Performance Based Financing
HOSPITAL QUALITY SUPERVISION CHECKLIST
Questionnaire for a Provincial/District/Mission Hospital Quality Review
Province: _______________________________________________________________________________
District: ________________________________________________________________________________
Hospital: _______________________________________________________________________________
Number of beds: ________ Catchment area population: __________________________________________
Date of supervision: ______________________________________________________________________
Name of supervisors and designation
|No. |Name of supervisor |Designation |
|1 | | |
|2 | | |
|3 | | |
|4 | | |
|5 | | |
I. Hospital Staffing
|STAFF |Establishment |In post |Vacant |Duration of vacancy |
|District Medical Officer | | | | |
|Government Medical Officer | | | | |
|Clinical Officer | | | | |
|Health Promotion Officer | | | | |
|District Nursing Officer | | | | |
|Matron | | | | |
|Sister in Charge | | | | |
|Sister in Charge Community | | | | |
|Principal State Certified Nurse | | | | |
|Sister General | | | | |
|State Certified Nurse | | | | |
|District TB Coordinator | | | | |
|District Environmental Health Officer | | | | |
|Environmental Health Officer | | | | |
|Environmentla Health Technician | | | | |
|Pharmacist | | | | |
|Pharmacy Technician | | | | |
|Dispensary Assistant | | | | |
|Nutritionist | | | | |
|Assistant Nutritionist | | | | |
|Radiographer | | | | |
|X-ray Operator | | | | |
|Dark Room Assistant | | | | |
|Physiotherapist | | | | |
|Medical Laboratory Scientist | | | | |
|District Health Service Administrator | | | | |
|Human Resource Officer | | | | |
|Health Information Assistant | | | | |
|Accountant | | | | |
|Accounting Assistant | | | | |
|Government Dental Officer | | | | |
|Dental Therapist | | | | |
|Dental Surgery Assistant | | | | |
|Rehabilitation Technician | | | | |
|CCSD Packer | | | | |
|Nurses with midwifery | | | | |
|Up skilled PCN | | | | |
|PCN | | | | |
|Operating theatre nurses | | | | |
|Nurse anaesthetist | | | | |
|Nurse aides | | | | |
|General hands | | | | |
|Non-medical staff or unqualified staff : Cook, , | | | | |
|Non-medical staff or unqualified staff : driver | | | | |
|Non-medical staff or unqualified staff : Laundry Hand , Senior Hand) | | | | |
ASSESSMENT SUMMARY
|I. |Available Points |Number of composite indicators |
|STRUCTURAL | | |
|SECTION | | |
| | |Score: |
| |*Please give a score for each of the criteria under each indicator as per the criteria in the right column |1: if all criterion have been |
| |*N.B. The items highlighted in bold are the indicators |met/ recorded |
| | |0: if all criterion have not been|
| | |met/ not recorded |
|1S |Outside appearance (when arriving at hospital): | |
|1S.1 |-Visible sign post | |
|1S.2 |-Fence/wall without holes and a gate that can be closed | |
|1S.3 |-Functional guard room with boom gate and functional light at the gate? | |
|1S.4 | -Direction signs with visiting times displayed | |
|2S |Maintenance of the ground: | |
|2S.1 |-Clean ground and grass cut | |
|2S.2 |-Garden well maintained with flower beds, trees or lawn, resting places (benches in shade),and with no animal | |
| |excrement, no litter or dangerous objects such as needles, syringes, gloves, used cotton wool, etc, | |
|2S.3 |-Sufficient parking area with clean pavements | |
|3S |Waste water drainage system | |
|3S.1 |-Connected to local sewage system (if not, septic tank must be available) | |
|4S |Incinerator within the premises: | |
|4S.1 |-Available, functional, fenced and being used | |
|5S |Waste pit for non-contaminated objects: | |
|5S.1 |-Waste pit with hole of minimum 3 metres depth fenced, without infected non decomposable (non – biodegradable) | |
| |objects available | |
| |(Waste pit is only required in hospitals where the city municipality is not collecting the non-contaminated | |
| |objects) | |
|6S |Lighting system | |
|6S.1 |-Electricity for at 24 hours a day, and 7 days a week | |
| |(Source of electricity: ZESA with backup system of either generator or solar energy and/or inventors). | |
