and tachycardia > 100 bpm or hypotension SBP < 100 or DBP <50) and check whether the following three items listed below were done for each identified case

- See the annex section of the checklist guideline for the details -PPH cause documented (atony, tear, retained placenta, other)

-Resuscitation for all PPH cases irrespective of the cause: manage Airway, Breathing and Circulation, secure two IV lines with two 16 G cannulas or any large size available, and run normal saline (NS) or ringer lactate (RL) -Management according to the cause:

-Uterine atony: Oxytocin 10 IU IM, massage, IV fluids, if bleeding continues 20 IU Oxytocin in 1L NS or RL solution at 60 drops/minute until uterus is firmly contracted-Retained placenta: controlled cord traction. If failed, manual removal -Vaginal/cervical laceration: sutured-Referred hospital with IV access if PPH not quickly controlled irrespective of the cause

ALL ITEMS PER PATIENT RECORD7C4 % women with signs of intra- or post-partum sepsis (fever,

foul-smelling discharge) treated with first dose of antibiotic and referred to hospital in last quarter

7C5 % pregnant women with severe pre-eclampsia and/or eclampsia managed according to the guideline in last quarterReview partographs of women who delivered in the last quarter and select those who fulfill the following criterion

Severe Pre-eclampsia: -Diastolic BP 100mm HG or more-proteinuria 3+ or more

Eclampsia: -Unconsciousness or Convulsions (fits)-dBP 110 mmHg or more-Proteinuria or 2+ or more in a pregnant women or a woman who has recently given birth

-Check whether the following three items listed below were done for each identified case:*see the annex section in the checklist guideline for details on management of severe pre-eclampsia and/or eclampsia

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-Maintain airway and if she is not breathing, assist breathing using bag and mask-Blood pressure monitored (if diastolic blood pressure (dBP) is ≥110 mmHg, Nifedipine 10 mg provided. If inadequate response after 20 minutes following first dose:

Repeat 10mg dose orally every 20 to 30 minutes until adequate dBP response is achieved, to a maximum of 40 mg given. Then 10-20 mg orally every 4-6 hours to maintain dBP 90-100 mmHg

* applicable only if dBP was ≥110mm Hg

-Magnesium sulphate 20% solution, 4gm IV over 5 minutes given. Followed promptly with 10g of 50% magnesium sulphate solution, 5gm in each buttock as deep IM injection with 1 ml of 2% lignocaine in the same syringe.

ALL ITEMS PER PATIENT RECORD7C6 % of neonates who did not cry/spontaneously breath

immediately after birth for whom resuscitation was immediately initiated in last quarter*Source of data: partographs*see the annex section in checklist guideline for details

7C7 % neonates with possible serious bacterial sepsis managed per standard in last quarter•Assessment of possible neonatal sepsis: Review all cases of newborn sepsis in last quarter from partographs and/or PNC register; and select 5 records for review that meet any of following probable sepsis criteria. *see checklist guideline criteria for chart audit

-if documented temperature >380 C or < 250 C (and not warming);- RR > 60 or <30 breaths per minute; -chest in-drawing or convulsion; -no movement on stimulation;- poor feeding/sucking or -umbilical redness, newborn treated with stat dose antibiotics and referred to hospital: Treatment: Benzyl Penicillin 100,000 units / and

Gentamycin 5 mg/kg first dose antibiotic and referred to hospital

*Source of data: partographs and/or PNC registerSUBTOTAL: ( Maximum available points: 42)

VERIFY THAT ALL QUESTIONS ARE FILLED IN Supervisor thanks the staff

Signature:

DMO/Representative………………………………………………………..

Nurse in Charge…………………….........................23

Counter verification………………………………………...

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ASSESTMENT FEEDBACK

I. Summary Comments on Results. Please note any trends, problems, exceptional or creative changes and results that you saw during your visit assessment

II. Noteworthy Improvement. Please note any improvement and include a few details of what they are doing and why it is unique

III. Difficulties/ Challenges. Please note any assessment area that seem to be having an especially difficult time in improving. Please include a few details about the problem, how it might be solved, and who might be involved

IV. Recommendations and suggestions for improvement. Please note that the feedback is more effective when emphasizes features of the clinical task to be performed (e.g. specifies a target performance, presents information on how target performance can be attained, and address change in performance observed since previous feedback

V. Follow up. Please review previous recommendations provided and assess if they were followed or not

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