| |Total points this quarter (MAXIMUM AVAILABLE Points: 11 POINTS) | |
|I.2 |Structural Indicators in Selected Departments: | |
|Indicators |Randomly select one department each quarter for indicators listed below. |Score: |
| |Please vary the department to be selected quarterly |1: if all criterion have been met/ recorded |
| |*Please give a score for each of the criteria under each indicator as per the criteria in the |0: if all criterion have not been met/ not recorded |
| |right column |N/A: if the indicator is not applicable in the selected |
| |*N.B. The items highlighted in bold are the indicators |department |
| |*if you write N/A for an indicator in a selected department, please deduct the points for the| |
| |indicator from the maximum available points | |
| | |Please select one department among the following four |
| | |departments ( encircle the selected department) and |
| | |assess indicators 7S-16S |
| | |1. OPD |
| | |2. FCH |
| | |3. Maternity Ward |
| | |4. Paediatric Ward |
|7S |Outside appearance of buildings | |
|7S.1 |-External appropriate wall finishing( painting, bricks or rough plastering) | |
|7S.2 |-Roof intact with well-maintained gutters, window panes | |
|8S |Inside appearance of building and its cleanliness | |
|8S.1 |-Walls and Floors- Clean, without cracks and floors-polished ( if required) and Ceiling / | |
| |roof intact without leaks neither cobwebs | |
|8S.2 |-Doors with locks and closing properly | |
|9S |Firefighting System: | |
|9S.1 |-Functional and serviced fire extinguishers with or without water hoses available and | |
| |accessible | |
|9S.2 |-Fire exits clearly marked and is there a clearly marked firefighting assembly area and | |
| |evacuation plan: Ask staff member on firefighting plan | |
|10S |Garbage bins in ground | |
|10S.1 |-Bins with lids and plastic lining available and not more than ¾ full without hazardous waste | |
| |(e.g. sharps, used cotton wool e.t.c) at accessible points | |
|11S |Presence of sufficient well maintained latrines/toilets | |
|11S.1 |-One water closet for every 6 inpatients or One water closet for every 20 outpatients | |
|11S.2 |-The toilet entries should be clearly marked for each sex and the male toilets should also | |
| |have a urinal | |
|11S.3 |-Recently cleaned without visible faecal matter or urine | |
|12S |Water and soap for hand washing: | |
|12S.1 |-Hand washing facilities with running water and soap available at accessible points | |
|13S |Waste collection | |
|13S.1 |-Waste collected and disposed daily or within 4 to 5 hours ( only for maternity ward) (Ask | |
| |staff member) | |
|13S.2 |Waste segregated with colour coding: | |
| |-Red/yellow for non-sharp infectious waste and sharp objects | |
| |-Black for communal non-sharp non-infectious wastes | |
| |and/or service area | |
| |*the bins and/or sharp boxes should not be more than ¾ full | |
|14S |Protective clothing and disinfectant use by cleaners: * Ask the available cleaners during the | |
| |assessment period | |
|14S.1 |-Cleaners have appropriate protective clothing (Heavy duty gloves, Uniforms, Dustcoats, | |
| |Gumboots, Face Mask) | |
|14S.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) | |
|15S |Professional staff appropriately dressed : | |
|15S.1 |-Clean with standard uniform, identification tag and lace up shoes. | |
|16S |Staff duty roster, staff leave calendar and clock in register (per department) including | |
| |maintenance and cleaning duty roster with timeline and signature column for cleaner and | |
| |supervisor: | |
|16S.1 |-Duty roster clearly visible including assigned nurse(s) and doctors(s) covering each ward for| |
| |each shift, including night and weekend coverage | |
|16S.2 |- The DOCTOR, NURSES actually present in the ward (Check the person/s on duty on the day of | |
| |visit) | |
|16S.3 |-Staff leave calendar complete and up to date, and displayed where all staff can see | |
|16S.4 |-Clock in register including maintenance and cleaning with timeline and supervisor signature | |
| |column | |
| |Sub-total points ( maximum available sub-total points: 20) | |
| | |Please select one department among the following two |
| | |departments ( encircle the selected department) and |
| | |assess indicators 17S-20S |
| | |1. OPD |
| | |2. FCH |
|17S |Good conditions in waiting area, meeting minimum standards: | |
|17S.1 |-With sufficient benches and / or chairs (according to daily attendance): calculate the | |
| |average daily attendance from the weekly attendance | |
|17S.2 |- Well/adequately ventilated with sufficient light adequate ventilation of waiting area: | |
| |If Open space with a shade or roof supported by brick or metal pillars or | |
| |If closed space: windows should measure at least 1/10 of floor area and at least ½ of window | |
| |area should be openable. | |
|18S |Consultancy rooms in good condition, meeting minimum standards | |
|18S.1 |-Windows with curtains or non-transparent glass and screen around bed | |
|18S.2 |-Functional doors with lock | |
|18S.3 |-Furniture (at least one chair and table for nurse/doctor, one chair for patient) | |
|18S.4 |-Hand washing facility | |
|18S .5 |-Examination bed in good condition and covered with clean linen | |
|19S |OPD fees, and medical aid companies: | |
|19S1 |-OPD fees and list of accepted medical aid companies accepted displayed in local vernacular | |
| |(when applicable) and easily visible for patients | |
|20S |Hygienic and aseptic conditions in wound dressing: | |
|20S.1 |-Bench and foot rest covered with Macintosh available | |
|20S.2 |-Bins for infected and contaminated objects with lid, plastic lining and foot pedal available | |
| |and not more than ¾ full | |
|20S.3 |-Sharp box well positioned and not more than ¾ full? | |
| |Sub- total points (maximum sub-total points: 11) | |
| | |Please select one department among the following two |
| | |departments ( encircle the selected department) and |
| | |assess indicators 21S-26S |
| | |1. Maternity Ward |
| | |2. Paediatric Ward |
|21S |Availability and status of furniture and other items | |
|21S.1 |-Beds, and mattresses with sheets, blankets, bedside lockers, benches on bed side available | |
| |and in good state (not broken, torn and clean) | |
|21S.2 |-Mosquito nets (in malaria endemic areas) available and in good state ( Not Applicable in | |
| |Non-Malaria Endemic area) | |
|21S.3 |-Fan and heater available when required | |
|22S |Bucket or basin for dirty linen: | |
|22S.1 |-Bins covered with a lid and not overflowing | |
|23S |Hygienic condition, access to water and space: | |
|23S.1 |-Clean and regular cleaned ( ask staff member or look at the weekly plan for cleaning) | |
|23S.2 |-Safe drinking water available and accessible | |
|23S.3 |-Enough space between beds (at least 1m between beds) | |
|23S.4 | -Well ventilated without bad smells | |
|23S.5 |-Shower with running water, and/ or container with at least 100 litres for patients to bath | |
| |with hot water available during winter? | |
|24S |Movable lockable drug trolleys: | |
|24S.1 |-Available with working locks? | |
|24S.2 |-Dangerous drugs cupboard (double locked) each with a different lock available | |
|24S.3 |-DDA registers available | |
| |Sub-total ( maximum sub-total available points: 12) | |
| |Total points this quarter (MAXIMUM AVAILABLE Points: 43 POINTS) | |
MANAGEMENT AND PLANNING: STAFF, POLICY, GUIDELINES, Medicines & SUPPLIES and Vaccines
|II.1 |ADMINISTRATION, FINANCE AND PLANNING |Score: |
| | |1: if all criterion have been |
| | |met/ recorded |
| | |0: if all criterion have not |
| | |been met/ not recorded |
|Indicators |*Assess at District Medical officer’s office/Administration and/or Finance Department /Matron office | |
| |*Please give a score for each of the criteria under each indicator as per the criteria in the right column | |
| |*N.B. The items highlighted in bold are the indicators | |
|1M |Mission statement , Vision, Values and patient charter | |
|1M.1 | -Displayed in public places and clearly visible | |
|2M |Catchment area map, spot map, monitoring graphs, demographic data:* Assess the indicator in the office of the DMO/Matron| |
| |or administrator office | |
|2M.1 |-Catchment area maps with current catchment population target population for services calculated correctly and displayed| |
|2M.2 |-Spot map showing recent or suspected out breaks with clear markings displayed | |
|2M.3 |-Monitoring graphs for different services displayed | |
|3M |Documentation of activities/ Operational Plan | |
|3M.1 |-Staff minute book/file available, well filed and up to date | |
|3M.2 |-Quarterly review reports, annual operational plan and annual progress report ( of previous year) available, well filed | |
| |and up to date | |
|4M |Management book, inventory register, maintenance book, returns( human, material and finance) | |
|4M.1 |- Available and up to date? | |
|5M |Service and maintenance plan for hospital equipment and vehicles | |
|5M.1 |-Plan available and being followed (Ask for reports and cross check with the plan) | |
|6M |Purchasing of medicines, equipment and consumables | |
|6M.1 |-MoHCC tender and procurement procedure documents available? | |
|6M.2 |-Functional CBU and PTC available | |
|6M.3 |-Medicines, equipment and consumables purchased as per the procedure? (ask the procurement committee to provide the | |
| |documents for an item which was purchased and cross check whether it was bought as per the MoHCC procedures) | |
|7M |Finance and accounting system | |
|7M.1 |-Financial and accounting documents available and well-kept in clearly labelled files including bank statements, payment| |
| |vouchers with attached support documents. | |
|7M.2 |-Document showing budget and revenues (GoZ, HSF, RBF, Donations) available | |
|7M.4 |-Managed by qualified staff (accountant/ accounts assistants)? | |
|7M.5 |-Financial reports which show expenditure of proper utilization of funds according to statutory requirements and minutes| |
| |of finance meetings available | |
|8M |Ambulance and communication systems | |
|8M.1 |-The hospital has a functional (24/7) ambulance | |
|8M.2 |-The hospital has a functional communication system (land line/cell phone/radio) | |
| |Total points this quarter: (Maximum Available Points: 17) | |
|II.2 |. INFECTION CONTROL |Score: |
| |*Please give a score for each of the criteria under each indicator as per the criteria in the right column |1: if all criterion have been |
| |*N.B. The items highlighted in bold are the indicators |met/ recorded |
| |*If N/A, please deduct the points for the indicator from the maximum available points |0: if all criterion have not |
| | |been met/ not recorded |
|9M |Infection control committee | |
| |*Assess the indicator by asking the infection control committee/focal person | |
|9M.1 |-The hospital has a functional infection control committee ( check for the minutes of meetings) | |
|9M.2 |-Infection control guideline available | |
|9M.3 |-The committee assesses implementation of infection control guidelines and taking measures according to the guideline? (| |
| |check in reports/minutes) | |
|10M |Sterilization of instruments: | |
| |Assess the indicator at CSSD (Central Steam Sterilizing Department) as all sterilizations are done in this department. | |
|10M.1 |-Functional Autoclave/ Steam steriliser available | |
|10M.2 |Sensitive tape available on sterilized packs and cords not used to tie packs ( check at least two packs) | |
|11M |Guidelines | |
|11M.1 |-Guidelines available and utilized (Ask a staff member at CSSD and compare the response with the guideline | |
|12M |Regular training of kitchen staffs on food handling: Check for training reports from Hospital Food Services Supervisor | |
| |and ask two kitchen staff members | |
|12M.1 |-Kitchen staff members receiving regular in house training (quarterly) on food handling | |
| |Total points this quarter: (Maximum Available Points: 7) | |
|II.3 |EMERGENCY SERVICES | |
|Indicators |*Please give a score for each of the criteria under each indicator as per the criteria in the right column |Score: |
| |*N.B. The items highlighted in bold are the indicators |1: if all criterion have been |
| |* |met/ recorded |
| | |0: if all criterion have not |
| | |been met/ not recorded |
|13M. |Staff Duty Roster for On call Medical doctor and support staff | |
|13M.1 |-Duty roster fully completed and posted in public place for medical and support staff on call through the month | |
| |(doctor, lab, x-ray, anaesthetist, theatre nurse and observed on the day of the visit)? | |
|13M.2 |-Response time for staff on call displayed and a review of calls made to ascertain response time | |
| |SUPPLIES | |
|14M |Are the following emergency airway equipment available and functional? | |
|14M.1 |-Suction machine, adult and paediatric laryngoscope, bag and mask (ambubag) (adult -and paediatric), oxygen. | |
|14M.2 |- If not functional was a report made? *Equipment should be easily accessible not stored under lock and key. | |
|15M |Emergency tray: | |
|15M.1 |-With all the necessary drugs (as from EDLIZ). 50% dextrose, adrenaline, lignocaine, diazepam, atropine, | |
|15M.2 |-Emergency tray book up to date, signed daily, no expired drugs | |
|15M.3 |-The tray is labelled? (should be including the drugs and accessories, with clearly legible and durable labels) | |
|16M |Important Accessories: | |
|16M.1 |-Cannula, syringes and needles, specimen bottles, | |
|16M.2 |-Swabs, strapping, disinfectant, gloves, face mask | |
|16M.3 |-Functional laryngoscope | |
|17M |IV fluids and blood : | |
|17M.1 |-Ringer lactate, 5% dextrose, and normal saline available and not expired and giving sets, drip stand | |
|17M.2 |Blood and blood products | |
| |Total points this quarter: (Maximum Available Points: 12) | |
|II.4. |OPERATING THEATRE | |
|Indicators |*Please give a score for each of the criteria under each indicator as per the criteria in the right column |Score: |
| |*N.B. The items highlighted in bold are the indicators |1: if all criterion have been met/|
| |*If N/A, please deduct the points for the indicator from the maximum available points |recorded |
| | |0: if all criterion have not been |
| | |met/ not recorded |
| | |N/A: not applicable |
|18M |Structure and Ventilation system, and register | |
|18M.1 |-Walls of durable material and easily washable walls, Non transparent windows and functional doors with floor | |
| |paved with vinyl/ ceramic tiles without cracks, ceiling in good state | |
|18M.2 |-Good appropriate air ventilation system: small meshed windows to let air in ( if only natural ventilation is | |
| |used) and/or air conditioner fitted without/with sealed windows ( if mechanical ventilation is used), and doors to| |
| |the aisle closed | |
|18M.3 |-Surgical register available and up to date? | |
| |SUPPLIES | |
|19M |Operating table | |
|19M.1 |-In good state with easy to clean mattress covered with waterproof material? | |
|19M.2 |- Functional hand rests with handcuffs & stir ups? | |
|19M.3 |-The table can be tilted and raised | |
|20M |Basic equipment and consumables: | |
| |-Are the following basic equipment & consumables available? | |
|20M.1 |Anaesthetic machine with :Patient monitor, ECG and ETCO2, Ambu Bag, Laryncoscope size 0-4 and O2 cylinder for back| |
| |up, functional failure alarm and7 ventilator | |
|20M.2 |Air way equipment: Endotracheal tubes size 3.5-8.5, Laryngeal mask sizes 2-5, Oral air way sizes 00-6, Intubating | |
| |intruder and all range sizes of face masks | |
|20M.3 |Efficient suction machine, fluid warmer, pressure pump infusion gadget, all range sizes of cannulas, syringes and | |
| |needles and defibrillator | |
|20M.4 |Medicines: ketamin, pethidine/morphine, metclorpromide, suxamethanium, atracurium, ephedrine, neostigmine, | |
| |diclophenac IM/supporitory | |
|20M.5 |Emergency drugs: adrenaline, atropine, NaHCO3, hydrocortisone, promethazine | |
|20M.6 |Inhalation anaesthetic agents: halothane and/or isoflurane , N2O and O2 cylinder | |
|21M |Movable lockable drug trolleys | |
|21M.1 |-Available with working locks? | |
|21M.2 |-Dangerous drugs cupboard (double locked) each with a different lock, with DDA registers available? | |
|22M | Emergency surgical packs (general and caesarean ): | |
|22M.1 | -At least 5 kits for each of the packs i.e. general and caesarean available | |
|23M |Gowning area and theatre clothing: | |
|23M.1 |-Available and has adequate washing and scrubbing space? | |
|23M.2 |-Has Pedal or elbow tap with disinfection device? | |
|23M.3 |- Running water and anti-septic available? | |
|23M.4 |-Surgical blouse, trousers, masks, hats, sandals and gumboots, goggles and gowning packs available | |
| |Total points this quarter: (Maximum Available Points: 19) | |
|II.5. |LABORATORY SERVICES | |
|Indicators |*Please give a score for each of the criteria under each indicator as per the criteria in the right column |Score: |
| |*N.B. The items highlighted in bold are the indicators |1: if all criterion have been met/ |
| | |recorded |
| | |0: if all criterion have not been |
| | |met/ not recorded |
|24M |Staffing of Laboratory: | |
|24M.1 |-Qualified (certified) staff (laboratory technician and/or lab scientist)? | |
|25M |Functionality of Laboratory after working hours:- | |
|25M.1 |-Functional and available for emergencies after working hours? * Verify after hour activities in the laboratory | |
| |register for the last quarter | |
|26M |Recording of results: | |
|26M.1 |-Laboratory register correctly and completely filled: | |
| |Check record of any month in the last quarter | |
|27M |Washing dirty pipettes: | |
|27M.1 |-Lab personnel wash dirty pipes in containers with antiseptic (except disposable pipettes)? | |
|28M |Internal and External quality assurance services: | |
|28M.1 |-Internal and external quality controls done | |
| |*Check for copy of report of internal and External quality assurance assessment report ( by ZINQAP) | |
| c |SUPPLIES | |
|29M |Parasite demonstration on plastic paper, in a colour book, or put on wall | |
|29M.1 |Blood smear: Vivax, Oval, Falciparum, Malariae | |
|29M.2 |Stools: Ascaris, entamoebae, ankylostome, schistosome | |
|30M |Microscope: | |
|30M.1 |-Available and in working condition (functional) with functional objectives - immersion oil – mirror or | |
| |electricity and – blades, cover glass, slides, GIEMSA | |
|31M |Equipment: | |
|31M.1 |-Centrifuge, full blood count machine, chemistry analyser machine, incubator and fume cup board (also serviced) | |
| |available and serviced and functional: | |
| |( Check in the maintenance register if the assessments were done monthly and signed for) | |
|32M |Reagents | |
|32M.1 |-Available for the equipment mentioned under 30M.1 and 31M.1? (Check stocks against minimum levels) | |
|32M.2 |-No expired stocks | |
|32M.3 |-Expiry and disposal register available | |
|33M |Are the following items available? | |
|33M.1 |-Gloves, specimen containers, appropriate protective clothing | |
| |Total points this quarter: (Maximum Available Points: 13) | |
|II.6. |PHARMACY (MEDICINES AND SUNDRIES STOCK MANAGEMENT) | |
|Indicators |*Please give a score for each of the criteria under each indicator as per the criteria in the right column |Score: |
| |*N.B. The items highlighted in bold are the indicators |1: if all criterion have been met/ |
| | |recorded |
| | |0: if all criterion have not been |
| | |met/ not recorded |
|34M |Staffing and Specimen Signature: | |
|34M.1 |-Pharmacy being manned by qualified staff (Pharmacist and/or Pharmacy technician)? | |
|34M.2 |-Specimen signatures for prescribers available at pharmacy? | |
|35M |Statutory instruments: | |
|35M.1 |-Medicines and Allied Substances Act available | |
|35M.2 |-Dangerous Drugs Act available | |
|36M |Availability of essential medicines: | |
| |-Availability for at least 90 days. | |
|36M.1 |Magnesium sulphate | |
|36M.2 |Gentamycin, Amoxicillin : select one and check its availability | |
|36M.3 |Oxytocin | |
|36M.4 |Contraceptives (implant, injectable, post-operative IUD, progestone- oral contraceptive, combined oral | |
| |contraceptive pills)* select one among the list and check its availability | |
|36M.5 |RHZE: rifampicin + isoniazid + pyrazinamide+Ethambutol | |
|36M.6 |Hydrochlorthiazide, Metformin, Insulin: select one and check its availability | |
|37M |HIV and AIDS medicines: | |
| |Availability for at least 90 days. | |
|37M.1 |Adult first line ART: | |
| |Preferred: TDF +3TC+NVP, alternate: TDF+3TC+EFV or ZDV+3TC+EFV/NVP ( could available in Dual or triple FDCs) | |
|37M.2 |Paediatric first line ART: | |
| |Preferred:AZT+3TC+NVP (3-10 yr old), AZT+3TC+LPV/r ( ................
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